R Sheu

Implementation of EPID transit dosimetry based on a through‐air dosimetry algorithm

PURPOSE A method to perform transit dosimetry with an electronic portal imaging device (EPID) by extending the commercial implementation of a published through-air portal dose image (PDI) prediction algorithm Van Esch et al. [Radiother. Oncol. 71, 223-234 (2004)] is proposed and validated. A detailed characterization of the attenuation, scattering, and EPID response behind objects in the beam path is used to convert through-air PDIs into transit PDIs. METHODS The EPID detector response beyond a range of water equivalent thicknesses (0-35 cm) and field sizes (3×3 to 22.2×29.6 cm(2)) was analyzed. A constant air gap between the phantom exit surface and the EPID was utilized. A model was constructed that accounts for the beams attenuation along the central axis, the presence of phantom scattered radiation, the detectors energy dependent response, and the difference in EPID off-axis pixel response relative to the central pixel. The efficacy of the algorithm was verified by comparing predicted and measured PDIs for IMRT fields delivered through phantoms of increasing complexity. RESULTS The expression that converts a through-air PDI to a transit PDI is dependent on the objects thickness, the irradiated field size, and the EPID pixel position. Monte Carlo derived narrow-beam linear attenuation coefficients are used to model the decrease in primary fluence incident upon the EPID due to the objects presence in the beam. This term is multiplied by a factor that accounts for the broad beam scatter geometry of the linac-phantom-EPID system and the detectors response to the incident beam quality. A 2D Gaussian function that models the nonuniformity of pixel response across the EPID detector plane is developed. For algorithmic verification, 49 IMRT fields were repeatedly delivered to homogeneous slab phantoms in 5 cm increments. Over the entire set of measurements, the average area passing a 3%∕3mm gamma criteria slowly decreased from 98% for no material in the beam to 96.7% for 35 cm of material in the beam. The same 49 fields were delivered to a heterogeneous slab phantom and on average, 97.1% of the pixels passed the gamma criteria. Finally, a total of 33 IMRT fields were delivered to the anthropomorphic phantom and on average, 98.1% of the pixels passed. The likelihood of good matches was independent of anatomical site. CONCLUSIONS A prediction of the transit PDI behind a phantom or patient can be created for the purposes of treatment verification via an extension of the Van Esch through-air PDI algorithm. The results of the verification measurements through phantoms indicate that further investigation through patients during their treatments is warranted.

Intracoronary brachytherapy for in-stent restenosis of drug-eluting stents

Purpose Given the limited salvage options for in-stent restenosis (ISR) of drug-eluting stents (DES), our high-volume cardiac catheterization laboratory has been performing intracoronary brachytherapy (ICBT) in patients with recurrent ISR of DES. This study analyzes their baseline characteristics and assesses the safety/toxicity of ICBT in this high-risk population. Methods and materials A retrospective analysis of patients treated with ICBT between September 2012 and December 2014 was performed. Patients with ISR twice in a single location were eligible. Procedural complications included vessel dissection, perforation, tamponade, slow/absent blood flow, and vessel closure. Postprocedural events included myocardial infarction, coronary artery bypass graft, congestive heart failure, stroke, bleeding, thrombosis, embolism, dissection, dialysis, or death occurring within 72 hours. A control group of patients with 2 episodes of ISR at 1 location who underwent percutaneous coronary intervention without ICBT was identified. Unpaired t tests and χ2 tests were used to compare the groups. Results There were 134 (78%) patients in the ICBT group with 141 treated lesions and 37 (22%) patients in the control group. There was a high prevalence of hyperlipidemia (>95%), hypertension (>95%), and diabetes (>50%) in both groups. The groups were well-balanced with respect to age, sex, and pre-existing medical conditions, with the exception of previous coronary artery bypass graft being more common the ICBT group. Procedural complication rates were low in the control and ICBT groups (0% vs 4.5%, P = .190). Postprocedural event rates were low (<5%) in both groups. Readmission rate at 30 days was 3.7% in the ICBT group and 5.4% in the control group (P = .649). Conclusions This is the largest recent known series looking at ICBT for recurrent ISR of DES. ICBT is a safe treatment option with similarly low rates (<5%) of procedural and postprocedural complications compared with percutaneous coronary intervention alone. This study establishes the safety of ICBT in a high-risk patient cohort.

A Feasibility Study of Tumor Motion Estimate With Regional Deformable Registration Method for 4-Dimensional Radiation Therapy of Lung Cancer.

This study aims to employ 4-dimensional computed tomography to quantify intrafractional tumor motion for patients with lung cancer to improve target localization in radiation therapy. A multistage regional deformable registration was implemented to calculate the excursion of gross tumor volume (GTV) during a breathing cycle. GTV was initially delineated on 0% phase of 4-dimensional computed tomography manually, and a subregion with 20 mm margin supplemented to GTV was generated with Eclipse treatment planning system (Varian Medical Systems, Palo Alto, California). The structures, together with the 4-dimensional computed tomography set, were exported into an in-house software, with which a 3-stage B-spline deformable registration was carried out to map the subregion and warp GTV contour to other breathing phases. The center of mass of the GTV was computed using the contours, and the tumor motion was appraised as the excursion of the center of mass between 0% phase and other phases. Application of the algorithm to the 10 patients showed that clinically satisfactory outcomes were achievable with a spatial accuracy around 2 mm for GTV contour propagation between adjacent phases and 3 mm between opposite phases. The tumor excursion was determined in the vast range of 1 mm through 1.6 cm, depending on the tumor location and tumor size. Compared to the traditional whole image-based registration, the regional method was found computationally a factor of 5 more efficient. The proposed technique has demonstrated its capability in extracting thoracic tumor motion and should find its application in 4-dimensional radiation therapy in the future to maximally utilize the available spatial–temporal information.

SU‐C‐18A‐06: Tracking Fuzzy Border Using Geodesic Curve and Its Application to Liver Segmentation On Planning CT

PURPOSE To investigate the feasibility of using geodesic curves to track fuzzy borders between liver and chest wall and to evaluate how it could improve the performance of automatic liver segmentation on treatment planning CT images. METHODS The performance of automatic liver segmentation usually suffers from the fuzzy borders between liver and the adjacent chest wall due to similar HU values on non-contrast-enhanced planning CT images. To address this issue, geodesic curves were used to track these fuzzy borders. We first constructed a horizontal gradient map on the coronal-view images. After automatically identifying one starting and one ending point, a minimal distance map (MDM) was constructed by evolving a front starting from an infinitesimal circle around the ending point to every pixel on the image. The value of each point in MDM represents the minimal distance from the point to the ending point, which combines both arc length and gradient magnitude along the path. The front evolution was numerically solved by fast-marching method. We coupled this method with our automatic liver segmentation method, in which an initial contour was firstly estimated by adaptive thresholding and then a distance-regularized geodesic active contour model was used to further refine the contour. Besides visual assessment, dice similarity coefficient (DSC) was calculated to quantitatively compare the computer-generated contours with manual outlines. RESULTS This study included five patients with 597 CT slices who received SBRT liver treatment. We observed clear separation between liver and chest wall after delineation. The results of automatic segmentation were in excellent agreement with manual outlines, yielding all DSCs higher than 0.9 with mean of 0.93. CONCLUSION The preliminary results demonstrate that geodesic curve can be used to track fuzzy borders between liver and chest wall, and thus to improve the performance of automatic liver segmentation on planning CT images.

SU‐FF‐T‐12: Comparison of Biological Effective Dose Between Protons and Seed Implant Plus IMRT for Prostate Treatment

Purpose: To use biological effective dose (BED) as a metric to compare the dosimetric difference between mixed modality photon treatment (LDR seed implant followed by IMRT treatment) and intensity‐modulated proton therapy (IMPT) for prostate cancer.Methods and Material: An in‐house program was developed to calculate the total BED for three patients who received mixed modality photon treatment (MMPT). These patients first received brachytherapy using Pd‐103 prescribed to a dose of 100 Gy to 90% of the prostate volume (112 Gy BED) followed by IMRT prescribed to a dose of 45‐Gy IMRT (85.5 Gy BED) to 95% of the PTV (6‐mm margin posteriorly and 1 cm elsewhere). To simulate IMPT, the inverse treatment planning system KonRad from German Cancer Research Center was used to design a two‐field opposed lateral IMPT plan delivered using the spot scanning technique and was prescribed to a total dose of 81 Gy to 95% of the PTV volume (153.9 Gy BED). Results: In all three cases, MMPT shows minimal difference in target coverage (98% of the prostate) compared to IMPT. MMPT had higher dose heterogeneity due to the high dose gradient close to the implanted seeds, but the areas of high dose are completely confined within the target borders The rectal and bladder biological effective DVH (BEDVH) both show that the histogram curve is higher for BEDs less than 100 Gy for MMPT compared to IMPT. The curves cross at 100 Gy and the MMPT histogram curve is lower than IMPT for all doses greater than 100 Gy. Conclusion: MMPT provides superior high BED (>100 Gy) normal tissue sparing compared to proton therapy for similar target coverage. In addition, considering the high‐cost of a proton facility, MMPT provides a more financially viable alternative to prostate cancer treatment.

SU-F-T-44: A Comparison of the Pre-Plan, Intra-Operative Plan, and Post-Implant Dosimetry for a Prostate Implant Case Using Prefabricated Linear Polymer-Encapsulated Pd-103

PURPOSE To investigate the reproducibility and limitations of Pd-103 prostate brachytherapy using fixed length linear sources (CivaString). METHODS An LDR prostate brachytherapy case which was preplanned on MR images with prefabricated linear polymer-encapsulated Pd-103 sources (CivaString) was studied and compared with ultrasound based intra-operative planning and CT based post-implant dosimetry. We evaluated the following parameters among the three studies: prostate geometry (volume and cross sectional area), needle position and alignment deviations, and dosimetry parameters (D90). RESULTS The prostate volumes and axial cross sectional areas at center of prostate were measured as 41.8, 39.3 and 36.8 cc, and 14.9, 14.3, and 11.3 respectively on pre-plan MR, inter-op US, and post-implant CT studies. The deviation of prostate volumes and axial cross sectional areas measured on pre-planning MR and intra-operative US were within 5%. 17 out of 19 pre-planned needles were positioned within 5mm (the template grid size). One needle location was adjusted intra-operatively and another needle was removed due to proximity to urethra. The needle pathways were not always parallel to the trans-rectal probe due to the flexibility of CivaString. The angle of deviation was up to 10 degrees. Two pairs of needles were exchanged to better fit the length of prostate at the time of implant. This resulted in a prostate D90 of 153.8 Gy (124%) and 131.4 Gy (106.7%) for intra-op and PID respectively. CONCLUSION Preplanning is a necessary part of implants performed with prefabricated linear polymer sources. However, as is often the case, there were real-time deviations from the pre-plan. Intra-op planning provides the ability conform to anatomy at the time of implant. Therefore, we propose to develop a systematic way to order extra strings of different length to provide the flexibility to perform intra-operative planning with fixed length strands.

Microdosimetric characteristics of 50 kV X rays at different depths for breast intraoperative radiotherapy.

An intraoperative radiation therapy (IORT) device with 50 kV X rays was designed to deliver a single dose to the tumour bed after local excision of breast cancer. The quality of a radiation can be determined by the microscopic distribution of energy transfers along and across the charged particle tracks. The lineal energy, y, serves as an accurate measure of local energy concentration. The dose mean lineal energy, yD, is an indicator of radiation quality. For low linear energy transfer radiation, the ratio of its dose mean lineal energy to that of (60)Co gamma rays can serve as a good indicator of the relative biological effectiveness (RBE) at low doses. In this study, microdosimetric simulations are performed for soft tissue irradiated by 50 kV X rays generated from the IORT device, with a 4-cm breast applicator attached. All energy transfers are recorded with the location coordinates in the tissue. Microdosimetric single events in a sphere of 1 µm in diameter are scored as a function of radial distances from the applicator surface. Single-event spectra are then constructed. From those single-event spectra, dose mean lineal energy is calculated. Compared with dose mean lineal energy of (60)Co gamma rays, the estimated RBEs at low doses are given for the X rays at different depths in the tissue. The RBEs at clinically relevant doses, as a function of depth, are also presented.

SU-E-T-438: Frameless Cranial Stereotactic Radiosurgery Immobilization Effectiveness Evaluation

Purpose: To evaluate immobilization effectiveness of Brainlab frameless mask in cranial stereotactic radiosurgery (SRS). Methods: Two sets of setup images were collected pre-and post-treatment for 24 frameless SRS cases. The pre-treatment images were obtained after applying 2D-2D kV image-guided shifts with patients in treatment position and approved by physicians; the post-treatment images were taken immediately after treatment completion. All cases were treated on a Novalis linac with ExacTrac positioning system and Exact Couch. The two image sets were compared with the correctional shifts measured by ExacTrac 6D auto-fusion. The shift differences were considered patient motion within the frameless mask and were used to evaluate its effectiveness for immobilization. Two-tailed paired t-test was applied for significance comparison. Results: The correctional shifts (mean±STD, median) of pre-and post-treatment images were 0.33±0.27mm, 0.26mm and 0.34±0.27mm, 0.23mm (p=0.740) in lateral direction; 0.32±0.29mm, 0.22mm and 0.48±0.30mm, 0.50mm (p=0.012) in longitudinal direction; 0.31±0.22mm, 0.24mm and 0.33±0.21mm, 0.36mm (p=0.623) in vertical direction. The radial correctional shifts (mean±STD, median) of pre -and post-treatment images were 0.60±0.38mm, 0.45mm and 0.75±0.31mm, 0.66mm (p=0.033). The shift differences (mean±STD, median, maximum) were 0.35±0.28mm, 0.3mm, 1.05mm, 0.34±0.28mm, 0.3mm, 1.00mm, 0.24±0.15mm, 0.21mm, 0.60mm and 0.61±0.32mm, 0.57mm, 1.40mm in lateral, longitudinal, vertical and radial direction, respectively. Two shifts greater than 1 mm (1.06mm and 1.02mm) were acquired from post-treatment images. However, the shift differences were only 0.09 and 0.19mm for these two shifts. Two patients with shift differences greater than 1mm (1.05 and 1.04mm) were observed and didn’t coincide with those two who had post-correctional shifts greater than 1mm. Conclusion: Image-guided SRS allowed us to set up patients with sub-millimeter accuracy relative to simulation position. However, patient motion during treatment could affect treatment accuracy. Our Result shows that Brainlab frameless mask provides reasonable patient immobilization and maintains the mean post-treatment position within sub-millimeter accuracy with some borderline results observed.

SU‐D‐BRD‐06: Creating a Safety Net for a Fully Automated, Script Driven Electronic Medical Record

Purpose: Demonstrate the effectiveness of in-house software in ensuring EMR workflow efficiency and safety. Methods: A web-based dashboard system (WBDS) was developed to monitor clinical workflow in real time using web technology (WAMP) through ODBC (Open Database Connectivity). Within Mosaiq (Elekta Inc), operational workflow is driven and indicated by Quality Check Lists (QCLs), which is triggered by automation software IQ Scripts (Elekta Inc); QCLs rely on user completion to propagate. The WBDS retrieves data directly from the Mosaig SQL database and tracks clinical events in real time. For example, the necessity of a physics initial chart check can be determined by screening all patients on treatment who have received their first fraction and who have not yet had their first chart check. Monitoring similar “real” events with our in-house software creates a safety net as its propagation does not rely on individual users input. Results: The WBDS monitors the following: patient care workflow (initial consult to end of treatment), daily treatment consistency (scheduling, technique, charges), physics chart checks (initial, EOT, weekly), new starts, missing treatments (>3 warning/>5 fractions, action required), and machine overrides. The WBDS can be launched from any web browser which allows the end user complete transparency and timely information. Since the creation of the dashboards, workflow interruptions due to accidental deletion or completion of QCLs were eliminated. Additionally, all physics chart checks were completed timely. Prompt notifications of treatment record inconsistency and machine overrides have decreased the amount of time between occurrence and execution of corrective action. Conclusion: Our clinical workflow relies primarily on QCLs and IQ Scripts; however, this functionality is not the panacea of safety and efficiency. The WBDS creates a more thorough system of checks to provide a safer and near error-less working environment.

SU-E-T-71: Commissioning and Acceptance Testing of a Commercial Monte Carlo Electron Dose Calculation Model (eMC) for TrueBeam

PURPOSE To provide commissioning and acceptance test data of the Varian Eclipse electron Monte Carlo model (eMC v.11) for TrueBeam linac. We also investigated the uncertainties in beam model parameters and dose calculation results for different geometric configurations. METHODS For beam commissioning, PTW CC13 thimble chamber and IBA Blue Phantom2 were used to collect PDD and dose profiles in air. Cone factors were measured with a parallel plate chamber (PTW N23342) in solid water. GafChromic EBT3 films were used for dose calculation verifications to compare with parallel plate chamber results in the following test geometries: oblique incident, extended distance, small cutouts, elongated cutouts, irregular surface, and heterogeneous layers. RESULTS Four electron energies (6e, 9e, 12e, and 15e) and five cones (6×6, 10×10, 15×15, 20×20, and 25×25) with standard cutouts were calculated for different grid sizes (1, 1.5,2, and 2.5 mm) and compared with chamber measurements. The results showed calculations performed with a coarse grid size underestimated the absolute dose. The underestimation decreased as energy increased. For 6e, the underestimation (max 3.3 %) was greater than the statistical uncertainty level (3%) and was systematically observed for all cone sizes. By using a 1mm grid size, all the calculation results agreed with measurements within 5% for all test configurations. The calculations took 21s and 46s for 6e and 15e (2.5mm grid size) respectively distributed on 4 calculation servants. CONCLUSION In general, commissioning the eMC dose calculation model on TrueBeam is straightforward and thedose calculation is in good agreement with measurements for all test cases. Monte Carlo dose calculation provides more accurate results which improves treatment planning quality. However, the normal acceptable grid size (2.5mm) would cause systematic underestimation in absolute dose calculation for lower energies, such as 6e. Users need to be cautious in this situation.