S Goddu

Salvage Radioembolization of Liver-dominant Metastases with a Resin-based Microsphere: Initial Outcomes

PURPOSE The use of radioembolization of hepatic metastases with yttrium-90 ((90)Y) microspheres is increasing. The present report describes the outcomes in a cohort of patients with metastatic liver tumors treated with a resin-based microsphere agent. MATERIALS AND METHODS Thirty patients with colon (n = 13), breast (n = 7), and other primary cancers (n = 10) were treated after the failure of first- and second-line therapy. Overall survival (OS), time to progression (TTP), and time to treatment failure (TTTF) were calculated from the first treatment. Response was measured according to Response Evaluation Criteria In Solid Tumors at interval follow-up imaging. RESULTS Thirty patients underwent 56 infusions of (90)Y, and 18 remained alive at the end of the study. Fourteen patients (47%) had a partial response or stable disease. OS (604 vs 251 days), TTP (223 vs 87 days), and TTTF (363 vs 87 days) were all significantly longer for patients who had a partial response or stable disease (P < .05). Median OS, TTP, and TTTF for patients with colorectal carcinoma were 357, 112, and 107 days, respectively, versus 638, 118, and 363 days in patients with other metastatic sources. Median survival was not reached for patients with breast carcinoma, and the TTP and TTTF were each 282 days. One patient (3%) experienced grade 3 toxicity (gastrointestinal ulceration). CONCLUSIONS (90)Y microsphere therapy produced promising survival rates compared with systemic salvage options, with minimal toxicity.

Fundamental properties of the delivery of volumetric modulated arc therapy (VMAT) to static patient anatomy

PURPOSE The primary goal of this article is to formulate volumetric modulated arc therapy (VMAT) delivery problem and study interdependence between several parameters (beam dose rate, gantry angular speed, and MLC leaf speed) in the delivery of VMAT treatment plan. The secondary aim is to provide delivery solution and prove optimality (minimal beam on time) of the solution. An additional goal of this study is to investigate alternative delivery approaches to VMAT (like constant beam dose rate and constant gantry angular speed delivery). METHOD The problem of the VMAT delivery is formulated as a control problem with machine constraints. The relationships between parameters of arc therapy delivery are derived under the constraint of treatment plan invariance and limitations on delivery parameters. The nonuniqueness of arc therapy delivery solutions is revealed from these relations. The most efficient delivery of arc therapy is then formulated as optimal control problem and solved by geometrical methods. A computer program is developed to find numerical solutions for deliveries of specific VMAT plan. RESULTS Explicit examples of VMAT plan deliveries are computed and illustrated with graphical representations of the variability of delivery parameters. Comparison of delivery parameters with that of Varians delivery are shown and discussed. Alternative delivery strategies such as constant gantry angular speed delivery and constant beam dose rate delivery are formulated and solutions are provided. The treatment times for all the delivery solutions are provided. CONCLUSION The investigations derive and prove time optimal VMAT deliveries. The relationships between delivery parameters are determined. The optimal alternative delivery strategies are discussed.

The world’s first single-room proton therapy facility: Two-year experience

PURPOSE This is a review of our 2-year experience with the first single-gantry proton therapy (PT) system. METHODS AND MATERIALS All patients were consented to participate on an institutional review board-approved prospective patient registry between December 2013 and December 2015. PT was delivered in a single-room facility using a synchrocyclotron with proton beam energy of 250 MeV. The dataset was interrogated for demographics, diagnosis, treatment modality, and clinical trial involvement. Cases were classified as simple or complex based on fields used and immobilization. The volume of photon patients treated in our department was collected between January 2011 and December 2015 to evaluate the impact of PT on our photon patient volume. RESULTS A total of 278 patients were treated with PT, including 228 (82%) adults and 50 (18%) pediatric cases. PT patients traveled a mean distance of 83.3 miles compared with 47.4 miles for photon patients queried in 2015. Rationale for treatment included reirradiation (20%), involvement in prospective clinical trial (14%), and proximity to critical structures to maximally spare organs at risk (66%). Forty patients were enrolled on 5 adult and 3 pediatric prospective clinical trials. The most common histologies treated were glioma (27%) and non-small cell lung cancer (18%) in adults, and medulloblastoma (22%) and low-grade glioma (24%) in pediatric patients. Prostate cancer composed 6% of PT. Complex cases composed 45% of our volume. Our photon patient volume increased yearly between 2011 and 2015, with 2780 patients completing photon treatment in 2011 and 3385 patients in 2015. PT composed 4% of overall patients treated with external beam radiation. CONCLUSIONS The installation of our single-gantry proton facility has expanded the treatment options within our cancer center, helping to increase the number of patients we see. Patients travel from twice as far away to receive this treatment, many for typical PT indications such as pediatrics or to participate in prospective clinical trials.

WE‐G‐BRB‐08: TG‐51 Calibration of First Commercial MRI‐Guided IMRT System in the Presence of 0.35 Tesla Magnetic Field

PURPOSE The first real-time-MRI-guided radiotherapy system has been installed in a clinic and it is being evaluated. Presence of magnetic field (MF) during radiation output calibration may have implications on ionization measurements and there is a possibility that standard calibration protocols may not be suitable for dose measurements for such devices. In this study, we evaluated whether a standard calibration protocol (AAPM- TG-51) is appropriate for absolute dose measurement in presence of MF. METHODS Treatment delivery of the ViewRay (VR) system is via three 15,000Ci Cobalt-60 heads positioned 120-degrees apart and all calibration measurements were done in the presence of 0.35T MF. Two ADCL- calibrated ionization-chambers (Exradin A12, A16) were used for TG-51 calibration. Chambers were positioned at 5-cm depth, (SSD=105cm: VRs isocenter), and the MLC leaves were shaped to a 10.5cm × 10.5 cm field size. Percent-depth-dose (PDD) measurements were performed for 5 and 10 cm depths. Individual output of each head was measured using the AAPM- TG51 protocol. Calibration accuracy for each head was subsequently verified by Radiological Physics Center (RPC) TLD measurements. RESULTS Measured ion-recombination (Pion) and polarity (Ppol) correction factors were less-than 1.002 and 1.006, respectively. Measured PDDs agreed with BJR-25 within ±0.2%. Maximum dose rates for the reference field size at VRs isocenter for heads 1, 2 and 3 were 1.445±0.005, 1.446±0.107, 1.431±0.006 Gy/minute, respectively. Our calibrations agreed with RPC- TLD measurements within ±1.3%, ±2.6% and ±2.0% for treatment-heads 1, 2 and 3, respectively. At the time of calibration, mean activity of the Co-60 sources was 10,800Ci±0.1%. CONCLUSIONS This study shows that the TG- 51 calibration is feasible in the presence of 0.35T MF and the measurement agreement is within the range of results obtainable for conventional treatment machines. Drs. Green, Goddu, and Mutic served as scientific consultants for ViewRay, Inc. Dr. Mutic is on the clinical focus group for ViewRay, Inc., and his spouse holds shares in ViewRay, Inc.

Commissioning and initial experience with the first clinical gantry-mounted proton therapy system

The purpose of this study is to describe the comprehensive commissioning process and initial clinical experience of the Mevion S250 proton therapy system, a gantry‐mounted, single‐room proton therapy platform clinically implemented in the S. Lee Kling Proton Therapy Center at Barnes‐Jewish Hospital in St. Louis, MO, USA. The Mevion S250 system integrates a compact synchrocyclotron with a C‐inner gantry, an image guidance system and a 6D robotic couch into a beam delivery platform. We present our commissioning process and initial clinical experience, including i) CT calibration; ii) beam data acquisition and machine characteristics; iii) dosimetric commissioning of the treatment planning system; iv) validation through the Imaging and Radiation Oncology Core credentialing process, including irradiations on the spine, prostate, brain, and lung phantoms; v) evaluation of localization accuracy of the image guidance system; and vi) initial clinical experience. Clinically, the system operates well and has provided an excellent platform for the treatment of diseases with protons. PACS number(s): 87.55.ne, 87.56.bdThe purpose of this study is to describe the comprehensive commissioning process and initial clinical experience of the Mevion S250 proton therapy system, a gantry-mounted, single-room proton therapy platform clinically implemented in the S. Lee Kling Proton Therapy Center at Barnes-Jewish Hospital in St. Louis, MO, USA. The Mevion S250 system integrates a compact synchrocyclotron with a C-inner gantry, an image guidance system and a 6D robotic couch into a beam delivery platform. We present our commissioning process and initial clinical experience, including i) CT calibration; ii) beam data acquisition and machine characteristics; iii) dosimetric commissioning of the treatment planning system; iv) validation through the Imaging and Radiation Oncology Core credentialing process, including irradiations on the spine, prostate, brain, and lung phantoms; v) evaluation of localization accuracy of the image guidance system; and vi) initial clinical experience. Clinically, the system operates well and has provided an excellent platform for the treatment of diseases with protons. PACS number(s): 87.55.ne, 87.56.bd.

SU‐E‐T‐352: Commissioning and Quality Assurance of the First Commercial Hybrid MRI‐IMRT System

Purpose: To describe the commissioning process for the first installed commercial MRI‐guided IMRT system (ViewRay, Village of Oakwood, OH) and outline quality assurance methods for this novel treatment modality. Methods: The ViewRay™ System (510(k) pending) consists of a 0.35‐T double‐doughnut MRI coupled with a gantry that houses three Co‐60 sources,each with an activity up to 15,000 Ci (120° apart). IMRT delivery is enabled by doubly‐focused MLCs that serve as the only beam‐shaping collimators for each head, allowing a maximum field size of 27.3 cm2 at the 105‐cm isocenter. MRIimaging is used prior to and during delivery for setup evaluation, adaptive radiotherapy, and gating. The challenges in commissioning as well as periodic and patient‐specific QA arise due to the presence of the magnetic field, unique geometry of this device which is not compatible with many of conventional RT QA devices and techniques, and the penumbra of a 2‐cm wide Co‐60 source. The following devices were used for commissioning and quality assurance tests: radiochromic and radiographic film, ionization chambers (Exradin A12 & A16), Sun Nuclears IC Profiler (Melbourne, FL), and a water tank. Tests were conducted to evaluate the beam profiles, penumbra, and PDDs. Also, tests to check MLC accuracy and reproducibility were evaluated. Results: Tests were developed to validate geometric performance of the device including a comprehensive set of MLC tests. Due to the low strength of the magnetic field, the mean free path of electrons in the ionization chamber volume is too long to have a noticeable curvature; therefore the magnetic field is not expected to have a noticeable effect on dose measurement. Conclusions: While the presence of the magnetic field limited the choice of QA devices, it was found that satisfactory methods for MRI‐IMRT machine QA exist and can be successfully employed. Drs. Green, Goddu, and Mutic served as scientific consultants for ViewRay, Inc. Dr. Mutic is on the clinical focus group for ViewRay, Inc., and his spouse holds shares in ViewRay, Inc.

SU-E-T-269: Differential Hazard Analysis For Conventional And New Linac Acceptance Testing Procedures

Purpose: New techniques and materials have recently been developed to expedite the conventional Linac Acceptance Testing Procedure (ATP). The new ATP method uses the Electronic Portal Imaging Device (EPID) for data collection and is presented separately. This new procedure is meant to be more efficient then conventional methods. While not clinically implemented yet, a prospective risk assessment is warranted for any new techniques. The purpose of this work is to investigate the risks and establish the pros and cons between the conventional approach and the new ATP method. Methods: ATP tests that were modified and performed with the EPID were analyzed. Five domain experts (Medical Physicists) comprised the core analysis team. Ranking scales were adopted from previous publications related to TG 100. The number of failure pathways for each ATP test procedure were compared as well as the number of risk priority numbers (RPN’s) greater than 100 were compared. Results: There were fewer failure pathways with the new ATP compared to the conventional, 262 and 556, respectively. There were fewer RPN’s > 100 in the new ATP compared to the conventional, 41 and 115. Failure pathways and RPN’s > 100 for individual ATP tests on average were 2 and 3.5 times higher in the conventional ATP compared to the new, respectively. The pixel sensitivity map of the EPID was identified as a key hazard to the new ATP procedure with an RPN of 288 for verifying beam parameters. Conclusion: The significant decrease in failure pathways and RPN’s >100 for the new ATP mitigates the possibilities of a catastrophic error occurring. The Pixel Sensitivity Map determining the response and inherent characteristics of the EPID is crucial as all data and hence results are dependent on that process. Grant from Varian Medical Systems Inc.

SU-E-T-775: Use of Electronic Portal Imaging Device (EPID) for Quality Assurance (QA) of Electron Beams On Varian Truebeam System

Purpose: In a previous study we have demonstrated the feasibility of using EPID to QA electron beam parameters on a single Varian TrueBeam LINAC. This study aims to provide further investigation on (1) reproducibility of using EPID to detect electron beam energy changes on multiple machines and (2) evaluation of appropriate calibration methods to compare results from different EPIDs. Methods: Ad-hoc mode electron beam images were acquired in developer mode with XML code. Electron beam data were collected on a total of six machines from four institutions. A custom-designed double-wedge phantom was placed on the EPID detector. Two calibration methods - Pixel Sensitivity Map (PSM) and Large Source-to-Imager Distance Flood Field (LSID-FF) - were used. To test the sensitivity of EPID in detecting energy drifts, Bending Magnet Current (BMC) was detuned to invoke energy changes corresponding to ∼±1.5 mm change in R50% of PDD on two machines from two institutions. Percent depth ionization (PDI) curves were then analyzed and compared with the respective baseline images using LSID-FF calibration. For reproducibility testing, open field EPID images and images with a standard testing phantom were collected on multiple machines. Images with and without PSM correction for same energies on different machines were overlaid and compared. Results: Two pixel shifts were observed in PDI curve when energy changes exceeded the TG142 tolerance. PSM showed the potential to correct the differences in pixel response of different imagers. With PSM correction, the histogram of images differences obtained from different machines showed narrower distributions than those images without PSM correction. Conclusion: EPID is sensitive for electron energy changes and the results are reproducible on different machines. When overlaying images from different machines, PSM showed the ability to partially eliminate the intrinsic variation of various imagers. Research Funding from Varian Medical Systems Inc.Dr. Sasa Mutic receives compensation for providing patient safety training services from Varian Medical Systems, the sponsor of this study.

A self-sufficient method for calibration of Varian electronic portal imaging device

Electronic portal imaging device (EPID) is currently used for dosimetric verification of IMRT fields and linac quality assurance (QA). It is critical to understand the dosimetric response and perform an accurate and robust calibration of EPID. We present the implementation of an efficient method for the calibration and the validation of a Varian EPID, which relies only on data collected with that specific device. The calibration method is based on images obtained with five shifts of EPID panel. With this method, the relative gain (sensitivity) of each element of a detector matrix is calculated and applied on top of the calibration determined with the flood-field procedure. The calibration procedure was verified using a physical wedge inserted in the beam line and the corrected profile shows consistent results with the measurements using a calibrated 2D array. This method does not rely on the beam profile used in the flood-field calibration process, which allows EPID calibration in 10 minutes with no additional equipment compared to at least 2 hours to obtain beam profile and scanning beam equipment requirement with the conventional method.

SU‐E‐T‐122: Routine Quality Assurance for the MEVION S250 Proton System

PURPOSE We have established a robust and efficient daily routine to ensure our proton radiotherapy imaging and delivery systems operate as expected. Our goal was to prioritize tests according to impact, and have them completed by our therapists in 30 minutes. METHODS Morning warm-up includes recording of machine startup parameter and noting faults, and connectivity to MOSAIQ. Safety checks include warning lights; Beam On, X-ray On, and Magnet On, audio/video, door interlocks, neutron detector, beam pause recovery, and pendant functions. Patient alignment checks include lasers vs. scribed phantom. Imaging checks include; panel distance, image and centering vs. lasers, isocentricity (scribed phantom), 2D/2D match (offset fiducials) using Daily (dosimetry) QA device, 6D table translations/angulations, and coincidence of proton and x-ray beam with film. Daily dosimetric checks focus on any one of 24 options available, using the Daily QA3 device and a range compensator (RC) idealized for the particular option. All options are checked over 5 weeks. With a single exposure the designated; range, modulation, output peak/plateau ratio, SOBP flatness, and lateral profile symmetry/flatness are measured and reviewed. The custom RC has 4 quadrants of different thickness that shadow detectors strategically, corresponding to one location in the plateau, two in the SOBP, and one just beyond the range. RESULTS Daily QA takes <30 minutes. The single exposure for dosimetric checks is sensitive enough to detect; a change in output of 1%, change in range and modulation of 1mm, and changes in SOBP flatness and profile attributes of 2%. Using the daily dosimetry device for imaging saves considerable time. CONCLUSION We have daily tests for an efficient yet robust to ensure patient and employee safety. These tests fall in line with the forthcoming TG224 report.