Timothy D. Solberg

Stereotactic body radiation therapy: The report of AAPM Task Group 101

Task Group 101 of the AAPM has prepared this report for medical physicists, clinicians, and therapists in order to outline the best practice guidelines for the external-beam radiation therapy technique referred to as stereotactic body radiation therapy (SBRT). The task group report includes a review of the literature to identify reported clinical findings and expected outcomes for this treatment modality. Information is provided for establishing a SBRT program, including protocols, equipment, resources, and QA procedures. Additionally, suggestions for developing consistent documentation for prescribing, reporting, and recording SBRT treatment delivery is provided.

A CT-based Monte Carlo simulation tool for dosimetry planning and analysis.

The Los Alamos code MCNP4A (Monte Carlo N-Particle version 4A) is currently used to simulate a variety of problems ranging from nuclear reactor analysis to boron neutron capture therapy. A graphical user interface has been developed that automatically sets up the MCNP4A geometry and radiation source requirements for a three-dimensional Monte Carlo simulation using computed tomography data. The major drawback for this dosimetry system is the amount of time to obtain a statistically significant answer. A specialized patch file has been developed that optimizes photon particle transport and dose scoring within the standard MCNP4A lattice geometry. The transport modifications produce a performance increase (number of histories per minute) of approximately 4.7 based upon a 6 MV point source centered within a 30 x 30 x 30 cm3 lattice water phantom and 1 x 1 x 1 mm3 voxels. The dose scoring modifications produce a performance increase of approximately 470 based upon a tally section of greater than 1 x 10(4) lattice elements and a voxel size of 5 mm3. Homogeneous and heterogeneous benchmark calculations produce good agreement with measurements using a standard water phantom and a high- and low-density heterogeneity phantom. The dose distribution from a typical mediastinum treatment planning setup is presented for qualitative analysis and comparison versus a conventional treatment planning system.

Use of the BrainLAB ExacTrac X-Ray 6D System in Image-Guided Radiotherapy

The ExacTrac X-Ray 6D image-guided radiotherapy (IGRT) system will be described and its performance evaluated. The system is mainly an integration of 2 subsystems: (1) an infrared (IR)-based optical positioning system (ExacTrac) and (2) a radiographic kV x-ray imaging system (X-Ray 6D). The infrared system consists of 2 IR cameras, which are used to monitor reflective body markers placed on the patients skin to assist in patient initial setup, and an IR reflective reference star, which is attached to the treatment couch and can assist in couch movement with spatial resolution to better than 0.3 mm. The radiographic kV devices consist of 2 oblique x-ray imagers to obtain high-quality radiographs for patient position verification and adjustment. The position verification is made by fusing the radiographs with the simulation CT images using either 3 degree-of-freedom (3D) or 6 degree-of-freedom (6D) fusion algorithms. The position adjustment is performed using the infrared system according to the verification results. The reliability of the fusion algorithm will be described based on phantom and patient studies. The results indicated that the 6D fusion method is better compared to the 3D method if there are rotational deviations between the simulation and setup positions. Recently, the system has been augmented with the capabilities for image-guided positioning of targets in motion due to respiration and for gated treatment of those targets. The infrared markers provide a respiratory signal for tracking and gating of the treatment beam, with the x-ray system providing periodic confirmation of patient position relative to the gating window throughout the duration of the gated delivery.

Phase versus amplitude sorting of 4D‐CT data

Image quality of CT scans suffers when objects undergo motion. Respiratory motion causes artifacts, which prevents adequate visualization of anatomy. Four‐dimensional CT (4D‐CT) is a method in which image reconstruction of moving objects is retrospectively gated according to the recorded phase information of the monitored motion pattern. Although several groups have investigated the use of 4D‐CT in radiotherapy, little has been detailed with regard to the sorting method. We present a new retrospective gating technique with sorting based on the amplitude of the motion trace. This method is compared to previously developed methods that sort based on phase. A 16‐slice CT scanner (Sensation 16, Siemens Medical Solutions, Erlangen, Germany) was used to acquire images of two phantoms on a motion platform moving in two dimensions. The motion was monitored using a strain gauge inserted inside an adjustable belt. A 180° interpolation was used for reconstruction after gating. Significant improvement using the amplitude‐sorting technique was observed, particularly when testing nonperiodic motion functions. PACS numbers: 87.59.Fm, 87.53.Kn, 87.57.Ce

DOSIMETRIC CONSEQUENCES OF INTRAFRACTION PROSTATE MOTION

PURPOSE To analyze characteristics of intrafraction prostate motion, monitored using the Calypso system, and investigate dosimetric consequences of the motion for different clinical target volume (CTV) to planning target volume (PTV) margins. METHODS AND MATERIALS Motion characteristics were analyzed for 1,267 tracking sessions and 35 patients. Using prostate-PTV margins of 0, 1, 2, 3, and 5 mm, dose metrics for the prostate gland, bladder, and rectum were evaluated for scenarios including patient population, individual patients showing the greatest motion during the course of treatment, and the individual session with the largest overall movement. Composite dose distributions incorporating motion blurring were calculated by convolving static intensity-modulated radiotherapy plans with corresponding motion probability functions. RESULTS For prostate-PTV margins of 2 mm or greater, intrafraction motion did not compromise prostate dose coverage for either the patient population or individual patients. For the patient showing the largest overall movement, the prostate equivalent uniform dose was reduced by only 17.4 cGy (0.23%), and the minimum prostate dose remained greater than 95% of the nominal dose. For margins less than 2 mm, the prostate dose-volume histogram in the same patient was slightly compromised, and the equivalent uniform dose was reduced by 38.5 cGy (0.51%). Sparing of the bladder and rectum was improved substantially by reducing margins. CONCLUSIONS Although significant motion can be observed during individual fractions, the dosimetric consequences are insignificant during a typical course of radiotherapy (30-40 fractions) with CTV-PTV margins of 2 mm or greater provided that the Calypso system is applied for pretreatment localization. Further reduction of the margin is possible if intrafraction realignment is performed.

Quality and safety considerations in stereotactic radiosurgery and stereotactic body radiation therapy: Executive summary

In summary, SRS and SBRT require a team-based approach, staffed by appropriately trained and credentialed specialists. SRS and SBRT training should become a required part of radiation oncology residency training and of Accreditation of Medical Physics Educational Programs accredited clinical medical physics training. SRS and SBRT require significant resources in personnel, specialized technology, and implementation time. A thorough feasibility analysis of resources required to achieve the clinical and technical goals must be performed and discussed with all personnel, including medical center administration. Because various disease sites may have different clinical and technical requirements, feasibility and planning discussions are needed prior to undertaking new disease sites. Treatment of SRS/SBRT patients should adhere to established national guidelines. Acceptance and commissioning protocols and tests must be developed to explore in detail every aspect of the individual and integrated systems with the goal of ensuring safe and effective operation. A comprehensive quality assurance program, encompassing all clinical, technical, and patient-specific treatment aspects, must be developed to ensure SRS and SBRT are performed in a safe and effective manner. Patient safety in radiation therapy is everyones responsibility. Professional organizations, regulators, vendors, and end-users must demonstrate a clear commitment to working closely together to ensure the highest levels of safety and efficacy in stereotactic radiosurgery and stereotactic body radiation therapy.

Dynamic arc radiosurgery field shaping: a comparison with static field conformal and noncoplanar circular arcs

PURPOSE Recent advances in field-shaping technology and linac multileaf collimator (MLC) integration have resulted in new approaches to performing stereotactic radiosurgery. We present a modeling study comparing the absolute dose distributions from three radiosurgery delivery techniques: a conventional approach utilizing noncoplanar circular arcs, a static field conformal approach, and a dynamic arc field-shaping approach. In the latter, the MLC leaves more in a continuous fashion, conforming to the beams-eye-view projection of the target at every increment along the path of an arc. METHODS AND MATERIALS For the analysis, we devised a simulated target consisting of three overlapping spheres. This was chosen because it offered a straightforward planning approach for all three techniques, primarily the multiple isocenter approach. In addition, three representative cases were selected from the prior radiosurgery experience. These range in increasing size, from 0.50 to 9.79 cm(3), and in complexity, requiring from 3 isocenters to 16 in the case of circular arcs. In each situation, the goals were twofold: (1) to cover the entire volume with as high an appropriate isodose level (90% in the case of the conformal and dynamic arc techniques, 50% in the case of circular collimators) while (2) minimizing the dose to normal brain and where applicable, any adjacent radiation-sensitive structures. Because of the latter requirement, a single isocenter circular arc approach was ruled out for the analysis. RESULTS In the case of large or irregularly shaped lesions, the circular arc technique requires multiple isocenters, producing a high level of dose heterogeneity within the target volume. Both the static field and dynamic arc conformal techniques, as with all single isocenter approaches, produce a highly homogeneous dose throughout the target region. For a given large dose, peripheral dose is decreased as additional beams or arc degrees are added with either of the conformal approaches. Dose--volume histogram analysis evaluating the peripheral dose shows that, in many cases, dose to surrounding structures can be reduced through the use of a conformal static or dynamic arc approach over the conventional multiple isocenter, circular arc techniques. CONCLUSIONS Dynamic arc shaping is an efficient and effective method for accurately delivering a homogeneous target dose while simultaneously minimizing peripheral dose in radiosurgery applications.

Dose distributions using kilovoltage x-rays and dose enhancement from iodine contrast agents

In x-ray phototherapy of brain tumours, the tumour is loaded with iodine and exposed to kilovoltage x-rays. Due to the high photoelectric cross sections of iodine, substantial photoelectric interactions occur. The flux of photoelectrons, characteristic x-rays and Auger electrons produce a localized dose enhancement. A modified computed tomography scanner, CTRx, can be used both for tumour localization and delivery of the dose enhancement therapy. Monte Carlo methods were employed to simulate the treatment of iodinated brain tumours with a CTRx. The calculated results reveal the effect of tumour iodine concentration on dose distribution, the degree of skull bone sparing with the application of multiple arcs, and the homogeneity of tumour dose distribution versus iodine concentration. A comparison with 10 MV stereotactic radiosurgery treatment shows the potential of CTRx treatment relative to conventional treatment modalities.

Hepatic irradiation augments engraftment of donor cells following hepatocyte transplantation

Engraftment of donor hepatocytes is a critical step that determines the success of hepatocyte transplantation. Rapid and efficient integration of donor cells would enable prompt liver repopulation of these cells in response to selective proliferative stimuli offered by a preparative regimen. We have earlier demonstrated that hepatic irradiation (HIR) in combination with a variety of hepatotrophic growth signals, such as partial hepatectomy and hepatocyte growth factor, can be used as a preparative regimen for liver repopulation of transplanted hepatocytes. In this study, we investigated the effects of HIR on engraftment of transplanted dipeptidyl peptidase IV (DPPIV)–positive hepatocytes in congeneic DPPIV‐deficient rats. HIR‐induced apoptosis of hepatic sinusoidal endothelial cells (SEC) within 6 hours of HIR resulted in dehiscence of the SEC lining in 24 hours. Although there was no change of the number of Kupffer cells after HIR, colloidal carbon clearance decreased 24 hours post HIR, indicating a suppression of phagocytic function. DPPIV+ donor cells were transplanted 24 hours after HIR (0–50 Gy). There was an HIR dose‐dependent increase in the donor hepatocyte mass engrafted in the liver parenchyma. The number of viable transplanted hepatocytes present in hepatic sinusoids or integrated in the parenchyma was greater in the HIR‐treated group at 3 and 7 days after transplantation compared with the sham controls. Finally, we validated these rodent studies in cynomolgus monkeys, demonstrating that a single 10‐Gy dose of HIR was sufficient to enhance engraftment of donor porcine hepatocytes. These data indicate that transient disruption of the SEC barrier and inhibition of the phagocytic function of Kupffer cells by HIR enhances hepatocyte engraftment and the integrated donor cell mass. Thus, preparative HIR could be potentially useful to augment hepatocyte transplantation. (HEPATOLOGY 2009;49:258‐267.)

Intracranial stereotactic positioning systems: Report of the American Association of Physicists in Medicine Radiation Therapy Committee Task Group No. 68

Intracranial stereotactic positioning systems (ISPSs) are used to position patients prior to precise radiation treatment of localized lesions of the brain. Often, the lesion is located in close proximity to critical anatomic features whose functions should be maintained. Many types of ISPSs have been described in the literature and are commercially available. These are briefly reviewed. ISPS systems provide two critical functions. The first is to establish a coordinate system upon which a guided therapy can be applied. The second is to provide a method to reapply the coordinate system to the patient such that the coordinates assigned to the patients anatomy are identical from application to application. Without limiting this study to any particular approach to ISPSs, this report introduces nomenclature and suggests performance tests to quantify both the stability of the ISPS to map diagnostic data to a coordinate system, as well as the ISPSs ability to be realigned to the patients anatomy. For users who desire to develop a new ISPS system, it may be necessary for the clinical team to establish the accuracy and precision of each of these functions. For commercially available systems that have demonstrated an acceptable level of accuracy and precision, the clinical team may need to demonstrate local ability to apply the system in a manner consistent with that employed during the published testing. The level of accuracy and precision required of an individual ISPS system is dependent upon the clinical protocol (e.g., fractionation, margin, pathology, etc.). Each clinical team should provide routine quality assurance procedures that are sufficient to support the assumptions of accuracy and precision used during the planning process. The testing of ISPS systems can be grouped into two broad categories, type testing, which occurs prior to general commercialization, and site testing, performed when a commercial system is installed at a clinic. Guidelines to help select the appropriate tests as well as recommendations to help establish the required frequency of testing are provided. Because of the broad scope of different systems, it is important that both the manufacturer and user rigorously critique the system and set QA tests appropriate to the particular device and its possible weaknesses. Major recommendations of the Task Group include: introduction of a new nomenclature for reporting repositioning accuracy; comprehensive analysis of patient characteristics that might adversely affect positioning accuracy; performance of testing immediately before each treatment to establish that there are no gross positioning errors; a general request to the Medical Physics community for improved QA tools; implementation of weekly portal imaging (perhaps cone beam CT in the future) as a method of tracking fractionated patients (as per TG 40); and periodic routine reviews of positioning accuracy.