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SU-F-T-600: Influence of Acuros XB and AAA Dose Calculation Algorithms On Plan Quality Metrics and Normal Lung Doses in Lung SBRT

PURPOSEnTo study the influence of superposition-beam model (AAA) and determinant-photon transport-solver (Acuros XB) dose calculation algorithms on the treatment plan quality metrics and on normal lung dose in Lung SBRT.nnnMETHODSnTreatment plans of 10 Lung SBRT patients were randomly selected. Patients were prescribed to a total dose of 50-54Gy in 3-5 fractions (10?5 or 18?3). Doses were optimized accomplished with 6-MV using 2-arcs (VMAT). Doses were calculated using AAA algorithm with heterogeneity correction. For each plan, plan quality metrics in the categories- coverage, homogeneity, conformity and gradient were quantified. Repeat dosimetry for these AAA treatment plans was performed using AXB algorithm with heterogeneity correction for same beam and MU parameters. Plan quality metrics were again evaluated and compared with AAA plan metrics. For normal lung dose, V20 and V5 to (Total lung- GTV) were evaluated.nnnRESULTSnThe results are summarized in Supplemental Table 1. PTV volume was mean 11.4 (±3.3) cm3 . Comparing RTOG 0813 protocol criteria for conformality, AXB plans yielded on average, similar PITV ratio (individual PITV ratio differences varied from -9 to +15%), reduced target coverage (-1.6%) and increased R50% (+2.6%). Comparing normal lung doses, the lung V20 (+3.1%) and V5 (+1.5%) were slightly higher for AXB plans compared to AAA plans. High-dose spillage ((V105%PD - PTV)/ PTV) was slightly lower for AXB plans but the % low dose spillage (D2cm) was similar between the two calculation algorithms.nnnCONCLUSIONnAAA algorithm overestimates lung target dose. Routinely adapting to AXB for dose calculations in Lung SBRT planning may improve dose calculation accuracy, as AXB based calculations have been shown to be closer to Monte Carlo based dose predictions in accuracy and with relatively faster computational time. For clinical practice, revisiting dose-fractionation in Lung SBRT to correct for dose overestimates attributable to algorithm may very well be warranted.

SU-F-J-142: Proposed Method to Broaden Inclusion Potential of Patients Able to Use the Calypso Tracking System in Prostate Radiotherapy

PURPOSEnTo introduce a non-standard method of patient setup, using BellyBoard immobilization, to better utilize the localization and tracking potential of an RF-beacon system with EBRT for prostate cancer.nnnMETHODSnAn RF-beacon phantom was imaged using a wide bore CT scanner, both in a standard level position and with a known rotation (4° pitch and 7.5° yaw). A commercial treatment planning system (TPS) was used to determine positional coordinates of each beacon, and the centroid of the three beacons for both setups. For each setup at the Linac, kV AP and Rt Lateral images were obtained. A full characterization of the RF-beacon system in clinical mode was completed for various beacons array-to-centroid distances, which includes vertical, lateral, and longitudinal offset data, as well as pitch and yaw offset measurements for the tilted phantom. For the single patient who has been setup using the proposed BellyBoard method, a supine simulation was first obtained. When abdominal protrusion was found to be exceeding the limits of the RF-Beacon system through distance-based analysis in the TPS, the patient is re-simulated prone with the BellyBoard. Array to centroid distance is measured again in the TPS, and if found to be within the localization or tracking region it is applied.nnnRESULTSnCharacterization of limitations for the RF-beacon system in clinical mode showed acceptable consistency of offset determination for phantom setup accuracy. The nonstandard patient setup method reduced the beacons centroid-to-array distance by 8.32cm, from 25.13cm to 16.81cm; completely out of tracking range (greater than 20cm) to within setup tracking range (less than 20cm).nnnCONCLUSIONnUsing the RF-beacon system in combination with this novel patient setup can allow patients who would otherwise not be candidates for beacon enhanced EBRT to now be able to benefit from the reduced PTV margins of this treatment method.

SU-F-T-231: Improving the Efficiency of a Radiotherapy Peer-Review System for Quality Assurance

PURPOSEnTo improve the efficiency of a radiotherapy peer-review system using a commercially available software application for plan quality evaluation and documentation.nnnMETHODSnA commercial application, FullAccess (Radialogica LLC, Version 1.4.4), was implemented in a Citrix platform for peer-review process and patient documentation. This application can display images, isodose lines, and dose-volume histograms and create plan reports for peer-review process. Dose metrics in the report can also be benchmarked for plan quality evaluation. Site-specific templates were generated based on departmental treatment planning policies and procedures for each disease site, which generally follow RTOG protocols as well as published prospective clinical trial data, including both conventional fractionation and hypo-fractionation schema. Once a plan is ready for review, the planner exports the plan to FullAccess, applies the site-specific template, and presents the report for plan review. The plan is still reviewed in the treatment planning system, as that is the legal record. Upon physicians approval of a plan, the plan is packaged for peer review with the plan report and dose metrics are saved to the database.nnnRESULTSnThe reports show dose metrics of PTVs and critical organs for the plans and also indicate whether or not the metrics are within tolerance. Graphical results with green, yellow, and red lights are displayed of whether planning objectives have been met. In addition, benchmarking statistics are collected to see where the current plan falls compared to all historical plans on each metric. All physicians in peer review can easily verify constraints by these reports.nnnCONCLUSIONnWe have demonstrated the improvement in a radiotherapy peer-review system, which allows physicians to easily verify planning constraints for different disease sites and fractionation schema, allows for standardization in the clinic to ensure that departmental policies are maintained, and builds a comprehensive database for potential clinical outcome evaluation.

SU-F-J-169: A Feasibility Study of Using MRI Alone in Abdominal Radiotherapy

PURPOSEnTo demonstrate the feasibility of a MRI alone workflow to support treatment planning and image guidance for abdominal radiotherapy.nnnMETHODSnAbdominal MR images (in-phase/out-phase/fat/water) were acquired for a patient with breath-hold using a Dixon pulse sequence. Air masks were created on in-phase images using intensity thresholding and morphological processing methods in order to separate air from bone. Pseudo-CT and DRRs were generated using a published method. To investigate the effect of heterogeneity corrections on dose calculations using pseudo-CT, three different plans (3-field 3D, 5-field IMRT and 2-arc VMAT) were performed to mimic pancreatic treatments (1.8Gy/fraction over 28 fractions).nnnRESULTSnThe DRRs created from pseudo-CT were of comparable quality as those created from CT. Comparing dose calculations with and without heterogeneity corrections between the 3 different plans, the biggest dosimetric differences were seen in the VMAT plan where modulation must occur across air-tissue interfaces such as those of the stomach and bowel. The DVHs for the VMAT plan showed ∼84cc difference at V50Gy in the small bowel. In terms of pseudo-CT quality, some small volumes of air in the bowel and stomach were misclassified as bone. The VMAT plan was re-optimized on pseudo-CT with 0 HU in the misclassified areas. The V50Gy in the small bowel differed by ∼90cc between the new VMAT plan with and without heterogeneity corrections.nnnCONCLUSIONnWe found that the use of MRI alone is feasible for abdominal treatment planning and image guidance. A difference between calculations with and without heterogeneity corrections was found that is most pronounced for VMAT where the traversal of air-tissue interfaces is unavoidable. Future work will be performed to minimize misclassification between bone and air.

SU‐F‐T‐589: HybridArc Planning Criteria for Brain SRS

PURPOSEnTo compare VMAT SRS plans, dynamic conformal arc (DCA) plans, and Brainlab iPlans capability of planning and delivering brain SRS plans by employing HybridArc. HybridArc utilizes both DCA and IMRT. Using HybridArc, the amount of DCA versus IMRT needs to be optimized.nnnMETHODSnFour SRS patients with the aim of reducing brainstem dose were selected for this study. All patients were contoured in iPlan and transferred to Eclipse for VMAT planning. In iPlan, DCA plans were created for each case. Moreover, nine HybridArc plans with DCA-IMRT ratios between 9:1 through 1:9 were created with a single ring structure generated by subtracting 3 mm expansion of target from a 10 mm expansion of the target. Two static IMRT beams were used in each of the five DCA arcs for HybridArc. The dose was prescribed to DCA only and HybridArc plans and normalized so that the target volume (TV) receives 100% dose to 99.5% of the TV to achieve 120% ∼ 130% max dose within targets. Following metrics were compared: PITV, V12Gy, CGIc, CGIg, CGI, brainstem max dose, and total monitor units (MUs).nnnRESULTSnA brainstem max dose comparable with VMAT from 30% IMRT and less with 50% or more IMRT could be achieved. PITV decreased with increasing IMRT portion and begins to saturate past an IMRT portion of 30%. The CGIg index, which represents how fast the dose falls off, was better with HybridArc in all HybridArc plans. Total MUs increased with increasing IMRT but less than VMAT in all cases.nnnCONCLUSIONnOverall, a lower brainstem max dose and a lower V12Gy with fewer MUs can be achieved with HybridArc. Considering all factors, it would be best to use a DCA-IMRT ratio of either 7:3 or 6:4.

SU-E-T-791: Validation of a Determinant Based Photon Transport Solver in Dose Perturbed By Diverse Media

Purpose: To validate a determinant based photon transport solver in dose imparted within different transition zone between different medium. Methods: Thickness (.2cm,.5cm, 1cm, 3cm) from various materials (Air - density=0.0012g/cm3, Cork-0.19g/cm3, Lung-0.26g/cm3, Bone-1.85g/cm3, Aluminum (Al)-2.7g/cm3, Titanium (Ti)-4.42g/cm3, Iron (Fe)-8g/cm3) were sandwiched by 10cm solid water. 6MV were used to study the calculation difference between a superposition photon beam model (AAA) and the determinant based Boltzmann photon transport solver (XB) at the upstream (I) and downstream boarder (II) of the medium, within the medium (III), and at far distance downstream away from medium (IV). Calculation was validated with available thickness of Air, Cork, Lung, Al, Ti and Fe. Results are presented as the ratio of the dose at the point with medium perturbation to the same point dose without perturbation. Results: Zone I showed different backscatter enhancement from high-density materials within the 5mm of the upstream border. AAA showed no backscatter at all, XB showed good agreement beyond 1mm upstream (1.18 vs 1.14, 1.09 vs 1.10, and 1.04 vs 1.05 for Fe, Ti, and Fe, respectively). Zone II showed a re-buildup after exiting high-density medium and Air but no build up for density close to water in both of the measurement and XB. AAA yielded the opposite results in Zone II. XB and AAA showed in Zone III very different absorption in high density medium and the Air. XB and measurement had high concordance regarding photon attenuation in Zone IV. AAA showed less agreement especially when the medium was Air or Fe. Conclusion: XB compared well with measurement in regions 1mm away from the interface. Planning using XB should be beneficial for External Beam Planning in situations with large air cavity, very low lung density, compact bone, and any kind of metal implant.

SU-E-T-104: An Examination of Dose in the Buildup and Build-Down Regions

Purpose: To examine dose in the buildup and build-down regions and compare measurements made with various models and dosimeters Methods: Dose was examined in a 30×30cm 2 phantom of water-equivalent plastic with 10cm of backscatter for various field sizes. Examination was performed with radiochromic film and optically-stimulated-luminescent-dosimeter (OSLD) chips, and compared against a plane-parallel chamber with a correction factor applied to approximate the response of an extrapolation chamber. For the build-down region, a correction factor to account for table absorption and chamber orientation in the posterior-anterior direction was applied. The measurement depths used for the film were halfway through their sensitive volumes, and a polynomial best fit curve was used to determine the dose to their surfaces. This chamber was also compared with the dose expected in a clinical kernel-based computer model, and a clinical Boltzmann-transport-equation-based (BTE) computer model. The two models were also compared against each other for cases with air gaps in the buildup region. Results: Within 3mm, all dosimeters and models agreed with the chamber within 10% for all field sizes. At the entrance surface, film differed in comparison with the chamber from +90% to +15%, the BTE-model by +140 to +3%, and the kernel-based model by +20% to −25%, decreasing with increasing field size. At the exit surface, film differed in comparison with the chamber from −10% to −15%, the BTE-model by −53% to −50%, the kernel-based model by −55% to −57%, mostly independent of field size. Conclusion: The largest differences compared with the chamber were found at the surface for all field sizes. Differences decreased with increasing field size and increasing depth in phantom. Air gaps in the buildup region cause dose buildup to occur again post-gap, but the effect decreases with increasing phantom thickness prior to the gap.

TU‐EF‐210‐05: A Fast and Efficient Method for Determining Coagulation Temperatures of Tissue‐Mimicking Thermal Therapy Gel Phantoms: Validated by Magnetic Resonance Thermometry

Purpose: To develop a simple and efficient method for determining coagulation temperatures of transparent thermal therapy gel phantoms. Tissue-mimicking thermal therapy phantoms (TMTTPs) that coagulate at specific temperatures are valuable tools for developing and evaluating treatment strategies related to therapy using focused ultrasound, laser, microwave or radiofrequency ablation. The specific formula for a TMTTP will depend on the application and as such finding the coagulation temperature for a specific TMTTP is crucial. Methods: We used a previously published TMTTP formula with 2% (w/v) of bovine serum albumin as the temperature sensitive protein. Using the programmable heating settings of a polymerase chain reaction (PCR) machine we heated 50 µl gel samples to various temperatures for 3 min and imaged them to determine the coagulation temperature by quantifying the resulting opacity. These measured coagulation temperatures were then validated using high-intensity focused ultrasound (HIFU) heating and magnetic resonance thermometry and T2 mapping using a clinical MR-HIFU system. Results: The PCR heating method produced consistent and reproducible coagulation of the gel samples, and the coagulation temperature was determined by a 7.5% increase in opacity compared to non-coagulated gel samples. The resulting coagulation temperatures for TMTTPs of increasing pH levels were found to be 43.6 ± 0.4 °C, 53.1 ± 0.8 °C and 60.1 ± 1.0 °C for a pH of 4.25, 4.50 and 4.75, respectively. The corresponding coagulation temperatures determined by MR thermometry were within the range of 50 to 55 °C for pH 4.50 and within 58 to 66 °C for pH 4.75. Conclusion: The PCR heating method provides a fast and reproducible measurement of the coagulation temperature of transparent TMTTPs. The temperatures determined using this method were well within the range of coagulation temperatures determined using the MR-thermometry validation. Dr. Ari Partanen is a paid employee of Philips Healthcare

SU-E-J-85: The Effect of Different Imaging Modalities On the Delineation of the True Spinal Cord for Spinal Stereotactic Body Radiation Therapy

Purpose: SBRT allows the delivery of high dose radiation treatments to localized tumors while minimizing dose to surrounding tissues. Due to the large doses delivered, accurate contouring of organs at risk is essential. In this study, differences between the true spinal cord as seen using MRI and CT myelogram (CTM) have been assessed in patients with spinal metastases treated using SBRT. Methods: Ten patients were identified that have both a CTM and a MRI. Using rigid registration tools, the MRI was fused to the CTM. The thecal sac and true cord were contoured using each imaging modality. Images were exported and analyzed for similarity by computing the Dice similarity coefficient and the modified Hausdorff distance (greatest distance from a point in one set to the closest point in the other set). Results: The Dice coefficient was calculated for the thecal sac (0.81 ±0.06) and true cord (0.63 ±0.13). These two measures are correlated; however, some points show a low true cord overlap despite a high overlap for the thecal sac. The Hausdorff distance for structure comparisons was also calculated. For thecal sac structures, the average value, 1.6mm (±1.1), indicates good overlap. For true cord comparison, the average value, 0.3mm (±0.16),morexa0» indicates very good overlap. The minimum Hausdorff distance between the true cord and thecal sac was on average 1.6mm (±0.9) Conclusion: The true cord position as seen in MRI and CTM is fairly constant, although care should be taken as large differences can be seen in individual patients. Avoidning the true cord in spine SBRT is critical, so the ability to visualize the true cord before performing SBRT to the vertebrae is essential. Here, CT myelogram appears an excellent, robust option, that can be obtained the day of treatment planning and is unaffected by uncertainties in image fusion.«xa0less

SU-E-T-502: Biometrically Accepted Patient Records

PURPOSEnTo implement a clinically useful palm vein pattern recognition biometric system to treat the correct treatment plan to the correct patient each and every time and to check-in the patient into the department to access the correct medical record.nnnMETHODSnA commercially available hand vein scanning system was paired to Aria and utilized an ADT interface from the hospital electronic health system. Integration at two points in Aria, version 11 MR2, first at the appointment tracker screen for the front desk medical record access and second at the queue screen on the 4D treatment console took place for patient daily time-out. A test patient was utilized to check accuracy of identification as well as to check that no unintended interactions take place between the 4D treatment console and the hand vein scanning system. This system has been in clinical use since December 2013.nnnRESULTSnSince implementation, 445 patients have been enrolled into our biometric system. 95% of patients learn the correct methodology of hand placement on the scanner in the first try. We have had two instances of patient not found because of a bad initial scan. We simply erased the scanned metric and the patient enrolled again in those cases. The accuracy of the match is 100% for each patient, we have not had one patient misidentified. We can state this because we still use patient photo and date of birth as identifiers. A QA test patient is run monthly to check the integrity of the system.nnnCONCLUSIONnBy utilizing palm vein scans along with the date of birth and patient photo, another means of patient identification now exits. This work indicates the successful implementation of technology in the area of patient safety by closing the gap of treating the wrong plan to a patient in radiation oncology. FOJP Service Corporation covered some of the costs of the hardware and software of the palm vein pattern recognition biometric system.