X Yang

Four-dimensional dose distributions of step-and-shoot IMRT delivered with real-time tumor tracking for patients with irregular breathing: Constant dose rate vs dose rate regulation

PURPOSE Dose-rate-regulated tracking (DRRT) is a tumor tracking strategy that programs the MLC to track the tumor under regular breathing and adapts to breathing irregularities during delivery using dose rate regulation. Constant-dose-rate tracking (CDRT) is a strategy that dynamically repositions the beam to account for intrafractional 3D target motion according to real-time information of target location obtained from an independent position monitoring system. The purpose of this study is to illustrate the differences in the effectiveness and delivery accuracy between these two tracking methods in the presence of breathing irregularities. METHODS Step-and-shoot IMRT plans optimized at a reference phase were extended to remaining phases to generate 10-phased 4D-IMRT plans using segment aperture morphing (SAM) algorithm, where both tumor displacement and deformation were considered. A SAM-based 4D plan has been demonstrated to provide better plan quality than plans not considering target deformation. However, delivering such a plan requires preprogramming of the MLC aperture sequence. Deliveries of the 4D plans using DRRT and CDRT tracking approaches were simulated assuming the breathing period is either shorter or longer than the planning day, for 4 IMRT cases: two lung and two pancreatic cases with maximum GTV centroid motion greater than 1 cm were selected. In DRRT, dose rate was regulated to speed up or slow down delivery as needed such that each planned segment is delivered at the planned breathing phase. In CDRT, MLC is separately controlled to follow the tumor motion, but dose rate was kept constant. In addition to breathing period change, effect of breathing amplitude variation on target and critical tissue dose distribution is also evaluated. RESULTS Delivery of preprogrammed 4D plans by the CDRT method resulted in an average of 5% increase in target dose and noticeable increase in organs at risk (OAR) dose when patient breathing is either 10% faster or slower than the planning day. In contrast, DRRT method showed less than 1% reduction in target dose and no noticeable change in OAR dose under the same breathing period irregularities. When ±20% variation of target motion amplitude was present as breathing irregularity, the two delivery methods show compatible plan quality if the dose distribution of CDRT delivery is renormalized. CONCLUSIONS Delivery of 4D-IMRT treatment plans, stemmed from 3D step-and-shoot IMRT and preprogrammed using SAM algorithm, is simulated for two dynamic MLC-based real-time tumor tracking strategies: with and without dose-rate regulation. Comparison of cumulative dose distribution indicates that the preprogrammed 4D plan is more accurately and efficiently conformed using the DRRT strategy, as it compensates the interplay between patient breathing irregularity and tracking delivery without compromising the segment-weight modulation.

Optimizing the MLC model parameters for IMRT in the RayStation treatment planning system

Unlike other commercial treatment planning systems (TPS) which model the rounded leaf end differently (such as the MLC dosimetric leaf gap (DLG) or rounded leaf‐tip radius), the RayStation TPS (RaySearch Laboratories, Stockholm, Sweden) models transmission through the rounded leaf end of the MLC with a step function, in which the radiation transmission through the leaf end is the square root of the average MLC transmission factor. We report on the optimization of MLC model parameters for the RayStation planning system. This (TPS) models the rounded leaf end of the MLC with the following parameters: leaf‐tip offset, leaf‐tip width, average transmission factor, and tongue and groove. We optimized the MLC model parameters for IMRT in the RayStation v. 4.0 planning system and for a Varian C‐series linac with a 120‐leaf Millennium MLC, and validated the model using measured data. The leaf‐tip offset is the geometric offset due to the rounded leaf‐end design and resulting divergence of the light/radiation field. The offset value is a function of the leaf‐tip position, and tabulated data are available from the vendor. The leaf‐tip width was iteratively evaluated by comparing computed and measured transverse dose profiles of MLC defined fields at dmax in water. In‐water profile comparisons were also used to verify the MLC leaf position (leaf‐tip offset). The average transmission factor and leaf tongue‐and‐groove width were derived iteratively by maximizing the agreement between measurements and RayStation TPS calculations for five clinical IMRT QA plans. Plan verifications were performed by comparing MapCHECK2 measurements and Monte Carlo calculations. The MLC model was validated using five test IMRT cases from the AAPM Task Group 119 report. Absolute gamma analyses (3 mm/3% and 2 mm/2%) were applied. In addition, computed output factors for MLC‐defined small fields (2×2,3×3,4×4,6×6 cm2) of both 6 MV and 18 MV photons were compared to those independently measured by the Imaging and Radiation Oncology Core (IROC), Houston, TX. 6 MV and 18 MV models were both determined to have the same MLC parameters: leaf‐tip offset=0.3 cm,2.5% transmission, and leaf tongue‐and‐groove width=0.05 cm. IMRT QA analysis for five test cases in TG‐119 resulted in a 100% passing rate with 3 mm/3% gamma analysis for 6 MV, and >97.5% for 18 MV. The passing rate was >94.6% for 6 MV and >90.9% for 18 MV when the 2 mm/2% gamma analysis criteria was applied. These results compared favorably with those published in AAPM Task Group 119. The reported MLC model parameters serve as a reference for other users. PACS number(s): 87.55.D, 87.56.nk

MO-F-BRC-05: Minimization of the Total Inter-Segment Time for the Real-Time Tumor Tracking with Step & Shoot IMRT

Purpose: We developed an algorithm to minimize total inter‐segment time (TIST) for the MLC‐based real‐time tumor tracking with step‐and‐shoot IMRT. This algorithm optimizes a starting phase of tumor motion for each segment to minimize TIST. Methods: The optimizing algorithm consists of four steps: (1) implementation of feathering motion for the closed leaves that will be opened at the next segment, (2) calculation of inter‐segment time for all segments, (3) reordering segments to minimize TIST, and (4) optimization of the starting phase of tumor motion for each segment to minimize TIST. Thirty step‐and‐shoot IMRT fields from five patients with lung and abdominal cancer were used to test the algorithm. Tumor motion was varied with a period (2.0 to 4.0 s) and a peak‐to‐peak distance (0.5 to 4.0 cm). TIST and duty cycle for each field were compared to those from the strategy of starting each segment at end‐of‐exhale. Results: The TIST was reduced by 54.0% on average (from 30.2 ± 16.9 to 13.9 ± 10.6 s) and, the effective duty cycle was increased from 32 ± 10% to 52 ± 15% for a tumor motion with 4 s and 1.0 cm peak‐to‐peak. More reduction in the TIST was observed from 45.1 to 72.1% with an increase of the period from 2 to 8 s; effect of reduction was degraded by 54.5 to 46.2% when the peak‐to‐peak increased from 0.5 to 4.0 cm. The TIST increased when a field size formed by x‐jaws increased (correlation coefficient: 0.7). Conclusions: : Total treatment time was reduced noticeably with the algorithm presented in this study so that real‐time tumor tracking can be delivered with step‐and‐shoot IMRT with an increased duty cycle. This research was supported in part by a NIH grant 1R01CA133539‐01A2 and in part by the Intramural Research Program of the NIH, NCI.

Clinical implementation of an electron monitor unit dosimetry system based on task group 71 report and a commercial calculation program

Many clinics still use monitor unit (MU) calculations for electron treatment planning and/or quality assurance (QA). This work (1) investigates the clinical implementation of a dosimetry system including a modified American Association of Physicists in Medicine-task group-71 (TG-71)-based electron MU calculation protocol (modified TG-71 electron [mTG-71E] and an independent commercial calculation program and (2) provides the practice recommendations for clinical usage. Following the recently published TG-71 guidance, an organized mTG-71E databook was developed to facilitate data access and subsequent MU computation according to our clinical need. A recently released commercial secondary calculation program - Mobius3D (version 1.5.1) Electron Quick Calc (EQC) (Mobius Medical System, LP, Houston, TX, USA), with inherent pencil beam algorithm and independent beam data, was used to corroborate the calculation results. For various setups, the calculation consistency and accuracy of mTG-71E and EQC were validated by their cross-comparison and the ion chamber measurements in a solid water phantom. Our results show good agreement between mTG-71E and EQC calculations, with average 2% difference. Both mTG-71E and EQC calculations match with measurements within 3%. In general, these differences increase with decreased cutout size, increased extended source to surface distance, and lower energy. It is feasible to use TG71 and Mobius3D clinically as primary and secondary electron MU calculations or vice versa. We recommend a practice that only requires patient-specific measurements in rare cases when mTG-71E and EQC calculations differ by 5% or more.

SU‐E‐T‐528: Is It Essential to QA HDR Applicators Annually in Clinic?

Purpose: There is no rigid prescription recommended for the periodic QA of HDR applicators in terms of what must be done and in what frequency. This study investigates the necessity of an annual QA program for HDR applicators, which was performed at an HDR clinic. Methods: In this clinic, all HDR applicators and dummy sources used for HDR treatment are tested on an annual basis. 10 different types of gyn applicators were involved including CT-compatible and non-CT compatible tandem & ovoid set, interstitial tandem &ring set, cylinder set Miami set, vaginal applicator set, ring set, Fletcher Williamson set. The annually QA tests for these applicators included (1) visual inspection, (2) mechanical integrity, (3) source positioning accuracy tests using kV imaging, or a combination of (1)– (3). The source positioning accuracy tolerance was 2mm. Over 100 tests were performed on 48 and 61 pieces of applicator components in 2013 and 2014, respectively. Results: Due to the annual QA, the degraded of applicators or dummy source were ascertained. The degradation either affected the feasibility of source delivery or introduced significant source position errors. The failure rate of the HDR applicator annual QA was 1.6% in 2013 and 2.4% in 2014. Each year, different problems on difference components were detected. The unacceptable applicator components were discarded and replaced by the new orders before affecting any patient treatment. This annual QA takes physicist half to one day to finish depending on his or her experience and expertise. Conclusion: The annual QA tests are determined as essential in clinic and should include visual inspection, mechanical integrity and source positioning accuracy tests. It is strongly suggested to perform annual HDR applicator QA in clinic to increase the confidence to deliver a safe, accurate and appropriate HDR treatment.

SU-E-T-182: Clinical Implementation of TG71-Based Electron MU Calculation and Comparison with a Commercial Secondary Calculation

Purpose: The TG-71 report was published in 2014 to present standardized methodologies for MU calculations and determination of dosimetric quantities. This work explores the clinical implementation of a TG71-based electron MU calculation algorithm and compares it with a recently released commercial secondary calculation program–Mobius3D (Mobius Medical System, LP). Methods: TG-71 electron dosimetry data were acquired, and MU calculations were performed based on the recently published TG-71 report. The formalism in the report for extended SSD using air-gap corrections was used. The dosimetric quantities, such PDD, output factor, and f-air factors were incorporated into an organized databook that facilitates data access and subsequent computation. The Mobius3D program utilizes a pencil beam redefinition algorithm. To verify the accuracy of calculations, five customized rectangular cutouts of different sizes–6×12, 4×12, 6×8, 4×8, 3×6 cm2–were made. Calculations were compared to each other and to point dose measurements for electron beams of energy 6, 9, 12, 16, 20 MeV. Each calculation / measurement point was at the depth of maximum dose for each cutout in a 10×10 cm2 or 15×15cm2 applicator with SSDs 100cm and 110cm. Validation measurements were made with a CC04 ion chamber in a solid water phantom for electron beams of energy 9 and 16 MeV. Results: Differences between the TG-71 and the commercial system relative to measurements were within 3% for most combinations of electron energy, cutout size, and SSD. A 5.6% difference between the two calculation methods was found only for the 6MeV electron beam with 3×6 cm2cutout in the 10×102cm applicator at 110cm SSD. Both the TG-71 and the commercial calculations show good consistency with chamber measurements: for 5 cutouts, <1% difference for 100cm SSD, and 0.5–2.7% for 110cm SSD. Conclusions: Based on comparisons with measurements, a TG71-based computation method and a Mobius3D program produce reasonably accurate MU calculations for electron-beam therapy.

SU-E-T-583: Optimizing the MLC Model Parameters for IMRT in the RayStation Treatment Planning System

PURPOSE To optimize the MLC model parameters for IMRT in the RayStation v.4.0 planning system and for a Varian C-series Linac with a 120-leaf Millennium MLC. METHODS The RayStation treatment planning system models rounded leaf-end MLC with the following parameters: average transmission, leaf-tip width, tongue-and-groove, and position offset. The position offset was provided by Varian. The leaf-tip width was iteratively evaluated by comparing computed and measured transverse dose profiles of MLC-defined fields at dmax in water. The profile comparison was also used to verify the MLC position offset. The transmission factor and leaf tongue width were derived iteratively by optimizing five clinical patient IMRT QA Results: brain, lung, pancreas, head-and-neck (HN), and prostate. The HN and prostate cases involved splitting fields. Verifications were performed with Mapcheck2 measurements and Monte Carlo calculations. Finally, the MLC model was validated using five test IMRT cases from the AAPM TG119 report. Absolute gamma analyses (3mm/3% and 2mm/2%) were applied. In addition, computed output factors for MLC-defined small fields (2×2, 3×3, 4×4, 6×6cm) of both 6MV and 18MV were compared to those measured by the Radiological Physics Center (RPC). RESULTS Both 6MV and 18MV models were determined to have the same MLC parameters: 2.5% transmission, tongue-and-groove 0.05cm, and leaftip 0.3cm. IMRT QA analysis for five cases in TG119 resulted in a 100% passing rate with 3mm/3% gamma analysis for 6MV, and >97.5% for 18MV. With 2mm/2% gamma analysis, the passing rate was >94.6% for 6MV and >90.9% for 18MV. The difference between computed output factors in RayStation and RPC measurements was less than 2% for all MLCdefined fields, which meets the RPCs acceptance criterion. CONCLUSION The rounded leaf-end MLC model in RayStation 4.0 planning system was verified and IMRT commissioning was clinically acceptable. The IMRT commissioning was well validated using guidance from the AAPMTG119 protocol.

SU-E-T-585: Commissioning of Electron Monte Carlo in Eclipse Treatment Planning System for TrueBeam

PURPOSE To commission electron Monte Carlo (eMC) algorithm in Eclipse Treatment Planning System (TPS) for TrueBeam Linacs, including the evaluation of dose calculation accuracy for small fields and oblique beams and comparison with the existing eMC model for Clinacs. METHODS Electron beam percent-depth-dose (PDDs) and profiles with and without applicators, as well as output factors, were measured from two Varian TrueBeam machines. Measured data were compared against the Varian TrueBeam Representative Beam Data (VTBRBD). The selected data set was transferred into Eclipse for beam configuration. Dose calculation accuracy from eMC was evaluated for open fields, small cut-out fields, and oblique beams at different incident angles. The TrueBeam data was compared to the existing Clinac data and eMC model to evaluate the differences among Linac types. RESULTS Our measured data indicated that electron beam PDDs from our TrueBeam machines are well matched to those from our Varian Clinac machines, but in-air profiles, cone factors and open-filed output factors are significantly different. The data from our two TrueBeam machines were well represented by the VTBRBD. Variations of TrueBeam PDDs and profiles were within the 2% /2mm criteria for all energies, and the output factors for fields with and without applicators all agree within 2%. Obliquity factor for two clinically relevant applicator sizes (10×10 and 15×15 cm^2) and three oblique angles (15, 30, and 45 degree) were measured for nominal R100, R90, and R80 of each electron beam energy. Comparisons of calculations using eMC of obliquity factors and cut-out factors versus measurements will be presented. CONCLUSION eMC algorithm in Eclipse TPS can be configured using the VTBRBD. Significant differences between TrueBeam and Clinacs were found in in-air profiles and open field output factors. The accuracy of the eMC algorithm was evaluated for a wide range of cut-out factors and oblique incidence.

SU‐E‐T‐403: Delivery Efficiency of StereoArc Stereotactic Body Radiotherapy (SBRT)

PURPOSE Traditional SBRT employs approximately 10 static beams with up to 20 Gy per fraction, requiring lengthy treatments which can be difficult for patients to tolerate, increasing the risk of movement, and causing discrepancies in the reproducibility of the breathing cycle. Commercial VMAT systems offer shorter treatment times with modulated beams; however, modulation is often not necessary or desired for small fields. Conformai arc therapy offers efficient beam delivery, but with only one aperture shape and constant beam weighting over all gantry angles. This study evaluates the efficiency of a new SBRT delivery Method: a conformai arc with multiple aperture shapes and variable dose rate. METHODS Three clinical SBRT cases were chosen for this study. Each static field was converted into an arc segment to create a StereoArc plan. Gantry angle ranges were determined from the clinical monitor units, with the MU/degree chosen to maximize the dose rate. All segments were merged into a single arc with variable dose rate. Dose distributions from the StereoArc plans were compared to the clinical static field plans using Pinnacle. Delivery times were compared between the static SBRT plans, both with and without Beam Automation, and equivalent StereoArc plans. All plans were delivered on a Varian TrueBeam using a dose rate of 1000 MU/min. RESULTS Dose differences between StereoArc and static plans were minimal. Delivery times for the static plans were 5-8 minutes, while delivery time with StereoArc was less than 3 minutes for all cases, which was equivalent to delivering the static plans with Beam Automation. CONCLUSIONS Delivery efficiency was improved up to 60%: from 8 minutes for static fields, to less than 3 minutes for StereoArc. StereoArc appears to be both an effective and efficient way of delivering SBRT for centers not wishing to modulate SBRT and without access to Beam Automation. This study is partially supported by NIH grant 1R01CA133539-01A2.

SU‐E‐J‐160: 4D Dynamic Arc of Non‐Modulated Variable‐Dose‐Rate Fields for Lung SBRT: A Feasibility Study

PURPOSE Conformal SBRT plans for Lung cancer with static gantry angles are ideal candidates for applying motion tracking because of: (1) better dosimetric conformity with reduced target margin and (2) easier and more faithful target tracking without intensity modulation. This work is to demonstrate that by delivering the target tracking during gantry rotation, we can significantly improve delivery efficiency without negatively affecting plan quality. METHODS A lung SBRT plan with static beams was created using CT images of the reference breathing phase. It is converted to an arc plan with variable dose rate followed by the conversion to a 4D plan with the segment aperture morphing (SAM) method (Gui 2010) with considerations of both target location and shape changes as depicted by the 4D CT. Gantry angle ranges were determined from the clinical monitor units, with the 22.2 MU/degree, which is chosen to maximize the dose rate. All segments of the dynamic 4D plan were merged into a single arc with variable dose rate. Each segment occupying 1/10 of the breathing period delivers 6.6 MUs at a dose rate of 1000 MU/min. Delivery time was measured and compared to the planned. RESULTS The dose distributions of the single phase 3D plan and the arc 4D plan showed little difference. The delivered time for the 4D arc plan agreed with the calculated time, and is almost the same as delivering the 3D plan without target tracking. A 12 Gy treatment takes less than 2.5 min. CONCLUSIONS The feasibility of a novel 4D delivery method where a 3D SBRT plan is converted into 4D arc delivery has been demonstrated. In addition to realizing the conventional target tracking benefits, our method further improves delivery efficiency, which is important for maintaining the geometric relationship between the target motion and the breathing surrogate during treatment. This study is supported by NIH_Grant_1R01CA133539-01 A2.