Y Niu

Is RapidArc more susceptible to delivery uncertainties than dynamic IMRT

PURPOSE Rotational IMRT has been adopted by many clinics for its promise to deliver treatments in a shorter amount of time than other conventional IMRT techniques. In this paper, the authors investigate whether RapidArc is more susceptible to delivery uncertainties than dynamic IMRT using fixed fields. METHODS Dosimetric effects of delivery uncertainties in dose rate, gantry angle, and MLC leaf positions were evaluated by incorporating these uncertainties into RapidArc and sliding window IMRT (SW IMRT) treatment plans for five head-and-neck and five prostate cases. Dose distributions and dose-volume histograms of original and modified plans were recalculated and compared using Gamma analysis and dose indices of planned treatment volumes (PTV) and organs at risk (OAR). Results of Gamma analyses using passing criteria ranging from 1%-1 mm up to 5%-3 mm were reported. RESULTS Systematic shifts in MLC leaf bank positions of SW-IMRT cases resulted in 2-4 times higher average percent differences than RapidArc cases. Uniformly distributed random variations of 2 mm for active MLC leaves had a negligible effect on all dose distributions. Sliding window cases were much more sensitive to systematic shifts in gantry angle. Dose rate variations during RapidArc must be much larger than typical machine tolerances to affect dose distributions significantly; dynamic IMRT is inherently not susceptible to such variations. CONCLUSIONS RapidArc deliveries were found to be more tolerant to variations in gantry position and MLC leaf position than SW IMRT. This may be attributed to the fact that the average segmental field size or MLC leaf opening is much larger for RapidArc. Clinically acceptable treatments may be delivered successfully using RapidArc despite large fluctuations in dose rate and gantry position.

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.

Planning 4D intensity-modulated arc therapy for tumor tracking with a multileaf collimator

This study introduces a practical four-dimensional (4D) planning scheme of IMAT using 4D computed tomography (4D CT) for planning tumor tracking with dynamic multileaf beam collimation. We assume that patients can breathe regularly, i.e. the same way as during 4D CT with an unchanged period and amplitude, and that the start of 4D-IMAT delivery can be synchronized with a designated respiratory phase. Each control point of the IMAT-delivery process can be associated with an image set of 4D CT at a specified respiratory phase. Target is contoured at each respiratory phase without a motion-induced margin. A 3D-IMAT plan is first optimized on a reference-phase image set of 4D CT. Then, based on the projections of the planning target volume in the beams eye view at different respiratory phases, a 4D-IMAT plan is generated by transforming the segments of the optimized 3D plan by using a direct aperture deformation method. Compensation for both translational and deformable tumor motion is accomplished, and the smooth delivery of the transformed plan is ensured by forcing connectivity between adjacent angles (control points). It is envisioned that the resultant plans can be delivered accurately using the dose rate regulated tracking method which handles breathing irregularities (Yi et al 2008 Med. Phys. 35 3955-62).This planning process is straightforward and only adds a small step to current clinical 3D planning practice. Our 4D planning scheme was tested on three cases to evaluate dosimetric benefits. The created 4D-IMAT plans showed similar dose distributions as compared with the 3D-IMAT plans on a single static phase, indicating that our method is capable of eliminating the dosimetric effects of breathing induced target motion. Compared to the 3D-IMAT plans with large treatment margins encompassing respiratory motion, our 4D-IMAT plans reduced radiation doses to surrounding normal organs and tissues.

SU-C-BRB-06: Dosimetric Impact of Breast Contour Reconstruction Errors in GammaPod Stereotactic Radiotherapy

PURPOSE The first GammaPod™ unit, a dedicated prone stereotactic treatment device for early stage breast cancer, has been installed and commissioned at University of Maryland School of Medicine. The objective of this study was to investigate potential dosimetric impact of inaccurate breast contour. METHODS In GammaPod treatments, patients beast is immobilized by a breast cup device (BCID) throughout the entire same-day imaging and treatment procedure. 28 different BICD sizes are available to accommodate patients with varying breast sizes. A mild suction helps breast tissue to conform to the shape of the cup with selected size. In treatment planning, dose calculation utilizes previously calculated dose distributions for available cup geometry rather than the breast shape from CT image. Patient CT images with breast cups indicate minor geometric discrepancy between the matched shape of the cup and the breast contour, i.e., the contour size is larger or smaller. In order to investigate the dosimetric impact of these discrepancies, we simulated such discrepancies and reassessed the dose to target as well as skin. RESULTS In vicinity of skin, hot/cold spots were found when matched cup size was smaller/larger than patients breast after comparing the corrected dose profiles from Monte Carlo simulation with the planned dose from TPS. The overdosing/underdosing of target could yield point dose differences as large as 5% due to these setup errors (D95 changes within 2.5%). Maximal skin dose was overestimated/underestimated up to 25%/45% when matched cup size was larger/smaller than real breast contour. CONCLUSION The dosimetric evaluation suggests substantial underdosing/overdosing with inaccurate cup geometry during planning, which is acceptable for current clinical trial. Further studies are needed to evaluate such impact to treating small volume close to skin.

WE-H-BRC-03: Failure Mode and Effects Analysis in the First Clinical Implementation of a Novel Stereotactic Breast Radiotherapy Device: GammaPod™

PURPOSE GammaPod™, the first stereotactic radiotherapy device for early stage breast cancer treatment, has been recently installed and commissioned at our institution. A multidisciplinary working group applied the failure mode and effects analysis (FMEA) approach to perform a risk analysis. METHODS FMEA was applied to the GammaPod™ treatment process by: 1) generating process maps for each stage of treatment; 2) identifying potential failure modes and outlining their causes and effects; 3) scoring the potential failure modes using the risk priority number (RPN) system based on the product of severity, frequency of occurrence, and detectability (ranging 1-10). An RPN of higher than 150 was set as the threshold for minimal concern of risk. For these high-risk failure modes, potential quality assurance procedures and risk control techniques have been proposed. A new set of severity, occurrence, and detectability values were re-assessed in presence of the suggested mitigation strategies. RESULTS In the single-day image-and-treat workflow, 19, 22, and 27 sub-processes were identified for the stages of simulation, treatment planning, and delivery processes, respectively. During the simulation stage, 38 potential failure modes were found and scored, in terms of RPN, in the range of 9ߝ392. 34 potential failure modes were analyzed in treatment planning with a score range of 16ߝ200. For the treatment delivery stage, 47 potential failure modes were found with an RPN score range of 16ߝ392. The most critical failure modes consisted of breast-cup pressure loss and incorrect target localization due to patient upper-body alignment inaccuracies. The final RPN score of these failure modes based on recommended actions were assessed to be below 150. CONCLUSION FMEA risk analysis technique was applied to the treatment process of GammaPod™, a new stereotactic radiotherapy technology. Application of systematic risk analysis methods is projected to lead to improved quality of GammaPod™ treatments. Ying Niu and Cedric Yu are affiliated with Xcision Medical Systems.

SU‐G‐BRB‐15: Verifications of Absolute and Relative Dosimetry of a Novel Stereotactic Breast Device: GammaPodTM

PURPOSE A dedicated stereotactic breast radiotherapy device, GammaPod, was developed to treat early stage breast cancer. The first clinical unit was installed and commissioned at University of Maryland. We report our methodology of absolute dosimetry in multiple calibration conditions and dosimetric verifications of treatment plans produced by the system. METHODS GammaPod unit is comprised of a rotating hemi-spherical source carrier containing 36 Co-60 sources and a concentric tungsten collimator providing beams of 15 and 25 mm. Absolute dose calibration formalism was developed with modifications to AAPM protocols for unique geometry and different calibration medium (acrylic, polyethylene or liquid water). Breast cup-size specific and collimator output factors were measured and verified with respect to Monte-Carlo simulations for single isocenter plans. Multiple isocenter plans were generated for various target size, location and cup-sizes in phantoms and 20 breast cancer patients images. Stereotactic mini-farmer chamber, OSL and TLD detectors as well as radio-chromic films were used for dosimetric measurements. RESULTS At the time of calibration (1/14/2016), absolute dose rate of the GammaPod was established to be 2.10 Gy/min in acrylic for 25 mm for sources installed in March 2011. Output factor for 15 mm collimator was measured to be 0.950. Absolute dose calibration was independently verified by IROC-Houston with a TLD/Institution ratio of 0.99. Cup size specific output measurements in liquid water for single isocenter were found to be within 3.0% of MC simulations. Point-dose measurements of multiple isocenter treatment plans were found to be within -1.0 ± 1.2 % of treatment planning system while 2-dimensional gamma analysis yielded a pass rate of 97.9 ± 2.2 % using gamma criteria of 3% and 2mm. CONCLUSION The first GammaPod treatment unit for breast stereotactic radiotherapy was successfully installed, calibrated and commissioned for patient treatments. An absolute dosimetry and dosimetric verification protocols were successfully created.

SU‐E‐T‐74: A Simple Model of Dose Falloff for Highly Convergent SBRT Beams

Purpose: The purpose of this study was to create a simple model of dose falloff outside the target for a SBRT system employing a highly convergent beam geometry. With an estimate of the rate of reduction in dose away from a target of a given size, dose to tissues at a given distance from the target can be estimated. Our hypothesis is that dose at a given distance away from the edge of a target can be approximated using an inverse square model. Methods: With the GammaPod™ system used for this study, thirty-six rotating Co-60 beams with circular cross section converge at an isocenter and then diverge distal to the isocenter. Dose falloff beyond the target is mainly due to reduction in beam overlap, which in turn depends on projected area of all beams and projected beam area swept out during rotation. Beams also decrease in intensity beyond the isocenter. The GammaPod™ TPS calculates dose via superposition of Monte Carlo-generated kernels, each corresponding to the convergence of beams at an isocenter within a stereotactic breast cup. Results: The factors above yield a simple inverse square-based model that has been compared with TPS predictions and measurements for a variety of targets. Good agreement is seen considering the simple nature of the model. Fitting of the treatment planning and measured dose falloff data with a power law expression yields a negative exponent close to 2, confirming the inverse square nature of dose falloff. Conclusion: It is possible to apply a simple inverse square dose falloff model for SBRT or SRS systems such as the GammaPod which employ a highly-convergent beam geometry. This can be useful in estimating the “worst case scenario” for dose to critical organs at a known distance from the edge of the target volume. Authors are employees of Xcision Medical Systems

SU‐E‐T‐442: Geometric Calibration and Verification of a GammaPod Breast SBRT System

Purpose: The first GammaPod™ unit for prone stereotactic treatment of early stage breast cancer has recently been installed and calibrated. Thirty-six rotating circular Co-60 beams focus dose at an isocenter that traverses throughout a breast target via continuous motion of the treatment table. The breast is immobilized and localized using a vacuum-assisted stereotactic cup system that is fixed to the table during treatment. Here we report on system calibration and on verification of geometric and dosimetric accuracy. Methods: Spatial calibration involves setting the origin of each table translational axis within the treatment control system such that the relationship between beam isocenter and table geometry is consistent with that assumed by the treatment planning system. A polyethylene QA breast phantom inserted into an aperture in the patient couch is used for calibration and verification. The comparison is performed via fiducial-based registration of measured single-isocenter dose profiles (radiochromic film) with kernel dose profiles. With the table calibrations applied, measured relative dose distributions were compared with TPS calculations for single-isocenter and dynamic (many-isocenter) treatment plans. Further, table motion accuracy and linearity was tested via comparison of planned control points with independent encoder readouts. Results: After table calibration, comparison of measured and calculated single-isocenter dose profiles show agreement to within 0.5 mm for each axis. Gamma analysis of measured vs calculated profiles with 3%/2mm criteria yields a passing rate of >99% and >98% for single-isocenter and dynamic plans respectively. This also validates the relative dose distributions produced by the TPS. Measured table motion accuracy was within 0.05 mm for all translational axes. Conclusion: GammaPod table coordinate calibration is a straightforward process that yields very good agreement between planned and measured relative dose distributions. The dynamic table motions used for dose painting are consistent with planned control points. CY, YN, PM, PH are employees of Xcision Medical Systems

TH‐CD‐304‐04: Absolute Dose Calibration of the First Stereotactic Breast Radiotherapy Device: GammaPod

Purpose: A dedicated stereotactic breast radiotherapy device, GammaPod, was developed to treat early stage breast cancer. The first clinical GammaPod unit is currently being commissioned to treat its first patient in summer 2015. We provide an absorbed dose calibration formalism following AAPM protocols with modifications for the calibration medium and unique geometry of GammaPod. We also provide cross-comparison of the dosimetric calibration using different types of dosimeters. Methods: GammaPod is comprised of a rotating hemi-spherical source carrier containing 36 Co-60 sources and a concentric rotating tungsten collimator providing beam diameters of 1.5 and 2.5 cm. A solid breast phantom made of ultra-high-molecular-weight polyethylene (density 0.935 g/cm3) with an effective depth of 7cm is used for absolute dose calibration. Due to the non-water equivalent medium, we utilized the former AAPM TG-21 protocol, but cross-compared the calibration with TG-51 calibrated OSLD and radiochromic film dosimeters. Polyethylene medium and chamber-specific calibration parameters are derived and provided for Exradin A-18 and Capintec PR-05P ionization chambers. Results: The first clinical unit was installed with a total Co-60 activity of 2672 Ci in November 2014. Maximum dose rate was determined to be 2.76 Gy/min and 2.63 Gy/min for 2.5 and 1.5 cm collimators respectively at 7 cm depth. The determination of Ngas and appropriate polyethylene dosimetric quantities (stopping power and absorption coefficient ratios) is performed using NIST data tables and supplied as reference for calibration of subsequent units. Calibration crosscheck was accomplished with OSLD and radiochromic films, both with secondary TG-51 based calibrations, yielding relative dose differences less than 1%. Conclusion: The first GammaPod treatment unit for breast stereotactic radiotherapy was successfully installed and calibrated for commencement of patient treatments in 2015. An absolute dose calibration formalism was established for the unique geometry of GammaPod and the method is validated with different detectors. P Hoban, Y Niu and C Yu are employees of Xcision Medical Systems.

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.