Intensity Modulated Radiation Therapy Fields Research Articles

Planning target volume-to-skin proximity for head-and-neck intensity modulated radiation therapy treatment planning

PurposeThe goal of this work is to evaluate planning target volume (PTV)-to-skin proximity versus plan quality as well as the effects of calculation voxel size on dose uncertainty in the surface region. Methods and MaterialsA right-sided clinical target volume with the lateral border 5 mm from the surface was delineated on the computed tomographic data of a head-and-neck phantom. A 5-mm PTV expansion was generated except laterally where distances of 0-5 mm were used. A 7-field intensity modulated radiation therapy plan was generated using the Eclipse treatment planning system. Optimization was performed where 95% of the PTV receives the prescription dose using a voxel size of 2 mm3. Dose calculations were repeated for voxel sizes of 1, 3, and 5 mm3. For each plan, 9 point dose values were obtained just inside the phantom surface, corresponding to a 2 cm × 2 cm grid near the central target region. Nine ultrathin thermoluminescent dosimeters were placed on the phantom surface corresponding to the grid. Measured and calculated dose values were compared. Conformality, homogeneity, and target coverage were compared as well. This process was repeated for volumetric modulated arc therapy (VMAT) calculated with a 2-mm3 voxel size. ResultsSurface dose is overestimated by the treatment planning system (TPS) by approximately 21% and 9.5% for 5- and 3-mm3 voxels, respectively, and is accurately predicted for 2-mm3 voxels. A voxel size of 1 mm3 results in underestimation by 11%. Conformality improves with increasing PTV-to-skin distance and a conformality index of unity is obtained for grid sizes between 1 and 3 mm3 and PTV-to-skin distances of 4-4.5 mm. Hot spot also improves and falls below 110% at 4-mm PTV-to-skin distance. Underdosage worsens as the PTV approaches the skin. All of the above appear to hold for volumetric modulated arc therapy. ConclusionsFor decreasing PTV-to-skin distance with this TPS, isodose conformality decreases, “hot spot” increases, and target coverage degrades. Surface dose is overestimated when voxel sizes greater than 2 mm3 are chosen, and underestimated for smaller voxels.

Passive tracking of linac clinical flow using radiofrequency identification technology

PurposeTo analyze the implementation of a passive radiofrequency identification (RFID) clinical system and to evaluate the clinical workflow on 2 linear accelerators using the RFID technology. Methods and MaterialsThe clinical area of a typical radiation therapy center was equipped with RFID readers and antennae, which included linear accelerator (linac) treatment vaults. Both were dual energy linacs (6 and 15 MV). One linac was an iX with RapidArc (Varian Medical Systems, Inc, Palo Alto, CA) and the other was a TrueBeam (Varian Medical Systems, Inc, Palo Alto, CA). Patients were given an RFID transponder card on their first day of treatment. Location timestamps were collected when the patients entered and exited the linac vaults. Each fraction was categorized by treatment machine, treatment site (brain, head and neck, prostate, and other), and treatment type (static field intensity modulated radiation therapy [IMRT], RapidArc, and 3-dimensional [3D]). The Mann-Whitney nonparametric test was used to determine statistical significance between median times in the linac vault. ResultsA total of 4302 fractions from 144 patients were analyzed over a 10-month period. With minimal staff training, an approximately 70% read reliability was achieved. The median treatment time for all treatment fractions on the TrueBeam linac was 11.0 minutes (n = 1425) while the median time was 11.9 minutes (n = 1576) on the iX linac (P < .0001). Median times for the RapidArc cases was 10.9 minutes (n = 610) and 12.0 minutes (n = 1729) for IMRT cases (P < .0001). Median values for 3D delivery versus modulated delivery (RapidArc and IMRT) were 9.8 minutes (n = 315) and 11.7 minutes (n = 2339), P < .0001. ConclusionsAutomatic remote reading of passive transponder cards is not without its challenges. However, with little or no clinical introduction, we experienced a read reliability that warrants further development. Our initial use of the system indicates that continual collection and analysis of workflow data may allow clinics to improve efficiency and safety.

The effect of the target-organ geometric complexity on the choice of delivery between RapidArc and sliding-window IMRT for nasopharyngeal carcinoma

We attempted to assess the effect of target-organ geometric complexity on the plan quality of sliding-window intensity-modulated radiotherapy (IMRT), double-arc (RA2), and triple-arc (RA3) RapidArc volumetric-modulated arc radiotherapy for nasopharyngeal carcinoma (NPC). Plans for 9-field sliding-window IMRT, RA2, and RA3 were optimized for 36 patients with NPC ranging from T1 to T4 tumors. Initially the patients were divided into 2 groups, with group A representing the most simple early stage (T1 and T2) cases, whereas group B represented the more complex advanced cases (T3 and T4). Evaluation was performed based on target conformity, target dose homogeneity, organ-sparing capability, and delivery efficiency. Based on the plan quality results, a subgroup of advanced cases, group B2, representing the most demanding task was distinguished and reported separately from the rest of the group B cases, B1. Detailed analysis was performed on the anatomic features for each group of cases, so that planners can easily identify the differences between B1 and B2. For the group A cases, RA3 plans were superior to the IMRT plans in terms of organ sparing, whereas target conformity and dose homogeneity were similar. For the group B1 cases, the RA3 plans produced almost equivalent plan quality as the IMRT plans. For the group B2 cases, for most of which large target volumes were adjacent to (5mm or less) and wrapping around the brain stem, RA2 and RA3 were inferior to the IMRT regarding both target dose homogeneity and conformity. RA2 plans were slightly inferior to IMRT and RA3 plans for most cases. The plan comparison results depend on the target to brain stem distances and the target sizes. The plan quality results together with the anatomic information may allow the evaluation of the 3 treatment options before actual planning.

Intensity‐modulated radiotherapy (IMRT) in pediatric low‐grade glioma

The objective of this study was to evaluate local control and patterns of failure in pediatric patients with low-grade glioma (LGG) who received treatment with intensity-modulated radiation therapy (IMRT). In total, 39 children received IMRT after incomplete resection or disease progression. Three methods of target delineation were used. The first was to delineate the gross tumor volume (GTV) and add a 1-cm margin to create the clinical target volume (CTV) (Method 1; n = 19). The second was to add a 0.5-cm margin around the GTV to create the CTV (Method 2; n = 6). The prescribed dose to the GTV was the same as dose to the CTV for both Methods 1 and 2 (median, 50.4 grays [Gy]). The final method was dose painting, in which a GTV was delineated with a second target volume (2TV) created by adding 1 cm to the GTV (Method 3; n = 14). Different doses were prescribed to the GTV (median, 50.4 Gy) and the 2TV (median, 41.4 Gy). The 8-year progression-free and overall survival rates were 78.2% and 93.7%, respectively. Seven failures occurred, all of which were local in the high-dose (≥95%) region of the IMRT field. On multivariate analysis, age ≤5 years at time of IMRT had a detrimental impact on progression-free survival. IMRT provided local control rates comparable to those provided by 2-dimensional and 3-dimensional radiotherapy. Margins ≥1 cm added to the GTV may not be necessary, because excellent local control was achieved by adding a 0.5-cm margin (Method 2) and by dose painting (Method 3).

Dosimetric impact of Acuros XB deterministic radiation transport algorithm for heterogeneous dose calculation in lung cancer.

The novel deterministic radiation transport algorithm, Acuros XB (AXB), has shown great potential for accurate heterogeneous dose calculation. However, the clinical impact between AXB and other currently used algorithms still needs to be elucidated for translation between these algorithms. The purpose of this study was to investigate the impact of AXB for heterogeneous dose calculation in lung cancer for intensity-modulated radiation therapy (IMRT) and volumetric-modulated arc therapy (VMAT). The thorax phantom from the Radiological Physics Center (RPC) was used for this study. IMRT and VMAT plans were created for the phantom in the Eclipse 11.0 treatment planning system. Each plan was delivered to the phantom three times using a Varian Clinac iX linear accelerator to ensure reproducibility. Thermoluminescent dosimeters (TLDs) and Gafchromic EBT2 film were placed inside the phantom to measure delivered doses. The measurements were compared with dose calculations from AXB 11.0.21 and the anisotropic analytical algorithm (AAA) 11.0.21. Two dose reporting modes of AXB, dose-to-medium in medium (Dm,m) and dose-to-water in medium (Dw,m), were studied. Point doses, dose profiles, and gamma analysis were used to quantify the agreement between measurements and calculations from both AXB and AAA. The computation times for AAA and AXB were also evaluated. For the RPC lung phantom, AAA and AXB dose predictions were found in good agreement to TLD and film measurements for both IMRT and VMAT plans. TLD dose predictions were within 0.4%-4.4% to AXB doses (both Dm,m and Dw,m); and within 2.5%-6.4% to AAA doses, respectively. For the film comparisons, the gamma indexes (± 3%∕3 mm criteria) were 94%, 97%, and 98% for AAA, AXB_Dm,m, and AXB_Dw,m, respectively. The differences between AXB and AAA in dose-volume histogram mean doses were within 2% in the planning target volume, lung, heart, and within 5% in the spinal cord. However, differences up to 8% between AXB and AAA were found at lung∕soft tissue interface regions for individual IMRT fields. AAA was found to be 5-6 times faster than AXB for IMRT, while AXB was 4-5 times faster than AAA for VMAT plan. AXB is satisfactorily accurate for the dose calculation in lung cancer for both IMRT and VMAT plans. The differences between AXB and AAA are generally small except in heterogeneous interface regions. AXB Dw,m and Dm,m calculations are similar inside the soft tissue and lung regions. AXB can benefit lung VMAT plans by both improving accuracy and reducing computation time.

Prostate and Patient Intrafraction Motion: Impact on Treatment Time-Dependent Planning Margins for Patients With Endorectal Balloon

To investigate intrafraction prostate and patient motion during different radiation therapy treatments as a function of treatment time; included were prostate patients with an endorectal balloon (ERB). Margins accounting for setup uncertainties and intrafraction motion were determined. The study included 17 patients undergoing prostate cancer radiation therapy. All patients received 3 fiducial gold markers implanted in the prostate and were then immobilized in the supine position with a knee support and treated with an ERB. Twelve patients with intermediate risk for pelvic lymph node metastases received intensity modulated radiation therapy (IMRT), and 5 patients at low risk received a 4-field box treatment. After setup based on skin marks, patients were imaged with a stereoscopic imaging system. If the marker displacement exceeded a 3-mm tolerance relative to planning computed tomography, patients were shifted and verification images were taken. All patients underwent additional imaging after treatment; IMRT patients also received additional imaging at halftime of treatment. Prostate and bone drifts were evaluated as a function of treatment time for more than 600 fractions, and margins were extracted. Patient motion evaluated by bone match was strongly patient dependent but in general was smallest in the superior-inferior (SI) direction. Prostate drifts were less patient dependent, showing an increase with treatment time in the SI and anterior-posterior (AP) directions. In the lateral (LAT) direction, the prostate stayed rather stable. Mean treatment times were 5.5 minutes for 4-field box, 10 minutes for 5-field boost IMRT, and 15 minutes or more for 9-field boost and 9-field pelvic IMRT treatments. Margins resulted in 2.2 mm, 3.9 mm, and 4.3 mm for 4-field box; 3.7 mm, 2.6 mm, and 3.6 mm for 5-field boost IMRT; 2.3 mm, 3.9 mm, and 6.2 mm for 9-field boost IMRT; and 4.2 mm, 5.1 mm, and 6.6 mm for 9-field pelvic IMRT in the LAT, SI, and AP directions, respectively. Intrafraction prostate and patient displacement increased with treatment time, showing different behaviors for the single directions of movement. Repositioning of the patients during long treatments or shorter treatment times will be necessary to further reduce the treatment margin.

Accuracy and precision of cone-beam computed tomography guided intensity modulated radiation therapy

PurposeTo assess the accuracy and precision of cone-beam computed tomography (CBCT)-guided intensity modulated radiation therapy (IMRT). Methods and MaterialsA 7-field intensity modulated radiation therapy plan was constructed for an anthropomorphic head phantom loaded with a custom cassette containing radiochromic film. The phantom was positioned on the treatment table at 9 locations: 1 “correct” position and 8 “misaligned” positions along 3 orthogonal axes. A commercial kilovoltage cone-beam computed tomography (kV-CBCT) system (VolumeView, Elekta AB, Stockholm, Sweden) was then used to align the phantom prior to plan delivery. The treatment plan was delivered using the radiation therapy delivery system (Infinity; Elekta AB) 3 times for each of the 9 positions, allowing film measurement of the delivered dose distribution in 3 orthogonal planes. Comparison of the planned and delivered dose profiles along the major axes provided an estimate of the accuracy and precision of CBCT-guided IMRT. ResultsOn average, targeting accuracy was found to be within 1 mm in all 3 major anatomic planes. Over all 54 measured dose profiles, the means and standard errors of the displacement of the center of the field between the measured and calculated profiles for each of the right-left, anterior-posterior, and superior-inferior axes were +0.08 ± 0.07 mm, +0.60 ± 0.08 mm, and +0.78 ± 0.16 mm, respectively. Agreement between planned and measured 80% profiles was less than 0.4 mm on either side along the right-left axis. A systematic shift of the measured profile of slightly less than 1 mm in anterior and superior directions was noted along the anterior-posterior and superior-inferior axes, respectively. ConclusionsSubmillimeter targeting accuracy can be achieved using a commercial kV-CBCT IGRT system.

Quantitative dosimetric assessment for effect of gold nanoparticles as contrast media on radiotherapy planning

In CT planning for radiation therapy, patients may be asked to have a medical procedure of contrast agent (CA) administration as required by their physicians. CA media improve quality of CT images and assist radiation oncologists in delineation of the target or organs with accuracy. However, dosimetric discrepancy may occur between scenarios in which CA media are present in CT planning and absent in treatment delivery. In recent preclinical experiments of small animals, gold nanoparticles (AuNPs) have been identified as an excellent contrast material of x-ray imaging.In this work, we quantitatively evaluate the effect of AuNPs to be used as a potential material of contrast enhancement in radiotherapy planning with an analytical phantom and clinical case. Conray 60, an iodine-based product for contrast enhancement in clinical uses, is included as a comparison. Other additional variables such as different concentrations of CA media, radiation delivery techniques and dose calculation algorithms are included. We consider 1-field AP, 4-field box, 7-field intensity modulated radiation therapy (IMRT) and a recent technique of volumetric modulated arc therapy (VMAT). CA media of AuNPs (Conray 60) with concentrations of 10%, 20%, 30%, 40% and 50% containing 28.2, 56.4, 84.6, 112.8 and 141.0mg of gold (iodine) per mL were prepared prior to CT scanning. A virtual phantom with a target where nanoparticle media are loaded and clinical case of gastric lymphoma in which the Conray 60 media were given to the patient prior to the CT planning are included for the study. Compared to Conray 60 media with concentration of 10%/50%, Hounsfield units for AuNP media of 10%/50% are 322/1608 higher due to the fact that atomic number of Au (Z=79) is larger than I (Z=53). In consequence, dosimetric discrepancy of AuNPs is magnified between presence and absence of contrast media. It was found in the phantom study that percent dose differences between presence and absence of CA media may be reduced by delivery techniques of 7-field IMRT or VMAT. To manage less than 3% of percent dose difference, it was suggested an upper limit of 15% (or 42.3mg Au/mL) of AuNP media in the phantom study; 8% (or 22.5mg Au/mL) in the specific clinical case.

Dosimetric Evaluation of Intensity Modulated Radiotherapy and 4-Field 3-D Conformal Radiotherapy in Prostate Cancer Treatment

The purpose of this dosimetric study is the targeted dose homogeneity and critical organ dose comparison of 7-field Intensity Modulated Radiotherapy (IMRT) and 3-D 4-field conformal radiotherapy. Cross sectional study. Twenty patients with low and moderate risk prostate cancer treated at Gülhane Military Medical School Radiation Oncology Department between January 2009 and December 2009 are included in this study. Two seperate dosimetric plans both for 7-field IMRT and 3D-CRT have been generated for each patient to comparatively evaluate the dosimetric status of both techniques and all the patients received 7-field IMRT. Dose-comparative evaluation of two techniques revealed the superiority of IMRT technique with statistically significantly lower femoral head doses along with reduced critical organ dose-volume parameters of bladder V60 (the volume receiving 60 Gy) and rectal V40 (the volume receiving 40 Gy) and V60. It can be concluded that IMRT is an effective definitive management tool for prostate cancer with improved critical organ sparing and excellent dose homogenization in target organs of prostate and seminal vesicles.

Model‐based prediction of portal dose images during patient treatment

Dosimetric verification of radiation therapy is crucial when delivering complex treatments like intensity modulated radiation therapy (IMRT) or volumetric modulated arc therapy (VMAT. Pretreatment verification, characterized by methods applied without the patient present and before the treatment start date, is typically carried out at most centers. In vivo dosimetric verification, characterized by methods applied with the patient present, is not commonly carried out in the clinic. This work presents a novel, model-based EPID dosimetry method that could be used for routine clinical in vivo patient treatment verification. The authors integrated a detailed fluence model with a patient scatter prediction model that uses a superposition of scatter energy fluence kernels, generated via Monte Carlo techniques, to determine patient scatter fluence delivered to the EPID. The total dose to the EPID was calculated using the sum of convolutions of the calculated energy fluence distribution entering the EPID with monoenergetic dose kernels, specific to the a-Si EPID. Measured images with simple, square fields delivered to slab phantoms were validated against predicted images. Measured and predicted images acquired during the delivery of IMRT fields to slabs and an anthropomorphic phantom were compared using the χ-comparison for 3% dose difference and 3 mm distance-to-agreement criteria. Predicted and measured images of the square fields with slabs in the field agreed within 2.5%. Predicted portal dose images of clinical IMRT fields delivered to slabs and an anthropomorphic phantom agreed with measured images within 3% and 3 mm for an average of at least 97% of the infield pixels (defined as >10% maximum field dose) for each case, over all fields. This work presents the first validation of the integration of a comprehensive fluence model with a patient and EPID radiation transport model that accounts for patient transmission, including complex factors such as patient scatter and the energy response of the a-Si detector. The portal dose image prediction model satisfies the 3% and 3 mm criteria for IMRT fields delivered to slab phantoms and could be used for patient treatment verification.

Application of the measurement-based Monte Carlo method in nasopharyngeal cancer patients for intensity modulated radiation therapy

This study aims to utilize a measurement-based Monte Carlo (MBMC) method to evaluate the accuracy of dose distributions calculated using the Eclipse radiotherapy treatment planning system (TPS) based on the anisotropic analytical algorithm. Dose distributions were calculated for the nasopharyngeal carcinoma (NPC) patients treated with the intensity modulated radiotherapy (IMRT). Ten NPC IMRT plans were evaluated by comparing their dose distributions with those obtained from the in-house MBMC programs for the same CT images and beam geometry. To reconstruct the fluence distribution of the IMRT field, an efficiency map was obtained by dividing the energy fluence of the intensity modulated field by that of the open field, both acquired from an aS1000 electronic portal imaging device. The integrated image of the non-gated mode was used to acquire the full dose distribution delivered during the IMRT treatment. This efficiency map redistributed the particle weightings of the open field phase-space file for IMRT applications. Dose differences were observed in the tumor and air cavity boundary. The mean difference between MBMC and TPS in terms of the planning target volume coverage was 0.6% (range: 0.0–2.3%). The mean difference for the conformity index was 0.01 (range: 0.0–0.01). In conclusion, the MBMC method serves as an independent IMRT dose verification tool in a clinical setting.

Initial experience with TrueBeam trajectory log files for radiation therapy delivery verification

PurposeTraditionally, initial and weekly chart checks involve checking various parameters in the treatment management system against the expected treatment parameters and machine settings. This process is time-consuming and labor intensive. We explore utilizing the Varian TrueBeam log files (Varian Medical System, Palo Alto, CA), which contain the complete delivery parameters for an end-to-end verification of daily patient treatments. Methods and MaterialsAn in-house software tool for 3-dimensional (3D) conformal therapy, enhanced dynamic wedge delivery, intensity modulated radiation therapy (IMRT), volumetric modulated radiation therapy, flattening filter-free mode, and electron therapy treatment verification was developed. The software reads the Varian TrueBeam log files, extracts the delivered parameters, and compares them against the original treatment planning data. In addition to providing an end-to-end data transfer integrity check, the tool also verifies the accuracy of treatment deliveries. This is performed as part of the initial chart check for IMRT plans and after first fraction for the 3D plans. The software was validated for consistency and accuracy for IMRT and 3D fields. ResultsBased on the validation results the accuracy of MLC, jaw and gantry positions were well within the expected values. The patient quality assurance results for 127 IMRT patients and 51 conventional fields were within 0.25 mm for multileaf collimator positions, 0.3 degree for gantry angles, 0.13 monitor units for monitor unit delivery accuracy, and 1 mm for jaw positions. The delivered dose rates for the flattening filter-free modes were within 1% of the planned dose rates. ConclusionsThe end-to-end data transfer check using TrueBeam log files and the treatment delivery parameter accuracy check provides an efficient, reliable beam parameter check process for various radiation delivery techniques.

Dosimetry Analysis of Three Kinds of Radiation Technique for Postoperative Gastric Cancer

Objective: To compare dose-volume histograms (DVHs) and the dose distribution of three-dimensional conformal radiotherapy(3DCRT),7 fields radiotherapy(7FRT) and intensity-modulated radiotherapy (IMRT) of treatment planning in gastric cancer. Methods: We selected 5 patients with gastric cancer, they were pathologically confirmed stage T3,T4 or N+ gastric cancer. All patients underwent radical gastrectomy. A dosimetry study was carried out on these five patients. For each patient, three kinds of treatment planning were designed with a prescribed dose of 45Gy to 95％of PTV.Many kinds of parameters of these plans in each patient were compared: isodose distributions line、dose-volume histogram(DVH)、V95%、V110%、CI、HI、EI of target volume and the dose of related critical organs. Results: IMRT was superior to 3DCRT and 7F-RT in dose uniformity（p＜0.05）, there was no statistical difference between 3DCRT and 7FRT in CI（p&gt;0.05）.IMRT had better dose conformity than 3DCRT and 7FRT（p＜0.05）, and 3DCRT was better than 7FRT in CI（p＜0.05）.IMRT showed better EI than 3DCRT and 7FRT（p＜0.05）,there was no statistical difference between 3DCRT and 7FRT in EI（p&gt;0.05）.IMRT had advantage at sparing liver compared with 3DCRT and 7FRT（p＜0.05）,7FRT showed better D1/3 of liver than 3DCRT（p＜0.05）,but there was no statistical difference between 3DCRT and 7FRT in Dmean of liver（p&gt;0.05）.IMRT expressed better Dmax of spinal cord than 3DCRT and 7F-RT（p＜0.05）, and 7FRT was better than IMRT in Dmax of spinal cord（p＜0.05）.But the dose received by the both kidneys were not significantly different. Conclusion: IMRT is superior to 3DCRT and 7FRT,and 3DCRT plans showed better CI and Dmax of spinal cord composed to 7FRT,and 7FRT was superior to 3DCRT in D1/3 of liver. IMRT for gastric cancer had physics advantage for clinical application.

Treatment Efficiency of Volumetric Modulated Arc Therapy in Comparison With Intensity-Modulated Radiotherapy in the Treatment of Prostate Cancer

Treatment with intensity-modulated radiation therapy (IMRT) is increasingly standard for prostate cancer. Volume-modulated arc therapy (VMAT) to deliver IMRT potentially enables shorter treatment time. The aim of this study was to test this hypothesis by measuring the average patient in-room time with VMAT versus dynamic multileaf collimator (DMLC) IMRT. Custom institutional software (RTMetrix) was used to mine the treatment times from the record-and-verify database. The in-room time (the time between patient entry and exit) was computed for each patient using RTMetrix. Average room time was compared between VMAT patients (n = 44) and IMRT patients (n = 99). Subgroup comparisons (1-arc or 2-arc VMAT, 5-field or 7-field IMRT, and electromagnetic transponder [Calypso] or gold-marker tracking) were performed. For all comparisons, 2-tailed, 2-sample, equal variance Student's t-tests were used. Average room time was significantly shorter for all VMAT versus DMLC IMRT (P = .0014) procedures, along with VMAT versus 7-field DMLC IMRT (P < .001), but not VMAT versus 5-field DMLC IMRT (P = .81). Room time was longer for Calypso versus gold seed patients (P < .001), but VMAT reduced treatment time in Calypso patients (P = .01). This resulted in Calypso VMAT patients' having similar treatment times to non-Calypso DMLC IMRT patients (P = .220). These data show that VMAT can shorten room times and improve patient throughput over 7-field DMLC IMRT. Additionally, the data demonstrate that treatment with VMAT permits the use of advanced prostate tracking (Calypso), resulting in similar room times as with standard 7-field DMLC IMRT with conventional tracking.

Dosimetric study of volumetric intensity-modulated arc therapy and fixed field intensity-modulated radiotherapy for cervix cancer

Objective To compare the dosimetry characteristics of volumetric intensity-modulated arc therapy (VIMAT) and fixed field intensity-modulated radiation therapy (FF-IMRT) for cervix cancer.Methods CT images of 13 patients with cervix uteri cancer were transferred into Eclipse planning system.FF-IMRT and VIMAT plans were optimized on an Eclipse treatment planning system using beam data generated for Varian trilogy linear accelerator.Planning target volume (PTV) and organs at risk were evaluated with dose-volume histogram.To appraise the difference between the techniques,the paired t-test was applied.Results Compared with the FF-IMRT plans,PTV95％ coverage of VIMAT plan group increased (t =9.84,P =0.000),PTV110％ became lower (t =-3.72,P =0.003),Dmax decreased (t =-3.51,P=0.005),and CI became worser (t=5.39,P=0.000).PTV105％,Dmean,and HI had no difference (t =-0.02,-0.60,1.13,P =0.842,0.560,0.283).V30 of the bladder was reduced by about 10％ (t =-4.99,P =0.000),and Dmean and Dmax were 1.4 Gy and 1.5 Gy lower respectively (t =-3.65,-18.03,P =0.004,0.000) ;V40 of the rectum was reduced by about 10％ (t =-2.99,P =0.012),and Dmean and Dmax were reduced by 0.6 Gy,0.8 Gy respectively (t =-2.98,-4.05,P =0.013,0.002) ;V30,V40 and V50 of the small intestine were reduced by 16％,10％ and 11％ (t =-10.85,-4.74,-8.66,P =0.000,0.001,0.000),and Dmax was reduced by 0.8 Gy (t =-9.45,P =0.000) ; V30,V40 and V50 of the bone marrow were reduced by 26％,19％ and 16％ (t =-22.10,-10.19,-4.04,P =0.000,0.000,0.002),and Dmean reduced by 1.9 Gy (t =-16.21,P =0.000) ; D5 of the left and right femoral heads were reduced by 1.6 Gy and 2.7 Gy (t =-2.89,-6.22,P =0.015,0.000).Dmax of the caudate equine was reduced by 1.5 Gy (t=-4.80,P=0.001).V20,V30,V40 and V50 of the body were reduced by 18％,18％,4％ and3％(t=-7.52,-11.75,-6.26,-6.94,P=0.000,0.000,0.000,0.000).Dmean and Dmax of the body decreased by 1.0 Gy and 0.4 Gy (t=-3.72,-3.51,P=0.000,0.005).Average machine unit (MU) decreased by 57％ (t =-40.54,P =0.000).Conclusions cervical cancer Patients with VIMAT technology can get equivalent or superior dose distribution compared with the FF-IMRT technology.And VIMAT technology could reduce MU.But the efficacy needs further clinical evaluation Key words: Cervix neoplasms/radiotherapy; Radiotherapy,fixed field intensity-modulated; Radiotherapy,volumetric modulated; Dosimetry

Dose Volume Analysis of Grade 2+ Late GI Toxicity on RTOG 0126 After High-dose 3DCRT or IMRT

Purpose/Objective(s): To report the long-term survival and toxicity outcomes with the use of ultra-high-dose intensity modulated radiation therapy (IMRT) to a dose of 86.4 Gy for patients with localized prostate cancer. Materials/Methods: Between August 1997 and December 2008, 1002 patients were treated to a dose of 86.4 Gy using a 5-7 field IMRT technique. Patients were stratified into prognostic risk groups based on the National Comprehensive Cancer Network risk-grouping system. Five hundred eighty-seven patients (59%) were treated with neoadjuvant and concurrent androgen-deprivation therapy. The median follow-up for the entire cohort was 5.5 years (range 1-14 years). Results: The 5and 10-year actuarial prostate-specific antigen (PSA) relapse-free survival outcomes for low-, intermediate-, and high-risk groups were 98.8 and 96.3%, 89.1 and 75.4%, and 76.1 and 65.8% (p < 0.001), respectively. On multivariate analysis, T stage (p Z 0.002), Gleason score (p < 0.001), and pretreatment PSA (iPSA) (p Z 0.008) were predictors for biochemical relapse. The 5and 10-year actuarial DMFS for low-, intermediate-, and high-risk groups was 99.4 and 96.8%, 97.4 and 93.6%, and 90.1 and 74.4% (p < 0.001), respectively. On multivariate analysis, T stage (p < 0.001), Gleason score (p < 0.001), and iPSA (p < 0.033) were predictive for DM. No prostate cancer-related deaths were observed in the low-risk group. The 5and 10-year actuarial CSS for intermediateand high-risk groups was 99.4 and 93.8%, and 96.6 and 82.2% (p Z 0.008), respectively. On multivariate analysis, only T stage (p Z 0.016) and Gleason score (p Z 0.003) were predictive for prostate cancer-related death. The incidence of grade 2 or higher late gastrointestinal (GI) and genitourinary (GU) toxicities were 4.4% and 17.1%, respectively. Late grade 3 GI and GU toxicity was experienced in 7 patients (0.7%) and 22 patients (2.2%), respectively. Of the 427 men with full potency at baseline, 317 men (74%) retained sexual function at time of last follow-up. Conclusions: This represents the largest cohort of patients treated with ultra-high-dose radiation to 86.4 Gy using IMRT for localized prostate cancer with the longest follow-up to date. Our findings indicate that this treatment results in excellent clinical outcomes and is well tolerated with acceptable toxicity. Author Disclosure: D. Spratt: None. X. Pei: None. J. Yamada: None. M.A. Kollmeier: None. B. Cox: None. Z. Zhang: None. M.J. Zelefsky: None.

Long-term Survival and Toxicity of Patients Treated With Ultra-high-dose IMRT for Localized Prostate Cancer

Purpose/Objective(s): To report the long-term survival and toxicity outcomes with the use of ultra-high-dose intensity modulated radiation therapy (IMRT) to a dose of 86.4 Gy for patients with localized prostate cancer. Materials/Methods: Between August 1997 and December 2008, 1002 patients were treated to a dose of 86.4 Gy using a 5-7 field IMRT technique. Patients were stratified into prognostic risk groups based on the National Comprehensive Cancer Network risk-grouping system. Five hundred eighty-seven patients (59%) were treated with neoadjuvant and concurrent androgen-deprivation therapy. The median follow-up for the entire cohort was 5.5 years (range 1-14 years). Results: The 5and 10-year actuarial prostate-specific antigen (PSA) relapse-free survival outcomes for low-, intermediate-, and high-risk groups were 98.8 and 96.3%, 89.1 and 75.4%, and 76.1 and 65.8% (p < 0.001), respectively. On multivariate analysis, T stage (p Z 0.002), Gleason score (p < 0.001), and pretreatment PSA (iPSA) (p Z 0.008) were predictors for biochemical relapse. The 5and 10-year actuarial DMFS for low-, intermediate-, and high-risk groups was 99.4 and 96.8%, 97.4 and 93.6%, and 90.1 and 74.4% (p < 0.001), respectively. On multivariate analysis, T stage (p < 0.001), Gleason score (p < 0.001), and iPSA (p < 0.033) were predictive for DM. No prostate cancer-related deaths were observed in the low-risk group. The 5and 10-year actuarial CSS for intermediateand high-risk groups was 99.4 and 93.8%, and 96.6 and 82.2% (p Z 0.008), respectively. On multivariate analysis, only T stage (p Z 0.016) and Gleason score (p Z 0.003) were predictive for prostate cancer-related death. The incidence of grade 2 or higher late gastrointestinal (GI) and genitourinary (GU) toxicities were 4.4% and 17.1%, respectively. Late grade 3 GI and GU toxicity was experienced in 7 patients (0.7%) and 22 patients (2.2%), respectively. Of the 427 men with full potency at baseline, 317 men (74%) retained sexual function at time of last follow-up. Conclusions: This represents the largest cohort of patients treated with ultra-high-dose radiation to 86.4 Gy using IMRT for localized prostate cancer with the longest follow-up to date. Our findings indicate that this treatment results in excellent clinical outcomes and is well tolerated with acceptable toxicity. Author Disclosure: D. Spratt: None. X. Pei: None. J. Yamada: None. M.A. Kollmeier: None. B. Cox: None. Z. Zhang: None. M.J. Zelefsky: None.

Is Belly Board Still Needed in IMRT for Rectal Cancer? The Change of Bladder Volume Affects the Determination

Prone positioned with belly board is an efficiency method to reduce the irradiated small bowel volume (ISBV) in three-dimensional conformal radiation therapy (3DCRT) for rectal cancer patients. The downside of treating patients in prone position is that compared to supine, the setup is less reproducible between and during fractions. Intensity-modulated radiation therapy (IMRT) technique has previously been demonstrated to be effective in reducing small bowel dose in comparison to 3DCRT for rectal cancer. Whether the belly board still needed in IMRT for rectal cancer is not well answered. The aim of this study was to compare the ISBV between prone positioned with belly board and supine positioned with flat table in IMRT for rectal cancer patients. Twenty patients scheduled to receive postoperative radiation therapy for rectal cancer underwent two series of CT scans, prone positioned with a belly board and supine positioned with a flat board, both combined using a full bladder protocol. On each scan, a 7-field IMRT plan was calculated. Bladder and individual loops of small bowel were contoured on each slice of the planning CT scan. A comparison of volume for small bowel and bladder in different position were performed. Comparison of V15 (volume received dose more than 15 Gy) for small bowel was made between prone and supine position with different device. Compared with supine position, all bladder volumes were decreased in the prone position. The ISBV of eight patients were increased when use belly board. The increase of ISBV was related to the decrease of bladder volume. If the relative change of bladder volume was more than 16%, the ISBV might increase when use belly board. There were no significant differences between patients undergoing IMRT with belly board and those without in terms of V15 for small bowel and ISBV (p = 0.245 and p = 0.944, respectively). If we used 16% as cutoff value to select patients, V15 for small bowel and ISBV of different position could meet marginal statistical significant (p = 0.062 and p = 0.072, respectively). The change of bladder volume in two different positions affected the ISBV. If the change less than 16%, a belly board still attributed to a significant bowel dose reduction when using IMRT and a full bladder protocol.

2D lag and signal nonlinearity correction in an amorphous silicon EPID and their impact on pretreatment dosimetric verification

This investigation provides measurements of signal lag and nonlinearity separately for the Varian aS500 electronic portal imaging device (EPID), and an algorithm to correct for these effects in 2D; their potential impact on intensity modulated radiation therapy (IMRT) verification is also investigated. The authors quantify lag, as a function of both delivered monitor units (MU) and time, by using a range of MUs delivered at a clinically used rate of 400 MU∕min. Explicit cumulative lag curves are thus determined for a range of MUs and times between the end of irradiation and the end of image acquisition. Signal nonlinearity is also investigated as a function of total MUs delivered. The family of cumulative lag curves and signal nonlinearity are then used to determine their effects on dynamic multileaf collimator (MLC) (IMRT) deliveries, and to correct for theses effects in 2D. Images acquired with an aS500 EPID and Varis Portal-Vision software were used to quantify detector lag and signal-nonlinearity. For the signal lag investigation, Portal-Vision's service monitor was used to acquire EPID images at a rate of 8 frames/s. The images were acquired during irradiation and 66 s thereafter, by inhibiting the M-holdoff-In signal of the Linac for a range of 4.5-198.5 MUs. Relative cumulative lag was calculated by integrating the EPID signal for a time after beam-off, and normalizing this to the integrated EPID signal accumulated during radiation. Signal nonlinearity was studied by acquiring 10 × 10 cm(2) open-field EPID images in "integrated image" mode for a range of 2-500 MUs, and normalized to the 100 MU case. All data were incorporated into in-house written software to create a 2D correction map for these effects, using the field's MLC file and a field-specific calculated 2D "time-map," which keeps track of the time elapsed from the last fluence delivered at each given point in the image to the end of the beam delivery. Relative cumulative lag curves reveal that the lag alone can deviate the EPID's perceived dose by as large as 6% (1 MU delivery, 60 s postirradiation). For signal nonlinearity relative to 100 MU, EPID signals per MU of 0.84 and 1.01 were observed for 2 and 500 MUs, respectively. Correction maps were applied to a 1 cm sweeping-window 14 × 14 cm(2) field and clinical head-and-neck IMRT field. A mean correction of 1.028 was implemented in the head-and-neck field, which significantly reduced lag-related asymmetries in the EPID images, and restored linearity to the EPID imager's dose response. Corrections made to the sweeping-field showed good agreement with the treatment planning system-predicted field, yielding an average percent difference of 0.05% ± 0.91%, compared to the -1.32% ± 1.02% before corrections, or 1.75% ± 1.04% when only a signal nonlinearity correction is made. Lag and signal-nonlinearity have been quantified for an aS500 EPID imager, and an effective 2D correction method has been developed which effectively removes nonlinearity and lag effects. Both of these effects were shown to negatively impact IMRT verifications. Especially fields that involve prolonged irradiation and small overall MUs should be corrected for in 2D.

Implementation of phantom-less IMRT delivery verification using Varian DynaLog files and R/V output

This study aims to evaluate the use of Varian radiotherapy dynamic treatment log (DynaLog) files to verify IMRT plan delivery as part of a routine quality assurance procedure. Delivery accuracy in terms of machine performance was quantified by multileaf collimator (MLC) position errors and fluence delivery accuracy for patients receiving intensity modulated radiation therapy (IMRT) treatment. The relationship between machine performance and plan complexity, quantified by the modulation complexity score (MCS) was also investigated. Actual MLC positions and delivered fraction of monitor units (MU), recorded every 50 ms during IMRT delivery, were extracted from the DynaLog files. The planned MLC positions and fractional MU were taken from the record and verify system MLC control file. Planned and delivered beam data were compared to determine leaf position errors with and without the overshoot effect. Analysis was also performed on planned and actual fluence maps reconstructed from the MLC control file and delivered treatment log files respectively. This analysis was performed for all treatment fractions for 5 prostate, 5 prostate and pelvic node (PPN) and 5 head and neck (H&N) IMRT plans, totalling 82 IMRT fields in ∼5500 DynaLog files. The root mean square (RMS) leaf position errors without the overshoot effect were 0.09, 0.26, 0.19 mm for the prostate, PPN and H&N plans respectively, which increased to 0.30, 0.39 and 0.30 mm when the overshoot effect was considered. Average errors were not affected by the overshoot effect and were 0.05, 0.13 and 0.17 mm for prostate, PPN and H&N plans respectively. The percentage of pixels passing fluence map gamma analysis at 3%/3 mm was 99.94 ± 0.25%, which reduced to 91.62 ± 11.39% at 1%/1 mm criterion. Leaf position errors, but not gamma passing rate, were directly related to plan complexity as determined by the MCS. Site specific confidence intervals for average leaf position errors were set at −0.03–0.12 mm for prostate and −0.02–0.28 mm for more complex PPN and H&N plans. For all treatment sites confidence intervals for RMS errors with the overshoot was set at 0–0.50 mm and for the percentage of pixels passing a gamma analysis at 1%/1 mm a confidence interval of 68.83% was set also for all treatment sites. This work demonstrates the successful implementation of treatment log files to validate IMRT deliveries and how dynamic log files can diagnose delivery errors not possible with phantom based QC. Machine performance was found to be directly related to plan complexity but this is not the dominant determinant of delivery accuracy.