Multileaf Collimator Research Articles

Intensity-Modulated Neutron Therapy (IMNT) for Head and Neck Cancer: Early Toxicity Outcomes

Locally advanced head & neck cancers (HNC) are challenging to treat due to abutment of critical, dose-limiting structures. Fast neutron radiotherapy (NT) is a high linear energy transfer (LET) modality that provides better local control than photons for radioresistant cancers such as salivary gland tumors, but there have been concerns of toxicity with 3D conformal neutron therapy in the past. Recent technological advances have enabled the planning and delivery of IMNT, which improves target conformality and may reduce toxicity compared to 3D conformal NT. We report the first clinical evaluation of early toxicity outcomes of IMNT for HNC. Study is a single-institution retrospective review of all HNC patients treated with curative-intent IMNT from 10/2022 to 2/2023, using a hospital-based cyclotron (50.5 MeV 1H+ beam incident on a Be target) equipped with an isocentric gantry and multileaf collimator (MLC). A commercial treatment planning system with custom neutron-specific scattering kernels was used for IMNT planning using 4-6 fields. Patient-specific quality assurance included ionization chamber measurements and a novel 12C(n,2n)11C positron emission portal imaging system. kV portal imaging was used to confirm patient setup prior to each treatment session. All patients were prescribed 18.4 Gy at 1.15 Gy/fraction, delivered 4 days/week, which is equivalent to an x-ray EQD2 of approximately 70 Gy (RBE ∼ 3.8). Clinical observations suggest the RBE for radioresistant HNC may be as large as 8. Patients underwent weekly toxicity assessment, and acute toxicities were graded (G) by CTCAE v5.0. Ten patients received IMNT, median age 61 (range 34-78). Primary tumor sites were base of tongue (n = 3), sinonasal (n = 3), parotid (n = 2), submandibular (n = 1), larynx (n = 1). Tumor histologies included adenoid cystic carcinoma (n = 7), other salivary gland carcinomas (n = 2) and mucosal melanoma (n = 1). Most had T4 disease (n = 8) and one had N3b disease. Six had surgical resection with high-risk features, and 6 had gross measurable disease prior to IMNT. None had concurrent systemic therapy. Uninvolved salivary glands were spared in most patients. All patients completed treatment. Median follow up was 22 days (0-48). Acute toxicities (n, G 1, 2, 3) included skin (8, 3, 0), dysgeusia (1, 6, 0), xerostomia (3, 5, 0), mucositis (2, 0, 5), nausea (3, 0, 1). One patient had >10% weight loss and brief admission for supportive care and PEG placement; one patient had prophylactic PEG; both regained oral independence during follow-up. There was no Grade 4+ toxicity. IMNT improves the therapeutic ratio compared to 3D conformal NT and expands indications for NT in patients with radiorefractory tumors. Acute toxicity compares favorably with photons. Longer clinical and toxicity follow-up is anticipated. A prospective trial is planned to evaluate quality of life measures.

Dosimetric Study of Total Marrow and Lymphoid Irradiation on a Ring Gantry-Based Medical Linac with a Two-Layer Multi-Leaf Collimator

In this study, we aimed to evaluate dosimetric quality of total marrow and lymphoid irradiation (TMLI) plans for a ring gantry-based medical Linac with a two-layer multi-leaf collimator. We retrospectively retrieved treatment planning CT images, structure sets, and plan dose for four adult patients, two male and two female, who previously received TMLI treatments on helical tomotherapy (HT) at our institution. TMLI plans were optimized for a ring gantry-based medical Linac with a two-layer multi-leaf collimator (Halcyon, Varian Medical Systems, Inc., Palo Alto, CA). A prescription dose of 12 Gy in 8 fractions was prescribed to the skeletal bones from the skull to mid-thigh, spleen, spinal canal, and lymphoid volume. Five or six isocenters were placed with equal spacing along the patient's longitudinal direction in each TMLI plan with two 6-MV flattening filter-free volumetric modulated arc therapy (VMAT) fields at each isocenter. Isocenter separation ranged from 15 cm to 16.5 cm. Each VMAT field has a field size of 28 cm to 28 cm with the collimator at 90° and a full gantry rotation. The nominal dose rate was 800 MU/minute, and the maximum gantry rotation speed was 24°/sec. Institutional dosimetric constraints were used for optimization including a mean lung dose limit of less than 8 Gy. All the plans were normalized so that 85% the primary planning target volume received the prescription dose. The average mean doses to the target volumes ranged from 12.2 to 12.6 Gy in the Halcyon TMLI plans, while they ranged from 12.1 to 12.5 Gy in the HT TMLI plans. Relative to the prescription dose, the average mean dose for normal organs ranged from 21.3% to 56.6% in the Halcyon TMLI plans, while it ranged from 10.1% to 68.4% in the clinical HT plans. The difference in the average mean dose to normal organs was less than 0.5 Gy except two organs between the Halcyon and HT TMLI plans. The average median dose for normal organs ranged from 18.2% to 48.8% relative to the prescription dose in the Halcyon TMLI plans. The mean lung dose (MLD) in the Halcyon TMLI plans met the institutional limit with an average dose of 6.75±0.42 Gy (range: 6.44 - 7.36 Gy), while the average MLD was 6.54±0.77 Gy (range: 6.24 - 7.22 Gy) in the HT plans (p-value = 0.71 in the paired t-test). The average total monitor unit in the Halcyon TMLI plans was 4,425±906 MU (range: 3,470 - 5,575 MU) with an average beam-on time of 5.1±1.3 minutes (range: 4.1 - 7.0 minutes), which excludes isocenter setup time, while the average beam-on time was 22.2±3.2 minutes (range: 19.6 - 26.1 minutes) with the HT plans. Halcyon TMLI plans met our institutional dosimetric constraints with adequate normal organ sparing and target dose coverage. The beam-on time with the Halcyon plans was significantly shorter than that with the HT plans, which could lead to shorter treatment time and increased patient comfort. This study showed the feasibility of TMLI treatments on the Halcyon machine. The same method could be used for total body irradiation on Halcyon.

A new Multi Leaf Collimator for the fission neutron therapy facility at FRM II

As a part of the general upgrade program of the fission neutron therapy facility MEDAPP at the research reactor FRM II, a newly designed, electronically operated Multi Leaf Collimator (MLC) was introduced. The design of the new collimator was optimized in order to increase dose output and to allow patient positioning closer to the collimator. The new collimator allows divergent and convergent beam shaping in order to maximize the effective area of the fission source used for irradiation. In comparison to the old MLC, the radiation dose for the staff is reduced by the motorized operation of the new MLC. The advanced beam shaping abilities of the new collimator are investigated by a comparison with depth dose curves and beam profiles of the old MLC. For the separation of neutron and gamma dose deposition in water, the two chamber dosimetry method recommended for mixed field dosimetry was applied. A re-calibration of the set of ionization chambers used for dosimetry in mixed neutron-gamma radiation fields at FRM II was performed. The calibration was done in a reference neutron field from 3H(p,n)3He-reactions in a low scattering environment. An overall increased dose output as intended by the design of the new MLC was shown. Also, improved dosimetric characteristics of the treatment field due to the optimized beam shaping abilities of the new MLC were demonstrated. In the calibration measurements of the magnesium ionization chamber used in the two chamber method, an unexpected increase of the neutron sensitivity by a factor of 8 was measured. The new MLC will enable more conformal dose delivery to the target volume in patients and therefore help to reduce healthy tissue damage by the application of neutron radiation.

Development and Quality Assurance of Multileaf Collimator (MLC) Auto-Feathering Junctions for Multi-Isocenter Supine Volumetric Modulated Arc Therapy (VMAT) Craniospinal Axis Irradiation on Halcyon.

Currently, there is alack of methods and tools that efficiently evaluate the auto-feathering junctions created by multileaf collimator (MLCs) for supine volumetric modulated arc therapy (VMAT) craniospinalirradiation (CSI) plans. We have investigated the feasibility of stitching together multi-isocenter fluence maps to then analyze the feathered junctions for patient-specific quality assurance (QA). Furthermore, we investigated the capability of Halcyon for the treatment of CSI patients.Three patients, who previously underwent VMAT CSI treatment on TrueBeam (6-MV flattening filter-free (FFF)) for 36 Gy in 20 fractionswerereplanned for Halcyon. A multi-isocenter approach with only translational superior-inferior shifts was used for both platforms. Each isocenter consists of two full arcs with anterior avoidance sectors, ±5° collimator rotations between arcs, and 5-8 cm of overlapping MLC auto-feathering junctions. All plans were QA'd via electronicportalimaging device (EPID) portal dosimetry and analyzed with a gamma criteria of 3%/3 mm. A variety of plan quality metrics were analyzed to evaluate dose distributions to the target, doses to organs at risk (OARs), and integral dose to the patient. A MATLAB script was developed to stitch the calculated and measured fluence maps in order to perform patient-specific QA for the composite fluence.The Halcyon plans provided highly conformal and homogenous dose distributions to the entire CSI target, superior to the clinical TrueBeam plans, while sparing critical organs with significantly lower values of V10Gy and V18Gy by up to 2% and 2.5%, respectively.Qualitative depictions of vertical dose profiles from the stitched DICOM of the entire CSI target for both planned and delivered fluence maps demonstrated equivalency, with slightly lower average pass rates with Halcyon (97%) compared to TrueBeam(99.9%). This approach to stitch multiple measured versus calculated EPID fluence maps has shown to be a feasible and accurate method and will be helpful for comprehensive VMAT CSI QA on both platforms. Further implementation of this script will be used in examining dosimetric impacts of daily patient positioning errors at MLC auto-feathering junctions.

Technical note: Preprocessing of portal images to improve image quality of VMAT-CT.

The concept of volumetric modulated arc therapy-computed tomography (VMAT-CT) was proposed more than a decade ago. However, its application has been very limited mainly due to the poor image quality. More specifically, the blurred areas in electronic portal imaging device (EPID) images collected during VMAT heavily degrade the image quality of VMAT-CT. The goal of this study was to propose systematic methods to preprocess EPID images and improve the image quality of VMAT-CT. Online region-based active contour method was introduced to binarize portal images. Multi-leaf collimator (MLC) motion modeling was developed to remove the MLC motion blur. Outlier filtering was then applied to replace the remaining artifacts with plausible data. To assess the impact of these preprocessing methods on the image quality of VMAT-CT, 44 clinical VMAT plans for several treatment sites (lung, esophagus, and head & neck) were delivered to a Rando phantom, and several real-patient cases were also acquired. VMAT-CT reconstruction was attempted for all the cases, and image quality was evaluated. All three preprocessing methods could effectively remove the blurred edges of EPID images. The combined preprocessing methods not only saved VMAT-CT from distortions and artifacts, but also increased the percentage of VMAT plans that can be reconstructed. The systematic preprocessing of portal images improves the image quality of VMAT-CT significantly, and facilitates the application of VMAT-CT as an effective image guidance tool.

Comparison of Progressive Resolution Optimizer and Photon Optimizer algorithms in RapidArc delivery for head and neck SIB treatments.

The aim of this study is to analyze and verify characterization of two different algorithms using simultaneous integrated boost (SIB) in head and neck (H&N) plans. In our study 15 patients were selected, who received radiation therapy by using Eclipse volumetric modulated arc therapy (VMAT) Progressive Resolution Optimizer (PRO) algorithm 15.1. The same cases were re-optimized using a Photon Optimizer (PO) algorithm 15.6.A total of 30 treatment plans (15 PRO-VMAT plans and 15 PO-VMAT plans) were produced in the present study. All plans were created using double full arcs, keeping the identical constraints, cost functions and optimization time. Plan evaluation was done using planning target volume (PTV) parameters (D98%, D95%, D50%, D2% mean dose and V105%), homogeneity index (HI), conformity index (CI), Monitor unit (MU) per degree with control points (CP), organ at risk (OAR) doses and gamma verification (Portal dosimetry and ArcCHECK) values were evaluated. Treatment was delivered in Varian Truebeam 2.5, energy 6 MV with Millennium 120 multileaf collimator (MLC). The PTV coverage (D95%) for PRO and PO were 98.7 ± 0.8 Gy, 98.8 ± 0.9 Gy, HI were 0.09 ± 0.02 and 0.09 ± 0.02, CI were 0.98 ± 0.01 and 0.99 ± 0.01. Monitor units (MU) for PRO and PO were 647.5 ± 137.9, 655.2 ± 138.4. The Portal dose results were [3%, 3mm (%) & 1 %, 1 mm (%)] for PO and PRO 100 ± 0.1, 95.1 ± 1.4 and 100 ± 0.1, 95.2 ± 1.3. For ArcCHECK were 99.9 ± 0.1, 94.7 ± 3.0 and 99.9 ± 0.1, 93.5 ± 3.9, respectively. Results showed that PTV coverage and OAR doses were comparable. For individual patients CI and HI of PO showed slightly higher values than PRO. MUs for PO were slightly increased as compared to PRO. MU per degree with each individual control points generated by PO showed a high degree of modulation compared to PRO. Hence, new PO optimizer can produce a comparable degree of plan while using the same PRO objectives.

Dosimetric impact of MLC positional errors on dose distribution in IMRT.

Optimizing the positional accuracy of multileaf collimators (MLC) for radiotherapy is important for dose accuracy and for reducing doses delivered to normal tissues. This study investigates dose sensitivity variations and complexity metrics of MLC positional error in volumetric modulated arc therapy and determines the acceptable ranges of MLC positional accuracy in several clinical situations. Treatment plans were generated for four treatment sites (prostate cancer, lung cancer, spinal, and brain metastases) using different treatment planning systems (TPSs) and fraction sizes. Each treatment plan introduced 0.25-2.0mm systematic or random MLC leaf bank errors. The generalized equivalent uniform dose (gEUD) sensitivity and complexity metrics (MU/Gy and plan irregularity) were calculated, and the correlation coefficients were assessed. Furthermore, the required tolerances for MLC positional accuracy control were calculated. The gEUD sensitivity showed the highest dependence of systematic positional error on the treatment site, followed by TPS and fraction size. The gEUD sensitivities were 6.7, 4.5, 2.5, and 1.7%/mm for Monaco and 8.9, 6.2, 3.4, and 2.3%/mm (spinal metastasis, lung cancer, prostate cancer, and brain metastasis, respectively) for RayStation. The gEUD sensitivity was strongly correlated with the complexity metrics (r=0.88-0.93). The minimum allowable positional error for MLC was 0.63, 0.34, 1.02, and 0.28mm (prostate, lung, brain, and spinal metastasis, respectively). The acceptable range of MLC positional accuracy depends on the treatment site, and an appropriate tolerance should be set for each treatment site with reference to the complexity metric. It is expected to enable easier and more detailed MLC positional accuracy control than before by reducing dose errors to patients at the treatment planning stage and by controlling MLC quality based on complexity metrics, such as MU/Gy.

Viability of the virtual cone technique using a fixed small multi-leaf collimator field for stereotactic radiosurgery of trigeminal neuralgia.

Dosimetric uncertainties in very small (≤1.5×1.5 cm2 ) photon fields are remarkably higher, which undermines the validity of the virtual cone (VC) technique with a diminutive and variable MLC fields. We evaluate the accuracy and reproducibility of the VC method with a very small, fixed MLC field setting, called a fixed virtual cone (fVC), for small target radiosurgery such as trigeminal neuralgia (TGN). The fVC is characterized by 0.5 cm x 0.5cm high-definition (HD) MLC field of 10MV FFF beam defined at 100cm SAD, while backup jaws are positioned at 1.5 cm x 1.5cm. A spherical dose distribution equivalent to 5mm (diameter) physical cone was generated using 10-14 non-coplanar, partial arcs. Dosimetric accuracy was validated using SRS diode (PTW 60018), SRS MapCHECK (SNC) measurements. As a quality assurance measure, 10 treatment plans (SRS) for TGN, consisting of various arc ranges at different collimator angles were analyzed using 6 MV FFF and 10 MV FFF beams, including a field-by-field study (n=130 fields). Dose outputs were compared between the Eclipse TPS and measurements (SRS MapCHECK). Moreover, dosimetric changes in the field defining fVC, prompted by a minute (±0.5-1.0mm) leaf shift, was examined among TPS, diode measurements, and Monte Carlo (MC) simulations. The beam model for fVC was validated (≤3% difference) using SRS MapCHECK based absolute dose measurements. The equivalent diameters of the 50% isodose distribution were found comparable to that of a 5mm cone. Additionally, the comparison of field output factors, dose per MU between the TPS and SRS diode measurements using the fVC field, including±1mm leaf shift, yielded average discrepancies within 5.5% and 3.5% for 6 MV FFF and 10 MV FFF beams, respectively. Overall, the fVC method is a credible alternative to the physical cone (5mm) that can be applied in routine radiosurgical treatment of TGN.

A convolution-superposition fluence model for the Siemens HD120 multi leaf collimator with application to a 3D VMAT dose engine

Purpose. To construct a fast-calculating fluence modelfor the Siemens HD120 multi leaf collimator (MLC) using convolution-superposition techniques, and to develop a 3D VMAT dose engine using this fluence model. This work offers analternative to time-consuming open-source Monte Carlo simulations for thosedeveloping in-house dose-calculating software for research or clinical needs.Methods. EPID-acquired images of sweeping-window and sweeping-checker field profiles were used to commission transmission, 2 Dinterleaf leakage, and tongue-and-groove maps specific to the HD120 MLC. These maps, along with a 2D head-scattermodel were incorporated into a convolution-superposition algorithm to provide a fluence model for the HD120 MLC. This fluence model was used to develop a 3D VMAT dose engine, where 3D pre-computed 6MV dose kernels (EGSnrc) and a 3D fluence curvature-correction map were incorporatedto calculate 3D VMAT doses in a 22 cm diameter cylindrical phantom. Four VMAT patient plans witha large range of PTV sizes (36 cc to 604 cc) were chosen to test the fluence model and dose engine. Results. Excellent agreement was observed between the simulated commissioning fields and measured EPID-responses. 2D 2%/2 mm gamma analysis yielded a 98.9% pass rate for 1 cm, 2 cm, and 4 cm sweeping-window fields. 2D 2%/2mm gamma analysis for outer/inner MLC leaves yielded 89.1%/77.0% and 95.2%/91.1% pass rates from 1 cm and 2 cm sweeping-checker fields. Mean 3%/3 mm gamma analysis showed excellent agreement between our dose engine and Eclipse (Acuros) regardless of PTV size: 98.7% pass rate, with 95.1% pass rate in the high-dose volume. Fluence calculation times were13.6 seconds per dynamic MLC field and 1.4 minutes/arc for 3D VMAT dose on a standard PC. Conclusions. A fast-calculating convolution-superposition fluence model has been commissioned for the Siemens HD120 MLC and incorporatedinto a 3D VMAT dose engine. This work can be used to facilitate the development of fast in-house dose-calculating software.

Robust mixed electron-photon radiation therapy planning for soft tissue sarcoma.

Mixed electron-photon beam radiation therapy (MBRT) is an emerging technique in which external electron and photon beams are simultaneously optimized into a single treatment plan. MBRT exploits the steep dose falloff and high surface dose of electrons while maintaining target conformity by leveraging the sharp penumbra ofphotons. This study investigates the dosimetric benefits of MBRT for soft tissue sarcoma (STS)patients. A retrospective cohort of 22 STS of the lower extremity treated with conventional photon-based Volumetric Modulated Arc Therapy (VMAT) were replanned with MBRT. Both VMAT and MBRT treatments were planned on the Varian TrueBeam linac using the Millenium multi-leaf collimator. No electron applicator, cutout or additional collimating devices were used for electron beams of MBRT plans. MBRT plans were optimized to use a combination of 6 MV photons and five electron energies (6, 9, 12, 16, 20 MeV) by a robust column generation algorithm. Electron beams in this study were planned at standard 100 cm source-axis distance (SAD). The dose to the clinical target volume (CTV), bone, normal tissue strip and other organs-at-risk (OARs) were compared using a Wilcoxon signed-ranktest. As part of the original VMAT treatment, tissue-equivalent bolus was required in 10 of the 22 patients. MBRT plans did not require bolus by virtue of the higher electron entrance dose. CTV coverage by the prescription dose was found to be clinically equivalent between plans of either modality: (MBRT) = 97.9 ± 0.2% versus (VMAT) = 98.1 ± 0.6% (p=0.34). Evaluating the absolute paired difference between doses to OARs in MBRT and VMAT plans, we observed lower to normal tissue in MBRT plans by 14.9 ± 3.2% ( ). Similarly, to bone was found to be decreased by 8.2 ± 4.0% ( ) of the bonevolume. For STS with subcutaneous involvement, MBRT offers statistically significant sparing of OARs without sacrificing target coverage when compared to VMAT. MBRT plans are deliverable on conventional linacs without the use of electron applicators, shortened source-to-surface distance (SSD) or bolus. This study shows that MBRT is a logistically feasible technique with clear dosimetricbenefits.

The effect of the tongue and groove of the multileaf collimator on dose distribution: examination of results of measurements and treatment planning system

Multileaf collimators play an important role in the field of radiotherapy and are widely used today. The effect of multileaf collimator structure on dose distribution should be well investigated and whether treatment planning systems reflect these effects on dose distribution should be examined. In our study, we examined the effect of tongue-and-groove on irregular fields and intensity-modulated radiotherapy plan. We also investigated the depth dependence of the tongue-and-groove effect. All fields are created in RayStation treatment planning system. Data obtained from treatment planning systems were compared with data obtained with 2-dimensional dose-measuring devices. We found the tongue-and-groove effect consistent in both measurements in single field measurements. We calculated dose reductions due to tongue-and-groove effect between 6% and 14%. When we examined the tongue-and-groove effect at different depths, we observed that the tongue-and-groove effect decreased as the depth increased. Although the tongue-and-groove effect did not create significant results on the dose distribution in multi-field use, we observed that this effect could occur at the edge of the field. Dose differences due to multileaf collimator structure should be examined by clinics. In addition, the extent to which treatment planning system takes these effects into account should be checked with some measurements. Otherwise, undesirable dose differences may be seen in the patient.

Machine Log File and Calibration Errors-based Patient-specific Quality Assurance (QA) for Volumetric Modulated Arc Therapy (VMAT).

Dose reconstructed based on linear accelerator (linac) log-files is one of the widely used solutions to perform patient-specific quality assurance (QA). However, it has a drawback that the accuracy of log-file is highly dependent on the linac calibration. The objective of the current study is to represent a new practical approach for a patient-specific QA during Volumetric modulated arc therapy (VMAT) using both log-file and calibration errors of linac. A total of six cases, including two head and neck neoplasms, two lung cancers, and two rectal carcinomas, were selected. The VMAT-based delivery was optimized by the TPS of Pinnacle^3 subsequently, using Elekta Synergy VMAT linac (Elekta Oncology Systems, Crawley, UK), which was equipped with 80 Multi-leaf collimators (MLCs) and the energy of the ray selected at 6 MV. Clinical mode log-file of this linac was used in this study. A series of test fields validate the accuracy of log-file. Then, six plans of test cases were delivered and log-file of each was obtained. The log-file errors were added to the corresponding plans through the house script and the first reconstructed plan was obtained. Later, a series of tests were performed to evaluate the major calibration errors of the linac (dose-rate, gantry angle, MLC leaf position) and the errors were added to the first reconstruction plan to generate the second reconstruction plan. At last, all plans were imported to Pinnacle and recalculated dose distribution on patient CT and ArcCheck phantom (SUN Nuclear). For the former, both target and OAR dose differences between them were compared. For the latter, γ was evaluated by ArcCheck, and subsequently, the surface dose differences between them were performed. Accuracy of log-file was validated. If error recordings in the log file were only considered, there were four arcs whose proportion of control points with gantry angle errors more than ± 1°larger than 35%. Errors of leaves within ± 0.5 mm were 95% for all arcs. The distinctness of a single control point MU was bigger, but the distinctness of cumulative MU was smaller. The maximum, minimum, and mean doses for all targets were distributed between -6.79E-02-0.42%, -0.38-0.4%, 2.69E-02-8.54E-02% respectively, whereas for all OAR, the maximum and mean dose were distributed between -1.16-2.51%, -1.21-3.12% respectively. For the second reconstructed dose: the maximum, minimum, and mean dose for all targets was distributed between 0.0995~5.7145%, 0.6892~4.4727%, 0.5829~1.8931% separately. Due to OAR, maximum and mean dose distribution was observed between -3.1462~6.8920%, -6.9899~1.9316%, respectively. Patient-specific QA based on the log-file could reflect the accuracy of the linac execution plan, which usually has a small influence on dose delivery. When the linac calibration errors were considered, the reconstructed dose was closer to the actual delivery and the developed method was accurate and practical.

THE COMPARISON OF 2D DOSE PATIENT-SPECIFIC QUALITY ASSURANCE BETWEEN MONTE CARLO-CONVOLUTION AND MODIFIED CLARKSON INTEGRATION ALGORITHM

A sophisticated machine of radiotherapy treatment process follows the complexity of the quality assurance (QA) measurement. Non-measurement QA becomes one of the solutions to reduce the medical physicists’ workload. However, this method has not been clinically established. This study compared two non-measurement methods of patient-specific quality assurance (PSQA) to find the feasible algorithm for the adaptive radiotherapy process. Monte Carlo-based (MC) PSQA used a phase space file of the medical linear accelerator (Linac) to obtain the photon energy fluence and forward projected to the isoplane. In contrast, Modified Clarkson Integration-based (MCI) used a non-uniform fluence map in the isoplane. For the modulated intensity, we used a pair of the dynamic log files of the multileaf-collimator (MLC) and then employed them in the algorithms. The dose distributions of MC and MCI methods were compared to the treatment planning system (TPS) using gamma index analysis. We found that the gamma pass rates (GPR) for MC-TPS and MCI-TPS were 99.54% and 99.57%, respectively. Further, the dose distribution in the off-axis region for the MCI method showed lesser accuracy due to the higher secondary dose contribution. The linac log file information can be used and calculated into a 2D dose distribution using both MC and MCI methods, providing high-accuracy results.

PRIMO Monte Carlo software as a tool for commissioning of an external beam radiotherapy treatment planning system.

The purpose was to validate the PRIMO Monte Carlo software to be used during the commissioning of a treatment planning system (TPS). The Acuros XB v. 16.1 algorithm of the Eclipse was configured for 6 MV and 6 MV flattening-filter-free (FFF) photon beams, from a TrueBeam linac equipped with a high-definition 120-leaf multileaf collimator (MLC). PRIMO v. 0.3.64.1814 software was used with the phase space files provided by Varian and benchmarked against the reference dosimetry dataset published by the Imaging and Radiation Oncology Core-Houston (IROC-H). Thirty Eclipse clinical intensity-modulated radiation therapy (IMRT)/volumetric modulated arc therapy (VMAT) plans were verified in three ways: 1) using the PTW Octavius 4D (O4D) system; 2) the Varian Portal Dosimetry system and 3) the PRIMO software. Clinical validation of PRIMO was completed by comparing the simulated dose distributions on the O4D phantom against dose measurements for these 30 clinical plans. Agreement evaluations were performed using a 3% global/2 mm gamma index analysis. PRIMO simulations agreed with the benchmark IROC-H data within 2.0% for both energies. Gamma passing rates (GPRs) from the 30 clinical plan verifications were (6 MV/6MV FFF): 99.4% ± 0.5%/99.9% ± 0.1%, 99.8% ± 0.4%/98.9% ± 1.4%, 99.7% ± 0.4%/99.7% ± 0.4%, for the 1), 2) and 3) verification methods, respectively. Agreement between PRIMO simulations on the O4D phantom and 3D dose measurements resulted in GPRs of 97.9% ± 2.4%/99.7% ± 0.4%. The PRIMO software is a valuable tool for dosimetric verification of clinical plans during the commissioning of the primary TPS.

Deep learning-based detection and classification of multi-leaf collimator modeling errors in volumetric modulated radiation therapy.

The purpose of this study was to create and evaluate deep learning-based models to detect and classify errors of multi-leaf collimator (MLC) modeling parameters in volumetric modulated radiation therapy (VMAT), namely the transmission factor (TF) and the dosimetric leaf gap (DLG). A total of 33 clinical VMAT plans for prostate and head-and-neck cancer were used, assuming a cylindrical and homogeneous phantom, and error plans were created by altering the original value of the TF and the DLG by±10, 20, and 30% in the treatment planning system (TPS). The Gaussian filters of and 1.0 were applied to the planar dose maps of the error-free plan to mimic the measurement dose map, and thus dose difference maps between the error-free and error plans were obtained. We evaluated 3 deep learning-based models, created to perform the following detections/classifications: (1) error-free versus TF error, (2) error-free versus DLG error, and (3) TF versus DLG error. Models to classify the sign of the errors were also created and evaluated. A gamma analysis was performed for comparison. The detection and classification of TF and DLG error were feasible for ; however, a considerable reduction of accuracy was observed for depending on the magnitude of error and treatment site. The sign of errors was detectable by the specifically trained models for and 1.0. The gamma analysis could not detect errors. We demonstrated that the deep learning-based models could feasibly detect and classify TF and DLG errors in VMAT dose distributions, depending on the magnitude of the error, treatment site, and the degree of mimicked measurement doses.

Applicability evaluation of the TRS-483 protocol for the determination of small-field output factors using different multi-leaf collimator and field-shaping types

PurposeTo evaluate the applicability of TRS-483 output correction factors (CFs) for small-field output factors (OFs) using different multi-leaf collimators (MLC) and field-shaping types. MethodsAll measurements were performed on TrueBeam, TrueBeam STx, and Halcyon using 6 MV flattening filter-free energy. Four detectors, including CC01, CC04, microDiamond, and EDGE, were used. Nominal field sizes ranging from 1 × 1 to 4 × 4, and 10 × 10 cm2 were used to measure small-field OFs at source-to-axis distance of 100 cm with a 0° gantry angle in a 3D water phantom. Further, the field-shaping types were defined using jaw collimator or MLC (five different configurations). A field size of 10 × 10 cm2 was used as the reference for calculation of OFs obtained as ratio of detector readings (OFdet). The percentage difference and coefficient of variation of OFdet and OFdet corrected by applying CF were compared for each field size and configuration. ResultsFor OFdet corrected by applying CF, the ranges of percentage difference and coefficient of variation in all configurations for ≥ 2 × 2 cm2 fields were reduced from 1.2–2.2 to 0.8–1.3 percentage points (%pt) and from 0.5–1.0 to 0.4–0.7%, respectively. For 1 × 1 cm2 field, the ranges of percentage difference and coefficient of variation were reduced from 3.3–5.7 to 1.2–2.2 %pt and from 2.2–3.7 to 0.8–1.1%, respectively. ConclusionsThe CFs described in TRS-483 dosimetry protocol have broad applicability in reducing OF variations between detectors under different MLC and field-shaping types.

Angular correction methodology and characterization of a high-resolution CMOS array for patient specific quality assurance on a robotic arm linac.

To develop an angular correction methodology and characterize a high-resolution complementary metal-oxide-semiconductor (CMOS) array for patient specific quality assurance on a robotic arm linear accelerator. Beam path files from the treatment planning software (TPS) were used to calculate the angle of radiation beam with respect to the detector plane. Beams from multiple discrete angles were delivered to the CMOS detector array and an angular dependency look up table (LUT) was created. The LUT was then used to correct for the angular dependency of the detector. An iso-centric 5mm fixed cone, non iso-centric multi-target fixed cone, 10mm Iris and a multi-leaf collimator (MLC) based collimated plan were delivered to the phantom and compared to the TPS with and without angular correction applied. Additionally, the CMOS array was compared to gafchromic film and a diode array. Large errors of up to 30% were observed for oblique angles. When angular correction was applied, the gamma passing rate increased from 99.2% to 100% (average gamma value decreased from 0.29 to 0.14) for the 5-mm iso-centric cone plan. Similarly, the passing rate increased from 84.0% to 100% for the Iris plan and from 49.98% to 98.4% for the MLC plan when angular correction was applied. For the multi-target plan, applying angular correction improved the gamma passing rate from 94% to 99.6%. The 5mm iso-centric fixed cone plan was also delivered to film, and the gamma passing rate was 91.3% when using gafchromic film as the reference dataset, whereas the diode array provided insufficient sampling for this plan. A methodology of calculating the beam angle based on the beam path files was developed and validated. The array was demonstrated to be superior to other quality assurance tools because of its sub-millimeter spatial resolution and immediate read out of the results.

The effects of flattening filter-free beams and aperture shape controller on the complexity of conventional large-field treatment plans.

The purpose of this study was to investigate the impact of using flattening filter-free (FFF) beams and the aperture shape controller (ASC) on the complexity of conventional large-field treatment plans. A total of 24 head and neck (H&N) and 24 prostate with pelvic nodes treatment plans were used in this study. Each plan was reoptimized using the original clinical objectives with both flattened and FFF beams, as well as six different ASC settings. The dosimetric qualities of each plan cohort were evaluated using commonly used dose-volume histogram values, and plan complexities were assessed through metrics including monitor unit (MU)/Dose, change in gantry speed, multileaf collimator (MLC) speed, the edge area ratio metric (EM), and the equivalent square length. No significant differences in dosimetric qualities were found between plans with flattened and FFF beams. The ASC settings did not have significant effects on dosimetric qualities in the H&N plan cohort, but the "very high" ASC setting resulted in poorer dosimetric results for the prostate plans. Plans with FFF beams had significantly higher MU/Dose compared to plans with flattened beams. The use of flattening filter (FF) had significant effects on the change in gantry speed, with flattened beams producing plans that required higher change in gantry speed. However, the FF did not have significant effects on MLC speed, EM, or equivalent square length. In contrast, ASC settings had significant effects on these three metrics; increasing the ASC level resulted in plans with decreasing MLC speed, lower edge area ratio, and higher equivalent square length. This study demonstrated that using FFF beams with various ASC settings, except for the "very high" level, can produce plans with reduced complexities without compromising dosimetric qualities in conventional large-field treatment plans.

Structural Design and Penumbra Analysis of Dynamic Multi-leaf Collimator Leaf End

Dynamic multi-leaf collimator, which has the function of radiation beam shaping, is a key executive component of tumor precise radiotherapy, and plays a core role in improving the accuracy, efficiency and quality of radiotherapy. A new type of collimator leaf end structure with circular arc and plane combination was studied, and collimator penumbra performance analysis model combining analytical expression and graphic analysis was developed. The influence of leaf end structure on penumbra was analyzed quantitatively, and a set of three-dimensional structure design of dynamic multi-leaf collimator was completed. The feasibility of the structural design and analysis model was verified through experimental measurements.

Transmission probability filter optimization for Agility MLC in Monaco treatment planning system.

In the Monte Carlo-based treatment planning system (TPS) Monaco, transmission probability filters (TPF) are utilized to describe the transmission through the multi leaf collimator (MLC). By having knowledge of the TPF parameters for various photon beam energies, adjusting the MLC transmission parameters becomes easier, enhancing the accuracy of the Monte Carlo algorithm in achieving a dose distribution that closely aligns with the irradiated dose at the Versa HD linear accelerator (linac). The objective of this study was to determine the TPF parameters for 6MV, 10MV, 6MV flattening filter free (FFF) and 10MV FFF for a Versa HD linac equipped with Agility MLC. The TPF parameters were adjusted using point dose measurements and vendor-provided fields specifically designed to fine-tune the MLC. After adjusting the TPF parameters, a gamma passing rate (GPR) analysis was conducted on 25 treatment plans to ensure that the Monte Carlo model, with the updated TPF parameters, accurately matched the actual linac delivery. The TPF values ranged from 0.0018 to 0.0032 for leaf transmission and 1.15 to 1.25 for Leaf Tip leakage across the different energies. The average GPR ranged from 97.8% for 10MV FFF to 98.5% for 6MV photon energies. Additionally, the TPF parameters for 6MV obtained in this study were consistent with previously published TPF values for 6MV photon energy. Hence, it was concluded that optimizing the TPF does not need to be performed for every individual Versa HD linac with Agility MLC. Instead, the published parameters can be applied to other Versa HD linacs to enhance clinical accuracy. In conclusion, this study determined the TPF parameters for 6MV and previously unpublished photon energies 10MV, 6MV FFF and 10MV FFF. These parameters can be easily transferred to other facilities, resulting in improved agreement between the dose distribution from the TPS and the linac.