On-board Imaging Research Articles

Towards Clinical Proton Minibeam Radiation Therapy (pMBRT): Development of Clinical pMBRT System Prototype and pMBRT-Specific Treatment Planning Method

Proton minibeam radiation therapy (pMBRT) is an emerging spatially fractionated RT (SFRT) modality that can provide very high therapeutic index compared to conventional radiotherapy methods and clinically-available SFRT methods (GRID and LATTICE). The biological data collected thus far encourage the preparation of clinical trials in pMBRT. This work is to facilitate the clinical translation of pMBRT by developing (1) the first clinical pMBRT system prototype worldwide, readily available for both small-animal biology studies and large-animal pMBRT trials; (2) pMBRT-specific treatment planning method with peak-valley dose ratio (PVDR) optimization capability for large animal and patient pMBRT trials, which is currently unavailable. The pMBRT system is based on clinically-used pencil-beam-scanning proton machine equipped with large-field clinical-size pMBRT collimator, pMBRT-dedicated treatment planning system, and KV/CBCT imaging guidance. The multi-slit brass collimator has 10 × 10 cm field size, 0.4mm width per slit and 4 mm center-to-center distance. The divergence of slits is tailed to the divergence of the proton beam. A unique universal collimator design is implemented, so that we can keep the outer fitting to the snout and conveniently inter-change collimators as needed. The pMBRT-specific treatment planning method jointly optimizes PVDR and dose objectives, to meet a minimal PVDR threshold and maximize PVDR, to avoid the situations where meeting dose objectives can compromise PVDR when PVDR were not optimized. In addition, the survival fraction for organs at risk is also optimized. The dose calculation engine is based on the Monte Carlo method using TOPAS. The optimization algorithm utilizes total variation and L1 sparsity regularization to maximize PVDR and iterative convex relaxation method to solve the optimization problem. Monte Carlo simulations via TOPAS were performed to design this large-field multi-slit collimator, using the beam structure and the beam data specific to our proton system, with mean dose rate of 8 Gy/min under clinical condition with the collimator in place. The feasibility of using this pMBRT system for small-animal studies has been demonstrated, with customized 3D printed holder for immobilizing small animals, on-board KV imaging system for accurate small-animal positioning, and the GAFchromic film for verifying radiation dose and PVDR. On the other hand, the efficacy of pMBRT-specific treatment planning method (with PVDR optimization capability) to improve PVDR has been demonstrated using retrospective patient planning studies in comparison with standard proton treatment planning method (without PVDR optimization capability). The initial development of a clinical pMBRT system prototype and pMBRT-specific treatment planning method of PVDR optimization capability has been completed with ongoing efforts to make this system ready for large-animal pMBRT studies.

The application of 3D-printed oral stents in intensity-modulated radiotherapy for oropharyngeal cancer and their dosimetric effect on organs at risk

BackgroundThis study investigates the accuracy of 3D-printed dental stents in intensity-modulated radiotherapy (IMRT) for oropharyngeal cancer (OPC) and their dosimetric effects on normal tissues.MethodsWe selected 60 patients with OPC who underwent IMRT in the Department of Oncology, Special Medical Center of Army Medical University. These patients were randomly assigned into 3D-printed oral stent, simple glass bottle, and nonstent groups (20 patients/group). The positioning error was analyzed with the onboard imaging system once a week after 5 fractions of IMRT. The conformity index (CI), homogeneity index (HI), radiation dose of organs at risk (OARs), and oral mucosal reaction were compared among the three groups.ResultsNo significant difference was observed in the conformity and uniformity of the target dose and the dose received by the spinal cord, larynx, and bilateral parotid glands among the three groups (P > 0.05). Meanwhile, the dose received by the upper cheek, hard palate, and soft palate of patients was significantly lower in the 3D-printed oral stent group than in the nonstent group (P < 0.05) but insignificantly different between the 3D-printed oral stent and simple glass bottle groups (P > 0.05). When compared with the nonstent group, the simple glass bottle group showed a markedly lower dose received by the upper cheek (P < 0.05) and an insignificantly different dose received by the hard palate and soft palate (P > 0.05). According to Common Terminology Criteria for Adverse Events v.5.0, the adverse response rate of the hard palate mucosa was lower in the 3D-printed oral stent group than in the simple glass bottle and nonstent groups (P < 0.05).ConclusionsFor OPC patients undergoing IMRT, the application of 3D-printed oral stents can significantly reduce the exposure dose of the upper cheek and hard palate and decrease the occurrence of adverse events such as oral mucositis although it cannot affect the positioning error.

Complete patient exposure during paediatric brain cancer treatment for photon and proton therapy techniques including imaging procedures.

In radiotherapy, especially when treating children, minimising exposure of healthy tissue can prevent the development of adverse outcomes, including second cancers. In this study we propose a validated Monte Carlo framework to evaluate the complete patient exposure during paediatric brain cancer treatment. Organ doses were calculated for treatment of a diffuse midline glioma (50.4 Gy with 1.8 Gy per fraction) on a 5-year-old anthropomorphic phantom with 3D-conformal radiotherapy, intensity modulated radiotherapy (IMRT), volumetric modulated arc therapy (VMAT) and intensity modulated pencil beam scanning (PBS) proton therapy. Doses from computed tomography (CT) for planning and on-board imaging for positioning (kV-cone beam CT and X-ray imaging) accounted for the estimate of the exposure of the patient including imaging therapeutic dose. For dose calculations we used validated Monte Carlo-based tools (PRIMO, TOPAS, PENELOPE), while lifetime attributable risk (LAR) was estimated from dose-response relationships for cancer induction, proposed by Schneider etal. Out-of-field organ dose equivalent data of proton therapy are lower, with doses between 0.6 mSv (testes) and 120 mSv (thyroid), when compared to photon therapy revealing the highest out-of-field doses for IMRT ranging between 43 mSv (testes) and 575 mSv (thyroid). Dose delivered by CT ranged between 0.01 mSv (testes) and 72 mSv (scapula) while a single imaging positioning ranged between 2 μSv (testes) and 1.3 mSv (thyroid) for CBCT and 0.03 μSv (testes) and 48 μSv (scapula) for X-ray. Adding imaging dose from CT and daily CBCT to the therapeutic demonstrated an important contribution of imaging to the overall radiation burden in the course of treatment, which is subsequently used to predict the LAR, for selected organs. The complete patient exposure during paediatric brain cancer treatment was estimated by combining the results from different Monte Carlo-based dosimetry tools, showing that proton therapy allows significant reduction of the out-of-field doses and secondary cancer risk in selected organs.

In silico trial of simulation-free hippocampal-avoidance whole brain adaptive radiotherapy

Background and PurposeHippocampal-avoidance whole brain radiotherapy (HA-WBRT) can be a time-consuming process compared to conventional whole brain techniques, thus potentially limiting widespread utilization. Therefore, we evaluated the in silico clinical feasibility, via dose-volume metrics and timing, by leveraging a computed tomography (CT)-based commercial adaptive radiotherapy (ART) platform and workflow in order to create and deliver patient-specific, simulation-free HA-WBRT. Materials and methodsTen patients previously treated for central nervous system cancers with cone-beam computed tomography (CBCT) imaging were included in this study. The CBCT was the adaptive image-of-the-day to simulate first fraction on-board imaging. Initial contours defined on the MRI were rigidly matched to the CBCT. Online ART was used to create treatment plans at first fraction. Dose-volume metrics of these simulation-free plans were compared to standard-workflow HA-WBRT plans on each patient CT simulation dataset. Timing data for the adaptive planning sessions were recorded. ResultsFor all ten patients, simulation-free HA-WBRT plans were successfully created utilizing the online ART workflow and met all constraints. The median hippocampi D100% was 7.8 Gy (6.6–8.8 Gy) in the adaptive plan vs 8.1 Gy (7.7–8.4 Gy) in the standard workflow plan. All plans required adaptation at first fraction due to both a failing hippocampal constraint (6/10 adaptive fractions) and sub-optimal target coverage (6/10 adaptive fractions). Median time for the adaptive session was 45.2 min (34.0–53.8 min). ConclusionsSimulation-free HA-WBRT, with commercially available systems, was clinically feasible via plan-quality metrics and timing, in silico.

Monte Carlo model of a prototype flat-panel detector for multi-energy applications in radiotherapy.

The incorporation of multi-energy capabilities into radiotherapy flat-panel detectors offers advantages including enhanced soft tissue visualization by reduction of signal from overlapping anatomy such as bone in 2D image projections; creation of virtual monoenergetic images for 3D contrast enhancement, metal artefact reduction and direct acquisition of relative electron density. A novel dual-layer on-board imager offering dual energy processing capabilities is being designed. As opposed to other dual-energy implementation techniques which require separate acquisition with two different x-ray spectra, the dual-layer detector design enables simultaneous acquisition of high and low energy images with a single exposure. A computational framework is required to optimize the design parameters and evaluate detector performance for specific clinical applications. In this study, we report on the development of a Monte Carlo (MC) model of the imager including model validation. The stack-up of the dual-layer imager (DLI) was implemented in GEANT4 Application for Tomographic Emission (GATE). The DLI model has an active area of 43×43 cm2 , with top and bottom Cesium Iodide (CsI) scintillators of 600 and 800μm thickness, respectively. Measurement of spatial resolution and imaging of dedicated multi-material dual-energy (DE) phantoms were used to validate the model. The modulation transfer function (MTF) of the detector was calculated for a 120 kVp x-ray spectrum using a 0.5mm thick tantalum edge rotated by 2.5o . For imaging validation, the DE phantom was imaged using a 140 kVp x-ray spectrum. For both validation simulations, corresponding measurements were done using an initial prototype of the imager. Agreement between simulations and measurement was assessed using normalized root mean square error (NRMSE) and 1D profile difference for the MTF and phantom images respectively. Further comparison between measurement and simulation was made using virtual monoenergetic images (VMIs) generated from basis material images derived using precomputed look-up tables. The MTF of the bottom layer of the dual-layer model shows values decreasing more quickly with spatial frequency, compared to the top layer, due to the thicker bottom scintillator thickness and scatter from the top layer. A comparison with measurement shows NRMSE of 0.013 and 0.015 as well as identical MTF50 of 0.8 mm1 and 1.0 mm1 for the top and bottom layer respectively. For the DE imaging of the DE-phantom, although a maximum deviation of 3.3% is observed for the 10mm aluminum and Teflon inserts at the top layer, the agreement for all other inserts is less than 2.2% of the measured value at both layers. Material decomposition of simulated scatter-free DE images gives an average accuracy in PMMA and aluminum composition of 4.9% and 10.3% for 11-30mm PMMA and 1-10mm aluminum objects respectively. A comparison of decomposed values using scatter containing measured and simulated DE images shows good agreement within statistical uncertainty. Validation using both MTF and phantom imaging shows good agreement between simulation and measurements. With the present configuration of the digital prototype, the model can generate material decomposed images and virtual monoenergetic images.

Spine Stereotactic Body Radiation Therapy Without Immobilization: Detailed Analysis of Intrafraction Motion Using High-Frequency kV Imaging During Irradiation

Spine SBRT requires high positioning accuracy and a stable patient to maximize target coverage and reduce excessive irradiation to organs at risk (OARs). Positional verification during spine SBRT delivery helps to ensure accurate positioning for all patients. We report our experience with non-invasive 3-dimensional (3D) target position monitoring during volumetric modulated arc therapy (VMAT) of spine metastases, in non-immobilized patients positioned using only a thin mattress and simple arm and knee supports. Fluoroscopic planar kV images were acquired at 7 frames/second using the on-board imaging system during VMAT spine SBRT. Template matching and triangulation were used to track the target in vertical, longitudinal and lateral direction. If the tracking trace deviated >1mm from the planned position in ≥1 direction, treatment was manually interrupted and 6D CBCT-based couch correction was performed. Tracking data was used to retrospectively analyze the target position. Positional data, agreement with CBCT, correlation between position of the couch and direction of any positional correction, and treatment times were analyzed. 175 fractions were analyzed. Delivery was interrupted 83 times in 66 fractions for a deviation >1mm. In 97% of cases the difference between tracking data and subsequent clinical shift performed after the CBCT match was ≤0.5mm. Lateral/longitudinal shift performed after intervention correlated with the couch roll/pitch at the start of treatment (correlation coefficient: -0.63/0.53). Mean (SD; range) time between start of first imaging and end of the last arc was 15.2 minutes (5.1;7.6-36.3). Spine tracking during irradiation can be used to prompt an intervention CBCT scan and repositioning, so that a spine SBRT target deviates by ≤1mm from the planned position, even in non-immobilized patients. kV tracking and CBCT are in good agreement. The data support verification CBCT after all 6 degrees-of-freedom positional corrections in non-immobilized spine SBRT patients.

The Radiotherapy: Basic Concepts And Recent Techniques Advances For Thoracic Malignancies.

Radiation therapy (RT) is a clinical modality treatment that uses ionizing radiation in the approach of malignant tumors, (and occasionally benign diseases). Since its inception, the goal of RT has been to cure cancer without excessive side effects. The most important factors affecting the results of RT are the tumor histology, its location and regional extent, the anatomic area of involvement and the geometric accuracy with which a calculated radiation dose is delivered. Radiotherapy is one of the basic treatment modalities in thoracic malignancies and is used across all histology types and stages. Technical developments of radiotherapy have further strengthened and redefined its place in the management of lung cancer. High precision intensity-modulated radiation therapy, volumetric modulated arc therapy, and stereotactic body radiation therapy (SBRT), coupled with management of tumor motion and on-board imaging, increased efficacy and markedly decreased treatment-related toxicity. With this brief review, the authors pretend to present basic concepts and recent techniques advances in the use of radiation therapy for thoracic malignancies.

Enhancing the target visibility with synthetic target specific digitally reconstructed radiograph for intrafraction motion monitoring: A proof-of-concept study.

Intrafraction motion monitoring in External Beam Radiation Therapy (EBRT) is usually accomplished by establishing a correlation between the tumor and the surrogates such as an external infrared reflector, implanted fiducial markers, or patient skin surface. These techniques either have unstable surrogate-tumor correlation or are invasive. Markerless real-time onboard imaging is a noninvasive alternative that directly images the target motion. However, the low target visibility due to overlapping tissues along the X-ray projection path makes tumor tracking challenging. To enhance the target visibility in projection images, a patient-specific model was trained to synthesize the Target Specific Digitally Reconstructed Radiograph (TS-DRR). Patient-specific models were built using a conditional Generative Adversarial Network (cGAN) to map the onboard projection images to TS-DRR. The standard Pix2Pix network was adopted as our cGAN model. We synthesized the TS-DRR based on the onboard projection images using phantom and patient studies for spine tumors and lung tumors. Using previously acquired CT images, we generated DRR and its corresponding TS-DRR to train the network. For data augmentation, random translations were applied to the CT volume when generating the training images. For the spine, separate models were trained for an anthropomorphic phantom and a patient treated with paraspinal stereotactic body radiation therapy (SBRT). For lung, separate models were trained for a phantom with a spherical tumor insert and a patient treated with free-breathing SBRT. The models were tested using Intrafraction Review Images (IMR) for the spine and CBCT projection images for the lung. The performance of the models was validated using phantom studies with known couch shifts for the spine and known tumor deformation for the lung. Both the patient and phantom studies showed that the proposed method can effectively enhance the target visibility of the projection images by mapping them into synthetic TS-DRR (sTS-DRR). For the spine phantom with known shifts of 1 mm, 2 mm, 3 mm, and 4 mm, the absolute mean errors for tumor tracking were 0.11 ± 0.05 mm in the x direction and 0.25 ± 0.08 mm in the y direction. For the lung phantom with known tumor motion of 1.8 mm, 5.8 mm, and 9 mm superiorly, the absolute mean errors for the registration between the sTS-DRR and ground truth are 0.1 ± 0.3 mm in both the x and y directions. Compared to the projection images, the sTS-DRR has increased the image correlation with the ground truth by around 83% and increased the structural similarity index measure with the ground truth by around 75% for the lung phantom. The sTS-DRR can greatly enhance the target visibility in the onboard projection images for both the spine and lung tumors. The proposed method could be used to improve the markerless tumor tracking accuracy for EBRT.

Feasibility study of CdZnTe and CdZnTeSe based high energy X-ray detector using linear accelerator

CdZnTeSe (CZTS) has attracted attention for applications in X- and gamma-ray detectors owing to its improved properties compared to those of CdZnTe (CZT). In this study, we grew and processed single crystals of CZT and CZTS using the Bridgeman method to confirm the feasibility of using a dosimeter for high-energy X-rays in radiotherapy. We evaluated their linearity and precision using the coefficient of determination (R2) and relative standard deviation (RSD). CZTS showed sufficient RSD values lower than 1.5% of the standard for X-ray dosimetry, whereas CZT's RSD values increased dramatically under some conditions. CZTS exhibited an R2 value of 0.9968 at 500 V/cm, whereas CZT has an R2 value of 0.9373 under the same conditions. The X-ray response of CZTS maintains its pulse shape at various dose rates, and its properties are improved by adding selenium to the CdTe matrix to lower the defect density and sub-grain boundaries. Thus, we validated that CZTS shows a better response than CZT to high-energy X-rays used for radiotherapy. Further, the applicability of an onboard imager, a high-energy X-ray (>6 MV) image, is presented. The proposed methodology and results can guide future advances in X-ray dose detection.

Application of repeat image analysis to radiation therapy imaging modalities as a quality improvement tool for image guided radiotherapy.

Repeat images contribute to excess patient dose and workflow inefficiencies and can be analyzed to identify potential areas for improvement within a program. Although routinely used in diagnostic imaging, repeat image analysis is not widely used in radiation therapy imaging, despite the role of imaging in the delivery of precise radiation treatments. Repeat image analysis was performed for on-board cone beam CT imagers and CT simulators within a radiation therapy department. Both the rate of repeat images and the reasons for the repeat images were analyzed. Data from nine conventional linear accelerators and three CT simulators were analyzed retrospectively over a 5-month period. Repeated images that were not part of the standard of care were considered repeat images. The repeat rate was expressed as the number of repeat scans as percentage of the total number of scans performed. The reasons for the repeats were collected and classified as either patient preparation, patient setup, patient motion, or machine error. These reasons were further classified into sub-categories. The overall repeat rate across the linear accelerators was 3.3%, with a maximum of 5% on any single machine. The repeat rate for the three CT simulators was 1.5%. The most common reasons for repeat images were patient preparation (incorrect bladder or rectal filling) and patient setup or positioning. Greater positioning challenges led to higher repeat rates on units that treat a large number of breast patients, palliative patients, or pediatric patients. Repeat image analysis can be applied within a radiation therapy department. Establishing baseline repeat rates and analyzing reasons for the repeat images can identify opportunities for improvements in terms of patient dose reduction and workflow efficiency for the program. Periodic repeat image analysis also permits monitoring the program for changes and for comparison against rates at other institutions.

PO-1734 Daily Elekta Unity beam checks with the on-board MV imager during the first year of clinical use

PO-1734 Daily Elekta Unity beam checks with the on-board MV imager during the first year of clinical use

Assessment of Setup Errors in Gynecological Malignancies Treated With Radiotherapy Using Onboard Imaging.

Introduction Radiotherapy plays a vital role in the management of gynecological malignancies. However, maintaining patient position poses a challenge during daily radiotherapy treatment of these patients. This study identifies and calculates setup errors in interfraction radiotherapy and optimum clinical target volume-planning target volume (CTV-PTV) margins in patients with gynecological malignancies. Material and methods A total of 38 patients with gynecological malignancies were included in the study. They were treated with a dose of 50 Gy in 25 fractions for five weeks, followed by brachytherapy. All patients were immobilized using a 4-point thermoplastic cast. Anteroposterior and lateral images were taken thrice weekly for five weeks. Setup verification was done using kilovoltage images obtained using Varian On-board Imager (Varian Medical System, Inc., Palo Alto, CA). Manual matching was done utilizing bony landmarks such as the widest portion of the pelvic brim, anterior border of S1 vertebrae, and pubic symphysis in the X, Y, and Z axes, respectively. Results A total of 1140 images were taken. The individual systematic errors ranged from -0.24 to 0.17 cm (LR), -0.15 to 0.19 cm (AP) and -0.36 to 0.29 cm (CC) while the individual random errors ranged from 0.04 to 0.36 cm (LR), 0.06 to 0.33 cm (AP) and 0.10 to 0.29 cm (CC). The calculated CTV-PTV margins in LR, AP and CC directions were 0.17, 0.18, and 0.25 cm (ICRU-62); 0.28, 0.31 and 0.47 cm in LR, AP and CC directions (Stroom's), and 0.32, 0.36 and 0.55 cm (Van Herk) respectively. Conclusion Based on this study, the calculated CTV-PTV margin is 6 mm in gynecological malignancies, and the present protocol of 7 mm of PTV margin is optimum.

Predicting tumour and normal tissue response during radiotherapy using radiomic analysis from on-board imaging: a systematic review

Predicting tumour and normal tissue response during radiotherapy using radiomic analysis from on-board imaging: a systematic review

Effect of 0.35 T and 1.5 T magnetic fields on superficial dose in MR-guided radiotherapy of laryngeal cancer

BackgroundTreatment of head and neck cancer on linear accelerators with on-board magnetic resonance imaging (MR-linac) might be beneficial to reduce side effects and increase accuracy. For many head and neck cancer patients, dose coverage of the often superficially located planning target volumes (PTVs) is required. This study examines the impact of the electron return effect (ERE) on the surface dose in MR-guided radiotherapy (MRgRT) compared to conventional radiotherapy. Materials and methodsFor this bicentric dosimetric study, 14 cases of laryngeal carcinomas with PTVs reaching up to the skin surface were included. For each patient, five different plans were compared, two VMAT plans (with and without a 5 mm bolus) and three IMRT MRgRT plans (0.35 T, 1.5 T and 0 T, each without bolus). Dose distributions were also validated with film measurements. ResultsA similar coverage on the most superficial 3–5 mm of the PTV was achieved in the VMAT plans with bolus and the MRgRT plans for both 0.35 T and 1.5 T. However, coverage on this region was usually not achieved for VMAT without bolus and the 0 T plans. The film measurements on phantoms confirmed the results with the relative error never exceeding the calculated differences between the plans. ConclusionThe present study could demonstrate that the ERE for both commercially available MR-linac variants provides sufficient coverage of the superficial tissue layers in MRgRT-plans for laryngeal carcinoma.

Investigation of Radiochromic Film Use for Source Position Verification through a LINAC On-Board Imager (OBI)

Background and Objectives: Quality assurance is an integral part of brachytherapy. Traditionally, radiographic films have been used for source position verification, however, in many clinics, computerized tomography simulators have replaced conventional simulators, and computerized radiography systems have replaced radiographic film processing units. With these advances, the problem of controlling source position verification without traditional radiographic films and conventional simulators has appeared. Materials and Methods: In this study, we investigated an alternative method for source position verification for brachytherapy applications. Source positions were evaluated using Gafchromic™ RTQA2 and EBT3 film and visually compared to exposed RTQA radiochromic film when using a Nucletron Oldelft Simulix HP conventional simulator and a Gammamed 12-i brachytherapy device for performance evaluation. Gafchromic film autoradiography was performed with a linear accelerator (LINAC) on-board imager (OBI). Radiochromic films are very suitable for evaluation by visual inspection with a LINAC OBI. Results: The results showed that this type of low-cost, easy-to-find material can be used for verification purposes under clinical conditions. Conclusions: It can be concluded that source-position quality assurance may be performed through a LINAC OBI device.

Assessment of organ and size-specific effective doses from cone beam CT (CBCT) in image-guided radiotherapy (IGRT) based on body mass index (BMI)

The ability of radiation therapy to deliver radiation doses accurately to tumour targets, while sparing normal tissues, has advanced remarkably over recent decades. A development that has been key to achieving this improvement has been the application of image-guidance that facilitates more precise delivery of the prescribed dose to the treatment site. A recent international survey showed that kV cone beam CT (CBCT) is the imaging modality used most widely for image guided radiation therapy (IGRT) procedures. However, IGRT will deliver additional radiation doses to patients that should be considered. The aims of this study were to (1) estimate organ and size-specific effective doses resulting from kV-CBCT chest and pelvis scans based on body mass index (BMI) of the patient, and (2) investigate the influence of patient size on imaging dose. A validated Monte Carlo model developed with BEAMnrc/EGSnrc was employed to simulate kV spectra generated by Varian on-board imaging (OBI) system. Organ and size-specific effective doses were assessed for adult phantoms in the National Cancer Institute (NCI) phantom library using DOSXYZnrc/EGSnrc code. The library has been reconstructed from images of CT patients, and contains 100 male and 93 female phantoms of a wide range of sizes. The phantoms were grouped into six categories based on body mass index (BMI) as classified by the world health organization. For all sizes, average doses to organs that lay fully or partially inside the field of the chest and pelvic scans were in the range of (0.20–3.06 mGy/100 mAs) and (0.17–4.47 mGy/100 mAs), and size-specific effective doses were (0.63 – 1.78 mSv/100 mAs) and (0.30 – 1.17 mSv/100 mAs), respectively. Patient size played a significant role in determining the imaging doses resulting from both scans. In general, organ and effective doses of chest and pelvic scans of thin patients were about 2–3 times larger than those of obese patients, with the impact of patient size on pelvis doses being slightly higher than on chest ones. Results of this study suggests that patient size should be taken into consideration when estimation and optimization of the imaging doses resulting from CBCT. Although development of patient size-specific CBCT protocols is a practical approach that can account for patient size, it has not been implemented worldwide. Results from this investigation might be used as a simple approach to obtain an estimation of the imaging doses for patients of various sizes based on BMI.

Evaluating on-board kVCT- and MVCT-based dose calculation accuracy using a thorax phantom for helical tomotherapy treatments

Purpose. To evaluate the impact of CT number calibration and imaging parameter selection on dose calculation accuracy relative to the CT planning process in thoracic treatments for on-board helical CT imaging systems used in helical tomotherapy. Methods and Materials. Direct CT number calibrations were performed with appropriate protocols for each imaging system using an electron density phantom. Large volume and SBRT treatment plans were simulated and optimized for planning CT scans of an anthropomorphic thorax phantom and transferred to registered kVCT and MVCT scans of the phantom as appropriate. Relevant DVH metrics and dose-difference maps were used to evaluate and compare dose calculation accuracy relative to the planning CT based on a variation in imaging parameters applied for the on-board systems. Results. For helical kVCT scans of the thorax phantom, median differences in DVH parameters for the large volume treatment plan were less than ±1% with dose to the target volume either over- or underestimated depending on the imaging parameters utilized for CT number calibration and thorax phantom acquisition. For the lung SBRT plan calculated on helical kVCT scans, median dose differences were up to –2.7% with a more noticeable dependence on parameter selection. For MVCT scans, median dose differences for the large volume plan were within +2% with dose to the target overestimated regardless of the imaging protocol. Conclusion. Accurate dose calculations (median errors of <±1%) using a thorax phantom simulating realistic patient geometry and scatter conditions can be achieved with images acquired with a helical kVCT system on a helical tomotherapy unit. This accuracy is considerably improved relative to that achieved with the MV-based approach. In a clinical setting, careful consideration should be made when selecting appropriate kVCT imaging parameters for this process as dose calculation accuracy was observed to vary with both parameter selection and treatment type.

AAPM Task Group Report 306: Quality control and assurance for tomotherapy: An update to Task Group Report 148.

Since the publication of AAPM Task Group (TG) 148 on quality assurance (QA) for helical tomotherapy, there have been many new developments on the tomotherapy platform involving treatment delivery, on-board imaging options, motion management, and treatment planning systems (TPSs). In response to a need for guidance on quality control (QC) and QA for these technologies, the AAPM Therapy Physics Committee commissioned TG 306 to review these changes and make recommendations related to these technology updates. The specific objectives of this TG were (1) to update, as needed, recommendations on tolerance limits, frequencies and QC/QA testing methodology in TG 148, (2) address the commissioning and necessary QA checks, as a supplement to Medical Physics Practice Guidelines (MPPG) with respect to tomotherapy TPS and (3) to provide risk-based recommendations on the new technology implemented clinically and treatment delivery workflow. Detailed recommendations on QA tests and their tolerance levels are provided for dynamic jaws, binary multileaf collimators, and Synchrony motion management. A subset of TPS commissioning and QA checks in MPPG 5.a. applicable to tomotherapy are recommended. In addition, failure mode and effects analysis has been conducted among TG members to obtain multi-institutional analysis on tomotherapy-related failure modes and their effect ranking.

Beam output checks of a commercial high-field magnetic resonance-guided radiotherapy machine with its on-board megavoltage imager.

Beam output checks of a commercial high-field magnetic resonance-guided radiotherapy machine can be performed with its on-board megavoltage imager (MVI). This is a fast and efficient method, but only recommended for daily checks. The aim of our study was to show its suitability for weekly checks by investigating its long-term agreement with the golden standard: ionization chamber measurements in a water tank. For one year, the output deviations obtained with both methods were compared. The difference was 0.1±0.3 (1SD) percentage point. This indicated an excellent agreement, and translated into a tolerance level of±2%.

Evaluation of Dose Calculation Based on Cone-Beam CT Using Different Measuring Correction Methods for Head and Neck Cancer Patients.

Purpose: To investigate and compare 2 cone-beam computed tomography (CBCT) correction methods for CBCT-based dose calculation. Materials and Methods: Routine CBCT image sets of 12 head and neck cancer patients who received volumetric modulated arc therapy (VMAT) treatment were retrospectively analyzed. The CBCT images obtained using an on-board imager (OBI) at the first treatment fraction were firstly deformable registered and padded with the kVCT images to provide enough anatomical information about the tissues for dose calculation. Then, 2 CBCT correction methods were developed and applied to correct CBCT Hounsfield unit (HU) values. One method (HD method) is based on protocol-specific CBCT HU to physical density (HD) curve, and the other method (HM method) is based on histogram matching (HM) of HU value. The corrected CBCT images (CBCTHD and CBCTHM for HD and HM methods) were imported into the original planning system for dose calculation based on the HD curve of kVCT (the planning CT). The dose computation result was analyzed and discussed to compare these 2 CBCT-correction methods. Results: Dosimetric parameters, such as the Dmean, Dmax and D5% of the target volume in CBCT plan doses, were higher than those in the kVCT plan doses; however, the deviations were less than 2%. The D2%, in parallel organs such as the parotid glands, the deviations from the CBCTHM plan dose were less than those of the CBCTHD plan dose. The differences were statistically significant (P < .05). Meanwhile, the V30 value based on the HM method was better than that based on the HD method in the oral cavity region (P = .016). In addition, we also compared the γ passing rates of kVCT plan doses with the 2 CBCT plan doses, and negligible differences were found. Conclusion: The HM method was more suitable for head and neck cancer patients than the HD one. Furthermore, with the CBCTHM-based method, the dose calculation result better matches the kVCT-based dose calculation.