Pinnacle Planning System Research Articles

Assessment of intrafraction motion and its dosimetric impact on prostate radiotherapy using an in-house developed position monitoring system.

To implement an in-house developed position monitoring software, SeedTracker, for conventional fractionation prostate radiotherapy, and study the effect on dosimetric impact and intrafraction motion. Thirty definitive prostate radiotherapy patients with implanted fiducial markers were included in the study. All patients were treated with VMAT technique and plans were generated using the Pinnacle planning system using the 6MV beam model for Elekta linear accelerator. The target dose of 60 Gy in 20 fractions was prescribed for 29 of 30 patients, and one patient was treated with the target dose of 78 Gy in 39 fractions. The SeedTracker position monitoring system, which uses the x-ray images acquired during treatment delivery in the Elekta linear accelerator and associated XVI system, was used for online prostate position monitoring. The position tolerance for online verification was progressively reduced from 5mm, 4mm, and to 3mm in 10 patient cohorts to effectively manage the treatment interruptions resulting from intrafraction motion in routine clinical practice. The delivered dose to target volumes and organs at risk in each of the treatment fractions was assessed by incorporating the observed target positions into the original treatment plan. In 27 of 30 patients, at least one gating event was observed, with a total of 177 occurrences of position deviation detected in 146 of 619 treatment fractions. In 5mm, 4mm, and 3mm position tolerance cohorts, the position deviations were observed in 13%, 24%, and 33% of treatment fractions, respectively. Overall, the mean (range) deviation of -0.4 (-7.2 to 5.3) mm, -0.9 (-6.1 to 15.6) mm, and -1.7 (-7.0 to 6.1) mm was observed in Left-Right, Anterior-Posterior, and Superior-Inferior directions, respectively. The prostate CTV D99 would have been reduced by a maximum value of 1.3 Gy compared to the planned dose if position deviations were uncorrected, but with corrections, it was 0.3 Gy. Similarly, PTV D98 would have been reduced by a maximum value of 7.6 Gy uncorrected, with this difference reduced to 2.2 Gy with correction. The V60 to the rectum increased by a maximum of 1.0% uncorrected, which was reduced to 0.5%. Online target position monitoring for conventional fractionation prostate radiotherapy was successfully implemented on a standard Linear accelerator using an in-house developed position monitoring software, with an improvement in resultant dose to prostate target volume.

Noncoplanar Volumetric Modulated Arc Therapy for Hepatocellular Carcinoma Based on a Cage-Like Radiotherapy System: A Simulation Study.

The incorporation of noncoplanar beam arrangements has been proposed in liver radiotherapy modalities, which can reduce the dose in normal tissues compared to coplanar techniques. Noncoplanar radiotherapy techniques for hepatocellular carcinoma treatment based on the Linac design have a limited effective arc angle to avoid collisions. To propose a novel noncoplanar volumetric modulated arc therapy technique based on a cage-like radiotherapy system and investigate its performance in hepatocellular carcinoma patients. The computed tomography was deflected 90° to meet the structure of a cage-like radiotherapy system and design the noncoplanar volumetric modulated arc therapy technique based on a cage-like radiotherapy system plan in the Pinnacle3 planning system. An noncoplanar volumetric modulated arc therapy technique based on a cage-like radiotherapy system plan was customized for each of 10 included hepatocellular carcinoma patients, with 6 dual arcs ranging from -30° to 30°. Six couch angles were set with an interval of 36° and distributed along with the longest diameter of planning target volume. The dosimetric parameters of noncoplanar volumetric modulated arc therapy technique based on a cage-like radiotherapy system plan were compared with the noncoplanar volumetric modulated arc therapy and volumetric modulated arc therapy plan. The 3 radiotherapy techniques regarding planning target volume were statistically different for D98%, D2%, conformity index, and homogeneity index with χ2 = 9.692, 14.600, 8.600, and 12.600, and P = .008, .001, .014, and .002, respectively. Further multiple comparisons revealed that noncoplanar volumetric modulated arc therapy technique based on a cage-like radiotherapy system significantly reduced the mean dose (P = .005) and V5 (P = .005) of the normal liver, the mean dose (P = .005) of the stomach, and V30 (P = .028) of the lung compared to noncoplanar volumetric modulated arc therapy. Noncoplanar volumetric modulated arc therapy technique based on a cage-like radiotherapy system significantly reduced the mean dose (P = .005) and V5 (P = .005) of the normal liver, the mean dose (P = .017) of the spinal cord, V50 (P = .043) of the duodenum, the maximum dose (P = .007) of the esophagus, and V30 (P = .047) of the whole lung compared to volumetric modulated arc therapy. The results indicate that noncoplanar volumetric modulated arc therapy technique based on a cage-like radiotherapy system protects the normal liver, stomach, and lung better than noncoplanar volumetric modulated arc therapy and protects the normal liver, spinal cord, duodenum, esophagus, and lung better than volumetric modulated arc therapy. The noncoplanar volumetric modulated arc therapy technique based on a cage-like radiotherapy system technique with the arrangement of noncoplanar arcs provided optimal dosimetric gains compared with noncoplanar volumetric modulated arc therapy and volumetric modulated arc therapy, except for the heart. Noncoplanar volumetric modulated arc therapy technique based on a cage-like radiotherapy system should be considered in more clinically challenging cases.

A knowledge-based intensity-modulated radiation therapy treatment planning technique for locally advanced nasopharyngeal carcinoma radiotherapy

BackgroundTo investigate the feasibility of a knowledge-based automated intensity-modulated radiation therapy (IMRT) planning technique for locally advanced nasopharyngeal carcinoma (NPC) radiotherapy.MethodsOne hundred forty NPC patients treated with definitive radiation therapy with the step-and-shoot IMRT techniques were retrospectively selected and separated into a knowledge library (n = 115) and a test library (n = 25). For each patient in the knowledge library, the overlap volume histogram (OVH), target volume histogram (TVH) and dose objectives were extracted from the manually generated plan. 5-fold cross validation was performed to divide the patients in the knowledge library into 5 groups before validating one group by using the other 4 groups to train each neural network (NN) machine learning models. For patients in the test library, their OVH and TVH were then used by the trained models to predict a corresponding set of mean dose objectives, which were subsequently used to generate automated plans (APs) in Pinnacle planning system via an in-house developed automated scripting system. All APs were obtained after a single step of optimization. Manual plans (MPs) for the test patients were generated by an experienced medical physicist strictly following the established clinical protocols. The qualities of the APs and MPs were evaluated by an attending radiation oncologist. The dosimetric parameters for planning target volume (PTV) coverage and the organs-at-risk (OAR) sparing were also quantitatively measured and compared using Mann-Whitney U test and Bonferroni correction.ResultsAPs and MPs had the same rating for more than 80% of the patients (19 out of 25) in the test group. Both AP and MP achieved PTV coverage criteria for no less than 80% of the patients. For each OAR, the number of APs achieving its criterion was similar to that in the MPs. The AP approach improved planning efficiency by greatly reducing the planning duration to about 17% of the MP (9.85 ± 1.13 min vs. 57.10 ± 6.35 min).ConclusionA robust and effective knowledge-based IMRT treatment planning technique for locally advanced NPC is developed. Patient specific dose objectives can be predicted by trained NN models based on the individual’s OVH and clinical TVH goals. The automated planning scripts can use these dose objectives to efficiently generate APs with largely shortened planning time. These APs had comparable dosimetric qualities when compared to our clinic’s manual plans.

Appropriate reduction of the fragmentation level of subfield sequences to improve the accuracy of field delivery in IMRT for nasopharyngeal carcinoma.

Objective:Due to the influence of gravity, inertia and friction, there will be deviation between the position of multileaf collimator (MLC) in the delivered field and the initial intensity modulated radiotherapy (IMRT) plan. This study explores the effects of the fragmentation level of subfield sequences on this deviation and seeks ways to improve the accuracy of field delivery in IMRT for nasopharyngeal carcinoma (NPC).Methods:30 patients with NPC were selected, and two groups (groups A and B) of IMRT plans were made in Pinnacle planning system. Different planning parameters were used for optimization so that the subfield sequence fragmentation level of Group B was significantly lower than that of Group A. With the MapCheck2, verification plan was implemented in two ways: 0o gantry angle and the actual treatment angle, then the differences between the two verification results of each group plan were analyzed.Results:The γ-passing rate verified at the actual treatment angle was lower than that of 0o gantry angle for each group plan, whereas the Group B plan shows small reduction. Mean change value (Δ) was decreased from 1.01% (Group A) to 0.40% (Group B) with 3%/3 mm criteria and 2.88% (Group A) to 1.52% (Group B) with 2%/2 mm criteria, respectively. The smaller the difference (Δ), the actual output dose of the field is more consistent with the original plan. There was no significant correlation between this change and the angle of the field.Conclusion:Appropriately reducing the fragmentation level of subfield sequence can reduce the effect of field angle on MLC position and improve the delivery accuracy of IMRT plan.Advances in knowledge:The fragmentation level of the subfield sequence may have an impact on the accuracy of the delivery of the plan. This study demonstrates this assumption by comparing the differences between 0° and actual angle verification. Mean change value (Δ) was decreased from Group A to Group B. The smaller the difference (Δ), the actual output dose of the field is more consistent with the original plan. The result of this study may help us to understand that appropriately increasing the subfield area and reducing the fragmentation level of the subfield sequence can reduce the difference between the two verification results, which can further improve the accuracy of the plan delivery in IMRT and tumor treatment.

Adaptive radiotherapy in patients receiving neoadjuvant radiation for soft tissue sarcoma.

The aim of this study is to evaluate tumor volume changes during preoperative radiotherapy and to assess the role of adaptive radiation. Contemporary neoadjuvant radiotherapy utilizes image guidance for precise treatment delivery. Moreover, it may depict changes in tumor size and shape. Between 2016 and 2018, 23 patients aged ≥18 years with soft tissue sarcoma were treated with neoadjuvant radiation followed by surgical resection. The tumor volumes (cc) were measured using the Pinnacle planning system prior to starting radiotherapy and during treatment, the changes in volume and absolute differences were estimated. Moreover, patient's position on the machine was evaluated to assess setup offsets. The triggers for plan adaptation were >1cm expansion or unacceptable setup offsets. The mean tumors volume at presentation was 810 cc (range, 55-4000). At last cone beam CT the tumor volume had changed in 14 patients (61%); it was stable in nine patients (39%). Disease regression was documented in eight patients (35%), with median shrinkage of -20.5% (range, -2 to -29%), while tumor progression was observed in six cases (26%), the median change was 12.5% (range, +10 to +25%).Adaptive radiation was required in four patients (17%). For the remaining 19 cases (83%), the dose distribution was adequate to cover target volumes. Change in soft tissue sarcoma volume during radiation is not uncommon. Image guidance should be used to reduce setup errors and to detect differences in tumor volume. Image guidance and adaptive radiation are paramount to ensure optimal radiation delivery.

A study of finite discontinuity-volumetric modulated arc therapy for mid-and distal-Esophageal Carcinoma

Objective To implement the finite discontinuity-volumetric modulated arc therapy (FD-VMAT) in the Pinnacle planning system, and to investigate its clinical significance. Methods Eight patients with thoracic esophageal cancer in our hospital were enrolled as subjects. FD-VMAT was fulfilled in the Pinnacle planning system using a developed program. FD-VMAT, VMAT, and fixed-field intensity-modulated radiotherapy (IMRT) plans were designed for each patient. The conformity index (CI) and homogeneity index (HI) of the planning target volume (PTV), doses to organs at risk, passing rate for plan verification, number of monitor units, and treatment time were used to evaluate the plans. Comparison between different plans was made by paired t test. Results For the PTV, there was no significant difference in CI between FD-VMAT and VAMT (P=0.186); FD-VMAT had a significantly worse HI than VMAT (P=0.001); however, both the CI and HI were significantly improved in FD-VMAT than in IMRT (P=0.006, 0.002). Compared with IMRT, FD-VMAT, retaining the advantage of VMAT, had pulmonary V20 and V30 significantly reduced by 19.79% and 20.32%, respectively (P=0.000, 0.000). For the pulmonary low-dose regions (≤V5), FD-VMAT retained the advantage of IMRT and had lower doses than VMAT.Particularly, pulmonary V2 was significantly reduced by 16.79%(P=0.000). The mean lung dose was significantly lower in FD-VMAT than in VMAT or IMRT (P=0.001, 0.000). There were no significant differences in D1cc to spinal cord PRV, heart V30, or passing rate for plan verification between the three therapies. The heart V40 and mean heart dose in FD-VMAT were similar to those in VMAT (P=0.175, 0.468), but significantly lower than those in IMRT (P=0.021, 0.002). FD-VMAT had a larger number of monitor units and longer treatment time than VMAT.Compared with IMRT, the number of monitor units and treatment time were reduced by 13.6% and 49.6% in FD-VMAT, respectively. Conclusions Compared with VMAT and IMRT, the application of the developed FD-VMAT in the treatment of thoracic esophageal cancer can further reduce the lung dose while keeping the PTV coverage, protection of the heart and spinal cord, and high efficacy. FD-VMAT is a new therapy available for thoracic esophageal cancer. Key words: Finite discontinuity-volumetric modulated arc therapy; Volumetric-modulated arc therapy; Intensity-modulated radiotherapy; Pinnacle treatment planning system; Esophageal Neoplasm

An analysis of interfractional and intrafractional prostate motion in hypofractionated precise radiotherapy for prostate cancer

Objective To investigate the interfractional and intrafractional prostate motion during hypofractionated precise radiotherapy for prostate cancer. Methods From 2013 to 2016, twenty-eight patients who received 5 Gy radiotherapy in 9 fractions for prostate cancer were enrolled as subjects. Every patient had three gold fiducials implanted into the prostate by transrectal ultrasound guidance two weeks before computed tomography (CT) simulation. All patients underwent CT scans in the supine position with full bladders and rectal balloons filled with 60 ml air. The Pinnacle planning system was used to design the treatment plans. Twenty-three patients were treated with a Synergy accelerator. Those patients underwent cone-beam CT (CBCT) scans prior to treatment. The set-up error was recorded by bone alignment between CBCT images and planning CT images. The prostate displacement was then recorded by gold fiducial alignment. The interfraction prostate displacement was defined by the difference between the above two parameters. The other 5 patients were treated with a Novalis accelerator. Based on gold fiducial alignment, the real-time tracking of gold fiducials was carried out by the ExacTrac system to evaluate the intrafractional prostate displacement. Results A total of 207 measurements of interfractional prostate displacement were made in the 23 patients before treatment. The mean interfractional prostate displacements in the left-right (LR), superior-inferior (SI), and anterior-posterior (AP) directions were (0.05±0.10), (0.20±0.22), and (0.19±0.18) cm, respectively. The displacements larger than 0.3 cm in the above three directions were observed in 1, 52, and 49 measurements, respectively, while the displacements larger than 0.5 cm in the three directions were observed in 1, 29, and 16 measurements, respectively. A total of 225 measurements of gold fiducial displacement were made in the 5 patients during treatment. The mean intrafractional prostate displacements in LR, SI, and AP directions were (0.61±0.50), (0.68±0.69), and (0.70±0.67) mm, respectively. The displacements larger than 3 mm in the three directions were observed in 0, 1, and 1 measurement, respectively. Conclusions In hypofractionated precise radiotherapy for prostate cancer, the interfractional prostate displacement is significantly larger than the intrafractional prostate displacement. The interfractional prostate displacement must be corrected before radiotherapy. In order to avoid off-target irradiation due to postural changes in patients, the tracking of the intrafractional prostate displacement is still necessary although the displacement is relatively small. The rectal balloon can help immobilize the prostate. Key words: Prostate motion; Interfraction; Intrafraction; Prostate neoplasms/hypofraction-ated radiotherapy

Spectral Imaging Technology-Based Evaluation of Radiation Treatment Planning to Remove Contrast Agent Artifacts.

This study employs dual-source computed tomography single-spectrum imaging to evaluate the effects of contrast agent artifact removal and the computational accuracy of radiotherapy treatment planning improvement. The phantom, including the contrast agent, was used in all experiments. The amounts of iodine in the contrast agent were 30, 15, 7.5, and 0.75 g/100 mL. Two images with different energy values were scanned and captured using dual-source computed tomography (80 and 140 kV). To obtain a fused image, 2 groups of images were processed using single-energy spectrum imaging technology. The Pinnacle planning system was used to measure the computed tomography values of the contrast agent and the surrounding phantom tissue. The difference between radiotherapy treatment planning based on 80 kV, 140 kV, and energy spectrum image was analyzed. For the image with high iodine concentration, the quality of the energy spectrum-fused image was the highest, followed by that of the 140-kV image. That of the 80-kV image was the worst. The difference in the radiotherapy treatment results among the 3 models was significant. When the concentration of iodine was 30 g/100 mL and the distance from the contrast agent at the dose measurement point was 1 cm, the deviation values (P) were 5.95% and 2.20% when image treatment planning was based on 80 and 140 kV, respectively. When the concentration of iodine was 15 g/100 mL, deviation values (P) were -2.64% and -1.69%. Dual-source computed tomography single-energy spectral imaging technology can remove contrast agent artifacts to improve the calculated dose accuracy in radiotherapy treatment planning.

SU‐F‐T‐238: Analyzing the Performance of MapCHECK2 and Delta4 Quality Assurance Phantoms in IMRT and VMAT Plans

Purpose:Intensity‐modulated radiotherapy (IMRT) and volumetric modulated arc therapy (VMAT) have been widely investigated for use in radiotherapy and found to have a highly conformal dose distribution. Delta4 is a novel cylindrical phantom consisting of 1069 p‐type diodes with true treatments measured in the 3D target volume. The goal of this study was to compare the performance of a Delta4 diode array for IMRT and VMAT planning with ion chamber and MapCHECK2.Methods:Fifty‐four IMRT (n=9) and VMAT (n=45) plans were imported to Philips Pinnacle Planning System 9.2 for recalculation with a solid water phantom, MapCHECK2, and the Delta4 phantom. To evaluate the difference between the measured and calculated dose, we used MapCHECK2 and Delta4 for a dose‐map comparison and an ion chamber (PTW 31010 Semiflex 0.125 cc) for a point‐dose comparison.Results:All 54 plans met the criteria of <3% difference for the point dose (at least two points) by ion chamber. The mean difference was 0.784% with a standard deviation of 1.962%. With a criteria of 3 mm/3% in a gamma analysis, the average passing rates were 96.86%±2.19% and 98.42%±1.97% for MapCHECK2 and Delta4, respectively. The student t‐test of MapCHECK2/Delta4, ion chamber/Delta4, and ion chamber/MapCHECK2 were 0.0008, 0.2944, and 0.0002, respectively. There was no significant difference in passing rates between MapCHECK2 and Delta4 for the IMRT plan (p = 0.25). However, a higher pass rate was observed in Delta4 (98.36%) as compared to MapCHECK2 (96.64%, p < 0.0001) for the VMAT plan.Conclusion:The Pinnacle planning system can accurately calculate doses for VMAT and IMRT plans. The Delta4 shows a similar result when compared to ion chamber and MapCHECK2, and is an efficient tool for patient‐specific quality assurance, especially for rotation therapy.

SU‐F‐T‐310: Does a Head‐Mounted Ionization Chamber Detect IMRT Errors?

Purpose:The conventional plan verification strategy is delivering a plan to a QA‐phantom before the first treatment. Monitoring each fraction of the patient treatment in real‐time would improve patient safety. We evaluated how well a new detector, the IQM (iRT Systems, Germany), is capable of detecting errors we induced into IMRT plans of three different treatment regions. Results were compared to an established phantom.Methods:Clinical plans of a brain, prostate and head‐and‐neck patient were modified in the Pinnacle planning system, such that they resulted in either several percent lower prescribed doses to the target volume or several percent higher doses to relevant organs at risk. Unaltered plans were measured on three days, modified plans once, each with the IQM at an Elekta Synergy with an Agility MLC. All plans were also measured with the ArcCHECK with the cavity plug and a PTW semiflex 31010 ionization chamber inserted. Measurements were evaluated with SNC patient software.Results:Repeated IQM measurements of the original plans were reproducible, such that a 1% deviation from the mean as warning and 3% as action level as suggested by the manufacturer seemed reasonable. The IQM detected most of the simulated errors including wrong energy, a faulty leaf, wrong trial exported and a 2 mm shift of one leaf bank. Detection limits were reached for two plans ‐ a 2 mm field position error and a leaf bank offset combined with an MU change. ArcCHECK evaluation according to our current standards also left undetected errors. Ionization chamber evaluation alone would leave most errors undetected.Conclusion:The IQM detected most errors and performed as well as currently established phantoms with the advantage that it can be used throughout the whole treatment. Drawback is that it does not indicate the source of the error.

SU-F-T-585: A Novel Phantom for Dosimetric Validation of SBRT for Spinal Lesions

Purpose: SBRT is proving to be a very efficacious treatment modality for an increasing number of indications, including spine lesions. We have developed a novel phantom to serve as an end-to-end QA tool for either patient specific QA or commissioning QA of SBRT for spine lesions. Methods: In this feasibility study, we have selected a patient with a single metastatic lesion in the L5 vertebral body. The patient's CT simulation scan was used to develop a VMAT treatment plan delivering 18Gy to at least 90% of the target volume, following the guidelines of RTOG 0631. The treatment plan was developed with the Pinnacle planning system using the adaptive convolution superposition calculation mode. The approved plan was re-calculated using the Monaco planning system. We performed a pseudo-in-vivo study whereby we manufactured two copies of a phantom to the exact shape and anatomy of the patient. The phantom was made from the CT images of the patient using a 3D printer with sub-millimeter accuracy. One phantom was filled with a gel dosimeter and the other was made with two ion chamber inserts to allow us to obtain point dose measurements in the target's center and the spinal cord. Results: The prescribed dose of 18Gy was planned for the target while keeping the maximum spinal cord dose to less than 14Gy in 0.03cc of the cord. The VMAT plan was delivered to both the gel dosimeter filed phantom and the phantom with the ion chambers. The 3D gel dosimetry revealed a very good agreement between the monte carlo and measured point and volumetric dose. Conclusion: A patient like phantom was developed and validated for use as an end-to-end tool of dose verification for SBRT of spine lesions. We found that gel dosimetry is ideally suited to assess positional and dosimetric accuracy in 3D. RTsafe provided the phantoms and the gel dosimeter used for this study

SU-F-T-377: Monte Carlo Re-Evaluation of Volumetric-Modulated Arc Plans of Advanced Stage Nasopharygeal Cancers Optimized with Convolution-Superposition Algorithm

Background: Commercial treatment planning system Pinnacle3 (Philips, Fitchburg, WI, USA) employs a convolution-superposition algorithm for volumetric-modulated arc radiotherapy (VMAT) optimization and dose calculation. Study of Monte Carlo (MC) dose recalculation of VMAT plans for advanced-stage nasopharyngeal cancers (NPC) is currently limited. Methods: Twenty-nine VMAT prescribed 70Gy, 60Gy, and 54Gy to the planning target volumes (PTVs) were included. These clinical plans achieved with a CS dose engine on Pinnacle3 v9.0 were recalculated by the Monaco TPS v5.0 (Elekta, Maryland Heights, MO, USA) with a XVMC-based MC dose engine. The MC virtual source model was built using the same measurement beam dataset as for the Pinnacle beam model. All MC recalculation were based on absorbed dose to medium in medium (Dm,m). Differences in dose constraint parameters per our institution protocol (Supplementary Table 1) were analyzed. Results: Only differences in maximum dose to left brachial plexus, left temporal lobe and PTV54Gy were found to be statistically insignificant (p> 0.05). Dosimetric differences of other tumor targets and normal organs are found in supplementary Table 1. Generally, doses outside the PTV in the normal organs are lower with MC than with CS. This is also true in the PTV54-70Gy doses but higher dose in the nasal cavity near the bone interfaces is consistently predicted by MC, possibly due to the increased backscattering of short-range scattered photons and the secondary electrons that is not properly modeled by the CS. The straight shoulders of the PTV dose volume histograms (DVH) initially resulted from the CS optimization are merely preserved after MC recalculation. Conclusion: Significant dosimetric differences in VMAT NPC plans were observed between CS and MC calculations. Adjustments of the planning dose constraints to incorporate the physics differences from conventional CS algorithm should be made when VMAT optimization is carried out directly with MC dose engine.

Pattern of regional recurrence after curative resection in locally advanced adenocarcinoma of gastroesophageal junction: Implication for elective lymphatic target delineation of radiotherapy.

158 Background: To investigated the regional recurrence pattern of Siewert type II/III AGE patients after curative resection and refine the clinical target volume (CTV) delineation of radiotherapy. Methods: From 2009 to 2013, 78 patients who were histopathologically diagnosed with locally advanced AGE (T3/4 or any N+, Siewert II/III) after curative resection and confirmed of regional recurrence in follow-up CT images were retrospectively reviewed. First regional recurrence was recorded and one diagnostic radiologist with specialty of gastrointestinal tract investigated. Pattern of regional failure at each node station were analyzed. Reference CT images were obtained from a healthy volunteer. We then delineated the epicenters of recurrence sites at the equivalent location, based on the same vessels of reference CT images compared with the recurrence CT images on Pinnacle planning system. The combined contour of all recurrence sites was presented on a digitally reconstructed radiograph (DRR) image. Results: Most recurrence occurred within 2 years of follow-up (Median, 10.9 m). Of all, 35 (44.9%) patients had regional failure (RF) only; 24 (38%) had RF simultaneous with distant failure; 11 (14.1%) were locoregional, and 8 (10.3%) had concurrent distant and locoreginal failure. The most common recurrent node stations were No.16 (62.8%), No. 9 (32.1%), No. 11 (24.4%), No. 8 (17.9%), No. 7 (16.7%), No. 112 (12.8%), No. 4 (12.8%) and No. 12 (10.3%), respectively. 11 patients (14.1%) had recurrence at mediastinal lymph nodes. There was no significant difference of NF between Siewert type II and III AEG except for No. 9 (42.2% vs 18.2%, P = 0.027). The frequency and location of RF was shown by CT and digitally reconstructed radiograph (DRR) images. A three-dimensional (3D) atlas based on vessel delineation and distribution of RF was established. Conclusions: The most prevalent regional recurrence in Siewert type II/III AEG patients after curative resection was along the abdominal aorta, celiac artery and splenic artery. Our findings suggest a modified elective lymphatic target volume for IMRT contours in those patients.

Quantitative analysis of brass compensators for commissioning of the Pinnacle planning system for IMRT.

Brass compensators for beam modulation present an alternative method for IMRT treatment planning to traditional dynamic leaf modulation. In this work, we present a detailed method to commission the Pinnacle treatment planning system for IMRT using brass compensators. Beam attenuation from various brass thicknesses were measured using an ion chamber, as well as a MapCHECK device, for a representative seven‐field IMRT plan. We show that Pinnacle's parameters for compensators can be optimized to match the measured results while still maintaining the original open‐beam model. Only Pinnacle's modified scatter factor and brass density value were adjusted. Beam attenuation in several brass slabs were optimized by minimizing a χ2 function of measured and modeled data for several depths in solid water. Using MapCHECK, Pinnacle's parameters were optimized by minimizing the number of points that fail during a gamma analysis of seven fields in a typical IMRT plan. Our results show that Pinnacle's 10X beam is best modeled using a brass density of 7.8 g/cm3 and a modified scatter factor of 0.1 cm−1.PACS numbers: 87.56.N, 87.56.ng, 87.55.kh, 87.55.de

Integration of BOLD-fMRI and DTI into radiation treatment planning for high-grade gliomas located near the primary motor cortexes and corticospinal tracts.

BackgroundThe main objective of this study was to evaluate the efficacy of integrating the blood oxygen level dependent functional magnetic resonance imaging (BOLD-fMRI) and diffusion tensor imaging (DTI) data into radiation treatment planning for high-grade gliomas located near the primary motor cortexes (PMCs) and corticospinal tracts (CSTs).MethodsA total of 20 patients with high-grade gliomas adjacent to PMCs and CSTs between 2012 and 2014 were recruited. The bilateral PMCs and CSTs were located in the normal regions without any overlapping with target volume of the lesions. BOLD-fMRI, DTI and conventional MRI were performed on patients (Karnofsky performance score ≥ 70) before radical radiotherapy treatment. Four different imaging studies were conducted in each patient: a planning computed tomography (CT), an anatomical MRI, a DTI and a BOLD-fMRI. For each case, three treatment plans (3DCRT, IMRT and IMRT_PMC&CST) were developed by 3 different physicists using the Pinnacle planning system.ResultsOur study has shown that there was no significant difference between the 3DCRT and IMRT plans in terms of dose homogeneity, but IMRT displayed better planning target volume (PTV) dose conformity. In addition, we have found that the Dmax and Dmean to the ipsilateral and contralateral PMC and CST regions were considerably decreased in IMRT_PMC&CST group (p < 0.001).ConclusionsIn conclusion, integration of BOLD-fMRI and DTI into radiation treatment planning is feasible and beneficial. With the assistance of the above-described techniques, the bilateral PMCs and CSTs adjacent to the target volume could be clearly marked as OARs and spared during treatment.

Effect of lung and target density on small-field dose coverage and PTV definition

We have studied the effect of target and lung density on block margin for small stereotactic body radiotherapy (SBRT) targets. A phantom (50 × 50 × 50cm3) was created in the Pinnacle (V9.2) planning system with a 23-cm diameter lung region of interest insert. Diameter targets of 1.6, 2.0, 3.0, and 4.0cm were placed in the lung region of interest and centered at a physical depth of 15cm. Target densities evaluated were 0.1 to 1.0g/cm3, whereas the surrounding lung density was varied between 0.05 and 0.6g/cm3. A dose of 100cGy was delivered to the isocenter via a single 6-MV field, and the ratio of the average dose to points defining the lateral edges of the target to the isocenter dose was recorded for each combination. Field margins were varied from none to 1.5cm in 0.25-cm steps. Data obtained in the phantom study were used to predict planning treatment volume (PTV) margins that would match the clinical PTV and isodose prescription for a clinical set of 39 SBRT cases. The average internal target volume (ITV) density was 0.73 ± 0.17, average local lung density was 0.33 ± 0.16, and average ITV diameter was 2.16 ± 0.8cm. The phantom results initially underpredicted PTV margins by 0.35cm. With this offset included in the model, the ratio of predicted-to-clinical PTVs was 1.05 ± 0.32. For a given target and lung density, it was found that treatment margin was insensitive to target diameter, except for the smallest (1.6-cm diameter) target, for which the treatment margin was more sensitive to density changes than the larger targets. We have developed a graphical relationship for block margin as a function of target and lung density, which should save time in the planning phase by shortening the design of PTV margins that can satisfy Radiation Therapy Oncology Group mandated treatment volume ratios.

SU-E-T-74: Commissioning of the Elekta VersaHD Linear Accelerator

Purpose: To present the commissioning process of recently-released Elekta VersaHD linear accelerator, equipped with Agility 160-leaf multileaf collimator and flattening-filter free (FFF) photon modes. Methods: In addition to routine QA procedures, we adopted an EPID-based method to perform the table rotation and Winston-Lutz tests, and a novel multiradiation isocenter alignment check. The beam data acquired include photon percent-depth dose (PDD) of 6X, 6XFFF, 10X, 10XFFF, and 15X in the field size from 2×2 to 40×40cm{sup 2}, profiles, collimator and phantom scatter factors (Sc and Sp), wedge factor, electron (6, 9, 12, and 15MeV) PDD and profiles, cone and cutout factors, and virtual SSD. Validation measurements were carried out in water tank to evaluate the accuracy of beam modeling by the Pinnacle planning system. End-to-End test and IMRT QA were performed to validate the overall delivery accuracy. A theoretical model has also been used to extract the primary dose ratio and off-axis beam softening effects by fitting photon beam profile measurements. Results: The PDDs of FFF beams with field size 10×10cm{sup 2} at 10cm depth, 100cm SSD were intentionally adjusted within 1% of the non-FFF beams. The photon profiles of 30×30cm{sup 2} at 10cm depth between non-FFF and FFF beams aremore » very different, OAR(10)=0.74 and 0.63, respectively, for 6XFFF and 10XFFF. The collimator and phantom scatter factors of FFF beam demonstrated smaller variation with field sizes. The EPID-based method demonstrated the maximum deviation between the table rotation axis and radiation isocenter is within 1mm, and the radiation isocenters are within 0.4mm relative to that of 6X. The validation measurement shows less than 2% deviation between the measurement and Pinnacle modeling for most of the test conditions. Conclusion: To the best of our knowledge, this is the first study reporting the Elekta VersaHD commissioning experience, which can be a valuable reference for the radiotherapy community.« less

SU-E-T-405: Robustness of Volumetric-Modulated Arc Therapy (VMAT) Plans to Systematic MLC Positional Errors

Purpose: To evaluate the dosimetric impact of systematic MLC positional errors (PEs) on the quality of volumetric-modulated arc therapy (VMAT) plans. Methods: Five patients with head-and-neck cancer (HN) and five patients with prostate cancer were randomly chosen for this study. The clinically approved VMAT plans were designed with 2–4 coplanar arc beams with none-zero collimator angles in the Pinnacle planning system. The systematic MLC PEs of 0.5, 1.0, and 2.0 mm on both MLC banks were introduced into the original VMAT plans using an in-house program, and recalculated with the same planned Monitor Units in the Pinnacle system. For each patient, the original VMAT plans and plans with MLC PEs were evaluated according to the dose-volume histogram information and Gamma index analysis. Results: For one primary target, the ratio of V100 in the plans with 0.5, 1.0, and 2.0 mm MLC PEs to those in the clinical plans was 98.8 ± 2.2%, 97.9 ± 2.1%, 90.1 ± 9.0% for HN cases and 99.5 ± 3.2%, 98.9 ± 1.0%, 97.0 ± 2.5% for prostate cases. For all OARs, the relative difference of Dmean in all plans was less than 1.5%. With 2mm/2% criteria for Gamma analysis, the passing rates were 99.0 ± 1.5% for HN cases and 99.7 ± 0.3% for prostate cases between the planar doses from the original plans and the plans with 1.0 mm MLC errors. The corresponding Gamma passing rates dropped to 88.9 ± 5.3% for HN cases and 83.4 ± 3.2% for prostate cases when comparing planar doses from the original plans and the plans with 2.0 mm MLC errors. Conclusion: For VMAT plans, systematic MLC PEs up to 1.0 mm did not affect the plan quality in term of target coverage, OAR sparing, and Gamma analysis with 2mm/2% criteria.

SU-E-T-610: Comparison of Treatment Times Between the MLCi and Agility Multileaf Collimators

Purpose: The Agility is a new 160-leaf MLC developed by Elekta for use in their Infinity and Versa HD linacs. As compared to the MLCi, the Agility increased the maximum leaf speed from 2 cm/s to 3.5 cm/s, and the maximum primary collimator speed from 1.5 cm/s to 9.0 cm/s. The purpose of this study was to determine if the Agility MLC resulted in improved plan quality and/or shorter treatment times. Methods: An Elekta Infinity that was originally equipped with a 80 leaf MLCi was upgraded to an 160 leaf Agility. Treatment plan quality was evaluated using the Pinnacle planning system with SmartArc. Optimization was performed once for the MLCi and once for the Agility beam models using the same optimization parameters and the same number of iterations. Patient treatment times were measured for all IMRT, VMAT, and SBRT patients treated on the Infinity with the MLCi and Agility MLCs. Treatment times were extracted from the EMR and measured from when the patient first walked into the treatment room until exiting the treatment room. Results: 11,380 delivery times were measured for patients treated with the MLCi, and 1,827 measurements have been made for the Agility MLC. The average treatment timesmore » were 19.1 minutes for the MLCi and 20.8 minutes for the Agility. Using a t-test analysis, there was no difference between the two groups (t = 0.22). The dose differences between patients planned with the MLCi and the Agility MLC were minimal. For example, the dose difference for the PTV, GTV, and cord for a head and neck patient planned using Pinnacle were effectively equivalent. However, the dose to the parotid glands was slightly worse with the Agility MLC. Conclusion: There was no statistical difference in treatment time, or any significant dosimetric difference between the Agility MLC and the MLCi.« less

SU-E-T-218: Investigating the Differences in Out-Of-Field Dose Between An Inherently Uniform Beam and a Flattening Filter Free Beam Made Uniform Through Inverse Modulation

Purpose: To characterize with physical measurements the out-of-field dose for flattening filter free (FFF) and IMRT flattened FFF photon beams less than 10 MV from a Siemens Artiste LINAC, field size dependence, thereof, and comparison with the Pinnacle planning system calculation. Methods: Single field plans were developed for 5×5cm^2 and 20×20cm^2 field sizes for 6MV and 7MV-FFF. An additional 7MV-FFF plan was developed for each field size with the purpose of delivering a uniform dose (7MV-FFFUniform), similar to 6MV, utilizing inverse modulation. The calculated and measured dose was normalized to achieve equivalence at 10cm depth in water. Out-of-field dose measurements were acquired with a farmer-type ionization chamber in solid water at incremental distances up to 90cm from the field edge at physical depths of 1.5cm and 5.0cm. The dose contribution from head leakage was determined by closing the jaws symmetrically and the MLC off-axis Results: Data collected show that the out-of-field dose for 6MV is generally greater than 7MV-FFF and 7MV-FFF-Uniform. The 7MV-FFF-Uniform dose is less than 7MV-FFF for the small field size, but similar for the larger field and may be attributed to the small IMRT segments of the 5x5 field developing narrow beam geometry with reduced scatter. The out-of-field dose from 7MV-FFF-Uniform for the 20×20 field was greater than 6MV and 7MV-FFF beyond 50cm from the field edge. Head leakage from the 7MV-FFF-Uniform segmental MU modulation was greater than the un-modulated beams. The calculated out-of-field dose was consistently −200% different than measured for a subset of points considered. Conclusion: The modulation required to deliver a uniform large field dose with 7MV-FFF will increase the peripheral dose to the patient in comparison to already physically flattened fields; however, the dose near the field edge will be reduced. If reliable out-of-field doses are needed physical measurements should be used.