TrueBeam STx System Research Articles

GATE Monte Carlo approach to heterogeneity dose distribution in small fields used in radiation therapy

The Accurate dosage prediction in Radiation Therapy is challenging, prompting a need for precision beyond conventional clinical Treatment Planning Systems (TPS). Monte Carlo-based methods are sought for their superior accuracy. The aim of this study is to compare dose distributions between the ACUROS algorithm and the GATE platform in various tissue densities and field sizes, focusing on smaller fields. This study was initiated with a homogeneous validation of the TrueBeam STX system, using measurements obtained from the Centre Hospitalier Interregional Edith Cavell (CHIREC) in Brussels. The validation compared dosimetric functions (Percentage Depth Dose (PDD), Dose profile (DP) and Collimator scatter fraction (CSF)) employing the GAMMA index with a 2% / 2 mm criterion tolerance. Following this, heterogeneous studies examined dose distributions between the ACUROS algorithm and the GATE platform in various tissue densities and field sizes, with a specific focus on smaller fields. Simulations were conducted using both platforms on chest phantoms with heterogeneous slabs representing bone, lung, and heart, each housing a central tumor. The impact of electronic equilibrium on tumors for different small field sizes was evaluated. Results showed a remarkable 99% agreement between measurements and GATE calculations in the homogeneous validation of the TrueBeam STX system. However, in heterogeneous studies, ACUROS consistently overestimated lung doses by up to 8% compared to GATE simulation, especially evident with a flattening filter and smaller beam sizes at density interfaces. This highlights significant dose estimation discrepancies between ACUROS and GATE, emphasizing the need for precise calculations. The findings support exploring Monte Carlo-based methods for enhanced accuracy in Radiation Therapy treatment planning.

A dosimetric comparison for SBRT plans of localized prostate cancer between Cyberknife and Varian Truebeam STX device

As the Stereotactic Body Radiotherapy (SBRT) approach began to increase in treating patients with localized prostate cancer, it became necessary to investigate which methods used in practice were better. The aim of this study is to perform a dosimetric comparison of the advantages and disadvantages of SBRT treatments for localized prostate cancer delivered by CyberKnife (CK) and Varian Truebeam STX (FF and FFF). Seventeen intermediate and high-risk patients with localized prostate cancer were included in the study. SBRT plans for the CK system and Varian Truebeam STX systems with and without Flattening Filters (Tru-FF and Tru-FFF) were prepared for each patient. Plans prepared for each patient were planned at a fraction dose of 6.7 Gy at 6 MV energy and a target dose of 33.5 Gy in 5 fractions. For all plans, cumulative dose-volume histograms (DVHs) were generated for target volumes and organs at risk (OAR). The maximum doses of PTV (41 Gy) in CK plans are higher than the maximum doses (35 Gy) in VMAT plans prepared with Tru-FF or Tru-FFF beams. The mean dose of the rectal wall (10.06 ± 2.40Gy for CK) is still relatively low compared to other plans (13.46 ± 2.16 Gy for Tru-FF and 13.61 ± 2.32 Gy for Tru-FFF). The bladder wall (14 Gy for CK, 26 Gy for Tru-FF and Tru-FFF) and femoral head (6.8 Gy for CK, 9 Gy for Tru-FF and 9.4 Gy Tru-FFF) doses were also lower for CK plans. The CK plans provide better tumour control due to low doses in critical organs and high target doses than the Tru-FF or Tru-FFF plans. It was observed that CK and VMAT plans for SBRT with 6 MV photon beams provided acceptable results in term of treatment planning criteria such as Conformity Index and Homogeneity Index. It is recommended to use a target tracking system to provide an accurate and reliable SBRT treatment with VMAT and CK techniques.

Correlation of the gamma passing rates with the differences in the dose-volumetric parameters between the original VMAT plans and actual deliveries of the VMAT plans

PurposeThe aim of this study was to investigate the correlations of the gamma passing rates (GPR) with the dose-volumetric parameter changes between the original volumetric modulated arc therapy (VMAT) plans and the actual deliveries of the VMAT plans (DV errors). We compared the correlations of the TrueBeam STx system to those of a C-series linac.MethodsA total of 20 patients with head and neck (H&N) cancer were retrospectively selected for this study. For each patient, two VMAT plans with the TrueBeam STx and Trilogy (C-series linac) systems were generated under similar modulation degrees. Both the global and local GPRs with various gamma criteria (3%/3 mm, 2%/2 mm, 2%/1 mm, 1%/2 mm, and 1%/1 mm) were acquired with the 2D dose distributions measured using the MapCHECK2 detector array. During VMAT deliveries, the linac log files of the multi-leaf collimator positions, gantry angles, and delivered monitor units were acquired. The DV errors were calculated with the 3D dose distributions reconstructed using the log files. Subsequently, Spearman’s rank correlation coefficients (rs) and the corresponding p values were calculated between the GPRs and the DV errors.ResultsFor the Trilogy system, the rs values with p < 0.05 showed weak correlations between the GPRs and the DV errors (rs<0.4) whereas for the TrueBeam STx system, moderate or strong correlations were observed (rs≥0.4). The DV errors in the V20Gy of the left parotid gland and those in the mean dose of the right parotid gland showed strong correlations (always with rs > 0.6) with the GPRs with gamma criteria except 3%/3 mm. As the GPRs increased, the DV errors decreased.ConclusionThe GPRs showed strong correlations with some of the DV errors for the VMAT plans for H&N cancer with the TrueBeam STx system.

Positioning accuracy of a single-isocenter multiple targets SRS treatment: A comparison between Varian TrueBeam CBCT and Brainlab ExacTrac.

This study compared the positioning accuracy between cone-beam CT (CBCT) and ExacTrac (ETX) for a single-isocenter multiple target stereotactic radiosurgery (SRS) on two TrueBeam STx systems. A single-isocenter treatment plan was simulated on an anthropomorphic head phantom with six spherical steel ball bearings (BBs). One of the BBs was chosen to be the isocenter. The five off-isocenter targets were located at various distances from the isocenter. MV portal images were generated to evaluate the deviations between the expected and the real center of the targets after CBCT and ETX positioning, respectively. The evaluation of the positioning accuracy for the isocenter target showed that CBCT and ETX positioning provided comparable, sub-millimetric results. Deviations in positioning accuracy were also calculated for all other targets, also showing comparable results for CBCT and ETX. Moreover, our study showed that the deviation between CBCT and ETX positioning were in better agreement for TBSTx1 and deviated slightly higher on TBSTx2 (maximum: 1.23mm at S/I direction), due to a less perfect alignment between the CBCT coordinate system and the ETX coordinate system on TBSTx2 compared to TBSTx1. This study also showed a correlation between the target positioning accuracy and the distance to the isocenter. The positioning accuracy of ETX and CBCT for targets located at isocenter and off-isocenter locations was compared on two treatment machines and found comparable. Our study highlights the importance of a proper calibration procedure, to ensure correct alignment between the CBCT, ETX and machine coordinate systems.

Prediction of VMAT delivery accuracy with textural features calculated from fluence maps

BackgroundComprehensively textural feature performance test from volumetric modulated arc therapy (VMAT) fluences to predict plan delivery accuracy.MethodsA total of 240 VMAT plans for various treatment sites were analyzed, with Trilogy and TrueBeam STx systems. Fluence maps superposed fluences at each control point per plan. The textural features were the angular second moment (ASM), inverse difference moment (IDM), contrast, variance, correlation, and entropy, calculated from fluence maps using three displacement distances. Correlation analysis of textural feature performance as predictors of VMAT delivery accuracy used global gamma passing rates with MapCHECK2 and ArcCHECK dosimeters, and mechanical delivery errors calculated from machine log files.ResultsSpearman’s rank correlation coefficients (r) of the ASM (d = 10) to the gamma passing rates with 1%/2 mm using the MapCHECK2 were 0.358 and 0.519, respectively (p < 0.001). For the ArcCHECK, they were 0.273 (p = 0.001) and 0.259 (p = 0.009), respectively. The r-values of the ASM (d = 10) to the Trilogy and TrueBeam STx MLC errors were − 0.843 and − 0.859, respectively (p < 0.001), and those to the MU delivery errors were − 0.482 and − 0.589, respectively (p < 0.001). The ASM (d = 10) showed better performance in predicting VMAT delivery accuracy.ConclusionsThe ASM (d = 10) calculated from VMAT plan fluence maps were strongly correlated with global gamma passing rates and MLC delivery errors, and can predict VMAT delivery accuracy.

On the need for tuning the dosimetric leaf gap for stereotactic treatment plans in the Eclipse treatment planning system.

The dosimetric leaf gap (DLG) and tongue‐and‐groove (T&G) effects are critical aspects in the modeling of multileaf collimators (MLC) in the treatment planning system (TPS). In this study, we investigated the dosimetric impact of limitations associated with the T&G modeling in stereotactic plans and its relationship with the need for tuning the DLG in the Eclipse TPS. Measurements were carried out using Varian TrueBeam STx systems from two different institutions. Test fields presenting MLC patterns with several MLC gap sizes (meanGap) and different amounts of T&G effect (TGi) were first evaluated. Secondly, dynamic conformal arc (DCA) and volumetric modulated arc therapy (VMAT) deliveries of stereotactic cases were analyzed in terms of meanGap and TGi. Two DLG values were used in the TPS: the measured DLG (DLGmeas) and an optimal DLG (DLGopt). Measured and calculated doses were compared according to dose differences and gamma passing rates (GPR) with strict local gamma criteria of 2%/2 mm. The discrepancies were analyzed for DLGmeas and DLGopt, and their relationships with both TGi and meanGap were investigated. DCA arcs involved significantly lower TGi and larger meanGap than VMAT arcs (P < 0.0001). By using DLGmeas in the TPS, the dose discrepancies increased as TGi increased and meanGap decreased for both test fields and clinical plans. Dose discrepancies dramatically increased with the ratio TGi/meanGap. Adjusting the DLG value was then required to achieve acceptable calculations and configuring the TPS with DLGopt led to an excellent agreement with median GPRs (2%/2 mm) > 99% for both institutions. We also showed that DLGopt could be obtained from the results of the test fields. We demonstrated that the need for tuning the DLG is due to the limitations of the T&G modeling in the Eclipse TPS. A set of sweeping gap tests modified to incorporate T&G effects can be used to determine the optimal DLG value.

Comparison of treatment plans between IMRT with MR-linac and VMAT for lung SABR

BackgroundThe aim of this study was to compare the plan quality of magnetic-resonance image-based intensity modulated radiation therapy (MRI-based-IMRT) with the MRIdian Linac system to that of volumetric modulated arc therapy (VMAT) with the TrueBeam STx system for lung stereotactic ablative radiotherapy (SABR).MethodsA total of 22 patients with tumors located in the lower lobe were retrospectively selected for the study. For each patient, both the MRI-based-IMRT and VMAT plans were generated using an identical CT image set and identical structures with the exception of the planning target volume (PTV). The PTVs of the MRI-based-IMRT were generated by adding an isotropic margin of 3 mm from the gross tumor volume, whereas those of VMAT were generated by adding an isotropic margin of 5 mm from the internal target volume. For both the MRI-based-IMRT and VMAT, the prescription doses to the PTVs were 60 Gy in four fractions.ResultsThe average PTV volume of the MRI-based-IMRT was approximately 4-times smaller than that of VMAT (p < 0.001). The maximum dose to the bronchi for the MRI-based-IMRT was smaller than that for the VMAT (20.4 Gy versus 24.2 Gy, p < 0.001). In addition, V40Gy of the rib for the MRI-based-IMRT was smaller than that for the VMAT (1.8 cm3 versus 7.7 cm3, p = 0.008). However, the maximum doses to the skin and spinal cord for the MRI-based-IMRT (33.0 Gy and 14.5 Gy, respectively) were larger than those for the VMAT (27.8 Gy and 11.0 Gy, respectively) showing p values of less than 0.02. For the ipsilateral lung, the mean dose, V20Gy, V10Gy, and V5Gy for the MRI-based-IMRT were smaller than those for the VMAT (all with p < 0.05). For the contralateral lung, V5Gy, V10Gy, D1500cc, and D1000cc for the MRI-based-IMRT were larger than those for the VMAT (all with p < 0.05). The mean dose and V50% of the whole body for the MRI-based-IMRT were smaller than those for the VMAT (0.9 Gy versus 1.2 Gy, and 78.7 cm3 versus 103.5 cm3, respectively, all at p < 0.001).ConclusionsThe MRI-based-IMRT using the MRIdian Linac system could reduce doses to bronchi, rib, ipsilateral lung, and whole body compared to VMAT for lung SABR when the tumor was located in the lower lobe.

Modulation indices and plan delivery accuracy of volumetric modulated arc therapy.

PurposeWe evaluated the performance of various modulation indices (MI) for volumetric modulated arc therapy (VMAT) to predict plan delivery accuracy.MethodsThe specific indices evaluated were MI quantifying the mechanical uncertainty (MI t), MI quantifying the mechanical and dose calculation uncertainties (MI c), MI for station parameter optimized radiation therapy (MISPORT), modulation complexity score for VMAT (MCS v), leaf travel modulation complexity score (LTMCS), plan averaged beam area (PA), plan averaged beam irregularity (PI), plan averaged beam modulation (PM), and plan normalized monitor unit (PMU) to predict VMAT delivery accuracy. By utilizing 240 VMAT plans generated with the Trilogy and TrueBeam STx, Spearman's rank correlation coefficients (r) were calculated between the MIs and measures of conventional methods.ResultsFor the Trilogy system, MI c showed the highest r values with gamma passing rates (GPRs) (r = −0.624 with P < 0.001 for MapCHECK2 and r = −0.655 with P < 0.001 for ArcCHECK). For TrueBeam STx, MI c also showed the highest r values with GPRs (r = −0.625 with P < 0.001 for the MapCHECK2 and r = −0.561 with P < 0.001 for the ArcCHECK). The MI t and MI c showed the highest r values to the MLC position errors for the Trilogy and TrueBeam STx systems (r = 0.770 with P < 0.001 and r = 0.712 with P < 0.001, respectively). The PA showed the highest percent of r values (P < 0.05) to differences in the dose‐volume parameters between original VMAT plans and actual deliveries for the Trilogy systems (30.9%). Both the MI t and MI c showed the highest percent of r values (P < 0.05) to differences in the dose‐volume parameters between original VMAT plans and actual deliveries for the TrueBeam STx systems (31.8%).ConclusionTo comprehensively review the results, the MI c showed the best performance to predict the VMAT delivery accuracy.

Dosimetric comparison of fractionated radiosurgery plans using frameless Gamma Knife ICON and CyberKnife systems with linear accelerator-based radiosurgery plans for multiple large brain metastases.

For patients with multiple large brain metastases with at least 1 target volume larger than 10 cm3, multifractionated stereotactic radiosurgery (MF-SRS) has commonly been delivered with a linear accelerator (LINAC). Recent advances of Gamma Knife (GK) units with kilovolt cone-beam CT and CyberKnife (CK) units with multileaf collimators also make them attractive choices. The purpose of this study was to compare the dosimetry of MF-SRS plans deliverable on GK, CK, and LINAC and to discuss related clinical issues. Ten patients with 2 or more large brain metastases who had been treated with MF-SRS on LINAC were identified. The median planning target volume was 18.31 cm3 (mean 21.31 cm3, range 3.42-49.97 cm3), and the median prescribed dose was 27.0 Gy (mean 26.7 Gy, range 21-30 Gy), administered in 3 to 5 fractions. Clinical LINAC treatment plans were generated using inverse planning with intensity modulation on a Pinnacle treatment planning system (version 9.10) for the Varian TrueBeam STx system. GK and CK planning were retrospectively performed using Leksell GammaPlan version 10.1 and Accuray Precision version 1.1.0.0 for the CK M6 system. Tumor coverage, Paddick conformity index (CI), gradient index (GI), and normal brain tissue receiving 4, 12, and 20 Gy were used to compare plan quality. Net beam-on time and approximate planning time were also collected for all cases. Plans from all 3 modalities satisfied clinical requirements in target coverage and normal tissue sparing. The mean CI was comparable (0.79, 0.78, and 0.76) for the GK, CK, and LINAC plans. The mean GI was 3.1 for both the GK and the CK plans, whereas the mean GI of the LINAC plans was 4.1. The lower GI of the GK and CK plans would have resulted in significantly lower normal brain volumes receiving a medium or high dose. On average, GK and CK plans spared the normal brain volume receiving at least 12 Gy and 20 Gy by approximately 20% in comparison with the LINAC plans. However, the mean beam-on time of GK (∼ 64 minutes assuming a dose rate of 2.5 Gy/minute) plans was significantly longer than that of CK (∼ 31 minutes) or LINAC (∼ 4 minutes) plans. All 3 modalities are capable of treating multiple large brain lesions with MF-SRS. GK has the most flexible workflow and excellent dosimetry, but could be limited by the treatment time. CK has dosimetry comparable to that of GK with a consistent treatment time of approximately 30 minutes. LINAC has a much shorter treatment time, but residual rotational error could be a concern.

Evaluation of the plan delivery accuracy of intensity-modulated radiation therapy by texture analysis using fluence maps

PurposeThe aim of this study is to evaluate the plan delivery accuracy of intensity-modulated radiation therapy (IMRT) by using textural features calculated from fluence maps. MethodsIn total, 202 IMRT plans were generated with the Trilogy (C-series linac) and TrueBeam STx systems. Fluence maps were obtained for each IMRT plan. With the fluence map, six textural features were calculated, namely angular second moment (ASM), inverse difference moment (IDM), contrast, variance, correlation, and entropy (particular displacement distances, d = 1, 5, and 10). To evaluate performances of textural features in predicting IMRT delivery accuracy, Spearman’s rank correlation coefficients (rs) were calculated between textural feature values and measures of conventional methods. ResultsFor Trilogy, correlation (d = 1) showed rs values of −0.764 (p < 0.001) with gamma passing rates of 2%/1 mm and 0.863 (p < 0.001) with multi-leaf collimator (MLC) errors. For TrueBeam STx, variance (d = 10) showed rs values of 0.691 (p < 0.001) with gamma passing rates of 1%/2 mm and −0.585 (p < 0.001) with MLC errors. ConclusionCorrelation (d = 1) for Trilogy and variance (d = 10) for TrueBeam STx demonstrated the potential in predicting IMRT delivery accuracy with high correlations to conventional IMRT delivery accuracy measures.

P179] Small field correction factors determination for the IBA razor nano chamber and the IBA razor chamber

Purpose The aim of this study was to measure small beam output factors (OFs) using the IBA Razor Nano Chamber (RNC) and the IBA Razor Chamber (RC) and to determine correction factors for comparison with Gafchromic EBT3 films. Methods The detectors were irradiated with 6 MV photon beams using a Varian TrueBeam STx system equipped with a HD multileaf collimator (MLC). Fields ranging from 0.5 × 0.5 to 10 × 10 cm2 were defined by both the X-Y collimator jaws and the MLC. The microchambers were used in parallel configuration at a source-surface distance of 100 cm and at 10 cm depth in a Sun Nuclear 3D SCANNER water phantom. Polarity correction factors kpol were evaluated for both the chambers and used to correct the raw measurements. Films were irradiated inside a Solid Water phantom in the same geometry. Results Deviations from unity of kpol were observed for field size less than 1 cm and greater than 2 cm, ranging from 0.943 to 1.025 for the RNC and from 0.970 to 1.005 for the RC. The output factors corrected for the polarity showed an underestimation for the smallest beam for both the detectors with respect to films (k = 1.033 and 1.052 for the RNC and the RC respectively). Correction factors values for beams ranging from 8 to 30 mm were close to unity. Conclusions OFs corrected for the RNC and the RC were in agreement with films, although an underestimation has been observed for the smallest beam connected to a small volume averaging effect. The similar behavior of the two ionization chambers is probably due to the same size of the electrode diameter (2 mm). Both the detectors could be used for output factors measurements in small beam geometry, albeit the magnitude of the polarity effect suggests to correct the readings carried out with the two chambers in order to achieve a better accuracy.

SU‐E‐T‐423: TrueBeam Small Field Dosimetry Using Commercial Plastic Scintillation and Other Stereotactic Detectors

Purpose:To perform dose profile and output factor (OF) measurements with the Exradin W1 plastic scintillation detector (PSD) for small fields made by the high‐definition multi‐leaf collimator (MLC) on the TrueBeam STx system and to compare them to values measured with an IBA CC01 ionization chamber and a Sun Nuclear Edge detector diode for 6 MV photon beams.Methods:The Exradin W1 is a new small volume near‐water equivalent and energy independent PSD manufactured by Standard Imaging, Inc. All measurements were performed in an IBA Blue Phantom water tank. Square MLC‐shaped fields with sides ranging from 0.5 cm to 2 cm and jawshaped fields with sides ranging from 1 cm to 40 cm were measured using an SAD setup at 10 cm depth. Dose profile and percent depth dose (PDD) measurements were also taken under the same conditions for MLC fields 0.5×0.5 and 1×1 cm2 in size with jaws at 2×2cm2. The CC01 and W1 were vertically mounted.Results:OFs measured with the W1 for jaw only square fields were consistent with the ones measured with a Farmers PTW TN33013 ion chamber (1.8% maximum deviation). OF and penumbra measurement results are presented below. PDDs measured for all detectors are within 1.5% for the 0.5×0.5 cm2 and within 1% for the 1×1 cm2 MLC fields.Output factors:MLC size W1 CC01 EDGE0.5cm 0.555 0.541 0.5851.0cm 0.716 0.702 0.7331.5cm 0.779 0.761 0.7772.0cm 0.804 0.785 0.796Penumbras (mm):MLC size W1 CC01 EDGE0.5cm 2.7 2.9 2.51.0cm 3.0 3.4 2.Conclusion:OFs measured for small MLC fields were consistent with the ones measured with the other stereotactic detectors. Measured penumbras are consistent with detector size. The Exradin W1 PSD is an excellent choice for characterizing MLC‐shaped small beam dosimetry used for stereotactic radiosurgery and body radiation therapy.Sam Beddar would like to disclose a NIH/NCI SBIR Phase II grant (2R44CA153824‐02A1) with Standard Imaging, Title: “Water‐Equivalent Plastic Scintillation Detectors for Small Field Radiotherapy”

SU-E-T-143: Dosimetric Characteristics of TrueBeam STx System with High Definition Multi-Leaf Collimator: Commissioning of Stereotactic Radiosurgery

IntroductionDosimetric characteristics of one TrueBeam STx treatment unit with a 120‐leaf high definition multileaf collimator (HD120MLC) are systematically measured for commissioning of stereotactic radiosurgery (SRS). Due to limited data available, it is important to make the dosimetric data available for reference.MethodsSRS commissioning data were acquired for two photon beam calculation algorithms of the treatment planning system iPlan (BrainLAB iPlan4.5): Clarkson method and Pencil Beam dose calculation (PBC) method. Major beam data required include percent depth dose (PDD), beam profile, and relative scatter factors for various field sizes. Generally, the PBC is used for HD120MLC based treatment planning, while Clarkson method is for cone‐based planning. ResultsPDD, beam profile and relative scatter data for the circular cones with diameters of 4, 6.0, 7.5, 10, 12.5, 15 mm were measured for 6X flattening‐filter‐free (FFF) and 10X FFF. The relative scatter factors range from 1.12 to 1.45 for 6X FFF and 0.81 to 1.23 for 10XFFF. Beam penumbra of 6XFFF and 10XFFF of each the circular cone were less than 2.5 mm for the 20% to 80% criterion. PDD and relative scatter data for HD120MLC were measured for various MLC fields with corresponding jaw settings for various energy modes: 6X, 6X FFF, 10X, 10X FFF and 15X, with an MLC filed down to 5mmx5mm. The transverse and diagonal beam profiles for HD120MLC were measured at different depths to generate source function correction models in iPlan. HD120MLC leakage for open jaw and close jaw are ∼1% and 0.0% for all the energy modes. The measured HD120MLC dynamic leaf shifts are 0.15, 0.11, 0.19, 0.18, 0.21 mm for 6X, 6XFFF, 10X, 10XFFF and 15X, less than 1/2 of those of the Novalis Tx system previous published.ConclusionThe commissioning data provided us valuable insights and might be useful for future reference.