Treatment Delivery Verification Research Articles

Feasibility of determining external beam radiotherapy dose using LuSy dosimeter.

Radiation dose measurement is an essential part of radiotherapy to verify the correct delivery of doses to patients and ensure patient safety. Recent advancements in radiotherapy technology have highlighted the need for fast and precise dosimeters. Technologies like FLASH radiotherapy and magnetic-resonance linear accelerators (MR-LINAC) demand dosimeters that can meet their unique requirements. One promising solution is the plastic scintillator-based dosimeter with high spatial resolution and real-time dose output. This study explores the feasibility of using the LuSy dosimeter, an in-house developed plastic scintillator dosimeter for dose verification across various radiotherapy techniques, including conformal radiotherapy (CRT), intensity-modulated radiation therapy (IMRT), volumetric-modulated arc therapy (VMAT), and stereotactic radiosurgery (SRS). A new dosimetry system, comprising a new plastic scintillator as the sensing material, was developed and characterized for radiotherapy beams. Treatment plans were created for conformal radiotherapy, IMRT, VMAT, and SRS and delivered to a phantom. LuSy dosimeter was used to measure the delivered dose for each plan on the surface of the phantom and inside the target volumes. Then, LuSy measurements were compared against an ionization chamber, MOSFET dosimeter, radiochromic films, and dose calculated using the treatment planning system (TPS). For CRT, surface dose measurement by LuSy dosimeter showed a deviation of -5.5% and -5.4% for breast and abdomen treatment from the TPS, respectively. When measuring inside the target volume for IMRT, VMAT, and SRS, the LuSy dosimeter produced a mean deviation of -3.0% from the TPS. Surface dose measurement resulted in higher TPS discrepancies where the deviations for IMRT, VMAT, and SRS were -2.0%, -19.5%, and 16.1%, respectively. The LuSy dosimeter was feasible for measuring radiotherapy doses for various treatment techniques. Treatment delivery verification enables early error detection, allowing for safe treatment delivery for radiotherapy patients.

Hypofractionated Radiotherapy in Gynecologic Malignancies-A Peek into the Upcoming Evidence.

Radiotherapy (RT) has a fundamental role in the treatment of gynecologic malignancies, including cervical and uterine cancers. Hypofractionated RT has gained popularity in many cancer sites, boosted by technological advances in treatment delivery and image verification. Hypofractionated RT uptake was intensified during the COVID-19 pandemic and has the potential to improve universal access to radiotherapy worldwide, especially in low-resource settings. This review summarizes the rationale, the current challenges and investigation efforts, together with the recent developments associated with hypofractionated RT in gynecologic malignancies. A comprehensive search was undertaken using multiple databases and ongoing trial registries. In the definitive radiotherapy setting for cervical cancers, there are several ongoing clinical trials from Canada, Mexico, Iran, the Philippines and Thailand investigating the role of a moderate hypofractionated external beam RT regimen in the low-risk locally advanced population. Likewise, there are ongoing ultra and moderate hypofractionated RT trials in the uterine cancer setting. One Canadian prospective trial of stereotactic hypofractionated adjuvant RT for uterine cancer patients suggested a good tolerance to this treatment strategy in the acute setting, with a follow-up trial currently randomizing patients between conventional fractionation and the hypofractionated dose regimen delivered in the former trial. Although not yet ready for prime-time use, hypofractionated RT could be a potential solution to several challenges that limit access to and the utilization of radiotherapy for gynecologic cancer patients worldwide.

Six-probe scintillator dosimeter for treatment verification in HDR-brachytherapy.

In vivo dosimetry (IVD) is gaining interest for treatment delivery verification in HDR-brachytherapy. Time resolved methods, including source tracking, have the ability both to detect treatment errors in real time and to minimize experimental uncertainties. Multiprobe IVD architectures holds promise for simultaneous dose determinations at the targeted tumor and surrounding healthy tissues while enhancing measurement accuracy. However, most of the multiprobe dosimeters developed so far either suffer from compactness issues or rely on complex data post-treatment. We introduce a novel concept of a compact multiprobe scintillator detector and demonstrate its applicability in HDR-brachytherapy. Our fabricated seven-fiber probing system is sufficiently narrow to be inserted in a brachytherapy needle or in acatheter. Our multiprobe detection system results from the parallel implementation of six miniaturized inorganic Gd2 O2 S:Tb scintillator detectors at the end of a bundle of seven fibers, one fiber is kept bare to assess the stem effect. The resulting system, which is narrower than 320 microns, is tested with a MicroSelectron 9.14 Ci Ir-192 HDR afterloader, in a water phantom. The detection signals from all six probes are simultaneously read with a sCMOS camera (at a rate of 0.06 s). The camera is coupled to a chromatic filter to cancel Cerenkov signal induced within the fibers upon exposure. By implementing an aperiodic array of six scintillating cells along the bundle axis, we first determine the range of inter-probe spacings leading to optimal source tracking accuracy (first tracking method). Then, three different source tracking algorithms involving all the scintillating probes are tested and compared. In each of these four methods, dwell positions are assessed from dose measurements and compared to the treatment plan. Dwell time is also determined and compared to the treatmentplan. The optimum inter-probe spacing for an accurate source tracking ranges from 15 to 35 mm. The optimum detection algorithm consists of adding the readout signals from all detector probes. In that case, the error to the planned dwell positions is of 0.01 ± 0.14 mm and 0.02 ± 0.29 mm at spacings between the source and detector axes of 5.5 and 40 mm, respectively. Using this approach, the average deviations to the expected dwell time are of s and s, at spacings between source and probe axes of 5.5 and 20 mm,respectively. Our six-probe Gd2 O2 S:Tb dosimeter coupled to a sCMOS camera can perform time-resolved treatment verification in HDR brachytherapy. This detection system of high spatial and temporal resolutions (0.25 mm and 0.06 s, respectively) provides a precise information on the treatment delivery via a dwell time and position verification of unmatched accuracy.

67 Dose Verification of MRI-Guided Online Adaptive Treatment Delivery for UGI Sites

67 Dose Verification of MRI-Guided Online Adaptive Treatment Delivery for UGI Sites

Evaluation of a new radiochromic film dosimeter, Gafchomic EBT4, for VMAT, SABR and HDR treatment delivery verification

Objective. To evaluate a new film for radiotherapy dosimetry, Gafchromic EBT4, compared to the current EBT3. To evaluate dose-response and verify test cases in MV external beam and HDR brachytherapy. Approach. Three lots (batches) of EBT4 and three lots of EBT3 films were calibrated at 6 MV over 0–1200 cGy range, using FilmQAPro software. Signal-to-noise of pixel value, reported dose (RD), and factors affecting dosimetry accuracy were evaluated (rotation of the film at scanning, energy response and post-exposure darkening). Both films were exposed to clinical treatment plans (VMAT prostate, SABR lung, single HDR source dwell, and ‘pseudo’ 3-channel HDR cervix brachytherapy). Film-RD was compared to TPS-calculated dose. Main results. EBT4 calibration curves had characteristics more favourable than EBT3 for radiation dosimetry, with improved signal to noise in film-RD of EBT4 compared to EBT3 (increase of average 46% in red and green channels at 500 cGy). Film rotation at scanning and post-exposure darkening was similar for the two films. The energy response of EBT4 is similar to EBT3. For all clinical case studies, EBT4 provided better agreement with the TPS-planned doses than EBT3. VMAT prostate gamma 3%/3 mm passing rate, EBT4 100.0% compared to EBT3 97.9%; SABR lung gamma 2%/2 mm, EBT4 99.6% and EBT3 97.9%; HDR cervix gamma 3%/2 mm, EBT4 97.7% and EBT3 95.0%. Significance. These results show EBT4 is superior to EBT3 for radiotherapy dosimetry validation of TPS plan delivery. Fundamental improvements in noise profile and calibration curve are reported for EBT4. All clinical test cases showed EBT4 provided equivalent or smaller difference in measured dose to TPS calculated dose than EBT3. Baseline data is presented on the achievable accuracy of film dosimetry in radiotherapy using the new Gafchromic EBT4 film.

Applications of Machine Learning to Improve the Clinical Viability of Compton Camera Based in vivo Range Verification in Proton Radiotherapy.

We studied the application of a deep, fully connected Neural Network (NN) to process prompt gamma (PG) data measured by a Compton camera (CC) during the delivery of clinical proton radiotherapy beams. The network identifies 1) recorded “bad” PG events arising from background noise during the measurement, and 2) the correct ordering of PG interactions in the CC to help improve the fidelity of “good” data used for image reconstruction. PG emission from a tissue-equivalent target during irradiation with a 150 MeV proton beam delivered at clinical dose rates was measured with a prototype CC. Images were reconstructed from both the raw measured data and the measured data that was further processed with a neural network (NN) trained to identify “good” and “bad” PG events and predict the ordering of individual interactions within the good PG events. We determine if NN processing of the CC data could improve the reconstructed PG images to a level in which they could provide clinically useful information about the in vivo range and range shifts of the proton beams delivered at full clinical dose rates. Results showed that a deep, fully connected NN improved the achievable contrast to noise ratio (CNR) in our images by more than a factor of 8x. This allowed the path, range, and lateral width of the clinical proton beam within a tissue equivalent target to easily be identified from the PG images, even at the highest dose rates of a 150 MeV proton beam used for clinical treatments. On average, shifts in the beam range as small as 3 mm could be identified. However, when limited by the amount of PG data measured with our prototype CC during the delivery of a single proton pencil beam (~1 × 109 protons), the uncertainty in the reconstructed PG images limited the identification of range shift to ~5 mm. Substantial improvements in CC images were obtained during clinical beam delivery through NN pre-processing of the measured PG data. We believe this shows the potential of NNs to help improve and push CC-based PG imaging toward eventual clinical application for proton RT treatment delivery verification.

Application of an in-house developed complementary metal-oxide-semiconductor-based optical computed tomography (CMOS-OCT) imaging system for stereotactic radiosurgery dosimetry using a PRESAGE® dosimeter

PRESAGE® dosimeter can be useful for 3D verification of radiotherapy treatment delivery when careful attention is given to the dosimeter measurement technique. Ideally, a low noise and fast optical CT scanning system is required for imaging the dosimeter for verification of advanced radiotherapy treatment delivery. We have developed a complementary metal-oxide-semiconductor (CMOS)-based optical computed tomography (OCT) system (CMOS-OCT), implementing the recent advances in CMOS active pixel sensor (APS) technology that offer on-chip image processing and high-speed readout. In this study, we present the dosimetric response of irradiated PRESAGE® dosimeter measured with the CMOS-OCT system and describe a feasibility study of using the calibrated system to verify stereotactic radiosurgery (SRS) treatment. PRESAGE® dosimeters were irradiated using a 6 MV Elekta Synergy linear accelerator to investigate dosimetric and geometric properties of PRESAGE® dosimeter with CMOS-OCT imaging system, in order to verify a clinical SRS treatment plan of the brain. The tomographic projection images of the PRESAGE® dosimeter were captured by the image sensor within 100 s for a 360-degree rotation. The CMOS-OCT imaging system showed good linearity in dose-response measured by PRESAGE® dosimeter. The correlation of the optical density (OD) changes measured from the CMOS-OCT with attenuation value measured using a calibrated UV/Vis spectrophotometer was found to be better than 0.996. The tomographic reconstruction of the dose distribution from the PRESAGE® showed good agreement when compared with the calculated dose distributions from the treatment planning software. The in-house CMOS-OCT imaging system is capable of visualising and verifying the dose distribution of stereotactic radiosurgery treatment. The CMOS-OCT imaging of the PRESAGE® dosimeter provides accurate dosimetric and geometric information on radiotherapy delivery in a three-dimensional volume, which is useful in advanced radiotherapy. The introduction of CMOS technology in the OCT improves the imaging speed of the dosimeters dose readout.

Development of a dosimeter prototype with machine learning based 3-D dose reconstruction capabilities

A 3-D dosimeter fills the need for treatment plan and delivery verification required by every modern radiation-therapy method used today. This report summarizes a proof-of-concept study to develop a water-equivalent solid 3-D dosimeter that is based on novel radiation-hard scintillating material. The active material of the prototype dosimeter is a blend of radiation-hard peroxide-cured polysiloxane plastic doped with scintillating agent P-Terphenyl and wavelength-shifter BisMSB. The prototype detector was tested with 6 MV and 10 MV x-ray beams at Ohio State University’s Comprehensive Cancer Center. A 3-D dose distribution was successfully reconstructed by a neural network specifically trained for this prototype. This report summarizes the material production procedure, the material’s water equivalency investigation, the design of the prototype dosimeter and its beam tests, as well as the details of the utilized machine learning approach and the reconstructed 3-D dose distributions.

PHSOR06 Presentation Time: 10:25 AM: A Novel Gamma Camera-Based System for Real-Time Visualization of 192Ir Source Position in High Dose Rate Brachytherapy

Purpose: The physical location of the 192Ir source in high-dose-rate (HDR) brachytherapy is currently invisible to the treatment team during treatment delivery. Although the in-room radiation monitor(s) can indicate whether the source is inside or outside the afterloader, the inability to easily visualize the physical source location makes it difficult in responding to radiation safety events and in treatment delivery verification. The purpose of this work was to develop a gamma camera-based imaging system for real-time visualization of the 192Ir source position during the HDR treatment delivery.

Performance of a new commercial high-definition 3D patient specific quality assurance system for CyberKnife robotic radiotherapy and radiosurgery

Conventional two dimensional and low-definition measurement techniques for dosimetric verification of radiotherapy treatment deliveries are no longer adequate in the era of hypofractionation and extremely high dose gradients. New quality assurance (QA) tools with 3D capability and high definition are urgently needed. The purpose of this study was to evaluate the performance of one of the first such commercial systems as applied to CyberKnife (CK) radiotherapy/radiosurgery system.This study employed the recently developed commercial 3D patient-specific quality assurance (PSQA) system. Tissue-equivalent radiochromic polymer gel dosimeters, sealed in light protective thin-wall glass spheres (CrystalBalls), were mounted in a high-precision acrylic QA stand. Patient treatment plans were superimposed on the simulator CT scan of one selected CrystalBall and were irradiated in CK machine. CrystalBalls were then scanned using a laser CT scanner (OCTOPUS, MGS Research, Inc., DBA 3D Dosimetry, Madison, CT, USA). The simulator CT scan and the laser CT scan of the CrystalBall were registered in 6D using the VOLQA (MGS Research, Inc., DBA 3D Dosimetry, Madison, CT, USA) software. Planned and delivered dose distributions were compared by means of 3D gamma passing rates at user-selected acceptance criteria. Cumulative 3D dose-volume histograms and overlays of orthogonal profiles and isodoses both in 2D and in 3D were also generated, along with voxel statistics for dose difference and distance-to-agreement criteria. Twelve stereotactic radiosurgery/stereotactic radiotherapy/stereotactic body radiation therapy patients were selected randomly such that each set of two represented one of the six diagnoses: brain metastasis, trigeminal neuralgia, spine metastasis, prostate cancer, lung cancer and liver cancer. The validation of the 3D system was carried out by comparing the 2D gamma passing rates for all the patients using EBT3 films sandwiched between PMMA slabs and then analyzed with PTW VeriSoft software.The 3D gamma passing rate averaged over all patients studied was (90.5 ± 6.7) % at acceptance criteria of 2% (local) dose difference and 2 mm distance-to-agreement down to 20% isodose. For 3% (local) dose difference and 3 mm distance-to-agreement (also down to 20% cutoff dose), the average passing rate was (96.0 ± 3.1) %.The results of the study presented here form part of the information needed to assess suitability of a system and hence, the results suggest that the new high-definition 3D CrystalBall system can be a useful PSQA tool as a part of quality assurance for CK.

Initial Clinical Experience of Cherenkov Imaging in External Beam Radiation Therapy Identifies Opportunities to Improve Treatment Delivery

The value of Cherenkov imaging as an on-patient, real-time, treatment delivery verification system was examined in a 64-patient cohort during routine radiation treatments in a single-center study. Cherenkov cameras were mounted in treatment rooms and used to image patients during their standard radiation therapy regimen for various sites, predominantly for whole breast and total skin electron therapy. For most patients, multiple fractions were imaged, with some involving bolus or scintillators on the skin. Measures of repeatability were calculated with a mean distance to conformity (MDC) for breast irradiation images. In breast treatments, Cherenkov images identified fractions when treatment delivery resulted in dose on the contralateral breast, the arm, or the chin and found nonideal bolus positioning. In sarcoma treatments, safe positioning of the contralateral leg was monitored. For all 199 imaged breast treatment fields, the interfraction MDC was within 7 mm compared with the first day of treatment (with only 7.5% of treatments exceeding 3 mm), and all but 1 fell within 7 mm relative to the treatment plan. The value of imaging dose through clear bolus or quantifying surface dose with scintillator dots was examined. Cherenkov imaging also was able to assess field match lines in cerebral-spinal and breast irradiation with nodes. Treatment imaging of other anatomic sites confirmed the value of surface dose imaging more broadly. Daily radiation therapy can be imaged routinely via Cherenkov emissions. Both the real-time images and the posttreatment, cumulative images provide surrogate maps of surface dose delivery that can be used for incident discovery and/or continuous improvement in many delivery techniques. In this initial 64-patient cohort, we discovered 6 minor incidents using Cherenkov imaging; these otherwise would have gone undetected. In addition, imaging provides automated, quantitative metrics useful for determining the quality of radiation therapy delivery.

In vivo dosimetry in brachytherapy: Requirements and future directions for research, development, and clinical practice

Brachytherapy can deliver high doses to the target while sparing healthy tissues due to its steep dose gradient leading to excellent clinical outcome. Treatment accuracy depends on several manual steps making brachytherapy susceptible to operational mistakes. Currently, treatment delivery verification is not routinely available and has led, in some cases, to systematic errors going unnoticed for years. The brachytherapy community promoted developments in in vivo dosimetry (IVD) through research groups and small companies. Although very few of the systems have been used clinically, it was demonstrated that the likelihood of detecting deviations from the treatment plan increases significantly with time-resolved methods. Time–resolved methods could interrupt a treatment avoiding gross errors which is not possible with time-integrated dosimetry. In addition, lower experimental uncertainties can be achieved by using source-tracking instead of direct dose measurements. However, the detector position in relation to the patient anatomy remains a main source of uncertainty. The next steps towards clinical implementation will require clinical trials and systematic reporting of errors and near-misses. It is of utmost importance for each IVD system that its sensitivity to different types of errors is well understood, so that end-users can select the most suitable method for their needs. This report aims to formulate requirements for the stakeholders (clinics, vendors, and researchers) to facilitate increased clinical use of IVD in brachytherapy. The report focuses on high dose-rate IVD in brachytherapy providing an overview and outlining the need for further development and research.

Anovel approach to SBRT patient quality assurance using EPID-based real-time transit dosimetry : Astep to QA with in vivo EPID dosimetry.

Intra- and inter-fraction organ motion is amajor concern in stereotactic body radiation therapy (SBRT). It may cause substantial differences between the planned and delivered dose distribution. Such delivery errors may lead to medical harm and reduce life expectancy for patients. The project presented here investigates and improves arapid method to detect such errors by performing online dose verification through the analysis of electronic portal imaging device (EPID) images. To validate the method, arespiratory phantom with inhomogeneous insert was examined under various scenarios: no-error and error-simulated measurements. Simulation of respiratory motions was practiced for target ranges up to 2 cm. Three types of treatment planning technique - 3DCRT (three-dimensional conformal radiation therapy), IMRT (intensity modulated radiation therapy), and VMAT (volumetricmodulated arc therapy - were generated for lung SBRT. Atotal of 54plans were generated to assess the influence of techniques on the performance of portal dose images. Subsequently, EPID images of 52SBRT patients were verified. Both for phantom and patient cases, dose distributions were compared using the gamma index method according to analysis protocols in the target volume. The comparison of error-introduced EPID-measured images to reference images showed no significant differences with 3%/3 mm gamma evaluation, though target coverage was strongly underestimated. Gamma tolerance of 2%/2 mm reported noticeable detection in EPID sensitivity for simulated errors in 3DCRT and IMRT techniques. The passing rates for 3DCRT, IMRT, and VMAT with 1%/1 mm in open field were 84.86%, 92.91%, and 98.75%, and by considering MLC-CIAO + 1 cm (threshold 5%), were 68.25%, 83.19%, and 95.29%, respectively. This study demonstrates the feasibility of EPID for detecting the interplay effects. We recommend using thin computed tomography slices and adding sufficient tumor margin in order to limit the dosimetric organ motion in hypofractionated irradiation with preserved plan quality. In the presence of respiratory and gastrointestinal motion, tighter criteria and consequently using local gamma evaluation should be considered, especially for VMAT. This methodology offers asubstantial step forward in in vivo dosimetry and the potential to distinguish errors depending on the gamma tolerances. Thus, the approach/prototype provides afast and easy quality assurance procedure for treatment delivery verification.

3D dosimetry for proton therapy

We have been developing novel 3-dimensional (3D) detector systems using organic plastic and liquid scintillators to measure and image the dose distribution from proton therapy beams in near-real time. Proof-of-concept and initial feasibility studies using a single charge-coupled device camera have already been conducted. Our recent studies focused on the characterization of scanning proton beams used for patient treatments using a 3D liquid scintillator-based detector system with a set of scientific-complementary metal-oxide-semiconductor (sCMOS) cameras. The basic concept consists of using a large volume of a solid or liquid scintillator to measure or image the dose distributions from proton beams in 3D. We recently developed a large liquid scintillator-based detector system consisting of a 20 × 20 × 20cm transparent acrylic tank filled with a water-equivalent, commercially available liquid scintillator that generates scintillation light when irradiated with protons. To track rapid spatial and dose variations in spot-scanned proton beams, we used 3 high-speed sCMOS cameras to image the scintillation light signals from 3 orthogonal projections in cine mode. Furthermore, we developed a new image acquisition approach that synchronized camera imaging times with dynamic pencil-beam deliveries to efficiently capture the dose and therefore enable accurate dosimetric calculations. This system was fully developed and characterized at the Proton Therapy Center at The University of Texas MD Anderson Cancer Center. We show that such systems can provide fast and accurate measurements of the range, lateral profile, and lateral position of scanning proton beams with excellent spatial resolution (0.21 mm). We also demonstrate that such detectors can rapidly measure proton beam characteristics and intensities at multiple energies, which makes them an ideal tool for scanned proton-beam systems, beam quality assurance studies, and verification of patient treatment delivery.

Frame-based radiosurgery of multiple metastases using single-isocenter volumetric modulated arc therapy technique.

Single‐isocenter volumetric modulated arc therapy (VMAT) technique can provide stereotactic radiosurgery (SRS) treatment with improved delivery efficiency for treating multiple metastases. Nevertheless, planning is time consuming and verification of frame‐based SRS setup, especially at noncoplanar angles, can be challenging. We report on a single‐isocenter VMAT technique with a special focus on improving treatment workflow and delivery verification to exploit the minimized patient motion of the frame‐based SRS. We developed protocols for preplanning and verification for VMAT and evaluated them for ten patient cases. Preplans based on MRI were used to generate comparable treatment plans using CT taken on the day of treatment after frame placement. Target positioning accuracy was evaluated by stereoscopic in‐room kV imaging. Dosimetric accuracy of the noncoplanar plan delivery was validated using measurement‐guided 3D dose reconstruction as well as film‐based end‐to‐end test with a Rando phantom. Average absolute differences of homogeneity indices, conformity indices, and V12Gy between MR preplans and CT‐based plans were within 5%. In‐room imaging positioning accuracy of 0.4 mm was verified to be independent of the distance to the isocenter. For treatment verification, average local and global passing rates of the 3D gamma (1 mm, 3%) were 86% and 99%, respectively. D99 values were matched within 5% for individual target structures (>0.5 cc). Additional film analysis confirmed dosimetric accuracy for small targets that had large verification errors in the 3D dose reconstruction. Our results suggest that the advantages of frame‐based SRS and noncoplanar single‐isocenter VMAT technique can be combined for efficient and accurate treatment of patients with multiple metastases.

Design and Implementation of a Multipurpose Phantom for Advanced Radiotherapy Treatment Delivery Verification

Design and Implementation of a Multipurpose Phantom for Advanced Radiotherapy Treatment Delivery Verification

An innovative gynecological HDR brachytherapy applicator system for treatment delivery and real-time verification

The multichannel vaginal cylinder (MVC) applicator employed for gynecological high dose rate (HDR) brachytherapy increases dose delivery complexity, and thus makes the treatment more prone to errors. A quality assurance (QA) procedure tracking the source throughout dose delivery can detect dwell position and time errors in the multiple channels of the applicator.A new MVC system with integrated real time in vivo treatment delivery QA has been developed based on diodes embedded on the outer surface of the MVC. It has been pre-calibrated and verified using a non-clinical treatment plan with consecutive test positions and dwell times within each catheter, followed by the delivery of ten clinical plans of adjuvant vaginal cuff brachytherapy following hysterectomy for endometrial cancer.The non-clinical verification showed overall mean dwell position and time discrepancies between the nominal and measured treatment of −0.2 ± 0.5 mm and −0.1 ± 0.1 s (k = 1), respectively. The clinical plans showed mean positional discrepancies of 0.2 ± 0.4 and 0.0 ± 0.8 mm, for the central and peripheral catheters, respectively, and mean dwell time discrepancies of −0.1 ± 0.2 and −0.0 ± 0.1 s for central and peripheral catheters, respectively.The innovative prototype of the MVC system has shown the ability to track the source with sub-mm and sub-second accuracy, and demonstrated potential for its incorporation into the clinical routine.

Characterization of MOSkin detector for in vivo dose verification during Cobalt-60 high dose-rate intracavitary brachytherapy

In vivo dosimetry in high dose-rate (HDR) intracavitary brachytherapy (ICBT) is important for assessing the true dose received by surrounding organs at risk during treatment. It also serves as part of the treatment delivery quality assurance and verification program with the use of a suitable dosimeter. Such a dosimeter should be characterized under brachytherapy conditions before clinical application to ensure the accuracy of in vivo measurement. In this study, a MOSFET-based detector, MOSkin, was calibrated and characterized under HDR Cobalt-60 (Co-60) brachytherapy source. MOSkin possessed the major advantages of having small physical and dosimetric sizes of 4.8 × 10−6 mm3 with the ability to provide real-time measurements. Using solid water and polymethyl methacrylate (PMMA) phantom, the detectors’ reproducibility, linearity, angular and distance dependency was tested for its suitability as an in vivo detector. Correction factors to account for differences in depth measurements were determined. The MOSkin detector showed a reliable response when tested under Co-60 brachytherapy range of doses with an excellent linearity of R2 = 0.9997 and acceptable reproducibility. A phantom verification study was also conducted to verify the differences between MOSkin responses and treatment planning (TPS) calculated doses. By taking into account several correction factors, deviations ranging between 0.01 and 0.4 Gy were found between MOSkin measured and TPS doses at measurement distance of 20–55 mm. The use of MOSkin as the dosimeter of choice for in vivo dosimetry under Co-60 brachytherapy condition is feasible.

An investigation of clinical treatment field delivery verification using cherenkov imaging: IMRT positioning shifts and field matching.

Cherenkov light emission has been shown to correlate with ionizing radiation dose delivery in solid tissue. An important clinical application of Cherenkov light is the real-time verification of radiation treatment delivery invivo. To test the feasibility of treatment field verification, Cherenkov light images were acquired concurrent with radiation beam delivery to standard and anthropomorphic phantoms. Specifically, we tested two clinical treatment scenarios: (a) Observation of field overlaps or gaps in matched 3D fields and (b) Patient positioning shifts during intensity modulated radiation therapy (IMRT) field delivery. Further development of this technique would allow real-time detection of treatment delivery errors on the order of millimeters so that patient safety and treatment quality can be improved. Cherenkov light emission was captured using a PI-MAX4 intensified charge coupled device (ICCD) system (Princeton Instruments). All radiation delivery was performed using a Varian Trilogy linear accelerator (linac) operated at 6MV or 18MV for photon and 6MeV or 16MeV for electron studies. Field matching studies were conducted with photon and electron beams at gantry angles of 0°, 15°, and 45°. For each modality and gantry angle, a total of three data sets were acquired. Overlap and gap distances of 0, 2, 5, and 10mm were tested and delivered to solid phantom material of 30×30×5cm3 . Phantom materials used were white plastic water and brown solid water. Tests were additionally performed on an anthropomorphic phantom with an irregular surface. Positioning shift studies were performed using IMRT fields delivered to a thoracic anthropomorphic phantom. For thoracic phantom measurements, the camera was placed laterally to observe the entire right side of the phantom. Fields were delivered with known translational patient positioning shifts in four directions. Changes in the Cherenkov fluence were evaluated through the generation of difference maps from unshifted Cherenkov images. All images were evaluated using ImageJ, Python, and MATLAB software packages. For matched fields, Cherenkov images were able to quantitate matched field separations with discrepancies between 2 and 4mm, depending on gantry angle and beam energy or modality. For all photon and electron beams delivered at a gantry angle of 0°, image analysis indicated average discrepancies of less than 2mm for all field gaps and overlaps, with 83% of matched fields exhibiting discrepancies less than 1mm. Beams delivered obliquely to the phantom surface exhibited average discrepancies as high as 4mm for electron beams delivered at large oblique angles. Finally, for IMRT field delivery, vertical and lateral patient positioning shifts of 2mm were detected in some cases, indicating the potential detectability threshold of using this technique alone. Our study indicates that Cherenkov imaging can be used to support and bolster current treatment delivery verification techniques, improving our ability to recognize and rectify millimeter-scale delivery and positioning errors.

Empirical approach to determination of appropriate criteria for PSQA in a new radiotherapy department

Patient specific quality assurance (PSQA) is a critical element of routine service in a radiotherapy department for verification of complex treatment delivery, particularly during the introduction of new techniques, equipment or treatment sites. There are traditional or recommended guidelines for passing criteria for PSQA, however, they may not continue to be appropriate for the current generation of techniques/QA equipment. We have undertaken a review of our PSQA to determine what is the most appropriate criteria and if it should vary based on equipment or treatment site. Additionally, we aim to streamline our PSQA by reducing the number of physical measurements and needed to determine what equipment is best suited to be used as a single form of measurement. The ideal PSQA system would have independent from the Linac, high resolution and sensitivity, resource efficiency. PSQA measurement data was collected for breast, prostate and palliative treatment sites using the ArcCheck,PerFraction and Portal Dosimetry and analysed against Eclipse using gamma scoring criteria. We determined we would expect to see a failure rate of 10% and various sensitivities of the gamma score were evaluated to find a passing criteria meeting this failure rate. It was found that 10% of all prostate plans fail at 97.2% for gamma analysis at 2%/2 mm. 10% of breast plans fail at 91% at 3%/3 mm gamma analysis. The pass threshold was found to vary between treatment sites and measurement technique. PerFraction is the likely solution for ongoing streamlined PSQA. Patient specific quality assurance (PSQA) is a critical element of routine service in a radiotherapy department for verification of complex treatment delivery, particularly during the introduction of new techniques, equipment or treatment sites. There are traditional or recommended guidelines for passing criteria for PSQA, however, they may not continue to be appropriate for the current generation of techniques/QA equipment. We have undertaken a review of our PSQA to determine what is the most appropriate criteria and if it should vary based on equipment or treatment site. Additionally, we aim to streamline our PSQA by reducing the number of physical measurements and needed to determine what equipment is best suited to be used as a single form of measurement. The ideal PSQA system would have independent from the Linac, high resolution and sensitivity, resource efficiency. PSQA measurement data was collected for breast, prostate and palliative treatment sites using the ArcCheck,PerFraction and Portal Dosimetry and analysed against Eclipse using gamma scoring criteria. We determined we would expect to see a failure rate of 10% and various sensitivities of the gamma score were evaluated to find a passing criteria meeting this failure rate. It was found that 10% of all prostate plans fail at 97.2% for gamma analysis at 2%/2 mm. 10% of breast plans fail at 91% at 3%/3 mm gamma analysis. The pass threshold was found to vary between treatment sites and measurement technique. PerFraction is the likely solution for ongoing streamlined PSQA.