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Title: SU-E-T-71: A Radiochromic Film Based Quantitative Assessment of Thermoplastic Mask Bolus Effect in Head and Neck IMRT/VMAT

Abstract

Purpose: To quantify the factors leading to thermoplastic mask bolus-associated-increased skin dose in head and neck IMRT/VMAT using EBT2 film. Methods: EBT2 film placed beneath a dual layer 3-point ORFIT head, neck and shoulder mask was used to test the effect of mask thickness, beam modulation, air gap, and beam obliquity on bolus effect. Mask thickness was varied based on the distribution of 1.6mm Orfilight layer on top of 2 mm Efficast layer. Beam modulation was varied by irradiating the film with an open field (no beam modulation) and a step and shoot field (beam modulation). Air gap between mask and film was varied from 0 to 5mm. Beam obliquity was varied by irradiating the film at gantry angles of 0°, 35°, and 70°.Finally, film strips placed on a Rando phantom under an Orfit mask, in regions of expected high dose, were irradiated using 5 IMRT and 5 VMAT plans with various modulation levels (modulation factor 2 to 5) and the results were compared with those obtained placing OSLDs at the same locations. Results: An 18–34% increase in mask bolus effect was observed for three factors where the effect of beam obliquity ≥ beam modulation > mask thickness. No increasemore » in mask bolus effect was observed for change in air gap. A 6–13% increase in dose due to mask bolus effect was observed on film strips. Conclusion: This work underlines the role of beam obliquity and beam modulation combined with thermoplastic mask thickness in increasing mask bolus-associated skin dose in head and neck IMRT/VMAT. One possible method of dose reduction, based on knowledge gained from this work, is inclusion of skin as an avoidance structure in treatment planning. Another approach is to design a mask with the least amount of thermoplastic material necessary for immobilization.« less

Authors:
; ; ; ; ; ; ; ;  [1]
  1. University of Maryland School of Medicine, Baltimore, MD (United States)
Publication Date:
OSTI Identifier:
22545201
Resource Type:
Journal Article
Resource Relation:
Journal Name: Medical Physics; Journal Volume: 42; Journal Issue: 6; Other Information: (c) 2015 American Association of Physicists in Medicine; Country of input: International Atomic Energy Agency (IAEA)
Country of Publication:
United States
Language:
English
Subject:
60 APPLIED LIFE SCIENCES; 61 RADIATION PROTECTION AND DOSIMETRY; BEAMS; FILM DOSIMETRY; HEAD; MODULATION; NECK; PHANTOMS; RADIATION DOSES; RADIOTHERAPY; RESPIRATORS; SKIN; THERMOPLASTICS; THICKNESS

Citation Formats

Kalavagunta, C, Lin, M, Snider, J, Xu, H, Schrum, A, Vadnais, P, Marter, K, Suntharalingam, M, and Prado, K. SU-E-T-71: A Radiochromic Film Based Quantitative Assessment of Thermoplastic Mask Bolus Effect in Head and Neck IMRT/VMAT. United States: N. p., 2015. Web. doi:10.1118/1.4924432.
Kalavagunta, C, Lin, M, Snider, J, Xu, H, Schrum, A, Vadnais, P, Marter, K, Suntharalingam, M, & Prado, K. SU-E-T-71: A Radiochromic Film Based Quantitative Assessment of Thermoplastic Mask Bolus Effect in Head and Neck IMRT/VMAT. United States. doi:10.1118/1.4924432.
Kalavagunta, C, Lin, M, Snider, J, Xu, H, Schrum, A, Vadnais, P, Marter, K, Suntharalingam, M, and Prado, K. Mon . "SU-E-T-71: A Radiochromic Film Based Quantitative Assessment of Thermoplastic Mask Bolus Effect in Head and Neck IMRT/VMAT". United States. doi:10.1118/1.4924432.
@article{osti_22545201,
title = {SU-E-T-71: A Radiochromic Film Based Quantitative Assessment of Thermoplastic Mask Bolus Effect in Head and Neck IMRT/VMAT},
author = {Kalavagunta, C and Lin, M and Snider, J and Xu, H and Schrum, A and Vadnais, P and Marter, K and Suntharalingam, M and Prado, K},
abstractNote = {Purpose: To quantify the factors leading to thermoplastic mask bolus-associated-increased skin dose in head and neck IMRT/VMAT using EBT2 film. Methods: EBT2 film placed beneath a dual layer 3-point ORFIT head, neck and shoulder mask was used to test the effect of mask thickness, beam modulation, air gap, and beam obliquity on bolus effect. Mask thickness was varied based on the distribution of 1.6mm Orfilight layer on top of 2 mm Efficast layer. Beam modulation was varied by irradiating the film with an open field (no beam modulation) and a step and shoot field (beam modulation). Air gap between mask and film was varied from 0 to 5mm. Beam obliquity was varied by irradiating the film at gantry angles of 0°, 35°, and 70°.Finally, film strips placed on a Rando phantom under an Orfit mask, in regions of expected high dose, were irradiated using 5 IMRT and 5 VMAT plans with various modulation levels (modulation factor 2 to 5) and the results were compared with those obtained placing OSLDs at the same locations. Results: An 18–34% increase in mask bolus effect was observed for three factors where the effect of beam obliquity ≥ beam modulation > mask thickness. No increase in mask bolus effect was observed for change in air gap. A 6–13% increase in dose due to mask bolus effect was observed on film strips. Conclusion: This work underlines the role of beam obliquity and beam modulation combined with thermoplastic mask thickness in increasing mask bolus-associated skin dose in head and neck IMRT/VMAT. One possible method of dose reduction, based on knowledge gained from this work, is inclusion of skin as an avoidance structure in treatment planning. Another approach is to design a mask with the least amount of thermoplastic material necessary for immobilization.},
doi = {10.1118/1.4924432},
journal = {Medical Physics},
number = 6,
volume = 42,
place = {United States},
year = {Mon Jun 15 00:00:00 EDT 2015},
month = {Mon Jun 15 00:00:00 EDT 2015}
}
  • Purpose: To quantitatively evaluate the bolus effect of thermoplalstic mask on patient skin dose during multi-field IMRT and VMAT treatment. Methods: The clinically approved target contours for five head and neck patients were deformably registered to an anthropomorphic Rando phantom. Two plans: Multifield IMRT plan with 7-9 beams and VMAT plan with 2-4 arcs were created for each patient following same dose constraints. 3mm skin was excluded from PTVs but not constrained during optimization. The prescription dose was 200-220 cGy/fraction. A thermoplastic head and shoulder mask was customized for the Rando phantom. Each plan was delivered to the phantom twicemore » with and without mask. During each delivery, two rectangular strips of EBT3 films (1cm x 6.8cm) were placed across the anterior upper and lower neck near PTVs to measure the surface dose. For consistency films were positioned at same locations for same patient. A total of 8 film strips were obtained for each patient. Film dose was calibrated in the range of 0-400cGy on the day of plan delivery. For dose comparison 3 regions of interests (ROIs) of 1×1 cm{sup 2} were selected at left, right and middle part of each film, resulting in 6 point doses at each plan delivery. Results: The films without mask show relatively uniform dose distribution while those with mask clearly show mesh pattern of mask, usually indicating an increase in skin dose. On average the increase in skin dose over all ROIs with mask was 31.9%(±14.8%) with a range of 11.4%- 58.4%. There is no statistically significant difference (p=0.44) between skin dose increase in VMAT (30.8%±15.3%) and IMRT delivery (33.0%±14.9%). Conclusion: Thermoplastic immobilization masks increase surface dose for HN patient by around 30%. The magnitude is comparable between multi-field IMRT and VMAT. Radiochromic EBT3 film serves as an effective tool to quantify bolus effect.« less
  • Purpose: The presence of high density dental amalgam in patient CT image data sets causes dose calculation errors for head and neck (HN) treatment planning. This study assesses and compares dosimetric variations in IMRT and VMAT treatment plans due to dental artifacts. Methods: Sixteen HN patients with similar treatment sites (oropharynx), tumor volume and extensive dental artifacts were divided into two groups: IMRT (n=8, 6 to 9 beams) and VMAT (n=8, 2 arcs with 352° rotation). All cases were planned with the Pinnacle 9.2 treatment planning software using the collapsed cone convolution superposition algorithm and a range of prescription dosemore » from 60 to 72Gy. Two different treatment plans were produced, each based on one of two image sets: (a)uncorrected; (b)dental artifacts density overridden (set to 1.0g/cm{sup 3}). Differences between the two treatment plans for each of the IMRT and VMAT techniques were quantified by the following dosimetric parameters: maximum point dose, maximum spinal cord and brainstem dose, mean left and right parotid dose, and PTV coverage (V95%Rx). Average differences generated for these dosimetric parameters were compared between IMRT and VMAT plans. Results: The average absolute dose differences (plan a minus plan b) for the VMAT and IMRT techniques, respectively, caused by dental artifacts were: 2.2±3.3cGy vs. 37.6±57.5cGy (maximum point dose, P=0.15); 1.2±0.9cGy vs. 7.9±6.7cGy (maximum spinal cord dose, P=0.026); 2.2±2.4cGy vs. 12.1±13.0cGy (maximum brainstem dose, P=0.077); 0.9±1.1cGy vs. 4.1±3.5cGy (mean left parotid dose, P=0.038); 0.9±0.8cGy vs. 7.8±11.9cGy (mean right parotid dose, P=0.136); 0.021%±0.014% vs. 0.803%±1.44% (PTV coverage, P=0.17). Conclusion: For the HN plans studied, dental artifacts demonstrated a greater dose calculation error for IMRT plans compared to VMAT plans. Rotational arcs appear on the average to compensate dose calculation errors induced by dental artifacts. Thus, compared to VMAT, density overrides for dental artifacts are more important when planning IMRT of HN.« less
  • Purpose: To compare dosimetric properties and monitor units (MU) of IMRT plans with several VMAT head and neck (H and N) plans. Methods: Seventeen unilateral H and N (UHN) and five bilateral H and N (BHN) patients initially treated with IMRT were replanned with VMAT. Several arc arrangements were studied for each patient: 1)for UHN, two 360° arcs, two 260° arcs, two 210° arcs, two 360° arcs with contralateral avoidance sectors, and 2)for BHN, two 360° arcs, two 360° arcs with bilateral avoidance sectors, two 360° arcs with bilateral avoidance sectors and a third arc limited to the upper neck.more » Optimization constraints were adjusted for each patient and plan. All plans were normalized to achieve the same highest-dose PTV coverage. Percent differences (IMRT-VMAT)/VMAT in MU, dose homogeneity (HI=maximum point dose/prescription dose), and organ-at-risk (OAR) metrics are reported and statistical significance evaluated (p<0.05; paired Student t-test). Results: Average reduction in MU with VMAT was 28% for UHN (p<0.0001) and 63% for BHN (p<0.0001). Average HI for UHN IMRT and 360° arc VMAT plans was 1.08 and for plans with arcs <360° average HI=1.10. Average HI for BHN IMRT was 1.07, for three-arc VMAT 1.08, and for two-arc VMAT 1.11. For UHN, two 210° arcs achieved lower contralateral parotid max (−2.6 Gy, p<0.02) and mean (−1.2 Gy, p=0.06) dose. For BHN two-arc plans, contralateral parotid mean dose increased (3.3 Gy, p<0.04) and larynx max dose increased (2.9 Gy, p<0.02) with no change in larynx mean dose. Conclusion: For UHN, 360degree arc VMAT consistently produced plans dosimetrically comparable to IMRT with the benefit of lower MU. VMAT with arcs <360degrees produced plans inferior to IMRT in dose homogeneity and without significantly improved OAR sparing. For BHN, three-arc plans were dosimetrically comparable to IMRT with lower MU, while two-arc plans were inferior to IMRT in HI and OAR dose. Research supported in part by a Kaye Family Award.« less
  • Purpose: To investigate if there is benefits of using flattening filter free (FFF) versus flattening filter (FF) beams during plan optimization for head and neck targets. Methods: Five head and neck cancer patients previously treated were selected for this study. Each plan was optimized for volumetric modulated arc therapy (VMAT) using 2 full arcs. Target volumes and the organs at risk (OAR) were outlined by the same physician. The prescription doses for each patient and the dose limits for each OAR were specified by the physician. For each patient four plans were created by varying the photon beam energy (6MVmore » vs 10MV) and the use of FF or FFF. For each patient the prescription dose and OAR dose limits remained unchanged. Furthermore, the number of optimization iterations remained the same for each plan without user interference. The plans were compared using dose volume histograms, conformity and homogeneity indices. Results: Our results showed that the plans optimized with FF beams produced more homogeneous dose distributions in the PTV than the ones with FFF beams (0.92 vs. 0.86 and 0.92 vs.85 for 6MVFF, 6MVFFF, 10MVFF and 10MVFFF respectively). The conformity was better for FFF beams than for FF beams (1.26 vs. 1.20 and 1.27 vs. 1.21 for 6MVFF, 6MVFFF, 10MVFF and 10MVFFF respectively). The overall minimum, maximum and means doses were reduced for the FFF plans by approximately 4% to 6%. All FFF plans allowed more sparing of organs at risk by 7% to 9% on average. Only one 10MVFFF plan had a 1% higher dose than the respective 10MVFF for the spinal cord. Conclusion: The 6MVFFF and 10MVFFF beams illustrated the improvement of normal tissue sparing while achieving similar target dose distribution compared to 6MVFF and 10MVFF beams. Further investigation is required to determine the magnitude of improvement. case specific, fluence-based optimization improved both PTV and OAR dosimetry in 80% of cases.« less
  • Purpose: VMAT involves two main sources of uncertainty: one related to the dose calculation accuracy, and the other linked to the continuous delivery of a discrete calculation. The purpose of this work is to present QuAArC, an alternative VMAT QA system to control and potentially reduce these uncertainties. Methods: An automated MC simulation of log files, recorded during VMAT treatment plans delivery, was implemented in order to simulate the actual treatment parameters. The linac head models and the phase-space data of each Control Point (CP) were simulated using the EGSnrc/BEAMnrc MC code, and the corresponding dose calculation was carried outmore » by means of BEAMDOSE, a DOSXYZnrc code modification. A cylindrical phantom was specifically designed to host films rolled up at different radial distances from the isocenter, for a 3D and continuous dosimetric verification. It also allows axial and/or coronal films and point measurements with several types of ion chambers at different locations. Specific software was developed in MATLAB in order to process and evaluate the dosimetric measurements, which incorporates the analysis of dose distributions, profiles, dose difference maps, and 2D/3D gamma index. It is also possible to obtain the experimental DVH reconstructed on the patient CT, by an optimization method to find the individual contribution corresponding to each CP on the film, taking into account the total measured dose, and the corresponding CP dose calculated by MC. Results: The QuAArC system showed high reproducibility of measurements, and consistency with the results obtained with the commercial system implemented in the verification of the evaluated treatment plans. Conclusion: A VMAT QA system based on MC simulation and high resolution dosimetry with film has been developed for treatment verification. It shows to be useful for the study of the real VMAT capabilities, and also for linac commissioning and evaluation of other verification devices.« less