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Title: SU-F-T-227: A Comprehensive Patient Specific, Structure Specific, Pre-Treatment 3D QA Protocol for IMRT, SBRT and VMAT - Clinical Experience

Abstract

Purpose: To present a 3D QA method and clinical results for 550 patients. Methods: Five hundred and fifty patient treatment deliveries (400 IMRT, 75 SBRT and 75 VMAT) from various treatment sites, planned on Raystation treatment planning system (TPS), were measured on three beam-matched Elekta linear accelerators using IBA’s COMPASS system. The difference between TPS computed and delivered dose was evaluated in 3D by applying three statistical parameters to each structure of interest: absolute average dose difference (AADD, 6% allowed difference), absolute dose difference greater than 6% (ADD6, 4% structure volume allowed to fail) and 3D gamma test (3%/3mm DTA, 4% structure volume allowed to fail). If the allowed value was not met for a given structure, manual review was performed. The review consisted of overlaying dose difference or gamma results with the patient CT, scrolling through the slices. For QA to pass, areas of high dose difference or gamma must be small and not on consecutive slices. For AADD to manually pass QA, the average dose difference in cGy must be less than 50cGy. The QA protocol also includes DVH analysis based on QUANTEC and TG-101 recommended dose constraints. Results: Figures 1–3 show the results for the three parametersmore » per treatment modality. Manual review was performed on 67 deliveries (27 IMRT, 22 SBRT and 18 VMAT), for which all passed QA. Results show that statistical parameter AADD may be overly sensitive for structures receiving low dose, especially for the SBRT deliveries (Fig.1). The TPS computed and measured DVH values were in excellent agreement and with minimum difference. Conclusion: Applying DVH analysis and different statistical parameters to any structure of interest, as part of the 3D QA protocol, provides a comprehensive treatment plan evaluation. Author G. Gueorguiev discloses receiving travel and research funding from IBA for unrelated to this project work. Author B. Crawford discloses receiving travel funding from IBA for unrelated to this project work.« less

Authors:
; ; ;  [1];  [2]; ; ; ;  [1];  [3]
  1. Massachusetts General Hospital Boston MA (United States)
  2. (United States)
  3. University of Massachusetts Lowell Lowell, MA (United States)
Publication Date:
OSTI Identifier:
22648844
Resource Type:
Journal Article
Resource Relation:
Journal Name: Medical Physics; Journal Volume: 43; Journal Issue: 6; Other Information: (c) 2016 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; DELIVERY; DIFFERENTIAL THERMAL ANALYSIS; LINEAR ACCELERATORS; PATIENTS; RADIATION DOSES; RADIOTHERAPY; REVIEWS

Citation Formats

Gueorguiev, G, Cotter, C, Young, M, Toomeh, D, University of Massachusetts Lowell Lowell, MA, Khan, F, Crawford, B, Turcotte, J, Sharp, G, and Mah’D, M. SU-F-T-227: A Comprehensive Patient Specific, Structure Specific, Pre-Treatment 3D QA Protocol for IMRT, SBRT and VMAT - Clinical Experience. United States: N. p., 2016. Web. doi:10.1118/1.4956366.
Gueorguiev, G, Cotter, C, Young, M, Toomeh, D, University of Massachusetts Lowell Lowell, MA, Khan, F, Crawford, B, Turcotte, J, Sharp, G, & Mah’D, M. SU-F-T-227: A Comprehensive Patient Specific, Structure Specific, Pre-Treatment 3D QA Protocol for IMRT, SBRT and VMAT - Clinical Experience. United States. doi:10.1118/1.4956366.
Gueorguiev, G, Cotter, C, Young, M, Toomeh, D, University of Massachusetts Lowell Lowell, MA, Khan, F, Crawford, B, Turcotte, J, Sharp, G, and Mah’D, M. 2016. "SU-F-T-227: A Comprehensive Patient Specific, Structure Specific, Pre-Treatment 3D QA Protocol for IMRT, SBRT and VMAT - Clinical Experience". United States. doi:10.1118/1.4956366.
@article{osti_22648844,
title = {SU-F-T-227: A Comprehensive Patient Specific, Structure Specific, Pre-Treatment 3D QA Protocol for IMRT, SBRT and VMAT - Clinical Experience},
author = {Gueorguiev, G and Cotter, C and Young, M and Toomeh, D and University of Massachusetts Lowell Lowell, MA and Khan, F and Crawford, B and Turcotte, J and Sharp, G and Mah’D, M},
abstractNote = {Purpose: To present a 3D QA method and clinical results for 550 patients. Methods: Five hundred and fifty patient treatment deliveries (400 IMRT, 75 SBRT and 75 VMAT) from various treatment sites, planned on Raystation treatment planning system (TPS), were measured on three beam-matched Elekta linear accelerators using IBA’s COMPASS system. The difference between TPS computed and delivered dose was evaluated in 3D by applying three statistical parameters to each structure of interest: absolute average dose difference (AADD, 6% allowed difference), absolute dose difference greater than 6% (ADD6, 4% structure volume allowed to fail) and 3D gamma test (3%/3mm DTA, 4% structure volume allowed to fail). If the allowed value was not met for a given structure, manual review was performed. The review consisted of overlaying dose difference or gamma results with the patient CT, scrolling through the slices. For QA to pass, areas of high dose difference or gamma must be small and not on consecutive slices. For AADD to manually pass QA, the average dose difference in cGy must be less than 50cGy. The QA protocol also includes DVH analysis based on QUANTEC and TG-101 recommended dose constraints. Results: Figures 1–3 show the results for the three parameters per treatment modality. Manual review was performed on 67 deliveries (27 IMRT, 22 SBRT and 18 VMAT), for which all passed QA. Results show that statistical parameter AADD may be overly sensitive for structures receiving low dose, especially for the SBRT deliveries (Fig.1). The TPS computed and measured DVH values were in excellent agreement and with minimum difference. Conclusion: Applying DVH analysis and different statistical parameters to any structure of interest, as part of the 3D QA protocol, provides a comprehensive treatment plan evaluation. Author G. Gueorguiev discloses receiving travel and research funding from IBA for unrelated to this project work. Author B. Crawford discloses receiving travel funding from IBA for unrelated to this project work.},
doi = {10.1118/1.4956366},
journal = {Medical Physics},
number = 6,
volume = 43,
place = {United States},
year = 2016,
month = 6
}
  • Purpose: The purpose of this study is to inter-compare and find statistically significant differences between flattened field fixed-beam (FB) IMRT with flattening-filter free (FFF) volumetric modulated arc therapy (VMAT) for stereotactic body radiation therapy SBRT. Methods: SBRT plans using FB IMRT and FFF VMAT were generated for fifteen SBRT lung patients using 6 MV beams. For each patient, both IMRT and VMAT plans were created for comparison. Plans were generated utilizing RTOG 0915 (peripheral, 10 patients) and RTOG 0813 (medial, 5 patients) lung protocols. Target dose, critical structure dose, and treatment time were compared and tested for statistical significance. Parametersmore » of interest included prescription isodose surface coverage, target dose heterogeneity, high dose spillage (location and volume), low dose spillage (location and volume), lung dose spillage, and critical structure maximum- and volumetric-dose limits. Results: For all criteria, we found equivalent or higher conformality with VMAT plans as well as reduced critical structure doses. Several differences passed a Student's t-test of significance: VMAT reduced the high dose spillage, evaluated with conformality index (CI), by an average of 9.4%±15.1% (p=0.030) compared to IMRT. VMAT plans reduced the lung volume receiving 20 Gy by 16.2%±15.0% (p=0.016) compared with IMRT. For the RTOG 0915 peripheral lesions, the volumes of lung receiving 12.4 Gy and 11.6 Gy were reduced by 27.0%±13.8% and 27.5%±12.6% (for both, p<0.001) in VMAT plans. Of the 26 protocol pass/fail criteria, VMAT plans were able to achieve an average of 0.2±0.7 (p=0.026) more constraints than the IMRT plans. Conclusions: FFF VMAT has dosimetric advantages over fixed beam IMRT for lung SBRT. Significant advantages included increased dose conformity, and reduced organs-at-risk doses. The overall improvements in terms of protocol pass/fail criteria were more modest and will require more patient data to establish difference trends of more statistical significance.« less
  • Purpose: Due to the high dose per fraction in SBRT, dose conformity and dose fall-off are critical. In patients with cervical cancer, rapid dose fall-off is particularly important to limit dose to the nearby rectum, small bowel, and bladder. This study compares the target volume dose fall-off for two radiation delivery techniques, fixed-field IMRT & VMAT, using non-coplanar beam geometries. Further comparisons are made between 6 and 10MV photon beam energies. Methods: Eleven (n=11) patients were planned in Pinnacle3 v9.10 with a NovalisTx (HD120 MLC) machine model using 6 and 10 MV photons. The following three techniques were used: (1)more » IMRT (10 non-coplanar beams) (2) Dual, coplanar 360° VMAT arcs (4° spacing), and (3) Triple, non-coplanar VMAT arcs (1 full arc and dual partial arcs). All plans were normalized such that 98% of the PTV received at least 28Gy/4Fx. Dose was calculated using a 2.0mm isotropic dose grid. To assess dose fall-off, twenty concentric 2mm thick rings were created around the PTV. The maximum dose in each ring was recorded and the data was fitted to model dose fall-off. A separate analysis was performed by separating target volumes into small (0–50cc), medium (51–80cc), and large (81–110cc). Results: Triple, non-coplanar VMAT arcs showed the best dose fall-off for all patients evaluated. All fitted regressions had an R{sup 2}≥0.99. At 10mm from the PTV edge, 10 MV VMAT3-arc had an absolute improvement in dose fall-off of 3.8% and 6.9% over IMRT and VMAT2-arc, respectively. At 30mm, 10 MV VMAT3-arc had an absolute improvement of 12.0% and 7.0% over IMRT and VMAT2-arc, respectively. Faster dose fall-off was observed for small volumes as opposed to medium and large ones—9.6% at 20mm. Conclusion: Triple, non-coplanar VMAT arcs offer the sharpest dose fall-off for cervical SBRT plans. This improvement is most pronounced when treating smaller target volumes.« less
  • Purpose: To investigate the sensitivity of traditional gamma-index-based fluence measurements for patient-specific measurements in VMAT delivered spine SBRT. Methods: The ten most recent cases for spine SBRT were selected. All cases were planned with Eclipse RapidArc for a TrueBeam STx. The delivery was verified using a point dose measurement with a Pinpoint 3D micro-ion chamber in a Standard Imaging Stereotactic Dose Verification Phantom. Two points were selected for each case, one within the target in a low dose-gradient region and one in the spinal cord. Measurements were localized using on-board CBCT. Cumulative and separate arc measurements were acquired with themore » ArcCheck and assessed using the SNC patient software with a 3%/3mm and 2%/2mm gamma analysis with global normalization and a 10% dose threshold. Correlations between data were determined using the Pearson Product-Moment Correlation. Results: For our cohort of patients, the measured doses were higher than calculated ranging from 2.2%–9.7% for the target and 1.0%–8.2% for the spinal cord. There was strong correlation between 3%/3mm and 2%/2mm passing rates (r=0.91). Moderate correlation was found between target and cord dose with a weak fit (r=0.67, R-Square=0.45). The cumulative ArcCheck measurements showed poor correlation with the measured point doses for both the target and cord (r=0.20, r=0.35). If the arcs are assessed separately with an acceptance criteria applied to the minimum passing rate between all arcs, a moderate negative correlation was found for the target and cord (r=−0.48, r= −0.71). The case with the highest dose difference (9.7%) received a passing rate of 97.2% for the cumulative arcs and 87.8% for the minimum with separate arcs. Conclusion: Our data suggest that traditional passing criteria using ArcCheck with cumulative measurements do not correlate well with dose errors. Separate arc analysis shows better correlation but may still miss large dose errors. Point dose verifications are recommended.« less
  • Purpose: To evaluate the proportion of liver SBRT cases in which robotic ultrasound image guidance concurrent with beam delivery can be deployed without interfering with clinically used VMAT beam configurations. Methods: A simulation environment incorporating LINAC, couch, planning CT, and robotic ultrasound guidance hardware was developed. Virtual placement of the robotic ultrasound hardware was guided by a target visibility map rendered on the CT surface. The map was computed on GPU by using the planning CT to simulate ultrasound propagation and attenuation along rays connecting skin surface points to a rasterized imaging target. The visibility map was validated in amore » prostate phantom experiment by capturing live ultrasound images of the prostate from different phantom locations. In 20 liver SBRT patients treated with VMAT, the simulation environment was used to place the robotic hardware and ultrasound probe at imaging locations indicated on the visibility map. Imaging targets were either entire PTV (range 5.9–679.5 ml) or entire GTV (range 0.9–343.4 ml). Presence or absence of mechanical collisions with LINAC, couch, and patient body as well as interferences with treated beams were recorded. Results: For PTV targets, robotic ultrasound guidance without mechanical collision was possible in 80% of the cases and guidance without beam interference was possible in 60% of the cases. For the smaller GTV targets, these proportions were 95% and 85% correspondingly. GTV size (1/20), elongated shape (1/20), and depth (1/20) were the main factors limiting the availability of non-interfering imaging positions. Conclusion: This study indicates that for VMAT liver SBRT, robotic ultrasound tracking of a relevant internal target would be possible in 85% of cases while using treatment plans currently deployed in the clinic. With beam re-planning in accordance with the presence of robotic ultrasound guidance, intra-fractional ultrasound guidance may be an option for 95% of the liver SBRT cases. This project was funded by NIH Grant R41CA174089.« less
  • Purpose: To commission the Monaco Treatment Planning System for the Novalis Tx machine. Methods: The commissioning of Monte-Carlo (MC), Collapsed Cone (CC) and electron Monte-Carlo (eMC) beam models was performed through a series of measurements and calculations in medium and in water. In medium measurements relied Octavius 4D QA system with the 1000 SRS detector array for field sizes less than 4 cm × 4 cm and the 1500 detector array for larger field sizes. Heterogeneity corrections were validated using a custom built phantom. Prior to clinical implementation, an end to end testing of a Prostate and H&N VMAT plansmore » was performed. Results: Using a 0.5% uncertainty and 2 mm grid sizes, Tables I and II summarize the MC validation at 6 MV and 18 MV in both medium and water. Tables III and IV show similar comparisons for CC. Using the custom heterogeneity phantom setup of Figure 1 and IGRT guidance summarized in Figure 2, Table V lists the percent pass rate for a 2%, 2 mm gamma criteria at 6 and 18 MV for both MC and CC. The relationship between MC calculations settings of uncertainty and grid size and the gamma passing rate for a prostate and H&N case is shown in Table VI. Table VII lists the results of the eMC calculations compared to measured data for clinically available applicators and Table VIII for small field cutouts. Conclusion: MU calculations using MC are highly sensitive to uncertainty and grid size settings. The difference can be of the order of several per cents. MC is superior to CC for small fields and when using heterogeneity corrections, regardless of field size, making it more suitable for SRS, SBRT and VMAT deliveries. eMC showed good agreement with measurements down to 2 cm − 2 cm field size.« less