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Title: SU-F-T-289: MLC Fluence Sonogram Based Delivery Quality Assurance for Bilateral Breast Irradiation

Abstract

Purpose: Performing DQA for Bilateral (B-L) breast tomotherapy is a challenging task due to the limitation of any commercially available detector array or film. Aim of this study is to perform DQA for B-L breast tomotherapy plan using MLC fluence sinogram. Methods: Treatment plan was generated on Tomotherapy system for B-L breast tumour. B-L breast targets were given 50.4 Gy prescribed over 28 fractions. Plan is generated with 6 MV photon beam & pitch was set to 0.3. As the width of the total target is 39 cm (left & right) length is 20 cm. DQA plan delivered without any phantom on the mega voltage computed tomography (MCVT) detector system. The pulses recorded by MVCT system were exported to the delivery analysis software (Tomotherapy Inc.) for reconstruction. The detector signals are reconstructed to a sonogram and converted to MLC fluence sonogram. The MLC fluence sinogram compared with the planned fluence sinogram. Also point dose measured with cheese phantom and ionization chamber to verify the absolute dose component Results: Planned fluence sinogram and reconstructed MLC fluence sinogram were compared using Gamma metric. MLC positional difference and intensity of the beamlet were used as parameters to evaluate gamma. 3 mm positional differencemore » and 3% beamlet intensity difference were used set for gamma calculation. A total of 26784 non-zero beamlets were included in the analysis out of which 161 beamlets had gamma more than 1. The gamma passing rate found to be 99.4%. Point dose measurements were within 1.3% of the calculated dose. Conclusion: MLC fluence sinogram based delivery quality assurance performed for bilateral breast irradiation. This would be a suitable alternate for large volume targets like bilateral breast, Total body irradiation etc. However conventional method of DQA should be used to validate this method periodically.« less

Authors:
; ; ; ; ;  [1];  [2];
  1. Division of Radiation Oncology, Medanta The Medicity, Gurgaon, Haryana (India)
  2. Department of Physics, School of Advanced sciences, VIT University, Vellore (India)
Publication Date:
OSTI Identifier:
22648900
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; COMPUTER CODES; COMPUTERIZED TOMOGRAPHY; CT-GUIDED RADIOTHERAPY; ELECTRIC POTENTIAL; IONIZATION CHAMBERS; MAMMARY GLANDS; PHOTON BEAMS; QUALITY ASSURANCE; RADIATION DOSES; WHOLE-BODY IRRADIATION

Citation Formats

Thiyagarajan, Rajesh, Karrthick, KP, Kataria, Tejinder, Mahendran, Ramu, Selvan, Tamil, Duraikannu, Palani, Raj, Nambi, and Arunai, N. SU-F-T-289: MLC Fluence Sonogram Based Delivery Quality Assurance for Bilateral Breast Irradiation. United States: N. p., 2016. Web. doi:10.1118/1.4956429.
Thiyagarajan, Rajesh, Karrthick, KP, Kataria, Tejinder, Mahendran, Ramu, Selvan, Tamil, Duraikannu, Palani, Raj, Nambi, & Arunai, N. SU-F-T-289: MLC Fluence Sonogram Based Delivery Quality Assurance for Bilateral Breast Irradiation. United States. doi:10.1118/1.4956429.
Thiyagarajan, Rajesh, Karrthick, KP, Kataria, Tejinder, Mahendran, Ramu, Selvan, Tamil, Duraikannu, Palani, Raj, Nambi, and Arunai, N. 2016. "SU-F-T-289: MLC Fluence Sonogram Based Delivery Quality Assurance for Bilateral Breast Irradiation". United States. doi:10.1118/1.4956429.
@article{osti_22648900,
title = {SU-F-T-289: MLC Fluence Sonogram Based Delivery Quality Assurance for Bilateral Breast Irradiation},
author = {Thiyagarajan, Rajesh and Karrthick, KP and Kataria, Tejinder and Mahendran, Ramu and Selvan, Tamil and Duraikannu, Palani and Raj, Nambi and Arunai, N},
abstractNote = {Purpose: Performing DQA for Bilateral (B-L) breast tomotherapy is a challenging task due to the limitation of any commercially available detector array or film. Aim of this study is to perform DQA for B-L breast tomotherapy plan using MLC fluence sinogram. Methods: Treatment plan was generated on Tomotherapy system for B-L breast tumour. B-L breast targets were given 50.4 Gy prescribed over 28 fractions. Plan is generated with 6 MV photon beam & pitch was set to 0.3. As the width of the total target is 39 cm (left & right) length is 20 cm. DQA plan delivered without any phantom on the mega voltage computed tomography (MCVT) detector system. The pulses recorded by MVCT system were exported to the delivery analysis software (Tomotherapy Inc.) for reconstruction. The detector signals are reconstructed to a sonogram and converted to MLC fluence sonogram. The MLC fluence sinogram compared with the planned fluence sinogram. Also point dose measured with cheese phantom and ionization chamber to verify the absolute dose component Results: Planned fluence sinogram and reconstructed MLC fluence sinogram were compared using Gamma metric. MLC positional difference and intensity of the beamlet were used as parameters to evaluate gamma. 3 mm positional difference and 3% beamlet intensity difference were used set for gamma calculation. A total of 26784 non-zero beamlets were included in the analysis out of which 161 beamlets had gamma more than 1. The gamma passing rate found to be 99.4%. Point dose measurements were within 1.3% of the calculated dose. Conclusion: MLC fluence sinogram based delivery quality assurance performed for bilateral breast irradiation. This would be a suitable alternate for large volume targets like bilateral breast, Total body irradiation etc. However conventional method of DQA should be used to validate this method periodically.},
doi = {10.1118/1.4956429},
journal = {Medical Physics},
number = 6,
volume = 43,
place = {United States},
year = 2016,
month = 6
}
  • Purpose: This work uses repeat images of intensity modulated radiation therapy (IMRT) fields to quantify fluence anomalies (i.e., delivery errors) that can be reliably detected in electronic portal images used for IMRT pretreatment quality assurance. Methods: Repeat images of 11 clinical IMRT fields are acquired on a Varian Trilogy linear accelerator at energies of 6 MV and 18 MV. Acquired images are corrected for output variations and registered to minimize the impact of linear accelerator and electronic portal imaging device (EPID) positioning deviations. Detection studies are performed in which rectangular anomalies of various sizes are inserted into the images. Themore » performance of detection strategies based on pixel intensity deviations (PIDs) and gamma indices is evaluated using receiver operating characteristic analysis. Results: Residual differences between registered images are due to interfraction positional deviations of jaws and multileaf collimator leaves, plus imager noise. Positional deviations produce large intensity differences that degrade anomaly detection. Gradient effects are suppressed in PIDs using gradient scaling. Background noise is suppressed using median filtering. In the majority of images, PID-based detection strategies can reliably detect fluence anomalies of {>=}5% in {approx}1 mm{sup 2} areas and {>=}2% in {approx}20 mm{sup 2} areas. Conclusions: The ability to detect small dose differences ({<=}2%) depends strongly on the level of background noise. This in turn depends on the accuracy of image registration, the quality of the reference image, and field properties. The longer term aim of this work is to develop accurate and reliable methods of detecting IMRT delivery errors and variations. The ability to resolve small anomalies will allow the accuracy of advanced treatment techniques, such as image guided, adaptive, and arc therapies, to be quantified.« less
  • During volumetric modulated arc therapy (VMAT) of head and neck cancer, some patients lose weight which may result in anatomical deviations from the initial plan. If these deviations are substantial a new treatment plan can be designed for the remainder of treatment (i.e., adaptive planning). Since the adaptive treatment process is resource intensive, one possible approach to streamlining the quality assurance (QA) process is to use the electronic portal imaging device (EPID) to measure the integrated fluence for the adapted plans instead of the currently-used ArcCHECK device (Sun Nuclear). Although ArcCHECK is recognized as the clinical standard for patient-specific VMATmore » plan QA, it has limited length (20 cm) for most head and neck field apertures and has coarser detector spacing than the EPID (10 mm vs. 0.39 mm). In this work we compared measurement of the integrated fluence using the EPID with corresponding measurements from the ArcCHECK device. In the past year nine patients required an adapted plan. Each of the plans (the original and adapted) is composed of two arcs. Routine clinical QA was performed using the ArcCHECK device, and the same plans were delivered to the EPID (individual arcs) in integrated mode. The dose difference between the initial plan and adapted plan was compared for ArcCHECK and EPID. In most cases, it was found that the EPID is more sensitive in detecting plan differences. Therefore, we conclude that EPID provides a viable alternative for QA of the adapted head and neck plans and should be further explored.« less
  • Purpose: Dosimetry using film, CR, electronic portal imaging, or other 2D detectors requires calibration of the raw image data to obtain dose. Typically, a series of known doses are given to the detector, the raw signal for each dose is obtained, and a calibration curve is created. This calibration curve is then applied to the measured raw signals to convert them to dose. With the advent of IMRT, film dosimetry for quality assurance has become a routine and labor intensive part of the physicist's day. The process of calibrating the film or other 2D detector takes time and additional filmmore » or images for performing the calibration, and comes with its own source of errors. This article studies a new methodology for the relative dose calibration of 2D imaging detectors especially useful for IMRT QA, which relies on the treatment plan dose image to provide the dose information which is paired with the raw QA image data after registration of the two images (plan-based calibration). Methods: Validation of the accuracy and robustness of the method is performed on ten IMRT cases performed using EDR2 film with conventional and plan-based calibration. Also, for each of the ten cases, a 5 mm registration error was introduced and the Gamma analysis was reevaluated. In addition, synthetic image tests were performed to test the limits of the method. The Gamma analysis is used as a measure of dosimetric agreement between plan and film for the clinical cases and a dose difference metric for the synthetic cases. Results: The QA image calibrated by the plan-based method was found to more accurately match the treatment plan doses than the conventionally calibrated films and also to reveal dose errors more effectively when a registration error was introduced. When synthetic acquired images were systematically studied, localized and randomly placed dose errors were correctly identified without excessive falsely passing or falsely failing pixels, unless the errors were concentrated in a majority of pixels in a contiguous narrow dose band. Irregularities seen in the calibration curve expose these errors. Conclusions: The plan-based calibration method was found to be an accurate, efficient procedure, capable of detecting IMRT QA relative dosimetry errors as well as, or better than conventional calibration methods.« less
  • Purpose: The Korean Radiation Oncology Group (KROG) 08-06 study protocol allowed radiation therapy (RT) technique to include or exclude breast cancer patients from receiving radiation therapy to the internal mammary lymph node (IMN). The purpose of this study was to assess dosimetric differences between the 2 groups and potential influence on clinical outcome by a dummy run procedure. Methods and Materials: All participating institutions were asked to produce RT plans without irradiation (Arm 1) and with irradiation to the IMN (Arm 2) for 1 breast-conservation treatment case (breast-conserving surgery [BCS]) and 1 mastectomy case (modified radical mastectomy [MRM]) whose computed tomographymore » images were provided. We assessed interinstitutional variations in IMN delineation and evaluated the dose-volume histograms of the IMN and normal organs. A reference IMN was delineated by an expert panel group based on the study guidelines. Also, we analyzed the potential influence of actual dose variation observed in this study on patient survival. Results: Although physicians intended to exclude the IMN within the RT field, the data showed almost 59.0% of the prescribed dose was delivered to the IMN in Arm 1. However, the mean doses covering the IMN in Arm 1 and Arm 2 were significantly different for both cases (P<.001). Due to the probability of overdose in Arm 1, the estimated gain in 7-year disease-free survival rate would be reduced from 10% to 7.9% for BCS cases and 7.1% for MRM cases. The radiation doses to the ipsilateral lung, heart, and coronary artery were lower in Arm 1 than in Arm 2. Conclusions: Although this dummy run study indicated that a substantial dose was delivered to the IMN, even in the nonirradiation group, the dose differences between the 2 groups were statistically significant. However, this dosimetric profile should be studied further with actual patient samples and be taken into consideration when analyzing clinical outcomes according to IMN irradiation.« less
  • Purpose: Breast cancer patients with bilateral implant reconstructions who require postmastectomy radiotherapy can pose unique treatment planning challenges. The use of VMAT may provide advantages over conventional tangent or multi-beam IMRT techniques. Moreover, daily setup uncertainly of the arm position, however, could have significant impact on accurate dose delivery. This study compares the plan qualities between non-AA and AA VMAT techniques. Methods: Three breast cancer patients receiving left chest wall and regional nodal irradiation with bilateral implant reconstructions were studied. PTV included chest wall and IMNs (PTV-CW), and supraclavicular and axillary lymph nodes (PTV-SCV). For each patient, one non-AA VMATmore » plan (VMAT-S) with 4 partial arcs encompassing the ipsilateral arm and three AA VMAT plans where no arcs were entering or existing through the ipsilateral arm were generated. VMAT-AA1 uses 2 arcs for PTV-CW and 2 arcs for PTV-SCV. VMAT-AA2 used two static fields for PTV-SCV with 2 arcs for PTV-CW. VMAT-AA3 used 2 narrow arcs for PTV-CW and 2 long arcs for all PTVs. Prescription dose (PD) was 50 Gy (25 fractions). All plans were normalized to have 95% of PD to 95 % of PTV. PTV dose inhomogeneity and dose to the heart, left lung, right thyroid dose and left humerus were evaluated. Results: For VMAT-S, VMAT-AA1, VMAT-AA2 and VMAT-AA3, respectively, the average and standard deviation (in Gy unless specified otherwise) of PTV D05 are 54.7±0.9, 55.9±0.4, 56.7±0.7 and 55.7±0.4; mean Heart dose: 7.1±0.7, 7.2±0.8, 7.3±0.9 and 6.9±1.0; left lung V20Gy (in %): 28.1±1.0, 28.8+2.2, 32.2±4.1 and 27.8±2.0; mean right thyroid dose: 8.1±0.6, 5.1±2.1, 2.1±0.4 and 5.0±2.0; mean left humerus dose: 20.0±4.4,15.6±4.4, 15.2±8.2 and 15.3±4.6. Conclusion: AA VMAT can produce acceptable clinical plans while eliminating dosimetric impact related to arm setup uncertainty. These data require validation in larger planning studies prior to routine clinical implantation.« less