Dosimetric effects caused by couch tops and immobilization devices: report of AAPM Task Group 176.

The dosimetric impact from devices external to the patient is a complex combination of increased skin dose, reduced tumor dose, and altered dose distribution. Although small monitor unit or dose corrections are routinely made for blocking trays, ion chamber correction factors, e.g., accounting for temperature and pressure, or tissue inhomogeneities, the dose perturbation of the treatment couch top or immobilization devices is often overlooked. These devices also increase skin dose, an effect which is also often ignored or underestimated. These concerns have grown recently due to the increased use of monolithic carbon fiber couch tops which are optimal for imaging for patient position verification but cause attenuation and increased skin dose compared to the "tennis racket" style couch top they often replace. Also, arc delivery techniques have replaced stationary gantry techniques which cause a greater fraction of the dose to be delivered from posterior angles. A host of immobilization devices are available and used to increase patient positioning reproducibility, and these also have attenuation and skin dose implications which are often ignored. This report of Task Group 176 serves to present a survey of published data that illustrates the magnitude of the dosimetric effects of a wide range of devices external to the patient. The report also provides methods for modeling couch tops in treatment planning systems so the physicist can accurately compute the dosimetric effects for indexed patient treatments. Both photon and proton beams are considered. A discussion on avoidance of high density structures during beam planning is also provided. An important aspect of this report are the recommendations the authors make to clinical physicists, treatment planning system vendors, and device vendors on how to make measurements of surface dose and attenuation and how to report these values. For the vendors, an appeal is made to work together to provide accurate couch top models in planning systems.

Two self-referencing methods for the measurement of beam spot position.

PURPOSE: Two quantitative methods of measuring electron beam spot position with respect to the collimator axis of rotation (CAOR) are described. METHODS: Method 1 uses a cylindrical ion chamber (IC) mounted on a jig corotational with the collimator making the relationship among the chamber, jaws, and CAOR fixed and independent of collimator angle. A jaw parallel to the IC axis is set to zero and the IC position adjusted so that the IC signal is approximately 50% of the open field value, providing a large dose gradient in the region of the IC. The cGy∕MU value is measured as a function of collimator rotation, e.g., every 30°. If the beam spot does not lie on the CAOR, the signal from the ion chamber will vary with collimator rotation. Based on a measured spatial sensitivity, the distance of the beam spot from the CAOR can be calculated from the IC signal variation with rotation. The 2nd method is image based. Two stainless steel rods, 3 mm in diameter, are mounted to a jig attached to the Linac collimator. The rods, offset from the CAOR, lay in different planes normal to the CAOR, one at 158 cm SSD and the other at 70 cm SSD. As the collimator rotates the rods move tangent along an envelope circle, the centers of which are on the CAOR in their respective planes. Three images, each at a different collimator rotation, containing the shadows of both rods, are acquired on the Linac EPID. At each angle the shadow of the rods on the EPID defines lines tangent to the projection of the envelope circles. From these the authors determine the projected centers of the two circles at different heights. From the distance of these two points using the two heights and the source to EPID distance, the authors calculate the distance of the beam spot from the CAOR. Measurements with all two techniques were performed on an Elekta Linac. Measurements were performed with the beam spot in nominal clinical position and in a deliberately offset position. Measurements were also performed using the Flexmap image registration∕ball-bearing test. RESULTS: Within their uncertainties, both methods report the same beam spot displacement. In clinical use, a total of 203 monthly beam spot measurements on 14 different beams showed an average displacement of 0.11 mm (σ = 0.07 mm) in-plane and 0.10 mm (σ = 0.07 mm) cross-plane with maximum displacement of 0.37 mm in-plane and 0.34 mm cross-plane. CONCLUSIONS: The methods described provide a quantitative measure of beam spot position, are easy to use, and provide another tool for Linac setup and quality assurance. Fundamental to the techniques is that they are self-referencing-i.e., they do not require the user to independently define the CAOR.

Junctioning longitudinally adjacent PTVs with Helical TomoTherapy.

Irradiation of longitudinally adjacent PTVs with Helical TomoTherapy (HT) may be clinically necessary, for example in treating a recurrent PTV adjacent to a previously-treated volume. In this work, the parameters which influence the cumulative dose distribution resulting from treating longitudinally adjacent PTVs are examined, including field width, pitch, and PTV location. In-phantom dose distributions were calculated for various on- and off-axis cylindrical PTVs and were verified by ion chamber and film measurement. Dose distributions were calculated to cover 95% of the PTV by the prescribed dose (DP) using 25 and 50 mm long HT fields with pitches of either 0.3 or 0.45. These dose distributions where then used to calculate the 3D dose distribution in the junction region between two PTVs. The best junction uniformity was obtained for fields of equal width, with larger fields providing better intra-PTV dose homogeneity than smaller fields. Junctioning fields of different widths resulted in a much larger dose inhomogeneity, but this could be improved significantly by dividing the junction end of the PTV treated with the smaller field into multiple (up to 4) sub-PTVs, with the prescribed dose in each sub-PTV decreasing with proximity to the junction region. This provided a PTV matching with dose homogeneity similar to that achieved when junctioning two PTVs, both irradiated by the 50 mm field, and provided a distribution where 95% of the PTV received at least the prescribed dose, with maximum excursions from prescribed dose varying from -19% to +13%. We conclude that junctioning adjacent PTVs is possible. Treating longitudinally adjacent PTVs with different widths is a challenge, but dose uniformity is improved by breaking PTVs into multiple contiguous sub-PTVs modified to feather (broaden) the effective junctioning region.

On-line rapid palliation using helical tomotherapy: a prospective feasibility study.

Rapid delivery of radiation therapy is expected to benefit patients requiring palliation. We investigated the feasibility of employing a helical tomotherapy unit to scan, plan, and deliver a radiation treatment in a single radiation therapy appointment. Eleven patients each had an MVCT scan acquired, a plan created, and delivery completed while the patient was on the treatment couch. Timelines for each step of the process were recorded for each patient, and compared with the conventional process for similar patients. Preliminary results show that patients routinely can be treated within a 1 hour appointment for the first fraction.

A study of prostate delineation referenced against a gold standard created from the visible human data.

PURPOSE: To measure inter- and intra-observer variation and systematic error in CT based prostate delineation, where individual delineations are referenced against a gold standard produced from photographic anatomical images from the Visible Human Project (VHP). MATERIALS AND METHODS: The CT and anatomical images of the VHP male form the basic data set for this study. The gold standard was established based on 1mm thick anatomical photographic images. These were registered against the 3mm thick CT images that were used for target delineation. A total of 120 organ delineations were performed by six radiation oncologists. RESULTS: The physician delineated prostate volume was on average 30% larger than the "true" prostate volume, but on average included only 84% of the gold standard volume. Our study found a systematic delineation error such that posterior portions of the prostate were always missed while anteriorly some normal tissue was always defined as target. CONCLUSIONS: Our data suggest that radiation oncologists are more concerned with the unintentional inclusion of rectal tissue than they are in missing prostate volume. In contrast, they are likely to overextend the anterior boundary of the prostate to encompass normal tissue such as the bladder.

Investigating treatment dose error due to beam attenuation by a carbon fiber tabletop.

Carbon fiber is commonly used in radiation therapy for treatment tabletops and various immobilization and support devices, partially because it is generally perceived to be almost radiotransparent to high-energy photons. To avoid exposure to normal tissue during modern radiation therapy, one must deliver the radiation from all gantry angles; hence, beams often transit the couch proximal to the patient. The effects of the beam attenuation by the support structure of the couch are often neglected in the planning process. In this study, we investigate the attenuation of 6-MV and 18-MV photon beams by a Medtec (Orange City, IA) carbon fiber couch. We have determined that neglecting the attenuation of oblique treatment fields by the carbon fiber couch can result in localized dose reduction from 4% to 16%, depending on energy, field size, and geometry. Further, we investigate the ability of a commercial treatment-planning system (Theraplan Plus v3.8) to account for the attenuation by the treatment couch. Results show that incorporating the carbon fiber couch in the patient model reduces the dose error to less than 2%. The variation in dose reduction as a function of longitudinal couch position was also measured. In the triangular strut region of the couch, the attenuation varied +/- 0.5% following the periodic nature of the support structure. Based on these findings, we propose the routine incorporation of the treatment tabletop into patient treatment planning dose calculations.

Using multileaf collimator interleaf leakage to extract absolute spatial information from electronic portal imaging device images.

Electronic portal imaging devices (EPIDs) are potentially valuable tools for linear accelerator quality assurance and for measuring and analyzing geometric variations in radiation treatment delivery. Geometric analysis is more robust if referenced against an absolute position such as the isocenter (collimator axis of rotation), allowing the observer to discriminate between various setup errors and jaw or multileaf collimator (MLC) calibration errors. Unfortunately, mechanical instabilities in EPIDs make such analysis difficult. In the present work, we describe how MLC interleaf radiation leakage, hidden in the background of portal images, can be extracted and analyzed to find the field isocenter perpendicular to leaf travel direction. The signal from the interleaf radiation leakage is extracted to provide a precise and accurate determination of the isocenter location in the direction perpendicular to MLC leaf travel. In the direction of leaf travel, the minimization of residuals between planned and measured leaf positions is used to determine the isocenter. This method assumes that leaf positioning errors are randomly distributed. The validity of the method for determining the angular deviation between EPID image grid lines and collimator angle and for determining the known isocenter position is experimentally established.