High-resolution fluence verification for treatment plan specific QA in ion beam radiotherapy.

Ion beam radiotherapy exploits the finite range of ion beams and the increased dose deposition of ions toward the end of their range in material. This results in high dose conformation to the target region, which can be further increased using scanning ion beams. The standard method for patient-plan verification in ion beam therapy is ionization chamber dosimetry. The spatial resolution of this method is given by the distance between the chambers (typically 1 cm). However, steep dose gradients created by scanning ion beams call for more information and improved spatial resolution. Here we propose a clinically applicable method, supplementary to standard patient-plan verification. It is based on ion fluence measurements in the entrance region with high spatial resolution in the plane perpendicular to the beam, separately for each energy slice. In this paper the usability of the RID256 L amorphous silicon flat-panel detector for the measurements proposed is demonstrated for carbon ion beams. The detector provides sufficient spatial resolution for this kind of measurement (pixel pitch 0.8 mm). The experiments were performed at the Heidelberg Ion-Beam Therapy Center in Germany. This facility is equipped with a synchrotron capable of accelerating ions from protons up to oxygen to energies between 48 and 430 MeV u(-1). Beam application is based on beam scanning technology. The measured signal corresponding to single energy slices was translated to ion fluence on a pixel-by-pixel basis, using calibration, which is dependent on energy and ion type. To quantify the agreement of the fluence distributions measured with those planned, a gamma-index criterion was used. In the patient field investigated excellent agreement was found between the two distributions. At least 95% of the slices contained more than 96% of points agreeing with our criteria. Due to the high spatial resolution, this method is especially valuable for measurements of strongly inhomogeneous fluence distributions like those in intensity-modulated treatment plans or plans including dose painting. Since no water phantom is needed to perform measurements, the flat-panel detector investigated has high potential for use with gantries. Before the method can be used in the clinical routine, it has to be sufficiently tested for each detector-facility combination.

Characterization of a flat-panel detector for ion beam spot measurements.

Dynamic beam delivery techniques are being increasingly used for cancer therapy. Scanning ion beams require extensive and time-demanding quality assurance procedures and beam tuning. Accordingly, fast measurement techniques improving the efficiency of the procedures and accommodating the safety requirements are highly desirable. Major requirements for a detector used for beam-shape measurements are high spatial resolution in two dimensions, reusability, online readout and easy handling. At the Heidelberg Ion Beam Therapy Facility (Germany), we examined the performance of the RID 256 L flat-panel detector for beam spot measurements. The two-dimensional beam profiles of proton and carbon ion beams measured were compared to measurements with radiographic films at intermediate energies using the index. The difference to the beam width measured with radiographic films of less than 3% demonstrates sufficient accuracy of ion beam width measurements possible with this detector for both proton and carbon ion beams. The beam shapes were also measured at different beam intensities. At both the highest and lowest energies available at the HIT, no beam spot-shape deformation was found with increasing beam intensities, as long as the boundary of the dynamic range was not exceeded. The signal leak along the readout direction was identified as an undesirable effect. However, due to small amplitudes and static beams, this effect is of minor importance for beam spot measurements. Distortion of results due to detector radiation damage was monitored. No detector radiation damage was observed over the experiments. Moreover, the observed short-time detector response stability (within ±0.1%) as well as medium term stability (within 0.5% in 15 months) was excellent. This flat-panel detector is compact and easy to use. Together with its low weight, this helps to speed up measurement procedures substantially. All these properties make this an ideal detector for the fast, high-resolution imaging of static ion beam spots needed for constancy measurements in daily beam quality assurance and for accelerator tuning. For daily use, radiation damage has to be monitored continuously and corrected for if necessary.

Enhancement of image quality with a fast iterative scatter and beam hardening correction method for kV CBCT.

The problem of the enormous amount of scattered radiation in kV CBCT (kilo voltage cone beam computer tomography) is addressed. Scatter causes undesirable streak- and cup-artifacts and results in a quantitative inaccuracy of reconstructed CT numbers, so that an accurate dose calculation might be impossible. Image contrast is also significantly reduced. Therefore we checked whether an appropriate implementation of the fast iterative scatter correction algorithm we have developed for MV (mega voltage) CBCT reduces the scatter contribution in a kV CBCT as well. This scatter correction method is based on a superposition of pre-calculated Monte Carlo generated pencil beam scatter kernels. The algorithm requires only a system calibration by measuring homogeneous slab phantoms with known water-equivalent thicknesses. In this study we compare scatter corrected CBCT images of several phantoms to the fan beam CT images acquired with a reduced cone angle (a slice-thickness of 14 mm in the isocenter) at the same system. Additional measurements at a different CBCT system were made (different energy spectrum and phantom-to-detector distance) and a first order approach of a fast beam hardening correction will be introduced. The observed image quality of the scatter corrected CBCT images is comparable concerning resolution, noise and contrast-to-noise ratio to the images acquired in fan beam geometry. Compared to the CBCT without any corrections the contrast of the contrast-and-resolution phantom with scatter correction and additional beam hardening correction is improved by a factor of about 1.5. The reconstructed attenuation coefficients and the CT numbers of the scatter corrected CBCT images are close to the values of the images acquired in fan beam geometry for the most pronounced tissue types. Only for extreme dense tissue types like cortical bone we see a difference in CT numbers of 5.2%, which can be improved to 4.4% with the additional beam hardening correction. Cupping is reduced from 20% to 4% with scatter correction and 3% with an additional beam hardening correction. After 3 iterations (small phantoms) and 6 to 7 iterations (large phantoms) the algorithm converges. Therefore the algorithm is very fast, that means 1.3 seconds per projection for 3 iterations on a standard PC.

Correction of patient positioning errors based on in-line cone beam CTs: clinical implementation and first experiences.

BACKGROUND: The purpose of the study was the clinical implementation of a kV cone beam CT (CBCT) for setup correction in radiotherapy. PATIENTS AND METHODS: For evaluation of the setup correction workflow, six tumor patients (lung cancer, sacral chordoma, head-and-neck and paraspinal tumor, and two prostate cancer patients) were selected. All patients were treated with fractionated stereotactic radiotherapy, five of them with intensity modulated radiotherapy (IMRT). For patient fixation, a scotch cast body frame or a vacuum pillow, each in combination with a scotch cast head mask, were used. The imaging equipment, consisting of an x-ray tube and a flat panel imager (FPI), was attached to a Siemens linear accelerator according to the in-line approach, i.e. with the imaging beam mounted opposite to the treatment beam sharing the same isocenter. For dose delivery, the treatment beam has to traverse the FPI which is mounted in the accessory tray below the multi-leaf collimator. For each patient, a predefined number of imaging projections over a range of at least 200 degrees were acquired. The fast reconstruction of the 3D-CBCT dataset was done with an implementation of the Feldkamp-David-Kress (FDK) algorithm. For the registration of the treatment planning CT with the acquired CBCT, an automatic mutual information matcher and manual matching was used. RESULTS AND DISCUSSION: Bony landmarks were easily detected and the table shifts for correction of setup deviations could be automatically calculated in all cases. The image quality was sufficient for a visual comparison of the desired target point with the isocenter visible on the CBCT. Soft tissue contrast was problematic for the prostate of an obese patient, but good in the lung tumor case. The detected maximum setup deviation was 3 mm for patients fixated with the body frame, and 6 mm for patients positioned in the vacuum pillow. Using an action level of 2 mm translational error, a target point correction was carried out in 4 cases. The additional workload of the described workflow compared to a normal treatment fraction led to an extra time of about 10-12 minutes, which can be further reduced by streamlining the different steps. CONCLUSION: The cone beam CT attached to a LINAC allows the acquisition of a CT scan of the patient in treatment position directly before treatment. Its image quality is sufficient for determining target point correction vectors. With the presented workflow, a target point correction within a clinically reasonable time frame is possible. This increases the treatment precision, and potentially the complex patient fixation techniques will become dispensable.

Linac-integrated kV-cone beam CT: technical features and first applications.

One of the most prominent imaging techniques in image-guided radiotherapy (IGRT) is the acquisition of cone beam computed tomographies (CBCTs) at the linac with the patient in treatment position. CBCTs provide accurate 3-dimensional (3D) knowledge about the patient's anatomy for every treatment fraction and are therefore well suited for all adaptive corrections of errors related to interfractional uncertainties of the treatment process. In this paper, we first describe the technical development and implementation of this new imaging technique at our linac, i.e., the hardware components and their operating parameters are discussed in detail for a standard image acquisition of CBCTs. Then, an extension of this approach for the acquisition of complete images for extended field of views--the "shifted detector" technique--is presented followed by a first investigation of how CBCTs can be reliably used for adaptive dose calculations. Finally, a first clinical application, the process of automatic patient positioning based on CBCT images, is discussed. From our investigations, we conclude that the technical development of linac-integrated CBCTs bears an enormous potential for the correction of interfractional treatment errors. However, image quality and reconstruction speed of the images leave room for improvement. The development of clinical strategies for the optimal application of this new image modality in a clinical environment is one the major tasks for the future.

[Validation of a scatter correction method for IMRT verification using portal imaging]. / Validierung einer Streukorrekturmethode zur IMRT-Verifikation mit Hilfe eines Portal-Imaging-Systems.

Complex dose-delivery techniques, as currently applied in intensity-modulated radiation therapy (IMRT), require a highly efficient treatment-verification process. The present paper deals with the problem of the scatter correction for therapy verification by use of portal images obtained by an electronic portal imaging device (EPID) based on amorphous silicon. It also presents an iterative method for the scatter correction of portal images based on Monte Carlo-generated scatter kernels. First applications of this iterative scatter-correction method for the verification of intensity-modulated treatments are discussed on the basis of MVCT- and dose reconstruction. Several experiments with homogeneous and anthropomorphic phantoms were performed in order to validate the scatter correction method and to investigate the precision and relevance in view of its clinical applicability. It is shown that the devised concept of scatter correction significantly improves the results of MVCT- and dose reconstruction models, which is in turn essential for an exact online IMRT verification.