Patient-specific online dose verification based on transmission detector measurements.

BACKGROUND AND PURPOSE: Since IMRT-techniques lead to an increasingly complicated environment, a patient specific IMRT-plan verification is recommended. Furthermore, verifications during patient irradiation and 3D dose reconstruction have the potential to improve treatment delivery, accuracy and safety. This study provides a detailed investigation of the new transmission detector (DTD) Dolphin (IBA Dosimetry, Germany) for online dosimetry. MATERIALS AND METHODS: The clinical performance of the DTD was tested by dosimetric plan verification in 2D and 3D for 18 IMRT-sequences. In 2D, DTD measurements were compared to a pre-treatment verification method and a treatment planning system by gamma index and dose difference evaluations. In 3D, dose-volume-histogram (DVH) indices and gamma analysis were evaluated. Furthermore, the error detection ability was tested with leaf position uncertainties and deviations in the linear accelerator (LINAC) output. RESULTS: The DTD measurements were in excellent agreement to reference measurements in both 2D (γ3%,3mm=(99.7±0.6)% <1, ΔD±5%=(99.5±0.5)%) and 3D. Only a small dose underestimation (<2%) within the target volume was observed when analyzing DVH-indices. Positional errors of the leaf banks larger than 1mm and errors in LINAC output larger than 2% were identified with the DTD. CONCLUSIONS: The DTD measures the delivered dose with sufficient accuracy and is therefore suitable for clinical routine.

Comparison of anisotropic aperture based intensity modulated radiotherapy with 3D-conformal radiotherapy for the treatment of large lung tumors.

PURPOSE/OBJECTIVE(S): IMRT allows dose escalation for large lung tumors, but respiratory motion may compromise delivery. A treatment plan that modulates fluence predominantly in the transversal direction and leaves the fluence identical in the direction of the breathing motion may reduce this problem. MATERIALS/METHODS: Planning-CT-datasets of 20 patients with Stage I-IV non small cell lung cancer (NSCLC) formed the basis of this study. A total of two IMRT plans and one 3D plan were created for each patient. Prescription dose was 60 Gy to the CTV and 70 Gy to the GTV. For the 3D plans an energy of 18 MV photons was used. IMRT plans were calculated for 6 MV photons with 13 coplanar and with 17 noncoplanar beams. Robustness of the used method of anisotropic modulation toward breathing motion was tested in a 13-field IMRT plan. RESULTS: As a consequence of identical prescription doses, mean target doses were similar for 3D and IMRT. Differences between 3D and 13- and 17-field IMRT were significant for CTV Dmin (43 Gy vs. 49.1 Gy vs. 48.6 Gy; p<0.001) and CTV D(95) (53.2 Gy vs. 55.0 Gy vs. 55.4 Gy; p=0.001). The D(mean) of the contralateral lung was significantly lower in the 17-field plans (17-field IMRT vs. 13- vs. 3D: 12.5 Gy vs. 14.8 Gy vs. 15.8 Gy: p<0.05). The spinal cord dose limit of 50 Gy was always respected in IMRT plans and only in 17 of 20 3D-plans. Heart D(max) was only marginally reduced with IMRT (3D vs. 13- vs. 17-field IMRT: 38.2 Gy vs. 36.8 Gy vs. 37.8 Gy). Simulated breathing motion caused only minor changes in the IMRT dose distribution (~0.5-1 Gy). CONCLUSIONS: Anisotropic modulation of IMRT improves dose delivery over 3D-RT and renders IMRT plans robust toward breathing induced organ motion, effectively preventing interplay effects.

Evaluation of a 2D detector array for patient-specific VMAT QA with different setups.

For pre-treatment plan verification of advanced treatment techniques such as intensity-modulated arc therapy, a fast and reliable dosimetric device is required. In this study, we investigated the suitability of MatriXX in different setups for verification of volumetric modulated arc therapy (VMAT) plans. If MatriXX is used in a stationary phantom (MULTICube), the measured dose is dependent on the beam angle. For the first setup (MatriXX/MULTICube), we developed correction factors (CFs) for each detector element (1020 CFs). We investigated the accuracy of these CFs by verifying 12 VMAT plans. In the second setup, we also assessed the suitability of MatriXX in a dedicated holder. Using this setup (MatriXX/Holder), 30 additional VMAT plans were verified. Deviations of up to ∼17% and ∼11% were noted for one of the ion chambers at 90° and 180° gantry positions. The influence of the beam angle dependence (MULTICube) can explicitly be seen when a gamma criterion of 2%/2 mm was chosen. An overall improvement of 4.3% of passing pixels (pp) was noted after applying beam angular-dependent CFs. When the gamma criterion was 3%/3 mm, the %pp was ≥ 95% without and ∼100% with correction. With the second setup, MatriXX/holder, we showed excellent agreement between measurements and calculations. The %pp averaged over all plans (30 VMAT treatment plans) was nearly ∼100%. The combination of MatriXX with MULTICube or with holder proved to be a fast and reliable method for pretreatment verification of arc therapy with sufficient accuracy.

Patient-specific 3D pretreatment and potential 3D online dose verification of Monte Carlo-calculated IMRT prostate treatment plans.

PURPOSE: Fast and reliable comprehensive quality assurance tools are required to validate the safety and accuracy of complex intensity-modulated radiotherapy (IMRT) plans for prostate treatment. In this study, we evaluated the performance of the COMPASS system for both off-line and potential online procedures for the verification of IMRT treatment plans. METHODS AND MATERIALS: COMPASS has a dedicated beam model and dose engine, it can reconstruct three-dimensional dose distributions on the patient anatomy based on measured fluences using either the MatriXX two-dimensional (2D) array (offline) or a 2D transmission detector (T2D) (online). For benchmarking the COMPASS dose calculation, various dose-volume indices were compared against Monte Carlo-calculated dose distributions for five prostate patient treatment plans. Gamma index evaluation and absolute point dose measurements were also performed in an inhomogeneous pelvis phantom using extended dose range films and ion chamber for five additional treatment plans. RESULTS: MatriXX-based dose reconstruction showed excellent agreement with the ion chamber (<0.5%, except for one treatment plan, which showed 1.5%), film (∼100% pixels passing gamma criteria 3%/3 mm) and mean dose-volume indices (<2%). The T2D based dose reconstruction showed good agreement as well with ion chamber (<2%), film (∼99% pixels passing gamma criteria 3%/3 mm), and mean dose-volume indices (<5.5%). CONCLUSION: The COMPASS system qualifies for routine prostate IMRT pretreatment verification with the MatriXX detector and has the potential for on-line verification of treatment delivery using T2D.

Experimental validation of a commercial 3D dose verification system for intensity-modulated arc therapies.

We validate the dosimetric performance of COMPASS®, a novel 3D quality assurance system for verification of volumetric-modulated arc therapy (VMAT) treatment plans that can correlate the delivered dose to the patient's anatomy, taking into account the tissue inhomogeneity. The accuracy of treatment delivery was assessed by the COMPASS® for 12 VMAT plans, and the resulting assessments were evaluated using an ionization chamber and film measurements. Dose-volume relationships were evaluated by the COMPASS® for three additional treatment plans and these were used to verify the accuracy of treatment planning dose calculations. The results matched well between COMPASS® and measurements for the ionization chamber (≤3%) and film (73-99% for gamma((3%/3 mm)) < 1 and 98-100% for gamma((5%/5 mm)) < 1) for the phantom plans. Differences in dose-volume statistics for the average dose to the PTV were within 2.5% for three treatment plans. For the structures located in the low-dose region, a maximum difference of <9% was observed. In its current implementation, the system could measure the delivered dose with sufficient accuracy and could project the 3D dose distribution directly on the patient's anatomy. Slight deviations were found for large open fields. These could be minimized by improving the COMPASS® in-built beam model.

A new strategy for online adaptive prostate radiotherapy based on cone-beam CT.

PURPOSE: Interfractional organ motion and patient positioning errors during prostate radiotherapy can have deleterious clinical consequences. It has become clinical practice to re-position the patient with image-guided translational position correction before each treatment to compensate for those errors. However, tilt errors can only be corrected with table corrections in six degrees of freedom or "full" adaptive treatment planning strategies. Organ shape deformations can only be corrected by "full" plan adaptation. This study evaluates the potential of instant treatment plan adaptation (fast isodose line adaptation with real-time dose manipulating tools) based on cone-beam CT (CBCT) to further improve treatment quality. METHODS AND MATERIALS: Using in-house software, CBCTs were modified to approximate a correct density calibration. To evaluate the dosimetric accuracy, dose distributions based on CBCTs were compared with dose distributions calculated on conventional planning CTs (PCT) for four datasets (one inhomogeneous phantom, three patient datasets). To determine the potential dosimetric benefit of a "full" plan adaptation over translational position correction, dose distributions were re-optimized using graphical "online" dose modification tools for three additional patients' CT-datasets with a substantially distended rectum while the original plans have been created with an empty rectum (single treatment fraction estimates). RESULTS: Absolute dose deviations of up to 51% in comparison to the PCT were observed when uncorrected CBCTs were used for replanning. After density calibration of the CBCTs, 97% of the dose deviations were