Machine performance and stability of the first clinical self-shielded stereotactic radiosurgery system: Initial 2-year experience.

This study provides insight into the overall system performance, stability, and delivery accuracy of the first clinical self-shielded stereotactic radiosurgery (SRS) system. Quality assurance procedures specifically developed for this unit are discussed, and trends and variations over the course of 2-years for beam constancy, targeting and dose delivery are presented. Absolute dose calibration for this 2.7 MV unit is performed to deliver 1 cGy/MU at dmax  = 7 mm at a source-to-axis-distance (SAD) of 450 mm for a 25 mm collimator. Output measurements were made with 2-setups: a device that attaches to a fixed position on the couch (daily) and a spherical phantom that attaches to the collimating wheel (monthly). Beam energy was measured using a cylindrical acrylic phantom at depths of 100 (D10 ) and 200 (D20 ) mm. Beam profiles were evaluated using Gafchromic film and compared with TPS beam data. Accuracy in beam targeting was quantified with the Winston-Lutz (WL) and end-to-end (E2E) tests. Delivery quality assurance (DQA) was performed prior to clinical treatments using Gafchromic EBT3/XD film. Net cumulative output adjustments of 15% (pre-clinical), 9% (1st year) and 3% (2nd year) were made. The mean output was 0.997 ± 0.010 cGy/MU (range: 0.960-1.046 cGy/MU) and 0.993 ± 0.029 cGy/MU (range: 0.884-1.065 cGy/MU) for measurements with the daily and monthly setups, respectively. The mean relative beam energy (D10 /D20 ) was 0.998 ± 0.004 (range: 0.991-1.006). The mean total targeting error was 0.46 ± 0.17 mm (range: 0.06-0.98 mm) for the WL and 0.52 ± 0.28 mm (range: 0.11-1.27 mm) for the E2E tests. The average gamma pass rates for DQA measurements were 99.0% and 90.5% for 2%/2 mm and 2%/1 mm gamma criteria, respectively. This SRS unit meets tolerance limits recommended by TG-135, MPPG 9a., and TG-142 with a treatment delivery accuracy similar to what is achieved by other SRS systems.

Technical note: Absolute dose measurements of a vault-free radiosurgery system.

BACKGROUND: Methods for accurate absolute dose (AD) calibration are essential for the proper functioning of radiotherapy treatment machines. Many systems do not conform to TG-51 calibration standards, and modifications are required. TG-21 calibration is also a viable methodology for these situations with the appropriate setup, equipment, and factors. It has been shown that both these methods result in minimal errors. A similar approach has been taken in calibrating the dose for a recent vault-free radiosurgery system. PURPOSE: To evaluate modified TG-21 and TG-51 protocols for AD calibrations of the ZAP-X radiosurgery system using ion chambers, film, and thermoluminescent dosimeters (TLDs). METHODS: The current treatment planning system for ZAP-X requires AD calibration at dmax (7 mm) and 450 mm source-to-axis distance. Both N D , w 60 C o [ G y / C ] $N_{D,w}^{{60}Co}[ {Gy/C} ]$ and Nx [R/C] calibration coefficients were provided by an accredited dosimetry calibration laboratory for a physikalisch technische werkstatten (PTW) 31010 chamber (0.125 cc). The vendor provides an f-bracket that can be mounted on the collimator. Various phantoms can then be attached to the f-bracket. A custom acrylic phantom was designed based on recommendations from TG-21 and technical report series-398 that places the chamber at 500 mm from the source with a depth of 44-mm acrylic and 456-mm SSD. Nx along with other TG-21 parameters was used to calculate the AD. Measurements using a PTW MP3-XS water tank and the same chamber were used to calculate AD using N D , w 60 C o $N_{D,w}^{{60}Co}$ and TG-51 factors. Dose verification was performed using Gafchromic film and 3rd party TLDs. RESULTS: Measurements from TG-51, TG-21 (utilizing the custom acrylic phantom), film, and TLDs agreed to within ± 2%. CONCLUSIONS: A modified TG-51 AD calculation in water is preferred but may not be practical due to the difficulty in tank setup. The TG-21 modified protocol using a custom acrylic phantom is an accurate alternative option for dose calibration. Both of these methods are within acceptable agreement and provide confidence in the system's AD calibration.

Small-field beam data acquisition, detector dependency, and film-based validation for a novel self-shielded stereotactic radiosurgery system.

PURPOSE: This study reports a single-institution experience with beam data acquisition and film-based validation for a novel self-shielded sterotactic radiosurgery unit and investigates detector dependency on field output factors (OFs), off-axis ratios (OARs), and percent depth dose (PDD) measurements within the context of small-field dosimetry. METHODS: The delivery platform for this unit consists of a 2.7-MV S-band linear accelerator mounted on coupled gimbals that rotate around a common isocenter (source-to-axis distance [SAD] = 450 mm), allowing for more than 260 noncoplanar beam angles. Beam collimation is achieved via a tungsten collimator wheel with eight circular apertures ranging from 4 mm to 25 mm in diameter. Three diodes (PTW 60012 Diode E, PTW 60018 SRS Diode, and Sun Nuclear EDGE) and a synthetic diamond detector (PTW 60019 micro Diamond [µD] detector) were used for OAR, PDD, and OF measurements. OFs were also acquired with a PTW 31022 PinPoint ionization chamber. Beam scanning was performed using a 3D water tank at depths of 7, 50, 100, 200, and 250 mm with a source-to-surface distance of 450 mm. OFs were measured at the depth of maximum dose (dmax  = 7 mm) with the SAD at 450 mm. Gafchromic EBT3 film was used to validate OF and profile measurements and as a reference detector for estimating correction factors for active detector OFs. Deviations in field size, penumbra, and PDDs across the different detectors were quantified. RESULTS: Relative OFs (ROFs) for the diodes were within 1.4% for all collimators except for 5 and 7.5 mm, for which SRS Diode measurements were higher by 1.6% and 2.6% versus Diode E. The µD ROFs were within 1.4% of the diode measurements. PinPoint ROFs were lower by >10% for the 4-mm and 5-mm collimators versus the Diode E and µD. Corrections to OFs using EBT3 film as a reference were within 1.2% for all diodes and the µD detector for collimators 10 mm and greater and within 2.0%, 2.8%, and 1.1% for the 7.5-, 5-, and 4-mm collimators, respectively. The maximum difference in full width at half maximum (FWHM) between the Diode E and the other active detectors was for the 25-mm collimator and was 0.09 mm (µD), 0.16 mm (SRS Diode), and 0.65 mm (EDGE). Differences seen in PDDs beyond the depth of dmax were <1% across the three diodes and the µD. FWHM and penumbra measurements made using EBT3 film were within 1.34% and 3.26%, respectively, of the processed profile data entered into the treatment planning system. CONCLUSIONS: Minimal differences were seen in OAR and PDD measurements acquired with the diodes and the µD. ROFs measured with the three diodes were within 2.6% and within 1.4% versus the µD. Gafchromic Film measurements provided independent verification of the OAR and OF measurements. Estimated corrections to OFs using film as a reference were <1.6% for the Diode E, EDGE, and µD detector.

Treatment planning system and beam data validation for the ZAP-X: A novel self-shielded stereotactic radiosurgery system.

PURPOSE: To evaluate the treatment planning system (TPS) performance of the ZAP-X stereotactic radiosurgery (SRS) system through nondosimetric, dosimetric, and end-to-end (E2E) tests. METHODS: A comprehensive set of TPS commissioning and validation tests was developed using published guidelines. Nondosimetric validation tests included information transfer, computed tomography-magnetic resonance (CT-MR) image registration, structure/contouring, geometry, dose tools, and CT density. Dosimetric validation included comparisons between TPS and water tank/Solid Water measurements for various geometries and beam arrangements and end-to-end (E2E) tests. Patient-specific quality assurance was performed with an ion chamber in the Lucy phantom and with Gafchromic EBT3 film in the CyberKnife head phantom. RadCalc was used for independent verification of monitor units. Additional E2E tests were performed using the RPC Gamma Knife thermoluminescent dosimeter (TLD) phantom, MD Anderson SRS head phantom, and PseudoPatient gel phantom for independent absolute dose verification. RESULTS: CT-MR image registrations with known translational and rotational offsets were within tolerance (<0.5 × maximum voxel dimension). Slice thickness and distance accuracy were within 0.1 mm, and volume accuracy was within 0 to 0.11 cm3 . Treatment planning system volume measurement uncertainty was within 0.1 to 0.4 cm3 . Ion chamber point-dose measurements for a single beam in a water phantom agreed to TPS-calculated values within ±4% for collimator diameters 10 to 25 mm, and ±6% for 7.5 mm, for all measured depths (7, 50, 100, 150, and 200 mm). In homogeneous Solid Water, point-dose measurements agreed to within ±4% for cones sizes 7.5 to 25 mm. With 1-cm high/low density inserts, measurements were within ±4.2% for cone sizes 10 to 25 mm. Film-based E2E using 4/5-mm cones resulted in a gamma passing rate (%GP) of 99.8% (2%/1.5 mm). Point-dose measurements in a Lucy phantom with an ion chamber using 36 beams distributed along three noncoplanar arcs agreed to within ±4% for cone sizes 10 to 25 mm. The RPC Gamma Knife TLD phantom yielded passing results with a measured-to-expected TLD dose ratio of 1.02. The MD Anderson SRS head phantom yielded passing results, with 4% TLD agreement and %GP of 95%/93% (5%/3 mm) for coronal/sagittal film planes. The RTsafe gel phantom gave %GP of >95% (5%/2 mm) for all four targets. For our first 58 patients, film-based patient-specific quality assurance has resulted in an average %GP of 98.7% (range, 94-100%) at 2%/2 mm. CONCLUSIONS: Core ZAP-X features were found to be functional. On the basis of our results, point-dose and planar measurements were in agreement with TPS calculations using multiple phantoms and setup geometries, validating the ZAP-X TPS beam model for clinical use.

Automatic detection of patient identification and positioning errors in radiation therapy treatment using 3-dimensional setup images.

PURPOSE: To develop an automated system that detects patient identification and positioning errors between 3-dimensional computed tomography (CT) and kilovoltage CT planning images. METHODS AND MATERIALS: Planning kilovoltage CT images were collected for head and neck (H&N), pelvis, and spine treatments with corresponding 3-dimensional cone beam CT and megavoltage CT setup images from TrueBeam and TomoTherapy units, respectively. Patient identification errors were simulated by registering setup and planning images from different patients. For positioning errors, setup and planning images were misaligned by 1 to 5 cm in the 6 anatomical directions for H&N and pelvis patients. Spinal misalignments were simulated by misaligning to adjacent vertebral bodies. Image pairs were assessed using commonly used image similarity metrics as well as custom-designed metrics. Linear discriminant analysis classification models were trained and tested on the imaging datasets, and misclassification error (MCE), sensitivity, and specificity parameters were estimated using 10-fold cross-validation. RESULTS: For patient identification, our workflow produced MCE estimates of 0.66%, 1.67%, and 0% for H&N, pelvis, and spine TomoTherapy images, respectively. Sensitivity and specificity ranged from 97.5% to 100%. MCEs of 3.5%, 2.3%, and 2.1% were obtained for TrueBeam images of the above sites, respectively, with sensitivity and specificity estimates between 95.4% and 97.7%. MCEs for 1-cm H&N/pelvis misalignments were 1.3%/5.1% and 9.1%/8.6% for TomoTherapy and TrueBeam images, respectively. Two-centimeter MCE estimates were 0.4%/1.6% and 3.1/3.2%, respectively. MCEs for vertebral body misalignments were 4.8% and 3.6% for TomoTherapy and TrueBeam images, respectively. CONCLUSIONS: Patient identification and gross misalignment errors can be robustly and automatically detected using 3-dimensional setup images of different energies across 3 commonly treated anatomical sites.

Pelvic nodal dosing with registration to the prostate: implications for high-risk prostate cancer patients receiving stereotactic body radiation therapy.

PURPOSE: To determine whether image guidance with rigid registration (RR) to intraprostatic markers (IPMs) yields acceptable coverage of the pelvic lymph nodes in the context of a stereotactic body radiation therapy (SBRT) regimen. METHODS AND MATERIALS: Four to seven kilovoltage cone-beam CTs (CBCTs) from 12 patients with high-risk prostate cancer were analyzed, allowing approximation of an SBRT regimen. The nodal clinical target volume (CTV(N)) and bladder were contoured on all kilovoltage CBCTs. The V100 CTV(N), expressed as a ratio to the same parameter on the initial plan, and the magnitude of translational shift between RR to the IPMs versus RR to the pelvic bones, were computed. The ability of a multimodality bladder filling protocol to minimize bladder height variation was assessed in a separate cohort of 4 patients. RESULTS: Sixty-five CBCTs were assessed. The average V100 CTV(N) was 92.6%, but for a subset of 3 patients the average was 80.0%, compared with 97.8% for the others (P<.0001). The average overall and superior-inferior axis magnitudes of the bony-to-fiducial translations were significantly larger in the subgroup with suboptimal nodal coverage (8.1 vs 3.9 mm and 5.8 vs 2.4 mm, respectively; P<.0001). Relative bladder height changes were also significantly larger in the subgroup with suboptimal nodal coverage (42.9% vs 18.5%; P<.05). Use of a multimodality bladder-filling protocol minimized bladder height variation (P<.001). CONCLUSION: A majority of patients had acceptable nodal coverage after RR to IPMs, even when approximating SBRT. However, a subset of patients had suboptimal nodal coverage. These patients had large bony-to-fiducial translations and large variations in bladder height. Nodal coverage should be excellent if the superior-inferior axis bony-to-fiducial translation and the relative bladder height change (both easily measured on CBCT) are kept to a minimum. Implementation of a strict bladder filling protocol may achieve this goal.

Assessing margin expansions of internal target volumes in 3D and 4D PET: a phantom study.

BACKGROUND AND PURPOSE: To quantify tumor volume coverage and excess normal tissue coverage using margin expansions of mobile target internal target volumes (ITVs) in the lung. MATERIALS AND METHODS: FDG-PET list-mode data were acquired for four spheres ranging from 1 to 4 cm as they underwent 1D motion based on four patient breathing trajectories. Both ungated PET images and PET maximum intensity projections (PET-MIPs) were examined. Amplitude-based gating was performed on sequential list-mode files of varying signal-to-background ratios to generate PET-MIPs. ITVs were first post-processed using either a Gaussian filter or a custom two-step module, and then segmented by applying a gradient-based watershed algorithm. Uniform and non-uniform 1 mm margins were added to segmented ITVs until complete target coverage was achieved. RESULTS: PET-MIPs required smaller uniform margins (4.7 vs. 11.3 mm) than ungated PET, with correspondingly smaller over-coverage volumes (OCVs). Non-uniform margins consistently resulted in smaller OCVs when compared to uniform margins. PET-MIPs and ungated PET had comparable OCVs with non-uniform margins, but PET-MIPs required smaller longitudinal margins (4.7 vs. 8.5 mm). Non-uniform margins were independent of sphere size. CONCLUSIONS: Gated PET-MIP images and non-uniform margins result in more accurate ITV delineation while reducing normal tissue coverage.

A comparison of amplitude-based and phase-based positron emission tomography gating algorithms for segmentation of internal target volumes of tumors subject to respiratory motion.

PURPOSE: To quantitatively compare the accuracy of tumor volume segmentation in amplitude-based and phase-based respiratory gating algorithms in respiratory-correlated positron emission tomography (PET). METHODS AND MATERIALS: List-mode fluorodeoxyglucose-PET data was acquired for 10 patients with a total of 12 fluorodeoxyglucose-avid tumors and 9 lymph nodes. Additionally, a phantom experiment was performed in which 4 plastic butyrate spheres with inner diameters ranging from 1 to 4 cm were imaged as they underwent 1-dimensional motion based on 2 measured patient breathing trajectories. PET list-mode data were gated into 8 bins using 2 amplitude-based (equal amplitude bins [A1] and equal counts per bin [A2]) and 2 temporal phase-based gating algorithms. Gated images were segmented using a commercially available gradient-based technique and a fixed 40% threshold of maximum uptake. Internal target volumes (ITVs) were generated by taking the union of all 8 contours per gated image. Segmented phantom ITVs were compared with their respective ground-truth ITVs, defined as the volume subtended by the tumor model positions covering 99% of breathing amplitude. Superior-inferior distances between sphere centroids in the end-inhale and end-exhale phases were also calculated. RESULTS: Tumor ITVs from amplitude-based methods were significantly larger than those from temporal-based techniques (P=.002). For lymph nodes, A2 resulted in ITVs that were significantly larger than either of the temporal-based techniques (P<.0323). A1 produced the largest and most accurate ITVs for spheres with diameters of ≥2 cm (P=.002). No significant difference was shown between algorithms in the 1-cm sphere data set. For phantom spheres, amplitude-based methods recovered an average of 9.5% more motion displacement than temporal-based methods under regular breathing conditions and an average of 45.7% more in the presence of baseline drift (P<.001). CONCLUSIONS: Target volumes in images generated from amplitude-based gating are larger and more accurate, at levels that are potentially clinically significant, compared with those from temporal phase-based gating.

A novel CT acquisition and analysis technique for breathing motion modeling.

To report on a novel technique for providing artifact-free quantitative four-dimensional computed tomography (4DCT) image datasets for breathing motion modeling. Commercial clinical 4DCT methods have difficulty managing irregular breathing. The resulting images contain motion-induced artifacts that can distort structures and inaccurately characterize breathing motion. We have developed a novel scanning and analysis method for motion-correlated CT that utilizes standard repeated fast helical acquisitions, a simultaneous breathing surrogate measurement, deformable image registration, and a published breathing motion model. The motion model differs from the CT-measured motion by an average of 0.65 mm, indicating the precision of the motion model. The integral of the divergence of one of the motion model parameters is predicted to be a constant 1.11 and is found in this case to be 1.09, indicating the accuracy of the motion model. The proposed technique shows promise for providing motion-artifact free images at user-selected breathing phases, accurate Hounsfield units, and noise characteristics similar to non-4D CT techniques, at a patient dose similar to or less than current 4DCT techniques.