SU-E-T-16: Statistical Variability and Confidence Intervals for Planar Dose QA Pass Rates.

PURPOSE: The most common metric for comparing measured to calculated dose planes is a pass rate generated using percent difference, distance-to-agreement (DTA), or some combination of the two (e.g. gamma evaluation). The grid of analyzed points often corresponds to a dosimeter array with low areal-density of point detectors. This work examines the statistical uncertainty of planar dose comparison pass rates and proposes methods for establishing confidence intervals for pass rates obtained with low detector-density arrays. METHODS: Absolute dose planes were acquired via EPID for twenty intensity-modulated fields of varying complexity. Matching calculated dose planes were created via treatment planning system. Pass rates for each dose plane pair (centered to CAX) were calculated with various %/DTA composite analysis techniques. Software was designed to selectively sample the high-density EPID matrix to simulate many low-density measured grids, each representing a different alignment with respect to CAX. Simulations were repeated (100 positional iterations per field) using grids of varying detector-densities and both random and orthogonal point-detector orientation. For each simulation, pass rates were calculated with various composite analysis techniques. RESULTS: Repositioning simulated low-density grids leads to a distribution of possible pass rates for each measured/calculated dose plane pair, independent of whether the detector grid is random or uniform. Distributions can be predicted using a binomial distribution by which a confidence interval (function of sampling density and observed pass rate) is approximated for each pass rate. For example, 95% confidence intervals for IMRT pass rates (2%,2mm) average +/-5.3% and +/-3.8% with 1-detector/cm2 and 2-detector/cm2 grids, respectively. CONCLUSIONS: Pass rates for low-density array measurements are not absolute and should be reported with both a full description of calculation method and confidence intervals quantifying their uncertainty. Results extend to 3D detector arrays. The concept of fixed 'action levels' for pass rates must be reexamined for low-density array measurements.

SU-E-T-639: Dosimetric Evaluation of VMAT for the Treatment of NSCLC with SBRT.

PURPOSE: To demonstrate the dosimetric potential of volumetric modulated arc therapy (VMAT) for the treatment of patients with medically inoperable stage I/II non-small cell lung cancer (NSCLC) with stereotactic body radiation therapy (SBRT). METHODS: Fourteen patients treated with 3D-CRT with varying tumor locations, tumor sizes and dose fractionation schemes were chosen for study. The target prescription doses were 48 Gy in 4 fractions, 52.5 Gy in 5 fractions, 57.5 Gy in 5 fractions and 60 Gy in 3 fractions for 2, 5, 1 and 6 patients, respectively. VMAT treatment plans with a mix of 2-3 full and/or partial non-coplanar arcs with 5°-25° separations were retrospectively generated using Eclipse version 10.0. The 3D-CRT and VMAT plans were then evaluated by comparing their target dose, critical structure dose, high dose spillage, and low dose spillage as defined according to RTOG 0813 and RTOG 0236 protocols. RESULTS: The VMAT treatment plans yielded an average 9.6-33.7% reduction in dose to critical structures and an average 12.0-12.5% increase in conformity compared with the treated 3D-CRT plans. The D2cm improved with VMAT in 11 of 14 cases. The 3 that worsened were still within the acceptance criteria. Of the 14 3D-CRT plans, 7 had a D2cm minor deviation, while only one of the 14 VMAT plans had a D2cm minor deviation. The R50% improved in 13 of the 14 VMAT cases. The 1 case that worsened was still within the acceptance criteria of the RTOG protocol. Of the 14 3D-CRT plans, 7 had an R50% deviation. Only 1 of the 14 VMAT plans had an R50% deviation, but it was still improved compared to the 3D-CRT plan. CONCLUSIONS: In this cohort of patients, no dosimetric compromises resulted from planning SBRT treatments with VMAT relative to the 3D-CRT treatment plans actually used in their treatment.

SU-E-T-156: Robust Algorithms for Correction of Predicted Electronic Portal Imager Response.

PURPOSE: Predicted electronic portal imaging device (EPID) response, as calculated by a commercial treatment planning system (TPS), is up to 15% lower than measured EPID response for off-axis IMRT fields. Two original algorithms are presented to correct for EPID prediction errors. The EPID prediction algorithm and a recent image-to-dose conversion algorithm are each tested for ability to identify TPS dose calculation errors. METHODS: By comparing test images to respective predictions, correction factors were calculated to modify the EPID diagonal calibration profile (applied via radial symmetry). Secondly, image/prediction comparisons were used to compute a 2D correction matrix for EPID predictions, to account for radially-asymmetric errors. Over 50 IMRT fields of varying complexity were tested with each correction technique, and with a diode array. Absolute dose and beam-profile errors were separately induced into the TPS and a number of IMRT plans were recalculated and measured with three systems - an EPID prediction system, an EPID image-to-dose conversion system, and a diode array - for comparison to verification plans. RESULTS: With the profile correction, TPS predictions agree much better with EPID measurements, yielding improvement in gamma pass rates (3%,3mm) of over 30% on average for off-axis IMRT fields. Since off-axis prediction errors are not radially-symmetric, the matrix correction further improves pass rates by 5% on average (up to 30%) for fields where the profile correction is limited. The EPID prediction system was unable to catch either induced TPS error, while both the image-to-dose conversion system and the diode array indicated both errors. CONCLUSIONS: Profile correction is effective and efficient though approximate, due to radial symmetry. The matrix correction is comprehensive but requires computational manipulation of DICOM images. Users must be aware that EPID prediction systems may be unable to catch delivered IMRT inaccuracies due to calculation errors downstream from the actual fluence calculation.

Using an EPID for patient-specific VMAT quality assurance.

PURPOSE: A patient-specific quality assurance (QA) method was developed to verify gantry-specific individual multileaf collimator (MLC) apertures (control points) in volumetric modulated arc therapy (VMAT) plans using an electronic portal imaging device (EPID). METHODS: VMAT treatment plans were generated in an Eclipse treatment planning system (TPS). DICOM images from a Varian EPID (aS1000) acquired in continuous acquisition mode were used for pretreatment QA. Each cine image file contains the grayscale image of the MLC aperture related to its specific control point and the corresponding gantry angle information. The TPS MLC file of this RapidArc plan contains the leaf positions for all 177 control points (gantry angles). In-house software was developed that interpolates the measured images based on the gantry angle and overlays them with the MLC pattern for all control points. The 38% isointensity line was used to define the edge of the MLC leaves on the portal images. The software generates graphs and tables that provide analysis for the number of mismatched leaf positions for a chosen distance to agreement at each control point and the frequency in which each particular leaf mismatches for the entire arc. RESULTS: Seven patients plans were analyzed using this method. The leaves with the highest mismatched rate were found to be treatment plan dependent. CONCLUSIONS: This in-house software can be used to automatically verify the MLC leaf positions for all control points of VMAT plans using cine images acquired by an EPID.

Dosimetric calibration and characterization for experimental mouse thoracic irradiation using orthovoltage x rays.

An experimental irradiation setup was designed to deliver a conformal field of thoracic irradiation to mice. The objective is to provide accurate dosimetric evaluation for the experimental setup, which involves a pie cage device holding up to 10 mice with concentric Cerrobend® shields to collimate the beam. The setup uses 250 kVp X rays, and it also involves an air gap, off-axis prescription point and plastic bag containing anesthetic isoflurane gas. The dose rate in cGy/min was determined as follows: absolute dose calibration for the open cone, measurements of output factor and percentage depth dose for the narrow ring-shaped lung aperture, measurements of bag attenuation, and evaluation of other factors specific to the treatment geometry. Dose enhancement at the skin surface caused by electron contamination from shielding material was also studied. The results showed an overall 25 ± 4% drop at lung mid-plane relative to the standard irradiation setup with the open cone. The increased surface dose from scattered electrons was reduced by addition of the air gap and plastic bag. In conclusion, more accurate dose delivery is achieved when correction factors specific to the animal irradiation setup are applied. Care should be taken when experiments with shields in direct contact with animal skin are involved.

Cardiac function after chemoradiation for esophageal cancer: comparison of heart dose-volume histogram parameters to multiple gated acquisition scan changes.

In this paper we determine if preoperative chemoradiation for locally advanced esophageal cancer leads to changes in cardiac ejection fraction. This is a retrospective review of 20 patients treated at our institution for esophageal cancer between 2000 and 2002. Multiple gated acquisition cardiac scans were obtained before and after platinum-based chemoradiation (50.4 Gy). Dose-volume histograms for heart, left ventricle and left anterior descending artery were analyzed. Outcomes assessed included pre- and postchemoradiation ejection fraction ratio and percentage change in ejection fraction postchemoradiation. A statistically significant difference was found between median prechemoradiation ejection fraction (59%) and postchemoradiation ejection fraction (54%) (P = 0.01), but the magnitude of the difference was not clinically significant. Median percentage volume of heart receiving more than 20, 30 and 40 Gy were 61.5%, 58.5% and 53.5%, respectively. Our data showed a clinically insignificant decline in ejection fraction following chemoradiation for esophageal cancer. We did not observe statistically or clinically significant associations between radiation dose to heart, left ventricle or left anterior descending artery and postchemoradiation ejection fraction.

Technical management of a pregnant patient undergoing radiation therapy to the head and neck.

The fetal dose in a pregnant patient undergoing radiation therapy to the head and neck region was investigated. Implicit in this study was the design and evaluation of a shield used to minimize the fetal dose. To evaluate the fetal dose, a phantom was irradiated with the fields designed for this patient's therapy. The peripheral dose was measured for each field individually, both without and with a custom shield designed to be placed about the patient's abdominal and pelvic regions. The total dose at the location of the fetus over the course of this patient's radiation therapy was then estimated from peripheral dose rate measurements made at several points within the simulated uterus. With no shielding, the total dose within the uterus of the patient would have ranged from 13.3 cGy at the cervix to 28 cGy at the fundus. With the shield applied, the uterine dose was significantly less: 3.3 cGy at the cervix to 8.6 cGy at the fundus. In fact, at every measurement point, the peripheral dose with the shield in place was 30% to 50% of the dose without the shield. Some data suggest that the rate of significant abnormalities induced by irradiation in utero increases with increasing dose within the range of total peripheral doses incurred during most radiation treatment courses. It is therefore prudent to make reasonable attempts at minimizing the dose to the lower abdominal and pelvic regions of any pregnant patient. The shield designed in this work accomplished this goal for this patient and is flexible enough to be used in the treatment of almost all tumor volumes.

Comparison of the homogeneity of breast dose distributions with and without the medial wedge.

Radiation of the intact breast often requires medial and lateral wedges to improve dose homogeneity of its pyramidal shape and to achieve acceptable cosmesis. There is some concern that radiation scatter from the medial wedge may contribute to cancer in the uninvolved breast, yet treatment without the medial wedge is associated with inhomogeneity of magnitudes that affect cosmesis. These homogeneities are identified on treatment plans generated at the central axis (CAX). It is not known if comparing isodose curves at the central axis reflect homogeneity in superior and inferior planes. A study was undertaken to both examine inhomogeneity with and without the medial wedge, and to determine if plan selection at the CAX was representative of homogeneity above and below the CAX. Ten consecutive patients with early breast cancers had cranial, CAX, and caudal CT images of each breast compared with two wedging conditions, lateral only (LW) and medial and lateral wedged conditions (dual wedges = DW). Dosimetry was optimized at the CAX for DW and LW conditions. Dose distributions and hot spots relative to prescribed dose were compared for cranial, CAX, and caudal images. Mean chest wall separations were measured. Six of ten patients had equivalent LW and DW distributions at the levels examined. Only one of these patients had a single off-axis hot spot > 20%. Six patients had comparable LW and DW dosimetry and acceptable hot spots at the central axis, as well as chest wall separations < or = 22 cm. In conclusion, if isodose configurations are commensurate at the CAX, these patients will have homogeneity above and below the CAX. In patients with chest wall separations < or = 22 cm, treatment without the medial wedge is feasible, sparing the contralateral breast dose with little compromise to inhomogeneity in the treated breast.

Characterization of the response of commercial diode detectors used for in vivo dosimetry.

The response of a commercially available diode-based in vivo dosimetry system was studied over a selection of clinically relevant photon beam setups. The dosimetry system consists of a dedicated multichannel electrometer with several diode detectors differing only in their equivalent wall buildup. Each detector is calibrated for a specific nominal beam energy and used clinically with that energy only. To study dosimeter response, a diode taped to the surface of a solid water phantom was irradiated simultaneously with an end-window chamber placed at a depth of dmax inside the same phantom. Photon beams with energies of Co-60, 6 and 18 MV were used. For each beam energy, the response of the diode relative to the given dose as measured by the end-window chamber was evaluated for open and wedged fields (0 degree to 60 degrees) with source-to-surface distances (SSDs) ranging from 75 to 120 cm and collimator settings from 5 x 5 to 40 x 40 cm2. It was found that diode response, i.e., diode reading per cGy of given dose, varies significantly with treatment beam setup. For example, increasing field size for a constant SSD causes a decrease of up to 15% in diode response relative to the given dose for 6 and 18 MV beams, while for Co-60 an increase in response of up to 5% results. Furthermore, increasing SSD for a fixed collimator setting results in decreased diode response (up to 10%) for all beams. The complicated dependence of diode response on beam setup necessitates the use of empirical response curves, similar to those evaluated in this work, to accurately convert clinical dosimeter reading to dose at depth.

A simple backup for a radiosurgery treatment planning system.

To calculate the dose distribution and the number of monitor unit (MU) per arc, all radiosurgery systems utilize some sort of computer. These computers are, of course, subject to equipment malfunction such as problems with the magnetic tape drive, keyboard, mouse, etc. Since most radiosurgery procedures are quite invasive and time consuming, it is important to have a reliable and reasonably accurate backup system for planning the treatment. This paper will show that a simple PC based system, along with a digitizer, may be used as a backup for a commercial, VAX based radiosurgery system. A complete radiosurgery planning procedure was carried out on a head phantom with a target imbedded inside. The treatment planning and verification using the PC based system is also compared with that using the VAX based system.

The use of customized spreadsheets in radiation therapy.

A number of radiation-therapy-related uses based on a commercially available spreadsheet program have been developed at our facility. The graphics and display capabilities inherent in these spreadsheet programs allow for concise visual results. The spreadsheets are used as an independent check for several types of radiation therapy dose calculations. External beam--a spreadsheet will verify the monitor units (MU) or time required to deliver a prescribed dose to a point on an isodose line as calculated by a commercial treatment planning system. Calibration--spreadsheet programs have been developed to perform the calculations necessary for the output calibration of cobalt and high-energy photon and electron beams according to the TG-21 protocol. The user must indicate which beam, electrometer, chamber, phantom material, temperature, pressure and depth of measurement that apply. Radiosurgery--the MU per arc is calculated based on the following: the average depth per arc as obtained from a commercial radiosurgery program, the collimator size, and the prescription dose. TBI--The patient's width is entered into the spreadsheet program, which then calculates the MU needed to deliver a prescribed dose to the midline.

Application of the "bioeffects" algorithm of a treatment planning system.

In this study, both a four-field box and two-field AP/PA treatment plan are combined with two insertions of Cs-137 in a tandem and ovoids setup, to evaluate the bioeffects program of a treatment planning system. External beam energies studied are 18 and 6 MV. It is shown that there is a slight difference in the 50-70 time dose fractionation (TDF) isolines when comparing 6 MV and 18 MV, for the AP/PA setup. There is practically no difference for TDF isoline values larger than 80 for both energies with either the four-field or the two-field setup. This is because the brachytherapy contributed the majority of the dose to the regions near the applicator and the TDF values reflect the higher dose delivered by the brachytherapy relative to the external beams in that region. For this simple evaluation of the bioeffects program, the combination of the external beam plan and the brachytherapy plan does not give us enhanced information on the effectiveness of the plan.

Accuracy of the point source approximation to high dose-rate Ir-192 sources.

The accuracy of the point source approximation used in dose calculations for an implant comprised of multiple high dose rate (HDR) Ir-192 source dwell positions is investigated. First, a single dwell position implant is modeled. The exposure rate about the source is calculated using both the point source approximation and the more rigorous line source formalism. A comparison of these calculated exposure rates is made. It is found that for each HDR Ir-192 source dwell position, the point source approximation results in a dose overestimation of 1% at a distance of 1 cm on the source transverse axis, while dose underestimations of more than 2% can be found at a distance of 1 cm on the source longitudinal axis. Even larger errors occur closer to the source. The results of this academic study are then extended to two clinical cases--an endobronchial treatment and a tandem and ovoids setup, both involving multiple source dwell positions. Since clinical HDR Ir-192 implants are comprised of many individual source dwell positions, there will be inaccuracy in the calculated overall dose distribution leading to dose delivery errors. For example, the dose delivered to a prescription point located 0.5 cm from an endobronchial applicator will be 3% lower than prescribed. Similar errors are produced in gynecologic implants. To decrease below 0.5% the dose delivery error resulting from the point source approximation, prescription points should be at a distance of at least 1 cm from any applicator. Since the dosimetry error is a direct result of the choice of model used to describe the source, the use of anisotropy factors accounting for the variation of photon fluence around the HDR Ir-192 source will not completely correct the calculation.

Evaluation of dose delivery based on a comparison of dosimetry calculations using open beam and wedged beam depth dose data.

The purpose of this study is to evaluate the magnitude of the error in dose delivery caused by the use of open beam depth dose data in dosimetry calculations for wedged photon beams. Isodose plans were calculated for treatments given in a 3-field isocentric prostate or rectal setup using an open AP beam with two lateral wedged beams. The dose distributions were first calculated using open beam depth dose data for all three fields. Next, the open beam data was used only for the AP field and true wedged beam depth dose data was substituted for the two lateral wedged fields. The magnitude of the depth dose variations for wedged vs open beams depends on the nominal beam energy, the wedge angle, and the depth of measurement. Consequently, isodose distributions calculated for wedged fields were found to be different when true wedged beam depth dose data was used instead of open beam data as is commonly done. Monitor unit calculations using a field size specific wedge factor show that dose delivery errors up to 4% can result from the use of open beam depth dose data in wedged beam dose distribution calculations for a 6-MV photon beam. Accurate treatment planning for wedged fields requires the use of wedged beam depth dose data specific to each wedge. Simply using open beam depth dose data in dose calculations for wedged beams will result in dose delivery errors, the magnitude of which depends on the combination of wedge angle, field size, and nominal beam energy.

Uncertainty in delivered dose resulting from the distribution of source activities in a Selectron LDR afterloader.

The uncertainty in the delivered dose resulting from the distribution of 137Cs source activity in a clinical Selectron LDR unit has been studied. A comparison is made of the dose delivered to a point 'A' in an implant with sources of equal activity to the actual dose delivered in the same implant with source activities randomly chosen from the population in the afterloader.

Measurements of the electron dose distribution near inhomogeneities using a plastic scintillation detector.

PURPOSE: Accurate measurement of the electron dose distribution near an inhomogeneity is difficult with traditional dosimeters which themselves perturb the electron field. We tested the performance of a new high resolution, water-equivalent plastic scintillation detector which has ideal properties for this application. METHODS AND MATERIALS: A plastic scintillation detector with a 1 mm diameter, 3 mm long cylindrical sensitive volume was used to measure the dose distributions behind standard benchmark inhomogeneities in water phantoms. The plastic scintillator material is more water equivalent than polystyrene in terms of its mass collision stopping power and mass scattering power. Measurements were performed for beams of electrons having initial energies of 6 and 18 MeV at depths from 0.2-4.2 cm behind the inhomogeneities. RESULTS: The detector reveals hot and cold spots behind heterogeneities at resolutions equivalent to typical film digitizer spot sizes. Plots of the dose distributions behind air, aluminum, lead, and formulations for cortical and inner bone-equivalent materials are presented. CONCLUSION: The plastic scintillation detector is suited for measuring the electron dose distribution near an inhomogeneity.

Implementation of a three-dimensional compensation system based on computed tomography generated surface contours and tissue inhomogeneities.

A computed tomography (CT) based system that compensates for patient surface contour and internal tissue inhomogeneity was implemented in our clinic. The compensators are fabricated with a mixture of tin granules and bee's wax. The tin/wax mixture was optimized for tin granule size and tin granule to wax ratio. The narrow beam attenuation coefficients were measured for 4-, 6-, 10-, and 24-MV photon beams. The compensator design and fabrication methodology were verified by measuring the dose distribution for a known surface contour irradiated with a compensated beam and for a known inhomogeneity that was submerged in a water phantom and irradiated with a compensated beam. For the surface contour, the uncompensated isodose levels varied by as much as 10% in the compensation plane and the compensator restored the isodose level to a variation of less than 1.3%. Measured and calculated doses for this surface contour were found to differ by less than 3.4%. For the inhomogeneity, the uncompensated isodose levels varied by 27% in the compensation plane and the compensator restored the isodose level to a variation of less than 1.5%. Measured and calculated doses for the known inhomogeneity were found to differ by less than 2%. Measurements of depth-dose curves indicate that the presence of the compensator in the beam does not significantly increase the surface dose. Twenty-six compensators have now been fabricated for clinical cases. In these patients, dose variations as great as 19% occurred in the plane of compensation prior to placing the compensator in the beam.(ABSTRACT TRUNCATED AT 250 WORDS)