The AAPM/ASTRO 2023 Core Physics Curriculum for Radiation Oncology Residents.

PURPOSE: The American Association of Physicists in Medicine Radiation Oncology Medical Physics Education Subcommittee (ROMPES) has updated the radiation oncology physics core curriculum for medical residents in the radiation oncology specialty. METHODS AND MATERIALS: Thirteen physicists from the United States and Canada involved in radiation oncology resident education were recruited to ROMPES. The group included doctorates and master's of physicists with a range of clinical or academic roles. Radiation oncology physician and resident representatives were also consulted in the development of this curriculum. In addition to modernizing the material to include new technology, the updated curriculum is consistent with the format of the American Board of Radiology Physics Study Guide Working Group to promote concordance between current resident educational guidelines and examination preparation guidelines. RESULTS: The revised core curriculum recommends 56 hours of didactic education like the 2015 curriculum but was restructured to provide resident education that facilitates best clinical practice and scientific advancement in radiation oncology. The reference list, glossary, and practical modules were reviewed and updated to include recent literature and clinical practice examples. CONCLUSIONS: ROMPES has updated the core physics curriculum for radiation oncology residents. In addition to providing a comprehensive curriculum to promote best practice for radiation oncology practitioners, the updated curriculum aligns with recommendations from the American Board of Radiology Physics Study Guide Working Group. New technology has been integrated into the curriculum. The updated curriculum provides a framework to appropriately cover the educational topics for radiation oncology residents in preparation for their subsequent career development.

Dosimetric impact and modeling of prone breast positioning device and couch structures.

In prone breast radiation, as the medial tangential beam usually passes through the immobilization board and couch, it is necessary to quantify the attenuation effect and the potential skin dose enhancement from these external structures. The prone breast board studied consists of an insert on which the contralateral breast rests and a board base indexed to the couch. Two different Varian couch systems were also studied. Transmission factors (TF) of the board were measured using a Farmer chamber at 4 cm depth. Couch TFs were measured using a thimble chamber centered in a cylindrical phantom. A custom support model was created in the treatment planning system (TPS). TFs were then computed in the TPS for comparison. Selected clinical plans were recomputed in the TPS incorporating external structures for target coverage evaluation. The correction for the attenuation effect in the TPS was also demonstrated. Skin dose effects were evaluated using a Markus parallel plate chamber with a 1 mm buildup cap. Measured insert TFs ranged 0.976 to 0.983 for 6 MV and 0.990 to 0.999 for 23 MV. Board base TFs ranged 0.979 to 0.985 for 6 MV and 0.989 to 0.998 for 23 MV. TPS values agreed within 0.9% and 0.5% for the insert and board base, respectively. Assigned Hounsfield units (HUs) providing the best agreement were 200, -100, and -900 for the insert, the board "base shell" and "base inside," respectively. Varian Exact Couch and Exact IGRT Couch TFs varied with respect to couch angle, with minimum values of 0.837 and 0.956, respectively, for 6 MV. The clinical treatment volume (CTV) and whole breast receiving 95% of the prescription dose (CTV-V95 and WB-V95) of selected patients demonstrated reduced coverage due to attenuation of external structures. Close proximity to the base increased skin dose by up to 25% to 30%. Contacting the insert increased skin dose by 65% to 93% for 6 MV and 117% to 157% for 23 MV, respectively. Results have shown reduced coverage by attenuating external structures. Proper modeling of immobilization devices and couch structures in the TPS should be implemented for accurate dose calculation. Increased surface doses were observed due to direct contact to the insert or close proximity to the base. Further study is required to quantify such a skin dose enhancement effect and its correlation to clinically apparent skin effects and toxicity.

Image artifacts caused by incorrect bowtie filters in cone-beam CT image-guided radiotherapy.

Certain models of cone beam computed tomography (CBCT) image-guided radiotherapy (IGRT) systems require manually placing the appropriate bowtie filter according to the relevant imaging protocol. Inadvertently using a wrong bowtie filter or no bowtie filter could cause unexpected image artifacts. In this work, CBCT image artifact patterns caused by different bowtie filter placement were evaluated. CBCT images of CT phantoms, that is, a Body Norm phantom, a Catphan® phantom and an anthropomorphic RANDO® phantom, were acquired at a Varian Trilogy® unit with an On-Board Imager® (OBI) system. Three image acquisition protocols were evaluated. For Standard Head protocol, half-fan bowtie and no bowtie filter were studied for comparison with the correct full-fan bowtie acquisition. For Pelvis and Low-Dose Thorax protocols, full-fan bowtie and no bowtie were studied for comparison with the correct half-fan bowtie acquisition. In addition, the possibility of reversed direction half-fan bowtie was also discussed. All possible scenarios of bowtie filter misplacement caused distinct artifacts regardless of protocols. These artifact patterns are different from the characteristic crescent artifact when correct bowtie filter was placed. Based on the artifact patterns described in this study we recommend reviewing image artifacts at time of image acquisition. If unexpected artifacts appear in the CBCT images, one should verify the correct placement of the bowtie filter and retake the image if necessary. However, it should also be stressed that using a wrong bowtie filter or forgetting to place the bowtie filter can cause increased patient dose. It is always a good practice to verify the bowtie filter placement before acquiring CBCT images for image-guided radiotherapy.

Improved dose homogeneity using electronic compensation technique for total body irradiation.

In total body irradiation (TBI) utilizing large parallel-opposed fields, the manual placement of lead compensators has conventionally been used to compensate for the varying thickness throughout the body. The goal of this study is to pursue utilizing the modern electronic compensation (E-comp) technique to more accurately deliver dose to TBI patients. Bilateral parallel-opposed TBI treatment plans were created using E-comp for 15 patients for whom CT data had been previously acquired. A desirable fluence pattern was manually painted within each field to yield a uniform dose distribution. The conventional compensation technique was simulated within the treatment planning system (TPS) using a field-in-field (FIF) method. This allows for a meaningful evaluation of the E-comp technique in comparison to the conventional method. Dose-volume histograms (DVH) were computed for all treatment plans. The mean total body dose using E-comp deviates from the prescribed dose (4 Gy) by an average of 2.4%. The mean total body dose using the conventional compensation deviates from the prescribed dose by an average of 4.5%. In all cases, the mean body dose calculated using E-comp technique deviates less than 10% from that of conventional compensation. The average reduction in maximum dose using E-comp compared to that of the conventional method was 30.3% ± 6.6% (standard deviation). In all cases, the s-index for the E-comp technique was lower (10.5% ± 0.7%) than that of the conventional method (15.8% ± 4.4%), indicating a more homogenous dose distribution. In conclusion, a large reduction in maximum body dose can be seen using the proposed E-comp technique while still producing a mean body dose that accurately complies with the prescription dose. Dose homogeneity was quantified using s-index which demonstrated a reduction in hotspots with E-comp technique. Electronic compensation technique is capable of more accurately delivering a total body dose compared to conventional methods.

Effects of collimator angle, couch angle, and starting phase on motion-tracking dynamic conformal arc therapy (4D DCAT).

PURPOSE: The aim of this study was to find an optimized configuration of collimator angle, couch angle, and starting tracking phase to improve the delivery performance in terms of MLC position errors, maximal MLC leaf speed, and total beam-on time of DCAT plans with motion tracking (4D DCAT). METHOD AND MATERIALS: Nontracking conformal arc plans were first created based on a single phase (maximal exhalation phase) of a respiratory motion phantom with a spherical target. An ideal model was used to simulate the target motion in superior-inferior (SI), anterior-posterior (AP), and left-right (LR) dimensions. The motion was decomposed to the MLC leaf position coordinates for motion compensation and generating 4D DCAT plans. The plans were studied with collimator angle ranged from 0° to 90°; couch angle ranged from 350°(-10°) to 10°; and starting tracking phases at maximal inhalation (θ=π/2) and exhalation (θ=0) phases. Plan performance score (PPS) evaluates the plan complexity including the variability in MLC leaf positions, degree of irregularity in field shape and area. PPS ranges from 0 to 1, where low PPS indicates a plan with high complexity. The 4D DCAT plans with the maximal and the minimal PPS were selected and delivered on a Varian TrueBeam linear accelerator. Gafchromic-EBT3 dosimetry films were used to measure the dose delivered to the target in the phantom. Gamma analysis for film measurements with 90% passing rate threshold using 3%/3 mm criteria and trajectory log files were analyzed for plan delivery accuracy evaluation. RESULTS: The maximal PPS of all the plans was 0.554, achieved with collimator angle at 87°, couch angle at 350°, and starting phase at maximal inhalation (θ=π/2). The maximal MLC leaf speed, MLC leaf errors, total leaf travel distance, and beam-on time were 20 mm/s, 0.39 ± 0.16 mm, 1385 cm, and 157 s, respectively. The starting phase, whether at maximal inhalation or exhalation had a relatively small contribution to PPS (0.01 ± 0.05). CONCLUSIONS: By selecting collimator angle, couch angle, and starting tracking phase, 4D DCAT plans with the maximal PPS demonstrated less MLC leaf position errors, lower maximal MLC leaf speed, and shorter beam-on time which improved the performance of 4D motion-tracking DCAT delivery.

The dose penumbra of a custom-made shield used in hemibody skin electron irradiation.

We report our technique for hemibody skin electron irradiation with a custom-made plywood shield. The technique is similar to our clinical total skin electron irradiation (TSEI), performed with a six-pair dual field (Stanford technique) at an extended source-to-skin distance (SSD) of 377 cm, with the addition of a plywood shield placed at 50 cm from the patient. The shield is made of three layers of stan-dard 5/8'' thick plywood (total thickness of 4.75 cm) that are clamped securely on an adjustable-height stand. Gafchromic EBT3 films were used in assessing the shield's transmission factor and the extent of the dose penumbra region for two different shield-phantom gaps. The shield transmission factor was found to be about 10%. The width of the penumbra (80%-to-20% dose falloff) was measured to be 12 cm for a 50 cm shield-phantom gap, and reduced slightly to 10 cm for a 35 cm shield-phantom gap. In vivo dosimetry of a real case confirmed the expected shielded area dose.

Evaluation of dosimetric effect caused by slowing with multi-leaf collimator (MLC) leaves for volumetric modulated arc therapy (VMAT).

BACKGROUND: This study is to report 1) the sensitivity of intensity modulated radiation therapy (IMRT) QA method for clinical volumetric modulated arc therapy (VMAT) plans with multi-leaf collimator (MLC) leaf errors that will not trigger MLC interlock during beam delivery; 2) the effect of non-beam-hold MLC leaf errors on the quality of VMAT plan dose delivery. MATERIALS AND METHODS: Eleven VMAT plans were selected and modified using an in-house developed software. For each control point of a VMAT arc, MLC leaves with the highest speed (1.87-1.95 cm/s) were set to move at the maximal allowable speed (2.3 cm/s), which resulted in a leaf position difference of less than 2 mm. The modified plans were considered as 'standard' plans, and the original plans were treated as the 'slowing MLC' plans for simulating 'standard' plans with leaves moving at relatively lower speed. The measurement of each 'slowing MLC' plan using MapCHECK®2 was compared with calculated planar dose of the 'standard' plan with respect to absolute dose Van Dyk distance-to-agreement (DTA) comparisons using 3%/3 mm and 2%/2 mm criteria. RESULTS: All 'slowing MLC' plans passed the 90% pass rate threshold using 3%/3 mm criteria while one brain and three anal VMAT cases were below 90% with 2%/2 mm criteria. For ten out of eleven cases, DVH comparisons between 'standard' and 'slowing MLC' plans demonstrated minimal dosimetric changes in targets and organs-at-risk. CONCLUSIONS: For highly modulated VMAT plans, pass rate threshold (90%) using 3%/3mm criteria is not sensitive in detecting MLC leaf errors that will not trigger the MLC leaf interlock. However, the consequential effects of non-beam hold MLC errors on target and OAR doses are negligible, which supports the reliability of current patient-specific IMRT quality assurance (QA) method for VMAT plans.

TBI lung dose comparisons using bilateral and anteroposterior delivery techniques and tissue density corrections.

This study compares lung dose distributions for two common techniques of total body photon irradiation (TBI) at extended source-to-surface distance calculated with, and without, tissue density correction (TDC). Lung dose correction factors as a function of lateral thorax separation are approximated for bilateral opposed TBI (supine), similar to those published for anteroposterior-posteroanterior (AP-PA) techniques in AAPM Report 17 (i.e., Task Group 29). 3D treatment plans were created retrospectively for 24 patients treated with bilateral TBI, and for whom CT data had been acquired from the head to the lower leg. These plans included bilateral opposed and AP-PA techniques- each with and without - TDC, using source-to-axis distance of 377 cm and largest possible field size. On average, bilateral TBI requires 40% more monitor units than AP-PA TBI due to increased separation (26% more for 23 MV). Calculation of midline thorax dose without TDC leads to dose underestimation of 17% on average (standard deviation, 4%) for bilateral 6 MV TBI, and 11% on average (standard deviation, 3%) for 23 MV. Lung dose correction factors (CF) are calculated as the ratio of midlung dose (with TDC) to midline thorax dose (without TDC). Bilateral CF generally increases with patient separation, though with high variability due to individual uniqueness of anatomy. Bilateral CF are 5% (standard deviation, 4%) higher than the same corrections calculated for AP-PA TBI in the 6 MV case, and 4% higher (standard deviation, 2%) for 23 MV. The maximum lung dose is much higher with bilateral TBI (up to 40% higher than prescribed, depending on patient anatomy) due to the absence of arm tissue blocking the anterior chest. Dose calculations for bilateral TBI without TDC are incorrect by up to 24% in the thorax for 6 MV and up to 16% for 23 MV. Bilateral lung CF may be calculated as 1.05 times the values published in Table 6 of AAPM Report 17, though a larger patient pool is necessary to better quantify this trend. Bolus or customized shielding will reduce lung maximum dose in the anterior thorax.

Dosimetric perturbation from cloth and paper gowns for total skin electron irradiation.

Traditionally, total skin electron patients remove all clothing for treatment. It is generally assumed that this is best for the treatment of superficial skin lesions out of concern clothing may significantly perturb dose. We investigate the dosimetric effect of patient gowns and determine the necessity of treating patients naked. Using GAFCHROMIC EBT2 film, dose to a cylindrical phantom was measured with cloth, paper, and tri-layer cloth gowns, compared to no covering. A 6 MeV electron beam with spoiler accessory was used at ~ 4 meters source-to-skin distance. The gantry was angled at 248° and 292°. The phantom was rotated at -60°, 0°, and 60° relative to the beam's central axis, simulating the Stanford technique. This was also repeated for films sandwiched between the phantom's discs. Using a Markus chamber, the effect of air gaps of 0 to 5 cm in cloth and paper gowns was measured. The water equivalent attenuation of the gowns was determined through transmission studies. Compared to no covering, films placed on the phantom surface revealed an average increase of 0.8% in dose for cloth, 1.8% for tri-layered cloth, and 0.7% for paper. Films sandwiched within the phantom showed only slight shift of the percent depth-dose curves. Markus chamber readings revealed 1.4% for tri-layered cloth, and < 0.2% for single layer cloth or paper. Air gaps appeared to have a minimal effect. Transmission measurements found that one layer of cloth is equal to 0.2mm of solid water. Cloth and paper gowns appear to slightly increase the dose to the skin, but will not introduce any significant dose perturbation (<1%). Gowns having folds and extra layers will have a small additional perturbation (<2%). To minimize perturbation, one should smooth out any folds or remove any pockets that form extra layers on the gown.

Potential increase in biological effectiveness from field timing optimization for stereotactic body radiation therapy.

PURPOSE: Stereotactic body radiation therapy (SBRT) is a radiotherapy technique which uses high dose fractions with multiple coplanar and noncoplanar beams. Due to the large fractional doses, treatments are typically protracted and there are more fields than in conventional radiation treatment schemes. The effect of temporal optimization on the biological effectiveness of SBRT is not well established. METHODS: In a cohort of actual SBRT patient treatments, the Lea-Catcheside protraction factor (G-value) was used to determine the optimal (Δ) and the least favorable (V) field. An actual field timing delivered in the clinic was included (C) for comparison. The lethal potential lethal (LPL) model was used to quantify the difference in survival fractions. Published data from three cell lines for non-small cell lung cancers: H460, H660, and H157 were used to acquire the parameters needed by the LPL model. The results are expressed as the ratios (V:Δ)(N) and (C:Δ)(N), where N is the number fractions in the SBRT protocols and Δ, V, and C are the survival fractions calculated from the corresponding temporal patterns. RESULTS: The results indicate that variability in the dose rate between fields does impact the optimization results. This dependence on dose rate, however, is small compared to the impact from the variability in doses between fields. The optimized field arrangements resembled previous studies, that maximization of cell kill is achieved by orienting the fields in a Δ shape sequence, where the fields with greatest dose are positioned in the center. Minimization of cell kill was achieved with a V-shaped orientation. Smallest dose fields were positioned centrally, and higher dose fields were placed in the beginning and end of the fraction. The survival fraction ratios calculated using the LPL demonstrated that regardless of the cell type the Δ shape had lower cell survival fractions compared to both the clinical example (C) and the V arrangement. For H460, with T(1/2) = 0.25 h, an average ratio of (C:Δ)(5)=13.9, suggesting the Δ pattern is approximately 14 times more effective than the clinical plan, after 5 fractions. CONCLUSIONS: Rearranging field timing for a SBRT treatment so that maximal dose is deposited in the central fields of treatment may optimize cell kill and potentially affect overall treatment outcome.

A dosimetric evaluation of VMAT for the treatment of non-small cell lung cancer.

The purpose of this study was 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). Fourteen patients treated with 3D CRT with varying tumor locations, tumor sizes, and dose fractionation schemes were chosen for study. The 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 two to three full and partial noncoplanar 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. In the most dosimetrically improved case, VMAT was able to decrease the dose from 17.35 Gy to 1.54 Gy to the heart. The D(2cm) decreased in 11 of 14 cases when using VMAT. The three that worsened were still within the acceptance criteria. Of the 14 3D CRT plans, seven had a D(2cm) minor deviation, while only one of the 14 VMAT plans had a D(2cm) minor deviation. The R(50%) improved in 13 of the 14 VMAT cases. The one case that worsened was still within the acceptance criteria of the RTOG protocol. Of the 14 3D CRT plans, seven had an R(50%) deviation. Only one of the 14 VMAT plans had an R(50%) deviation, but it was still improved compared to the 3D CRT plan. In this cohort of patients, no evident dosimetric compromises resulted from planning SBRT treatments with VMAT relative to the 3D CRT treatment plans actually used in their treatment.

Dosimetric impact of image artifact from a wide-bore CT scanner in radiotherapy treatment planning.

PURPOSE: Traditional computed tomography (CT) units provide a maximum scan field-of-view (sFOV) diameter of 50 cm and a limited bore size, which cannot accommodate a large patient habitus or an extended simulation setup in radiation therapy (RT). Wide-bore CT scanners with increased bore size were developed to address these needs. Some scanners have the capacity to reconstruct the CT images at an extended FOV (eFOV), through data interpolation or extrapolation, using projection data acquired with a conventional sFOV. Objects that extend past the sFOV for eFOV reconstruction may generate image artifacts resulting from truncated projection data; this may distort CT numbers and structure contours in the region beyond the sFOV. The purpose of this study was to evaluate the dosimetric impact of image artifacts from eFOV reconstruction with a wide-bore CT scanner in radiotherapy (RT) treatment planning. METHODS: Testing phantoms (i.e., a mini CT phantom with equivalent tissue inserts, a set of CT normal phantoms and anthropomorphic phantoms of the thorax and the pelvis) were used to evaluate eFOV artifacts. Reference baseline images of these phantoms were acquired with the phantom centrally positioned within the sFOV. For comparison, the phantoms were then shifted laterally and scanned partially outside the sFOV, but still within the eFOV. Treatment plans were generated for the thoracic and pelvic anthropomorphic phantoms utilizing the Eclipse treatment planning system (TPS) to study the potential effects of eFOV artifacts on dose calculations. All dose calculations of baseline and test treatment plans were carried out using the same MU. RESULTS: Results show that both body contour and CT numbers are altered by image artifacts in eFOV reconstruction. CT number distortions of up to -356 HU for bone tissue and up to 323 HU for lung tissue were observed in the mini CT phantom. Results from the large body normal phantom, which is close to a clinical patient size, show average CT number changes of up to -49 HU. Wider distribution (i.e., standard deviation) of the HU values was seen when the phantom was placed at more than 2.8 cm beyond the 50 cm sFOV. Anthropomorphic phantom studies with several standard beam configurations show that body contour distortion causes tumor dose calculation reduction of 3.0 and 1.9% for 6 and 23 MV x-rays, respectively, when not accounting for tissue heterogeneities during dose computation. When heterogeneity correction is used in planning, the competing effects of the body contour distortion and the CT number distortion cause a smaller error in tumor dose calculation. Less than 0.9% error in calculated dose was observed in volumetric modulated are therapy (VMAT) treatment plans. CONCLUSIONS: The image artifacts from eFOV reconstruction alter the CT numbers and body contours of the imaged objects, which has the potential to produce inaccuracies in dose calculations during radiotherapy treatment planning. The radiation therapy team should be aware of these image artifacts and their effects on target dose calculations during CT simulation as well as treatment planning.