In phantom assessment of superficial doses under TomoTherapy irradiation.

PURPOSE: Aim of this work is the assessment of build-up and superficial doses of different clinical Head&Neck plans delivered with Helical TomoTherapy (HT) (Accuray, Sunnyvale, CA). Depth dose profiles and superficial dose points were measured in order to evaluate the Treatment Planning System (TPS) capability of an accurate dose modeling in regions of disequilibrium. Geometries and scattering conditions were investigated, similar to the ones generally encountered in clinical treatments. METHODS: Measurements were performed with two dosimeters: Gafchromic® EBT3 films (Ashland Inc., Wayne, NJ) and a synthetic single crystal diamond detector (PTW-Frieburg microDiamond, MD). A modified version of the Alderson RANDO phantom was employed to house the detectors. A comparison with TPS data was carried out in terms of dose difference (DD) and distance-to-agreement (DTA). RESULTS: DD between calculated data and MD measurements are within 4% even in points with high spatial dose variation. For depth profiles, EBT3 data show a DDmax of 3.3% and DTAmax of 2.2mm, in low and high gradient regions, respectively, and compare well with MD data. EBT3 superficial points always results in measured doses lower than TPS evaluated ones, with a maximum DTA value of 1.5mm. CONCLUSIONS: Doses measured with the two devices are in good agreement and compare well with calculated data. The deviations found in the present work are within the reference tolerance level, suggesting that the HT TPS is capable of a precise dose estimation both in superficial regions and in correspondence with interfaces between air and PMMA.

GafChromic(®) EBT3 films for patient specific IMRT QA using a multichannel approach.

PURPOSE: To evaluate EBT3 for pre-treatment patient specific quality assurance (QA). The method we propose combines the experience gained in our center with the guidelines of the protocol proposed by Lewis et al. in 2012. To compare the multichannel approach with the single channel dosimetry. METHODS: Gafchromic® EBT3 films were irradiated both at linac and TomoTherapy and calibration curves were obtained. A series of irradiations with simple fields (uniform dose distributions on regular shaped targets) was performed. In a second stage, films were exposed to full clinical plans at linac (step and shoot IMRT and VMAT). At TomoTherapy dose maps were obtained for a clinical plan in three different coronal planes. Films were digitized using an Epson 10000XL scanner and FilmQA™ Pro software was employed for the analysis. RESULTS: The measured calibration curves suggest that, at least for the two beams taken into account (6 MV linac and TomoTherapy), a single calibration can be successfully adopted for each film lot. The application of the multichannel optimization method strongly improves the results in terms of gamma passing rates of the comparison between measured and calculated maps. CONCLUSIONS: Up to now EBT films, although attractive, were not preferred for routine patient specific QA due to their complex and time consuming processing and to the challenging work of characterization. The application of the mentioned protocol, together with some additional precautions, and the adoption of the multichannel optimization dosimetry, make this detector a handy and reliable tool for patient specific QA.

Surface imaging, portal imaging, and skin marker set-up vs. CBCT for radiotherapy of the thorax and pelvis.

AIM: The aim of this study was to compare surface imaging, portal imaging, and skin marker set-up in radiotherapy of thoracic and pelvic regions, using cone beam computed tomography (CBCT) data as the gold standard. PATIENTS AND METHODS: Twenty patients were included in this study. CBCT, surface acquisition (SA), and two orthogonal portal images (PI) were acquired during the first four treatment sessions. Patient set-up corrections, obtained by registering the planning CT with CBCT, were used as the gold standard. Registration results of the PI and SA were evaluated and compared with those obtained with CBCT. The advantage derived from using SA or PI verification systems over a skin marker set-up was also quantified. RESULTS: A statistically significant difference between PI and SA (in favour of PI) was observed in seven patients undergoing treatment of the pelvic region and in two patients undergoing treatment of the thoracic region. The use of SA or PI, compared with a skin marker set-up, improved patient positioning in 50% and 57% of the thoracic fractions, respectively. For pelvic fractions, the use of PI was beneficial in 73% of the cases, while the use of SA was beneficial in only 45%. Patient positioning worsened with SA, particularly along longitudinal and vertical directions. CONCLUSION: PI yielded more accurate registration results than SA for both pelvic and thoracic fractions. Compared with the skin marker set-up, PI performances were superior to SA for pelvic fractions while comparable results were obtained for thoracic fractions.

Four-dimensional computed tomography in accelerated partial breast irradiation planning: single series from a phase III trial.

PURPOSE: The aim of our study was to evaluate the usefulness of the four-dimensional computed tomography (4DCT) in accelerated partial breast irradiation (aPBI) planning. MATERIALS AND METHODS: At our Institute, we have been treating the index quadrant with external intensity-modulated radiation therapy in a phase III trial. For this study, we selected a sample of 10 patients with right- or left-sided breast cancer and surgical clips at the excision site. Contouring of the target was performed both using three-dimensional computed tomography (3DCT) and 4DCT imaging. On both 3DCT and 4DCT, we recorded the clinical target volume (CTV) and the planning target volume (PTV) and the coordinates of the PTV centroid. We calculated the treatment plans, according to our protocol, using the contours drawn on the 3DCT and 4DCT and evaluated target coverage and sparing of organs at risk (OAR). RESULTS: Median age of the patients was 63.5 years (range 52-75). The comparison between the 3DCT and 4DCT PTV volumes was not statistically significant (p = 0.79). Concerning centroid coordinates, the average absolute differences were 0.1 mm in the latero-lateral, 0.7 mm in the antero-posterior and 0.3 mm in the supero-inferior direction. No statistically significant differences were observed both in PTV coverage and OAR sparing; the 4D PTV contour is adequately covered when the plan based on the 3D contours is used. Target coverage was reduced on average by 1 % and no statistically significant difference was observed (p = 0.93). CONCLUSIONS: In our experience, no significant differences between PTV volumes, PTV coverage, OAR sparing and centroid position are evidenced when comparing 3DCT and 4DCT plans. Conventional 3DCT-based planning is adequate for aPBI.

Comparison of stereotactic plans for brain tumors with two different multileaf collimating systems.

Linac-based stereotactic radiosurgery (SRS) has been widely used for treating small intracranial lesions. This technique allows conforming the dose distribution to the planning target volume (PTV), providing a steep dose gradient with the surrounding normal tissues. This is realized through dedicated collimation systems. The present study aims to compare SRS plans with two collimating systems: the beam modulator (BM) of the Elekta Synergy linac and the DirexGroup micromultileaf collimator (µMLC). Seventeen patients (25 PTVs) were planned both with BM and µMLC (mounted on an Elekta Precise linac) using the Odyssey (PerMedics) treatment planning system (TPS). Plans were compared in terms of dose-volume histograms (DVH), minimum dose to the PTV, conformity index (CI), and homogeneity index (HI), as defined by the TPS, and doses to relevant organs at risk (OAR). The mean difference between the µMLC and the BM plans in minimum PTV dose was 5.7% ± 4.2% in favor of the µMLC plans. No statistically significant difference was found between the distributions of the CI values for the two planning modalities (p = 0.54), while the difference between the distributions of the HI values was statistically significant (p = 0.018). For both BM and µMLC plans, no differences were observed in CI and HI, depending on lesion size and shape. The PTV homogeneity achieved by BM plans was 15.1% ± 6.8% compared to 10.4% ± 6.6% with µMLC. Higher maximum and mean doses to OAR were observed in the BM plans; however, for both plans, dose constraints were respected. The comparison between the two collimating systems showed no substantial differences in terms of PTV coverage or OAR sparing. The improvements obtained by using µMLC are relatively small, and both systems turned out to be adequate for SRS treatments.

A synthetic diamond diode in volumetric modulated arc therapy dosimetry.

PURPOSE: The aim of this work is to investigate the behavior of a single crystal diamond diode (SCDD) for volumetric modulated arc therapy (VMAT) dose verifications. This delivery technique is one of the most severe test of a dosimeter performance due to the modulation of the dose rate achieved by simultaneously changing the velocity of the gantry and the position of the collimator leaves. The performed measurements with VMAT photon beams can therefore contribute to an overall global validation of the device to be used in dose distribution verifications. METHODS: The SCDD response to 6 MVRX has been tested and compared with reference ionization chambers and treatment planning system (TPS) calculations in different experiments: (a) measurements of output factors for small field sizes (square fields of side ranging between 8 mm and 104 mm) by SCDD and A1SL ionization chamber; (b) angular dependence evaluation of the entire experimental set-up by SCDD, A1SL, and Farmer ionization chambers; and (c) acquisition of dose profiles for a VMAT treatment of a pulmonary disease in latero-lateral and gantry-target directions by SCDD and A1SL ionization chamber. RESULTS: The output factors measured by SCDD favorably compare with the ones obtained by A1SL, whose response is affected by the lack of charged particle equilibrium and by averaging effect when small fields are involved. From the experiment on angular dependence, a good agreement is observed among the diamond diode, the ion chambers, and the TPS. In VMAT profiles, the absorbed doses measured by SCDD and A1SL compare well with the TPS calculated ones. An overall better agreement is observed in the case of the diamond dosimeter, which is also showing a better accuracy in terms of distance to agreement in the high gradient regions. CONCLUSIONS: Synthetic diamond diodes, whose performance were previously studied for conformal and IMRT radiotherapy techniques, were found to be suitable detectors also for dosimetric measurements in volumetric arc therapy treatments.

Accuracy of a 3D laser∕camera surface imaging system for setup verification of the pelvic and thoracic regions in radiotherapy treatments.

PURPOSE: The aim of this paper is to investigate the accuracy of a laser∕camera surface imaging system (Sentinel) when used on patients treated in the thorax or pelvic regions and to evaluate system employment conditions and patient setup procedures that provide more accurate results. METHODS: The system was tested on two groups of patients for whom different patient setup procedures and Sentinel employment conditions were considered. For the first group of 33 patients (FG) no changes to the usual setup procedures were made and a surface extension limited to the treated region was considered. For the second group of 14 patients (SG) the reproducibility of external body surfaces, including body parts not in close proximity to the treatment site, was optimized and a wider surface was captured. In all cases the system accuracy was evaluated comparing registration results from concurrent Sentinel and cone beam CT (CBCT) acquisitions for a total of 192 occasions. External body surfaces, extracted from planning CT studies, were used as reference in both cases, but for SG also surface data captured by Sentinel system at the first treatment were employed. RESULTS: In the 90th percentile of the distributions reporting CBCT and Sentinel registration parameters, absolute differences for FG were less than 6.4 mm and 3.8°. Better performances were observed for SG (≤5.7 mm and 2°). Mean absolute differences between three translation and three rotation parameters of CBCT and Sentinel were: less than 3.5 mm and 2.1° and 3.7 mm and 1.3° in FG for thorax and pelvis, respectively, and less than 2.8 mm and 1° and 2.7 mm and 0.9° for pelvis and thorax, respectively, in SG. No advantage in considering surface data captured by Sentinel as a reference instead of the surface extracted from the planning CT was observed. CONCLUSIONS: The accuracy of Sentinel system in detecting errors is influenced by the extension and reliability of the surface used. When the reproducibility of external body surfaces was optimized differences between CBCT and Sentinel registration parameters resulted less than 5.7 mm and 2° in the 90% of the pelvis and thorax considered cases. No advantage in considering a Sentinel acquisition as reference was observed.

A phantom evaluation of Sentinel(™), a commercial laser/camera surface imaging system for patient setup verification in radiotherapy.

PURPOSE: The aim of this study is to investigate the performance of Sentinel(™), a patient setup verification device based on a laser/camera system, when used on rigid-body phantoms. METHODS: The Sentinel system consists of a scanner unit, containing the laser and the camera, and surface-matching registration software. For the registration procedure, both a computed tomography (CT) and a Sentinel image can be used as a reference. Tests were performed on phantoms using an Elekta Synergy(®) beam modulator Linac equipped with a cone beam CT (CBCT), a HexaPOD RT couch top, and an iViewGT portal imaging system. Experiments conducted in this study tested reproducibility of the Sentinel surface acquisition and of set-up procedure, accuracy in quantifying known phantom mispositioning, and compared Sentinel, CBCT, and portal imaging system performance. RESULTS: Reproducibility of surface acquisition and setup procedure was better than 0.5 mm and 0.5° and 1 mm and 0.4°, respectively. The system accuracy was better than 1 mm and 1° when a Sentinel image was used as reference. A global worsening of Sentinel performance was observed using as reference an external surface extracted from CT study. This effect is probably due to small differences in considered surfaces, caused by different imaging modalities. The results obtained by testing the system on rigid phantoms were comparable to those obtained using CBCT and better than those obtained with conventional portal imaging systems. CONCLUSIONS: The Sentinel setup verification device is a reproducible and consistent system able to detect misalignments with accuracy better than 1 mm and 1°. When tested on rigid body phantoms, Sentinel and CBCT performed similarly. When compared to portal imaging, both Sentinel and CBCT were more accurate.

Accuracy of iView and PIPSpro registration software.

In radiotherapy, treatment portal images and digitally reconstructed radiographs (DRRs) are used to monitor patient setup during clinical routine. The output of the registration between the portal image and the reference DRR indicates the patient displacement. If the registration is not reliable, the patient positioning will not be accurate. The aim of this work is to assess the intrinsic and the global accuracy of iView and PIPSpro, two widely used registration software programs that implement a manual and a semiautomatic approach, respectively. The intrinsic accuracy was tested using a computer generated phantom, while the overall accuracy was evaluated registering the portal images and the DRRs of an Alderson RANDO phantom. For DRRs, four treatment planning systems (TPS) and three CT studies with different slice thicknesses were considered.This study demonstrates that the intrinsic accuracy of iView and PIPSpro were within 1 pixel and 1°. Using a DRR extracted from a 2 mm CT study, the overall accuracy of both methods was about 2 mm and 1°. When thicker CT slices are considered, the global accuracy of both methods worsens, and differences larger than 1.5° between the rotation parameters estimated with iView and PIPSpro are evident. The results obtained with iView and PIPSpro were nearly equivalent.

A simple method to test the geometrical reliability of digital reconstructed radiograph (DRR).

In radiotherapy treatment portal images and digitally reconstructed radiographs (DRRs) are the most frequently used image-guidance systems to monitor patient set-up during clinical routine. DRR is therefore a critical element in the process of virtual simulation and patient position verification in radiotherapy. The aim of this work was to assess the geometric reliability of the DRR generated by XiO, Pinnacle, Odyssey and Ocentra-Masterplan Treatment Planning Systems (TPS). Instead of the Computed Tomography (CT) images of a quality assurance phantom two synthetic phantoms were created and used to asses the linearity and the ray tracing reliability of the DRR generators. The obtained results demonstrate that the linearity and the reliability of DRR generators was less than 1 pixel for all TPSs.

Accelerated partial breast irradiation with IMRT: new technical approach and interim analysis of acute toxicity in a phase III randomized clinical trial.

PURPOSE: To evaluate with a randomized clinical trial the possibility of treating the index quadrant with external intensity-modulated radiotherapy (IMRT) in a selected group of patients with early-stage breast cancer and to analyze the acute toxicity. METHODS AND MATERIALS: From September 2005, a randomized Phase III clinical trial has been conducted to compare conventional (tangential field) fractionated whole breast treatment (Arm A) with accelerated partial breast irradiation plus intensity-modulated radiotherapy (Arm B). For intensity-modulated radiotherapy, the clinical target volume was drawn with a uniform 1-cm margin around the surgical clips in three dimensions. The ipsilateral and contralateral breast, ipsilateral and contralateral lung, heart, and spinal cord were contoured as organs at risk. All the regions of interest were contoured according to the International Commission on Radiation Units and Measurements reports 50 and 62 recommendations. RESULTS: In September 2008, 259 patients were randomized and treated. The mean clinical target volume in Arm B was 44 cm(3) and the mean planning target volume was 123 cm(3). The mean value of the ratio between the planning target volume and the ipsilateral breast volume was 21%. The rate of Grade 1 and Grade 2 acute skin toxicity was 22% and 19% in Arm A (Radiation Therapy Oncology Group scale), respectively. The tolerance in Arm B was excellent with only 5% Grade 1 and 0.8% Grade 2 acute skin toxicity. The planning constraints were fully satisfied in most patients. In a very few cases, this was not possible because of very unfavorable anatomy. Quality assurance procedures were performed according to our internal quality assurance protocol, with excellent results. CONCLUSION: In the present preliminary analysis, we have demonstrated that accelerated partial breast irradiation is feasible, with very low acute toxicity.

Design and implementation of a water phantom for IMRT, arc therapy, and tomotherapy dose distribution measurements.

The aim of this paper is to present a new phantom for arc therapy, intensity-modulated radiation therapy (IMRT), and tomotherapy dose distribution measurement in pretreatment verification. The presented phantom is innovative for its use of water as the tissue equivalent material, together with a technical solution specifically designed to support radiographic or radiochromic film and ionization chambers in any desired position. The phantom comprise a Plexiglas container, whose present shape and dimensions offer the possibility to simulate a human torso or abdomen; the container can be filled with water by opening the upper cover. On the internal side of the cover, a set of carbon pipes can support film in the desired coronal, axial, or sagittal planes. At one of the two ends of the phantom, an ionization chamber can be positioned parallel to the rotation axis of the accelerator gantry in all possible positions within a 20 cm diameter cylinder, for film calibration purposes. Inhomogeneities can be inserted into the phantom using the same carbon pipes and plastic sheets used to support film. An example of vertebra-shaped inserts made of bone equivalent material is reported. Radiochromic film can be dipped in water, while radiographic film must be protected to prevent damage. To accomplish this, radiographic film is laminated using a cold laminating film. In order to assess the effects of both the lamination itself and the effects of water on laminated Kodak EDR2 film, the optical density (OD) of conventional, laminated, and laminated film immersed in water and exposed to a range of doses from 0 to 300 cGy were compared. The OD of the three samples receiving the same radiation dose did not present any significant difference, thus proving that laminated EDR2 film can also be used in water. A prerequisite for any dosimetric comparison between planned and measured data is a proper film to plan registration. The solution proposed here is an extrinsic in-plane registration technique using four reference points marked on each film in predefined positions. The four points and the millimeter scales fixed on the carbon pipes that support the film are designed and manufactured so as to transfer onto the film the same reference system used during the planning procedure, thus allowing a straightforward registration. Tests to assess the accuracy of the proposed registration method demonstrate that the distances between measured and intended marker positions, evaluated for coronal, axial, and sagittal planes, were about 1 mm for both anteroposterior and lateral projections.

Calibration of the comet assay for the measurement of DNA damage in mammalian cells.

We used X-rays from a linear accelerator and from a low energy therapeutic source to calibrate the single cell gel electrophoresis (comet assay), a widely used method to measure DNA damage. Gamma-rays from 60Co, with known efficiency in inducing DNA breakage, were used as reference. Human lymphocytes and one murine tumour cell line, F10-M3 cells, were irradiated under different experimental conditions. A similar relationship between radiation dose and induced DNA damage was obtained with gamma- and X-rays. A calibration curve was constructed to convert the comet assay raw data into break frequency. The median levels of DNA breaks and oxidative damage in circulating lymphocytes from healthy volunteers were calculated to be 0.76 and 0.80 breaks/10(9) Da, respectively, (0.50 and 0.52 breaks/10(6) bp). The values of oxidative DNA damage were in the same order of magnitude as those found by others with HPLC methods.

Accuracy evaluation of image registration and segmentation tools used in conformal treatment planning of prostate cancer.

Segmentation and registration tools are commonly used in radiotherapy for target and at risk organs localisation. In this work the performances of three different segmentation tools and of a surface matching registration technique, used on computed tomography (CT) and magnetic resonance (MR) images for the treatment planning of conformal prostate carcinoma, are studied. The accuracy of the segmentation and registration tools was evaluated by phantom experiment and on patient data, respectively. A preliminary estimate of MR image distortion was also performed.

Comparison of different external beam treatment techniques to deliver high-dose irradiation to local recurrent rectal carcinoma.

AIMS AND BACKGROUND: Treatment of local-regional recurrent rectal carcinoma is a challenging problem, and local control may be dose dependent; doses should probably exceed 60 Gy. Our aim was to verify the possibility to deliver 66 Gy to the target, but less than 35 Gy to the small bowel, comparing different 3D irradiation techniques, in a selected group of patients. METHODS: Five patients with local recurrent rectal carcinoma were selected as representative of different presentations of the disease. Gross tumor volume and clinical target volume were defined [by RS]. Tumors ranged between 182 and 540 cc, and small bowel volumes between 748 and 1050 cc. A three-field technique, coplanar multiple fields, noncoplanar fields and a proton beam were compared using dose volume histograms. A positive result was scored when > or = 90% of the target received the prescribed dose with no more than 5% of the small bowel receiving more than 35 Gy. Doses were escalated in steps of 2 Gy from 60 to 66 Gy. RESULTS: The number of plans fitting the constraints were 7/19, 11/19, 18/19 for doses of 66 Gy, 64 Gy and 62 Gy, respectively. The stage of the tumor did not seem to correlate with the possibility to homogeneously cover the target with the prescribed dose. CONCLUSIONS: Simple coplanar and complex coplanar techniques (up to six fields), positioning the patient in a prone position with dislocation of the bowel, seem to be the best solutions to treat almost all of the patients with doses of 64 Gy. Where higher doses are concerned, it is not possible to suggest a "standard" solution. More personalized techniques have to be tested to define the best option.

Verification of IMRT fields by film dosimetry.

In intensity modulated radiation therapy (IMRT) the aim of an accurate conformal dose distribution is obtained through a complex process. This ranges from the calculation of the optimal distribution of fluence by the treatment planning system (TPS), to the dose delivery through a multilamellar collimator (MLC), with several segments per beam in the step and shoot approach. The above-mentioned consideration makes mandatory an accurate dosimetric verification of the IM beams. A high resolution and integrating dosimeter, like the radiographic film, permits one to simultaneously measure the dose in a matrix of points, providing a good means of obtaining dose distributions. The intrinsic limitation of film dosimetry is the sensitivity dependence on the field size and on the measurement depth. However, the introduction of a scattered radiation filter permits the use of a single calibration curve for all field sizes and measurement depths. In this paper the quality control procedure developed for dosimetric verification of IMRT technique is reported. In particular a system of film dosimetry for the verification of a 6 MV photon beam has been implemented, with the introduction of the scattered radiation filter in the clinical practice that permits one to achieve an absolute dose determination with a global uncertainty within 3.4% (1 s.d.). The film has been calibrated to be used both in perpendicular and parallel configurations. The work also includes the characterization of the Elekta MLC. Ionimetric independent detectors have been used to check single point doses. The film dosimetry procedure has been applied to compare the measured absolute dose distributions with the ones calculated by the TPS, both for test and clinical plans. The agreement, quantified by the gamma index that seldom reaches the 1.5 value, is satisfying considering that the comparison is performed between absolute doses.