Pre-clinical and clinical evaluation of the HYPERSCINT plastic scintillation dosimetry research platform for in vivo dosimetry during radiotherapy.

PURPOSE: The purpose of this work is to evaluate the Hyperscint-RP100 scintillation dosimetry research platform (Hyperscint-RP100, Medscint Inc., Quebec, QC, Canada) designed for clinical quality assurance (QA) for use in in vivo dosimetry measurements. METHODS: The pre-clinical evaluation of the scintillator was performed using a Varian TrueBeam linear accelerator. Dependency on field size, depth, dose, dose rate, and temperature were evaluated in a water tank and compared to calibration data from commissioning and annual QA. Angularity was evaluated with a 3D printed phantom. The clinical evaluation was first performed in two cadaver dogs, and then in three companion animal dogs receiving radiation therapy for nasal tumors. A treatment planning CT scan was performed for cadavers and clinical patients. Prior to treatment, the probe was inserted into the radiation field. Radiation was then delivered and measured with the scintillator. For cadavers, the treatment was repeated after making an intentional shift in patient position to simulate a treatment error. RESULTS: In the preclinical measurements the dose differed from annual measurements as follows: field size -0.77 to 0.43%, depth dose -0.36 to 1.14%, dose -0.54 to 2.93%, dose rate 0.3 to 3.6%, and angularity -1.18 to 0.01%. Temperature dependency required a correction factor of 0.11%/°C. In the two cadavers, the dose differed by -1.17 to 0.91%. The device correctly detected the treatment error when the heads were intentionally laterally shifted. In three canine clinical patients treated in multiple fractions, the detected dose ranged from 98.33 to 103.15%. CONCLUSION: Results of this new device are promising although more work is necessary to fully validate it for clinical dosimetry.

Synergistic structures in lyotropic lamellar gels.

In this work we present a systematic study on the microstructure of soft materials which combine the anisotropy of lyotropic liquid crystals with the mechanical stability of a physical gel. Systematic small-angle neutron (SANS) and X-ray (SAXS) scattering experiments were successfully used to characterize the lyotropic lamellar phase (Lα) of the system D2O -n-decanol - SDS which was gelled by two low molecular weight organogelators, 1,3:2,4-dibenzylidene-d-sorbitol (DBS) and 12-hydroxyoctadecanoic acid (12-HOA). Surprisingly, a pronounced shoulder appeared in the scattering curves of the lamellar phase gelled with 12-HOA, whereas the curves of the DBS-gelled Lα phase remained almost unchanged compared to the ones of the gelator-free Lα phase. The appearance of this additional shoulder strongly indicates the formation of a synergistic structure, which neither exists in the gelator-free Lα phase nor in the isotropic binary gel. By comparing the thicknesses of the 12-HOA (25-30 nm) and DBS (4-8 nm) gel fibers with the lamellar repeat distance (7.5 nm), we suggest that the synergistic structure originates from the minimization of the elastic free energy of the lamellar phase. In the case of 12-HOA, where the fiber diameter is significantly larger than the lamellar repeat distance, energetically unfavored layer ends can be prevented, when the layers cylindrically enclose the gel fibers. Interestingly, such structures mimic similar schemes found in neural cells, where axons are surrounded by lamellar myelin sheets.

Gelation of Lyotropic Liquid-Crystal Phases-The Interplay between Liquid Crystalline Order and Physical Gel Formation.

We present a systematical investigation of gelled lyotropic liquid crystals (LLCs). This new class of soft materials combines the anisotropy of LLCs with the mechanical stability of a physical gel. The studied LLC system consists of sodium dodecyl sulfate as a surfactant, n-decanol as a cosurfactant, and water as a solvent. At room temperature, four liquid crystalline phases (lamellar Lα, nematic Nd and Nc, and hexagonal H1) are formed depending on the composition. We were successful in gelling the lyotropic lamellar phase with the low-molecular-weight organogelator 12-hydroxyoctadecanoic acid (12-HOA). The obtained gelled lamellar phase shows optical birefringence, elastic response, and no macroscopic flow. However, we were not able to obtain gels with hexagonal or nematic structure. These findings can be explained twofold. When gelling the hexagonal phase, the long-range hexagonal order was destroyed and an isotropic gel was formed. The reason might be the incompatibility between the gel fiber network and the two-dimensional long-range translational order of the cylindrical micelles in the hexagonal phase. Otherwise, the lyotropic nematic phase was transformed into an anisotropic gel with the lamellar structure during gelation. Evidently, the addition of the gelator 12-HOA to the lyotropic system considerably widens the lamellar regime because the integration of the surface-active 12-HOA gelator molecules into the nematic micelles flattens out the micelle curvature. We further investigated the successfully gelated Lα phase to examine the impacts of the gel network and the remaining monomeric gelator on both the structure and properties of the gelled lamellar phase. Small-angle X-ray scattering results showed an arrested lamellar layer spacing in the gelled state, which indicates a higher translational order for the gelled lamellar phases in comparison with their gelator-free counterparts.

Gelling Lamellar Phases of the Binary System Water-Didodecyldimethylammonium Bromide with an Organogelator.

Does the presence of a gel network influence the properties of a lyotropic liquid crystal? Does the replacement of oil by a lyotropic liquid crystal influence the properties of an organogel? To answer these questions we study gelled lyotropic liquid crystals (LLC). In the present study we show that it is possible to gel the lamellar phase of the binary system water-didodecyl dimethylammonium bromide (2C12DAB) with the organogelator 12-hydroxyoctadecanoic acid (12-HOA). We compare various properties of the gelled LLC phases with the "parent systems", i.e., with the binary organogel consisting of n-decane-12-HOA and with the nongelled LC phases, respectively. Optical and electron microscopy, differential scanning calorimetry (DSC), rheometry, as well as small and wide-angle X-ray scattering (SWAXS) proved the coexistence of an Lα phase and a 12-HOA gel network in the gelled Lα phase. However, a small influence of the Lα phase on the gel properties was seen, namely slightly lower sol-gel transition temperatures and viscoelastic moduli of the gelled Lα phase compared to the binary gel. On the other hand, the presence of the gel also has an influence on the Lα phase: the interlayer spacing of the surfactant bilayers in the gelled Lα phases is slightly larger compared to the nongelled Lα phases, which is due to mixing part of the 12-HOA molecules in the Lα bilayers. Despite this mutual influence the structures of both the Lα phase and the gel network are hardly disturbed in the gelled Lα phase, i.e., that the self-assembly of the surfactant and of the gelator molecules clearly occur in an orthogonal way.

Dose delivered to the lumbosacral plexus from high-dose-rate brachytherapy for cervical cancer.

OBJECTIVE: To calculate dose delivered to the lumbosacral plexus (LSP) with cervical brachytherapy using 3-dimensional imaging, and to compare this with the position of the tandem in the pelvis using bony landmarks. We also report long-term LSP toxicity outcomes. METHODS AND MATERIALS: Treatment planning images from 55 patients treated with tandem and ring brachytherapy from October 2009 through November 2012 were reviewed. The LSP was contoured on planning computed tomographic scans to calculate dose received. Lumbosacral plexus dose was studied as a function of tandem distance from the sacrum and pubic symphysis (STratio) measured on digitally reconstructed radiographs. Patient and implant characteristics were included as covariates on LSP dose. Clinical follow up on LSP toxicity was recorded. RESULTS: Patients were prescribed 550 to 700 cGy using computed tomography-based imaged-guided brachytherapy for 4 to 5 fractions. The maximum dose to 2 cc (D2cc) of LSP ranged from 44 to 287 cGy per implant. The median D2cc was 118 cGy, corresponding to 18% of prescription dose. Patients with an STratio less than 0.33 (closer to the sacrum) and at least 0.33 had median LSP doses of 138 and 98 cGy, respectively. Lumbosacral plexus dose did not change significantly with body mass index, uterus position, or tumor stage. Two patients reported symptoms of peripheral neuropathy, with a median follow-up of 14.7 months. CONCLUSIONS: The mean D2cc per fraction to the LSP is roughly 20% of the prescribed high dose-rate and varies with the position of the tandem from the sacrum. The dose threshold for radiation-induced neuropathy of the LSP remains undefined.

INTER- AND INTRAFRACTION MOTION FOR STEREOTACTIC RADIOSURGERY IN DOGS AND CATS USING A MODIFIED BRAINLAB FRAMELESS STEREOTACTIC MASK SYSTEM.

Precise and accurate patient positioning is necessary when doing stereotactic radiosurgery (SRS) to ensure adequate dosing to the tumor and sparing of normal tissues. This prospective cross-sectional study aimed to assess feasibility of a commercially available modified frameless SRS positioning system for use in veterinary radiotherapy patients with brain tumors. Fifty-one dogs and 12 cats were enrolled. Baseline and verification CT images were acquired. The verification CT images from 32 dogs and five cats had sufficient images for fusion to baseline CT images. A rigid box-based fusion was performed to determine interfraction motion. Forty-eight dogs and 11 cats were assessed for intrafraction motion by cine CT. Seventy percent of dogs and 60% of cats had interfraction 3D vector translational shifts >1 mm, with mean values of 1.9 mm in dogs, and 1.8 mm in cats. In dogs muscle wasting was weakly correlated with translational shifts. The maximum angular interfraction motion observed was 6.3° (roll), 3.5° (pitch), and 3.3° (yaw). There was no correlation between angular interfraction motion and weight, brachycephaly, or muscle wasting. Fifty-seven percent of dogs and 50% of cats had respiration-related intrafraction motion. Of these, 4.5% of dogs and 10% of cats had intrafraction motion >1 mm. This study demonstrates the modified Brainlab system is feasible for SRS in dogs and cats. The smaller cranial size and difference in anatomy increases setup uncertainty in some animals beyond limits usually accepted in SRS. Image-guided positioning is recommended to achieve clinically acceptable setup accuracy (<1 mm) for SRS.

VALIDATION OF AN INDEXED RADIOTHERAPY HEAD POSITIONING DEVICE FOR USE IN DOGS AND CATS.

Setup variability affects the appropriate delivery of radiation and informs the setup margin required to treat radiation patients. Twenty-four veterinary patients with head and neck cancers were enrolled in this prospective, cross-sectional study to determine the accuracy of an indexed board immobilization device for positioning. Couch position values were defined at the first treatment based on setup films. At subsequent treatments, patients were moved to the previously defined couch location, orthogonal films were acquired, table position was modified, and displacement was recorded. The mean systematic displacement, random displacement, overall displacement, and mean displacement values of the three-dimensional (3D) vector were calculated. Three hundred thirty-two pairs of orthogonal setup films were analyzed for displacement in cranial-caudal, lateral, and dorsal-ventral directions. The mean systematic displacements were 0.5, 0.8, and 0.5 mm, respectively. The mean random displacements were 1.0, 1.1, and 0.7 mm, respectively. The overall displacements were 1.1, 1.4, and 0.9 mm, respectively. The mean 3D vector value was 1.6 mm with a standard deviation of 1.2 mm. Ninety-five percent of the vectors were <3.6 mm. These values were compared to data obtained with a previously used immobilization device. A t-test was used to compare the two devices. The 3D vector, random displacement in all directions, and overall displacement in the cranial-caudal and dorsal-ventral directions were significantly smaller than displacements with the previous device. The precision and accuracy of the indexed board device was superior to the historical head and neck device.

AAPM task group report 135.B: Quality assurance for robotic radiosurgery.

AAPM Task Group Report 135.B covers new technology components that have been added to an established radiosurgery platform and updates the components that were not well covered in the previous report. Considering the current state of the platform, this task group (TG) is a combination of a foundational task group to establish the basis for new processes/technology and an educational task group updating guidelines on the established components of the platform. Because the technology discussed in this document has a relatively small user base compared to C-arm isocentric linacs, the authors chose to emphasize the educational components to assist medical physicists who are new to the technology and have not had the opportunity to receive in-depth vendor training at the time of reading this report. The TG has developed codes of practice, introduced QA, and developed guidelines which are generally expected to become enduring practice. This report makes prescriptive recommendations as there has not been enough longitudinal experience with some of the new technical components to develop a data-based risk analysis.

Migration of implanted markers for image-guided lung tumor stereotactic ablative radiotherapy.

The purpose of this study was to quantify postimplantation migration of percutaneously implanted cylindrical gold seeds ("seeds") and platinum endovascular embolization coils ("coils") for tumor tracking in pulmonary stereotactic ablative radiotherapy (SABR). We retrospectively analyzed the migration of markers in 32 consecutive patients with computed tomography scans postimplantation and at simulation. We implanted 147 markers (59 seeds, 88 coils) in or around 34 pulmonary tumors over 32 procedures, with one lesion implanted twice. Marker coordinates were rigidly aligned by minimizing fiducial registration error (FRE), the root mean square of the differences in marker locations for each tumor between scans. To also evaluate whether single markers were responsible for most migration, we aligned with and without the outlier causing the largest FRE increase per tumor. We applied the resultant transformation to all markers. We evaluated migration of individual markers and FRE of each group. Median scan interval was 8 days. Median individual marker migration was 1.28 mm (interquartile range [IQR] 0.78-2.63 mm). Median lesion FRE was 1.56 mm (IQR 0.92-2.95 mm). Outlier identification yielded 1.03 mm median migration (IQR 0.52-2.21 mm) and 1.97 mm median FRE (IQR 1.44-4.32 mm). Outliers caused a mean and median shift in the centroid of 1.22 and 0.80 mm (95th percentile 2.52 mm). Seeds and coils had no statistically significant difference. Univariate analysis suggested no correlation of migration with the number of markers, contact with the chest wall, or time elapsed. Marker migration between implantation and simulation is limited and unlikely to cause geometric miss during tracking.

Online monitoring and error detection of real-time tumor displacement prediction accuracy using control limits on respiratory surrogate statistics.

PURPOSE: To evaluate Hotelling's T(2) statistic and the input variable squared prediction error (Q((X))) for detecting large respiratory surrogate-based tumor displacement prediction errors without directly measuring the tumor's position. METHODS: Tumor and external marker positions from a database of 188 Cyberknife Synchrony™ lung, liver, and pancreas treatment fractions were analyzed. The first ten measurements of tumor position in each fraction were used to create fraction-specific models of tumor displacement using external surrogates as input; the models were used to predict tumor position from subsequent external marker measurements. A partial least squares (PLS) model with four scores was developed for each fraction to determine T(2) and Q((X)) confidence limits based on the first ten measurements in a fraction. The T(2) and Q((X)) statistics were then calculated for every set of external marker measurements. Correlations between model error and both T(2) and Q((X)) were determined. Receiver operating characteristic analysis was applied to evaluate sensitivities and specificities of T(2), Q((X)), and T(2)∪Q((X)) for predicting real-time tumor localization errors >3 mm over a range of T(2) and Q((X)) confidence limits. RESULTS: Sensitivity and specificity of detecting errors >3 mm varied with confidence limit selection. At 95% sensitivity, T(2)∪Q((X)) specificity was 15%, 2% higher than either T(2) or Q((X)) alone. The mean time to alarm for T(2)∪Q((X)) at 95% sensitivity was 5.3 min but varied with a standard deviation of 8.2 min. Results did not differ significantly by tumor site. CONCLUSIONS: The results of this study establish the feasibility of respiratory surrogate-based online monitoring of real-time respiration-induced tumor motion model accuracy for lung, liver, and pancreas tumors. The T(2) and Q((X)) statistics were able to indicate whether inferential model errors exceeded 3 mm with high sensitivity. Modest improvements in specificity were achieved by combining T(2) and Q((X)) results.

In vivo dose measurement using TLDs and MOSFET dosimeters for cardiac radiosurgery.

In vivo measurements were made of the dose delivered to animal models in an effort to develop a method for treating cardiac arrhythmia using radiation. This treatment would replace RF energy (currently used to create cardiac scar) with ionizing radiation. In the current study, the pulmonary vein ostia of animal models were irradiated with 6 MV X-rays in order to produce a scar that would block aberrant signals characteristic of atrial fibrillation. The CyberKnife radiosurgery system was used to deliver planned treatments of 20-35 Gy in a single fraction to four animals. The Synchrony system was used to track respiratory motion of the heart, while the contractile motion of the heart was untracked. The dose was measured on the epicardial surface near the right pulmonary vein and on the esophagus using surgically implanted TLD dosimeters, or in the coronary sinus using a MOSFET dosimeter placed using a catheter. The doses measured on the epicardium with TLDs averaged 5% less than predicted for those locations, while doses measured in the coronary sinus with the MOSFET sensor nearest the target averaged 6% less than the predicted dose. The measurements on the esophagus averaged 25% less than predicted. These results provide an indication of the accuracy with which the treatment planning methods accounted for the motion of the target, with its respiratory and cardiac components. This is the first report on the accuracy of CyberKnife dose delivery to cardiac targets.

Experimental comparison of seven commercial dosimetry diodes for measurement of stereotactic radiosurgery cone factors.

PURPOSE: The purpose of this work is to assess the variation in performance of various commercially available dosimetry diodes for quantitative small field dosimetry, specifically by intercomparing measurements of SRS cone factors. METHODS: Measurements were made in 6 MV photon beams with fixed SRS cones for two accelerator-based SRS systems: a Varian Clinac iX (Varian/Zmed cones) at 600 MU/min and a CyberKnife model G4 at 800 MU/min. Measurements were made at 1.5 cm depth in water using the IBA Dosimetry "blue phantom" 3D scanning system, controlled by OMNIPRO-ACCEPT software. Source-to-detector distance was 100 cm for the Clinac, 80 cm for the CyberKnife. Two normalization methods were used for the Clinac, one directly referenced to diode measurements in a 10 cm x 10 cm square field and the other indirectly by "daisy-chaining" diode measurements to ion chamber measurement in the 10 cm x 10 cm reference field through an intermediate 4 cm x 4 cm square field. CyberKnife factors were referenced directly to measurements in the 60 mm reference field. Seven commercial diodes were evaluated: PTW TN60008, TN60012, TN60016, TN60017; IBA Dosimetry SFD; Sun Nuclear EDGE; Exradin SD1 (first generation prototype). RESULTS: With the exception of the SFD, all the evaluated devices yielded surprisingly consistent results. Standard deviations of Clinac factors for four diodes (SD1, EDGE, TN60008, and TN60012) ranged from approximately 0.50% at 30 mm to 2.0% at 5 mm cones size when referenced directly to the 10 cm x 10 cm measurement. The daisy-chaining strategy reduced the standard deviation to approximately 0.30% at 30 mm and 1.9% at 5 mm. Standard deviations for the same four diodes in the CyberKnife beam ranged up to approximately 1.0% at 5 mm. CONCLUSIONS: The inter-detector variation is small and appears to be systematic with detector packaging, more inherent filtration producing flatter curves for both the relatively hard Clinac beam and the softer CyberKnife beam. The daisy-chain strategy appears to be of limited value for most of the diodes, but does bring the SFD results into significantly better agreement with the others.

Report of AAPM TG 135: quality assurance for robotic radiosurgery.

The task group (TG) for quality assurance for robotic radiosurgery was formed by the American Association of Physicists in Medicine's Science Council under the direction of the Radiation Therapy Committee and the Quality Assurance (QA) Subcommittee. The task group (TG-135) had three main charges: (1) To make recommendations on a code of practice for Robotic Radiosurgery QA; (2) To make recommendations on quality assurance and dosimetric verification techniques, especially in regard to real-time respiratory motion tracking software; (3) To make recommendations on issues which require further research and development. This report provides a general functional overview of the only clinically implemented robotic radiosurgery device, the CyberKnife. This report includes sections on device components and their individual component QA recommendations, followed by a section on the QA requirements for integrated systems. Examples of checklists for daily, monthly, annual, and upgrade QA are given as guidance for medical physicists. Areas in which QA procedures are still under development are discussed.

Micellar Lyotropic Nematic Gels.

Lyotropic liquid crystal (LLC) gels are a new class of liquid crystal (LC) networks that combine the anisotropy of micellar LLCs with the mechanical stability of a gel. However, so far, only micellar LLC gels with lamellar and hexagonal structures have been obtained by the addition of gelators to LLCs. Here, the first examples of lyotropic nematic gels are presented. The key to obtain these nematic gels is the use of gelators that have a non-amphiphilic molecular structure and thus leave the size and shape of the micellar aggregates essentially unchanged. By adding these gelators to lyotropic nematic phases, an easy and reproducible way to obtain large amounts of lyotropic nematic gels is established. These nematic gels preserve the long-range orientational order and optical birefringence of a lyotropic nematic phase but have the mechanical stability of a gel. LLC nematic gels are promising new materials for elastic and anisotropic hydrogels to be applied as water-based stimuli-responsive actuators and sensors.

Electronic charting of radiation therapy planning and treatment: Report of Task Group 262.

While most Radiation Oncology clinics have adopted electronic charting in one form or another, no consensus document exists that provides guidelines for safe and effective use of the Radiation Oncology electronic medical records (RO-EMR). Task Group 262 was formed to provide these guidelines as well as to provide recommendations to vendors for improving electronic charting functionality in future. Guidelines are provided in the following areas: Implementation and training for the RO-EMR, acceptance testing and quality assurance (QA) of the RO-EMR, use of the RO-EMR as an information repository, use of the RO-EMR as a workflow manager, electronic charting for brachytherapy and nonstandard treatments, and information technology (IT) considerations associated with the RO-EMR. The report was based on a literature search by the task group, an extensive survey of task group members on their respective RO-EMR practices, an AAPM membership survey on electronic charting, as well as group consensus.

AAPM Task Group 264: The safe clinical implementation of MLC tracking in radiotherapy.

The era of real-time radiotherapy is upon us. Robotic and gimbaled linac tracking are clinically established technologies with the clinical realization of couch tracking in development. Multileaf collimators (MLCs) are a standard equipment for most cancer radiotherapy systems, and therefore MLC tracking is a potentially widely available technology. MLC tracking has been the subject of theoretical and experimental research for decades and was first implemented for patient treatments in 2013. The AAPM Task Group 264 Safe Clinical Implementation of MLC Tracking in Radiotherapy Report was charged to proactively provide the broader radiation oncology community with (a) clinical implementation guidelines including hardware, software, and clinical indications for use, (b) commissioning and quality assurance recommendations based on early user experience, as well as guidelines on Failure Mode and Effects Analysis, and (c) a discussion of potential future developments. The deliverables from this report include: an explanation of MLC tracking and its historical development; terms and definitions relevant to MLC tracking; the clinical benefit of, clinical experience with and clinical implementation guidelines for MLC tracking; quality assurance guidelines, including example quality assurance worksheets; a clinical decision pathway, future outlook and overall recommendations.

Findings of the AAPM Ad Hoc committee on magnetic resonance imaging in radiation therapy: Unmet needs, opportunities, and recommendations.

The past decade has seen the increasing integration of magnetic resonance (MR) imaging into radiation therapy (RT). This growth can be contributed to multiple factors, including hardware and software advances that have allowed the acquisition of high-resolution volumetric data of RT patients in their treatment position (also known as MR simulation) and the development of methods to image and quantify tissue function and response to therapy. More recently, the advent of MR-guided radiation therapy (MRgRT) - achieved through the integration of MR imaging systems and linear accelerators - has further accelerated this trend. As MR imaging in RT techniques and technologies, such as MRgRT, gain regulatory approval worldwide, these systems will begin to propagate beyond tertiary care academic medical centers and into more community-based health systems and hospitals, creating new opportunities to provide advanced treatment options to a broader patient population. Accompanying these opportunities are unique challenges related to their adaptation, adoption, and use including modification of hardware and software to meet the unique and distinct demands of MR imaging in RT, the need for standardization of imaging techniques and protocols, education of the broader RT community (particularly in regards to MR safety) as well as the need to continue and support research, and development in this space. In response to this, an ad hoc committee of the American Association of Physicists in Medicine (AAPM) was formed to identify the unmet needs, roadblocks, and opportunities within this space. The purpose of this document is to report on the major findings and recommendations identified. Importantly, the provided recommendations represent the consensus opinions of the committee's membership, which were submitted in the committee's report to the AAPM Board of Directors. In addition, AAPM ad hoc committee reports differ from AAPM task group reports in that ad hoc committee reports are neither reviewed nor ultimately approved by the committee's parent groups, including at the council and executive committee level. Thus, the recommendations given in this summary should not be construed as being endorsed by or official recommendations from the AAPM.

Failure mode and effect analysis-based quality assurance for dynamic MLC tracking systems.

PURPOSE: To develop and implement a failure mode and effect analysis (FMEA)-based commissioning and quality assurance framework for dynamic multileaf collimator (DMLC) tumor tracking systems. METHODS: A systematic failure mode and effect analysis was performed for a prototype real-time tumor tracking system that uses implanted electromagnetic transponders for tumor position monitoring and a DMLC for real-time beam adaptation. A detailed process tree of DMLC tracking delivery was created and potential tracking-specific failure modes were identified. For each failure mode, a risk probability number (RPN) was calculated from the product of the probability of occurrence, the severity of effect, and the detectibility of the failure. Based on the insights obtained from the FMEA, commissioning and QA procedures were developed to check (i) the accuracy of coordinate system transformation, (ii) system latency, (iii) spatial and dosimetric delivery accuracy, (iv) delivery efficiency, and (v) accuracy and consistency of system response to error conditions. The frequency of testing for each failure mode was determined from the RPN value. RESULTS: Failures modes with RPN > or = 125 were recommended to be tested monthly. Failure modes with RPN < 125 were assigned to be tested during comprehensive evaluations, e.g., during commissioning, annual quality assurance, and after major software/hardware upgrades. System latency was determined to be approximately 193 ms. The system showed consistent and accurate response to erroneous conditions. Tracking accuracy was within 3%-3 mm gamma (100% pass rate) for sinusoidal as well as a wide variety of patient-derived respiratory motions. The total time taken for monthly QA was approximately 35 min, while that taken for comprehensive testing was approximately 3.5 h. CONCLUSIONS: FMEA proved to be a powerful and flexible tool to develop and implement a quality management (QM) framework for DMLC tracking. The authors conclude that the use of FMEA-based QM ensures efficient allocation of clinical resources because the most critical failure modes receive the most attention. It is expected that the set of guidelines proposed here will serve as a living document that is updated with the accumulation of progressively more intrainstitutional and interinstitutional experience with DMLC tracking.

Interstitial High-Dose-Rate Gynecologic Brachytherapy: Clinical Workflow Experience From Three Academic Institutions.

An interstitial brachytherapy approach for gynecologic cancers is typically considered for patients with lesions exceeding 5 mm within tissue or that are not easily accessible for intracavitary applications. Recommendations for treating gynecologic malignancies with this approach are available through the American Brachytherapy Society, but vary based on available resources, staffing, and logistics. The intent of this manuscript is to share the collective experience of 3 academic centers that routinely perform interstitial gynecologic brachytherapy. Discussion points include indications for interstitial implants, procedural preparations, applicator selection, anesthetic options, imaging, treatment planning objectives, clinical workflows, timelines, safety, and potential challenges. Interstitial brachytherapy is a complex, high-skill procedure requiring routine practice to optimize patient safety and treatment efficacy. Clinics planning to implement this approach into their brachytherapy practice may benefit from considering the discussion points shared in this manuscript.