Technical note: A comparison of in-house 3D-printed and commercially available patient-specific skin collimators for use with electron beam therapy.

PURPOSE: Skin collimation is a useful tool in electron beam therapy (EBT) to decrease the penumbra at the field edge and minimize dose to nearby superficial organs at risk (OARs), but manually fabricating these collimation devices in the clinic to conform to the patient's anatomy can be a difficult and time intensive process. This work compares two types of patient-specific skin collimation (in-house 3D printed and vendor-provided machined brass) using clinically relevant metrics. METHODS: Attenuation measurements were performed to determine the thickness of each material needed to adequately shield both 6 and 9 MeV electron beams. Relative and absolute dose planes at various depths were measured using radiochromic film to compare the surface dose, flatness, and penumbra of the different skin collimation materials. RESULTS: Clinically acceptable thicknesses of each material were determined for both 6 and 9 MeV electron beams. Field width, flatness, and penumbra results between the two systems were very similar and significantly improved compared to measurements performed with no surface collimation. CONCLUSION: Both skin collimation methods investigated in this work generate sharp penumbras at the field edge and can minimize dose to superficial OARs compared to treatment fields with no surface collimation. The benefits of skin collimation are greatest for lower energy electron beams, and the benefits decrease as the measurement depth increases. Using bolus with skin collimation is recommended to avoid surface dose enhancement seen with collimators placed on the skin surface. Ultimately, the appropriate choice of material will depend on the desire to create these devices in-house or outsource the fabrication to a vendor.

Impact of proton PBS machine operating parameters on the effectiveness of layer rescanning for interplay effect mitigation in lung SBRT treatment.

BACKGROUND: Rescanning is a common technique used in proton pencil beam scanning to mitigate the interplay effect. Advances in machine operating parameters across different generations of particle therapy systems have led to improvements in beam delivery time (BDT). However, the potential impact of these improvements on the effectiveness of rescanning remains an underexplored area in the existing research. METHODS: We systematically investigated the impact of proton machine operating parameters on the effectiveness of layer rescanning in mitigating interplay effect during lung SBRT treatment, using the CIRS phantom. Focused on the Hitachi synchrotron particle therapy system, we explored machine operating parameters from our institution's current (2015) and upcoming systems (2025A and 2025B). Accumulated dynamic 4D dose were reconstructed to assess the interplay effect and layer rescanning effectiveness. RESULTS: Achieving target coverage and dose homogeneity within 2% deviation required 6, 6, and 20 times layer rescanning for the 2015, 2025A, and 2025B machine parameters, respectively. Beyond this point, further increasing the number of layer rescanning did not further improve the dose distribution. BDTs without rescanning were 50.4, 24.4, and 11.4 s for 2015, 2025A, and 2025B, respectively. However, after incorporating proper number of layer rescanning (six for 2015 and 2025A, 20 for 2025B), BDTs increased to 67.0, 39.6, and 42.3 s for 2015, 2025A, and 2025B machine parameters. Our data also demonstrated the potential problem of false negative and false positive if the randomness of the respiratory phase at which the beam is initiated is not considered in the evaluation of interplay effect. CONCLUSION: The effectiveness of layer rescanning for mitigating interplay effect is affected by machine operating parameters. Therefore, past clinical experiences may not be applicable to modern machines.

Analysis of patient-specific quality assurance for Elekta Unity adaptive plans using statistical process control methodology.

The Elekta Unity MR-linac utilizes daily magnetic resonance imaging (MRI) for online plan adaptation. In the Unity workflow, adapt to position (ATP) and adapt to shape (ATS) treatment planning options are available which represent a virtual shift or full re-plan with contour adjustments respectively. Both techniques generate a new intensity modulated radiation therapy (IMRT) treatment plan while the patient lies on the treatment table and thus adapted plans cannot be measured prior to treatment delivery. A statistical process control methodology was used to analyze 512 patient-specific IMRT QA measurements performed on the MR-compatible SunNuclear ArcCheck with a gamma criterion of 3%/2 mm using global normalization and a 10% low dose threshold. The lower control limit (LCL) was determined from 68 IMRT reference plan measurements, and a one-sided process capability ratio ( C p , l ) was used to assess the pass rates from 432 measured ATP and 80 measured ATS plans. Further analysis was performed to assess differences between SBRT or conventional fractionation pass rates and to determine whether there was any correlation between the pass rates and plan complexity. The LCL of the reference plans was determined to be a gamma pass rate of 0.958, and the C p , l of the measured ATP plans and measured ATS plans were determined to be 1.403 and 0.940 for ATP and ATS plans, respectively, while a C p , l of 0.902 and 1.383 was found for SBRT and conventional fractionations respectively. For plan complexity, no correlation was found between modulation degree and gamma pass rate, but a statistically significant correlation was observed between the beam-averaged aperture area and gamma pass rate. All adaptive plans passed the TG-218 guidelines, but the ATS and SBRT plans tended to have a smaller beam-averaged aperture area with slightly lower gamma pass rates.

Commissioning of a 1.5T Elekta Unity MR-linac: A single institution experience.

MR image-guided radiotherapy has the potential to improve patient care, but integration of an MRI scanner with a linear accelerator adds complexity to the commissioning process. This work describes a single institution experience of commissioning an Elekta Unity MR-linac, including mechanical testing, MRI scanner commissioning, and dosimetric validation. Mechanical testing included multileaf collimator (MLC) positional accuracy, measurement of radiation isocenter diameter, and MR-to-MV coincidence. Key MRI tests included magnetic field homogeneity, geometric accuracy, image quality, and the accuracy of navigator-triggered imaging for motion management. Dosimetric validation consisted of comparison between measured and calculated PDDs and profiles, IMRT measurements, and end-to-end testing. Multileaf collimator positional accuracy was within 1.0 mm, the measured radiation isocenter walkout was 0.20 mm, and the coincidence between MR and MV isocenter was 1.06 mm, which is accounted for in the treatment planning system (TPS). For a 350-mm-diameter spherical volume, the peak-to-peak deviation of the magnetic field homogeneity was 4.44 ppm and the geometric distortion was 0.8 mm. All image quality metrics were within ACR recommendations. Navigator-triggered images showed a maximum deviation of 0.42, 0.75, and 3.0 mm in the target centroid location compared to the stationary target for a 20 mm motion at 10, 15, and 20 breaths per minute, respectively. TPS-calculated PDDs and profiles showed excellent agreement with measurement. The gamma passing rate for IMRT plans was 98.4 ± 1.1% (3%/ 2 mm) and end-to-end testing of adapted plans showed agreement within 0.4% between ion-chamber measurement and TPS calculation. All credentialing criteria were satisfied in an independent end-to-end test using an IROC MRgRT phantom.

Stereotactic radiotherapy of appropriately selected meningiomas and metastatic brain tumor beds with gamma knife icon versus volumetric modulated arc therapy.

PURPOSE: To determine if the gamma knife icon (GKI) can provide superior stereotactic radiotherapy (SRT) dose distributions for appropriately selected meningioma and post-resection brain tumor bed treatments to volumetric modulated arc therapy (VMAT). MATERIALS AND METHODS: Appropriately selected targets were not proximal to great vessels, did not have sensitive soft tissue including organs-at-risk (OARs) within the planning target volume (PTV), and did not have concave tumors containing excessive normal brain tissue. Four of fourteen candidate meningioma patients and six of six candidate patients with brain tumor cavities were considered for this treatment planning comparison study. PTVs were generated for GKI and VMAT by adding 1 mm and 3 mm margins, respectively, to the GTVs. Identical PTV V100% -values were obtained for the GKI and VMAT plans for each patient. Meningioma and tumor bed prescription doses were 52.7-54.0 in 1.7-1.8 Gy fractions and 25 Gy in 5 Gy fractions, respectively. GKI dose rate was 3.735 Gy/min for 16 mm collimators. RESULTS: PTV radical dose homogeneity index was 3.03 ± 0.35 for GKI and 1.27 ± 0.19 for VMAT. Normal brain D1% , D5% , and D10% were lower for GKI than VMAT by 45.8 ± 10.9%, 38.9 ± 11.5%, and 35.4 ± 16.5% respectively. All OARs considered received lower maximum doses for GKI than VMAT. GKI and VMAT treatment times for meningioma plans were 12.1 ± 4.13 min and 6.2 ± 0.32 min, respectively, and, for tumor cavities, were 18.1 ± 5.1 min and 11.0 ± 0.56 min, respectively. CONCLUSIONS: Appropriately selected meningioma and brain tumor bed patients may benefit from GKI-based SRT due to the decreased normal brain and OAR doses relative to VMAT enabled by smaller margins. Care must be taken in meningioma patient selection for SRT with the GKI, even if they are clinically appropriate for VMAT.

Commissioning and performance evaluation of RadCalc for the Elekta unity MRI-linac.

Recent availability of MRI-guided linear accelerators has introduced a number of clinical challenges, particularly in the context of online plan adaptation. Paramount among these is verification of plan quality prior to patient treatment. Currently, there are no commercial products available for monitor unit verification that fully support the newly FDA cleared Elekta Unity 1.5 T MRI-linac. In this work, we investigate the accuracy and precision of RadCalc for this purpose, which is a software package that uses a Clarkson integration algorithm for point dose calculation. To this end, 18 IMRT patient plans (186 individual beams) were created and used for RadCalc point dose calculations. In comparison with the primary treatment planning system (Monaco), mean point dose deviations of 0.0 ± 1.0% (n = 18) and 1.7 ± 12.4% (n = 186) were obtained on a per-plan and per-beam basis, respectively. The dose plane comparison functionality within RadCalc was found to be highly inaccurate, however, modest improvements could be made by artificially shifting jaws and multi leaf collimator positions to account for the dosimetric shift due to the magnetic field (67.3% vs 96.5% mean 5%/5 mm gamma pass rate).

Normalize the response of EPID in pursuit of linear accelerator dosimetry standardization.

Normalize the response of electronic portal imaging device (EPID) is the first step toward an EPID-based standardization of Linear Accelerator (linac) dosimetry quality assurance. In this study, we described an approach to generate two-dimensional (2D) pixel sensitivity maps (PSM) for EPIDs response normalization utilizing an alternative beam and dark-field (ABDF) image acquisition technique and large overlapping field irradiations. The automated image acquisition was performed by XML-controlled machine operation and the PSM was generated based on a recursive calculation algorithm for Varian linacs equipped with aS1000 and aS1200 imager panels. Cross-comparisons of normalized beam profiles and 1.5%/1.5 mm 1D Gamma analysis was adopted to quantify the improvement of beam profile matching before and after PSM corrections. PSMs were derived for both photon (6, 10, 15 MV) and electron (6, 20 MeV) beams via proposed method. The PSM-corrected images reproduced a horn-shaped profile for photon beams and a relative uniform profiles for electrons. For dosimetrically matched linacs equipped with aS1000 panels, PSM-corrected images showed increased 1D-Gamma passing rates for all energies, with an average 10.5% improvement for crossline and 37% for inline beam profiles. Similar improvements in the phantom study were observed with a maximum improvement of 32% for 15 MV and 22% for 20 MeV. The PSM value showed no significant change for all energies over a 3-month period. In conclusion, the proposed approach correct EPID response for both aS1000 and aS1200 panels. This strategy enables the possibility to standardize linac dosimetry QA and to benchmark linac performance utilizing EPID as the common detector.

Technical Note: Improving the workflow in a carbon ion therapy center with custom software for enhanced patient care.

Carbon-ion radiation therapy (CIRT) is an up-and-coming modality for cancer treatment. Implementation of CIRT requires collaboration among specialists like radiation oncologists, medical physicists, and other healthcare professionals. Effective communication among team members is necessary for the success of CIRT. However, the current workflows involving data management, treatment planning, scheduling, and quality assurance (QA) can be susceptible to errors, leading to delays and decreased efficiency. With the aim of addressing these challenges, a team of medical physicists developed an in-house workflow management software using FileMaker Pro. This tool has streamlined the workflow and improved the efficiency and quality of patient care.

Optimizing spot intensity with lower bound constraints for IMPT: Exposing shortcomings and introducing an enhanced strategy.

BACKGROUND: Intensity Modulated Proton Therapy (IMPT) is a sophisticated radiation treatment allowing for precise dose distributions. However, conventional spot selection strategies in IMPT face challenges, particularly with minimum monitor unit (MU) constraints, affecting planning quality and efficiency. PURPOSE: This study introduces an innovative Two-Stage Mixed Integer Linear Programming (MILP) method to optimize spot intensity in IMPT with Lower Bound (LB) constraints. This method seeks to improve treatment planning efficiency and precision, overcoming limitations of existing strategies. METHODS: Our approach evaluates prevalent IMPT spot selection strategies, identifying their limitations, especially concerning MU constraints. We integrated LB constraints into a MILP framework, using a novel three-phase strategy for spot pool selection, to enhance performance over traditional heuristic methods and L1 + L∞ strategies. The method's efficacy was tested in eight study cases, using Dose-Volume Histograms (DVHs), spot selection efficiency, and computation time analysis for benchmarking against established methods. RESULTS: The proposed method showed superior performance in DVH quality, adhering to LB constraints while maintaining high-quality treatment plans. It outperformed existing techniques in spot selection, reducing unnecessary spots and balancing precision with efficiency. Cases studies confirmed the method's effectiveness in producing clinically feasible plans with enhanced dose distributions and reduced hotspots, especially in cases with elevated LB constraints. CONCLUSIONS: Our Two-Stage MILP strategy signifies a significant advancement in IMPT treatment planning. By incorporating LB constraints directly into the optimization process, it achieves superior plan quality and deliverability compared to current methods. This approach is particularly advantageous in clinical settings requiring minimum spot number and high MU LB constraints, offering the potential for improved patient outcomes through more precise and efficient radiation therapy plans.

Impact of time of day on outcomes after stereotactic radiosurgery for non-small cell lung cancer brain metastases.

BACKGROUND: This study tested the hypothesis that time of day of treatment with stereotactic radiosurgery (SRS) has an effect on local control (LC) and overall survival (OS) in a large cohort of patients with non-small cell lung cancer (NSCLC) brain metastases. METHODS: At Washington University in St. Louis, 437 patients with NSCLC were treated with SRS for NSCLC brain metastases. Receiver operating characteristics analysis was used to identify an optimal cut-point for OS relative to time of day. Kaplan-Meier log-rank statistics, and Cox regression univariate and multivariate analysis were employed to isolate any independent effect of treatment time on OS and LC. Matched-pair analysis was performed to isolate any independent effect of time on OS and LC of day while controlling for confounding variables. RESULTS: Receiver operating characteristics analysis identified a cut-point of 11:41 AM as providing the highest predictive value for OS. On univariate analysis, late SRS was associated with decreased OS, as was age, Karnofsky performance status, risk-stratification schemes, extracranial disease status, and overall burden of brain metastases. On univariate analysis for LC, late SRS was associated with decreased LC, as was burden of brain metastases. On multivariate analysis, only Graded Prognostic Assessment remained predictive of OS, and total number of targets and total tumor volume remained predictive of LC. Matched-pair analysis demonstrated no significant effect of time of day on LC or OS. CONCLUSIONS: Although earlier treatment appears to be associated with improved LC and OS, treatment time fails to remain significant when accounting for confounding variables.

Patient-specific independent 3D GammaPlan quality assurance for Gamma Knife Perfexion radiosurgery.

One of the most important aspects of quality assurance (QA) in radiation therapy is redundancy of patient treatment dose calculation. This work is focused on the patient-specific time and 3D dose treatment plan verification for stereotactic radiosurgery using Leksell Gamma Knife Perfexion (LGK PFX). The virtual model of LGK PFX was developed in MATLAB, based on the physical dimensions provided by the manufacturer. The ring-specific linear attenuation coefficients (LAC) and output factors (OFs) reported by the manufacturer were replaced by the measurement-based collimator size-specific OFs and a single LAC = 0.0065 mm-1. Calculation depths for each LGK PFX shot were obtained by ray-tracing technique, and the dose calculation formalism was similar to the one used by GammaPlan treatment planning software versions 8 and 9. The architecture of the QA process was based on the in-house online database search of the LGK PFX database search for plan-specific information. A series of QA phantom plans was examined to verify geometric and dosimetric accuracy of the software. The accuracy of the QA process was further evaluated through evaluation of a series of patient plans. The shot time/focus point dose verification for each shot took less than 1 sec/shot with full 3D isodose verification taking about 30 sec/shot on a desktop PC. GammaPlan database access time took less than 0.05 sec. The geometric accuracy (location of the point of maximum dose) of the phantom and patient plan was dependent on the resolution of the original dose matrix and was of the order of 1 dose element. Dosimetric accuracy of the independently calculated phantom and patient point (focus) doses was within 3.5% from the GammaPlan, with the mean = 2.3% and SD= 1.1%. The process for independent pretreatment patient-specific Gamma Knife Perfexion time and dose verification was created and validated.

Investigation of scan path optimization in improving proton pencil beam scanning continuous delivery.

Objective. To investigate the impact of scan path optimization on the dose accuracy and beam delivery time (BDT) of proton pencil beam scanning in the dose-driven continuous scanning (DDCS).Approach. A diverse set of six clinical plans, representing various spot patterns and treatment sites, was used to evaluate the effectiveness of scan time optimization and scan length optimization. The DDCS dose discrepancy and BDT with optimized scan paths was compared to the default serpentine scan path.Main results. Both scan time optimization and scan path optimization were able to reduce the DDCS dose discrepancy compared to the default serpentine scan path. All plans, except for the layer repainting lung plan, achieved a 2%/2 mm gamma pass rate of over 99% and less than 1% PTV DVH root mean square error (RMSE) through scan path optimization. In the case of the layer repainting lung plan, when compared to the default serpentine scan path, the 2%/2 mm gamma pass rate showed improvements from 91.3% to 93.1% and 95.8%, while the PTV DVH RMSE decreased from 2.1% to 1.7% and 1.1% for scan time optimization and scan length optimization, respectively. Although scan time optimization resulted in shorter total scan times for all plans compared to the default scan path and scan length optimization tended to have longer total scan times. However, due to the short total scan times and their minimal contribution to the total BDT, the impact of scan path optimization on the total BDT was practically negligible.Significance. Both scan time optimization and scan length optimization proved to be effective in minimizing DDCS dose discrepancy. No definitive winner can be determined between these two optimization approaches. Both scan time and scan length optimization had minimal effect on the total BDT.

Selecting Optimal Proton Pencil Beam Scanning Plan Parameters to Reduce Dose Discrepancy between Discrete Spot Plan and Continuous Scanning: A Proof-of-Concept Study.

Pencil beam scanning delivered with continuous scanning has several advantages over conventional discrete spot scanning. Such advantages include improved beam delivery efficiency and reduced beam delivery time. However, a move dose is delivered between consecutive spots with continuous scanning, and current treatment planning systems do not take this into account. Therefore, continuous scanning and discrete spot plans have an inherent dose discrepancy. Using the operating parameters of the state-of-the-art particle therapy system, we conducted a proof-of-concept study in which we systematically generated 28 plans for cubic targets with different combinations of plan parameters and simulated the dose discrepancies between continuous scanning and a planned one. A nomograph to guide the selection of plan parameters was developed to reduce the dose discrepancy. The effectiveness of the nomograph was evaluated with two clinical cases (one prostate and one liver). Plans with parameters guided by the nomograph decreased dose discrepancy than those used standard plan parameters. Specifically, the 2%/2 mm gamma passing rate increased from 96.3% to 100% for the prostate case and from 97.8% to 99.7% for the liver case. The CTV DVH root mean square error decreased from 2.2% to 0.2% for the prostate case and from 1.8% to 0.9% for the liver case. The decreased dose discrepancy may allow the relaxing of the delivery constraint for some cases, leading to greater benefits in continuous scanning. Further investigation is warranted.

A statistical approach to IMRT patient-specific QA.

PURPOSE: The intensity modulated radiation therapy (IMRT) patient-specific quality assurance (QA) (referred to as QA in this paper for simplicity) process is a time and resource intensive effort in every clinic. The use of a global QA tolerance criterion for all treatment sites may be too tight for some complex sites increasing false negatives and rejections of QA measurements which typically results in wasted efforts, treatment delays, and decreased efficiency. At the same time, other sites requiring a less complex plan might have a high false positive leading to approvals of QA measurements that actually need to be rejected. This work is an effort to adopt statistical tools to1. develop a tool to identify statistical variations in the process, monitor trends, detect outliers, and proactively identify drifts in the overall QA results;2. analyze the results of the QA process, identify similarities and differences between treatment plans of different treatment sites, and evaluate the possibility of site-specific tolerance levels for QA approval tolerances. METHODS: The analysis was performed for QA measurements made using two ion chamber points. A custom software tool was developed for data processing and analysis. This tool facilitated QA data collection, retrieval, visualization, real-time feedback, and advanced statistical analysis of the data. Statistical techniques based on analysis of variance were used to evaluate the need for site-specific tolerances and statistical process control was used to study statistical variations in the process. RESULTS: A retrospective analysis of the QA process variability was performed in order to identify site-specific tolerances for the QA measurements and to reduce false positive and false negative QA results. From the data, it can be seen that the treatment sites are significantly different and need site-specific tolerance levels for QA approval. The in-house developed tool was used to further monitor the QA process using individual (I), standard deviations (S), and exponentially weighted moving averages charts for process variability studies. CONCLUSIONS: The authors have studied the analysis of variance on ion chamber measurements made for IMRT treatment plans on different sites, identified similarities and differences between different sites, and thereby evaluated the need for site-specific tolerances for QA acceptance policy. The authors have proposed a way to calculate the appropriate tolerances for different treatment sites and illustrated the clinical usage. Variability at each step of the process increases the uncertainty in the process. The authors have explained the different approaches taken to reduce the variability at each step of the entire process. This process can be used for the benefit during∕as part of an IMRT commissioning process in any clinic. The authors have also developed a tool to automate the process of data collection, analysis, and monitoring the process quality via standard deviations and EWMA charts.

Technical note: electronic chart checks in a paperless radiation therapy clinic.

PURPOSE: EcCk, which stands for Electronic Chart ChecK, is a computer software and database system. It was developed to improve quality and efficiency of patient chart checking in radiation oncology departments. The core concept is to automatically collect and analyze patient treatment data, and to report discrepancies and potential concerns. METHODS: EcCk consists of several different computer technologies, including relational database, DICOM, dynamic HTML, and image processing. Implemented in MATLAB and C#, EcCk processes patient data in DICOM, PDF, Microsoft Word, database, and Pinnacle native formats. Generated reports are stored on the storage server and indexed in the database. A standalone report-browser program is implemented to allow users to view reports on any computer in the department. Checks are performed according to predefined logical rules, and results are presented through color-coded reports in which discrepancies are summarized and highlighted. Users examine the reports and take appropriate actions. The core design is intended to automate human task and to improve the reliability of the performed tasks. The software is not intended to replace human audits but rather to aid as a decision support tool. RESULTS: The software was successfully implemented in the clinical environment and has demonstrated the feasibility of automation of this common task with modern clinical tools. The software integrates multiple disconnected systems and successfully supports analysis of data in diverse formats. CONCLUSIONS: While the human is the ultimate expert, EcCk has a significant potential to improve quality and efficiency of patient treatment record audits, and to allow verification of tasks that are not easily performed by humans. EcCk can potentially relieve human experts from simple and repetitive tasks, and allow them to work on other important tasks, and in the end to improve the quality and safety of radiation therapy treatments.

Evaluation of the efficiency and effectiveness of independent dose calculation followed by machine log file analysis against conventional measurement based IMRT QA.

Experimental methods are commonly used for patient-specific IMRT delivery verification. There are a variety of IMRT QA techniques which have been proposed and clinically used with a common understanding that not one single method can detect all possible errors. The aim of this work was to compare the efficiency and effectiveness of independent dose calculation followed by machine log file analysis to conventional measurement-based methods in detecting errors in IMRT delivery. Sixteen IMRT treatment plans (5 head-and-neck, 3 rectum, 3 breast, and 5 prostate plans) created with a commercial treatment planning system (TPS) were recalculated on a QA phantom. All treatment plans underwent ion chamber (IC) and 2D diode array measurements. The same set of plans was also recomputed with another commercial treatment planning system and the two sets of calculations were compared. The deviations between dosimetric measurements and independent dose calculation were evaluated. The comparisons included evaluations of DVHs and point doses calculated by the two TPS systems. Machine log files were captured during pretreatment composite point dose measurements and analyzed to verify data transfer and performance of the delivery machine. Average deviation between IC measurements and point dose calculations with the two TPSs for head-and-neck plans were 1.2 ± 1.3% and 1.4 ± 1.6%, respectively. For 2D diode array measurements, the mean gamma value with 3% dose difference and 3 mm distance-to-agreement was within 1.5% for 13 of 16 plans. The mean 3D dose differences calculated from two TPSs were within 3% for head-and-neck cases and within 2% for other plans. The machine log file analysis showed that the gantry angle, jaw position, collimator angle, and MUs were consistent as planned, and maximal MLC position error was less than 0.5 mm. The independent dose calculation followed by the machine log analysis takes an average 47 ± 6 minutes, while the experimental approach (using IC and 2D diode array measurements) takes an average about 2 hours in our clinic. Independent dose calculation followed by machine log file analysis can be a reliable tool to verify IMRT treatments. Additionally, independent dose calculations have the potential to identify several problems (heterogeneity calculations, data corruptions, system failures) with the primary TPS, which generally are not identifiable with a measurement-based approach. Additionally, machine log file analysis can identify many problems (gantry, collimator, jaw setting) which also may not be detected with a measurement-based approach. Machine log file analysis could also detect performance problems for individual MLC leaves which could be masked in the analysis of a measured fluence.

An automated treatment plan alert system to safeguard cancer treatments in radiation therapy.

In radiation oncology, the intricate process of delivering radiation to a patient is detailed by the patient's treatment plan, which is data describing the geometry, construction and strength of the radiation machine and the radiation beam it emits. The patient's life depends upon the accuracy of the treatment plan, which is left in the hands of the vendor-specific software automatically generating the plan after an initial patient consultation and planning with a medical professional. However, corrupted and erroneous treatment plan data have previously resulted in severe patient harm when errors go undetected and radiation proceeds. The aim of this paper is to develop an automatic error-checking system to prevent the accidental delivery of radiation treatment to an area of the human body (i.e., the treatment site) that differs from the plan's documented intended site. To this end, we develop a method for structuring treatment plan data in order to feed machine-learning (ML) classifiers and predict a plan's treatment site. In practice, a warning may be raised if the prediction disagrees with the documented intended site. The contribution of this paper is in the strategic structuring of the complex, intricate, and nonuniform data of modern treatment planning and from multiple vendors in order to easily train ML algorithms. A three-step process utilizing up- and down-sampling and dimension reduction, the method we develop in this paper reduces the thousands of parameters comprising a single treatment plan to a single two-dimensional heat map that is independent of the specific vendor or construction of the machine used for treatment. Our heat-map structure lends itself well to feed well-established ML algorithms, and we train-test random forest, softmax, k-nearest neighbors, shallow neural network, and support vector machine using real clinical treatment plans from several hospitals in the United States. The paper demonstrates that the proposed method characterizes treatment sites so well that ML classifiers may predict head-neck, breast, and prostate treatment sites with an accuracy of about 94%. The proposed method is the first step towards a thorough, fully automated error-checking system in radiation therapy.

Reducing MRI-guided radiotherapy planning and delivery times via efficient leaf sequencing and segment shape optimization algorithms.

Objective.Extended treatment session times are an operational limitation in magnetic resonance imaging guided adaptive radiotherapy (MRIgRT). In this study a novel leaf sequencing algorithm called optimal fluence levels (OFL) and an optimization algorithm called pseudo gradient descent (PGD) are evaluated with respect to plan quality, beam complexity, and the ability to reduce treatment session times on the Elekta Unity MRIgRT system.Approach.Ten total patients were evaluated on this Institutional Review Board approved study: three with prostate cancer, three with oligometastases, two with pancreatic cancer, and two with liver cancer. Plans were generated using the clinical Monaco Hyperion optimizer and leaf sequencer and then re-optimized using OFL and PGD (OFL + PGD) while holding all IMRT constraints and planning parameters constant. All plans were normalized to ensure 95% of the PTV received the prescription dose. A paired t-test was used to evaluate statistical significance.Main Results.Plan quality in terms of dosimetric OAR sparing was found to be equivalent between the OFL + PGD and conventional Monaco Hyperion optimizer plans. The OFL + PGD plans had a reduction in optimization time of 51.4% ± 5.0% (p = 0.002) and reduction in treatment delivery time of 10.6% ± 7.5% (p = 0.005). OFL + PGD generated plans had on average 13.2% ± 12.6% fewer multi-leaf collimator (MLC) segments (p = 0.009) and 0.1 ± 0.1 lower plan averaged beam modulation (PM) (p = 0.004) relative to the Monaco Hyperion plans.Significance.The OFL + PGD algorithms more quickly generate Unity treatment plans that are faster to deliver than with the conventional approach and without compromising dosimetric plan quality. This is likely due to a delivery complexity reduction enabled by OFL + PGD relative to the Monaco Hyperion plans.

Clinical Implementational and Site-Specific Workflows for a 1.5T MR-Linac.

MR-guided adaptive radiotherapy (MRgART) provides opportunities to benefit patients through enhanced use of advanced imaging during treatment for many patients with various cancer treatment sites. This novel technology presents many new challenges which vary based on anatomic treatment location, technique, and potential changes of both tumor and normal tissue during treatment. When introducing new treatment sites, considerations regarding appropriate patient selection, treatment planning, immobilization, and plan-adaption criteria must be thoroughly explored to ensure adequate treatments are performed. This paper presents an institution's experience in developing a MRgART program for a 1.5T MR-linac for the first 234 patients. The paper suggests practical treatment workflows and considerations for treating with MRgART at different anatomical sites, including imaging guidelines, patient immobilization, adaptive workflows, and utilization of bolus.

Technical Note: An alternative approach to verify 6FFF beam dosimetry for Ethos and MR Linac without using a 3D water tank.

PURPOSE: The current approach to Linac beam dosimetry verification is typically performed utilizing a three-dimensional (3D) water tank system. The 3D beam scanning process is cumbersome, labor intensive, error-prone, and costly. This is especially challenging for the new Ethos system and MR Linacs with a ring gantry. This work proposes an alternative approach to verify 6FFF beam dosimetry for Ethos, ViewRay MRIdian® Linac, and other Linacs with 6FFF beam quality using two-dimensional (2D) ion chamber arrays. METHODS: Percentage depth dose (PDD) and profiles of an Ethos, an MRIdian® Linac, and several Linacs with 6FFF beams were measured at the nominal beam current. The beam energy was detuned by changing the bending magnet current on one TrueBeam. PDDs and profiles were measured for detuned beam energies. The peak shape of the 6FFF profile was defined by a "slope" parameter and unflatness. Correlations between peak slope and unflatness metrics vs PDDs were used to evaluate the sensitivity of beam energy to beam profile changes at different field sizes and depths. RESULTS: Strong correlations were found between peak slope and PDDs for all Linacs with 6FFF beam. The R-squared values in the linear regression fitting between PDD and peak slope and unflatness were 0.99 and 0.84, respectively. Both profile slope and unflatness were proportional to PDD at the 10 cm depth and the peak slope was 4.3 times more sensitive than PDD. We have identified that measurements with a shallow depth are preferred to quantify the beam energy consistency. CONCLUSIONS: Our work shows the feasibility of verifying 6FFF beam quality of Ethos, MR Linac, and other Linacs by defining a profile slope measured from 2D ionization chambers array devices. This new approach provides a simplified method for performing a routine beam quality check without using a 3D water tank system while maximizing cost effectiveness and efficiency.