Survey of patient-specific quality assurance practice for IMRT and VMAT.

A first-time survey across 15 cancer centers in Ontario, Canada, on the current practice of patient-specific quality assurance (PSQA) for intensity modulated radiation therapy (IMRT) and volumetric modulated arc therapy (VMAT) delivery was conducted. The objectives were to assess the current state of PSQA practice, identify areas for potential improvement, and facilitate the continued improvement in standardization, consistency, efficacy, and efficiency of PSQA regionally. The survey asked 40 questions related to PSQA practice for IMRT/VMAT delivery. The questions addressed PSQA policy and procedure, delivery log evaluation, instrumentation, measurement setup and methodology, data analysis and interpretation, documentation, process, failure modes, and feedback. The focus of this survey was on PSQA activities related to routine IMRT/VMAT treatments on conventional linacs, including stereotactic body radiation therapy but excluding stereotactic radiosurgery. The participating centers were instructed to submit answers that reflected the collective view or opinion of their department and represented the most typical process practiced. The results of the survey provided a snapshot of the current state of PSQA practice in Ontario and demonstrated considerable variations in the practice. A large majority (80%) of centers performed PSQA measurements on all VMAT plans. Most employed pseudo-3D array detectors with a true composite (TC) geometry. No standard approach was found for stopping or reducing frequency of measurements. The sole use of delivery log evaluation was not widely implemented, though most centers expressed interest in adopting this technology. All used the Gamma evaluation method for analyzing PSQA measurements; however, no universal approach was reported on how Gamma evaluation and pass determination criteria were determined. All or some PSQA results were reviewed regularly in two-thirds of the centers. Planning related issues were considered the most frequent source for PSQA failures (40%), whereas the most frequent course of action for a failed PSQA was to review the result and decide whether to proceed to treatment.

Method of computing direction-dependent margins for the development of consensus contouring guidelines.

BACKGROUND: Clinical target volume (CTV) contouring guidelines are frequently developed through studies in which experts contour the CTV for a representative set of cases for a given treatment site and the consensus CTVs are analyzed to generate margin recommendations. Measures of interobserver variability are used to quantify agreement between experts. In cases where an isotropic margin is not appropriate, however, there is no standard method to compute margins in specified directions that represent possible routes of tumor spread. Moreover, interobserver variability metrics are often measures of volume overlap that do not account for the dependence of disagreement on direction. To aid in the development of consensus contouring guidelines, this study demonstrates a novel method of quantifying CTV margins and interobserver variability in clinician-specified directions. METHODS: The proposed algorithm was applied to 11 cases of non-spine bone metastases to compute the consensus CTV margin in each direction of intraosseous and extraosseous disease. The median over all cases for each route of spread yielded the recommended margins. The disagreement between experts on the CTV margin was quantified by computing the median of the coefficients of variation for intraosseous and extraosseous margins. RESULTS: The recommended intraosseous and extraosseous margins were 7.0 mm and 8.0 mm, respectively. The median coefficient of variation quantifying the margin disagreement between experts was 0.59 and 0.48 for intraosseous and extraosseous disease. CONCLUSIONS: The proposed algorithm permits the generation of margin recommendations in relation to adjacent anatomy and quantifies interobserver variability in specified directions. This method can be applied to future consensus CTV contouring studies.

Early biomarker for radiation-induced wounds: day one post-irradiation assessment using hemoglobin concentration measured from diffuse optical reflectance spectroscopy.

Normal tissue radiation toxicities are evaluated subjectively and cannot predict the development of severe side-effects. Using a hand-held diffuse reflectance optical spectroscopy probe, we measured optical parameters in mouse skin 1-4 days after irradiation. Using a radiation toxicity model and a therapeutic mitigator described previously [BMC Cancer14, 614 (2014)], we found that hemoglobin (Hb) levels increased sharply 24 h after irradiation only in the irradiated group without the mitigator. This group also had the largest peak wound areas after 14 days. We conclude that increased Hb one day after skin irradiation predicts the severity of the subsequent irradiation-induced wound.

Perturbative diffusion theory formalism for interpreting temporal light intensity changes during laser interstitial thermal therapy.

In an effort to understand dynamic optical changes during laser interstitial thermal therapy (LITT), we utilize the perturbative solution of the diffusion equation in heterogeneous media to formulate scattering weight functions for cylindrical line sources. The analysis explicitly shows how changes in detected interstitial light intensity are associated with the extent and location of the volume of thermal coagulation during treatment. Explanations for previously reported increases in optical intensity observed early during laser heating are clarified using the model and demonstrated with experimental measurements in ex vivo bovine liver tissue. This work provides an improved understanding of interstitial optical signal changes during LITT and indicates the sensitivity and potential of interstitial optical monitoring of thermal damage.

Determination of the optical properties of turbid media using relative interstitial radiance measurements: Monte Carlo study, experimental validation, and sensitivity analysis.

Interstitial quantification of the optical properties of tissue is important in biomedicine for both treatment planning of minimally invasive laser therapies and optical spectroscopic characterization of tissues, for example, prostate cancer. In a previous study, we analyzed a method first demonstrated by Dickey et al., [Phys. Med. Biol. 46, 2359 (2001)] to utilize relative interstitial steady-state radiance measurements for recovering the optical properties of turbid media. The uniqueness of point radiance measurements were demonstrated in a forward sense, and strategies were suggested for improving performance under noisy experimental conditions. In this work, we test our previous conclusions by fitting the P3 approximation for radiance to Monte Carlo predictions and experimental data in tissue-simulating phantoms. Fits are performed at: 1. a single sensor position (0.5 or 1 cm), 2. two sensor positions (0.5 and 1 cm), and 3. a single sensor position (0.5 or 1 cm) with input knowledge of the sample's effective attenuation coefficient. The results demonstrate that single sensor radiance measurements can be used to retrieve optical properties to within approximately 20%, provided the transport albedo is greater than approximately 0.9. Furthermore, compared to the single sensor fits, employing radiance data at two sensor positions did not significantly improve the accuracy of recovered optical properties. However, with knowledge of the effective attenuation coefficient of the medium, optical properties can be retrieved experimentally to within approximately 10% for an albedo greater or equal to 0.5.

Models and measurements of light intensity changes during laser interstitial thermal therapy: implications for optical monitoring of the coagulation boundary location.

We have developed a multi-region spherical Monte Carlo (MC) model to simulate the dynamic changes in light intensity measured during laser interstitial thermal therapy (LITT). Model predictions were validated experimentally in tissue-simulating albumen phantoms with well-characterized optical properties that vary dynamically with LITT in a way similar to tissue. For long treatments (2.5 W, approximately 1800 s), the transient light intensity changes demonstrated better qualitative agreement with a three-region MC model (with an inner layer of fully coagulated optical properties, a middle layer of partially coagulated properties and an outer region of native properties); for short treatments (4 W, approximately 240 s), better qualitative agreement was seen with a two-region MC model (with an inner layer of fully coagulated properties and outer region of native properties). These differences were attributed to differences in coagulation formation during low- and high-powered heating regimes, respectively. At the end of heating, a three-region coagulation zone was observed for both heating schemes. Quantitatively, final light intensity changes at the end of heating were compared with changes predicted by both two- and three-region MC for the same experimentally measured coagulation size and found to agree within approximately 30% for both models. The developed MC model helps lend insight into the nature of thermal coagulation events occurring for low and high power LITT irradiation schemes.