Initial experience and patient tolerance of proton stereotactic body radiotherapy.

Purpose: To review our initial experience with proton-based SBRT to evaluate the planning outcomes and initial patient tolerance of treatment. Patients and methods: From Sep. 2019 to Dec. 2020, 52 patients were treated with proton SBRT to 62 lesions. Fractionation varied by indication and site with a median of 5 fractions and median fractional dose of 8 Gy. Planning outcomes, including plan heterogeneity, conformity, and PTV volume receiving 100% of the prescription dose (PTV V100%) were evaluated. Acute toxicities were prospectively recorded, and patient reported outcomes were assessed prior to and at completion of treatment using the MD Anderson Symptom Inventory (MDASI) and EQ-5D5L visual analogue score (VAS). Results: All treated patients completed their course of proton-based SBRT. The mean conformity index was 1.05 (range 0.51-1.48). R50% values were comparable to ideal photon parameters. PTV V100% was 89.9% on average (40.44% - 99.76%). 5 patients (10%) required plan modification due to setup or tumor changes. No patients developed a new grade 3 or greater toxicity during treatment. Comparing pretreatment to end of treatment timepoints, there was a significant improvement in the mean VAS (65 to 75, p = 0.014), with no significant change in the mean MDASI symptom (1.7, 1.8; p = 0.79) or interference (2.3, 2.4; p = 0.452) scores. Conclusion: Proton-based SBRT can achieve dosimetric goals required by major clinical photon trials. It was well-tolerated with no decrement in patient reported outcomes and a mean 10-point improvement in VAS at the conclusion of SBRT. Further follow-up is necessary for tumor control and late effects analysis.

Variability in commercially available deformable image registration: A multi-institution analysis using virtual head and neck phantoms.

PURPOSE: The purpose of this study was to evaluate the performance of three common deformable image registration (DIR) packages across algorithms and institutions. METHODS AND MATERIALS: The Deformable Image Registration Evaluation Project (DIREP) provides ten virtual phantoms derived from computed tomography (CT) datasets of head-and-neck cancer patients over a single treatment course. Using the DIREP phantoms, DIR results from 35 institutions were submitted using either Velocity, MIM, or Eclipse. Submitted deformation vector fields (DVFs) were compared to ground-truth DVFs to calculate target registration error (TRE) for six regions of interest (ROIs). Statistical analysis was performed to determine the variability between each DIR software package and the variability of users within each algorithm. RESULTS: Overall mean TRE was 2.04 ± 0.35 mm for Velocity, 1.10 ± 0.29 mm for MIM, and 2.35 ± 0.15 mm for Eclipse. The MIM mean TRE was significantly different than both Velocity and Eclipse for all ROIs. Velocity and Eclipse mean TREs were not significantly different except for when evaluating the registration of the cord or mandible. Significant differences between institutions were found for the MIM and Velocity platforms. However, these differences could be explained by variations in Velocity DIR parameters and MIM software versions. CONCLUSIONS: Average TRE was shown to be <3 mm for all three software platforms. However, maximum errors could be larger than 2 cm indicating that care should be exercised when using DIR. While MIM performed statistically better than the other packages, all evaluated algorithms had an average TRE better than the largest voxel dimension. For the phantoms studied here, significant differences between algorithm users were minimal suggesting that the algorithm used may have more impact on DIR accuracy than the particular registration technique employed. A significant difference in TRE was discovered between MIM versions showing that DIR QA should be performed after software upgrades as recommended by TG-132.

Multiple Computed Tomography Robust Optimization to Account for Random Anatomic Density Variations During Intensity Modulated Proton Therapy.

PURPOSE: To propose a method of optimizing intensity modulated proton therapy (IMPT) plans robust against dosimetric degradation caused by random anatomic variations during treatment. METHODS AND MATERIALS: Fifteen patients with prostate cancer treated with IMPT to the pelvic targets were nonrandomly selected. On the repeated quality assurance computed tomography (QACTs) for some patients, bowel density changes were observed and caused dose degradation because the treated plans were not robustly optimized (non-RO). To mitigate this effect, we developed a robust planning method based on 3 CT images, including the native planning CT and its 2 copies, with the bowel structures being assigned to air and tissue, respectively. The RO settings included 5 mm setup uncertainty and 3.5% range uncertainty on 3 CTs. This method is called pseudomultiple-CT RO (pMCT-RO). Plans were also generated using RO on the native CT only, with the same setup and range uncertainties. This method is referred to as single-CT RO (SCT-RO). Doses on the QACTs and the nominal planning CT were compared for the 3 planning methods. RESULTS: All 3 plan methods provided sufficient clinical target volumes D95% and V95% on the QACTs. For pMCT-RO plans, the normal tissue Dmax on QACTs of all patients was at maximum 109.1%, compared with 144.4% and 116.9% for non-RO and SCT-RO plans, respectively. On the nominal plans, the rectum and bladder doses were similar among all 3 plans; however, the volume of normal tissue (excluding the rectum and bladder) receiving the prescription dose or higher is substantially reduced in either pMCT-RO plans or SCT-RO plans, compared with the non-RO plans. CONCLUSIONS: We developed a robust optimization method to further mitigate undesired dose heterogeneity caused by random anatomic changes in pelvic IMPT treatment. This method does not require additional patient CT scans. The pMCT-RO planning method has been implemented clinically since 2017 in our center.

Technical Note: Plan-delivery-time constrained inverse optimization method with minimum-MU-per-energy-layer (MMPEL) for efficient pencil beam scanning proton therapy.

PURPOSE: This work aims to reduce dose delivery time of pencil beam scanning (PBS) proton plans, which is the dominant factor of total plan delivery time. A proton PBS system, such as Varian ProBeam proton therapy system, can be equipped with the proton dose rate that is linearly proportional to the minimum monitor unit (MU) (i.e., number of protons) of PBS spots before saturation. Thus dose delivery time can be potentially reduced by increasing the MU threshold. However, commercially available treatment planning systems and current methods only allow for a single MU threshold globally for all PBS spots (i.e., all energy layers), and consequently the room to increase this minimum-MU for reducing dose delivery time is very limited since higher minimum-MU can greatly degrade treatment plan quality. METHODS: Two major innovations of this work are the proposal of using variable MU thresholds locally adaptive to each energy layer, that is, minimum-MU-per-energy-layer (MMPEL), for reducing dose delivery time, and the joint optimization of plan delivery time and plan quality. Minimum-MU-per-energy-layer is formulated as a constrained optimization problem with objectives of dose-volume-histogram based planning constraints and plan delivery time, and minimum-MU constraints per energy layer for deliverable PBS spots. Minimum-MU-per-energy-layer is solved by iterative convex relaxations via alternating direction method of multipliers. RESULTS: Representative prostate, lung, brain, head-and-neck, breast, liver and pancreas cases were used to validate MMPEL. Minimum-MU-per-energy-layer reduced dose delivery time to 53%, 67%, 67%, 53%, 54%, 32%, and 14% respectively while maintaining a similar plan quality. Accepting a slightly degraded plan quality that still met all physician planning constraints, the treatment time could be further reduced to 26%, 35%, 41%, 34%, 32%, 16%, and 11% respectively, or in another word MMPEL accelerated the PBS plan delivery by 2-10 fold. CONCLUSIONS: A new proton PBS treatment planning method MMPEL with variable energy-adaptive MU thresholds is developed to optimize dose delivery time jointly with plan quality. The preliminary results suggest that MMPEL could substantially reduce dose delivery time.

Characterization of a new scintillation imaging system for proton pencil beam dose rate measurements.

The goal of this work was to create a technique that could measure all possible spatial and temporal delivery rates used in pencil-beam scanning (PBS) proton therapy. The proposed system used a fast scintillation screen for full-field imaging to resolve temporal and spatial patterns as it was delivered. A fast intensified CMOS camera used continuous mode with 10 ms temporal frame rate and 1 × 1 mm2 spatial resolution, imaging a scintillation screen during clinical proton PBS delivery. PBS plans with varying dose, dose rate, energy, field size, and spot-spacing were generated, delivered and imaged. The captured images were post processed to provide dose and dose rate values after background subtraction, perspective transformation, uniformity correction for the camera and the scintillation screen, and calibration into dose. The linearity in scintillation response with respect to varying dose rate, dose, and field size was within 2%. The quenching corrected response with varying energy was also within 2%. Large spatio-temporal variations in dose rate were observed, even for plans delivered with similar dose distributions. Dose and dose rate histograms and maximum dose rate maps were generated for quantitative evaluations. With the fastest PBS delivery on a clinical system, dose rates up to 26.0 Gy s-1 were resolved. The scintillation imaging technique was able to quantify proton PBS dose rate profiles with spot weight as low as 2 MU, with spot-spacing of 2.5 mm, having a 1 × 1 mm2 spatial resolution. These dose rate temporal profiles, spatial maps, and cumulative dose rate histograms provide useful metrics for the potential evaluation and optimization of dose rate in treatment plans.

A planning study of focal dose escalations to multiparametric MRI-defined dominant intraprostatic lesions in prostate proton radiation therapy.

OBJECTIVES: The purpose of this study is to investigate the dosimetric effect and clinical impact of delivering a focal radiotherapy boost dose to multiparametric MRI (mp-MRI)-defined dominant intraprostatic lesions (DILs) in prostate cancer using proton therapy. METHODS: We retrospectively investigated 36 patients with pre-treatment mp-MRI and CT images who were treated using pencil beam scanning (PBS) proton radiation therapy to the whole prostate. DILs were contoured on co-registered mp-MRIs. Simultaneous integrated boost (SIB) plans using intensity-modulated proton therapy (IMPT) were created based on conventional whole-prostate-irradiation for each patient and optimized with additional DIL coverage goals and urethral constraints. DIL dose coverage and organ-at-risk (OAR) sparing were compared between conventional and SIB plans. Tumor control probability (TCP) and normal tissue complication probability (NTCP) were estimated to evaluate the clinical impact of the SIB plans. RESULTS: Optimized SIB plans significantly escalated the dose to DILs while meeting OAR constraints. SIB plans were able to achieve 125, 150 and 175% of prescription dose coverage in 74, 54 and 17% of 36 patients, respectively. This was modeled to result in an increase in DIL TCP by 7.3-13.3% depending on α/ß and DIL risk level. CONCLUSION: The proposed mp-MRI-guided DIL boost using proton radiation therapy is feasible without violating OAR constraints and demonstrates a potential clinical benefit by improving DIL TCP. This retrospective study suggested the use of IMPT-based DIL SIB may represent a strategy to improve tumor control. ADVANCES IN KNOWLEDGE: This study investigated the planning of mp-MRI-guided DIL boost in prostate proton radiation therapy and estimated its clinical impact with respect to TCP and NTCP.

Minimum-MU and sparse-energy-layer (MMSEL) constrained inverse optimization method for efficiently deliverable PBS plans.

The deliverability of proton pencil beam scanning (PBS) plans is subject to the minimum monitor-unit (MU) constraint, while the delivery efficiency depends on the number of proton energy layers. This work develops an inverse optimization method for generating efficiently deliverable PBS plans. The proposed minimum-MU and sparse-energy-layer (MMSEL) constrained inverse optimization method utilizes iterative convex relaxations to handle the nonconvexity from minimum-MU constraint and dose-volume constraints, and regularizes group sparsity of proton spots to minimize the number of energy layers. The tradeoff between plan quality and delivery efficiency (in terms of the number of used energy layers) is controlled by the objective weighting of group sparsity regularization. MMSEL consists of two steps: first minimize for appropriate energy layers, and then with selected energy layers solve for the deliverable PBS plan. The solution algorithm for MMSEL is developed using alternating direction method of multipliers (ADMM). Range and setup uncertainties are modelled by robust optimization. MMSEL was validated using representative prostate, lung, and head-and-neck (HN) cases. The minimum-MU constraint was strictly enforced for all cases, so that all plans were deliverable. The number of energy layers was reduced by MMSEL to 78%, 76%, and 61% for prostate, lung and HN, respectively, while the similar plan quality was achieved. The number of energy layers was reduced by MMSEL to 54%, 57%, and 37% for prostate, lung and HN, respectively, while the plan quality was comprised and acceptable. MMSEL is proposed to strictly enforce minimum-MU constraint and minimize the number of energy layers during inverse optimization for efficiently deliverable PBS plans. In particular, the preliminary results suggest MMSEL potentially enables 25% to 40% reduction of energy layers while maintaining the similar plan quality.

Benchmarking of five commercial deformable image registration algorithms for head and neck patients.

Benchmarking is a process in which standardized tests are used to assess system performance. The data produced in the process are important for comparative purposes, particularly when considering the implementation and quality assurance of DIR algorithms. In this work, five commercial DIR algorithms (MIM, Velocity, RayStation, Pinnacle, and Eclipse) were benchmarked using a set of 10 virtual phantoms. The phantoms were previously developed based on CT data collected from real head and neck patients. Each phantom includes a start of treatment CT dataset, an end of treatment CT dataset, and the ground-truth deformation vector field (DVF) which links them together. These virtual phantoms were imported into the commercial systems and registered through a deformable process. The resulting DVFs were compared to the ground-truth DVF to determine the target registration error (TRE) at every voxel within the image set. Real treatment plans were also recalculated on each end of treatment CT dataset and the dose transferred according to both the ground-truth and test DVFs. Dosimetric changes were assessed, and TRE was correlated with changes in the DVH of individual structures. In the first part of the study, results show mean TRE on the order of 0.5 mm to 3 mm for all phan-toms and ROIs. In certain instances, however, misregistrations were encountered which produced mean and max errors up to 6.8 mm and 22 mm, respectively. In the second part of the study, dosimetric error was found to be strongly correlated with TRE in the brainstem, but weakly correlated with TRE in the spinal cord. Several interesting cases were assessed which highlight the interplay between the direction and magnitude of TRE and the dose distribution, including the slope of dosimetric gradients and the distance to critical structures. This information can be used to help clinicians better implement and test their algorithms, and also understand the strengths and weaknesses of a dose adaptive approach.

A margin-based analysis of the dosimetric impact of motion on step-and-shoot IMRT lung plans.

PURPOSE: Intrafraction motion during step-and-shoot (SNS) IMRT is known to affect the target dosimetry by a combination of dose blurring and interplay effects. These effects are typically managed by adding a margin around the target. A quantitative analysis was performed, assessing the relationship between target motion, margin size, and target dosimetry with the goal of introducing new margin recipes. METHODS: A computational algorithm was used to calculate 1,174 motion-encoded dose distributions and DVHs within the patient's CT dataset. Sinusoidal motion tracks were used simulating intrafraction motion for nine lung tumor patients, each with multiple margin sizes. RESULTS: D95% decreased by less than 3% when the maximum target displacement beyond the margin experienced motion less than 5 mm in the superior-inferior direction and 15 mm in the anterior-posterior direction. For target displacements greater than this, D95% decreased rapidly. CONCLUSIONS: Targets moving in excess of 5 mm outside the margin can cause significant changes to the target. D95% decreased by up to 20% with target motion 10 mm outside the margin, with underdosing primarily limited to the target periphery. Multi-fractionated treatments were found to exacerbate target under-coverage. Margins several millimeters smaller than the maximum target displacement provided acceptable motion protection, while also allowing for reduced normal tissue morbidity.

A virtual phantom library for the quantification of deformable image registration uncertainties in patients with cancers of the head and neck.

PURPOSE: Deformable image registration (DIR) is being used increasingly in various clinical applications. However, the underlying uncertainties of DIR are not well-understood and a comprehensive methodology has not been developed for assessing a range of interfraction anatomic changes during head and neck cancer radiotherapy. This study describes the development of a library of clinically relevant virtual phantoms for the purpose of aiding clinicians in the QA of DIR software. These phantoms will also be available to the community for the independent study and comparison of other DIR algorithms and processes. METHODS: Each phantom was derived from a pair of kVCT volumetric image sets. The first images were acquired of head and neck cancer patients prior to the start-of-treatment and the second were acquired near the end-of-treatment. A research algorithm was used to autosegment and deform the start-of-treatment (SOT) images according to a biomechanical model. This algorithm allowed the user to adjust the head position, mandible position, and weight loss in the neck region of the SOT images to resemble the end-of-treatment (EOT) images. A human-guided thin-plate splines algorithm was then used to iteratively apply further deformations to the images with the objective of matching the EOT anatomy as closely as possible. The deformations from each algorithm were combined into a single deformation vector field (DVF) and a simulated end-of-treatment (SEOT) image dataset was generated from that DVF. Artificial noise was added to the SEOT images and these images, along with the original SOT images, created a virtual phantom where the underlying "ground-truth" DVF is known. Images from ten patients were deformed in this fashion to create ten clinically relevant virtual phantoms. The virtual phantoms were evaluated to identify unrealistic DVFs using the normalized cross correlation (NCC) and the determinant of the Jacobian matrix. A commercial deformation algorithm was applied to the virtual phantoms to show how they may be used to generate estimates of DIR uncertainty. RESULTS: The NCC showed that the simulated phantom images had greater similarity to the actual EOT images than the images from which they were derived, supporting the clinical relevance of the synthetic deformation maps. Calculation of the Jacobian of the "ground-truth" DVFs resulted in only positive values. As an example, mean error statistics are presented for all phantoms for the brainstem, cord, mandible, left parotid, and right parotid. CONCLUSIONS: It is essential that DIR algorithms be evaluated using a range of possible clinical scenarios for each treatment site. This work introduces a library of virtual phantoms intended to resemble real cases for interfraction head and neck DIR that may be used to estimate and compare the uncertainty of any DIR algorithm.

Safety considerations for IGRT: Executive summary.

Radiation therapy is an effective cancer treatment that is constantly being transformed by technological innovation. Dedicated devices for fraction-by-fraction imaging and guidance within the treatment room have enabled image guided radiation therapy (IGRT) allowing clinicians to pursue highly conformal dose distributions, higher dose prescriptions, and shorter fractionation schedules. Capitalizing on IGRT-enabled accuracy and precision requires a strong link between IGRT practices and planning target volume (PTV) design. This is clearly central to high quality, safe radiation therapy. Failure to properly apply IGRT methods or to coordinate their use with an appropriate PTV margin can result in a treatment that is 'precisely wrong'. The white paper summarized in this executive summary recommends foundational elements and specific activities to maximize the safety and effectiveness of IGRT.

Quality assurance for image-guided radiation therapy utilizing CT-based technologies: a report of the AAPM TG-179.

PURPOSE: Commercial CT-based image-guided radiotherapy (IGRT) systems allow widespread management of geometric variations in patient setup and internal organ motion. This document provides consensus recommendations for quality assurance protocols that ensure patient safety and patient treatment fidelity for such systems. METHODS: The AAPM TG-179 reviews clinical implementation and quality assurance aspects for commercially available CT-based IGRT, each with their unique capabilities and underlying physics. The systems described are kilovolt and megavolt cone-beam CT, fan-beam MVCT, and CT-on-rails. A summary of the literature describing current clinical usage is also provided. RESULTS: This report proposes a generic quality assurance program for CT-based IGRT systems in an effort to provide a vendor-independent program for clinical users. Published data from long-term, repeated quality control tests form the basis of the proposed test frequencies and tolerances. CONCLUSION: A program for quality control of CT-based image-guidance systems has been produced, with focus on geometry, image quality, image dose, system operation, and safety. Agreement and clarification with respect to reports from the AAPM TG-101, TG-104, TG-142, and TG-148 has been addressed.

The dosimetric effect of intrafraction prostate motion on step-and-shoot intensity-modulated radiation therapy plans: magnitude, correlation with motion parameters, and comparison with helical tomotherapy plans.

PURPOSE: To determine the daily and cumulative dosimetric effects of intrafraction prostate motion on step-and-shoot (SNS) intensity-modulated radiation therapy (IMRT) plans, to evaluate the correlation of dosimetric effect with motion-based metrics, and to compare on a fraction-by-fraction basis the dosimetric effect induced in SNS and helical tomotherapy plans. METHODS AND MATERIALS: Intrafraction prostate motion data from 486 fractions and 15 patients were available. A motion-encoded dose calculation technique was used to determine the variation of the clinical target volume (CTV) D(95%) values with respect to the static plan for SNS plans. The motion data were analyzed separately, and the correlation coefficients between various motion-based metrics and the dosimetric effect were determined. The dosimetric impact was compared with that incurred during another IMRT technique to assess correlation across different delivery techniques. RESULTS: The mean (±1 standard deviation [SD]) change in D(95%) in the CTV over all 486 fractions was 0.2 ± 0.5%. After the delivery of five and 12 fractions, the mean (±1 SD) changes over the 15 patients in CTV D(95%) were 0.0 ± 0.2% and 0.1 ± 0.2%, respectively. The correlation coefficients between the CTV D(95%) changes and the evaluated motion metrics were, in general, poor and ranged from r = -0.2 to r = -0.39. Dosimetric effects introduced by identical motion in SNS and helical tomotherapy IMRT techniques were poorly correlated with a correlation coefficient of r = 0.32 for the CTV. CONCLUSIONS: The dosimetric impact of intrafraction prostate motion on the CTV is, in general, small. In only 4% of all fractions did the dosimetric consequence exceed 1% in the CTV. As expected, the cumulative effect was further reduced with fractionation. The poor correlations between the calculated motion parameters and the subsequent dosimetric effect implies that motion-based thresholds are of limited value in predicting the dosimetric impact of intrafraction motion. The dosimetric effects between the two evaluated delivery techniques were poorly correlated.

An endorectal balloon reduces intrafraction prostate motion during radiotherapy.

PURPOSE: To investigate the effect of endorectal balloons (ERBs) on intrafraction and interfraction prostate motion during radiotherapy. METHODS AND MATERIALS: Thirty patients were treated with intensity-modulated radiotherapy, to a total dose of 80 Gy in 40 fractions. In 15 patients, a daily-inserted air-filled ERB was applied. Prostate motion was tracked, in real-time, using an electromagnetic tracking system. Interfraction displacements, measured before each treatment, were quantified by calculating the systematic and random deviations of the center of mass of the implanted transponders. Intrafraction motion was analyzed in timeframes of 150 s, and displacements >1 mm, >3 mm, >5 mm, and >7 mm were determined in the anteroposterior, left-right, and superoinferior direction, and for the three-dimensional (3D) vector. Manual table corrections, made during treatment sessions, were retrospectively undone. RESULTS: A total of 576 and 567 tracks have been analyzed in the no-ERB group and ERB group, respectively. Interfraction variation was not significantly different between both groups. After 600 s, 95% and 98% of the treatments were completed in the respective groups. Significantly fewer table corrections were performed during treatment fractions with ERB: 88 vs. 207 (p = 0.02). Intrafraction motion was significantly reduced with ERB. During the first 150 s, only negligible deviations were observed, but after 150 s, intrafraction deviations increased with time. This resulted in cumulative percentages of 3D-vector deviations >1 mm, >3 mm, >5 mm, and >7 mm that were 57.7%, 7.0%, 0.7%, and 0.3% in the ERB-group vs. 70.2%, 18.1%, 4.6%, and 1.4% in the no-ERB group after 600 s. The largest reductions in the ERB group were observed in the AP direction. These data suggest that a 5 mm CTV-to-PTV margin is sufficient to correct for intrafraction prostate movements when using an ERB. CONCLUSIONS: ERB significantly reduces intrafraction prostate motion, but not interfraction variation, and may in particular be beneficial for treatment sessions longer than 150 s.

Analyzing the impact of intrafraction motion: correlation of different dose metrics with changes in target D95%.

PURPOSE: A number of techniques are available to determine the dosimetric impact of intrafraction motion during intensity modulated radiation therapy (IMRT). Motion-induced dose perturbations can be determined both computationally and experimentally using a number of different dosimetric metrics. However, these measures may lead to different conclusions regarding the clinical impact of motion. This study compares the analysis of identical dose perturbations using different dosimetric metrics. Calculated changes in target D95% are used as a reference. METHODS: A total of 3768 motion-encoded dose distributions were calculated for nine lung tumor patients. The motion-encoded dose distributions were compared to static dose distributions using three dosimetric metrics: 2D gamma, 3D gamma, and histogram analysis. Each of these metrics was used to analyze dose perturbations both globally and within the target structure. Furthermore, the failing voxels were analyzed separately according to failure mode, i.e., under vs. over-dosed voxels. Metrics were evaluated based on their agreement with changes in target D95%. Evaluations included the metrics' maximum average sensitivity and specificity (MASS) in detecting unacceptable deliveries, a coefficient correlated to ranking (tau), and the linear correlation coefficient, r. RESULTS: Of the evaluated metrics, the histogram metric restricted to the under-dosed voxels within the target agreed best with changes in target D95%. This metric achieved a MASS of 0.93, a tau of 0.69, and an r-value of 0.85. In comparison, the unrestricted 2D gamma metric achieved MASS = 0.77, tau = 0.40, and r = 0.67. Restricting the 2D gamma test both geographically and in failure mode increased the MASS to 0.85, tau to 0.70, and the r-value to 0.80. CONCLUSIONS: This study suggests that any clinical decisions based solely on an unrestricted 2D gamma metric are suboptimal. A geographic and failure mode restriction can improve results. The remaining uncertainties with non-DVH (dose volume histogram) based metrics should be kept in mind when they are used to evaluate the dosimetric impact of target motion.

An evaluation of intrafraction motion of the prostate in the prone and supine positions using electromagnetic tracking.

PURPOSE: To evaluate differences in target motion during prostate irradiation in the prone versus supine position using electromagnetic tracking to measure prostate mobility. MATERIALS/METHODS: Twenty patients received prostate radiotherapy in the supine position utilizing the Calypso Localization System® for prostate positioning and monitoring. For each patient, 10 treatment fractions were followed by a session in which the patient was repositioned prone, and prostate mobility was tracked. The fraction of time that the prostate was displaced by >3, 5, 7, and 10mm was calculated for each patient, for both positions (400 tracking sessions). RESULTS: Clear patterns of respiratory motion were seen in the prone tracks due to the influence of increased abdominal motion. Averaged over all patients, the prostate was displaced >3 and 5mm for 37.8% and 10.1% of the total tracking time in the prone position, respectively. In the supine position, the prostate was displaced >3 and 5mm for 12.6% and 2.9%, respectively. With both patient setups, inferior and posterior drifts of the prostate position were observed. Averaged over all prone tracking sessions, the prostate was displaced >3mm in the posterior and inferior directions for 11.7% and 9.5% of the total time, respectively. CONCLUSIONS: With real-time tracking of the prostate, it is possible to study the effects of different setup positions on the prostate mobility. The percentage of time the prostate moved >3 and 5mm was increased by a factor of three in the prone versus supine position. For larger displacements (>7 mm) no difference in prostate mobility was observed between prone and supine positions. To reduce rectal toxicity, radiotherapy in the prone position may be a suitable alternative provided respiratory motion is accounted for during treatment. Acute and late toxicity results remain to be evaluated for both patient positions.

QA for helical tomotherapy: report of the AAPM Task Group 148.

Helical tomotherapy is a relatively new modality with integrated treatment planning and delivery hardware for radiation therapy treatments. In view of the uniqueness of the hardware design of the helical tomotherapy unit and its implications in routine quality assurance, the Therapy Physics Committee of the American Association of Physicists in Medicine commissioned Task Group 148 to review this modality and make recommendations for quality assurance related methodologies. The specific objectives of this Task Group are: (a) To discuss quality assurance techniques, frequencies, and tolerances and (b) discuss dosimetric verification techniques applicable to this unit. This report summarizes the findings of the Task Group and aims to provide the practicing clinical medical physicist with the insight into the technology that is necessary to establish an independent and comprehensive quality assurance program for a helical tomotherapy unit. The emphasis of the report is to describe the rationale for the proposed QA program and to provide example tests that can be performed, drawing from the collective experience of the task group members and the published literature. It is expected that as technology continues to evolve, so will the test procedures that may be used in the future to perform comprehensive quality assurance for helical tomotherapy units.

A computational method for estimating the dosimetric effect of intra-fraction motion on step-and-shoot IMRT and compensator plans.

Intra-fraction organ motion during intensity-modulated radiation therapy (IMRT) treatment can cause differences between the planned and the delivered dose distribution. To investigate the extent of these dosimetric changes, a computational model was developed and validated. The computational method allows for calculation of the rigid motion perturbed three-dimensional dose distribution in the CT volume and therefore a dose volume histogram-based assessment of the dosimetric impact of intra-fraction motion on a rigidly moving body. The method was developed and validated for both step-and-shoot IMRT and solid compensator IMRT treatment plans. For each segment (or beam), fluence maps were exported from the treatment planning system. Fluence maps were shifted according to the target position deduced from a motion track. These shifted, motion-encoded fluence maps were then re-imported into the treatment planning system and were used to calculate the motion-encoded dose distribution. To validate the accuracy of the motion-encoded dose distribution the treatment plan was delivered to a moving cylindrical phantom using a programmed four-dimensional motion phantom. Extended dose response (EDR-2) film was used to measure a planar dose distribution for comparison with the calculated motion-encoded distribution using a gamma index analysis (3% dose difference, 3 mm distance-to-agreement). A series of motion tracks incorporating both inter-beam step-function shifts and continuous sinusoidal motion were tested. The method was shown to accurately predict the film's dose distribution for all of the tested motion tracks, both for the step-and-shoot IMRT and compensator plans. The average gamma analysis pass rate for the measured dose distribution with respect to the calculated motion-encoded distribution was 98.3 +/- 0.7%. For static delivery the average film-to-calculation pass rate was 98.7 +/- 0.2%. In summary, a computational technique has been developed to calculate the dosimetric effect of intra-fraction motion. This technique has the potential to evaluate a given plan's sensitivity to anticipated organ motion. With knowledge of the organ's motion it can also be used as a tool to assess the impact of measured intra-fraction motion after dose delivery.

A comparison of soft-tissue implanted markers and bony anatomy alignments for image-guided treatments of head-and-neck cancers.

PURPOSE: To compare the geometric alignments of soft-tissue implanted markers to the traditional bony-based alignments in head-and-neck cancers, on the basis of daily image guidance. Dosimetric impact of the two alignment techniques on target coverage is presented. METHODS AND MATERIALS: A total of 330 retrospective alignments (5 patients) were performed on daily megavoltage computed tomography (MVCT) image sets using both alignment techniques. Intermarker distances were tracked for all fractions to assess marker interfractional stability. Using a deformable image registration algorithm, target cumulative doses were calculated according to generated shifts on daily MVCT image sets. Target D95 was used as a dosimetric endpoint to evaluate each alignment technique. RESULTS: Intermarker distances overall were stable, with a standard deviation of <1.5 mm for all fractions and no observed temporal trends. Differences in shift magnitudes between both alignment techniques were found to be statistically significant, with a maximum observed difference of 8 mm in a given direction. Evaluation of technique-specific dose coverage based on D95 of target clinical target volume and planning target volume shows small differences (within +/-5%) compared with the kilovoltage CT plan. CONCLUSION: The use of daily MVCT imaging demonstrates that implanted markers in oral tongue and soft-palate cancers are stable localization surrogates. Alignments based on implanted markers generate shifts comparable overall to the traditional bony-based alignment, with no observed systematic difference in magnitude or direction. The cumulative dosimetric impact on target clinical target volume and planning target volume coverage was found to be similar, despite large observed differences in daily alignment shifts between the two techniques.

Validation of a computational method for assessing the impact of intra-fraction motion on helical tomotherapy plans.

In this work, a method for direct incorporation of patient motion into tomotherapy dose calculations is developed and validated. This computational method accounts for all treatment dynamics and can incorporate random as well as cyclical motion data. Hence, interplay effects between treatment dynamics and patient motion are taken into account during dose calculation. This allows for a realistic assessment of intra-fraction motion on the dose distribution. The specific approach entails modifying the position and velocity events in the tomotherapy delivery plan to accommodate any known motion. The computational method is verified through phantom and film measurements. Here, measured prostate motion and simulated respiratory motion tracks were incorporated in the dose calculation. The calculated motion-encoded dose profiles showed excellent agreement with the measurements. Gamma analysis using 3 mm and 3% tolerance criteria showed over 97% and 96% average of points passing for the prostate and breathing motion tracks, respectively. The profile and gamma analysis results validate the accuracy of this method for incorporating intra-fraction motion into the dose calculation engine for assessment of dosimetric effects on helical tomotherapy dose deliveries.