Digital Follow-Up and the Perspective of Patient-Centered Care in Oncology: What's the PROblem?

There is accumulating evidence from randomized trials suggesting that digital patient-centered care allows a more reliable detection of tumour-related symptoms and adverse events - with a direct impact on overall survival. Consequently, a variety of unsynchronized approaches were kicked off to (electronically) measure patient-reported outcomes (PROs). Despite increasing evidence that PRO data are highly relevant for patient care, the data generated in these initial projects lack standardized processing pathways in order to impact clinical routine; therefore, potential future routine PRO assessments require adequate analysis, storage and processing to allow a robust, reproducible and reliable incorporation into routine clinical decision-making. Here, we discuss relevant challenges of digital follow-up that need to be tackled to render PRO data as relevant to physicians as laboratory or biomarker data.

Automatically gated image-guided breath-hold IMRT is a fast, precise, and dosimetrically robust treatment for lung cancer patients.

BACKGROUND: High-dose radiotherapy of lung cancer is challenging. Tumors may move by up to 2 cm in craniocaudal and anteroposterior directions as a function of breathing cycle. Tumor displacement increases with treatment time, which consequentially increases the treatment uncertainty. OBJECTIVE: This study analyzed whether automatically gated cone-beam-CT (CBCT)-controlled intensity modulated fast deep inspiration breath hold (DIBH) stereotactic body radiation therapy (SBRT) in flattening filter free (FFF) technique and normofractionated lung DIBH intensity-modulated radiotherapy (IMRT)/volumetric-modulated arc therapy (VMAT) treatments delivered with a flattening filter can be applied with sufficient accuracy within a clinically acceptable timeslot. MATERIALS AND METHODS: Plans of 34 patients with lung tumors were analyzed. Of these patients, 17 received computer-controlled fast DIBH SBRT with a dose of 60 Gy (5 fractions of 12 Gy or 12 fractions of 5 Gy) in an FFF VMAT technique (FFF-SBRT) every other day and 17 received conventional VMAT with a flattening filter (conv-VMAT) and 2-Gy daily fractional doses (cumulative dose 50-70 Gy). RESULTS: FFF-SBRT plans required more monitor units (MU) than conv-VMAT plans (2956.6 ± 885.3 MU for 12 Gy/fraction and 1148.7 ± 289.2 MU for 5 Gy/fraction vs. 608.4 ± 157.5 MU for 2 Gy/fraction). Total treatment and net beam-on times were shorter for FFF-SBRT plans than conv-VMAT plans (268.0 ± 74.4 s vs. 330.2 ± 93.6 s and 85.8 ± 25.3 s vs. 117.2 ± 29.6 s, respectively). Total slot time was 13.0 min for FFF-SBRT and 14.0 min for conv-VMAT. All modalities could be delivered accurately despite multiple beam-on/-off cycles and were robust against multiple interruptions. CONCLUSION: Automatically gated CBCT-controlled fast DIBH SBRT in VMAT FFF technique and normofractionated lung DIBH VMAT can be applied with a low number of breath-holds in a short timeslot, with excellent dosimetric accuracy. In clinical routine, these approaches combine optimally reduced lung tissue irradiation with maximal delivery precision for patients with small and larger lung tumors.

MRI morphologic alterations after liver SBRT : Direct dose correlation with intermodal matching.

AIM: CT morphologic and histopathologic alterations have been reported after SBRT. We analyzed the correlation of MRI morphologic alterations with radiation doses to assess the potential for MRI-based dose-effect correlation in healthy liver tissue. PATIENTS AND METHODS: MRI data of 24 patients with liver metastases 7±3 weeks after image-guided SBRT in deep-inspiration breath-hold were retrospectively analyzed. MRI images were intermodally matched to the planning CT and corresponding dose distribution. Absolute doses were converted to EQD2,α/ß =x with α/ß values of 2, 3 for healthy liver tissue, 8 Gy for modelled predamaged liver tissue and 10 Gy for tumor tissue. RESULTS: A central nonenhancing area was observed within the isodose lines of nominally 48.2 ± 15.2 Gy, EQD2Gy/α/ß =10 92.5 ± 27.7 Gy. Contrast-enhancement around the central nonenhancing area was observed within the isodose lines of nominally 46.9 ± 15.3 Gy, EQD2Gy/α/ß =10 90.5 ± 28.3 Gy. Outside the high-dose volume, in the beam path, characteristic sharply defined, nonblurred MRI morphologic alterations were observed that corresponded with the following isodose lines: T1-intensity changes occurred at isodose lines of nominally 21.9 ± 6.7 Gy (EQD2,α/ß =2 42.5 ± 8.7 Gy, EQD2,α/ß =3 38.5 ± 7.6 Gy, EQD2,α/ß =8 30.2 ±6.3 Gy). T2-hyper/hypointensity was observed within isodose lines of nominally 22.4 ± 6.6 Gy (EQD2,α/ß=2 42.7 ± 8.1 Gy, EQD2,α/ß=3 38.7 ± 7 Gy; EQD2,α/ß=8 30.5 ± 5.9 Gy). CONCLUSIONS: Using deformable matching, direct spatial/dosimetric correlation of SBRT-induced changes in liver tissue was possible. In the PTV high-dose region, a central nonenhancing area and peripheral contrast medium accumulation was observed. Beam path doses of 38-42 Gy (EQD2,α/ß =2-3) induce characteristic MRI morphologic alterations.

Impact of flattening-filter-free radiation on the clonogenic survival of astrocytic cell lines.

BACKGROUND AND PURPOSE: Flattening-filter-free (FFF) beams are increasingly used in radiotherapy as delivery times can be substantially reduced. However, the relative biologic effectiveness (RBE) of FFF may be increased relative to conventional flattened (FLAT) beams due to differences in energy spectra. Therefore, we investigated the effects of FFF and FLAT beams on the clonogenic survival of astrocytoma cells. MATERIAL AND METHODS: Three cell lines (U251, U251-MGMT, and U87) were irradiated with 6-MV and 10-MV X-rays from a linear accelerator in FFF- or FLAT-beam modes at dose rates in the range of 0.5-24 Gy/min. The surviving fraction (SF) as function of dose (2-12 Gy) was determined by the colony formation assay and fitted by the linear-quadratic model. For both beams (FFF or FLAT), the cells were pelleted in conical 15-ml centrifuge tubes and irradiated at 2-cm depth in a 1 × 1-cm(2) area on the central axis of a 30 × 30-cm(2) field. Dosimetry was performed with a 0.3-cm(3) rigid ionization chamber. RBE was determined for FFF versus FLAT irradiation. RESULTS: The RBE of FFF at 7.3-11.3 Gy was 1.027 ± 0.013 and 1.063 ± 0.018 relative to FLAT beams for 6- and 10-MV beams, respectively, and was only significantly higher than 1 for 10 MV. Significantly increased survival rates were seen for lower dose rates (0.5 Gy/min FLAT vs. 5 Gy/min FLAT) at higher doses (11.9 Gy), while no differences were seen at dose rates ≥ 1.4 Gy/min (1.4 Gy/min FFF vs. 14 Gy/min FFF and 2.4 Gy/min FFF vs. 24 Gy/min FFF). CONCLUSIONS: FFF beams showed only a slightly increased RBE relative to FLAT beams in this experimental set-up, which is unlikely to result in clinically relevant differences in outcome.

A novel lateral disequilibrium inclusive (LDI) pencil-beam based dose calculation algorithm: evaluation in inhomogeneous phantoms and comparison with Monte Carlo calculations.

PURPOSE: Pencil-beam (PB) based dose calculation for treatment planning is limited by inaccuracies in regions of tissue inhomogeneities, particularly in situations with lateral electron disequilibrium as is present at tissue/lung interfaces. To overcome these limitations, a new "lateral disequilibrium inclusive" (LDI) PB based calculation algorithm was introduced. In this study, the authors evaluated the accuracy of the new model by film and ionization chamber measurements and Monte Carlo simulations. METHODS: To validate the performance of the new LDI algorithm implemented in Corvus 09, eight test plans were generated on inhomogeneous thorax and pelvis phantoms. In addition, three plans were calculated with a simple effective path length (EPL) algorithm on the inhomogeneous thorax phantom. To simulate homogeneous tissues, four test plans were evaluated in homogeneous phantoms (homogeneous dose calculation). RESULTS: The mean pixel pass rates and standard deviations of the gamma 4%/4 mm test for the film measurements were (96 +/- 3)% for the plans calculated with LDI, (70 +/- 5)% for the plans calculated with EPL, and (99 +/- 1)% for the homogeneous plans. Ionization chamber measurements and Monte Carlo simulations confirmed the high accuracy of the new algorithm (dose deviations < or = 4%; gamma 3%/3 mm > or = 96%). CONCLUSIONS: LDI represents an accurate and fast dose calculation algorithm for treatment planning.

Cone Beam CT-Based Daily Adaptive Planning or Defined-Filling Protocol for Neoadjuvant Gastric Cancer Radiation Therapy: A Comparison.

PURPOSE: This study aimed to investigate, in the setting of neoadjuvant gastric irradiation with integrated boost, whether cone beam computed tomography (CBCT)-based adaptive radiation therapy compared with a defined-filling protocol would be beneficial in terms of feasibility and achieving daily reproducible dose volume indexes of the planning target volume (PTV) and organs at risk (OARs) and workflow. METHODS AND MATERIALS: Planning computed tomography (PCT) and 25 CBCT scans of a previously treated patient were used, and neoadjuvant therapy of gastric carcinoma was simulated offline. PTVs and OARs were defined per the TOPGEAR protocol (PTV: 45 Gy/1.8 Gy), and an integrated boost (gross tumor volume [GTV]: 50.4 Gy/2.016 Gy) was added. The patient followed a filling regimen consisting of 12-hour fasting followed by 200 mL of water intake (2 glasses of water) immediately before irradiation. OARs and PTVs were newly contoured on each CBCT. Nonrigid registration of PCT and CBCT scans was performed. Nonadapted plans were recalculated on each CBCT (R-CBCT). Furthermore, an adapted plan was created for the new anatomy (A-CBCT). Dose parameters and comparison of R-CBCT and A-CBCT for the kidneys, liver, and heart were analyzed using a paired t test. RESULTS: A total of 200 plans for R-CBCT and A-CBCT were obtained. Mean gastric volumes were 277.32 cm3 (±54.40 cm3) in CBCT scans and 519.2 cm3 in PCT. Mean doses to the PTV did not differ meaningfully within the CBCT scans, with an average of 1.54%. The D95 improved in GTV coverage by 5.26% compared with the R-CBCT plan. Mean heart, liver, and right kidney doses were reduced with the A-CBCT plan by 35.74%, 10.71% and 29.47%, respectively. The R- and A-CBCT comparison for GTV and OARs was significantly different in all cases (P < .0001). CONCLUSIONS: Adaptive radiation therapy through deformable registration represents an important tool in neoadjuvant gastric irradiation, encompassing daily variability and organ motion, compared with the defined-filling protocol while improving OAR sparing.

Interaction between CIEDs and modern radiotherapy techniques: Flattening filter free-VMAT, dose-rate effects, scatter radiation, and neutron-generating energies.

BACKGROUND AND PURPOSE: Providing evidence for radiotherapy (RT)-induced effects on cardiac implantable electric devices (CIEDs) with focus on flattening filter free-volumetric modulated arc therapy (FFF-VMAT) at 6 and 10 MV as well as 3D-conformal radiotherapy (3D-CRT) at 18 MV. MATERIALS AND METHODS: 68 CIEDs (64 implantable cardioverter-defibrillators (ICDs) and 4 cardiac pacemakers (PMs)) were located on the left chest position on a slab phantom and irradiated under telemetrical surveillance either directly, or distant to 3D-CRT or FFF-VMAT, dose-rate 2500 cGy/min, and target dose of 150 Gy. Devices were placed within, close by (2.5 cm and 5 cm), and distant (35 cm) to the radiation field. Scatter radiation (SR) and photon neutrons (PN) were recorded. CIEDs were investigated in following groups: 1a) 18 MV 3D-CRT - 4 ICDs/4 PMs out of radiation field, 1b) 18 MV open field - 4 ICDs/4 PMs within radiation field, 2) 6 MV FFF-VMAT, 15 ICDs in 35 cm distance to VMAT, 3) 10 MV-FFF VMAT, 15 ICDs in 35 cm distance to VMAT, 4) 6 MV FFF-VMAT, 15 ICDs in 2.5 cm distance to VMAT, 5) 10 MV FFF-VMAT, 15 ICDs in 2.5 cm distance to VMAT. RESULTS: No incidents occurred at 6 MV FFF. 10 MV FFF-VMAT and 18 MV 3D-CRT resulted in data loss, reset, and erroneous sensing with inhibition of pacing (leading to inadequate defibrillation) in 8/34 ICDs and 2/4 PMs which were not located within radiation. Direct radiation triggered instantaneous defibrillation in 3/4 ICDs. CONCLUSIONS: 6 MV FFF-VMAT is safe even at high dose-rates of 2500 cGy/min, regardless whether CIEDs are located close (2.5 cm) or distant (35 cm) to the radiation beam. CIEDs should never be placed within radiation and energy should always be limited to 6 MV. At 6 MV, VMAT at high dose-rates can be used to treat tumors, which are located close to CIEDs.

Dynamic IMRT treatments of sinus region tumors: comparison of Monte Carlo calculations with treatment planning system calculations and ion chamber measurements.

Results are presented comparing Monte Carlo (MC) calculations for dynamic IMRT treatments of tumors in the sinus region with Eclipse treatment planning system dose calculations, and ion chamber measurements. The EGS4nrc MC code, BEAMnrc, was commissioned to simulate a Varian 21Ex Linac for both open and IMRT fields. The accuracy of the simulation for IMRT plans was evaluated using a head phantom by comparing MC, Eclipse, TLD results, and ion chamber in solid water phantom measurements. The MC code was then used to simulate dose distributions for five patients who were treated using dynamic IMRT for tumors in the sinus region. The results were compared with absolute and relative dose distributions calculated using Eclipse (pencil beam, modified-Batho inhomogeneity correction). Absolute dose differences were also compared with ion chamber results. Comparison of the doses calculated on the head phantom using MC, compared with Eclipse, ion chamber, and TLD measurements showed differences of -3.9%, -1.4%, and -2.0%, respectively (MC is colder). Relative dose distributions for the patient plans calculated using MC agreed well with those calculated using Eclipse with respect to targets and critical organs, indicating the modified-Batho correction is adequate. Average agreement for mean absolute target doses between MC and Eclipse was -3.0 +/-; 2.3% (1 s.d.). Agreement between ion chamber and Eclipse for these patients was -2.2 +/- 1.9%, compared with 0.2 +/- 2.0% for all head and neck IMRT patients. When Eclipse doses were corrected based on ion chamber results, agreement between MC and Eclipse was -0.7 +/- 2.0%, indicating a small systematic uncertainty in the doses calculated using the treatment planning system for this subset of patients.

Comparison of breast sequential and simultaneous integrated boost using the biologically effective dose volume histogram (BEDVH).

PURPOSE: A method is presented to radiobiologically compare sequential (SEQ) and simultaneously integrated boost (SIB) breast radiotherapy. METHODS: The method is based on identically prescribed biologically effective dose (iso-BED) which was achieved by different prescribed doses due to different fractionation schemes. It is performed by converting the calculated three-dimensional dose distribution to the corresponding BED distribution taking into consideration the different number of fractions for generic α/ß ratios. A cumulative BED volume histogram (BEDVH) is then derived from the BED distribution and is compared for the two delivery schemes. Ten breast cancer patients (4 right-sided and 6 left-sided) were investigated. Two tangential intensity modulated whole breast beams with two other oblique (with different gantry angles) beams for the boost volume were used. The boost and the breast target volumes with either α/ß = 10 or 3 Gy, and ipsi-lateral and contra-lateral lungs, heart, and contra-lateral breast as organs at risk (OARs) with α/ß = 3 Gy were compared. RESULTS: Based on the BEDVH comparisons, the use of SIB reduced the biological breast mean dose by about 3 %, the ipsi-lateral lung and heart by about 10 %, and contra-lateral breast and lung by about 7 %. CONCLUSION: BED based comparisons should always be used in comparing plans that have different fraction sizes. SIB schemes are dosimetrically more advantageous than SEQ in breast target volume and OARs for equal prescribed BEDs for breast and boost.

Deep Inspiration Breath Hold-Based Radiation Therapy: A Clinical Review.

Several recent developments in linear accelerator-based radiation therapy (RT) such as fast multileaf collimators, accelerated intensity modulation paradigms like volumeric modulated arc therapy and flattening filter-free (FFF) high-dose-rate therapy have dramatically shortened the duration of treatment fractions. Deliverable photon dose distributions have approached physical complexity limits as a consequence of precise dose calculation algorithms and online 3-dimensional image guided patient positioning (image guided RT). Simultaneously, beam quality and treatment speed have continuously been improved in particle beam therapy, especially for scanned particle beams. Applying complex treatment plans with steep dose gradients requires strategies to mitigate and compensate for motion effects in general, particularly breathing motion. Intrafractional breathing-related motion results in uncertainties in dose delivery and thus in target coverage. As a consequence, generous margins have been used, which, in turn, increases exposure to organs at risk. Particle therapy, particularly with scanned beams, poses additional problems such as interplay effects and range uncertainties. Among advanced strategies to compensate breathing motion such as beam gating and tracking, deep inspiration breath hold (DIBH) gating is particularly advantageous in several respects, not only for hypofractionated, high single-dose stereotactic body RT of lung, liver, and upper abdominal lesions but also for normofractionated treatment of thoracic tumors such as lung cancer, mediastinal lymphomas, and breast cancer. This review provides an in-depth discussion of the rationale and technical implementation of DIBH gating for hypofractionated and normofractionated RT of intrathoracic and upper abdominal tumors in photon and proton RT.

Comparison of breast simultaneous integrated boost (SIB) radiotherapy techniques.

PURPOSE: To dosimetrically evaluate different breast SIB techniques with respect to target coverage and organs at risk (OARs) doses. METHODS: Four IMRT techniques were compared in 12 patients. Three techniques employ tangential whole breast irradiation with either two coplanar fields (T-2F), or four non-coplanar fields (T-NC), or one Volumetric Modulated Arc Therapy (T-VMAT) for the boost volume. The fourth technique is a fully-modulated VMAT technique (f-VMAT). Dosimetric parameters were compared for the boost and breast target volumes as well as OARs. Delivery efficiency was analysed based on number of monitor units (MUs) and estimated delivery time. RESULTS: T-VMAT and f-VMAT ranked highest with respect to integral assessment of boost and breast treatment quality measures. T-VMAT significantly outperformed f-VMAT with respect to ipsi-lateral lung and left-sided patients' heart volumes ≥ 5 Gy (35 % ± 5 % vs. 52 % ± 6 % and 11 % ± 5 % vs. 22 % ± 6 %, respectively). f-VMAT significantly outperformed T-VMAT with respect to ipsi-lateral lung volume ≥ 20 Gy (13 % ± 2 % vs. 15 % ± 3 %) and heart volume ≥ 30 Gy in left breast cancer (0 % ± 0 % vs. 1 % ± 1 %). T-VMAT and f-VMAT needed 442 ± 58 and 1016 ± 152 MUs, respectively. CONCLUSIONS: The hybrid T-VMAT is considered the technique of choice due to its balance of quality, efficiency and dose to OARs.

Arc therapy for total body irradiation--a robust novel treatment technique for standard treatment rooms.

BACKGROUND AND PURPOSE: We developed a simple and robust total body irradiation (TBI) method for standard treatment rooms that obviates the need for patient translation devices. METHODS AND MATERIALS: Two generic arcs with rectangular segments for a patient thickness of 16 and 20 cm (arc16/arc20) were generated. An analytical fit was performed to determine the weights of the arc segments depending on patient thickness and gantry angle. Stability and absolute dose for both arcs were measured using EBT3 films in a range of solid water slab phantom thicknesses. Additionally ionization chamber measurements were performed every 10 cm at a source surface distance (SSD) of ∼ 200 cm. RESULTS: The measured standard deviation for arc16 is ± 3% with a flatness ⩽ 9.0%. Arc20 had a standard deviation of ± 3% with a flatness ⩽ 7.3% for all measured thicknesses. The theoretical curves proved to be accurate for the prediction of the segment weightings for the two arcs. In vivo measurements for the first 22 clinical patients showed a dose deviation of less than 3%. CONCLUSIONS: Arc therapy is a convenient and stable method for TBI. This cost-effective approach has been introduced clinically, obviating the need for field patches and to physically move the patient.

Development of a Geant4 based Monte Carlo Algorithm to evaluate the MONACO VMAT treatment accuracy.

A method to evaluate the dosimetric accuracy of volumetric modulated arc therapy (VMAT) treatment plans, generated with the MONACO™ (version 3.0) treatment planning system in realistic CT-data with an independent Geant4 based dose calculation algorithm is presented. Therefore a model of an Elekta Synergy linear accelerator treatment head with an MLCi2 multileaf collimator was implemented in Geant4. The time dependent linear accelerator components were modeled by importing either logfiles of an actual plan delivery or a DICOM-RT plan sequence. Absolute dose calibration, depending on a reference measurement, was applied. The MONACO as well as the Geant4 treatment head model was commissioned with lateral profiles and depth dose curves of square fields in water and with film measurements in inhomogeneous phantoms. A VMAT treatment plan for a patient with a thoracic tumor and a VMAT treatment plan of a patient, who received treatment in the thoracic spine region including metallic implants, were used for evaluation. MONACO, as well as Geant4, depth dose curves and lateral profiles of square fields had a mean local gamma (2%, 2mm) tolerance criteria agreement of more than 95% for all fields. Film measurements in inhomogeneous phantoms with a global gamma of (3%, 3mm) showed a pass rate above 95% in all voxels receiving more than 25% of the maximum dose. A dose-volume-histogram comparison of the VMAT patient treatment plans showed mean deviations between Geant4 and MONACO of -0.2% (first patient) and 2.0% (second patient) for the PTVs and (0.5±1.0)% and (1.4±1.1)% for the organs at risk in relation to the prescription dose. The presented method can be used to validate VMAT dose distributions generated by a large number of small segments in regions with high electron density gradients. The MONACO dose distributions showed good agreement with Geant4 and film measurements within the simulation and measurement errors.

GMC: a GPU implementation of a Monte Carlo dose calculation based on Geant4.

We present a GPU implementation called GMC (GPU Monte Carlo) of the low energy (<100 GeV) electromagnetic part of the Geant4 Monte Carlo code using the NVIDIA® CUDA programming interface. The classes for electron and photon interactions as well as a new parallel particle transport engine were implemented. The way a particle is processed is not in a history by history manner but rather by an interaction by interaction method. Every history is divided into steps that are then calculated in parallel by different kernels. The geometry package is currently limited to voxelized geometries. A modified parallel Mersenne twister was used to generate random numbers and a random number repetition method on the GPU was introduced. All phantom results showed a very good agreement between GPU and CPU simulation with gamma indices of >97.5% for a 2%/2 mm gamma criteria. The mean acceleration on one GTX 580 for all cases compared to Geant4 on one CPU core was 4860. The mean number of histories per millisecond on the GPU for all cases was 658 leading to a total simulation time for one intensity-modulated radiation therapy dose distribution of 349 s. In conclusion, Geant4-based Monte Carlo dose calculations were significantly accelerated on the GPU.

A Monte Carlo based source model for dose calculation of endovaginal TARGIT brachytherapy with INTRABEAM and a cylindrical applicator.

PURPOSE: To generate and validate a source model of a miniature X-ray generator (INTRABEAM, Carl Zeiss Surgical, Oberkochen, Germany) for endovaginal TARGeted Intra-operative radioTherapy (TARGIT) brachytherapy a Geant4-based Monte Carlo (MC) tool was developed. The model was used to calculate the accurate relative dose distribution for the source combined with a cylindrical applicator which was developed for endovaginal treatment. METHODS AND MATERIALS: Geometries with given materials of the X-ray source and applicator were implemented in a Geant4-based dose calculation framework. To reduce the calculation time, phase space files for a set of circular electron beam foci and different beam radii were precalculated. Different beam radii had to be considered because the exact electron beam path on the target is not known in advance. To estimate the electron beam radius distribution of the system, a least squares minimization between the EBT film measured relative dose distribution and the simulation was performed. RESULTS: Relative dose distributions were calculated and compared with Gafchromic EBT film measurements to validate the MC method. In a region of interest around the source, the 2%/2mm gamma criterion matched with 98%. Profiles showed excellent agreement between measurement and simulation. The calculation time to simulate an entire treatment was twelve minutes. CONCLUSIONS: The method was able to predict the radius and width of the trajectory where the electrons impact on the target. This enables the complete simulation. The developed method allows calculating relative dose distributions for endovaginal TARGIT brachytherapy matching measured relative dose distributions within clinically acceptable limits.

Patient-specific 3D pretreatment and potential 3D online dose verification of Monte Carlo-calculated IMRT prostate treatment plans.

PURPOSE: Fast and reliable comprehensive quality assurance tools are required to validate the safety and accuracy of complex intensity-modulated radiotherapy (IMRT) plans for prostate treatment. In this study, we evaluated the performance of the COMPASS system for both off-line and potential online procedures for the verification of IMRT treatment plans. METHODS AND MATERIALS: COMPASS has a dedicated beam model and dose engine, it can reconstruct three-dimensional dose distributions on the patient anatomy based on measured fluences using either the MatriXX two-dimensional (2D) array (offline) or a 2D transmission detector (T2D) (online). For benchmarking the COMPASS dose calculation, various dose-volume indices were compared against Monte Carlo-calculated dose distributions for five prostate patient treatment plans. Gamma index evaluation and absolute point dose measurements were also performed in an inhomogeneous pelvis phantom using extended dose range films and ion chamber for five additional treatment plans. RESULTS: MatriXX-based dose reconstruction showed excellent agreement with the ion chamber (<0.5%, except for one treatment plan, which showed 1.5%), film (∼100% pixels passing gamma criteria 3%/3 mm) and mean dose-volume indices (<2%). The T2D based dose reconstruction showed good agreement as well with ion chamber (<2%), film (∼99% pixels passing gamma criteria 3%/3 mm), and mean dose-volume indices (<5.5%). CONCLUSION: The COMPASS system qualifies for routine prostate IMRT pretreatment verification with the MatriXX detector and has the potential for on-line verification of treatment delivery using T2D.