[Decomposing a Beam Profile Constancy into Energy and Symmetry Components and Its Evaluation Using an Ionization Chamber Array].

PURPOSE: We have proposed a new formulation that can decompose the profile constancy defined in the AAPM TG 142 into energy and symmetry constancies by measuring beam profiles using an IC profiler (ICP). METHODS: Measured profiles were laterally inverted to calculate averaged profiles in the lateral direction, thereby cancelling asymmetric components. Validation tests were performed by comparing the proposed calculation and measured results under various experimental conditions. Calculated profile constancies were further compared to decomposed energy and symmetry constancies. RESULTS: The energy constancy calculated from the averaged beam profile by lateral inversion and the measured PDD(10) constancy agreed within 0.1% when only symmetries were varied. The calculated energy and symmetry constancies, and the measured results agreed within 0.2% when both energies and symmetries were varied. CONCLUSION: The linac beam profile constancy has been decomposed into energy and symmetry terms. The proposed formulation has been validated by comparing the calculations and the direct measurements using the ICP. We have shown that QA/QC for profile constancy tests can be efficiently performed using the proposed formulation.

Practical guidelines of online MR-guided adaptive radiotherapy.

The first magnetic resonance (MR)-guided radiotherapy system in Japan was installed in May 2017. Implementation of online MR-guided adaptive radiotherapy (MRgART) began in February 2018. Online MRgART offers greater treatment accuracy owing to the high soft-tissue contrast in MR-images (MRI), compared to that in X-ray imaging. The Japanese Society for Magnetic Resonance in Medicine (JSMRM), Japan Society of Medical Physics (JSMP), Japan Radiological Society (JRS), Japanese Society of Radiological Technology (JSRT), and Japanese Society for Radiation Oncology (JASTRO) jointly established the comprehensive practical guidelines for online MRgART. These guidelines propose the essential requirements for clinical implementation of online MRgART with respect to equipment, personnel, institutional environment, practice guidance, and quality assurance/quality control (QA/QC). The minimum requirements for related equipment and QA/QC tools, recommendations for safe operation of MRI system, and the implementation system are described. The accuracy of monitor chamber and detector in dose measurements should be confirmed because of the presence of magnetic field. The ionization chamber should be MR-compatible. Non-MR-compatible devices should be used in an area that is not affected by the static magnetic field (outside the five Gauss line), and their operation should be checked to ensure that they do not affect the MR image quality. Dose verification should be performed using an independent dose verification system that has been confirmed to be reliable through commissioning. This guideline proposes the checklists to ensure the safety of online MRgART. Successful clinical implementation of online MRgART requires close collaboration between physician, radiological technologist, nurse, and medical physicist.

Questionnaire survey on treatment planning techniques for lung stereotactic body radiotherapy in Japan.

This study aimed to obtain details regarding treatment planning techniques for lung stereotactic body radiation therapy (SBRT) employed at each institution in Japan by using a questionnaire survey. An Internet questionnaire survey on SBRT procedures performed in 2016 was conducted by the QA/QC committee of the Japan Society of Medical Physics from April to June 2017. The questionnaire assessed two aspects: the environment for SBRT at each institution and the treatment planning techniques with and without respiratory motion management techniques (RMMT). Of the 309 evaluated responses, 218 institutions had performed SBRT. A total of 186 institutions performed SBRT without RMMT and 139 institutions performed SBRT with RMMT. When respiratory motion was ≥10 mm, 69 institutions applied RMMT. The leading RMMT were breath holding (77 institutions), respiratory gating (49 institutions) and real-time tumor tracking (11 institutions). The most frequently used irradiation technique was 3D conformal radiotherapy, which was used in 145 institutions without RMMT and 119 institutions with RMMT. Computed tomography (CT) images acquired under free breathing were mostly used for dose calculation for patients treated without RMMT. The usage ratio of IMRT/VMAT to SBRT is low in Japan, compared to elsewhere in the world (<20% vs ≥70%). Among the available dose calculation algorithms, superposition convolution was the most frequently used regardless of RMMT; however, 2% of institutions have not yet made heterogeneity corrections. In the prescription setting, about half of the institutions applied point prescriptions. The survey results revealed the most frequently used conditions, which may facilitate standardization of treatment techniques in lung SBRT.

Definitive re-irradiation using intensity-modulated radiation therapy in cancers of the head and neck, focusing on rare tumors.

PURPOSE: To analyze the outcomes following re-irradiation for local recurrence of rare head and neck tumors. MATERIAL AND METHODS: We retrospectively analyzed 11 patients who had received intensity-modulated radiation therapy (IMRT) for recurrent tumors in the head and neck except for laryngopharynx. RESULTS: Primary tumor sites included the maxillary sinus, nasal cavity, and external ear canal in six, three, and two patients, respectively. The median follow-up times were 13 (range, 3-54) months. The median survival time was 17 months with 1- and 2-year survival rates of 63.64 and 39.77%, respectively. Among 11 patients, five experienced local failure in the follow-up period. The 1- and 2-year local control rates were 58 and 47%, respectively. Patients who had received a radiation dose of ≥3 Gy per fraction showed significantly better local control than those receiving less (p = .0419). One patient experienced Grade 3 facial pain as acute toxicity. Late toxicities included radiographic findings of partial central nervous system necrosis in three patients and Grade 3 osteonecrosis and Grade 3 facial nerve disorder in one patient. CONCLUSIONS: Re-irradiation of rare head and neck tumors using IMRT for loco-regional recurrence may be an acceptable treatment option.

[Radiofrequency Ablation under Computed Tomography during Arterial Portography for Hypovascular Liver Metastases from Advanced Pancreatic Cancer].

A 70's man had been treated with gemcitabine(GEM)and nab-paclitaxel(nabPTX)combination for advanced pancreatic tail cancer with splenic invasion and liver metastases. However, the primary lesion was not controlled, then intensity-modulat- ed radiation therapy(76.5 Gy/17 Fr)was performed for primary lesion. Three grown hypovascular liver metastases were detected by follow-up EOB-MRI and PET-computed tomography(CT)imaging with 18F-FDG. Unfortunately, these lesions were not detected by intravenous injection of contrast media with CT nor ultrasonography. Radiofrequency ablation(RFA) under computed tomography during arterial portography(CTAP)guidance was performed. The patient has been alive for 1 year after RFA with no recurrence. CTAP could be a feasible image guidance for the treatment of hypovascular liver metastases with RFA.

Clinical Assessment of Micro-residual Tumors during Stereotactic Body Radiation Therapy for Hepatocellular Carcinoma.

BACKGROUND: This study aimed to assess the need to consider microscopic invasion in terms of treatment planning in stereotactic body radiation therapy (SBRT) for hepatocellular carcinoma and elucidate the appropriate clinical target volume (CTV) margin. PATIENTS AND METHODS: A total of 121 patients (with 146 liver tumors) who underwent SBRT between July 2007 and August 2016 were analyzed, regarding overall survival and local control (LC). RESULTS: The 2- and 5-year LC rates were 91.5% and 89.8%, respectively. Planning target volume (PTV) margin <8 mm was associated with poor LC. Of the 77 patients with PTV margin of <8 mm, age <75 years was associated with poor LC, while alpha-fetoprotein (AFP) ≤20 ng/ml was associated with good LC. CONCLUSION: In patients with high AFP levels, there is a possibility of microscopic invasion around the tumor, suggesting that LC may be improved by adding an additional clinical target volume margin to the gross tumor volume.

Effect of primary tumor location and tumor size on the response to radiotherapy for liver metastases from colorectal cancer.

Metastatic liver tumors (MLTs) from colorectal cancer (CRC) are often treated with stereotactic body radiation therapy (SBRT). The present study aimed to examine the predictive factors for response of MLTs to SBRT. A total of 39 MLTs from 24 patients with CRC were retrospectively analyzed. Radiotherapy for MLT was typically performed with a prescribed dose equivalent to a biologically effective dose (BED)10 of 100 Gy. The median follow-up period was 16 months (range, 5-64 months). The median prescribed dose and total BED10 were 56 Gy (range, 45-72 Gy) and 97.5 Gy (range, 71.7-115.5 Gy), respectively, in a median of 8 fractions (range, 4-33 fractions). The 1- and 2-year local control rates were 67.2 and 35.9%, respectively. For patients with MLT treated with ablative SBRT (BED10 ≥100 Gy in ≤5 fractions), the 1- and 2-year local control rates were 83.3 and 62.5%, respectively. Univariate analysis showed that primary tumor location (left-sided colon), maximum tumor diameter (≤30 mm) and ablative SBRT (BED10 ≥100 Gy in ≤5 fractions) were significantly associated with improved local control (P=0.0058, P=0.0059 and P=0.0268, respectively). Multivariate analysis showed that tumor diameter was significantly associated with improved local control (P=0.0314). In addition, patients who received ablative SBRT had significantly prolonged overall survival times compared with those treated with non-ablative SBRT (P=0.0261). To conclude, tumors ≤30 mm that can be treated with ablative SBRT are associated with good local control rates. The primary tumor location may affect the radiosensitivity of MLTs.

Validation of the liver mean dose in terms of the biological effective dose for the prevention of radiation-induced liver damage.

AIM: The purpose of this study was to determine the optimal mean liver biologically effective dose (BED) to prevent radiation-induced liver disease (RILD) in stereotactic body radiation therapy (SBRT). BACKGROUND: The actual mean doses appropriate for liver irradiation in modern radiotherapy techniques have not been adequately investigated, although SBRT is sometimes alternatively performed using fractionated regimens. MATERIALS AND METHODS: SBRT treatment plans for liver tumors in 50 patients were analyzed. All distributions of the physical doses were transformed to BED2 using the linear-quadratic model. The relationship between physical doses and the BED2 for the liver were then analyzed, as was the relationship between the mean BED2 for the liver and the planning target volume (PTV). RESULTS: A significantly positive correlation was observed between the mean physical dose for the background liver and the mean BED2 for the whole liver (P < 0.0001, r = 0.9558). Using the LQ model, a mean BED2 of 73 and 16 Gy for the whole liver corresponded to the hepatic tolerable mean physical dose of 21 and 6 Gy for Child-Pugh A- and B-classified patients, respectively. Additionally, the PTV values were positively correlated with the BEDs for the whole liver (P < 0.0001, r = 0.8600), and the background liver (P < 0.0001, r = 0.7854). CONCLUSION: A mean BED2 of 73 and 16 Gy for the whole liver appeared appropriate to prevent RILD in patients with Child-Pugh classes A and B, respectively. The mean BED2 for the liver correlated well with the PTV.

Threshold doses and prediction of visually apparent liver dysfunction after stereotactic body radiation therapy in cirrhotic and normal livers using magnetic resonance imaging.

The purpose of the present study was to investigate the threshold dose for focal liver damage after stereotactic body radiation therapy (SBRT) in cirrhotic and normal livers using magnetic resonance imaging (MRI). A total of 64 patients who underwent SBRT for liver tumors, including 54 cirrhotic patients with hepatocellular carcinoma (HCC) and 10 non-cirrhotic patients with liver metastases, were analyzed. MRI was performed 3-6 months after SBRT, using gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid-enhanced T1-weighted sequences. All MRI datasets were merged with 3D dosimetry data. All dose distributions were corrected to the biologically effective dose using the linear-quadratic model with an assumed α/ß ratio of 2 Gy. The development of liver dysfunction was validly correlated with isodose distribution. The median biologically effective dose (BED2) that provoked liver dysfunction was 57.3 (30.0-227.9) and 114.0 (70.4-244.9) Gy in cirrhotic and normal livers, respectively (P = 0.0002). The BED2 associated with a >5% risk of liver dysfunction was 38.5 in cirrhotic livers and 70.4 Gy in normal livers. The threshold BED2 for liver dysfunction was not significantly different between Child-Pugh A and B patients (P = 0.0719). Moreover, the fractionation schedule was not significantly correlated with threshold BED2 for liver dysfunction in the cirrhotic liver (P = 0.1019). In the cirrhotic liver, fractionation regimen and Child-Pugh classification did not significantly influence the threshold BED2 for focal liver damage after SBRT. We suggest that the threshold BED2 for liver dysfunction after SBRT is 40 and 70 Gy in the cirrhotic and normal liver, respectively.

Delivery parameter variations and early clinical outcomes of volumetric modulated arc therapy for 31 prostate cancer patients: an intercomparison of three treatment planning systems.

We created volumetric modulated arc therapy (VMAT) plans for 31 prostate cancer patients using one of three treatment planning systems (TPSs)--ERGO++, Monaco, or Pinnacle--and then treated those patients. A dose of 74 Gy was prescribed to the planning target volume (PTV). The rectum, bladder, and femur were chosen as organs at risk (OARs) with specified dose-volume constraints. Dose volume histograms (DVHs), the mean dose rate, the beam-on time, and early treatment outcomes were evaluated and compared. The DVHs calculated for the three TPSs were comparable. The mean dose rates and beam-on times for Ergo++, Monaco, and SmartArc were, respectively, 174.3 ± 17.7, 149.7 ± 8.4, and 185.8 ± 15.6 MU/min and 132.7 ± 8.4, 217.6 ± 13.1, and 127.5 ± 27.1 sec. During a follow-up period of 486.2 ± 289.9 days, local recurrence was not observed, but distant metastasis was observed in a single patient. Adverse events of grade 3 to grade 4 were not observed. The mean dose rate for Monaco was significantly lower than that for ERGO++ and SmartArc (P < 0.0001), and the beam-on time for Monaco was significantly longer than that for ERGO++ and SmartArc (P < 0.0001). Each TPS was successfully used for prostate VMAT planning without significant differences in early clinical outcomes despite significant TPS-specific delivery parameter variations.

A dose-volume intercomparison of volumetric-modulated arc therapy, 3D static conformal, and rotational conformal techniques for portal vein tumor thrombus in hepatocellular carcinoma.

We created volumetric-modulated arc therapy (VMAT) plans for portal vein tumor thrombus (PVTT) in hepatocellular carcinoma, and compared the results with those from three-dimensional conformal radiotherapy (3D-CRT) and rotational conformal radiotherapy (R-CRT) plans. CT scan data from 10 consecutive patients with PVTT treated with 3D-CRT between January 2008 and January 2010 were utilized in the analysis. We analyzed the dosimetric properties of the plans for the 10 patients using the three different techniques with three different isocenter doses of 50, 56 and 60 Gy in 2-Gy fractions. The D95, Dmean, homogeneity index and conformity index were compared for the planning target volume (PTV). The Dmean, V20 and V30 were also compared for normal livers. The monitor units (MUs) and the treatment time were also evaluated. The normal liver V30 for VMAT was significantly less than that for 3D-CRT for the prescribed doses of 56 and 60 Gy (P < 0.05). It was also found that the normal liver V30 resulting from 3D-CRT was prohibitively increased when the prescribed dose was increased in two steps. For PTV D95, we found no significant differences between the three techniques for the 50- and 56-Gy prescriptions, or between VMAT and the other techniques for the 60-Gy prescription. The differences in the MUs and treatment times were not statistically significant between VMAT and 3D-CRT. We have demonstrated that VMAT may be a more advantageous technique for dose escalation reaching 60 Gy in the treatment of PVTT due to the reduced normal liver V30.

[Electronic portal image device dosimetry for volumetric modulated arc therapy].

Recently electronic portal image devices (EPIDs) have been widely used for quality assurance and dose verification. However there are no reports describing EPID dosimetry for Elekta volumetric modulated arc therapy (VMAT). We have investigated EPID dosimetry during VMAT delivery using a commercial software EPIDose with an Elekta Synergy linac. Dose rate dependence and the linac system sag during gantry rotation were measured. Gamma indices were calculated between measured doses using an EPID and calculation made by a treatment planning system for prostate VMAT test plans. The results were also compared to gamma indices using films and a two-dimensional detector array, MapCHECK2. The pass rates of the gamma analysis with a criterion of 3% and 2 mm for the three methods were over 96% with good consistency. Our results have showed that EPID dosimetry is feasible for Elekta VMAT.

Minimum requirements for commissioning and long-term quality assurance of Elekta multi-leaf collimator for volumetric modulated arc therapy.

We have proposed minimum requirements for commissioning and long-term quality assurance (QA) of an Elekta multi-leaf collimator (MLC) for volumetric modulated arc therapy (VMAT). The MLC leaf position accuracy during VMAT delivery was evaluated with the use of three different QA test plans: (1) a leaf gap-width test between opposing leaves by measurement of the isocenter dose during constant-gap sliding-window delivery with varied dose rates, MLC leaf speeds, and gantry angles; (2) a leaf position test by picket-fence delivery with and without gantry rotation; and (3) a leaf-bank symmetry test by measurement of the field geometry with different collimator angles at a fixed gantry position. All the QA test plans were created using an ERGO++ treatment-planning system. The leaf gap-width deviation was within 0.2 mm, the leaf position deviation was within 0.5 mm, and the leaf-bank symmetry error was within 0.5 mm under all the test conditions. MLC leaf position accuracy and long-term stability were confirmed by the proposed procedures.