Characterization of an Onboard Transmission Detector for Efficient Linear Accelerator Output Quality Assurance.

Purpose To investigate the potential to perform linear accelerator output quality assurance (QA) with the ScandiDos Delta4 Discover (Discover) onboard transmission detector. Materials and methods Using the ScandiDos Delta4 software (version 8), a conversion factor from raw signal to output was obtained via cross-calibration with an accredited dosimetry calibration laboratory (ADCL) calibrated ionization chamber for each photon energy, including flattening-filter-free (FFF) energies. With the calibration factor for 6 MV (6x) photon energy, output measurements were taken with both the Delta4 Discover and ion chamber and compared for output as a function of gantry angle and dose-rate dependence. Monitor unit (MU) linearity for 6x was measured and compared with ion chamber measurements. Additionally, the Discover was used to take output measurements, for 6x, approximately every hour throughout the course of a treatment day, and compared with ion chamber output measurements at the beginning and end of the treatment day. Results Output measurements for each photon energy were comparable with a maximum difference of -0.57% for flattened beams (6x) and 0.21% for FFF beams (10FFF). Output measurements using the Discover matched ion chamber output measurements at every dose rate within 2%, and within 1% for output as a function of gantry angle. MU linearity test agreed with ion chamber measurements with a maximum difference of 0.41%. Output measurements using the Discover showed a daily drift in output throughout the course of a treatment day of around 2% and correlated very well with ion chamber outputs measured at the beginning and end of the treatment day (within 0.2%). Conclusions The ScandiDos Delta4 Discover onboard transmission detector is able to accurately measure linear accelerator output comparable to ion chamber measurements.

The Effect of Measured Radiotherapy Dose on Intrathecal Drug Delivery System Function.

OBJECTIVES: Radiation therapy (RT) and intrathecal drug delivery systems (IDDS) are often used concurrently to optimize pain management in patients with cancer. Concern remains among clinicians regarding the potential for IDDS malfunction in the setting of RT. Here we assessed the frequency of IDDS malfunction in a large cohort of patients treated with RT. MATERIALS AND METHODS: Cancer patients with IDDS and subsequent RT at our institution from 2011 to 2019 were eligible for this study. Patients were excluded in the rare event that their IDDS was managed by an outside clinic and follow-up documentation was unavailable. Eighty-eight patients aged 22-88 years old (43% female, 57% male) representing 106 separate courses of RT were retrospectively identified. Patients received varying levels of radiation for treatment of cancer and cumulative dose to the IDDS was calculated. IDDS interrogation was subsequently performed by a pain specialist. Malfunction was recorded as deviation from the expected drug volume and/or device errors reported upon interrogation as defined by the manufacturer. RESULTS: Total measured RT dose to the IDDS ranged from 0 to 18.0 Gy (median = 0.2 Gy) with median dose of 0.04 Gy/fraction (range, 0-3.2 Gy/fraction). Ten pumps received a total dose >2 Gy and three received ≥5 Gy. Eighty-two percentage of patients had follow-up with a pain specialist for IDDS interrogation and all patients underwent follow-up with a healthcare provider following RT. There were zero incidences of IDDS malfunction related to RT. No patient had clinical evidence of radiation related pump malfunction at subsequent encounters. CONCLUSIONS: We found no evidence that RT in patients with IDDS led to device failure or dysfunction. While radiation oncologists and pain specialists should coordinate patient care, it does not appear that RT dose impacts the function of the IDDS to warrant significant clinical concern.

Evaluation of the effects of implementing a diode transmission device into the clinical workflow.

PURPOSE: This work investigated effects of implementing the Delta4 Discover diode transmission detector into the clinical workflow. METHODS: PDD and profile scans were completed with and without the Discover for a number of photon beam energies. Transmission factors were determined for all beam energies and included in Eclipse TPS to account for the attenuation of the Discover. A variety of IMRT plans were delivered to a Delta4 Phantom+ with and without the Discover to evaluate the Discover's effects on IMRT QA. An imaging QA phantom was used to assess the detector's effects on MV image quality. OSLDs placed on the Phantom+ were used to determine the detector's effects on superficial dose. RESULTS: The largest effect on PDDs after dmax was 0.5%. The largest change in beam profile symmetry and flatness was 0.2% and 0.1%, respectively. An average difference in gamma passing rates (2%/2 mm) of 0.2% was observed between plans that did not include the Discover in the measurement and calculation to plans that did include the Discover in the measurement and calculation. The Discover did not significantly change the MV image quality, and the largest observed increase in the relative superficial dose when the Discover was present was 1%. CONCLUSIONS: The effects the Discover has on the linac beam were found to be minimal. The device can be implemented into the clinic without the need to alter the TPS beam modeling, other than accounting for the device's attenuation. However, a careful workflow review to implement the Discover should be completed.

Using failure mode and effects analysis (FMEA) to generate an initial plan check checklist for improved safety in radiation treatment.

PURPOSE: To apply failure mode and effect analysis (FMEA) to generate an effective and efficient initial physics plan checklist. METHODS: A team of physicists, dosimetrists, and therapists was setup to reconstruct the workflow processes involved in the generation of a treatment plan beginning from simulation. The team then identified possible failure modes in each of the processes. For each failure mode, the severity (S), frequency of occurrence (O), and the probability of detection (D) was assigned a value and the risk priority number (RPN) was calculated. The values assigned were based on TG 100. Prior to assigning a value, the team discussed the values in the scoring system to minimize randomness in scoring. A local database of errors was used to help guide the scoring of frequency. RESULTS: Twenty-seven process steps and 50 possible failure modes were identified starting from simulation to the final approved plan ready for treatment at the machine. Any failure mode that scored an average RPN value of 20 or greater was deemed "eligible" to be placed on the second checklist. In addition, any failure mode with a severity score value of 4 or greater was also considered for inclusion in the checklist. As a by-product of this procedure, safety improvement methods such as automation and standardization of certain processes (e.g., dose constraint checking, check tools), removal of manual transcription of treatment-related information as well as staff education were implemented, although this was not the team's original objective. Prior to the implementation of the new FMEA-based checklist, an in-service for all the second checkers was organized to ensure further standardization of the process. CONCLUSION: The FMEA proved to be a valuable tool for identifying vulnerabilities in our workflow and processes in generating a treatment plan and subsequently a new, more effective initial plan checklist was created.

Evaluation of a surface imaging system's isocenter calibration methods.

AlignRT is a surface imaging system that has been utilized for localizing and tracking patient position during radiotherapy. AlignRT has two calibration procedures that can set the system's isocenter called "Monthly Calibration" (MC) and "Isocentre Calibration" (IC). The MC utilizes a calibration plate. In addition to the calibration plate, the IC utilizes a cubic phantom that is imaged with the linac treatment beam to aid in aligning the AlignRT and treatment-beam isocenters. This work evaluated the effects of misaligning the calibration plate during the calibration process. The plate was intentionally shifted away from isocenter ±3.0 mm in the longitudinal and lateral directions and ±1.0 mm in the longitudinal, lateral, and vertical directions. A mock stereotactic radiosurgery (SRS) treatment was used to evaluate the effects of the miscalibrations. An anthropomorphic head phantom was placed in an SRS treatment position and monitored with the AlignRT system. The AlignRT-indicated offsets were recorded at 270°, 315°, 0°, 45°, and 90° couch angles for each intentional misalignment of the calibration plate during the MC. The IC was also performed after each miscalibration, and the measurements were repeated and compared to the previous results. With intentional longitudinal and lateral shifts of ±3.0 mm and ±1.0 mm of the calibration plate, the average indicated offsets at couch rotations of ±90° were 4.3 mm and 1.6 mm, respectively. This was in agreement with the theoretical offset of √2*(shift-of-the-calibration plate). Since vertical shifts were along the rotation axis of the couch, these shifts had little effect on the offsets with changing couch angle. When the IC was applied, the indicated offsets were all within 0.5 mm for all couch angles for each of the miscalibrations. These offsets were in agreement with the known magnitude of couch walkout. The IC method effectively removes the potential miscalibration artifacts of the MC method due to misalignments of the calibration plate.

Failure mode and effects analysis and fault tree analysis of surface image guided cranial radiosurgery.

PURPOSE: Surface image guided, Linac-based radiosurgery (SIG-RS) is a modern approach for delivering radiosurgery that utilizes optical stereoscopic imaging to monitor the surface of the patient during treatment in lieu of using a head frame for patient immobilization. Considering the novelty of the SIG-RS approach and the severity of errors associated with delivery of large doses per fraction, a risk assessment should be conducted to identify potential hazards, determine their causes, and formulate mitigation strategies. The purpose of this work is to investigate SIG-RS using the combined application of failure modes and effects analysis (FMEA) and fault tree analysis (FTA), report on the effort required to complete the analysis, and evaluate the use of FTA in conjunction with FMEA. METHODS: A multidisciplinary team was assembled to conduct the FMEA on the SIG-RS process. A process map detailing the steps of the SIG-RS was created to guide the FMEA. Failure modes were determined for each step in the SIG-RS process, and risk priority numbers (RPNs) were estimated for each failure mode to facilitate risk stratification. The failure modes were ranked by RPN, and FTA was used to determine the root factors contributing to the riskiest failure modes. Using the FTA, mitigation strategies were formulated to address the root factors and reduce the risk of the process. The RPNs were re-estimated based on the mitigation strategies to determine the margin of risk reduction. RESULTS: The FMEA and FTAs for the top two failure modes required an effort of 36 person-hours (30 person-hours for the FMEA and 6 person-hours for two FTAs). The SIG-RS process consisted of 13 major subprocesses and 91 steps, which amounted to 167 failure modes. Of the 91 steps, 16 were directly related to surface imaging. Twenty-five failure modes resulted in a RPN of 100 or greater. Only one of these top 25 failure modes was specific to surface imaging. The riskiest surface imaging failure mode had an overall RPN-rank of eighth. Mitigation strategies for the top failure mode decreased the RPN from 288 to 72. CONCLUSIONS: Based on the FMEA performed in this work, the use of surface imaging for monitoring intrafraction position in Linac-based stereotactic radiosurgery (SRS) did not greatly increase the risk of the Linac-based SRS process. In some cases, SIG helped to reduce the risk of Linac-based RS. The FMEA was augmented by the use of FTA since it divided the failure modes into their fundamental components, which simplified the task of developing mitigation strategies.

Determining the effects of microsphere and surrounding material composition on (90)Y dose kernels using egsnrc and mcnp5.

PURPOSE: Recent advances in the imaging of (90)Y using positron emission tomography (PET) and improved uncertainty in the branching ratio for the internal pair production component of (90)Y decay allow for a more accurate determination of the activity distribution of (90)Y microspheres within a patient. This improved activity distribution can be convolved with the dose kernel of (90)Y to calculate the dose distribution within a patient. This work investigates the effects of microsphere and surrounding material composition on (90)Y dose kernels using egsnrc and mcnp5 and compares the results of these two transport codes. METHODS: Monte Carlo simulations were performed with egsnrc and mcnp5 to calculate the dose rate at multiple radial distances around various (90)Y sources. Point source simulations were completed with mcnp5 to determine the optimal electron transport settings for this work. After determining the optimal settings, point source simulations were completed using egsnrc (user code edknrc) and mcnp5 in water and liver [as defined by the International Commission on Radiation Units and Measurements (ICRU) Report 44]. The results were compared to ICRU Report 72 reference data. Point source simulations were also completed in water with a density of 1.06 g[middle dot]cm(-3) to evaluate the effect of the density of the surrounding material. Glass and resin microsphere simulations were performed with average and maximum diameter and density values (based on values given in the literature) in water and in liver. The results were compared to point source simulation results using the same transport code and in the same surrounding material. All simulations had statistical uncertainties less than 1%. RESULTS: The optimal transport settings in mcnp5 for this work included using the energy-and step-specific algorithm (DBCN 17J 2) and ESTEP set to 10. These settings were used for all subsequent simulations with mcnp5. The point source simulations in water for both egsnrc and mcnp5 were found to agree within 2% of the ICRU 72 reference data over the investigated range. Point source simulations in liver had large differences relative to ICRU 72, approaching -60% near the maximum range of (90)Y. These differences are mostly attributed to the difference in density between water (1.0 g[middle dot]cm(-3)) and liver (1.06 g[middle dot]cm(-3)). Glass and resin microsphere simulations showed a slight decrease in the dose rate near the maximum range of (90)Y relative to the point source simulations. The largest relative differences were approximately -4.2% and -2.8% for the glass and resin microspheres, respectively. Agreement between the egsnrc and mcnp5 simulations results was generally good. CONCLUSIONS: The presence of the microsphere material causes slight differences in the (90)Y dose kernel compared to those calculated with point sources. Large differences were seen between simulations in water and those in liver. For the most accurate calculation of the dose distribution, the density of the patient's liver should be accounted for in the calculation of the dose kernel. Lastly, due to the need to determine the optimal transport settings with mcnp5, electron transport with this code should be used with caution.

Primary calibration of coiled 103Pd brachytherapy sources.

Coiled 103Pd brachytherapy sources have been developed by RadioMed Corporation for use as low-dose-rate (LDR) interstitial implants. The coiled sources are provided in integer lengths from 1 to 6 cm and address many common issues seen with traditional LDR brachytherapy sources. The current standard for determining the air-kerma strength (SK) of low-energy LDR brachytherapy sources is the National Institute of Standards and Technology's Wide-Angle Free-Air Chamber (NIST WAFAC). Due to geometric limitations, however, the NIST WAFAC is unable to determine the S(K) of sources longer than 1 cm. This project utilized the University of Wisconsin's Variable-Aperture Free-Air Chamber (UW VAFAC) to determine the S(K) of the longer coiled sources. The UW VAFAC has shown agreement in S(K) values of 1 cm length coils to within 1% of those determined with the NIST WAFAC, but the UW VAFAC does not share the same geometric limitations as the NIST WAFAC. A new source holder was constructed to hold the coiled sources in place during measurements with the UW VAFAC. Correction factors for the increased length of the sources have been determined and applied to the measurements. Using the new source holder and corrections, the S(K) of 3 and 6 cm coiled sources has been determined. Corrected UW VAFAC data and ionization current measurements from well chambers have been used to determine calibration coefficients for use in the measurement of 3 and 6 cm coiled sources in well chambers. Thus, the UW VAFAC has provided the first transferable, primary measurement of low-energy LDR brachytherapy sources with lengths greater than 1 cm.

Angiographic analysis of blood flow modification in cerebral aneurysm models with a new asymmetric stent.

We have built new asymmetric stents for minimally invasive endovascular treatment of cerebral aneurysms. Each asymmetric stent consists of a commercial stent with a micro-welded circular mesh patch. The blood flow modification in aneurysm-vessel phantoms due to these stents was evaluated using x-ray angiographic analysis. However, the density difference between the radiographic contrast and the blood gives rise to a gravity effect, which was evaluated using an initial optical dye-dilution experiment. For the radiographic evaluations, curved-vessel phantoms instead of simple straight side-wall aneurysm phantoms were used in the characterization of meshes/stents. Six phantoms (one untreated, one treated with a commercial stent, and four treated with different asymmetric stents) with similar morphologies were used for comparison. We calculated time-density curves of the aneurysm region and then calculated the peak value (Pk) and washout rate (1/τ) after analytical curve fitting. Flow patterns in the angiograms showed reduction of vortex flow and slow washout in the dense mesh patch treated aneurysms. The meshes reduced Pk down to 21% and 1/τ down to 12% of the values for the untreated case. In summary, new asymmetric stents were constructed and their evaluation demonstrates that they may be useful in the endovascular treatment of aneurysms.