Sci-Thur AM: Planning - 12: Comparative study of SBRT lung dose calculation using Eclipse and Monte Carlo.

Stereotactic Body Radiation Therapy (SBRT) is an option for early stage non-small cell lung cancer treatment. In SBRT treatment, high biological effective dose is delivered to the patient within a small number of fractions. High level of confidence in accuracy is required in the entire treatment procedure, from patient setup, tumour delineation, treatment simulation and planning, to the final dose delivery. SBRT lung treatment utilizes small fields that are incident on large tissue inhomogeneities within the patient. It is difficult for commercially available treatment planning systems (TPS) to model the lack of charged particle equilibrium and the dose near tissue-lung interfaces accurately. The Monte Carlo (MC) technique calculates the dose distribution from the first principles thereby providing a feasible tool for verifying the dose distribution computed from TPS. In this study, we compared the SBRT dose distribution between Eclipse 8.9 and BEAMnrc/DOSXYZnrc for both conformal and RapidArc plans. Calculation results for five clinical SBRT conformal lung plans were compared. Eclipse and MC results for each plan showed good agreement in dose received by organs at risk. MC simulation predicted uniformly hotter or similar PTV coverage for three cases with tumor either small or attached to the chest wall. When tumor is inside lung and at relatively medium to larger size for SBRT, MC predicted lower PTV coverage. The variation in dose coverage may depend on the tumour size and its position within the lung. Dose comparison for RapidArc plans shows similar dependence.

Poster - Thur Eve - 70: Quantification of tumour dose enhancement at kilo-voltage energies due to the presence of gold nanoparticles during radiation therapy: EGSnrcMP Monte Carlo study.

One of the greatest challenges in radiation therapy is the ability to deliver a lethal dose of radiation to a tumour while sparing the surrounding normal tissues. In theory, the dose delivered to a tumour during photon-based radiation therapy can be enhanced by loading high atomic number (Z) materials into the tumour, which results in greater photoelectric absorption and hence increased photoelectron fluence within the tumour than in surrounding tissues. The EGSnrcMP Monte Carlo code, together with DOSXYZnrc, a three-dimensional voxel dose calculation module has been used to study the macroscopic dose enhancement factor (MDEF) in a tumour infused with gold nanoparticles at the kilo-voltage energies. We observed that gold nanoparticles infused in a tumour irradiated with kilo-voltage energies has the potential to enhance the tumour dose by a factor ranging from 0.25 to about 5 depending on the mean energy of the beam and the concentration of gold nanoparticles in the tumour. The increase in dose can be attributed to the significant increase in the photoelectron fluence within the tumour loaded with gold particles during the irradiation. Future studies will involve the characterization of the MDEF at megavoltage energies.

Poster - Thur Eve - 66: A planning comparison between RapidArc and intensity modulated radiotherapy for head and neck cancer.

Volumetric modulated arc therapy (VMAT) has recently been used to improve the dose distribution and efficiency of treatment delivery over the standard intensity-modulated radiotherapy (IMRT) technique. This study compares the dosimetry between RapidArc plan and standard IMRT plan for head and neck cancer. Three head and neck patients treated clinically with sliding window intensity-modulated radiotherapy (IMRT) technique at Grand River Regional Cancer Center were selected randomly and re-planned using RapidArc technique with 6 MV photon beams generated by a Varian 21EX linac with 120-leaf multileaf collimator. Three dose prescriptions were used to deliver 70 Gy, 63 Gy and 58.1 Gy to the regions of the primary tumors, intermediate-risk nodes and low-risk nodal level, respectively, in 35 fractions. Dosimetric comparison based on the dose-volume histogram, target coverage, organ at risk (OAR) dose sparing were studied between the RapidArc plan and IMRT plan. RapidArc technique from Varian Medical Systems showed superior target coverage, better OAR sparing, fewer monitor units per fraction with less treatment time over IMRT technique for head and neck cancers. The average homogeneity index, defined as the difference between the percentage dose covering 5% and 95% of the PTV, is 9.5 for RapidArc plan and 10.5 for IMRT plan. All RapidArc plans met the dose objectives for the primary OAR: spinal cord, brainstem, brain etc. Both parotid mean dose and D50% are lower for RapidArc plan than those of the IMRT plan. The technique is currently being used clinically at our cancer center.

Sci-Thurs PM: Delivery-11: Image guidance for prostate IMRT using low dose cone beam CT.

Linac-mounted cone beam computed tomography (CBCT) using Varian's On Board Imager (OBI) currently delivers significant imaging dose and lacks automatic methods for clinical target volume (CTV) registration. In this work, we address these two issues to enable frequent treatment corrections during a course of prostate intensity modulated radiation therapy (IMRT). The process starts by acquiring a low dose (low mAs) CBCT image after patient setup. The image is then used in one of two automatic image guidance strategies. The "global" technique provides the couch corrections necessary to improve patient setup by registering the CBCT to the planning CT. The "local" method involves non-rigid registration of the planning CT to the CBCT followed by automatic treatment re-optimization using the deformed planning CT and contours. Thus, the global method attempts to correct patient setup to match the planned treatment, while the local method corrects the treatment to match the patient setup. Both techniques were evaluated using images of an anthropomorphic male pelvis phantom. Global image guidance resulted in a registration error of 3.6 ± 1.3 mm (imaging dose independent) and high treatment doses to the bladder and rectum for large magnitude motion. The local technique always resulted in clinically acceptable treatment doses due to a reduced registration error of 2.3 ± 0.8 mm, obtained at 15% of the OBI's default dose (125 kVp, 2 mAs per projection). These preliminary results show that our automatic local image guidance technique reduces imaging dose and is sufficiently accurate and robust for application in prostate IMRT.

Poster - Thurs Eve-27: Method of estimating imaging dose to patients from on-line cone-beam computed tomography using patient size data.

The use of on-line kilovoltage cone-beam computed tomography (CBCT) is increasing as part of the current evolution of image-guided radiotherapy. At our institution, we use Varian's On Board Imager® (OBI) mainly for imaging prostate cancer patients. Since daily CBCT can add significant dose, we have performed a comprehensive set of dose measurements using acrylic cylindrical phantoms using ionization chambers as well as skin dose measurements using Thermoluminescence Dosimeters (TLD). The TLD were calibrated under chosen reference conditions (10×10 cm2 field size at 100 cm SSD) using the OBI beam with bowtie filters (125 kVp, 6.0 mm Al). For the patients, TLD were placed on the anterior, left and right lateral locations to give the peripheral dose. The CBCT dose values (in units of mGy/100mAs) were then used to model the central (phantom only) and peripheral dose (phantom and patients) as a function of equivalent diameter, deq , using exponential functions. Dose values measured in Rando phantom as well as published dose values agreed with the model quite well for deq ⩾ 24 cm (body), but there was higher variation in CBCT dose for deq ⩽ 18 cm (head). Hence, it is recommended that skin dose be measured for head scans to validate the estimate. This method provides a quick estimate of CBCT dose so that a decision can be made whether to incorporate it into the treatment prescription. Also, knowledge of CBCT dose as a function of patient size may enable reduction of the total mAs for smaller body scans.

Dosimetric impact of image-guided 3D conformal radiation therapy of prostate cancer.

The goal of this work is to quantify the impact of image-guided conformal radiation therapy (CRT) on the dose distribution by correcting patient setup uncertainty and inter-fraction tumour motion. This was a retrospective analysis that used five randomly selected prostate cancer patients that underwent approximately 15 computed tomography (CT) scans during their radiation treatment course. The beam arrangement from the treatment plan was imported into each repeat CT study and the dose distribution was recalculated for the new beam setups. Various setup scenarios were then compared to assess the impact of image guidance on radiation treatment precision. These included (1) daily alignment to skin markers, thus representing a conventional beam setup without image guidance, (2) alignment to bony anatomy for correction of daily patient setup error, thus representing on-line portal image guidance, and (3) alignment to the 'CTV of the day' for correction of inter-fraction tumour motion, thus representing on-line CT or ultrasound image guidance. Treatment scenarios (1) and (3) were repeated with a reduced CTV to PTV margin, where the former represents a treatment using small margins without daily image guidance. Daily realignment of the treatment beams to the prostate showed an average increase in minimum tumour dose of 1.5 Gy, in all cases where tumour 'geographic miss' without image guidance was apparent. However, normal tissue sparing did not improve unless the PTV margin was reduced. Daily realignment to the tumour combined with reducing the margin size by a factor of 2 resulted in an average escalation in tumour dose of 9.0 Gy for all five static plans. However, the prescription dose could be escalated by 13.8 Gy when accounting for changes in anatomy by accumulating daily doses using nonlinear image registration techniques. These results provide quantitative information on the effectiveness of image-guided radiation treatment of prostate cancer and demonstrate that the dosimetric impact is patient dependent.

Validation of contour-driven thin-plate splines for tracking fraction-to-fraction changes in anatomy and radiation therapy dose mapping.

The goal of this study is to validate a deformable model using contour-driven thin-plate splines for application to radiation therapy dose mapping. Our testing includes a virtual spherical phantom as well as real computed tomography (CT) data from ten prostate cancer patients with radio-opaque markers surgically implanted into the prostate and seminal vesicles. In the spherical mathematical phantom, homologous control points generated automatically given input contour data in CT slice geometry were compared to homologous control point placement using analytical geometry as the ground truth. The dose delivered to specific voxels driven by both sets of homologous control points were compared to determine the accuracy of dose tracking via the deformable model. A 3D analytical spherically symmetric dose distribution with a dose gradient of approximately 10% per mm was used for this phantom. This test showed that the uncertainty in calculating the delivered dose to a tissue element depends on slice thickness and the variation in defining homologous landmarks, where dose agreement of 3-4% in high dose gradient regions was achieved. In the patient data, radio-opaque marker positions driven by the thin-plate spline algorithm were compared to the actual marker positions as identified in the CT scans. It is demonstrated that the deformable model is accurate (approximately 2.5 mm) to within the intra-observer contouring variability. This work shows that the algorithm is appropriate for describing changes in pelvic anatomy and for the dose mapping application with dose gradients characteristic of conformal and intensity modulated radiation therapy.

Tracking the dose distribution in radiation therapy by accounting for variable anatomy.

The goal of this research is to calculate the daily and cumulative dose distribution received by the radiotherapy patient while accounting for variable anatomy, by tracking the dose distribution delivered to tissue elements (voxels) that move within the patient. Non-linear image registration techniques (i.e., thin-plate splines) are used along with a conventional treatment planning system to combine the dose distributions computed for each 3D computed tomography (CT) study taken during treatment. For a clinical prostate case, we demonstrate that there are significant localized dose differences due to systematic voxel motion in a single fraction as well as in 15 cumulative fractions. The largest positive dose differences in rectum, bladder and seminal vesicles were 29%, 2% and 24%, respectively, after the first fraction of radiation treatment compared to the planned dose. After 15 cumulative fractions, the largest positive dose differences in rectum, bladder and seminal vesicles were 23%, 32% and 18%, respectively, compared to the planned dose. A sensitivity analysis of control point placement is also presented. This method provides an important understanding of actual delivered doses and has the potential to provide quantitative information to use as a guide for adaptive radiation treatments.