Best Practice Recommendations for the Retention of Radiotherapy Records.

This paper offers best practice recommendations for the maintenance and retention of radiotherapy health records and technical information for cancer programmes. The recommendations are based on a review of the published and grey literature, feedback from key informants from seven countries and expert consensus. Ideally, complete health records should be retained for 5 years beyond the patient's lifetime, regardless of where they are created and maintained. Technical information constituting the radiotherapy plan should also be retained beyond the patient's lifetime for 5 years, including the primary images, contours of delineated targets and critical organs, dose distributions and other radiotherapy plan objects. There have been increased data storage and access requirements to support modern image-guided radiotherapy. Therefore, the proposed recommendations represent an ideal state of radiotherapy record retention to facilitate ongoing safe and effective care for patients as well as meaningful and informed retrospective research and policy development.

Improving superficial target delineation in radiation therapy with endoscopic tracking and registration.

PURPOSE: Target delineation within volumetric imaging is a critical step in the planning process of intensity modulated radiation therapy. In endoluminal cancers, endoscopy often reveals superficial areas of visible disease beyond what is seen on volumetric imaging. Quantitatively relating these findings to the volumetric imaging is prone to human error during the recall and contouring of the target. We have developed a method to improve target delineation in the radiation therapy planning process by quantitatively registering endoscopic findings contours traced on endoscopic images to volumetric imaging. METHODS: Using electromagnetic sensors embedded in an endoscope, 2D endoscopic images were registered to computed tomography (CT) volumetric images by tracking the position and orientation of the endoscope relative to a CT image set. Regions-of-interest (ROI) in the 2D endoscopic view were delineated. A mesh created within the boundary of the ROI was projected onto the 3D image data, registering the ROI with the volumetric image. This 3D ROI was exported to clinical radiation treatment planning software. The precision and accuracy of the procedure was tested on two solid phantoms with superficial markings visible on both endoscopy and CT images. The first phantom was T-shaped tube with X-marks etched on the interior. The second phantom was an anatomically correct skull phantom with a phantom superficial lesion placed on the pharyngeal surface. Markings were contoured on the endoscope images and compared with contours delineated in the treatment planning system based on the CT images. Clinical feasibility was tested on three patients with early stage glottic cancer. Image-based rendering using manually identified landmarks was used to improve the registration. RESULTS: Using the T-shaped phantom with X-markings, the 2D to 3D registration accuracy was 1.5-3.5 mm, depending on the endoscope position relative to the markings. Intraobserver standard variation was 0.5 mm. Rotational accuracy was within 2°. Using the skull phantom, registration accuracy was assessed by calculating the average surface minimum distance between the endoscopy and treatment planning contours. The average surface distance was 0.92 mm with 93% of all points in the 2D-endoscopy ROI within 1.5 mm of any point within the ROI contoured in the treatment planning software. This accuracy is limited by the CT imaging resolution and the electromagnetic (EM) sensor accuracy. The clinical testing demonstrated that endoscopic contouring is feasible. With registration based on em tracking only, accuracy was 5.6-8.4 mm. Image-based registration reduced this error to less than 3.5 mm and enabled endoscopic contouring in all cases. CONCLUSIONS: Registration of contours generated on 2D endoscopic images to 3D planning space is feasible, with accuracy smaller than typical set-up margins. Used in addition to standard 3D contouring methods in radiation planning, the technology may improve gross tumour volume (GTV) delineation for superficial tumors in luminal sites that are only visible in endoscopy.

Accuracy of finite element model-based multi-organ deformable image registration.

As more pretreatment imaging becomes integrated into the treatment planning process and full three-dimensional image-guidance becomes part of the treatment delivery the need for a deformable image registration technique becomes more apparent. A novel finite element model-based multiorgan deformable image registration method, MORFEUS, has been developed. The basis of this method is twofold: first, individual organ deformation can be accurately modeled by deforming the surface of the organ at one instance into the surface of the organ at another instance and assigning the material properties that allow the internal structures to be accurately deformed into the secondary position and second, multi-organ deformable alignment can be achieved by explicitly defining the deformation of a subset of organs and assigning surface interfaces between organs. The feasibility and accuracy of the method was tested on MR thoracic and abdominal images of healthy volunteers at inhale and exhale. For the thoracic cases, the lungs and external surface were explicitly deformed and the breasts were implicitly deformed based on its relation to the lung and external surface. For the abdominal cases, the liver, spleen, and external surface were explicitly deformed and the stomach and kidneys were implicitly deformed. The average accuracy (average absolute error) of the lung and liver deformation, determined by tracking visible bifurcations, was 0.19 (s.d.: 0.09), 0.28 (s.d.: 0.12) and 0.17 (s.d.: 0.07) cm, in the LR, AP, and IS directions, respectively. The average accuracy of implicitly deformed organs was 0.11 (s.d.: 0.11), 0.13 (s.d.: 0.12), and 0.08 (s.d.: 0.09) cm, in the LR, AP, and IS directions, respectively. The average vector magnitude of the accuracy was 0.44 (s.d.: 0.20) cm for the lung and liver deformation and 0.24 (s.d.: 0.18) cm for the implicitly deformed organs. The two main processes, explicit deformation of the selected organs and finite element analysis calculations, require less than 120 and 495 s, respectively. This platform can facilitate the integration of deformable image registration into online image guidance procedures, dose calculations, and tissue response monitoring as well as performing multi-modality image registration for purposes of treatment planning.

Implementing multiple static field delivery for intensity modulated beams.

A clinically oriented two-dimensional intensity-modulated beam delivery method is implemented using multiple static segmented fields, i.e., the "step-and-shoot" approach. Starting with a desired al" intensity distribution, it creates a multiple-level intensity approximation, and then constructs a sequence of segmented fields to deliver the multiple-level intensities using multileaf collimator (MLC) and independent backup jaws. The approach starts with a simple grouping of all the nonzero intensity values into a minimum number of clusters for a user specified deviation tolerance for the ideal plan. The k-means clustering algorithm is then employed to find the optimal levels of intensity that minimize the discrepancies between the ideal and the approximated intensities, without violating the user specified deviation tolerance. The multiple-level intensities are then decomposed into a sequence of machine deliverable segments. Apart from the first segment for each gantry angle, all the other segments are arranged to minimize the total travel distance of the leaves. The first segment covers the entire irradiated area and is used for treatment verification by electronic portal imaging. The implementation issues due to the physical constraints of the MLCs are also addressed.

Intensity modulation to improve dose uniformity with tangential breast radiotherapy: initial clinical experience.

PURPOSE: We present a new technique to improve dose uniformity and potentially reduce acute toxicity with tangential whole-breast radiotherapy (RT) using intensity-modulated radiation therapy (IMRT). The technique of multiple static multileaf collimator (sMLC) segments was used to facilitate IMRT. METHODS AND MATERIALS: Ten patients with early-stage breast cancer underwent treatment planning for whole-breast RT using a new method of IMRT. The three-dimensional (3D) dose distribution was first calculated for equally weighted, open tangential fields (i.e., no blocks, no wedges). Dose calculation was corrected for density effects with the pencil-beam superposition algorithm. Separate MLC segments were constructed to conform to the beam's-eye-view projections of the 3D isodose surfaces in 5% increments, ranging from the 120% to 100% isodose surface. Medial and lateral MLC segments that conformed to the lung tissue in the fields were added to reduce transmission. Using the beam-weight optimization utility of the 3D treatment planning system, the sMLC segment weights were then determined to deliver the most uniform dose to 100 reference points that were uniformly distributed throughout the breast. The accuracy of the dose calculation and resultant IMRT delivery was verified with film dosimetry performed on an anthropomorphic phantom. For each patient, the dosimetric uniformity within the breast tissue was evaluated for IMRT and two other treatment techniques. The first technique modeled conventional practice where wedges were derived manually without consideration of inhomogeneity effects (or density correction). A recalculation was performed with density correction to represent the actual dose delivered. In the second technique, the wedges were optimized using the same beam-weight optimization utility as the IMRT plan and included density correction. All dose calculations were based on the pencil-beam superposition algorithm. RESULTS: For the sMLC technique, treatment planning required approximately 60 min. Treatment delivery (including patient setup) required approximately 8-10 min. Film dosimetry measurements performed on an anthropomorphic phantom generally agreed with calculations to within +/- 3%. Compared to the wedge techniques, IMRT with sMLC segments resulted in smaller "hot spots" and a lower maximum dose, while maintaining similar coverage of the treatment volume. A median of only 0.1% of the treatment volume received > or = 110% of the prescribed dose when using IMRT versus 10% with standard wedges. A total of 6-8 segments were required with the majority of the dose delivered via the open segments. The addition of the lung-block segments to IMRT was of significant benefit for patients with a greater proportion of lung parenchyma within the irradiated volume. Since August 1999, 32 patients have been treated in the clinic with the IMRT technique. No patient experienced RTOG grade III or greater acute skin toxicity. CONCLUSION: The use of intensity modulation with an sMLC technique for tangential breast RT is an efficient and effective method for achieving uniform dose throughout the breast. It is dosimetrically superior to the treatment techniques that employ only wedges. Preliminary findings reveal minimal or no acute skin reactions for patients with various breast sizes.

Active breathing control (ABC) for Hodgkin's disease: reduction in normal tissue irradiation with deep inspiration and implications for treatment.

PURPOSE: Active breathing control (ABC) temporarily immobilizes breathing. This may allow a reduction in treatment margins. This planning study assesses normal tissue irradiation and reproducibility using ABC for Hodgkin's disease. METHODS AND MATERIALS: Five patients underwent CT scans using ABC obtained at the end of normal inspiration (NI), normal expiration (NE), and deep inspiration (DI). DI scans were repeated within the same session and 1-2 weeks later. To simulate mantle radiotherapy, a CTV1 was contoured encompassing the supraclavicular region, mediastinum, hila, and part of the heart. CTV2 was the same as CTV1 but included the whole heart. CTV3 encompassed the spleen and para-aortic lymph nodes. The planning target volume (PTV) was defined as CTV + 9 mm. PTVs were determined at NI, NE, and DI. A composite PTV (comp-PTV) based on the range of NI and NE PTVs was determined to represent the margin necessary for free breathing. Lung dose-mass histograms (DMH) for PTV1 and PTV2 and cardiac dose-volume histograms (DVH) for PTV3 were compared at the three different respiratory phases. RESULTS: ABC was well-tolerated by all patients. DI breath-holds ranged from 34 to 45 s. DMHs determined for PTV1 revealed a median reduction in lung mass irradiated at DI of 12% (range, 9-24%; n = 5) compared with simulated free-breathing. PTV2 comparisons also showed a median reduction of 12% lung mass irradiated (range, 8-28%; n = 5). PTV3 analyses revealed the mean volume of heart irradiated decreased from 26% to 5% with deep inspiration (n = 5). Lung volume comparisons between intrasession and intersession DI studies revealed mean variations of 4%. CONCLUSION: ABC is well tolerated and reproducible. Radiotherapy delivered at deep inspiration with ABC may decrease normal tissue irradiation in Hodgkin's disease patients.

Compensation of x-ray beam penumbra in conformal radiotherapy.

In radiotherapy, the gross tumor volume is surrounded by a clinically defined margin to allow for the presence of undetected malignant cells. Additional margins are added to accommodate positioning uncertainties and organ motion, creating a planning target volume, or PTV. Finally, a margin is included in the beam apertures surrounding the PTV to account for the dose fall-off at the beam edges (i.e., the "penumbra"). For higher energy beams and for low density tissues adjacent to the PTV, the beam aperture margin should be increased to account for the increased range of scattered photons and electrons. However, increased margins also increase the volume of normal tissue irradiated. In this work, the beam aperture margin is reduced by using filters and multileaf collimator (MLC) techniques to create compensating rinds of increased beam intensity. These compensation techniques were evaluated for 6 and 18 MV x rays by calculating penumbral widths as a function of the increased beam intensity in the rind, the rind width, and tissue density. Dose calculations were performed using a 3D superposition algorithm, which includes an extrafocal source model. Calculations were validated experimentally with film dosimetry. Results show the distance between the 95%-50% isodose lines is reduced from 11 mm to 4 mm for 6 MV x rays in the lung phantom, when the beam intensity is increased by 20% in a 10 mm wide rind. At 18 MV, this distance is reduced from 16 mm to 6 mm with a 20% increase in rind intensity, but a 15 mm wide rind is required. In all cases, penumbra compensation did not result in any appreciable increase in scatter dose outside the field boundaries. These results suggest that penumbra compensation is a practical means of controlling the beam aperture margin.

Monitor unit settings for intensity modulated beams delivered using a step-and-shoot approach.

Two linear accelerators have been commissioned for delivering IMRT treatments using a step-and-shoot approach. To assess beam startup stability for 6 and 18 MV x-ray beams, dose delivered per monitor unit (MU), beam flatness, and beam symmetry were measured as a function of the total number of MU delivered at a clinical dose rate of 400 MU per minute. Relative to a 100 MU exposure, the dose delivered per MU by both linear accelerators was found to be within +/-2% for exposures larger than 4 MU. Beam flatness and symmetry also met accepted quality assurance standards for a minimum exposure of 4 MU. We have found that the performance of the two machines under study is well suited to the delivery of step-and-shoot IMRT. A system of dose calculation has also been commissioned for applying head scatter corrections to fields as small as 1x1 cm2. The accuracy and precision of the relative output calculations in water was validated for small fields and fields offset from the axis of collimator rotation. For both 6 and 18 MV x-ray beams, the dose per MU calculated in a water phantom agrees with measured data to within 1% on average, with a maximum deviation of 2.5%. The largest output factor discrepancies were seen when the actual radiation field size deviated from the set field size. The measured output in water can vary by as much 16% for 1x1 cm2 fields, when the measured field size deviates from the set field size by 2 mm. For a 1 mm deviation, this discrepancy was reduced to 8%. Steps should be taken to ensure collimator precision is tightly controlled when using such small fields. If this is not possible, very small fields should not contribute to a significant portion of the treatment, or uncertainties in the collimator position may effect the accuracy of the dose delivered.

The effect of radiation on an ambulatory chemotherapy infusion pump.

BACKGROUND: Ambulatory infusion pumps are used to deliver concurrent chemotherapy with pelvic radiation therapy for patients with rectal carcinoma. The pump is worn around the waist and may be exposed to direct as well as scattered radiation, possibly leading to a complete malfunction, requiring a new pump, and/or changes in the pump timing, with clinically significant reductions in chemotherapy administration. METHODS: Two new ambulatory chemotherapy pumps were irradiated using a 6-megavolt linear accelerator. The first pump received gradually increasing doses to determine whether a complete malfunction were possible and the approximate dose. The second pump was irradiated with a single large dose of 20 Gray (Gy) followed by smaller doses of 2 Gy to characterize the dose better. After each dose of radiation was given to both pumps, an internal self-diagnostic test and an independent assessment of the pump timing were performed. RESULTS: The first pump malfunctioned completely at a cumulative dose of 38.6 Gy after receiving an individual dose of 20 Gy. The second pump tolerated the single dose of 20 Gy without difficulty and completely malfunctioned at doses of 40-42 Gy. The second pump exhibited a reduction in pump timing by 25% at a cumulative dose of 40 Gy, which resolved spontaneously by approximately 2 hours. CONCLUSIONS: Even if removed from the direct radiation beam, an individual pump could accumulate enough radiation for complete failure during the treatment of fewer than 20 patients. Prior to a complete malfunction, the flow rate of chemotherapy may decrease by 25% for a number of hours without detection. Additional work will be necessary to define further the nature of the reduction in pump timing observed.

The use of active breathing control (ABC) to reduce margin for breathing motion.

PURPOSE: For tumors in the thorax and abdomen, reducing the treatment margin for organ motion due to breathing reduces the volume of normal tissues that will be irradiated. A higher dose can be delivered to the target, provided that the risk of marginal misses is not increased. To ensure safe margin reduction, we investigated the feasibility of using active breathing control (ABC) to temporarily immobilize the patient's breathing. Treatment planning and delivery can then be performed at identical ABC conditions with minimal margin for breathing motion. METHODS AND MATERIALS: An ABC apparatus is constructed consisting of 2 pairs of flow monitor and scissor valve, 1 each to control the inspiration and expiration paths to the patient. The patient breathes through a mouth-piece connected to the ABC apparatus. The respiratory signal is processed continuously, using a personal computer that displays the changing lung volume in real-time. After the patient's breathing pattern becomes stable, the operator activates ABC at a preselected phase in the breathing cycle. Both valves are then closed to immobilize breathing motion. Breathing motion of 12 patients were held with ABC to examine their acceptance of the procedure. The feasibility of applying ABC for treatment was tested in 5 patients by acquiring volumetric scans with a spiral computed tomography (CT) scanner during active breath-hold. Two patients had Hodgkin's disease, 2 had metastatic liver cancer, and 1 had lung cancer. Two intrafraction ABC scans were acquired at the same respiratory phase near the end of normal or deep inspiration. An additional ABC scan near the end of normal expiration was acquired for 2 patients. The ABC scans were also repeated 1 week later for a Hodgkin's patient. In 1 liver patient, ABC scans were acquired at 7 different phases of the breathing cycle to facilitate examination of the liver motion associated with ventilation. Contours of the lungs and livers were outlined when applicable. The variation of the organ positions and volumes for the different scans were quantified and compared. RESULTS: The ABC procedure was well tolerated in the 12 patients. When ABC was applied near the end of normal expiration, the minimal duration of active breath-hold was 15 s for 1 patient with lung cancer, and 20 s or more for all other patients. The duration was greater than 40 s for 2 patients with Hodgkin's disease when ABC was applied during deep inspiration. Scan artifacts associated with normal breathing motion were not observed in the ABC scans. The analysis of the small set of intrafraction scan data indicated that with ABC, the liver volumes were reproducible at about 1%, and lung volumes to within 6 %. The excursions of a "center of target" parameter for the livers were less than 1 mm at the same respiratory phase, but were larger than 4 mm at the extremes of the breathing cycle. The inter-fraction scan study indicated that daily setup variation contributed to the uncertainty in assessing the reproducibility of organ immobilization with ABC between treatment fractions. CONCLUSION: The results were encouraging; ABC provides a simple means to minimize breathing motion. When applied for CT scanning and treatment, the ABC procedure requires no more than standard operation of the CT scanner or the medical accelerator. The ABC scans are void of motion artifacts commonly seen on fast spiral CT scans. When acquired at different points in the breathing cycle, these ABC scans show organ motion in three-dimension (3D) that can be used to enhance treatment planning. Reproducibility of organ immobilization with ABC throughout the course of treatment must be quantified before the procedure can be applied to reduce margin for conformal treatment.

Extrafocal radiation: a unified approach to the prediction of beam penumbra and output factors for megavoltage x-ray beams.

An extrafocal source model has been developed to explain the dependence of head scatter and beam penumbra on field size. In this model, the x-ray source of a medical linear accelerator is described by two components: a small but intense focal component; and a broadly distributed extrafocal component of low intensity. The extrafocal component is so large that it can be "eclipsed" by the field-defining collimators. Extrafocal radiation was found to account for 12% of the energy fluence on the central axis of the 6 MV x-ray beam from a Varian Clinac 2100 c accelerator. Head scatter factors were calculated "in-air" for symmetric, asymmetric, and half-blocked fields. Calculations agreed with measured values to better than 0.5%, on average. However, head scatter factors for asymmetric fields were underestimated by 1.2% when one of the field dimensions was reduced to 4 cm (the minimum jaw setting that was tested). The extrafocal source model was combined with a convolution/superposition dose calculation algorithm to calculate dose-per-monitor-unit calibration (output) factors and beam dose profiles in water. These dose calculations predict the degradation of the field edge as a function of field size, and calculate output factors to within 0.5%, on average. In the most extreme case of a 4 cm field width, output factors were underestimated by 2%. Dose profiles are predicted without the aid of an empirical fit to measured beam penumbra data. The extrafocal source model will be particularly useful for fields defined by independent jaw and multileaf collimation systems.

Dose calculations using convolution and superposition principles: the orientation of dose spread kernels in divergent x-ray beams.

The convolution/superposition method of dose calculation has the potential to become the preferred technique for radiotherapy treatment planning. When this approach is used for therapeutic x-ray beams, the dose spread kernels are usually aligned parallel to the central axis of the incident beam. While this reduces the computational burden, it is more rigorous to tilt the kernel axis to align it with the diverging beam rays that define the incident direction of primary photons. We have assessed the validity of the parallel kernel approximation by computing dose distributions using parallel and tilted kernels for monoenergetic photons of 2, 6, and 10 MeV; source-to-surface distances (SSDs) of 50, 80, and 100 cm; and for field sizes of 5 x 5, 15 x 15, and 30 x 30 cm2. Over most of the irradiated volume, the parallel kernel approximation yields results that differ from tilted kernel calculations by 3% or less for SSDs greater than 80 cm. Under extreme conditions of a short SSD, a large field size and high incident photon energy, the parallel kernel approximation results in discrepancies that may be clinically unacceptable. For 10-MeV photons, we have observed that the parallel kernel approximation can overestimate the dose by up to 4.4% of the maximum on the central axis for a field size of 30 x 30 cm2 applied with a SSD of 50 cm. Very localized dose underestimations of up to 27% of the maximum dose occurred in the penumbral region of a 30 x 30-cm2 field of 10-MeV photons applied with a SSD of 50 cm.

True three-dimensional dose computations for megavoltage x-ray therapy: a role for the superposition principle.

The objective of radiation therapy is to concentrate a prescribed radiation dose accurately within a target volume in the patient. Major advances in imaging technology have greatly improved our ability to plan radiation treatments in three dimensions (3D) and to verify the treatment geometrically, but there is a concomitant need to improve dosimetric accuracy. It has been recommended that radiation doses should be computed with an accuracy of 3% within the target volume and in radiosensitive normal tissues. We review the rationale behind this recommendation, and describe a new generation of 3D dose algorithms which are capable of achieving this goal. A true 3D dose calculation tracks primary and scattered radiations in 3D space while accounting for tissue inhomogeneities. In the past, dose distributions have been computed in a 2D transverse slice with the assumption that the anatomy of the patient dose not change abruptly in nearby slices. We demonstrate the importance of computing 3D scatter contributions to dose from photons and electrons correctly, and show the magnitude of dose errors caused by using traditional 2D methods. The Monte Carlo technique is the most general and rigorous approach since individual primary and secondary particle tracks are simulated. However, this approach is too time-consuming for clinical treatment planning. We review an approach that is based on the superposition principle and achieves a reasonable compromise between the speed of computation and accuracy in dose. In this approach, dose deposition is separated into two steps. Firstly, the attenuation of incident photons interacting in the absorber is computed to determine the total energy released in the material (TERMA). This quantity is treated as an impulse at each irradiated point. Secondly, the transport of energy by scattered photons and electrons is described by a point dose spread kernel. The dose distribution is the superposition of the kernels, weighted by the magnitude of the TERMA impulse for all interaction sites. In this review, we demonstrate the capabilities of the superposition method, particularly for situations of charged particle disequilibrium, and we report on the progress made by several research groups in adapting this method to clinical treatment planning. In the future, the superposition method will have a significant role in dose optimization for conformal irradiation techniques because of its close correspondence to image reconstruction by filtered back-projection.

Superior vena cava obstruction in fibrosing mediastinitis: demonstration of right-to-left shunt and venous collaterals.

Multiple venous collateral pathways have been described in patients with superior vena cava obstruction. Systemic venous-to-pulmonary venous communication is the most unusual, having been described in a few cases of thoracic malignancy. In a patient with fibrosing mediastinitis radionuclide venography with 99Tcm-macroaggregated albumin demonstrated a systemic venous-pulmonary venous right-to-left shunt in addition to systemic and portal venous collaterals. It is apparent that systemic venous-to-pulmonary venous anastomoses may occur in the absence of malignant disease.