Uncertainties in linac primary barrier transmission values.

Primary barrier design for linac shielding depends very sensitively on tenth value layer (TVL) data. Inaccuracies can lead to large discrepancies between measured and calculated values of the barrier transmission. Values of the TVL for concrete quoted in several widely used standard references are substantially different than those calculated more recently. The older standard TVL data predict significantly lower radiation levels outside primary barriers than the more recently calculated values under some circumstances. The difference increases with increasing barrier thickness and energy, and it can be as large as a factor of 4 for 18 MV and concrete thickness of 200 cm. This may be due to significant differences in the beam spectra between the earlier and the more recent calculations. Measured instantaneous air kerma rates sometimes show large variations for the same energy and thickness. This may be due to confounding factors such as extra material on, or inside the barrier, variable field size at the barrier, density of concrete, and distal distance from the barrier surface. In some cases, the older TVL data significantly underestimate measured instantaneous air kerma rates, by up to a factor of 3, even when confounding factors are taken into account. This could lead to the necessity for expensive remediation. The more recent TVL values tend to overestimate the measured instantaneous dose rates. Reference TVL data should be computed in a manner that is mathematically consistent with their use in the calculation of air kerma rate outside barriers directly from the linac "dose" rate in MU/min.

Evaluation of Dose Accuracy in the Near-Surface Region for Whole Breast Irradiation Techniques in a Multi-institutional Consortium.

PURPOSE: To assess the accuracy of dose calculations in the near-surface region for different treatment planning systems (TPSs), treatment techniques, and energies to improve clinical decisions for patients receiving whole breast irradiation (WBI). METHODS AND MATERIALS: A portable custom breast phantom was designed for dose measurements in the near-surface regions. Treatment plans of varying complexities were created at 8 institutions using 4 different TPSs on an anonymized patient data set (50 Gy in 25 fractions) and peer reviewed by participants. The plans were recalculated on the phantom data set. The phantom was aligned with predetermined shifts and laser marks or cone beam computed tomography, and the irradiation was performed using a variety of linear accelerators at the participating institutions. Dose was measured with radiochromic film placed at 0.5 and 1.0 cm depth and 3 locations per depth within the phantom. The film was scanned and analyzed >24 hours postirradiation. RESULTS: The percentage difference between the mean of the measured and calculated dose across the participating centers was -0.2 % ± 2.9%, with 95% of measurements within 6% agreement. No significant differences were found between the mean of the calculated and measured dose for all TPSs, treatment techniques, and energies at all depths and laterality investigated. Furthermore, no significant differences were observed between the mean of measured dose and the prescription dose of 2 Gy per fraction. CONCLUSION: These results demonstrate that dose calculations for clinically relevant WBI plans are accurate to within 6% of measurements in the near-surface region for various complexities, TPSs, linear accelerators, and beam energies. This work lays the necessary foundation for future studies investigating the correlation between near-surface dose and acute skin toxicities.

Comparative Effectiveness Analysis of 3D-Conformal Radiation Therapy Versus Intensity Modulated Radiation Therapy (IMRT) in a Prospective Multicenter Cohort of Patients With Breast Cancer.

PURPOSE: Simple intensity modulation of radiation therapy reduces acute toxicity compared with 2-dimensional techniques in adjuvant breast cancer treatment, but it remains unknown whether more complex or inverse-planned intensity modulated radiation therapy (IMRT) offers an advantage over forward-planned, 3-dimensional conformal radiation therapy (3DCRT). METHODS AND MATERIALS: Using prospective data regarding patients receiving adjuvant whole breast radiation therapy without nodal irradiation at 23 institutions from 2011 to 2018, we compared the incidence of acute toxicity (moderate-severe pain or moist desquamation) in patients receiving 3DCRT versus IMRT (either inverse planned or, if forward-planned, using ≥5 segments per gantry angle). We evaluated associations between technique and toxicity using multivariable models with inverse-probability-of-treatment weighting, adjusting for treatment facility as a random effect. RESULTS: Of 1185 patients treated with 3DCRT and conventional fractionation, 650 (54.9%) experienced acute toxicity; of 774 treated with highly segmented forward-planned IMRT, 458 (59.2%) did; and of 580 treated with inverse-planned IMRT, 245 (42.2%) did. Of 1296 patients treated with hypofractionation and 3DCRT, 432 (33.3%) experienced acute toxicity; of 709 treated with highly segmented forward-planned IMRT, 227 (32.0%) did; and of 623 treated with inverse-planned IMRT, 164 (26.3%) did. On multivariable analysis with inverse-probability-of-treatment weighting, the odds ratio for acute toxicity after inverse-planned IMRT versus 3DCRT was 0.64 (95% confidence interval, 0.45-0.91) with conventional fractionation and 0.41 (95% confidence interval, 0.26-0.65) with hypofractionation. CONCLUSIONS: This large, prospective, multicenter comparative effectiveness study found a significant benefit from inverse-planned IMRT compared with 3DCRT in reducing acute toxicity of breast radiation therapy. Future research should identify the dosimetric differences that mediate this association and evaluate cost-effectiveness.

Evaluation of VMAT Planning Strategies for Prostate Patients with Bilateral Hip Prosthesis.

Purpose: In this study, we investigate linac volumetric-modulated arc therapy (VMAT) planning strategies for bilateral hip prostheses prostate patients with respect to plan quality and deliverability, while limiting entrance dose to the prostheses. Methods: Three VMAT plans were retrospectively created for 20 patients: (1) partial arcs (PA), (2) 2 full arcs optimized with 500 cGy max prostheses dose (MD), and (3) 2 full arcs optimized with max dose-volume histogram (DVH) constraint of 500 cGy to 10% prostheses volume (MDVH). PA techniques contained 6 PA with beam angles that avoid entering each prosthesis. For each patient, other than prostheses constraints, the same Pinnacle VMAT optimization objectives were used. Plans were normalized with PTV D95% = 79.2 Gy prescription dose. Organ-at-risk DVH metrics, monitor units (MUs), conformality, gradient, and homogeneity indices were evaluated for each plan. Mean entrance prosthesis dose was determined in Pinnacle by converting each arc into static beams and utilizing only control points traversing each prosthesis. Plan deliverability was evaluated with SunNuclear ArcCheck measurements (gamma criteria 3%/2 mm) on an Elekta machine. Results: MD and MDVH had similar dosimetric quality, both improved DVH metrics for rectum and bladder compared to PA. Plan complexities among all plans were similar (average MUs: 441-518). Conformality, homogeneity, and gradient indices were significantly improved in MD and MDVH versus PA (P < .001). Gamma pass rates for MD (99.0 ± 1.2%) and MDVH (99.2 ± 0.99%) were comparable. A significant difference over PA was observed (96.8 ± 1.6%, P < .001). Field-by-field analysis demonstrated 12/20 PA plans resulted in fields with pass rates <95% versus 1/20 plans for MD and none for MDVH. Cumulative mean entrance doses to each prosthesis were 62.9 ± 17.7 cGy for MD plans and 83.4 ± 27.5 cGy for MDVH plans. Conclusion: MD and MDVH plans had improved dosimetric quality and deliverability over PA plans with minimal entrance doses (∼1% of prescription) to each prosthesis and are an improved alternative for bilateral prostheses prostate patients.

Simultaneous Optimization of Radiation-Imaging Coincidence for a Multi-Energy Linac.

INTRODUCTION: Medical physics guidelines stress the importance of radiation-imaging coincidence, especially for stereotactic treatments. However, multi-energy linear accelerators may only allow a single imaging isocenter. A procedure was developed to simultaneously optimize radiation-imaging isocenter coincidence for all linac photon energies on a Versa HD. MATERIALS AND METHODS: First, the radiation beam center of each energy was adjusted to match the collimator rotation axis using a novel method that combined ion chamber measurements with a modified Winston-Lutz (WL) test using images only at gantry, couch, and collimator angles of 0°. With all energies properly steered, an 8-field WL test was performed to determine average linac isocenter position across all energies, gantry, and collimator angles. Lasers and the kV imaging isocenter were calibrated to the average linac isocenter of all photon energies. Finally, A 12-field WL test consisting of gantry, couch, and collimator rotations was used to adjust the couch rotation axis to the average linac isocenter, thereby minimizing overall radiation-imaging isocentricity of the system. RESULTS: Using this method, the beam centers were calibrated within 0.10 mm of collimator rotation axis, and linac isocenter coincidence was within 0.20 mm for all energies. Couch isocenter coincidence was adjusted within 0.20 mm of average linac isocenter. Average radiation-imaging isocentricity for all energies was 0.89 mm (0.80-0.98 mm) for a single imaging isocenter. CONCLUSION: This work provides a method to adjust radiation-imaging coincidence within 1.0 mm for all energies on Elekta's Versa HD.

Intrafraction 4D-cone beam CT acquired during volumetric arc radiotherapy delivery: kV parameter optimization and 4D motion accuracy for lung stereotactic body radiotherapy (SBRT) patients.

PURPOSE: Elekta XVI 5.0 allows for four-dimensional cone beam computed tomography (4D CBCT) image acquisition during treatment delivery to monitor intrafraction motion. These images can have poorer image quality due to undersampling of kV projections and treatment beam MV scatter effects. We determine if a universal intrafraction preset can be used for stereotactic body radiotherapy (SBRT) lung patients and validate the accuracy of target motion characterized by XVI intrafraction 4D CBCT. METHODS: The most critical parameter within the intrafraction preset is the nominal AcquisitionInterval, which controls kV imaging acquisition frequency. An optimal value was determined by maximizing the kV frame number acquired up to 1000 frames, typical of pretreatment 4D CBCT. CIRS motion phantom intrafraction phase images for 16 SBRT beams were obtained. Mean target position, time-weighted standard deviation, and amplitude for these images as well as target motion for three SBRT lung patients were compared to respective pretreatment 4D CBCTs. Evaluation of intrafraction 4D CBCT reconstruction revealed inclusion of MV only images acquired to remove MV scatter effects. A workaround to remove these images was developed. RESULTS: AcquisitionInterval of 0.1°/frame was optimal. The number of kV frames acquired was 567-1116 and showed strong linear correlation with beam monitor unit (MUs). Phantom target motion accuracy was excellent with average differences in target position, standard deviation and amplitude range of ≤0.5 mm. Target tracking for SBRT patients also showed good agreement. Evaluation of phase sorting wave forms showed that inclusion of MV only images significantly impacts intrafraction image reconstruction for patients and use of workaround is necessary. CONCLUSIONS: A universal intrafraction imaging preset can be used safely for SBRT lung patients. The number of kV projections with MV delivery parameters varies; however images with fewer kV projections still provided accurate target position information. Impact of the reconstruction workaround was significant and is mandated for all 4D CBCT intrafraction imaging performed at our institution.

Early detection of potential errors during patient treatment planning.

PURPOSE: Data errors caught late in treatment planning require time to correct, resulting in delays up to 1 week. In this work, we identify causes of data errors in treatment planning and develop a software tool that detects them early in the planning workflow. METHODS: Two categories of errors were studied: data transfer errors and TPS errors. Using root cause analysis, the causes of these errors were determined. This information was incorporated into a software tool which uses ODBC-SQL service to access TPS's Postgres and Mosaiq MSSQL databases for our clinic. The tool then uses a read-only FTP service to scan the TPS unix file system for errors. Detected errors are reviewed by a physicist. Once confirmed, clinicians are notified to correct the error and educated to prevent errors in the future. Time-cost analysis was performed to estimate the time savings of implementing this software clinically. RESULTS: The main errors identified were incorrect patient entry, missing image slice, and incorrect DICOM tag for data transfer errors and incorrect CT-density table application, incorrect image as reference CT, and secondary image imported to incorrect patient for TPS errors. The software has been running automatically since 2015. In 2016, 84 errors were detected with the most frequent errors being incorrect patient entry (35), incorrect CT-density table (17), and missing image slice (16). After clinical interventions to our planning workflow, the number of errors in 2017 decreased to 44. Time savings in 2016 with the software is estimated to be 795 h. This is attributed to catching errors early and eliminating the need to replan cases. CONCLUSIONS: New QA software detects errors during planning, improving the accuracy and efficiency of the planning process. This important QA tool focused our efforts on the data communication processes in our planning workflow that need the most improvement.

Teflon cylindrical phantom for delivery quality assurance of stereotactic body radiotherapy (SBRT).

At our institution the standard delivery quality assurance (DQA) procedure for tomotherapy plans is accomplished with a water equivalent phantom, EDR2 film, and ion chamber point-dose measurements. Most plans deliver at most 5 Gy to the dose plane; however, recently a stereotactic body radiotherapy (SBRT) protocol has produced plans delivering upwards of 12 Gy to the film plane. EDR2 film saturates at a dose of ~ 7 Gy, requiring a modification of our DQA procedure for SBRT plans. To reduce the dose to the film plane and accommodate a possible move to SBRT using Varian RapidArc, a Teflon phantom has been constructed and tested. Our Teflon phantom is cylindrical in shape and of a similar design to the standard phantom. The phantom was MVCT scanned on the TomoTherapy system with images imported into the TomoTherapy and Varian Eclipse planning systems. Phantom images were smoothed to reduce artifacts for treatment planning purposes. Verification SBRT plans were delivered with film and point-dose benchmarked against the standard procedure. Verification tolerance criteria were 3% dose difference for chamber measurements and a gamma pass rate > 90% for film (criteria: 3 mm DTA, 3% dose difference, 10% threshold). The phantom sufficiently reduced dose to the film plane for DQA of SBRT plans. Both planning systems calculated accurate point doses in phantom, with the largest differences being 2.4% and 4.4% for TomoTherapy and Rapid Arc plans. Measured dose distributions correlated well with planning system calculations (γ < 1 for > 95%). These results were comparable to the standard phantom. The Teflon phantom appears to be a potential option for SBRT DQA. Preliminary data show that the planning systems are capable of calculating point doses in the Teflon, and the dose to the film plane is reduced sufficiently to allow for a direct measured DQA without the need for dose rescaling.

Lung SBRT: dosimetric and delivery comparison of RapidArc, TomoTherapy, and IMR.

This study seeks to compare fixed-field intensity-modulated radiation therapy (FF IMRT), RapidArc (RA), and helical tomotherapy (HT) to discover the optimal treatment modality to deliver SBRT to the peripheral lung. Eight patients with peripheral primary lung cancer were reviewed. Plans were prescribed a dose of 48 Gy and optimized similarly with heterogeneity corrections. Plan quality was assessed using conformality index (CI100%), homogeneity index (HI), the ratio of the 50% isodose volume to PTV (R50%) to assess intermediate dose spillage, and normal tissue constraints. Delivery efficiency was evaluated using treatment time and MUs. Dosimetric accuracy was assessed using gamma index (3% dose difference, 3 mm DTA, 10% threshold), and measured with a PTW ARRAY seven29 and OCTAVIUS phantom. CI100%, HI, and R50% were lowest for HT compared to seven-field coplanar IMRT and two-arc coplanar RA (p < 0.05). Normal tissue constraints were met for all modalities, except maximum rib dose due to close proximity to the PTV. RA reduced delivery time by 60% compared to HT, and 40% when compared to FF IMRT. RA also reduced the mean MUs by 77% when compared to HT, and by 22% compared to FF IMRT. All modalities can be delivered accurately, with mean QA pass rates over 97%. For peripheral lung SBRT treatments, HT performed better dosimetrically, reducing maximum rib dose, as well as improving dose conformity and uniformity. RA and FF IMRT plan quality was equivalent to HT for patients with minimal or no overlap of the PTV with the chest wall, but was reduced for patients with a larger overlap. RA and IMRT were equivalent, but the reduced treatment times of RA make it a more efficient modality.

Fast Monte Carlo simulation for total body irradiation using a (60)Co teletherapy unit.

Our institution delivers TBI using a modified Theratron 780 60Co unit. Due to limitations of our treatment planning system in calculating dose for this treatment, we have developed a fast Monte Carlo code to calculate dose distributions within the patient. The algorithm is written in C and uses voxel density information from CT images to calculate dose in heterogeneous media. To test the algorithm, film-based dose measurements were made separately in a simple water phantom with a high-density insert and a RANDO phantom and then compared to doses calculated by the Monte Carlo algorithm. In addition, a separate simulation in GEANT4 was run for the RANDO phantom and compared to both film and the in-house simulation. All results were analyzed using RIT113 film analysis software. Simulations in the water phantom accurately predict the depth of maximum dose in the phantom at 0.5 cm. The measured PDD along the central axis of the beam closely matches the PDD generated from the Monte Carlo code, deviating on average by only 3% along the depth of the water phantom. Dose measured at planes inside the high-density insert had a mean difference of 4.9% on cross-profile measurement. In the RANDO phantom, gamma pass rates vary between 91% and 99% at 3 mm, 3%, and were >99% at 5 mm, 5% for the four film planes measured. Profiles taken across the film and both simulations resulted in mean relative differences of < 2% for all profiles in each slice measured. The Monte Carlo algorithm presented here is potentially a viable method for calculating dose distributions delivered in TBI treatments at our center. While not yet refined enough to be the primary method of treatment planning, the algorithm at its current resolution determines the dose distribution for one patient within a few hours, and provides clinically useful information in planning TBI. With appropriate optimization, the Monte Carlo method presented here could potentially be implemented as a first-line treatment planning option for 60Co TBI.