A remote EPID-based dosimetric TPS-planned audit of centers for clinical trials: outcomes and analysis of contributing factors.

BACKGROUND: A novel remote method for external dosimetric TPS-planned auditing of intensity modulated radiotherapy (IMRT) and volumetric modulated arc therapy (VMAT) for clinical trials using electronic portal imaging device (EPID) has been developed. The audit has been applied to multiple centers across Australia and New Zealand. This work aims to assess the audit outcomes and explores the variables that contributed to the audit results. METHODS: Thirty audits were performed of 21 radiotherapy facilities, 17 facilities underwent IMRT audits and 13 underwent VMAT audits. The assessment was based on comparisons between the delivered doses derived from images acquired with EPIDs and planned doses from the local treatment planning systems (TPS). Gamma pass-rate (GPR) and gamma mean value (GMV) were calculated for each IMRT field and VMAT arc (total 268 comparisons). A multiple variable linear model was applied to the GMV results (3%/3 mm criteria) to assess the influence and significance of explanatory variables. The explanatory variables were Linac-TPS combination, TPS grid resolution, IMRT/VMAT delivery, age of EPID, treatment site, record and verification system (R&V) type and dose-rate. Finally, the audit results were compared with other recent audits by calculating the incidence ratio (IR) as a ratio of the observed mean/median GPRs for the remote audit to the other audits. RESULTS: The average (± 1 SD) of the centers' GPRs were: 99.3 ± 1.9%, 98.6 ± 2.7% & 96.2 ± 5.5% at 3%, 3 mm, 3%, 2 mm and 2%, 2 mm criteria respectively. The most determinative variables on the GMVs were Linac-TPS combination, TPS grid resolution and IMRT/VMAT delivery type. The IR values were 1 for seven comparisons, indicating similar GPRs of the remote audit with the reference audits and > 1 for four comparisons, indicating higher GPRs of the remote audit than the reference audits. CONCLUSION: The remote dosimetry audit method for clinical trials demonstrated high GPRs and provided results comparable to established more resource-intensive audit methods. Several factors were found to influence the results including some effect of Linac-TPS combination.

Real-time intrafraction prostate motion during linac based stereotactic radiotherapy with rectal displacement.

BACKGROUND: Kilovoltage Intrafraction Monitoring (KIM) is a method which determines the three-dimensional position of the prostate from two-dimensional kilovoltage (kV) projections taken during linac based radiotherapy treatment with real-time feedback. Rectal displacement devices (RDDs) allow for improved rectal dosimetry during prostate cancer treatment. This study used KIM to perform a preliminary investigation of prostate intrafraction motion observed in patients with an RDD in place. METHODS: Ten patients with intermediate to high-risk prostate cancer were treated with a Rectafix RDD in place during two boost fractions of 9.5-10 Gy delivered using volumetric modulated arc therapy (VMAT) on Clinac iX and Truebeam linacs. Two-dimensional kV projections were acquired during treatment. KIM software was used following treatment to determine the displacement of the prostate over time. The displacement results were analyzed to determine the percentage of treatment time the prostate spent within 1 mm, between 1 and 2 mm, between 2 and 3 mm and greater than 3 mm from its initial position. RESULTS: KIM successfully measured displacement for 19 prostate stereotactic boost fractions. The prostate was within 1 mm of its initial position for 84.8%, 1-2 mm for 14%, 2-3 mm 1.2% and ≥3 mm only 0.4% of the treatment time. CONCLUSIONS: In this preliminary study using KIM, KIM was successfully used to measure prostate intrafraction motion, which was found to be small in the presence of a rectal displacement device. TRIAL REGISTRATION: The Hunter New England Human Research Ethics Committee reference number is 14/08/20/3.01.

Technical note: TROG 15.01 SPARK trial multi-institutional imaging dose measurement.

PURPOSE: The Trans-Tasman Radiation Oncology Group (TROG) 15.01 Stereotactic Prostate Adaptive Radiotherapy utilizing Kilovoltage intrafraction monitoring (SPARK) trial is a multicenter trial using Kilovoltage Intrafraction Monitoring (KIM) to monitor prostate position during the delivery of prostate radiation therapy. KIM increases the accuracy of prostate radiation therapy treatments and allows for hypofractionation. However, an additional imaging dose is delivered to the patient. A standardized procedure to determine the imaging dose per frame delivered using KIM was developed and applied at four radiation therapy centers on three different types of linear accelerator. METHODS: Dose per frame for kilovoltage imaging in fluoroscopy mode was measured in air at isocenter using an ion chamber. Beam quality and dose were determined for a Varian Clinac iX linear accelerator, a Varian Trilogy, four Varian Truebeams and one Elekta Synergy at four different radiation therapy centers. The imaging parameters used on the Varian machines were 125 kV, 80 mA, and 13 ms. The Elekta machine was measured at 120 kV, 80 mA, and 12 ms. Absorbed doses to the skin and the prostate for a typical SBRT prostate treatment length were estimated according to the IPEMB protocol. RESULTS: The average dose per kV frame to the skin was 0.24 ± 0.03 mGy. The average estimated absorbed dose to the prostate for all five treatment fractions across all machines measured was 39.9 ± 2.6 mGy for 1 Hz imaging, 199.7 ± 13.2 mGy for 5 Hz imaging and 439.3 ± 29.0 mGy for 11 Hz imaging. CONCLUSIONS: All machines measured agreed to within 20%. Additional dose to the prostate from using KIM is at most 1.3% of the prescribed dose of 36.25 Gy in five fractions delivered during the trial.

Rectal protection in prostate stereotactic radiotherapy: a retrospective exploratory analysis of two rectal displacement devices.

INTRODUCTION: High rectal doses are associated with increased toxicity. A rectal displacement device (RDD) reduces rectal dose in prostate stereotactic body radiation therapy (SBRT). This study investigates any dosimetric difference between two methods of rectal displacement (Rectafix and SpaceOAR) for prostate SBRT. METHODS: Rectal dosimetry of 45 men who received SBRT within the PROMETHEUS trial was retrospectively examined, across two radiation therapy centres using the two RDD's. Men received a total dose (TD) of 19 or 20 Gy in two fractions followed by 46 Gy in 23 fractions. Centre 1 contributed 16 Rectafix and 10 SpaceOAR patients. Centre 2 contributed 19 Rectafix patients. Rectal dose volume histogram (DVH) data were recorded as a TD percentage at the following volume intervals; V1%, V2%, V5%, V10% and then 10% increments to V80%. As only one centre employed both RDD's, three sequential rectal dosimetry comparisons were performed; (1) centre 1 Rectafix versus centre 1 SpaceOAR; (2) centre 1 Rectafix versus centre 2 Rectafix and (3) centre 1+ centre 2 Rectafix versus centre 1 SpaceOAR. RESULTS: In comparison (1) Rectafix demonstrated lower mean doses at 9 out of 11 measured intervals (P = 0.0012). Comparison (2) demonstrated a moderate difference with centre 2 plans producing slightly lower rectal doses (P = 0.013). Comparison (3) further demonstrated that Rectafix returned lower mean doses than SpaceOAR (P < 0.001). Although all dose levels were in favour of Rectafix, in absolute terms differences were small (2.6-9.0%). CONCLUSIONS: In well-selected prostate SBRT patients, Rectafix and SpaceOAR RDD's provide approximately equivalent rectal sparing.

Virtual EPID standard phantom audit (VESPA) for remote IMRT and VMAT credentialing.

A virtual EPID standard phantom audit (VESPA) has been implemented for remote auditing in support of facility credentialing for clinical trials using IMRT and VMAT. VESPA is based on published methods and a clinically established IMRT QA procedure, here extended to multi-vendor equipment. Facilities are provided with comprehensive instructions and CT datasets to create treatment plans. They deliver the treatment directly to their EPID without any phantom or couch in the beam. In addition, they deliver a set of simple calibration fields per instructions. Collected EPID images are uploaded electronically. In the analysis, the dose is projected back into a virtual cylindrical phantom. 3D gamma analysis is performed. 2D dose planes and linear dose profiles are provided and can be considered when needed for clarification. In addition, using a virtual flat-phantom, 2D field-by-field or arc-by-arc gamma analyses are performed. Pilot facilities covering a range of planning and delivery systems have performed data acquisition and upload successfully. Advantages of VESPA are (1) fast turnaround mainly driven by the facility's capability of providing the requested EPID images, (2) the possibility for facilities performing the audit in parallel, as there is no need to wait for a phantom, (3) simple and efficient credentialing for international facilities, (4) a large set of data points, and (5) a reduced impact on resources and environment as there is no need to transport heavy phantoms or audit staff. Limitations of the current implementation of VESPA for trials credentialing are that it does not provide absolute dosimetry, therefore a Level I audit is still required, and that it relies on correctly delivered open calibration fields, which are used for system calibration. The implemented EPID based IMRT and VMAT audit system promises to dramatically improve credentialing efficiency for clinical trials and wider applications.

Real-time in vivo rectal wall dosimetry using MOSkin detectors during linac based stereotactic radiotherapy with rectal displacement.

BACKGROUND: MOSFET dosimetry is a method that has been used to measure in-vivo doses during brachytherapy treatments and during linac based radiotherapy treatment. Rectal displacement devices (RDDs) allow for safe dose escalation for prostate cancer treatment. This study used dual MOSkin detectors to assess real-time in vivo rectal wall dose in patients with an RDD in place during a high dose prostate stereotactic body radiation therapy (SBRT) boost trial. METHODS: The PROMETHEUS study commenced in 2014 and provides a prostate SBRT boost dose with a RDD in place. Twelve patients received two boost fractions of 9.5-10 Gy each delivered to the prostate with a dual arc volumetric modulated arc therapy (VMAT) technique. Two MOSkins in a face-to-face arrangement (dual MOSkin) were used to decrease angular dependence. A dual MOSkin was attached to the anterior surface of the Rectafix and read out at 1 Hz during each treatment. The planned dose at each measurement point was exported from the planning system and compared with the measured dose. The root mean square error normalised to the total planned dose was calculated for each measurement point and treatment arc for the entire course of treatment. RESULTS: The average difference between the measured and planned doses over the whole course of treatment for all arcs measured was 9.7% with a standard deviation of 3.6%. The cumulative MOSkin reading was lower than the total planned dose for 64% of the arcs measured. The average difference between the final measured and final planned doses for all arcs measured was 3.4% of the final planned dose, with a standard deviation of 10.3%. CONCLUSIONS: MOSkin detectors were an effective tool for measuring dose delivered to the anterior rectal wall in real time during prostate SBRT boost treatments for the purpose of both ensuring the rectal doses remain within acceptable limits during the treatment and for the verification of final rectal doses.

The first clinical implementation of a real-time six degree of freedom target tracking system during radiation therapy based on Kilovoltage Intrafraction Monitoring (KIM).

PURPOSE: We present the first clinical implementation of a real-time six-degree of freedom (6DoF) Kilovoltage Intrafraction Monitoring (KIM) system which tracks the cancer target translational and rotational motions during treatment. The method was applied to measure and correct for target motion during stereotactic body radiotherapy (SBRT) for prostate cancer. METHODS: Patient: A patient with prostate adenocarcinoma undergoing SBRT with 36.25Gy, delivered in 5 fractions was enrolled in the study. 6DoF KIM technology: 2D positions of three implanted gold markers in each of the kV images (125kV, 10mA at 11Hz) were acquired continuously during treatment. The 2D→3D target position estimation was based on a probability distribution function. The 3D→6DoF target rotation was calculated using an iterative closest point algorithm. The accuracy and precision of the KIM method was measured by comparing the real-time results with kV-MV triangulation. RESULTS: Of the five treatment fractions, KIM was utilised successfully in four fractions. The intrafraction prostate motion resulted in three couch shifts in two fractions when the prostate motion exceeded the pre-set action threshold of 2mm for more than 5s. KIM translational accuracy and precision were 0.3±0.6mm, -0.2±0.3mm and 0.2±0.7mm in the Left-Right (LR), Superior-Inferior (SI) and Anterior-Posterior (AP) directions, respectively. The KIM rotational accuracy and precision were 0.8°±2.0°, -0.5°±3.3° and 0.3°±1.6° in the roll, pitch and yaw directions, respectively. CONCLUSION: This treatment represents, to the best of our knowledge, the first time a cancer patient's tumour position and rotation have been monitored in real-time during treatment. The 6 DoF KIM system has sub-millimetre accuracy and precision in all three translational axes, and less than 1° accuracy and 4° precision in all three rotational axes.