Irradiator Commissioning and Dosimetry for Assessment of LQ α and ß Parameters, Radiation Dosing Schema, and in vivo Dose Deposition.

Radiation dosimetry is critical in the accurate delivery and reproducibility of radiation schemes in preclinical models for high translational relevance. Prior to performing any in vitro or in vivo experiments, the specific dose output for the irradiator and individual experimental designs must be assessed. Using an ionization chamber, electrometer, and solid water setup, the dose output of wide fields at isocenter can be determined. Using a similar setup with radiochromic films in the place of the ionization chamber, dose rates for smaller fields at different depths can also be determined. In vitro clonogenic survival assays of cancer cells in response to radiation treatment are inexpensive experiments that provide a measure of inherent radio-sensitivity of cell lines by fitting these data with the traditional linear-quadratic model. Model parameters estimated from these assays, combined with the principles of biologic effective doses, allows one to develop varying fractionation schedules for radiation treatment that provide equivalent effective doses in tumor-bearing animal experiments. This is an important factor to consider and correct for in comparing in vivo radiation therapy schedules to eliminate potential confounding of results due to variance in the delivered effective doses. Taken together, this article provides a general method for dose output verification preclinical animal and cabinet irradiators, in vitro assessment of radio-sensitivity, and verification of radiation delivery in small living organisms.

Report of Task Group 201 of the American Association of Physicists in Medicine: Quality management of external beam therapy data transfer.

With the advancement of data-intensive technologies, such as image-guided radiation therapy (IGRT) and intensity-modulated radiation therapy (IMRT), the amount and complexity of data to be transferred between clinical subsystems have increased beyond the reach of manual checking. As a result, unintended treatment deviations (e.g., dose errors) may occur if the treatment system is not closely monitored by a comprehensive data transfer quality management program (QM). This report summarizes the findings and recommendations from the task group (TG) on quality assurance (QA) of external beam treatment data transfer (TG-201), with the aim to assist medical physicists in designing their own data transfer QM. As a background, a section of this report describes various models of data flow (distributed data repositories and single data base systems) and general data test characteristics (data integrity, interpretation, and consistency). Recommended tests are suggested based on the collective experience of TG-201 members. These tests are for the acceptance of, commissioning of, and upgrades to subsystems that store and/or modify clinical treatment data. As treatment complexity continues to evolve, we will need to do and know more about ensuring the quality of data transfers. The report concludes with the recommendation to move toward data transfer open standards compatibility and to develop tools that automate data transfer QA.

Impact of Tumor Size on Local Control and Pneumonitis After Stereotactic Body Radiation Therapy for Lung Tumors.

PURPOSE: Stereotactic body radiation therapy (SBRT) is commonly used to treat primary or oligometastatic malignancies in the lung, but most of the available data that describe the safety and efficacy of SBRT are for smaller tumors. The purpose of this study was to evaluate the impact of tumor size, among other factors, on local control (LC) and radiation pneumonitis (RP) in patients who received lung SBRT. METHODS AND MATERIALS: This retrospective study included 144 patients with 100 primary (57.1%) and 75 metastatic (42.9%) lung tumors treated with SBRT between 2012 and 2018. Measurements of tumor size, treatment volume, histology, and radiation dose were evaluated for association with LC. Additional factors evaluated for association with the development of symptomatic RP included volume of the lung, heart, and central airway exposed to relevant doses of radiation. RESULTS: The median follow-up time was 15.0 months (interquartile range, 8.0-26.0 months). LC rates at 12 and 24 months posttreatment were 95.1% and 92.7%, respectively. LC at 1 year was higher for tumors <5 cm in diameter than for tumors >5 cm in diameter (98.2% vs 79.8%, respectively; P < .01). On univariate analysis, LC was associated with a smaller gross tumor volume (GTV) diameter (P < .01), GTV volume (P < .01), planning target volume (PTV) diameter (P < .01), PTV volume (P < .01), and larger PTV-to-GTV ratio (P = .04). Tumor histology and treatment intent were not correlated with LC. RP was associated with a higher ipsilateral lung mean lung dose (P = .02), V2.5 (P = .03), V5 (P = .02), V13 (P = .03), V20 (P = .05), V30 (P = .02), V40 (P = .02), and V50 (P = .03), and several similar total lung dose parameters and heart maximum point dose (P = .02). The optimal mean ipsilateral lung dose cutoff predictive of RP was 8.6 Gy. CONCLUSIONS: A larger tumor size and smaller PTV-to-GTV ratio was associated with local recurrence of lung tumors treated with SBRT, but ipsilateral lung doses were most associated with symptomatic RP.

The dosimetric effects of limited elective nodal irradiation in volumetric modulated arc therapy treatment planning for locally advanced non-small cell lung cancer.

OBJECTIVE: Contemporary radiotherapy guidelines for locally advanced non-small cell lung carcinoma (LA-NSCLC) recommend omitting elective nodal irradiation, despite the fact that evidence supporting this came primarily from older reports assessing comprehensive nodal coverage using 3D conformal techniques. Herein, we evaluated the dosimetric implications of the addition of limited elective nodal irradiation (LENI) to standard involved field irradiation (IFI) using volumetric modulated arc therapy (VMAT) planning. METHOD: Target volumes and organs-at-risk (OARs) were delineated on CT simulation images of 20 patients with LA-NSCLC. Two VMAT plans (IFI and LENI) were generated for each patient. Involved sites were treated to 60 Gy in 30 fractions for both IFI and LENI plans. Adjacent uninvolved nodal regions, considered high risk based on the primary tumor site and extent of nodal involvement, were treated to 51 Gy in 30 fractions in LENI plans using a simultaneous integrated boost approach. RESULTS: All planning objectives for PTVs and OARs were achieved for both IFI and LENI plans. LENI resulted in significantly higher esophagus Dmean (15.3 vs. 22.5 Gy, p < 0.01), spinal cord Dmax (34.9 vs. 42.4 Gy, p = 0.02) and lung Dmean (13.5 vs. 15.9 Gy, p = 0.02), V20 (23.0 vs. 27.9%, p = 0.03), and V5 (52.6 vs. 59.4%, p = 0.02). No differences were observed in heart parameters. On average, only 32.2% of the high-risk nodal volume received an incidental dose of 51 Gy when untargeted in IFI plans. CONCLUSION: The addition of LENI to VMAT plans for LA-NSCLC is feasible, with only modestly increased doses to OARs and marginal expected increase in associated toxicity.

Lung diaphragm tracking in CBCT images using spatio-temporal MRF.

In EBRT in order to monitor the intra fraction motion of thoracic and abdominal tumors, one of the standard approaches is to use the lung diaphragm apex as an internal marker. However, tracking the position of the apex from image based observations is a challenging problem, as it undergoes both position and shape variation. The purpose of this paper is to propose an alternative method for tracking the ipsi-lateral hemidiaphragm apex (IHDA) position on Cone Beam Computed Tomography (CBCT) projection images. A hierarchical method is proposed to track the IHDA position across the frames. The diaphragm state is modeled as a spatio-temporal Markov Random Field (MRF). The likelihood function is derived from the votes based on 4D-Hough space. The optimal state of the diaphragm is obtained by solving the associated energy minimization problem using graph-cuts. A heterogeneous GPU implementation is provided for the method using CUDA framework and the performance is compared with that of CPU implementation. The method was tested using 15 clinical CBCT images. The results demonstrate that the MRF formulation outperforms the full search method in terms of accuracy. The GPU based heterogeneous implementation of the proposed algorithm takes about 25s, which is 16% improvement over the existing benchmark. The proposed MRF formulation considers all the possible combinations from the 4D-Hough space and therefore results in better tracking accuracy. The GPU based implementation exploits the inherent parallelism in our algorithm to accelerate the performance thereby increasing the viability of the approach for clinical use.

Tumor control probability reduction in gated radiotherapy of non-small cell lung cancers: a feasibility study.

We studied the feasibility of evaluating tumor control probability (TCP) reductions for tumor motion beyond planned gated radiotherapy margins. Tumor motion was determined from cone-beam CT projections acquired for patient setup, intrafraction respiratory traces, and 4D CTs for five non-small cell lung cancer (NSCLC) patients treated with gated radiotherapy. Tumors were subdivided into 1 mm sections whose positions and doses were determined for each beam-on time point. (The dose calculation model was verified with motion phantom measurements.) The calculated dose distributions were used to generate the treatment TCPs for each patient. The plan TCPs were calculated from the treatment planning dose distributions. The treatment TCPs were compared to the plan TCPs for various models and parameters. Calculated doses matched phantom measurements within 0.3% for up to 3 cm of motion. TCP reductions for excess motion greater than 5mm ranged from 1.7% to 11.9%, depending on model parameters, and were as high as 48.6% for model parameters that simulated an individual patient. Repeating the worst case motion for all fractions increased TCP reductions by a factor of 2 to 3, while hypofractionation decreased these reductions by as much as a factor of 3. Treatment motion exceeding gating margins by more than 5 mm can lead to considerable TCP reductions. Appropriate margins for excess motion are recommended, unless applying daily tumor motion verification and adjusting thegating window.

Equivalent-quality unflattened photon beam modeling, planning, and delivery.

The clinical application of the flattening filter-free photon beam (FFF) has enjoyed greater use due to its advantage of reduced treatment time because of the increased dose rate. Its unique beam characteristics, along with the very high-dose rate, require a thorough knowledge of the capability and accuracy in FFF beam modeling, planning, and delivery. This work verifies the feasibility of modeling an equivalent quality unflattened photon beam (eqUF), and the dosimetric accuracy in eqUF beam planning and delivery. An eqUF beam with a beam quality equivalent to a conventional 6 MV photon beam with the filter in place (WF) was modeled for the Pinnacle3 TPS and the beam model quality was evaluated by gamma index test. Results showed that the eqUF beam modeling was similar to that of the WF beam, as the overall passing rate of the 2%/2 mm gamma index test was 99.5% in the eqUF beam model and 96% in the WF beam model. Hypofractionated IMRT plans were then generated with the same constraints using both WF and eqUF beams, and the similarity was evaluated by DVH comparison and generalized 3D gamma index test. The WF and eqUF plans showed no clinically significant differences in DVH comparison and, on average > 98% voxels passed the 3%/3 mm 3D gamma index test. Dosimetric accuracy in gated phantom delivery was verified by ion chamber and film measurements. All ion chamber measurements at the isocenter were within 1% of calculated values and film measurements passed the 3 mm/3% gamma index test with an overall passing rate > 95% in the high-dose and low-gradient region in both WF and eqUF cases. Treatment plan quality assurance (QA), using either measurement-based or independent calculation-based methods of ten clinically treated eqUF IMRT plans were analyzed. In both methods, the point dose differences were all within 2% difference. In the relative 2D dose distribution comparison, >95% points were within 3% dose difference or 3 mm DTA.

A new method of diaphragm apex motion detection from 2D projection images of mega-voltage cone beam CT.

To present a new method of estimating 3D positions of the ipsi-lateral hemi-diaphragm apex (IHDA) from 2D projection images of mega-voltage cone beam CT (MVCBCT). The detection framework reconstructs a 3D volume from all the 2D projection images. An initial estimated 3D IHDA position is determined in this volume based on an imaging processing pipeline, including Otsu thresholding, connected component labeling and template matching. This initial position is then projected onto each 2D projection image to create a region of interest (ROI). To accurately detect the IHDA position in 2D projection space, two methods, dynamic Hough transform (DHT) and a tracking approach based on a joint probability density function (PDF) are developed. Both methods utilize a double-parabola model to fit the 2D diaphragm boundary. The 3D IHDA motion in the superior-inferior (SI) direction is estimated from the initial static 3D position and the detected 2D positions in projection space. The two Hough-based detection methods are tested on 35 MVCBCT scans from 15 patients. The detection is compared to manually identified IHDA positions in 2D projection space by three clinicians. An average and standard deviation of 4.252 ± 3.354 and 2.485 ± 1.750 mm was achieved for DHT and tracking-based approaches respectively, compared with the inter-expert variance among three experts of 1.822 ± 1.106 mm. Based on the results of the scans, the PDF tracking-based approach appears more robust than the DHT. The combination of the automatic ROI localization and the tracking-based approach is a quicker and more accurate method of extracting 3D IHDA motion from 2D projection images.

Motion-compensated mega-voltage cone beam CT using the deformation derived directly from 2D projection images.

This paper presents a novel method for respiratory motion compensated reconstruction for cone beam computed tomography (CBCT). The reconstruction is based on a time sequence of motion vector fields, which is generated by a dynamic geometrical object shape model. The dynamic model is extracted from the 2D projection images of the CBCT. The process of the motion extraction is converted into an optimal 3D multiple interrelated surface detection problem, which can be solved by computing a maximum flow in a 4D directed graph. The method was tested on 12 mega-voltage (MV) CBCT scans from three patients. Two sets of motion-artifact-free 3D volumes, full exhale (FE) and full inhale (FI) phases, were reconstructed for each daily scan. The reconstruction was compared with three other motion-compensated approaches based on quantification accuracy of motion and size. Contrast-to-noise ratio (CNR) was also quantified for image quality. The proposed approach has the best overall performance, with a relative tumor volume quantification error of 3.39 ± 3.64% and 8.57 ± 8.31% for FE and FI phases, respectively. The CNR near the tumor area is 3.85 ± 0.42 (FE) and 3.58 ± 3.33 (FI). These results show the clinical feasibility to use the proposed method to reconstruct motion-artifact-free MVCBCT volumes.

Dosimetric properties of a beam quality-matched 6 MV unflattened photon beam.

The purpose of this study was to report the characteristics of an equivalent quality unflattened (eqUF) photon beam in clinical implementation and to provide a generalized method to describe unflattened (UF) photon beam profiles. An unflattened photon beam with a beam quality equivalent to the corresponding flat 6 MV photon beam (WF) was obtained by removing the flattening filter from a Siemens ONCOR Avant-Garde linear accelerator and adjusting the photon energy. A method independent from the WF beam profile was presented to describe UF beam profiles and other selected beam characteristics were examined. The short-term beam stability was examined by dynamic beam profiles, recorded every 0.072 s in static and gated delivery, and the long-term stability was evidenced by the five-year clinical quality assurance records. The dose rate was raised fivefold using the eqUF beam. The depth of maximum dose (d(max)) shifted 3 mm deeper, but the percent depth dose beyond d(max) was very similar to that of the WF beam. The surface dose and out-of-field dose were lower, but the penumbra was slightly wider. The variation in head scatter and phantom scatter with changes in field size was smaller; the variation in the profile shape with change in depth was also smaller. The eqUF beam is stable 0.072 s after the beam is turned on, and the five-year beam stability was comparable to that of the WF beam. A fivefold dose rate increase was observed in the eqUF beam with similar beam characteristics to other reported UF beam data except for a deeper dmax and a slightly wider penumbra. The initial and long-term stability of the eqUF beam profile is on parity with the WF beam. The UF beam profile can be described in the generalized method independently without relying on the WF beam profile.

A real-time respiratory motion monitoring system using KINECT: proof of concept.

PURPOSE: The purpose of this study is to investigate the feasibility of a low-cost respiratory motion monitoring system based on the Microsoft KINECT sensor. METHODS: The authors increased KINECT's inherent depth resolution from 1 cm to 1 mm via a motion magnification system. Using the KINECT software development kit, the authors programmed the KINECT to capture depth images and determine the average depth over a thoracic region of interest, viewed almost parallel to the subject's surface. KINECT respiratory traces (average depth vs time at a rate of 30 Hz) were acquired from four volunteers and compared with those simultaneously acquired using a commercially available strain gauge respiratory gating system. RESULTS: The correlation coefficient (CC) between KINECT and strain gauge traces varied from 0.958 to 0.978, with a mean CC of 0.969. This strong correlation was also demonstrated by the joint probability distribution and visual inspection. CONCLUSIONS: It is feasible to use the KINECT for respiratory motion tracking. Traces are similar to those of a clinically used strain gauge system. The KINECT-based system provides a new and economical way to monitor respiratory motion.

3D lung tumor motion model extraction from 2D projection images of mega-voltage cone beam CT via optimal graph search.

In this paper, we propose a novel method to convert segmentation of objects with quasi-periodic motion in 2D rotational cone beam projection images into an optimal 3D multiple interrelated surface detection problem, which can be solved by a graph search framework. The method is tested on lung tumor segmentation in projection images of mega-voltage cone beam CT (MVCBCT). A 4D directed graph is constructed based on an initialized tumor mesh model, where the cost value for this graph is computed from the point location of a silhouette outline of projected tumor mesh in 2D projection images. The method was first evaluated on four different sized phantom inserts (all above 1.9 cm in diameter) with a predefined motion of 3.0 cm to mimic the imaging of lung tumors. A dice coefficient of 0.87 +/- 0.03 and a centroid error of 1.94 +/- 1.31 mm were obtained. Results based on 12 MVCBCT scans from 3 patients obtained 0.91 +/- 0.03 for dice coefficient and 1.83 +/- 1.31 mm for centroid error, compared with a difference between two sets of independent manual contours of 0.89 +/- 0.03 and 1.61 +/- 1.19 mm, respectively.

Feasibility of using respiratory correlated mega voltage cone beam computed tomography to measure tumor motion.

The purpose of this study was to test the feasibility of using respiratory correlated mega voltage cone-beam computed tomography (MVCBCT), taken during patient localization, to quantify the size and motion of lung tumors. An imaging phantom was constructed of a basswood frame embedded with six different-sized spherical pieces of paraffin wax. The Quasar respiratory motion phantom was programmed to move the imaging phantom using typical respiratory motion. The moving imaging phantom was scanned using various MVCBCT imaging parameters, including two beam line types, two protocols with different ranges of rotation and different imaging doses. A static phantom was also imaged as a control. For all the 3D volumetric images, the contours of the six spherical inserts were measured manually. Compared with the nominal sphere diameter, the average relative error in the size of the respiratory correlated MVCBCT spheres ranged from 5.3% to 12.6% for the four largest spheres, ranging in size from 3.6 cc to 29 cc. Larger errors were recorded for the two smallest inserts. The average relative error in motion was 5.1% smaller than the programmed amplitude of 3.0 cm. We are able to conclude that it is feasible to use respiratory correlated MVCBCT to quantify tumor motion for lung cancer patients.

Diaphragm motion quantification in megavoltage cone-beam CT projection images.

PURPOSE: To quantify diaphragm motion in megavoltage (MV) cone-beam computed tomography (CBCT) projections. METHODS: User identified ipsilateral hemidiaphragm apex (IHDA) positions in two full exhale and inhale frames were used to create bounding rectangles in all other frames of a CBCT scan. The bounding rectangle was enlarged to create a region of interest (ROI). ROI pixels were associated with a cost function: The product of image gradients and a gradient direction matching function for an ideal hemidiaphragm determined from 40 training sets. A dynamic Hough transform (DHT) models a hemidiaphragm as a contour made of two parabola segments with a common vertex (the IHDA). The images within the ROIs are transformed into Hough space where a contour's Hough value is the sum of the cost function over all contour pixels. Dynamic programming finds the optimal trajectory of the common vertex in Hough space subject to motion constraints between frames, and an active contour model further refines the result. Interpolated ray tracing converts the positions to room coordinates. Root-mean-square (RMS) distances between these positions and those resulting from an expert's identification of the IHDA were determined for 21 Siemens MV CBCT scans. RESULTS: Computation time on a 2.66 GHz CPU was 30 s. The average craniocaudal RMS error was 1.38 +/- 0.67 mm. While much larger errors occurred in a few near-sagittal frames on one patient's scans, adjustments to algorithm constraints corrected them. CONCLUSIONS: The DHT based algorithm can compute IHDA trajectories immediately prior to radiation therapy on a daily basis using localization MVCBCT projection data. This has potential for calibrating external motion surrogates against diaphragm motion.

A rapid communication from the AAPM Task Group 201: recommendations for the QA of external beam radiotherapy data transfer. AAPM TG 201: quality assurance of external beam radiotherapy data transfer.

The transfer of radiation therapy data among the various subsystems required for external beam treatments is subject to error. Hence, the establishment and management of a data transfer quality assurance program is strongly recommended. It should cover the QA of data transfers of patient specific treatments, imaging data, manually handled data and historical treatment records. QA of the database state (logical consistency and information integrity) is also addressed to ensure that accurate data are transferred.

Information technology resource management in radiation oncology.

The ever-increasing data demands in a radiation oncology (RO) clinic require medical physicists to have a clearer understanding of the information technology (IT) resource management issues. Clear lines of collaboration and communication among administrators, medical physicists, IT staff, equipment service engineers and vendors need to be established. In order to develop a better understanding of the clinical needs and responsibilities of these various groups, an overview of the role of IT in RO is provided. This is followed by a list of IT related tasks and a resource map. The skill set and knowledge required to implement these tasks are described for the various RO professionals. Finally, various models for assessing one's IT resource needs are described. The exposition of ideas in this white paper is intended to be broad, in order to raise the level of awareness of the RO community; the details behind these concepts will not be given here and are best left to future task group reports.

Deriving motion from megavoltage localization cone beam computed tomography scans.

Cone beam computed tomography (CBCT) projection data consist of views of a moving point (e.g. diaphragm apex). The point is selected in identification views of extreme motion (two inhale, two exhale). The room coordinates of the extreme points are determined by source-to-view ray tracing intersections. Projected to other views, these points become opposite corners of a motion-bounding box. The view coordinates of the point, relative to the box, are used to interpolate between extreme room coordinates. Along with the views' time stamps, this provides the point's room coordinates as a function of time. CBCT-derived trajectories of a tungsten pin, moving 3 cm cranio-caudally and 1 cm elsewhere, deviate from expected ones by at most 1.06 mm. When deviations from the ideal imaging geometry are considered, mean errors are less than 0.2 mm. While CBCT-derived cranio-caudal positions are insensitive to the choice of identification views, the bounding box determination requires view separations between 15 and 163 degrees . Inhale views with the two largest amplitudes should be used, though corrections can account for different amplitudes. The information could be used to calibrate motion surrogates, adaptively define phase triggers immediately before gated radiotherapy and provide phase and amplitude sorting for 4D CBCT.

Leakage reduction for the Siemens Moduleaf.

The Moduleaf, an add-on miniature multileaf collimator (MMLC) for the Siemens Oncor linear accelerator, provides high resolution field shaping with a maximum inter-leaf leakage dose of 1.50% at 6 MV. However, beyond the maximum treatment field size, the distribution of leakage and scatter along the y axis is different from that of the x axis, with maximum leakage values of 1.53% and 0.39%, respectively. Such differences can not be modeled in the Pinnacle treatment planning system. Also, within the 10 cm x 12 cm treatment region, leakage from the crack between closed leaf ends was 3.76%. To resolve these issues, gaps in the Moduleaf frame were filled with lead sheets, and the Siemens MLC was operated in MLC mode, rather than bank mode, so that a rectangle of 10.4 cm x 11 cm was formed with the MLC leaves closed behind the Y jaws, whose opening was 10.4 cm. This significantly reduced the difference between the leakage patterns in the x and y directions, with maximum leakage doses of 0.43% outside the treatment region and 1.67% near the crack between abutting Moduleaf leaves. The modification also reduced the mean square error between Pinnacle profiles and measured profiles in the tail region.