Skin dose rate conversion factors after contamination with radiopharmaceuticals: influence of contamination area, epidermal thickness and percutaneous absorption.

Skin contamination with radiopharmaceuticals can occur during biomedical research and daily nuclear medicine practice as a result of accidental spills, after contact with bodily fluids of patients or by inattentively touching contaminated materials. Skin dose assessment should be carried out by repeated quantification to map the course of the contamination together with the use of appropriate skin dose rate conversion factors. Contamination is generally characterised by local spots on the palmar surface of the hand and complete decontamination is difficult as a result of percutaneous absorption. This specific issue requires special consideration as to the skin dose rate conversion factors as a measure for the absorbed dose rate to the basal layer of the epidermis. In this work we used Monte Carlo simulations to study the influence of the contamination area, the epidermal thickness and the percutaneous absorption on the absorbed skin dose rate conversion factors for a set of 39 medical radionuclides. The results show that the absorbed dose to the basal layer of the epidermis can differ by up to two orders of magnitude from the operational quantity Hp(0.07) when using an appropriate epidermal thickness in combination with the effect of percutaneous absorption.

Phase II study of helical tomotherapy for oligometastatic colorectal cancer.

BACKGROUND: To evaluate the efficacy and toxicity of helical tomotherapy in the treatment of oligometastatic colorectal cancer (CRC) patients who were not amenable for metastasectomy and/or (further) systemic treatment. PATIENTS AND METHODS: CRC patients with five or less metastases were enrolled. No limitations concerning dimension or localization of the metastases were imposed. Patients were treated with intensity-modulated and image-guided radiotherapy using helical tomotherapy, delivering a total dose of 40 Gy in fractions of 4 Gy. Positron emission tomography-computed tomography (PET-CT) was carried out at baseline and 3 months after the initiation of radiotherapy to evaluate the metabolic response rate according to PET Response Criteria in Solid Tumors (PERCIST) version 1.0. Side-effects were scored using National Cancer Institute Common Terminology Criteria for Adverse Events (NCI-CTC AE) version 3.0. RESULTS: Twenty-three patients were enrolled. A total of 52 metastases were treated. One patient (4%) experienced grade 3 vomiting; two patients (9%) grade 2 diarrhea and dysphagia, respectively. Twenty-two patients were evaluated by post-treatment PET-CT. Five (23%) and seven patients (32%) achieved a complete and partial metabolic response, respectively, resulting in an overall metabolic response rate of 55%. The actuarial 1-year local control, progression-free survival, and overall survival were 54%, 25% and 86%, respectively. CONCLUSION: The use of helical tomotherapy in oligometastatic CRC patients resulted in a promising metabolic response rate of 55%.

Alanine/EPR dosimetry applied to the verification of a total body irradiation protocol and treatment planning dose calculation using a humanoid phantom.

PURPOSE: To avoid complications in total body irradiation (TBI), it is important to achieve a homogeneous dose distribution throughout the body and to deliver a correct dose to the lung which is an organ at risk. The purpose of this work was to validate the TBI dose protocol and to check the accuracy of the 3D dose calculations of the treatment planning system. METHODS: Dosimetry based on alanine/electron paramagnetic resonance (EPR) was used to measure dose at numerous locations within an anthropomorphic phantom (Alderson) that was irradiated in a clinical TBI beam setup. The alanine EPR dosimetry system was calibrated against water calorimetry in a Co-60 beam and the absorbed dose was determined by the use of "dose-normalized amplitudes" A(D). The dose rate of the TBI beam was checked against a Farmer ionization chamber. The phantom measurements were compared to 3D dose calculations from a treatment planning system (Pinnacle) modeled for standard dose calculations. RESULTS: Alanine dosimetry allowed accurate measurements which were in accordance with ionization chamber measurements. The combined relative standard measurement uncertainty in the Alderson phantom was U(r)(A(D))=0.6%. The humanoid phantom was irradiated to a reference dose of 10 Gy, limiting the lung dose to 7.5 Gy. The ratio of the average measured dose midplane in the craniocaudal direction to the reference dose was 1.001 with a spread of +/- 4.7% (1 sd). Dose to the lung was measured in 26 locations and found, in average, 1.8% lower than expected. Lung dose was homogeneous in the ventral-dorsal direction but a dose gradient of 0.10 Gy cm(-1) was observed in the craniocaudal direction midline within the lung lobe. 3D dose calculations (Pinnacle) were found, in average, 2% lower compared to dose measurements on the body axis and 3% lower for the lungs. CONCLUSIONS: The alanine/EPR dosimetry system allowed accurate dose measurements which enabled the authors to validate their TBI dose protocol. Dose calculations based on a collapsed cone convolution dose algorithm modeled for regular treatments are accurate within 3% and can further be improved when the algorithm is modeled for TBI.

An overview of volumetric imaging technologies and their quality assurance for IGRT.

Image-guided radiation therapy (IGRT) aims at frequent imaging in the treatment room during a course of radiotherapy, with decisions made on the basis of this information. The concept is not new, but recent developments and clinical implementations of IGRT drastically improved the quality of radiotherapy and broadened its possibilities as well as its indications. In general IGRT solutions can be classified in planar imaging, volumetric imaging using ionising radiation (kV- and MV- based CT) or non-radiographic techniques. This review will focus on volumetric imaging techniques applying ionising radiation with some comments on Quality Assurance (QA) specific for clinical implementation. By far the most important advantage of volumetric IGRT solutions is the ability to visualize soft tissue prior to treatment and defining the spatial relationship between target and organs at risk. A major challenge is imaging during treatment delivery. As some of these IGRT systems consist of peripheral equipment and others present fully integrated solutions, the QA requirements will differ considerably. It should be noted for instance that some systems correct for mechanical instabilities in the image reconstruction process whereas others aim at optimal mechanical stability, and the coincidence of imaging and treatment isocentre needs special attention. Some of the solutions that will be covered in detail are: (a) A dedicated CT-scanner inside the treatment room. (b) Peripheral systems mounted to the gantry of the treatment machine to acquire cone beam volumetric CT data (CBCT). Both kV-based solutions and MV-based solutions using EPIDs will be covered. (c) Integrated systems designed for both IGRT and treatment delivery. This overview will explain some of the technical features and clinical implementations of these technologies as well as providing an insight in the limitations and QA procedures required for each specific solution.

Shielding requirements in helical tomotherapy.

Helical tomotherapy is a relatively new intensity-modulated radiation therapy (IMRT) treatment for which room shielding has to be reassessed for the following reasons. The beam-on-time needed to deliver a given target dose is increased and leads to a weekly workload of typically one order of magnitude higher than that for conventional radiation therapy. The special configuration of tomotherapy units does not allow the use of standard shielding calculation methods. A conventional linear accelerator must be shielded for primary, leakage and scatter photon radiations. For tomotherapy, primary radiation is no longer the main shielding issue since a beam stop is mounted on the gantry directly opposite the source. On the other hand, due to the longer irradiation time, the accelerator head leakage becomes a major concern. An analytical model based on geometric considerations has been developed to determine leakage radiation levels throughout the room for continuous gantry rotation. Compared to leakage radiation, scatter radiation is a minor contribution. Since tomotherapy units operate at a nominal energy of 6 MV, neutron production is negligible. This work proposes a synthetic and conservative model for calculating shielding requirements for the Hi-Art II TomoTherapy unit. Finally, the required concrete shielding thickness is given for different positions of interest.

Optimal control of set-up margins and internal margins for intra- and extracranial radiotherapy using stereoscopic kilovoltage imaging.

In this paper the clinical introduction of stereoscopic kV-imaging in combination with a 6 degrees-of-freedom (6 DOF) robotics system and breathing synchronized irradiation will be discussed in view of optimally reducing interfractional as well as intrafractional geometric uncertainties in conformal radiation therapy. Extracranial cases represent approximately 70% of the patient population on the NOVALIS treatment machine (BrainLAB A.G., Germany) at the AZ-VUB, which is largely due to the efficiency of the real-time positioning features of the kV-imaging system. The prostate case will be used as an example of those target volumes showing considerable changes in position from day-to-day, yet with negligible motion during the actual course of the treatment. As such it will be used to illustrate the on-line target localization using kV-imaging and 6 DOF patient adjustment with and without implanted radio-opaque markers prior to treatment. Small lung lesion will be used to illustrate the system's potential to synchronize the irradiation with breathing in coping with intrafractional organ motion.

On-line portal imaging: image quality defining parameters for pelvic fields--a clinical evaluation.

PURPOSE: A test of several image enhancement techniques, performed on on-line portal images in real clinical circumstances, is presented. In addition a score system enabling us to evaluate image quality on pelvic fields is proposed and validated. METHODS AND MATERIALS: Localization images (n = 546) generated by an on-line portal imaging system during the treatment of 13 patients on pelvic fields were obtained by delivering a radiation dose of 6-8 cGy by an 18 MV photon beam, and recorded with a silicon intensified target video camera with adjustable gain, kV- and black level. Set-up errors were corrected before continuing irradiation. A scoring system based on the number of visible bone-soft tissue edges and transformed to a scale 0 to 5 was developed to judge image quality. A validation of this classification of images was performed with the use of transsectional bone-densities (bone-density*radiological path length) specified at the score defining landmarks. A high pass filter was used on all images, additional on-line open field subtraction was performed on 242 fields. Off-line study was performed in which a panel consisting of two groups (one composed of three radiation oncologists, the other of three radiotherapy technologists), scored 470 pelvic fields without further enhancement, and the same images with Contrast Limited Adaptive Histogram Equalization (CLAHE) (Pizer et al.). Two different clipping levels (3.0 and 5.0) were studied. RESULTS: Gender and transsectional bone-densities were the most defining patient-related factors influencing image quality. Camera settings, gantry angle, and image post-processing were important non-patient-related factors. All investigators judged CLAHE to ameliorate low contrast images and to deteriorate good quality images (p < 0.001).

A feasibility study of high dose rate brachytherapy in solitary urinary bladder cancer.

PURPOSE: To determine the feasibility of high dose rate brachytherapy in the treatment of T1-T3 solitary bladder cancer and to compare results and side-effects to those obtained by others using conventional, i.e., low dose rate regimens. METHODS AND MATERIALS: Between July 1992 and 1995, 16 patients entered the study. Median age at diagnosis was 64 years (range: 45-79 years). Diagnostic transurethral resection showed four T1, five T2, and seven T3 lesions, all proven solitary by random biopsies. Radiotherapy consisted of low-dose preoperative external beam irradiation (3 x 3.5 Gy on the 3 consecutive days prior to implantation), followed by high dose rate brachytherapy (15 x 3 Gy during the 8 consecutive days thereafter). Median follow-up from the date of implantation was 23 months (range: 6-43 months). In 15 patients, cystoscopy was systematically performed during follow-up, whereas the 16th patient was followed on a clinical basis only. RESULTS: Recurrences have occurred in 2 of 15 evaluable patients (both stage T3): metastasis in 1 and combined local plus distant failure in the other patient. Cystoscopic evaluation showed persisting alterations of the implanted portion of the bladder mucosa in 11 of 15 evaluable patients (ulceration, calcifications, and/or punctiform bleedings). Symptomatic radiation cystitis was mild and transient in 14 but persisting and severe in 2 patients. CONCLUSION: This study documents the feasibility of high dose rate brachytherapy in a selected group of bladder cancer patients. Both patient outcome and side-effects are comparable to the best results obtained with low dose rate schedules. Additional follow-up is still needed to enforce the comparison.

Initial experience with intensity-modulated conformal radiation therapy for treatment of the head and neck region.

PURPOSE: The efficacy of a conventional, noninvasive fixation technique in combination with a commercially available system for conformal radiotherapy by intensity modulation of the treatment beam has been studied. METHODS AND MATERIALS: A slice-by-slice arc-rotation approach was used to deliver a conformal dose to the target and patient fixation was performed by means of thermoplastic casts. Eleven patients have been treated, of which 9 were for tumors of the head and neck region and 2 were for intracranial lesions. A procedure for target localization and verification of patient positioning suitable for this particular treatment technique has been developed based on the superposition of digitized portals with plots generated from the treatment-planning system. A dosimetric verification of the treatment procedure was performed with an anthropomorphic phantom: both absolute dose measurements (alanine and thermoluminescent detectors) and relative dose distribution measurements (film dosimetry) have been applied. The dose delivered outside the target has also been investigated. RESULTS: The dose verification with the anthropomorphic phantom yielded a ratio between measured and predicted dose values of 1.0 for different treatment schedules and the calculated dose distribution agreed with the measured dose distribution. Day-to-day variations in patient setup of 0.3 cm (translations) and 2.0 degrees (rotations) were considered acceptable for this particular patient population, whereas the verification protocol allowed detection of 0.1 cm translational errors and 1.0 rotational errors. CONCLUSIONS: The noninvasive fixation technique in combination with an adapted verification protocol proved to be acceptable for conformal treatment of the head and neck region. Dose measurements, in turn, confirmed the predicted dose values to the target and organs at risk within uncertainty. Daily monitoring becomes mandatory if an accuracy superior to 0.1 cm and 1.0 degree is required for patient setup.

Dynamic radiotherapy: interactive movement of patient couch for treatment of craniospinal axis.

PURPOSE: The various techniques that have been described for treatment of the craniospinal axis show the common challenge of edge matching between adjacent orthogonal and parallel photon beams. Such edge matching is needed because the maximum field length provided by modern treatment machines is generally insufficient to treat adults with less than three matching fields. Using the common techniques, field edge matching becomes difficult, if for medical reasons, the patient cannot be treated in the prone position. METHODS AND MATERIALS: A scanning couch technique is proposed, with the patient lying in supine position. After treating the cerebral and upper neck regions by two lateral opposed half beam fields defined by asymmetric collimators (split beam), the patient is being moved along the spinal axis through an 8.0 cm wide by 15.0 cm long posterior split beam (allowing edge matching with the lateral fields at the neck region) by means of remote controlled couch movement. Stopping and starting of the scanning field resulted in a linear decrease of dose on both sides of the scan. Two ways of resolving this problem were investigated. RESULTS: The administered dose varied less than 8.5% through the craniospinal axis. Flatness of the rectangular scanned field was 0.76%. Apart from dose homogeneity, patient comfort and decreased simulation time are major advantages. CONCLUSIONS: The proposed technique represents a suitable alternative using a common linear accelerator, requiring a remote couch controller as an additional component.

Electronic portal imaging with on-line correction of setup error in thoracic irradiation: clinical evaluation.

PURPOSE: To analyze setup errors and the feasibility of their on-line correction using electronic portal imaging in the irradiation of lung tumors. METHODS AND MATERIALS: Sixteen patients with lung cancer were irradiated through opposed anteroposterior fields. Localization images of anteroposterior fields were recorded with an electronic portal imaging device (EPID). Using an in-house developed algorithm for on-line comparison of portal images setup errors were measured and a correction of table position was performed with a remote couch control prior to treatment. In addition, residual errors were measured on the EPID verification image. Global and individual mean and standard deviation of setup errors were calculated and compared. The feasibility of the procedure was assessed measuring intra- and interobserver variability, influence of organ movement, reproducibility of error measurement, the extra time fraction needed for measuring and adjusting and the fraction of dose needed for imaging. RESULTS: In two setups the procedure could not be finished normally due to problems inherent to the procedure. The reproducibility, intraobserver variability, and influence of organ movements were each described by a distribution with a mean value less than or equal to 1 mm and a standard deviation (SD) of less than 1.5 mm. The interobserver variability showed to be a little bit larger (mean: 0.3 mm, SD: 1.7 mm). The mean time to perform the irradiation of the anteroposterior field was 4 +/- 1 min. The mean time for the measurement and correction procedure approximated 2.5 min. The mean extra time fraction was 65 +/- 24% (1 SD) with more than half of this coming from the error measurement. The dose needed for generation of EPID images was 5.9 +/- 1.4% of total treatment dose. The mean and SD of setup errors were, respectively, 0.1 and 4.5 mm for longitudinal and -2.0 and 5.7 mm for transversal errors. Of 196 measured translational errors 120 (61%) exceeded the adjustment criteria. For individual patients systematic and random setup errors can be as high as, respectively, 15.8 and 7.5 mm. Mean residual error and SD were for longitudinal direction 0.08 and 1.2 mm and for transversal direction -0.9 and 1.0 mm (pooled data). For individuals, the mean residual errors were smaller than 1 mm, with a typical SD per patient of less than 2 mm. CONCLUSION: Setup errors in thoracic radiation therapy are clinically important. On-line correction can be performed accurately with an objective measurement tool, although this prolongs the irradiation procedure for one field with 65%.

Use of a simulator with CT option in radiotherapy of macular degeneration.

PURPOSE: To assess the accuracy of a conventional simulation procedure in radiotherapy of age-related macular degeneration. METHODS AND MATERIALS: A computed tomographic (CT) extension attached to the treatment simulator was used to acquire CT images immediately after conventional simulation in 18 patients referred for treatment of age-related macular degeneration. Analysis was performed on 16 one-sided treatment cases for whom images were obtained. Error was estimated by the displacement between the observed treatment isocenter and the intended isocenter based on reconstructed eye geometry. RESULTS: Based on single slice measurements, the mean error amplitude was 2.3 mm (range 0.2-5.6). Based on three-dimensional eye globe reconstruction, the mean error amplitude was 2.8 mm (range 0.8-5.3). An incidental finding previously unreported was the lower image quality at the center of the simulator-CT image acquisition field. CONCLUSIONS: Small but significant errors from conventional simulation were noted. The integrated simulation-CT procedure may help correct the errors to improve the accuracy of simulation setup. The lower image quality at the center of image acquisition field requires adaptation of the simulation-CT procedure.

Interactive use of on-line portal imaging in pelvic radiation.

We have evaluated a fluoroscopic on-line portal imaging system in routine clinical radiotherapy, involving the treatment of 566 pelvic fields on 13 patients. The image was typically generated by delivering a radiation dose of 6-8 cGy. Comparison between portal image and simulator film was done by eye and all visible errors were corrected before continuing irradiation. If possible, these corrections were performed from outside the treatment room by moving the patient couch by remote control or by changing collimator parameters. Adjustments were performed on 289/530 (54.5%) evaluable fields or 229/278 (82.4%) evaluable patient set-ups. The lateral couch position was most frequently adjusted (n = 254). The absolute values of the adjustments were 6.8 mm mean (SD 6.6 mm) with a maximum of 40 mm. All absolute values of adjustments exceeding 25 mm were recorded in one patient and those exceeding 15 mm were observed in two patients. Both patients were obese females. Adjustments exceeding 5 mm were observed in all 13 patients. Related to the use of on-line portal imaging, treatment time was increased by a median of 36.5% (mean 45.8%; SD 42.1%). The range was 7.7 to 442%. The fraction of the total treatment time to perform corrections was 22.7% median (mean: 26.0; SD: 11.8%). Statistically significant systematic in-plane errors were found in 7/13 patients. A systematic error was detected on the lateral position of the field in five patients. In one patient a systematic error of the longitudinal field position and in one patient a rotational error was detected. For adjustments in the lateral direction the present method does not allow to detect lateral shifts of less than 2 mm. For adjustments in the longitudinal direction the sensitivity could not be estimated but the available data suggest that 80% of errors < or = 5 mm were not adjusted. In obese patients, random errors may be surprisingly large.

Assessment of the uncertainties in dose delivery of a commercial system for linac-based stereotactic radiosurgery.

PURPOSE: Linac-based stereotactic radiosurgery (SRS) was introduced in our department in 1992, and since then, more than 200 patients have been treated with this method. An in-house-developed algorithm for target localization and dose calculation has recently been replaced with a commercially available system. In this study, both systems have been compared, and positional accuracy, as well as dose calculation, have been verified experimentally. METHODS AND MATERIALS: The in-house-developed software for target localization and dose calculation is an extension to George Sherouse's GRATIS(R) software for radiotherapy treatment planning, and has been replaced by a commercial (BrainSCAN version 3.1; BrainLAB, Germany) treatment planning system (TPS) for SRS. The positional accuracy for the entire SRS procedure (from image acquisition to treatment) has been investigated by treatment of simulated targets in the form of 0.2-cm lead beads inserted into an anthropomorphic phantom. Both dose calculation algorithms have been verified against manual calculations (based on basic beam data and CT data from phantom and patients), and measurements with the anthropomorphic phantom applying ionization chamber, thermoluminescent detectors, and radiographic film. This analysis has been performed on a variety of experimental situations, starting with static beams and simple one-arc treatments, to more complex and clinical relevant applications. Finally, 11 patients have been evaluated with both TPS in parallel for comparison and continuity of clinical experience. RESULTS: Phantom studies evaluating the entire SRS procedure have shown that a target, localized by CT, can be irradiated with a positional accuracy of 0.08 cm in any direction with 95% confidence. Neglecting the influence of dose perturbation when the beam passes through bone tissue or air cavities, the calculated dose values obtained from both TPSs agreed within 1% (SD 1%) for phantom and patient studies. The application of a one-dimensional path length correction for tissue heterogeneity influences the treatment prescription 4% on average (SD 1%), which is in compliance with theoretical predictions. The phantom measurements confirmed the predicted dose at isocenter within uncertainty for the different treatment schedules in this study. CONCLUSION: The full SRS procedure applied to an anthropomorphic phantom has been used as a comprehensive method to assess the uncertainties involved in dose delivery and target positioning. The results obtained with both TPSs are in agreement with AAPM Report 54, TG 42 and clinical continuity is assured. However, the use of a one-dimensional path length correction will result in an increase of 4% in dose prescription, which is slightly more than that predicted in the literature.

Risk assessment of radiation-induced malignancies based on whole-body equivalent dose estimates for IMRT treatment in the head and neck region.

BACKGROUND AND PURPOSE: Intensity modulated radiation therapy (IMRT) has been introduced in our department for treatment of the head and neck region with the intention of reducing complications without compromising treatment outcome. However, these new treatment modalities inevitably require a substantial increase in monitor units per target dose yielding an increased risk of secondary malignancies induced by the treatment. This study aims at assessing the increased risk by means of in vivo measurements of the whole-body equivalent dose of both the conventional and the IMRT treatment techniques for head and neck lesions. MATERIAL AND METHODS: A conventional technique using parallel opposed, wedged treatment fields has been compared with a slice-by-slice arc rotation technique for IMRT. Both techniques were used to treat head and neck lesions with a 6-MV photon beam. Thermoluminescent badges and neutron bubble detectors designed for personnel monitoring have been applied to obtain the estimated whole-body equivalent dose on three patients for each treatment technique. The nominal probability coefficient for a lifetime risk of excess fatal cancer, recommended by the ICRP 60 has been used for risk estimates based on the estimated dose values. RESULTS: An estimated whole-body equivalent dose per monitor unit equal to 1.2 x 10(-2) mSv/MU and 1.6 x 10(-2) mSv/MU have been obtained with the conventional and IMRT technique, respectively. Applying the average amount of MU necessary to realize a 70 Gy target dose the estimated whole-body equivalent dose for both treatment techniques becomes 242 mSv (conventional) and 1969 mSv (IMRT), yielding an increase in the risk for secondary malignancies with a factor 8. CONCLUSIONS: Historically the risk of secondary malignancies has been accepted to take advantage of the possible benefits of improved local control and treatment outcome. However, the introduction of new and sophisticated treatment techniques will also increase the risk of radiation induced malignancies. Therefore, these risk estimates become important to assess whether the benefits of the treatment technique outweigh the possible risks.

Clinical implementation of an objective computer-aided protocol for intervention in intra-treatment correction using electronic portal imaging.

In order to test the feasibility of a protocol for intra-fractional adjustment of the patient position, during radiation therapy treatment in the pelvic region, a two-fold study is carried out. The protocol involves an objective quantitative measurement of the error in positioning starting from the comparison of a portal image with a reference image. The first part of the study applies the protocol to determine the efficacy of adjustment using subjective determination of the positioning errors by a clinician by measuring the residual errors after adjustment. A group of 13 patients was followed extensively throughout their treatment, analyzing 240 fields. In the second part the measurement itself determines the extent of readjustment of the position. Throughout the procedure elapsed time is measured to determine the extra time involved in using this procedure. For this part a group of 21 patients was followed yielding statistics on 218 fields. Using this computer aided protocol it is shown that systematic as well as random errors can be reduced to standard deviations of the order of 1 mm. The price to pay however is additional treatment time up to 58% of the treatment time without the protocol. Time analysis shows that the largest part of the added time is spent on the readjustment of the patients' position adding a mean of 37% of time to the treatment of one field. This is despite the fact that the readjustment was performed using a remote couch controller. Finally a statistical analysis shows that it is possible to select patients benefiting from the use of such a protocol after a limited number of fractions.

Characteristics and clinical application of a treatment simulator with Ct-option.

BACKGROUND AND PURPOSE: The integration of a scanner for computed tomography (CT) and a treatment simulator (Sim-CT, Elekta Oncology Systems, Crawley, UK) has been studied in a clinical situation. Image quality, hounsfield units (HU) and linearity have been evaluated as well as the implications for treatment planning. The additional dose to the patient has also been highlighted. MATERIAL AND METHODS: Image data is acquired using an array of solid state X-ray detectors attached externally to the simulator's image intensifier. Three different fields of view (FOV: 25.0 cm, 35.0 cm and 50.0 cm) with 0.2 cm, 0.5 cm and 1.0 cm slice thickness can be selected and the system allows for an aperture diameter of 92.0 cm at standard isocentric height. The CT performance has been characterized with several criteria: spatial resolution, contrast sensitivity, geometric accuracy, reliability of hounsfield units and the radiation output level. The spatial resolution gauge of the nuclear associates quality phantom (NAQP) as well as modulation transfer functions (MTF) have been applied to evaluate the spatial resolution. Contrast sensitivity and HU measurements have been performed by means of the NAQP and a HU conversion phantom that allows inserts with different electron densities. The computed tomography dose index (CTDI) of the CT-option has been monitored with a pencil shaped ionization chamber. Treatment planning and dose calculations for heterogeneity correction based on the Sim-CT images generated from an anthropomorphic phantom as well as from ten patients have been compared with similar treatment plans based on identical, yet diagnostic CT (DCT) images. RESULTS: The last row of holes that are resolved in the spatial resolution gauge of the NAQP are either 0.150 cm or 0.175 cm depending on the FOV and the applied reconstruction filter. These are consistent with the MTF curves showing cut-off frequencies ranging from 5.3 lp/cm to 7.1 lp/cm. Linear regression analysis of HU versus electron densities revealed a correlation coefficient of 0.99. Contrast, pixel size and geometric accuracy are within specifications. Computed tomography dose index values of 0.204 Gy/As and 0.069 Gy/As have been observed with dose measurements in the center of a 16 cm diameter and 32 cm diameter phantom, respectively for large FOV. Small FOV yields CTDI values of 0.925 Gy/As and 0.358 Gy/As which is a factor ten higher than the results obtained from a DCT under similar acquisition conditions. The phantom studies showed excellent agreement between dose distributions generated with the Sim-CT and DCT HU. The deviations between the calculated settings of monitor units as well as the maximum dose in three dimensions were less than 1% for the treatment plans based on either of these HU both for pelvic as well as thoracic simulations. The patient studies confirmed these results. CONCLUSIONS: The CT-option can be considered as an added value to the simulation process and the images acquired on the Sim-CT system are adequate for dose calculation with tissue heterogeneity correction. The good image quality, however, is compromised by the relative high dose values to the patient. The considerable load to the conventional X-ray tube currently limits the Sim-CT to seven image acquisitions per patient and therefore the system is limited in its capability to perform full three-dimensional reconstruction.

Automatic on-line electronic portal image analysis with a wavelet-based edge detector.

A fully automatic method for on-line electronic portal image analysis is proposed. The method uses multiscale edge detection with wavelets for both the field outline and the anatomical structures. An algorithm to extract and combine the information from different scales has been developed. The edges from the portal image are aligned with the edges from the reference image using chamfer matching. The reference is the first portal image of each treatment. The matching is applied first to the field and subsequently to the anatomy. The setup deviations are quantified as the displacement of the anatomical structures relative to the radiation beam boundaries. The performance of the algorithm was investigated for portal images with different contrast and noise level. The automatic analysis was used first to detect simulated displacements. Then the automatic procedure was tested on anterior-posterior and lateral portal images of a pelvic phantom. In both sets of tests the differences between the measured and the actual shifts were used to quantify the performance. Finally we applied the automatic procedure to clinical images of pelvic and lung regions. The output of the procedure was compared with the results of a manual match performed by a trained operator. The errors for the phantom tests were small: average standard deviation of 0.39 mm and 0.26 degrees and absolute mean error of 0.31 mm and 0.2 degrees were obtained. In the clinical cases average standard deviations of 1.32 mm and 0.6 degrees were found. The average absolute mean errors were 1.09 mm and 0.39 degrees. Failures were registered in 2% of the phantom tests and in 3% of the clinical cases. The algorithm execution is approximately 5 s on a 168 MHz Sun Ultra 2 workstation. The automatic analysis tool is considered to be a very useful tool for on-line setup corrections.

A computerized remote table control for fast on-line patient repositioning: implementation and clinical feasibility.

A computerized remote control for a Siemens ZXT treatment couch was implemented and its characteristics were investigated to establish its feasibility for on-line setup corrections, using portal imaging. Communication with the table was obtained by connecting it via a serial line to a work station. The treatment couch enables "goto" commands in the three main directions and around the isocenter. The accuracy of the movements after giving such a command was checked and the time for each movement was recorded. First, the movements into a single direction were studied (range of -4 to +4 cm and -4 degrees to +4 degrees). Each command was repeated four times. Second, the table was moved into the three main directions simultaneously. For this experiment a clinically relevant three-dimensional (3-D) normal distribution of shifts was used [N = 200, standard deviation (SD) 5 mm in the three main directions]. This latter experiment was done twice: without and with rotations (a distribution with SD 1 degrees). During the first experiment, with shifts into one direction, no systematic deviations were found. The overall accuracy of the shifts was 0.6 mm (1 SD) in each direction and 0.04 degrees (1 SD) for the rotations. The time required for a translation ranged between 4 and 13 s and for the rotation between 8 and 20 s. The second experiment with the 3-D distribution of setup errors yielded an error in the 3-D vector length equal to 0.96 mm (1 SD), independent of rotations. Shifts were performed in less than 11 s for 95% of the cases without rotations. When rotations were also performed, 95% of the movements finished in less than 16 s. In conclusion, the table movements are accurate and enable on-line setup corrections in daily clinical practice.