[Proposal of Requirements Definition Method on Radiation Therapy Information System].

The troubles arising in the introduction of the medical information system are mostly related to the requirement definition. The present study proposed the requirements definition method on radiation therapy information system (RTIS) by using business modeling. The interview was conducted with six medical professionals regarding the entire business in the radiotherapy department. These businesses were modeled using Diamond Mandala Matrix (DMM) and data flow diagram (DFD) methods. Subsequently, functional requirements on RTIS were defined based on these modeling. As a result, 21 DMMs and 129 DFDs were created and 120 functional requirements were defined. By defining the functional requirements of the users, mutual understanding with vendors will deepen, and avoid an expected trouble in introducing RTIS. DMM was effective as an initial modeling such as the interviews and the organization of businesses. DFD was also effective for the business improvement and the definition of system functional requirements.

[A Quality Assurance (QA) System with a Web Camera for High-dose-rate Brachytherapy].

PURPOSE: The quality assurance (QA) system that simultaneously quantifies the position and duration of an (192)Ir source (dwell position and time) was developed and the performance of this system was evaluated in high-dose-rate brachytherapy. METHODS: This QA system has two functions to verify and quantify dwell position and time by using a web camera. The web camera records 30 images per second in a range from 1,425 mm to 1,505 mm. A user verifies the source position from the web camera at real time. The source position and duration were quantified with the movie using in-house software which was applied with a template-matching technique. RESULTS: This QA system allowed verification of the absolute position in real time and quantification of dwell position and time simultaneously. It was evident from the verification of the system that the mean of step size errors was 0.31±0.1 mm and that of dwell time errors 0.1±0.0 s. Absolute position errors can be determined with an accuracy of 1.0 mm at all dwell points in three step sizes and dwell time errors with an accuracy of 0.1% in more than 10.0 s of the planned time. CONCLUSION: This system is to provide quick verification and quantification of the dwell position and time with high accuracy at various dwell positions without depending on the step size.

Influence of rotational setup error on tumor shift in bony anatomy matching measured with pulmonary point registration in stereotactic body radiotherapy for early lung cancer.

OBJECTIVE: To examine the correlation between the patient rotational error measured with pulmonary point registration and tumor shift after bony anatomy matching in stereotactic body radiotherapy for lung cancer. METHODS: Twenty-six patients with lung cancer who underwent stereotactic body radiotherapy were the subjects. On 104 cone-beam computed tomography measurements performed prior to radiation delivery, rotational setup errors were measured with point registration using pulmonary structures. Translational registration using bony anatomy matching was done and the three-dimensional vector of tumor displacement was measured retrospectively. Correlation among the three-dimensional vector and rotational error and vertebra-tumor distance was investigated quantitatively. RESULTS: The median and maximum rotational errors of the roll, pitch and yaw were 0.8, 0.9 and 0.5, and 6.0, 4.5 and 2.5, respectively. Bony anatomy matching resulted in a 0.2-1.6 cm three-dimensional vector of tumor shift. The shift became larger as the vertebra-tumor distance increased. Multiple regression analysis for the three-dimensional vector indicated that in the case of bony anatomy matching, tumor shifts of 5 and 10 mm were expected for vertebra-tumor distances of 4.46 and 14.1 cm, respectively. CONCLUSIONS: Using pulmonary point registration, it was found that the rotational setup error influences the tumor shift. Bony anatomy matching is not appropriate for hypofractionated stereotactic body radiotherapy with a tight margin.

Dosimetric impact of rotational setup errors in volumetric modulated arc therapy for postoperative cervical cancer.

We aimed to evaluate the impact of rotational setup errors on the doses received during postoperative volumetric-modulated arc therapy (VMAT) for cervical cancer. Overall, 121 cone-beam computed tomography (CBCT) sets from 20 patients were rigidly registered to reference computed tomography (CT) sets based on bony landmarks. The rotational setup errors (pitch, yaw and roll) were calculated. Then, 121 CT sets involving rotational setup errors were created, and the dose distribution in these CT sets were recalculated. The recalculated dosimetric parameters for the clinical target volume (CTV) and organs at risk (OAR) were compared to the reference values, and the correlation coefficients between the dosimetric parameter differences and rotational setup errors were calculated. Only the pitch setup error was moderately correlated with CTV coverage (r ≥ 0.40) and strongly correlated with V45 for the bladder (r ≥ 0.91) and V40 for the rectum, small bowel and bone marrow (r ≥ 0.91). The maximum dosimetric difference in a single fraction and overall fractions was -1.59% and -0.69% in D98 for the CTV, 11.72% and 5.17% in V45 for the bladder and -8.03% and -4.68% in V40 for the rectum, respectively. In conclusion, rotational setup errors only slightly impact dose coverage during postoperative cervical cancer VMAT. However, the pitch setup error occasionally affected the doses received by the bladder or the rectum in the overall fraction when the error was systematic. Thus, rotational setup errors should be corrected by adjusting six-degree-of-freedom (DOF) couches to reduce dosimetric differences in the OARs.

Preliminary analysis of the sequential simultaneous integrated boost technique for intensity-modulated radiotherapy for head and neck cancers.

The aim of this study was to compare three strategies for intensity-modulated radiotherapy (IMRT) for 20 head-and-neck cancer patients. For simultaneous integrated boost (SIB), doses were 66 and 54 Gy in 30 fractions for PTVboost and PTVelective, respectively. Two-phase IMRT delivered 50 Gy in 25 fractions to PTVelective in the First Plan, and 20 Gy in 10 fractions to PTVboost in the Second Plan. Sequential SIB (SEQ-SIB) delivered 55 Gy and 50 Gy in 25 fractions, respectively, to PTVboost and PTVelective using SIB in the First Plan and 11 Gy in 5 fractions to PTVboost in the Second Plan. Conformity indexes (CIs) (mean ± SD) for PTVboost and PTVelective were 1.09 ± 0.05 and 1.34 ± 0.12 for SIB, 1.39 ± 0.14 and 1.80 ± 0.28 for two-phase IMRT, and 1.14 ± 0.07 and 1.60 ± 0.18 for SEQ-SIB, respectively. CI was significantly highest for two-phase IMRT. Maximum doses (Dmax) to the spinal cord were 42.1 ± 1.5 Gy for SIB, 43.9 ± 1.0 Gy for two-phase IMRT and 40.3 ± 1.8 Gy for SEQ-SIB. Brainstem Dmax were 50.1 ± 2.2 Gy for SIB, 50.5 ± 4.6 Gy for two-phase IMRT and 47.4 ± 3.6 Gy for SEQ-SIB. Spinal cord Dmax for the three techniques was significantly different, and brainstem Dmax was significantly lower for SEQ-SIB. The compromised conformity of two-phase IMRT can result in higher doses to organs at risk (OARs). Lower OAR doses in SEQ-SIB made SEQ-SIB an alternative to SIB, which applies unconventional doses per fraction.

Couch height-based patient setup for abdominal radiation therapy.

There are 2 methods commonly used for patient positioning in the anterior-posterior (A-P) direction: one is the skin mark patient setup method (SMPS) and the other is the couch height-based patient setup method (CHPS). This study compared the setup accuracy of these 2 methods for abdominal radiation therapy. The enrollment for this study comprised 23 patients with pancreatic cancer. For treatments (539 sessions), patients were set up by using isocenter skin marks and thereafter treatment couch was shifted so that the distance between the isocenter and the upper side of the treatment couch was equal to that indicated on the computed tomographic (CT) image. Setup deviation in the A-P direction for CHPS was measured by matching the spine of the digitally reconstructed radiograph (DRR) of a lateral beam at simulation with that of the corresponding time-integrated electronic portal image. For SMPS with no correction (SMPS/NC), setup deviation was calculated based on the couch-level difference between SMPS and CHPS. SMPS/NC was corrected using 2 off-line correction protocols: no action level (SMPS/NAL) and extended NAL (SMPS/eNAL) protocols. Margins to compensate for deviations were calculated using the Stroom formula. A-P deviation > 5mm was observed in 17% of SMPS/NC, 4% of SMPS/NAL, and 4% of SMPS/eNAL sessions but only in one CHPS session. For SMPS/NC, 7 patients (30%) showed deviations at an increasing rate of > 0.1mm/fraction, but for CHPS, no such trend was observed. The standard deviations (SDs) of systematic error (Σ) were 2.6, 1.4, 0.6, and 0.8mm and the root mean squares of random error (σ) were 2.1, 2.6, 2.7, and 0.9mm for SMPS/NC, SMPS/NAL, SMPS/eNAL, and CHPS, respectively. Margins to compensate for the deviations were wide for SMPS/NC (6.7mm), smaller for SMPS/NAL (4.6mm) and SMPS/eNAL (3.1mm), and smallest for CHPS (2.2mm). Achieving better setup with smaller margins, CHPS appears to be a reproducible method for abdominal patient setup.

Phantom and clinical study of differences in cone beam computed tomographic registration when aligned to maximum and average intensity projection.

PURPOSE: To determine whether maximum or average intensity projection (MIP or AIP, respectively) reconstructed from 4-dimensional computed tomography (4DCT) is preferred for alignment to cone beam CT (CBCT) images in lung stereotactic body radiation therapy. METHODS AND MATERIALS: Stationary CT and 4DCT images were acquired with a target phantom at the center of motion and moving along the superior-inferior (SI) direction, respectively. Motion profiles were asymmetrical waveforms with amplitudes of 10, 15, and 20 mm and a 4-second cycle. Stationary CBCT and dynamic CBCT images were acquired in the same manner as stationary CT and 4DCT images. Stationary CBCT was aligned to stationary CT, and the couch position was used as the baseline. Dynamic CBCT was aligned to the MIP and AIP of corresponding amplitudes. Registration error was defined as the SI deviation of the couch position from the baseline. In 16 patients with isolated lung lesions, free-breathing CBCT (FBCBCT) was registered to AIP and MIP (64 sessions in total), and the difference in couch shifts was calculated. RESULTS: In the phantom study, registration errors were within 0.1 mm for AIP and 1.5 to 1.8 mm toward the inferior direction for MIP. In the patient study, the difference in the couch shifts (mean, range) was insignificant in the right-left (0.0 mm, ≤1.0 mm) and anterior-posterior (0.0 mm, ≤2.1 mm) directions. In the SI direction, however, the couch position significantly shifted in the inferior direction after MIP registration compared with after AIP registration (mean, -0.6 mm; ranging 1.7 mm to the superior side and 3.5 mm to the inferior side, P=.02). CONCLUSIONS: AIP is recommended as the reference image for registration to FBCBCT when target alignment is performed in the presence of asymmetrical respiratory motion, whereas MIP causes systematic target positioning error.

Craniocaudal safety margin calculation based on interfractional changes in tumor motion in lung SBRT assessed with an EPID in cine mode.

PURPOSE: To evaluate setup error and interfractional changes in tumor motion magnitude using an electric portal imaging device in cine mode (EPID cine) during the course of stereotactic body radiation therapy (SBRT) for non-small-cell lung cancer (NSCLC) and to calculate margins to compensate for these variations. MATERIALS AND METHODS: Subjects were 28 patients with Stage I NSCLC who underwent SBRT. Respiratory-correlated four-dimensional computed tomography (4D-CT) at simulation was binned into 10 respiratory phases, which provided average intensity projection CT data sets (AIP). On 4D-CT, peak-to-peak motion of the tumor (M-4DCT) in the craniocaudal direction was assessed and the tumor center (mean tumor position [MTP]) of the AIP (MTP-4DCT) was determined. At treatment, the tumor on cone beam CT was registered to that on AIP for patient setup. During three sessions of irradiation, peak-to-peak motion of the tumor (M-cine) and the mean tumor position (MTP-cine) were obtained using EPID cine and in-house software. Based on changes in tumor motion magnitude (∆M) and patient setup error (∆MTP), defined as differences between M-4DCT and M-cine and between MTP-4DCT and MTP-cine, a margin to compensate for these variations was calculated with Stroom's formula. RESULTS: The means (±standard deviation: SD) of M-4DCT and M-cine were 3.1 (±3.4) and 4.0 (±3.6) mm, respectively. The means (±SD) of ∆M and ∆MTP were 0.9 (±1.3) and 0.2 (±2.4) mm, respectively. Internal target volume-planning target volume (ITV-PTV) margins to compensate for ∆M, ∆MTP, and both combined were 3.7, 5.2, and 6.4 mm, respectively. CONCLUSION: EPID cine is a useful modality for assessing interfractional variations of tumor motion. The ITV-PTV margins to compensate for these variations can be calculated.

A preliminary study of in-house Monte Carlo simulations: an integrated Monte Carlo verification system.

PURPOSE: To develop an infrastructure for the integrated Monte Carlo verification system (MCVS) to verify the accuracy of conventional dose calculations, which often fail to accurately predict dose distributions, mainly due to inhomogeneities in the patient's anatomy, for example, in lung and bone. METHODS AND MATERIALS: The MCVS consists of the graphical user interface (GUI) based on a computational environment for radiotherapy research (CERR) with MATLAB language. The MCVS GUI acts as an interface between the MCVS and a commercial treatment planning system to import the treatment plan, create MC input files, and analyze MC output dose files. The MCVS consists of the EGSnrc MC codes, which include EGSnrc/BEAMnrc to simulate the treatment head and EGSnrc/DOSXYZnrc to calculate the dose distributions in the patient/phantom. In order to improve computation time without approximations, an in-house cluster system was constructed. RESULTS: The phase-space data of a 6-MV photon beam from a Varian Clinac unit was developed and used to establish several benchmarks under homogeneous conditions. The MC results agreed with the ionization chamber measurements to within 1%. The MCVS GUI could import and display the radiotherapy treatment plan created by the MC method and various treatment planning systems, such as RTOG and DICOM-RT formats. Dose distributions could be analyzed by using dose profiles and dose volume histograms and compared on the same platform. With the cluster system, calculation time was improved in line with the increase in the number of central processing units (CPUs) at a computation efficiency of more than 98%. CONCLUSIONS: Development of the MCVS was successful for performing MC simulations and analyzing dose distributions.