Characterization and commissioning of a Leksell Gamma Knife ICON system for framed and frameless stereotactic radiosurgery.

PURPOSE: The Leksell Gamma Knife Icon unit (IU) was introduced recently as an upgrade to the Perfexion unit (PU) at our Gamma Knife practice. In the current study, we sought mainly to characterize dosimetry and targeting accuracy of the IU treatment deliveries using both invasive frame and frameless treatment workflows. METHODS: Relative output factors were measured by delivering single-shot 4, 8 and 16 mm radiation profiles in the manufacturer's acrylonitrile butadiene styrene spherical phantom in coronal and sagittal planes using EBT3 film. Resultant dosimetry was compared with the manufacturer's dose calculation and derived output factors were compared with the manufacturer's published value. Geometric consistency of stereotactic coordinates based on cone-beam computed tomography (CBCT) versus the traditional conventional CT-based method was characterized using a rigid phantom containing nine fiducial indicators over four separate trials. End-to-end (E2E) testing using EBT3 film was designed to evaluate both dosimetric and geometric accuracy for hypothetical framed and frameless workflows. RESULTS: Relative output factors as measured by the manufacturer were independently confirmed using EBT3 film measurements to within 2%. The mean 3D radial discrepancy in stereotactic space between CBCT and CT-based definition over the sampled locations in our rigid geometry phantom was demonstrated to be between 0.40 mm and 0.56 mm over the set of trials, larger than prior reported values. E2E performed in 2D demonstrates sub-mm (and typically < 0.5 mm) accuracy for framed and frameless workflows; geometric accuracy of framed treatments using CBCT-defined stereotactic coordinates was shown to be slightly improved in comparison with those defined using conventional CT. Furthermore, in phantom, frameless workflows exhibited better accuracy than framed workflows for fractionated treatments, despite large magnitudes of introduced interfraction setup error. Accuracy of dosimetric delivery was confirmed in terms of qualitative comparisons of dose profiles and in terms of 2D gamma pass rates based on 1%/1 mm criteria. CONCLUSION: The IU was commissioned for clinical use of frameless and framed treatment protocols. The present study outlines an extensive E2E methodology for confirmation of dosimetric and geometric treatment accuracy.

Implementation of free breathing respiratory amplitude-gated treatments.

PURPOSE: The purpose of this study was to provide guidance in developing and implementing a process for the accurate delivery of free breathing respiratory amplitude-gated treatments. METHODS: A phase-based 4DCT scan is acquired at time of simulation and motion is evaluated to determine the exhale phases that minimize respiratory motion to an acceptable level. A phase subset average CT is then generated for treatment planning and a tracking structure is contoured to indicate the location of the target or a suitable surrogate over the planning phases. Prior to treatment delivery, a 4DCBCT is acquired and a phase subset average is created to coincide with the planning phases for an initial match to the planning CT. Fluoroscopic imaging is then used to set amplitude gate thresholds corresponding to when the target or surrogate is in the tracking structure. The final imaging prior to treatment is an amplitude-gated CBCT to verify both the amplitude gate thresholds and patient positioning. An amplitude-gated treatment is then delivered. This technique was commissioned using an in-house lung motion phantom and film measurements of a simple two-field 3D plan. RESULTS: The accuracy of 4DCBCT motion and target position measurements were validated relative to 4DCT imaging. End to end testing showed strong agreement between planned and film measured dose distributions. Robustness to interuser variability and changes in respiratory motion were demonstrated through film measurements. CONCLUSIONS: The developed workflow utilizes 4DCBCT, respiratory-correlated fluoroscopy, and gated CBCT imaging in an efficient and sequential process to ensure the accurate delivery of free breathing respiratory-gated treatments.

Design and characterization of an aperture system and spot configuration for ocular treatments with a gantry-based spot scanning proton beam.

BACKGROUND AND PURPOSE: Proton therapy is a key modality used in the treatment of ocular melanoma. Traditionally ocular sites are treated using a dedicated eyeline with a passively scattered proton beam and a brass aperture. This work aims to design and characterize a beam-collimating aperture to treat ocular targets with a gantry-based spot scanning proton beam. METHODS: A plastic aperture system that slides into the gantry nozzle of a spot scanning proton beam was designed and constructed. It consists of an intermediate scraper layer to attenuate stray protons and a 3D-printed patient-specific aperture positioned 5.7 cm from the surface of the eye. The aperture system was modeled in TOPAS and Monte Carlo simulations were validated with film measurements. Two different spot configurations were investigated for treatment planning and characterized based on lateral penumbra, central axis (CAX) dose and relative efficiency. Alignment and leakage were investigated through experimental film measurements. Range was verified using a multi-layer ionization chamber. Reference dose measurements were made with a PinPoint 3D ion chamber. Neutron dose was evaluated through Monte Carlo simulations. RESULTS: Aperture alignment with radiation isocenter was determined to be within 0.31 mm at a gantry angle of 0°. A single-spot configuration with a 10 mm diameter aperture yielded film-measured lateral penumbras of 1 mm to 1.25 mm, depending on depth in the spread-out Bragg peak. TOPAS simulations found that a single spot configuration results in a flat dose distribution for a 10 mm diameter aperture and provides a CAX dose of less than 106% for apertures less than 14 mm in diameter. For larger targets, adding four corner spots to fill in the dose distribution is beneficial. Trade-offs between lateral penumbra, CAX dose and relative efficiency were characterized for different spot configurations and can be used for future clinical decision-making. The aperture was experimentally determined to not affect proton beam range, and no concerning leakage radiation or neutron dose was identified. Reference dose measurements with a PinPoint ion chamber were within 2.1% of Monte Carlo calculated doses. CONCLUSION: The aperture system developed in this work provides a method of treating ocular sites on a gantry-based spot scanning proton system. Additional work to develop compatible gaze tracking and gating infrastructure is ongoing.

Application of a 2D frequency encoding sectoral approach to hyperpolarized 129Xe MRI at low field.

Inhaled hyperpolarized 129Xe MRI is a non-invasive and radiation risk free lung imaging method, which can directly measure the business unit of the lung where gas exchange occurs: the alveoli and acinar ducts (lung function). Currently, three imaging approaches have been demonstrated to be useful for hyperpolarized 129Xe MR in lungs: Fast Gradient Recalled Echo (FGRE), Radial Projection Reconstruction (PR), and spiral/cones. Typically, non-Cartesian acquisitions such as PR and spiral/cones require specific data post-processing, such as interpolating, regridding, and density-weighting procedures for image reconstruction, which often leads to smoothing effects and resolution degradation. On the other hand, Cartesian methods such as FGRE are not short-echo time (TE) methods; they suffer from imaging gradient-induced diffusion-weighting of the k-space center, and employ a significant number of radio-frequency (RF) pulses. Due to the non-renewable magnetization of the hyperpolarized media, the use of a large number of RF pulses (FGRE/PR) required for full k-space coverage is a significant limitation, especially for low field (<0.5 T) hyperpolarized gas MRI. We demonstrate an ultra-fast, purely frequency-encoded, Cartesian pulse sequence called Frequency-Encoding Sectoral (FES), which takes advantage of the long T2* of hyperpolarized 129Xe gas at low field strength (0.074 T). In contrast to PR/FGRE, it uses a much smaller number of RF pulses, and consequently maximizes image Signal-to-Noise Ratio (SNR) while shortening acquisition time. Additionally, FES does not suffer from non-uniform T2* decay leading to image blurring; a common issue with interleaved spirals/cones. The Cartesian k-space coverage of the proposed FES method does not require specific k-space data post-processing, unlike PR/FGRE and spiral/cones methods. Proton scans were used to compare the FES sequence to both FGRE and Phase Encoding Sectoral, in terms of their SNR values and imaging efficiency estimates. Using FES, proton and hyperpolarized 129Xe images were acquired from a custom hollow acrylic phantom (0.04L) and two normal rats (129Xe only), utilizing both single-breath and multiple-breath schemes. For the 129Xe phantom images, the apparent diffusion coefficient, T1, and T2* relaxation maps were acquired and generated. Blurring due to the T2* decay and B0 field variation were simulated to estimate dependence of the image resolution on the duration of the data acquisition windows (i.e. sector length), and temperature-induced resonance frequency shift from the low field magnet hardware.

Ionizing radiation-induced acoustics for radiotherapy and diagnostic radiology applications.

Acoustic waves are induced via the thermoacoustic effect in objects exposed to a pulsed beam of ionizing radiation. This phenomenon has interesting potential applications in both radiotherapy dosimetry and treatment guidance as well as low-dose radiological imaging. After initial work in the field in the 1980s and early 1990s, little research was done until 2013 when interest was rejuvenated, spurred on by technological advances in ultrasound transducers and the increasing complexity of radiotherapy delivery systems. Since then, many studies have been conducted and published applying ionizing radiation-induced acoustic principles into three primary research areas: Linear accelerator photon beam dosimetry, proton therapy range verification, and radiological imaging. This review article introduces the theoretical background behind ionizing radiation-induced acoustic waves, summarizes recent advances in the field, and provides an outlook on how the detection of ionizing radiation-induced acoustic waves can be used for relative and in vivo dosimetry in photon therapy, localization of the Bragg peak in proton therapy, and as a low-dose medical imaging modality. Future prospects and challenges for the clinical implementation of these techniques are discussed.

Experimental evaluation of x-ray acoustic computed tomography for radiotherapy dosimetry applications.

PURPOSE: The aim of this work was to experimentally demonstrate the feasibility of x-ray acoustic computed tomography (XACT) as a dosimetry tool in a clinical radiotherapy environment. METHODS: The acoustic waves induced following a single pulse of linear accelerator irradiation in a water tank were detected with an immersion ultrasound transducer. By rotating the collimator and keeping the transducer stationary, acoustic signals at varying angles surrounding the field were detected and reconstructed to form an XACT image. Simulated XACT images were obtained using a previously developed simulation workflow. Profiles extracted from experimental and simulated XACT images were compared to profiles measured with an ion chamber. A variety of radiation field sizes and shapes were investigated. RESULTS: XACT images resembling the geometry of the delivered radiation field were obtained for fields ranging from simple squares to more complex shapes. When comparing profiles extracted from simulated and experimental XACT images of a 4 cm × 4 cm field, 97% of points were found to pass a 3%/3 mm gamma test. Agreement between simulated and experimental XACT images worsened when comparing fields with fine details. Profiles extracted from experimental XACT images were compared to profiles obtained through clinical ion chamber measurements, confirming that the intensity of XACT images is related to deposited radiation dose. Seventy-seven percent of the points in a profile extracted from an experimental XACT image of a 4 cm × 4 cm field passed a 7%/4 mm gamma test when compared to an ion chamber measured profile. In a complicated puzzle-piece shaped field, 86% of the points in an XACT extracted profile passed a 7%/4 mm gamma test. CONCLUSIONS: XACT images with intensity related to the spatial distribution of deposited dose in a water tank were formed for a variety of field sizes and shapes. XACT has the potential to be a useful tool for absolute, relative and in vivo dosimetry.

On the Detectability of Acoustic Waves Induced Following Irradiation by a Radiotherapy Linear Accelerator.

Irradiating an object with a megavoltage photon beam generated by a clinical radiotherapy linear accelerator (linac) induces acoustic waves through the photoacoustic effect. The detection and characterization of such acoustic waves has potential applications in radiation therapy dosimetry. The purpose of this work was to gain insight into the properties of such acoustic waves by simulating and experimentally detecting them in a well-defined system consisting of a metal block suspended in a water tank. A novel simulation workflow was developed by combining radiotherapy Monte Carlo and acoustic wave transport simulation techniques. Different set-up parameters such as photon beam energy, metal block depth, metal block width, and metal block material were varied, and the simulated and experimental acoustic waveforms showed the same relative amplitude trends and frequency variations for such setup changes. The simulation platform developed in this work can easily be extended to other irradiation situations, and will be an invaluable tool for developing a radiotherapy dosimetry system based on the detection of the acoustic waves induced following linear accelerator irradiation.