Comparison of an anthropomorphic PRESAGE® dosimeter and radiochromic film with a commercial radiation treatment planning system for breast IMRT: a feasibility study

This work presents a comparison of an anthropomorphic PRESAGE® dosimeter and radiochromic film measurements with a commercial treatment planning system to determine the feasibility of PRESAGE® for 3D dosimetry in breast IMRT. An anthropomorphic PRESAGE® phantom was created in the shape of a breast phantom. A five-field IMRT plan was generated with a commercially available treatment planning system and delivered to the PRESAGE® phantom. The anthropomorphic PRESAGE® was scanned with the Duke midsized optical CT scanner (DMOS-RPC) and the OD distribution was converted to dose. Comparisons were performed between the dose distribution calculated with the Pinnacle3 treatment planning system, PRESAGE®, and EBT2 film measurements. DVHs, gamma maps, and line profiles were used to evaluate the agreement. Gamma map comparisons showed that Pinnacle3 agreed with PRESAGE® as greater than 95% of comparison points for the PTV passed a ± 3%/± 3 mm criterion when the outer 8 mm of phantom data were discluded. Edge artifacts were observed in the optical CT reconstruction, from the surface to approximately 8 mm depth. These artifacts resulted in dose differences between Pinnacle3 and PRESAGE® of up to 5% between the surface and a depth of 8 mm and decreased with increasing depth in the phantom. Line profile comparisons between all three independent measurements yielded a maximum difference of 2% within the central 80% of the field width. For the breast IMRT plan studied, the Pinnacle3 calculations agreed with PRESAGE® measurements to within the ±3%/± 3 mm gamma criterion. This work demonstrates the feasibility of the PRESAGE® to be fashioned into anthropomorphic shape, and establishes the accuracy of Pinnacle3 for breast IMRT. Furthermore, these data have established the groundwork for future investigations into 3D dosimetry with more complex anthropomorphic phantoms.

Feasibility of proton-activated implantable markers for proton range verification using PET

Proton beam range verification using positron emission tomography (PET) currently relies on proton activation of tissue, the products of which decay with a short half-life and necessitate an on-site PET scanner. Tissue activation is, however, negligible near the distal dose fall-off region of the proton beam range due to their high interaction energy thresholds. Therefore Monte Carlo simulation is often supplemented for comparison with measurement; however, this also may be associated with systematic and statistical uncertainties. Therefore, we sought to test the feasibility of using long-lived proton-activated external materials that are inserted or infused into the target volume for more accurate proton beam range verification that could be performed at an off-site PET scanner. We irradiated samples of ≥98% (18)O-enriched water, natural Cu foils, and >97% (68)Zn-enriched foils as candidate materials, along with samples of tissue-equivalent materials including (16)O water, heptane (C7H16), and polycarbonate (C16H14O3)n, at four depths (ranging from 100% to 3% of center of modulation (COM) dose) along the distal fall-off of a modulated 160 MeV proton beam. Samples were irradiated either directly or after being embedded in Plastic Water® or balsa wood. We then measured the activity of the samples using PET imaging for 20 or 30 min after various delay times. Measured activities of candidate materials were up to 100 times greater than those of the tissue-equivalent materials at the four distal dose fall-off depths. The differences between candidate materials and tissue-equivalent materials became more apparent after longer delays between irradiation and PET imaging, due to the longer half-lives of the candidate materials. Furthermore, the activation of the candidate materials closely mimicked the distal dose fall-off with offsets of 1 to 2 mm. Also, signals from the foils were clearly visible compared to the background from the activated Plastic Water® and balsa wood phantoms. These results indicate that markers made from these candidate materials could be used for in vivo proton range verification using an off-site PET scanner.

Improving patient safety: Factors leading to radiation therapy events in a large academic institution

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Background: The purpose of this study was to elucidate the factors associated with radiation therapy (RT) treatment events and near misses at a large academic institution. Methods: All RT patient events and near misses/good catches were prospectively collected using an electronic incident reporting system from April 1, 2011-April 30, 2013. The event origin was categorized according to the step in the treatment process (simulation, physician prescription, dosimetry/physics, treatment delivery and other). The incident database was linked to the RT delivery (record and verify) database which contains date of treatment, radiation beam duration, number of fractions, and type of treatment. A treatment record was defined as a unique site description and date/time. Results: There were 224 reported RT events or near misses/good catches analyzed, of which there were 59 RT treatment delivery events associated with 105 treatment records, including 0 level I (most severe), 18 level II, 35 level III (least severe), and 6 level IV (near misses/good catches) among the 13,899 patients and 468,489 treatments. The remaining 165 RT events occurred at the other steps of the treatment process. The overall rate of RT events and near misses was 161.2 per 10,000 patients. The rate of RT treatment delivery events and near misses was 42.4 per 10,000 patients and 2.2 per 10,000 treatment records. Logistical multivariate analysis showed that treatment on Tuesday (Odds Ratio = 2.50, 95% CI 1.67-3.73, p<0.001), first day of treatment (5.16, 95% CI 3.32-8.02, p<0.001), number of fractions (continuous) (0.98, 95% CI 0.96-0.997, p<0.03), intensity modulated radiation therapy (IMRT) (2.87, 95% CI 1.44-5.74, p=0.003), electron only fields (2.00, 95% CI 1.27-3.14, p=0.003), and radiation beam duration (continuous minutes) (1.03, 95% CI 1.02-1.04, p<0.001), were associated with RT treatment events and near misses, while age, proton treatment, number of fields and after hours treatment were not. Conclusions: Treatments delivered on Tuesdays, on the first day of treatment, with fewer fractions, with IMRT, with electron only fields, and with longer radiation beam duration were associated with an increased risk of RT treatment events.

Credentialing results from IMRT irradiations of an anthropomorphic head and neck phantom

PURPOSE

This study was performed to report and analyze the results of the Radiological Physics Center's head and neck intensity-modulated radiation therapy (IMRT) phantom irradiations done by institutions seeking to be credentialed for participation in clinical trials using intensity modulated radiation therapy.

METHODS

The Radiological Physics Center's anthropomorphic head and neck phantom was sent to institutions seeking to participate in multi-institutional clinical trials. The phantom contained two planning target volume (PTV) structures and an organ at risk (OAR). Thermoluminescent dosimeters (TLD) and film dosimeters were imbedded in the PTV. Institutions were asked to image, plan, and treat the phantom as they would treat a patient. The treatment plan should cover at least 95% of the primary PTV with 6.6 Gy and at least 95% of the secondary PTV with 5.4 Gy. The plan should limit the dose to the OAR to less than 4.5 Gy. The passing criteria were ±7% for the TLD in the PTVs and a distance to agreement of 4 mm in the high dose gradient area between the PTV and the OAR. Pass rates for different delivery types, treatment planning systems (TPS), linear accelerators, and linear accelerator-planning system combinations were compared.

RESULTS

The phantom was irradiated 1139 times by 763 institutions from 2001 through 2011. 929 (81.6%) of the irradiations passed the criteria. 156 (13.7%) irradiations failed only the TLD criteria, 21 (1.8%) failed only the film criteria, and 33 (2.9%) failed both sets of criteria. Only 69% of the irradiations passed a narrowed TLD criterion of ±5%. Varian-Elipse and TomoTherapy-HiArt combinations had the highest pass rates, ranging from 90% to 93%. Varian-Pinnacle(3), Varian-XiO, Siemens-Pinnacle(3), and Elekta-Pinnacle(3) combinations had pass rates that ranged from 66% to 81%.

CONCLUSIONS

The head and neck phantom is a useful credentialing tool for multi-institutional IMRT clinical trials. The most commonly represented linear accelerator-planning system combinations can all pass the phantom, though some combinations had higher passing percentages than others. Tightening the criteria would significantly reduce the number of institutions passing the credentialing criteria. Causes for failures include incorrect data entered into the TPS, inexact beam modeling, and software and hardware failures.

Determination of elemental tissue composition following proton treatment using positron emission tomography

Positron emission tomography (PET) has been suggested as an imaging technique for in vivo proton dose and range verification after proton induced-tissue activation. During proton treatment, irradiated tissue is activated and decays while emitting positrons. In this paper, we assessed the feasibility of using PET imaging after proton treatment to determine tissue elemental composition by evaluating the resultant composite decay curve of activated tissue. A phantom consisting of sections composed of different combinations of (1)H, (12)C, (14)N, and (16)O was irradiated using a pristine Bragg peak and a 6 cm spread-out Bragg-peak (SOBP) proton beam. The beam ranges defined at 90% distal dose were 10 cm; the delivered dose was 1.6 Gy for the near monoenergetic beam and 2 Gy for the SOBP beam. After irradiation, activated phantom decay was measured using an in-room PET scanner for 30 min in list mode. Decay curves from the activated (12)C and (16)O sections were first decomposed into multiple simple exponential decay curves, each curve corresponding to a constituent radioisotope, using a least-squares method. The relative radioisotope fractions from each section were determined. These fractions were used to guide the decay curve decomposition from the section consisting mainly of (12)C + (16)O and calculate the relative elemental composition of (12)C and (16)O. A Monte Carlo simulation was also used to determine the elemental composition of the (12)C + (16)O section. The calculated compositions of the (12)C + (16)O section using both approaches (PET and Monte Carlo) were compared with the true known phantom composition. Finally, two patients were imaged using an in-room PET scanner after proton therapy of the head. Their PET data and the technique described above were used to construct elemental composition ((12)C and (16)O) maps that corresponded to the proton-activated regions. We compared the (12)C and (16)O compositions of seven ROIs that corresponded to the vitreous humor, adipose/face mask, adipose tissue, and brain tissue with ICRU 46 elemental composition data. The (12)C and (16)O compositions of the (12)C + (16)O phantom section were estimated to within a maximum difference of 3.6% for the near monoenergetic and SOBP beams over an 8 cm depth range. On the other hand, the Monte Carlo simulation estimated the corresponding (12)C and (16)O compositions in the (12)C + (16)O section to within a maximum difference of 3.4%. For the patients, the (12)C and (16)O compositions in the seven ROIs agreed with the ICRU elemental composition data, with a mean (maximum) difference of 9.4% (15.2%). The (12)C and (16)O compositions of the phantom and patients were estimated with relatively small differences. PET imaging may be useful for determining the tissue elemental composition and thereby improving proton treatment planning and verification.

Comprehensive quality assurance for base of skull IMRT

Six base of skull IMRT treatment plans were delivered to Presage dosimeters within the RPC Head and Neck Phantom for quality assurance (QA) verification. Isotropic 2mm 3D data were acquired by optical-CT scanning with the DLOS system (Duke Large Optical-CT Scanner) and compared to the Eclipse (Varian) treatment plan. Normalized Dose Distribution (NDD) pass rates were obtained for a number of criteria. High quality 3D dosimetry data was observed from the DLOS system, illustrated here through colormaps, isodose lines, and profiles. Excellent agreement with the planned dose distributions was also observed with NDD analysis revealing > 90% pass rates (with criteria 3%, 2mm), and noise < 0.5%. The results comprehensively confirm the high accuracy of base-of-skull IMRT treatment in our clinic.

A quality assurance method that utilizes 3D dosimetry and facilitates clinical interpretation

PURPOSE

To demonstrate a new three-dimensional (3D) quality assurance (QA) method that provides comprehensive dosimetry verification and facilitates evaluation of the clinical significance of QA data acquired in a phantom. Also to apply the method to investigate the dosimetric efficacy of base-of-skull (BOS) intensity-modulated radiotherapy (IMRT) treatment.

METHODS AND MATERIALS

Two types of IMRT QA verification plans were created for 6 patients who received BOS IMRT. The first plan enabled conventional 2D planar IMRT QA using the Varian portal dosimetry system. The second plan enabled 3D verification using an anthropomorphic head phantom. In the latter, the 3D dose distribution was measured using the DLOS/Presage dosimetry system (DLOS = Duke Large-field-of-view Optical-CT System, Presage Heuris Pharma, Skillman, NJ), which yielded isotropic 2-mm data throughout the treated volume. In a novel step, measured 3D dose distributions were transformed back to the patient's CT to enable calculation of dose-volume histograms (DVH) and dose overlays. Measured and planned patient DVHs were compared to investigate clinical significance.

RESULTS

Close agreement between measured and calculated dose distributions was observed for all 6 cases. For gamma criteria of 3%, 2 mm, the mean passing rate for portal dosimetry was 96.8% (range, 92.0%-98.9%), compared to 94.9% (range, 90.1%-98.9%) for 3D. There was no clear correlation between 2D and 3D passing rates. Planned and measured dose distributions were evaluated on the patient's anatomy, using DVH and dose overlays. Minor deviations were detected, and the clinical significance of these are presented and discussed.

CONCLUSIONS

Two advantages accrue to the methods presented here. First, treatment accuracy is evaluated throughout the whole treated volume, yielding comprehensive verification. Second, the clinical significance of any deviations can be assessed through the generation of DVH curves and dose overlays on the patient's anatomy. The latter step represents an important development that advances the clinical relevance of complex treatment QA.

MO-D-BRB-04: The Approval Process for the Use of Proton Therapy in NCI-Sponsored Clinical Trials

PURPOSE

To describe the approval process for the use of proton therapy in NCI- sponsored clinical trials.

METHODS

The RPC has developed a comprehensive system for the approval of proton therapy centers for participation in clinical trials. The approval process includes: 1) completion of the proton facility questionnaire, 2) participation in the RPC's annual TLD remote audit program, 3) electronic submission of treatment planning data to the Image-Guided Therapy Center (ITC), and 4) successful completion of an on-site dosimetry review visit, including the irradiation of two of the RPC's anthropomorphic proton phantoms (prostate and spine). The on-site audits allow the RPC to review the institution's treatment planning process, from simulation to treatment delivery, as well as their quality assurance practices. The RPC performs a complete set of measurements that tests the CT simulator's CT# vs. RSP conversion curve, treatment planning data, on-board imaging, and treatment delivery. These measurements detect gross errors that might lead to inaccurate proton dose delivery. The review of the institutions' QA procedures allows the RPC to encourage all proton centers to maintain a consistent level of periodic monitoring of their proton therapy delivery. Upon completion of the visit, a full report is written detailing the results from the visit, phantom irradiation, and recommendations for improving their treatment delivery and QA.

RESULTS

To date, the RPC has approved seven proton therapy centers for the use of scattered or uniform scanning proton treatment delivery in clinical trials. Results of the phantom irradiations have identified an error in the HU vs RLSP curve. The site visits have identified several lapses in QA procedures, inappropriate HU vs RLSP values, and weaknesses in treatment planning.

CONCLUSIONS

The RPC's proton therapy approval process has been developed and has identified areas of improvement for proton centers to use proton therapy in clinical trials. Work supported by grants CA10953, CA059267, and CA81647 (NCI, DHHS).

SU-E-T-132: Investigation of Photon and Proton Overlapping Fields in PRESAGE- Dosimeters

PURPOSE

To evaluate the effects of overlapping dose volumes for varying field arrangements in two formulations of PRESAGE®: one intended for, and irradiated with, proton beams and the other photon beams.

METHODS

For each treatment modality (photon, proton), three overlapping field setups were performed. These included a stationary dosimeter irradiated over six fractions, a dosimeter shifted laterally to the field to deliver a dose plateau in two fractions, and a dosimeter rotated on its axis to deliver a two-field (for protons) and four-field (for photons) box treatment overlapping in the center of the dosimeter. All subsequent fractions were given within ten minutes and never less than one minute apart. Two cylindrical PRESAGE® dosimeters approximately 7.5 cm in length by 7.5 cm in diameter were irradiated for each setup. The dosimeters were paired, with one dosimeter given total dose by a single fraction while the other followed one of the overlapping field setups. The dosimeters were analyzed using an optical CT scanner and exported to the CERR environment where the doses were compared between paired dosimeters.

RESULTS

Dose profile comparisons showed relative dose agreement between paired dosimeters within 5% along the SOBP region of the proton formulation. In the case of the fractionated proton irradiation, there was an over-response while other setups resulted in under-responses. Dose agreement between the photon dosimeter treated with six fractions showed a dose under-response within 11% and never less than 5%. Future measurements will include the remaining field setups.

CONCLUSIONS

The proton formulation of PRESAGE® showed good dose agreement between single and multiple field irradiations. While the photon formulation had slightly less agreement, additional field setup comparisons may show improved results. These results will aid future measurements of overlapping field treatment plans delivered to PRESAGE® for treatment verification for proton and photon 3D dosimetry.

MO-D-BRB-02: The Radiological Physics Center's Quality Audit Program: Where Can We Improve?

PURPOSE

To analyze the findings of the Radiological Physics Center's (RPC) QA audits of institutions participating in NCI sponsored clinical trials.

METHODS

The RPC has developed an extensive Quality Assurance (QA) program over the past 44 years. This program includes on-site dosimetry reviews where measurements on therapy machines are made, records are reviewed and personnel are interviewed. The program's remote audit tools include mailed dosimeters (OSLD/TLD) to verify output calibration, comparison of dosimetry data with RPC 'standard' data, evaluation of benchmark and patient calculations to verify the treatment planning algorithms, review of institution's QA procedures and records, and use of anthropomorphic phantoms to verify tumor dose delivery. The RPC endeavors to assist institutions in finding the origins of any detected discrepancies, and to resolve them.

RESULTS

Ninety percent of institutions receiving dosimetry recommendations has remained level for the past 5 years. The most frequent recommendations were for not performing TG-40 QA tests, wedge factors, small field size output factors and off-axis factors. Since TG-51 was published, the number of beam calibrations audited during visits with ion chambers, that met the RPC's ±3% criterion, decreased initially but has risen to pre-TG-51 levels. The OSLD/TLD program shows that only ∼3% of the beams are outside our ±5% criteria, but these discrepancies are distributed over 12-20% of the institutions. The percent of institutions with ï,³ l beam outside the RPC's criteria is approximately the same whether OSLD/TLD or ion chambers were used. The first time passing rate for the anthropomorphic phantoms is increasing with time. The prostate phantom has the highest pass rate while the spine phantom has the lowest.

CONCLUSIONS

Numerous dosimetry errors continue to be discovered by the RPC's QA program and the RPC continues to play an important role in helping institutions resolve these errors. This work was supported by PHS grants CA10953 and CA081647 awarded by NCI.

SU-E-T-190: Design, Development, and Evaluation of a Modified, Anthropomorphic, Head, Quality Assurance Phantom for Use in Stereotactic Radiosurgery

PURPOSE

To develop and evaluate a modified anthropomorphic head phantom for evaluation of stereotactic radiosurgery (SRS) dose planning and delivery.

METHODS

A phantom was constructed from a water equivalent, plastic, head-shaped shell. The original phantom design, with only a spherical target, was modified to include a nonspherical target (pituitary) and an adjacent organ at risk (OAR) (optic chiasm), within 2 mm, simulating the anatomy encountered when treating acromegaly. The target and OAR spatial proximity provided a more realistic treatment planning and dose delivery exercise. A separate dosimetry insert contained two TLD for absolute dosimetry and radiochromic film, in the sagittal and coronal planes, for relative dosimetry. The prescription was 25Gy to 90% of the GTV with >= 10% of the OAR volume receiving >= 8Gy. The modified phantom was used to test the rigor of the treatment planning process, dosimeter reproducibility, and measured dose delivery agreement with calculated doses using a Gamma Knife, CyberKnife, and linear accelerator based radiosurgery systems.

RESULTS

TLD results from multiple irradiations using either a CyberKnife or Gamma Knife agreed with the calculated target dose to within 4.7% with a maximum coefficient of variation of+/-2.0%. Gamma analysis in the coronal and sagittal film planes showed an average passing rate of 99.3% and 99.5% using +/-5%/3mm criteria, respectively. A treatment plan for linac delivery was developed meeting the prescription guidelines. Dosimeter reproducibility and dose delivery agreement for the linac is expected to have results similar to the results observed with the CyberKnife and Gamma Knife.

CONCLUSIONS

A modified anatomically realistic SRS phantom was developed that provided a realistic clinical planning and delivery challenge that can be used to credential institutions wanting to participate in NCI funded clinical trials. Work supported by PHS CA010953, CA081647, CA21661 awarded by NCI. DHHS.

SU-E-T-95: Investigation of 3D Dosimetry for an Anthropomorphic Spine Phantom

PURPOSE

To evaluate 3D dosimetry for a spinal cord treatment plan delivery using the Radiological Physics Center's (RPC) anthropomorphic spine phantom.

METHODS

The RPC's spine phantom currently uses radiochromic film and thermoluminescent dosimeters (TLD) to evaluate spinal metastases treatments. A second dosimetry insert for the phantom was created to hold a PRESAGE® 3D dosimeter which matched the location of the TLD and film in the original insert. The phantom was CT imaged with each insert and an IMRT treatment plan was developed. The IMRT plan was delivered to the phantom twice; once with each insert. The film and PRESAGE® were scanned on a CCD microdensitometer and optical-CT system, reconstructed to a 2 mm slice width, respectively. The measured dose distributions were compared to the treatment plan calculated dose distribution using RPC in-house developed software or the Computational Environment for Radiotherapy Research (CERR). Film and PRESAGE® dose profiles were taken across several planes and compared for agreement. The distance to agreement (DTA) between the measured data and treatment plan, within the high dose gradient region, was quantified.

RESULTS

The PRESAGE® and plan dose profiles agreed to within 2and 1 mm in the AP and SI directions, respectively. The film and plan also agreed to within 2 mm across all profiles.

CONCLUSIONS

The PRESAGE® 3D dosimeter, based on these preliminary data, shows potential as a dosimeter for the RPC's phantom irradiation studies. Future work will add markers to the PRESAGE® insert to allow for a reproducible registration in CERR and a an optical-CT system, reconstructed to a 2 mm slice width dose calibration protocol will be created. CA 100835.