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Fagerstrom JM. Practical experience commissioning MRI-compatible tandem and ring applicators for use with the Bravos HDR afterloader. J Appl Clin Med Phys 2023; 24:e14094. [PMID: 37469228 PMCID: PMC10647988 DOI: 10.1002/acm2.14094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/10/2023] [Accepted: 06/22/2023] [Indexed: 07/21/2023] Open
Abstract
Five complete MR-conditionally approved ring sets, including fifteen tandems, and two additional rings, were commissioned at an institution intending to use them in an MRI planning environment with a Bravos HDR brachytherapy remote afterloader. Channel length, radiograph, autoradiograph, ring offset, and treatment interrupt measurements were performed, and applicators were assessed in both CT and MRI. During commissioning, one ring was found to be defective and was returned to the manufacturer for a replacement. The eventual complete applicator suite (including the replacement ring) was found to follow the manufacturer-provided specifications, including those delineated in vendor-provided 3D virtual models and those defined within the manufacturer's instructions for use documentation. Based on this work, an offset correction of -0.4 cm will be used for all tested rings using the Bravos system's internal distal dwell position correction feature during treatment preparation. This study reiterated the requirement for careful commissioning of each applicator intended for clinical service considering the intended use and the planned clinical environment and work processes.
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Affiliation(s)
- Jessica M. Fagerstrom
- Radiation OncologyUniversity of WashingtonSeattleWashingtonUSA
- Kaiser PermanenteSeattleWashingtonUSA
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Fagerstrom JM, Marotta JE. Example Radiation Oncology Policy for Managing Patients With Implanted Electronic Devices Other Than Implantable Cardiac Pacemakers or Defibrillators. Pract Radiat Oncol 2023; 13:558-564. [PMID: 37578411 DOI: 10.1016/j.prro.2023.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 06/23/2023] [Accepted: 07/13/2023] [Indexed: 08/15/2023]
Abstract
PURPOSE This article describes a community-based hospital's policy for the management of patients with medical implanted electronic devices other than pacemakers or implanted cardiac defibrillators (ICDs). The policy may be adapted as needed for other radiation oncology groups requiring a practical solution for managing the care of patients with implanted devices, noting the need for changes for departments offering proton, neutron, heavy ion, or magnetic resonance-guided linear accelerator (MR-linac) treatment modalities. METHODS AND MATERIALS The policy was developed using a risk-based approach, with each patient's risk level determined based on the patient's dependence on the device, the anticipated dose to the device, and the type of treatment used. A similar approach is used for patients with pacemakers or ICDs, but this policy was designed to accommodate patients with other types of devices with care managed outside the department. Such devices include, but are not limited to, hepatic pumps, intrathecal pain pumps, neurostimulators, cochlear implants, and loop recorders. RESULTS The resulting definitions, guidelines, and proposed workflow were presented at the institution's multidisciplinary radiation oncology quality assurance committee monthly meeting and adopted as department policy in 2022. Recommendations incorporated in the policy include levels of patient monitoring and timing of device interrogation to minimize the risk of device malfunction. CONCLUSIONS The policy was written to guide the management of treatment of patients with a range of medical implanted electronic devices. This policy is currently in operation at a community-based hospital.
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Affiliation(s)
- Jessica M Fagerstrom
- Department of Radiation Oncology, University of Washington, Seattle, Washington.
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Esposito M, Mancosu P, Bruschi A, Ghirelli A, Pini S, Alpi P, Barca R, Paoli CD, Meacci F, Leonulli BG, Fondelli S, Paoletti L, Scoccianti S, Russo S. The role of EPID in vivo dosimetry in the risk management of stereotactic lung treatments. Strahlenther Onkol 2023; 199:992-999. [PMID: 37256302 DOI: 10.1007/s00066-023-02081-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 03/26/2023] [Indexed: 06/01/2023]
Abstract
BACKGROUND AND OBJECTIVE In this work we report our experience with the use of in vivo dosimetry (IVD) in the risk management of stereotactic lung treatments. METHODS A commercial software based on the electronic portal imaging device (EPID) signal was used to reconstruct the actual planning target volume (PTV) dose of stereotactic lung treatments. The study was designed in two phases: i) in the observational phase, the IVD results of 41 consecutive patients were reviewed and out-of-tolerance cases were studied for root cause analysis; ii) in the active phase, the IVD results of 52 patients were analyzed and corrective actions were taken when needed. Moreover, proactive preventions were further introduced to reduce the risk of future failures. The error occurrence rate was analyzed to evaluate the effectiveness of proactive actions. RESULTS A total of 330 fractions were analyzed. In the first phase, 13 errors were identified. In the active phase, 12 errors were detected, 5 of which needed corrective actions; in 4 patients the actions taken corrected the error. Several preventions and barriers were introduced to reduce the risk of future failures: the planning checklist was updated, the procedure for vacuum pillows was improved, and use of the respiratory compression belt was optimized. A decrease in the failure rate was observed, showing the effectiveness of procedural adjustment. CONCLUSION The use of IVD allowed the quality of lung stereotactic body radiation therapy (SBRT) treatments to be improved. Patient-specific and procedural corrective actions were successfully taken as part of risk management, leading to an overall improvement in the dosimetric accuracy.
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Affiliation(s)
- Marco Esposito
- S. C. Fisica Sanitaria, Firenze-Azienda Sanitaria USL Toscana Centro, Via dell'Antella 58, 50012, Bagno a Ripoli, Firenze, Italy.
- International Center for Theoretical Physics, Strada Costiera, 11, 34151, Trieste, Italy.
| | - Pietro Mancosu
- Medical Physics Unit of Radiotherapy Dept., IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Andrea Bruschi
- S. C. Fisica Sanitaria, Firenze-Azienda Sanitaria USL Toscana Centro, Via dell'Antella 58, 50012, Bagno a Ripoli, Firenze, Italy
| | - Alessandro Ghirelli
- S. C. Fisica Sanitaria, Firenze-Azienda Sanitaria USL Toscana Centro, Via dell'Antella 58, 50012, Bagno a Ripoli, Firenze, Italy
| | - Silvia Pini
- S. C. Fisica Sanitaria, Firenze-Azienda Sanitaria USL Toscana Centro, Via dell'Antella 58, 50012, Bagno a Ripoli, Firenze, Italy
| | - Paolo Alpi
- S. C. Radioterapia, Firenze-Azienda Sanitaria USL Toscana Centro, Firenze, Italy
| | - Raffaella Barca
- S. C. Radioterapia, Firenze-Azienda Sanitaria USL Toscana Centro, Firenze, Italy
| | - Camilla Delli Paoli
- S. C. Radioterapia, Firenze-Azienda Sanitaria USL Toscana Centro, Firenze, Italy
| | - Fiammetta Meacci
- S. C. Radioterapia, Firenze-Azienda Sanitaria USL Toscana Centro, Firenze, Italy
| | | | - Simona Fondelli
- S. C. Radioterapia, Firenze-Azienda Sanitaria USL Toscana Centro, Firenze, Italy
| | - Lisa Paoletti
- S. C. Radioterapia, Firenze-Azienda Sanitaria USL Toscana Centro, Firenze, Italy
| | - Silvia Scoccianti
- S. C. Radioterapia, Firenze-Azienda Sanitaria USL Toscana Centro, Firenze, Italy
| | - Serenella Russo
- S. C. Fisica Sanitaria, Firenze-Azienda Sanitaria USL Toscana Centro, Via dell'Antella 58, 50012, Bagno a Ripoli, Firenze, Italy
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Jee KW, Verburg JM, Ruggieri TA, Bussière M, Trofimov AV. Modernization of safety environment for a dedicated beamline for proton ocular therapy. Med Phys 2023; 50:7093-7103. [PMID: 37782071 DOI: 10.1002/mp.16767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 08/25/2023] [Accepted: 09/19/2023] [Indexed: 10/03/2023] Open
Abstract
BACKGROUND Proton therapy is an effective treatment for ocular melanoma, and other tumors of the eye. The fixed horizontal beamline dedicated to ocular treatments at Massachusetts General Hospital was originally commissioned in 2002, with much of the equipment, safety features, and practices dating back to an earlier implementation at Harvard Cyclotron in the 1970s. PURPOSE To describe the experience of reevaluation and enhancement of the safety environment for one of the longest continuously operating proton therapy programs. METHODS Several enhancements in quality control had been introduced throughout the years of operation, as described in this manuscript, to better align the practice with the evolving standards of proton therapy and the demands of a modern hospital. We spotlight the design and results of the failure mode and effect analysis (FMEA), and subsequent actions introduced to mitigate the modes associated with elevated risk. The findings of the FMEA informed the specifications for the new software application, which facilitated the improved management of the treatment workflow and the image-guidance aspects of ocular treatments. RESULTS Eleven failure modes identified as having the highest risk are described. Six of these were mitigated with the clinical roll-out of a new application for image-guided radiation therapy (IGRT). Others were addressed through task automation, the broader introduction of checklists, and enhancements in pre-treatment staff-led time-out. CONCLUSIONS Throughout the task of modernizing the safety system of our dedicated ocular beamline, FMEA proved to be an effective instrument in soliciting inputs from the staff about safety and workflow concerns, helping to identify steps associated with elevated failure risks. Risks were reduced with the clinical introduction of a new IGRT application, which integrates quality management tools widely recognized for their role in risk mitigation: automation of the data transfer and workflow steps, and with the introduction of checklists and redundancy cross-checks.
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Affiliation(s)
- Kyung-Wook Jee
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Joost M Verburg
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Thomas A Ruggieri
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Marc Bussière
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Alexei V Trofimov
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
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Krauss RF, Balik S, Cirino ET, Hadley A, Hariharan N, Holmes SM, Kielar K, Lavvafi H, McCullough K, Palefsky S, Sawyer JP, Smith K, Tracy J, Winter JD, Wingreen NE. AAPM Medical Physics Practice Guideline 8.b: Linear accelerator performance tests. J Appl Clin Med Phys 2023; 24:e14160. [PMID: 37793084 PMCID: PMC10647991 DOI: 10.1002/acm2.14160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/23/2023] [Accepted: 08/24/2023] [Indexed: 10/06/2023] Open
Abstract
The purpose of this guideline is to provide a list of critical performance tests to assist the Qualified Medical Physicist (QMP) in establishing and maintaining a safe and effective quality assurance (QA) program. The performance tests on a linear accelerator (linac) should be selected to fit the clinical patterns of use of the accelerator and care should be given to perform tests which are relevant to detecting errors related to the specific use of the accelerator. Current recommendations for linac QA were reviewed to determine any changes required to those tests highlighted by the original report as well as considering new components of the treatment process that have become common since its publication. Recommendations are made on the acquisition of reference data, routine establishment of machine isocenter, basing performance tests on clinical use of the linac, working with vendors to establish QA tests and performing tests after maintenance and upgrades. The recommended tests proposed in this guideline were chosen based on consensus of the guideline's committee after assessing necessary changes from the previous report. The tests are grouped together by class of test (e.g., dosimetry, mechanical, etc.) and clinical parameter tested. Implementation notes are included for each test so that the QMP can understand the overall goal of each test. This guideline will assist the QMP in developing a comprehensive QA program for linacs in the external beam radiation therapy setting. The committee sought to prioritize tests by their implication on quality and patient safety. The QMP is ultimately responsible for implementing appropriate tests. In the spirit of the report from American Association of Physicists in Medicine Task Group 100, individual institutions are encouraged to analyze the risks involved in their own clinical practice and determine which performance tests are relevant in their own radiotherapy clinics.
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Affiliation(s)
| | - Salim Balik
- University of Southern CaliforniaLos AngelesCaliforniaUSA
| | | | - Austin Hadley
- Anchorage Radiation Oncology CenterAnchorageAlaskaUSA
| | | | | | | | | | | | | | | | - Koren Smith
- UMass Chan Medical School/IROC Rhode Island QA CenterLincolnRhode IslandUSA
| | | | - Jeff D. Winter
- Department of Medical PhysicsPrincess Margaret Cancer CentreTorontoOntarioCanada
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Lohmann D, Shariff M, Schubert P, Sauer TO, Fietkau R, Bert C. Unified risk analysis in radiation therapy. Z Med Phys 2023; 33:479-488. [PMID: 36210227 PMCID: PMC10751707 DOI: 10.1016/j.zemedi.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 08/29/2022] [Accepted: 08/31/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE The increasing complexity of new treatment methods as well as the Information Technology (IT) infrastructure within radiotherapy require new methods for risk analysis. This work presents a methodology on how to model the treatment process of radiotherapy in different levels. This subdivision makes it possible to perform workflow-specific risk analysis and to assess the impact of IT risks on the overall treatment workflow. METHODS A Unified Modeling Language (UML) activity diagram is used to model the workflows. The subdivision of the workflows into different levels is done with the help of swim lanes. The model created in this way is exported in an xml-compatible format and stored in a database with the help of a Python program. RESULTS Based on an existing risk analysis, the workflows CT Appointment, Glioblastoma Multiforme, and Deep Inspiration Breath Hold (DIBH) were modeled in detail. Part of the analysis are automatically generated workflow-specific risk matrices including risks of medical devices incorporated into a specific workflow. In addition, SQL queries allow to quickly retrieve e.g., the details of the medical device network installed in a department. CONCLUSION Activity diagrams of UML can be used to model workflows in radiotherapy. Through this, a connection between the different levels of the entire workflow can be established and workflow-specific risk analysis is possible.
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Affiliation(s)
- Daniel Lohmann
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstraße 27, 91054 Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany.
| | - Maya Shariff
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstraße 27, 91054 Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Philipp Schubert
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstraße 27, 91054 Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Tim Oliver Sauer
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstraße 27, 91054 Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstraße 27, 91054 Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Christoph Bert
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstraße 27, 91054 Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
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Gates EDH, Wallner K, Tiwana J, Ford E, Phillips M, Lu L, Dumane V, Sheu RD, Kim M. Improved safety and quality in intravascular brachytherapy: A multi-institutional study using failure modes and effects analysis. Brachytherapy 2023; 22:779-789. [PMID: 37716819 DOI: 10.1016/j.brachy.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 06/20/2023] [Accepted: 07/27/2023] [Indexed: 09/18/2023]
Abstract
PURPOSE Highlight safety considerations in intravascular brachytherapy (IVBT) programs, provide relevant quality assurance (QA) and safety measures, and establish their effectiveness. METHODS AND MATERIALS Radiation oncologists, medical physicists, and cardiologists from three institutions performed a failure modes and effects analysis (FMEA) on the radiation delivery portion of IVBT. We identified 40 failure modes and rated the severity, occurrence, and detectability before and after consideration of safety practices. Risk priority numbers (RPN) and relative risk rankings were determined, and a sample QA safety checklist was developed. RESULTS We developed a process map based on multi-institutional consensus. Highest-RPN failure modes were due to incorrect source train length, incorrect vessel diameter, and missing prior radiation history. Based on these, we proposed QA and safety measures: ten of which were not previously recommended. These measures improved occurrence and detectability: reducing the average RPN from 116 to 58 and median from 84 to 40. Importantly, the average RPN of the top 10% of failure modes reduced from 311 to 172. With QA considered, the highest risk failure modes were from contamination and incorrect source train length. CONCLUSIONS We identified several high-risk failure modes in IVBT procedures and practical safety and QA measures to address them.
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Affiliation(s)
- Evan D H Gates
- Department of Radiation Oncology, University of Washington, Seattle, WA.
| | - Kent Wallner
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - Jasleen Tiwana
- Division of Cardiology, University of Washington, Seattle, WA
| | - Eric Ford
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - Mark Phillips
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - Lan Lu
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH
| | - Vishruta Dumane
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ren-Dih Sheu
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Minsun Kim
- Department of Radiation Oncology, University of Washington, Seattle, WA
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Khaledi N, Khan R, Gräfe JL. Historical Progress of Stereotactic Radiation Surgery. J Med Phys 2023; 48:312-327. [PMID: 38223793 PMCID: PMC10783188 DOI: 10.4103/jmp.jmp_62_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 09/24/2023] [Accepted: 09/27/2023] [Indexed: 01/16/2024] Open
Abstract
Radiosurgery and stereotactic radiotherapy have established themselves as precise and accurate areas of radiation oncology for the treatment of brain and extracranial lesions. Along with the evolution of other methods of radiotherapy, this type of treatment has been associated with significant advances in terms of a variety of modalities and techniques to improve the accuracy and efficacy of treatment. This paper provides a comprehensive overview of the progress in stereotactic radiosurgery (SRS) over several decades, and includes a review of various articles and research papers, commencing with the emergence of stereotactic techniques in radiotherapy. Key clinical aspects of SRS, such as fixation methods, radiobiology considerations, quality assurance practices, and treatment planning strategies, are presented. In addition, the review highlights the technological advancements in treatment modalities, encompassing the transition from cobalt-based systems to linear accelerator-based modalities. By addressing these topics, this study aims to offer insights into the advancements that have shaped the field of SRS, that have ultimately enhanced the accuracy and effectiveness of treatment.
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Affiliation(s)
- Navid Khaledi
- Department of Medical Physics, Cancer Care Manitoba, Winnipeg, MB, Canada
| | - Rao Khan
- Department of Physics, Toronto Metropolitan University, Toronto, ON, Canada
- Department of Physics and Astronomy and Department of Radiation Oncology, Howard University, Washington, District of Columbia, USA
| | - James L. Gräfe
- Department of Physics, Toronto Metropolitan University, Toronto, ON, Canada
- Cancer Care Program, Dr. H. Bliss Murphy Cancer Center. 300 Prince Philip Drive St. John’s, NL, Canada
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Hirotaki K, Tomizawa K, Moriya S, Oyoshi H, Raturi V, Ito M, Sakae T. Fully automated volumetric modulated arc therapy planning for locally advanced rectal cancer: feasibility and efficiency. Radiat Oncol 2023; 18:147. [PMID: 37670390 PMCID: PMC10481560 DOI: 10.1186/s13014-023-02334-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 08/21/2023] [Indexed: 09/07/2023] Open
Abstract
BACKGROUND Volumetric modulated arc therapy (VMAT) for locally advanced rectal cancer (LARC) has emerged as a promising technique, but the planning process can be time-consuming and dependent on planner expertise. We aimed to develop a fully automated VMAT planning program for LARC and evaluate its feasibility and efficiency. METHODS A total of 26 LARC patients who received VMAT treatment and the computed tomography (CT) scans were included in this study. Clinical target volumes and organs at risk were contoured by radiation oncologists. The automatic planning program, developed within the Raystation treatment planning system, used scripting capabilities and a Python environment to automate the entire planning process. The automated VMAT plan (auto-VMAT) was created by our automated planning program with the 26 CT scans used in the manual VMAT plan (manual-VMAT) and their regions of interests. Dosimetric parameters and time efficiency were compared between the auto-VMAT and the manual-VMAT created by experienced planners. All results were analyzed using the Wilcoxon signed-rank sum test. RESULTS The auto-VMAT achieved comparable coverage of the target volume while demonstrating improved dose conformity and uniformity compared with the manual-VMAT. V30 and V40 in the small bowel were significantly lower in the auto-VMAT compared with those in the manual-VMAT (p < 0.001 and < 0.001, respectively); the mean dose of the bladder was also significantly reduced in the auto-VMAT (p < 0.001). Furthermore, auto-VMAT plans were consistently generated with less variability in quality. In terms of efficiency, the auto-VMAT markedly reduced the time required for planning and expedited plan approval, with 93% of cases approved within one day. CONCLUSION We developed a fully automatic feasible VMAT plan creation program for LARC. The auto-VMAT maintained target coverage while providing organs at risk dose reduction. The developed program dramatically reduced the time to approval.
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Affiliation(s)
- Kouta Hirotaki
- Doctoral Program in Medical Sciences, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Ibaraki, Japan
- Department of Radiological Technology, National Cancer Center Hospital East, Chiba, Japan
| | - Kento Tomizawa
- Department of Radiation Oncology, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, 277-8577, Kashiwa, Chiba, Japan.
| | | | - Hajime Oyoshi
- Department of Radiological Technology, National Cancer Center Hospital East, Chiba, Japan
| | - Vijay Raturi
- Department of Radiation Oncology, Apollomedics Hospital, Lucknow, India
| | - Masashi Ito
- Department of Radiological Technology, National Cancer Center Hospital East, Chiba, Japan
| | - Takeji Sakae
- Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
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O'Daniel JC, Giles W, Cui Y, Adamson J. A structured FMEA approach to optimizing combinations of plan-specific quality assurance techniques for IMRT and VMAT QA. Med Phys 2023; 50:5387-5397. [PMID: 37475493 DOI: 10.1002/mp.16630] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 06/23/2023] [Accepted: 06/26/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND Many commercial tools are available for plan-specific quality assurance (QA) of radiotherapy plans, with their functionality assessed in isolation. However, multiple QA tools are required to review the full range of potential errors. It is important to assess their effectiveness in combination with each other to look for ways to both streamline the QA process and to make certain that errors of high impact and/or high occurrence are caught before reaching patient treatment. PURPOSE To develop a structured method to assess the effective risk reduction of combinations of QA methods for IMRT/VMAT treatments. METHODS First, a structured prospective risk assessment was performed to establish the major failure modes (FMs) of IMRT/VMAT QA, and assign occurrence (O), severity (S), and baseline detectability (BD) rankings to them. The baseline assumed that chart checks and linear accelerator QA was performed, but no plan-specific secondary dose calculation or measurement was done. Second, the detectability of each FM for two secondary dose calculation methods and four plan measurement methods (point-based dose calculation, Monte-Carlo-based dose calculation, 2D fluence-based measurement, 2.5D phantom-based measurement, log file analysis with dose recalculation, and log file analysis combined with MLC QA) was determined. Third, we used a minimum detectability approach in addition to each FM's occurrence and severity to determine the optimal combination of QA methods. We analyzed the cumulative risk priority number of eight combinations of QA methods. The analysis was done on (1) all FMs, (2) FMs with high severity, (3) FMs with high-risk priority numbers (RPN) of O*S*BD, and (4) on FMs with both high severity and high RPN. RESULTS Our analysis resulted in 54 FMs, including commissioning, planning, data transfer, and linear accelerator failures. 1D secondary dose calculation plus measurement provided a 19%-22% risk reduction from baseline. 1D/3D secondary dose calculation plus log files created a 25%-32% reduction. 3D secondary dose calculation plus measurement resulted in a 27%-34% reduction. 3D secondary dose calculation plus log files with additional machine QA provided the greatest reduction of 31%-42%. CONCLUSION This novel structured approach to comparing combinations of QA methods will allow us to optimize our procedures, with the goal of detecting all clinically significant FMs. Our results show that log-file QA with 3D dose recalculation and supplemental machine QA provides better risk reduction than measurement-based QA. This work builds evidence to justify reducing or eliminating measurement-based PSQA with an independent 3D dose verification, log-file measurement, and appropriate supplementation of machine QA. The process also highlights FMs that cannot be caught by pre-treatment QA, prompting us to consider future directions for on-treatment QA.
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Affiliation(s)
- Jennifer C O'Daniel
- Department of Radiation Oncology, Duke University, Durham, North Carolina, USA
| | - William Giles
- Department of Radiation Oncology, Duke University, Durham, North Carolina, USA
| | - Yunfeng Cui
- Department of Radiation Oncology, Duke University, Durham, North Carolina, USA
| | - Justus Adamson
- Department of Radiation Oncology, Duke University, Durham, North Carolina, USA
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Xie L, Xu D, He K, Tian X. Machine learning-based radiotherapy time prediction and treatment scheduling management. J Appl Clin Med Phys 2023; 24:e14076. [PMID: 37592451 PMCID: PMC10476992 DOI: 10.1002/acm2.14076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 05/15/2023] [Accepted: 06/07/2023] [Indexed: 08/19/2023] Open
Abstract
PURPOSE The utility efficiency of medical devices is important, especially for countries such as China, which have a large population and shortage of medical care resources. Radiotherapy devices are among the most valuable and specialized equipment categories and carry enormous treatment loads. In this study, a novel method is proposed to improve the efficiency of a radiotherapy device (linac). Although scheduling management with accurate prediction of the entire treatment time included in each appointment, arrange a reasonable time duration for appointments and save time between patient shifts effectively. Tasks belonging to the treatment and non-treatment groups can be assigned more flexibly based on the availability of time. MATERIAL AND METHODS Data from 1665 patients, including patient positioning time (PT) and treatment time (TT), were collected in collaboration with the Radiotherapy Center of the Department of Oncology at the Second Affiliated Hospital of Kunming Medical University from November 2020 to August 2021. The features related to PT and TT were extracted and used to train the machine learning-based model to predict PT and TT in independent patients. The prediction results were subsequently applied to a minute-based scheduling tool. CONCLUSION Artificial intelligence is a promising approach to solve abstract problems with a specialized knowledge background. The results of this study show encouraging prediction outcomes in relation to effective scheduling management and could improve the efficiency of the linac. This successful trial broadens the meaning of medical data and potential future research directions in radiotherapy.
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Affiliation(s)
- Lisiqi Xie
- School of Information Science and EngineeringYunnan UniversityKunmingChina
| | - Dan Xu
- School of Information Science and EngineeringYunnan UniversityKunmingChina
| | - Kangjian He
- School of Information Science and EngineeringYunnan UniversityKunmingChina
| | - Xin Tian
- Department of Radiation OncologyThe Second Affiliated Hospital of Kunming Medical UniversityKunmingChina
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Halvorsen PH, Burmeister J, Hariharan N, Kim M, Lee B, Lincoln H, Morelli Z, Sala IM, Sethi A, Wang H. Resource Allocations for Common Radiation Oncology Procedures. Pract Radiat Oncol 2023; 13:e423-e441. [PMID: 37028645 DOI: 10.1016/j.prro.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 03/15/2023] [Accepted: 03/15/2023] [Indexed: 04/09/2023]
Abstract
PURPOSE Radiation Oncology is a complex, resource-intensive discipline. The complexity of the radiation oncology treatment process has increased significantly in recent years with the introduction of more advanced imaging, planning, and treatment delivery technology and enhanced use of multidisciplinary care paths. We conducted a multi-institutional study to estimate the average time by functional unit for a wide range of modern radiation oncology treatment regimens. METHODS AND MATERIALS Structured process mapping was performed for 24 treatment categories, and average time estimates for 6 functional groups were obtained for each process step through consultation with the full clinical team at each institution. Six geographically dispersed institutions participated in the study. Significant effort was invested in aggregate data analysis and clarification of assumptions. RESULTS The findings show significant variability in the resources expended for many treatment categories as well as the distribution of workload between functional units. Major factors in the variability include the rate of adoption of hypofractionation in external beam therapy, adoption of automation tools and standardization, and the transition to multimodality image-based planning in brachytherapy. CONCLUSIONS The data obtained from this study may be useful in designing institution-specific staffing models appropriate to the scope of radiation therapy services provided at each institution.
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Affiliation(s)
- Per H Halvorsen
- Radiation Oncology, Beth Israel Lahey Health, Lahey Division, Burlington, Massachusetts.
| | - Jay Burmeister
- Radiation Oncology, Karmanos Cancer Center, Wayne State University School of Medicine, Detroit, Michigan
| | - Navneeth Hariharan
- Radiation Oncology, Beth Israel Lahey Health, Lahey Division, Burlington, Massachusetts
| | - Minsun Kim
- Radiation Oncology, University of Washington, Seattle, Washington
| | - Brian Lee
- Radiation Oncology, Loyola University Medical Center, Maywood, Illinois
| | - Holly Lincoln
- Radiation Oncology, Yale University School of Medicine, New Haven, Connecticut
| | - Zackary Morelli
- Radiation Oncology, Beth Israel Lahey Health, Lahey Division, Burlington, Massachusetts
| | - Ina Marina Sala
- Radiation Oncology, Yale University School of Medicine, New Haven, Connecticut
| | - Anil Sethi
- Radiation Oncology, Loyola University Medical Center, Maywood, Illinois
| | - Hazel Wang
- Radiation Oncology, Northwestern Medicine, Warrenville, Illinois
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Li J, Wang D, Chan M. Predictive quality assurance for linear accelerator target failure using statistical process control. Biomed Phys Eng Express 2023; 9:055018. [PMID: 37437550 DOI: 10.1088/2057-1976/ace6a1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 07/12/2023] [Indexed: 07/14/2023]
Abstract
The performance of a linear accelerator (Linac) depends on the integrity of its x-ray target. The sudden failure of its target not only breaks down the Linac but also could contribute significant disruptions to patient care. This work is to develop a predicative quality assurance (QA) method using Statistical Process Control (SPC) and AutoRegressive Integrated Moving Average (ARIMA) modeling to identify the risk of target failure before it occurs. In the past years, we observed two incidents of target failure among our Linacs. Retrospectively, we collected past daily QA data (from both open fields and enhanced dynamic wedge (EDW) measurements) and analyzed its historical trend using methods of SPC and ARIMA. SPC is a technique that monitors process performance based on statistical analysis. ARIMA is a time-series forecasting algorithm that can be used to estimate future values based on its past pattern. Both have been evaluated for predictive QA in radiotherapy. Application of SPC on open beam QA data would not yield an early warning signal to the pending target failures. However, when the same SPC methodology applies to EDW measurements, the control limits were breached a couple of weeks before the target failed. EDW mechanism introduces nonuniform magnification factors over its wedge-directed beam profiles and is responsible for the sensitivity of its profile to changing beam properties induced by a degrading target. Further extension of the warning period may be possible by using ARIMA modeling. Predicative QA for EDW daily data using SPC and ARIMA methods may provide an early QA warning to incoming Linac target failure.
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Affiliation(s)
- Jingdong Li
- Memorial Sloan-Kettering Cancer Center at Basking Ridge, NJ, United States of America
| | - Dongxu Wang
- Memorial Sloan-Kettering Cancer Center at Basking Ridge, NJ, United States of America
| | - Maria Chan
- Memorial Sloan-Kettering Cancer Center at Basking Ridge, NJ, United States of America
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Dogan N, Mijnheer BJ, Padgett K, Nalichowski A, Wu C, Nyflot MJ, Olch AJ, Papanikolaou N, Shi J, Holmes SM, Moran J, Greer PB. AAPM Task Group Report 307: Use of EPIDs for Patient-Specific IMRT and VMAT QA. Med Phys 2023; 50:e865-e903. [PMID: 37384416 PMCID: PMC11230298 DOI: 10.1002/mp.16536] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 04/23/2023] [Accepted: 05/15/2023] [Indexed: 07/01/2023] Open
Abstract
PURPOSE Electronic portal imaging devices (EPIDs) have been widely utilized for patient-specific quality assurance (PSQA) and their use for transit dosimetry applications is emerging. Yet there are no specific guidelines on the potential uses, limitations, and correct utilization of EPIDs for these purposes. The American Association of Physicists in Medicine (AAPM) Task Group 307 (TG-307) provides a comprehensive review of the physics, modeling, algorithms and clinical experience with EPID-based pre-treatment and transit dosimetry techniques. This review also includes the limitations and challenges in the clinical implementation of EPIDs, including recommendations for commissioning, calibration and validation, routine QA, tolerance levels for gamma analysis and risk-based analysis. METHODS Characteristics of the currently available EPID systems and EPID-based PSQA techniques are reviewed. The details of the physics, modeling, and algorithms for both pre-treatment and transit dosimetry methods are discussed, including clinical experience with different EPID dosimetry systems. Commissioning, calibration, and validation, tolerance levels and recommended tests, are reviewed, and analyzed. Risk-based analysis for EPID dosimetry is also addressed. RESULTS Clinical experience, commissioning methods and tolerances for EPID-based PSQA system are described for pre-treatment and transit dosimetry applications. The sensitivity, specificity, and clinical results for EPID dosimetry techniques are presented as well as examples of patient-related and machine-related error detection by these dosimetry solutions. Limitations and challenges in clinical implementation of EPIDs for dosimetric purposes are discussed and acceptance and rejection criteria are outlined. Potential causes of and evaluations of pre-treatment and transit dosimetry failures are discussed. Guidelines and recommendations developed in this report are based on the extensive published data on EPID QA along with the clinical experience of the TG-307 members. CONCLUSION TG-307 focused on the commercially available EPID-based dosimetric tools and provides guidance for medical physicists in the clinical implementation of EPID-based patient-specific pre-treatment and transit dosimetry QA solutions including intensity modulated radiation therapy (IMRT) and volumetric modulated arc therapy (VMAT) treatments.
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Affiliation(s)
- Nesrin Dogan
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Ben J Mijnheer
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Kyle Padgett
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Adrian Nalichowski
- Department of Radiation Oncology, Karmanos Cancer Institute, Detroit, Michigan, USA
| | - Chuan Wu
- Department of Radiation Oncology, Sutter Medical Foundation, Roseville, California, USA
| | - Matthew J Nyflot
- Department of Radiation Oncology, University of Washington, Seattle, Washington, USA
| | - Arthur J Olch
- Department of Radiation Oncology, University of Southern California, and Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Niko Papanikolaou
- Division of Medical Physics, UT Health-MD Anderson, San Antonio, Texas, USA
| | - Jie Shi
- Sun Nuclear Corporation - A Mirion Medical Company, Melbourne, Florida, USA
| | | | - Jean Moran
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Peter B Greer
- Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Newcastle, NSW, Australia
- School of Information and Physical Sciences, University of Newcastle, Newcastle, NSW, Australia
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Solanki AA, Burmeister J, Mak RH, Moran JM. Looking Backward and Forward: Learning From and Updating the ASTRO Safety White Papers 10 Years Later. Pract Radiat Oncol 2023; 13:278-281. [PMID: 37162425 DOI: 10.1016/j.prro.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 03/02/2023] [Accepted: 03/06/2023] [Indexed: 05/11/2023]
Affiliation(s)
- Abhishek A Solanki
- Department of Radiation Oncology, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago, Maywood, Illinois.
| | - Jay Burmeister
- Department of Oncology, Wayne State University School of Medicine, Karmanos Cancer Center, Detroit, Michigan
| | - Raymond H Mak
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Jean M Moran
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
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Sohn JJ, Lim S, Das IJ, Yadav P. An integrated and fast imaging quality assurance phantom for a 0.35 T magnetic resonance imaging linear accelerator. Phys Imaging Radiat Oncol 2023; 27:100462. [PMID: 37449023 PMCID: PMC10338140 DOI: 10.1016/j.phro.2023.100462] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 06/17/2023] [Accepted: 06/20/2023] [Indexed: 07/18/2023] Open
Abstract
Purpose Periodic imaging quality assurance (QA) of magnetic resonance imaging linear accelerator (MRL) is critical. The feasibility of a new MRL imaging phantom used for QA in the low field was evaluated with automated image analysis of various parameters for accuracy and reproducibility. Methods and materials The new MRL imaging phantom was scanned across every 30 degrees of the gantry, having the on/off state of the linac in a low-field MRL system using three magnetic resonance imaging sequences: true fast imaging with steady-state precession (TrueFISP), T1 weighted (T1W), and T2 weighted (T2W). The DICOM files were used to calculate the imaging parameters: geometric distortion, uniformity, resolution, signal-to-noise ratio (SNR), and laser alignment. The point spread function (PSF) and edge spread function (ESF) were also calculated for resolution analysis. Results The phantom data showed a small standard deviation - and high consistency for each imaging parameter. The highest variability in data was observed with the true fast imaging sequence at the calibration angle, which was expected because of low resolution and short scan time (25 sec). The mean magnitude of the largest distortion measured within 200 mm diameter with TrueFISP was 0.31 ± 0.05 mm. The PSF, ESF, signal uniformity, and SNR measurements remained consistent. Laser alignment traditional offsets and angular deviation remained consistent. Conclusions The new MRL imaging phantom is reliable, reproducible, time effective, and easy to use for a 0.35 T MRL system. The results promise a more streamlined, time-saving, and error-free QA process for low-field MRL adapted in our clinical setting.
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Affiliation(s)
| | | | | | - Poonam Yadav
- Corresponding author at: Department of Radiation Oncology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.
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Bellala R, Kuppusamy A, Bellala VM, Tyagi T, Manoharan S, Gangarapu G, Bellala R. Review of clinical applications and challenges with surface-guided radiation therapy. J Cancer Res Ther 2023; 19:1160-1169. [PMID: 37787279 DOI: 10.4103/jcrt.jcrt_1147_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
Aim To evaluate the use of this new technique, surface-guided radiotherapy (SGRT), for patient setup and motion management in various cancers. Materials and Methods Data was collected from 533 patients, who received treatment in our hospital for various malignancies using SGRT from October 2019 to April 2021. We studied patient setup, interfraction position, and patient position during the breath-hold (BH) technique. The main advantage of SGRT is that, it is completely non-invasive and uses visible light to compare the patient's skin surface in the treatment room and planned treatment position. In this analysis, Monaco 5.51.10 (Elekta) treatment planning system, Versa HD Linear Accelerator, and AlignRT 6.2 (Vision RT) SGRT system were used. Results With SGRT, treatment setup time can be reduced with more precision and techniques like Deep inspiration breathhold (DIBH) can be done with very good compliance. Conclusion SGRT has shown improved accuracy in patient setup compared to conventional laser setup. The daily kilo voltage imaging frequency can be reduced; it helps in reducing additional radiation exposure due to imaging. SGRT has demonstrated reproducibility with adequate accuracy in BH treatments in DIBH for breast and SBRT.
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Affiliation(s)
- Ravishankar Bellala
- Department of Radiation Oncology, Omega Hospital, Arilova, Health City, Chinagadili, Visakhapatnam, Andhra Pradesh, India
| | - Anandakrishnan Kuppusamy
- Department of Radiation Oncology, Omega Hospital, Arilova, Health City, Chinagadili, Visakhapatnam, Andhra Pradesh, India
| | - Venkat Madhavi Bellala
- Department of Radiation Oncology, Omega Hospital, Arilova, Health City, Chinagadili, Visakhapatnam, Andhra Pradesh, India
| | - Tulika Tyagi
- Department of Radiation Oncology, Omega Hospital, Arilova, Health City, Chinagadili, Visakhapatnam, Andhra Pradesh, India
| | - Surendhiran Manoharan
- Department of Radiation Oncology, Omega Hospital, Arilova, Health City, Chinagadili, Visakhapatnam, Andhra Pradesh, India
| | - Gunasekhar Gangarapu
- Department of Radiation Oncology, Omega Hospital, Arilova, Health City, Chinagadili, Visakhapatnam, Andhra Pradesh, India
| | - Rishik Bellala
- Department of Radiation Oncology, Omega Hospital, Arilova, Health City, Chinagadili, Visakhapatnam, Andhra Pradesh, India
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Zarei M, Gershan V, Holmberg O. Safety in radiation oncology (SAFRON): Learning about incident causes and safety barriers in external beam radiotherapy. Phys Med 2023; 111:102618. [PMID: 37311337 DOI: 10.1016/j.ejmp.2023.102618] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/02/2023] [Accepted: 06/02/2023] [Indexed: 06/15/2023] Open
Abstract
PURPOSE Safety in Radiation Oncology (SAFRON) is a reporting and learning system on radiotherapy and radionuclide therapy incidents and near misses. The primary aim of this paper is to examine whether any discernible patterns exist in the causes of reported incidents and safety barriers within the SAFRON system concerning external beam radiotherapy. METHODS AND MATERIALS This study focuses on external beam radiotherapy incidents, reviewing 1685 reports since the inception of SAFRON until December 2021. Reports that did not identify causes of incidents and safety barriers were excluded from the final study population. RESULTS Simple two-dimensional radiotherapy or electron beam therapy were represented by 97 reports, three-dimensional conformal radiotherapy by 39 reports, modulated arc therapy by 12 reports, intensity modulated radiation therapy by 11 reports, stereotactic radiosurgery by 4 reports, and radiotherapy with protons or other particles by 1 report, while for 92 of them, no information on treatment method had been provided. Most of the reported incidents were minor incidents and were discovered by the radiation therapist. Inadequate direction/information in staff communication was the most frequently reported cause of incident, and regular independent chart check was the most common safety barrier. CONCLUSIONS The results indicate that the majority of incidents were reported by radiation therapists, and the majority of these incidents were classified as minor. Communication problems and failure to follow standards/procedures/practices were the most frequent causes of incidents. Furthermore, regular independent chart checking was the most frequently identified safety barrier.
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Affiliation(s)
- Maryam Zarei
- Radiation Protection of Patients Unit, Radiation Safety and Monitoring Section, Division of Radiation, Transport and Waste Safety, International Atomic Energy Agency, Vienna, Austria.
| | - Vesna Gershan
- Radiation Protection of Patients Unit, Radiation Safety and Monitoring Section, Division of Radiation, Transport and Waste Safety, International Atomic Energy Agency, Vienna, Austria
| | - Ola Holmberg
- Radiation Protection of Patients Unit, Radiation Safety and Monitoring Section, Division of Radiation, Transport and Waste Safety, International Atomic Energy Agency, Vienna, Austria
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Ma M, Yan H, Li M, Tian Y, Zhang K, Men K, Dai J. Determining the quality control frequency of an MR-linac using risk matrix (RM) analysis. J Appl Clin Med Phys 2023:e13984. [PMID: 37095706 PMCID: PMC10402679 DOI: 10.1002/acm2.13984] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 02/28/2023] [Accepted: 03/20/2023] [Indexed: 04/26/2023] Open
Abstract
PURPOSE Quality control (QC) is performed routinely through professional guidelines. However, the recommended QC frequency may not be optimal among different institutional settings. Here we propose a novel method for determining the optimal QC frequency using risk matrix (RM) analysis. METHODS AND MATERIALS A newly installed Magnetic Resonance linac (MR-linac) was chosen as the testing platform and six routine QC items were investigated. Failures of these QC items can adversely affect treatment outcome for the patient. Accordingly, each QC item with its assigned frequency forms a unique failure mode (FM). Using FM-effect analysis (FMEA), the severity (S), occurrence (O), and detection (D) of each FM was obtained. Next, S and D based on RM was used to determine the appropriate QC frequency. Finally, the performance of new frequency for each QC item was evaluated using the metric E = O/D. RESULTS One new QC frequency was the same as the old frequency, two new QC frequencies were less than the old ones, and three new QC frequencies were higher than the old ones. For six QC items, E values at the new frequencies were not less than their values at the old frequencies. This indicates that the risk of machine failure is reduced at the new QC frequencies. CONCLUSIONS The application of RM analysis provides a useful tool for determining the optimal frequencies for routine linac QC. This study demonstrated that linac QC can be performed in a way that maintains high performance of the treatment machine in a radiotherapy clinic.
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Affiliation(s)
- Min Ma
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hui Yan
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Minghui Li
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuan Tian
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ke Zhang
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kuo Men
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jianrong Dai
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Baehr A, Hummel D, Gauer T, Oertel M, Kittel C, Löser A, Todorovic M, Petersen C, Krüll A, Buchgeister M. Risk management patterns in radiation oncology-results of a national survey within the framework of the Patient Safety in German Radiation Oncology (PaSaGeRO) project. Strahlenther Onkol 2023; 199:350-359. [PMID: 35931889 PMCID: PMC10033570 DOI: 10.1007/s00066-022-01984-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 07/10/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE Risk management (RM) is a key component of patient safety in radiation oncology (RO). We investigated current approaches on RM in German RO within the framework of the Patient Safety in German Radiation Oncology (PaSaGeRO) project. Aim was not only to evaluate a status quo of RM purposes but furthermore to discover challenges for sustainable RM that should be addressed in future research and recommendations. METHODS An online survey was conducted from June to August 2021, consisting of 18 items on prospective and reactive RM, protagonists of RM, and self-assessment concerning RM. The survey was designed using LimeSurvey and invitations were sent by e‑mail. Answers were requested once per institution. RESULTS In all, 48 completed questionnaires from university hospitals, general and non-academic hospitals, and private practices were received and considered for evaluation. Prospective and reactive RM was commonly conducted within interprofessional teams; 88% of all institutions performed prospective risk analyses. Most institutions (71%) reported incidents or near-events using multiple reporting systems. Results were presented to the team in 71% for prospective analyses and 85% for analyses of incidents. Risk conferences take place in 46% of institutions. 42% nominated a manager/committee for RM. Knowledge concerning RM was mostly rated "satisfying" (44%). However, 65% of all institutions require more information about RM by professional societies. CONCLUSION Our results revealed heterogeneous patterns of RM in RO departments, although most departments adhered to common recommendations. Identified mismatches between recommendations and implementation of RM provide baseline data for future research and support definition of teaching content.
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Affiliation(s)
- Andrea Baehr
- Outpatient Center of the UKE GmbH, Department of Radiotherapy and Radiation Oncology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20251, Hamburg, Germany.
| | - Daniel Hummel
- Department of Radiotherapy and Genetics, Outpatient Center Stuttgart, University Hospital Tübingen, Stuttgart, Germany
| | - Tobias Gauer
- Department of Radiotherapy and Radiation Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Oertel
- Department of Radiation Oncology, University Hospital Münster, Münster, Germany
| | - Christopher Kittel
- Department of Radiation Oncology, University Hospital Münster, Münster, Germany
| | - Anastassia Löser
- Outpatient Center of the UKE GmbH, Department of Radiotherapy and Radiation Oncology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20251, Hamburg, Germany
| | - Manuel Todorovic
- Department of Radiotherapy and Radiation Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Cordula Petersen
- Department of Radiotherapy and Radiation Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas Krüll
- Outpatient Center of the UKE GmbH, Department of Radiotherapy and Radiation Oncology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20251, Hamburg, Germany
- Department of Radiotherapy and Radiation Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Markus Buchgeister
- Faculty of Mathematics-Physics-Chemistry (II), Berliner Hochschule für Technik, Berlin, Germany
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Claridge Mackonis ER, Hardcastle N, Haworth A. A survey of compliance with stereotactic ablative body radiotherapy quality recommendations. J Med Imaging Radiat Oncol 2023. [PMID: 36996443 DOI: 10.1111/1754-9485.13526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 03/05/2023] [Indexed: 04/01/2023]
Abstract
INTRODUCTION Many publications have proposed quality standards for stereotactic ablative body radiotherapy (SABR). However, data on the level of compliance with these guidelines is lacking in the literature. This study aimed to understand how these guidelines are applied in the clinic and to identify barriers to implementing such recommendations. METHODS Interviews were conducted with multidisciplinary staff at radiation oncology centres across New South Wales formulated around the RANZCR Guidelines for Safe Practice of Stereotactic Body (Ablative) Radiation Therapy. The interview responses were grouped into 20 topics, assessed against the guidelines and thematically analysed. RESULTS Good compliance with the guidelines was found, with more than 80% of centres achieving satisfactory results in more than half the topics. The areas with the lowest compliance were auditing, risk assessment and reporting recommendations. Barriers to the quality of SABR treatments included limited training opportunities, low patient numbers and a lack of clear requirements on comprehensive auditing and reporting. CONCLUSION Overall, the centres surveyed reported good compliance with most of the RANZCR SABR guidelines. The tasks with the lowest compliance were those that monitor quality outcomes. Potential strategies for improvement include inclusion in clinical trials and the use of databases which link treatment parameters, dosimetry and outcomes. Further work will focus on the barriers identified in this survey and propose practical solutions to improve compliance in these areas.
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Affiliation(s)
- Elizabeth Ruth Claridge Mackonis
- Institute of Medical Physics, School of Physics, University of Sydney, Sydney, New South Wales, Australia
- Department of Radiation Oncology, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia
| | - Nick Hardcastle
- Institute of Medical Physics, School of Physics, University of Sydney, Sydney, New South Wales, Australia
- Department of Physical Sciences, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Annette Haworth
- Institute of Medical Physics, School of Physics, University of Sydney, Sydney, New South Wales, Australia
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Petragallo R, Bertram P, Halvorsen P, Iftimia I, Low DA, Morin O, Narayanasamy G, Saenz DL, Sukumar KN, Valdes G, Weinstein L, Wells MC, Ziemer BP, Lamb JM. Development and multi-institutional validation of a convolutional neural network to detect vertebral body mis-alignments in 2D x-ray setup images. Med Phys 2023; 50:2662-2671. [PMID: 36908243 DOI: 10.1002/mp.16359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 02/11/2023] [Accepted: 02/16/2023] [Indexed: 03/14/2023] Open
Abstract
BACKGROUND Misalignment to the incorrect vertebral body remains a rare but serious patient safety risk in image-guided radiotherapy (IGRT). PURPOSE Our group has proposed that an automated image-review algorithm be inserted into the IGRT process as an interlock to detect off-by-one vertebral body errors. This study presents the development and multi-institutional validation of a convolutional neural network (CNN)-based approach for such an algorithm using patient image data from a planar stereoscopic x-ray IGRT system. METHODS X-rays and digitally reconstructed radiographs (DRRs) were collected from 429 spine radiotherapy patients (1592 treatment fractions) treated at six institutions using a stereoscopic x-ray image guidance system. Clinically-applied, physician approved, alignments were used for true-negative, "no-error" cases. "Off-by-one vertebral body" errors were simulated by translating DRRs along the spinal column using a semi-automated method. A leave-one-institution-out approach was used to estimate model accuracy on data from unseen institutions as follows: All of the images from five of the institutions were used to train a CNN model from scratch using a fixed network architecture and hyper-parameters. The size of this training set ranged from 5700 to 9372 images, depending on exactly which five institutions were contributing data. The training set was randomized and split using a 75/25 split into the final training/ validation sets. X-ray/ DRR image pairs and the associated binary labels of "no-error" or "shift" were used as the model input. Model accuracy was evaluated using images from the sixth institution, which were left out of the training phase entirely. This test set ranged from 180 to 3852 images, again depending on which institution had been left out of the training phase. The trained model was used to classify the images from the test set as either "no-error" or "shifted", and the model predictions were compared to the ground truth labels to assess the model accuracy. This process was repeated until each institution's images had been used as the testing dataset. RESULTS When the six models were used to classify unseen image pairs from the institution left out during training, the resulting receiver operating characteristic area under the curve values ranged from 0.976 to 0.998. With the specificity fixed at 99%, the corresponding sensitivities ranged from 61.9% to 99.2% (mean: 77.6%). With the specificity fixed at 95%, sensitivities ranged from 85.5% to 99.8% (mean: 92.9%). CONCLUSION This study demonstrated the CNN-based vertebral body misalignment model is robust when applied to previously unseen test data from an outside institution, indicating that this proposed additional safeguard against misalignment is feasible.
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Affiliation(s)
- Rachel Petragallo
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California, USA
| | | | - Per Halvorsen
- Department of Radiation Oncology, Beth Israel - Lahey Health, Burlington, Massachusetts, USA
| | - Ileana Iftimia
- Department of Radiation Oncology, Beth Israel - Lahey Health, Burlington, Massachusetts, USA
| | - Daniel A Low
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California, USA
| | - Olivier Morin
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California, USA
| | - Ganesh Narayanasamy
- Department of Radiation Oncology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Daniel L Saenz
- Department of Radiation Oncology, University of Texas HSC SA, San Antonio, Texas, USA
| | - Kevinraj N Sukumar
- Department of Radiation Oncology, Piedmont Healthcare, Atlanta, Georgia, USA
| | - Gilmer Valdes
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California, USA
| | - Lauren Weinstein
- Department of Radiation Oncology, Kaiser Permanente, South San Francisco, California, USA
| | - Michelle C Wells
- Department of Radiation Oncology, Piedmont Healthcare, Atlanta, Georgia, USA
| | - Benjamin P Ziemer
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California, USA
| | - James M Lamb
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California, USA
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Mao SPH, Han-Oh S, Moore J, Huang E, McNutt TR, Souranis AN, Briner V, Halthore A, Alcorn SR, Meyer JJ, Viswanathan AN, Wright JL. Selective de-implementation of routine in vivo dosimetry. J Appl Clin Med Phys 2023:e13953. [PMID: 36877712 DOI: 10.1002/acm2.13953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 01/25/2023] [Accepted: 01/30/2023] [Indexed: 03/07/2023] Open
Abstract
As cone-beam computed tomography (CBCT) has become the localization method for a majority of cases, the indications for diode-based confirmation of accurate patient set-up and treatment are now limited and must be balanced between proper resource allocation and optimizing efficiency without compromising safety. We undertook a de-implementation quality improvement project to discontinue routine diode use in non-intensity modulated radiotherapy (IMRT) cases in favor of tailored selection of scenarios where diodes may be useful. After analysis of safety reports from the last 5 years, literature review, and stakeholder discussions, our safety and quality (SAQ) committee introduced a recommendation to limit diode use to specific scenarios in which in vivo verification may add value to standard quality assurance (QA) processes. To assess changes in patterns of use, we reviewed diode use by clinical indication 4 months prior and after the implementation of the revised policy, which includes use of diodes for: 3D conformal photon fields set up without CBCT; total body irradiation (TBI); electron beams; cardiac devices within 10 cm of the treatment field; and unique scenarios on a case-by-case basis. We identified 4459 prescriptions and 1038 unique instances of diode use across five clinical sites from 5/2021 to 1/2022. After implementation of the revised policy, we observed an overall decrease in diode use from 32% to 13.2%, with a precipitous drop in 3D cases utilizing CBCT (from 23.2% to 4%), while maintaining diode utilization in the 5 selected scenarios including 100% of TBI and electron cases. By identifying specific indications for diode use and creating a user-friendly platform for case selection, we have successfully de-implemented routine diode use in favor of a selective process that identifies cases where the diode is important for patient safety. In doing so, we have streamlined patient care and decreased cost without compromising patient safety.
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Affiliation(s)
- Serena P H Mao
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Sarah Han-Oh
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Joseph Moore
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Ellen Huang
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Todd R McNutt
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Annette N Souranis
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Valerie Briner
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Aditya Halthore
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Sarah R Alcorn
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Jeffrey J Meyer
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Akila N Viswanathan
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Jean L Wright
- Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
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Stambaugh C, Yancey J, Shukla U, Melhus C, Stambaugh N. Daily Quality Assurance Efficiency Evaluation Using SunCHECK Machine and Machine Performance Check. Cureus 2023; 15:e35695. [PMID: 37012967 PMCID: PMC10066746 DOI: 10.7759/cureus.35695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2023] [Indexed: 03/06/2023] Open
Abstract
Purpose To investigate time efficiency, applicability, and accuracy of using a web-based, independent quality assurance (QA) platform and vendor-dependent based system check for daily linear accelerator (LINAC) QA. Methods Time needed to perform daily QA on a single (n=1) LINAC was collected for three months. Task Group report 142 (TG-142) compliant daily QA included dosimetry checks (four photon, four electron beams); imaging checks (planar kilovolt (kV) & megavolt (MV), kV cone-beam computed tomography (CBCT)); and mechanical and safety checks using SunCHECK Machine (SCM) (Sun Nuclear Inc., Melbourne, FL, USA). Additionally, Machine Performance Check (MPC) (Varian Medical Systems, Inc., Palo Alto, CA, USA) was performed for all energies. Four trained radiation therapists performed daily QA on both platforms. Data were collected to identify the time required to complete both SCM and MPC. Additionally, the two platforms were evaluated on usability and features. Output results were compared to our monthly standard to assess accuracy. Results On average, SCM took 22 minutes with a standard deviation of six minutes and MPC took 15 minutes with a standard deviation of three minutes. MPC output results were impacted due to the beam output being coupled to the beam profile changes. As a result, the two systems on average disagreed by -1.41% after three months despite being baselined at the same time point and output agreeing well initially (average difference of -0.1% across all energies). While there was overlap in the tests performed, SCM tests were more relevant to TG-142 while MPC tests were beneficial to machine service and, with a clear understanding of the limitations of the system, found suitable as a secondary backup to SCM for daily output verification. Conclusions This work demonstrates that a comprehensive TG-142 daily QA can be designed using SCM and MPC can be added as a beneficial tool and backup for output verification while still maintaining an efficient daily QA process.
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Uher K, Ehrbar S, Tanadini-Lang S, Dal Bello R. Reduction of patient specific quality assurance through plan complexity metrics for VMAT plans with an open-source TPS script. Z Med Phys 2023:S0939-3889(23)00011-9. [DOI: 10.1016/j.zemedi.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 01/17/2023] [Accepted: 02/09/2023] [Indexed: 03/31/2023]
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Richardson SL, Buzurovic IM, Cohen GN, Culberson WS, Dempsey C, Libby B, Melhus CS, Miller RA, Scanderbeg DJ, Simiele SJ. AAPM medical physics practice guideline 13.a: HDR brachytherapy, part A. J Appl Clin Med Phys 2023; 24:e13829. [PMID: 36808798 PMCID: PMC10018677 DOI: 10.1002/acm2.13829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 08/09/2022] [Accepted: 09/22/2022] [Indexed: 02/22/2023] Open
Abstract
The American Association of Physicists in Medicine (AAPM) is a nonprofit professional society whose primary purposes are to advance the science, education, and professional practice of medical physics. The AAPM has more than 8000 members and is the principal organization of medical physicists in the United States. The AAPM will periodically define new practice guidelines for medical physics practice to help advance the science of medical physics and to improve the quality of service to patients throughout the United States. Existing medical physics practice guidelines (MPPGs) will be reviewed for the purpose of revision or renewal, as appropriate, on their fifth anniversary or sooner. Each medical physics practice guideline represents a policy statement by the AAPM, has undergone a thorough consensus process in which it has been subjected to extensive review, and requires the approval of the Professional Council. The medical physics practice guidelines recognize that the safe and effective use of diagnostic and therapeutic radiology requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published practice guidelines and technical standards by those entities not providing these services is not authorized. The following terms are used in the AAPM practice guidelines: (1) Must and must not: Used to indicate that adherence to the recommendation is considered necessary to conform to this practice guideline. (2) Should and should not: Used to indicate a prudent practice to which exceptions may occasionally be made in appropriate circumstances. Approved by AAPM's Executive Committee April 28, 2022.
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Affiliation(s)
| | - Ivan M Buzurovic
- Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Gil'ad N Cohen
- Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | | | - Claire Dempsey
- Calvary Mater Newcastle Hospital University of Newcastle, Callaghan, Australia University of Washington, Seattle, USA
| | | | | | - Robin A Miller
- Multicare Regional Cancer Center, Northwest Medical Physics Center, Tacoma, WA, USA
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Chen Q, Rong Y, Burmeister JW, Chao EH, Corradini NA, Followill DS, Li XA, Liu A, Qi XS, Shi H, Smilowitz JB. AAPM Task Group Report 306: Quality control and assurance for tomotherapy: An update to Task Group Report 148. Med Phys 2023; 50:e25-e52. [PMID: 36512742 DOI: 10.1002/mp.16150] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 09/22/2022] [Accepted: 11/28/2022] [Indexed: 12/15/2022] Open
Abstract
Since the publication of AAPM Task Group (TG) 148 on quality assurance (QA) for helical tomotherapy, there have been many new developments on the tomotherapy platform involving treatment delivery, on-board imaging options, motion management, and treatment planning systems (TPSs). In response to a need for guidance on quality control (QC) and QA for these technologies, the AAPM Therapy Physics Committee commissioned TG 306 to review these changes and make recommendations related to these technology updates. The specific objectives of this TG were (1) to update, as needed, recommendations on tolerance limits, frequencies and QC/QA testing methodology in TG 148, (2) address the commissioning and necessary QA checks, as a supplement to Medical Physics Practice Guidelines (MPPG) with respect to tomotherapy TPS and (3) to provide risk-based recommendations on the new technology implemented clinically and treatment delivery workflow. Detailed recommendations on QA tests and their tolerance levels are provided for dynamic jaws, binary multileaf collimators, and Synchrony motion management. A subset of TPS commissioning and QA checks in MPPG 5.a. applicable to tomotherapy are recommended. In addition, failure mode and effects analysis has been conducted among TG members to obtain multi-institutional analysis on tomotherapy-related failure modes and their effect ranking.
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Affiliation(s)
- Quan Chen
- Radiation Oncology, City of Hope Medical Center, Duarte, California, USA
| | - Yi Rong
- Department of Radiation Oncology, Mayo Clinic Hospitals, Phoenix, Arizona, USA
| | - Jay W Burmeister
- Karmanos Cancer Center, Gershenson R.O.C., Detroit, Michigan, USA
- Department of Oncology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | | | | | - David S Followill
- Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - X Allen Li
- Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - An Liu
- Radiation Oncology, City of Hope Medical Center, Duarte, California, USA
| | - X Sharon Qi
- Radiation Oncology, UCLA School of Medicine, Los Angeles, California, USA
| | - Hairong Shi
- Radiation Oncology, Oklahoma Cancer Specialists and Research Institute, Tulsa, Oklahoma, USA
| | - Jennifer B Smilowitz
- Human Oncology and Medical Physics, University of Wisconsin-Madison, Madison, Wisconsin, USA
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Quality and Safety Considerations in Image Guided Radiation Therapy: An ASTRO Safety White Paper Update. Pract Radiat Oncol 2023; 13:97-111. [PMID: 36585312 DOI: 10.1016/j.prro.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/07/2022] [Accepted: 09/08/2022] [Indexed: 12/30/2022]
Abstract
PURPOSE This updated report on image guided radiation therapy (IGRT) is part of a series of consensus-based white papers previously published by the American Society for Radiation Oncology addressing patient safety. Since the first white papers were published, IGRT technology and procedures have progressed significantly such that these procedures are now more commonly used. The use of IGRT has now extended beyond high-precision treatments, such as stereotactic radiosurgery and stereotactic body radiation therapy, and into routine clinical practice for many treatment techniques and anatomic sites. Therefore, quality and patient safety considerations for these techniques remain an important area of focus. METHODS AND MATERIALS The American Society for Radiation Oncology convened an interdisciplinary task force to assess the original IGRT white paper and update content where appropriate. Recommendations were created using a consensus-building methodology, and task force members indicated their level of agreement based on a 5-point Likert scale from "strongly agree" to "strongly disagree." A prespecified threshold of ≥75% of raters who selected "strongly agree" or "agree" indicated consensus. SUMMARY This IGRT white paper builds on the previous version and uses other guidance documents to primarily focus on processes related to quality and safety. IGRT requires an interdisciplinary team-based approach, staffed by appropriately trained specialists, as well as significant personnel resources, specialized technology, and implementation time. A thorough feasibility analysis of resources is required to achieve the clinical and technical goals and should be discussed with all personnel before undertaking new imaging techniques. A comprehensive quality-assurance program must be developed, using established guidance, to ensure IGRT is performed in a safe and effective manner. As IGRT technologies continue to improve or emerge, existing practice guidelines should be reviewed or updated regularly according to the latest American Association of Physicists in Medicine Task Group reports or guidelines. Patient safety in the application of IGRT is everyone's responsibility, and professional organizations, regulators, vendors, and end-users must demonstrate a clear commitment to working together to ensure the highest levels of safety.
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Rahman M, Zhang R, Gladstone DJ, Williams BB, Chen E, Dexter CA, Thompson L, Bruza P, Pogue BW. Failure Mode and Effects Analysis for Experimental Use of FLASH on a Clinical Accelerator. Pract Radiat Oncol 2023; 13:153-165. [PMID: 36375771 PMCID: PMC10373055 DOI: 10.1016/j.prro.2022.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 08/21/2022] [Accepted: 10/07/2022] [Indexed: 11/13/2022]
Abstract
PURPOSE The use of a linear accelerator (LINAC) in ultrahigh-dose-rate (UHDR) mode can provide a conduit for wider access to UHDR FLASH effects, sparing normal tissue, but care needs to be taken in the use of such systems to ensure errors are minimized. The failure mode and effects analysis was carried out in a team that has been involved in converting a LINAC between clinical use and UHDR experimental mode for more than 1 year after the proposed methods of TG100. METHODS AND MATERIALS A team of 9 professionals with extensive experience were polled to outline the process map and workflow for analysis, and developed fault trees for potential errors, as well as failure modes that would result. The team scored the categories of severity magnitude, occurrence likelihood, and detectability potential in a scale of 1 to 10, so that a risk priority number (RPN = severity×occurrence×detectability) could be assessed for each. RESULTS A total of 46 potential failure modes were identified, including 5 with an RPN >100. These failure modes involved (1) patient set up, (2) gating mechanisms in delivery, and (3) detector in the beam stop mechanism. The identified methods to mitigate errors included the (1) use of a checklist post conversion, (2) use of robust radiation detectors, (3) automation of quality assurance and beam consistency checks, and (4) implementation of surface guidance during beam delivery. CONCLUSIONS The failure mode and effects analysis process was considered critically important in this setting of a new use of a LINAC, and the expert team developed a higher level of confidence in the ability to safely move UHDR LINAC use toward expanded research access.
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Affiliation(s)
- Mahbubur Rahman
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire; University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Rongxiao Zhang
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire; Department of Medicine, Radiation Oncology, Geisel School of Medicine, Dartmouth College Hanover, New Hampshire; Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - David J Gladstone
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire; Department of Medicine, Radiation Oncology, Geisel School of Medicine, Dartmouth College Hanover, New Hampshire; Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Benjamin B Williams
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire; Department of Medicine, Radiation Oncology, Geisel School of Medicine, Dartmouth College Hanover, New Hampshire; Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Erli Chen
- Cheshire Medical Center, Keene, New Hampshire
| | - Chad A Dexter
- Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Lawrence Thompson
- Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Petr Bruza
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire
| | - Brian W Pogue
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire; Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Department of Surgery, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire; Department of Medical Physics, Wisconsin Institutes for Medical Research, University of Wisconsin, Madison, Wisconsin
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Conroy L, Faught JT, Bowers E, Ecclestone G, Fong de Los Santos LE, Hsu A, Johnson JL, Kim GGY, Schechter N, Schubert LK, Sterling DA. Medical physics practice guideline 4.b: Development, implementation, use and maintenance of safety checklists. J Appl Clin Med Phys 2023; 24:e13895. [PMID: 36739483 PMCID: PMC10018656 DOI: 10.1002/acm2.13895] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 09/22/2022] [Accepted: 11/20/2022] [Indexed: 02/06/2023] Open
Abstract
The American Association of Physicists in Medicine (AAPM) is a nonprofit professional society whose primary purposes are to advance the science, education, and professional practice of medical physics. The AAPM has more than 8000 members and is the principal organization of medical physicists in the US. The AAPM will periodically define new practice guidelines for medical physics practice to help advance the science of medical physics and to improve the quality of service to patients throughout the US. Existing medical physics practice guidelines will be reviewed for the purpose of revision or renewal, as appropriate, on their fifth anniversary or sooner. Each medical physics practice guideline represents a policy statement by the AAPM, has undergone a thorough consensus process in which it has been subjected to extensive review, and requires the approval of the Professional Council. The medical physics practice guidelines recognize that the safe and effective use of diagnostic and therapeutic radiology requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published practice guidelines and technical standards by those entities not providing these services is not authorized. The following terms are used in the AAPM practice guidelines: Must and must not: Used to indicate that adherence to the recommendation is considered necessary to conform to this practice guideline. While must is the term to be used in the guidelines, if an entity that adopts the guideline has shall as the preferred term, the AAPM considers that must and shall have the same meaning. Should and should not: Used to indicate a prudent practice to which exceptions may occasionally be made in appropriate circumstances.
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Affiliation(s)
- Leigh Conroy
- Princess Margaret Cancer Centre, Toronto, Canada
| | | | | | | | | | - Annie Hsu
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | | | | | - Naomi Schechter
- University of Southern California, Los Angeles, California, USA
| | - Leah K Schubert
- University of Colorado School of Medicine, Aurora, Colorado, USA
| | - David A Sterling
- University of Minnesota Medical Center, Minneapolis, Minnesota, USA
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Liang J, Scripes PG, Tyagi N, Subashi E, Wunner T, Cote N, Chan CY, Ng A, Brennan V, Zakeri K, Wildberger C, Mechalakos J. Risk analysis of the Unity 1.5 T MR-Linac adapt-to-position workflow. J Appl Clin Med Phys 2023; 24:e13850. [PMID: 36411990 PMCID: PMC10018675 DOI: 10.1002/acm2.13850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 10/11/2022] [Accepted: 11/02/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND AND PURPOSE Newer technologies allow for daily treatment adaptation, providing the ability to account for setup variations and organ motion but comes at the cost of increasing the treatment workflow complexity. One such technology is the adapt-to-position (ATP) workflow on the Unity MR-Linac. Prospective risk assessment of a new workflow allows clinics to catch errors before they occur, especially for processes that include novel and unfamiliar steps. METHODS As part of a quality management program, failure modes and effects analysis was performed on the ATP treatment workflow following the recommendations of AAPM's Task Group 100. A multidisciplinary team was formed to identify and evaluate failure modes for all the steps taken during a daily treatment workflow. Failure modes of high severity and overall score were isolated and addressed. RESULTS Mitigations were determined for high-ranking failure modes and implemented into the clinic. High-ranking failure modes existed in all steps of the workflow. Failure modes were then rescored to evaluate the effectiveness of the mitigations. CONCLUSION Failure modes and effects analysis on the Unity MR-Linac highlighted areas in the ATP workflow that could be prone to failures and allowed our clinic to change the process to be more robust.
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Affiliation(s)
- Jiayi Liang
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Paola Godoy Scripes
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Neelam Tyagi
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ergys Subashi
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Theresa Wunner
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nicolas Cote
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ching-Yun Chan
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Angela Ng
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Victoria Brennan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kaveh Zakeri
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Cassandra Wildberger
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - James Mechalakos
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Zaini MM, Fagerstrom JM, Marshall EI, Hedrick KM, Zaks D, Tran H, Fitzgerald TM. Therapeutic radiation beam output and energy variation across clinics, technologies, and time. J Appl Clin Med Phys 2023:e13945. [PMID: 36848039 DOI: 10.1002/acm2.13945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 01/24/2023] [Accepted: 02/09/2023] [Indexed: 03/01/2023] Open
Abstract
Over the past several decades, a medical physics service group covering 35 clinical sites has provided routine monthly output and energy quality assurance for over 75 linear accelerators. Based on the geographical spread of these clinics and the large number of physicists involved in data acquisition, a systematic calibration procedure was established to ensure uniformity. A consistent measurement geometry and data collection technique is used across all machines for every calendar month, using a standardized set of acrylic slabs. Charge readings in acrylic phantoms are linked to AAPM's TG-51 formalism via a parameter denoted kacrylic , used to convert raw charge readings to machine output values. Statistical analyses of energy ratios and kacrylic values are presented. Employing the kacrylic concept with a uniform measurement geometry of similar acrylic blocks was found to be a reproducible and simple way of referencing a calibration completed in water under reference conditions and comparing to other machines, with the ability to alert physicists of outliers.
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Affiliation(s)
| | | | | | | | - Daniel Zaks
- Northwest Medical Physics Center, Lynnwood, Washington, USA
| | - Hung Tran
- Northwest Medical Physics Center, Lynnwood, Washington, USA
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Tanabe Y. [9. Safer and Ideal Radiation Treatment Planning]. Nihon Hoshasen Gijutsu Gakkai Zasshi 2023; 79:193-195. [PMID: 36804810 DOI: 10.6009/jjrt.2023-2152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Affiliation(s)
- Yoshinori Tanabe
- Faculty of Medicine, Graduate School of Health Sciences, Okayama University
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84
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Mizuno N, Okamoto H, Minemura T, Kawamura S, Tohyama N, Kurooka M, Kawamorita R, Nakamura M, Ito Y, Shioyama Y, Aoyama H, Igaki H. Establishing quality indicators to comprehensively assess quality assurance and patient safety in radiotherapy and their relationship with an institution's background. Radiother Oncol 2023; 179:109452. [PMID: 36572282 DOI: 10.1016/j.radonc.2022.109452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 12/11/2022] [Accepted: 12/18/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE Quality indicators (QIs) for radiotherapy have been proposed by several groups, but no study has been conducted to correlate the implementation of indicators specific to patient safety over the course of the clinical process with an institution's background. An initial large-scale survey was conducted to understand the implementation status of QIs established for quality assurance and patient safety in radiotherapy and the relationship between implementation status and an institutions' background. MATERIALS AND METHOD Overall, 68 QIs that were established by this research team after a pilot survey were used to assess structures and processes for quality assurance and patient safety. Data on the implementation of QIs and the institutions' backgrounds were obtained from designated cancer care hospitals in Japan. RESULTS Overall, 284 institutions (72 %) responded and had a median QI achievement rate of 60.8 %. QIs with low implementation rates, such as the implementation of an error reporting system and establishment of a quality assurance department, were identified. The QI achievement rate and scale of the institution were positively correlated, and the achievement rate of all QIs was significantly higher (p < 0.001) in institutions capable of advanced treatments, such as intensity-modulated radiotherapy, and those with a quality assurance department. CONCLUSION A large-scale survey on QIs revealed their implementation and relationship with a facility's background. QIs that require improvement were identified, and that these QIs might be effective in providing advanced medical care to many patients.
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Affiliation(s)
- Norifumi Mizuno
- Department of Radiation Oncology, St. Luke's International Hospital, Tokyo, Japan.
| | - Hiroyuki Okamoto
- Radiation Safety and Quality Assurance Division, National Cancer Center Hospital, Tokyo, Japan.
| | - Toshiyuki Minemura
- Division of Medical Support and Partnership, Institute for Cancer Control, National Cancer Center, Tokyo, Japan.
| | - Shinji Kawamura
- Graduate School of Health Sciences, Teikyo University, Fukuoka, Japan.
| | - Naoki Tohyama
- Division of Medical Physics, Tokyo Bay Makuhari Clinic for Advanced Imaging, Cancer Screening, and High-Precision Radiotherapy, Chiba, Japan.
| | - Masahiko Kurooka
- Department of Radiation Therapy, Tokyo Medical University Hospital, Tokyo, Japan.
| | - Ryu Kawamorita
- Department of Radiation Oncology, Tane General Hospital, Osaka, Japan.
| | - Masaru Nakamura
- Department of Radiology, Aichi Medical University Hospital, Aichi, Japan.
| | - Yoshinori Ito
- Department of Radiation Oncology, Showa University School of Medicine, Tokyo, Japan.
| | | | - Hidefumi Aoyama
- Department of Radiation Oncology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan.
| | - Hiroshi Igaki
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan.
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85
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Casanova Borca V, Radici L, Petrucci E, Piva C, Cante D, Pasquino M. Preliminary evaluation of a novel secondary check tool for intensity modulated radiotherapy treatment planning. Phys Med 2023; 106:102528. [PMID: 36610176 DOI: 10.1016/j.ejmp.2023.102528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 01/02/2023] [Accepted: 01/02/2023] [Indexed: 01/07/2023] Open
Abstract
PURPOSE To evaluate the dosimetric accuracy of the Delta4 Insight (DI) secondary-check dosimetry system. METHODS Absolute dosimetry in reference conditions, output factors, percent depth doses normalized and off-axis dose profiles for different field sizes calculated by DI were compared with measurements. Dose calculations for 20 clinical IMRT/VMAT plans generated in the TPS using both AAA or AcurosXB algorithms were compared with measurements. The average difference between calculated and measured point dose in high-dose region was calculated for all cases. 3D dose measurements were performed in Delta4 Phantom+ and a comparison between calculated and measured dose distributions was performed by means of the gamma analysis with 3 %/2 mm criteria. The dose distributions calculated by DI for 20 IMRT/VMAT plans were compared with those calculated by the TPS. RESULTS The absolute dosimetry computed by DI showed dose value in agreement with the measured one within 0.3 %. The average differences between measured and calculated output factors were less than 2.5 %. The average PDD differences were less than 0.6 %. An excellent agreement between calculations and off-axis measurements is found. The point doses calculated for the 20 recalculated plan showed good agreement with measurements with average differences less than 0.5 %. The average gamma pass rate values for the Delta4 Phantom + 3D dose analysis was greater than 97.%. The comparison of DI with theTPS showed good agreement for the used metrics. CONCLUSIONS Delta4 Insight may provide a useful independent secondary dose verification system for IMRT/VMAT plans, complementing the traditional global QA protocols.
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Affiliation(s)
| | - Lorenzo Radici
- Medical Physics Department, A.S.L. TO4, 10015 Ivrea (TO), Italy
| | | | - Cristina Piva
- Radiotherapy Department, A.S.L. TO4, 10015 Ivrea (TO), Italy
| | - Domenico Cante
- Radiotherapy Department, A.S.L. TO4, 10015 Ivrea (TO), Italy
| | - Massimo Pasquino
- Medical Physics Department, A.S.L. TO4, 10015 Ivrea (TO), Italy.
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Taylor PA, Miles E, Hoffmann L, Kelly SM, Kry SF, Sloth Møller D, Palmans H, Akbarov K, Aznar MC, Clementel E, Corning C, Effeney R, Healy B, Moore A, Nakamura M, Patel S, Shaw M, Stock M, Lehmann J, Clark CH. Prioritizing clinical trial quality assurance for photons and protons: A failure modes and effects analysis (FMEA) comparison. Radiother Oncol 2023; 182:109494. [PMID: 36708923 DOI: 10.1016/j.radonc.2023.109494] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/13/2023] [Accepted: 01/18/2023] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND PURPOSE The Global Clinical Trials RTQA Harmonization Group (GHG) set out to evaluate and prioritize clinical trial quality assurance. METHODS The GHG compiled a list of radiotherapy quality assurance (QA) tests performed for proton and photon therapy clinical trials. These tests were compared between modalities to assess whether there was a need for different types of assessments per modality. A failure modes and effects analysis (FMEA) was performed to assess the risk of each QA failure. RESULTS The risk analysis showed that proton and photon therapy shared four out of five of their highest-risk failures (end-to-end anthropomorphic phantom test, phantom tests using respiratory motion, pre-treatment patient plan review of contouring/outlining, and on-treatment/post-treatment patient plan review of dosimetric coverage). While similar trends were observed, proton therapy had higher risk failures, driven by higher severity scores. A sub-analysis of occurrence × severity scores identified high-risk scores to prioritize for improvements in RTQA detectability. A novel severity scaler was introduced to account for the number of patients affected by each failure. This scaler did not substantially alter the ranking of tests, but it elevated the QA program evaluation to the top 20th percentile. This is the first FMEA performed for clinical trial quality assurance. CONCLUSION The identification of high-risk errors associated with clinical trials is valuable to prioritize and reduce errors in radiotherapy and improve the quality of trial data and outcomes, and can be applied to optimize clinical radiotherapy QA.
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Affiliation(s)
- Paige A Taylor
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; The Imaging and Radiation Oncology Core, USA.
| | - Elizabeth Miles
- National Radiotherapy Trials Quality Assurance (RTTQA) Group, Mount Vernon Cancer Centre, Northwood, UK
| | - Lone Hoffmann
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Faculty of Health Sciences, Aarhus University, Aarhus, Denmark
| | - Sarah M Kelly
- SIOP Europe, The European Society for Paediatric Oncology, Clos Chapelle-aux-Champs 30, Brussels, Belgium; EORTC Headquarters, European Organisation for Research and Treatment of Cancer, Avenue E. Mounier 83, Brussels, Belgium; Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Stephen F Kry
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; The Imaging and Radiation Oncology Core, USA
| | - Ditte Sloth Møller
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Faculty of Health Sciences, Aarhus University, Aarhus, Denmark
| | - Hugo Palmans
- MedAustron Ion Therapy Center, Wiener Neustadt, Austria; Metrology for Medical Physics, National Physical Laboratory, Teddington, UK
| | - Kamal Akbarov
- Division of Human Health, Department of Nuclear Sciences and Applications, IAEA, Vienna, Austria
| | - Marianne C Aznar
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Enrico Clementel
- EORTC Headquarters, European Organisation for Research and Treatment of Cancer, Avenue E. Mounier 83, Brussels, Belgium
| | - Coreen Corning
- EORTC Headquarters, European Organisation for Research and Treatment of Cancer, Avenue E. Mounier 83, Brussels, Belgium
| | | | - Brendan Healy
- Australian Clinical Dosimetry Service, ARPANSA, Melbourne, Australia
| | | | - Mitsuhiro Nakamura
- Department of Advanced Medical Physics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Samir Patel
- Division of Radiation Oncology, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Maddison Shaw
- Australian Clinical Dosimetry Service, ARPANSA, Melbourne, Australia; School of Health and Biomedical Sciences, RMIT University, Melbourne, Australia
| | - Markus Stock
- MedAustron Ion Therapy Center, Wiener Neustadt, Austria; Karl Landsteiner University for Health Sciences, Austria
| | - Joerg Lehmann
- TROG Cancer Research, Newcastle, Australia; Department of Radiation Oncology, Calvary Mater Newcastle, Newcastle, Australia; School of Information and Physical Sciences, University of Newcastle, Newcastle, Australia; Institute of Medical Physics, University of Sydney, Sydney, Australia
| | - Catharine H Clark
- Metrology for Medical Physics, National Physical Laboratory, Teddington, UK; National Radiotherapy Trials Quality Assurance (RTTQA) Group, Mount Vernon Cancer Centre, Northwood, UK; Radiotherapy Physics, University College London Hospital, London, UK; Medical Physics and Bioengineering Department, University College London, London, UK
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Poder J, Rivard MJ, Howie A, Carlsson Tedgren Å, Haworth A. Risk and Quality in Brachytherapy From a Technical Perspective. Clin Oncol (R Coll Radiol) 2023:S0936-6555(23)00002-X. [PMID: 36682968 DOI: 10.1016/j.clon.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 11/23/2022] [Accepted: 01/04/2023] [Indexed: 01/15/2023]
Abstract
AIMS To provide an overview of the history of incidents in brachytherapy and to describe the pillars in place to ensure that medical physicists deliver high-quality brachytherapy. MATERIALS AND METHODS A review of the literature was carried out to identify reported incidents in brachytherapy, together with an evaluation of the structures and processes in place to ensure that medical physicists deliver high-quality brachytherapy. In particular, the role of education and training, the use of process and technical quality assurance and the role of international guidelines are discussed. RESULTS There are many human factors in brachytherapy procedures that introduce additional risks into the process. Most of the reported incidents in the literature are related to human factors. Brachytherapy-related education and training initiatives are in place at the societal and departmental level for medical physicists. Additionally, medical physicists have developed process and technical quality assurance procedures, together with international guidelines and protocols. Education and training initiatives, together with quality assurance procedures and international guidelines may reduce the risk of human factors in brachytherapy. CONCLUSION Through application of the three pillars (education and training; process control and technical quality assurance; international guidelines), medical physicists will continue to minimise risk and deliver high-quality brachytherapy treatments.
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Affiliation(s)
- J Poder
- Department of Radiation Oncology, St George Cancer Care Centre, Kogarah, New South Wales, Australia; School of Physics, University of Sydney, Camperdown, New South Wales, Australia; Centre for Medical Radiation Physics, University of Wollongong, Wollongong, New South Wales, Australia.
| | - M J Rivard
- Department of Radiation Oncology, Alpert Medical School of Brown University, Providence, RI, USA
| | - A Howie
- Department of Radiation Oncology, St George Cancer Care Centre, Kogarah, New South Wales, Australia
| | - Å Carlsson Tedgren
- Department of Health, Medicine and Caring Sciences (HMV), Radiation Physics, Linköping University, Linköping, Sweden; Medical Radiation Physics and Nuclear Medicine, The Karolinska University Hospital, Stockholm, Sweden; Department of Oncology Pathology, The Karolinska Institute, Stockholm, Sweden
| | - A Haworth
- School of Physics, University of Sydney, Camperdown, New South Wales, Australia
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McGurk R, Naheedy KW, Kosak T, Hobbs A, Mullins BT, Paradis KC, Kearney M, Roback D, Durney J, Adapa K, Chera BS, Marks LB, Moran JM, Mak RH, Mazur LM. Multi-Institutional Stereotactic Body Radiation Therapy Incident Learning: Evaluation of Safety Barriers Using a Human Factors Analysis and Classification System. J Patient Saf 2023; 19:e18-e24. [PMID: 35948321 PMCID: PMC9771927 DOI: 10.1097/pts.0000000000001071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Stereotactic body radiation therapy (SBRT) can improve therapeutic ratios and patient convenience, but delivering higher doses per fraction increases the potential for patient harm. Incident learning systems (ILSs) are being increasingly adopted in radiation oncology to analyze reported events. This study used an ILS coupled with a Human Factor Analysis and Classification System (HFACS) and barriers management to investigate the origin and detection of SBRT events and to elucidate how safeguards can fail allowing errors to propagate through the treatment process. METHODS Reported SBRT events were reviewed using an in-house ILS at 4 institutions over 2014-2019. Each institution used a customized care path describing their SBRT processes, including designated safeguards to prevent error propagation. Incidents were assigned a severity score based on the American Association of Physicists in Medicine Task Group Report 275. An HFACS system analyzed failing safeguards. RESULTS One hundred sixty events were analyzed with 106 near misses (66.2%) and 54 incidents (33.8%). Fifty incidents were designated as low severity, with 4 considered medium severity. Incidents most often originated in the treatment planning stage (38.1%) and were caught during the pretreatment review and verification stage (37.5%) and treatment delivery stage (31.2%). An HFACS revealed that safeguard failures were attributed to human error (95.2%), routine violation (4.2%), and exceptional violation (0.5%) and driven by personnel factors 32.1% of the time, and operator condition also 32.1% of the time. CONCLUSIONS Improving communication and documentation, reducing time pressures, distractions, and high workload should guide proposed improvements to safeguards in radiation oncology.
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Affiliation(s)
- Ross McGurk
- Department of Radiation Oncology, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Tara Kosak
- Department of Radiation Oncology, Brigham and Women’s Hospital/Dana-Farber Cancer Institute, Boston, MA
| | - Amy Hobbs
- Rex Cancer Center - UNC Rex Healthcare, Raleigh, NC
| | - Brandon T Mullins
- Department of Radiation Oncology, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Kelly C Paradis
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Meghan Kearney
- Department of Radiation Oncology, Brigham and Women’s Hospital/Dana-Farber Cancer Institute, Boston, MA
| | | | - Jeffrey Durney
- Department of Radiation Oncology, Brigham and Women’s Hospital/Dana-Farber Cancer Institute, Boston, MA
| | - Karthik Adapa
- Department of Radiation Oncology, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Bhishamjit S Chera
- Department of Radiation Oncology, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Lawrence B Marks
- Department of Radiation Oncology, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jean M Moran
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Raymond H Mak
- Department of Radiation Oncology, Brigham and Women’s Hospital/Dana-Farber Cancer Institute, Boston, MA
| | - Lukasz M Mazur
- Department of Radiation Oncology, The University of North Carolina at Chapel Hill, Chapel Hill, NC
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Alexander DA, Decker SM, Jermyn M, Bruza P, Zhang R, Chen E, McGlynn TL, Rosselot RA, Lee J, Rose ML, Williams BB, Pogue BW, Gladstone DJ, Jarvis LA. One Year of Clinic-Wide Cherenkov Imaging for Discovery of Quality Improvement Opportunities in Radiation Therapy. Pract Radiat Oncol 2023; 13:71-81. [PMID: 35777728 PMCID: PMC10984217 DOI: 10.1016/j.prro.2022.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/20/2022] [Accepted: 06/07/2022] [Indexed: 01/10/2023]
Abstract
PURPOSE Cherenkov imaging is clinically available as a radiation therapy treatment verification tool. The aim of this work was to discover the benefits of always-on Cherenkov imaging as a novel incident detection and quality improvement system through review of all imaging at our center. METHODS AND MATERIALS Multicamera Cherenkov imaging systems were permanently installed in 3 treatment bunkers, imaging continuously over a year. Images were acquired as part of normal treatment procedures and reviewed for potential treatment delivery anomalies. RESULTS In total, 622 unique patients were evaluated for this study. We identified 9 patients with treatment anomalies occurring over their course of treatment, which were only detected with Cherenkov imaging. Categorizing each event indicated issues arising in simulation, planning, pretreatment review, and treatment delivery, and none of the incidents were detected before this review by conventional measures. The incidents identified in this study included dose to unintended areas in planning, dose to unintended areas due to positioning at treatment, and nonideal bolus placement during setup. CONCLUSIONS Cherenkov imaging was shown to provide a unique method of detecting radiation therapy incidents that would have otherwise gone undetected. Although none of the events detected in this study reached the threshold of reporting, they identified opportunities for practice improvement and demonstrated added value of Cherenkov imaging in quality assurance programs.
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Affiliation(s)
- Daniel A Alexander
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire.
| | - Savannah M Decker
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire; Dose Optics LLC, Lebanon, New Hampshire
| | - Michael Jermyn
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire; Dose Optics LLC, Lebanon, New Hampshire
| | - Petr Bruza
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire; Dose Optics LLC, Lebanon, New Hampshire
| | - Rongxiao Zhang
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire; Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire; Dartmouth Cancer Center, Lebanon, New Hampshire
| | - Erli Chen
- Cheshire Medical Center, Keene, New Hampshire
| | | | | | - Jae Lee
- Dartmouth Cancer Center, Lebanon, New Hampshire
| | | | - Benjamin B Williams
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire; Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire; Dartmouth Cancer Center, Lebanon, New Hampshire
| | - Brian W Pogue
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire; Dose Optics LLC, Lebanon, New Hampshire; Department of Medical Physics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - David J Gladstone
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire; Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Lesley A Jarvis
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire; Dartmouth Cancer Center, Lebanon, New Hampshire
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90
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Moran JM, Bazan JG, Dawes SL, Kujundzic K, Napolitano B, Redmond KJ, Xiao Y, Yamada Y, Burmeister J. Quality and Safety Considerations in Intensity Modulated Radiation Therapy: An ASTRO Safety White Paper Update. Pract Radiat Oncol 2022; 13:203-216. [PMID: 36710210 DOI: 10.1016/j.prro.2022.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 11/11/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE This updated report on intensity modulated radiation therapy (IMRT) is part of a series of consensus-based white papers previously published by the American Society for Radiation Oncology (ASTRO) addressing patient safety. Since the first white papers were published, IMRT went from widespread use to now being the main delivery technique for many treatment sites. IMRT enables higher radiation doses to be delivered to more precise targets while minimizing the dose to uninvolved normal tissue. Due to the associated complexity, IMRT requires additional planning and safety checks before treatment begins and, therefore, quality and safety considerations for this technique remain important areas of focus. METHODS AND MATERIALS ASTRO convened an interdisciplinary task force to assess the original IMRT white paper and update content where appropriate. Recommendations were created using a consensus-building methodology, and task force members indicated their level of agreement based on a 5-point Likert scale, from "strongly agree" to "strongly disagree." A prespecified threshold of ≥75% of raters who select "strongly agree" or "agree" indicated consensus. CONCLUSIONS This IMRT white paper primarily focuses on quality and safety processes in planning and delivery. Building on the prior version, this consensus paper incorporates revised and new guidance documents and technology updates. IMRT requires an interdisciplinary team-based approach, staffed by appropriately trained individuals as well as significant personnel resources, specialized technology, and implementation time. A comprehensive quality assurance program must be developed, using established guidance, to ensure IMRT is performed in a safe and effective manner. Patient safety in the delivery of IMRT is everyone's responsibility, and professional organizations, regulators, vendors, and end-users must work together to ensure the highest levels of safety.
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Affiliation(s)
- Jean M Moran
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jose G Bazan
- Department of Radiation Oncology, Ohio State University, James Cancer Hospital and Solove Research Institute, Columbus, Ohio
| | | | | | - Brian Napolitano
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ying Xiao
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Yoshiya Yamada
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jay Burmeister
- Department of Oncology, Wayne State University School of Medicine, Karmanos Cancer Center, Detroit, Michigan
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Pearson M, Butterworth V, Misson‐Yates S, Naeem M, Gonzalez Vaz R, Eaton D, Greener T. Application of failure mode and effects analysis to validate a novel hybrid Linac QC program that integrates automated and conventional QC testing. J Appl Clin Med Phys 2022; 23:e13798. [PMID: 36453139 PMCID: PMC9797170 DOI: 10.1002/acm2.13798] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 09/01/2022] [Accepted: 09/09/2022] [Indexed: 12/05/2022] Open
Abstract
A hybrid quality control (QC) program was developed that integrates automated and conventional Linac QC, realizing the benefits of both automated and conventional QC, increasing efficiency and maintaining independent measurement methods. Failure mode and effects analysis (FMEA) was then applied in order to validate the program prior to clinical implementation. The hybrid QC program consists of automated QC with machine performance check and DailyQA3 array on the TrueBeam Linac, and Delta4 volumetric modulated arc therapy (VMAT) standard plan measurements, alongside conventional monthly QC at a reduced frequency. The FMEA followed the method outlined in TG-100. Process maps were created for each treatment type at our center: VMAT, stereotactic body radiotherapy (SBRT), conformal, and palliative. Possible failure modes were established by evaluating each stage in the process map. The FMEA followed semiquantitative methods, using data from our QC records from eight Linacs over 3 years for the occurrence estimates, and simulation of failure modes in the treatment planning system, with scoring surveys for severity and detectability. The risk priority number (RPN) was calculated from the product of the occurrence, severity, and detectability scores and then normalized to the maximum and ranked to determine the most critical failure modes. The highest normalized RPN values (100, 90) were found to be for MLC position dynamic for both VMAT and SBRT treatments. The next highest score was 35 for beam position for SBRT, and the majority of scores were less than 20. Overall, these RPN scores for the hybrid Linac QC program indicated that it would be acceptable, but the high RPN score associated with the dynamic MLC failure mode indicates that it would be valuable to perform more rigorous testing of the MLC. The FMEA proved to be a useful tool in validating hybrid QC.
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Affiliation(s)
- Michael Pearson
- Medical Physics DepartmentGuy's and St Thomas' HospitalLondonUK
| | | | - Sarah Misson‐Yates
- Medical Physics DepartmentGuy's and St Thomas' HospitalLondonUK,School of Biomedical Engineering & Imaging SciencesKing's College LondonLondonUK
| | - Marium Naeem
- Medical Physics DepartmentGuy's and St Thomas' HospitalLondonUK
| | | | - David Eaton
- Medical Physics DepartmentGuy's and St Thomas' HospitalLondonUK,School of Biomedical Engineering & Imaging SciencesKing's College LondonLondonUK
| | - Tony Greener
- Medical Physics DepartmentGuy's and St Thomas' HospitalLondonUK
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Goodburn RJ, Philippens MEP, Lefebvre TL, Khalifa A, Bruijnen T, Freedman JN, Waddington DEJ, Younus E, Aliotta E, Meliadò G, Stanescu T, Bano W, Fatemi‐Ardekani A, Wetscherek A, Oelfke U, van den Berg N, Mason RP, van Houdt PJ, Balter JM, Gurney‐Champion OJ. The future of MRI in radiation therapy: Challenges and opportunities for the MR community. Magn Reson Med 2022; 88:2592-2608. [PMID: 36128894 PMCID: PMC9529952 DOI: 10.1002/mrm.29450] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 08/17/2022] [Accepted: 08/22/2022] [Indexed: 01/11/2023]
Abstract
Radiation therapy is a major component of cancer treatment pathways worldwide. The main aim of this treatment is to achieve tumor control through the delivery of ionizing radiation while preserving healthy tissues for minimal radiation toxicity. Because radiation therapy relies on accurate localization of the target and surrounding tissues, imaging plays a crucial role throughout the treatment chain. In the treatment planning phase, radiological images are essential for defining target volumes and organs-at-risk, as well as providing elemental composition (e.g., electron density) information for radiation dose calculations. At treatment, onboard imaging informs patient setup and could be used to guide radiation dose placement for sites affected by motion. Imaging is also an important tool for treatment response assessment and treatment plan adaptation. MRI, with its excellent soft tissue contrast and capacity to probe functional tissue properties, holds great untapped potential for transforming treatment paradigms in radiation therapy. The MR in Radiation Therapy ISMRM Study Group was established to provide a forum within the MR community to discuss the unmet needs and fuel opportunities for further advancement of MRI for radiation therapy applications. During the summer of 2021, the study group organized its first virtual workshop, attended by a diverse international group of clinicians, scientists, and clinical physicists, to explore our predictions for the future of MRI in radiation therapy for the next 25 years. This article reviews the main findings from the event and considers the opportunities and challenges of reaching our vision for the future in this expanding field.
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Affiliation(s)
- Rosie J. Goodburn
- Joint Department of PhysicsInstitute of Cancer Research and Royal Marsden NHS Foundation TrustLondonUnited Kingdom
| | | | - Thierry L. Lefebvre
- Department of PhysicsUniversity of CambridgeCambridgeUnited Kingdom
- Cancer Research UK Cambridge Research InstituteUniversity of CambridgeCambridgeUnited Kingdom
| | - Aly Khalifa
- Department of Medical BiophysicsUniversity of TorontoTorontoOntarioCanada
| | - Tom Bruijnen
- Department of RadiotherapyUniversity Medical Center UtrechtUtrechtNetherlands
| | | | - David E. J. Waddington
- Faculty of Medicine and Health, Sydney School of Health Sciences, ACRF Image X InstituteThe University of SydneySydneyNew South WalesAustralia
| | - Eyesha Younus
- Department of Medical Physics, Odette Cancer CentreSunnybrook Health Sciences CentreTorontoOntarioCanada
| | - Eric Aliotta
- Department of Medical PhysicsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Gabriele Meliadò
- Unità Operativa Complessa di Fisica SanitariaAzienda Ospedaliera Universitaria Integrata VeronaVeronaItaly
| | - Teo Stanescu
- Department of Radiation Oncology, University of Toronto and Medical Physics, Princess Margaret Cancer CentreUniversity Health NetworkTorontoOntarioCanada
| | - Wajiha Bano
- Joint Department of PhysicsInstitute of Cancer Research and Royal Marsden NHS Foundation TrustLondonUnited Kingdom
| | - Ali Fatemi‐Ardekani
- Department of PhysicsJackson State University (JSU)JacksonMississippiUSA
- SpinTecxJacksonMississippiUSA
- Department of Radiation OncologyCommunity Health Systems (CHS) Cancer NetworkJacksonMississippiUSA
| | - Andreas Wetscherek
- Joint Department of PhysicsInstitute of Cancer Research and Royal Marsden NHS Foundation TrustLondonUnited Kingdom
| | - Uwe Oelfke
- Joint Department of PhysicsInstitute of Cancer Research and Royal Marsden NHS Foundation TrustLondonUnited Kingdom
| | - Nico van den Berg
- Department of RadiotherapyUniversity Medical Center UtrechtUtrechtNetherlands
| | - Ralph P. Mason
- Department of RadiologyUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - Petra J. van Houdt
- Department of Radiation OncologyNetherlands Cancer InstituteAmsterdamNetherlands
| | - James M. Balter
- Department of Radiation OncologyUniversity of MichiganAnn ArborMichiganUSA
| | - Oliver J. Gurney‐Champion
- Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam UMCUniversity of AmsterdamAmsterdamNetherlands
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93
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Maughan NM, Garcia-Ramirez JL, Huang FS, Willis DN, Iravani A, Amurao M, Luechtefeld D, Mhlanga JC, Perkins SM, Zoberi JE. Failure modes and effects analysis of pediatric I-131 MIBG therapy: Program design and potential pitfalls. Pediatr Blood Cancer 2022; 69:e29996. [PMID: 36102748 DOI: 10.1002/pbc.29996] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 08/19/2022] [Accepted: 08/22/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND There is growing interest among pediatric institutions for implementing iodine-131 (I-131) meta-iodobenzylguanidine (MIBG) therapy for treating children with high-risk neuroblastoma. Due to regulations on the medical use of radioactive material (RAM), and the complexity and safety risks associated with the procedure, a multidisciplinary team involving radiation therapy/safety experts is required. Here, we describe methods for implementing pediatric I-131 MIBG therapy and evaluate our program's robustness via failure modes and effects analysis (FMEA). METHODS We formed a multidisciplinary team, involving pediatric oncology, radiation oncology, and radiation safety staff. To evaluate the robustness of the therapy workflow and quantitatively assess potential safety risks, an FMEA was performed. Failure modes were scored (1-10) for their risk of occurrence (O), severity (S), and being undetected (D). Risk priority number (RPN) was calculated from a product of these scores and used to identify high-risk failure modes. RESULTS A total of 176 failure modes were identified and scored. The majority (94%) of failure modes scored low (RPN <100). The highest risk failure modes were related to training and to drug-infusion procedures, with the highest S scores being (a) caregivers did not understand radiation safety training (O = 5.5, S = 7, D = 5.5, RPN = 212); (b) infusion training of staff was inadequate (O = 5, S = 8, D = 5, RPN = 200); and (c) air in intravenous lines/not monitoring for air in lines (O = 4.5, S = 8, D = 5, RPN = 180). CONCLUSION Through use of FMEA methodology, we successfully identified multiple potential points of failure that have allowed us to proactively mitigate risks when implementing a pediatric MIBG program.
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Affiliation(s)
- Nichole M Maughan
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jose L Garcia-Ramirez
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Frederick S Huang
- Division of Hematology and Oncology, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Daniel N Willis
- Division of Hematology and Oncology, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Amir Iravani
- Division of Nuclear Medicine, Department of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Maxwell Amurao
- Division of Radiation Safety, Department of Environmental Health and Safety, Washington University in St. Louis, St. Louis, Missouri, USA
| | - David Luechtefeld
- Division of Radiation Safety, Department of Environmental Health and Safety, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Joyce C Mhlanga
- Division of Nuclear Medicine, Department of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Stephanie M Perkins
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jacqueline E Zoberi
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
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94
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Clinical implementation of the first Cherenkov imaging system in a community-based hospital. Tech Innov Patient Support Radiat Oncol 2022; 24:1-5. [PMID: 36118989 PMCID: PMC9472078 DOI: 10.1016/j.tipsro.2022.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 08/12/2022] [Accepted: 08/30/2022] [Indexed: 12/04/2022] Open
Abstract
Purpose To document experiences with one year of clinical implementation of the first Cherenkov imaging system and share the methods that we developed to utilize Cherenkov imaging to improve treatment delivery accuracy in real-time. Methods A Cherenkov imaging system was installed commissioned and calibrated for clinical use. The optimal room lighting conditions and imaging setup protocols were developed to optimize both image quality and patient experience. The Cherenkov images were analyzed for treatment setup and beam delivery verification. Results We have successfully implemented a clinical Cherenkov imaging system in a community-based hospital. Several radiation therapy patient setup anomalies were found in 1) exit dose to the contralateral breast, 2) dose to the chin due to head rotation for a supraclavicular field, 3) intrafractional patient motion during beam delivery, and 4) large variability (0.5 cm to 5 cm) in arm position between fractions. The system was used to deliver deep inspiration breath hold (DIBH) treatment delivery of an electron treatment beam. Clinical process and procedures were improved to mitigate the identified issues to ensure treatment delivery safety and to improve treatment accuracy. Conclusion The Cherenkov imaging system has proven to be a valuable clinical tool for the improvement of treatment delivery safety and accuracy at our hospital. With only minimal training the therapists were able to adjust or correct treatment positions during treatment delivery as needed. With future Cherenkov software developments Cherenkov imaging systems could provide daily surface guided radiotherapy (SGRT) and real time treatment delivery quality control for all 3D and clinical setup patients without adding additional radiation image dose as in standard kV, MV and CBCT image verifications. Cherenkov imaging can greatly improve clinical efficiency and accuracy, making real time dose delivery consistency verification and SGRT a reality.
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95
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Prediction and classification of VMAT dosimetric accuracy using plan complexity and log-files analysis. Phys Med 2022; 103:76-88. [DOI: 10.1016/j.ejmp.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 09/20/2022] [Accepted: 10/07/2022] [Indexed: 11/18/2022] Open
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96
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Errors detected during physics plan review for external beam radiotherapy. Phys Imaging Radiat Oncol 2022; 24:53-58. [PMID: 36185802 PMCID: PMC9519775 DOI: 10.1016/j.phro.2022.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 09/12/2022] [Accepted: 09/13/2022] [Indexed: 12/04/2022] Open
Abstract
Background and purpose Risk management in radiotherapy is of high importance. There is not much data published on errors occurring in the treatment planning process of external beam techniques. The aim of this study was to investigate errors occurring during physics plan review in external beam radiotherapy. Materials and methods Over a period of 14 months errors observed during the physical review process are reported. The errors were grouped and evaluated regarding treatment machine, technique, and treatment site. In addition, a correlation between frequency of errors and staff shortage was analyzed. Results Subgroups of grave errors (g-errors) and slight errors (s-errors) were defined to consider the different impact on the patient and clinical workflow of the errors. In 1056 plans reviewed, 110 errors (41 g-errors, 69 s-errors) were detected. The most common g-errors and s-errors were “Wrong gantry angle at setup field” (n = 19) and “Wrong field label” (n = 24), respectively. A correlation of number of errors and treatment machine, technique, or anatomical site could not be found. No correlation between staff shortage and number of errors was observed. Conclusions The process of reviewing treatment plans is a relevant topic to consider in risk analysis of the radiotherapy workflow. The review process could be improved by enhancements in the treatment planning systems, use of digital dose prescription, and treatment planning templates.
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97
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Okamoto H, Igaki H, Chiba T, Shibuya K, Sakasai T, Jingu K, Inaba K, Kuroda K, Aoki S, Tatsumi D, Nakamura M, Kadoya N, Furuyama Y, Kumazaki Y, Tohyama N, Tsuneda M, Nishioka S, Itami J, Onishi H, Shigematsu N, Uno T. Practical guidelines of online MR-guided adaptive radiotherapy. JOURNAL OF RADIATION RESEARCH 2022; 63:730-740. [PMID: 35946325 PMCID: PMC9494538 DOI: 10.1093/jrr/rrac048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/02/2022] [Indexed: 06/15/2023]
Abstract
The first magnetic resonance (MR)-guided radiotherapy system in Japan was installed in May 2017. Implementation of online MR-guided adaptive radiotherapy (MRgART) began in February 2018. Online MRgART offers greater treatment accuracy owing to the high soft-tissue contrast in MR-images (MRI), compared to that in X-ray imaging. The Japanese Society for Magnetic Resonance in Medicine (JSMRM), Japan Society of Medical Physics (JSMP), Japan Radiological Society (JRS), Japanese Society of Radiological Technology (JSRT), and Japanese Society for Radiation Oncology (JASTRO) jointly established the comprehensive practical guidelines for online MRgART. These guidelines propose the essential requirements for clinical implementation of online MRgART with respect to equipment, personnel, institutional environment, practice guidance, and quality assurance/quality control (QA/QC). The minimum requirements for related equipment and QA/QC tools, recommendations for safe operation of MRI system, and the implementation system are described. The accuracy of monitor chamber and detector in dose measurements should be confirmed because of the presence of magnetic field. The ionization chamber should be MR-compatible. Non-MR-compatible devices should be used in an area that is not affected by the static magnetic field (outside the five Gauss line), and their operation should be checked to ensure that they do not affect the MR image quality. Dose verification should be performed using an independent dose verification system that has been confirmed to be reliable through commissioning. This guideline proposes the checklists to ensure the safety of online MRgART. Successful clinical implementation of online MRgART requires close collaboration between physician, radiological technologist, nurse, and medical physicist.
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Affiliation(s)
- Hiroyuki Okamoto
- Radiation Safety and Quality Assurance Division, National Cancer Center Hospital, Tokyo, 104-0045, Japan
| | - Hiroshi Igaki
- Corresponding author. Department of Radiation Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan. Tel: +81(3)3542-2511; E-mail/Fax: , +81(3) 3547-5291
| | - Takahito Chiba
- Radiation Safety and Quality Assurance Division, National Cancer Center Hospital, Tokyo, 104-0045, Japan
| | - Keiko Shibuya
- Department of Radiation Oncology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, 545-8586, Japan
| | - Tatsuya Sakasai
- Department of Radiological Technology, National Cancer Center Hospital, Tokyo, 104-0045, Japan
| | - Keiichi Jingu
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Miyagi, 980-8574, Japan
| | - Koji Inaba
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, 104-0045, Japan
| | - Kagayaki Kuroda
- Department of Human and Information Science, School of Information Science and Technology, Tokai University, Hiratsuka, 259-1292, Japan
| | - Shigeki Aoki
- Department of Radiology, Juntendo University Graduate School of Medicine, Tokyo, 113-8421, Japan
| | | | - Mitsuhiro Nakamura
- Department of Information Technology and Medical Engineering, Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, 606-8507, Japan
| | - Noriyuki Kadoya
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Miyagi, 980-8574, Japan
| | - Yoshinobu Furuyama
- Department of Radiology, Chiba University Hospital, Chiba, 260-8677, Japan
| | - Yu Kumazaki
- Department of Radiation Oncology, International Medical Center, Saitama Medical University, Saitama, 350-1298, Japan
| | - Naoki Tohyama
- Division of Medical Physics, Tokyo Bay Advanced Imaging & Radiation Oncology Makuhari Clinic, Chiba, 261-0024, Japan
| | - Masato Tsuneda
- Department of Radiation Oncology, MR Linac ART Division, Graduate School of Medicine, Chiba University, Chiba, 260-8677, Japan
| | - Shie Nishioka
- Department of Radiation Oncology, Kyoto Second Red Cross Hospital, Kyoto, 602-8026, Japan
| | - Jun Itami
- Shin-Matsudo Accuracy Radiation Therapy Center, Shin-Matsudo Central General Hospital, Chiba, 270-0034, Japan
| | - Hiroshi Onishi
- Department of Radiology, University of Yamanashi, Yamanashi, 409-3898, Japan
| | - Naoyuki Shigematsu
- Department of Radiology, Keio University School of Medicine, Tokyo, 160-8582, Japan
| | - Takashi Uno
- Diagnostic Radiology and Radiation Oncology, Graduate School of Medicine, Chiba University, Chiba, 260-8677, Japan
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98
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Houlihan OA, Workman G, Hounsell AR, Prise KM, Jain S. In vivo dosimetry in pelvic brachytherapy. Br J Radiol 2022; 95:20220046. [PMID: 35635803 PMCID: PMC10996950 DOI: 10.1259/bjr.20220046] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 05/06/2022] [Accepted: 05/11/2022] [Indexed: 11/05/2022] Open
Abstract
ADVANCES IN KNOWLEDGE This paper describes the potential role for in vivo dosimetry in the reduction of uncertainties in pelvic brachytherapy, the pertinent factors for consideration in clinical practice, and the future potential for in vivo dosimetry in the personalisation of brachytherapy.
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Affiliation(s)
- Orla Anne Houlihan
- Department of Clinical Oncology, Northern Ireland Cancer
Centre, Belfast Health and Social Care Trust,
Belfast, UK
- Patrick G. Johnston Centre for Cancer Research, Queen's
University Belfast, Belfast,
UK
| | - Geraldine Workman
- Radiotherapy Physics, Northern Ireland Cancer Centre, Belfast
Health and Social Care Trust,
Belfast, UK
| | - Alan R Hounsell
- Patrick G. Johnston Centre for Cancer Research, Queen's
University Belfast, Belfast,
UK
- Radiotherapy Physics, Northern Ireland Cancer Centre, Belfast
Health and Social Care Trust,
Belfast, UK
| | - Kevin M Prise
- Patrick G. Johnston Centre for Cancer Research, Queen's
University Belfast, Belfast,
UK
| | - Suneil Jain
- Department of Clinical Oncology, Northern Ireland Cancer
Centre, Belfast Health and Social Care Trust,
Belfast, UK
- Patrick G. Johnston Centre for Cancer Research, Queen's
University Belfast, Belfast,
UK
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99
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Tang G, LoSasso T, Chan M, Hunt M. Impact of a Centralized Database System on Radiation Therapy Quality Assurance Management at a Large Health Care Network: 5 Years' Experience. Pract Radiat Oncol 2022; 12:e434-e441. [PMID: 35431152 PMCID: PMC9452445 DOI: 10.1016/j.prro.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 01/27/2022] [Accepted: 03/02/2022] [Indexed: 11/20/2022]
Abstract
PURPOSE This study reports the impact of using a centralized database system for major equipment quality assurance (QA) at a large institution. METHODS AND MATERIALS A centralized database system has been implemented for radiation therapy machine QA in our institution at 6 campuses with 11 computed tomographies and 22 linear accelerators (LINACs). The database system was customized to manage monthly and annual computed tomography and LINAC QA. This includes providing the same set of QA procedures across the enterprise, digitally storing all measurement records, and generating trend analyses. Compared with conventional methods (ie, paper forms), the effectiveness of the database system was quantified by changes in the compliance of QA tests and perceptions of staff to the efficiency of data retrieval and analyses. An anonymized questionnaire was provided to physicists enterprise-wide to assess workflow changes. RESULTS With the implementation of the database system, the compliance of QA test completion improved from 80% to >99% for the entire institution. This resonates with the 56% of physicists who found the database system helpful in guiding them through QA, and 25% of physicists found the contrary, and 19% reported no difference (n = 16). Meanwhile, 40% of physicists reported longer times needed to record data using the database system compared with conventional methods, and another 40% suggested otherwise. In addition, 87% and 80% found the database more efficient to analyze and retrieve previous data, respectively. This was also reflected by the shorter time taken to generate year-end QA statistics using the software (5 vs 30 min per LINAC). Overall, 94% of physicists preferred the centralized database system over conventional methods and endorsed continued use of the system. CONCLUSIONS A centralized database system is useful and can improve the effectiveness and efficiency of QA management in a large institution. With consistent data collection and proper data storage using a database, high-quality data can be obtained for failure modes and effects analyses as per TG 100.
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Affiliation(s)
- Grace Tang
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Thomas LoSasso
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Maria Chan
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Margie Hunt
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
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100
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Chang J, Jang S, Lalonde R, Huq SM. Fuzzy analytic hierarchy process-based risk priority number for risk assessments of commissioning process of a ring gantry LINAC. J Appl Clin Med Phys 2022; 23:e13760. [PMID: 35998202 DOI: 10.1002/acm2.13760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/18/2022] [Accepted: 08/02/2022] [Indexed: 11/08/2022] Open
Abstract
PURPOSE We propose a fuzzy analytic hierarchy process (AHP)-based risk priority number (RPN) method in failure modes and effects analysis (FMEA) to overcome the shortcomings of traditional RPN-based FMEA. Our research group has previously published the FMEA to mitigate the failure modes (FMs) for the commissioning process of a ring gantry LINAC. However, inter-relationships among FMs were observed in high ranked FMs due to a heavy reliance on imaging system. METHODS Fuzzy AHP was applied to determine relative weights of risk impacts based on inter-relationships among FMs. Since the time sequence dependency is a major factor for risk factors, a hierarchical structure of AHP was used to reflect the directional impacts such as causal influence and feedback loop. Two fuzzy weighted RPNs, called (RPNW and FRPNW , were calculated depending on the input values of severity (S), occurrence (O), and probability of not being detected (D) from the evaluators. The RPNW used numerical values, whereas the fuzzy values were used for FRPNW . Both RPNs were calculated by multiplying the weighted O, S, and D using the fuzzy AHP method. RESULTS The differences between the two fuzzy RPN rankings are due to inherent fuzzy uncertainty and deviations in O, S, and D values submitted by the evaluators. Considering all results of traditional and fuzzy-based FMEA, the two most highly ranked FMs were identified: errors in determining the non-isocentric SSD and SSD from MV images because of the unique features of the ring gantry LINAC. CONCLUSION This study has demonstrated the feasibility of the use of a fuzzy AHP-based RPN to perform comprehensive analysis and prioritization of FMs. The risk analysis using fuzzy AHP can be improved and/or refined based on the department's specific workflow and clinical preferences taking various priority weighting approaches into account.
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Affiliation(s)
- Jina Chang
- Department of Radiation Oncology, UPMC Hillman Cancer Center and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Siyoung Jang
- Department of Radiation Oncology, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts, USA
| | - Ron Lalonde
- Department of Radiation Oncology, UPMC Hillman Cancer Center and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Saiful M Huq
- Department of Radiation Oncology, UPMC Hillman Cancer Center and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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