The use of an electronic portal imaging device for exit dosimetry and quality control measurements

AAPM Task Group Report 307: Use of EPIDs for Patient-Specific IMRT and VMAT QA

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.

Dosimetric Validation of Digital Megavolt Imager for Flattening Filter Free Beams in the Pre-Treatment Quality Assurance of Stereotactic Body Radiation Therapy for Liver Metastases

Aim:

The aim is to evaluate the use of digital megavolt imager (DMI) aS1200 in portal dosimetry with flattening filter free (FFF) beams.

Materials and Methods:

Dosimetric properties of DMI is characterized at 6MV FFF beams for signal saturation, dose linearity, dependency on dose-rate and source-detector distance (SDD), signal lag (ghosting), and back scatter. Portal dosimetry is done for twenty volumetric modulated arc therapy (VMAT) based stereotactic body radiotherapy (SBRT) plans for the treatment of liver metastases and the results are compared with repeated measurements of Octavius 4D.

Results:

The detector signal to monitor unit (MU) ratio drops drastically below 25MU. The detector linearity with dose is within 1% and no evidence of signal saturation as such. The aS1200 response variation across various dose rates and SDD is <0.4% and <0.2% respectively. The effect of ghosting increased distinctly at higher dose rate but however it is negligible (0.1%). The impact of back scatter is <0.3% because of additional shielding provided at the back of the detector. The portal dosimetry results of SBRT QA plans evaluated at the gamma criteria of 2mm/2% (DTA/DD) both under global and local mode analysis has shown an average gamma passing rate of area gamma (<1) 97.9±0.8% and 96.4±0.9%. The SBRT QA results observed in aS1200 are inline and consistent with Octavius 4D measured results.

Conclusion:

The characteristics of aS1200 evaluated at FFF beams have shown its potential ability as QA tool and can be used in SBRT QA for liver metastases with greater confidence.

Evaluating the sensitivity of Halcyon's automatic transit image acquisition for treatment error detection: A phantom study using static IMRT

PURPOSE

The Varian Halcyon™ electronic portal imaging detector is always in-line with the beam and automatically acquires transit images for every patient with full-field coverage. These images could be used for "every patient, every monitor unit" quality assurance (QA) and eventually adaptive radiotherapy. This study evaluated the imager's sensitivity to potential clinical errors and day-to-day variations from clinical exit images.

METHODS

Open and modulated fields were delivered for each potential error. To evaluate output changes, monitor units were scaled by 2%-10% and delivered to solid water slabs and a homogeneous CIRS phantom. To mimic weight changes, 0.5-5.0 cm of buildup was added to the solid water. To evaluate positioning changes, a homogeneous and heterogeneous CIRS phantom were shifted 2-10 cm and 0.2-1.5 cm, respectively. For each test, mean relative differences (MRDs) and standard deviations in the pixel-difference histograms (σ_RD ) between test and baseline images were calculated. Lateral shift magnitudes were calculated using cross-correlation and edge-detection filtration. To assess patient variations, MRD and σ_RD were calculated from six prostate patients' daily exit images and compared between fractions with and without gas present.

RESULTS

MRDs responded linearly to output and buildup changes with a standard deviation of 0.3%, implying a 1% output change and 0.2 cm changes in buildup could be detected with 2.5σ confidence. Shifting the homogenous phantom laterally resulted in detectable MRD and σ_RD changes, and the cross-correlation function calculated the shift to within 0.5 mm for the heterogeneous phantom. MRD and σ_RD values were significantly associated with the presence of gas for five of the six patients.

CONCLUSIONS

Rapid analyses of automatically acquired Halcyon™ exit images could detect mid-treatment changes with high sensitivity, though appropriate thresholds will need to be set. This study presents the first steps toward developing effortless image evaluation for all aspects of every patient's treatment.

Evaluation of relative transmitted dose for a step and shoot head and neck intensity modulated radiation therapy using a scanning liquid ionization chamber electronic portal imaging device

The dose delivery verification for a head and neck static intensity modulated radiation therapy (IMRT) case using a scanning liquid ionization chamber electronic portal imaging device (SLIC-EPID) was investigated. Acquired electronic portal images were firstly converted into transmitted dose maps using an in-house developed method. The dose distributions were then compared with those calculated in a virtual EPID using the Pinnacle³ treatment planning system (TPS). Using gamma evaluation with the ΔD_max and DTA criteria of 3%/2.54 mm, an excellent agreement was observed between transmitted dose measured using SLIC-EPID and that calculated by TPS (gamma score approximately 95%) for large MLC fields. In contrast, for several small subfields, due to SLIC-EPID image blurring, significant disagreement was found in the gamma results. Differences between EPID and TPS dose maps were also observed for several parts of the radiation subfields, when the radiation beam passed through air on the outside of tissue. The transmitted dose distributions measured using portal imagers such as SLIC-EPID can be used to verify the dose delivery to a patient. However, several aspects such as accurate calibration procedure and imager response under different conditions should be taken into the consideration. In addition, SLIC-EPID image blurring is another important issue, which should be considered if the SLIC-EPID is used for clinical dosimetry verification.

Feasibility of using two-dimensional array dosimeter for in vivo dose reconstruction via transit dosimetry

Two-dimensional array dosimeters are commonly used to perform pretreatment quality assurance procedures, which makes them highly desirable for measuring transit fluences for in vivo dose reconstruction. The purpose of this study was to determine if an in vivo dose reconstruction via transit dosimetry using a 2D array dosimeter was possible. To test the accuracy of measuring transit dose distribution using a 2D array dosimeter, we evaluated it against the measurements made using ionization chamber and radiochromic film (RCF) profiles for various air gap distances (distance from the exit side of the solid water slabs to the detector distance; 0 cm, 30 cm, 40 cm, 50 cm, and 60 cm) and solid water slab thicknesses (10 cm and 20 cm). The backprojection dose reconstruction algorithm was described and evaluated. The agreement between the ionization chamber and RCF profiles for the transit dose distribution measurements ranged from -0.2% ~ 4.0% (average 1.79%). Using the backprojection dose reconstruction algorithm, we found that, of the six conformal fields, four had a 100% gamma index passing rate (3%/3 mm gamma index criteria), and two had gamma index passing rates of 99.4% and 99.6%. Of the five IMRT fields, three had a 100% gamma index passing rate, and two had gamma index passing rates of 99.6% and 98.8%. It was found that a 2D array dosimeter could be used for backprojection dose reconstruction for in vivo dosimetry.

Reduction of the effect of non-uniform backscatter from an E-type support arm of a Varian a-Si EPID used for dosimetry

Backscatter from the metallic components in the support arm is one of the sources of inaccuracy in dosimetry with Varian amorphous silicon electronic portal imaging devices (a-Si EPIDs). In this study, the non-uniform arm backscatter is blocked by adding lead sheets between the EPID and an E-type support arm. By comparing the EPID responses on and off the arm, with and without lead and considering the extra weight on the imager, 2 mm of lead was determined as the optimum thickness for both 6 and 18 MV beam energies. The arm backscatter at the central axis with the 2 mm lead in place decreased to 0.1% and 0.2% for the largest field size of 30 × 30 cm(2) using 6 and 18 MV beams, from 2.3% and 1.3% without lead. Changes in the source-to-detector distance (SDD) did not affect the backscatter component more than 1%. The symmetry of the in-plane profiles improved for all field sizes for both beam energies. The addition of lead decreased the contrast-to-noise ratio and resolution by 1.3% and 0.84% for images taken in 6 MV and by 0.5% and 0.38% for those in 18 MV beams. The displacement of the EPID central pixel was measured during a 360° gantry rotation with and without lead which was 1 pixel different. While the backscatter reduces with increasing lead thickness, a 2 mm lead sheet seems sufficient for acceptable dosimetry results without any major degradation to the routine performance of the imager. No increase in patient skin dose was detected.

Study of X-ray field junction dose using an a-Si electronic portal imaging device

Field junctions between megavoltage photon beams are important in modern radiotherapy for treatments such as head and neck and breast cancer. An electronic portal imaging device (EPID) may be used to study junction dose between two megavoltage X-ray fields. In this study, the junction dose was used to determine machine characteristics such as jaw positions and their reproducibility, collimator rotation and the effect of gantry rotation. All measurements were done on Varian linear accelerators with EPID (Varian, Palo Alto, CA). The results show reproducibility in jaw positions of approximately 0.3 mm for repeated jaw placement while EPID readings were reproducible within a standard deviation of 0.4% for fixed jaw positions. Junction dose also allowed collimator rotation error of 0.1 degrees to be observed. Dependence of junction dose on gantry rotation due to gravity was observed; the gravity effect being maximum at 180 degrees gantry angle (beam pointing up). EPIDs were found to be reliable tools for checking field junctions, which in turn may be used to check jaw reproducibility and collimator rotation of linacs.

Electron beam quality control using an amorphous silicon EPID

An amorphous silicon EPID has been investigated to determine whether it is capable of quality control constancy measurements for linear accelerator electron beams. The EPID grayscale response was found to be extremely linear with dose over a wide dose range and, more specifically, for exposures of 95-100 MU. Small discrepancies of up to 0.8% in linearity were found at 6 MeV (8-15 MeV showed better agreement). The shape of the beam profile was found to be significantly altered by scatter in air over the approximately 60 cm gap between the end of the applicator and the EPID. Nevertheless, relative changes in EPID-measured profile flatness and symmetry were linearly related to changes in these parameters at 95 cm focus to surface distance (FSD) measured using a 2D diode array. Similar results were obtained at 90 degrees and 270 degrees gantry angles. Six months of daily images were acquired and analyzed to determine whether the device is suitable as a constancy checker. EPID output measurements agreed well with daily ion chamber measurements, with a 0.8% standard deviation in the difference between the two measurement sets. When compared to weekly parallel plate chamber measurements, this figure dropped to 0.5%. A Monte Carlo (MC) model of the EPID was created and demonstrated excellent agreement between MC-calculated profiles in water and the EPID at 95 and 157 cm FSD. Good agreement was also found with measured EPID profiles, demonstrating that the EPID provides an accurate measurement of electron profiles. The EPID was thus shown to be an effective method for performing electron beam daily constancy checks.

Role of "the frame cycle time" in portal dose imaging using an aS500-II EPID

INTRODUCTION

This paper evaluates the role of an acquisition parameter, the frame cycle time "FCT", in the performance of an aS500-II EPID.

MATERIALS AND METHODS

The work presented rests on the study of the Varian EPID aS500-II and the image acquisition system 3 (IAS3). We are interested in integrated acquisition using asynchronous mode. For better understanding the image acquisition operation, we investigated the influence of the "frame cycle time" on the speed of acquisition, the pixel value of the averaged gray-scale frame and the noise, using 6 and 15MV X-ray beams and dose rates of 1-6Gy/min on 2100 C/D Linacs.

RESULTS

In the integrated mode not synchronized to beam pulses, only one parameter the frame cycle time "FCT" influences the pixel value. The pixel value of the averaged gray-scale frame is proportional to this parameter. When the FCT <55ms (speed of acquisition V(f/s)>18 frames/s), the speed of acquisition becomes unstable and leads to a fluctuation of the portal dose response. A timing instability and saturation are detected when the dose per frame exceeds 1.53MU/frame. Rules were deduced to avoid saturation and to optimize this dosimetric mode.

CONCLUSION

The choice of the acquisition parameter is essential for the accurate portal dose imaging.

A literature review of electronic portal imaging for radiotherapy dosimetry

Electronic portal imaging devices (EPIDs) have been the preferred tools for verification of patient positioning for radiotherapy in recent decades. Since EPID images contain dose information, many groups have investigated their use for radiotherapy dose measurement. With the introduction of the amorphous-silicon EPIDs, the interest in EPID dosimetry has been accelerated because of the favourable characteristics such as fast image acquisition, high resolution, digital format, and potential for in vivo measurements and 3D dose verification. As a result, the number of publications dealing with EPID dosimetry has increased considerably over the past approximately 15 years. The purpose of this paper was to review the information provided in these publications. Information available in the literature included dosimetric characteristics and calibration procedures of various types of EPIDs, strategies to use EPIDs for dose verification, clinical approaches to EPID dosimetry, ranging from point dose to full 3D dose distribution verification, and current clinical experience. Quality control of a linear accelerator, pre-treatment dose verification and in vivo dosimetry using EPIDs are now routinely used in a growing number of clinics. The use of EPIDs for dosimetry purposes has matured and is now a reliable and accurate dose verification method that can be used in a large number of situations. Methods to integrate 3D in vivo dosimetry and image-guided radiotherapy (IGRT) procedures, such as the use of kV or MV cone-beam CT, are under development. It has been shown that EPID dosimetry can play an integral role in the total chain of verification procedures that are implemented in a radiotherapy department. It provides a safety net for simple to advanced treatments, as well as a full account of the dose delivered. Despite these favourable characteristics and the vast range of publications on the subject, there is still a lack of commercially available solutions for EPID dosimetry. As strategies evolve and commercial products become available, EPID dosimetry has the potential to become an accurate and efficient means of large-scale patient-specific IMRT dose verification for any radiotherapy department.

Verification of dose delivery for a prostate sIMRT treatment using a SLIC-EPID

The current work focuses on the verification of transmitted dose maps, measured using a scanning liquid ionization chamber-electronic portal imaging device (SLIC-EPID) for a typical step-and-shoot prostate IMRT treatment using an anthropomorphic phantom at anterior-posterior (A-P), and several non-zero gantry angles. The dose distributions measured using the SLIC-EPID were then compared with those calculated in the modelled EPID for each segment/subfield and also for the corresponding total fields using a gamma function algorithm with a distance to agreement and dose difference criteria of 2.54mm and 3%, respectively.

Advanced image-guided external beam radiotherapy

The goal of radiation therapy is to eradicate tumor stem cells while sparing healthy tissue. Therefore, the first aim must be to delineate tumor from healthy tissue. Advanced imaging techniques will enable one to reduce the uncertainty of microscopic extension of disease. Ultimately, advanced functional imaging systems correlated with image-registered pathological specimens will allow one to delineate disease extent from normal tissue at the tumor periphery. When it is not possible to determine the CTV margin with reasonable certainty, the margins must remain generous and conformal avoidance methodology could and should be deployed to spare critical normal structures. Of equal importance to defining the CTV is the need to guarantee that this target is indeed treated. For this purpose, image guidance using a variety of systems including portal images, ultrasound devices, and CT scanners at the time of treatment has been implemented. Some image-guided methods, portal images for instance, are more amenable for use with rigid structures such as encountered in the sinus whereas others like ultrasound or CT scanners are able to account for nonrigid setup variations. Several strategies for preventing organ motion from degrading the precision that radiotherapy offers have been described. In particular, a CT scan at the time of treatment delivery can also be used as the basis to reconstruct the dose received by the patient. Dose reconstruction will allow the dose just delivered to be superimposed on the pretreatment CT scan and will allow one to compare the reconstructed delivered dose distribution with the planned dose distribution to assess discrepancies between these. Furthermore, reconstruction of the delivered dose distributions holds the promise of allowing one to accumulate dose delivered to the tumor and normal structures on a fraction per fraction basis. This will ultimately allow for the determination of treatment-specific tumor control probabilities and normal tissue complication probabilities.

Daily monitoring of linear accelerator beam parameters using an amorphous silicon EPID

An amorphous silicon EPID has been investigated to test its suitability as a daily check device for linac output and to provide daily monitoring of beam profile parameters such as flatness, symmetry, field size and wedge factor. Open and wedged 6 and 8 MV photon beams were collected on a daily basis for a period of just over a year and analysed in software to determine daily values of these parameters. Daily output results gave agreement between EPID measured dose and ion chamber measurements with a standard deviation of 0.65%. Step changes in flatness, symmetry and field size were readily detected by the EPID and could be correlated with adjustments made on service days and QC sessions. The results could also be used to assess the long term beam stability. Recalibration of the EPID required new baseline values of the parameters to be set. Wedge factors measured at one collimator angle proved stable but sensitive to changes in beam steering. The EPID proved to be a useful daily check device for linac output which can simultaneously be used for daily monitoring of beam profiles and field sizes.

Intensity-modulated radiation therapy and image-guided radiation therapy: small clinic implementation

In a small clinic with a small patient base, the implementation of IMRT/IGRT should be slow, measured, and meticulous. Most radiation oncologists in the United States have had no formal training in IMRT/IGRT because the modalities are so new. Proper patient selection and a team effort among the clinician, physicist, dosimetrist, and therapist are thus all the more critical. The clinician in the small clinic can take comfort in remembering that the technologies are new, but the principles of good radiation medicine are not. With patient selection, a team approach, and publication of data and maturation of the literature, IMRT/IGRT will become the new standard of care in academic centers, large private clinics, and small clinics alike.

Developments in electronic portal imaging systems

Verification of geometric accuracy at the time of treatment delivery has always been a necessary part of the radiotherapy process. Since the introduction of conformal and intensity-modulated radiotherapy, the consequences of patient positioning errors are more serious. Portal imaging has played a large part in fulfilling the need for improved geometric accuracy. This review examines how portal imaging has progressed through the development and evolution of electronic portal imaging devices (EPIDs). Changes in technology, including the current commercial systems, and how image quality has changed are presented. The clinical usage of EPIDs and the technological innovations being devised for further improvements in image quality and systems are considered.

Pretreatment verification of IMRT absolute dose distributions using a commercial a-Si EPID

A commercial amorphous silicon electronic portal imaging device (EPID) has been studied to investigate its potential in the field of pretreatment verifications of step and shoot, intensity modulated radiation therapy (IMRT), 6 MV photon beams. The EPID was calibrated to measure absolute exit dose in a water-equivalent phantom at patient level, following an experimental approach, which does not require sophisticated calculation algorithms. The procedure presented was specifically intended to replace the time-consuming in-phantom film dosimetry. The dosimetric response was characterized on the central axis in terms of stability, linearity, and pulse repetition frequency dependence. The a-Si EPID demonstrated a good linearity with dose (within 2% from 1 monitor unit), which represent a prerequisite for the application in IMRT. A series of measurements, in which phantom thickness, air gap between the phantom and the EPID, field size and position of measurement of dose in the phantom (entrance or exit) varied, was performed to find the optimal calibration conditions, for which the field size dependence is minimized. In these conditions (20 cm phantom thickness, 56 cm air gap, exit dose measured at the isocenter), the introduction of a filter for the low-energy scattered radiation allowed us to define a universal calibration factor, independent of field size. The off-axis extension of the dose calibration was performed by applying a radial correction for the beam profile, distorted due to the standard flood field calibration of the device. For the acquisition of IMRT fields, it was necessary to employ home-made software and a specific procedure. This method was applied for the measurement of the dose distributions for 15 clinical IMRT fields. The agreement between the dose distributions, quantified by the gamma index, was found, on average, in 97.6% and 98.3% of the analyzed points for EPID versus TPS and for EPID versus FILM, respectively, thus suggesting a great potential of this EPID for IMRT dosimetric applications.

Dose-guided radiation therapy with megavoltage cone-beam CT

Recent advances in fractionated external beam radiation therapy have increased our ability to deliver radiation doses that conform more tightly to the tumour volume. The steeper dose gradients delivered in these treatments make it increasingly important to set precisely the positions of the patient and the internal organs. For this reason, considerable research now focuses on methods using three-dimensional images of the patient on the treatment table to adapt either the patient position or the treatment plan, to account for variable organ locations. In this article, we briefly review the different adaptive methods being explored and discuss a proposed dose-guided radiation therapy strategy that adapts the treatment for future fractions to compensate for dosimetric errors from past fractions. The main component of this strategy is a procedure to reconstruct the dose delivered to the patient based on treatment-time portal images and pre-treatment megavoltage cone-beam computed tomography (MV CBCT) images of the patient. We describe the work to date performed to develop our dose reconstruction procedure, including the implementation of a MV CBCT system for clinical use, experiments performed to calibrate MV CBCT for electron density and to use the calibrated MV CBCT for dose calculations, and the dosimetric calibration of the portal imager. We also present an example of a reconstructed patient dose using a preliminary reconstruction program and discuss the technical challenges that remain to full implementation of dose reconstruction and dose-guided therapy.

Two-dimensional transmitted dose measurements using a scanning liquid ionization chamber EPID

The use of a scanning liquid ionization chamber electronic portal imaging device (SLIC-EPID) for two-dimensional transmitted dosimetry was investigated and a calibration method was developed using extended dose range (EDR2) film. In order to convert pixel value to dose, the acquired SLIC-EPID pixel values were calibrated using an ionization chamber on the central axis. The relationship between pixel values, dose rate and absorbed dose was identified for various linac output repetition rates. To correct EPIs for dosimetric purposes, the off-axis ratio of dose profiles measured by EPIDs and EDR2 film was used to derive correction factor matrices (CFMs) for a range of source-to-EPID distances (SEDs). The corrected relative dose maps acquired for different conditions, including open and wedged fields, measured using a SLIC-EPID were compared with EDR2 film images using a gamma function algorithm with distance to agreement (DTA) = 2.5 mm and dose difference (DeltaDmax) = 1% criteria. The results showed that (a) for two-dimensional dosimetric purposes, EPIDs must be calibrated using appropriate two-dimensional correction factors and (b) SLIC-EPIDs can be used to measure the transmitted dose with good accuracy.

The use of extended dose range film for dosimetric calibration of a scanning liquid-filled ionization chamber electronic portal imaging device

A scanning liquid‐filled ionization chamber electronic portal imaging device (SLIC‐EPID) and extended dose range (EDR2) films were used to evaluate transmitted dose profiles for homogeneous and inhomogeneous phantoms. Calibrated ionization chamber measurements were used to convert the pixel values acquired from the electronic portal images to dose. Because SLIC‐EPID was developed to have a uniform response for all liquid ionization chambers, the off‐axis dose values were reconstructed using a correction factor matrix, defined as the ratio of the relative EDR2 film and the corresponding EPID dose values measured in air. The transmitted dose distributions in the EPID detector layer were also modeled using a Pinnacle3 treatment planning system (TPS: Philips Radiation Oncology Systems, Milpitas, CA). The gamma function algorithm was then used to assess agreement between transmitted dose distributions measured using a SLIC‐EPID and EDR2 film, and those calculated using the TPS. For homogenous and inhomogeneous phantoms, more than 90% agreement was achieved using gamma criteria of 2% and 3 mm and 3% and 2.5 mm respectively. Our results indicate that the calibration procedure proposed in the present study should be performed if SLIC‐EPID is to be used as a reliable two‐dimensional transmitted dosimeter for clinical purposes.

PACS numbers: 87.53.Tf, 87.53.Oq

Calibration of an amorphous-silicon flat panel portal imager for exit-beam dosimetry

Amorphous-silicon flat panel detectors are currently used to acquire digital portal images with excellent image quality for patient alignment before external beam radiation therapy. As a first step towards interpreting portal images acquired during treatment in terms of the actual dose delivered to the patient, a calibration method is developed to convert flat panel portal images to the equivalent water dose deposited in the detector plane and at a depth of 1.5 cm. The method is based on empirical convolution models of dose deposition in the flat panel detector and in water. A series of calibration experiments comparing the response of the flat panel imager and ion chamber measurements of dose in water determines the model parameters. Kernels derived from field size measurements account for the differences in the production and detection of scattered radiation in the two systems. The dissimilar response as a function of beam energy spectrum is characterized from measurements performed at various off-axis positions and for increasing attenuator thickness in the beam. The flat panel pixel inhomogeneity is corrected by comparing a large open field image with profiles measured in water. To verify the accuracy of the calibration method, calibrated flat panel profiles were compared with measured dose profiles for fields delivered through solid water slabs, a solid water phantom containing an air cavity, and an anthropomorphic head phantom. Open rectangular fields of various sizes and locations as well as a multileaf collimator-shaped field were delivered. For all but the smallest field centered about the central axis, the calibrated flat panel profiles matched the measured dose profiles with little or no systematic deviation and approximately 3% (two standard deviations) accuracy for the in-field region. The calibrated flat panel profiles for fields located off the central axis showed a small -1.7% systematic deviation from the measured profiles for the in-field region. Out of the field, the differences between the calibrated flat panel and measured profiles continued to be small, approximately 0%-2% of the mean in-field dose. Further refinement of the calibration model should increase the accuracy of the procedure. This calibration method for flat panel portal imagers may be used as part of a validation scheme to verify the dose delivered to the patient during treatment.

Improving IMRT quality control efficiency using an amorphous silicon electronic portal imager

An amorphous silicon electronic portal imaging device (EPID) has been investigated to determine its usefulness and efficiency for performing linear accelerator quality control checks specific to step and shoot intensity modulated radiation therapy (IMRT). Several dosimetric parameters were measured using the EPID: dose linearity and segment to segment reproducibility of low dose segments, and delivery accuracy of fractions of monitor units. Results were compared to ion chamber measurements. Low dose beam flatness and symmetry were tested by overlaying low dose beam profiles onto the profile from a stable high-dose exposure and visually checking for differences. Beam flatness and symmetry were also calculated and plotted against dose. Start-up reproducibility was tested by overlaying profiles from twenty successive two monitor unit segments. A method for checking the MLC leaf calibration was also tested, designed to be used on a daily or weekly basis, which consisted of summing the images from a series of matched fields. Daily images were coregistered with, then subtracted from, a reference image. A threshold image showing dose differences corresponding to > 0.5 mm positional errors was generated and the number of pixels with such dose differences used as numerical parameter to which a tolerance can be applied. The EPID was found to be a sensitive relative dosemeter, able to resolve dose differences of 0.01 cGy. However, at low absolute doses a reproducible dosimetric nonlinearity of up to 7% due to image lag/ghosting effects was measured. It was concluded that although the EPID is suitable to measure segment to segment reproducibility and fractional monitor unit delivery accuracy, it is still less useful than an ion chamber as a tool for dosimetric checks. The symmetry/flatness test proved to be an efficient method of checking low dose profiles, much faster than any of the alternative methods. The MLC test was found to be extremely sensitive to sudden changes in MLC calibration but works best with a composite reference image consisting of an average of five successive days' images. When used in this way it proved an effective and efficient daily check of MLC calibration. Overall, the amorphous silicon EPID was found to be a suitable device for IMRT QC although it is not recommended for dosimetric tests. Automatic procedures for low monitor unit profile analysis and MLC leaf positioning yield considerable time-savings over traditional film techniques.

An Active Matrix Flat Panel Dosimeter (AMFPD) for in-phantom dosimetric measurements

An a-Si Active Matrix Flat Panel Imager (AMFPI) prototype developed in-house has been modified to function as an in-phantom dosimetry system providing high resolution two-dimensional (2-D) data. This Active Matrix Flat Panel Dosimeter (AMFPD) system can be used as a replacement device for standard in-phantom dosimeters, such as scanning ion chambers in water, or film in solid water. The initial characterization of the device demonstrates a wide dynamic range (up to 160 cGy), a stable calibration curve (less than 1.5% variation over 1 year), dose rate independence (less than 1%), and excellent agreement of output factors with ion chamber measurements for a range of field sizes (less than 2%). The device also compares well to film for 2-D planar dose distributions. It is expected that the AMFPD system will be useful for beam commissioning, algorithm verification test data, and routine IMRT quality assurance dosimetry.

The linear accelerator mechanical and radiation isocentre assessment with an electronic portal imaging device (EPID)

Regular checks on the performance of radiotherapy treatment units are essential and a variety of protocols has been published. These protocols identify that the determination of isocentre must be accurate and unambiguous since both the localization of a radiation field on a patient and positioning aids are referenced to it. An EPID (BIS 710) with a combined light and radiation scintillation detector screen was used to assess mechanical and radiation isocentres for different collimator and gantry angles. Crosshair positions within light field images were determined from fitted Gaussian intensity profiles and then used to calculate the displacement of the mechanical isocentre. For comparison, the position of the crosshair was also recorded on a graph paper. The radiation field centre was first calculated from the set up geometry for given gantry/collimator angles and then compared with measured values to assess the displacement of the radiation isocentre. The radiation isocentre was also checked by locating a marker, positioned on the couch, on the EPID radiation images for different treatment couch angles. The mechanical and radiation isocentres were determined from the EPID light field and radiation images respectively with an accuracy of 0.3 mm using simple PC based programs. The study has demonstrated the feasibility of using the EPID to assess mechanical and radiation isocentres of a linear accelerator in a quick and efficient way with a higher degree of accuracy achieved as compared to more conventional methods, e.g. the star shot.

Verification of patient position and delivery of IMRT by electronic portal imaging

BACKGROUND AND PURPOSE

The purpose of the work presented in this paper was to determine whether patient positioning and delivery errors could be detected using electronic portal images of intensity modulated radiotherapy (IMRT).

PATIENTS AND METHODS

We carried out a series of controlled experiments delivering an IMRT beam to a humanoid phantom using both the dynamic and multiple static field method of delivery. The beams were imaged, the images calibrated to remove the IMRT fluence variation and then compared with calibrated images of the reference beams without any delivery or position errors. The first set of experiments involved translating the position of the phantom both laterally and in a superior/inferior direction a distance of 1, 2, 5 and 10 mm. The phantom was also rotated 1 and 2 degrees . For the second set of measurements the phantom position was kept fixed and delivery errors were introduced to the beam. The delivery errors took the form of leaf position and segment intensity errors.

RESULTS

The method was able to detect shifts in the phantom position of 1 mm, leaf position errors of 2 mm, and dosimetry errors of 10% on a single segment of a 15 segment IMRT step and shoot delivery (significantly less than 1% of the total dose).

CONCLUSIONS

The results of this work have shown that the method of imaging the IMRT beam and calibrating the images to remove the intensity modulations could be a useful tool in verifying both the patient position and the delivery of the beam.

SIFT: A method to verify the IMRT fluence delivered during patient treatment using an electronic portal imaging device

PURPOSE

Radiotherapy patients are increasingly treated with intensity-modulated radiotherapy (IMRT) and high tumor doses. As part of our quality control program to ensure accurate dose delivery, a new method was investigated that enables the verification of the IMRT fluence delivered during patient treatment using an electronic portal imaging device (EPID), irrespective of changes in patient geometry.

METHODS AND MATERIALS

Each IMRT treatment field is split into a static field and a modulated field, which are delivered in sequence. Images are acquired for both fields using an EPID. The portal dose image obtained for the static field is used to determine changes in patient geometry between the planning CT scan and the time of treatment delivery. With knowledge of these changes, the delivered IMRT fluence can be verified using the portal dose image of the modulated field. This method, called split IMRT field technique (SIFT), was validated first for several phantom geometries, followed by clinical implementation for a number of patients treated with IMRT.

RESULTS

The split IMRT field technique allows for an accurate verification of the delivered IMRT fluence (generally within 1% [standard deviation]), even if large interfraction changes in patient geometry occur. For interfraction radiological path length changes of 10 cm, deliberately introduced errors in the delivered fluence could still be detected to within 1% accuracy. Application of SIFT requires only a minor increase in treatment time relative to the standard IMRT delivery.

CONCLUSIONS

A new technique to verify the delivered IMRT fluence from EPID images, which is independent of changes in the patient geometry, has been developed. SIFT has been clinically implemented for daily verification of IMRT treatment delivery.

A quality assurance method for analyzing and verifying intensity modulated fields

A quality assurance method is developed for measuring, verifying and analyzing intensity modulated radiation fields. It is applicable for rotational and fixed-beam intensity modulated radiation therapy (IMRT) treatments. A gantry-mount device was constructed to measure the transmission dose of an IMRT field using radiographic films. A double-exposure technique with optimal kernel estimate method was developed to minimize the errors from measurements. A chi2 confidence level test method was developed to detect the discrepancies between measured and prescribed IMRT fluence distributions. Our method was tested for rotational and fixed-beam IMRT treatment verifications. The method was found insensitive to the hardware-related parameters for rotational and fixed-beam IMRT deliveries. The chi2 confidence level test was found to be more sensitive than linear correlation method in detecting relative small errors for cases with a few segments or narrow regions of interest. In conclusion, we demonstrated a quantitative method for verifying and analyzing IMRT treatment deliveries.

Image guidance for precise conformal radiotherapy

PURPOSE

To review the state of the art in image-guided precision conformal radiotherapy and to describe how helical tomotherapy compares with the image-guided practices being developed for conventional radiotherapy.

MATERIALS AND METHODS

Image guidance is beginning to be the fundamental basis for radiotherapy planning, delivery, and verification. Radiotherapy planning requires more precision in the extension and localization of disease. When greater precision is not possible, conformal avoidance methodology may be indicated whereby the margin of disease extension is generous, except where sensitive normal tissues exist. Radiotherapy delivery requires better precision in the definition of treatment volume, on a daily basis if necessary. Helical tomotherapy has been designed to use CT imaging technology to plan, deliver, and verify that the delivery has been carried out as planned. The image-guided processes of helical tomotherapy that enable this goal are described.

RESULTS

Examples of the results of helical tomotherapy processes for image-guided intensity-modulated radiotherapy are presented. These processes include megavoltage CT acquisition, automated segmentation of CT images, dose reconstruction using the CT image set, deformable registration of CT images, and reoptimization.

CONCLUSIONS

Image-guided precision conformal radiotherapy can be used as a tool to treat the tumor yet spare critical structures. Helical tomotherapy has been designed from the ground up as an integrated image-guided intensity-modulated radiotherapy system and allows new verification processes based on megavoltage CT images to be implemented.

In vivo estimation of midline dose maps by transit dosimetry in head and neck radiotherapy

The aim of the present study is to compare the calculated midline dose map with the in vivo measured midline dose map, using portal detectors in conjunction with a pair of diodes. Measurements were performed in 10 patients treated for head/neck cancer and irradiated with lateral opposed 6 MV X-ray beams. The relative exit dose map, derived from transmission dose data of a portal film combined with the absolute entrance/exit dose measured by the diodes, can be used to derive the corresponding midline dose map by applying appropriate algorithms. Midplane dose values were estimated in eight relevant anatomic positions and compared with the corresponding calculated values with our three-dimensional (3D) treatment planning system using two-dimensional (2D) (Batho) and 3D (ETAR) inhomogeneity correction algorithms. In vivo estimated midplane doses agree within +/-3.5% relative to treatment planning calculations in 89 of 116 measurements points, with only 4 of 116 points outside +/-5%. A variation between measured and calculated dose can be found according to anatomical location. For air inhomogeneity, mean deviations were +2.2% (1 standard deviation (SD) approximately 1.7%) for both Batho and ETAR algorithms; for bone structures, mean deviations were approximately -0.6% (1 SD approximately 2.7%) for both algorithms. The worst agreement was found in the anterior neck where the mean deviation between measured and calculated midline dose was +3.1% (1 SD=1.4%) and +3.4% (1 SD= 2%) using Batho and ETAR, respectively. Sufficiently accurate 2D midplane dose maps may be simply obtained in vivo in the irradiation of head/neck cancer by using a portal detector in combination with a pair of diodes, in order to verify the dose actually delivered during treatment.

IMRT verification by three-dimensional dose reconstruction from portal beam measurements

A method of reconstructing three-dimensional, in vivo dose distributions delivered by intensity-modulated radiotherapy (IMRT) is presented. A proof-of-principle experiment is described where an inverse-planned IMRT treatment is delivered to an anthropomorphic phantom. The exact position of the phantom at the time of treatment is measured by acquiring megavoltage CT data with the treatment beam and a research prototype, flat-panel, electronic portal imaging device. Immediately following CT imaging, the planned IMRT beams are delivered using the multiple-static field technique. The delivered fluence is sampled using the same detector as for the CT data. The signal measured by the portal imaging device is converted to primary fluence using an iterative phantom-scatter estimation technique. This primary fluence is back-projected through the previously acquired megavoltage CT model of the phantom, with inverse attenuation correction, to yield an input fluence map. The input fluence maps are used to calculate a "reconstructed" dose distribution using the same convolution/superposition algorithm as for the original planning dose calculation. Both relative and absolute dose reconstructions are shown. For the relative measurements, individual beam weights are taken from measurements but the total dose is normalized at the reference point. The absolute dose reconstructions do not use any dosimetric information from the original plan. Planned and reconstructed dose distributions are compared, with the reconstructed relative dose distribution also being compared to film measurements.

Assessment of flatness and symmetry of megavoltage x-ray beam with an electronic portal imaging device (EPID)

The input/output characteristics of the Wellhofer BIS 710 electronic portal imaging device (EPID) have been investigated to establish its efficacy for periodic quality assurance (QA) applications. Calibration curves have been determined for the energy fluence incident on the detector versus the pixel values. The effect of the charge coupled device (CCD) camera sampling time and beam parameters (such as beam field size, dose rate, photon energy) on the calibration have been investigated for a region of interest (ROI) around the central beam axis. The results demonstrate that the pixel output is a linear function of the incident exposure, as expected for a video-based electronic portal imaging system. The field size effects of the BIS 710 are similar to that of an ion chamber for smaller field sizes up to 10 x 10 cm2. However, for larger field sizes the pixel value increases more rapidly. Furthermore, the system is slightly sensitive to dose rate and is also energy dependent The BIS 710 has been used in the current study to develop a QA procedure for measurements of flatness and symmetry of a linac x-ray beam. As a two-dimensional image of the radiation field is obtained from a single exposure of the BIS 710, a technique has been developed to calculate flatness and symmetry from a defined radiation area. The flatness and symmetry values obtained are different from those calculated conventionally from major axes only (inplane, crossplane). This demonstrates that the technique can pick up the "cold" and "hot" spots in the analysed area, providing thus more information about the radiation beam. When calibrated against the water tank measurements, the BIS 710 can be used as a secondary device to monitor the x-ray beam flatness and symmetry.

Portal dose image prediction for dosimetric treatment verification in radiotherapy. II. An algorithm for wedged beams

A method is presented for calculation of a two-dimensional function, T(wedge)(x,y), describing the transmission of a wedged photon beam through a patient. This in an extension of the method that we have published for open (nonwedged) fields [Med. Phys. 25, 830-840 (1998)]. Transmission functions for open fields are being used in our clinic for prediction of portal dose images (PDI, i.e., a dose distribution behind the patient in a plane normal to the beam axis), which are compared with PDIs measured with an electronic portal imaging device (EPID). The calculations are based on the planning CT scan of the patient and on the irradiation geometry as determined in the treatment planning process. Input data for the developed algorithm for wedged beams are derived from (the already available) measured input data set for transmission prediction in open beams, which is extended with only a limited set of measurements in the wedged beam. The method has been tested for a PDI plane at 160 cm from the focus, in agreement with the applied focus-to-detector distance of our fluoroscopic EPIDs. For low and high energy photon beams (6 and 23 MV) good agreement (approximately 1%) has been found between calculated and measured transmissions for a slab and a thorax phantom.

Portal imaging

Portal imaging is the acquisition of images with a radiotherapy beam. Imaging theory suggests that the quality of portal images could be much higher if the efficiency of the imaging media in detecting radiation could be improved. Introduction of new media (films and electronic portal imaging devices) has confirmed this by markedly increasing the quality of portal images. Images from these devices can then be used to verify a patient's treatment. Geometric verification requires the portal image to be registered with a reference image. Dosimetric verification requires the portal imager to be calibrated for dose. This review gives a brief overview of the current areas of interest in portal imaging: imaging theory; imaging media, film and electronic portal imaging devices; image registration; and dosimetry using these devices.

An iterative algorithm for reconstructing incident beam distributions from transmission measurements using electronic portal imaging

The problem of reconstructing incident radiotherapy beam profiles from electronic portal images recorded behind a phantom is addressed. To this end an iterative algorithm is presented, which is able to extract the input beam profile from a portal image by compensating for the attenuation of the beam and subtracting the amount of scatter emitted by the phantom. The algorithm requires only a thickness map of the phantom. Scatter is estimated using a superposition method based on precalculated Monte Carlo scatter kernels. The method is tested for a homogeneous water-equivalent slab phantom for simple rectangular and complex multileaf collimated fields. It is shown that the method produces a stable result within four iterations yielding an accuracy for the incident beam distribution of better than 3%.

Dosimetric investigation and portal dose image prediction using an amorphous silicon electronic portal imaging device

A two step algorithm to predict portal dose images in arbitrary detector systems has been developed recently. The current work provides a validation of this algorithm on a clinically available, amorphous silicon flat panel imager. The high-atomic number, indirect amorphous silicon detector incorporates a gadolinium oxysulfide phosphor scintillating screen to convert deposited radiation energy to optical photons which form the portal image. A water equivalent solid slab phantom and an anthropomorphic phantom were examined at beam energies of 6 and 18 MV and over a range of air gaps (approximately 20-50 cm). In the many examples presented here, portal dose images in the phosphor were predicted to within 5% in low-dose gradient regions, and to within 5 mm (isodose line shift) in high-dose gradient regions. Other basic dosimetric characteristics of the amorphous silicon detector were investigated, such as linearity with dose rate (+/- 0.5%), repeatability (+/- 2%), and response with variations in gantry rotation and source to detector distance. The latter investigation revealed a significant contribution to the image from optical photon spread in the phosphor layer of the detector. This phenomenon is generally known as "glare," and has been characterized and modeled here as a radially symmetric blurring kernel. This kernel is applied to the calculated dose images as a convolution, and is successfully demonstrated to account for the optical photon spread. This work demonstrates the flexibility and accuracy of the two step algorithm for a high-atomic number detector. The algorithm may be applied to improve performance of dosimetric treatment verification applications, such as direct image comparison, backprojected patient dose calculation, and scatter correction in megavoltage computed tomography. The algorithm allows for dosimetric applications of the new, flat panel portal imager technology in the indirect configuration, taking advantage of a greater than tenfold increase in detector sensitivity over a direct configuration.

Clinical use of electronic portal imaging: report of AAPM Radiation Therapy Committee Task Group 58

AAPM Task Group 58 was created to provide materials to help the medical physicist and colleagues succeed in the clinical implementation of electronic portal imaging devices (EPIDs) in radiation oncology. This complex technology has matured over the past decade and is capable of being integrated into routine practice. However, the difficulties encountered during the specification, installation, and implementation process can be overwhelming. TG58 was charged with providing sufficient information to allow the users to overcome these difficulties and put EPIDs into routine clinical practice. In answering the charge, this report provides; comprehensive information about the physics and technology of currently available EPID systems; a detailed discussion of the steps required for successful clinical implementation, based on accumulated experience; a review of software tools available and clinical use protocols to enhance EPID utilization; and specific quality assurance requirements for initial and continuing clinical use of the systems. Specific recommendations are summarized to assist the reader with successful implementation and continuing use of an EPID.

A feasible method for clinical delivery verification and dose reconstruction in tomotherapy

Delivery verification is the process in which the energy fluence delivered during a treatment is verified. This verified energy fluence can be used in conjunction with an image in the treatment position to reconstruct the full three-dimensional dose deposited. A method for delivery verification that utilizes a measured database of detector signal is described in this work. This database is a function of two parameters, radiological path-length and detector-to-phantom distance, both of which are computed from a CT image taken at the time of delivery. Such a database was generated and used to perform delivery verification and dose reconstruction. Two experiments were conducted: a simulated prostate delivery on an inhomogeneous abdominal phantom, and a nasopharyngeal delivery on a dog cadaver. For both cases, it was found that the verified fluence and dose results using the database approach agreed very well with those using previously developed and proven techniques. Delivery verification with a measured database and CT image at the time of treatment is an accurate procedure for tomotherapy. The database eliminates the need for any patient-specific, pre- or post-treatment measurements. Moreover, such an approach creates an opportunity for accurate, real-time delivery verification and dose reconstruction given fast image reconstruction and dose computation tools.

On the accuracy and effectiveness of dose reconstruction for tomotherapy

Dose reconstruction is a process that re-creates the treatment-time dose deposited in a patient provided there is knowledge of the delivered energy fluence and the patient's anatomy at the time of treatment. A method for reconstructing dose is presented. The process starts with delivery verification, in which the incident energy fluence from a treatment is computed using the exit detector signal and a transfer matrix to convert the detector signal to energy fluence. With the verified energy fluence and a CT image of the patient in the treatment position, the treatment-time dose distribution is computed using any model-based algorithm such as convolution/superposition or Monte Carlo. The accuracy of dose reconstruction and the ability of the process to reveal delivery errors are presented. Regarding accuracy, a reconstructed dose distribution was compared with a measured film distribution for a simulated breast treatment carried out on a thorax phantom. It was found that the reconstructed dose distribution agreed well with the dose distribution measured using film: the majority of the voxels were within the low and high dose-gradient tolerances of 3% and 3 mm respectively. Concerning delivery errors, it was found that errors associated with the accelerator, the multileaf collimator and patient positioning might be detected in the verified energy fluence and are readily apparent in the reconstructed dose. For the cases in which errors appear in the reconstructed dose, the possibility for adaptive radiotherapy is discussed.

A simple and robust method for in vivo midline dose map estimations using diodes and portal detectors

INTRODUCTION

This work investigates the possibility of using a pair of diodes on the beam axis in conjunction with a portal imaging detector to estimate in vivo midline dose distributions, without any additional patient information, related to the external body contour.

MATERIALS AND METHODS

In the proposed method, the patient is considered equivalent to a parallelepiped phantom with a thickness z equal to the patient's physical thickness on the field axis with a variable electronic density rho, depending on the water-equivalent thickness. Based on this assumption, if the air gap between portal detector and patient is kept small (within 10-15 cm), the relative exit dose map may be assumed to be equal to the corresponding map measured at the portal detector level by geometrical back projection to the corresponding exit points. The relative exit dose map is then normalized at the on-axis value measured by the exit diode. The entrance dose map is derived by correcting the absolute dose value measured with the diode at the entrance surface by the off-axis ratios. For each pair of entrance and exit doses, the midline dose may be estimated by applying algorithms reported in literature. The method was tested in 6 MV beams using portal film as detector and the Huyskens and Rizzotti algorithms for midline dose estimation. Tests on homogeneous cubic phantoms, homogeneous phantoms with varying thickness symmetrically (simulating head and neck regions) and asymmetrically (simulating abdomen/pelvis region), and a half-sphere phantom with simulating the breast, were performed. Midline doses estimated with the proposed method have been compared with corresponding ones measured by ionisation chamber.

RESULTS AND DISCUSSION

Results confirm that the proposed method can be used to estimate midplane dose maps within 2-3% for most clinically suitable situations. For homogeneous symmetrical phantoms the agreement between estimated and measured midline doses decreases with the phantom-portal film distance, the field sizes and the thickness. For homogeneous asymmetrical phantoms the percentage deviations are generally within 3%. Discrepancies larger than 3% (up to 5-6%) are found only for "stressed" irradiation geometries which are not linked with any clinical condition.

CONCLUSIONS

The obtained results not only show the accuracy of the proposed method but, due to its simplicity, suggest a rapid clinical implementation of this method in relevant clinical situations such as head-neck, breast and abdomen/pelvis irradiation. Previous investigations which confirmed the possibility of using portal detectors for transit dosimetry in inhomogeneous regions suggest the further exploration of the accuracy and the limits of the proposed method in such cases.

A two-step algorithm for predicting portal dose images in arbitrary detectors

Recently, portal imaging systems have been successfully demonstrated in dosimetric treatment verification applications, where measured and predicted images are quantitatively compared. To advance this approach to dosimetric verification, a two-step model which predicts dose deposition in arbitrary portal image detectors is presented. The algorithm requires patient CT data, source-detector distance, and knowledge of the incident beam fluence. The first step predicts the fluence entering a portal imaging detector located behind the patient. Primary fluence is obtained through ray-tracing techniques, while scatter fluence prediction requires a library of Monte Carlo-generated scatter fluence kernels. These kernels allow prediction of basic radiation transport parameters characterizing the scattered photons, including fluence and mean energy. The second step of the algorithm involves a superposition of Monte Carlo-generated pencil beam kernels, describing dose deposition in a specific detector, with the predicted incident fluence. This process is performed separately for primary and scatter fluence, and yields a predicted dose image. A small but noticeable improvement in prediction is obtained by explicitly modeling the off-axis energy spectrum softening due to the flattening filter. The algorithm is tested on a slab phantom and a simple lung phantom (6 MV). Furthermore, an anthropomorphic phantom is utilized for a simulated lung treatment (6 MV), and simulated pelvis treatment (23 MV). Data were collected over a range of air gaps (10-80 cm). Detectors incorporating both low and high atomic number buildup are used to measure portal image profiles. Agreement between predicted and measured portal dose is better than 3% in areas of low dose gradient (<30%/cm) for all phantoms, air gaps, beam energies, and detector configurations tested here. It is concluded that this portal dose prediction algorithm is fast, accurate, allows separation of primary and scatter dose, and can model arbitrary detectors.

Dosimetric properties of the Theraview fluoroscopic electronic portal imaging device

Electronic portal imaging devices (EPIDs) can be used for non-imaging applications in radiotherapy such as patient dosimetry. Of the systems available, the fluoroscopic camera-based EPID Theraview (InfiMed Inc.) has not been studied to date, and a review of the dosimetric properties of the system is presented here. In the "single set-up" mode of image acquisition, pixel intensity increases sublinearly with applied dose. The response was dependent on the system's video signal gain and showed a threshold dose to the detector in the range 0.05-0.35 cGy, and pixel saturation at detector doses in the range 1.2-1.6 cGy. Repeated exposures of the EPID were observed to be extremely reproducible (standard deviation 0.5%). The sensitivity of the system showed a linear decline of 0.04% day-1 over a 68-day period, during which time the relative off-axis response within 10 x 10 cm2 field was constant to within a standard deviation of 0.56%. The system shows spatial non-uniformity, which requires correction for application to dose measurements in two-dimensions. Warm-up of the camera control unit required a period of at least 40 min and was associated with an enhancement in pixel intensity of up to 12%. A radiation dose history effect was observed at doses as low as 0.2 Gy. Camera dark current was shown to be negligible at normal accelerator operation. No discernible image distortion was found. Mechanical stability on gantry rotation was also assessed and image displacement of up to 5 mm at the isocentre was observed. It was concluded that the device could be used for dosimetry provided necessary precautions were observed and corrections made.

Photon scatter in portal images: accuracy of a fluence based pencil beam superposition algorithm

The accuracy of a pencil beam algorithm to predict scattered photon fluence into portal imaging systems was studied. A data base of pencil beam kernels describing scattered photon fluence behind homogeneous water slabs (1-50 cm thick) at various air gap distances (0-100 cm) was generated using the EGS Monte Carlo code. Scatter kernels were partitioned according to particle history: singly-scattered, multiply-scattered, and bremsstrahlung and positron annihilation photons. Mean energy and mean angle with respect to the incident photon pencil beam were also scored. This data allows fluence, mean energy, and mean angular data for each history type to be predicted using the pencil beam algorithm. Pencil beam algorithm predictions for 6 and 24 MV incident photon beams were compared against full Monte Carlo simulations for several inhomogeneous phantoms, including approximations to a lateral neck, and a mediastinum treatment. The accuracy of predicted scattered photon fluence, mean energy, and mean angle was investigated as a function of air gap, field size, photon history, incident beam resolution, and phantom geometry. Maximum errors in mean energies were 0.65 and 0.25 MeV for the higher and lower energy spectra, respectively, and 15 degrees for mean angles. The ability of the pencil beam algorithm to predict scatter fluence decreases with decreasing air gap, with the largest error for each phantom occurring at the exit surface. The maximum predictive error was found to be 6.9% with respect to the total fluence on the central axis. By maintaining even a small air gap (approximately 10 cm), the error in predicted scatter fluence may be kept under 3% for the phantoms and beam energies studied here. It is concluded that this pencil beam algorithm is sufficiently accurate (using International Commission on Radiation Units and Measurements Report No. 24 guidelines for absorbed dose) over the majority of clinically relevant air gaps, for further investigation in a portal dose prediction algorithm.

Guide to clinical use of electronic portal imaging

The Electronic Portal Imaging Device (EPID) provides localization quality images and computer-aided analysis, which should in principal, replace portal film imaging. Modern EPIDs deliver superior image quality and an array of analysis tools that improve clinical decision making. It has been demonstrated that the EPID can be a powerful tool in the reduction of treatment setup errors and the quality assurance and verification of complex treatments. However, in many radiation therapy clinics EPID technology is not in routine clinical use. This low utilization suggests that the capability and potential of the technology alone do not guarantee its full adoption. This paper addresses basic considerations required to facilitate clinical implementation of the EPID technology and gives specific examples of successful implementations.

Evaluation of compensation in breast radiotherapy: a planning study using multiple static fields

PURPOSE

A method that uses electronic portal imaging to design intensity-modulated beams for compensation in breast radiotherapy was implemented using multiple static fields in a planning study. We present the results of the study to verify the algorithm, and to assess improvements to the dosimetry.

METHODS AND MATERIALS

Fourteen patients were imaged with computed tomography (CT) and on a treatment unit using an electronic portal imager. The portal imaging data were used to design intensity-modulated beams to give an ideal dose distribution in the breast. These beams were implemented as multiple static fields added to standard wedged tangential fields. Planning of these treatments was performed on a commercial treatment planning system (Target 2, IGE Medical Systems, Slough, U.K.) using the CT data for each patient. Dose-volume histogram (DVH) analysis of the plans with and without multileaf collimator (MLC) compensation was carried out. This work has been used as the basis for a randomized clinical trial investigating whether improvements in dosimetry are correlated with the reduction of long-term side effects from breast radiotherapy.

RESULTS

The planning analysis showed a mean increase in target volume receiving 95-105% of prescribed dose of 7.5% (range -0.8% to 15.9%) when additional MLC compensation was applied. There was no change to the minimum dose for all 14 patient data sets. The change in the volume of breast tissue receiving over 105% of prescribed dose, when applying MLC compensation, was between -1.4% and 11.9%, with positive numbers indicating an improvement. These effects showed a correlation with breast size; the larger the breast the greater the amount of improvement.

CONCLUSIONS

The method for designing compensation for breast treatments using an electronic portal imager has been verified using planning on CT data for 14 patients. An improvement was seen in planning when applying MLC compensation and this effect was greater the larger the breast size.

[Evolution of the use of the portal imaging device: prospective study over three years]

PURPOSE

To describe the evolution of the use of the electronic portal imaging device (EPID) over three periods.

MATERIAL AND METHODS

From 1990, as part of the quality assurance research programs, the radiotherapy department of the G.-F. Leclerc Centre of Dijon used EPID systems in a prospective fashion. During the first of the three periods (PER 1:1990-1993), the study consisted of analysis criteria determination, software efficiency improvement and a selection of patients who could benefit from the method. Eight hundred and forty-five images of 40 patients were analysed qualitatively and quantitatively. Two verifications per week were planned, and the action level for correction was 10 mm. Head and neck images were also displayed in 'cinema' presentation for internal movements analysis. From 1994 to 1995 (PER 2), off-line procedure (OLP) based upon early correction of the systematic error and the rules calculated from our previous experience were tested for checking the brain, head and neck (LOC 1: 396 images) and many of the pelvic irradiations (LOC 2: 260 images). A double-exposure procedure and/or movie loop presentation was reserved for other patients. During the last period (PER 3: 1996-1997), the OLP procedure was routinely performed in 54 patients (images: 321 LOC 1, 680 LOC 2).

RESULTS

LOC 1: deviations of < 3 mm increased from 75.5% during PER 1 to 81% during PER 2 to 83% during PER3. Conversely, deviations of 3-5 mm dropped from 19.5 to 13%, while deviations of more than 5 mm remained stable, around 5%. The actual standard error of the mean deviation observed was 2 mm. LOC 2: deviations of < 5 mm were observed in 81% of the cases during PER 1 and in 91% during PER 3 (89.5% in PER 2). These good results led to a decrease in deviation of 5 to 7 mm (11 to 6%) and also to a significant drop in deviations of more than 7 mm, 8 to 3% respectively. The actual precision obtained was 2.5 mm +/- 3 mm SD.

CONCLUSIONS

The OLP based upon the early correction of the systematic error led to a significant increase of setup accuracy of patients irradiated for the brain, head and neck, and especially for pelvic lesions.

A method to estimate the transit dose on the beam axis for verification of dose delivery with portal images

PURPOSE AND BACKGROUND

A feasibility study is performed to evaluate the possibility of using the transit dose of portal images on the beam axis to measure the accuracy in dose delivery. The algorithm and the method are tested on a breast phantom and on patients with a breast disease.

MATERIALS AND METHODS

To estimate the transit dose at various air gaps behind the patient, a method is proposed which applies, for a given air gap, the inverse square law to the primary component of the exit dose and an experimentally determined function for the scatter component of the exit dose. It is assumed that the primary component and the scattered component of the exit dose are given by the treatment planning system. The experimental function for the variation of the scattered component with the air gap, determined by phantom measurements, is modelled by an analytical function which contains only field size, air gap and one energy-dependent parameter.

RESULTS

The measurements on the breast phantom yield a maximum deviation between measured and estimated transit doses of 4.5%. The mean deviation is 0.9% with a standard deviation of the distribution of 2.3%. In vivo diode measurements on the same phantom yield a maximum deviation of 2.7%. Transit dose measurements on the beam axis for 45 portal images of breast patients show a mean deviation of 0.0% between the measured transit dose and the estimated transit dose. The standard deviation of the distribution is 4.4%. The method seems to be very sensitive to patient positioning and to discrepancies in breast thicknesses used for treatment planning.

CONCLUSION

Preliminary results on breast patients show that the method proposed to evaluate transit doses on the beam axis from portal images may be a valuable alternative to conventional in vivo exit dosimetry. The method can be implemented in a simple way and does not require additional time during the irradiation session, as exit dosimetry with diodes does. The transit dose is only considered in one point. Nevertheless, in the framework of quality assurance of treatment delivery, this study is an example of the possibilities of monitoring at the same time the visual evaluation of the irradiated volume as well as the dosimetric control (i.e. in Gy) of treatment delivery with portal images.

Variation of relative transit dose profiles with patient-detector distance

BACKGROUND AND PURPOSE

In view of using portal images for exit dosimetry, an experimental study is performed of relative transit dose profiles at different distances behind patients (and phantoms) and of their relation to the exit dose profile.

MATERIALS AND METHODS

Irregular, homogeneous polystyrene phantoms with a variable thickness to simulate head and neck (H&N) treatments (6-MV photon beam) are investigated by ionization chamber measurements performed close to the exit surface and at various distances behind the phantom (10, 20 and 30 cm). Similar measurements are performed for a rectangular phantom with large inhomogeneities (A1 and air). For one irregular homogeneous phantom and an irregular phantom containing an A1 inhomogeneity, ionization chamber measurements are performed at the exit surface, and a portal film image is taken at 30 cm behind the phantom. Portal films of a patient treated for a head and neck malignancy are evaluated for different air gaps behind the patient.

RESULTS

For the irregular phantoms, deviations up to 15% and more are observed between the exit dose profile (along the shaped surface of the phantom) and the transit profile close to the phantom (perpendicular to the beam axis). There is, however, a good agreement--within 3%--between the exit profile and the transit profile at 30 cm. For the rectangular, inhomogeneous phantom, the deviation between the exit profile and the transit dose profile at 30 cm does not exceed 5%; transit dose profiles overestimate the exit dose for the air cavity and underestimate the dose for the A1 inhomogeneity. Measurements on portal films of a H&N patient for different air gaps confirm the order of magnitude of the difference observed between transit dose profiles close to the patient and transit dose profiles at some distance behind the patient.

CONCLUSIONS

For 6-MV photon beam treatments with significant thickness variations (H&N), large variations (> 10%) are observed in transit dose profiles as a function of the air gap between the patient and the portal film. For this energy, a good agreement is found between the exit profile and the transit profile at about 30 cm behind the patient.