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O'Daniel J, Masgrau VH, Clark C, Esposito M, Lehmann J, McNiven A, Olaciregui-Ruiz I, Kry S. Which failures do patient-specific quality assurance systems need to catch? Med Phys 2024. [PMID: 39466302 DOI: 10.1002/mp.17468] [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: 06/16/2024] [Revised: 09/02/2024] [Accepted: 09/27/2024] [Indexed: 10/29/2024] Open
Abstract
BACKGROUND The Joint AAPM-ESTRO TG-360 is developing a quantitative framework to evaluate treatment verification systems used for patient-specific quality assurance (PSQA). A subgroup was commissioned to determine which potential failure modes had the greatest risk to treatment quality and safety, and therefore should be evaluated as part of the PSQA verification. PURPOSE To create an extensive database of potential radiotherapy failure modes that should be detected by PSQA and to determine their relative importance for maximizing treatment quality. METHODS The subgroup consisted of eight physicists from seven countries, including representatives from three international quality assurance groups. We collected error reports from RO-ILS, SAFRON, AAPM TG publications, and other literature, including international audits. We focused on the subset of failure modes that impact whether the planned dose matches the dose received by the patient. We performed a failure-mode-and-effects analysis (FMEA), estimating the severity (S), occurrence (O), and detectability (D) of each failure mode. Detectability was scored assuming that PSQA was not done but other routine clinical QA was performed, which allowed us to see the importance of PSQA for detecting each specific failure mode. We analyzed the risk priority number (RPN = O*S*D), O*S, and severity rankings to determine the priority of each failure mode. RESULTS We collected 394 error reports, which we categorized into 33 failure modes that underwent FMEA. Five failure modes were in the top ranks for both RPN and O*S analysis: four involving treatment planning system (TPS) commissioning and one regarding patient model errors. The highest-ranking RPN failure modes were: TPS algorithm limitations, TPS commissioning errors [multileaf collimator (MLC) modeling, output factor, percent-depth-dose/tissue-maximum-ratio (PDD/TMR), off-axis factor], and patient weight variation. The highest O*S failure modes were similar, with the addition of external patient position variation and incorrect linear accelerator isocenter and cGy/monitor units calibration. RPN and O*S analyses prioritized failure modes that impacted multiple patients with high occurrence and detectability scores, while severity analysis gave higher priority to single-patient modes with high severity scores. The highest-ranking severity modes were MLC sequence deletion, collision, and TPS isocenter incorrect. CONCLUSION We have developed a list of failure modes critical to be detected during PSQA and ranked them in order of importance. The top failure modes emphasize the importance of utilizing a variety of treatment verification systems for PSQA, from secondary dose calculation through in-vivo dosimetry, in order to detect all possible errors. For failure modes in the top quartile, PSQA is critical. Without adequate PSQA, these errors may go undetected unless caught by an external audit. This analysis can be useful for optimizing PSQA workflows and for designing evaluations of treatment verification systems, and will be used by the Joint AAPM-ESTRO TG-360 to determine an appropriate validation strategy.
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Affiliation(s)
| | | | - Catharine Clark
- University College London Hospital, London, UK
- University College London, London, UK
- National Physical Laboratory, London, UK
| | - Marco Esposito
- Azienda Sanitaria USL Toscana Centro, Firenze, Italy
- The Abdus Salam International Center for Theoretical, Trieste, Italy
| | - Joerg Lehmann
- Department of Radiation Oncology, Calvary Mater Newcastle, Waratah, Australia
- School of Information and Physical Sciences, University of Newcastle, Newcastle, Australia
- Institute of Medical Physics, University of Sydney, Sydney, Australia
| | - Andrea McNiven
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
- Tom Baker Cancer Center, Calgary, Alberta, Canada
| | - Igor Olaciregui-Ruiz
- The Netherlands Cancer Institute/Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Stephen Kry
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Brooks FMD, Glenn MC, Hernandez V, Saez J, Pollard-Larkin JM, Peterson CB, Howell RM, Nelson CL, Clark CH, Kry SF. Is the Imaging Radiation Oncology Core Head and Neck Credentialing Phantom an Effective Surrogate for Different Anatomic Sites? Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)03453-9. [PMID: 39362313 DOI: 10.1016/j.ijrobp.2024.09.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 08/19/2024] [Accepted: 09/20/2024] [Indexed: 10/05/2024]
Abstract
PURPOSE The Imaging Radiation Oncology Core (IROC) head and neck (H&N) phantom is used to credential institutions for intensity modulated radiation therapy delivery for all anatomic sites where delivery of modulated therapy is a primary challenge. This study evaluated how appropriate the use of this phantom is for varied clinical anatomy by evaluating how closely the IROC H&N phantom described clinical dose errors from beam modeling compared with various anatomic sites. METHODS AND MATERIALS The multileaf collimator (MLC) offset, transmission, percent depth dose, and 7 additional beam modeling parameters for a Varian accelerator were modified in RayStation to match community data at the 2.5th, 25th, 50th, 75th, and 97.5th percentile levels. Modifications were evaluated on 25 H&N phantom cases and 25 clinical cases (H&N, prostate, lung, mesothelioma, and brain), generating 2000 plan perturbations. Differences in mean dose delivered to clinical target volumes and maximum dose to organs at risk were compared between phantom and clinical plans to assess the relationship between dose deviations in phantom versus clinical target volumes and as a function of 18 different complexity metrics. RESULTS Perturbations to MLC offset and transmission parameters demonstrated the greatest impact on dose accuracy for phantom and clinical plans (for all anatomic sites). The phantom demonstrated equivalent or greater sensitivity to these parameter perturbations compared with clinical sites, largely aligning with treatment complexity. The mean MLC gap best described the impact of errors in treatment planning system beam modeling parameters in phantom plans and clinical plans from various anatomic sites. CONCLUSIONS When compared across various anatomic sites, the IROC H&N credentialing phantom exhibited similar or greater sensitivity to errors in the treatment planning system. As such, it is a suitable surrogate device for assessing institutional performance across various anatomic sites. If an institution successfully irradiates the phantom, that result confers confidence that intensity modulated radiation therapy to a wide range of anatomic sites can be successfully delivered by the institution.
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Affiliation(s)
- Fre'Etta M D Brooks
- University of Texas MD Anderson UTHealth Graduate School of Biomedical Sciences, Houston, Texas; Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mallory C Glenn
- University of Texas MD Anderson UTHealth Graduate School of Biomedical Sciences, Houston, Texas; Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Victor Hernandez
- Department of Medical Physics, Hospital Sant Joan de Reus, Institut d'Investigació Sanitària Pere Virgili, Tarragona, Spain
| | - Jordi Saez
- Department of Radiation Oncology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Julianne M Pollard-Larkin
- University of Texas MD Anderson UTHealth Graduate School of Biomedical Sciences, Houston, Texas; Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Christine B Peterson
- University of Texas MD Anderson UTHealth Graduate School of Biomedical Sciences, Houston, Texas; Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Rebecca M Howell
- University of Texas MD Anderson UTHealth Graduate School of Biomedical Sciences, Houston, Texas; Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Christopher L Nelson
- University of Texas MD Anderson UTHealth Graduate School of Biomedical Sciences, Houston, Texas; Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Catharine H Clark
- Department of Radiotherapy Physics, University College London Hospital, London, United Kingdom; Department of Medical Physics and Bioengineering, University College London, London, United Kingdom; Medical Physics Department, National Physical Laboratory, Teddington, United Kingdom
| | - Stephen F Kry
- University of Texas MD Anderson UTHealth Graduate School of Biomedical Sciences, Houston, Texas; Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, Texas.
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Tani K, Wakita A, Tohyama N, Fujita Y. Dosimetric impact of calibration coefficients determined using linear accelerator photon and electron beams for ionization chamber in an on-site dosimetry audit. JOURNAL OF RADIATION RESEARCH 2024; 65:619-627. [PMID: 39154377 PMCID: PMC11420846 DOI: 10.1093/jrr/rrae054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 06/18/2024] [Indexed: 08/20/2024]
Abstract
This study aimed to clarify the dosimetric impact of calibration beam quality for calibration coefficients of the absorbed dose to water for an ionization chamber in an on-site dosimetry audit. Institution-measured doses of 200 photon and 184 electron beams were compared with the measured dose using one year data before and after the calibration of the ionization chamber used. For photon and electron reference dosimetry, the agreements of the institution-measured dose against two measured doses in this audit were evaluated using the calibration coefficients determined using 60Co (${N}_{D,\mathrm{w},{}^{60}\mathrm{Co}}$) and linear accelerator (linac) (${N}_{D,\mathrm{w},Q}$) beams. For electron reference dosimetry, the agreement of two institution-measured doses against the measured dose was evaluated using${N}_{D,\mathrm{w},Q}$. Institution-measured doses were evaluated using direct- and cross-calibration coefficients. For photon reference dosimetry, the mean differences and standard deviation (SD) of institution-measured dose against the measured dose using ${N}_{D,\mathrm{w},{}^{60}\mathrm{Co}}$ and ${N}_{D,\mathrm{w},Q}$ were -0.1% ± 0.4% and -0.3% ± 0.4%, respectively. For electron reference dosimetry, the mean differences and SD of institution-measured dose using the direct-calibration coefficient against the measured dose using ${N}_{D,\mathrm{w},{}^{60}\mathrm{Co}}$ and ${N}_{D,\mathrm{w},Q}$ were 1.3% ± 0.8% and 0.8% ± 0.8%, respectively. Further, the mean differences and SD of institution-measured dose using the cross-calibration coefficient against the measured dose using ${N}_{D,\mathrm{w},Q}$ were -0.1% ± 0.6%. For photon beams, the dosimetric impact of introducing calibration coefficients determined using linac beams was small. For electron beams, it was larger, and the measured dose using ${N}_{D,\mathrm{w},Q}$ was most consistent with the institution-measured dose, which was evaluated using a cross-calibration coefficient.
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Affiliation(s)
- Kensuke Tani
- Division of Medical Physics, EuroMediTech Co., Ltd, 2-20-4 Higashi-Gotanda, Shinagawa, Tokyo 141-0022, Japan
| | - Akihisa Wakita
- Division of Medical Physics, EuroMediTech Co., Ltd, 2-20-4 Higashi-Gotanda, Shinagawa, Tokyo 141-0022, Japan
| | - Naoki Tohyama
- Department of Health Sciences, Komazawa University, 1-23-1 Komazawa, Setagaya, Tokyo 154-8525, Japan
| | - Yukio Fujita
- Department of Health Sciences, Komazawa University, 1-23-1 Komazawa, Setagaya, Tokyo 154-8525, Japan
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Muir B, Davis S, Dhanesar S, Hillman Y, Iakovenko V, Kim GGY, Alves VGL, Lei Y, Lowenstein J, Renaud J, Sarfehnia A, Siebers J, Tantôt L. AAPM WGTG51 Report 385: Addendum to the AAPM's TG-51 protocol for clinical reference dosimetry of high-energy electron beams. Med Phys 2024; 51:5840-5857. [PMID: 38980220 DOI: 10.1002/mp.17277] [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: 12/08/2023] [Revised: 03/29/2024] [Accepted: 06/14/2024] [Indexed: 07/10/2024] Open
Abstract
An Addendum to the AAPM's TG-51 protocol for the determination of absorbed dose to water is presented for electron beams with energies between 4 MeV and 22 MeV (1.70 cm ≤ R 50 ≤ 8.70 cm $1.70\nobreakspace {\rm cm} \le R_{\text{50}} \le 8.70\nobreakspace {\rm cm}$ ). This updated formalism allows simplified calibration procedures, including the use of calibrated cylindrical ionization chambers in all electron beams without the use of a gradient correction. Newk Q $k_{Q}$ data are provided for electron beams based on Monte Carlo simulations. Implementation guidance is provided. Components of the uncertainty budget in determining absorbed dose to water at the reference depth are discussed. Specifications for a reference-class chamber in electron beams include chamber stability, settling, ion recombination behavior, and polarity dependence. Progress in electron beam reference dosimetry is reviewed. Although this report introduces some major changes (e.g., gradient corrections are implicitly included in the electron beam quality conversion factors), they serve to simplify the calibration procedure. Results for absorbed dose per linac monitor unit are expected to be up to approximately 2 % higher using this Addendum compared to using the original TG-51 protocol.
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Affiliation(s)
- Bryan Muir
- Metrology Research Centre, National Research Council of Canada, Ottawa, Ontario, Canada
| | - Stephen Davis
- Department of Radiation Oncology, Miami Cancer Institute, Miami, Florida, USA
| | - Sandeep Dhanesar
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, Texa, USA
| | - Yair Hillman
- Department of Radiation Oncology, Sharett Institute of Oncology, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - Grace Gwe-Ya Kim
- Department of Radiation Medicine and Applied Sciences, UC San Diego School of Medicine, San Diego, California, USA
| | | | - Yu Lei
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Jessica Lowenstein
- Department of Radiation Physics, UT M.D. Anderson Cancer Center, Houston, Texa, USA
| | - James Renaud
- Metrology Research Centre, National Research Council of Canada, Ottawa, Ontario, Canada
| | - Arman Sarfehnia
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
- Department of Medical Physics, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jeffrey Siebers
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia, USA
| | - Laurent Tantôt
- Département de radio-oncologie, CIUSSS de l'Est-de-l'Île-de-Montréal - Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
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Saez J, Bar-Deroma R, Bogaert E, Cayez R, Chow T, Clark CH, Esposito M, Feygelman V, Monti AF, Garcia-Miguel J, Gershkevitsh E, Goossens J, Herrero C, Hussein M, Khamphan C, Kierkels RGJ, Lechner W, Lemire M, Nevelsky A, Nguyen D, Paganini L, Pasler M, Fernando Pérez Azorín J, Ramos Garcia LI, Russo S, Shakeshaft J, Vieillevigne L, Hernandez V. Universal evaluation of MLC models in treatment planning systems based on a common set of dynamic tests. Radiother Oncol 2023; 186:109775. [PMID: 37385376 DOI: 10.1016/j.radonc.2023.109775] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 06/19/2023] [Accepted: 06/23/2023] [Indexed: 07/01/2023]
Abstract
PURPOSE To demonstrate the feasibility of characterising MLCs and MLC models implemented in TPSs using a common set of dynamic beams. MATERIALS AND METHODS A set of tests containing synchronous (SG) and asynchronous sweeping gaps (aSG) was distributed among twenty-five participating centres. Doses were measured with a Farmer-type ion chamber and computed in TPSs, which provided a dosimetric characterisation of the leaf tip, tongue-and-groove, and MLC transmission of each MLC, as well as an assessment of the MLC model in each TPS. Five MLC types and four TPSs were evaluated, covering the most frequent combinations used in radiotherapy departments. RESULTS Measured differences within each MLC type were minimal, while large differences were found between MLC models implemented in clinical TPSs. This resulted in some concerning discrepancies, especially for the HD120 and Agility MLCs, for which differences between measured and calculated doses for some MLC-TPS combinations exceeded 10%. These large differences were particularly evident for small gap sizes (5 and 10 mm), as well as for larger gaps in the presence of tongue-and-groove effects. A much better agreement was found for the Millennium120 and Halcyon MLCs, differences being within ± 5% and ± 2.5%, respectively. CONCLUSIONS The feasibility of using a common set of tests to assess MLC models in TPSs was demonstrated. Measurements within MLC types were very similar, but TPS dose calculations showed large variations. Standardisation of the MLC configuration in TPSs is necessary. The proposed procedure can be readily applied in radiotherapy departments and can be a valuable tool in IMRT and credentialing audits.
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Affiliation(s)
- Jordi Saez
- Hospital Clínic de Barcelona, Department of Radiation Oncology, Barcelona, Spain.
| | - Raquel Bar-Deroma
- Rambam Health Care Campus, Department of Radiotherapy, Division of Oncology, Haifa, Israel
| | - Evelien Bogaert
- Ghent University Hospital and Ghent University, Department of Radiation Oncology, Ghent, Belgium
| | - Romain Cayez
- Oscar Lambret Center, Department of Medical Physics, Lille, France
| | - Tom Chow
- Juravinski Hospital and Cancer Centre at Hamilton Health Sciences, Department of Medical Physics, Ontario, Canada
| | - Catharine H Clark
- National Physical Laboratory, Metrology for Medical Physics Centre, London TW11 0PX, UK; Radiotherapy Physics, University College London Hospital, 250 Euston Rd, London NW1 2PG, UK; Dept Medical Physics and Bioengineering, University College London, Malet Place, London WC1 6BT, UK
| | - Marco Esposito
- AUSL Toscana Centro, Medical Physics Unit, Florence, Italy; The Abdus Salam International Center for Theoretical, Trieste, Italy
| | | | - Angelo F Monti
- ASST GOM Niguarda, Department of Medical Physics, Milano, Italy
| | - Julia Garcia-Miguel
- Consorci Sanitari de Terrassa, Department of Radiation Oncology, Terrassa, Spain
| | - Eduard Gershkevitsh
- North Estonia Medical Centre, Department of Medical Physics, Tallinn, Estonia
| | - Jo Goossens
- Iridium Netwerk, Department of Medical Physics, Antwerp, Belgium
| | - Carmen Herrero
- Centro Médico de Asturias-IMOMA, Department of Medical Physics, Oviedo, Spain
| | - Mohammad Hussein
- National Physical Laboratory, Metrology for Medical Physics Centre, London TW11 0PX, UK
| | - Catherine Khamphan
- Institut du Cancer - Avignon Provence, Department of Medical Physics, Avignon, France
| | - Roel G J Kierkels
- Radiotherapiegroep, Department of Medical Physics, Arnhem/Deventer, the Netherlands
| | - Wolfgang Lechner
- Medical University of Vienna, Department of Radiation Oncology, Vienna, Austria
| | - Matthieu Lemire
- CIUSSS de l'Est-de-l'Île-de-Montréal, Service de Radio-Physique, Montréal, Canada
| | - Alexander Nevelsky
- Rambam Health Care Campus, Department of Radiotherapy, Division of Oncology, Haifa, Israel
| | | | - Lucia Paganini
- Humanitas Clinical and Research Center, Radiotherapy and Radiosurgery Department, Rozzano, Italy
| | - Marlies Pasler
- Lake Constance Radiation Oncology Center, Department of Radiation Oncology, Singen, Friedrichshafen, Germany; Radiotherapy Hirslanden, St. Gallen, Switzerland
| | - José Fernando Pérez Azorín
- Medical Physics and Radiation Protection Department, Gurutzeta-Cruces University Hospital, Barakaldo, Spain; Biocruces Health Research Institute, Barakaldo, Spain
| | | | | | - John Shakeshaft
- Gold Coast University Hospital, ICON Cancer Centre, Gold Coast, Australia
| | - Laure Vieillevigne
- Institut Claudius Regaud-Institut Universitaire du Cancer de Toulouse, Department of Medical Physics, Toulouse, France
| | - Victor Hernandez
- Hospital Sant Joan de Reus, Department of Medical Physics, Reus, Spain; Universitat Rovira i Virgili, Tarragona, Spain
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Han C, Zhang J, Yu B, Zheng H, Wu Y, Lin Z, Ning B, Yi J, Xie C, Jin X. Integrating plan complexity and dosiomics features with deep learning in patient-specific quality assurance for volumetric modulated arc therapy. Radiat Oncol 2023; 18:116. [PMID: 37434171 DOI: 10.1186/s13014-023-02311-7] [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: 01/26/2023] [Accepted: 06/30/2023] [Indexed: 07/13/2023] Open
Abstract
PURPOSE To investigate the feasibility and performance of deep learning (DL) models combined with plan complexity (PC) and dosiomics features in the patient-specific quality assurance (PSQA) for patients underwent volumetric modulated arc therapy (VMAT). METHODS Total of 201 VMAT plans with measured PSQA results were retrospectively enrolled and divided into training and testing sets randomly at 7:3. PC metrics were calculated using house-built algorithm based on Matlab. Dosiomics features were extracted and selected using Random Forest (RF) from planning target volume (PTV) and overlap regions with 3D dose distributions. The top 50 dosiomics and 5 PC features were selected based on feature importance screening. A DL DenseNet was adapted and trained for the PSQA prediction. RESULTS The measured average gamma passing rate (GPR) of these VMAT plans was 97.94% ± 1.87%, 94.33% ± 3.22%, and 87.27% ± 4.81% at the criteria of 3%/3 mm, 3%/2 mm, and 2%/2 mm, respectively. Models with PC features alone demonstrated the lowest area under curve (AUC). The AUC and sensitivity of PC and dosiomics (D) combined model at 2%/2 mm were 0.915 and 0.833, respectively. The AUCs of DL models were improved from 0.943, 0.849, 0.841 to 0.948, 0.890, 0.942 in the combined models (PC + D + DL) at 3%/3 mm, 3%/2 mm and 2%/2 mm, respectively. A best AUC of 0.942 with a sensitivity, specificity and accuracy of 100%, 81.8%, and 83.6% was achieved with combined model (PC + D + DL) at 2%/2 mm. CONCLUSIONS Integrating DL with dosiomics and PC metrics is promising in the prediction of GPRs in PSQA for patients underwent VMAT.
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Affiliation(s)
- Ce Han
- Department of Radiotherapy Center, 1st Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ji Zhang
- Department of Radiotherapy Center, 1st Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Bing Yu
- Department of Radiotherapy Center, 1st Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Haoze Zheng
- Department of Radiotherapy Center, 1st Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yibo Wu
- Department of Radiotherapy Center, 1st Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zhixi Lin
- Department of Radiotherapy Center, 1st Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Boda Ning
- Department of Radiotherapy Center, 1st Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jinling Yi
- Department of Radiotherapy Center, 1st Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Congying Xie
- Department of Radiotherapy Center, 1st Affiliated Hospital of Wenzhou Medical University, Wenzhou, China.
- Department of Medical and Radiation Oncology, 2nd Affiliated Hospital of Wenzhou Medical University, Wenzhou, China.
| | - Xiance Jin
- Department of Radiotherapy Center, 1st Affiliated Hospital of Wenzhou Medical University, Wenzhou, China.
- School of Basic Medical Science, Wenzhou Medical University, Wenzhou, China.
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Lin LL, Ndlovu N, Lowenstein J, Wirth M, Lee J, Stier EA, Garg M, Kotzen J, Kadzatsa W, Palefsky J, Krown SE, Einstein MH. Quality Assurance in Clinical Trials Requiring Radiation Therapy in Sub-Saharan Africa. Int J Radiat Oncol Biol Phys 2023; 116:439-447. [PMID: 36493958 PMCID: PMC10360026 DOI: 10.1016/j.ijrobp.2022.11.042] [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: 08/21/2022] [Revised: 11/09/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE Given the increasing availability of radiation therapy in sub-Saharan Africa, clinical trials that include radiation therapy are likely to grow. Ensuring appropriate delivery of radiation therapy through rigorous quality assurance is an important component of clinical trial execution. We reviewed the process for credentialing radiation therapy sites and radiation therapy quality assurance through the Imaging and Radiation Oncology Core (IROC) Houston Quality Assurance Center for AIDS Malignancy Consortium (AMC)-081, a multicenter study of cisplatin and radiation therapy for women with locally advanced cervical cancer living with HIV, conducted by the AIDS Malignancy Consortium at 2 sites in South Africa and Zimbabwe. METHODS AND MATERIALS Women living with HIV with newly diagnosed stage IB2, IIA (>4 cm), IIB-IVA cervical carcinoma (per the 2009 International Federation of Gynecology and Obstetrics [FIGO] staging classifications) were enrolled in AMC-081. They received 3-dimensional conformal external beam radiation therapy (EBRT) to the pelvis (41.4-45 Gy) using a linear accelerator, high-dose-rate brachytherapy (6-9 Gy to point A with each fraction and up to 4 fractions), and concurrent weekly cisplatin (40 mg/m2). IROC reviewed EBRT and brachytherapy quality assurance records after treatment. RESULTS All of the 38 women enrolled in AMC-081 received ±5% of the protocol-specified prescribed dose of EBRT. Geometry of brachytherapy applicator placement was scored as per protocol in all implants. Doses to points A and B, International Commission on Radiation Units and Measurements (ICRU) bladder, or ICRU rectum required correction by IROC in >50% of the implants. In the final evaluation, 58% of participants (n = 22) were treated per protocol, 40% (n = 15) had minor protocol deviations, and 3% (n = 1) had major protocol deviations. No records were received within 60 days of treatment completion as requested in the protocol. CONCLUSIONS Major radiation therapy deviations were low, but timely submission of radiation therapy data did not occur. Future studies, especially those that include specialized radiation therapy techniques such as stereotactic or intensity-modulated radiation therapy, will require pathways to ensure timely and adequate quality assurance.
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Affiliation(s)
- Lilie L Lin
- Department of Radiation Oncology, University of Texas, MD Anderson Cancer Center, Houston, Texas.
| | - Ntokozo Ndlovu
- College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Jessica Lowenstein
- Department of Radiation Physics and the Imaging and Radiation Oncology Core, University of Texas, MD Anderson Cancer Center, Houston, Texas
| | | | - Jeannette Lee
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Elizabeth A Stier
- Department of Obstetrics and Gynecology, Boston University School of Medicine, Boston, Massachusetts
| | - Madhur Garg
- Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Yeshiva University, New York, New York
| | - Jeffrey Kotzen
- Department of Radiation Oncology, University of the Witwatersrand, Johannesburg, South Africa
| | - Webster Kadzatsa
- Department of Radiotherapy and Oncology, College of Health Science, University of Zimbabwe, Harare, Zimbabwe
| | - Joel Palefsky
- Department of Medicine, University of California, San Francisco, California
| | - Susan E Krown
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Mark H Einstein
- Department of Obstetrics, Gynecology, and Women's Health, Rutgers New Jersey Medical School, Newark, New Jersey
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Smith K, Ulin K, Knopp M, Kry S, Xiao Y, Rosen M, Michalski J, Iandoli M, Laurie F, Quigley J, Reifler H, Santiago J, Briggs K, Kirby S, Schmitter K, Prior F, Saltz J, Sharma A, Bishop-Jodoin M, Moni J, Cicchetti MG, FitzGerald TJ. Quality improvements in radiation oncology clinical trials. Front Oncol 2023; 13:1015596. [PMID: 36776318 PMCID: PMC9911211 DOI: 10.3389/fonc.2023.1015596] [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: 08/09/2022] [Accepted: 01/06/2023] [Indexed: 01/27/2023] Open
Abstract
Clinical trials have become the primary mechanism to validate process improvements in oncology clinical practice. Over the past two decades there have been considerable process improvements in the practice of radiation oncology within the structure of a modern department using advanced technology for patient care. Treatment planning is accomplished with volume definition including fusion of multiple series of diagnostic images into volumetric planning studies to optimize the definition of tumor and define the relationship of tumor to normal tissue. Daily treatment is validated by multiple tools of image guidance. Computer planning has been optimized and supported by the increasing use of artificial intelligence in treatment planning. Informatics technology has improved, and departments have become geographically transparent integrated through informatics bridges creating an economy of scale for the planning and execution of advanced technology radiation therapy. This serves to provide consistency in department habits and improve quality of patient care. Improvements in normal tissue sparing have further improved tolerance of treatment and allowed radiation oncologists to increase both daily and total dose to target. Radiation oncologists need to define a priori dose volume constraints to normal tissue as well as define how image guidance will be applied to each radiation treatment. These process improvements have enhanced the utility of radiation therapy in patient care and have made radiation therapy an attractive option for care in multiple primary disease settings. In this chapter we review how these changes have been applied to clinical practice and incorporated into clinical trials. We will discuss how the changes in clinical practice have improved the quality of clinical trials in radiation therapy. We will also identify what gaps remain and need to be addressed to offer further improvements in radiation oncology clinical trials and patient care.
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Affiliation(s)
- Koren Smith
- Imaging and Radiation Oncology Core-Rhode Island, Department of Radiation Oncology, UMass Chan Medical School, Lincoln, RI, United States
| | - Kenneth Ulin
- Imaging and Radiation Oncology Core-Rhode Island, Department of Radiation Oncology, UMass Chan Medical School, Lincoln, RI, United States
| | - Michael Knopp
- Imaging and Radiation Oncology Core-Ohio, Department of Radiology, The Ohio State University, Columbus, OH, United States
| | - Stephan Kry
- Imaging and Radiation Oncology Core-Houston, Division of Radiation Oncology, University of Texas, MD Anderson, Houston, TX, United States
| | - Ying Xiao
- Imaging and Radiation Oncology Core Philadelphia, Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, United States
| | - Mark Rosen
- Imaging and Radiation Oncology Core Philadelphia, Department of Radiology, University of Pennsylvania, Philadelphia, PA, United States
| | - Jeff Michalski
- Department of Radiation Oncology, Washington University, St Louis, MO, United States
| | - Matthew Iandoli
- Imaging and Radiation Oncology Core-Rhode Island, Department of Radiation Oncology, UMass Chan Medical School, Lincoln, RI, United States
| | - Fran Laurie
- Imaging and Radiation Oncology Core-Rhode Island, Department of Radiation Oncology, UMass Chan Medical School, Lincoln, RI, United States
| | - Jean Quigley
- Imaging and Radiation Oncology Core-Rhode Island, Department of Radiation Oncology, UMass Chan Medical School, Lincoln, RI, United States
| | - Heather Reifler
- Imaging and Radiation Oncology Core-Rhode Island, Department of Radiation Oncology, UMass Chan Medical School, Lincoln, RI, United States
| | - Juan Santiago
- Imaging and Radiation Oncology Core-Rhode Island, Department of Radiation Oncology, UMass Chan Medical School, Lincoln, RI, United States
| | - Kathleen Briggs
- Imaging and Radiation Oncology Core-Rhode Island, Department of Radiation Oncology, UMass Chan Medical School, Lincoln, RI, United States
| | - Shawn Kirby
- Imaging and Radiation Oncology Core-Rhode Island, Department of Radiation Oncology, UMass Chan Medical School, Lincoln, RI, United States
| | - Kate Schmitter
- Imaging and Radiation Oncology Core-Rhode Island, Department of Radiation Oncology, UMass Chan Medical School, Lincoln, RI, United States
| | - Fred Prior
- Department of Biomedical Informatics, University of Arkansas, Little Rock, AR, United States
| | - Joel Saltz
- Department of Biomedical Informatics, Stony Brook University, Stony Brook, NY, United States
| | - Ashish Sharma
- Department of Biomedical Informatics, Emory University, Atlanta, GA, United States
| | - Maryann Bishop-Jodoin
- Imaging and Radiation Oncology Core-Rhode Island, Department of Radiation Oncology, UMass Chan Medical School, Lincoln, RI, United States
| | - Janaki Moni
- Imaging and Radiation Oncology Core-Rhode Island, Department of Radiation Oncology, UMass Chan Medical School, Lincoln, RI, United States
| | - M. Giulia Cicchetti
- Imaging and Radiation Oncology Core-Rhode Island, Department of Radiation Oncology, UMass Chan Medical School, Lincoln, RI, United States
| | - Thomas J. FitzGerald
- Imaging and Radiation Oncology Core-Rhode Island, Department of Radiation Oncology, UMass Chan Medical School, Lincoln, RI, United States
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9
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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: 5] [Impact Index Per Article: 5.0] [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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10
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Geurts MW, Jacqmin DJ, Jones LE, Kry SF, Mihailidis DN, Ohrt JD, Ritter T, Smilowitz JB, Wingreen NE. AAPM MEDICAL PHYSICS PRACTICE GUIDELINE 5.b: Commissioning and QA of treatment planning dose calculations-Megavoltage photon and electron beams. J Appl Clin Med Phys 2022; 23:e13641. [PMID: 35950259 PMCID: PMC9512346 DOI: 10.1002/acm2.13641] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 04/04/2022] [Accepted: 04/06/2022] [Indexed: 11/23/2022] 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 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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11
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Schmidt MC, Raman CA, Wu Y, Yaqoub MM, Hao Y, Mahon RN, Riblett MJ, Knutson NC, Sajo E, Zygmanski P, Jandel M, Reynoso FJ, Sun B. Application programming interface guided QA plan generation and analysis automation. J Appl Clin Med Phys 2021; 22:26-34. [PMID: 34036736 PMCID: PMC8200500 DOI: 10.1002/acm2.13288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/15/2021] [Accepted: 04/23/2021] [Indexed: 11/11/2022] Open
Abstract
Purpose Linear accelerator quality assurance (QA) in radiation therapy is a time consuming but fundamental part of ensuring the performance characteristics of radiation delivering machines. The goal of this work is to develop an automated and standardized QA plan generation and analysis system in the Oncology Information System (OIS) to streamline the QA process. Methods Automating the QA process includes two software components: the AutoQA Builder to generate daily, monthly, quarterly, and miscellaneous periodic linear accelerator QA plans within the Treatment Planning System (TPS) and the AutoQA Analysis to analyze images collected on the Electronic Portal Imaging Device (EPID) allowing for a rapid analysis of the acquired QA images. To verify the results of the automated QA analysis, results were compared to the current standard for QA assessment for the jaw junction, light‐radiation coincidence, picket fence, and volumetric modulated arc therapy (VMAT) QA plans across three linacs and over a 6‐month period. Results The AutoQA Builder application has been utilized clinically 322 times to create QA patients, construct phantom images, and deploy common periodic QA tests across multiple institutions, linear accelerators, and physicists. Comparing the AutoQA Analysis results with our current institutional QA standard the mean difference of the ratio of intensity values within the field‐matched junction and ball‐bearing position detection was 0.012 ± 0.053 (P = 0.159) and is 0.011 ± 0.224 mm (P = 0.355), respectively. Analysis of VMAT QA plans resulted in a maximum percentage difference of 0.3%. Conclusion The automated creation and analysis of quality assurance plans using multiple APIs can be of immediate benefit to linear accelerator quality assurance efficiency and standardization. QA plan creation can be done without following tedious procedures through API assistance, and analysis can be performed inside of the clinical OIS in an automated fashion.
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Affiliation(s)
- Matthew C Schmidt
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA.,Department of Physics, University of Massachusetts Lowell, Lowell, MA, USA
| | - Caleb A Raman
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Yu Wu
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Mahmoud M Yaqoub
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Yao Hao
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Rebecca Nichole Mahon
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Matthew J Riblett
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Nels C Knutson
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Erno Sajo
- Department of Physics, University of Massachusetts Lowell, Lowell, MA, USA
| | - Piotr Zygmanski
- Brigham and Women's/ Dana Farber Cancer Institute/ Harvard Medical School, Boston, MA, USA
| | - Marian Jandel
- Department of Physics, University of Massachusetts Lowell, Lowell, MA, USA
| | - Francisco J Reynoso
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Baozhou Sun
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
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12
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Choi MG, Law M, Yoon DK, Tamura M, Matsumoto K, Otsuka M, Kim MS, Djeng SK, Monzen H, Suh TS. Simplified sigmoidal curve fitting for a 6 MV FFF photon beam of the Halcyon to determine the field size for beam commissioning and quality assurance. Radiat Oncol 2020; 15:273. [PMID: 33287828 PMCID: PMC7720380 DOI: 10.1186/s13014-020-01709-x] [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: 04/07/2020] [Accepted: 11/06/2020] [Indexed: 11/22/2022] Open
Abstract
Background An O-ring gantry-type linear accelerator (LINAC) with a 6-MV flattening filter-free (FFF) photon beam, Halcyon, includes a reference beam that contains representative information such as the percent depth dose, profile and output factor for commissioning and quality assurance. However, because it does not provide information about the field size, we proposed a method to determine all field sizes according to all depths for radiation therapy using simplified sigmoidal curve fitting (SCF). Methods After mathematical definition of the SCF using four coefficients, the defined curves were fitted to both the reference data (RD) and the measured data (MD). For good agreement between the fitting curve and the profiles in each data set, the field sizes were determined by identifying the maximum point along the third derivative of the fitting curve. The curve fitting included the field sizes for beam profiles of 2 × 2, 4 × 4, 6 × 6, 8 × 8, 10 × 10, 20 × 20 and 28 × 28 cm2 as a function of depth (at 1.3, 5, 10 and 20 cm). The field size results from the RD were compared with the results from the MD using the same condition. Results All fitting curves show goodness of fit, R2, values that are greater than 0.99. The differences in field size between the RD and the MD were within the range of 0 to 0.2 cm. The smallest difference in the field sizes at a depth of 10 cm, which is a surface-to-axis distance, was reported. Conclusion Application of the SCF method has been proven to accurately capture the field size of the preconfigured RD and the measured FFF photon beam data for the Halcyon system. The current work can be useful for beam commissioning as a countercheck methodology to determine the field size from RD in the treatment planning system of a newly installed Halcyon system and for routine quality assurance to ascertain the correctness of field sizes for clinical use of the Halcyon system.
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Affiliation(s)
- Min-Geon Choi
- Department of Biomedical Engineering and Research Institute of Biomedical Engineering, College of Medicine, The Catholic University of Korea, Seoul, 06591, Republic of Korea
| | - Martin Law
- Proton Therapy Pte Ltd., 1 Biopolis Drive, Singapore, 138622, Singapore
| | - Do-Kun Yoon
- Department of Biomedical Engineering and Research Institute of Biomedical Engineering, College of Medicine, The Catholic University of Korea, Seoul, 06591, Republic of Korea
| | - Mikoto Tamura
- Department of Medical Physics, Graduate School of Medical Sciences, Kindai University, Osaka-Sayama-Shi, 377-2, Ohno-Higashi, Osaka-Sayama-Shi, Osaka, 589-8511, Japan
| | - Kenji Matsumoto
- Department of Radiology, Kindai University Hospital, Osaka-Sayama-Shi, 377-2, Ono-Higashi, Osaka-Sayama-Shi, Osaka, 589-8511, Japan
| | - Masakazu Otsuka
- Department of Medical Physics, Graduate School of Medical Sciences, Kindai University, Osaka-Sayama-Shi, 377-2, Ohno-Higashi, Osaka-Sayama-Shi, Osaka, 589-8511, Japan
| | - Moo-Sub Kim
- Department of Biomedical Engineering and Research Institute of Biomedical Engineering, College of Medicine, The Catholic University of Korea, Seoul, 06591, Republic of Korea
| | - Shih-Kien Djeng
- Proton Therapy Pte Ltd., 1 Biopolis Drive, Singapore, 138622, Singapore
| | - Hajime Monzen
- Department of Medical Physics, Graduate School of Medical Sciences, Kindai University, Osaka-Sayama-Shi, 377-2, Ohno-Higashi, Osaka-Sayama-Shi, Osaka, 589-8511, Japan.
| | - Tae Suk Suh
- Department of Biomedical Engineering and Research Institute of Biomedical Engineering, College of Medicine, The Catholic University of Korea, Seoul, 06591, Republic of Korea.
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13
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Potter NJ, Mund K, Andreozzi JM, Li JG, Liu C, Yan G. Error detection and classification in patient-specific IMRT QA with dual neural networks. Med Phys 2020; 47:4711-4720. [PMID: 33460182 DOI: 10.1002/mp.14416] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 06/07/2020] [Accepted: 07/17/2020] [Indexed: 11/12/2022] Open
Abstract
PURPOSE Despite being the standard metric in patient-specific quality assurance (QA) for intensity-modulated radiotherapy (IMRT), gamma analysis has two shortcomings: (a) it lacks sensitivity to small but clinically relevant errors (b) it does not provide efficient means to classify the error sources. The purpose of this work is to propose a dual neural network method to achieve simultaneous error detection and classification in patient-specific IMRT QA. METHODS For a pair of dose distributions, we extracted the dose difference histogram (DDH) for the low dose gradient region and two signed distance-to-agreement (sDTA) maps (one in x direction and one in y direction) for the high dose gradient region. An artificial neural network (ANN) and a convolutional neural network (CNN) were designed to analyze the DDH and the two sDTA maps, respectively. The ANN was trained to detect and classify six classes of dosimetric errors: incorrect multileaf collimator (MLC) transmission (±1%) and four types of monitor unit (MU) scaling errors (±1% and ±2%). The CNN was trained to detect and classify seven classes of spatial errors: incorrect effective source size, 1 mm MLC leaf bank overtravel or undertravel, 2 mm single MLC leaf overtravel or undertravel, and device misalignment errors (1 mm in x- or y direction). An in-house planar dose calculation software was used to simulate measurements with errors and noise introduced. Both networks were trained and validated with 13 IMRT plans (totaling 88 fields). A fivefold cross-validation technique was used to evaluate their accuracy. RESULTS Distinct features were found in the DDH and the sDTA maps. The ANN perfectly identified all four types of MU scaling errors and the specific accuracies for the classes of no error, MLC transmission increase, MLC transmission decrease were 98.9%, 96.6%, and 94.3%, respectively. For the CNN, the largest confusion occurred between the 1-mm-MLC bank overtravel class and the 1-mm-device alignment error in x-direction class, which brought the specific accuracies down to 90.9% and 92.0%, respectively. The specific accuracy for the 2-mm-single MLC leaf undertravel class was 93.2% as it misclassified 5.7% of the class as being error free (false negative). Otherwise, the specific accuracy was above 95%. The overall accuracies across the fivefold were 98.3 ± 0.7% and 95.6% ± 1.5% for the ANN and the CNN, respectively. CONCLUSIONS Both the DDH and the sDTA maps are suitable features for error classification in IMRT QA. The proposed dual neural network method achieved simultaneous error detection and classification with excellent accuracy. It could be used in complement with the gamma analysis to potentially shift the IMRT QA paradigm from passive pass/fail analysis to active error detection and root cause identification.
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Affiliation(s)
- Nicholas J Potter
- Department of Radiation Oncology, University of Florida, Gainesville, FL, USA
| | - Karl Mund
- Department of Radiation Oncology, University of Florida, Gainesville, FL, USA
| | | | - Jonathan G Li
- Department of Radiation Oncology, University of Florida, Gainesville, FL, USA
| | - Chihray Liu
- Department of Radiation Oncology, University of Florida, Gainesville, FL, USA
| | - Guanghua Yan
- Department of Radiation Oncology, University of Florida, Gainesville, FL, USA
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14
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Edward SS, C Glenn M, Peterson CB, Balter PA, Pollard-Larkin JM, Howell RM, S Followill D, Kry SF. Dose calculation errors as a component of failing IROC lung and spine phantom irradiations. Med Phys 2020; 47:4502-4508. [PMID: 32452027 DOI: 10.1002/mp.14258] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 04/19/2020] [Accepted: 05/11/2020] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Between July 2013 and August 2019, 22% of the imaging and radiation oncology core (IROC) spine, and 15% of the moving lung phantom irradiations have failed to meet established acceptability criteria. The spine phantom simulates a highly modulated stereotactic body radiation therapy (SBRT) case, whereas the lung phantom represents a low-to-none modulation moving target case. In this study, we assessed the contribution of dose calculation errors to these phantom results and evaluated their effects on failure rates. METHODS We evaluated dose calculation errors by comparing the calculation accuracy of various institutions' treatment planning systems (TPSs) vs IROC-Houston's previously established independent dose recalculation system (DRS). Each calculation was compared with the measured dose actually delivered to the phantom; cases in which the recalculation was more accurate were interpreted as a deficiency in the institution's TPS. A total of 258 phantom irradiation plans (172 lung and 86 spine) were recomputed. RESULTS Overall, the DRS performed better than the TPSs in 47% of the spine phantom cases. However, the DRS was more accurate in 93% of failing spine phantom cases (with an average improvement of 2.35%), indicating a deficiency in the institution's treatment planning system. Deficiencies in dose calculation accounted for 60% of the overall discrepancy between measured and planned doses among spine phantoms. In contrast, lung phantom DRS calculations were more accurate in only 35% and 42% of all and failing lung phantom cases respectively, indicating that dose calculation errors were not substantially present. These errors accounted for only 30% of the overall discrepancy between measured and planned doses. CONCLUSIONS Dose calculation errors are common and substantial in IROC spine phantom irradiations, highlighting a major failure mode in this phantom and in clinical treatment management of these cases. In contrast, dose calculation accuracy had only a minimal contribution to failing lung phantom results, indicating that other failure modes drive problems with this phantom and similar clinical treatments.
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Affiliation(s)
- Sharbacha S Edward
- The University of Texas MD Anderson Cancer Center UT Health Graduate School of Biomedical Sciences, Houston, TX, 77030, USA.,IROC Houston Quality Assurance Center, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA.,Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Mallory C Glenn
- The University of Texas MD Anderson Cancer Center UT Health Graduate School of Biomedical Sciences, Houston, TX, 77030, USA.,IROC Houston Quality Assurance Center, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA.,Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Christine B Peterson
- The University of Texas MD Anderson Cancer Center UT Health Graduate School of Biomedical Sciences, Houston, TX, 77030, USA.,Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Peter A Balter
- The University of Texas MD Anderson Cancer Center UT Health Graduate School of Biomedical Sciences, Houston, TX, 77030, USA.,Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Julianne M Pollard-Larkin
- The University of Texas MD Anderson Cancer Center UT Health Graduate School of Biomedical Sciences, Houston, TX, 77030, USA.,Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Rebecca M Howell
- The University of Texas MD Anderson Cancer Center UT Health Graduate School of Biomedical Sciences, Houston, TX, 77030, USA.,Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - David S Followill
- The University of Texas MD Anderson Cancer Center UT Health Graduate School of Biomedical Sciences, Houston, TX, 77030, USA.,IROC Houston Quality Assurance Center, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA.,Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Stephen F Kry
- The University of Texas MD Anderson Cancer Center UT Health Graduate School of Biomedical Sciences, Houston, TX, 77030, USA.,IROC Houston Quality Assurance Center, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA.,Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
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15
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Lye J, Kry S, Shaw M, Gibbons F, Keehan S, Lehmann J, Kron T, Followill D, Williams I. A comparison of IROC and ACDS on-site audits of reference and non-reference dosimetry. Med Phys 2019; 46:5878-5887. [PMID: 31494941 PMCID: PMC6916618 DOI: 10.1002/mp.13800] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 07/19/2019] [Accepted: 08/05/2019] [Indexed: 11/18/2022] Open
Abstract
PURPOSE Consistency between different international quality assurance groups is important in the progress toward similar standards and expectations in radiotherapy dosimetry around the world, and in the context of consistent clinical trial data from international trial participants. This study compares the dosimetry audit methodology and results of two international quality assurance groups performing a side-by-side comparison at the same radiotherapy department, and interrogates the ability of the audits to detect deliberately introduced errors. METHODS A comparison of the core dosimetry components of reference and non-reference audits was conducted by the Imaging and Radiation Oncology Core (IROC, Houston, USA) and the Australian Clinical Dosimetry Service (ACDS, Melbourne, Australia). A set of measurements were conducted over 2 days at an Australian radiation therapy facility in Melbourne. Each group evaluated the reference dosimetry, output factors, small field output factors, percentage depth dose (PDD), wedge, and off-axis factors according to their standard protocols. IROC additionally investigated the Electron PDD and the ACDS investigated the effect of heterogeneities. In order to evaluate and compare the performance of these audits under suboptimal conditions, artificial errors in percentage depth dose (PDD), EDW, and small field output factors were introduced into the 6 MV beam model to simulate potential commissioning/modeling errors and both audits were tested for their sensitivity in detecting these errors. RESULTS With the plans from the clinical beam model, almost all results were within tolerance and at an optimal pass level. Good consistency was found between the two audits as almost all findings were consistent between them. Only two results were different between the results of IROC and the ACDS. The measurements of reference FFF photons showed a discrepancy of 0.7% between ACDS and IROC due to the inclusion of a 0.5% nonuniformity correction by the ACDS. The second difference between IROC and the ACDS was seen with the lung phantom. The asymmetric field behind lung measured by the ACDS was slightly (0.3%) above the ACDS's pass (optimal) level of 3.3%. IROC did not detect this issue because their measurements were all assessed in a homogeneous phantom. When errors were deliberately introduced neither audit was sensitive enough to pick up a 2% change to the small field output factors. The introduced PDD change was flagged by both audits. Similarly, the introduced error of using 25° wedge instead of 30° wedge was detectible in both audits as out of tolerance. CONCLUSIONS Despite different equipment, approach, and scope of measurements in on-site audits, there were clear similarities between the results from the two groups. This finding is encouraging in the context of a global harmonized approach to radiotherapy quality assurance and dosimetry audit.
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Affiliation(s)
- Jessica Lye
- Australian Clinical Dosimetry ServiceARPANSAMelbourneAustralia
| | - Stephen Kry
- Imaging and Radiation Oncology Core Houston QA CenterMD Anderson Cancer CenterHoustonTXUSA
| | - Maddison Shaw
- Australian Clinical Dosimetry ServiceARPANSAMelbourneAustralia
| | - Francis Gibbons
- Australian Clinical Dosimetry ServiceARPANSAMelbourneAustralia
- Sunshine Coast Hospital and Health ServiceBirtinyaQldAustralia
| | | | - Joerg Lehmann
- Australian Clinical Dosimetry ServiceARPANSAMelbourneAustralia
- Department of Radiation OncologyCalvary Mater NewcastleNewcastleAustralia
| | - Tomas Kron
- Peter MacCallum Cancer CentreMelbourneAustralia
| | - David Followill
- Imaging and Radiation Oncology Core Houston QA CenterMD Anderson Cancer CenterHoustonTXUSA
| | - Ivan Williams
- Australian Clinical Dosimetry ServiceARPANSAMelbourneAustralia
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16
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Irmen P, Reft C, Fitzherbert C, Solin L, Hand C. Verification of representative data for output factors of SRS cones utilizing IAEA TRS 483 recommendations. ACTA ACUST UNITED AC 2019; 64:215011. [DOI: 10.1088/1361-6560/ab47dd] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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17
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Nyflot MJ, Thammasorn P, Wootton LS, Ford EC, Chaovalitwongse WA. Deep learning for patient-specific quality assurance: Identifying errors in radiotherapy delivery by radiomic analysis of gamma images with convolutional neural networks. Med Phys 2018; 46:456-464. [PMID: 30548601 DOI: 10.1002/mp.13338] [Citation(s) in RCA: 94] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 12/04/2018] [Accepted: 12/05/2018] [Indexed: 12/18/2022] Open
Abstract
PURPOSE Patient-specific quality assurance (QA) for intensity-modulated radiation therapy (IMRT) is a ubiquitous clinical procedure, but conventional methods have often been criticized as being insensitive to errors or less effective than other common physics checks. Recently, there has been interest in the application of radiomics, quantitative extraction of image features, to radiotherapy QA. In this work, we investigate a deep learning approach to classify the presence or absence of introduced radiotherapy treatment delivery errors from patient-specific QA. METHODS Planar dose maps from 186 IMRT beams from 23 IMRT plans were evaluated. Each plan was transferred to a cylindrical phantom CT geometry. Three sets of planar doses were exported from each plan corresponding to (a) the error-free case, (b) a random multileaf collimator (MLC) error case, and (c) a systematic MLC error case. Each plan was delivered to the electronic portal imaging device (EPID), and planned and measured doses were used to calculate gamma images in an EPID dosimetry software package (for a total of 558 gamma images). Two radiomic approaches were used. In the first, a convolutional neural network with triplet learning was used to extract image features from the gamma images. In the second, a handcrafted approach using texture features was used. The resulting metrics from both approaches were input into four machine learning classifiers (support vector machines, multilayer perceptrons, decision trees, and k-nearest-neighbors) in order to determine whether images contained the introduced errors. Two experiments were considered: the two-class experiment classified images as error-free or containing any MLC error, and the three-class experiment classified images as error-free, containing a random MLC error, or containing a systematic MLC error. Additionally, threshold-based passing criteria were calculated for comparison. RESULTS In total, 303 gamma images were used for model training and 255 images were used for model testing. The highest classification accuracy was achieved with the deep learning approach, with a maximum accuracy of 77.3% in the two-class experiment and 64.3% in the three-class experiment. The performance of the handcrafted approach with texture features was lower, with a maximum accuracy of 66.3% in the two-class experiment and 53.7% in the three-class experiment. Variability between the results of the four machine learning classifiers was lower for the deep learning approach vs the texture feature approach. Both radiomic approaches were superior to threshold-based passing criteria. CONCLUSIONS Deep learning with convolutional neural networks can be used to classify the presence or absence of introduced radiotherapy treatment delivery errors from patient-specific gamma images. The performance of the deep learning network was superior to a handcrafted approach with texture features, and both radiomic approaches were better than threshold-based passing criteria. The results suggest that radiomic QA is a promising direction for clinical radiotherapy.
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Affiliation(s)
- Matthew J Nyflot
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA.,Department of Radiology, University of Washington, Seattle, WA, USA
| | - Phawis Thammasorn
- Department of Industrial Engineering, University of Arkansas, Fayetteville, AR, USA
| | - Landon S Wootton
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Eric C Ford
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - W Art Chaovalitwongse
- Department of Radiology, University of Washington, Seattle, WA, USA.,Department of Industrial Engineering, University of Arkansas, Fayetteville, AR, USA
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18
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Kry SF, Peterson CB, Howell RM, Izewska J, Lye J, Clark CH, Nakamura M, Hurkmans C, Alvarez P, Alves A, Bokulic T, Followill D, Kazantsev P, Lowenstein J, Molineu A, Palmer J, Smith SA, Taylor P, Wesolowska P, Williams I. Remote beam output audits: a global assessment of results out of tolerance. PHYSICS & IMAGING IN RADIATION ONCOLOGY 2018; 7:39-44. [PMID: 31872085 PMCID: PMC6927685 DOI: 10.1016/j.phro.2018.08.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Background and purpose Remote beam output audits, which independently measure an institution’s machine calibration, are a common component of independent radiotherapy peer review. This work reviews the results and trends of these audit results across several organisations and geographical regions. Materials and methods Beam output audit results from the Australian Clinical Dosimetry Services, International Atomic Energy Agency, Imaging and Radiation Oncology Core, and Radiation Dosimetry Services were evaluated from 2010 to the present. The rate of audit results outside a ±5% tolerance was evaluated for photon and electron beams as a function of the year of irradiation and nominal beam energy. Additionally, examples of confirmed calibration errors were examined to provide guidance to clinical physicists and auditing bodies. Results Of the 210,167 audit results, 1323 (0.63%) were outside of tolerance. There was a clear trend of improved audit performance for more recent dates, and while all photon energies generally showed uniform rates of results out of tolerance, low (6 MeV) and high (≥18 MeV) energy electron beams showed significantly elevated rates. Twenty nine confirmed calibration errors were explored and attributed to a range of issues, such as equipment failures, errors in setup, and errors in performing the clinical reference calibration. Forty-two percent of these confirmed errors were detected during ongoing periodic monitoring, and not at the time of the first audit of the machine. Conclusions Remote beam output audits have identified, and continue to identify, numerous and often substantial beam calibration errors.
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Affiliation(s)
- Stephen F Kry
- Imaging and Radiation Oncology Core, MD Anderson Cancer Center, Houston USA.,Department of Radiation Physics, MD Anderson Cancer Center, Houston USA
| | | | - Rebecca M Howell
- Department of Radiation Physics, MD Anderson Cancer Center, Houston USA.,Radiation Dosimetry Services, MD Anderson Cancer Center, Houston USA
| | - Joanna Izewska
- Dosimetry Laboratory, Dosimetry and Medical Radiation Physics Section, Division of Human Health, International Atomic Energy Agency, Vienna Austria
| | - Jessica Lye
- Australian Clinical Dosimetry Service, ARPANSA, Melbourne, Australia
| | - Catharine H Clark
- RadioTherapy Trials Quality Assurance Group, Mount Vernon Cancer Centre, London UK.,Metrology for Medical Physics, National Physical Laboratory, Teddington UK.,Department of Medical Physics, Royal Surrey County Hospital, Surrey UK
| | - Mitsuhiro Nakamura
- JCOG Division of Medical Physics, Department of Information Technology and Medical Engineering, Human Health Sciences, Graduate School of Medicine, Kyoto University
| | - Coen Hurkmans
- EORTC Radiation Oncology Group, Brussels, Belgium.,Department of radiation Oncology, Catharina Hospital Eindhoven, The Netherlands
| | - Paola Alvarez
- Imaging and Radiation Oncology Core, MD Anderson Cancer Center, Houston USA.,Department of Radiation Physics, MD Anderson Cancer Center, Houston USA
| | - Andrew Alves
- Australian Clinical Dosimetry Service, ARPANSA, Melbourne, Australia
| | - Tomislav Bokulic
- Dosimetry Laboratory, Dosimetry and Medical Radiation Physics Section, Division of Human Health, International Atomic Energy Agency, Vienna Austria
| | - David Followill
- Imaging and Radiation Oncology Core, MD Anderson Cancer Center, Houston USA.,Department of Radiation Physics, MD Anderson Cancer Center, Houston USA
| | - Pavel Kazantsev
- Dosimetry Laboratory, Dosimetry and Medical Radiation Physics Section, Division of Human Health, International Atomic Energy Agency, Vienna Austria
| | - Jessica Lowenstein
- Imaging and Radiation Oncology Core, MD Anderson Cancer Center, Houston USA.,Department of Radiation Physics, MD Anderson Cancer Center, Houston USA
| | - Andrea Molineu
- Imaging and Radiation Oncology Core, MD Anderson Cancer Center, Houston USA.,Department of Radiation Physics, MD Anderson Cancer Center, Houston USA
| | - Jacob Palmer
- Department of Radiation Physics, MD Anderson Cancer Center, Houston USA.,Radiation Dosimetry Services, MD Anderson Cancer Center, Houston USA
| | - Susan A Smith
- Department of Radiation Physics, MD Anderson Cancer Center, Houston USA.,Radiation Dosimetry Services, MD Anderson Cancer Center, Houston USA
| | - Paige Taylor
- Imaging and Radiation Oncology Core, MD Anderson Cancer Center, Houston USA.,Department of Radiation Physics, MD Anderson Cancer Center, Houston USA
| | - Paulina Wesolowska
- Dosimetry Laboratory, Dosimetry and Medical Radiation Physics Section, Division of Human Health, International Atomic Energy Agency, Vienna Austria
| | - Ivan Williams
- Australian Clinical Dosimetry Service, ARPANSA, Melbourne, Australia
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19
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Wootton LS, Nyflot MJ, Chaovalitwongse WA, Ford E. Error Detection in Intensity-Modulated Radiation Therapy Quality Assurance Using Radiomic Analysis of Gamma Distributions. Int J Radiat Oncol Biol Phys 2018; 102:219-228. [PMID: 30102197 DOI: 10.1016/j.ijrobp.2018.05.033] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 04/10/2018] [Accepted: 05/13/2018] [Indexed: 10/16/2022]
Abstract
PURPOSE To improve the detection of errors in intensity-modulated radiation therapy (IMRT) with a novel method that uses quantitative image features from radiomics to analyze gamma distributions generated during patient specific quality assurance (QA). METHODS AND MATERIALS One hundred eighty-six IMRT beams from 23 patient treatments were delivered to a phantom and measured with electronic portal imaging device dosimetry. The treatments spanned a range of anatomic sites; half were head and neck treatments, and the other half were drawn from treatments for lung and rectal cancers, sarcoma, and glioblastoma. Planar gamma distributions, or gamma images, were calculated for each beam using the measured dose and calculated doses from the 3-dimensional treatment planning system under various scenarios: a plan without errors and plans with either simulated random or systematic multileaf collimator mispositioning errors. The gamma images were randomly divided into 2 sets: a training set for model development and testing set for validation. Radiomic features were calculated for each gamma image. Error detection models were developed by training logistic regression models on these radiomic features. The models were applied to the testing set to quantify their predictive utility, determined by calculating the area under the curve (AUC) of the receiver operator characteristic curve, and were compared with traditional threshold-based gamma analysis. RESULTS The AUC of the random multileaf collimator mispositioning model on the testing set was 0.761 compared with 0.512 for threshold-based gamma analysis. The AUC for the systematic mispositioning model was 0.717 versus 0.660 for threshold-based gamma analysis. Furthermore, the models could discriminate between the 2 types of errors simulated here, exhibiting AUCs of approximately 0.5 (equivalent to random guessing) when applied to the error they were not designed to detect. CONCLUSIONS The feasibility of error detection in patient-specific IMRT QA using radiomic analysis of QA images has been demonstrated. This methodology represents a substantial step forward for IMRT QA with improved sensitivity and specificity over current QA methods and the potential to distinguish between different types of errors.
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Affiliation(s)
- Landon S Wootton
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, Washington.
| | - Matthew J Nyflot
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, Washington; Department of Radiology, University of Washington School of Medicine, Seattle, Washington
| | - W Art Chaovalitwongse
- Department of Radiology, University of Washington School of Medicine, Seattle, Washington; Department of Industrial Engineering, University of Arkansas, Fayetteville, Arkansas
| | - Eric Ford
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, Washington
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Kerns JR, Followill DS, Lowenstein J, Molineu A, Alvarez P, Taylor PA, Kry SF. Reference dosimetry data and modeling challenges for Elekta accelerators based on IROC-Houston site visit data. Med Phys 2018; 45:2337-2344. [PMID: 29537634 PMCID: PMC6592280 DOI: 10.1002/mp.12865] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 01/05/2018] [Accepted: 02/02/2018] [Indexed: 11/10/2022] Open
Abstract
PURPOSE Reference dosimetry data can provide an independent second check of acquired values when commissioning or validating a treatment planning system (TPS). The Imaging and Radiation Oncology Core at Houston (IROC-Houston) has measured numerous linear accelerators throughout its existence. The results of those measurements are given here, comparing accelerators and the agreement of measurement versus institutional TPS calculations. METHODS Data from IROC-Houston on-site reviews from 2000 through 2014 were analyzed for all Elekta accelerators, approximately 50. For each, consistent point dose measurements were conducted for several basic parameters in a water phantom, including percentage depth dose, output factors, small-field output factors, off-axis factors, and wedge factors. The results were compared by accelerator type independently for 6, 10, 15, and 18 MV. Distributions of the measurements for each parameter are given, providing the mean and standard deviation. Each accelerator's measurements were also compared to its corresponding TPS calculation from the institution to determine the level of agreement, as well as determining which dosimetric parameters were most often in error. RESULTS Accelerators were grouped by head type and reference dosimetric values were compiled. No class of linac had better overall agreement with its TPS, but percentage depth dose and output factors commonly agreed well, while small-field output factors, off-axis factors, and wedge factors often disagreed substantially from their TPS calculations. CONCLUSION Reference data has been collected and analyzed for numerous Elekta linacs, which provide an independent way for a physicist to double-check their own measurements to prevent gross treatment errors. In addition, treatment planning parameters more often in error have been highlighted, providing practical caution for physicists commissioning treatment planning systems for Elekta linacs.
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Affiliation(s)
- James R. Kerns
- Department of Radiation PhysicsThe University of Texas MD Anderson Cancer CenterHoustonTX77030USA
- Imaging and Radiation Oncology Core‐HoustonThe University of Texas MD Anderson Cancer CenterHoustonTX77030USA
- Graduate School of Biomedical SciencesThe University of Texas Health Science Center‐HoustonHoustonTX77030USA
| | - David S. Followill
- Department of Radiation PhysicsThe University of Texas MD Anderson Cancer CenterHoustonTX77030USA
- Imaging and Radiation Oncology Core‐HoustonThe University of Texas MD Anderson Cancer CenterHoustonTX77030USA
- Graduate School of Biomedical SciencesThe University of Texas Health Science Center‐HoustonHoustonTX77030USA
| | - Jessica Lowenstein
- Department of Radiation PhysicsThe University of Texas MD Anderson Cancer CenterHoustonTX77030USA
- Imaging and Radiation Oncology Core‐HoustonThe University of Texas MD Anderson Cancer CenterHoustonTX77030USA
| | - Andrea Molineu
- Department of Radiation PhysicsThe University of Texas MD Anderson Cancer CenterHoustonTX77030USA
- Imaging and Radiation Oncology Core‐HoustonThe University of Texas MD Anderson Cancer CenterHoustonTX77030USA
| | - Paola Alvarez
- Department of Radiation PhysicsThe University of Texas MD Anderson Cancer CenterHoustonTX77030USA
- Imaging and Radiation Oncology Core‐HoustonThe University of Texas MD Anderson Cancer CenterHoustonTX77030USA
| | - Paige A. Taylor
- Department of Radiation PhysicsThe University of Texas MD Anderson Cancer CenterHoustonTX77030USA
- Imaging and Radiation Oncology Core‐HoustonThe University of Texas MD Anderson Cancer CenterHoustonTX77030USA
| | - Stephen F. Kry
- Department of Radiation PhysicsThe University of Texas MD Anderson Cancer CenterHoustonTX77030USA
- Imaging and Radiation Oncology Core‐HoustonThe University of Texas MD Anderson Cancer CenterHoustonTX77030USA
- Graduate School of Biomedical SciencesThe University of Texas Health Science Center‐HoustonHoustonTX77030USA
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Lehmann J, Alves A, Dunn L, Shaw M, Kenny J, Keehan S, Supple J, Gibbons F, Manktelow S, Oliver C, Kron T, Williams I, Lye J. Dosimetric end-to-end tests in a national audit of 3D conformal radiotherapy. Phys Imaging Radiat Oncol 2018; 6:5-11. [PMID: 33458381 PMCID: PMC7807562 DOI: 10.1016/j.phro.2018.03.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 03/14/2018] [Accepted: 03/14/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND PURPOSE Independent dosimetry audits improve quality and safety of radiation therapy. This work reports on design and findings of a comprehensive 3D conformal radiotherapy (3D-CRT) Level III audit. MATERIALS AND METHODS The audit was conducted as onsite audit using an anthropomorphic thorax phantom in an end-to-end test by the Australian Clinical Dosimetry Service (ACDS). Absolute dose point measurements were performed with Farmer-type ionization chambers. The audited treatment plans included open and half blocked fields, wedges and lung inhomogeneities. Audit results were determined as Pass Optimal Level (deviations within 3.3%), Pass Action Level (greater than 3.3% but within 5%) and Out of Tolerance (beyond 5%), as well as Reported Not Scored (RNS). The audit has been performed between July 2012 and January 2018 on 94 occasions, covering approximately 90% of all Australian facilities. RESULTS The audit pass rate was 87% (53% optimal). Fifty recommendations were given, mainly related to planning system commissioning. Dose overestimation behind low density inhomogeneities by the analytical anisotropic algorithm (AAA) was identified across facilities and found to extend to beam setups which resemble a typical breast cancer treatment beam placement. RNS measurements inside lung showed a variation in the opposite direction: AAA under-dosed a target beyond lung and over-dosed the lung upstream and downstream of the target. Results also highlighted shortcomings of some superposition and convolution algorithms in modelling large angle wedges. CONCLUSIONS This audit showed that 3D-CRT dosimetry audits remain relevant and can identify fundamental global and local problems that also affect advanced treatments.
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Affiliation(s)
- Joerg Lehmann
- Australian Clinical Dosimetry Service (ACDS), Australian Radiation Protection and National Safety Agency (ARPANSA), 619 Lower Plenty Road, Yallambie, VIC 3085, Australia
- Institute of Medical Physics, School of Physics A28, University of Sydney NSW 2006, Australia
- School of Mathematical and Physical Sciences, The University of Newcastle, University Drive, Callaghan, NSW 2308, Australia
- School of Science, Royal Melbourne Institute of Technology (RMIT) University, 124 La Trobe Street, Melbourne, VIC 3000, Australia
| | - Andrew Alves
- Australian Clinical Dosimetry Service (ACDS), Australian Radiation Protection and National Safety Agency (ARPANSA), 619 Lower Plenty Road, Yallambie, VIC 3085, Australia
| | - Leon Dunn
- Australian Clinical Dosimetry Service (ACDS), Australian Radiation Protection and National Safety Agency (ARPANSA), 619 Lower Plenty Road, Yallambie, VIC 3085, Australia
| | - Maddison Shaw
- Australian Clinical Dosimetry Service (ACDS), Australian Radiation Protection and National Safety Agency (ARPANSA), 619 Lower Plenty Road, Yallambie, VIC 3085, Australia
- School of Science, Royal Melbourne Institute of Technology (RMIT) University, 124 La Trobe Street, Melbourne, VIC 3000, Australia
| | - John Kenny
- Australian Clinical Dosimetry Service (ACDS), Australian Radiation Protection and National Safety Agency (ARPANSA), 619 Lower Plenty Road, Yallambie, VIC 3085, Australia
| | - Stephanie Keehan
- Australian Clinical Dosimetry Service (ACDS), Australian Radiation Protection and National Safety Agency (ARPANSA), 619 Lower Plenty Road, Yallambie, VIC 3085, Australia
- School of Science, Royal Melbourne Institute of Technology (RMIT) University, 124 La Trobe Street, Melbourne, VIC 3000, Australia
| | - Jeremy Supple
- Australian Clinical Dosimetry Service (ACDS), Australian Radiation Protection and National Safety Agency (ARPANSA), 619 Lower Plenty Road, Yallambie, VIC 3085, Australia
| | - Francis Gibbons
- Australian Clinical Dosimetry Service (ACDS), Australian Radiation Protection and National Safety Agency (ARPANSA), 619 Lower Plenty Road, Yallambie, VIC 3085, Australia
| | - Sophie Manktelow
- Australian Clinical Dosimetry Service (ACDS), Australian Radiation Protection and National Safety Agency (ARPANSA), 619 Lower Plenty Road, Yallambie, VIC 3085, Australia
| | - Chris Oliver
- Australian Clinical Dosimetry Service (ACDS), Australian Radiation Protection and National Safety Agency (ARPANSA), 619 Lower Plenty Road, Yallambie, VIC 3085, Australia
| | - Tomas Kron
- Australian Clinical Dosimetry Service (ACDS), Australian Radiation Protection and National Safety Agency (ARPANSA), 619 Lower Plenty Road, Yallambie, VIC 3085, Australia
- School of Science, Royal Melbourne Institute of Technology (RMIT) University, 124 La Trobe Street, Melbourne, VIC 3000, Australia
- Department of Radiation Oncology, Peter MacCallum Cancer Center, 305 Grattan Street, Melbourne, VIC 3000, Australia
| | - Ivan Williams
- Australian Clinical Dosimetry Service (ACDS), Australian Radiation Protection and National Safety Agency (ARPANSA), 619 Lower Plenty Road, Yallambie, VIC 3085, Australia
| | - Jessica Lye
- Australian Clinical Dosimetry Service (ACDS), Australian Radiation Protection and National Safety Agency (ARPANSA), 619 Lower Plenty Road, Yallambie, VIC 3085, Australia
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Pasler M, Hernandez V, Jornet N, Clark CH. Novel methodologies for dosimetry audits: Adapting to advanced radiotherapy techniques. Phys Imaging Radiat Oncol 2018; 5:76-84. [PMID: 33458373 PMCID: PMC7807589 DOI: 10.1016/j.phro.2018.03.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 03/08/2018] [Accepted: 03/08/2018] [Indexed: 11/25/2022] Open
Abstract
With new radiotherapy techniques, treatment delivery is becoming more complex and accordingly, these treatment techniques require dosimetry audits to test advanced aspects of the delivery to ensure best practice and safe patient treatment. This review of novel methodologies for dosimetry audits for advanced radiotherapy techniques includes recent developments and future techniques to be applied in dosimetry audits. Phantom-based methods (i.e. phantom-detector combinations) including independent audit equipment and local measurement equipment as well as phantom-less methods (i.e. portal dosimetry, transmission detectors and log files) are presented and discussed. Methodologies for both conventional linear accelerator (linacs) and new types of delivery units, i.e. Tomotherapy, stereotactic devices and MR-linacs, are reviewed. Novel dosimetry audit techniques such as portal dosimetry or log file evaluation have the potential to allow parallel auditing (i.e. performing an audit at multiple institutions at the same time), automation of data analysis and evaluation of multiple steps of the radiotherapy treatment chain. These methods could also significantly reduce the time needed for audit and increase the information gained. However, to maximise the potential, further development and harmonisation of dosimetry audit techniques are required before these novel methodologies can be applied.
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Affiliation(s)
- Marlies Pasler
- Lake Constance Radiation Oncology Center Singen-Friedrichshafen, Germany
| | - Victor Hernandez
- Department of Medical Physics, Hospital Sant Joan de Reus, IISPV, Tarragona, Spain
| | - Núria Jornet
- Servei de RadiofísicaiRadioprotecció, Hospital de la Santa CreuiSant Pau, Spain
| | - Catharine H. Clark
- Department of Medical Physics, Royal Surrey County Hospital, Guildford, Surrey, UK
- Metrology for Medical Physics (MEMPHYS), National Physical Laboratory, Teddington, Middlesex, UK
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