Gating characteristics of an Elekta radiotherapy treatment unit measured with three types of detector

Accuracy of real-time respiratory motion tracking and time delay of gating radiotherapy based on optical surface imaging technique

Background

Surface-guided radiation therapy (SGRT) employs a non-invasive real-time optical surface imaging (OSI) technique for patient surface motion monitoring during radiotherapy. The main purpose of this study is to verify the real-time tracking accuracy of SGRT for respiratory motion and provide a fitting method to detect the time delay of gating.

Methods

A respiratory motion phantom was utilized to simulate respiratory motion using 17 cosine breathing pattern curves with various periods and amplitudes. The motion tracking of the phantom was performed by the Catalyst™ system. The tracking accuracy of the system (with period and amplitude variations) was evaluated by analyzing the adjusted coefficient of determination (A_R²) and root mean square error (RMSE). Furthermore, 13 actual respiratory curves, which were categorized into regular and irregular patterns, were selected and then simulated by the phantom. The Fourier transform was applied to the respiratory curves, and tracking accuracy was compared through the quantitative analyses of curve similarity using the Pearson correlation coefficient (PCC). In addition, the time delay of amplitude-based respiratory-gating radiotherapy based on the OSI system with various beam hold times was tested using film dosimetry for the Elekta Versa-HD and Varian Edge linacs. A dose convolution-fitting method was provided to accurately measure the beam-on and beam-off time delays.

Results

A_R² and RMSE for the cosine curves were 0.9990–0.9996 and 0.110–0.241 mm for periods ranging from 1 s to 10 s and 0.9990–0.9994 and 0.059–0.175 mm for amplitudes ranging from 3 mm to 15 mm. The PCC for the actual respiratory curves ranged from 0.9955 to 0.9994, which was not significantly affected by breathing patterns. For gating radiotherapy, the average beam-on and beam-off time delays were 1664 ± 72 and 25 ± 30 ms for Versa-HD and 303 ± 45 and 34 ± 25 ms for Edge, respectively. The time delay was relatively stable as the beam hold time increased.

Conclusions

The OSI technique provides high accuracy for respiratory motion tracking. The proposed dose convolution-fitting method can accurately measure the time delay of respiratory-gating radiotherapy. When the OSI technique is used for respiratory-gating radiotherapy, the time delay for the beam-on is considerably longer than the beam-off.

Low-cost Kinect Version 2 imaging system for breath hold monitoring and gating: Proof of concept study for breast cancer VMAT radiotherapy

Voluntary inspiration breath hold (VIBH) for left breast cancer patients has been shown to be a safe and effective method of reducing radiation dose to the heart. Currently, VIBH protocol compliance is monitored visually. In this work, we establish whether it is possible to gate the delivery of radiation from an Elekta linac using the Microsoft Kinect version 2 (Kinect v2) depth sensor to measure a patient breathing signal. This would allow contactless monitoring during VMAT treatment, as an alternative to equipment-assisted methods such as active breathing control (ABC). Breathing traces were acquired from six left breast radiotherapy patients during VIBH. We developed a gating interface to an Elekta linac, using the depth signal from a Kinect v2 to control radiation delivery to a programmable motion platform following patient breathing patterns. Radiation dose to a moving phantom with gating was verified using point dose measurements and a Delta4 verification phantom. 60 breathing traces were obtained with an acquisition success rate of 100%. Point dose measurements for gated deliveries to a moving phantom agreed to within 0.5% of ungated delivery to a static phantom using both a conventional and VMAT treatment plan. Dose measurements with the verification phantom showed that there was a median dose difference of better than 0.5% and a mean (3% 3 mm) gamma index of 92.6% for gated deliveries when using static phantom data as a reference. It is possible to use a Kinect v2 device to monitor voluntary breath hold protocol compliance in a cohort of left breast radiotherapy patients. Furthermore, it is possible to use the signal from a Kinect v2 to gate an Elekta linac to deliver radiation only during the peak inhale VIBH phase.

Usefulness of a new online patient-specific quality assurance system for respiratory-gated radiotherapy

PURPOSE

The accuracy of gated irradiation may decrease when treatment is performed with short "beam-on" times. Also, the dose is subject to variation between treatment sessions if the respiratory rate is irregular. We therefore evaluated the impact of the differences between gated and non-gated treatment on doses using a new online quality assurance (QA) system for respiratory-gated radiotherapy.

METHODS

We generated dose estimation models to associate dose and pulse information using a 0.6 cc Farmer chamber and our QA system. During gated irradiation with each of seven regular and irregular respiratory patterns, with the Farmer chamber readings as references, we evaluated our QA system's accuracy. We then used the QA system to assess the impact of respiratory patterns on dose distribution for three lung and three liver radiotherapy plans. Gated and non-gated plans were generated and compared.

RESULTS

There was agreement within 1.7% between the ionization chamber and our system for several regular and irregular motion patterns. For dose distributions with measured errors, there were larger differences between gated and non-gated treatment for high-dose regions within the planned treatment volume (PTV). Compared with a non-gated plan, PTV D_95% for a gated plan decreased by -1.5% to -2.6%. Doses to organs at risk were similar with both plans.

CONCLUSIONS

Our simple system estimated the radiation dose to the patient using only pulse information from the linac, even during irregular respiration. The quality of gated irradiation for each patient can be verified fraction by fraction.

Performance of a clinical gridded electron gun in magnetic fields: Implications for MRI-linac therapy

PURPOSE

MRI-linac therapy is a rapidly growing field, and requires that conventional linear accelerators are operated with the fringe field of MRI magnets. One of the most sensitive accelerator components is the electron gun, which serves as the source of the beam. The purpose of this work was to develop a validated finite element model (FEM) model of a clinical triode (or gridded) electron gun, based on accurate geometric and electrical measurements, and to characterize the performance of this gun in magnetic fields.

METHODS

The geometry of a Varian electron gun was measured using 3D laser scanning and digital calipers. The electric potentials and emission current of these guns were measured directly from six dose matched true beam linacs for the 6X, 10X, and 15X modes of operation. Based on these measurements, a finite element model (FEM) of the gun was developed using the commercial software opera/scala. The performance of the FEM model in magnetic fields was characterized using parallel fields ranging from 0 to 200 G in the in-line direction, and 0-35 G in the perpendicular direction.

RESULTS

The FEM model matched the average measured emission current to within 5% across all three modes of operation. Different high voltage settings are used for the different modes; the 6X, 10X, and 15X modes have an average high voltage setting of 15, 10, and 11 kV. Due to these differences, different operating modes show different sensitivities in magnetic fields. For in line fields, the first current loss occurs at 40, 20, and 30 G for each mode. This is a much greater sensitivity than has previously been observed. For perpendicular fields, first beam loss occurred at 8, 5, and 5 G and total beam loss at 27, 22, and 20 G.

CONCLUSIONS

A validated FEM model of a clinical triode electron gun has been developed based on accurate geometric and electrical measurements. Three different operating modes were simulated, with a maximum mean error of 5%. This gun shows greater sensitivity to in-line magnetic fields than previously presented models, and different operating modes show different sensitivity.

Does gated beam delivery impact delivery accuracy on an Elekta linac?

In this study, we evaluated the performance of an Elekta linac in the delivery of gated radiotherapy. Delivery accuracy was examined with an emphasis on the impact of using short gating windows (low monitor unit beam-on segments) or long beam hold times. The performance was assessed using a 20cm by 20cm open field with the radiation delivered using a range of beam-on and beam-off time periods. Gated delivery measurements were also performed for two SBRT plans delivered using volumetric modulated arc therapy (VMAT). Tests included both free-breathing based gating (covering a variety of gating windows) and simulated breath-hold based gating. An IBA MatriXX 2D ion chamber array was used for data collection, and the gating accuracy at low MU was evaluated using gamma passing rates. For the 20 cm by 20 cm open field, the measurements generally showed close agreement between the gated and non-gated beam deliveries. Discrepancies, however, began to appear with a 5-to-1 ratio of the beam-off to beam-on times. The discrepancies observed for these tight gating windows can be attributed to the small number of monitor units delivered during each beam-on segment. Dose distribution analysis from the delivery of the two SBRT plans showed gamma passing rates (± 1%, 2%/1 mm) in the range of 95% to 100% for gating windows of 25%, 38%, 50%, 63%, 75%, and 83%. Using a simulated sinusoidal breathing signal with a 4 second period, the gamma passing rate of free-breathing gating and breath-hold gating deliveries were measured in the range of 95.7% to 100%. In conclusion, the results demonstrate that Elekta linacs can accurately deliver respiratory gated treatments for both free-breathing and breath-hold patients. Some caution should be exercised with the use of very tight gating windows.

Technical aspects of real time positron emission tracking for gated radiotherapy

PURPOSE

Respiratory motion can lead to treatment errors in the delivery of radiotherapy treatments. Respiratory gating can assist in better conforming the beam delivery to the target volume. We present a study of the technical aspects of a real time positron emission tracking system for potential use in gated radiotherapy.

METHODS

The tracking system, called PeTrack, uses implanted positron emission markers and position sensitive gamma ray detectors to track breathing motion in real time. PeTrack uses an expectation-maximization algorithm to track the motion of fiducial markers. A normalized least mean squares adaptive filter predicts the location of the markers a short time ahead to account for system response latency. The precision and data collection efficiency of a prototype PeTrack system were measured under conditions simulating gated radiotherapy. The lung insert of a thorax phantom was translated in the inferior-superior direction with regular sinusoidal motion and simulated patient breathing motion (maximum amplitude of motion ±10 mm, period 4 s). The system tracked the motion of a (22)Na fiducial marker (0.34 MBq) embedded in the lung insert every 0.2 s. The position of the was marker was predicted 0.2 s ahead. For sinusoidal motion, the equation used to model the motion was fitted to the data. The precision of the tracking was estimated as the standard deviation of the residuals. Software was also developed to communicate with a Linac and toggle beam delivery. In a separate experiment involving a Linac, 500 monitor units of radiation were delivered to the phantom with a 3 × 3 cm photon beam and with 6 and 10 MV accelerating potential. Radiochromic films were inserted in the phantom to measure spatial dose distribution. In this experiment, the period of motion was set to 60 s to account for beam turn-on latency. The beam was turned off when the marker moved outside of a 5-mm gating window.

RESULTS

The precision of the tracking in the IS direction was 0.53 mm for a sinusoidally moving target, with an average count rate ∼250 cps. The average prediction error was 1.1 ± 0.6 mm when the marker moved according to irregular patient breathing motion. Across all beam deliveries during the radiochromic film measurements, the average prediction error was 0.8 ± 0.5 mm. The maximum error was 2.5 mm and the 95th percentile error was 1.5 mm. Clear improvement of the dose distribution was observed between gated and nongated deliveries. The full-width at halfmaximum of the dose profiles of gated deliveries differed by 3 mm or less than the static reference dose distribution. Monitoring of the beam on/off times showed synchronization with the location of the marker within the latency of the system.

CONCLUSIONS

PeTrack can track the motion of internal fiducial positron emission markers with submillimeter precision. The system can be used to gate the delivery of a Linac beam based on the position of a moving fiducial marker. This highlights the potential of the system for use in respiratory-gated radiotherapy.

Characteristics of gated treatment using an optical surface imaging and gating system on an Elekta linac

BACKGROUND

Knowing the technical characteristics of gated radiotherapy equipment is crucial for ensuring precise and accurate treatment when using techniques such as Deep-Inspiration Breath-Hold and gating under free breathing. With one of the first installations of the novel surface imaging system Catalyst™ (C-RAD AB, Sweden) in connection with an Elekta Synergy linear accelerator (Elekta AB, Sweden) via the Elekta Response Interface, characteristics like dose delivery accuracy and time delay were investigated prior to clinical implementation of gated treatments in our institution.

METHODS

In this study a moving phantom was used to simulate respiratory motion which was registered by the Catalyst™ system. The gating level was set manually. Within this gating window a trigger signal is automatically sent to the linac initiating treatment delivery. Dose measurements of gated linac treatment beams with different gating levels were recorded with a static 2D-Diode Array (MapCheck2, Sun Nuclear Co., USA) and compared to ungated reference measurements for different field sizes. In addition, the time delay of gated treatment beams was measured using radiographic film.

RESULTS

The difference in dose delivery between gated and ungated treatment decreases with the size of the chosen gating level. For clinically relevant gating levels of about 30%, the differences in dose delivery accuracy remain below 1%. In comparison with other system configurations in literature, the beam-on time delay shows a large deviation of 851 ms ± 100 ms.

CONCLUSIONS

When performing gated treatment, especially for free-breathing gating, factors as time delay and dose delivery have to be evaluated regularly in terms of a quality assurance process. Once these parameters are known they can be accounted and compensated for, e.g. by adjusting the pre-selected gating level or the internal target volume margins and by using prediction algorithms for breathing curves. The usage of prediction algorithms becomes inevitable with the high beam-on time delay which is reported here.

Delivery efficiency of an Elekta linac under gated operation

In this study, we have characterized the efficiency of an Elekta linac in the delivery of gated radiotherapy. We have explored techniques to reduce the beam‐on delay and to improve the delivery efficiency, and have investigated the impact of frequent beam interruptions on the dosimetric accuracy of gated deliveries. A newly available gating interface was installed on an Elekta Synergy. Gating signals were generated using a surface mapping system in conjunction with a respiratory motion phantom. A series of gated deliveries were performed using volumetric modulated arc therapy (VMAT) treatment plans previously generated for lung cancer patients treated with stereotactic body radiotherapy. Baseline values were determined for the delivery times. The machine was then tuned in an effort to minimize beam‐on delays and improve delivery efficiency. After that process was completed, the dosimetric accuracy of the gated deliveries was evaluated by comparing the measured and the planned coronal dose distributions using gamma index analyses. Comparison of the gated and the non‐gated deliveries were also performed. The results demonstrated that, with the optimal machine settings, the average beam‐on delay was reduced to less than 0.22 s. High dosimetric accuracy was demonstrated with gamma index passing rates no lower than 99.0% for all tests (3%/3 mm criteria). Consequently, Elekta linacs can provide a practical solution for gated VMAT treatments with high dosimetric accuracy and only a moderate increase in the overall delivery time.

PACS numbers: 87.56.bd, 87.55.de, 87.55.ne

Comparative study of a low-Z cone-beam computed tomography system

Computed tomography images have been acquired using an experimental (low atomic number (Z) insert) megavoltage cone-beam imaging system. These images have been compared with standard megavoltage and kilovoltage imaging systems. The experimental system requires a simple modification to the 4 MeV electron beam from an Elekta Precise linac. Low-energy photons are produced in the standard medium-Z electron window and a low-Z carbon electron absorber located after the window. The carbon electron absorber produces photons as well as ensuring that all remaining electrons from the source are removed. A detector sensitive to diagnostic x-ray energies is also employed. Quantitative assessment of cone-beam computed tomography (CBCT) contrast shows that the low-Z imaging system is an order of magnitude or more superior to a standard 6 MV imaging system. CBCT data with the same contrast-to-noise ratio as a kilovoltage imaging system (0.15 cGy) can be obtained in doses of 11 and 244 cGy for the experimental and standard 6 MV systems, respectively. Whilst these doses are high for everyday imaging, qualitative images indicate that kilovoltage like images suitable for patient positioning can be acquired in radiation doses of 1-8 cGy with the experimental low-Z system.

Temporal characterization and in vitro comparison of cell survival following the delivery of 3D-conformal, intensity-modulated radiation therapy (IMRT) and volumetric modulated arc therapy (VMAT)

A phantom was designed and implemented for the delivery of treatment plans to cells in vitro. Single beam, 3D-conformal radiotherapy (3D-CRT) plans, inverse planned five-field intensity-modulated radiation therapy (IMRT), nine-field IMRT, single-arc volumetric modulated arc therapy (VMAT) and dual-arc VMAT plans were created on a CT scan of the phantom to deliver 3 Gy to the cell layer and verified using a Farmer chamber, 2D ionization chamber array and gafchromic film. Each plan was delivered to a 2D ionization chamber array to assess the temporal characteristics of the plan including delivery time and 'cell's eye view' for the central ionization chamber. The effective fraction time, defined as the percentage of the fraction time where any dose is delivered to each point examined, was also assessed across 120 ionization chambers. Each plan was delivered to human prostate cancer DU-145 cells and normal primary AGO-1522b fibroblast cells. Uniform beams were delivered to each cell line with the delivery time varying from 0.5 to 20.54 min. Effective fraction time was found to increase with a decreasing number of beams or arcs. For a uniform beam delivery, AGO-1552b cells exhibited a statistically significant trend towards increased survival with increased delivery time. This trend was not repeated when the different modulated clinical delivery methods were used. Less sensitive DU-145 cells did not exhibit a significant trend towards increased survival with increased delivery time for either the uniform or clinical deliveries. These results confirm that dose rate effects are most prevalent in more radiosensitive cells. Cell survival data generated from uniform beam deliveries over a range of dose rates and delivery times may not always be accurate in predicting response to more complex delivery techniques, such as IMRT and VMAT.