Two-dimensional measurement of photon beam attenuation by the treatment couch and immobilization devices using an electronic portal imaging device

Dosimetric effects of supine immobilization devices on the skin in intensity-modulated radiation therapy for breast cancer: a retrospective study

Background

The dose perturbation effect of immobilization devices is often overlooked in intensity-modulated radiation therapy (IMRT) for breast cancer (BC). This retrospective study assessed the dosimetric effects of supine immobilization devices on the skin using a commercial treatment planning system.

Methods

Forty women with BC were divided into four groups according to the type of primary surgery: groups A and B included patients with left and right BC, respectively, who received 50 Gy radiotherapy in 25 fractions after radical mastectomy, while groups C and D included patients with left and right BC, respectively, who received breast-conservation surgery (BCS) and 40.05 Gy in 15 fractions as well as a tumor bed simultaneous integrated boost to 45 Gy. A 0.2-cm thick skin contour and two sets of body contours were outlined for each patient. Dose calculations were conducted for the two sets of contours using the same plan. The dose differences were assessed by comparing the dose-volume histogram parameter results and by plan subtraction.

Results

The supine immobilization devices for BC resulted in significantly increased skin doses, which may ultimately lead to skin toxicity. The mean dose increased by approximately 0.5 and 0.45 Gy in groups A and B after radical mastectomy and by 2.7 and 3.25 Gy in groups C and D after BCS; in groups A–D, the percentages of total normal skin volume receiving equal to or greater than 5 Gy (V₅) increased by 0.54, 1.15, 2.67, and 1.94%, respectively, while the V₁₀ increased by 1.27, 1.83, 1.36, and 2.88%; the V₂₀ by 0.85, 1.87, 2.76, and 4.86%; the V₃₀ by 1.3, 1.24, 10.58, and 11.91%; and the V₄₀ by 1.29, 0.65, 10, and 10.51%. The dose encompassing the planning target volume and other organs at risk, showed little distinction between IMRT plans without and with consideration of immobilization devices.

Conclusions

The supine immobilization devices significantly increased the dose to the skin, especially for patients with BCS. Thus, immobilization devices should be included in the external contour to account for dose attenuation and skin dose increment.

Trial registration

This study does not report on interventions in human health care.

Implementation of carbon fibre treatment couches in the XiO® and Monaco® Treatment Planning Systems

Purpose: Carbon fibre treatment couches on linear accelerators provide a strong, rigid framework for patient support. Patient safety is a priority, therefore the dosimetric properties of treatment couches need to be accurately incorporated in treatment plans, to minimize differences between planned and delivered dose. This study aims to determine the attenuation effect of treatment couches for 3-D Conformal Radiotherapy (3-D CRT) and to validate the implementation thereof in the XiO and Monaco treatment planning systems (TPS).

Material and methods: Attenuation measurements were performed on the ELEKTA Connexion couches of the ELEKTA Precise and Synergy-Agility linear accelerators. Measurements were made at 10° intervals in RMI-457 Solid water (30 cm x 30 cm x 30 cm) using a PTW Farmer-type ionization chamber (TW30013) positioned at the accelerator’s isocentre. The percentage attenuation was calculated as the ratio of the electrometer readings for parallel-opposed fields. The Computed Tomography (CT) data sets of the set-ups were obtained on a Philips Big Bore 16-slice CT scanner and exported to the TPS. The individual couch structures were delineated and electron density (ED) values were assigned using the commissioned CT-to-ED curve. Test treatment plans were generated with 100MU per field at 10° gantry intervals.

Results: The percentage attenuation was determined to be within 2% and 3% for beams perpendicular to the couch surface for XiO and Monaco, respectively. The maximum attenuation was observed for oblique fields which was significantly higher than the manufacturer specified values. TPS validation showed an agreement to 1% for XiO and Monaco. At extreme oblique angles, both planning systems overestimated this effect up to a maximum of 4%.

Conclusions: Couch attenuation differs significantly with gantry angle and beam energy. As a result, the treatment couch models should be included in all treatment planning calculations.

[Development of an In-house Couch Model to Improve Dose Attenuation Correction Accuracy for a Couch with Different Thickness in the Superior-inferior Direction]

As the couch used in external radiation therapy attenuate radiation by interaction, it is necessary to correct attenuation of radiation by inserting a couch model in the treatment planning systems. For a couch whose thickness is different in the superior-inferior direction, it is possible to perform dose calculations with an error within ±1% by using separate different couch models provided by vendors. However, it is difficult to correct attenuation correction accurately with a single couch model. In this study, we created an in-house couch model which can set couch shape and physical density in detail by acquiring CT images of actual couch. When we performed dose calculation by optimizing the physical densities of in-house and vendor couch, it was found that the difference between the measured and the calculated values can be significantly reduced by using in-house couch model. Additionally, by using in-house couch model, it is found that the dose attenuation can be corrected within ±1% for a couch whose thickness is different in the superior-inferior direction.

A simple and efficient method to measure beam attenuation through a radiotherapy treatment couch and immobilization devices

We propose a simple and efficient method to measure beam attenuation in one or two dimensions using an amorphous silicon electronic portal imaging device (a-Si EPID). The proposed method was validated against ionization chamber measurements. Beam attenuation through treatment couches (Varian Medical Systems) and immobilization devices (CIVCO Radiotherapy, USA) was examined. The dependency of beam attenuation on field size, photon energy, thickness of the couch, and the presence of a phantom were studied. Attenuation images were derived by computing the percentage difference between images obtained without and with a couch or immobilization devices determining the percentage of attenuation at the center and the mean attenuation. The beam attenuation measurements obtained with an a-Si EPID and an ionization chamber agreed to within ± 0.10 to 1.80%. No difference was noted between the center and mean of an attenuated image for a small field size of 5 × 5 cm², whereas a large field size of 15 × 15 cm² exhibited differences of up to 1.13%. For an 18 MV beam, the a-Si EPID required additional build-up material for accurate assessment of beam attenuation. The a-Si EPID could measure differences in beam attenuation through an image guided radiotherapy (IGRT) couch regardless of the variabilities in couch thickness. Interestingly, the addition of a phantom reduced the magnitude of attenuation by approximately 1.20% for a field size of 15 × 15 cm². A simple method is proposed that provides the user with beam attenuation data in either 2D or 1D within a few minutes.

Photon beam attenuation characteristics of three commercial radiation therapy treatment couch-tops

Aim

The purpose of the study was to investigate the detailed angularly dependent attenuation characteristics of three different commercial couch-tops: Varian IGRT, Qfix kVue Standard and Qfix kVue Dose Max couch-tops used in radiation therapy.

Materials and methods

The attenuation of photon beams by the treatment couch-tops was measured using a farmer chamber inserted at the centre of a 16 cm diameter cylindrical acrylic phantom for five different photon energies: 6 MV, 6FFF MV, 10 MV, 10FFF MV and 15 MV photon beams. The Varian IGRT couch-top has three different thicknesses thus attenuation measurements were done at the three different longitudinal locations. Measurements were made with the sliding support rails of the Qfix kVue Standard and Qfix kVue Dose Max couch-tops at both ‘rails-in’ and ‘rails-out’ positions. All measurements were taken for several projections through 360° movement of the gantry and for two different field sizes; 5×5 cm2 and 10×10 cm2.

Results and findings

The results indicate that the maximum attenuation of the Varian IGRT couch-top at the thin, medium and thick portions are 5·1, 5·7 and 8·9%, respectively, the Qfix kVue Standard couch with the rails-in and rails-out are 11·2 and 13·7%, respectively, and Qfix kVue Dose Max couch-top with rails-in and rails-out are 9·7 and 13·8%, respectively. The results from this study can be used to account for the couch-top attenuation during radiation treatment planning of patients treated with these couch-tops.

Quantification and comparison the dosimetric impact of two treatment couch model in VMAT

The use of Monte Carlo treatment planning systems (TPS) in radiation therapy has increased the dosimetric accuracy of VMAT treatment sequences. However, this accuracy is compromised by not including the treatment couch into the treatment planning process. Therefore, the impact of the treatment couch on radiation delivery output was determined, and two different couch models (uniform couch model A vs two components model B) were included and tested in the Monaco TPS to investigate which model can better quantify the couch influence on radiation dose. Relative attenuation measurements were performed following procedures outlined by TG‐176 with three phantom positions for A–B direction: on the left half (L), in the center (C) and on the right half (R) of the couch. As well as absolute dose comparison of static fields of 10 × 10 cm² that were delivered through the couch tops with that calculated in the TPS with the couch model at 2 mm and 5 mm computing grid size respectively. The most severe percentage deviation was 4.60% for the phantom positioned at the left half of the couch with 5 mm grid size at gantry angle 120°. The couch model was included in the TPS with a uniform ED of 0.26 g/cm³ or a two component model with a fiber 0.52 g/cm³ and foam core 0.1 g/cm³. After including the treatment couch, the maximum mean dose attenuation was reduced from 3.68% without couch included to (0.60, 0.83, 0.72, and 1.02) % for model A and model B at 2 and 5 mm voxel grid size. The results obtained showed that Model A performed better than the model B, demonstrating lower deviations from measurements and better robustness against dose grid resolution changes. Considering the results of this study, we propose the systematic introduction of the couch Model A in clinical routine. All the reported findings are valid for the Elekta iBEAM^® evo Extension 415 couch and these methods can also be used for other couch model.

[Optimization of Couch Modeling in the Change of Dose Calculation Methods and Their Versions]

In external radiotherapy, the X-ray beam passes through the treatment couch, leading to the dose reduction by the attenuation of the couch. As a method to compensate for the reduction, radiation treatment planning systems (RTPS) support virtual couch function, namely "couch modeling method". In the couch modeling method, the computed tomography (CT) numbers assigned to each structure should be optimized by comparing calculations to measurements for accurate dose calculation. Thus, re-optimization of CT numbers will be required when the dose calculation algorithm or their version changes. The purpose of this study is to evaluate the calculation accuracy of the couch modeling method in different calculation algorithms and their versions. The optimal CT numbers were determined by minimizing the difference between measured transmission factors and calculated ones. When CT numbers optimized by Anisotropic Analytical Algorithm (AAA) Ver. 8.6 were used, the maximum and the mean difference of transmission factor were 5.8% and 1.5%, respectively, for Acuros XB (AXB) Ver. 11.0. However, when CT numbers optimized by AXB Ver. 11.0 were used, they were 2.6% and 0.6%, respectively. The CT numbers for couch structures should be optimized when changing dose calculation algorithms and their versions. From the comparison of the measured transmission to calculation, it was found that the CT numbers had high accuracy.

Effects of Siemens TT-D carbon fiber table top on beam attenuation, and build up region of 6 MV photon beam

AIM

This study deals with Monte Carlo simulations of the effects which the 550 TXT carbon fiber couch can have on the relevant parameters of a 6 MV clinical photon beam in three field sizes.

BACKGROUND

According to the reports issued by the International Commission on Radiation Units and Measurements (ICRU), the calculated dose across a high gradient distribution should be within 2% of the relative dose, or within 0.2 cm of the isodose curve position in the target volume. Nowadays, the use of posterior oblique beam has become a common practice. It is clear that, in radiotherapy, the presence of the couch affects the beam intensity and, as a result, the skin dose.

MATERIALS AND METHODS

Firstly, Siemens linear accelerator validation for 6 MV photon beam was performed, and satisfactory agreement between Monte Carlo and experimental data for various field sizes was observed. Secondly, the couch transmission factor for the reference field size and depth was computed, and the skin dose enhancement by the couch was assessed.

RESULTS

The largest impact of the carbon fiber couch effect was observed for the 5 × 5 cm2 field size. Such evaluation has not been reported for this couch before.

CONCLUSION

Despite providing minimal attenuation for the primary radiation, the assumption that carbon fiber couches are radiotranslucent is not valid, and the effects of couches of this type on the transmission factor, and on the skin dose should be carefully investigated for each field size and depth.

Radiotherapy couches: is kevlar an obstacle? Attenuation study of three different tabletops

Introduction

Treatment tabletops are usually made of carbon fibre due to its high mechanical strength and rigidity, low specific density, extremely light and regularly considered radiotranslucent. Our clinic acquired a Calypso 4D Localization System where electromagnetic (EM) frequencies to detect implanted transponders in the patient are used. Carbon fibre is an electrical conductive material which interferes with EM frequencies. Therefore, in order to be able to use the Calypso System the carbon fibre tabletop in the treatment room must be replaced. It is our goal to determine the attenuation of the new, non-carbon fibre, tabletop in treatment delivery.

Materials and Methods

Measurements were performed using an ionisation chamber inserted in a slab phantom positioned at the isocenter for 6, 10 MV, 6 and 10 flattening filter free (FFF) MV photon beams. These measurements were performed with and without tabletop for 0°, 30° and 60° beam angle for a True Beam STx linac, for 5×5 cm2 and 10×10 cm2 field size beams. The attenuation was calculated for each measurement for each tabletop.

Results

At 0° incidence on the Exact IGRT Couch, the measured attenuation for 10×10 cm2 was 2·8 and 2·1% for 6 and 10 MV beams, respectively. For the same field size was measured 3·3 and 2·6% attenuation for 6 and 10 FFF MV beams, respectively. At the same incidence and regarding the other tabletops, the calculated attenuation is lower. For 10×10 cm2 field, there is 2·0, 1·4, 2·1 and 2·6% attenuation for 6, 10 MV, 6 and 10 FFF MV energy beams on the kVueTM Universal Couch. For the KvueTM Calypso® Couch 10×10 cm2 irradiation field, the measurements were 1·6, 1·3, 1·9 and 1·5%, respectively. This tendency is observed for all gantry angles.

Discussion

The attenuation outputs were definitely higher for the Varian Exact IGRT Couch when compared with the kVue tabletops. The attenuation measurements for the kVue tabletops were closer to each other. Nevertheless kVueTM Calypso® Varian tabletop showed smaller mean attenuation of the beams than kVueTM Universal Tip Insert for all measurements.

Conclusions

There was no loss in treatment quality administration due to beam attenuation in the tabletop when tabletops were exchanged because of Calypso system integration. There is no need to change between kVue tabletops whenever there is a regular treatment or a Calypso System guided treatment.

A practical method of modeling a treatment couch using cone-beam computed tomography for intensity-modulated radiation therapy and RapidArc treatment delivery

The effect of a treatment couch on dose perturbation is not always fully considered in intensity-modulated radiation therapy (IMRT) and volumetric modulated arc therapy (VMAT). In the course of inverse planning radiotherapy techniques, beam parameter optimization may change in the absence of the couch, causing errors in the calculated dose distributions. Although modern treatment planning systems (TPS) include data for the treatment couch components, they are not manufactured identically. Thus, variations in their Hounsfield unit (HU) values may exist. Moreover, a radiotherapy facility may wish to have a third-party custom tabletop installed that is not included by the TPS vendor. This study demonstrates a practical and simple method of acquiring reliable computed tomography (CT) data for the treatment couch and shows how the absorbed dose calculated with the modeled treatment couch can differ from that with the default treatment couch found in the TPS. We also experimentally verified that neglecting to incorporate the treatment couch completely in the treatment planning process might result in dose differences of up to 9.5% and 7.3% for 4-MV and 10-MV photon beams, respectively. Furthermore, 20 RapidArc and IMRT cases were used to quantify the change in calculated dose distributions caused by using either the default or modeled couch. From 2-dimensional (2D) ionization chamber array measurements, we observed large dose distribution differences between the measurements and calculations when the couch was omitted that varied according to the planning technique and anatomic site. Thus, incorporating the treatment couch in the dose calculation phase of treatment planning significantly decreases dose calculation errors.

MRI-based treatment planning with pseudo CT generated through atlas registration

PURPOSE

To evaluate the feasibility and accuracy of magnetic resonance imaging (MRI)-based treatment planning using pseudo CTs generated through atlas registration.

METHODS

A pseudo CT, providing electron density information for dose calculation, was generated by deforming atlas CT images previously acquired on other patients. The authors tested 4 schemes of synthesizing a pseudo CT from single or multiple deformed atlas images: use of a single arbitrarily selected atlas, arithmetic mean process using 6 atlases, and pattern recognition with Gaussian process (PRGP) using 6 or 12 atlases. The required deformation for atlas CT images was derived from a nonlinear registration of conjugated atlas MR images to that of the patient of interest. The contrasts of atlas MR images were adjusted by histogram matching to reduce the effect of different sets of acquisition parameters. For comparison, the authors also tested a simple scheme assigning the Hounsfield unit of water to the entire patient volume. All pseudo CT generating schemes were applied to 14 patients with common pediatric brain tumors. The image similarity of real patient-specific CT and pseudo CTs constructed by different schemes was compared. Differences in computation times were also calculated. The real CT in the treatment planning system was replaced with the pseudo CT, and the dose distribution was recalculated to determine the difference.

RESULTS

The atlas approach generally performed better than assigning a bulk CT number to the entire patient volume. Comparing atlas-based schemes, those using multiple atlases outperformed the single atlas scheme. For multiple atlas schemes, the pseudo CTs were similar to the real CTs (correlation coefficient, 0.787-0.819). The calculated dose distribution was in close agreement with the original dose. Nearly the entire patient volume (98.3%-98.7%) satisfied the criteria of chi-evaluation (<2% maximum dose and 2 mm range). The dose to 95% of the volume and the percentage of volume receiving at least 95% of the prescription dose in the planning target volume differed from the original values by less than 2% of the prescription dose (root-mean-square, RMS < 1%). The PRGP scheme did not perform better than the arithmetic mean process with the same number of atlases. Increasing the number of atlases from 6 to 12 often resulted in improvements, but statistical significance was not always found.

CONCLUSIONS

MRI-based treatment planning with pseudo CTs generated through atlas registration is feasible for pediatric brain tumor patients. The doses calculated from pseudo CTs agreed well with those from real CTs, showing dosimetric accuracy within 2% for the PTV when multiple atlases were used. The arithmetic mean process may be a reasonable choice over PRGP for the synthesis scheme considering performance and computational costs.

Depth dose comparison of measured and calculated dose for the Eclipse virtual carbon couch top models with air gap variation

This study assessed the accuracy of Eclipse™ (Varian Medical Systems, Palo Alto, CA, USA) treatment planning system (TPS) dose calculations when using virtual couch top models to account for couch presence in patient treatments. The Flat panel and Unipanel couch tops for the Varian Exact Couch were used in this study. Assigned Hounsfield unit (HU) for the virtual couch tops were varied and TPS calculated dose was compared to measured data to determine an optimal assigned HU. Air gaps of up to 10 cm were introduced between couch and phantom to assess the ability of the models to replicate dose in this situation, commonly seen clinically. Dose was measured at a range of depths, for each air gap thickness, in order to assess the model both near surface and at various depths beyond the dose maximum. Optimal HU was taken to be that which had the best agreement between measured and calculated dose over the range of gaps and depths tested. For the Flat panel couch top this was found to be -500 HU and for the Unipanel couch top, -200 HU. Default HU parameters originally set in the models was found to be not optimal for the whole range of depths studied. With optimal HU parameters set, there was good agreement between calculated and measured dose for depths greater than 0.5 cm, but discrepancies were still observed near surface. When implementing virtual couch top models, users could improve dose calculation accuracy by determining the optimal HU from comparisons over several clinical depths rather than a single depth.

[Dose impact of a carbon fiber couch for stereotactic body radiation therapy of lung tumors]

The aim of this study was to measure the dose attenuation caused by a carbon fiber radiation therapy table (Imaging Couch Top; ICT, BrainLab) and to evaluate the dosimetric impact of ICT during stereotactic body radiation therapy (SBRT) in lung tumors. The dose attenuation of ICT was measured using an ionization chamber and modeled by means of a treatment planning system (TPS). SBRT was planned with and without ICT in a lung tumor phantom and ten cases of clinical lung tumors. The results were analyzed from isocenter doses and a dose-volume histogram (DVH): D95, Dmean, V20, V5, homogeneity index (HI), and conformity index (CI). The dose attenuation of the ICT modeled with TPS agreed to within ±1% of the actually measured values. The isocenter doses, D95 and Dmean with and without ICT showed differences of 4.1-5% for posterior single field and three fields in the phantom study, and differences of 0.6-2.4% for five fields and rotation in the phantom study and six fields in ten clinical cases. The dose impact of ICT was not significant for five or more fields in SBRT. It is thus possible to reduce the dose effect of ICT by modifying the beam angle and beam weight in the treatment plan.

Confirmation of Skin Doses Resulting from Bolus Effect of Intervening Alpha-cradle and Carbon Fiber Couch in Radiotherapy

In this study, we verified the treatment planning calculations of skin doses with the incorporation of the bolus effect due to the intervening alpha-cradle (AC) and carbon fiber couch (CFC) using radiochromic EBT2 films. A polystyrene phantom (25 × 25 × 15 cm3) with six EBT2 films separated by polystyrene slabs, at depths of 0, 0.1, 0.2, 0.5, 1, 1.4 cm, was positioned above an AC, which was ~1 cm thick. The phantom and AC assembly were CT scanned and the CT-images were transferred to the treatment planning system (TPS) for calculations in three scenarios: (A) ignoring AC and CFC, (B) accounting for AC only, (C) accounting for both AC and CFC. A single posterior 10 × 10 cm2 field, a pair of posterior-oblique 10 × 10 cm2 fields, and a posterior IMRT field (6 MV photons from a Varian Trilogy linac) were planned. For each radiation field configuration, the same MU were used in all three scenarios in the TPS. Each plan for scenario C was delivered to expose a stack of EBT2 films in the phantom through AC and CFC. In addition, in vivo EBT2 film measurement on a lung cancer patient immobilized with AC undergoing IMRT was also included in this study. Point doses and planar distributions generated from the TPS for the three scenarios were compared with the data from the EBT2 film measurements. For all the field arrangements, the EBT2 film data including the in vivo measurement agreed with the doses calculated for scenario (C), within the uncertainty of the EBT2 measurements (~4%). For the single posterior field (a pair of posterior-oblique fields), the TPS generated doses were lower than the EBT2 doses by 34%, 33%, 31%, 13% (34%, 31%, 31%, 11%) for scenario A and by 27%, 25%, 22%, 8% (25%, 21%, 21%, 6%) for scenario B at the depths of 0, 0.1, 0.2, 0.5 cm, respectively. For the IMRT field, the 2D dose distributions at each depth calculated in scenario C agree with those measured data. When comparing the central axis doses for the IMRT field, we found the TPS generated doses for scenario A (B) were lower than the EBT2 data by 35%, 34%, 31%, 16% (29%, 26%, 23%, 10%) at the depths of 0, 0.1, 0.2, 0.5 cm, respectively. There were no significant differences for the depths of 1.0 and 1.4 cm for all the radiation fields studied. TPS calculation of doses in the skin layers accounting for AC and CFC was verified by EBT2 film data. Ignoring the presence of AC and/or CFC in TPS calculation would significantly underestimate the doses in the skin layers. For the clinicians, as more hypofractionated regimens and stereotactic regimens are being used, this information will be useful to avoid potential serious skin toxicities, and also assist in clinical decisions and report these doses accurately to relevant clinical trials/cooperative groups, such as RTOG.

A simple approach for EPID dosimetric calibration to overcome the effect of image-lag and ghosting

EPID dosimetry has known drawbacks. The main issue is that a measurable residual signal is observed after the end of irradiation for prolonged periods of time, thus making measurement difficult. We present a detailed analysis of EPID response and suggest a simple, yet accurate approach for calibration that avoids the complexity of incorporating ghosting and image-lag using the maximum integrated signal instead of the total integrated signal. This approach is linear with dose and independent of dose rate.

The clinical impact of the couch top and rails on IMRT and arc therapy

The clinical impact of the Varian Exact Couch on dose, volume coverage to targets and critical structures, and tumor control probability (TCP) has not been described. Thus, we examined their effects on IMRT and arc therapy. Five clinical prostate patients were planned with both 6 MV eight-field IMRT and 6 MV two-arc RapidArc techniques using the Eclipse treatment planning system. These plans neglected treatment couch attenuation, as is a common clinical practice. Dose distributions were then recalculated in Eclipse with the inclusion of the Varian Exact Couch (imaging couch top) and the rails in varying configurations. The changes in dose and coverage were evaluated using the dose-volume histograms from each plan iteration. We used a TCP model to calculate losses in tumor control resulting from not accounting for the couch top and rails. We also verified dose measurements in a phantom. Failure to account for the treatment couch and rails resulted in clinically unacceptable dose and volume coverage losses to the targets for both IMRT and RapidArc. The couch caused average prescription dose losses (relative to plans that ignored the couch) to the prostate of 4.2% and 2.0% for IMRT with the rails out and in, respectively, and 3.2% and 2.9% for RapidArc with the rails out and in, respectively. On average, the percentage of the target covered by the prescribed dose dropped to 35% and 84% for IMRT (rails out and in, respectively) and to 18% and 17% for RapidArc (rails out and in, respectively). The TCP was also reduced by as much as 10.5% (6.3% on average). Dose and volume coverage losses for IMRT plans were primarily due to the rails, while the imaging couch top contributed most to losses for RapidArc. Both the couch top and rails contribute to dose and coverage losses that can render plans clinically unacceptable. A follow-up study we performed found that the less attenuating unipanel mesh couch top available with the Varian Exact couch does not cause a clinically impactful loss of dose or coverage for IMRT but still causes an unacceptable loss for RapidArc. Therefore, both the imaging or mesh couch top and the rails should be accounted for in arc therapy. The imaging couch top should be accounted for in IMRT treatment planning or the mesh top can be used, which would not need to be accounted for, and the rails should be moved to avoid the beams during treatment.

Impact of 6MV photon beam attenuation by carbon fiber couch and immobilization devices in IMRT planning and dose delivery

Multiple fields in IMRT and optimization allow conformal dose to the target and reduced dose to the surroundings and the regions of interest. Thus we can escalate the dose to the target to achieve better tumor control with low morbidity. Orientation of multiple beams can be achieved by i) different gantry angles, ii) rotating patient's couch isocentrically. In doing so, one or more beam may pass through different materials like the treatment couch, immobilization cast fixation plate, head and neck rest or any other supportive device. Our observations for 6MV photon beam on PRIMUS-KXE2 with MED-TEC carbon fiber tabletop and 10 × 10 cm² field size reveals that the maximum dose attenuation by the couch was of the order of 2.96% from gantry angle 120-160°. Attenuation due to cast fixation base plate of PMMA alone was of the order of 5.8-10.55% at gantry angle between 0 and 90°. Attenuation due to carbon fiber base plate alone was 3.8-7.98%. Attenuation coefficient of carbon fiber and PMMA was evaluated and was of the order of 0.082 cm⁻¹ and 0.064 cm⁻¹ respectively. Most of the TPS are configured for direct beam incidence attenuation correction factors only. Whereas when the beam is obliquely incident on the couch, base plate, headrest and any other immobilization device get attenuated more than the direct beam incidence. The correction factors for oblique incidence beam attenuation are not configured in most of the commercially available treatment planning systems. Therefore, such high variations in dose delivery could lead to under-dosage to the target volume for treatments requiring multiple fields in IMRT and 3D-CRT and need to be corrected for monitor unit calculations.

Evaluating and modeling of photon beam attenuation by a standard treatment couch

The purpose of this study was to evaluate beam attenuation by treatment couch and build a treatment couch model in TPS to check for beam–couch intersection at the planning stage and deal with beam attenuation by treatment couch in dose calculation. In this study, a standard treatment couch, Siemens ZXT couch, has been incorporated into Pinnacle3 8.0 TPS, based on an existing TPS tool, model‐based segmentation (MBS). This was done by generating the couch's model from contours of the couch, together with the density information. Both the geometric and dosimetric accuracy of the couch model were evaluated. The test of beam–couch intersection prediction showed good agreement between predicted and measured results, and the differences were within 1° gantry rotation. For individual posterior oblique beams, the attenuation by metallic frames and PMMA couch top could reach nearly as high as 60% and 10%, respectively. For several posterior oblique beams (180°, 220°, 235°) that attenuated by the PMMA couch top, the calculated and measured dose distributions were compared. The dose differences at central axis were within 1%, and almost all points agreed with the calculations when the DD and DTA criteria of 3%/3 mm were adopted. The difference between calculated and measured attenuation factors were within 0.5%. This study demonstrates that the couch model created by MBS, which contains geometric and density information of the couch, can be used to detect the beam–couch intersection, and also is able to provide an accurate representation of the couch top attenuation properties in patient dose calculation.

PACS numbers: 87.55.D‐, 87.55.Gh, 87.55.km

Characterization of dose impact on IMRT and VMAT from couch attenuation for two Varian couches

In intensity-modulated radiation therapy (IMRT) and volumetric-modulated arc therapy (VMAT), the use of posterior oblique beams has become common. Beam attenuation by the treatment couch is not negligible when the couch is in the beam portal. In this study, we established the relationship of relative dose vs. beam angle for two Varian 21EX linacs, one equipped with the Exact couch (standard couch) with sliding side support rails, and the other equipped with the Exact image-guided radiation therapy (IGRT) carbon fiber couch. Measurements were performed using an ion chamber placed at the center of an acrylic cylindrical phantom positioned at the linac isocenter for 6 MV and 18 MV photon beams. Measurements were performed at three different field sizes (3 × 3, 5 × 5, and 10 × 10 cm2), and were repeated with the phantom positioned at different longitudinal locations on the couches. To evaluate beam attenuation by the standard couch in a clinical setting, two test IMRT plans and two test VMAT plans on the standard couch were delivered. The plans were generated with the sliding rails at the "in" position and delivered with the rails at both "in" and "out" positions. The dose difference to the ion chamber was determined. For oblique fields with 6 MV photons, the standard couch attenuated the radiation beam by up to 26.8%, while the carbon fiber IGRT couch attenuated the beam by up to 4.1%. In the clinical evaluation, the highest dose difference between rails set at the "in" and "out" positions was 2.6% in the IMRT case and 2.1% in the VMAT case. The magnitude of potential dose difference has been quantified and could be used for a quick estimation of dose difference due to couch attenuation in IMRT and VMAT.

Evaluation of two-dimensional bolus effect of immobilization/support devices on skin doses: a radiochromic EBT film dosimetry study in phantom

PURPOSE

In this study, the authors have quantified the two-dimensional (2D) perspective of skin dose increase using EBT film dosimetry in phantom in the presence of patient immobilization devices during conventional and IMRT treatments.

METHODS

For 6 MV conventional photon field, the authors evaluated and quantified the 2D bolus effect on skin doses for six different common patient immobilization/support devices, including carbon fiber grid with Mylar sheet, Orfit carbon fiber base plate, balsa wood board, Styrofoam, perforated AquaPlast sheet, and alpha-cradle. For 6 and 15 MV IMRT fields, a stack of two film layers positioned above a solid phantom was exposed at the air interface or in the presence of a patient alpha-cradle. All the films were scanned and the pixel values were converted to doses based on an established calibration curve. The authors determined the 2D skin dose distributions, isodose curves, and cross-sectional profiles at the surface layers with or without the immobilization/support device. The authors also generated and compared the dose area histograms (DAHs) and dose area products from the 2D skin dose distributions.

RESULTS

In contrast with 20% relative dose [(RD) dose relative to dmax on central axis] at 0.0153 cm in the film layer for 6 MV 10 x 10 cm2 open field, the average RDs at the same depth in the film layer were 71%, 69%, 55%, and 57% for Orfit, balsa wood, Styrofoam, and alpha-cradle, respectively. At the same depth, the RDs were 54% under a strut and 26% between neighboring struts of a carbon fiber grid with Mylar sheet, and between 34% and 56% for stretched perforated AquaPlast sheet. In the presence of the alpha-cradle for the 6 MV (15 MV) IMRT fields, the hot spot doses at the effective measurement depths of 0.0153 and 0.0459 cm were 140% and 150%, (83% and 89%), respectively, of the isocenter dose. The enhancement factor was defined as the ratio of a given DAH parameter (minimum dose received in a given area) with and without the support device. For 6 MV conventional 10 x 10 cm2 field, the enhancement factor was the highest (3.4) for the Orfit carbon fiber plate. As for the IMRT field, the enhancement factors varied with the size of the area of interest and were as high as 3.8 (4.3) at the hot spot of 5 cm2 area in the top film layer (0.0153 cm) for 6 MV (15 MV) beams.

CONCLUSIONS

Significant 2D bolus effect on skin dose in the presence of patient support and immobilization devices was confirmed and quantified with EBT film dosimetry. Furthermore, the EBT film has potential application for in vivo monitoring of the 2D skin dose distributions during patient treatments.

Verification of IMRT dose calculations using AAA and PBC algorithms in dose buildup regions

The purpose of this comparative study was to test the accuracy of anisotropic analytical algorithm (AAA) and pencil beam convolution (PBC) algorithms of Eclipse treatment planning system (TPS) for dose calculations in the low- and high-dose buildup regions. AAA and PBC algorithms were used to create two intensity-modulated radiotherapy (IMRT) plans of the same optimal fluence generated from a clinically simulated oropharynx case in an in-house fabricated head and neck phantom. The TPS computed buildup doses were compared with the corresponding measured doses in the phantom using thermoluminescence dosimeters (TLD 100). Analysis of dose distribution calculated using PBC and AAA shows an increase in gamma value in the dose buildup region indicating large dose deviation. For the surface areas of 1, 50 and 100 cm2, PBC overestimates doses as compared to AAA calculated value in the range of 1.34%-3.62% at 0.6 cm depth, 1.74%-2.96% at 0.4 cm depth, and 1.96%-4.06% at 0.2 cm depth, respectively. In high-dose buildup region, AAA calculated doses were lower by an average of -7.56% (SD = 4.73%), while PBC was overestimated by 3.75% (SD = 5.70%) as compared to TLD measured doses at 0.2 cm depth. However, at 0.4 and 0.6 cm depth, PBC overestimated TLD measured doses by 5.84% (SD = 4.38%) and 2.40% (SD = 4.63%), respectively, while AAA underestimated the TLD measured doses by -0.82% (SD = 4.24%) and -1.10% (SD = 4.14%) at the same respective depth. In low-dose buildup region, both AAA and PBC overestimated the TLD measured doses at all depths except -2.05% (SD = 10.21%) by AAA at 0.2 cm depth. The differences between AAA and PBC at all depths were statistically significant (p < 0.05) in high-dose buildup region, whereas it is not statistically significant in low-dose buildup region. In conclusion, AAA calculated the dose more accurately than PBC in clinically important high-dose buildup region at 0.4 cm and 0.6 cm depths. The use of an orfit cast increases the dose buildup effect, and this buildup effect decreases with depth.

Evaluation of the 'dose of the day' for IMRT prostate cancer patients derived from portal dose measurements and cone-beam CT

PURPOSE

High geometrical and dosimetrical accuracies are required for radiotherapy treatments where IMRT is applied in combination with narrow treatment margins in order to minimize dose delivery to normal tissues. As an overall check, we implemented a method for reconstruction of the actually delivered 3D dose distribution to the patient during a treatment fraction, i.e., the 'dose of the day'. In this article results on the clinical evaluation of this concept for a group of IMRT prostate cancer patients are presented.

MATERIALS AND METHODS

The actual IMRT fluence maps delivered to a patient were derived from measured EPID-images acquired during treatment using a previously described iterative method. In addition, the patient geometry was obtained from in-room acquired cone-beam CT images. For dose calculation, a mapping of the Hounsfield Units from the planning CT was applied. With the fluence maps and the modified cone-beam CT the 'dose of the day' was calculated. The method was validated using phantom measurements and evaluated clinically for 10 prostate cancer patients in 4 or 5 fractions.

RESULTS

The phantom measurements showed that the delivered dose could be reconstructed within 3%/3mm accuracy. For prostate cancer patients, the isocenter dose agreed within -0.4+/-1.0% (1 SD) with the planned value, while for on average 98.1% of the pixels within the 50% isodose surface the actually delivered dose agreed within 3% or 3mm with the planned dose. For most fractions, the dose coverage of the prostate volume was slightly deteriorated which was caused by small prostate rotations and small inaccuracies in fluence delivery. The dose that was delivered to the rectum remained within the constraints used during planning. However, for two patients a large degrading of the dose delivery was observed in two fractions. For one patient this was related to changes in rectum filling with respect to the planning CT and for the other to large intra-fraction motion during treatment delivery, resulting in mean underdosages of 16% in the prostate volume.

CONCLUSIONS

A method to accurately assess the 'dose of the day' was evaluated for prostate cancer patients treated with IMRT. To correct for observed dose deviations off-line dose-adaptive strategies will be developed.

Megavoltage photon beam attenuation by carbon fiber couch tops and its prediction using correction factors

The purpose of this study was to evaluate the effect of megavoltage photon beam attenuation (PBA) by couch tops and to propose a method for correction of PBA. Four series of phantom measurements were carried out. First, PBA by the exact couch top (ECT, Varian) and Imaging Couch Top (ICT, BrainLAB) was evaluated using a water-equivalent phantom. Second, PBA by Type-S system (Med-Tec), ECT and ICT was compared with a spherical phantom. Third, percentage depth dose (PDD) after passing through ICT was measured to compare with control data of PDD. Forth, the gantry angle dependency of PBA by ICT was evaluated. Then, an equation for PBA correction was elaborated and correction factors for PBA at isocenter were obtained. Finally, this method was applied to a patient with hepatoma. PBA of perpendicular beams by ICT was 4.7% on average. With the increase in field size, the measured values became higher. PBA by ICT was greater than that by Type-S system and ECT. PBA increased significantly as the angle of incidence increased, ranging from 4.3% at 180 degrees to 11.2% at 120 degrees . Calculated doses obtained by the equation and correction factors agreed quite well with the measured doses between 120 degrees and 180 degrees of angles of incidence. Also in the patient, PBA by ICT was corrected quite well by the equation and correction factors. In conclusion, PBA and its gantry angle dependency by ICT were observed. This simple method using the equation and correction factors appeared useful to correct the isocenter dose when the PBA effect cannot be corrected by a treatment planning system.

Assessment and management of radiotherapy beam intersections with the treatment couch

The impact of the treatment couch on a radiotherapy plan is rarely fully assessed during the treatment planning process. Incorporating a couch model into the treatment planning system (TPS) enables the planner to avoid or dosimetrically evaluate beam-couch intersections. In this work, we demonstrate how existing TPS tools can be used to establish this capability and assess the accuracy and effectiveness of the system through dose measurements and planning studies. Such capabilities may be particularly relevant for the planning of arc therapies.Treatment couch top models were introduced into a TPS by fusing their CT image sets with the patient CT dataset. Regions of interest characterizing couch elements were then imported and assigned appropriate densities in the TPS. Measurements in phantom agreed with TPS calculations to within 2% dose and 1 degrees gantry rotation. To clinically validate the model, a retrospective study was performed on patient plans that posed difficulties in beam-couch intersection during setup. Beam-couch intersection caused up to a 3% reduction in PTV coverage, defined by the 95% of the prescribed dose, and up to a 1% reduction in mean CTV coverage. Dose compensation strategies for IMRT treatments with beams passing through couch elements were investigated using a four-field IMRT plan with three beams passing through couch elements. In this study, ignoring couch effects resulted in point dose reductions of 8 +/- 3%.A methodology for incorporating detailed couch characteristics into a TPS has been established and explored. The method can be used to predict beam-couch intersections during planning, potentially eliminating the need for pretreatment appointments. Alternatively, if a beam-couch intersection problem arises, the impact of the couch can be assessed on a case-by-case basis and a clinical decision made based on full dosimetric information.

Determination of the photon beam attenuation by the Brainlab imaging couch: angular and field size dependence

Highly attenuating radiation treatment couches are no longer useful in the present era of radiotherapy utilizing IMRT and IGRT. Carbon fibers couch tops with its high tensile strength and low density present a useful alternative. The objective of the current study was to quantify the attenuation of megavoltage photons through a Brainlab imaging couch top and headrest at various angles and field sizes. At normal incidence, the couch attenuated 6 MV photons by 4.9% and 3.4% for 5 x 5 cm(2) and 10 x 10 cm(2) field sizes respectively. The headrest on the other hand only attenuated 6 MV photons by 2.5% and 1.6% respectively. There was no significant attenuation of the 18 MV beam by either the couch or the headrest. We found the attenuation to be dependent on the gantry angle, with the highest attenuation recorded at 1200. At this angle, the couch attenuated the 6 MV photon beam by 10% and 8.3% for the 5 x 5 cm(2) and 10 x 10 cm(2) field sizes respectively. Similarly, 18 MV photon beam was attenuated by 3.6% and 3.4% for the 5 x 5 cm(2) and 10 x 10 cm(2) field sizes at 1200 gantry angle. The highest attenuation for the headrest on the other hand occurred at 110 degrees gantry angle. For the 6 MV photon beam the headrest attenuation at this angle was 6.3% and 5.6% for the 5 x 5 cm(2) and 10 x 10 cm(2) field sizes respectively. Similarly for the 18 MV the attenuation was 2.3% and 2.1% 5 x 5 cm(2) and 10 x 10 cm(2) field sizes respectively. It apparent that the use of the Brainlab imaging couch and headrest in IMRT with posterior beams will results in significant decrease in the dose delivered to the target.

[MLC positioning checks and calibration with a portal imaging system]

For checking the leaf positions of a MLC (Multi Leaf Collimator) images are acquired with an EPID (Electronic Portal Imaging Device) and then evaluated with a programme (MLC check) developed in-house. During image acquisition a Perspex tray with two metal markers of known position (in the radiation field) is inserted in the satellite tray holder. After determination of the marker positions within the image coordinate system, the image can be transformed to the radiation field coordinate system. This allows the exact determination of the leaf tip positions relative to the radiation field. This evaluation can be applied to images of arbitrary field shapes, provided they were acquired in the same geometry (EPID position, gantry and collimator angles). The entire measurement procedure is based on images in bmp (Windows Bitmap) format, with a 1024 x 1024 matrix and a pixel depth of 24 bit (8 bit per color channel). A suitable marker plate can be manufactured without sophisticated workload; thus the method may be easily and cost effectively adapted at other locations.

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

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

Investigating treatment dose error due to beam attenuation by a carbon fiber tabletop

Carbon fiber is commonly used in radiation therapy for treatment tabletops and various immobilization and support devices, partially because it is generally perceived to be almost radiotransparent to high-energy photons. To avoid exposure to normal tissue during modern radiation therapy, one must deliver the radiation from all gantry angles; hence, beams often transit the couch proximal to the patient. The effects of the beam attenuation by the support structure of the couch are often neglected in the planning process. In this study, we investigate the attenuation of 6-MV and 18-MV photon beams by a Medtec (Orange City, IA) carbon fiber couch. We have determined that neglecting the attenuation of oblique treatment fields by the carbon fiber couch can result in localized dose reduction from 4% to 16%, depending on energy, field size, and geometry. Further, we investigate the ability of a commercial treatment-planning system (Theraplan Plus v3.8) to account for the attenuation by the treatment couch. Results show that incorporating the carbon fiber couch in the patient model reduces the dose error to less than 2%. The variation in dose reduction as a function of longitudinal couch position was also measured. In the triangular strut region of the couch, the attenuation varied +/- 0.5% following the periodic nature of the support structure. Based on these findings, we propose the routine incorporation of the treatment tabletop into patient treatment planning dose calculations.

A novel approach to accurate portal dosimetry using CCD-camera based EPIDs

A new method for portal dosimetry using CCD camera-based electronic portal imaging devices (CEPIDs) is demonstrated. Unlike previous approaches, it is not based on a priori assumptions concerning CEPID cross-talk characteristics. In this method, the nonsymmetrical and position-dependent cross-talk is determined by directly imaging a set of cross-talk kernels generated by small fields ("pencil beams") exploiting the high signal-to-noise ratio of a cooled CCD camera. Signal calibration is achieved by imaging two reference fields. Next, portal dose images (PDIs) can be derived from electronic portal dose images (EPIs), in a fast forward-calculating iterative deconvolution. To test the accuracy of these EPI-based PDIs, a comparison is made to PDIs obtained by scanning diode measurements. The method proved accurate to within 0.2+/-0.7% (1 SD), for on-axis symmetrical and asymmetrical fields with different field widths and homogeneous phantom thicknesses, off-axis Alderson thorax fields and a strongly modulated IMRT field. Hence, the proposed method allows for fast, accurate portal dosimetry. In addition, it is demonstrated that the CEPID cross-talk signal is not only induced by optical photon reflection and scatter within the CEPID structure, but also by high-energy back-scattered radiation from CEPID elements (mirror and housing) towards the fluorescent screen.

Evaluation of the Sinmed Mastercouch® as replacement for a standard couch

BACKGROUND AND PURPOSE

Introducing into practice a new carbon-fibre couch necessitates its evaluation with regard to the present clinical situation.

MATERIALS AND METHODS

In this study, a geometric and dosimetric evaluation has been made for the Sinmed Mastercouch as a replacement for the Elekta C-arm couch with Mylar-tennis racket combination. Geometrically, feasible gantry angles with regard to collision and beam intersection were discriminated as function of isocentric table rotation for 10 treatment isocentres. Dosimetrically, the build-up distortion and attenuation by the aforementioned tabletops and a carbon-fibre tabletop of an Elekta Precise simulator was measured. Finally, the clinical implications of these influences were assessed for a 3-field prostate treatment in three configurations: Mastercouch, C-arm couch and no-intersection situation.

RESULTS

With regard to collision, the largest advantages are observed for the Mastercouch with the Omega-shaped treatment module compared to the C-arm couch for isocentres located in the upper part of the body, thanks to its shape and the absence of any metal. Dosimetrically, one has to take into account the build-up loss and attenuation by beam intersection with Mastercouch and the carbon-fibre edges of the tennis racket (C-arm couch). The clinical relevance of these dosimetric aspects depends on the dose delivered by the compromised beams.

The effect of gantry angle on megavoltage photon beam attenuation by a carbon fiber couch insert

The use of rigid carbon fiber couch inserts in radiotherapy treatment couches is a well-established method of reducing patient set-up errors associated with couch sag. Several published studies have described such inserts as radiotranslucent with negligible attenuation of the radiation field. Most of these studies were conducted with the radiation field normally incident on the couch and there appears to be no evidence in the literature of the effect of the gantry angle on the extent of beam attenuation by the carbon fiber insert alone during external beam radiotherapy. In this study we examined the magnitude of this effect over a range of posterior oblique gantry angles using a cylindrical solid water phantom containing an ionization chamber placed isocentrically. It was found that a 6 MV photon beam, field size 10 x 5 cm, was attenuated significantly as the gantry angle approached the plane of the couch, from 2% at normal incidence and reaching 9% attenuation at angle of incidence 70 degrees. This could have serious implications regarding dose to the treatment volume for treatments requiring posterior oblique angles of incidence with a possible correction factor necessary in monitor unit calculations.

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

PURPOSE

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

METHODS AND MATERIALS

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

RESULTS

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

CONCLUSIONS

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