Dosimetric IMRT verification with a flat-panel EPID

A preliminary study of multispectral Cherenkov imaging and a Fricke-xylenol orange gel film (MCIFF) for online, absolute dose measurement

BACKGROUND

Cherenkov luminescence imaging has shown potential for relative dose distribution and field verification in radiation therapy. However, to date, limited research utilizing Cherenkov luminescence for absolute dose calibration has been conducted owing to uncertainties arising from camera positioning and tissue surface optical properties.

PURPOSE

This paper introduces a novel approach to multispectral Cherenkov luminescence imaging combined with Fricke-xylenol orange gel (FXG) film, termed MCIFF, which can enable online full-field absolute dose measurement. By integrating these two approaches, MCIFF allows for calibration of the ratio between two spectral intensities with absorbed dose, thereby enabling absolute dose measurement.

METHODS

All experiments are conducted on a Varian Clinac 23EX, utilizing an electron multiplying charge-coupled device (EMCCD) camera and a two-way image splitter for simultaneous capture of two-spectral Cherenkov imaging. In the first part of this study, the absorbance curves of the prepared FXG film, which receives different doses, are measured using a fluorescence spectrophotometer to verify the correlation between absorbance and dose. In the second part, the FXG film is positioned directly under the radiation beam to corroborate the dose measurement capacity of MCIFF across various beams. In the third part, the feasibility of MCIFF is tested in actual radiotherapy settings via a humanoid model, demonstrating its versatility with various radiotherapy materials.

RESULTS

The results of this study indicate that the logarithmic ratios of spectral intensities at wavelengths of 550 ± 50 and 700 ± 100 nm accurately reflect variations in radiation dose (R2 > 0.96) across different radiation beams, particle energies, and dose rates. The slopes of the fitting lines remain consistent under varying beam conditions, with discrepancies of less than 8%. The optical profiles obtained using the MCIFF exhibit a satisfactory level of agreement with the measured results derived from the treatment planning system (TPS) and EBT3 films. Specifically, for photon beams, the lateral distances between the 80% and 20% isodose lines, referred to as the penumbra (P80-20) values, obtained through TPS, EBT3 films, and MCIFF, are determined as 0.537, 0.664, and 0.848 cm, respectively. Similarly, for electron beams, the P80-20 values obtained through TPS, EBT3 films, and MCIFF are found to be 0.432, 0.561, and 0.634 cm, respectively. Furthermore, imaging of the anthropomorphic phantom demonstrates the practical application of MCIFF in real radiotherapy environments.

CONCLUSION

By combining an FXG film with Cherenkov luminescence imaging, MCIFF can calibrate Cherenkov luminescence to absorbed dose, filling the gap in online 2D absolute dose measurement methods in clinical practice, and providing a new direction for the clinical application of optical imaging to radiation therapy.

Comparison of deep learning models for building two-dimensional non-transit EPID Dosimetry on Varian Halcyon

Background

This study compared the effectiveness of five deep learning models in constructing non-transit dosimetry with an a-Si electronic portal imaging device (EPID) on Varian Halcyon. Deep learning model is increasingly used to support prediction and decision-making in several fields including oncology and radiotherapy.

Materials and methods

Forty-seven unique plans of data obtained from breast cancer patients were calculated using Eclipse treatment planning system (TPS) and extracted from DICOM format as the ground truth. Varian Halcyon was then used to irradiate the a-Si 1200 EPID detector without an attenuator. The EPID and TPS images were augmented and divided randomly into two groups of equal sizes to distinguish the validation and training-test data. Five different deep learning models were then created and validated using a gamma index of 3%/3 mm.

Results

Four models successfully improved the similarity of the EPID images and the TPS-generated planned dose images. Meanwhile, the mismatch of the constituent components and number of parameters could cause the models to produce wrong results. The average gamma pass rates were 90.07 ± 4.96% for A-model, 77.42 ± 7.18% for B-model, 79.60 ± 6.56% for C-model, 80.21 ± 5.88% for D-model, and 80.47 ± 5.98% for E-model.

Conclusion

The deep learning model is proven to run fast and can increase the similarity of EPID images with TPS images to build non-transit dosimetry. However, more cases are needed to validate this model before being used in clinical activities.

Development of a novel delivery quality assurance system based on simultaneous verification of dose distribution and binary multi-leaf collimator opening in helical tomotherapy

BACKGROUND

Intensity-modulated radiation therapy (IMRT) requires delivery quality assurance (DQA) to ensure treatment accuracy and safety. Irradiation techniques such as helical tomotherapy (HT) have become increasingly complex, rendering conventional verification methods insufficient. This study aims to develop a novel DQA system to simultaneously verify dose distribution and multi-leaf collimator (MLC) opening during HT.

METHODS

We developed a prototype detector consisting of a cylindrical plastic scintillator (PS) and a cooled charge-coupled device (CCD) camera. Scintillation light was recorded using a CCD camera. A TomoHDA (Accuray Inc.) was used as the irradiation device. The characteristics of the developed system were evaluated based on the light intensity. The IMRT plan was irradiated onto the PS to record a moving image of the scintillation light. MLC opening and light distribution were obtained from the recorded images. To detect MLC opening, we placed a region of interest (ROI) on the image, corresponding to the leaf position, and analyzed the temporal change in the light intensity within each ROI. Corrections were made for light changes due to differences in the PS shape and irradiation position. The corrected light intensity was converted into the leaf opening time (LOT), and an MLC sinogram was constructed. The reconstructed MLC sinogram was compared with that calculated using the treatment planning system (TPS). Light distribution was obtained by integrating all frames obtained during IMRT irradiation. The light distribution was compared with the dose distribution calculated using the TPS.

RESULTS

The LOT and the light intensity followed a linear relationship. Owing to MLC movements, the sensitivity and specificity of the reconstructed sinogram exceeded 97%, with an LOT error of - 3.9 ± 7.8%. The light distribution pattern closely resembled that of the dose distribution. The average dose difference and the pass rate of gamma analysis with 3%/3 mm were 1.4 ± 0.2% and 99%, respectively.

CONCLUSION

We developed a DQA system for simultaneous and accurate verification of both dose distribution and MLC opening during HT.

Preliminary study on dosimetry characteristics of a novel cylindrical dose verification system

OBJECTIVE

To develop a novel ionization chamber array dosimetry system, study its dosimetry characteristics, and perform preliminary tests for plan dose verification.

METHODS

The dosimetry characteristics of this new array were tested, including short-term and long-term reproducibility, dose linearity, dose rate dependence, field size dependence, and angular dependence. The open field and MLC field plans were designed for dose testing. Randomly select 30 patient treatment plans (10 intensity-modulated radiation therapy [IMRT] plans and 20 volumetric modulated arc therapy [VMAT] plans) that have undergone dose verification using Portal Dosimetry to perform verification measurement and evaluate dose verification test results.

RESULTS

The dosimetry characteristics of the arrays all performed well. The gamma passing rates (3%/2 mm) were more than 96% for the combined open field and MLC field plans. The average gamma pass rates were (99.54 ± 0.58)% and (96.70 ± 3.41)% for the 10 IMRT plans and (99.32 ± 0.89)% and (94.91 ± 6.01)% for the 20 VMAT plans at the 3%/2 mm and 2%/2 mm criteria, respectively, which is similar to the Portal Dosimetry's measurement results.

CONCLUSIONS

This novel ionization chamber array demonstrates good dosimetry characteristics and is suitable for clinical IMRT and VMAT plan verifications.

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

PURPOSE

Electronic portal imaging devices (EPIDs) have been widely utilized for patient-specific quality assurance (PSQA) and their use for transit dosimetry applications is emerging. Yet there are no specific guidelines on the potential uses, limitations, and correct utilization of EPIDs for these purposes. The American Association of Physicists in Medicine (AAPM) Task Group 307 (TG-307) provides a comprehensive review of the physics, modeling, algorithms and clinical experience with EPID-based pre-treatment and transit dosimetry techniques. This review also includes the limitations and challenges in the clinical implementation of EPIDs, including recommendations for commissioning, calibration and validation, routine QA, tolerance levels for gamma analysis and risk-based analysis.

METHODS

Characteristics of the currently available EPID systems and EPID-based PSQA techniques are reviewed. The details of the physics, modeling, and algorithms for both pre-treatment and transit dosimetry methods are discussed, including clinical experience with different EPID dosimetry systems. Commissioning, calibration, and validation, tolerance levels and recommended tests, are reviewed, and analyzed. Risk-based analysis for EPID dosimetry is also addressed.

RESULTS

Clinical experience, commissioning methods and tolerances for EPID-based PSQA system are described for pre-treatment and transit dosimetry applications. The sensitivity, specificity, and clinical results for EPID dosimetry techniques are presented as well as examples of patient-related and machine-related error detection by these dosimetry solutions. Limitations and challenges in clinical implementation of EPIDs for dosimetric purposes are discussed and acceptance and rejection criteria are outlined. Potential causes of and evaluations of pre-treatment and transit dosimetry failures are discussed. Guidelines and recommendations developed in this report are based on the extensive published data on EPID QA along with the clinical experience of the TG-307 members.

CONCLUSION

TG-307 focused on the commercially available EPID-based dosimetric tools and provides guidance for medical physicists in the clinical implementation of EPID-based patient-specific pre-treatment and transit dosimetry QA solutions including intensity modulated radiation therapy (IMRT) and volumetric modulated arc therapy (VMAT) treatments.

A convolutional neural network model for EPID-based non-transit dosimetry

PURPOSE

To develop an alternative computational approach for EPID-based non-transit dosimetry using a convolutional neural network model.

METHOD

A U-net followed by a non-trainable layer named True Dose Modulation recovering the spatialized information was developed. The model was trained on 186 Intensity-Modulated Radiation Therapy Step & Shot beams from 36 treatment plans of different tumor locations to convert grayscale portal images into planar absolute dose distributions. Input data were acquired from an amorphous-Silicon Electronic Portal Image Device and a 6 MV X-ray beam. Ground truths were computed from a conventional kernel-based dose algorithm. The model was trained by a two-step learning process and validated through a five-fold cross-validation procedure with sets of training and validation of 80% and 20%, respectively. A study regarding the dependance of the amount of training data was conducted. The performance of the model was evaluated from a quantitative analysis based the ϒ-index, absolute and relative errors computed between the inferred dose distributions and ground truths for six square and 29 clinical beams from seven treatment plans. These results were also compared to those of an existing portal image-to-dose conversion algorithm.

RESULTS

For the clinical beams, averages of ϒ-index and ϒ-passing rate (2%-2mm > 10% D_max ) of 0.24 (±0.04) and 99.29 (±0.70)% were obtained. For the same metrics and criteria, averages of 0.31 (±0.16) and 98.83 (±2.40)% were obtained with the six square beams. Overall, the developed model performed better than the existing analytical method. The study also showed that sufficient model accuracy can be achieved with the amount of training samples used.

CONCLUSION

A deep learning-based model was developed to convert portal images into absolute dose distributions. The accuracy obtained shows that this method has great potential for EPID-based non-transit dosimetry.

Enhanced Cherenkov imaging for real-time beam visualization by applying a novel carbon quantum dot sheeting in radiotherapy

BACKGROUND

Cherenkov imaging can be used to visualize the placement of the beam directly on the patient's surface tissue and evaluate the accuracy of treatment planning. However, Cherenkov emission intensity is lower than ambient light. At present, time gating is the only way to realize Cherenkov imaging with ambient light.

PURPOSE

This study proposes preparing a novel carbon quantum dot (cQD) sheeting to adjust the wavelength of Cherenkov emission to obtain the optimal wavelength meeting the sensitive detection region of the camera, meanwhile the total optical signal is also increased. By combining a specific filter, this approach might help in using lower-cost camera systems without intensifier-coupled to accomplish in vivo monitoring of the surface beam profile on patients with ambient light.

METHODS

The cQD sheetings were prepared by spin coating and UV curing with different concentrations. All experiments were performed on the Varian VitalBeam system and optical emission was captured using an electron multiplying charge-coupled device (EMCCD) camera. To quantify the optical characteristics and certify the improvement of light intensity as well as signal-to-noise ratio (SNR) of cQD sheeting, the first part of the study was carried out on solid water with 6 and 10 MV photon beams. The second part was carried out on an anthropomorphic phantom to explore the applicability of sheeting when using different radiotherapy materials and the imaging effect of sheeting with the impact of ambient light sources. Additionally, thanks to the narrow emission spectrum of the cQD, a band-pass filter was tested to reduce the effect from environmental lights.

RESULTS

The experimental results show that the optical intensity collected with sheeting has an excellent linear relationship (R²  > 0.99) with the dose for 6 and 10 MV photons. The full-width half maximum (FWHM) in x and y axis matched with the measured EBT film image, with accuracy in the range of ±1.2 and ±2.7 mm standard deviation, respectively. CQD sheeting can significantly improve the light intensity and SNR of optical images. Using 0.1 mg/ml sheeting as an example, the signal intensity is increased by 209%, and the SNR is increased by 147.71% at 6 MV photons. The imaging on the anthropomorphic phantom verified that cQD sheeting could be applied to different radiotherapy materials. The average optical intensity increased by about 69.25%, 63.72%, and 61.78%, respectively, after adding cQD sheeting to bolus, mask sample and the combination of bolus and mask. Corresponding SNR is improved by about 62.78%, 56.77%, and 68.80%, respectively. Through the sheeting, optical images with SNR > 5 can be obtained in the presence of ambient light and it can be improved through combining with a band-pass filter. When red ambient lights are on, the SNR is increased by about 98.85% after adding a specific filter.

CONCLUSION

Through a combination of cQD sheeting and corresponding filter, light intensity and SNR of optical images can be increased significantly, and it shed new light on the promotion of the clinical application of optical imaging to visualize the beam in radiotherapy.

The fast calibration model for dosimetry with an electronic portal imaging device

PURPOSE

The aim of this study was to develop an algorithm that corrects the image of an electronic portal imaging device (EPID) of a linear accelerator so that it can be used for dosimetric purposes, such as in vivo dosimetry or quality assurance for photon radiotherapy. For that purpose, the impact of the field size, phantom thickness, and the varying spectral photon distribution within the irradiation field on the EPID image was investigated.

METHODS

The EPID measurements were verified using reference measurements with ionization chambers. Therefore, absolute dose measurements with an ionization chamber and relative dose measurements with a detector array were performed. An EPID calibration and correction algorithm was developed to convert the EPID image to a dose distribution. The algorithm was validated by irradiating inhomogeneous phantoms using square fields as well as irregular IMRT fields.

RESULTS

It was possible to correct the influence of the field size, phantom thickness on the EPID signal as well as the homogenization of the image profile by several correction factors within 0.6%. A gamma index analysis (3%, 3 mm) of IMRT fields showed a pass rate of above 99%, when comparing to the planning system.

CONCLUSION

The developed algorithm enables an online dose measurement with the EPID during the radiation treatment. The algorithm is characterized by a robust, non-iterative, and thus real-time capable procedure with little measuring effort and does not depend on system-specific parameters. The EPID image is corrected by multiplying three independent correction factors. Therefore, it can easily be extent by further correction factors for other influencing variables, so it can be transferred to other linear accelerators and EPID configurations.

A method for in vivo treatment verification of IMRT and VMAT based on electronic portal imaging device

Background

Intensity-modulated radiation therapy (IMRT) and volume-modulated arc therapy (VMAT) are rather complex treatment techniques and require patient-specific quality assurance procedures. Electronic portal imaging devices (EPID) are increasingly used in the verification of radiation therapy (RT). This work aims to develop a novel model to predict the EPID transmission image (TI) with fluence maps from the RT plan. The predicted TI is compared with the measured TI for in vivo treatment verification.

Methods

The fluence map was extracted from the RT plan and corrections of penumbra, response, global field output, attenuation, and scatter were applied before the TI was calculated. The parameters used in the model were calculated separately for central axis and off-axis points using a series of EPID measurement data. Our model was evaluated using a CIRS thorax phantom and 20 clinical plans (10 IMRT and 10 VMAT) optimized for head and neck, breast, and rectum treatments.

Results

Comparisons of the predicted and measured images were carried out using a global gamma analysis of 3%/2 mm (10% threshold) to validate the accuracy of the model. The gamma pass rates for IMRT and VMAT were greater than 97.2% and 94.5% at 3%/2 mm, respectively.

Conclusion

We have developed an accurate and straightforward EPID-based quality assurance model that can potentially be used for in vivo treatment verification of the IMRT and VMAT delivery.

Deep learning-enabled EPID-based 3D dosimetry for dose verification of step-and-shoot radiotherapy

PURPOSE

The study aims at a novel dosimetry methodology to reconstruct a 3D dose distribution as imparted to a virtual cylindrical phantom using an electronic portal imaging device (EPID).

METHODS

A deep learning-based signal processing strategy, referred to as 3DosiNet, is utilized to learn a mapping from an EPID image to planar dose distributions at given depths. The network was trained with the volumetric dose exported from the clinical treatment planning system (TPS). Given the latent inconsistency between measurements and corresponding TPS calculations, unsupervised learning is formulated in 3DosiNet to capture abstractive image features that are less sensitive to the potential variations.

RESULTS

Validation experiments were performed using five regular fields and three clinical intensity-modulated radiation therapy (IMRT) cases. The measured dose profiles and percentage depth dose (PDD) curves were compared with those measured using standard tools in terms of the 1D gamma index. The mean gamma pass rates (2%/2 mm) over the regular fields are 100% and 97.3% for the dose profile and PDD measurements, respectively. The measured volumetric dose was compared to the corresponding TPS calculation in terms of the 3D gamma index. The mean 2%/2 mm gamma pass rates are 97.9% for square fields and 94.9% for the IMRT fields.

CONCLUSIONS

The system promises to be a practical 3D dosimetric tool for pre-treatment patient-specific quality assurance and further developed for in-treatment patient dose monitoring.

Validation of a secondary dose check tool against Monte Carlo and analytical clinical dose calculation algorithms in VMAT

PURPOSE

Patient-specific quality assurance (QA) is very important in radiotherapy, especially for patients with highly conformed treatment plans like VMAT plans. Traditional QA protocols for these plans are time-consuming reducing considerably the time available for patient treatments. In this work, a new MC-based secondary dose check software (SciMoCa) is evaluated and benchmarked against well-established TPS (Monaco and Pinnacle3 ) by means of treatment plans and dose measurements.

METHODS

Fifty VMAT plans have been computed using same calculation parameters with SciMoCa and the two primary TPSs. Plans were validated with measurements performed with a 3D diode detector (ArcCHECK) by translating patient plans to phantom geometry. Calculation accuracy was assessed by measuring point dose differences and gamma passing rates (GPR) from a 3D gamma analysis with 3%-2 mm criteria. Comparison between SciMoCa and primary TPS calculations was made using the same estimators and using both patient and phantom geometry plans.

RESULTS

TPS and SciMoCa calculations were found to be in very good agreement with validation measurements with average point dose differences of 0.7 ± 1.7% and -0.2 ± 1.6% for SciMoCa and two TPSs, respectively. Comparison between SciMoCa calculations and the two primary TPS plans did not show any statistically significant difference with average point dose differences compatible with zero within error for both patient and phantom geometry plans and GPR (98.0 ± 3.0% and 99.0 ± 3.0% respectively) well in excess of the typical 95 % clinical tolerance threshold.

CONCLUSION

This work presents results obtained with a significantly larger sample than other similar analyses and, to the authors' knowledge, compares SciMoCa with a MC-based TPS for the first time. Results show that a MC-based secondary patient-specific QA is a clinically viable, reliable, and promising technique, that potentially allows significant time saving that can be used for patient treatment and a per-plan basis QA that effectively complements traditional commissioning and calibration protocols.

Clinical translation of a new flat-panel detector for beam's-eye-view imaging

Electronic portal imaging devices (EPIDs) lend themselves to beams-eye view clinical applications, such as tumor tracking, but are limited by low contrast and detective quantum efficiency (DQE). We characterize a novel EPID prototype consisting of multiple layers and investigate its suitability for use under clinical conditions. A prototype multi-layer imager (MLI) was constructed utilizing four conventional EPID layers, each consisting of a copper plate, a Gd2O2S:Tb phosphor scintillator, and an amorphous silicon flat panel array detector. We measured the detector's response to a 6 MV photon beam with regards to modulation transfer function, noise power spectrum, DQE, contrast-to-noise ratio (CNR), signal-to-noise ratio (SNR), and the linearity of the detector's response to dose. Additionally, we compared MLI performance to the single top layer of the MLI and the standard Varian AS-1200 detector. Pre-clinical imaging was done on an anthropomorphic phantom, and the detector's CNR, SNR and spatial resolution were assessed in a clinical environment. Images obtained from spine and liver patient treatment deliveries were analyzed to verify CNR and SNR improvements. The MLI has a DQE(0) of 9.7%, about 5.7 times the reference AS-1200 detector. Improved noise performance largely drives the increase. CNR and SNR of clinical images improved three-fold compared to reference. A novel MLI was characterized and prepared for clinical translation. The MLI substantially improved DQE and CNR performance while maintaining the same resolution. Pre-clinical tests on an anthropomorphic phantom demonstrated improved performance as predicted theoretically. Preliminary patient data were analyzed, confirming improved CNR and SNR. Clinical applications are anticipated to include more accurate soft tissue tracking.

Clinical Experience of Intensity Modulated Radiotherapy Pre-Treatment Quality Assurance for Carcinoma Head and Neck Patients with EPID and IMatriXX in Rural Center

BACKGROUND

Radiation therapy techniques as Intensity Modulated Radiotherapy (IMRT), rapid arc have been used for treatment of cancer with high accuracy.

OBJECTIVE

Verification of planned and delivered dose distribution is important, therefore current study aims to analyse quality assurance (QA) results of IMRT by Electronic Portal Imaging Device (EPID) and IMatriXX in head and neck Carcinoma (Ca H&N) patients.

MATERIAL AND METHODS

In this experimental study, performance of an EPID and IMatriXX was assessed with dose measurements using ionization chamber. Calibrated IMatriXX and EPID are used for pre-treatment patient specific quality assurance (PSQA), for 122 patients' plans of Ca H&N with IMRT treatment technique on linear accelerator. Dose images were acquired and compared with gamma evaluation (3% / 3 mm) and three scalar parameters, named average γ (γ_avg), maximum γ (γ_max) and area gamma <1, were analyzed in the region of interest.

RESULTS

The γ correlation comparisons yielded average correlation of 0.990 and 0.982 for IMatriXX and EPID respectively. Maximum value of gamma is 0.998, while minimum gamma is 0.872 for IMatriXX and 0.953 for EPID. For students, unpaired 't' test analysis is applied for comparison to two data sets. P-value was set at 0.005 which, for this study, was computed 0.001, showing good correlation between measured data with IMatriXX and EPID.

CONCLUSION

The EPID and IMatriXX have significantly improved dosimetric properties, resulting in more sensitive, accurate measurements before actual treatment. The result shows EPID can be replaced with other dosimetry method and ionization chamber measurements. Portal imager is an efficient, accurate and sensitive dosimetry tool and is also the basis of pre-treatment quality assurance protocol.

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

Aim:

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

Materials and Methods:

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

Results:

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

Conclusion:

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

Technical Note: Alternating clinical usage of the integral quality monitor transmission detector

PURPOSE

The purpose of the study was the implementation of a method to use the integral quality monitor (IQM) transmission detector for occasional, alternating usage during patient treatment with intensity modulated radiotherapy. Due to attenuation, the transmission detector must be taken into account during the planning process. The proposed workflow is based on determining a dynamic transmission factor (dTF) required to scale the total number of MU of the original radiotherapy (RT) plan. Thus a very similar radiation therapy plan is obtained that can be used with the IQM detector.

METHODS

Ten clinically applied volumetric modulated arc therapy plans were delivered at two beam qualities. A dTF is calculated from each RT plan for which a collapsed RT plan was created for verification using a two-dimensional array with and without the IQM detector. The total number of MU of the original RT plan was scaled by the inverse of the dTF to obtain the modified RT plan for clinical use with the IQM detector. Validation was performed with an electronic three-dimensional phantom and via gamma analysis using strict criteria of 1%/1 mm.

RESULTS

Except for one outlier, the gamma pass rate between the original RT plan without IQM and the modified RT plan with IQM was always above 99.5%. The variations of the dTF were smaller than 1% for all tested RT plans.

CONCLUSIONS

The results show that the proposed workflow can be used clinically. Thus the IQM transmission detector can also be used occasionally for online verification of RT plans.

Improved error detection using a divided treatment plan in volume modulated arc therapy

Aim

We sought to improve error detection ability during volume modulated arc therapy (VMAT) by dividing and evaluating the treatment plan.

Background

VMAT involves moving a beam source delivering radiation to tumor tissue through an arc, which significantly decreases treatment time. Treatment planning for VMAT involves many parameters. Quality assurance before treatment is a major focus of research.

Materials and methods

We used an established VMAT prostate treatment plan and divided it into 12° × 30° sections. In all the sections, only image data that generated errors in one segment and those that were integrally acquired were evaluated by a gamma analysis. This was done with five different patient plans.

Results

The integrated image data resulting from errors in each section was 100% (tolerance 0.5 mm/0.5%) in the gamma analysis result in all image data. Division of the treatment plans produced a shift in the mean value of each gamma analysis in the cranial, left, and ventral directions of 94.59%, 98.83%, 96.58%, and the discrimination ability improved.

Conclusion

The error discrimination ability was improved by dividing and verifying the portal imaging.

Pretreatment Dose Verification in Volumetric Modulated Arc Therapy Using Liquid Ionization Chamber

Purpose:

The purpose of the present study was to evaluate the practicability of liquid ionization chamber (LIC) for pretreatment dose verification of the advanced radiotherapy techniques such as volumetric modulated arc therapy (VMAT).

Materials and Methods:

The dosimetric characteristics of LIC such as repeatability, sensitivity, monitor unit linearity, dose rate dependence, angular dependence, voltage-current response, and output factors were investigated in 6 MV therapeutic X-ray beams. The LIC was cross-calibrated against 0.125-cc air-filled thimble ionization chamber. A dedicated dosimetry insert made up of Perspex to incorporate the LIC at proper location in the intensity-modulated radiation therapy thorax phantom was locally fabricated. The collection efficiency and ion recombination correction factor was determined using the two-dose rate method. Pretreatment dose verification measurement of VMAT treatment plans were carried out using the liquid ionization chamber as well as small volume (0.125 cc) air-filled thimble ionization chamber. The measured dose values by the two dosimeters and TPS calculated dose at a given point were compared.

Results:

The relative percentage differences between the TPS calculated and measured doses were within ± 1.57% for LIC and ± 2.21% for 0.125 cc ionization chamber, respectively.

Conclusions:

The measured dose values by the two dosimeters and TPS calculated dose at a given point were found comparable suggesting that the LIC could be a good choice of dosimeter for pretreatment dose verification in VMAT.

Technical Note: EPID's response to 6 MV photons in a strong, parallel magnetic field

PURPOSE

Electronic portal imaging devices (EPIDs) are potentially useful for dosimetric verification in integrated MRI-linac systems. This work presents the reproducibility, linearity, image lag, and radiation field profiles in a conventional EPID, with and without a 0.5 T parallel magnetic field present in a 6 MV photon beam.

METHODS

An aS500 EPID was modified to function in strong magnetic fields. All measurements were made using the linac-MR installed at the Cross Cancer Institute. The EPID remained stationary on the couch between the measurements made with and without magnetic field. We measured short-term reproducibility of dark and flood fields, signal linearity from 1 to 500 MU irradiations, and image lag post 100 MU irradiation. An ion chamber was used to measure any linac output variations to correct the EPID signal due to these variations for the duration of experiment. X-axis and Y-axis radiation field profiles were obtained from the EPID image resulting from a 10 × 10 cm² radiation field delivery.

RESULTS

The average pixel value (±standard deviation) of flood field with and without magnetic fields were 57,876 ± 379 and 57,703 ± 366, respectively, and the corresponding average dark field pixel values were -32.05 ± 0.85 and -32.19 ± 0.97. The maximum difference in image linearity data with and without magnetic field is 0.2% which is well within the measurement uncertainty of 0.65%. Similarly, the image lag curves, with and without the magnetic field, were nearly identical. The first measured point, with mean lag signal of 1.44% without and 1.41% with magnetic field, shows that the largest difference is well below the uncertainty in the EPID signal measurement. The radiation field profiles obtained with and without magnetic fields were nearly identical; 91.3% of the X-axis and 95.2% of the Y-axis profile points pass a gamma criterion of 1% and 1 mm.

CONCLUSIONS

A conventional EPID imager with a 0.1 cm copper plate responds to 6 MV photons similarly irrespective of the strong magnetic field being off or on in the parallel orientation to the radiation beam. Thus, the EPID is a potentially useful tool for pretreatment dosimetric verification in linac-MR systems using parallel magnetic field.

The experience of a developing country using an electronic portal imaging device for the verification of patient positioning and dosimetry in radiotherapy for prostate cancer

Purpose

This is a retrospective study to evaluate the efficacy and safety of routine use of electronic portal imaging device (EPID) in intensity-modulated radiation therapy for localised prostate cancer.

Materials and methods

Data from 20 patients with localised prostate cancer treated by radical radiotherapy using intensity-modulated technique in Habib Bourguiba Hospital were analysed to define the action levels for pretreatment planer dose distribution of 100 treatment fields and the set-up errors of 418 portal imaging. Pretreatment planar dose distribution was measured with the EPID. The additional dose from repeated portal imaging was determined with treatment planning system.

Results

For all 100 fields, the predicted and the measured planar dose distribution agrees well with mean±standard deviation value for γmax=2·31±0·57, γavg=0·36±0·07 and γ%≤1=98·94%±0·71%, respectively. For the evaluation of set-up errors, the mean total errors with 1 SD in the lateral, longitudinal and vertical directions were 0·11±0·44 cm; 0·02±0·37 cm and −0·02±0·21 cm, respectively. The imaging additional dose was evaluated as 1 cGy per monitor unit.

Conclusion

EPID is a useful tool to verify pretreatment dose distribution and to assess the correct field position without a significant increase in the absorbed dose due to the repetition of portal imaging.

Commissioning and Evaluation of an Electronic Portal Imaging Device-Based In-Vivo Dosimetry Software

This study reports on our experience with the in-vivo dose verification software, EPIgray® (DOSIsoft, Cachan, France). After the initial commissioning process, clinical experiments on phantom treatments were evaluated to assess the level of accuracy of the electronic portal imaging device (EPID) based in-vivo dose verification.

EPIgray was commissioned based on the company’s instructions. This involved ion chamber measurements and portal imaging of solid water blocks of various thicknesses between 5 and 35 cm. Field sizes varied between 2 x 2 cm² and 20 x 20 cm². The determined conversion factors were adjusted through an additional iterative process using treatment planning system calculations. Subsequently, evaluation was performed using treatment plans of single and opposed beams, as well as intensity modulated radiotherapy (IMRT) plans, based on recommendations from the task group report TG-119 to test for dose reconstruction accuracy. All tests were performed using blocks of solid water slabs as a phantom.

For single square fields, the dose at isocenter was reconstructed within 3% accuracy in EPIgray compared to the treatment planning system dose. Similarly, the relative deviation of the total dose was accurately reconstructed within 3% for all IMRT plans with points placed inside a high-dose region near the isocenter. Predictions became less accurate than < 5% when the evaluation point was outside the treatment target. Dose at points 5 cm or more away from the isocenter or within an avoidance structure was reconstructed less reliably.

EPIgray formalism accuracy is adequate for an efficient error detection system with verifications performed in high-dose volumes. It provides immediate intra-fractional feedback on the delivery of treatment plans without affecting the treatment beam. Besides the EPID, no additional hardware is required. The software evaluates local point dose measurements to verify treatment plan delivery and patient positioning within 5% accuracy, depending on the placement of evaluation points.

Characterization of the a-Si EPID in the unity MR-linac for dosimetric applications

Electronic portal imaging devices (EPIDs) are frequently used in external beam radiation therapy for dose verification purposes. The aim of this study was to investigate the dose-response characteristics of the EPID in the Unity MR-linac (Elekta AB, Stockholm, Sweden) relevant for dosimetric applications under clinical conditions. EPID images and ionization chamber (IC) measurements were used to study the effects of the magnetic field, the scatter generated in the MR housing reaching the EPID, and inhomogeneous attenuation from the MR housing. Dose linearity and dose rate dependencies were also determined. The magnetic field strength at EPID level did not exceed 10 mT, and dose linearity and dose rate dependencies proved to be comparable to that on a conventional linac. Profiles of fields, delivered with and without the magnetic field, were indistinguishable. The EPID center had an offset of 5.6 cm in the longitudinal direction, compared to the beam central axis, meaning that large fields in this direction will partially fall outside the detector area and not be suitable for verification. Beam attenuation by the MRI scanner and the table is gantry angle dependent, presenting a minimum attenuation of 67% relative to the 90° measurement. Repeatability, observed over two months, was within 0.5% (1 SD). In order to use the EPID for dosimetric applications in the MR-linac, challenges related to the EPID position, scatter from the MR housing, and the inhomogeneous, gantry angle-dependent attenuation of the beam will need to be solved.

Online Combination of EPID & Cherenkov Imaging for 3-D Dosimetry in a Liquid Phantom

Online acquisition of Cherenkov and portal imaging data was combined with a reconstruction scheme called EC3-D, providing a full 3-D dosimetry of megavoltage X-ray beams in a water tank. The methodology was demonstrated and quantified in a single static beam. Furthermore, the dynamics and visualization of the 3-D dose reconstruction were demonstrated with a volumetric modulated arc therapy plan for TG-119 C-Shape geometry. The developed algorithm combines depth dose information, provided by Cherenkov images, with the lateral dose distribution, provided by the electronic portal imaging device. The strength of our approach lies in the acquisition of both imaging data streams with sub-millimeter theoretical resolution at 5-Hz frame-rate, which can be concurrently processed by the fast Fourier transform-based analysis, thus providing means for an efficient real-time 3-D dosimetry.

Investigating the Electronic Portal Imaging Device for Small Radiation Field Measurements

Purpose:

With the advent of state-of-the-art treatment technologies, the use of small fields has increased, and dosimetry in small fields is highly challenging. In this study, the potential use of Varian electronic portal imaging device (EPID) for small field measurements was explored for 6 and 15 MV photon beams.

Materials and Methods:

The output factors and profiles were measured for a range of jaw-collimated square field sizes starting from 0.8 cm × 0.8 cm to 10 cm × 10 cm using EPID. For evaluation purpose, reference data were acquired using Exradin A16 microionization chamber (0.007 cc) for output factors and stereotactic field diode for profile measurements in a radiation field analyzer.

Results:

The output factors of EPID were in agreement with the reference data for field sizes down to 2 cm × 2 cm and for 2 cm × 2 cm; the difference in output factors was +2.06% for 6 MV and +1.56% for 15 MV. For the lowest field size studied (0.8 cm × 0.8 cm), the differences were maximum; +16% for 6 MV and +23% for 15 MV photon beam. EPID profiles of both energies were closely matching with reference profiles for field sizes down to 2 cm × 2 cm; however, penumbra and measured field size of EPID profiles were slightly lower compared to its counterpart.

Conclusions:

EPID is a viable option for profile and output factor measurements for field sizes down to 2 cm × 2 cm in the absence of appropriate small field dosimeters.

Polymer gel dosimeters for pretreatment radiotherapy verification using the three-dimensional gamma evaluation and pass rate maps

Polymer gel dosimeters (PGDs) have been widely studied for use in the pretreatment verification of clinical radiation therapy. However, the readability of PGDs in three-dimensional (3D) dosimetry remain unclear. In this study, the pretreatment verifications of clinical radiation therapy were performed using an N-isopropyl-acrylamide (NIPAM) PGD, and the results were used to evaluate the performance of the NIPAM PGD on 3D dose measurement. A gel phantom was used to measure the dose distribution of a clinical case of intensity-modulated radiation therapy. Magnetic resonance imaging scans were performed for dose readouts. The measured dose volumes were compared with the planned dose volume. The relative volume histograms showed that relative volumes with a negative percent dose difference decreased as time elapsed. Furthermore, the histograms revealed few changes after 24h postirradiation. For the 3%/3mm and 2%/2mm criteria, the pass rates of the 12- and 24-h dose volumes were higher than 95%, respectively. This study thus concludes that the pass rate map can be used to evaluate the dose-temporal readability of PGDs and that the NIPAM PGD can be used for clinical pretreatment verifications.

A portal dosimetry dose prediction method based on collapsed cone algorithm using the clinical beam model

PURPOSE

Amorphous silicon electronical portal imaging devices (EPIDs) are widely used for dosimetric measurements in Radiation Therapy. The purpose of this work was to determine if a portal dose prediction method can be utilized for dose map calculations based on the linear accelerator model within a commercial treatment planning system (Pinnacle³ v8.0 m).

METHODS

The method was developed for a 6 MV photon beam on the Varian Clinac 21-EX, at a nominal dose rate of 400 MU/min. The Varian aS1000 EPID was unmounted from the linear accelerator and scanned to acquire CT images of the EPID. The CT images were imported into Pinnacle³ and were used as a quality assurance phantom to calculate dose on the EPID setup at a source to detector distance of 105 cm. The best match of the dose distributions was obtained considering the image plane located at 106 cm from the source to detector plane. The EPID was calibrated according to the manufacturer procedure and corrections were made for output factors. Arm-backscattering effect, based on profile correction curves, has been introduced. Five low-modulated and three high-modulated clinical planned treatments were predicted and measured with the method presented here and with MatriXX (IBA Dosimetry, Schwarzenbruck, Germany).

RESULTS

A portal dose prediction method based on Pinnacle³ was developed without modifying the commissioned parameters of the model in use in the clinic. CT images of the EPID were acquired and used as a quality assurance phantom. The CT images indicated a mean density of 1.16 g/cm³ for the sensitive area of the EPID. Output factor measured with the EPID were lower for small fields and larger for larger fields (beyond 10 × 10 cm² ). Arm-backscatter correction showed a better agreement at the target side of the EPID. Analysis of Gamma index comparison (3%, 3 mm) indicated a minimum of 97.4% pass rate for low modulated and 98.3% for high modulated treatments. Pass rates were similar for MatriXX measurements.

CONCLUSIONS

The method developed here can be easily implemented into clinic, as neither additional modeling of the clinical energy nor an independent image prediction algorithm are necessary. The main advantage of this method is that portal dose prediction is calculated with the same algorithm and beam model used for patient dose distribution calculation. This method was independently validated with an ionization chamber matrix.

Pixel response-based EPID dosimetry for patient specific QA

Increasing use of high dose rate, flattening filter free (FFF), and/or small‐sized field beams presents a significant challenge to the medical physics community. In this work, we develop a strategy of using a high spatial resolution and high frame rate amorphous silicon flat panel electronic portal imaging device (EPID) for dosimetric measurements of these challenging cases, as well as for conventional external beam therapy. To convert a series of raw EPID‐measured radiation field images into water‐based dose distribution, a pixel‐to‐pixel dose–response function of the EPID specific to the linac is essential. The response function was obtained by using a Monte Carlo simulation of the photon transport in the EPID with a comprehensive calibration. After the raw image was converted into the primary incident photon fluence, the fluence was further convolved into a water‐based dose distribution of the dynamic field by using a pregenerated pencil‐beam kernel. The EPID‐based dosimetric measurement technique was validated using beams with and without flattening filter of all energies available in Varian TrueBeam STx™. Both regularly and irregularly shaped fields measured using a PTW 729 ion chamber array in plastic water phantom. The technique was also applied to measure the distribution for a total of 23 treatment plans of different energies to evaluate the accuracy of the proposed approach. The EPID measurements of square fields of 4 × 4 cm² to 20 × 20 cm², circular fields of 2–15 cm diameters, rectangular fields of various sizes, and irregular MLC fields were in accordance with measurements using a Farmer chamber and/or ion chamber array. The 2D absolute dose maps generated from EPID raw images agreed with ion chamber measurements to within 1.5% for all fields. For the 23 patient cases examined in this work, the average γ‐index passing rate were found to be 99.2 ± 0.6%, 97.4 ± 2.4%, and 72.6 ± 8.4%, respectively, for criterions of 3 mm/3%, 2 mm/2%, and 1 mm/1%. The high spatial resolution and high frame rate EPID provides an accurate and efficient dosimetric tool for QA of modern radiation therapy. Accurate absolute 2D dose maps can be generated from the system for an independent dosimetric verification of treatment delivery.

EPID-based dosimetry to verify IMRT planar dose distribution for the aS1200 EPID and FFF beams

We proposed to perform a basic dosimetry commissioning on a new imager system, the Varian aS1200 electronic portal imaging device (EPID) and TrueBeam 2.0 linear accelerator for flattened (FF) and flattening filter‐free (FFF) beams, then to develop an image‐based quality assurance (QA) model for verification of the system delivery accuracy for intensity‐modulated radiation therapy (IMRT) treatments. For dosimetry testing, linearity of dose response with MU, imager lag, and effectiveness of backscatter shielding were investigated. Then, an image‐based model was developed to convert images to planar dose onto a virtual water phantom. The model parameters were identified using energy fluence of the Acuros treatment planning system (TPS) and, reference dose profiles and output factors measured at depths of 5, 10, 15, and 20 cm in water phantom for square fields. To validate the model, its calculated dose was compared to measured dose from MapCHECK 2 diode arrays for 36 IMRT fields at 10 cm depth delivered with 6X, 6XFFF, 10X, and 10XFFF energies. An in‐house gamma function was used to compare planar doses pixel‐by‐pixel. Finally, the method was applied to the same IMRT fields to verify their pretreatment delivery dose compared with Eclipse TPS dose. For the EPID commissioning, dose linearity was within 0.4% above 5 MU and ∼1% above 2 MU, measured lag was smaller than the previous EPIDs, and profile symmetry was improved. The model was validated with mean gamma pass rates (standard deviation) of 99.0% (0.4%), 99.5% (0.6%), 99.3% (0.4%), and 98.0% (0.8%) at 3%/3 mm for respectively 6X, 6XFFF, 10X, and 10XFFF beams. Using the same comparison criteria, the beam deliveries were verified with mean pass rates of 100% (0.0%), 99.6% (0.3%), 99.9% (0.1%), and 98.7% (1.4%). Improvements were observed in dosimetric response of the aS1200 imager compared to previous EPID models, and the model was successfully developed for the new system and delivery energies of 6 and 10 MV, FF, and FFF modes.

PACS number(s): 87.53.Oq, 87.53.Xd

Implementation and evaluation of a transit dosimetry system for treatment verification

PURPOSE

To evaluate a formalism for transit dosimetry using a phantom study and prospectively evaluate the protocol on a patient population undergoing 3D conformal radiotherapy.

METHODS

Amorphous silicon EPIDs were calibrated for dose and used to acquire images of delivered fields. The measured EPID dose map was back-projected using the planning CT images to calculate dose at pre-specified points within the patient using commercially available software, EPIgray (DOSIsoft, France). This software compared computed back-projected dose with treatment planning system dose. A series of tests were performed on solid water phantoms (linearity, field size effects, off-axis effects). 37 patients were enrolled in the prospective study.

RESULTS

The EPID dose response was stable and linear with dose. For all tested field sizes the agreement was good between EPID-derived and treatment planning system dose in the central axis, with performance stability up to a measured depth of 18cm (agreement within -0.5% at 10cm depth on the central axis and within -1.4% at 2cm off-axis). 126 transit images were analysed of 37 3D-conformal patients. Patient results demonstrated the potential of EPIgray with 91% of all delivered fields achieved the initial set tolerance level of ΔD of 0±5-cGy or %ΔD of 0±5%.

CONCLUSIONS

The in vivo dose verification method was simple to implement, with very few commissioning measurements needed. The system required no extra dose to the patient, and importantly was able to detect patient position errors that impacted on dose delivery in two of cases.

Development of an accurate EPID-based output measurement and dosimetric verification tool for electron beam therapy

PURPOSE

To develop an efficient and robust tool for output measurement and absolute dose verification of electron beam therapy by using a high spatial-resolution and high frame-rate amorphous silicon flat panel electronic portal imaging device (EPID).

METHODS

The dosimetric characteristics of the EPID, including saturation, linearity, and ghosting effect, were first investigated on a Varian Clinac 21EX accelerator. The response kernels of the individual pixels of the EPID to all available electron energies (6, 9, 12, 16, and 20 MeV) were calculated by using Monte Carlo (MC) simulations, which formed the basis to deconvolve an EPID raw images to the incident electron fluence map. The two-dimensional (2D) dose distribution at reference depths in water was obtained by using the constructed fluence map with a MC simulated pencil beam kernel with consideration of the geometric and structural information of the EPID. Output factor measurements were carried out with the EPID at a nominal source-surface distance of 100 cm for 2 × 2, 3 × 3, 6 × 6, 10 × 10, and 15 × 15 cm(2) fields for all available electron energies, and the results were compared with that measured in a solid water phantom using film and a Farmer-type ion chamber. The dose distributions at a reference depth specific to each energy and the flatness and symmetry of the 10 × 10 cm(2) electron beam were also measured using EPID, and the results were compared with ion chamber array and water scan measurements. Finally, three patient cases with various field sizes and irregular cutout shapes were also investigated.

RESULTS

EPID-measured dose changed linearly with the monitor units and showed little ghosting effect for dose rate up to 600 MU/min. The flatness and symmetry measured with the EPID were found to be consistent with ion chamber array and water scan measurements. The EPID-measured output factors for standard square fields of 2 × 2, 3 × 3, 6 × 6, 10 × 10, 15 × 15 cm(2) agreed with film and ion chamber measurements. The average discrepancy between EPID and ion chamber/film measurements was 0.81% ± 0.60% (SD) and 1.34% ± 0.75%, respectively. For the three clinical cases, the difference in output between the EPID- and ion chamber array measured values was found to be 1.13% ± 0.11%, 0.54% ± 0.10%, and 0.74% ± 0.11%, respectively. Furthermore, the γ-index analysis showed an excellent agreement between the EPID- and ion chamber array measured dose distributions: 100% of the pixels passed the criteria of 3%/3 mm. When the γ-index was set to be 2%/2 mm, the pass rate was found to be 99.0% ± 0.07%, 98.2% ± 0.14%, and 100% for the three cases.

CONCLUSIONS

The EPID dosimetry system developed in this work provides an accurate and reliable tool for routine output measurement and dosimetric verification of electron beam therapy. Coupled with its portability and ease of use, the proposed system promises to replace the current film-based approach for fast and reliable assessment of small and irregular electron field dosimetry.

Clinical Experience and Evaluation of Patient Treatment Verification With a Transit Dosimeter

PURPOSE

To prospectively evaluate a protocol for transit dosimetry on a patient population undergoing intensity modulated radiation therapy (IMRT) and to assess the issues in clinical implementation of electronic portal imaging devices (EPIDs) for treatment verification.

METHODS AND MATERIALS

Fifty-eight patients were enrolled in the study. Amorphous silicon EPIDs were calibrated for dose and used to acquire images of delivered fields. Measured EPID dose maps were back-projected using the planning computed tomographic (CT) images to calculate dose at prespecified points within the patient and compared with treatment planning system dose offline using point dose difference and point γ analysis. The deviation of the results was used to inform future action levels.

RESULTS

Two hundred twenty-five transit images were analyzed, composed of breast, prostate, and head and neck IMRT fields. Patient measurements demonstrated the potential of the dose verification protocol to model dose well under complex conditions: 83.8% of all delivered beams achieved the initial set tolerance level of ΔD of 0 ± 5 cGy or %ΔD of 0% ± 5%. Importantly, the protocol was also sensitive to anatomic changes and spotted that 3 patients from 20 measured prostate patients had undergone anatomic change in comparison with the planning CT. Patient data suggested an EPID-reconstructed versus treatment planning system dose difference action level of 0% ± 7% for breast fields. Asymmetric action levels were more appropriate for inversed IMRT fields, using absolute dose difference (-2 ± 5 cGy) or summed field percentage dose difference (-6% ± 7%).

CONCLUSIONS

The in vivo dose verification method was easy to use and simple to implement, and it could detect patient anatomic changes that impacted dose delivery. The system required no extra dose to the patient or treatment time delay and so could be used throughout the course of treatment to identify and limit systematic and random errors in dose delivery for patient groups.

Intensity-modulated radiation therapy dose verification using fluence and portal imaging device

Patient‐specific quality assurance for intensity‐modulated radiation therapy (IMRT) dose verification is essential. The aim of this study is to provide a new method based on the relative error distribution by comparing the fluence map from the treatment planning system (TPS) and the incident fluence deconvolved from the electronic portal imaging device (EPID) images. This method is validated for 10 head and neck IMRT cases. The fluence map of each beam was exported from the TPS and EPID images of the treatment beams were acquired. Measured EPID images were deconvolved to the incident fluence with proper corrections. The relative error distribution between the TPS fluence map and the incident fluence from the EPID was created. This was also created for a 2D diode array detector. The absolute point dose was measured with an ionization chamber, and the dose distribution was measured by a radiochromic film. In three cases, MLC leaf positions were intentionally changed to create the dose error as much as 5% against the planned dose and our fluence‐based method was tested using gamma index. Absolute errors between the predicted dose of 2D diode detector and of our method and measurements were 1.26%±0.65% and 0.78%±0.81% respectively. The gamma passing rate (3% global / 3 mm) of the TPS was higher than that of the 2D diode detector (p<0.02), and lower than that of the EPID (p<0.04). The gamma passing rate (2% global / 2 mm) of the TPS was higher than that of the 2D diode detector, while the gamma passing rate of the TPS was lower than that of EPID (p<0.02). For three modified plans, the predicted dose errors against the measured dose were 1.10%, 2.14%, and −0.87%. The predicted dose distributions from the EPID were well matched to the measurements. Our fluence‐based method provides very accurate dosimetry for IMRT patients. The method is simple and can be adapted to any clinic for complex cases.

PACS numbers: 87.55.D‐, 87.55.km, 87.55.Qr, 87.57.uq

Use of electronic portal imaging devices for electron treatment verification

This study aims to help broaden the use of electronic portal imaging devices (EPIDs) for pre-treatment patient positioning verification, from photon-beam radiotherapy to photon- and electron-beam radiotherapy, by proposing and testing a method for acquiring clinically-useful EPID images of patient anatomy using electron beams, with a view to enabling and encouraging further research in this area. EPID images used in this study were acquired using all available beams from a linac configured to deliver electron beams with nominal energies of 6, 9, 12, 16 and 20 MeV, as well as photon beams with nominal energies of 6 and 10 MV. A widely-available heterogeneous, approximately-humanoid, thorax phantom was used, to provide an indication of the contrast and noise produced when imaging different types of tissue with comparatively realistic thicknesses. The acquired images were automatically calibrated, corrected for the effects of variations in the sensitivity of individual photodiodes, using a flood field image. For electron beam imaging, flood field EPID calibration images were acquired with and without the placement of blocks of water-equivalent plastic (with thicknesses approximately equal to the practical range of electrons in the plastic) placed upstream of the EPID, to filter out the primary electron beam, leaving only the bremsstrahlung photon signal. While the electron beam images acquired using a standard (unfiltered) flood field calibration were observed to be noisy and difficult to interpret, the electron beam images acquired using the filtered flood field calibration showed tissues and bony anatomy with levels of contrast and noise that were similar to the contrast and noise levels seen in the clinically acceptable photon beam EPID images. The best electron beam imaging results (highest contrast, signal-to-noise and contrast-to-noise ratios) were achieved when the images were acquired using the higher energy electron beams (16 and 20 MeV) when the EPID was calibrated using an intermediate (12 MeV) electron beam energy. These results demonstrate the feasibility of acquiring clinically-useful EPID images of patient anatomy using electron beams and suggest important avenues for future investigation, thus enabling and encouraging further research in this area. There is manifest potential for the EPID imaging method proposed in this work to lead to the clinical use of electron beam imaging for geometric verification of electron treatments in the future.

Noncoplanar verification: a feasibility study using Philips' Pinnacle3 treatment planning system

Noncoplanar fields are normally used to improve the dose conformity of the target while sparing organs at risk. One of the methods to verify the dose distribution from the noncoplanar fields is by comparing their planar dose distributions from the treatment planning system (TPS) and the measured ones; for example, using film or electronic portal imaging devices (EPID). The planar dose distributions of the measurement tools, that are normally perpendicular to the central axis of the beam, can be calculated by creating special structures to mimic them in the TPS. With TPS commercially available today, however, it is not easy to create these special structures, especially in the noncoplanar configuration. For this work, we have written in‐house scripts in the Pinnacle³ TPS that can create the structures and define them as virtual planes. These virtual planes can be generated for any arbitrary gantry and couch angles, as well as source to planar distance, so that the planar dose maps at these planes can be computed. Two independent quality assurance (QA) tools were used to validate the planar dose distributions computed using the scripts for three open fields and one IMRT field at several different couch angles. The absolute planar dose patterns measured by the QA tools for all fields at all couch angles were found to be in good agreement, more than 95% (gamma criteria 3% delta dose and 3 mm distance to agreement), with the calculated ones by TPS. The results of this feasibility study can be valuable either for pretreatment dose verification or for in vivo dosimetry that directly implements the planar dose distributions from the TPS, particularly for the noncoplanar fields.

PACS numbers: 87.55.de, 87.55.Qr, 87.56.Fc

Evaluation of Dosimetry Check software for IMRT patient-specific quality assurance

The purpose of this study is to evaluate the use of the Dosimetry Check system for patient‐specific IMRT QA. Typical QA methods measure the dose in an array dosimeter surrounded by homogenous medium for which the treatment plan has been recomputed. With the Dosimetry Check system, fluence measurements acquired on a portal dosimeter is applied to the patient's CT scans. Instead of making dose comparisons in a plane, Dosimetry Check system produces isodose lines and dose‐volume histograms based on the planning CT images. By exporting the dose distribution from the treatment planning system into the Dosimetry Check system, one is able to make a direct comparison between the calculated dose and the planned dose. The versatility of the software is evaluated with respect to the two IMRT techniques — step and shoot and volumetric arc therapy. The system analyzed measurements made using EPID, PTW seven29, and IBA MatriXX, and an intercomparison study was performed. Plans from patients previously treated at our institution with treated anatomical site on brain, head & neck, liver, lung, and prostate were analyzed using Dosimetry Check system for any anatomical site dependence. We have recommendations and possible precautions that may be necessary to ensure proper QA with the Dosimetry Check system.

PACS number: 87.55.Qr, 87.56.Fc

Anatomy-based, patient-specific VMAT QA using EPID or MLC log files

In this project, we investigated the use of an electronic portal imaging device (EPID), together with the treatment planning system (TPS) and MLC log files, to determine the delivered doses to the patient and evaluate the agreement between the treatment plan and the delivered dose distribution. The QA analysis results are presented for 15 VMAT patients using the EPID measurements, the ScandiDos Delta4 dosimeter, and the beam fluence calculated from the multileaf collimator (MLC) log file. EPID fluence images were acquired in continuous acquisition mode for each of the patients and they were processed through an in-house MATLAB program to create an opening density matrix (ODM), which was used as the input fluence for the dose calculation in the TPS (Pinnacle3). The EPID used in this study was the aSi1000 Varian on a Novalis TX linac equipped with high-definition MLC. The actual MLC positions and gantry angles were retrieved from the MLC log files and the data were used to calculate the delivered dose distributions in Pinnacle. The resulting dose distributions were then compared against the corresponding planned dose distributions using the 3D gamma index with 3 mm/3% passing criteria. The ScandiDos Delta4 phantom was also used to measure a 2D dose distribution for all the 15 patients and a 2D gamma was calculated for each patient using the Delta4 software. The average 3D gamma using the EPID images was 96.1% ± 2.2%. The average 3D gamma using the log files was 98.7% ± 0.5%. The average 2D gamma from the Delta4 was 98.1% ± 2.1%. Our results indicate that the use of the EPID, combined with MLC log files and a TPS, is a viable method for QA of VMAT plans.

Radiochromic film-based quality assurance for CT-based high-dose-rate brachytherapy

PURPOSE

In the past, film dosimetry was developed into a powerful tool for external beam radiotherapy treatment verification and quality assurance. The objective of this work was the development and clinical testing of the EBT3 model GafChromic film based brachytherapy quality assurance (QA) system.

METHODS AND MATERIALS

Retrospective dosimetry study was performed to test a patient-specific QA system for preoperative endorectal brachytherapy that uses a radiochromic film dosimetry system. A dedicated phantom for brachytherapy applicator used for rectal cancer treatment was fabricated enabling us to compare calculated-to-measured dose distributions. Starting from the same criteria used for external beam intensity-modulated radiation therapy QA (3%, 3 mm), passing criteria for high- and low-dose gradient regions were subsequently determined. Finally, we investigated the QA system's sensitivity to controlled source positional errors on selected patient plans.

RESULTS

In low-dose gradient regions, measured dose distributions with criteria of 3%, 3 mm barely passed the test, as they showed 95% passing pixels. However, in the high-dose gradient region, a more stringent condition could be established. Both criteria of 2%, 3 mm and 3%, 2 mm with gamma function calculated using normalization to the same absolute dose value in both measured and calculated dose distributions, and matrix sizes rescaled to match each other showed more than 95% of pixels passing, on average, for 15 patient plans analyzed.

CONCLUSIONS

Although the necessity of the patient-specific brachytherapy QA needs yet to be justified, we described a radiochromic film dosimetry-based QA system that can be a part of the brachytherapy commissioning process, as well as yearly QA program.

Time dependent pre-treatment EPID dosimetry for standard and FFF VMAT

Methods to calibrate Megavoltage electronic portal imaging devices (EPIDs) for dosimetry have been previously documented for dynamic treatments such as intensity modulated radiotherapy (IMRT) using flattened beams and typically using integrated fields. While these methods verify the accumulated field shape and dose, the dose rate and differential fields remain unverified. The aim of this work is to provide an accurate calibration model for time dependent pre-treatment dose verification using amorphous silicon (a-Si) EPIDs in volumetric modulated arc therapy (VMAT) for both flattened and flattening filter free (FFF) beams. A general calibration model was created using a Varian TrueBeam accelerator, equipped with an aS1000 EPID, for each photon spectrum 6 MV, 10 MV, 6 MV-FFF, 10 MV-FFF. As planned VMAT treatments use control points (CPs) for optimization, measured images are separated into corresponding time intervals for direct comparison with predictions. The accuracy of the calibration model was determined for a range of treatment conditions. Measured and predicted CP dose images were compared using a time dependent gamma evaluation using criteria (3%, 3 mm, 0.5 sec). Time dependent pre-treatment dose verification is possible without an additional measurement device or phantom, using the on-board EPID. Sufficient data is present in trajectory log files and EPID frame headers to reliably synchronize and resample portal images. For the VMAT plans tested, significantly more deviation is observed when analysed in a time dependent manner for FFF and non-FFF plans than when analysed using only the integrated field. We show EPID-based pre-treatment dose verification can be performed on a CP basis for VMAT plans. This model can measure pre-treatment doses for both flattened and unflattened beams in a time dependent manner which highlights deviations that are missed in integrated field verifications.

Patient Specific Pre-Treatment QA Verification Using an EPID Approach

A software program [MU-EPID], has been developed to perform patient specific pre-treatment quality assurance (QA) verification for intensity modulated radiation therapy (IMRT) using fluence maps measured with an electronic portal imaging device (EPID). The software converts the EPID acquired images of each IMRT beam, to fluence maps that are equivalent to those calculated by the treatment planning system (TPS). The software has the capability to process Varian, Elekta and Siemens EPID DICOM images. In the present investigation, several IMRT plans for different treatment sites were used to validate the software using the Varian a-Si 1000 EPID with the Pinnacle TPS. A total of 20 IMRT plans of different treatment sites were analyzed. Isodose distributions, dose profiles, dose volume histograms (DVH's) and gamma analysis comparisons were performed to evaluate the accuracy of our method. A gamma index analysis of the isocenter coronal plane was done for each plan and showed an average of 97.44% of gamma passing rate using a 3% and 3 mm gamma criterion. Isodose, DVH and dose profile comparisons were conducted between the original calculated plan and the measured reconstructed plan from the EPID images processed through the MU-EPID software. The results suggest that MU-EPID can be used clinically for patient specific IMRT QA, providing a comprehensive 3D dosimetric evaluation through DVH comparison as well as an option for a 2D gamma analysis.