Validation of the Elekta iBEAM Evo couchtop modeling in the Monaco treatment planning system

Recently, carbon fiber (CF) has prevailed as the primary material used in radiotherapy couchtops. Modern couchtops incorporate the CF sandwich design, in which 2 thin CF plates sandwich an air-equivalent polymeric foam. Developments in radiotherapy necessitate irradiation from posterior angles through the couchtop. However, the presence of the couchtop needs proper modeling in the treatment planning system (TPS) due to attenuation; otherwise, the tumor dose is reduced. In the current study, an effort was made with the intent of finding the optimum electron density (ED) values for Elekta's iBEAM Evo couchtop components (CF and Foam Core (FC)) for its proper modeling in Monaco TPS. Also, the attenuation of the beam due to the couchtop's presence was investigated. A cylindrical phantom with an ionization chamber positioned at the isocenter was utilized for the measurements. The phantom was placed centrally on the iBEAM Evo couchtop and was irradiated with an Elekta Infinity linear accelerator's 6, 10, and 15 MV photon beams. The gantry angle was set at 0o and from 120o to 180o with an increment of 10o. The same procedure was designed and followed in Monaco TPS. Measured and calculated dose values were compared by calculating percentage deviation (PD). Attenuation has also been calculated using the measurements of the experimental setup and the Monaco calculations. The values of ED that provided the optimum agreement between measured and Monaco-calculated dose values while minimizing PD were 0.55 g/cm3 for CF, and 0.1 g/cm3 for FC. The maximum values of PD for the beams of 6, 10, and 15 MV were -0.62%, +1,78%, and +2.35%, respectively, for a 5 × 5 cm2 field size. Furthermore, Monaco predicted attenuation from 1.83% to 6.26% (calculated values), while from the measurements, an attenuation from 1.44% to 5.75% (measured values) regarding the posterior angles was found. Thus, good agreement was verified between the TPS calculations and experimental measurements. Elekta's iBEAM Evo couchtop modeling was successfully validated in Monaco TPS. The couchtop's presence alters the patient's dose regarding irradiation from the posterior angles. Due to the attenuation of the beam, proper incorporation, modeling, and validation of the couchtop are necessary to improve the radiotherapy outcome and ensure that each patient receives the optimal treatment.

Dosimetric effect of six degrees of freedom couch top with rotational setup error corrections in proton therapy

PURPOSE

To investigate the dosimetric effect of six degrees of freedom (6DoF) couch top with rotational corrections in proton therapy (PT).

METHODS

The water equivalent thickness (WET) was measured using a proton beam with a 6DoF couch top and patient immobilization base plate (PIBP) placed in front of a motorized water phantom. The accuracy verification was performed with the beam axis set perpendicular to the 6DoF couch top and tilted in 10° steps from 10° to 30°. Up to 3° rotational correction may be added during the actual treatment to correct the rotational setup error on our system. The measured and calculated values using the treatment planning system were compared. Additionally, the effect of the 3° difference was evaluated using actual measurements concerning each angle on the proton beam range.

RESULTS

The WET of the 6DoF couch top and PIBP were 8.5 ± 0.1 mm and 6.8 ± 0.1 mm, respectively. The calculation and the actual measurement at each angle agreed within 0.2 mm at the maximum. A maximum difference of approximately 0.6 mm was confirmed when tilted at 3° following 30° with the 6DoF couch top plus PIBP.

CONCLUSIONS

The dosimetric effect of the 6DoF couch top with rotational corrections in PT differs depending on the incidence angle on the couch top, and it increased with the increased oblique angle of incidence. However, the effect on the range was as small as 0.6 mm at the maximum. The amount of rotational correction, the angle of incidence of the beam, and the effect of rotational corrections on the proton beam range may differ depending on the structure of the couch top. Therefore, sufficient prior confirmation, and subsequent periodical quality assurance management are important.

Effect of linear accelerator carbon fiber couch on radiotherapy dose

This study aimed to explore the effect of carbon fiber couch on radiotherapy dose attenuation and gamma pass rate in intensity-modulated radiotherapy (IMRT) plans. A phantom inserted with an ionization chamber was placed at different positions of the couch, and the dose was measured by the chamber. Under the same positioning, the phantom dose was calculated using the real and virtual couch images, and the difference in the planned dose of radiotherapy was compared. Ten clinical IMRT plans were selected as dose verification data, and the gamma pass rates were compared between couch addition and non-addition conditions. When the radiation field was near 110° and 250°, the measured value attenuation coefficient of the ionization chamber at the joint of the couch was up to 34%; the attenuation coefficient of the treatment couch from the actual couch image calculated using the treatment planning system (TPS) was up to 33%; the attenuation coefficient of the virtual couch calculated using the TPS was up to 4.0%. The gamma pass rate of the dose verification near gantry angles 110° and 250° was low, and that of the joint could be lower than 85% under the condition of 3%/3 mm. The gamma pass rates of the radiation field passing through the couch were all affected. The dose was affected by the radiation field passing through the couch, with the largest effect when passing through the joint part of the treatment couch, followed by that of the main couch plate and extension plate. When the irradiation field passed through the joint and near 110° and 250° of the main couch, the dose difference was large, making it unsuitable for treatment.

Radiation dosimetry effect evaluation of a carbon fiber couch on novel uRT-linac 506c accelerator

Recently, a diagnostic helical CT is integrated into a linear accelerator, called uRT-linac 506c, whose CT scanning dataset can be directly used to do simulation. This novel structure provides a possibility for online adaptive radiotherapy. For adaptive radiotherapy, the carbon fiber couch is an essential external device for supporting and positioning patients. And the effect on dose attenuation and distribution caused by a couch is inevitable and vital for precise treatment. In this research, the couch equipped with uRT-linac 506c was evaluated on the radiation dosimetry effect. The treatment couch equipped on the uRT-linac 506c accelerator was evaluated, and its effect on the attenuation, surface dose and dose buildup were measured for different phantom positions (offset = 0 cm, offset =  + 10 cm and offset =  − 10 cm, respectively) and different gantry angles. Since uRT-linac 506c is exclusively capable to provide diagnostic CT scanning data with real relative electron density (RED), this CT scanning data of the couch can be used directly in uRT-TPS to design plans. This scanned couch dataset was designated as the model A. The model B was a dummy structure of a treatment couch inserted with artificially preset RED. The dose calculation accuracy of these two models was compared using PB, CC, and MC on uRT-TPS. With the effect of carbon fiber couch, the surface dose was increased at least 97.94% for 25 × 25 cm² field and 188.83% for 10 × 10 cm² field, compared with those without. At different phantom positions (offset = 0, + 10, − 10 cm), the attenuation for 6 MV photon beam at gantry angle 180° were 4.4%, 4.4%, and 4.3%, respectively, and varied with changes of gantry angle. There do exists dose deviation between measurement and TPS calculation with the involvement of treatment couch, among the three algorithms, MC presented the least deviation, and the model A made less and steadier deviation than the model B, showing promising superiority. The attenuation, surface dose, and buildup effects of the carbon fiber couch in this study were measured similarly to most counterparts. The dose deviation calculated based on the couch dataset scanned by the diagnostic helical CT was smaller than those based on a dummy couch. This result suggests that an accelerator equipped with a diagnostic CT, which can help reduce the dose deviation of the carbon fiber couch, is a promising platform for online adaptive radiotherapy.

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.

Clinical implementation of 3D in vivo dosimetry for abdominal and pelvic stereotactic treatments

PURPOSE

To analyze results from three years of in vivo transit EPID dosimetry of abdominal and pelvic stereotactic radiotherapy and to establish tolerance levels for routine clinical use.

MATERIAL

80 stereotactic VMAT treatments (152 fractions) targeting the abdomen or pelvis were analyzed. In vivo 3D doses were reconstructed with an EPID commercial algorithm. Gamma Agreement Index (GAI) and DVH differences in Planning Target Volume (PTV) and Clinical Target Volume (CTV) were evaluated. Initial tolerance level was set to GAI > 85% in PTV. Fractions Over Tolerance Level (OTL) were deemed to be due to set-up errors, incorrect use of immobilization devices, 4D errors, transit EPID algorithm errors and unknown/unidentified errors. Statistical Process Control (SPC) was applied to determine local tolerance levels.

RESULTS

Average GAI were (82.7 ± 20.9) % in PTV and (72.9 ± 29.7) % in CTV. 37.8% of fractions resulted OTL and were classified as: set-up errors (3.3%), incorrect use of immobilization devices (2.1%), 4D errors (2.1%), EPID transit algorithm errors (17.1%). OTL causes for the remaining 13.2% of fractions were not identified. The differences between PTV and CTV measured in vivo and calculated mean dose (average difference ± standard deviation) were (-3.3% ± 3.2%) and (-2.3% ± 3.0%). When tolerance levels based on SPC to PTV mean dose differences were applied, the percentage of OTL decreased to 7% and no EPID algorithm error occurred. One error was not identified.

CONCLUSIONS

The application of local tolerance levels to EPID in vivo dosimetry proved to be useful for detecting extra-lung SBRT treatment errors.

Assessment of dosimetric leaf gap correction factor in Mobius3D commissioning affected by couch top

This study assesses the dosimetric leaf gap (DLG) correction factor in Mobius3D commissioning affected by a couch top platform and calculates the optimal DLG value according to the point dose difference function. DLG optimizations were performed for 3 LINAC machines and a total of 30 patient volumetric modulated arc therapy plans (i.e., 10 plans per each LINAC). Point dose calculations were performed using an automatic dose calculation system in Mobius3D as well as Mobis3D calculation using a Mobius Verification Phantom (MVP)-based quality assurance plan with a carbon fiber couch top. Subsequently, the results were compared with measurement data. The averaged point dose measured for the MVP with a couch top decreased by approximately 2% relative to that without the couch top. The average of the optimal DLG factors increased by 1.153 mm due to the couch top effect for a dose decrease of 2% at the measured point. In the procedure of Mobius beam commissioning, users should adjust the DLG correction factor using a specific phantom (including MVP) with a couch top structure. If the DLG optimization were performed by using MVP automatic dose calculation system, the factor should be increased by approximately 1.2 mm per 2% dose difference considering user's couch top effect.

Couch modeling optimization for tomotherapy planning and delivery

We sought to validate new couch modeling optimization for tomotherapy planning and delivery. We constructed simplified virtual structures just above a default setting couch through a planning support system (MIM Maestro, version 8.2, MIM Software Inc, Cleveland, OH, USA). Based on ionization chamber measurements, we performed interactive optimization and determined the most appropriate physical density of these virtual structures in a treatment planning system (TPS). To validate this couch optimization, Gamma analysis and these statistical analyses between a three‐dimensional diode array QA system (ArcCHECK, Sun Nuclear, Melbourne, FL, USA) results and calculations from ionization chamber measurements were performed at 3%/2 mm criteria with a threshold of 10% in clinical QA plans. Using a virtual model consisting of a center slab density of 4.2 g/cm³ and both side slabs density of 1.9 g/cm³, we demonstrated close agreement between measured dose and the TPS calculated dose. Agreement was within 1% for all gantry angles at the isocenter and within 2% in off‐axis plans. In validation of the couch modeling in a clinical QA plan, the average gamma passing rate improved approximately 0.6%–5.1%. It was statistically significant (P < 0.05) for all treatment sites. We successfully generated an accurate couch model for a TomoTherapy TPS by interactively optimizing the physical density of the couch using a planning support system. This modeling proved to be an efficient way of correcting the dosimetric effects of the treatment couch in tomotherapy planning and delivery.

Dosimetric effects of a repositioning head frame system and treatment planning system dose calculation accuracy

This work aims to study the effect on surface dose and dose distribution caused by the Elekta Fraxion cranial immobilization system. The effect of Fraxion inclusion in Elekta Monaco treatment planning system and its calculation accuracy is also checked. To study the dose attenuation, a cylindrical phantom was located over the Elekta Fraxion with an IBA CC13 ionization chamber placed in the central insert at the linac isocenter. Dose measurements at multiple gantry angles were performed for three open fields, 10 × 10 cm, 5 × 5 cm and other smaller 2 × 2 cm. Measured doses were compared with the ones calculated by Monaco. Surface dose and dose distribution in the buildup region were measured placing several Gafchromic Films EBT3 at linac CAX between the slabs of a RW3 phantom located over Fraxion and read using FilmQA Pro software. Measures were performed for two open field sizes and results were compared with Monaco calculations. Measurements show a 1% attenuation for 180° gantry angle but it can be as high as 3.4% (5 × 5 open field) for 150°/210° gantry angle, as with these angles the beam goes through the Fraxion's headrest twice. If Fraxion is not included in the calculation Monaco calculation can result in a 3% difference between measured and calculated doses, while with Fraxion in the calculation, the maximum difference is 0.9%. Fraxion increases 3.7 times the surface dose, which can be calculated by Monaco with a difference lower than 2%. Monaco also calculated correctly the PDD for both open fields (2%) when Fraxion is included in the calculation. This work shows that the attenuation varies with gantry angle. The inclusion of Fraxion in Monaco improves the calculation from 3% difference to 1% in the worst case. Furthermore, the surface dose increment and the dose in the buildup region are correctly calculated.

Evaluation and verification of the QFix EncompassTM couch insert for intracranial stereotactic radiosurgery

The QFix Encompass^TM stereotactic radiosurgery (SRS) immobilization system consists of a thermoplastic mask that attaches to the couch insert to immobilize patients treated with intracranial SRS. This study evaluates the dosimetric impact and verifies a vendor provided treatment planning system (TPS) model in the Eclipse TPS. A thermoplastic mask was constructed for a Lucy 3D phantom, and was scanned with and without the Encompass^TM system. Attenuation measurements were performed in the Lucy phantom with and without the insert using a pinpoint ion chamber for energies of 6xFFF, 10xFFF and 6X, with three field sizes (2 × 2, 4 × 4, and 6 × 6 cm² ). The measurements were compared to two sets of calculations. The first set utilized the vendor provided Encompass TPS model (Encompass_TPS ), which consists of two structures: the Encompass and Encompass base structure. Three HU values for the Encompass (200, 300, 400) and Encompass Base (-600, -500, -400) structures were evaluated. The second set of calculations consists of the Encompass insert included in the external body contour (Encompass_EXT ) for dose calculation. The average measured percent attenuation in the posterior region of the insert ranged from 3.4%-3.8% for the 6xFFF beam, 2.9%-3.4% for the 10xFFF, and 3.3%-3.6% for the 6X beam. The maximum attenuation occurred at the region where the mask attaches to the insert, where attenuation up to 17% was measured for a 6xFFF beam. The difference between measured and calculated attenuation with either the Encompass_EXT or Encompass_TPS approach was within 0.5%. HU values in the Encompass_TPS model that provided the best agreement with measurement was 400 for the Encompass structure and -400 for the Encompass base structure. Significant attenuation was observed at the area where the mask attaches to the insert. Larger differences can be observed when using few static beams compared to rotational treatment techniques.

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.

A patient immobilization device for prone breast radiotherapy: Dosimetric effects and inclusion in the treatment planning system

PURPOSE

To assess the dosimetric impact of a patient positioning device for prone breast radiotherapy and assess the accuracy of a treatment planning system (TPS) in predicting this impact.

METHODS

Beam attenuation and build-up dose perturbations, quantified by ionization chamber and radiochromic film dosimetry, were evaluated for 3 components of the patient positioning device: the carbon fiber baseplate, the support cushions and the support wedge for the contralateral breast. Dose calculations were performed using the XVMC dose engine implemented in the Monaco TPS. All components were included during planning CT acquisition.

RESULTS

Beam attenuation amounted to 7.57% (6MV) and 5.33% (15MV) for beams obliquely intersecting the couchtop-baseplate combination. Beams traversing large sections of the support wedge were attenuated by 12.28% (6MV) and 9.37% (15MV). For the support cushion foam, beam attenuation remained limited to 0.11% (6MV) and 0.08% (15MV) per centimeter thickness. A substantial loss of dose build-up was detected when irradiating through any of the investigated components. TPS dose calculations accurately predicted beam attenuation by the baseplate and support wedge. A manual density overwrite was needed to model attenuation by the support cushion foam. TPS dose calculations in build-up regions differed considerably from measurements for both open beams and beams traversing the device components.

CONCLUSIONS

Irradiating through the components of the positioning device resulted in a considerable degradation of skin sparing. Inclusion of the device components in the treatment planning CT allowed to accurately model the most important attenuation effect, but failed to accurately predict build-up doses.

Surface dose variations in 6 and 10 MV flattened and flattening filter-free (FFF) photon beams

As the use of linear accelerators operating in flattening filter-free (FFF) modes becomes more widespread, it is important to have an understanding of the surface doses delivered to patients with these beams. Flattening filter removal alters the beam quality and relative contributions of low-energy X-rays and contamination electrons in the beam. Having dosimetric data to describe the surface dose and buildup regions under a range of conditions for FFF beams is important if clinical decisions are to be made. An Elekta Synergy linac with standard MLCi head has been commissioned to run at 6 MV and 10 MV running with the flattening filter in or out. In this linac the 6 MV FFF beam has been energy-matched to the clinical beam on the central axis (D10). The 10 MV beam energy has not been adjusted. The flattening filter in both cases is replaced by a thin (2 mm) stainless steel plate. A thin window parallel plate chamber has been used to measure a comprehensive set of surface dose data in these beams for variations in field size and SSD, and for the presence of attenuators (wedge, shadow tray, and treatment couch). Surface doses are generally higher in FFF beams for small field sizes and lower for large field sizes with a crossover at 10 × 10 cm2 at 6 MV and 25 × 25 cm2 at 10 MV. This trend is also seen in the presence of the wedge, shadow tray, and treatment couch. Only small differences (< 0.5%) are seen between the beams on varying SSD. At both 6 and 10 MV the filter-free beams show far less variation with field size than conventional beams. By removing the flattening filter, a source of contamination electrons is exchanged for a source of low-energy photons (as these are no longer attenuated). In practice these two components almost balance out. No significant effects on surface dose are expected by the introduction of FFF delivery.

Verification of the dose attenuation of a newly developed vacuum cushion for intensity-modulated radiation therapy of prostate cancer

This study measured the dose attenuation of a newly developed vacuum cushion for intensity-modulated radiation therapy (IMRT) of prostate cancer, and verified the effect of dose-correction accuracy in a radiation treatment planning system (RTPS). The new cushion was filled with polystyrene foams inflated 15-fold (Sφ ≒ 1 mm) to reduce contraction caused by air suction and was compared to normal polystyrene foam inflated to 50-fold (Sφ ≒ 2 mm). The dose attenuation at several thicknesses of compression bag filled with normal and low-inflation materials was measured using an ionization chamber; and then the calculated RTPS dose was compared to ionization chamber measurements, while the new cushion was virtually included as region of interest in the calculation area. The dose attenuation rate of the normal cushion was 0.010 %/mm (R (2) = 0.9958), compared to 0.031 %/mm (R (2) = 0.9960) in the new cushion. Although the dose attenuation rate of the new cushion was three times that of the normal cushion, the high agreement between calculated dose by RTPS and ionization chamber measurements was within approximately 0.005 %/mm. Thus, the results of the current study indicate that the new cushion may be effective in clinical use for dose calculation accuracy in RTPS.

Modeling of couch transmission in the RayStation treatment planning system

PURPOSE

To present our methods and results regarding the modeling of a carbon fiber couch (Varian Exact IGRT) in the RayStation treatment planning system (TPS).

METHODS

Three geometrical-models (GMs) were implemented in the TPS to represent the three different regions of the couch (thick, medium and thin). The materials and densities of each GM component were tuned to maximize the agreement between measured and calculated attenuations. Moreover, a couch computed-tomography (CT) scan was acquired and dosimetrically compared with the GMs. For validation, plan-specific quality assurance (QA) of VMAT plans (TG-119 cases, 5 prostate and 5 H&N clinical cases) was performed by comparing measured dose distributions with doses computed with and without including the GMs in the TPS.

RESULTS

Couch attenuations up to 4.3% were measured (energy: 6MV). Compared to couch CT, GMs could be modified to optimize the agreement with measurements and reduce dependence on the dose grid resolution. For both couch CT and GM, absolute deviations between measured and calculated attenuations were within 1.0%. When including the GMs in plan-specific QA, global 2%/2mm γ-pass rates showed an average improvement of 4.8% (p-value<0.001, max +18.6%). The couch reduced the mean dose to targets by up to 2.4% of the prescribed dose for prostate cases and up to 1.4% for H&N cases.

CONCLUSIONS

RayStation accurately considers the implemented couch GMs replicating measured attenuations within an uncertainty of 1.0%. Materials and densities are proposed for the Varian Exact IGRT couch. The results obtained justify introducing couch GMs in clinical routine.

Using dual-energy x-ray imaging to enhance automated lung tumor tracking during real-time adaptive radiotherapy

PURPOSE

Real-time, markerless localization of lung tumors with kV imaging is often inhibited by ribs obscuring the tumor and poor soft-tissue contrast. This study investigates the use of dual-energy imaging, which can generate radiographs with reduced bone visibility, to enhance automated lung tumor tracking for real-time adaptive radiotherapy.

METHODS

kV images of an anthropomorphic breathing chest phantom were experimentally acquired and radiographs of actual lung cancer patients were Monte-Carlo-simulated at three imaging settings: low-energy (70 kVp, 1.5 mAs), high-energy (140 kVp, 2.5 mAs, 1 mm additional tin filtration), and clinical (120 kVp, 0.25 mAs). Regular dual-energy images were calculated by weighted logarithmic subtraction of high- and low-energy images and filter-free dual-energy images were generated from clinical and low-energy radiographs. The weighting factor to calculate the dual-energy images was determined by means of a novel objective score. The usefulness of dual-energy imaging for real-time tracking with an automated template matching algorithm was investigated.

RESULTS

Regular dual-energy imaging was able to increase tracking accuracy in left-right images of the anthropomorphic phantom as well as in 7 out of 24 investigated patient cases. Tracking accuracy remained comparable in three cases and decreased in five cases. Filter-free dual-energy imaging was only able to increase accuracy in 2 out of 24 cases. In four cases no change in accuracy was observed and tracking accuracy worsened in nine cases. In 9 out of 24 cases, it was not possible to define a tracking template due to poor soft-tissue contrast regardless of input images. The mean localization errors using clinical, regular dual-energy, and filter-free dual-energy radiographs were 3.85, 3.32, and 5.24 mm, respectively. Tracking success was dependent on tumor position, tumor size, imaging beam angle, and patient size.

CONCLUSIONS

This study has highlighted the influence of patient anatomy on the success rate of real-time markerless tumor tracking using dual-energy imaging. Additionally, the importance of the spectral separation of the imaging beams used to generate the dual-energy images has been shown.

Generation and verification of QFix kVue Calypso-compatible couch top model for a dedicated stereotactic linear accelerator with FFF beams

This study details the generation, verification, and implementation of a treatment planning system (TPS) couch top model for patient support system used in conjunction with a dedicated stereotactic linear accelerator. Couch top model was created within the TPS using CT simulation images of the kVue Calpyso-compatible couchtop (with rails). Verification measurements were compared to TPS dose prediction for different energies (6 MV FFF and 10 MV FFF) and rail configurations (rails in and rails out) using: 1) central axis point-dose measurements with pinpoint chamber in water-equivalent phantom at 42 gantry angles for various field sizes (2 × 2 cm², 4 × 4 cm², 10 × 10 cm²); and 2) Gafchromic EBT3 film parallel to beam in acrylic slab to assess changes in surface and percent depth doses in PA geometry. To assess sensitivity of delivered dose to variations in patient lateral position, measurements at central axis using the pinpoint chamber geometry were taken at lateral couch displacements of 2, 5, and 10 mm for 6 MV FFF. The maximum percent difference for point-dose measurements was 3.24% (6 MV FFF) and 2.30% (10 MV FFF). The average percent difference for point-dose measurements was less than 1.10% for all beam energies and rail geometries. The maximum percent difference between calculated and measured dose can be as large as 13.0% if no couch model is used for dose calculation. The presence of the couch structures also impacts surface dose and PDD, which was evaluated with Gafchromic film measurements. The upstream shift in the depth of dose maximum (dmax) was found to be 10.5 mm for 6 MV FFF and 5.5 mm for 10 MV FFF for 'Rails In' configuration. Transmission of the treatment beam through the couch results in an increase in surface dose (absolute percentage) of approximately 50% for both photon energies (6 MV FFF and 10MV FFF). The largest sensitivity to lateral shifts occurred at the lateral boundary of the rail structures. The mean magnitude (standard deviation) of the deviation between shifted and centered measurements over all field sizes tested was 0.61% (0.61%) for 2 mm shifts, 0.46% (0.67%) for 5 mm shifts, and 0.86% (1.46%) for 10 mm shifts.

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.

Inverse planned constant dose rate volumetric modulated arc therapy (VMAT) as an efficient alternative to five-field intensity modulated radiation therapy (IMRT) for prostate

Purpose

The aim of this work was to determine if volumetric modulated arc therapy (VMAT) plans, created for constant dose-rate (cdrVMAT) delivery are a viable alternative to step and shoot five-field intensity modulated radiation therapy (IMRT).

Materials and methods

The cdrVMAT plans, inverse planned on a treatment planning system with no solution to account for couch top or rails, were created for delivery on a linear accelerator with no variable dose rate control system. A series of five-field IMRT and cdrVMAT plans were created using dual partial arcs (gantry rotating between 260° and 100°) with 4° control points for ten prostate patients with the average rectal constraint incrementally increased. Pareto fronts were compared for the planning target volume homogeneity and average rectal dose between the two techniques for each patient. Also investigated were tumour control probability and normal tissue complication probability values for each technique. The delivery parameters [monitor units (MU) and time] and delivery accuracy of the IMRT and VMAT plans were also compared.

Results

Pareto fronts showed that the dual partial arc plans were superior to the five-field IMRT plans, particularly for the clinically acceptable plans where average rectal doses were less for rotational plans (p = 0·009) with no statistical difference in target homogeneity. The cdrVMAT plans had significantly more MU (p = 0·005) but the average delivery time was significantly less than the IMRT plans by 42%. All clinically acceptable cdrVMAT plans were accurate in their delivery (gamma 99·2 ± 1·1%, 3%3 mm criteria).

Conclusions

Accurate delivery of dual partial arc cdrVMAT avoiding the couch top and rails has been demonstrated.

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 validation of carbon fiber imaging couch top modeling in two radiation therapy treatment planning systems: Philips Pinnacle3 and BrainLAB iPlan RT Dose

BACKGROUND

Carbon fiber (CF) is now the material of choice for radiation therapy couch tops. Initial designs included side metal bars for rigidity; however, with the advent of IGRT, involving on board imaging, new thicker CF couch tops without metal bars have been developed. The new design allows for excellent imaging at the expense of potentially unacceptable dose attenuation and perturbation.

OBJECTIVES

We set out to model the BrainLAB imaging couch top (ICT) in Philips Pinnacle(3) treatment planning system (TPS), to validate the already modeled ICT in BrainLAB iPlan RT Dose treatment planning system and to compute the magnitude of the loss in skin sparing.

RESULTS

Using CF density of 0.55 g/cm(3) and foam density of 0.03 g/cm(3), we demonstrated an excellent agreement between measured dose and Pinnacle(3) TPS computed dose using 6 MV beam. The agreement was within 1% for all gantry angle measured except for 120°, which was 1.8%. The measured and iPlan RT Dose TPS computed dose agreed to within 1% for all gantry angles and field sizes measured except for 100° where the agreement was 1.4% for 10 cm × 10 cm field size. Predicted attenuation through the couch by iPlan RT Dose TPS (3.4% - 9.5%) and Pinnacle(3) TPS (2% - 6.6%) were within the same magnitude and similar to previously reported in the literature. Pinnacle(3) TPS estimated an 8% to 20% increase in skin dose with increase in field size. With the introduction of the CF couch top, it estimated an increase in skin dose by approximately 46 - 90%. The clinical impact of omitting the couch in treatment planning will be dependent on the beam arrangement, the percentage of the beams intersecting the couch and their angles of incidence.

CONCLUSION

We have successfully modeled the ICT in Pinnacle(3) TPS and validated the modeled ICT in iPlan RT Dose. It is recommended that the ICT be included in treatment planning for all treatments that involve posteriors beams. There is a significant increase in skin dose that is dependent on the percentage of the beam passing through the couch and the angle of incidence.