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

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.

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

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

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

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

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.

Impact of radiation attenuation by a carbon fiber couch on patient dose verification

The aim of this study was to understand the difference between the measured and calculated irradiation attenuations obtained using two algorithms and to identify the influence of couch attenuation on patient dose verification. We performed eight tests of couch attenuation with two photon energies, two longitudinal couch positions, and two rail positions. The couch attenuation was determined using a radiation treatment planning system. The measured and calculated attenuations were compared. We also performed 12 verifications of head-and-neck and rectum cases by using a Delta phantom. The dose deviation (DD), distance to agreement (DTA), and gamma index of pencil-beam convolution (PBC) verifications were nearly the same. The agreement was least consistent for the anisotropic analytical algorithm (AAA) without the couch for the head-and-neck case, in which the DD, DTA, and gamma index were 74.4%, 99.3%, and 89%, respectively; for the rectum case, the corresponding values were 56.2%, 95.1%, and 92.4%. We suggest that dose verification should be performed using the following three metrics simultaneously: DD, DTA, and the gamma index.

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

AIM

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

Introduction

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

Materials and Methods

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

Results

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

Discussion

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

Conclusions

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

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.

Investigation on the effect of sharp phantom edges on point dose measurement during patient-specific dosimetry with Rapid Arc

The objective of this work was to investigate and quantify the effect of sharp edges of the phantom on the point dose measurement during patient-specific dosimetry with Rapid Arc (RA). Ten patients with carcinoma of prostate were randomly selected for this dosimetric study. Rapid Arc plans were generated with 6 MV X-rays in the Eclipse (v 8.6.14) with single arc (clockwise). Dosimetry verification plans were generated for two phantoms (cylindrical and rectangular). The cylindrical phantom was solid water (diameter 34 cm) and the rectangular phantom was a water phantom (25 cm × 25 cm × 10 cm). These phantoms were pre-scanned in computed tomography (CT) machine with cylindrical ionization chamber (FC65) in place. The plans were delivered with Novalis Tx linear accelerator with 6 MV X-rays for both the phantoms separately. The measured dose was compared with the planned dose for both the phantoms. Mean percentage deviation between measured and planned doses was found to be 4.19 (SD 0.82) and 3.63 (SD 0.89) for cylindrical and rectangular phantoms, respectively. No significant dosimetric variation was found due to the geometry (sharp edges) of the phantom. The sharp edges of the phantom do not perturb the patient specific Rapid Arc dosimetry significantly.

Effects on the photon beam from an electromagnetic array used for patient localization and tumor tracking

One of the main components in a Calypso 4D localization and tracking system is an electromagnetic array placed above patients that is used for target monitoring during radiation treatment. The beam attenuation and beam spoiling properties of the Calypso electromagnetic array at various beam angles were investigated. Measurements were performed on a Varian Clinac iX linear accelerator with 6 MV and 15 MV photon beams. The narrow beam attenuation properties were measured under a field size of 1 cm × 1 cm, with a photon diode placed in a cylindrical graphite buildup cap. The broad beam attenuation properties were measured under a field size of 10 cm × 10 cm, with a 0.6 cc cylindrical Farmer chamber placed in a polystyrene buildup cap. Beam spoiling properties of the array were studied by measuring depth-dose change from the array under a field size of 10 cm × 10 cm in a water-equivalent plastic phantom with an embedded Markus parallel plate chamber. Change in depth doses were measured with the array placed at distances of 2, 5, and 10 cm from the phantom surface. Narrow beam attenuation and broad beam attenuation from the array were found to be less than 2%-3% for both 6 MV and 15 MV beams at angles less than 40°, and were more pronounced at more oblique angles. Spoiling effects are appreciable at beam buildup region, but are insignificant at depths beyond dmax. Dose measurements in a QA phantom using patient IMRT and VMAT treatment plans were shown to have less than 2.5% dose difference with the Calypso array. The results indicate that the dose difference due to the placement of Calypso array is clinically insignificant.

[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.

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.