The accuracy of Acuros XB algorithm for radiation beams traversing a metallic hip implant - comparison with measurements and Monte Carlo calculations

A low-cost phantom design for evaluating spine SABR calculations in the presence of prosthetic vertebral stabilization

Dose-perturbation characteristics are important to consider during the calculation of radiation therapy protocols for patients who are going to receive high doses that would reach the tolerance limits of the spinal cord [1]. Several studies have investigated dose perturbations introduced by metal implants in close proximity to spine SABR treatments [2-7]. However, there is a lack of work assessing this effect using the RayStation TPS [8]. We present an initial design for a low-cost phantom to evaluate spine stereotactic ablative radiotherapy (SABR) in the presence of prosthetic vertebral stabilization. The phantom is modular, allowing the prosthetic at the centre of the phantom to be removed by exchanging the central block. It also includes space to insert ion chamber and film. The agreement of the RayStation TPS (v8.0B) collapsed cone convolution (CCC) calculation and measurement was determined for phantom versions with and without prosthetic. There was little to no change in the agreement between the measured and calculated dose when introducing metallic hardware. This suggests that our Raystation-based SABR planning approach for patients with spinal hardware meets clinical expectations. Departments without access to anthropomorphic phantoms may find this design useful but should test their phantom design in typical clinical settings to ensure it is robust to real world situations.

Extending deterministic transport capabilities for very-high and ultra-high energy electron beams

Focused Very-High Energy Electron (VHEE, 50-300 MeV) and Ultra-High Energy Electron (UHEE, > 300 MeV) beams can accurately target both large and deeply seated human tumors with high sparing properties, while avoiding the spatial requirements and cost of proton and heavy ion facilities. Advanced testing phases are underway at the CLEAR facilities at CERN (Switzerland), NLCTA at Stanford (USA), and SPARC at INFN (Italy), aiming to accelerate the transition to clinical application. Currently, Monte Carlo (MC) transport is the sole paradigm supporting preclinical trials and imminent clinical deployment. In this paper, we propose an alternative: the first extension of the nuclear-reactor deterministic chain NJOY-DRAGON for VHEE and UHEE applications. We have extended the Boltzmann-Fokker-Planck (BFP) multigroup formalism and validated it using standard radio-oncology benchmarks, complex assemblies with a wide range of atomic numbers, and comprehensive irradiation of the entire periodic table. We report that [Formula: see text] of water voxels exhibit a BFP-MC deviation below [Formula: see text] for electron energies under [Formula: see text]. Additionally, we demonstrate that at least [Formula: see text] of voxels of bone, lung, adipose tissue, muscle, soft tissue, tumor, steel, and aluminum meet the same criterion between [Formula: see text] and [Formula: see text]. For water, the thorax, and the breast intra-operative benchmark, typical average BFP-MC deviations of [Formula: see text] and [Formula: see text] were observed at [Formula: see text] and [Formula: see text], respectively. By irradiating the entire periodic table, we observed similar performance between lithium ([Formula: see text]) and cerium ([Formula: see text]). Deficiencies observed between praseodymium ([Formula: see text]) and einsteinium ([Formula: see text]) have been reported, analyzed, and quantified, offering critical insights for the ongoing development of the Evaluated Nuclear Data File mode in NJOY.

A comprehensive evaluation of advanced dose calculation algorithms for brain stereotactic radiosurgery

PURPOSE

Accurate dose calculation is important in both target and low dose normal tissue regions for brain stereotactic radiosurgery (SRS). In this study, we aim to evaluate the dosimetric accuracy of the two advanced dose calculation algorithms for brain SRS.

METHODS

Retrospective clinical case study and phantom study were performed. For the clinical study, 138 SRS patient plans (443 targets) were generated using BrainLab Elements Voxel Monte Carlo (VMC). To evaluate the dose calculation accuracy, the plans were exported into Eclipse and recalculated with Acuros XB (AXB) algorithm with identical beam parameters. The calculated dose at the target center (Dref), dose to 95% target volume (D95), and the average dose to target (Dmean) were compared. Also, the distance from the skull was analyzed. For the phantom study, a cylindrical phantom and a head phantom were used, and the delivered dose was measured by an ion chamber and EBT3 film, respectively, at various locations. The measurement was compared with the calculated doses from VMC and AXB.

RESULTS

In clinical cases, VMC dose calculations tended to be higher than AXB. It was found that the difference in Dref showed > 5% in some cases for smaller volumes < 0.3 cm3 . Dmean and D95 differences were also higher for small targets. No obvious trend was found between the dose difference and the distance from the skull. In phantom studies, VMC dose was also higher than AXB for smaller targets, and VMC showed better agreement with the measurements than AXB for both point dose and high dose spread.

CONCLUSION

The two advanced calculation algorithms were extensively compared. For brain SRS, AXB sometimes calculates a noticeable lower target dose for small targets than VMC, and VMC tends to have a slightly closer agreement with measurements than AXB.

Improvement of deep learning prediction model in patient-specific QA for VMAT with MLC leaf position map and patient's dose distribution

PURPOSE

Deep learning-based virtual patient-specific quality assurance (QA) is a novel technique that enables patient QA without measurement. However, this method could be improved by further evaluating the optimal data to be used as input. Therefore, a deep learning-based model that uses multileaf collimator (MLC) information per control point and dose distribution in patient's CT as inputs was developed.

METHODS

Overall, 96 volumetric-modulated arc therapy plans generated for prostate cancer treatment were used. We developed a model (Model 1) that can predict measurement-based gamma passing rate (GPR) for a treatment plan using data stored as a map reflecting the MLC leaf position at each control point (MLPM) and data of the dose distribution in patient's CT as inputs. The evaluation of the model was based on the mean absolute error (MAE) and Pearson's correlation coefficient (r) between the measured and predicted GPR. For comparison, we also analyzed models trained with the dose distribution in patient's CT alone (Model 2) and with dose distributions recalculated on a virtual phantom CT (Model 3).

RESULTS

At the 2%/2 mm criterion, MAE[%] and r for Model 1, Model 2, and Model 3 were 2.32% ± 0.43% and 0.54 ± 0.03, 2.70% ± 0.26%, and 0.32 ± 0.08, and 2.96% ± 0.23% and 0.24 ± 0.22, respectively; at the 3%/3 mm criterion, these values were 1.25% ± 0.05% and 0.36 ± 0.18, 1.57% ± 0.35% and 0.19 ± 0.20, and 1.39% ± 0.32% and 0.17 ± 0.22, respectively. This result showed that Model 1 exhibited the lowest MAE and highest r at both criteria of 2%/2 mm and 3%3 mm.

CONCLUSIONS

These findings showed that a model that combines the MLPM and dose distribution in patient's CT exhibited a better GPR prediction performance compared with the other two studied models.

Impact of Dose Perturbations Around Brachytherapy Seeds in External-Beam Radiotherapy Planning: A Fundamental and Clinical Validation Using Treatment Planning System-Based Monte Carlo Simulations

Background This study evaluates dose perturbations caused by nonradioactive seeds in clinical cases by employing treatment planning system-based Monte Carlo (TPS-MC) simulation. Methodology We investigated dose perturbation using a water-equivalent phantom and 20 clinical cases of prostate cancer (10 cases with seeds and 10 cases without seeds) treated at Fujita Health University Hospital, Japan. First, dose calculations for a simple geometry were performed using the RayStation MC algorithm for a water-equivalent phantom with and without a seed. TPS-independent Monte Carlo (full-MC) simulations and film measurements were conducted to verify the accuracy of TPS-MC simulation. Subsequently, dose calculations using TPS-MC were performed on CT images of clinical cases of prostate cancer with and without seeds, and the dose distributions were compared. Results In clinical cases, dose calculations using MC simulations revealed hotspots around the seeds. However, the size of the hotspot was not correlated with the number of seeds. The maximum difference in dose perturbation between TPS-MC simulations and film measurements was 3.9%, whereas that between TPS-MC simulations and full-MC simulations was 3.7%. The dose error of TPS-MC was negligible for multiple beams or rotational irradiation. Conclusions Hotspots were observed in dose calculations using TPS-MC performed on CT images of clinical cases with seeds. The dose calculation accuracy around the seeds using TPS-MC simulations was comparable to that of film measurements and full-MC simulations, with differences within 3.9%. Although the clinical impact of hotspots occurring around the seeds is minimal, utilizing MC simulations on TPSs can be beneficial to verify their presence.

Dosimetric comparison and evaluation of two computational algorithms in VMAT treatment plans

PURPOSE

This study aimed to assess the accuracy and dosimetric impact of the Acuros XB (AXB) algorithm compared to the Anisotropic Analytical Algorithm (AAA) in two situations. First, simple phantom geometries were set and analyzed; moreover, volumetric modulated arc therapy (VMAT) clinical plans for Head & Neck and lung cases were calculated and compared.

METHODS

First, a phantom study was performed to compare the algorithms with radiochromic EBT3 film doses using one PMMA slab phantom and two others containing foam or air gap. Subsequently, a clinical study was conducted, including 20 Head & Neck and 15 lung cases irradiated with the VMAT technique. The treatment plans calculated by AXB and AAA were evaluated in terms of planning target volume (PTV) coverage (V95% ), dose received by relevant organs at risk (OARs), and the impact of using AXB with a grid size of 1 mm. Finally, patient-specific quality assurance (PSQA) was performed and compared for 17 treatment plans.

RESULTS

Phantom dose calculations showed a better agreement of AXB with the film measurements. In the clinical study, AXB plans exhibited lower Conformity Index and PTV V95% , higher maximum PTV dose, and lower mean and minimum PTV doses for all anatomical sites. The most notable differences were detected in regions of intense heterogeneity. AXB predicted lower doses for the OARs, while the calculation time with a grid size of 1 mm was remarkably higher. Regarding PSQA, although AAA was found to exhibit slightly higher gamma passing rates, the difference did not affect the AXB treatment plan quality.

CONCLUSIONS

AXB demonstrated higher accuracy than AAA in dose calculations of both phantom and clinical conditions, specifically in interface regions, making it suitable for sites with large heterogeneities. Hence, such dosimetric differences between the two algorithms should always be considered in clinical practice.

Dosimetric evaluation of high-Z inhomogeneity with modern algorithms: A collaborative study

PURPOSE

To evaluate modern dose calculation algorithms with high-Z prosthetic devices used in radiation treatment.

METHODS

A bilateral hip prosthetic patient was selected to see the effect of modern algorithms from the commercial system for plan comparisons. The CT data with dose constraints were sent to various institutions for dose calculations. The dosimetric parameters, D98%, D90%, D50% and D2% were compared. A water phantom with an actual prosthetic device was used to measure the dose using a parallel plate ionization chamber.

RESULTS

Dosimetric variability in PTV coverage was significant (>10%) among various treatment planning algorithms. The comparison of PTV dosimetric parameters, D98%, D90%, D50% and D2% as well as organs at risk (OAR) have large discrepancies compared to our previous publication with older algorithms (https://doi.org/10.1016/j.ejmp.2022.02.007) but provides realistic dose distribution with better homogeneity index (HI). Backscatter and forward scatter attenuation of the prosthesis was measured showing differences <15.7% at the interface among various algorithms.

CONCLUSIONS

Modern algorithms dose distributions have improved greatly compared to older generation algorithms. However, there is still significant differences at high-Z-tissue interfaces compared to the measurements. To ensure accuracy, it's important to take precautions avoiding placing any prosthesis in the beam direction and using type C algorithms.

Monte Carlo modeling of Halcyon and Ethos radiotherapy beam using CAD geometry: validation and IAEA-compliant phase space

Objective.A Monte Carlo (MC) model of a Halcyon and Ethos (Varian Medical Systems, a Siemens Healthineers Company) radiotherapy beam was validated and field-independent phase space (PHSP) files were recorded above the dual-layer multileaf collimators (MLC).Approach.The treatment head geometry was modeled according to engineering drawings and the dual-layer MLC was imported from CAD (computer-aided design) files. The information for the incident electron beam was achieved from an iterative electromagnetic solver. The validation of the model was performed by comparing the dose delivered by the square MLC fields as well as complex field measurements.Main results.An electron phase space was generated from linac simulations and achieved improved MC results. The output factors for square fields were within 1% and the largest differences of 5% were found in the build-up region of PDDs and the penumbra region of profiles. With the more complicated MLC-shaped field (Fishbone), the largest differences of up to 8% were found in the MLC leaf tip region due to the uncertainty of the MLC positioning and the mechanical leaf gap value. The impact of the collimator rotation on the PHSP solution has been assessed with both small and large fields, confirming negligible effects on in-field and out-of-field dose distributions.Significance.A computational model of the Halcyon and Ethos radiotherapy beam with a high accuracy implementation of the MLC was shown to be able to reproduce the radiation beam characteristics with square fields and more complex MLC-shaped fields. The field-independent PHSP files that were produced can be used as an accurate treatment head model above the MLC, and reduce the time to simulate particle transport through treatment head components.

Feasibility of a multigroup Boltzmann-Fokker-Planck solution for electron beam dose calculations

Legacy nuclear-reactor Boltzmann solvers start clinical deployment as an alternative to Monte Carlo (MC) codes and Fermi-Eyges semiemprical models in radiation oncology treatment planning. Today's certified clinical solvers are limited to photon beams. In this paper, ELECTR, a state-of-the-art multigroup electron cross sections generation module in NJOY is presented and validated against Lockwood's calorimetric measurements, EGS-nrc and GEANT-4 for 1-20 MeV unidirectional electron beams. The nuclear-reactor DRAGON-5 solver is upgraded to access the library and solve the Boltzmann-Fokker-Planck (BFP) equation. A variety of heterogeneous radiotherapy and radiosurgery phantom configurations were used for validation purpose. Case studies include a thorax benchmark, that of a typical breast Intra-Operative Radiotherapy and a high-heterogeneity patient-like benchmark. For all beams, [Formula: see text] of the water voxels satisfied the American Association of Physicists in Medicine accuracy criterion for a BFP-MC dose error below [Formula: see text]. At least, [Formula: see text] of adipose, muscle, bone, lung, tumor and breast voxels satisfied the [Formula: see text] criterion. The average BFP-MC relative error was about [Formula: see text] for all voxels, beams and materials combined. By irradiating homogeneous slabs from [Formula: see text] (hydrogen) to [Formula: see text] (einsteinium), we reported performance and defects of the CEPXS mode [US. Sandia National Lab., SAND-89-1685] in ELECTR for the entire periodic table. For all Lockwood's benchmarks, NJOY-DRAGON dose predictions are within the experimental data precision for [Formula: see text] of voxels.

VMAT partial arc technique decreases dose to organs at risk in whole pelvic radiotherapy for prostate cancer when compared to full arc VMAT and IMRT

Whole pelvic radiotherapy (WPRT) can sterilize microscopic lymph node metastases in treatment of prostate cancer. WPRT, compared to prostate only radiotherapy (PORT), is associated with increased acute gastrointestinal, and hematological toxicities. To further explore minimizing normal tissue toxicities associated with WPRT in definitive IMRT for prostate cancer, this planning study compared dosimetric differences between static 9-field-IMRT, full arc VMAT, and mixed partial-full arc VMAT techniques. In this retrospective study, 12 prostate cancer patients who met the criteria for WPRT were randomly selected for this study. The initial volume, PTV46, included the prostate, seminal vesicles, and pelvic nodes with margin and was prescribed to 4600 cGy. The cone-down volume, PTV78, included the prostate and proximal seminal vesicles with margin to a total dose of 7800 cGy. For each CT image set, 3 plans were generated for each of the PTVs: an IMRT plan, a full arc (FA) VMAT plan, and a mixed partial-full arc (PFA) VMAT plan, using 6MV photons energy. According to RTOG protocols none of the plans had a major Conformity Index (CI) violation by any of the 3 planning techniques. PFA plan had the best mean CI index of 1.00 and significantly better than IMRT (p = 0.03) and FA (p = 0.007). For equivalent PTV coverage, the average composite gradient index of the PFA plans was better than the IMRT and the FA plans with values 1.92, 2.03, and 2.01 respectively. The defference was statistically significant between PFA/IMRT and PFA/FA, with p- values of < 0.001. The IMRT plans and the PFA plans provided very similar doses to the rectum, bladder, sigmoid colon, and femoral heads, which were lower than the dose in the FA plans. There was a significant decrease in the mean dose to the rectum from 4524 cGy with the FA to 4182 cGy with the PFA and 4091 cGy with IMRT (p < 0.001). The percent of rectum receiving 4000 cGy was also the highest with FA at 66.1% compared to 49.9% (PFA) and 47.5% (IMRT). There was a significant decrease in the mean dose to the bladder from 3922 cGy (FA) to 3551 cGy (PFA) and 3612 cGy (IMRT) (p < 0.001). The percent of bladder receiving 4000 cGy was also the highest with FA at 45.4% compared to 36.6% (PFA) and 37.4% (IMRT). The average mean dose to the sigmoid colon decreased from 4177 cGy (FA) to 3893 cGy (PFA) and 3819 cGy (IMRT). The average mean dose to the femoral heads decreased from 2091 cGy (FA) to 2026 cGy (PFA) and 1987 cGy (IMRT). Considering the improvement in plan quality indices recorded in this study including the dose gradient and the dose to organs at risk, mixed partial-full arc plans may be the preferred VMAT treatment technique over full arc plans for prostate cancer treatments that include nodal volumes.

Monte Carlo modeling of the Elekta Versa HD and patient dose calculation with EGSnrc/BEAMnrc

Introduction

Numerous studies have proven the Monte Carlo method to be an accurate means of dose calculation. Although there are several commercial Monte Carlo treatment planning systems (TPSs), some clinics may not have access to these resources. We present a method for routine, independent patient dose calculations from treatment plans generated in a commercial TPS with our own Monte Carlo model using free, open‐source software.

Materials and methods

A model of the Elekta Versa HD linear accelerator was developed using the EGSnrc codes. A MATLAB script was created to take clinical patient plans and convert the DICOM RTP files into a format usable by EGSnrc. Ten patients’ treatment plans were exported from the Monaco TPS to be recalculated using EGSnrc. Treatment simulations were done in BEAMnrc, and doses were calculated using Source 21 in DOSXYZnrc. Results were compared to patient plans calculated in the Monaco TPS and evaluated in Verisoft with a gamma criterion of 3%/2 mm.

Results

Our Monte Carlo model was validated within 1%/1‐mm accuracy of measured percent depth doses and profiles. Gamma passing rates ranged from 82.1% to 99.8%, with 7 out of 10 plans having a gamma pass rate over 95%. Lung and prostate patients showed the best agreement with doses calculated in Monaco. All statistical uncertainties in DOSXYZnrc were less than 3.0%.

Conclusion

A Monte Carlo model for routine patient dose calculation was successfully developed and tested. This model allows users to directly recalculate DICOM RP files containing patients’ plans that have been exported from a commercial TPS.

Dosimetric comparison of analytical anisotropic algorithm and the two dose reporting modes of Acuros XB dose calculation algorithm in volumetric modulated arc therapy of carcinoma lung and carcinoma prostate

Volumetric Modulated Arc Therapy (VMAT) is an important modality for radical radiotherapy of all major treatment sites. This study aims to compare Analytical Anisotropic Algorithm (AAA) and the two dose-reporting modes of Acuros XB (AXB) algorithm -the dose to medium option (D_m) and the dose to water option (D_w) in Volumetric Modulated Arc Therapy (VMAT) of carcinoma lung and carcinoma prostate. We also compared the measured dose with Treatment Planning System calculated dose for AAA and the two dose reporting options of Acuros XB using Electronic Portal Imaging Device (EPID) and ArcCHECK phantom. Treatment plans of twenty patients each who have already undergone radiotherapy for cancer of lung and cancer of prostate were selected for the study. Three sets of VMAT plans were generated in Eclipse Treatment Planning System (TPS), one with AAA and two plans with Acuros-D_m and Acuros-D_w options. The Dose Volume Histograms (DVHs) were compared and analyzed for Planning Target Volume (PTV) and critical structures for all the plans. Verification plans were created for each plan and measured doses were compared with TPS calculated doses using EPID and ArcCHECK phantom for all the three algorithms. For lung plans, the mean dose to PTV in the AXB-D_w plans was higher by 1.7% and in the AXB-D_m plans by 0.66% when compared to AAA plans. For prostate plans, the mean dose to PTV in the AXB-D_w plans was higher by 3.0% and in the AXB-D_m plans by 1.6% when compared to AAA plans. There was no difference in the Conformity Index (CI) between AAA and AXB-D_m and between AAA and AXB-D_w plans for both sites. But the homogeneity worsened in AXB-D_w and AXB-D_m plans when compared to AAA plans for both sites. AXB-D_w calculated higher dose values for PTV and all the critical structures with significant differences with one or two exceptions. Point dose measurements in ArcCHECK phantom showed that AXB-D_m and AXB-D_w options showed very small deviations with measured dose distributions than AAA for both sites. Results of EPID QA also showed better pass rates for AXB-D_w and AXB-D_m than AAA for both sites when gamma analysis was done for 3%/3 mm and 2%/2 mm criteria. With reference to the results, it is always better to choose Acuros algorithm for dose calculations if it is available in the TPS. AXB-D_w plans showed very high dose values in the PTV when compared to AAA and AXB-D_m in both sites studied. Also, the volume of PTV receiving 107% dose was significantly high in AXB-D_w plans compared to AXB-D_m plans in sites involving high density bones. Considering the results of dosimetric comparison and QA measurements, it is always better to choose AXB-D_m algorithm for dose calculations for all treatment sites especially when high density bony structures and complex treatment techniques are involved. For patient specific QA purposes, choosing AXB-D_m or AXB-D_w does not make any significant difference between calculated and measured dose distributions.

Accuracy of the doses computed by the Eclipse treatment planning system near and inside metal elements

Metal artefacts degrade clinical image quality which decreases the confidence of using computed tomography (CT) for the delineation of key structures for treatment planning and leads to dose errors in affected areas. In this work, we investigated accuracy of doses computed by the Eclipse treatment planning system near and inside metallic elements for two different computation algorithms. An impact of CT metal artefact reduction methods on the resulting calculated doses has also been assessed. A water phantom including Gafchromic film and metal inserts was irradiated (max dose 5 Gy) using a 6 MV photon beam. Three materials were tested: titanium, alloy 600, and tungsten. The phantom CT images were obtained with the pseudo-monoenergetic reconstruction (PMR) and the iterative metal artefact reduction (iMAR). Image sets were used for dose calculation using an Eclipse treatment planning station (TPS). Monte Carlo (MC) simulations were used to predict the true dose distribution in the phantom allowing for comparison with doses measured by film and calculated by TPS. Measured and simulated percentage depth doses (PDDs) were not statistically different (p > 0.618). Regional differences were observed at edges of metallic objects (max 8% difference). However, PDDs simulated with and without film were statistically different (p < 0.002). PDDs calculated by the Acuros XB algorithm based on the dose-to-medium approach best matched the MC reference regardless of the CT reconstruction methods and inserts used (p > 0.078). PDDs obtained using other algorithms significantly differ from the MC values (p < 0.011). The Acuros XB algorithm with a dose-to-medium approach provides reliable dose calculation in all metal regions when using the Varian system. The inability of the AAA algorithm to model backscatter dose significantly limits its clinical application in the presence of metal. No significant impact on the dose calculation was found for a range of metal artefact reduction strategies.

Dosimetric evaluation of high-Z inhomogeneity used for hip prosthesis: A multi-institutional collaborative study

PURPOSE

A multi-institutional investigation for dosimetric evaluation of high-Z hip prosthetic device in photon beam.

METHODS

A bilateral hip prosthetic case was chosen. An in-house phantom was built to replicate the human pelvis with two different prostheses. Dosimetric parameters: dose to the target and organs at risk (OARs) were compared for the clinical case generated by various treatment planning system (TPS) with varied algorithms. Single beam plans with different TPS for phantom using 6 MV and 15 MV photon beams with and without density correction were compared with measurement.

RESULTS

Wide variations in target and OAR dosimetry were recorded for different TPS. For clinical case ideal PTV coverage was noted for plans generated with Corvus and Prowess TPS only. However, none of the TPS were able to meet plan objective for the bladder. Good correlation was noticed for the measured and the Pinnacle TPS for corrected dose calculation at the interfaces as well as the dose ratio in elsewhere. On comparing measured and calculated dose, the difference across the TPS varied from -20% to 60% for 6 MV and 3% to 50% for the 15 MV, respectively.

CONCLUSION

Most TPS do not provide accurate dosimetry with high-Z prosthesis. It is important to check the TPS under extreme conditions of beams passing through the high-Z region. Metal artifact reduction algorithms may reduce the difference between the measured and calculated dose but still significant differences exist. Further studies are required to validate the calculational accuracy.

Radiotherapy-induced toxicity in prostate cancer patients with hip prostheses

Introduction

Acute and late toxicity was analysed for prostate cancer patients with bilateral hip prostheses, who received fixed field intensity modulated radiotherapy (IMRT). The aims were (1) to establish whether toxicity rates differed from those of a control group with normal hips, (2) to develop a volumetric modulated arc therapy (VMAT) approach for patients with prostheses and (3) to compare doses to bladder and rectum for the control group, prostheses group and VMAT replans for the prostheses group.

Methods

Genitourinary (GU) and gastrointestinal (GI) toxicity was scored using Common Terminology Criteria for Adverse Events version 5.0. The incidence of grade 2 or worse (G2+) toxicity was compared using Fisher’s exact test. Dose volume histograms (DVHs) and mean doses to organs at risk (OARs) were compared using signed rank tests.

Results

There were 17 patients in the prostheses group and 50 in the control group. Acute and late GU toxicity was similar. G2+ late GI toxicity incidence was 31% for the prostheses group and 14% for the control group (p = 0.14). Significant differences (p < 0.05) were seen between the OAR DVHs of the prostheses group who had IMRT and the control group for a range of intermediate doses. The rectum mean dose was significantly different (p < 0.001), but no difference was seen for the bladder mean dose (p = 0.08).

Conclusions

No significant differences were seen in GU and GI toxicity incidence between patients with bilateral hip prostheses and a control group. The DVHs for bladder and rectum were significantly higher for patients with prostheses planned with IMRT. Replanning using a VMAT technique significantly reduced doses to the OARs, whilst maintaining good planning target volume coverage.

Virtual bronchoscopy-guided lung SAbR: dosimetric implications of using AAA versus Acuros XB to calculate dose in airways

In previous works, we showed that incorporating individual airways as organs-at-risk (OARs) in the treatment of lung stereotactic ablative radiotherapy (SAbR) patients potentially mitigates post-SAbR radiation injury. However, the performance of common clinical dose calculation algorithms in airways has not been thoroughly studied. Airways are of particular concern because their small size and the density differences they create have the potential to hinder dose calculation accuracy. To address this gap in knowledge, here we investigate dosimetric accuracy in airways of two commonly used dose calculation algorithms, the anisotropic analytical algorithm (AAA) and Acuros-XB (AXB), recreating clinical treatment plans on a cohort of four SAbR patients. A virtual bronchoscopy software was used to delineate 856 airways on a high-resolution breath-hold CT (BHCT) image acquired for each patient. The planning target volumes (PTVs) and standard thoracic OARs were contoured on an average CT (AVG) image over the breathing cycle. Conformal and intensity-modulated radiation therapy plans were recreated on the BHCT image and on the AVG image, for a total of four plan types per patient. Dose calculations were performed using AAA and AXB, and the differences in maximum and mean dose in each structure were calculated. The median differences in maximum dose among all airways were ≤0.3Gy in magnitude for all four plan types. With airways grouped by dose-to-structure or diameter, median dose differences were still ≤0.5Gy in magnitude, with no clear dependence on airway size. These results, along with our previous airway radiosensitivity works, suggest that dose differences between AAA and AXB correspond to an airway collapse variation ≤0.7% in magnitude. This variation in airway injury risk can be considered as not clinically relevant, and the use of either AAA or AXB is therefore appropriate when including patient airways as individual OARs so as to reduce risk of radiation-induced lung toxicity.

Prostate radiotherapy in the setting of bilateral hip prostheses: All commonly used photon-based radiation approaches are feasible

The prevalence of hip prostheses is increasing. Prostate radiation delivery in the setting of hip prostheses is complicated by both imaging artifacts that interfere with volume delineation and dosimetric effects that must be addressed in the planning process. We hypothesized that with specialized planning, any photon-based definitive prostate radiotherapy approach may be utilized in patients with bilateral hip prostheses. Imaging data from sequential patients with prostate cancer and bilateral hip prostheses treated definitively with radiation were retrospectively reviewed. Bimodality imaging was used to define targets and organs at risk (OARs) along with specialized MRI sequences and/or orthopedic metal artifact reduction (OMAR) for MRI and CT artifact suppression, respectively. Multiple VMAT plans were generated for each set of patient images to include three fractionation schemes (conventional, hypofractionated, and SBRT), each with hip avoidance and with simulated normal hip. The ability to meet standard dose constraints was assessed for each plan type. Differences in target and OAR dosing between plans accounting for prosthetic hips via avoidance vs plans with simulated absence of prosthetic hip were also assessed. T-tests were used to compare dosimetric parameters. Ten patients with bilateral hip prostheses were identified, and 6 plans were created for each patient for a total of 60 radiation plans. Prosthetic hip avoidance did not result in failure to meet dose constraints for any patient. Hip avoidance resulted in minimal increases in high dose to the rectum and bladder (increases in mean V80%, V90%, and V95% ranged from 0.1% to 2.4%). Larger increases were seen at lower dose levels, with rectal V50% significantly increased in all three plan types with hip avoidance (conventional: 26.0% [standard deviation, SD 13.9] vs 16.9% [SD 10.2, p = 0.003]; hypofractionation: 26.4% [SD 13.3] vs 17.1% [SD 10.1, p = 0.002]; SBRT: 18.3% [SD 10.7] vs 10.5% [SD 6.9, p = 0.008]). Similarly, hip avoidance resulted in increases in bladder V50% to 31.7% (SD 16.8) vs 23.3% (SD 14.0, p = 0.001), 31.3% (SD 17.0) vs 23.3% (SD 13.8, p = 0.002), and 22.7% (SD 12.3) vs 16.5% (SD 12.6, p < 0.001) for conventional, hypofractionated, and SBRT plans, respectively. Hydrogel spacer resulted in reductions in rectal dose. For example, V70% for hip avoidance plans decreased with spacer presence to 8.3% (SD 6.7) vs 21.1% (SD 5.8, p = 0.021), 8.6% (SD 6.5) vs 21% (SD 5.7, p = 0.022), and 3.7% (SD 3.2) vs 15% (SD 8.2, p = 0.010) for conventional, hypofractionated, and SBRT plans, respectively. Any photon-based definitive prostate radiotherapy approach can be used with bimodality imaging for target and OAR definition and planning techniques to avoid dose attenuation effects of hip prostheses. Hydrogel spacer is a useful adjunct.

Dose-area product ratio in external small-beam radiotherapy: beam shape, size and energy dependencies in clinical photon beams

In small-field radiotherapy (RT), a significant challenge is to define the amount of radiation dose absorbed in the patient where the quality of the beam has to be measured with high accuracy. The properties of a proposed new beam quality specifier, namely the dose-area-product ratio at 20 and 10 cm depths in water or DAPR_20,10, were studied to yield more information on its feasibility over the conventional quality specifier tissue-phantom ratio or TPR_20,10. The DAPR_20,10may be measured with a large-area ionization chamber (LAC) instead of small volume chambers or semi-conductors where detector, beam and water phantom positioning and beam perturbations introduce uncertainties. The effects of beam shape, size and energy on the DAPR_20,10were studied and it was shown that the DAPR_20,10increases with increasing beam energy similarly to TPR_20,10but in contrast exhibits a small beam size and shape dependence. The beam profile outside the beam limiting devices has been shown to have a large contribution to the DAPR_20,10. There is potential in large area chambers to be used in DAPR measurement and its use in dosimetry of small-beam RT for beam quality measurements.

Feasibility of Monte-Carlo algorithm in comparison with collapse-cone dose calculation algorithm of a commercial treatment planning system in the presence of high-density metallic implant: a dosimetric study

BACKGROUND

The number of people with implanted hip prosthesis has grown worldwide. For radiotherapy planning of patients with hip implants, few main challenges are encountered. The aim of the present study was to evaluate the feasibility of different planning algorithms in the presence of high-density metallic implant in the treatment of patients with carcinoma cervix.

RESULTS

It was found that D_98% were 44.49 ± 0.11, 44.51 ± 0.13, 44.39 ± 0.22, and 44.45 ± 0.16 Gy for 4FMC6MV (4-field technique calculated with Monte-Carlo algorithm and 6 MV photon energy), 4FMC6MV_WP (4-field technique calculated with Monte-Carlo algorithm and 6 MV photon energy without prosthesis), 4FCC6MV (4-field technique calculated with collapse-cone-convolution algorithm and 6 MV photon energy), and 4FCC6MV_WP (4-field technique calculated with collapse-cone-convolution algorithm and 6 MV photon energy without prosthesis) respectively. Similarly, D_2% were 49.40 ± 0.84, 49.05 ± 0.76, 48.97 ± 0.91, and 48.57 ± 0.85 Gray (Gy) for 4FMC6MV, 4FMC6MV_WP, 4FCC6MV, and 4FCC6MV_WP respectively. The present study has not suggested any major difference between the Monte-Carlo (MC) and collapse-cone-convolution (CCC) calculation algorithm in the presence of high-Z metallic implants. Volume of bowel receiving 15 Gy dose has shown a significant difference with prosthesis cases. This study investigates that hip prosthesis creates considerable changes in the treatment planning of cervical malignancies.

CONCLUSION

CCC algorithm is in good agreement with MC calculation algorithm in the presence of high-density metallic implants in terms of target coverage and avoidance organ sparing except few parameters.

The robustness of prostate radiotherapy for patients with hip prosthesis

The aim of this study was to investigate prostate radiotherapy techniques for the patients with hip prosthesis in 4 different field setups. Volumetric Modulated Arc Therapy (VMAT) technique was used in 4 different cases: (1) using full VMAT arcs (VMAT_F); (2) same arcs as in case 1 but with avoidance sectors (VMAT_ASEC); (3) as case 2 but with the addition of a lateral static field through the prosthesis (VMAT_ASEC+STAT); (4) as in case 1 but with an automated structure avoidance option to avoid irradiation through the prosthesis (VMAT_ASTR). Fifteen previously treated prostate patients were retrospectively selected to this study. Treatment plans were created for all patients using all 4 techniques. The potential prosthesis misalignment in the treatment setup was modeled by moving the prosthesis 0.5, 1.0, and 1.5 cm ventrally and dorsally and recalculating the plans in each case. For VMAT_ASEC, the dose parameters for organs at risk were the highest and the dose coverage of the target volume was the poorest when compared to the other techniques. For VMAT_ASEC+STAT, the movement of the prosthesis changed the target dose distribution the most. VMAT_F and VMAT_ASTR fulfilled the planning criteria the best, even when the prosthesis was misaligned. VMAT_F radiated through the prosthesis more than VMAT_ASTR and increased the dose near the prosthesis surface when compared to VMAT_ASTR. VMAT_ASTR and VMAT_F were the most robust techniques for the patients with the hip prosthesis considering plan quality and the effect of positioning errors. The increased prosthesis surface dose with VMAT_F and possible dose calculation uncertainties favors the use of VMAT_ASTR.

Dosimetric evaluation of phantoms including metal objects with high atomic number for use in intensity modulated radiation therapy

The dosimetric effect of artefacts caused by metal hip prostheses in computed tomography imaging is most commonly encountered in the planning of prostate cancer treatment. In this study, a phantom, containing a metal with high atomic number, was prepared for intensity-modulated radiotherapy (IMRT) treatment plans to be used in quality assurance (QA) procedures. Two sets of image files, one without metal artefact correction (ORG) and another with MAR correction (MAR+), were sent to the treatment planning system. In this study, 12 IMRT treatment plans with different fields and segment numbers were calculated. The normal tissue complication probability (NTCP) values of imaginary organs at risk (OARs), such as the rectum and bladder, were investigated, as was the difference in dose maps for ORG and MAR+ derived by calculating gamma passing rates (GPRs). The MatriXX was used for the gamma evaluation of patient-specific IMRT QA measurements. The gamma evaluation was repeated, based on the measurements using an EBT³ gafchromic film, for the plan showing the lowest GPR. The mean relative difference in NTCP values between the two sets of image files was found to be 2.5, 2.1 and 1.4 for the rectum; and 5.33, 6.80 and 9.82 for the bladder, for the investigated 5-, 7- and 9-field beam arrangements, respectively. The relative differences and the standard deviations in GPRs for the standard and metal-containing phantoms were calculated for the MAR+ and ORG sets. The maximum difference found was 7.69% ± 0.88 for the 9-field beam arrangement calculated without metal artefact correction. In the IMRT QA procedures for prostate patients with hip prostheses, the application of a metal-containing phantom that is both easy and inexpensive to prepare, is considered to be a useful method for examining any dose changes involved in introducing a hip prosthesis. Therefore, it is recommended for use in clinics that do not have MAR correction algorithms.

6X acuros algorithm validation in the presence of inhomogeneities for VMAT treatment planning

Aim

To validate the Acuros®XB (AXB) dose calculation algorithm for a 6 MV beam from the Varian TrueBeam treatment units.

Background

Currently Anisotropic Analytic Algorithm (AAA) is clinically used on authors' department but AXB could replace it for VMAT treatments in regions where inhomogeneities and free air are present.

Materials and methods

Two steps are followed in the validation process of a new dose calculation algorithm. The first is to check the accuracy of algorithm for a homogenous phantom and regular fields. Multiple fields of increasing complexity have been acquired using a Mapcheck diode array. The accuracy of the algorithm was evaluated using the gamma analysis method. The second is to validate the algorithm in the presence of heterogeneous media. Planar absolute dose was measured with GafChromic®EBT2 film and was compared with the dose calculated by AXB. Gamma analysis was performed between Mapcheck measurements and AXB dose calculations, at a range of clinical source-surface distance.

Results

For SSDs ranging from 80 to 100 cm, the results show a minimum pass rate of 95% between AXB and Mapcheck acquisition. For open 6 MV photon beam interacting with a phantom with an air gap, the agreement after the air gap between AXB and GafChromic®EBT2 is less than 1% in the 3 × 3cm² field and less than 2% in the 10 × 10 cm² field.

Conclusions

AXB has advanced modelling of lateral electron transport that enables a more accurate dose calculation in heterogeneous regions and, compared with AAA, improves accuracy between different density interfaces. This will be of particular benefit for head/neck treatments.

Combined radiotherapy and concurrent tumor treating fields (TTFields) for glioblastoma: Dosimetric consequences on non-coplanar IMRT as initial results from a phase I trial

Background

Glioblastoma is a rapidly proliferating tumor. Patients bear an inferior prognosis with a median survival time of 14-16 months. Proliferation and repopulation are a major resistance promoting factor for conventionally fractionated radiotherapy. Tumor-Treating-Fields (TTFields) are an antimitotic modality applying low-intensity (1-3 V/cm), intermediate-frequency (100-300 kHz) alternating electric-fields. More recently interference of TTFields with DNA-damage-repair and synergistic effects with radiotherapy were reported in the preclinical setting. This study aims at examining the dosimetric consequences of TTFields applied during the course of radiochemotherapy.

Methods

Cone-beam-computed-tomography (CBCT)-data from the first seven patients of the PriCoTTF-phase-I-trial were used in a predefined way for dosimetric verification and dose-accumulation of the non-coplanar-intensity-modulated-radiotherapy (IMRT)-treatment-plans as well as geometric analysis of the transducer-arrays by which TTFields are applied throughout the course of treatment. Transducer-array-position and contours were obtained from the low-dose CBCT’s routinely made for image-guidance. Material-composition of the electrodes was determined and a respective Hounsfield-unit was assigned to the electrodes. After 6D-fusion with the planning-CT, the dose-distribution was recalculated using a Boltzmann-equation-solver (Acuros XB) and a Monte-Carlo-dose-calculation-engine.

Results

Overdosage in the scalp in comparison to the treatment plan without electrodes stayed below 8.5% of the prescribed dose in the first 2 mm below and also in deeper layers outside 1cm² at highest dose as obtained from dose-volume-histogram comparisons. In the clinical target volume (CTV), underdosage was limited to 2.0% due to dose attenuation by the electrodes in terms of D95 and the effective-uniform-dose. Principal-component-analysis (PCA) showed that the first principal-position-component of the variation of repeated array-placement in the direction of the largest variations and the perpendicular second-component spanning a tangential plane on the skull had a standard deviation of 1.06 cm, 1.23 cm, 0.96 cm, and 1.11 cm for the frontal, occipital, left and right arrays for the first and 0.70 cm, 0.71 cm, 0.79 cm, and 0.68 cm, respectively for the second-principal-component. The variations did not differ from patient-to-patient (p > 0.8, Kruskal-Wallis-tests). This motion led to a diminution of the dosimetric effects of the electrodes.

Conclusion

From a dosimetric point of view, dose deviations in the CTV due to transducer-arrays were not clinically significant in the first 7 patients and confirmed feasibility of combined adjuvant radiochemotherapy and concurrent TTFields.

PriCoTTF Trial: A phase I/II trial of TTFields prior and concomitant to radiotherapy in newly diagnosed glioblastoma.

DRKS-ID: DRKS00016667.

Date of Registration in DRKS: 2019/02/26.

Investigator Sponsored/Initiated Trial (IST/IIT): yes.

Ethics Approval/Approval of the Ethics Committee: Approved.

(leading) Ethics Committee Nr.: 18–8316-MF, Ethik-Kommission der Medizinischen.

Fakultät der Universität Duisburg-Essen.

EUDAMED-No. (for studies acc. to Medical Devices act): CIV-18-08-025247.

Effects of metal implants and a metal artifact reduction tool on calculation accuracy of AAA and Acuros XB algorithms in small fields

PURPOSE

In this study, the dosimetric accuracy of analytical anisotropic algorithm (AAA) and Acuros XB (AXB) dose calculation algorithms (Varian Medical Systems, Palo Alto, CA) was investigated for small radiation fields incident on phantoms of various metals that include stainless steel grade 316L (SS316L) and titanium alloy grade 5 (Ti5) implants. In addition, the effects of using metal artifact reduction for orthopedic implants (O-MAR, Philips Healthcare, Cleveland, OH) were evaluated.

METHODS

The evaluations of AAA and AXB were performed by comparing the crossline profiles calculated by AAA and AXB with GafChromic_TM EBT3 film measurements at the phantom-implant interfaces and in close vicinity of implant materials for small field sizes (1 × 1 cm² , 2 × 2 cm² , 3 × 3 cm² , and 4 × 4 cm² ) of a 6 MV flattening filter free photon beam. O-MAR corrected and uncorrected (UC) computed tomography (CT) images were used for dose calculations. The values of average and standard deviations (SD) of Hounsfield unit (HU) for selected regions of each case were evaluated. The differences in average dose percentages in defined regions were calculated to quantify the relative dosimetric changes between doses calculated on UC and O-MAR corrected CT images.

RESULTS

Compared to UC images, the values of SD were reduced, and the average HU became closer to its reference value in the O-MAR images. There was some discrepancy in average dose percentage differences between calculations using UC and O-MAR images at 1 cm above the SS316L implant (average dose percentage differences were AXB/UC = 5.9% and AXB/O-MAR = -1.2%; AAA/UC = 2.2%, and AAA/O-MAR = -0.8%). Neither AAA nor AXB algorithms predict increase in dose at upper phantom-implant interface (4.9%, 9.9%. 13.5%, and 13.8% for the fields from 1 × 1 cm² to 4 × 4 cm² , respectively). At the side of the SS316L implant (where dark streak artifacts exist), dose difference averages were estimated as - 1.1% and 22.3% when AXB/O-MAR and AXB/UC calculations are compared with EBT3 measurements, respectively. Dose predictions at 1 cm below the SS316L implant were underestimated by AXB/O-MAR (average -0.5%) and AXB/UC (average 2.0%).

CONCLUSIONS

The O-MAR tool was shown to have a favorable dosimetric effect or no effect on the calculations in the upper proximity of the implant materials. The dose differences between EBT3 film measurements and calculations at upper phantom-implant interfaces were smaller when they were calculated using O-MAR images. However, the dose differences increased when O-MAR corrected images were used for AAA calculations at lower phantom-implant interfaces. Use of O-MAR enabled closer agreement for the AXB algorithm, especially in the dark streak artifact regions. The O-MAR algorithm should be used when the dose is calculated with the AXB algorithm in cases of patients with the metal implants. The estimations using AAA and AXB algorithms, in phantom setups, with Ti5 implant material were found to be closer to the EBT3 film measurements, when compared with the same estimations using SS316L implant material.

Modeling AeroForm tissue expander for postmastectomy radiation therapy

The AeroForm chest wall tissue expander (TE) is a silicon shell containing a metallic CO₂ reservoir, placed surgically after mastectomy. The patient uses a remote control to release compressed CO₂ from the reservoir to inflate the expander. AeroForm poses challenges in a radiation therapy setting: The high density of the metallic reservoir causes imaging artifacts on the planning CT, which encumber structure definition and cause misrepresentation of density information, in turn affecting dose calculation. Additionally, convolution-based dose calculation algorithms may not be well-suited to calculate dose in and around high-density materials. In this study, a model of the AeroForm TE was created in Eclipse treatment planning system (TPS). The TPS model was validated by comparing measured to calculated transmission through the AeroForm. Transmission was measured with various geometries using radiochromic film. Dose was calculated with both Varian's Anisotropic Analytical Algorithm (AAA) and Acuros External Beam (AXB) algorithms. AAA and AXB were compared using dose profile and gamma analyses. While both algorithms modeled direct transmission well, AXB better modeled lateral scatter from the AeroForm TE. Clinical significance was evaluated using clinical data from four patients with AeroForm TEs. The AeroForm TPS model was applied, and RT plans were optimized using AAA, then re-calculated with AXB. Structures of clinical significance were defined and dose volume histogram analysis was performed. Compared to AXB, AAA overestimates dose in the AeroForm device. Changes in clinically significant regions were patient- and plan-specific. This study proposes a clinical procedure for modeling the AeroForm in a commercial TPS, and discusses the limitations of dose calculation in and around the device. An understanding of dose calculation accuracy in the vicinity of the AeroForm is critical for assessing individual plan quality, appropriateness of different planning techniques and dose calculation algorithms, and even the decision to use the AeroForm in a postmastectomy radiation therapy setting.

[Radiotherapy after tumour prostheses-status, indication, coordination]

BACKGROUND

Patients with complex tumour prostheses often require radiotherapy or radiochemotherapy.

OBJECTIVES

Possible tumour diagnoses, indications, planning and therapy procedures, and prognosis of radiotherapy in the context of an interdisciplinary treatment for bone sarcomas are reviewed, including interactions of metal prostheses with radiation and possible subsequent complications.

METHODS

Literature search, summary of personal experience.

RESULTS

Complex prosthetic procedures are usually applied to patients suffering from Ewing sarcoma or osteosarcoma. In patients with Ewing sarcoma, radiotherapy is an integral part of multimodal treatment, while in patients with osteosarcoma radiotherapy is indicated in special situations. Planning and implementation of radiotherapy treatment can be impaired by metal implants within the target volume (artefacts in the planning computerized tomography, interaction of metal with the therapeutic beam). However, it is-to our knowledge-a point of debate whether radiotherapy after implantation of a prosthesis could impair healing or prosthesis fixation to bone. The data available in the literature suggest that prostheses implanted after radiotherapy entail a higher rate of complications. Multidisciplinary treatment improves the prognosis for these patients markedly.

CONCLUSIONS

Patients with sarcomas of the bone undergoing interdisciplinary treatment consisting of surgery, radiotherapy and chemotherapy have a favourable prognosis and an acceptable functionality of the limb can be expected.

Calculation of absorbed dose in radiotherapy by solution of the linear Boltzmann transport equations

Over the last decade, dose calculations which solve the linear Boltzmann transport equations have been introduced into clinical practice and are now in widespread use. However, knowledge in the radiotherapy community concerning the details of their function is limited. This review gives a general description of the linear Boltzmann transport equations as applied to calculation of absorbed dose in clinical radiotherapy. The aim is to elucidate the principles of the method, rather than to describe a particular implementation. The literature on the performance of typical algorithms is then reviewed, in many cases with reference to Monte Carlo simulations. The review is completed with an overview of the emerging applications in the important area of MR-guided radiotherapy.

VMAT Optimization and Dose Calculation in the Presence of Metallic Hip Prostheses

INTRODUCTION

This research quantifies and compares the effect of hip prostheses on dose distributions calculated using collapsed cone convolution superposition and Monte Carlo (with and without correcting for the density of the implant and surrounding tissues). The use of full volumetric modulated arc therapy arcs versus volumetric modulated arc therapy arcs avoiding the hip implants (skip arcs) was also studied.

MATERIALS AND METHODS

Six prostate patients with hip prostheses were included in this study. The hip prostheses and the streaking artifacts on the computed tomography images were contoured by a single physician, and full volumetric modulated arc therapy arcs were created in the Pinnacle3 TPS. Copies of each plan were made, and the doses were recalculated with the densities of the prostheses and surrounding tissues overridden. The plans were then exported to Monaco and recalculated using a Monte Carlo dose calculation algorithm, with and without densities of the prosthesis and surrounding tissues overridden.

RESULTS

With density overrides, Pinnacle3 had a 4.4% error for ion chamber measurements. Monaco was within 0.2% of ion chamber measurement when density overrides were used. On average, when density overrides were used in Pinnacle3 for patient dose calculations, the planning target volume D95 value dropped from 99.3% to 82.7%. Monaco also showed decreased planning target volume coverage when plans were recalculated with correct density information. Full arc plans (with density overrides) for the patient with a bilateral prosthesis provided significant bladder sparing and some rectal sparing compared to skip arc plans.

CONCLUSION

When planning for prostate patients with hip prostheses, correct density information for implants and surrounding tissues should be used to optimize the plan and ensure optimal accuracy. If available, a Monte Carlo algorithm should be used as a second check. Full arcs could be used to spare dose to organs at risk, while maintaining adequate planning target volume coverage, when using a Monte Carlo dose calculation algorithm.

Emerging role of MRI in radiation therapy

Advances in multimodality imaging, providing accurate information of the irradiated target volume and the adjacent critical structures or organs at risk (OAR), has made significant improvements in delivery of the external beam radiation dose. Radiation therapy conventionally has used computed tomography (CT) imaging for treatment planning and dose delivery. However, magnetic resonance imaging (MRI) provides unique advantages: added contrast information that can improve segmentation of the areas of interest, motion information that can help to better target and deliver radiation therapy, and posttreatment outcome analysis to better understand the biologic effect of radiation. To take advantage of these and other potential advantages of MRI in radiation therapy, radiologists and MRI physicists will need to understand the current radiation therapy workflow and speak the same language as our radiation therapy colleagues. This review article highlights the emerging role of MRI in radiation dose planning and delivery, but more so for MR-only treatment planning and delivery. Some of the areas of interest and challenges in implementing MRI in radiation therapy workflow are also briefly discussed. Level of Evidence: 5 Technical Efficacy: Stage 5 J. Magn. Reson. Imaging 2018;48:1468-1478.

A depth dose study between AAA and AXB algorithm against Monte Carlo simulation using AIP CT of a 4D dataset from a moving phantom

Aim

To identifying depth dose differences between the two versions of the algorithms using AIP CT of a 4D dataset.

Background

Motion due to respiration may challenge dose prediction of dose calculation algorithms during treatment planning.

Materials and methods

The two versions of depth dose calculation algorithms, namely, Anisotropic Analytical Algorithm (AAA) version 10.0 (AAAv10.0), AAA version 13.6 (AAAv13.6) and Acuros XB dose calculation (AXB) algorithm version 10.0 (AXBv10.0), AXB version 13.6 (AXBv13.6), were compared against a full MC simulated 6X photon beam using QUASAR respiratory motion phantom with a moving chest wall. To simulate the moving chest wall, a 4 cm thick wax mould was attached to the lung insert of the phantom. Depth doses along the central axis were compared in the anterior and lateral beam direction for field sizes 2 × 2 cm², 4 × 4 cm² and 10 × 10 cm².

Results

For the lateral beam direction, the moving chest wall highlighted differences of up to 105% for AAAv10.0 and 40% for AXBv10.0 from MC calculations in the surface and buildup doses. AAAv13.6 and AXBv13.6 agrees with MC predictions to within 10% at similar depth. For anterior beam doses, dose differences predicted for both versions of AAA and AXB algorithm were within 7% and results were consistent with static heterogeneous studies.

Conclusions

The presence of the moving chest wall was capable of identifying depth dose differences between the two versions of the algorithms. These differences could not be identified in the static chest wall as shown in the anterior beam depth dose calculations.

Verification of Acuros XB dose algorithm using 3D printed low-density phantoms for clinical photon beams

The transport-based dose calculation algorithm Acuros XB (AXB) has been shown to accurately account for heterogeneities primarily through comparisons with Monte Carlo simulations. This study aims to provide additional experimental verification of AXB for clinically relevant flattened and unflattened beam energies in low density phantoms of the same material. Polystyrene slabs were created using a bench-top 3D printer. Six slabs were printed at varying densities from 0.23 to 0.68 g/cm3 , corresponding to different density humanoid tissues. The slabs were used to form different single and multilayer geometries. Dose was calculated with Eclipse™ AXB 11.0.31 for 6MV, 15MV flattened and 6FFF (flattening filter free) energies for field sizes of 2 × 2 and 5 × 5 cm2 . EBT3 film was inserted into the phantoms, which were irradiated. Absolute dose profiles and 2D Gamma analyses were performed for 96 dose planes. For all single slab configurations and energies, absolute dose differences between the AXB calculation and film measurements remained <3% for both fields in the high-dose region, however, larger disagreement was seen within the penumbra. For the multilayered phantom, percentage depth dose with AXB was within 5% of discrete film measurements. The Gamma index at 2%/2 mm averaged 98% in all combinations of fields, phantoms and photon energies. The transport-based dose algorithm AXB is in good agreement with the experimental measurements for small field sizes using 6MV, 6FFF and 15MV beams adjacent to various low-density heterogeneous media. This work provides preliminary experimental grounds to support the use of AXB for heterogeneous dose calculation purposes.

Dosimetric Impact of a Tumor Treating Fields Device for Glioblastoma Patients Undergoing Simultaneous Radiation Therapy

Purpose

A recent randomized phase III clinical trial in patients with glioblastoma demonstrated the efficacy of tumor treating fields (TTFields), in which alternating electric fields are applied via transducer arrays to a patient’s scalp. This treatment, when added to standard of care therapy, was shown to increase overall survival from 16 to 20.9 months. These results have generated significant interest in incorporating the use of TTFields during postoperative concurrent chemoradiation. However, the dosimetric impact of high-density electrodes on the scalp, within the radiation field, is unknown.

Methods

The dosimetric impact of TTFields electrodes in the radiation field was quantified in two ways: (1) dose calculated in a treatment planning system and (2) physical measurements of surface and deep doses. In the dose calculation comparison, a volumetric-modulated-arc-therapy (VMAT) radiation plan was developed on a CT scan without electrodes and then recalculated with electrodes. For physical measurements, the surface dose underneath TTFields electrodes were measured using a parallel plate ionization chamber and compared to measurements without electrodes for various incident beam angles and for 12 VMAT arc deliveries. Deep dose measurements were conducted for five VMAT plans using Scandidos Delta4 diode array: measured doses on two orthogonal diode arrays were compared.

Results

In the treatment planning system, the presence of the TTFields device caused mean reduction of PTV dose of 0.5–1%, and a mean increase in scalp dose of 0.5–1 Gy. Physical measurement showed increases of surface dose directly underneath by 30–110% for open fields with varying beam angles and by 70–160% for VMAT deliveries. Deep dose measurement by diode array showed dose decrease of 1–2% in most areas shadowed by the electrodes (max decrease 2.54%).

Conclusion

The skin dose in patients being treating with cranial irradiation for glioblastoma may increase substantially (130–260%) with the addition of concurrent TTFields electrodes on the scalp. However, the impact of dose attenuation by the electrodes on deep dose during VMAT treatment is of much smaller, but measureable, magnitude (1–2%). Clinical trials exploring concurrent TTFields with cranial irradiation for glioblastoma may utilize scalp-sparing techniques to mitigate any potential increase in skin toxicity.

Application of dual-energy CT to suppression of metal artefact caused by pedicle screw fixation in radiotherapy: a feasibility study using original phantom

The objective of the present study was the determination of the potential dosimetric benefits of using metal-artefact-suppressed dual-energy computed tomography (DECT) images for cases involving pedicle screw implants in spinal sites. A heterogeneous spinal phantom was designed for the investigation of the dosimetric effect of the pedicle-screw-related artefacts. The dosimetric comparisons were first performed using a conventional two-directional opposed (AP-PA) plan, and then a volumetric modulated arc therapy (VMAT) plan, which are both used for the treatment of spinal metastases in our institution. The results of Acuros^® XB dose-to-medium (Dm) and dose-to-water (Dw) calculations using different imaging options were compared with experimental measurements including the chamber and film dosimetries in the spinal phantom. A dual-energy composition image with a weight factor of  -0.2 and a dual-energy monochromatic image (DEMI) with an energy level of 180 keV were found to have superior abilities for artefact suppression. The Dm calculations revealed greater dosimetric effects of the pedicle screw-related artefacts compared to the Dw calculations. The results of conventional single-energy computed tomography showed that, although the pedicle screws were made from low-Z titanium alloy, the metal artefacts still have dosimetric effects, namely, an average (maximum) Dm error of 4.4% (5.6%) inside the spinal cord for a complex VMAT treatment plan. Our findings indicate that metal-artefact suppression using the proposed DECT (DEMI) approach is promising for improving the dosimetric accuracy near the implants and inside the spinal cord (average (maximum) Dm error of 1.1% (2.0%)).

Evaluation of dose calculation accuracy of treatment planning systems at hip prosthesis interfaces

There are an increasing number of radiation therapy patients with hip prosthesis. The common method of minimizing treatment planning inaccuracies is to avoid radiation beams to transit through the prosthesis. However, the beams often exit through them, especially when the patient has a double-prosthesis. Modern treatment planning systems employ algorithms with improved dose calculation accuracies but even these algorithms may not predict the dose accurately at high atomic number interfaces. The current study evaluates the dose calculation accuracy of three common dose calculation algorithms employed in two commercial treatment planning systems. A hip prosthesis was molded inside a cylindrical phantom and the dose at several points within the phantom at the interface with prosthesis was measured using thermoluminescent dosimeters. The measured doses were then compared to the predicted ones by the planning systems. The results of the study indicate all three algorithms underestimate the dose at the prosthesis interface, albeit to varying degrees, and for both low- and high-energy x rays. The measured doses are higher than calculated ones by 5-22% for Pinnacle Collapsed Cone Convolution algorithm, 2-23% for Eclipse Acuros XB, and 6-25% for Eclipse Analytical Anisotropic Algorithm. There are generally better agreements for AXB algorithm and the worst results are for the AAA.

Comparative study of old and new versions of treatment planning system using dose volume histogram indices of clinical plans

Recently, Eclipse treatment planning system (TPS) version 8.8 was upgraded to the latest version 13.6. It is customary that the vendor gives training on how to upgrade the existing software to the new version. However, the customer is provided less inner details about changes in the new software version. According to manufacturer, accuracy of point dose calculations and irregular treatment planning is better in the new version (13.6) compared to the old version (8.8). Furthermore, the new version uses voxel-based calculations while the earlier version used point dose calculations. Major difference in intensity-modulated radiation therapy (IMRT) plans was observed between the two versions after re-optimization and re-calculations. However, minor difference was observed for IMRT cases after performing only re-calculations. It is recommended TPS quality assurance to be performed after any major upgrade of software. This can be done by performing dose calculation comparisons in TPS. To assess the difference between the versions, 25 clinical cases from the old version were compared keeping all the patient data intact including the monitor units and comparing the differences in dose calculations using dose volume histogram (DVH) analysis. Along with DVH analysis, uniformity index, conformity index, homogeneity index, and dose spillage index were also compared for both versions. The results of comparative study are presented in this paper.

Difference in dose-volumetric data between the analytical anisotropic algorithm, the dose-to-medium, and the dose-to-water reporting modes of the Acuros XB for lung stereotactic body radiation therapy

The purpose of this study was to evaluate the difference in dose‐volumetric data between the analytical anisotropic algorithms (AAA) and the two dose reporting modes of the Acuros XB, namely, the dose to water (AXB−Dw) and dose to medium (AXB−Dm) in lung stereotactic body radiotherapy (SBRT). Thirty‐eight plans were generated using the AXB−Dm in Eclipse Treatment Planning System (TPS) and then recalculated with the AXB−Dw and AAA, using identical beam setup. A dose of 50 Gy in 4 fractions was prescribed to the isocenter and the planning target volume (PTV) D95%. The isocenter was always inside the PTV. The following dose‐volumetric parameters were evaluated; D2%, D50%, D95%, and D98% for the internal target volume (ITV) and the PTV. Two‐tailed paired Student's t‐tests determined the statistical significance. Although for most of the parameters evaluated, the mean differences observed between the AAA, AXB−Dmand AXB−Dw were statistically significant (p<0.05), absolute differences were rather small, in general less than 5% points. The maximum mean difference was observed in the ITV D50% between the AXB−Dm and the AAA and was 1.7% points under the isocenter prescription and 3.3% points under the D95 prescription. AXB−Dm produced higher values than AXB−Dw with differences ranging from 0.4 to 1.1% points under isocenter prescription and 0.0 to 0.7% points under the PTV D95% prescription. The differences observed under the PTV D95% prescription were larger compared to those observed for the isocenter prescription between AXB−Dm and AAA, AXB−Dm and AXB−Dw, and AXB−Dw and AAA. Although statistically significant, the mean differences between the three algorithms are within 3.3% points.

PACS number(s): 87.55.x, 87.55.D‐, 87.55.dk

Application of Metal Implant 16-Bit Imaging: New Technique in Radiotherapy

OBJECTIVE

This study aimed to evaluate the computed tomography number and the variation of dose distribution based on 12-bit, 16-bit, and revised 16-bit images while the metal bars were inserted.

METHODS

The phantoms containing stainless steel, titanium alloy, and aluminum bar were scanned with computed tomography. These images were reconstructed with 12-bit and 16-bit imaging technologies. The "cupping artifacts" computed tomography value of the metal object revised by Matlab software was called the revised 16-bit image. The computed tomography values of these metal materials were analyzed. Two radiotherapy treatment plans were designed using the treatment plan system: (1) gantry was of 0° irradiation field and (2) gantry was of 90° and 270° for 2 opposed irradiation fields. The dose profile and dose-volume histogram of a structure of interest were analyzed in various images. The analysis was based on the radiotherapy plan differences between 3 different imaging techniques (12-bit imaging, 16-bit imaging, and revised 16-bit imaging technologies).

RESULTS

For low-density metal object (computed tomography value <3071 Hounsfield unit, HU), the radiotherapy plan results were consistent based on 3 different imaging techniques. For high-density metal object (computed tomography value >3071 HU), the difference in radiotherapy plan results was obvious. The dose of 12-bit was 15.9% higher than revised 16-bit on average for the downstream of titanium rod. For stainless steel, this number reached up to 42.7%.

CONCLUSION

A 16-bit imaging technology of metal implants can distinguish the computed tomography value of different metal materials. Furthermore, the revised 16-bit imaging technology can improve the dose computational accuracy of radiotherapy plan with high-density metal implants.

Full Monte Carlo and measurement-based overall performance assessment of improved clinical implementation of eMC algorithm with emphasis on lower energy range

New version 13.6.23 of the electron Monte Carlo (eMC) algorithm in Varian Eclipse™ treatment planning system has a model for 4MeV electron beam and some general improvements for dose calculation. This study provides the first overall accuracy assessment of this algorithm against full Monte Carlo (MC) simulations for electron beams from 4MeV to 16MeV with most emphasis on the lower energy range. Beams in a homogeneous water phantom and clinical treatment plans were investigated including measurements in the water phantom. Two different material sets were used with full MC: (1) the one applied in the eMC algorithm and (2) the one included in the Eclipse™ for other algorithms. The results of clinical treatment plans were also compared to those of the older eMC version 11.0.31. In the water phantom the dose differences against the full MC were mostly less than 3% with distance-to-agreement (DTA) values within 2mm. Larger discrepancies were obtained in build-up regions, at depths near the maximum electron ranges and with small apertures. For the clinical treatment plans the overall dose differences were mostly within 3% or 2mm with the first material set. Larger differences were observed for a large 4MeV beam entering curved patient surface with extended SSD and also in regions of large dose gradients. Still the DTA values were within 3mm. The discrepancies between the eMC and the full MC were generally larger for the second material set. The version 11.0.31 performed always inferiorly, when compared to the 13.6.23.

Gafchromic EBT3 film dosimetry in electron beams - energy dependence and improved film read-out

For megavoltage photon radiation, the fundamental dosimetry characteristics of Gafchromic EBT3 film were determined in 60Co gamma ray beam with addition of experimental and Monte Carlo (MC)-simulated energy dependence of the film for 6 MV photon beam and 6 MeV, 9 MeV, 12 MeV, and 16 MeV electron beams in water phantom. For the film read-out, two phase correction of scanner sensitivity was applied: a matrix correction for scanning area and dose-dependent correction by iterative procedure. With these corrections, the uniformity of response can be improved to be within ± 50 pixel values (PVs). To improve the read-out accuracy, a procedure with flipped film orientations was established. With the method, scanner uniformity can be improved further and dust particles, scratches and/or dirt on scan-ner glass can be detected and eliminated. Responses from red and green channels were averaged for read-out, which decreased the effect of noise present in values from separate channels. Since the signal level with the blue channel is considerably lower than with other channels, the signal variation due to different perturbation effects increases the noise level so that the blue channel is not recommended to be used for dose determination. However, the blue channel can be used for the detection of emulsion thickness variations for film quality evaluations with unexposed films. With electron beams ranging from 6 MeV to 16 MeV and at reference measurement conditions in water, the energy dependence of the EBT3 film is uniform within 0.5%, with uncertainties close to 1.6% (k = 2). Including 6 MV photon beam and the electron beams mentioned, the energy dependence is within 1.1%. No notable differences were found between the experimental and MC-simulated responses, indicating negligible change in intrinsic energy dependence of the EBT3 film for 6 MV photon beam and 6 MeV-16 MeV electron beams. Based on the dosimetric characteristics of the EBT3 film, the read-out procedure established, the nearly uniform energy dependence found and the estimated uncertainties, the EBT3 film was concluded to be a suitable 2D dosimeter for measuring electron or mixed photon/electron dose distributions in water phantom. Uncertainties of 3.7% (k = 2) for absolute and 2.3% (k = 2) for relative dose were estimated.

Percentage depth dose calculation accuracy of model based algorithms in high energy photon small fields through heterogeneous media and comparison with plastic scintillator dosimetry

Small fields smaller than 4×4 cm2 are used in stereotactic and conformal treatments where heterogeneity is normally present. Since dose calculation accuracy in both small fields and heterogeneity often involves more discrepancy, algorithms used by treatment planning systems (TPS) should be evaluated for achieving better treatment results. This report aims at evaluating accuracy of four model‐based algorithms, X‐ray Voxel Monte Carlo (XVMC) from Monaco, Superposition (SP) from CMS‐Xio, AcurosXB (AXB) and analytical anisotropic algorithm (AAA) from Eclipse are tested against the measurement. Measurements are done using Exradin W1 plastic scintillator in Solid Water phantom with heterogeneities like air, lung, bone, and aluminum, irradiated with 6 and 15 MV photons of square field size ranging from 1 to 4 cm². Each heterogeneity is introduced individually at two different depths from depth‐of‐dose maximum (Dmax), one setup being nearer and another farther from the Dmax. The central axis percentage depth‐dose (CADD) curve for each setup is measured separately and compared with the TPS algorithm calculated for the same setup. The percentage normalized root mean squared deviation (%NRMSD) is calculated, which represents the whole CADD curve's deviation against the measured. It is found that for air and lung heterogeneity, for both 6 and 15 MV, all algorithms show maximum deviation for field size 1×1 cm2 and gradually reduce when field size increases, except for AAA. For aluminum and bone, all algorithms' deviations are less for 15 MV irrespective of setup. In all heterogeneity setups, 1×1 cm2 field showed maximum deviation, except in 6 MV bone setup. All algorithms in the study, irrespective of energy and field size, when any heterogeneity is nearer to Dmax, the dose deviation is higher compared to the same heterogeneity far from the Dmax. Also, all algorithms show maximum deviation in lower‐density materials compared to high‐density materials.

PACS numbers: 87.53.Bn, 87.53.kn, 87.56.bd, 87.55.Kd, 87.56.jf

Dosimetric impact of dental metallic crown on intensity-modulated radiotherapy and volumetric-modulated arc therapy for head and neck cancer

Metal dental restoration materials cause dose enhancement upstream and dose disturbance downstream of the high‐density inhomogeneous regions in which these materials are used. In this study, we evaluated the impact of a dental metallic crown (DMC) on intensity‐modulated radiotherapy (IMRT) and volumetric‐modulated arc therapy (VMAT) for head and neck cancer. Additionally, the possibility of sparing the oral mucosa from dose enhancement using an individual intraoral mouthpiece was evaluated. An experimental oral phantom was designed to verify the dosimetric impact of a DMC. We evaluated the effect on single beam, parallel opposing beam, arc beam, IMRT, and VMAT treatment plans. To evaluate the utility of a 3‐mm‐thick intraoral mouthpiece, the doses across the mouthpiece were measured. For single beam irradiation, the measured doses at the entrance and exit planes of the DMC were 51% higher and 21% lower than the calculated dose by the treatment planning system, respectively. The maximum dose enhancements were 22% and 46% for parallel opposing beams and the 90° arc rotation beam, respectively. For IMRT and VMAT, the measured doses adjacent to the DMC were 12.2%±6.3% (mean±1.96 SD) and 12.7%±2.5% higher than the calculated doses, respectively. With regard to the performance of the intraoral mouthpiece for the IMRT and VMAT cases, the disagreement between measured and calculated doses at the outermost surface of the mouthpieces were −2.0%, and 2.0%, respectively. Dose enhancements caused by DMC‐mediated radiation scattering occurred during IMRT and VMAT. Because it is difficult to accurately estimate the dose perturbations, careful consideration is necessary when planning head and neck cancer treatments in patients with DMCs. To spare the oral mucosa from dose enhancement, the use of an individual intraoral mouthpiece should be considered.

PACS numbers: 87.55.km, 87.55.N‐, 87.55.Qr

Clinical implications of Eclipse analytical anisotropic algorithm and Acuros XB algorithm for the treatment of lung cancer

The aim of the present study was to investigate the dose-volume variations of planning target volume (PTV) and organs at risks (OARs) in 15 left lung cancer patients comparing analytical anisotropic algorithm (AAA) versus Acuros XB algorithm. Originally, all plans were created using AAA with a template of dose constraints and optimization parameters, and the patients were treated using intensity modulated radiotherapy. In addition, another set of plans was created by performing only dose calculations using Acuros algorithm without doing any reoptimization. Thereby, in both set of plans, the entire plan parameters, namely, beam angle, beam weight, number of beams, prescribed dose, normalization point, region of interest constraints, number of monitor units, and plan optimization were kept constant. The evaluated plan parameters were PTV coverage at dose at 95% volume (TV95) of PTV (D95), the dose at 5% of PTV (D5), maximum dose (D_max), the mean dose (D_mean), the percent volume receiving 5 Gy (V5), 20 Gy (V20), 30 Gy (V30) of normal lung at risk (left lung- gross target volume [GTV], the dose at 33% volume (D33), at 67% volume (D67), and the D_mean (Gy) of the heart, the D_max of the spinal cord. Furthermore, homogeneity index (HI) and conformity index were evaluated to check the quality of the plans. Significant statistical differences between the two algorithms, P < 0.05, were found in D95, D_max, TV95, and HI of PTV. Furthermore, significant statistical differences were found in the dose parameters for the OARs, namely, V5, V20, and V30 of left lung-GTV, right lung (D_mean), D33, and D_mean of the heart, and D_max of the spine, respectively. Although statistical differences do exist, the magnitude of the differences is too small to cause any clinically observable effect.