A comparison of the quality assurance of four dosimetric tools for intensity modulated radiation therapy

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

2D IMRT QA passing rate dependency on coronal plane

Intensity modulated radiation therapy (IMRT) delivery involves a complex series of beam angles and multileaf collimator (MLC) arrangements, requiring quality assurance to be performed to validate delivery before treatment. The purpose of this work is to investigate the effect of dose gradient on quality assurance (QA) passing rate. Many (n = 40) IMRT plans were delivered and measured using a 2D planar array of ion chambers; additionally, eleven plans were measured at several coronal planes. For each measurement, dose gradient was assessed using a number of metrics and passing rate assessed at both 3%/3 mm and 3%/2 mm criteria. The passing rates of the various IMRT plans were shown to be generally correlated to gradient, with an average distance correlation of 0.54 ± 0.04 for the lateral dose gradient. The passing rate for an individual plan was shown to vary with coronal slice, though the correlation to dose gradient was not predictable. Even though the passing rate was strongly related to dose gradient for many of the plans, the signs of the correlations were not always negative, as hypothesized. The coronal plane at which QA is performed affects passing rate, though dose gradient may not easily be used to predict slices at which passing rate is higher.

Performance of 3D diamond detectors in small field dosimetry: The impact of pixel size

PURPOSE

Small photon beams used in radiotherapy techniques have inherent characteristics of charge particle disequilibrium and high-dose gradient making accurate dosimetry for such fields very challenging. By means of a 3D manufacturing technique, it is possible to create arrays of pixels with a very small sensitive volume for radiotherapy dosimetry. We investigate the impact of 3D pixels size on absorbed dose sensitivity, linearity of response with dose rate, reproducibility and beam profile measurements.

METHODS

Diamond detectors with different pixel sizes have been produced in the 3DOSE experiment framework. To investigate the pixels size impact, they were tested using an Elekta Synergy LINAC. Dose rate dependence, absorbed dose sensitivity, reproducibility and beam profile measurement accuracy have been investigated and compared with PTW 60019 and IBA SFD reference dosimeters.

RESULTS

All of the 3D pixels had a linear and reproducible response to the dose rate. The sensitivity of a pixel decreases with its size, although even the smallest pixel has a high absorbed dose sensitivity (15 nC/Gy). The penumbra width measured with the smallest pixel size was consistent with the PTW microDiamond and differed by 0.2 mm from the IBA SFD diode.

CONCLUSIONS

The study demonstrates that variation in pixel size do not affect the linearity of response with dose rate and the reproducibility of response. Due to the 3D geometry, the absorbed dose sensitivity of the detector remains high even for the smallest pixel, furthermore the pixel size was demonstrated to be of fundamental importance in the measurement of beam profiles.

Impact of stringent tolerance criteria on verification of absorbed dose distributions and evaluation through inhomogeneous media

Advances of radiation delivery devices have increased the complexity of the radiation oncology treatments. Herewith, outcome of the treatment, as well as patient safety, strongly depend on the consistency of absorbed dose delivery. Both can be ensured by comprehensive system of verification of calculated absorbed dose distributions. Standard method is evaluation of calculated absorbed dose distribution according to gamma method, using a 2-D detector and a homogeneous phantom, to obtain measured dose distribution. Purpose of this research was to investigate the influence of tolerance criteria on gamma passing rate. Additionally, the agreement in heterogeneous phantom was analysed. Absorbed dose calculations were performed using systems Monaco and XiO. Detector with 1020 ionization chambers in homogeneous phantom and semi-anthropomorphic phantom was used for measurements. Absorbed dose distributions of around 3500 patients were analysed using gamma method. In homogeneous phantom, average gamma passing rates were within tolerance for 3 %/2 mm. For measurements in heterogeneous media, the highest average gamma passing rate was obtained for small volumes of medium treatment complexity (??=93.84%), while large volumes of treatment with low complexity yielded the lowest gamma passing rates (??= 83.22%).

Verification of an optimizer algorithm by the beam delivery evaluation of intensity-modulated arc therapy plans

Background

In the case of dynamic radiotherapy plans, the fractionation schemes can have dosimetric effects. Our goal was to define the effect of the fraction dose on the plan quality and the beam delivery.

Materials and methods

Treatment plans were created for 5 early-stage lung cancer patients with different dose schedules. The planned total dose was 60 Gy, fraction dose was 2 Gy, 3 Gy, 5 Gy, 12 Gy and 20 Gy. Additionally renormalized plans were created by changing the prescribed fraction dose after optimization. The dosimetric parameters and the beam delivery parameters were collected to define the plan quality and the complexity of the treatment plans. The accuracy of dose delivery was verified with dose measurements using electronic portal imaging device (EPID).

Results

The plan quality was independent from the used fractionation scheme. The fraction dose could be changed safely after the optimization, the delivery accuracy of the treatment plans with changed prescribed dose was not lower. According to EPID based measurements, the high fraction dose and dose rate caused the saturation of the detector, which lowered the gamma passing rate. The aperture complexity score, the gantry speed and the dose rate changes were not predicting factors for the gamma passing rate values.

Conclusions

The plan quality and the delivery accuracy are independent from the fraction dose, moreover the fraction dose can be changed safely after the dose optimization. The saturation effect of the EPID has to be considered when the action limits of the quality assurance system are defined.

RapidArc treatment planning quality assurance using electronic portal imaging device for cervical cancer

Purpose:

The main objective of this study is to assure the quality of cervical cancer treatment plans using an electronic portal imaging device (EPID) in RapidArc techniques.

Materials and Methods:

Fifteen cases of cervical cancer patients undergoing RapidArc technique were selected to evaluate the quality assurance (QA) of their treatment. The computed tomography (CT) of each patient was obtained with 3-mm-slice thickness and transferred to the Eclipse treatment planning system. The prescribed dose (PD) of 50·4 Gy with 1·8 Gy per fraction to planning target volume (PTV) was used for each patient. The aim of treatment planning was to achieve 95% of PD to cover 97%, and dose to the PTV should not receive 105% of the PD. All RapidArc plans were created using the AAA algorithm and treated on Varian DHX using 6 MV photon beam, with two full arcs. Gamma analysis was used to evaluate the quality of the treatment plans with accepting criteria of 95% at 3%/3 mm.

Results:

In this study, maximum and average gamma values were 2·53 ± 0·409 and 0·195 ± 0·059 showing very small deviation and indicating the smaller difference between both predicted and portal doses. Gamma Area changes from > 0·8 to > 1·2. SD increased to 5·4% and mean standard error increased to 4·67%.

Conclusion:

On the basis of these outcomes, we can summarise that the EPID is a useful tool for QA in standardising and evaluating RapidArc treatment plans of cervical cancer in routine clinical practice.

Analysis of dose comparison techniques for patient-specific quality assurance in radiation therapy

Purpose

Gamma evaluation is the most commonly used technique for comparison of dose distributions for patient‐specific pretreatment quality assurance in radiation therapy. Alternative dose comparison techniques have been developed but not widely implemented. This study aimed to compare and evaluate the performance of several previously published alternatives to the gamma evaluation technique, by systematically evaluating a large number of patient‐specific quality assurance results.

Methods

The agreement indices (or pass rates) for global and local gamma evaluation, maximum allowed dose difference (MADD) and divide and conquer (D&C) techniques were calculated using a selection of acceptance criteria for 429 patient‐specific pretreatment quality assurance measurements. Regression analysis was used to quantify the similarity of behavior of each technique, to determine whether possible variations in sensitivity might be present.

Results

The results demonstrated that the behavior of D&C gamma analysis and MADD box analysis differs from any other dose comparison techniques, whereas MADD gamma analysis exhibits similar performance to the standard global gamma analysis. Local gamma analysis had the least variation in behavior with criteria selection. Agreement indices calculated for 2%/2 mm and 2%/3 mm, and 3%/2 mm and 3%/3 mm were correlated for most comparison techniques.

Conclusion

Radiation oncology treatment centers looking to compare between different dose comparison techniques, criteria or lower dose thresholds may apply the results of this study to estimate the expected change in calculated agreement indices and possible variation in sensitivity to delivery dose errors.

A study on the correlation between radiation field size and gamma index passing rate for MatriXX

This study aimed to analyze the influence of the radiation field size on the passing rate of the treatment planning system using MatriXX if the field irradiated the circuit.Two sets of static fields which were 10 cm and 30 cm in the left-right direction (X), and was 31 cm to 40 cm in gun-target direction (Y) were designed. In these fields, the gantry was 0 and the monitor units were 200 MU. Two plans from an esophagus carcinoma patient with a planning target volume of 86.4 cm and a cervical carcinoma patient with a planning target volume (PTV) of 2094.1 cm were chosen. The passing rates of these plans were gained without and with protecting the circuit area from lead alloys. The gamma analysis was used and the standard was set to 3%/3 mm.The verification passing rate decreased from 95.0% to 69.2% when X was 10 cm while Y increased from 31 cm to 40 cm. With the protection from low melting point lead alloys, the passing rate was from 96.2% to 89.6%. The results of the second set of plans without lead alloys were similar but the passing rate decreased more sharply. The passing rates of the 2 patients were 99.5% and 57.1%. With the protection of the lead alloys, their passing rates were 99.8% and 72.1%, respectively.The results showed that with the increase of the radiation field size in the Y direction, more areas were irradiated in the circuit, and the passing rate gradually decreases and dropped sharply at a certain threshold. After putting lead alloys above the circuit, the passing rate was much better in the static field but was still less than 90% in the second patient volumetric modulated arc therapy (VMAT) because the circuit was irradiate in other directions. In daily QA, we should pay attention to these patients with long size tumor.

Impact of plan parameters and modulation indices on patient-specific QA results for standard and stereotactic VMAT

PURPOSE

To demonstrate the impact of modulation indices and plan parameters on the gamma passing rates (GPR) of patient-specific quality assurance of standard and stereotactic volumetric modulated arc therapy (VMAT) plans.

METHODS

A total of 758 patients' QA plans were utilized, including standard VMAT plans with Trilogy (n = 87, group A) and TreuBeam STx (n = 332, group B), and 339 stereotactic VMAT plans with TrueBeam STx (group C). Modulation indices were obtained considering the speed and acceleration of the multileaf collimator (MLC) (MI_s, MI_a), and MLC, gantry speed, and dose rate changes (MI_t). The mean aperture size (MA), monitor unit (MU), and amount of jaw tracking (%JT) were acquired. Gamma analysis was performed with 2 mm/2% and 1 mm/2% for the standard and stereotactic VMAT plans, respectively. Statistical analyses were performed to investigate the correlation between modulation index/plan parameters and GPR.

RESULTS

Spearman's rank correlation to GPRs with MI_s, MI_a, and MI_t, were -0.44, -0.45, and -0.46 for group A; -0.39, -0.37, and -0.38 for group B; and -0.04, -0.11, and -0.10 for group C, respectively. While MU and MA showed significant correlations in all groups, %JT showed a significant correlation only with stereotactic VMAT plans. The most influential parameter combinations were MU-MA (r_s = 0.50), MI_s-%JT (r_s = 0.43), and MU-%JT (r_s = 0.38) for groups A, B, and C, respectively.

CONCLUSIONS

MLC modulation mostly affected the GPR in the delivery of standard VMAT plans, while MU and %JT showed more importance in stereotactic VMAT plans.

Patient-specific quality control for intensity-modulated radiation therapy and volumetric-modulated arc therapy using electronic portal imaging device and two-dimensional ion chamber array

Aim

The purpose of this study was to develop the patient-specific quality control (QC) process by most commonly used dosimeters in Bangladesh and recommend a suitable passing rate for QC, irrespective of the dosimetric tools used.

Materials and methods

Intensity-modulated radiation therapy (IMRT) and volumetric-modulated arc therapy (VMAT) plans of five head-and-neck (HN) and five prostate patients were selected for the patient-specific QC. These plans were generated using the Eclipse TPS v11·0 (Varian Medical Systems, Inc., Palo Alto, CA, USA) 6 MV X-ray from a Varian TrueBeam linear accelerator (Varian Medical Systems, Inc.) for each case. Each IMRT and VMAT plans were measured by two-dimensional (2D) ion chamber arrays (I’matriXX) and electronic portal imaging devices (EPID), respectively. The passing rates of the dosimetric tools were calculated using criteria of 3%/3 mm.

Results

The average passing rates (±SD) of I’matriXX for prostate and HN were 97·9±0·76 and 98·88±0·24, respectively. For VMAT verification, the average passing rates of EPID for prostate for arc1 and arc2 were 96·15±0·49 and 97·8±0·70, respectively; similarly, for HN the rates were 97·85±0·63 and 97·2±0·56, respectively.

Conclusion

The results showed that both the dosimeters can be used in patient-specific QC, although the EPID-based IMRT and VMAT QC is more advantageous in terms of time-saving and ease of use. Hence, for patient-specific QC, one can use the ion chamber arrays (I’matriXX) or EPID in hospital, but the systems need to be cross-checked.

Evaluation of two-dimensional dose distributions for pre-treatment patient-specific IMRT dosimetry

Background The accuracy of dose calculation is crucial for success of the radiotherapy treatment. One of the methods that represent the current standard for patient-specific dosimetry is the evaluation of dose distributions measured with an ionization chamber array inside a homogeneous phantom using gamma method. Nevertheless, this method does not replicate the realistic conditions present when a patient is undergoing therapy. Therefore, to more accurately evaluate the treatment planning system (TPS) capabilities, gamma passing rates were examined for beams of different complexity passing through inhomogeneous phantoms. Materials and methods The research was performed using Siemens Oncor Expression linear accelerator, Siemens Somatom Open CT simulator and Elekta Monaco TPS. A 2D detector array was used to evaluate dose distribution accuracy in homogeneous, semi-anthropomorphic and anthropomorphic phantoms. Validation was based on gamma analysis with 3%/3mm and 2%/2mm criteria, respectively. Results Passing rates of the complex dose distributions degrade depending on the thickness of non-water equivalent material. They also depend on dose reporting mode used. It is observed that the passing rate decreases with plan complexity. Comparison of the data for all set-ups of semi-anthropomorphic and anthropomorphic phantoms shows that passing rates are higher in the anthropomorphic phantom. Conclusions Presented results raise a question of possible limits of dose distribution verification in assessment of plan delivery quality. Consequently, good results obtained using standard patient specific dosimetry methodology do not guarantee the accuracy of delivered dose distribution in real clinical cases.

Extended localization and adaptive dose calculation using HU corrected cone beam CT: Phantom study

BACKGROUND AND AIM

The practicability of computing dose calculation on cone beam CT (CBCT) has been widely investigated. In most clinical scenarios, the craniocaudal scanning length of CBCT is found to be inadequate for localization. This study aims to explore extended tomographic localization and adaptive dose calculation strategies using Hounsfield unit (HU) corrected CBCT image sets.

MATERIALS AND METHODS

Planning CT (pCT) images of the Rando phantom (T12-to-midthigh) were acquired with pelvic-protocol using Biograph CT-scanner. Similarly, half-fan CBCT were acquired with fixed parameters using Clinac2100C/D linear accelerator integrated with an on-board imager with 2-longitudinal positions of the table. For extended localization and dose calculation, two stitching strategies viz., one with "penumbral-overlap" (S1) and the other with "no-overlap" (S2) and a local HU-correction technique were performed using custom-developed MATLAB scripts. Fluence modulated treatment plans computed on pCT were mapped with stitched CBCT and the dosimetric analyses such as dose-profile comparison, 3D-gamma (γ) evaluation and dose-volume histogram (DVH) comparison were performed.

RESULTS

Localizing scanning length of CBCT was extended by up to 15 cm and 16 cm in S1 and S2 strategies, respectively. Treatment plan mapping resulted in minor variations in the volumes of delineated structures and the beam centre co-ordinates. While the former showed maximum variations of -1.4% and -1.6%, the latter showed maximum of 1.4 mm and 2.7 mm differences in anteroposterior direction in S1 and S2 protocols, respectively. Dosimetric evaluations viz., dose profile and DVH comparisons were found to be in agreement with one another. In addition, γ-evaluation results showed superior pass-rates (≥98.5%) for both 3%/3 mm dose-difference (DD) and distance-to-agreement (DTA) and 2%/2 mm DD/DTA criteria with desirable dosimetric accuracy.

CONCLUSION

Cone beam tomographic stitching and local HU-correction strategies developed to facilitate extended localization and dose calculation enables routine adaptive re-planning while circumventing the need for repeated pCT.

A 3D correction method for predicting the readings of a PinPoint chamber on the CyberKnife® M6™ machine

The use of small fields in radiation therapy techniques has increased substantially in particular in stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT). However, as field size reduces further still, the response of the detector changes more rapidly with field size, and the effects of measurement uncertainties become increasingly significant due to the lack of lateral charged particle equilibrium, spectral changes as a function of field size, detector choice, and subsequent perturbations of the charged particle fluence. This work presents a novel 3D dose volume-to-point correction method to predict the readings of a 0.015 cc PinPoint chamber (PTW 31014) for both small static-fields and composite-field dosimetry formed by fixed cones on the CyberKnife^® M6^™ machine. A 3D correction matrix is introduced to link the 3D dose distribution to the response of the PinPoint chamber in water. The parameters of the correction matrix are determined by modeling its 3D dose response in circular fields created using the 12 fixed cones (5 mm-60 mm) on a CyberKnife^® M6^™ machine. A penalized least-square optimization problem is defined by fitting the calculated detector reading to the experimental measurement data to generate the optimal correction matrix; the simulated annealing algorithm is used to solve the inverse optimization problem. All the experimental measurements are acquired for every 2 mm chamber shift in the horizontal planes for each field size. The 3D dose distributions for the measurements are calculated using the Monte Carlo calculation with the MultiPlan^® treatment planning system (Accuray Inc., Sunnyvale, CA, USA). The performance evaluation of the 3D conversion matrix is carried out by comparing the predictions of the output factors (OFs), off-axis ratios (OARs) and percentage depth dose (PDD) data to the experimental measurement data. The discrepancy of the measurement and the prediction data for composite fields is also performed for clinical SRS plans. The optimization algorithm used for generating the optimal correction factors is stable, and the resulting correction factors were smooth in the spatial domain. The measurement and prediction of OFs agree closely with percentage differences of less than 1.9% for all the 12 cones. The discrepancies between the prediction and the measurement PDD readings at 50 mm and 80 mm depth are 1.7% and 1.9%, respectively. The percentage differences of OARs between measurement and prediction data are less than 2% in the low dose gradient region, and 2%/1 mm discrepancies are observed within the high dose gradient regions. The differences between the measurement and prediction data for all the CyberKnife based SRS plans are less than 1%. These results demonstrate the existence and efficiency of the novel 3D correction method for small field dosimetry. The 3D correction matrix links the 3D dose distribution and the reading of the PinPoint chamber. The comparison between the predicted reading and the measurement data for static small fields (OFs, OARs and PDDs) yield discrepancies within 2% for low dose gradient regions and 2%/1 mm for high dose gradient regions; the discrepancies between the predicted and the measurement data are less than 1% for all the SRS plans. The 3D correction method provides an access to evaluate the clinical measurement data and can be applied to non-standard composite fields intensity modulated radiation therapy point dose verification.

A Hybrid Conformal Planning Technique with Solitary Dynamic Portal for Postmastectomy Radiotherapy with Regional Nodes

PURPOSE

This study focuses on incorporation of a solitary dynamic portal (SDP) in conformal planning for postmastectomy radiotherapy (PMRT) with nodal regions with an intention to overcome the treatment planning limitations imposed by conventional techniques.

MATERIALS AND METHODS

Twenty-four patients who underwent surgical mastectomy followed by PMRT were included in this study. Initially, a treatment plan comprising tangential beams fitted to beam's-eye-view (BEV) of chest wall (CW) and a direct anterior field fitted to BEV of nodal region, both sharing a single isocenter was generated using Eclipse treatment planning system. Multiple field-in-fields with optimum beam weights (5% per field) were added primarily from the medial tangent, fitted to BEV of entire target volume, and finally converted into a dynamic portal. Dosimetric analysis for the treatment plans and fluence verification for the dynamic portals were performed.

RESULTS AND DISCUSSION

Conformal plans with SDP showed excellent dose coverage (V95%>95%), higher degree of tumor dose conformity (≤1.25) and homogeneity (≤0.12) without compromising the organ at risk sparing for PMRT with nodal region. Treatment plans with SDP considerably reduced the lower isodose spread to the ipsilateral lung, heart, and healthy tissue without affecting the dose homogeneity. Further, gamma evaluation showed more than 96% pixel pass rate for standard 3%/3 mm dose difference and distance-to-agreement criteria. Moreover, this plan offers less probability of "geometrical miss" at the highly irregular CW with regional nodal radiotherapy.

CONCLUSION

Hybrid conformal plans with SDP would facilitate improved dose distribution and reduced uncertainty in delivery and promises to be a suitable treatment option for complex postmastectomy CW with regional nodal irradiation.

Comparison of Dosimetric Performance among Commercial Quality Assurance Systems for Verifying Pretreatment Plans of Stereotactic Body Radiotherapy Using Flattening-Filter-Free Beams

The purpose of this study was to compare the performance of different commercial quality assurance (QA) systems for the pretreatment verification plan of stereotactic body radiotherapy (SBRT) with volumetric arc therapy (VMAT) technique using a flattening-filter-free beam. The verification for 20 pretreatment cancer patients (seven lung, six spine, and seven prostate cancers) were tested using three QA systems (EBT3 film, I'mRT MatriXX array, and MapCHECK). All the SBRT-VMAT plans were optimized in the Eclipse (version 11.0.34) treatment planning system (TPS) using the Acuros XB dose calculation algorithm and were delivered to the Varian TrueBeam® accelerator equipped with a high-definition multileaf collimator. Gamma agreement evaluation was analyzed with the criteria of 2% dose difference and 2 mm distance to agreement (2%/2 mm) or 3%/3 mm. The highest passing rate (99.1% for 3%/3 mm) was observed on the MapCHECK system while the lowest passing rate was obtained on the film. The pretreatment verification results depend on the QA systems, treatment sites, and delivery beam energies. However, the delivery QA results for all QA systems based on the TPS calculation showed a good agreement of more than 90% for both the criteria. It is concluded that the three 2D QA systems have sufficient potential for pretreatment verification of the SBRT-VMAT plan.

Automated algorithm for CBCT-based dose calculations of prostate radiotherapy with bilateral hip prostheses

OBJECTIVE

Cone beam CT (CBCT) images contain more scatter than a conventional CT image and therefore provide inaccurate Hounsfield units (HUs). Consequently, CBCT images cannot be used directly for radiotherapy dose calculation. The aim of this study is to enable dose calculations to be performed with the use of CBCT images taken during radiotherapy and evaluate the necessity of replanning.

METHODS

A patient with prostate cancer with bilateral metallic prosthetic hip replacements was imaged using both CT and CBCT. The multilevel threshold (MLT) algorithm was used to categorize pixel values in the CBCT images into segments of homogeneous HU. The variation in HU with position in the CBCT images was taken into consideration. This segmentation method relies on the operator dividing the CBCT data into a set of volumes where the variation in the relationship between pixel values and HUs is small. An automated MLT algorithm was developed to reduce the operator time associated with the process. An intensity-modulated radiation therapy plan was generated from CT images of the patient. The plan was then copied to the segmented CBCT (sCBCT) data sets with identical settings, and the doses were recalculated and compared.

RESULTS

Gamma evaluation showed that the percentage of points in the rectum with γ < 1 (3%/3 mm) were 98.7% and 97.7% in the sCBCT using MLT and the automated MLT algorithms, respectively. Compared with the planning CT (pCT) plan, the MLT algorithm showed -0.46% dose difference with 8 h operator time while the automated MLT algorithm showed -1.3%, which are both considered to be clinically acceptable, when using collapsed cone algorithm.

CONCLUSION

The segmentation of CBCT images using the method in this study can be used for dose calculation. For a patient with prostate cancer with bilateral hip prostheses and the associated issues with CT imaging, the MLT algorithms achieved a sufficient dose calculation accuracy that is clinically acceptable. The automated MLT algorithm reduced the operator time associated with implementing the MLT algorithm to achieve clinically acceptable accuracy. This saved time makes the automated MLT algorithm superior and easier to implement in the clinical setting.

ADVANCES IN KNOWLEDGE

The MLT algorithm has been extended to the complex example of a patient with bilateral hip prostheses, which with the introduction of automation is feasible for use in adaptive radiotherapy, as an alternative to obtaining a new pCT and reoutlining the structures.