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Purpose: The aim was to develop and evaluate an EPID-based MLC positional test that addresses known weaknesses of the picket fence test and has sufficient accuracy so that the AAPM MPPG 8.b. MLC position action limit of ± 0.5 mm can be implemented., Methods: Weaknesses and inaccuracies in the picket fence test were identified and a new test plan and analysis algorithm named stakitt was developed. Stakitt was evaluated for repeatability and for sensitivity on the Varian TrueBeam linac with both Millennium MLC and HDMLC and on a Varian Clinac with Millennium MLC. Sensitivity was tested via deliberate introduction of errors into the test plan of magnitude: ± 0.1, ± 0.5, ± 1.0 and ± 1.5 mm. Measured sensitivity was compared to published sensitivity of the picket fence test. Additionally, a use case was presented based on results from a TrueBeam linac to highlight the effect of MLC backlash on MLC positions at non-zero gantry angles., Results: Repeatability was observed to within 0.04 mm (3 SD) with the TrueBeams being more repeatable than the Clinac. The deliberately introduced errors were accurately measured to within 0.28 mm and were comparable to the traditional picket fence. Reduced accuracy was recorded for the HDMLC small leaves, which was attributed to an apparent variation in measured leaf width across the range of travel, which impacted the measurement of the leaf tip position. The clinical use case demonstrated variability in MLC leaf positions between gantry 90° and gantry 270° that were of the magnitude of the MLC backlash., Conclusion: The stakitt test addresses the weaknesses of the picket fence test and has accuracy appropriate for implementation of a ± 0.5 mm action limit. However, such an action limit may not be currently practical at non-zero gantry angles due to the impact of MLC leaf backlash., (© 2024 The Author(s). Journal of Applied Clinical Medical Physics published by Wiley Periodicals LLC on behalf of American Association of Physicists in Medicine.)

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., (© 2023 The Authors. Medical Physics published by Wiley Periodicals LLC on behalf of American Association of Physicists in Medicine.)

Purpose: Multi-leaf-collimator (MLC) leaf position accuracy is important for accurate dynamic radiotherapy treatment plan delivery. Machine log files have become widely utilized for quality assurance (QA) of such dynamic treatments. The primary aim is to test the sensitivity of machine log files in comparison to electronic portal imaging device (EPID)-based measurements to MLC position errors caused by leaf backlash. The secondary aim is to investigate the effect of MLC leaf backlash on MLC leaf motion during clinical dynamic plan delivery., Methods: The sensitivity of machine log files and two EPID-based measurements were assessed via a controlled experiment, whereby the length of the "T" section of a series of 12 MLC leaf T-nuts in a Varian Millennium MLC for a Trilogy C-series type linac was reduced by sandpapering the top of the "T" to introduce backlash. The built-in machine MLC leaf backlash test as well as measurements for two EPID-based dynamic MLC positional tests along with log files were recorded pre- and post-T-nut modification. All methods were investigated for sensitivity to the T-nut change by assessing the effect on measured MLC leaf positions. A reduced version of the experiment was repeated on a TrueBeam type linac with Millennium MLC., Results: No significant differences before and after T-nut modification were detected in any of the log file data. Both EPID methods demonstrated sensitivity to the introduced change at approximately the expected magnitude with a strong dependence observed with gantry angle. EPID-based data showed MLC positional error in agreement with the micrometer measured T-nut length change to 0.07 ± 0.05 mm (1 SD) using the departmental routine QA test. Backlash results were consistent between linac types., Conclusion: Machine log files appear insensitive to MLC position errors caused by MLC leaf backlash introduced via the T-nut. The effect of backlash on clinical MLC motions is heavily gantry angle dependent., (© 2022 The Authors. Journal of Applied Clinical Medical Physics published by Wiley Periodicals, LLC on behalf of The American Association of Physicists in Medicine.)

Background: The quality of radiotherapy delivery has been shown to significantly impact clinical outcomes including patient survival. To identify errors, institutions perform Patient Specific Quality Assurance (PSQA) assessing each individual radiotherapy plan prior to starting patient treatments. Externally administered Dosimetry Audits have found problems despite institutions passing their own PSQA. Hence a new audit concept which assesses the institution's ability to detect errors with their routine PSQA is needed., Methods: Purposefully introduced edits which simulated treatment delivery errors were embedded into radiation treatment plans of participating institutions. These were designed to produce clinically significant changes yet were mostly within treatment delivery specifications. Actual impact was centrally assessed for each plan. Institutions performed PSQA on each plan, without knowing which contained errors., Results: Seventeen institutions using six radiation treatment planning systems and two delivery systems performed PSQA on twelve plans each. Seventeen erroneous plans (across seven institutions) passed PSQA despite causing >5% increase in spinal cord dose relative to the original plans. Six plans (from four institutions) passed despite a >10% increase., Conclusions: This novel audit concept evolves beyond testing an institution's ability to deliver a single test case, to increasing the number of errors caught by institutions themselves, thus increasing quality of radiation therapy and impacting every patient treated. Administered remotely this audit also provides advantages in cost, environmental impact, and logistics., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Crown Copyright © 2022. Published by Elsevier B.V. All rights reserved.)

Purpose: Calibration of a radiotherapy electronic portal imaging device (EPID) using the pixel-sensitivity-map (PSM) in place of the flood field correction improves the utility of the EPID for quality assurance applications. Multiple methods are available for determining the PSM and this study provides an evaluation to inform on which is superior., Methods: Three different empirical methods ("Calvary Mater Newcastle" [CMN], "Varian," and "WashU") and a Monte Carlo-based method of PSM determination were investigated on a single Varian TrueBeam STx linear accelerator (linac) with an aS1200 EPID panel. PSM measurements were performed for each empirical method three successive times using the 6 MV beam. The resulting PSM from each method was compared to the Monte Carlo method as a reference using 2D percentage deviation maps and histograms plus crossplane profiles. The repeatability of generated PSMs was also assessed via 2D standard deviation (SD) maps and histograms. Additionally, the Beam-Response generated by removal of the PSM from a raw EPID image for each method was visually contrasted. Finally, the practicality of each method was assessed qualitatively and via the measured time required to acquire and export the required images., Results: The median pixel-by-pixel percentage deviation between each of the empirical PSM methods and the Monte Carlo PSM was -0.36%, 0.24%, and 0.74% for the CMN, Varian, and WashU methods, respectively. Ninety-five percent of pixels were found to be repeatable to within -0.21%, 0.08%, 0.19%, and 0.35% (1 SD) for the CMN, Monte Carlo, Varian, and WashU methods, respectively. The WashU method was found to be quickest for data acquisition and export and the CMN the slowest., Conclusion: For the first time four methods of generating the EPID PSM have been compared in detail and strengths and weaknesses of each method have been identified. All methods are considered likely to be clinically acceptable and with similar practical requirements., (© 2022 The Authors. Journal of Applied Clinical Medical Physics published by Wiley Periodicals, LLC on behalf of The American Association of Physicists in Medicine.)

Purpose: The EPID PSM is a useful EPID calibration method for QA applications. The dependence of the EPID PSM on the photon beam used to acquire it has been investigated in this study for the four available PSM methods. The aim is to inform upon the viability of applying a single PSM for all available photon beams to simplify PSM implementation and maintenance., Methods: Four methods of PSM determination were each measured once in a single session on a single TrueBeam ® STx linac using 6 MV, 10 MV, 6 MV Flattening-Filter-Free (FFF), and 10 MV FFF photon beams. The resultant PSM was assessed for both intra- and inter-method beam dependence via comparison between PSM of the same method compared to the 6 MV PSM and via comparison between PSM of the same beam with the corresponding Monte Carlo PSM. Comparisons were performed via 2D percentage deviation plots with associated histograms, 1D crossplane profiles, and via mean, median, and standard deviation percentage deviation statistics. Generated beam-response was compared qualitatively via 1D crossplane profile comparison and quantitatively via symmetry assessment with comparison to the IC profiler device., Results: The Varian method provided the most consistent PSM with varying photon beam, with median percent deviation from the 6 MV PSM within 0.14% for all other beams. Qualitatively, each method provided similar beam-response profiles. The measured beam-response symmetry agreed to within 0.2% between the Calvary Mater Newcastle (CMN) method and IC profiler, but agreement reduced to within 0.9% and 2.2% for the Varian and WashU methods. PSM percent deviation with Monte Carlo PSM was within 0.75% for all methods and beams., Conclusion: Results suggest that the PSM may be independent of photon beam to clinically relevant levels. The Varian method of PSM determination introduces the least beam dependence into the measured PSM., (© 2022 The Authors. Journal of Applied Clinical Medical Physics published by Wiley Periodicals, LLC on behalf of The American Association of Physicists in Medicine.)

Introduction: The Ethos treatment planning system allows for the rapid generation of online adaptive treatment plans while the patient is on the treatment couch. One promising application of online adaptive radiotherapy is its use in stereotactic radiotherapy. The purpose of this study was to ensure the Ethos treatment planning system (TPS) can produce clinically acceptable stereotactic plans, that are non-inferior to those from the Eclipse TPS., Method: Forty patients that received previous stereotactic radiotherapy treatment on a Halcyon, 20 of which were lung cases, and 20 that were brain cases, were replanned using the Ethos TPS. The generated IMRT and VMAT plans were compared to the clinical Eclipse VMAT plan., Results: This study found that the Ethos TPS can produce VMAT plans of equivalent quality (target coverage, conformity and OAR doses) to those from the Eclipse TPS for lung SBRT and brain SRT. The IMRT plans produced by the Ethos planning system were marginally inferior to Eclipse VMAT plans, with the differences likely primarily due to beam geometry rather than the optimization system. Ethos plans were generally more modulated than Eclipse plans. With careful selection of optimization structures and reduction in the body contour, VMAT plan generation time could be reduced by 87%., Conclusion: Ethos can generate stereotactic VMAT plans that are equivalent to those from Eclipse in the timeframe required for online adaptive radiotherapy., (Copyright © 2022 American Association of Medical Dosimetrists. Published by Elsevier Inc. All rights reserved.)

The aim of this study was to benchmark the accuracy of the VIrtual Phantom Epid dose Reconstruction (VIPER) software for pre-treatment dosimetric verification of multiple-target stereotactic radiosurgery (SRS). VIPER is an EPID-based method to reconstruct a 3D dose distribution in a virtual phantom from in-air portal images. Validation of the VIPER dose calculation was assessed using several MLC-defined fields for a 6 MV photon beam. Central axis percent depth doses (PDDs) and output factors were measured with an ionization chamber in a water tank, while dose planes at a depth of 10 cm in a solid flat phantom were acquired with radiochromic films. The accuracy of VIPER for multiple-target SRS plan verification was benchmarked against Monte Carlo simulations. Eighteen multiple-target SRS plans designed with the Eclipse treatment planning system were mapped to a cylindrical water phantom. For each plan, the 3D dose distribution reconstructed by VIPER within the phantom was compared with the Monte Carlo simulation, using a 3D gamma analysis. Dose differences (VIPER vs. measurements) generally within 2% were found for the MLC-defined fields, while film dosimetry revealed gamma passing rates (GPRs) ≥95% for a 3%/1 mm criteria. For the 18 multiple-target SRS plans, average 3D GPRs greater than 93% and 98% for the 3%/2 mm and 5%/2 mm criteria, respectively. Our results validate the use of VIPER as a dosimetric verification tool for pre-treatment QA of single-isocenter multiple-target SRS plans. The method requires no setup time on the linac and results in an accurate 3D characterization of the delivered dose., (© 2021 The Authors. Journal of Applied Clinical Medical Physics published by Wiley Periodicals, Inc. on behalf of American Association of Physicists in Medicine.)

Purpose: In multileaf collimator (MLC) tracking, the MLC positions from the original treatment plan are continuously modified to account for intrafraction tumor motion. As the treatment is adapted in real time, there is additional risk of delivery errors which cannot be detected using traditional pretreatment dose verification. The purpose of this work is to develop a system for real-time geometric verification of MLC tracking treatments using an electronic portal imaging device (EPID)., Methods: MLC tracking was utilized during volumetric modulated arc therapy (VMAT). During these deliveries, treatment beam images were taken at 9.57 frames per second using an EPID and frame grabber computer. MLC positions were extracted from each image frame and used to assess delivery accuracy using three geometric measures: the location, size, and shape of the radiation field. The EPID-measured field location was compared to the tumor motion measured by implanted electromagnetic markers. The size and shape of the beam were compared to the size and shape from the original treatment plan, respectively. This technique was validated by simulating errors in phantom test deliveries and by comparison between EPID measurements and treatment log files. The method was applied offline to images acquired during the LIGHT Stereotactic Ablative Body Radiotherapy (SABR) clinical trial, where MLC tracking was performed for 17 lung cancer patients. The EPID-based verification results were subsequently compared to post-treatment dose reconstruction., Results: Simulated field location errors were detected during phantom validation tests with an uncertainty of 0.28 mm (parallel to MLC motion) and 0.38 mm (perpendicular), expressed as a root-mean-square error (RMS Error ). For simulated field size errors, the RMS Error was 0.47 cm 2 and field shape changes were detected for random errors with standard deviation ≥ 2.5 mm. For clinical lung SABR deliveries, field location errors of 1.6 mm (parallel MLC motion) and 4.9 mm (perpendicular) were measured (expressed as a full-width-half-maximum). The mean and standard deviation of the errors in field size and shape were 0.0 ± 0.3 cm 2 and 0.3 ± 0.1 (expressed as a translation-invariant normalized RMS). No correlation was observed between geometric errors during each treatment fraction and dosimetric errors in the reconstructed dose to the target volume for this cohort of patients., Conclusion: A system for real-time delivery verification has been developed for MLC tracking using time-resolved EPID imaging. The technique has been tested offline in phantom-based deliveries and clinical patient deliveries and was used to independently verify the geometric accuracy of the MLC during MLC tracking radiotherapy., (© 2020 American Association of Physicists in Medicine.)

The use of trajectory log files for routine patient quality assurance is gaining acceptance. Such use requires the validation of the trajectory log itself. However, the accurate localization of a multileaf collimator (MLC) leaf while it is in motion remains a challenging task. We propose an efficient phantom-less technique using the EPID to verify the dynamic MLC positions with high accuracy. Measurements were made on four Varian TrueBeams equipped with M120 MLCs. Two machines were equipped with the S1000 EPID; two were equipped with the S1200 EPID. All EPIDs were geometrically corrected prior to measurements. Dosimetry mode EPID measurements were captured by a frame grabber card directly linked to the linac. All leaf position measurements were corrected both temporally and geometrically. The readout latency of each panel, as a function of pixel row, was determined using a 40 × 1.0 cm 2 sliding window (SW) field moving at 2.5 cm/s orthogonal to the row readout direction. The latency of each panel type was determined by averaging the results of two panels of the same type. Geometric correction was achieved by computing leaf positions with respect to the projected isocenter position as a function of gantry angle. This was determined by averaging the central axis position of fields at two collimator positions of 90° and 270°. The radiological to physical leaf end position was determined by comparison of the measured gap with that determined using a feeler gauge. The radiological to physical leaf position difference was found to be 0.1 mm. With geometric and latency correction, the proposed method was found to be improve the ability to detect dynamic MLC positions from 1.0 to 0.2 mm for all leaves. Latency and panel residual geometric error correction improve EPID-based MLC position measurement. These improvements provide for the first time a trajectory log QA procedure., (© 2021 The Authors. Journal of Applied Clinical Medical Physics is published by Wiley Periodicals LLC. on behalf of The American Association of Physicists in Medicine.)

Purpose: Stereotactic Ablative Radiotherapy (SABR) has recently emerged as a favourable treatment option for prostate cancer patients. With higher doses delivered over fewer fractions, motion adaptation is a requirement for accurate delivery of SABR. This study compared the efficacy of multileaf collimator (MLC) tracking vs. gating as a real-time motion adaptation strategy for prostate SABR patients enrolled in a clinical trial., Methods: Forty-four prostate cancer patients treated over five fractions in the TROG 15.01 SPARK trial were analysed in this study. Forty-nine fractions were treated using MLC tracking and 166 fractions were treated using beam gating and couch shifts. A time-resolved motion-encoded dose reconstruction method was used to evaluate the dose delivered using each motion adaptation strategy and compared to an estimation of what would have been delivered with no motion adaptation strategy implemented., Results: MLC tracking and gating both delivered doses closer to the plan compared to when no motion adaptation strategy was used. Differences between MLC tracking and gating were small with differences in the mean discrepancy from the plan of -0.3% (CTV D 98% ), 1.4% (CTV D 2% ), 0.4% (PTV D 95% ), 0.2% (rectum V 30Gy ) and 0.0% (bladder V 30Gy ). On average, 0.5 couch shifts were required per gated fractions with a mean interruption duration of 1.8 ± 2.6 min per fraction treated using gating., Conclusion: Both MLC tracking and gating were effective strategies at improving the accuracy of the dose delivered to the target and organs at risk. While dosimetric performance was comparable, gating resulted in interruptions to treatment., Clinical Trial Registration Number: NCT02397317., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Purpose: Kilovoltage intrafraction monitoring (KIM) is a novel software platform implemented on standard radiation therapy systems and enabling real-time image guided radiation therapy (IGRT). In a multi-institutional prospective trial, we investigated whether real-time IGRT improved the accuracy of the dose patients with prostate cancer received during radiation therapy., Methods and Materials: Forty-eight patients with prostate cancer were treated with KIM-guided SABR with 36.25 Gy in 5 fractions. During KIM-guided treatment, the prostate motion was corrected for by either beam gating with couch shifts or multileaf collimator tracking. A dose reconstruction method was used to evaluate the dose delivered to the target and organs at risk with and without real-time IGRT. Primary outcome was the effect of real-time IGRT on dose distributions. Secondary outcomes included patient-reported outcomes and toxicity., Results: Motion correction occurred in ≥1 treatment for 88% of patients (42 of 48) and 51% of treatments (121 of 235). With real-time IGRT, no treatments had prostate clinical target volume (CTV) D98% dose 5% less than planned. Without real-time IGRT, 13 treatments (5.5%) had prostate CTV D98% doses 5% less than planned. The prostate CTV D98% dose with real-time IGRT was closer to the plan by an average of 1.0% (range, -2.8% to 20.3%). Patient outcomes showed no change in the 12-month patient-reported outcomes compared with baseline and no grade ≥3 genitourinary or gastrointestinal toxicities., Conclusions: Real-time IGRT is clinically effective for prostate cancer SABR., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: Deep learning methods (DLMs) have recently been proposed to generate pseudo-CT (pCT) for magnetic resonance imaging (MRI) based dose planning. This study aims to evaluate and compare DLMs (U-Net and generative adversarial network [GAN]) using various loss functions (L2, single-scale perceptual loss [PL], multiscale PL, weighted multiscale PL) and a patch-based method (PBM)., Methods and Materials: Thirty-nine patients received a volumetric modulated arc therapy for prostate cancer (78 Gy). T 2 -weighted MRIs were acquired in addition to planning CTs. The pCTs were generated from the MRIs using 7 configurations: 4 GANs (L2, single-scale PL, multiscale PL, weighted multiscale PL), 2 U-Net (L2 and single-scale PL), and the PBM. The imaging endpoints were mean absolute error and mean error, in Hounsfield units, between the reference CT (CT ref ) and the pCT. Dose uncertainties were quantified as mean absolute differences between the dose volume histograms (DVHs) calculated from the CT ref and pCT obtained by each method. Three-dimensional gamma indexes were analyzed., Results: Considering the image uncertainties in the whole pelvis, GAN L2 and U-Net L2 showed the lowest mean absolute error (≤34.4 Hounsfield units). The mean errors were not different than 0 (P ≤ .05). The PBM provided the highest uncertainties. Very few DVH points differed when comparing GAN L2 or U-Net L2 DVHs and CT ref DVHs (P ≤ .05). Their dose uncertainties were ≤0.6% for the prostate planning target Volume V 95% , ≤0.5% for the rectum V 70Gy , and ≤0.1% for the bladder V 50Gy . The PBM, U-Net PL, and GAN PL presented the highest systematic dose uncertainties. The gamma pass rates were >99% for all DLMs. The mean calculation time to generate 1 pCT was 15 s for the DLMs and 62 min for the PBM., Conclusions: Generating pCT for MRI dose planning with DLMs and PBM provided low-dose uncertainties. In particular, the GAN L2 and U-Net L2 provided the lowest dose uncertainties together with a low computation time., (Crown Copyright © 2019. Published by Elsevier Inc. All rights reserved.)

Background: A novel remote method for external dosimetric TPS-planned auditing of intensity modulated radiotherapy (IMRT) and volumetric modulated arc therapy (VMAT) for clinical trials using electronic portal imaging device (EPID) has been developed. The audit has been applied to multiple centers across Australia and New Zealand. This work aims to assess the audit outcomes and explores the variables that contributed to the audit results., Methods: Thirty audits were performed of 21 radiotherapy facilities, 17 facilities underwent IMRT audits and 13 underwent VMAT audits. The assessment was based on comparisons between the delivered doses derived from images acquired with EPIDs and planned doses from the local treatment planning systems (TPS). Gamma pass-rate (GPR) and gamma mean value (GMV) were calculated for each IMRT field and VMAT arc (total 268 comparisons). A multiple variable linear model was applied to the GMV results (3%/3 mm criteria) to assess the influence and significance of explanatory variables. The explanatory variables were Linac-TPS combination, TPS grid resolution, IMRT/VMAT delivery, age of EPID, treatment site, record and verification system (R&V) type and dose-rate. Finally, the audit results were compared with other recent audits by calculating the incidence ratio (IR) as a ratio of the observed mean/median GPRs for the remote audit to the other audits., Results: The average (± 1 SD) of the centers' GPRs were: 99.3 ± 1.9%, 98.6 ± 2.7% & 96.2 ± 5.5% at 3%, 3 mm, 3%, 2 mm and 2%, 2 mm criteria respectively. The most determinative variables on the GMVs were Linac-TPS combination, TPS grid resolution and IMRT/VMAT delivery type. The IR values were 1 for seven comparisons, indicating similar GPRs of the remote audit with the reference audits and > 1 for four comparisons, indicating higher GPRs of the remote audit than the reference audits., Conclusion: The remote dosimetry audit method for clinical trials demonstrated high GPRs and provided results comparable to established more resource-intensive audit methods. Several factors were found to influence the results including some effect of Linac-TPS combination.

Purpose: To report on the primary and secondary outcomes of a prospective clinical trial of electromagnetic-guided multileaf collimator (MLC) tracking radiation therapy for prostate cancer., Methods and Materials: Twenty-eight men with prostate cancer were treated with electromagnetic-guided MLC tracking with volumetric modulated arc therapy. A total of 858 fractions were delivered, with the dose per fraction ranging from 2 to 13.75 Gy. The primary outcome was feasibility, with success determined if >95% of fractions were successfully delivered. The secondary outcomes were (1) the improvement in beam-target geometric alignment, (2) the improvement in dosimetric coverage of the prostate and avoidance of critical structures, and (3) no acute grade ≥3 genitourinary or gastrointestinal toxicity., Results: All 858 planned fractions were successfully delivered with MLC tracking, demonstrating the primary outcome of feasibility (P < .001). MLC tracking improved the beam-target geometric alignment from 1.4 to 0.90 mm (root-mean-square error). MLC tracking improved the dosimetric coverage of the prostate and reduced the daily variation in dose to critical structures. No acute grade ≥3 genitourinary or gastrointestinal toxicity was observed., Conclusions: Electromagnetic-guided MLC tracking radiation therapy for prostate cancer is feasible. The patients received improved geometric targeting and delivered dose distributions that were closer to those planned than they would have received without electromagnetic-guided MLC tracking. No significant acute toxicity was observed., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Volumetric-modulated arc therapy (VMAT) treatment delivery requires three key dynamic components; gantry rotation, dose rate modulation, and multi-leaf collimator motion, which are all simultaneously varied during the delivery. Misalignment of the gantry angle can potentially affect clinical outcome due to the steep dose gradients and complex MLC shapes involved. It is essential to develop independent gantry angle quality assurance (QA) appropriate to VMAT that can be performed simultaneously with other key VMAT QA testing. In this work, a simple and inexpensive fully independent gantry angle measurement methodology was developed that allows quantitation of the gantry angle accuracy as a function of time. This method is based on the analysis of video footage of a "Double dot" pattern attached to the front cover of the linear accelerator that consists of red and green circles printed on A4 paper sheet. A standard mobile phone is placed on the couch to record the video footage during gantry rotation. The video file is subsequently analyzed and used to determine the gantry angle from each video frame using the relative position of the two dots. There were two types of validation tests performed including the static mode with manual gantry angle rotation and dynamic mode with three complex test plans. The accuracy was 0.26° ± 0.04° and 0.46° ± 0.31° (mean ± 1 SD) for the static and dynamic modes, respectively. This method is user friendly, cost effective, easy to setup, has high temporal resolution, and can be combined with existing time-resolved method for QA of MLC and dose rate to form a comprehensive set of procedures for time-resolved QA of VMAT delivery system., (© 2017 The Authors. Journal of Applied Clinical Medical Physics published by Wiley Periodicals, Inc. on behalf of American Association of Physicists in Medicine.)

Purpose: An ideal commissioning and quality assurance (QA) program for Volumetric Modulated Arc Therapy (VMAT) delivery systems should assess the performance of each individual dynamic component as a function of gantry angle. Procedures within such a program should also be time-efficient, independent of the delivery system and be sensitive to all types of errors. The purpose of this work is to develop a system for automated time-resolved commissioning and QA of VMAT control systems which meets these criteria., Methods: The procedures developed within this work rely solely on images obtained, using an electronic portal imaging device (EPID) without the presence of a phantom. During the delivery of specially designed VMAT test plans, EPID frames were acquired at 9.5 Hz, using a frame grabber. The set of test plans was developed to individually assess the performance of the dose delivery and multileaf collimator (MLC) control systems under varying levels of delivery complexities. An in-house software tool was developed to automatically extract features from the EPID images and evaluate the following characteristics as a function of gantry angle: dose delivery accuracy, dose rate constancy, beam profile constancy, gantry speed constancy, dynamic MLC positioning accuracy, MLC speed and acceleration constancy, and synchronization between gantry angle, MLC positioning and dose rate. Machine log files were also acquired during each delivery and subsequently compared to information extracted from EPID image frames., Results: The largest difference between measured and planned dose at any gantry angle was 0.8% which correlated with rapid changes in dose rate and gantry speed. For all other test plans, the dose delivered was within 0.25% of the planned dose for all gantry angles. Profile constancy was not found to vary with gantry angle for tests where gantry speed and dose rate were constant, however, for tests with varying dose rate and gantry speed, segments with lower dose rate and higher gantry speed exhibited less profile stability. MLC positional accuracy was not observed to be dependent on the degree of interdigitation. MLC speed was measured for each individual leaf and slower leaf speeds were shown to be compensated for by lower dose rates. The test procedures were found to be sensitive to 1 mm systematic MLC errors, 1 mm random MLC errors, 0.4 mm MLC gap errors and synchronization errors between the MLC, dose rate and gantry angle controls systems of 1°. In general, parameters measured by both EPID and log files agreed with the plan, however, a greater average departure from the plan was evidenced by the EPID measurements., Conclusion: QA test plans and analysis methods have been developed to assess the performance of each dynamic component of VMAT deliveries individually and as a function of gantry angle. This methodology relies solely on time-resolved EPID imaging without the presence of a phantom and has been shown to be sensitive to a range of delivery errors. The procedures developed in this work are both comprehensive and time-efficient and can be used for streamlined commissioning and QA of VMAT delivery systems., (© 2017 American Association of Physicists in Medicine.)

A virtual EPID standard phantom audit (VESPA) has been implemented for remote auditing in support of facility credentialing for clinical trials using IMRT and VMAT. VESPA is based on published methods and a clinically established IMRT QA procedure, here extended to multi-vendor equipment. Facilities are provided with comprehensive instructions and CT datasets to create treatment plans. They deliver the treatment directly to their EPID without any phantom or couch in the beam. In addition, they deliver a set of simple calibration fields per instructions. Collected EPID images are uploaded electronically. In the analysis, the dose is projected back into a virtual cylindrical phantom. 3D gamma analysis is performed. 2D dose planes and linear dose profiles are provided and can be considered when needed for clarification. In addition, using a virtual flat-phantom, 2D field-by-field or arc-by-arc gamma analyses are performed. Pilot facilities covering a range of planning and delivery systems have performed data acquisition and upload successfully. Advantages of VESPA are (1) fast turnaround mainly driven by the facility's capability of providing the requested EPID images, (2) the possibility for facilities performing the audit in parallel, as there is no need to wait for a phantom, (3) simple and efficient credentialing for international facilities, (4) a large set of data points, and (5) a reduced impact on resources and environment as there is no need to transport heavy phantoms or audit staff. Limitations of the current implementation of VESPA for trials credentialing are that it does not provide absolute dosimetry, therefore a Level I audit is still required, and that it relies on correctly delivered open calibration fields, which are used for system calibration. The implemented EPID based IMRT and VMAT audit system promises to dramatically improve credentialing efficiency for clinical trials and wider applications.

Purpose Due to increasing complexity, modern radiotherapy techniques require comprehensive quality assurance (QA) programmes, that to date generally focus on the pre-treatment stage. The purpose of this paper is to provide a method for an individual patient treatment QA evaluation and identification of a "quality gap" for continuous quality improvement. Design/methodology/approach A statistical process control (SPC) was applied to evaluate treatment delivery using in vivo electronic portal imaging device (EPID) dosimetry. A moving range control chart was constructed to monitor the individual patient treatment performance based on a control limit generated from initial data of 90 intensity-modulated radiotherapy (IMRT) and ten volumetric-modulated arc therapy (VMAT) patient deliveries. A process capability index was used to evaluate the continuing treatment quality based on three quality classes: treatment type-specific, treatment linac-specific, and body site-specific. Findings The determined control limits were 62.5 and 70.0 per cent of the χ pass-rate for IMRT and VMAT deliveries, respectively. In total, 14 patients were selected for a pilot study the results of which showed that about 1 per cent of all treatments contained errors relating to unexpected anatomical changes between treatment fractions. Both rectum and pelvis cancer treatments demonstrated process capability indices were less than 1, indicating the potential for quality improvement and hence may benefit from further assessment. Research limitations/implications The study relied on the application of in vivo EPID dosimetry for patients treated at the specific centre. Sampling patients for generating the control limits were limited to 100 patients. Whilst the quantitative results are specific to the clinical techniques and equipment used, the described method is generally applicable to IMRT and VMAT treatment QA. Whilst more work is required to determine the level of clinical significance, the authors have demonstrated the capability of the method for both treatment specific QA and continuing quality improvement. Practical implications The proposed method is a valuable tool for assessing the accuracy of treatment delivery whilst also improving treatment quality and patient safety. Originality/value Assessing in vivo EPID dosimetry with SPC can be used to improve the quality of radiation treatment for cancer patients.

We proposed to perform a basic dosimetry commissioning on a new imager sys-tem, the Varian aS1200 electronic portal imaging device (EPID) and TrueBeam 2.0 linear accelerator for flattened (FF) and flattening filter-free (FFF) beams, then to develop an image-based quality assurance (QA) model for verification of the system delivery accuracy for intensity-modulated radiation therapy (IMRT) treat-ments. For dosimetry testing, linearity of dose response with MU, imager lag, and effectiveness of backscatter shielding were investigated. Then, an image-based model was developed to convert images to planar dose onto a virtual water phantom. The model parameters were identified using energy fluence of the Acuros treatment planning system (TPS) and, reference dose profiles and output factors measured at depths of 5, 10, 15, and 20 cm in water phantom for square fields. To validate the model, its calculated dose was compared to measured dose from MapCHECK 2 diode arrays for 36 IMRT fields at 10 cm depth delivered with 6X, 6XFFF, 10X, and 10XFFF energies. An in-house gamma function was used to compare planar doses pixel-by-pixel. Finally, the method was applied to the same IMRT fields to verify their pretreatment delivery dose compared with Eclipse TPS dose. For the EPID commissioning, dose linearity was within 0.4% above 5 MU and ~ 1% above 2 MU, measured lag was smaller than the previous EPIDs, and profile symmetry was improved. The model was validated with mean gamma pass rates (standard deviation) of 99.0% (0.4%), 99.5% (0.6%), 99.3% (0.4%), and 98.0% (0.8%) at 3%/3 mm for respectively 6X, 6XFFF, 10X, and 10XFFF beams. Using the same comparison criteria, the beam deliveries were verified with mean pass rates of 100% (0.0%), 99.6% (0.3%), 99.9% (0.1%), and 98.7% (1.4%). Improvements were observed in dosimetric response of the aS1200 imager compared to previous EPID models, and the model was successfully developed for the new system and delivery energies of 6 and 10 MV, FF, and FFF modes., (© 2016 The Authors.)

Multileaf collimator (MLC) positions should be precisely and independently mea-sured as a function of gantry angle as part of a comprehensive quality assurance (QA) program for volumetric-modulated arc therapy (VMAT). It is also ideal that such a QA program has the ability to relate MLC positional accuracy to patient-specific dosimetry in order to determine the clinical significance of any detected MLC errors. In this work we propose a method to verify individual MLC trajectories during VMAT deliveries for use as a routine linear accelerator QA tool. We also extend this method to reconstruct the 3D patient dose in the treatment planning sys-tem based on the measured MLC trajectories and the original DICOM plan file. The method relies on extracting MLC positions from EPID images acquired at 8.41fps during clinical VMAT deliveries. A gantry angle is automatically tagged to each image in order to obtain the MLC trajectories as a function of gantry angle. This analysis was performed for six clinical VMAT plans acquired at monthly intervals for three months. The measured trajectories for each delivery were compared to the MLC positions from the DICOM plan file. The maximum mean error detected was 0.07 mm and a maximum root-mean-square error was 0.8 mm for any leaf of any delivery. The sensitivity of this system was characterized by introducing random and systematic MLC errors into the test plans. It was demonstrated that the system is capable of detecting random and systematic errors on the range of 1-2mm and single leaf calibration errors of 0.5 mm. The methodology developed in the work has potential to be used for efficient routine linear accelerator MLC QA and pretreatment patient-specific QA and has the ability to relate measured MLC positional errors to 3D dosimetric errors within a patient volume., (© 2016 The Authors.)

In VMAT treatment delivery the ability of the linear accelerator (linac) to accurately control dose versus gantry angle is critical to delivering the plan correctly. A new VMAT test delivery was developed to specifically test the dose versus gantry angle with the full range of allowed gantry speeds and dose rates. The gantry-mounted IBA MatriXX with attached inclinometer was used in movie mode to measure the instantaneous relative dose versus gantry angle during the plan every 0.54 s. The results were compared to the expected relative dose at each gantry angle calculated from the plan. The same dataset was also used to compare the instantaneous gan-try speeds throughout the delivery compared to the expected gantry speeds from the plan. Measurements performed across four linacs generally show agreement between measurement and plan to within 1.5% in the constant dose rate regions and dose rate modulation within 0.1 s of the plan. Instantaneous gantry speed was measured to be within 0.11°/s of the plan (1 SD). An error in one linac was detected in that the nominal gantry speed was incorrectly calibrated. This test provides a practical method to quality-assure critical aspects of VMAT delivery including dose versus gantry angle and gantry speed control. The method can be performed with any detector that can acquire time-resolved dosimetric information that can be synchronized with a measurement of gantry angle. The test fulfils several of the aims of the recent Netherlands Commission on Radiation Dosimetry (NCS) Report 24, which provides recommendations for comprehensive VMAT quality assurance.

In volumetric-modulated arc therapy (VMAT) treatment delivery perfect beam symmetry is assumed by the planning system. This study aims to test this assumption and present a method of measuring time-resolved beam symmetry measurement during a VMAT delivery that includes extreme variations of dose rate and gantry speed. The Sun Nuclear IC Profiler in gantry mount was used to measure time-resolved in-plane and cross-plane profiles during plan delivery from which symmetry could be determined. Time-resolved symmetry measurements were performed throughout static field exposures at cardinal gantry angles, conformal arcs with constant dose rate and gantry speed, and during a VMAT test plan with gantry speed and dose rate modulation. Measurements were performed for both clockwise and counterclockwise gantry rotation and across four Varian 21iX lin-acs. The symmetry was found to be generally constant throughout the static field exposures to within 0.3% with an exception on one linac of up to 0.7%. Agreement in symmetry between cardinal angles was always within 1.0% and typically within 0.6%. During conformal arcs the results for clockwise and counterclockwise rotation were in agreement to within 0.3%. Both clockwise and counterclockwise tended to vary in similar manner by up to 0.5% during arc consistent with the cardinal gantry angle static field results. During the VMAT test plan the symmetry generally was in agreement with the conformal arc results. Greater variation in symmetry was observed in the low-dose-rate regions by up to 1.75%. All results were within clinically acceptable levels using the tolerances of NCS Report 24 (2015).

Purpose: Radiation treatments are trending toward delivering higher doses per fraction under stereotactic radiosurgery and hypofractionated treatment regimens. There is a need for accurate 3D in vivo patient dose verification using electronic portal imaging device (EPID) measurements. This work presents a model-based technique to compute full three-dimensional patient dose reconstructed from on-treatment EPID portal images (i.e., transmission images)., Methods: EPID dose is converted to incident fluence entering the patient using a series of steps which include converting measured EPID dose to fluence at the detector plane and then back-projecting the primary source component of the EPID fluence upstream of the patient. Incident fluence is then recombined with predicted extra-focal fluence and used to calculate 3D patient dose via a collapsed-cone convolution method. This method is implemented in an iterative manner, although in practice it provides accurate results in a single iteration. The robustness of the dose reconstruction technique is demonstrated with several simple slab phantom and nine anthropomorphic phantom cases. Prostate, head and neck, and lung treatments are all included as well as a range of delivery techniques including VMAT and dynamic intensity modulated radiation therapy (IMRT)., Results: Results indicate that the patient dose reconstruction algorithm compares well with treatment planning system computed doses for controlled test situations. For simple phantom and square field tests, agreement was excellent with a 2%/2 mm 3D chi pass rate ≥98.9%. On anthropomorphic phantoms, the 2%/2 mm 3D chi pass rates ranged from 79.9% to 99.9% in the planning target volume (PTV) region and 96.5% to 100% in the low dose region (>20% of prescription, excluding PTV and skin build-up region)., Conclusions: An algorithm to reconstruct delivered patient 3D doses from EPID exit dosimetry measurements was presented. The method was applied to phantom and patient data sets, as well as for dynamic IMRT and VMAT delivery techniques. Results indicate that the EPID dose reconstruction algorithm presented in this work is suitable for clinical implementation.

Purpose: Gantry-mounted megavoltage electronic portal imaging devices (EPIDs) have become ubiquitous on linear accelerators. WatchDog is a novel application of EPIDs, in which the image frames acquired during treatment are used to monitor treatment delivery in real time. We report on the preliminary use of WatchDog in a prospective study of cancer patients undergoing intensity modulated radiation therapy (IMRT) and volumetric modulated arc therapy (VMAT) and identify the challenges of clinical adoption., Methods and Materials: At the time of submission, 28 cancer patients (head and neck, pelvis, and prostate) undergoing fractionated external beam radiation therapy (24 IMRT, 4 VMAT) had ≥1 treatment fraction verified in real time (131 fractions or 881 fields). EPID images acquired continuously during treatment were synchronized and compared with model-generated transit EPID images within a frame time (∼0.1 s). A χ comparison was performed to cumulative frames to gauge the overall delivery quality, and the resulting pass rates were reported graphically during treatment delivery. Every frame acquired (500-1500 per fraction) was saved for postprocessing and analysis., Results: The system reported the mean ± standard deviation in real time χ 91.1% ± 11.5% (83.6% ± 13.2%) for cumulative frame χ analysis with 4%, 4 mm (3%, 3 mm) criteria, global over the integrated image., Conclusions: A real-time EPID-based radiation delivery verification system for IMRT and VMAT has been demonstrated that aims to prevent major mistreatments in radiation therapy., (Copyright © 2015 Elsevier Inc. All rights reserved.)

A new tool with the potential to verify and track jaw position during delivery has been developed. The method should be suitable for independent quality assurance for jaw position during jaw tracking dynamic IMRT and VMAT treatments. The jaw detection and tracking algorithm developed consists of five main steps. Firstly, the image is enhanced by removing a normalised predicted EPID image (that does not include the collimator transmission) from each cine EPID image. Then, using a histogram clustering technique a global intensity threshold level was determined. This threshold level was used to classify each pixel of the image as either under the jaws or under the MLC. Additionally, the collimator angle was automatically detected and used to rotate the image to vertical direction. Finally, this rotation allows the jaw positions to be determined using vertical and horizontal projection profiles. Nine IMRT fields (with static jaws) and a single VMAT clinical field (with dynamic jaws) were tested by determining the root mean square difference between planned and detected jaw positions. The test results give a detection accuracy of ±1 mm RMS error for static jaw IMRT treatments and ±1.5 mm RMS error for the dynamic jaw VMAT treatment. This method is designed for quality assurance and verification in modern radiation therapy; to detect the position of static jaws or verify the position of tracking jaws in more complex treatments. This method uses only information extracted from EPID images and it is therefore independent from the linear accelerator., (Copyright © 2014 Associazione Italiana di Fisica Medica. Published by Elsevier Ltd. All rights reserved.)

Using an amorphous silicon (a-Si) EPID for transit dosimetry requires detailed characterization of its dosimetric response in a variety of conditions. In this study, a measurement-based model was developed to calibrate an a-Si EPID response to dose for transit dosimetry by comparison with a reference ionization chamber. The ionization chamber reference depth and the required additional buildup thickness for electronic portal imaging devices (EPID) transit dosimetry were determined. The combined effects of changes in radiation field size, phantom thickness, and the off-axis distance on EPID transit dosimetry were characterized. The effect of scattered radiation on out-of-field response was investigated for different field sizes and phantom thicknesses by evaluation of the differences in image profiles and in-water measured profiles. An algorithm was developed to automatically apply these corrections to EPID images based on the user-specified field size and phantom thickness. The average phantom thickness and an effective field size were used for IMRT fields, and images were acquired in cine mode in the presence of an anthropomorphic phantom. The effective field size was defined as the percentage of the jaw-defined field that was involved during the delivery. Nine head and neck dynamic IMRT fields were tested by comparison with a MatriXX two-dimensional array dosimeter using the Gamma (3%, 3 mm) evaluation. A depth of 1.5 cm was selected as the ionization chamber reference depth. An additional 2.2 mm of copper buildup was added to the EPID. Comparison of EPID and MatriXX dose images for the tested fields showed that using a 10% threshold, the average number of points with Gamma index <1 was 96.5%. The agreement in the out-of field area was shown by selection of a 2% threshold which on average resulted in 94.8% of points with a Gamma index <1. The suggested method is less complicated than previously reported techniques and can be used for all a-Si EPIDs regardless of the manufacturer.

EPID images acquired in cine mode during arc therapy have inaccurate gantry angles recorded in their image headers. In this work, methods were developed to assess the accuracy of the gantry potentiometer for linear accelerators. As well, assessments of the accuracy of other, more accessible, sources of gantry angle information (i.e., treatment log files, analysis of EPID image headers) were investigated. The methods used in this study are generally applicable to any linear accelerator unit, and have been demonstrated here with Clinac/Trilogy systems. Gantry angle data were simultaneously acquired using three methods: i) a direct gantry potentiometer measurement, ii) an incremental rotary encoder, and iii) a custom-made radiographic gantry-angle phantom which produced unique wire intersections as a function of gantry angle. All methods were compared to gantry angle data from the EPID image header and the linac MLC DynaLog file. The encoder and gantry-angle phantom were used to validate the accuracy of the linac's potentiometer. The EPID image header gantry angles and the DynaLog file gantry angles were compared to the potentiometer. The encoder and gantry-angle phantom mean angle differences with the potentiometer were 0.13° ± 0.14° and 0.10°± 0.30°, respectively. The EPID image header angles analyzed in this study were within ± 1° of the potentiometer angles only 35% of the time. In some cases, EPID image header gantry angles disagreed by as much as 3° with the potentiometer. A time delay in frame acquisition was determined using the continuous acquisition mode of the EPID. After correcting for this time delay, 75% of the header angles, on average, were within ± 1° of the true gantry angle, compared to an average of only 35% without the correction. Applying a boxcar smoothing filter to the corrected gantry angles further improved the accuracy of the header-derived gantry angles to within ± 1° for almost all images (99.4%). An angle accuracy of 0.11° ± 0.04° was determined using a point-by-point comparison of the gantry angle data in the MLC DynaLog file and the potentiometer data. These simple correction methods can be easily applied to individual treatment EPID images in order to more accurately define the gantry angle.

A new tool has been developed to verify the trajectory of dynamic multileaf collimators (MLCs) used in advanced radiotherapy techniques using only the information provided by the electronic portal imaging devices (EPID) measured image frames. The prescribed leaf positions are resampled to a higher resolution in a pre-processing stage to improve the verification precision. Measured MLC positions are extracted from the EPID frames using a template matching method. A cosine similarity metric is then applied to synchronise measured and planned leaf positions for comparison. Three additional comparison functions were incorporated to ensure robust synchronisation. The MLC leaf trajectory error detection was simulated for both intensity modulated radiation therapy (IMRT) (prostate) and volumetric modulated arc therapy (VMAT) (head-and-neck) deliveries with anthropomorphic phantoms in the beam. The overall accuracy for MLC positions automatically extracted from EPID image frames was approximately 0.5 mm. The MLC leaf trajectory verification system can detect leaf position errors during IMRT and VMAT with a tolerance of 3.5 mm within 1 s.

Purpose: To design and develop a real-time electronic portal imaging device (EPID)-based delivery verification system for dynamic intensity modulated radiation therapy (IMRT) which enables detection of gross treatment delivery errors before delivery of substantial radiation to the patient., Methods: The system utilizes a comprehensive physics-based model to generate a series of predicted transit EPID image frames as a reference dataset and compares these to measured EPID frames acquired during treatment. The two datasets are using MLC aperture comparison and cumulative signal checking techniques. The system operation in real-time was simulated offline using previously acquired images for 19 IMRT patient deliveries with both frame-by-frame comparison and cumulative frame comparison. Simulated error case studies were used to demonstrate the system sensitivity and performance., Results: The accuracy of the synchronization method was shown to agree within two control points which corresponds to approximately ∼1% of the total MU to be delivered for dynamic IMRT. The system achieved mean real-time gamma results for frame-by-frame analysis of 86.6% and 89.0% for 3%, 3 mm and 4%, 4 mm criteria, respectively, and 97.9% and 98.6% for cumulative gamma analysis. The system can detect a 10% MU error using 3%, 3 mm criteria within approximately 10 s. The EPID-based real-time delivery verification system successfully detected simulated gross errors introduced into patient plan deliveries in near real-time (within 0.1 s)., Conclusions: A real-time radiation delivery verification system for dynamic IMRT has been demonstrated that is designed to prevent major mistreatments in modern radiation therapy.

Purpose: Pretreatment verification of volumetric modulated arc therapy (VMAT) dose delivery with electronic portal imaging device (EPID) uses images integrated over the entire delivery or over large subarcs. This work aims to develop a new method for gantry-angle-resolved verification of VMAT dose delivery using EPID., Methods: An EPID dose prediction model was used to calculate EPID images as a function of gantry angle for eight prostate patient deliveries. EPID image frames at 7.5 frames per second were acquired during delivery via a frame-grabber system. The gantry angle for each image was encoded in kV frames which were synchronized to the MV frames. Gamma analysis results as a function of gantry angle were assessed by integrating the frames over 2° subarcs with an angle-to-agreement tolerance of 0.5° about the measured image angle., Results: The model agreed with EPID images integrated over the entire delivery with average Gamma pass-rates at 2%, 2 mm of 99.7% (10% threshold). The accuracy of the kV derived gantry angle for each image was found to be 0.1° (1 SD) using a phantom test. For the gantry-resolved analysis all Gamma pass-rates were greater than 90% at 3%, 3 mm criteria (with only two exceptions), and more than 90% had a 95% pass-rate, with an average of 97.3%. The measured gantry angle lagged behind the predicted angle by a mean of 0.3°±0.3°, with a maximum lag of 1.3°., Conclusions: The method provides a comprehensive and highly efficient pretreatment verification of VMAT delivery using EPID. Dose delivery accuracy is assessed as a function of gantry angle to ensure accurate treatment.

Amorphous silicon electronic portal imaging devices (EPIDs) have been investigated and used for dosimetry in radiotherapy for several years. The presence of a phosphor scintillator layer in the structure of these EPIDs has made them sensitive to low-energy scattered and backscattered radiation. In this study, the backscattered radiation from the walls, ceiling, and floor of a linac bunker has been investigated as a possible source of inaccuracy in EPID dosimetry. EPID images acquired in integrated mode at discrete gantry angles and cine images taken during arcs were used with different field setups (18 × 18 and 10 × 10 cm2 open square fields at 150 and 105 cm source-to-detector distances) to compare the EPID response at different gantry angles. A sliding gap and a dynamic head-and-neck IMRT field and a square field with a 15 cm thick cylindrical phantom in the beam were also investigated using integrated EPID images at several gantry angles. The contribution of linac output variations at different angles was evaluated using a 2D array of ion chambers. In addition, a portable brick wall was moved to different distances from the EPID to check the effect at a single angle. The results showed an agreement of within 0.1% between the arc mode and gantry-static mode measurements, and the variation of EPID response during gantry rotation was about 1% in all measurement conditions.

The increasing popularity of intensity-modulated arc therapy (IMAT) treatments requires specifically designed linac quality assurance (QA) programs. Gantry angle is one of the parameters that has a major effect on the outcome of IMAT treatments since dose reconstruction for patient-specific QA relies on the gantry angle; therefore, it is essential to ensure its accuracy for correct delivery of the prescribed dose. In this study, a simple measurement method and algorithm are presented for QA of gantry angle measurements based on integrated EPID images acquired at distinct gantry angles and cine EPID images during an entire 360° arc. A comprehensive study was carried out to evaluate this method, as well as to evaluate two commercially available inclinometers (NG360 and IBA GAS supplied in conjunction with popular array dosimeters Delta4 and MatriXXEvolution, respectively) by comparing their simultaneous angle measurement results with the linac potentiometer readouts at five gantry speeds. In all tested measurement systems, the average differences with the reference angle data were less than 0.3° in static mode. In arc mode, at all tested gantry speeds the average difference was less than 0.1° for the IBA GAS and the proposed EPID-based method, and 0.6° for the NG360 after correction for the inherent systematic time delay of the inclinometer. The gantry rotation speed measured by the three independent systems had an average deviation of about 0.01°/s from the nominal gantry speed.

Purpose: In advanced radiotherapy treatments such as intensity modulated radiation therapy (IMRT) and volumetric modulated arc therapy (VMAT), verification of the performance of the multileaf collimator (MLC) is an essential part of the linac QA program. The purpose of this study is to use the existing measurement methods for geometric QA of the MLCs and extend them to more comprehensive evaluation techniques, and to develop dedicated robust algorithms to quantitatively investigate the MLC performance in a fast, accurate, and efficient manner., Methods: The behavior of leaves was investigated in the step-and-shoot mode by the analysis of integrated electronic portal imaging device (EPID) images acquired during picket fence tests at fixed gantry angles and arc delivery. The MLC was also studied in dynamic mode by the analysis of cine EPID images of a sliding gap pattern delivered in a variety of conditions including different leaf speeds, deliveries at fixed gantry angles or in arc mode, and changing the direction of leaf motion. The accuracy of the method was tested by detection of the intentionally inserted errors in the delivery patterns., Results: The algorithm developed for the picket fence analysis was able to find each individual leaf position, gap width, and leaf bank skewness in addition to the deviations from expected leaf positions with respect to the beam central axis with sub-pixel accuracy. For the three tested linacs over a period of 5 months, the maximum change in the gap width was 0.5 mm, the maximum deviation from the expected leaf positions was 0.1 mm and the MLC skewness was up to 0.2°. The algorithm developed for the sliding gap analysis could determine the velocity and acceleration∕deceleration of each individual leaf as well as the gap width. There was a slight decrease in the accuracy of leaf performance with increasing leaf speeds. The analysis results were presented through several graphs. The accuracy of the method was assessed as 0.01 mm for both the gap size and peak position determination., Conclusions: This study provides fast, easy, and accurate test methods for routine QA of the MLC performance and helps in faster troubleshooting of MLC problems in both IMRT and VMAT treatments.

In this study an amorphous silicon electronic portal imaging device (a-Si EPID) converted to direct detection configuration was investigated as a transit dosimeter for intensity modulated radiation therapy (IMRT). After calibration to dose and correction for a background offset signal, the EPID-measured absolute IMRT transit doses for 29 fields were compared to a MatriXX two-dimensional array of ionization chambers (as reference) using Gamma evaluation (3%, 3 mm). The MatriXX was first evaluated as reference for transit dosimetry. The accuracy of EPID measurements was also investigated by comparison of point dose measurements by an ionization chamber on the central axis with slab and anthropomorphic phantoms in a range of simple to complex fields. The uncertainty in ionization chamber measurements in IMRT fields was also investigated by its displacement from the central axis and comparison with the central axis measurements. Comparison of the absolute doses measured by the EPID and MatriXX with slab phantoms in IMRT fields showed that on average 96.4% and 97.5% of points had a Gamma index<1 in head and neck and prostate fields, respectively. For absolute dose comparisons with anthropomorphic phantoms, the values changed to an average of 93.6%, 93.7% and 94.4% of points with Gamma index<1 in head and neck, brain and prostate fields, respectively. Point doses measured by the EPID and ionization chamber were within 3% difference for all conditions. The deviations introduced in the response of the ionization chamber in IMRT fields were<1%. The direct EPID performance for transit dosimetry showed that it has the potential to perform accurate, efficient and comprehensive in vivo dosimetry for IMRT.

Purpose: Electronic portal imaging devices (EPIDs) are high resolution systems that produce electronic dose maps with minimal time required for equipment setup, and therefore potentially present a time-saving alternative for intensity modulated radiation therapy (IMRT) pretreatment verification. A modified commercial EPID was investigated operated with an opaque sheet blocking the optical signal produced in the phosphor layer as a precursor to a switched mode dual dosimetry-imaging EPID system. The purpose of this study was to investigate the feasibility of using this system for direct dose to water dosimetry for pretreatment IMRT verification., Methods: A Varian amorphous silicon EPID was modified by placing an opaque sheet between the Gd(2)S(2)O:Tb phosphor layer and the photodiode array to block the optical photons. The EPID was thus converted to a direct-detecting system (dEPID), in which the high energy radiation deposits energy directly in the photodiode array. The copper build-up was replaced with d(max) solid water. Sixty-one IMRT beams of varying complexity were delivered to the EPID, to EDR2 dosimetric film and to a 2D ion chamber array (MapCheck). EPID data was compared to film and MapCheck data using gamma analysis with 3%, 3mm pass criteria., Results: The fraction of points that passed the gamma test was on average 98.1% and 98.6%, for the EPID versus film and EPID versus MapCheck comparisons, respectively. In the case of comparison with film, the majority of observed discrepancies were associated with problems related to film sensitivity or processing., Conclusions: The very close agreement between EPID and both film and MapCheck data demonstrates that the modified EPID is suitable for direct dose to water measurement for pretreatment IMRT verification. These results suggest a reconfigured EPID could be an efficient and accurate dosimeter. Alternatively, optical switching methods could be developed to produce a dual-mode EPID with both dosimetry and imaging capabilities.

The routine use of electronic portal imaging devices (EPIDs) as dosimeters for radiotherapy quality assurance is complicated by the non-water equivalence of the EPID's dose response. A commercial EPID modified to a direct-detection configuration was previously demonstrated to provide water-equivalent dose response with d(max) solid water build-up and 10 cm solid water backscatter. Clinical implementation of the direct EPID (dEPID) requires a design that maintains the water-equivalent dose response, can be incorporated onto existing EPID support arms and maintains sufficient image quality for clinical imaging. This study investigated the dEPID dose response with different configurations of build-up and backscatter using varying thickness of solid water and copper. Field size output factors and beam profiles measured with the dEPID were compared with ionization chamber measurements of dose in water for both 6 MV and 18 MV. The dEPID configured with d(max) solid water build-up and no backscatter (except for the support arm) was within 1.5% of dose in water data for both energies. The dEPID was maintained in this configuration for clinical dosimetry and image quality studies. Close agreement between the dEPID and treatment planning system was obtained for an IMRT field with 98.4% of pixels within the field meeting a gamma criterion of 3% and 3 mm. The reduced sensitivity of the dEPID resulted in a poorer image quality based on quantitative (contrast-to-noise ratio) and qualitative (anthropomorphic phantom) studies. However, clinically useful images were obtained with the dEPID using typical treatment field doses. The dEPID is a water-equivalent dosimeter that can be implemented with minimal modifications to the standard commercial EPID design. The proposed dEPID design greatly simplifies the verification of IMRT dose delivery.

The fluence exiting a patient during beam delivery can be used as treatment delivery quality assurance, either by direct comparison with expected exit fluences or by backprojection to reconstruct the patient dose. Multiple possible sources of measured exit fluence deviations exist, including changes in the beam delivery and changes in the patient anatomy. The purpose of this work is to compare the deviations caused by these sources. Machine delivery-related variability is measured by acquiring multiple dosimetric portal images (DPIs) of several test fields without a patient/phantom in the field over a time period of 2 months. Patient anatomy-related sources of fluence variability are simulated by computing transmission DPIs for a prostate patient using the same incident fluence for 11 different computed tomography (CT) images of the patient anatomy. The standard deviation (SD) and maximum deviation of the exit fluence, averaged over 5 mm x 5 mm square areas, is calculated for each test set. Machine delivery fluence SDs as large as 1% are observed for a sample patient field and as large as 2.5% for a picket-fence dMLC test field. Simulations indicate that day-to-day patient anatomy variations induce exit fluence SDs as large as 3.5%. The largest observed machine delivery deviations are 4% for the sample patient field and 7% for the picket-fence field, while the largest difference for the patient anatomy-related source is 8.5%. Since daily changes in patient anatomy can result in substantial exit fluence deviations, care should be taken when applying fluence back-projection to ensure that such deviations are properly attributed to their source.

A simplified method of verifying intensity modulated radiation therapy (IMRT) fields using a Varian aS500 amorphous silicon electronic portal imaging device (EPID) is demonstrated. Unlike previous approaches, it does not involve time consuming or complicated analytical processing of the data. The central axis pixel response of the EPID, as well as the profile characteristics obtained from images acquired with a 6 MV photon beam, was examined as a function of field size. Ion chamber measurements at various depths in a water phantom were then collected and it was found that at a specific depth d(ref), the dose response and profile characteristics closely matched the results of the EPID analysis. The only manipulation required to be performed on the EPID images was the multiplication of a matrix of off axis ratio values to remove the effect of the flood field calibration. Similarly, d(ref) was found for 18 MV. Planar dose maps at d(ref) in a water phantom for a bar pattern, a strip pattern, and 14 clinical IMRT fields from two patient cases each being from a separate anatomical region, i.e., head and neck as well as the pelvis, for both energies were generated by the Pinnacle planning system (V7.4). EPID images of these fields were acquired and converted to planar dose maps and compared directly with the Pinnacle planar dose maps. Radiographic film dosimetry and a MapCHECK dosimetry device (Sun Nuclear Corporation, Melbourne, FL) were used as an independent verification of the dose distribution. Gamma analysis of the EPID, film, and Pinnacle planar dose maps generated for the clinical IMRT fields showed that approximately 97% of all points passed using a 3% dose/3 mm DTA tolerance test. Based on the range of fields studied, the author's results appear to justify using this approach as a method to verify dose distributions calculated on a treatment planning system, including complex intensity modulated fields.

The aim of this work was to experimentally determine the difference in response of an amorphous silicon (a-Si) electronic portal imaging device (EPID) to the open and multileaf collimator (MLC) transmitted beam components of intensity modulated radiation therapy (IMRT) beams. EPID dose response curves were measured for open and MLC transmitted (MLCtr) 10 x 10 cm2 beams at central axis and with off axis distance using a shifting field technique. The EPID signal was obtained by replacing the flood-field correction with a pixel sensitivity variation matrix correction. This signal, which includes energy-dependent response, was then compared to ion-chamber measurements. An EPID calibration method to remove the effect of beam energy variations on EPID response was developed for IMRT beams. This method uses the component of open and MLCtr fluence to an EPID pixel calculated from the MLC delivery file and applies separate radially dependent calibration factors for each component. The calibration procedure does not correct for scatter differences between ion chamber in water measurements and EPID response; these must be accounted for separately with a kernel-based approach or similar method. The EPID response at central axis for the open beam was found to be 1.28 +/- 0.03 of the response for the MLCtr beam, with the ratio increasing to 1.39 at 12.5 cm off axis. The EPID response to MLCtr radiation did not change with off-axis distance. Filtering the beam with copper plates to reduce the beam energy difference between open and MLCtr beams was investigated; however, these were not effective at reducing EPID response differences. The change in EPID response for uniform sliding window IMRT beams with MLCtr dose components from 0.3% to 69% was predicted to within 2.3% using the separate EPID response calibration factors for each dose component. A clinical IMRT image calibrated with this method differed by nearly 30% in high MLCtr regions from an image calibrated with an open beam calibration factor only. Accounting for the difference in EPID response to open and MLCtr radiation should improve IMRT dosimetry with a-Si EPIDs.

This work assessed the dosimetric performance of an amorphous silicon electronic portal imaging device (EPID) for measurement and quality assurance of enhanced dynamic wedge (EDW) profile and wedge factor. EPID measurements of EDW profiles were corrected for pixel sensitivity variation and spectral over-response relative to ion chamber and compared to ion-chamber and diode-array measurements. The dependence of EPID measurements on wedge direction and source to EPID distance was assessed. The long-term stability was investigated by weekly measurement of EDW profiles and wedge factors over a seven month interval. An empirical correction method was developed to improve EPID profile agreement with diode-array measurements. The EPID profiles differed from conventional measurements by up to 5%. Backscatter from the EPID housing was also found to affect measurements by up to 4%, resulting in changes in EPID measured profile with the direction of the moving jaw and source to EPID distance. EPID profile measurements varied by a maximum of 0.3% (1 SD) within the umbra, and wedge factors varied by 0.3% (1 SD) over the seven month interval. The correction function improved agreement between EPID and diode array to within 2% for all wedge angles and energies. Due to the ease of use and reproducibility of the EPID-measured EDW profiles the device is highly suited to regular measurement of EDW.

In this study we investigate the characteristics of a rounded leaf end multileaf collimator (MLC) that is used for delivering intensity-modulated radiotherapy (IMRT) with a Varian linear accelerator. The rounded leaf end MLC design results in an offset between the radiation field edge (the physical leaf position) and the light field (the geometric leaf position). We call this the radiation field offset (RFO). The leaf position is calibrated to the leaf tip at the mid-leaf plane. There is an additional offset between the geometric leaf position and the projected leaf tip position that varies as a function of distance from the collimator central axis due to the MLC geometry. We call this the leaf position offset (LPO). There is a lack of consistency in the interpretation and implementation of the RFO and the LPO in the literature. We investigated the RFO and the LPO on Varian's 600 C/D and 21 EX linear accelerators. We used a combination of film and ion chamber measurements of static, segmental MLC (SMLC) and dynamic MLC (DMLC) fields to quantify the leaf offsets across the range of leaf positions. We were able to improve the dosimetry at large off-axis positions with minor adjustments to the vendor's LPO file. The RFO was determined to within 0.1 mm accuracy at the collimator central axis. The measured RFO value depends on whether the method is based on the radiation field edge position or on an integral dose measurement. The integral dose method results in an RFO that is approximately 0.2 mm greater than the radiation field edge method. The difference is due to the MLC penumbra shape. We propose a methodology for measuring and implementing MLC leaf offsets that is suitable for both SMLC and DMLC IMRT. In addition, we propose some definitions that more clearly describe the MLC leaf position for accurate IMRT dosimetry.