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Automatic segmentation of 3D objects in computed tomography (CT) is challenging. Current methods, based mainly on artificial intelligence (AI) and end-to-end deep learning (DL) networks, are weak in garnering high-level anatomic information, which leads to compromised efficiency and robustness. This can be overcome by incorporating natural intelligence (NI) into AI methods via computational models of human anatomic knowledge.We formulate a hybrid intelligence (HI) approach that integrates the complementary strengths of NI and AI for organ segmentation in CT images and illustrate performance in the application of radiation therapy (RT) planning via multisite clinical evaluation.The system employs five modules: (i) body region recognition, which automatically trims a given image to a precisely defined target body region; (ii) NI-based automatic anatomy recognition object recognition (AAR-R), which performs object recognition in the trimmed image without DL and outputs a localized fuzzy model for each object; (iii) DL-based recognition (DL-R), which refines the coarse recognition results of AAR-R and outputs a stack of 2D bounding boxes (BBs) for each object; (iv) model morphing (MM), which deforms the AAR-R fuzzy model of each object guided by the BBs output by DL-R; and (v) DL-based delineation (DL-D), which employs the object containment information provided by MM to delineate each object. NI from (ii), AI from (i), (iii), and (v), and their combination from (iv) facilitate the HI system.The HI system was tested on 26 organs in neck and thorax body regions on CT images obtained prospectively from 464 patients in a study involving four RT centers. Data sets from one separate independent institution involving 125 patients were employed in training/model building for each of the two body regions, whereas 104 and 110 data sets from the 4 RT centers were utilized for testing on neck and thorax, respectively. In the testing data sets, 83% of the images had limitations such as streak artifacts, poor contrast, shape distortion, pathology, or implants. The contours output by the HI system were compared to contours drawn in clinical practice at the four RT centers by utilizing an independently established ground-truth set of contours as reference. Three sets of measures were employed: accuracy via Dice coefficient (DC) and Hausdorff boundary distance (HD), subjective clinical acceptability via a blinded reader study, and efficiency by measuring human time saved in contouring by the HI system. Overall, the HI system achieved a mean DC of 0.78 and 0.87 and a mean HD of 2.22 and 4.53 mm for neck and thorax, respectively. It significantly outperformed clinical contouring in accuracy and saved overall 70% of human time over clinical contouring time, whereas acceptability scores varied significantly from site to site for both auto-contours and clinically drawn contours.The HI system is observed to behave like an expert human in robustness in the contouring task but vastly more efficiently. It seems to use NI help where image information alone will not suffice to decide, first for the correct localization of the object and then for the precise delineation of the boundary.

To identify sources of systemic errors and estimate their effects, especially the vendor-provided sensitivity SCalibration nanoDot OSLDs were irradiated 50-300cGy under reference conditions. Raw OSLD readings MSOur findings suggest that M

Purpose This manuscript describes the experience of two institutions in commissioning the new HalcyonTM platform. Its purpose is to: (a) validate the pre-defined beam data, (b) compare relevant commissioning data acquired independently by two separate institutions, and (c) report on any significant differences in commissioning between the Halcyon linear accelerator and other medical linear accelerators. Methods Extensive beam measurements, testing of mechanical and imaging systems, including the multi-leaf collimator (MLC), were performed at the two institutions independently. The results were compared with published recommendations as well. When changes in standard practice were necessitated by the design of the new system, the efficacy of such changes was evaluated as compared to published approaches (guidelines or vendor documentation). Results Given the proper choice of detectors, good agreement was found between the respective experimental data and the treatment planning system calculations, and between independent measurements by the two institutions. MLC testing, MV imaging, and mechanical system showed unique characteristics that are different from the traditional C-arm linacs. Although the same methodologies and physics equipment can generally be used for commissioning the Halcyon, some adaptation of previous practices and development of new methods were also necessary. Conclusions We have shown that the vendor pre-loaded data agree well with the independent measured ones during the commission process. This verifies that a data validation instead of a full-data commissioning process may be a more efficient approach for the Halcyon. Measurement results could be used as a reference for future Halcyon users.

Independent verification of the dose per monitor unit (MU) to deliver the prescribed dose to a patient has been a mainstay of radiation oncology quality assurance. We discuss the role of secondary dose/MU calculation programs as part of a comprehensive Quality Assurance (QA) program. This report provides guidelines on calculation-based dose/MU verification for intensity modulated radiation therapy (IMRT) or volumetric modulated arc therapy (VMAT) provided by various modalities. We provide a review of various algorithms for "independent/second check" of monitor unit calculations for IMRT/VMAT. The report makes recommendations on the clinical implementation of secondary dose/MU calculation programs; on commissioning and acceptance of various commercially available secondary dose/MU calculation programs; on benchmark QA and periodic quality assurance; and on clinically reasonable action levels for agreement of secondary dose/MU calculation programs.

Purpose Establish and compare two metrics for monitoring beam energy changes in the Halcyon platform and evaluate the accuracy of these metrics across multiple Halcyon linacs. Method The first energy metric is derived from the diagonal normalized flatness (FDN ), which is defined as the ratio of the average measurements at a fixed off-axis equal distance along the open profiles in two diagonals to the measurement at the central axis with an ionization chamber array (ICA). The second energy metric comes from the area ratio (AR) of the quad wedge (QW) profiles measured with the QW on the top of the ICA. Beam energy is changed by adjusting the magnetron current in a non-clinical Halcyon. With D10cm measured in water at each beam energy, the relationships between FDN or AR energy metrics to D10cm in water is established with linear regression across six energy settings. The coefficients from these regressions allow D10cm (FDN ) calculation from FDN using open profiles and D10cm (QW) calculation from AR using QW profiles. Results Five Halcyon linacs from five institutions were used to evaluate the accuracy of the D10cm (FDN ) and the D10cm (QW) energy metrics by comparing to the D10cm values computed from the treatment planning system (TPS) and D10cm measured in water. For the five linacs, the D10cm (FDN ) reported by the ICA based on FDN from open profiles agreed with that calculated by TPS within -0.29 ± 0.23% and 0.61% maximum discrepancy; the D10cm (QW) reported by the QW profiles agreed with that calculated by TPS within -0.82 ± 1.27% and -2.43% maximum discrepancy. Conclusion The FDN -based energy metric D10cm (FDN ) can be used for acceptance testing of beam energy, and also for the verification of energy in periodic quality assurance (QA) processes.

Simple Summary:& nbsp;This study used GATE and GGEMS simulation toolkits, to estimate dose distribution on Brachytherapy procedures. Specific guidelines were followed as defined by the American Association of Physicists in Medicine (AAPM) as well as by the European SocieTy for Radiotherapy and Oncology (ESTRO). Several types of brachytherapy seeds were modelled and simulated, namely Low-Dose-Rate (LDR), High-Dose-Rate (HDR), and Pulsed-Dose-Rate (PDR). The basic difference between GATE and GGEMS is that GGEMS incorporates GPU capabilities, which makes the use of Monte Carlo (MC) simulations more accessible in clinical routine, by minimizing the computational time to obtain a dose map. During the validation procedure of both codes with protocol data, differences as well as uncertainties were measured within the margins defined by the guidelines. The study concluded that MC simulations may be utilized in clinical practice, to optimize dose distribution in real time, as well as to evaluate therapeutic plans.This study aims to validate GATE and GGEMS simulation toolkits for brachytherapy applications and to provide accurate models for six commercial brachytherapy seeds, which will be freely available for research purposes. The AAPM TG-43 guidelines were used for the validation of two Low Dose Rate (LDR), three High Dose Rate (HDR), and one Pulsed Dose Rate (PDR) brachytherapy seeds. Each seed was represented as a 3D model and then simulated in GATE to produce one single Phase-Space (PHSP) per seed. To test the validity of the simulations'' outcome, referenced data (provided by the TG-43) was compared with GATE results. Next, validation of the GGEMS toolkit was achieved by comparing its outcome with the GATE MC simulations, incorporating clinical data. The simulation outcomes on the radial dose function (RDF), anisotropy function (AF), and dose rate constant (DRC) for the six commercial seeds were compared with TG-43 values. The statistical uncertainty was limited to 1% for RDF, to 6% (maximum) for AF, and to 2.7% (maximum) for the DRC. GGEMS provided a good agreement with GATE when compared in different situations: (a) Homogeneous water sphere, (b) heterogeneous CT phantom, and (c) a realistic clinical case. In addition, GGEMS has the advantage of very fast simulations. For the clinical case, where TG-186 guidelines were considered, GATE required 1 h for the simulation while GGEMS needed 162 s to reach the same statistical uncertainty. This study produced accurate models and simulations of their emitted spectrum of commonly used commercial brachytherapy seeds which are freely available to the scientific community. Furthermore, GGEMS was validated as an MC GPU based tool for brachytherapy. More research is deemed necessary for the expansion of brachytherapy seed modeling.

When interacting with colleagues, patients, and members of the public, medical physicists are frequently asked questions about radiation doses, clinical benefits, and biological risks of medical imaging. This book collects some of the latest data and understanding on these subjects into a single concise and well-organized volume and makes it accessible to a wide variety of potential readers. The editors and many of the chapter authors are from Memorial Sloan Kettering Cancer Center. Despite the variety of authors, the content is well-organized and fits together seamlessly.

Proton therapy is an expanding radiotherapy modality in the United States and worldwide. With the number of proton therapy centers treating patients increasing, so does the need for consistent, high-quality clinical commissioning practices. Clinical commissioning encompasses the entire proton therapy system's multiple components, including the treatment delivery system, the patient positioning system, and the image-guided radiotherapy components. Also included in the commissioning process are the x-ray computed tomography scanner calibration for proton stopping power, the radiotherapy treatment planning system, and corresponding portions of the treatment management system. This commissioning report focuses exclusively on intensity-modulated scanning systems, presenting details of how to perform the commissioning of the proton therapy and ancillary systems, including the required proton beam measurements, treatment planning system dose modeling, and the equipment needed.

Thermoluminescent dosimeters (TLD) and optically stimulated luminescent dosimeters (OSLD) are practical, accurate, and precise tools for point dosimetry in medical physics applications. The charges of Task Group 191 were to detail the methodologies for practical and optimal luminescence dosimetry in a clinical setting. This includes: (a) to review the variety of TLD/OSLD materials available, including features and limitations of each; (b) to outline the optimal steps to achieve accurate and precise dosimetry with luminescent detectors and to evaluate the uncertainty induced when less rigorous procedures are used; (c) to develop consensus guidelines on the optimal use of luminescent dosimeters for clinical practice; and (d) to develop guidelines for special medically relevant uses of TLDs/OSLDs such as mixed photon/neutron field dosimetry, particle beam dosimetry, and skin dosimetry. While this report provides general guidelines for TLD and OSLD processes, the report provides specific details for TLD-100 and nanoDotTM dosimeters because of their prevalence in clinical practice.

Managing radiotherapy patients with implanted cardiac devices (implantable cardiac pacemakers and implantable cardioverter-defibrillators) has been a great practical and procedural challenge in radiation oncology practice. Since the publication of the AAPM TG-34 in 1994, large bodies of literature and case reports have been published about different kinds of radiation effects on modern technology implantable cardiac devices and patient management before, during, and after radiotherapy. This task group report provides the framework that analyzes the potential failure modes of these devices and lays out the methodology for patient management in a comprehensive and concise way, in every step of the entire radiotherapy process.

Objectives: The American Association of Physicists in Medicine (AAPM) Task Groups (TG) 204 and 220 introduced a method to estimate patient dose by introducing the Size-Specific Dose Estimate (SSDE). They provided patient size-specific conversion factors that could be applied to volumetric CT Dose Index CTDIvol to estimate patient dose in terms of SSDE based on either effective diameter (Deff) or water equivalent diameter (Dw). Our study presented an alternative method to manually estimate SSDE for the everyday clinical routine chest CT that can be readily used and does not require sophisticated computer programming. Methods: For 16 adult patients undergoing chest CT, the method employed an average relative electron density (ρelung = 0.3) for the lung tissue and a ρetissue of 1.0 for the other tissues to scale the lateral thickness and compute the effective lateral thickness on the patient’s axial image. The proposed method estimated a “corrected” Deff (Deffcorr) to replace Dw and compared results with TG220 and a second method proposed by Huda et al, for the same set of CT studies. Results: The results showed comparable behavior for all methods. There is overall agreement especially between this study and TG220. Largest differences were +13.3% and+15.9% from TG220 and Huda values, respectively. Patient size correlation showed strong correlation with the TG220 and Huda et al methods. Conclusions: A simple, quick manual method to estimate CT patient radiation dose in terms of SSDE was proposed as an alternative where sophisticated computer programming is not available. It can be readily used during any clinical chest CT scanning. Advances in knowledge: The paper is novel as it presents simple, quick manual method to estimate CT patient radiation dose in chest imaging. The process can be used as alternative in cases no sophisticated computer programming is available.

The purpose of this study is to investigate the dosimetric impact of multi‐leaf collimator (MLC) positioning errors on a Varian Halcyon for both random and systematic errors, and to evaluate the effectiveness of portal dosimetry quality assurance in catching clinically significant changes caused by these errors. Both random and systematic errors were purposely added to 11 physician‐approved head and neck volumetric modulated arc therapy (VMAT) treatment plans, yielding a total of 99 unique plans. Plans were then delivered on a preclinical Varian Halcyon linear accelerator and the fluence was captured by an opposed portal dosimeter. When comparing dose–volume histogram (DVH) values of plans with introduced MLC errors to known good plans, clinically significant changes to target structures quickly emerged for plans with systematic errors, while random errors caused less change. For both error types, the magnitude of clinically significant changes increased as error size increased. Portal dosimetry was able to detect all systematic errors, while random errors of ±5 mm or less were unlikely to be detected. Best detection of clinically significant errors, while minimizing false positives, was achieved by following the recommendations of AAPM TG‐218. Furthermore, high‐ to moderate correlation was found between dose DVH metrics for normal tissues surrounding the target and portal dosimetry pass rates. Therefore, it may be concluded that portal dosimetry on the Halcyon is robust enough to detect errors in MLC positioning before they introduce clinically significant changes to VMAT treatment plans.

Contouring (segmentation) of Organs at Risk (OARs) in medical images is required for accurate radiation therapy (RT) planning. In current clinical practice, OAR contouring is performed with low levels of automation. Although several approaches have been proposed in the literature for improving automation, it is difficult to gain an understanding of how well these methods would perform in a realistic clinical setting. This is chiefly due to three key factors - small number of patient studies used for evaluation, lack of performance evaluation as a function of input image quality, and lack of precise anatomic definitions of OARs. In this paper, extending our previous body-wide Automatic Anatomy Recognition (AAR) framework to RT planning of OARs in the head and neck (H&N) and thoracic body regions, we present a methodology called AAR-RT to overcome some of these hurdles. AAR-RT follows AAR's 3-stage paradigm of model-building, object-recognition, and object-delineation. Model-building: Three key advances were made over AAR. (i) AAR-RT (like AAR) starts off with a computationally precise definition of the two body regions and all of their OARs. Ground truth delineations of OARs are then generated following these definitions strictly. We retrospectively gathered patient data sets and the associated contour data sets that have been created previously in routine clinical RT planning from our Radiation Oncology department and mended the contours to conform to these definitions. We then derived an Object Quality Score (OQS) for each OAR sample and an Image Quality Score (IQS) for each study, both on a 1-to-10 scale, based on quality grades assigned to each OAR sample following 9 key quality criteria. Only studies with high IQS and high OQS for all of their OARs were selected for model building. IQS and OQS were employed for evaluating AAR-RT's performance as a function of image/object quality. (ii) In place of the previous hand-crafted hierarchy for organizing OARs in AAR, we devised a method to find an optimal hierarchy for each body region. Optimality was based on minimizing object recognition error. (iii) In addition to the parent-to-child relationship encoded in the hierarchy in previous AAR, we developed a directed probability graph technique to further improve recognition accuracy by learning and encoding in the model "steady" relationships that may exist among OAR boundaries in the three orthogonal planes. Object-recognition: The two key improvements over the previous approach are (i) use of the optimal hierarchy for actual recognition of OARs in a given image, and (ii) refined recognition by making use of the trained probability graph. Object-delineation: We use a kNN classifier confined to the fuzzy object mask localized by the recognition step and then fit optimally the fuzzy mask to the kNN-derived voxel cluster to bring back shape constraint on the object. We evaluated AAR-RT on 205 thoracic and 298 H&N (total 503) studies, involving both planning and re-planning scans and a total of 21 organs (9 - thorax, 12 - H&N). The studies were gathered from two patient age groups for each gender - 40-59 years and 60-79 years. The number of 3D OAR samples analyzed from the two body regions was 4301. IQS and OQS tended to cluster at the two ends of the score scale. Accordingly, we considered two quality groups for each gender - good and poor. Good quality data sets typically had OQS ≥ 6 and had distortions, artifacts, pathology etc. in not more than 3 slices through the object. The number of model-worthy data sets used for training were 38 for thorax and 36 for H&N, and the remaining 479 studies were used for testing AAR-RT. Accordingly, we created 4 anatomy models, one each for: Thorax male (20 model-worthy data sets), Thorax female (18 model-worthy data sets), H&N male (20 model-worthy data sets), and H&N female (16 model-worthy data sets). On "good" cases, AAR-RT's recognition accuracy was within 2 voxels and delineation boundary distance was within ∼1 voxel. This was similar to the variability observed between two dosimetrists in manually contouring 5-6 OARs in each of 169 studies. On "poor" cases, AAR-RT's errors hovered around 5 voxels for recognition and 2 voxels for boundary distance. The performance was similar on planning and replanning cases, and there was no gender difference in performance. AAR-RT's recognition operation is much more robust than delineation. Understanding object and image quality and how they influence performance is crucial for devising effective object recognition and delineation algorithms. OQS seems to be more important than IQS in determining accuracy. Streak artifacts arising from dental implants and fillings and beam hardening from bone pose the greatest challenge to auto-contouring methods.

Purpose A new dual-layer multi-leaf collimator (MLC) system with several improved characteristics was introduced with the Varian Halcyon™ treatment platform. This study evaluated this new MLC’s impact on head and neck plan quality and delivery efficiency. Methods Nine patients were retrospectively studied with Institutional Review Board (IRB) approval. To compare plan quality between the Halcyon dual-layer MLC and Truebeam® MLC, all patients were replanned with the same prescription and target coverage following the institutional clinical protocol for both platforms and using both intensity modulated radiation therapy (IMRT) or volumetrically modulated arc therapy (VMAT) techniques. Organs-at-risk (OAR) dose-volume histogram (DVH) statistics were compared along with total plan monitor units (MU). To evaluate delivery efficiency, actual beam-on time for five patients’ plans were recorded and compared. To evaluate the impact of MLC performance parameters on plan quality, virtual MLC models were generated by matching Truebeam MLC’s parameters to those of the Halcyon dual-layer MLC both individually and combined. OAR doses were then compared between these virtual MLCs, the Truebeam MLC, and the actual Halcyon MLC. Results Overall the Halcyon dual-layer MLC provided similar plan quality compared to Truebeam MLC for VMAT plans, and improved sparing for majority of the OARs when using IMRT. Paired comparison showed median dose differences in mean doses to the parotids, cochlea, esophagus, and larynx ranged from -0.83 Gy to 0.37 Gy for VMAT, and from -4.79 Gy to -0.04 Gy for IMRT, with negative values indicating improved performance by Halcyon. Despite a slight increase in plan MU, the Halcyon reduced the total beam-on time by 42.8 ± 8.5%. Virtual MLC simulations demonstrated that matching MLC transmission accounted for nearly half of the total dose difference between Halcyon and Truebeam IMRT plans. Conclusion When compared to the Truebeam, the Halcyon’s dual-layer MLC achieved similar plan quality using VMAT, and improved OAR sparing using IMRT, while providing nearly twice as fast treatment delivery. Reduction in MLC transmission is the dominating factor contributing to dosimetric differences in OAR sparing.

The American Association of Physicists in Medicine (AAPM) is a nonprofit professional society whose primary purposes are to advance the science, education and professional practice of medical physics. The AAPM has more than 8,000 members and is the principal organization of medical physicists in the United States. The AAPM will periodically define new practice guidelines for medical physics practice to help advance the science of medical physics and to improve the quality of service to patients throughout the United States. Existing medical physics practice guidelines will be reviewed for the purpose of revision or renewal, as appropriate, on their fifth anniversary or sooner. Each medical physics practice guideline represents a policy statement by the AAPM, has undergone a thorough consensus process in which it has been subjected to extensive review, and requires the approval of the Professional Council. The medical physics practice guidelines recognize that the safe and effective use of diagnostic and therapeutic radiology requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published practice guidelines and technical standards by those entities not providing these services is not authorized. The following terms are used in the AAPM practice guidelines:• Must and Must Not: Used to indicate that adherence to the recommendation is considered necessary to conform to this practice guideline.• Should and Should Not: Used to indicate a prudent practice to which exceptions may occasionally be made in appropriate circumstances.

Purpose Patient-specific IMRT QA measurements are important components of processes designed to identify discrepancies between calculated and delivered radiation doses. Discrepancy tolerance limits are neither well defined nor consistently applied across centers. The AAPM TG-218 report provides a comprehensive review aimed at improving the understanding and consistency of these processes as well as recommendations for methodologies and tolerance limits in patient-specific IMRT QA. Methods The performance of the dose difference/distance-to-agreement (DTA) and γ dose distribution comparison metrics are investigated. Measurement methods are reviewed and followed by a discussion of the pros and cons of each. Methodologies for absolute dose verification are discussed and new IMRT QA verification tools are presented. Literature on the expected or achievable agreement between measurements and calculations for different types of planning and delivery systems are reviewed and analyzed. Tests of vendor implementations of the γ verification algorithm employing benchmark cases are presented. Results Operational shortcomings that can reduce the γ tool accuracy and subsequent effectiveness for IMRT QA are described. Practical considerations including spatial resolution, normalization, dose threshold, and data interpretation are discussed. Published data on IMRT QA and the clinical experience of the group members are used to develop guidelines and recommendations on tolerance and action limits for IMRT QA. Steps to check failed IMRT QA plans are outlined. Conclusion Recommendations on delivery methods, data interpretation, dose normalization, the use of γ analysis routines and choice of tolerance limits for IMRT QA are made with focus on detecting differences between calculated and measured doses via the use of robust analysis methods and an in-depth understanding of IMRT verification metrics. The recommendations are intended to improve the IMRT QA process and establish consistent, and comparable IMRT QA criteria among institutions.

Purpose: To calculate the output factor (OPF) of any irregularly shaped electron beam at extended SSD. Methods: Circular cutouts were prepared from 2.0 cm diameter to the maximum possible size for 15 × 15 applicator cone. In addition, two irregular cutouts were prepared. For each cutout, percentage depth dose (PDD) at the standard SSD and doses at different SSD values were measured using 6, 9, 12, and 16 MeV electron beam energies on a Varian 2100C LINAC and the distance at which the central axis electron fluence becomes independent of cutout size was determined. The measurements were repeated with an ELEKTA Synergy LINAC using 14 × 14 applicator cone and electron beam energies of 6, 9, 12, and 15 MeV. The PDD measurements were performed using a scanning system and two diodes—one for the signal and the other a stationary reference outside the tank. The doses of the circular cutouts at different SSDs were measured using PTW 0.125 cm3 Semiflex ion-chamber and EDR2 films. The electron fluence was measured using EDR2 films. Results: For each circular cutout, the lateral buildup ratio (LBR) was calculated from the measured PDD curve using the open applicator cone as the reference field. The effective SSD (SSDeff) of each circular cutout was calculated from the measured doses at different SSD values. Using the LBR value and the radius of the circular cutout, the corresponding lateral spread parameter [σR (z)] was calculated. Taking the cutout size dependence of σR (z) into account, the PDD curves of the irregularly shaped cutouts at the standard SSD were calculated. Using the calculated PDD curve of the irregularly shaped cutout along with the LBR and SSDeff values of the circular cutouts, the output factor of the irregularly shaped cutout at extended SSD was calculated. Finally, both the calculated PDD curves and output factor values were compared with the measured values. Conclusions: The improved LBR method has been generalized to calculate the output factor of electron therapy at extended SSD. The percentage difference between the calculated and the measured output factors of irregularly shaped cutouts in a clinical useful SSD region was within 2%. Similar results were obtained for all available electron energies of both Varian 2100C and ELEKTA Synergy machines.

Patient-specific IMRT QA measurements are important components of processes designed to identify discrepancies between calculated and delivered radiation doses. Discrepancy tolerance limits are neither well defined nor consistently applied across centers. The AAPM TG-218 report provides a comprehensive review aimed at improving the understanding and consistency of these processes as well as recommendations for methodologies and tolerance limits in patient-specific IMRT QA.The performance of the dose difference/distance-to-agreement (DTA) and γ dose distribution comparison metrics are investigated. Measurement methods are reviewed and followed by a discussion of the pros and cons of each. Methodologies for absolute dose verification are discussed and new IMRT QA verification tools are presented. Literature on the expected or achievable agreement between measurements and calculations for different types of planning and delivery systems are reviewed and analyzed. Tests of vendor implementations of the γ verification algorithm employing benchmark cases are presented.Operational shortcomings that can reduce the γ tool accuracy and subsequent effectiveness for IMRT QA are described. Practical considerations including spatial resolution, normalization, dose threshold, and data interpretation are discussed. Published data on IMRT QA and the clinical experience of the group members are used to develop guidelines and recommendations on tolerance and action limits for IMRT QA. Steps to check failed IMRT QA plans are outlined.Recommendations on delivery methods, data interpretation, dose normalization, the use of γ analysis routines and choice of tolerance limits for IMRT QA are made with focus on detecting differences between calculated and measured doses via the use of robust analysis methods and an in-depth understanding of IMRT verification metrics. The recommendations are intended to improve the IMRT QA process and establish consistent, and comparable IMRT QA criteria among institutions.

Introduction Radiolabeled RGD peptides that specifically target integrin α ν β 3 have great potential in early tumor detection through noninvasive monitoring of tumor angiogenesis. Based on previous findings of our group on radiopeptides containing positively charged aminoacids, we developed a new cyclic cRGDfK derivative, c(RGDfK)-(Orn) 3 -CGG. This new peptide availing the polar linker (Orn) 3 and the 99m Tc-chelating moiety CGG (Cys-Gly-Gly) is appropriately designed for 99m Tc-labeling, as well as consequent conjugation onto nanoparticles. Methods A tumor imaging agent, c(RGDfK)-(Orn) 3 -[CGG- 99m Tc], is evaluated with regard to its radiochemical, radiobiological and imaging characteristics. Results The complex c(RGDfK)-(Orn) 3 -[CGG- 99m Tc] was obtained in high radiochemical yield (> 98%) and was stable in vitro and ex vivo . It presented identical to the respective, fully analytically characterized 185/187 Re complex retention time in RP-HPLC. In contrary to other RGD derivatives, we showed that the new radiopeptide exhibits kidney uptake and urine excretion due to the ornithine linker. High tumor uptake (3.87 ± 0.48% ID/g at 60 min p.i.) was observed and was maintained relatively high even at 24 h p.i. (1.83 ± 0.05 % ID/g), thus providing well-defined scintigraphic imaging. Accumulation in other organs was negligible. Blocking experiments indicated target specificity for integrin receptors in U87MG glioblastoma cells. Conclusion Due to its relatively high tumor uptake, renal elimination and negligible abdominal localization, the new 99m Tc-RGD peptide is considered promising in the field of imaging α ν β 3 -positive tumors. However, the preparation of multifunctional SPECT/MRI contrast agents (RGD-conjugated nanoparticles) for dual modality imaging of integrin expressing tumors should be further investigated.

This is the 4th edition of a book on the physics of radiation therapy that covers basic principles and new technologies in the field and how these apply to the clinical practice. It is a well-referenced and easy to read text. The text is designed as an alternative or supplement to other well-established books in the field of radiotherapy physics. In addition, the authors have made an extra effort to provide a concise summary of the objectives for every chapter. They even set aside a chapter on patient safety and quality improvement. This article is protected by copyright. All rights reserved.

Purpose To present our novel technique for brain metastases (low-dose whole brain radiation therapy [WBRT] with simultaneous integrated boost (SIB) and focal, frameless stereotactic intensity modulated radiotherapy [IMRT]) in the context of patterns of failure, dosimetry, acute toxicity, and overall survival for 3 different radiation techniques. Methods and Materials We retrospectively reviewed 92 patients undergoing radiation for brain metastases via the following: (1) "prophylactic" WBRT to a low dose (median 30 Gy) with an SIB to the gross tumor volume plus 2-3 mm margin (median dose 45 Gy) in 10-15 fractions; (2) focal, frameless image-guided stereotactic IMRT (S-IMRT) in 5 fractions to tumor only (median 30 Gy); or (3) conventional (c)WBRT using 2 lateral opposed beams in 10-15 fractions (30-37.5 Gy). The primary endpoints were local (LBC), distant (DBC), and total brain control (TBC) for each of the 3 types of brain radiation. Survival, toxicity, and dosimetry were reported as secondary endpoints. Results LBC was achieved in 72%, 78%, and 56% for SIB, S-IMRT, and cWBRT, respectively. DBC (ie, no new brain metastases) was observed in 92%, 67%, and 81% for SIB, S-IMRT, and cWBRT, respectively. TBC (LBC + DBC) was 72%, 67%, and 56% for SIB, S-IMRT, and cWBRT, respectively. No statistical difference in overall survival was observed (P = .067), and only 1 patient experienced biopsy proven radionecrosis. Conclusions TBC after low-dose WBRT with SIB was acceptable and at least comparable to S-IMRT and cWBRT. SIB seems to be a safe and effective treatment strategy for patients with brain metastases and may efficiently combine the benefits of cWBRT and stereotactic radiosurgery.

AAPM Task Group 119 has produced quantitative confidence limits as baseline expectation values for IMRT commissioning. A set of test cases was developed to assess the overall accuracy of planning and delivery of IMRT treatments. Each test uses contours of targets and avoidance structures drawn within rectangular phantoms. These tests were planned, delivered, measured, and analyzed by nine facilities using a variety of IMRT planning and delivery systems. Each facility had passed the Radiological Physics Center credentialing tests for IMRT. The agreement between the planned and measured doses was determined using ion chamber dosimetry in high and low dose regions, film dosimetry on coronal planes in the phantom with all fields delivered, and planar dosimetry for each field measured perpendicular to the central axis. The planar dose distributions were assessed using gamma criteria of 3%/3 mm. The mean values and standard deviations were used to develop confidence limits for the test results using the concept confidence limit = /mean/ + 1.96sigma. Other facilities can use the test protocol and results as a basis for comparison to this group. Locally derived confidence limits that substantially exceed these baseline values may indicate the need for improved IMRT commissioning.

The goal of Task Group 25 (TG-25) of the Radiation Therapy Committee of the American Association of.Physicists in Medicine (AAPM) was to provide a methodology and set of procedures for a medical physicist performing clinical electron beam dosimetry in the nominal energy range of 5-25 MeV. Specifically, the task group recommended procedures for acquiring basic information required for acceptance testing and treatment planning of new accelerators with therapeutic electron beams. Since the publication of the TG-25 report, significant advances have taken place in the field of electron beam dosimetry, the most significant being that primary standards laboratories around the world have shifted from calibration standards based on exposure or air kerma to standards based on absorbed dose to water. The AAPM has published a new calibration protocol, TG-51, for the calibration of high-energy photon and electron beams. The formalism and dosimetry procedures recommended in this protocol are based on the absorbed dose to water calibration coefficient of an ionization chamber at 60Co energy, N60Co(D,w), together with the theoretical beam quality conversion coefficient k(Q) for the determination of absorbed dose to water in high-energy photon and electron beams. Task Group 70 was charged to reassess and update the recommendations in TG-25 to bring them into alignment with report TG-51 and to recommend new methodologies and procedures that would allow the practicing medical physicist to initiate and continue a high quality program in clinical electron beam dosimetry. This TG-70 report is a supplement to the TG-25 report and enhances the TG-25 report by including new topics and topics that were not covered in depth in the TG-25 report. These topics include procedures for obtaining data to commission a treatment planning computer, determining dose in irregularly shaped electron fields, and commissioning of sophisticated special procedures using high-energy electron beams. The use of radiochromic film for electrons is addressed, and radiographic film that is no longer available has been replaced by film that is available. Realistic stopping-power data are incorporated when appropriate along with enhanced tables of electron fluence data. A larger list of clinical applications of electron beams is included in the full TG-70 report available at http://www.aapm.org/pubs/reports. Descriptions of the techniques in the clinical sections are not exhaustive but do describe key elements of the procedures and how to initiate these programs in the clinic. There have been no major changes since the TG-25 report relating to flatness and symmetry, surface dose, use of thermoluminescent dosimeters or diodes, virtual source position designation, air gap corrections, oblique incidence, or corrections for inhomogeneities. Thus these topics are not addressed in the TG-70 report.

Asymmetric collimators or heavily blocked fields with physical wedges are still encountered in daily practice. In such cases, a reliable dosimetry system is necessary to perform manual dose and monitor unit calculations in order to independently verify the calculations of commercial treatment planning systems. In this work, primary wedged off-axis ratios (POAR(w)s) that account for changes in the beam intensity along both the wedge gradient and perpendicular directions of the photon field, when asymmetric collimators are applied, were measured experimentally at specific depths. The measurements were made in phantom with an ion chamber along the wedge gradient and the perpendicular directions under 'good geometry' conditions. A consistent formalism was presented that could easily be implemented in the clinical environment as an independent verification of the calculations by a treatment planning system. The accuracy of the method was found to be dependent on the specific wedge used, off-axis distance and depth in the phantom. In our study, the accuracy was within 2% in most cases for both energies. We concluded that the primary wedged off-axis ratios when used along with open symmetric field dosimetric parameters could provide adequate accuracy for manual monitor unit calculations.

We present results of investigations of the clinical significance of variations in the value of the 4-mm-collimator output factor, OF4/18. Changes in treatment volume, dose-volume histograms (DVHs), and isodose distributions were studied, by varying OF4/18 up to 20. The variations were performed on a sample of clinical patient treatment plans for which the 4 mm collimator was used. Although smaller effects are noted for the prescription isodose line, greater dosimetric changes occur for higher dose regions within the target. 2003 American College of Medical Physics.

To calculate the output factor (OPF) of any irregularly shaped electron beam at extended SSD.Circular cutouts were prepared from 2.0 cm diameter to the maximum possible size for 15 × 15 applicator cone. In addition, two irregular cutouts were prepared. For each cutout, percentage depth dose (PDD) at the standard SSD and doses at different SSD values were measured using 6, 9, 12, and 16 MeV electron beam energies on a Varian 2100C LINAC and the distance at which the central axis electron fluence becomes independent of cutout size was determined. The measurements were repeated with an ELEKTA Synergy LINAC using 14 × 14 applicator cone and electron beam energies of 6, 9, 12, and 15 MeV. The PDD measurements were performed using a scanning system and two diodes-one for the signal and the other a stationary reference outside the tank. The doses of the circular cutouts at different SSDs were measured using PTW 0.125 cm(3) Semiflex ion-chamber and EDR2 films. The electron fluence was measured using EDR2 films.For each circular cutout, the lateral buildup ratio (LBR) was calculated from the measured PDD curve using the open applicator cone as the reference field. The effective SSD (SSDeff) of each circular cutout was calculated from the measured doses at different SSD values. Using the LBR value and the radius of the circular cutout, the corresponding lateral spread parameter [σR(z)] was calculated. Taking the cutout size dependence of σR(z) into account, the PDD curves of the irregularly shaped cutouts at the standard SSD were calculated. Using the calculated PDD curve of the irregularly shaped cutout along with the LBR and SSDeff values of the circular cutouts, the output factor of the irregularly shaped cutout at extended SSD was calculated. Finally, both the calculated PDD curves and output factor values were compared with the measured values.The improved LBR method has been generalized to calculate the output factor of electron therapy at extended SSD. The percentage difference between the calculated and the measured output factors of irregularly shaped cutouts in a clinical useful SSD region was within 2%. Similar results were obtained for all available electron energies of both Varian 2100C and ELEKTA Synergy machines.

Hypothesis Dual-modality imaging agents, such as radiolabeled iron oxide nanoparticles (IO-NPs), are promising candidates for cancer diagnosis and therapy. We developed and evaluated aminosilane coated Fe 3 O 4 (10 ± 2 nm) as a tumor imaging agent in nuclear medicine through 3-aminopropyltriethoxysilane (APTES) functionalization. We evaluated this multimeric system of targeted 99m Tc-labeled nanoparticles (NPs) conjugated with a new RGD derivate (cRGDfK-Orn 3 -CGG), characterized as NPs-RGD as a potential thermal therapy delivery vehicle. Experiments Transmission Electron Microscopy (TEM) and spectroscopy techniques were used to characterize the IO-NPs indicating their functionalization with peptides. Radiolabeled IO-NPs (targeted, non-targeted) were evaluated with regard to their radiochemical, radiobiological and imaging characteristics. In vivo studies were performed in normal and α ν β 3 -positive tumor (U87MG glioblastoma) bearing mice. We also demonstrated that this system could reach ablative temperatures in vivo . Findings Both radiolabeled IO-NPs were obtained in high radiochemical yield (>98%) and proved stable in vitro . The in vivo studies for both IO-NPs have shown significant liver and spleen uptake at all examined time points in normal and U87MG glioblastoma tumor-bearing mice, due to their colloidal nature. We have confirmed through in vivo biodistribution studies that the non-targeted 99m Tc-NPs poorly internalized in the tumor, while the targeted 99m Tc-NPs-RGD, present 9-fold higher tumor accumulation at 1 h p.i. Accumulation of both IO-NPs in other organs was negligible. Blocking experiments indicated target specificity for integrin receptors in U87MG glioblastoma cells. The preliminary in vivo study of applied alternating magnetic field showed that the induced hyperthermia is feasible due to the aid of IO-NPs.

Purpose Patient-specific IMRT QA measurement is a process designed to identify discrepancies between calculated and delivered doses. Error tolerance limits are not well-defined or consistently applied across centers. To improve the understanding and consistency of this process, the AAPM TG-218 report provides recommendations for tolerance limits and methodologies in patient-specific IMRT QA. Methods The performance of the dose difference/distance-to-agreement (DTA) and gamma verification metrics are investigated. Measurement methods are reviewed and followed by a discussion of the pros and cons of each. Methodologies for absolute dose verification are discussed and new IMRT QA verification tools are presented. Literature on the expected or achievable agreement between measurements and calculations for different types of planning and delivery systems was reviewed and analyzed. Different vendor implementations of verification algorithms were tested using benchmark cases. Results Operational shortcomings that can reduce the tool effectiveness and accuracy for IMRT QA are described. Practical considerations including spatial resolution, normalization, dose threshold, and data interpretation are discussed. Published data on IMRT QA and the clinical experience of the group members were used to develop guidelines and recommendations on tolerance and action limits for IMRT QA. Conclusion Recommendations on delivery methods, data interpretation, normalization, the use of gamma analysis routines and choice of tolerance limits for IMRT QA are made. The focus is on detecting differences between calculated and measured doses using robust analysis methods and an in-depth understanding of IMRT verification metrics. The recommendations are intended to improve the IMRT QA process and establish consistent and comparable criteria among institutions for IMRT QA.

This article reviews Neutron physics for nuclear reactors, unpublished writings by Enrico Fermi by S. Esposito, O. Pisanti , Hackensack, NJ 2010. (Hardcover) 704 pp. Price: $111.00. 978–981–4392–22–4.

AAPM Task Group 119 has produced quantitative confidence limits as baseline expectation values for IMRT commissioning. A set of test cases was developed to assess the overall accuracy of planning and delivery of IMRT treatments. Each test uses contours of targets and avoidance structures drawn within rectangular phantoms. These tests were planned, delivered, measured, and analyzed by nine facilities using a variety of IMRT planning and delivery systems. Each facility had passed the Radiological Physics Center credentialing tests for IMRT. The agreement between the planned and measured doses was determined using ion chamber dosimetry in high and low dose regions, film dosimetry on coronal planes in the phantom with all fields delivered, and planar dosimetry for each field measured perpendicular to the central axis. The planar dose distributions were assessed using gamma criteria of 3%/3 mm. The mean values and standard deviations were used to develop confidence limits for the test results using the concept confidence limit = /mean/ + 1.96sigma. Other facilities can use the test protocol and results as a basis for comparison to this group. Locally derived confidence limits that substantially exceed these baseline values may indicate the need for improved IMRT commissioning.

The purpose of our study was to develop a user-independent computerized tool for the automated segmentation and quantitative assessment of in vivo-acquired digital subtraction angiography (DSA) images. Vessel enhancement was accomplished based on the concept of image structural tensor. The developed software was tested on a series of DSA images acquired from one animal and two human angiogenesis models. Its performance was evaluated against manually segmented images. A receiver's operating characteristic curve was obtained for every image with regard to the different percentages of the image histogram. The area under the mean curve was 0.89 for the experimental angiogenesis model and 0.76 and 0.86 for the two clinical angiogenesis models. The coordinates of the operating point were 8.3% false positive rate and 92.8% true positive rate for the experimental model. Correspondingly for clinical angiogenesis models, the coordinates were 8.6% false positive rate and 89.2% true positive rate and 9.8% false positive rate and 93.8% true positive rate, respectively. A new user-friendly tool for the analysis of vascular networks in DSA images was developed that can be easily used in either experimental or clinical studies. Its main characteristics are robustness and fast and automatic execution. J Digit Imaging

Purpose: To date, there isn’t formal approach for flattening filter-free (FFF) linac vault shielding evaluation, thus, we propose an extension to NCRP#151 to accommodate the recent large number of FFF linac installations.Methods and Materials: We extended the approach in NCRP#151 to design two Truebeam vaults in our new cancer center for hypofractionated treatments. Monte Carlo calculations have characterized primary, scattered, leakage and neutron radiations from FFF-modes. These calculations have shown that: a) FFF primary beam is softer on the central-axis compared to flattening filtered (FF), b) the lateral dose profile is peaked on the central axis and less integral target current is required to generate the same tumor dose with the FF beam. Thus, the TVLs for FFF mode are smaller than those of the FF mode and the scatter functions of the FF mode (NCRP#151) may not be appropriate for FFF-mode, c) the neutron source strength and fluence for 18X-FFF is smaller than 18X-FF, but it is not of a concern here, no 18X-FFF-mode is available on the linac under investigation. Results: These barrier thickness are smaller (12% reduction on the average) than those computed for conventional FF mode with same realistic primary workload since, the primary TVLs used here are smaller and the WL is smaller than the conventional (almost half reduced), keeping the TADR in tolerance. Conclusions: A comprehensive method for shielding barrier calculations based on dedicated data for FFF-mode linacs is highly desired. Meanwhile, we provide an extension to NCRP#151 to accommodate the shielding design of such installations. It is also shown that if a vault is already designed for IMRT/VMAT and SABR hypofractionated treatments with FFF-mode linac, the vault can also be used for a FFF mode linac replacement, leaving some leeway for slightly higher workload on the FFF linac.

Purpose: To calculate the output factor (OPF) of any irregularly shaped electron beam at extended SSD Methods: Using Cerrobend block, circular cutouts with diameter ranging from 2.0cm to the maximum possible size for 15×15 applicator of Varian 2100C and 14×14 applicator of ELEKTA Synergy LINACs were prepared. In addition, two irregular cutouts were made. For each cutout, percentage depth dose (PDD) at standard SSD and point doses at different SSD were measured in water using Scanditronix diodes and PTW 0.125 cm3 ion-chambers, respectively. In addition, the distance at which electron fluence along the central axis becomes independent of cutout size was determined using EDR2 films. On each LINAC, electron beam energies of 6, 9, 12, and 15/20 MeV were used. Results: Using the open applicator as the reference field, the lateral buildup ratio (LBR) for each circular cutout as a function of depth was calculated. From the LBR value and radius of the cutout, the corresponding lateral spread parameter (σR(z)) was determined. Taking the cutout side dependence of σR(z)) into account, PDD of the irregular cutouts at the standard SSD were calculated. From the point dose measurement at different SSDs, the effective SSD of each cutout was calculated. Taking the calculated PDD of the irregular cutout and effective SSD (SSDeff) of the circular cutout into account, OPFs of the irregular cutout at extended SSD values were calculated. Finally, the calculated output factors were compared with the measured values. Conclusion: In this research, the improved LBR method has been generalized to calculate output factor of irregular cutouts at extended SSD. In a clinically useful region, the percentage difference between the measured and the calculated output factors of the irregular cutouts was within 2%. Similar results were obtained for all available electron energies of both Varian 2100C and ELEKTA Synergy machines.

Purpose: Contemporary ultrasound (US) systems have gained the confidence of medical community among other imaging modalities such as CT and MRI. However, US images carry a granular pattern, so called speckle, which constitutes a major image quality degradation factor. A new Markov random fields (MRF) model is proposed for the detection and removal of speckle noise in ultrasound images. Methods: 20 ultrasound images were analyzed. The MRF model design comprised two distinct sources of information: (a) the likelihood function that characterizes the contrast likelihood at a site, and (b) the a priori knowledge derived from the wavelet transform of the US image. The likelihood probability density function (pdf) is approximated by the combination of the intensity distribution and the wavelet transform modules (WTM) values of individual regions in the image. The a priori knowledge or contextual information is described by the positions and the angle vector of the WTM values. The combination of these sources builds the MRF model and provides an accurate edge map that is employed in the speckle reduction procedure that follows. Results: The proposed MRF model addresses the speckle problem that dominates US imaging. Speckle noise is reduced significantly while all edges remained intact. It exhibited similar results in terms of speckle index (SI), signal‐to‐mean‐square‐error ratio (S/mse) and edge preservation index s compared with the commercially available denoising packet introduced by General Electric termed as Speckle Reduction Imaging (SRI). Conclusion: Experimental results have demonstrated that an efficient speckle suppression algorithm can improve the overall image quality, which in turns could improve the decision‐making procedure in ultrasound imaging.