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The planning target volume (PTV) depends on the method of radiotherapy guidance. This study aimed to measure the systemic and random errors using an online marker matching and offline bone structure matching to estimate PTV marker , PTV bone , or PTV laser for treatment verification and radiotherapy guidance, especially in centers lacking radiotherapy fiducial markers (FMs). Thirty patients with localized prostate cancer who were treated with FM-based dose escalation protocol were included. The initial set-up was done with laser marks and daily megavoltage images were acquired. The systematic and random errors were calculated. PTV marker , defined as the sum of maximum marker migration, and PTV calculated to compensate for the difference between online marker matching and offline analysis of marker matching. PTV marker was added to estimated PTV from online marker matching to obtain PTV laser . PTV skin marks migration , was calculated and deducted from PTV laser to acquire PTV bone . The mean maximum marker migration was 2 ± 1.2 mm. The resultant values of PTV marker were 2.7 ± 0.6 mm, 3.3 ± 1.1 mm, and 4.4 ± 2.2 mm, in the lateral (lat.), longitudinal (long) & vertical (vert.) directions, respectively, whereas values of PTV laser were 13 ± 0.6 mm, 17.7 ± 1.1 mm, and 15.8 ± 2.2 mm, and PTV bone were 5.9 ± 0.6 mm, 8.6 ± 1.1 mm, 7.2 ± 2.2 mm, respectively, in the lat., long., and vert. directions. Our results show that PTV needed with FM-based image guidance ranged between 3 and 4 mm in the three cardinal directions, was 10 mm smaller than that required with laser skin marks guidance, and narrower by 5 mm compared to that obtained by offline bone structure image matching.

Purpose: It has been suggested that the Real-time Position Management (RPM) marker block should be placed directly on the breast or sternum to verify deep inspiration breath hold (DIBH) level for breast radiotherapy. We explore three potential issues with this practice: (a) surface dose effect of placing the marker block in the primary beam; (b) effect of marker block tilt on the accuracy of the RPM system; and (c) correlation between marker block positions on the patient surface and internal chest wall position., Methods: (a) The surface dose under the two-, four-, and six-dot marker blocks was measured at incident angles of 0° and 30°; (b) the motion amplitude detected when using the two- and six-dot marker blocks was recorded for block tilts from 0° to 60° about the RPM camera line of sight; (c) the correlation between median displacement of the chest wall and median displacement of the surface contour between breath holds was investigated for superior, middle, and inferior block positions using contours extracted from portal images of eight left-sided breast cancer patients., Results: (a) The marker blocks increased the surface dose for a 6 MV direct field by 48.2-52.2% of D max ; (b) at lateral tilts greater than 10°, the two-dot marker block overestimated the motion amplitude; however, the six-dot marker block amplitude remained accurate up to 60°; (c) the whole, superior, and middle surface positions were strongly correlated with chest wall displacement (R 2 = 0.83; R 2 = 0.90; R 2 = 0.83), whereas the inferior position was moderately correlated (R 2 = 0.36)., Conclusions: The RPM marker block can be placed on the breast for DIBH treatments; however, caution should be used regarding surface dose effects. The two-dot marker block should not be used for block tilts beyond 20°. Marker block placement at a middle or superior position on the breast results in the strongest correlation with chest wall position., (© 2016 American Association of Physicists in Medicine.)

Treatment of superficial tumors that move with respiration (e.g. lung tumors) using spot-scanning proton therapy (SSPT) is a high-priority research area. The recently developed real-time image-gated proton beam therapy (RGPT) system has proven to be useful for treating moving tumors deep inside the liver. However, when treating superficial tumors, the proton's range is small and so is the sizes of range straggling, making the Bragg-peaks extremely sharp compared to those located in deep-seated tumors. The extreme sharpness of Bragg-peaks is not always beneficial because it necessitates a large number of energy layers to make a spread-out Bragg-peak, resulting in long treatment times, and is vulnerable to motion-induced dose deterioration. We have investigated a method to treat superficial moving tumors in the lung by the development of an applicator compatible with the RGPT system. A mini-ridge filter (MRF) was developed to broaden the pristine Bragg-peak and, accordingly, decrease the number of required energy layers to obtain homogeneous irradiation. The applicator position was designed so that the fiducial marker's trajectory can be monitored by fluoroscopy during proton beam-delivery. The treatment plans for three lung cancer patients were made using the applicator, and four-dimensional (4D) dose calculations for the RGPT were performed using patient respiratory motion data. The effect of the MRF on the dose distributions and treatment time was evaluated. With the MRF, the number of energy layers was decreased to less than half of that needed without it, whereas the target volume coverage values (D99%, D95%, D50%, D2%) changed by less than 1% of the prescribed dose. Almost no dose distortion was observed after the 4D dose calculation, whereas the treatment time decreased by 26%-37%. Therefore, we conclude that the developed applicator compatible with RGPT is useful to solve the issue in the treatment of superficial moving tumors with SSPT.

Purpose: To assess the utility of 10 s and 20 s modeling periods, rather than the 40 s currently used, in the clinical construction of practical correlation models (CMs) in dynamic tumor tracking irradiation using the Vero4DRT., Methods: The CMs with five independent parameters (CM parameters) were analyzed retrospectively for 10 consecutive lung cancer patients. CM remodeling was performed two or three times per treatment session. Three different CMs trained over modeling periods of 10, 20, and 40 s were built from a single, original CM log file. The predicted target positions were calculated from the CM parameters and the vertical displacement of infrared markers on the abdomen (PIR) during the modeling. We assessed how the CM parameters obtained over modeling periods of T s (T = 10, 20, and 40 s) were robust to changes in respiratory patterns after several minutes. The mimic-predicted target positions after several minutes were computed based on the previous CM parameters and PIR during the next modeling. The 95th percentiles of the differences between mimic-predicted and detected target positions over 40 s (E95robust,T: T = 10, 20, and 40 s) were then calculated., Results: Strong correlations greater than 0.92 were observed between the E95robust,20 and E95robust,40 values. Meanwhile, irregular respiratory patterns with inconsistent amplitudes of motion created differences between the E95robust,10 and E95robust,40 values of ≥10 mm., Conclusions: The accuracies of CMs derived using 20 s were almost identical to those obtained over 40 s, and superior to those obtained over 10 s., (Copyright © 2015 Associazione Italiana di Fisica Medica. Published by Elsevier Ltd. All rights reserved.)

Purpose: Recent knowledge on the effects of cardiac toxicity warrants greater precision for left-sided breast radiotherapy. Different breath-hold (BH) maneuvers (abdominal vs thoracic breathing) can lead to chest wall positional variations, even though the patient's tidal volume remains consistent. This study aims to investigate the feasibility of using optical tracking for real-time quality control of active breathing coordinator (ABC)-assisted deep inspiration BH (DIBH)., Methods: An in-house optical tracking system (OTS) was used to monitor ABC-assisted DIBH. The stability and localization accuracy of the OTS were assessed with a ball-bearing phantom. Seven patients with left-sided breast cancer were included. A free-breathing (FB) computed tomography (CT) scan and an ABC-assisted BH CT scan were acquired for each patient. The OTS tracked an infrared (IR) marker affixed over the patient's xiphoid process to measure the positional variation of each individual BH. Using the BH within which the CT scan was performed as the reference, the authors quantified intra- and interfraction BH variations for each patient. To estimate the dosimetric impact of BH variations, the authors studied the positional correlation between the marker and the left breast using the FB CT and BH CT scans. The positional variations of 860 BHs as measured by the OTS were retrospectively incorporated into the original treatment plans to evaluate their dosimetric impact on breast and cardiac organs [heart and left anterior descending (LAD) artery]., Results: The stability and localization accuracy of the OTS was within 0.2 mm along each direction. The mean intrafraction variation among treatment BHs was less than 2.8 mm in all directions. Up to 12.6 mm anteroposterior undershoot, where the patient's chest wall displacement of a BH is less than that of a reference BH, was observed with averages of 4.4, 3.6, and 0.1 mm in the anteroposterior, craniocaudal, and mediolateral directions, respectively. A high positional correlation between the marker and the breast was found in the anteroposterior and craniocaudal directions with respective Pearson correlation values of 0.95 and 0.93, but no mediolateral correlation was found. Dosimetric impact of BH variations on breast coverage was negligible. However, the mean heart dose, mean LAD dose, and max LAD dose were estimated to increase from 1.4/7.4/18.6 Gy (planned) to 2.1/15.7/31.0 Gy (delivered), respectively., Conclusions: In ABC-assisted DIBH, large positional variation can occur in some patients, due to their different BH maneuvers. The authors' study has shown that OTS can be a valuable tool for real-time quality control of ABC-assisted DIBH.

Hadrontherapy is an innovative radiation therapy modality for which one of the main key advantages is the target conformality allowed by the physical properties of ion species. However, in order to maximise the exploitation of its potentialities, online monitoring is required in order to assert the treatment quality, namely monitoring devices relying on the detection of secondary radiations. Herein is presented a method based on Monte Carlo simulations to optimise a multi-slit collimated camera employing time-of-flight selection of prompt-gamma rays to be used in a clinical scenario. In addition, an analytical tool is developed based on the Monte Carlo data to predict the expected precision for a given geometrical configuration. Such a method follows the clinical workflow requirements to simultaneously have a solution that is relatively accurate and fast. Two different camera designs are proposed, considering different endpoints based on the trade-off between camera detection efficiency and spatial resolution to be used in a proton therapy treatment with active dose delivery and assuming a homogeneous target.

Purpose of Review: Focal therapy is gaining interest and this organ-preserving treatment is heading towards becoming an alternative for the conventional surgery and radiation. The purpose of this review is to determine what evidence is required to make focal therapy a viable option for treatment of localized prostate cancer., Recent Findings: There is still a lack of high-level evidence for the different focal treatment modalities. The early-stage focal therapy trials are conducted including a various selection of patients and different pretreatment assessment and follow-up, resulting in incomparable data. Recent literature shows it is paramount to extend the amount of biopsies and to alter the way of taking the biopsies with the template-assisted or image-guided approach. To date, multiparametric MRI is the most effective imaging technique in selecting patients for focal therapy., Summary: Focal therapy trials are at the early stage of clinical development, with the majority still being phase I studies. To make focal therapy an accepted segment of standard therapy, it needs to proceed toward phase II and III trials. These trials should be conducted with an effective trial design, which will lead to more comparable oncological, functional and quality of life outcomes. Furthermore, it is essential to improve the localization of tumor foci in order to increase the accuracy of spatial targeting of cancer.

The aim of this study was to design a cylindrical stepwedge phantom and an appropriate treatment procedure, based on which parameters of tomotherapy machine and generated beam of radiation will be defined. The accuracy of parameter determination, which can be defined with the aid of the measurement system, was also evaluated. The cylindrical phantom that we developed and manufactured (stepwedge phantom) consists of four cylinders with different diameters made of polycaprolactam-PA-6, i.e. material with high mechanical strength, low water absorption (making measurements repeatable) and a density comparable to that of human soft tissues. The appropriate treatment procedure is carried out in a dynamic mode, which is focused on specific properties of the tomotherapy machine. It means that a phantom situated on the couch moves to the inside of the rotating linear accelerator. A total of 18 procedures were implemented in order to calculate the following parameters: couch velocity, dose rate value at a depth, Dose Ratio coefficients, dose variation (so-called Dose Flatness) coefficients, and the time of gantry rotation. Reference intervals for these parameters were determined to be as follows: for the couch velocity: ±1.2%, the average dose rate measured at depth: ±1.8%, the calculated values of the coefficients Dose Ratio: ±0.5% and Dose Flatness: (0.53-0.65)%, the time of gantry rotation: ±3%. The final results showed that during a single irradiation procedure, which lasts 5 min, the cylindrical stepwedge phantom allows to precisely determine the values of the above-mentioned parameters. Its use in the daily dosimetric measurements can ensure better control of the work of the tomotherapy machine., (Copyright © 2011 Associazione Italiana di Fisica Medica. Published by Elsevier Ltd. All rights reserved.)

Purpose: With the increasing use of external 3D optical tracking cameras to guide modern radiation therapy procedures, it has become vitally important to have an accurate camera to linear accelerator (LINAC) reference frame calibration. To eliminate errors present in current calibration procedures based on the manual hand alignment of a device using the light field crosshairs and in room guidance lasers, a semiautomated quantitative calibration approach requiring only use of an electronic portal imaging device (EPID) was developed., Methods: A phantom comprised of seven highly IR reflective plastic BBs was placed on the LINAC treatment couch and imaged with both a 3D stereoscopic IR imager and the on board megavoltage (MV) EPID imager. Having knowledge of the optically determined 3D positions and projected EPID images of the BBs, simulated annealing was used to optimize the location of the BBs in the LINAC frame using four different optimization functions. Singular value decomposition was then used to calculate the transformation matrix between the camera and LINAC reference frames. Results were then compared to a traditional camera calibration method for overall accuracy., Results: Using modeled data, the simulated annealing process was able to determine the actual locations of the BBs with a RMSE of 0.23 mm. Using projection images acquired with an MV imager, the process was able to determine locations of BBs within .26 mm. The results depend on the choice of optimization function., Conclusions: Results show that the method can be used to provide highly accurate spatial registration between an external 3D imaging reference frame and the LINAC frame. The experimental MV imager results, while not as precise as the simulated results, exceed 1 mm accuracy and the current accepted AAPM TG-142 standard of ≤2 mm positioning accuracy.

We have previously developed a tumour tracking system, which adapts the aperture of a Siemens 160 MLC to electromagnetically monitored target motion. In this study, we exploit the use of a novel linac-mounted kilovoltage x-ray imaging system for MLC tracking. The unique in-line geometry of the imaging system allows the detection of target motion perpendicular to the treatment beam (i.e. the directions usually featuring steep dose gradients). We utilized the imaging system either alone or in combination with an external surrogate monitoring system. We equipped a Siemens ARTISTE linac with two flat panel detectors, one directly underneath the linac head for motion monitoring and the other underneath the patient couch for geometric tracking accuracy assessments. A programmable phantom with an embedded metal marker reproduced three patient breathing traces. For MLC tracking based on x-ray imaging alone, marker position was detected at a frame rate of 7.1 Hz. For the combined external and internal motion monitoring system, a total of only 85 x-ray images were acquired prior to or in between the delivery of ten segments of an IMRT beam. External motion was monitored with a potentiometer. A correlation model between external and internal motion was established. The real-time component of the MLC tracking procedure then relied solely on the correlation model estimations of internal motion based on the external signal. Geometric tracking accuracies were 0.6 mm (1.1 mm) and 1.8 mm (1.6 mm) in directions perpendicular and parallel to the leaf travel direction for the x-ray-only (the combined external and internal) motion monitoring system in spite of a total system latency of ~0.62 s (~0.51 s). Dosimetric accuracy for a highly modulated IMRT beam--assessed through radiographic film dosimetry--improved substantially when tracking was applied, but depended strongly on the respective geometric tracking accuracy. In conclusion, we have for the first time integrated MLC tracking with x-ray imaging in the in-line geometry and demonstrated highly accurate respiratory motion tracking.

Increased accuracy in radiation delivery to a patient provided by scanning particle beams leads to high demands on quality assurance (QA). To meet the requirements, an extensive quality assurance programme has been implemented at the Heidelberg Ion Beam Therapy Center. Currently, high-resolution radiographic films are used for beam spot position measurements and homogeneity measurements for scanned fields. However, given that using this film type is time and equipment demanding, considerations have been made to replace the radiographic films in QA by another appropriate device. In this study, the suitability of the flat-panel detector RID 256 L based on amorphous silicon was investigated as an alternative method. The currently used radiographic films were taken as a reference. Investigations were carried out for proton and carbon ion beams. The detectors were irradiated simultaneously to allow for a direct comparison. The beam parameters (e.g. energy, focus, position) currently used in the daily QA procedures were applied. Evaluation of the measurements was performed using newly implemented automatic routines. The results for the flat-panel detector were compared to the standard radiographic films. Additionally, a field with intentionally decreased homogeneity was applied to test the detector's sensitivities toward possible incorrect scan parameters. For the beam position analyses, the flat-panel detector results showed good agreement with radiographic films. For both detector types, deviations between measured and planned spot distances were found to be below 1% (1 mm). In homogeneously irradiated fields, the flat-panel detector showed a better dose response homogeneity than the currently used radiographic film. Furthermore, the flat-panel detector is sensitive to field irregularities. The flat-panel detector was found to be an adequate replacement for the radiographic film in QA measurements. In addition, it saves time and equipment because no post-exposure treatment and no developer and darkroom facilities are needed.

Purpose: The study aims at investigating how far image quality (MTF and NPS) differs in between CT, CBCT and DVT units and how far the geometrical 3 D accuracy and the HU calibration differ in respect to surgical or radio therapeutic planning., Materials and Methods: X ray image stacks have been made using a new designed test device which contains structures for measuring MTF, NPS, the 3 D accuracy and the Hounsfield calibration (jaw or skull program). The image stacks of the transversal images were analyzed with a dedicated computer program., Results: The MTF values are correlated with the physical resolution (CT and DVT) and are influenced by the used Kernel (CT). The NPS values are limited to an intra system comparison due to the insufficient HU accuracy. The 3 D accuracy is comparable in between the system types., Conclusions: The values of image quality are not yet correlated with dose values: NPS. Investigations to an appropriate dosimetry are ongoing to establish the ratio between dose and image quality (ALARA principle). No fundamental difference between the systems can be stated in respect radio therapeutic planning: improper HU calibration accuracy in CBCT and DVT units. The geometric 3 D accuracy of high performance DVT systems is greater than that of CT Systems., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: To provide quantitative information on the image registration differences from multiple systems for image-guided radiotherapy (IGRT) credentialing and margin reduction in clinical trials., Methods and Materials: Images and IGRT shift results from three different treatment systems (Tomotherapy Hi-Art, Elekta Synergy, Varian Trilogy) have been sent from various institutions to the Image-Guided Therapy QA Center (ITC) for evaluation for the Radiation Therapy Oncology Group (RTOG) trials. Nine patient datasets (five head-and-neck and four prostate) were included in the comparison, with each patient having 1-4 daily individual IGRT studies. In all cases, daily shifts were re-calculated by re-registration of the planning CT with the daily IGRT data using three independent software systems (MIMvista, FocalSim, VelocityAI). Automatic fusion was used in all calculations. The results were compared with those submitted from institutions. Similar regions of interest (ROIs) and same initial positions were used in registrations for inter-system comparison. Different slice spacings for CBCT sampling and different ROIs for registration were used in some cases to observe the variation of registration due to these factors., Results: For the 54 comparisons with head-and-neck datasets, the absolute values of differences of the registration results between different systems were 2.6±2.1 mm (mean±SD; range 0.1-8.6 mm, left-right [LR]), 1.7±1.3 mm (0.0-4.9 mm, superior-inferior [SI]), and 1.8±1.1 mm (0.1-4.0 mm, anterior-posterior [AP]). For the 66 comparisons in prostate cases, the differences were 1.1±1.0 mm (0.0-4.6 mm, LR), 2.1±1.7 mm (0.0-6.6 mm, SI), and 2.0±1.8 mm (0.1-6.9 mm, AP). The differences caused by the slice spacing variation were relatively small, and the different ROI selections in FocalSim and MIMvista also had limited impact., Conclusion: The extent of differences was reported when different systems were used for image registration. Careful examination and quality assurance of the image registration process are crucial before considering margin reduction using IGRT in clinical trials., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Purpose: Optical image-guided systems (e.g., AlignRT, frameless SonArray, ExacTrac) have been used with advantages of avoiding excessive radiation exposure and real-time patient monitoring. Although these systems showed proven accuracy, they need to modify a full facemask for patients with H&N cancer and brain tumor. We developed an optical-based guidance system to manage interfractional and intrafractional setup errors by tracking external markers behind a full facemask., Methods: Infra-red (IR) reflecting markers were attached on the face of a head phantom and then the phantom was immobilized by a full face thermoplastic mask. A stereo camera system consisting of two CCD cameras was mounted on the inferior wall of treatment room. The stereo camera system was calibrated to reconstruct 3D coordinates of multiple markers with respect to the isocenter using the direct linear transform (DLT) algorithm. The real-time position of the phantom was acquired, through the stereo camera system, by detecting the IR markers behind the full facemask. The detection errors with respect to the reference positions of planning CT images were calculated in six degrees of freedom (6-DOF) by a rigid-body registration technique., Results: The calibration accuracy of the system was in submillimeter (0.33 mm +/- 0.27 mm), which was comparable to others. The mean distance between each of marker positions of optical images and planning CT images was 0.50 mm +/- 0.67 mm. The maximum deviations of 6-DOF registration were less than 1 mm and 1 degrees for the couch translation and rotation, respectively., Conclusions: The developed system showed the accuracy and consistency comparable to the commercial optical guided systems, while allowing us to simultaneously immobilize patients with a full face thermoplastic mask.

Purpose: In-treatment fiducial tracking has recently received attention as a method for improving treatment accuracy, dose conformity, and sparing of healthy tissue. 3-D fiducial localization in arc-radiotherapy remains challenging due to the motion of targets and the complexity of arc deliveries. We propose a novel statistical method for estimating 3-D fiducial motion using limited 2-D megavoltage (MV) projections., Methods: 3-D fiducial motion was estimated by a maximum a posteriori (MAP) approach to integrating information of fiducial projections with prior knowledge of target motion. To obtain the imaging geometries, short sequences of MV projections were selected in which fiducials were continuously visible. The MAP algorithm estimated the 3-D motion by maximizing the probability of displacement of fiducials in the sequences. Prior knowledge of target motion from a large statistical sample was built into the model to enhance the accuracy of estimation. In the case that a motion prior was unavailable, the algorithm can be simplified to the maximum likelihood (ML) approach. To compare tracking performance, a multiprojection geometric method was also presented by extending the typical two-project ion geometric estimation approach. The algorithms were evaluated using clinical prostate motion traces, and the performance was measured in quality indices and statistical evaluation., Results: The results showed that the MAP method significantly outperforms the geometric method in all measures. In our simulations, the MAP method achieved an accuracy of less than 1 mm RMS error using only five continuous projections, whereas the geometric method required 15 projections to achieve a similar result., Conclusions: The approach presented can accurately estimate tumor motion using a limited number of continuous projections. The MAP motion estimation is superior to both the ML and geometric estimation methods.

Aims and Methods: Delivery of high radiation doses while simultaneously sparing organs at risk requires advanced imaging for target volume definition, highly conformal dose distributions of intensity modulated radiotherapy (IMRT), and narrow planning target volume (PTV) margins. Three-dimensional image-guided radiotherapy (IGRT) with cone-beam computer tomography (CBCT), which results in more precise target localization, is quickly replacing two-dimensional (2D) IGRT. An overview on the clinical applications of kilovoltage gantry-mounted CBCT systems with emphasis on the most frequently targeted body sites (prostate, lung, head and neck) is provided based on a review of the relevant literature. Alternative imaging methods and their advantages/disadvantages are discussed., Results: IGRT with soft tissue detection improves set-up accuracy and is currently replacing 2D verification and frame-based stereotactic treatments; safety margins are significantly reduced by this IGRT technology. In addition, systematic changes of tumor volume and shape and of the normal tissue can be monitored allowing for adaptation of radiotherapy. IGRT in combination with conformal treatment planning allows for hypofractionated dose escalation, which results in improved rates of local tumor control with low rates of toxicity., Conclusion: CBCT allows for daily pretreatment position verification and online correction of set-up errors which improves the precision of patient repositioning with the possibility of shrinking safety margins, sparing organs at risk, and escalating radiation doses. A trend for better clinical outcome can be observed.

Purpose: Helical tomotherapy is a complex delivery technique, integrating CT image guidance and intensity modulated radiotherapy in a single system. The integration of the CT detector ring on the gantry not only allows patient position verification but is also often used to perform various QA procedures. This convenience lacks the rigor of a machine-independent QA process., Methods: In this article, a Si strip detector, known as the Dose Magnifying Glass (DMG), was used to perform machine-independent QA measurements of the multileaf collimator alignment, leaf open time threshold, and leaf fluence output factor (LFOF)., Results: The DMG measurements showed good agreements with EDR2 film for the MLC alignment test while the CT detector agrees well with DMG measurements for leaf open time threshold and LFOF measurements. The leaf open time threshold was found to be approximately 20 ms. The LFOF measured with the DMG agreed within error with the CT detector measured LFOF., Conclusions: The DMG with its 0.2 mm spatial resolution coupled to TERA ASIC allowed real-time high temporal resolution measurements of the tomotherapy leaf movement. In conclusion, DMG was shown to be a suitable tool for machine-independent QA of a tomotherapy unit.

The development and acceptance of new image-guided radiotherapy (IGRT) technologies have often been initiated with the treatment of prostate cancer. Imaging and tracking of the prostate during a treatment course has yielded a great deal of information about the motion and deformation of the gland during radiotherapy, and has led the way toward the development of more accurate treatment methods including dose-guided and adaptive strategies. Now, there is long-term experience with the use of fiducials and electromagnetic implantable beacons that give high-quality tracking of prostate motion. From analyzing these extensive tracking data sets, a clear understanding of prostate motion and its dosimetric significance has developed. This knowledge can now be used to define current expectations and guidelines for clinical care. The random nature of prostate motion requires daily localization if treatment is to be delivered with small margins. Interfraction motion can have a significant impact on prostate gland dosimetry, and even more of an impact on the seminal vesicles and possibly intraprostatic tumor areas. The dosimetric impact on normal structures (bladder/rectum) is less clear, and there are significant individual variations. Interfraction and intrafraction rotations and deformations of the prostate are routinely detected. The dosimetric impact of these motions of the prostate gland is minimal when daily localization is used, even when the treatment margins are small. However, deformations of the seminal vesicles, rectum and bladder are much more pronounced. The dosimetric impact of deformation of the rectum and bladder is highly variable among patients, and the clinical consequences remain unclear. Daily volumetric imaging and dosimetry may become quite important for these volumes. Due to the random nature of motion/deformation during prostate radiotherapy, adaptive radiotherapy ideally would be performed as an on-line process. On-line adaptive radiotherapy requires robust deformable registration and replanning programs. These are beginning to emerge in useful clinic applications., (Copyright © 2011 S. Karger AG, Basel.)

There is a broad push in the cancer imaging community to eventually replace linear tumor measurements with three-dimensional evaluation of tumor volume. To evaluate the potential accuracy of volume measurement in tumors by CT, a gelatin phantom consisting of 55 polymethylmethacrylate (PMMA) spheres spanning diameters from 1.6 mm to 25.4 mm was fabricated and scanned using thin slice (0.625 mm) CT (GE LightSpeed 16). Nine different reconstruction combinations of field of view dimension (FOV = 20, 30, 40 cm) and CT kernel (standard, lung, bone) were analyzed. Contiguous thin-slice images were averaged to produce CT images with greater thicknesses (1.25, 2.50, 5.0 mm). Simple grayscale thresholding techniques were used to segment the PMMA spheres from the gelatin background, where a total of 1800 spherical volumes were evaluated across the permutations studied. The geometric simplicity of the phantom established upper limits on measurement accuracy. In general, smaller slice thickness and larger sphere diameters produced more accurate volume assessment than larger slice thickness and smaller sphere diameter. The measured volumes were smaller than the actual volumes by a common factor depending on slice thickness; overall, 0.625 mm slices produced on average 18%, 1.25 mm slices produced 22%, 2.5 mm CT slices produced 29%, and 5.0 mm slices produced 39% underestimates of volume (mm3). Field of view did not have a significant effect on volume accuracy. Reconstruction algorithm significantly affected volume accuracy (p < 0.0001), with the lung kernel having the smallest error, followed by the bone and standard kernels. The results of this investigation provide guidance for CT protocol development and may guide the development of more advanced techniques to promote quantitatively accurate CT volumetric analysis of tumors.

Purpose: This work presents the introduction of a quality assurance program for the On-Board Imager (OBI, Varian) kVCBCT system, together with the results of 1 year monthly testing., Materials and Methods: Firstly the geometric precision and stability of the equipment and of the associated software were evaluated using the Marker phantom. The coincidence of the accelerator isocenter and the imager isocenter was verified as well as the accuracy of the registration of kVCBCT with reference CT images. Then, the kVCBCT image quality was evaluated using the Catphan 504 phantom and ArtiScan software (Aquilab) for both full-fan (FF) and half-fan (HF) imaging modes., Results: The kVCBCT isocenter and image registration with correction of the table position were found to be within a tolerance of 2.0mm. Concerning the kVCBCT image quality, image noise and uniformity, the Hounsfield units (HU) stability and linearity, geometric distorsion and high contrast resolution were all found to be within the manufacturer's recommendations for both FF and HF modes. However, the low contrast resolution for the HF mode did not meet the manufacturer's specifications., Conclusion: The quality assurance tests introduced have defined the initial system characteristics and their evolution during a period of 1 year, demonstrating the stability of the OBI.

Small animal research allows detailed study of biological processes, disease progression and response to therapy with the potential to provide a natural bridge to the clinical environment. The small animal radiation research platform (SARRP) is a portable system for precision irradiation with beam sizes down to approximately 0.5 mm and optimally planned radiation with on-board cone-beam CT (CBCT) guidance. This paper focuses on the geometric calibration of the system for high-precision irradiation. A novel technique for the calibration of the treatment beam is presented, which employs an x-ray camera whose precise positioning need not be known. Using the camera system we acquired a digitally reconstructed 3D 'star shot' for gantry calibration and then developed a technique to align each beam to a common isocenter with the robotic animal positioning stages. The calibration incorporates localization by cone-beam CT guidance. Uncorrected offsets of the beams with respect to the calibration origin ranged from 0.4 mm to 5.2 mm. With corrections, these alignment errors can be reduced to the sub-millimeter range. The calibration technique was used to deliver a stereotactic-like arc treatment to a phantom constructed with EBT Gafchromic films. All beams were shown to intersect at a common isocenter with a measured beam (FWHM) of approximately 1.07 mm using the 0.5 mm collimated beam. The desired positioning accuracy of the SARRP is 0.25 mm and the results indicate an accuracy of 0.2 mm. To fully realize the radiation localization capabilities of the SARRP, precise geometric calibration is required, as with any such system. The x-ray camera-based technique presented here provides a straightforward and semi-automatic method for system calibration.

The Dose Verification System (DVS) is the first implantable radiation dosimeter designed for in situ measurement of dose delivered to the tissue being irradiated. The success of radiation therapy is predicated on maximizing tumor cell death and minimizing normal tissue toxicity. Tumor control increases with the delivery of appropriate radiation doses to the target area. These doses have been determined from in vitro and animal studies, which generated specific dose-response data. However, there has not been a practical system available to ensure that the appropriate dose was being delivered in situ to monitor the daily patient dose during radiation therapy. Studies have shown that dose variations can occur. Recently completed pivotal clinical studies using the DVS found a greater than 7% (positive or negative) change in cumulative dose in seven out of 36 (19%) breast cancer patients; and six out of 29 (21%) and eight out of 19 (42%) patients during large-field and boost irradiation of the prostate. The device is an important step to enable physicians to expand the concept of individualization of therapy.

The authors have developed an automatic quality assurance method based on computerized tomography (CT) data for physically manufactured proton range compensators. Eight range compensators used for proton therapy at their institution were scanned using CT and their depth distributions were compared with data provided by a proton treatment planning system (TPS). The depth difference (DD), distance to agreement (DTA), and a composite analysis (CA) indicating regions that passed either of the tests were used for depth verification. When the tolerance limits were set at 3 mm for DD and 1 mm for DTA, the average percentages of points exceeding the acceptance criteria for DD, DTA, and CA for the eight compensators were 9.0%, 5.3% and 3.2%, respectively. In general, the percentages of points exceeding the acceptance criteria were much higher in DD than in DTA analysis and mismatch of depth was greater in regions with high depth gradients. This is considered to arise mainly because of systematic errors such as the physical size of the drill, slight bending or slipping of the drill bit near high gradient regions, the limit of CT resolution, and the uncertainty in CT number. When the tolerance limit of DTA was increased from 1 to 2 mm, the average percentage of points exceeding the acceptance criteria for DTA was reduced from 5.3% to 0.9%. Their results show that depth comparison of proton range compensators based on CT images can provide more systematic data than does the current method, in which a representative group of drill points is measured manually.

Helical tomotherapy is a technique for delivering intensity modulated radiation therapy treatments using a continuously rotating linac. In this approach, fan beams exiting the linac are dynamically modulated in synchrony with the motion of the gantry and couch. Helical IMRT deliveries have been applied to treating surface lesions, and the purpose of this study was to evaluate the accuracy of dose calculated by the TomoTherapy HiArt treatment planning system for superficial planning target volumes (PTVs). TomoTherapy treatment plans were developed for three superficial PTVs (2-, 4-, and 6-cm deep radially by 90 degrees azimuthally by 4-cm longitudinally) contoured on a 27-cm diameter cylindrical white opaque, high-impact polystyrene phantom. The phantom included removable transverse and sagittal film cassettes that contained bare Kodak EDR2 films cut such that their edges matched the phantom surface (+/-0.05 cm). The phantom was aligned to the machine's isocenter (+/-0.05 cm) and was irradiated according to the treatment plans. Films were scanned with a Vidar film digitizer, and optical densities were converted to dose using a calibration determined from a 6 MV perpendicular film exposure. This perpendicular calibration required that axial film doses (parallel irradiation) be scaled by 1.02 so that mid-arc depth doses matched those measured in the sagittal plane (perpendicular irradiation). All film readings were scaled by 0.935 to correct for over-response due to phantom Cerenkov light. Measured dose distributions were registered to calculated ones and compared. Calculated doses overpredicted measured doses by as much as 9.5% of the prescribed dose at depths less than 1 cm. At depths greater than 1 cm, calculated dose distributions showed agreement to measurement within 5% in the high-dose region and within 0.2 cm distance-to-agreement in the dose falloff regions. In the low-dose region posterior to the PTVs (<10% of the prescribed dose), the dose algorithm underpredicted the dose by 1%-2% of the prescribed dose. Clinically, it is recommended that 1 cm of bolus be used on the surface to ensure that cancerous tissues less than 1 cm depth are not underdosed.

An original questionnaire was used to investigate the available types of reference and treatment image verification equipment and specific practices related to image analysis. A section on treatment site-specific imaging was included. The questionnaire was distributed to all radiation oncology facilities in Australia and New Zealand. A response rate of 87% (40/46) was achieved. Most facilities (90%) in Australia and New Zealand reported the availability of electronic portal imaging devices. Use of computer software to assist with image interpretation was indicated by 92% of centres. Frequency of image acquisition and tolerance levels used for radical treatment sites were variable, but palliative treatment site protocols were more consistent between treatment facilities. In conclusion, departments should strive to use evidence-based protocols and guidelines to ensure acceptable accuracy in treatment delivery.

The National Cancer Institute-sponsored Advanced Technology Quality Assurance (QA) Consortium, which consisted of the Image-Guided Therapy QA Center, Radiation Therapy Oncology Group, Radiological Physics Center, Quality Assurance Review Center, and Resource Center for Emerging Technologies, has pioneered the development of an infrastructure and QA method for advanced technology clinical trials that requires volumetric digital data submission of a protocol patient's treatment plan and verification data. In particular, the Image-Guided Therapy QA Center has nearly 15 years experience in facilitating QA review for Radiation Therapy Oncology Group advanced technology clinical trials. This QA process includes (1) a data integrity review for completeness of protocol required elements, the format of data, and possible data corruption, and recalculation of dose-volume histograms; (2) a review of compliance with target volume and organ-at-risk contours by study chairs; and (3) a review of dose prescription and dose heterogeneity compliance by the Radiation Therapy Oncology Group Headquarters Dosimetry Group or the Radiological Physics Center dosimetrists (for brachytherapy protocols). This report reviews the lessons learned and the QA challenges presented by the use of advanced treatment modalities in clinical trials requiring volumetric digital data submission.

The CyberKnife is a complex, emerging technology that is a significant departure from current stereotactic radiosurgery and external beam radiotherapy technologies. In its clinical application and quality assurance (QA) approach, the CyberKnife is currently situated somewhere in between stereotactic radiosurgery and radiotherapy. The clinical QA for this image-guided treatment delivery system typically follows the vendor's guidance, mainly because of the current lack of vendor-independent QA recommendations. The problem has been exacerbated because very little published data are available for QA for the CyberKnife system, especially for QA of the interaction between individual system components. The tools and techniques for QA of the CyberKnife are under development and will continue to improve with longer clinical experience of the users. The technology itself continues to evolve, forcing continuous changes and adaptation of QA. To aid in the process of developing comprehensive guidance on CyberKnife QA, a database of errors based on users reporting incidents and corrective actions would be desirable. The goal of this work was to discuss the status of QA guidelines in the clinical implementation of the CyberKnife system. This investigation was done from the perspective of an active clinical and research site using the CyberKnife.

Radiotherapy relies on images to plan, guide, and assess treatment. Image registration, fusion, and segmentation are integral to these processes; specifically for aiding anatomic delineation, assessing organ motion, and aligning targets with treatment beams in image-guided radiation therapy (IGRT). Future developments in image registration will also improve estimations of the actual dose delivered and quantitative assessment in patient follow-up exams. This article summarizes common and emerging technologies and reviews the role of image registration, fusion, and segmentation in radiotherapy processes. The current quality assurance practices are summarized, and implications for clinical procedures are discussed.

In-room radiography is not a new concept for image-guided radiation therapy. Rapid advances in technology, however, have made this positioning method convenient, and thus radiograph-based positioning has propagated widely. The paradigms for quality assurance of radiograph-based positioning include imager performance, systems integration, infrastructure, procedure documentation and testing, and support for positioning strategy implementation.

Recent advances in radiation delivery techniques, such as intensity-modulated radiation therapy, provide unprecedented ability to exquisitely control three-dimensional dose distribution. Development of on-board imaging and other image-guidance methods significantly improved our ability to better target a radiation beam to the tumor volume. However, in reality, accurate definition of the location and boundary of the tumor target is still problematic. Biologic and physiologic imaging promises to solve the problem in a fundamental way and has a more and more important role in patient staging, treatment planning, and therapeutic assessment in radiation therapy clinics. The last decade witnessed a dramatic increase in the use of positron emission tomography and computed tomography in radiotherapy practice. To ensure safe and effective use of nuclide imaging, a rigorous quality assurance (QA) protocol of the imaging tools and integration of the imaging data must be in place. The application of nuclide imaging in radiation oncology occurs at different levels of sophistication. Quantitative use of the imaging data in treatment planning through image registration and standardized uptake value calculation is often involved. Thus, QA should not be limited to the performance of the scanner, but should also include the process of implementing image data in treatment planning, such as data transfer, image registration, and quantitation of data for delineation of tumors and sensitive structures. This presentation discusses various aspects of nuclide imaging as applied to radiotherapy and describes the QA procedures necessary for the success of biologic image-guided radiation therapy.

The success of stereotactic radiosurgery has stimulated significant interest in the application of such an approach for the treatment of extracranial tumors. The potential benefits of reduced healthcare costs and improved patient outcomes that could be realized in a high-precision, hypofractionated treatment paradigm are numerous. Image-guidance technologies are eliminating the historic requirement for rigid head fixation and will also accelerate the clinical implementation of the approach in extracranial sites. An essential prerequisite of "frameless" stereotactic systems is that they provide localization accuracy consistent with the safe delivery of a therapeutic radiation dose given in one or few fractions. In this report, we reviewed the technologies for frameless localization of cranial and extracranial targets with emphasis on the quality assurance aspects.

State-of-the-art radiotherapy treatment delivery has changed dramatically during the past decade, moving from manual individual field setup and treatment to automated computer-controlled delivery of complex treatments, including intensity-modulated radiotherapy and other similarly complex delivery strategies. However, the quality assurance methods typically used to ensure treatment is performed precisely and correctly have not evolved in a similarly dramatic way. This paper reviews the old manual treatment process and use of record-and-verify systems, and describes differences with modern computer-controlled treatment delivery. The process and technology used for computer-controlled treatment delivery are analyzed in terms of potential (and actual) problems, as well as relevant published guidance on quality assurance. The potential for improved quality assurance for computer-controlled delivery is discussed.

Compared with conventional three-dimensional (3D) conformal radiation therapy and intensity-modulated radiation therapy treatments, quality assurance (QA) for motion-adaptive radiation therapy involves various challenges because of the added temporal dimension. Here we discuss those challenges for three specific techniques related to motion-adaptive therapy: namely respiratory gating, breath holding, and four-dimensional computed tomography. Similar to the introduction of any other new technologies in clinical practice, typical QA measures should be taken for these techniques also, including initial testing of equipment and clinical procedures, as well as frequent QA examinations during the early stage of implementation. Here, rather than covering every QA aspect in depth, we focus on some major QA challenges. The biggest QA challenge for gating and breath holding is how to ensure treatment accuracy when internal target position is predicted using external surrogates. Recommended QA measures for each component of treatment, including simulation, planning, patient positioning, and treatment delivery and verification, are discussed. For four-dimensional computed tomography, some major QA challenges have also been discussed.

We reviewed the quality assurance procedures that have been used to test fan- and cone-beam megavoltage-based in-room imaging systems. Phantom-based tests have been used to establish the geometric accuracy and precision of megavoltage-based systems. However, the clinical implementation of any system is accompanied by challenges that are best tested in a clinical setting using clinical images. To objectively judge and monitor image quality, a set of standard tests and phantoms can be used. The image noise and spatial and contrast resolution have been assessed using standard computed tomography phantoms. The dose to the patient resulting from the imaging procedure can be determined using calculations or measurements. The off-line use of patient images is of interest for the evaluation of dosimetric changes throughout the treatment course. The accuracy of the dosimetric calculations based on the megavoltage images has been tested for the fan- and cone-beam systems. Some of the described tests are typically performed before the clinical implementation of the imaging system; others are suited to monitor the system's performances.

Quality assurance has long been implemented in radiation treatment as systematic actions necessary to provide adequate confidence that the radiation oncology service will satisfy the given requirements for quality care. The existing reports from the American Association of Physicists in Medicine Task Groups 40 and 53 have provided highly detailed QA guidelines for conventional radiotherapy and treatment planning. However, advanced treatment processes recently developed with emerging high technology have introduced new QA requirements that have not been addressed previously in the conventional QA program. Therefore, it is necessary to expand the existing QA guidelines to also include new considerations. Image-guided adaptive radiation therapy (IGART) is a closed-loop treatment process that is designed to include the individual treatment information, such as patient-specific anatomic variation and delivered dose assessed during the therapy course in treatment evaluation and planning optimization. Clinical implementation of IGART requires high levels of automation in image acquisition, registration, segmentation, treatment dose construction, and adaptive planning optimization, which brings new challenges to the conventional QA program. In this article, clinical QA procedures for IGART are outlined. The discussion focuses on the dynamic or four-dimensional aspects of the IGART process, avoiding overlap with conventional QA guidelines.

The introduction of volumetric X-ray image-guided radiotherapy systems allows improved management of geometric variations in patient setup and internal organ motion. As these systems become a routine clinical modality, we propose a daily quality assurance (QA) program for cone-beam computed tomography (CBCT) integrated with a linear accelerator. The image-guided system used in this work combines a linear accelerator with conventional X-ray tube and an amorphous silicon flat-panel detector mounted orthogonally from the accelerator central beam axis. This article focuses on daily QA protocols germane to geometric accuracy of the CBCT systems and proposes tolerance levels on the basis of more than 3 years of experience with seven CBCT systems used in our clinic. Monthly geometric calibration tests demonstrate the long-term stability of the flex movements, which are reproducible within +/-0.5 mm (95% confidence interval). The daily QA procedure demonstrates that, for rigid phantoms, the accuracy of the image-guided process can be within 1 mm on average, with a 99% confidence interval of +/-2 mm.

The traditional prescriptive quality assurance (QA) programs that attempt to ensure the safety and reliability of traditional external beam radiation therapy are limited in their applicability to such advanced radiation therapy techniques as three-dimensional conformal radiation therapy, intensity-modulated radiation therapy, inverse treatment planning, stereotactic radiosurgery/radiotherapy, and image-guided radiation therapy. The conventional QA paradigm, illustrated by the American Association of Physicists in Medicine Radiation Therapy Committee Task Group 40 (TG-40) report, consists of developing a consensus menu of tests and device performance specifications from a generic process model that is assumed to apply to all clinical applications of the device. The complexity, variation in practice patterns, and level of automation of high-technology radiotherapy renders this "one-size-fits-all" prescriptive QA paradigm ineffective or cost prohibitive if the high-probability error pathways of all possible clinical applications of the device are to be covered. The current approaches to developing comprehensive prescriptive QA protocols can be prohibitively time consuming and cost ineffective and may sometimes fail to adequately safeguard patients. It therefore is important to evaluate more formal error mitigation and process analysis methods of industrial engineering to more optimally focus available QA resources on process components that have a significant likelihood of compromising patient safety or treatment outcomes.

This paper reports on the commissioning of an Elekta cone-beam computed tomography (CT) system at one of the first U.S. sites to install a "regular," off-the-shelf Elekta Synergy (Elekta, Stockholm, Sweden) accelerator system. We present the quality assurance (QA) procedure as a guide for other users. The commissioning had six elements: (1) system safety, (2) geometric accuracy (agreement of megavoltage and kilovoltage beam isocenters), (3) image quality, (4) registration and correction accuracy, (5) dose to patient and dosimetric stability, and (6) QA procedures. The system passed the safety tests, and agreement of the isocenters was found to be within 1 mm. Using a precisely moved skull phantom, the reconstruction and alignment algorithm was found to be accurate within 1 mm and 1 degree in each dimension. Of 12 measurement points spanning a 9x9x15-cm volume in a Rando phantom (The Phantom Laboratory, Salem, NY), the average agreement in the x, y, and z coordinates was 0.10 mm, -0.12 mm, and 0.22 mm [standard deviations (SDs): 0.21 mm, 0.55 mm, 0.21 mm; largest deviations: 0.6 mm, 1.0 mm, 0.5 mm] respectively. The larger deviation for the y component can be partly attributed to the CT slice thickness of 1 mm in that direction. Dose to the patient depends on the machine settings and patient geometry. To monitor dose consistency, air kerma (output) and half-value layer (beam quality) are measured for a typical clinical setting. Air kerma was 6.3 cGy (120 kVp, 40 mA, 40 ms per frame, 360-degree scan, S20 field of view); half value layer was 7.1 mm aluminum (120 kV, 40 mA). We suggest performing items 1, 2, and 3 monthly, and 4 and 5 annually. In addition, we devised a daily QA procedure to verify agreement of the megavoltage and kilovoltage isocenters using a simple phantom containing three small steel balls. The frequency of all checks will be reevaluated based on data collected during about 1 year.

Aims and Background: The performance characteristics of a commercial multileaf collimator (MLC) for intensity modulated radiation therapy (IMRT) and a comprehensive quality assurance program (QA) to be performed during the commissioning of the MLC were investigated., Materials and Methods: The midleaf transmission and interleaf leakage, the in-plane penumbra and its in-plane/cross-plane variation, the cross-plane penumbra and its in-plane/cross-plane variation, and the leaf positional accuracy of a high-energy photon (6 MV) Sli Precise Elekta linear accelerator were measured. Kodak EDR2 Ready Pack film was used for MLC transmission measurement; for the other characterization measurements we used Kodak X-Omat XV2 Ready Pack film placed at 5 cm depth in a solid RW3 phantom. Each film was digitized with a laser scanning photodensitometer VXR-12 Plus using the Omni Pro-Accept 6.OA film dosimetry system and converted to dose by means of H&D curves. The dose calibration measurements were performed with a Farmer ionization chamber according to the guidelines of the IAEA Technical Report No. 277., Results: The average midleaf transmission and interleaf leakage were 1.8% +/- 0.1% and 2.1% +/- 0.2%, respectively. The average value of the cross-plane penumbra was 5.4 mm +/- 0.3 mm with maximum variation less than 0.4 mm and 1.0 mm in the in-plane and cross-plane direction, respectively. The average value of the in-plane penumbra was 3.2 mm +/- 0.2 mm and 3.5 mm +/- 0.2 mm for the step side and groove side of the leaves, respectively. A dose profile perpendicular to the direction of the leaf travel passing through the central axis shows a tongue-and-groove effect of about 33%. The positional accuracy of the leaves was investigated according to AAPM Report No. 72 TG50; the deviation of the net optical density along all the match lines was less than +/- 20%. Moreover, the results obtained with a step field technique showed a positional accuracy of less than 1 mm., Conclusions: The results suggest the necessity of extensive knowledge of the MLC dosimetric characteristics for IMRT applications in order to allow physicists to study their influence on treatment delivery and to perform a comprehensive routine QA program of the investigated parameters.

Image-guided radiotherapy using a three-dimensional (3D) camera as the on-board surface imaging system requires precise and accurate registration of the 3D surface images in the treatment machine coordinate system. Two simple calibration methods, an analytical solution as three-point matching and a least-squares estimation method as multipoint registration, were introduced to correlate the stereo-vision surface imaging frame with the machine coordinate system. Both types of calibrations utilized 3D surface images of a calibration template placed on the top of the treatment couch. Image transformational parameters were derived from corresponding 3D marked points on the surface images to their given coordinates in the treatment room coordinate system. Our experimental results demonstrated that both methods had provided the desired calibration accuracy of 0.5 mm. The multipoint registration method is more robust particularly for noisy 3D surface images. Both calibration methods have been used as our weekly QA tools for a 3D image-guided radiotherapy system.

The development of conformal radiotherapy techniques (CRT) and intensity modulated CRT requires an accurate delineation of target structures and organs at risk. Thus, additional information provided by anatomical and/or functional imaging modalities can be used for volume of interest determination combined with traditionally used Computed Tomography imaging (CT): for instance, functional or morphological Magnetic Resonance Imaging (f MRI or m MRI) or Positron Emission Tomography (PET). A prerequisite to the simultaneous use of this information is image registration. Due to the differences between the images and the information they provide, a quality control of image registration process for radiotherapy is mandatory. The purpose of this article is to present the difficulties in implementing such controls and to show the necessity for a clinical validation on patient's images. The last part of this work presents the possible interest in using f MRI to help radio-oncologists in the treatment planning for gliomas associated to image coregistration and quality control considerations.

Purpose: Test and comparison of various 2-D real-time detectors for dosimetric quality assurance (QA) of intensity-modulated radiotherapy (IMRT) with the vision to replace radiographic films for 2-D dosimetry., Material and Methods: All IMRT treatment plans were created with the Konrad software (Siemens OCS). The final dose calculation was also carried out in Konrad. A Mevatron Primus (Siemens OCS) linear accelerator which provides 6-MV and 15-MV highenergy photon beams was used for the delivery of segmented multileaf-modulated IMRT. Three different 2-D detectors, each based on a different physical (interaction) principle, were tested for the field-related IMRT verification: (1) the MapCheck diode system (Sun Nuclear), (2) the I'mRT QA scintillation detector (Scanditronix/Wellhöfer), and the Seven29 ionization chamber array (PTW). The performance of these detector arrays was evaluated against IMRT dose distributions created and calculated with Konrad and the results obtained were compared with film measurements performed with radiographic films (EDR2, Kodak). Additionally, measurements were performed with point detectors, such as diamond, diodes (PTW) and ionization chambers (PTW, Scanditronics/ Wellhöfer) and radiochromic films (GafChromic film MD55, ISP)., Results: The results obtained with all three 2-D detector systems were in good agreement with calculations performed with the treatment-planning system and with the standard dosimetric tools, i.e., films or various point dose detectors. It could be shown that all three systems offer dosimetric characteristics required for performing field-related IMRT QA with relative dose measurements. The accuracy of the 2-D detectors was mostly +/- 3% normalized to dose maximum for a wide dynamic range. The maximum deviations did not exceed +/- 5% even in regions with a steep dose gradient. The main differences between the detector systems were the spatial resolution, the maximal field size, and the ability to perform absolute dosimetric measurements., Conclusion: Commercial 2-D detectors have the potential to replace films as an "area detector" for field-related verification of IMRT. The on-line information provided by the respective systems can even improve the efficiency of the QA procedures.

Advanced radiation therapy for intracranial disease has focused on set-up accuracy for the past 15 years. However, quality control in the prescribed dose is actually as important as the tumor set-up in radiation therapy. Because of the complexity of the three-dimensional radiation treatment planning system in recent years, the highly quality-controlled prescription of the dose has now been reappraised as the mainstream to improve the treatment outcome of radiation therapy for intracranial disease. The Japanese Committee for Quality Control of Radiation Therapy has developed fundamental requirements such as a QC committee in each hospital, a medical physicist, dosimetrists (QC members), and an external audit.

The resolution of multileaf collimators (MLCs) is limited by their finite leaf width. A commercial package (HD-270) uses 3D couch translation and leaf adjustments to emulate smaller leaf widths. In this paper, we report on the commissioning of this feature using software testing, dial gauge measurements, and film dosimetry. We also identify a variety of limitations: software bugs and truncation artifacts, MLC leaf positioning uncertainties (random variations, systematic gantry dependence and backlash), and uncertainties in couch positioning. These reduce the capabilities of this implementation below that achievable theoretically.