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Purpose: SRS MapCHECK (SMC) is a commercially available patient‐specific quality assurance (PSQA) tool for stereotactic radiosurgery (SRS) applications. This study investigates the effects of degree of modulation, location off‐axis, and low dose threshold (LDT) selection on gamma pass rates (GPRs) between SMC and treatment planning system, Analytical Anisotropic Algorithm (AAA), or Vancouver Island Monte Carlo (VMC++ algorithm) system calculated dose distributions. Methods: Volumetric‐modulated arc therapy (VMAT) plans with modulation factors (MFs) ranging from 2.7 to 10.2 MU/cGy were delivered to SMC at isocenter and 6 cm off‐axis. SMC measured dose distributions were compared against AAA and VMC++ via gamma analysis (3%/1 mm) with LDT of 10% to 80% using SNC Patient software. Results: Comparing on‐axis SMC dose against AAA and VMC++ with LDT of 10%, all AAA‐calculated plans met the acceptance criteria of GPR ≥ 90%, and only one VMC++ calculated plan was marginally outside the acceptance criteria with pass rate of 89.1%. Using LDT of 80% revealed decreasing GPR with increasing MF. For AAA, GPRs reduced from 100% at MF of 2.7 MU/cGy to 57% at MF of 10.2 MU/cGy, and for VMC++ calculated plans, the GPRs reduced from 89% to 60% in the same MF range. Comparison of SMC dose off‐axis against AAA and VMC++ showed more pronounced reduction of GPR with increasing MF. For LDT of 10%, AAA GPRs reduced from 100% to 83% in the MF range of 2.7 to 9.8 MU/cGy, and VMC++ GPR reduced from 100% to 91% in the same range. With 80% LDT, GPRs dropped from 100% to 42% for both algorithms. Conclusions: MF, dose calculation algorithm, and LDT selections are vital in VMAT‐based SRT PSQA. LDT of 80% enhances sensitivity of gamma analysis for detecting dose differences compared to 10% LDT. To achieve better agreement between calculated and SMC dose, it is recommended to limit the MF to 4.6 MU/cGy on‐axis and 3.6 MU/cGy off‐axis. [ABSTRACT FROM AUTHOR]

Background: EBT-XD film specially designed for high dose verifications such as stereotactic treatments. The dose response of the film can be affected by several factors, the curly nature of the film being one of them. In this study this curly nature of the film was investigated for stereotactic body radiotherapy (SBRT) plan verifications. Materials and methods: For this study, 18 SBRT (11 prostate, 3 spines, and 4 lungs) cases were enrolled. For all the cases, VMAT plans were created in the Monaco treatment planning system and plan was delivered in Elekta Versa HD linear accelerator and delivered fluence was captured by EBT-XD films. All films were scanned with and without a compression plate. All the films were analyzed using the single-channel film method using the red channel. Results: A significant difference in the gamma passing rates (GPR) for the films scanned with and without the compression plate was observed. The maximum percentage differences in GPR between using and not using a compression plate were 12.7% for 1% 1 mm, 8.1% for 2% 2 mm, 7.5% for 3% 2 mm, and 5% for 3% 3mm criteria. Similarly, the mean %difference in GPR was 5.8% for 1% 1 mm, 2.4% for 2% 2 mm, 1.6% for 3% 2 mm and 0.96% for 3% 3 mm criteria. Conclusion: The results suggest that placing a compression plate over the film during scanning provided a great advantage in achieving a more accurate gamma passing rate irrespective of gamma criteria. [ABSTRACT FROM AUTHOR]

Background: Metal Artifact Reduction (MAR) is very important in terms of dose calculation and optimization accuracy in radiotherapy (RT). There are many MAR programs available commercially. In this study, a MAR program was developed using MATLAB software (MATLAB-MAR), and the effect of the developed MATLAB-MAR on radiotherapy dose distribution was examined. Materials and Methods: In line with the purpose of the study, a phantom containing metal with a high atomic number (z=82) was created, and computer tomography (CT) of the phantom was taken. MAR developed with MATLAB software and a commercial metal artifact reduction (Smart-MAR) were applied on CT slices. The Hounsfield unit (HU), visually, artefact size and gamma evaluation effects of MATLAB-MAR, Smart-MAR and Without-MAR slices in the CMS XiO planning systems. Results: As a result of the study, the best visually and HU improvement was seen in MATLAB-MAR. Moreover, in the dose distribution evaluation made by gamma analysis, an improvement was observed in MATLAB-MAR. Conclusion: Although similar values were obtained with MATLAB-MAR and the commercial software, it was determined that MATLAB-MAR was more advantageous than the commercial software in terms of being cost-free, providing results in a shorter time, not requiring reconstruction, and being open to development. [ABSTRACT FROM AUTHOR]

Monte Carlo (MC) techniques are regarded as an accurate method to simulate the dose calculation in radiotherapy for many years. The present paper aims to validate the simulated model of the 6-MV beam of OMID linear accelerator (BEHYAAR Company) by EGSnrc codes system and also investigate the effects of initial electron beam parameters (energy, radial full width at half maximum, and mean angular spread) on dose distributions. For this purpose, the comparison between the calculated and measured percentage depth dose (PDD) and lateral dose profiles was done by gamma index (GI) with 1%-1 mm acceptance criteria. MC model validating was done for 3 cm × 3 cm, 5 cm × 5 cm, 8 cm × 8 cm, 10 cm × 10 cm, and 20 cm × 20 cm field sizes. To study the sensitivity of model to beam parameters, the field size was selected as 10 cm × 10 cm and 30 cm × 30 cm. All lateral dose profiles were obtained at 10 cm. Excellent agreement was achieved with a 99.2% GI passing percentage for PDD curves and at least 93.8% GI for lateral dose profiles for investigated field sizes. Our investigation confirmed that the lateral dose profile severely depends on the considered source parameters in this study. PDD only considerably depends on the initial electron beam energy. Therefore, source parameters should not be specified independently. These results indicate that the current model of OMID 6-MV Linac is well established, and the accuracy of the simulation is high enough to be used in various applications.

Aim: In this study, efficacy of collapsed cone algorithm-generated intensity-modulated radiation therapy (IMRT) and volumetric-modulated arc therapy (VMAT) were evaluated for treatment of thoracic esophageal cancer. Materials and Methods: Ten previously treated patients with VMAT were considered for evaluation. The planning parameters were evaluated in terms of max dose, mean dose, Homogeneity Index, Conformity Index for planning target volume, and organ at risk doses. Total monitor unit, treatment time, and gamma passing index were also reported. Results: The target dose coverage of the VMAT and IMRT plans achieved the clinical dosimetric criteria for all ten patients in the evaluation. Under the condition of equivalent target dose distribution, the VMAT plan's Conformity Index, monitor unit, treatment time, and gamma passing index rate were superior than in the IMRT plan, and the result was statistically significant. Conclusion: Collapsed cone algorithm-based VMAT can have a more effective and better approach for esophageal cancer than IMRT. [ABSTRACT FROM AUTHOR]

Purpose: The Medical Physics Working Group of the Radiation Therapy Study Group at the Japan Clinical Oncology Group is currently developing a virtual audit system for intensity‐modulated radiation therapy dosimetry credentialing. The target dosimeters include films and array detectors, such as ArcCHECK (Sun Nuclear Corporation, Melbourne, Florida, USA) and Delta4 (ScandiDos, Uppsala, Sweden). This pilot study investigated the feasibility of our virtual audit system using previously acquired data. Methods: We analyzed 46 films (32 and 14 in the axial and coronal planes, respectively) from 29 institutions. Global gamma analysis between measured and planned dose distributions used the following settings: 3%/3 mm criteria (the dose denominator was 2 Gy), 30% threshold dose, no scaling of the datasets, and 90% tolerance level. In addition, 21 datasets from nine institutions were obtained for array evaluation. Five institutions used ArcCHECK, while the others used Delta4. Global gamma analysis was performed with 3%/2 mm criteria (the dose denominator was the maximum calculated dose), 10% threshold dose, and 95% tolerance level. The film calibration and gamma analysis were conducted with in‐house software developed using Python (version 3.9.2). Results: The means ± standard deviations of the gamma passing rates were 99.4 ± 1.5% (range, 92.8%–100%) and 99.2 ± 1.0% (range, 97.0%–100%) in the film and array evaluations, respectively. Conclusion: This pilot study demonstrated the feasibility of virtual audits. The proposed virtual audit system will contribute to more efficient, cheaper, and more rapid trial credentialing than on‐site and postal audits; however, the limitations should be considered when operating our virtual audit system. [ABSTRACT FROM AUTHOR]

Background: To develop a fully automated in-house gamma analysis software for the "Cheese" phantom-based delivery quality assurance (QA) of helical tomotherapy plans. Methods: The developed in-house software was designed to automate several procedures, which need to be manually performed using commercial software packages. The region of interest for the analysis was automatically selected by cropping out film edges and thresholding dose values (>10% of the maximum dose). The film-measured dose was automatically aligned to the computed dose using an image registration algorithm. An optimal film scaling factor was determined to maximize the percentage of pixels passing gamma (gamma passing rate) between the measured and computed doses (3%/3 mm criteria). This gamma analysis was repeated by introducing setup uncertainties in the anterior–posterior direction. For 73 tomotherapy plans, the gamma analysis results using the developed software were compared to those analyzed by medical physicists using a commercial software package. Results: The developed software successfully automated the gamma analysis for the tomotherapy delivery quality assurance. The gamma passing rate (GPR) calculated by the developed software was higher than that by the clinically used software by 3.0%, on average. While, for 1 of the 73 plans, the GPR by the manual gamma analysis was higher than 90% (pass/fail criteria), the gamma analysis using the developed software resulted in fail (GPR < 90%). Conclusions: The use of automated and standardized gamma analysis software can improve both the clinical efficiency and veracity of the analysis results. Furthermore, the gamma analyses with various film scaling factors and setup uncertainties will provide clinically useful information for further investigations. [ABSTRACT FROM AUTHOR]

Background and purpose: Deep learning (DL) provides high sensitivity for detecting and identifying errors in pre-treatment radiotherapy quality assurance (QA). This work’s objective was to systematically evaluate the impact of different dose comparison and image preprocessing methods on DL model performance for error identification in pre-treatment QA. Materials and methods: For 53 volumetric modulated arc therapy (VMAT) and 69 stereotactic body radiotherapy (SBRT) treatment plans of lung cancer patients, mechanical errors were simulated (MLC leaf positions, monitor unit scaling, collimator rotation). Two classification levels were assessed: error type (Level 1) and error magnitude (Level 2). Portal dose images with and without errors were compared using standard (gamma analysis), simple (absolute/relative dose difference, ratio) and alternative (distance-to-agreement, structural similarity index, gradient) dose comparison methods. For preprocessing, different normalization methods (min/max and mean/standard deviation) and image resolutions (32 × 32, 64 × 64 and 128 × 128) were evaluated. All possible combinations of classification level, dose comparison, normalization method and image size resulted in 144 input datasets for DL networks for error identification. Results: Average accuracy was highest for simple dose comparison methods (Level 1: 97.7%, Level 2: 78.1%) while alternative methods scored lowest (Level 1: 91.6%, Level 2: 71.2%). Mean/stdev normalization particularly improved Level 2 classification. Higher image resolution improved error identification, although for SBRT lower image resolution was also sufficient. Conclusions: The choice of dose comparison method has the largest impact on error identification for pre-treatment QA using DL, compared to image preprocessing. Model performance can improve by using simple dose comparison methods, mean/stdev normalization and high image resolution.

Background: This study aimed to optimize efficiency in Monte Carlo (MC) simulation using sensitivity analysis of a beam model. Methods: The BEAMnrc-based model of 6 MV beam of a Siemens Primus linac was developed. For sensitivity analysis, the effect of the electron source, treatment head, and virtual phantom specifications on calculated percent depth dose (PDD) and lateral dose profiles was evaluated. Results: The optimum mean energy (E) and the full width at half maximum (FWHM) of the intensity distribution of the electron beam were calculated as 6.7 MeV and 3 mm, respectively. Increasing E from 6.1 to 6.7 MeV, increased the PDD in the fall-off region by 4.70% and decreased the lateral profile by 8.76%. Changing the FWHM had a significant effect on the buildup region of PDD and the horns and out-of-field regions of the lateral profile. Increasing the collimators opening by 0.5 mm, PDD increased by 2.13% and the central and penumbra regions of profiles decreased by 1.98% and 11.40% respectively. Collimator properties such as thickness and density were effective in changing the penumbra (11.32% for 0.25 cm increment) and the out-of-field (22.82% for 3 g/cm3) regions of the lateral profiles. Conclusion: Analysis of a 6 MV model showed that PDD profiles were more sensitive to changes in energy than to FWHM of the electron source. The lateral profiles were sensitive to E, FWHM, and collimator opening. The density of the collimator affected only the out-of-field region of lateral profiles. The findings of this study may be used to make benchmarking of an MC beam model more efficient. [ABSTRACT FROM AUTHOR]

Monte Carlo simulations of medical linear accelerator heads help in visualizing the energy spectrum and angular spread of photons and electrons, energy deposition, and scattering from each of the head components. Hence, the purpose of this study was to validate the Monte Carlo model of the Elekta synergy medical linear accelerator equipped with stereotactic radio surgical connical collimators. For this, the Elekta synergy medical linear accelerator was modelled using the EGSnrc Monte Carlo code. The model results were validated using the measured data. The primary electron beam parameters, beam size, and energy were tuned to match the measured data; a dose profile with a field size of 40 × 40 cm2 and percentage depth dose with a field size of 10 × 10 cm2 were matched during tuning. The validation of the modelled data with the measurement results was performed using gamma analysis, point dose, and field size comparisons. For small radiation fields, relative output factors were also compared. The gamma analysis revealed good agreement between the Monte Carlo modeling results and the measured data. A gamma pass rate of more than 95% was obtained for field sizes of 40 × 40 cm2 to 2 × 2 cm2 with gamma criteria of 1% and 1 mm for the dose difference (DD) and distance to agreement (DTA), respectively; this gamma pass rate was more than 98% for the corresponding values of 2% and 2 mm for the DD and DTA, respectively. A gamma pass rate of more than 99% was obtained for a percentage depth dose with 1 mm and 1% criteria. The field size was also in good agreement with the measurement results, and the maximum deviation observed was 1.1%. The stereotactic cone field also passed this analysis with a gamma pass rate of more than 98% for dose profiles and 99% for the percentage depth dose. The small field output factor exhibited a deviation of 4.3%, 3.4%, and 1.9% for field sizes of 5 mm, 7.5 mm, and 10 mm, respectively. Thus, the Monte Carlo model of the Elekta Linear accelerator was successfully validated. The validation of radio surgical cones passed the analysis in terms of the dose profiles and percentage depth dose. The small field relative output factors exhibited deviations of up to 4.3%, and to resolve this, detector-specific and field-specific correction factors must be derived.

The high-density measurement (HDm) mode of the ArcCHECK device can achieve a twofold resolution enhancement compared to the standard measurement (Sm) mode. The aim of this study was to evaluate the effect of HDm on the gamma passing rate (GPR) for the patient-specific quality assurance (PSQA) in head and neck cancer. We retrospectively evaluated 30 patients who underwent volumetric modulated arc therapy (VMAT) for head and neck cancer. Absolute gamma analysis was performed on Sm and HDm data. We also investigated correlations between the modulation complexity score for VMAT (MCSv) and differences in the GPR between the two measurement modes. The global GPR of Sm and HDm was 81.0% ± 8.4% and 82.6% ± 7.6% for the 2%/2 mm criterion, 94.0% ± 4.1% and 94.9% ± 3.6% for the 3%/2 mm criterion, and 96.6% ± 2.4% and 97.0% ± 2.4% for the 3%/3 mm criterion, respectively. HDm slightly improved GPR (p < 0.01) for the 2%/2 mm criterion. Differences in GPR between Sm and HDm for the 2%/2 mm, 3%/2 mm, and 3%/3 mm criteria were 1.6% ± 3.0%, 0.8% ± 2.0%, and 0.4% ± 1.2%, respectively. No correlation was identified between the MCSv and the difference in GPR between Sm and HDm. Despite an improvement in GPR with HDm, the difference in GPR between Sm and HDm was approximately 2% even when the tighter criteria were used. Moreover, the change in the GPR between Sm and HDm did not depend on plan complexity. Thus, the effect of HDm on GPR is limited for the PSQA in VMAT for head and neck cancer. [ABSTRACT FROM AUTHOR]

In this study, the feasibility of using electronic portal imaging device (EPID) as an analysing equipment for bolus material was evaluated in terms of its dosimetric parameters. Seven superflab bolus material samples, 4 samples of 0.5 cm (S1–S4) and 3 samples of 1 cm thickness (S5–S7), were analysed and compared with tissue equivalent water phantom, which was selected for reference material. Gamma analysis method was used to evaluate the dose distribution of the boluses. In addition, 487,204 point-dose values of each bolus were compared with the point-doses of corresponding reference material by using Spearman’s correlation coefficient analysis. The passing rates varied from 58.3 to 100% for 0.5 cm thick samples, and on the other hand, the passing rates of all the 1 cm thick boluses were 100%. All the correlation coefficient values were above 0.975. The correlation was statistically significant for all the samples (p < 0.001). The correlation coefficient of S4 bolus sample was the highest among the 0.5 cm thick bolus samples with a result of 0.989. Likewise, S5 and S6 bolus samples were the highest among the 1 cm thick ones with a result of 0.995. The results indicated that the material planned to be used as bolus can be evaluated with EPID in daily use.

Carbon ion therapy treatments can be monitored non-invasively with in-beam Positron Emission Tomography (PET). At CNAO the INSIDE in-beam PET scanner has been used in a clinical trial (NCT03662373) to monitor cancer treatments with proton and carbon therapy. In this work we present the analysis results of carbon therapy data, acquired during the first phase of the clinical trial, analyzing data of nine patients treated at CNAO for various malignant tumors in the head-and-neck region. The patient group contained two patients requiring replanning, and seven patients without replanning, based on established protocols. For each patient the PET images acquired along the course of treatment were compared with a reference, applying two analysis methods: the beam-eye-view (BEV) method and the γ -index analysis. Time trends in several parameters were investigated, as well as the agreement with control CTs, if available. Regarding the BEV-method, the average sigma value σ was 3.7 mm of range difference distributions for patients without changes (sensitivity of the INSIDE detector). The 3D-information obtained from the BEV analysis was partly in agreement with what was observed in the control CT. The data quality and quantity was insufficient for a definite interpretation of the time trends. We analyzed carbon therapy data acquired with the INSIDE in-beam PET detector using two analysis methods. The data allowed to evaluate sensitivity of the INSIDE detector for carbon therapy and to make several recommendations for the future. • Nine carbon therapy patients were monitored with in-beam PET (NCT03662373). • Two analysis methods were applied: gamma-index and Beam-Eye-View analysis. • The sensitivity of the INSIDE detector was evaluated for carbon therapy. • More data is needed to verify time trends in the analysis parameters and to relate them to anatomical changes. • The reliability of the 3D information should be studied in the future. [ABSTRACT FROM AUTHOR]

Gamma (γ) analysis is the most important method for dose verification and dose distribution comparison. Because of the inconsistency of the coordinate system definitions and directions of different dose distributions and the inconsistent reference point settings, in γ analysis, the dose distributions should often be aligned for comparison. However, the alignment method of the current commonly used γ analysis software is extremely simple, and there are significant errors in processing the dose distribution of the large radiation field, which seriously affect the accuracy of the dose analysis and comparison. Aligning the two-dimensional dose distribution requires performing spatial transformations such as translation and rotation to achieve the same spatial position of the corresponding dose points on the two dose maps. Because the distance between different points must be constant during this alignment process, in this study, the alignment problem is transformed into a rigid registration problem. A rigid registration method based on normalized cross-correlation is used to register the dose distribution map calculated using a treatment planning system with the actually measured dose distribution map and output the corresponding translation amount after registration. 36 groups of static intensity-modulated quality assurance data designed using the pinnacle3 treatment planning system, whose planning system is consistent with the measured center point, are selected; 18 groups are small irradiation fields, and the other 18 groups are large irradiation fields. PTW VeriSoft software is used to calculate the γ passing rate under 3%/3 mm, 3%/2 mm, and 2%/2 mm pass standards separately. For small irradiation fields, the results of the direct calculation of different standard γ passing rates after alignment with VeriSoft and rigid registration are identical. Among them, under the 3%/3 mm pass standard, the results of VeriSoft alignment and rigid registration are compared with those directly calculated， the average differences in γ passing rate are 0.5% and 0.3%, respectively. For the large irradiation field, compared with the directly calculated γ passing rate results, the average differences of the γ passing rate under 3%/3 mm, 3%/2 mm, and 2%/2 mm pass standards after VeriSoft alignment are 17.1%, 23.3%, and 28.3%, respectively, with ten groups of cases all exhibiting great differences. The average differences of the γ passing rate under the 3%/3 mm, 3%/2 mm, and 2%/2 mm standards after rigid registration and direct calculation are 0.4%, 1.1%, and 2.3%, respectively, and the average difference is small. Rigid registration solves the problem of significant errors in VeriSoft’s handling of large-field dose distributions. It can be used as a method for the alignment of dose distributions in different fields when verifying the dose of radiation treatment plans.

Purpose: The Task Group 218 (TG‐218) report was published by the American Association of Physicists in Medicine in 2018, recommending the appropriate use of gamma index analysis for patient‐specific quality assurance (PSQA). The paper demonstrates that PSQA for radiotherapy in Japan appropriately applies the gamma index analysis considering TG‐218. Materials/methods: This survey estimated the acceptance state of radiotherapeutic institutes or facilities in Japan for the guideline using a web‐based questionnaire. To investigate an appropriate PSQA of the facility‐specific conditions, we researched an optimal tolerance or action level for various clinical situations, including different treatment machines, clinical policies, measurement devices, staff or their skills, and patient conditions. The responded data were analyzed using principal component analysis (PCA) and multidimensional scaling (MDS). The PCA focused on factor loading values of the first contribution over 0.5, whereas the MDS focused on mapped distances among data. Results: Responses were obtained from 148 facilities that use intensity‐modulated radiation therapy (IMRT), which accounted for 42.8% of the probable IMRT use in Japan. This survey revealed the appropriate application of the following universal criteria for gamma index analysis from the guideline recommendation despite the facility‐specific variations (treatment machines/the number of IMRT cases/facility attributes/responded [representative] expertise or staff): (a) 95% pass rate, (b) 3% dose difference and 2‐mm distance‐to‐agreement, and (c) 10% threshold dose. Conditions (a)–(c) were the principal components of the data by the PCA method and were mapped in a similar distance range, which was easily clustered from other gamma index analytic factors by the MDS method. Conditions (a)–(c) were the universally essential factors for the PSQA in Japan. Conclusion: We found that the majority of facilities using IMRT in each region of Japan complied with the guideline and conducted PSQA with deliberation under the individual facility‐specific conditions. [ABSTRACT FROM AUTHOR]

The effect on Gamma Passing Rate is studied by changing the Photon Energy in the Patient Specific Quality Assurance in Pelvic IMRT using EPID and MatriXX keeping PSQA device at Isocenter. Dose verification of 62 patients, suffering from pelvic malignancies and treated with Intensity modulated radiation therapy (IMRT), with EPID and MatriXX using gamma criteria of 3%/3 mm, 3%/2 mm, 2%/3 mm, 2%/2 mm and investigated the effect on Gamma Passing Rate (%GP) by changing beam energy from 6 MV to 10 MV. The results demonstrated that the behavior of gamma passing rate decreases as criteria is changed from 3%/3 mm to strict criteria. The mean gamma passing rate for 6 MV beam were (%GP±Standard Deviation σ) 99.64±0.81, 99.45±1.08, 97.57±2.12, 96.17±2.63 using the criteria 3%/3 mm, 3%/2 mm, 2%/3 mm, 2%/2 mm respectively in EPID. For MatriXX, the mean %GP were 96.69±4.11, 93.85±5.31, 88.17±10.63, 82.2±12.28 respectively. For 10 MV, the mean (%GP±Std. Dev) were 99.64±0.81, 99.45±1.08, 97.57±2.12, 96.17±2.63 for in EPID, 96.69±4.11, 93.85±5.31, 88.17±10.63, 82.2±12.28 for MatriXX respectively. Difference between %GP for 6 MV and 10 MV beam were -0.01, -0.11, 1.08, 1.61 with gamma criteria of 3%/3 mm, 3%/2 mm, 2%/3 mm, 2%/2 in EPID. For MatriXX, difference between %GP for 6 MV and 10 MV beam were -0.40, -0.24, 0.96, 1.62 respectively. It can be concluded that applying more strict gamma criteria results in low gamma passing rate. There is marked difference in Gamma Passing Rate (%GP) with change in photon energy. [ABSTRACT FROM AUTHOR]

Conical collimators are effective and readily available accessories for the field shaping of small stereotactic fields, however the measurements required to accurately characterise the smallest radiation fields are difficult, prone to large errors, and there is little published commissioning data to compare measurements against. The aim of this investigation was to commission the cone dose calculation algorithm of a Varian Eclipse treatment planning system for a Varian 5 mm cone attached to a Varian TrueBeam linear accelerator beam-matched to the Varian Golden Beam Data (GBD). Tissue maximum ratios (TMRs) and off-axis ratios (OARs) were measured using PTW 60019 microDiamond and PTW 60018 SRS Diode detectors for a flattening filter free 6MV beam. The output factor (OF) was measured with the microDiamond and EBT-XD film. Results were compared to the GBD for this cone and an OF measured by the Australian Clinical Dosimetry Service during an independent audit. Film dosimetry was used to evaluate Eclipse dose calculations in a solid water phantom and end-to-end accuracy with an anthropomorphic head phantom. Output correction factors were derived from IAEA TRS-483. Gamma analysis was used to compare measured TMRs and OARs, and to compare Eclipse dose planes with film dosimetry results. Comparisons between measured and GBD TMRs passed gamma analysis within the specified criteria, while differences between distances to agreement for OARs measured with different detectors was attributed to different volume averaging characteristics. The OFs measured with the microDiamond and film agreed within measurement uncertainty. It was decided to configure Eclipse with the microDiamond measured OF and the SRS Diode measured TMR and OAR data. This was validated with various comparisons carried out to confirm both measurement accuracy and Eclipse configuration. [ABSTRACT FROM AUTHOR]

Background: The gamma index and dose–volume histogram (DVH)-based patient-specific quality assurance (QA) measures commonly applied in radiotherapy planning are unable to simultaneously deliver detailed locations and magnitudes of discrepancy between isodoses of planned and delivered dose distributions. By exploiting statistical classification performance measures such as sensitivity or specificity, compliance between a planned and delivered isodose may be evaluated locally, both for organs-at-risk (OAR) and the planning target volume (PTV), at any specified isodose level. Thus, a patient-specific QA tool may be developed to supplement those presently available in clinical radiotherapy. Materials and methods: A method was developed to locally establish and report dose delivery errors in three-dimensional (3D) isodoses of planned (reference) and delivered (evaluated) dose distributions simultaneously as a function the dose level and of spatial location. At any given isodose level, the total volume of delivered dose containing the reference and the evaluated isodoses is locally decomposed into four subregions: true positive—subregions within both reference and evaluated isodoses, true negative—outside of both of these isodoses, false positive—inside the evaluated isodose but not the reference isodose, and false negatives—inside the reference isodose but not the evaluated isodose. Such subregions may be established over the whole volume of delivered dose. This decomposition allows the construction of a confusion matrix and calculation of various indices to quantify the discrepancies between the selected planned and delivered isodose distributions, over the complete range of values of dose delivered. The 3D projection and visualization of the spatial distribution of these discrepancies facilitates the application of the developed method in clinical practice. Results: Several clinical photon radiotherapy plans were analyzed using the developed method. In some plans at certain isodose levels, dose delivery errors were found at anatomically significant locations. These errors were not otherwise highlighted—neither by gamma analysis nor by DVH-based QA measures. A specially developed 3D projection tool to visualize the spatial distribution of such errors against anatomical features of the patient aids in the proposed analysis of therapy plans. Conclusions: The proposed method is able to spatially locate delivery errors at selected isodose levels and may supplement the presently applied gamma analysis and DVH-based QA measures in patient-specific radiotherapy planning. [ABSTRACT FROM AUTHOR]

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Purpose: An area of focus in radiotherapy is the treatment of oligometastatic lung cancer using highly conformal techniques such as SBRT, performed using VMAT that involves flattening filter free (FFF) beams. This study proposes a new calibration procedure for PTW Octavius 1600SRS detector array and was designed to also evaluate clinical and dosimetric aspects of a patient-specific quality assurance (PSQA) for lung SBRT patients., Methods: The cohort consists of 20 patients, treated for lung metastases using SBRT with 50 Gy dose in 5 fractions (10 Gy/fr). The proposed calibration method uses only one calibration factor determined at maximum dose rate of 6MV FFF photon beam. The dosimetric accuracy of achieving a high dose gradient was analyzed using the RTOG 0915 protocol and was confirmed by PSQA procedures using the PTW Octavius 1600SRS detector., Results: Conformity index, gradient index, maximum dose at 2 cm and V 20 parameters were evaluated with clinical favorable results, with only two plans with lesions situated in the inferior lobe exceeding the deviation allowed for the gradient index. Gamma passing rates using the new calibration method were 98.93% and 99.38% for different gamma criteria of 2 mm/2% and 1 mm/3%, respectively., Conclusions: The proposed method for calibration using one calibration factor at maximum dose rate for the involved photon beam shows clinically acceptable gamma passing rates. Employing the RTOG 0915 protocol for lung SBRT treatment plan evaluation brings important dosimetric information about treatment plan quality and dose gradient fall-off which can be correlated with the results achieved during the pretreatment verification procedures., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Associazione Italiana di Fisica Medica e Sanitaria. Published by Elsevier Ltd. All rights reserved.)

Monte Carlo (MC) techniques are regarded as an accurate method to simulate the dose calculation in radiotherapy for many years. The present paper aims to validate the simulated model of the 6-MV beam of OMID linear accelerator (BEHYAAR Company) by EGSnrc codes system and also investigate the effects of initial electron beam parameters (energy, radial full width at half maximum, and mean angular spread) on dose distributions. For this purpose, the comparison between the calculated and measured percentage depth dose (PDD) and lateral dose profiles was done by gamma index (GI) with 1%-1 mm acceptance criteria. MC model validating was done for 3 cm × 3 cm, 5 cm × 5 cm, 8 cm × 8 cm, 10 cm × 10 cm, and 20 cm × 20 cm field sizes. To study the sensitivity of model to beam parameters, the field size was selected as 10 cm × 10 cm and 30 cm × 30 cm. All lateral dose profiles were obtained at 10 cm. Excellent agreement was achieved with a 99.2% GI passing percentage for PDD curves and at least 93.8% GI for lateral dose profiles for investigated field sizes. Our investigation confirmed that the lateral dose profile severely depends on the considered source parameters in this study. PDD only considerably depends on the initial electron beam energy. Therefore, source parameters should not be specified independently. These results indicate that the current model of OMID 6-MV Linac is well established, and the accuracy of the simulation is high enough to be used in various applications., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Journal of Medical Signals & Sensors.)

To assess the effect of respiratory movement on dose distribution via intensity-modulated radiotherapy (IMRT) in patients with lung cancer based on real respiratory movement parameters. Twenty-seven patients with lung cancer who underwent four-dimensional computed tomography (4DCT) and received IMRT were analyzed retrospectively to determine the three-dimensional tumor motion amplitude and respiratory period. Based on the above movement parameters, the dose distribution of the tumor on the respiratory movement platform in the head-foot and left-right directions was measured. The difference in IMRT dose distribution between the respiratory motion and static states was compared using the two-dimensional gamma analysis method, and the effect of respiratory motion on dose verification was analyzed. The mean respiratory motion period of patients was 3.3 s, and the mean tumor motion amplitude in the head-foot direction (5.6 mm) was greater than that in the left-right direction (2.1 mm) and the anterior-posterior direction (2.3 mm), with the maximum at 18 mm. The γ-passage rate tended to decrease gradually with the increase intumor motion amplitude. When the tumor motion amplitude was greater than 3 mm, the γ passage rate was less than 95% in most beams. The differences of γ-passage rates grouped by the median respiratory period were statistically significant in the left-right directional motion state. IMRT dose validation in lung canceris affected by the amplitude of tumor motion and the respiratory motion cycle. Respiratory motion management techniques are recommended for patients with a large respiratory motion amplitude to improve the accuracy of dose delivery to the target.

• Planned dose for passive motion management is inherently imprecise. • Traditional dosimetry audit scoring approaches may be unsuitable as a result. • Region of interest gamma is a promising mechanism to detect most errors. • Scoring should be supported by multiple metrics targeted at specific error sources. Dosimetry audits for passive motion management require dynamically-acquired measurements in a moving phantom to be compared to statically calculated planned doses. This study aimed to characterise the relationship between planning and delivery errors, and the measured dose in the Imaging and Radiation Oncology Core (IROC) thorax phantom, to assess different audit scoring approaches. Treatment plans were created using a 4DCT scan of the IROC phantom, equipped with film and thermoluminescent dosimeters (TLDs). Plans were created on the average intensity projection from all bins. Three levels of aperture complexity were explored: dynamic conformal arcs (DCAT), low-, and high-complexity volumetric modulated arcs (VMATLo, VMATHi). Simulated-measured doses were generated by modelling motion using isocenter shifts. Various errors were introduced including incorrect setup position and target delineation. Simulated-measured film doses were scored using gamma analysis and compared within specific regions of interest (ROIs) as well as the entire film plane. Positional offsets were estimated based on isodoses on the film planes, and point doses within TLD contours were compared. Motion-induced differences between planned and simulated-measured doses were evident even without introduced errors Gamma passing rates within target-centred ROIs correlated well with error-induced dose differences, while whole film passing rates did not. Isodose-based setup position measurements demonstrated high sensitivity to errors. Simulated point doses at TLD locations yielded erratic responses to introduced errors. ROI gamma analysis demonstrated enhanced sensitivity to simulated errors compared to whole film analysis. Gamma results may be further contextualized by other metrics such as setup position or maximum gamma. [ABSTRACT FROM AUTHOR]

The purpose of the study was to compare the results of gamma value based film analysis according to the used type of self-developer film and software product.

Abstract Objective This study compared the dose verification results between plans created based on computed tomography (CT) scan and digital virtual phantom. Methods We retrospectively analyzed the treatment plan of 10 patients with head and neck cancer. CT scanned phantom and digital virtual phantom measured using Delta4 3‐D matrix were used to generate verification plans for each patient. The doses based on the effective measurement volume of the two phantoms were compared, and the verification results were analyzed using gamma index analysis. Results For the body, the minimum dose, the maximum dose, the average dose, and the total dose were 0.72 ± 0.46 cGy, 251.86 ± 49.83 cGy, 58.10 ± 10.93 cGy, and 154.67 ± 20.28 cGy, respectively, in the CT‐scan group, and 0.62 ± 0.36 cGy, 248.34 ± 48.59 cGy, 57.20 ± 10.77 cGy, and 151.57 ± 19.73 cGy, respectively in the Uniform group. The difference between the groups was significant (P 95%, but the Uniform group had a higher passing rate than the CT‐scan group. Conclusions Because the passing rate was higher in the Uniform group than in the CT‐scan group, it is recommended to use digital virtual phantom modules to generate verification plans in clinical practice.

Purpose: The present study aims to design and fabricate a novel, versatile, and cost-effective Polymethyl Methacrylate (PMMA) head phantom for the dosimetric pretreatment verification of radiotherapy (RT) treatment plans. Materials and Methods: The head phantom designing involves slice-wise modeling of an adult head using PMMA. The phantom has provisions to hold detectors such as ionization chambers of different sizes, Gafchromic films, gel dosimeter, and optically stimulated luminescence dosimeter. For the point dose verification purpose, 15 volumetric modulated arc therapy patient plans were selected, and doses were measured using a CC13 ionization chamber. The percentage gamma passing rate was calculated for acceptance criteria 3%/3 mm and 2%/2 mm using OmniPro I'mRT film QA software, and Gafchromic EBT3 films were used for 2D planar dose verification. Results: Treatment planning system calculated, and the measured point doses showed a percentage deviation ranged from 0.26 to 1.92. The planar dose fluence measurements, for set acceptance criteria of 3%/3 mm and 2%/2 mm, percentages of points having gamma value

Purpose: To investigate intrinsic sensitivity of an electronic portal imaging device (EPID) and the ArcCHECK detector and to use this in assessing their performance in detecting delivery variations for lung SBRT VMAT. The effect of detector spatial resolution and dose matrix interpolation on the gamma pass rate was also considered. Materials and methods: Fifteen patients' lung SBRT VMAT plans were used. Delivery variations (errors) were introduced by modifying collimator angles, multi‐leaf collimator (MLC) field sizes and MLC field shifts by ±5, ±2, and ±1 degrees or mm (investigating 103 plans in total). EPID and ArcCHECK measured signals with introduced variations were compared to measured signals without variations (baseline), using OmniPro‐I'mRT software and gamma criteria of 3%/3 mm, 2%/2 mm, 2%/1 mm, and 1%/1 mm, to test each system's basic performance. The measurement sampling resolution for each was also changed to 1 mm and results compared to those with the default detector system resolution. Results: Intrinsic detector sensitivity analysis, that is, comparing measurement to baseline measurement, rather than measurement to plan, demonstrated the intrinsic constraints of each detector and indicated the limiting performance that users might expect. Changes in the gamma pass rates for ArcCHECK, for a given introduced error, were affected only by dose difference (DD %) criteria. However, the EPID showed only slight changes when changing DD%, but greater effects when changing distance‐to‐agreement criteria. This is pertinent for lung SBRT where the minimum dose to the target will drop dramatically with geometric errors. Detector resolution and dose matrix interpolation have an impact on the gamma results for these SBRT plans and can lead to false positives or negatives in error detection if not understood. Conclusion: The intrinsic sensitivity approach may help in the selection of more meaningful gamma criteria and the choice of optimal QA device for site‐specific dose verification. [ABSTRACT FROM AUTHOR]

Intensity modulated radiotherapy is the developed technique of 3 dimensional conformal radiation therapy. In this method, irradiated fields can be seperated into many subfields that are called segments. Each segments radiation dose can be adjusted. Intensity modulated radiotherapy plans have complex segments and high gradient dose regions. Therefore, quality assurance of intensity modulated radiotherapy plans are very important. The aim of this study is to perform quality assurance tests of intensity modulated radiotherapy plans by using different dosimetric systems and compare of results. Intensity modulated radiotherapy treatment plans of thirty patients quality assurance were tested using Matrixx and Delta4. Then, gamma pass rates that were determined as a result of the gamma analysis done using gamma pass-fail criteria that had values of different dose difference and distance to agreement. In our study, the difference between the mean values of gamma pass rates determined before were statistically examined and there was significant difference between two dosimetric systems. [Med-Science 2019; 8(1.000): 63-6]

Background: Intensity modulated radiation therapy (IMRT) is an advanced method for delivery of three dimensional therapies, which provides optimal dose distribution with giving multiple nonuniform fluency to the patient. The complex dose distribution of IMRT should be checked to ensure that the accurate dose is delivered. Today, film dosimetry is a powerful tool for radiotherapy treatment Quality Assurance (QA) and a good method to verify dose distribution in phantoms. Objective: This study aimed to evaluate the accuracy of IMRT treatment planning system, Prowess Panther® software, with Gafchromic EBT3 films in a inhomogeneity phantom Method: The IMRT plan was generated by Prowess Panther® treatment planning system (TPS) version 5.2 on a inhomogeneity phantom, then it was irradiated by ONCOR linear accelerator (Linac) with 6 (MV) photon beam energy. The Gafchromic EBT3 film located between the phantom has measured the dose distribution.­ To compare between TPS calculated doses and film measured doses, Gamma criteria 3%/3 mm, 4%/4 mm, 5%/5 mm, 6%/6 mm and 7%/7 mm Dose Difference (DD) and Distance to Agreement (DTA), respectively were used. Results: Gammas passing rates for PTV are obtained 67.5% for 3%/3mm, 78.8% for 4%/4mm, 86.3% for 5%/5mm, 91.2% for 6%/6mm and 94.3% for 7%/7mm and for organs at risk is 72.4% for 3%/3mm, 82.8% for 4%/4mm, 89.8% for 5%/5mm, 93.3% for 6%/6mm and 95.4% for 7%/7mm (respectively DD/DTA). By increasing the range of criteria the capability increased. Conclusion: The results show that the use of EBT3 film in a inhomogeneity phantoms allows us to evaluate the dose differences between the EBT3 measured dose distribution and TPS calculated dose distribution .Hence, a result Prowess Panther® TPS can be used for IMRT technique treatment.

Purpose: To investigate a novel gamma analysis system for dose verification results in terms of clinical significance. Methods and Materials: The modified scheme redefined the computational domain of the conventional gamma analysis with the projections of beams and the regions of interest (ROI). We retrospectively studied 6 patients with the conventional and the modified gamma analysis schemes while compared their performances. The cold spots ratio of the planning target volume (PTV) and the hot spots ratio of the organs at risk (OAR) were also computed by the modified scheme to assess the clinical significance. Results: The result of the gamma passing rate in the modified method was conformable to that in the conventional method with a cut-off threshold of 5%. The cold spots ratio of PTV and hot spots ratio of OAR were able to be evaluated by the modified scheme. For an introduced 7.1% dose error, the discrimination ratio in gamma passing rate of the conventional method was lower than 2%, while it was improved to 5% by the modified method. Conclusions: The modified gamma analysis scheme had a comparable quality as the conventional scheme in terms of dose inspection. Besides, it could improve the clinical significance of the QA result and provide the assessment for ROI-specific discrepancy. The modified scheme could also be conveniently integrated into the conventional dose verification process, benefiting the less developed regions where high-end 3D dose verification devices are not affordable. [ABSTRACT FROM AUTHOR]

Aim: The aim of this work was to study the acceptability of plans prepared for prostate patients treated by volumetric modulated arc therapy (VMAT) with the vision to evaluate the quality of plans and test pre-treatment quality assurance (QA). Material methods: VMAT plans of 35 patients, planned on the Eclipse Treatment Planning System (Aria 15), were included in the study. Plan acceptability was checked using statistical analysis, which includes homogeneity index, radical and median homogeneity index, coverage and uniformity index. Dose–volume histograms (DVH) of the plans were also studied to check prescribed dose (PD), Dmax, Dmin, D5 and D95. Portal dosimetry was also done by gamma analysis using 3%/3 mm criterion. SD and mean SD error were also calculated and analysed. Results: Statistical analysis showed a mean HI of 1·054, coverage 0·959, UI 1·055, mDHI 0·962 and rDHI 0·866. SD of HI, coverage, UI, mDHI and rDHI was 0·019, 0·019, 0·014, 0·013 and 0·030, respectively. From the DVHs, mean of D5, D95, Dmin and Dmax was calculated at 6,252·9, 5,757·4, 6,413·3 and 5,657·7 cGy, respectively, with a prescribed dose of 6,000 cGy. According to gamma analysis, area gamma < 1 was 99·12% with a tolerance limit of 95%, maximum gamma was 1·466 with a tolerance limit of 3·5, average gamma was 0·388 with a tolerance limit of 0·5, area gamma > 1·2 was 0·242% with a tolerance limit of 0·5%, maximum dose difference was 0·6 with a tolerance limit of 1·0 and average dose difference was 0·029 with a tolerance limit of 0·2. Conclusion: All three computations showed the results to be within acceptable limits. VMAT possesses a unique feature of delivering the whole treatment with only two rotations of the gantry. VMAT has an improved efficiency of delivery for equivalent dosimetric quality. [ABSTRACT FROM AUTHOR]

The accuracy of radiotherapy is the subject of continuous discussion, and dosimetry methods, particularly in dynamic techniques, are being developed. At the same time, many oncology centers develop quality procedures, including pretreatment and online dose verification and proper patient tracking methods. This work aims to present the possibility of using portal dosimetry in the assessment of radiotherapy repeatability. The analysis was conducted on 74 cases treated with dynamic techniques. Transit dosimetry was made for each collision‐free radiation beam. It allowed the comparison of summary fluence maps, obtained for fractions with the corresponding summary maps from all other treatment fractions. For evaluation of the compatibility in the fluence map pairs (6798), the gamma coefficient was calculated. The results were considered in four groups, depending on the used radiotherapy technique: stereotactic fractionated radiotherapy, breath‐hold, free‐breathing, and conventionally fractionated other cases. The chi2 or Fisher's exact test was made depending on the size of the analyzed set and also Mann–Whitney U‐test was used to compare treatment repeatability of different techniques. The aim was to test whether the null hypothesis of error‐free therapy was met. The patient is treated repeatedly if the P‐value in all the fluence maps sets is higher than the level of 0.01. The best compatibility between treatment fractions was obtained for the stereotactic technique. The technique with breath‐holding gave the lowest percentage of compliance of the analyzed fluence pairs. The results indicate that the repeatability of the treatment is associated with the radiotherapy technique. Treated volume location is also an essential factor found in the evaluation of treatment accuracy. The EPID device is a useful tool in assessing the repeatability of radiotherapy. The proposed method of fluence maps comparison also allows us to assess in which therapeutic session the patient was treated differently from the other fractions. [ABSTRACT FROM AUTHOR]

Abstract Background To evaluate the difference of absorbed doses calculated to medium and to water by a Monte Carlo (MC) algorithm based treatment planning system (TPS), and to assess the potential clinical impact to dose prescription. Methods Thirty patients, 10 nasopharyngeal cancer (NPC), 10 lung cancer and 10 bone metastases cases, were selected for this study. For each case, the treatment plan was generated using a commercial MC based TPS and dose was calculated to medium (Dm). The plan was recalculated for dose to water (Dw) using the same Monitor Units (MU) and control points. The differences between Dm and Dw were qualitatively evaluated by dose-volume parameters and by the plan subtraction method. All plans were measured using the MapCheck2, and gamma passing rates were calculated. Results For NPC and Lung cases, the mean differences between Dw and Dm for the targets were less than 2% and the maximum difference was 3.9%. The maximum difference of D2% for the organs at risk (OARs) was 6.7%. The maximum differences between Dw and Dm were as high as 10% in certain high density regions. For bone metastases cases, the mean differences between Dw and Dm for the targets were more than 2.2% and the maximum difference was 7.1%. The differences between Dw and Dm for the OARs were basically negligible. At 3%&3 mm criterion, the gamma passing rate of Dw plan and Dm plan were close (> 94%). Conclusion The differences between Dw and Dm has little clinical impact for most clinical cases. In bony structures the differences may become clinically significant if the target/OAR is receiving doses close to its tolerance limit which can potentially influence the selection or rejection of a particular plan.

Purpose: To externally validate a hidden Markov model (HMM) for classifying gamma analysis results of in vivo electronic portal imaging device (EPID) measurements into different categories of anatomical change for lung cancer patients. Additionally, the relationship between HMM classification and deviations in dose‐volume histogram (DVH) metrics was evaluated. Methods: The HMM was developed at CHU de Québec (CHUQ), and trained on features extracted from gamma analysis maps of in vivo EPID measurements from 483 fractions (24 patients, treated with three‐dimensional 3D‐CRT or intensity modulated radiotherapy), using the EPID measurement of the first treatment fraction as reference. The model inputs were the average gamma value, standard deviation, and average value of the highest 1% of gamma values, all averaged over all beams in a fraction. The HMM classified each fraction into one of three categories: no anatomical change (Category 1), some anatomical change (no clinical action needed, Category 2) and severe anatomical change (clinical action needed, Category 3). The external validation dataset consisted of EPID measurements from 263 fractions of 30 patients treated at Maastro with volumetric modulated arc therapy (VMAT) or hybrid plans (containing both static beams and VMAT arcs). Gamma analysis features were extracted in the same way as in the CHUQ dataset, by using the EPID measurement of the first fraction as reference (γQ), and additionally by using an EPID dose prediction as reference (γM). For Maastro patients, cone beam computed tomography (CBCT) scans and image‐guided radiotherapy (IGRT) classification of these images were available for each fraction. Contours were propagated from the planning CT to the CBCTs, and the dose was recalculated using a Monte Carlo dose engine. Dose‐volume histogram metrics for targets and organs‐at‐risk (OARs: lungs, heart, mediastinum, spinal cord, brachial plexus) were extracted for each fraction, and compared to the planned dose. HMM classification of the external validation set was compared to threshold classification based on the average gamma value alone (a surrogate for clinical classification at CHUQ), IGRT classification as performed at Maastro, and differences in DVH metrics extracted from 3D dose recalculations on the CBCTs. Results: The HMM achieved 65.4%/65.0% accuracy for γQ and γM, respectively, compared to average gamma threshold classification. When comparing HMM classification with IGRT classification, the overall accuracy was 29.7% for γQ and 23.2% for γM. Hence, HMM classification and IGRT classification of anatomical changes did not correspond. However, there is a trend towards higher deviations in DVH metrics with classification into higher categories by the HMM for large OARs (lungs, heart, mediastinum), but not for the targets and small OARs (spinal cord, brachial plexus). Conclusion: The external validation shows that transferring the HMM for anatomical change classification to a different center is challenging, but can still be valuable. The HMM trained at CHUQ cannot be used directly to classify anatomical changes in the Maastro data. However, it may be possible to use the model in a different capacity, as an indicator for changes in the 3D dose based on two‐dimensional EPID measurements. [ABSTRACT FROM AUTHOR]

• Gamma surface plots feature rich information describing levels of agreement. • These plots are useful for investigating borderline results and failures. • They have the potential to spotlight errors that may go unnoticed in other analyses. This work presents a novel method of visualising the results of patient-specific quality assurance (QA) for modulated radiotherapy treatment plans, using a three-dimensional distribution of gamma pass rates, referred to as the "gamma surface". The method was developed to aid in comparing borderline and failing QA plans, and to better compare patient-specific QA results between departments. Gamma surface plots were created for a representative sample of situations encountered during patient-specific QA. To produce a gamma surface plot, for each QA result, gamma pass rates were plotted as a heat map, with dose difference on one axis and distance-to-agreement on the other. This involved the calculation of 100 × 100 gamma pass rates over a dose difference and distance-to-agreement grid. As examples, five 220 × 680 arrays of dose points from radiotherapy treatment plans were compared against measurement data consisting of 21 × 66 arrays of dose points spaced 10 mm apart. The gamma surface plots facilitated the rapid evaluation of criteria combinations for each plan, clearly highlighting the difference between plans that are modelled and delivered well, and those that are not. Large scale features were also evident in each surface, hinting at potential over-modulation, systematic dose errors, and small or large scale areas of disagreement in the distributions. Gamma surface plots are a useful tool for investigating QA failures and borderline results, and have the capacity to grant insights into treatment plan QA performance that may otherwise be missed. [ABSTRACT FROM AUTHOR]

Objective: This study compared the dose verification results between plans created based on computed tomography (CT) scan and digital virtual phantom. Methods: We retrospectively analyzed the treatment plan of 10 patients with head and neck cancer. CT scanned phantom and digital virtual phantom measured using Delta4 3‐D matrix were used to generate verification plans for each patient. The doses based on the effective measurement volume of the two phantoms were compared, and the verification results were analyzed using gamma index analysis. Results: For the body, the minimum dose, the maximum dose, the average dose, and the total dose were 0.72 ± 0.46 cGy, 251.86 ± 49.83 cGy, 58.10 ± 10.93 cGy, and 154.67 ± 20.28 cGy, respectively, in the CT‐scan group, and 0.62 ± 0.36 cGy, 248.34 ± 48.59 cGy, 57.20 ± 10.77 cGy, and 151.57 ± 19.73 cGy, respectively in the Uniform group. The difference between the groups was significant (P < 0.05). In the Delta4 analysis software, the dose deviation, distance to agreement, and gamma passing rates were 73.39 ± 10.75%, 95.25 ± 1.00%, and 96.67 ± 1.415%, respectively in the CT‐scan group, and 83.36 ± 10.15%, 98.61 ± 0.810%, and 99.38 ± 0.452%, respectively, in the Uniform group. The two plans were significantly different (P < 0.05), and there was a 3% difference in the gamma passing rate. Therefore, the conclusions relating to the examined dose applied, the groups were significantly higher than those of CT‐scan groups. (both P‐values were <0.05). As the parameter value increases, the difference decreases. In the 3 mm/3% standard, both groups met the clinical requirement of gamma passing rate of >95%, but the Uniform group had a higher passing rate than the CT‐scan group. Conclusions: Because the passing rate was higher in the Uniform group than in the CT‐scan group, it is recommended to use digital virtual phantom modules to generate verification plans in clinical practice. [ABSTRACT FROM AUTHOR]

To analyse the impact of different optimization strategies on the compatibility between planned and delivered doses during radiotherapy of cervical cancer. Four treatment plans differing in optimisation strategies were prepared for ten cervical cancer cases. These were: volumetric modulated arc therapy with (_OPT) and without optimization of the doses in the bone marrow and for two sets of margins applied to the clinical target volume that arose from image guidance based on the bones (IG(B)) and soft tissues (IG(ST)). The plans were subjected to dosimetric verification by using the ArcCHECK system and 3DVH software. The planned dose distributions were compared with the corresponding measured dose distributions in the light of complexity of the plans and its deliverability. The clinically significant impact of the plans complexity on their deliverability is visible only for the gamma passing rates analysis performed in a local mode and directly in the organs. While more general analyses show statistically significant differences, the clinical relevance of them has not been confirmed. The analysis showed that IG(ST)_OPT and IG(B)_OPT significantly differ from IG(ST) and IG(B). The clinical acceptance of IG(ST)_OPT obtained for hard combinations of gamma acceptance criteria (2%/2 mm) confirm its satisfactory deliverability. In turn, for IG(B)_OPT in the case of the rectum, the combination of 2%/2 mm did not meet the criteria of acceptance. Despite the complexity of the IG(ST)_OPT, the results of analysis confirm the acceptance of its deliverability when 2%/2 mm gamma acceptance criteria are used during the analysis. [ABSTRACT FROM AUTHOR]

Purpose: The present study aims to design and fabricate a novel, versatile, and cost-effective Polymethyl Methacrylate (PMMA) head phantom for the dosimetric pretreatment verification of radiotherapy (RT) treatment plans. Materials and Methods: The head phantom designing involves slice-wise modeling of an adult head using PMMA. The phantom has provisions to hold detectors such as ionization chambers of different sizes, Gafchromic films, gel dosimeter, and optically stimulated luminescence dosimeter. For the point dose verification purpose, 15 volumetric modulated arc therapy patient plans were selected, and doses were measured using a CC13 ionization chamber. The percentage gamma passing rate was calculated for acceptance criteria 3%/3 mm and 2%/2 mm using OmniPro I'mRT film QA software, and Gafchromic EBT3 films were used for 2D planar dose verification. Results: Treatment planning system calculated, and the measured point doses showed a percentage deviation ranged from 0.26 to 1.92. The planar dose fluence measurements, for set acceptance criteria of 3%/3 mm and 2%/2 mm, percentages of points having gamma value <1 were in the range of 99.17 ± 0.25 to 99.88 ± 0.15 and 93.16 ± 0.38 to 98.89 ± 0.23, respectively. Measured dose verification indices were within the acceptable limit. Conclusions: The dosimetric study reveals that head phantom can be used for routine pretreatment verification for the cranial RT, especially for stereotactic radiosurgery/RT as a part of patient-specific quality assurance. The presently fabricated and validated phantom is novel, versatile, and cost-effective, and many institutes can afford it. [ABSTRACT FROM AUTHOR]

Purpose: We performed three-dimensional (3D) dose reconstruction-based pretreatment verification to evaluate gamma analysis acceptance criteria in volumetric modulated arc therapy (VMAT) for prostate cancer. Materials and Methods: Pretreatment verification for 28 VMAT plans for prostate cancer was performed using the COMPASS system with a dolphin detector. The 3D reconstructed dose distribution of the treatment planning system calculation (TC) was compared with that of COMPASS independent calculation (CC) and COMPASS reconstruction from the dolphin detector measurement (CR). Gamma results (gamma failure rate and average gamma value [GFR and γAvg]) and dose-volume histogram (DVH) deviations, 98%, 2% and mean dose-volume difference (DD98%, DD2% and DDmean), were evaluated. Gamma analyses were performed with two acceptance criteria, 2%/2 mm and 3%/3 mm. Results: The GFR in 2%/2 mm criteria were less than 8%, and those in 3%/3 mm criteria were less than 1% for all structures in comparisons between TC, CC, and CR. In the comparison between TC and CR, GFR and γAvg in 2%/2 mm criteria were significantly higher than those in 3%/3 mm criteria. The DVH deviations were within 2%, except for DDmean (%) for rectum and bladder. Conclusions: The 3%/3 mm criteria were not strict enough to identify any discrepancies between planned and measured doses, and DVH deviations were less than 2% in most parameters. Therefore, gamma criteria of 2%/2 mm and DVH related parameters could be a useful tool for pretreatment verification for VMAT in prostate cancer. [ABSTRACT FROM AUTHOR]

OBJECTIVE: This study aims to benchmark a Monte Carlo (MC) model of the 18 MV photon beam produced by the Siemens Oncor® linac using the BEAMnrc and DOSXYZnrc codes. METHODS: By matching the percentage depth doses and beam profiles calculated by MC simulations with measurements, the initial electron beam parameters including electron energy, full width at half maximum (spatial FWHM), and mean angular spread were derived for the 10×10 cm2 and 20×20 cm2 field sizes. The MC model of the 18 MV photon beam was then validated against the measurements for different field sizes (5×5, 30×30 and 40×40 cm2) by gamma index analysis. RESULTS: The optimum values for electron energy, spatial FWHM and mean angular spread were 14.2 MeV, 0.08 cm and 0.8 degree, respectively. The MC simulations yielded the comparable measurement results of these optimum parameters. The gamma passing rates (with acceptance criteria of 1% /1 mm) for percentage depth doses were found to be 100% for all field sizes. For cross-line profiles, the gamma passing rates were 100%, 97%, 95%, 96% and 95% for 5×5, 10×10, 20×20, 30×30 and 40×40 cm2 field sizes, respectively. CONCLUSIONS: By validation of the MC model of Siemens Oncor® linac using various field sizes, it was found that both dose profiles of small and large field sizes were very sensitive to the changes in spatial FWHM and mean angular spread of the primary electron beam from the bending magnet. Hence, it is recommended that both small and large field sizes of the 18 MV photon beams should be considered in the Monte Carlo linac modeling. [ABSTRACT FROM AUTHOR]

Background and purpose: This study reported the justification and selection of acceptable γ criteria with respect to low (6 MV) and high (15 MV) photon beams for intensity-modulated radiation therapy quality assurance (IMRT QA) using the Gafchromic external beam therapy 3 (EBT3) film. Materials and methods: Five-field step-and-shoot IMRT was used to treat 16 brain IMRT patients using the dual-energy DHX-S linear accelerator (Varian Medical System, Palo Alto, CA, USA). Dose comparisons between computed values of the treatment planning system (TPS) and Gafchromic EBT3 film were evaluated based on γ analysis using the Film QA Pro software. The dose distribution was analysed with gamma area histograms (GAHs) generated using different γ criteria (3%/2 mm, 3%/3 mm and 5%/3 mm) for the 6 and 15 MV photon beams, to optimise the best distance-to-agreement (DTA) criteria with respect to the beam energy. Results: From the comparison between the dose distributions acquired from the TPS and EBT3 film, a DTA criterion of 3%/2 mm showed less dose differences (DDs) with passing rates up to 93% for the 6 MV photon beams, while for the 15 MV a relaxed DTA criterion of 5%/3 mm was consistent with the DD acceptability criteria with a 95% passing rate. Conclusions: Our results suggested that high-energy photon beams required relaxed DTA criteria for the brain IMRT QA, while low-energy photon beams showed better results even with tight DTA criteria. [ABSTRACT FROM AUTHOR]

Linear accelerator (linac) commissioning and quality assurance measurements are time‐consuming tasks that often require a water tank scanning system to acquire profile scans for full characterization of dosimetric beam properties. To increase efficiency, a method is demonstrated to acquire variable resolution, photon beam profile data using a commercially available ion chamber array (0.5 cm detector spacing). Field sizes of 2 × 2, 5 × 5, 10 × 10, and 15 × 15 cm2 were acquired at depths in solid water of dmax, 5 cm, and 10 cm; additionally, beam profiles for field sizes of 25 × 25 and 40 × 40 cm2 were acquired at 5 cm depth in solid water at x‐ray energies of 6 and 23 MV. 1D composite profiles were generated by combining discrete point measurements made at multiple couch positions. The 1D composite profile dataset was evaluated against a commissioning dataset acquired with a 3D water tank scan system utilizing (a) 0.125 cc ion chamber for 5 × 5, 10 × 10, 15 × 15, 25 × 25, and 40 × 40 field sizes and (b) a solid state detector for 2 × 2 cm2 field size. The two datasets were compared to the gamma criteria at 1%/1 mm and 2%/2 mm tolerance. Almost all pass rates exceeded 95% at 2%/2 mm except for the 6 MV 2 × 2 cm2 field size at dmax. Pass rates at 1%/1 mm ranged from 51% to 99%, with an average pass rate of 82%. A fourfold reduction in MU was achieved for scans larger than 15 × 15 cm2 using this method compared to the water tank scans. Further, dynamic wedge measurements acquired with the ion chamber array showed reasonable agreement with the treatment planning system. This method opens up new possibilities for rapid acquisition of variable resolution 2D–3D dosimetric data mitigating the need for acquiring all scan data with in‐water measurements. [ABSTRACT FROM AUTHOR]

Purpose: Well-known defect of TG-43 based algorithms used in brachytherapy is a lack of information about interaction cross-sections, which are determined not only by electron density but also by atomic number. TG-186 recommendations with using of MBDCA (model-based dose calculation algorithm), accurate tissues segmentation, and the structure’s elemental composition continue to create difficulties in brachytherapy dosimetry. For the clinical use of new algorithms, it is necessary to introduce reliable and repeatable methods of treatment planning systems (TPS) verification. The aim of this study is the verification of calculation algorithm used in TPS for shielded vaginal applicators as well as developing verification procedures for current and further use, based on the film dosimetry method. Material and methods : Calibration data was collected by separately irradiating 14 sheets of Gafchromic® EBT films with the doses from 0.25 Gy to 8.0 Gy using HDR 192Ir source. Standard vaginal cylinders of three diameters were used in the water phantom. Measurements were performed without any shields and with three shields combination. Gamma analyses were performed using the VeriSoft® package. Results : Calibration curve was determined as third-degree polynomial type. For all used diameters of unshielded cylinder and for all shields combinations, Gamma analysis were performed and showed that over 90% of analyzed points meets Gamma criteria (3%, 3 mm). Conclusions : Gamma analysis showed good agreement between dose distributions calculated using TPS and measured by Gafchromic films, thus showing the viability of using film dosimetry in brachytherapy.

Purpose: To present a new adaptive radiotherapy (ART) method based on relative gamma analysis and patient classification for the identification of anatomical changes that induce a sufficient dosimetric impact to affect the treatment delivery and require complete replanning. Methods: This retrospective study includes 55 patients treated for a head and neck cancer with IMRT, VMAT, or 3D conformal RT. Electronic Portal Imaging Device images for all treatment fields were acquired daily at every fraction. CBCTs were collected at least once a week. Gamma analysis was performed using the first fraction of the treatment as a reference once validated that it was delivered without error. Gamma analysis parameters (<γ>, standard deviation and the Top 1% γ) were used to define categories using statistic from a k‐means clustering analysis. From these categories an action threshold was defined and correlated with dosimetric changes. For 23 of 55 patients, the V100% for PTV was computed for both, the planning CT and original contours deformed onto CBCT acquired at the last fraction. These values were then compared with 2D image relative γ‐analysis of EPID images. Sensitivity and specificity of the method for the detection of dosimetric changes were computed. Results: Three categories indicating an increasing level of change with the planned treatment were identified. A threshold was established for which patients were at risk of deviation at <γ> = 0.42. From 23 recomputing plans, it has been confirmed that patients with a strong dosimetric impact were above this threshold, with a specificity of 0.80 and a sensitivity of 0.84. Conclusions: The specificity and the sensitivity value confirmed the performance of the method to detect anatomical changes. The γ‐analysis threshold correlated well with morphological changes that have a relevant dosimetric impact. Analysis of daily EPID images provides a method to identify patients at risk of deviation from their planned treatment and can support an early replanning decision. [ABSTRACT FROM AUTHOR]

The aim of this study was to compare dosimetry with Gafchromic EBT2 and EBT3 films to the ion chamber array PTW seven29 in terms of their performance in clinical IMRT plan verification. A methodology for film processing and calibration was developed. Calibration curves were obtained in MATLAB and in FilmQA Pro. The best calibration curve was then used to calibrate EBT2 and EBT3 films for IMRT plan verification measurements. Films were placed in several coronal planes into an RW3 slab phantom and irradiated with a clinical IMRT plan for prostate and lymph nodes using 18 MV photon beams. Individual fields were tested and irradiated with gantry at 0°. Results were evaluated using gamma analysis with 3%/3 mm criteria in OmniPro I’mRT version 1.7. The same measurements were performed with the ion chamber array PTW seven29 in RW3 slabs (different depths) and in the OCTAVIUS II phantom (isocenter depth only; both original and nominal gantry angles). Results were evaluated in PTW VeriSoft version 3.1 using the same criteria. Altogether, 45 IMRT planes were tested with film and 25 planes with the PTW 2D-ARRAY seven29. Film measuerements showed different results than ion chamber matrix measurements. With PTW 2D-ARRAY seven29, worse results were obtained when the detector was placed into the OCTAVIUS phantom than into the RW3 slab phantom, and the worst pass rates were seen for rotational measurements. EBT2 films showed inconsistent results and could differ significantly for different planes in one field. EBT3 films seemed to give the best results of all the tested configurations. [ABSTRACT FROM AUTHOR]