Dosimetric verification of intensity modulated beams produced with dynamic multileaf collimation using an electronic portal imaging device

Dose distributions can often be significantly improved by modulating the two-dimensional intensity profile of the individual x-ray beams. One technique for delivering intensity modulated beams is dynamic multileaf collimation (DMLC). However, DMLC is complex and requires extensive quality assurance. In this paper a new method is presented for a pretreatment dosimetric verification of these intensity modulated beams utilizing a charge-coupled device camera based fluoroscopic electronic portal imaging device (EPID). In the absence of the patient, EPID images are acquired for all beams produced with DMLC. These images are then converted into two-dimensional dose distributions and compared with the calculated dose distributions. The calculations are performed with a pencil beam algorithm as implemented in a commercially available treatment planning system using the same absolute beam fluence profiles as used for calculation of the patient dose distribution. The method allows an overall verification of (i) the leaf trajectory calculation (including the models to incorporate collimator scatter and leaf transmission), (ii) the correct transfer of the leaf sequencing file to the treatment machine, and (iii) the mechanical and dosimetrical performance of the treatment unit. The method was tested for intensity modulated 10 and 25 MV photon beams; both model cases and real clinical cases were studied. Dose profiles measured with the EPID were also compared with ionization chamber measurements. In all cases both predictions and EPID measurements and EPID and ionization chamber measurements agreed within 2% (1 sigma). The study has demonstrated that the proposed method allows fast and accurate pretreatment verification of DMLC.     

Verification of multileaf collimator leaf positions using an electronic portal imaging device

An automated method is presented for determining individual leaf positions of the Siemens dual focus multileaf collimator (MLC) using the Siemens BEAMVIEW(PLUS) electronic portal imaging device (EPID). Leaf positions are computed with an error of 0.6 mm at one standard deviation (sigma) using separate computations of pixel dimensions, image distortion, and radiation center. The pixel dimensions are calculated by superimposing the film image of a graticule with the corresponding EPID image. A spatial correction is used to compensate for the optical distortions of the EPID, reducing the mean distortion from 3.5 pixels (uncorrected) per localized x-ray marker to 2 pixels (1 mm) for a rigid rotation and 1 pixel for a third degree polynomial warp. A correction for a nonuniform dosimetric response across the field of view of the EPID images is not necessary due to the sharp intensity gradients across leaf edges. The radiation center, calculated from the average of the geometric centers of a square field at 0 degrees and 180 degrees collimator angles, is independent of graticule placement error. Its measured location on the EPID image was stable to within 1 pixel based on 3 weeks of repeated extensions/retractions of the EPID. The MLC leaf positions determined from the EPID images agreed to within a pixel of the corresponding values measured using film and ionization chamber. Several edge detection algorithms were tested: contour, Sobel, Roberts, Prewitt, Laplace, morphological, and Canny. These agreed with each other to within < or = 1.2 pixels for the in-air EPID images. Using a test pattern, individual MLC leaves were found to be typically within 1 mm of the corresponding record-and-verify values, with a maximum difference of 1.8 mm, and standard deviations of <0.3 mm in the daily reproducibility. This method presents a fast, automatic, and accurate alternative to using film or a light field for the verification and calibration of the MLC.     

Requirements for leaf position accuracy for dynamic multileaf collimation

Intensity modulated radiation therapy can be achieved by driving the leaves of a multileaf collimator (MLC) across an x-ray therapy beam. Algorithms to generate the required leaf trajectories assume that the leaf positions are exactly known to the MLC controller. In practice, leaf positions depend upon calibration accuracy and stability and may vary within set tolerances. The purpose of this study was to determine the effects of potential leaf position inaccuracies on intensity modulated beams. Equations are derived which quantify the absolute error in delivered monitor units given a known error in leaf position. The equations have been verified by ionization chamber measurements in dynamically delivered flat fields, comparing deliveries in which known displacements have been applied to the defined leaf positions with deliveries without displacements applied. The equations are then applied to two clinical intensity modulations: an inverse planned prostate field and a breast compensating field. It is shown that leaf position accuracy is more critical for a highly modulated low-dose intensity profile than a moderately modulated high-dose intensity profile. Suggestions are given regarding the implications for quality control of dynamic MLC treatments.     

Use of an amorphous silicon electronic portal imaging device for multileaf collimator quality control and calibration

Multileaf collimator (MLC) calibration and quality control is a time-consuming procedure typically involving the processing, scanning and analysis of films to measure leaf and collimator positions. Faster and more reliable calibration procedures are required for these tasks, especially with the introduction of intensity modulated radiotherapy which requires more frequent checking and finer positional leaf tolerances than previously. A routine quality control (QC) technique to measure MLC leaf bank gain and offset, as well as minor offsets (individual leaf position relative to a reference leaf), using an amorphous silicon electronic portal imaging device (EPID) has been developed. The technique also tests the calibration of the primary and back-up collimators. A detailed comparison between film and EPID measurements has been performed for six linear accelerators (linacs) equipped with MLC and amorphous silicon EPIDs. Measurements of field size from 4 to 24 cm with the EPID were systematically smaller than film measurements over all field sizes by 0.4 mm for leaves/back-up collimators and by 0.2 mm for conventional collimators. This effect is due to the gain calibration correction applied by the EPID, resulting in a 'flattening' of primary beam profiles. Linac dependent systematic differences of up to 0.5 mm in individual leaf/collimator positions were also found between EPID and film measurements due to the difference between the mechanical and radiation axes of rotation. When corrections for these systematic differences were applied, the residual random differences between EPID and film were 0.23 mm and 0.26 mm (1 standard deviation) for field size and individual leaf/back-up collimator position, respectively. Measured gains (over a distance of 220 mm) always agreed within 0.4 mm with a standard deviation of 0.17 mm. Minor offset measurements gave a mean agreement between EPID and film of 0.01+/-0.10 mm (1 standard deviation) after correction for the tilt of the EPID and small rotational misalignments between leaf banks and the back-up collimators used as a reference straight edge. Reproducibility of EPID measurements was found to be very high, with a standard deviation of <0.05 mm for field size and <0.1 mm for individual leaf/collimator positions for a 10x10 cm2 field. A standard set of QC images (three field sizes defined both by leaves only and collimators only) can be acquired in less than 20 min and analysed in 5 min.     

Dosimetric verification of x-ray fields with steep dose gradients using an electronic portal imaging device

Regions with steep dose gradients are often encountered in clinical x-ray beams, especially with the growing use of intensity modulated radiotherapy (IMRT). Such regions are present both at field edges and, for IMRT, in the vicinity of the projection of sensitive anatomical structures in the treatment field. Dose measurements in these regions are often difficult and labour intensive, while dose prediction may be inaccurate. A dedicated algorithm developed in our institution for conversion of pixel values, measured with a charged coupled device camera based fluoroscopic electronic portal imaging device (EPID), into absolute absorbed doses at the EPID plane has an accuracy of 1-2% for flat and smoothly modulated fields. However, in the current algorithm there is no mechanism to correct for the (short-range) differences in lateral electron transport between water and the metal plate with the fluorescent layer in the EPID. Moreover, lateral optical photon transport in the fluorescent layer is not taken into account. This results in large deviations (>10%) in the penumbra region of these fields. We have investigated the differences between dose profiles measured in water and with the EPID for small heavily peaked fields. A convolution kernel has been developed to empirically describe these differences. After applying the derived kernel to raw EPID images, a general agreement within 2% was obtained with the water measurements in the central region of the fields, and within 0.03 cm in the penumbra region. These results indicate that the EPID is well suited for accurate dosimetric verification of steep gradient x-ray fields.     

Dosimetric properties of an amorphous silicon electronic portal imaging device for verification of dynamic intensity modulated radiation therapy

Dosimetric properties of an amorphous silicon electronic portal imaging device (EPID) for verification of dynamic intensity modulated radiation therapy (IMRT) delivery were investigated. The EPID was utilized with continuous frame-averaging during the beam delivery. Properties studied included effect of buildup, dose linearity, field size response, sampling of rapid multileaf collimator (MLC) leaf speeds, response to dose-rate fluctuations, memory effect, and reproducibility. The dependence of response on EPID calibration and a dead time in image frame acquisition occurring every 64 frames were measured. EPID measurements were also compared to ion chamber and film for open and wedged static fields and IMRT fields. The EPID was linear with dose and dose rate, and response to MLC leaf speeds up to 2.5 cm s(-1) was found to be linear. A field size dependent response of up to 5% relative to dmax ion-chamber measurement was found. Reproducibility was within 0.8% (1 standard deviation) for an IMRT delivery recorded at intervals over a period of one month. The dead time in frame acquisition resulted in errors in the EPID that increased with leaf speed and were over 20% for a 1 cm leaf gap moving at 1.0 cm s(-1). The EPID measurements were also found to depend on the input beam profile utilized for EPID flood-field calibration. The EPID shows promise as a device for verification of IMRT, the major limitation currently being due to dead-time in frame acquisition.     

Quantitative measurement of MLC leaf displacements using an electronic portal image device

The success of an IMRT treatment relies on the positioning accuracy of the MLC (multileaf collimator) leaves for both step-and-shoot and dynamic deliveries. In practice, however, there exists no effective and quantitative means for routine MLC QA and this has become one of the bottleneck problems in IMRT implementation. In this work we present an electronic portal image device (EPID) based method for fast and accurate measurement of MLC leaf positions at arbitrary locations within the 40 cm x 40 cm radiation field. The new technique utilizes the fact that the integral signal in a small region of interest (ROI) is a sensitive and reliable indicator of the leaf displacement. In this approach, the integral signal at a ROI was expressed as a weighted sum of the contributions from the displacements of the leaf above the point and the adjacent leaves. The weighting factors or linear coefficients of the system equations were determined by fitting the integral signal data for a group of pre-designed MLC leaf sequences to the known leaf displacements that were intentionally introduced during the creation of the leaf sequences. Once the calibration is done, the system can be used for routine MLC leaf positioning QA to detect possible leaf errors. A series of tests was carried out to examine the functionality and accuracy of the technique. Our results show that the proposed technique is potentially superior to the conventional edge-detecting approach in two aspects: (i) it deals with the problem in a systematic approach and allows us to take into account the influence of the adjacent MLC leaves effectively; and (ii) it may improve the signal-to-noise ratio and is thus capable of quantitatively measuring extremely small leaf positional displacements. Our results indicate that the technique can detect a leaf positional error as small as 0.1 mm at an arbitrary point within the field in the absence of EPID set-up error and 0.3 mm when the uncertainty is considered. Given its simplicity, efficiency and accuracy, we believe that the technique is ideally suitable for routine MLC leaf positioning QA.     

A test tool for the visual verification of light and radiation fields using film or an electronic portal imaging device

We describe the design and evaluation of a simple test tool which can be used in conjunction with either film or an electronic portal imaging device (EPID) to verify light and radiation fields and their congruence. The precision of the technique is better than 0.5 mm under all conditions tested. When used with film the accuracy or offset of the technique (the difference between test tool observations and a scanned conventional film) is better than 0.5 mm but, with an EPID as the image receptor, the accuracy dropped to, in one trial, 0.86 mm. The offset may be due to a systematic observer bias in determining the 50% O.D. level on the image, compounded, in the case of EPID measurements, by image acquisition and display parameters. Thus, when used with an EPID, calibration of the system will be required if absolute field dimensions are required. When used with film, the test tool method described here is of sufficient accuracy and precision to confirm the compliance of light and radiation field parameters with currently accepted quality control protocols.     

Sampling considerations for intensity modulated radiotherapy verification using electronic portal imaging

A model has been developed to describe the sampling process that occurs when intensity modulated radiotherapy treatments (delivered with a multileaf collimator) are imaged with an electronic portal imaging device that acquires a set of frames with a finite dead-time between them. The effects of the imaging duty cycle and frame rate on the accuracy of dosimetric verification have been studied. A frame interval of 1 s with 25%, 50% and 75% duty cycle, and a 50% duty cycle with frame intervals of 1, 2, 4, 8, and 16 s have been studied for a smoothly varying hemispherical intensity profile, and a 50% duty cycle with frame intervals of 1, 2, 4, and 8 s for a pixellated distribution. In addition an intensity modulated beam for breast radiotherapy has been modeled and imaged for 0.33 s frame time and 1, 2, and 3 s frame separation. The results show that under sparse temporal sampling conditions, errors of the order of 10% may ensue and occur with an oscillatory pattern. For the beams studied, imaging with a 1 or 2 s frame interval resulted in small errors at the 1%-2% level, for all duty cycles shown.     

Dosimetric investigation and portal dose image prediction using an amorphous silicon electronic portal imaging device.

A two step algorithm to predict portal dose images in arbitrary detector systems has been developed recently. The current work provides a validation of this algorithm on a clinically available, amorphous silicon flat panel imager. The high-atomic number, indirect amorphous silicon detector incorporates a gadolinium oxysulfide phosphor scintillating screen to convert deposited radiation energy to optical photons which form the portal image. A water equivalent solid slab phantom and an anthropomorphic phantom were examined at beam energies of 6 and 18 MV and over a range of air gaps (approximately 20-50 cm). In the many examples presented here, portal dose images in the phosphor were predicted to within 5% in low-dose gradient regions, and to within 5 mm (isodose line shift) in high-dose gradient regions. Other basic dosimetric characteristics of the amorphous silicon detector were investigated, such as linearity with dose rate (+/- 0.5%), repeatability (+/- 2%), and response with variations in gantry rotation and source to detector distance. The latter investigation revealed a significant contribution to the image from optical photon spread in the phosphor layer of the detector. This phenomenon is generally known as "glare," and has been characterized and modeled here as a radially symmetric blurring kernel. This kernel is applied to the calculated dose images as a convolution, and is successfully demonstrated to account for the optical photon spread. This work demonstrates the flexibility and accuracy of the two step algorithm for a high-atomic number detector. The algorithm may be applied to improve performance of dosimetric treatment verification applications, such as direct image comparison, backprojected patient dose calculation, and scatter correction in megavoltage computed tomography. The algorithm allows for dosimetric applications of the new, flat panel portal imager technology in the indirect configuration, taking advantage of a greater than tenfold increase in detector sensitivity over a direct configuration.     

Radiotherapy treatment verification using radiological thickness measured with an amorphous silicon electronic portal imaging device: Monte Carlo simulation and experiment

This work validates the use of an amorphous-silicon, flat-panel electronic portal imaging device (a-Si EPID) for use as a gauge of patient or phantom radiological thickness, as an alternative to dosimetry. The response of the a-Si EPID is calibrated by adapting a technique previously applied to scanning liquid ion chamber EPIDs, and the stability, accuracy and reliability of this calibration are explored in detail. We find that the stability of this calibration, between different linacs at the same centre, is sufficient to justify calibrating only one of the EPIDs every month and using the calibration data thus obtained to perform measurements on all of the other linacs. Radiological thickness is shown to provide a reliable means of relating experimental measurements to the results of BEAMnrc Monte Carlo simulations of the linac-phantom-EPID system. For these reasons we suggest that radiological thickness can be used to verify radiotherapy treatment delivery and identify changes in the treatment field, patient position and target location, as well as patient physical thickness.     

Leaf position verification during dynamic beam delivery: a comparison of three applications using electronic portal imaging

The use of a dynamic multileaf collimator (MLC) to deliver intensity-modulated beams presents a problem for conventional verification techniques. The use of electronic portal imaging to track MLC leaves during beam delivery has been shown to provide a solution to this problem. An experimental comparison of three different verification systems, each using a different electronic portal imaging technology, is presented. Two of the systems presented are commercially available imagers with in-house modifications, with the third system being an in-house built experimental system. The random and systematic errors present in each of the verifications systems are measured and presented, together with the study of the effects of varying dose rate and leaf speed on verification system performance. The performance of the three systems is demonstrated to be very similar, with an overall accuracy in comparing measured and prescribed collimator trajectories of approximately +/-1.0 mm. Systematic errors in the percentage delivered dose signal provided by the accelerator are significant and must be corrected for good performance of the current systems. It is demonstrated that, with suitable modifications, commercially available portal imaging systems can be used to verify dynamic MLC beam delivery.     

Investigation of the optimal backscatter for an aSi electronic portal imaging device

The effects of backscattered radiation on the dosimetric response of the Varian aS500 amorphous silicon electronic portal imaging device (EPID) are studied. Measurements demonstrate that radiation backscattered from the EPID mechanical support structure causes 5% asymmetries in the detected signal. To minimize the effect of backscattered radiation from the support structure, this work proposes adding material downstream of the EPID phosphor which provides uniform backscattering material to the phosphor and attenuates backscatter from the support structure before it reaches the phosphor. Two material locations were studied: downstream of the existing image cassette and within the cassette, immediately downstream of the flat-panel imager glass panel. Monte Carlo simulations were used to determine the thicknesses of water, Pb and Cu backscattering materials required to saturate the backscattered signal response for 6 MV and 18 MV beams for material thicknesses up to 50 mm. Water was unable to saturate the backscattered signal for thicknesses up to 50 mm for both energies. For Pb, to obtain a signal within 1% of saturation, 3 mm was required at 6 MV, and 6.8 mm was required at 18 MV. For Cu, thicknesses of 20.6 mm and 22.6 mm were required for the 6 MV and 18 MV beams, respectively. For saturation thicknesses, at 6 MV, the Cu backscatter enhanced the signal more than for Pb (Cu 1.25, Pb 1.11), but at 18 MV the reverse was found (Cu 1.19, Pb 1.23). This is due to the fact that at 6 MV, the backscattered radiation signal is dominated by low-energy scattered photons, which are readily attenuated by the Pb, while at 18 MV, electron backscatter contributes substantially to the signal. Image blurring caused by backscatter spread was less for Pb than Cu. Placing Pb immediately downstream of the glass panel further reduced the signal spread and increased the backscatter enhancement to 1.20 and 1.39 for the 6 MV and 18 MV beams, respectively. Overall, it is determined that adding approximately 5 mm of Pb between the detector and the mechanical support structure will substantially reduce the nonuniformity in the backscattered signals for 6 MV and 18 MV photon beams.     

Verification of the optimal backscatter for an aSi electronic portal imaging device

Electronic portal imaging devices (EPIDs), currently used for determining proper patient placement during irradiation in a radiotherapy treatment, can also be used as dosimeters. However, the Varian aS500 portal imager exhibits dosimetric artefacts caused by non-uniform backscatter from mechanical support structures located behind the imager. Monte Carlo simulations predict that adding 5 mm of Pb behind the imaging cassette will reduce the non-uniform backscatter to <1% for 6 MV and to <1.5% for 18 MV photon beams. This study experimentally tested this hypothesis by comparing images using an unmodified test imager and an imager modified by adding 3 and 5 mm of Pb behind the imaging cassette. Using the modified imager containing 5 mm of Pb, the non-uniform backscatter was reduced to <0.5% for 6 MV and <0.6% for 18 MV beams. Addition of the 5 mm of Pb increased the detector contrast by 3.5% +/- 0.5% at 6 MV and 5.0% +/- 0.7% at 18 MV, and increased the resolution by 0.9% +/- 0.2% at 6 MV and 0.5% +/- 0.12% at 18 MV.     

Accurate measurement of the dynamic response of a scanning electronic portal imaging device

An important condition for the safe introduction of dynamic intensity modulated radiotherapy (IMRT) using a multileaf collimator (MLC) is the ability to verify the leaf trajectories. In order to verify IMRT using an electronic portal imaging device (EPID), the EPID response should be accurate and fast. Noninstantaneous dynamic response causes motion blurring. The aim of this study is to develop a measurement method to determine the magnitude of the geometrical error as a result of motion blurring for imagers with scanning readout. The response of a liquid-filled ionization chamber EPID, as an example of a scanning imager, on a moving beam is compared with the response of a diode placed at the surface of the EPID. The signals are compared under the assumption that all EPID rows measure the same dose rate when a straight moving field edge is imaged. The measurements are performed at several levels of attenuation to investigate the influence of dose rate on the response of the detector. The accuracy of the measurement method is better than 0.25 mm. We found that the liquid-filled ionization chamber EPID does not suffer from significant motion blurring under clinical circumstances. Using a maximum gradient edge detector to determine the field edge in an image obtained by a liquid-filled ionization chamber EPID, errors smaller than 1 mm are found at a dose rate of 105 MU/min and a field edge speed of 1.1 cm/s. The errors reduce at higher dose rates. The presented method is capable of quantifying the geometrical errors in determining the position of the edge of a moving field with subpixel accuracy. The errors in field edge position determined by a liquid-filled ionization chamber EPID are negligible in clinical practice. Consequently, these EPIDs are suitable for geometric IMRT verification, as far as dynamic response is concerned.     

Dose-response and ghosting effects of an amorphous silicon electronic portal imaging device

The purpose of this study was to investigate the dose-response characteristics, including ghosting effects, of an amorphous silicon-based electronic portal imaging device (a-Si EPID) under clinical conditions. EPID measurements were performed using one prototype and two commercial a-Si detectors on two linear accelerators: one with 4 and 6 MV and the other with 8 and 18 MV x-ray beams. First, the EPID signal and ionization chamber measurements in a mini-phantom were compared to determine the amount of buildup required for EPID dosimetry. Subsequently, EPID signal characteristics were studied as a function of dose per pulse, pulse repetition frequency (PRF) and total dose, as well as the effects of ghosting. There was an over-response of the EPID signal compared to the ionization chamber of up to 18%, with no additional buildup layer over an air gap range of 10 to 60 cm. The addition of a 2.5 mm thick copper plate sufficiently reduced this over-response to within 1% at clinically relevant patient-detector air gaps (> 40 cm). The response of the EPIDs varied by up to 8% over a large range of dose per pulse values, PRF values and number of monitor units. The EPID response showed an under-response at shorter beam times due to ghosting effects, which depended on the number of exposure frames for a fixed frame acquisition rate. With an appropriate build-up layer and corrections for dose per pulse, PRF and ghosting, the variation in the a-Si EPID response can be reduced to well within +/- 1%.     

IMRT verification with a camera-based electronic portal imaging system

An evaluation of the capabilities of a commercially available camera-based electronic portal imaging system for intensity-modulated radiotherapy verification is presented. Two modifications to the system are demonstrated which use a novel method to tag each image acquired with the delivered dose measured by the linac monitor chamber and reduce optical cross-talk in the imager. A detailed performance assessment is presented, including measurements of the optical decay characteristics of the system. The overall geometric accuracy of the system is determined to be +/-2.0 mm, with a dosimetric accuracy of +/-1.25 MU. Finally a clinical breast IMRT treatment, delivered by dynamic multileaf collimation, is successfully verified both by tracking the position of each leaf during beam delivery and recording the integrated intensity observed over the entire beam.