A feasible method for clinical delivery verification and dose reconstruction in tomotherapy

Delivery verification is the process in which the energy fluence delivered during a treatment is verified. This verified energy fluence can be used in conjunction with an image in the treatment position to reconstruct the full three-dimensional dose deposited. A method for delivery verification that utilizes a measured database of detector signal is described in this work. This database is a function of two parameters, radiological path-length and detector-to-phantom distance, both of which are computed from a CT image taken at the time of delivery. Such a database was generated and used to perform delivery verification and dose reconstruction. Two experiments were conducted: a simulated prostate delivery on an inhomogeneous abdominal phantom, and a nasopharyngeal delivery on a dog cadaver. For both cases, it was found that the verified fluence and dose results using the database approach agreed very well with those using previously developed and proven techniques. Delivery verification with a measured database and CT image at the time of treatment is an accurate procedure for tomotherapy. The database eliminates the need for any patient-specific, pre- or post-treatment measurements. Moreover, such an approach creates an opportunity for accurate, real-time delivery verification and dose reconstruction given fast image reconstruction and dose computation tools.     

Monte Carlo calculation of helical tomotherapy dose delivery

Helical tomotherapy delivers intensity modulated radiation therapy using a binary multileaf collimator (MLC) to modulate a fan beam of radiation. This delivery occurs while the linac gantry and treatment couch are both in constant motion, so the beam describes, from a patient/phantom perspective, a spiral or helix of dose. The planning system models this continuous delivery as a large number (51) of discrete gantry positions per rotation, and given the small jaw/fan width setting typically used (1 or 2.5 cm) and the number of overlapping rotations used to cover the target (pitch often <0.5), the treatment planning system (TPS) potentially employs a very large number of static beam directions and leaf opening configurations to model the modulated fields. All dose calculations performed by the system employ a convolution/superposition model. In this work the authors perform a full Monte Carlo (MC) dose calculation of tomotherapy deliveries to phantom computed tomography (CT) data sets to verify the TPS calculations. All MC calculations are performed with the EGSnrc-based MC simulation codes, BEAMnrc and DOSXYZnrc. Simulations are performed by taking the sinogram (leaf opening versus time) of the treatment plan and decomposing it into 51 different projections per rotation, as does the TPS, each of which is segmented further into multiple MLC opening configurations, each with different weights that correspond to leaf opening times. Then the projection is simulated by the summing of all of the opening configurations, and the overall rotational treatment is simulated by the summing of all of the projection simulations. Commissioning of the source model was verified by comparing measured and simulated values for the percent depth dose and beam profiles shapes for various jaw settings. The accuracy of the MLC leaf width and tongue and groove spacing were verified by comparing measured and simulated values for the MLC leakage and a picket fence pattern. The validated source and MLC configuration were then used to simulate a complex modulated delivery from fixed gantry angle. Further, a preliminary rotational treatment plan to a delivery quality assurance phantom (the "cheese" phantom) CT data set was simulated. Simulations were compared with measured results taken with an A1SL ionization chamber or EDR2 film measurements in a water tank or in a solid water phantom, respectively. The source and MLC MC simulations agree with the film measurements, with an acceptable number of pixels passing the 2%/1 mm gamma criterion. 99.8% of voxels of the MC calculation in the planning target volume (PTV) of the preliminary plan passed the 2%/2 mm gamma value test. 87.0% and 66.2% of the voxels in two organs at risk (OARs) passed the 2%/2 mm tests. For a 3%/3 mm criterion, the PTV and OARs show 100%, 93.2%, and 86.6% agreement, respectively. All voxels passed the gamma value test with a criterion of 5%/3 mm. The Tomo-Therapy TPS showed comparable results.     

Measurement of superficial dose from a static tomotherapy beam

Superficial doses were measured for static TomoTherapy Hi-Art beams for normal and oblique incidence. Dose was measured at depths < or = 2 cm along the central axis of 40 x 5 cm2 and 40 x 2.5 cm2 beams at normal incidence for source to detector distances (SDDs) of 55, 70, and 85 cm. Measurements were also made at depths normal to the phantom surface for the same beams at oblique angles of 30 degrees, 45 degrees, 60 degrees, 75 degrees, and 83 degrees from the normal. Data were collected with a Gammex/RMI model 449 parallel-plate chamber embedded in a solid water phantom and with LiF thermoluminescent dosimeters (TLDs) in the form of powder. For comparison, measurements were made on a conventional 6 MV beam (Varian Clinac 2100C) at normal incidence and at an oblique angle of 60 degrees from the normal. TomoTherapy surface dose varied with the distance from the source and the angle of incidence. For normal incidence, surface dose increased from 0.16 to 0.43 cGy/MU as the distance from the source decreased from 85 to 55 cm for the 40 x 5 cm2 field and increased from 0.12 to 0.32 cGy/MU for the 40 x 2.5 cm2 field. As the angle of incidence increased from 0 degrees to 83 degrees, surface dose increased from 0.24 to 0.63 cGy/MU for the 40 x 5 cm2 field and from 0.18 to 0.58 cGy/MU for the 40 x 2.5 cm2 field. For normal incidence at 55 cm SDD, the surface dose relative to the dose at d(max) for the 40 x 5 cm2 TomoTherapy Hi-Art beam was 31% less than that from a conventional, flattening filter based linear accelerator. These data should prove useful in accessing the accuracy of the TomoTherapy treatment planning system to predict the dose at superficial depths for a static beam delivery.     

On the biophysical interpretation of the mathematical product of dose and relative biological effectiveness

The mathematical product of dose and relative biological effectiveness (DR) is commonly used empirically as the 'effective' dose of radiations. It is often interpreted as the equivalent dose of a reference radiation, such that the individual DRs of the radiation components are summed like physical doses in a mixture of radiations with different RBE values. It is shown that such a physical interpretation of DR would be both mathematically and logically inconsistent unless the action of each radiation has a constant RBE value for all end-effects. This is contrary to general experimental findings. Based on the isoeffect biological connotation in the definition of RBE, a biophysical interpretation is being introduced in this paper in which DR is always interpreted with respect to a particular end-effect on which the RBE value is evaluated, somewhat similar to having an extra biological dimension. Hence, only DRs evaluated for the same end-effect can be meaningfully computed together in a mixture. From the empirical results of radiobiological experiments using mixtures of radiations of different qualities, DRs of radiation components are shown to be additive in a mixture just like physical doses. A convenient linear computation framework is, therefore, available for the use of DRs in the empirical calculation of effect of mixtures of radiations of different qualities. The bearing of this biophysical interpretation of DR on radiation protection and treatment planning is discussed.     

On the impact of longitudinal breathing motion randomness for tomotherapy delivery

The purpose of this study is to explain the unplanned longitudinal dose modulations that appear in helical tomotherapy (HT) dose distributions in the presence of irregular patient breathing. This explanation is developed by the use of longitudinal (1D) simulations of mock and surrogate data and tested with a fully 4D HT delivered plan. The 1D simulations use a typical mock breathing function which allows more flexibility to adjust various parameters. These simplified simulations are then made more realistic by using 100 surrogate waveforms all similarly scaled to produce longitudinal breathing displacements. The results include the observation that, with many waveforms used simultaneously, a voxel-by-voxel probability of a dose error from breathing is found to be proportional to the realistically random breathing amplitude relative to the beam width if the PTV is larger than the beam width and the breathing displacement amplitude. The 4D experimental test confirms that regular breathing will not result in these modulations because of the insensitivity to leaf motion for low-frequency dynamics such as breathing. These modulations mostly result from a varying average of the breathing displacements along the beam edge gradients. Regular breathing has no displacement variation over many breathing cycles. Some low-frequency interference is also possible in real situations. In the absence of more sophisticated motion management, methods that reduce the breathing amplitude or make the breathing very regular are indicated. However, for typical breathing patterns and magnitudes, motion management techniques may not be required with HT because typical breathing occurs mostly between fundamental HT treatment temporal and spatial scales. A movement beyond only discussing margins is encouraged for intensity modulated radiotherapy such that patient and machine motion interference will be minimized and beneficial averaging maximized. These results are found for homogeneous and longitudinal on-axis delivery for unplanned longitudinal dose modulations.     

Investigation of dose homogeneity for loose helical tomotherapy delivery in the context of breath-hold radiation therapy

Loose helical delivery is a potential solution to account for respiration-driven tumour motion in helical tomotherapy (HT). In this approach, a treatment is divided into a set of interlaced 'loose' helices commencing at different gantry angles. Each loose helix covers the entire target length in one gantry rotation during a single breath-hold. The dosimetric characteristics of loose helical delivery were investigated by delivering a 6 MV photon beam in a HT-like manner. Multiple scenarios of conventional 'tight' HT and loose helical deliveries were modelled in treatment planning software, and carried out experimentally with Kodak EDR2 film. The advantage of loose helical delivery lies in its ability to produce a more homogeneous dose distribution by eliminating the 'thread' effect-an inherent characteristic of HT, which results in dose modulations away from the axis of gantry rotation. However, loose helical delivery was also subjected to undesirable dose modulations in the direction of couch motion (termed 'beating' effect), when the ratio between the number of beam projections per gantry rotation (n) and pitch factor (p) was a non-integer. The magnitude of dose modulations decreased with an increasing n/p ratio. The results suggest that for the current HT unit (n = 51), dose modulations could be kept under 5% by selecting a pitch factor smaller than 7. A pitch factor of this magnitude should be able to treat a target up to 30 cm in length. Loose helical delivery should increase the total session time only by a factor of 2, while the planning time should stay the same since the total number of beam projections remains unchanged. Considering its dosimetric advantage and clinical practicality, loose helical delivery is a promising solution for the future HT treatments of respiration-driven targets.     

ArcCheck探测螺旋断层放疗误差的敏感性

目的:针对螺旋断层放疗（HT）系统,分析ArcCheck验证患者计划通过率对治疗床运动速度误差、机架旋转周期误差、机架起始角度误差、多叶准直器叶片开启时间误差的敏感性。方法:选取9例行HT的鼻咽癌患者计划,由自编程序生成与原计划相对应的误差计划。应用点剂量及Gamma分析,计算得出上述误差的临床可检测误差值。结果:所有患者的原计划采用3%/2 mm、2%/1 mm标准时的平均Gamma通过率分别为97.49%±1.08%、73.38%±4.31%。应用3%/2 mm通过率标准时,可检测的最小误差分别为治疗床运动速度:-1.58%、1.38%（上下限阈值）,机器旋转周期:-1.68%、1.31%（上下限阈值）,机架起始角度误差:2.50°,多叶准直器叶片开启时间:1.62%。而应用2%/1 mm标准时,检测精度得到提升,可检测的最小误差分别为治疗床运动速度:-0.69%、1.27%,机器旋转周期:-0.69%、0.69%,机架起始角度误差:2.06°,多叶准直器叶片开启时间:0.52%。结论:ArcCheck与电离室测量点剂量联用与单独使用ArcCheck Gamma通过率相比并未表现出明显优势,ArcCheck可以检测出临床相关的照射误差,更为严格的Gamma通过率标准可以明显提高误差计划的检测精度。     

Fast radiographic film calibration procedure for helical tomotherapy intensity modulated radiation therapy dose verification

Film dosimetry offers an advantageous in-phantom planar dose verification tool in terms of spatial resolution and ease of handling for quality assurance (QA) of intensity modulated radiation therapy (IMRT) plans. A critical step in the success of such a technique is that the film calibration be appropriately conducted. This paper presents a fast and efficient film calibration method for a helical tomotherapy unit using a single sheet of film. Considering the unique un-flattened cone shaped profile from a helical tomotherapy beam, a custom leaf control file (sinogram) was created, to produce a valley shaped intensity pattern. There are eleven intensity steps in the valley pattern, representing varying dose values from 38 to 265 cGy. This dose range covers the most commonly prescribed doses in fractionated IMRT treatments. An ion chamber in a solid water phantom was used to measure the dose in each of the eleven steps. For daily film calibration the whole procedure, including film exposure, processing, digitization and analysis, can be completed within 15 min, making it practical to use this technique routinely. This method is applicable to film calibration on a helical tomotherapy unit and is particularly useful in IMRT planar dose verification due to its efficiency and reproducibility. In this work, we characterized the dose response of the KODAK EDR2 ready-pack film which was used to develop the step valley dose maps and the IMRT QA planar doses. A comparison between the step valley technique and multifilm based calibration showed that both calibration methods agreed with less than 0.4% deviation in the clinically useful dose ranges.     

Asymmetric fan beams (AFB) for improvement of the craniocaudal dose distribution in helical tomotherapy delivery

Helical tomotherapy (HT) is a novel radiotherapy technique that utilizes intensity modulated fan beams that deliver highly conformal dose distributions in a helical beam trajectory. The most significant limitation in dose delivery with a constant fan beam thickness (FBT) is the penumbra width of the dose distribution in the craniocaudal direction, which is equivalent to the FBT. We propose to employ a half-blocked fan beam at start and stop location to reduce the penumbra width by half. By opening the jaw slowly during the helical delivery until the desired FBT is achieved it is possible to create a sharper edge in the superior and inferior direction from the target. The technique was studied using a tomotherapy beam model implemented on a commercial treatment planning system (Theraplan Plus V3.0). It was demonstrated that the dose distribution delivered using a 25 mm fan beam can be improved significantly, to reduce the dose to normal structures located superiorly and inferiorly of the target. Dosimetry for this technique is straightforward down to a FBT of 15 mm and implementation should be simple as no changes in couch movement are required compared to a standard HT delivery. We conclude that the use of asymmetric collimated fan beams for the start and stop of the helical tomotherapeutic dose delivery has the potential of significantly improving the dose distribution in helical tomotherapy.     

The influence of the size of the grid used for dose calculation on the accuracy of dose estimation

The standard presentation of a dose distribution as an isodose map is based on interpolation between dose values calculated on a matrix of equally spaced points. We explored the question of how the spacing of the grid used for the dose matrix affects the error due to interpolating the dose at any point. We defined two types of errors: the dose error, which is the difference between the interpolated and true dose at a given point; and the position error, which is the distance between the point of interest and the nearest point which has, in fact, the dose value estimated for the point of interest. We examine the problem using both an analytical beam profile (a Fermi function) and measured 60Co, x-ray and proton beam profiles. Our analysis showed that the interpolation errors are proportional to the curvature of the dose distribution and are relatively high in regions on either side of, but not including, the steepest part of the penumbra. Our results showed how big an interpolation error one should expect for a given size of the calculation grid. The specification of accuracy should be cast in the form of a pair of requirements, one for dose and the other for position. At a given point, only one of the two requirements needs to be satisfied. The position requirement is almost always the less demanding in clinical practice and permits the use of a larger grid spacing than if only a dose requirement is applied.(ABSTRACT TRUNCATED AT 250 WORDS)     

The impact of linac output variations on dose distributions in helical tomotherapy

It has been suggested for quality assurance purposes that linac output variations for helical tomotherapy (HT) be within +/-2% of the long-term average. Due to cancellation of systematic uncertainty and averaging of random uncertainty over multiple beam directions, relative uncertainties in the dose distribution can be significantly lower than those in linac output. The sensitivity of four HT cases with respect to linac output uncertainties was assessed by scaling both modeled and measured systematic and random linac output uncertainties until a dose uncertainty acceptance criterion failed. The dose uncertainty acceptance criterion required the delivered dose to have at least a 95% chance of being within 2% of the planned dose in all of the voxels in the treatment volume. For a random linac output uncertainty of 5% of the long-term mean, the maximum acceptable amplitude of the modeled, sinusoidal, systematic component of the linac output uncertainty for the four cases was 1.8%. Although the measured linac output variations represented values that were outside of the +/-2% tolerance, the acceptance criterion did not fail for any of the four cases until the measured linac output variations were scaled by a factor of almost three. Thus, the +/-2% tolerance in linac output variations for HT is a more conservative tolerance than necessary.     

Design and implementation of a water phantom for IMRT, arc therapy, and tomotherapy dose distribution measurements

The aim of this paper is to present a new phantom for arc therapy, intensity-modulated radiation therapy (IMRT), and tomotherapy dose distribution measurement in pretreatment verification. The presented phantom is innovative for its use of water as the tissue equivalent material, together with a technical solution specifically designed to support radiographic or radiochromic film and ionization chambers in any desired position. The phantom comprise a Plexiglas container, whose present shape and dimensions offer the possibility to simulate a human torso or abdomen; the container can be filled with water by opening the upper cover. On the internal side of the cover, a set of carbon pipes can support film in the desired coronal, axial, or sagittal planes. At one of the two ends of the phantom, an ionization chamber can be positioned parallel to the rotation axis of the accelerator gantry in all possible positions within a 20 cm diameter cylinder, for film calibration purposes. Inhomogeneities can be inserted into the phantom using the same carbon pipes and plastic sheets used to support film. An example of vertebra-shaped inserts made of bone equivalent material is reported. Radiochromic film can be dipped in water, while radiographic film must be protected to prevent damage. To accomplish this, radiographic film is laminated using a cold laminating film. In order to assess the effects of both the lamination itself and the effects of water on laminated Kodak EDR2 film, the optical density (OD) of conventional, laminated, and laminated film immersed in water and exposed to a range of doses from 0 to 300 cGy were compared. The OD of the three samples receiving the same radiation dose did not present any significant difference, thus proving that laminated EDR2 film can also be used in water. A prerequisite for any dosimetric comparison between planned and measured data is a proper film to plan registration. The solution proposed here is an extrinsic in-plane registration technique using four reference points marked on each film in predefined positions. The four points and the millimeter scales fixed on the carbon pipes that support the film are designed and manufactured so as to transfer onto the film the same reference system used during the planning procedure, thus allowing a straightforward registration. Tests to assess the accuracy of the proposed registration method demonstrate that the distances between measured and intended marker positions, evaluated for coronal, axial, and sagittal planes, were about 1 mm for both anteroposterior and lateral projections.     

The accuracy of single-seed dose superposition for I-125 implants

The Monte Carlo method was used to study perturbations of single I-125 seed dose distributions created by the presence of one or three neighboring seeds for the case of seeds immersed in a water phantom. Perturbation factors were determined within the geometric shadow of neighboring seeds for two-seed designs, four-seed spacings, and several choices of dose point. The results were compared to dose estimates obtained by the simple superposition of single-seed data for one- and two-plane implants. Some significant differences were found.     

近距离放射治疗照射剂量准确性的研究

目的:研究我院近距离放疗照射剂量的准确性。方法:用显活度App穴Ci雪和空气比释动能率K觶穴cGy·m2·h-1雪两种方法校准192Ir源强。在水箱中心放置PTWM2331电离室,距电离室中心2cm处放置4根施源针,角度互为90°,运行预先设计的计划,测量剂量与处方剂量相对照。结果:用显活度校准源强最大误差-6.8%,平均误差4.38%,用空气比释动能率校准源强最大误差3.1%,平均误差2.4%。处方剂量与测量剂量的最大偏差5.11%,平均偏差3.87%。结论:用空气比释动能率K觶校准源强好于用显活度App校准源强。我院近距离治疗机的所有物理照射剂量的平均准确性符合ICRU24号报告提出的好于±5%的标准。     

C-Arm imaging for brachytherapy source reconstruction: geometrical accuracy

We study the accuracy of brachytherapy source reconstruction using C-Arm images. We use a phantom embedded with dummy ribbons in a regular pattern, placed at the rotation center of the C-Arm. With a commercial reconstruction jig, radiographic films are taken without the image intensifier. The average error in reconstructed seed coordinates is 0.1 cm. However, the jig is inconvenient for patient procedures. For C-Arm reconstruction without the jig, the magnifications of the image intensifier along orthogonal directions are different. We "stretch" the image to equalize the magnifications. Afterward, seed reconstruction has an average error of 0.1 cm in all directions.