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At least 577 records · Page 32
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DOE OSTI2014

SU-E-T-422: Correlation Between 2D Passing Rates and 3D Dose Differences for Pretreatment VMAT QA

Purpose: Volumetric modulated arc therapy (VMAT) quality assurance (QA) is typically using QA methods and action levels taken from fixedbeam intensity-modulated radiotherapy (IMRT) QA methods. However, recent studies demonstrated that there is no correlation between the percent gamma passing rate (%GP) and the magnitude of dose discrepancy between the planned dose and the actual delivered dose for IMRT. The purpose of this study is to investigate whether %GP is correlated with clinical dosimetric difference for VMAT. Methods: Twenty nasopharyngeal cancer (NPC) patients treated with dual-arc simultaneous integrated boost VMAT and 20 esophageal cancer patients treated with one-arc VMAT were enrolled in this study. Pretreatment VMAT QA was performed by a 3D diode array ArcCheck. Acceptance criteria of 2%/2mm, 3%/3mm, and 4%/4mm were applied for 2D %GP. Dose values below 10% of the per-measured normalization maximum dose were ignored.Mean DVH values obtained from 3DVH software and TPS were calculated and percentage dose differences were calculated. Statistical correlation between %GP and percent dose difference was studied by using Pearson correlation. Results: The %GP for criteria 2%/2mm, 3%/3mm, and 4%/4mm were 82.33±4.45, 93.47±2.31, 97.13±2.41, respectively. Dose differences calculated from 3DVH and TPS for beam isocenter, mean dose of PTV, maximum dose of PTV, D2 of PTV and D98 of PTV were -1.04±3.24, -0.74±1.71, 2.92±3.62, 0.89±3.29, -1.46±1.97, respectively. No correction were found between %GP and dose differences. Conclusion: There are weak correlations between the 2D %GP and dose differences calculated from 3DVH. The %GP acceptance criteria of 3%/3mm usually applied for pretreatment QA of IMRT and VMAT is not indicating strong clinical correlation with 3D dose difference. 3D dose reconstructions on patient anatomy may be necessary for physicist to predict the accuracy of delivered dose for VMAT QA.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2014

SU-E-T-460: Comparison of Proton and IMRT Planning for Head and Neck Cancer

Purpose: A retrospective study comparing proton and intensity-modulated radiation therapy (IMRT) for head and neck cancer Methods: This study consists of six H and N cancer patients that underwent proton as well as IMRT planning. Patients analyzed had unilateral target volumes, one had prior RT. 3D-conformal proton therapy (3D-CPT) plans with multiple field uniform scanning were generated for delivery on the inclined beam line. IMRT was planned using fixed field sliding window. Final plan evaluations were performed by a radiation oncologist and a physicist. Metrics for comparison included tumor coverage, organ sparing with respect to spinal cord, brainstem, parotids, submandibulars, oral cavity, larynx, brachial plexus, cochleas, normal brain tissue, and skin using relevant indices for these structures. Dose volume histograms were generated as well as a qualitative comparison of isodose distributions between the two modalities. Planning and treatment delivery times were compared. Results: Results showed that IMRT plans offered better conformality in the high dose region as demonstrated by the conformality index for each plan. Ipsilateral cochlea, submandibular gland, and skin doses were lower with IMRT than proton therapy. There was significant sparing of larynx, oral cavity, and brainstem with proton therapy compared to IMRT. This translated into direct patient benefit with no evidence of hoarseness, mucositis, or nausea. Contralateral parotid and submandibular glands were equally spared. IMRT had shorter planning/parts fabrication and treatment times which needs to be taken into account when deciding modality. Conclusion: Sparing of clinically significant normal tissue structures such as oral cavity and larynx for unilateral H and N cancers was seen with 3D-CPT versus IMRT. However, this is at the expense of less conformality at the high dose region and higher skin dose. Future studies are needed with full gantry systems and pencil beam scanning as these deliveries would be expected to further improve conformality and normal tissue sparing.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2014

SU-E-T-471: Small Field Jaw/MLC Reference Data

Purpose: In recent years the need for small field data of MLCs has increased due to the use of intensity-modulated radiation (IMRT), but moreover the use of stereotactic body radiation (SBRT) has increased, which uses not simply small field sizes, but small jaw and field sizes together. Having reference data for these small fields that is reliable would be invaluable to the physics community. Our study has gathered these values and the data distributions from the Radiological Physics Center's (RPC) site visits between 1990 and the present. Methods: For all measurements, the RPC used a 25 × 25 × 25cm water phantom placed at 100cm SSD. All measurements were made with an Exradin A16 cylindrical ion chamber at an effective depth of 10 cm. A total of 42 Varian machine measurements were used to compose the data for a 6 MV beam and 5 TrueBeam 6 MV flattening filter free (FFF) beams were used for FFF data. Results: Jaw/MLC fields were measured for both 6 MV and 6 MF FFF beams with the jaws and MLCs both at the following field sizes: 6×6, 4×4, 3×3, and 2×2cm. Measurements were normalized to the 10×10 field readings (defined by the jaws and MLC). Spread in the data was minimal and demonstrates a high level of accuracy of acquired data. Conclusion: Small field Jaw/MLC reference data for Varian 6MV and 6 MV FFF beams has been analyzed and presented here, composed of the aggregation of numerous RPC site visits. Obtaining reliable small field data remains difficult, however the RPC has collected high fidelity small field Jaw/MLC data. The data are presented as a reference along with their distributions, in such a way that the physicist can act based upon their own desired agreement with the reference data.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2014

SU-E-T-477: An Efficient Dose Correction Algorithm Accounting for Tissue Heterogeneities in LDR Brachytherapy

Purpose: Seed brachytherapy is currently used for adjuvant radiotherapy of early stage prostate and breast cancer patients. The current standard for calculation of dose surrounding the brachytherapy seeds is based on American Association of Physicist in Medicine Task Group No. 43 (TG-43 formalism) which generates the dose in homogeneous water medium. Recently, AAPM Task Group No. 186 emphasized the importance of accounting for tissue heterogeneities. This can be done using Monte Carlo (MC) methods, but it requires knowing the source structure and tissue atomic composition accurately. In this work we describe an efficient analytical dose inhomogeneity correction algorithm implemented using MIM Symphony treatment planning platform to calculate dose distributions in heterogeneous media. Methods: An Inhomogeneity Correction Factor (ICF) is introduced as the ratio of absorbed dose in tissue to that in water medium. ICF is a function of tissue properties and independent of source structure. The ICF is extracted using CT images and the absorbed dose in tissue can then be calculated by multiplying the dose as calculated by the TG-43 formalism times ICF. To evaluate the methodology, we compared our results with Monte Carlo simulations as well as experiments in phantoms with known density and atomic compositions. Results: The dose distributions obtained through applying ICF to TG-43 protocol agreed very well with those of Monte Carlo simulations as well as experiments in all phantoms. In all cases, the mean relative error was reduced by at least 50% when ICF correction factor was applied to the TG-43 protocol. Conclusion: We have developed a new analytical dose calculation method which enables personalized dose calculations in heterogeneous media. The advantages over stochastic methods are computational efficiency and the ease of integration into clinical setting as detailed source structure and tissue segmentation are not needed. University of Toronto, Natural Sciences and Engineering Research Council of Canada.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2014

SU-E-T-486: Effect of the Normalized Prescription Isodose Line On Target Dose Deficiency in Lung SBRT Based On Monte Carlo Calculation

Purpose: To investigate the impact of normalized prescription isodose line on target dose deficiency calculated with Monte Carlo (MC) vs. pencil Beam (PB) in lung SBRT. RTOG guidelines recommend prescription lines between 60% and 90% for lung SBRT. How this affects the magnitude of MC-calculated target dose deficiency has never been studied. Methods: Under an IRB-approved protocol, four lung SBRT patients were replanned following RTOG0813 by a single physicist. For each patient, four alternative plans were generated based on PB calculation prescribing to 60–90% isodose lines, respectively. Each plan consisted of 360o coplanar dynamic conformal arcs with beam apertures manually optimized to achieve similar dose coverage and conformity for all plans of the same patient. Dose distribution was calculated with MC and compared to that with PB. PTV dose-volume endpoints were compared, including Dmin, D5, Dmean, D95, and Dmax. PTV V100 coverage, conformity index (CI), and heterogeneity index (HI) were also evaluated. Results: For all 16 plans, median (range) PTV V100 and CI were 99.7% (97.5–100%) and 1.27 (1.20–1.41), respectively. As expected, lower prescription line resulted in higher target dose heterogeneity, yielding median (range) HI of 1.26 (1.05–1.51) for all plans. Comparing MC to PB, median (range) D95, Dmean, D5 PTV dose deficiency were 18.9% (11.2–23.2%), 15.6% (10.0–22.7%), and 9.4%(5.5–13.6%) of the prescription dose, respectively. The Dmean, D5, and Dmax deficiency was found to monotonically increase with decreasing prescription line from 90% to 60%, while the Dmin deficiency monotonically decreased. D95 deficiency exhibited more complex trend, reaching the largest deficiency at 80% for all patients. Conclusion: Dependence on prescription isodose line was found for MC-calculated PTV dose deficiency of lung SBRT. When comparing reported MC dose deficiency values from different institutions, their individual selections of prescription line should be considered in addition to other factors affecting the deficiency magnitude.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2014

SU-E-T-627: Failure Modes and Effect Analysis for Monthly Quality Assurance of Linear Accelerator

Purpose: To develop and implement a failure mode and effect analysis (FMEA) on routine monthly Quality Assurance (QA) tests (physical tests part) of linear accelerator. Methods: A systematic failure mode and effect analysis method was performed for monthly QA procedures. A detailed process tree of monthly QA was created and potential failure modes were defined. Each failure mode may have many influencing factors. For each factor, a risk probability number (RPN) was calculated from the product of probability of occurrence (O), the severity of effect (S), and detectability of the failure (D). The RPN scores are in a range of 1 to 1000, with higher scores indicating stronger correlation to a given influencing factor of a failure mode. Five medical physicists in our institution were responsible to discuss and to define the O, S, D values. Results: 15 possible failure modes were identified and all RPN scores of all influencing factors of these 15 failue modes were from 8 to 150, and the checklist of FMEA in monthly QA was drawn. The system showed consistent and accurate response to erroneous conditions. Conclusion: The influencing factors of RPN greater than 50 were considered as highly-correlated factors of a certain out-oftolerance monthly QA test. FMEA is a fast and flexible tool to develop an implement a quality management (QM) frame work of monthly QA, which improved the QA efficiency of our QA team. The FMEA work may incorporate more quantification and monitoring fuctions in future.

07 ISOTOPE AND RADIATION SOURCES↗
DOE OSTI2014

SU-E-CAMPUS-I-06: Y90 PET/CT for the Instantaneous Determination of Both Target and Non-Target Absorbed Doses Following Hepatic Radioembolization

Purpose The process of converting Yttrium-90 (Y90) PET/CT images into 3D absorbed dose maps will be explained. The simple methods presented will allow the medical physicst to analyze Y90 PET images following radioembolization and determine the absorbed dose to tumor, normal liver parenchyma and other areas of interest, without application of Monte-Carlo radiation transport or dose-point-kernel (DPK) convolution. Methods Absorbed dose can be computed from Y90 PET/CT images based on the premise that radioembolization is a permanent implant with a constant relative activity distribution after infusion. Many Y90 PET/CT publications have used DPK convolution to obtain 3D absorbed dose maps. However, this method requires specialized software limiting clinical utility. The Local Deposition method, an alternative to DPK convolution, can be used to obtain absorbed dose and requires no additional computer processing. Pixel values from regions of interest drawn on Y90 PET/CT images can be converted to absorbed dose (Gy) by multiplication with a scalar constant. Results There is evidence that suggests the Local Deposition method may actually be more accurate than DPK convolution and it has been successfully used in a recent Y90 PET/CT publication. We have analytically compared dose-volume-histograms (DVH) for phantom hot-spheres to determine the difference between the DPK and Local Deposition methods, as a function of PET scanner point-spread-function for Y90. We have found that for PET/CT systems with a FWHM greater than 3.0 mm when imaging Y90, the Local Deposition Method provides a more accurate representation of DVH, regardless of target size than DPK convolution. Conclusion Using the Local Deposition Method, post-radioembolization Y90 PET/CT images can be transformed into 3D absorbed dose maps of the liver. An interventional radiologist or a Medical Physicist can perform this transformation in a clinical setting, allowing for rapid prediction of treatment efficacy by comparison to published tumoricidal thresholds.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2014

SU-F-19A-05: Experimental and Monte Carlo Characterization of the 1 Cm CivaString 103Pd Brachytherapy Source

Purpose: To determine the in-air azimuthal anisotropy and in-water dose distribution for the 1 cm length of the CivaString {sup 103}Pd brachytherapy source through measurements and Monte Carlo (MC) simulations. American Association of Physicists in Medicine Task Group No. 43 (TG-43) dosimetry parameters were also determined for this source. Methods: The in-air azimuthal anisotropy of the source was measured with a NaI scintillation detector and simulated with the MCNP5 radiation transport code. Measured and simulated results were normalized to their respective mean values and compared. The TG-43 dose-rate constant, line-source radial dose function, and 2D anisotropy function for this source were determined from LiF:Mg,Ti thermoluminescent dosimeter (TLD) measurements and MC simulations. The impact of {sup 103}Pd well-loading variability on the in-water dose distribution was investigated using MC simulations by comparing the dose distribution for a source model with four wells of equal strength to that for a source model with strengths increased by 1% for two of the four wells. Results: NaI scintillation detector measurements and MC simulations of the in-air azimuthal anisotropy showed that ≥95% of the normalized data were within 1.2% of the mean value. TLD measurements and MC simulations of the TG-43 dose-rate constant, line-source radial dose function, and 2D anisotropy function agreed to within the experimental TLD uncertainties (k=2). MC simulations showed that a 1% variability in {sup 103}Pd well-loading resulted in changes of <0.1%, <0.1%, and <0.3% in the TG-43 dose-rate constant, radial dose distribution, and polar dose distribution, respectively. Conclusion: The CivaString source has a high degree of azimuthal symmetry as indicated by the NaI scintillation detector measurements and MC simulations of the in-air azimuthal anisotropy. TG-43 dosimetry parameters for this source were determined from TLD measurements and MC simulations. {sup 103}Pd well-loading variability results in minimal variations in the in-water dose distribution according to MC simulations. This work was partially supported by CivaTech Oncology, Inc. through an educational grant for Joshua Reed, John Micka, Wesley Culberson, and Larry DeWerd and through research support for Mark Rivard.

07 ISOTOPE AND RADIATION SOURCES↗
DOE OSTI2014

SU-F-BRF-04: Evaluation of Five Commercially-Available Algorithms for Deformable Image Registration

Purpose: Deformable image registration (DIR) is increasingly being used in various clinical applications. Although there are several DIR packages all making successful attempts at modeling complex anatomical changes using even more complex mathematical approximations, they are all subject to various uncertainties. Many studies have attempted to quantify the spatial uncertainty with DIR. This is the first study to compare the uncertainty for interfraction DIR for 5 different commercially-available algorithms. The aim of this study was to benchmark the performance of the most commonlyused DIR algorithms offered through these 5 software packages: Eclipse, MIM, Pinnacle, RaySearch, and Velocity. Methods: A set of 10 virtual H'N phantoms [Pukala et al. MedPhys. 40(11) 2013] with known deformations were used to determine the spatial errors that might be seen when performing DIR. The “ground-truth” deformation vector field (DVF) was compared to the DVF output of the 5 commercially-available algorithms in order to evaluate spatial errors for six regions of interest (ROIs): brainstem, cord, mandible, left parotid, right parotid, and the external body contour. Results: We found that each software package had varying uncertainties with the various ROIs, but were generally all comparable to one another – with mean spatial errors for each algorithm below 3.5 mm for each ROI (averaged across all phantoms). We also found that no single algorithm was the clear winner over the other 4 algorithms. However, at times, we found huge maximum errors in our results (e.g. phantom #9 maximum errors: right parotid = 22.9 mm, external contour = 30.5mm) with the varying DIR algorithms. Conclusion: Although our evaluation was limited to H'N patients, we show that our methods are a single-assessment analysis tool that could be used by any physicist, within any type of facility, to compare their DIR software before initiating widespread use within their daily radiotherapy practice.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2014

MO-E-BRD-01: Adapt-A-Thon - Texas Hold’em Invitational

Software tools for image-based adaptive radiotherapy such as deformable image registration, contour propagation and dose mapping have progressed beyond the research setting and are now commercial products available as part of both treatment planning systems and stand-alone applications. These software tools are used together to create clinical workflows to detect, track and evaluate changes in the patient and to accumulate dose. Deviations uncovered in this process are used to guide decisions about replanning/adaptation with the goal of keeping the delivery of prescribed dose “on target” throughout the entire course of radiotherapy. Since the output from one step of the adaptive process is used as an input for another, it is essential to understand and document the uncertainty associated with each of the step and how these uncertainties are propagated. This in turn requires an understanding how the underlying tools work. Unfortunately, important details about the algorithms used to implement these tools are scarce or incomplete, too often for competitive reasons. This is in contrast to the situation involving other basic treatment planning algorithms such as dose calculations, where the medical physics community essentially requires vendors to provide physically important details about their underlying theory and clinical implementation. Vendors should adopt this same level of information sharing when it comes to the tools and techniques for image guided adaptive radiotherapy. The goal of this session is to start this process by inviting vendors and medical physicists to discuss and demonstrate the available tools and describe how they are intended to be used in clinical practice. The format of the session will involve a combination of formal presentations, interactive demonstrations, audience participation and some friendly “Texas style” competition. Learning Objectives: Understand the components of the image-based adaptive radiotherapy process. Understand the how these components are implemented in various commercial systems. Understand the different use cases and workflows currently supported these tools.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2014

MO-E-18C-01: Open Access Web-Based Peer-To-Peer Training and Education in Radiotherapy

Purpose: Current training and education delivery models have limitations which result in gaps in clinical proficiency with equipment, procedures, and techniques. Educational and training opportunities offered by vendors and professional societies are by their nature not available at point of need or for the life of clinical systems. The objective of this work is to leverage modern communications technology to provide peer-to-peer training and education for radiotherapy professionals, in the clinic and on demand, as they undertake their clinical duties. Methods: We have developed a free of charge web site ( https://i.treatsafely.org ) using the Google App Engine and datastore (NDB, GQL), Python with AJAX-RPC, and Javascript. The site is a radiotherapy-specific hosting service to which user-created videos illustrating clinical or physics processes and other relevant educational material can be uploaded. Efficient navigation to the material of interest is provided through several RT specific search tools and videos can be scored by users, thus providing comprehensive peer review of the site content. The site also supports multilingual narration\translation of videos, a quiz function for competence assessment and a library function allowing groups or institutions to define their standard operating procedures based on the video content. Results: The website went live in August 2013 and currently has over 680 registered users from 55 countries; 27.2% from the United States, 9.8% from India, 8.3% from the United Kingdom, 7.3% from Brazil, and 47.5% from other countries. The users include physicists (57.4%), Oncologists (12.5%), therapists (8.2%) and dosimetrists (4.8%). There are 75 videos to date including English, Portuguese, Mandarin, and Thai. Conclusion: Based on the initial acceptance of the site, we conclude that this open access web-based peer-to-peer tool is fulfilling an important need in radiotherapy training and education. Site functionality should expand in the future to include document sharing and continuing education credits.

61 RADIATION PROTECTION AND DOSIMETRY↗
DOE OSTI2014

MO-E-18C-04: Advanced Computer Simulation and Visualization Tools for Enhanced Understanding of Core Medical Physics Concepts

Purpose: Most medical physics programs emphasize proficiency in routine clinical calculations and QA. The formulaic aspect of these calculations and prescriptive nature of measurement protocols obviate the need to frequently apply basic physical principles, which, therefore, gradually decay away from memory. E.g. few students appreciate the role of electron transport in photon dose, making it difficult to understand key concepts such as dose buildup, electronic disequilibrium effects and Bragg-Gray theory. These conceptual deficiencies manifest when the physicist encounters a new system, requiring knowledge beyond routine activities. Methods: Two interactive computer simulation tools are developed to facilitate deeper learning of physical principles. One is a Monte Carlo code written with a strong educational aspect. The code can “label” regions and interactions to highlight specific aspects of the physics, e.g., certain regions can be designated as “starters” or “crossers,” and any interaction type can be turned on and off. Full 3D tracks with specific portions highlighted further enhance the visualization of radiation transport problems. The second code calculates and displays trajectories of a collection electrons under arbitrary space/time dependent Lorentz force using relativistic kinematics. Results: Using the Monte Carlo code, the student can interactively study photon and electron transport through visualization of dose components, particle tracks, and interaction types. The code can, for instance, be used to study kerma-dose relationship, explore electronic disequilibrium near interfaces, or visualize kernels by using interaction forcing. The electromagnetic simulator enables the student to explore accelerating mechanisms and particle optics in devices such as cyclotrons and linacs. Conclusion: The proposed tools are designed to enhance understanding of abstract concepts by highlighting various aspects of the physics. The simulations serve as virtual experiments that give deeper and long lasting understanding of core principles. The student can then make sound judgements in novel situations encountered beyond routine clinical activities.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2014

MO-E-9A-01: Risk Based Quality Management: TG100 In Action

One of the goals of quality management in radiation therapy is to gain high confidence that patients will receive the prescribed treatment correctly. To accomplish these goals professional societies such as the American Association of Physicists in Medicine (AAPM) has published many quality assurance (QA), quality control (QC), and quality management (QM) guidance documents. In general, the recommendations provided in these documents have emphasized on performing device-specific QA at the expense of process flow and protection of the patient against catastrophic errors. Analyses of radiation therapy incidents find that they are most often caused by flaws in the overall therapy process, from initial consult through final treatment, than by isolated hardware or computer failures detectable by traditional physics QA. This challenge is shared by many intrinsically hazardous industries. Risk assessment tools and analysis techniques have been developed to define, identify, and eliminate known and/or potential failures, problems, or errors, from a system, process and/or service before they reach the customer. These include, but are not limited to, process mapping, failure modes and effects analysis (FMEA), fault tree analysis (FTA), and establishment of a quality management program that best avoids the faults and risks that have been identified in the overall process. These tools can be easily adapted to radiation therapy practices because of their simplicity and effectiveness to provide efficient ways to enhance the safety and quality of treatment processes. Task group 100 (TG100) of AAPM has developed a risk-based quality management program that uses these tools. This session will be devoted to a discussion of these tools and how these tools can be used in a given radiotherapy clinic to develop a risk based QM program. Learning Objectives: Learn how to design a process map for a radiotherapy process. Learn how to perform a FMEA analysis for a given process. Learn what Fault tree analysis is all about. Learn how to design a quality management program based upon the information obtained from process mapping, FMEA and FTA.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2014

MO-F-16A-02: Simulation of a Medical Linear Accelerator for Teaching Purposes

Purpose: Detailed functioning of linear accelerator physics is well known. Less well developed is the basic understanding of how the adjustment of the linear accelerator's electrical components affects the resulting radiation beam. Other than the text by Karzmark, there is very little literature devoted to the practical understanding of linear accelerator functionality targeted at the radiotherapy clinic level. The purpose of this work is to describe a simulation environment for medical linear accelerators with the purpose of teaching linear accelerator physics. Methods: Varian type lineacs were simulated. Klystron saturation and peak output were modelled analytically. The energy gain of an electron beam was modelled using load line expressions. The bending magnet was assumed to be a perfect solenoid whose pass through energy varied linearly with solenoid current. The dose rate calculated at depth in water was assumed to be a simple function of the target's beam current. The flattening filter was modelled as an attenuator with conical shape, and the time-averaged dose rate at a depth in water was determined by calculating kerma. Results: Fifteen analytical models were combined into a single model called SIMAC. Performance was verified systematically by adjusting typical linac control parameters. Increasing klystron pulse voltage increased dose rate to a peak, which then decreased as the beam energy was further increased due to the fixed pass through energy of the bending magnet. Increasing accelerator beam current leads to a higher dose per pulse. However, the energy of the electron beam decreases due to beam loading and so the dose rate eventually maximizes and the decreases as beam current was further increased. Conclusion: SIMAC can realistically simulate the functionality of a linear accelerator. It is expected to have value as a teaching tool for both medical physicists and linear accelerator service personnel.

43 PARTICLE ACCELERATORS↗
DOE OSTI2014

MO-F-16A-04: Case Study: Estimation of Peak Skin Dose Following a Physician Reported “High Dose” Case and Sentinel Event Considerations

Purpose: This work offers as a teaching example a reported high dose fluoroscopy case and the workflow the institution followed to self-report a radiation overdose sentinel event to the Joint Commission. Methods: Following the completion of a clinical case in a hybrid OR room with a reported air kerma of >18 Gy at the Interventional Reference Point (IRP) the physicians involved in the case referred study to the institution's Radiation Safety Committee (RSC) for review. The RSC assigned a Diagnostic Medical Physicist (DMP) to estimate the patient's Peak Skin Dose (PSD) and analyze the case. Following the DMP's analysis and estimate of a PSD of >15 Gy the institution's adverse event committee was convened to discuss the case and to self-report the case as a radiation overdose sentinel event to the Joint Commission. The committee assigned a subgroup to perform the root cause analysis and develop institutional responses to the event. Results: The self-reporting of the sentinel event and the associated root cause analysis resulted in several institutional action items that are designed to improve process and safety. A formal reporting and analysis mechanism was adopted to review fluoroscopy cases with air kerma greater than 6 Gy at the IRP. An improved and formalized radiation safety training program for physicians using fluoroscopy equipment was implemented. Additionally efforts already under way to monitor radiation exposure in the Radiology department were expanded to include all fluoroscopy equipment capable of automated dose reporting. Conclusion: The adverse event review process and the root cause analysis following the self-reporting of the sentinel event resulted in policies and procedures that are expected to improve the quality and safe usage of fluoroscopy throughout the institution.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2014

MO-PIS-Exhibit Hall-01: Tools for TG-142 Linac Imaging QA I

Partners in Solutions is an exciting new program in which AAPM partners with our vendors to present practical “hands-on” information about the equipment and software systems that we use in our clinics. The therapy topic this year is solutions for TG-142 recommendations for linear accelerator imaging QA. Note that the sessions are being held in a special purpose room built on the Exhibit Hall Floor, to encourage further interaction with the vendors. Automated Imaging QA for TG-142 with RIT Presentation Time: 2:45 – 3:15 PM This presentation will discuss software tools for automated imaging QA and phantom analysis for TG-142. All modalities used in radiation oncology will be discussed, including CBCT, planar kV imaging, planar MV imaging, and imaging and treatment coordinate coincidence. Vendor supplied phantoms as well as a variety of third-party phantoms will be shown, along with appropriate analyses, proper phantom setup procedures and scanning settings, and a discussion of image quality metrics. Tools for process automation will be discussed which include: RIT Cognition (machine learning for phantom image identification), RIT Cerberus (automated file system monitoring and searching), and RunQueueC (batch processing of multiple images). In addition to phantom analysis, tools for statistical tracking, trending, and reporting will be discussed. This discussion will include an introduction to statistical process control, a valuable tool in analyzing data and determining appropriate tolerances. An Introduction to TG-142 Imaging QA Using Standard Imaging Products Presentation Time: 3:15 – 3:45 PM Medical Physicists want to understand the logic behind TG-142 Imaging QA. What is often missing is a firm understanding of the connections between the EPID and OBI phantom imaging, the software “algorithms” that calculate the QA metrics, the establishment of baselines, and the analysis and interpretation of the results. The goal of our brief presentation will be to establish and solidify these connections. Our talk will be motivated by the Standard Imaging, Inc. phantom and software solutions. We will present and explain each of the image quality metrics in TG-142 in terms of the theory, mathematics, and algorithms used to implement them in the Standard Imaging PIPSpro software. In the process, we will identify the regions of phantom images that are analyzed by each algorithm. We then will discuss the process of the creation of baselines and typical ranges of acceptable values for each imaging quality metric.

07 ISOTOPE AND RADIATION SOURCES↗
DOE OSTI2014

MO-G-BRE-04: Automatic Verification of Daily Treatment Deliveries and Generation of Daily Treatment Reports for a MR Image-Guided Treatment Machine

Purpose: Two aims of this work were to develop a method to automatically verify treatment delivery accuracy immediately after patient treatment and to develop a comprehensive daily treatment report to provide all required information for daily MR-IGRT review. Methods: After systematically analyzing the requirements for treatment delivery verification and understanding the available information from a novel MR-IGRT treatment machine, we designed a method to use 1) treatment plan files, 2) delivery log files, and 3) dosimetric calibration information to verify the accuracy and completeness of daily treatment deliveries. The method verifies the correctness of delivered treatment plans and beams, beam segments, and for each segment, the beam-on time and MLC leaf positions. Composite primary fluence maps are calculated from the MLC leaf positions and the beam-on time. Error statistics are calculated on the fluence difference maps between the plan and the delivery. We also designed the daily treatment delivery report by including all required information for MR-IGRT and physics weekly review - the plan and treatment fraction information, dose verification information, daily patient setup screen captures, and the treatment delivery verification results. Results: The parameters in the log files (e.g. MLC positions) were independently verified and deemed accurate and trustable. A computer program was developed to implement the automatic delivery verification and daily report generation. The program was tested and clinically commissioned with sufficient IMRT and 3D treatment delivery data. The final version has been integrated into a commercial MR-IGRT treatment delivery system. Conclusion: A method was developed to automatically verify MR-IGRT treatment deliveries and generate daily treatment reports. Already in clinical use since December 2013, the system is able to facilitate delivery error detection, and expedite physician daily IGRT review and physicist weekly chart review.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2014

MO-G-BRE-05: Clinical Process Improvement and Billing in Radiation Oncology: A Case Study of Applying FMEA for CPT Code 77336 (continuing Medical Physics Consultation)

Purpose: The improvement of quality in healthcare can be assessed by Failure Mode and Effects Analysis (FMEA). In radiation oncology, FMEA, as applied to the billing CPT code 77336, can improve both charge capture and, most importantly, quality of the performed services. Methods: We created an FMEA table for the process performed under CPT code 77336. For a given process step, each member of the assembled team (physicist, dosimetrist, and therapist) independently assigned numerical values for: probability of occurrence (O, 1–10), severity (S, 1–10), and probability of detection (D, 1–10) for every failure mode cause and effect combination. The risk priority number, RPN, was then calculated as a product of O, S and D from which an average RPN was calculated for each combination mentioned above. A fault tree diagram, with each process sorted into 6 categories, was created with linked RPN. For processes with high RPN recommended actions were assigned. 2 separate R and V systems (Lantis and EMR-based ARIA) were considered. Results: We identified 9 potential failure modes and corresponding 19 potential causes of these failure modes all resulting in unjustified 77336 charge and compromised quality of care. In Lantis, the range of RPN was 24.5–110.8, and of S values – 2–10. The highest ranking RPN of 110.8 came from the failure mode described as “end-of-treatment check not done before the completion of treatment”, and the highest S value of 10 (RPN=105) from “overrides not checked”. For the same failure modes, within ARIA electronic environment with its additional controls, RPN values were significantly lower (44.3 for end-of-treatment missing check and 20.0 for overrides not checked). Conclusion: Our work has shown that when charge capture was missed that also resulted in some services not being performed. Absence of such necessary services may result in sub-optimal quality of care rendered to patients.

29 ENERGY PLANNING, POLICY, AND ECONOMY↗