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At least 631 records · Page 35
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DOE OSTI2015

SU-E-J-16: Automatic Image Contrast Enhancement Based On Automatic Parameter Optimization for Radiation Therapy Setup Verification

Purpose: In RT patient setup 2D images, tissues often cannot be seen well due to the lack of image contrast. Contrast enhancement features provided by image reviewing software, e.g. Mosaiq and ARIA, require manual selection of the image processing filters and parameters thus inefficient and cannot be automated. In this work, we developed a novel method to automatically enhance the 2D RT image contrast to allow automatic verification of patient daily setups as a prerequisite step of automatic patient safety assurance. Methods: The new method is based on contrast limited adaptive histogram equalization (CLAHE) and high-pass filtering algorithms. The most important innovation is to automatically select the optimal parameters by optimizing the image contrast. The image processing procedure includes the following steps: 1) background and noise removal, 2) hi-pass filtering by subtracting the Gaussian smoothed Result, and 3) histogram equalization using CLAHE algorithm. Three parameters were determined through an iterative optimization which was based on the interior-point constrained optimization algorithm: the Gaussian smoothing weighting factor, the CLAHE algorithm block size and clip limiting parameters. The goal of the optimization is to maximize the entropy of the processed Result. Results: A total 42 RT images were processed. The results were visually evaluated by RT physicians and physicists. About 48% of the images processed by the new method were ranked as excellent. In comparison, only 29% and 18% of the images processed by the basic CLAHE algorithm and by the basic window level adjustment process, were ranked as excellent. Conclusion: This new image contrast enhancement method is robust and automatic, and is able to significantly outperform the basic CLAHE algorithm and the manual window-level adjustment process that are currently used in clinical 2D image review software tools.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2015

SU-E-J-78: Adaptive Planning Workflow in a Pencil Beam Scanning Proton Therapy Center

Purpose: The susceptibility of proton therapy to changes in patient setup and anatomy necessitates an adaptive planning process. With the right planning tools and clinical workflow, an adaptive plan can be created in a timely manner without adding significant workload to the treatment planning staff. Methods: In our center, a weekly QA CT is performed on most patients to assess setup, anatomy change, and tumor response. The QA CT is fused to the treatment planning CT, the contours are transferred via deformable registration, and the plan dose is recalculated on the QA CT. A physicist assesses the dose distribution, and an adaptive plan is requested based on tumor coverage or OAR dose changes. After the physician confirms or alters the deformed contours, a dosimetrist develops an adaptive plan using our TPS adaptation module. The plan is assessed for robustness and is then reviewed by the physician. Patient QA is performed within three days following the first adapted treatment. Results: Of the patients who received QA CTs, 19% required at least one adaptive plan (18.5% H&N, 18.5% brain, 11.1% breast, 14.8% chestwall, 14.8% lung, 18.5% pelvis and 3.8% abdomen). Of these patients, 14% went on a break, while the remainder was treated with the previous plan during the re-planning process. Adaptive plans were performed based on tumor shrinkage, anatomy change or positioning uncertainties for 37.9%, 44.8%, and 17.3% of the patients, respectively. On average, 3 full days are required between the QA CT and the first adapted plan treatment. Conclusion: Adaptive planning is a crucial component of proton therapy and should be applied to any site when the QA CT shows significant deviation from the plan. With an efficient workflow, an adaptive plan can be applied without delaying patient treatment or burdening the dosimetry and medical physics team.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2015

SU-E-J-90: Lobar-Level Lung Ventilation Analysis Using 4DCT and Deformable Image Registration

Purpose: To assess regional changes in human lung ventilation and mechanics using four-dimensional computed tomography (4DCT) and deformable image registration. This work extends our prior analysis of the entire lung to a lobe-based analysis. Methods: 4DCT images acquired from 20 patients prior to radiation therapy (RT) were used for this analysis. Jacobian ventilation and motion maps were computed from the displacement field after deformable image registration between the end of expiration breathing phase and the end of inspiration breathing phase. The lobes were manually segmented on the reference phase by a medical physicist expert. The voxel-by-voxel ventilation and motion magnitude for all subjects were grouped by lobes and plotted into cumulative voxel frequency curves respectively. In addition, to eliminate the effect of different breathing efforts across subjects, we applied the inter-subject equivalent lung volume (ELV) method on a subset of the cohort and reevaluated the lobar ventilation. Results: 95% of voxels in the lung are expanding during inspiration. However, some local regions of lung tissue show far more expansion than others. The greatest expansion with respiration occurs within the lower lobes; between exhale and inhale the median expansion in lower lobes is approximately 15%, while the median expansion in upper lobes is 10%. This appears to be driven by a subset of lung tissues within the lobe that have greater expansion; twice the number of voxels in the lower lobes (20%) expand by > 30% when compared to the upper lobes (10%). Conclusion: Lung ventilation and motion show significant difference on the lobar level. There are different lobar fractions of driving voxels that contribute to the major expansion of the lung. This work was supported by NIH grant CA166703.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2015

SU-E-J-103: Propagation of Rectum and Bladder Contours for Tandem and Ring (T&R) HDR Treatment Using Deformable Image Registration

Purpose: To investigate the feasibility of using DIR to propagate the manually contoured rectum and bladder from the 1st insertion to the new CT images on subsequent insertions and evaluate the segmentation performance. Methods: Ten cervical cancer patients, who were treated by T&R brachytherapy in 3–4 insertions, were retrospectively collected. In each insertion, rectum and bladder were manually delineated on the planning CT by a physicist and verified by a radiation oncologist. Using VelocityAI (Velocity Medical Solutions, Atlanta, GA), a rigid registration was firstly employed to match the bony structures between the first insertion and each of the following insertions, then a multi-pass B-spine DIR was carried out to further map the sub volume that encompasses rectum and bladder. The resultant deformation fields propagated contours, and dice similarity coefficient (DSC) was used to quantitatively evaluate the agreement between the propagated contours and the manually-delineated organs. For the 3rd insertion, we also evaluated if the segmentation performance could be improved by propagating the contours from the most recent insertion, i.e., the 2nd insertion. Results: On average, the contour propagation took about 1 minute. The average and standard deviation of DSC over all insertions and patients was 0.67±0.10 (range: 0.44–0.81) for rectum, and 0.78±0.07 (range: 0.63–0.87) for bladder. For the 3rd insertion, propagating contours from the 2nd insertion could improve the segmentation performance in terms of DSC from 0.63±0.10 to 0.72±0.08 for rectum, and from 0.77±0.07 to 0.79±0.06 for bladder. A Wilcoxon signed rank test indicated that the improvement was statistically significant for rectum (p = 0.004). Conclusion: The preliminary results demonstrate that deformable image registration could efficiently and accurately propagate rectum and bladder contours between CT images in different T&R brachytherapy fractions. We are incorporating the propagated contours into our learning-based method to further segment these organs.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2015

SU-E-J-218: Novel Validation Paradigm of MRI to CT Deformation of Prostate

Purpose: Deformable registration algorithms are inherently difficult to characterize in the multi-modality setting due to a significant differences in the characteristics of the different modalities (CT and MRI) as well as tissue deformations. We present a unique paradigm where this is overcome by utilizing a planning-MRI acquired within an hour of the planning-CT serving as a surrogate for quantifying MRI to CT deformation by eliminating the issues of multi-modality comparisons. Methods: For nine subjects, T2 fast-spin-echo images were acquired at two different time points, the first several weeks prior to planning (diagnostic-MRI) and the second on the same day as the planning-CT (planning-MRI). Significant effort in patient positioning and bowel/bladder preparation was undertaken to minimize distortion of the prostate in all datasets. The diagnostic-MRI was rigidly and deformably aligned to the planning-CT utilizing a commercially available deformable registration algorithm synthesized from local registrations. Additionally, the quality of rigid alignment was ranked by an imaging physicist. The distances between corresponding anatomical landmarks on rigid and deformed registrations (diagnostic-MR to planning-CT) were evaluated. Results: It was discovered that in cases where the rigid registration was of acceptable quality the deformable registration didn’t improve the alignment, this was true of all metrics employed. If the analysis is separated into cases where the rigid alignment was ranked as unacceptable the deformable registration significantly improved the alignment, 4.62mm residual error in landmarks as compared to 5.72mm residual error in rigid alignments with a p-value of 0.0008. Conclusion: This paradigm provides an ideal testing ground for MR to CT deformable registration algorithms by allowing for inter-modality comparisons of multi-modality registrations. Consistent positioning, bowel and bladder preparation may Result in higher quality rigid registrations than typically achieved which limits the impact of deformable registrations. In this study cases where significant differences exist, deformable registrations provide significant value.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2015

SU-E-J-242: Volume-Dependence of Quantitative Imaging Features From CT and CE-CT Images of NSCLC

Purpose: To determine whether tumor volume plays a significant role in the values obtained for texture features when they are extracted from computed tomography (CT) images of non-small cell lung cancer (NSCLC). We also sought to identify whether features can be reliably measured at all volumes or if a minimum volume threshold should be recommended. Methods: Eleven features were measured on 40 CT and 32 contrast-enhanced CT (CECT) patient images for this study. Features were selected for their prognostic/diagnostic value in previous publications. Direct correlations between these textures and volume were evaluated using the Spearman correlation coefficient. Any texture that the Wilcoxon rank-sum test was used to compare the variation above and below a volume cutoff. Four different volume thresholds (5, 10, 15, and 20 cm{sup 3}) were tested. Results: Four textures were found to be significantly correlated with volume in both the CT and CE-CT images. These were busyness, coarseness, gray-level nonuniformity, and run-length nonuniformity with correlation coefficients of 0.92, −0.96, 0.94, and 0.98 for the CT images and 0.95, −0.97, 0.98, and 0.98 for the CE-CT images. After volume normalization, the correlation coefficients decreased substantially. For the data obtained from the CT images, the results of the Wilcoxon rank-sum test were significant when volume thresholds of 5–15 cm3 were used. No volume threshold was shown to be significant for the CE-CT data. Conclusion: Equations for four features that have been used in several published studies were found to be volume-dependent. Future studies should consider implementing normalization factors or removing these features entirely to prevent this potential source of redundancy or bias. This work was supported in part by National Cancer Institute grant R03CA178495-01. Xenia Fave is a recipient of the American Association of Physicists in Medicine Graduate Fellowship.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2015

SU-E-T-84: A Survey On Radiotherapy Table Tolerances and Couch Overrides of Over 350 Institutions

Purpose: Table overrides are relatively common in radiotherapy, yet are a potential safety concern. The goal of this study was to survey current departmental policies on treatment couch overrides and table tolerance values used clinically. Methods: A 25 question electronic survey on couch overrides and tolerances was sent to full members of the AAPM. In the first part of the survey, participants were asked: if table overrides were allowed at their institution, who was allowed to perform these overrides, and if imaging was required with overrides. In the second part of the survey, individuals were asked to provide table tolerance data for the following sites: brain/head & neck, lung, breast, abdomen/pelvis and prostate. Each site was further divided into IMRT/VMAT and 3D conformal techniques. Free-text spaces were provided, allowing respondents to enter any table tolerance data they were unable to specify under the treatment sites listed. Results: A total of 361 individuals responded, of which approximately half participated in the couch tolerances portion of the survey. Overall, 86% of respondents’ institutions allow couch tolerance overrides at treatment. Therapists were the most common staff members permitted to perform overrides, followed by physicists, dosimetrists, and physicians, respectively. Of the institutions allowing overrides, 34% reported overriding daily. More than half of the centers require documentation of the override and/or a setup image (acquired after override) to radiographically verify the treatment site. With respect to table tolerances, groups resulting from the free-text responses were at the two extremes; SRS/SBRT were the tightest, while clinical setup/mets/extremities were the most generous. There was no qualitative difference between IMRT/VMAT and 3D conformal table tolerances. Conclusion: This work is intended to stimulate a discussion within the radiotherapy community. This discussion, supplemented by the survey results provides an opportunity for institutions to enhance patient safety during daily treatment delivery.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2015

SU-E-T-87: A TG-100 Approach for Quality Improvement of Associated Dosimetry Equipment

Purpose: Dosimetry protocols devote so much time to the discussion of ionization chamber choice, use and performance that is easy to forget about the importance of the associated dosimetry equipment (ADE) in radiation dosimetry - barometer, thermometer, electrometer, phantoms, triaxial cables, etc. Improper use and inaccuracy of these devices may significantly affect the accuracy of radiation dosimetry. The purpose of this study is to evaluate the risk factors in the monthly output dosimetry procedure and recommend corrective actions using a TG-100 approach. Methods: A failure mode and effects analysis (FMEA) of the monthly linac output check procedure was performed to determine which steps and failure modes carried the greatest risk. In addition, a fault tree analysis (FTA) was performed to expand the initial list of failure modes making sure that none were overlooked. After determining the failure modes with the highest risk priority numbers (RPNs), 11 physicists were asked to score corrective actions based on their ease of implementation and potential impact. The results were aggregated into an impact map to determine the implementable corrective actions. Results: Three of the top five failure modes were related to the thermometer and barometer. The two highest RPN-ranked failure modes were related to barometric pressure inaccuracy due to their high lack-of-detectability scores. Six corrective actions were proposed to address barometric pressure inaccuracy, and the survey results found the following two corrective actions to be implementable: 1) send the barometer for recalibration at a calibration laboratory and 2) check the barometer accuracy against the local airport and correct for elevation. Conclusion: An FMEA on monthly output measurements displayed the importance of ADE for accurate radiation dosimetry. When brainstorming for corrective actions, an impact map is helpful for visualizing the overall impact versus the ease of implementation.

07 ISOTOPE AND RADIATION SOURCES↗
DOE OSTI2015

SU-E-T-97: An Analysis of Knowledge Based Planning for Stereotactic Body Radiation Therapy of the Spine

Purpose: Creating high quality SBRT treatment plans for the spine is often tedious and time consuming. In addition, the quality of treatment plans can vary greatly between treatment facilities due to inconsistencies in planning methods. This study investigates the performance of knowledge-based planning (KBP) for spine SBRT. Methods: Treatment plans were created for 28 spine SBRT patients. Each case was planned to meet strict dose objectives and guidelines. After physician and physicist approval, the plans were added to a custom model in a KBP system (RapidPlan, Varian Eclipse v13.5). The model was then trained to be able to predict estimated DVHs and provide starting objective functions for future patients based on both generated and manual objectives. To validate the model, ten additional spine SBRT cases were planned manually as well as using the model objectives. Plans were compared based on planning time and quality (ability to meet the plan objectives, including dose metrics and conformity). Results: The average dose to the spinal cord and the cord PRV differed between the validation and control plans by <0.25% demonstrating iso-toxicity. Six out of 10 validation plans met all dose objectives without the need for modifications, and overall, target dose coverage was increased by about 4.8%. If the validation plans did not meet the dose requirements initially, only 1–2 iterations of modifying the planning parameters were required before an acceptable plan was achieved. While manually created plans usually required 30 minutes to 3 hours to create, KBP can be used to create similar quality plans in 15–20 minutes. Conclusion: KBP for spinal tumors has shown to greatly decrease the amount of time required to achieve high quality treatment plans with minimal human intervention and could feasibly be used to standardize plan quality between institutions. Supported by Varian Medical Systems.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2015

SU-E-T-98: An Analysis of TG-51 Electron Beam Calibration Correction Factor Uncertainty

Purpose: To analyze the uncertainty of the TG-51 electron beam calibration correction factors for farmer type ion chambers currently used by institutions visited by IROC Houston. Methods: TG-51 calibration data were collected from 181 institutions visited by IROC Houston physicists for 1174 and 197 distinct electron beams from modern Varian and Elekta accelerators, respectively. Data collected and analyzed included ion chamber make and model, nominal energy, N{sub D,w}, I{sub 50}, R{sub 50}, k’R{sub 50}, d{sub ref}, P{sub gr} and pdd(d{sub ref}). k’R{sub 50} data for parallel plate chambers were excluded from the analysis. Results: Unlike photon beams, electron nominal energy is a poor indicator of the actual energy as evidenced by the range of R{sub 50} values for each electron beam energy (6–22MeV). The large range in R{sub 50} values resulted k’R{sub 50} values with a small standard deviation but large range between maximum value used and minimum value (0.001–0.029) used for a specific Varian nominal energy. Varian data showed more variability in k’R{sub 50} values than the Elekta data (0.001–0.014). Using the observed range of R{sub 50} values, the maximum spread in k’R{sub 50} values was determined by IROC Houston and compared to the spread of k’R{sub 50} values used in the community. For Elekta linacs the spreads were equivalent, but for Varian energies of 6 to 16MeV, the community spread was 2 to 6 times larger. Community P{sub gr} values had a much larger range of values for 6 and 9 MeV values than predicted. The range in Varian pdd(d{sub ref} ) used by the community for low energies was large, (1.4–4.9 percent), when it should have been very close to unity. Exradin, PTW Roos and PTW farmer chambers N{sub D,w} values showed the largest spread, ≥11 percent. Conclusion: While the vast majority of electron beam calibration correction factors used are accurate, there is a surprising spread in some of the values used.

07 ISOTOPE AND RADIATION SOURCES↗
DOE OSTI2015

SU-E-T-105: An FMEA Survey of Intensity Modulated Radiation Therapy (IMRT) Step and Shoot Dose Delivery Failure Modes

Purpose: To assess the perception of TG-142 tolerance level dose delivery failures in IMRT and the application of FMEA process to this specific aspect of IMRT. Methods: An online survey was distributed to medical physicists worldwide that briefly described 11 different failure modes (FMs) covered by basic quality assurance in step- and-shoot IMRT at or near TG-142 tolerance criteria levels. For each FM, respondents estimated the worst case H&N patient percent dose error and FMEA scores for Occurrence, Detectability, and Severity. Demographic data was also collected. Results: 181 individual and three group responses were submitted. 84% were from North America. Most (76%) individual respondents performed at least 80% clinical work and 92% were nationally certified. Respondent medical physics experience ranged from 2.5–45 years (average 18 years). 52% of individual respondents were at least somewhat familiar with FMEA, while 17% were not familiar. Several IMRT techniques, treatment planning systems and linear accelerator manufacturers were represented. All FMs received widely varying scores ranging from 1–10 for occurrence, at least 1–9 for detectability, and at least 1–7 for severity. Ranking FMs by RPN scores also resulted in large variability, with each FM being ranked both most risky (1st ) and least risky (11th) by different respondents. On average MLC modeling had the highest RPN scores. Individual estimated percent dose errors and severity scores positively correlated (p<0.10) for each FM as expected. No universal correlations were found between the demographic information collected and scoring, percent dose errors, or ranking. Conclusion: FMs investigated overall were evaluated as low to medium risk, with average RPNs less than 110. The ranking of 11 FMs was not agreed upon by the community. Large variability in FMEA scoring may be caused by individual interpretation and/or experience, thus reflecting the subjective nature of the FMEA tool.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2015

SU-E-T-106: An Institutional Review of Using Commercially Available Software to Evaluate Treatment Plan Quality for Various Treatment Sites and Beam Deliveries

Purpose: Use Sun Nuclear Quality Reports™ with PlanIQ™ to evaluate different treatment delivery techniques for various treatment sites. Methods: Fifteen random patients with different treatment sites were evaluated. These include the Head/Neck, prostate, pelvis, lung, esophagus, axilla, bladder and abdomen. Initially, these sites were planned on the Pinnacle {sup 3} V9.6 treatment planning system and utilized nine 6MV step-n-shoot IMRT fields. The RT plan, dose and structure sets were sent to Quality Reports™ where a DVH was recreated and the plans were compared to a unique Plan Algorithm for each treatment site. Each algorithm has its own plan quality metrics and objectives, which include the PTV coverage, PTV maximum dose, the prescription dose outside the target, doses to the critical structures, and the global maximum dose and its location. Each plan was scored base on meeting each objective. Plans may have been reoptimized and reevaluated with Quality Reports™ based on the initial score. PlanIQ™ was used to evaluate if any objective not met was achievable or difficult to obtain. A second plan using VMAT delivery was created for each patient and scored with Quality Reports™. Results: There were a wide range of scores for the different treatment sites with some scoring better for IMRT plans and some better for the VMAT deliveries. The variation in the scores could be attributed to the treatment site, location, and shape of the target. Most deliveries were chosen for the VMAT due to the short treatment times and quick patient throughput with acceptable plan scores. Conclusion: The tools are provided for both physician and dosimetrist to objectively evaluate the use of VMAT delivery versus the step-n-shoot IMRT delivery for various sites. PlanIQ validates if objectives can be met. For the physicist, a concise pass/fail report is created for plan evaluation.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2015

SU-E-T-186: Cloud-Based Quality Assurance Application for Linear Accelerator Commissioning

Purpose: To identify anomalies and safety issues during data collection and modeling for treatment planning systems Methods: A cloud-based quality assurance system (AQUIRE - Automated QUalIty REassurance) has been developed to allow the uploading and analysis of beam data aquired during the treatment planning system commissioning process. In addition to comparing and aggregating measured data, tools have also been developed to extract dose from the treatment planning system for end-to-end testing. A gamma index is perfomed on the data to give a dose difference and distance-to-agreement for validation that a beam model is generating plans consistent with the beam data collection. Results: Over 20 linear accelerators have been commissioning using this platform, and a variety of errors and potential saftey issues have been caught through the validation process. For example, the gamma index of 2% dose, 2mm DTA is quite sufficient to see curves not corrected for effective point of measurement. Also, data imported into the database is analyzed against an aggregate of similar linear accelerators to show data points that are outliers. The resulting curves in the database exhibit a very small standard deviation and imply that a preconfigured beam model based on aggregated linear accelerators will be sufficient in most cases. Conclusion: With the use of this new platform for beam data commissioning, errors in beam data collection and treatment planning system modeling are greatly reduced. With the reduction in errors during acquisition, the resulting beam models are quite similar, suggesting that a common beam model may be possible in the future. Development is ongoing to create routine quality assurance tools to compare back to the beam data acquired during commissioning. I am a medical physicist for Alzyen Medical Physics, and perform commissioning services.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2015

SU-E-T-204: Comparison of Absorbed-Dose to Water in High-Energy Photon Beams Based On Addendum AAPM TG-51, IAEA TRS-398, and JSMP 12

Purpose: Several clinical reference dosimetry protocols for absorbed-dose to water have recently been published: The American Association of Physicists in Medicine (AAPM) published an Addendum to the AAPM’s TG-51 (Addendum TG-51) in April 2014, and the Japan Society of Medical Physics (JSMP) published the Japan Society of Medical Physics 12 (JSMP12), a clinical reference dosimetry protocol, in September 2012. This investigation compared and evaluated the absorbed-dose to water of high-energy photon beams according to Addendum TG-51, International Atomic Energy Agency Technical Report Series No. 398 (TRS-398), and JSMP12. Methods: Differences in the respective beam quality conversion factors with Addendum TG-51, TRS-398, and JSMP12 were analyzed and the absorbed-dose to water using 6- and 10-MV photon beams was measured according to the protocols recommended in Addendum TG-51, TRS-398, and JSMP12. The measurements were conducted using two Farmer-type ionization chambers, Exradin A12 and PTW 30013. Results: The beam quality conversion factors for both the 6- and 10-MV photon beams with Addendum TG-51 were within 0.6%, in agreement with the beam quality conversion factors with TRS-398 and JSMP12. The Exradin A12 provided an absorbed-dose to water ratio from 1.003 to 1.006 with TRS-398 / Addendum TG-51 and from 1.004 to 1.005 with JSMP 12 / Addendum TG-51, whereas the PTW 30013 provided a ratio of 1.001 with TRS-398 / Addendum TG-51 and a range from 0.997 to 0.999 with JSMP 12 / Addendum TG-51. Conclusion: Despite differences in the beam quality conversion factor, no major differences were seen in the absorbed-dose to water with Addendum TG-51, TRS-398, and JSMP12. However, Addendum TG-51 provides the most recent data for beam quality conversion factors based on Monte Carlo simulation and greater detail for the measurement protocol. Therefore, the absorbed-dose to water measured with Addendum TG-51 is an estimate with less uncertainty.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2015

SU-E-T-269: Differential Hazard Analysis For Conventional And New Linac Acceptance Testing Procedures

Purpose: New techniques and materials have recently been developed to expedite the conventional Linac Acceptance Testing Procedure (ATP). The new ATP method uses the Electronic Portal Imaging Device (EPID) for data collection and is presented separately. This new procedure is meant to be more efficient then conventional methods. While not clinically implemented yet, a prospective risk assessment is warranted for any new techniques. The purpose of this work is to investigate the risks and establish the pros and cons between the conventional approach and the new ATP method. Methods: ATP tests that were modified and performed with the EPID were analyzed. Five domain experts (Medical Physicists) comprised the core analysis team. Ranking scales were adopted from previous publications related to TG 100. The number of failure pathways for each ATP test procedure were compared as well as the number of risk priority numbers (RPN’s) greater than 100 were compared. Results: There were fewer failure pathways with the new ATP compared to the conventional, 262 and 556, respectively. There were fewer RPN’s > 100 in the new ATP compared to the conventional, 41 and 115. Failure pathways and RPN’s > 100 for individual ATP tests on average were 2 and 3.5 times higher in the conventional ATP compared to the new, respectively. The pixel sensitivity map of the EPID was identified as a key hazard to the new ATP procedure with an RPN of 288 for verifying beam parameters. Conclusion: The significant decrease in failure pathways and RPN’s >100 for the new ATP mitigates the possibilities of a catastrophic error occurring. The Pixel Sensitivity Map determining the response and inherent characteristics of the EPID is crucial as all data and hence results are dependent on that process. Grant from Varian Medical Systems Inc.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2015

SU-E-T-273: Do Task Group External Beam QA Recommendations Guarantee Accurate Treatment Plan Dose Delivery?

Purpose: AAPM task groups 40/142 have provided an invaluable set of goals for physicists designing QA programs, attempting to standardize what would otherwise likely be a highly variable phenomenon across institutions. However, with the complexity of modalities such as VMAT, we hypothesize that following these guidelines to the letter might still allow unacceptable dose discrepancies. To explore this hypothesis we simulated machines bordering on QA acceptability, and calculated the effect on patient plans. Methods: Two errant machines were simulated in Aria/Eclipse, each just within task group criteria for output, percent depth dose, beam profile, gantry and collimator rotations, and jaw and MLC positions. One machine minimized dose to the PTV (machine A) and the other maximized dose to the OARs (machine B). Clinical treatment plans (3-phase prostate, n=3; hypofractionated lung, n=1) were calculated on these machines and the dose distributions compared. A prostate case was examined for contribution of error sources and evaluated using delivery QA data. Results: The prostate plans showed mean decreases in target D95 of 9.9% of prescription dose on machine A. On machine B, The rectal and bladder V70Gy each increased by 7.1 percentage points, while their V45Gy increased by 16.2% and 15.0% respectively. In the lung plan, the target D95 decreased by 12.8% and the bronchial tree Dmax increased by 21% of prescription dose, on machines A and B. One prostate plan showed target dose errors of 3.8% from MLC changes, 2% from output, ∼3% from energy and ∼0.5% from other factors. This plan achieved an 88.4% gamma passing rate using 3%/3mm using ArcCHECK. Conclusion: In the unlikely event that a machine exhibits all maximum errors allowed by TG 40/142, unacceptably large changes in dose delivered are possible especially in highly modulated VMAT plans, despite the machine passing routine QA.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2015

SU-E-T-361: Energy Dependent Radiation/light-Field Misalignment On Truebeam Linear Accelerator

Purpose: Verifying the co-incidence of the radiation and light field is recommended by TG-142 for monthly and annual checks. On a digital accelerator, it is simple to verify that beam steering settings are consistent with accepted and commissioned values. This fact should allow for physicists to verify radiation-light-field co-incidence for a single energy and accept that Result for all energies. We present a case where the radiation isocenter deviated for a single energy without any apparent modification to the beam steering parameters. Methods: The radiation isocenter was determined using multiple Methods: Gafchromic film, a BB test, and radiation profiles measured with a diode. Light-field borders were marked on Gafchromic film and then irradiated for all photon energies. Images of acceptance films were compared with films taken four months later. A phantom with a radio-opaque BB was aligned to isocenter using the light-field and imaged using the EPID for all photon energies. An unshielded diode was aligned using the crosshairs and then beam profiles of multiple field sizes were obtained. Field centers were determined using Omni-Pro v7.4 software, and compared to similar scans taken during commissioning. Beam steering parameter files were checked against backups to determine that the steering parameters were unchanged. Results: There were no differences between the configuration files from acceptance. All three tests demonstrated that a single energy had deviated from accepted values by 0.8 mm in the inline direction. The other two energies remained consistent with previous measurements. The deviated energy was re-steered to be within our clinical tolerance. Conclusions: Our study demonstrates that radiation-light-field coincidence is an energy dependent effect for modern linacs. We recommend that radiation-light-field coincidence be verified for all energies on a monthly basis, particularly for modes used to treat small fields, as these may drift without influencing results from other tests.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2015

SU-E-T-420: Failure Effects Mode Analysis for Trigeminal Neuralgia Frameless Radiosurgery

Purpose: Functional radiosurgery has been used successfully in the treatment of trigeminal neuralgia but presents significant challenges to ensuring the high prescription dose is delivered accurately. A review of existing practice should help direct the focus of quality improvement for this treatment regime. Method: Failure modes and effects analysis was used to identify the processes in preparing radiosurgery treatment for TN. The map was developed by a multidisciplinary team including: neurosurgeon, radiation oncology, physicist and therapist. Potential failure modes were identified for each step in the process map as well as potential causes and end effect. A risk priority number was assigned to each cause. Results: The process map identified 66 individual steps (see attached supporting document). Corrective actions were developed for areas of high risk priority number. Wrong site treatment is at higher risk for trigeminal neuralgia treatment due to the lack of site specific pathologic imaging on MR and CT – additional site specific checks were implemented to minimize the risk of wrong site treatment. Failed collision checks resulted from an insufficient collision model in the treatment planning system and a plan template was developed to address this problem. Conclusion: Failure modes and effects analysis is an effective tool for developing quality improvement in high risk radiotherapy procedures such as functional radiosurgery.

60 APPLIED LIFE SCIENCES↗