A study to determine the impact of IMPT optimization techniques on prostate synthetic CT image sets dose comparison against CT image sets

BackgroundThe objective of this study is to determine the impact of intensity modulated proton therapty (IMPT) optimization techniques on the proton dose comparison of commercially available magnetic resonance for calculating attenuation (MRCA T) images, a synthetic computed tomography CT (sCT) based on magnetic resonance imaging (MRI) scan against the CT images and find out the optimization technique which creates plans with the least dose differences against the regular CT image sets.Material and methodsRegular CT data sets and sCT image sets were obtained for 10 prostate patients for the study. Six plans were created using six distinct IMPT optimization techniques including multi-field optimization (MFO), single field uniform dose (SFUD) optimization, and robust optimization (RO) in CT image sets. These plans were copied to MRCA T, sCT datasets and doses were computed. Doses from CT and MRCA T data sets were compared for each patient using 2D dose distribution display, dose volume histograms (DVH), homogeneity index (HI), conformation number (CN) and 3D gamma analysis. A two tailed t-test was conducted on HI and CN with 5% significance level with a null hypothesis for CT and sCT image sets.ResultsAnalysis of ten CT and sCT image sets with different IMPT optimization techniques shows that a few of the techniques show significant differences between plans for a few evaluation parameters. Isodose lines, DVH, HI, CN and t-test analysis shows that robust optimizations with 2% range error incorporated results in plans, when re-computed in sCT image sets results in the least dose differences against CT plans compared to other optimization techniques. The second best optimization technique with the least dose differences was robust optimization with 5% range error.ConclusionThis study affirmatively demonstrates the impact of IMPT optimization techniques on synthetic CT image sets dose comparison against CT images and determines the robust optimization with 2% range error as the optimization technique which gives the least dose difference when compared to CT plans.     

A practical methodology to improve the dosimetric accuracy of MR-based radiotherapy simulation for brain tumors

PurposeTo investigate the dosimetric accuracy of synthetic computed tomography (sCT) images generated by a clinically-ready voxel-based MRI simulation package, and to develop a simple and feasible method to improve the accuracy.Methods20 patients with brain tumor were selected to undergo CT and MRI simulation. sCT images were generated by a clinical MRI simulation package. The discrepancy between planning CT and sCT in CT number and body contour were evaluated. To resolve the discrepancies, an sCT specific CT-relative electron density (RED) calibration curve was used, and a layer of pseudo-skin was created on the sCT. The dosimetric impact of these discrepancies, and the improvement brought about by the modifications, were evaluated by a planning study. Volumetric modulated arc therapy (VMAT) treatment plans for each patient were created and optimized on the planning CT, which were then transferred to the original sCT and the modified-sCT for dose re-calculation. Dosimetric comparisons and gamma analysis between the calculated doses in different images were performed.ResultsThe average gamma passing rate with 1%/1 mm criteria was only 70.8% for the comparison of dose distribution between planning CT and original sCT. The mean dose difference between the planning CT and the original sCT were −1.2% for PTV D₉₅ and −1.7% for PTV D_max, while the mean dose difference was within 0.7 Gy for all relevant OARs. After applying the modifications on the sCT, the average gamma passing rate was increased to 92.2%. Mean dose difference in PTV D₉₅ and D_max were reduced to −0.1% and −0.3% respectively. The mean dose difference was within 0.2 Gy for all OAR structures and no statistically significant difference were found.ConclusionsThe modified-sCT demonstrated improved dosimetric agreement with the planning CT. These results indicated the overall dosimetric accuracy and practicality of this improved MR-based treatment planning method.     

Evaluation of a multi-atlas CT synthesis approach for MRI-only radiotherapy treatment planning

Background and purposeComputed tomography (CT) imaging is the current gold standard for radiotherapy treatment planning (RTP). The establishment of a magnetic resonance imaging (MRI) only RTP workflow requires the generation of a synthetic CT (sCT) for dose calculation. This study evaluates the feasibility of using a multi-atlas sCT synthesis approach (sCT_a) for head and neck and prostate patients.Material and methodsThe multi-atlas method was based on pairs of non-rigidly aligned MR and CT images. The sCT_a was obtained by registering the MRI atlases to the patient’s MRI and by fusing the mapped atlases according to morphological similarity to the patient. For comparison, a bulk density assignment approach (sCT_bda) was also evaluated. The sCT_bda was obtained by assigning density values to MRI tissue classes (air, bone and soft-tissue). After evaluating the synthesis accuracy of the sCTs (mean absolute error), sCT-based delineations were geometrically compared to the CT-based delineations. Clinical plans were re-calculated on both sCTs and a dose-volume histogram and a gamma analysis was performed using the CT dose as ground truth.ResultsResults showed that both sCTs were suitable to perform clinical dose calculations with mean dose differences less than 1% for both the planning target volume and the organs at risk. However, only the sCT_a provided an accurate and automatic delineation of bone.ConclusionsCombining MR delineations with our multi-atlas CT synthesis method could enable MRI-only treatment planning and thus improve the dosimetric and geometric accuracy of the treatment, and reduce the number of imaging procedures.     

Evaluation of a cycle-generative adversarial network-based cone-beam CT to synthetic CT conversion algorithm for adaptive radiation therapy

PurposeImage-guided radiation therapy could benefit from implementing adaptive radiation therapy (ART) techniques. A cycle-generative adversarial network (cycle-GAN)-based cone-beam computed tomography (CBCT)-to-synthetic CT (sCT) conversion algorithm was evaluated regarding image quality, image segmentation and dosimetric accuracy for head and neck (H&N), thoracic and pelvic body regions.MethodsUsing a cycle-GAN, three body site-specific models were priorly trained with independent paired CT and CBCT datasets of a kV imaging system (XVI, Elekta). sCT were generated based on first-fraction CBCT for 15 patients of each body region. Mean errors (ME) and mean absolute errors (MAE) were analyzed for the sCT. On the sCT, manually delineated structures were compared to deformed structures from the planning CT (pCT) and evaluated with standard segmentation metrics. Treatment plans were recalculated on sCT. A comparison of clinically relevant dose-volume parameters (D₉₈, D₅₀ and D₂ of the target volume) and 3D-gamma (3%/3mm) analysis were performed.ResultsThe mean ME and MAE were 1.4, 29.6, 5.4 Hounsfield units (HU) and 77.2, 94.2, 41.8 HU for H&N, thoracic and pelvic region, respectively. Dice similarity coefficients varied between 66.7 ± 8.3% (seminal vesicles) and 94.9 ± 2.0% (lungs). Maximum mean surface distances were 6.3 mm (heart), followed by 3.5 mm (brainstem). The mean dosimetric differences of the target volumes did not exceed 1.7%. Mean 3D gamma pass rates greater than 97.8% were achieved in all cases.ConclusionsThe presented method generates sCT images with a quality close to pCT and yielded clinically acceptable dosimetric deviations. Thus, an important prerequisite towards clinical implementation of CBCT-based ART is fulfilled.     

Comparison of three-dimensional patient-specific dosimetry systems with delivery errors: Toward a new synchronous measurement method

PurposeThis study proposed a synchronous measurement method for patient-specific dosimetry using two three-dimensional dose verification systems with delivery errors.MethodsTwenty hypofractionated radiotherapy treatment plans for patients with lung cancer were retrospectively reviewed. Monitor unit (MU) changes, leaf in-position errors, and angles of deviation of the collimator were intentionally introduced to investigate the detection sensitivity of the EDose + EPID (EE) and Dolphin + Compass (DC) systems.ResultsBoth systems accurately detected the MU modifications and had a similar ability to detect leaf in-position errors. The detection of multi-leaf collimator (MLC) errors was difficult for the whole body using different gamma criteria. When the introduced MLC error was 1.0 mm, the numbers of errors detected in the clinical target volume (CTV) by the EE system were 20, 20, and 20 and the numbers of errors detected by the DC system were 18, 19, and 20, at 3%/2 mm, 2%/2 mm, and 1%/1 mm, respectively. The average dose deviation of all DVH parameters exceeded 3%. The gamma and DVH evaluation results remained unchanged for the DC system when different collimator angle errors were introduced. The number of errors detected by the EE system was <11 for each anatomical structure for all gamma criteria. The mean dose deviation of the CTV was not distinguished.ConclusionsThis synchronous measurement approach can effectively eliminate the influence of random errors during treatment. The EE and DC systems reconstruct the three-dimensional dose distribution accurately and are convenient and reliable for dose verification.     

Deep learning methods to generate synthetic CT from MRI in radiotherapy: A literature review

PurposeIn radiotherapy, MRI is used for target volume and organs-at-risk delineation for its superior soft-tissue contrast as compared to CT imaging. However, MRI does not provide the electron density of tissue necessary for dose calculation. Several methods of synthetic-CT (sCT) generation from MRI data have been developed for radiotherapy dose calculation. This work reviewed deep learning (DL) sCT generation methods and their associated image and dose evaluation, in the context of MRI-based dose calculation.MethodsWe searched the PubMed and ScienceDirect electronic databases from January 2010 to March 2021. For each paper, several items were screened and compiled in figures and tables.ResultsThis review included 57 studies. The DL methods were either generator-only based (45% of the reviewed studies), or generative adversarial network (GAN) architecture and its variants (55% of the reviewed studies). The brain and pelvis were the most commonly investigated anatomical localizations (39% and 28% of the reviewed studies, respectively), and more rarely, the head-and-neck (H&N) (15%), abdomen (10%), liver (5%) or breast (3%). All the studies performed an image evaluation of sCTs with a diversity of metrics, with only 36 studies performing dosimetric evaluations of sCT.ConclusionsThe median mean absolute errors were around 76 HU for the brain and H&N sCTs and 40 HU for the pelvis sCTs. For the brain, the mean dose difference between the sCT and the reference CT was <2%. For the H&N and pelvis, the mean dose difference was below 1% in most of the studies. Recent GAN architectures have advantages compared to generator-only, but no superiority was found in term of image or dose sCT uncertainties. Key challenges of DL-based sCT generation methods from MRI in radiotherapy is the management of movement for abdominal and thoracic localizations, the standardization of sCT evaluation, and the investigation of multicenter impacts.     

Effect of the modification of CT scanner calibration curves on dose using density correction methods for chest cancer

PurposeThis work sought to establish whether the choice of CT scanner calibration curve has a significant effect on dose computation using density correction methods for chest cancer.Material and methodsCIRS^®062 phantom was used to calculate the Hounsfield Unit using 80, 120 and 140 kV. Four CT calibration curves were implanted in the Eclipse^® TPS. Forty-two irradiation fields for 4 patients with lung cancer were included and analysed. The patients were treated with 3-dimensional radiation therapy. For each patient, 3 treatment plans were generated using exactly the same beam configuration. In plan 1, the dose was calculated using the Modified Batho (MB) method. In plan 2, the dose was calculated using the Batho power law (BPL) method. In plan 3, the dose was calculated using the Equivalent Tissue Air Ratio (ETAR) method. To evaluate the treatment plans computed by the three methods, the monitor units, dose volume histograms, conformity index, homogeneity index, planning target volumes conformity index, geometrical index and 2D gamma index were compared. The statistical analysis was carried out using Wilcoxon signed rank test.ResultsThe three density correction methods in plans 1, 2 and 3 using tested curves produced a difference less than 1% for MUs and DVH. Wilcoxon test showed a statically significant difference for MUs using ETAR method with calibration curves based on 80 and 120 kV. There was no significant difference for the quality indices between plan 1, 2 and 3, (P > 0.05), but a significant difference for the planning target volumes conformity index between plans 1, 2 and 3 (P < 0.05) was observed. The 2D gamma analysis showed that 100% of pixels had gamma ≤ 1.ConclusionThe impact of the modification of CT calibration curves on dose is negligible for chest cancer using density correction methods. One calibration curve can be used to take into account the density correction for lung.     

A role for magnetic susceptibility in synthetic computed tomography

PurposeRadiotherapy treatment planning based on magnetic resonance imaging (MRI) benefits from increased soft-tissue contrast and functional imaging. MRI-only planning is attractive but limited by the lack of electron density information required for dose calculation, and the difficulty to differentiate air and bone. MRI can map magnetic susceptibility to separate bone from air. A method is introduced to produce synthetic CT (sCT) through automatic voxel-wise assignment of CT numbers from an MRI dataset processed that includes magnetic susceptibility mapping.MethodsVolumetric multi-echo gradient echo datasets were acquired in the heads of five healthy volunteers and fourteen patients with cancer using a 3 T MRI system. An algorithm for CT synthesis was designed using the volunteer data, based on fuzzy c-means clustering and adaptive thresholding of the MR data (magnitude, fat, water, and magnetic susceptibility). Susceptibility mapping was performed using a modified version of the iterative phase replacement algorithm. On patient data, the algorithm was assessed by direct comparison to X-ray computed tomography (CT) scans.ResultsThe skull, spine, teeth, and major sinuses were clearly distinguished in all sCT, from healthy volunteers and patients. The mean absolute CT number error between X-ray CT and sCT in patients ranged from 78 and 134 HU.ConclusionSusceptibility mapping using MRI can differentiate air and bone for CT synthesis. The proposed method is automated, fast, and based on a commercially available MRI pulse sequence. The method avoids registration errors and does not rely on a priori information, making it suitable for nonstandard anatomy.     

Trajectory log file sensitivity: A critical analysis using DVH and EPID

Aim

The aim of this study was to investigate the sensitivity of the trajectory log file based quality assurance to detect potential errors such as MLC positioning and gantry positioning by comparing it with EPID measurement using the most commonly used criteria of 3%/3?mm.

Validation of a method for “dose of the day” calculation in head-neck tomotherapy by using planning ct-to-MVCT deformable image registration

PurposeThe aim of this study was to test the feasibility and dosimetric accuracy of a method that employs planning CT-to-MVCT deformable image registration (DIR) for calculation of the daily dose for head and neck (HN) patients treated with Helical Tomotherapy (HT).MethodsFor each patient, the planning kVCT (CTplan) was deformably registered to the MVCT acquired at the 15th therapy session (MV15) with a B-Spline Free Form algorithm using Mattes mutual information (open-source software 3D Slicer), resulting in a deformed CT (CTdef). On the same day as MVCT15, a kVCT was acquired with the patient in the same treatment position (CT15). The original HT plans were recalculated both on CTdef and CT15, and the corresponding dose distributions were compared; local dose differences <2% of the prescribed dose (DD2%) and 2D/3D gamma-index values (2%-2 mm) were assessed respectively with Mapcheck SNC Patient software (Sun Nuclear) and with 3D-Slicer.ResultsOn average, 87.9% ± 1.2% of voxels were found for DD2% (on average 27 slices available for each patient) and 94.6% ± 0.8% of points passed the 2D gamma analysis test while the 3D gamma test was satisfied in 94.8% ± 0.8% of body’s voxels.ConclusionsThis study represents the first demonstration of the dosimetric accuracy of kVCT-to-MVCT DIR for dose of the day computations. The suggested method is sufficiently fast and reliable to be used for daily delivered dose evaluations in clinical strategies for adaptive Tomotherapy of HN cancer.     

Bladder dose–surface maps and urinary toxicity: Robustness with respect to motion in assessing local dose effects

The purpose of this study was to quantify the impact of inter-fraction modifications of bladder during RT of prostate cancer on bladder dose surface maps (DSM).Eighteen patients treated with daily image-guided Tomotherapy and moderate hypofractionation (70–72.8 Gy at 2.5–2.6 Gy/fr in 28 fractions and full bladder) were considered. Bladder contours were delineated on co-registered daily Megavoltage CT (MVCT) by a single observer and copied on the planning CT to generate dose–volume/surface histograms (DVH/DSH) and bladder DSMs. Discrepancies between planned and daily absorbed doses were analyzed through the average of individual systematic errors, the population systematic errors and the population random errors for the DVH/DSHs and DSMs.In total, 477 DVH/DSH and 472 DSM were available. DSH and DVH showed small population systematic errors of absolute surfaces (<3.4 cm²) and volumes (<8.4 cm³) at the highest doses.The dose to the posterior bladder base assessed on DSMs showed a mean systematic error below 1 Gy, with population systematic and random errors within 4 and 3 Gy, respectively. The region surrounding this area shows higher mean systematic errors (1–3 Gy), population systematic (8–11 Gy) and random (5–7 Gy) errors.In conclusion, DVH/DSH and DSMs are quite stable with respect to inter-fraction variations in the high-dose region, within about 2 cm from bladder base. Larger systematic variations occur in the anterior portion and cranially 2.5–3.5 cm from the base.Results suggest that dose predictors related to the high dose area (including the trigone dose) are likely to be sufficiently reliable with respect to the expected variations due to variable bladder filling.     

Combined PET/CT for IMRT treatment planning of NSCLC: Contrast-enhanced CT images for Monte Carlo dose calculation

PurposeCombined PET/CT imaging has been proposed as an integral part of radiotherapy treatment planning (TP). Contrast-enhanced CT (ceCT) images are frequently acquired as part of the PET/CT examination to support target delineation. The aim of this dosimetric planning study was to investigate the error introduced by using a ceCT for intensity modulated radiotherapy (IMRT) TP with Monte Carlo dose calculation for non-small cell lung cancer (NSCLC).Material and methodsNine patients with NSCLC prior to chemo-RT were included in this retrospective study. For each patient non-enhanced, low-dose CT (neCT), ceCT and [¹⁸F]-FDG-PET emission data were acquired within a single examination. Manual contouring and TP were performed on the ceCT. An additional set of independent target volumes was auto-segmented in PET images. Dose distributions were recalculated on the neCT. Differences in dosimetric parameters were evaluated.ResultsDose differences in PTV and lungs were small for all patients. The maximum difference in all PTVs when using ceCT images for dose calculation was ?2.1%, whereas the mean difference was less than ?1.7%. Maximum differences in the lungs ranged from ?1.8% to 2.1% (mean: ?0.1%). In four patients an underestimation of the maximum spinal cord dose between 2% and 3.2% was observed, but treatment plans remained clinically acceptable.ConclusionsMonte Carlo based IMRT planning for NSCLC patients using ceCT allows for correct dose calculation. A direct comparison to neCT-based treatment plans revealed only small dose differences. Therefore, ceCT-based TP is clinically safe as long as the maximum acceptable dose to organs at risk is not approached.     

Clinical verification of treatment planning dose calculation in lung SBRT with GATE Monte Carlo simulation code

PurposeThis study aims to use GATE/Geant4 simulation code to evaluate the performance of dose calculations with Anisotropic Analytical Algorithm (AAA) in the context of lung SBRT for complex treatments considering images of patients.MethodsFour cases of non-small cell lung cancer treated with SBRT were selected for this study. Irradiation plans were created with AAA and recalculated end to end using Monte Carlo (MC) method maintaining field configurations identical to the original plans. Each treatment plan was evaluated in terms of PTV and organs at risk (OARs) using dose-volume histograms (DVH). Dosimetric parameters obtained from DVHs were used to compare AAA and MC.ResultsThe comparison between the AAA and MC DVH using gamma analysis with the passing criteria of 3%/3% showed an average passing rate of more than 90% for the PTV structure and 97% for the OARs. Tightening the criteria to 2%/2% showed a reduction in the average passing rate of the PTV to 86%. The agreement between the AAA and MC dose calculations for PTV dosimetric parameters (V₁₀₀; V₉₀; Homogeneity index; maximum, minimum and mean dose; CI_Paddick and D_2cm) was within 18.4%. For OARs, the biggest differences were observed in the spinal cord and the great vessels.ConclusionsIn general, we did not find significant differences between AAA and MC. The results indicate that AAA could be used in complex SBRT cases that involve a larger number of small treatment fields in the presence of tissue heterogeneities.     

Delta4 Discover transmission detector: A comprehensive characterization for in-vivo VMAT monitoring

ObjectiveTo investigate the dosimetric behaviour, influence on photon beam fluence and error detection capability of Delta⁴ Discover transmission detector.MethodsThe transmission detector (TRD) was characterized on a TrueBeam linear accelerator with 6 MV beams. Linearity, reproducibility and dose rate dependence were investigated. The effect on photon beam fluence was evaluated in terms of beam profiles, percentage depth dose, transmission factor and surface dose for different open field sizes. The transmission factor of the 10x10 cm² field was entered in the TPS’s configuration and its correct use in the dose calculation was verified recalculating 17 clinical IMRT/VMAT plans. Surface dose was measured for 20 IMRT fields. The capability to detect different delivery errors was investigated evaluating dose gamma index, MLC gamma index and leaf position of 15 manually modified VMAT plans.ResultsTRD showed a linear dependence on MU. No dose rate dependence was observed. Short-term and long-term reproducibility were within 0.1% and 0.5%. The presence of the TRD did not significantly affect PDDs and profiles. The transmission factor of the 10x10 cm² field size was 0.985 and 0.983, for FF and FFF beams respectively. The 17 recalculated plans met our clinical gamma-index passing rate, confirming the correct use of the transmission factor by the TPS. The surface dose differences for the open fields increase for shorter SSDs and greater field size. Differences in surface dose for the IMRT beams were less than 2%. Output variation ≥2%, collimator angle variations within 0.3°, gantry angle errors of 1°, jaw tracking and leaf position errors were detected.ConclusionsDelta⁴ Discover shows good linearity and reproducibility, is not dependent on dose rate and does not affect beam quality and dose profiles. It is also capable to detect dosimetric and geometric errors and therefore it is suitable for monitoring VMAT delivery.     

A convolution neural network for higher resolution dose prediction in prostate volumetric modulated arc therapy

PurposeThis study aims to investigate the feasibility of using convolutional neural networks to predict an accurate and high resolution dose distribution from an approximated and low resolution input dose.MethodsSixty-six patients were treated for prostate cancer with VMAT. We created the treatment plans using the Acuros XB algorithm with 2 mm grid size, followed by the dose calculated using the anisotropic analytical algorithm with 5 mm grid with the same plan parameters. U-net model was used to predict 2 mm grid dose from 5 mm grid dose. We investigated the two models differing for the training data used as input, one used just the low resolution dose (D model) and the other combined the low resolution dose with CT data (DC model). Dice similarity coefficient (DSC) was calculated to ascertain how well the shape of the dose-volume is matched. We conducted gamma analysis for the following: DVH from the two models and the reference DVH for all prostate structures.ResultsThe DSC values in the DC model were significantly higher than those in the D model (p < 0.01). For the CTV, PTV, and bladder, the gamma passing rates in the DC model were significantly higher than those in the D model (p < 0.002–0.02). The mean doses in the CTV and PTV for the DC model were significantly better matched to those in the reference dose (p < 0.0001).ConclusionsThe proposed U-net model with dose and CT image used as input predicted more accurate dose.     

Clinically relevant quality assurance (QA) for prostate RapidArc plans: Gamma maps and DVH-based evaluation

The aim of this paper is to evaluate clinically relevant quality assurance (QA) tests for RapidArc prostate patients. 26 plans were verified by the COMPASS system that provides an independent angle response and a reconstruction of dose distribution in patient CT model. Plan data were imported from treatment planning system via DICOM. The fluencies, measured by a 2D detector, were used by COMPASS to forward calculate dose in CT patients and reconstruct dose-volume-histogram (DVH). The gamma analysis was performed, using both the criteria 3%-3-mm and 2%-2 mm, for the whole grid patient and the per-structure volume. A DVH-based analysis was accomplished for target and organs-at-risk (OAR). The correlation between gamma passing rates and DVH discrepancies was performed using Pearson's test. Sensitivity, specificity and accuracy of whole and per-structure gamma method were calculated.No significant DVH deviation was observed for target and OAR. Weak correlation between gamma passing rates and dosimetric deviations was observed, all significant r-values were negative. The whole gamma method shows lack of sensitivity to detect dosimetric deviations >5%. Instead, a better balance between sensitivity and specificity was obtained employing per structure gamma both with 3%-3 mm and 2%-2 mm criteria.Because of the poor correlation between DVH goals and gamma passing rates, we encourage the DVH-based gamma passing rates, when it is possible. At least, a gamma method specific for structure was strongly suggested.     

Multi-institutional comparison of simulated treatment delivery errors in ssIMRT,manually planned VMAT and autoplan-VMAT plans for nasopharyngeal radiotherapy

PurposeTo quantify the impact of simulated errors for nasopharynx radiotherapy across multiple institutions and planning techniques (auto-plan generated Volumetric Modulated Arc Therapy (ap-VMAT), manually planned VMAT (mp-VMAT) and manually planned step and shoot Intensity Modulated Radiation Therapy (mp-ssIMRT)).MethodsTen patients were retrospectively planned with VMAT according to three institution’s protocols. Within one institution two further treatment plans were generated using differing treatment planning techniques. This resulted in mp-ssIMRT, mp-VMAT, and ap-VMAT plans. Introduced treatment errors included Multi Leaf Collimator (MLC) shifts, MLC field size (MLCfs), gantry and collimator errors. A change of more than 5% in most selected dose metrics was considered to have potential clinical impact. The original patient plan total Monitor Units (MUs) were correlated to the total number of dose metrics exceeded.ResultsThe impact of different errors was consistent, with ap-VMAT plans (two institutions) showing larger dose deviations than mp-VMAT created plans (one institution). Across all institutions’ VMAT plans the significant errors included; ±5° for the collimator angle, ±5 mm for the MLC shift and +1, ±2 and ±5 mm for the MLC field size. The total number of dose metrics exceeding tolerance was positively correlated to the VMAT total plan MUs (r = 0.51, p < 0.001), across all institutions and techniques.ConclusionsDifferences in VMAT robustness to simulated errors across institutions occurred due to planning method differences. Whilst ap-VMAT was most sensitive to MLC errors, it also produced the best quality treatment plans. Mp-ssIMRT was most robust to errors. Higher VMAT treatment plan complexity led to less robust plans.     

Comparison of three commercial dosimetric systems in detecting clinically significant VMAT delivery errors

AimTo study the sensitivity of three commercial dosimetric systems, Delta4, Multicube and Octavius4D, in detecting Volumetric Modulated Arc Therapy (VMAT) delivery errors.MethodsFourteen prostate and head and neck (H&N) VMAT plans were considered for this study. Three types of errors were introduced into the original plans: gantry angle independent and dependent MLC errors, and gantry angle dependent dose errors. The dose matrix measured by each detector system for the no-error and error introduced delivery were compared with the reference Treatment Planning System (TPS) calculated dose matrix for no-error plans using gamma (γ) analysis with 2%/2 mm tolerance criteria. The ability of the detector system in identifying the minimum error in each scenario was assessed by analysing the gamma pass rates of no error delivery and error delivery using a Wilcoxon signed-rank test. The relative sensitivity of the system was assessed by determining the slope of the gamma pass line for studied error magnitude in each error scenario.ResultsIn the gantry angle independent and dependent MLC error scenario the Delta4, Multicube and Octavius4D systems detected a minimum 2 mm error. In the gantry angle dependent dose error scenario all studied systems detected a minimum 3% and 2% error in prostate and H&N plans respectively. In the studied detector systems Multicube showed relatively less sensitivity to the errors in the majority of error scenarios.ConclusionThe studied systems identified the same magnitude of minimum errors in all considered error scenarios.     

3D-printed patient-specific pelvis phantom for dosimetry measurements for prostate stereotactic radiotherapy with dominant intraprostatic lesion boost

AimDeveloping and assessing the feasibility of using a three-dimensional (3D) printed patient-specific anthropomorphic pelvis phantom for dose calculation and verification for stereotactic ablative radiation therapy (SABR) with dose escalation to the dominant intraprostatic lesions.Material and methodsA 3D-printed pelvis phantom, including bone-mimicking material, was fabricated based on the computed tomography (CT) images of a prostate cancer patient. To compare the extent to which patient and phantom body and bones overlapped, the similarity Dice coefficient was calculated. Modular cylindrical inserts were created to encapsulate radiochromic films and ionization chamber for absolute dosimetry measurements at the location of prostate and at the boost region. Gamma analysis evaluation with 2%/2mm criteria was performed to compare treatment planning system calculations and measured dose when delivering a 10 flattening filter free (FFF) SABR plan and a 10FFF boost SABR plan.ResultsDice coefficients of 0.98 and 0.91 were measured for body and bones, respectively, demonstrating agreement between patient and phantom outlines. For the boost plans the gamma analysis yielded 97.0% of pixels passing 2%/2mm criteria and these results were supported by the chamber average dose difference of 0.47 ± 0.03%. These results were further improved when overriding the bone relative electron density: 97.3% for the 2%/2mm gamma analysis, and 0.05 ± 0.03% for the ionization chamber average dose difference.ConclusionsThe modular patient-specific 3D-printed pelvis phantom has proven to be a highly attractive and versatile tool to validate prostate SABR boost plans using multiple detectors.