Optimized matching of film dosimetry with calculated doses for IMRT quality assurance

We develop a new method with a global optimization for registering films to calculate doses for intensity-modulated radiation therapy (IMRT) and intensity-modulated radiosurgery (IMRS) quality assurance (QA). Both absolute point dosimetry and two-dimensional (2D) film dosimetry are performed through the IMRT and IMRS using Clinac 21EX's 120 millenium MLC and BrainLab's micro-MLC, respectively. The measured and calculated dose distributions are superimposed by coincidence of their origins, followed by comparison of the point doses at all matched positions. Then, with the optimization algorithm the setup error of the dosimeter is corrected. An example of IMRT cases shows that the average percentage showing 3% of dose difference for 10 patients has been reduced from 19% to 9%, before and after optimization and weight, respectively. Similar results are obtained for IMRS. This method dramatically reduces the difference between measured and calculated dose distributions in all cases investigated.     

Three-dimensional quality assurance of IMRT prostate plans using gel dosimetry

Intensity modulated radiotherapy (IMRT) is one of the most modern radiation therapy treatment techniques. Although IMRT can deliver high and complex conformational doses to the tumor volume, its implementation requires rigorous quality assurance (QA) procedures that include a dosimetric pre-treatment verification of individual patient planning. This verification usually involves measuring a small volume of absolute dose with an ionization chamber and checking bi-dimensional fluency with an array of detectors. The planning technique has tri-dimensional characteristics, but no tridimensional dosimetry has been established in the clinical routine. One strategy to perform three-dimensional dosimetry is to use polymeric gels associated with magnetic resonance imaging to evaluate dose distribution. Here, we have compared the results of conventional QA procedures involving one- and two-dimensional dosimetry to the results of three-dimensional dosimetry conducted with MAGIC-f gel in 10 cases of prostate cancer IMRT planning. More specifically, we used the gamma index (3%/3 mm) to compare the results of three-dimensional dosimetry to the expected dose distributions obtained with the treatment planning system. Except for one IMRT treatment plan, the gel dosimetry results agreed with the conventional quality control and provided an overview of dose distribution in the target volume.     

A novel method for dose distribution registration using fiducial marks made by a megavoltage beam in film dosimetry for intensity-modulated radiation therapy quality assurance

PurposePhotographic film is widely used for the dose distribution verification of intensity-modulated radiation therapy (IMRT). However, analysis for verification of the results is subjective. We present a novel method for marking the isocenter using irradiation from a megavoltage (MV) beam transmitted through slits in a multi-leaf collimator (MLC).MethodsWe evaluated the effect of the marking irradiation at 500 monitor units (MU) on the total transmission through the MLC using an ionization chamber and Radiochromic Film. Film dosimetry was performed for quality assurance (QA) of IMRT plans. Three methods of registration were used for each film: marking by irradiating with an MV beam through slits in the MLC (MLC-IC); marking with a fabricated phantom (Phantom-IC); and a subjective method based on isodose lines (Manual). Each method was subjected to local γ-analysis.ResultsThe effect of the marking irradiation on the total transmission was 0.16%, as measured by a ionization chamber at a 10-cm depth in a solid phantom, while the inter-leaf transmission was 0.3%, determined from the film. The mean pass rates for each registration method agreed within ±1% when the criteria used were a distance-to-agreement (DTA) of 3 mm and a dose difference (DD) of 3%. For DTA/DD criteria of 2 mm/3%, the pass rates in the sagittal plane were 96.09 ± 0.631% (MLC-IC), 96.27 ± 0.399% (Phantom-IC), and 95.62 ± 0.988% (Manual).ConclusionThe present method is a versatile and useful method of improving the objectivity of film dosimetry for IMRT QA.     

Fast protocol for radiochromic film dosimetry using a cloud computing web application

PurposeTo investigate the feasibility of a fast protocol for radiochromic film dosimetry to verify intensity-modulated radiotherapy (IMRT) plans.Method and materialsEBT3 film dosimetry was conducted in this study using the triple-channel method implemented in the cloud computing application (Radiochromic.com). We described a fast protocol for radiochromic film dosimetry to obtain measurement results within 1 h.Ten IMRT plans were delivered to evaluate the feasibility of the fast protocol. The dose distribution of the verification film was derived at 15, 30, 45 min using the fast protocol and also at 24 h after completing the irradiation. The four dose maps obtained per plan were compared using global and local gamma index (5%/3 mm) with the calculated one by the treatment planning system. Gamma passing rates obtained for 15, 30 and 45 min post-exposure were compared with those obtained after 24 h.ResultsSmall differences respect to the 24 h protocol were found in the gamma passing rates obtained for films digitized at 15 min (global: 99.6% ± 0.9% vs. 99.7% ± 0.5%; local: 96.3% ± 3.4% vs. 96.3% ± 3.8%), at 30 min (global: 99.5% ± 0.9% vs. 99.7% ± 0.5%; local: 96.5% ± 3.2% vs. 96.3 ± 3.8%) and at 45 min (global: 99.2% ± 1.5% vs. 99.7% ± 0.5%; local: 96.1% ± 3.8% vs. 96.3 ± 3.8%).ConclusionsThe fast protocol permits dosimetric results within 1 h when IMRT plans are verified, with similar results as those reported by the standard 24 h protocol.     

Use of a control film piece in radiochromic film dosimetry

PurposeRadiochromic films change their color upon irradiation due to polymerization of the sensitive component embedded within the sensitive layer. However, agents, other than monitored radiation, can lead to a change in the color of the sensitive layer (temperature, humidity, UV light) that can be considered as a background signal and can be removed from the actual measurement by using a control film piece. In this work, we investigate the impact of the use of control film pieces on both accuracy and uncertainty of dose measured using radiochromic film based reference dosimetry protocol.MethodsWe irradiated “control” film pieces (EBT3 GafChromic^TM film model) to known doses in a range of 0.05–1 Gy, and five film pieces of the same size to 2, 5, 10, 15 and 20 Gy, considered to be “unknown” doses. Depending on a dose range, two approaches to incorporating control film piece were investigated: signal and dose corrected method.ResultsFor dose values greater than 10 Gy, the increase in accuracy of 3% led to uncertainty loss of 5% by using dose corrected approach. At lower doses and signals of the order of 5%, we observed an increase in accuracy of 10% with a loss of uncertainty lower than 1% by using the corrected signal approach.ConclusionsIncorporation of the signal registered by the control film piece into dose measurement analysis should be a judgment call of the user based on a tradeoff between deemed accuracy and acceptable uncertainty for a given dose measurement.     

Automated quality assurance and patient dosimetry in diagnostic radiology

It has been generally considered that improved methods of quality assurance would reduce the population dose from diagnostic radiology. This paper describes the development of a computerized method of automatically monitoring tube and generator parameters to perform on-line quality assurance, whilst undertaking various patient dosimetry measurements and calculations for each exposure. The method involves interfacing a microcomputer to a microprocessor controlled X-ray generator. Details of the various interfacing methods and modifications to the X-ray unit are given. The instrument enables quality assurance to be performed for every exposure by comparing tube and generator parameters against nominal settings. The software automatically warns the operator of any deviations from accepted limiting values. When a patient is examined, details of the examination and projection are entered into a database. The exposure area product and field size are monitored for each exposure. This data, together with information on tube potential and examination/projection is used to deduce patient entrance skin dose and energy imparted. Doses to individual organs are estimated using normalized organ dose data and a knowledge of tube potential and field size.     

Effect of verification imaging on in vivo dosimetry results using Gafchromic EBT3 film

In this work, the apparent treatment dose that kV planar or CBCT imaging contributes to Gafchromic EBT3 film used for in vivo dosimetry, was investigated. Gafchromic EBT3 film pieces were attached to a variety of phantoms and irradiated using the linear accelerator’s built-in kV imaging system, in both kV planar mode and CBCT mode. To evaluate the sensitivity of the film in the clinical scenario where dose contributions are received from both imaging and treatment, additional pieces of film were irradiated using base doses of 50 cGy and then irradiated using selected kV planar and CBCT techniques. For kV planar imaging, apparent treatment doses of up to 3.4 cGy per image pair were seen. For CBCT, apparent treatment doses ranged from 0.22 cGy to 3.78 cGy. These apparent doses were reproducible with and without the inclusion of the 50 cGy base dose. The contribution of apparent treatment dose from both planar kV as well as CBCT imaging can be detected, even in conjunction with an actual treatment dose. The magnitude of the apparent dose was found to be dependent on patient geometry, scanning protocol, and measurement location. It was found that the apparent treatment dose from the imaging could add up to 8% of additional uncertainty to the in vivo dosimetry result, if not taken into account. It is possible for this apparent treatment dose to be accounted for by subtraction of the experimentally determined apparent doses from in vivo measurements, as demonstrated in this work.     

Validation of Dolphin dosimetry in three dimensional patient-specific quality assurance programme

AimThe aim of this study is to commission and validate Dolphin-Compass dosimetry as a patient-specific Quality Assurance (QA) device.BackgroundThe advancement of radiation therapy in terms of highly conformal delivery techniques demands a novel method of patient-specific QA. Dolphin-Compass system is a dosimetry solution capable of doing different QA in radiation therapy.Materials and methodsDolphin, air-vented ionization detector array mounted on Versa-HD Linear Accelerator (LINAC) was used for measurements. The Compass is a dose computation algorithm which requires modelling of LINAC head similar to other Treatment Planning Systems (TPS). The dosimetry system was commissioned after measuring the required beam data. The validation was performed by comparison of treatment plans generated in Monaco TPS against the measurement data. Different types of simple, complex, static and dynamic radiation fields and highly conformal treatment plans of patients were used in this study.ResultsFor all field sizes, point doses obtained from Dolphin-Compass dosimetry were in good agreement with the corresponding TPS calculated values in most of the regions, except the penumbra, outside field and at build-up depth. The results of gamma passing rates of measurements by using different Multi-leaf Collimator patterns and Intensity Modulated Radiation Therapy fluence were also found to be in good correlation with the corresponding TPS values.ConclusionsThe commissioning and validation of dosimetry was performed with the help of various fields, MLC patterns and complex treatment plans. The present study also evaluated the efficiency of the 3D dosimetry system for the QA of complex treatment plans.     

Gafchromic film dosimetry: Four years experience using FilmQA Pro software and Epson flatbed scanners

Purposes: To assess performance of FilmQA Pro software for pre-treatment patient-specific quality assurance (QA), using radiochromic films and two commercial flatbed scanners. To evaluate a novel multichannel approach compared to the classical red channel evaluation.Material and methodsPatient films (mostly EBT2 films, one box of EBT3) were digitalized using successively two flatbed scanners: the A4-size Epson V750 and the A3-size Epson 10000XL. Prior to patient dose verification, basic characteristics of films and scanners were investigated. Patient films were analyzed using FilmQA Pro software, which enables to use the signal from all three colour channels (Red, Green, Blue).ResultsCompared to the red channel evaluation, multichannel evaluation presents better passing rates with regard to local gamma index. As expected, we obtained better results using A3-size scanner compared to A4-size scanner, especially when considering large region of interest. An observation of great interest was made for both scanners: after intensive use, a tilting in the blue transmittance profiles appeared in the lamp direction, making multichannel analysis unsuitable for accurate dose evaluation.     

On the re-calibration process in radiochromic film dosimetry

PurposeThe accuracy and precision of the dose estimates obtained with radiochromic film dosimetry are investigated in a clinical environment. The improvement in the accuracy of dose estimates reached with corrective methods is analyzed. Two novel re-calibration algorithms for radiochromic film dosimetry are presented.MethodsTwo different EBT3 lots are evaluated in two different centres. They are calibrated in Varian linacs and read in two different EPSON scaners. Once the lots are calibrated, three films per lot are considered and divided into stripes that are exposed to known doses. Several dosimetry protocols usually employed in radiochromic film dosimetry are used to convert film responses to absorbed doses. These protocols are characterized by different choices of the film responses or different sensitometric curves. Finally, the accuracy and reproducibility of the dose estimates is investigated with and without the corrective methods.Results and ConclusionsThe variabilities that affect radiochromic film dosimetry, such as intra-lot variability, inter-scan variability, post-exposure time and film autodevelopment may give rise to inaccuracies in the dose estimates. However, the implementation of re-calibration methods leads to more accurate dose estimates. All the investigated protocols showed more accurate and reproducible results when the re-calibrated methods were employed. So, the novel re-calibration methods may be applied in order to improve the accuracy and reproducibility of radiochromic film dosimetry.     

Quality assurance issues and PACS

Quality assessment and assurance is a growing concern in all areas of health care. The concern is fueled by a body of evidence that indicates that quality of care is not optimal, and in many instances, is unacceptably low. Although different standards for quality have been proposed, health outcome is the ultimate standard, since improving health is the goal of the health care system. The effects of PACS on health outcome are not known. A PAC system has the potential to improve quality, especially if it makes the diagnostic process more efficient, but evidence that such improvement actually occurs is so far lacking.     

Reference radiochromic film dosimetry: Review of technical aspects

For decades, film was used as a powerful two-dimensional (2D) dosimetry tool for radiotherapy treatment verification and quality assurance. Unlike the old silver-halide based radiographic films, radiochromic films change its color upon irradiation without the need for chemical development. Radiation dose deposited within a sensitive layer of the radiochromic film initiates polymerization of the active component, the degree of which depends on the amount of energy deposited. Response of the film to radiation is commonly expressed in terms of optical density change, which can be easily measured by any photometric device. However, a number of factors may have an impact on the signal detected by the measuring device. This review summarizes technical aspects associated with the establishment of reference radiochromic film dosimetry and its subsequent use for either clinical or research applications.     

Quality assurance of isocentres for passive proton beam nozzles using motion capture cameras

PurposeThe objective of this work is to determine mechanical, radiation, and imaging isocentres in three-dimensional (3D) coordinates and verifying coincidence of isocentres of passively scattered proton beam using a visual tracking system (VTS) and an in-house developed phantom named the Eagle.MethodsThe Eagle phantom consists of two modules: The first, named Eagle-head, is used for determining 3D mechanical isocentre of gantry rotation. The second, named Eagle-body, is used for determining 3D radiation and imaging isocentres. The Eagle-body has four slots wherein radiochromic films were inserted for measuring the 3D radiation isocentre and a metal bead was embedded in the centre of one cube to determine the imaging isocentre; this was determined by analysing cone-beam computed tomography images of the cube. Infrared reflective markers that can be tracked by VTS were attached to the Eagle at predetermined locations. The tracked data were converted into 3D treatment room coordinates. The developed method was compared with other methods to assess accuracy.ResultsThe isocentres were determined in mm with respect to the laser isocentre. The mechanical, radiation, and imaging isocentres were (−0.289, 0.189, 0.096), (−0.436, −0.217, 0.009), and (0.134, 0.142, 0.103), respectively. When compared with other methods, the difference in coordinates was (−0.033, −0.107, 0.014) and (0.003, 0.067, 0.039) for radiation and imaging isocentres, respectively.ConclusionThe developed system was found to be useful in providing fast and accurate measurements of the three isocentres in the 3D treatment room coordinate system.     

Quality assurance of human papillomavirus testing

The External Quality Assurance (EQA) in medical microbiology in the Czech Republic is well organized. It is coordinated by the Accreditation Department of the Centre of Epidemiology and Microbiology (AD-CEM) of the National Institute of Public Health in Prague. Since 1993 when the first samples were sent out the number of programmes and participating laboratories has been rapidly increasing. EQA for Human papillomavirus (HPV) has been available since 2000. As has been shown for other programmes, the EQA for HPV has proved to be useful, helping to improve the accuracy of analyses and contributing to the standardization of methods of HPV DNA testing. EQA for HPV has been well received by routine laboratories, demonstrated by a high number of these institutions voluntarily participating in EQA.     

Quality assurance in cervical cancer screening

Objectives. to examine the effectiveness of introducing External Quality Assessment (EQA) into all laboratories which undertake gynaecological cytopathology. to assess pathologists and cytotechnologists regularly for their competence to screen cervical smears, regardless of their standing in the laboratory hierarchy or their experience of gynaecological cytopathology.
Methods. Each participant was asked to screen and report on 10 slides during a 2 h period. the assessment was carried out by a facilitator under the direction of a specially appointed EQA Committee. A maximum score of 20 points was awarded for a completely correct set of answers. A minus score was awarded for a missed abnormal smear. Seventeen pathology laboratories in North West Thames Regional Health Authority participated; 146 cytologists were assessed.
Results. A pilot and four rounds of EQA have been completed and a total 5350 smears examined. Out of 2568 dyskaryotic (abnormal) smears screened, 0.7% were not identified correctly. of the 146 cytologists taking part in the assessment, 95% achieved a score of 17 or more. Three participants were identified who did not reach an acceptable level of competence and appropriate remedial action was taken.
Conclusion. the EQA scheme detected unacceptable levels of performance which can be quickly rectified. Participation of 100% has been maintained on a voluntary basis, and 4 years experience of the scheme confirms that a very high standard of screening prevails in the Region. the study illustrates that voluntary self-regulation is acceptable in the NHS, and the introduction of similar EQA schemes on a national scale will go a long way to establishing confidence in the cervical cancer screening programme.     

Quality assurance for polychromatic flow cytometry

This protocol outlines a three-part quality assurance program to optimize, calibrate and monitor flow cytometers used to measure cells labeled with five or more fluorochromes (a practice known as polychromatic flow cytometry). The initial steps of this program (system optimization) ensure that the instrument's lasers, mirrors and filters are optimally configured for the generation and transmission of multiple fluorescent signals. To determine the sensitivity and dynamic range of each fluorescence detector, the system is then calibrated by measuring fluorescence over a range of photomultiplier tube (PMT) voltages by determining the PMT voltage range and linearity (Steps 2-10) and validating the PMT voltage (Steps 11-17). Finally, to ensure consistent performance, we provide procedures to monitor the precision, accuracy and sensitivity of fluorescence measurements over time. All three aspects of this program should be performed upon installation, or whenever changes occur along the flow cytometer's optical path. However, only a few of these procedures need to be carried out on a routine basis.