Browsing by Subject "Medical physics"

As complex radiotherapy techniques become more readily-practiced, comprehensive 3D dosimetry is a growing necessity for advanced quality assurance. However, clinical implementation has been impeded by a wide variety of factors, including the expense of dedicated optical dosimeter readout tools, high operational costs, and the overall difficulty of use. To address these issues, a novel dry-tank optical CT scanner was designed for PRESAGE 3D dosimeter readout, relying on 3D printed components and omitting costly parts from preceding optical scanners. This work details the design, prototyping, and basic commissioning of the Duke Integrated-lens Optical Scanner (DIOS).

The convex scanning geometry was designed in ScanSim, an in-house Monte Carlo optical ray-tracing simulation. ScanSim parameters were used to build a 3D rendering of a convex ‘solid tank’ for optical-CT, which is capable of collimating a point light source into telecentric geometry without significant quantities of refractive-index matched fluid. The model was 3D printed, processed, and converted into a negative mold via rubber casting to produce a transparent polyurethane scanning tank. The DIOS was assembled with the solid tank, a 3W red LED light source, a computer-controlled rotation stage, and a 12-bit CCD camera. Initial optical phantom studies show negligible spatial inaccuracies in 2D projection images and 3D tomographic reconstructions. A PRESAGE 3D dose measurement for a 4-field box treatment plan from Eclipse shows 95% of voxels passing gamma analysis at 3%/3mm criteria. Gamma analysis between tomographic images of the same dosimeter in the DIOS and DLOS systems show 93.1% agreement at 5%/1mm criteria. From this initial study, the DIOS has demonstrated promise as an economically-viable optical-CT scanner. However, further improvements will be necessary to fully develop this system into an accurate and reliable tool for advanced QA.

Pre-clinical animal studies are used as a conventional means of translational research, as a midpoint between in-vitro cell studies and clinical implementation. However, modern small animal radiotherapy platforms are primitive in comparison with conventional linear accelerators. This work also investigates a series of 3D printed tools to expand the treatment capabilities of the X-RAD 225Cx orthovoltage irradiator, and applies them to a feasibility study of hippocampal avoidance in rodent whole-brain radiotherapy.

As an alternative material to lead, a novel 3D-printable tungsten-composite ABS plastic, GMASS, was tested to create precisely-shaped blocks. Film studies show virtually all primary radiation at 225 kVp can be attenuated by GMASS blocks of 0.5cm thickness. A state-of-the-art software, BlockGen, was used to create custom hippocampus-shaped blocks from medical image data, for any possible axial treatment field arrangement. A custom 3D printed bite block was developed to immobilize and position a supine rat for optimal hippocampal conformity. An immobilized rat CT with digitally-inserted blocks was imported into the SmART-Plan Monte-Carlo simulation software to determine the optimal beam arrangement. Protocols with 4 and 7 equally-spaced fields were considered as viable treatment options, featuring improved hippocampal conformity and whole-brain coverage when compared to prior lateral-opposed protocols. Custom rodent-morphic PRESAGE dosimeters were developed to accurately reflect these treatment scenarios, and a 3D dosimetry study was performed to confirm the SmART-Plan simulations. Measured doses indicate significant hippocampal sparing and moderate whole-brain coverage.

Since 2010, Duke University Medical Center has used the single-isocenter technique to treat patients with multiple brain metastases. The purpose of this project is to compare treatment planning techniques for these patients who received treatment. First, we want to determine if volumetric modulated arc therapy (VMAT) or dynamic conformal arc therapy (DCAT) is the better method for treatment for incoming patients. Next, we want to know if using U-frame or frameless masks provide better plan quality. Lastly, we want to test the use of a stationary couch to simulate imaging while treating with the moving gantry. DCAT plans were created for each of the 40 single-isocenter patients who received VMAT at Duke University Medical Center from 2016 to 2018. These patients were randomly selected based only on the number of metastases, from 2 to 14. We created the DCAT plans using 5 couch positions, 2 collimator angles, and 100° arcs on BrainLab Elements. We modeled U-frame and frameless masks using 100° and 180° arcs, respectively. To simulate imaging, we kept the couch at 0° while using only 180° arcs. The clinical VMAT plans delivered to the 40 patients had an average conformity index of 1.47 and average gradient index of 8.57. Average whole-brain V3 Gy and V5 Gy were 14.07% and 5.80%, respectively. In comparison, using DCAT the conformity index was 1.75 and the gradient index was 6.87. Whole-brain V3 Gy and V5 Gy were 11.25% and 5.59%, respectively. The frameless mask plans had conformity and gradient indexes of 1.68 and 6.39 and V3 Gy and V5 Gy of 11.39% and 5.09%, respectively. Using VMAT for the imaging cases, we found conformity and gradient indexes of 1.59 and 11.99 and V3 Gy and V5 Gy of 18.04% and 8.41%. Using DCAT for the imaging cases had conformity and gradient indexes of 2.02 and 9.86 and V3 Gy and V5 Gy of 14.21% and 7.25%, respectively. Overall, VMAT plans had higher conformity index with lower gradient index at the cost of healthy brain protection compared to DCAT. Frameless masks also increased the conformity index and decreased the gradient index with no significant impact on low doses to the brain. The use of imaging while treating should be considered with the benefit when imaging on a case-by-case basis.

Translational cancer research has been around for many years and has resulted

in many advancements in cancer treatment. Preclinical radiation therapy is an important

tool used in some studies to better understand the biological effects due to radiation.

Current preclinical radiation treatment techniques do not emulate the advanced

techniques used in cancer clinics, such as intensity modulated radiation therapy (IMRT).

In this work we explore the possibility of developing and implementing an IMRT

treatment capability for an orthovoltage micro irradiator used for small animal research.

In order to implement IMRT to the micro irradiator, every step of the radiation

therapy treatment process had to be evaluated, developed, and tested. The first step was

to develop and treatment planning software that can be used for small animal studies.

Using the open source Computational Environment for Radiotherapy Research (CERR)

and adapting it for use with an orthovoltage irradiator, monte carlo dose calculations

could be performed for small animal data sets. CERR does not have the ability to

optimize dose calculations, so a Matlab script was developed and written for inverse

optimization for treatment planning. Treatment plans were designed and optimized for

several small animal cases to evaluate the optimization algorithm. Following successful

simulation development, treatment delivery techniques needed to be developed. 3D

printing was used as a tool to create physical compensators that could be used as an

add-on device to the micro irradiator. With the capability of submillimeter printing

resolution, 3D printing has the capability to handle the high resolution required for very

small structures inside of small animals. Using the simulation data, another Matlab

script was developed to create both compensator and inverse compensator 3D models.

Many materials and techniques were evaluated to determine the best method for

compensator production. Materials were tested for attenuation properties, printing

capabilities, and ease of use until a satisfactory result was achieved.

Once the simulation and delivery techniques were developed to a satisfactory

level, an end to end test was designed to verify the IMRT capability. Using a 2.2 cm

diameter cylindrical Presage® dosimeter as the quality assurance (QA) device/patient, a

treatment plan was created based on the geometry of the Radiologic Physics Center

(RPC) Head and Neck phantom design. The dose tolerances used for the inverse

optimization were the same as the RPC Head and Neck protocol with a stricter tolerance

for the organ at risk (OAR). Compensators were produced for the plan and both 2D and

3D analysis was performed. Radiochromic film was used for 2D dose map analysis.

Gamma analysis was performed using 2D film data with varying criteria for distance to

agreement and dose difference. 3D analysis was done by delivering the treatment plan

to the Presage® dosimeter. Using optical-CT for dose readout of the dosimeter,

qualitative analysis was performed to show the 3D delivered dose data.

The end to end test showed strong evidence that IMRT could be implemented on

the small animal irradiator. The 9 field treatment plan was delivered in under 30

minutes with no mechanical or collisional issues. The 2D dose analysis showed 7 out of 9

treatment fields had a passing rate greater than 90% for a gamma analysis using 10%/0.5

mm tolerances. 3D dose analysis showed promising spatial resolution of the dose

modulation. As a feasibility and an initial testing study for a new treatment technique on

the small animal irradiator, these results showed the capability of the 3D printed

compensators to modulate dose with high spatial precision and moderately accurate

dose delivery.

Oropharyngeal Squamous Cell Carcinoma (OPSCC) is by far the most predominant form of head and neck cancer in the United States. The survival rate for OPSCC is very high, which, while fortunate, yields many patients who are left with the late term toxicities consequent of their treatment. This project aimed to use patient-reported outcome (PRO) data from two sources – the PRO-CTCAE and the QLQ-C30 – along with the dosimetric data of patients that have already been treated, in order to characterize retrospectively a relationship between patient dosimetric data and the severity of response of PRO data. In particular, PRO data was used as a way to characterize the severity of patient-experienced xerostomia and dysphagia. Additionally, this data was used to fit the radiobiological parameters for two normal tissue complication probability (NTCP) models: the Lyman-Kutcher-Burman (LKB) model, and the Relative Seriality (RS) model. Overall, it was found that the PRO-CTCAE data was more robust than the QLQ-C30 data in its characterization. Based on the PRO-CTCAE data, the V52 (volume which receives at least 52 Gy) of the combined constrictors and the V59 of the superior pharyngeal constrictor show the strongest relationship with patient-reported dysphagia. Additionally, the V27 of the contralaterals and the V12 of the contralateral parotid show the strongest relationship with patient-reported xerostomia. Furthermore, it was found that the dose response curves for both NTCP models fit the data with similar accuracy.

The need for clinically intuitive metrics for patient-specific quality assurance in radiation therapy has been well-documented (Zhen, Nelms et al. 2011). A novel transform method has shown to be effective at converting full-density 3D dose measurements made in a phantom to dose values in the patient geometry, enabling comparisons using clinically intuitive metrics such as dose-volume histograms (Oldham et al. 2011). This work investigates the transform method and compares its calculated dose-volume histograms (DVHs) to DVH values calculated by a Delta4 QA device (Scandidos), marking the first comparison of a true 3D system to a semi-3D device using clinical metrics. Measurements were made using Presage 3D dosimeters, which were readout by an in-house optical-CT scanner. Three patient cases were chosen for the study: one head-and-neck VMAT treatment and two spine IMRT treatments. The transform method showed good agreement with the planned dose values for all three cases. Furthermore, the transformed DVHs adhered to the planned dose with more accuracy than the Delta4 DVHs. The similarity between the Delta4 DVHs and the transformed DVHs, however, was greater for one of the spine cases than it was for the head-and-neck case, implying that the accuracy of the Delta4 Anatomy software may vary from one treatment site to another. Overall, the transform method, which incorporates data from full-density 3D dose measurements, provides clinically intuitive results that are more accurate and consistent than the corresponding results from a semi-3D Delta4 system.

Purpose: HNC IMRT treatment planning is a challenging process that relies heavily on the planner's experience. Previously, we used the single, best match from a library of manually planned cases to semi-automatically generate IMRT plans for a new patient. The current multi-case Knowledge Based Radiation Therapy (MC-KBRT) study utilized different matching cases for each of six individual organs-at-risk (OARs), then combined those six cases to create the new treatment plan.

Methods: From a database of 103 patient plans created by experienced planners, MC-KBRT plans were created for 40 (17 unilateral and 23 bilateral) HNC "query" patients. For each case, 2D beam's-eye-view images were used to find similar geometric "match" patients separately for each of 6 OARs. Dose distributions for each OAR from the 6 matching cases were combined and then warped to suit the query case's geometry. The dose-volume constraints were used to create the new query treatment plan without the need for human decision-making throughout the IMRT optimization. The optimized MC-KBRT plans were compared against the clinically approved plans and Version 1 (original KBRT) using the dose metrics: mean, median, and maximum (brainstem and cord+5mm) doses.

Results: Compared to Version 1, MC-KBRT had no significant reduction of the dose to any of the OARs in either unilateral/bilateral cases. Compared to the manually-planned unilateral cases, there was significant reduction of the oral cavity mean/median dose (>2Gy) at the expense of the contralateral parotid. Compared to the manually-planned bilateral cases, reduction of dose was significant in the ipsilateral parotid, larynx, and oral cavity (>3Gy mean/median) while maintaining PTV coverage.

Conclusion: MC-KBRT planning in head and neck cancer generates IMRT plans with equivalent dose sparing to manually created plans. MC-KBRT using multiple case matches does not show significant dose reduction compared to using a single match case with dose warping.

The utilization of brachytherapy practice in clinics has been declining over the years. The decline has been linked to a variety of factors including a lack of training opportunities. To improve the quality of intracavitary and interstitial HDR brachytherapy education, a multi-material modular 3D printed pelvic phantom kit prototype simulating normal and cervix pathological conditions has been developed. This comprehensive training phantom is intended to serve as a novel aid in the “300 in 10 Strategy” put forward by the American Brachytherapy Society which calls to train 30 competent brachytherapists per year over the next 10 years.

Patient anatomy was derived from anonymized pelvic CT and MRI scans from different representative patients who had been diagnosed with cervical cancer. The dimensions of patients’ uterine canal sizes and uterine body sizes were measured and used to construct a variety of uteri based off of the averages and standard deviations of the subjects in our study.

The length of the uterine body was measured from top of the fundus to the top of the cervix. The width of the uterine body was measured at the top of the cervix and also measured across the midpoint between the cervix and the fundus. High risk clinical target volumes (HR-CTV) were also extracted from these patients. 3D Slicer (Slicer 4.10.1) was used to import and convert contoured DICOM data into a 3D model. Organs of interest for our prototype include the vaginal canal, uterus, and cervix. A standard rectum, and bladder were also printed.

Individual STL files were imported into Autodesk Meshmixer (3.5.4) and manipulated to include more representative features such as hollowed out cavities and canals. Modular components of the phantom were designed and integrated into patient anatomy using 3D modeling software Shapr3D (Stratasys, 3.35.0).

Flexible and rigid materials were assigned to each component of the phantom. Vero Clear (Stratasys) was assigned to rigid design components including modularity connections. Agilus30 (Stratasys) was assigned to the more flexible components including the vaginal canal, uterus, rectum, and bladder. Each flexible component was assigned a shore hardness value ranging from 30-80 to further individualize the level of flexibility. The finalized prototype was printed using a Stratasys J750 PolyJet printer.

The prototype kit consists of four uteri. The three anteverted uteri in the kit are based on the smallest, the average, and the largest dimensions from our patient set. The fourth uterus is retroverted and uses average dimensions. The four uteri incorporate two embedded HR-CTVs through color staining in the uterine body prints. Four clip-on HR-CTV sections that expand outside the cervix and uterine body are also part of the kit to mimic different pathology. All uterus bodies and the vaginal canal are printed using clear Agilus (shore 30a), and the HR-CTVs are printed externally and into the uterine bodies using a blend of colored Vero and Agilus (shore 40a) as a means of evaluation for tandem/ovoids and needle placement. The bladder surface and rectum are printed in Agilus, shore 35a and 70a, respectively. The outer box was printed using Vero Clear, shore 90. The full kit which consists of an outer box, vulvar entrance, vaginal canal, four uteruses, two embedded HR-CTVs, four clip-on HR-CTVs, a standard bladder, and standard rectum, costs $631 in printing material expenses. This low-cost comprehensive training kit may be used to improve resident comfort in performing gynecological brachytherapy procedures.

Purpose: Clinical brachytherapy systems are capable of delivering very high doses with high dose gradients. It is important therefore to be able to accurately verify the doses calculated by brachytherapy treatment planning. Current dose verification methods are limited by poor resolution, and in the presence of large dose gradients, may give non-­representative results [1]. This thesis aims to evaluate the feasibility of a novel radiochromic dosimetry system for in-­vivo dose verification in organs at risk (bladder and rectum) in high dose rate (HDR) intracavitary gynecological brachytherapy through a comparison with a gold standard.

Methods: A novel dosimeter PRESAGE®-­IV designed for in-­vivo dosimetry is investigated. PRESAGE®-­IV dosimeters are small cylinders 4mm in diameter by 20mm in height. When irradiated, the dosimeters change color in proportion to the local absorbed dose. The dosimeters were irradiated to doses between 1-­15 Gy. Two methods were investigated for readout of this radiochromic response: (i) a volume averaged readout by conventional spectrophotometer, and (ii) a line profile readout by a novel 2D projection imaging method utilizing a high-­resolution (50 micron) telecentric optical system. Method (i) is considered the gold standard, as it is has been extensively used with PRESAGE® in well-­defined optical-­cuvettes. The feasibility of PRESAGE®-­IV was evaluated by comparison to standard PRESAGE® in optical-­cuvettes. The feasibility of the high-­resolution readout (method ii) was evaluated by direct comparison against method (i). Dosimeters were also tested in-­vivo on six patients undergoing Iridium-­192 HDR intracavitary brachytherapy treatments and dose measurements were compared to Eclipse Treatment Planning System (Varian Medical Systems).

Results: When compared to the gold standard (optical-­cuvettes), the sensitivity and noise of PRESAGE®-­IV shows a linear relationship in sensitivity between 1-­15 Gy with a 95% confidence interval in the slope (0.8703 +/-­ 0.0192). The feasibility of the high-­resolution readout (method ii) evaluated by direct comparison against method (i) resulted in a sensitivity of 0.0136 ± 0.0002 and for the spectrophotometer 0.0135 ± 0.0002, which is a 0.74% difference in sensitivity within the 95% confidence interval. Examination of patient data showed large differences, and on average gave 19% and 22% differences in measured doses vs. Eclipse measurements in the bladder and rectum, respectively.

Conclusions: Results show that a novel radiochromic dosimetry system for in-­vivo dose verification in organs at risk is feasible. The conventional spectrophotometer readout method had the limitation that it averages the change in optical density over a 10 mm area of the dosimeter. The novel, high-­resolution 2D readout technique was found to have the advantage of producing images that could be further analyzed through line profiles in any area of the dosimeter. Due to the large differences in measured doses for organs at risk, further work is needed to validate dosimeter-­positioning technique.

Positron emission tomography (PET) is a nuclear medicine diagnostic imaging exam of metabolic processes in the body. Radiotracers, which consist of positron emitting radioisotopes and a molecular probe, are introduced into the body, emitted radiation is detected, and tomographic images are reconstructed. The primary clinical PET application is in oncology using a glucose analogue radiotracer, which is avidly taken up by some cancers.

It is well known that PET performance and image quality degrade as body size increases, and epidemiological studies over the past two decades show that the adult US population's body size has increased dramatically and continues to increase. Larger patients have more attenuating material that increases the number of emitted photons that are scattered or absorbed within the body. Thus, for a fixed amount of injected radioactivity and acquisition duration, the number of measured true coincidence events will decrease, and the background fractions will increase. Another size-related factor, independent of attenuation, is the volume throughout which the measured coincidence counts are distributed: for a fixed acquisition duration, as the body size increases, the counts are distributed over a larger area. This is true for both a fixed amount of radioactivity, where the concentration decreases as size increases, and a fixed concentration, where the amount radioactivity increases with size.

Time-of-flight (TOF) PET is a recently commercialized technology that allows the localization, with a certain degree of error, of a positron annihilation using timing differences in the detection of coincidence photons. Both heuristic and analytical evaluations predict that TOF PET will have improved performance and image quality compared to non-TOF PET, and this improvement increases as body size increases. The goal of this dissertation is to parameterize the image quality improvement of TOF PET compared to non-TOF PET as a function of body size. Currently, no standard for comparison exists.

Previous evaluations of TOF PET's improvement have been made with either computer-simulated data or acquired data using a few discrete phantom sizes. A phantom that represents a range of attenuating dimensions, that can have a varying radioactivity distribution, and that can have radioactive inserts positioned throughout its volume would facilitate characterizing PET system performance and image quality as a function of body size. A fillable, tapered phantom, was designed, simulated, and constructed. The phantom has an oval cross-section ranging from 38.5 × 49.5 cm to 6.8 × 17.8 cm, a length of 51.1 cm, a mass of 6 kg (empty), a mass of 42 kg (water filled), and 1.25-cm acrylic walls.

For this dissertation research, PET image quality was measured using multiple, small spheres with diameters near the spatial resolution of clinical whole-body PET systems. Measurements made on a small sphere, which typically include a small number of image voxels, are susceptible to fluctuations over the few voxels, so using multiple spheres improves the statistical power of the measurements that, in turn, reduces the influence of these fluctuations. These spheres were arranged in an array and mounted throughout the tapered phantom's volume to objectively measure image quality as a function of body size. Image quality is measured by placing regions of interest on images and calculating contrast recovery, background variability, and signal to noise ratio.

Image quality as a function of body size was parameterized for TOF compared to non-TOF PET using 46 1.0-cm spheres positioned in six different body sizes in a fillable, tapered phantom. When the TOF and non-TOF PET images were reconstructed for matched contrast, the square of the ratio of the images' signal-to-noise ratios for TOF to non-TOF PET was plotted as a function, f(D), of the radioactivity distribution size, D, in cm. A linear regression was fit to the data: f(D) = 0.108D - 1.36. This was compared to the ratio of D and the localization error, σ_d, based on the system timing resolution, which is approximately 650 ps for the TOF PET system used for this research. With the image quality metrics used in this work, the ratio of TOF to non-TOF PET fits well to a linear relationship and is parallel to D/σ_d. For D < 20 cm, there is no image quality improvement, but for radioactivity distributions D > 20 cm, TOF PET improves image quality over non-TOF PET. PET imaging's clinical use has increased over the past decade, and TOF PET's image quality improvement for large patients makes TOF an important new technology because the occurrence of obesity in the US adult population continues to increase.

Purpose:

A new development in linac-based intracranial stereotactic radiosurgery (SRS) and extracranial stereotactic body radiation therapy (SBRT) is treatment of multiple targets using single isocenter volumetric modulated arc therapy (VMAT) technique, dramatically reducing treatment time while maintaining high target conformality and steep dose gradients between targets and surrounding organs at risk (OAR). In VMAT, the gantry rotates around the patient while continuously delivering radiation. Throughout the VMAT arc, the beam is modulated based on an inverse optimization algorithm in order to spare organs at risk. Single isocenter multi-target VMAT has already been implemented for intracranial SRS and is increasingly used for extracranial SBRT treatments. Despite the increasing popularity of this technique, certain inherent clinically meaningful challenges warrant further investigation. Specifically, single isocenter, multifocal SRS and SBRT can result in small volumes targets with a large off-axis distance from the treatment isocenter. Consequently, angular errors in the collimator, patient support assembly (PSA), or gantry could have an increased impact on target coverage, warranting a re-evaluation of routine linear accelerator QA tolerance recommendations in TG-142. Also, questions have arisen regarding the ability of clinical dose calculation algorithms to calculate dose accurately for these cases at large off-axis distances. Specifically, it is questionable whether or not the MLC model used is sophisticated enough to accurately model the dose off axis. This is of concern because the MLC leaves have different dimensions outside of the HD region, but the dosimetric-leaf-gap model used is the same for both regions. Applying the single isocenter technique to extracranial SBRT of oligometastases introduces additional unique challenges that must be addressed. These include greater intra and inter-fractional setup uncertainties, and dosimetric interplay since immobilization is more difficult and internal motion is non-negligible. The purpose of this thesis is to explore these specific physics and treatment planning considerations for single isocenter multi-target intracranial radiosurgery and extracranial SBRT.

Materials and Methods:

Intracranial SRS

For single isocenter multifocal stereotactic radiosurgery, we evaluated potential dose deviations from mechanical errors in PSA, collimator, and gantry angle within the tolerance recommended by TG-142 for radiosurgery machines. Systematic errors in PSA, collimator, and gantry angle were introduced at the recommended tolerance levels into both multifocal SRS plans and traditional single target SRS using dynamic conformal arcs, and the resulting dosimetric effect were quantified within the treatment planning system. In addition, we quantified the accuracy of the treatment planning system dose calculation algorithm for targets located at large off-axis distances with 3D Slicer analysis software. The dose distribution from the treatment planning system was compared to the distribution measured using a high-resolution 3D dosimetry system (PRESAGE®/Optical-CT). Comparisons were made using DVH and gamma analysis (criteria: 2mm/3%, 3mm/3%, and 3mm/5%). DVH comparisons included a shell analysis in which we compared the dose from 2mm within the target to the target’s surface, the surface to 2mm outside the target, and 2mm to 4mm outside the target for both the plan and the dosimeter.

Extracranial SBRT

For applying the single isocenter multifocal technique to extracranial oligometastases, we propose a treatment method that addresses intra and inter-fractional motion as well as dosimetric interplay. The developed technique uses a Single Isocenter with Distinct Optimizations (SIDO) in which all Volumetric Modulated Arc Therapy (VMAT) fields share an isocenter but each field treats only one target. When necessary, setup uncertainties from rotations and deformations are mitigated by applying a couch translation between VMAT arcs, and interplay is minimized using dynamic conformal arcs (DCAs) as the starting point for inverse optimization. We evaluated this planning technique using relevant dose indices including conformity index, gradient index and modulation factor.

Results:

Intracranial SRS

Induced errors at TG-142 tolerance levels showed the greatest change in multifocal SRS target coverage for collimator and gantry rotations, while minimal change in coverage was noted for errors in PSA rotation. For single isocenter cases, the largest dose discrepancies were a result of 1° errors in the collimator and gantry angles, specifically with respect to the volume of the PTV receiving the prescription dose. These errors caused up to 33% and 18% deviations, respectively, to the volume of the PTV receiving the prescription dose with mean deviations of 5% and 2%, respectively. When the collimator and gantry errors in single isocenter plans were reduced to 0.5°, the discrepancies in the volume of the PTV receiving the prescription dose were reduced to a max value of <5% for the gantry and collimator with mean values of approximately 1%. For 1° errors in DCA plans, however, deviations to the volume of the PTV receiving the prescription dose did not exceed 5% for the collimator, couch, or gantry and similar results were seen in all other dosimetric indices investigated.

A preliminary analysis of the Eclipse dose calculation algorithm in comparison to actual dose delivered to targets shows agreement with 89.46%, 94.87%, and 96.39% of voxels having a passing gamma index with criteria of 2mm/3%, 3mm/3%, and 3mm/5% respectively (distance from isocenter ranged from 0-10cm). Targets within 8cm of the isocenter showed less than 2% discrepancy between the plan and measurement with respect to the percent of the target receiving the prescription dose. The target at 10cm from the isocenter, however, had a 15% discrepancy between the plan and measurement with respect to the percent of the target receiving the prescription dose and therefore warrants further investigation.

Extracranial SBRT

As the distance between targets increases, the probability for requiring a second translation between treatment arcs also increases. Assuming a margin of 5mm and considering six lung and five liver patient cases, a second translational shift would be required 0%, ~10%, and ~25% of the time for target separations of 5cm, 10cm, and 15cm respectively.

For greater than 3cm separation between targets in extracranial SBRT, SIDO and SIDO with DCA have an average conformity index of 0.862, and 0.864 respectively, which is comparable to the average conformity of traditional multifocal treatment techniques at these target separations of 0.901. When separation between PTVs is less than 3cm, however, traditional single isocenter VMAT has superior conformity with a mean value of 0.875, as opposed to 0.772 and 0.782 for SIDO and SIDO with DCA respectively; and decreasing conformity with decreasing target separation. SIDO with DCA had superior GI over all other planning techniques for almost all cases with a mean value of 7.31 across all target separations. SIDO with DCA even performed better than the DCA technique with a mean GI of 7.43 across all target separations, which was assumed to be the best method for obtaining a desirable GI. SIDO with DCA had a comparable MF to the DCA plans and was closer to 1 than all other planning techniques. The mean MF values across all target separations for SIDO with DCA and DCA were 1.17 and 0.83 respectively.

Conclusions:

Intracranial SRS

Institutions utilizing a single isocenter VMAT technique for multifocal disease should pay careful attention to the angular mechanical tolerances in designing a robust and complete QA program, especially with respect to the collimator and gantry recommended tolerances. We recommend reducing collimator and gantry tolerances from 1.0° to 0.5° to decrease the potential magnitude of deviations between the planning and delivered dose distributions. The PRESAGE®/Optical-CT 3D dosimetry system verified the accuracy of the Eclipse dose calculation algorithm to within 2% for targets located up to 8cm from the isocenter. Further investigation is required for more distal targets, as they did not have sufficient agreement.

Extracranial SBRT

A single isocenter approach for SBRT treatment of extracranial oligometastases may be feasible using the proposed SIDO and SIDO with DCA treatment planning techniques. SIDO for extracranial oligometastases allows flexibility to mitigate spatial uncertainties from rotation and deformation, and has comparable dosimetry to traditional VMAT with low modulation when inverse optimization begins with DCAs. These advantages make SIDO beneficial for target separations of greater than 3cm, however, for target separations less than 3cm a traditional single isocenter technique is more appropriate.