Impact of Audio-Visual Assisted Therapeutic Ambience in Radiotherapy (AVATAR) on Anesthesia Use, Payer Charges, and Treatment Time in Pediatric Patients.
Practical radiation oncology
Balazy, K. E., Gutkin, P. M., Skinner, L., von Eyben, R., Fowler, T., Pinkham, D. W., Rodriguez, S., Maxim, P. G., Donaldson, S. S., Loo, B. W., Bush, K., Hiniker, S. M.
2020
Abstract
PURPOSE: Pediatric radiotherapy requires optimal immobilization that often necessitates daily anesthesia. To decrease anesthesia use, we implemented a novel XXX system which projects video onto a radiolucent screen within the child's line of vision to provide attentional diversion. We investigated its reduction on anesthesia use, payer charges, and treatment time, as well as its impact on radiation delivery.METHODS AND MATERIALS: A 6-year retrospective analysis was performed among children undergoing radiotherapy (n=224), 3 years before and 3 after introduction of XXX. The frequency of anesthesia use before and after XXX implementation, as well as radiotherapy treatment times were compared. The number of spared anesthesia treatments allowed for a charge to payer analysis. To document lack of surface dose perturbation by XXX, a phantom craniospinal treatment course was delivered both with and without XXX. Additionally, an ion chamber course was delivered to document changes to dose at depth.RESULTS: More children were able to avoid anesthesia use entirely in the post-XXX cohort, compared to the pre-XXX cohort (73.2% vs 63.4%, p=0.03) and fewer required anesthesia for each treatment (18.8% vs 33%; p = 0.03). XXX introduction reduced anesthesia use for all ages studied. Treatment time per session was reduced by 38% using XXX compared to anesthesia. There were 326 fewer anesthesia sessions delivered over three years after XXX was introduced, with an estimated savings of > $500,000. OSLDs revealed a small increase in dose of 0.8%-9.5% with XXX, while the use of a thermomolded face mask increased skin dose as much as 58%.CONCLUSIONS: XXX introduction decreased anesthesia use in children undergoing radiotherapy; more avoided anesthesia entirely, and fewer needed it for every treatment. This resulted in a reduction in treatment time, and savings of nearly $550,000 in approximately 3 years, with minimal perturbation of radiotherapy dose delivery.
View details for DOI 10.1016/j.prro.2019.12.009
View details for PubMedID 31935524
Abstract
To develop and implement an automated plan check (APC) tool using a Six Sigma methodology with the aim of improving safety and efficiency in external beam radiotherapy.The Six Sigma define-measure-analyze-improve-control (DMAIC) framework was used by measuring defects stemming from treatment planning that were reported to the departmental incidence learning system (ILS). The common error pathways observed in the reported data were combined with our departmental physics plan check list, and AAPM TG-275 identified items. Prioritized by risk priority number (RPN) and severity values, the check items were added to the APC tool developed using Varian Eclipse Scripting Application Programming Interface (ESAPI). At 9 months post-APC implementation, the tool encompassed 89 check items, and its effectiveness was evaluated by comparing RPN values and rates of reported errors. To test the efficiency gains, physics plan check time and reported error rate were prospectively compared for 20 treatment plans.The APC tool was successfully implemented for external beam plan checking. FMEA RPN ranking re-evaluation at 9 months post-APC demonstrated a statistically significant average decrease in RPN values from 129.2 to 83.7 (P < .05). After the introduction of APC, the average frequency of reported treatment-planning errors was reduced from 16.1% to 4.1%. For high-severity errors, the reduction was 82.7% for prescription/plan mismatches and 84.4% for incorrect shift note. The process shifted from 4? to 5? quality for isocenter-shift errors. The efficiency study showed a statistically significant decrease in plan check time (10.1 ± 7.3 min, P = .005) and decrease in errors propagating to physics plan check (80%).Incorporation of APC tool has significantly reduced the error rate. The DMAIC framework can provide an iterative and robust workflow to improve the efficiency and quality of treatment planning procedure enabling a safer radiotherapy process.
View details for DOI 10.1002/acm2.12678
View details for PubMedID 31423729
Abstract
Purpose: The purpose of this study was to determine the impact of splenic and thoracic bone marrow irradiation on hematologic toxicity in the setting of chemoradiation therapy for esophageal cancer.Methods and materials: We analyzed 60 patients with carcinoma of the distal esophagus or gastroesophageal junction who received concurrent chemoradiation in the preoperative or definitive setting. Dosimetric and volumetric parameters were calculated for the spleen, thoracic spine, and posterior ribs. The primary endpoint was grade ?3 hematologic toxicity (HT3+). Associations were assessed using logistic and linear regression models.Results: Twenty-one patients (35%) experienced HT3+, including 18 patients with leukopenia and 5 with thrombocytopenia. Higher spleen V5-V20 was correlated with a lower risk of HT3+ on multivariable analysis (odds ratio: 0.83 per 10cm3 increase in V10; P=.013). A dose-dependent decrease in spleen volume was observed after radiation therapy, and a greater decrease was independently associated with a lower risk of HT3+ (odds ratio: 0.93 per 1% volume decrease; P=.014). Dosimetric parameters of the thoracic spine were not significantly associated with HT3+.Conclusions: A greater decrease in spleen size after radiation therapy and a higher spleen V5-V20 were independently associated with a lower risk of severe hematologic toxicity. Splenic irradiation may mitigate leukopenia associated with chemoradiation therapy.
View details for DOI 10.1016/j.adro.2018.02.005
View details for PubMedID 30202799
Abstract
Medulloblastoma patients are treated with surgery, radiation and chemotherapy. Radiation dose to the temporal lobe may be associated with neurocognitive sequelae. Longitudinal changes of temporal lobe cortical thickness may result from neurodevelopmental processes such as synaptic pruning. This study applies longitudinal image analysis to compare developmental change in cortical thickness in medulloblastoma (MB) patients who were treated by combined modality therapy to that of cerebellar juvenile pilocytic astrocytoma (JPA) patients who were treated by surgery alone. We hypothesized that the rates of developmental change in cortical thickness would differ between these two groups. This retrospective cohort study assessed changes in cortical thickness over time between MB and JPA patients. High-resolution magnetic resonance (MR) images of 14 MB and 7 JPA subjects were processed to measure cortical thickness of bilateral temporal lobe substructures. A linear mixed effects model was used to identify differences in substructure longitudinal changes in cortical thickness. The left temporal lobe exhibited overall increased cortical thickness in MB patients relative to JPA patients who showed overall cortical thinning (mean annual cortical thickness change: MB 0.14 mm/year versus JPA -0.018 mm/year across all substructures), particularly in the inferior temporal lobe substructures (p?
View details for DOI 10.1007/s11060-017-2453-5
View details for PubMedID 28534154
Abstract
To determine if regional ventilation within irradiated lung volume predicts change in pulmonary function test (PFT) measurements after stereotactic ablative radiotherapy (SABR) of lung tumors.We retrospectively identified 27 patients treated from 2007 to 2014 at our institution who received: (1) SABR without prior thoracic radiation; (2) pre-treatment 4-dimensional computed tomography (4-D CT) imaging; (3) pre- and post-SABR PFTs <15months from treatment. We defined the ventilation ratio (VR20BED3) as the quotient of mean ventilation (mean Jacobian-based per-voxel volume change on deformably registered inhale/exhale 4-D CT phases) within the 20Gy biologically effective dose (?/?=3Gy) isodose volume and that of the total lung volume (TLV).Most patients had moderate to very severe COPD by GOLD criteria (n=19, 70.1%). Higher VR20BED3 significantly predicted worse change in Forced Expiratory Volume/s normalized by baseline value (?FEV1/FEV1pre, p=0.04); n=7 had VR20BED3>1 (high regional ventilation) and worse ?FEV1/FEV1pre (median=-0.16, range=-0.230 to -0.20). Five had VR20BED3<1 (low regional ventilation) and improved ?FEV1/FEV1pre (median=0.13, range=0.07 to 0.20). In a multivariable linear model, increasing VR20BED3 and time to post-SABR PFT predicted decreasing ?FEV1/FEV1pre (R(2)=0.25, p=0.03).After SABR to high versus low functioning lung regions, we found worsened or improved global pulmonary function, respectively. If pre-SABR VR20BED3 is validated as a predictor of eventual post-SABR PFT in larger studies, it may be used for individualized treatment planning to preserve or even improve pulmonary function after SABR.
View details for DOI 10.1016/j.radonc.2017.03.021
View details for PubMedID 28460826
Abstract
A challenging problem in trajectory optimization for radiotherapy is properly handling the synchronization of the medical accelerators dynamic delivery. The initial coarse sampling of control points implemented in a Progressive Resolution Optimization type approach (VMAT) routinely results in MLC aperture forming contention issues as the sampling resolution increases. This work presents an approach to optimize continuous, beam-on radiation trajectories through exploration of the anatomical topology present in the patient and formation of a novel dual-metric graph optimization problem.This work presents a new perspective on trajectory optimization in radiotherapy using the concept of sectioning (TORUS). TORUS avoids degradation of 3D dose optimization quality by mapping the connectedness of target regions from the BEV perspective throughout the space of deliverable coordinates. This connectedness information is then incorporated into a graph optimization problem to define ideal trajectories. The unique usage of two distance functions in this graph optimization permits the TORUS algorithm to generate efficient dynamic trajectories for delivery while maximizing the angular flux through all PTV voxels. 3D dose optimization is performed for trajectories using a commercial TPS progressive resolution optimizer.The TORUS algorithm is applied to three example treatments: chest wall, scalp, and the TG-119 C-shape phantom. When static collimator coplanar trajectories are generated for the chest wall and scalp cases, the TORUS trajectories are found to outperform both 7 field IMRT and 2 arc VMAT plans in delivery time, organ at risk sparing, conformality, and homogeneity. For the TG-119 phantom, when static couch and collimator non-coplanar trajectories are optimized, TORUS trajectories have superior sparing of the central core avoidance with shorter delivery times, with similar dose conformality and homogeneity.The TORUS algorithm is able to automatically generate trajectories having improved plan quality and delivery time over standard IMRT and VMAT treatments. TORUS offers an exciting and promising avenue forward toward increasing dynamic capabilities in radiation delivery.
View details for DOI 10.1002/mp.12270
View details for PubMedID 28397968
Abstract
Radiation therapy is an important component of treatment for many childhood cancers. Depending upon the age and maturity of the child, pediatric radiation therapy often requires general anesthesia for immobilization, position reproducibility, and daily treatment delivery. We designed and clinically implemented a radiation therapy-compatible audiovisual system that allows children to watch streaming video during treatment, with the goal of reducing the need for daily anesthesia through immersion in video.We designed an audiovisual-assisted therapeutic ambience in radiation therapy (AVATAR) system using a digital media player with wireless streaming and pico projector, and a radiolucent display screen positioned within the child's field of view to him or her with sufficient entertainment and distraction for the duration of serial treatments without the need for daily anesthesia. We piloted this system in 25 pediatric patients between the ages of 3 and 12 years. We calculated the number of fractions of radiation for which this system was used successfully and anesthesia avoided and compared it with the anesthesia rates reported in the literature for children of this age.Twenty-three of 25 patients (92%) were able to complete the prescribed course of radiation therapy without anesthesia using the AVATAR system, with a total of 441 fractions of treatment administered when using AVATAR. The median age of patients successfully treated with this approach was 6 years. Seven of the 23 patients were initially treated with daily anesthesia and were successfully transitioned to use of the AVATAR system. Patients and families reported an improved treatment experience with the use of the AVATAR system compared with anesthesia.The AVATAR system enables a high proportion of children to undergo radiation therapy without anesthesia compared with reported anesthesia rates, justifying continued development and clinical investigation of this technique.
View details for DOI 10.1016/j.prro.2017.01.007
View details for PubMedID 28242188
Abstract
To determine if pre-treatment non-target lung FDG-PET uptake predicts for symptomatic radiation pneumonitis (RP) following lung stereotactic ablative radiotherapy (SABR).We reviewed a 258 patient database from our institution to identify 28 patients who experienced symptomatic (grade ? 2) RP after SABR, and compared them to 57 controls who did not develop symptomatic RP. We compared clinical, dosimetric and functional imaging characteristics between the 2 cohorts including pre-treatment non-target lung FDG-PET uptake.Median follow-up time was 26.9 months. Patients who experienced symptomatic RP had significantly higher non-target lung FDG-PET uptake as measured by mean SUV (p < 0.0001) than controls. ROC analysis for symptomatic RP revealed area under the curve (AUC) of 0.74, with sensitivity 82.1% and specificity 57.9% with cutoff mean non-target lung SUV > 0.56. Predictive value increased (AUC of 0.82) when mean non-target lung SUV was combined with mean lung dose (MLD). We developed a 0-2 point model using these 2 variables, 1 point each for SUV > 0.56 or MLD > 5.88 Gy equivalent dose in 2 Gy per fraction (EQD2), predictive for symptomatic RP in our cohort with hazard ratio 10.01 for score 2 versus 0 (p < 0.001).Patients with elevated pre-SABR non-target lung FDG-PET uptake are at increased risk of symptomatic RP after lung SABR. Our predictive model suggests patients with mean non-target lung SUV > 0.56 and MLD > 5.88 Gy EQD2 are at highest risk. Our predictive model should be validated in an external cohort before clinical implementation.
View details for DOI 10.1016/j.radonc.2016.05.007
View details for PubMedID 27267049
Abstract
Dose and monitor units (MUs) represent two important facets of a radiation therapy treatment. In current practice, verification of a treatment plan is commonly done in dose domain, in which a phantom measurement or forward dose calculation is performed to examine the dosimetric accuracy and the MU settings of a given treatment plan. While it is desirable to verify directly the MU settings, a computational framework for obtaining the MU values from a known dose distribution has yet to be developed. This work presents a strategy to calculate independently the MUs from a given dose distribution of volumetric modulated arc therapy (VMAT) and station parameter optimized radiation therapy (SPORT).The dose at a point can be expressed as a sum of contributions from all the station points (or control points). This relationship forms the basis of the proposed MU verification technique. To proceed, the authors first obtain the matrix elements which characterize the dosimetric contribution of the involved station points by computing the doses at a series of voxels, typically on the prescription surface of the VMAT/SPORT treatment plan, with unit MU setting for all the station points. An in-house Monte Carlo (MC) software is used for the dose matrix calculation. The MUs of the station points are then derived by minimizing the least-squares difference between doses computed by the treatment planning system (TPS) and that of the MC for the selected set of voxels on the prescription surface. The technique is applied to 16 clinical cases with a variety of energies, disease sites, and TPS dose calculation algorithms.For all plans except the lung cases with large tissue density inhomogeneity, the independently computed MUs agree with that of TPS to within 2.7% for all the station points. In the dose domain, no significant difference between the MC and Eclipse Anisotropic Analytical Algorithm (AAA) dose distribution is found in terms of isodose contours, dose profiles, gamma index, and dose volume histogram (DVH) for these cases. For the lung cases, the MC-calculated MUs differ significantly from that of the treatment plan computed using AAA. However, the discrepancies are reduced to within 3% when the TPS dose calculation algorithm is switched to a transport equation-based technique (Acuros?). Comparison in the dose domain between the MC and Eclipse AAA/Acuros calculation yields conclusion consistent with the MU calculation.A computational framework relating the MU and dose domains has been established. The framework does not only enable them to verify the MU values of the involved station points of a VMAT plan directly in the MU domain but also provide a much needed mechanism to adaptively modify the MU values of the station points in accordance to a specific change in the dose domain.
View details for DOI 10.1118/1.4906185
View details for PubMedID 25652504
View details for PubMedCentralID PMC4312348
Abstract
To develop a method for dose reconstruction by incorporating the interplay effect between aperture modulation and target motion, and to assess the dosimetric impact of real-time prostate motion during volumetric modulated arc therapy (VMAT).Clinical VMAT plans were delivered with the TrueBeam linac for 8 patients with prostate cancer. The real-time target motion during dose delivery was determined based on the 2-dimensional fiducial localization using an onboard electronic portal imaging device. The target shift in each image was correlated with the control point with the same gantry angle in the VMAT plan. An in-house-developed Monte Carlo simulation tool was used to calculate the 3-dimensional dose distribution for each control point individually, taking into account the corresponding real-time target motion (assuming a nondeformable target with no rotation). The delivered target dose was then estimated by accumulating the dose from all control points in the plan. On the basis of this information, dose-volume histograms and 3-dimensional dose distributions were calculated to assess their degradation from the planned dose caused by target motion. Thirty-two prostate motion trajectories were analyzed.The minimum dose to 0.03 cm(3) of the gross tumor volume (D0.03cc) was only slightly degraded after taking motion into account, with a minimum value of 94.1% of the planned dose among all patients and fractions. However, the gross tumor volume receiving prescription dose (V100%) could be largely affected by motion, dropping below 60% in 1 trajectory. We did not observe a correlation between motion magnitude and dose degradation.Prostate motion degrades the delivered dose to the target in an unpredictable way, although its effect is reduced over multiple fractions, and for most patients the degradation is small. Patients with greater prostate motion or those treated with stereotactic body radiation therapy would benefit from real-time prostate tracking to reduce the margin.
View details for DOI 10.1016/j.ijrobp.2013.12.015
View details for PubMedID 24661670
Abstract
To propose a nonisocentric treatment strategy as a special form of station parameter optimized radiation therapy, to improve sparing of critical structures while preserving target coverage in breast radiation therapy.To minimize the volume of exposed lung and heart in breast irradiation, we propose a novel nonisocentric treatment scheme by strategically placing nonconverging beams with multiple isocenters. As its name suggests, the central axes of these beams do not intersect at a single isocenter as in conventional breast treatment planning. Rather, the isocenter locations and beam directions are carefully selected, in that each beam is only responsible for a certain subvolume of the target, so as to minimize the volume of irradiated normal tissue. When put together, the beams will provide an adequate coverage of the target and expose only a minimal amount of normal tissue to radiation. We apply the nonisocentric planning technique to 2 previously treated clinical cases (breast and chest wall).The proposed nonisocentric technique substantially improved sparing of the ipsilateral lung. Compared with conventional isocentric plans using 2 tangential beams, the mean lung dose was reduced by 38% and 50% using the proposed technique, and the volume of the ipsilateral lung receiving ?20 Gy was reduced by a factor of approximately 2 and 3 for the breast and chest wall cases, respectively. The improvement in lung sparing is even greater compared with volumetric modulated arc therapy.A nonisocentric implementation of station parameter optimized radiation therapy has been proposed for breast radiation therapy. The new treatment scheme overcomes the limitations of existing approaches and affords a useful tool for conformal breast radiation therapy, especially in cases with extreme chest wall curvature.
View details for DOI 10.1016/j.ijrobp.2013.12.029
View details for PubMedID 24606852
Abstract
To propose a nonisocentric treatment strategy as a special form of station parameter optimized radiation therapy, to improve sparing of critical structures while preserving target coverage in breast radiation therapy.To minimize the volume of exposed lung and heart in breast irradiation, we propose a novel nonisocentric treatment scheme by strategically placing nonconverging beams with multiple isocenters. As its name suggests, the central axes of these beams do not intersect at a single isocenter as in conventional breast treatment planning. Rather, the isocenter locations and beam directions are carefully selected, in that each beam is only responsible for a certain subvolume of the target, so as to minimize the volume of irradiated normal tissue. When put together, the beams will provide an adequate coverage of the target and expose only a minimal amount of normal tissue to radiation. We apply the nonisocentric planning technique to 2 previously treated clinical cases (breast and chest wall).The proposed nonisocentric technique substantially improved sparing of the ipsilateral lung. Compared with conventional isocentric plans using 2 tangential beams, the mean lung dose was reduced by 38% and 50% using the proposed technique, and the volume of the ipsilateral lung receiving ?20 Gy was reduced by a factor of approximately 2 and 3 for the breast and chest wall cases, respectively. The improvement in lung sparing is even greater compared with volumetric modulated arc therapy.A nonisocentric implementation of station parameter optimized radiation therapy has been proposed for breast radiation therapy. The new treatment scheme overcomes the limitations of existing approaches and affords a useful tool for conformal breast radiation therapy, especially in cases with extreme chest wall curvature.
View details for DOI 10.1016/j.ijrobp.2013.12.029
View details for PubMedID 24606852
Abstract
To develop a fast and robust technique for the determination of optimized photon spectra for flattening filter free (FFF) beams to be applied in convolution/superposition dose calculations.A two-step optimization method was developed to derive optimal photon spectra for FFF beams. In the first step, a simple functional form of the photon spectra proposed by Ali ["Functional forms for photon spectra of clinical linacs," Phys. Med. Biol. 57, 31-50 (2011)] is used to determine generalized shapes of the photon spectra. In this method, the photon spectra were defined for the ranges of field sizes to consider the variations of the contributions of scattered photons with field size. Percent depth doses (PDDs) for each field size were measured and calculated to define a cost function, and a collapsed cone convolution (CCC) algorithm was used to calculate the PDDs. In the second step, the generalized functional form of the photon spectra was fine-tuned in a process whereby the weights of photon fluence became the optimizing free parameters. A line search method was used for the optimization and first order derivatives with respect to the optimizing parameters were derived from the CCC algorithm to enhance the speed of the optimization. The derived photon spectra were evaluated, and the dose distributions using the optimized spectra were validated.The optimal spectra demonstrate small variations with field size for the 6 MV FFF beam and relatively large variations for the 10 MV FFF beam. The mean energies of the optimized 6 MV FFF spectra were decreased from 1.31 MeV for a 3 × 3 cm(2) field to 1.21 MeV for a 40 × 40 cm(2) field, and from 2.33 MeV at 3 × 3 cm(2) to 2.18 MeV at 40 × 40 cm(2) for the 10 MV FFF beam. The developed method could significantly improve the agreement between the calculated and measured PDDs. Root mean square differences on the optimized PDDs were observed to be 0.41% (3 × 3 cm(2)) down to 0.21% (40 × 40 cm(2)) for the 6 MV FFF beam, and 0.35% (3 × 3 cm(2)) down to 0.29% (40 × 40 cm(2)) for the 10 MV FFF beam. The first order derivatives from the functional form were found to improve the speed of computational time up to 20 times compared to the other techniques.The derived photon spectra resulted in good agreements with measured PDDs over the range of field sizes investigated. The suggested method is easily applicable to commercial radiation treatment planning systems since it only requires measured PDDs as input.
View details for DOI 10.1118/1.4797469
View details for Web of Science ID 000317945900027
View details for PubMedID 23556891
Abstract
The purpose of this study is to simulate random and systematic RapidArc delivery errors for external beam prostate radiotherapy plans in order to determine the dose sensitivity for each error type. Ten prostate plans were created with a single 360° arc. The DICOM files for these treatment plans were then imported into an in-house computer program that introduced delivery errors. Random and systematic gantry position (0.25°, 0.5°, 1°), monitor unit (MU) (1.25%, 2.5%, 5%), and multileaf collimator (MLC) position (0.5, 1, 2 mm) errors were introduced. The MLC errors were either random or one of three types of systematic errors, where the MLC banks moved in the same (MLC gaps remain unchanged) or opposing directions (increasing or decreasing the MLC gaps). The generalized equivalent uniform dose (gEUD) was calculated for the original plan and all treatment plans with errors introduced. The dose sensitivity for the cohort was calculated using linear regression for the gantry position, MU, and MLC position errors. Because there was a large amount of variability for systematic MLC position errors, the dose sensitivity of each plan was calculated and correlated with plan MU, mean MLC gap, and the percentage of MLC leaf gaps less than 1 and 2 cm for each individual plan. We found that random and systematic gantry position errors were relatively insignificant (< 0.1% gEUD change) for gantry errors up to 1°. Random MU errors were also insignificant, and systematic MU increases caused a systematic increase in gEUD. For MLC position errors, random MLC errors were relatively insignificant up to 2 mm as had been determined in previous IMRT studies. Systematic MLC shift errors caused a decrease of approximately -1% in the gEUD per mm. For systematic MLC gap open errors, the dose sensitivity was 8.2%/mm and for MLC gap close errors the dose sensitivity was -7.2%/mm. There was a large variability for MLC gap open/close errors for the ten RapidArc plans which correlated strongly with MU, mean gap width, and percentage of MLC gaps less than 1 or 2cm. This study evaluates the magnitude of various simulated RapidArc delivery errors by calculating gEUED on various prostate plans.
View details for PubMedID 21844850
Abstract
Multi-leaf collimator (MLC) positional errors occur during intensity modulated radiation therapy (IMRT) and volumetric modulated arc therapy (VMAT) deliveries. The impact of such errors has been evaluated for IMRT but not VMAT. The purpose of this work is to understand how random and systematic VMAT MLC positional errors affect the patient dose distribution.Eight head and neck single arc (360°) VMAT treatment plans were created. Random and two types of systematic MLC errors were simulated for error magnitudes of 0.25, 0.5, 1, 2 and 5mm. The two types of systematic MLC errors were: (1) MLC banks are shifted in the same direction (left or right) and (2) MLC banks are shifted in opposing directions resulting in smaller or larger field shapes. The MLC errors were simulated, for all control points, on both banks of active MLC leaves only.There is a linear correlation of MLC errors with gEUD for all error types. The gEUD dose sensitivities with MLC error for the PTV70 were -0.2, -0.9, -2.8 and 1.9 Gy/mm for random, systematic shift, systematic close and systematic open MLC errors, respectively. The sensitivity of VMAT plans to MLC positional errors was similar to those of IMRT plans with less than 50 segments but much less than those created for a step and shoot with more than 50 segments or sliding-window delivery technique. To maintain the PTV70 to within 2% would require that MLC open/close errors be within 0.6mm.Radiation therapy centers should have adequate quality assurance programs in place to assess open/close MLC errors (i.e. leaf gap errors) as they tend to be more impactful than random or systematic MLC shift errors.
View details for DOI 10.1016/j.radonc.2010.06.013
View details for Web of Science ID 000285222200035
View details for PubMedID 20817291
Abstract
Monte Carlo simulation of clinical treatment plans require, in general, a coordinate transformation to describe the incident radiation field orientation on a patient phantom coordinate system. The International Electrotechnical Commission (IEC) has defined an accelerator coordinate system along with positive directions for gantry, couch and collimator rotations. In order to describe the incident beam's orientation with respect to the patient's coordinate system, DOSXYZnrc simulations often require transformation of the accelerator's gantry, couch and collimator angles to describe the incident beam. Similarly, versions of the voxelized Monte Carlo code (VMC(++)) require non-trivial transformation of the accelerator's gantry, couch and collimator angles to standard Euler angles ?, ?, ?, to describe an incident phase space source orientation with respect to the patient's coordinate system. The transformations, required by each of these Monte Carlo codes to transport phase spaces through a phantom, have been derived with a rotation operator approach. The transformations have been tested and verified against the Eclipse treatment planning system.
View details for DOI 10.1007/s13246-010-0037-1
View details for Web of Science ID 000288432000008
View details for PubMedID 21053115
Abstract
The purpose of this study was to develop an efficient method to determine the optimal intensity distribution of the pretarget electron beam in a Monte Carlo (MC) accelerator model able to most accurately reproduce a set of measured photon field profiles for a given accelerator geometry and nominal photon beam energy. The method has the ability to reduce the number of simulations required to commission a MC accelerator model and has achieved better agreement with measurement than other methods described in literature. The method begins from a cylindrically symmetric pretarget electron beam (radius of 0.5 cm) of uniform intensity. This beam is subdivided into annular regions of fluence for which each region is individually transported through the accelerator head and into a water phantom. A simulated annealing search is then performed to determine the optimal combination of weights of the annular fluences that provide a best match between the measured dose distributions and the weighted sum of annular dose distributions for particular pretarget electron energy. When restricted to Gaussian intensity distributions, the optimization determined an optimal FWHM=1.34 mm for 18.0 MeV electrons, with a RMSE=0.49% on 40 x 40 cm2 lateral profiles. When allowed to deviate from Gaussian intensities a further reduction in RMSE was achieved. For our Clinac 21 EX accelerator MC model (based on the 1996 Varian Oncology Systems, Monte Carlo Project package), the optimal unrestricted intensity distribution was found to be a Gaussian-like solution (18.0 MeV, FWHM= 1.10 mm, 40 x 40 cm2 profile, and RMSE=0.15%) with the presence of an extra focal halo contribution on the order of 10% of the maximum Gaussian intensity. Using the optimally derived intensity, 10 x 10 and 4 x 4 cm2 profiles were found to be in agreement with measurement with a maximum RMSE=0.49%. The optimized Gaussian and unrestricted values of the electron beam FWHM were both within the range of those inferred by focal spot image measurements performed by Jaffray et al. ["X-ray sources of medical linear accelerators: Focal and extra-focal radiation," Med. Phys. 20, 1417-1427 (1993)]. The inference of an extra focal pretarget electron component may be an indicator of a deficiency in the MC model and needs further investigation.
View details for DOI 10.1118/1.3130102
View details for Web of Science ID 000266442000039
View details for PubMedID 19610319
Abstract
RapidArc radiotherapy technology from Varian Medical Systems is one of the most complex delivery systems currently available, and achieves an entire intensity-modulated radiation therapy (IMRT) treatment in a single gantry rotation about the patient. Three dynamic parameters can be continuously varied to create IMRT dose distributions-the speed of rotation, beam shaping aperture and delivery dose rate. Modeling of RapidArc technology was incorporated within the existing Vancouver Island Monte Carlo (VIMC) system (Zavgorodni et al 2007 Radiother. Oncol. 84 S49, 2008 Proc. 16th Int. Conf. on Medical Physics). This process was named VIMC-Arc and has become an efficient framework for the verification of RapidArc treatment plans. VIMC-Arc is a fully automated system that constructs the Monte Carlo (MC) beam and patient models from a standard RapidArc DICOM dataset, simulates radiation transport, collects the resulting dose and converts the dose into DICOM format for import back into the treatment planning system (TPS). VIMC-Arc accommodates multiple arc IMRT deliveries and models gantry rotation as a series of segments with dynamic MLC motion within each segment. Several verification RapidArc plans were generated by the Eclipse TPS on a water-equivalent cylindrical phantom and re-calculated using VIMC-Arc. This includes one 'typical' RapidArc plan, one plan for dual arc treatment and one plan with 'avoidance' sectors. One RapidArc plan was also calculated on a DICOM patient CT dataset. Statistical uncertainty of MC simulations was kept within 1%. VIMC-Arc produced dose distributions that matched very closely to those calculated by the anisotropic analytical algorithm (AAA) that is used in Eclipse. All plans also demonstrated better than 1% agreement of the dose at the isocenter. This demonstrates the capabilities of our new MC system to model all dosimetric features required for RapidArc dose calculations.
View details for DOI 10.1088/0031-9155/53/19/N01
View details for Web of Science ID 000259116100022
View details for PubMedID 18758001
Abstract
As radiotherapy treatment planning moves toward Monte Carlo (MC) based dose calculation methods, the MC beamlet is becoming an increasingly common optimization entity. At present, methods used to produce MC beamlets have utilized a particle source model (PSM) approach. In this work we outline the implementation of a phase-space-based approach to MC beamlet generation that is expected to provide greater accuracy in beamlet dose distributions. In this approach a standard BEAMnrc phase space is sorted and divided into beamlets with particles labeled using the inheritable particle history variable. This is achieved with the use of an efficient sorting algorithm, capable of sorting a phase space of any size into the required number of beamlets in only two passes. Sorting a phase space of five million particles can be achieved in less than 8 s on a single-core 2.2 GHz CPU. The beamlets can then be transported separately into a patient CT dataset, producing separate dose distributions (doselets). Methods for doselet normalization and conversion of dose to absolute units of Gy for use in intensity modulated radiation therapy (IMRT) plan optimization are also described.
View details for DOI 10.1088/0031-9155/53/18/N01
View details for Web of Science ID 000258728800027
View details for PubMedID 18711246
Abstract
The purpose of this study is to develop a method for determining the initial parameters of the pre-target electron beam within a Monte Carlo (MC) accelerator model able to produce accurate 18 MV 40×40 cm(2) photon field profiles. We have developed a novel method by which the electron beam intensity distribution can be reverse engineered to reproduce measured dose distributions. The method begins from a cylindrically symmetric pre-target electron beam (radius 0.5 cm) of uniform intensity. This beam is subdivided into annular regions of fluence for which each region is individually transported through the accelerator head and into a water phantom. A simulated annealing search is then performed to determine the optimal combination of weights of the annular fluences that provide a best match between measured dose distributions and the weighted sum of annular dose distributions. Remarkably, the intensity distribution converges to a solution that is predominantly Gaussian, with a FWHM=1.1mm. In addition, the solution contains an important secondary "extra focal halo" on the order of 10% of the maximum Gaussian intensity. Agreement of the 40×40 cm(2) photon field profiles with measurement was within 0.5%. The method greatly reduces the effort required to commission a MC accelerator model for clinical use and has achieved better agreement with measurement than other methods described in the literature. Our derived value of the electron beam FWHM agrees with that measured by Jaffray et al, 1993, and the "extra focal halo" is in qualitative agreement with their measurements of extra focal radiation.
View details for DOI 10.1118/1.2965965
View details for PubMedID 28512888
Abstract
It is well known that the use of a phase space in Monte Carlo simulation introduces a baseline level of variance that cannot be suppressed through the use of standard particle recycling techniques. This variance (termed latent phase-space variance by Sempau et al) can be a significant limiting factor in achieving accurate, low-uncertainty dose scoring results, especially near the surface of a phantom. A BEAMnrc component module (MCTWIST) has been developed to reduce the presence of latent variance in phase-space-based Monte Carlo simulations by implementing azimuthal particle redistribution (APR). For each recycled use of a phase-space particle a random rotation about the beam's central axis is applied, effectively utilizing cylindrical symmetry of the particle fluence and therefore providing a more accurate representation of the source. The MCTWIST module is unique in that no physical component is actually added to the accelerator geometry. Beam modifications are made by directly transforming particle characteristics outside of BEAMnrc/EGSnrc particle transport. Using MCTWIST, we have demonstrated a reduction in latent phase-space variance by more than a factor of 20, for a 10 x 10 cm(2) field, when compared to standard phase-space particle recycling techniques. The reduction in latent variance has enabled the achievement of dramatically smoother in-water dose profiles. This paper outlines the use of MCTWIST in Monte Carlo simulation and quantifies for the first time the latent variance reduction resulting from exploiting cylindrical phase-space symmetry.
View details for DOI 10.1088/0031-9155/52/14/021
View details for Web of Science ID 000247400000021
View details for PubMedID 17664612
Abstract
This work introduces an EGSnrc-based Monte Carlo (MC) beamlet does distribution matrix into a direct aperture optimization (DAO) algorithm for IMRT inverse planning. The technique is referred to as Monte Carlo-direct aperture optimization (MC-DAO). The goal is to assess if the combination of accurate Monte Carlo tissue inhomogeneity modeling and DAO inverse planning will improve the dose accuracy and treatment efficiency for treatment planning. Several authors have shown that the presence of small fields and/or inhomogeneous materials in IMRT treatment fields can cause dose calculation errors for algorithms that are unable to accurately model electronic disequilibrium. This issue may also affect the IMRT optimization process because the dose calculation algorithm may not properly model difficult geometries such as targets close to low-density regions (lung, air etc.). A clinical linear accelerator head is simulated using BEAMnrc (NRC, Canada). A novel in-house algorithm subdivides the resulting phase space into 2.5 X 5.0 mm2 beamlets. Each beamlet is projected onto a patient-specific phantom. The beamlet dose contribution to each voxel in a structure-of-interest is calculated using DOSXYZnrc. The multileaf collimator (MLC) leaf positions are linked to the location of the beamlet does distributions. The MLC shapes are optimized using direct aperture optimization (DAO). A final Monte Carlo calculation with MLC modeling is used to compute the final dose distribution. Monte Carlo simulation can generate accurate beamlet dose distributions for traditionally difficult-to-calculate geometries, particularly for small fields crossing regions of tissue inhomogeneity. The introduction of DAO results in an additional improvement by increasing the treatment delivery efficiency. For the examples presented in this paper the reduction in the total number of monitor units to deliver is approximately 33% compared to fluence-based optimization methods.
View details for DOI 10.1118/1.2336509
View details for Web of Science ID 000241424100009
View details for PubMedID 17089832
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