[en] The clinical introduction of volumetric x-ray image-guided radiotherapy systems necessitates formal commissioning of the hardware and image-guided processes to be used and drafts quality assurance (QA) for both hardware and processes. Satisfying both requirements provides confidence on the system's ability to manage geometric variations in patient setup and internal organ motion. As these systems become a routine clinical modality, the authors present data from their QA program tracking the image quality performance of ten volumetric systems over a period of 3 years. These data are subsequently used to establish evidence-based tolerances for a QA program. The volumetric imaging systems used in this work combines a linear accelerator with conventional x-ray tube and an amorphous silicon flat-panel detector mounted orthogonally from the accelerator central beam axis, in a cone-beam computed tomography (CBCT) configuration. In the spirit of the AAPM Report No. 74, the present work presents the image quality portion of their QA program; the aspects of the QA protocol addressing imaging geometry have been presented elsewhere. Specifically, the authors are presenting data demonstrating the high linearity of CT numbers, the uniformity of axial reconstructions, and the high contrast spatial resolution of ten CBCT systems (1-2 mm) from two commercial vendors. They are also presenting data accumulated over the period of several months demonstrating the long-term stability of the flat-panel detector and of the distances measured on reconstructed volumetric images. Their tests demonstrate that each specific CBCT system has unique performance. In addition, scattered x rays are shown to influence the imaging performance in terms of spatial resolution, axial reconstruction uniformity, and the linearity of CT numbers

[en] Purpose: We have developed a semi-automated dose accumulation workflow for Head and Neck Cancer (HNC) patients to evaluate volumetric and dosimetric changes that take place during radiotherapy. This work will be used to assess how dosimetric changes affect both toxicity and disease control, hence inform the feasibility and design of a prospective HNC adaptive trial. Methods: RayStation 4.5.2 features deformable image registration (DIR), where structures already defined on the planning CT image set can be deformably mapped onto cone-beam computed tomography (CBCT) images, accounting for daily treatment set-up shifts and changes in patient anatomy. The daily delivered dose can be calculated on each CBCT and mapped back to the planning CT to allow dose accumulation. The process is partially automated using Python scripts developed in collaboration with RaySearch. Results: To date we have performed dose accumulation on 18 HNC patients treated at our institution during 2013–2015 under REB approval. Our semi-automated process establishes clinical feasibility. Generally, dose accumulation for the entire treatment course of one case takes 60–120 minutes: importing all CBCTs requires 20–30 minutes as each patient has 30 to 40 treated fractions; image registration and dose accumulation require 60–90 minutes. This is in contrast to the process without automated scripts where dose accumulation alone would take 3–5 hours. Conclusions: We have developed a reliable workflow for retrospective dose tracking in HNC using RayStation. The process has been validated for HNC patients treated on both Elekta and Varian linacs with CBCTs acquired on XVI and OBI platforms respectively.

[en] A FDG-PET/CT image feature with optimal prognostic potential for locally-advanced non-small cell lung cancer (LA-NSCLC) patients has yet to be identified, and neither has the optimal time for FDG-PET/CT response assessment; furthermore, nodal features have been largely ignored in the literature. We propose to identify image features or imaging time point with maximal prognostic power.

[en] Purpose: To examine incident rates in external beam radiation therapy (RT) as significant changes in technology were introduced. Materials and methods: From 2001 to 2007, several technological and practice enhancements were made. All treatment incident reports, including near misses (from 2004), were classified, under a research ethics board approval, according to type (prescription or geometry), cause (location, documentation, non-compliance, laterality, prescribed change, human error, planning/dosimetry, software/hardware malfunction, and accessory), and clinical impact (none, minor, moderate, and severe). Trend analysis was performed retrospectively. Results: One thousand and sixty three reports were analyzed. The average incident rate per 100 RT course was 1.7 ± 0.4; excluding near misses, this rate fell to 1.4 ± 0.3. Both rates showed a downward trend. The occurrence of events due to treatment accessories (0.75-0.28), prescribed changes to treatment parameters (0.17-0.03), and location (0.41-0.17) have decreased, while documentation-related incidents have risen (0.03-0.37). The proportion of incidents is highest at the planning and treatment stages. Conclusion: Our analysis has shown that while technological and process enhancements can reduce certain error pathways, others can be created. Trends in incident rates have been assessed, indicating robustness of our practice in view of these changes.

[en] Purpose: To determine the geometric accuracy of lung cancer radiotherapy using daily volumetric, cone-beam CT (CBCT) image guidance and online couch position adjustment. Methods and Materials: Initial setup accuracy using localization CBCT was analyzed in three lung cancer patient cohorts. The first (n = 19) involved patients with early-stage non-small-cell lung cancer (NSCLC) treated using stereotactic body radiotherapy (SBRT). The second (n = 48) and third groups (n = 20) involved patients with locally advanced NSCLC adjusted with manual and remote-controlled couch adjustment, respectively. For each group, the couch position was adjusted when positional discrepancies exceeded ±3 mm in any direction, with the remote-controlled couch correcting all three directions simultaneously. Adjustment accuracy was verified with a second CBCT. Population-based setup margins were derived from systematic (Σ) and random (σ) positional errors for each group. Results: Localization imaging demonstrates that 3D positioning errors exceeding 5 mm occur in 54.5% of all delivered fractions. CBCT reduces these errors; post-correction Σ and σ ranged from 1.2 to 1.9 mm for Group 1, with 82% of all fractions within ±3 mm. For Group 2, Σ and σ ranged between 0.8 and 1.8 mm, with 76% of all treatment fractions within ±3 mm. For Group 3, the remote-controlled couch raised this to 84%, and Σ and σ were reduced to 0.4 to 1.7 mm. For each group, the postcorrection setup margins were 4 to 6 mm, 3 to 4 mm, and 2 to 3 mm, respectively. Conclusions: Using IGRT, high geometric accuracy is achievable for NSCLC patients, potentially leading to reduced PTV margins, improved outcomes and empowering adaptive radiation therapy for lung cancer

[en] The introduction of volumetric X-ray image-guided radiotherapy systems allows improved management of geometric variations in patient setup and internal organ motion. As these systems become a routine clinical modality, we propose a daily quality assurance (QA) program for cone-beam computed tomography (CBCT) integrated with a linear accelerator. The image-guided system used in this work combines a linear accelerator with conventional X-ray tube and an amorphous silicon flat-panel detector mounted orthogonally from the accelerator central beam axis. This article focuses on daily QA protocols germane to geometric accuracy of the CBCT systems and proposes tolerance levels on the basis of more than 3 years of experience with seven CBCT systems used in our clinic. Monthly geometric calibration tests demonstrate the long-term stability of the flex movements, which are reproducible within ±0.5 mm (95% confidence interval). The daily QA procedure demonstrates that, for rigid phantoms, the accuracy of the image-guided process can be within 1 mm on average, with a 99% confidence interval of ±2 mm

[en] The Canadian Partnership for Quality Radiotherapy (CPQR) and the Canadian Organization of Medical Physicist’s (COMP) Quality Assurance and Radiation Safety Advisory Committee (QARSAC) have worked together in the development of a suite of Technical Quality Control (TQC) Guidelines for radiation treatment equipment and technologies, that outline specific performance objectives and criteria that equipment should meet in order to assure an acceptable level of radiation treatment quality. Early community engagement and uptake survey data showed 70% of Canadian centers are part of this process and that the data in the guideline documents reflect, and are influencing the way Canadian radiation treatment centres run their technical quality control programs. As the TQC development framework matured as a cross-country initiative, guidance documents have been developed in many clinical technologies. Recently, there have been new TQC documents initiated for Gamma Knife and Cyberknife technologies where the entire communities within Canada are involved in the review process. At the same time, QARSAC reviewed the suite as a whole for the first time and it was found that some tests and tolerances overlapped across multiple documents as single tests could pertain to multiple quality control areas. The work to streamline the entire suite has allowed for improved usability of the suite while keeping the integrity of single quality control areas. The suite will be published by the JACMP, in the coming year.

[en] An image-guidance process for using cone-beam computed tomography (CBCT) for stereotactic body radiation therapy (SBRT) of peripheral lung lesions is presented. Respiration correlated CBCT on the treatment unit and four dimensional computed tomography (4DCT) from planning are evaluated for assessing respiration-induced target motion during planning and treatment fractions. Image-guided SBRT was performed for 12 patients (13 lesions) with inoperable early stage non-small cell lung carcinoma. Kilovoltage (kV) projections were acquired over a 360 degree gantry rotation and sorted based on the pixel value of an image-based aperture located at the air-tissue interface of the diaphragm. The sorted projections were reconstructed to provide volumetric respiration correlated CBCT image datasets at different phases of the respiratory cycle. The 4D volumetric datasets were directly compared with 4DCT datasets acquired at the time of planning. For ten of 12 patients treated, the lung tumour motion, as measured by respiration correlated CBCT on the treatment unit, was consistent with the tumour motion measured by 4DCT at the time of planning. However, in two patients, maximum discrepancies observed were 6 and 10 mm in the anterior-posterior and superior-inferior directions, respectively. Respiration correlated CBCT acquired on the treatment unit allows target motion to be assessed for each treatment fraction, allows target localization based on different phases on the breathing cycle, and provides the facility for adaptive margin design in radiation therapy of lung malignancies. The current study has shown that the relative motion and position of the tumour at the time of treatment may not match that of the planning 4DCT scan. Therefore, application of breathing motion data acquired at simulation for tracking or gating radiation therapy may not be suitable for all patients - even those receiving short course treatment techniques such as SBRT

[en] Purpose: To validate the van Herk margin formula for lung radiation therapy using realistic dose calculation algorithms and respiratory motion modeling. The robustness of the margin formula against variations in lesion size, peak-to-peak motion amplitude, tissue density, treatment technique, and plan conformity was assessed, along with the margin formula assumption of a homogeneous dose distribution with perfect plan conformity.Methods: 3DCRT and IMRT lung treatment plans were generated within the ORBIT treatment planning platform (RaySearch Laboratories, Sweden) on 4DCT datasets of virtual phantoms. Random and systematic respiratory motion induced errors were simulated using deformable registration and dose accumulation tools available within ORBIT for simulated cases of varying lesion sizes, peak-to-peak motion amplitudes, tissue densities, and plan conformities. A detailed comparison between the margin formula dose profile model, the planned dose profiles, and penumbra widths was also conducted to test the assumptions of the margin formula. Finally, a correction to account for imperfect plan conformity was tested as well as a novel application of the margin formula that accounts for the patient-specific motion trajectory.Results: The van Herk margin formula ensured full clinical target volume coverage for all 3DCRT and IMRT plans of all conformities with the exception of small lesions in soft tissue. No dosimetric trends with respect to plan technique or lesion size were observed for the systematic and random error simulations. However, accumulated plans showed that plan conformity decreased with increasing tumor motion amplitude. When comparing dose profiles assumed in the margin formula model to the treatment plans, discrepancies in the low dose regions were observed for the random and systematic error simulations. However, the margin formula respected, in all experiments, the 95% dose coverage required for planning target volume (PTV) margin derivation, as defined by the ICRU; thus, suitable PTV margins were estimated. The penumbra widths calculated in lung tissue for each plan were found to be very similar to the 6.4 mm value assumed by the margin formula model. The plan conformity correction yielded inconsistent results which were largely affected by image and dose grid resolution while the trajectory modified PTV plans yielded a dosimetric benefit over the standard internal target volumes approach with up to a 5% decrease in the V20 value.Conclusions: The margin formula showed to be robust against variations in tumor size and motion, treatment technique, plan conformity, as well as low tissue density. This was validated by maintaining coverage of all of the derived PTVs by 95% dose level, as required by the formal definition of the PTV. However, the assumption of perfect plan conformity in the margin formula derivation yields conservative margin estimation. Future modifications to the margin formula will require a correction for plan conformity. Plan conformity can also be improved by using the proposed trajectory modified PTV planning approach. This proves especially beneficial for tumors with a large anterior–posterior component of respiratory motion

[en] Purpose: To compare intensity-modulated radiotherapy (IMRT) with conformal RT (CRT) for hypofractionated isotoxicity liver RT and explore dose escalation using IMRT for the same/improved nominal risk of liver toxicity in a treatment planning study. Methods and Materials: A total of 26 CRT plans were evaluated. Prescription doses (24-54 Gy within six fractions) were individualized on the basis of the effective liver volume irradiated maintaining ≤5% risk of radiation-induced liver disease. The dose constraints included bowel (0.5 cm³) and stomach (0.5 cm³) to ≤30 Gy, spinal cord to ≤25 Gy, and planning target volume (PTV) to ≤140% of the prescribed dose. Two groups were evaluated: (1) PTV overlapping or directly adjacent to serial functioning normal tissues (n = 14), and (2) the liver as the dose-limiting normal tissue (n = 12). IMRT plans using direct machine parameter optimization maintained the CRT plan beam arrangements, an estimated radiation-induced liver disease risk of 5%, and underwent dose escalation, if all normal tissue constraints were maintained. Results: IMRT improved PTV coverage in 19 of 26 plans (73%). Dose escalation was feasible in 9 cases by an average of 3.8 Gy (range, 0.6-13.2) in six fractions. Three of seven plans without improved PTV coverage had small gross tumor volumes (≤105 cm³) already receiving 54 Gy, the maximal prescription dose allowed. In the remaining cases, the PTV range was 9.6-689 cm³; two had overlapped organs at risk; and one had four targets. IMRT did not improve these plans owing to poor target coverage (n = 2) and nonliver (n = 2) dose limits. Conclusion: Direct machine parameter optimization IMRT improved PTV coverage while maintaining normal tissue tolerances in most CRT liver plans. Dose escalation was possible in a minority of patients