[en] Purpose: The CyberKnife delivers a large number of beams originating at different non-planar positions and with different orientation. We study how much the quality of treatment plans depends on the beams considered during plan optimization. Particularly, we evaluate a new approach to search for optimal treatment plans in parallel by running optimization steps concurrently. Methods: So far, no deterministic, complete and efficient method to select the optimal beam configuration for robotic SRS/SBRT is known. Considering a large candidate beam set increases the likelihood to achieve a good plan, but the optimization problem becomes large and impractical to solve. We have implemented an approach that parallelizes the search by solving multiple linear programming problems concurrently while iteratively resampling zero weighted beams. Each optimization problem contains the same set of constraints but different variables representing candidate beams. The search is synchronized by sharing the resulting basis variables among the parallel optimizations. We demonstrate the utility of the approach based on an actual spinal case with the objective to improve the coverage. Results: The objective function is falling and reaches a value of 5000 after 49, 31, 25 and 15 iterations for 1, 2, 4, and 8 parallel processes. This corresponds to approximately 97% coverage in 77%, 59%, and 36% of the mean number of iterations with one process for 2, 4, and 8 parallel processes, respectively. Overall, coverage increases from approximately 91.5% to approximately 98.5%. Conclusion: While on our current computer with uniform memory access the reduced number of iterations does not translate into a similar speedup, the approach illustrates how to effectively parallelize the search for the optimal beam configuration. The experimental results also indicate that for complex geometries the beam selection is critical for further plan optimization

[en] Purpose: To assess the plan robustness and safety margin in SRS from 4DMGDR in E2E QA based on clinical objectives. Methods: OCTAVIUS SRS 1000 detector array and 4D phantom (PTW, Freiburg, Germany) were used to measure 5 coplanar SRS plans with 1 and 2 mm planning target volume (PTV). 3 targets were clinical, and 2 were virtual simulated to be 1mm from the brainstem (BS), and between chiasm (CS) and optic nerve (ON). Planning was done on Monaco v5.0 (Elekta, Maryland Heights, MO) to achieve 95–99% PTV and 100% gross tumor volume (GTV) prescription dose coverage. CBCT setup of the 4D phantom by 6D robotic couch was performed as for real patient. 4D-MGDR in patient CT and dosimetric analysis were performed in PTW Verisoft v6.1. The safety margin that achieved 100% GTV coverage was determined, and doses to 2% (D2%) of BS, ON and CS were assessed from E2E QA. Results: 100% GTV coverage was achieved with 1mm margin for 2 plans and 2mm margin for all plans. 98.3% and 99.4% GTV coverage were found in E2E QA for 1mm PTVs that either had sharp changing contour, or was nearby CS and ON or BS, and had either low planned minimum GTV dose (∼101% of the prescribed dose vs.∼106%) or compromised PTV coverage (95% vs. 99%). D2% to CS obtained with 4D-MGDR for one virtual target were 18.8Gy for 1mm PTV and 19.2Gy for 2mm PTV, exceeding the planned tolerance of 18Gy/3 fractions for prescription dose of 24Gy. Conclusion: 1mm margin is generally sufficient for dose planning and machine delivery errors. Irregular GTV with just enough dose coverage to spare critical organs may need 2mm margin at the costs of possible higher organ doses. 4D MGDR in an E2E QA approach can put the treatment plan evaluation in clinical perspectives

[en] Purpose: The aim of this study was to measure the dose profile and output factors with a CyberKnife accelerator using a TM60019 microDiamond detector and a 1000SRS liquid chamber array (both PTW Freiburg, Germany). Methods: An MP3 water phantom (PTW, Freiburg) was positioned along the robotic world coordinate system. The TM60019 detector was adjusted to the center of the according fields and the semiconductor axis was aligned with the beam direction. Profiles at 5cm water depth and SSD = 80 cm were measured along the robotic x axis and y axis for the cylindrical collimators of the CyberKnife (diameter 60, 50, 40, 30, 20, 15, 12.5, 10, 7.5 and 5mm). To determine the output factors the dose profile was measured at 0.1 mm steps around the field center to find the maximum dose value. The liquid chamber array (1000SRS) measurement was performed with the same setup, but with RW3 buildup. Results: The 1000SRS measurements closely conform with the TM60019 profile measurement in all profile regions and for all collimator sizes. The profile measurement is influenced by the almost equal spatial resolution of the TM60019 detector (radius of the sensitive area 1.1mm) and of the 1000SRS liquid chamber array (single chamber width 2.3mm). The measured dose profiles have not been corrected for this limited spatial resolution. Rather we purpose to consider that spatial dose averaging over 2 mm wide regions might be justified in view of patient positioning inaccuracies and of the spaces in tissue participating in the biological radiation responses. Conclusion: The 1000SRS data points conform with the TM60019 profile measurements at all profile regions showing the applicability of liquid ion chamber arrays with the CyberKnife system

[en] Purpose: To cross-validate the MGDR of COMPASS (IBA dosimetry, GmbH, Germany) and OCTAVIUS 4D system (PTW, Freiburg, Germany). Methods: Volumetric-modulated arc plans (5 head-and-neck and 3 prostate) collapsed to 40° gantry on the OCTAVIUS 4D phantom in QA mode on Monaco v5.0 (Elekta, CMS, Maryland Heights, MO) were delivered on a Elekta Agility linac. This study was divided into two parts: (1) error-free measurements by gantry-mounted EvolutionXX 2D array were reconstructed in COMPASS (IBA dosimetry, GmbH, Germany), and by OCTAVIUS 1500 array in Versoft v6.1 (PTW, Freiburg, Germany) to obtain the 3D doses (COM4D and OCTA4D). COM4D and OCTA4D were compared to the raw measurement (OCTA3D) at the same detector plane for which OCTAVIUS 1500 was perpendicular to 0° gantry axis while the plans were delivered at gantry 40°; (2) beam steering errors of energy (Hump=-2%) and symmetry (2T=+2%) were introduced during the delivery of 5 plans to compare the MGDR doses COM4D-Hump (COM4D-2T), OCTA4D-Hump (OCTA4D-2T), with raw doses OCTA3D-Hump (OCTA3D-2T) and with OCTA3D to assess the error reconstruction and detection ability of MGDR tools. All comparisons used Υ-criteria of 2%(local dose)/2mm and 3%/3mm. Results: Averaged Υ passing rates were 85% and 96% for COM4D,and 94% and 99% for OCTA4D at 2%/2mm and 3%/3mm criteria respectively. For error reconstruction, COM4D-Hump (COM4D-2T) showed 81% (93%) at 2%/2mm and 94% (98%) at 3%/3mm, while OCTA4D-Hump (OCTA4D-2T) showed 96% (96%) at 2%/2mm and 99% (99%) at 3%/3mm. For error detection, OCTA3D doses were compared to COM4D-Hump (COM4D-2T) showing Υ passing rates of 93% (93%) at 2%/2mm and 98% (98%), and to OCTA4D-Hump (OCTA4D -2T) showing 94% (99%) at 2%/2mm and 81% (96%) at 3%/3mm, respectively. Conclusion: OCTAVIUS MGDR showed better agreement to raw measurements in both error- and error-free comparisons. COMPASS MGDR deviated from the raw measurements possibly owing to beam modeling uncertainty

[en] Purpose: To validate the MGDR of OCTAVIUS 4D system (PTW, Freiburg, Germany) for quality assurance (QA) of volumetric-modulated arc radiotherapy (VMAT). Methods: 4D-MGDR measurements were divided into two parts: 1) square fields from 2×2 to 25×25 cm"2 at 0°, 10° and 45° gantry, and 2) 8 VMAT plans (5 nasopharyngeal and 3 prostate) collapsed to gantry 40° in QA mode in Monaco v5.0 (Elekta, CMS, Maryland Heights, MO) were delivered on the OCTAVIUS 4D phantom with the OCTAVIUS 1500 detector plane perpendicular to either the incident beam to obtain the reconstructed dose (OCTA4D) or the 0° gantry axis to obtain the raw doses (OCTA3D) in Verisoft 6.1 (PTW, Freiburg, Germany). Raw measurements of OCTA3D were limited to < 45° gantry to avoid >0.5% variation of detector angular response with respect to 0° gantry as determined previously. Reconstructed OCTA4D and raw OCTA3D doses for all plans were compared at the same detector plane using γ criteria of 2% (local dose)/2mm and 3%/3mm criteria. Results: At gantry 0° and 10°, the γ results for all OCTA4D on detector plane coinciding with OCTA3D were over 90% at 2%/2mm except for the largest field (25×25 cm"2 ) showing >88%. For square field at 45° gantry, γ passing rate is > 90% for fields smaller than 15x 15cm2 but < 80% for field size of 20 x20 cm"2 upward. For VMAT, γ results showed 94% and 99% passing rate at 2%/2mm and 3%/3mm, respectively. Conclusion: OCTAVIUS 4D system has compromised accuracy in reconstructing dose away from the central beam axis, possibly due to the off-axis softening correction and errors of the percent depth dose data necessary as input for MGDR. Good results in VMAT delivery suggested that the system is relatively reliable for VMAT with small segments

[en] Purpose: Investigating the relative sensitivity of Monte Carlo (MC) and Pencil Beam (PB) dose calculation algorithms to low-Z (titanium) metallic artifacts is important for accurate and consistent dose reporting in post¬operative spinal RS. Methods: Sensitivity analysis of MC and PB dose calculation algorithms on the Monaco v.3.3 treatment planning system (Elekta CMS, Maryland Heights, MO, USA) was performed using CT images reconstructed without (plain) and with Orthopedic Metal Artifact Reduction (OMAR; Philips Healthcare system, Cleveland, OH, USA). 6MV and 10MV volumetric-modulated arc (VMAT) RS plans were obtained for MC and PB on the plain and OMAR images (MC-plain/OMAR and PB-plain/OMAR). Results: Maximum differences in dose to 0.2cc (D0.2cc) of spinal cord and cord +2mm for 6MV and 10MV VMAT plans were 0.1Gy between MC-OMAR and MC-plain, and between PB-OMAR and PB-plain. Planning target volume (PTV) dose coverage changed by 0.1±0.7% and 0.2±0.3% for 6MV and 10MV from MC-OMAR to MC-plain, and by 0.1±0.1% for both 6MV and 10 MV from PB-OMAR to PB-plain, respectively. In no case for both MC and PB the D0.2cc to spinal cord was found to exceed the planned tolerance changing from OMAR to plain CT in dose calculations. Conclusion: Dosimetric impacts of metallic artifacts caused by low-Z metallic spinal hardware (mainly titanium alloy) are not clinically important in VMAT-based spine RS, without significant dependence on dose calculation methods (MC and PB) and photon energy ≥ 6MV. There is no need to use one algorithm instead of the other to reduce uncertainty for dose reporting. The dose calculation method that should be used in spine RS shall be consistent with the usual clinical practice

[en] The purpose of this study was to evaluate and compare two clinical tracking systems for radiosurgery with regard to their dosimetric and geometrical accuracy in liver SBRT: the robot-based CyberKnife and the gimbal-based Vero. Both systems perform real-time tumour tracking by correlating internal tumour and external surrogate motion. CyberKnife treatment plans were delivered to a high resolution 2D detector array mounted on a 4D motion platform, with the platform simulating (a) tumour motion trajectories extracted from the corresponding CyberKnife predictor log files and (b) the tumour motion trajectories with superimposed baseline-drift. Static reference and tracked dose measurements were compared and dosimetric as well as geometrical uncertainties analyzed by a planning structure-based evaluation. For (a), γ-passing rates inside the CTV (γ-criteria of 1% / 1 mm) ranged from 95% to 100% (CyberKnife) and 98% to 100% (Vero). However, dosimetric accuracy decreases in the presence of the baseline-drift. γ-passing rates for (b) ranged from 26% to 92% and 94% to 99%, respectively; i.e. the effect was more pronounced for CyberKnife. In contrast, the Vero system led to maximum dose deviations in the OAR between  +1.5 Gy to  +6.0 Gy (CyberKnife:  +0.5 Gy to  +3.5 Gy). Potential dose shifts were interpreted as motion-induced geometrical tracking errors. Maximum observed shift ranges were  −1.0 mm to  +0.7 mm (lateral) /−0.6 mm to  +0.1 mm (superior–inferior) for CyberKnife and  −0.8 mm to  +0.2 mm /−0.8 mm to  +0.4 mm for Vero. These values illustrate that CyberKnife and Vero provide high precision tracking of regular breathing patterns. Even for the modified motion trajectory, the obtained dose distributions appear to be clinical acceptable with regard to literature QA γ-criteria of 3% / 3 mm. (paper)

[en] Purpose: Atrial fibrillation (AF) is the most common cardiac arrhythmia, affecting >2.5M Americans and >4.5M Europeans. AF is usually treated with minimally-invasive, time consuming catheter ablation techniques. Radiosurgery of the pulmonary veins (PV) has been proposed for AF treatment, however is challenging due to the complex respiratory and cardiac motion patterns. We hypothesize that an MRI-linac could solve the difficult real-time targeting and adaptation problem. In this study we quantified target motion ranges on cardiac MRI and analyzed the dosimetric benefits of margin reduction assuming real-time MRI tracking was applied. Methods: For the motion study, four human subjects underwent real-time cardiac MRI under free breathing. The target motion on coronal and axial cine planes was analyzed using a template matching algorithm. For the planning study, an ablation line at each PV antrum was defined as target on an AF patient scheduled for catheter ablation. Various safety margins ranging from 0mm (perfect tracking) to 8mm (untracked motion) were added to the target defining the PTV. 30Gy single fraction IMRT plans were then generated. Finally, the influence of a 1T magnetic field on treatment beam delivery was calculated using the Geant4 Monte Carlo algorithm to simulate the dosimetric impact of MRI guidance. Results: The motion study showed the mean respiratory motion of the target area on MRI was 8.4mm (SI), 1.7mm (AP) and 0.3mm (LR). Cardiac motion was small (<2mm). The planning study showed that with increasing safety margins to encompass untracked motion, dose tolerances for OARs such as the esophagus and airways were exceeded by >100%. The magnetic field had little impact on the dose distribution. Conclusion: Our results indicate that real-time MRI tracking of the PVs seems feasible. Accurate image guidance for high-dose AF radiosurgery is essential since safety margins covering untracked target motion will result in unacceptable treatment plans

[en] Purpose: The purpose of this study is the correction of the lateral scanner artifact, i.e., the effect that, on a large homogeneously exposed EBT3 film, a flatbed scanner measures different optical densities at different positions along thex axis, the axis parallel to the elongated light source. At constant dose, the measured optical densitiy profiles along this axis have a parabolic shape with significant dose dependent curvature. Therefore, the effect is shortly called the parabola effect. The objective of the algorithm developed in this study is to correct for the parabola effect. Any optical density measured at given position x is transformed into the equivalent optical density c at the apex of the parabola and then converted into the corresponding dose via the calibration of c versus dose. Methods: For the present study EBT3 films and an Epson 10000XL scanner including transparency unit were used for the analysis of the parabola effect. The films were irradiated with 6 MV photons from an Elekta Synergy accelerator in a RW3 slab phantom. In order to quantify the effect, ten film pieces with doses graded from 0 to 20.9 Gy were sequentially scanned at eight positions along thex axis and at six positions along the z axis (the movement direction of the light source) both for the portrait and landscape film orientations. In order to test the effectiveness of the new correction algorithm, the dose profiles of an open square field and an IMRT plan were measured by EBT3 films and compared with ionization chamber and ionization chamber array measurement. Results: The parabola effect has been numerically studied over the whole measuring field of the Epson 10000XL scanner for doses up to 20.9 Gy and for both film orientations. The presented algorithm transforms any optical density at positionx into the equivalent optical density that would be measured at the same dose at the apex of the parabola. This correction method has been validated up to doses of 5.2 Gy all over the scanner bed with 2D dose distributions of an open square photon field and an IMRT distribution. Conclusions: The algorithm presented in this study quantifies and corrects the parabola effect of EBT3 films scanned in commonly used commercial flatbed scanners at doses up to 5.2 Gy. It is easy to implement, and no additional work steps are necessary in daily routine film dosimetry

[en] Robotic radiosurgery using more than one circular collimator can improve treatment plan quality and reduce total monitor units (MU). The rationale for an iris collimator that allows the field size to be varied during treatment delivery is to enable the benefits of multiple-field-size treatments to be realized with no increase in treatment time due to collimator exchange or multiple traversals of the robotic manipulator by allowing each beam to be delivered with any desired field size during a single traversal. This paper describes the Iris(TM) variable aperture collimator (Accuray Incorporated, Sunnyvale, CA, USA), which incorporates 12 tungsten-copper alloy segments in two banks of six. The banks are rotated by 30 deg. with respect to each other, which limits the radiation leakage between the collimator segments and produces a 12-sided polygonal treatment beam. The beam is approximately circular, with a root-mean-square (rms) deviation in the 50% dose radius of <0.8% (corresponding to <0.25 mm at the 60 mm field size) and an rms variation in the 20-80% penumbra width of about 0.1 mm at the 5 mm field size increasing to about 0.5 mm at 60 mm. The maximum measured collimator leakage dose rate was 0.07%. A commissioning method is described by which the average dose profile can be obtained from four profile measurements at each depth based on the periodicity of the isodose line variations with azimuthal angle. The penumbra of averaged profiles increased with field size and was typically 0.2-0.6 mm larger than that of an equivalent fixed circular collimator. The aperture reproducibility is ≤0.1 mm at the lower bank, diverging to ≤0.2 mm at a nominal treatment distance of 800 mm from the beam focus. Output factors (OFs) and tissue-phantom-ratio data are identical to those used for fixed collimators, except the OFs for the two smallest field sizes (5 and 7.5 mm) are considerably lower for the Iris Collimator. If average collimator profiles are used, the assumption of circular symmetry results in dose calculation errors that are <1 mm or <1% for single beams across the full range of field sizes; errors for multiple non-coplanar beam treatment plans are expected to be smaller. Treatment plans were generated for 19 cases using the Iris Collimator (12 field sizes) and also using one and three fixed collimators. The results of the treatment planning study demonstrate that the use of multiple field sizes achieves multiple plan quality improvements, including reduction of total MU, increase of target volume coverage and improvements in conformality and homogeneity compared with using a single field size for a large proportion of the cases studied. The Iris Collimator offers the potential to greatly increase the clinical application of multiple field sizes for robotic radiosurgery.