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Radiation therapy is the standard treatment for localized gastric mucosa-associated lymphoid tissue (MALT) lymphoma. The ETHOS system (Varian Medical System) has enabled us to perform cone beam computed tomography (CBCT)-guided online adaptive radiation therapy (oART). This study presents a retrospective dosimetric analysis for interfractional and intrafractional change and treatment time in oART for gastric MALT lymphoma. We included 3 male patients with gastric MALT lymphoma who underwent exhalation breath-hold fasting oART using the SpiroDynr'X system. Treatment details and plans (3 reference [REF] plans, 51 scheduled [SCH] plans, and adapted [ADP] plans) were retrospectively analyzed. Doses to the clinical target volume in planning CT (CTV&#95;REF), CTV1, and CTV2 (representing the stomach in planning and preirradiation CBCT, respectively) and planning target volume (PTV) in the planning CBCT were estimated. D 2% , D 98% , D 50% , and D mean for these volumes, along with organ-at-risk doses, were examined across the 3 plans. The PTV dose coverage of CTV2 on preirradiation CBCT was calculated. CBCT-guided oART was completed within the scheduled period, using the ADP plans instead of the SCH plans on each treatment day in all cases. The average treatment time was approximately 45 minutes. CTV1 and CTV2 exhibited intrafractional and interfractional variations, fluctuating above and below CTV&#95;REF. Some ADP plans resulted in incomplete PTV coverage of CTV2, but the unincluded volume was <1% of CTV2. D 50% , D 98% , and D mean of CTV1, CTV2, and PTV were significantly improved in the ADP plans than in the SCH plans. Moreover, the D mean to the liver and kidneys was reduced in the ADP plans. CBCT-guided oART in patients with gastric MALT lymphoma demonstrated that ADP plans improved CTV1, CTV2, and PTV doses and reduced the mean bilateral kidney and liver doses, suggesting that it may offer enhanced treatment precision for gastric MALT lymphoma., Competing Interests: Disclosures Megumi Uto and Hiraku Iramina report funding support from JSPS KAKENHI Grant numbers 21K15548 and 22K15844. Takashi Mizowaki reports grants or contracts from Varian Medical Systems, Hitachi Ltd, and Brainlab AG regarding educational projects and collaborative research projects. Takashi Mizowaki also reports the payment or honoraria for speakers bureau from Varian Medical Systems, Hitachi Ltd, Brainlab AG, and Elekta KK, and has a leadership or fiduciary role on the Board of Directors in the Japanese Society for Radiation Oncology, Japan Radiological Society, Japan Society of Clinical Oncology, and Japan Society of Urologic Oncology., (Copyright © 2024 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.)

In this study, we aimed to conduct a survey on the current clinical practice of, staffing for, commissioning of, and staff training for online adaptive radiotherapy (oART) in the institutions that installed commercial oART systems in Japan, and to share the information with institutions that will implement oART systems in future. A web-based questionnaire, containing 107 questions, was distributed to nine institutions in Japan. Data were collected from November to December 2023. Three institutions each with the MRIdian (ViewRay, Oakwood Village, OH, USA), Unity (Elekta AB, Stockholm, Sweden), and Ethos (Varian Medical Systems, Palo Alto, CA, USA) systems completed the questionnaire. One institution (MRIdian) had not performed oART by the response deadline. Each institution had installed only one oART system. Hypofractionation, and moderate hypofractionation or conventional fractionation were employed in the MRIdian/Unity and Ethos systems, respectively. The elapsed time for the oART process was faster with the Ethos than with the other systems. All institutions added additional staff for oART. Commissioning periods differed among the oART systems owing to provision of beam data from the vendors. Chambers used during commissioning measurements differed among the institutions. Institutional training was provided by all nine institutions. To the best of our knowledge, this was the first survey about oART performed using commercial systems in Japan. We believe that this study will provide useful information to institutions that installed, are installing, or are planning to install oART systems., (© 2024. The Author(s), under exclusive licence to Japanese Society of Radiological Technology and Japan Society of Medical Physics.)

Machine- and patient-specific quality assurance (QA) is essential to ensure the safety and accuracy of radiotherapy. QA methods have become complex, especially in high-precision radiotherapy such as intensity-modulated radiation therapy (IMRT) and volumetric modulated arc therapy (VMAT), and various recommendations have been reported by AAPM Task Groups. With the widespread use of IMRT and VMAT, there is an emerging demand for increased operational efficiency. Artificial intelligence (AI) technology is quickly growing in various fields owing to advancements in computers and technology. In the radiotherapy treatment process, AI has led to the development of various techniques for automated segmentation and planning, thereby significantly enhancing treatment efficiency. Many new applications using AI have been reported for machine- and patient-specific QA, such as predicting machine beam data or gamma passing rates for IMRT or VMAT plans. Additionally, these applied technologies are being developed for multicenter studies. In the current review article, AI application techniques in machine- and patient-specific QA have been organized and future directions are discussed. This review presents the learning process and the latest knowledge on machine- and patient-specific QA. Moreover, it contributes to the understanding of the current status and discusses the future directions of machine- and patient-specific QA., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Japanese Radiation Research Society and Japanese Society for Radiation Oncology.)

Purpose: Target positions should be acquired during beam delivery for accurate lung stereotactic body radiotherapy. We aimed to perform kilovoltage (kV) imaging during beam irradiation (intra-irradiation imaging) under phase-gated conditions and evaluate its performance., Methods: Catphan 504 and QUASAR respiratory motion phantoms were used to evaluate image quality and target detectability, respectively. TrueBeam STx linac and the Developer Mode was used. The imaging parameters were 125 kVp and 1.2 mAs/projection. Flattened megavoltage (MV) X-ray beam energies 6, 10 and 15 MV and un-flattened beam energies 6 and 10 MV were used with field sizes of 5 × 5 and 15 × 15 cm 2 and various frame rates for intra-irradiation imaging. In addition, using a QUASAR phantom, intra-irradiation imaging was performed during intensity-modulated plan delivery. The root-mean-square error (RMSE) of the CT-number for the inserted rods, image noise, visual assessment, and contrast-to-noise ratio (CNR) were evaluated., Results: The RMSEs of intra-irradiation cone-beam computed tomography (CBCT) images under gated conditions were 50-230 Hounsfield Unit (HU) (static < 30 HU). The noise of the intra-irradiation CBCT images under gated conditions was 15-35 HU, whereas that of the standard CBCT images was 8.8-27.2 HU. Lower frame rates exhibited large RMSEs and noise; however, the iterative reconstruction algorithm (IR) was effective at improving these values. Approximately 7 fps with the IR showed an equivalent CNR of 15 fps without the IR. The target was visible on all the gated intra-irradiation CBCT images., Conclusion: Several image quality improvements are required; however, intra-irradiated CBCT images showed good visual target detection., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Associazione Italiana di Fisica Medica e Sanitaria. Published by Elsevier Ltd. All rights reserved.)

Background: For patient-specific quality assurance (PSQA) for small targets, the dose resolution can change depending on the characteristics of the dose calculation algorithms., Purpose: This study aimed to evaluate the influence of the dose calculation algorithms Acuros XB (AXB), anisotropic analytical algorithm (AAA), photon Monte Carlo (pMC), and collapsed cone (CC) on a helical diode array using volumetric-modulated arc therapy (VMAT) for small targets., Materials and Methods: ArcCHECK detectors were inserted with a physical depth of 2.9 cm from the surface. To evaluate the influence of the dose calculation algorithms for small targets, rectangular fields of 2×100, 5×100, 10×100, 20×100, 50×100, and 100×100 mm 2 were irradiated and measured using ArcCHECK with TrueBeam STx. A total of 20 VMAT plans for small targets, including the clinical sites of 19 brain metastases and one spine, were also evaluated. The gamma passing rates (GPRs) were evaluated for the rectangular fields and the 20 VMAT plans using AXB, AAA, pMC, and CC., Results: For rectangular fields of 2×100 and 5×100 mm 2 , the GPR at 3%/2 mm of AXB was < 50% because AXB resulted in a coarser dose resolution with narrow beams. For field sizes > 10×100 mm2, the GPR at 3%/2 mm was > 88.1% and comparable for all dose calculation algorithms. For the 20 VMAT plans, the GPRs at 3%/2 mm were 79.1 ± 15.7%, 93.2 ± 5.8%, 94.9 ± 4.1%, and 94.5 ± 4.1% for AXB, AAA, pMC, and CC, respectively., Conclusion: The behavior of the dose distribution on the helical diode array differed depending on the dose calculation algorithm for small targets. Measurements using ArcCHECK for VMAT with small targets can have lower GPRs owing to the coarse dose resolution of AXB around the detector area., (© 2024 The Authors. Journal of Applied Clinical Medical Physics is published by Wiley Periodicals, Inc. on behalf of The American Association of Physicists in Medicine.)

This study aimed to identify systematic errors in measurement-, calculation-, and prediction-based patient-specific quality assurance (PSQA) methods for volumetric modulated arc therapy (VMAT) on lung cancer and to standardize the gamma passing rate (GPR) by considering systematic errors during data assimilation. This study included 150 patients with lung cancer who underwent VMAT. VMAT plans were generated using a collapsed-cone algorithm. For measurement-based PSQA, ArcCHECK was employed. For calculation-based PSQA, Acuros XB was used to recalculate the plans. In prediction-based PSQA, GPR was forecasted using a previously developed GPR prediction model. The representative GPR value was estimated using the least-squares method from the three PSQA methods for each original plan. The unified GPR was computed by adjusting the original GPR to account for systematic errors. The range of limits of agreement (LoA) were assessed for the original and unified GPRs based on the representative GPR using Bland-Altman plots. For GPR (3%/2 mm), original GPRs were 94.4 ± 3.5%, 98.6 ± 2.2% and 93.3 ± 3.4% for measurement-, calculation-, and prediction-based PSQA methods and the representative GPR was 95.5 ± 2.0%. Unified GPRs were 95.3 ± 2.8%, 95.4 ± 3.5% and 95.4 ± 3.1% for measurement-, calculation-, and prediction-based PSQA methods, respectively. The range of LoA decreased from 12.8% for the original GPR to 9.5% for the unified GPR across all three PSQA methods. The study evaluated unified GPRs that corrected for systematic errors. Proposing unified criteria for PSQA can enhance safety regardless of the methods used., (© 2024. Australasian College of Physical Scientists and Engineers in Medicine.)

Background: Centrally located lung tumours present a challenge because of their tendency to exhibit symptoms such as airway obstruction, atelectasis, and bleeding. Surgical resection of these tumours often requires sacrificing the lungs, making definitive radiotherapy the preferred alternative to avoid pneumonectomy. However, the proximity of these tumours to mediastinal organs at risk increases the potential for severe adverse events. To mitigate this risk, we propose a dual-method approach: deep inspiration breath-hold (DIBH) radiotherapy combined with adaptive radiotherapy. The aim of this single-centre, single-arm phase II study is to investigate the efficacy and safety of DIBH daily online adaptive radiotherapy., Methods: Patients diagnosed with centrally located lung tumours according to the International Association for the Study of Lung Cancer recommendations, are enrolled and subjected to DIBH daily online adaptive radiotherapy. The primary endpoint is the one-year cumulative incidence of grade 3 or more severe adverse events, as classified by the Common Terminology Criteria for Adverse Events (CTCAE v5.0)., Discussion: Delivering definitive radiotherapy for centrally located lung tumours presents a dilemma between ensuring optimal dose coverage for the planning target volume and the associated increased risk of adverse events. DIBH provides measurable dosimetric benefits by increasing the normal lung volume and distancing the tumour from critical mediastinal organs at risk, leading to reduced toxicity. DIBH adaptive radiotherapy has been proposed as an adjunct treatment option for abdominal and pelvic cancers. If the application of DIBH adaptive radiotherapy to centrally located lung tumours proves successful, this approach could shape future phase III trials and offer novel perspectives in lung tumour radiotherapy., Trial Registration: Registered at the Japan Registry of Clinical Trials (jRCT; https://jrct.niph.go.jp/ ); registration number: jRCT1052230085 ( https://jrct.niph.go.jp/en-latest-detail/jRCT1052230085 )., (© 2024. The Author(s).)

Purpose: This study aimed to demonstrate the potential clinical applicability of an organ-contour-driven auto-matching algorithm in image-guided radiotherapy., Methods: This study included eleven consecutive patients with cervical cancer who underwent radiotherapy in 23 or 25 fractions. Daily and reference magnetic resonance images were converted into mesh models. A weight-based algorithm was implemented to optimize the distance between the mesh model vertices and surface of the reference model during the positioning process. Within the cost function, weight parameters were employed to prioritize specific organs for positioning. In this study, three scenarios with different weight parameters were prepared. The optimal translation and rotation values for the cervix and uterus were determined based on the calculated translations alone or in combination with rotations, with a rotation limit of ±3°. Subsequently, the coverage probabilities of the following two planning target volumes (PTV), an isotropic 5 mm and anisotropic margins derived from a previous study, were evaluated., Results: The percentage of translations exceeding 10 mm varied from 9% to 18% depending on the scenario. For small PTV sizes, more than 80% of all fractions had a coverage of 80% or higher. In contrast, for large PTV sizes, more than 90% of all fractions had a coverage of 95% or higher. The difference between the median coverage with translational positioning alone and that with both translational and rotational positioning was 1% or less., Conclusion: This algorithm facilitates quantitative positioning by utilizing a cost function that prioritizes organs for positioning. Consequently, consistent displacement values were algorithmically generated. This study also revealed that the impact of rotational corrections, limited to ±3°, on PTV coverage was minimal., (© 2023 The Authors. Journal of Applied Clinical Medical Physics published by Wiley Periodicals, LLC on behalf of The American Association of Physicists in Medicine.)

Purpose: To develop a prediction model (PM) for target positioning using diaphragm waveforms extracted from CBCT projection images., Methods: Nineteen patients with lung cancer underwent orthogonal rotational kV x-ray imaging lasting 70 s. IR markers placed on their abdominal surfaces and an implanted gold marker located nearest to the tumor were considered as external surrogates and the target, respectively. Four different types of regression-based PM were trained using surrogate motions and target positions for the first 60 s, as follows: Scenario A: Based on the clinical scenario, 3D target positions extracted from projection images were used as they were (PM CL ). Scenario B: The short-arc 4D-CBCT waveform exhibiting eight target positions was obtained by averaging the target positions in Scenario A. The waveform was repeated for 60 s (W 4D-CBCT ) by adapting to the respiratory phase of the external surrogate. W 4D-CBCT was used as the target positions (PM 4D-CBCT ). Scenario C: The Amsterdam Shroud (AS) signal, which depicted the diaphragm motion in the superior-inferior direction was extracted from the orthogonal projection images. The amplitude and phase of W 4D-CBCT were corrected based on the AS signal. The AS-corrected W 4D-CBCT was used as the target positions (PM AS-4D-CBCT ). Scenario D: The AS signal was extracted from single projection images. Other processes were the same as in Scenario C. The prediction errors were calculated for the remaining 10 s., Results: The 3D prediction error within 3 mm was 77.3% for PM 4D-CBCT , which was 12.8% lower than that for PM CL . Using the diaphragm waveforms, the percentage of errors within 3 mm improved by approximately 7% to 84.0%-85.3% for PM AS-4D-CBCT in Scenarios C and D, respectively. Statistically significant differences were observed between the prediction errors of PM 4D-CBCT and PM AS-4D-CBCT ., Conclusion: PM AS-4D-CBCT outperformed PM 4D-CBCT , proving the efficacy of the AS signal-based correction. PM AS-4D-CBCT would make it possible to predict target positions from 4D-CBCT images without gold markers., (© 2023 The Authors. Journal of Applied Clinical Medical Physics published by Wiley Periodicals, LLC on behalf of The American Association of Physicists in Medicine.)

Background: Radiomics analysis using on-board volumetric images has attracted research attention as a method for predicting prognosis during treatment; however, the lack of standardization is still one of the main concerns., Purpose: This study investigated the factors that influence the reproducibility of radiomic features extracted from on-board volumetric images using an anthropomorphic radiomics phantom. Furthermore, a phantom experiment was conducted with different treatment machines from multiple institutions as external validation to identify reproducible radiomic features., Methods: The phantom was designed to be 35 × 20 × 20 cm with eight types of heterogeneous spheres (⌀ = 1, 2, and 3 cm). On-board volumetric images were acquired using 15 treatment machines from eight institutions. Of these, kilovoltage cone-beam computed tomography (kV-CBCT) image data acquired from four treatment machines at one institution were used as an internal evaluation dataset to explore the reproducibility of radiomic features. The remaining image data, including kV-CBCT, megavoltage-CBCT (MV-CBCT), and megavoltage computed tomography (MV-CT) provided by seven different institutions (11 treatment machines), were used as an external validation dataset. A total of 1,302 radiomic features, including 18 first-order, 75 texture, 465 (i.e., 93 × 5) Laplacian of Gaussian (LoG) filter-based, and 744 (i.e., 93 × 8) wavelet filter-based features, were extracted within the spheres. The intraclass correlation coefficient (ICC) was calculated to explore feature repeatability and reproducibility using an internal evaluation dataset. Subsequently, the coefficient of variation (COV) was calculated to validate the feature variability of external institutions. An absolute ICC exceeding 0.85 or COV under 5% was considered indicative of a highly reproducible feature., Results: For internal evaluation, ICC analysis showed that the median percentage of radiomic features with high repeatability was 95.2%. The ICC analysis indicated that the median percentages of highly reproducible features for inter-tube current, reconstruction algorithm, and treatment machine were decreased by 20.8%, 29.2%, and 33.3%, respectively. For external validation, the COV analysis showed that the median percentage of reproducible features was 31.5%. A total of 16 features, including nine LoG filter-based and seven wavelet filter-based features, were indicated as highly reproducible features. The gray-level run-length matrix (GLRLM) was classified as containing the most frequent features (N = 8), followed by the gray-level dependence matrix (N = 7) and gray-level co-occurrence matrix (N = 1) features., Conclusions: We developed the standard phantom for radiomics analysis of kV-CBCT, MV-CBCT, and MV-CT images. With this phantom, we revealed that the differences in the treatment machine and image reconstruction algorithm reduce the reproducibility of radiomic features from on-board volumetric images. Specifically, the most reproducible features for external validation were LoG or wavelet filter-based GLRLM features. However, the acceptability of the identified features should be examined in advance at each institution before applying the findings to prognosis prediction., (© 2023 American Association of Physicists in Medicine.)

Purpose: Quantifying intra-fractional six-degree-of-freedom (6DoF) residual errors or motion from approved patient setups is necessary for accurate beam delivery in spine stereotactic body radiotherapy. However, previously reported errors were not acquired during beam delivery. Therefore, we aimed to quantify the 6DoF residual errors and motions during arc beam delivery using a concurrent cone-beam computed tomography (CBCT) imaging technique, intra-irradiation CBCT., Methods: Consecutive 15 patients, 19 plans for various treatment sites, and 199 CBCT images were analyzed. Pre-irradiation CBCT was performed to verify shifts from the initial patient setup using the ExacTrac system. During beam delivery by two or three co-planar full-arc rotations, CBCT imaging was performed concurrently. Subsequently, an intra-irradiation CBCT image was reconstructed. Pre- and intra-irradiation CBCT images were rigidly registered to a planning CT image based on the bone to quantify 6DoF residual errors., Results: 6DoF residual errors quantified using pre- and intra-irradiation CBCTs were within 2.0 mm/2.0°, except for one measurement. The mean elapsed time (mean ± standard deviation [min:sec]) after pre-irradiation CBCT to the end of the last arc beam delivery was 6:08 ± 1:25 and 7:54 ± 2:14 for the 2- and 3-arc plans, respectively. Root mean squares of residual errors for several directions showed significant differences; however, they were within 1.0 mm/1.0°. Time-dependent analysis revealed that the residual errors tended to increase with elapsed time., Conclusion: The errors represent the optimal intra-fractional error compared with those acquired using the pre-, inter-beam, and post-6DoF image guidance and can be acquired within a standard treatment timeslot., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Associazione Italiana di Fisica Medica e Sanitaria. Published by Elsevier Ltd. All rights reserved.)

Purpose: This study performed an automatic measurement of the off-axis beam-positioning accuracy at a single isocenter via the TrueBeam Developer mode and evaluated the beam-positioning accuracy considering the effect of couch rotational errors., Methods: TrueBeam STx and the Winston-Lutz test-dedicated phantom, with a 3 mm diameter steel ball, were used in this study. The phantom was placed on the treatment couch, and the Winston-Lutz test was performed at the isocenter for four gantry angles (0°, 90°, 180°, and 270°) using an electronic portal imaging device. The phantom offset positions were at distances of 0, 25, 50, 75, and 100 mm from the isocenter along the superior-inferior, anterior-posterior, and left-right directions. Seventeen patterns of multileaf collimator-shaped square fields of 10 × 10 mm 2 were created at the isocenter and off-axis positions for each gantry angle. The beam-positioning accuracy was evaluated with couch rotation along the yaw-axis (0°, ± 0.5°, and ± 1.0°)., Results: The mean beam-positioning errors at the isocenter and off-isocenter distances (from the isocenter to ±100 mm) were 0.46-0.60, 0.44-0.91, and 0.42-1.11 mm for the couch angles of 0°, ±0.5°, and ±1°, respectively. The beam-positioning errors increased as the distance from the isocenter and couch rotation increased., Conclusion: These findings suggest that the beam-positioning accuracy at the isocenter and off-isocenter positions can be evaluated quickly and automatically using the TrueBeam Developer mode. The proposed procedure is expected to contribute to an efficient evaluation of the beam-positioning accuracy at off-isocenter positions., (© 2022 The Authors. Journal of Applied Clinical Medical Physics published by Wiley Periodicals, LLC on behalf of The American Association of Physicists in Medicine.)

Purpose: The purpose of this study was to demonstrate the potential utility of cone-beam computed tomography (CBCT)-guided online adaptive radiotherapy (ART) under end-exhalation breath-hold (EE-BH) conditions for pancreatic cancer (PC)., Methods: Eleven PC patients who underwent 15-fraction volumetric-modulated arc therapy under EE-BH conditions were included. Planning CT images and daily 165 CBCT images were imported into a dedicated treatment planning system. The prescription dose was set to 48 Gy in 15 fractions. The reference plan was automatically generated along with predefined clinical goals. After segmentation was completed on CBCT images, two different plans were generated: One was an adapted (ADP) plan in which re-optimization was performed on the anatomy of the day, and the other was a scheduled (SCH) plan, which was the same as the reference plan. The dose distributions calculated using the synthetic CT created from both planning CT and CBCT were compared between the two plans. Independent calculation-based quality assurance was also performed for the ADP plans, with a gamma passing rate of 3%/3 mm., Results: All clinical goals were successfully achieved during the reference plan generation. Of the 165 sessions, gross tumor volume D 98% and clinical target volume D 98% were higher in 100 (60.1%) and 122 (74.0%) ADP fractions. In each fraction, the V 3 Gy  < 1 cm 3 of the stomach and duodenum was violated in 47 (28.5%) and 48 (29.1%), respectively, of the SCH fractions, whereas no violations were observed in the ADP fractions. There were statistically significant differences in the dose-volume indices between the SCH and ADP fractions (p < 0.05). The gamma passing rates were above 95% in all ADP fractions., Conclusions: The CBCT-guided online ART under EE-BH conditions successfully reduced the dose to the stomach and duodenum while maintaining target coverage., (© 2022 The Authors. Journal of Applied Clinical Medical Physics published by Wiley Periodicals, LLC on behalf of The American Association of Physicists in Medicine.)

In this study, an independent dose verification plugin (DVP) using the Eclipse Scripting Application Programming Interface (ESAPI) for brachytherapy was developed. The DVP was based on the general 2D formalism reported in AAPM-TG43U1. The coordinate and orientation of each source position were extracted from the translation matrix acquired from the treatment planning system (TPS), and the distance between the source and verification point (r) was calculated. Moreover, the angles subtended by the center-tip and tip-tip of the hypothetical line source with respect to the verification point (θ and β) were calculated. With r, θ, β and the active length of the source acquired from the TPS, the geometry function was calculated. As the TPS calculated the radial dose function, g(r), and 2D anisotropy function, F(r,θ), by interpolating and extrapolating the corresponding table stored in the TPS, the DVP calculated g(r) and F(r,θ) independently from equations fitted with the Monte Carlo data. The relative deviation of the fitted g(r) and F(r,θ) for the GammaMed Plus HDR 192Ir source was 0.5% and 0.9%, respectively. The acceptance range of the relative dose difference was set to ±1.03% based on the relative deviation between the fitted functions and Monte Carlo data, and the linear error propagation law. For 64 verification points from sixteen plans, the mean of absolute values of the relative dose difference was 0.19%. The standard deviation (SD) of the relative dose difference was 0.17%. The DVP maximizes efficiency and minimizes human error for the brachytherapy plan check., (© The Author(s) 2022. Published by Oxford University Press on behalf of The Japanese Radiation Research Society and Japanese Society for Radiation Oncology.)

To evaluate the reproducibility of dose-based radiomic (dosiomic) features between dose-calculation algorithms for lung stereotactic body radiation therapy (SBRT). We analyzed 105 patients with early-stage non-small cell lung cancer who underwent lung SBRT between March 2011 and December 2017. Radiation doses of 48, 60, and 70 Gy were prescribed to the isocenter in 4-8 fractions. Dose calculations were performed using X-ray voxel Monte Carlo (XVMC) on the iPlan radiation treatment planning system (RTPS). Thereafter, the radiation doses were recalculated using the Acuros XB (AXB) and analytical anisotropic algorithm (AAA) on the Eclipse RTPS while maintaining the XVMC-calculated monitor units and beam arrangements. A total of 6808 dosiomic features were extracted without preprocessing (112 shape, 144 first-order, and 600 texture features) or with wavelet filters to eight decompositions (1152 first-order and 4800 texture features). Features with absolute pairwise concordance correlation coefficients-|CC con |-values exceeding or equaling 0.85 were considered highly reproducible. Subgroup analyses were performed considering the wavelet filters and prescribed doses. The numbers of highly reproducible first-order and texture features were 34.8%, 26.9%, and 31.0% for the XVMC-AXB, XVMC-AAA, and AXB-AAA pairs, respectively. The maximum difference between the mean |CC con | values was 0.70 and 0.11 for the subgroup analyses of wavelet filters and prescribed dose, respectively. The application of wavelet filter-based dosiomic analyses may be limited when using different types of dose-calculation algorithms for lung SBRT., (© 2022. Japanese Society of Radiological Technology and Japan Society of Medical Physics.)

Purpose: The purpose of this planning study was to develop an acceptable technique for highly hypofractionated intensity-modulated radiation therapy using simultaneous integrated boost technique (SIB-hHF-RT) for nonmetastatic National Comprehensive Cancer Network high-risk prostate cancer., Materials and Methods: We created SIB-hHF-RT plans for 14 nonmetastatic prostate cancer patients with MRI-detectable intraprostatic lesions (IPLs) and without intestines locating close to the seminal vesicle and prostate. We prescribed 57 Gy for IPLs and 54 Gy for the remainder of planning target volume (PTV) in 15 fractions. The IPLs were contoured based on magnetic resonance imaging, and PTV was generated by adding 6-8-mm margins to the clinical target volume. For the dose-volume constraints of organs at risk (OARs), the same constraints as 54 Gy plans were used so as not to increase the toxicity., Results: All created plans fulfilled the dose-volume constraints of all targets and OARs. The median estimated beam-on time was 108.5 s. For patient-specific quality assurance, the global gamma passing rates (3%/2 mm) with 10% dose threshold criteria were greater than 93% in all cases and greater than 95% in 11 cases., Conclusion: SIB-hHF-RT plans were developed that fulfill the acceptable dose-volume constraints and pass patient-specific quality assurance. We believe these plans can be applied to selected patients with nonmetastatic prostate cancer., (© 2021. Japan Radiological Society.)

Purpose: To evaluate damage reduction in cardiac implantable electronic devices (CIEDs) caused by photoneutrons in high-energy X-ray radiotherapy using a neutron-shielding sheet (NSS)., Methods: The NSS consists of a bolus with a thickness of 1 or 2 cm (Bls1 or Bls2) as a moderator and several absorbers (20%, 50%, or 80% B 4 C silicone sheet [B 4 C20, B 4 C50, or B 4 C80] or a 40% LiF silicone sheet [LiF40]). First, a linear accelerator (LINAC) with a water-equivalent phantom was modeled in the simulation and measured experimentally. Several NSSs were placed on the phantom, a Eu:LiCaAlF 6 scintillator was placed between the phantom and the NSS, and X-rays were irradiated. The relative counts (Cr = counts when placing the NSS or Bls2) were compared between the experiment and simulation. Second, CIED damage was evaluated in the simulation. The relative damage (Dr = damage when placing or not placing the NSS) was compared among all the NSSs. In addition, the γ-ray and leaking X-ray dose from B 4 C was measured using a dosimetric film. After determining the optimal NSS combination, Dr value analysis was performed by changing the length of one side and the thickness., Results: The Cr values of the simulation and experiment agreed within a 30% percentage difference, except for Bare or LiF40-only. The Dr value was reduced by 43% when Bls2 + B 4 C80 was applied. The photon dose was less than 5 cGy/1500 MU. The Dr values were smaller for the smaller lengths of one side of B 4 C80 and decreased as the M-layer thickness increased., Conclusions: The CIED damage induced by photoneutrons generated by a LINAC was effectively reduced by applying the optimal NSS., (Copyright © 2021 Associazione Italiana di Fisica Medica. Published by Elsevier Ltd. All rights reserved.)

Cone-beam computed tomography (CBCT) images acquired during volumetric modulated arc therapy (VMAT; ii-CBCT) can be used to calculate actual delivered doses (ADDs). However, such ii-CBCT images are degraded by scattered megavoltage x-rays (MV-scatters). We aimed to evaluate the dose calculation accuracy of the MV-scatter uncorrected or corrected ii-CBCT images acquired during VMAT deliveries. For MV-scatter correction on concurrent kilovoltage projections (P MVkV ), projections consisting only of MV-scatters (P MVS ) were acquired under the same MV beam parameters and gantry angles and subtracted from P MVkV (P MVScorr ). In addition, the projections by kilovoltage beams were acquired for reference (P kV ). The corresponding CBCT images were reconstructed using the Feldkamp-Davis-Kress algorithm (CBCT MVkV , CBCT MVScorr , and CBCT kV as reference). A multi-energy phantom with rods of various relative electron densities (REDs) was used to generate a CBCT-number-to-RED conversion table. First, CBCT kV was reconstructed. Then, the mean CBCT-numbers within each rod were extracted, and a reference table was generated. Concurrent kilovoltage imaging with various field sizes was also demonstrated, and CBCT MVkV and CBCT MVScorr were reconstructed. The extracted CBCT-numbers of each ii-CBCT image were converted into REDs using the reference table. Next, the absolute differences of RED between the ii-CBCT image and CBCT kV were calculated. Ten VMAT plans using a 10 MV flattening-filter-free beam were used for concurrent imaging of an anthropomorphic torso phantom. Moreover, an iterative reconstruction algorithm (IRA) was used for CBCT MVScorr . The plans were recalculated for the corresponding CBCT MVkV , CBCT MVScorr , CBCT MVScorr+IRA , and CBCT kV with the reference table. Finally, the doses were evaluated using 3D gamma analysis (1%/1 mm). The median difference ranges between CBCT MVkV /CBCT MVScorr and the reference values were -0.58 to -0.10/-0.03 to 0.00. The median gamma pass rates of the doses on CBCT MVkV , CBCT MVScorr , and CBCT MVScorr+IRA to the rate on CBCT kV were 70.4, 99.5, and 98.2%, respectively. CBCT MVScorr were comparable with CBCT kV for calculating the ADD from VMAT.

Objective: To quantify and correct megavoltage (MV) scattered X-rays (MV-scatter) on an image acquired using a linac-mounted kilovoltage (kV) imaging subsystem., Methods and Materials: A linac-mounted flat-panel detector (FPD) was used to acquire an image containing MV-scatter by activating the FPD only during MV beam irradiation. 6-, 10-, and 15 MV with a flattening-filter (FF; 6X-FF, 10X-FF, 15X-FF), and 6- and 10 MV without an FF (6X-FFF, 10X-FFF) were used. The maps were acquired by changing one of the irradiation parameters while the others remained fixed. The mean pixel values of the MV-scatter were normalized to the 6X-FF reference condition (MV-scatter value). An MV-scatter database was constructed using these values. An MV-scatter correction experiment with one full arc image acquisition and two square field sizes (FSs) was conducted. Measurement- and estimation-based corrections were performed using the database. The image contrast was calculated at each angle., Results: The MV-scatter increased with a larger FS and dose rate. The MV-scatter value factor varied substantially depending on the FPD position or collimator rotation. The median relative error ranges of the contrast for the image without, and with the measurement- and estimation-based correction were -10.9 to -2.9, and -1.5 to 4.8 and -7.4 to 2.6, respectively, for an FS of 10.0 × 10.0 cm 2 ., Conclusions: The MV-scatter was strongly dependent on the FS, dose rate, and FPD position. The MV-scatter correction improved the image contrast., Advances in Knowledge: The MV-scatters on the TrueBeam linac kV imaging subsystem were quantified with various MV beam parameters, and strongly depended on the fieldsize, dose rate, and flat panel detector position. The MV-scatter correction using the constructed database improved the image quality., (© 2020 The Authors. Published by the British Institute of Radiology.)

Purpose: To evaluate (a) the effects of megavoltage (MV)-scatter on concurrent kilovoltage (kV) projections (P MVkV ) acquired during rotational delivery, and (b) the image quality of intra-irradiation cone-beam computed tomography (ii-CBCT) images acquired during prostate volumetric-modulated arc therapy (VMAT) delivery., Methods: Experiment (1): P MVkV s were acquired with various MV beam parameters using a cylindrical phantom: field size (FS), MV energy (6 or 15 MV), dose rate (DR), and gantry speed. The average pixel values were calculated in a region on each P MVkV which were extracted at eight equally spaced gantry angles. Experiment (2): 11 one-arc and seven two-arc 15 MV prostate VMAT plans were used along with a pelvis phantom. One plan was selected from each of arc plans and its MV energy was changed to 6 MV. After P MVkV s were acquired, projections consisting of MV-scatter only (P MVS ) were acquired with closing kV blades and subtracted from P MVkV (P MVScorr ). Projections by kV beams only were acquired (P kV ). The corresponding CBCT images were reconstructed (CBCT MVkV , CBCT MVScorr , and CBCT kV ). The root-mean-square errors (RMSEs) were calculated in prostate region and 3D gamma analysis was conducted, in which the CBCT-number was used instead of doses between ii-CBCT images and CBCT kV (30 HU/1 mm)., Results: Experiment (1): The MV-scatters were dependent on the FSs, MV energies, and DRs. Experiment (2): The median RMSEs for CBCT MVScorr were decreased by 107.5 HU (1-arc) and 42.9 HU (2-arc) compared to those for CBCT MVkV . The median GPRs for CBCT MVScorr were 94.7% (1-arc) and 93.4% (2-arc), while those for CBCT MVkV were 61.1% and 79.9%, respectively. GPRs for 6 MV plans were smaller than those for 15 MV plans., Conclusions: The number of MV-scatters increased with larger FSs and DRs, and smaller MV energy. The MV-scatters were corrected on the CBCT MVScorr regardless of the number of arcs., (© 2020 The Authors. Journal of Applied Clinical Medical Physics published by Wiley Periodicals LLC on behalf of American Association of Physicists in Medicine.)

Purpose: The purpose of this study was to predict and classify the gamma passing rate (GPR) value by using new features (3D dosiomics features and combined with plan and dosiomics features) together with a machine learning technique for volumetric modulated arc therapy (VMAT) treatment plans., Methods and Materials: A total of 888 patients who underwent VMAT were enrolled comprising 1255 treatment plans. Further, 24 plan complexity features and 851 dosiomics features were extracted from the treatment plans. The dataset was randomly split into a training/validation (80%) and test (20%) dataset. The three models for prediction and classification using XGBoost were as follows: (i) plan complexity features-based prediction method (plan model); (ii) 3D dosiomics feature-based prediction model (dosiomics model); (iii) a combination of both the previous models (hybrid model). The prediction performance was evaluated by calculating the mean absolute error (MAE) and the correlation coefficient (CC) between the predicted and measured GPRs. The classification performance was evaluated by calculating the area under curve (AUC) and sensitivity., Results: MAE and CC at γ2%/2 mm in the test dataset were 4.6% and 0.58, 4.3% and 0.61, and 4.2% and 0.63 for the plan model, dosiomics model, and hybrid model, respectively. AUC and sensitivity at γ2%/2 mm in test dataset were 0.73 and 0.70, 0.81 and 0.90, and 0.83 and 0.90 for the plan model, dosiomics model, and hybrid model, respectively., Conclusions: A combination of both plan and dosiomics features with machine learning technique can improve the prediction and classification performance for GPR., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Purpose: To measure the scattered x-rays of megavoltage (MV) and kilovoltage (kV) beams (MV scatter and kV scatter, respectively) on the orthogonal kV imaging subsystems of Vero4DRT., Methods: Images containing MV- and kV-scatter from another source only (i.e., MV- and kV-scatter maps) were acquired for each investigated flat panel detector. The reference scatterer was a water-equivalent cuboid phantom. The maps were acquired by changing one of the following parameters from the reference conditions while keeping the others fixed: field size: 10.0 × 10.0 cm 2 ; dose rate: 400 MU/min; gantry and ring angles: 0°; kV collimator aperture size at isocenter: 10.0 × 10.0 cm 2 : tube voltage: 110 kV; and exposure: 0.8 mAs. The average pixel values of MV- and kV-scatter (i.e., the MV- and kV-scatter values) at the center of each map were calculated and normalized to the MV-scatter value under the reference conditions (MV- and kV-scatter value factor, respectively). In addition, an MV- and kV-scatter correction experiment with intensity-modulated beams was performed using a phantom with four gold markers (GMs). The ratios between the intensities of the GMs and those of their surroundings were calculated., Results: The measurements showed a strong dependency of the MV-scatter on the field size and dose rate. The maximum MV-scatter value factors were 2.0 at a field size of 15.0 × 15.0 cm 2 and 2.5 at a dose rate of 500 MU/min. The maximum kV-scatter value was 0.48 with a fully open kV collimator aperture. In the phantom experiment, the intensity ratios of kV images with MV- and kV-scatter were decreased from the reference ones. After correction of kV-scatter only, MV-scatter only, and both MV- and kV-scatter, the intensity ratios gradually improved., Conclusions: MV- and kV-scatter could be corrected by subtracting the scatter maps from the projections, and the correction improved the intensity ratios of the GMs., (© 2020 The Authors. Journal of Applied Clinical Medical Physics published by Wiley Periodicals LLC on behalf of American Association of Physicists in Medicine.)

This study aimed to investigate the feasibility of independent calculation-based verification of volumetric-modulated arc therapy (VMAT)-stereotactic body radiotherapy (SBRT) for patients with lung cancer using a secondary treatment planning system (sTPS). In all, 50 patients with lung cancer who underwent VMAT-SBRT between April 2018 and May 2019 were included in this study. VMAT-SBRT plans were devised using the Collapsed-Cone Convolution in RayStation (primary TPS: pTPS). DICOM files were transferred to Eclipse software (sTPS), which utilized the Eclipse software, and the dose distribution was then recalculated using Acuros XB. For the verification of dose distribution in homogeneous phantoms, the differences among pTPS, sTPS, and measurements were evaluated using passing rates of a dose difference of 5% (DD5%) and gamma index of 3%/2 mm (γ3%/2 mm). The ArcCHECK cylindrical diode array was used for measurements. For independent verification of dose-volume parameters per the patient's geometry, dose-volume indices for the planning target volume (PTV) including D 95% and the isocenter dose were evaluated. The mean differences (± standard deviations) between the pTPS and sTPS were then calculated. The gamma passing rates of DD5% and γ3%/2 mm criteria were 99.2 ± 2.4% and 98.6 ± 3.2% for pTPS vs. sTPS, 92.9 ± 4.0% and 94.1 ± 3.3% for pTPS vs. measurement, and 93.0 ± 4.4% and 94.3 ± 4.1% for sTPS vs. measurement, respectively. The differences between pTPS and sTPS for the PTVs of D 95% and the isocenter dose were -3.1 ± 2.0% and -2.3 ± 1.8%, respectively. Our investigation of VMAT-SBRT plans for lung cancer revealed that independent calculation-based verification is a time-efficient method for patient-specific quality assurance., (© 2020 The Authors. Journal of Applied Clinical Medical Physics published by Wiley Periodicals, Inc. on behalf of American Association of Physicists in Medicine.)

The number of patients with head and neck squamous cell carcinoma (HNC) with mediastinal involvement is small, and appropriate treatment techniques have not been widely discussed. This study aimed to compare the efficacy of radiotherapy planning techniques in reducing lung irradiation while retaining target coverage. Among all HNC patients with mediastinal involvement who underwent radiotherapy between 2007 and 2014 at our hospital, seven consecutive patients were included in this study. Four different treatment plans were generated for each patient as follows: seven-field intensity-modulated radiation therapy (IMRT), modified IMRT in which the lateral beams avoided the lungs, three-full-arc volumetric-modulated arc therapy (VMAT), and VMAT with lung avoidance. We compared the outcomes of IMRT and VMAT plans using the paired t-test. After modifications were made to avoid lung irradiation, IMRT values for V 5Gy and V 20Gy decreased from 713.2 to 503.6 cm 3 (p = 0.011) and from 338.8 cm 3 to 267.0 cm 3 (p = 0.058), respectively. In the case of VMAT, lung V 5Gy and V 20Gy values decreased from 754.8 to 601.0 cm 3 (p = 0.004) and from 328.5 to 255.7 cm 3 (p = 0.020), respectively. Other factors did not significantly differ between the plans. In both IMRT and VMAT planning, lung doses were significantly reduced following the modification of the beams that cross the lungs with target coverage maintenance.

We evaluated the performance of a newly developed three-dimensional (3D) model-based global-to-local registration of multiple organs, by comparing it with a 3D model-based global registration in the prostate region. This study included 220 prostate cancer patients who underwent intensity-modulated radiotherapy or volumetric-modulated arc therapy. Our registration proceeded sequentially, i.e. global registration including affine and piece-wise affine transformation followed by local registration. As a local registration, Laplacian-based and finite element method-based registration was implemented in Algorithm A and B, respectively. Algorithm C was for global registration alone. The template models for the prostate, seminal vesicles, rectum and bladder were constructed from the first 20 patients, and then three different registrations were performed on these organs for the remaining 200 patients, to assess registration accuracy. The 75th percentile Hausdorff distance was <1 mm in Algorithm A; it was >1 mm in Algorithm B, except for the prostate; and 3.9 mm for the prostate and >7.8 mm for other organs in Algorithm C. The median computation time to complete registration was <101, 30 and 16 s in Algorithms A, B and C, respectively. Analysis of variance revealed significant differences among Algorithms A-C in the Hausdorff distance and computation time. In addition, no significant difference was observed in the difference of Hausdorff distance between Algorithm A and B with Tukey's multiple comparison test. The 3D model-based global-to-local registration, especially that implementing Laplacian-based registration, completed surface registration rapidly and provided sufficient registration accuracy in the prostate region., (© The Author(s) 2019. Published by Oxford University Press on behalf of The Japan Radiation Research Society and Japanese Society for Radiation Oncology.)

Purpose: The dosimetric accuracies of volumetric modulated arc therapy (VMAT) plans were predicted using plan complexity parameters via machine learning., Methods: The dataset consisted of 600 cases of clinical VMAT plans from a single institution. The predictor variables (n = 28) for each plan included complexity parameters, machine type, and photon beam energy. Dosimetric measurements were performed using a helical diode array (ArcCHECK), and the dosimetric accuracy of the passing rates for a 5% dose difference (DD5%) and gamma index of 3%/3 mm (γ3%/3 mm) were predicted using three machine learning models: regression tree analysis (RTA), multiple regression analysis (MRA), and neural networks (NNs). First, the prediction models were applied to 500 cases of the VMAT plans. Then, the dosimetric accuracy was predicted using each model for the remaining 100 cases (evaluation dataset). The error between the predicted and measured passing rates was evaluated., Results: For the 600 cases, the mean ± standard deviation of the measured passing rates was 92.3% ± 9.1% and 96.8% ± 3.1% for DD5% and γ3%/3 mm, respectively. For the evaluation dataset, the mean ± standard deviation of the prediction errors for DD5% and γ3%/3 mm was 0.5% ± 3.0% and 0.6% ± 2.4% for RTA, 0.0% ± 2.9% and 0.5% ± 2.4% for MRA, and -0.2% ± 2.7% and -0.2% ± 2.1% for NN, respectively., Conclusions: NNs performed slightly better than RTA and MRA in terms of prediction error. These findings may contribute to increasing the efficiency of patient-specific quality-assurance procedures., (© 2019 American Association of Physicists in Medicine.)

Purpose: To perform quality assurance of non-coplanar, volumetric-modulated arc therapy featuring continuous couch rotation (CCR-VMAT) using a C-arm linear accelerator., Methods: We planned and delivered CCR-VMAT using the TrueBeam Developer Mode. Treatment plans were created for both a C-shaped phantom and five prostate cancer patients using seven CCR trajectories that lacked collisions; we used RayStation software (ver. 4.7) to this end. Subsequently, verification plans were generated. The mean absolute error (MAE) between the center of an MV-imaged steel ball and the radiation field was calculated using the Winston-Lutz test. The MAEs between planned and actual irradiation values were also calculated from trajectory logs. In addition, correlation coefficients (r values) among the MAEs of gantry angle, couch angle, and multi-leaf collimator (MLC) position, and mechanical parameters including gantry speed, couch speed, MLC speed, and beam output, were estimated. The dosimetric accuracies of planned and measured values were also assessed using ArcCHECK., Results: The MAEs ±2 standard deviations as revealed by the Winston-Lutz test for all trajectories were 0.3 ± 0.3 mm in two dimensions. The MAEs of the gantry, couch, and MLC positions calculated from all trajectory logs were within 0.04°, 0.08°, and 0.02 mm, respectively. Deviations in the couch angle (r = 0.98, p < 0.05) and MLC position (r = 0.86, p < 0.05) increased significantly with speed. The MAE of the beam output error was less than 0.01 MU. The mean gamma passing rate ± 2 SD (range) of the 3%/3 mm, 3%/1 mm, and 5%/1 mm was 98.1 ± 1.9% (95.7-99.6%), 87.2 ± 2.8% (80.2-96.7%), and 96.3 ± 2.8% (93.9-99.6%), respectively., Conclusions: CCR-VMAT delivered via the TrueBeam Developer Mode was associated with high-level geometric and mechanical accuracy, thus affording to high dosimetric accuracy. The CCR-VMAT performance was stable regardless of the trajectory chosen.

Purpose: A contrast-enhancing agent is imperative for the accurate target delineation of pancreatic tumors. This study demonstrates the potential use of treatment planning for patients with pancreatic tumors based on the water density image (WDI) generated by dual-energy computed tomography (DECT)., Methods: Tissue characterization and multi-energy phantom scanning were performed through DECT and the physical characteristics of the WDI and a virtual monochromatic image (VMI) were assessed. The measured and the corresponding theoretical electron density relative to water (RED) and mass density (MD) were compared. Treatment plans based on the WDI (TP WDI ) and VMI (TP VMI ) were compared for 22 pancreatic cancer patients who underwent contrast-enhanced DECT scan., Results: The total absolute difference in the HU value between the conventional 120 kVp images and the VMI was the smallest at the energy level of 77 keV (3.3 HU), and the VMI at 77 keV was used for subsequent analysis. The difference between the measured and theoretical values of RED and MD for iodine using the VMI (>15%) was larger than that using WDI (<4%). In clinical cases, the maximum difference in the dosimetric parameters between TP WDI and TP WDI for the planning target volume was 3.0% when the doses were calculated using AXB, and for the duodenum, it was 1.7%., Conclusions: The WDI estimated the RED and MD accurately and could form the basis for a new treatment planning approach for pancreatic cancer using contrast-enhancing agent., (© 2018 American Association of Physicists in Medicine.)

We evaluated two dual-energy cone-beam computed tomography (DE-CBCT) methodologies for a bench-top micro-CBCT system to reduce metal artifacts on reconstructed images. Two filter-based DE-CBCT methodologies were tested: (i) alternative spectral switching and (ii) simultaneous beam splitting. We employed filters of 0.6-mm-thick tin and 0.1-mm-thick tungsten to generate high- and low-energy spectra from 120 kVp X-rays, respectively. The spectral switching method was imitated by two half scans with different filters (pseudo-switching). Filters were placed and between the X-ray tube and a phantom ('1-u,' '2-u'), a phantom and a flat panel detector ('1-d,' '2-d'), and compared with (iii) two half scans at 80 and 140 kVp [pseudo-(80,140)]. For the splitting method, two half-width filters were aligned along a rotating axis. Projections were separated into halves and merged with corresponding areas of opposed projections after one full rotation. A solid 30-mm-diameter acrylic phantom and an acrylic phantom with four 5-mm-diameter titanium rods were used. DE images were generated by weighted summation of the high- and low-energy images. The blending factor was changed from 0 to +5 in increments of 0.01. Relative errors (REs) of the linear attenuation coefficients of the two phantoms and the contrast-to-noise ratios (CNRs) between the titanium and acrylic regions were compared. All methods showed zero REs except for the method (2-d). CNRs for pseudo-switching with upstream placement were 1.4-fold larger than CNRs for the pseudo-(80,140) method. CNRs for the downstream placements were small. It was concluded that the pseudo-switching method with upstream placement is appropriate for reducing metal artifacts.

Background: During therapeutic beam irradiation, an unvisualized three-dimensional (3D) target position should be estimated using an external surrogate with an estimation model. Training periods for the developed model with no additional imaging during beam irradiation were optimized using clinical data., Methods: Dual-source 4D-CBCT projection data for 20 lung cancer patients were used for validation. Each patient underwent one to three scans. The actual target positions of each scan were equally divided into two equal parts: one for the modeling and the other for the validating session. A quadratic target position estimation equation was constructed during the modeling session. Various training periods for the session-i.e., modeling periods (T M )-were employed: T M  ∈ {5,10,15,25,35} [s]. First, the equation was used to estimate target positions in the validating session of the same scan (intra-scan estimations). Second, the equation was then used to estimate target positions in the validating session of another temporally different scan (inter-scan estimations). The baseline drift of the surrogate and target between scans was corrected. Various training periods for the baseline drift correction-i.e., correction periods (T C s)-were employed: T C  ∈ {5,10,15; T C  ≤ T M } [s]. Evaluations were conducted with and without the correction. The difference between the actual and estimated target positions was evaluated by the root-mean-square error (RMSE)., Results: The range of mean respiratory period and 3D motion amplitude of the target was 2.4-13.0 s and 2.8-34.2 mm, respectively. On intra-scan estimation, the median 3D RMSE was within 1.5-2.1 mm, supported by previous studies. On inter-scan estimation, median elapsed time between scans was 10.1 min. All T M s exhibited 75th percentile 3D RMSEs of 5.0-6.4 mm due to baseline drift of the surrogate and the target. After the correction, those for each T M s fell by 1.4-2.3 mm. The median 3D RMSE for both the 10-s T M and the T C period was 2.4 mm, which plateaued when the two training periods exceeded 10 s., Conclusions: A widely-applicable estimation model for the 3D target positions during beam irradiation was developed. The optimal T M and T C for the model were both 10 s, to allow for more than one respiratory cycle., Trial Registration: UMIN000014825 . Registered: 11 August 2014.

Knowledge of the imaging doses delivered to patients and accurate dosimetry of the radiation to organs from various imaging procedures is becoming increasingly important for clinicians. The purposes of this study were to calculate imaging doses delivered to the organs of lung cancer patients during real-time tumor tracking (RTTT) with three-dimensional (3D), and four-dimensional (4D) cone-beam computed tomography (CBCT), using Monte Carlo techniques to simulate kV X-ray dose distributions delivered using the Vero4DRT. Imaging doses from RTTT, 3D-CBCT and 4D-CBCT were calculated with the planning CT images for nine lung cancer patients who underwent stereotactic body radiotherapy (SBRT) with RTTT. With RTTT, imaging doses from correlation modeling and from monitoring of imaging during beam delivery were calculated. With CBCT, doses from 3D-CBCT and 4D-CBCT were also simulated. The doses covering 2-cc volumes (D2cc) in correlation modeling were up to 9.3 cGy for soft tissues and 48.4 cGy for bone. The values from correlation modeling and monitoring were up to 11.0 cGy for soft tissues and 59.8 cGy for bone. Imaging doses in correlation modeling were larger with RTTT. On a single 4D-CBCT, the skin and bone D2cc values were in the ranges of 7.4-10.5 cGy and 33.5-58.1 cGy, respectively. The D2cc from 4D-CBCT was approximately double that from 3D-CBCT. Clinicians should Figure that the imaging dose increases the cumulative doses to organs.

Purpose: To quantify the accuracy of extracted target motion trajectories in dual-source four-dimensional cone-beam computed tomography (4D-CBCT) by comparison with the actual three-dimensional (3D) target motion acquired simultaneously during 4D-CBCT scan., Materials and Methods: 4D-CBCT scans were performed for 19 different sinusoidal-like patterns and 13 lung cancer patients with implanted markers. Internal (In) or external (Ex) surrogates with amplitude (Amp)- or phase (Ph)-based sorting were used for the reconstructions. The targets were a pseudo-tumor and implanted marker for the phantom and clinical studies, respectively. The accuracy was evaluated by determining the maximum error (MaxE i ) between the 3D target position extracted from 4D-CBCT and the actual 3D target position detected by fluoroscopy in each ith phase (0⩽i⩽7)., Results: Median peak-to-peak target displacements in the superior-inferior (SI) direction were 20.6 and 20.6mm in the phantom and clinical studies, respectively. In the phantom and clinical studies, the maximum of median MaxE i s in the SI direction was 4.6 and 9.2mm in the In&#95;Ph reconstruction. In the clinical study, the maximum of median MaxE i s was observed during the end-inhalation phase among all reconstruction approaches., Conclusions: This study showed the magnitude of underestimation toward the inferior direction of target motion in clinical 4D-CBCT., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Purpose: Photographic film is widely used for the dose distribution verification of intensity-modulated radiation therapy (IMRT). However, analysis for verification of the results is subjective. We present a novel method for marking the isocenter using irradiation from a megavoltage (MV) beam transmitted through slits in a multi-leaf collimator (MLC)., Methods: We evaluated the effect of the marking irradiation at 500 monitor units (MU) on the total transmission through the MLC using an ionization chamber and Radiochromic Film. Film dosimetry was performed for quality assurance (QA) of IMRT plans. Three methods of registration were used for each film: marking by irradiating with an MV beam through slits in the MLC (MLC-IC); marking with a fabricated phantom (Phantom-IC); and a subjective method based on isodose lines (Manual). Each method was subjected to local γ-analysis., Results: The effect of the marking irradiation on the total transmission was 0.16%, as measured by a ionization chamber at a 10-cm depth in a solid phantom, while the inter-leaf transmission was 0.3%, determined from the film. The mean pass rates for each registration method agreed within ± 1% when the criteria used were a distance-to-agreement (DTA) of 3 mm and a dose difference (DD) of 3%. For DTA/DD criteria of 2mm/3%, the pass rates in the sagittal plane were 96.09 ± 0.631% (MLC-IC), 96.27 ± 0.399% (Phantom-IC), and 95.62 ± 0.988% (Manual)., Conclusion: The present method is a versatile and useful method of improving the objectivity of film dosimetry for IMRT QA., (Copyright © 2015 Associazione Italiana di Fisica Medica. Published by Elsevier Ltd. All rights reserved.)