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Linac based radiosurgery to multiple metastases is commonly planned with volumetric modulated arc therapy (VMAT) as it effectively achieves high conformality to complex target arrangements. However, as the number of targets increases, VMAT can struggle to block between targets, which can lead to highly modulated and/or nonconformal multi-leaf collimator (MLC) trajectories that unnecessarily irradiation of healthy tissue. In this study we introduce, describe, and evaluate a treatment planning technique called Conformal Arc Informed VMAT (CAVMAT), which aims to reduce the dose to healthy tissue while generating highly conformal treatment plans. CAVMAT is a hybrid technique which combines the conformal MLC trajectories of dynamic conformal arcs with the MLC modulation and versatility of inverse optimization. CAVMAT has 3 main steps. First, targets are assigned to subgroups to maximize MLC blocking between targets. Second, arc weights are optimized to achieve the desired target dose, while minimizing MU variation between arcs. Third, the optimized conformal arc plan serves as the starting point for limited inverse optimization to improve dose conformity to each target. Twenty multifocal VMAT cases were replanned with CAVMAT with 20Gy applied to each target. The total volume receiving 2.5Gy[cm3], 6Gy[cm3], 12Gy[cm3], and 16Gy[cm3], conformity index, treatment delivery time, and the total MU were used to compare the VMAT and CAVMAT plans. In addition, CAVMAT was compared to a broad range of planning strategies from various institutions (108 linear accelerator based plans, 14 plans using other modalities) for a 5-target case utilized in a recent plan challenge. For the linear accelerator-based plans, a plan complexity metric based on aperture opening area and perimeter, total monitor units (MU), and MU for a given aperture opening was utilized in the plan challenge scoring algorithm to compare the submitted plans to CAVMAT. After re-planning the 20 VMAT cases, CAVMAT reduced the average V2.5Gy[cm3] by 25.25 ± 19.23%, V6Gy[cm3] by 13.68 ± 18.97%, V12Gy[cm3] by 11.40 ± 19.44%, and V16Gy[cm3] by 6.38 ± 19.11%. CAVMAT improved conformity by 3.81 ± 7.57%, while maintaining comparable target dose. MU for the CAVMAT plans increased by 24.35 ± 24.66%, leading to an increased treatment time of 2 minutes. For the plan challenge case, CAVMAT was 1 of 12 linac based plans that met all plan challenge scoring criteria. Compared to the average submitted VMAT plan, CAVMAT increased the V10%Gy[%] of healthy tissue (Brain-PTV) by roughly 3.42%, but in doing so was able to reduce the V25%Gy[%] by roughly 3.73%, while also reducing V50%Gy[%], V75%Gy[%], and V100%Gy[%]. The CAVMAT technique successfully eliminated insufficient MLC blocking between targets prior to the inverse optimization, leading to less complex treatment plans and improved tissue sparing. Tissue sparing, improved conformity, and decreased plan complexity at the cost of slight increase in treatment delivery time indicates CAVMAT to be a promising method to treat brain metastases.

Purpose Manual delineation (MD) of organs at risk (OAR) is time and labor intensive. Auto-delineation (AD) can reduce the need for MD, but because current algorithms are imperfect, manual review and modification is still typically used. Recognizing that many OARs are sufficiently far from important dose levels that they do not pose a realistic risk, we hypothesize that some OARs can be excluded from MD and manual review with no clinical effect. The purpose of this study was to develop a method that automatically identifies these OARs and enables more efficient workflows that incorporate AD without degrading clinical quality. Methods and Materials Preliminary dose map estimates were generated for n = 10 patients with head and neck cancers using only prescription and target-volume information. Conservative estimates of clinical OAR objectives were computed using AD structures with spatial expansion buffers to account for potential delineation uncertainties. OARs with estimated dose metrics below clinical tolerances were deemed low priority and excluded from MD and/or manual review. Final plans were then optimized using high-priority MD OARs and low-priority AD OARs and compared with reference plans generated using all MD OARs. Multiple different spatial buffers were used to accommodate different potential delineation uncertainties. Results Sixty-seven out of 201 total OARs were identified as low-priority using the proposed methodology, which permitted a 33% reduction in structures requiring manual delineation/review. Plans optimized using low-priority AD OARs without review or modification met all planning objectives that were met when all MD OARs were used, indicating clinical equivalence. Conclusions Prioritizing OARs using estimated dose distributions allowed a substantial reduction in required MD and review without affecting clinically relevant dosimetry.

Evaluation of the dose distribution delivered in a radiosurgery treatment of an acoustic neuroma using an adapted Alderson phantom and radiochromic film to assess absolute dose. A system was developed to perform the dose measurements, using the Alderson Rando phantom´s head carrying a modified slice, where a material reproducing the tumor was inserted. The phantom’s head with the modified slice was irradiated in a medical linear accelerator, using a procedure similar to that adopted in real cases, and radiochromic films were used to assess dose values. The suitability of the dose distribution delivered in the treatment was evaluated by comparing the Dose Volume Histograms, obtained from the Treatment Planning System (TPS) and by radiochromic film measurements. An agreement around 3% between experimental data and TPS´s calculations, showing an acceptable concordance with the planning results. T he established approach of transforming 2D arrays of dose in a 3D one is satisfactory, validating it. T he developed method shows to be an excellent alternative to quality control in radiosurgery using the radiochromic film to assess absolute dose.

Introduction: Within an International Atomic Energy Agency (IAEA) co-ordinated research project (CRP), a remote end-to-end dosimetric quality audit for intensity modulated radiation therapy (IMRT)/ volumetric arc therapy (VMAT) was developed to verify the radiotherapy chain including imaging, treatment planning and dose delivery. The methodology as well as the results obtained in a multicentre pilot study and national trial runs conducted in close cooperation with dosimetry audit networks (DANs) of IAEA Member States are presented. Material and methods: A solid polystyrene phantom containing a dosimetry insert with an irregular solid water planning target volume (PTV) and organ at risk (OAR) was designed for this audit. The insert can be preloaded with radiochromic film and four thermoluminescent dosimeters (TLDs). For the audit, radiotherapy centres were asked to scan the phantom, contour the structures, create an IMRT/VMAT treatment plan and irradiate the phantom. The dose prescription was to deliver 4 Gy to the PTV in two fractions and to limit the OAR dose to a maximum of 2.8 Gy. The TLD measured doses and film measured dose distributions were compared with the TPS calculations. Results: Sixteen hospitals from 13 countries and 64 hospitals from 6 countries participated in the multicenter pilot study and in the national runs, respectively. The TLD results for the PTV were all within +/- 5% acceptance limit for the multicentre pilot study, whereas for national runs, 17 participants failed to meet this criterion. All measured doses in the OAR were below the treatment planning constraint. The film analysis identified seven plans in national runs below the 90% passing rate gamma criteria. Conclusion: The results proved that the methodology of the IMRT/VMAT dosimetric end-to-end audit was feasible for its intended purpose, i.e., the phantom design and materials were suitable; the phantom was easy to use and it was robust enough for shipment. Most importantly the audit methodology was capable of identifying suboptimal IMRT/VMAT delivery.

Background and purpose: An audit methodology for verifying the implementation of output factors (OFs) of small fields in treatment planning systems (TPSs) used in radiotherapy was developed and tested through a multinational research group and performed on a national level in five different countries. Materials and methods: Centres participating in this study were asked to provide OFs calculated by their TPSs for 10 × 10 cm2, 6 × 6 cm2, 4 × 4 cm2, 3 × 3 cm2 and 2 × 2 cm2 field sizes using an SSD of 100 cm. The ratio of these calculated OFs to reference OFs was analysed. The action limit was ±3% for the 2 × 2 cm2 field and ±2% for all other fields. Results: OFs for more than 200 different beams were collected in total. On average, the OFs for small fields calculated by TPSs were generally larger than measured reference data. These deviations increased with decreasing field size. On a national level, 30% and 31% of the calculated OFs of the 2 × 2 cm2 field exceeded the action limit of 3% for nominal beam energies of 6 MV and for nominal beam energies higher than 6 MV, respectively. Conclusion: Modern TPS beam models generally overestimate the OFs for small fields. The verification of calculated small field OFs is a vital step and should be included when commissioning a TPS. The methodology outlined in this study can be used to identify potential discrepancies in clinical beam models. Keywords: Dosimetry audit, Small field output factors, Treatment planning system

PURPOSE To quantify the error detection power of a new treatment delivery error detection method. The method validates monitor unit (MU) resolved beam apertures using real-time EPID images. METHODS The on-board EPID imager was used to measure cine-EPID (~10 Hz) images for 27 beams from 15 VMAT/SBRT clinical treatment plans and five nonclinical plans. For each frame acquisition, planned apertures were interpolated from the treatment plan multileaf collimator (MLC) positions expected during the frame acquisition interval. Inaccurate deliveries were identified by monitoring in-aperture missed fluence and out-of-aperture excess fluence beyond a specified buffer. Delivery errors were simulated by perturbing the planned MLC positions before comparison with nonperturbed measured apertures. Systematic 1-5 mm MLC leaf shifts were used to train a logistic regression model to determine the error detection threshold. Model accuracy was monitored using tenfold cross-validation. The model's error detection ability was tested with other error modes: plan control point (CP) weight perturbations, collimator rotations, random MLC leaf position errors, EPID imager shift, and stuck MLC leaf. The error detection accuracy was evaluated using the Matthews correlation coefficient (MCC) and the false positive rate (FPR). Per-beam error thresholds of >1, >5, and >10% errant frames were tested to label per-beam errors. The model also was tested for its ability to distinguish five cases with highly similar plans and compared with gamma analysis. RESULTS Delivery errors were detected by monitoring intended per-frame images with a 2 mm MLC buffer. Frame-by-frame aperture errors were identified with an optimal threshold of 0.3% of the expected aperture area. The per-frame FPR was 0.02%. The MCC was 1.00 (perfect classification) for detection based on 1% of frames for random CP weight shift, 3 mm random MLC shifts, 90° and 180° collimator rotations, and an MLC leaf stuck after 10% of the beam delivery. The MCC for 2°, 4°, and 8° collimator rotation were 0.53, 0.76, and 0.96, respectively, for the 1% of beam delivery threshold. The 3 mm EPID shift had poor detection, with a minimum MCC of 0.14. The highly similar plans were reliably detected by the aperture check but were not detectable with gamma analysis. CONCLUSION The high error detection sensitivity and low FPR makes the aperture check error detection method well suited to pretreatment and during-treatment beam delivery quality assurance (QA). The aperture check detects subtle beam delivery errors, including those resulting from MLC leaf positioning deviations, CP MU shifts, and stuck MLC leaves. Furthermore, the method can distinguish between highly similar treatment plans. Since the aperture check method monitors for the aperture shapes over a given MU interval, it is also sensitive to errors in MU per CP, without requiring dosimetric calibration of the EPID. The aperture check is one part of a Swiss cheese error detection scheme, which provides redundant error testing of multiple error modes, including nonaperture related errors. The rapid error detection, at 1% of a beam's delivery, make the aperture check a potential candidate for QA of on-line adaptive radiotherapy, or other situations in which pretreatment delivery QA is impractical.

In recent years, there have been major changes in radiotherapy, particularly in dose delivery for treatments using the techniques of Three-Dimensional Conformal Radiation Therapy (3D-CRT), Intensity-Modulated Radiation Therapy (IMRT) and Volumetric Modulated Arc Therapy (VMAT). However, in the literature, no workload results for radiation therapy treatments performed exclusively with the VMAT technique were found. In this study, a new workload and a new VMAT factor will be proposed. For such, patient data originating from management and planning systems were acquired, such as dose values, monitor units, numbers of arcs per patient and number of hypofractionated treatments. The average clinical workload values for conventional treatments were 328 Gy/week, resulting in a VMAT factor of 1.97; similarly, for hypofractionated treatments, the clinical workload was 33Gy/week and the VMAT factor was 1.54. The total workload has a value of 596 Gy/week, less than the value used in the facility shielding design, 1250 Gy/week, and the average value of VMAT factor for conventional and hypofractionated treatments showed that a smaller amount of C should be used at facilities that perform exclusive VMAT treatment.

An ‘in house’ software was developed with MATLAB in order to perform optimized dose calculations in radiotherapy. The aim of this work is to demonstrate an improvement on the Multichannel method using robust optimization that deals with optimization problems where robustness is sought against uncertainty. An optimization framework was developed in order to compare remaining error from optimization process of robust methods against the conventional triple-channel method. The proposed robust method minimizes the dose difference over all channels compared to the original triple-channel method, mainly over clinical dose range. Even if a Gafchromic EBT2 film irradiated by composite IMRT fields is analyzed, more consistent values than the ones obtained by the triple-channel method are found and Newton Rings patterns are minimized. When robust methods are applied, the difference between blue and red channel doses was found to be very small, about 10 4 times less than obtained by triple-channel optimization. It is well known that one outlier may cause a large error in a least squares estimator. The blue channel correction of non-uniformities may have best performance when robust optimization is used. A variety of anomalies (artifacts, Newton rings and other disturbances) behave differently from natural Gaussian random noise such as variations of the thickness. The use of robust optimization methods might be more realistic since this approach uses fatter tail distributions as the Laplace and could mitigate the Newton’s Rings Pattern.

O objetivo deste trabalho e submeter filmes radiocromicos, dosimetros termoluminescentes e câmara de ionizacao a situacoes identicas de irradiacao, com a finalidade de se avaliarem as suas capacidades em medir doses perifericas. O crescente aumento de sobreviventes ao câncer infantil tem criado a necessidade de se investigarem as causas das sequelas do tratamento. Mensuracoes de radiacoes perifericas a regiao alvo da radioterapia incrementam o conhecimento do assunto e auxiliam na elaboracao de metodos de protecao. Como o espectro da radiacao na periferia e diferente do encontrado no feixe, a independencia energetica supostamente oferecida em filmes radiocromicos pode suplantar a dependencia energetica encontrada em câmaras de ionizacao e TLDs, de forma a descartar a necessidade de correcoes de valores se filmes forem utilizados. Neste trabalho os tres dosimetros foram submetidos as doses decorrentes da emissao de feixes de 6 MV, campo 10 cm x 10 cm e 500 UM. Os dosimetros foram posicionados a 0, 10, 17,5 e 30 cm do raio central, sempre sob 5 cm de agua. Os resultados encontrados mostraram que os valores apresentados pelos filmes possuem alto desvio padrao da media e que para resultados mais conclusivos e necessario prosseguir com as irradiacoes, empregando feixes mais intensos.

The purpose of this study is to investigate the influence of lung heterogeneity inside a soft tissue phantom on percentage depth dose (PDD). PDD curves were obtained experimentally using LiF:Mg,Ti (TLD-100) thermoluminescent detectors and applying Eclipse treatment planning system algorithms Batho, modified Batho (M-Batho or BMod), equivalent TAR (E-TAR or EQTAR), and anisotropic analytical algorithm (AAA) for a 15 MV photon beam and field sizes of 1 x 1, 2 x 2, 5 x 5, and 10 x 10 cm 2 . Monte Carlo simulations were performed using the DOSRZnrc user code of EGSnrc. The experimental results agree with Monte Carlo simulations for all irradiation field sizes. Comparisons with Monte Carlo calculations show that the AAA algorithm provides the best simulations of PDD curves for all field sizes investigated. However, even this algorithm cannot accurately predict PDD values in the lung for field sizes of 1 x 1 and 2 x 2 cm 2 . An overdosage in the lung of about 40% and 20% is calculated by the AAA algorithm close to the interface soft tissue/lung for 1 x 1 and 2 x 2 cm 2 field sizes, respectively. It was demonstrated that differences of 100% between Monte Carlo results and the algorithms Batho, modified Batho, and equivalent TAR responses may exist inside the lung region for the 1 x 1 cm 2 field.

The combination of radiotherapy treatments and breast reconstruction, using temporary tissue expanders, generates several concerns due to the presence of a magnetic valve inside the radiation field. The objective of this work is to evaluate a radiotherapy treatment planning for a patient using a tissue expander. Isodose curve maps, obtained using radiochromic films, were compared to the ones calculated with two different dose calculation algorithms of the Eclipse radiotherapy Treatment Planning System (TPS), considering the presence or absence of the heterogeneity. The TPS calculation considering the presence of the heterogeneity shows changes around 5% in the isodose curves when they were compared with the calculation without heterogeneity correction. This calculation did not take in account the real density value of the heterogeneity. This limitation was quantified to be around 10% in comparison with the TPS calculation and experimental measurements using the radiochromic film. These results show that the magnetic valve should be taken in account in dose calculations of the TPS. With respect to the AAA and Pencil Beam Convolution algorithms, when the calculation is compared with the real distribution, AAA presents a distribution more similar to experimental dose distribution.

In the radiotherapy treatment planning of a lesion located in the head region with small field radiation beams, the heterogeneity corrections play an important role. In this work, we investigated the influence of a bony heterogeneity on dose profile inside a soft tissue phantom containing a bony material. PDD curves were obtained by simulation using the Monte Carlo code EGSnrc and employing Eclipse(R) treatment planning system algorithms (Batho, Modified Batho, Equivalent TAR and Anisotropic Analytic Algorithm) for a 15 MV photon beam and field sizes of 2x2 and 10x10 cm(2). The Equivalent TAR method exhibited better agreement with Monte Carlo simulations for the 2x2 cm(2) field size. The magnitude of the effect on PDD due to the bony heterogeneity for 1x1, 2x2 and 10x10 cm(2) field sizes increases to 10, 5 and 3%, respectively.