Purpose
Patient‐specific IMRT QA measurements are important components of processes designed to identify discrepancies between calculated and delivered radiation doses. Discrepancy tolerance limits ...are neither well defined nor consistently applied across centers. The AAPM TG‐218 report provides a comprehensive review aimed at improving the understanding and consistency of these processes as well as recommendations for methodologies and tolerance limits in patient‐specific IMRT QA.
Methods
The performance of the dose difference/distance‐to‐agreement (DTA) and γ dose distribution comparison metrics are investigated. Measurement methods are reviewed and followed by a discussion of the pros and cons of each. Methodologies for absolute dose verification are discussed and new IMRT QA verification tools are presented. Literature on the expected or achievable agreement between measurements and calculations for different types of planning and delivery systems are reviewed and analyzed. Tests of vendor implementations of the γ verification algorithm employing benchmark cases are presented.
Results
Operational shortcomings that can reduce the γ tool accuracy and subsequent effectiveness for IMRT QA are described. Practical considerations including spatial resolution, normalization, dose threshold, and data interpretation are discussed. Published data on IMRT QA and the clinical experience of the group members are used to develop guidelines and recommendations on tolerance and action limits for IMRT QA. Steps to check failed IMRT QA plans are outlined.
Conclusion
Recommendations on delivery methods, data interpretation, dose normalization, the use of γ analysis routines and choice of tolerance limits for IMRT QA are made with focus on detecting differences between calculated and measured doses via the use of robust analysis methods and an in‐depth understanding of IMRT verification metrics. The recommendations are intended to improve the IMRT QA process and establish consistent, and comparable IMRT QA criteria among institutions.
In the past few years, radiotherapy (RT) has experienced a major technological innovation with the development of hybrid machines combining magnetic resonance (MR) imaging and linear accelerators. ...This new technology for MR-guided cancer treatment has the potential to revolutionize the field of adaptive RT due to the opportunity to provide high-resolution, real-time MR imaging before and during treatment application. However, from a technical point of view, several challenges remain which need to be tackled to ensure safe and robust real-time adaptive MR-guided RT delivery. In this manuscript, several technical challenges to MR-guided RT are discussed. Starting with magnetic field strength tradeoffs, the potential and limitations for purely MR-based RT workflows are discussed. Furthermore, the current status of real-time 3D MR imaging and its potential for real-time RT are summarized. Finally, the potential of quantitative MR imaging for future biological RT adaptation is highlighted.
To incorporate a quality control tool, according to previous planning experience and patient-specific anatomic information, into the intensity-modulated radiotherapy (IMRT) plan generation process ...and to determine whether the tool improved treatment plan quality.
A retrospective study of 42 IMRT plans demonstrated a correlation between the fraction of organs at risk (OARs) overlapping the planning target volume and the mean dose. This yielded a model, predicted dose = prescription dose (0.2 + 0.8 1 - exp(-3 overlapping planning target volume/volume of OAR)), that predicted the achievable mean doses according to the planning target volume overlap/volume of OAR and the prescription dose. The model was incorporated into the planning process by way of a user-executable script that reported the predicted dose for any OAR. The script was introduced to clinicians engaged in IMRT planning and deployed thereafter. The script's effect was evaluated by tracking δ = (mean dose-predicted dose)/predicted dose, the fraction by which the mean dose exceeded the model.
All OARs under investigation (rectum and bladder in prostate cancer; parotid glands, esophagus, and larynx in head-and-neck cancer) exhibited both smaller δ and reduced variability after script implementation. These effects were substantial for the parotid glands, for which the previous δ = 0.28 ± 0.24 was reduced to δ = 0.13 ± 0.10. The clinical relevance was most evident in the subset of cases in which the parotid glands were potentially salvageable (predicted dose <30 Gy). Before script implementation, an average of 30.1 Gy was delivered to the salvageable cases, with an average predicted dose of 20.3 Gy. After implementation, an average of 18.7 Gy was delivered to salvageable cases, with an average predicted dose of 17.2 Gy. In the prostate cases, the rectum model excess was reduced from δ = 0.28 ± 0.20 to δ = 0.07 ± 0.15. On surveying dosimetrists at the end of the study, most reported that the script both improved their IMRT planning (8 of 10) and increased their efficiency (6 of 10).
This tool proved successful in increasing normal tissue sparing and reducing interclinician variability, providing effective quality control of the IMRT plan development process.
Atomically thin two-dimensional semiconductors such as MoS2 hold great promise for electrical, optical and mechanical devices and display novel physical phenomena. However, the electron mobility of ...mono- and few-layer MoS2 has so far been substantially below theoretically predicted limits, which has hampered efforts to observe its intrinsic quantum transport behaviours. Potential sources of disorder and scattering include defects such as sulphur vacancies in the MoS2 itself as well as extrinsic sources such as charged impurities and remote optical phonons from oxide dielectrics. To reduce extrinsic scattering, we have developed here a van der Waals heterostructure device platform where MoS2 layers are fully encapsulated within hexagonal boron nitride and electrically contacted in a multi-terminal geometry using gate-tunable graphene electrodes. Magneto-transport measurements show dramatic improvements in performance, including a record-high Hall mobility reaching 34,000 cm(2) V(-1) s(-1) for six-layer MoS2 at low temperature, confirming that low-temperature performance in previous studies was limited by extrinsic interfacial impurities rather than bulk defects in the MoS2. We also observed Shubnikov-de Haas oscillations in high-mobility monolayer and few-layer MoS2. Modelling of potential scattering sources and quantum lifetime analysis indicate that a combination of short-range and long-range interfacial scattering limits the low-temperature mobility of MoS2.
In vertebrates, including humans, individuals harbor gut microbial communities whose species composition and relative proportions of dominant microbial groups are tremendously varied. Although ...external and stochastic factors clearly contribute to the individuality of the microbiota, the fundamental principles dictating how environmental factors and host genetic factors combine to shape this complex ecosystem are largely unknown and require systematic study. Here we examined factors that affect microbiota composition in a large (n = 645) mouse advanced intercross line originating from a cross between C57BL/6J and an ICR-derived outbred line (HR). Quantitative pyrosequencing of the microbiota defined a core measurable microbiota (CMM) of 64 conserved taxonomic groups that varied quantitatively across most animals in the population. Although some of this variation can be explained by litter and cohort effects, individual host genotype had a measurable contribution. Testing of the CMM abundances for cosegregation with 530 fully informative SNP markers identified 18 host quantitative trait loci (QTL) that show significant or suggestive genomewide linkage with relative abundances of specific microbial taxa. These QTL affect microbiota composition in three ways; some loci control individual microbial species, some control groups of related taxa, and some have putative pleiotropic effects on groups of distantly related organisms. These data provide clear evidence for the importance of host genetic control in shaping individual microbiome diversity in mammals, a key step toward understanding the factors that govern the assemblages of gut microbiota associated with complex diseases.
Purpose
The improved soft tissue contrast of magnetic resonance imaging (MRI) compared to computed tomography (CT) makes it a useful imaging modality for radiotherapy treatment planning. Even when MR ...images are acquired for treatment planning, the standard clinical practice currently also requires a CT for dose calculation and x‐ray–based patient positioning. This increases workloads, introduces uncertainty due to the required inter‐modality image registrations, and involves unnecessary irradiation. While it would be beneficial to use exclusively MR images, a method needs to be employed to estimate a synthetic CT (sCT) for generating electron density maps and patient positioning reference images. We investigated 2D and 3D convolutional neural networks (CNNs) to generate a male pelvic sCT using a T1‐weighted MR image and compare their performance.
Methods
A retrospective study was performed using CTs and T1‐weighted MR images of 20 prostate cancer patients. CTs were deformably registered to MR images to create CT‐MR pairs for training networks. The proposed 2D CNN, which contained 27 convolutional layers, was modified from the state‐of‐the‐art 2D CNN to save computational memory and prepare for building the 3D CNN. The proposed 2D and 3D models were trained from scratch to map intensities of T1‐weighted MR images to CT Hounsfield Unit (HU) values. Each sCT was generated in a fivefold cross‐validation framework and compared with the corresponding deformed CT (dCT) using voxel‐wise mean absolute error (MAE). The sCT geometric accuracy was evaluated by comparing bone regions, defined by thresholding at 150 HU in the dCTs and the sCTs, using dice similarity coefficient (DSC), recall, and precision. To evaluate sCT patient positioning accuracy, bone regions in dCTs and sCTs were rigidly registered to the corresponding cone‐beam CTs. The resulting paired Euler transformation vectors were compared by calculating translation vector distances and absolute differences of Euler angles. Statistical tests were performed to evaluate the differences among the proposed models and Han’s model.
Results
Generating a pelvic sCT required approximately 5.5 s using the proposed models. The average MAEs within the body contour were 40.5 ± 5.4 HU (mean ± SD) and 37.6 ± 5.1 HU for the 2D and 3D CNNs, respectively. The average DSC, recall, and precision for the bone region (thresholding the CT at 150 HU) were 0.81 ± 0.04, 0.85 ± 0.04, and 0.77 ± 0.09 for the 2D CNN, and 0.82 ± 0.04, 0.84 ± 0.04, and 0.80 ± 0.08 for the 3D CNN, respectively. For both models, mean translation vector distances are less than 0.6 mm with mean absolute differences of Euler angles less than 0.5°.
Conclusions
The 2D and 3D CNNs generated accurate pelvic sCTs for the 20 patients using T1‐weighted MR images. Statistical tests indicated that the proposed 3D model was able to generate sCTs with smaller MAE and higher bone region precision compared to 2D models. Results of patient alignment tests suggested that sCTs generated by the proposed CNNs can provide accurate patient positioning. The accuracy of the dose calculation using generated sCTs will be tested and compared for the proposed models in the future.
Dosimetry tools and techniques for IMRT Low, Daniel A.; Moran, Jean M.; Dempsey, James F. ...
Medical physics (Lancaster),
March 2011, Letnik:
38, Številka:
3
Journal Article
Recenzirano
Odprti dostop
Intensity modulated radiation therapy (IMRT) poses a number of challenges for properly measuring commissioning data and quality assurance (QA) radiation dose distributions. This report provides a ...comprehensive overview of how dosimeters, phantoms, and dose distribution analysis techniques should be used to support the commissioning and quality assurance requirements of an IMRT program. The proper applications of each dosimeter are described along with the limitations of each system. Point detectors, arrays, film, and electronic portal imagers are discussed with respect to their proper use, along with potential applications of 3D dosimetry. Regardless of the IMRT technique utilized, some situations require the use of multiple detectors for the acquisition of accurate commissioning data. The overall goal of this task group report is to provide a document that aids the physicist in the proper selection and use of the dosimetry tools available for IMRT QA and to provide a resource for physicists that describes dosimetry measurement techniques for purposes of IMRT commissioning and measurement-based characterization or verification of IMRT treatment plans. This report is not intended to provide a comprehensive review of commissioning and QA procedures for IMRT. Instead, this report focuses on the aspects of metrology, particularly the practical aspects of measurements that are unique to IMRT. The metrology of IMRT concerns the application of measurement instruments and their suitability, calibration, and quality control of measurements. Each of the dosimetry measurement tools has limitations that need to be considered when incorporating them into a commissioning process or a comprehensive QA program. For example, routine quality assurance procedures require the use of robust field dosimetry systems. These often exhibit limitations with respect to spatial resolution or energy response and need to themselves be commissioned against more established dosimeters. A chain of dosimeters, from secondary standards to field instruments, is established to assure the quantitative nature of the tests. This report is intended to describe the characteristics of the components of these systems; dosimeters, phantoms, and dose evaluation algorithms. This work is the report of AAPM Task Group 120.
To investigate the dosimetric improvements in stereotactic body radiation therapy for patients with larger or central lung tumors using a highly noncoplanar 4π planning system.
This study involved 12 ...patients with centrally located or larger lung tumors previously treated with 7- to 9-field static beam intensity modulated radiation therapy to 50 Gy. They were replanned using volumetric modulated arc therapy and 4π plans, in which a column generation method was used to optimize the beam orientation and the fluence map. Maximum doses to the heart, esophagus, trachea/bronchus, and spinal cord, as well as the 50% isodose volume, the lung volumes receiving 20, 10, and 5 Gy were minimized and compared against the clinical plans. A dose escalation study was performed to determine whether a higher prescription dose to the tumor would be achievable using 4π without violating dose limits set by the clinical plans. The deliverability of 4π plans was preliminarily tested.
Using 4π plans, the maximum heart, esophagus, trachea, bronchus and spinal cord doses were reduced by 32%, 72%, 37%, 44%, and 53% (P≤.001), respectively, and R50 was reduced by more than 50%. Lung V20, V10, and V5 were reduced by 64%, 53%, and 32% (P≤.001), respectively. The improved sparing of organs at risk was achieved while also improving planning target volume (PTV) coverage. The minimal PTV doses were increased by the 4π plans by 12% (P=.002). Consequently, escalated PTV doses of 68 to 70 Gy were achieved in all patients.
We have shown that there is a large potential for plan quality improvement and dose escalation for patients with larger or centrally located lung tumors using noncoplanar beams with sufficient quality and quantity. Compared against the clinical volumetric modulated arc therapy and static intensity modulated radiation therapy plans, the 4π plans yielded significantly and consistently improved tumor coverage and critical organ sparing. Given the known challenges in central structure dose constraints in stereotactic body radiation therapy to the lung, 4π planning may increase efficacy and reduce toxicity.
In men with a detectable prostate-specific antigen (PSA) level after prostatectomy for prostate cancer, salvage prostate bed radiotherapy (PBRT) results in about 70% of patients being free of ...progression at 5 years. A three-group randomised trial was designed to determine whether incremental gains in patient outcomes can be achieved by adding either 4–6 months of short-term androgen deprivation therapy (ADT) to PBRT, or both short-term ADT and pelvic lymph node radiotherapy (PLNRT) to PBRT.
The international, multicentre, randomised, controlled SPPORT trial was done at 283 radiation oncology cancer treatment centres in the USA, Canada, and Israel. Eligible patients (aged ≥18 years) were those who after prostatectomy for adenocarcinoma of the prostate had a persistently detectable or an initially undetectable and rising PSA of between 0·1 and 2·0 ng/mL. Patients with and without lymphadenectomy (N0/Nx) were eligible if there was no clinical or pathological evidence of lymph node involvement. Other eligibility criteria included pT2 or pT3 disease, prostatectomy Gleason score of 9 or less, and a Zubrod performance status of 0–1. Eligible patients were randomly assigned to receive PBRT alone at a dose of 64·8–70·2 Gy at 1·8 Gy per fraction daily (group 1), PBRT plus short-term ADT (group 2), or PLNRT (45 Gy at 1·8 Gy per fraction, and then a volume reduction made to the planning target volume for the remaining 19·8–25 ·2 Gy) plus PBRT plus short-term ADT (group 3). The primary endpoint was freedom from progression, in which progression was defined as biochemical failure according to the Phoenix definition (PSA ≥2 ng/mL over the nadir PSA), clinical failure (local, regional, or distant), or death from any cause. A planned interim analysis of 1191 patents with minimum potential follow-up time of 5 years applied a Haybittle-Peto boundary of p<0·001 (one sided) for comparison of 5-year freedom from progression rates between the treatment groups. This trial is registered with ClinicalTrials.gov, NCT00567580. The primary objectives of the trial have been completed, although long-term follow-up is continuing.
Between March 31, 2008, and March 30, 2015, 1792 eligible patients were enrolled and randomly assigned to the three treatment groups (592 to group 1 PBRT alone, 602 to group 2 PBRT plus short-term ADT, and 598 to group 3 PLNRT plus PBRT plus short-term ADT). 76 patients subsequently found to be ineligible were excluded from the analyses; thus, the evaluable patient population comprised 1716 patients. At the interim analysis (n=1191 patients; data cutoff May 23, 2018), the Haybittle-Peto boundary for 5-year freedom from progression was exceeded when group 1 was compared with group 3 (difference 17·9%, SE 2·9%; p<0·0001). The difference between groups 2 and 3 did not exceed the boundary (p=0·0063). With additional follow-up beyond the interim analysis (the final planned analysis; data cutoff May 26, 2021), at a median follow-up among survivors of 8·2 years (IQR 6·6–9·4), the 5-year freedom from progression rates in all 1716 eligible patients were 70·9% (95% CI 67·0–74·9) in group 1, 81·3% (78·0–84·6) in group 2, and 87·4% (84·7–90·2) in group 3. Per protocol criteria, freedom from progression in group 3 was superior to groups 1 and 2. Acute (≤3 months after radiotherapy) grade 2 or worse adverse events were significantly more common in group 3 (246 44% of 563 patients) than in group 2 (201 36% of 563; p=0·0034), which, in turn, were more common than in group 1 (98 18% of 547; p<0·0001). Similar findings were observed for grade 3 or worse adverse events. However, late toxicity (>3 months after radiotherapy) did not differ significantly between the groups, apart from more late grade 2 or worse blood or bone marrow events in group 3 versus group 2 (one-sided p=0·0060) attributable to the addition of PLNRT in this group.
The results of this randomised trial establish the benefit of adding short-term ADT to PBRT to prevent progression in prostate cancer. To our knowledge, these are the first such findings to show that extending salvage radiotherapy to treat the pelvic lymph nodes when combined with short-term ADT results in meaningful reductions in progression after prostatectomy in patients with prostate cancer.
National Cancer Institute.
The γ tool was developed to quantitatively compare dose distributions, either measured or calculated. Before computing γ, the dose and distance scales of the two distributions, referred to as ...evaluated and reference, are renormalized by dose and distance criteria, respectively. The renormalization allows the dose distribution comparison to be conducted simultaneously along dose and distance axes. The γ quantity, calculated independently for each reference point, is the minimum distance in the renormalized multidimensional space between the evaluated distribution and the reference point. The γ quantity degenerates to the dose-difference and distance-to-agreement tests in shallow and very steep dose gradient regions, respectively. Since being introduced, the γ quantity has been used by investigators to evaluate dose calculation algorithms, and compare dosimetry measurements. This manuscript examines the γ distribution behavior in two dimensions and evaluates the γ distribution in the presence of data noise. Noise in the evaluated distribution causes the γ distribution to be underestimated relative to the no-noise condition. Noise in the reference distribution adds noise in the γ distribution in proportion to the normalized dose noise. In typical clinical use, the fraction of points that exceed 3% and 3 mm can be extensive, so we typically use 5% and 2–3 mm in clinical evaluations. For clinical cases, the calculation time is typically 5 minutes for a
1×1
mm
2
interpolated resolution on an 800 MHz Pentium 4 for a
14.1×15.2
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radiographic film.
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