Knowledge-based model building for treatment planning for prostate cancer using commercial treatment planning quality assurance software tools


Comparative analysis of two dose-volume histogram prediction tools for treatment planning in volumetric-modulated arc therapy: A multi-planner study


Investigation of uncertainty in internal target volume definition for lung stereotactic body radiotherapy

This study evaluated the validity of internal target volumes (ITVs) defined by three- (3DCT) and four-dimensional computed tomography (4DCT), and subsequently compared them with actual movements during treatment. Five patients with upper lobe lung tumors were treated with stereotactic body radiotherapy (SBRT) at 48 Gy in four fractions. Planning 3DCT images were acquired with peak-exhale and peak-inhale breath-holds, and 4DCT images were acquired in the cine mode under free breathing. Cine images were acquired using an electronic portal imaging device during irradiation. Tumor coverage was evaluated based on the manner in which the peak-to-peak breathing amplitude on the planning CT covered the range of tumor motion (± 3 SD) during irradiation in the left-right, anteroposterior, and cranio-caudal (CC) directions. The mean tumor coverage of the 4DCT-based ITV was better than that of the 3DCT-based ITV in the CC direction. The internal margin should be considered when setting the irradiation field for 4DCT. The proposed 4DCT-based ITV can be used as an efficient approach in free-breathing SBRT for upper-lobe tumors of the lung because its coverage is superior to that of 3DCT.


Differences between professionals in planning treatment for patients with stage III lung cancer using treatment-planning QA software

Reports of Practical Oncology and Radiotherapy


Influence of Pitch on Surface Dose Distribution and Image Noise of Computed Tomography Scans

This study evaluated the effect of pitch on 256-slice helical computed tomography (CT) scans. Cylindrical water phantoms (CWP) were measured using axial and helical scans with various pitch values. The surface dose distributions of CWP were measured, and reconstructed images were obtained using filtered back-projection (FBP) and iterative model reconstruction (IMR). The image noise in each reconstructed image was decomposed into a baseline component and another component that varied along the z-axis. The baseline component of the image noise was highest at the center of the reconstructed image and decreased toward the edges. The normalized 2D power spectra for each pitch were almost identically distributed. Furthermore, the ratios of the 2D power spectra for IMR and FBP at different pitch values were obtained. The magnitudes of the components varying along the z-axis were smallest at the center of the reconstructed image and increased toward the edge. The ratios of the 3D power spectra on the fx axis for IMR and FBP at different pitch values were obtained. The results showed that the effect of the pitch was related to the component that varied along the z-axis. Furthermore, the pitch had a smaller effect on IMR than on FBP.


Predicting the complexity of head-and-neck volumetric-modulated arc therapy planning using a radiation therapy planning quality assurance software

The more complex the treatment plan, the higher the possibility of errors in dose verification. Recently, a treatment planning quality assurance (QA) software (PlanIQ) with a function to objectively evaluate the quality of volumetric-modulated arc therapy (VMAT) treatment plans by scoring and calculating the ideal dose-volume histogram has been marketed. This study aimed to assess the association between the scores of ideal treatment plans identified using PlanIQ and the results of dose verification and to investigate whether the results of dose verification can be predicted based on the complexity of treatment plans. Dose verification was performed using an ionization chamber dosimeter, a radiochromic film, and a three-dimensional dose verification system, Delta4 PT. Correlations between the ideal treatment plan scores obtained by PlanIQ and the results of the absolute dose verification and dose distribution verification were obtained, and it was examined whether dose verifications could be predicted from the complexity of the treatment plans. Even when the score from the ideal treatment plan was high, the results of absolute dose verification and dose distribution verification were sometimes poor. However, even when the score from the ideal treatment plan was low, the absolute volume verification and dose distribution verification sometimes yielded good results. Treatment plan complexity can be determined in advance from the ideal treatment plan score calculated by PlanIQ. However, it is difficult to predict the results of dose verification using an ideal treatment plan.


Development of a high-resolution two-dimensional detector-based dose verification system for tumor-tracking irradiation in the CyberKnife system

We aim to evaluate the basic characteristics of SRS MapCHECK (SRSMC) for CyberKnife (CK) and establish a dose verification system using SRSMC for the tumor-tracking irradiation for CK. The field size and angular dependence of SRSMC were evaluated for basic characterization. The output factors (OPFs) and absolute doses measured by SRSMC were compared with those measured using microDiamond and microchamber detectors and those calculated by the treatment planning system (TPS). The angular dependence was evaluated by comparing the SRSMC with a microchamber. The tumor-tracking dose verification system consists of SRSMC and a moving platform. The doses measured using SRSMC were compared with the doses measured using a microchamber and radiochromic film. The OPFs and absolute doses of SRSMC were within ±3.0% error for almost all field sizes, and the angular dependence was within ±2.0% for all incidence angles. The absolute dose errors between SRSMC and TPS tended to increase when the field size was smaller than 10 mm. The absolute doses of the tumor-tracking irradiation measured using SRSMC and those measured using a microchamber agreed within 1.0%, and the gamma pass rates of SRSMC in comparison with those of the radiochromic film were greater than 95%. The basic characteristics of SRSMC for CK presented acceptable results for clinical use. The results of the tumor-tracking dose verification system realized using SRSMC were equivalent to those of conventional methods, and this system is expected to contribute toward improving the efficiency of quality control in many facilities.

Journal of Applied Clinical Medical Physics


Development of a B1 correction method without additional scanning VFA T1 map.


Development of self-calibrating B1 correction for three-dimensional variable flip angle T1 mapping


Radiomics analysis of [18F]-fluoro-2-deoxyglucose positron emission tomography for the prediction of cervical lymph node metastasis in tongue squamous cell carcinoma

This study aimed to create a predictive model for cervical lymph node metastasis (CLNM) in patients with tongue squamous cell carcinoma (SCC) based on radiomics features detected by [F]-fluoro-2-deoxyglucose (F-FDG) positron emission tomography (PET). A total of 40 patients with tongue SCC who underwent F-FDG PET imaging during their first medical examination were enrolled. During the follow-up period (mean 28 months), 20 patients had CLNM, including six with late CLNM, whereas the remaining 20 patients did not have CLNM. Radiomics features were extracted from F-FDG PET images of all patients irrespective of metal artifact, and clinicopathological factors were obtained from the medical records. Late CLNM was defined as the CLNM that occurred after major treatment. The least absolute shrinkage and selection operator (LASSO) model was used for radiomics feature selection and sequential data fitting. The receiver operating characteristic curve analysis was used to assess the predictive performance of the F-FDG PET-based model and clinicopathological factors model (CFM) for CLNM. Six radiomics features were selected from LASSO analysis. The average values of the area under the curve (AUC), accuracy, sensitivity, and specificity of radiomics analysis for predicting CLNM from F-FDG PET images were 0.79, 0.68, 0.65, and 0.70, respectively. In contrast, those of the CFM were 0.54, 0.60, 0.60, and 0.60, respectively. The F-FDG PET-based model showed significantly higher AUC than that of the CFM. The F-FDG PET-based model has better potential for diagnosing CLNM and predicting late CLNM in patients with tongue SCC than the CFM.


Differences in image density adjustment parameters on the image matching accuracy of a floor-mounted kV X-ray image-guided radiation therapy system

This study aimed to investigate the effect of two different image density adjustment parameters on the results of image matching at six degrees of freedom using radiographic images generated by the ExacTrac X-ray system in brain stereotactic radiosurgery (SRS). This study comprised 32 patients who underwent brain SRS at our hospital from January 2020 to December 2020. In this study, (1) the default parameter (an image density parameter between "tissue" and "bone") was an image density parameter for digitally reconstructed radiograph (DRR) generation used at many facilities, and (2) the bone parameter was the steepest contrast parameter used at our hospital. Of the 32 patients, 24 (75%) had a couch angle of 0.5 mm or more in the translational direction or 0.5° or more in the rotational direction, and 10 (31%) had a couch angle of 1.0 mm or more in the translational direction or 1.0° or more in the rotational direction. Among the 131 cases of all couch angles, 46 (35%) cases had a translational direction of 0.5 mm or more or a rotational direction of 0.5° or more, and 15 (11%) had a translational direction of 1.0 mm or more or a rotational direction of 1.0° or more. The results of this study indicate the usefulness of using appropriate DRR parameters for each case, rather than using the default settings. The use of appropriate DRR parameters can lead to accurate position matching results, leading to fewer image-guided radiation therapy shots and a lower imaging dose.


Estimation of imaging intervals and intra-fraction displacement in CyberKnife image-guided radiotherapy for intracranial lesions


Influence of distant scatterer on air kerma measurement in the evaluation of diagnostic X-rays using Monte Carlo simulation

The evaluation of the entrance surface dose (ESD) ensures safe radiation doses for X-ray imaging patients. The air kerma free-in-air value used to estimate ESD may be affected by those X-rays that scatter from the scatterer placed behind the chamber at the time of measurement, thereby leading to assessment errors. Therefore, the influence of scattered radiation on air kerma measurements was investigated. Monte Carlo simulations were performed for various detector-to-scatterer distances and scatterer materials. The simulation results were compared with actual measurements to confirm the simulation accuracy. The source-chamber distance was set to 50 and 100 cm for the experimental measurements and simulation, respectively, and the chamber-scatterer distance was varied. The Monte Carlo simulation results reproduced the actual measurements with an accuracy of 3.5%. The effect of backscattering varied with the tube voltage and irradiation field size. The effect was observed in the order of prominence for the following scatterer materials: water-equivalent phantom, acrylic, concrete, lead, and iron. Furthermore, this effect decreased exponentially with increasing chamber-scatterer distance. For a field size of 10 × 10 cm, the finite-distance backscatter factor decreased with an increasing chamber-scatterer distance for all materials. The cause of backscattering in diagnostic X-ray energy regions differs depending on the scatterer material, as well as the photon energy and field size. Backscattering decreases exponentially as the distance between the detector and scatterer increases.


Impact of treatment planning quality assurance software on volumetric-modulated arc therapy plans for prostate cancer patients

Software that evaluates the quality of treatment plans (PlanIQ) has become commercially available in recent years. It includes a feasibility assessment tool that provides the ideal dose volume histogram (DVH) for each organ at risk, based on the ideal dose falloff from the prescribed dose at the target boundary. It is important to investigate whether the PlanIQ assessment tool (Feasibility DVH) can assist treatment planners who have limited to no experience in treatment planning. Therefore, the present study aimed to evaluate this tool's usefulness for improving the quality of treatment plans. This study included 5 patients with prostate cancer. The treatment planners were 2 graduate students, 2 undergraduate students, and one clinical planner. All students were radiological technology and medical physics students with no clinical experience. Two different volumetric-modulated arc therapy (VMAT) plans were developed before and after Feasibility DVH. The quality of each treatment plan was evaluated based on a scoring system implemented in PlanIQ. Of 5 patients included, 4 received improved treatment plans when Feasibility DVH was used. Moreover, 4 of 5 treatment planners showed improvement in treatment planning using Feasibility DVH. The findings suggest that using the Feasibility DVH tool may improve treatment plans for different planners and patients. However, planners at any level of experience should be trained to check the dose distribution in addition to checking the DVH, which depends on the adequacy of the contours.


Automatic Contour Segmentation of Cervical Cancer using Artificial Intelligence

In cervical cancer treatment, radiation therapy is selected based on the degree of tumor progression, and radiation oncologists are required to delineate tumor contours. To reduce the burden on radiation oncologists, an automatic segmentation of the tumor contours would prove useful. To the best of our knowledge, automatic tumor contour segmentation has rarely been applied to cervical cancer treatment. In this study, diffusion-weighted images (DWI) of 98 patients with cervical cancer were acquired. We trained an automatic tumor contour segmentation model using 2D U-Net and 3D U-Net to investigate the possibility of applying such a model to clinical practice. A total of 98 cases were employed for the training, and they were then predicted by swapping the training and test images. To predict tumor contours, six prediction images were obtained after six training sessions for one case. The six images were then summed and binarized to output a final image through automatic contour segmentation. For the evaluation, the Dice similarity coefficient (DSC) and Hausdorff distance (HD) was applied to analyze the difference between tumor contour delineation by radiation oncologists and the output image. The DSC ranged from 0.13 to 0.93 (median 0.83, mean 0.77). The cases with DSC <0.65 included tumors with a maximum diameter < 40 mm and heterogeneous intracavitary concentration due to necrosis. The HD ranged from 2.7 to 9.6 mm (median 4.7 mm). Thus, the study confirmed that the tumor contours of cervical cancer can be automatically segmented with high accuracy.


Usability of detecting delivery errors during treatment of prostate VMAT with a gantry-mounted transmission detector

Volumetric-modulated arc therapy (VMAT) requires highly accurate control of multileaf collimator (MLC) movement, rotation speed of linear accelerator gantry, and monitor units during irradiation. Pretreatment validation and monitoring of these factors during irradiation are necessary for appropriate VMAT treatment. Recently, a gantry mounted transmission detector "Delta Discover® (D4D)" was developed to detect errors in delivering doses and dose distribution immediately after treatment. In this study, the performance of D4D was evaluated. Simulation plans, in which the MLC position was displaced by 0.5, 1.0, 1.5, 2.0, 2.5, and 3.0 mm from the clinically used original plans, were created for ten patients who received VMAT treatment for prostate cancer. Dose deviation (DD), distance-to-agreement (DTA), and gamma index analysis (GA) for each plan were evaluated by D4D. These results were compared to the results (DD, DTA and GA) measured by Delta Phantom + (D4P). We compared the deviations between the planned and measured values of the MLC stop positions A-side and B-side in five clinical cases of prostate VMAT during treatment and measured the GA values. For D4D, when the acceptable errors for DD, DTA, and GA were determined to be ≤3%, ≤2 mm, and ≤3%/2 mm, respectively, the minimum detectable errors in the MLC position were 2.0, 1.5, and 1.5 mm based on DD, DTA, and GA respectively. The corresponding minimum detectable MLC position errors were 2.0, 1.0, and 1.5 mm, respectively, for D4P. The deviation between the planned and measured position of MLC stopping point of prostate VMAT during treatment was stable at an average of -0.09 ± 0.05 mm, and all GA values were above 99.86%. In terms of delivering doses and dose distribution of VMAT, error detectability of D4D was comparable to that of D4P. The transmission-type detector "D4D" is thus suitable for detecting delivery errors during irradiation.


Estimation of X-ray Energy Spectrum of Cone-Beam Computed Tomography Scanner Using Percentage Depth Dose Measurements and Machine Learning Approach

Journal of the Physical Society of Japan


Dosimetric impacts of beam-hardening filter removal for the CyberKnife system

Equipment refurbishment was performed to remove the beam-hardening filter (BHF) from the CyberKnife system (CK). This study aimed to confirm the change in the beam characteristics between the conventional CK (present-BHF CK) and CK after the BHF was removed (absent-BHF CK) and evaluate the impact of BHF removal on the beam quality correction factors k. The experimental measurements of the beam characteristics of the present- and absent-BHF CKs were compared. The CKs were modeled using Monte Carlo simulations (MCs). The energy fluence spectra were calculated using MCs. Finally, k were estimated by combining the MC results and analytic calculations based on the TRS-398 and TRS-483 approaches. All gamma values for percent depth doses and beam profiles between each CK were less than 0.5 following the 3%/1 mm criteria. The percentage differences for tissue-phantom ratios at depths of 20 and 10 cm and percentage depth doses at 10 cm between each CK were -1.20% and -0.97%, respectively. The MC results demonstrated that the photon energy fluence spectrum of the absent-BHF CK was softer than that of the present-BHF CK. The k values for the absent-BHF CK were in agreement within 0.02% with those for the present-BHF CK. The photon energy fluence spectrum was softened by the removal of BHF. However, no remarkable impact was observed for the measured beam characteristics and k. Therefore, the previous findings of the k values for the present-BHF CK can be directly used for the absent-BHF CK.


Analysis of prostate intensity- and volumetric-modulated arc radiation therapy planning quality with PlanIQTM

The purpose of this study was to assess the quality of treatment planning using the PlanIQ software and to investigate whether it is possible to improve the quality of treatment planning using the "Feasibility dose-volume histogram (DVH) " implemented in the PlanIQ software. Using the PlanIQ software, we retrospectively analyzed the learning curve regarding the quality of the treatment plans for 148 patients of prostate intensity-modulated radiation therapy and volumetric-modulated radiation therapy performed at our institution over the past eight years. We also sought to examine the possibility of improving treatment planning quality by re-planning in 47 patients where the quality of the target dose and the dose limits for organs at risk (OARs) were inadequate. The re-planning treatment plans referred to the Feasibility DVH implemented in the PlanIQ software and modified the treatment planning system based on the target dose and OAR constraints. Analysis of the learning curve of the treatment plans quality using PlanIQ software retrospectively showed a trend of improvement in the treatment plan quality from year to year. The improvement in the treatment plans quality was more influenced by dose reduction in the OARs than by target coverage. In all cases where re-planning was performed, the improvement in the treatment plan's quality resulted in a better treatment plan than the one adopted for delivery to patients in the clinical plan. The PlanIQ provided insights into the quality of the treatment plans at our institution and identified problems and areas for improvement in the treatment plans, allowing for the development of appropriate treatment plans for specific patients.

Journal of Applied Clinical Medical Physics


Effect of dental metal artifact conversion volume on dose distribution in head-and-neck volumetric-modulated arc therapy

Purpose: During treatment planning for head-and-neck volumetric-modulated arc therapy (VMAT), manual contouring of the metal artifact area of artificial teeth is done, and the area is replaced with water computed tomography (CT) values for dose calculation. This contouring of the metal artifact areas, which is performed manually, is subject to human variability. The purpose of this study is to evaluate and analyze the effect of inter-observer variation on dose distribution.Methods: The subjects were 25 cases of cancer of the oropharynx for which VMAT was performed. Six radiation oncologists (ROs) performed metal artifact contouring for all of the cases. Gross tumor volume, clinical target volume, planning target volume (PTV), and oral cavity were evaluated. The contouring of the six ROs was divided into two groups, small and large groups. A reference RO was determined for each group and the dose distribution was compared with those of the other radiation oncologists by gamma analysis (GA).As an additional experiment, we changed the contouring of each dental metal artifact area, creating enlarged contours (L), reduced contours (S), and undrawn contours (N) based on the contouring by the six ROs and compared these structure-sets.Results: The evaluation of inter-observer variation showed no significant difference between the large and small groups, and the GA pass rate was 100%. Similar results were obtained comparing structure-sets L and S, but in the comparison of structure-sets L and N, there were cases with pass rates below 70%.Conclusions: The results show that the artificial variability of manual artificial tooth metal artifact contouring has little effect on the dose distribution of VMAT. However, it should be noted that the dose distribution may change depending on the contouring method in cases where the overlap between PTV and metal artifact areas is large.


Determination of reproducibility of end-exhaled breath-holding in stereotactic body radiation therapy


The effect of rectal gas on dose distribution during prostate cancer treatment using full arc and partial arc Volumetric Modulated Arc Therapy (VMAT) treatment plans

In this study, we investigated the effect of rectal gas on the dose distribution of prostate cancer using a volumetric modulated arc therapy (VMAT) treatment planning. The first is the original structure set, clinical target volume (CTV), the rectum, and the bladder used clinically. The second is a structure set (simulated gas structure set) in which the overlapping part of the rectum and PTV is overwritten with Hounsfield Unit -950 as gas. Full arc and limited gantry rotation angle with VMAT were the two arcs. The VMAT of the full arc was 181°-179° in the clockwise (CW) direction and 179°-181° in the counterclockwise (CCW) direction. Three partial arcs with a limited gantry rotation angle were created: 200°-160 °CW and 160°-200 °CCW; 220°-140 °CW and 140°-220 °CCW; and finally, 240°-120 °CW and 120°-240 °CCW. The evaluation items were dose difference, distance to agreement, and gamma analysis. In the CTV, the full arc was the treatment planning technique with the least effect of rectal gas. In the rectum, when the gantry rotation angle range was short, the pass rate tended to reduce for all evaluation indices. The bladder showed no characteristic change between the treatment planning techniques in any of the evaluation indices. The VMAT treatment planning with the least effect on dose distribution caused by rectal gas was shown to be a full arc.

Reports of Practical Oncology and Radiotherapy


Impact of Changes in Body Contours on Radiation Therapy Dose Distribution After Uterine Cervical Cancer Surgery

Patients receiving postoperative irradiation for uterine cervical cancer might not be able to eat during radiation therapy because of the effects of concurrent chemo-radiotherapy; this may lead to changes in the patient's body shape during treatment. When performing image-guided radiotherapy, it is necessary to determine immediately whether treatment can be performed on the day or whether re-planning is required. The purpose of this study was to determine indicators for re-planning by examining the effects of changing body contours on radiation therapy dose. The original body contour was reduced by 1 cm in the front portion (structure-set 1). Based on the original dose distribution, the dose recalculation was performed with a structure set created using the body contour of structure-set 1. The difference between the original and recalculated dose distributions of structure-set 1 was evaluated through gamma analysis (GA). In the GA results for dose distribution obtained via recalculation with structure-set 1, a pass rate of 90% or more was obtained for a criterion of 2 mm/2% in all cases. The results suggest that dose re-planning is rarely required when the body shape is reduced by only 1 cm in the front.


Simplification of Head and Neck Volumetric Modulated Arc Therapy Patient-specific Quality Assurance, Using a Delta4 PT

In many facilities, intensity-modulated radiation therapy (IMRT), and volumetric modulated arc therapy (VMAT) use intensity-modulated beams, formed by a multi-leaf collimator (MLC). In IMRT and VMAT, MLC and linear accelerator errors (both geometric and dose), can significantly affect the doses administered to patients. Therefore, IMRT and VMAT treatment plans must include the use of patient-specific quality assurance (QA) before treatment to confirm dose accuracy. In this study, we compared and analyzed the results of dose verification using a multi-dimensional dose verification system Delta4 PT, an ionization chamber dosimeter, and gafchromic film, using data from 52 patients undergoing head and neck VMAT as the test material. Based on the results of the absolute dose verification for the ionization chamber dosimeter and Delta4 PT, taking an axial view, the upper limit of the 95% confidence interval was 3.13%, and the lower limit was -3.67%, indicating good agreement. These results mean that as long as absolute dose verification for the axial view does not deviate from this range, Delta4 PT can be used as an alternative to an ionization chamber dosimeter for absolute dose verification. When we then reviewed dose distribution verification, the pass rate for Delta4 PT was acceptable, and was less varied than that of gafchromic film. This results in that provided the pass rate result for Delta4 PT does not fall below 96%, it can be used as a substitute for gafchromic film in dose distribution verification. These results indicate that patient-specific QA could be simplified.


Long-term stability of a three-dimensional dose verification system.

Recently, the number of patients undergoing intensity-modulated radiation therapy and volumetric modulated arc therapy has increased with the expansion of the adaptation site. However, it is necessary to improve the efficiency of time-consuming dose verification. Therefore, patient-specific quality assurance is expected to shift from dose verification using a conventional ionization chamber dosimeter and film to a three-dimensional dose verification system. However, caution is required when using a three-dimensional dose verification system, especially when it comes to the calibration of the detector. Calibration is performed regularly, but not all necessary verifications are done routinely. There are many uncertainties on how the sensitivity of the three-dimensional dose verification system changes over time. In this study, on the same day, when dose verification using a three-dimensional system for one head and neck case was performed, dose verification using a conventional ionization chamber dosimeter and film was also performed once every two months, for 2 years. From the results of the absolute dose and dose distribution verification using the ionization chamber dosimeter and Gafchromic film, the output of the linear accelerator, mechanical accuracy and precision were secured. From the results of the three-dimensional dose verification system, when the distance to agreement was evaluated at 2 mm and 3 mm, and gamma analysis was performed at 2 mm/2% and 3 mm/3%, the passing rate was almost 100%, and a sensitivity change in 2 years was not observed.


Emission image of X-ray-irradiated CR-39 stick doped with methylviologen-encapsulated silica nanocapsules using LED light

Progress in Nuclear Science and Technology


Clinical outcomes of hypofractionated image-guided multifocal irradiation using volumetric-modulated arc therapy for brain metastases.

Volumetric-modulated arc therapy (VMAT) can be used to design hypofractionated radiotherapy treatment plans for multiple brain metastases. The purpose of this study was to evaluate treatment outcomes of hypofractionated image-guided multifocal irradiation using VMAT (HFIGMI-VMAT) for brain metastases. From July 2012 to December 2016, 67 consecutive patients with 601 brain metastases were treated with HFIGMI-VMAT at our institution. The prescribed dose was 50 Gy to a 95% volume of the planning target volume in 10 fractions. Fifty-five of the 67 patients had non-small-cell lung cancer, and the remaining 12 had other types of cancer. The median number of brain metastases was five, and the median maximum diameter was 1.2 cm. The median duration of follow-up was 12.0 months (range, 1.9-44.8 months), and the median survival time 18.7 months. Four patients with six lesions had local recurrences. The local control rate in the 64 assessed patients was 98.4% and 95.3% at 6 and 12 months, respectively (three died before assessment). The local control rate for the 572 assessed lesions was 99.8% and 99.3% at 6 and 12 months, respectively. Thirty-nine patients developed distant brain metastases, the distant brain control rate being 59.7% and 40.5% at 6 and 12 months, respectively. Acute toxicities were generally mild (Grade 1-2). Three patients (4.5%) developed radiation necrosis requiring corticosteroid therapy. The HFIGMI-VMAT technique with flat dose delivery was well tolerated and achieved excellent local control. This technique is a promising treatment option for patients with multiple and large brain metastases.


Influence of multi-leaf collimator leaf transmission on head and neck intensity-modulated radiation therapy and volumetric-modulated arc therapy planning.

The aim of this study was to quantify the effect of multi-leaf collimators (MLCs) with different leaf widths on the planning of intensity-modulated radiation therapy (IMRT) and volumetric-modulated arc therapy (VMAT). Toward this objective, dose transmission through a high-definition 120-leaf MLC (HD120MLC) and 120-leaf Millennium MLC (M120MLC) was investigated, using it with a test case and clinical case studies. In test case, studies with IMRT and VMAT plans, the difference in MLC leaf width had a limited effect on planning target volumes (PTVs). Organs at risk (OARs) were more affected by a reduction in dose transmission through the MLC than by a reduction in MLC leaf width. The results of the test case studies and clinical case studies were mostly similar. In the latter, the different MLCs had no effect on the PTV regardless of the treatment method; however, the HD120MLC plans achieved dose reductions to OARs similar to or larger than the dose reduction of the M120MLC plans. The similar results of the test case and clinical case studies showed that despite a limitation of the irradiation field size, the HD120MLC plans were superior.


Multi-institutional Validation Study of Commercially Available Deformable Image Registration Software for Thoracic Images.

To assess the accuracy of the commercially available deformable image registration (DIR) software for thoracic images at multiple institutions. Thoracic 4-dimensional (4D) CT images of 10 patients with esophageal or lung cancer were used. Datasets for these patients were provided by DIR-lab (dir-lab.com) and included a coordinate list of anatomic landmarks (300 bronchial bifurcations) that had been manually identified. Deformable image registration was performed between the peak-inhale and -exhale images. Deformable image registration error was determined by calculating the difference at each landmark point between the displacement calculated by DIR software and that calculated by the landmark. Eleven institutions participated in this study: 4 used RayStation (RaySearch Laboratories, Stockholm, Sweden), 5 used MIM Software (Cleveland, OH), and 3 used Velocity (Varian Medical Systems, Palo Alto, CA). The ranges of the average absolute registration errors over all cases were as follows: 0.48 to 1.51 mm (right-left), 0.53 to 2.86 mm (anterior-posterior), 0.85 to 4.46 mm (superior-inferior), and 1.26 to 6.20 mm (3-dimensional). For each DIR software package, the average 3-dimensional registration error (range) was as follows: RayStation, 3.28 mm (1.26-3.91 mm); MIM Software, 3.29 mm (2.17-3.61 mm); and Velocity, 5.01 mm (4.02-6.20 mm). These results demonstrate that there was moderate variation among institutions, although the DIR software was the same. We evaluated the commercially available DIR software using thoracic 4D-CT images from multiple centers. Our results demonstrated that DIR accuracy differed among institutions because it was dependent on both the DIR software and procedure. Our results could be helpful for establishing prospective clinical trials and for the widespread use of DIR software. In addition, for clinical care, we should try to find the optimal DIR procedure using thoracic 4D-CT data.

International Journal of Radiation Oncology*Biology*Physics


Characterization of stochastic noise and post-irradiation density growth for reflective-type radiochromic film in therapeutic photon beam dosimetry.

The aim of this study is to investigate the dosimetric uncertainty of stochastic noise and the post-irradiation density growth for reflective-type radiochromic film to obtain the appropriate dose from the exactly controlled film density. Film pieces were irradiated with 6-MV photon beams ranging from 0 to 400cGy. The pixel values (PVs) of these films were obtained using a flatbed scanner at elapsed times of 1min to 120h between the end of irradiation and the film scan. The means and standard deviations (SDs) of the PVs were calculated. The SDs of the converted dose scale, u, and the dose increases resulting from the PV increases per ±29min at each elapsed time, u, were computed. The combined dose uncertainties from these two factors, u, were then calculated. A sharp increase in the PV occurred within the first 3h after irradiation, and a slight increase continued from 3h to 120h. u was independent of post-irradiation elapsed time. Sharp decreases in u were obtained within 1h after irradiation, and slight decreases in u were observed from 1 to 24h after irradiation. u first decreased 1h after irradiation and remained constant afterward. Assuming that the post-irradiation elapsed times of all of the related measurements are synchronized within ±29min, the elapsed time should be at least 1h in our system. It is important to optimize the scanning protocol for each institution with consideration of the required measurement uncertainty and acceptable latency time.


Dose impact of rectal gas on prostatic IMRT and VMAT

In this study, we compared the dose impact of the heterogeneity caused by rectal gas using two methods of treatment planning for intensity-modulated radiotherapy (IMRT) and volumetric-modulated arc therapy (VMAT). In addition to the structure set used for the standard treatment plan, we created a structure set for evaluation for each patient. These sets were transferred to the same isocenter as the respective treatment plans for IMRT and VMAT that were to become the standard. Values were then recalculated. During the standard prostatic IMRT and VMAT treatment planning, all study participants met dose restrictions in place at our hospital. Dose restrictions were fulfilled in treatment plans for evaluation, excluding those with a clinical target volume (CTV) of V(100%) and planning target volume (PTV) of D95 when the rectum was excluded. However, in treatment plans for evaluation, IMRT was shown to have a higher concordance rate with standard treatment plans than VMAT. If rectal gas is present during either IMRT or VMAT, a dose decrease will occur in relation to CTV and PTV, suggesting that a plan does not eliminate adverse effects on organs at risk.


Radiosensitivity Uncertainty Evaluation for the In Vitro Biophysical Modeling of EMT6 Cells

The aims of this study were to evaluate the cell survival uncertainty distribution of radiation and to assess the accuracy of predictions of tumor response by using three different in vitro experimental cell cultures with radiosensitizers (including etanidazole). Using EMT6 cells and X-rays, the cell survival fraction was obtained from 15, 34, and 21 different experiments under normoxic, hypoxic, and hypoxic-plus-radiosensitizer culture, respectively. The α coefficients were 0.257 ± 0.188, 0.078 ± 0.080, and 0.182 ± 0.116 Gy(-1), respectively. The β coefficients were 0.0159 ± 0.0208, 0.0076 ± 0.0113, and 0.0062 ± 0.0077 Gy(-2), respectively. The α coefficient and the dose that killed half of the clonogens population (D50) were significantly different between normoxic cell and hypoxic cell cultures (p<0.01), respectively. The use of radiosensitizers under hypoxic conditions improved radiosensitivity. Our results suggest that parameter value distributions are required for biophysical modeling of applications for radiotherapy.


Clinical evaluation of automatic contours for head and neck region using deformable image registration software

The purpose of this study was to clinically evaluate the automatic outline extraction properties using general-purpose deformable image registration (DIR) software for the head and neck region. To this end, we evaluated the following: (1) the difference between manual outline extraction carried out by a radiation therapy specialist and automatic outline extraction using the DIR software, and (2) the precision of the automatic outline extraction for the diachronic figure change and change in the organ shape. The manually-extracted outline and that extracted using the DIR software closely resembled each other at 0.70. Further, in the same case, the automatic outline extraction precision of the DIR software was greater at about 0.80. Our findings suggest DIR software to be useful for lessening the work involved in outline extraction.

Japanese Journal of Radiological Technology


A comparison of four commercial radiation treatment planning systems for prostate intensity modulated radiation therapy

At present, every manufacturer of intensity modulated radiation therapy (IMRT) equipment uses multi-leaf collimators (MLCs); however, each company's intensity modulation methods and dose calculation algorithms differ. This study used four typical radiation treatment planning systems (RTPSs) employed domestically for prostate IMRT plans to carry out 15 case studies by one planner based on the dose limits at this clinic. The results were used to compare the differences, if any, in RTPS treatment plans. With prostate IMRT plans, an overlap area exists between the PTV and the rectum. For this reason, while observing dose limits of 60-75 Gy (within the dose tolerated by the rectum), securing uniformity and concentration of dose is essential to create the most appropriate treatment plan for the PTV and other targets. Although each RTPS uses different planning methods, it was generally possible to observe this clinic's dose limits by adjusting the parameter values. When identical beam data is used, it is possible to create similar treatment plans.


Changes of tumor and normal structures of the neck during radiation therapy for head and neck cancer requires adaptive strategy.

The treatment period over which radiation therapy is administered extends over several weeks. Since tumor shrinkage in response to radiation therapy and weight loss due to radiation-induced mucositis may impact on the dose distribution in both target and organ at risk in patients with head and neck cancer, the anatomical changes of tumor and neck volumes during this period should be taken into consideration. We investigated the anatomical changes that occurred in the target and normal structure of the neck during radiation therapy for pharyngeal cancer, and evaluated the necessity of an adaptive strategy. Ten patients with pharyngeal cancer who underwent radical chemoradiation therapy using 3-dimensional conformal radiation therapy RT (66-70 Gy in 33-35 fractions) between April 2009 and September 2010 were enrolled in the study. Patients underwent CT scans every week during their course of treatment. We analyzed the CT data in the radiation treatment planning system and measured changes of tumor, organ at risk, and neck volume. Gross tumor volume (GTV) was rapidly reduced by 28% of the original volume on average in the first 3 weeks. The right and left submandibular glands volume decreased to 70% and 63% of their initial volumes on average, respectively. The volume of the neck in the radiation fields decreased to 89% of its initial volume on average by the sixth week mainly caused by body weight loss due to acute radiation morbidity. Considerable anatomical change in the radiation filed that will affect dose distribution of the target and organ at risk was observed during radiation therapy for head and neck cancer.

The Journal of Medical Investigation : JMI


Comparison of Various Image Guided Radiation Therapy Systems; Image-guided Localization Accuracy and Patient Throughput

Image guided radiation therapy(IGRT)における位置補正精度と患者スループットの装置間比較

In this study, we evaluated various image guided radiation therapy (IGRT) systems regarding accuracy and patient throughput for conventional radiation therapy. We compared between 2D-2D match (the collation by 2 X-rays directions), cone beam computed tomography (CBCT), and ExacTrac X-Ray system using phantom for CLINAC iX and Synergy. All systems were able to correct within almost 1 mm. ExacTrac X-Ray system showed in particular a high accuracy. As for patient throughput, ExacTrac X-Ray system was the fastest system and 2D-2D match for Synergy was the slowest. All systems have enough ability with regard to accuracy and patient throughput on clinical use. ExacTrac X-Ray system showed superiority with accuracy and throughput, but it is important to note that we have to choose the IGRT technique depending on the treatment site, the purpose, and the patient's state.


Impact of multileaf collimator leaf positioning accuracy on intensity modulated radiation therapy.

マルチリーフコリメータの位置精度が強度変調放射線治療に及ぼす影響

In multileaf collimator (MLC)-based intensity modulated radiation therapy (IMRT), the dose is influenced by the uncertainty of MLC driving control. In this study, we examined the influence of MLC driving control accuracy on dose evaluation (gamma analysis) by evaluating 60-day MLC driving control accuracy (stationary positioning accuracy and positioning reproducibility) once a week as well as measuring IMRT dose distribution. The MLC positioning accuracy accompanied variation over time and tended to expand by 0.1 to 0.15 mm in one week and about 1 mm in 60 days. In terms of reproducibility, errors were within 0.2 mm for more than 95%. For prostate IMRT, when MLC stationary positioning accuracy was around 1 mm, no significant difference was observed in the pass rate in gamma analysis. Therefore, the results suggest that regular maintenance by setting a permissible value determined by the MLC positioning accuracy test can be an effective indicator in the future for maintaining the safety of IMRT.


強度変調放射線治療におけるradiographic filmと radiochromic filmの比較評価

Purpose: Radiographic film is generally used for inspection of dose distribution in intensity modulated radiation therapy (IMRT) at many institutions. However, the distribution of filmless systems can be expected to be used increasingly in the future. Therefore, we confirmed the utility of radiochromic film by comparing it with radiographic film that does not need an automatic processor. Result: Difference in does measured by radiographic film and radiochromic film tended to increase in the low does area, but it was limited in a range of 1.5%. Conclusion: When the dose distribution was verified in a highly accurate radiation therapy such as IMRT, the results suggested that radiochromic film can be useful in addition to radiographic film.


Use of a diagnostic positron emission tomography-computed tomography system for planning radiotherapy positioning: distortion of the tabletop.

The aim of this study was to evaluate distortion of the tabletop in a diagnostic positron emission tomography-computed tomography (PET-CT) system to determine its suitability for planning radiotherapy positioning. Distortion of the tabletop was compared among PET-CT, lineac CT, and CT simulator systems. A phantom or angiography catheter was fixed to the tabletop and imaged after iron plate weight loading. The acquired images were analyzed using radiotherapy planning software. Distortion of the tabletop was measured based on the displayed coordinates. Sinking represented the greatest distortion of the tabletop in all systems. Using the same baseline, the maximum sinking were -0.4, -0.2, and +0.4 cm, respectively. The distortion of the tabletop in the PET-CT system was more similar to that in the lineac CT than in the CT simulator system. Distortion of the tabletop in a diagnostic PET-CT system may be within the acceptable range to allow its use for planning radiotherapy positioning.


Quality Assurance of I-125 Seed Permanent Implant Therapy Using a Self-color Developing Reflection-type Dosimetry Sheet Film

We evaluated a self-color developing sheet-type film for the detection of dead seeds in I-125 permanent implant therapy for prostate cancer. As a preliminary study, we irradiated X-rays to a self-developing reflection-type sheet film and created a relational curve between absorbed dose and film density. I-125 seeds were placed on a film and the approximate absorbed dose of I-125 was calculated from the relational curve of X-rays. A cartridge in which a dead seed was loaded among 10 I-125 seeds was placed on the film and the detectability of the dead seed was evaluated. Using the relational curve of X-rays, it was possible to measure the approximate absorbed dose of I-125 seeds and to easily detect a dead seed at a glance. Using sterilized film, it was possible to detect a dead seed. The self-developing film method is feasible for the detection of a dead seed in a cartridge without re-sterilization of seeds.


透過型積算線量計(In vivo Dosimetry)はどこまでわかるのか

透過型積算線量計(In vivo Dosimetry)はどこまでわかるのか


放射線治療計画QAソフトウェア利活用

放射線治療計画QAソフトウェア利活用


DIRの受入試験，コミッショニング，QA

DIRの受入試験，コミッショニング，QA


市販Deformable Image Registration ソフトウェアの臨床における問題点