Dose distribution comparison in volumetric-modulated arc therapy plans for head and neck cancers with and without an external body contour extended technique

AimThis study compared volumetric-modulated arc therapy (VMAT) plans for head and neck cancers with and without an external body contour extended technique (EBCT).BackgroundDose calculation algorisms for VMAT have limitations in the buildup region.Materials and methodsThree VMAT plans were enrolled, with one case having a metal artifact from an artificial tooth. The proper dose was calculated using Eclipse version 11.0. The body contours were extended 2 cm outward from the skin surface in three-dimensional space, and the dose was recalculated with an anisotropic analytical algorithm (AAA) and Acuros XB (AXB). Monitor units (MUs) were set, and the dose distributions in the planning target volume (PTV), clinical target volume, and organ at risk (OAR) and conformity index (CI) with and without an EBCT were compared. The influence of a metal artifact outside of the thermoplastic head mask was also compared.ResultsThe coverage of PTV by the 95% dose line near the patient’s skin was increased drastically by using an EBCT. Plan renormalization had a negligible impact on MUs and doses delivered to OARs. CI of PTV with a 6-MV photon beam was closer to 1 than that with a 10-MV photon beam when both AAA and AXB were used in all cases. Metal artifacts outside the head mask had no effect on dose distribution.ConclusionsAn EBCT is needed to estimate the proper dose at object volumes near the patient’s skin and can improve the accuracy of the calculated dose at target volumes

Comparison of patient-specific intensity modulated radiation therapy quality assurance for the prostate across multiple institutions

AimTo evaluate the success of a patient-specific intensity modulated radiation therapy (IMRT) quality assurance (QA) practice for prostate cancer patients across multiple institutions using a questionnaire survey.BackgroundThe IMRT QA practice involves different methods of dose distribution verification and analysis at different institutions.Materials and MethodsTwo full-arc volumetric modulated arc therapy (VMAT) plan and 7 fixed-gantry IMRT plan with DMLC were used for patient specific QA across 22 institutions. The same computed tomography image and structure set were used for all plans. Each institution recalculated the dose distribution with fixed monitor units and without any modification. Single-point dose measurement with a cylindrical ionization chamber and dose distribution verification with a multi-detector or radiochromic film were performed, according to the QA process at each institution.ResultsTwenty-two institutions performed the patient-specific IMRT QA verifications. With a single-point dose measurement at the isocenter, the average difference between the calculated and measured doses was 0.5 ± 1.9%. For the comparison of dose distributions, 18 institutions used a two or three-dimensional array detector, while the others used Gafchromic film. In the γ test with dose difference/distance-to-agreement criteria of 3%−3 mm and 2%−2 mm with a 30% dose threshold, the median gamma pass rates were 99.3% (range: 41.7%–100.0%) and 96.4% (range: 29.4%–100.0%), respectively.ConclusionThis survey was an informative trial to understand the verification status of patient-specific IMRT QA measurements for prostate cancer. In most institutions, the point dose measurement and dose distribution differences met the desired criteria

Dose difference between anisotropic analytical algorithm (AAA) and Acuros XB (AXB) caused by target’s air content for volumetric modulated arc therapy of head and neck cancer

Background: We clarified the dose difference between the anisotropic analytical algorithm (AAA) and Acuros XB (AXB) with increasing target’s air content using a virtual phantom and clinical cases. Material and methods: Whole neck volumetric modulated arc therapy (VMAT) plan was transferred into a virtual phantom with a cylindrical air structure at the center. The diameter of the air structure was changed from 0 to 6 cm, and the target’s air content defined as the air/planning target volume (PTV) in percent (air/PTV) was varied. VMAT plans were recalculated by AAA and AXB with the same monitor unit (MU) and multi-leaf collimator (MLC) motions. The dose at each air/PTV (5%–30%) was compared between each algorithm with D98%, D95%, D50% and D2% for the PTV. In addition, MUs were also compared with the same MLC motions between the D95% prescription with AAA (AAA_D95%), AXB_D95%, and the prescription to 100% minus air/PTV (AXB_D100%-air/PTV) in clinical cases of HNC. Results: When air/PTV increased (5–30%), the dose differences between AAA and AXB for D98%, D95%, D50% and D2% were 3.08–15.72%, 2.35–13.92%, 0.63–4.59%, and 0.14–6.44%, respectively. At clinical cases with air/PTV of 5.61% and 28.19%, compared to AAA_D95%, the MUs differences were, respectively, 2.03% and 6.74% for AXB_D95% and 1.80% and 0.50% for AXB_D100%-air/PTV. Conclusion: The dose difference between AAA and AXB increased as the target’s air content increased, and AXB_D95% resulted in a dose escalation over AAA_D95% when the target’s air content was ≥ 5%. The D100%-air/PTV of PTV using AXB was comparable to the D95% of PTV using AAA

SPECT-CT fusion in the diagnosis of hyperparathyroidism

Objective(s): In this study, we aimed to analyze the relationship between the diagnostic ability of fused single photon emission computed tomography/computed tomography (SPECT/CT) images in localization of parathyroid lesions and the size of adenomas or hyperplastic glands. Methods: Five patients with primary hyperparathyroidism (PHPT) and 4 patients with secondary hyperparathyroidism (SHPT) were imaged 15 and 120 minutes after the intravenous injection of technetium99mmethoxyisobutylisonitrile (99mTc-MIBI). All patients underwent surgery and 5 parathyroid adenomas and 10 hyperplastic glands were detected. Pathologic findings were correlated with imaging results. Results: The SPECT/CT fusion images were able to detect all parathyroid adenomas even with the greatest axial diameter of 0.6 cm. Planar scintigraphy and SPECT imaging could not detect parathyroid adenomas with an axial diameter of 1.0 to 1.2 cm. Four out of 10 (40%) hyperplastic parathyroid glands were diagnosed, using planar and SPECT imaging and 5 out of 10 (50%) hyperplastic parathyroid glands were localized, using SPECT/CT fusion images. Conclusion: SPECT/CT fusion imaging is a more useful tool for localization of parathyroid lesions, particularly parathyroid adenomas, in comparison with planar and or SPECT imaging

Evaluation of multiple institutions’ models for knowledge-based planning of volumetric modulated arc therapy (VMAT) for prostate cancer

Abstract Background The aim of this study was to evaluate the performance of a commercial knowledge-based planning system, in volumetric modulated arc therapy for prostate cancer at multiple radiation therapy departments. Methods In each institute, > 20 cases were assessed. For the knowledge-based planning, the estimated dose (ED) based on geometric and dosimetric information of plans was generated in the model. Lower and upper limits of estimated dose were saved as dose volume histograms for each organ at risk. To verify whether the models performed correctly, KBP was compared with manual optimization planning in two cases. The relationships between the EDs in the models and the ratio of the OAR volumes overlapping volume with PTV to the whole organ volume (Voverlap/Vwhole) were investigated. Results There were no significant dosimetric differences in OARs and PTV between manual optimization planning and knowledge-based planning. In knowledge-based planning, the difference in the volume ratio of receiving 90% and 50% of the prescribed dose (V90 and V50) between institutes were more than 5.0% and 10.0%, respectively. The calculated doses with knowledge-based planning were between the upper and lower limits of ED or slightly under the lower limit of ED. The relationships between the lower limit of ED and Voverlap/Vwhole were different among the models. In the V90 and V50 for the rectum, the maximum differences between the lower limit of ED among institutes were 8.2% and 53.5% when Voverlap/Vwhole for the rectum was 10%. In the V90 and V50 for the bladder, the maximum differences of the lower limit of ED among institutes were 15.1% and 33.1% when Voverlap/Vwhole for the bladder was 10%. Conclusion Organs’ upper and lower limits of ED in the models correlated closely with the Voverlap/Vwhole. It is important to determine whether the models in KBP match a different institute’s plan design before the models can be shared

SPECT-CT fusion in the diagnosis of hyperparathyroidism

Objective(s): In this study, we aimed to analyze the relationship between the diagnostic ability of fused single photon emission computed tomography/computed tomography (SPECT/CT) images in localization of parathyroid lesions and the size of adenomas or hyperplastic glands. Methods: Five patients with primary hyperparathyroidism (PHPT) and 4 patients with secondary hyperparathyroidism (SHPT) were imaged 15 and 120 minutes after the intravenous injection of technetium99mmethoxyisobutylisonitrile (99mTc-MIBI). All patients underwent surgery and 5 parathyroid adenomas and 10 hyperplastic glands were detected. Pathologic findings were correlated with imaging results. Results: The SPECT/CT fusion images were able to detect all parathyroid adenomas even with the greatest axial diameter of 0.6 cm. Planar scintigraphy and SPECT imaging could not detect parathyroid adenomas with an axial diameter of 1.0 to 1.2 cm. Four out of 10 (40%) hyperplastic parathyroid glands were diagnosed, using planar and SPECT imaging and 5 out of 10 (50%) hyperplastic parathyroid glands were localized, using SPECT/CT fusion images. Conclusion: SPECT/CT fusion imaging is a more useful tool for localization of parathyroid lesions, particularly parathyroid adenomas, in comparison with planar and or SPECT imaging

Commissioning and quality assurance of Dynamic WaveArc irradiation

A novel three-dimensional unicursal irradiation technique "Dynamic WaveArc" (DWA), which employs simultaneous and continuous gantry and O-ring rotation during dose delivery, has been implemented in Vero4DRT. The purposes of this study were to develop a commissioning and quality assurance procedure for DWA irradiation, and to assess the accuracy of the mechanical motion and dosimetric control of Vero4DRT. To determine the mechanical accuracy and the dose accuracy with DWA irradiation, 21 verification test patterns with various gantry and ring rotational directions and speeds were generated. These patterns were irradiated while recording the irradiation log data. The differences in gantry position, ring position, and accumulated MU (EG, ER, and EMU, respectively) between the planned and actual values in the log at each time point were evaluated. Furthermore, the doses delivered were measured using an ionization chamber and spherical phantom. The constancy of radiation output during DWA irradiation was examined by comparison with static beam irradiation. The mean absolute error (MAE) of EG and ER were within 0.1° and the maximum error was within 0.2°. The MAE of EMU was within 0.7 MU, and maximum error was 2.7 MU. Errors of accumulated MU were observed only around control points, changing gantry, and ring velocity. The gantry rotational range, in which EMU was greater than or equal to 2.0 MU, was not greater than 3.2%. It was confirmed that the extent of the large differences in accumulated MU was negligibly small during the entire irradiation range. The variation of relative output value for DWA irradiation was within 0.2%, and this was equivalent to conventional arc irradiation with a rotating gantry. In conclusion, a verification procedure for DWA irradiation was designed and implemented. The results demonstrated that Vero4DRT has adequate mechanical accuracy and beam output constancy during gantry and ring rotation

Evaluation of lung toxicity risk with computed tomography ventilation image for thoracic cancer patients.

BackgroundFour-dimensional computed tomography (4D-CT) ventilation is an emerging imaging modality. Functional avoidance of regions according to 4D-CT ventilation may reduce lung toxicity after radiation therapy. This study evaluated associations between 4D-CT ventilation-based dosimetric parameters and clinical outcomes.MethodsPre-treatment 4D-CT data were used to retrospectively construct ventilation images for 40 thoracic cancer patients retrospectively. Fifteen patients were treated with conventional radiation therapy, 6 patients with hyperfractionated radiation therapy and 19 patients with stereotactic body radiation therapy (SBRT). Ventilation images were calculated from 4D-CT data using a deformable image registration and Jacobian-based algorithm. Each ventilation map was normalized by converting it to percentile images. Ventilation-based dosimetric parameters (Mean Dose, V5 [percent lung volume receiving ≥5 Gy], and V20 [percent lung volume receiving ≥20 Gy]) were calculated for highly and poorly ventilated regions. To test whether the ventilation-based dosimetric parameters could be used predict radiation pneumonitis of ≥Grade 2, the area under the curve (AUC) was determined from the receiver operating characteristic analysis.ResultsFor Mean Dose, poorly ventilated lung regions in the 0-30% range showed the highest AUC value (0.809; 95% confidence interval [CI], 0.663-0.955). For V20, poorly ventilated lung regions in the 0-20% range had the highest AUC value (0.774; 95% [CI], 0.598-0.915), and for V5, poorly ventilated lung regions in the 0-30% range had the highest AUC value (0.843; 95% [CI], 0.732-0.954). The highest AUC values for Mean Dose, V20, and V5 were obtained in poorly ventilated regions. There were significant differences in all dosimetric parameters between radiation pneumonitis of Grade 1 and Grade ≥2.ConclusionsPoorly ventilated lung regions identified on 4D-CT had higher AUC values than highly ventilated regions, suggesting that functional planning based on poorly ventilated regions may reduce the risk of lung toxicity in radiation therapy

Correction: Evaluation of lung toxicity risk with computed tomography ventilation image for thoracic cancer patients.

[This corrects the article DOI: 10.1371/journal.pone.0204721.]

Accuracy of image guidance using free-breathing cone-beam computed tomography for stereotactic lung radiotherapy.

Movement of the target object during cone-beam computed tomography (CBCT) leads to motion blurring artifacts. The accuracy of manual image matching in image-guided radiotherapy depends on the image quality. We aimed to assess the accuracy of target position localization using free-breathing CBCT during stereotactic lung radiotherapy. The Vero4DRT linear accelerator device was used for the examinations. Reference point discrepancies between the MV X-ray beam and the CBCT system were calculated using a phantom device with a centrally mounted steel ball. The precision of manual image matching between the CBCT and the averaged intensity (AI) images restructured from four-dimensional CT (4DCT) was estimated with a respiratory motion phantom, as determined in evaluations by five independent operators. Reference point discrepancies between the MV X-ray beam and the CBCT image-guidance systems, categorized as left-right (LR), anterior-posterior (AP), and superior-inferior (SI), were 0.33 ± 0.09, 0.16 ± 0.07, and 0.05 ± 0.04 mm, respectively. The LR, AP, and SI values for residual errors from manual image matching were -0.03 ± 0.22, 0.07 ± 0.25, and -0.79 ± 0.68 mm, respectively. The accuracy of target position localization using the Vero4DRT system in our center was 1.07 ± 1.23 mm (2 SD). This study experimentally demonstrated the sufficient level of geometric accuracy using the free-breathing CBCT and the image-guidance system mounted on the Vero4DRT. However, the inter-observer variation and systematic localization error of image matching substantially affected the overall geometric accuracy. Therefore, when using the free-breathing CBCT images, careful consideration of image matching is especially important