Agenda. 1.1 Why pre-treament dosimetry in IMRT/VMAT? 1.2 Verification systems in IMRT/VMAT: from 0D to 3D (4D) dosimetry to real time dosimetry

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1 Controlli di qualità preclinici in IMRT statica e dinamica Michele Stasi S.C. Fisica Sanitaria, A.O. Ordine Mauriziano D.O. Fisica Sanitaria, IRCCS Candiolo TORINO mstasi@mauriziano.it Agenda 1. Introduction 1.1 Why pre-treament dosimetry in IMRT/VMAT? 1.2 Verification systems in IMRT/VMAT: from 0D to 3D (4D) dosimetry to real time dosimetry 2. Critical aspects in pre-treatment dosimetry 3. Advanced dosimetric systems: towards estimated patient dose distribution (IRCCS Candiolo experience) 1

2 Why is it so important to perform dosimetric verifications (1)? 3D-CRT Precise knowledge of dose erogation in field (higher dose if compared to 2D radiotherapy) Boundary dosimetry is important because of the OARs proximity to the target. OARs are partially shielded by the fields shaped on PTV dosimetric verification of penumbra and out of field areas! IMRT Compared to 3D-CRT: complex dose distributions, high dose gradients, concavity Problems relating to the boundary dose extended to all the irradiated volume: high dose gradient areas even in field High MU number Rotational + modulate therapy TPS dosimetric verification methodologies (point dose, profiles) In vivo dosimetry From Pre-treament verification Towards on-line dosimetry (patient dosimetry) Why is it so important to perform dosimetric verifications (2)? The radiotherapic techniques are becoming more and more complex (IMRT, VMAT, Tomotherapy, CyberKnife), meanwhile the dose control is always more difficult AND NECESSARY (?!) 2

3 Irradiation and conformation techniques evolution increasing the total number of fields and beamlets Higher conformity with a higher beamlets number in Tomo bl vs 700 bl for standard IMRT vs 3/6 for 3D-CRT Better optimization with a higher degrees of freedom number Higher dose gradients N. beamlet High LET TOMOTHERAPY IMAT IMRT 3D CRT MV KV Conformation capability Let s do it... 3

4 Or not...? Yes! it is the responsibility of the medical physicist to promote the highest quality medical services for patients. In the case of IMRT patients, it is necessary to perform individual patient-specific testing to verify that the dose delivered is the dose planned. Keep in mind that the validation of individual IMRT plans is not a panacea. It offers no value in addressing potential problems in the planning process. The best use of a physicist s time would be to commission the IMRT planning/delivery system, validate the MUs for individual plans, and play an active role in the clinical No! Let s do it... 4

5 Or not? Yes! Even if it is necessary to train in process statistical analysis and considering the single plan intrinsic control limits, it is necessary to perform it just to intercept the coarse deviations A single measure performed before a treatment could create a false sense of security If, for the test, we use different files from the ones used to treat patients, what are we really checking? Any file can corrupt during the treatment time There could be more effective QC (maybe not now!) Single patient test don t give us guarantees e.g. for RTOG credentialing process It would be necessary a FMEA analysis to improve safety No! IMRT QA: 5 levels &.. And later? QC on patients (set-up before the treatment) 4. IMRT plan pre-treatment verification (fluence maps, UM, isodoses) 3. Commissioning TPS/IP and IMRT treatment simulation on a phantom for dose verification 2. Small field dosimetry 1. Basic QC on LINAC and MLC 5

6 Workflow pre treament QC Copy in Phantom CALCULATED MEASURED MATCHING? Which verification systems to use in IMRT (1)? 1. MU verification: from ionization (micro)chambers, to array detector to independent verification systems (as MUcheck) 2. Dose distribution verification (fluence): from traditional films (Kodak X-OMAT-V, EDR2) to Gaf Chromic and 2D detectors arrays 6

7 Which verification systems to use in IMRT (2)? 3. 3D/4D Dosimetry 4. Integrated on-line systems for real-time dosimetry 3D dosimetry Why? TomoTherapy &.( RapidArc, VMAT, IMAT) Need of QA system for new irradiation geometry 7

8 3D geometry PTW OCTAVIUS 729 From 2D to 3D (4D) dose point RT-SmartIMRT 1 Scandidos DELTA 4 SNC ArcCheck 2 3 8

9 How to evaluate measured vs calculated dose distribution (indirect fluence verification)? Gamma Index method (Low) How it works dose difference (%) for low gradients Distance To Agreement (DTA in mm) per high gradients dose Reference data set Evaluated data set Acceptance: Acceptability: D max (e.g. 3 3 %) %) DTA (e.g. 3mm) min D D 2 2 max 2 d DTA Acceptability if < 1 2 < 1 posizione > IRCCS Candiolo: in IMRT 3 mm, 3%, < 1 for GP%> 95% (90%) points the treatment is OK Gamma index but which Gamma index? Local Gamma index vs Global Gamma index Local gamma (Low, standard approach -intercomparison point by point) Variable error bar as a function of punctual dose Global gamma (Van Dick) D prescribed /die D MAX /die Fixed global error bar, calculated as a percentage of the dose (prescribed or max) Global gamma is less restrictive than local gamma in low-dose areas (especially in case of hypofractions) and in SMART/SIB treatments (e.g. same error bar for high-dose and low-dose areas) 9

10 Open questions Which is the connection between function and clinic? What to accept the 90% (or 95%) of the points with <1 means? What does a shift (mm) mean in dosimetrical (DVH) and clinical terms? Method Function<1with: a 90%threshold 3%, 3mm No shift Induced Shift CC 3 mm!! 10

11 Specific verification for every patient We learn a lot from diligent Dose (IMRT) QA We detect delivery errors We detect TPS errors and imperfections We detect MLC/Gantry rotation by Linac We can fix some problems Specific verification for every patient What do we miss in the pre-treatment verification? What is the inter-fraction variation influence? Does the delivery give a correct dose distribution? Are the therapeutic requirements (DVH PTV, OAR) respected? In 2D/3D verification (isodoses, gamma function): How much do the revealed deviations influence clinically (e.g. we accept < 1 nel 90% of the cases and for the remaining 10%...?) on line dosimetry in vivo dosimetry in IMRT Real time Dosimetry (?) towards estimated patient dose distribution!!! 11

12 First approach at on-line dosimetric system Compass (IBA Dosimetry) Rivelator to the Linac gantry Software Transmission ionization chamber (T2D) or MatriXX (pixel chambers) On-line reconstruction of 3D dose on patient geometry Verification during patient treatment Compass basic concept CT registration of patient anatomy 3D distribution reconstruction 12

13 COMPASS LIMITS T2D attenuation ( 3%) Not friendly (a new TPS.) Expensive Let us try a new approach towards Real DVH on CT patients 13

14 2D-Dosimetry Mapcheck1 Mapcheck2 MatriXX Compass Prototype Gafchromic EBT2 + scanner Epson1000 1D-Dosimetry TomoDose IC Profiler THE NETWORK DOSIMETRY at IRCSS CANDIOLO (TO) 3D(4D)-Dosimetry ArcCheck 0D-Dosimetry I.C. + micro I.C. + Water/Solid Phantoms Software Dosimetry ImSure 3DVH Pre-treatment static-imrt verification at IRCCS Candiolo (TO) TPS: Cadplan Eclipse 8.0, Pinnacle 9 CLINAC: 600 (Varian), 6 MV with millennium MLC Since 2002 to 2004: Since 2004 to 2010: 27 pts - film dosimetry & microchamber 125 pts - Mapcheck1/MatriXX & microchamber Since 2006 up to now: 180 pts ImSure (Mucheck) Since 2011 up to now: 142 pts - Mapcheck2 14

15 ROTATIONAL TECHNIQUES & pre treatment IRCCS Candiolo since October 2010 Tomo HiArt since March 2012 Tomo HD ArcCheck & Tomotherapy Around 500 patients checked with ArcCheck (every Tomo-patient): - HR/HHR prostate (35%) - Prostate recurrence (18%) - Radical H&N (20%) - H&N recurrence (11%) - Rectum Bruxelles protocol (10%) - Others (chordoma, breast, lung, pancreas) (6%) 15

16 Global Gamma Index %PASS 99.3 (3% 3mm) Local Gamma Index, DDT=5cGy %PASS 99.3 Local Gamma Index, DDT=3cGy %PASS 96.8 The reference point can be the local dose point of every single comparison point or a global dose point. The selection of the reference point may have a huge influence on the result, especially in the low dose area. Local Gamma Index, DDT=1cGy %PASS 95.9 One patient, too much 3%/3mm 2%/2mm TH 0 TH 5 TH10 TH 0 TH 5 TH10 Dose diffmin (DDT) 1 cgy Dose diffmin (DDT) 2 cgy Dose diffmin (DDT) 3 cgy Dose diffmin (DDT) 4 cgy Dose diffmin (DDT) 5 cgy Gamma globale (van Dick) max 99.5 min 76.6 which choice? Difference 30% 16

17 Clinical case Tomotherapy Pelvis+ prostate Clinical case Tomotherapy Pelvis+ prostate 17

18 What is the clinically meaning? 18 failed points, the most out of T <1 98.7% 19 failed points on T <1 97.3% 19 failed points on T <1 97.3% Pts n failed points The majority out of T <1 98.7% Pts n. 1 Then, who is the best patient? 18

19 ArcCheck: training statistical analysis Average %GP ± standard deviation, calculated both with local and global normalization and 10% TH value Tumour site %GP (3%/3mm) %GP (2%/2mm) %GP (1%/1mm) 2cGy 3cGy 5cGy Global 2cGy 3cGy 5cGy Global 2cGy 3cGy 5cGy Global Prostate 95±3 96±3 99±1 98±1 86±6 91±5 97±3 94±5 68±8 81±8 94±4 78±9 HN 95±4 96±4 98±2 97±2 87±6 92±5 97±3 96±3 72±9 82±7 94±4 75±9 Other sites 90±9 92±7 97±3 96±4 80±11 86±9 94±5 88±10 63±12 75±12 89±10 54±11 The variability of %GP obtained confirmed the necessity to establish defined agreement criteria that could be universal and comparable between institutions. In particular, %GP does not depend on the choice of TH; the choice of DDT strongly influences the %GP for Local calculations. In situations in which deviations in low dose regions may indicate a dosimetrical impact on critical structures, a local normalization approach method should be used. Dose QA Today? What do these errors mean? Are they clinically significant? What are the best passing criteria? Let us return to a simple question: How was the plan dose approved in the first place? 19

20 3D Dose and DVH 3DVH (SNC) - Workflow Plan TPS Plan TPS phantom Dose Plan TPS patient Dose Plan Strucuture 3DVH Application that uses the classical 2D QA measures (and now also the 3D ones) to perturb the patient dose planned on TPS to obtain the equivalent 3D plan actually erogated. 20

21 Med Phys - Dec 12 Tomotherapy pre-treatment patient plan verification: analysis of Gamma Passing rate variability S. Bresciani, A. Di Dia, A. Maggio, C. Cutaia, A.Miranti, M. Stasi To investigate the predictive power of a common conventional IMRT QA performance metric, %GP through the analysis of the sensitivity and of the correlation between %GP and different dose discrepancies DVH perturbed ( real patient DVH) - DVHplanning 27 PP IMRT patients 15 HN IMRT patients Pretreatment verifications were performed for all patients plans 2D-Array: MapCheck 2D-Array: MapCheck 2 routinely used in our Institute, with absolute dose calibration, and the software SNC patient (Sun Nuclear Corporation, Melbourne, FL) 21

22 Evaluation of the% GP: average %GP calculated for PP and HN patients For all of the patients we evaluated the %GP using two different calculation methods and three different acceptance criteria. In the overall sample, we calculated a total number of 252 %GP data points. Maximum and minimum values %GP DVH values PTV: we took into account as relevant dose values D Mean and D 95%. OAR: D 2% (dose to 2% volume) for the spinal cord and D Mean for parotids (HN patients), V 50Gy and V 70Gy are taken into account for rectum and D Mean for bladder (PP patients) Anatomical Region Structure Analyzed Dose PTV1 (Pelvic Lymph Nodes) D Mean, D 95 PP PTV2 (Boost) D Mean, D 95 Rectum V 50, V 70 Bladder D Mean PTV Boost D Mean, D 95 HN Spinal Cord D 2% Parotid R D Mean Parotid L D Mean 22

23 Correlation analysis PP, correlation between %GP calculated using global method and 1%/1 mm criterion, 2%/2mm criterion and 3%/3mm criterion and the %DE for D Mean of the PTV Boost and for V 50 of the rectum HR Prostate Index of correlation between %GP with different acceptance criteria and %DE for different structures and DVH parameters 1%/1mm 2%/2mm 3%/3mm Significative correlation for PTV (> with 3%/3mm crietrion) Linear correlation weak/moderate -0.4<r<-0.7 Significative correlation only for some OARs Local and global are equivalent p=

24 HN, correlation between %GP calculated using local method and 1%/1mm criterion, 2%/2mm criterion and 3%/3mm criterion and the %DE for D Mean of the PTV Boost and for D Mean of the L-Parotid. Head & Neck Index of correlation between %GP with different acceptance criteria and %DE for different structures and DVH parameters Significative correlation for PTV(>3%3mm, no 1%%1mm) Linear correlation weak/moderate -0.4<r<-0.7 Significative correlation only for spinal cord Local and global are not equivalent p=

25 Global results of correlation Comparing the results obtained with the different gamma criteria, the number of correlations obtained using was: 3%/3 mm: 75% of cases 2%/2 mm: 63% of the cases 1%/1 mm: 25% of the cases Moreover, the strength of correlation decreased significantly passing from acceptance criterion 3%/3 mm to 1%/1 mm. Take Home Pre-treatment dosimetry is useful but it is not panacea 3D/4D Dosimetry is necessary in Tomo and VMAT (coeherent with geometric and irradiation technique) Necessity to go towards the Patient dose! Gamma Index informations is insufficient for clinical evaluation Warning: Large variability of gamma-index method Gamma index method has a weak correlation with clinical structures (moderate with PTV ) 3%-3mm criterion: the most number of correlations 25

26 Grazie dell Attenzione! 26

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