QUALITY ASSURANCE IN RADIOTHERAPY THERAPY EQUIPMENT
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1 QUALITY ASSURANCE IN RADIOTHERAPY THERAPY EQUIPMENT G. Guidi Az. Ospedaliero-Universitaria di Modena - Policlinico, Modena Guidi.Gabriele@policlinico.mo.it Phone:
2 AGENDA Overview of the concept Documents and guideline Evolution of the equipment and of the QA programs Doubts and questions Today, I will not provide methods for QA and specific tests you can find multiple way for QA.look into the problems! 2
3 Basic differences in modern Radiation Therapy Delivery 3D-Conformal Radiation Therapy (3D-CRT) Intensity Modulated Radiation Therapy Volumetric Modulated Radiation Therapy (IMRT/VMAT) Fluence Map 3
4 DEFINE CLINICAL OBJECTIVES AND NEEDS FOR THE FUTURE 3DCRT Static Target 3DCRT Dynamic Target NO Motion evaluation 3DCRT Dynamic Target 4DCT Motion Evaluation (ITV) 4DRT Dynamic Target 4DCT Motion Limitation 4DRT Dynamic Target 4DRT Technologies Phases beam-on 20-60% Abdominal Compressor MIP 4DCT Reconstruction Deformation analysis Dose accumulation Internal Marker Tracking Dynamic MLC Robotic Couch Organs Motion Compensation Daily Adaptive RT DIBH Deformable Registration Dose Accumulation Reduce margins Improve delivery efficacy and efficiency 4
5 NEW CONCEPT FOR TECHNOLOGY AND TREATMENT Outside Point Of View Inside Point Of View Need to synchronize the beam If you lost the synchronization, than you will not treat any tumours Tracking What s happen inside? With Tracking you don t know Tracking You don t see anything inside you believe than you treat the tumours 5
6 SETUP QA PROGRAMS AND DO IT!! 6
7 HAVE A LOOK (STUDY!) OF THE GUIDELINE. ADJUST BASED ON YOUR REQUIREMENTS YOU DO NOT NEED TO INVENT! 7
8 THERAPY : EQUIPMENT'S EVOLUTION NEXT GENERATION LINAC MRI LINAC PET PROTON AND CARBON..THERAPY 8
9 CLINICAL NEEDS 9
10 i.e. BREAST, SUPRACLAVEAR BREAST AND BILATERAL BREAST WITH INTERNAL MAMMARY 10
11 i.e. METS, MULTIPLE LESIONS AND TOTAL LYMPHOID IRRADIATION 11
12 i.e. PROSTATE AND ABDOMINAL LESIONS 12
13 i.e. HEAD&NECK 13
14 i.e. MESOTHELIOMA AND LUNG LESION 14
15 i.e. BRAIN AND RADIOSURGERY 15
16 i.e. CRANIO SPINAL IRRADIATION AND TOTAL BODY IRRADIATION 16
17 TOTAL SKIN ELECTRON & SKIN IRRADIATION (con Bolus). Skin Electron Irradiation (SEI) Total Skin Electron Irradiation (TSEI) 17
18 TECHNOLOGY EVOLUTION AND REQUIREMENTS 18
19 MODENA RADIATION ONCOLOGY ROADMAP 180 cm Tomotherapy - 4DCT Lesion 3D-CRT VMAT with FFF DIBH & 4DRT 10 cm IMRT Head & Body Stereotactic Radiosurgery VMAT 1 cm Radiation + Nanotechnology & Genomic Proton 1 mm Easy Treatment Complex 19
20 NETWORK AND SYSTEMS Hospital System TPS Treatment Planning System RADIOSURGERY (Ergo-3DLine) Elekta Precise + asi + MicroMLC BRACHYTHERAPY (Nucletron) Desktop RT iview GT Ergo MicroMLC Siemens Primus + BeamviewTI PLATO (Nucletron) Primeview Beamview TI Radiology Department CT-MRI/fMRI Regenerated CT + Cobalt 20
21 NETWORK AND SYSTEMS Hospital System Legal Digital Repository TPS Treatment Planning System 4D Planning PINNACLE (Philips-TA) DICOM RT Archive Tomotherapy Tomotherapy IMPAC (R&V) RADIOSURGERY (Ergo-Elekta) ONCENTRA (Nucletron) IMPAC (R&V) Elekta Precise + asi + MicroMLC Regional PACS TOMOPLAN (Tomotherapy) BRACHYTHERAPY (Nucletron) IMPAC (R&V) iview GT Ergo MicroMLC Siemens Primus + BeamviewTI MONACO (Elekta) Proton TPS IMPAC (R&V) Beamview TI Radiology Department CT-MRI/fMRI-CT/PET-CT/SPECT Elekta 4DSynergy+VMAT+dMLC+FFF+CBCT 4DCT Toshiba Large Bore + Vision RT & ABC Elekta Synergy+ asi (Carpi) IMPAC (R&V) IMPAC (R&V) iviewgt 21
22 NETWORK AND SYSTEMS Hospital System Legal Digital Repository TPS Treatment Planning System Raystation (RaysearchLab) PINNACLE (Philips) DICOM RT Archive Tomotherapy Tomotherapy IMPAC (R&V) Homemade Software ONCENTRA (ELEKTA) IMPAC (R&V) Elekta Precise + asi + MicroMLC Regional PACS TOMOPLAN (Tomotherapy) BRACHYTHERAPY (Nucletron) IMPAC (R&V) iview GT Ergo MicroMLC Siemens Primus + BeamviewTI MONACO (Elekta) QA Software (IBA MyQA, COMPASS) IMPAC (R&V) Beamview TI Radiology Department CT-MRI/fMRI-CT/4DPET-CT/SPECT Elekta 4DSynergy+VMAT+dMLC+FFF+CBCT 4DCT Toshiba Large Bore + Vision RT & ABC Elekta Synergy+ asi (Carpi) +Compass IMPAC (R&V) IMPAC (R&V) iviewgt 22
23 i.e Guideline for implementation 23
24 WHICH QA PROGRAMS? WHICH TESTS? i.e.. LINAC QA Geometry and mechanical Dosimetric MLC Safety and collision Imaging EPID/ CBCT Couch Radiosurgery Positioning (frame vs. frameless) Accuracy Rotational of gantry and collimator SBRT Positioning (frame vs. frameless) Accuracy Rotational of gantry and collimator IMRT Penumbra Inter/interleafs MLC Interdigitation VMAT MLC Interdigitation Leafs speed Doserate Different Therapy Low Doserate/Low MU Low Dosedose/High MU High Doserate/Low MU High doserate /High MU 4D Therapy Breath synch Beam on/off and delivery (DIBH) Ramp-up of the beam-on Gantry rotation speed Constant Variable Doserate Constant Variable Discrete Complete procedure after interruption 3DCRT IMRT dmlc or Sliding Windows VMAT Radiosurgery SBRT Isocenter junction Junction of the beam and divergence Non-Homogeneity condition Cerrobend Block? Tray Real-time monitor systems Log files analysis Unpredictable cases (near missing or errors) Connectivity with IOS. 24
25 25
26 i.e. LINAC QA 26
27 DEFINE TOLERANCE.. 27
28 DEFINE FREQUENCY AND PARAMETERS 28
29 IMAGING QA 29
30 i.e. QA FOR TREATMENT MACHINE USING FLAT PANEL 30
31 DURING THE COMMISSIONING YOU NEED TO VERIFY THE TOLERANCE... AND DEFINE THE FUTURE BASELINE VMAT MACHINE FFF MACHINE AGREEMENT TPS-PLAN-DELIVERY 31
32 i.e. POTENTIAL QA AND ERROR DETECTED 32
33 SOMETIME OBJECTS AND PHANTOM CAN HELP THE WORK-LIFE 33
34 IDENTIFY OR PREVENT SOURCE OF ERRORS? Look for: Small or big errors? Rare or frequent errors? Random or systematic errors? Unpredictable or newly errors? To be accurate once a year (annual QA) or to be adequate everyday (Daily QA)?: 34
35 IMMOBILIZATION DEVICE QA OR NOT QA? LINAC COMPLIANT OR NOT? 35
36 IN PRACTICE? «UMARELL CONCEPT» Expert Brainstorming- Multiple-criteria decision Decision Maker Wrong Workflow or Healthcare Model Error investigation Results: Simplify and prevent accident 36
37 DEFINE THE BASELINE AND REPEAT FREQUENTLY (AS LOW AS REASONABLE) THE QA TEST 37
38 i.e. Isocenter and MLC position (Picket, Fence) Tests 38
39 Analyze and look at the trends vs. the baseline.. 39
40 Trace and Record any Data 40
41 Simplify theory (i.e. Six Sigma) 41
42 ALTERNATIVE - INDEPENDENT REAL-TIME BEAM MONITOR SYSTEM Modena Hospital Possible QA of the LINAC Pre-Treatment QA activities Error prevention instead of error management Intra-fractional verification system Real-Time user interaction Automated monitoring of every single treatment fraction Courtesy of Andrew Jongho Jung Princess Margaret Cancer Centre (Toronto) Patient delivery and safety improved in real-time In-Vivo evaluation Modena Hospital 42
43 IMRT plan 18 segments Irradiated with 6 MV photon Constant 50 MU/segment dose output IQM MAP QA - DAILY QA TEST FIELDS mean variability (for all segments) 0,7% and standard deviation of 4,7% this is true for all segments except the 1 st one. 43
44 VMAT RESULTS Gantry angle ( ) MU error 1% 2% 3% 4% 5% 10% 20% 0 0,2% 1,0% 2,1% 1,8% 2,9% 7,9% 16,8% 20 2,5% 2,4% 3,1% 5,4% 4,1% 9,1% 21,1% 40 3,6% 4,6% 6,2% 5,6% 6,7% 12,3% 20,4% 60 1,4% 2,4% 3,1% 4,0% 5,4% 10,0% 20,3% 80 1,3% 0,8% 4,4% 2,7% 5,1% 9,1% 19,1% 100 2,4% 2,3% 3,5% 2,2% 4,5% 9,3% 19,6% 120 2,8% 1,2% 3,4% 3,6% 5,6% 9,3% 21,9% 140 1,6% 1,6% 4,8% 2,1% 4,4% 11,9% 18,9% 160 2,9% 2,8% 3,5% 3,3% 4,5% 8,4% 19,9% 180 1,8% -1,8% -0,3% -0,4% 6,1% 9,2% 18,3% 200 1,8% -0,4% 2,1% 0,9% 2,5% 9,3% 19,2% 220 0,9% 1,0% 1,4% 1,6% 2,5% 8,6% 18,7% 240 1,9% 1,7% 4,6% 3,3% 5,3% 8,9% 19,5% 260 2,8% 2,6% 3,8% 2,5% 5,6% 9,1% 20,1% 280 4,0% 5,2% 5,0% 8,0% 7,8% 12,9% 25,8% 300 2,1% 3,4% 3,1% 5,3% 4,5% 9,8% 20,5% 320 2,0% 3,4% 3,6% 4,5% 6,4% 12,0% 21,2% 340 2,0% 2,4% 4,6% 5,1% 6,8% 11,7% 22,4% 44
45 WE NEED INSTRUMENTS TO PREVENT ACCIDENT AND FOR QA YOU MUST PRETEND IT! IMRT - Intensity Modulated Radiation Therapy Tomotherapy Total Lynphoid Irradiation 4D-Radiation Therapy Radiosurgery SBRT 45
46 SOME OTHER DOCUMENTS TO TEST THE AGREEMENT BETWEEN PLAN AND DELVERY AAPM Report No. 62: Quality Assurance for Clinical Radiotherapy Treatment Planning (December 1998) IAEA Technical Report Series No. 430 : Commissioning and Quality Assurance of Computerized Planning Systems for Radiation Treatment of Cancer (October 2004) IAEA TEC-DOC No 1540: Specification for Acceptance Testing of Radiotherapy Treatment Planning Systems 46
47 i.e. SPATIAL EVALUATION AND IMAGING QA 47
48 Modeling of the measures (Theory vs. Practice) 48
49 MEASURE MISTAKE EFFECTS Effect of shifting depth-ionization data measured with cylindrical chambers upstream by 0.6 r cav for photon beams and 0.5 r cav for electron beams (with r cav = 1.0 cm). For the electron beams, (b), further corrections are applied to obtain the %dd(x) curve shown. 49
50 SCATTER KERNEL 50
51 Fluence vs. Dose (Water vs. Inhomogeneous) 51
52 QA QUALITY ASSURANCE INSTRUMENTS (i.e. Adaptive RT could based on CBCT calculation or we could need phantom for gating verification) 52
53 i.s. Experimental QA in Tomotherapy for Gating QA 53
54 i.s. Experimental QA in LINAC for Gating QA 54
55 DOUBTS AND QUESTIONS? 55
56 That s too much!!! (Praha 2009 : Tomotherapy Meeting) Un maestro in pensione 56
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