Tools for IMRT Commissioning: Clarification: Not about devices

Static and Rotating Gantries

• Wednesday’s CE presentation on
AAPM 2009 IMRT Metrology discussed devices
TH-B-BRC-01 • This talk is about commissioning
processes

Gary A. Ezzell, Ph.D.

Fang Fang Yin, Ph.D.
Ying Xiao, Ph.D

TG-119 RPC results - 2008

• Task group 119 was charged with • 250 irradiations of H&N

expanding on the “IMRT Guidance phantom
Document” from 2003 • 28% had failed …
- Chaired by Ying Xiao, PhD - 7% dose in low
• Motivated by on-going concerns about gradient
practical IMRT commissioning and QA - 4 mm DTA in high
gradient

1

Focus on IMRT commissioning
• Presumption is that the high failure
rate indicates inadequate
commissioning of the IMRT planning
and delivery system
• Need for better information about
when is the dosimetric accuracy “good
enough”
How to quantify “good enough”?
• Use concept of “confidence limit” from
Venselaar, refined by Palta
• For a set of (measured – expected)
values:
- CL = |mean| + 1.96 *
• TG-119 combined results from 9
centers to obtain confidence limits to
be a baseline for comparison
TG-119 Goal: Determine what is
achievable in practice
• Define a suite of planning problems
• Define a measurement protocol
• Compare results from different
institutions that had passed the RPC
credentialing for IMRT
• Use the results to recommend
minimum criteria for acceptability
How to use TG-119 information?
• Local institutions can perform the suite
of tests, comparing their
measurements to predictions and
creating a local “confidence limit”
• If the local confidence limit exceeds
that of the TG-119 group, then that
may indicate a problem with the local
commissioning
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 TG-119 Status Participants

Mayo Clinic Arizona University of California, San

• Report submitted to Medical Physics Francisco
Thomas Jefferson University
• Accepted for publication pending Hospital University of Florida
revision Robert Wood Johnson Virginia Commonwealth
• Some changes in methodology and University Hospital University

results may occur – treat as Memorial Sloan Kettering Charleston Radiation

Cancer Center Therapy Consultants
preliminary
Karmanos Cancer Center

Equipment Dosimetry tools

• Linacs • Rectangular plastic phantom

• Composite irradiation
- 5 Varian, 2 Elekta, 2 Siemens,
measurements
1 Tomotherapy
- Chamber of suitable size
• Planning systems - Film in coronal planes
- 4 Pinnacle, 3 Eclipse, 1 CMS, 1 - Gamma criteria: 3%, 3 mm
Tomotherapy, 1 In-house

3
 Dosimetry tools Preliminary tests to assess uncertainties

• Individual field measurements • AP:PA

- Detector array, film, EPID - Set chamber
reading to dose
• Gamma criteria: 3%, 3 mm
conversion
• Bands 2 4 6 8 10 12 14 16 18 20

- Overlapping AP:PA 4

fields to different 8

10

doses
12

14

16

18

20
Referenc e:Eclipse D os e Map
Bands.dcm

Bands – assess composite and per-field Mock clinical cases

2 4 6 8 10 12 14 16 18 20

8
• Model common clinical cases
• Use consistent approach
10

12

14

16

Refer enc e:Ec lipse Dose Map

Bands.dcm
18

20 - 6 MV
- 7 – 9 coplanar fields, equally spaced
• Dose goals specified so plans are
similar

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 Mock Head/Neck Mock Head/Neck

Dose goals Beam arrangement

PTV 90% of volume to receive at least 50 Gy
99% of volume to receive at least 46.5 Gy
<= 20% of volume to receive more than 55 Gy
Cord No part of volume to receive more than 40 Gy
Parotids 50% of volume to receive less than 20 Gy
6 MV, 9 fields at 40o intervals from the vertical
Chamber measurement points
Isocenter, in the mid PTV and 4.0 cm posterior, mid spinal cord
Film planes
Isocenter, in the mid PTV and 4.0 cm posterior, mid spinal cord

Multi-Target Mock Prostate

25 Gy PTV 95% 75.60 Gy

5% > 83 Gy
50 Gy
12.5 Gy Rectum 30% 70 Gy
10% > 75 Gy

Bladder 30% 70 Gy
Three cylindrical targets are stacked along the axis of 10% > 75 Gy
rotation. Each has a diameter of approximately 4 cm
and length of 4 cm

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 CShape Results - Chamber

• (Measured – Plan) / Dose per fraction

• High dose region
- Average difference: 0.2%
- Standard deviation: 2.2%
- Confidence limit: 4.4%
• Low dose region
- Average difference: 0.6%
- Standard deviation: 3.0%
Target: 95% 50 Gy; 10% > 55 Gy
- Confidence limit: 6.5%
Core: 5% > 25 Gy (easier version);
10 Gy (harder version)

Film measurements – composite

Chamber – high dose region irradiations
Composite Ion Chamber Dosimetry
High Dose Plane
• Gamma criteria: 3% dose, 3 mm DTA
0.070
0.060
0.050 • Permitted to normalize film data to
(Meas-Plan)/Dose per fraction

0.040
0.030
0.020
Prostate
Head/Neck
corresponding chamber measurement
0.010
MultiTarget
0.000
CShape50
-0.010
-0.020 CShape20
-0.030 Bands
-0.040
-0.050
• CL: (100 – mean) + 1.96 *
-0.060
-0.070
A B C D E F G H I J
Institution

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 Film measurements – composite
irradiations
• High dose planes (5 - 7 reports)
• Low dose planes (3 - 4 reports)
- 96.4 ± 4.3% of points passed
• Confidence limit:
- (100% – 96.4%) + 1.96 * 4.3%= 12.0%
- i.e. 88%
Individual field measurements
• Gamma: 3 %, 3 mm DTA
- Absolute Dose, 10% Threshold, Van Dyk %
Difference, Apply Measurement Uncertainty
• Average pass rate: 97.9 ± 2.5%
• Confidence limit
- (100% - 97.9%) + 1.96 * 2.5% = 7.0%
- i.e. 93%
Individual field measurements
• 7 institutions reported
- 5 used diode array (MapCheck)
- 1 used film, 1 used EPID
• 5 with diode array sent plan and
measurement data to one institution
for consistent analysis
TG-119 limitations
• Test suite not comprehensive, may need to
be expanded to reflect local practice
- Large pelvic regions
- Complex H&N
• Relatively few contributors
• Gamma results highly dependent on
implementation
• Does not identify reasons for failures
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 Using TG-119 process

• Download test suite images and

instructions:
http://www.aapm.org/pubs/tg119/default.asp
• Do plans, measurements, and analysis
per instructions
• Compare local CL to TG-119 group’s
- If much larger, could indicate
problems