3D in vivo dosimetry using megavoltage cone-beam CT and EPID dosimetry.

Department of Radiation Oncology (MAASTRO), GROW Research Institute, University Medical Centre Maastricht, Maastricht, The Netherlands.
International journal of radiation oncology, biology, physics (Impact Factor: 4.59). 05/2009; 73(5):1580-7. DOI: 10.1016/j.ijrobp.2008.11.051
Source: PubMed

ABSTRACT To develop a method that reconstructs, independently of previous (planning) information, the dose delivered to patients by combining in-room imaging with transit dose measurements during treatment.
A megavoltage cone-beam CT scan of the patient anatomy was acquired with the patient in treatment position. During treatment, delivered fields were measured behind the patient with an electronic portal imaging device. The dose information in these images was back-projected through the cone-beam CT scan and used for Monte Carlo simulation of the dose distribution inside the cone-beam CT scan. Validation was performed using various phantoms for conformal and IMRT plans. Clinical applicability is shown for a head-and-neck cancer patient treated with IMRT.
For single IMRT beams and a seven-field IMRT step-and-shoot plan, the dose distribution was reconstructed within 3%/3mm compared with the measured or planned dose. A three-dimensional conformal plan, verified using eight point-dose measurements, resulted in a difference of 1.3 +/- 3.3% (1 SD) compared with the reconstructed dose. For the patient case, planned and reconstructed dose distribution was within 3%/3mm for about 95% of the points within the 20% isodose line. Reconstructed mean dose values, obtained from dose-volume histograms, were within 3% of prescribed values for target volumes and normal tissues.
We present a new method that verifies the dose delivered to a patient by combining in-room imaging with the transit dose measured during treatment. This verification procedure opens possibilities for offline adaptive radiotherapy and dose-guided radiotherapy strategies taking into account the dose distribution delivered during treatment sessions.

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    ABSTRACT: To investigate for prostate cancer patients the comparison of 'in-vivo' measured portal dose images (PDIs) with predictions based on a kilovoltage cone-beam CT scan (CBCT), acquired during the same treatment fraction, as an alternative for pre-treatment verification. For evaluation purposes, predictions were also performed using the patients' planning CTs (pCT). To get reliable CBCT electron densities for PDI predictions, Hounsfield units from the pCT were mapped onto the CBCT, while accounting for non-rigidity in patient anatomy in an approximate way. PDI prediction accuracy was first validated for an anatomical phantom, using IMRT treatment plans of ten prostate cancer patients. Clinical performance was studied using data acquired for 50 prostate cancer patients. For each patient, 4--5 CBCTs were available, resulting in a total of 1413 evaluated images. Measured and predicted PDIs were compared using gamma-analyses with 3% global dose difference and 3 mm distance to agreement as reference criteria. Moreover, the pass rate for automated PDI comparison was assessed. To quantify improvements in IMRT fluence verification accuracy results from multiple fractions were combined by generating a gamma-image with values halfway the minimum and median gamma values, pixel by pixel. For patients, CBCT-based PDI predictions showed a high agreement with measurements, with an average percentage of rejected pixels of 1.41% only. In spite of possible intra-fraction motion and anatomy changes, this was only slightly larger than for phantom measurements (0.86%). For pCT-based predictions, the agreement deteriorated (average percentage of rejected pixels 2.98%), due to an enhanced impact of anatomy variations. For predictions based on CBCT, combination of the first 2 fractions yielded gamma results in close agreement with pre-treatment analyses (average percentage of rejected pixels 0.63% versus 0.35%, percentage of rejected beams 0.6% versus 0%). For the pCT-based approach, only combination of the first 5 fractions resulted in acceptable agreement with pre-treatment results. In-room acquired CBCT scans can be used for high accuracy IMRT fluence verification based on in-vivo measured EPID images. Combination of gamma results for the first 2 fractions can largely compensate for small accuracy reductions, with respect to pre-treatment verification, related to intra-fraction motion and anatomy changes.
    Radiation Oncology 09/2013; 8(1):211. · 2.11 Impact Factor
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    ABSTRACT: In vivo dosimetry is now widely recommended to avoid major treatment error. Transit dosimetry using portal imagers allows fast and accurate in vivo dose verifications. Several teams have published clinical studies but no recommendation has been proposed to define tolerance levels and validation criteria. This study proposes a simple methodology to assess the overall standard deviation of transit dosimetry and was applied to our transit dosimetry method. In a first step, the uncertainties due to the dose reconstruction method are evaluated. Their estimation is based on a set of geometries, representative of clinical situations for which 45 points of measurement have been defined. In a second step, we studied the variations of our method in clinical situations. During the treatment session of the patient, the dose was reconstructed and the differences between reconstructed dose and prescribed dose were used to define a realistic tolerance level, adapted to the clinical routine. Then, a methodology is proposed to determine if the transit dosimetry method, with the defined tolerance level allows detecting significant treatment errors (>5% of the prescribed dose). RESULTS - CONCLUSION: Applying this methodology we concluded that a tolerance level of 6.5% (k=2) can be associated with our method. With this value, it is demonstrated that in many cases differences of 5% (or less) on the prescribed dose can be detected. This study demonstrates clearly that in vivo transit dosimetry is not able to detect all the treatment errors but remains an ultimate and efficient tool in many situations.
    Cancer/Radiothérapie 10/2013; · 1.48 Impact Factor
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