

ORIGINAL ARTICLE 



Year : 2011  Volume
: 36
 Issue : 1  Page : 1521 

Dosimetric evaluation of a threedimensional treatment planning system
Appasamy Murugan^{1}, Xavier Sidonia Valas^{2}, Kuppusamy Thayalan^{2}, Velayudham Ramasubramanian^{3}
^{1} Medical Physics Division, Dr. Kamakshi Memorial Hospital, No:1, Radial Road, Pallikaranai, Chennai  600 100, Tamil Nadu; Nuclear and Medical Physics Division, School of Advanced Sciences, VIT University, Vellore  632 014, Tamil Nadu, India ^{2} Medical Physics Division, Dr. Kamakshi Memorial Hospital, No:1, Radial Road, Pallikaranai, Chennai  600 100, Tamil Nadu, India ^{3} Nuclear and Medical Physics Division, School of Advanced Sciences, VIT University, Vellore  632 014, Tamil Nadu, India
Date of Submission  29Apr2010 
Date of Decision  21Jun2010 
Date of Acceptance  11Aug2010 
Date of Web Publication  12Jan2011 
Correspondence Address: Appasamy Murugan Medical Physics Division, Dr. Kamakshi Memorial Hospital, No:1, Radial Road, Pallikaranai, Chennai  600 100. Tamil Nadu India
Source of Support: None, Conflict of Interest: None  Check 
DOI: 10.4103/09716203.75467
Abstract   
The computerized treatment planning system plays a major role in radiation therapy in delivering correct radiation dose to the patients within ±5% as recommended by the ICRU. To evaluate the dosimetric performance of the Treatment Planning system (TPS) with threedimensional dose calculation algorithm using the basic beam data measured for 6 MV Xrays. Eleven numbers of test cases were created according to the Technical Report Series430 (TRS 430) and are used to evaluate the TPS in a homogeneous water phantom. These cases involve simple field arrangements as well as the presence of a lowdensity material in the beam to resemble an air inhomogeneity. Absolute dose measurements were performed for the each case with the MU calculation given by the TPS, and the measured dose is compared with the corresponding TPS calculated dose values. The result yields a percentage difference maximum of 2.38% for all simple test cases. For complex test cases in the presence of inhomogeneity, beam modifiers or beam modifiers with asymmetric fields a maximum percentage difference of 5.94% was observed. This study ensures that the dosimetric calculations performed by the TPS are within the accuracy of ±5% which is very much warranted in patient dose delivery. The test procedures are simple, not only during the installation of TPS, but also repeated at periodic intervals.
Keywords: Dosimetric evaluation, treatment planning system, Technical Report Series430
How to cite this article: Murugan A, Valas XS, Thayalan K, Ramasubramanian V. Dosimetric evaluation of a threedimensional treatment planning system. J Med Phys 2011;36:1521 
How to cite this URL: Murugan A, Valas XS, Thayalan K, Ramasubramanian V. Dosimetric evaluation of a threedimensional treatment planning system. J Med Phys [serial online] 2011 [cited 2019 Dec 12];36:1521. Available from: http://www.jmp.org.in/text.asp?2011/36/1/15/75467 
Introduction   
Radiotherapy aims to cure, or locally control the disease, while concurrently minimizing complications in normal tissues. The radiation dose must be delivered within ±5% of the prescribed dose. ^{[1],[2],[3]} The treatment planning and dosimetry are the main steps in radiotherapy, which includes calibration of the equipments, determination of absorbed dose under reference conditions, phantom measurements under nonreference conditions, calculation of dose distribution in the patient and, finally, treatment delivery via monitor units or treatment time calculation. Consideration of the uncertainties associated with each of the above steps and their propagation increases the demand for accuracy in the dose calculation algorithm employed in the treatment planning. Therefore, quality assurance (QA) is necessary in the commissioning stage of the treatment planning system (TPS) prior to their use in clinical practice.
In the present work, the dosimetric performance of a commercial TPS with a threedimensional calculation algorithm (Plato V 2.7.2, Nucletron B.V) is studied using a basic beam data set measured for a 6 MV Xray beam and a set of test case configurations which are based on the TRS430. The aim is to determine the accuracy of our TPS in dose calculation in a homogenous phantom as well as in the presence of inhomogeneity, and potential limitations of the dose calculation algorithm.
Materials and Methods   
Treatment planning system
The TPS agreement with the treatment machine is based on IEC 1217 conventions ^{[4]} for specifying gantry angle, collimator angle, table angle, wedge orientation and patient orientation, and TPS software operates in a UNIX environment. The photon beam dose calculation algorithm employed by TPS comprises a convolution based approach where the energy fluence distribution is convolved with a dose pencil beam. ^{[5]} The dose pencil beam consists of depthindependent width and depthdependent relative weight. Thus the dose calculation at any arbitrary depth in a homogeneous water phantom involves only one single convolution step for each of the three components. For other depths, the pencil beam components are added using the depthdependent relative weights. Convolution of the energy fluence distribution with a Gaussian source distribution kernel allows for optimization of the fit between the measured and the calculated edge of the field. Inhomogeneities are taken into account by applying the equivalent tissueair ratio (ETAR) method introduced by Sontag and Cunningham, ^{[6]} as described by Yu and Wong. ^{[7]}
Instrumentation and technique
Beam data and test point doses were measured for a 6 MV Xray beam (Quality Index0.665) of a Linear Accelerator (Primus, Siemens, Germany). Percentage depth dose curves and beam profiles were measured with a fully computerized radiation field analyzer (Blue phantom, ScanditronixWellhofer, Germany) equipped with a thimble type ionization chamber and semiconductor detectors for relative dose measurements. Absolute dose measurements were performed with ionization chambers (0.13 cc, 0.6 cc farmer type and 40 cc parallel plate type, ScanditronixWellhofer) connected to an electrometer (Dose 1, ScanditronixWellhofer, Germany). The chamber was calibrated for N _{D, W} according to the IAEA TRS398 dosimetry protocol. ^{[8]}
Basic beam data
The basic beam data were measured under reference conditions of source to surface distance (SSD _{ref} ) = 100 cm, reference field (FS _{ref} ) =10 x 10 cm ^{2} , reference depth (r _{ref} ) =10 cm. The machine was calibrated to deliver 1 cGy/MU at the depth of maximum dose (D _{max} ) at 1.7 cm. The beam data used for beam modeling include the following parameters.
Depth dose data
Open beam depth dose data along the central axis of square field sizes of: 3, 5, 8, 10, 12, 15, 18, 20, 25, 30, 40 (cm x cm) for depths from 0 up to 30 cm were measured.
Offaxis beam profiles
For each of the abovementioned square fields, five open beam profiles at various depths of D_{max} , 5 cm, 10 cm, 15 cm, and 20 cm were acquired.
Wedge field data
Depth dose data and five beam profiles for square field sizes of 3, 5, 10, 15, and 20 (cm x cm) were used for each wedge of 15°, 30°, 45°, and 60° nominal angles. Differences between calculated and measured profiles were minimized by adjustment of weight factors according to the comparison of the calculated wedged beam profiles at depths of 3, 5, 10, 15, and 20 cm with corresponding measured values. The comparison and evaluation of differences between calculated and measured beam data were performed in a trial and error fashion using the Beam Data Analysis Software (BDAS).
The output factors, wedge factors, tray transmission factors, and block transmission factors also acquired for the minimum to maximum field size as an input data for the TPS.
Test data
The selected test cases representing different aspects of the dose computation process as proposed by TRS 430 ^{[9]} and other authors ^{[10],[11],[12],[13]} were created. Point dose measurements were performed, and the measured doses were compared with that of TPS calculated values. Test point measurements correspond to different depths ranging from 0.2 to and 15 cm along the central axis for the reference SSD _{ref} =100 cm, unless otherwise stated.
Test case 1
Square fields ranging from 3 x 3 cm ^{2} (the smallest used in our department) up to 28 x 28 cm ^{2} at the depth of 10 and 15 cm along the central beam axis.
Test case 2
Rectangular fields were produced by exchanging the x and y jaws (x × y and y 0× x) without collimator rotation. Rectangular fields and equivalent square fields were also examined along the beam axis.
Test case 3
SSD variation: 13 test points of isocentric setup were investigated in the beam axis, it includes the Anterior and posterior, box and tangential arrangements of clinical situations with symmetric as well as asymmetric fields.
Test case 4
Wedge filter: square fields of 10 x 10 cm ^{2} and 20 x 20 cm ^{2} modified with 15°, 30° and 45° wedge filter were investigated at the depth of 10 cm. Two measurements were performed along the beam axis for each of the possible wedge orientations. The average measured dose value was then compared with the corresponding calculated value.
Test case 5
Central block: a diverging cerrobend block of 4 x 16 cm ^{2} dimension at the isocenter and 7.5 cm thickness resulting in 95% effective attenuation was investigated. Point dose measurements were performed for square fields of 10 x 10 cm ^{2} , 15 x 15 cm ^{2} at the depth 10 cm for a SSD of 100 and 90 cm and at a distance of 0.5 and 1 cm away from the shielding block (2.5 and 3 cm from the central beam axis). The dose values were compared with the corresponding calculated values.
Test case 6
Offcenter planes: point dose measurements were performed for a variety of square fields and offcentred planes, i.e. [5 cm x 5 cm, 2 cm], [7 cm x 7 cm, 3 cm], [10 cm x 10 cm, 4 cm], [13 cm x 13 cm, 5 cm], [15 cm x 15 cm, 6 cm]. The average of the four offcenter dose points in the crossplane and inplane directions was used as the mean off center dose value in both measurements and calculations.
Test case 7
Oblique incidence: the aim of this test was to check the ability of the TPS to account for oblique incidence and skin contour variation. Using an isocentric setup and gantry angles of ±20°, ±30°, the dose was determined at two depths of 5 cm and 10 cm along the central beam axis for FSD _{(Gantry angle=0°)} =95 cm and FSD _{(Gantry angle=0°)} = 90 cm. Field sizes perpendicular to the beam direction were 10 cm x 10 cm, 15 cm x 15 cm and 20 cm x 20 cm respectively.
Test case 8
Inhomogeneous medium: An air gap of 3 cm height was created in the solid water phantom to check the ability of the TPS to account for the presence of inhomogeneities. The inhomogeneity was perpendicular to the beam axis and shape with a 20 x 20 cm ^{2} side area and 3 cm thickness. Point dose was measured at 10 cm depth, SSD = 100 cm along the central axis for square field sizes of 5 x 5 cm ^{2} , 8 x 8 cm ^{2} , 10 x 10 cm ^{2} , 15 x 15 cm ^{2} .
Test case 9
Asymmetric wedged fields: 16 number of test points were created at the depth of 10 and 15 cm along the beam axis with asymmetric field sizes {10 cm x 15(Y _{1} :5,Y _{2} :10) cm}, {3(X _{1} :2,X _{2} :3) cm x 10 cm}, {2 cm x 12(Y _{1} :8,Y _{2} :4) cm}, {13(X _{1} :9,X _{2} :4) cm x 7 cm} with universal wedges of 15^{°} and 45^{°} with both way of insertion.
Test case 10
Buildup region behavior: 75 number of test points were created in the buildup region form 0.2 cm to 1.0 in steps of 1 mm and 1 cm to 2.2 cm in steps of 2mm for the field sizes of 5, 10, and 20 cm ^{2} with open, shielding tray, and wedge. The doses were measured using a parallel plate chamber.
Test case 11
Shaped fields: Three irregular shapes were created using cerrobend blocks as to simulate 3D conformal treatment and 11 number of test points were created at the depths of 3, 5, 10, and 15 cm for simple and complex geometries.
Results   
Calculated (D_{calc} ) and measured (D_{meas}) dose values were compared for each of the eleven test cases. The TPS dosimetric performance was evaluated by calculating the deviation (δ) at the specific depth, ^{[14],[15],[16]} using
In total, 201 test point measurements and calculations were compared for the 6 MV photon beam of the linear accelerator. The final outcome of the comparison is summarized in [Table 1], in the form of mean, maximum, and minimum deviations.
In test case 1, the TPS calculations for open square fields are in good agreement with measured values presenting a minimum deviation of 0.28 % and a maximum deviation of 1.57 % [Figure 1] and none of the test points exceed the recommended tolerance level of 2%. The results also reveal that as field size increases, deviations become negative, since the TPS tends to underestimate dose in relatively large fields. It may be the limitation of the algorithm that is used, and our results are agreeing with that of Sandilos et al. ^{[16]}  Figure 1 :Dose comparisons: Histograms of the differences between calculated and measured values in percentage for test case 1.
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In test case 2, open rectangular fields were investigated. The minimum and maximum deviations are found to be 0.08% and 2.38% [Figure 2]. Except in two points, all of the test points satisfy the tolerance level of 2%. This finding, combined with the dosimetric verification of calculations for rectangular fields, supports the adequacy of the equivalent square method. Moreover, a trend of TPS dose underestimation with increasing field size is also observed for rectangular fields.  Figure 2 :Dose comparisons: Histograms of the differences between calculated and measured values in percentage for test case 2
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In test case 3, the influence of SSD variation on TPS dose calculations was investigated. The maximum and minimum deviations are found to be 0.15% and 1.44% [Figure 3]. None of the 13 test point measurements exceeded the tolerance level of 3%. As SSD decreases, absolute deviations were found to increase for all field sizes, being within the acceptable tolerance level. TPS dose calculations were smaller than measured values for most of the points.  Figure 3 :Dose comparisons: Histograms of the differences between calculated and measured values in percentage for test case 3
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In test case 4, the influence of introduction of wedge filters in the field were investigated. A minimum deviation of 0.24% and a maximum of 4.09% were observed [Figure 4]. Four of the 12 test points, the deviation are found to be more than the prescribed limit of 3% by Venselaar et al. ^{[15]} TPS was found to overestimate dose and also the deviation between the measured and calculated values were increasing with the wedge angles. In test case 5 the influence of introduction of central block in the beam was investigated. Four test points were measured in the inner beam and ^{[9]} maximum and minimum deviations of 0.13% and 1.92% were observed [Figure 5]. The results for all test points presented positive deviation, which were well within the recommended tolerance limit of 3%. This implies proper configuration of the TPS shielding block.  Figure 4 :Dose comparisons: Histograms of the differences between calculated and measured values in percentage for test case 4
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 Figure 5 :Dose comparisons: Histograms of the differences between calculated and measured values in percentage for test case 5
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In test case 6, the accuracy of dose calculation in the offcentred plane were investigated, presenting a maximum and minimum deviation of 0.4% and 2.64%. Except in two points all other points are well within the tolerance level of 3%. The deviations are presented in [Figure 6]. The test case 7 investigates the influence oblique incidence of beam in the dose calculation algorithm, the deviations were found to be a minimum of 0.92% and a maximum of 0.81% [Figure 7], which is well within the acceptance limit of 3%. The deviations were found to increase with an oblique angle.  Figure 6 :Dose comparisons: Histograms of the differences between calculated and measured values in percentage for test case 6
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 Figure 7 :Dose comparisons: Histograms of the differences between calculated and measured values in percentage for test case 7
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The test case 8 investigates the accountability of density correction by the treatment planning system; the deviations were found to be in the range of 0.93% to 2.67% [Figure 8]. None of the test points exceeded the criterion of 3%. In test case 9, the influence of wedge filters in the asymmetric field were investigated, except in 2 test points of small field sizes all other point the deviations are well within the tolerance level of 4% as shown in the [Figure 9].  Figure 8 :Dose comparisons: Histograms of the differences between calculated and measured values in percentage for test case 8
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 Figure 9 :Dose comparisons: Histograms of the differences between calculated and measured values in percentage for test case 9
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In test case 10, the buildup region behavior was analyzed by measuring dose at 75 test points for open, wedged and shielding tray fields using the parallel plate chamber (PPC40, ScanditronixWellhofer, Germany). The buildup region has been divided into three parts as 2030%, 3080%, and 80100% dose regions. In the region of 0.2 cm to 0.5 cm (2030% dose), a maximum deviation of 14.28% and a minimum deviation of 10.82% is observed, and from 0.6 cm to 1.2 cm (3080% dose region) of buildup region a maximum deviation of 13.16% and a minimum deviation of 3.51% is observed, in the region of 1.2 cm to 1.6 cm a maximum deviation of 15.63% and a minimum deviation of 13.16% is observed for the field size of 10 cm ^{2} [Figure 10]. The same pattern is observed for 5 and 20 cm ^{2} field sizes. The deviation were less only in the region of 30% to 80% of buildup dose region. All the deviations are within the tolerance limit of 20%. ^{[9]} The introduction of shielding tray increases the deviation in the 2030% dose region, and the deviations were found to be in the negative side. In the wedge field, at 3080% of buildup dose region a maximum deviation of 12.61% and a minimum deviation of 1.68% is observed [Figure 11]; it may be due to the beam hardening. The deviations are found to be well below the tolerance limit of 50%. ^{[9]} In test case 11, cerrobend blockshaped field were used, a minimum deviation of 0.44% and a maximum deviation of 5.94% are absorbed [Figure 12], and the maximum deviation is absorbed in the complex geometry. ^{[9]} All other points are well within the tolerance limit of 2%.  Figure 10 :Dose comparisons: Histograms of the differences between calculated and measured values in percentage at different depths for 10 cm2 field size for test case 10
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 Figure 11 :Dose comparisons: Histograms of the differences between calculated and measured values in percentage at different depths for 10 cm2 field size with Shielding tray and wedge for test case 10
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 Figure 12 :Dose comparisons: Histograms of the differences between calculated and measured values in percentage for test case 11
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Discussion   
The first criteria published by Van Dyk et al. in 1993 ^{[10]} are characterized by increased tolerance limits due to the fact that most of the TPS were using twodimensional algorithms at the time. The recommendations of AAPM TG53 report in 1998, ^{[17]} report 7 of the Swiss Society for Radiobiology and Medical Physics (SSRMP) in 1997 ^{[14]} and Venselaar et al. in 2001 ^{[15]} are generally more strict, but realistic for a properly functioning dose calculation algorithm. When the complexity of the geometry increases, however, tolerance limits may have to be less strict relative to beam modelling geometry. In this work the set of tolerance limits proposed by Venselaar et al. and TRS 430 is followed. The test cases used can be divided in three groups in terms of increasing complexity of the test configuration. The first group includes simple geometrical test cases (square and rectangular fields, SSD variation, off centre plane and oblique incidence) where dose calculations are performed in a homogeneous phantom for fields without special accessories. The second group includes complex geometrical test cases (wedge, central block, and inhomogeneities). The third group consists of more complex geometries which include combination of first and second groups. The first group of checks (test cases 1, 2, 3, 6, 7 and 11) has also been studied by Alam et al., ^{[1]} Venselaar et al., ^{[15]} and Sandilos et al. ^{[16]} for the older PLATO versions 1.21, 2.01, and 2.2.3, respectively. The Nucletron Plato version 1.21 employs a twodimensional dose calculation algorithm, while versions 2.01 (Venselaar et al.), 2.2.3 (Sandilos et al.), and 2.7.2 (present study) employ a 3D dose calculation algorithm. Comparing results of these previous studies ^{[1],[15],[16]} with those of the present work for version 2.7.2, a continuous improvement of the system is evident. Although older TPS versions also met the tolerance limit for these test cases, a reduction of calculated to measured dose deviations is reported here. The above conclusion assumes ideal modeling of these systems.
In the second group of checks (test cases 4, 5 and 8), differences between the calculated and measured values are well within the tolerance limit of ±3% except for some points in the wedged fields. The present results are comparable with that of Sandilos et al. ^{[16]} Third group of check (Test case 9) examines more complex geometries, and most of the test point results fall within ±4% of tolerance.
However, it should be noted that only the accuracy of the dose calculation algorithm has been investigated without examining other potential inaccuracies associated with the geometry in the TPS (CT image acquisition and transfer, graphical display of 3D radiation beams, etc.). In addition, results of this work are limited to the 6 MV of the Linear accelerator photon beams.
Conclusion   
An attempt has been made to study the performance of the TPS (PLATO V 2.7.2) by using 11 numbers of test cases and 201point dose measurements for a 6 MV photon beam. The measured and TPScalculated point doses are well within the tolerance of ±5%. The study concludes that (i) for higher field sizes the TPS tends to underestimate the dose for both square and rectangular field sizes, (ii) for smaller SSDs the deviations were found to increase, (iii) TPS was found to overestimate the dose for increasing wedge angles, (iv) the deviation were found to increase with an increase of obliquity of a beam angle, (v) in the buildup region analysis, the deviation were less only in the 3080% of buildup dose region, the deviation were found to be less in wedged fields when compared with open fields and this may be due to the beam hardening effect.
The study has ensured the correctness of the beam data entered in the TPS during the commissioning. The usefulness of test data provided by TRS 430 and Venselaar et al. are verified for QA and intercomparison of new radiotherapy treatment planning systems. Nevertheless, the beam modelling and basic data entered in each system depend on the user and the particular features of each system. This present methodology may be used to inter compare TPS, in various hospitals. This study also ensures that dosimetric calculations performed by the TPS is very accurate and enables the user to achieve the accuracy of ±5%, which is very much warranted in patient dose delivery.
Acknowledgement   
We acknowledge and thank the Dr. Kamakshi Memorial Hospital and the management for the providing the facility to carry out the work.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]
[Table 1]
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