Journal of Medical Physics
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   2018| April-June  | Volume 43 | Issue 2  
    Online since June 18, 2018

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Dosimetric comparison of irregular surface compensator and field-in-field for whole breast radiotherapy
Nao Kuwahata, Hideki Fujita, Hideaki Yamanishi, Eiichiro Okazaki, Haruyuki Fukuda
April-June 2018, 43(2):79-84
DOI:10.4103/jmp.JMP_73_17  PMID:29962684
Purpose: The purpose of the present study was to evaluate the dosimetric benefits of the irregular surface compensator (ISC) technique for whole breast radiotherapy compared with the field-in-field (FIF) technique. Materials and Methods: Radiotherapy was planned using both techniques in 50 breast cancer patients (25 left sided and 25 right sided). The Eclipse treatment planning system (Varian Medical Systems) was used for dose calculations. For the FIF technique, subfields were added to the main fields to reduce hot and cold regions; for the ISC technique, the fluence editor application was used to extend the optimal fluence. Planning target volume dose, dose homogeneity index (DHI), maximum dose, ipsilateral lung, and heart doses for the left breast irradiation and monitor unit (MU) counts required for treatment were compared between the two techniques. Results: Compared with the FIF technique, the ISC technique significantly decreased DHI values and volumes receiving >105% of the prescription dose, and increased volumes receiving >95% of the dose and MU count (P < 0.01 for all comparisons). For the heart and ipsilateral lung, the FIF technique significantly reduced volumes receiving >5 Gy compared with the ISC technique (P < 0.01); however, volumes receiving >10, 20, and 30 Gy and the values of a mean dose did not differ significantly between the techniques (P > 0.05). Conclusions: The ISC technique is preferred over the FIF technique.
  1,184 172 -
Validation of a software upgrade in a monte carlo treatment planning system by comparison of plans in different versions
P Mohandass, D Khanna, D Manigandan, Narendra Kumar Bhalla, Abhishek Puri
April-June 2018, 43(2):93-99
DOI:10.4103/jmp.JMP_7_18  PMID:29962686
Purpose: Validation of a new software version of a Monte Carlo treatment planning system through comparing plans generated by two software versions in volumetric-modulated arc therapy (VMAT) for lung cancer. Materials and Methods: Three patients who were treated with 60 Gy/30 fractions in Elekta Synergy™ linear accelerator by VMAT technique with 2% statistical uncertainty (SU) were chosen for the study. Multiple VMAT plans were generated using two different software versions of Monaco treatment planning system TPS (V5.10.02 and V5.11). By keeping all other parameters constant, originally accepted plans were recalculated for the SUs of 0.5%, 1%, 2%, 3%, 4%, and 5%. For plan evaluation, the metrics compared were conformity Index (CI), homogeneity Index (HI), dose coverage to planning target volume (PTV), organ at risk (OAR) doses to spinal cord, pericardium, bilateral lungs-PTV, esophagus, liver, normal tissue integral dose (NTID), volumes receiving dose >5 and >10 Gy, calculation time (tCT), and gamma pass rates. Results: In both versions, CI and HI improved as the SU increased from 0.5% to 5%. No significant dose difference was observed in Dmean to PTV, bilateral lungs-PTV, pericardium, esophagus, liver, normal tissue volume receiving >5, and >10 Gy and NTID. It was observed that while the tCT and gamma pass rates decreased, the maximum dose to PTV increased as the SU increased. No other significant dose differences were observed between the two MC versions compared. Conclusion: For lung VMAT plans, in both versions, SU could be accepted up to 3% per plan with reduced tCT without compromising plan quality and deliverability by accepting variations in point dose and an inhomogeneous dose within the target. The plan quality of Monaco™V5.10.02 was similar to Monaco™TPS-V5.11 except for tCT.
  1,083 162 -
Radiation dose measurements in a 256-slice computed tomography scanner
Victor J Weir, Jie Zhang
April-June 2018, 43(2):85-92
DOI:10.4103/jmp.JMP_129_17  PMID:29962685
Purpose: The purpose of this study is to compare computed tomography (CT) radiation dose measurement methods proposed by TG111, International Electrotechnical Commission (IEC), and a direct dose profile integral (DPI) measurement method. Methods: Pencil and Farmer ion chambers are used for integrating dose profiles at different beam widths in a 60 cm long body phantom. Resulting DPI is used to calculate CT dose index (CTDI) at each beam width. Measurements are also done for a pencil chamber inserted into a 15 cm body phantom at the reference beam width. The reference measurement is scaled with pencil chamber measurements in air at different beam widths, according to the IEC approach. Finally, point dose measurements are done with a Farmer chamber under equilibrium conditions according to the TG111 method. All CTDIs calculated from measured data are compared to the scanner displayed CTDIs. Results: Calculated CTDIs, at different beam widths, using the IEC approach are within 20% of CTDIs calculated from DPI measurements in a 60 cm long body phantom. Dose Length Integral (DLI) obtained from TG111 method is close to the results obtained from DPI measurements. Scanner displayed CTDIs are lower than all measured values by up to 38% at the techniques used. Conclusion: Although the IEC method is the easiest to use compared to the TG111 and direct DPI measurement method, it underestimates dose indices by about 20%. CTDIs displayed on the GE scanner are lower than those measured in this study by up to 38%.
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Patient-Specific quality assurance protocol for volumetric modulated arc therapy using dose volume histogram
Christopher Low, Warren Toye, Peter Phung, Christopher Huston
April-June 2018, 43(2):112-118
DOI:10.4103/jmp.JMP_138_17  PMID:29962689
A retrospective study was performed to explore the use of dose volume histogram (DVH) metrics in a patient-specific quality assurance protocol for volumetric modulated arc therapy (VMAT). Fourteen head and neck (HN) and ten brain patients treated with VMAT at the Launceston General Hospital were retrospectively analyzed using the new protocol to identify cases where patient dose errors exceed the established action levels that were not originally detected by either point dose and/or gamma index methods. The Sun Nuclear 3DVH software was used to estimate the dose delivered to the patient volume in terms of DVH dose errors. Thus, three different pretreatment verification methods were used to assess if a plan was considered acceptable. In two particular cases, the dose difference determined with point dose was above the established threshold, although it was found that this was due to the placement of the chamber in the phantom. In all cases, 3DVH confirmed that the dose delivered to target volumes (planning target volume – D50%) and to relevant organs at risk was within prescribed dose tolerances.This study has demonstrated the integration of DVH metrics into a VMAT PSQA protocol to provide clinically meaningful results that complement point dose and gamma index measurements. 3DVH should be regarded as an investigative tool that may be useful in diagnosing the cause of failed plans since it allows dose errors to be related to the patient anatomy.
  725 128 -
Dosimetric, radiobiological and secondary cancer risk evaluation in head-and-neck three-dimensional conformal radiation therapy, intensity-modulated radiation therapy, and volumetric modulated arc therapy: A phantom study
Jalil Ur Rehman, Muhammad Isa, Nisar Ahmad, Gulfam Nasar, H M. Noor Ul Huda Khan Asghar, Zaheer Abbas Gilani, James C. L. Chow, Muhammad Afzal, Geoffrey S Ibbott
April-June 2018, 43(2):129-135
DOI:10.4103/jmp.JMP_106_17  PMID:29962691
This analysis estimated secondary cancer risks after volumetric modulated arc therapy (VMAT) and compared those risks to the risks associated with other modalities of head-and-neck (H&N) radiotherapy. Images of H&N anthropomorphic phantom were acquired with a computed tomography scanner and exported via digital imaging and communications in medicine (DICOM) standards to a treatment planning system. Treatment plans were performed using a VMAT dual-arc technique, a nine-field intensity-modulated radiation therapy (IMRT) technique, and a four-field three-dimensional conformal therapy (3DCRT) technique. The prescription dose was 66.0 Gy for all three techniques, but to accommodate the range of dosimeter responses, we delivered a single dose of 6.60 Gy to the isocenter. The lifetime risk for secondary cancers was estimated according to National Council on Radiation Protection and Measurements (NCRP) Report 116. VMAT delivered the lowest maximum doses to esophagus (23 Gy), and normal brain (40 Gy). In comparison, maximum doses for 3DCRT were 74% and 40%, higher than those for VMAT for the esophagus, and normal brain, respectively. The normal tissue complication probability and equivalent uniform dose for the brain (2.1%, 0.9%, 0.8% and 3.8 Gy, 2.6 Gy, 2.3 Gy) and esophagus (4.2%, 0.7%, 0.4% and 3.7 Gy, 2.2 Gy, 1.8 Gy) were calculated for the 3DCRT, IMRT and VMAT respectively. Fractional esophagus OAR volumes receiving more than 20 Gy were 3.6% for VMAT, 23.6% for IMRT, and 100% for 3DCRT. The calculations for mean doses, NTCP, EUD and OAR volumes suggest that the risk of secondary cancer induction after VMAT is lower than after IMRT and 3DCRT.
  697 91 -
Validation of delivery consistency for intensity-modulated radiation therapy and volumetric-modulated arc therapy plans
Wui Ann Woon, Paul B Ravindran, Piyasiri Ekayanake, Yivonne Yih Fang Lim
April-June 2018, 43(2):119-128
DOI:10.4103/jmp.JMP_109_17  PMID:29962690
The delivery consistency of a Varian Edge linear accelerator over the entire course of treatment for nasopharynx carcinoma (NPC) and prostate cancer intensity-modulated radiation therapy (IMRT) and volumetric-modulated arc therapy (VMAT) treatment plans was investigated using four different approaches. Three NPCs and three prostate plans were delivered in 34 and 29 consecutive days, respectively, using a Varian Edge equipped with a 120 high-definition (HD) multileaf collimator (MLC). All deliveries were measured with an electronic portal imaging device (EPID), and MapCheck2 and ArcCheck commercial systems with gamma analysis used to compare the results of all daily measurements against the pretreatment patient-specific quality assurance. The daily log files generated were also assessed for differences between the actual and planned doses using an in-house program to replace the original values in the DICOM plan files with the delivered parameter values from the log file, and then exporting the plans back to the treatment planning system for reconstruction of the actual dose delivered. The trajectory log file and EPID methods showed very good agreement, with minimal deviations between the daily delivered and reference doses. However, comparisons of the MapCheck2 and ArcCheck with the EPID revealed statistically significant differences (P < 0.001, one-tailed) with greater daily fluctuations, raising concerns over the performance, and reliability of the MapCheck2 and ArcCheck systems when being used to identify IMRT and VMAT plans with poor dosimetric accuracy. We conclude that the Varian Edge linear accelerator equipped with a 120 HD MLC can consistently deliver IMRT and VMAT plans over the entire treatment course.
  530 103 -
A practical method to optimize quality assurance results of arc therapy plans in beam modeling
Jinyu Xue, Hesheng Wang, David Barbee, Matthew Schmidt, Indra J Das
April-June 2018, 43(2):106-111
DOI:10.4103/jmp.JMP_144_17  PMID:29962688
Dosimetric accuracy of a volumetric modulated arc therapy (VMAT) plan is directly related to the beam model, particularly with multileaf collimator characterization. Inappropriate dosimetric leaf gap (DLG) value can lead to a suboptimal beam model, with significant failure in patient-specific quality assurance (PSQA) of VMAT plans. This study addressed the systematic issue of beam modeling and developed a practical method to determine the optimal DLG value for a beam model. Several complex VMAT plans were selected for the quality assurance analysis using the variable DLG values. The results of three-dimensional (3D) Gamma analysis as a function of the DLG at 3%/3 mm, 2%/2 mm, and 1%/1 mm criteria were fitted by a polynomial curve. The DLG value corresponding to the maximum Gamma passing rate for each polynomial fitting function was derived, and the average was calculated to be the optimal DLG value for each model. The 3D Gamma analysis was repeated with the optimal DLG value to verify the dosimetric accuracy of each VMAT case by PSQA. Gamma passing rates are seen to vary considerably with the DLG values and different analysis criteria (3%/3 mm, 2%/2 mm, and 1%/1 mm) for each case. The optimal DLG derived for each model was 1.16 mm and 1.10 mm, much larger than the measured value (about 0.3 mm). The beam models with the optimal DLG was able to produce an average Gamma passing rate of 97.1% (range, 94.6%– 99.1%) at 3%/3 mm and 93.5% (range, 89.0%– 96.5%) at 2%/2 mm for one beam model, and 97.1% (range, 94.8%– 99.1%) at 3%/3 mm, and 93.3% (range, 88.8%– 96.7%) at 2%/2 mm for another. The overall accuracy of dose calculation for VMAT plans should be optimized with a compromise of varied modulation complexities in a beam model. We have developed a practical method to derive the optimal DLG value for each beam model based on the Gamma passing criterion. This technique should be applicable in general for all beam energies and patient cases.
  471 93 -
A homogeneous water-equivalent anthropomorphic phantom for dosimetric verification of radiotherapy plans
Manikandan Arjunan, Sureka Chandra Sekaran, Biplab Sarkar, Sujatha Manikandan
April-June 2018, 43(2):100-105
DOI:10.4103/jmp.JMP_123_17  PMID:29962687
Water is treated as radiological equivalent to human tissue. While this seems justified, there is neither mathematical proof nor sufficient experimental evidence that a water phantom can be treated as equivalent to human tissue. The aim of this work is to simulate and validate a water phantom that is tissue equivalent in terms of the dosimetric characteristics of both water and human tissue Dynamic, intensity-modulated radiotherapy plans for two head and neck, one brain, one pelvis, and three lung/mediastinum cases were chosen for this study. Using a treatment planning system (TPS) (Eclipse, Varian Medical System, Polo Alto, CA, USA) and Anisotropic Analytic Algorithm in a grid resolution of 5 mm × 5 mm, a patient-equivalent water phantom was calculated from all rays in the isocentric plane as an array of water equivalent depths (dWE). These rays were plotted versus isocentric separation and ray-tracing direction.Planar doses were compared between the isocentric plane in the patient computed tomography and the water equivalent phantom using gamma criteria of 2%–2 mm and 3%–3 mm. Except in one lung case, >95% gamma agreement was seen when using 3%–3 mm and >90% pass rate was seen when using 2%–2 mm. For head and neck cases, gamma-fail was restricted to the periphery. For mediastinum cases, gamma-fail was restricted to the lungs. This study demonstrates that a heterogeneous patient can be converted to a water phantom with comparable dosimetric characteristics and disagreements restricted to the lung area for both modulated and open beams. Potential sources of error include the dWEcalculation and TPS dose computation.
  407 126 -
Interfraction dose variations in organs at risk during CT-based high-dose-rate brachytherapy in locally advanced carcinoma cervix: An early experience of a tertiary care Center
Neelam Sharma, Manoj K Semwal, Abhishek Purkayastha
April-June 2018, 43(2):136-140
DOI:10.4103/jmp.JMP_136_17  PMID:29962692
Purpose: Dose received by organs at risk (OAR) in high-dose-rate (HDR) intracavitary brachytherapy (ICBT) for locally advanced cervical cancer impacts the late toxicity profile of the treatment. In the present study, we analyzed the inter-fraction variations of the minimum dose received by the most irradiated 2cc volumes (D2cc) of the OARs in ICBT. Methods and Materials: This prospective study included 40 patients with cervical cancer stage FIGO IIB-IVA treated with HDR ICBT and concomitant chemoradiotherapy with Computerized tomography (CT)- based three-dimensional planning. In addition, for 20 (of the 40) patients, the first fraction plan was superimposed on the second fraction images for studying its dosimteric impact on the OAR. The D2ccdata for the OAR was statistically analyzed for interfraction variations with Chi-square test or Fisher exact test as applicable. Paired t-test was used to compare the difference in means for the D2ccvalues between the three fractions. Results: The interfraction variations of the D2ccvalues of the OAR were statistically insignificant having P = 0.41, 0.8, and 0.20 for bladder, rectum, and sigmoid, respectively. Further, in 6 out of 20 cases, wherein first fraction plan was superimposed on second fraction images, the OAR doses exceeded the prescribed tolerance limits. Conclusion: We did not find variations in the OAR doses when each fraction was planned and treated individually. However, we found that if a single plan is used to treat subsequent fractions, OAR doses may exceed tolerance in about 30% of the cases. We believe that a larger sample size with improved compliance of bladder and bowel protocols would be needed to arrive at definitive conclusions.
  393 90 -
Documentation of a new intracavitary applicator for transrectal hyperthermia designed for prostate cancer cases: A phantom study
Vassilis Kouloulias, Aggeliki Nikolakopoulou, Irene Karanasiou, Christos Antypas, Christina Armpilia, Nikolaos Uzunoglou
April-June 2018, 43(2):141-145
DOI:10.4103/jmp.JMP_67_17  PMID:29962693
Concerning clinical trials, intracavitary hyperthermia has already shown antitumor activity and has a potential role in the treatment of prostate cancer. The aim of this study was to document a new intracavitary applicator operating at 433 MHz, designed for transrectal hyperthermia, as well as to assess the specific absorption rate (SAR) distributions in terms of temperature measurements in a soft-tissue phantom. The microwave applicator consists of a dipole-type λ/2, a reflector, and the cooling system. The applicator was placed into a soft-tissue gel-phantom box that was mimicking the dielectric properties of the normal tissue. A calibrated thermometer was implanted inside the phantom at specific locations, to calculate temperature distributions. The maximum value of the SAR was 108 W/kg on the surface's central area at the footprint of the antenna, while the penetration depth was at around 3 cm. Our experimental measurements confirmed the role of the reflector concerning the directivity in a certain area and non icotropic, by means of protecting normal tissues around the prostate. The SAR experimental measurements showed that our applicator might be used effectively as a treatment device for prostate cancer, demonstrating a clear advantage over other similar transrectal devices.
  339 67 -
Erratum: Magnetic resonance imaging for adaptive cobalt tomotherapy: A proposal

April-June 2018, 43(2):146-146
DOI:10.4103/0971-6203.234536  PMID:29962694
  180 54 -
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