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SWSW--AAPMAAPM--FMOFM Joint Meeting FMOFM Joint Meeting QuerQueréétaro 2007 taro 2007
IGRT;IGRT;Implications for Implications for
Quality AssuranceQuality AssuranceLuis Fong, Ph.D.
SWSW--AAPMAAPM--FMOFM Meeting 2007FMOFM Meeting 2007IGRT; Implications for QAIGRT; Implications for QA
* Sandra Vieira, “Dosimetric Verification of Intensity Modulated Radiotherapy with an Electronic Portal Imaging Device”. Thesis, 2005. (drawn by Andy Bahnert)
Image-Guided Radiation Therapy (IGRT) concept
SWSW--AAPMAAPM--FMOFM Meeting 2007FMOFM Meeting 2007IGRT; Implications for QAIGRT; Implications for QA
RT ProcessPrescription
Setup & Immobilization
Image Acquisition
Treatment Planning& Evaluation
Information Transfer& Management
Evaluation & Verification
TreatmentDelivery
PlanValidation
Corrective Intervention
MonitoringTreatment
IGRT FB loop
Target Localization
Technologies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
+ IGRT
Advantages:
SWSW--AAPMAAPM--FMOFM Meeting 2007FMOFM Meeting 2007IGRT; Implications for QAIGRT; Implications for QA
Target Localization Technologies (TLT)
Cyberknife
kV RadiographicUltrasound Portal Imaging
Varian OBI™Elekta Synergy™TomoTherapyHi-Art™
Siemens PRIMATOM™
kV and MV Cone-beam CTMV CTkV CT
Markers(Active & Passive)
Courtesy of Michael Sharpe, Ph.D. Princess Margaret Hospital, Toronto, CANADA
SWSW--AAPMAAPM--FMOFM Meeting 2007FMOFM Meeting 2007IGRT; Implications for QAIGRT; Implications for QA
IGRT implementation process
• Decided that is time for IGRT
• Shop around• Purchase the
technology• Acceptance testing• Clinical
Commissioning
• Develop QA periodic tests:– Daily– Weekly– Monthly– Annual
• Provide proper training
• Ready to Go...
SWSW--AAPMAAPM--FMOFM Meeting 2007FMOFM Meeting 2007IGRT; Implications for QAIGRT; Implications for QA
IGRT Feedback LoopPrescription
Setup & Immobilization
Imaging Acquisition
Treatment Planning& Evaluation
Information Transfer& Management
Corrective Intervention
Evaluation & Verification
MonitoringTreatment
TreatmentDelivery
PlanValidation
IGRT FB loop
SWSW--AAPMAAPM--FMOFM Meeting 2007FMOFM Meeting 2007IGRT; Implications for QAIGRT; Implications for QA
Clinical Implementation of ANYNew Technology
• Define clinical Questions BEFORE You Start!• Do your homework:
– Understand the IGRT solution: the clinical and technological limitations, the implementation process and the clinical advantages of the particular technology (papers, research, meetings, conferences, workshops, etc.)
• Understand how well the IGRT solution answers the clinical question you want to address.
• Understand how well the IGRT solution fits into the processes and infrastructure of your clinic.
• Get What you Need and also better fits your Processes!
SWSW--AAPMAAPM--FMOFM Meeting 2007FMOFM Meeting 2007IGRT; Implications for QAIGRT; Implications for QA
Other Implications of new IGRT solutions
• Computing, networks, data storage
• Workload & workflow– Planning, Imaging, Treatment
time
• Risk/Benefit: – Imaging dose to untreated
anatomy– Geometric miss
• Backup system in case of IGRT solution failure
• Inter-discipline collaboration– shifting from traditional roles
• Decision making– Professional autonomy,
scope of practice
• Training & Education– Adoption– Practice guidelines,
communication and adaptation
– Organizational learning
SWSW--AAPMAAPM--FMOFM Meeting 2007FMOFM Meeting 2007IGRT; Implications for QAIGRT; Implications for QA
IGRT implementation process
• Decided that is time for IGRT
• Shop around• Purchase the
technology• Acceptance testing• Clinical
Commissioning
• Develop QA periodic tests:– Daily– Weekly– Monthly– Annually
• Provide proper training
• Ready to Go...
There are no specific QA guidelines for
all the new technologies
SWSW--AAPMAAPM--FMOFM Meeting 2007FMOFM Meeting 2007IGRT; Implications for QAIGRT; Implications for QA
Example of Clinical Implementation of IGRT Solutions
SWSW--AAPMAAPM--FMOFM Meeting 2007FMOFM Meeting 2007IGRT; Implications for QAIGRT; Implications for QA
Definition of the Clinical Application
• The primary applications of EPID include:– Verification of patient setup– Assessment of target and organ motion. – Daily localization for prostate cancer patients
• Current research includes use of EPIDs:– for compensator design and verification, – treatment machine QA– patient dosimetry
SWSW--AAPMAAPM--FMOFM Meeting 2007FMOFM Meeting 2007IGRT; Implications for QAIGRT; Implications for QA
Understanding the technology behind the solution
ConverterDetector
Data AcquisitionData ConversionImager Controller
Software Tools:• Image Acquisition Control• Image Enhancement • Image Analysis• Image Review• Matching
Beam
ImageStorage
Connectivity with other systems
SWSW--AAPMAAPM--FMOFM Meeting 2007FMOFM Meeting 2007IGRT; Implications for QAIGRT; Implications for QA
Understand the Clinical Application of the IGRT solution
EPID for Treatment of Prostate Cancer
Bony Anatomy Vs. Fiducial Markers
SWSW--AAPMAAPM--FMOFM Meeting 2007FMOFM Meeting 2007IGRT; Implications for QAIGRT; Implications for QA
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15mm
Perc
ent
3DI VM 3DI B.A. 3DF VM 3DF B.A.
Effect of Correction: 3D - Target vs. Bones
Target p < 0.001Bones p = 0.46
Bones No change
Target Better
SWSW--AAPMAAPM--FMOFM Meeting 2007FMOFM Meeting 2007IGRT; Implications for QAIGRT; Implications for QA
0%
20%
40%
60%
80%
100%
0 2 4 6 8 10 12 14
mm
Perc
ent
Pre VM C-C Pre B.A. C-C Thru VM C-C Thru B.A. C-C
Effect of Correction: Sup-Inf Component
Target better p<0.001
Fiducial MarkersVs.
Bony anatomy
Bones worse p<0.001
SWSW--AAPMAAPM--FMOFM Meeting 2007FMOFM Meeting 2007IGRT; Implications for QAIGRT; Implications for QA
Using formulation proposed by Van Herk IJROBP 2002
Impact on Margins
SWSW--AAPMAAPM--FMOFM Meeting 2007FMOFM Meeting 2007IGRT; Implications for QAIGRT; Implications for QA
Understanding and Testing the IGRT ToolDetected Field Edge Reference Field Edge
Anatomy MatchingDifference
SWSW--AAPMAAPM--FMOFM Meeting 2007FMOFM Meeting 2007IGRT; Implications for QAIGRT; Implications for QA
Shift Calculation Spreadsheet
SWSW--AAPMAAPM--FMOFM Meeting 2007FMOFM Meeting 2007IGRT; Implications for QAIGRT; Implications for QA
Shift Calculation and AssessmentPre-port Ant Field
Pre-port Right Lat Field
SWSW--AAPMAAPM--FMOFM Meeting 2007FMOFM Meeting 2007IGRT; Implications for QAIGRT; Implications for QA
Patient data base
SWSW--AAPMAAPM--FMOFM Meeting 2007FMOFM Meeting 2007IGRT; Implications for QAIGRT; Implications for QA
Implementation of IGRT solution in the Clinic Process Flow
Gold seeds implanted in the patient Simulation
R & V System(Multi-AccessTM)
Tx Planning:Localization fields are part of Tx
Contour seeds and bonny anatomy
Corrective Intervention
Information transfer from TPS to:
Matching Software(Portal-VisionTM)
Images Acquired(Localization Fields)
Patient TxMonitoring Tx
Patient Setup
IGRT FB loop
SWSW--AAPMAAPM--FMOFM Meeting 2007FMOFM Meeting 2007IGRT; Implications for QAIGRT; Implications for QA
IGRT Feedback Loop
Yes
Excel spreadsheetData entree and Calc
ANT & RT LATPre-Tx
Images during Tx(Two Fields)Patient Tx
Physician reviews &Approves
Matching(Portal-VisionTM)
Patient Setup
Matching(Portal-VisionTM)
If SystematicShift
Physicist reviews shifts (After 5 Tx’s)
RecommendsSystematic shift
Apply shift
No
If 3D > 4mm
Yes
SWSW--AAPMAAPM--FMOFM Meeting 2007FMOFM Meeting 2007IGRT; Implications for QAIGRT; Implications for QA
IGRT Feedback Loop
YesYes
Excel spreadsheetData entree and Calc
ANT & RT LATPre-Tx
Images during Tx(Two Fields)Patient Tx
Physician reviews &Approves
Matching(Portal-VisionTM)
Patient Setup
Matching(Portal-VisionTM)
If SystematicShift
Physicist reviews shifts (After 5 Tx’s)
RecommendsSystematic shift
Apply shift
NoNo
If 3D > 4mm
YesYes
Successful IGRT QA program
Gold seeds implanted in the patient Simulation
R & V System(Multi-AccessTM)
Tx Planning:Localization fields are part of Tx
Contour seeds and bonny anatomy
Corrective Intervention
Information transfer from TPS to:
Matching Software(Portal-VisionTM)
Images Acquired(Localization Fields)
Patient TxMonitoring Tx
Patient Setup
IGRT FB loop
SWSW--AAPMAAPM--FMOFM Meeting 2007FMOFM Meeting 2007IGRT; Implications for QAIGRT; Implications for QA
General QA points for EPID imager• Safety
– Arm and Imager collision interlock (Monthly)
• Mechanical Functionality– Arm and imager position
(Monthly)• Image quality
– Calibration (Monthly)– Noise (Daily & Monthly)– Contrast (Daily & Monthly)
• Data Transfer
SWSW--AAPMAAPM--FMOFM Meeting 2007FMOFM Meeting 2007IGRT; Implications for QAIGRT; Implications for QA
New Technologiesor
Technology Upgrades
SWSW--AAPMAAPM--FMOFM Meeting 2007FMOFM Meeting 2007IGRT; Implications for QAIGRT; Implications for QA
1.15 mm 0.75 mm 0.35 mm18S-3/218S-5/218S-4/235-5/3
0.46 mm0.89 mm
0.75 mm0.75 mm
MV
MV Image6 MV6 MU
400 MU/min
kV
kV Image75 kV80 mA40 ms
COOKTM Coils (Platinum) VisiCoilsTM (Gold)
SWSW--AAPMAAPM--FMOFM Meeting 2007FMOFM Meeting 2007IGRT; Implications for QAIGRT; Implications for QA
New Hardware 4DITCTM
OBITM
Investigate how the new
technology fits into our processes and
infrastructure
SWSW--AAPMAAPM--FMOFM Meeting 2007FMOFM Meeting 2007IGRT; Implications for QAIGRT; Implications for QA
Guideline for QA MV, kV & CB-CT
SWSW--AAPMAAPM--FMOFM Meeting 2007FMOFM Meeting 2007IGRT; Implications for QAIGRT; Implications for QA
Preparing for 4D IGRT
SWSW--AAPMAAPM--FMOFM Meeting 2007FMOFM Meeting 2007IGRT; Implications for QAIGRT; Implications for QA
0 %
4D CT & Phase Sorting
10 %
20 %
30 %
40 %
50 %
60 %
70 %80 %
90 %
• Use time-stamps to correlate:
Surrogate Phase
Image Phase
• GE LightspeedTM
scanner• Varian RPMTM
respiration management system
Courtesy of Yildirim Mutaf Ph.D.
SWSW--AAPMAAPM--FMOFM Meeting 2007FMOFM Meeting 2007IGRT; Implications for QAIGRT; Implications for QA
Improving Temporal Accuracy • Quality of 4D imaging relies on accurate association of
the surrogate motion with the target– Accurate respiration determination / surrogate information– Temporal Accuracy → Spatial Accuracy
• In order to test the validity of the calculations performed by the commercial system, an in-house phase-calculation software was developed– Uses the raw data for the amplitude of the surrogate
displacement
Courtesy of Yildirim Mutaf Ph.D.
SWSW--AAPMAAPM--FMOFM Meeting 2007FMOFM Meeting 2007IGRT; Implications for QAIGRT; Implications for QA
PhaseCalc-ulation Software• User-friendly interface• Receives the raw data for the
displacement record of the surrogate marker
• Performs an independent calculation for the phase of the motion
• Compares the independent result to vendor calculation
• Lists the deviations as a list of slice locations for easier interpretation
Courtesy of Yildirim Mutaf Ph.D.
SWSW--AAPMAAPM--FMOFM Meeting 2007FMOFM Meeting 2007IGRT; Implications for QAIGRT; Implications for QA
Example Case• A valid respiration peak was missed with the commercial software
causing sub-optimal phase assignments to be used during image sorting…
• Deviations are observed for about 45 % of the clinical 4DCT cases– As large as 4-5 missing peaks are also observed…
• Similar observations are reported by other investigatorsE. R. Reitzel, G. T. Chen, Med. Phys. 33, 377 (2006)
A real patient study
Courtesy of Yildirim Mutaf Ph.D.
SWSW--AAPMAAPM--FMOFM Meeting 2007FMOFM Meeting 2007IGRT; Implications for QAIGRT; Implications for QA
Modified Phase Assignments
Pixel Difference Image=-Original Phase
Assignments
Cor
onal
Vie
w 1
Cor
onal
Vie
w 2
Courtesy of Yildirim Mutaf Ph.D.
SWSW--AAPMAAPM--FMOFM Meeting 2007FMOFM Meeting 2007IGRT; Implications for QAIGRT; Implications for QA
Comparing new IGRT solutions with what you already know
EPID+
Fiducial Markers
New Immobilization
Devices
2D kV Imaging
Gating
Ultrasound
SWSW--AAPMAAPM--FMOFM Meeting 2007FMOFM Meeting 2007IGRT; Implications for QAIGRT; Implications for QA
SWSW--AAPMAAPM--FMOFM Meeting 2007FMOFM Meeting 2007IGRT; Implications for QAIGRT; Implications for QA
The residual motion considered in the planning process was around 5 mm
SWSW--AAPMAAPM--FMOFM Meeting 2007FMOFM Meeting 2007IGRT; Implications for QAIGRT; Implications for QA
Conclusion• Define the clinical application.• Create a team representing the different areas of the
department, that will use and manage the IGRT solution.• Take some time to understand the IGRT solution.• Look for the IGRT solution that addresses your clinical
need. • Understand how well the IGRT solution fits into the
processes and infrastructure of your clinic.• Get What you Need.• Test, Test, Test…• Develop a comprehensive QA program
that fits your processes.
SWSW--AAPMAAPM--FMOFM Meeting 2007FMOFM Meeting 2007IGRT; Implications for QAIGRT; Implications for QA
Contributions• Michael Herman, Ph.D., Mayo Clinic, Rochester, MN• Jon Kruse, Ph.D. , Mayo Clinic, Rochester, MN• Yildirim Mutaf, Ph.D. , Mayo Clinic, Rochester, MN• Michael Sharpe, Ph.D. Princess Margaret Hospital, Toronto, CA
SWSW--AAPMAAPM--FMOFM Meeting 2007FMOFM Meeting 2007IGRT; Implications for QAIGRT; Implications for QA
Some Useful References• Herman, M. G., J. M. Balter, et al. (2001). "Clinical use of electronic portal imaging: report of
AAPM Radiation Therapy Committee Task Group 58." Medical Physics 28(5): 712-37.• Yoo, S., G. Y. Kim, et al. (2006). "A quality assurance program for the on-board imagers." Medical
Physics 33(11): 4431-47.• Van den Heuvel, F., T. Powell, et al. (2003). "Independent verification of ultrasound based image-
guided radiation treatment, using electronic portal imaging and implanted gold markers." Medical Physics 30(11): 2878-87.
• Serago, C. F., S. J. Buskirk, et al. (2006). "Comparison of daily megavoltage electronic portal imaging or kilovoltage imaging with marker seeds to ultrasound imaging or skin marks for prostate localization and treatment positioning in patients with prostate cancer." International Journal of Radiation Oncology, Biology, Physics 65(5): 1585-92.
• Berbeco, R. I., T. Neicu, et al. (2005). "A technique for respiratory-gated radiotherapy treatment verification with an EPID in cine mode." Physics in Medicine & Biology 50(16): 3669-79.
• Schallenkamp, J. M., M. G. Herman, et al. (2005). "Prostate position relative to pelvic bony anatomy based on intraprostatic gold markers and electronic portal imaging." International Journal of Radiation Oncology, Biology, Physics 63(3): 800-11.
• Keall PJ, Mageras GS, Balter JM, et al., “The management of respiratory motion in radiation oncology; AAPM Report No. 91, Task Group 76”, Med Phys (2006);33: pp. 3874–3900.
SWSW--AAPMAAPM--FMOFM Meeting 2007FMOFM Meeting 2007IGRT; Implications for QAIGRT; Implications for QA
Thanks!
Ready for some
questions
?
SWSW--AAPMAAPM--FMOFM Meeting 2007FMOFM Meeting 2007IGRT; Implications for QAIGRT; Implications for QA