RadiationOncology,Physics,Image GuidedRadiotherapy(IGRT)

ID: 000491

Approved:30 Aug 2011

Last Modified: 29 Oct 2012

Review Due:30 Aug 2012

Target Audience:

ThisprotocolisaimedatprovidinginformationonImageGuidedRadiotherapy (IGRT)principlesandpracticesforthefollowingradiationoncologyhealth professionals:

I I I I

RadiationOncologists RadiationOncologyRegistrars RadiationOncologyMedicalPhysicsRegistrars RadiationTherapists

Overview

Thisprotocolisdesignedtobeusedasaneducationalresourceand provideanoverviewtoImageGuidedRadiotherapy(IGRT)principlesand practices. IGRTinvolvesdailyimagingandpositioninginterventionto accuratelytargetthetumour. IGRT deliveryhasdevelopedquicklyforsometreatmentsites.The inherentcomplexityofIGRTforeachtreatmentsiteisvariableand dependentonfactorssuchastargetdose,organsatrisk(OAR)doses, stabilityofpositionandinternalorganmotion. Advancesinavailabletechnology,suchasremotecouchmotion,andthe capabilityforkVimagingonmodernlinearacceleratorshavefacilitated IGRTdevelopment. Naturally,astechnologyevolvessodothemodalitiestoperformIGRT.In 2011, IGRTmightbeperformedbasedonarangeofimagingmodalities includingelectronicportalimaging(EPID),megavoltageconebeamCT (MVCBCT),kVimages,kVCBCT,ultrasoundandrespiratorymotion sensors.

Key References:

1. 2. 3.

4.

5. 6. 7.

TG104TheRoleofInroomkVXRayImagingforpatientsetupand targetlocalisationDec2009 TG144KlienE,HanleyJ,BayouthJ,YinFF,SimonW,DresserS,Serago C,AguirreF,MaL,ArjomandyB,LiuC.AAPMTaskGroupReport144 Qualityassuranceofmedicalaccelerators2009 TG101BenedictS,YeniceK,FollowillD,GalvinJ,HinsonW,KavanaghB, KeallP,LovelockM,MeeksS,Papiez,PurdieT,SadagopanR,SchellM, SalterB,SchiesingerD,ShiuA,SolbergT,SongD,StieberV,TimermanR, TomeW,VerellenD,WangL,YinFF.Stereotacticbodyradiationtherapy: ThereportofAAPMTaskgroup101.MedPhys37(8)2010 TG75MurphyM,BalterJ,BalterS,BenComoJ,DasI,JiangS,MCM, OlivieraG,RodebaughR,RuchalaK,ShiratoH,YinFF.Themanagement ofimagingdoseduringimageguidedradiotherapy:ReportoftheAAPM TaskGroup75MedPhys34(10)2007 TG111AAPMTaskGroup111ReportComprehensiveMethodologyforthe evaluationofRadiationDoseinXRayComputedTomography:TheFuture ofCTdosimetryFeb2010 SeminarsinRadiationOncologyIGRTspecial2004.Vol14,(1):1100 IMRT,IGRT,SBRTAdvancesintheTreatmentplanningandDeliveryof Radiotherapy.EdJohnLMeyer.Kargerpublishing.

Page 1 of 7

Radiation Oncology, Physics, Image Guided Radiotherapy (IGRT)

IGRTModalities

ImagingModality
1.ElectronicPortalImaging(EPI) Mostlinearaccelerators haveanelectronicimagingpanelattachedtocapturetreatment verificationimagesusingthetreatmentbeam.
I

Exampleofimages

thisdevicecanbeusedtoacquireradiographicof fluoroscopicimagesforpatientalignment theEPIwilltypicallyrequire14MUandwillproducean imageofqualityhighenoughtovisualisebonesclearly animageofthetreatmentportalisusuallyaccompaniedby anexpandedfieldsizeimagetoallowvisualisationof surroundinganatomyandthemegavoltage(MV)imaging dosescanbeeasilyincludedintheplanneddoseinmost treatmentplanningsoftware

2.MegavoltageConeBeamCT(MVCBCT)MVCBCThasbeen implementedonSiemenslinearacceleratorsutilisingthe treatmentbeamtoacquireprojectionsforreconstructionasa CBCTimage.

I

theuseofMV reducesstreakingartefact forhighZ materialsthatwouldbepresentwithkVimaging,but lowerscontrastforneartissuematerialsanddosehas beenreportedtobehigherthankVCBCT itshouldbenoted,thatsomelinearaccelerator(linac) manufacturersnowoffera lowMV(13MV)imagingbeam thathasahighercontrastthanthe6MVbeam potentially,suchalowMV beam mightbesynchronised betweenthe6MV treatmentpulsesfor"liveimaging" duringatreatmentandthiswouldhavevarious applications typical 6MVdoserangeforMVCBCTis510cGy1

3.Kilovoltage(kV)ElektaandVarianlinearacceleratorscanbe purchasedwithadditionalXraytubesmountedonthelinac gantrytoproduceakVbeamthatprojectsorthogonallytothe treatmentbeamtoanimagingreceptormountedontheopposite side.

I

thisdevicecanbeusedtoacquireradiographicor fluoroscopicimagesforpatientalignment thehighimagequalityandminimaldose(oftheorderof 1/100cGy)havemadeorthogonalkVimagingthecurrent standardforIGRT standalone(roommounted)systemslikeBrainlab Exactrachavefloorandceilingmountedxraysystems thatprovideatrueroomseyeviewindependentofthe treatmentsystem onedisadvantageof kVimagingisthatitisdifficult to incorporatetheimagingrelateddose intoplanned treatmentdose,duetothe differenceinbiological effects betweenkVandMVbeams

4.KilovoltageConebeamCT(KVCBCT)VarianandElektacan provideakVCBCToptionthatacquiresaCBCTfromtheextrax raygenerators.

I

theseprovidehighqualityimageforpositioning,however

Page 2 of 7

Radiation Oncology, Physics, Image Guided Radiotherapy (IGRT)

imagequalityiscurrentlylowerthanhelicalCTandnot goodenoughfordiagnosis theimagesare adequate fordosecalculationinmany situations,howeverthisshouldonlybe attemptedafter carefulinvestigation significantartefact(mainlycuppingartefact)andoffaxis hardening maycauseproblemsforuseofelectrondensity calibrationcurves.Artefactfrominternalgasandbonesmay alsoobscureanatomyforalignment imagesareapproximately 15cmlong withcouchcentred, duetoseparationanddimensionoftheimagingpanel. This mayresultinpartiallymissinglargetargetvolumesand organsatrisk(OARs),whichisimportantforstudieswhere youneedcompleteorgans therangeofcentraldosesfromCBCTisvariouslyquotedas 0.2to10cGy2

5.UltrasoundUltrasoundimagesprovidearadiationfreeimage.
I

however, theaccuracyofpositioningbasedonthese imagescanbeheavilyuserdependent21 22 ultrasoundisusefulindelineationofsofttissuedetail,and haslimitedutilityincloseproximitytobone remoteultrasounddevicestoremoveuserinducedimaging variationsrealtime applicationareanareaofactive investigation

6.Respiratory/externalmotionsensorsAnumberofdevicesare availabletoimageordetectmarkersonthepatientsskin, therebyusingexternalbodycontourasasurrogateforinternal motion.

I

thesedevicescanuseinfraredtodetectthepositionof markersplacedonthepatientrelativetoisocentre (Brainlab,VarianOpticalGuidancePlatform)or,couldread thedeformationofagridprojectedontothepatient(Align RT) othersystems,likeVarianRealtimePosition Management(RPM),ElektaActiveBreathingCoordinator andANSAIbeltsarespecificallydesignedtogatethe treatmentdeliveryortheimageacquisitiontoaccountfor breathingmotion

ResidualaccuracyoftheIGRTsystem
WhileitisimportanttosetupathoroughQAregimentotestallcomponentsoftheIGRTprocess,thereareresidual uncertaintieswithinthesystemthatshouldalsobecarefullyconsideredbyyourIGRTteam.Residualuncertaintiesarecovered bythePTVmargin(encompassingtheinternaltargetvolume(ITV)andwillinclude:
I

I I I

mechanicalreproducibilityflexinimagingpanelandxraytubewithgantryrotation,couchmovementsteppingand couchslop contouringinaccuracydifferentimagingmodalities,window/level(W/L),SUVs,meanCTversus4DCT intrafractionmotion accuracy/reproducibilityofsurrogate

Thesemaybedifficulttoaddressbutmustbeconsideredbytheteam.

ImageRegistration
Increasingly,theplanningCTimageisbeingfusedwithothermodalities(CBCT,MRIandPET)tobetteridentifytargets,and reducecontouringuncertainty.Insomecases,theimagesacquiredoutsidetheradiotherapydepartmentwillnotbeacquired withthepatientinthetreatmentpositionandthiscomplicatestheregistrationprocess.Mostradiotherapyplanningsystems haverigidregistrationandmanywillhaveautomatedprocesses. However,deformableregistrationmaybemoreusefulin overcomingmisregistrationduetopatientpositionand isparticularlyusefulinadaptiveradiotherapy (seebelow).

Page 3 of 7

Radiation Oncology, Physics, Image Guided Radiotherapy (IGRT)

Autosegmentationtoolswillusuallyusegradienttechniquestofitfromavendororuserlibraryofstructurecontours.These shouldbecheckedtoconfirmthattheymatchyourdepartmentcontourprotocolorClinicalTrialprotocol.Othersegmentationtools canmatchbyweightingacertainpartoftheimagesothatmoreemphasisisplacedonaccuracyinadefinedregionofthe image.

CBCTImagingDose
ThedosetothepatientfromakVCBCTacquisitionmaybehighly variable,and differsignificantlyfromthevendorspublished values. ItisimportanttohaveagoodunderstandingofthemetricsusedbyvendorstodescribepatientdosefromCBCTand tounderstandthelimitsofthatmetric. Doserelatedquantitiesthatmightbeusedinclude:
I I I

centraldose(CDTC ) (measureddoseinGyforaparticularphantomgeometry) doselengthproduct(DLP)(doseinGymieperlengthoffield) computedtomographydoseindex(CTDI)anditsvarieties G measuredinwaterCTDI w

G G G

measuredalonga100mmlengthCTDI100 alongthephantomcentre c peripheralp

MostofthevendorswillpublishadoseincGyandaCTDIwtheformerisacentraldosepointmeasuredinaunitdensity

cylindricalphantomandthesecondisaweightedaverageofmeasureddosecentrallyandperipherally.Bothofthesemetrics wereoriginallydesignedforhelicalCTanddodemonstratesomeshortcomingsfromCBCTastheoffaxisbeamquality hardens.FurtherdetailonthesequantitiescanbeobtainedfromAAPMTG111:thefutureofCTDosimetryFeb20103.See alsoPoint/CounterpointbyBrenner2006.4 Itisgoodpractisetomeasurethedoseinarangeofscenarioswithvariousphantomgeometrieslocally.FornewIGRT techniquesitmaybeusefultocalculateaCBCTdosefactorastheratioofdosemeasuredintheparticulargeometryand techniquetoastandardgeometry/technique. CBCTdoseshouldbemeasuredwithanappropriatedetectorthatwillexhibitlowenergydependence,highreproducibility,low stemeffect(readingfromdetectorsteminfield),highsignal/noiseratio,lowdoserateeffects.Beawareofvaryingdoserate, chambervolumeandtheatomicnumberofthematerialusedfortheionchamberscentralelectrode.Severalstudieshave showncomputersimulations(MonteCarlomodelling)ofkVCBCTdosedistributions23, 24. Forsomesiteswithsmallhighorlow densityvolumes(likepelvis),thekVdosedistributioninthepatientfromCBCThasbeenreportedtobefairlyuniform.Itmight bereasonableinsuchcasestoattributeasingle dosevalueperCBCTforthesepatients(basedonmeasurementinthe centreofacylindricalphantomofsuitabledimension). The patientimagingdose foraCBCTacquisitionwillvaryduetofiltersinthebeam,aperturedimension,beamsettings, geometryofsubject,anddensityofinternalstructures. Someoftheseparameterscanbeexploitedtoreducethedose,togetherwithpostprocessing.

SitespecificIGRT Prostate
ProstatetumourswereanearlyproponentforIGRTbecause: 1. 2. 3. 4. Theprostateisamobileorgan(requiringdailytargeting) FiducialmarkersarevisibleinEPIDacquisitions(allowingtargeting) Improvedtargetingaidsindoseescalation Queriesaroundtheprostatessensitivitytofractionation(a/ratio)leadingtotheattractionofhypofractionation

Theprostatewilldeformandmoveandsowillthesurroundingnormaltissue.Therehavebeenmanystudiesshowing potentialgeographicmissesfrompositioningbasedonbonymatches.Thecurrentstandardisdailyorthogonalimaging, which is generallykVimaging.CBCTmayprovidefurtherinformation oncompliancewithbladder/rectumprotocols,patient contourvariationsand patienttilt. Fiducialmarkersareimplantedusingtransrectalultrasound(TRUS)1weekpriortosimulation,allowinganyswellingtoreduce priortoCTsimulation.Usually34markers(each~1x3mm)areimplantedforeasyvisualisationinpretreatmentimages. Stability ofthesemarkers(nonmigration)throughacourseoftreatmenthasbeenestablished19 20. Fiducialmarkersarenow widelythoughtofasastandardofcareforintactprostateRT. Markersmaybe accidentallyimplantedintherectalwallorseminalvesicles(SV). Thesemaybeusedforpositioning ifthey remaininsitu, butextremecareshouldbetakentoidentifythecorrectmarker andsomesofttissuereferencemightbeuseful. IfamarkerisplacedintheSV'sorrectalwallitshouldbeclearlynoted,soitcan beignoredduringonlineregistration. DosecalculationsmaybeperformedonCBCTimagesinsomesituationsandthiswilldependonthedoseaccuracyrequired.It

Page 4 of 7

Radiation Oncology, Physics, Image Guided Radiotherapy (IGRT)

isimportanttoinvolveaPhysicistinyourIGRTteamtoinvestigatesuchpotentialsituations beforetheyoccur.Adose calculationwithouthomogeneitycorrectionwillconsideranyshapechanges,butnotdensitychanges.Afulldosecalculation withasuperpositionalgorithmwillcompensateforallcontouredstructures.Asmentionedpreviouslythiswillnotaccountfor anysuddenintrafractionanatomychanges. Thereareseveralmethodstoreduceprostatemotionincluding:
I

rectalballoonssomeevidencesuggestsimprovedstabilityoftheprostatewithrectalballoons.Studieshavealso shownreducedrectaldoseduetoexpansionofrectalwall,variationsinprostatetiltduetovariableinsertion,increased superiorinferiormotion.However,patientcomfortandtolerabilityneedstobeconsidered5 dietarythepatientdietcanbemodified,howevertherearemixedresultsintheliteratureaboutthisimproving prostatestability bladderfillingprotocol'comfortablyfull'askpatienttodrinkfixedvolumeofwaterpriortosimulationandtreatment.It isrecommendedtoassesscompliancewithpretreatmentimagingifpossibleie:CBCT,ultrasound rectalvacuum/enemathiscanbeusedatsimulationwhereafullrectummaycauseasignificantsystematicerrorif notreplicatedthroughcourseoftreatment

Autoregistrationalgorithmsworkwellforprostatefiducialmarkersandthepelvisgenerally.However,manualconfirmationof theautomatchis recommended. Autosegmentationofpelvicanatomyisnowavailablethroughanumberofvendors.Thistechnologywillpresentthenewly acquiredCBCTwithcontourswhenitfirstappearsonscreen.Itissuggestedthattheaccuracywillneedtobethoroughly investigatedpriortouse.ThistechnologyholdsgreatpromiseforthedevelopmentofadaptiveplanningandIGRT.

HeadandNeck
IGRThasbeenrapidly developedforheadandneckradiotherapybecause rapidtumourproliferation/shrinkageduring treatment,andpatientweightlossduetopoordietinducedbytreatment/tumoursideeffectsresultsinlargechangesin patientanatomy. Thesepatientsaregenerallywellfixatedandthereislittleintrafractionvariation(exceptforswallowingaction). TheIGRT imagingoptionsthatarebestsuitedinclude
I I I

matchingtobonefromorthogonalimages matchingtobonefromCBCT matchingtobonefromCBCTwithofflineCBCTreviewtoassessmagnitudeofshapechanges,possiblyleadingto replanning matchingtobonewithautosegmentation,autoregistrationandrecalculation

Ifthepatientshapechangewillcauseasignificantdoseerrorondeliverythentheplanmaybereplanned.Currently,changes notedonvisualcheckofthepatientbytheradiationtherapistsduringdailypatientpositioningorFSDcheck wouldindicate theneedforarepeatplanningCT.However,anumberofotherindicesincluding:bodycontourvariation,treatmentDVH variation,pointdosevariationandnormaltissueshapechangesmayalsoindicatetheneedforreplanning.Thereplanning processusuallytakesaboutonetothreedays,incorporatingindependentchecking/QAprocesses,soitcanbeincorporated quicklyintothetreatment.

LungandBreastIGRT
BothlungandbreastIGRTrequiremanagementofrespiratorymotion.Theoptionsavailableincludereducingthemotion, gatingdelivery,accountingformotioninPTVexpansionandtracking.Organmotionmaybereducedbyabdominal compression,breathholdandcoachingofthepatient,activebreathingcontrolandbiofeedbacktechnologies. Bothofthesesitesarechallengingfordosecalculation(duetotangentialbeams,lung/boneinterfaces,smallfields)and generallyhavepoorCBCTimagequality.Theseissuesremainanactiveareaofinvestigationandwillneedtoberesolvedprior toeffectiveimplementationofhighprecisionradiotherapytechniquesforlungandbreastradiotherapy.

StereotacticBodyRadiotherapy(SBRT)
SBRTinvolvesextracranialhypofractionatedtreatments(<5fractions) thatrequiretheprecisionaccuracyofIGRT.Likecranial stereotactic,theIGRTmethodsaretrendingawayfromtheoriginsofusingastereotacticframeboltedtothepatienttowards imageguidance.Theneedfor imageguidanceaccuracyisheightenedforthesetreatments,asdemonstratedinAAPMReport 144 15 byaseparatelistofrequirementsforthismodalitycomparedagainstconventionalradiotherapy.(SeealsoAAPMTG101 SBRT16) TheliteratureshowsseveralsitescurrentlybeingtreatedwithSBRTincludingliver,lung,spineandprostate.Notethatmany ofthesepublicationsreporttreatmentwithanAccurayCyberknifedevice,noneofwhicharecurrentlypresentin

Australia. IGRTprerequisitesfortheseincludepre,duringandposttreatmentimagingtoverifythemeantumourposition(and isocentre),andqualifyanycorrelationsformonitoringatumourmotionsurrogate.TheresidualerrorintheIGRTsystemshould bequantifiedas<2mm. Theradiobiologyofhypofractionationispoorlyunderstood,hypofractionationoffersareducednumberoffractionsto correctforanyerrorsandoftenthetargetsarewithinmmofOARs.Itisrecommendedtofollowtheguideofcurrentclinical trialsforSBRT.Alimitedlistisprovidedbelow,notingthattechnicalandclinicalissueswithdifferentpatientgroupsarehighly distinctandindividualized.

Page 5 of 7

Radiation Oncology, Physics, Image Guided Radiotherapy (IGRT)

I

LiverRTOG0438isadoseescalationstudyforlivermetastaseswith10fractionsof3.55.0Gy.SomeoftheIGRT issuesspecifictoliverSBRTinclude: G liverisaparallelorgansodoesexhibitavolumeeffect. G theliverismobileanddeformsduringtreatment G liverlesionsaredifficulttoseeintreatmentimagessuggestingthatfiducialmarkerscouldbeused.

MotionmanagementtechniquesshouldbeemployedfromplanningCTonwardstoaccuratelycontourtheliverandinternal targetvolume(ITV). ThetreatmentcanbegatedtorespiratorymotionwithsetupusingfluoroorCBCT.Poulsenetal2011 haveimplementedafluoroscopictrackingtechniquetomonitorthepositionoffiducialsduringtreatment.

I

LungRTOG0813isadoseescalationstudystartingwith 5x10Gy. RTOG0915compares1x34Gyvs4x12Gy.Thereis alsoaTROGTrialTROG0902CHISELcomparing3x20Gyagainstconventional30x2Gy.SomeoftheIGRTissuesspecific tolungSBRTinclude: G requirementfora4DCTdatasetforplanningwithanITVcreatedfromthemaximumintensityprojection(MIP) andiftreatingfreebreathing,thenthedoseiscalculatedonthemeanCTdataset. G option forgatingafreebreathingtreatmentortreatingduring breathholdtoreduceITV andplannedlungdose. G thereareanumberofgatingsignalsthatcouldbeusedincludingaRPMmarkerblock,Ansaibelt,surfacecontour AlignRTorrespiratoryoutput.Exhalebreatheholdisgenerallyconsideredmorestablethaninhale,butmaybe difficultforthepatientgiventhattheyhavelungdisease.Thebreatheholdcanbeguidedbyaudioand/orvisual assistance.TheAutomatedBreathingControl(ABC)devicewillrestrictbreathingremotely. G treatmentplanningusuallyrequiresa714noncoplanarbeamarrangement.However,thereisliterature investigatingtheroleof VolumetricModulatedArctherapy(VMAT).Anearlyconcernaroseregardinginterplayfor dMLCdeliverywithbreathingmotionbuttheliteratureisnotconclusiveeitherwayonthispoint.During treatment,thesimulationsetupwillbereproducedandforfreebreathing,verifiedwithmultipleCBCTimages duringeachfractionasthereisevidenceofbaselineshiftingafterabout6minutesoftreatment. Treatmenttime canbeextensiveduetothecomplexityofthedelivery(manynoncoplanarbeams,largeMU,andcarefulsetup). SpineAnablativedoseisdeliveredtospinemetastasesavoidingthespinalcord.RTOG0631iscomparingasingle 16Gyfractiontothestandard8Gyfraction.SomeoftheIGRTissuesspecifictospineSBRTinclude: G highlyaccuratepatientsetupwiththePTVoftenonly12mmfromthespinalcordoritsplanningriskvolume (PRV). G theuseofanablativedoseinasinglefractionshouldbedifferentiatedfromtheexistingspinalcordtolerance dataon2Gyfractions ProstateThereisemergingevidenceforprostatetreatmentsof35Gy45Gyin5fractions.Themostmaturedatais fromMSKCCandStanford.SomeIGRTissuesspecifictoprostateSBRTinclude: G potentialforrapidanderraticprostatemovementintrafraction(evidencesfromCalypsodata) G requirementforintrafractionmotiondetectionandaction.Actionsmightincludegatingthetreatmentortracking thecouch/MLCto'follow'themotion G mostofthepublisheddataisfromcentresusingtheAccuray Cyberknifedevicethathasregularintrafraction imagingandtrackingcapability

QAofanIGRTsystem
ThereisguidanceinthreemainreferencesYooetal6,Verellenetal7 andAAPMTG134(2009).TheQAprogramwilldepend ontheuseandthesystem.TheQAprogramwillincludemechanicalsystemtests,imagequalitytests, daily,monthly,and treatmenttypetests.

ClinicalTrials
Increasingly,clinicaltrialsinvolvehighdosesthatrequireprecisetargeting.Uniformityintheapplicationoftheseprotocols across participatingsitesiscriticaltoavoidmisadministrationandconsistencyforaccuratereporting. InAustraliaandNewZealand,IGRTisconsideredexplicitlythroughtheTROGIGRTworkingparty.Astandardquestionnaire hasbeenimplementedinthePROFIT,trialanddevelopedfurtherforRAVESandCHISELtorequirestringentcredentialing activities.ThecredentialingactivitieshaveincludedsubmissionofIGRTprotocols,dummyruns,dosemeasurements,setup accuracymeasurementsandviewingofIGRTsystemsinplay.Inthefuture,credentialingactivitiesmightbeperformedbythe newlysetupAustralianClinicalDosimetry Service(ACDS),similartoRTOGwhousetheRPCforcredentialing.

Advancedresearchtopics AdaptiveRadiotherapyART
Adaptiveradiotherapyistheconceptofadaptingthetreatmentplanbasedonthegeometryontheday.Thebasicsteps for onlineARTinclude
I I I I I I

acquiringapatientCTimage deformablyregistertheimageandcontours recalculatedosewithoriginalplan assesssuitabilityofplan ifacceptablethentreat otherwise,reoptimise,recalculateandthentreat

Page 6 of 7

Radiation Oncology, Physics, Image Guided Radiotherapy (IGRT)

Thereareseveralwaystoperformeachstepandsomeoftheprocesscouldbeperformedoffline.TheOfflineARTprocess mightincludetakingthedecisionofassessingsuitabilityoftheoriginalplantothetreatedpatientgeometryoffline.Inthe currentsettingiestandardtechnology, thisisamorefeasibleoption.Theassessmentwillbemadeon theprevious days' images,orpossiblyanumberofpreviousdaysimagestoreviewdailyandsystematicchanges. CurrentresearchshowsthattheonlineARTprocess canbeperformedwithinaresearchenvironmentinaslowas40susing graphicalprocessingunits(GPU)8, 9,howeverwithcommercialproductsthetimerequiredforthisprocessiscloserto10 20min.ResearchisalsocontinuingintoreplanningduringVMATdelivery.

4Dplanning
Thisresearchareainvolvesplanningatreatmentdeliverythathasatimecomponentandmightinvolvetrackingthetumourin realtimeie:movingcouch/MLCto'follow'thetumourusingavarietyofimagingmodalities.Theplanningprocesswillrequire eitherasurrogateformotion(externalmarkerblock,skinsurfaceinfraredinternalfiducial)orawayofvisualisingthesoft tissue,generallythroughimaging.Verificationmayusefluoroscopicimaging,and/or4DCBCT.

References
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. Vanantwerp,A.E.,S.M.Raymond,M.C.Addington,etal.2010."Dosimetricevaluationbetweenmegavoltage conebeamcomputedtomographyandbodymassindexforintracranial,thoracic,andpelviclocalization."Med Dosim. Islam,M.K.,T.G.Purdie,B.D.Norrlinger,etal.2006."Patientdosefromkilovoltageconebeamcomputed tomographyimaginginradiationtherapy."MedPhys33(6):15731582. AAPMTG111ReportTheFutureofCTDosimetry2010 Brenner,D.J.2006."Itistimetoretirethecomputedtomographydoseindex(CTDI)forCTqualityassuranceand doseoptimization.Fortheproposition."MedPhys33(5):11891190. Smeenk,R.J.,B.S.Teh,E.B.Butler,etal.2010."Istherearoleforendorectalballoonsinprostateradiotherapy? Asystematicreview."RadiotherOncol95(3):277282.Linktoexternalarticle Yoo,S.,G.Y.Kim,R.Hammoud,etal.2006."Aqualityassuranceprogramfortheonboardimagers."MedPhys 33(11):44314447. Verellen,D.,M.DeRidder,K.Tournel,etal.2008."Anoverviewofvolumetricimagingtechnologiesandtheir qualityassuranceforIGRT."ActaOncol47(7):12711278. McNutt,T.,Jacques.S.Radiation2010TherapyDoseCalculationusingGraphicsProcessingUnits(Abstract). MedPhys37(6):3452 Jiang,S.Gu,X.Men,C.etal2010.aRealtimereplanningforonlineadaptiveradiotherapyAAPM2010Abstract MedPhys37(6):3542. Rong,Y.,J.Smilowitz,D.Tewatia,etal.2010."DosecalculationonkVconebeamCTimages:aninvestigationof theHudensityconversionstabilityanddoseaccuracyusingthesitespecificcalibration."MedDosim35(3):195 207. Alaei,P.,G.DingandH.Guan.2010."InclusionofthedosefromkilovoltageconebeamCTintheradiationtherapy treatmentplans."MedPhys37(1):244248. Sharpe,M.B.,D.J.Moseley,T.G.Purdie,etal.2006."ThestabilityofmechanicalcalibrationforakVconebeam computedtomographysystemintegratedwithlinearaccelerator."MedPhys33(1):136144. Walter,C.,J.BodaHeggemann,H.Wertz,etal.2007."Phantomandinvivomeasurementsofdoseexposureby imageguidedradiotherapy(IGRT):MVportalimagesvs.kVportalimagesvs.conebeamCT."RadiotherOncol85 (3):418423.Linktoexternalarticle AAPMTG104TheRoleofInroomkVXRayImagingforpatientsetupandtargetlocalisationDec2009Link toexternalarticle AAPMTG144KlienE,HanleyJ,BayouthJetal2009.AAPMTaskGroupReport144Qualityassuranceof medicalaccelerators. AAPMTG101BenedictS,YeniceK,FollowillDetal2010.Stereotacticbodyradiationtherapy:Thereportof AAPMTaskgroup101.MedPhys37(8)2010 AAPMTG75MurphyM,BalterJ,BalterSetal2007.Themanagementofimagingdoseduringimageguided radiotherapy:ReportoftheAAPMTaskGroup75MedPhys34(10)2007 AAPMTG111AAPMTaskGroup111ReportComprehensiveMethodologyfortheevaluationofRadiationDose inXRayComputedTomography:TheFutureofCTdosimetryFeb2010 Wu,J.,T.Haycocks,H.Alasti,etal.2001."Positioningerrorsandprostatemotionduringconformalprostate radiotherapyusingonlineisocentresetupverificationandimplantedprostatemarkers."RadiotherOncol61 (2):127133. Schallenkamp,J.M.,M.G.Herman,J.J.Kruse,etal.2005."Prostatepositionrelativetopelvicbonyanatomy basedonintraprostaticgoldmarkersandelectronicportalimaging."IntJRadiatOncolBiolPhys63(3):800811. Kuban,D.A.,L.Dong,R.Cheung,etal.2005."Ultrasoundbasedlocalization."SeminRadiatOncol15(3):180 191. Artignan,X.,M.H.Smitsmans,J.V.Lebesque,etal.2004."Onlineultrasoundimageguidanceforradiotherapyof prostatecancer:impactofimageacquisitiononprostatedisplacement."IntJRadiatOncolBiolPhys59(2):595 601. Ding,G.X.,P.Munro,J.Pawlowski,etal.2010."ReducingradiationexposuretopatientsfromkVCBCTimaging." RadiotherOncol97(3):585592. Downes,P.,R.Jarvis,E.Radu,etal.2009."MonteCarlosimulationandpatientdosimetryforakilovoltagecone beamCTunit."MedPhys36(9):41564167.

Thecurrencyofthisinformationisguaranteedonlyupuntilthedateofprinting,foranyupdatespleasecheckwww.eviq.org.au 02Apr2013

Page 7 of 7