QUALITY ASSURANCE IN RADIOTHERAPY THERAPY EQUIPMENT - G. Guidi Az. Ospedaliero-Universitaria di Modena - Policlinico, Modena ...
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QUALITY ASSURANCE IN RADIOTHERAPY
THERAPY EQUIPMENT
G. Guidi
Az. Ospedaliero-Universitaria di Modena - Policlinico, Modena
Guidi.Gabriele@policlinico.mo.it
Phone: +39 059 422 5699
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AGENDA
• Overview of the concept
• Documents and guideline
• Evolution of the equipment and of the QA programs
• Doubts and questions
• Today, I will not provide methods for QA and specific tests… you can
find multiple way for QA
• ….look into the problems!
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Basic differences in modern Radiation Therapy Delivery
3D-Conformal Radiation Therapy Intensity Modulated Radiation Therapy
(3D-CRT) Volumetric Modulated Radiation Therapy
(IMRT/VMAT)
Fluence Map
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DEFINE CLINICAL OBJECTIVES AND NEEDS FOR THE FUTURE
3DCRT 3DCRT 3DCRT “4DRT” 4DRT
Static Target Dynamic Target Dynamic Target Dynamic Target Dynamic Target
NO Motion evaluation 4DCT Motion Evaluation (ITV) 4DCT Motion Limitation 4DRT Technologies
Phases beam-on 20-60% Internal Marker Tracking
Abdominal Compressor Dynamic MLC
MIP 4DCT Reconstruction Robotic Couch
Deformation analysis Organs Motion Compensation
Dose accumulation Daily Adaptive RT
DIBH
Deformable Registration
Dose Accumulation
• Reduce margins
• Improve delivery efficacy and efficiency
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NEW CONCEPT FOR TECHNOLOGY AND TREATMENT
Outside Point Of View Inside Point Of View
Need to synchronize the beam
If you lost the
synchronization, than you
will not treat any tumours
Tracking What’s happen inside? Tracking
With Tracking you don’t know You don’t see anything inside....
... you believe than you treat the
tumours
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SETUP QA PROGRAMS AND DO IT!!
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HAVE A LOOK (STUDY !) OF THE GUIDELINE….
ADJUST BASED ON YOUR REQUIREMENTS…YOU DO NOT NEED TO INVENT!
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THERAPY : EQUIPMENT'S EVOLUTION
NEXT GENERATION
• LINAC MRI
• LINAC PET
• PROTON AND CARBON
• ………..THERAPY
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CLINICAL NEEDS
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i.e. BREAST, SUPRACLAVEAR BREAST AND BILATERAL BREAST WITH INTERNAL MAMMARY
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 10i.e. METS, MULTIPLE LESIONS AND TOTAL LYMPHOID IRRADIATION
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 11i.e. PROSTATE AND ABDOMINAL LESIONS
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 12i.e. HEAD&NECK
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 13i.e. MESOTHELIOMA AND LUNG LESION
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 14i.e. BRAIN AND RADIOSURGERY
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 15i.e. CRANIO SPINAL IRRADIATION AND TOTAL BODY IRRADIATION
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 16TOTAL SKIN ELECTRON & SKIN IRRADIATION (con Bolus) ….
Skin Electron Irradiation (SEI)
Total Skin Electron Irradiation (TSEI)
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 17TECHNOLOGY EVOLUTION AND REQUIREMENTS
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 18MODENA RADIATION ONCOLOGY … ROADMAP
180 cm
Tomotherapy - 4DCT
Lesion 3D-CRT
VMAT with FFF – DIBH & 4DRT
10 cm
IMRT
Head & Body
Stereotactic
VMAT
Radiosurgery
1 cm
Radiation + Nanotechnology & Genomic
Proton
1 mm
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 192005 - NETWORK AND SYSTEMS
TPS
Hospital Treatment Planning System
System
RADIOSURGERY Elekta Precise + aSi +
(Ergo-3DLine) MicroMLC
Desktop RT
BRACHYTHERAPY
iView GT
(Nucletron)
Ergo MicroMLC
Siemens Primus + BeamviewTI
PLATO
(Nucletron)
Primeview
Beamview TI
Radiology Department CT-MRI/fMRI Regenerated CT + Cobalt
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Tomotherapy
TPS
Hospital Legal Digital
System Repository Treatment Planning System
DICOM RT
Archive
4D Planning PINNACLE
(Philips-TA)
Tomotherapy
IMPAC (R&V)
RADIOSURGERY ONCENTRA Elekta Precise + aSi + MicroMLC
(Ergo-Elekta) (Nucletron)
IMPAC (R&V)
IMPAC (R&V)
TOMOPLAN BRACHYTHERAPY iView GT
(Tomotherapy) (Nucletron) Ergo MicroMLC
Regional
PACS
Siemens Primus + BeamviewTI
MONACO Proton TPS
(Elekta)
IMPAC (R&V)
Beamview TI
Elekta Synergy+ aSi (Carpi)
Radiology Department CT-MRI/fMRI-CT/PET-CT/SPECT Elekta 4DSynergy+VMAT+dMLC+FFF+CBCT
4DCT Toshiba Large Bore + Vision RT & ABC
IMPAC (R&V)
iViewGT
IMPAC (R&V)
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 212017 - NETWORK AND SYSTEMS
Tomotherapy
TPS
Hospital Legal Digital Treatment Planning System
System Repository DICOM RT
Archive
Raystation PINNACLE
(RaysearchLab) (Philips)
Tomotherapy
IMPAC (R&V)
Homemade ONCENTRA Elekta Precise + aSi + MicroMLC
Software (ELEKTA)
IMPAC (R&V)
TOMOPLAN IMPAC (R&V)
BRACHYTHERAPY
(Tomotherapy) iView GT
(Nucletron)
Regional Ergo MicroMLC
PACS
Siemens Primus + BeamviewTI
MONACO QA Software
(Elekta) (IBA MyQA,
COMPASS)
IMPAC (R&V)
Beamview TI
Elekta Synergy+ aSi (Carpi)
Radiology Department CT-MRI/fMRI-CT/4DPET-CT/SPECT Elekta 4DSynergy+VMAT+dMLC+FFF+CBCT +Compass
4DCT Toshiba Large Bore + Vision RT & ABC
IMPAC (R&V)
iViewGT
IMPAC (R&V)
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 22i.e Guideline for implementation
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 23WHICH QA PROGRAMS? WHICH TESTS? i.e…..
• LINAC QA
• Geometry and mechanical • 4D Therapy
• Dosimetric • Breath synch
• MLC • Beam on/off and delivery (DIBH)
• Safety and collision • Ramp-up of the beam-on
• Imaging • Gantry rotation speed
• EPID/ CBCT • Constant
• Couch • Variable
• Radiosurgery • Doserate
• Positioning (frame vs. frameless) • Constant
• Accuracy • Variable
• Rotational of gantry and collimator • Discrete
• SBRT • Complete procedure after interruption
• Positioning (frame vs. frameless) • 3DCRT
• Accuracy • IMRT
• Rotational of gantry and collimator • dMLC or Sliding Windows
• IMRT • VMAT
• Penumbra • Radiosurgery
• Inter/interleafs • SBRT
• MLC Interdigitation • Isocenter junction
• VMAT • Junction of the beam and divergence
• MLC Interdigitation • Non-Homogeneity condition
• Leafs speed • Cerrobend Block?
• Doserate • Tray
• Different Therapy • Real-time monitor systems
• Low Doserate/Low MU • Log files analysis
• Low Dosedose/High MU • Unpredictable cases (near missing or errors)
• High Doserate/Low MU • Connectivity with IOS
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 24Dedicata a
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 25i.e. LINAC QA
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 26DEFINE TOLERANCE …..
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 27DEFINE FREQUENCY AND PARAMETERS
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 28IMAGING QA
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 29…i.e. QA FOR TREATMENT MACHINE USING FLAT PANEL
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 30…DURING THE COMMISSIONING YOU NEED TO VERIFY THE TOLERANCE….
….. AND DEFINE THE FUTURE BASELINE
VMAT MACHINE
FFF MACHINE
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 31i.e. POTENTIAL QA AND ERROR DETECTED
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 32SOMETIME OBJECTS AND PHANTOM CAN HELP THE WORK-LIFE
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 33IDENTIFY OR PREVENT SOURCE OF ERRORS?
Look for:
Small or big errors?
Rare or frequent errors?
Random or systematic errors?
Unpredictable or newly errors?
To be accurate once a year (annual QA)
or to be adequate everyday (Daily QA)?:
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 34IMMOBILIZATION DEVICE…QA OR NOT QA? LINAC COMPLIANT OR NOT?
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 35………… IN PRACTICE? «UMARELL CONCEPT»
Expert Brainstorming- Multiple-criteria decision
Decision Maker
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Wrong Workflow or Healthcare Model – Error investigation Results: Simplify and prevent accident
4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 36DEFINE THE BASELINE AND REPEAT FREQUENTLY (AS LOW AS REASONABLE) THE QA TEST
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 37i.e. Isocenter and MLC position (Picket, Fence) Tests
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 38Analyze and look at the trends vs. the baseline…..
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 39Trace and Record any Data
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 40Simplify theory (i.e. Six Sigma)
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 41ALTERNATIVE - INDEPENDENT REAL-TIME BEAM MONITOR SYSTEM
Beta-Tested @ Modena Hospital
• Possible QA of the LINAC
• Pre-Treatment QA activities
• Error prevention instead of error
management
• Intra-fractional verification system
• Real-Time user interaction
• Automated monitoring of every
single treatment fraction
Courtesy of Andrew Jongho Jung Princess Margaret Cancer Centre (Toronto)
• Patient delivery and safety improved
in real-time
• In-Vivo evaluation
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 42IQM MAP QA - DAILY QA TEST FIELDS
• IMRT plan
• 18 segments
• Irradiated with 6 MV photon
• Constant 50 MU/segment dose output
mean variability (for all segments) 0,7% and standard deviation of 4,7%
this is true for all segments
except the 1st one.
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 43VMAT RESULTS
MU error
Gantry angle (°)
1% 2% 3% 4% 5% 10% 20%
0 0,2% 1,0% 2,1% 1,8% 2,9% 7,9% 16,8%
20 2,5% 2,4% 3,1% 5,4% 4,1% 9,1% 21,1%
40 3,6% 4,6% 6,2% 5,6% 6,7% 12,3% 20,4%
60 1,4% 2,4% 3,1% 4,0% 5,4% 10,0% 20,3%
80 1,3% 0,8% 4,4% 2,7% 5,1% 9,1% 19,1%
100 2,4% 2,3% 3,5% 2,2% 4,5% 9,3% 19,6%
120 2,8% 1,2% 3,4% 3,6% 5,6% 9,3% 21,9%
140 1,6% 1,6% 4,8% 2,1% 4,4% 11,9% 18,9%
160 2,9% 2,8% 3,5% 3,3% 4,5% 8,4% 19,9%
180 1,8% -1,8% -0,3% -0,4% 6,1% 9,2% 18,3%
200 1,8% -0,4% 2,1% 0,9% 2,5% 9,3% 19,2%
220 0,9% 1,0% 1,4% 1,6% 2,5% 8,6% 18,7%
240 1,9% 1,7% 4,6% 3,3% 5,3% 8,9% 19,5%
260 2,8% 2,6% 3,8% 2,5% 5,6% 9,1% 20,1%
280 4,0% 5,2% 5,0% 8,0% 7,8% 12,9% 25,8%
300 2,1% 3,4% 3,1% 5,3% 4,5% 9,8% 20,5%
320 2,0% 3,4% 3,6% 4,5% 6,4% 12,0% 21,2%
340 2,0% 2,4% 4,6% 5,1% 6,8% 11,7% 22,4%
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 44WE NEED INSTRUMENTS TO PREVENT ACCIDENT AND FOR QA… YOU MUST PRETEND IT!
IMRT - Intensity Modulated Radiation Therapy
Tomotherapy
Total Lynphoid Irradiation
4D-Radiation Therapy Radiosurgery
SBRT
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 45SOME OTHER DOCUMENTS TO TEST THE AGREEMENT BETWEEN PLAN AND DELVERY
• AAPM Report No. 62: Quality Assurance for Clinical
Radiotherapy Treatment Planning (December 1998)
• IAEA Technical Report Series No. 430 : Commissioning and
Quality Assurance of Computerized Planning Systems for
Radiation Treatment of Cancer (October 2004)
• IAEA TEC-DOC No 1540: Specification for Acceptance Testing of
Radiotherapy Treatment Planning Systems
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 46i.e. SPATIAL EVALUATION AND IMAGING QA
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 47Modeling of the measures (Theory vs. Practice)
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 48MEASURE MISTAKE EFFECTS
Effect of shifting depth-ionization data measured with cylindrical chambers upstream by 0.6
rcav for photon beams and 0.5 rcav for electron beams (with rcav = 1.0 cm). For the electron
beams, (b), further corrections are applied to obtain the %dd(x) curve shown.
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 49SCATTER KERNEL
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 50Fluence vs. Dose (Water vs. Inhomogeneous)
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 51QA – QUALITY ASSURANCE INSTRUMENTS
(i.e. Adaptive RT could based on CBCT calculation or we could need phantom for gating verification)
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 52i.s. Experimental QA in Tomotherapy for Gating QA
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 53i.s. Experimental QA in LINAC for Gating QA
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 54DOUBTS AND QUESTIONS?
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 55“That’s too much!!!”
(Praha 2009 : Tomotherapy Meeting)
Un maestro in pensione…
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4/3/2017 G. Guidi - http://medicalphysicsresearch.weebly.com/ 56You can also read
