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QA FOR RT SUPPLEMENT Int. J. Radiation Oncology Biol. Phys., Vol. 71, No. 1, Supplement, pp.JPB@ mvmp.net Conflict of interest: J. Balog owns common stock in S113 TomoTherapy Inc; and E. Soisson receives financial support from TomoTherapy Inc. Received Feb 17, 2007, and in revised form Sept 13, 2007. Accepted for publication Oct 2, 2007. " id="pdf-obj-0-2" src="pdf-obj-0-2.jpg">

QA FOR RT SUPPLEMENT

Int. J. Radiation Oncology Biol. Phys., Vol. 71, No. 1, Supplement, pp. S113–S117, 2008 Copyright 2008 Elsevier Inc. Printed in the USA. All rights reserved 0360-3016/08/$–see front matter

doi:10.1016/j.ijrobp.2007.10.001

HELICAL TOMOTHERAPY QUALITY ASSURANCE

JOHN BALOG, PH.D.,* AND EMILIE SOISSON, M.S. y

*Department of Radiation Oncology, Mohawk Valley Medical Physics, Rome, NY; and y Department of Human Oncology, University of Wisconsin, Madison WI

Helical tomotherapy uses a dynamic delivery in which the gantry, treatment couch, and multileaf collimator leaves are all in motion during treatment. This results in highly conformal radiotherapy, but the complexity of the deliv- ery is partially hidden from the end-user because of the extensive integration and automation of the tomotherapy control systems. This presents a challenge to the medical physicist who is expected to be both a system user and an expert, capable of verifying relevant aspects of treatment delivery. A related issue is that a clinical tomotherapy planning system arrives at a customer’s site already commissioned by the manufacturer, not by the clinical phys- icist. The clinical physicist and the manufacturer’s representative verify the commissioning at the customer site before acceptance. Theoretically, treatment could begin immediately after acceptance. However, the clinical phys- icist is responsible for the safe and proper use of the machine. In addition, the therapists and radiation oncologists need to understand the important machine characteristics before treatment can proceed. Typically, treatment begins about 2 weeks after acceptance. This report presents an overview of the tomotherapy system. Helical tomotherapy has unique dosimetry characteristics, and some of those features are emphasized. The integrated treatment planning, delivery, and patient-plan quality assurance process is described. A quality assurance protocol is proposed, with an emphasis on what a clinical medical physicist could and should check. Additionally, aspects of a tomotherapy quality assurance program that could be checked automatically and remotely because of its inherent imaging system and integrated database are discussed. 2008 Elsevier Inc.

INTRODUCTION

The helical TomoTherapy Hi-ART system was designed for dedicated integrated image-guided intensity-modulated radiotherapy (IMRT). Helical tomotherapy is characterized by radiation delivery in which the patient is constantly trans- lated through a continuously rotating radiation beam mounted on a slip-ring gantry (1–3). A short in-line 6-MV linear accelerator and its associated radiofrequency system are mounted on a computed tomography (CT)-like ring gan- try. A primary collimator shapes the radiation beam to be 40 cm in the transverse direction and 5 cm in the longitudinal direction (into the gantry bore), creating a fan beam. A set of moveable jaws further collimates the fan beam down to as little as 1 cm wide in the longitudinal direction, and a binary multileaf collimator (MLC) continuously provides intensity modulation during the helical radiation delivery. The MLC has 64 leaves across the transverse beam direction. Image guidance is accomplished with an on-board megavolt- age CT (MVCT) detector mounted on the gantry opposite the linear accelerator. The linear accelerator is detuned to operate at approximately 3 MV when used as an imaging source. Data collected in the detector during the scan are recon-

structed to provide an image that can be registered with the planning reference image (4, 5). The integrated, dynamic nature of helical tomotherapy requires quality assurance (QA) that is different, than that for conventional linear accelerators. Although the dynamic components and synchrony requirements add new challenges to QA (6–8), other design simplifications make the process easier. For example, the collimator does not rotate, no wedges or other accessories are used, and the couch does not rotate. At present, only three longitudinal field widths, 5, 2.5, and 1.0 cm, have been commissioned into the planning system. All field widths are collimated by the single move- able set of jaws. Only one photon energy is provided for treat- ment (nominally 6 MV), and no electron mode is available. Furthermore, without a flattening filter and associated beam steering, it is less likely that related beam profile asymmetries will arise. Specific QA protocols vary among users but most should follow American Association of Physicists in Medicine Task Group report 40 guidelines (9), applicable. Conven- tional external beam QA is component based such that the clinical physicist starts measuring basic machine parameters

Reprint requests to: John Balog, Ph.D., Department of Radiation Oncology, Mohawk Valley Medical Physics, 127 Dixon Dr., Rome, NY 13440. Tel: (315) 271-9614; (315) 671-1803; E-mail: JPB@ mvmp.net

Conflict of interest: J. Balog owns common stock in

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TomoTherapy Inc; and E. Soisson receives financial support from TomoTherapy Inc. Received Feb 17, 2007, and in revised form Sept 13, 2007. Accepted for publication Oct 2, 2007.

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(i.e., profiles, percentage depth dose [PDD], output factors) and then progresses to planning system commissioning and plan verification. Tomotherapy QA is process orientated. The focus is on verification of dynamic treatment delivery. At present, it is important for physicists to take responsibility to thoroughly educate themselves about the system and pro- cess to determine first what can go wrong and then what tests to perform, and the associated specifications, to prevent any adverse consequences.

TOMOTHERAPY TREATMENT PLANNING COMMISSIONING AND ACCEPTANCE TESTING

In contrast to conventional systems, TomoTherapy sets the output of the linear accelerator and the configuration of the collimation only to a fixed standard. This defines a specific energy fluence model for its convolution-superposition- based planning system that depends on the slice width (1, 2.5, or 5 cm width defined at the isocenter). A full set of beam data is collected at the factory, alignment tests are performed, and the machine is adjusted to meet in-house specifications for agreement with the standard model. Clini- cal physicists should receive copies of those data for eventual comparison with the annual QA data. On-site acceptance test- ing of the machine consists of a set of alignment and dosimet- ric verification tests. The site acceptance testing procedure is performed by the clinical physicist in cooperation with an on- site TomoTherapy representative. The linear accelerator and MLC mechanical alignment is tested first. The MLC offset must be less than 1.5 mm. It is also necessary to ensure that the linear accelerator is cen- tered with respect to the primary collimator in the longitudi- nal direction to within 0.5 mm. Finally, it is important to ensure that the beam does not diverge in the longitudinal direction more than 0.5 mm. Also, the jaw and MLC twist should be less than 0.5 . The treatment machine has a stationary green laser system that is centered on the virtual isocenter, which is 70 cm out of the bore from the actual isocenter. This facilitates patient setup, because it is done unencumbered by the bore. All green lasers must be accurate to within 1 mm. The home positions of the moveable red lasers are matched to this location to within 1 mm. It must be verified that the couch moves perpendicular to the gantry plane with a divergence in the International Electrotechnical Commission-X direction of <2 mm. Diver- gence must also be <2 mm with the couch moving to its full extent in the International Electrotechnical Commis- sion-Z direction. The cobra motion of the couch is also tested at this time. The couch must be within 2 mm of its expected horizontal position throughout the useful vertical range. In ad- dition, the couch must be level in its fully retracted position. The MLC characteristics are tested as a part of the machine commissioning. The MLC response is quantified during commissioning by way of detector analysis (10). The leaves do not move in and out of the fan beam instantaneously but have latencies resulting from their transit time of about 20 ms.

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TomoImage verification also occurs during commission- ing. A scan of the TomoTherapy-provided cylindrical phan- tom, ‘‘cheese phantom,’’ with a set of density and resolution plugs inserted should be scanned to ensure that all plugs are visible on a ‘‘normal’’ scan with no ring, streak, or button artifacts present in the image. The scan dose should be mea- sured at this time and be <2.0 cGy. The largest three rows of holes on the resolution plugs should be able to be distin- guished from their neighbors. As is consistent with other treatment units, commissioning includes taking a full set of profiles in the transverse and lon- gitudinal directions at several depths using a water tank, in addition to a PDD measurement for each field width. The pro- files collected with a water tank system should match the standard model. If the profiles do not match, the beam-line parameters should be adjusted until the shapes agree to a gamma value of 1 that corresponds to a 2% dose difference and 2 mm distance-to-agreement value. The 25% width of the transverse profiles at 15 cm should match to within 1% of the reference values. Likewise, the 50% field width should be within 1% of the standard. The PDD profiles should be within 2% of the reference values from 10 to 200 mm. Beam stability should be checked to ensure a rotational variation of less than 2 mm. The output should be measured in centigrays per minute at a 1.5 cm depth and 85 source- to-axis distance, and the monitor chambers should be cali- brated so that 1 monitor unit is approximately equal to 1 cGy on this display, although this is not necessary to ensure correct output. Finally, the beam ramp-up time should be determined to be <10 s. After the static beam measurements have been verified, IMRT delivery verification can be performed using the standard factory IMRT plans. This set of six plans is set up the same at every site. Two plans are run for each field width, one with an on-axis target and the other with an off- axis target. Six measurements are taken across a plane across the central axis, with two measurements in the high-dose region and four outside the target volume in gra- dient regions. The measured dose should be within 3% of the calculated in-treatment region and within 3 mm in the gradient regions. Before commissioning is complete, baseline values should be acquired that can be used for future testing. Once the machine has met all the aforementioned specifications, a ‘‘Rotational Variation’’ procedure is run in which data are collected from the detector during a 5-min procedure in which the gantry is rotating constantly for 5 min while the field is opened to the maximal jaw setting (42 mm). The energy fluence is collected by the on-board detectors and compared with the standard data set regularly by the Tomo- Therapy field service engineer.

TOMOTHERAPY QA

Daily machine QA

Daily QA can be performed by qualified radiation thera- pists but must be under the direction of a qualified medical

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physicist. Daily QA should verify the MVCT image quality, red and green laser positions, visible and audible indica- tors, couch translation accuracy, energy, and integral dose output. After running an ‘‘Airscan’’ procedure to calibrate the de- tector array, MVCT image quality can be confirmed on a daily basis by noting the presence of any new imaging artifacts. Red and green lasers are generally checked by noting their position relative to some baseline position. Sites that choose to treat any patients without MVCT image guidance should be more diligent about daily laser testing. Daily output measurements should be integrations of the dose as the chamber and phantom pass through the beam. This IMRT delivery verification should be in lieu of (or in addition to) the static output measurements typically made at the beam central axis, because the dose delivered to any point is the integration of dose from the start to the end of patient motion. Integral dose measurements made with the phantom setup at the virtual isocenter test the couch and laser accuracy, the beam output, and the longitudinal field width. Daily output checks can be done for one treatment field width with a tolerance of 3% for physicist notification and 5% for halting treatment. In addition to a rotational output check, daily energy ver- ification is also recommended, as well as a check of the displayed monitor units per minute. Energy is generally mea- sured by taking a ratio of the measurements at two different depths and ensuring that the ratio of these values is within 2% of the baseline. Any major shifts in the monitor units per minute (more than 2%) should also be reported to a physicist.

Monthly machine QA

A qualified clinical medical physicist should perform QA tests on a monthly basis. The monthly QA should include more comprehensive tests of those parameters included in the daily tests, as well as testing couch motion integrity and machine synchrony. Again, all visible and audible indicators should be checked monthly. The bunker door is interlocked and should be in- cluded in the monthly QA program. Likewise, the numerous emergency-off buttons should be cycled through the monthly QA program. More comprehensive laser testing should be done at the monthly QA testing. An easy test is to center the cheese phan- tom on the virtual isocenter and then acquire TomoImages. Several slices should be selected in front of the virtual isocen- ter and the same number behind it. The resultant images should confirm that the phantom image is centered. The radi- opaque markers present on the phantom center should be viewable on the center slice. The extent of imaging QA should depend on how the sys- tem is being used. If MVCT images are regularly used for treatment planning, it is important to ensure that the CT num- bers remain constant and that the images are void of any significant artifacts. It is necessary only to perform a qualita- tive assessment of overall image quality for image fusion

purposes only. Using density and image resolution plugs in the cheese phantom, high- and low-contrast resolution, noise, and uniformity can be quantified, if desired. A measure of beam energy by sampling the output ratios at two depths should be obtained. The monthly energy ratio should be within 2% of the baseline. TomoTherapy recom- mends taking measurements at 10- and 20-cm depths in solid water and comparing both to a measurement at 1.5 cm for completeness. In addition, the static integral dose output at 1.5 cm should be within 2% of the expected value. Intensity-modulated RT plan verification should be per- formed using a standard plan. An absolute dose measurement should be taken in the high-dose region and should be within 3% of the calculated dose. It is important to test the plans run for all commissioned field widths. Verifying a plan run with one field width does not ensure that plans run with all field widths are within the specifications. All field widths should be verified in this manner on a schedule deemed rea- sonable by the user. The moving couch presents many QA challenges. The pa- tient would be overdosed 1% if the couch traveled 1% too slow, because all treated areas would be within the primary beam 1% longer. Additionally, the patient areas would even- tually be mistreated as the couch-speed error continued. A 5% speed error for a total treatment length of 20 cm would result in a 1-cm positional error at the end of treatment. The most dangerous error possible with tomotherapy would be for the couch to stop during treatment. Therapists should be instructed to verify that the couch position continuously changes during treatment by observing the graphical user interface readout. However, that relies on the manufacturer’s system properly displaying such information and is not inde- pendent. Visual verification is difficult because of the slow speed (<1 mm/s). The manufacturer has extensive verifica- tion in the couch control, but clinical testing is important. The clinical physicist should independently verify couch motion during treatment at least once a month. Monthly integral dose output and longitudinal beam profile shapes should be checked at a single depth for each commis- sioned field width, because they are so important for the inte- gral dose delivered. A 1-mm profile change for a 10-mm field width would result in an approximate 10% dose change. The profile shape should be analyzed for each commissioned field width. This should include an analysis of the full width half maximum of each profile to submillimeter accuracy. Gener- ally, field widths are checked using one of two methods. To- pographic procedures using an ion chamber passing through the beam and resultant charge profiles can be measured. In ad- dition, film can be used by irradiating it with a static field for all three field widths. With the film at 85 cm source-to-axis distance, the full width half maximum of the Y-axis film pro- file should match the nominal field to within 1%. Some measure of the transverse profile shape should be quantified on a monthly basis to ensure that no indications of target failure are present. Off-axis ratios should be within 2% of expected values. One method to record lateral profile

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constancy is to use film. Devices are also available from var- ious manufacturers for this purpose. The couch and gantry synchrony can be tested using film as described by Fenwick et al. (6). Alternatively, they can be tested using the TomoTherapy-supplied multichannel electrometer that can sample as fast as every 100 ms, which allows output vs. gantry position and output vs. couch posi- tion to be analyzed (7).

Annual machine QA

Annual QA measurements should be performed by aquali- fied clinical physicist. Annual testing should mimic the tomo- therapy commissioning procedures and specifications but be adapted to use the equipment and QA tools available to the physicist performing the tests. The physicist should refer to the machine commissioning section for specific procedures and specifications. Some details of the annual QA testing are described in the following paragraphs. First, static beam data should be collected using a water tank. Longitudinal profile shapes at the standard commis- sioning depths (1.5, 5.0, 10.0, 15.0, and 20.0 cm) should be measured and compared with initial commissioning data. The transverse field profiles, ‘‘cone’’ profiles, at commission- ing depths should also be measured. A Task Group report 51- type calibration can be performed for a static beam and has been described previously (12), or another check of machine output should be performed. Annual measurements should include a check of the beam geometry (11). All tests described in the machine commissioning should be included. The linear accelerator and MLC alignment can be checked as described in ‘‘To- moTherapy Treatment Planning Commissioning and Ac- ceptance Testing’’ but using film instead of the detector if no software to analyze the detector data is available. Most of the necessary ‘‘.xml’’ files for the tests performed in commissioning should be located in the hard drive of the operator’s station computer, if they are not already listed in the database, and can be used in the annual testing. The beam geometry should be consistent with the commis- sioning specifications. Image parameters such as resolution, geometric accuracy, density, and dose should also be verified. Again, the extent of this testing is up to the discretion of the user. Demanding, but clinically realistic, IMRT plans should be delivered either annually or whenever beam changes are suspected. The PDD, longitudinal field shapes, trans-

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verse field shape, and MLC response could all change within tolerances, but the combined effect on a treatment might not be clear. The clinical physicist should anticipate this possibility and design a few IMRT plans to benchmark treatment delivery.

Patient-specific QA Patient-specific QA starts by transferring the delivered dose distribution onto a phantom using an integrated tab within the planning station. The user selects a previously scanned phantom, positions the phantom with respect to the machine geometry so that is at a convenient location for dose measurement, and then recalculates the patient dose on that phantom. Most users choose the cheese phantom for QA, in which films can be irradiated in the coronal or sag- ittal orientation to acquire a planar representation of the dose distribution. The absolute dose is measured with an A1SL ion chamber that can be positioned anywhere across the central axis of the phantom. Separate QA procedures are created from the delivery quality assurance plan on the tomotherapy planning station that can then be delivered at the operator’s station. The QA phantom can be imaged first for setup veri- fication with the planned phantom position using image fu- sion. After the film is exposed and processed, the film analysis features included in the planning system can be used with a film image and associated film calibration file. The analysis tools include profile and isodose comparisons and a gamma calculation. The absolute measured dose with an ion chamber located in a homogenous high-dose region should be 5% of the calculated dose.

CONCLUSION

The tomotherapy machine and treatment process differs from conventional treatment accelerators in a number of ways, making QA for this unit different from that for con- ventional accelerators. Clinical physicists need to under- stand the tomotherapy differences and similarities to fulfill their role in ensuring correct technical treatment delivery. Helical tomotherapy involves many moving parts. QA pro- grams should test them collectively. We presented a QA program for daily, monthly, and annual QA testing that in- cluded procedures, specifications, and schedules, but each clinical physicist is responsible for the actual QA program in their clinic.

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