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IMRT Commissioning and Verification Measurements on Siemens

(ARTISTE)Linear Accelerator

Article · January 2012

DOI: 10.21608/resoncol.2012.438

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 Kasr El-aini J. Clin. Oncol. nucl. med.

Original article vol. 8, no. 1-2, Jan.-April. 2012:18-25

IMRT Commissioning and Verification Measurements on Siemens (ARTISTE)

Linear Accelerator

Tamer Dawod1, Yousri Rostom2, Mahmoud Abouzeid3 and Mostafa Mosad1

Clinical Oncology and Nuclear Med. Department, Fac. Of Medicine, Mansoura University, 2Clinical
1

Oncology and Nuclear Med. Department, Fac. Of Medicine, Alexandria University and 3Physics
Department, Fac. Of Science, Mansoura University.

This study carried out in Ayadi Almostkbal Oncology Center – Alexandria, measurements carried on siemens
linear accelerator (ARTISTE) which produces photons with energy 6 and 10 MV.
This study aimed to dosimetric and verification measurements to apply step-and-shoot intensity modulated
radiation therapy (IMRT) technique on patients. IMRT is a technology in radiation oncology that delivers

Original
radiation more precisely to the tumor while relatively sparing the surrounding normal tissues.

article
Dosimetric measurements were carried out by using linear accelerator siemens (ARTISTE), PTW dosimetry
system (relative and absolute) and slab solid phantom, using this tools we measure percentage depth dose,
beam profile, flatness and symmetry. The measured data was collected and entered (transferred) to the treatment
planning system CMS (XIO) for calculating dose distribution.
These measurements were verified by comparing dose distribution came out planning system with dose
distribution measured by PTW 2D-Array on linear accelerator.
Dosimetry involves more than accounting for delivered dose. It involves ensuring that the MLC shapes are
accurate and are correctly assigned to the patient. Any changes in shaping must be correctly and accurately
incorporated into the field sequence. The information system should be implemented in a way that ensures
good quality assurance practices.
Key words: IMRT, MLC, 2D-Array, dosimetry, radiation oncology.
Corresponding author: tamer dawod E-mail: [email protected]

Introduction

Intensity modulated radiation therapy (IMRT) is a and maintained. Also, computing the needed intensity
technology in radiation oncology that delivers radiation patterns and machine instructions to create them
more precisely to the tumor while relatively sparing into the treatment planning system. The computer
the surrounding normal tissues1-3. It also introduces algorithms associated with the planning system has to
concepts of inverse planning and computer-controlled be commissioned for dose calculation accuracy7.
radiation deposition and normal tissue avoidance in
contrast to the conventional trial-and-error approach4. In general IMRT requires the use of the so-
IMRT became one of the most important treatment called ''inverse'' treatment planning system that work
techniques in radiation oncology because of its ability backwards from a desired dose distribution to the
to create multiple targets and multiple avoidance fluence distribution needed to approximate those dose
structures, to treat different targets simultaneously distributions. Inverse planning system is not truly
to different doses, as well as to weight targets and inverse, because this is mathematically impossible,
avoidance structures according to their importance5. inverse planning programs are only able to approximate
By delivering radiation with greater precision, IMRT the desired dose distributions with physical fluence
has been shown to minimize acute treatment-related patterns8.
morbidity, making dose escalation feasible which may
ultimately improve local tumor control6. The Multileaf position calibration is the single most
important mechanical QA item for MLC-based IMRT
Intensity modulated radiation therapy (IMRT) is an delivery. One of the few calibration tests that should be
extension of 3D conformal radiation therapy (3DCRT). measured is the gap between leaves when the leaves were
Thus, there are new capabilities of linear accelerators supposed to be closed or nearly closed. One important
and collimators that need to be installed, commissioned, consideration for MLCs with rounded leaf ends is the

Kasr-El-Aini Journal Of Clinical Oncology And Nuclear Medicine

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Kasr-El-Aini Journal Of Clinical Oncology And Nuclear Medicine
Vol. 8 | No. 1-2 2012 Tamer Dawod et al.

position difference between the radiation field edge and The flatness was calculated at field size measured with
the light field edge (acting as surrogate for line between the 50% of the dose along the central axis, which is known
the radiation source and the tangent to the rounded leaf as radiological field width11. Dmax and Dmin are the
end). Because of the leaf geometry with rounded leaf maximum and minimum dose within the flattened region
ends, this position difference can be significant. For referred to the dose value at the central axis respectively.
IMRT, this difference leads to significant dose delivery
errors if not properly modeled by the treatment planning Symmetry was a measure of whether the beam’s
system. The tests of the leaf calibration accuracy have dose consistent on each side of the beam profile and is
typically relied on the irradiation of radiographic film defined as the being maximum ratio within the flattened
using a specific radiation pattern that relies on the region, multiplied with 10012,13.
interaction of the steep penumbra and the sensitivity of
the abutment dose on calibration errors [9]. Total Scatter Factors (TSCFs) [14] was Measured
in water at SSD = 100 cm with pinpoint ionization
MATERIALS AND METHODS chamber at reference depth (10cm) for collimator
setting of : 1x1, 2x2, 3x3, 4x4, 5x5, 6x6, 8x8, 10x10,
This study was carried out using the measuring 12x12, 15x15, 18x18, 20x20, 25x25, 30x30, 35x35,
equipment's and irradiation facilities, namely: Siemens 40x40 cm2. The measurements for field sizes from
Linac (ARTISTE), CMS (Xio 4.5) 3D planning system, 5x5 cm2 to 40x40 cm2 were repeated and verified by
PTW dosimetry system, 2D-array dosimeter and Slab 0.6 cm3 ionization chamber. Absolute output for reference
solid phantom, used for all measurements required for field size (10x10 cm2), was measured at reference depth
verifications, QA, and analysis. (10 cm) employing the same setup used to collect TSCF.

The central axis depth doses were measured using Collimator Factor (Sc)15 measurement was carried
a commercially available PTW water scanning system. out in air (using mini-phantom) at SSD=100 cm with
The radiation of photon beam was detected via two (Pinpoint) ionization chamber at reference depth
Semiflex ionization chambers (0.125 cm3). For 6 MV (10 cm) at isocenter for the collimator settings of: 1x1,
energy, the measurements were made at 100 cm FSD 2x2, 3x3, 4x4, 5x5, 6x6, 8x8, 10x10, 12x12, 15x15,
for different open square field sizes in the range from 18x18, 20x20, 25x25, 30x30, 35x35, and 40x40 cm2.
2x2 to 40x40 cm2 and depths from 0.0 to 35.0 cm with
increment 1.0 mm and 2.0 mm along the central axis. Phantom Scatter Correction Factor (PSCFs) was
The data for every field size were normalized to 100% computed from (Total Scatter Factor / Collimator
at the depth of maximum dose dmax (reference depth factor) above.
at 10 cm x 10 cm field size), which corresponds to
1.5 cm10. Physical Wedge Transmission Factor was measured
in water phantom at SSD = 100 cm using (0.6 cc)
Beam profiles measurements were also used chamber at reference depth (10 cm) for collimator
in conjunction with percentage depth doses in the setting of: 5x5, 10x10, 15x15, 20x20, 25x25 cm2 and
calculation of isodose distributions. The measurements maximum wedged square field size. Physical Wedge
were experimentally determined using 0.125 cm3 transmission factors were also calculated as a ratio
ionization chamber as in the case of depth dose against standard field size 10 x 10 cm2.
measurements except in which the scanning ionization
chamber moves transversely along x and y directions Collimator Transmission was measured by using a
of the water phantom. The ionization chamber was mini-phantom16:
scanned across the radiation field of square sides
5x5 cm and 30x30 cm2 with increment 2 mm. The beam Measuring the dose rate on the CAX of the beam for
profiles were measured at depths in the range from the smallest collimator setting at isocenter that covers
dmax to 30 cm in a water phantom for each field size the entire mini-phantom.
with a constant FSD of 100 cm.
Close the width jaws down to as close to zero as
Beam profile parameters were obtained by obtainable and move the mini-phantom as needed to
MEPHYSTO software that is used with automatic make sure no beam is intercepting the phantom and
scanning system. The beam parameters, homogeneity measure the dose rate.
(flatness), symmetry and penumbra were measured for
both longitudinal and transverse axis of each field size The PTW 2D-Array (seven 29) in combination with
at different depths. They were referring to the flattened the VeriSoft analysis software were used as a dosimetric
region of the beam profile scan. verification tool for IMRT fields as the following17:
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Kasr-El-Aini Journal Of Clinical Oncology And Nuclear Medicine
Vol. 8 | No. 1-2 2012 IMRT Commissioning and Verification Measurements on Siemens (ARTISTE)

• Determining the MUs for 1 Gy with 6 MV the photon beam traverse through the phantom19,20. The
photons by 10x10 cm field size. Absolute dose was percent depth dose increases with the field size due to
measured at 10 cm depth in RW3 slab phantom the increase in scattered radiation at larger field sizes. In
at FSD = 90.8 cm (5 cm was used as backscatter addition, it is obvious from the Figure (1) that the surface
material). dose increases with the field size because of the increase
• The 2D-array was put into RW3 phantom and in scattered radiation. The depth of maximum dose was
adjusted to have an effective measuring depth of found to be at 1.5 ± 0.1 cm for 6 MV21 photon beam over
10 cm. the range of field sizes from 2x2 to 40x40 cm2. After
• Calibration factor was determined by dose coming the radiation beam has penetrated to the dmax, there is a
from the reading of the array chambers on the gradual decrease in the dose22.
central beam axis for 1 Gy irradiation.
• A plan of 10x10 field size at 10 cm depth by the Figures (2) and (3) show an open beam profile
same setup conditions was carried out by using the measurements of 6 MV Siemens (ARTISTE) Linac.
treatment planning system. Across the radiation field 2x2 cm2 and 10x10 cm2 at
• The planning dose cube IMRT plan was exported depths ranged from dmax to 30 cm.
via dicom format to PTW Verisoft on 2D-Array and
compared with the corresponding measured intensity The resulting beam profile scans demonstrate the
map (gamma test) and applying the correction factors variation in flatness and symmetry of the field size as a
between planning system and absolute dosimetry function of the specified depths (1.5, 5, 10, 15, 20, 25
and between the 2D-Array and absolute dosimetry. and 30 cm)23. The beam homogeneity increases with
• The Gamma Index Analysis is the most common the field size and depth in which affecting in the beam
method to compare two IMRT matrices with respect uniformity24. This increase in the homogeneity value
to dose difference and a physical distance between is illustrated in more detail in Figure (4), in this figure
the comparison point r18. the beam profiles for field size 10 x 10 cm2 at depths
1.5, 10, and 20 cm are normalized to the dose at the
center of the field, thus obtaining an off-axis ratio (OAR)
for each off axis distance.
Where
Additional measured parameters including Total
Scatter Factors (TSCFs), Collimator Factors (Sc)25 and
Phantom Scatter Correction Factors26 (PSCFs) are shown
in Table (1).

Verification measurements:
The verification method adopted here is to transfer
And the CT based treatment plan to a homogenous phantom.
The plan is then recalculated in the TPS for this phantom.
Measurements were performed in the phantom by
2D-Array. The calculated dose distribution in the phantom
Is the difference between dose values on the is compared with measurements in the phantom. The dose
calculated and measured distributions, respectively the distributions calculation in the phantom must be exactly the
pass–fail criteria therefore become same beam and MLC settings were used as in the patient
case (all angles for the plan were reset to zero degree to
Ɣ (rm) ≤ 1, calculation passes, Ɣ (rm) > 1, calculation be measured using 2D- array). If the measurements and
fails. the calculations in the phantom are within acceptable
tolerances, the IMRT plan is considered to be accurate
• After that the profile should be alright, if this does to deliver to the patient17,27-30. When an IMRT treatment
not work, then there is a problem somewhere. plan has been accepted for patient treatment, it has to be
verified according to the description above.
RESULTS
IMRT mainly used for treatments of the prostate, head
Commissioning data: and neck tumors and for irradiations of the breast if the
Figure (1) illustrates the influence of the open internal mammary lymph node chain has to be included
field sizes on the percent depth dose curves. They are into the target volume. Figure (5) shows a comparison
characterized by the buildup of dose at the surface between measured and calculated plan for verification of
reaching a maximum dose, then the dose decreases as real patient IMRT plan (prostate).
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Kasr-El-Aini Journal Of Clinical Oncology And Nuclear Medicine
Vol. 8 | No. 1-2 2012 Tamer Dawod et al.

According to the tolerance values for homogeneous calculation can fail though it is within the set criteria.
simple fields, the penumbra region should be within For example if we are comparing two dose points of 4%
2 mm or 10%. By just studying the profiles by eye and 1% dose, and the dose criteria is set to be 2%, this
it is hard to say, especially in the z-direction in the will lead to a gamma value larger than 1 (4%-1%)/2%).
penumbra region, if the result is within the tolerance. A The 3% dose difference can still be within acceptable
gamma evaluation with 3% and 3 mm criteria is shown tolerances but the gamma calculation fails.
in Figure (5), revealing that it is only in the penumbra
region that acceptance fails. The colours of the palette Five IMRT fields with a total of 72 segments for
range are set to be green for 100% (γ = 1), and accepted a real prostate patient were used for comparison and
regions are green and most yellow. Regions that fail are verification. The results presented in Figure (5) indicate
shown in red. The gamma test evaluation method is not a quite good agreement between measured and TPS
good tool for evaluation of low dose regions, where the calculated doses.

Figure 1: PDDs of 6 MV photon beam for open square fields Figure 3: Beam profiles of 6MV photon beam for (10 x 10 cm2)
sizes at FSD = 100 cm in water phantom. field size at depths of (1.5, 5, 10, 15, 20, 25 and 30 cm).

Figure 4: Dose profiles for (10 x 10 cm2) at 1.5, 10, and 20 cm

Figure 2: Beam profiles of 6MV photon beam for (2 x 2 cm )
2
depth normalized to unity at the center of the field for 6MV
field size at depths of (1.5, 5, 10, 15, 20, 25 and 30 cm). photon beam.

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Kasr-El-Aini Journal Of Clinical Oncology And Nuclear Medicine
Vol. 8 | No. 1-2 2012 IMRT Commissioning and Verification Measurements on Siemens (ARTISTE)

Figure 5: All fields of IMRT real prostate patient isodose verification and gamma distributions: Comparison between 2D-Array
measured data and the corresponding exported data coming from the treatment planning system. (2D-Array measurements were at zero
angel degree)

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Kasr-El-Aini Journal Of Clinical Oncology And Nuclear Medicine
Vol. 8 | No. 1-2 2012 Tamer Dawod et al.

Table 1: The measured Total Scatter Factors (TSCFs), Collimator Factors (Sc) and calculated Phantom Scatter Correction Factors
(PSCFs) for 6MV photon beam.
Field size Reading (water) cGy TSCF Reading (air) cGy Sc PSCF

1x1 41.3 0.596735 12.73 0.222 2.685

2X2 54.04 0.780812 45.85 0.801 0.975

3X3 57.05 0.824303 53.31 0.931 0.886

4X4 59.4 0.858257 54.86 0.958 0.896

5X5 61.51 0.888744 55.44 0.968 0.918

6X6 63.39 0.915908 55.92 0.976 0.938

8X8 66.66 0.963156 56.72 0.990 0.972

10X10 69.21 1 57.27 1.000 1.000

12X12 71.29 1.030053 57.73 1.008 1.022

15X15 73.84 1.066898 58.19 1.016 1.050

18X18 76.13 1.099986 58.65 1.024 1.074

20X20 77.35 1.117613 59.2 1.034 1.081

25X25 80.26 1.159659 61.09 1.067 1.087

30X30 82.76 1.195781 62.24 1.087 1.100

35X35 84.77 1.224823 63.23 1.104 1.109

40X40 85.96 1.242017 63.52 1.109 1.120

DISCUSSION deliver highly modulated fields can produce substantial

dosimetric error33-35.
Commissioning data:
Commissioning of a conventional treatment planning IMRT verification:
system requires both non-dosimetric and dosimetric Our results demonstrate that the 2D-Array can be
tests31,32. Non-dosimetric tests include such items as used to accurately and efficiently verify the dosimetry
image registration and conversion, image and isodose of IMRT treatment delivery. The setting of MapCheck
display, and hardcopy devices. Dosimetric tests include comparison tolerance criteria is challenging and needs to
comparisons between measurements and planning system take into account the uncertainties of the intensity-map
predictions of, for example, depth doses, open and wedge measurements, the MLC calibration, radiation delivery
beam profiles, and handling of inhomogeneities. Both and treatment plan dose calculation. Van Dyke et al.31 and
measurements and dose calculations must be accurate, the AAPM task group 5336 suggest criteria of 3% of dose
if the two are to match. Unlike conventional systems, difference and 4 and 3 mm, respectively, for dosimetry of
IMRT planning systems must account for the additional conformal therapy beam.
complexity due to modulation of the fluence distribution.
In general, the more complex the modulations the greater Our tolerances between measurements and
are the additional uncertainties that are introduced calculations are set at 3% / 3 mm. The disagreement
above those that already exist for conventional field between the measured and calculated dose maps increases
calculations. So, by comparing the previously presented generally with the number of segments per beam and
commissioning data which carried out on Artiste Linac with the use of small segments delivering an appreciable
with many similar published data coming from other fraction of the MUs.
Linacs (Elekta). We found that there are some slightly
differences in most collected and compared data that For IMRT treatments, this becomes impractical and
specially related to MLC characteristics. The reason more elaborate QA measures are therefore necessary.
for this difference is coming from the different leaf When carrying out commissioning data and QA
width and high number of leaves (MLC) which is 160 measurements for IMRT fields, it is preferable to use
leaves on Artiste Linac instead of 80 or 120 leaves for the MU that will be delivered for the patient treatment,
Elekta Linac. The narrow MLC openings required to since this will affect the MU per segment for step-and-
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Kasr-El-Aini Journal Of Clinical Oncology And Nuclear Medicine
Vol. 8 | No. 1-2 2012 IMRT Commissioning and Verification Measurements on Siemens (ARTISTE)

shoot technique. Individual field checks may be either 6. Teh BS, Woo SY, Butler EB. Intensity Modulated
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