IMRT/VMAT: AAPM

Recommendations for
Commissioning and
Delivery Verification
Emilie Soisson, Ph.D.
ICTP 2019
 Learning Objectives
• To understand IMRT/VMAT commissioning
and QA
• To be able to describe available measurement
tools and analysis technique
• To be able to describe the limitations of each
technique and future directions
 Commissioning
• IMRT and VMAT can be available usually with
minor hardware and software upgrades
• Validation can be challenging
• Commissioning is require for both planning
and delivery to make sure planned doses can
be delivered accurately
 IMRT/VMAT – MLC tests

• Additional MLC
tests may be
required
Dosimetry
– Leaf gap
– Transmission
Mechanical
– Speed
– Positioning
Chui CS, Spirou S, LoSasso T. Testing of dynamic
multileaf collimation. Med Phys. 1996;23:635-
641
 MLC Characteristics

From Deng et al. The MLC tongue-and-groove

From Shende et al. Reports of Practical Oncology & Radiotherapy effect on IMRT dose distributions. Phys. Med.
Volume 22, Issue 6, November–December 2017, Pages 485-494 Biol. 46 (2001) 1039–1060
 Inter- and Intra-leaf Leakage

LoSasso T, Chui CS, Ling CC. Physical and dosimetric aspects of a multileaf
collimation system used in the dynamic mode for implementing intensity-
modulated radiotherapy. Med Phys. 1998;25:1919-1927
Accuracy of MLC During RapidArc

Image of a film that was

exposed twice to the 1-
mm-wide picket fence
pattern, once at
stationary gantry angle
and a second time in
RapidArc mode.
Ling et al. International Journal of Radiation Oncology • Biology • Physics
Volume 72, Issue 2, Pages 575-581 (October 2008)
Copyright © 2008 Elsevier Inc. Terms and Conditions
Intentional Leaf Positioning Errors Fig. 4

A film exposed to the 1-mm-wide picket

Copyright © 2008 Elsevier Inc. Terms and Conditions
fence pattern with “intentional” errors in
fence width and position.
 Fig. 5
Ability to vary Dose Rate and
Gantry Speed

Film exposed to a RapidArc QA plan,

combining different dose-rates, gantry
ranges, and gantry speeds, to give the
same monitor unit (MU) to the different
International Journal of Radiation Oncology • Biology • Physics 2008parts of the
72, 575-581DOI: field.
(10.1016/j.ijrobp.2008.05.060)
Copyright © 2008 Elsevier Inc. Terms and Conditions
MLC Tests for VMAT

https://radimage.com/solutions/mlc-qa/
Recommended
Monthly
 IMRT/VMAT Commissioning - TPS
• AAPM MPPG 5a recommends the following
tests
• VMAT, Segmental IMRT, and Dynamic IMRT
need to be validated separately
Test Description
1 Verify small field PDD <2x2cm2, MLC shaped
2 Output for small MLC defined Small MLC defined segments
field
3 AAPM TG-119 tests Plan, measure and compare benchmark cases

4 Clinical tests Plan, measure and compare representative clinical

cases
5 External Review Sim, plan, and treat anthropomorphic phantom

From AAPM MPPG 5a. Journal of Applied Clinical Medical Physics, Vol. 16, No. 5, 2015
MPPG 5A Additional Resources
 Other IMRT/VMAT Commissioning
• Ezzel GA, Galvin JM, Low D et al. Guidance document on
delivery, treatment planning, and clinical implementation
of IMRT: report of the IMRT subcommittee of the AAPM
radiation therapy committee. Med Phys. 2003; 30:2089-
2115.
• Ling et al. Commissioning and quality assurance of rapidarc
delivery system. IJROBP.2008 Oct 1;72(2):575-81 (Varian)
• Beford et al. Commissioning of Voumetric Modulated Arc
Therapy (VMAT). IJROBP. 2009;73:537-545. (Elekta)
• ESTRO Booklet 9
• AAPM MPPG 5A
• AAPM TG119, 120, 218
• Read the manual!
 AAPM Recommendations:
Report of Task Group 120

“This report provides a

comprehensive overview of how dosimeters,
phantoms, and dose distribution analysis
techniques
should be used to support the commissioning
and quality assurance requirements of an IMRT
Med. Phys. 38(3). March 2011.
Program.”
Phantoms
 AAPM Recommendations: Point
Dose
• Absolute dose • Measurement location
– Calibrated cylindrical – Homogeneous (<10%)
ion chamber
– <10% dose difference
– Size should be small 2mm from detector
enough to limit dose
heterogeneity across
the volume to <10%
– Avoid high z central • Reference dose
electrode – Calculated average
– Leakage <5% of over collecting
reading (correction volume
>2%) – Avoid point dose
 AAPM Recommendations: 2D
Detectors
• Detectors • Recommendations
– Film – Use for relative
– Diode Arrays dosimetry
– Ion chamber arrays – Film calibration protocol
– EPID – Commissioning with film
before moving to 2D
arrays for routine QA
Diode Arrays
TG 120: Sample Recommendations
Diode Arrays
EPID
TG 120: Sample Recommendations
EPID
 Basic Pre-Treatment IMRT PSQA
Rationale
• MU calculations and delivery are complex so a
simple backup MU check may not be
possible/adequate
• The patient’s plan can be measured by copying
the plan to a phantom and performing a
calculation of the patient’s fields on a phantom
• Point dose measurements in addition to a
comparison of the planar dose distribution
should be performed
JACMP. 12 (2) 2011.
 How Often?
• Prior to delivery of every plan?
• When simple backup MU calculation is not possible
or does not pass?
• Until you have data on X number of cases?
 CPQR Recommedations

• IMRT1: PSQA
– Or can be dropped with “rigorous” statistical analysis
• IMRT 2: Set of commissioning plans that mimic clinical cases
• IMRT 3: Case chosen for repeat delivery on quarterly basis
• IMRT 4: Annual review of IMRT protocol (passing criteria, methods,
frequency, etc.)
• IMRT 5: External audit
RPC/QARC credentialing for RTOG/COG IMRT protocols
QA Audits
IROC Audit
Med. Phys. 40(2) 2013. Criteria +/- 7%DD, 4mm DTA
 Reasons for Failing Results
• Incorrect data entered into the TPS
• Inexact beam modeling
• Software and hardware failures
 AAPM TG 119: Commissioning Tests
for IMRT
• Reaction to RPC results showing failing IMRT QA
results at many institutions
• Created a set of standard plans and analysis
techniques to commission IMRT
• Compared results between institutions
 IMRT commissioning: Multiple institution planning and dosimetry comparisons, a report from AAPM
Task Group 119

Medical Physics
Volume 36, Issue 11, pages 5359-5373, 30 NOV 2016 DOI: 10.1118/1.3238104
http://onlinelibrary.wiley.com/doi/10.1118/1.3238104/full#f1
 IMRT commissioning: Multiple institution planning and dosimetry comparisons, a report from AAPM
Task Group 119

Medical Physics
Volume 36, Issue 11, pages 5359-5373, 30 NOV 2016 DOI: 10.1118/1.3238104
http://onlinelibrary.wiley.com/doi/10.1118/1.3238104/full#f2
 IMRT commissioning: Multiple institution planning and dosimetry comparisons, a report from AAPM
Task Group 119

Medical Physics
Volume 36, Issue 11, pages 5359-5373, 30 NOV 2016 DOI: 10.1118/1.3238104
http://onlinelibrary.wiley.com/doi/10.1118/1.3238104/full#f3
 IMRT commissioning: Multiple institution planning and dosimetry comparisons, a report from AAPM
Task Group 119

Medical Physics
Volume 36, Issue 11, pages 5359-5373, 30 NOV 2016 DOI: 10.1118/1.3238104
http://onlinelibrary.wiley.com/doi/10.1118/1.3238104/full#f4
 IMRT commissioning: Multiple institution planning and dosimetry comparisons, a report from AAPM
Task Group 119

Medical Physics
Volume 36, Issue 11, pages 5359-5373, 30 NOV 2016 DOI: 10.1118/1.3238104
http://onlinelibrary.wiley.com/doi/10.1118/1.3238104/full#f5
 TG 119 Continued
• Treatment plans were created and analyzed in
several institutions
• Recommendations for action and tolerance provided
• Data sets are available for download on the AAPM
web site to allow individual sites
– Allow for comparison to these sites using the same data
sets
• Suggested that these standard plans be used in
commissioning to improve results
• Provide baseline tests for machine changes
 Gamma Passing Rate

• Percentage of points analyzed that pass the

DD and DTA criteria
• General looking for pass rates above 90%
• Wide variety in practice in the USA/Canada
 Gamma Index
Gamma is the Euclidian distance between an evaluated distribution and each point in an
evaluated distribution. Gamma is a tool to compare dose distributions. It has
limitations that must be considered in IMRT QA analysis.

Low, D. (2015). The importance of 3D dosimetry. In Journal of Physics: Conference

Series (Vol. 573, No. 1, p. 012009). IOP Publishing.
 Dosimetry tools and techniques for IMRT

Medical Physics
Volume 38, Issue 3, pages 1313-1338, 16 FEB 2011 DOI: 10.1118/1.3514120
http://onlinelibrary.wiley.com/doi/10.1118/1.3514120/full#f3
Pitfalls of the Gamma Index
 Conclusions Nelms et al.
• Real-world cases where systematic errors
were not detected with 3%/3mm
– Error introduced to TPS, linac, delivery method,
setup
• More sensitive metrics should be used to
evaluate the accuracy of dose calculation
algorithms, delivery systems, and QA devices.
 Gamma analysis dependence on specified low‐dose thresholds for VMAT QA

Global Normalization
Journal of Applied Clinical Medical Physics
Volume 16, Issue 6, pages 263-272, 8 NOV 2015 DOI: 10.1120/jacmp.v16i6.5696
http://onlinelibrary.wiley.com/doi/10.1120/jacmp.v16i6.5696/full#acm20263-fig-0001
 Gamma analysis dependence on specified low‐dose thresholds for VMAT QA

Journal of Applied Clinical Medical Physics

Volume 16, Issue 6, pages 263-272, 8 NOV 2015 DOI: 10.1120/jacmp.v16i6.5696 Local normalization
http://onlinelibrary.wiley.com/doi/10.1120/jacmp.v16i6.5696/full#acm20263-fig-0002
 Conclusion
• The low dose threshold that is chosen and the
normalization technique, global or local, greatly
impact Gamma passing rates
 Impact of Noise on Gamma Analysis

Jiang Graves, Y., Jia, X., & Jiang, S. B. (2013). Effect of statistical fluctuation in Monte
Carlo based photon beam dose calculation on gamma index evaluation. Physics in
Medicine and Biology, 58, 1839.
 Conclusion
• Gamma can be artificially high or low
depending on the noise in either your measured
or calculated distribution
 Resolution

Low, D. (2015). The importance of 3D dosimetry. In Journal of Physics: Conference

Series (Vol. 573, No. 1, p. 012009). IOP Publishing.
 Recommendations for Gamma
• Need interpolation • Don’t blindly use
between calc points pass/fail criteria
to get good results • If points fail by a lot,
• Noisy distributions look at this point
result in artificially • Know where
low gamma results anatomically the
points fail
 Recommendations from AAPM
TG 218 (in press)
• Measurements should be • Calibration compared
a true composite against a standard dose at
– Ensure detector has no each measurement
angular dependence • Normalization
– No perpendicular – Global versus local
composite, prone to normalization
masking delivery errors
– Normalization point should
• Absolute Dose vs. Relative be in a low gradient, high
dose dose region ≥90% of the
• Exclude areas with little max dose
or no clinical relevance – Local normalization can be
used for commissioning
– Ignore large areas of low
dose that change the pass
rate
 218 Recommendations Cont.
• Tolerance and action • Site specific tolerance and
– Tolerance ≥95% with action levels are
3%/2mm encouraged as long as it is
– Action ≥90% with 3%/2mm better than these universal
– Ignore points <10% of rx dose recommendations
• Resolution is important for – For example if at your site you
gamma analysis, need to can only get 80%/3mm, then
use DTA of <3mm to detect you have to do better.
MLC errors • Make sure you have the
– Understand software appropriate equipment
• Log results to know how
you are doing
 What to do when plans fail
• Look at where it fails • Failing Gamma rates
and determine if it is should be investigated!
relevant
• Don’t just look at
statistics, look at all
points above gamma
1.5
• Replanning should be
an option (allow ample
time for QA)
Clinical Example
Head and Neck PSQA w/ArcCheck
Beam Enters through Couch
Beam that Does Not Enter Through
Couch
Composite
 Other IMRT Verification Methods
• Software that analyses beam delivery files (i.e.
Varian Dynalogs, Mobius)
• Import plan DVH and compare to library of
standard plans or set of established dose
constraints to assess plan quality
• Second TPS or Monte Carlo
 Use of Treatment Log Files (3D)
• Record treatment leaf
position
• 3D delivered dose is
calculated in the patient
CT using collapsed cone
convolution
• Allows for assessment
of the impact of
delivery errors on dose
to the patient
 Role of Mobius in Automating QA
SafetyNet: streamlining and automating QA in radiotherapy

Journal of Applied Clinical Medical Physics

Volume 17, Issue 1, pages 387-395, 8 JAN 2016 DOI: 10.1120/jacmp.v17i1.5920
http://onlinelibrary.wiley.com/doi/10.1120/jacmp.v17i1.5920/full#acm20387-fig-0003
 Other IMRT Verification Methods
• In general, these methods do
not look at accuracy of
heterogeneity corrections
• Calculate plan in a second
treatment planning system
 Radify Interface

Proportion of complex plans increasing resulting in a need for more accurate MU verification.
Improved accuracy may eliminate the need for measurements.
Slide courtesy of Marc-André Renaud
 Dose Difference

Slide courtesy of Marc-André Renaud