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DOE OSTI2016

SU-F-T-19: The Consistency Dosimetric Analysis of the Accelerated Breast Brachytherapy

Purpose: To assess the best approach in accept a treatment plan for APBI Savi patients. Should we run a treatment verification test prior to delivering it to the patient? Should we check each CT scan in regards to the initial one in dosimetrical terms? Do we need deformable registration and adaptive planning for each fraction? These are the questions we want to answer running a dosimetric analysis of the dose variances for APBI treatments who receive 10 fractions and no re-planning has been done being considered unnecessary with today’s means of assessment. Methods: A retrospective analysis of 30 patients treated with SAVI applicators were considered for this study. The CT scans taken before each treatment were imported in the treatment planning system and registered with the initial CT scan. The images were fused together with respective to the applicator, using landmark registration. Dosimetric evaluations were performed. Dose received by skin, ribs and PTV on CT images with respect to the initial treatment plan were recorded including maximum, average and minimum dose Results: All the structures displayed changes in volume over the 10 fractions of treatment. The cavities reduction in volume was considerable with a maximum reduction of over 10%. The PTV-eval is covered better due to this fact while the critical organs manifest an increase in the total and maximum dose delivered. Ribs and skin surface that are required by B39 protocol to be monitored can acquire maximum doses of 20% to 30% respectively. Conclusion: A dosimetric evaluation prior to the initial treatment and prior to each of the 10 fractions is proven to be necessary. Deformable registration and adaptive planning have to be studied more and eventually implemented for every patient who received more than one fraction of any type of brachytherapy treatment. Immobilization ad localization methods must be improved and studied further.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2016

SU-F-T-26: A Study of the Consistency of Brachytherapy Treatments for Vaginal Cuff

Purpose: To evaluate to treatment consistency over the total number of fractions when treatment what HDR brachytherapy using the ML cylinders. At the same time the dosimetric impact on the critical organs is monitored over the total number of fractions. Methods: A retrospective analysis of 10 patients treated with Cylinder applicators, from 2015–2016 were considered for this study. The CT scans of these patients, taken before each treatment were separately imported in to the treatment planning system and paired with the initial CT scan after completing the contouring. Two sets of CT images were fused together with respective to the applicator, using landmark registration. The doses of each plan were imported as well and a cumulative dosimetric analysis was made for bladder, bowels, and rectum and PTV. Results: No contour of any of the OAR was exactly similar when CT images were fused on each other. The PTV volumes vary from fraction to fraction. There was always a difference between the doses received by the OARs between treatments. The maximum dose varied between 5% and 30% in rectum and bladder. The minimum dose varied between 5% and 8% in rectum and bladder. The average dose varied between 15% and 20% in rectum and bladder. Deviation in placement were noticed between fractions. Conclusion: The variation in volumes of OARs and isodoses near the OARs, indicate that the estimated doses to OARs on the planning system may not be the same dose delivered to the patient in all the fractions. There are no major differences between the prescribed dose and the delivered dose over the total number of fractions. In some cases the critical organs will benefit if the consecutive plans will made after the CT scans will be registered with the initial scan and then planned.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2016

SU-F-T-92: Clinical Benefit for Breast and Chest Wall Setup in Using a Breast Board

Purpose: To validate benefit of using a breast board (BB) by analyzing the geometry and dosimetry changes of the regions of interest (ROIs) between CT scans with and without BB. Methods: Seven patients, two chest walls (CW) and five breasts, use BB at CT simulation and no BB at diagnostic CT were included. By using deformable image registration software (Velocity AI), diagnostic CT and planning CT were rigidly co-registered according to the thoracic cage at the target. The heart and the target were then deformedly matched and the contours of the planned ROIs were transferred to the diagnostic CT. Which were brought back to the planning CT data set though the initial rigid co-registration in order to keep the deformed ROIs redefined in the diagnostic CT. Anatomic shifts and volume changes of a ROI beyond the rigid translation were recorded and dosimetry changes to ROIs were compared with recalculated DVHs. Results: Patient setup without the BB had small but systematic heart shifts superiorly by ∼5 mm. Torso rotations in two cases moved the heart in opposite directions by ∼10 mm. The breast target volume, shape, and locations were significantly changed with arm extension over the head but not in cases with the arm extended laterally. Breast setup without BB could increase the mean dose to the heart and the maximal dose to the anterior ventricle wall by 1.1 and 6.7 Gy, respectively. Conclusion: A method for evaluation of breast setup technique is introduced and applied for patients. Results of systematic heart displacement without using the BB and the potential increase of heart doses encourage us to further investigate the current trend of not using a BB for easy setup and CT scans. Using a BB would likely increase patient sag during prolonged IMRT and real-time patient position monitoring is clinically desired.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2016

SU-F-T-119: Development of Heart Prediction Model to Increase Accuracy of Dose Reconstruction for Radiotherapy Patients

Purpose: To assess individual variation in heart volume and location in order to develop a prediction model of the heart. This heart prediction model will be used to calculate individualized heart doses for radiotherapy patients in epidemiological studies. Methods: Chest CT images for 30 adult male and 30 adult female patients were obtained from NIH Clinical Center. Image-analysis computer programs were used to segment the whole heart and 8 sub-regions and to measure the volume of each sub- region and the dimension of the whole heart. An analytical dosimetry method was used for the 30 adult female patients to estimate mean heart dose during conventional left breast radiotherapy. Results: The average volumes of the whole heart were 803.37 cm{sup 3} (COV 18.8%) and 570.19 cm{sup 3} (COV 18.8%) for adult male and female patients, respectively, which are comparable with the international reference volumes of 807.69 cm{sup 3} for males and 596.15 cm{sup 3} for females. Some patient characteristics were strongly correlated (R{sup 2}>0.5) with heart volume and heart dimensions (e.g., Body Mass Index vs. heart depth in males: R{sup 2}=0.54; weight vs. heart width in the adult females: R{sup 2}=0.63). We found that the mean heart dose 3.805 Gy (assuming prescribed dose of 50 Gy) in the breast radiotherapy simulations of the 30 adult females could be an underestimate (up to 1.6-fold) or overestimate (up to 1.8-fold) of the patient-specific heart dose. Conclusion: The study showed the significant variation in patient heart volumes and dimensions, resulting in substantial dose errors when a single average heart model is used for retrospective dose reconstruction. We are completing a multivariate analysis to develop a prediction model of the heart. This model will increase accuracy in dose reconstruction for radiotherapy patients and allow us to individualize heart dose calculations for patients whose CT images are not available.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2016

SU-F-T-133: Uniform Scanning Proton Therapy for Lung Cancer: Toxicity and Its Correlation with Dosimetry

Purpose: To analyze the toxicity of uniform scanning proton therapy for lung cancer patients and its correlation with dose distribution. Methods: In this study, we analyzed the toxicity of 128 lung cancer patients, including 18 small cell lung cancer and 110 non small cell lung cancer patients. Each patient was treated with uniform scanning proton beams at our center using typically 2–4 fields. The prescription was typically 74 Cobalt gray equivalent (CGE) at 2 CGE per fraction. 4D Computerized Tomography (CT) scans were used to evaluate the target motion and contour the internal target volume, and repeated 3 times during the course of treatment to evaluate the need for plan adaptation. Toxicity data for these patients were obtained from the proton collaborative group (PCG) database. For cases of grade 3 toxicities or toxicities of interest such as esophagitis and radiation dermatitis, dose distributions were reviewed and analyzed in attempt to correlate the toxicity with radiation dose. Results: At a median follow up time of about 21 months, none of the patients had experienced Grade 4 or 5 toxicity. The most common adverse effect was dermatitis (81%: 52%-Grade 1, 28%-Grade 2, and 1% Grade 3), followed by fatigue (48%), Cough (46%), and Esophagitis (45%), as shown in Figure 1. Severe toxicities, such as Grade 3 dermatitis or pain of skin, had a clear correlation with high radiation dose. Conclusion: Uniform scanning proton therapy is well tolerated by lung cancer patients. Preliminary analysis indicates there is correlation between severe toxicity and high radiation dose. Understanding of radiation resulted toxicities and careful choice of beam arrangement are critical in minimizing toxicity of skin and other organs.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2016

SU-F-T-434: Development of a Fan-Beam Optical Scanner Using CMOS Array for Small Field Dosimetry

Purpose: To design and construct a second generation optical computed tomography (OCT) system using a fan-beam with a CMOS array detector for the 3D dosimetry with polymer gel and radiochromic solid dosimeters. The system was specifically designed for the small field dosimetry. Methods: The optical scanner used a fan-beam laser, which was produced from a collimated red laser beam (λ=620 nm) with a 15-degree laser-line generating lens. The fan-beam was sent through an index-matching bath which holds the sample stage and a sample. The emerging laser light was detected with a 2.54 cm-long CMOS array detector (512 elements). The sample stage rotated through the full 360 degree projection angles at 0.9-degree increments. Each projection was normalized to the unirradiated sample at the projection angle to correct for imperfections in the dosimeter. A larger sample could be scanned by using a motorized mirror and linearly translating the CMOS detector. The height of the sample stage was varied for a full 3D scanning. The image acquisition and motor motion was controlled by a computer. The 3D image reconstruction was accomplished by a fan-beam reconstruction algorithm. All the software was developed inhouse with MATLAB. Results: The scanner was used on both PRESAGE and PAGAT gel dosimeters. Irreconcilable refraction errors were seen with PAGAT because the fan beam laser line refracted away from the detector when the field was highly varying in 3D. With PRESAGE, this type of error was not seen. Conclusion: We could acquire tomographic images of dose distributions by the new OCT system with both polymer gel and radiochromic solid dosimeters. Preliminary results showed that the system was more suited for radiochromic solid dosimeters since the radiochromic dosimeters exhibited minimal refraction and scattering errors. We are currently working on improving the image quality by thorough characterization of the OCT system.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2016

SU-F-T-436: A Method to Evaluate Dosimetric Properties of SFGRT in Eclipse TPS

Purpose: The objective was to develop a method for dose distribution calculation of spatially-fractionated-GRID-radiotherapy (SFGRT) in Eclipse treatment-planning-system (TPS). Methods: Patient treatment-plans with SFGRT for bulky tumors were generated in Varian Eclipse version11. A virtual structure based on the GRID pattern was created and registered to a patient CT image dataset. The virtual GRID structure was positioned on the iso-center level together with matching beam geometries to simulate a commercially available GRID block made of brass. This method overcame the difficulty in treatment-planning and dose-calculation due to the lack o-the option to insert a GRID block add-on in Eclipse TPS. The patient treatment-planning displayed GRID effects on the target, critical structures, and dose distribution. The dose calculations were compared to the measurement results in phantom. Results: The GRID block structure was created to follow the beam divergence to the patient CT images. The inserted virtual GRID block made it possible to calculate the dose distributions and profiles at various depths in Eclipse. The virtual GRID block was added as an option to TPS. The 3D representation of the isodose distribution of the spatially-fractionated beam was generated in axial, coronal, and sagittal planes. Physics of GRID can be different from that for fields shaped by regular blocks because the charge-particle-equilibrium cannot be guaranteed for small field openings. Output factor (OF) measurement was required to calculate the MU to deliver the prescribed dose. The calculated OF based on the virtual GRID agreed well with the measured OF in phantom. Conclusion: The method to create the virtual GRID block has been proposed for the first time in Eclipse TPS. The dosedistributions, in-plane and cross-plane profiles in PTV can be displayed in 3D-space. The calculated OF’s based on the virtual GRID model compare well to the measured OF’s for SFGRT clinical use.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2016

SU-F-T-441: Dose Calculation Accuracy in CT Images Reconstructed with Artifact Reduction Algorithm

Purpose: Accuracy of radiotherapy dose calculation in patients with surgical implants is complicated by two factors. First is the accuracy of CT number, second is the dose calculation accuracy. We compared measured dose with dose calculated on CT images reconstructed with FBP and an artifact reduction algorithm (OMAR, Philips) for a phantom with high density inserts. Dose calculation were done with Varian AAA and AcurosXB. Methods: A phantom was constructed with solid water in which 2 titanium or stainless steel rods could be inserted. The phantom was scanned with the Philips Brillance Big Bore CT. Image reconstruction was done with FBP and OMAR. Two 6 MV single field photon plans were constructed for each phantom. Radiochromic films were placed at different locations to measure the dose deposited. One plan has normal incidence on the titanium/steel rods. In the second plan, the beam is at almost glancing incidence on the metal rods. Measurements were then compared with dose calculated with AAA and AcurosXB. Results: The use of OMAR images slightly improved the dose calculation accuracy. The agreement between measured and calculated dose was best with AXB and image reconstructed with OMAR. Dose calculated on titanium phantom has better agreement with measurement. Large discrepancies were seen at points directly above and below the high density inserts. Both AAA and AXB underestimated the dose directly above the metal surface, while overestimated the dose below the metal surface. Doses measured downstream of metal were all within 3% of calculated values. Conclusion: When doing treatment planning for patients with metal implants, care must be taken to acquire correct CT images to improve dose calculation accuracy. Moreover, great discrepancies in measured and calculated dose were observed at metal/tissue interface. Care must be taken in estimating the dose in critical structures that come into contact with metals.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2016

SU-F-T-642: Sub Millimeter Accurate Setup of More Than Three Vertebrae in Spinal SBRT with 6D Couch

Purpose: To assess the initial setup accuracy in treating more than 3 vertebral body levels in spinal SBRT using a 6D couch. Methods: We retrospectively analyzed last 20 spinal SBRT patients (4 cervical, 9 thoracic, 7 lumbar/sacrum) treated in our clinic. These patients in customized immobilization device were treated in 1 or 3 fractions. Initial setup used ExacTrac and Brainlab 6D couch to align target within 1 mm and 1 degree, following by a cone beam CT (CBCT) for verification. Our current standard practice allows treating a maximum of three continuous vertebrae. Here we assess the possibility to achieve sub millimeter setup accuracy for more than three vertebrae by examining the residual error in every slice of CBCT. The CBCT had a range of 17.5 cm, which covered 5 to 9 continuous vertebrae depending on the patient and target location. In the study, CBCT from the 1st fraction treatment was rigidly registered with the planning CT in Pinnacle. The residual setup error of a vertebra was determined by expanding the vertebra contour on the planning CT to be large enough to enclose the corresponding vertebra on CBCT. The margin of the expansion was considered as setup error. Results: Out of the 20 patients analyzed, initial setup accuracy can be achieved within 1 mm for a span of 5 or more vertebrae starting from T2 vertebra to inferior vertebra levels. 2 cervical and 2 upper thoracic patients showed the cervical spine was difficult to achieve sub millimeter accuracy for multi levels without a customized immobilization headrest. Conclusion: If the curvature of spinal columns can be reproduced in customized immobilization device during treatment as simulation, multiple continuous vertebrae can be setup within 1 mm with the use of a 6D couch.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2016

SU-F-T-658: Out-Of-Field Dose Comparison for TrueBeam Low Energy Beams for Extended Distances: Measurement Vs Monte Carlo Simulation

Purpose: Patient dose far from the treatment field is comprised of scatter from within the patient, and treatment head leakage. We quantify the treatment head leakage for TrueBeam linear accelerator for 6X and 6X-FFF beams by comparing measurements to Monte Carlo simulations for a variety of jaw sizes and collimator rotations. This work is conceptually similar to that of Kry et al. (Medical Physics 2006; 33: 4405), who considered a Clinac linear accelerator. Methods: Measurements were made using an EXRADIN A101 ion chamber positioned in the patient plane, at distances up to 100 cm from isocenter. Simulations were done using VirtuaLinac, the GEANT4-based Monte Carlo model of the TrueBeam treatment head, and an in-house (U. Virginia) GEANT4-based code. In-house code modelled an ion chamber with build-up, based on a CT scan of the chamber. VirtuaLinac included a detailed model of the treatment head shielding, and was run on the Amazon Web Services cloud to generate spherical phase space files surrounding the treatment head. These phase space files were imported into the in-house code. Results: Initial comparisons between measurements and simulation showed an excess of dose in the in-plane direction, away from the gantry, in the simulations. This was traced to an incomplete model of the shielding—specifically, the component holding the primary collimator was smaller in the model than in the TrueBeam. Modifications were made to VirtuaLinac to more closely match the engineering drawings. In the in-plane direction, the lowest out of field dose was away from gantry (negative abscissa values) at around 60 cm from isocenter, for fields smaller than 10×10 cm2. Out of field dose decreased with decreasing jaw size. Flattening-filter free beam produced out-of-field doses as low as 65% of those with flattened beam. Conclusion: Doses determined from simulation and measurement were in close agreement. Funding support from the Jefferson Trust Foundation.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2016

SU-F-T-679: Monte Carlo Simulation On Surface Dose in Preclinical Irradiation Using Monoenergetic Photon Beams

Purpose: This study investigated the surface dose variation in preclinical irradiation using small animal, when monoenergetic photon beams with energy range from 50 keV to 1.25 MeV were used. Methods: Inhomogeneous, homogeneous and bone-tissue homogeneous mouse phantom based on the same CT image set were used. The homogeneous and bone-tissue homogeneous phantom were created with the relative electron density of all and only bone voxels of the mouse overridden to one, respectively. Monte Carlo simulation based on the EGSnrc-based code was used to calculate the surface dose, when the phantoms were irradiated by a 360° photon arc with energies ranging from 50 keV to 1.25 MeV. The mean surface doses of the three phantoms were calculated. In addition, the surface doses from partial arcs, 45°–315°, 125°–225°, 45°–125° and 225°–315° covering the anterior, posterior, right lateral and left lateral region of the mouse were determined using different photon beam energies. Results: When the prescribed dose at the isocenter of the mouse was 2 Gy, the maximum mean surface doses, found at the 50-keV photon beams, were 0.358 Gy, 0.363 Gy and 0.350 Gy for the inhomogeneous, homogeneous and bone-tissue homogeneous mouse phantom, respectively. The mean surface dose of the mouse was found decreasing with an increase of the photon beam energy. For surface dose in different orientations, the lateral regions of the mouse were receiving lower dose than the anterior and posterior regions. This may be due to the increase of beam attenuation along the horizontal (left-right) axis than the vertical (anterior-posterior) in the mouse. Conclusion: It is concluded that consideration of phantom inhomogeneity in the dose calculation resulted in a lower mean surface dose of the mouse. The mean surface dose also decreased with an increase of photon beam energy in the kilovoltage range.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2016

SU-G-206-03: CTDI Per KV at Phantom Center and Periphery: Comparison Between Major CT Manufacturers

Purpose: The purpose of this study was to: 1) compare scanners output by measuring normalized CTDIw (mGy/100mAs) in different CT makes and models and at different kV’s, and 2) quantify the relationship between kV and CTDI and compare this relationship between the different manufacturers. Methods: Study included forty scanners of major CT manufacturers and of various models. Exposure was measured at center and 12 o’clock holes of head and body CTDI phantoms, at all available kV’s, and with the largest or second largest available collimation in each scanner. Average measured CTDI’s from each CT manufacturer were also plotted against kV and the fitting equation: CTDIw (normalized) = a.kVb was calculated. The power (b) value may be considered as an indicator of spectral filtration, which affects the degree of beam hardening. Also, HVLs were measured at several scanners. Results: Results showed GE scanners, on average, had higher normalized CTDIw than those of Siemens and Philips, in both phantom sizes and at all kV’s. ANOVA statistic indicated the difference was statistically significant (p < 0.05). Comparison between Philips and Siemens, however, was not statistically significant. Curve fitting showed b values ranged from 2.4 to 2.9 (for Head periphery and center, respectively); and was about 2.8 for Body phantom periphery, and 3.2 at the center of Body phantom. Fitting equations (kV vs. CTDI) will be presented and discussed. GE’s CTDIw vs. HVL showed very strong correlation (r > 0.99). Conclusion: Partial characterization of scanners output was performed which may be helpful in dose estimation to internal organs. The relatively higher output from GE scanners may be attributed to lower filtration. Work is still in progress to obtain CTDI values from other scanners as well as to measure their HVLs.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2016

SU-G-JeP1-14: Respiratory Motion Tracking Using Kinect V2

Purpose: Investigate capability and accuracy of Kinect v2 camera for tracking respiratory motion to use as a tool during 4DCT or in combination with motion management during radiotherapy treatments. Methods: Utilizing the depth sensor on the Kinect as well as code written in C#, the respiratory motion of a patient was tracked by recording the depth (distance) values obtained at several points on the patient. Respiratory traces were also obtained using Varian’s RPM system, which traces the movement of a propriety marker placed on the patient’s abdomen, as well as an Anzai belt, which utilizes a pressure sensor to track respiratory motion. With the Kinect mounted 60 cm above the patient and pointing straight down, 11 breathing cycles were recorded with each system simultaneously. Relative displacement values during this time period were saved to file. While RPM and the Kinect give displacement values in distance units, the Anzai system has arbitrary units. As such, displacement for all three are displayed relative to the maximum value for the time interval from that system. Additional analysis was performed between RPM and Kinect for absolute displacement values. Results: Analysis of the data from all three systems indicates the relative motion obtained from the Kinect is both accurate and in sync with the data from RPM and Anzai. The absolute displacement data from RPM and Kinect show similar displacement values throughout the acquisition except for the depth obtained from the Kinect during maximum exhalation (largest distance from Kinect). Conclusion: By simply utilizing the depth data of specific points on a patient obtained from the Kinect, respiratory motion can be tracked and visualized with accuracy comparable to that of the Varian RPM and Anzai belt.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2016

SU-G-JeP3-04: Estimating 4D CBCT from Prior Information and Extremely Limited Angle Projections Using Structural PCA and Weighted Free-Form Deformation

Purpose: To investigate the feasibility of using structure-based principal component analysis (PCA) motion-modeling and weighted free-form deformation to estimate on-board 4D-CBCT using prior information and extremely limited angle projections for potential 4D target verification of lung radiotherapy. Methods: A technique for lung 4D-CBCT reconstruction has been previously developed using a deformation field map (DFM)-based strategy. In the previous method, each phase of the 4D-CBCT was generated by deforming a prior CT volume. The DFM was solved by a motion-model extracted by global PCA and a free-form deformation (GMM-FD) technique, using data fidelity constraint and the deformation energy minimization. In this study, a new structural-PCA method was developed to build a structural motion-model (SMM) by accounting for potential relative motion pattern changes between different anatomical structures from simulation to treatment. The motion model extracted from planning 4DCT was divided into two structures: tumor and body excluding tumor, and the parameters of both structures were optimized together. Weighted free-form deformation (WFD) was employed afterwards to introduce flexibility in adjusting the weightings of different structures in the data fidelity constraint based on clinical interests. XCAT (computerized patient model) simulation with a 30 mm diameter lesion was simulated with various anatomical and respirational changes from planning 4D-CT to onboard volume. The estimation accuracy was evaluated by the Volume-Percent-Difference (VPD)/Center-of-Mass-Shift (COMS) between lesions in the estimated and “ground-truth” on board 4D-CBCT. Results: Among 6 different XCAT scenarios corresponding to respirational and anatomical changes from planning CT to on-board using single 30° on-board projections, the VPD/COMS for SMM-WFD was reduced to 10.64±3.04%/1.20±0.45mm from 21.72±9.24%/1.80±0.53mm for GMM-FD. Using 15° orthogonal projections, the VPD/COMS was further reduced to 1.91±0.86%/0.31±0.42mm based on SMM-WFD. Conclusion: Compared to GMM-FD technique, the SMM-WFD technique can substantially improve the 4D-CBCT estimation accuracy using extremely small scan angles to provide ultra-fast 4D verification. This work was supported by the National Institutes of Health under Grant No. R01-CA184173 and a research grant from Varian Medical Systems.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2016

SU-G-JeP3-14: Positioning and Dosimetric Uncertainties in Image-Guided Radiation Therapy with Respiratory Gating

Purpose: To investigate quantitatively positioning and dosimetric uncertainties due to 4D-CT intra-phase motion in the internal-target-volume (ITV) associated with radiation therapy using respiratory-gating for patients setup with image-guidance-radiation-therapy (IGRT) using free-breathing or average-phase CT-images. Methods: A lung phantom with an embedded tissue-equivalent target is imaged with CT while it is stationary and moving. Four-sets of structures are outlined: (a) the actual target on CT-images of the stationary-target, (b) ITV on CT-images for the free-moving phantom, (c) ITV’s from the ten different phases (10–100%) and (d) ITV on the CT-images generated from combining 3 phases: 40%–50%–60%. The variations in volume, length and center-position of the ITV’s and their effects on dosimetry during dose delivery for patients setup with image-guidance are investigated. Results: Intra-phase motion due to breathing affects the volume, center position and length of the ITVs from different respiratory-phases. The ITV’s vary by about 10% from one phase to another. The largest ITV is measured on the free breathing CT images and the smallest is on the stationary CT-images. The ITV lengths vary by about 4mm where it may shrink or elongated depending on the motion-phase. The center position of the ITV varies between the different motion-phases which shifts upto 10mm from the stationary-position which is nearly equal to motion-amplitude. This causes systematic shifts during dose delivery with beam gating using certain phases (40%–50%–60%) for patients setup with IGRT using free-breathing or average-phase CT-images. The dose coverage of the ITV depends on the margins used for treatment-planning-volume where margins larger than the motion-amplitudes are needed to ensure dose coverage of the ITV. Conclusion: Volume, length, and center position of the ITV’s change between the different motion phases. Large systematic shifts are induced by respiratory-gating with ITVs on certain phases when patients are setup with IGRT using free-breathing or average-phase CT-images.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2016

SU-G-JeP3-15: Is the Reproducibility with Respect to Bone of Tumor Position at Simulation for Breath Hold CT Scans Correlated to the Reproducibility for Multiple Breath Hold CBCTs at Treatment in SBRT Thoracic Patients?

Purpose: To evaluate correlation between the reproducibility of tumor position under feedback guided voluntary deep inspiration breath hold gating at simulation and at treatment. Methods: All patients treated with breath hold (BH) have 3-6 BH CTs taken at simulation (sim). In addition, if the relationship between the tumor and nearby bony anatomy on treatment BH CT(or CBCT) is found to be greater than 5 mm different at treatment than it was at sim, a repeat BH CT is taken before treatment. We retrospectively analyzed the sim CTs for 19 patients who received BH SBRT lung treatments and had repeat BH CT on treatment. We evaluated the reproducibility of the tumor position during the simulation CTs and compared this to the reproducibility of the tumor position on the repeat treatment CT with our in-house CT alignment software (CT-Assisted Targeting for Radiotherapy). Results: Comparing the tumor position for multiple simulation BH CTs, we calculated: maximum difference (max) = 0.69cm; average difference (x) = 0.28cm; standard deviation (σ) = 0.18cm. Comparing the repeat BH CBCTs on treatment days we calculated: max = 0.44cm; x = 0.16cm; σ = 0.22cm. We also found that for 95% of our BH cases, the absolute variation in tumor position within the same imaging day was within 5mm of the range at the time of simulation and treatment. We found that 75% of the BH cases had less residual tumor motion on treatment days than at simulation. Conclusion: This suggests that a GTV contour based upon the residual tumor motion in multiple BH datasets plus 2 mm margin should be sufficient to cover the full range of residual tumor motion on treatment days.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2016

SU-G-IeP4-07: Feasibility of Low Dose 18FDG PET in Pediatric Oncology Patients

Purpose: To evaluate and demonstrate the feasibility of low dose FDG PET in pediatric oncology patients using virtual dose reduction as well as true patients PET/CT scans. Methods: Wholebody 18F-FDG PET/CT of 39 clinical pediatric patients (0.16±0.06MBq/kg) were scanned on a Gemini TF 64 system at 75±5 min post FDG injection using 3min/bed. Based on the 180s/bed listmode PET data, subsets of total counts in 120s, 90s, 60s, 30s and 15s per bed position were extracted for PET reconstruction to simulate lower dose PET at 2/3th, 1/2th, 1/3th, 1/6th and 1/12th dose levels. PET/CT scans of Jaszczak PET phantom with 6 hot hollow spheres varying with sizes and contrast ratios were performed (real PET versus simulated PET) to validate the methodology of virtual dose PET simulation. Region of interests (ROIs) were placed on lesions and normal anatomical tissues with quantitative and qualitative assessment performed. Significant lower FDG dose PET/CT of 5 research adolescents were scanned to validate the proposal and low dose PET feasibility. Results: Although all lesions are visible on the 1/12th dose PET, overall PET image quality appears to be influenced in a multi-factorial way. 30%–60% dose reduction from current standard of care FDG PET is recommended to maintain equivalent quality and PET quantification. An optimized BMI-based FDG administration is recommended (from 1.1±0.5 mCi for BMI < 18.5 to 4.8±1.5 mCi for BMI > 30). A linear lowest “Dose-BMI” relationship is given. SUVs from 1/12th to full dose PETs were identified as consistent (R2 = 1.08, 0.99, 1.01, 1.00 and 0.98). No significant variances of count density, SUV and SNR were found across certain dose ranges (p<0.01). Conclusion: Pediatric PET/CT can be performed using current time-of-flight systems at substantially lower PET doses (30–60%) than the standard of care PET/CT without compromising qualitative and quantitative image quality in clinical.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2016

SU-G-IeP4-13: PET Image Noise Variability and Its Consequences for Quantifying Tumor Hypoxia

Purpose: The values in a PET image which represent activity concentrations of a radioactive tracer are influenced by a large number of parameters including patient conditions as well as image acquisition and reconstruction. This work investigates noise characteristics in PET images for various image acquisition and image reconstruction parameters. Methods: Different phantoms with homogeneous activity distributions were scanned using several acquisition parameters and reconstructed with numerous sets of reconstruction parameters. Images from six PET scanners from different vendors were analyzed and compared with respect to quantitative noise characteristics. Local noise metrics, which give rise to a threshold value defining the metric of hypoxic fraction, as well as global noise measures in terms of noise power spectra (NPS) were computed. In addition to variability due to different reconstruction parameters, spatial variability of activity distribution and its noise metrics were investigated. Patient data from clinical trials were mapped onto phantom scans to explore the impact of the scanner’s intrinsic noise variability on quantitative clinical analysis. Results: Local noise metrics showed substantial variability up to an order of magnitude for different reconstruction parameters. Investigations of corresponding NPS revealed reconstruction dependent structural noise characteristics. For the acquisition parameters, noise metrics were guided by Poisson statistics. Large spatial non-uniformity of the noise was observed in both axial and radial direction of a PET image. In addition, activity concentrations in PET images of homogeneous phantom scans showed intriguing spatial fluctuations for most scanners. The clinical metric of the hypoxic fraction was shown to be considerably influenced by the PET scanner’s spatial noise characteristics. Conclusion: We showed that a hypoxic fraction metric based on noise characteristics requires careful consideration of the various dependencies in order to justify its quantitative validity. This work may result in recommendations for harmonizing QA of PET imaging for multi-institutional clinical trials.

60 APPLIED LIFE SCIENCES↗