Medical Dosimetry 39 (2014) 276281

Medical Dosimetry
journal homepage: www.meddos.org

Initial experience of ArcCHECK and 3DVH software for RapidArc

treatment plan verication
Erminia Infusino, Ph.D., Alessandra Mameli, Ph.D., Roberto Conti, R.T., Diego Gaudino, Ph.D.,
Gerardina Stimato, Ph.D., Luca Bellesi, Ph.D., Rolando Maria DAngelillo, M.D.,
Sara Ramella, M.D., Marcello Benassi, Ph.D., and Lucio Trodella, M.D.
Department of Radiotherapy, Universit Campus Bio-medico di Roma, Rome, Italy

A R T I C L E I N F O

A B S T R A C T

Article history:
Received 2 January 2014
Received in revised form
6 March 2014
Accepted 10 April 2014

The purpose of this study was to perform delivery quality assurance with ArcCHECK and 3DVH system
(Sun Nuclear, FL) and to evaluate the suitability of this system for volumetric-modulated arc therapy
(VMAT) (RapidArc [RA]) verication. This software calculates the delivered dose distributions in patients
by perturbing the calculated dose using errors detected in uence or planar dose measurements. The
device is tested to correlate the gamma passing rate (%GP) and the composite dose predicted by 3DVH
software. A total of 28 patients with prostate cancer who were treated with RA were analyzed. RA
treatments were delivered to a diode array phantom (ArcCHECK), which was used to create a planned
dose perturbation (PDP) le. The 3DVH analysis used the dose differences derived from comparing the
measured dose with the treatment planning system (TPS)-calculated doses to perturb the initial TPScalculated dose. The 3DVH then overlays the resultant dose on the patient's structures using the resultant
PDP beams. Measured dose distributions were compared with the calculated ones using the gamma
index (GI) method by applying the global (Van Dyk) normalization and acceptance criteria, i.e., 3%/3 mm.
Paired differences tests were used to estimate statistical signicance of the differences between the
composite dose calculated using 3DVH and %GP. Also, statistical correlation by means of logistic
regression analysis has been analyzed. Dose-volume histogram (DVH) analysis for patient plans revealed
small differences between treatment plan calculations and 3DVH results for organ at risk (OAR), whereas
planning target volume (PTV) of the measured plan was systematically higher than that predicted by the
TPS. The t-test results between the planned and the estimated DVH values showed that mean values
were incomparable (p o 0.05). The quality assurance (QA) gamma analysis 3%/3 mm showed that in all
cases there were only weak-to-moderate correlations (Pearson r: 0.12 to 0.74). Moreover, clinically
relevant differences increased with increasing QA passing rate, indicating that some of the largest dose
differences occurred in the cases of high QA passing rates, which may be called false negatives. The
clinical importance of any disagreement between the measured and the calculated dose is often difcult
to interpret; however, beam errors (either in delivery or in TPS calculation) can affect the effectiveness of
the patient dose. Further research is needed to determinate the role of a PDP-type algorithm to
accurately estimate patient dose effect.
& 2014 American Association of Medical Dosimetrists.

Keywords:
3DVH
Quality assurance
ArcCHECK
Gamma index

Introduction
RapidArc (RA) (Varian Medical Systems, CA) is a form of
volumetric-modulated arc therapy (VMAT) that entered clinical
use in 2008. VMAT delivery requires a stricter mechanical

Reprint requests to: Erminia Infusino, Department of Radiotherapy, Universit

Campus Bio-medico di Roma, via alvaro del portillo 200, Rome, Italy.
E-mail: e.infusino@unicampus.it
http://dx.doi.org/10.1016/j.meddos.2014.04.004
0958-3947/Copyright 2014 American Association of Medical Dosimetrists

performance for the linear accelerator than intensity-modulated

radiation therapy (IMRT) delivery does because of the simultaneous gantry speed, dose rate, and multileaf collimator aperture
shape variations. Therefore, it requires a dosimetric verication
before treatment because of the complexity of the delivery
beam.1-4
The pretreatment dosimetric verication comprises a comparison of a measurement dose with the treatment planning
system (TPS)-calculated dose. This can be performed either on a

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277

Fig. 1. Sagittal, axial, and coronal dose planes for a representative data set of the 28 data sets studied. (Color version of gure is available online.)

beam-by-beam basis using 2-dimensional (2D) measurement or

on a whole-treatment basis using a 2D-measured dose plane or a
3-dimensional (3D) measurement. In many cases, the lm is
replaced with a diode array or electronic portal imaging device
that provides a beam-by-beam dose analysis rather than a composite dose analysis.
Conventional VMAT QA is usually performed by applying the
patient plan to a phantom with simple geometry and comparing
the measured and the calculated phantom dose distribution. When
comparing the measured and the calculated dose in phantom,
the gamma index (GI) that combines the percentage dose difference (%DD) and the distance to agreement (DTA) is calculated for
each pixel. The gamma passing rate (%GP) (the portion of pixels
that has a GI less than 1) is then calculated for judgment on the QA
result.
There have been many studies on suggested acceptance levels for
planar IMRT-VMAT QA.5-10 Some of these studies base action levels
on retrospective statistical analysis of the performance levels/metrics
that have been achieved over many plans and IMRT beams.5-10
In a report of the American Association of Physicists in
Medicine Task Group 1195 and other studies5-9 as well, the 3%/
3-mm criterion is common and is employed as the composite DTA
metric; therefore, the 3% dose difference and the 3-mm DTA

criteria were reported as those most commonly used by clinicians11 in per patient planar IMRT QA.
It was shown in a recent study that per-beam planar %GPs do
not predict the clinical effect on the patient in terms of changes in
dose-volume histogram (DVH) values for the clinical target volume
(CTV) and organs at risk (OARs).12
Indeed there have been several software systems that claim the
capability to estimate patient dose based on QA measurement,
such as the COMPASS system (IBA-Wellhofer, Bahnhofstrasse
590592 Schwarzenbruck, Germany), Dosimetry Check (Math Resolutions, LLC, Gales Lane, Columbia), and 3DVH (Sun Nuclear
Corporation, Melbourne, Florida). The potential of using such
products to perform patient DVHbased IMRT QA is in need of
further investigation.
In this study, we used the software program 3DVH with the
ArcCHECK to investigate the correlation among %GP obtained
during standard per-beam pretreatment QA tests.
The 3DVH software purports to be able to take beam measurements from a plan and reconstruct the full 3D dose distribution
within the patient for comparison with the TPS calculations.
The 3DVH system was designed to incorporate the beam-bybeam phantom doses (measured and calculated) back into the
patient's images, structures, and TPS dose using planned dose

Fig. 2. Sample differences between the DVH obtained by TPS and the composite dose predicted by the 3DVH software. (Color version of gure is available online.)

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E. Infusino et al. / Medical Dosimetry 39 (2014) 276281

Table 1
Examples of the average %GP of patients evaluated

Table 3
The DVH parameters calculated by the TPS Eclipse and by the software 3DVH for
PTVs and OARs and the relative p value

Patient

Mean %GP

1
2
3
4
5
6
7

98.1
99.0
98.5
98.0
98.4
97.6
97.0

Structure

Parameter

%DD

Mean dose difference (Gy)/fz

p value

PTV
PTV
Rectum
Bladder
Penile bulb
Femoral head dx
Femoral head sx

Dmean
D95%
Dmean
Dmean
Dmean
Dmean
Dmean

2.8
2.2
0.5
1.2
6
0.6
2.5

0.1
0.02
 0.04
 0.03
 0.1
 0.003
 0.03

o 0.05
0.26
0.55
o 0.05
o 0.05
o 0.05
o 0.05

dx = right; fz = fraction; sx = left.

perturbation (PDP) for estimating the delivered patient dose and

DVHs in 3D.13 The software uses the dose differences found
between the ArcCHECK measurement and the TPS dose calculation
for each beam and projects those differences back into the TPS 3D
dose calculation to obtain an estimate of the actual delivered 3D
dose distribution.

Methods
All patients with prostate cancer underwent radical radiotherapy up to 80 Gy to
the prostate and seminal vesicles with standard fractionation (2 Gy/die). Patients
were immobilized by customized devices with an empty rectum and a moderately
full bladder. Every day treatment was veried by cone-beam computed tomography scans. Gross tumor volume included the prostate and seminal vesicles
(proximal thirds), CTV was dened as gross tumor volume 3-mm circumferential
margin, and planning target volume (PTV) was dened as CTV 5-mm circumferential margin. The whole PTV received 95% to 105% of the prescribed dose. The
rectum, bladder, penile bulb, and femoral heads were set as OARs, and dose
constraints have been dened according to the quantitative analyses of normal
tissue effects in the clinic criteria.14
RA technique
Treatment planning was performed using photon beams of TrueBeam, with
nominal energies of 6 MV. RA plans were optimized for 2 arcs (rotation of 3581, from
1791 to 1811 clockwise (CW) and counterclockwise (CCW)), where multileaf collimator (maximum: 5 mm/deg and 2.5 cm/s), dose rate (maximum: 600 MU/min), and
gantry speed (maximum: 72 s/turn, i.e.,  5 deg/s) are optimized simultaneously to
achieve the desired degree of modulation. All dose distributions were computed with
the anisotropic analytical algorithm implemented in the Eclipse planning system
with a calculation grid resolution of 2.5 mm.
A total of 28 DMLC prostate RA treatment plans were exported as DICOM
radiation therapy (RT) data sets from the planning system. These plans were
delivered to a 3D diode array (ArcCHECK, Sun Nuclear). Measured doses were
compared with the dose planes from the original plan, and dose differences were
used as input to 3DVH to calculate a delivered dose in the patient.
GI evaluation
The quality assurance on RA treatment plans is performed by creating a
verication plan in the Eclipse TPS. This was achieved by copying the treatment
plan onto volumetric phantom devices. The predicted dose to the detector planes
was calculated with a dose grid resolution of 2.5 mm, it is sufcient to keep the
dose error within 2%.15 This value was adopted for RA treatment plans.
Pretreatment verications were performed for all patient plans by acquiring
plane dose distributions of each treatment eld. Measurements were taken using
the diode array, routinely used in our institute, with absolute dose calibration, and
the software ArcCHECK.

Table 2
Evaluation of the %DD mean for 28 DVHs
Structure

Parameter

DD/fz mean (Gy)

%DD

PTV
PTV
Rectum
Bladder
Penile bulb
Femoral head dx
Femoral head sx

Dmean
D95%
Dmean
Dmean
Dmean
Dmean
Dmean

0.07
0.02
 0.04
 0.03
 0.10
 0.01
 0.03

2.8
2.2
0.5
1.2
6
0.6
2.5

dx = right; fz = fraction; sx = left.

ArcCHECK is a cylindrical water-equivalent phantom with a 3D array of 1386

diode detectors, arranged in a spiral pattern, with 10-mm sensor spacing.
The per-beam IMRT QA dose distributions of each treatment plan were
analyzed by employing the GI method16; by adopting the method proposed by
Zhen et al.,17 %GP was generated for each pair of planes using the global gamma
calculation method and the acceptance criterion, 3%/3 mm.
The gamma analysis of patient treatment plans presented within this section
was done using only a single criterion (3%/3 mm) owing to the lack of relevance of
the 2%/2-mm and the 1%/1-mm criteria. In the per-beam planar analysis, all
patients had average %GPs of more than 95% for the 3%/3-mm criterion.
Software
The 3DVH uses the PDP algorithm to estimate the dose to be delivered to the
patient and patient DVH using conventional planar IMRT-VMAT QA data as inputs.
The goal is to produce clinically relevant metrics to replace conventional metrics
that are limited in both sensitivity and specicity.13,18 The major function of the
PDP algorithm is to use conventional per-beam planar dose QA methods to feed a
sophisticated 3D perturbation system that corrects the original 3D patient dose as
generated by the TPS and outputs a 3D patient dose grid that has built into it the
manifestation of any errors detected by the planar QA.20
The PDP method does not introduce new sources of variation or error that may
occur with an independent 3D dose algorithm (i.e., variations that might not be
errors but just differences of the new algorithm vs the TPS algorithm). PDP alters
dose only if and where dose differences are detected in dosimetry array
systems.21,22 As an output, the 3DVH software compares the DVHs calculated by
TPS with the ones obtained from perturbation, and it shows dose distributions,
both alone and as comparison, in the sagittal, coronal, and axial planes of
patients.23 Figure 1 shows samples of sagittal, axial, and coronal dose planes.
Figure 2 illustrates a comparison between DVH obtained by TPS and the composite
dose predicted by the 3DVH software.

Results
Planar dose distributions acquired during pretreatment verications, RT plan, structure set, dose, and computed tomography
images (the latter is optional) exported from TPS were loaded on
the software 3DVH. Overall, 2 kinds of comparisons were made,
the rst was a 2D/3D gamma evaluation, and the second was a
DVHs comparison.
DVHs provided by the 3DVH (delivered dose distribution from
pretreatment verications) were compared with those calculated
by Eclipse (planned dose distribution) using the following dosevolume parameters: Dmean for all structures, and Dmean and D95
for PTVs.
Differences in the DVH parameters were calculated as

D
 3DVH DTPS 
%DD 
  100
DTPS
where D3DVH was the dose value shown by the software 3DVH, and
DTPS was the dose value reported by TPS. This analysis was
performed, for each patient, on PTVs and some OARs of the
anatomically treated district (the rectum, bladder, penile bulb,
femoral head dx [right], and femoral head sx [left]).
We calculated mean DVH values obtained using both 3DVH and
TPS. To verify whether our procedures were affected by systematic
errors, we performed a t-test statistical analysis between the mean
values.

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279

Fig. 3. Correlation between the %GP calculated using the global 3%/3-mm criterion and the %DD for Dmean of the PTV, PTV 95%, rectum, bladder, penile bulb, femoral dx, and
femoral sx. (Color version of gure is available online.)

The t-test compares the actual difference between 2 means in

relation to the variation in the data (expressed as the standard
deviation of the difference between the means). The signicance level
for a given hypothesis test is a value for which a p value less than or
equal to is considered statistically signicant. These values correspond to the probability of observing such an extreme value by
chance. Therefore, p o 0.05 was considered incomparable. These
data are analyzed to determine the systematic error, , which can be

dened as the mean of differences between D3DVH and DTPS for all
organs.
In addition, we determined the degree to which the DVH values
are associated using the Pearson correlation coefcient (r). This
correlation test is used to measure the strength of a linear
association between 2 variables. The Pearson correlation coefcient, r, can take a range of values from 1 to  1. A value
of 0 indicates that there is no association between the 2 variables.

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E. Infusino et al. / Medical Dosimetry 39 (2014) 276281

Table 4
Indexes of correlation between %GP and %DD for different structures
Structure

Parameter

PTV
PTV
Rectum
Bladder
Penile bulb
Femoral head dx
Femoral head sx

Dmean
D95%
Dmean
Dmean
Dmean
Dmean
Dmean

0.57
0.12
0.74
0.38
0.69
0.37
0.36

dx = right; sx = left.

A value greater than 0 indicates a positive association, that is, as

the value of one variable increases, so does the value of the other
variable. A value less than 0 indicates a negative association, that
is, as the value of one variable increases, the value of the other
variable decreases. The magnitude of the correlation coefcient
determines the strength of the correlation. Although there are no
hard-and-fast rules for describing correlational strength, generally
0 o |r| o 0.3 is a weak correlation
0.3 o |r| o0.7 is a moderate correlation
|r| 4 0.7 is a strong correlation
GI passing rates of 3%/3 mm were evaluated for all the patients.
Table 1 shows average %GP calculated for some patients. The %DD
was calculated for all patients and is reported in Table 2. Mean DVH
values, t-test p values, and systematic error are illustrated in Table 3.
The t-test result between the planned and estimated DVH
values showed that mean values were incomparable (p o 0.05),
this indicates that there were systematic errors, whereas D95
means for PTVs were comparable (p 4 0.05).
The number of correlations changed for different structures:
Fig. 3 shows the correlation between %GP calculated using the
global method and the %DD for PTV and OARs' dose values.
The QA gamma analysis 3%/3 mm showed that in nearly every case,
there was only a weak-to-moderate correlation between the GP% and
the absolute %DDs (Pearson r: 0.12 to 0.74, Table 4), with the exception
of the rectum (p 0.74). The rectum is a unique organ for which a
nonsignicant difference between the planned and estimated dose
values (p 0.55) has been observed, whereas a statistically signicant
difference has been observed for the others organs.

Conclusions
The aim of this article was to evaluate the predictive meaning
of the GI, in terms of correlation between the %GP obtained
during standard pretreatment QA tests and the dose discrepancy
between planned DVH and patients' perturbed DVH. This article
evaluated whether the standard action levels used by most clinics
(3%/3 mm with a 95% passing rate and global normalization) are
justied.
The 3DVH is a useful tool to calculate delivered dose distributions during patient-specic IMRT and VMAT quality assurance. The intended use is to incorporate the ArcCHECK (or
electronic portal imaging device or MapCHECK) measurements
and patient's DICOM RT structure set, dose, and plan les to
reconstruct the 3D dose within the patient and to allow the
computation and comparison of the DVH curves, planned and
delivered, for the anatomical structures that were of interest
during the planning of the patient's treatment, rendering
phantom-based dose analysis obsolete. The process requires no
extra time when compared with standard QA with the
ArcCHECK.

In our study, we started by verifying the consistency of 3DVH with

our clinical VMAT plans. Differences between planned and measured
dose were obtained when verifying real patient plans. For the
selected DVH dose values, we found a signicant difference between
mean doses calculated by TPS and 3DVH (Tables 2 and 3), especially
PTV, the measured plan was systematically higher than that predicted
by the TPS. However, their interpretation in clinical terms based on a
common gamma analysis is not unmistakable and remains unclear.
The results of correlation analysis showed that all r values were
low. This proved the weak correlation between the %GP and the
absolute %DDs.

Discussion
The 3DVH validity was demonstrated in previous
articles.8,10,12,20,21 In our study, we started by verifying the consistency of 3DVH with our clinical IMRT plans.
The patient dose QA methodology is used to accurately estimate the effect of errors on patient anatomy dose metrics.
There is a lack of correlation between conventional IMRT QA
performance metrics (%GPs) and dose differences in critical anatomical regions of interest. The most common acceptance criteria
and published actions levels therefore have insufcient, or at least
unproven, predictive power for per patient IMRT QA. However,
these criteria does not ensure that clinically acceptable dose errors.
There have not yet been correlation studies to prove, or
disprove, whether these accepted methods for IMRT QA and their
associated acceptance criteria are good predictors of clinically
relevant patient dose errors in per patient IMRT QA.
Recent experimental studies, which reveal the limited sensitivity of gamma analysis to patient dose deviation under different
IMRT errors, have been carried out.16,18,19,24 In fact, it was shown in
a recent study that per-beam planar %GPs do not predict the
clinical effect on the patient in terms of the changes in DVH values
for the CTV and OARs,12 which has questioned the feasibility of %
GP-based IMRT QA.
The gamma analysis did not give clear information on whether a
plan should be accepted. Kruse18 has recently shown that the
average passing rate that would be clinically acceptable for one
patient could be unacceptable for another. Consequently, pretreatment checks should be done taking into account the clinical
tolerances of the OAR and the PTV and not relying on %GPs. To do
this, there is a need for a tool, such as 3DVH software, that could
show the effect of the measured planar differences in the histogram.
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