Quality Assurance for Patient Radiotherapy Treatments

Philip Mayles

Quality Assurance Issues

Correct Identification Critical Communications Dosimetric Accuracy Relative Dose Distribution Geometric Accuracy Data Integrity

What determines the intended dose ?

Factors Affecting Dose Prescription

EXPERIENCE Patient Tolerance Consistent dose over time Dose may need to differ for different patients Standard protocols Data from other centres - National and Consistent dose between International centres Radiobiological Data

Required accuracy
Reference Point Dose
3% standard deviation (Brahme 1988) = 6% as 95% confidence limit

Dose Distribution
5% standard deviation

Position
4mm (Mijnheer et al 1987) 1-2mm with special fixation

Accuracy Achievable
Calibration Determination of dose in non standard conditions Treatment planning Treatment delivery

Accuracy Achievable Calibration

Air Kerma Water Calibration of Field Instrument 1% 0.75% Absorbed Dose at Ref Point
Physical data Measurement Dose monitor variation 2.5% 0.75% 0.75% 1% 1%

Total

3.0%

1.5%

Accuracy Achievable Determination of Dose in Non Standard Conditions

Uncertainty in dose distribution basic data
2 - 2.5%

Output Factors etc

2.5%

Accuracy Achievable Treatment Planning

Real tissue densities Patient Data Dimensions Structure Uncertainty in computed plan Additional for inhomogeneity Clinical acceptability of plan 1% 2% 2% 1% >1.5% 2%

Total

>3%

Accuracy Achievable - Patient Treatment

Patient setup relative to isocentre 1% Isocentre/SSD 0.5% Organ and Patient Movement 2% Variations in machine performance 3% Total 3.8%

Accuracy Achievable - All Factors

Uncertainty can be 6-7% Single field Reference Point 2.5-3% Other Points 4% Parallel opposed Reference Point 4% Other Points 4-5% Multiple field treatments Homogeneous 5-6% Heterogeneity 5.5-7%

Sources of error
Incorrect calibration of machine
Errors around 2-3% in dose Errors around 3mm in position

Incorrect patient setup

Errors around 4-5% in dose Errors around 10mm in position

Machine interlock failure

Errors up to 500%

Human error
Errors up to 60%

Lessons learned from accidental exposures in Radiotherapy

IAEA Safety Report 17

Independent checks
Having a second person check data and repeat calculations or measurements is an important way of finding mistakes Independent checks should be routine Independent checks should use a different method wherever possible In vivo dosimetry is a useful independent check

Safety critical communication

Prescription Input data for preparation of treatment plan Proposed treatment plan and calculation, prescribed dose Patient immobilisation and shielding aids Confirmed plan Equipment fault report Request for maintenance Instruction to discontinue treatment Maintenance complete

Data transfer
Incorrect plan most probable problem Incorrect transfer low risk Use fluence maps with iView

Geometric Accuracy
Includes isocentre setup Difficult to test Film measurements
MedTec phantom Kodak EDR film

Film dosimetry for volume measurements has many difficulties

Optical Scanned Gel

Courtesy of Mark Oldham

In Vivo Dosimetry
Ultimate method of verifying dose But difficult to guarantee accuracy Aim at 3-5% uncertainty

Courtesy of Ginette Marinello

Varian OBI Linac

On-board kV imaging Radiographic mode - Inter-fraction Marker matching - Inter-fraction Fluoroscopic mode - Intra-fraction Cone Beam CT - Inter-fraction

Total Spinal Irradiation

Children being treated under anaesthetic Dose from imaging is an important consideration kV imaging gives much less dose

Cone Beam CT

Cone Beam CT
Verification of Stereotactic Treatments

SRT and H+N IMRTverification using CBCT

Sarcoma of the heart

Thyroid
Patients neck flexion had changed Spinal cord dose on superior slices more critical

Gating

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Varian Experimental
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Proton Issues
Geometric issues are equally important Third dimension is governed by energy
i.e. range

Uncertainty in RBE