QA & DOSIMETRY NEWS. Respiratory MotionSim TM. Introducing. Quality Reports [EMR] Plan Quality Management»

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1 QA & DOSIMETRY NEWS Serving the Radiation Oncology Community Since 1984 Published by Sun Nuclear Corporation 2014 ESTRO Edition Quality Reports [EMR] Plan Quality Management» From the CEO The Metrics of Quality, and Quality in Motion» IC PROFILER TM Hear how the IC PROFILER has become the cornerstone of efficient linac QA» Introducing Respiratory MotionSim TM Understanding Motion Effects on Estimated Patient Dose» What s New Product release highlights» Your Most Valuable QA and Dosimetry Tools

2 IC PROFILER TM Cancer Partners UK Cornerstone of Efficient Linac QA First centre opened August 2009 A privately-funded network of radiotherapy centres around the UK, with eight centres so far: Portsmouth, Southampton, Elstree, Birmingham, Nottingham, Guilford, Milton Keynes, Oxford, and more planned 5 Elekta Synergy linacs and 3 Elekta Versa HD linacs currently, all linacs beam-matched CT planning, MR Fusion, Breath-hold, IMRT, IGRT at every site Central Mosaiq and Pinnacle servers networking all sites Cancer Partners UK is unusual among radiotherapy facilities; instead of one large building with multiple linacs sharing a set of QA resources, CPUK has a network of single-linac centers across the UK, necessitating compact, efficient, and cost-effective QA tools. We have one large water tank, the 3D SCANNER TM, and it s usually situated at the center that s about to open, which means all the other centers need QA devices instead of the large water tank, said John Pettingell, CPUK Director of Clinical Services. The solution is to stock each center with a 1D SCANNER and an IC PROFILER. Beyond that, CPUK uses a number of other Sun Nuclear devices, including Daily QA 3, MapCHECK 2, and ArcCHECK. One of the things we really like about Sun Nuclear is the range of equipment we get. It s very useful that all the devices use the same power/data cable. And with the software, once you get to know one device, like Daily QA 3, the software for all the other devices works in the same way for things like device calibration and dose calibration etc which makes our lives a lot easier! Linac QA with IC PROFILER CPUK sites use the IC PROFILER to measure symmetry, flatness and energy. flatness and symmetry results they analyze the data from the central ion chamber for variation in output at the different gantry angles compared to the output at gantry 0 o. It s great! We get the output variation with gantry angle results for free as it doesn t involve any extra machine time and it s much easier than trying to do the same measurements with ion chambers and water phantoms. In a traditional center, if a linac goes down, it may be possible to accommodate scheduled patients on other linacs. But at singlelinac CPUK sites, this is more of an inconvenience to the patient. Pettingell said IC PROFILER helps them shorten any linac down time. After a major repair, incident or linac servicing, the IC PROFILER allows us to get back up and running very quickly compared to scanning the beam with a water tank. One feature that contributes to this efficiency is Beam Tuning in PROFILER Software. It shows a profile of the beam as it is being acquired, as well as a mirror image of that profile. As the engineer steers the beam, one can see symmetry improve in real time. The engineers absolutely love this device because it s so fast and easy to symmetrize the beam. In a half hour, you can check beam flatness and symmetry at various angles (using the Gantry Mounted Fixture). You could never do that with other devices. It s also nice to get these measurements from ion chambers like those we d use in a water tank. Pettingell says they conduct monthly QA using measurements of 30cm x 30cm fields with 1cm solid water atop the IC PROFILER. Every three months, this same setup is used at the four cardinal gantry angles using the Gantry Mounted Fixture. In addition to IC PROFILER

3 The Metrics of Quality, and Quality in Motion Dear Colleagues, It s an exciting time. Radiation Oncology continues to rapidly evolve with new and better tools to deliver more precise dose to smaller targets with fewer fractions. Knowledge based planning, high dose rate, flattening filter free, micro MLC and stereotactic modalities are just some of the major treatment options which are quickly expanding into the mainstream of radiotherapy. The power of these new tools is matched only by the importance of ensuring they are properly implemented and quality controlled. At Sun Nuclear, as leaders in QA and Dosimetry, the more dedicated we are to creating and providing the most accurate and efficient suite of QA and Dosimetry products, the more questions we have. In terms of metrics, beyond plan matching actual, what is being done to verify that the intended plan is itself of high quality? Does the plan achieve the goals and objectives of your clinical team? How do we quantify plan quality in a comprehensive, yet efficient and standardized manner? Those questions have been the driver for a new product we are proud to offer called Quality Reports [EMR]. Patient motion is another challenge and we re proud to now offer Respiratory MotionSim TM. We know that even with the best treatment technology and physics efforts to verify quality of plan and delivery, factoring patient motion can unsettle the best of intentions. Respiratory MotionSim TM solves that problem by providing an accurate evaluation of motion effects on estimated patient dose. Contributing to the advancement of radiation oncology and the high promise it holds for many cancer patients is paramount to Sun Nuclear. Our commitment to partnering with and providing medical physicists a suite of innovative quality assurance tools is the driving mission of our company and is reflected in these new products. Learn more in this issue and be sure to stop by the new Sun Nuclear exhibit at the ESTRO Congress where we ll have live product demonstrations, informative talks and details about our Satellite Symposium. We look forward to seeing you there. Warm regards, Jeff Simon Chief Executive Officer What s New Respiratory MotionSim Understand motion effects on estimated patient dose Determine if motion management is necessary Quality assure motion management plans No need for additional hardware Quality Reports [EMR] Plan quality metrics enable quality management and continual improvement Facilitates powerful and accessible electronic plan review and chart rounds Automates comprehensive and customized reports vital for billing and audits Compatible with all TPS systems, delivery modalities, and R&V systems 3DVH 3.0 Support for non-coplanar arc deliveries 3D phantom dose with VirtualGel QuickStat templates for standardization and reuse SNC Patient 6.5 Software Patient plan MLC QA for ArcCHECK 3D gantry isocentricity machine QA SNC350p A proven solution for electron reference dosimetry Incorporates design elements as described by Dr. Roos to minimize perturbation effect Waterproof, well-guarded, parallel-plate ionization chamber White chamber body allows easy visualization of setup SNC125c Thimble ionization chamber for photon and electron measurements Measurements in air or water for absolute and relative dosimetry Waterproof and fully-guarded White chamber body for crosshair and laser visibility SNC Dosimetry Software Scan compare function Adaptive Data Density RayStation support Monaco TPS scan group updates TrueBeam protocol included New scan speeds Coming Soon Per Fraction QA Solution Utilizes daily per-patient delivery data for analysis Data automatically imported in real-time from R&V system Dashboard provides cumulative results per machine at a glance Customized alerts according to clinic needs Results are stored for reporting and historical analysis Learn more at our Satellite Symposium and In-Booth Talks Reserve your seat today!

4 Respiratory MotionSim TM Understanding Motion Effects on Estimated Patient Dose 3DVH continues to change the landscape of per-patient dose QA by providing evidence-based understanding of how to detect, diagnose, and mitigate systematic errors that would otherwise go undetected DVH 3.0 introduces the Planned Dose Perturbation (PDP) algorithm with time-resolved ArcCHECK measurements a combination we call AC-PDP. AC-PDP enables proven accuracy in measurement-guided dose reconstruction on the patient anatomy. It also introduces true 4D dosimetry, where high-density and high-resolution 3D dose grids are computed at a time resolution of approximately 0.2 seconds for all IMRT and VMAT plans. 5-6 Figure 1. Dose to lung target in axial (A) and coronal (B) planes, are calculated without motion by TPS. Motion envelope against left lung as seen in Respiratory MotionSim 4D trajectory module (C). Dose differences caused by motion effects as simulated by Respiratory MotionSim are shown overlaid on coronal TPS dose (D) and CT reconstruction (E). When 4D dose dynamics are combined with the ability to define 4D motion trajectories, you then realize the potential for dosimetric motion simulation. For each moving voxel, the perturbation of dose caused by motion (i.e. dose accrued and corrected in the moving versus static scenario) is quantified with accuracy, incorporating gradient effects and interplay. 5,7-8 In this way, Respiratory MotionSim (RMS), harnesses the full 4D potential of AC-PDP within 3DVH. The Respiratory MotionSim module: Simulates motion effects for all external-beam photon plans: 3D conformal, IMRT, and VMAT Simulates non-gated vs. gated delivery, and different gating windows (i.e. duty cycles ) Simulates respiratory motion and non-cyclical motion, such as intrafraction prostate motion Requires no physical motion device; motion is performed via software simulation using the 4D dose dynamics rendered by AC-PDP Allows motion trajectories automatically derived based on per-phase contours of a 4D CT image-set or manually entered with up to six-degrees of freedom Other 3DVH 3.0 Enhancements 3DVH 3.0 introduces many other improvements beyond motion simulation. These new features enhance the efficiency, usability, and analytical capabilities of 3DVH: Support for non-coplanar arc deliveries 3D phantom dose with VirtualGel Define QuickStat templates for standardization and reuse References 1. Nelms BE et al. Evaluating IMRT and VMAT dose accuracy: Practical examples of failure to detect systematic errors when applying a commonly used metric and action levels. Med Phys Nov; 40(11) 2. Zhen et al. Moving from gamma passing rates to patient DVH-based QA metrics in pretreatment dose QA. Med Phys Oct; 38(10) 3. Stasi et al. Pretreatment patient-specific IMRT quality assurance: A correlation study between gamma index and patient clinical dose volume histogram. Med Phys Dec; 39(12) 4. Carrasco et al. 3D DVH-based metric analysis versus per-beam planar analysis in IMRT pretreatment verification. Med Phys Aug; 39(8) 5. Nelms BE et al. VMAT QA: measurement-guided 4D dose reconstruction on a patient. Med Phys Jul; 39(7) 6. Opp et al. Validation of measurement-guided 3D VMAT dose reconstruction on a heterogeneous anthropomorphic phantom. J Appl Clin Med Phys Jul; 14(4) 7. Feygelman et al. Motion as a perturbation: Measurement-guided dose estimates to moving patient voxels during modulated arc deliveries. Med Phys Feb; 40(2) 8. Stambaugh et al. Experimentally studied dynamic dose interplay does not meaningfully affect target dose in VMAT SBRT lung treatments. Med Phys Sep; 40(9) 9. Feygelman et al. Cross-validation of two commercial methods for volumetric high-resolution dose reconstruction on a phantom for non-coplanar VMAT beams. Radiother Oncol Jan 17

5 Quality Reports [EMR] Plan Quality Management Quality Reports is a software solution that fills a critical gap in plan quality assessment and electronic medical record (EMR) tracking for radiation oncology. Quality Reports facilitates powerful and accessible electronic plan review and chart rounds, and automates comprehensive and customized reports vital to billing and site accreditation. Clinics can now track user-defined plan metrics enabling quality management and continual improvement for planning. Quality Reports is compatible with all treatment planning systems (TPS), delivery modalities, and record and verify (R&V) systems. The software introduces the Plan Quality Algorithm as a way to design and automate protocols. This method will integrate with your workflow to generate and track plan quality metrics. The algorithm allows you to define any number of dose, DVH, or conformity metrics, and score them based on clinical priority. Score functions allow the customization of tolerance levels for minimally acceptable and ideal achievement. For instance, if your site has developed protocols or uses industry standard protocols, all of those elements can be automatically extracted by the Plan Quality Algorithm. Once designed, metrics that might normally take minutes per plan to generate with your TPS, are automatically generated by Quality Reports in seconds. You can analyze plan performance versus your history of performance for the same protocols. This introduces Statistical Process Control for intuitively monitoring variability and trends, and flagging outliers. Plan Quality Metric Scoresheet Plan Quality Distribution Plan Quality Algorithm automates the documentation of plan objectives and ensures the physician s intent is captured prior to planning, which is critical for audits. Once targets and critical anatomy are contoured, they can be analyzed with the Plan Quality Algorithm to ensure that all critical regions-of-interest (ROI) are defined. If non-standard ROI naming is detected, you can customize a library of ROI synonyms to allow multiple names to map to the same structure. Use Quality Reports during planning to check plan performance as you optimize. Numerical scoring and intuitive color-coding facilitates analysis and saves time. Plan review and peer review by the clinical team (locally or remotely) is enabled by reviewing electronic reports and/or interacting with the plan using the Quality Reports intuitive interface. The Plan Quality Scoresheets and analysis vs. performance history promote rapid review and a higher level of discovery. Plan Summary Integrating Quality Reports Across the Workflow There are seven key areas where Quality Reports integrates into your per-patient workflow Analyze per-patient dose QA estimations of patient dose (e.g. 3DVH outputs) with clinical relevance as defined by your Plan Quality Algorithms. Output consistent and comprehensive EMR reports across all TPS and delivery modalities, driving out variability in the e-documentation. Report content and aesthetics are customizable. Track plan quality metrics with performance histories of plan quality outputs (comprehensive metrics as well as individual sub-metrics). Quality Reports supports a practice in many ways. First and foremost, it is an objective tool to evaluate treatment plans. It enables planners to evaluate plans and improve them in a timely and efficient manner. There are tools to create Practice Quality Improvement projects that meet the requirements for MOC for physicians and physicists. Quality Reports can help practice efficiencies and compliance by giving you the ability to easily create the documentation required for billing. Rebecca McInturf, Chief Therapist/Dosimetrist Manager-Radiation/Imaging Services Cancer Care Centers of South Texas

6 To Do ESTRO Events Sun Nuclear Satellite Symposium Learn how the latest developments in QA and Dosimetry are being applied to enhance patient safety. WHEN: Monday, April 7 th, 2014 at 13:00 14:15 WHERE: Schubert rooms 1, 2, 3 (2nd floor) Reed Messe Vienna GmbH Congress Center Lunch will be provided. SYMPOSIUM AGENDA 13:00 Welcome Address 13:05 VMAT QA in Phantom and in Patient Christina Skourou, Ph.D. St. Luke s Radiation Oncology Network, Ireland 13:25 TPS Commissioning with a Cylindrical 3D Water Tank Ricardo Tortosa Oliver, M.S. Hospital IMED Elche, Spain 13:45 A Novel Solution for Plan Quality Assessment and Reporting Greg Robinson, M.S. Radiation Oncology Resources, USA 14:05 A New Solution for Per Fraction QA Jeff Kapatoes, Ph.D. Sun Nuclear Corporation, USA Sun Nuclear In-Booth Talks #5500 Hear from medical physicists on how Sun Nuclear solutions enhance their clinical workflow. TALK SCHEDULE Saturday, April 5 th 10:05 Impact of Criteria and Metrics to Patient QA 14:00 TPS Commissioning Experience with 3D SCANNER 15:50 A Novel Solution for Plan Quality Assessment and Reporting Sunday, April 6 th 10:05 Annual QA Using 3D SCANNER 14:00 IC PROFILER for Linac QA & Acceptance 15:50 Clinically Relevant QA with 3DVH Monday, April 7 th 10:05 Respiratory Motion Simulation with 3DVH 15:50 A New Solution for SRS End-to-End Testing Live Demos! Stop by for a Free ESTRO Souvenir T-Shirt Reserve your seat today: Scan QR code to register for Satellite Symposium and In-Booth Talks Your Most Valuable QA and Dosimetry Tools