Quality Assurance

Imaging Device / IGRT

Cesar Della Biancia, PhD
Assistant Attending Physicist
Medical Physics Department
Memorial Sloan-Kettering Cancer Center
New York, USA
 Table of Contents

• Introduction
• Clinical Commissioning
• Periodic Quality Control (QC) Testing
• Selection of IGRT Technology
 Table of Contents

• Introduction
• Clinical Commissioning
• Periodic Quality Control (QC) Testing
• Selection of IGRT Technology
 Introduction
• Commissioning and Quality Assurance of all IGRT-enabled
technologies are essential.

• American Association of Physicists in Medicine (AAPM) has

issued several task group (TG) reports:
• TG #104: The role of in-room kV x-ray imaging for patient setup and
target localization.
• TG #142: Quality Assurance of medical accelerators.
• TG #101: Stereotactic Body radiation therapy.
• TG #76: The management of respiratory motion in radiation
oncology.
• TG #179: Quality assurance for image-guided radiation therapy
utilizing CT-based technologies.
 Introduction
• Quality Assurance involves the following:
• Acceptance Testing
• Clinical Commissioning
• Periodic Quality Control (QC) Testing
• Patient-specific QA
 Table of Contents

• Introduction
• Clinical Commissioning
• Periodic Quality Control (QC) Testing
• Selection of IGRT Technology
 Clinical Commissioning
• Prepare equipment and staff for clinical work
• Training
• Safety
• Comprehensive of baseline values for QA

• No specific guidance yet … TG Reports → guidelines for clinical

use and QA of the IGRT imaging systems and procedures.

• Clinical factors to consider:

• Accuracy of process
• Staff workload
• Patient tolerance
• Dose
• Resources (time, staffing)
• Applicability
• Clinical context
 Clinical Commissioning
• Implementation is greatly facilitated when performed in parallel
with existing image guidance technology:
• Portal Imaging with implanted markers
• Ultrasound

• Head-to-Head comparison
• CBCT vs US
• CBCT vs Portal Imaging
• CBCT vs in-room CT
 Clinical Commissioning
Dry Runs during commissioning
• Choose phantom that allows for independent verification of
accuracy.

• Treat phantom exactly like a live patient:

• Planning scan (test orientation information!)
• Treatment plan (isocenter location!)
• Record & Verification (R&V) system
• Remote setup correction → automated couch
• Have Radiation Therapists perform setup and treatment
• Image or localization review

• Identify and solve problems before they are clinical problems

(workarounds).
 Table of Contents

• Introduction
• Clinical Commissioning
• Periodic Quality Control (QC) Testing
• Selection of IGRT Technology
 Periodic Quality Control (QC) Testing
• Safety

• Geometric Accuracy

• System stability

• Image Quality

• System infrastructure

• Dose
 Periodic Quality Control (QC) Testing
Safety
• Test all interlocks:
• Door
• kV source arm
• Plat panel arm
• Terminate key

• Visual inspection:
• No loose covers
• Hanging wires

• Test all collision detection devices.

• Test all relevant radiation monitors.

 Periodic Quality Control (QC) Testing
Geometric accuracy
• Coincidence between imaging isocenter and treatment isocenter
(MV isocenter).

• The MV EPID is used as the “Gold Standard” as it provides direct

reference to the treatment beam line.
• 1 mm for stereotactic procedures
• 2 mm for all other procedures

• Customized QA phantoms have been developed for different

IGRT systems, including kV and MV imaging systems of a Linac
and MVCT imaging systems of a helical TomoTherapy.
 Periodic Quality Control (QC) Testing
Geometric accuracy – Coincidence with MV isocenter
• Direct Method
• Place object directly at radiation isocenter
• Calibrate IGRT device against that object
• “Burn” beam isocenter directly into the image dataset
• Sub-millimeter accuracy
• Takes sometime to perform

BB

Variations of the Winston-Lutz test used for brain stereotactic QA

Lutz, Winston, Maleki. Int Journal Rad Oncol Biol Phys 14:373-381; 1998
 Periodic Quality Control (QC) Testing
Geometric accuracy – Coincidence with MV isocenter
 Periodic Quality Control (QC) Testing
Geometric accuracy – Coincidence with MV isocenter
IsoCube Phantom

Marker Phantom

Cube Phantom
 Periodic Quality Control (QC) Testing
Geometric accuracy – Daily Geometry QC
• Align phantom with lasers

• Acquire portal images (AP &

Lat) and assess central axis

• Acquire CBCT

• Difference between predicted

couch displacements (MV &
kV) should be < 2 mm
 Periodic Quality Control (QC) Testing
Geometric accuracy – Daily Geometry QC
• Warms up tube

• Checks for sufficient space

• Test remote-controlled couch

correction

• Can be well integrated in QA

performed by Radiation
Therapists
 Periodic Quality Control (QC) Testing
Image Quality
• Comprehensive QA procedures (including Imaging Quality)
have been reported:
• For Varian OBI systems (Yoo et al.)1
• For EPID (Gopal et al.)2
• For MV CBCT (Gayou et al.)3

• Image quality procedures include:

• Scale
• Spacial resolution
• Noise
• Uniformity
• Signal Linearity (CT numbers)
 Periodic Quality Control (QC) Testing
Image Quality – Scale

• Geometric calibration to tie

isocenter to enter of
volumetric reconstruction.

• Scale to relate all pixels to

isocenter.

Bissonnette et al.4
Periodic Quality Control (QC) Testing
Image Quality – Spacial Resolution

Spacial resolution for Synergy and OBI. Bissonnette et al.4

 Periodic Quality Control (QC) Testing
Image Quality – Uniformity

• Standard CT tests

• Baseline non-uniformity
index:

Bissonnette et al.4
Periodic Quality Control (QC) Testing
Image Quality – Linearity of CT numbers

Linearity of CT numbers: 7 units

(Synergy + OBI). Bissonnette et al.4

Bissonnette et al.4
 Periodic Quality Control (QC) Testing
Image Quality Phantom

• 20 cm diameter

• Four 2 cm sections:
o 1 solid water section for noise
and uniformity
o 2 sections with inserts for
contrast resolution
o 1 section with bar groups for
spacial resolution
Gayou et al.3

• 12 beads for position

accuracy
Periodic Quality Control (QC) Testing
Image Quality – Resolution vs Exposure

Gayou et al.3
 Periodic Quality Control (QC) Testing
Image Quality – Leeds Phantom TOR 18FG
(Leeds Test Objects Ltd. UK)

• Monitor brightness and

contrast level adjustment.

• Resolution limit (0.5 to 5.0

LP/mm).

• Low contrast large-detail

detectability (18 details)

• Circular geometry (Lead Circle)

 Periodic Quality Control (QC) Testing
Image Quality – Leeds Phantom TOR 18FG
(Leeds Test Objects Ltd. UK)
Low contrast resolution Fluoroscopic Radiographic
• Tolerance: > 11-12 disks
• Fluoro: 70kVp, 32mA, 6ms
→ 11-13 disks
• Radio: 75kVp, 25mA, 6ms
→ 13-15 disks

Spatial resolution
• Tolerance: > 11th group
• Fluoro: 50-80kVp, 80mA,
32ms → 11th group
• Radio: 50-80kVp, 80mA,
120ms → 10-12th group
 Table of Contents

• Introduction
• Clinical Commissioning
• Periodic Quality Control (QC) Testing
• Selection of IGRT Technology
 Selection of IGRT Technology
Ten key points to consider when selecting IGRT technology:
1. Clinical objectives (dose escalation/normal tissue sparing)
2. Structures of interest (target and normal structures)
3. Strength of surrogates (skin markers, bony land-marks, implanted
fiducial markers, etc.)
4. Desired level of geometric precision (SRS, Hypofractionation)
5. Uncertainties to be managed through the use of margins
6. Method of intervention/correction (degrees of freedom)
7. Techniques of managing tumor motion
8. Magnitude of dose gradients
9. Available treatment capacity and patient load (treatment/hours)
10. Identification of individuals responsible for maintenance and
development
 Summary
• Several QA programs have been proposed for IGRT systems
• No “formal” guidance from AAPM task group report – YET
• TG #179 formed to look at CT-based IGRT technologies QA

• Common elements to all reports:

• Geometry accuracy and precision
• Image Quality

• Daily QC of geometric accuracy is recommended.

• Recognize the value of IGRT systems as a measurement tool

for new and existing procedures.

• Training of staff is mandatory.

 References
1. Yoo S, Yin FF. Dosimetric feasibility of cone-beam CT-based treatment planning caompared
to CT base treatment planning. Int J Radiat Oncol Biol Phys 2006;66:1553-1561.
2. Gopal A, Samant SS. Use of line-pair resolution phantom for comprehensive quality
assurance of electronic portal imaging devices based on fundamental imaging metrics. Med
Phys 2009;36:2006-2015.
3. Gayou O, Miften M. Commissioning and clinical implementation of a mega-voltage cone
beam CT system for treatment localization. Med Phys 2007;34:3183-3192.
4. Bissonette et al. A quality assurance program for image quality of cone-beam CT guidance in
radiation therapy. Med Phys 2008;35:1807-1815.
 Thanks!!

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New York City

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