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Quality Assurance for IGRT

Roman Wicha, PhD


Varian Medical Systems
Stanford IGRT Course 2008

VARIAN Medical Systems

IGRT QA

Agenda

VMS IGRT Solution

IGRT QA Tests

QA Tools

Examples of QA Protocols

Summary

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VMS IGRT Solution -On-Board ImagerTM (OBI)


X-ray Source
- Varian G242
aSi Imaging Panel
- Varian PaxScan 4030CB
Robotic Arms
- 3 pivot points:
Shoulder, elbow and wrist
- Completely retractable
- Position feedback control
Software
- Custom software for image
acquisition and registration
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VMS IGRT Solution

On Board Imager

Radiographic mode

Fluoroscopic mode

Interaction with Respiratory Gating (RPM) System


available

Cone Beam CT (CBCT)

Acuity

Hi-Energy Linear Accelerator

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Radiographic Mode

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Radiographic Mode: Anatomy


1.

Setup patient

2.

Extend arms

3.

Exit treatment room

4.

Remotely acquire AP and lateral kV


images

5.

Compare current images to


reference images (DRRs)

Automated

Manual

6.

Calculate couch motion required to


correct setup

7.

Move couch remotely

8.

Reacquire and reanalyze to confirm


setup correction

9.

Retract arms remotely

10.

Treat

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Sample images

Images courtesy of Karolinska Institute

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Kilovoltage Radiographs

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Cone-Beam CT

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CBCT Mode
1.

Setup patient

2.

Extend arms

3.

Exit treatment room

4.

Acquire CBCT Dataset

5.

Compare current images to


reference CT images

Manual

Automated

6.

Calculate couch motion required to


correct setup

7.

Move couch remotely

8.

Reacquire and reanalyze to confirm


setup correction?

9.

Retract arms remotely

10.

Treat
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Clinical Results Hirslanden Klinik, Aarau

CT

CBCT

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Clinical Results Emory

CBCT

CBCT

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CT Simulator

Intrafraction motion

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Pretreatment Fluoroscopic Verification of Gating

Setup patient

Extend arms

Rotate gantry to first field

Exit treatment room

Remotely acquire fluoro

MLC aperture turns


green/red, indicating when
the gate is open/closed

Verify target remains within


aperture

Repeat for other fields

Retract arms remotely

Treat

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IGRT QA

Number of IGRT installations is increasing

There are limited guidelines for QA available


as of now

Yoo et all., A quality assurance program for the onboard imager, Medical Physics, Vol. 33, No. 11,
November 2006

IGRT QA should contain

All the tests done for 3D CRT and IMRT

Additional test related to image guidance

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IGRT QA

Primarily a machine QA

There are no patient specific tests for IGRT (on top of


the ones performed for IMRT)

Parameters to be tested

Safety

Mechanical and optical

X-Ray beam

Imaging

Functionality

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IGRT QA Daily Checks

Anti-collision system

Warning lights and audio warning for kV


beam, interlocks

Motion enable from OBI control console


and hand pendants

kV source / kV detector / MV detector


positioning accuracy

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Daily checks Anti-collison

MV detector arm

Detector

Front

Side

kV source arm

kV detector arm

Arm

Arm

Source

Detector

Front

Front

Side

Side

Back

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IGRT QA Safety

Daily checks

kV source door interlock

Warning lights and audio warning for kV beam

Motion enable from OBI control console

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Motion Enable

Detector and arm motion is only possible when motion enable bars on the
hand pendant or motion enable button on the OBI console are pressed
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Position calibration Daily Option 1

Vertical axis calibration

Position arms to the predefined position


(e.g. kVS 100cm, kVD 50 cm, MVD 50 cm)

Measure distance from detector cover / kV source


plate to the isocenter

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Position calibration Daily Option 2

Longitudinal and lateral axis calibration

Position kV Blade Calibration Plate on the table

Move table to the isocenter

Align kV Blade Calibration Plate with Clinac


crosshair

Acquire an image

Compare position of digital graticule with the


center cross of the plate

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Position Calibration Daily - Option 2

Tolerance

displacement < 2 mm

Procedure

Set Gantry 90o, measure the Lat displacement of


KVD using ceiling laser and measure the Vertical
displacement using cross-hair
Set Gantry 270o, measure the Lat displacement of
KVS using ceiling laser and measure the Vertical
displacement using cross-hair

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Position calibration Daily Option 3

The Cube Isocenter Phantom was used for this daily QA procedure
Two sets of 1-mm lead shots (bbs) were used to define 2 separate
spatial locations (points)
In each set, one bb is on the anterior side (AP bb) and the other (Lat
bb) is on the lateral side of the phantom
The first set defines the isocenter and the second set defines a point
1.5 cm anterior, inferior, and lateral from the isocenter

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Adapted from Rabih Hammoud

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Position calibration Daily Option 3

The OBI daily QA procedure starts with setting up the Cube phantom
center (central bb set) at the mechanical isocenter of the linac by using
the cross hairs projections anteriroly and laterally
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Adapted from Rabih Hammoud

Position calibration Daily Option 3

Lat DRR

Lat KV Image

Using the plan created from Eclipse, AP MV and Lat KV images were acquired
(shown only Lat image)
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Adapted from Rabih Hammoud

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Position calibration Daily Option 3

Lat DRR

KV Lat Image

AP DRR

MV AP Image

The alignment of the central bbs with the digital graticule (representing the imager
isocenter) will be checked from both AP and Lat images
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Adapted from Rabih Hammoud

Position calibration Daily Option 3

Long: __ mm OK 1.5 mm

Long: __ mm OK 1.5 mm

Lat:

Vert: __ mm OK 1.5 mm

__ mm OK 1.5 mm

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Adapted from Rabih Hammoud

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Results

Daily mismatch
distance (mm)

MV Isocenter Check
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0

S/I
R/L

3 5 7 9 11 13 15 17 19 21 23 25 27 29 31
Daily m easurem ent (days)

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Courtesy of Rabih Hammoud, presented at AAPM

Results

Daily mismatch
distance (mm)

KV Isocenter Check
1.4
1.2
1
0.8
0.6
0.4
0.2
0

S/I
A/P

1 3

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5 7 9 11 13 15 17 19 21 23 25 27 29 31
Daily Measurem ent (days)

Courtesy of Rabih Hammoud, presented at AAPM

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IGRT QA Monthly Checks

Safety

OBI laser crosshair

Arms isocentric calibration

Arm run out

Blades calibration

Couch motion

Linear

Rotation

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IGRT QA Safety

Emergency off (part of Clinac QA)

Backup motion controller

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OBI Laser Crosshair

Using Clinac lasers position Isocenter cube to


the isocenter

With gantry at 0, position kV source arm to


100 cm

Switch on OBI laser and verify its projection


on the cube

Repeat for gantry angles 90, 270

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Arms Isocenter Calibration

Position kV arm to 0,0,0 and verify that the


center of the detector is aligned with the
isocenter of the machine

Repeat for MV arm

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Arm run out - I

Position arm to 0,0,20

Verify that the crosshair or OBI laser


projection is aligned with the center of the
detector

Move detector along the vertical axis and


verify the run out throughout the whole range
of the motion

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Arm run out - II

Position kV Blade Calibration Plate on the table

Move table to the isocenter

Align kV Blade Calibration Plate with Clinac crosshair

Position arm to 3-4 different positions along the


vertical axis (e.g. 20, 40, 50, 70)

Acquire image at each position

Compare position of digital graticule with the center


cross on the Calibration Plate

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Blades calibration

Done using fluoro mode

Blade calibration tool placed at isocenter

Set up blades to given size

Verify blades alignment with the calibration


tool

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IGRT QA Monthly Checks

Isocenter alignment of MV and kV beam

MV Image Quality

kV Image quality

Shift calculation

Measurement tools

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Isocenter Accuracy

Tolerance

Coincidence of treatment isocenter and


imaging center < 1.5 mm

Preparation

Phantom with a center marker

QA plan with a setup field (AP or Lat) and DRR

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Courtesy of Dr. Sua Yoo, Duke University

Isocenter Accuracy

Procedure

Set the phantom center at the isocenter based on calibrated


lasers, crosshair, and SSD

Acquire a kV image in OBI

Measure the displacement of the center marker from the center


of the graticule in OBI
Cube phantom

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Blade Calibration
Plate

Marker phantom

Courtesy of Dr. Sua Yoo, Duke University

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Isocenter over Gantry Rotation


Tolerance

Accuracy isocenter over gantry rotation < 2 mm

Preparation

Volume phantom with a center marker

QA plan with setup fields of various gantry/source


angles

0o, 90o, 180o, and 270o

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Modified from Dr. Sua Yoo, Duke University

Isocenter accuracy
(May 2005 Apr 2006)

: Error in phantom setup Re-QA


X: Laser misalignment Laser adjusted
: Error in KVD calibration KVD re-calibrated

Mechanical accuracy
Isocenter over gantry rotation (Dec, 05 July, 06)

S
R

G0
P

S
A

G90
R

S
L

G180
A

S
P

0.2
Displacement (cm)

G270

(May 2005 Apr 2006)

0.1
KVS

0.0
-0.1
-0.2

KVD
KVS

Ver

KVD

Long

KVS KVD

Lat

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Courtesy of Dr. Sua Yoo, Duke University

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MV Image Quality

Set up detector

Place phantom on top of the


detector

Acquire and analyze image


(use Quality setting in the
sequence template)

max R determines contrast

max C determines resolution

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IGRT QA Imaging chain

Weekly checks

Image quality with imaging phantom

Monthly checks

High contrast resolution

Gray scale linearity

Low contrast sensitivity

Image geometry

Distance

Angle

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Results Image Quality

Fluoroscopic

Radiographic

Low contrast resolution


Tolerance: > 11 12 disks
Fluoro: 70 kVp, 32 mA, 6ms 11 13 disks
Radio: 75 kVp, 25 mA, 6ms 13 15 disks
Spatial resolution
Tolerance: > 11th group
Fluoro: 50-80kVp, 80mA, 32ms 9 11th group
Radio: 50-80kVp, 80mA, 120ms 10 12th group

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Courtesy of Dr. Sua Yoo, Duke University

IGRT QA OBI Shift calculation

OBI Geometric Phantom

Crosshair #1 reference

Crosshair #2 test

Crosshairs shifted by the known distance

4 markers inside phantom

Reference image for setup fields at reference crosshair

kV/kV, MV/kV and Marker Match for fields setup at test


crosshair

Verify distance calculated by OBI algorithm

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Shift Calculation 2D / 2D

Accuracy of 2D2D match and couch shift <


2 mm

kV images (AP/Lat)

Preparation

Phantom

2D2D match

1.

Phantom with off-center markers at


known positions, or

2.

phantom with a center marker placed


at known position.

Match DRRs graticule


to off centered marker

QA plan with orthogonal setup fields and


DRR

Apply couch shift


Remote shift couch
Verify couch in room

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Before match

After match

Courtesy of Dr. Sua Yoo, Duke University

Results
2D2D match and couch shift
(May 2005 Apr 2006)

2D2D match accuracy

Couch shift accuracy

2
1

1
Lat

0
Ver

-1

Long

Difference (mm)

Phantom Setup at Iso

Tolerance

Disagreement (mm)

1
0

Ver

Long

3
Lat

-1
-2

Ver: Ant +/Post ; Long: Inf +/Sup ; Lat: Rt +/Lt

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Courtesy of Dr. Sua Yoo, Duke University

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Measurement tools

Measurement of

Distance

Area

Angle

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IGRT QA Annual Checks

Annual checks

kV beam output parameters

kV, mA, exposure time

HVL

Automatic Brightness Control (ABC) for fluoroscopy

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IGRT QA CBCT Tests

Daily checks

Geometry

HU calibration spot check

Annually (Monthly)

Uniformity

Contrast

Resolution

HU calibration

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CBCT Daily Check

Position CATPHAN on the table

Acquire CBCT

Verify geometry

Verify HU

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CBCT Annual test

Position Norm Phantom on the table

Acquire CBCT

Measure profile and verify uniformity of HU

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Results HU Uniformity

ROI

Full fan

Half fan

Top

- 4.8 8.7

- 14.6 10.4

Right

- 3.4 8.9

- 14.6 11.6

Bottom

- 7.3 8.4

- 13.4 10.1

Left

- 8.5 7.8

- 15.9 9.6

Center

18.0 9.0

15.6 11.3

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Full-fan

Half-fan

Courtesy of Dr. Sua Yoo, Duke University

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Contrast

Performance
0.5 %

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Resolution

Performance
10 lp/cm

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Results CBCT Image Quality

Half fan

Low contrast
resolution

Disk 4

Disk 5

Disk 4

Spatial
resolution

Group 6

Group 8

Group 6

Slice thickness

0.1 mm

2.39 2.60

2.45 2.51

Spatial linearity

0.5 mm

49.8 50.2

49.8 50.0

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Half-fan

Spatial
resolution

Full fan

Low contrast
resolution

Full-fan
Tolerance

Courtesy of Dr. Sua Yoo, Duke University

HU Calibration

1. Air =-1000

2. LDPE = -100

3. Acrylic = 120

4. Teflon = 990

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Results HU linearity

Full fan

Half fan

Teflon

989.0 10.5

1007.8 22.8

Delin

363.1 10.7

354.0 15.1

Acrylic

96.0 9.0

116.1 12.3

Poly-

- 42.8 8.8

- 48.5 10.5

LDPE

- 101.2 8.8

- 106.9 16.1

PMP

- 196.6 8.6

- 206.5 12.7

Air

- 998.3 2.4

- 995.7 13.3

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Full-fan

Half-fan

Courtesy of Dr. Sua Yoo, Duke University

QA Tools delivered with OBI and CBCT

On Board Imager

Isocenter cube

Blade calibration plate

Leads TORR-18FG phantom

OBI geometric phantom on Exact Bar

RPM

RPM Gating phantom

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On-Board Imager Phantoms

OBI Geometric Phantom:


overall accuracy
and precision of the system

Isocenter Cube:
alignment of the kV to the
MV beam

Leeds TORR-18FG Phantom:


kV image quality

RPM-Gating phantom:
gated radiographs
and pretreatment fluoroscopic
verification of gating

kV Blade Calibration Plate:


calibrate the kV blades

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QA Tools delivered with OBI and CBCT

Cone Beam CT

NORM calibration phantoms

CATPHAN

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Norm calibration

Norm Phantom

CATPHAN

To correct for scatter

Geometry

2 Norm phantoms

Resolution

HU

Contrast

Head

Body

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Examples of QA Protocols

Courtesy of Sua Yoo, PhD, Duke University

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Daily OBI

Weekly OBI

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Monthly OBI

(continues)
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Monthly CBCT

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(continues)

Automated IGRT QA Works in Progress

IGRT QA is straightforward, but may require


some time to acquire and analyze data

It maybe possible to automate some of the


QA steps

Weihua Mao, Louis Lee, and Lei Xing Development of a QA phantom and automated
analysis tool for geometric quality assurance of onboard MV and kV x-ray imaging systems,
submitted to Med. Phys.

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Automated IGRT QA Works in Progress

Courtesy Lei Xing, Stanford


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Summary

OBI and CBCT are increasingly used in the


clinical routine

Development of commissioning and QA


procedures is needed to accomplish safe
delivery of IGRT

QA should cover

Safety

Mechanical and optical

Imaging

Functional tests

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