On The Accuracy and Effectiveness of Dose Reconstruction For Tomotherapy

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On the accuracy and effectiveness of dose reconstruction for tomotherapy
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2001 Phys. Med. Biol. 46 943
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INSTITUTE OF PHYSICS PUBLISHING PHYSICS IN MEDICINE AND BIOLOGY
Phys. Med. Biol. 46 (2001) 943–966 www.iop.org/Journals/pb PII: S0031-9155(01)16355-4
On the accuracy and effectiveness of dose

reconstruction for tomotherapy
J M Kapatoes1,2 , G H Olivera1,2 , J P Balog2 , H Keller1 , P J Reckwerdt2
and T R Mackie1,2
1 University of Wisconsin–Madison, 1300 University Ave, Rm 1530, Madison, WI 53706, USA
2 TomoTherapy, Inc, 2228 Evergreen Rd, Middleton, WI 53562, USA
Received 14 August 2000, in final form 12 December 2000
Abstract
Dose reconstruction is a process that re-creates the treatment-time dose
deposited in a patient provided there is knowledge of the delivered energy
fluence and the patient’s anatomy at the time of treatment. A method for
reconstructing dose is presented. The process starts with delivery verification,
in which the incident energy fluence from a treatment is computed using the
exit detector signal and a transfer matrix to convert the detector signal to energy
fluence. With the verified energy fluence and a CT image of the patient in the
treatment position, the treatment-time dose distribution is computed using any
model-based algorithm such as convolution/superposition or Monte Carlo.
The accuracy of dose reconstruction and the ability of the process to
reveal delivery errors are presented. Regarding accuracy, a reconstructed dose
distribution was compared with a measured film distribution for a simulated
breast treatment carried out on a thorax phantom. It was found that the
reconstructed dose distribution agreed well with the dose distribution measured
using film: the majority of the voxels were within the low and high dose-gradient
tolerances of 3% and 3 mm respectively. Concerning delivery errors, it was
found that errors associated with the accelerator, the multileaf collimator and
patient positioning might be detected in the verified energy fluence and are
readily apparent in the reconstructed dose. For the cases in which errors appear
in the reconstructed dose, the possibility for adaptive radiotherapy is discussed.
1. Introduction
It was shown in previous works (Kapatoes et al 1998, 1999a) that the energy fluence exiting a
temporal multileaf collimator (MLC) could be verified using the signal collected in a detector
behind the patient. This process is called radiation delivery verification (RDV). Corrections
must be made to the signal for leakage and transmission, and the combination tongue-and-
groove/penumbra effects. The energy fluence can be verified either on a pulse-by-pulse basis
or a projection-by-projection basis. Pulse-by-pulse results can be averaged to yield projection-
by-projection results. Using the projection-by-projection energy fluence in conjunction with an
0031-9155/01/040943+24$30.00 © 2001 IOP Publishing Ltd Printed in the UK 943

944 J M Kapatoes et al
image in the treatment position, the full three-dimensional dose distribution can be computed.
This process is called dose reconstruction (DR) (Kapatoes et al 1999b, 2000a, McNutt et al
1997, Olivera et al 1999).
Tomotherapy (Mackie et al 1993, 1999, Olivera et al 1999) is a radiotherapy technique that
employs an intensity-modulated fan-beam to deliver highly conformal or conformal avoidance
(Aldridge et al 1998) treatments. Tomotherapy treatments can be conducted sequentially (Carol
et al 1992, 1996b, 1997) or helically (Mackie et al 1993, 1999, Olivera et al 1999). In helical
tomotherapy, the accelerator, a MLC system, an exit detector associated with the accelerator
and a CT imaging system are mounted onto a single ring gantry. Such an approach provides
delivery and verification capabilities that were heretofore limited or altogether unavailable.
Specifically, the tomotherapy machines will be capable of inverse treatment planning via
optimization (Olivera et al 1998, Reckwerdt et al 2000, Shepard et al 2000), megavoltage CT
imaging in the treatment position (Ruchala et al 1999a, b, 2000a–c), registration of the patient
position in projection space (Fitchard et al 1999a, b, 2000), delivery modification without the
need to reoptimize (Olivera et al 1999, 2000), RDV and DR.
Studies have previously been conducted into the possibilities for RDV and DR for standard
radiotherapy (SRT) and intensity-modulated radiotherapy (IMRT). As proposed by Webb
(1997), verification can be categorized according to the tools and methods involved:
(a) Mechanical verifications on the source side.
(b) Conducting treatments on phantoms.
(c) In vivo dosimetry through detectors placed on or inside the body.
(d) Electronic portal imaging devices (EPIDs).
(e) Real-time dose simulation.
In particular, category (c) verification includes film and diode investigations of exit dose levels
(Bogaerts et al 2000, Fiorino et al 1993, Van Dam et al 1992, Wong et al 1990). When
combined with entrance dose measurements, midline doses have been estimated (Huyskens
et al 1994, Lanson et al 1999, Leunens et al 1990a, b, Mangili et al 1999). Ying et al
(1990) extended this to calculate transverse dose distributions within a simulated patient using
simulated images from portal films. However, film has the disadvantage that processing time
is required, while diodes only allow for verification of a few points.
Greater interest has been shown in category (d) verification for dosimetric applications.
EPIDs offer the advantage of on-line verification in two dimensions, combining the intrinsic
advantages of diodes and film. There are two types of EPIDs that have been studied extensively:
those using a scintillator, mirror and CCD camera (Aoki et al 1990, Hansen et al 1996, Heijman
et al 1995, Kirby and Williams 1993, 1995, Kroonwijk et al 1997, 1998, Pasma et al 1998a, b,
1999) and those using a matrix of liquid-filled ion chambers (Boellaard et al 1996, 1997a, b,
1998a, b, Essers et al 1995, 1996, Keller et al 1998, McNutt et al 1996a, b, Yin et al 1994,
Zhu et al 1995). The majority of these studies have focused on comparing portal dose, exit
dose or midline dose derived from the EPID signals with dose measured using a diode or ion
chamber. A few of these studies present fully reconstructed EPID-derived dose distributions
within a phantom or patient (Aoki et al 1990, Hansen et al 1996, McNutt et al 1996a, 1997).
These last investigations fall between categories (d) and (e), and have the most in common
with the techniques in this work since a fully reconstructed patient dose distribution can be
generated.
The focus of this paper is to analyse the accuracy of dose reconstruction and display
how delivery errors appear in the reconstructed dose. Specifically, the accuracy is addressed
by comparing dose reconstruction with a measured film distribution, and, regarding error,
issues arising from the accelerator, MLC and patient positioning are presented. Concerning
Dose reconstruction for tomotherapy 945
the accelerator, the effects of a decrease in output are investigated. For the MLC, problems
caused by stuck leaves are discussed. Finally, positioning errors of 2 mm, 5 mm, and 2◦
rotation are examined. If such errors can be accurately identified, there exists the opportunity
for remediation in the subsequent fraction(s) (adaptive radiotherapy).
2. Theory
2.1. Radiation delivery verification

The theory of this process is described in Kapatoes et al (1999a), but a brief summary will be
given. The signal in any detector element of a multichamber detector can be written as the
sum of the energy fluence contributions from each leaf, provided these energy fluence values
are weighted properly. This is written mathematically as

si = Dij ψj (1)
j
where si is the signal in detector element i, ψj is the energy fluence emitted from leaf j and
Dij is the signal in detector element i per unit of energy fluence from leaf j . This Dij value
is the weighting value. This can be written in a form that includes all detector elements by
writing equation (1) in vector/matrix form:
s = Dψ. (2)
Here s is the vector of signal in all detector elements for one projection, ψ is the vector of
energy fluence emitted from all leaves for one projection and D is the matrix of weighting
values for one projection. The energy fluence is found by multiplying the pseudoinverse of
this transfer matrix, D−1∗ , by the signal vector s
ψ = D−1∗ s. (3)
As the D matrix is generally non-square, a numerical approach is taken in finding the inverse
matrix (Press et al 1988, Wilkinson and Reinsch 1971). From the above equations, it should
be clear that D is a transfer matrix allowing one to move from signal in the detector plane
to energy fluence in the MLC plane, and vice versa. A final important point regarding these
equations is that we relate detector signal, not dose, to the energy fluence. This can be done
because the primary and scatter characteristics for each leaf at each beam angle are contained
within D since the matrix is measured. This is advantageous as extensive knowledge regarding
the detector’s dose-response characteristics is not required explicitly.
Implicit in the signal profiles of the above equations and the profiles gathered in creating
D are corrections for leakage and transmission (L&T), and tongue-and-groove/penumbra
(TAG/P). These corrections are critical in obtaining accurate fluence results. For the NOMOS
MIMiC MLC (Sewickly, PA), the process can underestimate the energy fluence values by as
much as 20% or overestimate by 5–10% without considerations made for L&T and TAG/P
respectively (Kapatoes et al 1999a). Since these phenomena conflict with one another, results
become confusing if not corrected. These errors are inherent in the method but the magnitudes
may change depending upon the MLC system.
2.2. Dose reconstruction

With the energy fluence calculated using equation (3) and an accurate representation of the
patient’s anatomy at the time of treatment (Ruchala et al 1999a, b, 2000a–c, Jaffray and
Siewerdsen 2000, Jaffray et al 1995) dose reconstruction can be performed. The algorithm
used to compute dose is convolution/superposition (C/S), although any model-based algorithm

would suffice (e.g. Monte Carlo). The three-dimensional dose distribution calculated in this
way is compared with the planned dose distribution. Thus, the deposited dose is compared with
the planned dose. Furthermore, such information provides the basis for adaptive radiotherapy
in which errors occurring in one fraction can be remediated in the subsequent fraction(s).
3. Materials and methods
3.1. Creating D
The variables in equation (3) have time dependence. To maintain consistency with the
optimization process, which creates optimized fluence patterns from a finite number of
equiangular projections, one matrix is created per projection. This approach also has the
added benefit that memory requirements are kept low (e.g. each matrix requires 40 kbytes).
However, since detector signal is collected for each beam pulse there appears to be a conflict
in equation (3). This is resolved by multiplying the signal profile for each beam pulse by
the matrix corresponding to the projection into which the beam pulse occurred. Thus the
group of beam pulses corresponding to a projection p are multiplied by the single D matrix
corresponding to projection p. This approximation has proven valid for projection angular
intervals of 8◦ or less (Kapatoes et al 1999a).
The two principal methods used to generate D are found in Kapatoes et al (1999a, 2000b),
but will be briefly reviewed. The most straightforward method is to measure the matrices
(Kapatoes et al 1999a). This is done by opening a leaf individually for a small number (three
to five) of beam pulses for a projection p. The signal profiles are then averaged together and
this average signal profile is placed into column j (for leaf j ) of the D matrix for projection
p. This is repeated for each leaf and for all projections. The measurement would need to
be conducted just before or after treatment using the same pitch as the treatment to ensure
that the anatomy characterized in the signal profiles of the D matrix is consistent with that
during treatment. This measurement can be time-consuming but can be shortened if multiple
leaves are measured at one time (for instance, measure profiles for all odd-numbered leaves,
then repeat for even-numbered leaves). The latter approach requires knowledge of the scatter
effects of each opened leaf on the other opened leaves.
As an alternative to measurement, the matrices can be obtained using a CT in the treatment
position and a database of measured signal profiles (Kapatoes et al 2000b). The database is a
function of radiological pathlength (RP) and detector-to-patient distance (DPD). A treatment-
time CT is used to compute these parameters for each leaf over all projections. This approach
eliminates the extra machine time required to directly measure the transfer matrix on the patient
and produces results that are almost identical to those using a measured transfer matrix. For
these reasons, the database technique is the method we currently use and plan to implement
clinically. However, because this work involved phantoms studies, D matrices were measured
since measurement is the most accurate approach: there are no assumptions regarding the
relationship between energy fluence and signal. Moreover, a large number of pulses (200)
were used to measure D as measurement dose to the phantom was not a concern.
3.2. Delivery implementation

The helical tomotherapy optimization software computes dose from a finite number of beam
angles, as if the gantry stops in the centre of each projection to deliver its dose. With a
helical treatment unit such as the clinical tomotherapy prototype this is obviously not how
the delivery is achieved in practice. Delivery is implemented by opening and closing the
leaves symmetrically about the arc (projection) centreline, synonymous to the approach of the
NOMOS (Sewickly, PA) Peacock system. This delivery strategy can cause error in the fluence
calculation if it is not accounted for properly. These inaccuracies and appropriate correction
methods are described in Kapatoes et al (2000c) but are briefly reviewed in the following
paragraph.
The two primary sources of error involve leaf latency and the relationship between the D
matrix and the arc over which each leaf is to be opened. For a binary MLC system, leaf latency
is defined as the finite amount of time a leaf takes in moving from a completely opened to
closed state, or vice versa. As this radiation delivery verification method involves binning the
treatment beam pulses into projections, beam pulses can be incorrectly assigned since latency
introduces a delay in the opening and closing of a leaf. Regarding the relationship between D
and a leaf’s open arc, it is more accurate to only use the measured beam pulses that correspond
to the arc over which a leaf is to be opened during treatment rather than all measured pulses
from the full arc in creating the D column for a given leaf in a given projection. For this work,
considerations were made for both issues to minimize potential errors in the computed energy
fluence values.
3.3. Tomotherapy workbench

All measurements were carried out on the tomotherapy benchtop located in the Physical
Sciences Laboratory of the University of Wisconsin–Madison. Details regarding the benchtop
can be found in Balog et al (1999) or Kapatoes et al (1999a).
3.4. Simulated breast treatment

3.4.1. Phantom. This delivery was carried out using a thorax phantom (Balog 1998). An
MVCT transverse image of the phantom is shown in figure 1(a). This phantom consists of two
cast acrylic cylinders, each with a diameter of 22.9 cm. The wall of the left cylinder was cut
away and the right cylinder was connected such that the left cylinder obtained a crescent-moon
shape. Inside the right cylinder is another cast acrylic cylinder with a diameter of 10.2 cm.
The right cylinder and the 10.2 cm inside cylinder were cut in half such that a piece of film
could be placed vertically between them. The walls were sealed so that the whole phantom
was able to hold water. The inside cylinder was filled with a low-density material (rolled oats,
0.3 g cm−3 ) to mimic lung tissue. A half cylinder of the same material was placed in the
crescent-shaped cylinder to simulate the contralateral lung. The cross section of the phantom
shown in the figure does not change in the inferior–superior direction.
3.4.2. Planning and delivery. For this treatment, dose was optimized for 45 projections per
rotation over 32 helical rotations. Ideally, tomotherapy treatments will be optimized with 71
projections per rotation. The chosen number of projections was a compromise between the
latency of the leaves and the maximum film dose. Leaf latency introduces artefacts in the dose
distribution if the projection time is too short. Leaves of the NOMOS system require between
50 and 100 ms to move from a fully closed to opened state, and vice versa. Artefacts have been
shown to be small for projection times of 500–1000 ms and trivial for 1000 ms or more (Balog
1998). However, it is desirable to keep the maximum dose to the film within the linear range of
the film. Thus, film considerations demand that the projection time is not too long to prevent
film saturation. A projection time of 600 ms was selected at a dose rate of 100 cGy min−1 at
Figure 1. (a) Megavoltage CT image of the thorax phantom used for the breast treatment. The
acrylic shells were filled with water to simulate tissue and lung-equivalent material to simulate lung
tissue. (b) Diagram defining the rotational coordinate system used in orienting the films. Films
were measured every 10◦ (starting at 0), and 10 extra films were obtained at 5◦ intervals in high
dose-gradient regions. (Adapted with permission from Balog (1998).) (c) Measured film dose
distribution for slice 16 of the breast treatment. The film data for all angles were combined and
then interpolated to produce the full, 3D dose distribution.
isocentre, yielding a maximum film dose of 42.9 cGy and a total treatment time of 14 min and
24 s (32 slices × 45 projections/slice × 600 ms/projection).
The pitch for the treatment was set at 0.5 to minimize junctioning problems as reported
for sequential tomotherapy (Balog 1998, Carol et al 1996a, Low 1997, Yang et al 1997).
As the longitudinal distance translated in one full rotation was 0.38 cm, the delivery covered
12.19 cm of the phantom in the inferior–superior direction. Thus, this treatment was designed
to encompass the axilla region to the internal mammary node chain. Regions of interest (ROIs)
for three slices are displayed in figure 2. Slice 7 (figure 2(a)) is the most inferior slice shown and
features all ROIs. The ROIs seen in slice 16 (figure 2(b)) are representative of a large portion of
Figure 2. Regions of interest for the breast treatment: (a) slice 7, (b) slice 16, (c) slice 23. Slice 23
simulates a superior slice (e.g. axilla nodes), therefore the contralateral breast is not present.
the treatment since these ROIs were the same for slices 11–21. The large tumour region situated
close to the lung is paramount in this image. Slice 23 (figure 2(c)) is theoretically located in the
upper thorax area near the axilla nodes, thus the contralateral breast is not seen in this image.
3.4.3. Film measurement. The 3D dose distribution was measured using film (Balog 1998).
Proper sampling of the dose distribution requires that a film be obtained at least every 10◦ . This
results in a data point every 2 cm at the periphery of the phantom, and implies that 18 films be
obtained to sample the entire right cylinder. Zero degrees was defined as the film orientation
that was parallel to the central axis of the beam at the start of the delivery (figure 1(b)). In
addition to a film measurement every 10◦ , treatment films were obtained for the following
angles in an effort to more effectively sample the high dose-gradient regions: 35◦ , 55◦ , 65◦ ,
75◦ , 85◦ , 115◦ , 125◦ , 135◦ , 145◦ and 155◦ . The accuracy of the angular film position was ±1◦ .
Finally, calibration films were also acquired to convert the optical density values to dose.
The films were processed simultaneously, so the accuracy of the film dosimetry is
consistent with such circumstances: 2% for areas of the same film and 3% between films
(ICRU 1984). Films were aligned with one another using the dose profile at the centre of the
film phantom: this profile was very distinctive such that inferior–superior alignment to within
1 mm was achieved. This also conveniently allowed every film to be normalized to the others.
Once aligned, the 28 radial treatment film images were interpolated (bilinear) into rectangular
coordinates so the measured dose could be displayed on a slice-by-slice basis. An example of
this is shown in figure 1(c) for slice 16. Using the MVCT image as a reference (figure 1(a)),
the notch in the dose image is explained because the film jacket abutted the other cylinder for
sector A but could extend outward into the air for sector B.
3.5. Issues investigated

3.5.1. Positional errors. The area in which radiation delivery verification and dose
reconstruction have the greatest potential to improve treatment quality is patient positioning.
The reason for this is related to the frequency of occurrence: errors in positioning are much
more common and may affect treatments daily. Furthermore, with the on-board CT capabilities
of helical tomotherapy, accurate positioning information may be obtained for each fraction.
Breast treatments were carried out with the phantom shifted by 2 mm and 5 mm with respect
to the reference position, and rotated 2◦ about the centre of the phantom. RDV and DR were
performed for all three cases. The 2 mm shift was chosen because it is the positional tolerance
that we expect to obtain for our verification processes (Fitchard et al 1999a, Olivera et al
1999). The rotational study was done in conjunction with the latency study to ascertain that
small rotational shifts (2◦ or less) in the pattern of intensity result in insignificant changes in
dose.
3.5.2. Delivery errors involving the treatment unit. Another area in which radiation delivery
verification and dose reconstruction could prove beneficial is in illuminating errors that occur
with hardware components, specifically the accelerator and MLC. The processes provide an
independent, secondary check of such systems and quantify the effects that errors with such
systems have on the verified energy fluence and patient dose. To investigate the effects of
accelerator problems, a 10% linear decrease in output was introduced into the detector signal
of the breast treatment. The 10% magnitude was chosen due to the fact that the maximum
tolerance for output variation without treatment termination is ±5% for most accelerators.
Even though modern accelerators are very reliable and such output changes within a treatment
are unlikely, we sought to discover the impact of such error on the verification techniques.
For the MLC, it is possible for the leaf state verification to fail and a leaf to become stuck in
the opened position with hazardous consequences if the treatment were not terminated. To
test this effect on the tomotherapy benchtop, the MIMiC’s mechanical verification system that
would stop a treatment under such circumstances was disabled.
3.6. Quantitative tools for analysis of energy fluence and dose

Assessing the accuracy of energy fluence results calculated using equation (3) is
straightforward, as a simple difference can be made between the planned and verified energy
fluence values. The only issue needing attention is the choice of a normalization value. For all
difference sinograms in this work, the average energy fluence of the optimized sinogram was
used as the normalization value. In this way, the difference values are related to the average
expected energy fluence value. Such an approach possesses clinical relevance since errors in
leaves prescribed a large energy fluence will be readily seen. These leaves will be clinically
more relevant as they deliver a large fraction of the dose, thus their error requires appropriate
attention.
For dose distribution analysis, complications arise due to the presence of gradients. Thus
dose cannot be accurately evaluated using only a subtraction of distributions. For this reason,
the method proposed by Kapatoes et al (2000d) is used. This approach is a generalization of
the procedure outlined by Van Dyk et al (1993) for treatment planning commissioning. It is
proposed that both distributions be compared in their gradient components first, followed by
a dose-difference ( D) and distance-to-agreement (DTA) analysis. The gradient comparison
accounts for the fact that there may be a complete mismatch of dose gradients between the
reconstructed and planned distributions. Once D and DTA values are obtained, a numerical
index for each voxel can be found that is similar to that proposed by Low et al (1998). The
numerical index ξ is found by the following:

DTA D

ξhigh-gradient voxels =
ξlow-gradient voxels = . (4)
DTA tolerance D tolerance
A ξ value of 1 or less is considered acceptable. Though a volume can have both high- and
low-gradient voxels, this approach is amenable to averaging or display since the ξ values are
dimensionless. Furthermore, the high and low gradients can be subdivided and tolerances
assigned to each region. Such a method was employed. First, both distributions were
normalized to the average of the planned tumour dose. Low-gradient voxels were classified
as high dose (above 85%) or low dose (below 85%); and the high-gradient voxels were
categorized into avoidance gradients (above 30% cm−1 ) or incidental gradients (15% cm−1 –
30% cm−1 ). The choice for the high-low-dose threshold will be treatment specific and can
be found by analysing differential dose-volume histograms of each target structure and the
entire treatment volume. Avoidance gradients are typically associated with target/region-at-
risk (RAR) boundaries, and incidental gradients are found at target/normal tissue borders. This
division resulted in four regions. The tolerances for high dose, low dose, avoidance gradients
and incidental gradients were 3%, 3%, 3 mm and 3 mm respectively, although different values
could be used.
One final criterion was applied in using this method. For a full comparison of two dose
distributions, all voxels were considered. Such was the case for the comparison between
the optimized, film and reconstructed distributions since we hoped to evaluate as a whole how
accurate the dose reconstruction was (section 4.2). However, for actual treatments an outcome-
based approach can be taken in which overdosed tumour voxels and underdosed non-tumour
voxels are not considered to be erroneous. This was done for the studies of delivery errors
(sections 4.3 and 4.4) as such voxels were assigned an error value of zero.
4. Results and discussion
4.1. Energy fluence verification and analysis

The planned energy fluence sinogram and the verification sinogram computed using
equation (3) are shown for the breast treatment in figures 3(a) and (b), respectively. The
greyscale used mimics that for film as black implies high intensity (large energy fluence
value) and white implies low intensity (small energy fluence value). The absolute value of
the difference of these sinograms, normalized to the mean planned energy fluence value, is
shown in figure 3(c). Qualitatively, the sinograms appear very similar and the differences very
small. This agreement is confirmed quantitatively in figure 3(d), which is a histogram of the
energy fluence difference values computed with 1% bins on integer intervals. The majority of
Figure 3. (a)–(c) Energy fluence sinograms for the breast treatment. (a) Planned sinogram.
(b) Verification sinogram. (c) Magnitude of the difference sinogram, found by taking the absolute
value of the subtraction of (a) and (b) and then normalizing to the mean of the non-zero planned
energy fluence values (a). (d) Histogram of the difference values found in (c). The sinograms are
indeed very similar, as the large majority of leaves have differences within ±2%.
errors lie in the −0.5% to +0.5% bin. In fact, over 84% of the leaves had energy fluence errors
between −2% and +2%.
Further sinogram analysis illustrates how some error correlates with planned energy
fluence. Close inspection of the difference sinogram shows that there is a small, systematic
negative energy fluence error throughout the treatment (repetitive white streaks in (c)). Cross-
referencing these areas with the planned sinogram in (a) reveals that this error occurred in
areas of low energy fluence (20% or lower). This is caused by leaf latency as discussed in
section 3.2. When a leaf is required to be opened for 100 ms or less, the leaf may be opened
for a portion of the designated time or it may never open at all, leading to a lack of delivered
photons.
4.2. Comparison with measured 3D film dose distribution

Dose was computed using the optimized and verification sinograms and is shown in figure 4.
Dose was also measured with film as detailed in section 3.4.3. The 30% (solid), 50% (dash-
dot-dot), and 90% (dash) isodose lines for the optimized (black), reconstructed (white), and
measured film (grey) distributions are displayed in figure 4(a) for slice 16. The optimized
and measured film distributions were normalized to their respective averages of the dose in
Figure 4. (a) Slice 16 isodose lines for the planned (black), reconstructed (white), and film (grey)
dose distributions superimposed on the CT image. The agreement between the three distributions is
quite good. (b) Dose volume histogram (DVH) for the three distributions, establishing concurrence
for the entire volume.
the tumour region. The reconstructed dose was normalized to the average of the optimized
distribution. Similar to energy fluence analysis, the agreement is quite good. A dose-volume
histogram (DVH) is given in figure 4(b). The curves for the optimized and reconstructed
distributions are almost indistinguishable as most of the symbols lie on top of one another.
The film agrees quite well with both distributions for all structures. This pattern of agreement
was consistent for all other slices of the distributions.
The IMRT dose distribution comparison method described in section 3.6 is employed in
figure 5. Voxel classifications are shown in figure 5(a) for slice 16 of the reconstructed dose
distribution. High-dose voxels are shown in black, low dose in white, avoidance gradients
in light grey, and incidental gradients in dark grey. The gradients tend to conform to the
outer boundary of the tumour, surrounding the high-dose voxels of the tumour region. For
each voxel, ξ values were computed using equation (4). The measured film and reconstructed
distributions were compared with the optimized distribution to create these results. Contour
ξ maps comparing slice 16 of the optimized distribution with that from the reconstructed
and film distributions are displayed in figures 5(b) and (c), respectively. A ξ value of 1.0
implies that a voxel is just at tolerance; a value of 2.0 implies that the voxel is two times larger
than tolerance, and so on. The tolerances for high dose, low dose, avoidance gradients and
incidental gradients were 3%, 3%, 3 mm and 3 mm respectively. The film ξ map is redisplayed
in figure 5(d) with an overlay of the positions of the measured films used to create the axial
dose distribution.
The reconstructed ξ map (figure 5(b)) shows that all values are below 1, indicating that the
optimized and reconstructed distributions agree very well. The film ξ map (figure 5(c)) shows
that the errors are small for the majority of the slice. The tumour region has few large errors
with the exception of the build-up region at the right interface. This area was underdosed in
the film distribution. The cause of this was a loss of electronic equilibrium at the edge of the
film due to a 2 mm indentation of the phantom wall at the edge (machining error). Thus, even
though the dose code does not include electron contamination (which in principle should cause
Figure 5. (a) Slice 16 voxel classification image for the reconstructed distributions. High dose,
low gradient voxels (<15% cm−1 , >85% normalized dose) are in black; low dose, low gradient
voxels (<15% cm−1 , <85% normalized dose) are in grey; incidental gradient voxels (>15% cm−1 ,
<30% cm−1 ) are in dark grey; and avoidance gradients (>30% cm−1 ) are in light grey. (b) Contour
map of ξ values comparing the planned and reconstructed dose distributions. (c) Contour map of
ξ values comparing the planned and film dose distributions. (d) Same as (c), but with lines added
marking the positions of the measured films. Large ξ values (implying large error) either lie between
the wedge-shaped region between two films, or within a high gradient region. These errors are
primarily caused by uncertainty in film placement (±1◦ ).
the film dose to be higher than the planned dose at the edge), the loss of electronic equilibrium
was significant enough to make the film dose lower.
The reason for the remainder of the large error in the film distribution is caused by
uncertainty in the exact position of the individual films (section 3.4). The magnitude of the
resulting error will depend upon the angular discrepancy and the region in the dose distribution
(high or low gradient). An incorrectly positioned film will lead to errors in all interpolated
values on either side of the film. The dose code is not a likely cause of the large errors
as computational inaccuracies would have led to a systematic error in the entire planned
distribution. Rather, figures 5(c) and (d) illustrate that most of the large error regions fit inside
the wedged-shaped area between two measured film positions. Regarding the patch of large
Table 1. Average ξ values with standard deviation values in parentheses comparing the planned
with the measured film and reconstructed dose distributions. An average ξ value of 1.0 or less
implies that the voxels are within tolerance on average.
Comparison
Film versus Reconstructed

Region planned versus planned
Tumour 0.82 (0.78) 0.06 (0.05)
Lung 0.82 (0.50) 0.20 (0.16)
Spinal cord 0.49 (0.23) 0.23 (0.12)
error just outside the left border of the tumour region, this was a high dose gradient region.
Even though extra films were taken to sample the region more accurately, the stated uncertainty
in the film’s angular position of ±1◦ (section 3.4.3) can easily lead to difficulty in accurately
characterizing this region of rapidly changing dose.
The average and standard deviation of the ξ values are given in table 1. It should be noted
that the average ξ values for all structures are below 1 (implying within tolerance) for both the
film and reconstructed comparisons. Though a good indicator, this does not necessarily mean
that the treatment is correct. It is possible that there may be a few voxels with very large error
and that these will not affect the average or standard deviation of the ξ values in a significant
manner. The contour ξ maps become important for such a case.
Finally, region-by-region histograms of the D or DTA values are shown for the
reconstructed distribution (figures 6(a) and (b)) and film distribution (figures 6(c) and (d)).
These histograms provide the positivity or negativity of the error, which is lacking in ξ . The
sharpness of the reconstructed histograms again validates the agreement of this dose distribution
with the optimized dose distribution. Likewise for the film dose, though the histograms are
broader, the concurrence as a whole is good. Thus, since the reconstructed and film dose
distributions both agree with the optimized distribution, this implies that dose reconstructed
using the method of this paper is an accurate indicator of the dose that was deposited during
this treatment.
4.3. Detecting positional error

4.3.1. Shift of 2 mm. The sinogram of difference values between the optimized (figure 3(a))
and verification sinograms for the treatment in which the breast phantom was shifted 2 mm (not
shown) is provided in figure 7(a). There do not appear to be any large errors in the sinogram
and the histogram of difference values (not shown) supported this as it was very similar to
figure 3(d). However, a systematic error, albeit small, appears to be present in the sinogram. A
pattern of lighter pixels on the top of the sinogram and darker pixels on the bottom (implying
slightly larger energy fluence errors) repeats itself throughout the delivery.
To examine the effects on dose, reconstruction was performed using a verification sinogram
from a D matrix that was measured with the phantom shifted 2 mm (not shown). This resulted
in a verification sinogram similar to that of figure 3(b). Dose was then computed using a CT
that simulated the 2 mm shifted position. The resulting dose distribution was then shifted
back to allow for comparison with the optimized dose. The effects on the dose are shown in
figures 7(b)–(d). Almost all ξ values are below 1 (figure 7(b)), and the DVH (figure 7(c)) lines
show very little difference with respect to the optimized DVH lines. The tumour and lung
curves appear to be shifted very slightly inward from the optimized lines for larger fractions
Figure 6. Error histograms by voxel classification for the tumour and lung dose volumes comparing
the planned with the reconstructed ((a) and (b)) and film ((c) and (d)) dose distributions.
Table 2. Average ξ values with standard deviation values in parentheses for the breast treatment
in which the thorax phantom was shifted 2 mm. An average ξ value of 1.0 or less implies that the
voxels are within tolerance on average.
Reconstructed versus
Region planned
Tumour 0.29 (0.25)
Near lung 0.42 (0.24)
Spinal cord 0.26 (0.23)
Far lung 0.07 (0.12)
Contra. Breast 0.14 (0.59)
of volume. The largest differences are seen in the tumour voxel histogram, which is not as
sharply peaked as that produced from the reference position dose distribution (figure 6(a)).
Even though the treatment is acceptable (table 2), the fact that some error is elucidated for
shifts as small as 2 mm is an indicator of the sensitivity of these validation processes.
Figure 7. Results for the breast treatment in which the thorax phantom was shifted 2 mm. (a)
Energy fluence difference sinogram. (b) Contour map of ξ values. (c) DVH. (d) Error histogram
by voxel classification for the entire tumour volume. The overall effect of the 2 mm shift on energy
fluence and dose is minimal, but discrepancies are present, as systematic error is seen in (a) that
was not present in the non-shifted results (figure 3(c)), and the tumour error histogram is not as
sharply peaked when compared to the non-shifted delivery (figure 6(a)).
4.3.2. Rotation of 2◦ . The same series of figures as those used for analysing the 2 mm
shifted results are displayed for the 2◦ rotated breast phantom in figure 8. Similar observations
apply, but the differences are slightly greater. The fact that the overall errors are larger is not
surprising. Using geometrical arguments, it can be shown that voxels along the edge of the
phantom that were most distal from the point of rotation were shifted by nearly 4 mm. Thus
the error would be expected to be larger than the 2 mm shifted case far from the rotational
centre. The average ξ values are still one standard deviation within tolerance (table 3). Thus
the dose distribution is still acceptable in spite of the rotation. This also confirms that latency
has little effect on the overall dose distribution since leaf latency of 100 ms may result in a
rotational shift in the delivered energy fluence of at most 2◦ .
4.3.3. Shift of 5 mm. This case resulted in the largest errors in both energy fluence and dose
for the cases studied. For the fluence results, attention should be directed to the systematic
pattern of black and white pixels on the edges of the sinogram throughout the entire delivery.
This is the error that resulted from the 5 mm shift and is similar but larger that that seen for
the 2 mm shifted case. The contour map of ξ (figure 9(b)) illustrates that the error is larger
than the other cases and is spatially concentrated on the tumour boundaries. The effect on
Figure 8. Results for the breast treatment in which the thorax phantom was rotated 2◦ . (a) Energy
fluence difference sinogram. (b) Contour map of ξ values. (c) DVH. (d) Error histogram by voxel
classification for the tumour region. The overall effect of the 2◦ rotation on energy fluence and dose
is still small, but the discrepancies are beginning to increase in magnitude and are more noticeable
in every figure. Most importantly, the number of underdosed tumour voxels is increasing as seen
in (b) and (d).
Table 3. Average ξ values with standard deviation values in parentheses for the breast treatment in
which the thorax phantom was rotated 2◦ . An average ξ value of 1.0 or less implies that the voxels
are within tolerance on average.
Region planned
Tumour 0.43 (0.41)
Near lung 0.52 (0.22)
Far lung 0.16 (0.14)
dose is seen in the DVH (figure 9(c)) as the reconstructed tumour curve is shifted noticeably
inward. The tumour error histogram (figure 9(d)) is broader and smaller-peaked than both of
the previous cases. Finally, the average ξ values are still below 1 (table 4), but the value is the
closest to 1 of the patient offset cases.
Since errors of this magnitude may warrant remediation, a comment regarding adaptive
radiotherapy will be offered. For this case, adapting the treatment would certainly be possible
Figure 9. Results for the breast treatment in which the thorax phantom was shifted 5 mm. (a) Energy
fluence difference sinogram. (b) Contour map of ξ values. (c) DVH. (d) Error histogram by voxel
classification for the entire tumour volume. The overall effect of the 5 mm shift on energy fluence
and dose is the greatest of the positioning cases presented. The portion of underdosed tumour has
increased (c) and these voxels are along the left border of the tumour, as seen best in (b). This is
a very good example of how dose reconstruction could provide a means to correct such errors, as
effective adaptive radiotherapy could increase dose to this area over the subsequent fraction(s).
in which the thorax phantom was shifted 5 mm. An average ξ value of 1.0 or less implies that the
voxels are within tolerance on average.
Region planned
Tumour 0.62 (0.62)
Near lung 0.70 (0.62)
Far lung 0.17 (0.12)
since, as the ξ map depicts, the areas of the large error do not lie in any RAR, thus the dose
to any of these regions need not be altered. The dose to the tumour can be slightly raised by
irradiating more normal tissue.
Figure 10. Results for a simulated 10% decrease in accelerator output during the breast treatment.
(a) Energy fluence difference sinogram. (b) Contour map of ξ values. (c) DVH. (d) Error histogram
by voxel classification for the entire tumour volume. The tumour is significantly underdosed.
4.4. Detecting delivery errors
4.4.1. Detecting accelerator error. The effects of the 10% linear decrease in accelerator
output are shown in figure 10. The impact on both the energy fluence and dose is clearly seen.
The fluence values grow more and more negative (grey to white) as the treatment progresses.
The contour ξ map for slice 23 (figure 10(b)) shows that by the end of the treatment there are
large discrepancies between the planned and reconstructed dose values for the entire tumour
region. The dose-volume histogram (DVH) for this simulation (figure 10(c)) illustrates how
the reconstructed tumour line is shifted significantly inward from the planned line, while for
the other ROIs the shift is minimal. Thus, the effect appears to be concentrated in the area
prescribed the most dose: the tumour ROI. The histogram of tumour error (figure 10(d))
displays how the high-dose voxels are shifted in the negative direction, centred on −6%. The
averages and standard deviations of the ξ values for this case are shown in table 5. Note that
all values are within tolerance (ξ 1) with the exception of the tumour.
Similar to the 5 mm case, it may be desirable to remediate errors of this magnitude. For
this case, the chances for adaptive radiotherapy are quite good. The dosimetric error could be
corrected by boosting the tumour dose in the subsequent fraction(s). To maintain the RARs at
their existing levels, some of the normal tissue dose will have to increase. Thus the adapted
DVH would probably possess lines for the tumour and ‘other regions’ that are shifted to the right
of the corresponding optimized lines in figure 10(c), while the RAR lines could remain the same.
Figure 11. Results for the breast treatment in which the leaf 13 became stuck in the open position.
(a) Verification sinogram. (b) Contour map of ξ values. (c) Slice 16 greyscale dose image. Notice
the ring of high dose caused by the leaf. (d) DVH. The overall effect of the stuck leaf is clear as
much of the near lung and normal tissue is overdosed well above tolerance.
in which an accelerator decrease of 10% was simulated. An average ξ value of 1.0 or less implies
that the voxels are within tolerance on average.
Region planned
Tumour 1.35 (0.34)
Near lung 0.65 (0.23)
Far lung 0.35 (0.12)
4.4.2. Stuck leaves. In figure 11(a), the verification sinogram is shown for a breast treatment
in which leaf number 6 and (especially) 13 became fixed in the opened position. Since the
colour black refers to a leaf emitting a maximal amount of energy fluence, the dark strip parallel
to the long axis of the figure in the verification sinogram implies that leaf 13 was fixed in the
opened position for most of the treatment. The radiation delivery verification method clearly
records the leaf becoming stuck open. Although such an event should not occur in a clinical
situation with MIMiC’s verification system connected, it is advantageous to have a separate,
independent check of the leaves that this technique provides.
in which a leaf became stuck opened. An average ξ value of 1.0 or less implies that the voxels are
within tolerance on average.
Region planned
Tumour 0.07 (0.34)
Near lung 2.20 (2.76)
Far lung 0.51 (0.62)
With the effects on the energy fluence known, it was now possible to investigate the impact
of this leaf on the dose (figures 11(b)–(d)). The contour map of ξ illustrates a large area of
voxels with large error throughout the lung and normal tissue. The areas of large error appear
as rays emanating from the isocentre since the dose code computes dose from a finite number
of projections (sections 3.2 and 3.4.2). As expected, the ξ values inside the tumour are very
low since overdosed tumour voxels are not considered to be erroneous. The greyscale dose
image displays the ring of high dose very nicely (figure 11(c)). Finally, all DVH lines for
the reconstructed distribution, especially those for the tumour and the near lung, are shifted
outward with respect to the optimized lines (figure 11(d)). The average ξ values (table 6)
dictate that voxels in the tumour, near lung and spinal cord are all above tolerance. Moreover,
the standard deviations of the far lung and contralateral breast indicate that many voxels in
these regions were outside tolerance. The treatment is obviously unacceptable.
For this case, the chances for adaptive radiotherapy need to be studied further. The
dosimetric error in the RARs would have to be corrected by decreasing the intensity of beams
that pass through these regions. However, in doing so the tumour dose may suffer and it is
unclear if the over-dosage as seen in figure 11(c) would exactly compensate for the probable
underdosage brought on by the adapted delivery. Studies into the possible reoptimization
strategies to remediate such cases need to be investigated.
5. Conclusion
Techniques for verifying the energy fluence delivered and the dose deposited for a simulated
breast treatment on a thorax phantom have been presented. Energy fluence sinograms,
difference sinograms, and histograms of difference values were utilized to compare the planned
and verified energy fluence. A conventional mode of comparing dose distributions is employed
(dose-volume histograms), and new approaches to IMRT dose distribution comparison are
also used such as contour maps of ξ (where ξ is defined as the absolute value of the dose
difference for low-gradient or distance to agreement for high-gradient voxels, divided by their
respective tolerance value), average and standard deviation of ξ values and region-by-region
error histograms. It was found that the reconstructed dose distribution for the treatment in
the reference position agreed very well with the optimized distribution (tumour ξavg = 0.06,
σξ = 0.05; near lung ξavg = 0.20, σξ = 0.16). Furthermore, since the optimized and measured
film distributions agreed (tumour ξavg = 0.82, σξ = 0.78; near lung ξavg = 0.82, σξ = 0.50),
the reconstruction process accurately described the three-dimensional dose delivered during
the breast treatment.
The usefulness of the processes was demonstrated for positional and delivery errors.
Inaccuracies were often discovered in the verified energy fluence, and were always revealed
in the reconstructed dose. For positioning errors, it was found that 2 mm shifts (expected
tomotherapy set-up precision) and 2◦ rotation (maximal offset caused by leaf latency) resulted
in insignificant effects on the dose delivered (tumour ξavg = 0.29, σξ = 0.25; tumour
ξavg = 0.43, σξ = 0.41 respectively). Errors caused by a 5 mm shift were found to be within
tolerance on average (tumour ξavg = 0.62) but some tumour voxels were outside of tolerance
(tumour σξ = 0.62), implying an underdosage. Regarding accelerator output variations, a
simulated 10% decrease in output resulted in a loss of energy fluence and subsequently an
underdosed tumour region (ξavg = 1.35, σξ = 0.34). Lastly, dosimetric issues were raised
when a leaf fixed in the opened position produced a significant over-dosage in the regions at
risk (RARs) (near lung ξavg = 2.20, σξ = 2.76; spinal cord ξavg = 1.17, σξ = 1.43).
An important clinical issue that is not addressed in this paper but which is common
to all IMRT techniques that junction fields within a target is that of intrafraction motion (e.g.
breathing). Such motion may cause errors in delivery verification if there is a significant change
in the expected radiological pathlength for a given leaf (Kapatoes et al 2000b). Similarly,
problems would occur with the reconstructed dose since the dose is computed on a static CT
image of the patient. Problems can be avoided by gating the treatment so that the anatomy upon
which the fluence is verified and the dose computed is consistent with that during the treatment.
The fact that the delivery verification and/or dose reconstruction processes readily revealed
errors illustrates the clinical value of these processes. Moreover, delivery verification in its
current state can be done in real-time, and with a fast enough dose computation engine, the
same applies for dose reconstruction. At a minimum, as a post-processing technique it may
be feasible to adapt the subsequent fraction(s) to account for dosimetric errors. The processes
thus give the physicist and oncologist confidence in the treatment unit by confirming that the
deposited dose agrees with the planned dose, and in cases where it does not, allowing for
the possibility of remediation. Such an approach to radiotherapy will improve the quality of
treatments and, ultimately, treatment outcomes.
Acknowledgments
The authors would like to thank K J Ruchala for the MVCT image in figure 1. JMK would like
to thank E A Schloesser and D W Pearson for their efforts with and upkeep of the tomotherapy
benchtop throughout these measurements. JMK and TRM are grateful for the support of the
NCI-sponsored, University of Wisconsin Radiological Sciences grant T32-CA09206, and NIH
grant CA 48902.
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On The Accuracy and Effectiveness of Dose Reconstruction For Tomotherapy

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On the accuracy and effectiveness of dose reconstruction for tomotherapy

2001 Phys. Med. Biol. 46 943

Please note that terms and conditions apply.

On the accuracy and effectiveness of dose

Received 14 August 2000, in final form 12 December 2000

0031-9155/01/040943+24$30.00 © 2001 IOP Publishing Ltd Printed in the UK 943

2.1. Radiation delivery verification

2.2. Dose reconstruction

used to compute dose is convolution/superposition (C/S), although any model-based algorithm

3. Materials and methods

3.2. Delivery implementation

3.3. Tomotherapy workbench

3.4. Simulated breast treatment

3.5. Issues investigated

3.6. Quantitative tools for analysis of energy fluence and dose

4. Results and discussion

4.1. Energy fluence verification and analysis

4.2. Comparison with measured 3D film dose distribution

Film versus Reconstructed

4.3. Detecting positional error

4.4. Detecting delivery errors

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