8/17/2011
Implementation and Quality Assurance
Considerations for Volumetric Modulated
Arc Therapy (VMAT)*
Report of writing group from TETAWG under Therapy
Physics Committee (TPC) of AAPM
Writing Group members:
James M. Galvin, Q. Jackie Wu, David M. Shepard,
Richard A. Popple, Ying Xiao, Fang-Fang Yin
*This report is currently under review for publication
Potential Advantages of
Volumetric Modulated Arc Therapy
(VMAT)
VMAT is faster?
VMAT produces higher quality plans??
VMAT uses fewer monitor units resulting in a lower
patient total body dose??
What is
Volumetric Modulated Arc Therapy
(VMAT)?
• Volumetric modulated arc therapy (VMAT) is an arc-
based dose delivery approach that produces highly
conformal dose distributions similar to those generated
with static gantry intensity modulated radiation therapy
(SG-IMRT)
Potential Advantages of
Volumetric Modulated Arc Therapy
(VMAT)
VMAT is faster?
• Has conventional IMRT been optimized to reduce
treatment delivery time?
• Does a limited field size increase the time for
conventional IMRT?
• How does the quality of the treatment plan determine
the treatment time comparison?
1
 8/17/2011

Potential Advantages of Potential Advantages of

Volumetric Modulated Arc Therapy Volumetric Modulated Arc Therapy
(VMAT) (VMAT)
VMAT uses fewer monitor units resulting in a lower
VMAT produces higher quality plans?? patient total body dose??
• When is better best? A multiobjective perspective Mark • Monitor units go up when small field size MLC
H. Phillips and Clay Holdsworth Med Phys 38, 1635 (2011) require split fields
• Rotating the field for VMAT increases available field
size

Volumetric Modulated Arc Therapy

Volumetric Modulated Arc Therapy
(VMAT)
(VMAT)
• Due to the necessary synchronization of both dose
rate and gantry motion with MLC movement, it is
• During arc beam delivery the dose rate, the speed of the clear that VMAT involves new and different QA
gantry, and the position of the MLC leaves can be varied steps relative to SG-IMRT
dynamically
• It is for this reason that the Therapy Emerging
Technology Assessment Working Group
(TETAWG) of the Therapy Physics Committee
initiated a report on VMAT

2

Volumetric Modulated Arc Therapy
(VMAT)
• This report includes information for Acceptance
Testing, Commissioning, and Routine QA for
VMAT
• The Routine QA description includes a
recommendation for patient-specific QA
measurements
Implementation
• The TETAWG report follows the two-step procedure suggested in
the publication by Ezzell, G. A., Galvin, J. M. et al. (2003)
"Guidance document on delivery, treatment planning, and clinical
implementation of IMRT: report of the IMRT Subcommittee of the
AAPM Radiation Therapy Committee." Med Phys 30(8) pp 2089-
115:
(1) a group of tests that evaluate the performance of individual
components of the overall delivery system; and
(2) tests that evaluate the end result of the IMRT (in this case
VMAT) dose delivery.
8/17/2011
Implementation
• The VMAT Report uses information from two early reports:
– Bedford and Warrington, "Commissioning of volumetric
modulated arc therapy,” Int J Radiat Oncol Biol Phys. 73, 537-45
(2009)
– Ling, Zhang, Archambault, Bocanek, Tang, and Losasso,
"Commissioning and quality assurance of RapidArc radiotherapy
delivery system," Int J Radiat Oncol Biol Phys. 72, 575-81 (2008)
• These reports touch on the different aspects mentioned in the
last slide with varying emphasis
• The aim of the TETAWG report is to provide needed details for
overall safe use of this new technology
Implementation
The TETAWG report deals with Acceptance Testing, Commissioning and
Routine QA for MAT. This report separates, as recommended in the
Ezzell paper, the testing into the components listed below
•Specific Component QA
– Follows TG142 as much as possible
– Describes the testing procedures
•End-to-end testing
– Includes recommendations for benchmark end-to-end testing
– Includes recommendations for patient-specific QA measurements
3
 8/17/2011

Table 1 – Testing Procedures for VMAT

Description Purpose of Test Test Tolerance Frequency
Implementation
Isocenter stability, through
MLC component-
specific tests
and between leaf
leakage
See TG 142 See TG 142 See TG 142
Specific Tests:
Dynamic dose Absolute dose accuracy for ±4% relative to static abutted field
Sliding window dose test Com
calibration test dynamic delivery irradiation

MLC calibration with

dynamic prescription
Slide-and-shoot field abutment test AT, Com, Annual • Field flatness and symmetry at all cardinal angles for range of
±5% from baseline beam profile and
MLC calibration with
Asynchronous sliding window field abutment tests/four
±1mm from average line and for
the gantry zero position
dose rates (from lowest to highest available for VMAT).
VMAT component-
specific tests
moving window
prescription
cardinal gantry angles, various dose rates
AT, Com, Monthly
This test with the same tolerance level given below is listed
Beam profile stability as
Field flatness/symmetry various gantry angles (four
cardinal angles) and dose rates (including highest
±1% relative to baseline (defined relative
to profile at gantry zero position AT, Com, Annual
in the AAPM TG 142 report. However, TG 142 does not
function of dose rate
and lowest used for VMAT)2 and standard dose rate) include the requirement to perform the testing for the range
VMAT rotational
accuracy test
Test of VMAT component
synchronization with Rotational Accuracy Test ±10% local dose at periphery AT, Com, Monthly of dose rates that will be used for VMAT delivery. It is
gantry rotation
important to point out here that the tolerance limits are in
End-to-end data Data transfer among various 95% of points in agreement to 3% and 3
transfer check systems
Benchmark end-to-end test including dose measurement
mm
AT, Com, Monthly
addition to the deviations allowed in TG 142.
Interruption test
Ability to resume treatment
after interuption of Interrupt delivery in middle and restart
98% of points in agreement to 2% and 2
mm compared to uninterrupted test
AT, Com,
Annual
• Tolerance: ±1% from reference gantry zero dose profile for
beam on

End-to-end patient- Verify each patient’s Apply patient’s plan to generic phantom with ion Before start of all
standard dose rate.
95% points in agreement to 5% and 5 mm
specific check treatment chamber and film new plans

Note: This information is intended as an example only! Values can change during review of this report.

Volumetric Modulated Arc Therapy

Implementation (VMAT)
F o ll o w in g
Figure shows the leaf trajectories
Specific Tests: for each leaf pair for the
lea f
tra jec to ry
L ead in g
asynchronous leaf position test. lea f

• Perform the asynchronous sliding window. (See the leaf Notice that the leaves hold at tra jec to ry

positions that are separated by 2.0

trajectories of this test in nest slide.) The asynchronous sliding cm. The entire irradiation is
window test should be performed at four different cardinal carried out with the beam on at a
gantry angles to test effect of gravity on MLC movement. This constant dose rate. The dashed
prescription is designed to mimic the complex MLC movement line shows that the time each T im e

used for VMAT delivery, but does not include the gantry point in a detector (usually film)
motion. The tolerance values are extracted from both TG 142 sees the unobstructed beam is
(the ±1 value) and the Bedford et al reference (the ±5% intensity
constant throughout the irradiation
process. However, the holding of
change). the leaf positions at positions that
• Tolerance: ±5% intensity change relative to gantry zero baseline are spaced by 2.0 cm tests the
profile and ±1 mm from average abutment line for gantry zero ability of the leading and following
leaves to stop at the exact same
position. place.
L ea f P o sitio n (c m )

4
 8/17/2011

Implementation
Specific Tests:

• Perform the rotational accuracy test described in

section 4.3. See also the leaf trajectories for this
test in Figure 2. This test is designed to guarantee
synchrony of all (including gantry movement)
dynamically varying parameters during VMAT
delivery.
• Tolerances: ±10% local dose at periphery
(c) Sliding window prescription with leaf pauses, dose profile
parallel to the direction of leaf motion. (Copied from Bedford, JL and Warrington, AP Int. J. Radiation
Oncology Biol. Phys., Vol. 73, No. 2, pp. 537–545, 2009)

Volumetric Modulated Arc Therapy

(VMAT)
Figure illustrates the
irradiation of a trans-
axially placed film with
a rectangular field that
tracks the center axis of
the cylinder as the
gantry rotates. The
rotational isocenter is
placed near the
periphery of the
phantom so that
the aperture must sweep
from side-to-side as the Fig. 3. Rotation tests on the Beam Modulator unit. (a) Radial dose profile,
VMAT delivery normalized to the center. (Copied from Bedford, JL and Warrington, AP Int. J. Radiation Oncology Biol.
proceeds. Phys., Vol. 73, No. 2, pp. 537–545, 2009)

5
 8/17/2011

Implementation
There are other ways for performing this test!

• The TETAWG report highlights this method

because it does not depend on the availability
of log files to verify synchronization
• The reference from Ling et al given in an
earlier slide describes an slternative approach
for this testing
Fig. 3.The line of interest lies at 6 cm from the center. (b) A 640 MU symmetric
(central axis) prescription. (c) 640 MU asymmetric (off-axis) prescription. Isodoses
are normalized to approximately 6 cm off-axis and are in intervals of 4%. (Copied from
Bedford, JL and Warrington, AP Int. J. Radiation Oncology Biol. Phys., Vol. 73, No. 2, pp. 537–545, 2009)

Implementation Implementation
There are other ways for performing this test!
Specific Tests:
• There are many devices available for this
type of testing for VMAT • End-to-end test for benchmark cases
• These devices will not necessarily give you
(AAPM Task Group 119)
the same information • Tolerance: 95% of points in agreement
• They must provide equivalent information to 4% and 4 mm

6
 8/17/2011

Implementation Implementation
Specific Tests:
Specific Tests:
• Treatment interruption test. Use benchmark end-to-end test
• Perform patient-specific end-to-end QA that includes measurement of dose distribution and absolute
dose at a point. Interrupt beam in middle of delivery and
measurements prior to the start of treatment and for continue treatment to completion. The tolerance levels set
any plan change for this test are for comparison to test results for the same
prescription when an interruption was not introduced. Thus,
• Tolerance: 95% points in agreement to 5% and 5 the overall deviation from the calculated dose distribution is
mm on the order of 6% and 6 mm.
• Tolerance: 98% of points in agreement to 2% and 2 mm
compare with reference uninterrupted delivery

Table 1 – Testing Procedures for VMAT

Description Purpose of Test Test Tolerance Frequency
Conclusions
Isocenter stability, through
MLC component-
and between leaf See TG 142 See TG 142 See TG 142
specific tests
leakage

Dynamic dose
calibration test
Absolute dose accuracy for
dynamic delivery
Sliding window dose test
±4% relative to static abutted field
irradiation
Com • The synchronization of subsystems and beam
MLC calibration with
dynamic prescription
Slide-and-shoot field abutment test
±5% from baseline beam profile and
AT, Com, Annual parameters during VMAT delivery requires extra
VMAT component-
MLC calibration with
moving window
Asynchronous sliding window field abutment tests/four
±1mm from average line and for
the gantry zero position
AT, Com, Monthly
QA steps and procedures relative to standard IMRT
cardinal gantry angles, various dose rates
specific tests prescription

Field flatness/symmetry various gantry angles (four ±1% relative to baseline (defined relative
dose delivery
Beam profile stability as
function of dose rate
cardinal angles) and dose rates (including highest
and lowest used for VMAT)2
to profile at gantry zero position
and standard dose rate)
AT, Com, Annual
• The TETAWG report on VMAT Acceptance
VMAT rotational
accuracy test
Test of VMAT component
synchronization with
gantry rotation
Rotational Accuracy Test ±10% local dose at periphery AT, Com, Monthly Testing, Commissioning and Routine QA describes
End-to-end data Data transfer among various
Benchmark end-to-end test including dose measurement
95% of points in agreement to 3% and 3
AT, Com, Monthly
the additional tests needed for this new treatment
transfer check systems mm

Ability to resume treatment

modality
98% of points in agreement to 2% and 2 AT, Com,
Interruption test after interuption of Interrupt delivery in middle and restart
mm compared to uninterrupted test Annual
beam on

End-to-end patient- Verify each patient’s Apply patient’s plan to generic phantom with ion Before start of all
95% points in agreement to 5% and 5 mm
specific check treatment chamber and film new plans

Note: This information is intended as an example only! Values can change during review of this report.

7
 8/17/2011

Thank You