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

VARIAN Medical Systems

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
VARIAN Medical Systems

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

VARIAN Medical Systems

Radiographic Mode

VARIAN Medical Systems

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

VARIAN Medical Systems

Sample images

Images courtesy of Karolinska Institute

VARIAN Medical Systems

Kilovoltage Radiographs

VARIAN Medical Systems

Cone-Beam CT

VARIAN Medical Systems

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
VARIAN Medical Systems

Clinical Results Hirslanden Klinik, Aarau

CT

CBCT

VARIAN Medical Systems

Clinical Results Emory

CBCT

CBCT

VARIAN Medical Systems

CT Simulator

Intrafraction motion

VARIAN Medical Systems

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

VARIAN Medical Systems

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

VARIAN Medical Systems

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

VARIAN Medical Systems

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

VARIAN Medical Systems

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

VARIAN Medical Systems

IGRT QA Safety

Daily checks

kV source door interlock

Warning lights and audio warning for kV beam

Motion enable from OBI control console

VARIAN Medical Systems

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
VARIAN Medical Systems

10

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

VARIAN Medical Systems

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

VARIAN Medical Systems

11

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

VARIAN Medical Systems

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

VARIAN Medical Systems

Adapted from Rabih Hammoud

12

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
VARIAN Medical Systems

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)
VARIAN Medical Systems

Adapted from Rabih Hammoud

13

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
VARIAN Medical Systems

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

VARIAN Medical Systems

Adapted from Rabih Hammoud

14

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)

VARIAN Medical Systems

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

VARIAN Medical Systems

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

15

IGRT QA Monthly Checks

Safety

OBI laser crosshair

Arms isocentric calibration

Arm run out

Blades calibration

Couch motion

Linear

Rotation

VARIAN Medical Systems

IGRT QA Safety

Emergency off (part of Clinac QA)

Backup motion controller

VARIAN Medical Systems

16

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

VARIAN Medical Systems

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

VARIAN Medical Systems

17

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

VARIAN Medical Systems

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

VARIAN Medical Systems

18

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

VARIAN Medical Systems

IGRT QA Monthly Checks

Isocenter alignment of MV and kV beam

MV Image Quality

kV Image quality

Shift calculation

Measurement tools

VARIAN Medical Systems

19

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

VARIAN Medical Systems

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

VARIAN Medical Systems

Blade Calibration
Plate

Marker phantom

Courtesy of Dr. Sua Yoo, Duke University

20

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

VARIAN Medical Systems

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

VARIAN Medical Systems

Courtesy of Dr. Sua Yoo, Duke University

21

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

VARIAN Medical Systems

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

VARIAN Medical Systems

22

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

VARIAN Medical Systems

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

VARIAN Medical Systems

23

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

VARIAN Medical Systems

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

VARIAN Medical Systems

Courtesy of Dr. Sua Yoo, Duke University

24

Measurement tools

Measurement of

Distance

Area

Angle

VARIAN Medical Systems

IGRT QA Annual Checks

Annual checks

kV beam output parameters

kV, mA, exposure time

HVL

Automatic Brightness Control (ABC) for fluoroscopy

VARIAN Medical Systems

25

IGRT QA CBCT Tests

Daily checks

Geometry

HU calibration spot check

Annually (Monthly)

Uniformity

Contrast

Resolution

HU calibration

VARIAN Medical Systems

CBCT Daily Check

Position CATPHAN on the table

Acquire CBCT

Verify geometry

Verify HU

VARIAN Medical Systems

26

CBCT Annual test

Position Norm Phantom on the table

Acquire CBCT

Measure profile and verify uniformity of HU

VARIAN Medical Systems

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

VARIAN Medical Systems

Full-fan

Half-fan

Courtesy of Dr. Sua Yoo, Duke University

27

Contrast

Performance
0.5 %

VARIAN Medical Systems

Resolution

Performance
10 lp/cm

VARIAN Medical Systems

28

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

VARIAN Medical Systems

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

VARIAN Medical Systems

29

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

VARIAN Medical Systems

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

VARIAN Medical Systems

30

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

VARIAN Medical Systems

QA Tools delivered with OBI and CBCT

Cone Beam CT

NORM calibration phantoms

CATPHAN

VARIAN Medical Systems

31

Norm calibration

Norm Phantom

CATPHAN

To correct for scatter

Geometry

2 Norm phantoms

Resolution

HU

Contrast

Head

Body

VARIAN Medical Systems

Examples of QA Protocols

Courtesy of Sua Yoo, PhD, Duke University

VARIAN Medical Systems

32

Daily OBI

Weekly OBI

VARIAN Medical Systems

Monthly OBI

(continues)
VARIAN Medical Systems

33

Monthly CBCT

VARIAN Medical Systems

(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.

VARIAN Medical Systems

34

Automated IGRT QA Works in Progress

Courtesy Lei Xing, Stanford

VARIAN Medical Systems

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

VARIAN Medical Systems

35