International Journal of Cancer Therapy and Oncology www.ijcto.org Corresponding author: Shanmugam Thirumalai Swamy; Department of Radiation Oncology, Yashoda Hospitals, Hyderabad, India. Cite this article as: Thirumalai-Swamy S, Anuradha C, Kathirvel M, Arun G, Subramanian S. Pretreatment quality assurance of volumetric modulated arc therapy on patient CT scan using indirect 3D dosimetry system. Int J Cancer Ther Oncol 2014; 2(4):020416. DOI:10.14319/ijcto.0204.16 Pretreatment quality assurance of volumetric modulated arc therapy on patient CT scan using indirect 3D dosimetry system Shanmugam Thirumalai Swamy1,2, Chandrasekaran Anuradha2, Murugesan Kathirvel1, Gandhi Arun1, Shanmuga Subramanian1 1Department of Radiation Oncology, Yashoda Hospitals, Hyderabad, India 2School of Advanced Sciences, VIT University, Vellore, India Received August 29, 2014; Revised October 16, 2014; Accepted October 18, 2014; Published Online October 22, 2014 Original Article Abstract Purpose: Aim of this study is to clinically implement the COMPASS 3D dosimetry system for pretreatment quality assurance of volumetric modulated arc therapy (VMAT-RapidArc) treatment plans. Methods: For this study, 10 head and neck (H&N) and pelvis VMAT plans dose response from Linac was measured using COMPASS system along with MatriXXEvolution and 3D dose reconstructed in the patient computed tomography (CT) scan. Dose volume histograms and 3D gamma were used to evaluate difference between the measured and calculated values. In order to validate the COMPASS system, dose response for open fields were acquired for both homogeneous and inhomogeneous phantoms. Results: The average dose difference between Eclipse treatment planning system (TPS) calculated and COMPASS measured (homogenous medium) in normalization region, inner region, penumbra region and buildup region was less than ±2%. In inhomogeneous phantom, there was a maximum difference -3.17% in lung, whereas the difference other densities was within ±2%. The systematic increase in the average 3D gamma be- tween the TPS calculated and COMPASS measured for VMAT plans with known dose errors and multi-leaf collimator (MLC) offset errors shows that COMPASS system was sensitive enough to find clinical significant errors. The 3D dose parameters (D95, D1, and average dose) of all H&N and pelvis patients were well within the clinically acceptable tolerance level of ±5%. The average 3D gammas for planning target volumes (PTV) and organ at risks (OAR) of the patients were less than 0.6. Conclusion: The results from this study show that COMPASS along with MatriXXEvolution can be effectively used for pretreatment verification of VMAT plans in the patient anatomy. Keywords: COMPASS; VMAT; 3D Gamma; Pretreatment QA Introduction In advanced radiotherapy techniques, each patient's treat- ment plan is customized, to produce high gradient dose dis- tribution to the target and low dose to the critical organs. Volumetric Modulated Arc Therapy (VMAT- RapidArc) produces highly conformal dose distribution by simultane- ously changing multi-leaf collimator (MLC) position, dose rate and gantry speed during patient treatment.1-3 Complex treatment deliveries demand a comprehensive quality assur- ance (QA) procedure. American Association of Physicists in Medicine Task Group (AAPM TG)-824 recommends verifica- tion of intensity modulated treatment plans with an inde- pendent QA method before treatment delivery. Traditionally pretreatment QA’s are performed in a phantom using ion chamber, film, 2D array, and electronic portal imaging de- vice (EPID). Each of these devices has been proven useful but has its own limitations.5-11 Position of ion chamber in the high dose gradient area leads to discrepancy between meas- ured and the treatment planning system (TPS) calculated dose. Film shows excellent spatial resolution; however, problems like chemical processing, scanner readout, and time delay exists. A 2D array shows the dose distribution immediately after the treatment delivery, but their results have limited resolution. Also, results provided by them can- not be directly used to identify delivery errors in tumor and normal tissues. Benjamin et al.12 showed that there is lack of correlation between gamma passing rates from 2D array and dose differences in critical anatomic regions of interest. To address this issue, alternate QA techniques has been devel- oped to verify the 3D dose distribution by measuring fluence at different gantry angle using ion chamber matrix or EPID in a patient computed tomography (CT) scan.13-18 The COMPASS QA system (IBA Dosimetry, Germany) is one such technique which uses MatriXXEvolution along with gantry http://ijcto.org/index.php/IJCTO/index http://ejourpub.com/ http://dx.doi.org/10.14319/ijcto.0204.16 2 Thirumalai Swamy et al.: 3D pretreatment QA for VMAT International Journal of Cancer Therapy and Oncology www.ijcto.org © Thirumalai Swamy et al. ISSN 2330-4049 angle sensor. It consists of (i) a measurement-based dose reconstruction, and (ii) model-based dose calculation. Measurement based dose reconstruction (i) Detector dose response is predicted from the patient treatment plan parameters. (ii) Measured dose response from the MatrixEvolution is then compared with predicted dose re- sponse. (iii) The difference between the predicted and meas- ured response along with correction kernel was used to de- rive the reconstruction fluence. Finally reconstructed flu- ence is fed to the dose engine based on collapsed cone model for computation of 3D dose within the patient CT scan. The dose calculated from the reconstructed fluence is referred as “indirectly measured” (COMPASS measured). Model based dose calculation COMPASS system can compute dose in patient CT scan us- ing inbuilt beam model. The purpose of the dose computa- tion is to provide an independent cross-verification of TPS calculated dose. In addition, COMPASS has a facility to compare the 3D dose distribution and dose volume histograms (DVH) between measured and TPS calculated. Previous studies have validat- ed the dose reconstruction method of COMPASS system for fixed field IMRT against film based QA in phantoms.13, 15, 17 Ramesh et al.14 has shown the experimental validation of COMPASS system for rotational IMRT in inhomogeneous phantom. This study focuses on pretreatment QA of VMAT treatment plan on “measurement based dose reconstruction”. We have evaluated the performance of COMPASS 3D do- simetry system clinically: (i) In open field sizes (10 × 10 cm2 and 20 × 20 cm2) to evaluate the accuracy of beam modeling both in homogeneous and inhomogeneous media, (ii) To check the accuracy of the system in detecting MLC and dose errors and (iii) To implement the system for VMAT patient specific QA. Methods and Materials All measurements were performed using 6 MV photon beam from dual energy Clinac-iX (Varian Medical Systems, Palo Alto, USA). The machine was equipped with millennium 120 MLC, on-board imager (OBI) and maximum dose rate of 600 MU/min. Conventional pretreatment QA for VMAT plans were performed with point dose measurements and 2D pla- nar dosimetry using 0.13 cc ionization chamber in a cube phantom and MatriXXEvolution in multicube phantom (IBA Dosimetry) respectively. MatriXXEvolution contains 1020 paral- lel plane ion chambers (32 × 32 matrix) with an active area of 24.4 × 24.4 cm2 having 7.62 mm resolution at isocenter of 100 cm. In point dose measurement, percentage dose variation was calculated between the measured dose using ion cham- ber and the calculated dose in Eclipse TPS. For 2D planar dosimetry (frontal plane), global gamma analysis was per- formed using OmniPro Im’RT software with criteria of 3% dose difference (DD) and 3mm distance to agreement (DTA). In this study, COMPASS (V2.1) was used as a pretreatment 3D QA tool to validate VMAT plans. Dose response from treatment plans was measured using MatriXXEvolution with 5 cm RW3 buildup plates and gantry angle sensor placed on a gantry holder mount, Figure 1 (source to detector distance of 76.2 cm). The dose calculation engine in the COMPASS sys- tem is collapsed cone convolution/superposition (CCC/S) algorithm, whereas Eclipse TPS uses Analytical Anisotropic Algorithm (AAA). Since these two algorithms use different approach in dose calculation, simple open field sizes were first validated in both homogeneous and inhomogeneous mediums. FIG.1: Setup for the pretreatment quality assurance for VMAT treatment delivery. MatriXXEvolution with 5 cm RW3 buildup plates and gantry angle sensor placed on a gantry holder mount with source to detector distance-76.2 cm. Open field measurements To verify the accuracy of beam modeling and algorithm dif- ference, the fluence for MLC defined open fields (ranging from 5 × 5 cm2 to 25 × 25 cm2) were acquired by COMPASS system on a homogeneous phantom. Average dose calculated and measured by Eclipse TPS and COMPASS QA system respectively were compared at normalization, inner, outer, penumbra and buildup regions as per AAPM TG-53 19 rec- ommendations (Figure 2a). Average dose had been compared for different Hounsfield unit (HU) mediums teflon (990 HU), derlin (340 HU), acrylic (120 HU), polystyrene (-35 HU), LDPE (-100 HU), PMP (-200 HU) and air (-1000 HU) in CAT Phantom (Figure 2b). This average dose comparison was done for two sets of MLC defined open fields (10 × 10 cm2 and 20 × 20 cm2) in an in- homogeneous phantom. Volume 2 • Number 4 • 2014 International Journal of Cancer Therapy and Oncology 3 www.ijcto.org © Thirumalai Swamy et al. ISSN 2330-4049 FIG.2 (a): Homogeneous phantom created in Eclipse TPS as per AAPM TG-53 recommendations. Based on beam geometry, phantom was bro- ken into different regions to analyze the agreement between TPS calculated and COMPASS measured dose. FIG. 2(b): Transverse view of CAT phantom CT scan with different HU medium. FIG. 3: Dose distribution and DVH comparison between Eclipse TPS calculated and COMPASS measured for an H&N patient. Intentional error measurements To validate the accuracy of the COMPASS system, VMAT plans with known dose error of ±3 and ±5% and MLC errors of 1, 3 and 5 mm due to one side of MLC bank mis-calibration were delivered. For 2D planar dosimetry, dose plane from TPS plan without error was used as refer- ence in OmniPro Im’RT software for gamma analysis. For 3D dosimetry, VMAT plan without error was exported to COMPASS system. Patient plan evaluation 10 head & neck (H&N) and 10 pelvis VMAT plans with two full arcs (181°-179° clock wise / counter clock wise) were chosen for this study. The H&N patients contain three plan- ning target volumes (PTV) with different level of dose pre- scription (simultaneous integrated boost, Figure 3) and single PTV for pelvis patients. VMAT plans were optimized in Eclipse TPS (version 8.9) using Progressive Resolution Opti- mizer -II and final dose calculations were performed using AAA with 2.5 mm grid resolution. For pretreatment 3D QA, these VMAT plans along with patient’s CT scan, structure set and 3D dose planes were exported to COMPASS in DICOM RT format. On treatment machine, MatriXXEvolution (Trigger Mode) was used for measuring dose response. COMPASS system calcu- lates predicted dose response using DICOM RT plan param- eters (gantry angle, MLC position, MU, etc) from TPS, de- tector model and in-built beam model. This predicted dose response was compared against the corresponding measured dose response and the difference was incorporated in dose calculation (Figure 4). The final dose distribution was recon- structed on patient CT using CCC/S algorithm with same grid size of 2.5 mm. The average doses for PTV’s and organs 4 Thirumalai Swamy et al.: 3D pretreatment QA for VMAT International Journal of Cancer Therapy and Oncology www.ijcto.org © Thirumalai Swamy et al. ISSN 2330-4049 at risk (OAR’s) in H&N as well as pelvis patients were com- pared between TPS calculated and COMPASS measured. Dose to 95% of the PTV volume (D95) and max dose to spi- nal cord (D1) was also evaluated. The average 3D global gamma was calculated using criteria of 3mm DTA and 3% DD. Results Open fields The percentage difference of average dose between TPS cal- culated and COMPASS measured for different region and HU material were shown in Figure 5a and 5b respectively. In order to understand the dose difference arising from the beam modeling, the open field measurements were analyzed. Percentage difference of average dose for all open fields in normalization, inner, penumbra and buildup regions was less than AAPM TG-53 19 recommended value 0.5%, 1.5%, 10% (2mm) and 20% respectively. For outer region suggested value was 2%, but in our study due to low dose a maximum difference of 8.3% was observed. FIG. 4: The predicted dose response by COMPASS system was com- pared against the corresponding measured dose response from Ma- triXXEvolution. The difference in response was incorporated in final dose reconstruction. FIG. 5 (a): Percentage difference in average dose for different regions of interest in homogeneous phantom for MLC defined open fields size of 5 × 5 cm2, 10 × 10 cm2, 15 × 15 cm2, 20 × 20 cm2 and 25 × 25 cm2 respectively. FIG. 5 (b): Percentage difference in average dose for different HU material in CAT phantom for MLC defined open fields 10 × 10 cm2 and 20 × 20 cm2 Intentional errors Table 1 shows the gamma agreement index (GAI) for known dose and MLC errors between TPS calculated and MatriXXEvolution measured in multicube phantom. GAI is defined as percentage of points passing the gamma evaluation criteria. COMPASS system provides the clinical rele- vance of dose and MLC errors by calculating the average dose difference and 3D gamma for PTV, rectum and bladder. TABLE 1: Shows gamma agreement index (GAI) for measurements with intentional dose and MLC errors, whereas COMPASS system provides the clinical relevance of errors by calculating the average 3D gamma and dose difference for PTV, rectum and bladder. Description GAI average 3D gamma % difference in average dose PTV Rectum Bladder PTV Rectum Bladder Without Error 97.5 0.33 0.28 0.25 -0.73 3.11 -2.77 3% Dose Error 94.8 1.03 0.27 0.55 -3.80 0.56 -5.28 5% Dose Error 89.9 1.50 0.38 0.69 -5.64 -2.66 -6.96 -3% Dose Error 92.4 0.58 0.40 0.21 2.04 5.22 0.58 -5% Dose Error 87.3 1.22 0.61 0.45 4.39 7.62 2.81 1mm MLC Error 94.3 0.45 0.28 0.5 -1.06 2.61 -6.53 3mm MLC Error 92.95 0.77 0.45 0.41 -1.61 2.18 3.33 5mm MLC Error 85.65 1.08 0.61 0.78 -0.96 1.30 7.93 Volume 2 • Number 4 • 2014 International Journal of Cancer Therapy and Oncology 5 www.ijcto.org © Thirumalai Swamy et al. ISSN 2330-4049 TABLE 2: 3D gamma and dose volume difference between Eclipse TPS calculated and COMPASS measured for 10 H&N patients PTV’s and OAR'S. For same patients, point dose difference from ion chamber and 2D gamma from planar dosimetry were listed. Parameters Structure Pt-1 Pt-2 Pt-3 Pt-4 Pt-5 Pt-6 Pt-7 Pt-8 Pt-9 Pt-10 Mean ±SD % of point dose difference 0.97 1.07 -1.11 -0.67 -0.93 -1.29 -2.60 2.09 -2.45 0.63 -0.43 1.56 gamma agreement index 96.1 97.0 97.9 95.1 96.7 95.5 97.9 98.3 98.1 95.1 96.7 1.26 % difference in average dose PTV1 -2.02 -1.53 -2.07 -2.46 -2.09 -1.94 -1.18 -1.25 -0.79 -2.97 -1.83 0.65 PTV2 -2.36 -1.47 -1.98 -2.69 -2.08 -1.36 -1.41 -1.38 -0.96 -2.42 -1.81 0.57 PTV3 -2.56 -0.35 -1.62 -1.88 -2.91 -1.37 -2.62 -2.65 -1.65 -2.71 -2.03 0.81 Rt Parotid 0.71 -4.00 -3.93 -1.89 4.74 -3.10 -2.75 2.38 -2.05 -4.52 -1.44 3.07 Lt Parotid -2.42 -2.69 0.33 3.76 3.13 -2.50 1.23 -0.51 -1.28 3.99 0.30 2.62 Spinal cord -2.95 -1.12 -2.87 -3.17 -0.83 -1.49 0.23 -1.23 -0.57 -1.18 -1.52 1.13 average 3D gamma PTV1 0.37 0.33 0.49 0.31 0.41 0.57 0.40 0.36 0.27 0.44 0.40 0.09 PTV2 0.39 0.30 0.45 0.36 0.44 0.41 0.36 0.33 0.27 0.48 0.38 0.07 PTV3 0.43 0.24 0.30 0.41 0.46 0.52 0.46 0.56 0.40 0.54 0.43 0.10 Rt Parotid 0.14 0.30 0.08 0.22 0.25 0.40 0.22 0.11 0.13 0.30 0.22 0.10 Lt Parotid 0.31 0.26 0.18 0.22 0.29 0.28 0.14 0.09 0.11 0.14 0.20 0.08 Spinal cord 0.39 0.11 0.36 0.21 0.20 0.37 0.24 0.15 0.11 0.18 0.23 0.11 % difference in D95 PTV1 -1.95 -2.83 -1.80 -2.22 -2.28 -1.05 -0.26 -0.91 -0.90 -2.50 -1.67 0.84 PTV2 -2.29 -1.10 -1.72 -2.23 -2.36 0.29 -0.99 -1.80 -0.52 -2.24 -1.50 0.89 PTV3 -2.20 0.86 -0.23 -0.84 -2.56 1.85 -1.35 -2.68 -0.16 -2.33 -0.96 1.54 % difference in D1 Spinal cord -1.88 -1.00 -3.17 -1.14 -1.37 -2.84 -0.27 -3.60 0.85 -1.96 -1.64 1.36 TABLE 3: 3D gamma and dose volume difference between Eclipse TPS calculated and COMPASS measured for 10 pelvis patients. Parameters Structure Pt-1 Pt-2 Pt-3 Pt-4 Pt-5 Pt-6 Pt-7 Pt-8 Pt-9 Pt-10 Mean ± SD % of point dose difference 0.16 2.71 0.32 1.6 -0.91 0.1 0.93 0.16 -1.07 -1.11 0.29 1.22 gamma agreement index 98.4 97.2 98.6 99.1 95.1 96.4 97.7 96.3 97.0 97.9 97.4 1.22 % difference in average dose PTV -1.82 -1.27 -0.42 -0.83 -1.29 -1.52 -0.16 -0.60 -1.49 0.82 -0.86 0.79 Rectum 0.43 0.50 1.64 2.35 0.40 0.18 3.49 0.39 -3.45 1.13 0.71 1.81 Bladder -3.75 -1.97 0.02 -2.03 -1.93 -1.63 -2.38 -2.61 1.06 0.78 -1.44 1.56 Bowel -3.19 -0.68 13.1 15.5 0.16 -0.53 17.6 3.34 -0.87 -2.46 4.20 7.99 average 3D gamma PTV 0.50 0.40 0.18 0.28 0.41 0.44 0.42 0.26 0.33 0.33 0.36 0.10 Rectum 0.33 0.27 0.20 0.21 0.34 0.14 0.27 0.15 0.12 0.27 0.23 0.08 Bladder 0.40 0.34 0.12 0.24 0.41 0.26 0.23 0.18 0.06 0.23 0.25 0.11 Bowel 0.28 0.23 0.11 0.18 0.26 0.18 0.2 0.25 0.19 0.20 0.21 0.05 % difference in D95 PTV 0.34 -0.41 0.23 0.07 -0.20 -0.64 -2.43 -0.78 -0.43 -1.43 -0.57 0.84 VMAT plans In Table 2, 10 H&N patients percentage difference of average dose, percentage difference of D95 and D1 and average 3D gamma between Eclipse TPS calculated and COMPASS measured for PTV's and critical OAR's were listed. Also, percentage variation of point dose measurement and GAI was listed. Table 3 summarizes the percentage difference of average dose, percentage difference of D95 and average 3D gamma for PTV, rectum, bladder and bowel for 10 pelvis patients. Discussion Advantage of COMPASS 3D dosimetry system over other QA systems is its capability of performing 3D dose recon- struction on patient CT scan using beam modeling, detector measurement and treatment plan. The dose calculation algo- rithm in an inhomogeneous medium was completely differ- ent in Eclipse TPS and COMPASS 3D dosimetry system. The COMPASS uses CCC/S algorithm, where the dose calculation is based primarily on a point source dose spread array. The Eclipse TPS uses AAA wheredose calculation is based on a pencil beam in association with lateral density scaling. In CCC/S, the dose at a point from a point source of given TERMA (total energy released per unit mass) to the dose at another location in a patient can be calculated by scaling both primary and scatter. Point to point density scaling of this kind is not feasible by the pencil beam kernel method. The point spread kernel based method allows greater flexi- bility in dealing with 3D inhomogeneous medium than pen- cil beam kernel. Due to this, maximum average dose differ- ence of 3.2% in air was observed.14, 20 Open field measure- ments provide vital information for fine tuning of beam 6 Thirumalai Swamy et al.: 3D pretreatment QA for VMAT International Journal of Cancer Therapy and Oncology www.ijcto.org © Thirumalai Swamy et al. ISSN 2330-4049 modeling and help to understand the efficiency of dose re- construction, especially in the buildup, air and penumbra region, so that one can set the tolerance level when OAR falls in region of interest. For example, in H&N patients lips lie in surface (build-up), trachea lies in air and cochlea lies in the field border (penumbra). For PTV in Table 1, there was a systematic decrease in GAI and increase in average 3D gamma with respect to increase in treatment delivery errors. However, 2D planar dosimetry does not provide any clinically relevant information about the results,12 whereas COMPASS system provides the signif- icance of error in PTV and as well as in OAR’s. The infor- mation provided by traditional 1D point dosimetry and 2D planar devices cannot easily be translated onto dose devia- tions in the tumor and/or at OAR's. DVH based evaluation will be a good alternative since it allows physicist and physi- cian to accept or reject the treatment plan based on the dose difference in PTV and OAR's. Measurements based dose reconstruction of COMPASS enables us to verify the treat- ment delivery with acceptable accuracy (±5%). PTV in Table 1 shows there was a systematic increase and decrease in the percentage difference of average dose with respect to known dose delivery errors, and an increase in average 3D gamma with planned MLC errors.16,21 In the COMPASS system, the difference between predicted and measured response is into two components.16 The first component is a scaling correc- tion (Acorr) factor, which is used to find dose errors (incorrect MU) and the second component is the remaining residual response, which is used to reconstruct MLC errors. The cal- culation grid resolution used in the TPS and COMPASS af- fects the accuracy of the dose distribution calculated. Litera- tures have reported that a 2.5 mm isotropic grid produces an accuracy of about 1% in the high-dose gradient region of an IMRT plan consisting of multiple fields.23 Benedict et al.23 and Park et al.24 have recommend grid size less than 3 mm for stereotactic treatments. In both Eclipse TPS and COM- PASS QA system grid size resolution can be varied from 1 mm to 5 mm, for our study we have chosen 2.5 mm grid size. Although smaller grid size can yield more accurate results, 2.5 mm grid size was chosen by optimizing the accuracy and computational time. The results show that 3D dose parameters were well within the clinically acceptable tolerance level of ±5%.22 The aver- age 3D gamma for PTV's and OAR’s for twenty patients used in this study were less than the recommended value of 0.6 by Visser et al.17 In three pelvis cases due to low dose of bowel, the percentage difference of average dose was more than 10%. DVH in COMPASS provides many statistical tools; however, we cannot judge plan quality by choosing one cri- teria, as the percentage difference in average dose, dose at volume and volume at dose will be too high for structure lying in low dose region. For higher deviation of fluence over small distances there are limitations due to the recon- struction capabilities of COMPASS and chamber resolution of MatriXXEvolution. So COMPASS may slightly underestimate and/oroverestimate the actual delivered dose for OAR's.14 Despite local inaccuracies in the dose reconstruction, Godart et al.16 have proven that COMPASS can be used to perform pretreatment verification of IMRT treatment plans. COM- PASS can compute dose in patient CT scan using only inbuilt beam model (without measurements). This model based dose calculation, function as an independent secondary TPS veri- fication. COMPASS have dose calculation engine (CCC/S) similar to TPS, it not only verify the plan parameters (MU) but also provides anatomically localized QA dose infor- mation. Kunnanchath et al.25 have showed good agreement in comparison of Eclipse TPS calculated vs COMPASS calcu- lated with average dose difference less than 1% and average gamma less than 0.5 for PTV and OAR’s of 10 head and neck and 10 pelvis IMRT plans. Previous studies have shown that measurement (MatriXXEvolution) based dose reconstruction in phantom images were in excellent agreement with the ion chamber results and planar dosimetry (film).13-15 Our study shows that COMPASS is a better system than point and 2D planar dosimetry by providing the 3D dose discrepancies in the region of interest in patient anatomy. Conclusion Traditionally QA methods are performed in a phantom and it is often difficult to quantify and interpret the results in patient anatomy. The ability of the COMPASS software to reconstruct the 3D dose distribution on patient CT from the measurements, provides a unique perspective for medical physicist and radiation oncologist to evaluate the patient’s QA plan. The results from this study show that the COM- PASS along with MatriXXEvolution can be effectively used for pretreatment verification of VMAT plans and it is good enough to find clinical significant errors in dose delivery. Conflict of interest The authors declare that they have no conflicts of interest. The authors alone are responsible for the content and writ- ing of the paper. References 1. Vanetti E, Clivio A, Nicolini G, et al. Volumetric modulated arc radiotherapy for carcinomas of the oro-pharynx, hypo-pharynx and larynx: a treat- ment planning comparison with fixed field IMRT. Radiother Oncol 2009; 92:111-7. 2. Rana S, Pokharel S, Zheng Y, et al. Treatment planning study comparing proton therapy, Rapi- dArc and intensity modulated radiation therapy for a synchronous bilateral lung cancer case. Int J Cancer Ther Oncol 2014; 2:020216. http://dx.doi.org/10.1016/j.radonc.2008.12.008 http://dx.doi.org/10.14319/ijcto.0202.16 Volume 2 • Number 4 • 2014 International Journal of Cancer Therapy and Oncology 7 www.ijcto.org © Thirumalai Swamy et al. ISSN 2330-4049 3. Subramanian S, Srinivas C, Ramalingam K, et al. Volumetric modulated arc-based hypofractionated stereotactic radiotherapy for the treatment of se- lected intracranial arteriovenous malformations: dosimetric report and early clinical experience. Int J Radiat Oncol Biol Phys 2012; 82:1278-84. 4. Ezzell GA, Galvin JM, Low D, et al. Guidance document on delivery, treatment planning, and clinical implementation of IMRT: report of the IMRT Subcommittee of the AAPM Radiation Therapy Committee. Med Phys 2003; 30:2089-115. 5. Dong L, Antolak J, Salehpour M, et al. Pa- tient-specific point dose measurement for IMRT monitor unit verification. Int J Radiat Oncol Biol Phys 2003; 56:867-77. 6. Masi L, Casamassima F, Doro R, Francescon P. Quality assurance of volumetric modulated arc therapy: Evaluation and comparison of different dosimetric systems. Med Phys 2011; 38: 612-22. 7. Herzen J, Todorovic M, Cremers F, et al. Dosimet- ric evaluation of a 2D pixel ionization chamber for implementation in clinical routine. Phys Med Biol 2007; 52:1197-208. 8. Fenoglietto P, Laliberte B, Ailleres N, et al. Eight years of IMRT quality assurance with ionization chambers and film dosimetry: experience of the Montpellier Comprehensive Cancer Center. Radiat Oncol 2011; 6:85. 9. Charland PM, Chetty IJ, Yokoyama S, Fraass BA. Dosimetric comparison of extended dose range film with ionization measurements in water and lung equivalent heterogeneous media exposed to mega- voltage photons. J Appl Clin Med Phys 2003; 4: 25-39. 10. Howell RM, Smith IP, Jarrio CS. Establishing ac- tion levels for EPID-based QA for IMRT. J Appl Clin Med Phys 2008; 9: 16- 2721. 11. Nicolini G, Vanetti E, Clivio A, et al. The GLAaS algorithm for portal dosimetry and quality assur- ance of RapidArc, an intensity modulated rotation- al therapy. Radiat Oncol 2008; 3:24. 12. Nelms BE, Zhen H, Tomé WA. Per-beam, planar IMRT QA passing rates do not predict clinically relevant patient dose errors. Med Phys 2011; 38:1037-44. 13. Boggula R, Jahnke L, Wertz H, et al. Pa- tient-specific 3D pretreatment and potential 3D online dose verification of Monte Carlo-calculated IMRT prostate treatment plans. Int J Radiat Oncol Biol Phys 2011; 81:1168-75. 14. Boggula R, Lorenz F, Mueller L, et al. Experimental validation of a commercial 3D dose verification system for intensity-modulated arc therapies. Phys Med Biol 2010; 55:5619-33. 15. Korevaar EW, Wauben DJ, van der Hulst PC, et al. Clinical introduction of a linac head-mounted 2D detector array based quality assurance system in head and neck IMRT. Radiother Oncol 2011; 100:446-52. 16. Godart J, Korevaar EW, Visser R, et al. Reconstruc- tion of high-resolution 3D dose from matrix meas- urements: error detection capability of the COM- PASS correction kernel method. Phys Med Biol 2011; 56:5029-43. 17. Visser R, Wauben DJ, de Groot M, et al. Efficient and reliable 3D dose quality assurance for IMRT by combining independent dose calculations with measurements. Med Phys 2013; 40:021710. 18. Venkataraman S, Malkoske KE, Jensen M, et al. The influence of a novel transmission detector on 6 MV x-ray beam characteristics. Phys Med Biol 2009; 54:3173-83. 19. Fraass B, Doppke K, Hunt M, et al. American Asso- ciation of Physicists in Medicine Radiation Thera- py Committee Task Group 53: quality assurance for clinical radiotherapy treatment planning. Med Phys 1998; 25:1773-829. 20. Hasenbalg F, Neuenschwander H, Mini R, Born EJ. Collapsed cone convolution and analytical aniso- tropic algorithm dose calculations compared to VMC++ Monte Carlo simulations in clinical cases. Phys Med Biol 2007; 52:3679-91. 21. Fredh A, Scherman JB, Fog LS, Rosenschöld PM. Patient QA systems for rotational radiation thera- py: a comparative experimental study with inten- tional errors. Med Phys 2013; 40:031716. 22. Thwaites D. Accuracy required and achievable in radiotherapy dosimetry: have modern technology and techniques changed our views? J Phys 2013; 444: 012006. 23. Park JY, Kim S, Park HJ, et al. Optimal set of grid size and angular increment for practical dose cal- culation using the dynamic conformal arc tech- nique: a systematic evaluation of the dosimetric ef- fects in lung stereotactic body radiation therapy. Radiat Oncol 2014; 9:5. 24. Benedict SH, Yenice KM, Followill D, et al. Stere- otactic body radiation therapy: the report of AAPM Task Group 101. Med Phys 2010; 37:4078-101. 25. Kunnanchath J, Majumdar SKD, Tharmarnadar G, et al. Validation of compass QA system and the in- dependent verification of dose calculation algo- rithm for IMRT patient specific plans. Transworld Medical Journal 2014; 2:170-5. http://dx.doi.org/10.1016/j.ijrobp.2011.02.005 http://dx.doi.org/10.1118/1.1591194 http://dx.doi.org/10.1016/S0360-3016(03)00197-4 http://dx.doi.org/10.1118/1.3533900 http://dx.doi.org/10.1088/0031-9155/52/4/023 http://dx.doi.org/10.1186/1748-717X-6-85 http://dx.doi.org/10.1120/1.1522990 http://dx.doi.org/10.1120/1.1522990 http://www.ncbi.nlm.nih.gov/pubmed/18716584 http://dx.doi.org/10.1186/1748-717X-3-24 http://dx.doi.org/10.1118/1.3544657 http://dx.doi.org/10.1016/j.ijrobp.2010.09.010 http://dx.doi.org/10.1088/0031-9155/55/19/001 http://dx.doi.org/10.1016/j.radonc.2011.09.007 http://dx.doi.org/10.1088/0031-9155/56/15/023 http://dx.doi.org/10.1118/1.4774048 http://dx.doi.org/10.1088/0031-9155/54/10/014 http://dx.doi.org/10.1118/1.598373 http://dx.doi.org/10.1088/0031-9155/52/13/002 http://dx.doi.org/10.1118/1.4788645 http://dx.doi.org/10.1088/1742-6596/444/1/012006 http://dx.doi.org/10.1186/1748-717X-9-5 http://dx.doi.org/10.1118/1.3438081 http://www.tmjournals.com/pdf/Validation%20of%20compass%20QA%20system%20and%20the%20independent%20verification%20of%20dose%20calculation%20algorithm%20for%20IMRT%20patient%20specific%20plans.pdf