VMAT QA

DISCLAIMER
The Clinical Implementation of a QA program in any form of radiotherapy
is the responsibility of the local physicist. In seeking guidance, the
physicist must look for advice from reliable sources qualified to provide
such recommendations.
Elekta inc. does not claim to be an accredited educational institution in a
position to make any recommendations on the subject, and as such, the
contents of this training material is intended to be a recollection of our
best thoughts on the matter and not an authoritative opinion.
While our best efforts have been dedicated to the preparation of this
material by collecting the experience we have on the subject, we can not
guarantee the objectivity nor the accuracy of every statement.
Elekta Inc does not assume any liability from the use of the contents of
this material. The physicist is encouraged to obtain proper guidance
from accredited sources according to the state of the art of the practice.

What is VMAT ?

Essentially Rotational IMRT

What makes VMAT good ?

Decreased treatment time (~ 2 minutes per arc)

Reduction of MU with similar plan quality

Effectively improving plan quality by decreasing the
likelihood of intra-fraction movement.
Current Elekta solutions: ERGO++ and Monaco
Monaco will support both Elekta and Varian*.

* WIP

Available HW solutions

Features of Elekta VMAT

Single or multiple arc delivery

Single arc
Faster treatment time

Multiple arcs
Results in higher dose conformance
and lower peripheral dose
e.g. in complex head and neck cases

Coplanar or non-coplanar delivery

Couch rotation enables noncoplanar delivery

Features of Elekta VMAT

Dynamic Collimator rotation
Simultaneous collimator
rotation adds a crucial dose
control option

3D cone beam imaging

Elekta XVI cone beam =
three-dimensional target
location for accurate VMAT
delivery

And all this means

More moving pieces
Added complexity to hardware and software
New and Unexpected failure modes

More QA
but
this is what we already know how to do

VMAT vs IMRT
VMAT adds more complexity to the practice, but we
already were at the stage in which we dont trust anything
So for IMRT we do per patient QA with measurements

And we will continue the practice with VMAT

Just with a little bit more paranoia

Where to start
As always in the machine !
Mechanical movements, Isocenter localization, etc. look for
gravity sags.
Dose/Dose rate constancy for arcs, MU linearity at low MUs
MLC and Jaws Calibration
for ALL the gantry / collimator angles !

but
The chain is as strong as the weakest link

Is probably a good moment to revisit our entire Rad Onc

QA program, using for example guidelines like TG 40,
TG45, TG 53, IAEA TRS 430, IAEA TECDOC-1540,
IAEA TECDOC-1583 etc.

VMAT QA
-Require Special techniques and equipment

QA STEPS
During Commissioning of the technique
Extensive testing of multiple plans
Use films !
Use electronic devices too, make sure you know how they work and what
their limitations are (i.e, QA the QA device first).
Think about Dose/Dose rate dependencies, measure it !
Beware of directional dependencies, get data from manufacturer !

Collapsed Techniques (in wich you shoot an entire sequence from a fixed
direction or collimator position )can not be trusted as the sole method

During routine use

Electronic devices have the time advantage
Collapsed Techniques are allowed (assuming regular machine QA)

General QA Considerations
Use homogeneous density option for
homogeneous phantoms.
Use special cttoed files for some
devices
Phantom studyset is copied to the
patient file, and disconnected from
the phantom patient after that, so
updates are not carried over.
Use DICOM dose export from QA
activity for volumetric devices like D4
and arccheck.
MC variance represents the relative
error per segment, so open fields
needs lower variance, like 0.5%

QA Devices :Delta 4
Manufacturer : Scandidos, Upsala, Sweeden
-2D diode arrays (two arrays at 45 deg)
-It uses an inclinometer to sense gantry pos.
-Heavy piece made of PMMA, ED=1.12
-Calibration is cumbersome but is done only
once a year
-Pretty reliable, although software is primitive
(for our standards).
-System is synchronized with the Linac pulses
(no noise between pulses !), using terminal ST.

QA Devices :Delta 4
Calibration of the panels

QA Devices :Delta 4
Daily use

QA Devices :Delta 4
Software

QA Devices :ArcCheck
Manufacturer : SunNuclear

-Cylindrical array of diodes in a

spiral geometry.
-Light weight, made of water
equivalent material or of PMMA
-Easy to use interface, Mapchecklike

-Different devices can fit in the

inner space
-Only one cable ! And can be
used for Arccheck or Mapcheck.

QA Devices :ArcCheck
Made of water-equivalent or PMMA
Homogeneous ?

Monaco and ArcCheck

We need to use a custom made CT to ED file assigned to the CT scan of
the phantom, the tail should not go lower than 0.05 due to internal usage
of the phantom data. High density will be 1 (Water eq.) or 1.12 (PMMA)
If using special
inserts, a
regular
CTtoED file
can be used.
After dose is
calculated, we
will export the
dicom dose
and plan.

QA Devices :ArcCheck

Same
Software
can be used
for
Mapcheck
or
Arccheck.

QA Devices : 2D arrays
Mapcheck

(Sunnuclear)

Matrixx

(IBA)

729

(PTW)

QA Devices : 2D arrays
Gantry mount can be risky since you will
get the same reading no matter what
the machine does with gantry and
collimator, so it only checks the MLC
leaf positions and MUs.

2D arrays: MatriXX
Ionization chamber array, 1020 air-vented chambers.

7.6 mm chamber separation

Can be used with a custom-built configurable cubic
phantom.

Aluminum plate and screws inside.

There is an optional inclinometer, highly recommended.

2D arrays: MatriXX
Needs to
be CTscanned.
Large
artifacts in
the image
set. Force
density.

2D arrays: MatriXX
Like all 2D arrays, it has strong directional dependencies*

Bocanek et al, ESTRO 2008

Starting w/partial arcs

Using simple devices, we can learn a lot

We are not subject to blurring due to

averaging

We can use the devices we already have.

Partial arcs

Collapsed Techniques
Once you know it works, routine QA can be simplified
Monaco QA Module offers this unique QA feature, the entire sequence is
built into a single dynamic beam at vertical Gantry position
IT should never be you only tool, since the failure modes can be different

Conclusions
VMAT offers new advantages but also incorporates
more moving parts
QA is a critical component of VMAT but thats not
new !
QA of VMAT doesnt need to be much more
cumbersome than standard IMRT QA
So after all is not that hard !

Thank you