title: A real time dose monitoring and dose reconstruction tool for patient specific VMAT QA and delivery.
abstract: OBJECTIVE
  To develop a real time dose monitoring and dose reconstruction tool to identify and quantify sources of errors during patient specific volumetric modulated arc therapy (VMAT) delivery and quality assurance.
  
  
  METHODS
  The authors develop a VMAT delivery monitor tool called linac data monitor that connects to the linac in clinical mode and records, displays, and compares real time machine parameters with the planned parameters. A new measure, called integral error, keeps a running total of leaf overshoot and undershoot errors in each leaf pair, multiplied by leaf width, and the amount of time during which the error exists in monitor unit delivery. Another tool reconstructs Pinnacle(3)™ format delivered plan based on the saved machine logfile and recalculates actual delivered dose in patient anatomy. Delivery characteristics of various standard fractionation and stereotactic body radiation therapy (SBRT) VMAT plans delivered on Elekta Axesse and Synergy linacs were quantified.
  
  
  RESULTS
  The MLC and gantry errors for all the treatment sites were 0.00 ± 0.59 mm and 0.05 ± 0.31°, indicating a good MLC gain calibration. Standard fractionation plans had a larger gantry error than SBRT plans due to frequent dose rate changes. On average, the MLC errors were negligible but larger errors of up to 6 mm and 2.5° were seen when dose rate varied frequently. Large gantry errors occurred during the acceleration and deceleration process, and correlated well with MLC errors (r = 0.858, p = 0.0004). PTV mean, minimum, and maximum dose discrepancies were 0.87 ± 0.21%, 0.99 ± 0.59%, and 1.18 ± 0.52%, respectively. The organs at risk (OAR) doses were within 2.5%, except some OARs that showed up to 5.6% discrepancy in maximum dose. Real time displayed normalized total positive integral error (normalized to the total monitor units) correlated linearly with MLC (r = 0.9279, p < 0.001) and gantry errors (r = 0.742, p = 0.005). There is a strong correlation between total integral error and PTV mean (r = 0.683, p = 0.015), minimum (r = 0.6147, p = 0.033), and maximum dose (r = 0.6038, p = 0.0376).
  
  
  CONCLUSIONS
  Errors may exist during complex VMAT planning and delivery. Linac data monitor is capable of detecting and quantifying mechanical and dosimetric errors at various stages of planning and delivery.
authors.affiliation: Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, MI, USA. Neelam.Tyagi@beaumont.edu
authors.forename: Neelam
authors.initials: N
authors.lastname: Tyagi
authors.forename: Kai
authors.initials: K
authors.lastname: Yang
authors.forename: David
authors.initials: D
authors.lastname: Gersten
authors.forename: Di
authors.initials: D
authors.lastname: Yan
mesh_terms: D000465:Algorithms; D011381:Programming Languages; D011785:Quality Assurance, Health Care / Q000379:methods; D011874:Radiometry / Q000379:methods* / Q000592:standards; D011879:Radiotherapy Dosage; D011880:Radiotherapy Planning, Computer-Assisted / Q000379:methods* / Q000592:standards; D020266:Radiotherapy, Conformal / Q000379:methods* / Q000592:standards; D012984:Software; D012985:Software Design; D014481:United States