title: γ+ index: A new evaluation parameter for quantitative quality assurance.
abstract: OBJECTIVE
  The accuracy of dose delivery and the evaluation of differences between calculated and delivered dose distributions, has been studied by several groups. The aim of this investigation is to extend the gamma index by including radiobiological information and to propose a new index that we will here forth refer to as the gamma plus (γ+). Furthermore, to validate the robustness of this new index in performing a quality control analysis of an IMRT treatment plan using pure radiobiological measures such as the biologically effective uniform dose (D) and complication-free tumor control probability (P+).
  
  
  METHODS
  A new quality assurance index, the (γ+), is proposed based on the theoretical concept of gamma index presented by Low et al. (1998). In this study, the dose difference, including the radiobiological dose information (biological effective dose, BED) is used instead of just the physical dose difference when performing the γ+ calculation. An in-house software was developed to compare different dose distributions based on the γ+ concept. A test pattern for a two-dimensional dose comparison was built using the in-house software platform. The γ+ index was tested using planar dose distributions (exported from the treatment planning system) and delivered (film) dose distributions acquired in a solid water phantom using a test pattern and a theoretical clinical case. Furthermore, a lung cancer case for a patient treated with IMRT was also selected for the analysis. The respective planar dose distributions from the treatment plan and the film were compared based on the γ+ index and were evaluated using the radiobiological measures of P+ and D.
  
  
  RESULTS
  The results for the test pattern analysis indicate that the γ+ index distributions differ from those of the gamma index since the former considers radiobiological parameters that may affect treatment outcome. For the theoretical clinical case, it is observed that the γ+ index varies for different treatment parameters (e.g. dose per fraction). The dose area histogram (DAH) from the plan and film dose distributions are associated with P+ values of 50.8% and 49.0%, for a D to the target of 54.0 Gy and 53.3 Gy, respectively.
  
  
  CONCLUSIONS
  The γ+ index shows advantageous properties in the quantitative evaluation of dose delivery and quality control of IMRT treatments because it includes information about the expected responses and radiobiological doses of the individual tissues.
authors: Department of Radiation Oncology, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA. Electronic address: stathakis@uthscsa.edu.
authors: Sotirios
authors: S
authors: Stathakis
authors: Department of Radiation Oncology, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA; Department of Medical Radiation Physics, Karolinska Institutet & Stockholm University, Stockholm, Sweden.
authors: Panayiotis
authors: P
authors: Mavroidis
authors: Department of Radiation Oncology, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA.
authors: Chengyu
authors: C
authors: Shi
authors: Department of Radiation Oncology, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA.
authors: Jun
authors: J
authors: Xu
authors: Department of Radiation Oncology, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA.
authors: Kevin I
authors: KI
authors: Kauweloa
authors: Department of Radiation Oncology, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA.
authors: Ganesh
authors: G
authors: Narayanasamy
authors: Department of Radiation Oncology, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA.
authors: Niko
authors: N
authors: Papanikolaou
mesh_terms: D005720:Gamma Rays; D006801:Humans; D008175:Lung Neoplasms / Q000532:radiotherapy; D011786:Quality Control; D011829:Radiation Dosage
keywords: Gamma index; IMRT; Quality assurance; γ(+) index