Risk Management of Clinical Reference Dosimetry of a Large Hospital Network Using Statistical Process Control

Managing TG-51 reference dosimetry in a large hospital network can be a challenging task. The objectives of this study are to investigate the effectiveness of using Statistical Process Control (SPC) to manage TG-51 workflow in such a network. All the sites in the network performed the annual reference dosimetry in water according to TG-51. These data were used to cross-calibrate the same ion chambers in plastic phantoms for monthly QA output measurements. An energy-specific dimensionless beam quality cross-calibration factor, , was derived to monitor the process across multiple sites. The SPC analysis was then performed to obtain the mean, , standard deviation, σk, the Upper Control Limit (UCL) and Lower Control Limit (LCL) in each beam. This process was first applied to 15 years of historical data at the main campus to assess the effectiveness of the process. A two-year prospective study including all 30 linear accelerators spread over the main campus and seven satellites in the network followed. The ranges of the control limits (±3σ) were found to be in the range of 1.7% - 2.6% and 3.3% - 4.2% for the main campus and the satellite sites respectively. The wider range in the satellite sites was attributed to variations in the workflow. Standardization of workflow was also found to be effective in narrowing the control limits. The SPC is effective in identifying variations in the workflow and was shown to be an effective tool in managing large network reference dosimetry.

Dosimetric Effect of Cobalt-Chrome Stabilization Hardware in Paraspinal Radiation Treatments

High density materials are assigned with an apparent density of 3.2 g/cm3 in 12-bit CT images due to saturation. This is often ignored in planning for spine tumors with titanium (density 4.40 g/cm3) spinal hardware. However, new cobalt-chrome hardware has a density of 8.11 g/cm3, which would increase dosimetric uncertainty if the true density is not utilized in planning. This effect was evaluated in this study. Calculation accuracy was examined using MapCHECK2 with a single 20 × 10 cm2 field with a titanium and a cobalt-chrome rod in a solid water phantom for 6X, 6FFF and 15X, at 2 cm and 6 cm beneath the rods. Measurement was compared to the calculation with density override (DO) with the true density and to the calculation with no-density override (NDO). Additionally, the dosimetric effect in clinical treatment plans was investigated for six IMRT and VMAT paraspinal cases. Plan quality was compared with the original NDO calculation and the DO recalculation. Compared to measurements, the treatment planning system (TPS) overestimated the dose locally by up to 13.2% for cobalt-chrome and 4.8% for titanium with NDO calculations. DO calculations improved the differences to 8.4% and 4.0%, respectively. Scatter from the rod increased the lateral dose and diminished as depth increased but was not properly accounted for by the TPS even with the correct density assigned. For the clinical plans, PTV coverage was lowered by an average of ~1.0% (range: 0.5% - 2.0%) and ~0.3% (range: 0.2% - 0.7%) in DO recalculations for cobalt-chrome and titanium, respectively. In conclusion, neglecting the true density of cobalt-chrome hardware during planning may result in an unexpected decrease in target coverage.