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SECTION Page #

I. Introduction ............................................................................................................................................................................................. 4

II. Downloading and Installing the Software.............................................................................................................................................. 4

III. Getting Started......................................................................................................................................................................................... 5 • Import Options (color channel selection) ...................................................................................................................................... 6 • Scanner TWAIN Source Selection ................................................................................................................................................. 6 • Saving a New Case/Patient ............................................................................................................................................................. 7 • Opening/Deleting a Case/Patient.................................................................................................................................................... 7

IV. Patient QA................................................................................................................................................................................................ 8 1. Import Calculations - Select the “Import Calculations” task from the “Patient QA” window to begin this section. .............................. 8 • NOMOS Corvus Calculations Import ........................................................................................................................................... 9 • 3D DICOM Calculations Import.................................................................................................................................................... 9 • Manual Image Resolution Input .................................................................................................................................................. 10 • Image Multiplication ..................................................................................................................................................................... 10 • Minimize/Maximize Dataset Groups ........................................................................................................................................... 11 • Treatment Planning System Output File Extensions ................................................................................................................. 12 • Removing Files from a Dataset..................................................................................................................................................... 12 • Undo File Import ........................................................................................................................................................................... 13

2. Import Films - Select the “Import Films” task from the “Patient QA” window to begin this section. .................................................. 14 3. Register - Select the “Register” task from the “Patient QA” window to begin this section. .................................................................. 15 • Registration Reset.......................................................................................................................................................................... 15 • Measurements ................................................................................................................................................................................ 15 • Window Level Adjustment (brightness and contrast)................................................................................................................ 16 • Zoom and Lock Viewports ........................................................................................................................................................... 16 • Creating a New Fiducial Template .............................................................................................................................................. 20 • Recommended Fiducial Template Design ................................................................................................................................... 20

4. Calibrate - Select the “Calibrate” task from the “Patient QA” window to begin this section................................................................ 22 • Designating the Background Image ............................................................................................................................................. 22 • Generating the Response Curve ................................................................................................................................................... 22 • Save/Open Calibration Curve ...................................................................................................................................................... 23 • Correcting for Processor Variations............................................................................................................................................ 23 • Automated Dose Value Input (optional)....................................................................................................................................... 24 • Converting Film Images to Dose .................................................................................................................................................. 25

5. Evaluate - Select the “Evaluate” task from the “Patient QA” window to begin this section. ................................................................ 26 • Normalization - Select the “Normalization” button [5.A.3] to open the Normalization window [Figure 5.B]............................. 27 • Isolines ............................................................................................................................................................................................ 29 • Dose and Spatial Adjustments...................................................................................................................................................... 30 • Profiles............................................................................................................................................................................................ 31 • Units Selection................................................................................................................................................................................ 32 • Evaluation Maps............................................................................................................................................................................ 33

6. Reports..................................................................................................................................................................................................... 37 • New Report .................................................................................................................................................................................... 37 • Adding Data to a Report ............................................................................................................................................................... 37 • View Reports.................................................................................................................................................................................. 38 • Report Lay-Out ............................................................................................................................................................................. 39 • Report Navigation ......................................................................................................................................................................... 39

V. Physics QA.............................................................................................................................................................................................. 40 1. Flatness & Symmetry.............................................................................................................................................................................. 40

2. StarShot Analysis .................................................................................................................................................................................... 45

3. Multileaf collimator (MLC)Analysis………………………………………………………………………………………………………………..50

TTAABBLLEE OOFF CCOONNTTEENNTTSS

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4. End-To-End Test……………………………………………………………………………………………………………………………………….58

VI. Database Options ................................................................................................................................................................................... 66 • Database Selection ......................................................................................................................................................................... 66 • Dataset Group Set-up.................................................................................................................................................................... 67 • Other Database Information ........................................................................................................................................................ 68

Index 69

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I. Introduction FILMQA™ is a sophisticated quantitative analysis tool specifically designed to simplify and streamline your IMRT QA process. FILMQA™’s unmatched flexibility allows the user to work with any film and any scanner, and employs an intuitive design with easy-to-use features. When combined with GGAAFFCCHHRROOMMIICC®® EEBBTT dosimetry film and a professional flat-bed color scanner, FILMQA™ is ideal for the fast-paced, processorless environment of the modern hospital. The purpose of the FILMQA™ User’s Guide is to familiarize you, the user, with the many useful features of FILMQA™. Use the Table of Contents to easily navigate to the desired section, or read through the step-by-step instructions for a complete FILMQA™ demonstration. Our goal is to provide both an in-depth introduction to, and a quick reference for, all of the features available in FILMQA™. The “Patient QA” portion of this user’s guide will reference the demo case (provided with FILMQA™) to demonstrate the proper procedures to follow for a complete IMRT case analysis. This demo showcases a BrainLAB BrainSCAN® treatment plan (consisting of seven individual fluence maps, as well as the composite distribution of the coronal plane) and compares it to the corresponding irradiated GGAAFFCCHHRROOMMIICC®® EEBBTT patient films. The “Patient QA” section is a representative example of the steps to follow for a fast, easy, and complete IMRT QA analysis. II. Downloading and Installing the Software FILMQA™ verification software is available from the 3Cognition website, at www.3cognition.com. Simply go to the download section and fill out the “FILMQA™ Demo Request Form.” When the form is complete, select the “Submit” button. Follow the instructions provided in the ensuing email for downloading, installation, and registration.

Once the software has been unlocked, there will be a fully functional copy of FILMQA™ installed on your computer. It can now be used to do your IMRT film dosimetry. FILMQA™ can utilize any TWAIN driven scanner software installed on your computer for the purpose of digitizing dosimetry film. Note: Now would be a good time to install the software provided with your scanner (where applicable). For detailed installation and scanner set-up instructions, refer to the following documents: Epson Professional series scanner set-up – QAI 367; Vidar VXR-16 installation and set-up - QAI 367A and QAI 368, respectively. These and other protocol documentation available at www.gafchromic.com.

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III. Getting Started When you first open FILMQA™, a splash screen window similar to Figure A will appear. Click anywhere on that window to continue opening the software.

Figure A Note: The software version, your “Site ID”, and the “License Expiration” are located on this screen (Figure A). This may be useful information if you need to update to a newer version or acquire a new license for the software. FILMQA™ is fully opened and operational when you see the window in Figure B.

Figure B

Site ID: Your ID License Expiration

The “Patient QA” window displays the six-step task list to be followed for the analysis. After you complete the steps for each task, you will simply select the next task to continue with your analysis.

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• Import Options (color channel selection) Since GAFCHROMIC® EBT dosimetry film produces blue images, the greatest response is obtained in the red color channel. FILMQA™ software has a menu option to select which color channel (red, green or blue) of an RGB image to use for calibration and data analysis (Red is default). In the drop-down menu under “File”, select “Options”. In the options window [Figure C], choose “Import”, select the red color channel, and click “OK”. All subsequent operations on the images will be performed on the red color channel. This step is not necessary if radiographic films are being used in the analysis.

Figure C • Scanner TWAIN Source Selection If you have more than one TWAIN driven scanner software installed on your computer, you can select which scanner to use for your film digitization by choosing the appropriate TWAIN source. In the drop-down menu under “File”, select “Scan > Select TWAIN source…”. After you highlight the appropriate source, push the “Select” button to save your scanner selection. All subsequent scans will be done using the selected scan source. If you do not see the desired scanner in the “Sources:” list, then the TWAIN driver for that scanner is not installed. The TWAIN driver for any given scanner must be installed for use in FILMQA™.

Figure D

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• Saving a New Case/Patient To save a case at any point during an analysis, in the drop-down menu under “File”, select “Save as…” [Figure E]. If you have not previously saved this patient and/or case, input the information into the appropriate fields and select “OK”. To save a new case for an existing patient, simply select the patient from the “Existing Patients” window, fill in the information in the “Create Case” window, and select “OK”. During an analysis, it is good practice to periodically save your data. If you have already saved the patient and case information, simply select “Save” in the drop-down menu under “File” and FILMQA™ will save your progress. • Opening/Deleting a Case/Patient To open a previously saved case, in the drop-down menu under “File”, select “Open Case…”. Select the desired patient and case from the list, or use the search fields to search the database for the desired patient and case, and select “OK”. To delete a previously saved case, in the drop-down menu under “File”, select “Delete Case…”. Select the desired patient and case from the list to be deleted, or use the search fields to search the database for the desired patient and case, and select “Delete Case”. To delete the patient from the database, select “Delete Patient”. Deleting a patient from the database will delete all cases associated with that patient.

Figure E

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IV. Patient QA The “Patient QA” portion of FILMQA™ is specifically designed for fast, easy, and sophisticated IMRT plan verification. The “Patient QA” window displays the six-step task list to be followed for the analysis. After you complete the steps for each task, you will simply select the next task to continue with your analysis. 1. Import Calculations - Select the “Import Calculations” task from the “Patient QA” window to begin this section. The first task in your IMRT analysis is to import the calculations from the treatment planning system. Select the appropriate “File Type” [1.A.1] and find the directory where your calculations are located using the “File Browser” [1.A.2]. You can individually select the calculations to be analyzed, or select all of them by checking the “Select All Files in Folder” check-box [1.A.3]. Choose the appropriate group from the “Group Information” drop-down box [1.A.4] and then add those images to that group by selecting the “Add Dataset(s)” button [1.A.5]. The thumbnail images of your calculations are added to the analysis and placed in the selected group on the left [1.A.6].

Note: The “Filter” box (1.A.7) will filter the appropriate files for the “File Type” chosen. If you do not see the files you are looking for and you are sure you are in the correct directory, check to see that you have selected the appropriate “File Type” (1.A.1). If you want to see all of the files in the selected folder, choose the “*.*” option from the “Filter” box.

1.A.2

1.A.3 1.A.7

1.A.1

1.A.4

1.A.6

Figure 1.A

1.A.5

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• NOMOS Corvus Calculations Import If you use NOMOS Corvus as your treatment planning system, you will be prompted to input the “Resolution (mm)” and “Max Dose (cGy)” of the image when you select the “Add Dataset(s)” button. Input the appropriate values and press “OK”.

Figure 1.B • 3D DICOM Calculations Import If you use wish to import one or more planes from a 3D DICOM Dose volume exported by your treatment planning system, select the 3-D calculation file from the file list and the “Dose Volume Import” window will appear. In the “Plane Selection” window, choose the plane and slice you would like imported into the analysis and select “Import Plane”. Multiple planes and slices can be imported into a given analysis using the “Dose Volume Import” window. When you have imported all of the desired fields into the analysis, select “Exit”.

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Figure 1.C • Manual Image Resolution Input In the unlikely event the imported image resolution data is inaccurate, FILMQA™ has a feature that will allow you to manually input the image resolution information. After you import your image, right-click on the thumbnail (now on the left under the group name) and select the “Set DPI…” option. Set the resolution of the image and press “OK”.

Figure 1.D

• Image Multiplication FILMQA™ allows you to multiply the image information (i.e. dose, level, etc.) by a factor of your choosing. After you import the image, right-click on the thumbnail (now on the left under the group name) and select the “Multiply…” option. Input the multiplication factor desired for the image and press “OK”. Although an available option, this feature is not commonly used for standard IMRT QA.

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Figure 1.E • Minimize/Maximize Dataset Groups At any time during your analysis you can minimize or maximize the view of any dataset group. To do this, select the “+” or “-" sign, located to the left of the dataset name [1.F.1].

6.d.1 1.F.1

Figure 1.F

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• Treatment Planning System Output File Extensions FILMQA™ supports a multitude of treatment planning system (TPS) output files to be used for an IMRT analysis. Each TPS has its own output file format that is denoted by a specific file extension. The following table displays the treatment planning systems with their corresponding output file extensions:

TPS BrainLAB BrainSCAN

CMS Xio

CMS Focus

NOMOS Corvus

Nucletron Oncentra

Nucletron Plato Dose Grid

Nucletron TheraPlan

Plus

Philips ADAC

Pinnacle Prowess Tomotherapy Varian

Eclipse

File Extensions .flu, .dat .txt .txt .tif .dcm starts

with .D .dcm .header, .img* .dcm .header,

.img* .dcm

Figure 1.G

FILMQA™ also allows the use of generic “.tiff” and DICOM (“.dcm”) files. *Note: The “.img” file will not be visible while importing into FILMQA™, but it is necessary for the “.img” file to be present in the same directory of your computer as the “.header” file. • Removing Files from a Dataset Files in a dataset group can be individually removed from the analysis. To remove files from a dataset group, simply click-and-drag the thumbnail image to the trash can icon in the FILMQA™ main window [1.H.1]. To remove an entire dataset, the images must be removed one at a time. Once the final image has been removed, the dataset will no longer appear under the “Patient QA” task list.

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• Undo File Import In case of accidental import of files into a dataset, FILMQA™ makes it easy to quickly remove those files from the analysis. After the files have been imported, the “Add Dataset(s)” button is temporarily replaced with an “Undo” button [1.H.2]. Selecting the undo button will remove the most recently imported files. This feature is available in both the “Import Calculations” and “Import Films” tasks.

1.H.1

1.H.2

Figure 1.H

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2. Import Films - Select the “Import Films” task from the “Patient QA” window to begin this section. The second task is to import the digitized film images into the analysis. This can be done several ways:

1. If the film images already exists on your computer as “.tiff” files, select the “Tiff” file type [2.A.1] and find the appropriate directory where your film files are located using the “File Browser” [2.A.2]. Individually select the images to be analyzed, or select all of them by checking the “Select All Files in Folder” check-box [2.A.3]. Choose the appropriate group from the “Group Information” drop-down box [2.A.4] and add those images to that group by selecting the “Add Dataset(s)” button [2.A.5]. The thumbnail images of your digitized films are added to the analysis and placed in the selected group on the left [2.A.6].

2. Since FILMQA™ has the ability to operate TWAIN driven scanner software, film images can also be imported into the analysis directly from your scanner. To do this, select the group you would like to put the images into [2.A.4], type in an appropriate prefix you would like your files to be labeled with [2.A.7], and select the “Scan” button in the “Scanner” window [2.A.7]. After your scanner software interface loads, scan all of the films for your analysis and then exit the scanner software interface. All of your digitized images will be in the desired color channel and placed in the previously selected group [2.A.6]. For scanner software set-up, refer to QAI 367 (Epson) and QAI 367A (Vidar).

Figure 2.A

2.A.2

2.A.5

2.A.7

2.A.1

2.A.4

2.A.6

2.A.8

Note: The three thumbnail images represent the three color channels (red, green, and blue, respectively) [2.A.8]. The green box around the first (red) image means you have selected the red color channel image to be used for the analysis. A single click on any of these images will select/deselect the image(s) to be imported.

2.A.3

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3. Register - Select the “Register” task from the “Patient QA” window to begin this section. The Third task is to register the orientation of the digitized film images with respect to the treatment plan calculation images. This section covers the three techniques that can be used to register the orientation of the patient films. Drag-and-drop one of the patient thumbnail images [3.A.1] into the “Image to Register” window [3.A.2], and the corresponding calculation image [3.A.3] into the “Reference Image” window [3.A.4]. At this point, the two images are not yet registered.

FILMQA™ offers the option to reset the image registration, take measurements of an image, and adjust the window levels (brightness and contrast) of the images while in the “Register” task. • Registration Reset At any point in the registration process, FILMQA™ allows you to reset the image to its original orientation (prior to registration). To do this, right-click on the “Image to Register” window [3.A.5] and select “Reset Registration” from the menu. • Measurements Measurements can be made by selecting the “Draw Profile” tool [3.A.6] and drawing a line in either image window. The length of that line will be displayed under the “Magnify Position” window, along with the “Cursor Position (mm)” and “Cursor Value” [3.A.7]. The “Magnify Position” window will show a magnified image of the area under the position of your cursor when it is in either image window.

3.A.1

3.A.2

3.A.3 3.A.4

3.A.5

3.A.6

3.A.7

Figure 3.A

3.A.8

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• Window Level Adjustment (brightness and contrast) To adjust the window level and window width (i.e. brightness and contrast) of an image, select the “WL and WW” button [3.A.8] and click-and-drag the cursor over the image window. Click-and-dragging the cursor vertically will adjust the window level, and click-and-dragging the cursor horizontally will adjust the window width. These adjustments help to view the image better and will not affect the analysis results. FILMQA™ offers several methods by which one can register an image. They are as follows:

1. Manual Registration (Rotate/Invert/Swap Axes) Select the “Manual Registration” tab [3.B.1]. Here, there are tools to quickly swap the axes, invert either the X or Y-axes, and also to rotate the image by ±90 or 180 degrees [3.B.2]. Use these tools to move the axes until your image is in the correct orientation. You may also use the “Nudge” tool to perform translations and rotations of the image, relative to the axes [3.B.3]. The “Fine-Course” slider-bar control is used to calibrate the movements of the “Nudge” tool [3.B.4]. Upon completion of an image registration, green crosshairs appear on the thumbnail image at the detected center [3.B.5] (representing the central axes of the beam).

Figure 3.B • Zoom and Lock Viewports Use the slider bar to zoom in/out on the selected viewport window [3.B.6]. Selecting the “Lock viewports…” option [3.B.7] will bring both viewport windows to the same zoom location, and, when the cursor is brought over either viewport window, a cross-hair will appear to correlate the cursor position [3.B.8]. The zoom bar is also available in the “Calibrate” and “Evaluate” tasks.

3.B.1

9.1 9.2 3.B.2

3.B.3

3.B.4

3.B.6

3.B.7

9.113.B.8

3.B.5

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2. Manual Registration (Align to Axes) Manual registration can also be done using the “Align to Axes” option. Select the “Navigate” tool [3.C.1]. To translate the image, click and move either the X or Y-axis to the desired location [3.C.2]. Also, by grabbing the ends of either axis, you can rotate the image [3.C.3]. When you are satisfied that you have the correct center and orientation, push the “Align to Axes” button to register the image [3.C.4]. Upon completion of an image registration, green crosshairs appear on the thumbnail image at the detected center [3.C.5] (representing the central axes of the beam).

Figure 3.C

3.C.1

9.53.C.23.C.3

3.C.4

3.C.5

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3. Relative Registration Select the “Relative Registration” tab [3.D.1]. Using this registration method will allow you to define spatially-related points that will correlate the film image to the calculation image. Select the “Add POI” tool [3.D.2] and use this to define the common points on the film and calculation images (three or more) [3.D.3]. To remove a point, select the “Delete POI” tool [3.D.4] and click near the point to be deleted. To move a POI to a different location, select the “Move POI” tool [3.D.5] and drag-and-drop the POI to the desired location.

As you place points on the image, the “Fiducials” window list [3.D.6] will populate with the coordinates of the POI, in the order they were placed there. For the relative registration feature to work, it is necessary for there to be at least three POI placed on both the “Image to Register” (blue dots) and the “Reference Image” (red dots). The order of POI placement is not important; only the spatial orientation is important. By selecting the “Solve Matching” button [3.D.7], FILMQA™ will determine which points best correspond to each other, by finding the permutation that has the lowest “Registration Error” (this error has units of mm). This is used to calculate the transformation needed to align the two images. You can now preview the orientation by selecting and holding the “Preview” button [3.D.8]. If the resulting registration is satisfactory, select the “Apply” button [3.D.9] and the image will remain in the newly registered orientation. Upon completion of an image registration, green crosshairs appear on the thumbnail image at the detected center [3.D.10] (representing the central axes of the beam). To clear all of the fiducial POI (and their corresponding coordinates) from an image, select the “Clear Fiducials” button [3.D.11].

Figure 3.D

3.D.1

10.1 3.D.3

3.D.6

3.D.4

3.D.5

3.D.7

3.D.8

3.D.9

3.D.2

3.C.103.D.11

3.D.10

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• Relative Registration Fine Adjustments Fine spatial adjustments on POI can be done using the “Magnify Position” windows [Figure 3.D]. To do this, select the POI from the “Fiducials” list and the location of the selected POI will appear in the “Magnify Position” window (the green and red cross-hairs will also appear in the image windows over the POI selected). Use the curser in the “Magnify Position” window to move the POI to the desired location.

4. Fiducial Map Detection (automated fiducial detection) The Fiducial Map Detection registration method is the best, most convenient way to register the orientation of the patient film images. This feature allows you to register the orientation of all of the films in the analysis with one click. FILMQA™ employs the use of user-definable fiducial maps to identify fiducial marks (of known coordinates) placed on the dosimetry film. Once the appropriate fiducial map is selected, one click is all it will take to align all of the films in your analysis. Before you can use this feature you must have created a fiducial template and used it to mark your patient films prior to irradiation (see next section).

Select the “Fiducial Map Detection” tab [3.E.1]. In the drop-down menu [3.E.2], select the particular fiducial map used on the film images (assuming that the film has been marked with fiducial marks). Be sure to check the “Detect all in group” option, and then select the “Detect” button [3.E.3]. The patient film images will become aligned with the fiducial map. For each successful detection, green crosshairs appear on the thumbnail image at the detected center [3.E.4] (representing the central axes of the beam).

Figure 3.E

3.E.1

3.E.4 3.E.3

3.E.2

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• Creating a New Fiducial Template This feature will allow you to define the coordinates for the location of known fiducial marks, and use the resulting fiducial template to quickly and easily register the orientation of the patient films. To use this feature, you will need to design a fiducial template that has four or more points, and has an asymmetric shape. The coordinates of the points (with respect to the isocenter) must be known and will be used in the creation of the template. From the drop-down menu [3.E.2], select “-Create New Map-“. The “Image Mapping Tool” will appear [Figure 3.F]. In the “Fiducial Mapping” window, select “New” [3.F.1]. Fill in the “Title”, “Site”, and “Created By” information and select “OK” [3.F.2]. This information will be used to identify your new fiducial map. Select the “Move ROI” tool [3.F.3] and left-click your mouse near the first fiducial mark you would like to map [3.F.4]. If FILMQA™ recognizes that point, the magnify window will center on that point in an enlarged view. Select the “Add” button [3.F.5] in the “Fiducials” window and type in the point’s corresponding X and Y coordinates [3.F.6]. Select “OK” to save that point. Left-click your mouse over the next fiducial point you would like to map and type in the corresponding X and Y coordinates for that point. Repeat this process until you have included all the points you would like for this fiducial map. When you have finished defining the coordinates for all of your fiducial points, you may test the newly created template by selecting the “Detect Fiducials” button [3.F.7]. If the result is satisfactory, select the “Save” button in the “Fiducial Mapping” window to save this map. To apply this fiducial map to the current image, select the “Apply” button [3.F.8]. Select the “Exit” button to return to the registration screen. Your new template will now be available in the drop-down box in the “Fiducial Mapping” window [3.E.2].

• Recommended Fiducial Template Design When designing a fiducial template for use with the automated “Fiducial Map Detection” registration option, it is important for the spatial arrangement of the points to be unambiguous, so that the orientation of the patient films can be uniquely determined. To accomplish this, an asymmetric design should be employed that uses a minimum of four points. It is recommended that at least three of those points reside on-axis. The use of on-axis points can prove useful as a visual verification for manual registration in the event that fiducial detection fails.

3.F.4 3.F.2 3.F.1

3.F.6

3.F.3

3.F.5

Figure 3.F

3.F.8

3.F.7

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5. Phantom Detection (automated phantom detection) New in FILMQA™, has the ability to detect films from specific phantoms. These include the new Ball Cube II phantom from Accuray. The Ball Cube II includes two sets of laser cut films [3.G.1] that are placed in the Ball Cube II phantom orthogonal to each other. The films allow measurements of the Anterior-Left (A-L) and Anterior-Superior (A-S) planes. Begin by selecting the appropriate phantom [3.G.2] and the corresponding picture will be show [3.G.3]. FILMQA™, includes power detection routines that have been customized to the Ball Cube II phantom. One has complete control over these detection routines as well as any processing that is done upon successful detection. In particular one can crop the films upon detection, fill in the laser cut slits as well as fill in the laser cut holes [3.G.4]. Furthermore one can control the cropping [3.G.5] from the default setting which is set to the size of the laser cut films. The laser cut films can be filled to allow better comparison with the corresponding calculation sets where one can control the margin beyond the laser cut slits and holes that FilmQA uses to fill in the data [3.G.6]. FILMQA™allows two registration techniques, rigid-body and non-rigid body [3.G.8]. In rigid-body method, FILMQA™does not modify pixel resolution of the image but merely translates and rotates the image until the laser cut holes best match the expected positions. The other option, non-rigidy body (recommended method), FILMQA™can also adjust the pixel resolution essentially allow skewing and distortion for a better match. This has the effect of correcting for slight spatial inaccuracies in the scanner. Clicking the Detect Films button FILMQA™ will in a single-click detect, crop and remove laser cuts (if desired) [3.G.8].

3.G.1

3.G.2

3.G.3

3.G.4

3.G.5

3.G.6

3.G.7

3.G.8

Figure 3.G

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4. Calibrate - Select the “Calibrate” task from the “Patient QA” window to begin this section. The fourth task is to calibrate the patient films and convert them to dose images. This is accomplished by using a calibration film(s) that has been exposed to known doses to generate a response curve. This response curve will be used to correlate the pixel-values of the exposed regions to dose values. Converting the images to dose will allow you to compare the film images with the calculation images in a common plane (in dose-space).

• Designating the Background Image FILMQA™ has a powerful built-in feature that makes use of the unexposed film image to correct for non-uniformities of your scanner. In order to make use of this feature, right-click on the thumbnail image of the unexposed film [4.A.1] and select “Background Image” from the menu. The letters “BGD” appear on the thumbnail image, confirming the selection as the designated background image. Then, select the “Apply background corrections” option [4.A.8]. Note: All of the images must be the same size for this correction to work properly. • Generating the Response Curve Click on the thumbnail of the calibration film [4.A.2] to show the image in the display window. Select the “Draw ROI” tool [4.A.3] and draw a small region of interest at the center of one of the calibration fields [4.A.4]. Click on the “Add ROI” button to open the “Response Curve Point” window [4.A.5]. Enter the dose value for that area and select “OK”. Then select the “Move ROI” tool [4.A.6], move the ROI to the other calibration fields, and enter the corresponding dose values. As you input values into the table, your response curve will be generated. Select the appropriate “Function” that draws the best-fitting line for your points [4.A.7]. Be sure to select the “Apply Background Corrections” check box AFTER all dose values are entered [4.A.8]. To remove all of the ROI from the calibration image and the corresponding data from the list/graph, select the “Clear” button [4.A.9].

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• Save/Open Calibration Curve After inputting the values for your response curve, FILMQA™ allows you to save that curve for future use. To save a calibration curve, draw your ROI’s and fill in the appropriate values for the calibration film (as demonstrated in the previous section). Be sure to select “Apply background corrections”. Click “Save…” [4.B.1], fill in all of the information fields, and select the “Save” button.

Figure 4.B The “Response Library Manager” can be used to open, edit, and delete saved calibration curves. Select “open…” to open the “Response Library Manager” [4.B.3]. Use the drop-down menu and select the desired calibration curve [4.B.4] (they are labeled by the date they were created with the most recently saved curve at the top of the list). Select “open” to use the selected response curve for your analysis, select “Edit” to modify the “Response Information” [Figure 4.B.1], or select “Delete” to delete the selected response curve from the database. The specifications of a selected response curve are displayed at the bottom of the “Response Library Manager” window [4.B.5]. • Correcting for Processor Variations FILMQA™ has the ability to correct for processor drift and other processor variations. While processing radiographic films for IMRT analysis, slight variations in the processor (i.e. temperature, chemical mixture, etc.) could cause film-to-film variations that may lead to inaccurate evaluation results. To correct for this, it is necessary to irradiate two (2) calibration films (both with the same dose-value calibration fields) and set aside two (2) unexposed films. When processing the batch of films, process one calibration film and one unexposed film first, process the patient films, and then process the remaining calibration and unexposed films last. During your FILMQA™ analysis, be sure to import both digitized calibration and unexposed films into the patient film dataset. While in the “Calibrate” task, follow the steps for generating the response curve (use both calibration films). Select the “Correct for processor variations” option [4.B.6], designate both unexposed films as the background films [4.A.1], and be sure to select the “Apply Background Corrections” option.

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• Automated Dose Value Input (optional) The use of a pre-defined dose list can be employed to automatically input the dose values for the individual calibration fields (i.e. FILMQA™ will automatically input the dose value when the “Add ROI” button is selected [4.A.5]). If you have already set up the dose-list text document (see Creating a Dose-List), use the drop-down box to select the appropriate dose list [4.B.2] and select the check box next to the drop-down box to activate the feature. Now when you draw your ROI on a calibration field and select “Add ROI”, the dose value for that ROI will automatically be placed in the “Value” field [4.A.5]. Move the ROI to the subsequent calibration fields, select “Add ROI”, and select “OK”. The order in which the calibration fields are selected must be followed according to the dose-list.

Creating a Dose-List The values for the dose-list are stored in a text document located in the “Calibration” folder in the FILMQA™ directory of your computer (i.e. C:\Program Files\3cognition\FilmQA\Calibration). To create a new dose list, you will have to open an existing dose-list, modify it, and save it under a different name. It is very important that only the values in the individual fields are modified. Do not modify the format of the text file. Open the text file named “DOSE.8-step” [Figure 4.C] (located in the “Calibration” Folder). Modify the following fields with the appropriate information: File Version, Title (this is the name of the dose-list that will be displayed in the drop-down box [4.B.2]), Site, Created By, Creation Date, Creation Time, Comments, Number of Points, and the dose values under “Dose (cGy)”. When editing the dose values, input the individual values on a separate line and arrange them in the order the calibration fields are oriented on the calibration film. After all of the fields are modified to your satisfaction, save the text file with a distinct and representative name. It is recommended that the dose-list text file is labeled with the prefix “DOSE.“ for easy distinction (e.g. “DOSE.8-step”, “DOSE.# of steps.date created”, etc).

Figure 4.C

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• Converting Film Images to Dose To convert your films images to dose using your newly-generated Response Curve, choose the appropriate group from the “Group Information” drop-down box [4.D.1] and then click the “Convert Dataset(s)” button [4.D.2]. The thumbnail images of your converted images are added to the analysis and placed in the selected group on the left [4.D.3].

Figure 4.D Note: FILMQA™ automatically minimizes the group(s) consisting of unconverted films after the images have been converted to dose [4.D.4].

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5. Evaluate - Select the “Evaluate” task from the “Patient QA” window to begin this section. The fifth task is to evaluate the converted patient dose images with the calculation images. FILMQA™ offers a multitude of quantitative analysis tools with which to do your analysis. Drag-and-drop one of the patient thumbnail images [5.A.1] into the top window, and the corresponding calculation image [5.A.2] into the bottom window. In order to begin the quantitative evaluation process, these images need to be normalized (see explanation in “Normalization” section, p.24).

Figure 5.A Note: FILMQA™ makes it easy to cycle to the next pair of film/calculation images. This feature can be utilized throughout the Evaluation task by using the thumbnail arrows located at the bottom left of the main “Evaluation” task window [5.A.7] and at the bottom of the “Normalization” window [5.B.3]. You can also cycle through the individual images to be normalized in the “Normalization” window [5.B.4]. • Field Identification The “Identification” window in the “General” tab can be used to input the “Field ID” information [5.A.8]. This designation information will be displayed under the “FIELD INFO” section of the report [6.C.1].

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• Normalization - Select the “Normalization” button [5.A.3] to open the Normalization window [Figure 5.B]. By default, FILMQA™ uses the maximum dose value of each image as the 100% level for that image [5.A.4], and the isodose lines (or “Isolines”) represent a dose percentage of that maximum value [5.A.5]. For the calculation images, FILMQA™ imports the maximum dose value data from the treatment planning system. However, for the patient film images, FILMQA™ selects the maximum dose found on the image (once converted to dose). Fiducial marks, labels, or writing on the film image may result in the designated maximum dose of the image to not reflect the actual maximum dose. Since FILMQA™ sets the 100% level to this value, the isolines for the patient films (thin lines) will generally not match the isolines for the calculations (thick lines) [5.A.6]. In order to correct this and compare the images quantitatively, the images must be normalized. FILMQA™ offers several methods by which one can normalize an image. They are as follows:

1. Absolute (cGy) - Normalization of a composite distribution Use this option if the same number of monitor units was used in the treatment plan calculation as was used to expose the film. Select the “Absolute (cGy)” option in the “Normalization Method” window [5.B.1]. Selecting the “Match normalizations” button [5.B.2] will set the level of the patient film image equal to the level of the calculation image. Select “OK” to invoke this normalization and return to the “Evaluate” task.

Figure 5.B

NOTE: FILMQA™ has a feature that will allow you to normalize all of your films at the same time. If all of the images in the calculation and patient film dataset groups require the exact same normalization and both sets of images are in the correct order with respect to each other, select the “Matches entire group” option [5.B.5] before you select the “Match normalizations” button [5.B.2].

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2. Absolute (cGy/MU) - Normalization of an individual fluence map Use this option if a different number of monitor units was used in the calculation as was used to expose the film. Input the number of monitor units used in the calculation in the “Monitor Units (MU)” field in the “Primary normalization” window, and input the number of monitor units used to expose the film in the “Monitor Units (MU)” field in the “Secondary normalization” window [5.C.1]. Select the “Absolute (cGy/MU)” option in the “Normalization Method” window [5.C.2]. Selecting the “Match normalizations” button [5.C.3] will correctly set up the patient film level. Select “OK” to invoke this normalization and return to the “Evaluate” task.

Figure 5.C NOTE: FILMQA™ has a feature that will allow you to normalize all of your films at the same time. If all of the images in the calculation and patient film dataset groups require the exact same normalization and both sets of images are in the correct order with respect to each other, select the “Apply MU settings to entire group” button after you input the corresponding number of monitor units. Then select the “Matches entire group” option [5.C.4] and the “Match normalization” button [5.C.3].

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• Isolines The “Isolines” tool compares specific dose levels of the patient films to the calculations. To view the isoline contours (isolines) of the patient and calculation images, select the “Isolines” tab [5.D.1]. The calculation contours are represented by the thick lines, and the patient film contours are represented by the thin lines [5.D.2].

Figure 5.D

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To change the contour line settings (i.e. color, level, etc.) of either the calculation or the patient film, right-click on the image window, select “Properties…” [5.D.3], and select the “Isolines” tab. You can also change the isoline levels and color palette in the “Isoline definition” window by selecting the “isolines…” button [5.D.4].

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FILMQA™ offers two different display modes for isoline comparisons. They are as follows:

1. Multiple Levels - You can view multiple isodose levels by selecting the “Multiple levels” option in the “Isoline Mode” window [5.E.1]. You can see this mode demonstrated in Figure 5.D.

2. Dynamic Level - You can also view individual isodose levels by selecting the “Dynamic level” option in the

“Isoline Mode” window [5.E.1] and moving the “Dynamic Level (%)” slider bar to the desired level value [5.E.2].The isolines will refresh/change in real-time as you scan the slider bar to a different value.

FILMQA™ also allows isodose contours to be displayed with the dose image in the background. This feature is demonstrated in Figure 5.E and can be implemented by selecting the “show background image” option [5.E.3].

Figure 5.E • Dose and Spatial Adjustments While in the “Evaluation” task, there is the option to adjust the alignment, and scale the dose, of the patient film images. To do this, select the “Dose & spatial adjustments” tab [5.E.4]. The “Spatial” buttons can be used to perform translations and rotations of the image, relative to the axes [5.E.5]. The “Fine-Course” slider-bar control is used to calibrate the movements [5.E.6]. The “Dose” slider bar can be used to adjust the dose of the patient image by ±15% (a factor of 1.150 to 0.850) [5.E.7]. All adjustments made using the “Dose & spatial adjustments” tools are recorded in the “User Adjustments” window [5.E.8] and documented in the statistics of the report.

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• Profiles The “Profiles” tool is used to show a cross-sectional comparison of the calculated dose to the dose delivered to the patient film. In order to compare the images on the same “Dose (%)” scale (the “Relative (%)” option), the images must be normalized (see “Normalization”, pp.24-25). To view the profiles of the patient and calculation images, select the “Profiles” tab [5.F.1]. Horizontal / Vertical Profiles The green and red lines [5.F.2] on the images indicate the locations of the horizontal and vertical profiles, respectively. Click-and-drag on the profile line to shift to a different location. The profile graph will refresh/change in real-time as you move the profile line across the image. The thumbnail image on the graph also shows where the profile is being measured [5.F.3]. The color of the lines used for the graph [5.F.4] is determined by the color of that dataset group. The blue line on the graph represents the dose-difference profile.

Figure 5.F

Profile Export

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FILMQA™ can be used to export the patient field profile data into a simple text document (.txt) for analysis in spreadsheet or other data analysis programs. After the profile location has been chosen, select the “Save” button [5.F.5], name the file, and save it in an appropriate directory.

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Oblique Profiles To view a specific oblique profile, select the “oblique” profile mode option [5.G.1] and use the cursor to draw the desired profile in either the top or bottom image window. The profile will be displayed in real-time as you draw the profile. Both of the image windows and the thumbnail image on the graph show where the profile is being measured (blue line). If you bring your cursor over the graph, the cross-hairs denote the profile position [5.G.2]. The dose statistics for that position are shown in the “Statistics” window [5.G.3]. This feature is available in all of the profile modes.

Figure 5.G • Units Selection While in the “Evaluate” task, FILMQA™ offers the option to do the analysis in units of “Relative (%)”, “Absolute (cGy)”, or “Absolute (cGy/MU)”. The desired units for the analysis can be chosen in the “Units” window [5.G.4] in the “Profiles” tab. The “Relative (%)” is the default selection, and is based on the scale defined in the “Normalization” window [Figures 5.B & 5.C]. The measurements/calculations displayed on the Y-axis and the “Statistics” window are in the selected units. Figure 5.G demonstrates the “Absolute (cGy/MU)” option.

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• Evaluation Maps FILMQA™ includes a selection of evaluation maps which can be used to compare the dose-distribution of the patient films to the dose-distribution of the calculations. These include a Dose-Difference map, a Gamma map, and a Distance-to-Agreement (DTA) map. Each map shows an over-lay comparison of the images on a pixel-by-pixel basis. To view the evaluation maps, select the “Evaluation maps” tab [5.H.1]. The user-defined tolerance criteria for each map can be set by clicking the button to the right of the selection [5.H.2] and entering the desired value. These values are displayed next to the map title [5.H.3] Dose-Difference Map The Dose-Difference map graphically displays the pixel-by-pixel dose-difference between the calculation and patient film images based on the user-defined tolerance criterion. Select the small box (button) next to the “Dose-Difference” map selection to set the tolerance criterion [5.H.2] (as described above).

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Distance-to-Agreement (DTA) Map The Distance-to-Agreement (DTA) map shows the pixels that find a matching dose-value based on the user-defined distance criterion. The DTA map is useful in regions of high dose gradients since a small change in displacement/distance will have a big effect on dose. Select the small box next to the “DTA” map selection to set the tolerance criterion [5.I.1]. In the DTA analysis, the software is looking at the calculated dose at a specific location and determining the distance to the nearest point with the same dose on the patient film. If the distance to agreement is greater than the tolerance criterion, the map displays that pixel in red. For distances slightly less than the criterion, the pixels are displayed in yellow, shading to green and blue as the DTA approaches zero.

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Gamma Map The Gamma map is a qualitative map that is a mathematical combination of the dose-difference and difference-to-agreement calculations. Select the small box next to the “Gamma” map selection to set the tolerance criteria [5.J.1].

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Histogram The “Histogram” option [5.K.1] can be used to show a quantitative interpretation of the data presented by a given evaluation map. The associated histogram for each map quantifies the number of pixels passing based on the user-defined tolerance criteria (i.e. “Dose (%)”, “Distance (mm)”) [5.K.2]. Select the small box next to the map selections to set the tolerance criteria of your maps [see Figures 5.H – 5.J]. Only the pixels within the confines of the image window are used in the quantitative histogram calculation. You can include/exclude portions of the images used in the calculation by using the zoom bar to confine your region of interest [5.K.3], or by using the “Confine to ROI” feature. Confine Histogram Calculation to Region of Interest (ROI) To define a region of interest where the calculations will be made, select the “Draw ROI” tool [5.K.4] and draw the region of interest in one of the viewports [5.K.5]. Once you have defined the region of interest, select the “Confine to ROI” option [5.K.6] and FILMQA™ will update the histogram data to include only the points that lie within the defined region of interest.

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6. Reports FILMQA™ has the ability to generate customizable HTML reports from your evaluation data. These reports are saved in the FILMQA™ database for future reference and can be printed for inclusion in your patient chart. Reports can be viewed using FILMQA™ or through the use of a web browser, and can easily be made accessible over your local area network (LAN). • New Report To create a new report, select the “new…” button in the “Reports” window [6.A.1]. Enter the report label and select “OK”. If either of the report generation buttons are selected before a new report is created, the “New Report” window will automatically open for you to input the new report label. • Adding Data to a Report There are two ways evaluation data can be added to a report: either as a single view or as a snapshot view. By selecting the “add current view” button [6.A.2], FILMQA™ will add only the view that is currently on display to the report (e.g. the oblique profile view [Figure 6.A]). By selecting the “add snapshot” button [6.A.3], FILMQA™ will add a snapshot page to the report that contains four user-defined evaluation views. This “snapshot” can be customized in the “Customize Snapshot Page”. Select the “customize” button [6.A.4] and choose which evaluation views you would like to see in your report by moving the slider bars to the desired view [6.A.5]. Select the “Apply” button to secure this format for subsequent snapshot view reports.

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• View Reports To view generated reports, select the “Reports” task from the “Patient QA” window. In the report summary page [Figure 6.B], the most recently generated report is listed first and displays the report date, name, site treated, case label, and number of pages contained within the report. Individual reports can be viewed by selecting the report thumbnail [6.B.1]. While in the reports task, FILMQA™ also offers the ability to open, delete, and print any of the reports in the database [6.B.2].

Figure 6.B

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• Report Lay-Out Figure 6.C shows an example of a single view report. The “FIELD INFO” window lists patient information pertinent to the selected field [6.C.1], including the database used and the Case/Report folder locations. Any spatial adjustments or dose-scaling done during the evaluation task are documented and displayed below the four evaluation views, along with the statistics of the Dose-Difference, Distance-to-Agreement, and Gamma calculations [6.C.2]. Reports can also be customized to include your organization’s logo [6.C.3] (Refer to “Other Database Options”, pg. 38). The date/time the report was generated and the physicist who generated the report are noted at the bottom of each report [6.C.4]. The information displayed under “FIELD INFO” is input while saving or generating a report for a case. • Report Navigation There are four navigation buttons located in the top right corner of the report. These buttons can be used to go to the next or previous page of a given report [6.C.5], the first page in a report [6.C.6], or the report summary page [6.C.7].

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V. Physics QA FILMQA™ now includes several physics QA tools. This section describes some of the tools available. 1. Flatness & Symmetry Start by importing the scanned film containing the exposed field for which you wish to analyze the Flatness & Symmetry.

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Next click on the “Register” task and drag-and-drop the dataset in the “image-to-register” window and register the film. The film should be registered to the light-field crosshairs or lasers. Proper registration of the film is important as it allows one to compute the offset of the radiation center from the user defined origin (cross-hairs or lasers).

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The next task is to convert this exposed field for which flatness & symmetry measurements are needed to dose space. Begin by clicking on the “Calibrate” task on the left and then selecting the image. If one has a background image and calibration images then one can use these to convert the exposed image for which flatness & symmetry measurements are required to dose.

It is sometimes not practical to do this and if one does not have calibration images, one can simply do a 2-point calibration by selecting the background region and central axis dose to create a calibration curve. For typical exposures where the central axis dose is around 100 cGy, regions outside the exposed field will get some small amount of exposure from scatter and leakage. Typically this is around 1-2% of the central axis dose. Begin by drawing a small ROI (around 1x1 cm in size) over an area of the film away from the exposed region and then clicking “add ROI...” button and entering a dose of between 1-2% of the central axis dose (e.g. 1.5 cGy) and then draw another ROI at the central axis and entering a exposed dose (e.g. 100 cGy).

Next choose the “linear” fitting option and convert the image to dose.

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We are now ready to analyze the flatness & symmetry. Next, click on the “Physics QA” menu at the top and choose the “Flatness & Symmetry…” option.

Next drag-and-drop the image (converted to dose) into the “Flatness & Symmetry” viewport to see the flatness & symmetry results. Using the slider at the bottom, zoom in until the exposed field fills around 60-80% of the viewport, then choose the appropriate protocol for analysis.

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Fill in the relevant reference information and save the case before adding a report for printing. Below is a sample report showing the flatness & symmetry results as well as brief description of the protocol used in the analysis.

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2. StarShot Analysis The StarShot Analysis does not require images that have been converted to dose. Start by importing the scanned films with the exposed StarShots for testing the collimator, couch and gantry rotations.

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Next click on the “Register” task and drag-and-drop the datasets in the “image-to-register” window and register each film. The films must be registered to the light-field crosshairs or lasers. Proper registration of the film is important as it allows one to compute the offsets from the user defined origin (cross-hairs or lasers).

Next click on the “Physics QA” menu at the top and choose the “StarShot Analysis…” option.

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Now drag-and-drop the relevant image into the viewport for which you wish to do a StarShot analysis.

Fill in the appropriate reference information and choose the appropriate test “collimator”, “couch” or “gantry”. On the image you will see two red circles that show the area over the image will be analyzed. It is important that the each circle clearly crosses over each beam center as shown above. Inappropriate selections can result in a failed analysis.

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Once the appropriate analysis area has been selected, click on the Make sure the “Analyze” button.

If successful, the following results will be displayed (which can be toggled on or off):

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Below is a sample report showing the StarShot analysis results.

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3. Multileaf collimator (MLC) Analysis FilmQA MLC Analysis can evaluate both Bayouth and Picket Fence (MSK) dose patterns. In the following sections performing the Bayouth Pattern MLC Analysis is described. By using a different calibration curve generated for the picket fence pattern, it can be used for the “Picket Fence (MSK)” pattern as well. To do so, open the saved response curve from the “Response Library Manager” window in the “Calibrate” task (see below Figure: 1).

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Bayouth MLC Analysis Start by importing the scan image of the film exposed to Bayouth dose pattern, the scan image of the film exposed to open field dose, and the scan image of the unexposed film [1.A.1].

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Next click on the “Register” [1.B.1] task, and drag and drop the film image exposed to Bayouth dose pattern in the “image-to-register” window [1.B.2] and register it. The film should be centered relative to the axes. Select the “Manual Registration” tab [1.B.3] and use the “Nudge” tool [1.B.4] to perform translations and rotations of the image, relative to the axes. The “Fine-Course” slider-bar control is used to calibrate the movements of the “Nudge” tool [1.B.5]. Upon completion of an image registration, green crosshairs appear on the thumbnail image at the detected center [1.B.6]

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The next task is to convert this scan image of the Bayouth pattern dose exposed film to dose using the other two films (the unexposed film and the open-field exposed film). Select the “Calibrate” [1.C.1] task and begin by dragging and dropping the open-field exposed film. Begin by drawing a small ROI [1.C.2] over an area of the film away from the exposed region and then clicking “Add ROI” button [1.C.3] and entering a dose value of 0 cGy and then draw another ROI [1.C.2] at the exposed region and entering a dose value of 100 cGy. To asssign the unexposed film as a background image, right-click on the thumbnail image of the unexposed film and select “Background Image” from the menu. After checking the “Apply Background Correction” box [1.C.4], choose the “linear” fitting [1.C.5] option and convert the image to dose [1.C.6].

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To begin conducting the MLC Analysis, click on the “Physics QA” menu at the top and choose the “MLC Analysis” option.

Figure: 5 The “MLC Analysis” module should be launched as below.

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Figure: 7 Next drag and drop the dose-converted film image into the viewport window. In “MLC Template” tab [1.D.1], select the appropriate template. There are the options in the “MLC Template Spatial Position & Scaling” [1.D.2] to perform translations and rotations of the template, and to scale the template. The “Fine-Course” slider-bar control is used to calibrate the movements. In the “Profiles” tab [1.D.4], one can obtain a cross-sectional comparison of the dose to the position of x-axis, y-axis or the length for horizontal, vertical, or oblique profiles, respectively. FilmQA offers the option to do the analysis in units of “Relative (%)” or “Absolute (cGy)”. One can simply export the profile data into a simple text document (.txt) for analysis in spreadsheet or other data analysis programs by clicking the save button.

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Next click on the MLC Analysis tab [1.E.1] to perform MLC QA (see below Figure: 8). Fill the MLC QA Parameters window [1.E.2] with the appropriate values, relative to the method followed to expose the film. To determine the dosimetric effect of MLC leaf positioning in a given tolerance range, fill the “Tolerances” window [1.E.3]. Select the relevant test from the drop down menu [1.E.4] and click the “Analyze MLC Pattern” button [1.E.5]. The display of “X1 Leaf positioning” is shown on the right of the window. By clicking the “Display Analysis” drop-down menu [1.E.6], one can change the type of analysis.

Figure: 8 Fill in the relevant reference information [1.E.7] and save the case before adding a report for printing.

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Below is a sample report showing the Bayouth Test results for the “X1 Leaf positioning”.

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4. End-To-End Test (Accuray) The End-To-End Test in FilmQA has the ability to compare measured-films directly to Multiplan calculations. It includes customized routines for analyzing laser-cut radiochromic films specific to the Ball Cube II. This allows the determination of both targeting errors due to planning and delivery targeting errors. 1. Importing Multiplan calculation Start by importing the calculations from a 3-D DICOM dose volume exported by your treatment planning system. Select the Accuray CyberKnife as the “File Type” [1.A.1] and find the directory where your calculations are located using the “File Browser” [1.A.2]. Choose the appropriate group from the “Group Information” drop-down box [1.A.3]. By selecting the 3-D calculation file in the file list [1.A.4], “Dose Volume Import” dialog box will appear (See Figure 2).

Figure 1: End-To-End Test

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Figure 2: Dose Volume Import Module After the “Dose Volume Import” window appears, click on the “Accuray” tab [1.B.1]. In the phantom drop-down menu, there are three choices; Ball Cube II, Baby Blue and Arbitrary Plane [1.B.2]. FilmQA includes customized routines for analyzing laser-cut radiochromic films specific to the Ball Cube II. At the MultiPlan Fiducials section, click the icon on the right for the file path for XML file containing the 8-fiducials (identifying the location of the laser-cut holes on the film on the Anterior-Left and Anterior-Superior films) [1.B.3]. The A-L dose plane is obtained from the 3-D dose matrix by using the coordinates of the 4 A-L plane fiducials from the XML file. With the A-L plane selected [1.B.4], click on the Import Plane button [1.B.5], and then select and import the A-S plane. Click the Exit button when done [1.B.6].

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Figure 3: After importing the two orthogonal planes In Figure 3, the thumbnails of the two orthogonal dose planes that have been loaded are displayed [1.C.1]. 2. Importing films Click on the Import Films option [2.A.1], and select the TIFF File Type [2.A.2] if it is not already selected. If necessary scan the films directly into FilmQA by clicking on the Scan button [2.A.3] to launch the scanner software. After your scanner software interface loads, scan all of the films for your analysis and then exit the scanner software. By default, FilmQA extracts the 16-bit red channel, which has the greatest sensitivity. All of your digitized images will be placed in the selected group on the left pane [2.A.4]. If the films have previously been scanned, find the appropriate directory where your film files are located using the “File Browser” [2.A.5]. Choose the appropriate group from the “Group Information” drop-down box [2.A.6] and add those images to that group by selecting the “Add Dataset(s)” button [2.A.7]. The thumbnail images of your digitized films are added to the analysis, and placed in the selected group on the left pane [2.A.4].

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Figure 4: The importing of scanned film images 3. Registering films FilmQA has the ability to detect films from specific phantoms, including the Ball Cube II phantom from Accuray. Two sets of laser cut films [3.A.1] are placed in the Ball Cube II phantom orthogonal to each other. These films allow dose measurements in the A-L and A-S planes. Begin by selecting the appropriate phantom [3.A.2] as shown [3.A.3]. FilmQA has powerful detection algorithms that can crop the film images upon detection, and fill in the laser cut slits and holes in them [3.A.4]. You can change the amount of the cropping [3.A.5] from the default setting of the size of the laser cut films. The margins beyond the laser cut slits and holes that FilmQA uses to fill in the data [3.A.6] can be changed also to allow better comparison with the corresponding calculation sets. FilmQA allows two registration techniques, rigid-body and non-rigid body [3.A.7]. In rigid-body method, FilmQA does not modify pixel resolution of the image but merely translates and rotates the image until the laser cut holes best match the expected positions. The other option, non-rigid body (recommended method), FilmQA can also skew and distort the images to correcting for the small dimensional inaccuracies in the scanning process. Click the “Detect Films” button for detecting and cropping film images, and if desired, for removing laser cuts from them. [3.A.8].

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Figure 5: Automatic registration, cropping, and filling of the film image 4. Converting films to measured dose To convert the films to dose using the calibration film(s), choose the “Calibration” option [4.A.1]. Drag and drop the background film thumbnail into the viewport [4.A.2] and draw a small region-of-interest (ROI) [4.A.3]. As the background film is unexposed, enter 0 cGy as dose value [4.A.5] after clicking on the “Add ROI” button [4.A.4].

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Figure 6: Entering the calibration point for the background film For the entering the calibration points for the exposed calibration films, drag and drop their images in the viewport [4.B.1]. For each dose draw a small ROI [4.B.2] and click on “Add ROI” [4.B.3] button and enter the dose value [4.B.4], building up a calibration curve to convert the films to dose [4.B.5]. Choose the function that fits a curve best [4.B.6]. Click the “Convert Dataset(s)” button [4.B.7] to apply the calibration curve to the scanned film images; converting them to dose images and placing them under their group [4.B.8]. Afterwards, only the calculation and the dose converted film datasets are shown in the left pane [4.B.9], and the group containing the un-converted scanned film images is collapsed.

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Figure 7: Building up a calibration curve 5. End-To-End Test Select the End-To-End Test option [5.A.1] under the Physics QA menu. Set the “Data Type” is to “Calculation” [5.A.2]. Drag and drop the A-L and A-S planes dose calculations into their windows [5.A.3]. Click the “Process” button [5.A.4], to have the two orthogonal planes analyzed and the contours at the set level (80% by default) detected [5.A.5]. When done, the detected areas as well as left, anterior, and superior errors, plus the computed targeting error of the plan are reported. These computed deviations and the targeting errors inform of the difference between the plan and a perfectly centered spherical dose distribution. To analyze the dose-converted images of the films, switch the “Data Type” to Film [5.A.2]. Drag and drop the A-L and A-S planes dose-converted film images into their windows. Click the “Process” button [5.A.4], to have the two orthogonal planes analyzed and the contours at the set level (80% by default) detected [5.A.5]. When done, the detected areas as well as left, anterior, and superior errors, plus the delivered targeting error are reported. These computed deviations and the targeting errors inform of the difference between a perfectly centered spherical dose distribution and the dose. The total targeting error [5.A.7] is a comparison between the spatial distributions of the planned and delivered doses. It is a measure of the capability of the CyberKnife system in tracking the fiducials and targeting the planned dose location.

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Click on the “Add Snapshot” button [5.A.8] to open the “Save Case” window for inputting the patient information. To save a new case for an existing patient, simply select the patient from the “Existing Patients” window, fill in the information in the “Create Case” window, and select “OK”. To view the generated End-To-End Test report, select the “Reports” task from the “Patient QA” window. While in the reports task, FilmQA also offers the ability to open, delete, and print any of the reports in the database.

Figure 8: The End-To-End Test Module

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VI. Database Options FILMQA™ utilizes a proprietary database to save patient case information. The database can be easily customized and personalized to meet the needs of your facility. By default, the “Demo” database is used by FILMQA™ to demonstrate the available options but it is recommended that a site-specific database be established and saved. • Database Selection To designate which database to use, or to change to a different database, select the “Options…” choice in the drop-down menu under “File”. In the “FilmQA Options” window, choose “File Paths”, select the icon next to the “FILMQA Database” field, select the desired database, click “Open”, and then select “OK”. Shut down and restart FILMQA™. All subsequent cases will be saved in the selected database.

Figure 7.A

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• Dataset Group Set-up The dataset groups used when importing calculations or measurements (i.e. calculation images and film images) can be customized in the “Group Manager” window. The “Group Manager” window can be accessed via the “Dataset” drop-down menu, the button next to the “Group Name”, or by selecting the “-Create New Group-“ choice in the “Group Name” drop-down box. To create a new group, designate the group type (Calculation or Measurement), input the group name, click on the color box and select the group’s color, and select the “Add” button. This dataset group will now be available for subsequent data imports.

Figure 7.B

Note: Click on the “Group Palette” option while creating/updating a calculation dataset group to toggle ‘color’ / ‘black & white’ images. Calculations imported as color images will show high dose areas in red and low dose areas in black on the following scale:

Color Image Black and White Image

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• Other Database Information Site-specific information displayed on reports or used while saving cases can also be customized. This information includes facility names and logos, physician and physicist names, treatment device specifications, and digitizer and media specifications. Select the group to be customized in the “Database” drop-down menu, input the data fields, and select “OK”. To change the facility logo, click on the picture and search the computer directory for the desired picture logo (must be in “jpg” or “jpeg” format). The data will be stored in the selected database for future use. Fields marked with “ * “ are required fields.

Figure 7.C

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Index

A Absolute (cGy) - Normalization of a composite distribution, 26 Absolute (cGy/MU) - Normalization of an individual fluence map, 27 Adding Data to a Report, 37 Apply background corrections, 21 Automated Dose Value Input, 23

B brightness and contrast, 15

C Calibrate, 21 Clear registration POI, 17 Confine Histogram Calculation to Region of Interest (ROI), 36 Converting Film Images to Dose, 24 Correcting for Processor Variations, 22 Creating a Dose-List, 23 Creating a New Fiducial Template, 19

D Database Options, 41, 51 Database Selection, 51 Dataset Group Set-up, 52 Designating the Background Image, 21 Distance-to-Agreement (DTA) Map, 33 Dose and Spatial Adjustments, 29 Dose-Difference Map, 32 Downloading and Installing the Software, 4 Dynamic Level, 29

E Evaluate, 25 Evaluation Maps, 32

F Fiducial Map Detection (automated fiducial detection), 18, 20 Flatness, 41

G Gamma Map, 35 Generating the Response Curve, 21 Getting Started, 5

H Histogram, 36 Horizontal / Vertical Profiles, 30

I Image Multiplication, 10 Import Calculations, 8, 41, 46 Import Films, 13 Import Options (color channel selection), 6 Introduction, 4 isoline contours, 28 Isolines, 28

M Manual Image Resolution Input, 10 Manual Registration (Align to Axes), 16 Manual Registration (Rotate/Invert/Swap Axes), 15 Measurements, 14 Minimize/Maximize Dataset Groups, 11 Multiple Levels, 29

N New Report, 37 NOMOS Corvus Calculations Import, 8 Normalization, 26 Normalization of a composite distribution, 26 Normalization of an individual fluence map, 27 Nucletron Plato Dose Grid Calculations Import, 9

O Oblique Profiles, 31 Opening/Deleting a Case/Patient, 7 Other Database Information, 52

P Patient QA, 8 Profile Export, 30 Profiles, 30

R Recommended Fiducial Template Design, 19 Register, 14 Registration Reset, 14 Relative Registration, 17 Relative Registration Fine Adjustments, 18 Removing Files from a Dataset, 12 Report Lay-Out, 40 Report Navigation, 40 Reports, 37 Response Library Manager, 22

S Save/Open Calibration Curve, 22 Saving a New Case/Patient, 7 Scanner TWAIN Source Selection, 6 StarShot, 46 Symmetry, 41

T Treatment Planning System Output File Extensions, 11

U Undo File Import, 12 Units Selection, 31

V View Reports, 39

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W Window Level Adjustment (brightness and contrast), 15

Z Zoom and Lock Viewports, 15