# Quality assurance of online adaptive radiotherapy workflows using film dosimetry in a 3D printed thorax anthropomorphic phantom

## TL;DR

Researchers tested a 3D-printed thorax phantom to ensure accuracy in adaptive radiotherapy workflows, finding it effective for quality assurance.

## Contribution

A custom 3D-printed anthropomorphic phantom was used for end-to-end QA in adaptive radiotherapy, showing robustness to anatomical deviations.

## Key findings

- Gamma pass rates exceeded 95% for 24 out of 30 film measurements.
- The QA method detected density deviations of up to 1000 Hounsfield Units.
- The workflow was deemed safe and robust for clinical use.

## Abstract

•End-to-end test with an anthropomorphic phantom in adaptive radiotherapy is feasible.•For 30 film measurements, 24 had gamma pass-rates of >95 % with 4 % / 2 mm.•The end-to-end test was sensitive for deviating densities (∼1000 Hounsfield Units).•The online adaptive workflow was deemed safe and within clinical criteria.

End-to-end test with an anthropomorphic phantom in adaptive radiotherapy is feasible.

For 30 film measurements, 24 had gamma pass-rates of >95 % with 4 % / 2 mm.

The end-to-end test was sensitive for deviating densities (∼1000 Hounsfield Units).

The online adaptive workflow was deemed safe and within clinical criteria.

Quality Assurance for online adaptive radiotherapy (oART) can be challenging. Several tests can demonstrate the dosimetric and position accuracy, but commercial phantoms are often not anatomically representative. The aim of this study was to investigate the accuracy of cone-beam computed tomography guided oART palliative and breast cancer trials by using a 3D printed thorax anthropomorphic phantom.

An anthropomorphic phantom was 3D printed for this study which accommodates film through the spine, breast, heart, and lungs. Dose was measured for spine and breast treatment plans, whilst variations were simulated which can occur during treatment. Measurements were compared to calculated dose on the planning (pCT) and synthetic computed tomography (sCT) using gamma pass rate criteria of minimal 95  % (for gamma of 4  %/2 mm). Differences between the mean gamma were tested for significance.

Measurements done with positional and target volume changes showed no significant difference between the gamma analyses for the pCT and sCT (p = 0.15), indicating a robust and safe workflow. For extreme variations, difference was found between gamma analyses for the pCT and sCT (p = 0.051). Pass rates were all >95  %, except for three measurements in which the sCT showed density errors up to 1000 Hounsfield Units.

This QA approach for oART, which used film measurements in a custom 3D-printed anthropomorphic phantom was able to validate the accuracy of the oART workflow when anatomical deviations arise and could be suitable as end-to-end test in the future.