Backscatter factors are important parameters in the determination of dose for kilovoltage x-ray beams. However, backscatter factors are difficult to measure experimentally, and tabulated values are based largely on Monte Carlo calculations. In this study we have determined new backscatter factors by both experimental and Monte Carlo methods, and compared them with existing backscatter factors published in the AAPM TG-61 protocol. The purpose of this study is twofold: (1) to evaluate the overall effectiveness of using Gafchromic EBT film for backscatter factor measurements and (2) to determine whether existing Monte Carlo-calculated backscatter factors need to be updated. We measured backscatter factors using Gafchromic EBT film for three field sizes (2, 4 and 6 cm diameter cones) and three kilovoltage beam qualities, including 280 kVp for which similar measurements have not previously been reported. We also present new Monte Carlo-calculated backscatter factors obtained using the EGSnrc/BEAMnrc code system to simulate the Pantak kilovoltage x-ray unit used in our measurements. The results were compared with backscatter factors tabulated in the AAPM TG-61 protocol for kilovoltage x-ray dosimetry. The largest difference between our measured and calculated backscatter factors and the AAPM TG-61 values was found to be 2.5%. This agreement is remarkably good, considering that the AAPM TG-61 values consist of a combination of experimental and Monte Carlo calculations obtained over 20 years ago using different measurement techniques, as well as older Monte Carlo code and cross-section data. Furthermore, our Monte Carlo-calculated backscatter factors agree within 1% with the AAPM TG-61 values for all beam qualities and field sizes. Our Gafchromic film measurements had slightly larger differences with the AAPM TG-61 backscatter factors, up to approximately 2% for the 6 cm diameter cone at a beam quality of 50 kVp. The largest difference in backscatter factors, of 2.5%, was found between Monte Carlo-calculated and Gafchromic film-measured data for the 100 kVp x-ray beam with the 4 cm diameter cone. The differences in backscatter factors between the three data sets (measurements, calculations and published values) are all within the uncertainties from our Gafchromic film measurements and Monte Carlo calculations. Our results demonstrate the suitability of using Gafchromic EBT film to measure equipment-specific backscatter factors for kilovoltage x-ray beams over the entire energy range and also confirm that backscatter factors published in kilovoltage dosimetry protocols still remain valid.

Purpose: Kilovoltage intrafraction monitoring (KIM) scheme has been successfully used to simultaneously monitor 3D tumor motion during radiotherapy. Recently, an iterative closest point (ICP) algorithm was implemented in KIM to also measure rotations about three axes, enabling real‐time tracking of tumor motion in six degrees‐of‐freedom (DoF). This study aims to evaluate the accuracy of the six DoF motion estimates of KIM by comparing it with the corresponding motion (i) measured by the Calypso; and (ii) derived from kV/MV triangulation. Methods: (i) Various motions (static and dynamic) were applied to a CIRS phantom with three embedded electromagnetic transponders (Calypso Medical) using a 5D motion platform (HexaMotion) and a rotating treatment couch while both KIM and Calypso were used to concurrently track the phantom motion in six DoF. (ii) KIM was also used to retrospectively estimate six DoF motion from continuous sets of kV projections of a prostate, implanted with three gold fiducial markers (2 patients with 80 fractions in total), acquired during the treatment. Corresponding motion was obtained from kV/MV triangulation using a closed form least squares method based on three markers’ positions. Only the frames where all three markers were present were used in the analysis. The mean differences between the corresponding motion estimates were calculated for each DoF. Results: Experimental results showed that the mean of absolute differences in six DoF phantom motion measured by Calypso and KIM were within 1.1° and 0.7 mm. kV/MV triangulation derived six DoF prostate tumor better agreed with KIM estimated motion with the mean (s.d.) difference of up to 0.2° (1.36°) and 0.2 (0.25) mm for rotation and translation, respectively. Conclusion: These results suggest that KIM can provide an accurate six DoF intrafraction tumor during radiotherapy.

Purpose: In current practice, imaging is typically performed prior to treatment; the cancer target motion during treatment is unknown. We present the first clinical implementation of real time Kilovoltage Intrafraction Monitoring (KIM) system which tracks the cancer target translational and rotational motions during treatment. Methods: KIM technology: KIM estimates the 3D position of the target tumour based on segmented 2D positions of the three implanted fiducials in each of the kV images (125 kV, 10 mA at 11 fps) taken continuously during the treatment arc. The 2D‐3D target estimation is based on a probability distribution function, obtained during pre‐treatment CBCT. Rotations about each axis with the centroid of the markers as the pivot were calculated using the iterative closest point algorithm in real time. Patient: A patient with prostate adenocarcinoma undergoing stereotactic body radiotherapy (SBRT) with 36.25 Gy delivered in 5 fractions (Varian TrueBeam, 6X, VMAT) was enrolled in the study. The trial complies with Australian ethical and regulatory standards. Results: Of the 5 fractions of treatment the patient received, KIM was utilised successfully in 4 fractions with 3 couch shifts due to large persistent prostate movements (>2mm for more than 5 seconds). KIM translational accuracy and precision in comparison with post treatment kV‐MV triangulation are 0.28±0.59 mm, −0.19±0.25 mm and 0.23±0.69 mm in the Left‐Right, Superior‐Inferior and Anterior‐Posterior directions, respectively. KIM rotational accuracy as compared with triangulation is: 0.429°±2.22°, −0.44°±4.7° and 0.06°±1.08° in the roll, pitch and yaw direction, respectively. Conclusion: The first six degree of freedom KIM system was successfully implemented clinically. The presented KIM system has sub‐millimeters accuracy and precision in all three translational axes, and less than 1° of mean error in all three rotational axes. Acknowledgement: This work is supported by Cancer Australia grants APPXXX, APPYYY.

Purpose: With wide use of CBCT in IGRT, extracting the 3D target trajectory from CBCT projection images would be useful to manage intra‐ fraction motion for motion inclusive, gated and tumor tracking delivery methods. The purpose of this work was to develop a target trajectory estimation method from CBCT by employing inter‐dimensional correlation between each direction of target motion, and demonstrate its feasibility with a liver SBRT case. Methods: To estimate the target trajectory from CBCT projection images we utilize an inter‐dimensional correlation between each direction of target motion: LR(t)=a_LR×SI(t)+b_LR, AP(t)=a_AP×SI(t)+b_AP. The parameters of the simple linear correlation model were determined with least‐squares estimation by minimizing the discrepancy between the measured and model‐estimated projection positions on the imager coordinates. The method was demonstrated using a CBCT projection images obtained during liver SBRT treatment for 3D/3D matching purpose using On‐board imager of a Varian iX machine. From each projection image of the CBCT, positions of an implanted gold seed were extracted using Varian research tool (RPM‐Fluoro). The estimated trajectory was compared with the marker trajectory obtained from 10‐binned respiratory phase 4DCT. Results: In general the estimated trajectory followed well the reference trajectory from 4DCT in the case. Mean root‐ mean‐square error of the model estimation was 0.67mm in lateral direction and 0.00mm in longitudinal direction on the imager coordinates. Conclusions: A simple 3D marker trajectory estimation method using CBCT projection images was developed. Preliminary results show that it could be used to accurately localize a moving tumor.