Feasibility of Megavoltage CT for High-Dose Retrospective Planning of Helical Tomotherapy and Linac Treatment Plans: Hepatocellular Carcinoma Cancer Case

Document Type : Original Paper


1 Department of Physics, Faculty of Mathematics and Natural Sciences, Universitas Indonesia

2 Department of Physics, Faculty of Mathematics and Natural Sciences, Universitas Indonesia, Depok, West Java, 16424, Indonesia Department of Radiotherapy, Cipto Mangunkusumo General Hospital, Jakarta, 10430, Indonesia

3 Department of Radiotherapy, Cipto Mangunkusumo General Hospital, Jakarta, 10430, Indonesia

4 Department of Physics, Faculty of Mathematics and Natural Sciences, Universitas Indonesia, Depok, West Java, 16424, Indonesia


Introduction: This work aimed to investigate the use of megavoltage CT (MVCT) images for retrospective planning in high-dose and low-fractionation radiation techniques for Helical Tomotherapy and Linac.
Material and Methods: This work used pre-treatment MVCT images for retrospective planning in high-dose hypofractionation of eight hepatocellular carcinoma (HCC) patients using the stereotactic body radiation therapy (SBRT) technique. The dose per fraction was 5.5–8 Gy in 4–5 fractions. As the patients were scanned with Helical Tomotherapy (HT) MVCT before each treatment, the selected MVCT images were registered to kVCT for re-contouring, and then the images were exported to HT and Linac for planning. The kVCT scan images were also exported from HT to Linac for planning in Linac. The final plans were compared and analyzed using the following parameters: conformity index (CI), paddick conformity index (PCI), homogeneity index (HI), and organs at risk (OAR) constraints. The dose verification was performed by gamma passing rate (GPR) test using EBT3 films.
Results: CI values ​​were found in the range 0.7–1.00 ( : 0.95 ± 0.063), PCI values were found from 0.81 to 0.96 ( : 0.87 ± 0.04), and HI values were found from 0.02 to 0.53 ( : 0.16 ± 0.12). OAR constraints were clinically acceptable. Distance-to-agreement of 3mm and dose difference of 3% was used as GPR criteria for each plan modality.
Conclusion: These results suggest that MVCT could be used as an alternative modality for high-dose re-planning in HT and Linac as well as being used for position verification.


Main Subjects

  1. Langen KM, Zhang Y, Andrews RD, Hurley ME, Meeks SL, Poole DO, et al. Initial experience with megavoltage (MV) CT guidance for daily prostate alignments. Int J Radiat Oncol Biol Phys. 2005;62(5):1517–
  2. Yadav P, Tolakanahalli R, Rong Y, Paliwal BR. The effect and stability of MVCT images on adaptive TomoTherapy. J Appl Clin Med Phys. 2010;11(4):4–
  3. Lu W, Olivera GH, Chen Q, Ruchala K, Haimerl J, Meeks SL, et al. Deformable registration of the planning image (kVCT) and the daily images (MVCT) for adaptive radiation therapy. Phys Med Biol. 2006;51:4357–
  4. Xu S, Xie C, Dai X, Ju Z, Gong H, PLA RG. Adaptive Dose Calculation and Verification using MVCT Images. Int J Radiat Oncol. 2011;81(Suppl)(2):2011.
  5. Perna L, Sini C, Cozzarini C, Agnello G, Cattaneo GM, Hysing LB, et al. Deformable registration-based segmentation of the bowel on Megavoltage CT during pelvic radiotherapy. Phys Medica. 2016;32(7):898–
  6. Yadav P, Kozak K, Tolakanahalli R, Ramasubramanian V, Paliwal BR, Welsh JS, et al. Adaptive planning using megavoltage fan-beam CT for radiation therapy with testicular shielding. Med Dosim. 2012;37(2):157–
  7. Branchini M, Broggi S, Dell I, Mauro G, Calandrino R, Gisella N, et al. Skin dose calculation during radiotherapy of head and neck cancer using deformable image registration of planning and mega-voltage computed tomography scans. Phys Imaging Radiat Oncol. 2018;8:44–
  8. Langen KM, Meeks SL, Poole DO, Wagner TH, Willoughby TR, Kupelian PA, et al. The use of megavoltage CT ( MVCT ) images for dose recomputations. Phys Med Biol. 2005;50:4259–
  9. You S, Seong J, Koom W, Kim Y, Lee I, Jeon B. Treatment Margin Analysis using MVCT Image in Radiotherapy of Liver Tumor. Proc 50th Annu ASTRO Meet. 2008;S253.
  10. Branchini M, Fiorino C, Oca ID, Belli ML, Perna L, Muzio N Di, et al. Validation of a method for ‘‘dose of the day” calculation in head-neck tomotherapy by using planning ct-to-MVCT deformable image registration. Phys Medica. 2017;39:73–
  11. Branchini M, Broggi S, Belli ML, Fiorino C, Cattaneo GM, Perna L, et al. Towards adaptive Tomotherapy: planning CT to MVCT deformable image registration for dose calculation. ESTRO 35. S851.
  12. Yang JD, Hainaut P, Gores GJ, Amadou A, Plymoth A, Roberts LR. A global view of hepatocellular carcinoma: trends, risk, prevention and management. Nat Rev Gastroenterol Hepatol. 2019;Oct;16(10):589-604.
  13. Wang P, Chung N, Hsu W, Chang F, Jang C, Scorsetti M. Stereotactic body radiation therapy in hepatocellular carcinoma : Optimal treatment strategies based on liver segmentation and functional hepatic reserve. Reports Pract Oncol Radiother. 2015;20(6):417–
  14. Lam M, Cheng H, Ngan R. Stereotactic Body Radiation Therapy for Hepatocellular Carcinoma : Review of a Local Hospital. Hong Kong J Radiol. 2017;20:205–
  15. Yadav P, Ramasubramanian V, Paliwal BR. Feasibility study on effect and stability of adaptive radiotherapy on kilovoltage cone beam CT. Radiology and oncology. 2011;45(3):220–
  16. Yuan Z, Nair CK, Benedict SH, Valicenti RK, Rao S, Fragoso RC, et al. Converting Treatment Plans From Helical Tomotherapy to L-Shape Linac : Clinical Workflow and Dosimetric Evaluation. Technology in cancer research & treatment. 2018;17(619):1–
  17. Zhao Q, Wang R, Zhu J, Jin L, Zhu K, Xu X, et al. Superiority of helical tomotherapy on liver sparing and dose escalation in hepatocellular carcinoma : a comparison study of three-dimensional conformal radiotherapy and intensity-modulated radiotherapy. OncoTarget Ther. 2016;3807–
  18. Koca T, Basaran H, Sezen D, Karaca S, Ors Y, Arslan D, et al. Comparison of Linear Accelerator and Helical Tomotherapy Plans for Glioblastoma Multiforme Patients. Asian Pacific J Cancer Prev. 2014;15:7811–
  19. Zang X, Penagaricano J, Moros EG, Corry PM, Yan Y, Ratanatharathorn V aneerat. Dosimetric comparison of helical tomotherapy and linac-imrt treatment plans for head and neck cancer patients. Med Dosim. 2010;35(4):264–
  20. Fast M, Schoot A Van De, Lindt T Van De, Carbaat C, Heide U Van Der, Sonke J. Tumor Trailing for Liver SBRT on the MR-Linac. Radiat Oncol Biol. 2019;103(2):468–
  21. Menzel HG. Journal of the International Commission on Radiation Units and Measurements Report 83. J ICRU. 2010;10(1):1–
  22. Paddick I. A simple scoring ratio to index the conformity of radiosurgical treatment plans. J Neurosurg. 2000;93(Suppl 3):219–
  23. Vaezzadeh SA, Allahverdi M, Nedaie HA, Aghili M, Esfehani M. Comparison of conventional and 3D conformal treatments using linac energies for prostate cancer. 2012;10:145–
  24. Dawson LA, Zhu A, Knox J, Krishnan S, Craig T, Hong TS, et al. Randomized phase III study of sorafenib versus stereotactic body radiation therapy followed by sorafenib in hepatocellular carcinoma. Radiation Therapy Oncology Group (RTOG). 2012;1112.
  25. Hussein M, Clark CH, Nisbet A. Challenges in calculation of the gamma index in radiotherapy – Towards good practice. Phys Medica. 2017;36:1–
  26. Langen KM, Papanikolaou N, Balog J, Crilly R, Followill D, Goddu SM, et al. QA for helical tomotherapy: Report of the AAPM Task Group 148. Med Phys. 2010;37(9):4817–
  27. Alber M, Broggi S, Wagter DC, et al. Guidlines for the verification of IMRT. ESTRO 9. 2008;
  28. Azzi A, Dimitri FY, Pawiro SA. The implementation in-house dose verification for IMRT and VMAT on breast cancer and NPC cases. J Phys Conf Ser. 2016;694(1).
  29. Hu Y, Byrne M, Archibald-heeren B, Squires M, Teh A, Seiffert K, et al. A feasibility study on the use of tomotherapy megavoltage computed tomography images for palliative patient treatment planning. J Med Phys. 42:163–
  30. Zhu J, Bai T, Gu J, Sun Z, Wei Y, Li B, et al. Effects of megavoltage computed tomographic scan methodology on setup verification and adaptive dose calculation in helical TomoTherapy. Radiation Oncology. 2018;1–
  31. Xu Y, Deng W, Yang S, Li P, Kong Y, Tian Y, et al. Dosimetric comparison of the helical tomotherapy, volumetric- modulated arc therapy and radiotherapy for stage IIB-IIIB non- small cell lung cancer. Scientific reports. 2017;(October):1–
  32. Lee T., Fang F., Chao P., et al. Dosimetric comparisons of helical tomotherapy and step-and-shoot intensity-modulated radio- therapy in nasopharyngeal carcinoma. Radiother Oncol. 2008;89:89–
  33. Chung E, Kwon D, Park T, Kang H, Chung Y. Clinical implementation of Dosimetry Check TM for TomoTherapy® delivery quality assurance. J Appl Clin Med Phys. 2018;19:193–
  34. Cho S, Goh Y, Kim C, Kim H, Jeong JH, Lee SB, et al. Patient QA System Using Delta4 Phantom for Tomotherapy : A Comparative Study with EBT3 Film. J Korean Phys Soc. 2019;74(8):816–
  35. Bresciani S, Dia A Di, Maggio A, Cutaia C, Miranti A, Infusino E, et al. Tomotherapy treatment plan quality assurance : The impact of applied criteria on passing rate in gamma index method. Med Phys. 2013;121711.