RTOG: Committee Minutes - Medical Physics

Committee Minutes - Medical Physics

MEDICAL PHYSICS COMMITTEE (January, 2008)

Michael T. Gillin, Ph.D., Chair

The Medical Physics Committee met on Friday, January 18, 2008. The first speaker was the chair. The chair addressed a number of issues including database integration. RTOG has a database in Philadelphia at headquarters. The ITC database is located in St. Louis. The tissue bank database will soon be located in San Francisco. In the long run, RTOG needs a mechanism to access and integrate information in multiple databases. In the next grant, RTOG plans to be paperless and filmless. Significant questions remain to be answered, including what data to be collected and who will manage it. On a national level, protons have gained in importance as compared to six months ago. RTOG is being asked about using its resources for a registry study which would compare protons, IMRT and brachytherapy.

Robert Jeraj, University of Wisconsin, discussed IRAT, an integrated image response assessment team concept. This team consists of oncologists, radiologists and physicists. A discussion was held on the use of PET in RTOG protocols. The Medical Physics Committee plans on developing a survey for participating in RTOG institutions to service a base line relative to the use of PET in treatment planning and/or treatment assessment.

James Purdy, UCD, presented an update on the ATC meeting, which is held the day before the RTOG meeting. The ATC is in the first year of the newly funded grant. The ATC is working with CaBIG™ in a goal of making commercial systems CaBIG™ compliant. The ATC is working with a number of cooperative groups including the RTOG. Between the ITC and the QARC all of the North American cooperative groups are covered. The QARC's database is moving towards compliance with CaBIG™.

Marsha Urie, QARC, made a brief presentation. Dr. Urie reported QARC has made significant efforts on the last several years to address the needs of participating institutions.

Geoffrey Ibbott, RPC, made a presentation on RPC efforts. The RPC continues to monitor machine calibrations. Dr. Ibbott reported the number of TLDs that fall outside the 5% limit remains at about 3%. The RPC visits approximately 40 institutions per year. Approximately 25% have some dosimetry issue that results in RPC recommendations. The RPC continues their credentialing efforts with anthropomorphic phantoms. The RPC has begun to monitor proton therapy centers.

The RPC has made significant progress in the implementation of CERR, as developed by Joe Deasy, Washington University. The RPC continues to evaluate lung phantom data, as requested by the RTOG in July 2007, to see if there dose agreement within the planned target volume is within 5% or 5mm. This is important activity as the practice of radiation oncology in the United States moves from older algorithms to newer algorithms.

Betty O'Meara, from RTOG headquarters, reported for headquarters. Ms. O'Meara reported the number of paper initial and final reviews is decreasing dramatically as the RTOG moves to electronic submissions. A discussion was held on the facility questionnaire for RTOG 0617. The consensus was improvements can be made in this questionnaire. Ms. O'Meara reported RTOG is currently conducting 2 day study chair workshops. A number of medical physicists have been invited to these workshops and will continue to be invited. Ms. O'Meara reported rules and responsibilities for study chairs are now provided prior to agreeing to share a study.

The RTOG grant is due in several weeks. The site visit is scheduled for Washington D.C. in mid July. The RTOG is asking for 6-7 years of funding. The activities on Sunday of this semi-annual meeting will be devoted to finishing the grant.

MEDICAL PHYSICS COMMITTEE (June, 2007)

Michael T. Gillin, Ph.D., Chair

The RTOG Medical Physics Committee met in Philadelphia on June 22, 2007, as part of the RTOG Semi- Annual Meeting. The first topic discussed was the criteria for algorithms other than superposition/convolution to be met as part of the heterogeneous dose calculation requirements for future RTOG protocols. These potential criteria were vigorously discussed. The criteria, which were adopted by the RTOG Medical Physics Committee, agreement between measured dose using the RPC lung phantom and the calculated dose, as calculated by older algorithms, e.g. Clarkson or pencil beam, is across the PTV shall be within plus or minus 5% or 5 mm. It is generally understood this criteria may change in time, as additional information becomes available, but such criteria are needed in order to proceed with RTOG 0617.

James Galvin, D.Sc. presented the draft RTOG guidelines for IGRT. The purpose of these guidelines is to provide base line information for individuals who are drawing up image guided protocols. These draft guidelines led to a wide ranging discussion. Dr. Galvin promised to circulate the updated guidelines sometime after the meeting.

Betty O'Meara, CMD, presented the RTOG headquarters report. It is noted this is the last time this report will be presented in its traditional format. Since the last meeting forty-six (46) cases received initial review and one hundred sixty nine (169) cases received final review. The Medical Physics Committee was informed about a two (2) day meeting which is a workshop for study chairs. This meeting is held twice a year approximately in August and then again in March. It is possible to invite physicists to this meeting.

James Purdy, Ph.D., presented the report from QuASAR (quality assurance submission, analysis and review) as part of the report from the Image Guided Therapy QA Center to the RTOG. Dr. Purdy noted approximately 25-30% of the digital data submitted to the ITC had issues of one type or another. Thus substantial ITC resources were being used to ensure data integrity. This is an unexpected mandate as part of the QA process. The ITC is currently providing access for treatment planning data for sixteen active RTOG protocols, including one jointly conducted with NSABP. Dr. Purdy reported there were two requests for data to the ITC. One of these requests was from a commercial venture while another was from MSKCC.

Geoffrey Ibbott, Ph.D., presented the report from the Radiological Physics Center. Dr. Ibbott reported the RPC as a subcontract with CERR and will soon have tools for two dimensional comparison of film with the calculated dose. This capability will help immensely in addressing the criteria issue for agreement between calculated and measured dose using various types of algorithms. This capability should be available to the RPC in early fall, 2007. Dr. Ibbott reported his recent experience using the RPC lung phantom with the accuracy planning system. Dr. Ibbott also reported the RPC is developing proton facility monitoring, using TLD and bang gels. He stated the RPC will soon be able to visit the proton facilities.

Dr. Galvin expressed interest in the topic of patient dose received from imaging in image guided radiation therapy procedures. The RTOG Medical Physics Committee will appoint a task group to study this issue. One potential approach is to collect the total number of monitoring units delivered to the patient as part of image guided therapies. Members of this task group will include Drs. Galvin, Purdy and Huq.

MEDICAL PHYSICS COMMITTEE (February, 2007)

Michael T. Gillin, Ph.D., Chair

The Medical Physics Committee meeting began at 2 pm on Friday, February 2, 2007. Approximately 40 people were in attendance. The chair made some general announcements and then introduced a guest speaker, J. Daniel Bourland, Ph.D.

Dr. Bourland, from Wake Forest University, discussed the use of PET in radiation oncology treatment planning. He emphasized the challenges in the definition of the region of interest in using PET. There are some issues which are specific to PET imaging, including the truncation of specific values from PET as they are transmitted to the treatment planning system, the 3-5 mm spatial resolution, and the 128 x 128 format. The ITC reported they had an off set issue when dealing with PET images. Dr. Bourland noted in most cases the PET images first were sent to a diagnostic work station before they were forwarded to a treatment planning system. It is possible the diagnostic work station modified some of the information contained in the images.

Elizabeth O'Meara, Director, RTOG Headquarters Dosimetry presented the RTOG report. For final reviews, the overall compliance rate was 89%. Credentialing is required in 21 studies. It was emphasized the final approval is granted by the RTOG and not by the RPC or the ATC. There are now 30 protocols for which data is submitted in a digital format. There are 7 active 3D-CRT protocols and 10 active IMRT protocols. There are 6 IMRT protocols in development. There are 4 active brachytherapy protocols and 2 brachytherapy protocols in development. There are 4 lung SBRT protocols in development. The credentialing process to support these protocols has become quite complicated.

James Purdy, Ph.D. PI, ATC presented the report for the ATC. The ITC is now actively supporting 10 RTOG protocols. A credentialing grid, which indicated which institution is credentialed for which protocol, was discussed. In addition, plans to migrate from a site specific protocol credentialing to a modality based credentialing approach was discussed. There was broad support for this concept. The ATC will support a task group. The RTOG will have a representative on this task group to explore this concept.

The ITC priorities include the following:

Transition from ATC method one towards immigration with industry informatics efforts and caBIG compliant software.

Pilot the migration of various responsibilities from St. Louis to RTOG Philadelphia using protocol RTOG 0126.

Refine the ATC conjectioning methodology.

Further develop QA processes for protocols requiring multiple modality imaging (PET, MRI, Image fusion, etc.).

The ITC is working with RTOG Headquarters to increase the digital capabilities of RTOG headquarters to manage specific protocols. This is an important development as the RTOG migrates to an all digital format.

Geoffrey Ibbott, Ph.D., Director, Radiological Physics Center presented the report from the RPC. The RPC is currently monitoring 1500 institutions, 100 of which are from outside North America. In the last year they visited 45 institutions. The RPC is performing brachytherapy review for the RTOG. There are 553 institutions credentialed for participation in the partial breast radiation protocol, RTOG 0413. The RPC is working hard to develop systems to confirm the calibration of proton beams. The RPC is also working on image guided phantoms.

A substantial discussion was held on the credentialing for lung protocols. The established criteria include agreement between measured and calculated dose at the center of the target of 0.97 + 0.05. In addition, the distance to agreement should be within + 5 mm at all sides of the target along the 3 profiles. A proposed new criterion was presented, namely that 90% of the central points along the 3 perpendicular profiles, considering only the central 80% of the PTV, have measured to plan doses agreeing to within 7%. Ninety-six (96%) of the convolution/superposition systems studied and 82% of the pencil beam/Clarkson systems studied would meet this criterion. In addition, there would be a 5 mm distance to agreement in the penumbra.

The RPC reported 7 of the 9 convolution treatment planning systems studied and 2 of the 8 pencil beam studied would be credentialed using this criterion. The discussion was held as to whether the criteria should be 7% agreement or 10% agreement. Recommendation was to recommend a 7% agreement to the Lung Cancer Committee for their response.

The RPC's vision for support of proton clinical trials includes adoption of a calibration protocol with traceability to NIST, design devices for monitoring beam calibration, and design, evaluate and implement modified anthropomorphic phantoms for evaluating proton beam delivery.

Ken Forrester, Ph.D. reported on RTOG Lung Cancer Committee activities. The Lung Cancer Committee is developing 4 different stereotactic protocols, namely RTOG 0617, 0618, 0624, and 0633. A discussion of physics details specific to each protocol was held.

At the end of the meeting a general discussion was held on issues associated with the use of PET in RTOG protocols. The general consensus was the ACRIN credentialing process represented a reasonable first step to ensure RTOG institutions would use PET images for this process with basic QA requirements. The Medical Physics Committee will draft a small white paper on the use of PET in the radiation oncology environment.

MEDICAL PHYSICS COMMITTEE (June, 2006)

Michael Gillin, PhD, Chair

The RTOG Medical Physics Committee met on June 23, 2006. The first topic discussed was the draft ATC Guidelines for the use of IMRT for intra-thoracic treatments, May 31, 2006. The chair noted he had previously sent comments to Dr. Deye. A wide-ranging discussion of this document was held. The comments tended to be more of an editorial nature than a substantive of nature. These comments were considered and an updated version of this document was produced. (The current version of the document, which is dated July 19, 2006, can be found on the RTOG homepage.)

Ken Forester, PhD, presented a report from the Lung Cancer Committee. The open protocols which were reviewed included RTOG 0236, a Phase II trial of stereotactic body radiotherapy in the treatment of patients with medically inoperable Stage I/II non-small cell lung cancer, RTOG 0515, a comparative study for gross tumor volume definition with or without PET fusion for patients with non-small cell lung carcinoma, and RTOG 0523, a protocol involving both chemotherapy and radiation. The method of dose specification for protocols in the thorax was discussed. All cured of protocols should have doses specified using heterogenic corrections. This can be done by specifying the dose of 95% of the planning target volume, as apposed to specifying the dose to a single point, which has been the customary method.

Lung Cancer Committee protocols and development were discussed. Included in this discussion was RTOG 0618, a stereotactic body radiation therapy protocol for operable patients, RTOG 0264, a stereotactic body radiotherapy for inoperable peripheral lung lesions, RTOG 06XX a stereotactic body radiotherapy protocol for central lesions, RTOG 0617 a phase III inoperative central lesion protocol with Dr. Bradley as the PI. Recommendations from the Medical Physics Committee relative to meeting the ATC Guidelines for the use of IMRT were discussed.

Betty Martin, CMD, from RTOG Headquarters presented the RTOG Radiation Oncology Quality Assurance Report. There was a 98.7% compliance in the initial reviews done in this last time period. There were 284 cases which underwent final review up to this point in the year 2006. The compliance rates for final reviews were 93%. The credentialing schema for RTOG 0232, the RTBrachyGU protocol was discussed. IMRT is now permitted. The Head and Neck protocol RTOG 0234, a phase II randomized trial of surgery followed by chemo radiotherapy plus C225, was discussed. IMRT is permitted for this protocol. Relative to protocol RTOG 0236, benchmark credentialing is allowed. RTOG 0438, a phase I trial of highly conformal radiation therapy for patients with liver metastasis was reviewed. Two institutions are actively being credentialed for this protocol. Other institutions were encouraged to become credentialed. RTOG protocol 0413, NSABP protocol B-39 was discussed. It is noted the remote review is available for this study for the PIs.

Geoffrey Ibbott, PhD, Director, Radiological Physics Center, presented the RPC report to the RTOG Medical Physics Committee. The RPC is monitoring 1,434 institutions in North America, many of which are RTOG members, as well as 2 international RTOG members. Approximately 1.5% of the RPC TLD measurements exceeded the RPC's 5% criterion. These discrepancies were distributed so approximate 11% of monitoring institutions were found to have at least 1 or more beams outside of the criteria. There were 28 RTOG institutions who were delinquent in returning their TLD by more than 3 months. There were 3 institutions who were delinquent by more than 6 months. In addition, the RPC believes one institution appears to have inadequate physic support. This institution was identified to the RTOG Membership Evaluation Committee. The TLD reports have been converted to electronic format.

An Eclipse workstation for independent review of brachytherapy has been installed at the RPC. The RPC remains very busy with its credentialing procedures and with the associated phantoms. There were 34% of institutions who failed to meet the criteria on the first attempt to irradiate the phantom. The criteria are 7% for dose and more than 4 mm distance to agreement. The RPC presented very interesting data on different algorithms and the differences between the doses is calculated using a heterogeneous algorithm as to appose to a homogeneous algorithm. In addition data was presented which compared measured dose by TLD vs. heterogeneity-calculated dose. On the average, the dose delivered to the target was 3% lower then that calculated by the treatment plan. For the comparison of the dose at the point of measurement, all algorithms, including the Clarkson scatter integration technique appeared to work almost equally as well. However, when comparing density corrected to density non-corrected dose differences of up to 18% to the dose in the center of the target volume were noted.

The RPC has been busy credentialing institutions for RTOG 0413 PBI protocol. As of June 15, 2006, there were 416 institutions which had been credentialed for one or more modalities for this protocol.

The RPC presented data, which indicated the number of institutions have completed the RPC's credentialing requirements, is significantly greater than the number actually credentialed by the RTOG. The differences are believed to be due to the institutions failure to complete the digital data submission requirements of the ATC, which includes successful transmission of a treatment plan to the ITC.

The RPC has begun work in the use of proton beams in RTOG protocols. The RPC is investigating the suitability of its TLD program for the measurement of proton beams.

Walter Bosch, DSc, presented the report from the ATC/ITC. Dr. Bosch noted there had been a change in the network. The new server is ITCsubnet.wustl.edu this change, which was mandated by Washington University, has been successfully completed. The ITC is now managing more than 3,000 complete data sets. It is collecting information at the rate of 5GB per week; it is supporting currently 13 RTOG protocols. The total number of protocols supported is 19.

The ATC is active with caBIG in its in vivo imaging workspace. The ATC website will have broader educational material in this upcoming year. There are challenges and opportunities relative to ATC support for clinical trials. The ATC is requesting a more formal mechanism to decide which clinical trials will be supported by ATC funding. Among the opportunities, which are available, are having stereotactic radiosurgery or radiotherapy systems become ATC compliant. Clearly, PET imaging and image fusion is an important are that needs to have appropriate QA performed for it. The management for 4D CT studies is an important unsolved issue. The amount of information associated with image-guided radiotherapy will also be a challenge to manage. Finally, adaptive radiation therapy with daily confirmation and potential patient repositioning using onboard imaging will also result in substantially larger data sets than have been previously managed.

The ATC plans to have increased integration with industry informatics. It is noted the RTOG grant renewal and the ATC grant renewal occur at approximately the same time in 2007.

The meeting lasted approximately 2.5 hours. More than 50 people were in attendance.

MEDICAL PHYSICS COMMITTEE (March, 2006)

Michael T. Gillin, Ph.D., Chair

The RTOG Medical Physics Committee met on January 20, 2006. The meeting opened with comments from the chair. The chair noted there have been changes in the RTOG meeting schedule. The IGRT Committee was scheduled to meet on Saturday at 3 p.m. The Major Disease Sites Committees were meeting on Saturday with the exception of the Brain Tumor and the Gynecology Cancer Committees, which were meeting at 4 p.m. on Friday. The chair noted the renewal RTOG Grant was due in approximately one year and two weeks. The first draft is due in June 2006. The chair now plans to appoint a task group to help work on the Medical Physics portion of the grant. The chair noted the RTOG is now more than just a North American Cooperative Group. There are affiliate members in Israel and Korea.

The question of credentialing was discussed. There is a dilemma with respect to using closed protocols to credential institutions for new protocols. How should institutions, which have not been previously credentialed for the IMRT Head and Neck protocols, be credentialed for the up coming Head and Neck IMRT protocol? If an institution was successfully credentialed using the Head and Neck Phantom, then should that institution be credentialed for all other IMRT protocols? Will this also hold when there are IMRT motion protocols?

The chair noted there is an ATC draft document for the use of IMRT for thoracic tumors. This document has been given to the Medical Physics Committee for review and comment.

The chair discussed new delivery systems. Is Tomotherapy always an IMRT delivery system? Can a set of specifications be defined such that this would not be the case? Special issues regarding these protons were discussed. These issues include the use of PTV, the 1.1 RBE, and the calibration of these breams.

The chair discussed the question of data mining of existing RTOG data. The chair noted there is one physics secondary analysis request waiting, which has Ken Forester as the PI. There is another idea, which needs to be submitted. The ATC has discussed a proposal to develop another mechanism to obtain access to the data at the ITC.

The RT Quality Assurance Philadelphia Headquarters report to the RTOG Medical Physics Committee was received. The total overall compliance for initial reviews was 96%. The overall compliance for final reviews was 88%. Final reviews are conducted at the semi-annual meetings and at headquarters. The credentialing process for the RTOG 0232 was discussed in detail. This credentialing process involves the ITC, RPC, and RTOG Headquarters. The credentialing process for RTOG 0234 was also discussed. There is an ATC review workstation at RTOG Headquarters in Philadelphia and it is routinely being used. The report ended with an image of the RT Quality Assurance Staff.

The Radiological Physics Center report was given by Geoff Ibbott. TLD is being sent to 1400 institutions. Approximately 4.5% of these institutions are delinquent which is defined as 6 months or greater in returning their TLDs. International members will receive TLDs. The RPC visited approximately 40 institutions in the last calendar year and continue to find errors. Approximately 70% of the institutions receive at least one significant dosimetry recommendation. The impact on cooperative group protocols of these recommendations and for improved dosimetry is not clear. The priorities for RPC visits are patient accrual, TLD issues, chart problems, and other issues.

The RPC has an Eclipse planning system with brachyvision. This is one of several steps in the transition to electronic chart review by the RPC.

There are 247 institutions which have been credentialed for RTOG 0413. Electronic submission for credentialing is the preferred method. There are 64 institutions have been credentialed for the RTOG 0232 protocol. In addition there are 30+ institutions have submitted patients to this protocol.

The number of RPC head and neck phantoms currently is 8. The RPC hopes to increase this number to 15-18. There are 122 institutions which have been credentialed using this phantom.

The RPC prostate phantom has been sent to 16 institutions. There are 4 of these phantoms. There are 3 RPC lung phantoms. They have been sent to 6 RTOG institutions. There are 2 RPC liver phantoms. They have been sent to 3 RTOG institutions.

The RPC is preparing to monitor proton facilities.

The RPC is planning to develop a proposal over the next several months to better define phantoms and credentialing procedures. They envision a tier system for credentialing, which ranges from simple to complex. A simple credentialing could be a questionnaire and dry run, while a complex credentialing could involve a phantom with motion.

The Advance Technology Consortium (ATC) report was given by Jim Purdy. A list of the ATC compliantly and planning systems per modality was presented. Progress had recently been made on 2 commercial proton-planning systems. There are now 331 credentialed institutions, with over 100 new institutions, thanks in part to the partial breast and radiation protocol. Progress was reported with BrainLab and with Tomotherapy. Tomotherapy has agreed to provide its customers with the research PC with data exchange software.

The chair of the RTOG Medical Physics Committee has been on the ITC web site reviewing proton plans. The ATC are requesting they be provided with a list of tools that are needed for this review for proton dosimetry.

There will be an ITC/WUCON Network reconfiguration later in 2006. This should be watched closely as it may affect the ability of institutions to transmit data to the ITC.

There is a proposal by Joe Deasy for guidelines for a request for ATC data by various investigators.

James Galvin provided a discussion of RTOG 0326, the lung stereotactic protocol, and RTOG 0438, the liver stereotactic protocol. Dr. Galvin is performing a daily reproducibility study on 52 patients entered into RTOG 0236. The study is funded, in part, by the Pennsylvania Tobacco settlement money. There are 8 institutions which have been credentialed to enter patients onto this protocol.

Bill Bice sent in a discussion of RTOG 0232. At the present time, 10% of the required cases have been approved. There have been contrary issues identified in the central review process. There are 27 of 87 cases which had no issues.

Ken Forester provided a report from the RTOG Lung Cancer Committee. A phase II protocol for medically operable patients using a stereotactic treatment technique is being developed. This will include both IMRT treatment techniques and Tomotherapy. A new phase III study is being developed. This study will use heterogeneity corrections. A long discussion was held on the ATC proposal for guidelines for the use of IMRT for thoracic tumors. The RTOG Medical Physics Committee has been asked to comment on this.

The chair led a discussion of areas to be emphasized in the next RTOG grant. The general consensus was imaging should be an important component of the medical physics contribution in the next RTOG grant. Images include both treatment planning and treatment delivery. Other less important themes should be the new delivery systems.

MEDICAL PHYSICS COMMITTEE (June, 2005)

Michael T. Gillin, Ph.D., Chair

RTOG Medical Physics Committee met on June 24, 2005 in Philadelphia at a new earlier time on Friday. There were approximately 50 people in attendance representing more than 25 institutions. The Chair began the meeting by providing a list of when the various RTOG committees were meeting with the new times and dates. The Chair announced the RTOG had accepted two new international members, one in Israel and one in Korea. Also he announced the University of Colorado was a new full member. The chair reviewed the grant renewal deadlines. The first draft is due in the spring, 2006. The final draft is due in December 2006. The NCI review is scheduled for May 2007.

The Chair described the NCI Clinical Trials Working Group. Beginning in 2006, the NCI will implement a massive nationwide restructuring of its Cancer Clinical Trials Enterprise at a cost of approximately $113M. There are 4 themes to this NCI restructuring plan. These themes are:

1) Coordination, which includes the creation of a comprehensive database containing information on all NCI funded trials.
2) Priority/Scientific Quality, which includes the Scientific Steering Committee, which will seek an improvement in patient accrual rates and address a better quality of life standard.
3) Standardization, which includes a National Clinical Trials IT infrastructure, which is fully interoperable with the NCI ‘s Cancer Bioinformatics Grid (caBIG).
4) Operational Efficiency, which is designed to increase the rate of patient accrual and reduce operational barriers.

There will be a NCI Internal Committee, which will develop recommendations to, among other things, provide ongoing integration over sight of clinical trials supported by the NCI.

The Chair presented a brief list of major themes for the RTOG, which involve technology and which might be part of the next grant. These themes include:

1) Improved target definition (4D CT, MRS, PET)
2) Improved in room target localization (OBI, motion tracking)
3) New treatment delivery techniques (Tomotherapy, Cyberknife, Protons)

The new in treatment room imaging capabilities, which many institutions are currently installing, represent an opportunity to develop a technology evaluation protocol. For example, a protocol could evaluate cone beam CT localization of the prostate versus ultrasound localization of the prostate versus fiducial localization of the prostate. Is it within the mission of the RTOG to be conducting such protocols?

The Chair provided a brief list of the medical physicist contributions within the cooperative group setting. These contributions include working on protocols to ensure clarity and consistency in the tactical provisions of those protocols. In addition, the development and definition of appropriate QA standards for specific protocols. Another important contribution is the definition of minimal institutional criteria to participate in specific protocols, with the implied credentialing mechanisms and criteria. The Chair noted there are certain open questions, which has been raised as a result of the NCI IMRT Guidelines. These questions include the development of guidelines to address heterogeneity questions and target motion for protocols, which call for IMRT treatments for patients with lung cancer. A specific physics question involves the definition of heterogeneity correction criteria, which most likely will not be met by older Clarkson type algorithms.

The Chair discussed PET and its use in Radiation Oncology. A discussion was held on the basic QA issues associated with use of PET images to define target volumes for RTOG protocols. It is not clear if this is an RTOG medical physics committee issue or a broader issue for the community in general to be addressed by an AAPM task group.

The Chair briefly discussed secondary analysis opportunities. It was noted this might be an opportunity for medical physicists. The Chair noted recently there have two investigator initiative approved studies. There has also been a request from a commercial company for access to RTOG data. This request is being reviewed by the RTOG.

Dr. Galvin presented the RTOG Radiation Oncology Quality Assurance Report. Initial Radiation Oncology Review for 2005 was considered for 305 cases. There was an overall compliance rate of 95.2%. 225 cases were reviewed in 2005 for final review. There was an overall compliance rate of 87% in the final review.

Geoffrey Ibbott, PhD, Director Radiological Physics Center, presented the RPC Report to the RTOG Medical Physics Committee. In the last 2 years, the RPC has visited 49 RTOG Institutions. RPC has participated in the credentialing of 54 institutions for RTOG 0232-Prostate LDR Brachytherapy Protocol. The RPC has participated in the credentialing of 6 institutions for RTOG 0321-Prostate HDR Brachytherapy Protocol. The RPC has participated in the credentialing of 70 institutions for RTOG 0413-The Partial Breast Radiation Protocol.

The RPC has a stereotactic lung protocol for credentialing for RTOG 0236. Criteria have been agreed upon between the RPC and the RTOG Medical Physics Committee relative to the agreement between measured and calculated doses on this phantom. The TLD to institutional dose ratio is between 0.92 and 1.02. The distance to agreement is less than or equal to 5 mm. The PTV must receive greater than or equal to 95% of the prescribed dose of 20 Gy. 99% of the PTV must receive 90% of the treatment dose for 18 Gy. The lung dose must be less than or equal to 11.7 Gy at a distance of 2 cm radial distance from the PTV.

The RPC has a reciprocating liver phantom for credentialing for RTOG 0438. A description of that phantom was provided. The RPC is in the process of developing a phantom for mesothelioma IMRT. The RPC is also developing a phantom for RTOG 0418, a phase II IMRT protocol for endometrial or cervical cancer.

James Purdy, PhD provided the report from the Advance Technology Consortium. The ATC consists of the Image Guided Therapy Center, RCET, QARC, RPC, and the RTOG. Dr. Purdy provided a summary of the ATC support for the following protocols: RTOG 0022, 0117, 0126, 0225, 0319, and 0321. Dr. Purdy presented a summary of the ATC meeting, which had been held the day before at the RTOG Headquarters in Philadelphia. Dr. Purdy reminded attendees the ATC meets the day before the RTOG meeting and he invited all interested parties to attend, but requested he receive notification of attendance in order to assure appropriate amount of food is available. Dr. Purdy announced the ATC would be present at the annual meetings of the AAMD, the AAPM, and the ASTRO. Dr. Purdy was pleased to note the Canadian NCI had been able to utilize methodology developed by ATC in support of Canadian protocol. In addition, the ATC has been instrumental in supporting a Japanese protocol. The ATC has expressed concern relative to the amount of work that is in the pipeline. There are a number of RTOG protocols, which are based upon receiving support from the ATC.

William Bice, Ph.D. provided an update on RTOG 0232. James Galvin, DSc, provided an update on the patient set up reproducibility study he is conducting as part of RTOG 0236. Ken Forster, Ph.D. provided an update on lung committee activities. Dr. Forester noted protocol RTOG 0236, the stereotactic lung protocol, offered an opportunity to review PET data from the pretreatment PET study. He noted there was a second protocol in development, which utilizes technique for non-small cell lung cancer. RTOG 0516 is a protocol being developed which utilizes PET staging for limited stage non-small cell lung cancer protocol. RTOG 0523 has the potential of using IMRT, which will require the NCI issues to be addressed. Dr. Forester noted the RTOG Lung Cancer Committee is adopting a prescription to a volume that is 95% of the PTV should be covered by the prescription isotope surface. There was a discussion on issues associated with motion and with heterogeneity corrections.

MEDICAL PHYSICS COMMITTEE (January, 2005)

Michael T. Gillin, Ph.D., Chair

The Medical Physics Committee met on January 21, 2005 in Phoenix, Arizona. Approximately forty people were in attendance. These individuals represented more than twenty different institutions.

The Chair opened the meeting with his report. The Chair noted RTOG would be submitting its new grant in two years and two weeks. The Chair reminded the committee members in his opinion, the role RTOG Medical Physics Committee included the following:

Help the RTOG defined priorities, which includes defining the appropriate balance between the burden of QA and the needs of the group.
Identify RTOG needs especially with respect to high tech protocols and imaging
Collaborate with other non-RTOG groups who are active in clinical trials
Collaborate within the RTOG to insure RTOG Protocols meet RTOG standards
Meet semi-annually, which now includes both the RTOG meeting and ATC meeting

The Chair noted he had received at least two verbal complaints on the day of this meeting relative to the burden of QA. One complaint was lack of integration across all cooperative groups, which may result in a possible duplication of efforts with one institution needing to be credentialed by several groups. The second complaint involved issues of credentialing on the institution patient population, as opposed to standard image set, to be supplied by the cooperative group, upon which various volumes might be defined and planned on.

The Chair indicated one important task for the RTOG Medical Physics Committee was to identify the next generation of physicists who would be active within RTOG and other cooperative groups. The Chair noted he had reviewed a list of those physicists who had signed up in advance for this meeting and observed many familiar faces. The Chair requested ideas for attracting younger physicists from the major institutions for the June, 2005 meeting.

The Chair reviewed those former institutions that had submitted twenty-five or more cases to the RTOG in calendar year 2004. The Chair also noted one important contribution of physicists at their own institutions is to support the RTOG by providing help to dosimetrists, research nurses, and oncologists as required.

The Chair stated the RTOG Medical Physics priorities included the following:

Inter-thoracic dose prescriptions
Incorporate multiple motion correction approaches into RTOG protocols
Generic site specific credentials or partial credentials
Imaging to include PET MR, and various fusion approaches.

The Chair noted the Lung Cancer Committee and the Medical Physics Committee had endorsed the use of heterogeneity corrections using modular algorithms. The recommendations are consistent with those of the AAPM TG 65. These two Committees recommend the incorporation of heterogeneity corrections into all future RTOG protocols.

The Chair discussed the following general topics:

New treatment delivery systems, which include both Tomotherapy and protons.
Identification of protocols in which in room imaging will play an important contribution.
The induction of treatment couches with six degrees freedom – would this cause any specific issues or concerns?
The future directions for SRS/SRT – will there be important protocols for cranial SRS or will there be additional extracranial SRT protocols?

The Chair noted the NCI had recently introduced new guidelines for the use of IMRT in clinical trials. These guidelines have fourteen protocol requirements, which include a 3D volumetric imaging study, nomenclature of the NCI IMRT working group ICRU Reports 50 and 62, a rational for these a choice of margins (IMSM) to be used expansion of the CTV to the PTV, the heterogeneity corrected dose distribution, a clear definition of the dose prescription and dose heterogeneity allowed throughout the PTV, and the use of IMRT for intra-thoracic treatments, in which significant heterogeneities are encountered and tumor mobility is likely, is permitted only when corrections for heterogeneities accounting for target motion are addressed satisfactorily in the design of the protocol.

Dr. James Galvin presented the RTOG Radiation Oncology Quality Assurance Report. Overall compliance rate of approximately 98% was achieved for initial review. In 2004 the study chair for 1,763 cases performed final reviews. The overall compliance rate was approximately 86%. Dr. Galvin reported specifically on the following protocols:

RTOG 0032 – 67 patients enrolled, this protocol is now closed
RTOG 0126 – 448 patients out of a total of 1,500 patients have been enrolled, the study is still open.
RTOG 0225 – 38 out of a total of 65 patients have been enrolled, this protocol is still open
RTOG 0232 – 86 out of a total of 1,500 patients have been enrolled, this study is still open
RTOG 0326 – 3 patients have been entered. There are three credentialing institutions. Dr. Galvin is performing the mini-study of patient positioning as part of this protocol

The Radiological Physics Center Report was provided by Dr. Ibbott. Dr. Ibbott announced a change in RPC procedure as of 10/1/04 the routine measurement of electron depth dose has been discontinued. However, the RPC will measurement percentage depth dose for all new machines at all energies. The RPC is developing a TLD irradiation jig for Tomotherapy units. RPC is active in benchmarks for the credentialing program for the partial breast irradiation protocol, the LDR prostrate brachytherapy protocol, and the HDR prostrate brachytherapy program. In addition, the RPC now has a number of head and neck phantoms, pelvis phantoms and two lung phantoms. The liver phantom is in development. The RPC provided a complex flow diagram relative to the credentialing process for each partial breast irradiation modality. There was substantial discussion of the credentialing for the low dose rate brachytherapy protocol RTOG 0232. Over fifty institutions have been credentialed to enter patients under this protocol. However, the vast majority of these institutions have not entered any patients. Given the data presented by the RPC, it is difficult to see the credentialing process is holding up that patient accrual.

The Advanced Technology Consortium (ATC) Report was presented by Dr. Purdy. Dr. Purdy invited physicists to attend the ATC Consortium Meeting, which is held the day before the RTOG meeting, he asked physicists to provide previous notification of their desire attend. There is a new ATC web site. There was substantial discussion relative to the ATC priority list. Dr. Purdy reported the time from initial to final credentialing for institutions for protocol RTOG 0022 and 0225 was ninety-five days. However for protocol RTOG 0319 this has been reduced substantially to approximately twenty days.

Dr. William Bice presented an update on RTOG 0232. This protocol is expected to enroll 1,520 patients. However less than one hundred patients have been enrolled to this point. The third party assay of seeds is an expectable method for seed assay. There was substantial discussion regarding adding IMRT to the external beam portion of this protocol.

Dr. Kenneth Forester discussed the adoption of a heterogeneity corrected protocol. In addition, he discussed motion controls when treating thoracic patients with an IMRT technique.

Dr. Jim Galvin discussed Tomotherapy and other new treatment delivery mechanisms. It was decided an independent review of the calibration is a requirement. Thus this stresses the importance of RPC TLD phantom for this device. There was a discussion of the requirements for annual QA and for the methods by which the device is initially commissioned. There was some confusion as to the company’s responsibilities versus the institution’s responsibilities. It was not clear if Tomotherapy could submit data in a digital fashion, at this point in time. Dr. Galvin announced there would be soon a paper appearing in Medical Physics from the University of Wisconsin, which outline their opinions as to an appropriate annual review.

There was a general discussion as to the added value of irradiating the phantoms, which were supplied by the RPC. This was compared to the QARC approach of having the institution submit a benchmark. The RPC noted at least 3% of the 10 cm x 10 cm blocks are not properly irradiated. The QARC Representative reported 25-33% of their benchmark cases are found not to be acceptable. It was generally concluded there is a need for some type of credentialing within the general community for high tech protocols. The exact details of this credentialing would vary as the high tech modality mature and as this knowledge developed a broader base within the radiation oncology community.

The Medical Physics Committee passed the following motion:

It is the opinion of the Medical Physics Committee that either the QARC benchmark or the RPC phantom is an accepted method for credentialing in the event that an IMRT option is developed as part of protocol RTOG 0232.

There was a discussion of the need to update the application for membership within the RTOG. There was also the discussion of the physicist(s) at affiliate institutions. There was at least one comment that protocols RTOG 0225 was not written in a clear manner.

MEDICAL PHYSICS COMMITTEE (June, 2004)

Michael T. Gillin, Ph.D., Chair

The Medical Physics Committee meeting began at approximately 4:00 p.m. on Friday, 6/25/04. The meeting was scheduled to last 90 minutes. However, after 90 minutes, the meeting changed rooms and continued for another 60 minutes. Approximately 60 people from approximately 20 + different institutions were present at the meeting.

The meeting began with announcements by the Chair. The Chair noted Marck Bellerive of Dartmouth Hitchcock Medical Center was the official representative from the New Investigators Committee. The Chair also noted there was a change in the CME methodology for this meeting. The Chair recommended members attending this committee meeting could also attend the Lung Cancer Committee meeting on Saturday morning. There was a symposium organized during the Lung Cancer Committee meeting on topics that are of interest to medical physics. The Chair also noted the Image Guided Radiotherapy Committee meeting started at 9:30 a.m. on Saturday morning. The Chair announced he was a member of the Publications Committee and served as a Physics member of that committee.

The Chair provided a follow-up on the Lung Symposium, which was held in the January meeting in New Orleans. He congratulated those participants who have already provided their write up. He commented immediately following the January meeting, he had submitted two requests for secondary analysis. As a member of the Publications Committee, he had seen one of those requests but not the other. The Chair stated his goal was to develop recommendations for the RTOG with respect to dose prescriptions and a heterogeneous environment.

Dr. Saiful Huq provided the Oncologists with an RTOG Radiation Oncology Quality Assurance Report. The initial Radiation Oncology review for 2004 was completed in 405 cases. There was an overall compliance rate of 97.1% for the cases actually reviewed and those not sampled for initial review, assuming the same compliance. The study Chairs performed final reviews of 764 cases. The overall compliance rate for final review was 90%. The majority of those cases were not in compliance were due to factors beyond the control of the RTOG, such as patient refusal or disease progression.

RTOG headquarters has performed a prostate localization survey. One-hundred and twenty-nine institutions responded. Sixty-eight of those institutions performed daily localization, while 45 of those institutions provide weekly localization.

The Radiological Physics Center (RPC) provided a written report to the Medical Physics Committee. The director of the RPC, Dr. Geoffrey Ibbott, reviewed the highlights of this written report. The RPC monitors approximately 1,400 radiotherapy facilities. The RPC proposed discontinuing a measurement of the electron percentage depth dose as only less than 1/10^th of 1% showed a problem. The RTOG Medical Physics Committee endorsed this concept. Dr. Ibbott reported 18 RTOG institutions failed to return TLD safety during a period of time was greater than six months. The RPC will continue to work on encouraging institutions to submit their TLD in a timely manner.

Dr. Ibbott spent substantial time discussing the different contributions of the RPC to the RTOG’s credentialing activities. Dr. Ibbott reported the demand for the Head & Neck Phantom is slow. As of the date of this report, 82 institutions have irradiated the Phantom one or more times. Eighty-one reports have been sent. Fifty-one institutions have passed and thirty have failed. The prostate Phantom has been sent to 14 institutions. Seven institutions have passed, one institution has failed, and six are being evaluated or were un-evaluable. Some institutions are not following the instructions as well as they should. This results in re-radiation being required as the necessary dose may not have been delivered. The Lung Phantom is being used to credential institutions for RTOG 0236, the stereotactic radiotherapy to lung protocol. Five institutions have irradiated the Phantom. The criteria for passing this test have yet to be established. The Lung Phantom has also been used to evaluate the accuracy of heteogeneity corrections. It was discovered convolution algorithms provided significantly better dosimetry data than do Pencil Beam or Clarkson algorithms, under the commissions evaluated.

The RPC requested a time limit be established to complete the entire credentialing process. The RPC proposed a three-month limit for submission of the treatment plan by new electronic data exchange to the ATC as well as submission of the Phantom to the RPC. There are several institutions have waited at least six months to complete this credentialing process. This request was discussed in some detail. The conclusion was there will be a strong request the institutions complete the entire process promptly, as opposed to defining a specific time limit. There was general agreement a time period stretching greater than six months was unacceptable.

The Advanced Technology Consortium (ATC) provided a written report. Dr. Purdy reviewed the highlights of this report. He noted some institutions were constructing significant firewalls to protect their institution. Data can be exchanged using CD’s. Dr. Purdy noted there were approximately 2000 completed digital data sets submitted over the last 10 years. With respect to credentialing, in the future, ATC communications will be submitted to the entire team, including oncologists, dosimetrists, and physicists. The goal is to have all team members at a specific institution be informed as to the status of their credentialing activities.

Dr. Purdy expressed concern regarding institutions only completed part of the credentialing process. The same issue was identified by the RPC. Credentialing requires both the Phantom work and the digital exchange work to be completed.

Dr. Purdy announced significant progress with respect to data exchange and the Nucletron high dose rate remote after loading planning system. This work is being performed at the Medical College of Wisconsin in conjunction with Nucletron.

RTOG 0245 is a Phase I, II trial of highly conformal radiation therapy for patients with unresectable primary hepatobiliary cancer and liver metastases. Dr. Purdy asked if a phantom was going to be required for this protocol and credentialing required. At this point in time it is not clear. Dr. Schell and Dr. Galvin are scheduled to work together to clarify issues associated with this protocol.

The Chair distributed an initial draft of comments regarding heterogeneous dose prescriptions for lung protocols. There was a substantial discussion of this draft document. One conclusion reached was older algorithms, such as the Clarkson algorithms, did not provide sufficiently accurate results to be permitted to be used in the heterogeneous dose prescription environment. It was also suggested the technique for the definition of the gross tumor volume should be specified. There was a discussion of whether the prescription should be defined in terms of coverage of 100% of the CTV as opposed to some percentage, for example, 93%, of the PTV. No final conclusion was reached on this topic.

It was decided other RTOG institutions would be asked to review 10 patients following the recommendations contained in this dose prescription. Possible institutions include Washington University, Thomas Jefferson University, Mayo Clinic, and Tom Baker. The current data is from M. D. Anderson. Additional data from other planning systems at other institutions would help establish a more general foundation to make recommendations. The Chair promised to modify the draft and then contact these institutions.

In addition to addressing the question of heterogeneous dose prescriptions, the question of motion was also raised. The RPC is developing a motion phantom. Approaches as to how incorporate motion into RTOG protocols remain to be defined. In addition, also remaining to be defined are QA activities associated with correction of respiratory motion. A vigorous discussion was held on this.

MEDICAL PHYSICS COMMITTEE (January, 2004)

Michael T. Gillin, Ph.D., Chair

The RTOG Medical Physics Committee met on Friday, January 16, 2004, from approximately 4:00 p.m. – 6:00 p.m. Approximately 50 people were present representing approximately 30 institutions. The chair opened the meeting with a report on the recently completed RTOG Symposium Optimization of Thoracic Radiation. The chair announced that it was his intention to build on this topic and to recommend to the Lung Cancer Committee, a dose prescription, which is density, corrected. It was the opinion of the chair that this was a very successful symposium and the chair thanked all of the presenters and attendees.

The chair briefly discussed RTOG 0126 and noted that IMRT treatment approaches are now permitted. The chair also commented on RTOG 0319, which is a partial breast irradiation protocol. The chair announced that in December, initial work had begun to transmit images into digital format between M. D. Anderson Cancer Center and RTOG headquarters. Finally, the chair commented on his experience the previous day in reviewing data for RTOG 0023. The chair stated that it was extremely difficult to review black and white dose distributions. These are copies of color dose distributions. The chair urged the attending physicists to pay close attention to the quality of data being submitted by their institution.

Betty Martin, of RTOG Headquarters, presented a brief report on her activities with the Advanced Technology Consortium. James Purdy, Ph.D., principle investigator for the Advanced Technology Consortium, presented his report to the RTOG. The ATC’s mission is to facilitate the conduct of MCI sponsored advanced technology radiation therapy clinical trials while maintaining patient confidentiality. This effort to date has involved supportive clinical trials requiring digital data transmissions for all radiation therapy data objects. The ATC’s major developmental efforts are focused on:

A written report was received from the Radiological Physics Center. The RPC now regularly reports to the RTOG QC Committee and the Membership Evaluation Committee regarding compliance with TLD audit program and the payment of the participation fee. The RTOG Quality Control and Membership Evaluation Committees have agreed on a procedure for putting institutions on probation or suspending them, for non-compliance with the RPC audits. The RPC is presently monitoring 1,340 treatment sites. During 2003, the RPC monitored 7,000 beams at 920 institutions. 2.8% of the beams monitored were outside of the RPC 5% criteria, but 16% of the institutions have at least 1 beam outside of those criteria. The RPC have recredentialed for the institutions to participate in RTOG 0232. The 62 institutions previously credentialed for RTOG 9805 and 0019 may be grandfathered if they have not changed personnel, treatment planning system, or seed.

The RPC reported on their anthropomorphic phantom program. This includes pelvic phantoms, which will be used to participate in our credentialed institutions in RTOG 0126. The RPC proposed to use the same criteria for the pelvic phantom as used for the head and neck phantom, namely TLD agreement within 7% and distance to agreement in the high dose region of less than or equal to 4mm. The RPC also has a lung phantom, which they intend to use for credentialing for RTOG 0236, the stereotactic lung protocol. The head and neck IMRT phantom has been sent out 77 times to 52 institutions. Thirty-four institutions have passed the criteria and 13 institutions are still attempting to meet the criteria. Four institutions are in progress and 1 institution has informed the RPC that they will not repeat the phantom irradiation. Of the 14 institutions failing to meet their criteria, 12 failed to meet the TLD criteria and 8 failed the distance to agreement criteria. Several institutions failed both criteria. The RPC now uses the web tools provided by the ITC to re-evaluate the institutions calculations of dosage to the TLDS. The RPC reported that there is a short waiting list for these phantoms at this point in time. There are seven institutions with a priority 3 and one institution with a priority 2 waiting for the head and neck phantom.

An institution recently approached the RPC regarding the 3D CRT benchmark. This institution uses a field in fuel breast treatment technique, and the question arose as to whether their technique actually constituted IMRT. The RPC prepared guidelines to distinguish between IMRT and 3D CRT treatments. These guidelines stated that field in fuel treatments are not IMRT if all of the following criteria are met:

The RPC requested that the RTOG Medical Physics Committee discuss these guidelines.

Saiful, Huq Ph.D, presented the RTOG Radiation Oncology quality assurance report. This report contained information on initial reviews and on final reviews. For initial reviews in 2003, there were 1,442 cases. There was an overall compliance rate of 97.6% for the cases actually reviewed and those not sampled. Study chair final reviews were performed for 1,551 cases in 2003. The overall scores for cases receiving final review were 84% overall compliance.

There was a discussion of the applications for membership to join RTOG. In 2003, there were 56 applications for membership. Fourteen of these applications are approved but not activated. Ten are from joint centers, and two are from CCOP. Dr. Robert Kline from the Mayo Clinic suggested that it would be useful to receive feedback to the full member institutions, both the PI and the Physicist, relative to applications sent to headquarters for review.

Next ensued a general discussion of several issues. The following actions were taken:

MEDICAL PHYSICS COMMITTEE (June, 2003)

Michael T. Gillin, Ph.D., Chair

The RTOG Medical Physics committee met on Friday afternoon, June 27^th from approximately 4:00pm to 5:45pm in the Delta Centre-Ville Hotel in Montreal. There were approximately thirty people in attendance representing more than ten institutions.

The chair opened the meeting welcoming everyone to Montreal. The chair discussed one major contribution made in the past six months to RTOG, namely the development of a workaround for the use the Corvus planning system for IMRT protocols. This workaround is based upon a suggestion developed at Thomas Jefferson University Hospital with the details being established at M.D. Anderson Cancer Center. This workaround is now posted on the ITC website. The chair emphasized that it is additional work for an institution wishing to use it. However, it appears that the vendor will not be providing an appropriate solution until sometime next calendar year.

Dr. Saiful Huq provided the RTOG Headquarters’ Dosimetry report. The overall compliance rate for initial review is ninety-eight percent. The overall compliance rate for those cases reviewed within the last five months for final review was eighty-five percent. Headquarters dosimetry attempted to discern any trends relative to either initial review or final review. No obvious trends were identified. Dr. Huq and the Chair alerted the attendees that the RTOG would be adopting criteria and consequences for institutions whose data quality was poor.

Dr. Geoffrey Ibbott, director of the Radiological Physics Center, brought a written report of the activities of the RPC. One issue that Dr. Ibbott brought to the attention to the committee was the small number of institutions who was not responsive in the participating in the TLD program. Dr. Ibbott will be providing the Quality Assurance Committee and the Membership Committee with a list of institutions who for whatever reason were able to participate in this required program. Dr. Ibbott provided reports on the prostate brachytherapy credentialing activities. He reported that each of the seventy-three institutions that have been credentialed received a letter asking for any changes in personnel or seed type or planning equipment. This is in preparation for RTOG 0232. Dr. Ibbott also reported on the GYN brachytherapy credentialing activity of the RPC. The RPC was asked to evaluate the first implant plans submitted by the institutions. To date, forty-seven brachytherapy plans from nineteen institutions have been evaluated. Of these, nine institutions have submitted at least the two required plans to essentially comply with the protocol. Dr. Ibbott also reported on the various RPC anthropomorphic phantoms. The IMRT phantom has been the one with the greatest activity. The RPC is refining this phantom. In addition, the RPC is making progress in implementing a gel dosimeter with this phantom. The RPC is using the ITC-RCET software tools for the electronic transmission of images and treatment plan information for both external beam and brachytherapy. The RPC indicated that that credentialing for the IMRT RTOG protocols requires both a submission of dry run to the ITC and the phantom to the RPC. Both of these organizations are then notifying the RTOG dosimetry headquarters of successful completion of these requirements by the institution so that RTOG headquarters can notify the institution.

James A. Purdy, Ph.D., ATC, Principal Investigator, provided the report from the ATC. This report was distributed as a handout at registration for the RTOG meeting. As of June 18, 2003, the ATC is supporting seven RTOG protocols. In addition, they have committed the resources to seven additional RTOG protocols. The ATC is anxious to support other cooperative groups but at this point in time they have not received any digital information from any other cooperative group. Dr. Purdy reported that there will be a new ATC website available this fall, which is being designed by IT professionals as opposed to medical physicists. Dr. Purdy also announced that at the upcoming AAPM and ASTRO meetings there would be an ATC presence. One purpose of this presence is to alert Radiation Oncologists and Medical Physicists on the ability of various planning systems to transmit required data in either the RTOG format or the DICOM-RT format. This is particularly important, as the phase III protocol RTOG 0232 requires credentialing and electronic data submission. This protocol is a phase III study comparing combined external beam radiation and transperineall brachtherapy versus brachtherapy alone for selected patients with intermediate risk prostatic carcinoma. This protocol was opened for patient accrual on June 11^th 2003. Dr. Purdy also discussed the work around developed for the Corvus system. He also emphasized that this represented additional effort on behalf of the institution that wished to use this system. Dr. Prudy announced that there would be a meeting of the ATC immediately preceding the RTOG meeting and those representatives of QARC attended this meeting. The ATC meeting is scheduled for November 7, 2003 at the COG meeting in Dallas.

The Chair then led a discussion on old/new issues. The first issue involved density corrected dose prescriptions. The Chair proposed that the challenge for the Medical Physics Committee was providing the Radiation Oncologists with appropriate data in order to convince them that it was time to modify the traditional dose prescription approach to one that was density corrected. The possibility of using either an existing phantom or a specially developed phantom for both measurement and calculation purposes was discussed. The chair suggested that with the emergence of Monte Carlo as a calculational technique that it was certainly appropriate to review this long-standing issue.

The Chair also asked the membership to think about specifications and quality assurance mechanisms for new treatment techniques, especially those involving gating or ABC. In addition, the Chair noted that PET imaging was becoming routine at many institutions and that it would soon find its way into RTOG protocols. The Chair noted that earlier Dr. Purdy had reported that there were still some issues in DICOM transmission of this data. The Chair suggested that it was time for the Medical Physics Committee to be thinking about criteria for incorporating both PET and MRS information into treatment planning for RTOG protocols.

The Chair promised that he would be e-mailing the membership on multiple issues between now and the next RTOG meeting. The meeting ended at approximately 5:45 PM.

MEDICAL PHYSICS COMMITTEE (January, 2003)

Michael T. Gillin, Ph.D., Chair

The meeting was very well attended with over 40 people from at least 25 different institutions. The Chair briefly discussed issues associated with accrual and membership. The Chair explained that there are at least two criteria for full members to maintain their membership, that full members need to accrue at least 25 cases from the full member institution and at least 50 cases from the full member and their affiliate members. The Chair noted that this system, which had been established some time ago, was being re-evaluated and that the Membership Evaluation Committee would be initiating a discussion of these criteria. The Chair also noted that the Quality Control Committee was proposing a procedure to deal with institutions, which have three unsatisfactory site visits in a row, and another procedure to deal with institutions whose patients fall into the “Not Evaluable for Review” category. The Chair urged physicists to discuss these issues with their institution’s RTOG PI.

Dr. Huq presented the report from the RTOG Radiation Oncology Quality Assurance. A written report was provided. In 2002 initial radiation oncology review was considered for 1,625 cases. The overall compliance rate was 95% for the cases actually reviewed. In 2002, the study chair final reviews were performed for 1,846 cases. 87% of these cases were determined to be either per protocol or with an acceptable variation. In addition, there were 58 cases reviewed for SRS protocols. Only 66% of these cases were judged to be per protocol or with acceptable variation for the radiosurgery component on the SRS Protocols. This did not include the external beam evaluation on these SRS trials.

Dr. Ibbott presented the report from the Radiological Physics Center (RPC). A handout was provided. In 2002 the RPC visited 44 institutions with 248 megavoltage beams. For prostate brachytherapy, the RPC has issued 68 credentials to 64 institutions. The RPC noted that there are now 11 I-125 seeds models and 4 Pd-103 seed models that meet the AAPM prerequisites. Dr. Ibbott spent substantial time reviewing the results of the irradiation of the IMRT phantom. The agreement between the RPC and nine of the first ten institutions is quite good, within 2%, but the percent standard deviation was large for the critical structure, namely 13.9%. The RPC made the following suggestions relative to criteria upon which to judge subsequent phantom irradiations: (1) For the PTV’s, the TLD value must be within 7% of the planned value. (2)For the Organ at Risk, 4 mm is the maximum shift between the calculated dose line and the measured dose line. The Chair promised to circulate these suggested criteria to the members of the Medical Physics Committee for their review and comments. It is noted that 2 of the next 4 irradiations of the phantom do not meet the criteria for the PTV’s.

Dr. Purdy presented the report from the Image-Guided Therapy Center (ITC), which is part of the Advanced Technology QA Consortium (ATC). The ATC consists of the ITC, RCET, RPC, QARC, and RTOG HQ Dosimetry. The ATC mission is to facilitate the conduct of NCI sponsored advanced technology radiation therapy clinical trials while maintaining patient confidentiality. The ATC is currently supporting 6 RTOG protocols and has committed resources to support 7 additional RTOG protocols. In fact, at this point in time the ATC is only supporting RTOG protocols.

The ATC announced in its report that the ITC has suspended approval of Marconi AcQPlan and Nomos Corvus pending resolution with the ITC of data exchange issues. This announcement was the first time that this action was brought to the attention of the Medical Physics Committee. The ATC report did not describe the data exchange issues for these previously acceptable systems.

Dr. Galvin provided a brief discussion of the NOMOS data exchange issues and noted that he had developed a solution to the data exchange issue. It is noted that at least 12 of the 19 patients entered onto RTOG 0022 were entered using Corvus. It was noted that a meeting was scheduled for Saturday at noon to review this solution.

Dr. Xia briefly described RTOG 0025, which is scheduled to be open soon. Dr. Bice briefly described RTOG 0232, which is also scheduled to be open soon. It was noted that institutions would be requested to choose between I-125 and Pd-103 to use on this protocol. The IMRT modification for RTOG 0126 was briefly discussed. Also discussed was credentialing for RTOG 0023.

MEDICAL PHYSICS COMMITTEE (June, 2002)

Michael T. Gillin, Ph.D. Chair

The first item of business was a presentation made by Ms. Betty Martin to Mr. Bill Harms, Jr., which acknowledged the contributions that Mr. Harms had made to the activities of the RTOG, especially with respect to dosimetry quality assurance. Mr. Harms has accepted a new position and will be leaving the IT Center in St. Louis.

The chair presented his report, which included a discussion of IMRT, with an emphasis on the recently published NCI guidelines for the use of this modality, a discussion of H-0022, and a discussion of the Oropharynx protocol. The chair next discussed RTOG L-0236, a phase II trial of extra cranial stereotactic radioablation in the treatment with patients medical inoperable stage I non-small cell lung cancer. This protocol requires a fixed, three dimensional, coordinated system (a stereo tactic body frame) with fudicals. The current version of the protocol does not require breathing control devices as the PI feels that they are not necessary. This protocol requires the delivery of three fractions of twenty gray each over a time period of one to two weeks. Patient immobilization is crucial. The current plan is to require three different CT scans of the patient on three different days to determine the ability to reproduce the patient in the treatment position.

The chair next discussed the development of single, unified credentialing form to be used by all cooperative groups for credentialing institutions who wish to participate in prostate brachytherapy protocols. The chair has requested that the RTOG approve the use of this form and that the RTOG accept this form as a credentialing document. The chair then presented a discussion of some data from P-0019. Approximately, twenty-five percent of the cases have been finished. Some tentative initial impressions include the activity ranges from 0.20 to greater than 0.4 mCi/seed, some patients received implant dose which was substantially greater than the prescription dose, and that there is still disagreement in the evaluation target volume between the institution submitted data and the centrally reviewed data.

Dr. Saiful Huq, represented the RTOG QA office presented the report from RTOG Headquarters. Overall compliance with the initial review was 94%. Overall compliance for the 348 cases that underwent final review since last meeting was 86%. Headquarters report used a new bar graph presentation to summarize the data. This was very well received.

Dr. Geoffrey Ibbott presented the report from the Radiological Physics Center (RPC). The RPC will provide a written report later. Dr. Ibbott reported that approximately 25% of the institutions that participate in cooperative trials have converted to TG 51 protocol. Dr. Ibbott reported that essentially every institution that received an on-site visit from the RPC received a recommendation to improve their dosemetric system. Dr. Ibbott noted that some institutions were unresponsive to suggestion for changes and requested help from the RTOG Medical Physics Committee. The chair requested that the RPC report at each semi-annual meeting and the number of RTOG institutions who are unresponsive to requests to update their Dosimetry system. The chair suggested that this would be the first step in a combined effort to have RTOG institutions, if any, become more responsive to these requests. The RPC reported the results of the radiation of the IMRT phantom from the first ten institutions. The plan is to use this data as criteria in evaluating subsequent institutions. A long discussion was held on the appropriate criteria. The chair promised to circulate the criteria to the RTOG Medical Physics Committee for their comments and evaluation. A discussion was held as to the challenges associated with maintaining an adequate record of credentialed personnel and planning systems. The chair promised to work with the RPC to develop an appropriate form. The group that would be responsible for inputting and maintaining this data in some sort of database format is yet to be determined. The RPC presented a brief discussion on developments of his phantoms including a lung phantom, a prostate phantom, and a breast phantom.

Dr. James Purdy presented the report for the Image Guided Therapy Center. Forty-two institutions have been successfully credentialed for RTOG 98-03, the 3D dose escalation brain study. Seven institutions have been successfully credentialed for RTOG H-0022, the IMRT Oropharynx protocol. Twenty-nine institutions have been credentialed to participate in RTOG L-0117 Lung Protocol. Fifty-four institutions have been credentialed to participate in RTOG P-0126. Progress continues in the implementation of DICOM 3.0 data exchange. Two different planning systems have submitted data using this format. This data submission was done by the vendors. The ITC is still waiting for data submission using this format from a user. Dr. Purdy reported on the recent meeting of the advanced technology center (ATC) QA grant activities. The name of this group has changed to the Advanced Technology Consortium. A discussion was held on the long range goal of moving away from a data review system based on hard copies and film towards a data review system which would be completely digital in nature. It was acknowledge that while significant progress was made towards this goal, it will still require substantial time before all protocols can reviewed in this fashion.

Dr. James Galvin presented a report on the radio ablation lung protocol. His discussion included the requirement for a body frame with fudicials and for a determination of the effectiveness of the immobilization system for the patient.

The chair concluded the two hour meeting with another acknowledgement of the contributions that Mr. Harms has made to the RTOG over a number of years. The chair wished him well in his new position. The meeting ended at approximately 6:00 pm. Over 25 people attended, representing 14 different institutions.

MEDICAL PHYSICS COMMITTEE (January, 2002)

Michael T. Gillin, Ph.D. Chair

The Medical Physics Committee met at approximately six o’clock on Friday, February 1, 2002. Immediately prior to this meeting, the Medical Physics Committee had organized a three hour workshop on IMRT. The goals of the workshop included:

The workshop had eight speakers. Four different commercial planning systems were shown to be able to provide appropriate solutions to the dosimetric constraints as defined in the protocol. The workshop was very well attended. Participants received handouts including the dosimetry section of RTOG H-0022, the dosimetry section of RTOG 99-11 and RTOG H-0022 dry run guidelines, the 3DCRT-IMRT QA facility questionnaire, appendix VI entitled 3DCRT-IMRT for oropharyngeal cancer quality assurance guidelines for RTOG H-0022.

There were over thirty attendees at the Medical Physics Committee meeting from twenty different institutions. The committee meeting began with a report from the Chair which included a brief review of the just completed workshop. The Chair observed that there had been excellent interactions between Principal Investigator’s offices on RTOG H-0022 and the Medical Physics Committee. The Chair noted, however, that there was no physics name associated with the QA of this protocol. The Chair noted the one major challenge facing the RTOG would be central review for various IMRT treatments of planning and delivery systems. The Chair requested that any member of the Medical Physics Committee or anyone in attendance contact him providing ideas as to how such central review could be accomplished in a reasonable fashion.

The Chair then presented a review of the QA on RTOG 98-05 as of January 25, 2002, eighty-four patients were available with both institution and central review by radiation oncologists. The conclusions reached by the Chair in his review of this material is that central review is vital, that additional work is needed to modify existing forms to collect all required data, that some criteria can be developed to evaluate implants entered on to these protocols, and that it is possible to conduct a cooperative group trial using this modality. There was a discussion of the data presented and how it would impact on developing protocol 1084, which is a phase III protocol involving brachytherapy in both arms. Dr. Prestidge stated that appropriate mechanisms needed to be developed which included contributions from the Medical Physics Committee in order for there to be adequate central review of patients entered onto this protocol.

Dr. Huq presented a report from RTOG headquarters relative to radiation oncology quality assurance. Analysis of data from headquarters indicated that 95% of the data submitted for initial review was in compliance. The overall compliance rate for the study chair final review in 2001 was 84%. A total of 1,556 cases underwent final review this year.

Dr. Geoffrey Ibbott presented a report from the Radiological Physics Center (RPC). The RPC promised to send a written report at a later date. Dr. Ibbott reviewed the activities of the RPC in credentialed institutions to participate in prostate brachytherapy protocols. Dr. Ibbott announced that the RPC would be sending a letter to all institutions who had been credentialed for either RTOG 98-05 or RTOG P-0019 reminding them that they had been credentialed for the upcoming phase III prostate brachytherapy protocol. The letter would also inquire as to their intention to remain with the type of source they were credentialed with and also remind the institution that this new protocol would permit the use of Pd-103 sources. If institutions wish to be credentialed with the Pd-103 source they need to submit the appropriate data. Dr. Ibbott requested that the RTOG accept credentialing from other cooperative groups for the RTOG protocols. The Chair requested that Dr. Ibbott send the Chair a formal letter requesting such acceptance and provide reasons why the RTOG should do so. The Chair then promised to ask RTOG leadership to consider such a request.

Dr. Ibbott discussed the IMRT phantom and the results from those institutions that had planned and treated this phantom. Within the last week, the RPC had received the radiation results from two additional institutions, bringing a total of eight institutions who completed this exercise. Once the data is analyzed from these institutions, it will be possible to develop criteria by which the radiation of the phantom can be judged. The RPC will share these results when they become available.

The lung phantom remains in development by the RPC. The chair expressed interest in this phantom for use by the RTOG once the development is complete. Dr. Ibbott announced that the RPC has a new phone number, although the old phone number will continue to be valid for some time.

William B. Harms, Sr., BS, presented a report from the Image Guided Therapy Center (ITC). Institutions continue to become credentialed for participation in prostate, lung, and super glioblastoma multiforme and oral pharynx protocols. Currently, there are four institutions credentialed to input patients on to H-0022 while there are other applications in progress. Significant problems have been identified relative to at least one of the commercial IMRT planning systems. The Medical Physics Vice Chair and Chair will draft and send a letter to this commercial venture, which outlines these issues and urging this company to address them as soon as possible.

The ITC has submitted its renewal grant application. In a private conversation with Dr. James Purdy, the Chair of the Medical Physics Committee learned that assuming appropriate funding there would be personnel changes associated with the ITC and there would be quicker response to information sent by various institutions for credentialing for various protocols.

The phase III brachytherapy protocol was discussed again. There are now apparently two commercial planning systems which can submit data in a digital format to the ITC center for the purposes of remote review. There was speculation as to how the central review would be conducted for this protocol.

Under new business, the Chair announced progress and the development of criteria for an image database for gynecologic applications. One purpose of this database would be to have data available in the future to gain a better understanding of the dose distribution in and around the cervix and paracervical tissues and potentially to relate this to local control and complications.

The Chair encouraged members to request IMRT phantom and reminded members to participate in two RTOG protocols that permitted the use of IMRT to eradiate the phantom. The Chair summarized the two major issues which are currently facing the Medical Physics Committee, namely:

The Chair thanked all those in attendance. The Chair especially thanked the HQ dosimetry staff for their continued support and especially for their support at the workshop that afternoon. The meeting adjourned at approximately 7:45 in the evening.

MEDICAL PHYSICS COMMITTEE (November, 2001)

Michael T. Gillin, Ph.D., Chair

The Medical Physics Committee met on Friday June 29^th 2001 beginning at 4:00 PM. There were approximately 30 people in attendance representing more than ten institutions. The chairman began the meeting with a brief summary of the recent NCI grant site visit comments. The chairman was pleased to note that the Medical Physics Committee was rated as outstanding, as was Image Guided Radiotherapy Committee. The Chair noted that in general RTOG did quite well.

The chair reviewed different credentialing processes for the single fractionated stereotactic radiosurgery protocols and the fractionated stereotactic radiotherapy protocol, BR-0023.

The chair reminded everyone that this was a completely different credentialing process, and if their institution wished to participate they would need to become credentialed.

The chair stated that one goal of this meeting was to arrive at a consensus on how to proceed with some technical issues relative to protocol H-0022. With in the last several weeks, the IG QA center identified some issues relative to data sets which had been sent to them for review for this protocol. One issue is that the Corus treatment planning system did not send plan and target volumes. The chair presented one solution to this issue which was to use several data sets. One data set would contain CTV. The second data set would contained a user defined PTV, the critical structures, the treatment plan, and the dose volume histograms. The chair had partially tested this approach at his institution and was planning on sending them to the IG QA center for their review within the next 30 days. Other issues with respect to the Corus treatment planning system involved the assignment of various pixels to various structures. The goal would be to pixels assigned to one structure during the optimization process, while being assigned to their basic structure during the dose analysis process. It is to everyone’s understanding that the current version of the software does not do that. A substantial discussion of these issues entailed. The Chair agreed to write a letter to the three PIs of this protocol which would outline these details and which would request a conference call to arrive at mutually agreed upon solutions.

The headquarters report was presented by Saiful Huq, Ph.D. In the last six months the initial review had a 97% compliance rate. In the last six months the final final rate was 80% for those cases reviewed. RTOG 97-04 had the poorest compliance rate. Headquarters is taking steps to have additional information forwarded at the time of initial review so that the compliance rate for this protocol will improve.

The Radiological Physics Center report was presented Geoffrey Ibbott, Ph.D. Dr. Ibbott announced that a paper entitled Dose specifications and quality assurance of RTOG protocol 95-17, a cooperative group study of Iiridium–192 breast implants as sole therapy has been accepted for oral presentation at the AAPM meeting this summer, with Will Hanson as the presenter. The change in calibration from TG-21 to TG-51 was discussed in detail. The approval process for RTOG protocols involving prostate brachthearpy was discussed. It is noted that the clinical review has been previously carried on by Dr. Allan Pollack. Dr. Pollack has left M.D. Anderson and has been replaced by Dr. Deborah Kuban, who will provide the RTOG will this service. The Head and Neck IMRT were discussed in detail. There are now four data points from three institutions. The dose delivered to the two target volumes of this phantom by the three institutions was within plus or minus 10%. The RPC acknowledged that they were still challenged by the process of relating the film dose distribution acquired in the phantom with the absolute dose. They will continue to work on that issue. Other phantoms were briefly discussed.

The report from the Image Guided Quality Assurance Center was presented by James A. Purdy, Ph.D. Institutions continue to be credentialed for RTOG 93-11 and RTOG 98-03. The initial credentialing activities for H-0023 were discussed. The digital transfer of data for prostate brachytherapy has been successfully accomplished by one institution. The Image Guided Therapy QA Center has set as a goal for itself to have DICOM3 data exchange available before the end of the year. This would allow planning systems who have implemented this to be used in RTOG protocols which require data exchange. They would continue to maintain the RTOG data exchange for the foreseeable future. Their report included a summary of an Advanced Technology Center QA meeting, which was held this spring at the NCI. The next meeting of this group is to be held M.D. Anderson in August of this year. The IGRT QA center discussed continued progress with review tools. Which generally acknowledged that this is a very important activity for future protocols, especially the phase III prostate brachtherapy protocol. The IGRT QA center had reviewed the treatment instructions for the IMRT phantom and has provided the chair with some modification for the purposes of clarification of this phantom. The chair promised to review this.

The Chair presented a power point presentation of cases entered onto RTOG 98-03. The purpose of this presentation would be to have such information be present on the RTOG website. The presentation was well received and one important improvement was suggested, namely to show beams eye views of the target volumes and the apertures. The chair will make that modification and forward the presentation to RTOG headquarters for a posting on the website. Other institutions will encouraged to prepare similar power point presentations and send them to the chair for review and subsequent posting on the website.

MEDICAL PHYSICS COMMITTEE (June, 2000)

Michael T. Gillin, Ph.D., Chair

The Medical Physics Committee met at two separate occasions during this semi-annual meeting. The first was the scheduled meeting between 4pm and 5:30pm on Friday, June 23. Approximately 30 people were in attendance. The chairman presented an overview of the activities of RTOG with emphasis on the upcoming grant renewal. The chairman announced that the first version of the Medical Physics portion of the grant had been written and reviewed. The second version was due on July 21, 2000. The chairman requested volunteers to review this document and provide him with suggestions. The chairman presented slides showing his initial grant preparation talk.

The second item of business was the report from Headquarters. For initial review, Headquarters reported the total overall compliance rate of 96%. Headquarters did express concern about the rising rate of delinquent forms. (Delinquent forms were defined as forms that were more than 24 days late in being sent to Headquarters for initial review). The report from Headquarters contained a list of the institution’s name and the study number for each delinquent report. Headquarters generated this report in response to a request from the QA Committee. In addition, there was a delinquent count by study name. The Headquarters report also contained information on the final review. In year 2000 to date, approximately 708 cases have received final review. Data is presented per protocol. It is difficult to integrate this data, which is activity in the year 2000, with the overall activity for each particular protocol. For example, endnote protocols will have more non-invaluable case for review than protocols that are actively accruing patients. Also contained in the Headquarters report was the deviation unacceptable summary for final review by institutions and by study number. The QA and the Membership Evaluation Committee hope to use this information to help institutions limit the number of cases which are unacceptable.

The Radiological Physics Center provided a written report. The RPC announced that their grant was funded for the next five years. The grant award was 2.6% above the previous years award. This may necessity a change, mainly an increase of institutional fees to $500 per year. The RPC is appealing to the NCI for additional funds before they institute that increase. The RPC is moving their offices to another building in August. The RPC announced they implemented DG 51 on January 1, 2000 for its TLD program and on site dosimetry review visits. The RPC noted that most institutions have yet to convert to this dosimetry protocol.

The RPC has received 58 applications for credentialing for RTOG protocol 98-05. To date 41 institutions have been approved and 8 institutions are still pending. Twenty-Five of the 41 institutions have submitted patients to RTOG 98-05. This protocol is now closed. However, the Medical Physics Chair thanked the RPC for these activities and reminded RPC that RTOG will open another prostate brachytherapy implant protocol this year and thus it is important that institutions continued to be credentialed for these activities.

The RPC described four different phantoms under development, namely an informal head and neck phantom, a breast phantom, a heterogeneous lung phantom and conformal pelvis phantom. The chair of the Medical Physics Committee thanked the RPC for their continued efforts in this area and expressed the opinion that this was very an important QA development.

The chair presented a summary of the dosimetry data on the first thirty patients who had been entered into the RTOG 98-05. The data indicates that there is a difference the posted implant prostate as defined on central review as opposed to being defined by the individual institutions. Several suggestions were received by the chair relative to strengthen the review of this data. These suggestions included having a diagnostic radiologist redefine the same prostate more than once. It was suggested that calculations be done which are independent of specific organ definitions.

The 3D-QA Center submitted their written report. The 3D-QA Center announced forty-one institutions were now credentialed to participate in RTOG 95-06, nineteen institutions were credentialed to participate in RTOG 93-11 and fifteen institutions were credentialed in RTOG 90-03. Additional institutions are in the process of being credentialed. The 3D-QA Center announced that they too are moving. They will be moving next week and have a new address and new telephone numbers. The 3D-QA Center stated that their new addresses and telephone numbers could be found on their web site. Mr. Harms of the 3D-QA Center briefly discussed remote review tools.

The meeting adjourned for the day with the chairman announcing that between 8:30AM and 10:00AM on Saturday morning that there would be a meeting to review progress on the IMRT protocol.

The Medical Physics Committee reconvened on Saturday morning at 8:30AM. Approximately fifteen people were in attendance. Substantial discussion was held on issues relating to the QA for the conformal radiation protocol for head and neck cancer. This protocol has been sent NCI for review. The chair stated he expected this protocol to open by the end of the year and that it was important to define and initiate the credentialing process. The conclusion reached at this meeting was that the credentialing process should involve two separate steps. Institutions would be provisionally credentialed and be able to enter patients on to this protocol after they had successfully met the requirements of the 3D-QA Center. Mr. Harms promised the chair that he would have the first draft to the chair by the middle of July 2000. The institutions would receive full credentials once they had successfully irradiated and planned the head and neck phantom being developed by the RPC. The RPC expected to have the final design of this phantom be complete by September 1, 2000. This phantom has had one field test and issues resulted from that test were discussed. These modifications in design of this phantom were suggested as a result of that field test. It is a request of the chair that at least one version of the phantom be available to be sent to participating institutions by October 1, 2000. The first institutions that the phantom should go to include the institutions represented by the RPC Center and institutions were the physics personnel is deeply involved in the QA aspects of this protocol. With respect to the work being doing at the 3D-QA Center, a standard of set of CT images was agreed on. These images were presented to the institutions in two separate steps. The first step has the images only presented and have the institutions defined through required anatomy. This definition of required anatomy would then be sent to the QA Center. The second step would be for the institution to receive the same set of images with the required anatomy already on the images. Thus the institutions would be planning from the same data set including both anatomy and contours. The plans will then be sent to the QA Center for review.

It was suggested that the Physics community should contact their software vendors to insure that their vendors will be able to send IMRT data to the QA Center for review. In addition, it was suggested that the Physics community also contact the software vendors to insure that they are implementing data so that prostate brachytherapy declaration can be sent to the QA Center for review.