Ensuring the safety and quality of patient treatments in radiotherapy is an ongoing challenge—especially for departments with diverse treatment machines from multiple commercial vendors. For this reason, physicists Francesca Romana Giglioli and Veronica Richetto, decided to evaluate ClearCheck, an automated plan evaluation tool, at Città della Salute e della Scienza di Torino.
To understand how ClearCheck would impact the treatment of over 3,300 patients per year (650 of which are stereotactic cases) in a busy department, Francesca and Veronica evaluated the Radformation Software with a small, targeted cohort of SBRT/SRS patients planned using RayStation® and treated on an Elekta Versa® HD.
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Collision Check Detects Errors Before They Occur
One of the ClearCheck features, which allows to save considerable time in replanning is its Collision Check feature; ClearCheck’s Collision Check module is designed to carefully evaluate patient setups for potential gantry or imager head (CBCT) collisions with either the patient or the table. Assessing collision risk is critical for plans that include non-coplanar fields, very lateral lesions, or large patients.
The first pair of these patients was a three-field lung SBRT patient that presented with a real collision risk involving initial positioning of the gantry to treat one of the arc fields. In these scenarios, a collision would have occurred when the technician rotated the gantry to position for beam delivery. It was only avoidable if the technician moved the couch prior to gantry rotation, followed by a repositioning of the couch. Had this plan been evaluated during the planning process with ClearCheck, this likely could have been avoided.
With a warning distance of 4cm and checking full rotation, a collision was detected during gantry rotation.
“We simulated arcs and checked for real collisions on the machine. In ClearCheck, by setting a safety margin of 4 cm, a collision was flagged exactly when the gantry physically collided.”
-Physicist Francesca Romana Giglioli
This patient setup required careful monitoring and couch motion/repositioning to avoid collision risk. Using a 4cm warning distance, a collision was detected during gantry rotation, validating the functionality of the Collision Check system.
In another instance, a cranial SRS treatment with several non-coplanar fields and couch kicks, served as a true clinical test, as the non-coplanar fields were deliberately generated to test the software’s ability to detect actual collisions on the accelerator. On the machine, the patient geometry was established and treatment fields were executed. This clinical simulation resulted in true collision risk, and retrospective review with Collision Check flagged the fields at 310° and 10° couch rotation—with a 2 cm safety margin—as a potential risk.
The SRS plan resulted in two issues when clinical simulation was performed. Using a 2cm warning distance, both collisions were properly detected during gantry rotation using ClearCheck's Collision Check
Automated Plan Evaluation Impacts Efficiency, Standardization, and Quality
Manually documenting key patient dose constraints for a number of targets and organs at risk can be time-consuming, especially with stereotactic plans, which can be very complicated plans. Using ClearCheck for these patients, they’re able to thoroughly evaluate the plan using major dosimetric constraints for organs at risk using metrics like mean dose, hot spots (D0.1cc), and mean volume spared.
“ClearCheck certainly saves time compared to manual checking and increases the number of parameters being reviewed,” says Veronica Richetto.
But more than that, ClearCheck supports consensus nomenclature as recommended by TG-263, which reduces variability in structure naming across institutions, vendors, and time. For clinics that haven’t yet transitioned to recommended naming conventions, the software provides the ability to assign alias names as appropriate.
The physics team found value in ClearCheck’s plan parameter checks as well. One of their retrospective patient plans had an issue in which the treatment couch was not taken into account during calculations. “We have the same treatment couch in both the CT and the Linac, so we use the real densities from the CT,” says Richetto. “The couch is defined as a "support" in RayStation so that the system takes it into account without displaying the dose. If it’s not defined as a support, the system doesn’t recognize it because it’s outside the external contour.” ClearCheck property flagged this issue in a retrospective analysis.
Enhancing Confidence for Complex Patient Plans
Evaluating ClearCheck as part of the SBRT/SBS planning workflow at Città della Salute e della Scienza di Torino demonstrated its ability to catch critical setup and planning issues—before they impact treatment. By automating collision prediction, dose constraint evaluation, and more, ClearCheck not only improved safety and plan quality but also helped streamline and standardize the review process in a mixed Elekta/Raystation environment.