development and use of a computer system in a radiotherapy department: sisgrad

Ink J. Radiation Oncology Biol. Phys., Vol. 13, pp. 1949-1955 0360-3016/87 $3.00 + .OO

Printed in the U.S.A. All rights reserved. Copyright 0 1987 Pergamon Journals Ltd.

l Computer Applications

DEVELOPMENT AND USE OF A COMPUTER SYSTEM IN A RADIOTHERAPY DEPARTMENT: SISGRAD

ANDRE COSTA, PH.D.,* CLAUDE-MICHEL LALANNE, M.D.,? SERGE MARC& PH.D.,* MICHEL LECA, PH.D.,* PHILIPPE RAMEAU, PH.D.,* PIERRE CHAUVEL, M.D.,t

MICHEL H~RY, M.D.,? JEAN-LEON LAGRANGE, M.D.t AND JACQUES VERSCHOORE, M.D.?

Centre Antoine Lacassagne, 36, Voie Romaine, 06054 Nice Cedex, France

SISGRAD, the interactive computer system of the Antoine-Lacassagne Cancer Center Radiotherapy Department, has been operational since January 1982. It completes the computerized dosimetry system installed several years earlier and is fully integrated with the institution’s central computer network. SISGRAD is in charge of surveillance of the radiotherapy treatments given by the Center’s three radiotherapy units (1400 patients per year); it is also used for administrative purposes in the Department and physically connects all of the Department’s operating stations. SISGRAD consists of a series of microcomputers connected to a common mass memory; each microcomputer is used as an intelligent console. SISGRAD was developed to guarantee that the treatments comply with prescriptions, to supply extemporaneous dosimetric data, to improve administrative work, and to supply banks with data for statistical analysis and research. SISGRAD actively intervenes to guarantee treatment quality and helps to improve therapy-related security factors. The present text describes the results of clinical use over a 4- year period. The consequences of integration of the system within the Department are analyzed, with special emphasis being placed on SISGRAD’s role in the prevention and detection of errors in treatment prescription and delivery.

Microcomputers, Equipment control, Quality confrol, Radiotherapy, Files, Treatment monitoring, Databases.

INTRODUCTION

The introduction of medical computer systems has un- questionably played a significant role in the progress made over the past years in cancer treatment. Computer- ized dosimetry has now stot manual techniques for external beam irradiation, and allows dose computation for complex cases (irregular fields, heterogenities, 3-dimensional calculations).4X7~‘4,15~‘8,2’,39’41 For curietherapy, the development of computer systems had led to the creation of software adapted to new techniques and permits per- sonalized dose calculations for various clinical applications. 17,37*38 The installation of interactive minicomput- ers in the Radiotherapy Department has led to the use of software permitting selection of the best treatment solu- tion for external beam irradiation and curietherapy.3,8,‘3 All of these different computer systems have contributed to ensuring a high degree of quality in the planning and preparation of radiotherapy schemes.

At the same time, generalization of integrated computer systems has considerably improved the management and operation of both laboratories and the various medical departments. Several management programs have also been developed for radiotherapy and radiodi- agnostic applications.6,19~22,23~30 Data centralization by a computer system associated with a user network has proved extremely valuable for the creation, consultation, and updating of information. In the Radiotherapy De- partment in particular, the necessity for a means of monitoring correct treatment delivery has long been appar- ent. 25,26,40 Much work has been done using minicomput- ers and large computer networks for the monitoring and surveillance of therapy.2,9,20,29,32 One of the main obsta- cles encountered concerns the high cost of the relevant computer equipment in comparison to the cost of the actual treatment apparatus.

The introduction of microprocessors provided a means of getting around this obstacle, allowing the devel-

* Physics Department. t Radiotherapy Department. $ Data Processing Department. Reprint requests to: And& Costa.

Acknowledgements-The authors wish to thank Nancy Ra- meau and Bernard Fontaine for their assistance in the prepara-

tion of this report, as well as all the technicians and secretarial staff. The authors are very grateful to Michel Berto, Nicole Brassart, Daniel Celeschi, Adel Courdi, Jean-Marie Gabillat and Alain Ramaioli for their assistance during this work.

Accepted for publication 29 June 1987.

1949

1950 I. J. Radiation Oncology 0 Biology 0 Physics December 1987, Volume 13, Number 12

opment of systems for monitoring radiotherapy and managing radiotherapy data. Various systems have been developed,‘,‘6,33,42 and commercialized.* In most cases, however, microprocessors have been used for surveillance of only a single treatment unit. In 1978, we there- fore began development of SISGRAD (Systkme Infor- matique pour le Suivi de traitement et la Gestion du Dipartement de RADiothirapie). This system completes the dosimetric equipment previously installed in the Department, and has been notified several times. 11,12,27,28

SISGRAD constitutes an essential step in optimization of radiation therapy as well as quality control of the entire treatment program.5,‘o~3’~34,36 A total of 8 man/ year was required to arrive at this network of microcomputers connected to a common mass memory. On the basis of, and in addition to operations required for the preparation of irradiation schemes, the aims of this system include verification that the prescribed treatments are delivered, preparation of dosimetric data, improvement of Department management, and supply of data to the various banks for statistical analysis and research purposes. SISGRAD became operational in 1982 as part of a technical ensemble comprising three treatment units equipped with sensors allowing computerized dosimetry and as part of the institution’s central computer network INFOCAL.8s’3,35 Now that the system has been in clinical use for 4 years, with some 1400 patients treated each year, a certain number of comments are warranted concerning system operation and its ability to satisfy its pro-

Radiotherapy secretariat

Fig. 1. SISGRAD: General configuration.

sensors which also deliver analog signals. The presence of sensors allows digital recopying of the number of the compensating filters. The terminals connected to these three radiotherapy units are also equipped with electronic clocks which time the duration of irradiation (accuracy: 0.10 set) and are independent of the unit’s own clocks.

posed goals.

METHODS

Material

AND MATERIALS

SISGRAD (Fig. 1) is composed of 7 terminals connected in star formation to a multiplexer associated with a mass memory. Each terminal consists of a 48 Kb RAM microcomputert (cycle 1 I.LS) plus a keyboard and monitor. The mass memory is formed by a 10 Mb disk (Con- stellation Corvus; Winchester technology) partitioned into 67 volumes (track-to-track access time 3 ms). The multiplexer (Constellation Corvus) can handle up to 8 terminals connected in star formation: other multiplex- ers can be added.

1. Radiotherapy unit terminals. The first three terminals are connected to the radiotherapy units,+ two 60 Co units and a linac, by acquisition interfaces. The two 60 Co units are factory-equipped with potentiometric sensors for analog measurement of five essential parameters. The most recent cobalt unit has a treatment bed whose 5 degrees of movement are monitored by potentiometric

The acquisition interfaces of the two cobalt therapy units have 16 analog input channels and 1 digital input channel. Analog acquisitions are coded on 12 bits at the output; allowance being made for program-introduced delays, the 30 ps conversion time allows parameter acquisition in 8 ms.

The linear accelerator is factory-equipped with the op tional system for monitoring the unit’s main parameters; this system delivers an asynchronous message (2000 baud). The interface supplied with the linear accelerator accepts this asynchronous message and can acquire 8 parameter values in lOOms.§ These values allow control of the number of monitor-units delivered. The three terminals prohibit or authorize irradiation through the inter- mediary of relays: These relays can be taken out of service by using a key switch or a specific software instruc- tion. A monitor in each treatment room and at each

* Sincer, C.G.R. MeV (But, France), Veriflex@ Nuson, Brondby, Denmark.

t Apple II, Apple Computer Inc., Cupertino, Ca., U.S.A.

$ Theratron 780, A.E.C.L., Canada, Sagittaire, C.G.R. MeV, But, France.

Q Sincer, C.G.R. MeV, But, France.

Radiotherapy computer system 0 A. COSTA et ai. 1951

command station provides real-time visualization of the various parameters monitored and the parameters required for treatment preparation.

2. Terminals in the physics department. Two terminals are installed in the physics department; one is equipped with a two-directional 120 cps dot matrix printer. These two terminals are used for batch processing, general monitoring of computer network and automatic sequential jobs during the night. One of these two terminal is connected to a high transfer speed video safe- keeping unit with an approximate capacity of 30 Mb.** This terminal is also connected to two 5-inch 160 Kb floppy disk units, making the system compatible with outside programs.

3. Terminal in the secretariat. Connected to a 34 cps dot matrix printer, the secretariat printer also accepts a 2400 baud asynchronous line allowing exchanges with the INFOCALtt central computer system.*’

4. Terminal in the conference room. Located next to the dosimetry system,@ this terminal is connected to both this system and INFOCAL by a 2400 baud asynchronous line; a switch allows operation with one system or the other.

Software andjles The software used consists of some 100 modules with

a global capacity of 600 Kb. All programs have been writ- ten in BASIC Software* except for a few system modules developed in Assembler 6502. Two hundred Kb of the 650 Kb files serve as buffers. The 10 main files comprise data for patients currently undergoing treatment (over 250 patients and 650 beams). In programs and files, this application occupies the equivalent of 16 disk volumes, divided equally between programs and files.

1. Software. The software can be classified in 6 main categories:

1.

2.

3. 4.

5.

6.

1.

Modules for acquisition of the patient’s personal data and technical data for patients undergoing treatment; Modules for monitoring treatment units and recording of results; Modules for diffusion of results and file updating; Modules for manual correction of erroneous data in the files; Modules for data report printing and visualization of information; Module for inter-computer transmission.

Details on categories are provided hereunder:

Acquisition of personal data and technical data. Per- sonal data, the diagnosis in brief, the prescribed medical treatment, and the characteristics of the target volumes for irradiation are all entered at the secretariat

2.

3.

4.

5.

6.

before therapy is started. This procedure replaces typewritten reports, prepared previously. The technical parameters are entered in the physics department when dosimetric calculations are made; no extra work is required on the part of the physicists. The scheduled target volume doses are transmitted directly by the computer to be used for dosimetric computations. A simplified procedure is used to acquire data on patients treated on an emergency basis; treatment parameters can also be modified if authorized by the at- tending physician. Control films data are acquired on line, extemporaneously, from the treatment unit to the computer. The terminal located in the conference room is used to acquire curietherapy and contact therapy technical parameters as well as information needed for invoicing purposes. It can be used also for calculations or connections with the central or dosimetry computers. Monitoring qftreatment units. The parameters neces- sary for treatment and patient positioning are displayed at the three terminals located at the irradiation units. Display is controlled from the control stations located outside of the treatment rooms; a second monitor reproduces the display inside the room. Agreement between scheduled treatment parameters and the values actually recorded at the therapy units is checked by a computer in real time. Therapy is physically prevented from proceeding if discrepancies exceed the limit of tolerance. During irradiation, any modifications in parameters detected at the ma- chines, although highly improbable, are signalled by the program; the duration of irradiation is also checked, and the machine is stopped if the predeter- mined time is exceeded. Upon completion of irradiation, the actual parameter values and doses delivered are recorded in the files. Distribution of results. All data entered at the key- boards or transmitted directly by the irradiation units are fed into the specialized files. Data correction. The files can be modified manually to correct human errors, to take technical modifications into account, and to correct for any technical breakdowns that may have occurred. Report printing and data visualization. All file data can be visualized at all terminals; access is limited by codes. Treatment summaries are printed both at regular intervals and on request. Inter-computer transfers. Data entered in the central INFOCAL system are transmitted to the radiotherapy system. In return, technical information fol- lowing completion of irradiation is transmitted to INFOCAL.

** HR-7600s VCR, J.V.C., Japan. $$ SIRCIS, Informatek, LesUlis, France, Planigray, C.G.R. tt Two PDP 1 l/44, Two VAX 750, Digital Equipment, MeV, But, France.

U.S.A. *Applesoft@, Apple Computer Inc., Cupertino, Ca., U.S.A.

1952 I. J. Radiation Oncology 0 Biology 0 Physics

2. Files. The three types of files concern: patients, beams, and general information. The “patient” and “beam” files are subdivided into current and temporary files.

Patient files (Table 1). Current files recapitulate personal patient data (civil status, target volumes) as defined at the start of treatment or after authorized modifications. The temporary files recapitulate as- yet-unverified data from the treatment units and the secretariat. Beamjles (Table 1). Each current patient file is associated with one or more beam files; these current files contain the treatment parameters for each beam as determined at the start of treatment or after authorized modifications. They also contain the doses delivered each day by each beam. The temporary files recapitulate as-yet-unverified data from the treatment units and the secretariat. General information jiles. (a) Target volume thesaurus: this file is used for automatic coding of the target volumes entered in uncoded language at the radiotherapy secretariat. (b) Files for machine parameter adjustment coefficients: these files are used to recalcu- late the values of the parameters recorded at the irradiation units to compensate for electronic drift. (c) File for “non-working days”: used for printing out ap- pointment schedules and calculation of weekly irradiation doses.

Operation 1. Data acquisition. Data acquisition is “transparent”

for users. As an example, most of the irradiation parameters are acquired during obligatory calculation of the duration of exposure. Repetitive acquisition of data is avoided as much as possible. When conflict does arise for multiple inputs, priority is given to the most reliable source. Acquired data is validated at regular intervals.

2. Automatic coding of disease and target volumes. The major problem with data coding is the difficulty of manually searching for the numerical code correspond- ing to an uncoded entry in a thesaurus. The difficulty may be such that coding actually becomes impossible from a practical standpoint. To eliminate this problem, we have devised an automatic search system which lo- cates the appropriate numerical code using key words de- fining the target volumes. When the secretary enters the target volumes in uncoded language, the system scans the thesaurus-made up of W.H.O., U.I.C.C. codes24,43 and synonyms used in our department-for the numerical code and standard text that best corresponds to the uncoded text. The standard text is an ordered subgroup of texts in the thesaurus. This thesaurus is available on request. Coding is beneficial because the denomination of target volumes is standardized, and there is a subse- quent improvement in the accuracy of terminology. Cor- relations can also be made on an international level with

December 1987, Volume 13, Number 12

Table 1. Treatment parameters recorded by the computer

Last name First name Date of start of treatment Patient identification Tumor site code Number of first treatment day Number of treatment days Physician code Total dose at reference point Number of target volumes Number of beams Codes of blocking trays Code of wedges Lung depth Treatment machine code Source-tumor distance or source-skin distance Tumor depth (reference point) Field width Field length Head swivel angle Collimator angle Gantry angle Session dose Weekly dose Total dose Target volume codes

other studies concerning certain common anatomic disease sites.

3. Document print-out. Computer print-outs are ob- tained for the various “stages” of patients’ stays in the Radiotherapy Department. On a patient’s initial presentation, the computer system prints a summary of treatment plans which is included in the medical file. Every day, using the data acquired during the radiotherapy sessions, the computer prepares a summary of both scheduled and actually recorded treatment parameters. This summary allows detection of any treatment anomalies. Treatment reports listing the doses effectively received by patients are also printed at regular intervals (every week, upon completion of treatment, or when requested by a physician). These reports allow the radiotherapists and physicists to follow the delivery of doses to the target volumes. Various documents required for administrative purposes are printed at regular intervals, and some of them also serve for intra-department statistical analy- ses of the workload. The treatment summary printed upon completion of treatment is included in the medical file, and a copy is sent to the patient’s personal physician.

4. Treatment parameter tolerances.

I. Physical uncertainties. Certain uncertainties exist concerning the agreement between the parameter values acquired by the computer system and the true values of these same parameters at the treatment units. These uncertainties have two main causes: (a) fluctu- ation of the acquired value around a mean value (background noise); (b) difference between acquired values and values displayed at the treatment units

Radiotherapy computer system 0 A. COSTA et al. 1953

(discordance among probes). These uncertainties can create doubt in the minds of the technicians in charge of positioning the therapy units. Two solutions have been developed: (a) the system displays the average of 5 readings for all acquired analog parameters; this avoids oscillation due to background noise; (b) when, after averaging, the acquired parameter value is sufficiently close to the scheduled value, this scheduled value is displayed rather than the acquired value. Technical uncertainties. In certain circumstances, the irradiation unit has to be placed in a position slightly different from that scheduled by the physician. The system permits a certain degree of tolerance for positioning, provided thatthe change involves no danger for the patient and-does not fundamentally modify treatment. Tolerance. To allow for the various physical and technical uncertainties, tolerance limits have been defined for all parameters; the system prohibits treatment if the threshold values are exceeded. Tolerance limits included: + or - 2 mm for the width and length of the irradiation field + or - 1 degree for the gantry angle and head rotation 15 degrees for collimator rotation. No tolerance is al- lowed for the number of the collimator filter, the electron energy, the dose rate, the number of monitor units scheduled for use before irradiation, or the duration of irradiation.

DISCUSSION

The design and development of the SISGRAD system required a concerted effort on the part of all those in- volved; similar efforts have continued since the system became operational. During 4 years since SISGRAD has been in use and has controlled over 200,000 irradiation beams, it has proved to be a valuable detector of anomalies in the operation of the Radiotherapy Department. The preparation and application of treatments has be- come more precise; by guaranteeing the uniformity and accuracy of the data stored for a treatment which is prescribed and applied by different persons, SISGRAD im- proves the security of the entire treatment program.

When the system first started operation, the main ob- jection of the technicians was the time required to enter patient parameters (file number, name, beam number). Globally, however, no time is lost during the preparation of treatment session, especially because the parameters are displayed within the treatment room. Furthermore, as the terminals are interconnected, the technicians do not have to enter parameters at the start of treatment; this represents a considerable savings in time in comparison to analogous system in which this data is entered at the treatment units themselves. SISGRAD has also considerably improved the scheduling of the appointments

for the various treatment units, saving an average of 10 or so hours a week.

Automatic coding of the disease and target volumes during acquisition of the treatment summaries in the Ra- diotherapy secretariat does not increase the amount of time required to type the medical file reports. This coding process, which introduces a supplementary degree of precision in terminology, would be impossible without the help of SISGRAD; the physicians would not accept the loss of time resulting from manual coding. Auto- matic coding requires that each physician specify the target volumes using a limited number of terms borrowed from a given lexicon, made up of the most frequently used terms and for which synonyms are permitted. This system allows to complete medical databases already in place on the general hospital computer system INFO- CAL. Consequently, the database can be used, first: to know all the actual and past medical data relative to a patient; second: to study at a later time, in an epidemiol- ogy context.

A significant change has also taken place in the Physics Department. The physicists now dispose of files and documents (namely dose information) which make it easier to follow the progress of therapy. Quality control is now performed systematically and for all patients, something which was impossible previously; this requires approximately 20 man/hr per week. Although the creation of the basic data files takes place in a “transparent” manner, at the same time the duration of irradiation is calculated, a specialist is required on a part-time basis to analyze daily documents concerning treatments given each day and the follow-up and improvement of the system itself.

Most anomalies are detected by the system immedi- ately prior to the start of treatment, and thus have no consequences. Daily analysis of data recorded for treatments given the previous day permits detection of any other anomalies. Anomalies can be classed in several categories:

1.

2.

3.

Anomalies related to the actual “paper” medical file (treatment sheet) which is still in use; an average of one omission or doe transcription error is detected every month; Human errors: dangerous shift of a patient from one cobalt unit to the other (average of 1 a year); Mechanicals breakdowns: (a) problems with the irradiation unit clocks (twice in 3 years); (b) problems with the display units of the collimators and the arm and collimator rotation angles. It seems pertinent at this point to underline the relative rudimentary na- ture of the sensors supplied as an option by the treatment unit manufacturers; the sophisticated localiza- tion technology available for CT scanners would be a welcome progress in irradiation equipment.

Mention should also be made of the value of the re- dundancy of data available through SISGRAD; as exam- ples, two “lost” treatment sheets were able to be reconsti-

1954 I. J. Radiation Oncology 0 Biology 0 Physics December 1987, Volume 13, Number 12

tuted, an excessive mechanical play modifying the collimator opening as a function of the treatment arm position was detected by the system.

In addition, the various parameters checked are no longer subject to error and most of the other anomalies found would have gone undetected without SISGRAD. For dynamic treatments, note that fixed field treatment is prohibited, and the angles at both the start and completion of irradiation are checked. The rotation position (anterior or posterior) and the direction (right/left or left/ right) are not checked. As all of the irradiation parameters are not controlled, owing to equipment-related limi- tations, significant errors are still possible in the parameters displayed but not checked by SISGRAD (skin- source distance, shields, diffusers, etc.). In addition to the benefits brought about in the quality of treatment, the quantity of data than can now be grouped together in the computerized medical file of each patient has also been increased.

of patients treated over 10 years at our center, these fig- ures correspond to a treatment cost increase of only 100 French francs per patient ( 1% of the cost of treatment).

Finally, to comply with French law (law no 78-17 of January 1, 1978), the introduction of administrative and medical data in a computerized file has been registered with the French national commission in charge of such files.

CONCLUSION

The SISGRAD computer system allows automatic management of:

SISGRAD is currently being connected to a more recent computer* oriented towards exploitation of data generated by our institution’s whole body CT scanner.t Along with those controls performed already, plans call for computerized verification of the skin-source distance and specific accessories such as additional diffusers. In- stallation of more recent higher performance microcomputers is also envisaged so that jobs can be performed simultaneously; this will also improve system compati- bility with the institution’s general computer network.

1.

2.

3.

4.

Collection of data concerning irradiation plans and dosimetric calculations before radiotherapy begins; Real-time validation of major irradiation parameters at the actual treatment site; Storage of irradiation-related data collected during the successive irradiations sessions; Preparation of the treatment and irradiation summaries.

Development costs for SISGRAD can be estimated at around 200,000 French francs for equipment ( 1% of the cost of the irradiation units) and approximately 1,600,OOO francs for the software; applied to the number

Such a system has multiple advantages: for the patient, the guarantee that the treatment program designed by the physician is properly executed; for the technician, protection from error; for the physician, available at all times of information on treatment progress, including precise indication of doses already delivered; for the physicist, automatic computation of irradiation doses and establishment of the summary upon completion of treatment, and constant follow-up of treatments already administered; for the administrator, the preparation of bookkeeping and statistical data; for the epidemiologist, the availability of data is always up to date.

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