A MC-based anthropomorphic test case for commissioning model-based dose calculation in interstitial breast 192-Ir HDR brachytherapy.

PURPOSE: To provide the first clinical test case for commissioning of 192 Ir brachytherapy model-based dose calculation algorithms (MBDCAs) according to the AAPM TG-186 report workflow. ACQUISITION AND VALIDATION METHODS: A computational patient phantom model was generated from a clinical multi-catheter 192 Ir HDR breast brachytherapy case. Regions of interest (ROIs) were contoured and digitized on the patient CT images and the model was written to a series of DICOM CT images using MATLAB. The model was imported into two commercial treatment planning systems (TPSs) currently incorporating an MBDCA. Identical treatment plans were prepared using a generic 192 Ir HDR source and the TG-43-based algorithm of each TPS. This was followed by dose to medium in medium calculations using the MBDCA option of each TPS. Monte Carlo (MC) simulation was performed in the model using three different codes and information parsed from the treatment plan exported in DICOM radiation therapy (RT) format. Results were found to agree within statistical uncertainty and the dataset with the lowest uncertainty was assigned as the reference MC dose distribution. DATA FORMAT AND USAGE NOTES: The dataset is available online at http://irochouston.mdanderson.org/rpc/BrachySeeds/BrachySeeds/index.html,https://doi.org/10.52519/00005. Files include the treatment plan for each TPS in DICOM RT format, reference MC dose data in RT Dose format, as well as a guide for database users and all files necessary to repeat the MC simulations. POTENTIAL APPLICATIONS: The dataset facilitates the commissioning of brachytherapy MBDCAs using TPS embedded tools and establishes a methodology for the development of future clinical test cases. It is also useful to non-MBDCA adopters for intercomparing MBDCAs and exploring their benefits and limitations, as well as to brachytherapy researchers in need of a dosimetric and/or a DICOM RT information parsing benchmark. Limitations include specificity in terms of radionuclide, source model, clinical scenario, and MBDCA version used for its preparation.

Dual-energy CT evaluation of 3D printed materials for radiotherapy applications.

Objective. There is a continuous increase in 3D printing applications in several fields including medical imaging and radiotherapy. Although there are numerous advantages of using 3D printing for the development of customized phantoms, bolus, quality assurance devices and other clinical applications, material properties are not well known and printer settings can affect considerably the properties (e.g. density, isotropy and homogeneity) of the printed parts. This study aims to evaluate several materials and printer properties to identify a range of tissue-mimicking materials.Approach. Dual-energy CT was used to obtain the effective atomic number (Zeff) and relative electron density (RED) for thirty-one different materials including different colours of the same filament from the same manufacturer and the same type of filament from different manufacturers. In addition, a custom bone equivalent filament was developed and evaluated since a high-density filament with a composition similar to bone is not commercially available. Printing settings such as infill density, infill pattern, layer height and nozzle size were also evaluated.Main results. Large differences were observed for HU (288), RED (>10%) andZeff(>50%) for different colours of the same filament due to the colour pigment. Results show a wide HU variation (-714 to 1104), RED (0.277 to 1.480) andZeff(5.22 to 12.39) between the printed samples with some materials being comparable to commercial tissue-mimicking materials and good substitutes to a range of materials from lung to bone. Printer settings can result in directional dependency and significantly affect the homogeneity of the samples.Significance. The use of DECT to extract RED, andZeffallows for quantitative imaging and dosimetry using 3D printed materials equivalent to certified tissue-mimicking tissues.

Time-resolved QA and brachytherapy applicator commissioning: Towards the clinical implementation.

PURPOSE: Brachytherapy has a busy workflow relying on manual steps to ensure accurate delivery of the treatment. Systematic treatment errors have been reported due to faulty equipment, inadequate quality assurance (QA) and applicator commissioning methods. This study describes the use of a novel method, the Iridium Imaging System for QA (IrIS - QA), to automate and improve the applicator commissioning for HDR 192Ir brachytherapy. METHODS AND MATERIALS: A 3D printed holder attached to an Imaging Panel (IP) has been developed to: (1) acquire a high-definition projection of the applicator using the gamma rays of the 192Ir source for imaging; (2) Track the source within the applicator verifying in a time-resolved manner the dwell positions and dwell times with a high resolution. Results obtained for two applicator models are described in this manuscript. RESULTS: IrIS-QA is capable of measuring the dwell times with an accuracy better than 0.1 s and interdwell distances with submillimetre precision. The applicators tested in the study showed good agreement between planned and delivered dwell times and positions, with mean and maximum dwell position deviations below 0.5 mm and 1.3 mm, respectively. Dwell time measurements showed agreement superior to 0.05 s except for the first dwell position for which up to 0.15 s differences were observed. CONCLUSIONS: IrIS-QA is a compact system that includes many features necessary to improve the accuracy and efficiency of applicator commissioning and daily QA. No commercial system exists with similar capabilities. IrIS-QA is intended to replace current clinical procedures using film dosimetry.

Advanced design, simulation, and dosimetry of a novel rectal applicator for contact brachytherapy with a conventional HDR 192Ir source.

PURPOSE: Dose escalation yields higher complete response to rectal tumors, which may enable the omission of surgery. Dose escalation using 50 kVp contact x-ray brachytherapy (CXB) allow the treatment of a selective volume, resulting in low toxicity and organs-at-risk preservation. However, the use of CXB devices is limited because of its high cost and lack of treatment planning tools. Hence, the MAASTRO applicator (for HDR 192Ir sources) was developed and characterized by measurements and Monte Carlo simulations to be a cost-effective alternative to CXB devices. METHODS AND MATERIALS: A cylindrical applicator with lateral shielding was designed to be used with a rectoscope using its tip as treatment surface. Both the applicator and the rectoscope have a slanted edge to potentially allow easier placement against tumors. The applicator design was achieved by Monte Carlo modeling and validated experimentally with film dosimetry, using the Papillon 50 (P50) device as reference. RESULTS: The applicator delivers CXB doses in less than 9 min using a 20375 U source for a treatment area of approximately 20 × 20 mm2 at 2 mm depth. Normalized at 2 mm, the dose falloff for depths of 0 mm, 5 mm, and 10 mm are 130%, 70%, and 43% for the P50 and 140%, 67%, and 38% for the MAASTRO applicator, respectively. CONCLUSIONS: The MAASTRO applicator was designed to use HDR 192Ir sources to deliver a dose distribution similar to those of CXB devices. The applicator may provide a cost-effective solution for endoluminal boosting with clinical treatment planning system integration.

In vivo dosimetry in brachytherapy: Requirements and future directions for research, development, and clinical practice.

Brachytherapy can deliver high doses to the target while sparing healthy tissues due to its steep dose gradient leading to excellent clinical outcome. Treatment accuracy depends on several manual steps making brachytherapy susceptible to operational mistakes. Currently, treatment delivery verification is not routinely available and has led, in some cases, to systematic errors going unnoticed for years. The brachytherapy community promoted developments in in vivo dosimetry (IVD) through research groups and small companies. Although very few of the systems have been used clinically, it was demonstrated that the likelihood of detecting deviations from the treatment plan increases significantly with time-resolved methods. Time-resolved methods could interrupt a treatment avoiding gross errors which is not possible with time-integrated dosimetry. In addition, lower experimental uncertainties can be achieved by using source-tracking instead of direct dose measurements. However, the detector position in relation to the patient anatomy remains a main source of uncertainty. The next steps towards clinical implementation will require clinical trials and systematic reporting of errors and near-misses. It is of utmost importance for each IVD system that its sensitivity to different types of errors is well understood, so that end-users can select the most suitable method for their needs. This report aims to formulate requirements for the stakeholders (clinics, vendors, and researchers) to facilitate increased clinical use of IVD in brachytherapy. The report focuses on high dose-rate IVD in brachytherapy providing an overview and outlining the need for further development and research.

Mechanical evaluation of the Bravos afterloader system for HDR brachytherapy.

PURPOSE: The Bravos afterloader system was released by Varian Medical Systems in October of 2018 for high-dose-rate brachytherapy with 192Ir sources, containing new features such as the CamScale (a new device for daily quality assurance and system recalibration), channel length verification, and different settings for rigid and flexible applicators. This study mechanically evaluated the Bravos system precision and accuracy for clinically relevant scenarios, using dummy sources. METHODS AND MATERIALS: The system was evaluated after three sets of experiments: (1) The CamScale was used to verify inter- and intra-channel dwelling variability and system calibration; (2) A high-speed camera was used to verify the source simulation cable movement inside a transparent quality assurance device, where dwell positions, dwell times, transit times, speed profiles, and accelerations were measured; (3) The source movement inside clinical applicators was captured with an imaging panel while being exposed to an external kV source. Measured and planned dwell positions and times were compared. RESULTS: Maximum deviations between planned and measured dwell positions and times for the source cable were 0.4 mm for the CamScale measurements and 0.07 seconds for the high-speed camera measurements. Mean dwell position deviations inside clinical applicators were below 1.2 mm for all applicators except the ring that required an offset correction of 1 mm to achieve a mean deviation of 0.4 mm. CONCLUSIONS: Features of the Bravos afterloader system provide a robust and precise treatment delivery. All measurements were within manufacturer specifications.

Dose to water versus dose to medium from cavity theory applied to small animal irradiation with kilovolt x-rays.

Dose reporting is a matter of concern in the preclinical field as the different dose descriptors dose-to-water-in-medium [Formula: see text] and dose-to-medium-in-medium [Formula: see text] coexist. For kV photons differences between both quantities are expected to be amplified due to photon energy absorption coefficients differences for different media, and could represent a limiting factor for accurate translation of pre-clinical research into clinical trials. The main goal of this study was to analyse the relationship between [Formula: see text] and [Formula: see text] for kV irradiation of small animals, using different flavours of the intermediate cavity theory (ICT). Irradiations of mathematical phantoms and a mouse CT scan, both with different voxel sizes and materials, were investigated. A modified version of the Monte Carlo code DOSXYZnrc was used to derive [Formula: see text] and convert to [Formula: see text] using ICT. Local photon spectra were generated in different regions of the mouse. Depending on energy and cavity size, which we equate to the voxel size, [Formula: see text] ranged from 0.68 to 4.37 times [Formula: see text]. Higher kV energy combined with very small cavity sizes yielded decreased [Formula: see text] in comparison to [Formula: see text]; this behaviour was reversed for larger cavities combined with lower kV energies. Hence, the impact of the cavity dimensions on estimated [Formula: see text] is significant on pre-clinical kV beams. [Formula: see text] and [Formula: see text] in the ex vivo male mouse were found to differ by -29% to 286%. Caution is advised when using the ICT due to a lack of consensus on weighting factor (d-parameter) deriving methods; for the same irradiation conditions, different d-values affected [Formula: see text] up to 20%. Pre-clinically, such divergence between dose descriptors could enable biological damage. The abiding debate over which quantity to favour is foreseen to linger while it is unclear which quantity correlates better with the biological effects of ionizing irradiation: preclinical radiotherapy might represent an ideal platform for measurement-based studies to settle this fundamental question. Finally, dose distribution comparisons require caution and should use the same reporting quantity.

A systematic review comparing radiation toxicity after various endorectal techniques.

PURPOSE: A clinical complete response is seen after neoadjuvant chemoradiation for rectal tumors in 15%-20% of patients. These patients can potentially be spared mutilating total mesorectal excision surgery through a watch-and-wait policy. Recent studies show that dose escalation by a radiation boost increases the clinical complete response rate. The boost dose to the tumor can be administered through external beam radiotherapy or through internal radiotherapy using techniques like contact therapy, low-dose-rate or high-dose-rate brachytherapy (BT). However, limited information is available concerning treatment-related toxicity of these techniques. With this systematic review, we aim to summarize and compare published data concerning acute and late toxicity after contact X-ray therapy (CXT) and BT for rectal cancer. METHODS AND MATERIALS/RESULTS: Thirty-eight studies reporting toxicity after endorectal radiation techniques for rectal cancer were included, resulting in 3682 patients for analysis. Direct comparison of toxicity by the different radiation modes was hampered by various combinations of endorectal techniques, a lack of clear reporting of toxicity scores, dose prescription, technique used, and treated volumes. ≥ Grade 3 rectal toxicity was reported in 2.9% of patients having received only CXT; 6.3% of patients who received only BT had Grade 3 rectal toxicity, and BT also caused Grade 3 urinary toxicity in 1 patient. CONCLUSION: All techniques reported some ≥ Grade 3 toxicity. Toxicity after CXT was confined to the rectum, whereas after BT, urogenital toxicity and skin toxicity were seen as well. Unfortunately, few specific conclusions could be drawn regarding the dose-related risk of toxicity for the various techniques due to nonuniform reporting strategies and missing information. To enable future comparisons and improvements, the endorectal radiation field urgently needs consensus guidelines on dose reporting, dose prescription, treatment volume specification, and toxicity reporting.

A novel rectal applicator for contact radiotherapy with HDR 192Ir sources.

PURPOSE: Dose escalation to rectal tumors leads to higher complete response rates and may thereby enable omission of surgery. Important advantages of endoluminal boosting techniques include the possibility to apply a more selective/localized boost than using external beam radiotherapy. A novel brachytherapy (BT) rectal applicator with lateral shielding was designed to be used with a rectoscope for eye-guided positioning to deliver a dose distribution similar to the one of contact x-ray radiotherapy devices, using commonly available high-dose-rate 192Ir BT sources. METHODS AND MATERIALS: A cylindrical multichannel BT applicator with lateral shielding was designed by Monte Carlo modeling, validated experimentally with film dosimetry and compared with results found in the literature for the Papillon 50 (P50) contact x-ray radiotherapy device regarding rectoscope dimensions, radiation beam shape, dose fall-off, and treatment time. RESULTS: The multichannel applicator designed is able to deliver 30 Gy under 13 min with a 20350 U (5 Ci) source. The use of multiple channels and lateral shielding provide a uniform circular treatment surface with 22 mm in diameter. The resulting dose fall-off is slightly steeper (maximum difference of 5%) than the one generated by the P50 device with the 22 mm applicator. CONCLUSIONS: A novel multichannel rectal applicator for contact radiotherapy with high-dose-rate 192Ir sources that can be integrated with commercially available treatment planning systems was designed to produce a dose distribution similar to the one obtained by the P50 device.

A novel system for commissioning brachytherapy applicators: example of a ring applicator.

A novel system was developed to improve commissioning and quality assurance of brachytherapy applicators used in high dose rate (HDR). It employs an imaging panel to create reference images and to measure dwell times and dwell positions. As an example: two ring applicators of the same model were evaluated. An applicator was placed on the surface of an imaging panel and a HDR 192Ir source was positioned in an imaging channel above the panel to generate an image of the applicator, using the gamma photons of the brachytherapy source. The applicator projection image was overlaid with the images acquired by capturing the gamma photons emitted by the source dwelling inside the applicator. We verified 0.1, 0.2, 0.5 and 1.0 cm interdwell distances for different offsets, applicator inclinations and transfer tube curvatures. The data analysis was performed using in-house developed software capable of processing the data in real time, defining catheters and creating movies recording the irradiation procedure. One applicator showed up to 0.3 cm difference from the expected position for a specific dwell position. The problem appeared intermittently. The standard deviations of the remaining dwell positions (40 measurements) were less than 0.05 cm. The second ring applicator had a similar reproducibility with absolute coordinate differences from expected values ranging from -0.10 up to 0.18 cm. The curvature of the transfer tube can lead to differences larger than 0.1 cm whilst the inclination of the applicator showed a negligible effect. The proposed method allows the verification of all steps of the irradiation, providing accurate information about dwell positions and dwell times. It allows the verification of small interdwell positions (⩽0.1 cm) and reduces measurement time. In addition, no additional radiation source is necessary since the HDR 192Ir source is used to generate an image of the applicator.

Online pretreatment verification of high-dose rate brachytherapy using an imaging panel.

Brachytherapy is employed to treat a wide variety of cancers. However, an accurate treatment verification method is currently not available. This study describes a pre-treatment verification system that uses an imaging panel (IP) to verify important aspects of the treatment plan. A detailed modelling of the IP was only possible with an extensive calibration performed using a robotic arm. Irradiations were performed with a high dose rate (HDR) 192Ir source within a water phantom. An empirical fit was applied to measure the distance between the source and the detector so 3D Cartesian coordinates of the dwell positions can be obtained using a single panel. The IP acquires 7.14 fps to verify the dwell times, dwell positions and air kerma strength (Sk). A gynecological applicator was used to create a treatment plan that was registered with a CT image of the water phantom used during the experiments for verification purposes. Errors (shifts, exchanged connections and wrong dwell times) were simulated to verify the proposed verification system. Cartesian source positions (panel measurement plane) have a standard deviation of about 0.02 cm. The measured distance between the source and the panel (z-coordinate) have a standard deviation up to 0.16 cm and maximum absolute error of ≈0.6 cm if the signal is close to sensitive limit of the panel. The average response of the panel is very linear with Sk. Therefore, Sk measurements can be performed with relatively small errors. The measured dwell times show a maximum error of 0.2 s which is consistent with the acquisition rate of the panel. All simulated errors were clearly identified by the proposed system. The use of IPs is not common in brachytherapy, however, it provides considerable advantages. It was demonstrated that the IP can accurately measure Sk, dwell times and dwell positions.

HDR 192Ir source speed measurements using a high speed video camera.

PURPOSE: The dose delivered with a HDR (192)Ir afterloader can be separated into a dwell component, and a transit component resulting from the source movement. The transit component is directly dependent on the source speed profile and it is the goal of this study to measure accurate source speed profiles. METHODS: A high speed video camera was used to record the movement of a (192)Ir source (Nucletron, an Elekta company, Stockholm, Sweden) for interdwell distances of 0.25-5 cm with dwell times of 0.1, 1, and 2 s. Transit dose distributions were calculated using a Monte Carlo code simulating the source movement. RESULTS: The source stops at each dwell position oscillating around the desired position for a duration up to (0.026 ± 0.005) s. The source speed profile shows variations between 0 and 81 cm/s with average speed of ∼ 33 cm/s for most of the interdwell distances. The source stops for up to (0.005 ± 0.001) s at nonprogrammed positions in between two programmed dwell positions. The dwell time correction applied by the manufacturer compensates the transit dose between the dwell positions leading to a maximum overdose of 41 mGy for the considered cases and assuming an air-kerma strength of 48 000 U. The transit dose component is not uniformly distributed leading to over and underdoses, which is within 1.4% for commonly prescribed doses (3-10 Gy). CONCLUSIONS: The source maintains its speed even for the short interdwell distances. Dose variations due to the transit dose component are much lower than the prescribed treatment doses for brachytherapy, although transit dose component should be evaluated individually for clinical cases.

A medical image-based graphical platform -- features, applications and relevance for brachytherapy.

PURPOSE: Brachytherapy dose calculation is commonly performed using the Task Group-No 43 Report-Updated protocol (TG-43U1) formalism. Recently, a more accurate approach has been proposed that can handle tissue composition, tissue density, body shape, applicator geometry, and dose reporting either in media or water. Some model-based dose calculation algorithms are based on Monte Carlo (MC) simulations. This work presents a software platform capable of processing medical images and treatment plans, and preparing the required input data for MC simulations. METHODS AND MATERIALS: The A Medical Image-based Graphical platfOrm-Brachytherapy module (AMIGOBrachy) is a user interface, coupled to the MCNP6 MC code, for absorbed dose calculations. The AMIGOBrachy was first validated in water for a high-dose-rate (192)Ir source. Next, dose distributions were validated in uniform phantoms consisting of different materials. Finally, dose distributions were obtained in patient geometries. Results were compared against a treatment planning system including a linear Boltzmann transport equation (LBTE) solver capable of handling nonwater heterogeneities. RESULTS: The TG-43U1 source parameters are in good agreement with literature with more than 90% of anisotropy values within 1%. No significant dependence on the tissue composition was observed comparing MC results against an LBTE solver. Clinical cases showed differences up to 25%, when comparing MC results against TG-43U1. About 92% of the voxels exhibited dose differences lower than 2% when comparing MC results against an LBTE solver. CONCLUSION: The AMIGOBrachy can improve the accuracy of the TG-43U1 dose calculation by using a more accurate MC dose calculation algorithm. The AMIGOBrachy can be incorporated in clinical practice via a user-friendly graphical interface.