Feasibility of using a transmission ion chamber for QA tests of medical linear accelerators.

PURPOSE: To study the feasibility of using the Integral Quality Monitoring (IQM) system for routine quality assurance (QA) of photon beams. METHODS: The IQM system is a commercially available dose delivery verification tool, which consists of a spatially sensitive large area transmission ion chamber, mounted on the Linac collimator, and a calculation algorithm to predict the signals in response to radiation beams. By comparing the measured and predicted signals the system verifies the accuracy of beam delivery. The ion chamber unit is a battery powered system including a dual-electrometer, temperature and pressure sensors, and inclinometers. The feasibility of using the IQM system for routine QA tests was investigated by measuring constancy values of beam parameters, with specially designed tests fields, and comparing them with those determined by a conventional system. RESULTS: The sensitivity of the beam output constancy measurements by the IQM system was found to agree with those measured by a Farmer type ion chamber placed in water phantoms to within 0.1% for typical daily output variation of ± 0.5% and ± 1%. The beam symmetry was measured with a 4 cm × 4 cm aperture at multiple off-axis distances and was found to have a highly linear relationship with those measured in a water phantom scan for intentionally introduced asymmetry between -3% and +3%. The beam flatness was measured with a two-field ratio method and was found to be linearly correlated with those measured by water phantom scan. The dosimetric equivalent of a picket fence test performed by the IQM system can serve as a constancy check of the multileaf collimator (MLC) bank positioning test. CONCLUSIONS: The IQM system has been investigated for constancy measurements of various beam parameters for photon beams. The results suggest that the system can be used for most of the routine QA tests effectively and efficiently.

A comparison of methods to estimate organ doses in CT when utilizing approximations to the tube current modulation function.

PURPOSE: Most methods to estimate patient dose from computed tomography (CT) exams have been developed based on fixed tube current scans. However, in current clinical practice, many CT exams are performed using tube current modulation (TCM). Detailed information about the TCM function is difficult to obtain and therefore not easily integrated into patient dose estimate methods. The purpose of this study was to investigate the accuracy of organ dose estimates obtained using methods that approximate the TCM function using more readily available data compared to estimates obtained using the detailed description of the TCM function. METHODS: Twenty adult female models generated from actual patient thoracic CT exams and 20 pediatric female models generated from whole body PET∕CT exams were obtained with IRB (Institutional Review Board) approval. Detailed TCM function for each patient was obtained from projection data. Monte Carlo based models of each scanner and patient model were developed that incorporated the detailed TCM function for each patient model. Lungs and glandular breast tissue were identified in each patient model so that organ doses could be estimated from simulations. Three sets of simulations were performed: one using the original detailed TCM function (x, y, and z modulations), one using an approximation to the TCM function (only the z-axis or longitudinal modulation extracted from the image data), and the third was a fixed tube current simulation using a single tube current value which was equal to the average tube current over the entire exam. Differences from the reference (detailed TCM) method were calculated based on organ dose estimates. Pearson's correlation coefficients were calculated between methods after testing for normality. Equivalence test was performed to compare the equivalence limit between each method (longitudinal approximated TCM and fixed tube current method) and the detailed TCM method. Minimum equivalence limit was reported for each organ. RESULTS: Doses estimated using the longitudinal approximated TCM resulted in small differences from doses obtained using the detailed TCM function. The calculated root-mean-square errors (RMSE) for adult female chest simulations were 9% and 3% for breasts and lungs, respectively; for pediatric female chest and whole body simulations RMSE were 9% and 7% for breasts and 3% and 1% for lungs, respectively. Pearson's correlation coefficients were consistently high for the longitudinal approximated TCM method, ranging from 0.947 to 0.999, compared to the fixed tube current value ranging from 0.8099 to 0.9916. In addition, an equivalence test illustrated that across all models the longitudinal approximated TCM is equivalent to the detailed TCM function within up to 3% for lungs and breasts. CONCLUSIONS: While the best estimate of organ dose requires the detailed description of the TCM function for each patient, extracting these values can be difficult. The presented results show that an approximation using available data extracted from the DICOM header provides organ dose estimates with RMSE of less than 10%. On the other hand, the use of the overall average tube current as a single tube current value was shown to result in poor and inconsistent estimates of organ doses.

Peak skin and eye lens radiation dose from brain perfusion CT based on Monte Carlo simulation.

OBJECTIVE: The purpose of our study was to accurately estimate the radiation dose to skin and the eye lens from clinical CT brain perfusion studies, investigate how well scanner output (expressed as volume CT dose index [CTDI(vol)]) matches these estimated doses, and investigate the efficacy of eye lens dose reduction techniques. MATERIALS AND METHODS: Peak skin dose and eye lens dose were estimated using Monte Carlo simulation methods on a voxelized patient model and 64-MDCT scanners from four major manufacturers. A range of clinical protocols was evaluated. CTDI(vol) for each scanner was obtained from the scanner console. Dose reduction to the eye lens was evaluated for various gantry tilt angles as well as scan locations. RESULTS: Peak skin dose and eye lens dose ranged from 81 mGy to 348 mGy, depending on the scanner and protocol used. Peak skin dose and eye lens dose were observed to be 66-79% and 59-63%, respectively, of the CTDI(vol) values reported by the scanners. The eye lens dose was significantly reduced when the eye lenses were not directly irradiated. CONCLUSION: CTDI(vol) should not be interpreted as patient dose; this study has shown it to overestimate dose to the skin or eye lens. These results may be used to provide more accurate estimates of actual dose to ensure that protocols are operated safely below thresholds. Tilting the gantry or moving the scanning region further away from the eyes are effective for reducing lens dose in clinical practice. These actions should be considered when they are consistent with the clinical task and patient anatomy.

The feasibility of patient size-corrected, scanner-independent organ dose estimates for abdominal CT exams.

PURPOSE: A recent work has demonstrated the feasibility of estimating the dose to individual organs from multidetector CT exams using patient-specific, scanner-independent CTDIvol-to-organ-dose conversion coefficients. However, the previous study only investigated organ dose to a single patient model from a full-body helical CT scan. The purpose of this work was to extend the validity of this dose estimation technique to patients of any size undergoing a common clinical exam. This was done by determining the influence of patient size on organ dose conversion coefficients generated for typical abdominal CT exams. METHODS: Monte Carlo simulations of abdominal exams were performed using models of 64-slice MDCT scanners from each of the four major manufacturers to obtain dose to radiosensitive organs for eight patient models of varying size, age, and gender. The scanner-specific organ doses were normalized by corresponding CTDIvol values and averaged across scanners to obtain scanner-independent CTDIvol-to-organ-dose conversion coefficients for each patient model. In order to obtain a metric for patient size, the outer perimeter of each patient was measured at the central slice of the abdominal scan region. Then, the relationship between CTDIvol-to-organ-dose conversion coefficients and patient perimeter was investigated for organs that were directly irradiated by the abdominal scan. These included organs that were either completely ("fully irradiated") or partly ("partially irradiated") contained within the abdominal exam region. Finally, dose to organs that were not at all contained within the scan region ("nonirradiated") were compared to the doses delivered to fully irradiated organs. RESULTS: CTDIvol-to-organ-dose conversion coefficients for fully irradiated abdominal organs had a strong exponential correlation with patient perimeter. Conversely, partially irradiated organs did not have a strong dependence on patient perimeter. In almost all cases, the doses delivered to nonirradiated organs were less than 5%, on average across patient models, of the mean dose of the fully irradiated organs. CONCLUSIONS: This work demonstrates the feasibility of calculating patient-specific, scanner-independent CTDIvol-to-organ-dose conversion coefficients for fully irradiated organs in patients undergoing typical abdominal CT exams. A method to calculate patient-specific, scanner-specific, and exam-specific organ dose estimates that requires only knowledge of the CTDIvol for the scan protocol and the patient's perimeter is thus possible. This method will have to be extended in future studies to include organs that are partially irradiated. Finally, it was shown that, in most cases, the doses to nonirradiated organs were small compared to the dose to fully irradiated organs.

The feasibility of a scanner-independent technique to estimate organ dose from MDCT scans: using CTDIvol to account for differences between scanners.

PURPOSE: Monte Carlo radiation transport techniques have made it possible to accurately estimate the radiation dose to radiosensitive organs in patient models from scans performed with modern multidetector row computed tomography (MDCT) scanners. However, there is considerable variation in organ doses across scanners, even when similar acquisition conditions are used. The purpose of this study was to investigate the feasibility of a technique to estimate organ doses that would be scanner independent. This was accomplished by assessing the ability of CTDIvol measurements to account for differences in MDCT scanners that lead to organ dose differences. METHODS: Monte Carlo simulations of 64-slice MDCT scanners from each of the four major manufacturers were performed. An adult female patient model from the GSF family of voxelized phantoms was used in which all ICRP Publication 103 radiosensitive organs were identified. A 120 kVp, full-body helical scan with a pitch of 1 was simulated for each scanner using similar scan protocols across scanners. From each simulated scan, the radiation dose to each organ was obtained on a per mA s basis (mGy/mA s). In addition, CTDIvol values were obtained from each scanner for the selected scan parameters. Then, to demonstrate the feasibility of generating organ dose estimates from scanner-independent coefficients, the simulated organ dose values resulting from each scanner were normalized by the CTDIvol value for those acquisition conditions. RESULTS: CTDIvol values across scanners showed considerable variation as the coefficient of variation (CoV) across scanners was 34.1%. The simulated patient scans also demonstrated considerable differences in organ dose values, which varied by up to a factor of approximately 2 between some of the scanners. The CoV across scanners for the simulated organ doses ranged from 26.7% (for the adrenals) to 37.7% (for the thyroid), with a mean CoV of 31.5% across all organs. However, when organ doses are normalized by CTDIvoI values, the differences across scanners become very small. For the CTDIvol, normalized dose values the CoVs across scanners for different organs ranged from a minimum of 2.4% (for skin tissue) to a maximum of 8.5% (for the adrenals) with a mean of 5.2%. CONCLUSIONS: This work has revealed that there is considerable variation among modern MDCT scanners in both CTDIvol and organ dose values. Because these variations are similar, CTDIvol can be used as a normalization factor with excellent results. This demonstrates the feasibility of establishing scanner-independent organ dose estimates by using CTDIvol to account for the differences between scanners.

Reducing radiation dose to selected organs by selecting the tube start angle in MDCT helical scans: a Monte Carlo based study.

PURPOSE: Previous work has demonstrated that there are significant dose variations with a sinusoidal pattern on the peripheral of a CTDI 32 cm phantom or on the surface of an anthropomorphic phantom when helical CT scanning is performed, resulting in the creation of "hot" spots or "cold" spots. The purpose of this work was to perform preliminary investigations into the feasibility of exploiting these variations to reduce dose to selected radiosensitive organs solely by varying the tube start angle in CT scans. METHODS: Radiation dose to several radiosensitive organs (including breasts, thyroid, uterus, gonads, and eye lenses) resulting from MDCT scans were estimated using Monte Carlo simulation methods on voxelized patient models, including GSF's Baby, Child, and Irene. Dose to fetus was also estimated using four pregnant female models based on CT images of the pregnant patients. Whole-body scans were simulated using 120 kVp, 300 mAs, both 28.8 and 40 mm nominal collimations, and pitch values of 1.5, 1.0, and 0.75 under a wide range of start angles (0 degree-340 degrees in 20 degrees increments). The relationship between tube start angle and organ dose was examined for each organ, and the potential dose reduction was calculated. RESULTS: Some organs exhibit a strong dose variation, depending on the tube start angle. For small peripheral organs (e.g., the eye lenses of the Baby phantom at pitch 1.5 with 40 mm collimation), the minimum dose can be 41% lower than the maximum dose, depending on the tube start angle. In general, larger dose reductions occur for smaller peripheral organs in smaller patients when wider collimation is used. Pitch 1.5 and pitch 0.75 have different mechanisms of dose reduction. For pitch 1.5 scans, the dose is usually lowest when the tube start angle is such that the x-ray tube is posterior to the patient when it passes the longitudinal location of the organ. For pitch 0.75 scans, the dose is lowest when the tube start angle is such that the x-ray tube is anterior to the patient when it passes the longitudinal location of the organ. CONCLUSIONS: Helical MDCT scanning at pitch 1.5 and pitch 0.75 results in "cold spots" and "hot spots" that are created both at surface and in-depth locations within patients. For organs that have a relatively small longitudinal extent, dose can vary considerably with different start angles. While current MDCT systems do not provide the user with the ability to control the tube start angle, these results indicate that in these specific situations (pitch 1.5 or pitch 0.75, small organs and especially small patients), there could be significant dose savings to organs if that functionality would be provided.

Variability of surface and center position radiation dose in MDCT: Monte Carlo simulations using CTDI and anthropomorphic phantoms.

The larger coverage afforded by wider z-axis beams in multidetector CT (MDCT) creates larger cone angles and greater beam divergence, which results in substantial surface dose variation for helical and contiguous axial scans. This study evaluates the variation of absorbed radiation dose in both cylindrical and anthropomorphic phantoms when performing helical or contiguous axial scans. The approach used here was to perform Monte Carlo simulations of a 64 slice MDCT. Simulations were performed with different radiation profiles (simulated beam widths) for a given collimation setting (nominal beam width) and for different pitch values and tube start angles. The magnitude of variation at the surface was evaluated under four different conditions: (a) a homogeneous CTDI phantom with different combinations of pitch and simulated beam widths, (b) a heterogeneous anthropomorphic phantom with one measured beam collimation and various pitch values, (c) a homogeneous CTDI phantom with fixed beam collimation and pitch, but with different tube start angles, and (d) pitch values that should minimize variations of surface dose-evaluated for both homogeneous and heterogeneous phantoms. For the CTDI phantom simulations, peripheral dose patterns showed variation with percent ripple as high as 65% when pitch is 1.5 and simulated beam width is equal to the nominal collimation. For the anterior surface dose on an anthropomorphic phantom, the percent ripple was as high as 40% when the pitch is 1.5 and simulated beam width is equal to the measured beam width. Low pitch values were shown to cause beam overlaps which created new peaks. Different x-ray tube start angles create shifts of the peripheral dose profiles. The start angle simulations showed that for a given table position, the surface dose could vary dramatically with minimum values that were 40% of the peak when all conditions are held constant except for the start angle. The last group of simulations showed that an "ideal" pitch value can be determined which reduces surface dose variations, but this pitch value must take into account the measured beam width. These results reveal the complexity of estimating surface dose and demonstrate a range of dose variability at surface positions for both homogeneous cylindrical and heterogeneous anthropomorphic phantoms. These findings have potential implications for small-sized dosimeter measurements in phantoms, such as with TLDs or small Farmer chambers.

A method to generate equivalent energy spectra and filtration models based on measurement for multidetector CT Monte Carlo dosimetry simulations.

The purpose of this study was to present a method for generating x-ray source models for performing Monte Carlo (MC) radiation dosimetry simulations of multidetector row CT (MDCT) scanners. These so-called "equivalent" source models consist of an energy spectrum and filtration description that are generated based wholly on the measured values and can be used in place of proprietary manufacturer's data for scanner-specific MDCT MC simulations. Required measurements include the half value layers (HVL1 and HVL2) and the bowtie profile (exposure values across the fan beam) for the MDCT scanner of interest. Using these measured values, a method was described (a) to numerically construct a spectrum with the calculated HVLs approximately equal to those measured (equivalent spectrum) and then (b) to determine a filtration scheme (equivalent filter) that attenuates the equivalent spectrum in a similar fashion as the actual filtration attenuates the actual x-ray beam, as measured by the bowtie profile measurements. Using this method, two types of equivalent source models were generated: One using a spectrum based on both HVL1 and HVL2 measurements and its corresponding filtration scheme and the second consisting of a spectrum based only on the measured HVL1 and its corresponding filtration scheme. Finally, a third type of source model was built based on the spectrum and filtration data provided by the scanner's manufacturer. MC simulations using each of these three source model types were evaluated by comparing the accuracy of multiple CT dose index (CTDI) simulations to measured CTDI values for 64-slice scanners from the four major MDCT manufacturers. Comprehensive evaluations were carried out for each scanner using each kVp and bowtie filter combination available. CTDI experiments were performed for both head (16 cm in diameter) and body (32 cm in diameter) CTDI phantoms using both central and peripheral measurement positions. Both equivalent source model types result in simulations with an average root mean square (RMS) error between the measured and simulated values of approximately 5% across all scanner and bowtie filter combinations, all kVps, both phantom sizes, and both measurement positions, while data provided from the manufacturers gave an average RMS error of approximately 12% pooled across all conditions. While there was no statistically significant difference between the two types of equivalent source models, both of these model types were shown to be statistically significantly different from the source model based on manufacturer's data. These results demonstrate that an equivalent source model based only on measured values can be used in place of manufacturer's data for Monte Carlo simulations for MDCT dosimetry.

Dose to radiosensitive organs during routine chest CT: effects of tube current modulation.

OBJECTIVE: The aims of this study were to estimate the dose to radiosensitive organs (glandular breast and lung) in patients of various sizes undergoing routine chest CT examinations with and without tube current modulation; to quantify the effect of tube current modulation on organ dose; and to investigate the relation between patient size and organ dose to breast and lung resulting from chest CT examinations. MATERIALS AND METHODS: Thirty voxelized models generated from images of patients were extended to include lung contours and were used to represent a cohort of women of various sizes. Monte Carlo simulation-based virtual MDCT scanners had been used in a previous study to estimate breast dose from simulations of a fixed-tube-current and a tube current-modulated chest CT examinations of each patient model. In this study, lung doses were estimated for each simulated examination, and the percentage organ dose reduction attributed to tube current modulation was correlated with patient size for both glandular breast and lung tissues. RESULTS: The average radiation dose to lung tissue from a chest CT scan obtained with fixed tube current was 23 mGy. The use of tube current modulation reduced the lung dose an average of 16%. Reductions in organ dose (up to 56% for lung) due to tube current modulation were more substantial among smaller patients than larger. For some larger patients, use of tube current modulation for chest CT resulted in an increase in organ dose to the lung as high as 33%. For chest CT, lung dose and breast dose estimates had similar correlations with patient size. On average the two organs receive approximately the same dose effects from tube current modulation. CONCLUSION: The dose to radiosensitive organs during fixed-tube-current and tube current-modulated chest CT can be estimated on the basis of patient size. Organ dose generally decreases with the use of tube current-modulated acquisition, but patient size can directly affect the dose reduction achieved.

Monte Carlo simulations to assess the effects of tube current modulation on breast dose for multidetector CT.

Tube current modulation was designed to reduce radiation dose in CT imaging while maintaining overall image quality. This study aims to develop a method for evaluating the effects of tube current modulation (TCM) on organ dose in CT exams of actual patient anatomy. This method was validated by simulating a TCM and a fixed tube current chest CT exam on 30 voxelized patient models and estimating the radiation dose to each patient's glandular breast tissue. This new method for estimating organ dose was compared with other conventional estimates of dose reduction. Thirty detailed voxelized models of patient anatomy were created based on image data from female patients who had previously undergone clinically indicated CT scans including the chest area. As an indicator of patient size, the perimeter of the patient was measured on the image containing at least one nipple using a semi-automated technique. The breasts were contoured on each image set by a radiologist and glandular tissue was semi-automatically segmented from this region. Previously validated Monte Carlo models of two multidetector CT scanners were used, taking into account details about the source spectra, filtration, collimation and geometry of the scanner. TCM data were obtained from each patient's clinical scan and factored into the model to simulate the effects of TCM. For each patient model, two exams were simulated: a fixed tube current chest CT and a tube current modulated chest CT. X-ray photons were transported through the anatomy of the voxelized patient models, and radiation dose was tallied in the glandular breast tissue. The resulting doses from the tube current modulated simulations were compared to the results obtained from simulations performed using a fixed mA value. The average radiation dose to the glandular breast tissue from a fixed tube current scan across all patient models was 19 mGy. The average reduction in breast dose using the tube current modulated scan was 17%. Results were size dependent with smaller patients getting better dose reduction (up to 64% reduction) and larger patients getting a smaller reduction, and in some cases the dose actually increased when using tube current modulation (up to 41% increase). The results indicate that radiation dose to glandular breast tissue generally decreases with the use of tube current modulated CT acquisition, but that patient size (and in some cases patient positioning) may affect dose reduction.

Radiation dose to the fetus for pregnant patients undergoing multidetector CT imaging: Monte Carlo simulations estimating fetal dose for a range of gestational age and patient size.

PURPOSE: To use Monte Carlo simulations of a current-technology multidetector computed tomographic (CT) scanner to investigate fetal radiation dose resulting from an abdominal and pelvic examination for a range of actual patient anatomies that include variation in gestational age and maternal size. MATERIALS AND METHODS: Institutional review board approval was obtained for this HIPAA-compliant retrospective study. Twenty-four models of maternal and fetal anatomy were created from image data from pregnant patients who had previously undergone clinically indicated CT examination. Gestational age ranged from less than 5 weeks to 36 weeks. Simulated helical scans of the abdominal and pelvic region were performed, and a normalized dose (in milligrays per 100 mAs) was calculated for each fetus. Stepwise multiple linear regression was performed to analyze the correlation of dose with gestational age and anatomic measurements of maternal size and fetal location. Results were compared with several existing fetal dose estimation methods. RESULTS: Normalized fetal dose estimates from the Monte Carlo simulations ranged from 7.3 to 14.3 mGy/100 mAs, with an average of 10.8 mGy/100 mAs. Previous methods yielded values of 10-14 mGy/100 mAs. The correlation between gestational age and fetal dose was not significant (P = .543). Normalized fetal dose decreased linearly with increasing patient perimeter (R(2) = 0.681, P < .001), and a two-factor model with patient perimeter and fetal depth demonstrated a strong correlation with fetal dose (R(2) = 0.799, P < .002). CONCLUSION: A method for the estimation of fetal dose from models of actual patient anatomy that represented a range of gestational age and patient size was developed. Fetal dose correlated with maternal perimeter and varied more than previously recognized. This correlation improves when maternal size and fetal depth are combined.

Antiproton radiotherapy.

Antiprotons are interesting as a possible future modality in radiation therapy for the following reasons: When fast antiprotons penetrate matter, protons and antiprotons have near identical stopping powers and exhibit equal radiobiology well before the Bragg-peak. But when the antiprotons come to rest at the Bragg-peak, they annihilate, releasing almost 2 GeV per antiproton-proton annihilation. Most of this energy is carried away by energetic pions, but the Bragg-peak of the antiprotons is still locally augmented with approximately 20-30 MeV per antiproton. Apart from the gain in physical dose, an increased relative biological effect also has been observed, which can be explained by the fact that some of the secondary particles from the antiproton annihilation exhibit high-LET properties. Finally, the weakly interacting energetic pions, which are leaving the target volume, may provide a real time feedback on the exact location of the annihilation peak. We have performed dosimetry experiments and investigated the radiobiological properties using the antiproton beam available at CERN, Geneva. Dosimetry experiments were carried out with ionization chambers, alanine pellets and radiochromic film. Radiobiological experiments were done with V79 WNRE Chinese hamster cells. The radiobiological experiments were repeated with protons and carbon ions at TRIUMF and GSI, respectively, for comparison. Several Monte Carlo particle transport codes were investigated and compared with our experimental data obtained at CERN. The code that matched our data best was used to generate a set of depth dose data at several energies, including secondary particle-energy spectra. This can be used as base data for a treatment planning software such as TRiP. Our findings from the CERN experiments indicate that the biological effect of antiprotons in the plateau region may be reduced by a factor of 4 for the same biological target dose in a spread-out Bragg-peak, when comparing with protons. The extension of TRiP to handle antiproton beams is currently in progress. This will enable us to perform planning studies, where the potential clinical consequences can be examined, and compared to those of other beam modalities such as protons, carbon ions, or IMRT photons.

Time-course of effects of external beam radiation on [18F]FDG uptake in healthy tissue and bone marrow.

The utility of PET for monitoring responses to radiation therapy have been complicated by metabolically active processes in surrounding normal tissues. We examined the time-course of [18F]FDG uptake in normal tissues using small animal-dedicated PET during the 2 month period following external beam radiation. Four mice received 12 Gy of external beam radiation, in a single fraction to the left half of the body. Small animal [18F]FDG-PET scans were acquired for each mouse at 0 (pre-radiation), 1, 2, 3, 4, 5, 8, 12, 19, 24, and 38 days following irradiation. [18F]FDG activity in various tissues was compared between irradiated and non-irradiated body halves before, and at each time point after irradiation. Radiation had a significant impact on [18F]FDG uptake in previously healthy tissues, and time-course of effects differed in different types of tissues. For example, liver tissue demonstrated increased uptake, particularly over days 3-12, with the mean left to right uptake ratio increasing 52% over mean baseline values (p < 0.0001). In contrast, femoral bone marrow uptake demonstrated decreased uptake, particularly over days 2-8, with the mean left to right uptake ratio decreasing 26% below mean baseline values (p = 0.0005). Significant effects were also seen in lung and brain tissue. Radiation had diverse effects on [18F]FDG uptake in previously healthy tissues. These kinds of data may help lay groundwork for a systematically acquired database of the time-course of effects of radiation on healthy tissues, useful for animal models of cancer therapy imminently, as well as interspecies extrapolations pertinent to clinical application eventually.

Report of the AAPM Task Group No. 105: Issues associated with clinical implementation of Monte Carlo-based photon and electron external beam treatment planning.

The Monte Carlo (MC) method has been shown through many research studies to calculate accurate dose distributions for clinical radiotherapy, particularly in heterogeneous patient tissues where the effects of electron transport cannot be accurately handled with conventional, deterministic dose algorithms. Despite its proven accuracy and the potential for improved dose distributions to influence treatment outcomes, the long calculation times previously associated with MC simulation rendered this method impractical for routine clinical treatment planning. However, the development of faster codes optimized for radiotherapy calculations and improvements in computer processor technology have substantially reduced calculation times to, in some instances, within minutes on a single processor. These advances have motivated several major treatment planning system vendors to embark upon the path of MC techniques. Several commercial vendors have already released or are currently in the process of releasing MC algorithms for photon and/or electron beam treatment planning. Consequently, the accessibility and use of MC treatment planning algorithms may well become widespread in the radiotherapy community. With MC simulation, dose is computed stochastically using first principles; this method is therefore quite different from conventional dose algorithms. Issues such as statistical uncertainties, the use of variance reduction techniques, the ability to account for geometric details in the accelerator treatment head simulation, and other features, are all unique components of a MC treatment planning algorithm. Successful implementation by the clinical physicist of such a system will require an understanding of the basic principles of MC techniques. The purpose of this report, while providing education and review on the use of MC simulation in radiotherapy planning, is to set out, for both users and developers, the salient issues associated with clinical implementation and experimental verification of MC dose algorithms. As the MC method is an emerging technology, this report is not meant to be prescriptive. Rather, it is intended as a preliminary report to review the tenets of the MC method and to provide the framework upon which to build a comprehensive program for commissioning and routine quality assurance of MC-based treatment planning systems.

Improvements in prostate brachytherapy dosimetry due to seed stranding.

PURPOSE: Prostate brachytherapy with suture embedded seeds has emerged as a popular technique to reduce seed migration and to improve dosimetry. Various trials have shown improved dosimetry with seed fixity, whereas others have shown no benefit and possible detriment to suture embedded seeds. In order to contribute to the understanding of whether seed stranding improves dosimetry, we present retrospective data from our institution. METHODS AND MATERIALS: We analyzed 80 patients treated between April 29, 2001 and June 19, 2006, receiving I-125 monotherapy for prostate cancer. Brachytherapy patients at the University of California, Los Angeles (UCLA) were initially treated using a transperineal approach with loose seeds. Subsequent to October 26, 2002, all patients were implanted using suture embedded seeds. Dosimetric quantifiers were calculated based on a CT obtained 1-month postimplantation. RESULTS: Dosimetry of patients treated with stranded seeds showed significant improvement. Specifically, the V100 (volume of the prostate receiving 100% of the prescribed dose) improved from 88% to 92% (p<0.05), and the D90 (maximum dose received by 90% of the prostate) improved from 143 to 155 Gy (p<0.05). CONCLUSIONS: At UCLA, the use of suture embedded seeds resulted in a significant improvement in our dosimetric quantifiers. Based upon other published studies, this improvement in dosimetry may translate into improved patient outcomes.

Estimating organ doses from tube current modulated CT examinations using a generalized linear model.

PURPOSE: Currently, available Computed Tomography dose metrics are mostly based on fixed tube current Monte Carlo (MC) simulations and/or physical measurements such as the size specific dose estimate (SSDE). In addition to not being able to account for Tube Current Modulation (TCM), these dose metrics do not represent actual patient dose. The purpose of this study was to generate and evaluate a dose estimation model based on the Generalized Linear Model (GLM), which extends the ability to estimate organ dose from tube current modulated examinations by incorporating regional descriptors of patient size, scanner output, and other scan-specific variables as needed. METHODS: The collection of a total of 332 patient CT scans at four different institutions was approved by each institution's IRB and used to generate and test organ dose estimation models. The patient population consisted of pediatric and adult patients and included thoracic and abdomen/pelvis scans. The scans were performed on three different CT scanner systems. Manual segmentation of organs, depending on the examined anatomy, was performed on each patient's image series. In addition to the collected images, detailed TCM data were collected for all patients scanned on Siemens CT scanners, while for all GE and Toshiba patients, data representing z-axis-only TCM, extracted from the DICOM header of the images, were used for TCM simulations. A validated MC dosimetry package was used to perform detailed simulation of CT examinations on all 332 patient models to estimate dose to each segmented organ (lungs, breasts, liver, spleen, and kidneys), denoted as reference organ dose values. Approximately 60% of the data were used to train a dose estimation model, while the remaining 40% was used to evaluate performance. Two different methodologies were explored using GLM to generate a dose estimation model: (a) using the conventional exponential relationship between normalized organ dose and size with regional water equivalent diameter (WED) and regional CTDIvol as variables and (b) using the same exponential relationship with the addition of categorical variables such as scanner model and organ to provide a more complete estimate of factors that may affect organ dose. Finally, estimates from generated models were compared to those obtained from SSDE and ImPACT. RESULTS: The Generalized Linear Model yielded organ dose estimates that were significantly closer to the MC reference organ dose values than were organ doses estimated via SSDE or ImPACT. Moreover, the GLM estimates were better than those of SSDE or ImPACT irrespective of whether or not categorical variables were used in the model. While the improvement associated with a categorical variable was substantial in estimating breast dose, the improvement was minor for other organs. CONCLUSIONS: The GLM approach extends the current CT dose estimation methods by allowing the use of additional variables to more accurately estimate organ dose from TCM scans. Thus, this approach may be able to overcome the limitations of current CT dose metrics to provide more accurate estimates of patient dose, in particular, dose to organs with considerable variability across the population.

The biological effectiveness of antiproton irradiation.

BACKGROUND AND PURPOSE: Antiprotons travel through tissue in a manner similar to that for protons until they reach the end of their range where they annihilate and deposit additional energy. This makes them potentially interesting for radiotherapy. The aim of this study was to conduct the first ever measurements of the biological effectiveness of antiprotons. MATERIALS AND METHODS: V79 cells were suspended in a semi-solid matrix and irradiated with 46.7MeV antiprotons, 48MeV protons, or (60)Co gamma-rays. Clonogenic survival was determined as a function of depth along the particle beams. Dose and particle fluence response relationships were constructed from data in the plateau and Bragg peak regions of the beams and used to assess the biological effectiveness. RESULTS: Due to uncertainties in antiproton dosimetry we defined a new term, called the biologically effective dose ratio (BEDR), which compares the response in a minimally spread out Bragg peak (SOBP) to that in the plateau as a function of particle fluence. This value was approximately 3.75 times larger for antiprotons than for protons. This increase arises due to the increased dose deposited in the Bragg peak by annihilation and because this dose has a higher relative biological effectiveness (RBE). CONCLUSION: We have produced the first measurements of the biological consequences of antiproton irradiation. These data substantiate theoretical predictions of the biological effects of antiproton annihilation within the Bragg peak, and suggest antiprotons warrant further investigation.

Attenuation-based size metric for estimating organ dose to patients undergoing tube current modulated CT exams.

PURPOSE: Task Group 204 introduced effective diameter (ED) as the patient size metric used to correlate size-specific-dose-estimates. However, this size metric fails to account for patient attenuation properties and has been suggested to be replaced by an attenuation-based size metric, water equivalent diameter (DW). The purpose of this study is to investigate different size metrics, effective diameter, and water equivalent diameter, in combination with regional descriptions of scanner output to establish the most appropriate size metric to be used as a predictor for organ dose in tube current modulated CT exams. METHODS: 101 thoracic and 82 abdomen/pelvis scans from clinically indicated CT exams were collected retrospectively from a multidetector row CT (Sensation 64, Siemens Healthcare) with Institutional Review Board approval to generate voxelized patient models. Fully irradiated organs (lung and breasts in thoracic scans and liver, kidneys, and spleen in abdominal scans) were segmented and used as tally regions in Monte Carlo simulations for reporting organ dose. Along with image data, raw projection data were collected to obtain tube current information for simulating tube current modulation scans using Monte Carlo methods. Additionally, previously described patient size metrics [ED, DW, and approximated water equivalent diameter (DWa)] were calculated for each patient and reported in three different ways: a single value averaged over the entire scan, a single value averaged over the region of interest, and a single value from a location in the middle of the scan volume. Organ doses were normalized by an appropriate mAs weighted CTDIvol to reflect regional variation of tube current. Linear regression analysis was used to evaluate the correlations between normalized organ doses and each size metric. RESULTS: For the abdominal organs, the correlations between normalized organ dose and size metric were overall slightly higher for all three differently (global, regional, and middle slice) reported DW and DWa than they were for ED, but the differences were not statistically significant. However, for lung dose, computed correlations using water equivalent diameter calculated in the middle of the image data (DW,middle) and averaged over the low attenuating region of lung (DW,regional) were statistically significantly higher than correlations of normalized lung dose with ED. CONCLUSIONS: To conclude, effective diameter and water equivalent diameter are very similar in abdominal regions; however, their difference becomes noticeable in lungs. Water equivalent diameter, specifically reported as a regional average and middle of scan volume, was shown to be better predictors of lung dose. Therefore, an attenuation-based size metric (water equivalent diameter) is recommended because it is more robust across different anatomic regions. Additionally, it was observed that the regional size metric reported as a single value averaged over a region of interest and the size metric calculated from a single slice/image chosen from the middle of the scan volume are highly correlated for these specific patient models and scan types.

Accuracy of Monte Carlo simulations compared to in-vivo MDCT dosimetry.

PURPOSE: The purpose of this study was to assess the accuracy of a Monte Carlo simulation-based method for estimating radiation dose from multidetector computed tomography (MDCT) by comparing simulated doses in ten patients to in-vivo dose measurements. METHODS: MD Anderson Cancer Center Institutional Review Board approved the acquisition of in-vivo rectal dose measurements in a pilot study of ten patients undergoing virtual colonoscopy. The dose measurements were obtained by affixing TLD capsules to the inner lumen of rectal catheters. Voxelized patient models were generated from the MDCT images of the ten patients, and the dose to the TLD for all exposures was estimated using Monte Carlo based simulations. The Monte Carlo simulation results were compared to the in-vivo dose measurements to determine accuracy. RESULTS: The calculated mean percent difference between TLD measurements and Monte Carlo simulations was -4.9% with standard deviation of 8.7% and a range of -22.7% to 5.7%. CONCLUSIONS: The results of this study demonstrate very good agreement between simulated and measured doses in-vivo. Taken together with previous validation efforts, this work demonstrates that the Monte Carlo simulation methods can provide accurate estimates of radiation dose in patients undergoing CT examinations.

Dosimetric parameters for three low-energy brachytherapy sources using the Monte Carlo N-particle code.

Monte Carlo calculations have been performed for the purpose of characterizing the dosimetric properties of three brachytherapy sources. The three sources are manufactured by Syncor Pharmaceuticals Inc. and consist of two 125I seeds (BT-125-1 and BT-125-2) and one 103Pd seed (BT-103-3). The BT-125-1 and BT-125-2 seed consists of a solid palladium and silver core, respectively. A thin layer (0.5 microm) of 125I is adsorbed onto the solid core for each seed and encased within a titanium housing. The BT-103-3 seed consists of a central gold marker and four resin balls encased within a titanium housing. A thin layer of 103Pd is bonded onto each resin ball. The dosimetric properties, including the dose rate constant, radial dose function, and anisotropy were calculated in water according to the TG-43 protocol using the Monte Carlo N-Particle code. The dose rate constant was calculated to be 0.955+/-0.005 and 0.967+/-0.005 cGyh(-1) U(-1) for the BT-125-1 and BT- 125-2 seeds, respectively. A dose rate constant of 0.659+/-0.005 cGy h(-1) U(-1) was calculated for the BT-103-3 seed. Radial dose function, g(r), calculated to a distance of 10 cm, and an isotropy function, F(r, theta), calculated for radii from 0.5 to 7.0 cm, were found to be in close agreement with previously published data.