Mitigation of motion effects in pencil-beam scanning - Impact of repainting on 4D robustly optimized proton treatment plans for hepatocellular carcinoma.

Proton fields delivered by the active scanning technique can be interfered with the intrafractional motion. This in-silico study seeks to mitigate the dosimetric impacts of motion artifacts, especially its interplay with the time-modulated dose delivery. Here four-dimensional (4d) robust optimization and dose repainting, which is the multiple application of the same field with reduced fluence, were combined. Two types of repainting were considered: layered and volumetric repainting. The time-resolved dose calculation, which is necessary to quantify the interplay effect, was integrated into the treatment planning system and validated. Nine clinical cases of hepatocellular carcinoma (HCC) showing motion in the range of 0.4-1.5cm were studied. It was found that the repainted delivery of 4D robustly optimized plans reduced the impact of interplay effect as quantified by the homogeneity index within the clinical target volume (CTV) to a tolerable level. Similarly, the fractional over- and underdosage was reduced sufficiently for some HCC cases to achieve the purpose of motion management. This holds true for both investigated types of repainting with small dosimetric advantages of volume repainting over layered repainting. Volume repainting, however, cannot be applied clinically in proton centers with slow energy changes. Thus, it served as a reference in the in-silico evaluation. It is recommended to perform the dynamic dose calculation for individual cases to judge if robust optimization in conjunction with repainting is sufficient to keep the interplay effect within bounds.

Motion effects in proton treatments of hepatocellular carcinoma-4D robustly optimised pencil beam scanning plans versus double scattering plans.

Pencil beam scanning (PBS) proton therapy enables better dose conformality for complex anatomical geometries than passive proton scattering techniques, but is more susceptible to organ motion. This becomes an issue when treating moving tumours in the thorax or abdomen. Novel four-dimensional treatment planning approaches have been developed to increase the robustness of PBS plans against motion. However, their efficacy still needs to be examined by means of 4D dynamically accumulated dose (4DDD) analyses. This study investigates the potential use of 4D robust optimisation to maintain sufficient target coverage in the presence of organ motion, while sparing surrounding healthy tissue, for hepatocellular carcinoma (HCC). The liver is particularly suited to study motion interplay effects since the treatment region exhibits smaller density gradients and more homogeneous tissue than targets in the thorax, making it less prone to range errors. A facility-specific beam time model, developed and experimentally validated previously, was used for the clinical evaluation. 4DDD analyses of eleven target volumes did not show a significant improvement of the target coverage using 4D robust optimisation, but a reduction of the dose to close-by organs at risk. Interplay effects were averaged out for the applied fractionation scheme of 15 fractions. Contrary to PBS, passive double scattering (DS) plans yielded homogeneous 4DDD dose distributions in a single fraction. But, in some cases, they exceeded organ at risk dose limits, which were only satisfied in PBS. The average normal liver dose could be decreased by almost 6% compared to non-robustly optimised PBS plans and by 16% compared to DS plans when implementing 4D robust optimisation. Except for some very small tumours with large motion amplitudes, 4D robustly optimised PBS plans were found to be clinically acceptable even without supplementary motion mitigation techniques.

Dose Distributions and Treatment Margins in Ocular Brachytherapy with 106Ru Eye Plaques.

Brachytherapy with 106Ru eye plaques is the most common treatment modality for small to medium-sized uveal melanomas in Europe. So far, no standardized or widely accepted dose prescription protocol for the irradiation of intraocular tumors with 106Ru eye plaques has been defined. For 125I plaques, the minimum dose required for tumor control should be at least 85 Gy. Concerning 106Ru plaques, the dose prescriptions at the University Hospital of Essen foresees minimum doses of 700 Gy to the tumor base and 130 Gy to the tumor apex. These dose prescriptions are expected to ensure sufficient treatment margins. We apply these dose prescriptions to different eye plaque types and tumor sizes and discuss the resulting treatment margins. These investigations are based on Monte Carlo simulations of dose distributions of 3 different eye plaque types. The treatment margin in apical direction has an expansion of at least 0.8 mm for all investigated eye plaques. For symmetrically formed eye plaques, the treatment margin at the base of the tumor goes beyond the visible edge of the plaque. This study focuses on the shape of 85-Gy isodose lines and on treatment margins for different eye plaque types and tumor sizes and shall help exchange knowledge for ocular brachytherapy.

Experimental validation of a 4D dose calculation routine for pencil beam scanning proton therapy.

Respiratory induced organ motion poses a major challenge for high-precision radiotherapy such as pencil beam scanning proton therapy (PBS). In order to employ PBS for target regions affected by respiratory motion, the implementation of dedicated motion mitigation techniques should be considered and residual uncertainties need to be assessed. For the latter purpose, a routine simulating the delivery of a scanned proton beam to a moving target was developed and implemented in the commercial treatment planning system RayStation. The time structure of the beam delivery was extracted from electronic irradiation protocols of the delivery system. Alternatively to electronic irradiation protocols, an empirical time model of the beam delivery was created to allow for prospective estimations of interplay effects between target motion and pencil beam scanning. The experimental validation of the routine was performed using a two-dimensional ionization chamber array and a dynamic phantom. A 4D CT data set, including 10 respiratory phases, provided the spatial temporal information about the phantom motion. The dosimetric comparison of the measured and the calculated dose distribution yielded gamma pass rates above 96% using a 3% dose difference and a 3mm distance to agreement criterion. Thus, a tool for the evaluation of interplay effects is available in a clinical software environment and patient-specific quality assurance can be extended to dynamic treatment scenarios.

Energy dependent response of plastic scintillation detectors to photon radiation of low to medium energy.

PURPOSE: Plastic scintillation detectors are promising candidates for the dosimetry of low- to medium-energy photons but quantitative knowledge of their energy response is a prerequisite for their correct use. The purpose of this study was to characterize the energy dependent response of small scintillation detectors (active volume <1 mm(3)) made from the commonly used plastic scintillator BC400. METHODS: Different detectors made from BC400 were calibrated at a number of radiation qualities ranging from 10 to 280 kV and at a (60)Co beam. All calibrations were performed at the Physikalisch-Technische Bundesanstalt, the National Metrology Institute of Germany. The energy response in terms of air kerma, dose to water, and dose to the scintillator was determined. Conversion factors from air kerma to dose to water and to dose to the scintillator were derived from Monte Carlo simulations. In order to quantitatively describe the energy dependence, a semiempirical model known as unimolecular quenching or Birks' formula was fitted to the data and from this the response to secondary electrons generated within the scintillator material BC400 was derived. RESULTS: The detector energy response in terms of air kerma differs for different scintillator sizes and different detector casings. It is therefore necessary to take attenuation within the scintillator and in the casing into account when deriving the response in terms of dose to water from a calibration in terms of air kerma. The measured energy response in terms of dose to water for BC400 cannot be reproduced by the ratio of mean mass energy-absorption coefficients for polyvinyl toluene to water but shows evidence of quenching. The quenching parameter kB in Birks' formula was determined to be kB = (12.3 ± 0.9) mg MeV(-1) cm(-2). CONCLUSIONS: The energy response was quantified relative to the response to (60)Co which is the common radiation quality for the calibration of therapy dosemeters. The observed energy dependence could be well explained with the assumption of ionization quenching as described by Birks' formula. Plastic scintillation detectors should be calibrated at the same radiation quality that they will be used at and changes of the spectrum within the application need to be considered. The authors results can be used to evaluate the range of validity of a given calibration.

Integral image rendering procedure for aberration correction and size measurement.

The challenge in rendering integral images is to use as much information preserved by the light field as possible to reconstruct a captured scene in a three-dimensional way. We propose a rendering algorithm based on the projection of rays through a detailed simulation of the optical path, considering all the physical properties and locations of the optical elements. The rendered images contain information about the correct size of imaged objects without the need to calibrate the imaging device. Additionally, aberrations of the optical system may be corrected, depending on the setup of the integral imaging device. We show simulation data that illustrates the aberration correction ability and experimental data from our plenoptic camera, which illustrates the capability of our proposed algorithm to measure size and distance. We believe this rendering procedure will be useful in the future for three-dimensional ophthalmic imaging of the human retina.

Development of a high precision dosimetry system for the measurement of surface dose rate distribution for eye applicators.

PURPOSE: The therapeutic outcome of the therapy with ophthalmic applicators is highly dependent on the application of a sufficient dose to the tumor, whereas the dose applied to the surrounding tissue needs to be minimized. The goal for the newly developed apparatus described in this work is the determination of the individual applicator surface dose rate distribution with a high spatial resolution and a high precision in dose rate with respect to time and budget constraints especially important for clinical procedures. Inhomogeneities of the dose rate distribution can be detected and taken into consideration for the treatment planning. METHODS: In order to achieve this, a dose rate profile as well as a surface profile of the applicator are measured and correlated with each other. An instrumental setup has been developed consisting of a plastic scintillator detector system and a newly designed apparatus for guiding the detector across the applicator surface at a constant small distance. It performs an angular movement of detector and applicator with high precision. RESULTS: The measurements of surface dose rate distributions discussed in this work demonstrate the successful operation of the measuring setup. Measuring the surface dose rate distribution with a small distance between applicator and detector and with a high density of measuring points results in a complete and gapless coverage of the applicator surface, being capable of distinguishing small sized spots with high activities. The dosimetrical accuracy of the measurements and its analysis is sufficient (uncertainty in the dose rate in terms of absorbed dose to water is <7%), especially when taking the surgical techniques in positioning of the applicator on the eyeball into account. CONCLUSIONS: The method developed so far allows a fully automated quality assurance of eye applicators even under clinical conditions. These measurements provide the basis for future calculation of a full 3D dose rate distribution, which then can be used as input for a refined clinical treatment planning system. The improved dose rate measurements will facilitate a clinical study, which could correlate the therapeutic outcome of a brachytherapy treatment with an applicator and its individual dose rate distribution.