Practical guidelines for personal monitoring and estimation of effective dose and dose to the lens of the eye in interventional procedures.

Estimation of effective dose and dose to the lens of the eye for workers involved in interventional procedures is challenging. The interventional procedures in question involve high doses and, due to this, workers need to wear protective garments. As a result, various methodologies have been developed to assess the effective dose and dose to the lens of the eye. In the present study, measurements from four European dosimetry services, over and under protective garments, have been collected and analysed in order to provide practical guidelines based on the routine use of personal dosemeters from staff in interventional workplaces. The advantages and limitations of using one or two dosemeters are discussed.

Validation of the MC-GPU Monte Carlo code against the PENELOPE/penEasy code system and benchmarking against experimental conditions for typical radiation qualities and setups in interventional radiology and cardiology.

INTRODUCTION: Interventional procedures are associated with potentially high radiation doses to the skin. The 2013/59/EURATOM Directive establishes that the equipment used for interventional radiology must have a device or a feature informing the practitioner of relevant parameters for assessing patient dose at the end of the procedure. Monte Carlo codes of radiation transport are considered to be one of the most reliable tools available to assess doses. However, they are usually too time consuming for use in clinical practice. This work presents the validation of the fast Monte Carlo code MC-GPU for application in interventional radiology. METHODOLOGIES: MC-GPU calculations were compared against the well-validated Monte Carlo simulation code PENELOPE/penEasy by simulating the organ dose distribution in a voxelized anthropomorphic phantom. In a second phase, the code was compared against thermoluminescent measurements performed on slab phantoms, both in a calibration laboratory and at a hospital. RESULTS: The results obtained from the two simulation codes show very good agreement, differences in the output were within 1%, whereas the calculation time on the MC-GPU was 2500 times shorter. Comparison with measurements is of the order of 10%, within the associated uncertainty. CONCLUSIONS: It has been verified that MC-GPU provides good estimates of the dose when compared to PENELOPE program. It is also shown that it presents very good performance when assessing organ doses in very short times, less than one minute, in real clinical set-ups. Future steps would be to simulate complex procedures with several projections.

Radiation-induced lens opacities: Epidemiological, clinical and experimental evidence, methodological issues, research gaps and strategy.

In 2011, the International Commission on Radiological Protection (ICRP) recommended reducing the occupational equivalent dose limit for the lens of the eye from 150 mSv/year to 20 mSv/year, averaged over five years, with no single year exceeding 50 mSv. With this recommendation, several important assumptions were made, such as lack of dose rate effect, classification of cataracts as a tissue reaction with a dose threshold at 0.5 Gy, and progression of minor opacities into vision-impairing cataracts. However, although new dose thresholds and occupational dose limits have been set for radiation-induced cataract, ICRP clearly states that the recommendations are chiefly based on epidemiological evidence because there are a very small number of studies that provide explicit biological and mechanistic evidence at doses under 2 Gy. Since the release of the 2011 ICRP statement, the Multidisciplinary European Low Dose Initiative (MELODI) supported in April 2019 a scientific workshop that aimed to review epidemiological, clinical and biological evidence for radiation-induced cataracts. The purpose of this article is to present and discuss recent related epidemiological and clinical studies, ophthalmic examination techniques, biological and mechanistic knowledge, and to identify research gaps, towards the implementation of a research strategy for future studies on radiation-induced lens opacities. The authors recommend particularly to study the effect of ionizing radiation on the lens in the context of the wider, systemic effects, including in the retina, brain and other organs, and as such cataract is recommended to be studied as part of larger scale programs focused on multiple radiation health effects.

Report of IRPA task group on issues and actions taken in response to the change in eye lens dose limit.

In 2018, the International Radiation Protection Association (IRPA) established its third task group (TG) on the implementation of the eye lens dose limit. To contribute to sharing experience and raising awareness within the radiation protection community about protection of workers in exposure of the lens of the eye, the TG conducted a questionnaire survey and analysed the responses. This paper provides an overview of the results of the questionnaire.

Effect of the radiation protective apron on the response of active and passive personal dosemeters used in interventional radiology and cardiology.

In fluoroscopy guided interventional procedures, workers use protective garments and often two personal dosemeters, the readings of which are used for the estimation of the effective dose; whereas the dosemeter above the protection can be used for the estimation of the equivalent dose of the lens of the eye. When a protective apron is worn the scattered field that reaches the dosemeter is different from the case where no protection is used; this study analyses the changes in the response of seven passive and eight active personal dosemeters (APDs) when they are placed above a lead or lead equivalent garment for S-Cs and x-ray diagnostic qualities. Monte Carlo simulations are used to support the experimental results. It is found that for passive dosemeters, the influence on the dosemeter's response to the lead or lead equivalent was within the range 15%-38% for the x-ray qualities. This effect is smaller, of the order of 10%, when lead-free garments are used, and much smaller, within 1%-10%, for most of the APDs used in the study. From these results it is concluded that when comparing passive and active dosemeter measurements worn above the protection, a difference of 20%-40% is expected. The effect is small when deriving the effective dose from double dosimetry algorithms, but it can be of major importance when eye lens monitoring is based on the use of the dosemeter worn above the protection.

A European survey on the regulatory status for the estimation of the effective dose and the equivalent dose to the lens of the eye when radiation protection garments are used.

Following the proposal of the ICRP for the reduction of the dose limit for the lens of the eye, which has been adopted by the International Atomic Energy Agency and the European Council, concerns have been raised about the implementation of proper dose monitoring methods as defined in national regulations, and about the harmonisation between European countries. The European Radiation Dosimetry Group organised a survey at the end of 2017, through a web questionnaire, regarding national dose monitoring regulations. The questions were related to: double dosimetry, algorithms for the estimation of the effective dose, methodology for the determination of the equivalent dose to the lens of the eye and structure of the national dose registry. The results showed that more than 50% of the countries that responded to the survey have legal requirements about the number and the position of dosemeters used for estimation of the effective dose when radiation protection garments are used. However, in only five out of 26 countries are there nationally approved algorithms for the estimation of the effective dose. In 14 out of 26 countries there is a legal requirement to estimate the dose to the lens of the eye. All of the responding countries use some kind of national database for storing individual monitoring data but in only 12 out of 26 countries are the estimated effective dose values stored. The personal dose equivalent at depth 3 mm is stored in the registry of only seven out of 26 countries. From the survey, performed just before the implementation of the European Basic Safety Standards Directive, it is concluded that national occupational exposure frameworks require intensive and immediate work under the coordination of the competent authorities to bring them into line with the latest basic safety standards and achieve harmonisation between European countries.

Report of IRPA task group on the impact of the eye lens dose limits.

In 2012 IRPA established a task group (TG) to identify key issues in the implementation of the revised eye lens dose limit. The TG reported its conclusions in 2013. In January 2015, IRPA asked the TG to review progress with the implementation of the recommendations from the early report and to collate current practitioner experience. This report presents the results of a survey on the view of the IRPA professionals on the new limit to the lens of the eye and on the wider issue of tissue reactions. Recommendations derived from the survey are presented. This report was approved by IRPA Executive Council on 31 January 2017.

Status of eye lens radiation dose monitoring in European hospitals.

A questionnaire was developed by the members of WG12 of EURADOS in order to establish an overview of the current status of eye lens radiation dose monitoring in hospitals. The questionnaire was sent to medical physicists and radiation protection officers in hospitals across Europe. Specific topics were addressed in the questionnaire such as: knowledge of the proposed eye lens dose limit; monitoring and dosimetry issues; training and radiation protection measures. The results of the survey highlighted that the new eye lens dose limit can be exceeded in interventional radiology procedures and that eye lens protection is crucial. Personnel should be properly trained in how to use protective equipment in order to keep eye lens doses as low as reasonably achievable. Finally, the results also highlighted the need to improve the design of eye dosemeters in order to ensure satisfactory use by workers.

Dose variations in tumor volumes and organs at risk during IMRT for head-and-neck cancer.

Many head-and-neck cancer (HNC) patients treated with radiotherapy suffer significant anatomical changes due to tumor shrinkage or weight loss. The purpose of this study was to assess dose changes over target volumes and organs at risk during intensity-modulated radiotherapy for HNC patients. Sixteen HNC IMRT patients, all requiring bilateral neck irradiation, were enrolled in the study. A CTplan was performed and the initial dose distribution was calculated. During the treatment, two subsequent CTs at the 15th (CT15) and 25th (CT25) fractions were acquired. The initial plan was calculated on the CT15 and CT25, and dose-volume differences related to the CTplan were assessed. For target volumes, mean values of near-maximun absorbed dose (D2%) increased at the 25th fraction, and doses covering 95% and 98% of volume decreased significantly at the 15th fraction. Contralateral and ipsilateral parotid gland mean doses increased by 6.1% (range: -5.4, 23.5%) and 4.7% (range: -9.1, 22.3%), respectively, at CT25. The D2% in the spinal cord increased by 1.8 Gy at CT15. Mean absorbed dose increases at CT15 and CT25 were observed in: the lips, 3.8% and 5.3%; the oral cavity, 3.5% and 2.5%; and lower middle neck structure, 1.9% and 1.6%. Anatomical changes during treatment of HNC patients affect dose distribution and induce a loss of dose coverage to target volumes and an overdosage to critical structures. Appropriate organs at risk have to be contoured and monitored in order to know if the initial plan remains suitable during the course of the treatment. Reported dosimetric data can help to identify patients who could benefit from adaptive radiotherapy.

SBRT of lung tumours: Monte Carlo simulation with PENELOPE of dose distributions including respiratory motion and comparison with different treatment planning systems.

The purpose of this work was to simulate with the Monte Carlo (MC) code PENELOPE the dose distribution in lung tumours including breathing motion in stereotactic body radiation therapy (SBRT). Two phantoms were modelled to simulate a pentagonal cross section with chestwall (unit density), lung (density 0.3 g cm(-3)) and two spherical tumours (unit density) of diameters respectively of 2 cm and 5 cm. The phase-space files (PSF) of four different SBRT field sizes of 6 MV from a Varian accelerator were calculated and used as beam sources to obtain both dose profiles and dose-volume histograms (DVHs) in different volumes of interest. Dose distributions were simulated for five beams impinging on the phantom. The simulations were conducted both for the static case and including the influence of respiratory motion. To reproduce the effect of breathing motion different simulations were performed keeping the beam fixed and displacing the phantom geometry in chosen positions in the cranial and caudal and left-right directions. The final result was obtained by combining the different position with two motion patterns. The MC results were compared with those obtained with three commercial treatment planning systems (TPSs), two based on the pencil beam (PB) algorithm, the TMS-HELAX (Nucletron, Sweden) and Eclipse (Varian Medical System, Palo Alto, CA), and one based on the collapsed cone algorithm (CC), Pinnacle(3) (Philips). Some calculations were also carried out with the analytical anisotropic algorithm (AAA) in the Eclipse system. All calculations with the TPSs were performed without simulated breathing motion, according to clinical practice. In order to compare all the TPSs and MC an absolute dose calibration in Gy/MU was performed. The analysis shows that the dose (Gy/MU) in the central part of the gross tumour volume (GTV) is calculated for both tumour sizes with an accuracy of 2-3% with PB and CC algorithms, compared to MC. At the periphery of the GTV the TPSs overestimate the dose up to 10%, while in the lung tissue close to the GTV PB algorithms overestimate the dose and the CC underestimates it. When clinically relevant breathing motions are included in the MC simulations, the static calculations with the TPSs still give a relatively accurate estimate of the dose in the GTV. On the other hand, the dose at the periphery of the GTV is overestimated, compared to the static case.

Monte Carlo simulation of MOSFET detectors for high-energy photon beams using the PENELOPE code.

The aim of this work was the Monte Carlo (MC) simulation of the response of commercially available dosimeters based on metal oxide semiconductor field effect transistors (MOSFETs) for radiotherapeutic photon beams using the PENELOPE code. The studied Thomson&Nielsen TN-502-RD MOSFETs have a very small sensitive area of 0.04 mm(2) and a thickness of 0.5 microm which is placed on a flat kapton base and covered by a rounded layer of black epoxy resin. The influence of different metallic and Plastic water build-up caps, together with the orientation of the detector have been investigated for the specific application of MOSFET detectors for entrance in vivo dosimetry. Additionally, the energy dependence of MOSFET detectors for different high-energy photon beams (with energy >1.25 MeV) has been calculated. Calculations were carried out for simulated 6 MV and 18 MV x-ray beams generated by a Varian Clinac 1800 linear accelerator, a Co-60 photon beam from a Theratron 780 unit, and monoenergetic photon beams ranging from 2 MeV to 10 MeV. The results of the validation of the simulated photon beams show that the average difference between MC results and reference data is negligible, within 0.3%. MC simulated results of the effect of the build-up caps on the MOSFET response are in good agreement with experimental measurements, within the uncertainties. In particular, for the 18 MV photon beam the response of the detectors under a tungsten cap is 48% higher than for a 2 cm Plastic water cap and approximately 26% higher when a brass cap is used. This effect is demonstrated to be caused by positron production in the build-up caps of higher atomic number. This work also shows that the MOSFET detectors produce a higher signal when their rounded side is facing the beam (up to 6%) and that there is a significant variation (up to 50%) in the response of the MOSFET for photon energies in the studied energy range. All the results have shown that the PENELOPE code system can successfully reproduce the response of a detector with such a small active area.