EPID-based in vivo dosimetry using Dosimetry Check™: Overview and clinical experience in a 5-yr study including breast, lung, prostate, and head and neck cancer patients.

BACKGROUND: Independent verification of the dose delivered by complex radiotherapy can be performed by electronic portal imaging device (EPID) dosimetry. This paper presents 5-yr EPID in vivo dosimetry (IVD) data obtained using the Dosimetry Check (DC) software on a large cohort including breast, lung, prostate, and head and neck (H&N) cancer patients. MATERIAL AND METHODS: The difference between in vivo dose measurements obtained by DC and point doses calculated by the Eclipse treatment planning system was obtained on 3795 radiotherapy patients treated with volumetric modulated arc therapy (VMAT) (n = 842) and three-dimensional conformal radiotherapy (3DCRT) (n = 2953) at 6, 10, and 15 MV. In cases where the dose difference exceeded ±10% further inspection and additional phantom measurements were performed. RESULTS: The mean and standard deviation ( µ ± σ ) of the percentage difference in dose obtained by DC and calculated by Eclipse in VMAT was: 0.19 ± 3.89 % in brain, 1.54 ± 4.87 % in H&N, and 1.23 ± 4.61 % in prostate cancer. In 3DCRT, this was 1.79 ± 3.51 % in brain, - 2.95 ± 5.67 % in breast, - 1.43 ± 4.38 % in bladder, 1.66 ± 4.77 % in H&N, 2.60 ± 5.35% in lung and - 3.62 ± 4.00 % in prostate cancer. A total of 153 plans exceeded the ±10% alert criteria, which included: 88 breast plans accounting for 7.9% of all breast treatments; 28 H&N plans accounting for 4.4% of all H&N treatments; and 12 prostate plans accounting for 3.5% of all prostate treatments. All deviations were found to be as a result of patient-related anatomical deviations and not from procedural errors. CONCLUSIONS: This preliminary data shows that EPID-based IVD with DC may not only be useful in detecting errors but has the potential to be used to establish site-specific dose action levels. The approach is straightforward and has been implemented as a radiographer-led service with no disruption to the patient and no impact on treatment time.

Dose evaluation of Grid Therapy using a 6 MV flattening filter-free (FFF) photon beam: A Monte Carlo study.

PURPOSE: Spatially fractionated radiotherapy is a strategy to overcome the main limitation of radiotherapy, i.e., the restrained normal tissue tolerances. A well-known example is Grid Therapy, which is currently performed at some hospitals using megavoltage photon beams delivered by Linacs. Grid Therapy has been successfully used in the management of bulky abdominal tumors with low toxicity. The aim of this work was to evaluate whether an improvement in therapeutic index in Grid Therapy can be obtained by implementing it in a flattening filter-free (FFF) Linac. The rationale behind is that the removal of the flattening filter shifts the beam energy spectrum towards lower energies and increase the photon fluence. Lower energies result in a reduction of lateral scattering and thus, to higher peak-to-valley dose ratios (PVDR) in normal tissues. In addition, the gain in fluence might allow using smaller beams leading a more efficient exploitation of dose-volume effects, and consequently, a better normal tissue sparing. METHODS: Monte Carlo simulations were used to evaluate realistic dose distributions considering a 6 MV FFF photon beam from a standard medical Linac and a cerrobend mechanical collimator in different configurations: grid sizes of 0.3 × 0.3 cm2 , 0.5 × 0.5 cm2 , and 1 × 1 cm2 and a corresponding center-to-center (ctc) distance of 0.6, 1, and 2 cm, respectively (total field size of 10 × 10 cm2 ). As figure of merit, peak doses in depth, PVDR, output factors (OF), and penumbra values were assessed. RESULTS: Dose at the entrance is slightly higher than in conventional Grid Therapy. However, it is compensated by the large PVDR obtained at the entrance, reaching a maximum of 35 for a grid size of 1 × 1 cm2 . Indeed, this grid size leads to very high PVDR values at all depths (≥ 10), which are much higher than in standard Grid Therapy. This may be beneficial for normal tissues but detrimental for tumor control, where a lower PVDR might be requested. In that case, higher valley doses in the tumor could be achieved by using an interlaced approach and/or adapting the ctc distance. The smallest grid size (0.3 × 0.3 cm2 ) leads to low PVDR at all depths, comparable to standard Grid Therapy. However, the use of very thin beams might increase the normal tissue tolerances with respect to the grid size commonly used (1 × 1 cm2 ). The gain in fluence provided by FFF implies that the important OF reduction (0.6) will not increase treatment time. Finally, the intermediate configuration (0.5 × 0.5 cm2 ) provides high PVDR in the first 5 cm, and comparable PVDR to previous Grid Therapy works at depth. Therefore, this configuration might allow increasing the normal tissue tolerances with respect to Grid Therapy thanks to the higher PVDR and thinner beams, while a similar tumor control could be expected. CONCLUSIONS: The implementation of Grid Therapy in an FFF photon beam from medical Linac might lead to an improvement of the therapeutic index. Among the cases evaluated, a grid size of 0.5 × 0.5 cm2 (1-cm-ctc) is the most advantageous configuration from the physics point of view. Radiobiological experiments are needed to fully explore this new avenue and to confirm our results.

Field correction factors for a PTW-31016 Pinpoint ionization chamber for both flattened and unflattened beams. Study of the main sources of uncertainties.

PURPOSE: The primary aim of this study was to determine correction factors, kQclin,Qmsrfclin,fmsr for a PTW-31016 ionization chamber on field sizes from 0.5 cm × 0.5 cm to 2 cm × 2 cm for both flattened (FF) and flattened filter-free (FFF) beams produced in a TrueBeam clinical accelerator. The secondary objective was the determination of field output factors, ΩQclin,Qmsrfclin,fmsr over this range of field sizes using both Monte Carlo (MC) simulation and measurements. METHODS: kQclin,Qmsrfclin,fmsr for the PTW-31016 chamber were calculated by MC simulation for field sizes of 0.5 cm × 0.5 cm, 1 cm × 1 cm, and 2 cm × 2 cm. MC simulations were performed with the PENELOPE code system for the 10 MV FFF Particle Space File from a TrueBeam linear accelerator (LINAC) provided by the manufacturer (Varian Medical Systems, Inc. Palo Alto, CA, USA). Simulations were repeated taking into account chamber manufacturing tolerances and accelerator jaw positioning in order to assess the uncertainty of the calculated correction factors. Output ratios were measured on square fields ranging from 0.5 cm × 0.5 cm to 10 cm × 10 cm for 6 MV and 10 MV FF and FFF beams produced by a TrueBeam using a PTW-31016 ionization chamber; a Sun Nuclear Edge detector (SunNuclear Corp., Melbourne, FL, USA) and TLD-700R (Harshaw, Thermo Scientific, Waltham, MA, USA). The validity of the proposed correction factors was verified using the calculated correction factors for the determination of ΩQclin,Qmsrfclin,fmsr using a PTW-31016 at the four TrueBeam energies and comparing the results with both TLD-700R measurements and MC simulations. Finally, the proposed correction factors were used to assess the correction factors of the SunNuclear Edge detector. RESULTS: The present work provides a set of MC calculated correction factors for a PTW-31016 chamber used on a TrueBeam FF and FFF mode. For the 0.5 cm × 0.5 cm square field size, kQclin,Qmsrfclin,fmsr is equal to 1.17 with a combined uncertainty of 2% (k = 1). A detailed analysis of the most influential parameters is presented in this work. PTW-31016 corrected measurements were used for the determination of ΩQclin,Qmsrfclin,fmsr for 6 MV and 10 MV FF and FFF and the results were in agreement with values obtained using a TLD-700R detector (differences < 3% for a 0.5 cm square field) for the four energies studied. Uncertainty in field collimation was found to be the main source of influence of ΩQclin,Qmsrfclin,fmsr and caused differences of up to 15% between calculations and measurements for the 0.5 cm × 0.5 cm field. This was also confirmed by repeating the same measurements at two different institutions. CONCLUSIONS: This study confirms the need to introduce correction factors when using a PTW-31016 chamber and the hypothesis of their low energy dependence. MC simulation has been shown to be a useful methodology to determine detector correction factors for small fields and to analyze the main sources of uncertainty. However, due to the influence of the LINAC jaw setup for field sizes below or equal to 1 cm, MC methods are not recommended in this range for field output factor calculations.