Evaluation of the RUBY modular QA phantom for planar and non-coplanar VMAT and stereotactic radiations.

PURPOSE: This study evaluates the clinical use of the RUBY modular QA phantom for linac QA to validate the integrity of IGRT workflows including the congruence of machine isocenter, imaging isocenter, and room lasers. The results have been benchmarked against those obtained with widely used systems. Additionally, the RUBY phantom has been implemented to perform system QA (End-to-End testing) from imaging to radiation for IGRT-based VMAT and stereotactic radiations at an Elekta Synergy linac. MATERIAL AND METHODS: The daily check of IGRT workflow was performed using the RUBY phantom, the Penta-Guide, and the STEEV phantom. Furthermore, Winston-Lutz tests was carried out with the RUBY phantom and a ball-bearing phantom to determine the offsets and the diameters of the isospheres of gantry, collimator, and couch rotations, with respect to the room lasers and kV-imaging isocenter. System QA was performed with the RUBY phantom and STEEV phantom for eight VMAT treatment plans. Additionally, the visibility of the embedded objects within these phantoms in the images and the results of CT and MR image fusions were evaluated. RESULTS: All systems used for daily QA of IGRT workflows show comparable results. Calculated shifts based on CBCT imaging agree within 1 mm to the expected values. The results of the Winston-Lutz test based on kV imaging (2D planar and CBCT) or room lasers are consistent regardless of the system tested. The point dose values in the RUBY phantom agree to the expected values calculated using algorithms in Masterplan and Monte Carlo engine in Monaco within 3% of the clinical acceptance criteria. CONCLUSION: All the systems evaluated in this study yielded comparable results in terms of linac QA and system QA procedures. A system QA protocol has been derived using the RUBY phantom to check the IGRT-based VMAT and stereotactic radiations workflow at an Elekta Synergy linac.

Computed tomography dosimetry with high-resolution detectors commonly used in radiotherapy - an energy dependence study.

New methods of dosimetry in computed tomography (CT) X-ray fields require the use of high-resolution detectors instead of pencil-type ionization chambers typically used for CT dose index (CTDI) measurements. This paper presents a study on the suitability of a wide range of ionization chambers, diodes, and a two-dimensional detector array, used primarily in radiation therapy, for CT and cone-beam CT dosimetry. Specifically, the energy dependence of these detectors from 50 kVp up to 125 kVp is reported. All measurements were performed in reference to a calibrated diode for use in this energy region. The radiation quality correction factors provided by the manufacturer were used, depending on the measured half-value layer (HVL) for the particular X-ray beam. Our study demonstrated the general usability of thimble ionization chambers. These thimble ionization chambers showed a maximum variation in energy response of 5%. Ionization chambers with even smaller sensitive volume, and which exhibit similar variation in energy dependence, can be used if higher spatial resolution is required. Furthermore, the investigated detectors are better suited for dosimetry at CT and CBCT units than conventional large volume or flat detectors, due to their rotational symmetry. Nevertheless, a flat detector can be used for certain measurement tasks, such as the acquisition of percent depth-dose curves or beam profiles for nonrotating beams, which are important for beam characterization.

[Detector Based Determination of Water Absorbed Dose According to DIN 6800 Teil 1: Suggestion for an Extension of the Fundamental Formalism]. / Ermittlung der Wasser-Energiedosis nach der Sondenmethode gemäß DIN 6800 Teil 1: Vorschlag für eine Erweiterung der Grundgleichung.

For any detector to be used for the determination of absorbed dose at the point of measurement in water a basic equation is required to convert the reading of the detector into absorbed dose in water. The German DIN 6800 part 1 provides a general formalism for that. A further differentiated formalism applicable to photon dosimetry is suggested in this work. This modified formalism presents the two following still general and at the same time fundamental properties of any dosimetry detector: a) a clear distinction of correction factors with respect to the physical processes involved during the measurement, and b) the fact that the process of energy absorption in the detector is determined by the spectral distribution of the fluence of the secondary charged particles. It is concluded that based on the modified formalism and knowing this spectral distribution within the detector a general method is available with benefits for ionization chambers as well as for any other dosimetry detector and which is applicable at reference as well as non-reference conditions without any preconditions.

In vivo alanine/electron spin resonance (ESR) dosimetry in radiotherapy of prostate cancer: a feasibility study.

PURPOSE: We have developed a device to evaluate the potential of alanine/electron spin resonance (ESR) dosimetry for quality assurance in 3D conformal radiotherapy for prostate cancer. It consists of a rectal balloon carrying eight alanine dosimeter probes and two metal markers to document the exact position of the balloon. We measured the effects of an air-filled rectal balloon on the dose at the rectal wall and compared these results with the applied dose distribution of the treatment planning system. MATERIALS AND METHODS: During 10 fractions with 2.0 Gy per fraction, the accumulated doses were measured in 3 patients. The results of the ESR measurements were compared to the applied doses. RESULTS: It was possible to insert the device without clinical complications and without additional rectal discomfort for the patients. The measurements of the dose accumulated at the anterior and the posterior rectal wall agreed with the applied dose within a mean deviation of 1.5% (overestimation of the dose) and 3.5% (underestimation of the dose), respectively. However, clinically significant differences between applied and measured rectal doses were seen in a patient with a hip prosthesis. In this case, the dose at the anterior rectal wall was overestimated by the TPS by about 11% and the dose at the posterior rectal wall was underestimated by approximately 7%. CONCLUSION: The method presented in this study is useful for quality control of irradiations in vivo.

Dosimetric characteristics of an unshielded p-type Si diode: linearity, photon energy dependence and spatial resolution.

The unshielded Si diode PTW 60012, used for accurate measurements of the transversal dose profiles of narrow photon beams, has been investigated with regard to its linearity, photon energy dependence and spatial resolution. The diode shows a slight supralinearity, i.e., increase of the response with pulse dose, by 3% over the pulse dose range 0.1 to 0.8 mGy. In p-type silicon, supralinearity results from the increased chance for radiation-induced electrons to escape recombination when the pulse dose increases. Over the energy range from 6 to 15 MV, the response decreases by about 4%. This small variation of the response results from partial compensation between the influences of the secondary electron energy on the mass stopping power ratio silicon/water and on electron backscattering from the silicon chip. The lateral response function of the examined diode has a full half width of 1.3 mm. Dose profiles of 5 mm half-width can still be recorded with negligible error.

Efficacy and the toxicity of the interstitial high-dose-rate brachytherapy in the management of recurrent keloids: 5-year outcomes.

PURPOSE: Recurring keloids are a clinical challenge. Interdisciplinary treatments are required in most cases. Owing to the wide variety of concepts, the optimal treatment regime remains unclear. Our clinic established a protocol of perioperative interstitial high-dose-rate brachytherapy with three fractions of 6 Gy and achieved an excellent 2-year local control rate of 94% (In search of the optimal treatment of keloids: Report of a series and a review of the literature). This report is an update on our long-term results of prospective study. Twenty-nine patients were included with a median followup of 5 years. METHODS AND MATERIALS: From 2009 to 2015, 29 patients with 37 recurrent keloids were treated with perioperative interstitial high-dose-rate brachytherapy; 3 patients had been previously treated with adjuvant external beam radiotherapy and presented with recurrences in the pretreated area. Brachytherapy was given in three fractions with a single dose of 6 Gy in 5-mm tissue depth and covered the scar in total length. Followup visits were scheduled at 6 weeks, 3 months, 6 months, 1 year, and annually thereafter. Therapeutic outcome was assessed in terms of recurrence, acute and late complications, and cosmetic results. RESULTS: No procedure-related complications occurred. Improvement of keloid-related symptoms was noticed in all patients after treatment. After a median followup of 49.7 months (range: 7.9-91.9 months), three keloid recurrences and two hypertrophied scars were observed. CONCLUSIONS: Our results suggest that brachytherapy may be advantageous in the management of high-risk keloids, even after failure of external beam radiotherapy and other treatment procedures. Our three-fraction treatment schedule reduces the treatment period to 2 days and is therefore convenient for the patients.

Determination of the active volumes of solid-state photon-beam dosimetry detectors using the PTB proton microbeam.

PURPOSE: This study aims at the experimental determination of the diameters and thicknesses of the active volumes of solid-state photon-beam detectors for clinical dosimetry. The 10 MeV proton microbeam of the PTB (Physikalisch-Technische Bundesanstalt, Braunschweig) was used to examine two synthetic diamond detectors, type microDiamond (PTW Freiburg, Germany), and the silicon detectors Diode E (PTW Freiburg, Germany) and Razor Diode (Iba Dosimetry, Germany). The knowledge of the dimensions of their active volumes is essential for their Monte Carlo simulation and their applications in small-field photon-beam dosimetry. METHODS: The diameter of the active detector volume was determined from the detector current profile recorded by radially scanning the proton microbeam across the detector. The thickness of the active detector volume was determined from the detector's electrical current, the number of protons incident per time interval and their mean stopping power in the active volume. The mean energy of the protons entering this volume was assessed by comparing the measured and the simulated influence of the thickness of a stack of aluminum preabsorber foils on the detector signal. RESULTS: For all detector types investigated, the diameters measured for the active volume closely agreed with the manufacturers' data. For the silicon Diode E detector, the thickness determined for the active volume agreed with the manufacturer's data, while for the microDiamond detectors and the Razor Diode, the thicknesses measured slightly exceeded those stated by the manufacturers. DISCUSSION: The PTB microbeam facility was used to analyze the diameters and thicknesses of the active volumes of photon dosimetry detectors for the first time. A new method of determining the thickness values with an uncertainty of ±10% was applied. The results appear useful for further consolidating detailed geometrical knowledge of the solid-state detectors investigated, which are used in clinical small-field photon-beam dosimetry.

Interstitial high-dose-rate brachytherapy as salvage treatment for locally recurrent prostate cancer after definitive radiation therapy: Toxicity and 5-year outcome.

PURPOSE: We report our results with interstitial high-dose-rate brachytherapy (HDR-BT) as a salvage therapy option after external beam therapy with or without BT. Emphasis was put on toxicity and 5-year outcome. METHODS AND MATERIALS: From 2003 to 2011, 29 patients with local failure after previous radiotherapy for prostate cancer were treated with salvage interstitial HDR-BT. The diagnosis of local recurrence was made on the basis of choline positron emission tomography. Salvage HDR-BT was given in three fractions with a single dose of 10 Gy per fraction and weekly. The target volume covered the peripheral zone of the prostate and the positron emission tomography-positive area. Acute and late toxicities were documented according to common terminology criteria for adverse events (CTCAE v 4.0). RESULTS: Twenty-two patients with minimum followup of 60 months were analyzed. The 5-year overall survival was 95.5% with a disease-specific survival of 100%. The 5-year biochemical control was 45%. Late grade 2 gastrointestinal toxicities were observed in two patients (9%). No grade 3 or higher gastrointestinal late toxicities were observed. Urinary incontinence found in 2 patients (9%) and grade 2 obstruction of urinary tract occurred in one patient (4%). CONCLUSIONS: Interstitial HDR-BT was feasible and effective in the treatment of locally recurrent prostate cancer after definitive radiotherapy. The long-term toxicity was low and acceptable.

Two-dimensional ionization chamber arrays for IMRT plan verification.

In this paper we describe a concept for dosimetric treatment plan verification using two-dimensional ionization chamber arrays. Two different versions of the 2D-ARRAY (PTW-Freiburg, Germany) will be presented, a matrix of 16 x 16 chambers (chamber cross section 8 mm x 8 mm; the distance between chamber centers, 16 mm) and a matrix of 27 x 27 chambers (chamber cross section 5 mm x 5 mm; the distance between chamber centers is 10 mm). The two-dimensional response function of a single chamber is experimentally determined by scanning it with a slit beam. For dosimetric plan verification, the expected two-dimensional distribution of the array signals is calculated via convolution of the planned dose distribution, obtained from the treatment planning system, with the two-dimensional response function of a single chamber. By comparing the measured two-dimensional distribution of the array signals with the expected one, a distribution of deviations is obtained that can be subjected to verification criteria, such as the gamma index criterion. As an example, this verification method is discussed for one sequence of an IMRT plan. The error detection capability is demonstrated in a case study. Both versions of two-dimensional ionization chamber arrays, together with the developed treatment plan verification strategy, have been found to provide a suitable and easy-to-handle quality assurance instrument for IMRT.

Changes of the optical characteristics of radiochromic films in the transition from EBT3 to EBT-XD films.

A new type of radiochromic film, the EBT-XD film, has been introduced with the aim to reduce the orientation effect and the lateral response artifact occurring in the use of radiochromic films together with flatbed scanners. The task of the present study is to quantify the changes of optical characteristics involved with the transition from the well-known EBT3 films to the new EBT-XD films, using the optical bench arrangement already applied by Schoenfeld et al (2014 Phys. Med. Biol. 59 3575-97). Largely reduced polarization effects and the almost complete loss of the anisotropy of the scattered light produced in a radiation-exposed film have been observed. The Rayleigh-Debye-Gans theory is used to understand these optical changes as arising from the reduced length-to-width ratio of the LiPCDA polymer crystals in the active layer of the EBT-XD film. The effect of these changes on the flatbed scanning artifacts will be shortly addressed, but treated in more detail in a further paper.

The origin of the flatbed scanner artifacts in radiochromic film dosimetry-key experiments and theoretical descriptions.

The optical origin of the lateral response and orientation artifacts, which occur when using EBT3 and EBT-XD radiochromic films together with flatbed scanners, has been reinvestigated by experimental and theoretical means. The common feature of these artifacts is the well-known parabolic increase in the optical density OD(x) = -log10 I(x)/I 0(x) versus offset x from the scanner midline (Poppinga et al 2014 Med. Phys. 41 021707). This holds for landscape and portrait orientations as well as for the three color channels. Dose-independent optical subjects, such as neutral density filters, linear polarizers, the EBT polyester foil and diffusive glass, also present the parabolic lateral artifact when scanned with a flatbed scanner. The curvature parameter c of the parabola function OD(x) = c 0 + cx 2 is found to be a linear function of the dose, the parameters of which are influenced by the film orientation and film type, EBT3 or EBT-XD. The ubiquitous parabolic shape of function OD(x) is attributed (a) to the optical path-length effect (van Battum et al 2016 Phys. Med. Biol. 61 625-49), due to the increasing obliquity of the optical scanner light associated with increasing offset x from the scanner midline, and (b) and (c) to the partial polarization and scattering of the light leaving the film, which affect the ratio [Formula: see text], thus making OD(x) increase with x 2. The orientation effect results from the changes of effects (b) and (c) associated with turning the film position, and thereby the orientation of the polymer structure of the sensitive film layer. In a comparison of experimental results obtained with selected optical subjects, the relative weights of the contributions of the optical path-length effect and the polarization and scattering of light leaving the films to the lateral response artifact have been estimated to be of the same order of magnitude. Mathematical models of these causes for the parabolic shape of function OD(x) are given as appendices.

The artefacts of radiochromic film dosimetry with flatbed scanners and their causation by light scattering from radiation-induced polymers.

Optical experiments and theoretical considerations have been undertaken in order to understand the causes of the 'orientation effect' and the 'parabola effect', the artefacts impairing the desired light absorption measurement on radiochromic EBT3 films with flatbed scanners. EBT3 films exposed to doses up to 20.9 Gy were scanned with an Epson Expression 10000XL flatbed scanner in landscape and portrait orientation. The horizontally and vertically polarized light components of the scanner were determined, and another Epson Expression 10000XL flatbed scanner was disassembled to examine its optical components. The optical properties of exposed and unexposed EBT3 films were studied with incident polarized and unpolarized white light, and the transmitted red light was investigated for its polarization and scattering properties including the distribution of the scattering angles. Neutral density filters were studied for comparison. Guidance was sought from the theory of light scattering from rod-like macromolecular structures. The drastic dose-dependent variation of the transmitted total light current as function of the orientation of front and rear polarizers, interpreted by light scattering theory, shows that the radiation-induced polymerization of the monomers of EBT3 films produces light scattering oscillators preferably polarized at right angles with the coating direction of the film. The directional distribution of the scattered light is partly anisotropic, with a preferred scattering plane at right angles with the coating direction, indicating light scattering from stacks of coherently vibrating oscillators piled up along the monomer crystals. The polyester carrier film also participates in these effects. The 'orientation' and 'parabola' artefacts due to flatbed scanning of radiochromic films can be explained by the interaction of the polarization-dependent and anisotropic light scattering from exposed and unexposed EBT3 films with the quantitative difference between the scanner's horizontally and vertically polarized light supply and with the limited directional acceptance of the scanner's light recording system.