Pharyngeal Constrictor Dose-Volume Histogram Metrics and Patient-Reported Dysphagia in Head and Neck Radiotherapy.

AIMS: Head and neck radiotherapy long-term survival continues to improve and the management of long-term side-effects is moving to the forefront of patient care. Dysphagia is associated with dose to the pharyngeal constrictors and can be measured using patient-reported outcomes to evaluate its effect on quality of life. The aim of the present study was to relate pharyngeal constrictor dose-volume parameters with patient-reported outcomes to identify prognostic dose constraints. MATERIALS AND METHODS: A 64-patient training cohort and a 24-patient testing cohort of oropharynx and nasopharynx cancer patients treated with curative-intent chemoradiotherapy were retrospectively examined. These patients completed the MD Anderson Dysphagia Inventory outcome survey at 12 months post-radiotherapy to evaluate late dysphagia: a composite score lower than 60 indicated dysphagia. The pharyngeal constrictor muscles were subdivided into four substructures: superior, middle, inferior and cricopharyngeal. Dose-volume histogram (DVH) metrics for each of the structure combinations were extracted. A decision tree classifier was run for each DVH metric to identify dose constraints optimising the accuracy and sensitivity of the cohort. A 60% accuracy threshold and feature selection method were used to ensure statistically significant DVH metrics were identified. These dose constraints were then validated on the 24-patient testing cohort. RESULTS: Existing literature dose constraints only had two dose constraints performing above 60% accuracy and sensitivity when evaluated on our training cohort. We identified two well-performing dose constraints: the pharyngeal constrictor muscle D63% < 55 Gy and the superior-middle pharyngeal constrictor combination structure V31Gy < 100%. Both dose constraints resulted in ≥73% mean accuracy and ≥80% mean sensitivity on the training and testing patient cohorts. In addition, a pharyngeal constrictor muscle mean dose <57 Gy resulted in a mean accuracy ≥74% and mean sensitivity ≥60%. CONCLUSION: Mid-dose pharyngeal constrictor muscle and substructure combination dose constraints should be used in the treatment planning process to reduce late patient-reported dysphagia.

Dosimetric effects of polyethylene glycol surface coatings on gold nanoparticle radiosensitization.

One of the main appeals of using gold nanoparticles (GNPs) as radiosensitizers is that their surface coatings can be altered to manipulate their pharmacokinetic properties. However, Monte Carlo studies of GNP dosimetry tend to neglect these coatings, potentially changing the dosimetric results. This study quantifies the dosimetric effects of including a polyethylene glycol (PEG) surface coating on GNPs over both nanoscopic and microscopic ranges. Two dosimetric scales were explored using PENELOPE Monte Carlo simulations. In microscopic simulations, 500-1000 GNPs, with and without coatings, were placed in cavities of side lengths 0.8-4 µm, and the reduction of dose deposited to surrounding medium within these volumes due to the coating was quantified. Including PEG surface coatings of up to 20 nm thickness resulted in reductions of up to 7.5%, 4.0%, and 2.0% for GNP diameters of 10, 20, and 50 nm, respectively. Nanoscopic simulations observed the dose falloff in the first 500 nm surrounding a single GNP both with and without surface coatings of various thicknesses. Over the first 500 nm surrounding a single GNP, the presence of a PEG surface coating reduced dose by 5-26%, 8-28%, 8-30%, and 8-34% for 2, 10, 20, and 50 nm diameter GNPs, respectively, for various energies and coating thicknesses. Reductions in dose enhancement due to the inclusion of a GNP surface coating are non-negligible and should be taken into consideration when investigating GNP dose enhancement. Further studies should be carried out to investigate the biological effects of these coatings.

Safety and efficacy of paramedic treatment of regular supraventricular tachycardia: a randomised controlled trial.

INTRODUCTION: Supraventricular tachycardias (SVTs) are a common cause of acute hospital presentations. Adenosine is an effective treatment. To date, no studies have directly compared paramedic-with hospital-delivered treatment of acute SVT with adenosine. METHOD: Randomised controlled trial comparing the treatment of SVT and discharge by paramedics with conventional emergency department (ED)-based care. Patients were excluded if they had structural heart disease or contraindication to adenosine. Discharge time, follow-up management, costs and patient satisfaction were compared. RESULTS: Eighty-six patients were enrolled: 44 were randomised to paramedic-delivered adenosine (PARA) and 42 to conventional care (ED). Of the 37 patients in the PARA group given adenosine, the tachycardia was successfully terminated in 81%. There was a 98% correlation between the paramedics' ECG diagnosis and that of two electrophysiologists. No patients had any documented adverse events in either group. The discharge time was lower in the PARA group than in the ED group (125 min (range 55-9513) vs 222 min (range 72-26 153); p=0.01), and this treatment strategy was more cost-effective (£282 vs £423; p=0.01). The majority of patients preferred this management approach. Being treated and discharged by paramedics did not result in the patients being less likely to receive ongoing management of their arrhythmia and cardiology follow-up. CONCLUSIONS: Patients with SVT can effectively and safely be treated with adenosine delivered by trained paramedics. Implementation of paramedic-delivered acute SVT care has the potential to reduce healthcare costs without compromising patient care. TRIAL REGISTRATION NUMBER: NCT02216240.

Optimization of photon beam energies in gold nanoparticle enhanced arc radiation therapy using Monte Carlo methods.

As a recent area of development in radiation therapy, gold nanoparticle (GNP) enhanced radiation therapy has shown potential to increase tumour dose while maintaining acceptable levels of healthy tissue toxicity. In this study, the effect of varying photon beam energy in GNP enhanced arc radiation therapy (GEART) is quantified through the introduction of a dose scoring metric, and GEART is compared to a conventional radiotherapy treatment. The PENELOPE Monte Carlo code was used to model several simple phantoms consisting of a spherical tumour containing GNPs (concentration: 15 mg Au g-1 tumour, 0.8 mg Au g-1 normal tissue) in a cylinder of tissue. Several monoenergetic photon beams, with energies ranging from 20 keV to 6 MeV, as well as 100, 200, and 300 kVp spectral beams, were used to irradiate the tumour in a 360° arc treatment. A dose metric was then used to compare tumour and tissue doses from GEART treatments to a similar treatment from a 6 MV spectrum. This was also performed on a simulated brain tumour using patient computed tomography data. GEART treatments showed potential over the 6 MV treatment for many of the simulated geometries, delivering up to 88% higher mean dose to the tumour for a constant tissue dose, with the effect greatest near a source energy of 50 keV. This effect is also seen with the inclusion of bone in a brain treatment, with a 14% increase in mean tumour dose over 6 MV, while still maintaining acceptable levels of dose to the bone and brain.

Interpreting short and medium exposure etched-track radon measurements to determine whether an action level could be exceeded.

Radon gas is naturally occurring, and can concentrate in the built environment. It is radioactive and high concentration levels within buildings, including homes, have been shown to increase the risk of lung cancer in the occupants. As a result, several methods have been developed to measure radon. The long-term average radon level determines the risk to occupants, but there is always pressure to complete measurements more quickly, particularly when buying and selling the home. For many years, the three-month exposure using etched-track detectors has been the de facto standard, but a decade ago, Phillips et al. (2003), in a DEFRA funded project, evaluated the use of 1-week and 1-month measurements. They found that the measurement methods were accurate, but the challenge lay in the wide variation in radon levels - with diurnal, seasonal, and other patterns due to climatic factors and room use. In the report on this work, and in subsequent papers, the group proposed methodologies for 1-week, 1-month and 3-month measurements and their interpretation. Other work, however, has suggested that 2-week exposures were preferable to 1-week ones. In practice, the radon remediation industry uses a range of exposure times, and further guidance is required to help interpret these results. This paper reviews the data from this study and a subsequent 4-year study of 4 houses, re-analysing the results and extending them to other exposures, particularly for 2-week and 2-month exposures, and provides comprehensive guidance for the use of etched-track detectors, the value and use of Seasonal Correction Factors (SCFs), the uncertainties in short and medium term exposures and the interpretation of results.

A method for converting dose-to-medium to dose-to-tissue in Monte Carlo studies of gold nanoparticle-enhanced radiotherapy.

Gold nanoparticles (GNPs) have shown potential in recent years as a means of therapeutic dose enhancement in radiation therapy. However, a major challenge in moving towards clinical implementation is the exact characterisation of the dose enhancement they provide. Monte Carlo studies attempt to explore this property, but they often face computational limitations when examining macroscopic scenarios. In this study, a method of converting dose from macroscopic simulations, where the medium is defined as a mixture containing both gold and tissue components, to a mean dose-to-tissue on a microscopic scale was established. Monte Carlo simulations were run for both explicitly-modeled GNPs in tissue and a homogeneous mixture of tissue and gold. A dose ratio was obtained for the conversion of dose scored in a mixture medium to dose-to-tissue in each case. Dose ratios varied from 0.69 to 1.04 for photon sources and 0.97 to 1.03 for electron sources. The dose ratio is highly dependent on the source energy as well as GNP diameter and concentration, though this effect is less pronounced for electron sources. By appropriately weighting the monoenergetic dose ratios obtained, the dose ratio for any arbitrary spectrum can be determined. This allows complex scenarios to be modeled accurately without explicitly simulating each individual GNP.

RBE of kV CBCT radiation determined by Monte Carlo DNA damage simulations.

Due to the higher LET of kilovoltage (kV) radiation, there is potential for an increase in relative biological effectiveness (RBE) of absorbed doses of radiation from kV cone beam computed tomography (CBCT) sources in reference to megavoltage or Co-60 doses. This work develops a method for accurately coupling a Monte Carlo (MC) radiation transport code (PENELOPE) with the damage simulation (MCDS) to predict relative numbers of DNA double strand breaks (DSBs). The MCDS accounts for slowing down of electrons and delta ray production within the cell nucleus; however, determining the spectrum of electrons incident on the cell nucleus from photons interacting in a larger region of tissue is not trivial. PENELOPE simulations were conducted with a novel tally algorithm invoked where electrons incident on a detection material were tracked and both the incident energy and the final deposited dose were recorded. The DSB yield predicted by a set of MCDS runs of monoenergetic electrons was then looked up in a table and weighted by the specific energy of the incident electron. Our results indicate that the RBE for DSB induction is 1.1 for diagnostic x-rays with energies from 80 to 125 kVp. We found no significant change in RBE with depth or filtration. The predicted absolute DSB yields are about three times lower for cells irradiated under anoxic conditions than the yield in cells irradiated under normoxic (5%) or fully aerobic (100%) conditions. However, oxygen concentration has a negligible (± 0.02) effect on the RBE of kV CBCT x-rays.

The cost effectiveness of radon reduction programmes in domestic housing in England and Wales: the impact of improved radon mapping and housing trends.

In the UK, excessive levels of radon gas have been detected in domestic housing. Areas where 1% of existing homes were found to be over the Action Level of 200Bq·m(-3) were declared to be Radon Affected Areas. Building Regulations have been introduced which require that, for areas where between 3% and 10% of existing houses are above the Action Level, new homes should be built with basic radon protection using a membrane, and that, where 10% or more of existing homes exceed this level, new homes should be built with full radon protection. Initially these affected areas followed administrative boundaries, known as Counties. However, with increasing numbers of measurements of radon levels in domestic homes recorded in the national database, these areas have been successively refined into smaller units - 5km grid squares in 1999, down to 1km grid squares in 2007. One result is the identification of small areas with raised radon levels within regions where previously no problem had been identified. In addition, some parts of areas that were previously considered radon affected are now considered low, or no, risk. Our analysis suggests that the net result of improved mapping is to increase the number of affected houses. Further, the process is more complex for local builders, and inspectors, who need to work out whether radon protection in new homes is appropriate. Our group has assessed the cost-effectiveness of radon remediation programmes, and has applied this analysis to consider the cost-effectiveness of providing radon protection in both new and existing homes. This includes modelling the potential failure rate of membranes, and whether testing radon levels in new homes is appropriate. The analysis concludes that it is more cost effective to provide targeted radon protection in high radon areas, although this introduces more complexity. The paper also considers the trend in housing to a greater proportion of apartments, the regional variations in types of housing and the decreasing average number of occupants in each dwelling, and concludes that data and methods are now available to respond to the health risks of radon at a local level, in keeping with a general initiative to prioritise responses to health and social welfare issues at a more local level.

Skin dose in longitudinal and transverse linac-MRIs using Monte Carlo and realistic 3D MRI field models.

PURPOSE: The magnetic fields of linac-MR systems modify the path of contaminant electrons in photon beams, which alters patient skin dose. To accurately quantify the magnitude of changes in skin dose, the authors use Monte Carlo calculations that incorporate realistic 3D magnetic field models of longitudinal and transverse linac-MR systems. METHODS: Finite element method (FEM) is used to generate complete 3D magnetic field maps for 0.56 T longitudinal and transverse linac-MR magnet assemblies, as well as for representative 0.5 and 1.0 T Helmholtz MRI systems. EGSnrc simulations implementing these 3D magnetic fields are performed. The geometry for the BEAMnrc simulations incorporates the Varian 600C 6 MV linac, magnet poles, the yoke, and the magnetic shields of the linac-MRIs. Resulting phase-space files are used to calculate the central axis percent depth-doses in a water phantom and 2D skin dose distributions for 70 µm entrance and exit layers using DOSXYZnrc. For comparison, skin doses are also calculated in the absence of magnetic field, and using a 1D magnetic field with an unrealistically large fringe field. The effects of photon field size, air gap (longitudinal configuration), and angle of obliquity (transverse configuration) are also investigated. RESULTS: Realistic modeling of the 3D magnetic fields shows that fringe fields decay rapidly and have a very small magnitude at the linac head. As a result, longitudinal linac-MR systems mostly confine contaminant electrons that are generated in the air gap and have an insignificant effect on electrons produced further upstream. The increase in the skin dose for the longitudinal configuration compared to the zero B-field case varies from ∼1% to ∼14% for air gaps of 5-31 cm, respectively. (All dose changes are reported as a % of D(max).) The increase is also field-size dependent, ranging from ∼3% at 20 × 20 cm(2) to ∼11% at 5 × 5 cm(2). The small changes in skin dose are in contrast to significant increases that are calculated for the unrealistic 1D magnetic field. For the transverse configuration, the entrance skin dose is equal or smaller than that of the zero B-field case for perpendicular beams. For a 10 × 10 cm(2) oblique beam the transverse magnetic field decreases the entry skin dose for oblique angles less than ±20° and increases it by no more than 10% for larger angles up to ±45°. The exit skin dose is increased by 42% for a 10 × 10 cm(2) perpendicular beam, but appreciably drops and approaches the zero B-field case for large oblique angles of incidence. CONCLUSIONS: For longitudinal linac-MR systems only a small increase in the entrance skin dose is predicted, due to the rapid decay of the realistic magnetic fringe fields. For transverse linac-MR systems, changes to the entrance skin dose are small for most scenarios. For the same geometry, on the exit side a fairly large increase is observed for perpendicular beams, but significantly drops for large oblique angles of incidence. The observed effects on skin dose are not expected to limit the application of linac-MR systems in either the longitudinal or transverse configuration.

Clinical consequences of changing the sliding window IMRT dose rate.

Changing pulse repetition frequency or dose rate used for IMRT treatments can alter the number of monitor units (MUs) and the time required to deliver a plan. This work was done to develop a practical picture of the magnitude of these changes. We used Varian's Eclipse Treatment Planning System to calculate the number of MUs and beam-on times for a total of 40 different treatment plans across an array of common IMRT sites including prostate/pelvis, prostate bed, head and neck, and central nervous system cancers using dose rates of 300, 400 and 600 MU/min. In general, we observed a 4%-7% increase in the number of MUs delivered and a 10-40 second decrease in the beam-on time for each 100 MU/min of dose rate increase. The increase in the number of MUs resulted in a reduction of the "beam-on time saved". The exact magnitude of the changes depended on treatment site and planning target volume. These changes can lead to minor, but not negligible, concerns with respect to radiation protection and treatment planning. Although the number of MUs increased more rapidly for more complex treatment plans, the absolute beam-on time savings was greater for these plans because of the higher total number of MUs required to deliver them. We estimate that increasing the IMRT dose rate from 300 to 600 MU/min has the potential to add up to two treatment slots per day for each IMRT linear accelerator. These results will be of value to anyone considering general changes to IMRT dose rates within their clinic.

WE-E-BRB-06: Monte Carlo Calculations of the Skin Dose for Longitudinal Linac-MR System Using Realistic Three-Dimensional Magnetic Field Modeling.

PURPOSE: This study quantifies the effects of the magnetic field of a longitudinal linac-MR system (B-field parallel to beam direction) on skin dose due to the confinement of contaminant electrons, using Monte Carlo calculations and realistic 3-D models of the magnetic field. METHODS: The complete realistic 3-D magnetic fields generated by the bi-planar Linac-MR magnet assembly are calculated with the finite element method using Opera- 3D. EGSnrc simulations are performed in the presence of ∼0.6T and IT MRI fields that have realistic rapid fall-off of the fringe field. The simulation geometry includes a Varian 600C 6MV linac, the yoke and magnetic shields of the MRIs, and features an isocentre distance of 126 cm. Phase spaces at the surface of a water phantom are scored using BEAMnrc; DOSXYZnrc is used to score the resulting CAX percent depth-doses in the phantom and the 2D skin dose distributions in the first 70 urn layer. For comparison, skin doses are also calculated in the absence of magnetic field and using a 1-D magnetic field with an unrealistic fringe field. The effects of field size and air gap (between phantom surface and magnet pole) are also examined. RESULTS: Analysis of the phase-space and dose distributions reveals that significant containment of electrons occurs primarily close to the uniform magnetic field region. The increase in skin dose due to the magnetic field depends on the air gap, varying from 1% to 13% for air gaps of 5 to 31 cm, respectively. The increase is also field-size dependent, varying from 3% at 20×20 cm2 to 11% at 5×5 cm2. CONCLUSIONS: Calculations based on various realistic MRI 3D magnetic-field maps that appropriately account for the rapid decay of the fringe field show that the increase in the patient skin dose of a longitudinal Linac-MR system is clinically insignificant.

Sci-Sat AM: Brachy - 06: Monte carlo DNA damage simulations of kV cbct radiation.

When performed daily, cone beam CT (CBCT) images can accumulate radiation dose to non-negligible levels. Because kV x-rays have a larger relative biological effectiveness (RBE) than its MV x-rays, the accumulated absorbed dose needs to be multiplied by an appropriate RBE to better evaluate the impact of CBCT dose in a treatment planning context. We investigated this question using PENLEOPE simulations to look in detail at the electron energy spectra produced by kV x-rays and Co-60 γ-rays in biologically motivated geometries. The electron spectra were input into the published Monte Carlo Damage Simulation (MCDS) and used to estimate the average number of double strand breaks (DSBs) per Gy per cell. Our results suggest an approximately 10% increase in the RBE for DSB induction. For the majority of treatment planning scenarios where imaging dose is only a small fraction of the total delivered dose to target volumes and organs at risk, the increase in RBE is not critical to be factored in, however for it may play a significant role in predicting the induction of secondary cancers.

Poster - Thur Eve - 55: Monte Carlo simulations of variations in planned dose distributions in a prostate patient population.

Clinical outcome studies with clear and objective endpoints are necessary to make informed radiotherapy treatment decisions. Commonly, clinical outcomes are established after lengthy and costly clinical trials are performed and the data are analyzed and published. One the challenges with obtaining meaningful data from clinical trials is that by the time the information gets to the medical profession the results may be less clinically relevant than when the trial began, An alternative approach is to estimate clinical outcomes through patient population modeling. We are developing a mathematical tool that uses Monte Carlo techniques to simulate variations in planned and delivered dose distributions of prostate patients receiving radiotherapy. Ultimately, our simulation will calculate a distribution of Tumor Control Probabilities (TCPs) for a population of patients treated under a given protocol. Such distributions can serve as a metric for comparing different treatment modalities, planning and setup approaches, and machine parameter settings or tolerances with respect to outcomes on broad patient populations. It may also help researchers understand differences one might expect to find before actually doing the clinical trial. As a first step and for the focus of this abstract we wanted to see if we could answer the question: "Can a population of dose distributions of prostate patients be accurately modeled by a set of randomly generated Gaussian functions?" Our results have demonstrated that using a set of randomly generated Gaussian functions can simulate a distribution of prostate patients.

Lung-cancer reduction from smoking cessation and radon remediation: a preliminary cost-analysis in Northamptonshire, UK.

Domestic radon levels in parts of the United Kingdom are sufficiently high as to increase the risk of lung-cancer among residents. Public health campaigns in the county of Northamptonshire, a designated radon Affected Area with 6.3% of homes having average radon levels in excess of the UK Action Level of 200 Bq m(-3), have encouraged householders to test for radon and then, if indicated to be necessary, to carry out remediation in their homes. These campaigns have been only partially successful, since to date only 40% of Northamptonshire houses have been tested, and only 15% of those householders finding raised levels have proceeded to remediate. Those who remediate have been shown to have smaller families, to be older, and to include fewer smokers than the average population, suggesting that current strategies to reduce domestic radon exposure are not reaching those most at risk. During 2004-2005, the NHS Stop-Smoking Services in Northamptonshire assisted 2847 smokers to quit to the 4-week stage, the 15% (435) of these 4-week quitters remaining quitters at 1year forming the subjects of a retrospective study considering whether smoking cessation campaigns contribute significantly to radon risk reduction. Quantitative assessment of the risk of lung-cancer among the study population, from knowledge of the individuals' age, gender, and smoking habits, together with the radon levels in their homes, demonstrates that smoking cessation programmes have significant added value in reducing the incidence of lung-cancer in radon Affected Areas, and contribute a substantially greater health benefit at a lower cost than the alternative strategy of reducing radon levels in the smokers' homes, while they remain smokers. Both radon remediation and smoking cessation programmes are very cost effective in Northamptonshire, with smoking cessation being significantly more cost effective, and these are potentially valuable programmes to drive health improvements through promotion of the uptake or environmental management for radon in the home.

Lung dosimetry in a linac-MRI radiotherapy unit with a longitudinal magnetic field.

PURPOSE: There is interest in developing linac-MR systems for MRI-guided radiation therapy. To date, the designs for such linac-MR devices have been restricted to a transverse geometry where the static magnetic field is oriented perpendicular to the direction of the incident photon beam. This work extends possibilities in this field by proposing and examining by Monte Carlo simulations, a probable longitudinal configuration where the magnetic field is oriented in the same direction as the photon beam. METHODS: The EGSnrc Monte Carlo (MC) radiation transport codes with algorithms implemented to account for the magnetic field deflection of charged particles were used to compare dose distributions for linac-MR systems in transverse and longitudinal geometries. Specifically, the responses to a 6 MV pencil photon beam incident on water and lung slabs were investigated for 1.5 and 3.0 T magnetic fields. Further a five field lung plan was simulated in the longitudinal and transverse geometries across a range of magnetic field strengths from 0.2 through 3.0 T. RESULTS: In a longitudinal geometry, the magnetic field is shown to restrict the radial spread of secondary electrons to a small degree in water, but significantly in low density tissues such as lung in contrast to the lateral shift in dose distribution seen in the transverse geometry. These effects extend to the patient case, where the longitudinal configuration demonstrated dose distributions more tightly confined to the primary photon fields, which increased dose to the planning target volume (PTV), bettered dose homogeneity within a heterogeneous (in density) PTV, and reduced the tissue interface effects associated with the transverse geometry. CONCLUSIONS: Dosimetry issues observed in a transverse linac-MR geometry such as changes to the depth dose distribution and tissue interface effects were significantly reduced or eliminated in a longitudinal geometry on a representative lung plan. Further, an increase in dose to the PTV, resulting from the magnetic field confining electrons to the forward direction, shows potential for a reduction in dose to the surrounding tissues.

An integrated 6 MV linear accelerator model from electron gun to dose in a water tank.

PURPOSE: The details of a full simulation of an inline side-coupled 6 MV linear accelerator (linac) from the electron gun to the target are presented. Commissioning of the above simulation was performed by using the derived electron phase space at the target as an input into Monte Carlo studies of dose distributions within a water tank and matching the simulation results to measurement data. This work is motivated by linac-MR studies, where a validated full linac simulation is first required in order to perform future studies on linac performance in the presence of an external magnetic field. METHODS: An electron gun was initially designed and optimized with a 2D finite difference program using Child's law. The electron gun simulation served as an input to a 6 MV linac waveguide simulation, which consisted of a 3D finite element radio-frequency field solution within the waveguide and electron trajectories determined from particle dynamics modeling. The electron gun design was constrained to match the cathode potential and electron gun current of a Varian 600C, while the linac waveguide was optimized to match the measured target current. Commissioning of the full simulation was performed by matching the simulated Monte Carlo dose distributions in a water tank to measured distributions. RESULTS: The full linac simulation matched all the electrical measurements taken from a Varian 600C and the commissioning process lead to excellent agreements in the dose profile measurements. Greater than 99% of all points met a 1%/1mm acceptance criterion for all field sizes analyzed, with the exception of the largest 40 x 40 cm2 field for which 98% of all points met the 1%/1mm acceptance criterion and the depth dose curves matched measurement to within 1% deeper than 1.5 cm depth. The optimized energy and spatial intensity distributions, as given by the commissioning process, were determined to be non-Gaussian in form for the inline side-coupled 6 MV linac simulated. CONCLUSIONS: An integrated simulation of an inline side-coupled 6 MV linac has been completed and benchmarked matching all electrical and dosimetric measurements to high accuracy. The results showed non-Gaussian spatial intensity and energy distributions for the linac modeled.

Relative biological damage and electron fluence in and out of a 6 MV photon field.

Scattered radiation in the penumbra of a megavoltage radiation therapy beam can deposit a non-negligible dose in the healthy tissue around a target volume. The lower energy of the radiation in this region suggests that its biological effectiveness might not be the same as that of the open beam. In this work, we determined the relative biological damage in normal human fibroblasts after megavoltage irradiation in two geometries. The first was an open-beam irradiation and the second was a blocked configuration in which only scattered radiation could reach the target cells. The biological damage was evaluated by the gamma-H2AX immunofluorescence assay, which is capable of detecting DNA double-strand breaks in individual cells. We report that the scattered radiation is more effective at producing biological damage than the open beam radiation. We found a 27% enhancement in the net mean nuclear gamma-H2AX fluorescence intensity at 2 Gy and a 48% enhancement at 4 Gy. These findings are of interest due to the increased doses of penumbral radiation close to target volumes both in dose escalation studies and in IMRT treatment deliveries where high dose gradients exist for the purpose of conformal avoidance of healthy tissues.