Evaluation and improvement of angular response for a commercial 2D detector array for patient-specific QA.

PURPOSE: MatriXX ionization chamber array has been widely used for the composite dose verification of IMRT/VMAT plans. However, in addition to its dose response dependence on gantry angle, there seems to be an offset between the beam axis and measured dose profile by MatriXX for oblique beam incidence at various gantry angles, leading to unnecessary quality assurance (QA) fails. In this study, we investigated the offset at various setup conditions and how to eliminate or decrease it to improve the accuracy of MatriXX for IMRT/VMAT plan verification with original gantry angles. METHODS: We measured profiles for a narrow beam with MatriXX located at various depths in increments of 0.5 mm from the top to bottom of the sensitive volume of the array detectors and gantry angles from 0° to 360°. The optimal depth for QA measurement was determined at the depth where the measured profile had minimum offset. RESULTS: The measured beam profile offset varies with incident gantry angle, increasing from vertical direction to lateral direction, and could be over 3 cm at vendor-recommended depth for near lateral direction beams. The offset also varies with depth, and the minimum offset (almost 0 for most oblique beams) was found to be at a depth of ∼2.5 mm below the vendor suggested depth, which was chosen as the optimal depth for all QA measurements. Using the optimal depth we determined, QA results (3%/2 mm Gamma analysis) were largely improved with an average of 99.4% gamma passing rate (no fails for 95% criteria) for 10 IMRT and VMAT plans with original gantry angles compared to 94.1% using the vendor recommended depth. CONCLUSIONS: The improved accuracy and passing rate for QA measurement performed at the optimal depth with original gantry angles would lead to reduction in unnecessary repeated QA or plan changes due to QA system errors.

Determination of machine-specific tolerances using statistical process control analysis of long-term uniform scanning proton machine QA results.

PURPOSE: The purpose of this study was twofold: (a) report the long-term monthly quality assurance (QA) dosimetry results of the uniform scanning beam delivery system, and (b) derive the machine-specific tolerances based on the statistic process control (SPC) methodology and compare them against the AAPM TG224 recommended tolerances. METHODS: The Oklahoma Proton Center has four treatment rooms (TR1, TR2, TR3, and TR4) with a cyclotron and a universal nozzle. Monthly QA dosimetry results of four treatment rooms over a period of 6 yr (Feb 2014-Jan 2020) were retrieved from the QA database. The dosimetry parameters included dose output, range, flatness, and symmetry. The monthly QA results were analyzed using the SPC method, which included individuals and moving range (I-MR) chart. The upper control limit (UCL) and lower control limit (LCL) were set at 3σ above and below the mean value, respectively. RESULTS: The mean difference in dose output was -0.3% (2σ = ±0.9% and 3σ = ±1.3%) in TR1, 0% (2σ = ±1.4% and 3σ = ±2.1%) in TR2, -0.2% (2σ = ±1.0% and 3σ = ±1.6%) in TR3, and -0.5% (2σ = ±0.9% and 3σ = ±1.3%) in TR4. The mean flatness and symmetry differences of all beams among the four treatment rooms were within ±1.0%. The 3σ for the flatness difference ranged from ±0.5% to ±1.2%. The 3σ for the symmetry difference ranged from ±0.4% to ±1.4%. The SPC analysis showed that the 3σ for range 10 cm (R10), R16, and R22 were within ±1 mm, whereas the 3σ for R28 exceeded ±1 mm in two rooms (3σ = ±1.9 mm in TR2 and 3σ = ±1.3 mm in TR3). CONCLUSION: The 3σ of the dose output, flatness, and symmetry differences in all four rooms were comparable to the TG224 tolerance (±2%). For the uniform scanning system, if the measured range is compared against the requested range, it may not always be possible to achieve the range difference within ±1 mm (TG224) for all the ranges.

Dosimetric and radiobiological impact of intensity modulated proton therapy and RapidArc planning for high-risk prostate cancer with seminal vesicles.

INTRODUCTION: The purpose of this study was to evaluate the dosimetric and radiobiological impact of intensity modulated proton therapy (IMPT) and RapidArc planning for high-risk prostate cancer with seminal vesicles. METHODS: Ten high-risk prostate cancer cases were included in this retrospective study. For each case, IMPT plans were generated using multiple field optimisation (MFO) technique (two fields) with XiO treatment planning system (TPS), whereas RapidArc plans were generated using double-arc technique (two full arcs) with Eclipse TPS. IMPT and RapidArc plans were optimised for a total prescription dose of 79.2 Gy (relative biological effectiveness (RBE)) and 79.2 Gy, respectively, using identical dose-volume constraints. IMPT and RapidArc plans were then normalised such that at least 95% of the planning target volume (PTV) received the prescription dose. RESULTS: The mean and maximum PTV doses were comparable in IMPT plans (80.1 ± 0.3 Gy (RBE) and 82.6 ± 1.0 Gy (RBE) respectively) and RapidArc plans (80.3 ± 0.3 Gy and 82.8 ± 0.6 Gy respectively) with P = 0.088 and P = 0.499 respectively. The mean doses of the rectum and bladder were found to be significantly lower in IMPT plans (16.9 ± 5.8 Gy (RBE) and 17.5 ± 5.4 Gy (RBE) respectively) when compared to RapidArc plans (41.9 ± 5.7 Gy and 32.5 ± 7.8 Gy respectively) with P < 0.000 and P < 0.000 respectively. For the rectum, IMPT produced lower V30 (21.0 ± 9.6% vs. 68.5 ± 10.0%; P < 0.000), V50 (14.3 ± 5.8% vs. 45.0 ± 10.0%; P < 0.000) and V70 (6.9 ± 3.4% vs. 12.8 ± 3.6%; P < 0.000) compared to RapidArc. For the bladder, IMPT produced lower V30 (23.2 ± 7.0% vs. 50.9 ± 15.6%; P < 0.000) and V50 (16.6 ± 5.4% vs. 25.1 ± 9.6%; P = 0.001), but similar V70 (9.7 ± 3.5% vs. 10.5 ± 4.2%; P = 0.111) compared to RapidArc. RapidArc produced lower mean dose for both the right femoral head (19.5 ± 4.2 Gy vs. 27.4 ± 4.5 Gy (RBE); P < 0.000) and left femoral head (18.0 ± 4.3 Gy vs. 28.0 ± 5.6 Gy (RBE); P < 0.000). Both IMPT and RapidArc produced comparable bladder normal tissue complication probability (NTCP) (0.6 ± 0.2% vs. 0.5 ± 0.2%; P = 0.152). The rectal NTCP was found to be lower using IMPT (0.8 ± 0.7%) than using RapidArc (1.7 ± 0.7%) with P < 0.000. CONCLUSION: Both IMPT and RapidArc techniques provided comparable mean and maximum PTV doses. For the rectum, IMPT produced better dosimetric results in the low-, medium- and high-dose regions and lower NTCP compared to RapidArc. For the bladder, the NTCP and dosimetric results in the high-dose region were comparable in both sets of plans, whereas IMPT produced better dosimetric results in the low- and medium-dose regions.

An end-to-end assessment of range uncertainty in proton therapy using animal tissues.

Accurate assessment of range uncertainty is critical in proton therapy. However, there is a lack of data and consensus on how to evaluate the appropriate amount of uncertainty. The purpose of this study is to quantify the range uncertainty in various treatment conditions in proton therapy, using transmission measurements through various animal tissues. Animal tissues, including a pig head, beef steak, and lamb leg, were used in this study. For each tissue, an end-to-end test closely imitating patient treatments was performed. This included CT scan simulation, treatment planning, image-guided alignment, and beam delivery. Radio-chromic films were placed at various depths in the distal dose falloff region to measure depth dose. Comparisons between measured and calculated doses were used to evaluate range differences. The dose difference at the distal falloff between measurement and calculation depends on tissue type and treatment conditions. The estimated range difference was up to 5, 6 and 4 mm for the pig head, beef steak, and lamb leg irradiation, respectively. Our study shows that the TPS was able to calculate proton range within about 1.5% plus 1.5 mm. Accurate assessment of range uncertainty in treatment planning would allow better optimization of proton beam treatment, thus fully achieving proton beams' superior dose advantage over conventional photon-based radiation therapy.

Minimizing treatment planning errors in proton therapy using failure mode and effects analysis.

PURPOSE: Failure mode and effects analysis (FMEA) is a widely used tool to evaluate safety or reliability in conventional photon radiation therapy. However, reports about FMEA application in proton therapy are scarce. The purpose of this study is to apply FMEA in safety improvement of proton treatment planning at their center. METHODS: The authors performed an FMEA analysis of their proton therapy treatment planning process using uniform scanning proton beams. The authors identified possible failure modes in various planning processes, including image fusion, contouring, beam arrangement, dose calculation, plan export, documents, billing, and so on. For each error, the authors estimated the frequency of occurrence, the likelihood of being undetected, and the severity of the error if it went undetected and calculated the risk priority number (RPN). The FMEA results were used to design their quality management program. In addition, the authors created a database to track the identified dosimetric errors. Periodically, the authors reevaluated the risk of errors by reviewing the internal error database and improved their quality assurance program as needed. RESULTS: In total, the authors identified over 36 possible treatment planning related failure modes and estimated the associated occurrence, detectability, and severity to calculate the overall risk priority number. Based on the FMEA, the authors implemented various safety improvement procedures into their practice, such as education, peer review, and automatic check tools. The ongoing error tracking database provided realistic data on the frequency of occurrence with which to reevaluate the RPNs for various failure modes. CONCLUSIONS: The FMEA technique provides a systematic method for identifying and evaluating potential errors in proton treatment planning before they result in an error in patient dose delivery. The application of FMEA framework and the implementation of an ongoing error tracking system at their clinic have proven to be useful in error reduction in proton treatment planning, thus improving the effectiveness and safety of proton therapy.

Impact of grid size on uniform scanning and IMPT plans in XiO treatment planning system for brain cancer.

The main purposes of this study are to: 1) evaluate the accuracy of XiO treatment planning system (TPS) for different dose calculation grid size based on head phan-tom measurements in uniform scanning proton therapy (USPT); and 2) compare the dosimetric results for various dose calculation grid sizes based on real computed tomography (CT) dataset of pediatric brain cancer treatment plans generated by USPT and intensity-modulated proton therapy (IMPT) techniques. For phantom study, we have utilized the anthropomorphic head proton phantom provided by Imaging and Radiation Oncology Core (IROC). The imaging, treatment planning, and beam delivery were carried out following the guidelines provided by the IROC. The USPT proton plan was generated in the XiO TPS, and dose calculations were performed for grid size ranged from 1 to 3 mm. The phantom containing thermoluminescent dosimeter (TLDs) and films was irradiated using uniform scanning proton beam. The irradiated TLDs were read by the IROC. The calculated doses from the XiO for different grid sizes were compared to the measured TLD doses provided by the IROC. Gamma evaluation was done by comparing calculated planar dose distribution of 3 mm grid size with measured planar dose distribution. Additionally, IMPT plan was generated based on the same CT dataset of the IROC phantom, and IMPT dose calculations were performed for grid size ranged from 1 to 3 mm. For comparative purpose, additional gamma analysis was done by comparing the planar dose distributions of standard grid size (3 mm) with that of other grid sizes (1, 1.5, 2, and 2.5 mm) for both the USPT and IMPT plans. For patient study, USPT plans of three pediatric brain cancer cases were selected. IMPT plans were generated for each of three pediatric cases. All patient treatment plans (USPT and IMPT) were generated in the XiO TPS for a total dose of 54 Gy (relative biological effectiveness [RBE]). Treatment plans (USPT and IMPT) of each case was recalculated for grid sizes of 1, 1.5, 2, and 2.5 mm; these dosimetric results were then compared with that of 3 mm grid size. Phantom study results: There was no distinct trend exhibiting the dependence of grid size on dose calculation accuracy when calculated point dose of different grid sizes were compared to the measured point (TLD) doses. On average, the calculated point dose was higher than the measured dose by 1.49% and 2.63% for the right and left TLDs, respectively. The gamma analysis showed very minimal differences among planar dose distributions of various grid sizes, with percentage of points meeting gamma index criteria 1% and 1 mm to be from 97.92% to 99.97%. The gamma evaluation using 2% and 2mm criteria showed both the IMPT and USPT plans have 100% points meeting the criteria. Patient study results: In USPT, there was no very distinct relationship between the absolute difference in mean planning target volume (PTV) dose and grid size, whereas in IMPT, it was found that the decrease in grid size slightly increased the PTV maximum dose and decreased the PTV mean dose and PTVD99% . For the PTV doses, the average differences were up to 0.35 Gy (RBE) and 1.47 Gy (RBE) in the USPT and IMPT plans, respectively. Dependency on grid size was not very clear for the organs at risk (OARs), with average difference ranged from -0.61 Gy (RBE) to 0.53 Gy (RBE) in the USPT plans and from -0.83 Gy (RBE) to 1.39 Gy (RBE) in the IMPT plans. In conclusion, the difference in the calculated point dose between the smallest grid size (1 mm) and the largest grid size (3 mm) in phantom for USPT was typically less than 0.1%. Patient study results showed that the decrease in grid size slightly increased the PTV maximum dose in both the USPT and IMPT plans. However, no distinct trend was obtained between the absolute difference in dosimetric parameter and dose calculation grid size for the OARs. Grid size has a large effect on dose calculation efficiency, and use of 2 mm or less grid size can increase the dose calculation time significantly. It is recommended to use grid size either 2.5 or 3 mm for dose calculations of pediatric brain cancer plans generated by USPT and IMPT techniques in XiO TPS.

Dosimetric impact of number of treatment fields in uniform scanning proton therapy planning of lung cancer.

The main purpose of this study was to perform a treatment planning study for lung cancer comparing 2-field (2F) versus 3-field (3F) techniques in uniform scanning proton therapy (USPT). Ten clinically approved lung cancer treatment plans delivered using USPT at our proton center were included in this retrospective study. All 10 lung cases included 4D computed tomography (CT) simulation. The delineation of target volumes was done based on the maximum intensity projection (MIP) images. Both the 3F and 2F treatment plans were generated for the total dose of 74 cobalt-gray-equivalent (CGE) with a daily dose of 2 CGE. 3F plan was generated by adding an extra beam in the 2F plan. Various dosimetric parameters between 2F and 3F plans were evaluated. 3F plans produced better target coverage and conformality as well as lower mean dose to the lung, with absolute difference between 3F and 2F plans within 2%. In contrast, the addition of third beam led to increase of low-dose regions (V20 and V5) in the lung in 3F plans compared to the ones in 2F plans with absolute difference within 2%. Maximum dose to the spinal cord was lower in 2F plans. Mean dose to the heart and esophagus were comparable in both 3F and 2F plans. In conclusion, the 3F technique in USPT produced better target coverage and conformality, but increased the low-dose regions in the lung when compared to 2F technique.

Dosimetric study of uniform scanning proton therapy planning for prostate cancer patients with a metal hip prosthesis, and comparison with volumetric-modulated arc therapy.

The main purposes of this study were to 1) investigate the dosimetric quality of uniform scanning proton therapy planning (USPT) for prostate cancer patients with a metal hip prosthesis, and 2) compare the dosimetric results of USPT with that of volumetric-modulated arc therapy (VMAT). Proton plans for prostate cancer (four cases) were generated in XiO treatment planning system (TPS). The beam arrangement in each proton plan consisted of three fields (two oblique fields and one lateral or slightly angled field), and the proton beams passing through a metal hip prosthesis was avoided. Dose calculations in proton plans were performed using the pencil beam algorithm. From each proton plan, planning target volume (PTV) coverage value (i.e., relative volume of the PTV receiving the prescription dose of 79.2 CGE) was recorded. The VMAT prostate planning was done using two arcs in the Eclipse TPS utilizing 6 MV X-rays, and beam entrance through metallic hip prosthesis was avoided. Dose computation in the VMAT plans was done using anisotropic analytical algorithm, and calculated VMAT plans were then normalized such that the PTV coverage in the VMAT plan was the same as in the proton plan of the corresponding case. The dose-volume histograms of calculated treatment plans were used to evaluate the dosimetric quality of USPT and VMAT. In comparison to the proton plans, on average, the maximum and mean doses to the PTV were higher in the VMAT plans by 1.4% and 0.5%, respectively, whereas the minimum PTV dose was lower in the VMAT plans by 3.4%. The proton plans had lower (or better) average homogeneity index (HI) of 0.03 compared to the one for VMAT (HI = 0.04). The relative rectal volume exposed to radiation was lower in the proton plan, with an average absolute difference ranging from 0.1% to 32.6%. In contrast, using proton planning, the relative bladder volume exposed to radiation was higher at high-dose region with an average absolute difference ranging from 0.4% to 0.8%, and lower at low- and medium-dose regions with an average absolute difference ranging from 2.7% to 10.1%. The average mean dose to the rectum and bladder was lower in the proton plans by 45.1% and 22.0%, respectively, whereas the mean dose to femoral head was lower in VMAT plans by an average difference of 79.6%. In comparison to the VMAT, the proton planning produced lower equivalent uniform dose (EUD) for the rectum (43.7 CGE vs. 51.4 Gy) and higher EUD for the femoral head (16.7 CGE vs. 9.5 Gy), whereas both the VMAT and proton planning produced comparable EUDs for the prostate tumor (76.2 CGE vs. 76.8 Gy) and bladder (50.3 CGE vs. 51.1 Gy). The results presented in this study show that the combination of lateral and oblique fields in USPT planning could potentially provide dosimetric advantage over the VMAT for prostate cancer involving a metallic hip prosthesis.

Measurements of lateral penumbra for uniform scanning proton beams under various beam delivery conditions and comparison to the XiO treatment planning system.

PURPOSE: The main purposes of this study were to (1) investigate the dependency of lateral penumbra (80%-20% distance) of uniform scanning proton beams on various factors such as air gap, proton range, modulation width, compensator thickness, and depth, and (2) compare the lateral penumbra calculated by a treatment planning system (TPS) with measurements. METHODS: First, lateral penumbra was measured using solid-water phantom and radiographic films for (a) air gap, ranged from 0 to 35 cm, (b) proton range, ranged from 8 to 30 cm, (c) modulation, ranged from 2 to 10 cm, (d) compensator thickness, ranged from 0 to 20 cm, and (e) depth, ranged from 7 to 15 cm. Second, dose calculations were computed in a virtual water phantom using the XiO TPS with pencil beam algorithm for identical beam conditions and geometrical configurations that were used for the measurements. The calculated lateral penumbra was then compared with the measured one for both the horizontal and vertical scanning magnets of our uniform scanning proton beam delivery system. RESULTS: The results in the current study showed that the lateral penumbra of horizontal scanning magnet was larger (up to 1.4 mm for measurement and up to 1.0 mm for TPS) compared to that of vertical scanning magnet. Both the TPS and measurements showed an almost linear increase in lateral penumbra with increasing air gap as it produced the greatest effect on lateral penumbra. Lateral penumbra was dependent on the depth and proton range. Specifically, the width of lateral penumbra was found to be always lower at shallower depth than at deeper depth within the spread out Bragg peak (SOBP) region. The lateral penumbra results were less sensitive to the variation in the thickness of compensator, whereas lateral penumbra was independent of modulation. Overall, the comparison between the results of TPS with that of measurements indicates a good agreement for lateral penumbra, with TPS predicting higher values compared to measurements. CONCLUSIONS: Lateral penumbra of uniform scanning proton beams depends on air gap, proton range, compensator thickness, and depth, whereas lateral penumbra is not dependent on modulation. The XiO TPS typically overpredicted lateral penumbra compared to measurements, within 1 mm for most cases, but the difference could be up to 2.5 mm at a deep depth and large air gap.

Tumor Spheroids as an in vitro model for determining the therapeutic response to proton beam radiotherapy and thermally sensitive nanocarriers.

Multicellular Tumor Spheroids (MCTS) strongly resemble tumor tissues, which makes them useful tools for radiation biology studies and screening of various chemotherapeutics. The goal of this pilot study was to use MCTS as an in vitro model to determine the response of cells to low temperature-sensitive liposomes (LTSLs) encapsulating doxorubicin (Dox) and proton beam radiotherapy (PBRT). Prior to treatment, MCTS were characterized for morphology and LTSLs were characterized for size, encapsulation efficiency, and ability to thermally release Dox (a model anticancer agent). Two groups of MCTS were treated with LTSL in combination with mild hyperthermia (40-42 °C) or PBRT alone in the presence of appropriate controls. Cytotoxic response was assessed after 48-72 h using an acid phosphatase assay. At 72 h, LTSL in combination with heat significantly reduced the viability of MCTS (15-30%) compared to the control (P < 0.05). A similar cytotoxic response was observed with PBRT treatment. The data suggest that like a monolayer cell culture, MCTS can be used to determine cytotoxic outcomes of thermal and proton therapy.

A novel daily QA system for proton therapy.

We describe the design and use of a daily quality assurance (QA) system for proton therapy. The QA system is designed to check the overall readiness of proton therapy system consistently within certain reference tolerances by a home-made QA device (the QA device). The QA device is comprised of a commercially available QA device, rf-Daily QA 3, a home-made acrylic phantom, a set of acrylic compensators with various thicknesses, and a mechanical indexing jig. The indexing jig indexes the rf-Daily QA 3, as well as the acrylic phantom, onto the patient treatment couch. Embedded fiducial markers in the acrylic phantom are used to check X-ray image quality and positioning alignment accuracy of the imaging system. The rf-Daily QA 3 is used to check proton beam output, range and symmetry with one single beam delivery. We developed in-house software to calculate beam range and symmetry, based on various ion chambers' readings inside the rf-Daily QA 3. With a single setup and one beam irradiation, the QA system is employed to check couch movement, laser alignment, image registration, and reference proton beam characteristics. The simplicity and robustness of this QA system allows for a total QA time of less than 20 minutes per room. The system has been in use at three proton therapy centers since June 2009.

Measurements of neutron dose equivalent for a proton therapy center using uniform scanning proton beams.

PURPOSE: Neutron exposure is of concern in proton therapy, and varies with beam delivery technique, nozzle design, and treatment conditions. Uniform scanning is an emerging treatment technique in proton therapy, but neutron exposure for this technique has not been fully studied. The purpose of this study is to investigate the neutron dose equivalent per therapeutic dose, H/D, under various treatment conditions for uniform scanning beams employed at our proton therapy center. METHODS: Using a wide energy neutron dose equivalent detector (SWENDI-II, ThermoScientific, MA), the authors measured H/D at 50 cm lateral to the isocenter as a function of proton range, modulation width, beam scanning area, collimated field size, and snout position. They also studied the influence of other factors on neutron dose equivalent, such as aperture material, the presence of a compensator, and measurement locations. They measured H/D for various treatment sites using patient-specific treatment parameters. Finally, they compared H/D values for various beam delivery techniques at various facilities under similar conditions. RESULTS: H/D increased rapidly with proton range and modulation width, varying from about 0.2 mSv/Gy for a 5 cm range and 2 cm modulation width beam to 2.7 mSv/Gy for a 30 cm range and 30 cm modulation width beam when 18 × 18 cm(2) uniform scanning beams were used. H/D increased linearly with the beam scanning area, and decreased slowly with aperture size and snout retraction. The presence of a compensator reduced the H/D slightly compared with that without a compensator present. Aperture material and compensator material also have an influence on neutron dose equivalent, but the influence is relatively small. H/D varied from about 0.5 mSv/Gy for a brain tumor treatment to about 3.5 mSv/Gy for a pelvic case. CONCLUSIONS: This study presents H/D as a function of various treatment parameters for uniform scanning proton beams. For similar treatment conditions, the H/D value per uncollimated beam size for uniform scanning beams was slightly lower than that from a passive scattering beam and higher than that from a pencil beam scanning beam, within a factor of 2. Minimizing beam scanning area could effectively reduce neutron dose equivalent for uniform scanning beams, down to the level close to pencil beam scanning.

Commissioning of output factors for uniform scanning proton beams.

PURPOSE: Current commercial treatment planning systems are not able to accurately predict output factors and calculate monitor units for proton fields. Patient-specific field output factors are thus determined by either measurements or empirical modeling based on commissioning data. The objective of this study is to commission output factors for uniform scanning beams utilized at the ProCure proton therapy centers. METHODS: Using water phantoms and a plane parallel ionization chamber, the authors first measured output factors with a fixed 10 cm diameter aperture as a function of proton range and modulation width for clinically available proton beams with ranges between 4 and 31.5 cm and modulation widths between 2 and 15 cm. The authors then measured the output factor as a function of collimated field size at various calibration depths for proton beams of various ranges and modulation widths. The authors further examined the dependence of the output factor on the scanning area (i.e., uncollimated proton field), snout position, and phantom material. An empirical model was developed to calculate the output factor for patient-specific fields and the model-predicted output factors were compared to measurements. RESULTS: The output factor increased with proton range and field size, and decreased with modulation width. The scanning area and snout position have a small but non-negligible effect on the output factors. The predicted output factors based on the empirical modeling agreed within 2% of measurements for all prostate treatment fields and within 3% for 98.5% of all treatment fields. CONCLUSIONS: Comprehensive measurements at a large subset of available beam conditions are needed to commission output factors for proton therapy beams. The empirical modeling agrees well with the measured output factor data. This investigation indicates that it is possible to accurately predict output factors and thus eliminate or reduce time-consuming patient-specific output measurements for proton treatments.

Theoretical and empirical investigations of KCl : Eu2+ for nearly water-equivalent radiotherapy dosimetry.

PURPOSE: The low effective atomic number, reusability, and other computed radiography-related advantages make europium doped potassium chloride (KCl : Eu2+) a promising dosimetry material. The purpose of this study is to model KCl : Eu2+ point dosimeters with a Monte Carlo (MC) method and, using this model, to investigate the dose responses of two-dimensional (2D) KCl : Eu2+ storage phosphor films (SPFs). METHODS: KCl : Eu2+ point dosimeters were irradiated using a 6 MV beam at four depths (5-20 cm) for each of five square field sizes (5 x 5-25 x 25 cm2). The dose measured by KCl : Eu2+ was compared to that measured by an ionization chamber to obtain the magnitude of energy dependent dose measurement artifact. The measurements were simulated using DOSXYZnrc with phase space files generated by BEAMnrcMP. Simulations were also performed for KCl : Eu2+ films with thicknesses ranging from 1 microm to 1 mm. The work function of the prototype KCl : Eu2+ material was determined by comparing the sensitivity of a 150 microm thick KCl : Eu2+ film to a commercial BaFBr0.85 I0.15 : Eu(2+)-based SPF with a known work function. The work function was then used to estimate the sensitivity of a 1 microm thick KCl : Eu2+ film. RESULTS: The simulated dose responses of prototype KCl : Eu2+ point dosimeters agree well with measurement data acquired by irradiating the dosimeters in the 6 MV beam with varying field size and depth. Furthermore, simulations with films demonstrate that an ultrathin KCl : Eu2+ film with thickness of the order of 1 microm would have nearly water-equivalent dose response. The simulation results can be understood using classic cavity theories. Finally, preliminary experiments and theoretical calculations show that ultrathin KCl : Eu2+ film could provide excellent signal in a 1 cGy dose-to-water irradiation. CONCLUSIONS: In conclusion, the authors demonstrate that KCl : Eu(2+)-based dosimeters can be accurately modeled by a MC method and that 2D KCl : Eu2+ films of the order of 1 microm thick would have minimal energy dependence. The data support the future research and development of a KCl : Eu2+ storage phosphor-based system for quantitative, high-resolution multidimensional radiation therapy dosimetry.

Monte Carlo simulation of the neutron spectral fluence and dose equivalent for use in shielding a proton therapy vault.

Neutron production is of principal concern when designing proton therapy vault shielding. Conventionally, neutron calculations are based on analytical methods, which do not accurately consider beam shaping components and nozzle shielding. The goal of this study was to calculate, using Monte Carlo modeling, the neutron spectral fluence and neutron dose equivalent generated by a realistic proton therapy nozzle and evaluate how these data could be used in shielding calculations. We modeled a contemporary passive scattering proton therapy nozzle in detail with the MCNPX simulation code. The neutron spectral fluence and dose equivalent at various locations in the treatment room were calculated and compared to those obtained from a thick iron target bombarded by parallel proton beams, the simplified geometry on which analytical methods are based. The neutron spectral fluence distributions were similar for both methods, with deeply penetrating high-energy neutrons (E > 10 MeV) being most prevalent along the beam central axis, and low-energy neutrons predominating the neutron spectral fluence in the lateral region. However, unlike the inverse square falloff used in conventional analytical methods, this study shows that the neutron dose equivalent per therapeutic dose in the treatment room decreased with distance approximately following a power law, with an exponent of about -1.63 in the lateral region and -1.73 in the downstream region. Based on the simulated data according to the detailed nozzle modeling, we developed an empirical equation to estimate the neutron dose equivalent at any location and distance in the treatment vault, e.g. for cases in which detailed Monte Carlo modeling is not feasible. We applied the simulated neutron spectral fluence and dose equivalent to a shielding calculation as an example.

Quantitative megavoltage radiation therapy dosimetry using the storage phosphor KCl: Eu2+.

This work, for the first time, reports the use of europium doped potassium chloride (KCl:Eu2+) storage phosphor for quantitative megavoltage radiation therapy dosimetry. In principle, KCl:Eu2+ functions using the same photostimulatated luminescence (PSL) mechanism as commercially available BaFBr0.85I0.15:Eu2+ material that is used for computed radiography (CR) but features a significantly smaller effective atomic number--18 versus 49--making it a potentially useful material for nearly tissue-equivalent radiation dosimetry. Cylindrical KCl:Eu2+ dosimeters, 7 mm in diameter and 1 mm thick, were fabricated in-house. Dosimetric properties, including radiation hardness, response linearity, signal fading, dose rate sensitivity, and energy dependence, were studied with a laboratory optical reader after irradiation by a linear accelerator. The overall experimental uncertainty was estimated to be within +/-2.5%. The findings were (1) KCl:Eu2+ showed satisfactory radiation hardness. There was no significant change in the stimulation spectra after irradiation up to 200 Gy when compared to a fresh dosimeter, indicating that this material could be reused at least 100 times if 2 Gy per use was assumed, e.g., for patient-specific IMRT QA. (2) KCl:Eu2+ exhibited supralinear response to dose after irradiation from 0 to 800 cGy. (3) After x ray irradiation, the PSL signal faded with time and eventually reached a fading rate of about 0.1 % /h after 12 h. (4) The sensitivity of the dosimeter was independent of the dose rate ranging from 15 to 1000 cGy/min. (5) The sensitivity showed no beam energy dependence for either open x ray or megavoltage electron fields. (6) Over-response to low-energy scattered photons was comparable to radiographic film, e.g., Kodak EDR2 film. By sandwiching dosimeters between low-energy photon filters (0.3 mm thick lead foils) during irradiation, the over-response was reduced. The authors have demonstrated that KCl:Eu2+ dosimeters have many desirable dosimetric characteristics that make the material conducive to radiation therapy dosimetry. In the future, a large-area KCl:Eu2+-based CR plate with a thickness of the order of a few microns, created using modern thin film techniques, could provide a reusable, quantitative, high-resolution two-dimensional dosimeter with minimal energy dependence.

The risk of developing a second cancer after receiving craniospinal proton irradiation.

The purpose of this work was to compare the risk of developing a second cancer after craniospinal irradiation using photon versus proton radiotherapy by means of simulation studies designed to account for the effects of neutron exposures. Craniospinal irradiation of a male phantom was calculated for passively-scattered and scanned-beam proton treatment units. Organ doses were estimated from treatment plans; for the proton treatments, the amount of stray radiation was calculated separately using the Monte Carlo method. The organ doses were converted to risk of cancer incidence using a standard formalism developed for radiation protection purposes. The total lifetime risk of second cancer due exclusively to stray radiation was 1.5% for the passively scattered treatment versus 0.8% for the scanned proton beam treatment. Taking into account the therapeutic and stray radiation fields, the risk of second cancer from intensity-modulated radiation therapy and conventional radiotherapy photon treatments were 7 and 12 times higher than the risk associated with scanned-beam proton therapy, respectively, and 6 and 11 times higher than with passively scattered proton therapy, respectively. Simulations revealed that both passively scattered and scanned-beam proton therapies confer significantly lower risks of second cancers than 6 MV conventional and intensity-modulated photon therapies.

Stray radiation dose and second cancer risk for a pediatric patient receiving craniospinal irradiation with proton beams.

Proton beam radiotherapy unavoidably exposes healthy tissue to stray radiation emanating from the treatment unit and secondary radiation produced within the patient. These exposures provide no known benefit and may increase a patient's risk of developing a radiogenic cancer. The aims of this study were to calculate doses to major organs and tissues and to estimate second cancer risk from stray radiation following craniospinal irradiation (CSI) with proton therapy. This was accomplished using detailed Monte Carlo simulations of a passive-scattering proton treatment unit and a voxelized phantom to represent the patient. Equivalent doses, effective dose and corresponding risk for developing a fatal second cancer were calculated for a 10-year-old boy who received proton therapy. The proton treatment comprised CSI at 30.6 Gy plus a boost of 23.4 Gy to the clinical target volume. The predicted effective dose from stray radiation was 418 mSv, of which 344 mSv was from neutrons originating outside the patient; the remaining 74 mSv was caused by neutrons originating within the patient. This effective dose corresponds to an attributable lifetime risk of a fatal second cancer of 3.4%. The equivalent doses that predominated the effective dose from stray radiation were in the lungs, stomach and colon. These results establish a baseline estimate of the stray radiation dose and corresponding risk for a pediatric patient undergoing proton CSI and support the suitability of passively-scattered proton beams for the treatment of central nervous system tumors in pediatric patients.

AMBIENT DOSE EQUIVALENT VERSUS EFFECTIVE DOSE FOR QUANTIFYING STRAY RADIATION EXPOSURES TO A PATIENT RECEIVING PROTON THERAPY FOR PROSTATE CANCER.

The purpose of this study was to evaluate the suitability of the quantity ambient dose equivalent H*(10) as a conservative estimate of effective dose E for estimating stray radiation exposures to patients receiving passively scattered proton radiotherapy for cancer of the prostate. H*(10), which is determined from fluence free-in-air, is potentially useful because it is simpler to measure or calculate because it avoids the complexities associated with phantoms or patient anatomy. However, the suitability of H*(10) as a surrogate for E has not been demonstrated for exposures to high-energy neutrons emanating from radiation treatments with proton beams. The suitability was tested by calculating H*(10) and E for a proton treatment using a Monte Carlo model of a double-scattering treatment machine and a computerized anthropomorphic phantom. The calculated E for the simulated treatment was 5.5 mSv/Gy, while the calculated H*(10) at the isocenter was 10 mSv/Gy. A sensitivity analysis revealed that H*(10) conservatively estimated E for the interval of treatment parameters common in proton therapy for prostate cancer. However, sensitivity analysis of a broader interval of parameters suggested that H*(10) may underestimate E for treatments of other sites, particularly those that require large field sizes. Simulations revealed that while E was predominated by neutrons generated in the nozzle, neutrons produced in the patient contributed up to 40% to dose equivalent in near-field organs.

REDUCING STRAY RADIATION DOSE FOR A PEDIATRIC PATIENT RECEIVING PROTON CRANIOSPINAL IRRADIATION.

The aim of this study was to quantify stray radiation dose from neutrons emanating from a proton treatment unit and to evaluate methods of reducing this dose for a pediatric patient undergoing craniospinal irradiation. The organ equivalent doses and effective dose from stray radiation were estimated for a 30.6-Gy treatment using Monte Carlo simulations of a passive scattering treatment unit and a patient-specific voxelized anatomy. The treatment plan was based on computed tomography images of a 10-yr-old male patient. The contribution to stray radiation was evaluated for the standard nozzle and for the same nozzle but with modest modifications to suppress stray radiation. The modifications included enhancing the local shielding between the patient and the primary external neutron source and increasing the distance between them. The effective dose from stray radiation emanating from the standard nozzle was 322 mSv; enhancements to the nozzle reduced the effective dose by as much as 43%. These results add to the body of evidence that modest enhancements to the treatment unit can reduce substantially the effective dose from stray radiation.