To frame or not to frame? Cone-beam CT-based analysis of head immobilization devices specific to linac-based stereotactic radiosurgery and radiotherapy.

PURPOSE: Noninvasive frameless systems are increasingly being utilized for head immobilization in stereotactic radiosurgery (SRS). Knowing the head positioning reproducibility of frameless systems and their respective ability to limit intrafractional head motion is important in order to safely perform SRS. The purpose of this study was to evaluate and compare the intrafractional head motion of an invasive frame and a series of frameless systems for single fraction SRS and fractionated/hypofractionated stereotactic radiotherapy (FSRT/HF-SRT). METHODS: The noninvasive PinPoint system was used on 15 HF-SRT and 21 SRS patients. Intrafractional motion for these patients was compared to 15 SRS patients immobilized with Cosman-Roberts-Wells (CRW) frame, and a FSRT population that respectively included 23, 32, and 15 patients immobilized using Gill-Thomas-Cosman (GTC) frame, Uniframe, and Orfit. All HF-SRT and FSRT patients were treated using intensity-modulated radiation therapy on a linear accelerator equipped with cone-beam CT (CBCT) and a robotic couch. SRS patients were treated using gantry-mounted stereotactic cones. The CBCT image-guidance protocol included initial setup, pretreatment and post-treatment verification images. The residual error determined from the post-treatment CBCT was used as a surrogate for intrafractional head motion during treatment. RESULTS: The mean intrafractional motion over all fractions with PinPoint was 0.62 ± 0.33 mm and 0.45 ± 0.33 mm, respectively, for the HF-SRT and SRS cohort of patients (P-value = 0.266). For CRW, GTC, Orfit, and Uniframe, the mean intrafractional motions were 0.30 ± 0.21 mm, 0.54 ± 0.76 mm, 0.73 ± 0.49 mm, and 0.76 ± 0.51 mm, respectively. For CRW, PinPoint, GTC, Orfit, and Uniframe, intrafractional motion exceeded 1.5 mm in 0%, 0%, 5%, 6%, and 8% of all fractions treated, respectively. CONCLUSIONS: The noninvasive PinPoint system and the invasive CRW frame stringently limit cranial intrafractional motion, while the latter provides superior immobilization. Based on the results of this study, our clinical practice for malignant tumors has evolved to apply an invasive CRW frame only for metastases in eloquent locations to minimize normal tissue exposure.

Investigation of Dose Falloff for Intact Brain Metastases and Surgical Cavities Using Hypofractionated Volumetric Modulated Arc Radiotherapy.

INTRODUCTION: Intact brain metastases tend to be small and spherical compared to postsurgery brain cavities, which tend to be large and irregular shaped and, as a result, a challenge with respect to treatment planning. The purpose of the present study is to develop guidelines for normal brain tissue dose and to investigate whether there is a dependence on target type for patients treated with hypofractionated volumetric modulated arc radiotherapy (HF-VMAT). METHODS: Treatment plans from a total of 100 patients and 136 targets (55 cavity and 81 intact) were retrospectively reviewed. All targets were treated with HF-VMAT with total doses ranging between 20 and 30 gray (Gy) in 5 fractions. All plans met institutional objectives for organ-at-risk constraints and were clinically delivered. Dose falloff was quantified using gradient index (GI) and distance between the 100% and 50% isodose lines (R50). Additionally, the dose to normal brain tissue (brain contour excluding all gross tumor or clinical target volumes) was assessed using volume receiving specific doses (Vx) where x ranged from 5 to 30 Gy. Best-fit curves using power law relationships of the form y = ax(b) were generated for GI, R50, and Vx (normal brain tissue) versus target volume. RESULTS: There was a statistically significant difference in planning target volume (PTV) for cavities versus intact metastases with mean volumes of 37.8 cm(3) and 9.5 cm(3), respectively (P < .0001). The GI and R50 were statistically different: 3.4 and 9.8 mm for cavities versus 4.6 and 8.3 mm for intact metastases (P < .0001). The R50 increased with PTV with power law coefficients (a, b) = (6.3, 0.12) and (5.9, 0.15) for cavities and intact, respectively. GI decreased with PTV with coefficients (a, b) = (5.9, -0.18) and (5.7, -0.14) for cavities and intact, respectively. The normal brain tissue Vx also exhibited power law relationships with PTV for x = 20 to 28.8 Gy. In conclusion, target volume is the main predictor of dose falloff. The results of the present study can be used for determining target volume-based thresholds for dose falloff and normal brain tissue dose-volume constraints.

Quality Assurance Results for a Commercial Radiosurgery System: A Communication.

The purpose of this communication is to inform the radiosurgery community of quality assurance (QA) results requiring attention in a commercial FDA-approved linac-based cone stereo-tactic radiosurgery (SRS) system. Standard published QA guidelines as per the American Association of Physics in Medicine (AAPM) were followed during the SRS system's commissioning process including end-to-end testing, cone concentricity testing, image transfer verification, and documentation. Several software and hardware deficiencies that were deemed risky were uncovered during the process and QA processes were put in place to mitigate these risks during clinical practice. In particular, the present work focuses on daily cone concentricity testing and commissioning-related findings associated with the software. Cone concentricity/alignment is measured daily using both optical light field inspection, as well as quantitative radiation field tests with the electronic portal imager. In 10 out of 36 clini-cal treatments, adjustments to the cone position had to be made to align the cone with the collimator axis to less than 0.5 mm and on two occasions the pre-adjustment measured offset was 1.0 mm. Software-related errors discovered during commissioning included incorrect transfer of the isocentre in DICOM coordinates, improper handling of non-axial image sets, and complex handling of beam data, especially for multi-target treatments. QA processes were established to mitigate the occurrence of the software errors. With proper QA processes, the reported SRS system complies with tolerances set out in established guidelines. Discussions with the vendor are ongoing to address some of the hardware issues related to cone alignment.

The performance of an optical cone-beam CT scanner adapted for radiochromic film dosimetry.

The primary purpose of this study was to evaluate commercial optical cone-beam computed tomography (CBCT) scanners as devices for reading EBT2 radiochromic film. A secondary objective was to implement a spatial correction for stray light present within optical CBCT systems. Square (12.7 × 12.7 cm²) EBT2 films were positioned vertically in the middle of a small water-filled tank, co-linear with the central beam axis of a 12 MeV electron beam. A total dose of 4.0 Gy was delivered at depth of 3.0 cm. Films were imaged prior to irradiation and 24 hours post-irradiation. Two different models of scanners, Vista15™ and Vista10™, were used to read out the irradiated films. In the Vista15™ scanner, residual light scatter was corrected for using: 1) a single vertical slot array and 2) a slot pair array that produced a vertical fan beam of light. Vista10™ was modified to have a smaller acceptance angle of scattered light and further corrections for residual scatter were made using a multiple slot array. With these different geometries, composite 'open field' and 'shadow field' images were generated and processed to create 'glare-free' pre and post-irradiation film images respectively, from which the net optical density (OD) was calculated. Results were compared against the open light field measurement in which no correction for stray light was made. Using the above scanners, EBT2 films were additionally read out to obtain 12 MeV electron and 6 MV photon percentage depth doses. By correcting for stray light it was found that the central-axis change in the net OD increased particularly in the 12 MeV electron build-up region and at the depth of maximum dose (d(max) = 3.0 cm) where light transmission is lowest. In the open light field measurement acquired with the Vista15™ scanner the net OD was 0.87 +/-0.02. Using single vertical slot array geometry to correct for stray light, the net OD was 0.94 +/-0.02, while with the slot pair array the net OD was 0.99 +/-0.02. For the same film read out with the 'modified' Vista10™ scanner and corrected for scattered light using the multiple slot array technique, a maximum net OD of 1.30 +/-0.02 was obtained. This latter value is comparable to published data obtained with EBT2 film read out with a spectrophotometer. For 12 MeV electron and 6 MV photon percentage depth doses measured with EBT2 film, agreement with thimble ion chamber measurements is shown. The results demonstrate that accurate radiochromic film densitometry can be achieved with optical CBCT scanners and slot array masks that correct for spatially varying stray light within these devices.

Radiochromic leuco dye micelle hydrogels: II. Low diffusion rate leuco crystal violet gel.

Radiation-sensitive hydrogels offer the capability of verifying intricate dose distributions in three-dimensional (3D) space conveniently in a single measurement with sub-millimetre spatial resolution. In this study, a new radiochromic hydrogel called leuco crystal violet (LCV) micelle gel is introduced. Upon irradiation, LCV converts to crystal violet (CV(+)). Triton X-100 micelles are used to provide the required hybrid-interfacing environment to dissolve LCV. The diffusion coefficient of the LCV gel has been measured to be 0.036 +/- 0.001 mm(2) h(-1), which is a factor of 25 times less than the standard radiochromic ferrous xylenol-orange (FX) gel; LCV gels without Triton X-100 micelles have a diffusion coefficient of 0.33 +/- 0.02 mm(2) h(-1). The LCV gel formulation contains: 1 mM LCV, 25 mM trichloroacetic acid, 4 mM Triton X-100 and 4% w/w gelatin. The primary innovative feature of this 3D hydrogel is that the radiation-induced CV(+) dye is more soluble in the Triton X-100 micelles than in the surrounding water which consequently leads to more stable post-irradiation dose distributions. A dosimetric characterization revealed that the dose response is reproducible to within 1% over three separate batches, independent of energy, dose rate and dose fractionation but is affected by the temperature ( approximately 4% per degree C) during irradiation. LCV micelle gels scanned optically with a yellow light source are a promising system for 3D dose verification. They may prove to be, especially, useful for scanning large volume dosimeters (i.e. 20 cm) since they are easily manufactured, transparent and near colourless prior to irradiation.

Three-dimensional dosimetry of small megavoltage radiation fields using radiochromic gels and optical CT scanning.

The dosimetry of small fields as used in stereotactic radiotherapy, radiosurgery and intensity-modulated radiation therapy can be challenging and inaccurate due to partial volume averaging effects and possible disruption of charged particle equilibrium. Consequently, there exists a need for an integrating, tissue equivalent dosimeter with high spatial resolution to avoid perturbing the radiation beam and artificially broadening the measured beam penumbra. In this work, radiochromic ferrous xylenol-orange (FX) and leuco crystal violet (LCV) micelle gels were used to measure relative dose factors (RDFs), percent depth dose profiles and relative lateral beam profiles of 6 MV x-ray pencil beams of diameter 28.1, 9.8 and 4.9 mm. The pencil beams were produced via stereotactic collimators mounted on a Varian 2100 EX linear accelerator. The gels were read using optical computed tomography (CT). Data sets were compared quantitatively with dosimetric measurements made with radiographic (Kodak EDR2) and radiochromic (GAFChromic EBT) film, respectively. Using a fast cone-beam optical CT scanner (Vista), corrections for diffusion in the FX gel data yielded RDFs that were comparable to those obtained by minimally diffusing LCV gels. Considering EBT film-measured RDF data as reference, cone-beam CT-scanned LCV gel data, corrected for scattered stray light, were found to be in agreement within 0.5% and -0.6% for the 9.8 and 4.9 mm diameter fields, respectively. The validity of the scattered stray light correction was confirmed by general agreement with RDF data obtained from the same LCV gel read out with a laser CT scanner that is less prone to the acceptance of scattered stray light. Percent depth dose profiles and lateral beam profiles were found to agree within experimental error for the FX gel (corrected for diffusion), LCV gel (corrected for scattered stray light), and EBT and EDR2 films. The results from this study reveal that a three-dimensional dosimetry method utilizing optical CT-scanned radiochromic gels allows for the acquisition of a self-consistent volumetric data set in a single exposure, with sufficient spatial resolution to accurately characterize small fields.

An apparent threshold dose response in ferrous xylenol-orange gel dosimeters when scanned with a yellow light source.

Freshly prepared radiochromic ferrous xylenol-orange (FX) gels optically scanned with a light source exhibit a threshold dose response that is thermally and wavelength dependent. Correction for this threshold dose leads to accurate dose calibration and better reproducibility in multiple fraction radiation exposures. The objective of this study was to determine the cause of the threshold dose effect and to control it through improved dose calibration procedures. The results of a systematic investigation into the chemical cause revealed that impurities within the various FX gel constituents (i.e. xylenol-orange, gelatin, sulfuric acid and ferrous ammonium sulfate) were not directly responsible for the threshold dose. Rather, it was determined that the threshold dose response stems from a spectral sensitivity to different chemical complexes that are formed at different dose levels in FX gels between ferric (Fe(III)) ions and xylenol-orange (XO), i.e. Fe(III)i:XOj. A double Fe(III)2:XO1 complex preferentially absorbs at longer wavelengths (i.e. yellow), while at shorter wavelengths (i.e. green) the sensitivity is biased toward the single Fe(III)1:XO1 complex. As a result, when scanning with yellow light, freshly prepared FX gels require a minimum concentration of Fe(III) ions to shift the equilibrium concentration to favor the predominant production of the double Fe(III)2:XO1 complex at low doses. This can be accomplished via pre-irradiation of freshly prepared gels to a priming dose of approximately 0.5 Gy or allowing auto-oxidation to generate the startup concentration of Fe(III) ions required to negate the apparent threshold dose response.

Three-dimensional dose verification for intensity-modulated radiation therapy in the radiological physics centre head-and-neck phantom using optical computed tomography scans of ferrous xylenol-orange gel dosimeters.

PURPOSE: To extend the Radiological Physics Centre (RPC) intensity-modulated radiation therapy dose verification protocol to three dimensions using optical computed tomography (CT) scans of ferrous xylenol-orange (FX) gels. METHODS AND MATERIALS: The dosimetry insert in the RPC head-and-neck phantom was replaced with an FX cylindrical gel dosimeter. Two gels were calibrated, independently irradiated with 6-MV X-ray beams and scanned using laser and cone-beam (Vista) optical CT, respectively. For matching dose slices, measured dose distributions were compared with Pinnacle3 computed distributions. RESULTS: Within high-dose regions and low gradients, doses measured using laser CT were 2% to 3% less than the computed dose, whereas with cone-beam CT they were 4% to 5% less. Inside the central 90% of the gel cylinder diameter, the fraction of voxels satisfying the two-dimensional gamma analysis (5% dose difference, 3-mm distance to agreement) with laser-beam- and cone-beam-measured dose distributions were 98.4% and 99.0%, respectively. A three-dimensional gamma analysis with cone-beam data revealed that 96.7% of voxels within the central 90% gel volume satisfied the above criteria. Within the axial and sagittal planes through the primary planning target volume (PTV), computed and measured doses using GAFChromicEBT film (RPC measured) and cone-beam scanned FX gel generally agreed. At equivalent points in the planning target volumes, computed, thermoluminescent dosimeter (RPC-measured), and gel point doses agreed to within 5.1% in absolute dose. CONCLUSIONS: Laser and cone-beam CT yield comparable dose distributions in high-dose regions. The RPC head phantom and optical CT-scanned FX gels can be used for accurate intensity-modulated radiation therapy dose verification in three dimensions.

An NMR relaxometry and gravimetric study of gelatin-free aqueous polyacrylamide dosimeters.

In conformal radiation therapy, a high dose of radiation is given to a target volume to increase the probability of cure, and care is taken to minimize the dose to surrounding healthy tissue. The techniques used to achieve this are very complicated and the precise verification of the resulting three-dimensional (3D) dose distribution is required. Polyacrylamide gelatin (PAG) dosimeters with magnetic resonance imaging and optical computed tomography scanning provide the required 3D dosimetry with high spatial resolution. Many basic studies have characterized these chemical dosimeters that polymerize under irradiation. However, the investigation of the fundamental properties of the radiation-induced polymerization in PAG dosimeters is complicated by the presence of the background gelatin matrix. In this work, a gelatin-free model system for the study of the basic radiation-induced polymerization in PAG dosimeters has been developed. Experiments were performed on gelatin-free dosimeters, named aqueous polyacrylamide (APA) dosimeters, containing equal amounts of acrylamide and N,N'-methylene-bisacrylamide. The APA dosimeters were prepared with four different total monomer concentrations (2, 4, 6 and 8% by weight). Nuclear magnetic resonance (NMR) spin-spin and spin-lattice proton relaxation measurements at 20 MHz, and gravimetric analyses performed on all four dosimeters, show a continuous degree of polymerization over the dose range of 0-25 Gy. The developed NMR model explains the relationship observed between the relaxation data and the amount of crosslinked polymer formed at each dose. This model can be extended with gelatin relaxation data to provide a fundamental understanding of radiation-induced polymerization in the conventional PAG dosimeters.

Examination of Jeltrate Plus as a tissue equivalent bolus material.

A product available commercially for making dental impressions, Jeltrate Plus, was evaluated as a tissue equivalent bolus material. Jeltrate Plus was found to be tissue equivalent in 6 and 15 MV photon energy beams and 6, 12, and 20 MeV electron energy beams. As a first step, different preparations for making the bolus material were investigated and an optimal mixture was determined to be two parts Jeltrate Plus powder to three parts water by weight. A suitable method for storing the material was found to be in a water filled plastic container. Since the product is fairly inexpensive and is easily and quickly made and moulded into different shapes, it is an excellent bolus material to use when treating irregular patient contours.