Federated Learning Survival Model and Potential Radiotherapy Decision Support Impact Assessment for Non-small Cell Lung Cancer Using Real-World Data.

AIMS: The objective of this study was to develop a two-year overall survival model for inoperable stage I-III non-small cell lung cancer (NSCLC) patients using routine radiation oncology data over a federated (distributed) learning network and evaluate the potential of decision support for curative versus palliative radiotherapy. METHODS: A federated infrastructure of data extraction, de-identification, standardisation, image analysis, and modelling was installed for seven clinics to obtain clinical and imaging features and survival information for patients treated in 2011-2019. A logistic regression model was trained for the 2011-2016 curative patient cohort and validated for the 2017-2019 cohort. Features were selected with univariate and model-based analysis and optimised using bootstrapping. System performance was assessed by the receiver operating characteristic (ROC) and corresponding area under curve (AUC), C-index, calibration metrics and Kaplan-Meier survival curves, with risk groups defined by model probability quartiles. Decision support was evaluated using a case-control analysis using propensity matching between treatment groups. RESULTS: 1655 patient datasets were included. The overall model AUC was 0.68. Fifty-eight percent of patients treated with palliative radiotherapy had a low-to-moderate risk prediction according to the model, with survival times not significantly different (p = 0.87 and 0.061) from patients treated with curative radiotherapy classified as high-risk by the model. When survival was simulated by risk group and model-indicated treatment, there was an estimated 11% increase in survival rate at two years (p < 0.01). CONCLUSION: Federated learning over multiple institution data can be used to develop and validate decision support systems for lung cancer while quantifying the potential impact of their use in practice. This paves the way for personalised medicine, where decisions can be based more closely on individual patient details from routine care.

Automated detection, delineation and quantification of whole-body bone metastasis using FDG-PET/CT images.

Non-small cell lung cancer (NSCLC) patients with the metastatic spread of disease to the bone have high morbidity and mortality. Stereotactic ablative body radiotherapy increases the progression free survival and overall survival of these patients with oligometastases. FDG-PET/CT, a functional imaging technique combining positron emission tomography (PET) with 18 F-fluorodeoxyglucose (FDG) and computer tomography (CT) provides improved staging and identification of treatment response. It is also associated with reduction in size of the radiotherapy tumour volume delineation compared with CT based contouring in radiotherapy, thus allowing for dose escalation to the target volume with lower doses to the surrounding organs at risk. FDG-PET/CT is increasingly being used for the clinical management of NSCLC patients undergoing radiotherapy and has shown high sensitivity and specificity for the detection of bone metastases in these patients. Here, we present a software tool for detection, delineation and quantification of bone metastases using FDG-PET/CT images. The tool extracts standardised uptake values (SUV) from FDG-PET images for auto-segmentation of bone lesions and calculates volume of each lesion and associated mean and maximum SUV. The tool also allows automatic statistical validation of the auto-segmented bone lesions against the manual contours of a radiation oncologist. A retrospective review of FDG-PET/CT scans of more than 30 candidate NSCLC patients was performed and nine patients with one or more metastatic bone lesions were selected for the present study. The SUV threshold prediction model was designed by splitting the cohort of patients into a subset of 'development' and 'validation' cohorts. The development cohort yielded an optimum SUV threshold of 3.0 for automatic detection of bone metastases using FDG-PET/CT images. The validity of the derived optimum SUV threshold on the validation cohort demonstrated that auto-segmented and manually contoured bone lesions showed strong concordance for volume of bone lesion (r = 0.993) and number of detected lesions (r = 0.996). The tool has various applications in radiotherapy, including but not limited to studies determining optimum SUV threshold for accurate and standardised delineation of bone lesions and in scientific studies utilising large patient populations for instance for investigation of the number of metastatic lesions that can be treated safety with an ablative dose of radiotherapy without exceeding the normal tissue toxicity.

Quality assurance of VMAT on flattened and flattening filter-free accelerators using a high spatial resolution detector.

PURPOSE: This study investigated the use of high spatial resolution solid-state detectors (DUO and Octa) combined with an inclinometer for machine-based quality assurance (QA) of Volumetric Modulated Arc Therapy (VMAT) with flattened and flattening filter-free beams. METHOD: The proposed system was inserted in the accessory tray of the gantry head of a Varian 21iX Clinac and a Truebeam linear accelerator. Mutual dependence of the dose rate (DR) and gantry speed (GS) was assessed using the standard Varian customer acceptance plan (CAP). The multi-leaf collimator (MLC) leaf speed was evaluated under static gantry conditions in directions parallel and orthogonal to gravity as well as under dynamic gantry conditions. Measurements were compared to machine log files. RESULTS: DR and GS as a function of gantry angle were reconstructed using the DUO/inclinometer and in agreement to within 1% with the machine log files in the sectors of constant DR and GS. The MLC leaf speeds agreed with the nominal speeds and those extracted from the machine log files to within 0.03 cm s-1 . The effect of gravity on the leaf motion was only observed when the leaves traveled faster than the nominal maximum velocity stated by the vendor. Under dynamic gantry conditions, MLC leaf speeds ranging between 0.33 and 1.42 cm s-1 were evaluated. Comparing the average MLC leaf speeds with the machine log files found differences between 0.9% and 5.7%, with the largest discrepancy occurring under conditions of fastest leaf velocity, lowest DR and lowest detector signal. CONCLUSIONS: The investigation on the use of solid-state detectors in combination with an inclinometer has demonstrated the capability to provide efficient and independent verification of DR, GS, and MLC leaf speed during dynamic VMAT delivery. Good agreement with machine log files suggests the detector/inclinometer system is a useful tool for machine-specific VMAT QA.

2D monolithic silicon-diode array detectors in megavoltage photon beams: does the fabrication technology matter? A medical physicist's perspective.

A family of prototype 2D monolithic silicon-diode array detectors (MP512, Duo, Octa) has been proposed by the Centre for Medical Radiation Physics, University of Wollongong (Australia) for relative dosimetry in small megavoltage photon beams. These detectors, which differ in the topology of their 512 sensitive volumes, were originally fabricated on bulk p-type substrates. More recently, they have also been fabricated on epitaxial p-type substrates. In the literature, their performance has been individually characterized for quality assurance (QA) applications. The present study directly assessed and compared that of a MP512-bulk and that of a MP512-epitaxial in terms of radiation hardness, long-term stability, response linearity with dose, dose per pulse and angular dependence. Their measurements of output factors, off-axis ratios and percentage depth doses in square radiation fields collimated by the jaws and produced by 6 MV and 10 MV flattened photon beams were then benchmarked against those by commercially available detectors. The present investigation was aimed at establishing, from a medical physicist's perspective, how the bulk and epitaxial fabrication technologies would affect the implementation of the MP512s into a QA protocol. Based on results, the MP512-epitaxial would offer superior radiation hardness, long-term stability and achievable uniformity and reproducibility of the response across the 2D active area.

Comparison of multi-institutional pre-treatment verification for VMAT of nasopharynx with delivery errors.

PURPOSE: Measurement-based pre-treatment verification with phantoms frequently uses gamma analysis to assess acceptable delivery accuracy. This study evaluates the sensitivity of a commercial system to simulated machine errors for three different institutions' Volumetric Modulated Arc Therapy (VMAT) planning approaches. METHODS: VMAT plans were generated for ten patients at three institutions using each institution's own protocol (manually-planned at institution 1; auto-planned at institutions 2 and 3). Errors in Multi-Leaf Collimator (MLC) field size (FS), MLC shift (S), and collimator angle (C) of -5, -2, -1, 1, 2 and 5 mm or degrees were introduced. Dose metric constraints discriminated which error magnitudes were considered unacceptable. The smallest magnitude error treatment plans deemed clinically unacceptable (typically for a 5% dose change) were delivered to the ArcCHECK for all institutions, and with a high-dose point ion chamber measurement in 2 institutions. Error detection for different gamma analysis criteria was compared. RESULTS: Not all deliberately introduced VMAT plan errors were detected using a typical 3D 3%/3 mm global gamma pass rate of 95%. Considering all institutions, gamma analysis was least sensitive to negative FS errors. The most sensitive was a 2%/2 mm global analysis for institution 1, whilst for institution 2 it was 3%/3 mm global analysis. The majority of errors (58/59 for institution 1, 54/60 for institution 3) were detected using ArcCHECK and ion chamber measurements combined. CONCLUSIONS: Not all clinically unacceptable errors are detected. Combining ion chamber measurements with gamma analysis improved sensitivity and is recommended. Optimum gamma settings varied across institutions.

A novel high-resolution 2D silicon array detector for small field dosimetry with FFF photon beams.

PURPOSE: Flattening filter free (FFF) beams are increasingly being considered for stereotactic radiotherapy (SRT). For the first time, the performance of a monolithic silicon array detector under 6 and 10 MV FFF beams was evaluated. The dosimeter, named "Octa" and designed by the Centre for Medical Radiation Physics (CMRP), was tested also under flattened beams for comparison. METHODS: Output factors (OFs), percentage depth-dose (PDD), dose profiles (DPs) and dose per pulse (DPP) dependence were investigated. Results were benchmarked against commercially available detectors for small field dosimetry. RESULTS: The dosimeter was shown to be a 'correction-free' silicon array detector for OFs and PDD measurements for all the beam qualities investigated. Measured OFs were accurate within 3% and PDD values within 2% compared against the benchmarks. Cross-plane, in-plane and diagonal DPs were measured simultaneously with high spatial resolution (0.3 mm) and real time read-out. A DPP dependence (24% at 0.021 mGy/pulse relative to 0.278 mGy/pulse) was found and could be easily corrected for in the case of machine specific quality assurance applications. CONCLUSIONS: Results were consistent with those for monolithic silicon array detectors designed by the CMRP and previously characterized under flattened beams only, supporting the robustness of this technology for relative dosimetry for a wide range of beam qualities and dose per pulses. In contrast to its predecessors, the design of the Octa offers an exhaustive high-resolution 2D dose map characterization, making it a unique real-time radiation detector for small field dosimetry for field sizes up to 3 cm side.

Angular independent silicon detector for dosimetry in external beam radiotherapy.

PURPOSE: In this work, the "edgeless" silicon detector technology is investigated, in combination with an innovative packaging solution, to manufacture silicon detectors with negligible angular response. The new diode is also characterized as a dosimeter for radiotherapy with the aim to verify its suitability as a single detector for in vivo dosimetry as well as large area 2D array that does not require angular correction to their response. METHODS: For the characterisation of the "edgeless-drop-in" detector technology, a set of samples have been manufactured with different sensitive areas (1 × 1 and 0.5 × 0.5 mm(2)) and different thicknesses (0.1 and 0.5 mm) in four different combinations of top and peripheral p-n junction fabricated on p-type and n-type silicon substrates. The diode probes were tested in terms of percentage depth dose (PDD), dose rate, and linearity and compared to ion chambers. Measurements of the output factor have been compared to film. The angular response of the diodes probes has been tested in a cylindrical PMMA phantom, rotated with bidirectional accuracy of 0.25° under 10 × 10 cm(2) 6 MV Linac photon beam. The radiation hardness has been investigated as well as the effect of radiation damage on the angular and dose rate response of the diode probes when irradiated with photons from a Co-60 gamma source up to dose of 40 kGy. RESULTS: The PDDs measured by the edgeless detectors show an agreement with the data obtained using ion chambers within ±2%. The output factor measured with the smallest area edgeless diodes (0.5 × 0.5 mm(2)-0.1 and 0.5 mm thick) matches EBT3 film to within 2% for square field size from 10 to 0.5 cm side equivalent distance. The dose rate dependence in a dose per pulse range of 0.9 × 10(-5)-2.7 × 10(-4) Gy/pulse was less than -7% and +300% for diodes fabricated on p-type and n-type substrates, respectively. The edgeless diodes fabricated on the p-type substrate demonstrated degradation of the response as a function of the irradiation dose within 5%-15%, while diodes on the n-type substrate show a variation of approximately 30% after 40 kGy. The angular response of all probes is minimal (within 2%) but the N on N and P on P configurations show the best performances with an angular dependence of ±1.0% between 0° and 180° in the transversal direction. In this configuration, the space charge region of the passive diode extends from the behind and sidewall toward the anode on the top providing beneficial electric field distribution in the peripheral area of the diode. Such performance has also been tested after irradiation by Co-60 up to 40 kGy with no measurable change in angular response. CONCLUSIONS: A new edgeless-drop-in silicon diode fabrication and packaging technology has been used to develop detectors that show no significant angular dependence in their response for dosimetry in radiation therapy. From the characterisation of the diodes, proposed in a wide range of different geometries and configurations, the authors recommend the P-on-P detectors in conjunction with "drop in" packaging technology as the candidate for further development as single diode probe or 2D diode array for dosimetry in radiotherapy.

MagicPlate-512: A 2D silicon detector array for quality assurance of stereotactic motion adaptive radiotherapy.

PURPOSE: Spatial and temporal resolutions are two of the most important features for quality assurance instrumentation of motion adaptive radiotherapy modalities. The goal of this work is to characterize the performance of the 2D high spatial resolution monolithic silicon diode array named "MagicPlate-512" for quality assurance of stereotactic body radiation therapy (SBRT) and stereotactic radiosurgery (SRS) combined with a dynamic multileaf collimator (MLC) tracking technique for motion compensation. METHODS: MagicPlate-512 is used in combination with the movable platform HexaMotion and a research version of radiofrequency tracking system Calypso driving MLC tracking software. The authors reconstruct 2D dose distributions of small field square beams in three modalities: in static conditions, mimicking the temporal movement pattern of a lung tumor and tracking the moving target while the MLC compensates almost instantaneously for the tumor displacement. Use of Calypso in combination with MagicPlate-512 requires a proper radiofrequency interference shielding. Impact of the shielding on dosimetry has been simulated by (GEANT)4 and verified experimentally. Temporal and spatial resolutions of the dosimetry system allow also for accurate verification of segments of complex stereotactic radiotherapy plans with identification of the instant and location where a certain dose is delivered. This feature allows for retrospective temporal reconstruction of the delivery process and easy identification of error in the tracking or the multileaf collimator driving systems. A sliding MLC wedge combined with the lung motion pattern has been measured. The ability of the MagicPlate-512 (MP512) in 2D dose mapping in all three modes of operation was benchmarked by EBT3 film. RESULTS: Full width at half maximum and penumbra of the moving and stationary dose profiles measured by EBT3 film and MagicPlate-512 confirm that motion has a significant impact on the dose distribution. Motion, no motion, and motion with MLC tracking profiles agreed within 1 and 0.4 mm, respectively, for all field sizes tested. Use of electromagnetic tracking system generates a fluctuation of the detector baseline up to 10% of the full scale signal requiring a proper shielding strategy. MagicPlate-512 is also able to reconstruct the dose variation pulse-by-pulse in each pixel of the detector. An analysis of the dose transients with motion and motion with tracking shows that the tracking feedback algorithm used for this experiment can compensate effectively only the effect of the slower transient components. The fast changing components of the organ motion can contribute only to discrepancy of the order of 15% in penumbral region while the slower components can change the dose profile up to 75% of the expected dose. CONCLUSIONS: MagicPlate-512 is shown to be, potentially, a valid alternative to film or 2D ionizing chambers for quality assurance dosimetry in SRS or SBRT. Its high spatial and temporal resolutions allow for accurate reconstruction of the profile in any conditions with motion and with tracking of the motion. It shows excellent performance to reconstruct the dose deposition in real time or retrospectively as a function of time for detailed analysis of the effect of motion in a specific pixel or area of interest.

A two dimensional silicon detectors array for quality assurance in stereotactic radiotherapy: MagicPlate-512.

PURPOSE: Silicon diode arrays are commonly implemented in radiation therapy quality assurance applications as they have a number of advantages including: real time operation (compared to the film) and high spatial resolution, large dynamic range and small size (compared to ionizing chambers). Most diode arrays have detector pitch that is too coarse for routine use in small field applications. The goal of this work is to characterize the two-dimensional monolithic silicon diode array named "MagicPlate-512" (MP512) designed for QA in stereotactic body radiation therapy (SBRT) and stereotactic radio surgery (SRS). METHODS: MP512 is a silicon monolithic detector manufactured on ap-type substrate. An array contains of 512 pixels with size 0.5×0.5 mm2 and pitch 2 mm with an overall dimension of 52×52 mm2. The MP512 monolithic detector is wire bonded on a printed circuit board 0.5 mm thick and covered by a thin layer of raisin to preserve the silicon detector from moisture and chemical contamination and to protect the bonding wires. Characterization of the silicon monolithic diode array response was performed, and included pixels response uniformity, dose linearity, percent depth dose, output factor, and beam profiling for beam sizes relevant to SBRT and SRS and depth dose response in comparison with ionization chamber. RESULTS: MP512 shows a good dose linearity (R2=0.998) and repeatability within 0.2%. The measured depth dose response for field size of 10×10 cm2 agreed to within 1.3%, when compared to a CC13 ionization chamber for depths in PMMA up to 30 cm. The output factor of a 6 MV Varian 2100EX medical linac beam measured by MP512 at the isocenter agrees to within 2% when compared to PTW diamond, Scanditronix point EDD-2 diode and MOSkin detectors for field sizes down to 1×1 cm2. An over response of 4% was observed for square beam size smaller than 1 cm when compared to EBT3 films, while the beam profiles (FWHM) of MP512 match to within 2% the data measured by radiochromic film. CONCLUSIONS: The response of the 2D detector array, MP512, has been evaluated. The properties of the array demonstrated suitability for use as in phantom dosimeter for QA in SRS and SBRT. Although MP512 matches film measurements down to 1×1 cm2 well, it showed a discrepancy of 4% in the determination of output factors of beams smaller than 0.5×0.5 cm2 due to the field perturbation generated by the large amount of silicon surrounding the central diode. MP512 is highly capable of measuring beam size (FWHM) and has a discrepancy of less than 1.3% when compared to EBT3 film. A reduction in the detector pitch to less than 2 mm would improve the penumbra reconstruction accuracy at the cost readout electronics complexity.

Characterization of a novel two dimensional diode array the "magic plate" as a radiation detector for radiation therapy treatment.

PURPOSE: Intensity modulated radiation therapy (IMRT) utilizes the technology of multileaf collimators to deliver highly modulated and complex radiation treatment. Dosimetric verification of the IMRT treatment requires the verification of the delivered dose distribution. Two dimensional ion chamber or diode arrays are gaining popularity as a dosimeter of choice due to their real time feedback compared to film dosimetry. This paper describes the characterization of a novel 2D diode array, which has been named the "magic plate" (MP). It was designed to function as a 2D transmission detector as well as a planar detector for dose distribution measurements in a solid water phantom for the dosimetric verification of IMRT treatment delivery. METHODS: The prototype MP is an 11 × 11 detector array based on thin (50 µm) epitaxial diode technology mounted on a 0.6 mm thick Kapton substrate using a proprietary "drop-in" technology developed by the Centre for Medical Radiation Physics, University of Wollongong. A full characterization of the detector was performed, including radiation damage study, dose per pulse effect, percent depth dose comparison with CC13 ion chamber and build up characteristics with a parallel plane ion chamber measurements, dose linearity, energy response and angular response. RESULTS: Postirradiated magic plate diodes showed a reproducibility of 2.1%. The MP dose per pulse response decreased at higher dose rates while at lower dose rates the MP appears to be dose rate independent. The depth dose measurement of the MP agrees with ion chamber depth dose measurements to within 0.7% while dose linearity was excellent. MP showed angular response dependency due to the anisotropy of the silicon diode with the maximum variation in angular response of 10.8% at gantry angle 180°. Angular dependence was within 3.5% for the gantry angles ± 75°. The field size dependence of the MP at isocenter agrees with ion chamber measurement to within 1.1%. In the beam perturbation study, the surface dose increased by 12.1% for a 30 × 30 cm(2) field size at the source to detector distance (SDD) of 80 cm whilst the transmission for the MP was 99%. CONCLUSIONS: The radiation response of the magic plate was successfully characterized. The array of epitaxial silicon based detectors with "drop-in" packaging showed properties suitable to be used as a simplified multipurpose and nonperturbing 2D radiation detector for radiation therapy dosimetric verification.

Independent quality assurance of a helical tomotherapy machine using the dose magnifying glass.

PURPOSE: Helical tomotherapy is a complex delivery technique, integrating CT image guidance and intensity modulated radiotherapy in a single system. The integration of the CT detector ring on the gantry not only allows patient position verification but is also often used to perform various QA procedures. This convenience lacks the rigor of a machine-independent QA process. METHODS: In this article, a Si strip detector, known as the Dose Magnifying Glass (DMG), was used to perform machine-independent QA measurements of the multileaf collimator alignment, leaf open time threshold, and leaf fluence output factor (LFOF). RESULTS: The DMG measurements showed good agreements with EDR2 film for the MLC alignment test while the CT detector agrees well with DMG measurements for leaf open time threshold and LFOF measurements. The leaf open time threshold was found to be approximately 20 ms. The LFOF measured with the DMG agreed within error with the CT detector measured LFOF. CONCLUSIONS: The DMG with its 0.2 mm spatial resolution coupled to TERA ASIC allowed real-time high temporal resolution measurements of the tomotherapy leaf movement. In conclusion, DMG was shown to be a suitable tool for machine-independent QA of a tomotherapy unit.

The use of a silicon strip detector dose magnifying glass in stereotactic radiotherapy QA and dosimetry.

PURPOSE: Stereotactic radiosurgery/therapy (SRS/SRT) is the use of radiation ablation in place of conventional surgical excision to remove or create fibrous tissue in small target volumes. The target of the SRT/SRS treatment is often located in close proximity to critical organs, hence the requirement of high geometric precision including a tight margin on the planning target volume and a sharp dose fall off. One of the major problems with quality assurance (QA) of SRT/SRS is the availability of suitable detectors with the required spatial resolution. The authors present a novel detector that they refer to as the dose magnifying glass (DMG), which has a high spatial resolution (0.2 mm) and is capable of meeting the stringent requirements of QA and dosimetry in SRS/SRT therapy. METHODS: The DMG is an array of 128 phosphor implanted n+ strips on a p-type Si wafer. The sensitive area defined by a single n+ strip is 20 x 2000 microm2. The Si wafer is 375 microm thick. It is mounted on a 0.12 mm thick Kapton substrate. The authors studied the dose per pulse (dpp) and angular response of the detector in a custom-made SRS phantom. The DMG was used to determine the centers of rotation and positioning errors for the linear accelerator's gantry, couch, and collimator rotations. They also used the DMG to measure the profiles and the total scatter factor (S(cp)) of the SRS cones. Comparisons were made with the EBT2 film and standard S(cp) values. The DMG was also used for dosimetric verification of a typical SRS treatment with various noncoplanar fields and arc treatments when applied to the phantom. RESULTS: The dose per pulse dependency of the DMG was found to be < 5% for a dpp change of 7.5 times. The angular response of the detector was investigated in the azimuthal and polar directions. The maximum polar angular response was 13.8% at the gantry angle of 320 degrees, which may be partly due to the phantom geometry. The maximum azimuthal angular response was 15.3% at gantry angles of 90 degrees and 270 degrees. The angular response at the gantry angle of 180 degrees was 6.3%. A correction function was derived to correct for the angular dependence of the detector, which takes into account the contribution of the azimuthal and polar angular response at different treatment couch positions. The maximum positioning errors due to collimator, gantry, and couch rotation were 0.2 +/- 0.1, 0.4 +/- 0.1, and 0.4 +/- 0.2 mm, respectively. The SRS cone S(cp) agrees very well with the standard data with an average difference of 1.2 +/- 1.1%. Comparison of the relative intensity profiles of the DMG and EBT2 measurements for a simulated SRS treatment shows a maximum difference of 2.5%. CONCLUSIONS: The DMG was investigated for dose per pulse and angular dependency. Its application to SRS/SRT delivery verification was demonstrated. The DMG with its high spatial resolution and real time capability allows measurement of dose profiles for cone applicators down to 5 mm in diameter, both accurately and rapidly as required in typical SRS/SRT deliveries.

A silicon strip detector dose magnifying glass for IMRT dosimetry.

PURPOSE: Intensity modulated radiation therapy (IMRT) allows the delivery of escalated radiation dose to tumor while sparing adjacent critical organs. In doing so, IMRT plans tend to incorporate steep dose gradients at interfaces between the target and the organs at risk. Current quality assurance (QA) verification tools such as 2D diode arrays, are limited by their spatial resolution and conventional films are nonreal time. In this article, the authors describe a novel silicon strip detector (CMRP DMG) of high spatial resolution (200 microm) suitable for measuring the high dose gradients in an IMRT delivery. METHODS: A full characterization of the detector was performed, including dose per pulse effect, percent depth dose comparison with Farmer ion chamber measurements, stem effect, dose linearity, uniformity, energy response, angular response, and penumbra measurements. They also present the application of the CMRP DMG in the dosimetric verification of a clinical IMRT plan. RESULTS: The detector response changed by 23% for a 390-fold change in the dose per pulse. A correction function is derived to correct for this effect. The strip detector depth dose curve agrees with the Farmer ion chamber within 0.8%. The stem effect was negligible (0.2%). The dose linearity was excellent for the dose range of 3-300 cGy. A uniformity correction method is described to correct for variations in the individual detector pixel responses. The detector showed an over-response relative to tissue dose at lower photon energies with the maximum dose response at 75 kVp nominal photon energy. Penumbra studies using a Varian Clinac 21EX at 1.5 and 10.0 cm depths were measured to be 2.77 and 3.94 mm for the secondary collimators, 3.52 and 5.60 mm for the multileaf collimator rounded leaf ends, respectively. Point doses measured with the strip detector were compared to doses measured with EBT film and doses predicted by the Philips Pinnacle treatment planning system. The differences were 1.1% +/- 1.8% and 1.0% +/- 1.6%, respectively. They demonstrated the high temporal resolution capability of the detector readout system, which will allow one to investigate the temporal dose pattern of IMRT and volumetric modulated are therapy (VMAT) deliveries. CONCLUSIONS: The CMRP silicon strip detector dose magnifying glass interfaced to a TERA ASIC DAQ system has high spatial and temporal resolution. It is a novel and valuable tool for QA in IMRT dose delivery and for VMAT dose delivery.

First mothering over 35 years: questioning the association of maternal age and pregnancy risk.

Women having a first baby at 35+ years are commonly considered to be "at risk" for pregnancy complications. This understanding appears to be based primarily on age, and curerntly many healthy women are included in this category. There is clear evidence to suggest that, for these women, being considered "at risk" is anxiety provoking. In this Australian qualitative study of first mothering over 35 years, we found four risk-related themes, "realizing I was at risk," "hoping for reassurance," "dealing with uncertainty," and "getting through it/negotiating risk." We concluded that successful adjustment to motherhood related principally to participants negotiating risk and also to the infant growing and becoming more responsive. Attitudes of health professionals were found to contribute to rather than ameliorate participant dilemmas. Understanding how healthy women over 35 years engage with and negotiate notions of risk may assist health professionals in the provision of more meaningful maternal support for this growing group of women.

Comparison of new clinical and scintigraphic algorithms for the diagnosis of pulmonary embolism.

Since the publication of the modified Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) criteria for the diagnosis of pulmonary embolism (PE), new clinical and scintigraphic diagnostic algorithms (the McMaster clinical criteria, the PisaPED simplified scintigraphic grading and the Miettinen logistic regression analysis) have been reported although the results have not been reproduced in other sites. Ventilation-perfusion lung scintigraphy was performed in 238 consecutive patients with a provisional diagnosis of PE. Scans were reported as normal/very low, low, intermediate or high probability for PE using standardized criteria. Each patient received a clinical grading of probability of PE as low, moderate or high using the McMaster clinical criteria. Using the PisaPED criteria (an alternate simplified scintigraphic grading system using the perfusion scan alone) each scan was also graded as normal/near normal, abnormal but not PE, or abnormal and PE. Using the logistic regression algorithm of Miettinen each scan received a numerical probability of PE. Frequencies for differing levels of probability of PE varied widely between the various algorithms. Cross tabulations revealed correlation of the standardized criteria with the Miettinen grading but not with the McMaster or the PisaPED gradings. We were unable to reproduce similar results using the McMaster clinical grading or the PisaPED simplified scintigraphic grading although the Miettinen logistic regression formula gave comparable results. New algorithms are not automatically transferable to new environments.

Effect of hip prostheses on radiotherapy dose.

A small but growing proportion of patients requiring radiotherapy for prostate cancer have one or two hip prostheses which may shadow the target and affect the dose distribution. Approximately 10 such patients are treated at the Illawarra Cancer Care Centre per year. Hence a study was undertaken to examine the accuracy of various treatment methods that involve some of the treatment fields travelling through the prosthesis. A fixed-field measurement showed a dose reduction of 52% in the shadow of the prosthesis. A Monte Carlo simulation confirmed an increase in dose on the distal surface of the prosthesis of 35%. Of more clinical relevance, however, is the dose distribution due to the overall combined field treatment. Using a power law correction benchmarked against thermoluminescent dosimeters and Gafchromic film, three different beam set-ups for patient treatment were planned and the dose variation analysed. A four-field brick technique gave a dose variation across the target volume of +/- 15% whereas a dual arc technique gave a dose variation of only +/- 5%. A four-field oblique technique gave a dose variation of only +/- 2% across the target volume but the oblique field technique included extra dose to the rectum.

Menopause: Irish women's voices.

OBJECTIVE: To gain an understanding of the cultural meanings of menopause for Irish women. DESIGN: Phenomenological, using Colaizzi's methodology to focus on the menopausal stories of Irish women. PARTICIPANTS AND SETTING: Six Irish women who were postmenopausal by 1-6 years were interviewed about their experiences. The participants were all mothers of five or more surviving children, chosen to exclude women who may have wished for more children. These women lived in small villages in rural southern Ireland. The taped interviews were conducted in the participants' homes. RESULTS: The sociocultural context of menopause in Ireland is described, including common perceptions of fertility and social timing of childbirth, and the meaning and significance of loss of fertility at menopause. The predominant themes found were a shared sense of relief at reaching menopause, a sense of acceptance of menopause as a natural event in a woman's life cycle, and a sense of satisfaction at having successfully raised their families to adulthood. There was also a bittersweet paradox of associated menopausal symptoms, particularly heavy bleeding. CONCLUSION: Rural Irish women in this study experience menopause as a normal process of aging and do not associate it with illness. Their experiences are strongly contextual and support the view that menopause is a complex phenomenon experienced within a sociocultural context.

Planar versus SPET imaging in the assessment of condylar growth.

The aim of this study was to compare two methods of quantifying 99Tc(m)-methylene diphosphonate uptake in the mandibular condyle. The study groups consisted of 23 patients with mandibular asymmetry and 16 normal volunteers aged 10-30 years. The accuracy and reproducibility of SPET using condyle-to-clivus ratios was compared with planar analysis using condyle-to-L4 (fourth lumbar vertebra) ratios. Quantitative analysis was correlated with semi-quantitative grading by three observers. Normal ranges for condyle-to-L4 and condyle-to-clivus ratios in individuals aged 11 years or over were determined. These ratios are useful in the serial monitoring of patients with condylar hyperplasia to establish when condylar growth has ceased and hence the type of surgery performed. Visual interpretation of condylar activity should use a combination of planar and SPET images and be performed in conjunction with quantitative analysis. Semi-quantitative grading on SPET images detected more subtle differences in condylar activity than planar images (using quantitative analysis as a standard).

Improved spatial resolution by MOSFET dosimetry of an x-ray microbeam.

Measurement of the lateral profile of the dose distribution across a narrow x-ray microbeam requires a dosimeter with a micron resolution. We investigated the use of a MOSFET dosimeter in an "edge-on" orientation with the gate insulating oxide layer parallel to the direction of the beam. We compared results using this technique to Gafchromic film measurements of a 200 micrometer wide planar x-ray microbeam. The microbeam was obtained by using a vernier micrometer-driven miniature collimator attached to a Therapax DXT300 x-ray machine operated at 100 kVp. The "edge-on" application allows utilization of the ultra thin sensitive volume of the MOSFET detector. Spatial resolution of both the MOSFET and Gafchromic film dosimeters appeared to be of about 1 micrometer. The MOSFET dosimeter appeared to provide more uniform dose profiles with the advantage of on-line measurements.

Retropharyngeal abscess on a Ga-67 scan: a case report.

A retropharyngeal abscess is a potentially fatal deep neck infection. Classical symptoms include fever, neck swelling, sore throat, dysphagia, and cervical rigidity. Sometimes small children present with nonspecific symptoms. We report a rare case whereby the Ga-67 citrate scan was the first investigation to reveal an inflammatory process in the retropharyngeal or submastoid region of a 3-year-old child with sepsis. This directed the line of investigation to a more precise anatomic imaging modality, CT scanning, to localize the abscess. With prompt administration of intravenous antibiotics, the child recovered quickly and did not require surgery. The Ga-67 scan is thus a useful screening test to detect inflammatory foci because of its high sensitivity. It is also valuable in the follow-up of the patient's response to therapy.