Spread-out Bragg peak measurements using a compact quality assurance range calorimeter at the Clatterbridge cancer centre.

Objective.The superior dose conformity provided by proton therapy relative to conventional x-ray radiotherapy necessitates more rigorous quality assurance (QA) procedures to ensure optimal patient safety. Practically however, time-constraints prevent comprehensive measurements to be made of the proton range in water: a key parameter in ensuring accurate treatment delivery.Approach.A novel scintillator-based device for fast, accurate water-equivalent proton range QA measurements for ocular proton therapy is presented. Experiments were conducted using a compact detector prototype, the quality assurance range calorimeter (QuARC), at the Clatterbridge cancer centre (CCC) in Wirral, UK for the measurement of pristine and spread-out Bragg peaks (SOBPs). The QuARC uses a series of 14 optically-isolated 100 × 100 × 2.85 mm polystyrene scintillator sheets, read out by a series of photodiodes. The detector system is housed in a custom 3D-printed enclosure mounted directly to the nozzle and a numerical model was used to fit measured depth-light curves and correct for scintillator light quenching.Main results.Measurements of the pristine 60 MeV proton Bragg curve found the QuARC able to measure proton ranges accurate to 0.2 mm and reduced QA measurement times from several minutes down to a few seconds. A new framework of the quenching model was deployed to successfully fit depth-light curves of SOBPs with similar range accuracy.Significance.The speed, range accuracy and simplicity of the QuARC make the device a promising candidate for ocular proton range QA. Further work to investigate the performance of SOBP fitting at higher energies/greater depths is warranted.

Determination of output factor for CyberKnife using scintillation dosimetry and deep learning.

Objective. Small-field dosimetry is an ongoing challenge in radiotherapy quality assurance (QA) especially for radiosurgery systems such as CyberKnifeTM. The objective of this work is to demonstrate the use of a plastic scintillator imaged with a commercial camera to measure the output factor of a CyberKnife system. The output factor describes the dose on the central axis as a function of collimator size, and is a fundamental part of CyberKnife QA and integral to the data used in the treatment planning system.Approach. A self-contained device consisting of a solid plastic scintillator and a camera was build in a portable Pelicase. Photographs were analysed using classical methods and with convolutional neural networks (CNN) to predict beam parameters which were then compared to measurements.Main results. Initial results using classical image processing to determine standard QA parameters such as percentage depth dose (PDD) were unsuccessful, with 34% of points failing to meet the Gamma criterion (which measures the distance between corresponding points and the relative difference in dose) of 2 mm/2%. However, when images were processed using a CNN trained on simulated data and a green scintillator sheet, 92% of PDD curves agreed with measurements with a microdiamond detector to within 2 mm/2% and 78% to 1%/1 mm. The mean difference between the output factors measured using this system and a microdiamond detector was 1.1%. Confidence in the results was enhanced by using the algorithm to predict the known collimator sizes from the photographs which it was able to do with an accuracy of less than 1 mm.Significance. With refinement, a full output factor curve could be measured in less than an hour, offering a new approach for rapid, convenient small-field dosimetry.

Technical challenges for FLASH proton therapy.

There is growing interest in the radiotherapy community in the application of FLASH radiotherapy, wherein the dose is delivered to the entire treatment volume in less than a second. Early pre-clinical evidence suggests that these extremely high dose rates provide significant sparing of healthy tissue compared to conventional radiotherapy without reducing the damage to cancerous cells. This interest has been reflected in the proton therapy community, with early tests indicating that the FLASH effect is also present with high dose rate proton irradiation. In order to deliver clinically relevant doses at FLASH dose rates significant technical hurdles must be overcome in the accelerator technology before FLASH proton therapy can be realised. Of these challenges, increasing the average current from the present clinical range of 1-10 nA to in excess of 100 nA is at least feasible with existing technology, while the necessity for rapid energy adjustment on the order of a few milliseconds is much more challenging, particularly for synchrotron-based systems. However, the greatest challenge is to implement full pencil beam scanning, where scanning speeds 2 orders of magnitude faster than the existing state-of-the-art will be necessary, along with similar improvements in the speed and accuracy of associated dosimetry. Hybrid systems utilising 3D-printed patient specific range modulators present the most likely route to clinical delivery. However, to correctly adapt and develop existing technology to meet the challenges of FLASH, more pre-clinical studies are needed to properly establish the beam parameters that are necessary to produce the FLASH effect.

Beam characterisation studies of the 62 MeV proton therapy beamline at the Clatterbridge Cancer Centre.

The Clatterbridge Cancer Centre (CCC) in the United Kingdom is the world's first hospital proton beam therapy facility, providing treatment for ocular cancers since 1989. A 62 MeV beam of protons is produced by a Scanditronix cyclotron and transported through a passive delivery system. In addition to the long history of clinical use, the facility supports a wide programme of experimental work and as such, an accurate and reliable simulation model of the treatment beamline is highly valuable. However, as the facility has seen several changes to the accelerator and beamline over the years, a comprehensive study of the CCC beam dynamics is needed to firstly examine the beam optics. An extensive analysis was required to overcome facility related constraints to determine fundamental beamline parameters and define an optical lattice written with the Methodical Accelerator Design (MAD-X) and the particle tracking Beam Delivery Simulation (BDSIM) code. An optimised case is presented and simulated results of the optical functions, beam distribution, losses and the transverse rms beam sizes along the beamline are discussed. Corresponding optical and beam information was used in TOPAS to simulate transverse beam profiles and compared to EBT3 film measurements. We provide an overview of the magnetic components, beam transport, cyclotron, beam and treatment related parameters necessary for the development of a present day optical model of the facility. This work represents the first comprehensive study of the CCC facility to date, as a basis to determine input beam parameters to accurately simulate and completely characterise the beamline.

A scintillator-based range telescope for particle therapy.

The commissioning and operation of a particle therapy centre requires an extensive set of detectors for measuring various parameters of the treatment beam. Among the key devices are detectors for beam range quality assurance. In this work, a novel range telescope based on a plastic scintillator and read out by a large-scale CMOS sensor is presented. The detector is made of a stack of 49 plastic scintillator sheets with a thickness of 2-3 mm and an active area of 100 × 100 mm2, resulting in a total physical stack thickness of 124.2 mm. This compact design avoids optical artefacts that are common in other scintillation detectors. The range of a proton beam is reconstructed using a novel Bragg curve model that incorporates scintillator quenching effects. Measurements to characterise the performance of the detector were carried out at the Heidelberger Ionenstrahl-Therapiezentrum (HIT, Heidelberg, GER) and the Clatterbridge Cancer Centre (CCC, Bebington, UK). The maximum difference between the measured range and the reference range was found to be 0.41 mm at a proton beam range of 310 mm and was dominated by detector alignment uncertainties. With the new detector prototype, the water-equivalent thickness of PMMA degrader blocks has been reconstructed within ± 0.1 mm. An evaluation of the radiation hardness proves that the range reconstruction algorithm is robust following the deposition of 6,300 Gy peak dose into the detector. Furthermore, small variations in the beam spot size and transverse beam position are shown to have a negligible effect on the range reconstruction accuracy. The potential for range measurements of ion beams is also investigated.

A mathematical expression for depth-light curves of therapeutic proton beams in a quenching scintillator.

PURPOSE: Recently, there has been increasing interest in the development of scintillator-based detectors for the measurement of depth-dose curves of therapeutic proton beams (Beaulieu and Beddar [2016], Phys Med Biol., 61:R305-R343). These detectors allow the measurement of single beam parameters such as the proton range or the reconstruction of the full three-dimensional dose distribution. Thus, scintillation detectors could play an important role in beam quality assurance, online beam monitoring, and proton imaging. However, the light output of the scintillator as a function of dose deposition is subject to quenching effects due to the high-specific energy loss of incident protons, particularly in the Bragg peak. The aim of this work is to develop a model that describes the percent depth-light curve in a quenching scintillator and allow the extraction of information about the beam range and the strength of the quenching. METHODS: A mathematical expression of a depth-light curve, derived from a combination of Birks' law (Birks [1951], Proc Phys Soc A., 64:874) and Bortfeld's Bragg curve (Bortfeld [1997], Med Phys., 24:2024-2033) that is termed a "quenched Bragg" curve, is presented. The model is validated against simulation and measurement. RESULTS: A fit of the quenched Bragg model to simulated depth-light curves in a polystyrene-based scintillator shows good agreement between the two, with a maximum deviation of 2.5% at the Bragg peak. The differences are larger behind the Bragg peak and in the dose build-up region. In the same simulation, the difference between the reconstructed range and the reference proton range is found to be always smaller than 0.16 mm. The comparison with measured data shows that the fitted beam range agrees with the reference range within their respective uncertainties. CONCLUSIONS: The quenched Bragg model is, therefore, an accurate tool for the range measurement from quenched depth-dose curves. Moreover, it allows the reconstruction of the beam energy spread, the particle fluence, and the magnitude of the quenching effect from a measured depth-light curve.

Technical Note: Simulation of dose buildup in proton pencil beams.

PURPOSE: The purpose of this study is to characterize the magnitude and depth of dose buildup in pencil beam scanning proton therapy. METHODS: We simulate the integrated depth-dose curve of realistic proton pencil beams in a water phantom using the Geant4 Monte Carlo toolkit. We independently characterize the electronic and protonic components of dose buildup as a function of proton beam energy from 40 to 400 MeV, both with and without an air gap. RESULTS: At clinical energies, electronic buildup over a distance of about 1 mm leads to a dose reduction at depth of the basal layer (0.07 mm) by up to 6% compared to if no buildup effect were present. Protonic buildup reduces the dose to the basal layer by up to 16% and has effects at depths of up to 150 mm. Secondary particles with a mass number A > 1 do not contribute to dose buildup. An air gap of 1 m has no significant effect on protonic buildup but reduces electronic buildup below 1%. CONCLUSIONS: Protonic and electronic dose buildup are relevant for accurate dosimetry in proton therapy although a realistic air gap reduces the electronic buildup to levels where it can be safely neglected. We recommend including electrons and secondary protons in Monte Carlo-based treatment planning systems down to a predicted range of 10-20 µ m in order to accurately model the dose at depths of the basal layer, no matter the size of the air gap between nozzle and patient.

Clinical categorization for elective surgery in Victoria.

AIM: The aim of the present paper was to assess trends in clinician's utilization of urgency categories for elective surgery. METHODS: The present paper reviews the additions to the Victorian elective surgery waiting list for hip replacement and prostatectomy as recorded by the Elective Surgery Information System database. Review of general trends in utilization over two separate 12 month periods were undertaken. RESULTS: There is inconsistency in categorization of patients referred to the waiting list for hip joint replacement and prostatectomy. An increasing trend to categorize patients as semi-urgent (category 2) in preference to non-urgent (category 3) emerged over this period (category creep). Semi-urgent cases might be competing for access within the category 2 band with less urgent cases. CONCLUSIONS: There seems to be an increasing imbalance between demand for and availability of elective surgery for lower urgency elective surgical procedures. This imbalance, characterized by lengthening waiting times, means that not all patients will receive treatment within the clinically recommended waiting times. The variable approach to categorization of urgency suggests that the process lacks objectivity and consensus. Simple clinical tools to assist prioritization are currently being evaluated in Victoria (Australia) and other countries.