Neutron and photon out-of-field doses at cardiac implantable electronic device (CIED) depths.

The accuracy of an out-of-field dose from an Elekta Synergy accelerator calculated using the X-ray Voxel Monte Carlo (XVMC) dose algorithm in the Monaco treatment planning system (TPS) for both low-energy (6 MV) and high-energy (15 MV) photons at cardiac implantable electronic device (CIED) depths was investigated through a comparison between MCNPX simulated out-of-field doses and measured out-of-field doses using three high spatial and sensitive active detectors. In addition, total neutron equivalent dose and fluence at CIED depths of a 15-MV dose from an Elekta Synergy accelerator were calculated, and the corresponding CIED relative neutron damage was quantified. The results showed that for 6-MV photons, the XVMC dose algorithm in Monaco underestimated out-of-field doses in all off-axis distances (average errors: -17% at distances X < 10 cm from the field edge and -31% at distances between 10 < X ≤ 16 cm from the field edge), with an increasing magnitude of underestimation for high-energy (15 MV) photons (up to 11%). According to the results, an out-of-field photon dose at a shallower CIED depth of 1 cm was associated with greater statistical uncertainty in the dose estimate compared to a CIED depth of 2 cm and clinical depth of 10 cm. Our results showed that the relative neutron damage at a CIED depth range for 15 MV photon is 36% less than that reported for 18 MV photon in the literature.

The effect of stereotactic body radiotherapy (SBRT) using flattening filter-free beams on cardiac implantable electronic devices (CIEDs) in clinical situations.

PURPOSE: This study focused on determining risks from stereotactic radiotherapy using flattening filter-free (FFF) beams for patients with cardiac implantable electronic device (CIEDs). Two strategies were employed: a) a retrospective analysis of patients with CIEDs who underwent stereotactic radiosurgery (SRS)/SBRT at the Peter MacCallum Cancer Centre between 2014 and 2018 and b) an experimental study on the impact of FFF beams on CIEDs. METHODS: A retrospective review was performed. Subsequently, a phantom study was performed using 30 fully functional explanted CIEDs from two different manufacturers. Irradiation was carried out in a slab phantom with 6-MV and 10-MV FFF beams. First, a repetition-rate test (RRT) with a range of beam pulse frequencies was conducted. Then, multifraction SBRT (48 Gy/4 Fx) and single-fraction SBRT (28 Gy/1 Fx) treatment plans were used for lung tumors delivered to the phantom. RESULTS: Between 2014 and 2018, 13 cases were treated with an FFF beam (6 MV, 1400 MU/min or 10 MV, 2400 MU/min), and 15 cases were treated with a flattening filter (FF) beam (6 MV, 600 MU/min). All the devices were positioned outside the treatment field at a distance of more than 5 cm, except for one case, and no failures were reported due to SBRT/SRS. In the phantom rep-rate tests, inappropriate sensing occurred, starting at a rep-rate of 1200 MU/min. Cardiac implantable electronic device anomalies during and after delivering VMAT-SBRT with a 10-MV FFF beam were observed. CONCLUSIONS: The study showed that caution should be paid to managing CIED patients when they undergo SBRT using FFF beams, as it is recommended by AAPM TG-203. Correspondingly, it was found that for FFF beams although there is small risk from dose-rate effects, delivering high dose of radiation with beam energy greater than 6 MV and high-dose rate to CIEDs positioned in close vicinity of the PTV may present issues.

A review and analysis of stereotactic body radiotherapy and radiosurgery of patients with cardiac implantable electronic devices.

The implementation of stereotactic body radiation therapy (SBRT) and stereotactic radiosurgery (SRS) has greatly increased due to its convenience and advantages from perspectives ranging from radiobiology to radio physics. Because SBRT/SRS delivers high doses in few fractions, precise dose delivery to target volumes and sufficient sparing of adjacent organs at risk (OARs) are required. Achieving these conflicting objectives is challenging for all patients receiving SBRT/SRS and may be particularly challenging when SBRT/SRS is adopted for treating patients with cardiac implantable electronic devices (CIEDs) because cumulative doses in CIEDs must be limited. Published research considering the different aspects of stereotactic treatment in patients with CIEDs was reviewed to summarise their findings in the following sections: (I) conventional linear accelerator (linac)-based SBRT and SRS; (II) CyberKnife, Gamma-Knife, VERO and helical tomotherapy SBRT and SRS; and (III) proton therapy. A total of 65 patients who had CIEDs and underwent SRS, SBRT, or SABR treatments were identified in the reviewed studies. The functionality of the CIEDs was assessed for 58 patients. Of those, CIED malfunctions (such as data loss, mode change, and inappropriate shock) were reported in four patients (6.89%). This review highlights the available sparse information in the literature by posing questions for future research.

A multicenter dosimetry study to evaluate the imaging dose from Elekta XVI and Varian OBI kV-CBCT systems to cardiovascular implantable electronic devices (CIEDs).

The increasing use of daily CBCT in radiotherapy has raised concerns about the additional dose delivered to the patient, and it can also become a concern issue for those patients with cardiovascular implantable electronic devices (CIEDs) (Pacemaker [PM] and Implantable Cardioverter Defibrillator [ICD]). Although guidelines highly recommend that the cumulative dose received by CIEDs should be kept as low as possible, and a safe threshold based on patient risk classification needs to be respected, this additional imaging dose is not usually considered. Four centers with different dosimetry systems and different CBCT imaging protocols participated in this multicenter study to investigate the imaging dose to the CIEDs from Elekta XVI and Varian OBI kV-CBCT systems. It was found that although imaging doses received by CIEDs outside the CBCT field are negligible, special attention should be paid to this value when CIEDs are inside the field because the daily use of CBCT can sometimes contribute considerably to the total dose received by a CIED.

Evaluation of localized region-based segmentation algorithms for CT-based delineation of organs at risk in radiotherapy.

BACKGROUND AND PURPOSE: In radiation therapy, defining the precise borders of cancerous tissues and adjacent normal organs has a significant effect on the therapy outcome. Deformable models offer a unique and robust approach to medical image segmentation. The objective of this study was to investigate the reliability of segmenting organs-at-risk (OARs) using three well-known local region-based level-set techniques. METHODS AND MATERIALS: A total of 1340 non-enhanced and enhanced planning computed tomography (CT) slices of eight OARs (the bladder, rectum, kidney, clavicle, humeral head, femoral head, spinal cord, and lung) were segmented by using local region-based active contour, local Chan-Vese, and local Gaussian distribution models. Quantitative metrics, namely Hausdorff Distance (HD), Mean Absolute Distance (MAD), Dice coefficient (DC), Percentage Volume Difference (PVD) and Absolute Volumetric Difference (AVD), were adopted to measure the correspondence between detected contours and the manual references drawn by experts. RESULTS: The results showed the feasibility of using local region-based active contour methods for defining six of the OARs (the bladder, kidney, clavicle, humeral head, spinal cord, and lung) when adequate intensity information is available. While the most accurate results were achieved for lung (DC = 0.94) and humeral head (DC = 0.92), a poor level of agreement (DC < 0.7) was obtained for both rectum and femur. CONCLUSION: Incorporating local statistical information in level set methods yields to satisfactory results of OARs delineation when adequate intensity information exists between the organs. However, the complexity of adjacent organs and the lack of distinct boundaries would result in a considerable segmentation error.

Tabulated square-shaped source model for linear accelerator electron beam simulation.

CONTEXT: Using this source model, the Monte Carlo (MC) computation becomes much faster for electron beams. AIMS: The aim of this study was to present a source model that makes linear accelerator (LINAC) electron beam geometry simulation less complex. SETTINGS AND DESIGN: In this study, a tabulated square-shaped source with transversal and axial distribution biasing and semi-Gaussian spectrum was investigated. SUBJECTS AND METHODS: A low energy photon spectrum was added to the semi-Gaussian beam to correct the bremsstrahlung X-ray contamination. After running the MC code multiple times and optimizing all spectrums for four electron energies in three different medical LINACs (Elekta, Siemens, and Varian), the characteristics of a beam passing through a 10 cm × 10 cm applicator were obtained. The percentage depth dose and dose profiles at two different depths were measured and simulated. RESULTS: The maximum difference between simulated and measured percentage of depth doses and dose profiles was 1.8% and 4%, respectively. The low energy electron and photon spectrum and the Gaussian spectrum peak energy and associated full width at half of maximum and transversal distribution weightings were obtained for each electron beam. The proposed method yielded a maximum computation time 702 times faster than a complete head simulation. CONCLUSIONS: Our study demonstrates that there was an excellent agreement between the results of our proposed model and measured data; furthermore, an optimum calculation speed was achieved because there was no need to define geometry and materials in the LINAC head.

Magnetic resonance imaging-based target volume delineation in radiation therapy treatment planning for brain tumors using localized region-based active contour.

PURPOSE: To evaluate the clinical application of a robust semiautomatic image segmentation method to determine the brain target volumes in radiation therapy treatment planning. METHODS AND MATERIALS: A local robust region-based algorithm was used on MRI brain images to study the clinical target volume (CTV) of several patients. First, 3 oncologists delineated CTVs of 10 patients manually, and the process time for each patient was calculated. The averages of the oncologists' contours were evaluated and considered as reference contours. Then, to determine the CTV through the semiautomatic method, a fourth oncologist who was blind to all manual contours selected 4-8 points around the edema and defined the initial contour. The time to obtain the final contour was calculated again for each patient. Manual and semiautomatic segmentation were compared using 3 different metric criteria: Dice coefficient, Hausdorff distance, and mean absolute distance. A comparison also was performed between volumes obtained from semiautomatic and manual methods. RESULTS: Manual delineation processing time of tumors for each patient was dependent on its size and complexity and had a mean (±SD) of 12.33 ± 2.47 minutes, whereas it was 3.254 ± 1.7507 minutes for the semiautomatic method. Means of Dice coefficient, Hausdorff distance, and mean absolute distance between manual contours were 0.84 ± 0.02, 2.05 ± 0.66 cm, and 0.78 ± 0.15 cm, and they were 0.82 ± 0.03, 1.91 ± 0.65 cm, and 0.7 ± 0.22 cm between manual and semiautomatic contours, respectively. Moreover, the mean volume ratio (=semiautomatic/manual) calculated for all samples was 0.87. CONCLUSIONS: Given the deformability of this method, the results showed reasonable accuracy and similarity to the results of manual contouring by the oncologists. This study shows that the localized region-based algorithms can have great ability in determining the CTV and can be appropriate alternatives for manual approaches in brain cancer.