COMP report: CPQR technical quality control guidelines for radiation treatment centers.

The Canadian Organization of Medical Physicists (COMP), in close partnership with the Canadian Partnership for Quality Radiotherapy (CPQR) has developed a series of Technical Quality Control (TQC) guidelines for radiation treatment equipment. These guidelines outline the performance objectives that equipment should meet in order to ensure an acceptable level of radiation treatment quality. The TQC guidelines have been rigorously reviewed and field tested in a variety of Canadian radiation treatment facilities. The development process enables rapid review and update to keep the guidelines current with changes in technology. This announcement provides an introduction to the guidelines, describing their scope and how they should be interpreted. Details of recommended tests can be found in separate, equipment specific TQC guidelines published in the JACMP (COMP Reports), or the website of the Canadian Partnership for Quality Radiotherapy (www.cpqr.ca).

Production, review, and impact of technical quality control guidelines in a national context.

A close partnership between the Canadian Partnership for Quality Radiotherapy (CPQR) and the Canadian Organization of Medical Physicist's (COMP) Quality Assurance and Radiation Safety Advisory Committee (QARSAC) has resulted in the development of a suite of Technical Quality Control (TQC) guidelines for radiation treatment equipment; they outline specific performance objectives and criteria that equipment should meet in order to assure an acceptable level of radiation treatment quality. The adopted framework for the development and maintenance of the TQCs ensures the guidelines incorporate input from the medical physics com-munity during development, measures the workload required to perform the QC tests outlined in each TQC, and remain relevant (i.e., "living documents") through subsequent planned reviews and updates. The framework includes consolidation of existing guidelines and/or literature by expert reviewers, structured stages of public review, external field-testing, and ratification by COMP. This TQC develop-ment framework is a cross-country initiative that allows for rapid development of robust, community-driven living guideline documents that are owned by the com-munity and reviewed to keep relevant in a rapidly evolving technical environment. Community engagement and uptake survey data shows 70% of Canadian centers are part of this process and that the data in the guideline documents reflect, and are influencing, the way Canadian radiation treatment centers run their technical quality control programs. For a medium-sized center comprising six linear accelerators and a comprehensive brachytherapy program, we evaluate the physics workload to 1.5 full-time equivalent physicists per year to complete all QC tests listed in this suite.

Radiotherapeutic Management of Non-Small Cell Lung Cancer in the Minimal Resource Setting.

Lung cancer is the most common cancer worldwide and the fifth most common cause of death globally. Its incidence continues to increase, especially within low- and middle-income countries (LMICs), which have limited capacity to address the growing need for treatment. The standard of care for lung cancer treatment often involves radiation therapy (RT), which plays an important therapeutic role in curative-intent treatment of early-stage to locally advanced disease, as well as in palliation. The infrastructure, equipment, and human resources required for RT may be limited in LMICs. However, this narrative review discusses the scope of the problem of lung cancer in LMICs, the role of RT technologies in lung cancer treatment, and RT capacity in developing countries. Strategies are presented for maximizing the availability and impact of RT in settings with minimal resource availability, and areas for potential future innovation are identified. Priorities for LMICs involve increasing access to RT equipment and trained health care professionals, ensuring quality of care, providing guidance on priority setting with limited resources, and encouraging innovation to increase the economic efficiency of RT delivery. Several international initiatives are currently under way and represent important first steps toward scaling up RT in LMICs to treat lung cancer.

Cobalt-60 tomotherapy: clinical treatment planning and phantom dose delivery studies.

PURPOSE: Investigations have shown that a Cobalt-60 (Co-60) radioactive source has the potential to play a role in intensity modulated radiation therapy (IMRT). In this paper, Co-60 tomotherapy's conformal dose delivery potential is evaluated by delivering conformal dose plans on a cylindrical homogeneous phantom containing clinical structures similar to those found in a typical head and neck (H&N) cancer. Also, the clinical potential of Co-60 tomotherapy is investigated by generating 2D clinical treatment plans for H&N and prostate anatomical regions. These plans are compared with the 6 MV based treatment plans for modalities such as linear accelerator-based tomotherapy and broad beam IMRT, and 15 MV based 3D conformal radiation therapy (3DCRT). METHODS: For experimental validation studies, clinical and nonclinical conformal dose patterns were delivered on circular, homogeneous phantoms containing GafChromic film. For clinical planning study, dose calculations were performed with the EGSnrc Monte Carlo program, where a Theratronics 780C Co-60 unit and a 6 MV linear accelerator were modeled with a MIMiC binary multileaf collimator. An inhouse inverse treatment planning system was used to optimize tomotherapy plans using the same optimization parameters for both Co-60 and 6 MV beams. The IMRT and 3DCRT plans for the clinical cases were generated entirely in the Eclipse treatment planning system based on inhouse IMRT and 3DCRT site specific protocols. RESULTS: The doses delivered to the homogeneous phantoms agreed with the calculations, indicating that it is possible to deliver highly conformal doses with the Co-60 unit. The dose distributions for Co-60 tomotherapy clinical plans for both clinical cases were similar to those obtained with 6 MV based tomotherapy and IMRT, and much more conformal compared to 3DCRT plans. The dose area histograms showed that the Co-60 plans achieve the dose objectives for the targets and organs at risk. CONCLUSIONS: These results confirm that Co-60 tomotherapy is capable of providing state-of-the-art conformal dose delivery and could be used for the treatment of targets in both small and larger separation anatomical regions.

Investigation of photon shielding property changes in curing high density concrete.

High density concrete is usually used for radiation shielding around radiotherapy treatment rooms. Because the concrete is specified differently at the design, construction, and verification stages, the relationship between the intended performance and the actual performance of the shielding material might not be entirely clear. In this study, cylindrical samples of high density shielding concrete were taken as each section of a new radiotherapy bunker was poured. The shielding performance of each sample [measured by beam attenuation and tenth-value layers (TVL)] was evaluated for 15 MV and 6 MV x-ray beams and for the 1.25 MeV monoenergetic gamma beam from a Co source. Transmission curves to 3 TVL were mapped for a representative sample. The samples were also imaged and analyzed using Co Cone Beam Computed Tomography (CoCBCT). Results indicate no significant change in the TVL of high density concrete samples as they cure. The minor fluctuations in shielding properties observed are explained by the heterogeneous structure of the samples as indicated in the CoCBCT images.

Medical physics staffing for radiation oncology: a decade of experience in Ontario, Canada.

The January 2010 articles in The New York Times generated intense focus on patient safety in radiation treatment, with physics staffing identified frequently as a critical factor for consistent quality assurance. The purpose of this work is to review our experience with medical physics staffing, and to propose a transparent and flexible staffing algorithm for general use. Guided by documented times required per routine procedure, we have developed a robust algorithm to estimate physics staffing needs according to center-specific workload for medical physicists and associated support staff, in a manner we believe is adaptable to an evolving radiotherapy practice. We calculate requirements for each staffing type based on caseload, equipment inventory, quality assurance, educational programs, and administration. Average per-case staffing ratios were also determined for larger-scale human resource planning and used to model staffing needs for Ontario, Canada over the next 10 years. The workload specific algorithm was tested through a survey of Canadian cancer centers. For center-specific human resource planning, we propose a grid of coefficients addressing specific workload factors for each staff group. For larger scale forecasting of human resource requirements, values of 260, 700, 300, 600, 1200, and 2000 treated cases per full-time equivalent (FTE) were determined for medical physicists, physics assistants, dosimetrists, electronics technologists, mechanical technologists, and information technology specialists, respectively.

Aperture superposition dose model versus pencil beam superposition dose model for a finite size Cobalt-60 source for tomotherapy deliveries.

PURPOSE: The finite size pencil beam (FSPB) superposition method is a commonly used dose calculation method in intensity modulated radiation therapy (IMRT). The FSPB model assumes that dose for a broad intensity modulated beam can be calculated by superposition of dose from small, pencil-like beams. However, this model is limited to point-like radiation sources and is not valid for finite size sources, such as a Cobalt-60 (Co-60) source of 2 cm diameter. In this paper, the authors present results that show the limitation of this model and propose an alternative model, namely the aperture superposition (AS) model, to calculate photon dose for intensity modulated beams arising from finite size radiation sources. METHODS: The AS model is based on adding beam apertures rather than pencil beams. Each aperture is defined as a series of adjacently opened leaves of a multileaf collimator with no closed leaves in between them. The apertures are calculated using the EGSnrc Monte Carlo program. The accuracy of the AS model was tested for dose calculations of fan beams, as encountered in tomotherapy treatment plans. The results were compared with the FSPB model and GafChromic film measurements. The measurements and simulations were performed for a clinical Theratronics T780C Co-60 unit with MIMiC binary multileaf collimator mounted on it. RESULTS: The comparisons between the AS model and film measurements show agreement better than 1.5% in the high dose regions and 3.7% in the low dose regions. On the contrary, film measurement comparisons to the FSPB model show that the FSPB model underestimates the dose by up to 7% for small field sizes such as 2 × 2 cm(2) and 20% for larger field sizes such as 20 × 2 cm(2). CONCLUSIONS: The results presented in this paper indicate that the AS model provides better accuracy than the FSPB model when calculating dose for fan beams from large radiation sources. The implementation of this model to the current treatment planning systems has the scope of advancing Co-60 based IMRT and tomotherapy.

Small field dose delivery evaluations using cone beam optical computed tomography-based polymer gel dosimetry.

This paper explores the combination of cone beam optical computed tomography with an N-isopropylacrylamide (NIPAM)-based polymer gel dosimeter for three-dimensional dose imaging of small field deliveries. Initial investigations indicate that cone beam optical imaging of polymer gels is complicated by scattered stray light perturbation. This can lead to significant dosimetry failures in comparison to dose readout by magnetic resonance imaging (MRI). For example, only 60% of the voxels from an optical CT dose readout of a 1 l dosimeter passed a two-dimensional Low's gamma test (at a 3%, 3 mm criteria, relative to a treatment plan for a well-characterized pencil beam delivery). When the same dosimeter was probed by MRI, a 93% pass rate was observed. The optical dose measurement was improved after modifications to the dosimeter preparation, matching its performance with the imaging capabilities of the scanner. With the new dosimeter preparation, 99.7% of the optical CT voxels passed a Low's gamma test at the 3%, 3 mm criteria and 92.7% at a 2%, 2 mm criteria. The fitted interjar dose responses of a small sample set of modified dosimeters prepared (a) from the same gel batch and (b) from different gel batches prepared on the same day were found to be in agreement to within 3.6% and 3.8%, respectively, over the full dose range. Without drawing any statistical conclusions, this experiment gives a preliminary indication that intrabatch or interbatch NIPAM dosimeters prepared on the same day should be suitable for dose sensitivity calibration.

Cone-beam optical computed tomography for gel dosimetry II: imaging protocols.

This work develops imaging protocols for improved dose readout of a Fricke-xylenol orange-gelatin (FXG) gel-filled 1 L polyethylene terephthalate (PETE) jar dosimeter using a commercial Vista(TM) cone-beam optical computed tomography (CT) scanner from Modus Medical Devices Inc. (London, ON, Canada). To ensure good management of light source-detector stability, it was determined that (a) a minimum of 2 h warm-up time is necessary prior to dosimeter scanning, (b) the light source should be kept on until the completion of the last data scan except for the minimum amount of time required to acquire dark field images, and (c) the optional Vista software projection image normalization routine should be used in image reconstruction. The institution of dosimeter scan time and temperature control was strongly indicated from the experiments. A standard post-irradiation wait time of 30 min measured to within ±30 s was established to minimize the measurement uncertainties due to dosimeter development and diffusion. To alleviate thermochromic behavior leading to inaccurate dose readout, holding bath warm up and pre-scan temperature adjustment procedures were developed to control dosimeter temperature to within ±0.2 °C. The possibility of stray light minimizing protocols was also investigated and deemed to be unnecessary. The largest significant sources of stray light in the system were identified as being due to angled scatter from the dosimeter gelatin matrix and refraction from the jar wall interfaces. It was concluded that these phenomena would be better addressed through dosimeter modification and an inter-jar dose-to-attenuation calibration methodology, rather than by setting additional imaging protocols.

Dosimetry of interface region near closed air cavities for Co-60, 6 MV and 15 MV photon beams using Monte Carlo simulations.

Underdosing of treatment targets can occur in radiation therapy due to electronic disequilibrium around air-tissue interfaces when tumors are situated near natural air cavities. These effects have been shown to increase with the beam energy and decrease with the field size. Intensity modulated radiation therapy (IMRT) and tomotherapy techniques employ combinations of multiple small radiation beamlets of varying intensities to deliver highly conformal radiation therapy. The use of small beamlets in these techniques may therefore result in underdosing of treatment target in the air-tissue interfaces region surrounding an air cavity. This work was undertaken to investigate dose reductions near the air-water interfaces of 1x1x1 and 3x3x3 cm(3) air cavities, typically encountered in the treatment of head and neck cancer utilizing radiation therapy techniques such as IMRT and tomotherapy using small fields of Co-60, 6 MV and 15 MV photons. Additional investigations were performed for larger photon field sizes encompassing the entire air-cavity, such as encountered in conventional three dimensional conformal radiation therapy (3DCRT) techniques. The EGSnrc/DOSXYZnrc Monte Carlo code was used to calculate the dose reductions (in water) in air-water interface region for single, parallel opposed and four field irradiations with 2x2 cm(2) (beamlet), 10x2 cm(2) (fan beam), 5x5 and 7x7 cm(2) field sizes. The magnitude of dose reduction in water near air-water interface increases with photon energy; decreases with distance from the interface as well as decreases as the number of beams are increased. No dose reductions were observed for large field sizes encompassing the air cavities. The results demonstrate that Co-60 beams may provide significantly smaller interface dose reductions than 6 MV and 15 MV irradiations for small field irradiations such as used in IMRT and tomotherapy.

Cone beam optical computed tomography for gel dosimetry I: scanner characterization.

The ongoing development of easily accessible, fast optical readout tools promises to remove one of the barriers to acceptance of gel dosimetry as a viable tool in cancer clinics. This paper describes the characterization of a number of basic properties of the Vista cone beam CCD-based optical scanner, which can obtain high resolution reconstructed data in less than 20 min total imaging and reconstruction time. The suitability of a filtered back projection cone beam reconstruction algorithm is established for optically absorbing dosimeters using this scanner configuration. The system was then shown to be capable of imaging an optically absorbing media-filled 1 L polyethylene terephthalate (PETE) jar dosimeter to a reconstructed voxel resolution of 0.5 x 0.5 x 0.5 mm(3). At this resolution, more than 60% of the imaged volume in the dosimeter exhibits minimal spatial distortion, a measurement accuracy of 3-4% and the mean to standard deviation signal-to-noise ratio greater than 100 over an optical absorption range of 0.06-0.18 cm(-1). An inter-day scan precision of 1% was demonstrated near the upper end of this range. Absorption measurements show evidence of stray light perturbation causing artifacts in the data, which if better managed would improve the accuracy of optical readout. Cone beam optical attenuation measurements of scattering dosimeters, on the other hand, are nonlinearly affected by angled scatter stray light. Scatter perturbation leads to significant cupping artifacts and other inaccuracies that greatly limit the readout of scattering polymer gel dosimeters with cone beam optical CT.

The role of Cobalt-60 in modern radiation therapy: Dose delivery and image guidance.

The advances in modern radiation therapy with techniques such as intensity-modulated radiation therapy and image-guided radiation therapy (IMRT and IGRT) have been limited almost exclusively to linear accelerators. Investigations of modern Cobalt-60 (Co-60) radiation delivery in the context of IMRT and IGRT have been very sparse, and have been limited mainly to computer-modeling and treatment-planning exercises. In this paper, we report on the results of experiments using a tomotherapy benchtop apparatus attached to a conventional Co-60 unit. We show that conformal dose delivery is possible and also that Co-60 can be used as the radiation source in megavoltage computed tomography imaging. These results complement our modeling studies of Co-60 tomotherapy and provide a strong motivation for continuing development of modern Cobalt-60 treatment devices.

Practical and clinical considerations in Cobalt-60 tomotherapy.

Cobalt-60 (Co-60) based radiation therapy continues to play a significant role in not only developing countries, where access to radiation therapy is extremely limited, but also in industrialized countries. Howver, technology has to be developed to accommodate modern techniques, including image guided and adaptive radiation therapy (IGART). In this paper we describe some of the practical and clinical considerations for Co-60 based tomotherapy by comparing Co-60 and 6 MV linac-based tomotherapy plans for a head and neck (HandN) cancer and a prostate cancer case. The tomotherapy IMRT plans were obtained by modeling a MIMiC binary multi-leaf collimator attached to a Theratron-780c Co-60 unit and a 6 MV linear accelerator (CL2100EX). The EGSnrc/BEAMnrc Monte Carlo (MC) code was used for the modeling of the treatment units with the MIMiC collimator and EGSnrc/DOSXYZnrc code was used for beamlet dose data. An in-house inverse treatment planning program was then used to generate optimized tomotherapy dose distributions for the H and N and prostate cases. The dose distributions, cumulative dose area histograms (DAHs) and dose difference maps were used to evaluate and compare Co-60 and 6 MV based tomotherapy plans. A quantitative analysis of the dose distributions and dose-volume histograms shows that both Co-60 and 6 MV plans achieve the plan objectives for the targets (CTV and nodes) and OARs (spinal cord in HandN case, and rectum in prostate case).

Investigation of an efficient source design for Cobalt-60-based tomotherapy using EGSnrc Monte Carlo simulations.

Recent investigations demonstrate a strong potential for Cobalt-60 (Co-60)-based tomotherapy. Reported work suggests that Co-60-based tomotherapy offers a clinically and commercially viable alternative to megavoltage x-ray-based tomotherapy. Tomotherapy applications use a combination of intensity-modulated fan beams to deliver highly conformal radiotherapy. However, conventional Co-60 units are designed to give large uniform rectangular fields using an isotropic radioactive source in a cylindrical geometry. Such cylindrical source geometry likely provides a sub-optimal use of the radioactivity within the source volume for tomotherapy applications due to a significant loss of radiated energy outside the fan beam collimation system. To investigate a more efficient source geometry suitable for Co-60 tomotherapy applications, a computer code was written to model an isotropic source in a 6-faced polyhedron geometry such as cube, parallelepiped, prism and truncated pyramid. This code was integrated with the existing EGSnrc/BEAMnrc Monte Carlo (MC) code. The integrated source code was thoroughly tested, validated and used to investigate the energy spectra, radiation output and self-shielding properties of various rectangular-shaped (RS) Co-60 sources. Fan beam dose profiles were calculated for various cylindrical and RS Co-60 sources for a range of source-to-axis distances (SAD), multi-leaf collimator-to-isocentre distances (CID) and modified collimator systems. Fringe and penumbra distances were analysed for the simulated dose profiles. Our results demonstrate that clinically acceptable fringe and penumbra distances can be achieved by a careful selection of SAD, CID, source shape and dimensions and modified collimator system. Significant overall gain in radiation output of the 20 x 1 cm(2) fan beams can be achieved by an optimal selection of the source geometry for a given active volume of Co-60. The overall gain includes the effects of change in packing density (accounting for self-absorption) and change in source shape.

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.

Evaluation of an automated seed loader for seed calibration in prostate brachytherapy.

Automated seed loaders for permanent prostate implants are now commercially available. Besides improved radiation safety, these systems offer seed assay capability and ease of needle loading, making preplanned as well as intra-operative implant procedures more time-efficient. The Isoloader (Mentor Corp., CA) uses individual I125 seeds (SL-125 ProstaSeed) loaded in up to 199 chambers inside a shielded cartridge. The unit performs seed counting and calibration using a builtin solid-state detector. In order to evaluate the reproducibility and accuracy of the calibration process, two test cartridges were measured with the Isoloader itself and compared with a well-type ionization chamber (HDR-1000Plus, Standard Imaging). The air kerma strength measurements for all seeds using the Isoloader had a standard deviation of about 2.7%. For the eight seeds assayed more intensively using both the Isoloader and well chamber, the standard deviations of the measurements for each seed were in the range of 0.8% to 2.8% and 0.6% to 1.3%, respectively. The variation in the Isoloader calibration is attributed to small detector solid angle and bead geometry within seed capsules (verified by radiographs). The reproducibility of the air kerma strength measured by the Isoloader was comparable to that from the well chamber and was clinically acceptable. Seed strength measured with the Isoloader was on average 1% 2% larger than that measured with the well chamber, indicating that the accuracy of the Isoloader was clinically acceptable.