Evolution of clinical radiotherapy physics practice under COVID-19 constraints.

As the COVID-19 spread continues to challenge the societal and professional norms, radiotherapy around the globe is pushed into an unprecedented transformation. We will discuss how clinical physics has transformed to ascertain safety and quality standards across four facilities around the world through diversity of action, innovation, and scientific flexibility.

Monte Carlo study of the relationship between skin dose and optically stimulated luminescence dosimeter dose in Pd-103 permanent breast seed implant brachytherapy.

PURPOSE: To establish a method for estimating skin dose for patients with permanent breast seed implant based on in vivo optically stimulated luminescence dosimeters (OSLDs) measurements. METHODS AND MATERIALS: Monte Carlo simulations were performed in a simple breast phantom using the EGSnrc user code egs_brachy. Realistic models of the IsoAid Advantage Pd-103 brachytherapy source and Landauer nanoDot OSLD were created to model in vivo skin dose measurements where an OSLD would be placed on the skin of a patient with permanent breast seed implant following implantation. Doses to a 0.2 cm3 volume of skin beneath the OSLD and to the sensitive volume within the OSLD were calculated, and the ratio of these values was found for various seed positions inside the breast phantom. The maximum value of this ratio may be used as a conversion factor that would allow skin dose to be estimated from in vivo OSLD measurements. RESULTS: Conversion factors of 0.5 and 1.44 are recommended for OSLDs calibrated to dose to Al2O3 and water, respectively, at the point of measurement in the OSLD. These factors were not significantly affected by the addition of extra seeds in the dose calculations. CONCLUSIONS: A method for estimating skin dose from OSLD measurements was proposed. Individual institutions should calibrate OSLDs to Pd-103 seeds to apply the results of this work clinically.

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).

Characterizing 3D printing in the fabrication of variable density phantoms for quality assurance of radiotherapy.

PURPOSE: To present characterization, process flow, and applications of 3D fabricated low density phantoms for radiotherapy quality assurance (QA). MATERIAL AND METHODS: A Rostock 3D printer using polystyrene was employed to print slabs of varying relative electron densities (0.18-0.75). A CT scan was used to calibrate infill-to-density and characterize uniformity of the print. Two printed low relative density rods (0.18, 0.52) were benchmarked against a commercial CT-electron-density phantom. Density scaling of Anisotropic Analytical Algorithm (AAA) was tested with EBT3 film for a 0.57 slab. Gamma criterion of 3% and 3 mm was used for analysis. RESULTS: 3D printed slabs demonstrated uniformity for densities 0.4-0.75. The printed 0.52 rod had close agreement with the commercial phantom. Dosimetric comparison for 0.57 density slab showed >95% agreement between calculation and measurements. CONCLUSION: 3D printing allows fabrication of variable density phantoms for QA needs of a small clinic.

Assessing the deviation from the inverse square law for orthovoltage beams with closed-ended applicators.

In this report, we quantify the divergence from the inverse square law (ISL) of the beam output as a function of distance (standoff) from closed-ended applicators for a modern clinical orthovoltage unit. The divergence is clinically significant exceeding 3% at a 1.2 cm distance for 4 × 4 and 10 × 10 cm2 closed-ended applicators. For all investigated cases, the measured dose falloff is more rapid than that predicted by the ISL and, therefore, causes a systematic underdose when using the ISL for dose calculations at extended SSD. The observed divergence from the ISL in closed-ended applicators can be explained by the end-plate scattering contribution not accounted for in the ISL calculation. The standoff measurements were also compared to the predictions from a home-built kV dose computation algorithm, kVDoseCalc. The kVDoseCalc computation predicted a more rapid falloff with distance than observed experimentally. The computation and measurements agree to within 1.1% for standoff distances of 3 cm or less for 4 × 4 cm2 and 10 × 10 cm2 field sizes. The overall agreement is within 2.3% for all field sizes and standoff distances measured. No significant deviation from the ISL was observed for open-ended applicators for standoff distances up to 10 cm.

Energy response of EBT3 radiochromic films: implications for dosimetry in kilovoltage range.

The objective of this study is to evaluate the suitability of recently introduced radiochromic film EBT3 for clinical dosimetry in the kilovoltage (kV) range. For this purpose, a kV X-ray irradiator, X RAD 320ix in the range 70 to 300 kVp, a clinical 60Co source, a 6 MV and an 18 MV X-ray clinical beam from a Varian linear accelerator were calibrated following AAPM dosimetry protocols. EBT3 films from two different EBT3 batches were placed side-by-side on the surface of a water phantom; doses from 0.5 to 4 Gy were delivered. Similarly, irradiations were performed for 60Co and 6 and 18 MV beams in a water equivalent phantom. Films were reproducibly placed at the center of a flatbed scanner and 48-bit RGB scans were obtained both pre- and postirradiations. Net optical density (netOD) and response for a given radiation quality relative to 60Co was determined for each EBT3 film. The netOD of the red color showed reproducible response (within 1%) for both batches when irradiated using the 60Co source. For a given dose of 1 Gy of kVp X-ray, the response relative to 60Co using the three color channels (red, green, and blue) decreases with decrease in kVp, reaching a maximum underresponse of ~ 20% for the 70 kVp. A significant underresponse of ~ 5% was observed at 300kVp. Responses of MV X-ray beams with respect to 60Co at the 1 Gy dose level showed no statistically significant difference. A relatively small difference in the response was observed between the two EBT3 batches used in this study in the kV X-ray range.

FracMod: a computational tool for assessing IMRT field modulation.

The authors develop and investigate a user-friendly computational tool (FracMod) to quantify modulation complexity in planned IMRT fields. FracMod comprises a graphical user interface and variogram fractal dimension (FD) analysis tool developed by the authors using MATLAB(®), and made freely available at http://www.medphysfiles.com/index.php. FracMod is investigated for its ability to identify overly-modulated dynamic IMRT fields designed for prostatic carcinoma treatments. A set of 5 prostate alone plans and 5 prostate plus pelvic node plans were used to choose FD cut-points that ensure no false positives in distinguishing between moderate and high field modulation. IMRT quality control (QC) was performed on all the treatment fields using Varian(®) Portal Dosimetry and MapCHECK™. Receiver operating characteristic analysis was used to quantitatively compare the classification performance of FD and the number of monitor units (MUs). The effect of dose rate on the average leaf pair opening (ALPO) and the number of MUs delivered was also investigated. The variogram FD performed better than the number of MUs in identifying overly-modulated fields. FD thresholds >2.15 for prostate alone and >2.20 for prostate plus pelvic nodes correctly identified 75% and 100% of the high modulation fields, respectively, with no false positives. With appropriate cut-points, MapCHECK™ identified the most highly modulated IMRT fields, whereas Varian(®) Portal Dosimetry could not. As expected, ALPO decreases with increasing modulation and increasing dose rate. FracMod is a user-friendly tool that allows one to accurately quantify and identify overly-modulated IMRT fields at the treatment planning stage before they are sent for patient-specific QC.

Total body irradiation dose optimization based on radiological depth.

We have previously demonstrated the use of Eclipse fluence optimization to define aperture sizes for a novel aperture modulated translating bed total body irradiation (TBI) technique. The purposes of the present study were to identify, characterize, and correct for sources of error inherent in our previous fluence optimization technique, and to develop a clinically viable fluence optimization module for the translating bed TBI technique. Aperture modulated TBI is delivered by translating the patient at constant speed on a custom bed under a modulated radiation beam. The patient is then turned from supine to prone and the process repeated, resulting in an AP-PA treatment. Radiological depths were calculated along divergent ray lines through individual CT slices of a RANDO phantom. Beam apertures, defined using a dynamic multileaf collimator (DMLC), were generated using calculated radiological depths and calibration factors that relate fluence to aperture size in a dynamic environment. These apertures were defined every 9 mm along the phantom superior-inferior axis. The calculated beam apertures were further modified to account for scatter within the patient. For dose calculation purposes the individual MLC files were imported into Eclipse. For treatment delivery, dynamic MLC files for both AP and PA beams were generated and delivered dynamically. Dose homogeneity in the head and neck region of the RANDO phantom was within ± 4% of the prescribed dose with this novel technique compared to -5% to +7% with our previous aperture modulated technique based on Eclipse fluence optimization. Fluence optimization and beam aperture calculation using the new technique offers a ten-fold reduction in planning time and significantly reduces the likelihood of user error during the planning process. In conclusion, a clinically viable aperture modulated translating bed TBI technique that employs dynamically shaped MLC-defined beam apertures based on radiological depth calculations, has been developed.

Fractal analysis for assessing the level of modulation of IMRT fields.

PURPOSE: To investigate the potential of three fractal dimension (FD) analysis methods (i.e., the variation, power spectrum, and variogram methods) as metrics for quantifying the degree of modulation in planned intensity modulated radiation therapy (IMRT) treatment fields, and compare the most suitable FD method to the number of monitor units (MUs), the average leaf gap, and the 2D modulation index (2D MI) for assessing modulation. METHODS: The authors implemented, validated, and compared the variation, power spectrum, and variogram methods for computing the FD. Validation of the methods was done using mathematical fractional Brownian surfaces of known FD that ranged in size from 128 × 128 to 512 × 512. The authors used a test set consisting of seven head and neck carcinoma plans (50 prescribed treatment fields) to choose an FD cut-point that ensures no false positives (100% specificity) in distinguishing between moderate and high degrees of field modulation. The degree of field modulation was controlled by adjusting the fluence smoothing parameters in the Eclipse™ treatment planning system (Varian Medical Systems, Palo Alto, CA). The moderate modulation fields were representative of the degree of modulation used clinically at the authors' institution. The authors performed IMRT quality assurance (QA) on the 50 test fields using the MapCHECK™ device. The FD cut-point was applied to a validation set consisting of four head and neck plans (28 fields). The area under the curve (AUC) from receiver operating characteristic (ROC) analysis was used to compare the ability of FD, number of MUs, average leaf gap, and the 2D MI for distinguishing between the moderate and high modulation fields. RESULTS: The authors found the variogram FD method to be the most suitable for assessing the modulation complexity of IMRT fields for head and neck carcinomas. Pass rates as measured by the gamma criterion for the MapCHECK™ IMRT field measurements were higher for the moderately modulated fields, and a gamma criterion with 1 mm distance-to-agreement and 1% dose difference showed a clear separation between the 94% pass rates of the moderate and high modulation groups. From the ROC analysis of the test set, the authors found the AUC of the variogram FD, number of MUs, average leaf gap, and 2D MI methods to be 0.99 (almost perfect), 0.91 (excellent), 0.91 (excellent), and 0.92 (excellent), respectively. A cut-point of FD > 2.25 correctly identified 92.8% of the high modulation fields and 100% of the moderately modulated fields in the validation set, satisfying the condition of no false positives. CONCLUSIONS: Of the three FD methods investigated, the variogram method is the most accurate and precise metric for identifying high modulation treatment fields. It is also more accurate and precise than the number of MUs, the average leaf gap, and the 2D MI. Although MapCHECK™ IMRT QA does a reasonable job at identifying high modulation fields, the variogram FD method provides one with the opportunity to quantitatively and accurately assess modulation and adjust overly modulated fields at the treatment planning stage before they are sent to the treatment machine for QA or patient treatment.

On the use of the MLC dosimetric leaf gap as a quality control tool for accurate dynamic IMRT delivery.

PURPOSE: MLC leaf gap consistency is critical for the accurate delivery of dynamic IMRT plans. It is estimated that a systematic MLC leaf gap change of 0.6 mm will result in a 2% change to the equivalent uniform dose to a clinical target volume for a typical head and neck sliding window (SW) IMRT plan. The aim of this work is to use the measured dosimetric leaf gap (DLG) to verify the dosimetric reproducibility of dynamically delivered SW IMRT plans. This study focuses on Varian linacs equipped with the 120 Millennium MLC and the Eclipse treatment planning system (TPS), but can be extended to other linac/MLC/TPS combination. METHODS: An ionization chamber, a diode array, and an electronic portal imaging device (EPID) were used to assess the DLG in zero (central axis), one, and two dimensions, respectively. The DLG for zero and two dimensions was derived from measurements of SW fields of decreasing width (2, 1.5, 1, and 0.5 cm). The DLG in one dimension was measured directly from a single SW sweeping across a linear diode array. This one-dimensional DLG measurement was based on the full width at half maximum (FWHM) of the dose rate versus time spectrum. RESULTS: The DLG derived from ion chamber measurements at central axis agrees to within 0.1 mm, with the DLG measured directly from the FWHM of dose rate versus time spectrum. The measured DLG depends on the control points used for the MLC SW fields. When two control points were used, the DLG measured at central axis showed an increase of 0.6 mm with respect to the same measurements performed using three or more control points. The two-dimensional distribution of DLG obtained using the EPID identified leaf gap errors as small as +/- 0.2 mm in isolated areas away from central axis. CONCLUSIONS: Comprehensive measurements of the DLG in 0D, 1D, and 2D provide an accurate assessment of DLG value required during TPS commissioning. These DLG measurements can also be used as a quality control tool to quantify changes of the MLC calibration and leaf gap consistency, which is critical for the accurate delivery of dynamically delivered SW IMRT plans.

A comparison of Monte Carlo and Fermi-Eyges-Hogstrom estimates of heart and lung dose from breast electron boost treatment.

PURPOSE: Electrons are commonly used in the treatment of breast cancer primarily to deliver a tumor bed boost. We compared the use of the Monte Carlo (MC) method and the Fermi-Eyges-Hogstrom (FEH) algorithm to calculate the dose distribution of electron treatment to normal tissues. METHODS AND MATERIALS: Ten patients with left-sided breast cancer treated with breast-conservation therapy at the University of California, San Francisco, were included in this study. Each patient received an electron boost to the surgical bed to a dose of 1,600 cGy in 200 cGy fractions prescribed to 80% of the maximum. Doses to the left ventricle (LV) and the ipsilateral lung (IL) were calculated using the EGS4 MC system and the FEH algorithm implemented on the commercially available Pinnacle treatment planning system. An anthromorphic phantom was irradiated with radiochromic film in place to verify the accuracy of the MC system. RESULTS: Dose distributions calculated with the MC algorithm agreed with the film measurements within 3% or 3 mm. For all patients in the study, the dose to the LV and IL was relatively low as calculated by MC. That is, the maximum dose received by up to 98% of the LV volume was < 100 cGy/day. Less than half of the IL received a dose in excess of 30 cGy/day. When compared with MC, FEH tended to show reduced penetration of the electron beam in lung, and FEH tended to overestimate the bremsstrahlung dose in regions well beyond the electron practical range. These differences were clinically likely to be of little significance, comprising differences of less than one-tenth of the LV and IL volume at doses > 30 cGy and differences in maximum dose of < 35 cGy/day to the LV and 80 cGy/day to the IL. CONCLUSIONS: From our series, using clinical judgment to prescribe the boost to the surgical bed after breast-conserving treatment results in low doses to the underlying LV and IL. When calculated dose distributions are desired, MC is the most accurate, but FEH can still be used.