Acrylonitrile Butadiene Styrene (ABS) plastic based low cost tissue equivalent phantom for verification dosimetry in IMRT.

A novel IMRT phantom was designed and fabricated using Acrylonitrile Butadiene Styrene (ABS) plastic. Physical properties of ABS plastic related to radiation interaction and dosimetry were compared with commonly available phantom materials for dose measurements in radiotherapy. The ABS IMRT phantom has provisions to hold various types of detectors such as ion chambers, radiographic/radiochromic films, TLDs, MOSFETs, and gel dosimeters. The measurements related to pre-treatment dose verification in IMRT of carcinoma prostate were carried out using ABS and Scanditronics-Wellhoffer RW3 IMRT phantoms for five different cases. Point dose data were acquired using ionization chamber and TLD discs while Gafchromic EBT and radiographic EDR2 films were used for generating 2-D dose distributions. Treatment planning system (TPS) calculated and measured doses in ABS plastic and RW3 IMRT phantom were in agreement within +/-2%. The dose values at a point in a given patient acquired using ABS and RW3 phantoms were found comparable within 1%. Fluence maps and dose distributions of these patients generated by TPS and measured in ABS IMRT phantom were also found comparable both numerically and spatially. This study indicates that ABS plastic IMRT phantom is a tissue equivalent phantom and dosimetrically it is similar to solid/plastic water IMRT phantoms. Though this material is demonstrated for IMRT dose verification but it can be used as a tissue equivalent phantom material for other dosimetry purposes in radiotherapy.

Quick, efficient and effective patient-specific intensity-modulated radiation therapy quality assurance using log file and electronic portal imaging device.

AIM: The aim of work is to explore a quick, efficient, and effective patient-specific intensity-modulated radiation therapy (IMRT) quality assurance (QA). MATERIALS AND METHODS: Software tools were developed to extract and analyze the multi-leaf collimator (MLC) leaf positions (LPs) from electronic portal imaging device (EPID) images for Varian C-series machine and TrueBeam, to extract useful data from MLC log file of C-series linear accelerator (LINAC), to extract useful information from the trajectory log binary file of TrueBeam LINAC, to compare LPs derived from EPID images with log file/trajectory log data, and to analyze IMRT treatment files using the MATLAB programming language. The difference in LP determined from the trajectory log and EPID images was proposed for patient-specific QA. RESULTS: It was found that the differences in LP for regular radiation fields generated using stationary leaves are <0.5 mm for all the field sizes while for regular radiation fields generated using the moving leaves are more but <2 mm. The differences in LPs for IMRT field were also determined and found to be <2 mm. CONCLUSIONS: The methodology demonstrated can be used for establishing the accuracy of trajectory log data and for independent routine IMRT QA by generating single number like gamma index to indicate pass or fail of an IMRT treatment plan. The QA indices such as numbers of occurrences of ≥2 mm error in LPS are found more than 5% of total number of occurrences; the dosimetric review of planned treatment is advisable.

Practical considerations in using calculated healthy-tissue complication probabilities for treatment-plan optimization.

PURPOSE: Healthy and neoplastic tissues are generally exposed nonuniformly to ionizing radiation. It is thus useful to develop algorithms that predict the probability of tumor control or normal tissue complication probability (NTCP) for any given spatial pattern of dose delivery. The questions addressed here concern: (a) the sensitivity of the NTCP predictions to the actual model used for extrapolation from uniform irradiation (where some clinical data exist) to nonuniform exposures, (b) its dependence on tissue type, and (c) consequences for treatment-plan optimization. METHODS AND MATERIALS: Two (of several possible) NTCP formulations are used here: the Lyman model and a binomial equation. The effective volume-reduction scheme of Kutcher and Burman is used to obtain the NTCP for an arbitrary distribution of dose. NTCP was calculated for seven organs by postulating a dose distribution of maximum nonuniformity. RESULTS: Both models fit available NTCP data well, but have very different extrapolations for exposures of small tissue volumes and very low values of NTCP (e.g., < 5%) where no data exist. Organs with pronounced volume effects (lung, kidneys) show substantial NTCP differences between the two models. Even in organs where the volume effect is small (e.g., spinal cord, brain), differences in NTCP due to the model selected may still have serious clinical consequences, as an actual example (for the spinal cord) indicates. CONCLUSIONS: NTCP calculations based on extrapolations to volume fractions and/or NTCP levels for which reliable data do not exist depend on the model used to fit the data and the degree of dose nonuniformity. If NTCP is to be used in treatment-plan optimization, the prudent approach is to design plans that reproduce the conditions under which available dose-volume data were taken (e. g., uniform dose distributions).

A little to a lot or a lot to a little: is NTCP always minimized in multiport therapy?

PURPOSE: We address the question of whether or not, for the same average (or integral) dose, a smaller uniform dose to an entire normal tissue structure always results in a lower normal tissue complication probability (NTCP) than does a proportionally larger dose to a partial volume of the same structure. METHODS AND MATERIALS: A recent compilation of NTCP data and two theoretical formulations of the dependence of NTCP on dose and partial volume irradiated-the Lyman probit equation and the binomial model-are used to examine this question. Both models fit equally well available NTCP data. RESULTS: Empirical data indicate that for lung, kidney, and possibly liver (but not for esophagus, brain, or heart), given a fixed tumor dose and fixed integral dose, NTCP can be minimized by irradiating a partial volume fraction rather than the entire normal organ. The binomial model supports this interpretation, whereas the probit model predicts that for all organs uniform irradiation of the whole organ always results in the lowest possible NTCP. CONCLUSIONS: In contrast to what is commonly believed, this study suggests that for at least two normal tissues, namely lung and kidney, there may be situations where "a lot to a little" (i.e., fewer treatment ports) will result in higher tumor control probability and better treatment plan than "a little to a lot" (i.e., multifield treatment). This finding, which is independent of the binomial or probit models used here, depends only on the accuracy of the empirical NTCP data. It is also interesting to note that: a) lung and kidney are commonly classified as parallel tissues, while the others have more of a serial architecture; and b) the choice of the NTCP model can have a profound impact on treatment planning decisions.

An independent dose-to-point calculation program for the verification of high-dose-rate brachytherapy treatment planning.

PURPOSE: We describe computer software that performs, quickly and accurately, secondary dose calculations for high-dose-rate (HDR) treatment plans, including those employed for prostate treatments. METHODS: The program takes as primary input the data file used by the HDR remote afterloader console for treatment. Dosimetric calculations are performed using the Meisberger polynomial and the anisotropy table for the HDR Iridium-192 source. For standard applicators, treatment geometry is automatically reconstructed and the dose is calculated at relevant reference point(s). Template-based treatment plans (e.g., prostate) require additional user input; the dose calculation is then performed at user-selected reference points. A total dwell time calculation for volume and planar implants using the Manchester tables was also implemented. RESULTS: For fixed-geometry HDR procedures, secondary dose calculations are within 2% of the treatment plan, and results are available for review instantly. For more general applications, the calculated and planned doses are typically within 3% at the prescription isodose line. The Manchester-based dwell time calculation is within 10% of the planned time.

Microdosimetric evaluation of relative biological effectiveness for 103Pd, 125I, 241Am, and 192Ir brachytherapy sources.

PURPOSE: To determine the microdosimetric-derived relative biological effectiveness (RBE) of 103Pd, 125I, 241Am, and 192Ir brachytherapy sources at low doses and/or low dose rates. METHODS AND MATERIALS: The Theory of Dual Radiation Action can be used to predict expected RBE values based on the spatial distribution of energy deposition at microscopic levels from these sources. Single-event lineal energy spectra for these isotopes have been obtained both experimentally and theoretically. A grid-defined wall-less proportional counter was used to measure the lineal energy distributions. Unlike conventional Rossi proportional counters, the counter used in these measurements has a conducting nylon fiber as the central collecting anode and has no metal parts. Thus, the Z-dependence of the photoelectric effect is eliminated as a source of measurement error. Single-event spectra for these brachytherapy sources have been also calculated by: (a) the Monte Carlo code MCNP to generate the electron slowing down spectrum, (b) transport of monoenergetic electron tracks, event by event, with our Monte Carlo code DELTA, (c) using the concept of associated volume to obtain the lineal energy distribution f(y) for each monoenergetic electron, and (d) obtaining the composite lineal energy spectrum for a given brachytherapy source based on the electron spectrum calculated at step (a). RESULTS: Relative to 60Co, the RBE values obtained from this study are: 2.3 for 103Pd, 2.1 for 125I, 2.1 for 241Am, and 1.3 for 192Ir. CONCLUSIONS: These values are consistent with available data from in vitro cell survival experiments. We suggest that, at least for these brachytherapy sources, microdosimetry may be used as a credible alternative to time-consuming (and often uncertain) radiobiological experiments to obtain information on radiation quality and make reliable predictions of RBE in low dose rate brachytherapy.

Physician/patient-driven risk assignment in radiation oncology: reality or fancy?

PURPOSE: Treatment plan optimization in radiation oncology entails designing multiple x-ray beams to irradiate a tumor to a dose that will achieve locoregional control while minimizing normal tissue complications. For some anatomical sites, it is possible to estimate tumor control probabilities (TCP) and normal tissue complication probabilities (NTCP) as a function of radiation dose. Thus, treatment plan optimization can be based on biologic end points rather than on dose calculations alone. Given multiple plans with different NTCPs and TCPs, a tradeoff must be made between maximizing TCP and maintaining an acceptable NTCP. How do physicians reach these decisions? Can the process be quantified? Should patients participate in the process? METHODS AND MATERIALS: Physicians and patients were asked to rank a series of treatment plans having different combinations of TCP and NTCP. Responses were parametrized into a figure of merit (FM) equation which quantifies predilections of TCP and NTCP. RESULTS: Physician-based FM equations are site- and patient-specific. Variations exist among physicians, but treatment plan selection is often conservative in accordance with the primum non nocere dictum. FM equations generated from the responses of patients suggest that some patients may be willing to accept higher treatment toxicity in exchange for increased TCP. CONCLUSION: The term "optimized treatment plan" contains inherently subjective criteria which reflect one's willingness to accept treatment morbidity in exchange for probability of cure. These criteria may differ among patients and/or physicians. A quantifiable FM may permit the design of custom-made treatment plans that include physician and patient input.

Dosimetric considerations for catheter-based beta and gamma emitters in the therapy of neointimal hyperplasia in human coronary arteries.

PURPOSE: Recent data indicate that intraluminal irradiation of coronary arteries following balloon angioplasty reduces proliferation of smooth muscle cells, neointima formation, and restenosis. We present calculations for various isotopes and geometries in an attempt to identify suitable source designs for such treatments. METHODS AND MATERIALS: Analytical calculations of dose distributions and dose rates are presented for 192Ir, 125I, 103Pd, 32P, and 90Sr for use in intracoronary irradiation. The effects of source geometry and positioning accuracy are studied. RESULTS: Accurate source centering, high dose rate, well-defined treatment volume, and radiation safety are all of concern; 15-20 Gy are required to a length of 2-3 cm of vessel wall (2-4 mm diameter). Dose must be confined to the region of the angioplasty, with reduced doses to normal tissues. Beta emitters have radiation safety advantages, but may not have suitable ranges for treating large diameter vessels. Gamma emitters deliver larger doses to normal tissues and to staff. Low energy x-ray emitters such as 125I and 103Pd reduce these risks but are not available at high enough activities. The feasibility of injecting a radioactive liquid directly into the angioplasty balloon is also explored. CONCLUSIONS: Accurate source centering is found to be of great importance. If this can be accomplished, then high energy beta emitters such as 90Sr would be ideal sources. Otherwise, gamma emitters such as 192Ir may be optimal. A liquid beta source would have optimal geometry and dose distribution, but available sources, such as 32P are unsafe for use with available balloon catheters.

Derivations of relative biological effectiveness for the high-let radiations produced during boron neutron capture irradiations of the 9L rat gliosarcoma in vitro and in vivo.

PURPOSE: Relative biological effectiveness (RBE) values for the high linear-energy-transfer particles produced during boron neutron capture therapy have generally been based on theoretical considerations or in vitro experiments. The purpose of this study was to independently determine RBE values for all of the boron neutron capture therapy dose components. METHODS AND MATERIALS: Clonogenic cell survival data were obtained for 9L rat gliosarcoma cells irradiated in the Brookhaven Medical Research Reactor thermal neutron beam both in vitro and as an intracerebral tumor. These data were analyzed using the linear quadratic model for cell survival to derive measured RBE values for all beam components and for a number of different boron compounds. RESULTS: In the absence of boron, the combined effects of the protons from the nitrogen capture, 14N(n,p)14C, and the fast neutron scatter, 1H(n,n')p, reactions generated RBEs of 3.7 in vitro and 3.2 in an in vivo/in vitro excision assay, compared to 250 kVp X rays using an end point of 1% cell survival. Apparent RBEs for the 10B(n,alpha)7Li reaction products were calculated from cell survival data following reactor irradiations in the presence of the amino acid p-boronophenylalanine, the sulfhydryl dodecaborate monomer or dimer, or boric acid. Apparent RBEs for the 10B(n,alpha)7Li reaction ranged from 1.2 to 9.8 depending on which boron compound was used. RBEs from the in vitro studies were consistently higher than from the in vivo/in vitro studies. Under any conditions, the apparent RBE for the 10B(n,alpha)7Li reaction with p-boronophenylalanine was higher than that with any other boron compound tested. CONCLUSIONS: Generally accepted RBE values for the fast neutron and 14N(n,p)14C reaction components of the total dose are too low. The apparent RBEs calculated for the 10B(n,alpha)7Li reaction were compound-dependent and consistent with differences in the distribution of 10B relative to glioma cell nuclei.

Treatment planning for prostate implants using magnetic-resonance spectroscopy imaging.

PURPOSE: Recent studies have demonstrated that magnetic-resonance spectroscopic imaging (MRSI) of the prostate may effectively distinguish between regions of cancer and normal prostatic epithelium. This diagnostic imaging tool takes advantage of the increased choline plus creatine versus citrate ratio found in malignant compared to normal prostate tissue. The purpose of this study is to describe a novel brachytherapy treatment-planning optimization module using an integer programming technique that will utilize biologic-based optimization. A method is described that registers MRSI to intraoperative-obtained ultrasound images and incorporates this information into a treatment-planning system to achieve dose escalation to intraprostatic tumor deposits. METHODS: MRSI was obtained for a patient with Gleason 7 clinically localized prostate cancer. The ratios of choline plus creatine to citrate for the prostate were analyzed, and regions of high risk for malignant cells were identified. The ratios representing peaks on the MR spectrum were calculated on a spatial grid covering the prostate tissue. A procedure for mapping points of interest from the MRSI to the ultrasound images is described. An integer-programming technique is described as an optimization module to determine optimal seed distribution for permanent interstitial implantation. MRSI data are incorporated into the treatment-planning system to test the feasibility of dose escalation to positive voxels with relative sparing of surrounding normal tissues. The resultant tumor control probability (TCP) is estimated and compared to TCP for standard brachytherapy-planned implantation. RESULTS: The proposed brachytherapy treatment-planning system is able to achieve a minimum dose of 120% of the 144 Gy prescription to the MRS positive voxels using (125)I seeds. The preset dose bounds of 100-150% to the prostate and 100-120% to the urethra were maintained. When compared to a standard plan without MRS-guided optimization, the estimated TCP for the MRS-optimized plan is superior. The enhanced TCP was more pronounced for smaller volumes of intraprostatic tumor deposits compared to estimated TCP values for larger lesions. CONCLUSIONS: Using this brachytherapy-optimization system, we could demonstrate the feasibility of MRS-optimized dose distributions for (125)I permanent prostate implants. Based on probability estimates of anticipated improved TCP, this approach may have an impact on the ability to safely escalate dose and potentially improve outcome for patients with organ-confined but aggressive prostatic cancers. The magnitude of the TCP enhancement, and therefore the risks of ignoring the MR data, appear to be more substantial when the tumor is well localized; however, the gain achievable in TCP may depend quite considerably on the MRS tumor-detection efficiency.

Radiobiological effectiveness (RBE) of megavoltage X-ray and electron beams in radiotherapy.

Recent experiments indicate that significant differences exist in the microdosimetric properties (i.e., lineal energy distributions) of megavoltage X-ray and electron beams used in radiation therapy. In particular, dose averaged values of lineal energy for 18 MeV electrons are 10-30% lower than for 10 MeV bremsstrahlung X rays, which in turn are 30-60% lower than for 250 kVp X rays. Differences of this magnitude may manifest themselves in observable radiobiological effectiveness (RBE) differences between these radiations. Cell survival data have been obtained for line DLD-1 human tumor cells on all three of the above radiation sources. Results clearly demonstrate an RBE difference between orthovoltage and megavoltage radiation (P = 0.001). A small difference is also measured in RBE between megavoltage photons and megavoltage electrons, but the difference is not statistically significant (P = 0.25). All biological, dosimetric, and microdosimetric data were obtained under nearly identical geometric conditions. These data raise interesting questions vis à vis the applicability of microdosimetric theories in the interpretation of biological effects.

Microdosimetry for boron neutron capture therapy.

Preclinical studies for boron neutron capture therapy (BNCT) using epithermal neutrons are ongoing at several laboratories. The absorbed dose in tumor cells is a function of the thermal neutron flux at depth, the microscopic boron concentration, and the size of the cell. Dosimetry is therefore complicated by the admixture of thermal, epithermal, and fast neutrons, plus gamma rays, and the array of secondary high-linear-energy-transfer particles produced within the patient from neutron interactions. Microdosimetry can be a viable technique for determining absorbed dose and radiation quality. A 2.5-cm-diameter tissue-equivalent gas proportional counter has been built with 50 parts per million (ppm) 10B incorporated into the walls and counting gas to simulate the boron uptake anticipated in tumors. Measurements of lineal energy (y) spectra for BNCT in simulated volumes of 1-10 microns diameter show a dose enhancement factor of 4.3 for 30 ppm boron, and a "y" of 250 keV/microns for the boron capture process. Chamber design plus details of experimental and calculated linear energy spectra will be presented.

Input of treatment planning data via a video frame grabber.

Video frame grabbers are powerful devices which perform rapid conversion of video images into digital format for subsequent computer processing. Recently, the cost of these devices has become competitive with sonic and magnetic digitizing tablets commonly used in radiation therapy treatment planning. Frame grabbers, plus all associated hardware/software can be interfaced to a variety of personal or microcomputers, and allow input of irregular treatment field and patient contour data into standard treatment planning systems. Such a system is described, which offers advantages of speed, accuracy, and resolution as compared to more conventional digitizing systems.

Pion in vivo dosimetry using aluminum activation.

The method of aluminum activation to 24Na has been shown feasible as a high-LET, in vivo dosimeter for clinical pion beams at the Clinton P. Anderson Meson Physics Facility in Los Alamos. A 3 X 3 in. phi NaI (Tl) well detector measures the 24Na activity following exposure by windowing the 2.75 MeV photopeak. Calculations of the 24Na activity agree well with experiment if one assumes a production ratio of 0.075 24Na/stopped pi- in aluminum, and an in-flight cross section of 26 mb. The activity is produced primarily by stopping pions although 15-25% of the activity is the result of neutrons. Thus, the induced activation is a good measure of high-LET dose. By comparison with high-LET dose measured by a 7.6 mu silicon detector and a Rossi chamber, the amount of high-LET dose per activation is found to be 1.35 X 10(-6) rad/(24Na/gm Al). A clinical setup has been installed and a sample patient measurement is compared with high-LET dose calculated by treatment planning programs.

A three-film technique for reconstruction of radioactive seed implants.

Computer dose calculations for interstitial implants of radioactive seeds require a knowledge of the spatial coordinates of each seed in the implant. These coordinates are usually constructed from the seed images on either an orthogonal or a stereo pair of radiographs. Such a procedure, however, requires that each seed can be identified on each film. We have developed a computer algorithm which computes the locations of the seeds from a set of two stereo and one AP radiographs, even when seed identities on all films are indeterminable. This is done by means of a ray tracing technique. Under ideal conditions the projections from the three films uniquely define all seed locations. Under clinical conditions, however, where digitizing uncertainties and patient movement are inevitable, the algorithm must determine the most likely set of seed locations from the larger set of all possible seed locations. The criteria for making this selection, as well as clinical examples, are presented.

Errors in wedged field isodose distributions.

A combination of wedged field and beam rotation can result in treatment planning errors. A simple formula is given which describes this effect.

A language for generating tomographic images of mathematical phantoms.

A computer language is presented that can be used to generate image files, as if the images are created with a CT or a MR scanner. The language defines objects in the "scanner's" coordinate system, as sets of quadratic inequalities. Each of these objects, e.g., an ellipsoid or a half-plane or a cylinder, has its own density. Objects can be superimposed and collections of objects are allowed to translate and rotate. The language allows for a concise way of describing complex objects with precisely defined geometries and densities. An implementation of the language can be used for testing, developing, and analyzing diagnostic software, treatment planning systems, etc. A software module that is based on the language can be made available. The utility of the module for acceptance testing of radiation therapy treatment planning systems is described.

Microdosimetric single-event spectra for megavoltage electrons.

Experimental techniques have been developed for obtaining single-event microdosimetric spectra from hospital based linear accelerators. Therapeutic electrons of 12, 15, 18, and 20 MeV from Clinic 18 and 20 accelerators have been produced at ultralow dose rates. Details of the experimental methods have been described previously by the authors. Single-event lineal energy spectra for these beams, as measured by a Rossi chamber differ significantly from cobalt-60 both in shape and dose average lineal energy (yd) which, depending on electron energy, can be 20-40% lower. The spectral peaks for electrons are greatly enhanced compared to cobalt. The yd for electrons also differs from previously reported values for 10-15 MV photon beams. These differences are less pronounced than for differences with cobalt. Spectral peaks and shapes correlate well with the actual electron stopping powers in tissue. The theory of dual radiation action predicts changes in relative biological effectiveness at low doses for megavoltage photon and electrons. Although at clinical doses the predicted differences are not statistically significant.

Determination of the relative angle between orthogonal films for radioactive implants.

Dose calculations for radioactive seed implants require knowledge of the three-dimensional source coordinates. These are usually determined from a pair of orthogonal radiographs. However, occasionally localization films are taken with portable, and/or nonisocentric x-ray units, and no assurances can be made as to whether or not the films were truly exposed in an orthogonal geometry. A three-dimensional magnification ring is described (consisting of three mutually orthogonal rings) which permits the treatment planner to accurately establish the exact source rotation angle used when exposing the films. This angle can in turn be used when reconstructing source coordinates, to insure accuracy in treatment planning.

Microdosimetry of 10-15 MeV bremsstrahlung x rays.

Experimental techniques have been developed for obtaining microdosimetric spectra on a hospital-based linear accelerator. Teletherapy beams of 10 and 15 MeV bremsstrahlung x rays from a Varian Clinac-18 and Clinac-20, respectively, have been produced at ultralow dose rates (50-200 microGy/h) which enables direct measurements of lineal energy distributions with a conventional Rossi-type gas proportional counter. Extensive measurements have been made to insure that the dosimetric properties of these low dose rate beams are nearly identical to those produced under high dose rate clinical conditions. Analytical procedures have been developed to correct measured lineal energy spectra for pileup caused by the low duty factor of the linear accelerator. The lineal energy spectra of these megavoltage beams differ significantly from Co-60, with dose averaged lineal energies (yD) being 20%-30% lower than for Co-60. Although such differences may not be important at clinical doses, the theory of dual radiation action does predict a lower biological effectiveness for these beams at very low dose levels.