On the relationships between electron spot size, focal spot size, and virtual source position in Monte Carlo simulations.

PURPOSE: Every year, new radiotherapy techniques including stereotactic radiosurgery using linear accelerators give rise to new applications of Monte Carlo (MC) modeling. Accurate modeling requires knowing the size of the electron spot, one of the few parameters to tune in MC models. The resolution of integrated megavoltage imaging systems, such as the tomotherapy system, strongly depends on the photon spot size which is closely related to the electron spot. The aim of this article is to clarify the relationship between the electron spot size and the photon spot size (i.e., the focal spot size) for typical incident electron beam energies and target thicknesses. METHODS: Three electron energies (3, 5.5, and 18 MeV), four electron spot sizes (FWHM = 0, 0.5, 1, and 1.5 mm), and two tungsten target thicknesses (0.15 and 1 cm) were considered. The formation of the photon beam within the target was analyzed through electron energy deposition with depth, as well as photon production at several phase-space planes placed perpendicular to the beam axis, where only photons recorded for the first time were accounted for. Photon production was considered for "newborn" photons intersecting a 45 x 45 cm2 plane at the isocenter (85 cm from source). Finally, virtual source position and "effective" focal spot size were computed by back-projecting all the photons from the bottom of the target intersecting a 45 x 45 cm2 plane. The virtual source position and focal spot size were estimated at the plane position where the latter is minimal. RESULTS: In the relevant case of considering only photons intersecting the 45 x 45 cm2 plane, the results unambiguously showed that the effective photon spot is created within the first 0.25 mm of the target and that electron and focal spots may be assumed to be equal within 3-4%. CONCLUSIONS: In a good approximation photon spot size equals electron spot size for high energy X-ray treatments delivered by linear accelerators.

Preimplantation genetic diagnosis for gender selection in the USA.

Preimplantation genetic diagnosis (PGD) for gender selection for non-medical reasons has been considered an unethical procedure by several authors and agencies in the Western society on the basis that it could disrupt the sex ratio, that it discriminates against women and that it leads to disposal of normal embryos of the non-desired gender. In this study, the analysis of a large series of PGD procedures for gender selection from a wide geographical area in the USA shows that, in general, there is no deviation in preference towards any specific gender except for a preference of males in some ethnic populations of Chinese, Indian and Middle Eastern origin that represent a small percentage of the US population. In cases where only normal embryos of the non-desired gender are available, 45.5% of the couples elect to cancel the transfer, while 54.5% of them are open to have embryos transferred of the non-desired gender, this fact being strongly linked to cultural and ethnic background of the parents. In addition this study adds some evidence to the proposition that, in couples with previous children of a given gender, there is no biological predisposition towards producing embryos of that same gender. Based on these facts, it seems that objections to gender selection formulated by ethics committees and scientific societies are not well founded.

Monte Carlo evaluation of the convolution/superposition algorithm of Hi-Art tomotherapy in heterogeneous phantoms and clinical cases.

The reliability of the convolution/superposition (C/S) algorithm of the Hi-Art tomotherapy system is evaluated by using the Monte Carlo model TomoPen, which has been already validated for homogeneous phantoms. The study was performed in three stages. First, measurements with EBT Gafchromic film for a 1.25 x 2.5 cm2 field in a heterogeneous phantom consisting of two slabs of polystyrene separated with Styrofoam were compared to simulation results from TomoPen. The excellent agreement found in this comparison justifies the use of TomoPen as the reference for the remaining parts of this work. Second, to allow analysis and interpretation of the results in clinical cases, dose distributions calculated with TomoPen and C/S were compared for a similar phantom geometry, with multiple slabs of various densities. Even in conditions of lack of lateral electronic equilibrium, overall good agreement was obtained between C/S and TomoPen results, with deviations within 3%/2 mm, showing that the C/S algorithm accounts for modifications in secondary electron transport due to the presence of a low density medium. Finally, calculations were performed with TomoPen and C/S of dose distributions in various clinical cases, from large bilateral head and neck tumors to small lung tumors with diameter of < 3 cm. To ensure a "fair" comparison, identical dose calculation grid and dose-volume histogram calculator were used. Very good agreement was obtained for most of the cases, with no significant differences between the DVHs obtained from both calculations. However, deviations of up to 4% for the dose received by 95% of the target volume were found for the small lung tumors. Therefore, the approximations in the C/S algorithm slightly influence the accuracy in small lung tumors even though the C/S algorithm of the tomotherapy system shows very good overall behavior.

Monte Carlo simulation of helical tomotherapy with PENELOPE.

Helical tomotherapy (HT) delivers intensity-modulated radiation therapy (IMRT) using the simultaneous movement of the couch, the gantry and the binary multileaf collimator (MLC), a procedure that differs from conventional dynamic or step-and-shoot IMRT. A Monte Carlo (MC) simulation of HT in the helical mode therefore requires a new approach. Using validated phase-space files (PSFs) obtained through the MC simulation of the static mode with PENELOPE, an analytical model of the binary MLC, called the 'transfer function' (TF), was first devised to perform the transport of particles through the MLC much faster than time-consuming MC simulation and with no significant loss of accuracy. Second, a new tool, called TomoPen, was designed to simulate the helical mode by rotating and translating the initial coordinates and directions of the particles in the PSF according to the instantaneous position of the machine, transporting the particles through the MLC (in the instantaneous configuration defined by the sinogram), and computing the dose distribution in the CT structure using PENELOPE. Good agreement with measurements and with the treatment planning system of tomotherapy was obtained, with deviations generally well within 2%/1 mm, for the simulation of the helical mode for two commissioning procedures and a clinical plan calculated and measured in homogeneous conditions.

The impact of linac output variations on dose distributions in helical tomotherapy.

It has been suggested for quality assurance purposes that linac output variations for helical tomotherapy (HT) be within +/-2% of the long-term average. Due to cancellation of systematic uncertainty and averaging of random uncertainty over multiple beam directions, relative uncertainties in the dose distribution can be significantly lower than those in linac output. The sensitivity of four HT cases with respect to linac output uncertainties was assessed by scaling both modeled and measured systematic and random linac output uncertainties until a dose uncertainty acceptance criterion failed. The dose uncertainty acceptance criterion required the delivered dose to have at least a 95% chance of being within 2% of the planned dose in all of the voxels in the treatment volume. For a random linac output uncertainty of 5% of the long-term mean, the maximum acceptable amplitude of the modeled, sinusoidal, systematic component of the linac output uncertainty for the four cases was 1.8%. Although the measured linac output variations represented values that were outside of the +/-2% tolerance, the acceptance criterion did not fail for any of the four cases until the measured linac output variations were scaled by a factor of almost three. Thus, the +/-2% tolerance in linac output variations for HT is a more conservative tolerance than necessary.

[Level of knowledge of Quality Commitment Campaign and of "do not do" recommendations amongst general practitioners, pediatricians and nurses Primary Care]. / Grado de conocimiento de la campaña Compromiso por la Calidad y de las recomendaciones no hacer entre médicos de familia, pediatras y enfermería de Atención Primaria.

BACKGROUND: To evaluate if the Quality Commitment Campaign (QCC) was sufficiently known among primary care professionals (PC), and second, to evaluate the knowledge about certain recommendations of what should not be done in PC. METHODS: A observational study was conducted. General practitioners (GP), pediatricians (PED) and nursing (NUR) participated. A direct question was asked about whether QCC was known and a set of dichotomous questions based on the "do not do" recommendations to assess their knowledge. A sample size of 288 professionals from each group was the minimum required for a sampling error of 5%, 95% confidence level and p=0.75. The field study was conducted with the collaboration of health services and professional and scientific organizations. Data were described by frequencies and mean (standard deviation), and compared by means of ?2/Fisher or ANOVA and t-test. RESULTS: A total of 1,904 professionals (936 GP, 682 PED and 286 NUR) answered. The QCC initiative was known by 828 (43.5%) professionals: 524 (56.0%) GP, 234 (34.3%) PED and 70 (24.5%) NUR (p<0.001). All the questions were correctly answered by 652 (69.7%) GP, 631 (92.5%) PED and 116 (40.6%) NUR. Significantly more mistakes (p<0.001) were made by those who did not know the QCC, worked in the private sector or were not considered responsible for overuse. Despite not knowing the QCC, 60% GP and 90% PED answered all the questions of the test correctly. CONCLUSIONS: NUR and GP could benefit from a greater diffusion of the QCC. As could those working in the private sector and those who believe that professionals have little responsibility for unnecessary overuse.

The denoising of Monte Carlo dose distributions using convolution superposition calculations.

Monte Carlo (MC) dose calculations can be accurate but are also computationally intensive. In contrast, convolution superposition (CS) offers faster and smoother results but by making approximations. We investigated MC denoising techniques, which use available convolution superposition results and new noise filtering methods to guide and accelerate MC calculations. Two main approaches were developed to combine CS information with MC denoising. In the first approach, the denoising result is iteratively updated by adding the denoised residual difference between the result and the MC image. Multi-scale methods were used (wavelets or contourlets) for denoising the residual. The iterations are initialized by the CS data. In the second approach, we used a frequency splitting technique by quadrature filtering to combine low frequency components derived from MC simulations with high frequency components derived from CS components. The rationale is to take the scattering tails as well as dose levels in the high-dose region from the MC calculations, which presumably more accurately incorporates scatter; high-frequency details are taken from CS calculations. 3D Butterworth filters were used to design the quadrature filters. The methods were demonstrated using anonymized clinical lung and head and neck cases. The MC dose distributions were calculated by the open-source dose planning method MC code with varying noise levels. Our results indicate that the frequency-splitting technique for incorporating CS-guided MC denoising is promising in terms of computational efficiency and noise reduction.

[Proposals for the study of the second victim phenomenon in Spanish Primary Care Centres and Hospitals]. / Propuestas para el estudio del fenómeno de las segundas víctimas en España en atención primaria y hospitales.

OBJECTIVE: To identify the Spanish studies conducted since 2014 on second victims. Its main objective was to identify a global response to the second victim problem, assessing the impact of adverse events (AE) on caregivers and developing of a set of tools to reduce their impact. METHOD: Descriptive studies in which a sample of managers and safety coordinators from Hospitals and Primary Care were surveyed to determine the activities being carried out as regards second victims, as well as a sample of health professionals to describe their experience as a second victims. Qualitative studies are included to design a guide of recommended actions following an AE, an online awareness program on this phenomenon, an application (app) with activities on safety that are the responsibility of the managers, and a web tool for the analysis of AEs. RESULTS: A total of 1,493 professionals (managers, safety coordinators and caregivers) from eight Spanish regions participated. The guide of recommendations, the online program, and the developed applications are accessible on the website: www.segundasvictimas.es, which has received more than 2,500 visits in one year. DISCUSSION: Study results represent a starting point in the study of the second victim phenomenon in Spain. The tools developed raise the awareness of the medical healthcare community about this problem, and provide professionals with basic skills to manage the impact of AEs.

The helical tomotherapy thread effect.

Inherent to helical tomotherapy is a dose variation pattern that manifests as a "ripple" (peak-to-trough relative to the average). This ripple is the result of helical beam junctioning, completely unique to helical tomotherapy. Pitch is defined as in helical CT, the couch travel distance for a complete gantry rotation relative to the axial beam width at the axis of rotation. Without scattering or beam divergence, an analytical posing of the problem as a simple integral predicts minima near a pitch of 1/n where n is an integer. A convolution-superposition dose calculator (TomoTherapy, Inc.) included all the physics needed to explore the ripple magnitude versus pitch and beam width. The results of the dose calculator and some benchmark measurements demonstrate that the ripple has sharp minima near p=0.86(1/n). The 0.86 factor is empirical and caused by a beam junctioning of the off-axis dose profiles which differ from the axial profiles as well as a long scatter tail of the profiles at depth. For very strong intensity modulation, the 0.86 factor may vary. The authors propose choosing particular minima pitches or using a second delivery that starts 180 deg off-phase from the first to reduce these ripples: "Double threading." For current typical pitches and beam widths, however, this effect is small and not clinically important for most situations. Certain extremely large field or high pitch cases, however, may benefit from mitigation of this effect.

Evaluation of a diode array for QA measurements on a helical tomotherapy unit.

A helical tomotherapy system is used in our clinic to deliver intensity-modulated radiation therapy (IMRT) treatments. Since this machine is designed to deliver IMRT treatments, the traditional field flatness requirements are no longer applicable. This allows the unit to operate without a field flatness filter and consequently the 400 mm wide fan beam is highly inhomogeneous in intensity. The shape of this beam profile is mapped during machine commissioning and for quality assurance purposes the shape of the beam profile needs to be monitored. The use of a commercial diode array for quality assurance measurements is investigated. Central axis beam profiles were acquired at different depths using solid water built-up material. These profiles were compared with ion chamber scans taken in a water tank to test the accuracy of the diode array measurements. The sensitivity of the diode array to variations in the beam profile was checked. Over a seven week period, beam profiles were repeatedly measured. The observed variations are compared with those observed with an on-board beam profile monitor. The diode measurements were in agreement with the ion chamber scans. In the high dose, low gradient region the average ratio between the diode and ion chamber readings was 1.000 +/- 0.005 (+/- 1 standard deviation). In the penumbra region the agreement was poorer but all diodes passed the distance to agreement (DTA) requirement of 2 mm. The trend in the beam profile variations that was measured with the diode array device was in agreement with the on-board monitor. While the calculated amount of variation differs between the devices, both were sensitive to subtle variations in the beam profile. The diode array is a valuable tool to quickly and accurately monitor the beam profile on a helical tomotherapy unit.

The use of megavoltage CT (MVCT) images for dose recomputations.

Megavoltage CT (MVCT) images of patients are acquired daily on a helical tomotherapy unit (TomoTherapy, Inc., Madison, WI). While these images are used primarily for patient alignment, they can also be used to recalculate the treatment plan for the patient anatomy of the day. The use of MVCT images for dose computations requires a reliable CT number to electron density calibration curve. In this work, we tested the stability of the MVCT numbers by determining the variation of this calibration with spatial arrangement of the phantom, time and MVCT acquisition parameters. The two calibration curves that represent the largest variations were applied to six clinical MVCT images for recalculations to test for dosimetric uncertainties. Among the six cases tested, the largest difference in any of the dosimetric endpoints was 3.1% but more typically the dosimetric endpoints varied by less than 2%. Using an average CT to electron density calibration and a thorax phantom, a series of end-to-end tests were run. Using a rigid phantom, recalculated dose volume histograms (DVHs) were compared with plan DVHs. Using a deformed phantom, recalculated point dose variations were compared with measurements. The MVCT field of view is limited and the image space outside this field of view can be filled in with information from the planning kVCT. This merging technique was tested for a rigid phantom. Finally, the influence of the MVCT slice thickness on the dose recalculation was investigated. The dosimetric differences observed in all phantom tests were within the range of dosimetric uncertainties observed due to variations in the calibration curve. The use of MVCT images allows the assessment of daily dose distributions with an accuracy that is similar to that of the initial kVCT dose calculation.

Tomotherapy.

Tomotherapy is delivery of intensity-modulated, rotational radiation therapy using a fan-beam delivery. The NOMOS (Sewickley, PA) Peacock system is an example of sequential (or serial) tomotherapy that uses a fast-moving, actuator-driven multileaf collimator attached to a conventional C-arm gantry to modulate the beam intensity. In helical tomotherapy, the patient is continuously translated through a ring gantry as the fan beam rotates. The beam delivery geometry is similar to that of helical computed tomography (CT) and requires the use of slip rings to transmit power and data. A ring gantry provides a stable and accurate platform to perform tomographic verification using an unmodulated megavoltage beam. Moreover, megavoltage tomograms have adequate tissue contrast and resolution to provide setup verification. Assuming only translational and rotational offset errors, it is also possible to determine the offsets directly from tomographic projections, avoiding the time-consuming image reconstruction operation. The offsets can be used to modify the leaf delivery pattern to match the beam to the patient's anatomy on each day of a course of treatment. If tomographic representations of the patient are generated, this information can also be used to perform dose reconstruction. In this way, the actual dose distribution delivered can be superimposed onto the tomographic representation of the patient obtained at the time of treatment. The results can be compared with the planned isodose on the planning CT. This comparison may be used as an accurate basis for adaptive radiotherapy whereby the optimized delivery is modified before subsequent fractions. The verification afforded tomotherapy allows more precise conformal therapy. It also enables conformal avoidance radiotherapy, the complement to conformal therapy, for cases in which the tumor volume is ill-defined, but the locations of sensitive structures are adequately determined. A clinical tomotherapy unit is under construction at the University of Wisconsin.

Theoretical calculation of electronic stopping power of water vapor by proton impact.

The energy loss of proton beams in water vapor is analyzed with a full quantum-mechanical treatment, the distorted-wave model. This model takes into account distortion effects due to the long-range Coulomb potential. Projectile energies from 10 keV up to 1 MeV are considered. Mean stopping power and equilibrium charge-state fractions are calculated and compared with experimental data. The validity of Bragg's additivity rule is investigated.

Monte Carlo study of a highly efficient gas ionization detector for megavoltage imaging and image-guided radiotherapy.

The imaging characteristics of an arc-shaped xenon gas ionization chamber for the purpose of megavoltage CT imaging were investigated. The detector consists of several hundred 320 microm thick gas cavities separated by thin tungsten plates of the same thickness. Dose response, efficiency and resolution parameters were calculated using Monte Carlo simulations. The calculations were compared to measurements taken in a 4 MV photon beam, assuming that the measured signal in the chambers corresponds to the therein absorbed dose. The measured response profiles for narrow and broad incident photon beams could be well reproduced with the Monte Carlo calculations. They show, that the quantum efficiency is 29.2% and the detective quantum efficiency at zero frequency DQE(0) is 20.4% for the detector arc placed in focus with the photon source. For a detector placed out of focus, these numbers even increase. The efficiency of this kind of radiation detector for megavoltage radiation therefore surpasses the reported efficiency of existing detector technologies. The resolution of the detector is quantified with calculated and measured line spread functions. The corresponding modulation transfer functions were determined for different thicknesses of the tungsten plates. They show that the resolution is only slightly dependent on the plate thickness but is predominantly determined by the cell size of the detector. The optimal plate thickness is determined by a tradeoff between quantum efficiency, total signal generation and resolution. Thicker plates are more efficient but the total signal and the resolution decrease with plate thickness. In conclusion, a gas ionization chamber of the described type is a highly efficient megavoltage radiation detector, allowing to obtain CT images with very little dose for a sufficient image quality for anatomy verification. This kind of detector might serve as a model for a future generation of highly efficient radiation detectors.

A simple model for examining issues in radiotherapy optimization.

Convolution/superposition software has been used to produce a library of photon pencil beam dose matrices. This library of pencil beams is designed to serve as a tool for both education and investigation in the field of radiotherapy optimization. The elegance of this pencil beam model stems from its cylindrical symmetry. Because of the symmetry, the dose distribution for a pencil beam from any arbitrary angle can be determined through a simple rotation of a pre-computed dose matrix. Rapid dose calculations can thus be performed while maintaining the accuracy of a convolution/superposition based dose computation. The pencil beam data sets have been made publicly available. It is hoped that the data sets will facilitate a comparison of a variety of optimization and delivery approaches. This paper will present a number of studies designed to demonstrate the usefulness of the pencil beam data sets. These studies include an examination of the extent to which a treatment plan can be improved through either an increase in the number of beam angles and/or a decrease in the collimator size. A few insights into the significance of heterogeneity corrections for treatment planning for intensity modulated radiotherapy will also be presented.

A feasible method for clinical delivery verification and dose reconstruction in tomotherapy.

Delivery verification is the process in which the energy fluence delivered during a treatment is verified. This verified energy fluence can be used in conjunction with an image in the treatment position to reconstruct the full three-dimensional dose deposited. A method for delivery verification that utilizes a measured database of detector signal is described in this work. This database is a function of two parameters, radiological path-length and detector-to-phantom distance, both of which are computed from a CT image taken at the time of delivery. Such a database was generated and used to perform delivery verification and dose reconstruction. Two experiments were conducted: a simulated prostate delivery on an inhomogeneous abdominal phantom, and a nasopharyngeal delivery on a dog cadaver. For both cases, it was found that the verified fluence and dose results using the database approach agreed very well with those using previously developed and proven techniques. Delivery verification with a measured database and CT image at the time of treatment is an accurate procedure for tomotherapy. The database eliminates the need for any patient-specific, pre- or post-treatment measurements. Moreover, such an approach creates an opportunity for accurate, real-time delivery verification and dose reconstruction given fast image reconstruction and dose computation tools.

Contribution from the inner shell of water vapour to dose profiles under proton and alpha particle irradiation.

Doubly differential cross sections for electron emission calculated using the CDW-EIS model and a simple approximation for the electron transport in the target are used to obtain dose profiles around the ion path for proton and alpha particles in water vapour. The contribution from each initial molecular orbital is determined. At large distances from the track, discrepancies are found with other models and with the well known r-2 dependence.

On the verification of the incident energy fluence in tomotherapy IMRT.

For any radiotherapy verification technique, it is desirable that issues with the accelerator, multileaf collimator and patient position be detected. In previous works, an effective method for this level of verification was presented. This paper identifies second-order issues affecting the part of the process in which the incident energy fluence is verified. These problems will affect any rotational intensity-modulated radiotherapy delivery that divides each rotation or arc into projections: however the solutions offered in this paper are specific to the method previously developed. The issues affecting the energy fluence verification method include leaf bouncing. delivery implementation and leaf latency. All three matters were found to introduce small errors in the verified energy fluence values for a small fraction of leaf states. The overall effect on the deposited dose over the course of a rotational delivery involving thousands of beam pulses per rotation is negligible. Regardless, effective correction strategies are presented; these are utilized in order to characterize both the delivered energy fluence and deposited dose as accurately as possible.

Calibration of a tomotherapeutic MVCT system.

Megavoltage CT provides the ability to image the patient before, during or after a radiotherapy treatment. This allows one to verify not only the placement of a patient's external boundary, but also the locations of internal anatomy. In addition, the reconstructed MVCT values are potentially useful for treatment planning inhomogeneity corrections and dose reconstruction. To this end, dosimetric calibration of the University of Wisconsin Tomotherapy Benchtop MVCT system was investigated. It was found that MVCT values correlate extremely well with electron density and that unlike kilovoltage CT, this correlation is well maintained for higher atomic number materials. Improvements of the order of 1% in the dosimetric calculations of high atomic number materials should be possible by deriving input images from MVCT as opposed to kVCT, and calibrating in terms of electron density, as opposed to physical density.

Iterative approaches to dose optimization in tomotherapy.

This paper will present the results of an investigation into three iterative approaches to inverse treatment planning. These techniques have been examined in the hope of developing an optimization algorithm suitable for the large-scale problems that are encountered in tomotherapy. The three iterative techniques are referred to as the ratio method, iterative least-squares minimization and the maximum-likelihood estimator. Our results indicate that each of these techniques can serve as a useful tool in tomotherapy optimization. As compared with other mathematical programming techniques, the iterative approaches can reduce both memory demands and time requirements. In this paper, the results from small- and large-scale optimizations will be analysed. It will also be demonstrated that the flexibility of the iterative techniques can be greatly enhanced through the use of dose-volume histogram based penalty functions and/or through the use of weighting factors assigned to each region of the patient. Finally, results will be presented from an investigation into the stability of the iterative techniques.