Using an EPID for patient-specific VMAT quality assurance.

PURPOSE: A patient-specific quality assurance (QA) method was developed to verify gantry-specific individual multileaf collimator (MLC) apertures (control points) in volumetric modulated arc therapy (VMAT) plans using an electronic portal imaging device (EPID). METHODS: VMAT treatment plans were generated in an Eclipse treatment planning system (TPS). DICOM images from a Varian EPID (aS1000) acquired in continuous acquisition mode were used for pretreatment QA. Each cine image file contains the grayscale image of the MLC aperture related to its specific control point and the corresponding gantry angle information. The TPS MLC file of this RapidArc plan contains the leaf positions for all 177 control points (gantry angles). In-house software was developed that interpolates the measured images based on the gantry angle and overlays them with the MLC pattern for all control points. The 38% isointensity line was used to define the edge of the MLC leaves on the portal images. The software generates graphs and tables that provide analysis for the number of mismatched leaf positions for a chosen distance to agreement at each control point and the frequency in which each particular leaf mismatches for the entire arc. RESULTS: Seven patients plans were analyzed using this method. The leaves with the highest mismatched rate were found to be treatment plan dependent. CONCLUSIONS: This in-house software can be used to automatically verify the MLC leaf positions for all control points of VMAT plans using cine images acquired by an EPID.

The transit dose component of high dose rate brachytherapy: direct measurements and clinical implications.

PURPOSE: To measure the transit dose produced by a moving high dose rate brachytherapy source and assess its clinical significance. METHODS AND MATERIALS: The doses produced from source movement during Ir-192 HDR afterloading were measured using calibrated thermoluminescent dosimeter rods. Transit doses at distances of 0.5-4.0 cm from an endobronchial applicator were measured using a Lucite phantom accommodating 1 x 1 x 6 mm thermoluminescent rods. Surface transit dose measurements were made using esophageal and endobronchial catheters, a gynecologic tandem, and an interstitial needle. RESULTS: No difference was detected in thermoluminescent dosimeter rod responses to 4 MV and Ir-192 spectra (427 nC/Gy) in a range of dose between 2 and 300 cGy. The transit dose at 0.5 cm from an endobronchial catheter was 0.31 cGy/(Curie-fraction) and followed an inverse square fall-off with increasing distance. Surface transit doses ranged from 0.38 cGy/(Curie-fraction) for an esophageal catheter to 1.03 cGy/(Curie-fraction) for an endobronchial catheter. Source velocity is dependent on the interdwell distance and varies between 220-452 mm/sec. A numeric algorithm was developed to calculate total transit dose, and was based on a dynamic point approximation for the moving high dose rate source. This algorithm reliably predicted the empirical transit doses and demonstrated that total transit dose is dependent on source velocity, number of fractions, and source activity. Surface transit doses are dependent on applicator diameter and wall material and thickness. Total transit doses within or outside the desired treatment volume are typically < 100 cGy, but may exceed 200 cGy when using a large number of fractions with a high activity source. CONCLUSION: Current high dose rate brachytherapy treatment planning systems calculate dose only from source dwell positions and assume a negligible transit dose. Under certain clinical circumstances, however, the transit dose can exceed 200 cGy to tissues within and outside the prescribed treatment volume. These additional, unrecognized doses could increase potential late tissue complications, as predicted by the linear quadratic model. To enhance the clinical safety and accuracy of high dose rate brachytherapy, total transit dose should be included in calculated isodose distributions. Significant transit doses to tissues outside the treatment volume should be documented.

Radiographic visualization of vaginal cylinders in gynecologic high dose rate brachytherapy.

PURPOSE: To develop a marker system allowing an accurate determination of vaginal applicator dimensions and geometry from a radiograph. METHODS AND MATERIALS: The markers consist of two sets of gold seeds embedded into each cylinder identifying the cylinder diameter, and a thin stainless steel disk interposed between adjacent cylinders identifying their interface. An evaluation of the dosimetric properties of the markers was undertaken. An applicator was assembled using four cylinders (4 cm diameter) surrounding a stainless steel uterine tandem with a stainless steel disk 0.05 mm thick and 3.6 cm in diameter interposed between each consecutive pair of cylinders. The assembly was placed on a film and an Ir-192 high dose rate source was programmed to a single dwell position within the applicator. The markers were removed and a second film was exposed with the same dwell position and time. This procedure was repeated with various dwell positions along the applicator. A scanning densitometer was used to measure the density profiles and isodensity distributions of each film. RESULTS: The optical density profiles and isodensity distributions with and without the markers in place were identical for all source dwell positions except when the source was centered in the plane of one of the stainless steel disks, where a maximum decrease of less than 2% in the dose rate was measured. The disks had no effect on the profiles measured along axes more than 2 cm from the projection of the applicator central axis on the film. CONCLUSION: The markers provide geometrical information about the position of the applicator relative to the anatomy necessary for optimized treatment planning. Slight dose perturbations resulting from the markers do occur, but only for dwell positions that center the source in the plane of a disk, and even then only at points very close to the disk. The markers can therefore be ignored from a dosimetric point of view.

Measurements of the electron dose distribution near inhomogeneities using a plastic scintillation detector.

PURPOSE: Accurate measurement of the electron dose distribution near an inhomogeneity is difficult with traditional dosimeters which themselves perturb the electron field. We tested the performance of a new high resolution, water-equivalent plastic scintillation detector which has ideal properties for this application. METHODS AND MATERIALS: A plastic scintillation detector with a 1 mm diameter, 3 mm long cylindrical sensitive volume was used to measure the dose distributions behind standard benchmark inhomogeneities in water phantoms. The plastic scintillator material is more water equivalent than polystyrene in terms of its mass collision stopping power and mass scattering power. Measurements were performed for beams of electrons having initial energies of 6 and 18 MeV at depths from 0.2-4.2 cm behind the inhomogeneities. RESULTS: The detector reveals hot and cold spots behind heterogeneities at resolutions equivalent to typical film digitizer spot sizes. Plots of the dose distributions behind air, aluminum, lead, and formulations for cortical and inner bone-equivalent materials are presented. CONCLUSION: The plastic scintillation detector is suited for measuring the electron dose distribution near an inhomogeneity.

Nuclear magnetic relaxation characterization of irradiated Fricke solution.

The spin-lattice relaxation rate R1(= T1(-1) of irradiated Fricke solution was studied as a function of the absorbed dose D. The R1 increases linearly with dose up to D approximately 400 Gy after which the response saturates. A model describing the R1 of a solution of either ferrous (Fe2+) or ferric (Fe3+) ions is presented; it is based on the spin relaxation of protons on water molecules in the bulk and protons on water molecules in the coordination shells of the ions with fast exchange occurring between the two water environments. All inherent relaxation parameters of the different proton groups are determined empirically at NMR frequencies of 9 and 25 MHz. An extension of the model is made to describe the spin-lattice relaxation behavior of irradiated Fricke solution. Good agreement between model predictions and experimental results is observed. The model relates the spin-lattice relaxation rate of a Fricke dosimeter to the chemical yield of ferric ion, thus potentially creating an absolute NMR dosimetry technique. Various practical aspects of the NMR-Fricke system, such as the optimal initial ferrous concentration and the NMR frequency dependence of the sensitivity, are described.

Surface dose in intracavitary orthovoltage radiotherapy.

Radiotherapy with orthovoltage techniques is often the prime treatment for localized superficial malignancies. Surface doses and depth doses measured with cylindrical and end-window Farmer chambers are presented for various orthovoltage x-ray beams in the range from 80 to 300 kVp, both for open beams and beams collimated with commercial intracavitary leaded-glass cones. For radiation fields collimated by a diaphragm positioned at a distance from the patient surface (open beams) there is a small skin-sparing effect. On the other hand, the surface doses with commercial leaded-glass intracavitary cones can exhibit a fivefold increase compared to the open-beam dose maxima. Beyond a depth of approximately 0.2 mm in a tissue-equivalent phantom, the doses measured for open beams and beams collimated with intracavitary cones are essentially identical. The increase in the surface dose observed with intracavitary cones is attributed to photoelectrons and recoil electrons produced in the cones. The high surface doses are measured by thin-wall parallel-plate ionization chambers but cannot be measured with cylindrical Farmer chambers since these chambers have wall thicknesses too large for the transmission of electrons produced in the cone. Since cylindrical Farmer chambers are typically used for calibration of radiation output, the high surface doses produced by the intracavitary cones may be overlooked; they can, however, be reduced to open-beam values by simple modifications to the cones.

Implementation of a three-dimensional compensation system based on computed tomography generated surface contours and tissue inhomogeneities.

A computed tomography (CT) based system that compensates for patient surface contour and internal tissue inhomogeneity was implemented in our clinic. The compensators are fabricated with a mixture of tin granules and bee's wax. The tin/wax mixture was optimized for tin granule size and tin granule to wax ratio. The narrow beam attenuation coefficients were measured for 4-, 6-, 10-, and 24-MV photon beams. The compensator design and fabrication methodology were verified by measuring the dose distribution for a known surface contour irradiated with a compensated beam and for a known inhomogeneity that was submerged in a water phantom and irradiated with a compensated beam. For the surface contour, the uncompensated isodose levels varied by as much as 10% in the compensation plane and the compensator restored the isodose level to a variation of less than 1.3%. Measured and calculated doses for this surface contour were found to differ by less than 3.4%. For the inhomogeneity, the uncompensated isodose levels varied by 27% in the compensation plane and the compensator restored the isodose level to a variation of less than 1.5%. Measured and calculated doses for the known inhomogeneity were found to differ by less than 2%. Measurements of depth-dose curves indicate that the presence of the compensator in the beam does not significantly increase the surface dose. Twenty-six compensators have now been fabricated for clinical cases. In these patients, dose variations as great as 19% occurred in the plane of compensation prior to placing the compensator in the beam.(ABSTRACT TRUNCATED AT 250 WORDS)

Dosimetry of large wedged high-energy photon beams.

The dependence of the wedge factor and central axis depth dose on field size was evaluated for 6-, 10-, and 24-MV wedged photon beams for field sizes up to 40 x 40 cm2. The wedge factor for 60 degrees, 45 degrees, 30 degrees, and 15 degrees wedges in a 24-MV beam was found to vary by as much as 25%, 12%, 9%, and 5%, respectively, over a field size range of 5 x 5 to 40 x 40 cm2. For 10 and 6 MV wedged beams, the wedge factors varied by up to 17% and 15%, respectively, over the same field size range. The depth dose curves for the wedged beams differed significantly from the open beam profiles. At 6 MV, the wedges caused beam hardening while at 24 MV, with the exception of the 15 degrees wedge, all wedged beams were softer than the open beams, for all field sizes. At 10 MV, wedged fields of size less than 20 x 20 cm2 were hardened relative to the open beam, whereas larger wedged fields had depth dose values within +/- 1% of the 10-MV open-beam depth dose data. Accurate treatment planning for large wedged fields and high-energy photon beams thus requires the use of wedged beam depth dose curves and field size specific wedge factors. It was established that an equivalent square field for a rectangular wedged field can be determined using the standard open beam formulation. The largest difference between the wedge factor for a rectangular beam and its equivalent square beam was 2.5% and occurred for 24-MV elongated fields.(ABSTRACT TRUNCATED AT 250 WORDS)

Thermal and scatter effects on the radiation sensitivity of well chambers used for high dose rate Ir-192 calibrations.

High dose rate (HDR) iridium sources must be calibrated regularly because of the short half-life of Ir-192. High dose rate sources can now be calibrated using a new well-type chamber that allows easy, reproducible source calibrations. The chamber includes a styrofoam insulator that surrounds the source in the well. A study of the radiation sensitivity of the well chamber exposed to an HDR Ir-192 source at two different activities (300 and 230 GBq) revealed that the sensitivity of the chamber varies by as much as 1.1% as the chamber is moved toward a scattering surface. Second, with the styrofoam insulator removed, the air temperature within the ion collecting volume increased during exposure, causing a gradual decrease in chamber sensitivity of 0.15% in 30 min. This temperature increase was caused by heat transfer from radiation emitted by the Ir-192 source, and diminished as the source decayed. However, with the styrofoam insulator around the central aluminum tube in the well, the source cannot heat the collecting volume and thus thermal equilibrium between the ion collecting volume and its environment is maintained throughout an exposure. The radiation sensitivity of the commercial well chamber was found to be constant for exposure times of 30 min.

Uncertainty in delivered dose resulting from the distribution of source activities in a Selectron LDR afterloader.

The uncertainty in the delivered dose resulting from the distribution of 137Cs source activity in a clinical Selectron LDR unit has been studied. A comparison is made of the dose delivered to a point 'A' in an implant with sources of equal activity to the actual dose delivered in the same implant with source activities randomly chosen from the population in the afterloader.

The use of customized spreadsheets in radiation therapy.

A number of radiation-therapy-related uses based on a commercially available spreadsheet program have been developed at our facility. The graphics and display capabilities inherent in these spreadsheet programs allow for concise visual results. The spreadsheets are used as an independent check for several types of radiation therapy dose calculations. External beam--a spreadsheet will verify the monitor units (MU) or time required to deliver a prescribed dose to a point on an isodose line as calculated by a commercial treatment planning system. Calibration--spreadsheet programs have been developed to perform the calculations necessary for the output calibration of cobalt and high-energy photon and electron beams according to the TG-21 protocol. The user must indicate which beam, electrometer, chamber, phantom material, temperature, pressure and depth of measurement that apply. Radiosurgery--the MU per arc is calculated based on the following: the average depth per arc as obtained from a commercial radiosurgery program, the collimator size, and the prescription dose. TBI--The patient's width is entered into the spreadsheet program, which then calculates the MU needed to deliver a prescribed dose to the midline.

Characterization of the response of commercial diode detectors used for in vivo dosimetry.

The response of a commercially available diode-based in vivo dosimetry system was studied over a selection of clinically relevant photon beam setups. The dosimetry system consists of a dedicated multichannel electrometer with several diode detectors differing only in their equivalent wall buildup. Each detector is calibrated for a specific nominal beam energy and used clinically with that energy only. To study dosimeter response, a diode taped to the surface of a solid water phantom was irradiated simultaneously with an end-window chamber placed at a depth of dmax inside the same phantom. Photon beams with energies of Co-60, 6 and 18 MV were used. For each beam energy, the response of the diode relative to the given dose as measured by the end-window chamber was evaluated for open and wedged fields (0 degree to 60 degrees) with source-to-surface distances (SSDs) ranging from 75 to 120 cm and collimator settings from 5 x 5 to 40 x 40 cm2. It was found that diode response, i.e., diode reading per cGy of given dose, varies significantly with treatment beam setup. For example, increasing field size for a constant SSD causes a decrease of up to 15% in diode response relative to the given dose for 6 and 18 MV beams, while for Co-60 an increase in response of up to 5% results. Furthermore, increasing SSD for a fixed collimator setting results in decreased diode response (up to 10%) for all beams. The complicated dependence of diode response on beam setup necessitates the use of empirical response curves, similar to those evaluated in this work, to accurately convert clinical dosimeter reading to dose at depth.

Evaluation and quality control of a commercial 3-D dose compensator system.

A commercially available software/hardware system for automated design and fabrication of three-dimensional dose compensator molds has been tested for accuracy and precision as well as for its ability to provide adequate dose compensation at depth. To date, we have used this system to treat more than 50 patients with either head and neck or lung malignancies. In 19 head and neck patients (38 compensators) the use of a customized compensator resulted in an average reduction of dose variance in the target volume from 13.8% (range of 7%-21%) with uncompensated parallel-opposed fields to 4.5% (2%-7%) with custom-compensated parallel-opposed fields. A similar reduction was seen in the dose variation across lung tumor volumes. The custom compensators were also tested for accuracy of fabrication and positioning; both were found to be accurate within +/- 1 mm of the design specifications for all compensators tested. Last, the dosimetric properties of the compensators were studied. The ratios of measured open-beam dose profiles to measured compensated-beam dose profiles were compared with the ratio of similar profiles calculated with a treatment planning system. These ratios were equal within +/- 2.9%, thus providing evidence of the fidelity of the compensator to its design and the accuracy of the treatment planning algorithm that designs 34 each compensator.

Accuracy of the point source approximation to high dose-rate Ir-192 sources.

The accuracy of the point source approximation used in dose calculations for an implant comprised of multiple high dose rate (HDR) Ir-192 source dwell positions is investigated. First, a single dwell position implant is modeled. The exposure rate about the source is calculated using both the point source approximation and the more rigorous line source formalism. A comparison of these calculated exposure rates is made. It is found that for each HDR Ir-192 source dwell position, the point source approximation results in a dose overestimation of 1% at a distance of 1 cm on the source transverse axis, while dose underestimations of more than 2% can be found at a distance of 1 cm on the source longitudinal axis. Even larger errors occur closer to the source. The results of this academic study are then extended to two clinical cases--an endobronchial treatment and a tandem and ovoids setup, both involving multiple source dwell positions. Since clinical HDR Ir-192 implants are comprised of many individual source dwell positions, there will be inaccuracy in the calculated overall dose distribution leading to dose delivery errors. For example, the dose delivered to a prescription point located 0.5 cm from an endobronchial applicator will be 3% lower than prescribed. Similar errors are produced in gynecologic implants. To decrease below 0.5% the dose delivery error resulting from the point source approximation, prescription points should be at a distance of at least 1 cm from any applicator. Since the dosimetry error is a direct result of the choice of model used to describe the source, the use of anisotropy factors accounting for the variation of photon fluence around the HDR Ir-192 source will not completely correct the calculation.

Evaluation of dose delivery based on a comparison of dosimetry calculations using open beam and wedged beam depth dose data.

The purpose of this study is to evaluate the magnitude of the error in dose delivery caused by the use of open beam depth dose data in dosimetry calculations for wedged photon beams. Isodose plans were calculated for treatments given in a 3-field isocentric prostate or rectal setup using an open AP beam with two lateral wedged beams. The dose distributions were first calculated using open beam depth dose data for all three fields. Next, the open beam data was used only for the AP field and true wedged beam depth dose data was substituted for the two lateral wedged fields. The magnitude of the depth dose variations for wedged vs open beams depends on the nominal beam energy, the wedge angle, and the depth of measurement. Consequently, isodose distributions calculated for wedged fields were found to be different when true wedged beam depth dose data was used instead of open beam data as is commonly done. Monitor unit calculations using a field size specific wedge factor show that dose delivery errors up to 4% can result from the use of open beam depth dose data in wedged beam dose distribution calculations for a 6-MV photon beam. Accurate treatment planning for wedged fields requires the use of wedged beam depth dose data specific to each wedge. Simply using open beam depth dose data in dose calculations for wedged beams will result in dose delivery errors, the magnitude of which depends on the combination of wedge angle, field size, and nominal beam energy.

Application of the "bioeffects" algorithm of a treatment planning system.

In this study, both a four-field box and two-field AP/PA treatment plan are combined with two insertions of Cs-137 in a tandem and ovoids setup, to evaluate the bioeffects program of a treatment planning system. External beam energies studied are 18 and 6 MV. It is shown that there is a slight difference in the 50-70 time dose fractionation (TDF) isolines when comparing 6 MV and 18 MV, for the AP/PA setup. There is practically no difference for TDF isoline values larger than 80 for both energies with either the four-field or the two-field setup. This is because the brachytherapy contributed the majority of the dose to the regions near the applicator and the TDF values reflect the higher dose delivered by the brachytherapy relative to the external beams in that region. For this simple evaluation of the bioeffects program, the combination of the external beam plan and the brachytherapy plan does not give us enhanced information on the effectiveness of the plan.

A simple backup for a radiosurgery treatment planning system.

To calculate the dose distribution and the number of monitor unit (MU) per arc, all radiosurgery systems utilize some sort of computer. These computers are, of course, subject to equipment malfunction such as problems with the magnetic tape drive, keyboard, mouse, etc. Since most radiosurgery procedures are quite invasive and time consuming, it is important to have a reliable and reasonably accurate backup system for planning the treatment. This paper will show that a simple PC based system, along with a digitizer, may be used as a backup for a commercial, VAX based radiosurgery system. A complete radiosurgery planning procedure was carried out on a head phantom with a target imbedded inside. The treatment planning and verification using the PC based system is also compared with that using the VAX based system.

Comparison of the homogeneity of breast dose distributions with and without the medial wedge.

Radiation of the intact breast often requires medial and lateral wedges to improve dose homogeneity of its pyramidal shape and to achieve acceptable cosmesis. There is some concern that radiation scatter from the medial wedge may contribute to cancer in the uninvolved breast, yet treatment without the medial wedge is associated with inhomogeneity of magnitudes that affect cosmesis. These homogeneities are identified on treatment plans generated at the central axis (CAX). It is not known if comparing isodose curves at the central axis reflect homogeneity in superior and inferior planes. A study was undertaken to both examine inhomogeneity with and without the medial wedge, and to determine if plan selection at the CAX was representative of homogeneity above and below the CAX. Ten consecutive patients with early breast cancers had cranial, CAX, and caudal CT images of each breast compared with two wedging conditions, lateral only (LW) and medial and lateral wedged conditions (dual wedges = DW). Dosimetry was optimized at the CAX for DW and LW conditions. Dose distributions and hot spots relative to prescribed dose were compared for cranial, CAX, and caudal images. Mean chest wall separations were measured. Six of ten patients had equivalent LW and DW distributions at the levels examined. Only one of these patients had a single off-axis hot spot > 20%. Six patients had comparable LW and DW dosimetry and acceptable hot spots at the central axis, as well as chest wall separations < or = 22 cm. In conclusion, if isodose configurations are commensurate at the CAX, these patients will have homogeneity above and below the CAX. In patients with chest wall separations < or = 22 cm, treatment without the medial wedge is feasible, sparing the contralateral breast dose with little compromise to inhomogeneity in the treated breast.

Technical management of a pregnant patient undergoing radiation therapy to the head and neck.

The fetal dose in a pregnant patient undergoing radiation therapy to the head and neck region was investigated. Implicit in this study was the design and evaluation of a shield used to minimize the fetal dose. To evaluate the fetal dose, a phantom was irradiated with the fields designed for this patient's therapy. The peripheral dose was measured for each field individually, both without and with a custom shield designed to be placed about the patient's abdominal and pelvic regions. The total dose at the location of the fetus over the course of this patient's radiation therapy was then estimated from peripheral dose rate measurements made at several points within the simulated uterus. With no shielding, the total dose within the uterus of the patient would have ranged from 13.3 cGy at the cervix to 28 cGy at the fundus. With the shield applied, the uterine dose was significantly less: 3.3 cGy at the cervix to 8.6 cGy at the fundus. In fact, at every measurement point, the peripheral dose with the shield in place was 30% to 50% of the dose without the shield. Some data suggest that the rate of significant abnormalities induced by irradiation in utero increases with increasing dose within the range of total peripheral doses incurred during most radiation treatment courses. It is therefore prudent to make reasonable attempts at minimizing the dose to the lower abdominal and pelvic regions of any pregnant patient. The shield designed in this work accomplished this goal for this patient and is flexible enough to be used in the treatment of almost all tumor volumes.