Impact of bowel and rectum air on target dose with robustly optimized intensity-modulated proton therapy plans.

PURPOSE: Pelvic target dose from intensity-modulated proton therapy (IMPT) is sensitive to patient bowel motion. Robustly optimized plans in regard to bowel filling may improve the dose coverage in the treatment course. Our purpose is to investigate the effect of air volume in large and small bowel and rectum on target dose from IMPT plans. METHODS AND MATERIAL: Data from 17 cancer patients (11 prostate, 3 gynecologic, 2 colon, and 1 embryonal rhabdomyosarcoma) with planning CT (pCT) and weekly or biweekly scanned quality assurance CTs (QACTs; 82 QACT scans total) were studied. Air in bowels and rectum traversed by proton pencil beams was contoured. The robust treatment plan was made by using 3 CT sets: the pCT set and 2 virtual CT sets that were copies of pCT but in which the fillings of bowels and rectum were overridden to be either air or muscle. Each plan had 2-5 beams with a mean of 3 beams. Targets in the pCT were mapped to the QACTs by deformable image registration, and the dose in QACTs was calculated. Dose coverage (D99 and D95) and correlations between dose coverage and changes in air volume were analyzed. The significance of the correlation was analyzed by t test. RESULTS: Mean changes of D99 in QACTs were within 3% of those in the pCT for all prostate and colon cases but >3% in 2 of the 3 gynecologic cases and in the embryonal rhabdomyosarcoma case. Of these three cases with mean change of D99 > 3%, air volume may be the main cause in 2. For the prostate cases, correlation coefficients were <0.7 between change in air volume and change in D99 and D95, because other anatomy changes also contributed to dose deviation. Correlation coefficients in the non-prostate cases were >0.9 between D99 change and rectum and between D95 change and small bowel, indicating a greater effect of the air volume on target dose. CONCLUSION: The air volume may still have an important effect on target dose coverage in treatment plans using 3 CT sets, particularly when the air is traversed by multiple beams.

Determining the optimal dosimetric leaf gap setting for rounded leaf-end multileaf collimator systems by simple test fields.

Individual QA for IMRT/VMAT plans is required by protocols. Sometimes plans cannot pass the institute's QA criteria. For the Eclipse treatment planning system (TPS) with rounded leaf-end multileaf collimator (MLC), one practical way to improve the agreement of planned and delivered doses is to tune the value of dosimetric leaf gap (DLG) in the TPS from the measured DLG. We propose that this step may be necessary due to the complexity of the MLC system, including dosimetry of small fields and the tongue-and-groove (T&G) effects, and report our use of test fields to obtain linac-specific optimal DLGs in TPSs. More than 20 original patient plans were reoptimized with the linac-specific optimal DLG value. We examined the distribution of gaps and T&G extensions in typical patient plans and the effect of using the optimal DLG on the distribution. The QA pass rate of patient plans using the optimal DLG was investigated. The dose-volume histograms (DVHs) of targets and organs at risk were checked. We tested three MLC systems (Varian millennium 120 MLC, high-definition 120 MLC, and Siemens 160 MLC) installed in four Varian linear accelerators (linacs) (TrueBEAM STx, Trilogy, Clinac 2300 iX, and Clinac 21 EX) and 1 Siemens linac (Artiste). With an optimal DLG, the individual QA for all those patient plans passed the institute's criteria (95% in DTA test or gamma test with 3%/3 mm/10%), even though most of these plans had failed to pass QA when using original DLGs optimized from typical patient plans or from the optimization process (automodeler) of Pinnacle TPS. Using either our optimal DLG or one optimized from typical patient plans or from the Pinnacle optimization process yielded similar DVHs.

Proton beam therapy: a fad or a new standard of care.

PURPOSE OF REVIEW: Newer methods and advances in radiation therapy promise to reduce the risk of complications in children who require irradiation. They have secured the role of radiation therapy in the treatment of a variety of pediatric central nervous system and solid tumors and for young patients enrolled on clinical trials. RECENT FINDINGS: Proton therapy is the latest advancement in radiation therapy. Its availability is increasing as new centers are built throughout the United States. Pediatric specialists should understand that proton therapy is in its pioneering stage of development and that advantages have not been quantitatively demonstrated. Proton therapy clearly reduces collateral radiation dose to normal tissue when compared with photon (X-ray)-based methods of irradiation and has the potential to selectively and safely escalate dose to high-risk tumors; however, research results are lacking in both of these areas, leading to some confusion among pediatric specialists with regard to indications and the need to refer patients for this limited resource and expensive form of radiation therapy. SUMMARY: This review highlights a number of issues surrounding proton therapy in children and supports the use of proton therapy in clinical trials.

Comprehensive assessment of proton plans with three different beam delivery systems for multiple brain metastases.

Purpose: To compare plan quality among photon volumetric arc therapy (VMAT), Gamma Knife, and three different proton beam modalities. Methods: Fifty-five brain lesions from 20 patients were planned with three different proton spot size ranges of cyclotron-generated proton beams, CPBs (spot size σ: 2.7-7.0 mm), linear accelerator proton beams, LPBs (σ: 2.9-5.5 mm), and linear accelerator proton minibeams, LPMBs (σ: 0.9-3.9 mm), with and without apertures and compared against photon VMAT and Gamma Knife plans. Dose coverage to each lesion for each proton and photon plan was set to 99% of the GTV receiving the prescription (Rx) dose. All proton plans used ±2 mm setup uncertainty and ±2% range uncertainty in robust evaluation to achieve V100%Rx > 95% of the GTV. Apertures were applied to proton beams irradiating tumors <1 cm3 volume and located <2.5 cm depth. Conformity index (CI), gradient index (GI), V12 Gy, V4.5 Gy, and mean brain dose were compared across all plan types. The Wilcoxon signed rank test was utilized to determine statistical significance of dosimetric results compared between photon and proton plans. Results: When compared to CPB generated plans, average CI and GI were significantly better for the LPB and LPMB plans. Aperture-based IMPT plans showed improvement from Gamma Knife for all dosimetric metrics. Aperture-based IMPT plans also showed improvement in all dosimetric metrics for shallow tumors (d < 2.5 cm) when compared with non-aperture-based plans. Conclusion: The LPB and LPMB stand as excellent alternatives to CPB or photon therapy and significantly increase the preservation of normal tissue.

Cyclotron and linear accelerator generated scanning proton beams for lung cancer SBRT: Interplay effects and mitigations.

BACKGROUND: Pencil beam scanning (PBS) proton therapy for moving targets is known to be impacted by interplay effects between the scanning beam and organ motion. While respiratory motion in the thoracic region is the major cause for organ motion, interplay effects depend on the delivery characteristics of proton accelerators. PURPOSE: To evaluate the impact of different types of PBS proton accelerators and spot sizes on interplay effects, mitigations, and plan quality for Stereotactic Body Radiation Therapy (SBRT) treatment of non-small cell lung cancer (NSCLC). METHODS: Twenty NSCLC patients treated with photon SBRT were selected to represent varying tumor volumes and respiratory motion amplitudes (median: 0.6 cm with abdominal compression) for this retrospective study. For each patient, plans were created using: (1) cyclotron-generated proton beams (CPB) with spot sizes of σ = 2.7-7.0 mm; (2) linear accelerator proton beams (LPB) (σ = 2.9-5.5 mm); and (3) linear accelerator proton minibeams (LPMB) (σ = 0.9-3.9 mm). The energy switching time is one second for CPB, and 0.005 s for LPMB and LPB. Plans were robustly optimized on the gross tumor volume (GTV) using each individual phase of four-dimensional computed tomography (4DCT) scans. Initially, single-field optimization (SFO) plans were evaluated; if the plan quality did not meet the dosimetric requirement, multi-field optimization (MFO) was used. MFO plans were created for all patients for comparisons. For each patient, all plans were normalized to have the same dose received by 99% of the GTV. Interplay effects were evaluated by computing the dose on 10 breathing phases, based on the spot distribution. Volumetric repainting (VR) was performed 2-6 times for each plan. We compared volume receiving 100% of the prescribed dose (V100%RX) of the GTV, and normal lung V20Gy. RESULTS: Twelve of 20 plans can be optimized sufficiently with SFO. SFO plans were less sensitive to the interplay effect compared to MFO plans in terms of target coverage for both LPB and LPMB. The following comparisons showed results utilizing the MFO technique. In the interplay evaluation without repainting, the mean V100%RX of the GTV were 99.42 ± 0.6%, 97.52 ± 3.9%, and 94.49 ± 7.3% for CPB, LPB, and LPMB plans, respectively. Following VR (2 × for CPB; 3 × for LPB; 5 × for LPMB), V100%RX of the GTV were improved (on average) by 0.13%, 1.84%, and 4.63%, respectively, achieving the acceptance criteria of V100%RX > 95%. Because of fast energy switch in linear accelerator proton machines, the delivery time for VR plans was the lowest for LPB plans, while delivery time for LPMB was on average 1 min longer than CPB plans. The advantage of small spot machines was better sparing in normal lung V20Gy, even when VR was applied. CONCLUSION: In the absence of repainting, proton machines with large spot sizes generated more robust plans against interplay effects. The number of VR increased with decreasing spot sizes to achieve the acceptance criteria. VR improved the plan robustness against interplay effects for modalities with small spot sizes and fast energy changes, preserving the low dose sparing aspect of the LPMB, even when motion is included.

Technical note: Determination of proton linear energy transfer from the integral depth dose.

BACKGROUND: Proton linear energy transfer (LET) is associated with the relative biological effectiveness of radiation on tissues. Monte Carlo (MC) simulations have been known to be the preferred method to calculate LET. Detectors have also been built to measure LET, but they need to be calibrated with MC simulations. PURPOSE: To propose and test a MC-free method for determining LET from the measured integral depth dose (LFI) of the protons of interest. METHOD AND MATERIALS: LFI consists of three steps: (1) IDD measurements, (2) extraction of energy spectrum (ES) from the IDD, and (3) LET determination from the extracted ES and the stopping power of each energy. To validate the accuracy of the extraction of ES, we use Gaussian ES to synthesize IDD, extract ES from the synthesized IDD, and then compare the original (ground truth) and extracted ES. LETs calculated from the original and extracted ES are also compared. To obtain the LET of protons of interest, we measure IDDs by a large-area plane-parallel ionization chamber in water. Finally, TOPAS MC is employed to simulate IDDs, ES, and LETs. From the simulated IDD, the extracted ES and LET are compared with the simulations from TOPAS MC. RESULTS: From the synthesized IDDs, the LETs agreed excellently when the peak energies ≥10 and 1.25 MeV with depth resolutions 0.1 and 0.01 mm, respectively. For energy <1.25 MeV, even higher depth resolution than 0.01 mm is required. From the MC simulated IDDs, our track-averaged LET excellently agreed with MC simulation, but not the LETd . Our LETd was smaller than MC simulated LETd in the shallow region but larger in the distal Bragg peak region. CONCLUSION: LET can be accurately determined from the IDD. This method can be used in the clinic to commission or validate LETs from other measurement methods or a treatment planning system.

Heat stress does not induce wasting symptoms in the giant California sea cucumber (Apostichopus californicus).

Oceanic heatwaves have significant impacts on disease dynamics in marine ecosystems. Following an extreme heatwave in Nanoose Bay, British Columbia, Canada, a severe sea cucumber wasting event occurred that resulted in the mass mortality of Apostichopus californicus. Here, we sought to determine if heat stress in isolation could trigger wasting symptoms in A. californicus. We exposed sea cucumbers to (i) a simulated marine heatwave (22 °C), (ii) an elevated temperature treatment (17 °C), or (iii) control conditions (12 °C). We measured the presence of skin lesions, mortality, posture maintenance, antipredator defences, spawning, and organ evisceration during the 79-hour thermal exposure, as well as 7-days post-exposure. Both the 22 °C and 17 °C treatments elicited stress responses where individuals exhibited a reduced ability to maintain posture and an increase in stress spawning. The 22 °C heatwave was particularly stressful, as it was the only treatment where mortality was observed. However, none of the treatments induced wasting symptoms as observed in the Nanoose Bay event. This study provides evidence that sea cucumber wasting may not be triggered by heat stress in isolation, leaving the cause of the mass mortality event observed in Nanoose unknown.

Beam characteristics in two different proton uniform scanning systems: a side-by-side comparison.

PURPOSE: To compare clinically relevant dosimetric characteristics of proton therapy fields produced by two uniform scanning systems that have a number of similar hardware components but employ different techniques of beam spreading. METHODS: This work compares two technologically distinct systems implementing a method of uniform scanning and layer stacking that has been developed independently at Indiana University (IU) and by Ion Beam Applications, S. A. (IBA). Clinically relevant dosimetric characteristics of fields produced by these systems are studied, such as beam range control, peak-to-entrance ratio (PER), lateral penumbra, field flatness, effective source position, precision of dose delivery at different gantry angles, etc. RESULTS: Under comparable conditions, both systems controlled beam range with an accuracy of 0.5 mm and a precision of 0.1 mm. Compared to IBA, the IU system produced pristine peaks with a slightly higher PER (3.23 and 3.45, respectively) and smaller, symmetrical, lateral in-air penumbra of 1 mm compared to about 1.9/2.4 mm in the inplane/crossplane (IP/CP) directions for IBA. Large field flatness results in the IP/CP directions were similar: 3.0/2.4% for IU and 2.9/2.4% for IBA. The IU system featured a longer virtual source-to-isocenter position, which was the same for the IP and CP directions (237 cm), as opposed to 212/192 cm (IP/CP) for IBA. Dose delivery precision at different gantry angles was higher in the IBA system (0.5%) than in the IU system (1%). CONCLUSIONS: Each of the two uniform scanning systems considered in this work shows some attractive performance characteristics while having other features that can be further improved. Overall, radiation field characteristics of both systems meet their clinical specifications and show comparable results. Most of the differences observed between the two systems are clinically insignificant.

The effects of motion on the dose distribution of proton radiotherapy for prostate cancer.

Proton radiotherapy of the prostate basal or whole seminal vesicles using scattering delivery systems is an effective treatment of prostate cancer that has been evaluated in prospective trials. Meanwhile, the use of pencil beam scanning (PBS) can further reduce the dose in the beam entrance channels and reduce the dose to the normal tissues. However, PBS dose distributions can be affected by intra- and interfractional motion. In this treatment planning study, the effects of intra- and interfractional organ motion on PBS dose distributions are investigated using repeated CT scans at close and distant time intervals. The minimum dose (Dmin) and the dose to 2% and 98% of the volumes (D2% and D98%), as well as EUD in the clinical target volumes (CTV), is used as measure of robustness. In all patients, D98% was larger than 96% and D2% was less than 106% of the prescribed dose. The combined information from Dmin, D98% and EUD led to the conclusion that there are no relevant cold spots observed in any of the verification plans. Moreover, it was found that results of single field optimization are more robust than results from multiple field optimizations.

Ultra-high dose rate radiation production and delivery systems intended for FLASH.

Higher dose rates, a trend for radiotherapy machines, can be beneficial in shortening treatment times for radiosurgery and mitigating the effects of motion. Recently, even higher doses (e.g., 100 times greater) have become targeted because of their potential to generate the FLASH effect (FE). We refer to these physical dose rates as ultra-high (UHDR). The complete relationship between UHDR and the FE is unknown. But UHDR systems are needed to explore the relationship further and to deliver clinical UHDR treatments, where indicated. Despite the challenging set of unknowns, the authors seek to make reasonable assumptions to probe how existing and developing technology can address the UHDR conditions needed to provide beam generation capable of producing the FE in preclinical and clinical applications. As a preface, this paper discusses the known and unknown relationships between UHDR and the FE. Based on these, different accelerator and ionizing radiation types are then discussed regarding the relevant UHDR needs. The details of UHDR beam production are discussed for existing and potential future systems such as linacs, cyclotrons, synchrotrons, synchrocyclotrons, and laser accelerators. In addition, various UHDR delivery mechanisms are discussed, along with required developments in beam diagnostics and dose control systems.

Lateral dose profile characterization in scanning particle therapy.

PURPOSE: In light-ion beam dose delivery with the scanning technique the spacing between adjacent spots is an important parameter during treatment planning. In order to study the effect of spot spacing on dose conformity and robustness for single field uniform dose configurations, fundamental geometrical properties of placement of Gaussian beamlets are explored. In particular, the dependence of penumbra width and flatness on spot width and spot spacing is investigated. METHODS: Infinitesimal calculus and analytical methods are used to derive simple expressions for the lateral penumbra and the flatness of one-dimensional dose profiles in continuous scanning and uniform discrete spot scanning. In the same way expressions for the fundamental modes of perturbation of the spot sequence are developed. A numerical, matrix-based approach is followed to optimize weights spot-by-spot. RESULTS: Generally the lateral penumbra widths lie between 1.13 sigma(b) and 1.68 sigma(b) with sigma(b) being the standard deviation of the beam spot profile. For regularly placed spots of equal weight with spot spacing lambda the lateral penumbra is given by 1.68 sigma' where sigma' results from quadratic subtraction of lambda/square root of 12 from sigma(b). The quantization error is identified as additional parameter describing the lateral dose conformity. It's variance is given by lambda2/12 for a bunch of spots with uniform weights. The matrix-based optimization of weights for a one-dimensional dose box results in a lateral penumbra of typically 1.4 sigma(b). This value reduces to about 1.3 sigma(b) if also the positions of the beam spots are optimized for the considered field size. The analytical formulas for uniform discrete scanning can be used as rough approximations of the best-case scenarios for weight-optimized dose profiles if the spot spacing is defined as effective spot spacing. CONCLUSIONS: The trade-off between flatness, quantization error, and robustness on the one side and penumbra width on the other side can be described analytically for equally weighted spots. Treatment planning systems often perform a least-squares optimization of the individual spot weights which results in smaller lateral penumbras and smaller quantization errors than for uniform discrete scanning. However, the benefit of this weight optimization decreases with increasing lambda (in the regime lambda > sigma(b)). The spot spacing, which is obtained from the scenario that the optimization objective is met by uniform discrete scanning, poses a sharp upper limit for the spot spacing lambda in weight optimization methods.

Technical note: Extraction of proton pencil beam energy spectrum from measured integral depth dose in a cyclotron proton beam system.

PURPOSE: Proton pencil beam energy spectrum is an essential parameter for calculations of dose and linear energy transfer. We extract the energy spectrum from measured integral depth dose (IDD). METHODS: A measured IDD (measIDD) in water is decomposed into many IDDs of mono-energetic pencil beams (monoIDDs) in water. A simultaneous iterative technique is used to do the decomposition that extracts the energy spectrum of protons from the measIDD. The monoIDDs are generated by our analytic random walk model-based proton dose calculation algorithm. The linear independence of the monoIDDs is considered and high spatial resolution monoIDDs are used to improve their linear independence. To validate the extraction, first we use synthesized IDDs (synIDD) with Gaussian energy spectrum and compare the extracted energy spectrum with the Gaussian; second, for the energy spectrum extracted from measIDDs, the accuracy of the extraction is validated by comparing the calculated IDD from the energy spectrum with the measIDD. The measIDDs are derived from commissioning of a cyclotron proton pencil beam system with a Bragg peak ionization chamber. The nominal energy of the pencil beams is from 70 to 245 MeV. The monoIDDs are generated for energies from 0.05 to 275 MeV in steps of 0.05 MeV with a spatial resolution of 1 mm. RESULTS: The difference of the extracted and original Gaussian energy spectrum peaked at 75 and 80 MeV was <1%. As the energy decreased, the difference increased but was reduced by using 0.1-mm monoIDDs. The difference was not sensitive to the energy interval of monoIDDs when the interval increased from 0.05 to 1 MeV. For the energy spectrum extraction from measIDDs, there was a main peak near the nominal energy but the spectrum was not in Gaussian distribution. In three example cases (70, 160, and 245 MeV), the relative differences of the measIDDs and calculated IDDs were within 3.4%, 2.9%, and 4.7% of the Bragg peak value, respectively. Fitting the spectrum by Gaussian distribution, we had σ = 0.87, 1.51, and 0.86 MeV, respectively, for these three examples, and the relative differences of the resultant calculated IDDs from the measIDDs were within 4.7%, 7.4%, and 4.5%, respectively. CONCLUSIONS: Our algorithm accurately extracted the energy spectrum from the synIDDs and measIDDs. High-resolution monoIDDs are necessary to extract low-energy spectrum. Energy spectrum extraction from measIDD reveals important information for beam modeling.

No effect of passive integrated transponder tagging method on survival or body condition in a northern population of Black-capped Chickadees (Poecile atricapillus).

Passive integrated transponder (PIT) tags allow a range of individual-level data to be collected passively and have become a commonly used technology in many avian studies. Although the potential adverse effects of PIT tags have been evaluated in several species, explicit investigations of their impacts on small (<12 g) birds are limited. This is important, because it is reasonable to expect that smaller birds could be impacted more strongly by application of PIT tags. In this study, we individually marked Black-capped Chickadees (Poecile atricapillus), a small (circa 10 g) passerine, at the University of Alberta Botanic Garden to evaluate potential lethal and sublethal effects of two PIT tagging methods: attachment to leg bands or subcutaneous implantation. We used a Cox proportional hazards model to compare the apparent survival of chickadees with leg band (N = 79) and implanted PIT tags (N = 77) compared with control birds that received no PIT tags (N = 76) over the subsequent 2 years based on mist net recaptures. We used radio-frequency identification (RFID) redetections of leg band PIT tags to evaluate sex-specific survival and increase the accuracy of our survival estimates. We also used a generalized linear regression model to compare the body condition of birds recaptured after overwintering with leg band PIT tags, implanted PIT tags, or neither. Our analysis found no evidence for adverse effects of either PIT tagging method on survival or body condition. While we recommend carefully monitoring study animals and evaluating the efficacy of different PIT tagging methods, we have shown that both leg band and subcutaneously implanted PIT tags ethical means of obtaining individualized information in a small passerine.

Clinical commissioning of intensity-modulated proton therapy systems: Report of AAPM Task Group 185.

Proton therapy is an expanding radiotherapy modality in the United States and worldwide. With the number of proton therapy centers treating patients increasing, so does the need for consistent, high-quality clinical commissioning practices. Clinical commissioning encompasses the entire proton therapy system's multiple components, including the treatment delivery system, the patient positioning system, and the image-guided radiotherapy components. Also included in the commissioning process are the x-ray computed tomography scanner calibration for proton stopping power, the radiotherapy treatment planning system, and corresponding portions of the treatment management system. This commissioning report focuses exclusively on intensity-modulated scanning systems, presenting details of how to perform the commissioning of the proton therapy and ancillary systems, including the required proton beam measurements, treatment planning system dose modeling, and the equipment needed.

Validation of dosimetric field matching accuracy from proton therapy using a robotic patient positioning system.

Large area, shallow fields are well suited to proton therapy. However, due to beam production limitations, such volumes typically require multiple matched fields. This is problematic due to the relatively narrow beam penumbra at shallow depths compared to electron and photon beams. Therefore, highly accurate dose planning and delivery is required. As the dose delivery includes shifting the patient for matched fields, accuracy at the 1-2 millimeter level in patient positioning is also required. This study investigates the dosimetric accuracy of such proton field matching by an innovative robotic patient positioner system (RPPS). The dosimetric comparisons were made between treatment planning system calculations, radiographic film and ionization chamber measurements. The results indicated good agreement amongst the methods and suggest that proton field matching by a RPPS is accurate and efficient.

Technical Note: Design and characterization of a large diameter parallel plate ionization chamber for accurate integral depth dose measurements with proton beams.

PURPOSE: The goal was to develop and test a large diameter parallel plate ionization chamber capable of intercepting at least 98% of the proton beamlets tested with the system. METHODS: A commercial synchrotron proton therapy system was used for the study (Hitachi, Ltd, Hitachi City, Japan; Model: Probeat-V). The energies investigated were in the range of 100 to 192 MeV. Three beam spot options available from the system were used. A PTW Bragg peak IC of diameter 84 mm (BP84) (Model PTW34070) was employed for comparison in a scanning water phantom. A prototype of 150 mm diameter was produced (PTW, Freiburg, Germany; model: T34089) and used for the testing. Monte Carlo calculations were also performed with FLUKA to guide the BP150 design and for comparison to the radiological measurements. For comparison, a 40 cm diameter ideal virtual detector was included in the Monte Carlo model. RESULTS: The measured proton range R90 agrees between the BP84 and BP150 ionization chambers within +0.06/-0.27 mm across the energies 100-192 MeV, which is less than the daily experimental setup uncertainty of 0.4 mm. The differences in the absolute integral depth dose curves (IDDs) between the BP84 and BP150 ranged from 0.3% to 1.0% for the spot sizes and beam energies tested. As predicted by the Monte Carlo modeling, the greatest differences were found in the plateau region of the IDDs. Also, the IDDs measured with the BP150 were very similar to those of the ideal 40 cm diameter detector Monte Carlo simulations. CONCLUSIONS: We conclude that the BP150 offers a small, but a useful reduction in uncertainty from the nuclear halo effect for the system under test.

Range and modulation dependencies for proton beam dose per monitor unit calculations.

Calculations of dose per monitor unit (D/MU) are required in addition to measurements to increase patient safety in the clinical practice of proton radiotherapy. As in conventional photon and electron therapy, the D/MU depends on several factors. This study focused on obtaining range and modulation dependence factors used in D/MU calculations for the double scattered proton beam line at the Midwest Proton Radiotherapy Institute. Three dependencies on range and one dependency on modulation were found. A carefully selected set of measurements was performed to discern these individual dependencies. Dependencies on range were due to: (1) the stopping power of the protons passing through the monitor chamber; (2) the reduction of proton fluence due to nuclear interactions within the patient; and (3) the variation of proton fluence passing through the monitor chamber due to different source-to-axis distances (SADs) for different beam ranges. Different SADs are produced by reconfigurations of beamline elements to provide different field sizes and ranges. The SAD effect on the D/MU varies smoothly as the beam range is varied, except at the beam range for which the first scatterers are exchanged and relocated to accommodate low and high beam ranges. A geometry factor was devised to model the SAD variation effect on the D/MU. The measured D/MU variation as a function of range can be predicted within 1% using the three modeled dependencies on range. Investigation of modulated beams showed that an analytical formula can predict the D/MU dependency as a function of modulation to within 1.5%. Special attention must be applied when measuring the D/MU dependence on modulation to avoid interplay between range and SAD effects.

Energy spectrum control for modulated proton beams.

In proton therapy delivered with range modulated beams, the energy spectrum of protons entering the delivery nozzle can affect the dose uniformity within the target region and the dose gradient around its periphery. For a cyclotron with a fixed extraction energy, a rangeshifter is used to change the energy but this produces increasing energy spreads for decreasing energies. This study investigated the magnitude of the effects of different energy spreads on dose uniformity and distal edge dose gradient and determined the limits for controlling the incident spectrum. A multilayer Faraday cup (MLFC) was calibrated against depth dose curves measured in water for nonmodulated beams with various incident spectra. Depth dose curves were measured in a water phantom and in a multilayer ionization chamber detector for modulated beams using different incident energy spreads. Some nozzle entrance energy spectra can produce unacceptable dose nonuniformities of up to +/-21% over the modulated region. For modulated beams and small beam ranges, the width of the distal penumbra can vary by a factor of 2.5. When the energy spread was controlled within the defined limits, the dose nonuniformity was less than +/-3%. To facilitate understanding of the results, the data were compared to the measured and Monte Carlo calculated data from a variable extraction energy synchrotron which has a narrow spectrum for all energies. Dose uniformity is only maintained within prescription limits when the energy spread is controlled. At low energies, a large spread can be beneficial for extending the energy range at which a single range modulator device can be used. An MLFC can be used as part of a feedback to provide specified energy spreads for different energies.

AAPM task group 224: Comprehensive proton therapy machine quality assurance.

PURPOSE:  Task Group (TG) 224 was established by the American Association of Physicists in Medicine's Science Council under the Radiation Therapy Committee and Work Group on Particle Beams. The group was charged with developing comprehensive quality assurance (QA) guidelines and recommendations for the three commonly employed proton therapy techniques for beam delivery: scattering, uniform scanning, and pencil beam scanning. This report supplements established QA guidelines for therapy machine performance for other widely used modalities, such as photons and electrons (TG 142, TG 40, TG 24, TG 22, TG 179, and Medical Physics Practice Guideline 2a) and shares their aims of ensuring the safe, accurate, and consistent delivery of radiation therapy dose distributions to patients. METHODS:  To provide a basis from which machine-specific QA procedures can be developed, the report first describes the different delivery techniques and highlights the salient components of the related machine hardware. Depending on the particular machine hardware, certain procedures may be more or less important, and each institution should investigate its own situation. RESULTS:  In lieu of such investigations, this report identifies common beam parameters that are typically checked, along with the typical frequencies of those checks (daily, weekly, monthly, or annually). The rationale for choosing these checks and their frequencies is briefly described. Short descriptions of suggested tools and procedures for completing some of the periodic QA checks are also presented. CONCLUSION:  Recommended tolerance limits for each of the recommended QA checks are tabulated, and are based on the literature and on consensus data from the clinical proton experience of the task group members. We hope that this and other reports will serve as a reference for clinical physicists wishing either to establish a proton therapy QA program or to evaluate an existing one.

Management of radiotherapy patients with implanted cardiac pacemakers and defibrillators: A Report of the AAPM TG-203†.

Managing radiotherapy patients with implanted cardiac devices (implantable cardiac pacemakers and implantable cardioverter-defibrillators) has been a great practical and procedural challenge in radiation oncology practice. Since the publication of the AAPM TG-34 in 1994, large bodies of literature and case reports have been published about different kinds of radiation effects on modern technology implantable cardiac devices and patient management before, during, and after radiotherapy. This task group report provides the framework that analyzes the potential failure modes of these devices and lays out the methodology for patient management in a comprehensive and concise way, in every step of the entire radiotherapy process.