C. Talamonti

Accelerated Partial Breast Irradiation With IMRT: New Technical Approach and Interim Analysis of Acute Toxicity in a Phase III Randomized Clinical Trial

PURPOSE To evaluate with a randomized clinical trial the possibility of treating the index quadrant with external intensity-modulated radiotherapy (IMRT) in a selected group of patients with early-stage breast cancer and to analyze the acute toxicity. METHODS AND MATERIALS From September 2005, a randomized Phase III clinical trial has been conducted to compare conventional (tangential field) fractionated whole breast treatment (Arm A) with accelerated partial breast irradiation plus intensity-modulated radiotherapy (Arm B). For intensity-modulated radiotherapy, the clinical target volume was drawn with a uniform 1-cm margin around the surgical clips in three dimensions. The ipsilateral and contralateral breast, ipsilateral and contralateral lung, heart, and spinal cord were contoured as organs at risk. All the regions of interest were contoured according to the International Commission on Radiation Units and Measurements reports 50 and 62 recommendations. RESULTS In September 2008, 259 patients were randomized and treated. The mean clinical target volume in Arm B was 44 cm(3) and the mean planning target volume was 123 cm(3). The mean value of the ratio between the planning target volume and the ipsilateral breast volume was 21%. The rate of Grade 1 and Grade 2 acute skin toxicity was 22% and 19% in Arm A (Radiation Therapy Oncology Group scale), respectively. The tolerance in Arm B was excellent with only 5% Grade 1 and 0.8% Grade 2 acute skin toxicity. The planning constraints were fully satisfied in most patients. In a very few cases, this was not possible because of very unfavorable anatomy. Quality assurance procedures were performed according to our internal quality assurance protocol, with excellent results. CONCLUSION In the present preliminary analysis, we have demonstrated that accelerated partial breast irradiation is feasible, with very low acute toxicity.

Pretreatment verification of IMRT absolute dose distributions using a commercial a-Si EPID.

A commercial amorphous silicon electronic portal imaging device (EPID) has been studied to investigate its potential in the field of pretreatment verifications of step and shoot, intensity modulated radiation therapy (IMRT), 6 MV photon beams. The EPID was calibrated to measure absolute exit dose in a water-equivalent phantom at patient level, following an experimental approach, which does not require sophisticated calculation algorithms. The procedure presented was specifically intended to replace the time-consuming in-phantom film dosimetry. The dosimetric response was characterized on the central axis in terms of stability, linearity, and pulse repetition frequency dependence. The a-Si EPID demonstrated a good linearity with dose (within 2% from 1 monitor unit), which represent a prerequisite for the application in IMRT. A series of measurements, in which phantom thickness, air gap between the phantom and the EPID, field size and position of measurement of dose in the phantom (entrance or exit) varied, was performed to find the optimal calibration conditions, for which the field size dependence is minimized. In these conditions (20 cm phantom thickness, 56 cm air gap, exit dose measured at the isocenter), the introduction of a filter for the low-energy scattered radiation allowed us to define a universal calibration factor, independent of field size. The off-axis extension of the dose calibration was performed by applying a radial correction for the beam profile, distorted due to the standard flood field calibration of the device. For the acquisition of IMRT fields, it was necessary to employ home-made software and a specific procedure. This method was applied for the measurement of the dose distributions for 15 clinical IMRT fields. The agreement between the dose distributions, quantified by the gamma index, was found, on average, in 97.6% and 98.3% of the analyzed points for EPID versus TPS and for EPID versus FILM, respectively, thus suggesting a great potential of this EPID for IMRT dosimetric applications.

Organs at risk in the brain and their dose-constraints in adults and in children: A radiation oncologist’s guide for delineation in everyday practice

PURPOSE Accurate organs at risk definition is essential for radiation treatment of brain tumors. The aim of this study is to provide a stepwise and simplified contouring guide to delineate the OARs in the brain as it would be done in the everyday practice of planning radiotherapy for brain cancer treatment. METHODS Anatomical descriptions and neuroimaging atlases of the brain were studied. The dosimetric constraints used in literature were reviewed. RESULTS A Computed Tomography and Magnetic Resonance Imaging based detailed atlas was developed jointly by radiation oncologists, a neuroradiologist and a neurosurgeon. For each organ brief anatomical notion, main radiological reference points and useful considerations are provided. Recommended dose-constraints both for adult and pediatric patients were also provided. CONCLUSIONS This report provides guidelines for OARs delineation and their dose-constraints for the treatment planning of patients with brain tumors.

Characterization of a Silicon Strip Detector and a YAG:Ce Calorimeter for a Proton Computed Radiography Apparatus

Today, there is a steadily growing interest in the use of proton beams for tumor therapy, as they permit to tightly shape the dose delivered to the target reducing the exposure of the surrounding healthy tissues. Nonetheless, accuracy in the determination of the dose distribution in proton-therapy is up to now limited by the uncertainty in stopping powers, which are presently calculated from the photon attenuation coefficients measured by X-ray tomography. Proton computed tomography apparatus (pCT) has been proposed to directly measure the stopping power and reduce this uncertainty. Main problem with proton imaging is the blurring effect introduced by multiple Coulomb scattering: single proton tracking is a promising technique to face this difficulty. As a first step towards a pCT system, we designed a proton radiography (pCR) prototype based on a silicon microstrip tracker (to characterize particle trajectories) and a segmented YAG:Ce calorimeter (to measure their residual energy). Aim of the system is to detect protons with a ~1 MHz particle rate of and with kinetic energy in the range 250-270 MeV, high enough to pass through human body. Design and development of the pCR prototype, as well as the characterization of its single components, are described in this paper.

Monte Carlo Studies of a Proton Computed Tomography System

Proton therapy is a precise forms of radiation therapy that makes use of high energy proton compared to the conventional, more commonly used and less precise x-ray and electron beams. On the other hand, to fully exploit the proton therapy advantages, very accurate quality controls of the treatments are required. These are mainly related to the dose calculations and treatment planning. Actually dose calculations are routinely performed on the basis of X-ray computed tomography while a big improvement could be obtained with the direct use of protons as the imaging system. In this work we report the results of Monte Carlo simulations for the study of an imaging system based on the use of high energy protons: the proton computed tomography (pCT). The main limitation of the pCT and the current adopted technical solutions, based on the use of the most likely path (MLP) approximation are illustrated. Simulation results are compared with experimental data obtained with a first prototype of pCT system tested with 200 MeV proton beams available at the Loma Linda University Medical Center (LLUMC) (CA).

Epitaxial silicon devices for dosimetry applications

A straightforward improvement of the efficiency and long term stability of silicon dosimeters has been obtained with a n+-p junction surrounded by a guard-ring structure implanted on an epitaxial p-type Si layer grown on a Czochralski substrate. The sensitivity of devices made on 50-μm-thick epitaxial Si degrades by only 7% after an irradiation with 6MeV electrons up to 1.5kGy, and shows no significant further decay up to 10kGy. These results prove the enhanced radiation tolerance and stability of epitaxial diodes as compared to present state-of-the-art Si devices.

A synthetic diamond diode in volumetric modulated arc therapy dosimetry

PURPOSE The aim of this work is to investigate the behavior of a single crystal diamond diode (SCDD) for volumetric modulated arc therapy (VMAT) dose verifications. This delivery technique is one of the most severe test of a dosimeter performance due to the modulation of the dose rate achieved by simultaneously changing the velocity of the gantry and the position of the collimator leaves. The performed measurements with VMAT photon beams can therefore contribute to an overall global validation of the device to be used in dose distribution verifications. METHODS The SCDD response to 6 MVRX has been tested and compared with reference ionization chambers and treatment planning system (TPS) calculations in different experiments: (a) measurements of output factors for small field sizes (square fields of side ranging between 8 mm and 104 mm) by SCDD and A1SL ionization chamber; (b) angular dependence evaluation of the entire experimental set-up by SCDD, A1SL, and Farmer ionization chambers; and (c) acquisition of dose profiles for a VMAT treatment of a pulmonary disease in latero-lateral and gantry-target directions by SCDD and A1SL ionization chamber. RESULTS The output factors measured by SCDD favorably compare with the ones obtained by A1SL, whose response is affected by the lack of charged particle equilibrium and by averaging effect when small fields are involved. From the experiment on angular dependence, a good agreement is observed among the diamond diode, the ion chambers, and the TPS. In VMAT profiles, the absorbed doses measured by SCDD and A1SL compare well with the TPS calculated ones. An overall better agreement is observed in the case of the diamond dosimeter, which is also showing a better accuracy in terms of distance to agreement in the high gradient regions. CONCLUSIONS Synthetic diamond diodes, whose performance were previously studied for conformal and IMRT radiotherapy techniques, were found to be suitable detectors also for dosimetric measurements in volumetric arc therapy treatments.

A proton Computed Tomography system for medical applications

Proton Computed Tomography (pCT) can improve the accuracy of both patient positioning and dose calculation in proton therapy, enabling to accurately reconstruct the electron density distribution of irradiated tissues. A pCT prototype, equipped with a silicon tracker and a YAG:Ce calorimeter, has been manufactured by an Italian collaboration. First tests under proton beam allowed obtaining good quality tomographic images of a non-homogeneous phantom. Manufacturing of a new large area system with real-time data acquisition is under way.

Small field output factors evaluation with a microDiamond detector over 30 Italian centers

PURPOSE The aim of the study was a multicenter evaluation of MLC&jaws-defined small field output factors (OF) for different linear accelerator manufacturers and for different beam energies using the latest synthetic single crystal diamond detector commercially available. The feasibility of providing an experimental OF data set, useful for on-site measurements validation, was also evaluated. METHODS This work was performed in the framework of the Italian Association of Medical Physics (AIFM) SBRT working group. The project was subdivided in two phases: in the first phase each center measured OFs using their own routine detector for nominal field sizes ranging from 10×10cm2 to 0.6×0.6cm2. In the second phase, the measurements were repeated in all centers using the PTW 60019 microDiamond detector. RESULTS The project enrolled 30 Italian centers. Micro-ion chambers and silicon diodes were used for OF measurements in 24 and 6 centers respectively. Gafchromic films and TLDs were used for very small field OFs in 3 and 1 centers. Regarding the measurements performed with the users detectors, OF standard deviations (SD) for field sizes down to 2×2cm2 were in all cases <2.7%. In the second phase, a reduction of around 50% of the SD was obtained using the microDiamond detector. CONCLUSIONS The measured values presented in this multicenter study provide a consistent dataset for OFs that could be a useful tool for improving dosimetric procedures in centers. The microDiamond data present a small variation among the centers confirming that this detector can contribute to improve overall accuracy in radiotherapy.

A proton Computed Tomography based medical imaging system

This paper reports on the activity of the INFN PRIMA/RDH collaboration in the development of proton Computed Tomography (pCT) systems based on single proton tracking and residual energy measurement. The systems are made of a silicon microstrip tracker and a YAG:Ce crystal calorimeter to measure single protons trajectory and residual energy, respectively. A first prototype of pCT scanner, with an active area of about 5 × 5 cm2 and a data rate capability of 10 kHz, has been constructed and characterized with 62 MeV protons at INFN Laboratori Nazionali del Sud in Catania (Italy) and with 180 MeV protons at The Svedberg Laboratory (TSL) in Uppsala (Sweden). Results of these measurements, including tomographic reconstructions of test phantoms, will be shown and discussed. An upgraded system with an extended field of view (up to ~ 5 × 20 cm2) and an increased event rate capability up to one MHz, presently under development, will be also described.