Chester S. Reft

Dosimetric considerations for patients with HIP prostheses undergoing pelvic irradiation. Report of the AAPM Radiation Therapy Committee Task Group 63.

This document is the report of a task group of the Radiation Therapy Committee of the AAPM and has been prepared primarily to advise hospital physicists involved in external beam treatment of patients with pelvic malignancies who have high atomic number (Z) hip prostheses. The purpose of the report is to make the radiation oncology community aware of the problems arising from the presence of these devices in the radiation beam, to quantify the dose perturbations they cause, and, finally, to provide recommendations for treatment planning and delivery. Some of the data and recommendations are also applicable to patients having implanted high-Z prosthetic devices such as pins, humeral head replacements. The scientific understanding and methodology of clinical dosimetry for these situations is still incomplete. This report is intended to reflect the current state of scientific understanding and technical methodology in clinical dosimetry for radiation oncology patients with high-Z hip prostheses.

The energy dependence and dose response of a commercial optically stimulated luminescent detector for kilovoltage photon, megavoltage photon, and electron, proton, and carbon beams

Optically stimulated luminescent detectors, which are widely used in radiation protection, offer a number of potential advantages for application in radiation therapy dosimetry. Their introduction into this field has been somewhat hampered by the lack of information on their radiation response in megavoltage beams. Here the response of a commercially available optically stimulated luminescent detector (OSLD) is determined as a function of energy, absorbed dose to water, and linear energy transfer (LET). The detector response was measured as a function of energy for absorbed doses from 0.5 to 4.0 Gy over the following ranges: 125 kVp to 18 MV for photons, 6-20 MeV for electrons, 50-250 MeV for protons, and 290 MeV/u for the carbon ions. For the low LET beams, the response of the detector was linear up to 2 Gy with supralinearity occurring at higher absorbed doses. For the kilovoltage photons, the detector response relative to 6 MV increased with decreasing energy due to the higher atomic number of aluminum oxide (11.2) relative to water (7.4). For the megavoltage photons and electrons, the response was independent of energy. The response for protons was also independent of energy, but it was about 6% higher than its response to 6 MV photons. For the carbon ions, the dose response was linear for a given LET from 0.5 to 4.0 Gy, and no supralinearity was observed. However, it did exhibit LET dependence on the response relative to 6 MV photons decreasing from 1.02 at 1.3 keV/microm to 0.41 at 78 keV/microm. These results provide additional information on the dosimetric properties for this particular OSL detector and also demonstrate the potential for their use in photon, electron, and proton radiotherapy dosimetry with a more limited use in high LET radiotherapy dosimetry.

In vivo and phantom measurements of the secondary photon and neutron doses for prostate patients undergoing 18 MV IMRT

For intensity modulated radiation therapy (IMRT) treatments 6MV photons are typically used, however, for deep seated tumors in the pelvic region, higher photon energies are increasingly being employed. IMRT treatments require more monitor units (MU) to deliver the same dose as conformal treatments, causing increased secondary radiation to tissues outside the treated area from leakage and scatter, as well as a possible increase in the neutron dose from photon interactions in the machine head. Here we provide in vivo patient and phantom measurements of the secondary out-of-field photon radiation and the neutron dose equivalent for 18MV IMRT treatments. The patients were treated for prostate cancer with 18MV IMRT at institutions using different therapy machines and treatment planning systems. Phantom exposures at the different facilities were used to compare the secondary photon and neutron dose equivalent between typical IMRT delivered treatment plans with a six field three-dimensional conformal radiotherapy (3DCRT) plan. For the in vivo measurements LiF thermoluminescent detectors (TLDs) and Al2O3 detectors using optically stimulated radiation were used to obtain the photon dose and CR-39 track etch detectors were used to obtain the neutron dose equivalent. For the phantom measurements a Bonner sphere (25.4cm diameter) containing two types of TLDs (TLD-600 and TLD-700) having different thermal neutron sensitivities were used to obtain the out-of-field neutron dose equivalent. Our results showed that for patients treated with 18MV IMRT the photon dose equivalent is greater than the neutron dose equivalent measured outside the treatment field and the neutron dose equivalent normalized to the prescription dose varied from 2 to 6mSv∕Gy among the therapy machines. The Bonner sphere results showed that the ratio of neutron equivalent doses for the 18MV IMRT and 3DCRT prostate treatments scaled as the ratio of delivered MUs. We also observed differences in the measured neutron dose equivalent among the three therapy machines for both the in vivo and phantom exposures.

Radiotherapy of the resected mandible following stainless steel plate fixation

There is general concern among otolaryngologists that irradiation of a stainless steel prosthesis used in mandibular reconstruction may cause irradiation overdosage to adjacent tissues.

Determination of the source position for the electron beams from a high-energy linear accelerator

We have investigated the energy and field-size dependence of the source position of the electron beams from a Varian Clinac-2,500 accelerator. Three independent experimental methods were used: (1) multipinhole camera (MPC), (2) back projection of the full width at half maximum (FWHM), and (3) the inverse square law (ISL). The positions of the virtual and effective sources were calculated using the multiple Coulomb scattering (MCS) formalism. The results obtained from the MPC agree, within the experimental uncertainties, with the calculated values for the virtual source position. Similarly, the results from the FWHM method agree with the calculations with the exception of those for small field sizes at the lower energies. This is consistent with the fact that both kinds of measurements are not very sensitive to scattering in the photon and electron collimators. In contrast, the source position determined by the ISL method shows strong dependence on field size and energy, and does not agree with the values predicted by the MCS formalism. This is due to contamination from electrons scattered in the x ray and electron collimation system. The techniques and results reported here should be generally applicable to other scatter foil linear accelerators.

High-energy total body irradiation as preparation for bone marrow transplantation in leukemia patients: Treatment technique and related complications

PURPOSE Bone marrow transplantation with conditioning regimens that include total-body irradiation (TBI) is widely used in patients with acute lymphoblastic and acute myelocytic leukemias. The major causes of death in this population are relapse of leukemia, infection, and treatment related complications. Our purpose was to achieve a homogenous radiation dose distribution and to minimize the dose to the lungs, liver, and kidneys so that the incidence of organ injury was reduced. METHODS AND MATERIALS Dose to the bone marrow, midplane, and periphery was quantified by use of thermoluminescent detectors in a bone-equivalent tissue phantom. In an effort to reduce the risk of complications, we treated relapsed or refractory leukemia patients with TBI administered in fractionated, parallel opposed large fields with 24 MV photons, using tissue compensation and partial-transmission lung shielding. Tissue toxicities were then determined. RESULTS Dose quantitation in bone-equivalent and tissue-equivalent phantoms demonstrated that backscatter and pair production interactions adjacent to bone increased the bone marrow dose by 6 to 11%. At an SSD of 400 cm and at patient diameters of 20 to 40 cm, the percent inhomogeneity across the phantom with 24 MV photons was 0 to 0.3%, compared to 4 to 6% for 6 MV photons. End-organ toxicities consisted of clinical interstitial pneumonitis in six patients, idiopathic interstitial pneumonitis in three patients, renal toxicity in seven patients, and veno-occlusive disease of the liver in one patient. Toxicities did not correlate with fractionation schedule. CONCLUSIONS Total-body irradiation administered with 24 MV photons increases the dose deposition in bone marrow through pair production and backscatter interactions occurring in bone. Because percent depth dose increases with SSD, the 24 MV beam is more penetrating at a 400 cm distance than at 100 cm and dose homogeneity is improved with higher energies. Thus, the incidence of radiation-mediated injury to lung, liver, and kidney is reduced. This is an effective preparatory regimen for patients with high-risk leukemias requiring bone marrow transplantation.

A new source localization algorithm with no requirement of one-to-one source correspondence between biplane radiographs.

Conventional source localization algorithms require a one-to-one source correspondence between films. This requirement makes source localization cumbersome and error prone because multiple sources must be carefully digitized and some sources can be obscured or missed. A new source localization algorithm is described in this paper. The algorithm fits a ribbon or needle image on film to a linear-quadratic equation, then analytically determines the 3-D ribbon locus by its image on the other projection, and finally localizes the sources in the ribbon by tracing along the ribbon image. Only three points per ribbon per film are required, and corresponding points need not be identified on the other film. Phantom experiments and tests on clinical cases demonstrate that the source localization algorithm can increase the efficiency by a factor of up to 5, improve accuracy to about 1 mm, and reconstruct obscured or shifted sources without decreased accuracy and efficiency. The simplicity and minimal entry of data make this technique desirable for clinical use.

Intensity-modulated radiotherapy for a prostate patient with a metal prosthesis.

When treating prostate patients having a metallic prosthesis with radiation, a 3D conformal radiotherapy (3DCRT) treatment plan is commonly created using only those fields that avoid the prosthesis in the beams-eye view (BEV). With a limited number of portals, the resulting plan may compromise the dose sparing of the rectum and bladder. In this work, we investigate the feasibility of using intensity-modulated radiotherapy (IMRT) to treat prostate patients having a metallic prosthesis. Three patients, each with a single metallic prosthesis, who were previously treated at the University of Chicago Medical Center for prostate cancer, were selected for this study. Clinical target volumes (CTV = prostate + seminal vesicles), bladder, and rectum volumes were identified on CT slices. Planning target volumes (PTV) were generated in 3D by a 1-cm expansion of the CTVs. For these comparative studies, treatment plans were generated from CT data using 3DCRT and IMRT treatment planning systems. The IMRT plans used 9 equally-spaced 6-MV coplanar fields, with each field avoiding the prosthesis. The 3DCRT plans used 5 coplanar 18-MV fields, with each field avoiding the prosthesis. A 1-cm margin around the PTV was used for the blocks. Each of the 9-field IMRT plans spared the bladder and rectum better than the corresponding 3DCRT plan. In the IMRT, plans, a bladder volume receiving 80% or greater dose decreased by 20-77 cc, and a volume rectal volume receiving 80% or greater dose decreased by 24-40 cc. One negative feature of the IMRT plans was the homogeneity across the target, which ranged from 95% to 115%.

Monitor Unit Calculations for External Photon and Electron Beams

Based on clinical dose-response data, the ICRU states that dosimetry systems must be capable of delivering dose to an accuracy of 5%. Many factors contribute to both random and systematic deviations in dose delivery, including daily patient setup, target delineation, and dose calculation. The accurate determination of dose per monitor unit (MU) at a single calculation point is an essential part of this process. There are many methods used to determine linear accelerator MUs in the United States. In 1997, the European Society for Therapeutic Radiology and Oncology (ESTRO) published the IAEA’s recommendations for photon beam calculations. Although highly detailed, this document is limited to photon calculations on the central axis, and does not cover asymmetric fields, dynamic wedges or multileaf collimators. Furthermore, the ESTRO methodology is scarcely utilized within this country, due to its extensive use of new nomenclature and lack of formal AAPM endorsement. In the spring of 1999, the Southeast Chapter of the American Association of Physicists in Medicine sponsored a symposium entitled “Monitor Unit Calculations for External Photon and Electron Beams.” Rather than recommending a standard formalism, speakers in the two-day symposium were asked to describe the calculation method they use in a specific clinical situation. The proceedings of this symposium became the framework for the book Monitor Unit Calculations for External Photon & Electron Beams, published last year. This presentation will discuss the major findings of this work.

Dosimetry of Sr-90 ophthalmic applicators.

Sr-90 ophthalmic applicators are commonly used for the treatment of superficial eye disorders. Although a variety of dosimetric devices such as film, thermoluminescent dosimeters (TLDs), ion chambers, and radiochromic foils have been used to measure the peak dose at the applicator surface, there is no internationally agreed upon calibration procedure. Recently, large discrepancies among calibrations of the same applicator at three institutions have been reported. Here we describe a technique to obtain the peak dose rate at the applicator surface using LiF TLDs. The technique can be used for the calibration of flat as well as curved surface applicators. Results for two flat and three concave applicators are presented. Our measurement of the surface dose rate for one of the flat applicators is compared with those obtained by four other institutions, each using different dosimetric devices.