Daniel E. Hyer

An organ and effective dose study of XVI and OBI cone-beam CT systems

The main purpose of this work was to quantify patient organ doses from the two kilovoltage cone beam computed tomography (CBCT) systems currently available on medical linear accelerators, namely the X‐ray Volumetric Imager (XVI, Elekta Oncology Systems) and the On‐Board Imager (OBI, Varian Medical Systems). Organ dose measurements were performed using a fiber‐optic coupled (FOC) dosimetry system along with an adult male anthropomorphic phantom for three different clinically relevant scan sites: head, chest, and pelvis. The FOC dosimeter was previously characterized at diagnostic energies by Hyer et al. [Med Phys 2009;36(5):1711–16] and a total uncertainty of approximately 4% was found for in‐phantom dose measurements. All scans were performed using current manufacturer‐installed clinical protocols and appropriate bow‐tie filters. A comparison of image quality between these manufacturer‐installed protocols was also performed using a Catphan 440 image quality phantom. Results indicated that for the XVI, the dose to the lens of the eye (1.07 mGy) was highest in a head scan, thyroid dose (19.24 mGy) was highest in a chest scan, and gonad dose (29 mGy) was highest in a pelvis scan. For the OBI, brain dose (3.01 mGy) was highest in a head scan, breast dose (5.34 mGy) was highest in a chest scan, and gonad dose (34.61 mGy) was highest in a pelvis scan. Image quality measurements demonstrated that the OBI provided superior image quality for all protocols, with both better spatial resolution and low‐contrast detectability. The measured organ doses were also used to calculate a reference male effective dose to allow further comparison of the two machines and imaging protocols. The head, chest, and pelvis scans yielded effective doses of 0.04, 7.15, and 3.73 mSv for the XVI, and 0.12, 1.82, and 4.34 mSv for the OBI, respectively. PACS number: 87.57.uq

Construction of anthropomorphic phantoms for use in dosimetry studies

This paper reports on the methodology and materials used to construct anthropomorphic phantoms for use in dosimetry studies, improving on methods and materials previously described by Jones et al. [Med Phys. 2006;33(9):3274–82]. To date, the methodology described has been successfully used to create a series of three different adult phantoms at the University of Florida (UF). All phantoms were constructed in 5 mm transverse slices using materials designed to mimic human tissue at diagnostic photon energies: soft tissue‐equivalent substitute (STES), lung tissue‐equivalent substitute (LTES), and bone tissue‐equivalent substitute (BTES). While the formulation for BTES remains unchanged from the previous epoxy resin compound developed by Jones et al. [Med Phys. 2003;30(8):2072—81], both the STES and LTES were redesigned utilizing a urethane‐based compound which forms a pliable tissue‐equivalent material. These urethane‐based materials were chosen in part for improved phantom durability and easier accommodation of real‐time dosimeters. The production process has also been streamlined with the use of an automated machining system to create molds for the phantom slices from bitmap images based on the original segmented computed tomography (CT) datasets. Information regarding the new tissue‐equivalent materials, as well as images of the construction process and completed phantom, are included. PACS number: 87.53.Bn

Characterization of a water-equivalent fiber-optic coupled dosimeter for use in diagnostic radiology.

This work reports on the characterization of a new fiber-optic coupled (FOC) dosimeter for use in the diagnostic radiology energy range. The FOC dosimeter was constructed by coupling a small cylindrical plastic scintillator, 500 microm in diameter and 2 mm in length, to a 2 m long optical fiber, which acts as a light guide to transmit scintillation photons from the sensitive element to a photo-multiplier tube (PMT). A serial port interface on the PMT permits real-time monitoring of light output from the dosimeter via a custom computer program. The FOC dosimeter offered excellent sensitivity and reproducibility, allowing doses as low as 0.16 mGy to be measured with a coefficient of variation of only 3.64%. Dose linearity was also excellent with a correlation coefficient of 1.000 over exposures ranging from 0.16 to 57.29 mGy. The FOC dosimeter exhibited little angular dependence from axial irradiation, varying by less than 5% over an entire revolution. A positive energy dependence was observed and measurements performed within a scatter medium yielded a 10% variation in sensitivity as beam quality changed due to hardening and scatter across a 16 cm depth range. The current dosimetry system features an array of five PMTs to allow multiple FOC dosimeters to be monitored simultaneously. Overall, the system allows for rapid and accurate dose measurements relevant to a range of diagnostic imaging applications.

Estimation of organ doses from kilovoltage cone-beam CT imaging used during radiotherapy patient position verification

PURPOSE The purpose of this study was to develop a practical method for estimating organ doses from kilovoltage cone-beam CT (CBCT) that can be performed with readily available phantoms and dosimeters. The accuracy of organ dose estimates made using the ImPACT patient dose calculator was also evaluated. METHODS A 100 mm pencil chamber and standard CT dose index (CTDI) phantoms were used to measure the cone-beam dose index (CBDI). A weighted CBDI (CBDI(W)) was then calculated from these measurements to represent the average volumetric dose in the CTDI phantom. By comparing CBDI(W) to the previously published organ doses, organ dose conversion coefficients were developed. The measured CBDI values were also used as inputs for the ImPACT calculator to estimate organ doses. All CBDI dose measurements were performed on both the Elekta XVI and Varian OBI at three clinically relevant locations: Head, chest, and pelvis. RESULTS The head, chest, and pelvis protocols yielded CBDI(W) values of 0.98, 16.62, and 24.13 mGy for the XVI system and 5.17, 6.14, and 21.57 mGy for the OBI system, respectively. Organ doses estimated with the ImPACT CT dose calculator showed a large range of variation from the previously measured organ doses, demonstrating its limitations for use with CBCT. CONCLUSIONS The organ dose conversion coefficients developed in this work relate CBDI(W) values to organ doses previously measured using the same clinical protocols. Ultimately, these coefficients will allow for the quick estimation of organ doses from routine measurements performed using standard CTDI phantoms and pencil chambers.

A dynamic collimation system for penumbra reduction in spot-scanning proton therapy: Proof of concept

PURPOSE In the absence of a collimation system the lateral penumbra of spot scanning (SS) dose distributions delivered by low energy proton beams is highly dependent on the spot size. For current commercial equipment, spot size increases with decreasing proton energy thereby reducing the benefit of the SS technique. This paper presents a dynamic collimation system (DCS) for sharpening the lateral penumbra of proton therapy dose distributions delivered by SS. METHODS The collimation system presented here exploits the property that a proton pencil beam used for SS requires collimation only when it is near the target edge, enabling the use of trimmers that are in motion at times when the pencil beam is away from the target edge. The device consists of two pairs of parallel nickel trimmer blades of 2 cm thickness and dimensions of 2 cm×18 cm in the beams eye view. The two pairs of trimmer blades are rotated 90° relative to each other to form a rectangular shape. Each trimmer blade is capable of rapid motion in the direction perpendicular to the central beam axis by means of a linear motor, with maximum velocity and acceleration of 2.5 m/s and 19.6 m/s2, respectively. The blades travel on curved tracks to match the divergence of the proton source. An algorithm for selecting blade positions is developed to minimize the dose delivered outside of the target, and treatment plans are created both with and without the DCS. RESULTS The snout of the DCS has outer dimensions of 22.6×22.6 cm2 and is capable of delivering a minimum treatment field size of 15×15 cm2. Using currently available components, the constructed system would weigh less than 20 kg. For irregularly shaped fields, the use of the DCS reduces the mean dose outside of a 2D target of 46.6 cm2 by approximately 40% as compared to an identical plan without collimation. The use of the DCS increased treatment time by 1-3 s per energy layer. CONCLUSIONS The spread of the lateral penumbra of low-energy SS proton treatments may be greatly reduced with the use of this system at the cost of only a small penalty in delivery time.

The dosimetric impact of heterogeneity corrections in high-dose-rate 192Ir brachytherapy for cervical cancer: Investigation of both conventional Point-A and volume-optimized plans

PURPOSE To evaluate the dosimetric impact of heterogeneity corrections on both conventional and volume-optimized high-dose-rate (HDR) ¹⁹²Ir brachytherapy tandem-and-ovoid treatment plans. METHODS AND MATERIALS Both conventional and volume-optimized treatment plans were retrospectively created using eight unique CT data sets. In the volume-optimized plans, the clinical target volume (CTV) and organs-at-risk (rectum, bladder, and sigmoid) were contoured on the CT data sets by a single physician. For each plan, dose calculations representing homogeneous water medium were performed using the Task Group (TG-43) formalism and dose calculations with heterogeneity corrections were performed using a commercially available treatment planning system. RESULTS For the conventional plans, the change in dose between TG-43 and heterogeneity-corrected calculations was assessed for the following points: Point-A (left and right) and International Commission on Radiation Units and Measurements (ICRU) 38 defined rectum and bladder points. It was found that the dose to the ICRU bladder decreased the most (-2.2±0.9%), whereas ICRU rectum (-1.7±0.8%), Point-A right (-1.1±0.4%), and Point-A left (-1.0±0.3%) also showed decreases with heterogeneity-corrected calculations. For the volume-optimized plans, the change in dose between TG-43 and heterogeneity-corrected calculations was assessed for the following dose-volume histogram parameters: D(90) of the CTV and D(2cc) of the rectum, bladder, and sigmoid. It was found that D(90) of the CTV decreased by -1.9±0.7% and D(2cc) decreased by -2.6±1.4%, -1.0±0.4%, and -2.0±0.6% for the rectum, bladder and sigmoid, respectively, with heterogeneity-corrected calculations. CONCLUSIONS Heterogeneity corrections on high-dose rate plans were found to have only a small dosimetric impact over TG-43-based dose calculations for both conventional Point-A and volume-optimized plans.

Effects of spot size and spot spacing on lateral penumbra reduction when using a dynamic collimation system for spot scanning proton therapy

The purpose of this work was to investigate the reduction in lateral dose penumbra that can be achieved when using a dynamic collimation system (DCS) for spot scanning proton therapy as a function of two beam parameters: spot size and spot spacing. This is an important investigation as both values impact the achievable dose distribution and a wide range of values currently exist depending on delivery hardware. Treatment plans were created both with and without the DCS for in-air spot sizes (σair) of 3, 5, 7, and 9 mm as well as spot spacing intervals of 2, 4, 6 and 8 mm. Compared to un-collimated treatment plans, the plans created with the DCS yielded a reduction in the mean dose to normal tissue surrounding the target of 26.2-40.6% for spot sizes of 3-9 mm, respectively. Increasing the spot spacing resulted in a decrease in the time penalty associated with using the DCS that was approximately proportional to the reduction in the number of rows in the raster delivery pattern. We conclude that dose distributions achievable when using the DCS are comparable to those only attainable with much smaller initial spot sizes, suggesting that the goal of improving high dose conformity may be achieved by either utilizing a DCS or by improving beam line optics.

Impact of spot size on plan quality of spot scanning proton radiosurgery for peripheral brain lesions.

PURPOSE To determine the plan quality of proton spot scanning (SS) radiosurgery as a function of spot size (in-air sigma) in comparison to x-ray radiosurgery for treating peripheral brain lesions. METHODS Single-field optimized (SFO) proton SS plans with sigma ranging from 1 to 8 mm, cone-based x-ray radiosurgery (Cone), and x-ray volumetric modulated arc therapy (VMAT) plans were generated for 11 patients. Plans were evaluated using secondary cancer risk and brain necrosis normal tissue complication probability (NTCP). RESULTS For all patients, secondary cancer is a negligible risk compared to brain necrosis NTCP. Secondary cancer risk was lower in proton SS plans than in photon plans regardless of spot size (p = 0.001). Brain necrosis NTCP increased monotonically from an average of 2.34/100 (range 0.42/100-4.49/100) to 6.05/100 (range 1.38/100-11.6/100) as sigma increased from 1 to 8 mm, compared to the average of 6.01/100 (range 0.82/100-11.5/100) for Cone and 5.22/100 (range 1.37/100-8.00/100) for VMAT. An in-air sigma less than 4.3 mm was required for proton SS plans to reduce NTCP over photon techniques for the cohort of patients studied with statistical significance (p = 0.0186). Proton SS plans with in-air sigma larger than 7.1 mm had significantly greater brain necrosis NTCP than photon techniques (p = 0.0322). CONCLUSIONS For treating peripheral brain lesions--where proton therapy would be expected to have the greatest depth-dose advantage over photon therapy--the lateral penumbra strongly impacts the SS plan quality relative to photon techniques: proton beamlet sigma at patient surface must be small (<7.1 mm for three-beam single-field optimized SS plans) in order to achieve comparable or smaller brain necrosis NTCP relative to photon radiosurgery techniques. Achieving such small in-air sigma values at low energy (<70 MeV) is a major technological challenge in commercially available proton therapy systems.

A method for modeling laterally asymmetric proton beamlets resulting from collimation.

PURPOSE To introduce a method to model the 3D dose distribution of laterally asymmetric proton beamlets resulting from collimation. The model enables rapid beamlet calculation for spot scanning (SS) delivery using a novel penumbra-reducing dynamic collimation system (DCS) with two pairs of trimmers oriented perpendicular to each other. METHODS Trimmed beamlet dose distributions in water were simulated with MCNPX and the collimating effects noted in the simulations were validated by experimental measurement. The simulated beamlets were modeled analytically using integral depth dose curves along with an asymmetric Gaussian function to represent fluence in the beams eye view (BEV). The BEV parameters consisted of Gaussian standard deviations (sigmas) along each primary axis (σ(x1),σ(x2),σ(y1),σ(y2)) together with the spatial location of the maximum dose (μ(x),μ(y)). Percent depth dose variation with trimmer position was accounted for with a depth-dependent correction function. Beamlet growth with depth was accounted for by combining the in-air divergence with Hongs fit of the Highland approximation along each axis in the BEV. RESULTS The beamlet model showed excellent agreement with the Monte Carlo simulation data used as a benchmark. The overall passing rate for a 3D gamma test with 3%/3 mm passing criteria was 96.1% between the analytical model and Monte Carlo data in an example treatment plan. CONCLUSIONS The analytical model is capable of accurately representing individual asymmetric beamlets resulting from use of the DCS. This method enables integration of the DCS into a treatment planning system to perform dose computation in patient datasets. The method could be generalized for use with any SS collimation system in which blades, leaves, or trimmers are used to laterally sharpen beamlets.

Theoretical Benefits of Dynamic Collimation in Pencil Beam Scanning Proton Therapy for Brain Tumors: Dosimetric and Radiobiological Metrics

PURPOSE To quantify the dosimetric benefit of using a dynamic collimation system (DCS) for penumbra reduction during the treatment of brain tumors by pencil beam scanning proton therapy (PBS PT). METHODS AND MATERIALS Collimated and uncollimated brain treatment plans were created for 5 patients previously treated with PBS PT and retrospectively enrolled in an institutional review board-approved study. The in-house treatment planning system, RDX, was used to generate the plans because it is capable of modeling both collimated and uncollimated beamlets. The clinically delivered plans were reproduced with uncollimated plans in terms of target coverage and organ at risk (OAR) sparing to ensure a clinically relevant starting point, and collimated plans were generated to improve the OAR sparing while maintaining target coverage. Physical and biological comparison metrics, such as dose distribution conformity, mean and maximum doses, normal tissue complication probability, and risk of secondary brain cancer, were used to evaluate the plans. RESULTS The DCS systematically improved the dose distribution conformity while preserving the target coverage. The average reduction of the mean dose to the 10-mm ring surrounding the target and the healthy brain were 13.7% (95% confidence interval [CI] 11.6%-15.7%; P<.0001) and 25.1% (95% CI 16.8%-33.4%; P<.001), respectively. This yielded an average reduction of 24.8% (95% CI 0.8%-48.8%; P<.05) for the brain necrosis normal tissue complication probability using the Flickinger model, and 25.1% (95% CI 16.8%-33.4%; P<.001) for the risk of secondary brain cancer. A general improvement of the OAR sparing was also observed. CONCLUSION The lateral penumbra reduction afforded by the DCS increases the normal tissue sparing capabilities of PBS PT for brain cancer treatment while preserving target coverage.