Elinore Wieslander

Comparison of dose calculation algorithms for treatment planning in external photon beam therapy for clinical situations.

A study of the performance of five commercial radiotherapy treatment planning systems (TPSs) for common treatment sites regarding their ability to model heterogeneities and scattered photons has been performed. The comparison was based on CT information for prostate, head and neck, breast and lung cancer cases. The TPSs were installed locally at different institutions and commissioned for clinical use based on local procedures. For the evaluation, beam qualities as identical as possible were used: low energy (6 MV) and high energy (15 or 18 MV) x-rays. All relevant anatomical structures were outlined and simple treatment plans were set up. Images, structures and plans were exported, anonymized and distributed to the participating institutions using the DICOM protocol. The plans were then re-calculated locally and exported back for evaluation. The TPSs cover dose calculation techniques from correction-based equivalent path length algorithms to model-based algorithms. These were divided into two groups based on how changes in electron transport are accounted for ((a) not considered and (b) considered). Increasing the complexity from the relatively homogeneous pelvic region to the very inhomogeneous lung region resulted in less accurate dose distributions. Improvements in the calculated dose have been shown when models consider volume scatter and changes in electron transport, especially when the extension of the irradiated volume was limited and when low densities were present in or adjacent to the fields. A Monte Carlo calculated algorithm input data set and a benchmark set for a virtual linear accelerator have been produced which have facilitated the analysis and interpretation of the results. The more sophisticated models in the type b group exhibit changes in both absorbed dose and its distribution which are congruent with the simulations performed by Monte Carlo-based virtual accelerator.

Dose perturbation in the presence of metallic implants: treatment planning system versus Monte Carlo simulations.

An increasing number of patients receiving radiation therapy have metallic implants such as hip prostheses. Therefore, beams are normally set up to avoid irradiation through the implant; however, this cannot always be accomplished. In such situations, knowledge of the accuracy of the used treatment planning system (TPS) is required. Two algorithms, the pencil beam (PB) and the collapsed cone (CC), are implemented in the studied TPS. Comparisons are made with Monte Carlo simulations for 6 and 18 MV. The studied materials are steel, CoCrMo, Orthinox, TiAlV and Ti. Monte Carlo simulated depth dose curves and dose profiles are compared to CC and PB calculated data. The CC algorithm shows overall a better agreement with Monte Carlo than the PB algorithm. Thus, it is recommended to use the CC algorithm to get the most accurate dose calculation both for the planning target volume and for tissues adjacent to the implants when beams are set up to pass through implants.

A Monte Carlo study of a flattening filter-free linear accelerator verified with measurements

A Monte Carlo model of an Elekta Precise linear accelerator has been built and verified by measured data for a 6 and 10 MV photon beam running with and without a flattening filter in the beam line. In this study the flattening filter was replaced with a 6 mm thick copper plate, provided by the linac vendor, in order to stabilize the beam. Several studies have shown that removal of the filter improves some properties of the photon beam, which could be beneficial for radiotherapy treatments. The investigated characteristics of this new beam included output, spectra, mean energy, half value layer and the origin of scattered photons. The results showed an increased dose output per initial electron at the central axis of 1.76 and 2.66 for the 6 and 10 MV beams, respectively. The number of scattered photons from the accelerator head was reduced by (31.7 ± 0.03)% (1 SD) for the 6 MV beam and (47.6 ± 0.02)% for the 10 MV beam. The photon energy spectrum of the unflattened beam was softer compared to a conventional beam and did not vary significantly with the off-axis distance, even for the largest field size (0-20 cm off-axis).

Modelling of an Orthovoltage X-ray Therapy Unit with the EGSnrc Monte Carlo Package

Simulations with the EGSnrc code package of an orthovoltage x-ray machine have been performed. The BEAMnrc code was used to transport electrons, produce x-ray photons in the target and transport of these through the treatment machine down to the exit level of the applicator. Further transport in water or CT based phantoms was facilitated by the DOSXYZnrc code. Phase space files were scored with BEAMnrc and analysed regarding the energy spectra at the end of the applicator. Tuning of simulation parameters was based on the half-value layer quantity for the beams in either Al or Cu. Calculated depth dose and profile curves have been compared against measurements and show good agreement except at shallow depths. The MC model tested in this study can be used for various dosimetric studies as well as generating a library of typical treatment cases that can serve as both educational material and guidance in the clinical practice

A virtual linear accelerator for verification of treatment planning systems

A virtual linear accelerator is implemented into a commercial pencil-beam-based treatment planning system (TPS) with the purpose of investigating the possibility of verifying the system using a Monte Carlo method. The characterization set for the TPS includes depth doses, profiles and output factors, which is generated by Monte Carlo simulations. The advantage of this method over conventional measurements is that variations in accelerator output are eliminated and more complicated geometries can be used to study the performance of a TPS. The difference between Monte Carlo simulated and TPS calculated profiles and depth doses in the characterization geometry is less than +/-2% except for the build up region. This is of the same order as previously reported results based on measurements. In an inhomogeneous, mediastinum-like case, the deviations between TPS and simulations are small in the unit-density regions. In low-density regions, the TPS overestimates the dose, and the overestimation increases with increasing energy from 3.5% for 6 MV to 9.5% for 18 MV. This result points out the widely known fact that the pencil beam concept does not handle changes in lateral electron transport, nor changes in scatter due to lateral inhomogeneitics. It is concluded that verification of a pencil-beam-based TPS with a Monte Carlo based virtual accelerator is possible, which facilitates the verification procedure.

Dose response evaluation of a low-density normoxic polymer gel dosimeter using MRI.

A low-density (approximately 0.6 g cm(-3)) normoxic polymer gel, containing the antioxidant tetrakis (hydroxymethyl) phosponium (THP), has been investigated with respect to basic absorbed dose response characteristics. The low density was obtained by mixing the gel with expanded polystyrene spheres. The depth dose data for 6 and 18 MV photons were compared with Monte Carlo calculations. A large volume phantom was irradiated in order to study the 3D dose distribution from a 6 MV field. Evaluation of the gel was carried out using magnetic resonance imaging. An approximately linear response was obtained for 1/T2 versus dose in the dose range of 2 to 8 Gy. A small decrease in the dose response was observed for increasing concentrations of THP. A good agreement between measured and Monte Carlo calculated data was obtained, both for test tubes and the larger 3D phantom. It was shown that a normoxic polymer gel with a reduced density could be obtained by adding expanded polystyrene spheres. In order to get reliable results, it is very important to have a uniform distribution of the gel and expanded polystyrene spheres in the phantom volume.

Influence of dose calculation algorithms on the predicted dose distributions and NTCP values for NSCLC patients

PURPOSE To investigate differences in calculated doses and normal tissue complication probability (NTCP) values between different dose algorithms. METHODS Six dose algorithms from four different treatment planning systems were investigated: Eclipse AAA, Oncentra MasterPlan Collapsed Cone and Pencil Beam, Pinnacle Collapsed Cone and XiO Multigrid Superposition, and Fast Fourier Transform Convolution. Twenty NSCLC patients treated in the period 2001-2006 at the same accelerator were included and the accelerator used for treatments were modeled in the different systems. The treatment plans were recalculated with the same number of monitor units and beam arrangements across the dose algorithms. Dose volume histograms of the GTV, PTV, combined lungs (excluding the GTV), and heart were exported and evaluated. NTCP values for heart and lungs were calculated using the relative seriality model and the LKB model, respectively. Furthermore, NTCP for the lungs were calculated from two different model parameter sets. Calculations and evaluations were performed both including and excluding density corrections. RESULTS There are found statistical significant differences between the calculated dose to heart, lung, and targets across the algorithms. Mean lung dose and V20 are not very sensitive to change between the investigated dose calculation algorithms. However, the different dose levels for the PTV averaged over the patient population are varying up to 11%. The predicted NTCP values for pneumonitis vary between 0.20 and 0.24 or 0.35 and 0.48 across the investigated dose algorithms depending on the chosen model parameter set. The influence of the use of density correction in the dose calculation on the predicted NTCP values depends on the specific dose calculation algorithm and the model parameter set. For fixed values of these, the changes in NTCP can be up to 45%. CONCLUSIONS Calculated NTCP values for pneumonitis are more sensitive to the choice of algorithm than mean lung dose and V20 which are also commonly used for plan evaluation. The NTCP values for heart complication are, in this study, not very sensitive to the choice of algorithm. Dose calculations based on density corrections result in quite different NTCP values than calculations without density corrections. It is therefore important when working with NTCP planning to use NTCP parameter values based on calculations and treatments similar to those for which the NTCP is of interest.

A virtual-accelerator-based verification of a Monte Carlo dose calculation algorithm for electron beam treatment planning in homogeneous phantoms

By introducing Monte Carlo (MC) techniques to the verification procedure of dose calculation algorithms in treatment planning systems (TPSs), problems associated with conventional measurements can be avoided and properties that are considered unmeasurable can be studied. The aim of the study is to implement a virtual accelerator, based on MC simulations, to evaluate the performance of a dose calculation algorithm for electron beams in a commercial TPS. The TPS algorithm is MC based and the virtual accelerator is used to study the accuracy of the algorithm in water phantoms. The basic test of the implementation of the virtual accelerator is successful for 6 and 12 MeV (gamma < 1.0, 0.02 Gy/2 mm). For 18 MeV, there are problems in the profile data for some of the applicators, where the TPS underestimates the dose. For fields equipped with patient-specific inserts, the agreement is generally good. The exception is 6 MeV where there are slightly larger deviations. The concept of the virtual accelerator is shown to be feasible and has the potential to be a powerful tool for vendors and users.

Low-dose rate brachytherapy with I-125 seeds has an excellent 5-year outcome with few side effects in patients with low-risk prostate cancer

Abstract Background: Low-dose rate brachytherapy (LDR-BT) has been used in Sweden for more than a decade for treatment of low-risk prostate cancer. This study presents the outcome for patients treated with LDR-BT at a single institution with focus on the association between dose and biochemical failure-free survival (BFFS). Methods: In total 195 patients were treated with LDR-BT between 2004 and 2008. The patients were followed systematically for side effects for at least one year. PSA levels were followed regularly from three months and for at least five years. Outcome was analyzed in relation to clinical variables at baseline and to radiotherapy data. Results: Kaplan-Meier estimated BFFS at five years was 95.7%. Dose to the prostate in terms of D90% was significantly associated with BFFS [HR 0.90 (95%CI 0.83−0.96), p = 0.002]. Conclusion: Out data confirmed that absorbed dose is a predictive factor for BFFS for low-risk patients without androgen deprivation therapy. With our treatment routines and dosimetry, a D90% in the range of 170−180 Gy gives excellent outcomes with acceptable toxicity for patients with low-risk prostate cancer.

Experience from long-term monitoring of RAKR ratios in 192Ir brachytherapy

BACKGROUND Ratios of values of brachytherapy source strengths, as measured by hospitals and vendors, comprise constant differences as, e.g., systematic errors in ion chamber calibration factors and measurement setup. Such ratios therefore have the potential to reveal the systematic changes in routines or calibration services at either the hospital or the vendor laboratory, which could otherwise be hidden by the uncertainty in the source strength values. METHODS The RAKR of each new source in 13 afterloading units at five hospitals were measured by well-type ion chambers and compared to values for the same source stated on vendor certificates. RESULTS Differences from unity in the ratios of RAKR values determined by hospitals and vendors are most often small and stable around their mean values to within +/- 1.5%. Larger deviations are rare but occur. A decreasing ratio, seen at two hospitals for the same source, was useful in detecting an erroneous pressure gauge at the vendors site. CONCLUSIONS Establishing a mean ratio of RAKR values, as measured at the hospital and supplied on the vendor certificate, and monitoring this as a function of time are an easy way for the early detection of problems with equipment or routines at either the hospital or the vendor site.