Geetha Menon

IMRT for the breast: a comparison of tangential planning techniques

Three intensity-modulated tangential beam radiotherapy plan types for breast cancer treatment were evaluated based on PTV homogeneity index (HI) and equivalent uniform dose (EUD), heart V30 and EUD, whole lung V20 and EUD, and typical planning time compared to conventional 2D plans. 20 early-stage breast cancer patients were CT-scanned in the supine position, and tangential field extent, gantry and collimator angles were chosen. Four treatment plans were created for each patient: conventional, dynamically wedged plan based on the dose distribution on the central axial slice; forward planned IMRT; surface compensated plan created using an Eclipse tool and hybrid IMRT plan combining open and inverse-optimized fields. All three IMRT planning techniques represent significant improvement in PTV HI and EUD compared to conventional plans. Among the IMRT plans, the hybrid IMRT plan produced the best HI. IMRT lowered heart V30 and lung V20, but no significant differences in heart or lung EUD were detected between IMRT techniques. The IMRT technique with the shortest planning time was the compensated plan, followed by the hybrid IMRT. IMRT planning provides dosimetric benefits in breast cancer patients. The selection of the most appropriate IMRT technique must include careful consideration of the resources available.

Experimental determination of the anisotropy function and anisotropy factor for model 6711 I-125 seeds.

Model 6711 125I seeds are commonly used in permanent brachytherapy implants. While recommended dose distribution parameters for these sources have been published by AAPM TG-43, several investigators have recently questioned the presence of seemingly unphysical fluctuations in the anisotropy function data. Seeking to understand these, we measured the dimensions of eight model 6711 seeds radiographically, and made a new experimental determination of the anisotropy function and factor using thermoluminescent dosimeters (TL-100 chips and minicubes) in a solid water phantom. It was found that variations in seed capsule end weld thickness, and movement within the capsule of the Ag rod onto which the 125I is adsorbed, were present for all sources and thus contributed to experimental uncertainty. Averaging results from two different sources, from data acquired at the same time from diametrically opposed quadrants of the phantom, and from repeated measurements yielded anisotropy function values similar to those of TG-43 but characterized by greater precision (< or = 3% for radial distance r < or = 3 cm and < or = 1% for r > or = 4 cm), an absence of sharp fluctuations, and reduced magnitudes at r = 1 cm. The measured values can be well represented by an analytic function similar to that proposed by Furhang and Anderson to fit the TG-43 data. Values of the anisotropy factor derived from this function by integration exhibit little variation with r, in agreement with earlier diode data but in contrast to TG-43 data, and can also be represented by an analytic function. Finally, a difference in TLD chip and minicube reproducibility, observed here and by earlier investigators, is explained by reference to recent work (done concurrently with ours) as stemming from variations in dosimeter orientation and automated reader positioning/heating for minicubes.

Compensator quality control with an amorphous silicon EPID.

The calibration and quality control of compensators is conventionally performed with an ion chamber in a water-equivalent phantom. In our center, the compensator factor and four off-axis fluence ratios are measured to verify the central axis beam modulation and orientation of the compensator. Here we report the investigation of an alternative technique for compensator quality control using an amorphous silicon electronic portal imaging device (a-Si EPID). Preliminary experiments were performed to identify appropriate EPID operating parameters for this relative dosimetric study and also to quantify EPID operation. The pixel value versus energy fluence response of the EPID for both open and compensated fields was then determined, and expressed via calibration curves. For open fields the response was seen to be linear, whereas for compensated fields it exhibited a small quadratic component. To account for field size effects, we measured EPID scatter factors. These exhibited small but non-negligible dependencies on compensator thickness and source-detector distance. Finally, a number of test and clinical compensators were evaluated to assess the suitability of the EPID for compensator quality control. Our results indicate that the a-Si EPID can measure clinical compensator factors and off-axis energy fluence ratios to within 2% of values measured by a Farmer chamber on average, and so is a suitable ion chamber replacement.

Radiochromic film calibration for low‐energy seed brachytherapy dose measurement

PURPOSE Radiochromic film dosimetry is typically performed for high energy photons and moderate doses characterizing external beam radiotherapy (XRT). The purpose of this study was to investigate the accuracy of previously established film calibration procedures used in XRT when applied to low-energy, seed-based brachytherapy at higher doses, and to determine necessary modifications to achieve similar accuracy in absolute dose measurements. METHODS Gafchromic EBT3 film was used to measure radiation doses upwards of 35 Gy from 75 kVp, 200 kVp, 6 MV, and (∼28 keV) I-125 photon sources. For the latter irradiations a custom phantom was built to hold a single I-125 seed. Film pieces were scanned with an Epson 10000XL flatbed scanner and the resulting 48-bit RGB TIFF images were analyzed using both FilmQA Pro software andMATLAB. Calibration curves relating dose and optical density via a rational functional form for all three color channels at each irradiation energy were determined with and without the inclusion of uncertainties in the measured optical densities and dose values. The accuracy of calibration curve variations obtained using piecewise fitting, a reduced film measurement area for I-125 irradiation, and a reduced number of dose levels was also investigated. The energy dependence of the film lot used was also analyzed by calculating normalized optical density values. RESULTS Slight differences were found in the resulting calibration curves for the various fitting methods used. The accuracy of the calibration curves was found to improve at low doses and worsen at high doses when including uncertainties in optical densities and doses, which may better represent the variability that could be seen in film optical density measurements. When exposing the films to doses > 8 Gy, two-segment piecewise fitting was found to be necessary to achieve similar accuracies in absolute dose measurements as when using smaller dose ranges. When reducing the film measurement area for the I-125 irradiations, the accuracy of the calibration curve was degraded due to the presence of localized film heterogeneities. No degradation in the calibration curves was found when reducing the number of calibration points down to only 4, but with piecewise fitting, 6 calibration points as well as a blank film are required. Variations due to photon energy in film optical density of up to 3% were found above doses of 2 Gy. CONCLUSIONS A modified procedure for performing EBT3 film calibration was established for use with low-energy brachytherapy seeds and high dose exposures. The energy dependence between 6 MV and I-125 photons is significant such that film calibrations should be done with an appropriately low-energy source when performing low-energy brachytherapy dose measurements. Two-segment piecewise fitting with the inclusion of errors in measured optical density as well as dose was found to result in the most accurate calibration curves. Above doses of 1 Gy, absolute dose measurements can be made with an accuracy of 1.6% for 6 MV beams and 5.7% for I-125 seed exposures if using the I-125 source for calibration, or 2.3% if using the 75 kVp photon beam for calibration.

Dosimetric evaluation of breast radiotherapy in a dynamic phantom

This phantom study quantifies changes in delivered dose due to respiratory motion for four breast radiotherapy planning techniques: three intensity-modulated techniques (forward-planned, surface-compensated and hybrid intensity-modulated radiation therapy (IMRT)); using a combination of open fields and inverse planned IMRT) and a 2D conventional technique. The plans were created on CT images of a wax breast phantom with a cork lung insert, and dose distributions were measured using films inserted through slits in the axial and sagittal planes. Films were irradiated according to each plan under a static (modeling breathhold) and three dynamic conditions--isocenter set at mid-respiratory cycle with motion amplitudes of 1 and 2 cm and at end-cycle with 2 cm motion amplitude (modeling end-exhale). Differences between static and moving deliveries were most pronounced for the more complex planning techniques with hot spots of up to 107% appearing in the anterior portion of all three IMRT plans at the largest motion at the end-exhale set-up. The delivered dose to the moving phantom was within 5% of that to the static phantom for all cases, while measurement accuracy was ±3%. The homogeneity index was significantly decreased only for the 2 cm motion end-exhale set-up; however, this same motion increased the equivalent uniform dose because of improved posterior breast coverage. Overall, the study demonstrates that the effect of respiratory motion is negligible for all planning techniques except in occasional instances of large motion.

Measurement of relative output for 90Sr ophthalmic applicators using radiochromic film

The treatment of various superficial lesions of the eye has, for many years, been conducted using strontium 90 (90Sr) ophthalmic applicators that have a steep dose gradient near their surface. A new applicator acquired by a treatment facility must have its output compared with that of any older applicators already in use to ensure consistent treatments. These measurements may be done using available dosimeters such as film and thermoluminescent detectors. Our work made use of radiochromic film and a document scanner to perform relative output measurements for 4 different 90Sr ophthalmic applicators acquired from the same manufacturer (Amersham Healthcare, Arlington Heights, IL) over a span of 28 years. Relative outputs were found to vary by < 10% with respect to the manufacturers values, which is well within the uncertainty limit for absolute output of 20% specified by the manufacturer. The film measurements were verified using thermoluminescent dosimeters. Radiochromic film was also used to obtain a percentage depth dose curve and a 2 dimensional isodose distribution in a plane perpendicular to the active surface for the newest applicator (SIA 20).

Experimental verification of Advanced Collapsed-cone Engine for use with a multichannel vaginal cylinder applicator

&NA; Model‐based dose calculation algorithms have recently been incorporated into brachytherapy treatment planning systems, and their introduction requires critical evaluation before clinical implementation. Here, we present an experimental evaluation of Oncentra® Brachy Advanced Collapsed‐cone Engine (ACE) for a multichannel vaginal cylinder (MCVC) applicator using radiochromic film. A uniform dose of 500 cGy was specified to the surface of the MCVC using the TG‐43 dose formalism under two conditions: (a) with only the central channel loaded or (b) only the peripheral channels loaded. Film measurements were made at the applicator surface and compared to the doses calculated using TG‐43, standard accuracy ACE (sACE), and high accuracy ACE (hACE). When the central channel of the applicator was used, the film measurements showed a dose increase of (11 ± 8)% (k = 2) above the two outer grooves on the applicator surface. This increase in dose was confirmed with the hACE calculations, but was not confirmed with the sACE calculations at the applicator surface. When the peripheral channels were used, a periodic azimuthal variation in measured dose was observed around the applicator. The sACE and hACE calculations confirmed this variation and agreed within 1% of each other at the applicator surface. Additionally for the film measurements with the central channel used, a baseline dose variation of (10 ± 4)% (k = 2) of the mean dose was observed azimuthally around the applicator surface, which can be explained by offset source positioning in the central channel.

Transit dose contributions to intracavitary and interstitial PDR brachytherapy treatments.

The objective of this study was to determine the magnitude of transit dose contributions to the planned dose in common intracavitary and interstitial brachytherapy treatments delivered using a pulsed dose rate (PDR) remote afterloader. The total transit dose arises from the travel of the radiation source into (entry) and out of (exit) the applicator, and between the dwell positions (inter-dwell). In this paper, we used a well-type ionization chamber to measure the transit dose component for a PDR afterloader and compared the results against measurements for a high dose rate (HDR) afterloader. Our results show that for typical intracavitary and interstitial treatments, the major contribution to transit dose is from the entry+exit source travel, as the inter-dwell component is effectively compensated for (<0.5%) by the afterloader. The transit dose was generally found to be larger for PDR treatments than for HDR treatments, as it is influenced by the source activity, dwell times and number of radiation pulses. The overall increase in the planned dose contributed by the transit dose in a typical intracavitary PDR treatment was estimated to be <2%, but much higher for interstitial treatments. This study shows that the effect of the transit dose on common clinical intracavitary PDR brachytherapy treatments is practically negligible, but requires attention in highly fractionated large volume interstitial treatments.

Compensator thickness verification using an a‐Si EPID

Electronic portal imaging devices (EPIDs) are being increasingly employed to make therapy verification and dose measurements in the clinic. In this work, we investigate the use of an amorphous silicon (a-Si) EPID to verify the accuracy of compensator fabrication and mounting. Compensator thickness estimates on a two-dimensional grid were calculated from the primary component of transmission obtained by subtracting a modeled scatter component from the total transmission measured with the EPID. The primary component was related to the thickness via an exponential relation that includes beam hardening. Implementation of the method involved determination of: (i) a calibration curve relating EPID pixel values to energy fluence for open and attenuated fields, which was found to be linear for open fields but to have a small quadratic component for attenuated beams; (ii) EPID scatter factors to account for field size effects, which exhibited a small dependence on compensator thickness and field size; (iii) the attenuation coefficient of the steel shot compensator material, which varied slightly with off-axis distance and field size, and (iv) an analytical model to predict scatter from the compensator, which was calculated to be <4% at the standard EPID imaging distance of 140 cm. Thickness distributions were then measured for several types of attenuators including flat, test, and clinical compensators. Although uncertainties associated with compensator manufacturing were non-negligible and made assessment of thickness measurement uncertainty difficult, we estimate the latter to be approximately 0.5 mm for steel shot compensators of thickness <4 cm.

A brief look at model-based dose calculation principles, practicalities, and promise

Model-based dose calculation algorithms (MBDCAs) have recently emerged as potential successors to the highly practical, but sometimes inaccurate TG-43 formalism for brachytherapy treatment planning. So named for their capacity to more accurately calculate dose deposition in a patient using information from medical images, these approaches to solve the linear Boltzmann radiation transport equation include point kernel superposition, the discrete ordinates method, and Monte Carlo simulation. In this overview, we describe three MBDCAs that are commercially available at the present time, and identify guidance from professional societies and the broader peer-reviewed literature intended to facilitate their safe and appropriate use. We also highlight several important considerations to keep in mind when introducing an MBDCA into clinical practice, and look briefly at early applications reported in the literature and selected from our own ongoing work. The enhanced dose calculation accuracy offered by a MBDCA comes at the additional cost of modelling the geometry and material composition of the patient in treatment position (as determined from imaging), and the treatment applicator (as characterized by the vendor). The adequacy of these inputs and of the radiation source model, which needs to be assessed for each treatment site, treatment technique, and radiation source type, determines the accuracy of the resultant dose calculations. Although new challenges associated with their familiarization, commissioning, clinical implementation, and quality assurance exist, MBDCAs clearly afford an opportunity to improve brachytherapy practice, particularly for low-energy sources.