George Ciangaru

Commissioning of the discrete spot scanning proton beam delivery system at the University of Texas M.D. Anderson Cancer Center, Proton Therapy Center, Houston.

PURPOSE To describe a summary of the clinical commissioning of the discrete spot scanning proton beam at the Proton Therapy Center, Houston (PTC-H). METHODS Discrete spot scanning system is composed of a delivery system (Hitachi ProBeat), an electronic medical record (Mosaiq V 1.5), and a treatment planning system (TPS) (Eclipse V 8.1). Discrete proton pencil beams (spots) are used to deposit dose spot by spot and layer by layer for the proton distal ranges spanning from 4.0 to 30.6 g/cm2 and over a maximum scan area at the isocenter of 30 x 30 cm2. An arbitrarily chosen reference calibration condition has been selected to define the monitor units (MUs). Using radiochromic film and ion chambers, the authors have measured spot positions, the spot sizes in air, depth dose curves, and profiles for proton beams with various energies in water, and studied the linearity of the dose monitors. In addition to dosimetric measurements and TPS modeling, significant efforts were spent in testing information flow and recovery of the delivery system from treatment interruptions. RESULTS The main dose monitors have been adjusted such that a specific amount of charge is collected in the monitor chamber corresponding to a single MU, following the IAEA TRS 398 protocol under a specific reference condition. The dose monitor calibration method is based on the absolute dose per MU, which is equivalent to the absolute dose per particle, the approach used by other scanning beam institutions. The full width at half maximum for the spot size in air varies from approximately 1.2 cm for 221.8 MeV to 3.4 cm for 72.5 MeV. The measured versus requested 90% depth dose in water agrees to within 1 mm over ranges of 4.0-30.6 cm. The beam delivery interlocks perform as expected, guarantying the safe and accurate delivery of the planned dose. CONCLUSIONS The dosimetric parameters of the discrete spot scanning proton beam have been measured as part of the clinical commissioning program, and the machine is found to function in a safe manner, making it suitable for patient treatment.

Patient-specific quality assurance for prostate cancer patients receiving spot scanning proton therapy using single-field uniform dose

PURPOSE To describe our experiences with patient-specific quality assurance (QA) for patients with prostate cancer receiving spot scanning proton therapy (SSPT) using single-field uniform dose (SFUD). METHODS AND MATERIALS The first group of 249 patients with prostate cancer treated with SSPT using SFUD was included in this work. The scanning-beam planning target volume and number of monitor units were recorded and checked for consistency. Patient-specific dosimetric measurements were performed, including the point dose for each plan, depth doses, and two-dimensional (2D) dose distribution in the planes perpendicular to the incident beam direction for each field at multiple depths. The γ-index with 3% dose or 3-mm distance agreement criteria was used to evaluate the 2D dose distributions. RESULTS We observed a linear relationship between the number of monitor units and scanning-beam planning target volume. The difference between the measured and calculated point doses (mean ± SD) was 0.0% ± 0.7% (range, -2.9% to 1.8%). In general, the depth doses exhibited good agreement except at the distal end of the spread-out Bragg peak. The pass rate of γ-index (mean ± SD) for 2D dose comparison was 96.2% ± 2.6% (range, 90-100%). Discrepancies between the measured and calculated dose distributions primarily resulted from the limitation of the model used by the treatment planning system. CONCLUSIONS We have established a patient-specific QA program for prostate cancer patients receiving SSPT using SFUD.

Commissioning dose computation models for spot scanning proton beams in water for a commercially available treatment planning system

PURPOSE To present our method and experience in commissioning dose models in water for spot scanning proton therapy in a commercial treatment planning system (TPS). METHODS The input data required by the TPS included in-air transverse profiles and integral depth doses (IDDs). All input data were obtained from Monte Carlo (MC) simulations that had been validated by measurements. MC-generated IDDs were converted to units of Gy mm(2)/MU using the measured IDDs at a depth of 2 cm employing the largest commercially available parallel-plate ionization chamber. The sensitive area of the chamber was insufficient to fully encompass the entire lateral dose deposited at depth by a pencil beam (spot). To correct for the detector size, correction factors as a function of proton energy were defined and determined using MC. The fluence of individual spots was initially modeled as a single Gaussian (SG) function and later as a double Gaussian (DG) function. The DG fluence model was introduced to account for the spot fluence due to contributions of large angle scattering from the devices within the scanning nozzle, especially from the spot profile monitor. To validate the DG fluence model, we compared calculations and measurements, including doses at the center of spread out Bragg peaks (SOBPs) as a function of nominal field size, range, and SOBP width, lateral dose profiles, and depth doses for different widths of SOBP. Dose models were validated extensively with patient treatment field-specific measurements. RESULTS We demonstrated that the DG fluence model is necessary for predicting the field size dependence of dose distributions. With this model, the calculated doses at the center of SOBPs as a function of nominal field size, range, and SOBP width, lateral dose profiles and depth doses for rectangular target volumes agreed well with respective measured values. With the DG fluence model for our scanning proton beam line, we successfully treated more than 500 patients from March 2010 through June 2012 with acceptable agreement between TPS calculated and measured dose distributions. However, the current dose model still has limitations in predicting field size dependence of doses at some intermediate depths of proton beams with high energies. CONCLUSIONS We have commissioned a DG fluence model for clinical use. It is demonstrated that the DG fluence model is significantly more accurate than the SG fluence model. However, some deficiencies in modeling the low-dose envelope in the current dose algorithm still exist. Further improvements to the current dose algorithm are needed. The method presented here should be useful for commissioning pencil beam dose algorithms in new versions of TPS in the future.

Experimental characterization of the low-dose envelope of spot scanning proton beams

In scanned proton beam radiotherapy, multiple pencil beams are used to deliver the total dose to the target volume. Because the number of such beams can be very large, an accurate dosimetric characterization of every single pencil beam is important to provide adequate input data for the configuration of the treatment planning system. In this work, we present a method to measure the low-dose envelope of single pencil beams, known to play a meaningful role in the dose computation for scanned proton beams. We measured the low-dose proton beam envelope, which extends several centimeters outwards from the center of each single pencil beam, by acquiring lateral dose profile data, down to relative dose levels that were a factor of 10(4) lower than the central axis dose. The overall effect of the low-dose envelope on the total dose delivered by multiple pencil beams was determined by measuring the dose output as a function of field size. We determined that the low-dose envelope can be influential even for fields as large as 20 cm x 20 cm.

A procedure for calculation of monitor units for passively scattered proton radiotherapy beams

The purpose of this study is to validate a monitor unit (MU) calculation procedure for passively scattered proton therapy beams. The output dose per MU (d/MU) of a therapeutic radiation beam is traditionally calibrated under specific reference conditions. These conditions include beam energy, field size, suitable depth in water or water equivalent phantom in a low dose gradient region with known relative depth dose, and source to point of calibration distance. Treatment field settings usually differ from these reference conditions leading to a different d/MU that needs to be determined for delivering the prescribed dose. For passively scattered proton beams, the proton specific parameters, which need to be defined, are related to the energy, lateral scatterers, range modulating wheel, spread out Bragg peak (SOBP) width, thickness of any range shifter, the depth dose value relative to the normalization point in the SOBP, and scatter both from the range compensator and inhomogeneity in the patient. Following the custom for photons or electrons, a set of proton dosimetry factors, representing the changes in the d/MU relative to a reference condition, can be defined as the relative output factor (ROF), SOBP factor (SOBPF), range shifter factor (RSF), SOBP off-center factor (SOBPOCF), off-center ratio (OCR), inverse square factor (ISF), field size factor (FSF), and compensator and patient scatter factor (CPSF). The ROF, SOBPF, and RSF are the major contributors to the d/MU and were measured using an ion chamber in water tank during the clinical commissioning of each beam to create a dosimetry beam data table to be used for calculating the monitor units. The following simple formula is found to provide an independent method to determine the d/MU at the point of interest (POI) in the patient, namely, (d/MU) = ROF SOBPF. RSF SOBPOCF.OCR.FSF.ISF.CPSF. The monitor units for delivering the intended dose (D) to the POI can be obtained from MU = D / (d/MU). The accuracy and robustness of the above formula were validated by calculating the d/MU in water for many different combinations of beam parameters and comparing it with the corresponding measured d/MU by an ion chamber in a water or water/plastic phantom. This procedure has been in use for MU calculation for patient treatment fields at our facility since May 2006. The differences in the calculated and measured values of the d/MU for 623 distinct fields used for patient treatment during the period of May 2006 to February 2007 are within 2% for 99% of these fields. The authors conclude that an intuitive formula similar to the one used for monitor unit calculation of therapeutic photon beams can be used to compute the monitor units of passively scattered proton therapy beams.

Monte Carlo investigation of the low-dose envelope from scanned proton pencil beams

Scanned proton pencil beams carry a low-dose envelope that extends several centimeters from the individual beams central axis. Thus, the total delivered dose depends on the size of the target volume and the corresponding number and intensity of beams necessary to cover the target volume uniformly. This dependence must be considered in dose calculation algorithms used by treatment planning systems. In this work, we investigated the sources of particles contributing to the low-dose envelope using the Monte Carlo technique. We used a validated model of our institutions scanning beam line to determine the contributions to the low-dose envelope from secondary particles created in a water phantom and particles scattered in beam line components. Our results suggested that, for high-energy beams, secondary particles produced by nuclear interactions in the water phantom are the major contributors to the low-dose envelope. For low-energy beams, the low-dose envelope is dominated by particles undergoing multiple Coulomb scattering in the beam line components and water phantom. Clearly, in the latter situation, the low-dose envelope depends directly on beam line design features. Finally, we investigated the dosimetric consequences of the low-dose envelope. Our results showed that if not modeled properly the low-dose envelope may cause clinically relevant dose disturbance in the target volume. This work suggested that this low-dose envelope is beam line specific for low-energy beams, should be thoroughly experimentally characterized and validated during commissioning of the treatment planning system, and therefore is of great concern for accurate delivery of proton scanning beam doses.

An MCNPX Monte Carlo model of a discrete spot scanning proton beam therapy nozzle

PURPOSE The purposes of this study were to validate a discrete spot scanning proton beam nozzle using the Monte Carlo (MC) code MCNPX and use the MC validated model to investigate the effects of a low-dose envelope, which surrounds the beams central axis, on measurements of integral depth dose (IDD) profiles. METHODS An accurate model of the discrete spot scanning beam nozzle from The University of Texas M. D. Anderson Cancer Center (Houston, Texas) was developed on the basis of blueprints provided by the manufacturer of the nozzle. The authors performed simulations of single proton pencil beams of various energies using the standard multiple Coulomb scattering (MCS) algorithm within the MCNPX source code and a new MCS algorithm, which was implemented in the MCNPX source code. The MC models were validated by comparing calculated in-air and in-water lateral profiles and percentage depth dose profiles for single pencil beams with their corresponding measured values. The models were then further tested by comparing the calculated and measured three-dimensional (3-D) dose distributions. Finally, an IDD profile was calculated with different scoring radii to determine the limitations on the use of commercially available plane-parallel ionization chambers to measure IDD. RESULTS The distance to agreement, defined as the distance between the nearest positions of two equivalent distributions with the same value of dose, between measured and simulated ranges was within 0.13 cm for both MCS algorithms. For low and intermediate pencil beam energies, the MC simulations using the standard MCS algorithm were in better agreement with measurements. Conversely, the new MCS algorithm produced better results for high-energy single pencil beams. The IDD profile calculated with cylindrical tallies with an area equivalent to the area of the largest commercially available ionization chamber showed up to 7.8% underestimation of the integral dose in certain depths of the IDD profile. CONCLUSIONS The authors conclude that a combination of MCS algorithms is required to accurately reproduce experimental data of single pencil beams and 3-D dose distributions for the scanning beam nozzle. In addition, the MC simulations showed that because of the low-dose envelope, ionization chambers with radii as large as 4.08 cm are insufficient to accurately measure IDD profiles for a 221.8 MeV pencil beam in the scanning beam nozzle.

Dose perturbations from implanted helical gold markers in proton therapy of prostate cancer

Implanted gold fiducial markers are widely used in radiation therapy to improve targeting accuracy. Recent investigations have revealed that metallic fiducial markers can cause severe perturbations in dose distributions for proton therapy, suggesting smaller markers should be considered. The objective of this study was to estimate the dosimetric impact of small gold markers in patients receiving proton therapy for prostate cancer. Small, medium, and large helical wire markers with lengths of 10 mm and helix diameters of 0.35 mm, 0.75 mm, and 1.15 mm, respectively, were implanted in an anthropomorphic phantom. Radiographic visibility was confirmed using a kilovoltage x‐ray imaging system, and dose perturbations were predicted from Monte Carlo simulations and confirmed by measurements. Monte Carlo simulations indicated that size of dose perturbation depended on marker size, orientation, and distance from the beams end of range. Specifically, the perturbation of proton dose for the lateral‐opposed‐pair treatment technique was 31% for large markers and 23% for medium markers in a typical oblique orientation. Results for perpendicular and parallel orientations were respectively lower and higher. Consequently, these markers are not well suited for use in patients receiving proton therapy for prostate cancer. Dose perturbation was not observed for the small markers, but these markers were deemed too fragile for transrectal implantation in the prostate. PACS number: 87.53.Pb

Benchmarking analytical calculations of proton doses in heterogeneous matter.

A proton dose computational algorithm, performing an analytical superposition of infinitely narrow proton beamlets (ASPB) is introduced. The algorithm uses the standard pencil beam technique of laterally distributing the central axis broad beam doses according to the Moliere scattering theory extended to slablike varying density media. The purpose of this study was to determine the accuracy of our computational tool by comparing it with experimental and Monte Carlo (MC) simulation data as benchmarks. In the tests, parallel wide beams of protons were scattered in water phantoms containing embedded air and bone materials with simple geometrical forms and spatial dimensions of a few centimeters. For homogeneous water and bone phantoms, the proton doses we calculated with the ASPB algorithm were found very comparable to experimental and MC data. For layered bone slab inhomogeneity in water, the comparison between our analytical calculation and the MC simulation showed reasonable agreement, even when the inhomogeneity was placed at the Bragg peak depth. There also was reasonable agreement for the parallelepiped bone block inhomogeneity placed at various depths, except for cases in which the bone was located in the region of the Bragg peak, when discrepancies were as large as more than 10%. When the inhomogeneity was in the form of abutting air-bone slabs, discrepancies of as much as 8% occurred in the lateral dose profiles on the air cavity side of the phantom. Additionally, the analytical depth-dose calculations disagreed with the MC calculations within 3% of the Bragg peak dose, at the entry and midway depths in the phantom. The distal depth-dose 20%-80% fall-off widths and ranges calculated with our algorithm and the MC simulation were generally within 0.1 cm of agreement. The analytical lateral-dose profile calculations showed smaller (by less than 0.1 cm) 20%-80% penumbra widths and shorter fall-off tails than did those calculated by the MC simulations. Overall, this work validates the usefulness of our ASPB algorithm as a reasonably fast and accurate tool for quality assurance in planning wide beam proton therapy treatment of clinical sites either composed of homogeneous materials or containing laterally extended inhomogeneities that are comparable in density and located away from the Bragg peak depths.

Experimental validation of a Monte Carlo proton therapy nozzle model incorporating magnetically steered protons

The purpose of this study is to validate the accuracy of a Monte Carlo calculation model of a proton magnetic beam scanning delivery nozzle developed using the Geant4 toolkit. The Monte Carlo model was used to produce depth dose and lateral profiles, which were compared to data measured in the clinical scanning treatment nozzle at several energies. Comparisons were also made between measured and simulated off-axis profiles to test the accuracy of the models magnetic steering. Comparison of the 80% distal dose fall-off values for the measured and simulated depth dose profiles agreed to within 1 mm for the beam energies evaluated. Agreement of the full width at half maximum values for the measured and simulated lateral fluence profiles was within 1.3 mm for all energies. The position of measured and simulated spot positions for the magnetically steered beams agreed to within 0.7 mm of each other. Based on these results, we found that the Geant4 Monte Carlo model of the beam scanning nozzle has the ability to accurately predict depth dose profiles, lateral profiles perpendicular to the beam axis and magnetic steering of a proton beam during beam scanning proton therapy.