Gustavo Kertzscher

In vivo dosimetry in brachytherapy

In vivo dosimetry (IVD) has been used in brachytherapy (BT) for decades with a number of different detectors and measurement technologies. However, IVD in BT has been subject to certain difficulties and complexities, in particular due to challenges of the high-gradient BT dose distribution and the large range of dose and dose rate. Due to these challenges, the sensitivity and specificity toward error detection has been limited, and IVD has mainly been restricted to detection of gross errors. Given these factors, routine use of IVD is currently limited in many departments. Although the impact of potential errors may be detrimental since treatments are typically administered in large fractions and with high-gradient-dose-distributions, BT is usually delivered without independent verification of the treatment delivery. This Vision 20/20 paper encourages improvements within BT safety by developments of IVD into an effective method of independent treatment verification.

Identifying afterloading PDR and HDR brachytherapy errors using real-time fiber-coupled Al2O3:C dosimetry and a novel statistical error decision criterion

BACKGROUND AND PURPOSE The feasibility of a real-time in vivo dosimeter to detect errors has previously been demonstrated. The purpose of this study was to: (1) quantify the sensitivity of the dosimeter to detect imposed treatment errors under well controlled and clinically relevant experimental conditions, and (2) test a new statistical error decision concept based on full uncertainty analysis. MATERIALS AND METHODS Phantom studies of two gynecological cancer PDR and one prostate cancer HDR patient treatment plans were performed using tandem ring applicators or interstitial needles. Imposed treatment errors, including interchanged pairs of afterloader guide tubes and 2-20mm source displacements, were monitored using a real-time fiber-coupled carbon doped aluminum oxide (Al(2)O(3):C) crystal dosimeter that was positioned in the reconstructed tumor region. The error detection capacity was evaluated at three dose levels: dwell position, source channel, and fraction. The error criterion incorporated the correlated source position uncertainties and other sources of uncertainty, and it was applied both for the specific phantom patient plans and for a general case (source-detector distance 5-90 mm and position uncertainty 1-4mm). RESULTS Out of 20 interchanged guide tube errors, time-resolved analysis identified 17 while fraction level analysis identified two. Channel and fraction level comparisons could leave 10mm dosimeter displacement errors unidentified. Dwell position dose rate comparisons correctly identified displacements ≥ 5mm. CONCLUSION This phantom study demonstrates that Al(2)O(3):C real-time dosimetry can identify applicator displacements ≥ 5mm and interchanged guide tube errors during PDR and HDR brachytherapy. The study demonstrates the shortcoming of a constant error criterion and the advantage of a statistical error criterion.

In vivo dosimetry: trends and prospects for brachytherapy

The error types during brachytherapy (BT) treatments and their occurrence rates are not well known. The limited knowledge is partly attributed to the lack of independent verification systems of the treatment progression in the clinical workflow routine. Within the field of in vivo dosimetry (IVD), it is established that real-time IVD can provide efficient error detection and treatment verification. However, it is also recognized that widespread implementations are hampered by the lack of available high-accuracy IVD systems that are straightforward for the clinical staff to use. This article highlights the capabilities of the state-of-the-art IVD technology in the context of error detection and quality assurance (QA) and discusses related prospects of the latest developments within the field. The article emphasizes the main challenges responsible for the limited practice of IVD and provides descriptions on how they can be overcome. Finally, the article suggests a framework for collaborations between BT clinics that implemented IVD on a routine basis and postulates that such collaborations could improve BT QA measures and the knowledge about BT error types and their occurrence rates.

Adaptive error detection for HDR/PDR brachytherapy: guidance for decision making during real-time in vivo point dosimetry.

PURPOSE This study presents an adaptive error detection algorithm (AEDA) for real-time in vivo point dosimetry during high dose rate (HDR) or pulsed dose rate (PDR) brachytherapy (BT) where the error identification, in contrast to existing approaches, does not depend on an a priori reconstruction of the dosimeter position. Instead, the treatment is judged based on dose rate comparisons between measurements and calculations of the most viable dosimeter position provided by the AEDA in a data driven approach. As a result, the AEDA compensates for false error cases related to systematic effects of the dosimeter position reconstruction. Given its nearly exclusive dependence on stable dosimeter positioning, the AEDA allows for a substantially simplified and time efficient real-time in vivo BT dosimetry implementation. METHODS In the event of a measured potential treatment error, the AEDA proposes the most viable dosimeter position out of alternatives to the original reconstruction by means of a data driven matching procedure between dose rate distributions. If measured dose rates do not differ significantly from the most viable alternative, the initial error indication may be attributed to a mispositioned or misreconstructed dosimeter (false error). However, if the error declaration persists, no viable dosimeter position can be found to explain the error, hence the discrepancy is more likely to originate from a misplaced or misreconstructed source applicator or from erroneously connected source guide tubes (true error). RESULTS The AEDA applied on two in vivo dosimetry implementations for pulsed dose rate BT demonstrated that the AEDA correctly described effects responsible for initial error indications. The AEDA was able to correctly identify the major part of all permutations of simulated guide tube swap errors and simulated shifts of individual needles from the original reconstruction. Unidentified errors corresponded to scenarios where the dosimeter position was sufficiently symmetric with respect to error and no-error source position constellations. The AEDA was able to correctly identify all false errors represented by mispositioned dosimeters contrary to an error detection algorithm relying on the original reconstruction. CONCLUSIONS The study demonstrates that the AEDA error identification during HDR/PDR BT relies on a stable dosimeter position rather than on an accurate dosimeter reconstruction, and the AEDAs capacity to distinguish between true and false error scenarios. The study further shows that the AEDA can offer guidance in decision making in the event of potential errors detected with real-time in vivo point dosimetry.

Use of novel fibre-coupled radioluminescence and RADPOS dosimetry systems for total scatter factor measurements in small fields

A dosimetry system based on Al2O3:C radioluminescence (RL), and RADPOS, a novel 4D dosimetry system using microMOSFETs, were used to measure total scatter factors, (S(c,p))(f(clin))(det), for the CyberKnife robotic radiosugery system. New Monte Carlo calculated correction factors are presented and applied for the RL detector response for the 5, 7.5 and 10 mm collimators in order to correct for the detector geometry and increased photoelectric cross section of Al2O3:C relative to water. For comparison, measurements were also carried out using a micro MOSFET, PTW60012 diode and GAFCHROMIC(®) film (EBT and EBT2). Uncorrected (S(c,p))(f(clin))(det) were obtained by taking the ratio of the detector response for each collimator to that for the 60 mm diameter reference field. Published Monte Carlo calculated correction factors were applied to the RADPOS, microMOSFET and diode detector measurements to yield corrected field factors, Ω(f(clin),f(msr))(Q(clin),Q(msr)), following the terminology of a recent formalism introduced for small and composite field relative dosimetry. With corrections, the RL measured Ω(f(clin),f(msr))(Q(clin),Q(msr)) were 0.656  ±  0.002, 0.815  ±  0.002 and 0.865  ±  0.003 for the 5, 7.5 and 10 mm collimators, respectively. This was in good agreement with RADPOS corrected field factors of 0.650  ±  0.010, 0.816  ±  0.024 and 0.867  ±  0.010 for the 5, 7.5 and 10 mm collimators, respectively. Both RL and RADPOS total scatter factors agreed within approximately two standard deviations of the GAFCHROMIC film values (average of EBT and EBT2) of 0.640  ±  0.006, 0.806  ±  0.007 and 0.859  ±  0.09. Corrected total scatter factors for all dosimetry systems agreed within one standard deviation for collimator sizes 10-60 mm. Our study suggests that the microMOSFET/RADPOS and optical fibre-coupled RL dosimetry system are well suited for total scatter factor measurements over the entire range of field sizes, provided that appropriate correction factors are applied for the collimator diameters smaller than 10 mm.

Ruby-based inorganic scintillation detectors for 192Ir brachytherapy

We tested the potential of ruby inorganic scintillation detectors (ISDs) for use in brachytherapy and investigated various unwanted luminescence properties that may compromise their accuracy. The ISDs were composed of a ruby crystal coupled to a poly(methyl methacrylate) fiber-optic cable and a charge-coupled device camera. The ISD also included a long-pass filter that was sandwiched between the ruby crystal and the fiber-optic cable. The long-pass filter prevented the Cerenkov and fluorescence background light (stem signal) induced in the fiber-optic cable from striking the ruby crystal, which generates unwanted photoluminescence rather than the desired radioluminescence. The relative contributions of the radioluminescence signal and the stem signal were quantified by exposing the ruby detectors to a high-dose-rate brachytherapy source. The photoluminescence signal was quantified by irradiating the fiber-optic cable with the detector volume shielded. Other experiments addressed time-dependent luminescence properties and compared the ISDs to commonly used organic scintillator detectors (BCF-12, BCF-60). When the brachytherapy source dwelled 0.5 cm away from the fiber-optic cable, the unwanted photoluminescence was reduced from  >5% to  <1% of the total signal as long as the ISD incorporated the long-pass filter. The stem signal was suppressed with a band-pass filter and was  <3% as long as the source distance from the scintillator was  <7 cm. Some ruby crystals exhibited time-dependent luminescence properties that altered the ruby signal by  >5% within 10 s from the onset of irradiation and after the source had retracted. The ruby-based ISDs generated signals of up to 20 times that of BCF-12-based detectors. The study presents solutions to unwanted luminescence properties of ruby-based ISDs for high-dose-rate brachytherapy. An optic filter should be sandwiched between the ruby crystal and the fiber-optic cable to suppress the photoluminescence. Furthermore, we recommend avoiding ruby crystals that exhibit significant time-dependent luminescence.

Inorganic scintillation detectors based on Eu-activated phosphors for 192Ir brachytherapy

The availability of real-time treatment verification during high-dose-rate (HDR) brachytherapy is currently limited. Therefore, we studied the luminescence properties of the widely commercially available scintillators using the inorganic materials Eu-activated phosphors Y2O3:Eu, YVO4:Eu, Y2O2S:Eu, and Gd2O2S:Eu to determine whether they could be used to accurately and precisely verify HDR brachytherapy doses in real time. The suitability for HDR brachytherapy of inorganic scintillation detectors (ISDs) based on the 4 Eu-activated phosphors in powder form was determined based on experiments with a 192Ir HDR brachytherapy source. The scintillation intensities of the phosphors were 16-134 times greater than that of the commonly used organic plastic scintillator BCF-12. High signal intensities were achieved with an optimized packing density of the phosphor mixture and with a shortened fiber-optic cable. The influence of contaminating Cerenkov and fluorescence light induced in the fiber-optic cable (stem signal) was adequately suppressed by inserting between the fiber-optic cable and the photodetector a 25 nm band-pass filter centered at the emission peak. The spurious photoluminescence signal induced by the stem signal was suppressed by placing a long-pass filter between the scintillation detector volume and the fiber-optic cable. The time-dependent luminescence properties of the phosphors were quantified by measuring the non-constant scintillation during irradiation and the afterglow after the brachytherapy source had retracted. We demonstrated that a mixture of Y2O3:Eu and YVO4:Eu suppressed the time-dependence of the ISDs and that the time-dependence of Y2O2S:Eu and Gd2O2S:Eu introduced large measurement inaccuracies. We conclude that ISDs based on a mixture of Y2O3:Eu and YVO4:Eu are promising candidates for accurate and precise real-time verification technology for HDR BT that is cost effective and straightforward to manufacture. Widespread dissemination of this technology could lead to an improved understanding of error types and frequencies during BT and to improved patient safety during treatment.

WE-DE-201-10: Pitfalls When Using Ruby as An Inorganic Scintillator Detector for Ir-192 Brachytherapy Dosimetry

PURPOSE To study the promising potential of inorganic scintillator detectors (ISDs) and investigate various unwanted luminescence properties which may compromise their accuracy. METHODS The ISDs were comprised of a ruby crystal coupled to a polymethyl methacrylate (PMMA) fiber-optic cable and a charged coupled device camera. A new type of ISD was manufactured and included a long-pass filter that was sandwiched between the crystal and the fiber-optic cable. The purpose of the filter was to suppress the Cerenkov and fluorescence background light induced in the PMMA (the stem signal) from striking the ruby crystal, generating unwanted ruby excitation. A variety of experiments were performed to characterize the ruby based ISDs. The relative contribution of the induced ruby signal and the stem signal were quantified while exposing the detector and a bare fiber-optic cable to a high dose rate (HDR) brachytherapy (BT) source, respectively. The unwanted ruby excitation was quantified while irradiating the fiber-optic cable with the detector volume shielded. Other experiments addressed time-dependent luminescence properties and a comparison to other commonly used organic scintillator detectors (BCF-12, BCF-60). RESULTS When the BT source dwelled 0.5 cm away from the fiber-optic cable, the unwanted ruby excitation amounted to >5% of the total signal if the source-distance from the scintillator was >7 cm. However, the unwanted excitation was suppressed to <1% if the ISD incorporated an optic filter. The stem signal was suppressed with a 20 nm band-pass filter and was <3% as long as the source-distance was <7 cm. The ruby based ISDs generated signal up to 20(40) times that of BCF-12(BCF-60). CONCLUSION The study presents solutions to unwanted luminescence properties of ruby based ISDs for HDR BT. An optic filter should be sandwiched between the scintillator volume and the fiber-optic cable to prevent the stem signal to excite the ruby crystal.

Sci—Fri PM: Delivery — 07: Cyberknife relative output factor measurements using fiber‐coupled luminescence, MOSFETS and RADPOS dosimetry system

Novel dosimetry systems based on Al2 O3 :C radioluminescence (RL) and a 4D dosimetry system (RADPOS) from Best Medical Canada were used to measure the relative output factor (ROF) on Cyberknife. Measurements were performed in a solid water phantom at the depth of 1.5 cm and SSD = 78.5 cm for cones from 5 to 60 mm. ROFs were also measured using a mobileMOSFET system (Best Medical Canada) and EBT1 and EBT2 GAFCHROMIC® (ISP, Ashland) radiochromic films. For cone sizes 12.5-60 mm all detector results were in agreement within the measurement uncertainty. The microMOSFET/RADPOS measurements (published corrections applied) yielded ROFs of 0.650 ± 1.9%, 0.811 ± 0.9% and 0.843 ± 1.7% for the 5, 7.5 and 10 mm cones, respectively, and were in excellent agreement with radiochromic film values (averaged for EBT1 and EBT2) of 0.645 ± 1.4%, 0.806 ± 1.1% and 0.859 ± 1.1%. Monte-Carlo calculated correction factors were applied to the RL readings to correct for excessive scatter due to the relatively high effective atomic number of Al2 O3 (Z=10.2) compared to water for the 5, 7.5 and 10 mm cones. When these corrections are applied to our RL detector measurements, we obtain ROFs of 0.656 ± 0.3% and 0.815 ± 0.3% and 0.865 ± 0.3% for 5, 7.5 and 10 mm cones. Our study shows that the microMOSFET/RADPOS and optical fiber-coupled RL dosimetry system are well suited for Cyberknife cone output factors measurements over the entire range of field sizes, provided that appropriate correction factors are applied for the smallest cone sizes (5, 7.5 and 10 mm).