Indra J. Das

Dosimetric accuracy at low monitor unit settings

Dosimetric accuracies at low monitor units are evaluated for linear accelerators from various manufacturers. A large error is observed in the majority of the accelerators. The error can be positive or negative. Although the error can exceed 20% for the first few monitor units, it is usually less than 5% when more than 10 monitor units are delivered. When low doses are required proper precautions should be taken for dosimetric accuracy including the beam energy, beam flatness and dose per monitor unit.

Determination of zero-field size percent depth doses and tissue maximum ratios for stereotactic radiosurgery and IMRT dosimetry

In this study, zero-field percent depth dose (PDD) and tissue maximum ratio (TMR) for 6MV x rays have been determined by extrapolation from dosimetric measurements over the field size range 1×1-10×10cm2. The key to small field dosimetry is the selection of a proper dosimeter for the measurements, as well as the alignment of the detector with the central axis (CAX) of beam. The measured PDD results are compared with those obtained from Monte Carlo (MC) simulation to examine the consistency and integrity of the measured data from which the zero-field PDD is extrapolated. Of the six most commonly used dosimeters in the clinic, the stereotactic diode field detector (SFD), the PTW Pinpoint, and the Exradin A14 are the most consistent and produce results within 2% of each other over the entire field size range 1×1-40×40cm2. Although the diamond detector has the smallest sensitive volume, it is the least stable and tends to disagree with all other dosimeters by more than 10%. The zero-field PDD data extrapolated from larger field measurements obtained with the SFD are in good agreement with the MC results. The extrapolated and MC data agree within 2.5% over the clinical depth range (dmax-30cm), when the MC data for the zero field are derived from a 1×1cm2 field simulation using a miniphantom (1×1×48cm3). The agreement between the measured PDD and the MC data based on a full phantom (48×48×48cm3) simulation is fairly good within 1% at shallow depths to approximately 5% at 30cm. Our results seem to indicate that zero-field TMR can be accurately calculated from PDD measurements with a proper choice of detector and a careful alignment of detector axis with the CAX.

State of dose prescription and compliance to international standard (ICRU-83) in intensity modulated radiation therapy among academic institutions

PURPOSEnThe purpose of this study was to evaluate dose prescription and recording compliance to international standard (International Commission on Radiation Units & Measurements [ICRU]-83) in patients treated with intensity modulated radiation therapy (IMRT) among academic institutions.nnnMETHODS AND MATERIALSnTen institutions participated in this study to collect IMRT data to evaluate compliance to ICRU-83. Under institutional review board clearance, data from 5094 patients-including treatment site, technique, planner, physician, prescribed dose, target volume, monitor units, planning system, and dose calculation algorithm-were collected anonymously. The dose-volume histogram of each patient, as well as dose points, doses delivered to 100% (D100), 98% (D98), 95% (D95), 50% (D50), and 2% (D2), of sites was collected and sent to a central location for analysis. Homogeneity index (HI) as a measure of the steepness of target and is a measure of the shape of the dose-volume histogram was calculated for every patient and analyzed.nnnRESULTSnIn general, ICRU recommendations for naming the target, reporting dose prescription, and achieving desired levels of dose to target were relatively poor. The nomenclature for the target in the dose prescription had large variations, having every permutation of name and number contrary to ICRU recommendations. There was statistically significant variability in D95, D50, and HI among institutions, tumor site, and technique with P values < .01. Nearly 95% of patients had D50 higher than 100% (103.5 ± 6.9) of prescribed dose and varied among institutions. On the other hand, D95 was close to 100% (97.1 ± 9.4) of prescribed dose. Liver and lung sites had a higher D50 compared with other sites. Pelvic sites had a lower variability indicated by HI (0.13 ± 1.21). Variability in D50 is 101.2 ± 8.5, 103.4 ± 6.8, 103.4 ± 8.2, and 109.5 ± 11.5 for IMRT, tomotherapy, volume modulated arc therapy, and stereotactic body radiation therapy with IMRT, respectively.nnnCONCLUSIONSnNearly 95% of patient treatments deviated from the ICRU-83 recommended D50 prescription dose delivery. This variability is significant (P < .01) in terms of treatment site, technique, and institution. To reduce dosimetric and associated radiation outcome variability, dose prescription in every clinical trial should be unified with international guidelines.

Dosimetric evaluation of synthetic CT for magnetic resonance-only based radiotherapy planning of lung cancer

BackgroundInterest in MR-only treatment planning for radiation therapy is growing rapidly with the emergence of integrated MRI/linear accelerator technology. The purpose of this study was to evaluate the feasibility of using synthetic CT images generated from conventional Dixon-based MRI scans for radiation treatment planning of lung cancer.MethodsEleven patients who underwent whole-body PET/MR imaging following a PET/CT exam were randomly selected from an ongoing prospective IRB-approved study. Attenuation maps derived from the Dixon MR Images and atlas-based method was used to create CT data (synCT). Treatment planning for radiation treatment of lung cancer was optimized on the synCT and subsequently copied to the registered CT (planCT) for dose calculation. Planning target volumes (PTVs) with three sizes and four different locations in the lung were planned for irradiation. The dose-volume metrics comparison and 3D gamma analysis were performed to assess agreement between the synCT and CT calculated dose distributions.ResultsMean differences between PTV doses on synCT and CT across all the plans were −0.1%u2009±u20090.4%, 0.1%u2009±u20090.5%, and 0.4%u2009±u20090.5% for D95, D98 and D100, respectively. Difference in dose between the two datasets for organs at risk (OARs) had average differences of −0.14u2009±u20090.07xa0Gy, 0.0%u2009±u20090.1%, and −0.1%u2009±u20090.2% for maximum spinal cord, lung V20, and heart V40 respectively. In patient groups based on tumor size and location, no significant differences were observed in the PTV and OARs dose-volume metrics (pu2009>u20090.05), except for the maximum spinal-cord dose when the target volumes were located at the lung apex (pu2009=u20090.001). Gamma analysis revealed a pass rate of 99.3%u2009±u20091.1% for 2%/2xa0mm (dose difference/distance to agreement) acceptance criteria in every plan.ConclusionsThe synCT generated from Dixon-based MRI allows for dose calculation of comparable accuracy to the standard CT for lung cancer treatment planning. The dosimetric agreement between synCT and CT calculated doses warrants further development of a MR-only workflow for radiotherapy of lung cancer.

Interface dose perturbation as a measure of megavoltage photon beam energy

The description of the quality of a photon beam has usually been characterized by a single value such as the half-value layer, the effective attenuation coefficient, the percent depth dose, and most recently by the ionization ratio (IR). Although the IR is simple and easy to measure, it lacks sensitivity at photon energies above 10 MV. This paper describes a method based on dose perturbation at an interface and defines the forward dose perturbation factor (FDPF) as a measure of beam quality. Comparisons between the two methods are given for photon energies ranging from 60Co to 24 MV. The results show that the FDPF method is more sensitive to spectral changes at photon energies above 10 MV than the IR.

Dosimetric evaluation and clinical application of virtual mini-multileaf collimator.

One of the major concerns with multileaf collimators (MLC) is the jagged field edge that produces a larger penumbra compared with that produced by a Cerrobend block. The dosimetric undulation of the MLC can be minimized by replacing an existing MLC with a mini-MLC, an expensive replacement, or by software implementation, which essentially converts a regular MLC into a virtual mini-MLC. In this study, the dosimetry in the penumbra region of a virtual mini-MLC replacing the Cerrobend block is investigated for clinical applications. HD270, a software program implemented by Siemens (Concord, CA), combines the use of an MLC and a table translation perpendicular to the leaf plane to produce a smooth field edge, thus reducing isodose undulation. Three different step resolutions are available: 5 mm, 3 mm, and 2 mm. Using film dosimetry, the penumbra regions are studied at two different depths for clinical blocks and corresponding MLC setup, as well as HD270 with different resolutions for both 6-MV and 15-MV x-ray beams. The dose delivery time for HD270 on auto-sequencing mode is compared with the use of Cerrobend blocks. The clinical applications of HD270 in head-and-neck (head and neck) and prostate treatments are investigated. For single-field irradiation, the 80–20% penumbra widths for both the 45° block and the circular block are reduced with HD270 compared with MLC for both 6 and 15 MV at different depths. At 2-mm resolution, the scalloping isodose lines (IDLs) with MLC completely disappear, although the penumbra is still larger than the Cerrobend block. On the other hand, the difference in dose undulations between 2-mm and 3-mm resolution is small. In the head and neck irradiation, the 80–20% widths with HD270 are 1 to 2 mm less than MLC, but they are still 2 mm wider than with a Cerrobend block. The 50% IDL is reduced by 2 mm with HD270 compared with MLC, which provides safety near spinal cord. Dose-volume histogram (DVH) calculations for the different shielding techniques indicate that the HD270 improves the spinal cord dose distribution significantly compared with MLC. A similar improvement in dose undulation is observed for the prostate case. In the dose region, >60% of the prescribed dose, there is approximately 10% less irradiated volume for the rectum when HD270 (3 mm resolution) is employed compared with MLC. The treatment time was compared with that from the Cerrobend block, and it was found that even at 3-mm resolution, there is a 20% reduction in treatment time in a head and neck treatment; with a 2-mm resolution, there is a 15% increase in time. The isodose undulation due to MLC can be significantly reduced with the HD270. Clinical application with HD270 for head and neck and prostate irradiation provides a smaller penumbra region compared with MLC, although it still gives a larger one compared with the Cerrobend block. In the clinical cases presented in this study, the 3-mm resolution is the most effective in improving the penumbra and delivery time. The HD270 implementation is a versatile and cost-effective solution for reducing MLC undulation.

Technical Note: Magnetic field effects on Gafchromic‐film response in MR‐IGRT

PURPOSEnMagnetokinetic changes may affect crystal orientation and polymerization within the active layer of radiochromic film (RCF). This effect is investigated in a magnetic resonance image-guided radiotherapy unit within the context of film dosimetry.nnnMETHODSnGafchromic EBT2 RCF was irradiated in a 30 × 30 × 30 cm3 solid water phantom using a Co-60 MRI guided radiotherapy system (B = 0.35 T) under normal operating conditions, and under the exact conditions and setup without a magnetic field. Fifteen 20.3 × 25.4 cm2 EBT2 film sheets were placed at three different depths (d = 0.5, 5, and 10 cm) using five different treatment plans. The plans were computed using the MRIdian (ViewRay, Inc.) treatment planning system to deliver doses between 0 and 17.6 Gy. Films were analyzed before and after irradiation to obtain the net optical density (netOD) for each color channel separately. Scanning electron microscope (SEM) images were obtained to compare the active layer of selected samples.nnnRESULTSnThe results indicated that the red channel netOD decreased between 0.013 and 0.123 (average of 0.060 ± 0.033) for doses above 2.8 Gy, with a linear increase in this effect for higher doses. Green channel netOD showed similar results with a decrease between 0.012 and 0.105 (average of 0.041 ± 0.027) for doses above 3.5 Gy. The blue channel showed the weakest effect with a netOD decrease between 0.013 and 0.029 (average of 0.020 ± 0.006) for doses above 8.0 Gy. SEM images show changes in crystal orientation within active layer in RCF exposed in a magnetic field.nnnCONCLUSIONSnThe presence of a magnetic field affects crystal orientation and polymerization during irradiation, where netOD decreased by an average of 8.7%, 8.0%, and 4.3% in the red, green, and blue channels, respectively. The under response was dependent on dose and differed by up to 15% at 17.6 Gy.

Dose distributions in regions containing beta sources: Plane interface in a homogeneous medium

An analytic model to calculate dose distributions in regions containing beta sources is developed along with a solution for the dose distribution in an infinite, homogeneous medium in which there is a uniform, monenergetic, isotropic source distribution on only one side of a plane. Comparisons with published Monte Carlo calculations are made.

Empowering Intensity Modulated Proton Therapy Through Physics and Technology: An Overview

Considering the clinical potential of protons attributable to their physical characteristics, interest in proton therapy has increased greatly in this century, as has the number of proton therapy installations. Until recently, passively scattered proton therapy was used almost entirely. Notably, the overall clinical results to date have not shown a convincing benefit of protons over photons. A rapid transition is now occurring with the implementation of the most advanced form of proton therapy, intensity modulated proton therapy (IMPT). IMPT is superior to passively scattered proton therapy and intensity modulated radiation therapy (IMRT) dosimetrically. However, numerous limitations exist in the present IMPT methods. In particular, compared with IMRT, IMPT is highly vulnerable to various uncertainties. In this overview we identify three major areas of current limitations of IMPT: treatment planning, treatment delivery, and motion management, and discuss current and future efforts for improvement. For treatment planning, we need to reduce uncertainties in proton range and in computed dose distributions, improve robust planning and optimization, enhance adaptive treatment planning and delivery, and consider how to exploit the variability in the relative biological effectiveness of protons for clinical benefit. The quality of proton therapy also depends on the characteristics of the IMPT delivery systems and image guidance. Efforts are needed to optimize the beamlet spot size for both improved dose conformality and faster delivery. For the latter, faster energy switching time and increased dose rate are also needed. Real-time in-room volumetric imaging for guiding IMPT is in its early stages with cone beam computed tomography (CT) and CT-on-rails, and continued improvements are anticipated. In addition, imaging of the proton beams themselves, using, for instance, prompt γ emissions, is being developed to determine the proton range and to reduce range uncertainty. With the realization of the advances described above, we posit that IMPT, thus empowered, will lead to substantially improved clinical results.

Dosimetric evaluation of magnetic resonance-generated synthetic CT for radiation treatment of rectal cancer

Purpose The purpose of this study was to assess the dosimetric equivalence of magnetic resonance (MR)-generated synthetic CT (synCT) and simulation CT for treatment planning in radiotherapy of rectal cancer. Methods This study was conducted on eleven patients who underwent whole-body PET/MR and PET/CT examination in a prospective IRB-approved study. For each patient synCT was generated from Dixon MR using a model-based method. Standard treatment planning directives were used to create a four-field box (4F), an oblique four-field (O4F) and a volumetric modulated arc therapy (VMAT) plan on synCT for treatment of rectal cancer. The plans were recalculated on CT with the same monitor units (MUs) as that of synCT. Dose-volume metrics of planning target volume (PTV) and organs at risk (OARs) as well as gamma analysis of dose distributions were evaluated to quantify the difference between synCT and CT plans. All plans were calculated using the analytical anisotropic algorithm (AAA). The VMAT plans on synCT and CT were also calculated using the Acuros XB algorithm for comparison with the AAA calculation. Results Medians of absolute differences in PTV metrics between synCT and CT plans were 0.2%, 0.2% and 0.3% for 4F, O4F and VMAT respectively. No significant differences were observed in OAR dose metrics including bladder V40Gy, mean dose in bladder, bowel V45Gy and femoral head V30Gy in any techniques. Gamma analysis with 2%/2mm dose difference/distance to agreement criteria showed median passing rates of 99.8% (range: 98.5 to 100%), 99.9% (97.2 to 100%), and 99.9% (99.4 to 100%) for 4F, O4F and VMAT, respectively. Using Acuros XB dose calculation, 2%/2mm gamma analysis generated a passing rate of 99.2% (97.7 to 99.9%) for VMAT plans. Conclusion SynCT enabled dose calculation equivalent to conventional CT for treatment planning of 3D conformal treatment as well as VMAT of rectal cancer. The dosimetric agreement between synCT and CT calculated doses demonstrated the potential of MR-only treatment planning for rectal cancer using MR generated synCT.