L Young

125I brachytherapy k-edge dose enhancement with AgTPPS4

Photon activation is a radiotherapy technique in which an element is added to the absorbing medium to raise the probability that a photoelectric interaction will occur, thus causing an increase in the absorption of ionizing radiation. Binding energies of key elements within an absorbing medium are closely matched with the incident photon energies to maximize the production of free electrons and subsequent absorption of their kinetic energies. The purpose of this research was to quantify potential dose enhancement using a silver tetraphenyl sulfonato porphyrin (AgTPPS4) in tumors as a photon activator for use with interstitial 125I brachytherapy. A three-dimensional Monte Carlo dosimetry model was developed using the EGS4 coding system. The photon source was modeled using spectral gamma emissions from models 6702 or 6711 brachytherapy seeds for comparison. Absorbed dose within the tumor volume was calculated for AgTPPS4 concentrations ranging between 0 and 20 mmol/kg tumor weight. These theoretical studies demonstrated linear increases in dose absorbed by the tumor with corresponding increases in AgTPPS4 concentration. The required AgTPPS4 concentration (RSC) to achieve at least a ten percent absorbed dose increase is approximately 6.5 mmol/kg tumor weight for model 6702 seeds. In vivo biodistribution and in vitro toxicity studies were conducted to determine if the theoretically derived RSC could be achieved biologically. Cell toxicity studies showed that TPPS4 porphyrin derivatives were cytotoxic at concentrations required to provide significant brachytherapy dose enhancement. Reverse phase HPLC confirmed that toxicity was due to intrinsic properties of the TPPS4 molecule, not the presence of free silver, drug impurities, or metabolites. Further research is necessary to develop a nontoxic molecular carrier for delivering silver to the DNA of tumor cells.

Validation of K-edge 125I brachytherapy enhancement with silver compounds

Brachytherapy with radioactive seeds implanted within the tumour volume has demonstrated good success rates in treating certain cancers. In an effort to improve the curative rates in cancer patients, ongoing research is being conducted to enhance the amount of radiation dose that is absorbed within the tumour volume while minimizing the dose absorbed by the surrounding normal tissue. One method for enhancing tumour dose absorption with 125I brachytherapy seeds is to increase the number of photoelectric atomic interactions within the tumour volume by introducing small quantities of a silver compound, taking advantage of the K-edge effect. Because low-energy electrons and Auger electrons are the primary sources of brachytherapy dose enhancement, acquiring accurate experimental measurements of absorbed dose increases is a major challenge. To circumvent this problem, an x ray fluorescence excitation spectroscopy dosimetry technique supplemented with clinically accepted dosimetry calculations was developed to estimate relative absorbed dose increases in a water phantom containing up to 7.5 mM of silver. Excellent agreement was observed between theoretically derived Monte Carlo dosimetric predictions and experimental measurements. These results successfully demonstrated that K-edge enhanced 125I brachytherapy is indeed possible with future development of a non-toxic silver chelate.

Clinical Positioning Accuracy for Multisession Stereotactic Radiotherapy With the Gamma Knife Perfexion

Multisession stereotactic radiation therapy is increasingly being seen as a preferred option for intracranial diseases in close proximity to critical structures and for larger target volumes. The objective of this study is to investigate the reproducibility of the Extend system from Elekta. A retrospective review was conducted for all patients treated with multisession Gamma Knife between July 2010 and June 2015, including both malignant and benign lesions. Eighty-four patients were treated in this 5-year span. The average residual daily setup uncertainty was 0.48 (0.19) mm. We compare measurements of setup uncertainty from the Extend system to measurements performed with a linac-based approach previously used in our center. The Extend system has significantly reduced setup uncertainty for fractionated intracranial treatments at our institution. Positive results were observed in a small population of edentulous patients. The Extend system compares favorably with other approaches to delivering intracranial stereotactic radiotherapy and is a robust, simple-to-use, and precise method for treating multisession intracranial lesions.

SU-E-T-484: In Vivo Dosimetry Tolerances in External Beam Fast Neutron Therapy

Purpose: Optical stimulated luminescence (OSL) dosimetry with Landauer Al2O3:C nanodots was developed at our institution as a passive in vivo dosimetry (IVD) system for patients treated with fast neutron therapy. The purpose of this study was to establish clinically relevant tolerance limits for detecting treatment errors requiring further investigation. Methods: Tolerance levels were estimated by conducting a series of IVD expected dose calculations for square field sizes ranging between 2.8 and 28.8 cm. For each field size evaluated, doses were calculated for open and internal wedged fields with angles of 30°, 45°, or 60°. Theoretical errors were computed for variations of incorrect beam configurations. Dose errors, defined as the percent difference from the expected dose calculation, were measured with groups of three nanodots placed in a 30 x 30 cm solid water phantom, at beam isocenter (150 cm SAD, 1.7 cm Dmax). The tolerances were applied to IVD patient measurements. Results: The overall accuracy of the nanodot measurements is 2–3% for open fields. Measurement errors agreed with calculated errors to within 3%. Theoretical estimates of dosimetric errors showed that IVD measurements with OSL nanodots will detect the absence of an internal wedge or a wrong wedge angle. Incorrect nanodot placement on a wedged field is more likely to be caught if the offset is in the direction of the “toe” of the wedge where the dose difference in percentage is about 12%. Errors caused by an incorrect flattening filter size produced a 2% measurement error that is not detectable by IVD measurement alone. Conclusion: IVD with nanodots will detect treatment errors associated with the incorrect implementation of the internal wedge. The results of this study will streamline the physicists’ investigations in determining the root cause of an IVD reading that is out of normally accepted tolerances.

Validating FMEA output against incident learning data: A study in stereotactic body radiation therapy: Validating FMEA output against incident learning data

PURPOSE Though failure mode and effects analysis (FMEA) is becoming more widely adopted for risk assessment in radiation therapy, to our knowledge, its output has never been validated against data on errors that actually occur. The objective of this study was to perform FMEA of a stereotactic body radiation therapy (SBRT) treatment planning process and validate the results against data recorded within an incident learning system. METHODS FMEA on the SBRT treatment planning process was carried out by a multidisciplinary group including radiation oncologists, medical physicists, dosimetrists, and IT technologists. Potential failure modes were identified through a systematic review of the process map. Failure modes were rated for severity, occurrence, and detectability on a scale of one to ten and risk priority number (RPN) was computed. Failure modes were then compared with historical reports identified as relevant to SBRT planning within a departmental incident learning system that has been active for two and a half years. Differences between FMEA anticipated failure modes and existing incidents were identified. RESULTS FMEA identified 63 failure modes. RPN values for the top 25% of failure modes ranged from 60 to 336. Analysis of the incident learning database identified 33 reported near-miss events related to SBRT planning. Combining both methods yielded a total of 76 possible process failures, of which 13 (17%) were missed by FMEA while 43 (57%) identified by FMEA only. When scored for RPN, the 13 events missed by FMEA ranked within the lower half of all failure modes and exhibited significantly lower severity relative to those identified by FMEA (p = 0.02). CONCLUSIONS FMEA, though valuable, is subject to certain limitations. In this study, FMEA failed to identify 17% of actual failure modes, though these were of lower risk. Similarly, an incident learning system alone fails to identify a large number of potentially high-severity process errors. Using FMEA in combination with incident learning may render an improved overview of risks within a process.

Validating FMEA output against incident learning data

PURPOSE Though failure mode and effects analysis (FMEA) is becoming more widely adopted for risk assessment in radiation therapy, to our knowledge, its output has never been validated against data on errors that actually occur. The objective of this study was to perform FMEA of a stereotactic body radiation therapy (SBRT) treatment planning process and validate the results against data recorded within an incident learning system. METHODS FMEA on the SBRT treatment planning process was carried out by a multidisciplinary group including radiation oncologists, medical physicists, dosimetrists, and IT technologists. Potential failure modes were identified through a systematic review of the process map. Failure modes were rated for severity, occurrence, and detectability on a scale of one to ten and risk priority number (RPN) was computed. Failure modes were then compared with historical reports identified as relevant to SBRT planning within a departmental incident learning system that has been active for two and a half years. Differences between FMEA anticipated failure modes and existing incidents were identified. RESULTS FMEA identified 63 failure modes. RPN values for the top 25% of failure modes ranged from 60 to 336. Analysis of the incident learning database identified 33 reported near-miss events related to SBRT planning. Combining both methods yielded a total of 76 possible process failures, of which 13 (17%) were missed by FMEA while 43 (57%) identified by FMEA only. When scored for RPN, the 13 events missed by FMEA ranked within the lower half of all failure modes and exhibited significantly lower severity relative to those identified by FMEA (p = 0.02). CONCLUSIONS FMEA, though valuable, is subject to certain limitations. In this study, FMEA failed to identify 17% of actual failure modes, though these were of lower risk. Similarly, an incident learning system alone fails to identify a large number of potentially high-severity process errors. Using FMEA in combination with incident learning may render an improved overview of risks within a process.

Commissioning optically stimulated luminescence in vivo dosimeters for fast neutron therapy

PURPOSE Clinical in vivo dosimeters intended for use with photon and electron therapies have not been utilized for fast neutron therapy because they are highly susceptible to neutron damage. The objective of this work was to determine if a commercial optically stimulated luminescence (OSL) in vivo dosimetry system could be adapted for use in fast neutron therapy. METHODS A 50.5 MeV fast neutron beam generated by a clinical neutron therapy cyclotron was used to irradiate carbon doped aluminum oxide (Al2O3:C) optically simulated luminescence dosimeters (OSLDs) in a solid water phantom under standard calibration conditions, 150 cm SAD, 1.7 cm depth, and 10.3 × 10.0 cm field size. OSLD fading and electron trap depletion studies were performed with the OSLDs irradiated with 20 and 50 cGy and monitored over a 24-h period to determine the optimal time for reading the dosimeters during calibration. Four OSLDs per group were calibrated over a clinical dose range of 0-150 cGy. RESULTS OSLD measurement uncertainties were lowered to within ±2%-3% of the expected dose by minimizing the effect of transient fading that occurs with neutron irradiation and maintaining individual calibration factors for each dosimeter. Dose dependent luminescence fading extended beyond the manufacturers recommended 10 min period for irradiation with photon or electron beams. To minimize OSL variances caused by inconsistent fading among dosimeters, the observed optimal time for reading the OSLDs postirradiation was between 30 and 90 min. No field size, wedge factor, or gantry angle dependencies were observed in the OSLDs irradiated by the studied fast neutron beam. CONCLUSIONS Measurements demonstrated that uncertainties less than ±3% were attainable in OSLDs irradiated with fast neutrons under clinical conditions. Accuracy and precision comparable to clinical OSL measurements observed with photons can be achieved by maintaining individual OSLD calibration factors and minimizing transient fading effects.

SU-E-T-365: Dosimetric Impact of Dental Amalgam CT Image Artifacts On IMRT and VMAT Head and Neck Plans

PURPOSE The presence of high density dental amalgam in patient CT image data sets causes dose calculation errors for head and neck (HN) treatment planning. This study assesses and compares dosimetric variations in IMRT and VMAT treatment plans due to dental artifacts. METHODS Sixteen HN patients with similar treatment sites (oropharynx), tumor volume and extensive dental artifacts were divided into two groups: IMRT (n=8, 6 to 9 beams) and VMAT (n=8, 2 arcs with 352° rotation). All cases were planned with the Pinnacle 9.2 treatment planning software using the collapsed cone convolution superposition algorithm and a range of prescription dose from 60 to 72Gy. Two different treatment plans were produced, each based on one of two image sets: (a)uncorrected; (b)dental artifacts density overridden (set to 1.0g/cm3 ). Differences between the two treatment plans for each of the IMRT and VMAT techniques were quantified by the following dosimetric parameters: maximum point dose, maximum spinal cord and brainstem dose, mean left and right parotid dose, and PTV coverage (V95%Rx). Average differences generated for these dosimetric parameters were compared between IMRT and VMAT plans. RESULTS The average absolute dose differences (plan a minus plan b) for the VMAT and IMRT techniques, respectively, caused by dental artifacts were: 2.2±3.3cGy vs. 37.6±57.5cGy (maximum point dose, P=0.15); 1.2±0.9cGy vs. 7.9±6.7cGy (maximum spinal cord dose, P=0.026); 2.2±2.4cGy vs. 12.1±13.0cGy (maximum brainstem dose, P=0.077); 0.9±1.1cGy vs. 4.1±3.5cGy (mean left parotid dose, P=0.038); 0.9±0.8cGy vs. 7.8±11.9cGy (mean right parotid dose, P=0.136); 0.021%±0.014% vs. 0.803%±1.44% (PTV coverage, P=0.17). CONCLUSION For the HN plans studied, dental artifacts demonstrated a greater dose calculation error for IMRT plans compared to VMAT plans. Rotational arcs appear on the average to compensate dose calculation errors induced by dental artifacts. Thus, compared to VMAT, density overrides for dental artifacts are more important when planning IMRT of HN.

SU-E-T-247: Multi-Leaf Collimator Model Adjustments Improve Small Field Dosimetry in VMAT Plans.

PURPOSE The Elekta beam modulator linac employs a 4-mm micro multileaf collimator (MLC) backed by a fixed jaw. Out-of-field dose discrepancies between treatment planning system (TPS) calculations and output water phantom measurements are caused by the 1-mm leaf gap required for all moving MLCs in a VMAT arc. In this study, MLC parameters are optimized to improve TPS out-of-field dose approximations. METHODS Static 2.4 cm square fields were created with a 1-mm leaf gap for MLCs that would normally park behind the jaw. Doses in the open field and leaf gap were measured with an A16 micro ion chamber and EDR2 film for comparison with corresponding point doses in the Pinnacle TPS. The MLC offset table and tip radius were adjusted until TPS point doses agreed with photon measurements. Improvements to the beam models were tested using static arcs consisting of square fields ranging from 1.6 to 14.0 cm, with 45° collimator rotation, and 1-mm leaf gap to replicate VMAT conditions. Gamma values for the 3-mm distance, 3% dose difference criteria were evaluated using standard QA procedures with a cylindrical detector array. RESULTS The best agreement in point doses within the leaf gap and open field was achieved by offsetting the default rounded leaf end table by 0.1 cm and adjusting the leaf tip radius to 13 cm. Improvements in TPS models for 6 and 10 MV photon beams were more significant for smaller field sizes 3.6 cm or less where the initial gamma factors progressively increased as field size decreased, i.e. for a 1.6cm field size, the Gamma increased from 56.1% to 98.8%. CONCLUSION The MLC optimization techniques developed will achieve greater dosimetric accuracy in small field VMAT treatment plans for fixed jaw linear accelerators. Accurate predictions of dose to organs at risk may reduce adverse effects of radiotherapy.

SU‐E‐T‐75: Commissioning Optically Stimulated Luminescence Dosimeters for Fast Neutron Therapy

PURPOSE Fast neutrons therapy used at the University of Washington is clinically proven to be more effective than photon therapy in treating salivary gland and other cancers. A nanodot optically stimulated luminescence (OSL) system was chosen to be commissioned for patient in vivo dosimetry for neutron therapy. The OSL-based radiation detectors are not susceptible to radiation damage caused by neutrons compared to diodes or MOSFET systems. METHODS An In-Light microStar OSL system was commissioned for in vivo use by radiating Landauer nanodots with neutrons generated from 50.0 MeV protons accelerated onto a beryllium target. The OSLs were calibrated the depth of maximum dose in solid water localized to 150 cm SAD isocenter in a 10.3 cm square field. Linearity was tested over a typical clinical dose fractionation range i.e. 0 to 150 neutron-cGy. Correction factors for transient signal fading, trap depletion, gantry angle, field size, and wedge factor dependencies were also evaluated. The OSLs were photo-bleached between radiations using a tungsten-halogen lamp. RESULTS Landauer sensitivity factors published for each nanodot are valid for measuring photon and electron doses but do not apply for neutron irradiation. Individually calculated nanodot calibration factors exhibited a 2-5% improvement over calibration factors computed by the microStar InLight software. Transient fading effects had a significant impact on neutron dose reading accuracy compared to photon and electron in vivo dosimetry. Greater accuracy can be achieved by calibrating and reading each dosimeter within 1-2 hours after irradiation. No additional OSL correction factors were needed for field size, gantry angle, or wedge factors in solid water phantom measurements. CONCLUSION OSL detectors are a useful for neutron beam in vivo dosimetry verification. Dosimetric accuracy comparable to conventional diode systems can be achieved. Accounting for transient fading effects during the neutron beam calibration is a critical component for achieving comparable accuracy.