Luc Beaulieu

Report of the Task Group 186 on model-based dose calculation methods in brachytherapy beyond the TG-43 formalism: Current status and recommendations for clinical implementation

The charge of Task Group 186 (TG-186) is to provide guidance for early adopters of model-based dose calculation algorithms (MBDCAs) for brachytherapy (BT) dose calculations to ensure practice uniformity. Contrary to external beam radiotherapy, heterogeneity correction algorithms have only recently been made available to the BT community. Yet, BT dose calculation accuracy is highly dependent on scatter conditions and photoelectric effect cross-sections relative to water. In specific situations, differences between the current water-based BT dose calculation formalism (TG-43) and MBDCAs can lead to differences in calculated doses exceeding a factor of 10. MBDCAs raise three major issues that are not addressed by current guidance documents: (1) MBDCA calculated doses are sensitive to the dose specification medium, resulting in energy-dependent differences between dose calculated to water in a homogeneous water geometry (TG-43), dose calculated to the local medium in the heterogeneous medium, and the intermediate scenario of dose calculated to a small volume of water in the heterogeneous medium. (2) MBDCA doses are sensitive to voxel-by-voxel interaction cross sections. Neither conventional single-energy CT nor ICRU∕ICRP tissue composition compilations provide useful guidance for the task of assigning interaction cross sections to each voxel. (3) Since each patient-source-applicator combination is unique, having reference data for each possible combination to benchmark MBDCAs is an impractical strategy. Hence, a new commissioning process is required. TG-186 addresses in detail the above issues through the literature review and provides explicit recommendations based on the current state of knowledge. TG-43-based dose prescription and dose calculation remain in effect, with MBDCA dose reporting performed in parallel when available. In using MBDCAs, it is recommended that the radiation transport should be performed in the heterogeneous medium and, at minimum, the dose to the local medium be reported along with the TG-43 calculated doses. Assignments of voxel-by-voxel cross sections represent a particular challenge. Electron density information is readily extracted from CT imaging, but cannot be used to distinguish between different materials having the same density. Therefore, a recommendation is made to use a number of standardized materials to maintain uniformity across institutions. Sensitivity analysis shows that this recommendation offers increased accuracy over TG-43. MBDCA commissioning will share commonalities with current TG-43-based systems, but in addition there will be algorithm-specific tasks. Two levels of commissioning are recommended: reproducing TG-43 dose parameters and testing the advanced capabilities of MBDCAs. For validation of heterogeneity and scatter conditions, MBDCAs should mimic the 3D dose distributions from reference virtual geometries. Potential changes in BT dose prescriptions and MBDCA limitations are discussed. When data required for full MBDCA implementation are insufficient, interim recommendations are made and potential areas of research are identified. Application of TG-186 guidance should retain practice uniformity in transitioning from the TG-43 to the MBDCA approach.

Dual-energy CT-based material extraction for tissue segmentation in Monte Carlo dose calculations

Monte Carlo (MC) dose calculations are performed on patient geometries derived from computed tomography (CT) images. For most available MC codes, the Hounsfield units (HU) in each voxel of a CT image have to be converted into mass density (rho) and material type. This is typically done with a (HU; rho) calibration curve which may lead to mis-assignment of media. In this work, an improved material segmentation using dual-energy CT-based material extraction is presented. For this purpose, the differences in extracted effective atomic numbers Z and the relative electron densities rho(e) of each voxel are used. Dual-energy CT material extraction based on parametrization of the linear attenuation coefficient for 17 tissue-equivalent inserts inside a solid water phantom was done. Scans of the phantom were acquired at 100 kVp and 140 kVp from which Z and rho(e) values of each insert were derived. The mean errors on Z and rho(e) extraction were 2.8% and 1.8%, respectively. Phantom dose calculations were performed for 250 kVp and 18 MV photon beams and an 18 MeV electron beam in the EGSnrc/DOSXYZnrc code. Two material assignments were used: the conventional (HU; rho) and the novel (HU; rho, Z) dual-energy CT tissue segmentation. The dose calculation errors using the conventional tissue segmentation were as high as 17% in a mis-assigned soft bone tissue-equivalent material for the 250 kVp photon beam. Similarly, the errors for the 18 MeV electron beam and the 18 MV photon beam were up to 6% and 3% in some mis-assigned media. The assignment of all tissue-equivalent inserts was accurate using the novel dual-energy CT material assignment. As a result, the dose calculation errors were below 1% in all beam arrangements. Comparable improvement in dose calculation accuracy is expected for human tissues. The dual-energy tissue segmentation offers a significantly higher accuracy compared to the conventional single-energy segmentation.

The evolution of brachytherapy treatment planning

Brachytherapy is a mature treatment modality that has benefited from technological advances. Treatment planning has advanced from simple lookup tables to complex, computer-based dose-calculation algorithms. The current approach is based on the AAPM TG-43 formalism with recent advances in acquiring single-source dose distributions. However, this formalism has clinically relevant limitations for calculating patient dose. Dose-calculation algorithms are being developed based on Monte Carlo methods, collapsed cone, and solving the linear Boltzmann transport equation. In addition to improved dose-calculation tools, planning systems and brachytherapy treatment planning will account for material heterogeneities, scatter conditions, radiobiology, and image guidance. The AAPM, ESTRO, and other professional societies are working to coordinate clinical integration of these advancements. This Vision 20/20 article provides insight into these endeavors.

Measurement accuracy and Cerenkov removal for high performance, high spatial resolution scintillation dosimetry

With highly conformal radiation therapy techniques such as intensity-modulated radiation therapy, radiosurgery, and tomotherapy becoming more common in clinical practice, the use of these narrow beams requires a higher level of precision in quality assurance and dosimetry. Plastic scintillators with their water equivalence, energy independence, and dose rate linearity have been shown to possess excellent qualities that suit the most complex and demanding radiation therapy treatment plans. The primary disadvantage of plastic scintillators is the presence of Cerenkov radiation generated in the light guide, which results in an undesired stem effect. Several techniques have been proposed to minimize this effect. In this study, we compared three such techniques-background subtraction, simple filtering, and chromatic removal-in terms of reproducibility and dose accuracy as gauges of their ability to remove the Cerenkov stem effect from the dose signal. The dosimeter used in this study comprised a 6-mm(3) plastic scintillating fiber probe, an optical fiber, and a color charge-coupled device camera. The whole system was shown to be linear and the total light collected by the camera was reproducible to within 0.31% for 5-s integration time. Background subtraction and chromatic removal were both found to be suitable for precise dose evaluation, with average absolute dose discrepancies of 0.52% and 0.67%, respectively, from ion chamber values. Background subtraction required two optical fibers, but chromatic removal used only one, thereby preventing possible measurement artifacts when a strong dose gradient was perpendicular to the optical fiber. Our findings showed that a plastic scintillation dosimeter could be made free of the effect of Cerenkov radiation.

Validation of GEANT4, an object‐oriented Monte Carlo toolkit, for simulations in medical physics

GEANT4 (GEometry ANd Tracking 4) is an object-oriented Monte Carlo simulation toolkit that has been developed by a worldwide collaboration of scientists. It simulates the passage of particles through matter. In order to validate GEANT4 for medical physics applications, different simulations are conducted. The results are compared to published results based on three Monte Carlo codes widely used in medical physics: MCNP, EGS4, and EGSnrc. When possible, the simulation results are also compared to experimental data. Different geometries are tested (multilayer and homogeneous phantoms), different sources considered (point-source and broad parallel beam), and different primary particles simulated (photons and electrons) at different energies. For the heterogeneous media, there are notable differences between the Monte Carlo codes reaching up to over 5% in relative difference. For the monoenergetic electrons in a homogeneous medium, the difference between GEANT4 and the experimental measurements is similar to the difference between EGSnrc and the experimental measurements; for the depth-dose curves, the difference expressed as a fraction of the peak dose is always smaller than 4%. We conclude that GEANT4 is a promising Monte Carlo simulation toolkit for low-energy medical applications.

Correction of CT artifacts and its influence on Monte Carlo dose calculations

Computed tomography (CT) images of patients having metallic implants or dental fillings exhibit severe streaking artifacts. These artifacts may disallow tumor and organ delineation and compromise dose calculation outcomes in radiotherapy. We used a sinogram interpolation metal streaking artifact correction algorithm on several phantoms of exact-known compositions and on a prostate patient with two hip prostheses. We compared original CT images and artifact-corrected images of both. To evaluate the effect of the artifact correction on dose calculations, we performed Monte Carlo dose calculation in the EGSnrc/DOSXYZnrc code. For the phantoms, we performed calculations in the exact geometry, in the original CT geometry and in the artifact-corrected geometry for photon and electron beams. The maximum errors in 6 MV photon beam dose calculation were found to exceed 25% in original CT images when the standard DOSXYZnrc/CTCREATE calibration is used but less than 2% in artifact-corrected images when an extended calibration is used. The extended calibration includes an extra calibration point for a metal. The patient dose volume histograms of a hypothetical target irradiated by five 18 MV photon beams in a hypothetical treatment differ significantly in the original CT geometry and in the artifact-corrected geometry. This was found to be mostly due to miss-assignment of tissue voxels to air due to metal artifacts. We also developed a simple Monte Carlo model for a CT scanner and we simulated the contribution of scatter and beam hardening to metal streaking artifacts. We found that whereas beam hardening has a minor effect on metal artifacts, scatter is an important cause of these artifacts.

The liquid to vapor phase transition in excited nuclei

The thermal component of the 8 GeV/c pi+ Au data of the ISiS Collaboration is shown to follow the scaling predicted by Fishers model when Coulomb energy is taken into account. Critical exponents tau and sigma, the critical point (p(c),rho(c),T(c)), surface energy coefficient c(0), enthalpy of evaporation DeltaH, and critical compressibility factor C(F)(c) are determined. For the first time, the experimental phase diagrams, (p,T) and (T,rho), describing the liquid vapor coexistence of finite neutral nuclear matter have been constructed.

Spectral method for the correction of the Cerenkov light effect in plastic scintillation detectors: A comparison study of calibration procedures and validation in Cerenkov light‐dominated situations

PURPOSE The purposes of this work were: (1) To determine if a spectral method can accurately correct the Cerenkov light effect in plastic scintillation detectors (PSDs) for situations where the Cerenkov light is dominant over the scintillation light and (2) to develop a procedural guideline for accurately determining the calibration factors of PSDs. METHODS The authors demonstrate, by using the equations of the spectral method, that the condition for accurately correcting the effect of Cerenkov light is that the ratio of the two calibration factors must be equal to the ratio of the Cerenkov light measured within the two different spectral regions used for analysis. Based on this proof, the authors propose two new procedures to determine the calibration factors of PSDs, which were designed to respect this condition. A PSD that consists of a cylindrical polystyrene scintillating fiber (1.6 mm3) coupled to a plastic optical fiber was calibrated by using these new procedures and the two reference procedures described in the literature. To validate the extracted calibration factors, relative dose profiles and output factors for a 6 MV photon beam from a medical linac were measured with the PSD and an ionization chamber. Emphasis was placed on situations where the Cerenkov light is dominant over the scintillation light and on situations dissimilar to the calibration conditions. RESULTS The authors found that the accuracy of the spectral method depends on the procedure used to determine the calibration factors of the PSD and on the attenuation properties of the optical fiber used. The results from the relative dose profile measurements showed that the spectral method can correct the Cerenkov light effect with an accuracy level of 1%. The results obtained also indicate that PSDs measure output factors that are lower than those measured with ionization chambers for square field sizes larger than 25 x 25 cm2, in general agreement with previously published Monte Carlo results. CONCLUSIONS The authors conclude that the spectral method can be used to accurately correct the Cerenkov light effect in PSDs. The authors confirmed the importance of maximizing the difference of Cerenkov light production between calibration measurements. The authors also found that the attenuation of the optical fiber, which is assumed to be constant in the original formulation of the spectral method, may cause a variation of the calibration factors in some experimental setups.

Water-equivalent dosimeter array for small-field external beam radiotherapy

With the increasing complexity of dose patterns external beam radiotherapy, there is a great need for new types of dosimeters. We studied the first prototype of a new dosimeter array consisting of water-equivalent plastic scintillating fibers for dose measurement in external beam radiotherapy. We found that this array allows precise, rapid dose evaluation of small photon fields. Starting with a dosimeter system constructed with a single scintillating fiber coupled to a clear optical fiber and read using a charge coupled device camera, we looked at the dosimeters spatial resolution under small radiation fields and angular dependence. Afterward, we analyzed the cameras light collection to determine the maximum array size that could be built. Finally, we developed a prototype made of ten scintillating fiber detectors to study the behavior and precision of this system in simple dosimetric situations. The scintillation detector showed no measurable angular dependence. Comparison of the scintillation detector and a small-volume ion chamber showed agreement except for 1 x 1 and 0.5 x 5.0 cm (2) fields where the output factor measured by the scintillator was higher. The actual field of view of the camera could accept more than 4000 scintillating fiber detectors simultaneously. Evaluation of the dose profile and depth dose curve using a prototype with ten scintillating fiber detectors showed precise, rapid dose evaluation even with placement of more than 75 optical fibers in the field to simulate what would happen in a larger array. We concluded that this scintillating fiber dosimeter array is a valuable tool for dose measurement in external beam radiotherapy. It possesses the qualities necessary to evaluate small and irregular fields with various incident angles such as those encountered in intensity-modulated radiotherapy, radiosurgery, and tomotherapy.

Sensitivity of low energy brachytherapy Monte Carlo dose calculations to uncertainties in human tissue composition.

PURPOSE The objective of this work is to assess the sensitivity of Monte Carlo (MC) dose calculations to uncertainties in human tissue composition for a range of low photon energy brachytherapy sources:I125, P103d, C131s, and an electronic brachytherapy source (EBS). The low energy photons emitted by these sources make the dosimetry sensitive to variations in tissue atomic number due to the dominance of the photoelectric effect. This work reports dose to a small mass of water in medium Dw,m as opposed to dose to a small mass of medium in medium Dm,m. METHODS Mean adipose, mammary gland, and breast tissues (as uniform mixture of the aforementioned tissues) are investigated as well as compositions corresponding to one standard deviation from the mean. Prostate mean compositions from three different literature sources are also investigated. Three sets of MC simulations are performed with theGEANT4 code: (1) Dose calculations for idealized TG-43-like spherical geometries using point sources. Radial dose profiles obtained in different media are compared to assess the influence of compositional uncertainties. (2) Dose calculations for four clinical prostate LDR brachytherapy permanent seed implants using I125 seeds (Model 2301, Best Medical, Springfield, VA). The effect of varying the prostate composition in the planning target volume (PTV) is investigated by comparing PTV D90 values. (3) Dose calculations for four clinical breast LDR brachytherapy permanent seed implants using P103d seeds (Model 2335, Best Medical). The effects of varying the adipose/gland ratio in the PTV and of varying the elemental composition of adipose and gland within one standard deviation of the assumed mean composition are investigated by comparing PTV D90 values. For (2) and (3), the influence of using the mass density from CT scans instead of unit mass density is also assessed. RESULTS Results from simulation (1) show that variations in the mean compositions of tissues affect low energy brachytherapy dosimetry. Dose differences between mean and one standard deviation of the mean composition increasing with distance from the source are observed. It is established that theI125 and C131s sources are the least sensitive to variations in elemental compositions while P103d is most sensitive. The EBS falls in between and exhibits complex behavior due to significant spectral hardening. Results from simulation (2) show that two prostate compositions are dosimetrically equivalent to water while the third shows D90 differences of up to 4%. Results from simulation (3) show that breast is more sensitive than prostate with dose variations of up to 30% from water for 70% adipose/30% gland breast. The variability of the breast composition adds a ±10% dose variation. CONCLUSIONS Low energy brachytherapy dose distributions in tissue differ from water and are influenced by density, mean tissue composition, and patient-to-patient composition variations. The results support the use of a dose calculation algorithm accounting for heterogeneities such as MC. Since this work shows that variations in mean tissue compositions affect MC dosimetry and result in increased dose uncertainties, the authors conclude that imaging tools providing more accurate estimates of elemental compositions such as dual energy CT would be beneficial.