Marimuthu Sankaralingam

An assessment of the efficiency of methods for measurement of the computed tomography dose index (CTDI) for cone beam (CBCT) dosimetry by Monte Carlo simulation

The IEC has introduced a practical approach to overcome shortcomings of the CTDI100 for measurements on wide beams employed for cone beam (CBCT) scans. This study evaluated the efficiency of this approach (CTDIIEC) for different arrangements using Monte Carlo simulation techniques, and compared CTDIIEC to the efficiency of CTDI100 for CBCT. Monte Carlo EGSnrc/BEAMnrc and EGSnrc/DOSXYZnrc codes were used to simulate the kV imaging system mounted on a Varian TrueBeam linear accelerator. The Monte Carlo model was benchmarked against experimental measurements and good agreement shown. Standard PMMA head and body phantoms with lengths 150, 600, and 900 mm were simulated. Beam widths studied ranged from 20-300 mm, and four scanning protocols using two acquisition modes were utilized. The efficiency values were calculated at the centre (εc) and periphery (εp) of the phantoms and for the weighted CTDI (εw). The efficiency values for CTDI100 were approximately constant for beam widths 20-40 mm, where εc(CTDI100), εp(CTDI100), and εw(CTDI100) were 74.7  ±  0.6%, 84.6  ±  0.3%, and 80.9  ±  0.4%, for the head phantom and 59.7  ±  0.3%, 82.1  ±  0.3%, and 74.9  ±  0.3%, for the body phantom, respectively. When beam width increased beyond 40 mm, ε(CTDI100) values fell steadily reaching ~30% at a beam width of 300 mm. In contrast, the efficiency of the CTDIIEC was approximately constant over all beam widths, demonstrating its suitability for assessment of CBCT. εc(CTDIIEC), εp(CTDIIEC), and εw(CTDIIEC) were 76.1  ±  0.9%, 85.9  ±  1.0%, and 82.2  ±  0.9% for the head phantom and 60.6  ±  0.7%, 82.8  ±  0.8%, and 75.8  ±  0.7%, for the body phantom, respectively, within 2% of ε(CTDI100) values for narrower beam widths. CTDI100,w and CTDIIEC,w underestimate CTDI∞,w by ~55% and ~18% for the head phantom and by ~56% and ~24% for the body phantom, respectively, using a clinical beam width 198 mm. The CTDIIEC approach addresses the dependency of efficiency on beam width successfully and correction factors have been derived to allow calculation of CTDI∞.

A Monte Carlo investigation of cumulative dose measurements for cone beam computed tomography (CBCT) dosimetry

Many studies have shown that the computed tomography dose index (CTDI100) which is considered as a main dose descriptor for CT dosimetry fails to provide a realistic reflection of the dose involved in cone beam computed tomography (CBCT) scans. Several practical approaches have been proposed to overcome drawbacks of the CTDI100. One of these is the cumulative dose concept. The purpose of this study was to investigate four different approaches based on the cumulative dose concept: the cumulative dose (1) f(0,150) and (2) f(0,∞) with a small ionization chamber 20 mm long, and the cumulative dose (3) f100(150) and (4) f100(∞) with a standard 100 mm pencil ionization chamber. The study also aimed to investigate the influence of using the 20 and 100 mm chambers and the standard and the infinitely long phantoms on cumulative dose measurements. Monte Carlo EGSnrc/BEAMnrc and EGSnrc/DOSXYZnrc codes were used to simulate a kV imaging system integrated with a TrueBeam linear accelerator and to calculate doses within cylindrical head and body PMMA phantoms with diameters of 16 cm and 32 cm, respectively, and lengths of 150, 600, 900 mm. f(0,150) and f100(150) approaches were studied within the standard PMMA phantoms (150 mm), while the other approaches f(0,∞) and f100(∞) were within infinitely long head (600 mm) and body (900 mm) phantoms. CTDI∞ values were used as a standard to compare the dose values for the approaches studied at the centre and periphery of the phantoms and for the weighted values. Four scanning protocols and beams of width 20-300 mm were used. It has been shown that the f(0,∞) approach gave the highest dose values which were comparable to CTDI∞ values for wide beams. The differences between the weighted dose values obtained with the 20 and 100 mm chambers were significant for the beam widths <120 mm, but these differences declined with increasing beam widths to be within 4%. The weighted dose values calculated within the infinitely long phantoms with both the chambers for the beam widths ≤140 were within 3% of those within the standard phantoms, but the differences rose to be within 15% at wider beams. By comparing the approaches studied in this investigation with other methodologies taking into account the efficiency of the approach as a dose descriptor and the simplicity of the implementation in the clinical environment, the f(0,150) method may be the best for CBCT dosimetry combined with the use of correction factors.

Quantitative comparison of volumetric modulated arc therapy and intensity modulated radiotherapy plan quality in sino-nasal cancer

The aim of this study was to compare various dosimetric parameters of dynamic mlc intensity modulated radiotherapy (IMRT) plans with volumetric modulated arc therapy (VMAT) plans for sino-nasal cancers, which are rare and complex tumors to treat with radiotherapy. IMRT using five fields, coplanar in the sagittal plane and VMAT employing two coplanar arc plans were created for five patients. The plans were assessed by comparing Conformity Index and Sigma Index (dose homogeneity) in the Planning Target Volume (PTV) and through comparison of dose-volume characteristics to the following organs at risk (OARs): Spinal cord, brainstem, eye, ipsilateral and contralateral optic nerve and the volume of brain receiving 10% of the prescribed dose (V10%). The total monitor units required to deliver the plan were also compared. Conformity Index was found to be superior in VMAT plans for three patients and in IMRT plans for two patients. Dose homogeneity within the PTV was better with VMAT plans for all five cases. The mean difference in Sigma Index was 0.68%. There was no significant difference in dose between IMRT and VMAT plans for any of the OARs assessed in these patients. The monitor units were significantly reduced in the VMAT plan in comparison to the IMRT plan for four out of five patients, with mean reduction of 66%. It was found in this study that for the treatment of sino-nasal cancer, VMAT produced minimal, and statistically insignificant improvement in dose homogeneity within the PTV when compared with IMRT. VMAT plans were delivered using significantly fewer monitor units. We conclude in this study that VMAT does not offer significant improvement of treatment for sino-nasal cancer over the existing IMRT techniques, but the findings may change with a larger sample of patients in this rare condition.

A Monte Carlo study of organ and effective doses of cone beam computed tomography (CBCT) scans in radiotherapy.

Cone-beam CT (CBCT) scans utilised for image guided radiation therapy (IGRT) procedures have become an essential part of radiotherapy. The aim of this study was to assess organ and effective doses resulting from new CBCT scan protocols (head, thorax, and pelvis) released with a software upgrade of the kV on-board-imager (OBI) system. Organ and effective doses for protocols of the new software (V2.5) and a previous version (V1.6) were assessed using Monte Carlo (MC) simulations for the International Commission on Radiological Protection (ICRP) adult male and female reference computational phantoms. The number of projections and the mAs values were increased and the size of the scan field was extended in the new protocols. Influence of these changes on organ and effective doses of the scans was investigated. The OBI system was modelled in EGSnrc/BEAMnrc, and organ doses were estimated using EGSnrc/DOSXYZnrc. The MC model was benchmarked against experimental measurements. Organ doses resulting from the V2.5 protocols were higher than those of V1.6 for organs that were partially or fully inside the scans fields, and increased by (3-13)%, (10-77)%, and (13-21)% for the head, thorax, and pelvis protocols for both phantoms, respectively. As a result, effective doses rose by 14%, 17%, and 16% for the male phantom, and 13%, 18%, and 17% for the female phantom for the three scan protocols, respectively. The scan field extension for the V2.5 protocols contributed significantly in the dose increases, especially for organs that were partially irradiated such as the thyroid in head and thorax scans and colon in the pelvic scan. The contribution of the mAs values and projection numbers was minimal in the dose increases, up to 2.5%. The field size extension plays a major role in improving the treatment output by including more markers in the field of view to match between CBCT and CT images and hence setting up the patient precisely. Therefore, a trade-off between the risk and benefits of CBCT scans should be considered, and the dose increases should be monitored. Several recommendations have been made for optimisation of the patient dose involved for IGRT procedures.

Investigation of practical approaches to evaluating cumulative dose for cone beam computed tomography (CBCT) from standard CT dosimetry measurements: a Monte Carlo study

A function called Gx(L) was introduced by the International Commission on Radiation Units and Measurements (ICRU) Report-87 to facilitate measurement of cumulative dose for CT scans within long phantoms as recommended by the American Association of Physicists in Medicine (AAPM) TG-111. The Gx(L) function is equal to the ratio of the cumulative dose at the middle of a CT scan to the volume weighted CTDI (CTDIvol), and was investigated for conventional multi-slice CT scanners operating with a moving table. As the stationary table mode, which is the basis for cone beam CT (CBCT) scans, differs from that used for conventional CT scans, the aim of this study was to investigate the extension of the Gx(L) function to CBCT scans. An On-Board Imager (OBI) system integrated with a TrueBeam linac was simulated with Monte Carlo EGSnrc/BEAMnrc, and the absorbed dose was calculated within PMMA, polyethylene (PE), and water head and body phantoms using EGSnrc/DOSXYZnrc, where the body PE body phantom emulated the ICRU/AAPM phantom. Beams of width 40-500 mm and beam qualities at tube potentials of 80-140 kV were studied. Application of a modified function of beam width (W) termed Gx(W), for which the cumulative dose for CBCT scans f (0) is normalized to the weighted CTDI (CTDIw) for a reference beam of width 40 mm, was investigated as a possible option. However, differences were found in Gx(W) with tube potential, especially for body phantoms, and these were considered to be due to differences in geometry between wide beams used for CBCT scans and those for conventional CT. Therefore, a modified function Gx(W)100 has been proposed, taking the form of values of f (0) at each position in a long phantom, normalized with respect to dose indices f 100(150)x measured with a 100 mm pencil ionization chamber within standard 150 mm PMMA phantoms, using the same scanning parameters, beam widths and positions within the phantom. f 100(150)x averages the dose resulting from a CBCT scan over the 100 mm length. Like the Gx(L) function, the Gx(W)100 function showed only a weak dependency on tube potential at most positions for the phantoms studied. The results were fitted to polynomial equations from which f (0) within the longer PMMA, PE, or water phantoms can be evaluated from measurements of f 100(150)x. Comparisons with other studies, suggest that these functions may be suitable for application to any CT or CBCT scan acquired with stationary table mode.

Study of diffusion weighted MRI as a predictive biomarker of response during radiotherapy for high and intermediate risk squamous cell cancer of the oropharynx: The MeRInO study

Introduction and background A significant proportion of patients with intermediate and high risk squamous cell cancer of the oropharynx (OPSCC) continue to relapse locally despite radical chemoradiotherapy (CRT). The toxicity of the current combination of intensified dose per fraction radiotherapy and platinum based chemotherapy limits further uniform intensification. If a predictive biomarker for outcomes from CRT can be identified during treatment then individualised and adaptive treatment strategies may be employed. Methods/design The MeRInO study is a prospective observational imaging study of patients with intermediate and high risk, locally advanced OPSCC receiving radical RT or concurrent CRT Patients undergo diffusion weighted MRI prior to treatment (MRI_1) and during the third week of RT (MRI_2). Apparent diffusion coefficient (ADC) measurements will be made on each scan for previously specified target lesions (primary and lymph nodes) and change in ADC calculated. Patients will be followed up and disease status for each target lesion noted. The primary aim of the MeRInO study is to determine the threshold change in ADC from baseline to week 3 of RT that may identify the sub-group of non-responders during treatment. Discussion The use of DW-MRI as a predictive biomarker during RT for SCC H&N is in its infancy but studies to date have found that response to treatment may indeed be predicted by comparison of DW-MRI carried out before and during treatment. However, previous studies have included all sub-sites and biological sub-types. Establishing ADC thresholds that predict for local failure is an essential step towards using DW-MRI to improve the therapeutic ratio in treating SCC H&N. This would be done most robustly in a specific H&N sub-site and in sub-types with similar biological behaviour. The MeRInO study will help establish these thresholds in OPSCC.

Evaluation of cumulative dose for cone‐beam computed tomography (CBCT) scans within phantoms made from different compositions using Monte Carlo simulations

Measurement of cumulative dose f(0,150) with a small ionization chamber within standard polymethyl methacrylate (PMMA) CT head and body phantoms, 150 mm in length, is a possible practical method for cone‐beam computed tomography (CBCT) dosimetry. This differs from evaluating cumulative dose under scatter equilibrium conditions within an infinitely long phantom f(0,∞), which is proposed by AAPM TG‐111 for CBCT dosimetry. The aim of this study was to investigate the feasibility of using f(0,150) to estimate values for f(0,∞) in long head and body phantoms made of PMMA, polyethylene (PE), and water, using beam qualities for tube potentials of 80−140 kV. The study also investigated the possibility of using 150 mm PE phantoms for assessment of f(0,∞) within long PE phantoms, the ICRU/AAPM phantom. The influence of scan parameters, composition, and length of the phantoms was investigated. The capability of f(0,150) to assess f(0,∞) has been defined as the efficiency and assessed in terms of the ratios ϵ(f(0,150)/f(0,∞)). The efficiencies were calculated using Monte Carlo simulations for an On‐Board Imager (OBI) system mounted on a TrueBeam linear accelerator. Head and body scanning protocols with beams of width 40−500 mm were used. Efficiencies ϵ(PMMA/PMMA) and ϵ(PE/PE) as a function of beam width exhibited three separate regions. For beam widths <150 mm, ϵ(PMMA/PMMA) and ϵ(PE/PE) values were greater than 90% for the head and body phantoms. The efficiency values then fell rapidly with increasing beam width before levelling off at 74% for ϵ(PMMA/PMMA) and 69% for ϵ(PE/PE) for a 500 mm beam width. The quantities ϵ(PMMA/PE) and ϵ(PMMA/Water) varied with beam width in a different manner. Values at the centers of the phantoms for narrow beams were lower and increased to a steady state for ∼100−150 mm wide beams, before declining with increasing the beam width, whereas values at the peripheries decreased steadily with beam width. Results for ϵ(PMMA/PMMA) were virtually independent of tube potential, but there was more variation for ϵ(PMMA/PE) and ϵ(PMMA/Water). f(0,150) underestimated f(0,∞) for beam widths used for CBCT scans, thus it is necessary to use long phantoms, or apply conversion factors (Cfs) to measurements with standard PMMA CT phantoms. The efficiency values have been used to derive (Cfs) to allow evaluation of f(0,∞) from measurements of f(0,150). The (Cfs) only showed a weak dependence on scan parameters and scanner type, and so may be suitable for general application. PACS number: 87.55.K‐, 87.57.Q‐, 87.57.uq.Measurement of cumulative dose f(0,150) with a small ionization chamber within standard polymethyl methacrylate (PMMA) CT head and body phantoms, 150 mm in length, is a possible practical method for cone-beam computed tomography (CBCT) dosimetry. This differs from evaluating cumulative dose under scatter equilibrium conditions within an infinitely long phantom f(0,∞), which is proposed by AAPM TG-111 for CBCT dosimetry. The aim of this study was to investigate the feasibility of using f(0,150) to estimate values for f(0,∞) in long head and body phantoms made of PMMA, polyethylene (PE), and water, using beam qualities for tube potentials of 80-140 kV. The study also investigated the possibility of using 150 mm PE phantoms for assessment of f(0,∞) within long PE phantoms, the ICRU/AAPM phantom. The influence of scan parameters, composition, and length of the phantoms was investigated. The capability of f(0,150) to assess f(0,∞) has been defined as the efficiency and assessed in terms of the ratios ϵ(f(0,150)/f(0,∞)). The efficiencies were calculated using Monte Carlo simulations for an On-Board Imager (OBI) system mounted on a TrueBeam linear accelerator. Head and body scanning protocols with beams of width 40-500 mm were used. Efficiencies ϵ(PMMA/PMMA) and ϵ(PE/PE) as a function of beam width exhibited three separate regions. For beam widths <150 mm, ϵ(PMMA/PMMA) and ϵ(PE/PE) values were greater than 90% for the head and body phantoms. The efficiency values then fell rapidly with increasing beam width before levelling off at 74% for ϵ(PMMA/PMMA) and 69% for ϵ(PE/PE) for a 500 mm beam width. The quantities ϵ(PMMA/PE) and ϵ(PMMA/Water) varied with beam width in a different manner. Values at the centers of the phantoms for narrow beams were lower and increased to a steady state for ∼100-150 mm wide beams, before declining with increasing the beam width, whereas values at the peripheries decreased steadily with beam width. Results for ϵ(PMMA/PMMA) were virtually independent of tube potential, but there was more variation for ϵ(PMMA/PE) and ϵ(PMMA/Water). f(0,150) underestimated f(0,∞) for beam widths used for CBCT scans, thus it is necessary to use long phantoms, or apply conversion factors (Cfs) to measurements with standard PMMA CT phantoms. The efficiency values have been used to derive (Cfs) to allow evaluation of f(0,∞) from measurements of f(0,150). The (Cfs) only showed a weak dependence on scan parameters and scanner type, and so may be suitable for general application. PACS number: 87.55.K-, 87.57.Q-, 87.57.uq.