Pedro Andreo

On the clinical spatial resolution achievable with protons and heavier charged particle radiotherapy beams.

The sub-millimetre precision often claimed to be achievable in protons and light ion beam therapy is analysed using the Monte Carlo code SHIELD-HIT for a broad range of energies. Based on the range of possible values and uncertainties of the mean excitation energy of water and human tissues, as well as of the composition of organs and tissues, it is concluded that precision statements deserve careful reconsideration for treatment planning purposes. It is found that the range of I-values of water stated in ICRU reports 37, 49 and 73 (1984, 1993 and 2005) for the collision stopping power formulae, namely 67 eV, 75 eV and 80 eV, yields a spread of the depth of the Bragg peak of protons and heavier charged particles (carbon ions) of up to 5 or 6 mm, which is also found to be energy dependent due to other energy loss competing interaction mechanisms. The spread is similar in protons and in carbon ions having analogous practical range. Although accurate depth-dose distribution measurements in water can be used at the time of developing empirical dose calculation models, the energy dependence of the spread causes a substantial constraint. In the case of in vivo human tissues, where distribution measurements are not feasible, the problem poses a major limitation. In addition to the spread due to the currently accepted uncertainties of their I-values, a spread of the depth of the Bragg peak due to the varying compositions of soft tissues is also demonstrated, even for cases which could be considered practically identical in clinical practice. For these, the spreads found were similar to those of water or even larger, providing support to international recommendations advising that body-tissue compositions should not be given the standing of physical constants. The results show that it would be necessary to increase the margins of a clinical target volume, even in the case of a water phantom, due to an intrinsic basic physics uncertainty, adding to those margins usually considered in normal clinical practice due to anatomical or therapeutic strategy reasons. Individualized patient determination of tissue composition along the complete beam path, rather than CT Hounsfield numbers alone, would also probably be required even to reach sub-centimetre precision.

On the Monte Carlo simulation of small-field micro-diamond detectors for megavoltage photon dosimetry

Monte Carlo (MC) calculated detector-specific output correction factors for small photon beam dosimetry are commonly used in clinical practice. The technique, with a geometry description based on manufacturer blueprints, offers certain advantages over experimentally determined values but is not free of weaknesses. Independent MC calculations of output correction factors for a PTW-60019 micro-diamond detector were made using the EGSnrc and PENELOPE systems. Compared with published experimental data the MC results showed substantial disagreement for the smallest field size simulated ([Formula: see text] mm). To explain the difference between the two datasets, a detector was imaged with x rays searching for possible anomalies in the detector construction or details not included in the blueprints. A discrepancy between the dimension stated in the blueprints for the active detector area and that estimated from the electrical contact seen in the x-ray image was observed. Calculations were repeated using the estimate of a smaller volume, leading to results in excellent agreement with the experimental data. MC users should become aware of the potential differences between the design blueprints of a detector and its manufacturer production, as they may differ substantially. The constraint is applicable to the simulation of any detector type. Comparison with experimental data should be used to reveal geometrical inconsistencies and details not included in technical drawings, in addition to the well-known QA procedure of detector x-ray imaging.

Consistency in reference radiotherapy dosimetry: resolution of an apparent conundrum when (60)Co is the reference quality for charged-particle and photon beams.

Substantial changes in ion chamber perturbation correction factors in (60)Co γ-rays, suggested by recent Monte Carlo (MC) calculations, would cause a decrease of about 1.5% in the reference dosimetry of all types of charged particles (electrons, protons and heavier ions) based on calculated kQ values. It has gone largely unnoticed that the ratio of calibration coefficients ND, w, Co60 and NK, air, Co60 yields an experimental value of Fch, Co60 =u2009(sw-airu2009pch)Co60 through ND, air, Co60. Coefficients provided by the IAEA and traceable to the BIPM for 91 NE-2571 chambers result in an average Fch, Co60 which is compared with published (and new) MC simulations and with the value in IAEA TRS-398. It is shown that TRS-398 agrees within 0.12% with the experimental Fch, Co60. The 1.5% difference resulting from MC calculations (1.1% for the new simulations) cannot be justified using current fundamental data and BIPM standards if consistency in the entire dosimetry chain is sought. For photons, MC kQ factors are compared with TRS-398. Using the same uncertainty for Wair, the two sets of data overlap considerably. Experimental kQ values from standards laboratories lie between the two sets of calculated values, showing no preference for one set over the other. Observed chamber-to-chamber differences, that include the effect of waterproof sleeves (also seen for (60)Co), justify the recommendation in TRS-398 for kQ values specifically measured for the user chamber. Current developments on I-values for the stopping powers of water and graphite are presented. A weighted average Iwater = 78 ± 2u2009eV is obtained from published experimental and DRF-based values; this would decrease sw-air for all types of radiotherapy beams between 0.3% and 0.6%, and would consequently decrease the MC derived Fch, Co60. The implications of a recent proposal for Igraphite = 81u2009eV are analysed, resulting in a potential decrease of 0.7% in NK, air, Co60 which would raise the experimental Fch, Co60; this would result in an increase of about 0.8% in the current TRS-398 value when referred to the BIPM standards. MC derived Fch, Co60 using new stopping powers would then agree at a level of 0.1% with the experimental value, confirming the need for consistency in the dosimetry chain data. Should world average standards be used as reference, the figures would become +0.4% for TRS-398 and -0.3% for the MC calculation. Fch, Q calculated for megavoltage photons using new stopping powers would decrease by between 0.2% and 0.5%. When they enter as a ratios in kQ, differences with MC values based on current key data would be within 0.2% but their discrepancy with kQ experimental photon values remains unresolved. For protons the new data would require an increase in Wair, Q of about 0.6%, as this is inferred from a combination of calorimetry and ionometry. This consistent scenario would leave unchanged the current TRS-398 kQ (NE-2571) data for protons, as well as for ions heavier than protons unless new independent Wair, Q values become available. Also in these advanced radiotherapy modalities, the need for maintaining data consistency in an analysis that unavoidably must include the complete dosimetry chain is demonstrated.

Fluence correction factors for graphite calorimetry in a low-energy clinical proton beam: I. Analytical and Monte Carlo simulations

The conversion of absorbed dose-to-graphite in a graphite phantom to absorbed dose-to-water in a water phantom is performed by water to graphite stopping power ratios. If, however, the charged particle fluence is not equal at equivalent depths in graphite and water, a fluence correction factor, kfl, is required as well. This is particularly relevant to the derivation of absorbed dose-to-water, the quantity of interest in radiotherapy, from a measurement of absorbed dose-to-graphite obtained with a graphite calorimeter. In this work, fluence correction factors for the conversion from dose-to-graphite in a graphite phantom to dose-to-water in a water phantom for 60 MeV mono-energetic protons were calculated using an analytical model and five different Monte Carlo codes (Geant4, FLUKA, MCNPX, SHIELD-HIT and McPTRAN.MEDIA). In general the fluence correction factors are found to be close to unity and the analytical and Monte Carlo codes give consistent values when considering the differences in secondary particle transport. When considering only protons the fluence correction factors are unity at the surface and increase with depth by 0.5% to 1.5% depending on the code. When the fluence of all charged particles is considered, the fluence correction factor is about 0.5% lower than unity at shallow depths predominantly due to the contributions from alpha particles and increases to values above unity near the Bragg peak. Fluence correction factors directly derived from the fluence distributions differential in energy at equivalent depths in water and graphite can be described by kfl = 0.9964 + 0.0024·zw-eq with a relative standard uncertainty of 0.2%. Fluence correction factors derived from a ratio of calculated doses at equivalent depths in water and graphite can be described by kfl = 0.9947 + 0.0024·zw-eq with a relative standard uncertainty of 0.3%. These results are of direct relevance to graphite calorimetry in low-energy protons but given that the fluence correction factor is almost solely influenced by non-elastic nuclear interactions the results are also relevant for plastic phantoms that consist of carbon, oxygen and hydrogen atoms as well as for soft tissues.

Monte Carlo calculation of beam quality correction factors in proton beams using detailed simulation of ionization chambers

This work calculates beam quality correction factors (kQ) in monoenergetic proton beams using detailed Monte Carlo simulation of ionization chambers. It uses the Monte Carlo code penh and the electronic stopping powers resulting from the adoption of two different sets of mean excitation energy values for water and graphite: (i) the currently ICRU 37 and ICRU 49 recommended Iw = 75 eV and Ig = 78 eV and (ii) the recently proposed Iw = 78 eV and Ig = 81.1 eV. Twelve different ionization chambers were studied. The k Q factors calculated using the two different sets of I-values were found to agree with each other within 1.6% or better. k Q factors calculated using current ICRU I-values were found to agree within 2.3% or better with the k Q factors tabulated in IAEA TRS-398, and within 1% or better with experimental values published in the literature. k Q factors calculated using the new I-values were also found to agree within 1.1% or better with the experimental values. This work concludes that perturbation correction factors in proton beams--currently assumed to be equal to unity--are in fact significantly different from unity for some of the ionization chambers studied.

The research versus clinical service role of medical physics

Medicalphysicistsworkingin radiotherapydepartments inhos-pitals are often facing a challenge in balancing their time andefforts between clinical demands in routine practice and theirambitions toward research and development of the field. Thisdilemma is certainly not unique to medical physics, but it maybe accentuated in our field because of the contrast between phy-sics as a scientific discipline, and the clinical realities in a hospital.The dilemma reminds one of the classical dilemma in Goethe’sFaust: ‘‘Two souls, alas, are dwelling in my breast’’.One ‘‘soul’’ of the medical physicist is strictly devoted to guar-anteeing the safe and accurate delivery of radiation to patients,including the search for optimal treatment solutions, efficientlysolving the associated technical and clinical problems, and ulti-mately to providing a considerable contribution to the care of can-cer patients in close collaboration with radiation oncologists andother professionals.The research ‘‘soul’’ of medical physicists, on the other hand, isdevoted to explore new methods, tools, and models. These endeav-ors have led to extraordinary innovation and growth, incorporatingthe intrinsic inter-disciplinary and translational vocation of ourdiscipline. The dramatic evolution of radiation oncology in the lastdecades was largely initiated and progressed by medical physics[1]. However, this rapid evolution has changed the role and theperspectives of medical physicists over time, putting more andmore emphasis on the support of the increasingly demanding com-plex technologies [2,3]. Today the two cited ‘‘souls’’ of medicalphysicists appear sometimes competitive and sometimes synergis-tic, but in many cases they are not clearly enough identified andunderstood. This paper is based on a symposium dedicated to thisissue, organized at the annual ESTRO meeting held in Vienna inApril 2014 in collaboration with the American Association of Physi-cists in Medicine (AAPM) and the European Federation of MedicalPhysics (EFOMP). The aim of the paper is to convey and synthesizethe perspectives shared in this session.Harmonization of the medical physics profession within EuropeThe standing of medical physicists both as researchers and asclinical service providers is highly variable across the globe, par-ticularly within Europe. In Europe, EFOMP has worked towardthe harmonization of the medical physics profession,issuing sever-al policy statements, providing recommendations on the roles ofthe medical physicist and promoting it as a Regulated Health CareProfession [4]. Despite pressure from EFOMP and the recent Direc-tives 2005/36/EC and 2013/55/EC related to professional qualifica-tions [5,6], the medical physicist has not yet been included in aformal recognition process in many European countries.The implementation of a robust educational track is an essentialfoundation to the path toward recognition and accreditation ofmedical physicists within Europe: in line with this, EFOMP andESTRO developed a Qualification and Curricular framework basedon the Bologna Process [7]. Despite the existence of this powerfulharmonization tool, a recent survey still revealed a lack of profes-sional recognition within the medical physics community. Thereseems to be a dichotomy between medical physicists as profes-sionals applying science in healthcare ‘‘having a role in researchand development of new methodologies’’ [8] and a widespreadfeeling to be mainly involved in technical support.The changing professional role of medical physics in the USIn the United States, the AmericanBoard of Radiology(ABR) cer-tification requirements for medical physicists have had a profoundimpact toward tightening of both the professional role and theresearch role of medical physicists. Compliance with the ABR cer-tification requirements is overseen by the Commission onAccreditation of Medical Physics Educational Programs (CAMPEP),and now training from a CAMPEP-accredited medical physics pro-gram is compulsory to obtain ABR certification.These requirements have triggered a chain of events, rangingfrom detailed specification of the professional training require-ments, establishment of a number of Doctorate of Medical Physics(DMP) degree programs and creation of new residency training

Spencer–Attix water/medium stopping-power ratios for the dosimetry of proton pencil beams

This paper uses Monte Carlo simulations to calculate the Spencer-Attix water/medium stopping-power ratios (sw, med) for the dosimetry of scanned proton pencil beams. It includes proton energies from 30 to 350 MeV and typical detection materials such as air (ionization chambers), radiochromic film, gadolinium oxysulfide (scintillating screens), silicon and lithium fluoride. Track-ends and particles heavier than protons were found to have a negligible effect on the water/air stopping-power ratios (sw, air), whereas the mean excitation energy values were found to carry the largest source of uncertainty. The initial energy spread of the beam was found to have a minor influence on the sw, air values in depth. The water/medium stopping-power ratios as a function of depth in water were found to be quite constant for air and radiochromic film-within 2.5%. Also, the sw, med values were found to have no clinically relevant dependence on the radial distance-except for the case of gadolinium oxysulfide and proton radiography beams. In conclusion, the most suitable detection materials for depth-dose measurements in water were found to be air and radiochromic film active layer, although a small correction is still needed to compensate for the different sw, med values between the plateau and the Bragg peak region. Also, all the detection materials studied in this work-except for gadolinium oxysulfide-were found to be suitable for lateral dose profiles and field-specific dose distribution measurements in water.

Spectral distribution of particle fluence in small field detectors and its implication on small field dosimetry

Purpose: Correction factors for the relative dosimetry of narrow megavoltage photon beams have recently been determined in several publications. These corrections are required because of the several small‐field effects generally thought to be caused by the lack of lateral charged particle equilibrium (LCPE) in narrow beams. Correction factors for relative dosimetry are ultimately necessary to account for the fluence perturbation caused by the detector. For most small field detectors the perturbation depends on field size, resulting in large correction factors when the field size is decreased. In this work, electron and photon fluence differential in energy will be calculated within the radiation sensitive volume of a number of small field detectors for 6 MV linear accelerator beams. The calculated electron spectra will be used to determine electron fluence perturbation as a function of field size and its implication on small field dosimetry analyzed. Methods: Fluence spectra were calculated with the user code PenEasy, based on the PENELOPE Monte Carlo system. The detectors simulated were one liquid ionization chamber, two air ionization chambers, one diamond detector, and six silicon diodes, all manufactured either by PTW or IBA. The spectra were calculated for broad (10 cm × 10 cm) and narrow (0.5 cm × 0.5 cm) photon beams in order to investigate the field size influence on the fluence spectra and its resulting perturbation. The photon fluence spectra were used to analyze the impact of absorption and generation of photons. These will have a direct influence on the electrons generated in the detector radiation sensitive volume. The electron fluence spectra were used to quantify the perturbation effects and their relation to output correction factors. Results: The photon fluence spectra obtained for all detectors were similar to the spectrum in water except for the shielded silicon diodes. The photon fluence in the latter group was strongly influenced, mostly in the low‐energy region, by photoabsorption in the high‐Z shielding material. For the ionization chambers and the diamond detector, the electron fluence spectra were found to be similar to that in water, for both field sizes. In contrast, electron spectra in the silicon diodes were much higher than that in water for both field sizes. The estimated perturbations of the fluence spectra for the silicon diodes were 11–21% for the large fields and 14–27% for the small fields. These perturbations are related to the atomic number, density and mean excitation energy (I‐value) of silicon, as well as to the influence of the “extracameral”‘ components surrounding the detector sensitive volume. For most detectors the fluence perturbation was also found to increase when the field size was decreased, in consistency with the increased small‐field effects observed for the smallest field sizes. Conclusions: The present work improves the understanding of small‐field effects by relating output correction factors to spectral fluence perturbations in small field detectors. It is shown that the main reasons for the well‐known small‐field effects in silicon diodes are the high‐Z and density of the “extracameral” detector components and the high I‐value of silicon relative to that of water and diamond. Compared to these parameters, the density and atomic number of the radiation sensitive volume material play a less significant role.

Monte Carlo simulations in radiotherapy dosimetry

BackgroundThe use of the Monte Carlo (MC) method in radiotherapy dosimetry has increased almost exponentially in the last decades. Its widespread use in the field has converted this computer simulation technique in a common tool for reference and treatment planning dosimetry calculations.MethodsThis work reviews the different MC calculations made on dosimetric quantities, like stopping-power ratios and perturbation correction factors required for reference ionization chamber dosimetry, as well as the fully realistic MC simulations currently available on clinical accelerators, detectors and patient treatment planning.ConclusionsIssues are raised that include the necessity for consistency in the data throughout the entire dosimetry chain in reference dosimetry, and how Bragg-Gray theory breaks down for small photon fields. Both aspects are less critical for MC treatment planning applications, but there are important constraints like tissue characterization and its patient-to-patient variability, which together with the conversion between dose-to-water and dose-to-tissue, are analysed in detail. Although these constraints are common to all methods and algorithms used in different types of treatment planning systems, they make uncertainties involved in MC treatment planning to still remain “uncertain”.

Correction factors for ionization chamber measurements with the ‘Valencia’ and ‘large field Valencia’ brachytherapy applicators

Treatment of small skin lesions using HDR brachytherapy applicators is a widely used technique. The shielded applicators currently available in clinical practice are based on a tungsten-alloy cup that collimates the source-emitted radiation into a small region, hence protecting nearby tissues. The goal of this manuscript is to evaluate the correction factors required for dose measurements with a plane-parallel ionization chamber typically used in clinical brachytherapy for the Valencia and large field Valencia shielded applicators. Monte Carlo simulations have been performed using the PENELOPE-2014 system to determine the absorbed dose deposited in a water phantom and in the chamber active volume with a Type A uncertainty of the order of 0.1%. The average energies of the photon spectra arriving at the surface of the water phantom differ by approximately 10%, being 384 keV for the Valencia and 343 keV for the large field Valencia. The ionization chamber correction factors have been obtained for both applicators using three methods, their values depending on the applicator being considered. Using a depth-independent global chamber perturbation correction factor and no shift of the effective point of measurement yields depth-dose differences of up to 1% for the Valencia applicator. Calculations using a depth-dependent global perturbation factor, or a shift of the effective point of measurement combined with a constant partial perturbation factor, result in differences of about 0.1% for both applicators. The results emphasize the relevance of carrying out detailed Monte Carlo studies for each shielded brachytherapy applicator and ionization chamber.