A novel phantom and procedure providing submillimeter accuracy in daily QA tests of accelerators used for stereotactic radiosurgery*.

Stereotactic radiosurgery (SRS) places great demands on spatial accuracy. Steel BBs used as markers in quality assurance (QA) phantoms are clearly visible in MV and planar kV images, but artifacts compromise cone-beam CT (CBCT) isocenter localization. The purpose of this work was to develop a QA phantom for measuring with sub-mm accuracy isocenter congruence of planar kV, MV, and CBCT imaging systems and to design a practical QA procedure that includes daily Winston-Lutz (WL) tests and does not require computer aid. The salient feature of the phantom (Universal Alignment Ball (UAB)) is a novel marker for precisely localizing isocenters of CBCT, planar kV, and MV beams. It consists of a 25.4mm diameter sphere of polymethylmetacrylate (PMMA) containing a concentric 6.35mm diameter tungsten carbide ball. The large density difference between PMMA and the polystyrene foam in which the PMMA sphere is embedded yields a sharp image of the sphere for accurate CBCT registration. The tungsten carbide ball serves in finding isocenter in planar kV and MV images and in doing WL tests. With the aid of the UAB, CBCT isocenter was located within 0.10 ± 0.05 mm of its true positon, and MV isocenter was pinpointed in planar images to within 0.06 ± 0.04mm. In clinical morning QA tests extending over an 18 months period the UAB consistently yielded measurements with sub-mm accuracy. The average distance between isocenter defined by orthogonal kV images and CBCT measured 0.16 ± 0.12 mm. In WL tests the central ray of anterior beams defined by a 1.5 × 1.5 cm2 MLC field agreed with CBCT isocenter within 0.03 ± 0.14 mm in the lateral direction and within 0.10 ± 0.19 mm in the longitudinal direction. Lateral MV beams approached CBCT isocenter within 0.00 ± 0.11 mm in the vertical direction and within -0.14 ± 0.15 mm longitudinally. It took therapists about 10 min to do the tests. The novel QA phantom allows pinpointing CBCT and MV isocenter positions to better than 0.2 mm, using visual image registration. Under CBCT guidance, MLC-defined beams are deliverable with sub-mm spatial accuracy. The QA procedure is practical for daily tests by therapists.

End-to-end test of spatial accuracy in Gamma Knife treatments for trigeminal neuralgia.

PURPOSE: Spatial accuracy is most crucial when small targets like the trigeminal nerve are treated. Although current quality assurance procedures typically verify that individual apparatus, like the MRI scanner, CT scanner, Gamma Knife, etc., are meeting specifications, the cumulative error of all equipment and procedures combined may exceed safe margins. This study uses an end-to-end approach to assess the overall targeting errors that may have occurred in individual patients previously treated for trigeminal neuralgia. METHODS: The trigeminal nerve is simulated by a 3 mm long, 3.175 mm (1/8 in.) diameter MRI-contrast filled cavity embedded within a PMMA plastic capsule. The capsule is positioned within the head frame such that the location of the cavity matches the Gamma Knife coordinates of an arbitrarily chosen, previously treated patient. Gafchromic EBT2 film is placed at the center of the cavity in coronal and sagittal orientations. The films are marked with a pinprick to identify the cavity center. Treatments are planned for radiation delivery with 4 mm collimators according to MRI and CT scans using the clinical localizer boxes and acquisition protocols. Shots are planned so that the 50% isodose surface encompasses the cavity. Following irradiation, the films are scanned and analyzed. Targeting errors are defined as the distance between the pinprick, which represents the intended target, and the centroid of the 50% isodose line, which is the center of the radiation field that was actually delivered. RESULTS: Averaged over ten patient simulations, targeting errors along the x, y, and z coordinates (patient's left-to-right, posterior-to-anterior, and head-to-foot) were, respectively, -0.060 ± 0.363, -0.350 ± 0.253, and 0.348 ± 0.204 mm when MRI was used for treatment planning. Planning according to CT exhibited generally smaller errors, namely, 0.109 ± 0.167, -0.191 ± 0.144, and 0.211 ± 0.094 mm. The largest errors along individual axes in MRI- and CT-planned treatments were, respectively, -0.761 mm in the y-direction and 0.428 mm in the x-direction, well within safe limits. CONCLUSIONS: The highly accurate dose delivery was possible because the Gamma Knife, MRI scanner, and other equipment performed within tight limits and scans were acquired using the thinnest slices and smallest pixel sizes available. Had the individual devices performed only near the limits of their specifications, the cumulative error could have left parts of the trigeminal nerve undertreated. The presented end-to-end test gives assurance that patients had received the expected high quality treatment. End-to-end tests should become part of clinical practice.

Study of a spherical phantom for Gamma knife dosimetry.

Four 16 cm diameter spherical phantoms were modeled in this study: a homogenous water phantom, and three water phantoms with 1 cm thick shell each made of different materials (PMMA, Plastic WaterTM and polystyrene). The PENELOPE Monte Carlo code was utilized to simulate photon beams from the Leksell Gamma Knife (LGK) unit and to determine absorbed dose to water (Dw) from a single 18 mm beam delivered to each phantom. A score spherical volume of 0.007 cm3 was used to simulate the dimensions of the sensitive volume of the Exradin A-16 ionization chamber, in the center of the phantom. In conclusion, the PMMA shell filled with water required a small correction for the determination of the absorbed dose, while remaining within the statistical uncertainty of the calculations (+/- 0.71). Plastic WaterTM and polystyrene shells can be used without correction. There is a potential advantage to measuring the 4 mm helmet output using these spherical water phantoms.

Radioprotective effect of American ginseng on human lymphocytes at 90 minutes postirradiation: a study of 40 cases.

BACKGROUND: Ionizing radiation (IR) initiates intracellular oxidative stress through enhanced formation of reactive oxygen species (ROS) that attack DNA leading to cell death. Because of the diversity of IR applied in medicine, agriculture, industry, and the growing threats of global terrorism, the acquisition of radioprotectors is an urgent need for the nation. However, the applicability of radioprotectors currently under investigation is limited due to their inherent toxicity. OBJECTIVE: This study investigated the effect of a standardized North American ginseng extract (NAGE, total ginsenoside content: 11.7%) on DNA damage in human lymphocytes at 90 minutes postirradiation. DESIGN: With the application of NAGE (250-1000 microg mL(-1)) at 90 minutes postirradiation (1 and 2 Gy), DNA damage in lymphocytes obtained from 40 healthy individuals was evaluated by cytokinesis-block micronucleus assay. Similar experiments were also performed in lymphocytes treated with WR-1065 (1 mmol/L or 3 mmol/L). In addition, before and after irradiation, lymphocytes obtained from 10 individuals were measured for their total antioxidant capacity (TAC) and the reactive oxygen species (ROS). RESULTS: The significant effect of NAGE against (137)Cs-induced micronuclei (MN) in lymphocytes is concentration dependent. NAGE (750 microg mL(-1)) reduced MN yield by 50.7% after 1 Gy and 35.9% after 2 Gy exposures, respectively; these results were comparable to that of WR-1065. Furthermore, we also found that NAGE reduces MN yield and ROS but increases TAC in lymphocytes. CONCLUSIONS: Our results suggest that NAGE is a relatively nontoxic natural compound that holds radioprotective potential in human lymphocytes even when applied at 90 minutes postirradiation. One of the radioprotective mechanisms may be mediated through the scavenging of free radicals and enhancement of the intracellular TAC.