Assessment of HDR brachytherapy-replicating prostate radiotherapy planning for tomotherapy, cyberknife and VMAT.

A dosimetric study was undertaken to assess the ability of Cyberknife (CK), Volumetric Modulated Arc Therapy (VMAT), and TomoTherapy (Tomo) to generate treatment plans that mimic the dosimetry of high dose-rate brachytherapy (HDR BT) for prostate cancer. The project aimed to assess the potential of using stereotactic body radiotherapy (SBRT) for boost treatment of high-risk prostate cancer patients where HDR BT in combination with conformal external beam radiotherapy (EBRT) is the standard of care. The datasets of 6 prostate patients previously treated with HDR BT were collated. VMAT, CK, and TomoTherapy treatment plans were generated for each dataset using the target and organ-at-risk structures as defined by the Radiation Oncologist during the HDR BT treatment process. The HDR BT plan isodoses were also converted into planning structures to assist the other modalities to achieve a HDR BT-like dose distribution. CK plans were created using both the iris collimator (IC) and a multileaf collimator (MLC). Comparison of the techniques was made based on dose-volume indices. Each plan was created at centres experienced using the respective treatment planning systems (TPS). Planning target volume (PTV V100%), i.e., the volume of the planning target volume (PTV) receiving 100% of the relative dose, in VMAT and TomoTherapy SBRT plans was higher than HDR BT plans. PTV V150% and V200%, i.e., volume of the PTV receiving 150% and 200% of the relative dose, were approached on all the CK MLC and TomoTherapy SBRT plans. However, it is not presently achievable for "virtual brachytherapy" SBRT to replicate the same high intraprostatic doses as HDR BT while meeting the constraints on the organs-at-risk (OARs). Half of the CK IC plans achieved PTV V150% but this was at the expense of high rectal dose. TomoTherapy and CK MLC plans achieved PTV V150% and V200% but the bladder dose was higher compared to CK IC plans. VMAT exhibited excellent PTV coverage based on V100 and OAR sparing, but without any ability to achieve the high intra-prostatic doses of HDR (V150% and V200%). SBRT techniques can be used to deliver hypofractionated radiotherapy to the PTV V100%. Based on the comparison of "physical" dose distributions, SBRT cannot presently achieve the same high intraprostatic doses as HDR BT while respecting the OAR constraints. SBRT still remains an attractive treatment option for delivering hypofractionated treatments for prostate cancer compared to HDR BT, in particular as it is less invasive and less resource intensive. Long-term outcomes of clinical trials comparing HDR BT and SBRT "prostate boosts" may show whether the high intraprostatic doses are clinically significant and correlate with outcomes.

Technical Note: Small field dose correction factors for radiochromic film in lung phantoms.

PURPOSE: Radiochromic film has been established as a detector that can be used without the need for perturbation correction factors for small field dosimetry in water. However, perturbation factors in low density media such as lung have yet to be published. This study calculated the factors required to account for the perturbation of radiochromic film when used for small field dosimetry in lung equivalent material. METHOD: Monte Carlo simulations were used to calculate dose to Gafchromic EBT3 film when placed inside a lung phantom. The beam simulated had a nominal energy of 6 MV and the field sizes simulated ranged from 10 × 10 mm2 to 30 × 30 mm2 . The lung density simulated was varied between 0.2 and 0.3 g/cm3 . Each simulation was repeated with the film replaced by lung material (the same as the surrounding medium), and the required correction factors for film dosimetry in lung ( D M e d , Q D D e t , Q ) were calculated by dividing the dose in lung by the dose in film. RESULTS: For field sizes 30 × 30 mm2 and larger, no correction factors were required. At a 20 × 20 mm2 field size, small corrections were required, but were within the approximate accuracy of film dosimetry (~2%). For a 10 × 10 mm2 field size, significant correction factors need to be applied (0.935 for lung density of 0.20 g/cm3 to 0.963 for lung density of 0.30 g/cm3 ). The values lower than one mean that the film is over-responding. At the "upstream" lung-water interface the correction factors were close to unity; while at the downstream interface the corrections required were marginally smaller to those at the center of lung. One centimeter or more away from the interfaces, the correction factor did not vary as a function distance from the interface (in the beam direction). Away from the central axis (perpendicular to the beam direction), the correction factors increased slightly (away from unity) as a function of off-axis distance, before abruptly changing direction at the penumbra, with the film actually under-responding by ~10% outside the field edges. CONCLUSION: Accurate dosimetry of very small fields (15 × 15 mm2 or smaller) using radiochromic film requires correction factors for the perturbation of the film on the surrounding lung material. This correction factor was as high as 6.5% for a 10 × 10 mm2 field size and a density of 0.2 g/cm3 . This will increase if either the density or the field size decrease further. This correction factor does not vary as a function of depth in lung once charged particle equilibrium is established.

Recommendations for simulating and measuring with biofabricated lung equivalent materials based on atomic composition analysis.

Monte Carlo simulations of lung equivalent materials often involve the density being artificially lowered rather than a true lung tissue (or equivalent plastic) and air composition being simulated. This study used atomic composition analysis to test the suitability of this method. Atomic composition analysis was also used to test the suitability of 3D printing PLA or ABS with air to simulate lung tissue. It was found that there was minimal atomic composition difference when using an artificially lowered density, with a 0.8 % difference in Nitrogen the largest observed. Therefore, excluding infill pattern effects, lowering the density of the lung tissue (or plastic) in simulations should be sufficiently accurate to simulate an inhaled lung, without the need to explicitly include the air component. The average electron density of 3D printed PLA and air, and ABS and air were just 0.3 % and 1.3 % different to inhaled lung, confirming their adequacy for MV photon dosimetry. However large average atomic number differences (5.6 % and 20.4 % respectively) mean that they are unlikely to be suitable for kV photon dosimetry.

Predicting the required thickness of custom shielding materials in kilovoltage radiotherapy beams.

The planning and delivery of kilovoltage (kV) radiotherapy treatments involves the use of custom shielding designed and fabricated for each patient. This study investigated methods by which the required thickness of custom shielding could be predicted for non-standard shielding materials fabricated using 3D printing techniques. Seven kV radiation beams from a WOmed T-300 X-ray therapy unit were modelled using SpekPy software, and AAPM TG-61 data were used to account for backscatter and spectral effects, for incrementally increasing thicknesses of Pb, W-PLA composite and Cu-PLA composite materials. The same beams were used to perform physical transmission measurements, and the thickness of each material required to achieve 5% beam transmission was determined. While the measured transmission factors for Pb, W-PLA and Cu-PLA shielding generally exceeded the calculated transmission factors, these differences had minimal effect on the derived thicknesses of shielding required to achieve 5% transmission, where calculations agreed with measurements within 0.5 mm for Pb at all available energies (70-300 kVp), within 1.4 mm for W-PLA at all available energies, and within 2.1 mm for Cu-PLA at superficial treatment energies (70-100 kVp). The incremental transmission factor calculation method described and validated in this study could be used, in combination with the conservative addition of 1-2 mm of additional material, to estimate shielding requirements for novel materials in therapeutic kilovoltage beams. However, if calculated shielding thicknesses equate to 10 mm or more, then additional verification measurements should be performed and the clinical suitability of the novel shielding material should be re-evaluated.

A comparative study of three small-field detectors for patient specific stereotactic arc dosimetry.

This paper examines the difference in patient specific dosimetry using three different detectors of varying active volume, density and composition, for quality assurance of stereotactic treatments. A PTW 60017 unshielded electron diode, an Exradin W1 scintillator, and a PTW 31014 PinPoint small volume ionisation chamber were setup in a Lucy 3D QA phantom, and were positioned at the isocentre of an Elekta Axesse, with beam modulator collimator, using Exactrac and a HexaPODTM couch. Dose measurements were acquired for 43 stereotactic arcs, and compared to BrainLAB iPlan version 3.0.0 treatment planning system (TPS) calculations using a pencil beam algorithm. It was found that for arcs with field sizes [Formula: see text] mm, the properties of a detector have minimal impact on the measured doses, with all three detectors agreeing with the TPS (to within 5%). However, for field sizes [Formula: see text] mm, only the scintillator was found to yield results to within 5% of the TPS. The dose discrepancies were found to increase with decreasing field size. It is recommended that for field sizes [Formula: see text] mm, a water equivalent dosimeter like the Exradin W1 scintillator be used in order to minimise detector composition perturbations in the measured doses.

Use of a megavoltage electronic portal imaging device to identify prosthetic materials.

To achieve accurate dose calculations in radiation therapy the electron density of patient tissues must be known. This information is ordinarily gained from a computed tomography (CT) image that has been calibrated to allow relative electron density (RED) to be determined from CT number. When high density objects such as metallic prostheses are involved, direct use of the CT data can become problematic due to the artefacts introduced by high attenuation of the beam. This requires manual correction of the density values, however the properties of the implanted prosthetic are not always known. A method is introduced where the RED of such an object can be determined using the treatment beam of a linear accelerator with an electronic portal imaging device. The technique was tested using a metallic hip replacement that was placed within a container of water. Compared to the theoretical RED of 6.8 for cobalt-chromium alloy, these measurements calculated a value of 6.4 ± 0.7. This would allow the distinction of an implant as Co-Cr or steel, which have similar RED, or titanium, which is much less dense with an RED of 3.7.

The dependence of computed tomography number to relative electron density conversion on phantom geometry and its impact on planned dose.

A computed tomography number to relative electron density (CT-RED) calibration is performed when commissioning a radiotherapy CT scanner by imaging a calibration phantom with inserts of specified RED and recording the CT number displayed. In this work, CT-RED calibrations were generated using several commercially available phantoms to observe the effect of phantom geometry on conversion to electron density and, ultimately, the dose calculation in a treatment planning system. Using an anthropomorphic phantom as a gold standard, the CT number of a material was found to depend strongly on the amount and type of scattering material surrounding the volume of interest, with the largest variation observed for the highest density material tested, cortical bone. Cortical bone gave a maximum CT number difference of 1,110 when a cylindrical insert of diameter 28 mm scanned free in air was compared to that in the form of a 30 × 30 cm(2) slab. The effect of using each CT-RED calibration on planned dose to a patient was quantified using a commercially available treatment planning system. When all calibrations were compared to the anthropomorphic calibration, the largest percentage dose difference was 4.2 % which occurred when the CT-RED calibration curve was acquired with heterogeneity inserts removed from the phantom and scanned free in air. The maximum dose difference observed between two dedicated CT-RED phantoms was ±2.1 %. A phantom that is to be used for CT-RED calibrations must have sufficient water equivalent scattering material surrounding the heterogeneous objects that are to be used for calibration.

A methodological approach to reporting corrected small field relative outputs.

PURPOSE: The goal of this work was to set out a methodology for measuring and reporting small field relative output and to assess the application of published correction factors across a population of linear accelerators. METHODS AND MATERIALS: Measurements were made at 6 MV on five Varian iX accelerators using two PTW T60017 unshielded diodes. Relative output readings and profile measurements were made for nominal square field sizes of side 0.5 to 1.0 cm. The actual in-plane (A) and cross-plane (B) field widths were taken to be the FWHM at the 50% isodose level. An effective field size, defined as √FS eff=A · B, was calculated and is presented as a field size metric. FSeff was used to linearly interpolate between published Monte Carlo (MC) calculated [Formula in text] values to correct for the diode over-response in small fields. RESULTS: The relative output data reported as a function of the nominal field size were different across the accelerator population by up to nearly 10%. However, using the effective field size for reporting showed that the actual output ratios were consistent across the accelerator population to within the experimental uncertainty of ± 1.0%. Correcting the measured relative output using [Formula in text] at both the nominal and effective field sizes produce output factors that were not identical but differ by much less than the reported experimental and/or MC statistical uncertainties. CONCLUSIONS: In general, the proposed methodology removes much of the ambiguity in reporting and interpreting small field dosimetric quantities and facilitates a clear dosimetric comparison across a population of linacs.

Determination of RW3-to-water mass-energy absorption coefficient ratio for absolute dosimetry.

The measurement of absorbed dose to water in a solid-phantom may require a conversion factor because it may not be radiologically equivalent to water. One phantom developed for the use of dosimetry is a solid water, RW3 white-polystyrene material by IBA. This has a lower mass-energy absorption coefficient than water due to high bremsstrahlung yield, which affects the accuracy of absolute dosimetry measurements. In this paper, we demonstrate the calculation of mass-energy absorption coefficient ratios, relative to water, from measurements in plastic water and RW3 with an Elekta Synergy linear accelerator (6 and 10 MV photon beams) as well as Monte Carlo modeling in BEAMnrc and DOSXYZnrc. From this, the solid-phantom-to-water correction factor was determined for plastic water and RW3.

Measurement of ultrasonic attenuation coefficient in polymer gel dosimeters.

A technique is described for investigation of the ultrasonic attenuation coefficient for evaluation of absorbed dose in polymer gel dosimeters. Using this technique the attenuation coefficient as a function of absorbed dose in PAG and MAGIC polymer gel dosimeters was measured. The ultrasonic attenuation coefficient dose sensitivity for PAG was found to be 2.9 +/- 0.3 dB m(-1) Gy(-1) and for MAGIC gel 4.2 +/- 0.3 dB m(-1) Gy(-1). Unlike previous studies of ultrasonic attenuation in polymer gel dosimeters this technique enables a direct measure of the attenuation coefficient.