A study of polarity effect for various ionization chambers in kilovoltage x-ray beams.

BACKGROUND: Ionization chambers play an essential role in dosimetry measurements for kilovoltage (kV) x-ray beams. Despite their widespread use, there is limited data on the absolute values for the polarity correction factors across a range of commonly employed ionization chambers. PURPOSE: This study aimed to investigate the polarity effects for five different ionization chambers in kV x-ray beams. METHODS: Two plane-parallel chambers being the Advanced Markus and Roos and three cylindrical chambers; 3D PinPoint, Semiflex and Farmer chamber (PTW, Freiburg, Germany), were employed to measure the polarity correction factors. The kV x-ray beams were produced from an Xstrahl 300 unit (Xstrahl Ltd., UK). All measurements were acquired at 2 cm depth in a PTW-MP1 water tank for beams between 60 kVp (HVL 1.29 mm Al) and 300 kVp (HVL 3.08 mm Cu), and field sizes of 2-10 cm diameter for 30 cm focus-source distance (FSD) and 4 × 4 cm2 - 20 × 20 cm2 for 50 cm FSD. The ionization chambers were connected to a PTW-UNIDOS electrometer, and the polarity effect was determined using the AAPM TG-61 code of practice methodology. RESULTS: The study revealed significant polarity effects in ionization chambers, especially in those with smaller volumes. For the plane-parallel chambers, the Advanced Markus chamber exhibited a maximum polarity effect of 2.5%, whereas the Roos chamber showed 0.3% at 150 KVp with the 10 cm circular diameter open-ended applicator. Among the cylindrical chambers at the same beam energy and applicator, the Pinpoint chamber exhibited a 3% polarity effect, followed by Semiflex with 1.7%, and Farmer with 0.4%. However, as the beam energy increased to 300 kVp, the polarity effect significantly increased reaching 8.5% for the Advanced Markus chamber and 13.5% for the PinPoint chamber at a 20 × 20 cm2 field size. Notably, the magnitude of the polarity effect increased with both the field size and beam energy, and was significantly influenced by the size of the chamber's sensitive volume. CONCLUSIONS: The findings demonstrate that ionization chambers can exhibit substantial polarity effects in kV x-ray beams, particularly for those chambers with smaller volumes. Therefore, it is important to account for polarity corrections when conducting relative dose measurements in kV x-ray beams to enhance the dosimetry accuracy and improve patient dose calculations.

A multi-detector comparison to determine convergence of measured relative output factors for small field dosimetry.

The TRS-483 Code of Practice (CoP) provides generic relative output correction factors, [Formula: see text], for a range of detectors and beam energies as used in small field dosimetry. In this work, the convergence of the relative output factors (ROFs) for 6 MV X-ray beams with and without flattening filters was investigated under different combinations of beam collimation and published detector correction factors. The SFD, PFD and CC04 (IBA) were used to measure ROFs of a TrueBeam STx linear accelerator with small fields collimated by the high-definition MLC, which has 2.5 and 5.0 mm projected leaves. Two configurations were used for the collimators: (1) fixed jaws at 10 × 10 cm2 and (2) with a 2 mm offset from the MLC edge, in line with the recommended geometry from IROC-H as part of their auditing program and published dataset. The [Formula: see text] factors for the three detectors were taken from the TRS483 CoP and other published works. The average differences of ROFs measured by detectors under MLC fields with fixed jaws and with 2 mm jaws offset for the 6 MV-WFF beam are 1.4% and 1.9%, respectively. Similarly, they are 2.3% and 2.4% for the 6MV-FFF beam. The relative differences between the detector-average ROFs and the corresponding IROC-H dataset are 2.0% and 3.1% for the 6 MV-WFF beam, while they are 2.4% and 3.2% for the 6MV-FFF beam at the smallest available field size of 2 × 2 cm2. For smaller field sizes, the average ROFs of the three detectors and corresponding results from Akino and Dufreneix showed the largest difference to be 6.6% and 6.2% under the 6 MV-WFF beam, while they are 3.4% and 3.6% under the 6 MV-WFF beam at the smallest field size of 0.5 × 0.5 cm2. Some well-published specific output correction factors for different small field detector types give better convergence in the calculation of the relative output factor in comparison with the generic data provided by the TRS-483 CoP. Relative output factor measurements should be performed as close as possible to the clinical settings including a combination of collimation systems, beam types and using at least three different types of small field detector for more accurate computation of the treatment planning system. The IROC-H dataset is not available for field size smaller than 2 × 2 cm2 for double checks and so that user should carefully check with other publications with the same setting.

Evaluation of 3D-printed bolus for radiotherapy using megavoltage X-ray beams.

A radiotherapy bolus is a tissue-equivalent material placed on the skin to adjust the surface dose of megavoltage X-ray beams used for treatment. In this study, the dosimetric properties of two 3D-printed filament materials, polylactic acid (PLA) and thermoplastic polyether urethane (TPU), used as radiotherapy boluses, were investigated. The dosimetric properties of PLA and TPU were compared with those of several conventional bolus materials and RMI457 Solid Water. Percentage depth-dose (PDD) measurements in the build-up region were performed for all materials using 6 and 10 MV photon treatment beams on Varian linear accelerators. The results showed that the differences in the PDDs of the 3D-printed materials from the RMI457 Solid Water were within 3%, whereas those of the dental wax and SuperFlab gel materials were within 5%. This indicates that PLA and TPU 3D-printed materials are suitable radiotherapy bolus materials.

Impact of Palliative Care Clinical Pharmacists in an Inpatient Care Setting on Total Health Care Expenditures.

Background: Inpatient palliative care clinical pharmacy specialists (IPCPS) on multidisciplinary palliative care (PC) teams have expanding roles in the treatment of pain, nausea, and other symptoms for patients with serious illnesses. Objectives: The aim of this study was to assess the clinical and financial outcomes associated with an IPCPS on an inpatient PC team. Setting and Design: This was a retrospective cohort study conducted in Colorado. Adult patients with an inpatient stay and a PC consult between October 1, 2016 and February 28, 2019 were included. Patients were assigned to the observation group if they received PC from a clinical pharmacist and control group if they received usual PC. The primary outcome was the 180-day change in daily total cost-of-care expenditures. Secondary outcomes included length of index hospitalization and 180-day change in daily morphine milligram equivalents (MME), health care utilization, and opioid adverse effects (AE). Results: A total of 1543 patients were included with 228 and 1315 in the IPCPS and usual care groups, respectively. After adjustment, the IPCPS group had a greater median decrease in daily expenditures (-$22 vs. $6, p = 0.003), higher median increase in daily MME (16.5 vs. 9.7 mg, p = 0.007), and fewer patients with a subsequent hospitalization (34.2% vs. 39.2%, p = 0.010) or urgent care visit (10.5% vs. 14.6%, p = 0.024) but longer mean index hospitalization (9.3 vs. 7.7 days, p = 0.003) and no differences in AE during follow-up (all p > 0.05). Conclusion: IPCPS participation on the PC team can be a component of health care cost reduction while contributing to patient-centered quality care.

Dosimetric Comparison of Volumetric Modulated Arc Therapy and Intensity Modulated Radiation Therapy for Soft Tissue Sarcoma of the Extremities.

PURPOSE: Radiation therapy is a standard part of limb conserving therapy for extremity soft tissue sarcoma (STS) at high risk of recurrence. Toxic effects increase with radiation dose and volume of normal tissue irradiated. This study sought to compare dosimetry of volumetric modulated arc therapy (VMAT) with intensity modulated radiation therapy (IMRT) and to investigate the optimal planning technique. METHODS AND MATERIALS: Twenty patients with extremity STS who underwent preoperative radiation therapy (50 Gy in 25 fractions) between 2016 and 2020 at a specialised sarcoma center were included. The original treatment techniques were sliding window IMRT or 3-dimensional conformal. VMAT plans were retrospectively generated according to the original tumor and organ-at-risk constraints. Quality assurance was performed as per departmental protocol. Wilcoxon signed-rank test was used to compare dosimetric parameters (for planning target volume [PTV], in-field bone, and soft tissue structures), monitor units (MUs), and treatment time. RESULTS: Median patient age was 65 years and the majority were male (n = 14, 70%). The most common subtype was undifferentiated pleomorphic sarcoma (n = 14, 70%), and most tumors were located on the thigh (n = 12, 60%). Median PTV was 1110 cm3 and median volume of in-field bone 236 cm3. VMAT plans had significantly lower average MU (480 vs 862 MU, P < .001) and overall treatment time (300 vs 153 seconds, P < .001). PTV coverage favored VMAT, with marginally higher mean, minimum, and maximum doses and higher conformity index. However, differences were not statistically significant. Dose to infield bone and soft tissue structures were similar or slightly lower with VMAT. CONCLUSIONS: In extremity STS, VMAT plans demonstrated a favorable trend toward tumor coverage and dose conformity compared with IMRT along with significantly lower MUs and half the overall treatment time.

An evaluation of solid state detectors for the relative dosimetry of kilovoltage X-ray beams.

INTRODUCTION: Kilovoltage (kV) X-ray beams are an essential modality in radiotherapy. Solid state detectors are widely available in radiotherapy departments, but their use for kV dosimetry has been limited to date. This study aimed to evaluate the dosimetric performance of a range of solid state detectors for kV dosimetry. METHOD: Percentage depth doses (PDDs) and relative output factors (ROFs) were measured on an XStrahl 300 unit (XStrahl-Ltd., UK) using 60, 100, 150, and 300 kVp X-ray beams. The fields were defined by circular applicators with field sizes of 2, 5, 8, and 10 cm diameter and square applicators of field sizes 10 × 10 and 20 × 20 cm2 . The following Physikalisch-Technische Werkstätten (PTW) dosimeters were used for measurements: Advanced Markus, PinPoint 3D and Semiflex ionization chambers; photon, electron, and stereotactic radiosurgery (SRS) diodes plus the microDiamond detector. All PDDs were normalized at 5 mm depth, and ROFs were measured at 3 mm depth to avoid collisions with the end of the applicators. ROFs measured using chambers were corrected for polarity and ion-recombination effects. RESULTS AND DISCUSSION: PDD measurements for 60, 100, and 150 kVp beams exhibited good agreement between all diodes and the ionization chambers over the entire range of depths except in the first few millimeters near the surface. However, for the 300 kVp, all diode detectors exhibited an overresponding behavior compared to reference depth dose data measured with the Advanced Markus chamber. ROFs with the diodes were higher than the Advanced Markus chamber at low energy, and the magnitude of these differences is inversely proportional to the field sizes. The PTW P diode showed the highest variation of up to 15% in the output factor compared to the Advanced Markus chamber. CONCLUSION: This study evaluated the dosimetric performance of a range of solid state detectors in kV relative dosimetry. This study showed that diode detectors are a suitable replacement for ionization chambers for the PDD measurement of low energy kV beams (60-150 kVp) except for the PDD of 60 kVp with the smaller field sizes. However, an overresponding behavior of diode detectors at 300 kVp beams shows that diode detectors are not suitable for the PDD measurement of high energy kV beams. Generally, all solid state detectors overresponded to ROF measurements, indicating that it is not suitable for ROF measurements. In general, both shielded and unshielded diodes produced a similar dosimetric response, which demonstrates that the energy dependence of solid state detectors should be considered before they are used for any kV relative dosimetric measurements.

A novel extrapolation method using OSL detectors for very small field output factor measurement for stereotactic radiosurgery.

Appropriate methods for the determination of very small X-ray beam output factors are essential to ensure correct clinical outcomes for stereotactic radiosurgery. To date, substantial work has been performed in identifying and quantifying suitable dosimeters for relative output factor (ROF) measurements including recent IAEA published recommendations. In this work, we provide a novel method using optically stimulated luminescent dosimeters (OSLDs) with different effective sizes of the readout area to determine ROFs. This involves applying an extrapolation technique to assess ROFs for 6MV SRS X-ray beams with field diameters ranging from 4 to 30 mm as defined by the Brainlab SRS cones. By combining the use of multiple sized OSLDs and water droplets to remove air gaps located around the OSLD detectors, both volume averaging and density variation effects were minimised to estimate ROFs for an extrapolated zero volume detector. The measured results showed that for a 4 mm diameter cone, the ROF was 0.660 ± 0.032 (2SD) as compared to 0.661 ± 0.01 and 0.651 ± 0.018 for the PTW 600019 microDiamond detector and Gafchromic EBT3 film respectively. Whilst the uncertainties were larger than conventional detectors, the technique shows promise and improvements in accuracy may be obtained by higher quality manufacturing techniques. Based on these results, using OSLDs with different effective sizes of readout area and an extrapolation technique shows promise for use as an independent verification tool for very small X-ray field ROFs in the clinical department.

Monte Carlo calculated output correction factors for Gafchromic EBT3 film for relative dosimetry in small stereotactic radiosurgery fields.

To calculate small field output correction factors, [Formula: see text], for Gafchromic EBT3 film using Monte Carlo simulations. These factors were determined for a Novalis Trilogy linear accelerator equipped with Brainlab circular cones with diameters of 4.0 to 30.0 mm. The BEAMnrc Monte Carlo code was used to simulate the Novalis Trilogy linear accelerator and the Brainlab cones with diameters 4.0 to 30 mm. The DOSXYZnrc code was used to simulate Gafchromic EBT3 film with the atomic composition specified by the manufacturer. Small field correction factors were calculated according to new IAEA TRS-483 Code of Practice for small field dosimetry. The depth of calculation was 10 cm and a source to surface distance of 100 cm. The X-ray beam used in the simulations was a 6 MV SRS. The correction factors were then used to determine field output factors with Gafchromic EBT3 film. These field output factors were validated using three solid state detectors and applying correction factors from the TRS-483 Code of Practice. The solid state detectors were IBA SFD diode, PTW 60018 SRS diode and PTW 60019 microDiamond. The Monte Carlo calculated output correction factors, [Formula: see text], for Gafchromic EBT3 film ranged between 0.998 to 1.004 for Brainlab circular cones with diameters between 4.0 and 30.0 mm. The uncertainty for these factors was 2.0%. The field output factors obtained with Gafchromic EBT3 film were within 2% of the mean results obtained with the three solid state detectors. For field sizes 4 mm diameter and above, Gafchromic EBT3 film has field output correction factors within 1% of unity. Therefore, Gafchromic EBT3 film can be considered to be correction less and supports the assumption made about this film in the TRS-483 Code of Practice.

Skin and build up dose determination for a 2.5 MV medical linear accelerator imaging beam.

The 2.5 MV Imaging beam produced by a Varian TrueBeam linear accelerator produces a dose build up effect at the beam entrance similar to other high energy photon beams. The surface dose values were found to range from 39% of maximum dose at a 5 cm × 5 cm field size up to 69% of maximum at a 40 cm × 40 cm field. The depth of maximum dose deposition was found to range from 5 mm at smaller field sizes to 4 mm at larger field sizes. Whilst large absorbed doses will not be delivered utilizing these beams, the data provided will allow the medical physics community to assess and estimate doses to patient's skin and subcutaneous tissue from low energy MV imaging beams.

Australasian recommendations for quality assurance in kilovoltage radiation therapy from the Kilovoltage Dosimetry Working Group of the Australasian College of Physical Scientists and Engineers in Medicine.

The Australasian College of Physical Scientists and Engineers in Medicine (ACPSEM) Radiation Oncology Specialty Group (ROSG) formed a series of working groups to develop recommendations for guidance of radiation oncology medical physics practice within the Australasian setting. These recommendations provide a standard for safe work practices and quality control. It is the responsibility of the medical physicist to ensure that locally available equipment and procedures are sufficiently sensitive to establish compliance. The recommendations are endorsed by the ROSG, have been subject to independent expert reviews and have also been approved by the ACPSEM Council. For the Australian audience, these recommendations should be read in conjunction with the Tripartite Radiation Oncology Practice Standards and should be read in conjunction with relevant national, state or territory legislation which take precedence over the ACPSEM publication Radiation Oncology Reform Implementation Committee (RORIC) Quality Working Group, RANZCR, 2011a; Kron et al. Clin Oncol 27(6):325-329, 2015; Radiation Oncology Reform Implementation Committee (RORIC) Quality Working Group, RANZCR, 2018a, b).

Impact of audiovisual biofeedback on interfraction respiratory motion reproducibility in liver cancer stereotactic body radiotherapy.

INTRODUCTION: Irregular breathing motion exacerbates uncertainties throughout a course of radiation therapy. Breathing guidance has demonstrated to improve breathing motion consistency. This was the first clinical implementation of audiovisual biofeedback (AVB) breathing guidance over a course of liver stereotactic body radiotherapy (SBRT) investigating interfraction reproducibility. METHODS: Five liver cancer patients underwent a screening procedure prior to CT sim during which patients underwent breathing conditions (i) AVB, or (ii) free breathing (FB). Whichever breathing condition was more regular was utilised for the patient's subsequent course of SBRT. Respiratory motion was obtained from the Varian respiratory position monitoring (RPM) system (Varian Medical Systems). Breathing motion reproducibility was assessed by the variance of displacement across 10 phase-based respiratory bins over each patient's course of SBRT. RESULTS: The screening procedure yielded the decision to utilise AVB for three patients and FB for two patients. Over the course of SBRT, AVB significantly improved the relative interfraction motion by 32%, from 22% displacement difference for FB patients to 15% difference for AVB patients. Further to this, AVB facilitated sub-millimetre interfraction reproducibility for two AVB patients. CONCLUSION: There was significantly less interfraction motion with AVB than FB. These findings demonstrate that AVB is potentially a valuable tool in ensuring reproducible interfraction motion.

A study on the suitability of the PTW microDiamond detector for kilovoltage x-ray beam dosimetry.

Kilovoltage x-ray beams are widely used in treating skin cancers and in biological irradiators. In this work, we have evaluated four dosimeters (ionization chambers and solid state detectors) in their suitability for relative dosimetry of kilovoltage x-ray beams in the energy range of 50 - 280kVp. The solid state detectors, which have not been investigated with low energy x-rays, were the PTW 60019 microDiamond synthetic diamond detector and the PTW 60012 diode. The two ionization chambers used were the PTW Advanced Markus parallel plate chamber and the PTW PinPoint small volume chamber. For each of the dosimeters, percentage depth doses were measured in water over the full range of x-ray beams and for field sizes ranging from 2cm diameter to 12 × 12cm. In addition, depth doses were measured for a narrow aperture (7mm diameter) using the PTW microDiamond detector. For comparison, the measured data was compared with Monte Carlo calculated doses using the EGSnrc Monte Carlo package. The depth dose results indicate that the Advanced Markus parallel plate and PinPoint ionization chambers were suitable for depth dose measurements in the beam quality range with an uncertainty of less than 3%, including in the regions closer to the surface of the water as compared with Monte Carlo depth dose data for all six energy beams. The response of the PTW Diode E detector was accurate to within 4% for all field sizes in the energy range of 50-125kVp but showed larger variations for higher energies of up to 12% with the 12 × 12cm field size. In comparison, the microDiamond detector had good agreement over all energies for both smaller and larger field sizes generally within 1% as compared to the Advanced Markus chamber field and Monte Carlo calculations. The only exceptions were in measuring the dose at the surface of the water phantom where larger differences were found. For the 7mm diameter field, the agreement between the microDiamond detector and Monte Carlo calculations was good being better than 1% except at the surface. Based on these results, the PTW microDiamond detector has shown to be a suitable detector for relative dosimetry of low energy x-ray beams over a wide range of x-ray beam energies.

Characterization of a novel scale maille contralateral breast shield: SMART Armor.

During breast radiotherapy treatment, the contralateral breast receives radiation doses to the skin and subcutaneous tissue caused mainly from incident electron contamination and low energy photon scatter radiation. Measurements have shown that for a typical hybrid tangential treatment, these dose levels can be up to 17% of maximum applied prescription dose if no shielding is used during the treatment process. This work examined the use of different shielding metals, aluminum, copper, and lead to reduce peripheral radiation dose to evaluate the optimal metal to form the basis of a contralateral breast radiation shield. This work also shows a simple but novel method to substantially reduce this unwanted radiation dose with the use of a copper scale maille sheet which can be easily and accurately draped over a patient's contralateral breast during treatment. The copper scale maille is flexible and can thus conform around typical breast shapes. It can also form irregular shaped edges to match those outlined by typical tangential treatment fields. As the shield is made from copper, it is nontoxic and can potentially be used directly on patients for treatment. The designed copper scale maille has shown to reduce contralateral breast skin and subcutaneous dose by up to 80% for typical radiation fields used in breast radiotherapy.

Practical time considerations for optically stimulated luminescent dosimetry (OSLD) in total body irradiation.

Total body irradiation (TBI) treatments are used to treat the whole body in preparation for hematopoietic stem cell (or bone marrow) transplantation. Our standard clinical regimen is a 12 Gy in 6 fraction, bi-daily technique using 6 MV X-rays at an extended Source-to-Surface distance (SSD) of 300 cm. Utilizing these characteristics, the beam dose rate is reduced below 7 cGy/min as is standard for TBI treatment. Dose received by the patient is monitored using optically stimulated luminescent dosimetry (OSLD). This work presents some practical calibration corrections based on time-dependant factors for OSLD calibration related to TBI procedure. Results have shown that a negligible difference is seen in OSL sensitivity for 6 MV X-rays irradiated in standard SSD (100 cm) and high dose rate (600 cGy/min) conditions compared to extended SSD (300 cm) and low TBI dose rate (6 cGy/min) conditions. Results have also shown that whilst short term signal fading occurs in the OSL after irradiation at a high dose rate (37% reduction in signal in the first 15 min), thereafter, negligible differences are seen in the OSL signal between 600 and 7 cGy/min irradiations. Thus a direct comparison can be made between calibration OSLs and clinical TBI OSLs between 15 min and 2 h. Finally a table is presented to provide corrections between calibration OSL readout and clinical TBI dose readout for a period up to 7 days. Combining these three results allows users to pre-irradiate their calibration OSLs at standard dose rate and SSD, up to 1 week prior to clinical treatment, and still provide accurate in-vivo dosimetry. This can help with time saving and work efficiency in the clinic.

An experimental extrapolation technique using the Gafchromic EBT3 film for relative output factor measurements in small x-ray fields.

PURPOSE: An experimental extrapolation technique is presented, which can be used to determine the relative output factors for very small x-ray fields using the Gafchromic EBT3 film. METHODS: Relative output factors were measured for the Brainlab SRS cones ranging in diameters from 4 to 30 mm(2) on a Novalis Trilogy linear accelerator with 6 MV SRS x-rays. The relative output factor was determined from an experimental reducing circular region of interest (ROI) extrapolation technique developed to remove the effects of volume averaging. This was achieved by scanning the EBT3 film measurements with a high scanning resolution of 1200 dpi. From the high resolution scans, the size of the circular regions of interest was varied to produce a plot of relative output factors versus area of analysis. The plot was then extrapolated to zero to determine the relative output factor corresponding to zero volume. RESULTS: Results have shown that for a 4 mm field size, the extrapolated relative output factor was measured as a value of 0.651 ± 0.018 as compared to 0.639 ± 0.019 and 0.633 ± 0.021 for 0.5 and 1.0 mm diameter of analysis values, respectively. This showed a change in the relative output factors of 1.8% and 2.8% at these comparative regions of interest sizes. In comparison, the 25 mm cone had negligible differences in the measured output factor between zero extrapolation, 0.5 and 1.0 mm diameter ROIs, respectively. CONCLUSIONS: This work shows that for very small fields such as 4.0 mm cone sizes, a measureable difference can be seen in the relative output factor based on the circular ROI and the size of the area of analysis using radiochromic film dosimetry. The authors recommend to scan the Gafchromic EBT3 film at a resolution of 1200 dpi for cone sizes less than 7.5 mm and to utilize an extrapolation technique for the output factor measurements of very small field dosimetry.

Radiation dose measurements of an on-board imager X-ray unit using optically-stimulated luminescence dosimeters.

Cone beam computed tomography (CBCT) is now widely used to image radiotherapy patients prior to treatment for the purpose of accurate patient setup. However each CBCT image delivered to a patient increases the total radiation dose that they receive. The measurement of the dose delivered from the CBCT images is not readily performed in the clinic. In this study, we have used commercially available optically stimulated luminescence (OSLD) dosimeters to measure the dose delivered by the Varian OBI on a radiotherapy linear accelerator. Calibration of the OSLDs was achieved by using a therapeutic X-ray unit. The dose delivered by a head CBCT scan was found to be 3.2 ± 0.3 mGy which is similar in magnitude to the dose of a head computed tomography (CT) scan. The results of this study suggest that the radiation hazard associated with CBCT is of a similar nature to that of conventional CT scans. We have also demonstrated that the OSLDs are suitable for these low X-ray dose measurements.