Response of the ArcCHECK® device at 6 MV and 15 MV for VMAT and IMRT quality control.

PURPOSE: To study the response of the ArcCHECK® device as VMAT and IMRT verification system. METHODS: Various tests analyzing the linearity, the repeatability and the angular dependence of the device response, its dependence with the pulse repetition rate and the leakage losses were performed. The long-term response in dose measurements and the uniformity of the detectors conforming the system were controlled using a statistical process control program. The Elekta Infinity™ 6 and 15MV photon beams were used. RESULTS: The device showed excellent repeatability and linearity. The differences between the responses obtained for any pair of angular incidences were less than 2%. The absorbed dose increased by 3% when the pulse repetition rate varied from 50 to 600MU/min. Results are in overall agreement with those found in previous works for the ArcCHECK®, in which a reduced number of the device diodes were analyzed, and for the MapCheck®, an older 2D device that used the same diodes. Charge losses were found to be negligible except for some of the diodes of the device. The statistical process control program is a very useful tool to control the correct functioning of the device in the long term. CONCLUSIONS: The results of the analysis carried out indicate that the working and stability conditions of the ArcCHECK® device are adequate for its purpose. The dependence with the pulse repetition rate should be considered when VMAT or similar treatments are evaluated. A control program for the statistical monitoring of the device would be desirable and useful.

A radiobiological study of the schemes with a low number of fractions in high-dose-rate brachytherapy as monotherapy for prostate cancer.

PURPOSE: Schemes with high doses per fraction and small number of fractions are commonly used in high-dose-rate brachytherapy (HDR-BT) for prostate cancer. Our aim was to analyze the differences between published clinical results and the predictions of radiobiological models for absorbed dose required in a single fraction monotherapy HDR-BT. MATERIAL AND METHODS: Published HDR-BT clinical results for low- and intermediate-risk patients with prostate cancer were revised. For 13 clinical studies with 16 fractionation schedules between 1 and 9 fractions, a dose-response relation in terms of the biochemical control probability (BC) was established using Monte Carlo-based statistical methods. RESULTS: We obtained a value of α/ß = 22.8 Gy (15.1-60.2 Gy) (95% CI) much larger than the values in the range 1.5-3.0 Gy that are usually considered to compare the results of different fractionation schemes in prostate cancer radiotherapy using doses per fraction below 6 Gy. The doses in a single fraction producing BC = 90% and 95% were 22.3 Gy (21.5-24.2 Gy) and 24.3 Gy (23.0-27.9 Gy), respectively. CONCLUSIONS: The α/ß obtained in our analysis of 22.8 Gy for a range of dose per fraction between 6 and 20.5 Gy was much greater than the one currently estimated for prostate cancer using low doses per fraction. This high value of α/ß explains reasonably well the data available in the region of high doses per fraction considered.

Evaluation of the overdiagnosis in breast screening programmes using a Monte Carlo simulation tool: a study of the influence of the parameters defining the programme configuration.

OBJECTIVES: To build up and test a Monte Carlo simulation procedure for the investigation of overdiagnosis in breast screening programmes (BSPs). DESIGN: A Monte Carlo tool previously developed has been adapted for obtaining the quantities of interest in order to determine the overdiagnosis: the annual and cumulative number of cancers detected by screening, plus interval cancers, for a population following the BSP, and detected clinically for the same population in the absence of screening. Overdiagnosis is obtained by comparing these results in a direct way. RESULTS: Overdiagnosis between 7% and 20%, depending on the specific configuration of the programme, have been found. These range of values is in agreement with some of the results available for actual BSPs. In the cases analysed, a reduction of 11% at most has been found in the number of invasive tumours detected by screening in comparison to those clinically detected in the control population. It has been possible to establish that overdiagnosis is almost entirely linked to ductal carcinoma in situ tumours. CONCLUSIONS: The use of Monte Carlo tools may facilitate the analysis of overdiagnosis in actual BSPs, permitting to address the role played by various quantities of relevance for them.

Radiobiological parameters for breast cancer: a Monte Carlo analysis of START trial published results.

OBJECTIVE:: Trial results are usually given in terms of end point confidence intervals, the data concerning the participating patients being not available. Sometimes, it would be useful or necessary to obtain derived quantities, such as dose-response relationships, from the known information. In this work, we describe a methodology that allows to do that and illustrate it by analyzing the UK standardization of breast radiotherapy (START) trials. METHODS:: Using Monte Carlo techniques, virtual data sets were generated by sampling trial outcome distributions in terms of the tumor control probability (described by means of a logistic dose response and the equations of isoeffect in the linear-quadratic model). After fitting the available experimental data, the radiobiological parameters of interest and their confidence intervals were obtained from the TCP vs 'EQD2 curve in which the surgery effect is also taken into account. RESULTS:: The value of [Formula: see text] obtained for breast cancer was 3.6 Gy, with a 95% confidence interval of (1.5,15.5) Gy, in agreement with the one estimated by the START group. The time factor, referred to a scheme of 2 Gy per fraction, was 0.74 (0.41,2.67) Gy day-1, of the same order than that estimated for head and neck cancers. CONCLUSION:: A methodology permitting an analysis of trial results was developed and tested with the results of the START trials. The procedure does not require detailed knowledge of the distributions actually found in the trials. The values obtained for the parameters are similar to those of the START estimations and this can be considered an independent confirmation of their validity, thus showing the model usefulness. The methodology presented here relies on basic statistical methods that are general enough to permit it to be applied to any kind of trial. This may be particularly interesting when the original data are no longer available. ADVANCES IN KNOWLEDGE:: The main novelty of this paper is to provide with a Monte Carlo based tool that permits an independent analysis of published trial results in order to obtain radiobiological parameters without a detailed knowledge of the data corresponding to the participating patients.

Impact of cardiosynchronous brain pulsations on Monte Carlo calculated doses for synchrotron micro- and minibeam radiation therapy.

PURPOSE: The purpose of this study was to assess the effects of brain movements induced by heartbeat on dose distributions in synchrotron micro- and minibeam radiation therapy and to develop a model to help guide decisions and planning for future clinical trials. METHODS: The Monte Carlo code PENELOPE was used to simulate the irradiation of a human head phantom with a variety of micro- and minibeam arrays, with beams narrower than 100 µm and above 500 µm, respectively, and with radiation fields of 1 × 2 cm and 2 × 2 cm. The dose in the phantom due to these beams was calculated by superposing the dose profiles obtained for a single beam of 1 µm × 2 cm. A parameter δ, accounting for the total displacement of the brain during the irradiation and due to the cardiosynchronous pulsation, was used to quantify the impact on peak-to-valley dose ratios and the full width at half maximum. RESULTS: The difference between the maximum (at the phantom entrance) and the minimum (at the phantom exit) values of the peak-to-valley dose ratio reduces when the parameter δ increases. The full width at half maximum remains almost constant with depth for any δ value. Sudden changes in the two quantities are observed at the interfaces between the various tissues (brain, skull, and skin) present in the head phantom. The peak-to-valley dose ratio at the center of the head phantom reduces when δ increases, remaining above 70% of the static value only for minibeams and δ smaller than ∼200 µm. CONCLUSIONS: Optimal setups for brain treatments with synchrotron radiation micro- and minibeam combs depend on the brain displacement due to cardiosynchronous pulsation. Peak-to-valley dose ratios larger than 90% of the maximum values obtained in the static case occur only for minibeams and relatively large dose rates.

Air density dependence of the soft X-ray PTW 34013 ionization chamber.

PURPOSE: We studied the dependence on air density of the response of the PTW 34013 ionization chamber, recently upgraded for dosimetry control of low energy X-ray beams. METHODS: Measurements were performed by changing the pressure conditions inside a pressure chamber. The behavior of the measurements against the air density inside this chamber was analyzed. X-ray beams generated with 50, 70, 100, 150 and 200 kVp and the two electrometer polarities were considered. RESULTS: For all beams studied, measurements corrected with the conventional temperature and pressure factor showed a residual dependence on the air density that was described with a linear function of the air density. For the 50 and 70 kVp beams, corrected measurements remained ∼1% smaller than the value found at standard pressure/temperature conditions, for both electrometer polarities and for the air density range typical in clinical conditions. For air densities smaller than the standard one, measurements found for 100, 150 and 200 kVp beams were below or above the value found at standard pressure and temperature when the negative or positive electrometer polarities were used, respectively. The differences with the measurements at standard conditions were less than 1% for the 100 kVp beam and below 4% for the other two beams. CONCLUSIONS: The PTW 34013 ionization chamber showed a dependence on the air density that is not properly described with the usual temperature and pressure correction factor. This residual dependence is negligible for low energy beams, for which this chamber is recommended, but is more substantial for beams with energy above 80 kVp.

Monte Carlo dosimetric characterization of the Flexisource Co-60 high-dose-rate brachytherapy source using PENELOPE.

PURPOSE: 60Co sources have been commercialized as an alternative to 192Ir sources for high-dose-rate (HDR) brachytherapy. One of them is the Flexisource Co-60 HDR source manufactured by Elekta. The only available dosimetric characterization of this source is that of Vijande et al. [J Contemp Brachytherapy 2012; 4:34-44], whose results were not included in the AAPM/ESTRO consensus document. In that work, the dosimetric quantities were calculated as averages of the results obtained with the Geant4 and PENELOPE Monte Carlo (MC) codes, though for other sources, significant differences have been quoted between the values obtained with these two codes. The aim of this work is to perform the dosimetric characterization of the Flexisource Co-60 HDR source using PENELOPE. METHODS AND MATERIALS: The MC simulation code PENELOPE (v. 2014) has been used. Following the recommendations of the AAPM/ESTRO report, the radial dose function, the anisotropy function, the air-kerma strength, the dose rate constant, and the absorbed dose rate in water have been calculated. RESULTS: The results we have obtained exceed those of Vijande et al. In particular, the absorbed dose rate constant is ∼0.85% larger. A similar difference is also found in the other dosimetric quantities. The effect of the electrons emitted in the decay of 60Co, usually neglected in this kind of simulations, is significant up to the distances of 0.25 cm from the source. CONCLUSIONS: The systematic and significant differences we have found between PENELOPE results and the average values found by Vijande et al. point out that the dosimetric characterizations carried out with the various MC codes should be provided independently.

Monte Carlo systems used for treatment planning and dose verification.

General-purpose radiation transport Monte Carlo codes have been used for estimation of the absorbed dose distribution in external photon and electron beam radiotherapy patients since several decades. Results obtained with these codes are usually more accurate than those provided by treatment planning systems based on non-stochastic methods. Traditionally, absorbed dose computations based on general-purpose Monte Carlo codes have been used only for research, owing to the difficulties associated with setting up a simulation and the long computation time required. To take advantage of radiation transport Monte Carlo codes applied to routine clinical practice, researchers and private companies have developed treatment planning and dose verification systems that are partly or fully based on fast Monte Carlo algorithms. This review presents a comprehensive list of the currently existing Monte Carlo systems that can be used to calculate or verify an external photon and electron beam radiotherapy treatment plan. Particular attention is given to those systems that are distributed, either freely or commercially, and that do not require programming tasks from the end user. These systems are compared in terms of features and the simulation time required to compute a set of benchmark calculations.

A Monte Carlo analysis of breast screening randomized trials.

PURPOSE: To analyze breast screening randomized trials with a Monte Carlo simulation tool. METHODS: A simulation tool previously developed to simulate breast screening programmes was adapted for that purpose. The history of women participating in the trials was simulated, including a model for survival after local treatment of invasive cancers. Distributions of time gained due to screening detection against symptomatic detection and the overall screening sensitivity were used as inputs. Several randomized controlled trials were simulated. Except for the age range of women involved, all simulations used the same population characteristics and this permitted to analyze their external validity. The relative risks obtained were compared to those quoted for the trials, whose internal validity was addressed by further investigating the reasons of the disagreements observed. RESULTS: The Monte Carlo simulations produce results that are in good agreement with most of the randomized trials analyzed, thus indicating their methodological quality and external validity. A reduction of the breast cancer mortality around 20% appears to be a reasonable value according to the results of the trials that are methodologically correct. Discrepancies observed with Canada I and II trials may be attributed to a low mammography quality and some methodological problems. Kopparberg trial appears to show a low methodological quality. CONCLUSION: Monte Carlo simulations are a powerful tool to investigate breast screening controlled randomized trials, helping to establish those whose results are reliable enough to be extrapolated to other populations and to design the trial strategies and, eventually, adapting them during their development.

Photon beam quality correction factors for the NE2571A and NE2581A thimble ionization chambers using PENELOPE.

The beam quality correction factor kQ,Q0 and the perturbation factor pQ for photon beams were calculated for the NE2571A and NE2581A ionization chambers, using the Monte Carlo simulation code PENELOPE. Results are compared to those quoted for the NE2571 and NE2581 chambers in previous works. Both kQ,Q0 and pQ obtained for NE2571A and NE2581A chambers agree with those of their predecessors NE2571 and NE2581 ones.

Characterization of the PTW SourceCheck ionization chamber with the Valencia lodgment for (125)I seed verification.

In brachytherapy using (125)I seed implants, a verification of the air kerma strength of the sources used is required. Typically, between 40 and 100 seeds are implanted. Checking all of them is unaffordable, especially when seeds are disposed in sterile cartridges. Recently, a new procedure allowing the accomplishment of the international recommendations has been proposed for the seedSelectron system of Elekta Brachytherapy. In this procedure, the SourceCheck ionization chamber is used with a special lodgment (Valencia lodgment) that allows to measure up to 10 seeds simultaneously. In this work we analyze this procedure, showing the feasibility of the approximations required for its application, as well as the effect of the additional dependence with the air density that shows the chamber model used. Uncertainty calculations and the verification of the approximation needed to obtain a calibration factor for the Valencia lodgment are carried out. The results of the present work show that the chamber dependence with the air density is the same whether the Valencia lodgment is used or not. On the contrary, the chamber response profile is influenced by the presence of the lodgment. The determination of this profile requires various measurements due to the nonnegligible variability found between different experiments. If it is considered, the uncertainty in the determination of the air-kerma strength increases from 0.5% to 1%. Otherwise, a systematic additional uncertainty of 1% would occur. This could be relevant for the comparison between user and manufacturer measurements that is mandatory in the case studied here.

Dosimetric characterization of the (60)Co BEBIG Co0.A86 high dose rate brachytherapy source using PENELOPE.

(60)Co sources are being used as an alternative to (192)Ir sources in high dose rate brachytherapy treatments. In a recent document from AAPM and ESTRO, a consensus dataset for the (60)Co BEBIG (model Co0.A86) high dose rate source was prepared by using results taken from different publications due to discrepancies observed among them. The aim of the present work is to provide a new calculation of the dosimetric characteristics of that (60)Co source according to the recommendations of the AAPM and ESTRO report. Radial dose function, anisotropy function, air-kerma strength, dose rate constant and absorbed dose rate in water have been calculated and compared to the results of previous works. Simulations using the two different geometries considered by other authors have been carried out and the effect of the cable density and length has been studied.

On the shape of the Task Group 43 anisotropy factor for linear brachytherapy sources at short distances.

PURPOSE: To investigate the peak shown by the American Association of Physicists in Medicine (AAPM) Task Group 43 1D anisotropy function at short distances from the source. METHODS AND MATERIALS: The 1D anisotropy function of an ideal nonencapsulated photon linear source is calculated. A simple analytical model developed to evaluate the dose because of photon point-like sources has been applied. Previously, the model has been tested by comparing the values obtained for the various Task Group 43 dosimetric functions with those calculated with the Monte Carlo code PENELOPE for three different photon energies. RESULTS: The model is able to reproduce the behavior of the 1D anisotropy function, describing the maximum that appears at a distance between 1 and 2 mm from the source. The reason for this behavior has been identified in terms of the contributions of the source activity inside and outside the scoring sphere. CONCLUSIONS: Although it is not usually shown in reference data, this behavior should be taken into account for accurate dosimetric calculations.

Dependence with air density of the response of the PTW SourceCheck ionization chamber for low energy brachytherapy sources.

PURPOSE: Air-communicating well ionization chambers are commonly used to assess air kerma strength of sources used in brachytherapy. The signal produced is supposed to be proportional to the air density within the chamber and, therefore, a density-independent air kerma strength is obtained when the measurement is corrected to standard atmospheric conditions using the usual temperature and pressure correction factor. Nevertheless, when assessing low energy sources, the ionization chambers may not fulfill that condition and a residual density dependence still remains after correction. In this work, the authors examined the behavior of the PTW 34051 SourceCheck ionization chamber when measuring the air kerma strength of (125)I seeds. METHODS: Four different SourceCheck chambers were analyzed. With each one of them, two series of measurements of the air kerma strength for (125)I selectSeed(TM) brachytherapy sources were performed inside a pressure chamber and varying the pressure in a range from 747 to 1040 hPa (560 to 780 mm Hg). The temperature and relative humidity were kept basically constant. An analogous experiment was performed by taking measurements at different altitudes above sea level. RESULTS: Contrary to other well-known ionization chambers, like the HDR1000 PLUS, in which the temperature-pressure correction factor overcorrects the measurements, in the SourceCheck ionization chamber they are undercorrected. At a typical atmospheric situation of 933 hPa (700 mm Hg) and 20 °C, this undercorrection turns out to be 1.5%. Corrected measurements show a residual linear dependence on the density and, as a consequence, an additional density dependent correction must be applied. The slope of this residual linear density dependence is different for each SourceCheck chamber investigated. The results obtained by taking measurements at different altitudes are compatible with those obtained with the pressure chamber. CONCLUSIONS: Variations of the altitude and changes in the weather conditions may produce significant density corrections, and that effect should be taken into account. This effect is chamber-dependent, indicating that a specific calibration is necessary for each particular chamber. To our knowledge, this correction has not been considered so far for SourceCheck ionization chambers, but its magnitude cannot be neglected in clinical practice. The atmospheric pressure and temperature at which the chamber was calibrated need to be taken into account, and they should be reported in the calibration certificate. In addition, each institution should analyze the particular response of its SourceCheck ionization chamber and compute the adequate correction factors. In the absence of a suitable pressure chamber, a possibility for this assessment is to take measurements at different altitudes, spanning a wide enough air density range.

A simple modification of TG-43 based brachytherapy dosimetry with improved fitting functions: application to the selectSeed source.

A variation of TG-43 protocol for seeds with cylindrical symmetry aiming at a better description of the radial and anisotropy functions is proposed. The TG-43 two dimensional formalism is modified by introducing a new anisotropy function. Also new fitting functions that permit a more robust description of the radial and anisotropy functions than usual polynomials are studied. The relationship between the new anisotropy function and the anisotropy factor included in the one-dimensional TG-43 formalism is analyzed. The new formalism is tested for the (125)I Nucletron selectSeed brachytherapy source, using Monte Carlo simulations performed with PENELOPE. The goodness of the new parameterizations is discussed. The results obtained indicate that precise fits can be achieved, with a better description than that provided by previous parameterizations. Special care has been taken in the description and fitting of the anisotropy factor near the source. The modified formalism shows advantages with respect to the usual one in the description of the anisotropy functions. The new parameterizations obtained can be easily implemented in the clinical planning calculation systems, provided that the ratio between geometry factors is also modified according to the new dose rate expression.

Calculation of beam quality correction factors for various thimble ionization chambers using the Monte Carlo code PENELOPE.

The beam quality correction factor [Formula: see text] and the perturbation factor pQ, commonly considered in dosimetry with ionization chambers, were calculated for the NE2571 and the Standard Imaging A19 and A12S chambers, using the Monte Carlo simulation code PENELOPE. For the NE2571 chamber, the values of [Formula: see text] obtained are in very good agreement with those found in previous works by Wulff et al. and Muir and Rogers with the code EGSnrc and also with the experimental results summarized in the NCS code of practice. For pQ, a difference of ∼0.4% has been found between our results and those obtained with EGSnrc for (60)Co and this difference increases slightly with TPR10(20) values. These factors have been calculated also for the A19 and A12S chambers of Standard Imaging. The values of [Formula: see text] show reasonable agreement with those recently calculated by Muir and Rogers and the measurements of McEwen.

Monte Carlo simulation of COMS ophthalmic applicators loaded with Bebig I25.S16 seeds and comparison with planning system predictions.

PURPOSE: To simulate the Bebig model I125.S16 source and obtain AAPM Task Group Report 43 brachytherapy dosimetry parameters for comparison to consensus and previously published values. The seed model will then be incorporated into a Monte Carlo model of COMS eye plaques and simulation results will be used for seed-carrier set modeling in a commercial planning system. METHODS: PENELOPE was used to simulate the seed and the applicators for different sizes and loading levels. The corresponding TG-43U1 dosimetric parameters of the seed were calculated. Bebig Plaque Simulator was used. RESULTS: The air kerma strength, the dose rate constant and the radial dose and 2D anisotropy functions found showed a good agreement with those published by other authors. Dose distributions were determined for the 12 and 20 mm COMS plaques loaded with a single seed and for the 12 mm plaque fully loaded. The plaque effect on the eye dose and the interseed absorption were evaluated. If the plaque is loaded with a single seed, the dose in the central axis reduces about 10% at 5-6 mm depth with respect to the case in which the plaque is not present. This reduction does not depend on the plaque size. When the plaque is fully loaded, an additional reduction in the dose with respect to the dose in water is observed mainly due to the effect of the Silastic carrier. The mean dose reduction in the central axis of the 12 mm plaque due to the interseed absorption was 0.5%. A new physics file for the planning system was created with the results obtained from the simulations. Results obtained using this adapted model for the 12 mm plaque fully loaded agreed with the corresponding simulation. Dose rate at the prescription point differs 4.7% when the adapted model is used instead of the default model. CONCLUSIONS: Simulation results for COMS plaques are consistent with those published for other seeds. The planning system studied appears as a good tool for dose calculation in ophthalmic brachytherapy treatments. The new physics model, built up from Monte Carlo results, has been commissioned by comparing calculations made with the planning system to those obtained from Monte Carlo simulations.

A Monte Carlo tool to study the mortality reduction due to breast screening programs.

PURPOSE: To develop a Monte Carlo tool that permits to study the reduction in breast cancer mortality rate due to breast screening programs. METHODS: Simulations implement woman histories undergoing a screening program, include a model of survival after local treatment of invasive cancers and use distributions of time gained due to screening detection against symptomatic detection and overall sensitivity of the screening obtained previously. Mortalities for the whole woman population and for those women with ages within the range considered in the program have been calculated. RESULTS: For the whole woman population, a reduction in breast cancer mortality up to 29% has been found for a configuration that includes women aged between 50 and 70 years, with a screening interval of two years and 100% acceptance rate. If an acceptance of 70% is considered, this percentage reduces to 20%. If, in the same conditions, the program starts at 40 years, the reduction of the mortality reaches 24% while if the screening interval is one year, this percentage raises to 28%. If mortalities are calculated for those women with ages within the range included in the program these reductions are greater and no significant differences are found between the programs with age ranges [50-70] and [40-70]. In the model, radio-induced cancers have no effect in survival. CONCLUSIONS: The results agree reasonably well with those of different trials. Mortality reductions of 12%-20% (between two and four deaths per year and 10(5) women) are obtained only for acceptances above 50%. This could be considered as a threshold for the acceptance, which appears to be a critical parameter.

Obtaining the intrinsic electron spectrum of linear accelerators using the relation between the current of the bending magnet and the absorbed dose in water.

PURPOSE: To present a novel methodology to model the intrinsic electron spectra of a linear accelerator and its situation with respect to the energy window. METHODS: The spectra are obtained by fitting the variation of R(50) and the maximum dose rate measured in a water phantom with the bending magnet current. The obtained spectra are verified with a realistic Monte Carlo simulation of the accelerator. RESULTS: The intrinsic spectra and their relative position with respect to the energy window of the bending magnet have been obtained for a Siemens Mevatron KDS and an ELEKTA SL20 accelerators. CONCLUSIONS: Using this method in the commissioning and scheduled revisions of the accelerator, the tuning of the current of the bending magnet could be done in such a way that both the quality of the beam and the dose rate would reach a better long-term stability.

Effect of the multiple scattering of electrons in Monte Carlo simulation of LINACS.

Results obtained from Monte Carlo simulations of the transport of electrons in thin slabs of dense material media and air slabs with different widths are analyzed. Various general purpose Monte Carlo codes have been used: PENELOPE, GEANT3, GEANT4, EGSNRC, MCNPX. Non-negligible differences between the angular and radial distributions after the slabs have been found. The effects of these differences on the depth doses measured in water are also discussed.