Extended nodal radiotherapy for prostate cancer relapse guided with [11C]-choline PET/CT: ten-year results in patients enrolled in a prospective trial.

AIMS: To report long-term outcomes of relapsed prostate cancer (PC) patients treated in a prospective single-arm study with extended-nodal radiotherapy (ENRT) and [11C]-choline positron emission tomography (PET)/computed tomography (CT)-guided simultaneous integrated boost (SIB) to positive lymph nodes (LNs). METHODS: From 12/2009 to 04/2015, 60 PC patients with biochemical relapse and positive LNs only were treated in this study. ENRT at a median total dose (TD) = 51.8 Gy/28 fr and PET/CT-guided SIB to positive LNs at a median TD = 65.5 Gy was prescribed. Median PSA at relapse was 2.3 (interquartile range, IQR:1.3-4.0) ng/ml. Median number of positive LNs: 2 (range: 1-18). Androgen deprivation therapy (ADT) was prescribed for 48 patients for a median of 30.7 (IQR: 18.5-43.1) months. RESULTS: Median follow-up from the end of salvage treatment was 121.8 (IQR: 116.1, 130.9) months; 3-, 5-, and 10-year BRFS were 45.0%, 36.0%, and 24.0%, respectively; DMFS: 67.9%, 57.2%, and 45.2%; CRFS: 62.9%, 53.9%, and 42.0%; and OS: 88.2%, 76.3%, and 47.9%, respectively. Castration resistance (p < 0.0001) and ≥ 6 positive LN (p = 0.0024) significantly influenced OS at multivariate analysis. Castration resistance (p < 0.0001 for both) influenced DMFS and CRFS in multivariate analysis. CONCLUSIONS: In PC relapsed patients treated with ENRT and [11C]-choline-PET/CT-guided SIB for positive LNs, with 10-year follow-up, a median Kaplan-Meier estimate CRFS of 67 months and OS of 110 months were obtained. These highly favorable results should be confirmed in a prospective, randomized trial.

Simultaneous detection of Aspergillus nidulans, Aspergillus luchuensis and Lichtheimia sp. in a bovine abortion.

Abortion in dairy cattle may be caused by infectious (viruses, fungi and protozoa) and non-infectious causes mostly related to bad management practices and genetic factors. Recently, the significant contribution of mycotic infection to bovine abortion has been recognized. This report describes an abortion case in a Chianina cow due to Aspergillus nidulans, Aspergillus luchuensis and Lichtheimia sp. diagnosed by histology, cytology, culture and molecular assays. A mixed infection due to more than one fungus in abortion is rarely demonstrated. To our knowledge, this is the first case of bovine abortion caused by co-infection with three different moulds.

Moderate Hypofractionation with Simultaneous Integrated Boost in Prostate Cancer: Long-term Results of a Phase I-II Study.

AIMS: To report 5 year outcome and late toxicity in prostate cancer patients treated with image-guided tomotherapy with a moderate hypofractionated simultaneous integrated boost approach. MATERIALS AND METHODS: In total, 211 prostate cancer patients, 78 low risk, 53 intermediate risk and 80 high risk were treated between 2005 and 2011. Intermediate- and high-risk patients received 51.8 Gy to pelvic lymph nodes and concomitant simultaneous integrated boost to prostate up to 74.2 Gy/28 fractions, whereas low-risk patients were treated to the prostate only with 71.4 Gy/28 fractions. Daily megavoltage computed tomography (MVCT) image guidance was applied. Androgen deprivation was prescribed for a median duration of 6 months for low-risk patients (for downsizing), 12 months for intermediate-risk and 36 months for high-risk patients. The 5 year biochemical relapse-free survival (bRFS), cancer-specific survival (CSS), overall survival and late gastrointestinal and genitourinary CTCAE.v3 toxicity were assessed. The effect of several clinical variables on both outcome and gastrointestinal/genitourinary toxicity was tested by uni- and multivariate Cox regression analyses. RESULTS: After a median follow-up of 5 years, the late toxicity actuarial incidence was: genitourinary ≥ grade 2: 20.2%; genitourinary ≥ grade 3: 5.9%; gastrointestinal ≥ grade 2: 17%; gastrointestinal ≥ grade 3: 6.3% with lower prevalence at the last follow-up visit (≥ grade 3: genitourinary: 1.9%; gastrointestinal: 1.9%). Major predictors of ≥ grade 3 genitourinary and gastrointestinal late toxicity were genitourinary acute toxicity ≥ grade 2 (hazard ratio: 4.9) and previous surgery (hazard ratio: 3.4). The overall 5 year bRFS was 93.7% (low risk: 94.6%; intermediate risk: 96.2%; high risk: 91.1%), overall survival and CSS were 88.6% (low risk: 90.5%; intermediate risk: 87.4%; high risk: 87%) and 97.5% (low risk: 98.7%; intermediate risk: 95%; high risk: 94.3%), respectively. Risk classes and androgen deprivation were not significantly correlated with either bRFS, overall survival or CSS. Twelve patients experienced a biochemical relapse but none experienced clinically proven local and/or pelvic recurrence. CONCLUSION: A satisfactory 5 year outcome with an acceptable toxicity profile was observed. The combination of image-guided radiotherapy-intensity-modulated radiotherapy, high equivalent 2 Gy dose (EQD2) with a moderate hypofractionated approach and extensive prophylactic lymph node irradiation also leads to very good outcome in high-risk patients.

Characterisation of Yersinia pseudotuberculosis isolated from animals with yersiniosis during 1996-2013 indicates the presence of pathogenic and Far Eastern strains in Italy.

Yersinia pseudotuberculosis is a pathogen that infects both animals and humans worldwide. The epidemiology of infection caused by Y. pseudotuberculosis is poorly understood; however, its outbreaks have been traced back to a probable source in wildlife. This study aimed to characterise Y. pseudotuberculosis isolates collected from animals with yersiniosis. This study included 90 isolates of Y. pseudotuberculosis collected from different animals with yersiniosis between 1996 and 2013 in Italy. The isolates were tested for antimicrobial susceptibility and were biotyped. Genes associated with virulence plasmid pYV and those encoding O-antigen, high pathogenicity island (HPI), and superantigenic toxin (YPM) were determined by performing PCR. Pulsed-field gel electrophoresis (PFGE) was performed using NotI and SpeI enzymes, and 3 dendrograms were generated. No antibiotic resistance was found. The presence of pYV was shown in 57 out of 90 isolates. Virulence profiles of majority of the isolates indicated that they belonged to O:1a and O:1b serotypes, biotype 1, and genetic type 2. Isolates belonging to O:2a serotype were detected in sheep and cattle and were found to be associated (for the first time) with septicemia in hares. Y. pseudotuberculosis isolates belonging to O:5a and O:12-O13 serotypes were also detected in hares. To our knowledge, this is the first study to detect Y. pseudotuberculosis isolates belonging to the O:12-O13 serotype from a clinical case in Europe. Results of PFGE indicated that it was a reliable method for investigating the genetic relatedness of Y. pseudotuberculosis isolates. Thus, characterisation of Y. pseudotuberculosis infection in animals should be considered a possible tool for the surveillance of pseudotuberculosis.

Biological optimization of simultaneous boost on intra-prostatic lesions (DILs): sensitivity to TCP parameters.

The aim of this investigation was to explore the potential of biological optimization in the case of simultaneous integrated boost on intra-prostatic dominant lesions (DIL) and evaluating the impact of TCP parameters uncertainty. Different combination of TCP parameters (TD50 and γ50 in the Poisson-like model), were considered for DILs and the prostate outside DILs (CTV) for 7 intermediate/high-risk prostate patients. The aim was to maximize TCP while constraining NTCPs below 5% for all organs at risk. TCP values were highly depending on the parameters used and ranged between 38.4% and 99.9%; the optimized median physical doses were in the range 94-116 Gy and 69-77 Gy for DIL and CTV respectively. TCP values were correlated with the overlap PTV-rectum and the minimum distance between rectum and DIL. In conclusion, biological optimization for selective dose escalation is feasible and suggests prescribed dose around 90-120 Gy to the DILs. The obtained result is critically depending on the assumptions concerning the higher radioresistence in the DILs. In case of very resistant clonogens into the DIL, it may be difficult to maximize TCP to acceptable levels without violating NTCP constraints.

An outbreak of bovine besnoitiosis in beef cattle born in central Italy.

An outbreak of bovine besnoitiosis in three female, 15-18 months old beef cattle in central Italy is here described. All the animals were born in central Italy without any recent contact with imported animals. The animals were in poor body conditions and showed symptoms and clinical signs consistent with chronic besnoitiosis. The diagnosis was confirmed by histopathologic examinations of skin biopsies and whole body at necropsy, showing typical 50-100 µ cysts engulfing superficial dermis in skin and lamina propria in mucosae; lesions were confined to skin and respiratory mucosae, and cysts were not seen in any other tissue. Bovine besnoitiosis is rapidly spreading among European countries and in our case the affected animals were born in the farm and not recent admission was referred, so it is likely to consider this as an autoctone outbreak of the disease in Italy. This case, taken together with other recently reported ones, suggest to consider Italy among potentially endemic areas for bovine besnoitiosis.

Comparative study of permanent interstitial prostate brachytherapy post-implant evaluation among seven Italian institutes.

BACKGROUND AND PURPOSE: The purposes of this multicentric study are (a) the evaluation of four different commercially available treatment planning systems (TPSs) and (b) to verify whether the dosimetric results are comparable, also when considering the inter-observer variabilities and the different scanning protocols used. This work is to be considered a first step to test the value of multicentric studies based on dosimetric evaluation of the quality of the implants. PATIENTS AND METHODS: Four different TPSs were used and the following tests were performed:Comparison of the parameters and mathematical algorithms used; comparison of the dose distributions generated by three different geometries of sources based on 32 dose-points on each source geometry. An octagonal geometric phantom was used to compare volume algorithms and dose-volume histogram (DVH) calculations (V150(Gy), V100(Gy), V50(Gy) and V25(Gy)). Comparison of the post-plan source distribution performed on a prostate-phantom implanted with (125)I seeds. A CT scan of the phantom was obtained at each participating center. Both the geometrical coordinates (with respect to the most caudal one), and the spread of the geometrical distribution, were calculated. The volumes included within different isodoses were also collected. Comparison of the post-plan source distribution performed on an actual patient. Post-plan V100% and D90(Gy) derived from seed distributions obtained by different operators were calculated, using the same target delineation. RESULTS: All the considered TPSs satisfied the AAPM dosimetric parameter recommendations. Point-dose examinations revealed differences smaller than 5%, except for one of the systems. Although the volume algorithm was not the same for all systems, no statistically significant difference was found in the volume measurements. The DVHs also presented differences smaller than 5%, except for one TPS. The distances between the seeds, based on the same CT images, showed a mean SD of 0.13 mm. The mean maximum difference of the position of each seed was 0.36 mm. The most significant errors were made in the cranio-caudal direction (mean maximal difference: 0.44 mm); here the size of the step between slices played an important role. The algorithm of source positioning of the different TPSs may also help explain this difference. The compiled DVHs showed differences smaller than 5%. Post-plans derived from different seed distributions showed a mild dependence upon operators. We obtained a mean value of 97.8 and 152.7 with a percentage of SD of 0.43 and 1.7, respectively, for V100% and D90(Gy). CONCLUSIONS: Three-dimensional (3D) geometric reconstructions of seed distributions are slightly dependent upon the operators and the scanning protocols have little effect on the dosimetric evaluation. Some relevant discrepancies were found between one of the TPSs and the other three if few sources were used; increasing the number of seeds those differences became less pronounced. Multicentric studies on the quality of prostate implants based on post-implant dosimetry are feasible, provided an accurate step-wise evaluation of the procedure be performed.

Seed migration in prostate brachytherapy: a re-implant case report.

Seed embolisation to the lung is a possible risk following permanent prostate brachytherapy. The purpose of this work is to analyse a seed migration case and to suggest methods to reduce such occurrences. With this aim, the clinical history of the patient who experienced seed migration, the implant technique and the pre- and post-plan procedures have been investigated. The massive seed migration has been detected in the patient by means of a pelvic X-ray and a CT-scan of the thorax. The use of loose seeds, the implant technique and the presence of unfavourable anatomical characteristics, have been recognised as possible causes of this event. The use of linked seeds embedded in vicryl sutures for the peripheral portions of prostate, and the development of an implant technique based on both transverse and longitudinal ultrasound guidance are proposed in order to reduce seed migration.

Polarity effects of ionization chambers used in tbi dosimetry due to cable irradiation.

This paper presents the results of an investigation on polarity effects in total-body irradiation (TBI) dosimetry. Thimble (NE2571, 0.6 cc) and plane-parallel (Markus NE2534 0.055 cc) chambers were investigated in a 30 x 30 x 30-cm3 acrylic phantom in TBI conditions (6-MV x-rays). The thimble chamber was positioned at the midline and at the entrance and exit Dmax (1.5 cm from the phantom surface) levels. The Markus chamber, which is generally used for skin dose estimations, was positioned at various depths from the entrance surface of the phantom (from 0- to 2-cm depth). The polarity factor (Ppol) was defined as (Q+ + Q-)/2Q-, where Q+ and Q- were the collected charges at positive and negative bias voltage, respectively. The variations of Ppol with many parameters (absorbed dose, dose rate, the presence or absence of a 1-cm acrylic spoiler, irradiated cable length) were investigated. Results show that Ppol is quite small (within 1.002 for on-axis measurements and 1.005 for off-axis measurements) for the NE2571 chamber when the beam spoiler is placed. Ppol was significantly higher without the beam spoiler (within 1.008 for on-axis measurements, up to 1.02 for off-axis measurements). Concerning the Markus chamber, for on-axis skin dose measurements, Ppol was found to be less than unity (around 0.988) or more than unity (around 1.0035), respectively, with and without the beam spoiler. Possible "directional effects" of the currents generated in the cable were investigated for both chambers and found to be insignificant. This shows that the application of Ppol correction has to be considered a reliable procedure in minimizing these effects. When the beam spoiler is placed, the cable has to be drawn to minimize the portion of cable just outside the beam; if this is not the case, Ppol may significantly vary (for the NE2571 chamber values up to 1.0035 were found for on-axis measurements).

Quality assurance by systematic in vivo dosimetry: results on a large cohort of patients.

BACKGROUND: In vivo dosimetry is widely considered to be an important tool for quality assurance in external radiotherapy. INTRODUCTION: In this study we report on our experience over more than 4 years in systematic in vivo dosimetry with diodes. MATERIALS AND METHODS: From November '94 an in vivo entrance dosimetry check was performed for every new patient irradiated at one of our treatment units (Linac 6/100, 6 MV X-rays). Diodes were calibrated in terms of entrance dose; appropriate correction factors had been previously assessed (taking SSDs, field width, wedge, oblique incidence and blocking tray into account) and were individually applied to in vivo diode readings. The in vivo measured entrance dose was compared with the expected one, with a 5% action level; if a larger deviation was found, all treatment parameters were verified, and the in vivo dosimetry check was repeated. During the period November '94-May '99, 2824 measurements on 1433 patients were collected. RESULTS: Nine out of 1433 (0.63%) serious systematic errors (leading to a 5% or more on the delivered dose to the PTV) were detected by in vivo dosimetry; four out of nine would produce a 10% or more error if not detected. The rate of serious systematic errors detected by an independent check of treatment chart and MU calculation was found to be 1.5%, showing that less than 1/3 of the errors escapes this check. One hundred and twelve out of 1433 (7.8%) patients had more than one check: the rate of second checks was significantly higher for breast patients (31/250, 12.4%) against non-breast patients (81/1183, 6.8%, P=0.003). A number of patients demonstrated a persistent relatively large error even after two or more checks. For almost all patients the cause of the deviation was assessed; the most frequent cause was the difficulty in correctly positioning the patient and/or the diode. When analyzing the distribution of the deviations between measured and expected entrance doses (excluding first checks in the case of repetition of the in vivo dosimetry control) the mean deviation was 0.4% with a standard deviation equal to 3.0%. The rates of deviations larger than 5 and 7% were 9.9 and 2.6%, respectively. When considering the same data taking the average deviation in the case of opposed beams, the SD became 2.6% and the rates of deviations larger than 5 and 7%, respectively, 5.2 and 0.8%. When dividing the beams according to their orientation, significantly higher rates of large deviations (>5 and 7%) were found for oblique and posterior-anterior (PA) fields against lateral and anterior-posterior (AP) fields (P<0.05). Similarly, higher rates of large deviations were found for wedged fields against unwedged fields (P<0.03) and for blocked fields against unblocked fields (P<0.01). When dividing the data according to the anatomical district, accuracy was worse for breast (mean deviation 0.1%, 1 SD: 3.5%) and neck AP-PA fields (mean deviation 1%, 1 SD: 3,4%). Better accuracy was found for vertebrae (0.1%, 1 SD 2. 1%) and brain patients (-0.7%, 1 SD: 2.6%). During the considered period, in vivo dosimetry was also able to promptly detect a systematic error caused by a wrong resetting of the simulator height couch indicator, with a consequent error in the estimate of patient thickness of about 4 cm. CONCLUSIONS: In our experience, systematic in vivo dosimetry demonstrated to be a valid tool for quality assurance, both in detecting systematic errors which may escape the data transfer/MU calculation check and in giving an effective way of estimating the accuracy of treatment delivery.

In-vivo dosimetry by diode semiconductors in combination with portal films during TBI: reporting a 5-year clinical experience.

BACKGROUND AND PURPOSE: In-vivo dosimetry is vital to assure an accurate delivery of total body irradiation (TBI). In-vivo lung dosimetry is strongly recommended because of the risk of radiation-induced interstitial pneumonia (IP). Here we report on our 5-year experience with in-vivo dosimetry using diodes in combination with portal films and assessing the effectiveness of in-vivo dosimetry in improving the accuracy of the treatment. Moreover, we wished to investigate in detail the possibility of in-vivo portal dosimetry to yield individual information on the lung dose and to evaluate the impact of CT planning on the correspondence between stated and in-vivo measured doses. MATERIALS AND METHODS: From March 1994 to March 1999, 229 supine-positioned patients were treated at our Institute with TBI, using a 6 MV X-rays opposed lateral beam technique. 146 patients received 10 Gy given in three fractions, once a day (FTBI), shielding the lungs by the arms; 70 received 12-13.2 Gy, given in 6-11 fractions, 2-3 fractions per day (HFTBI): in this case about 2/3 of the lungs were shielded by moulded blocks (mean shielded lung dose equal to 9 or 9.5 Gy). Thirteen patients received 8 Gy given in a single fraction (SFTBI, lung dose: 7 Gy). For all HFTBI and FTBI patients, midline in-vivo dosimetry was performed at the first fraction by positioning two diodes pairs (one at entrance and one at the exit side) at the waist (umbilicus) and at the pelvis (ankles). If at least one of the two diodes doses (waist-pelvis) was outside +/-5% from the prescribed dose, actions could be initiated, together with possible checks on the following fractions. Transit dosimetry by portal films was performed for most patients; for 165 of them (117 and 48, respectively for FTBI and HFTBI) the midline in-vivo dose distribution of the chest region was derived and mean lung dose assessed. As a CT plan was performed for all HFTBI patients, for these patients, the lung dose measured by portal in-vivo dosimetry was compared with the expected value. RESULTS: Concerning all diodes data, 528 measurements were available: when excluding the data of the first fraction(s) of the patients undergoing corrections (n = 392), mean and SD were respectively 0.0% and 4.5% (FTBI: -0.3 +/- 4.8%; HFTBI: 0.4 +/- 3.9%). In total 105/229 patients had a change after the first fraction and 66/229 were controlled by in-vivo dosimetry for more than one fraction. Since January 1998 a CT plan is performed for FTBI patients too: when comparing the diodes data before and after this date, a significant improvement was found (i.e. rate of deviations larger than 5% respectively equal to 30.7% and 13.1%, P = 0.007). When considering only the patients with a CT plan, the global SD reduced to 3.5%. Concerning transit dosimetry data, for FTBI, the mean (midline) lung dose was found to vary significantly from patient to patient (Average 9.13 +/- 0.81 Gy; range 7.4-11.4 Gy); for the HFTBI patients the mean deviation between measured and expected lung dose was 0.0% (1 SD = 3.8%). CONCLUSIONS: In vivo dosimetry is an effective tool to improve the accuracy of TBI. The impact of CT planning for FTBI significantly improved the accuracy of the treatment delivery. Transit dosimetry data revealed a significant inter-patient variation of the mean lung dose among patients undergoing the same irradiation technique. For patients with partial lung shielding (HFTBI), an excellent agreement between measured and expected lung dose was verified.

1D dynamic beam modulation: methods to counteract inertia effects.

Dynamic modulation can be affected by inaccuracies when the required acceleration is larger than the highest allowed by the mechanical characteristics of the whole apparatus. In this study, inertia effects have been investigated with regard to the single absorber 1D modulation, analysing primarily how the acceleration performed by the modulating system affects the realization of 'single absorber' fluence profiles and the type of correction which could be devised. The observed percentage deviations from desired modulation at the lowest fluence coordinate of single minimum fluence profiles, when no correction is applied, were almost negligible for 'easy' modulations of the incident fluence (i.e. slow gradients); deviations became increasingly relevant as the moving absorber executed steeper gradients (a 17.6% higher dose being delivered in the minimum position when a 0.2 modulation is required). By applying the proposed corrections, the single absorber performances were improved to a satisfactory level, with a maximum deviation from desired modulation in the minima within 1.6%.

Dosimetric evaluation of a commercial 3-D treatment planning system using Report 55 by AAPM Task Group 23.

BACKGROUND AND PURPOSE: A relevant part of radiotherapy treatment planning system QA concerns dose calculation verification. Report 55 by AAPM TG-23 is an instrument for performing dosimetric evaluation of treatment planning systems in case of external photon beams. It was employed by different groups in three radiotherapy departments for controlling performances of RTPS CadPlan Varian-Dosetek, versions 2.7.9, 3.0.6 and 3.1.1. MATERIALS AND METHODS: Once the basic data of the AAPM 4 MV and 18 MV X-ray units had been converted into the CadPlan format and the AAPM units configured, the whole set of TG23 tests were carried out on three different systems. According to Report 55, comparisons between values measured by TG-23 and calculated by RTPS were made in terms of dose at selected points and radiological field width at different depths. RESULTS: As far as dose is concerned, 266 data were compared for 4 MV and 297 for 18 MV. Ninety-five-point-nine percent of dose deviations for 4 MV and 92.6% for 18 MV are less than 2%. Most of the relevant discrepancies for both energies occur in a test case where dose has to be calculated under a long narrow block centred on the beam axis. Deviations as much as 6.1% for 4 MV and -7.5% for 18 MV were observed in points at 1 cm depth under the block. Poor results were also observed in the rectangular field 25 x 5, in points outside the field edges under collimators. As regards radiological field width, 58 out of 64 comparisons for 4 MV occurred in the range +/- 2 mm. For 18 MV the biggest deviation was -2.2 mm. CONCLUSIONS: The TG-23 tests demonstrated that the accuracy of the RTPS in dose calculation is good in most of the typical radiotherapy applications. Our results are better than those recently published for other RTPS. The TG-23 package turned out to be an effective instrument for QA and calculation verification, as well as being a powerful method for training purpose in configuring and using a RTPS.

Dose calculation and dosimetry tests for clinical implementation of 1D tissue-deficit compensation by a single dynamic absorber.

BACKGROUND AND PURPOSE: In this study the possibilities for implementing 1D tissue-deficit compensation techniques by a dynamic single absorber were investigated. This research firstly involved a preliminary examination on the accuracy of a pencil beam-based algorithm, implemented for irregularly shaped photon beams in our 3D treatment planning system (TPS) (Cadplan 2.7, Varian-Dosetek Oy), in calculating dose distributions delivered in ID non-uniform fields. Once the reliability of the pencil beam (PB) algorithm for dose calculations in non-uniform beams was verified, we proceeded to test the feasibility of tissue-deficit compensation using our single absorber modulator. As an example, we considered a mantle field technique. MATERIALS AND METHODS: To evaluate the accuracy of the method employed in calculating dose distributions delivered in 1D non-uniform fields, three different fluence profiles, which could be considered as a small sample representative of clinically relevant applications, were selected. The incident non-uniform fluences were simulated by the sum of simple blocked fields (i.e. with rectangular 'strip' blocks, one per beam) properly weighed by the 'modulation factors' Fi, defined in each interval of the subdivided profile as the ratio between the desired fluence and the open field fluence. Depth dose distributions in a cubic phantom were then calculated by the TPS and compared with the corresponding doses (at 5 and 10 cm acrylic depths) delivered by the single absorber modulation system. In the present application, the absorber speed profile able to compensate for the tissue deficit along the cranio-caudal direction and then homogenizing the dose distribution on a 'midline' isocentric plane with sufficient accuracy can be directly derived from anatomic data, such as the SSDs (source-skin distances) along the patient contour. The compensation can be verified through portal dosimetry techniques (using a traditional port film system). RESULTS: The technique was tested in isocentric conditions on the humanoid RANDO phantom in a clinically suitable situation. The agreement between expected/calculated and measured incident/exit dose profiles was found to be within 4%, with deviations generally around 1-2%. As for the PB accuracy investigation for dose calculations in non-uniform fields, calculated versus measured dose profiles were found to be in good agreement, indicating a satisfactory accuracy of the method employed for dose calculation in 1D non-uniform photon beams. A better performance should be expected if the incident fluences could be directly inserted in the TPS. CONCLUSIONS: The results show that the proposed technique should be sufficiently reliable for clinical application. The main advantages are its simplicity and the possibility of application on Linacs which have no complex options for dynamic control of collimators.

Variations of tumor control and rectum complication probabilities due to random set-up errors during conformal radiation therapy of prostate cancer.

BACKGROUND AND PURPOSE: The effect of random set-up errors on tumor control probability (TCP) and rectum complication probability (NTCP) on 3D conformal treatment planning of prostate cancer has been investigated by applying the convolution method originally proposed by Leong (Leong, J. Implementation of random positioning error in computerized radiation treatment planning systems as a result of fractionation. Phys. Med. Biol. 32: 327-334, 1987). MATERIALS AND METHODS: The combined influence of the standard deviation of the random shifts probability distribution (sigma) of the dose and of the Beam's-eye-view margin (M) between the clinical target volume (CTV) and the edge of the blocks have been investigated in two patients. RESULTS AND CONCLUSIONS: Random set-up error has been found to decrease TCP (for a typical 70 Gy CTV mean dose) by up to 6% for a 1 cm margin (sigma = 7 mm). When M is equal to or larger than 1.5 cm, no relevant effects on TCP are obtained. Maximum acceptable TCP values (corresponding to a rectum NTCP equal to 5%) have been derived and the dependence on sigma and M has been investigated.

Detection of systematic errors in external radiotherapy before treatment delivery.

The execution of an independent control of monitor units (MU) and dose distribution calculation, together with a check of the data reported in the treatment chart is an effective tool in strongly reducing the occurrence of systematic errors before treatment delivery. In this paper we report the results of the analysis of 6272 controls (about 5000 patients) registered over more than 5 years; 70 serious errors (producing a deviation larger than 5% from the prescribed daily dose) and 147 minor errors were detected and corrected before the start of the treatment. The error rate was found to be strongly operator-dependent (serious error rate ranging from 0.3 to 2.5% when considering different operators). A time-trend analysis showed a significant reduction of serious errors, i.e. 1.5% in the period from September 1991 to April 1994 compared to 0.9% in the period from April 1994 to November 1996. However, even if the double check was highly effective in revealing human errors, three serious systematic errors (errors occurring during the calculation/planning/transcription phases) escaped the control and were detected by diode in vivo dosimetry during the period October 1994 to November 1996 (in 650 patients controlled).