Current best estimates of beam quality correction factors for reference dosimetry of clinical proton beams.

Objective. To review the currently available data on beam quality correction factors,kQ,for ionization chambers in clinical proton beams and derive their current best estimates for the updated recommendations of the IAEA TRS-398 Code of Practice.Approach. The reviewed data come from 20 publications from whichkQvalues can be derived either directly from calorimeter measurements, indirectly from comparison with other chambers or from Monte Carlo calculated overall chamber factors,fQ.For cylindrical ionization chambers, a distinction is made between data obtained in the centre of a spread-out Bragg peak and those obtained in the plateau region of single-energy fields. For the latter, the effect of depth dose gradients has to be considered. To this end an empirical model for previously published displacement correction factors for single-layer scanned beams was established, while for unmodulated scattered beams experimental data were used. From all the data, chamber factors,fQ,and chamber perturbation correction factors,pQ,were then derived and analysed.Main results. The analysis showed that except for the beam quality dependence of the water-to-air mass stopping power ratio and, for cylindrical ionization chambers in unmodulated beams, of the displacement correction factor, there is no remaining beam quality dependence of the chamber perturbation correction factorspQ.Based on this approach, average values of the beam quality independent part of the perturbation factors were derived to calculatekQvalues consistent with the data in the literature.Significance. The resulting data from this analysis are current best estimates ofkQvalues for modulated scattered beams and single-layer scanned beams used in proton therapy. Based on this, a single set of harmonized values is derived to be recommended in the update of IAEA TRS-398.

Experimental determination ofkQfactors for two types of ionization chambers in scanned proton beams.

Objective.Experimental determination of beam qualitykQfactors for two types of Farmer ionization chambers, NE2571 and IBA FC65-G, in a scanned proton beam for three nominal energies (140 MeV, 180 MeV and 220 MeV) based on water calorimetry.Approach.Beam quality correction factors were determined comparing the results obtained with water calorimetry and ionometry. Water calorimetry was performed to determine the absorbed dose at a depth of measurement in water of 5 g cm-2, limited by the extension of the calorimeter glass vessel used. For the ionometry, two chambers of each type were included in the study. The ionization chambers were calibrated in terms of absorbed dose to water in60Co at the Swedish Secondary Standard Dosimetry Laboratory, directly traceable to the BIPM, and were used according to the IAEA TRS-398 Code of Practice.Main results. ThekQvalues determined in the present work have been compared with the values tabulated in TRS-398 and its forthcoming update and also with those obtained in previous water calorimetric measurements and Monte Carlo calculations. All results were found to agree within the combined uncertainties of the different data.Significance. It is expected that the present work will serve as an experimental contribution tokQ-factors for the two chamber types and three scanned proton beam qualities used.

Clinical validation of a commercially available deep learning software for synthetic CT generation for brain.

BACKGROUND: Most studies on synthetic computed tomography (sCT) generation for brain rely on in-house developed methods. They often focus on performance rather than clinical feasibility. Therefore, the aim of this work was to validate sCT images generated using a commercially available software, based on a convolutional neural network (CNN) algorithm, to enable MRI-only treatment planning for the brain in a clinical setting. METHODS: This prospective study included 20 patients with brain malignancies of which 14 had areas of resected skull bone due to surgery. A Dixon magnetic resonance (MR) acquisition sequence for sCT generation was added to the clinical brain MR-protocol. The corresponding sCT images were provided by the software MRI Planner (Spectronic Medical AB, Sweden). sCT images were rigidly registered and resampled to CT for each patient. Treatment plans were optimized on CT and recalculated on sCT images for evaluation of dosimetric and geometric endpoints. Further analysis was also performed for the post-surgical cases. Clinical robustness in patient setup verification was assessed by rigidly registering cone beam CT (CBCT) to sCT and CT images, respectively. RESULTS: All sCT images were successfully generated. Areas of bone resection due to surgery were accurately depicted. Mean absolute error of the sCT images within the body contour for all patients was 62.2 ± 4.1 HU. Average absorbed dose differences were below 0.2% for parameters evaluated for both targets and organs at risk. Mean pass rate of global gamma (1%/1 mm) for all patients was 100.0 ± 0.0% within PTV and 99.1 ± 0.6% for the full dose distribution. No clinically relevant deviations were found in the CBCT-sCT vs CBCT-CT image registrations. In addition, mean values of voxel-wise patient specific geometric distortion in the Dixon images for sCT generation were below 0.1 mm for soft tissue, and below 0.2 mm for air and bone. CONCLUSIONS: This work successfully validated a commercially available CNN-based software for sCT generation. Results were comparable for sCT and CT images in both dosimetric and geometric evaluation, for both patients with and without anatomical anomalies. Thus, MRI Planner is feasible to use for radiotherapy treatment planning of brain tumours.

Prospective Clinical Feasibility Study for MRI-Only Brain Radiotherapy.

OBJECTIVES: MRI-only radiotherapy (RT) provides a workflow to decrease the geometric uncertainty introduced by the image registration process between MRI and CT data and to streamline the RT planning. Despite the recent availability of validated synthetic CT (sCT) methods for the head region, there are no clinical implementations reported for brain tumors. Based on a preceding validation study of sCT, this study aims to investigate MRI-only brain RT through a prospective clinical feasibility study with endpoints for dosimetry and patient setup. MATERIAL AND METHODS: Twenty-one glioma patients were included. MRI Dixon images were used to generate sCT images using a CE-marked deep learning-based software. RT treatment plans were generated based on MRI delineated anatomical structures and sCT for absorbed dose calculations. CT scans were acquired but strictly used for sCT quality assurance (QA). Prospective QA was performed prior to MRI-only treatment approval, comparing sCT and CT image characteristics and calculated dose distributions. Additional retrospective analysis of patient positioning and dose distribution gamma evaluation was performed. RESULTS: Twenty out of 21 patients were treated using the MRI-only workflow. A single patient was excluded due to an MRI artifact caused by a hemostatic substance injected near the target during surgery preceding radiotherapy. All other patients fulfilled the acceptance criteria. Dose deviations in target were within ±1% for all patients in the prospective analysis. Retrospective analysis yielded gamma pass rates (2%, 2 mm) above 99%. Patient positioning using CBCT images was within ± 1 mm for registrations with sCT compared to CT. CONCLUSION: We report a successful clinical study of MRI-only brain radiotherapy, conducted using both prospective and retrospective analysis. Synthetic CT images generated using the CE-marked deep learning-based software were clinically robust based on endpoints for dosimetry and patient positioning.

Gradient corrections for reference dosimetry using Farmer-type ionization chambers in single-layer scanned proton fields.

PURPOSE: The local depth dose gradient and the displacement correction factor for Farmer-type ionization chambers are quantified for reference dosimetry at shallow depth in single-layer scanned proton fields. METHOD: Integrated radial profiles as a function of depth (IRPDs) measured at three proton therapy centers were smoothed by polynomial fits. The local relative depth dose gradient at measurement depths from 1 to 5 cm were derived from the derivatives of those fits. To calculate displacement correction factors, the best estimate of the effective point of measurement was derived from reviewing experimental and theoretical determinations reported in the literature. Displacement correction factors for the use of Farmer-type ionization chambers with their reference point (at the center of the cavity volume) positioned at the measurement depth were derived as a ratio of IRPD values at the measurement depth and at the effective point of measurement. RESULTS: Depth dose gradients are as low as 0.1-0.4% per mm at measurement depths from 1 to 5 cm in the highest clinical proton energies (with residual ranges higher than 15 cm) and increase to 1% per mm at a residual range of 4 cm and become larger than 3% per mm for residual ranges lower than 2 cm. The literature review shows that the effective point of measurement of Farmer-type ionization chambers is, similarly as for carbon ion beams, located 0.75 times the cavity radius closer to the beam origin as the center of the cavity. If a maximum displacement correction of 2% is deemed acceptable to be included in calculated beam quality correction factors, Farmer-type ICs can be used at measurements depths from 1 to 5 cm for which the residual range is 4 cm or larger. If one wants to use the same beam quality correction factors as applicable to the conventional measurement point for scattered beams, located at the center of the SOBP, the relative standard uncertainty on the assumption that the displacement correction factor is unity can be kept below 0.5% for measurement depths of at least 2 cm and for residual ranges of 15 cm or higher. CONCLUSION: The literature review confirmed that for proton beams the effective point of measurement of Farmer-type ionization chambers is located 0.75 times the cavity radius closer to the beam origin as the center of the cavity. Based on the findings in this work, three options can be recommended for reference dosimetry of scanned proton beams using Farmer-type ionization chambers: (a) positioning the effective point of measurement at the measurement depth, (b) positioning the reference point at the measurement depth and applying a displacement correction factor, and (c) positioning the reference point at the measurement depth without applying a displacement correction factor. Based on limiting the acceptable uncertainty on the gradient correction factor to 0.5% and the maximum deviation of the displacement perturbation correction factor from unity to 2%, the first two options can be allowed for residual ranges of at least 4 cm while the third option only for residual ranges of at least 15 cm.

Implementation of water calorimetry in a 180 MeV scanned pulsed proton beam including an experimental determination of kQ for a Farmer chamber.

Water calorimetric measurements have been performed in a 180 MeV scanned pulsed proton beam and the absorbed dose determined has been compared with the results obtained using two NE2571 Farmer chambers and the IAEA TRS-398 code of practice. The depth of measurement in water corresponded to a residual range of R(res) = 16.5 cm, corresponding to a mean energy of about 150 MeV. Ionization chambers were calibrated in terms of the absorbed dose to water in (60)Co at the Swedish Secondary Standard Dosimetry Laboratory, directly traceable to Bureau International des Poids et Mesures. The present experimental investigation has shown that water calorimetry is feasible in a high-energy scanned pulsed proton beam. When comparing the results obtained with water calorimetry and ionometry, the beam quality correction factor, k(Q), could be determined for the two NE2571 ionization chambers used. The k(Q)-factor was found to be 1.032 +/- 0.013, which is in good agreement with the factor tabulated in IAEA TRS-398 for this chamber type (1.039 +/- 0.018). The present result has also been compared with a previously obtained result in a passively scattered proton beam having similar energy. This comparison yielded a 1.1% deviation, which is not significant considering the combined uncertainties of the two experimental determinations of k(Q). The dominating contribution to the combined uncertainty stems from the correction factor for ion recombination in the scanned proton beam (1%), and further studies are required in order to reduce this uncertainty and reveal any possible differences in the k(Q)-factor between these two proton beam delivery techniques.

RapidArc volumetric modulated therapy planning for prostate cancer patients.

PURPOSE: Recently, Varian Medical Systems have announced the introduction of a new treatment technique, RapidArc, in which dose is delivered over a single gantry rotation with dynamically variable MLC positions, dose rate and gantry speed. At Rigshospitalet, the RapidArc technique was brought into clinical practice in May 2008 for treatment of prostate cancer patients. We report here our experiences with performing treatment planning using the Eclipse RapidArc optimization software for this patient group. MATERIAL AND METHODS: A stand-alone installation of Eclipse 8.5 with RapidArc optimization capability was performed at Rigshospitalet. Patient data for 8 prostate cancer patients were imported, most of whom were previously treated at Rigshospitalet using IMRT. Three of the patients were treated at Rigshospitalet using the RapidArc technique. Treatment plans were optimized using objectives as given by standard guidelines for clinical treatment planning. RapidArc plans were compared to the IMRT plans by which the patients were actually treated or in the three cases treated with the RapidArc technique to IMRT plans achieved using standard guidelines. Comparison was done with respect to target coverage, doses to rectum and bladder, over-all maximum dose and number of monitor units. RESULTS: Overall, the RapidArc treatment plans gave better or equal sparing of the organs at risk than the IMRT treatment plans. The number of monitor units was lower in most cases, by up to approximately 75%. However, the target dose homogeneity was not as high as for IMRT. The low-dose bath was larger than for IMRT. CONCLUSION: RapidArc optimization is very promising, especially regarding the potential of reducing the number of monitor units, while providing good sparing of organs at risk. Some improvement is still warranted with respect to achieving high target dose homogeneity.

Dosimetric verification of RapidArc treatment delivery.

PURPOSE: Recently, Varian Medical Systems have announced the introduction of a new treatment technique, in which dose is delivered over a single gantry rotation with variable MLC positions, dose rate and gantry speed. In February 2008, a preclinical installation of the RapidArc beam delivery approach was carried out on a Varian Clinac at Rigshospitalet in Copenhagen. The purpose of the installation was to perform measurements to verify the correctness of doses delivered with the RapidArc technique. In May 2008, the clinical release of the RapidArc application was installed at Rigshospitalet. METHODS AND MATERIALS: Nine treatment plans were generated in the Eclipse version 8.5 including the RapidArc optimizer for H&N and prostate cases. The plans were delivered to the Scandidos Delta4 cylindrical diode array phantom. First, the measured dose distributions were compared with the calculated doses. All plans were then delivered several times to verify consistency of the delivery. Gamma analysis was used to verify the correspondence between dose distributions. The temporal resolution of the delivery was analysed by investigating the arc segments between control points separately. RESULTS: Overall, good agreement was observed between measured and calculated doses in most cases with gamma values above 1 in >95% of measured points. The reproducibility of delivery was also very high. Gamma analysis between two consecutive runs of the same delivery plan generally showed gamma values above 1 in none of the measured points, and dose deviation less than 1%. Temporal analysis showed small discrepancies between doses delivered between control points (approximately 2 degrees of the rotation) in consecutive runs of a plan, however these were cancelled out in the accumulated dose. CONCLUSION: The delivery of RapidArc beam delivery has been verified to correspond well with calculated dose distributions for a number of different cases. The delivery was very reproducible, and was carried out with high stability of the accelerator performance.

Reference dosimetry in a scanned pulsed proton beam using ionisation chambers and a Faraday cup.

In order to give the correct dose to a patient, the monitor chamber for a proton scanning system has to be calibrated. As recombination of ion pairs occurs in the monitor chamber, the relation between the number of particles traversing it per time unit and the ionization chamber signal is not linear. A method developed for a scanned pulsed proton beam taking the nonlinear monitor signal into account is described. A vital part of the reference dosimetry procedure is to determine the absorbed dose under reference conditions, which is recommended to be done with an ionization chamber. For a scanned pulsed proton beam, the recombination in the ionization chamber is not negligible and the signal from the ionization chamber has to be corrected. In this work, it is shown that although the pulse length is comparable to the ion transit time the beam can be considered as continuously scanned if the applied high voltage is not too small. Also shown is that the two-voltage formula for a continuous beam is under some conditions applicable for a continuous scanned beam as well.

Experimental determination of beam quality factors, kQ, for two types of Farmer chamber in a 10 MV photon and a 175 MeV proton beam.

Absorbed doses determined with a sealed water calorimeter operated at 4 degrees C are compared with the results obtained using ionization chambers and the IAEA TRS-398 code of practice in a 10 MV photon beam (TPR(20,10) = 0.734) and a 175 MeV proton beam (at a depth corresponding to the residual range, R(res) = 14.7 cm). Three NE 2571 and two FC65-G ionization chambers were calibrated in terms of absorbed-dose-to-water in (60)Co at the Swedish secondary standard dosimetry laboratory, directly traceable to the BIPM. In the photon beam quality, calorimetry was found to agree with ionometry within 0.3%, confirming the k(Q) values tabulated in TRS-398. In contrast, a 1.8% deviation was found in the proton beam at 6 g cm(-2) depth, suggesting that the TRS-398 tabulated k(Q) values for these two ionization chamber types are too high. Assuming no perturbation effect in the proton beam for the ionization chambers, a value for (w(air)/e)(Q) of 33.6 J C(-1) +/- 1.7% (k = 1) can be derived from these measurements. An analytical evaluation of the effect from non-elastic nuclear interactions in the ionization chamber wall indicates a perturbation effect of 0.6%. Including this estimated result in the proton beam would increase the determined (w(air)/e)(Q) value by the same amount.

Evaluation of image quality of lumbar spine images: a comparison between FFE and VGA.

PURPOSE: The aim of the present study is to compare two different methods for evaluation of the quality of clinical X-ray images. METHODS: Based on fifteen lumbar spine radiographs, two new sets of images were created. A hybrid image set was created by adding two distributions of artificial lesions to each original image. The image quality parameters spatial resolution and noise were manipulated and a total of 210 hybrid images were created. A set of 105 disease-free images was created by applying the same combinations of spatial resolution and noise to the original images. The hybrid images were evaluated with the free-response forced error experiment (FFE) and the normal images with visual grading analysis (VGA) by nine experienced radiologists. RESULTS: In the VGA study, images with low noise were preferred over images with higher noise levels. The alteration of the MTF had a limited influence on the VGA score. For the FFE study, the visibility of the lesions was independent of the sharpness and the noise level. No correlation was found between the two image quality measures. CONCLUSIONS: FFE is a precise method for evaluation of image quality, but the results are only valid for the type of lesion used in the study, whereas VGA is a more general method for clinical image quality assessment. The results of the FFE study indicate that there might be a potential to lower the dose levels in lumbar spine radiography without losing important diagnostic information.

Inter-observer variation in masked and unmasked images for quality evaluation of clinical radiographs.

PURPOSE: To investigate the influence of masking on the inter-observer variation in image quality evaluation of clinical radiographs of chest and lumbar spine. BACKGROUND: Inter-observer variation is a big problem in image quality evaluation since this variation is often much bigger than the variation in image quality between, for example, two radiographic systems. In this study, we have evaluated the effect of masking on the inter-observer variation. The idea of the masking was to force every observer to view exactly the same part of the image and to avoid the effect of the overall 'first impression' of the image. A discussion with a group of European expert radiologists before the study indicated that masking might be a good way to reduce the inter-observer variation. METHODS: Five chest and five lumbar spine radiographs were collected together with detailed information regarding exposure conditions. The radiographs were digitised with a high-performance scanner and five different manipulations were performed, simulating five different exposure conditions. The contrast, noise and spatial resolution were manipulated by this method. The images were printed onto the film and the individual masks were produced for each film, showing only the parts of the images that were necessary for the image quality evaluation. The quality of the images was evaluated on ordinary viewing boxes by a large group of experienced radiologists. The images were examined with and without the masks with a set of image criteria (if fulfilled, 1 point; and not fulfilled, 0 point), and the mean score was calculated for each simulated exposure condition. RESULTS: The results of this study indicate that-contrary to what was supposed-the inter-observer variation increased when the images were masked. In some cases, especially for chest, this increase was statistically significant. CONCLUSIONS: Based on the results of this study, image masking in studies of fulfilment of image criteria cannot be recommended.

Linear energy transfer dependence of a normoxic polymer gel dosimeter investigated using proton beam absorbed dose measurements.

Three-dimensional dosimetry with good spatial resolution can be performed using polymer gel dosimetry, which has been investigated for dosimetry of different types of particles. However, there are only sparse data concerning the influence of the linear energy transfer (LET) properties of the radiation on the gel absorbed dose response. The purpose of this study was to investigate possible LET dependence for a polymer gel dosimeter using proton beam absorbed dose measurements. Polymer gel containing the antioxidant tetrakis(hydroxymethyl)phosphonium (THP) was irradiated with 133 MeV monoenergetic protons, and the gel absorbed dose response was evaluated using MRI. The LET distribution for a monoenergetic proton beam was calculated as a function of depth using the Monte Carlo code PETRA. There was a steep increase in the Monte Carlo calculated LET starting at the depth corresponding to the front edge of the Bragg peak. This increase was closely followed by a decrease in the relative detector sensitivity (Srel = Dgel/Ddiode), indicating that the response of the polymer gel detector was dependent on LET. The relative sensitivity was 0.8 at the Bragg peak, and reached its minimum value at the end of the proton range. No significant effects in the detector response were observed for LET < 4.9 keV microm(-1), thus indicating that the behaviour of the polymer gel dosimeter would not be altered for the range of LET values expected in the case of photons or electrons in a clinical range of energies.

Real-time optical-fibre luminescence dosimetry for radiotherapy: physical characteristics and applications in photon beams.

A new optical-fibre radiation dosimeter system, based on radioluminescence and optically stimulated luminescence from carbon-doped aluminium oxide, was developed and tested in clinical photon beams. This prototype offers several features, such as a small detector (1 x 1 x 2 mm3), high sensitivity, real-time read-out and the ability to measure both dose rate and absorbed dose. The measurements describing reproducibility and output dependence on dose rate, field size and energy all had standard deviations smaller than 1%. The signal variation with the angle of incidence was smaller than 2% (1 SD). Measurements performed in clinical situations suggest the potential of using this real-time system for in vivo dosimetry in radiotherapy.