Innovations in Radiotherapy Technology.

Many low- and middle-income countries, together with remote and low socioeconomic populations within high-income countries, lack the resources and services to deal with cancer. The challenges in upgrading or introducing the necessary services are enormous, from screening and diagnosis to radiotherapy planning/treatment and quality assurance. There are severe shortages not only in equipment, but also in the capacity to train, recruit and retain staff as well as in their ongoing professional development via effective international peer-review and collaboration. Here we describe some examples of emerging technology innovations based on real-time software and cloud-based capabilities that have the potential to redress some of these areas. These include: (i) automatic treatment planning to reduce physics staffing shortages, (ii) real-time image-guided adaptive radiotherapy technologies, (iii) fixed-beam radiotherapy treatment units that use patient (rather than gantry) rotation to reduce infrastructure costs and staff-to-patient ratios, (iv) cloud-based infrastructure programmes to facilitate international collaboration and quality assurance and (v) high dose rate mobile cobalt brachytherapy techniques for intraoperative radiotherapy.

Dosimetric evaluation of a novel polymer gel dosimeter for proton therapy.

PURPOSE: The aim of this study is to evaluate the dosimetric performance of a newly developed proton-sensitive polymer gel formulation for proton therapy dosimetry. METHODS: Using passive scattered modulated and nonmodulated proton beams, the dose response of the gel was assessed. A next-generation optical CT scanner is used as the readout mechanism of the radiation-induced absorbance in the gel medium. Comparison of relative dose profiles in the gel to ion chamber profiles in water is performed. A simple and easily reproducible calibration protocol is established for routine gel batch calibrations. Relative stopping power ratio measurement of the gel medium was performed to ensure accurate water-equivalent depth dose scaling. Measured dose distributions in the gel were compared to treatment planning system for benchmark irradiations and quality of agreement is assessed using clinically relevant gamma index criteria. RESULTS: The dosimetric response of the gel was mapped up to 600 cGy using an electron-based calibration technique. Excellent dosimetric agreement is observed between ion chamber data and gel. The most notable result of this work is the fact that this gel has no observed dose quenching in the Bragg peak region. Quantitative dose distribution comparisons to treatment planning system calculations show that most (> 97%) of the gel dose maps pass the 3%/3 mm gamma criterion. CONCLUSIONS: This study shows that the new proton-sensitive gel dosimeter is capable of reproducing ion chamber dose data for modulated and nonmodulated Bragg peak beams with different clinical beam energies. The findings suggest that the gel dosimeter can be used as QA tool for millimeter range verification of proton beam deliveries in the dosimeter medium.

Dosimetric effect of source centering and residual plaque for beta-emitting catheter based intravascular brachytherapy sources.

Catheter-based radiation delivery systems employing both beta-particle and gamma-ray emitters are currently being investigated for their efficacy in addressing restenosis following percutaneous coronary intervention (PCI). The dosimetric consequences of source centering within the arterial lumen and presence of residual plaque are potentially important issues for the uniform delivery of dose to the arterial tissue. In this study, we have examined the effect of source centering on the resulting dose to the arterial wall from clinical intravascular brachytherapy sources containing 32P and 90Sr/Y90. Monte Carlo simulations using the MCNP code were performed for these catheter-based sources with offsets of 0.5 mm and 1 mm from the center of the arterial lumen in homogenous water medium as well as in the presence of residual plaque. Three different positions were modeled and the resulting dose values were analyzed to assess their impact on the resulting dose distribution. The results indicate a variation ranging from -40% to +70% for 32P source and -30% to +50% for 90Sr/90Y at a radial distance of 2 mm from the center of the coronary artery, relative to the dose from a centered source, for a 0.5 mm offset. The variation for a 1 mm offset ranges from -65% to +182% for 32P source and to -50% to +140% for 90Sr/90Y. A concentric residual plaque layer was also modeled so as to assess the combined influence of offset and residual plaque on the dosimetry. Finally the effect of cardiac motion and its potential impact on catheter position and hence the dose distribution is also examined by considering two separate cases of catheter displacement. The results indicate that dose variations range between -28% to +91% when it is assumed that cardiac motion causes catheter movement during coronary lesion irradiation.

An algorithm for automatic, computed-tomography-based source localization after prostate implant.

Permanent implant of the prostate using I-125 and Pd-103 seeds is a popular choice of treatment for early-stage prostate cancer in the United States. Evaluation of the quality of the implant is best based on the calculated dose distribution from postimplant computed tomography (CT) images. This task, however, has been time-consuming and inaccurate. We have developed an algorithm for automatic source localization from postimplant CT images. The only requirement of this algorithm is knowledge of the number of seeds present in the prostate, thus minimizing the need for human intervention. The algorithm processes volumetric CT data from the patient, and pixels of higher CT numbers are categorized into classes of definite and potential source pixels. A multithresholding technique is used to further determine the number of seeds and their precise locations in the CT volume data. A graphic user interface was developed to facilitate operator review of and intervention in the calculation and the results of the algorithm. This algorithm was tested on two phantoms containing nonradioactive seeds, one with 20 seeds in discrete locations and another with 100 seeds with small distances between seeds. The tests showed that the algorithm was able to identify the seed locations to within 1 mm of their physical locations for discrete seed locations. It was further able to separate seeds at close proximity to each other while maintaining an average seed localization error of less than 2 mm, with no operator intervention required.

External-beam radiation therapy for improved dialysis access patency: feasibility and early safety.

Rectenwald, J. E., Pretus, H. A., Seeger, J. M., Huber, T. S., Mendenhall, N. P., Zlotecki, R. A., Palta, J. R., Li, Z. F., Hook, S. Y., Sarac, T. P., Welborn, M. B., Klingman, N. V., Abouhamze, Z. S. and Ozaki, C. K. External-Beam Radiation Therapy for Improved Dialysis Access Patency: Feasibility and Early Safety. Radiat. Res. 156, 53-60 (2001).Prosthetic dialysis access grafts fail secondary to neointimal hyperplasia at the venous anastomosis. We hypothesized that postoperative single-fraction external-beam radiation therapy to the venous anastomosis of hemodialysis grafts can be used safely in an effort to improve access patency. Dogs (n = 8) underwent placement of expanded polytetrafluoroethylene grafts from the right carotid artery to the left jugular vein. Five dogs received single-fraction external-beam photon irradiation (8 Gy) to the venous anastomosis after surgery. Controls were not irradiated. Shunt angiograms were completed 3 and 6 months postoperatively. Anastomoses, mid-graft, and the surrounding tissues were analyzed. Immunohistochemistry for smooth muscle cell alpha-actin, proliferating cellular nuclear antigen (PCNA), and apoptosis was performed. Incisions healed well, though all animals developed wound seromas. One control suffered graft thrombosis 4 months postoperatively. Angiography/histology confirmed severe neointimal hyperplasia at the venous anastomosis. The remaining seven dogs developed similar amounts of neointimal hyperplasia. PCNA studies showed no accelerated fibroproliferative response at irradiated anastomoses compared to controls. Skin incisions and soft tissues over irradiated anastomoses revealed no radiation-induced changes or increase in apoptosis. Thus we conclude that postoperative single-fraction external-beam irradiation of the venous anastomosis of a prosthetic arteriovenous graft that mimics the situation in humans is feasible and safe with regard to early wound healing.

Experimental measurements of dosimetric parameters on the transverse axis of a new 125I source.

Permanent prostate implant using 125I or 103Pd sources is a common treatment choice in the management of early prostate cancer. As sources of new designs are developed and marketed for application in permanent prostate implants, it is of paramount importance that their dosimetric characteristics are carefully determined, in order to maintain a high accuracy of patient treatment. This report presents the results of experimental measurements of the dosimetric parameters performed for a newly available 125I seed source, the model MED3631-A/M source (IoGold), manufactured by North American Scientific, Inc. The measurements were performed in a large scanning water phantom, using a diode detector. The positioning of the source and the diode detector was achieved by a computer-controlled positioning mechanism in the scanning water phantom. The dose rate constant in water for the new 125I source was measured in comparison with an existing 125I source of similar design and verified using thermoluminescent dosimetry (TLD) measurement. The radial dose function values for the source were measured using the diode detector. The measurement technique and the results are compared with the dose distribution parameters for the 125I sources discussed in the AAPM TG43 report and elsewhere [Med. Phys. 26, 570-573 (1999)]. For the dose rate constant in water of the new source, it is recommended that a value of 0.950 cGy/U-hr be used based on the NIST 1985 air-kerma strength calibration standard, or 1.060 cGy/U-hr based on the 1999 NIST air-kerma strength standard. The measured radial dose function values for the MED3631-A/M source agree closely with those of the model 6702 source. It is therefore recommended that the radial dose function values for the model 6702 125I source, as recommended by the AAPM TG43 report, be adopted for the new source as well.

Monte Carlo calculations and experimental measurements of dosimetry parameters of a new 103Pd source.

Permanent prostate implantation using 125I (iodine) or 103Pd (palladium) sources is a popular treatment option in the management of early prostate cancer. As sources of new designs are developed and marketed for application in permanent prostate implantations, their dosimetric characteristics must be carefully determined in order to maintain the accuracy of patient treatment. This report presents the results of experimental measurements and Monte Carlo calculations of the dosimetric parameters performed for a newly available 103Pd seed source. The measurements were performed in a large scanning water phantom using a diode detector. The positioning of the source and detector was achieved by a computer-controlled positioning mechanism in the scanning water phantom. The dose rate constant in water for the new 103Pd source was determined from measurements with the diode detector calibrated with 125I sources of known air-kerma strength. The radial dose function values for the source were measured using the diode detector. Monte Carlo photon transport calculations were then used to calculate the dosimetric parameters of dose rate constant, radial dose function, and anisotropy function using an accurate geometric model of the source. The measured dose rate constant of 0.693 cGy/U-hr compares well with the Monte Carlo calculated value of 0.677 cGy/U-hr. These results are further compared with data on existing 103Pd sources.

Two-effective-source method for the calculation of in-air output at various source-to-detector distances in wedged fields.

A simple algorithm was developed for calculation of the in-air output at various source-to-detector distances (SDDs) on the central axis for wedged fields. In the algorithm we dealt independently with two effective sources, one for head scatter and the other for wedge scatter. Varian 2100C with 18 and 8 MV photon beams was used to examine this algorithm. The effective source position for head scatter for wedged fields was assumed to be the same as that for open fields, and the effective source position for wedge scatter was assumed to be a certain distance upstream from the physical location of the wedge. The shift of the effective source for wedge scatter, w, was found to be independent of field size. Moreover, we observed no systematic dependency of w on wedge angle or beam energy. One value, w = 5.5 cm, provided less than 1% difference in in-air outputs through the whole experimental range, i.e., 6 x 6 to 20 x 20 cm2 field size (15 x 20 cm2 for 60 degrees wedge), 15 degrees-60 degrees wedge angle, 80-130 cm SDD, and both 18 and 8 MV photon beams. This algorithm can handle the case in which use of a tertiary collimator with an external wedge makes the field size for the determination of wedge scatter different from that for head scatter. In this case, without the two-effective-source method, the maximum of 4.7% and 2.6% difference can be given by the inverse square method and one-effective-source method in a 45 degrees wedged field with 18 MV. Differences can be larger for thicker wedges. Enhanced dynamic wedge (EDW) fields were also examined. It was found that no second effective source is required for EDW fields.

A generalized solution for the calculation of in-air output factors in irregular fields.

Three major contributors of scatter radiation to the in-air output of a medical linear accelerator are the flattening filter, wedge, and tertiary collimator. These were considered separately in the development of an algorithm to be used to set up an in-air output factor calculation formalism for open and wedge fields of irregular shape. A detector's eye view (DEV) field defined at the source plane was used to account for the effects of collimator exchange and the partial blockage of the flattening filter by the tertiary collimator in the determination of head scatter. An irregular field determined at the source plane by a DEV was segmented and mapped back into the detector plane by a field-mapping method. Field mapping was performed by using a geometric conversion factor and equivalent field relationships for head scatter. The scatter contribution of each segmented equivalent field at the detector plane was summed by Clarkson integration. The same methodology was applied for determining both tertiary collimator and wedge scatter contribution. However, the field size that determined the amount of scatter contribution was not the same for each component. For tertiary collimator scatter and external wedge scatter, a field projected to the detector plane was used directly. Comparisons of calculated and measured values for in-air output factors showed good agreement for both open and external wedge fields. This algorithm can also be used for multileaf collimator (MLC) fields irrespective of the position of the MLC (i.e., whether the MLC replaces one secondary collimator or is used as a tertiary collimator). The measurement and parameterization of tertiary collimator scatter is necessary to account for its contribution to the in-air output. Because a source-plane field is mapped into the detector plane, no additional dosimetric data acquisition is necessary for the calculation of head scatter.

The equivalent square concept for the head scatter factor based on scatter from flattening filter.

The equivalent field relationship between square and circular fields for the head scatter factor was evaluated at the source plane. The method was based on integrating the head scatter parameter for projected shaped fields in the source plane and finding a field that produced the same ratio of head scatter to primary dose on the central axis. A value of sigma/R approximately equal to 0.9 was obtained, where sigma was one-half of the side length of the equivalent square and R was the radius of the circular field. The assumptions were that the equivalent field relationship for head scatter depends primarily on the characteristics of scatter from the flattening filter, and that the differential scatter-to-primary ratio of scatter from the flattening filter decreases linearly with the radius, within the physical radius of the flattening filter. Lam and co-workers showed empirically that the area-to-perimeter ratio formula, when applied to an equivalent square formula at the flattening filter plane, gave an accurate prediction of the head scatter factor. We have analytically investigated the validity of the area-to-perimeter ratio formula. Our results support the fact that the area-to-perimeter ratio formula can also be used as the equivalent field formula for head scatter at the source plane. The equivalent field relationships for wedge and tertiary collimator scatter were also evaluated.

Photon beam skin dose analyses for different clinical setups.

A comprehensive set of data on skin dose for 8 MV and 18 MV photon beams from a medical linear accelerator was measured using a parallel-plate chamber to document the effect of field size, source-to-surface distance (SSD), off-axis distance, acrylic block tray, wedge (external standard wedge), Lipowitz's metal block, multileaf collimator (MLC), and dynamic wedge. The skin dose increased as field size increased from 5 X 5 cm2 to 40 X 40 cm2 (6% to 38% for 8 MV and 5% to 44% for 18 MV beam). With the use of an acrylic block tray, the skin dose increased for all field sizes (7% to 59% for 8 MV and 5% to 62% for 18 MV beam), but the increase was minimal for small fields. The skin dose with a wedge showed a much more complex trend. It was generally lower than the dose for an open field, but higher in the case of large fields and higher degree wedges. When both wedge and block tray were used, the tray was a major contributor to the skin dose because some of the contaminant electrons from the wedge assembly were absorbed by the block tray. Field-shaping blocks increased the skin dose, but, interestingly, the block tray reduced the skin dose for small blocked fields treated with a high-energy photon beam. The effect of an MLC on skin dose was very similar to that of a Lipowitz's metal block, but its magnitude was less. The skin dose was higher for dynamic wedge fields than it was for standard wedge fields. As SSD decreased, the skin dose increased, and this effect was dominant in larger field sizes. The SSD effect was enhanced in the presence of an acrylic block tray. The skin dose off-axis was the same as at the central axis, or smaller. A similar pattern of behavior of the skin dose is expected for photon beams from other linear accelerators.

On the calculation of mean restricted collision stopping powers.

An analytical method for the calculation of ratios of mean restricted collision stopping powers (L/rho)(g)m averaged over the charged particle spectra and the photon spectrum that is accurate to first order has been developed, and it has been explored whether a moderate change in the photon fluence spectrum with field size has an effect on the mean restricted collision stopping power ratio in high-Z materials. The results of this study indicate that for the case of a miniphantom, moderate changes in the photon fluence spectrum have only a weak effect on the ratios of mean restricted collision stopping powers.

Optimized dose distribution of a high dose rate vaginal cylinder.

PURPOSE: To present a comparison of optimized dose distributions for a set of high-dose-rate (HDR) vaginal cylinders calculated by a commercial treatment-planning system with benchmark calculations using Monte-Carlo-calculated dosimetry data. METHODS AND MATERIALS: Optimized dose distributions using both an isotropic and an anisotropic dose calculation model were obtained for a set of HDR vaginal cylinders. Mathematical optimization techniques available in the computer treatment-planning system were used to calculate dwell times and positions. These dose distributions were compared with benchmark calculations with TG43 formalism and using Monte-Carlo-calculated data. The same dwell times and positions were used for a quantitative comparison of dose calculated with three dose models. RESULTS: The isotropic dose calculation model can result in discrepancies as high as 50%. The anisotropic dose calculation model compared better with benchmark calculations. The differences were more significant at the apex of the vaginal cylinder, which is typically used as the prescription point. CONCLUSION: Dose calculation models available in a computer treatment-planning system must be evaluated carefully to ensure their correct application. It should also be noted that when optimized dose distribution at a distance from the cylinder surface is calculated using an accurate dose calculation model, the vaginal mucosa dose becomes significantly higher, and therefore should be carefully monitored.

A quality assurance test tool for high dose-rate remote afterloading brachytherapy units.

A QA test tool is designed to quantitatively measure the HDR source positioning error, and to facilitate quick and dependable HDR timer linearity test and daily output constancy check. The test tool consists of two concentric disks. The lower disk has a cutout for inserting an HDR catheter, and the upper disk accepts a diode or miniature ionization chamber and can rotate relative to the lower disk. Ionization readings from the source (transferred to the center of the disks) are obtained at two rotational positions of the upper disk which houses the detector. The ratio of the readings is used to determine the source-positioning error of the HDR unit relative to the nominal source position by a simple triangulation principle. Experimental measurements confirm that the QA test tool is sensitive to approximately 0.2 mm variance in source positioning errors. In addition, the QA test tool is suitable for other common HDR QA tests such as the source travel step size test, the daily HDR unit output constancy check, and the timer linearity test. Its simple and robust design permits routine clinical use and provides a high confidence level in the accurate operation of HDR units.

Electron contamination in 8 and 18 MV photon beams.

The contribution from contaminant electrons in the buildup region of a photon beam must be separated when calculating the dose using a photon convolution kernel. Their contribution can be extrapolated from fractional depth dose (FDD) data using the fractional depth kerma (or the "equilibrium dose") derived from measured quantities such as beam attenuation with depth, phantom scatter factor as a function of field size and depth, and inverse-square law for the incident photon beam. Good agreement is observed between the extrapolated and the EGS4 Monte Carlo simulated, primary dose-to-kerma ratios in the surface region for the photon beams, excluding electron contamination. The FDD was measured using a Scanditronix photon diode and was normalized to a reference depth far beyond maximum range of contaminant electrons. An analysis for the 8 and 18 MV photon beams from a Varian 2100CD indicates that at a source-to-surface distance (SSD) of 100 cm, the maximum electron contaminant dose (relative to its maximum FDD) varies from 1% to 33% for 8 MV and 2% to 44% for 18 MV, for square collimator settings ranging from 5 to 40 cm (defined at 100 cm from the source). This value at a depth of maximum dose (2 cm for 8 MV and 3.5 cm for 18 MV) can reach 1% for 8 MV and 2.3% for 18 MV. This contaminant electron dose is almost independent of SSD for 8 MV and starts to fall off for 18 MV at SSDs larger than 120 cm. Compared with the open beam, the contaminant electron dose increases when a solid tray is used, and the magnitude of increase increases with field size, reaching 19% and 16% for a 40 x 40 cm2 field for 8 and 18 MV photons, respectively. The contaminant electron dose increases slightly for a blocked beam compared with an open beam of the same field size if a tray is used in both cases. The contaminant electron dose for the wedged field is less than that for an open field. However, the reduction is less significant at larger collimator settings (c = 20 cm) and may increase slightly for 8 MV photons.

Characterizing output for the Varian enhanced dynamic wedge field.

The output factor for an enhanced dynamic wedge (EDW) field, like that for a dynamic wedge field, is a complex function of the field dimension in the wedge direction. The large change in output for different field sizes (varying more than 40% for a 60 degrees wedge angle) is due to rescaling of the golden segmented treatment table (GSTT), which specifies the cumulative monitor unit weighting as a function of moving jaw position. The rescaling of the GSTT results in increased output on the central axis with a decrease in the value of the final moving jaw position in the wedge plane. The output factor (in air or in water) on the central axis of an EDW field can be predicted to within 1% by multiplying the output factor (in air or in water) of an open field of the same size with the ratio of the normalized GSTT (NGSTT) value at 4.5 cm, which corresponds to a 10 cm x 10 cm square field, to the NGSTT value at the final moving jaw position for the EDW field. Once the NGSTT factor is separated from the output for EDW fields, the field-size-dependent wedge factor varies less than 1%. This approach allows a simple and accurate determination of the output factor for rectangular and asymmetric EDW fields. The equivalent square method for determining output for rectangular fields applies to EDW fields with the same precision as it does to open fields. The output for EDW fields strongly depends on the final moving jaw position. Every 5-mm change in the final moving jaw position causes 3.5-5.4% error in monitor unit calculation.

An equivalent square field formula for determining head scatter factors of rectangular fields.

A simple formula is derived for the calculation of an equivalent square field that gives the same head scatter factor as a given rectangular field. This formula is based strictly on the configuration of a medical linear accelerator treatment head. The geometric parameters used are the distances between the target and the top of each field-defining aperture. The formula accounts for both the effect of field elongation and the collimator exchange effect. This method predicts the output to within 1% accuracy for both open and wedged fields and does not require any new measured data other than the field size dependence of head scatter for a range of square field sizes. Interestingly, the formula we derived has the same format as the formula that was empirically obtained by Vadash and Bjärngard [Med. Phys. 20, 733-734 (1993)].

Commissioning of enhanced dynamic wedge on a ROCS RTP system.

The enhanced dynamic wedge (EDW) is clinically commissioned on a ROCS RTPS (Version 5.03) in a manner similar to that used for any standard physical wedge. The required data set for implementation includes central axis depth dose, and open and wedge beam profiles at several depths and output factors. The features distinguishing the EDW from the physical wedge are a sharp change in output with field size in the wedge plane and a primary intensity difference at the end of the wedge field because the moving jaw stops 0.5 cm short of the fixed jaw position for all field sizes, for safety reasons. The monitor unit (MU) calculation for an EDW field in ROCS is based on scaling factors that are derived from a normalized golden STT (NGSTT). This approach requires no change in the data file structure of ROCS. It was found that the output for EDW is very sensitive to the value of final moving jaw position. Every 0.5 cm difference between planned and set value can cause 3.5% error.

Performance evaluation of a diode array for enhanced dynamic wedge dosimetry.

The performance of a diode array (Profiler) was evaluated by comparing its enhanced dynamic wedge (EDW) profiles measured at various depths with point measurements using a 0.03 cm3 ionization chamber on a commercial linear accelerator. The Profiler, which covers a 22.5 cm width, was used to measure larger field widths by concatenating three data sets into a larger field. An innovative wide-field calibration technique developed by the manufacturer of the device was used to calibrate the individual diode sensitivity, which can vary by more than 10%. Profiles of EDW measured with this device at several depths were used to construct isodose curves using the percentage depth dose curve measured by the ionization chamber. These isodose curves were used to check those generated by a commercial treatment planning system. The profiles measured with the diode array for both 8 and 18 MV photon beams agreed with those of the ionization chamber within a standard deviation of 0.4% in the field (defined as 80% of the field width) and within a maximum shift of less than 2 mm in the penumbra region. The percentage depth dose generally agreed to within 2% except in the buildup region. The Profiler was extremely useful as a quality assurance tool for EDW and as a dosimetry measurement device with tremendous savings in data acquisition time.