Report of AAPM Task Group 155: Megavoltage photon beam dosimetry in small fields and non-equilibrium conditions.

Small-field dosimetry used in advance treatment technologies poses challenges due to loss of lateral charged particle equilibrium (LCPE), occlusion of the primary photon source, and the limited choice of suitable radiation detectors. These challenges greatly influence dosimetric accuracy. Many high-profile radiation incidents have demonstrated a poor understanding of appropriate methodology for small-field dosimetry. These incidents are a cause for concern because the use of small fields in various specialized radiation treatment techniques continues to grow rapidly. Reference and relative dosimetry in small and composite fields are the subject of the International Atomic Energy Agency (IAEA) dosimetry code of practice that has been published as TRS-483 and an AAPM summary publication (IAEA TRS 483; Dosimetry of small static fields used in external beam radiotherapy: An IAEA/AAPM International Code of Practice for reference and relative dose determination, Technical Report Series No. 483; Palmans et al., Med Phys 45(11):e1123, 2018). The charge of AAPM task group 155 (TG-155) is to summarize current knowledge on small-field dosimetry and to provide recommendations of best practices for relative dose determination in small megavoltage photon beams. An overview of the issue of LCPE and the changes in photon beam perturbations with decreasing field size is provided. Recommendations are included on appropriate detector systems and measurement methodologies. Existing published data on dosimetric parameters in small photon fields (e.g., percentage depth dose, tissue phantom ratio/tissue maximum ratio, off-axis ratios, and field output factors) together with the necessary perturbation corrections for various detectors are reviewed. A discussion on errors and an uncertainty analysis in measurements is provided. The design of beam models in treatment planning systems to simulate small fields necessitates special attention on the influence of the primary beam source and collimating devices in the computation of energy fluence and dose. The general requirements for fluence and dose calculation engines suitable for modeling dose in small fields are reviewed. Implementations in commercial treatment planning systems vary widely, and the aims of this report are to provide insight for the medical physicist and guidance to developers of beams models for radiotherapy treatment planning systems.

A practical method for quantifying dose in bone and lung using TLDs when using 6 and 15 MV photon beams.

This paper presents a practical method for converting dose measured with thermoluminescent dosimeters (TLD) to dose in lung and bone for 6 MV and 15 MV photon beams. Monte Carlo (MC) simulations and Burlin cavity theory calculations were performed to calculate [Formula: see text], the dose-to-TLD to dose-to-medium conversion factor. A practical method was proposed for converting TLD-measured-dose to dose-in-medium using the TLD dose calibration in water and [Formula: see text] dose-to-medium to dose-to-water conversion factor. Theoretical calculations for [Formula: see text] were performed using photon spectrum weighted parameters and were compared with MC simulations. Verification of the proposed method was done using phantoms having either bone or lung equivalent slabs stacked in between solid water slabs. Percent depth dose (PDD) curves were measured using 0.089 cm thick LiF:Mg,Ti (TLD-100) dosemeters placed at various depths within these phantoms. They were then corrected with [Formula: see text] factors using the proposed dose conversion method, and were compared with the MC simulations. For 6 MV beam, the MC calculated [Formula: see text] factors were 0.942 and 1.002 for bone and lung, and for 15 MV it was 0.927 and 1.005 for bone and lung, respectively. The difference between the MC simulated and spectrum weighted theoretical [Formula: see text] factors were within 3% for both lung and bone. The PDD curves measured with TLD-100 chips that were corrected using the proposed method agreed well within 1.5% of the MC simulated PDD curves for both the water/lung/water and water/bone/water (WBW) phantoms. The dose-to-medium correction using MC simulated [Formula: see text] is convenient, easy, and accurate. Therefore, it can be used instead of Burlin cavity theory, especially in media with high atomic numbers such as bone for accurate dose quantification.

AAPM TG 191: Clinical use of luminescent dosimeters: TLDs and OSLDs.

Thermoluminescent dosimeters (TLD) and optically stimulated luminescent dosimeters (OSLD) are practical, accurate, and precise tools for point dosimetry in medical physics applications. The charges of Task Group 191 were to detail the methodologies for practical and optimal luminescence dosimetry in a clinical setting. This includes: (a) to review the variety of TLD/OSLD materials available, including features and limitations of each; (b) to outline the optimal steps to achieve accurate and precise dosimetry with luminescent detectors and to evaluate the uncertainty induced when less rigorous procedures are used; (c) to develop consensus guidelines on the optimal use of luminescent dosimeters for clinical practice; and (d) to develop guidelines for special medically relevant uses of TLDs/OSLDs such as mixed photon/neutron field dosimetry, particle beam dosimetry, and skin dosimetry. While this report provides general guidelines for TLD and OSLD processes, the report provides specific details for TLD-100 and nanoDotTM dosimeters because of their prevalence in clinical practice.

Management of radiotherapy patients with implanted cardiac pacemakers and defibrillators: A Report of the AAPM TG-203†.

Managing radiotherapy patients with implanted cardiac devices (implantable cardiac pacemakers and implantable cardioverter-defibrillators) has been a great practical and procedural challenge in radiation oncology practice. Since the publication of the AAPM TG-34 in 1994, large bodies of literature and case reports have been published about different kinds of radiation effects on modern technology implantable cardiac devices and patient management before, during, and after radiotherapy. This task group report provides the framework that analyzes the potential failure modes of these devices and lays out the methodology for patient management in a comprehensive and concise way, in every step of the entire radiotherapy process.

Verification of representative data for output factors of SRS cones utilizing IAEA TRS 483 recommendations.

Measurements of small fields continue to be a clinical challenge despite the recent work done to identify their characteristics. Due to this challenge, many physicists use representative data supplied by their vendors to verify their own measurements for small field output factors. However, with recent guidelines being released in IAEA TRS 483, the question remains if this representative data provides an accurate representation for small field dosimetry. A Sun Nuclear EDGE detector, PTW 60012 stereotactic diode, and GafChromic EBT3 films were used to measure the output factor for a set of Varian SRS cones (4 mm-17.5 mm diameters) on a TrueBeam linear accelerator. The measured output factors were then compared to the Varian provided SRS representative data. IAEA TRS 483 recommendations for measuring small field output factors were applied and the impact of those recommendations were examined. The EDGE detector showed good agreement with the representative data when correction factors were not applied (0.01%-1.64% difference) but the PTW 60012 diode showed larger deviation (0.61%-3.35% difference). The EBT3 film showed the largest difference with the representative data (0.66%-9.19%). After application of IAEA TRS 483 detector specific correction factors the output factors measured by the diodes showed good agreement with the EBT3 film for 6MV (<1.8% difference) but showed a large deviation with the representative data (up to 9% difference). The 6FFF energy output factors agreed between the EDGE, the PTW 60012, and EBT3 Film. This work shows that the use of uncorrected representative data on the Truebeam can lead to a significant over estimation of the SRS cone output factors.

Sensitivity evaluation and selective plane imaging geometry for x-ray-induced luminescence imaging.

PURPOSE: X-ray-induced luminescence (XIL) is a hybrid x-ray/optical imaging modality that employs nanophosphors that luminescence in response to x-ray irradiation. X-ray-activated phosphorescent nanoparticles have potential applications in radiation therapy as theranostics, nanodosimeters, or radiosensitizers. Extracting clinically relevant information from the luminescent signal requires the development of a robust imaging model that can determine nanophosphor distributions at depth in an optically scattering environment from surface radiance measurements. The applications of XIL in radiotherapy will be limited by the dose-dependent sensitivity at depth in tissue. We propose a novel geometry called selective plane XIL (SPXIL), and apply it to experimental measurements in optical gel phantoms and sensitivity simulations. METHODS: An imaging model is presented based on the selective plane geometry which can determine the detected diffuse optical signal for a given x-ray dose and nanophosphor distribution at depth in a semi-infinite, optically homogenous material. The surface radiance in the model is calculated using an analytical solution to the extrapolated boundary condition. Y2 O3 :Eu3+ nanoparticles are synthesized and inserted into various optical phantom in order to measure the luminescent output per unit dose for a given concentration of nanophosphors and calibrate an imaging model for XIL sensitivity simulations. SPXIL imaging with a dual-source optical gel phantom is performed, and an iterative Richardson-Lucy deconvolution using a shifted Poisson noise model is applied to the measurements in order to reconstruct the nanophosphor distribution. RESULTS: Nanophosphor characterizations showed a peak emission at 611 nm, a linear luminescent response to tube current and nanoparticle concentration, and a quadratic luminescent response to tube voltage. The luminescent efficiency calculation accomplished with calibrated bioluminescence mouse phantoms determines 1.06 photons were emitted per keV of x-ray radiation absorbed per g/mL of nanophosphor concentration. Sensitivity simulations determined that XIL could detect a concentration of 1 mg/mL of nanophosphors with a dose of 1 cGy at a depth ranging from 2 to 4 cm, depending on the optical parameters of the homogeneous diffuse optical environment. The deconvolution applied to the SPXIL measurements could resolve two sources 1 cm apart up to a depth of 1.75 cm in the diffuse phantom. CONCLUSIONS: We present a novel imaging geometry for XIL in a homogenous, diffuse optical environment. Basic characterization of Y2 O3 :Eu3+ nanophosphors are presented along with XIL/SPXIL measurements in optical gel phantoms. The diffuse optical imaging model is validated using these measurements and then calibrated in order to execute initial sensitivity simulations for the dose-depth limitations of XIL imaging. The SPXIL imaging model is used to perform a deconvolution on a dual-source phantom, which successfully reconstructs the nanophosphor distributions.

In vivo dosimetry in external beam radiotherapy.

In vivo dosimetry (IVD) is in use in external beam radiotherapy (EBRT) to detect major errors, to assess clinically relevant differences between planned and delivered dose, to record dose received by individual patients, and to fulfill legal requirements. After discussing briefly the main characteristics of the most commonly applied IVD systems, the clinical experience of IVD during EBRT will be summarized. Advancement of the traditional aspects of in vivo dosimetry as well as the development of currently available and newly emerging noninterventional technologies are required for large-scale implementation of IVD in EBRT. These new technologies include the development of electronic portal imaging devices for 2D and 3D patient dosimetry during advanced treatment techniques, such as IMRT and VMAT, and the use of IVD in proton and ion radiotherapy by measuring the decay of radiation-induced radionuclides. In the final analysis, we will show in this Vision 20∕20 paper that in addition to regulatory compliance and reimbursement issues, the rationale for in vivo measurements is to provide an accurate and independent verification of the overall treatment procedure. It will enable the identification of potential errors in dose calculation, data transfer, dose delivery, patient setup, and changes in patient anatomy. It is the authors' opinion that all treatments with curative intent should be verified through in vivo dose measurements in combination with pretreatment checks.

Off-label use of medical products in radiation therapy: summary of the report of AAPM Task Group No. 121.

Medical products (devices, drugs, or biologics) contain information in their labeling regarding the manner in which the manufacturer has determined that the products can be used in a safe and effective manner. The Food and Drug Administration (FDA) approves medical products for use for these specific indications which are part of the medical product's labeling. When medical products are used in a manner not specified in the labeling, it is commonly referred to as off-label use. The practice of medicine allows for this off-label use to treat individual patients, but the ethical and legal implications for such unapproved use can be confusing. Although the responsibility and, ultimately, the liability for off-label use often rests with the prescribing physician, medical physicists and others are also responsible for the safe and proper use of the medical products. When these products are used for purposes other than which they were approved, it is important for medical physicists to understand their responsibilities. In the United States, medical products can only be marketed if officially cleared, approved, or licensed by the FDA; they can be used if they are not subject to or specifically exempt from FDA regulations, or if they are being used in research with the appropriate regulatory safeguards. Medical devices are either cleared or approved by FDA's Center for Devices and Radiological Health. Drugs are approved by FDA's Center for Drug Evaluation and Research, and biological products such as vaccines or blood are licensed under a biologics license agreement by FDA's Center for Biologics Evaluation and Research. For the purpose of this report, the process by which the FDA eventually clears, approves, or licenses such products for marketing in the United States will be referred to as approval. This report summarizes the various ways medical products, primarily medical devices, can legally be brought to market in the United States, and includes a discussion of the approval process, along with manufacturers' responsibilities, labeling, marketing and promotion, and off-label use. This is an educational and descriptive report and does not contain prescriptive recommendations. This report addresses the role of the medical physicist in clinical situations involving off-label use. Case studies in radiation therapy are presented. Any mention of commercial products is for identification only; it does not imply recommendations or endorsements of any of the authors or the AAPM. The full report, containing extensive background on off-label use with several appendices, is available on the AAPM website (http://www.aapm.org/pubs/reports/).

The energy dependence and dose response of a commercial optically stimulated luminescent detector for kilovoltage photon, megavoltage photon, and electron, proton, and carbon beams.

Optically stimulated luminescent detectors, which are widely used in radiation protection, offer a number of potential advantages for application in radiation therapy dosimetry. Their introduction into this field has been somewhat hampered by the lack of information on their radiation response in megavoltage beams. Here the response of a commercially available optically stimulated luminescent detector (OSLD) is determined as a function of energy, absorbed dose to water, and linear energy transfer (LET). The detector response was measured as a function of energy for absorbed doses from 0.5 to 4.0 Gy over the following ranges: 125 kVp to 18 MV for photons, 6-20 MeV for electrons, 50-250 MeV for protons, and 290 MeV/u for the carbon ions. For the low LET beams, the response of the detector was linear up to 2 Gy with supralinearity occurring at higher absorbed doses. For the kilovoltage photons, the detector response relative to 6 MV increased with decreasing energy due to the higher atomic number of aluminum oxide (11.2) relative to water (7.4). For the megavoltage photons and electrons, the response was independent of energy. The response for protons was also independent of energy, but it was about 6% higher than its response to 6 MV photons. For the carbon ions, the dose response was linear for a given LET from 0.5 to 4.0 Gy, and no supralinearity was observed. However, it did exhibit LET dependence on the response relative to 6 MV photons decreasing from 1.02 at 1.3 keV/microm to 0.41 at 78 keV/microm. These results provide additional information on the dosimetric properties for this particular OSL detector and also demonstrate the potential for their use in photon, electron, and proton radiotherapy dosimetry with a more limited use in high LET radiotherapy dosimetry.

Characterization of a novel phantom for three-dimensional in vitro cell experiments.

A novel intensity-modulated radiation therapy (IMRT) phantom for use in three-dimensional in vitro cell experiments, based on a commercially available system (CIRS Inc., Norfolk, VA), was designed and fabricated. The water-equivalent plastic phantom can, with a set of water-equivalent plastic inserts, enclose 1-3 multi-well tissue culture plates. Dosimetry within the phantom was assessed using thermoluminescence dosimeters (TLDs) and film. The phantom was loaded with three tissue culture plates, and an array of TLDs or a set of three films was placed underneath each plate within the phantom, and then irradiated using an IMRT plan created for it. Measured doses from each dosimeter were compared to those acquired from the treatment planning system. The percent differences between TLD measurements and the corresponding points in the treatment plan ranged from 1.3% to 2.9%, differences which did not show statistical significance. Average point-by-point percent dose differences for each film plane ranged from 1.6% to 3.1%. The percentage dose difference for which 95% of the points in the film matched those corresponding to the calculated dose plane to within 3.0% ranged from 2.8% to 4.2%. The good agreement between predicted and measured dose shows that the phantom is a useful and efficient tool for three-dimensional in vitro cell experiments.

In vivo and phantom measurements of the secondary photon and neutron doses for prostate patients undergoing 18 MV IMRT.

For intensity modulated radiation therapy (IMRT) treatments 6 MV photons are typically used, however, for deep seated tumors in the pelvic region, higher photon energies are increasingly being employed. IMRT treatments require more monitor units (MU) to deliver the same dose as conformal treatments, causing increased secondary radiation to tissues outside the treated area from leakage and scatter, as well as a possible increase in the neutron dose from photon interactions in the machine head. Here we provide in vivo patient and phantom measurements of the secondary out-of-field photon radiation and the neutron dose equivalent for 18 MV IMRT treatments. The patients were treated for prostate cancer with 18 MV IMRT at institutions using different therapy machines and treatment planning systems. Phantom exposures at the different facilities were used to compare the secondary photon and neutron dose equivalent between typical IMRT delivered treatment plans with a six field three-dimensional conformal radiotherapy (3DCRT) plan. For the in vivo measurements LiF thermoluminescent detectors (TLDs) and Al2O3 detectors using optically stimulated radiation were used to obtain the photon dose and CR-39 track etch detectors were used to obtain the neutron dose equivalent. For the phantom measurements a Bonner sphere (25.4 cm diameter) containing two types of TLDs (TLD-600 and TLD-700) having different thermal neutron sensitivities were used to obtain the out-of-field neutron dose equivalent. Our results showed that for patients treated with 18 MV IMRT the photon dose equivalent is greater than the neutron dose equivalent measured outside the treatment field and the neutron dose equivalent normalized to the prescription dose varied from 2 to 6 mSv/Gy among the therapy machines. The Bonner sphere results showed that the ratio of neutron equivalent doses for the 18 MV IMRT and 3DCRT prostate treatments scaled as the ratio of delivered MUs. We also observed differences in the measured neutron dose equivalent among the three therapy machines for both the in vivo and phantom exposures.

Internal barium shielding to minimize fetal irradiation in spiral chest CT: a phantom simulation experiment.

PURPOSE: To use a phantom to prospectively examine the attenuating effect of barium sulfate as an internal shield to protect the fetus. MATERIALS AND METHODS: In an adult-size phantom, 1- and 2-cm-thick acrylic slabs containing 315 or 630 mL of water, 2% or 40% barium sulfate suspension, and a 1-mm lead sheet were placed under the diaphragm. In 17 experiments, fetal dose was measured by using thermoluminescent dosimeters that were placed immediately under (near field) and 10 cm below (far field) the water slab (eight experiments), barium sulfate slab (eight experiments), and lead sheet (one experiment). In a pulmonary embolism protocol, the phantom was scanned with single-detector spiral computed tomography (CT) at 130 kVp and 230 mAs. RESULTS: The control radiation dose was 3.60 mSv+/-0.54 (standard deviation) with the water slab at near field, where the uterus dome is at near term, and 0.507 mSv+/-0.07 with the water slab at far field, the uterus position during early gestation. Scattered radiation was attenuated 13% and 21% with 2% barium sulfate and 87% and 96% with 40% barium sulfate, as calculated in the near and far fields, respectively, and 99% with the 1-mm lead sheet. The extrapolated attenuations for 5%-40% barium sulfate suspensions indicated that beyond a 30% suspension, attenuation increased further only slightly. CONCLUSION: Study results in the phantom experiment suggest that fetal irradiation during maternal chest CT can be reduced substantially with barium shielding.

A case study of radiotherapy planning for a bilateral metal hip prosthesis prostate cancer patient.

The purpose of this report is to communicate the observed advantage of intensity-modulated radiotherapy (IMRT) in a patient with bilateral metallic hip prostheses. In this patient with early-stage low-risk disease, a dose of 74 Gy was planned in two phases--an initial 50 Gy to the prostate and seminal vesicles and an additional 24 Gy to the prostate alone. Each coplanar beam avoided the prosthesis in the beam's eye view. Using the same target expansions for each phase, IMRT and 3D-conformal radiotherapy (CRT) plans were compared for target coverage and inhomogeneity as well as dose to the bladder and rectum. The results of the analysis demonstrated that IMRT provided superior target coverage with reduced dose to normal tissues for both individual phases of the treatment plan as well as for the composite treatment plan. The dose to the rectum was significantly reduced with the IMRT technique, with a composite V 80 of 35% for the IMRT plan versus 70% for 3D-CRT plan. Similarly, the dose to the bladder was significantly reduced with a V 80 of 9% versus 20%. Overall, various dosimetric parameters revealed the corresponding 3D-CRT plan would not have been acceptable. The results indicate significant success with IMRT in a clinical scenario where there were no curative alternatives for local treatment other than external beam radiotherapy. Therefore, definitive external beam radiation of prostate cancer patients with bilateral prosthesis is made feasible with IMRT. The work described herein may also have applicability to other groups of patients, such as those with gynecological or other pelvic malignancies.

Dosimetric considerations for patients with HIP prostheses undergoing pelvic irradiation. Report of the AAPM Radiation Therapy Committee Task Group 63.

This document is the report of a task group of the Radiation Therapy Committee of the AAPM and has been prepared primarily to advise hospital physicists involved in external beam treatment of patients with pelvic malignancies who have high atomic number (Z) hip prostheses. The purpose of the report is to make the radiation oncology community aware of the problems arising from the presence of these devices in the radiation beam, to quantify the dose perturbations they cause, and, finally, to provide recommendations for treatment planning and delivery. Some of the data and recommendations are also applicable to patients having implanted high-Z prosthetic devices such as pins, humeral head replacements. The scientific understanding and methodology of clinical dosimetry for these situations is still incomplete. This report is intended to reflect the current state of scientific understanding and technical methodology in clinical dosimetry for radiation oncology patients with high-Z hip prostheses.