Target localization and toxicity in dose-escalated prostate radiotherapy with image-guided approach using daily planar kilovoltage imaging.

Dose escalation with intensity-modulated radiation therapy (IMRT) for carcinoma of the prostate has augmented the need for accurate prostate localization prior to dose delivery. Daily planar kilovoltage (kV) imaging is a low-dose image-guidance technique that is prevalent among radiation oncologists. However, clinical outcomes evaluating the benefit of daily kV imaging are lacking. The purpose of this study was to report our clinical experience, including prostate motion and gastrointestinal (GI) and genitourinary (GU) toxicities, using this modality. A retrospective analysis of 100 patients treated consecutively between December 2005 and March 2008 with definitive external beam IMRT for T1c-T4 disease were included in this analysis. Prescription doses ranged from 74-78 Gy (median, 76) in 2 Gy fractions and were delivered following daily prostate localization using on-board kV imaging (OBI) to localize gold seed fiducial markers within the prostate. Acute and late toxicities were graded as per the NCI CTCAEv3.0. The median follow-up was 22 months. The magnitude and direction of prostate displacement and daily shifts in three axes are reported. Of note, 9.1% and 12.9% of prostate displacements were ≥ 5 mm in the anterior-posterior and superior-inferior directions, respectively. Acute grade 2 GI and GU events occurred in 11% and 39% of patients, respectively, however no grade 3 or higher acute GI or GU events were observed. Regarding late toxicity, 2% and 17% of patients developed grade 2 toxicities, and similarly no grade 3 or higher events had occurred by last follow-up. Thus, kV imaging detected a substantial amount of inter-fractional displacement and may help reduce toxicity profiles, especially high grade events, by improving the accuracy of dose delivery.

The influence of air cavities on interface doses for photon beams.

PURPOSE: As the quantification of dose in homogeneous media is now better understood, it is necessary to further quantify effects from heterogeneous media. The most extreme case is related to air cavities. Although dose corrections at large distances beyond a cavity are accountable by attenuation differences, perturbations at air-tissue interfaces are complex to measure or calculate. These measurements helps understand the physical processes that govern these perturbations. METHODS AND MATERIALS: A thin window parallel-plate chamber and a special diode were used for measurements with various air cavity geometries (layer, channel, cubic cavity, triangle) in x-ray beams of 4 and 15 MV. RESULTS: Underdosing effects occur at both the distal and proximal air cavity interfaces. The magnitude depends on geometry, energy, and field sizes. As the cavity thickness increases, the central axis dose at the distal interface decreases. Increasing field size remedied the underdosing, as did the introduction of lateral walls. Following a 2.0 cm wide air channel for a 4 MV, 4 x 4 cm2 field there was an 11% underdose at the distal interface, while a 2.0 cm cubic cavity yielded only a 3% loss. Measurements at the proximal interface showed losses of 5% to 8%. For a 4 MV parallel opposed beam irradiation the losses at the interfaces were 10% for a channel cavity (in comparison with the homogeneous case) and 1% for a cube. The losses were slightly larger for the 15 MV beam. Underdosage at the lateral interface was 4% and 8% for the 4 MV and 15 MV beams, respectively. CONCLUSION: Although reports suggest better clinical results using lower photon energies with the presence of air cavities, there is no reliable dose calculation algorithm to predict interface doses accurately. The measurements reported here can be used to guide the development of new calculation models under nonequilibrium conditions. This situation is of clinical concern when lesions such as larynx carcinoma beyond air cavities are irradiated.

Dosimetry of 125I sources in a low-density material using scaling.

One may apply O'Connor's scaling theorem to dose measurements with brachytherapy sources in order to overcome the difficulties associated with the need for high spatial accuracy. This possibility has been evaluated by measuring the dose distribution around 125I sources in a low-density styrofoam phantom and comparing it with the dose distributions in water and solid water. Some generalization of the scaling theorem is proposed to allow for the minor differences in atomic composition between styrofoam and water, and the distances are scaled according to the ratio of the linear attenuation coefficients, instead of the physical densities, of the two media. The validity of this application of the scaling theorem has also been tested using Monte Carlo calculations. The results indicate that the scaling of the styrofoam measurements to water is a useful approximation in brachytherapy dosimetry.

Three-dimensional dose distribution of total body irradiation by a dual source total body irradiator.

This study describes the three-dimensional dosimetric characteristics of total body irradiation by our dedicated irradiation unit, which consists of two modified 4-MV linear accelerators mounted opposite each other, providing a field size of 220 cm x 80 cm at the midplane. Our dose calculation algorithm considers the three-dimensional contour of the patient to evaluate the primary and scatter doses. The data base for the calculation includes tissue-to-maximum ratios measured for the large fields. The lung dose correction was calculated using the methods of Batho or ratio of TMR. The accuracy of the calculated dose distributions was verified by measurements with ionization chambers in a humanoid phantom. We also describe and verified a technique to achieve desirable midline lung doses using lead shields. The flexibility and the accuracy of the planning system offers the potential in optimizing the therapeutic ratio for total body treatments.

Doses on the central axes of narrow 6-MV x-ray beams.

The absorbed doses on the central axes of narrow beams (radii 0.07-2.5 cm) of 6-MV x rays have been studied by experiments and Monte Carlo simulations. The measurements were made in a geometry used for irradiation of intracranial lesions. For radii less than 1.0 cm the dose on the central axis is progressively reduced due to electron disequilibrium. This leads to measurement artifacts when the detector is too large, as was readily observed with ionization chambers. Radiographic and radiochromic films were used with densitometric evaluation to provide the resolution necessary to measure absorbed doses for the narrowest beams. The contribution by phantom-scattered photons is significant even at small field sizes, and scatter factors were determined from the experimental results. Photons scattered by the auxiliary collimator did not add appreciably to the dose on the central axis. The data were used to characterize the dose-to-kerma ratio as a function of beam radius. Differences between experimental results and those from Monte Carlo calculations were observed.

Monte Carlo calculations of scatter to primary ratios for normalisation of primary and scatter dose.

The separation of total absorbed dose into primary and scatter components is a commonly used technique in photon dose calculations. The primary dose component can be characterised by a measured narrow beam attenuation coefficient and a single normalisation value which establishes the relative proportion of the primary to the total dose at some reference depth and field size. The determination of this normalisation value from measured data requires an extrapolation of measured values for finite field sizes to obtain a zero field size value. We have used Monte Carlo simulations to score primary and scatter dose for photon beams of 4, 6, 10, 15 and 24 MV and report values of the scatter to primary ratio at the depth of dose maximum for the circular equivalent of a 10 cm x 10 cm field. These values have an uncertainty of less than 1% and can be used in lieu of extrapolation of measured data to establish the relative magnitude of the primary dose for a wide range of photon beam energies.

Three-dimensional photon dose distributions with and without lung corrections for tangential breast intact treatments.

The influence of lung volume and photon energy on the 3-dimensional dose distribution for patients treated by intact breast irradiation is not well established. To investigate this issue, we studied the 3-dimensional dose distributions calculated for an 'average' breast phantom for 60Co, 4 MV, 6 MV, and 8 MV photon beams. For the homogeneous breast, areas of high dose ('hot spots') lie along the periphery of the breast near the posterior plane and near the apex of the breast. The highest dose occurs at the inferior margin of the breast tissue, and this may exceed 125% of the target dose for lower photon energies. The magnitude of these 'hot spots' decreases for higher energy photons. When lung correction is included in the dose calculation, the doses to areas at the left and right margin of the lung volume increase. The magnitude of the increase depends on energy and the patient anatomy. For the 'average' breast phantom (lung density 0.31 g/cm3), the correction factors are between 1.03 to 1.06 depending on the energy used. Higher energy is associated with lower correction factors. Both the ratio-of-TMR and the Batho lung correction methods can predict these corrections within a few percent. The range of depths of the 100% isodose from the skin surface, measured along the perpendicular to the tangent of the skin surface, were also energy dependent. The range was 0.1-0.4 cm for 60Co and 0.5-1.4 cm for 8 MV. We conclude that the use of higher energy photons in the range used here provides lower value of the 'hot spots' compared to lower energy photons, but this needs to be balanced against a possible disadvantage in decreased dose delivered to the skin and superficial portion of the breast.

Attenuation in very narrow photon beams.

When one measures the half-value layer (HVL) or the attenuation coefficient (mu) in a high-energy photon beam, it is necessary to use a narrow beam to eliminate the scattered photons produced in the attenuator. However, lateral electron equilibrium will be compromised if the beam is too small. If the HVL and mu are based on measurements of absorbed dose, the results will then depend on field size for a polyenergetic photon spectrum. The measured values also become sensitive to detector properties. This has been examined by experiments and Monte Carlo calculations. The field size should be sufficient for lateral electron equilibrium to prevent ambiguities in the resulting HVL or mu, which are of the order of 10% for 6-MV X rays.

The influence of ionization chamber and phantom design on the measurement of lung dose in photon beams.

Lung dose correction factors, commonly defined as the ratios of ionization chamber readings in the heterogeneous and homogeneous phantoms, have been compared with those based on accurately determined doses. An analysis of stopping power values, Pwall values, and measurements in lunglike and waterlike materials showed that the wall material and thickness are not very critical in the determination of lung dose correction factors under conditions of electronic equilibrium. When lateral electronic equilibrium is not established due to the extended range of scattered electrons in the low density material, Prepl differs significantly from unity for ionization chambers with thick walls which do not match the lung material in density. An attempt has been made to characterize this effect as a function of photon energy, lung density, field size, and wall thickness.

Benchmark measurements for lung dose corrections for X-ray beams.

A well defined set of clinically relevant reference measurements for photon dose calculations in the presence of the lung have been provided. These benchmark data were mainly obtained in low-density (rho = 0.31 gcm-3) lunglike material as well as in waterlike plastic for 4 and 15 MV X-ray beams. Some additional measurements were performed with materials having a density of 0.015 gcm-3 and 0.18 gcm-3. Phantom geometries included simple layered geometries, finite lung cross section geometries, simulated mediastinum geometries, and simulated tumor in lung geometries. The data are reported as central axis depth doses. A number of parameters were varied, including the field size, the lung geometry, and the distance in and behind the lung.

Radiosurgery for arteriovenous malformations of the brain using a standard linear accelerator: rationale and technique.

We have recently initiated a program for irradiating small, unresectable arteriovenous malformations (AVM's) in the brain. The treatments are delivered using a modified and carefully calibrated 6 MV linac. We are using high, single doses (15 to 25 Gy) with a goal of sclerosing the vessels and preventing hemorrhages. This technique, radiosurgery, is somewhat controversial in the radiotherapy community. Since the treatment is given in a single sitting, rather than in the more conventional pattern of multiple small daily fractions, there is some concern about late radiation damage to the normal brain tissue. However an extensive review of the literature leads us to the conclusion that if a technique is used that keeps the volume irradiated to high dose small, radiosurgery is a safe and efficacious treatment for small (less than 2.5 cm) AVM's. To decrease the risk of necrosis of normal brain tissue, it is important to confine the high dose region as tightly as possible to the target volume. Precise target localization and patient immobilization is achieved using a stereotactic head frame which is used during angiography, CT scanning, and during the radiation treatment. This minimizes the margin of safety that must be added to the target volume for errors in localization and set-up. The treatment is delivered using multiple noncoplanar arcs, with small, sharp edged X ray beams, and with the center of the AVM at isocenter. This produces a rapid dropoff of dose beyond the target volume. Early results in our first few patients are encouraging.

Lead-polystyrene transition zone dosimetry in high-energy photon beams.

In order to study the dose enhancement under sheets of lead positioned directly on the skin of patients, parallel-plate ionization chamber measurements in high-energy photon beams (4-15 MV) were performed below a lead-polystyrene interface. The dose in the transition zone can be much higher or lower than in the situation with full buildup of polystyrene. The enhancement of ionization directly beneath the lead-polystyrene interface, compared to the ionization at a reference depth in polystyrene, increases with photon energy and field size. The field size dependence is due to an increase in relative contribution to the energy fluence of low-energy photons scattered in the phantom and for the 4 MV beam also to photons scattered in the head of the accelerator. By adding a thin (100 microns) plastic absorber against the lead, the low-energy and large-angle electrons, which give rise to the enhanced interface dose, can largely be removed. The data indicate that lead as bolus material should only be used with extreme caution.

Measurements of dose distributions in small beams of 6 MV x-rays.

Dose distributions produced by small circular beams of 6 MV x-rays have been measured using ionisation chambers of small active volume. Specific quantities measured include tissue maximum ratios (TMR), total scatter correction factors (St), collimator scatter correction factors (Sc) and off-axis ratios (OAR). Field sizes ranged from 12.5 to 30 mm diameter, and were defined by machined auxiliary collimators with the movable jaws set for a 4 cm x 4 cm field size. Due to the lack of complete lateral electronic equilibrium for these small fields, the accuracy of the measurements was also investigated. This was accomplished by studying dose response as a function of detector size. Uncertainties of 2.5% were observed for the central axis dose in the 12.5 mm field when measuring with an ionisation chamber with a diameter of 3.5 mm. The total scatter correction factor exhibits a strong field size dependence for fields below 20 mm diameter, while the collimator scatter correction factor is constant and is defined by the setting of the movable jaws. Off-axis ratio measurements show larger dose gradients at the beam edges than those achieved with conventional collimator systems. Corrected profiles measured with an ionisation chamber are compared with measurements made with photographic film and LiF thermoluminescent dosemeters.

Heterogeneity model for photon beams incorporating electron transport.

A method of calculating photon doses in heterogeneous media incorporating electron transport is studied. The dose is represented as the convolution of kerma with an exponential longitudinal electron spread function which describes the penetration of electrons from one medium to another. At large distances from an interface, the dose approaches an asymptotic value equal to the kerma multiplied by a constant describing the degree of longitudinal and lateral electron equilibrium. For the simple situations studied, this asymptotic dose is adequately described by O'Connor's scaling theorem. The method is compared with both Monte Carlo calculations and measurements for a 15-MV photon beam for various geometries and field sizes. It predicts the dose in regions of electron disequilibrium to within 2% in most cases. In situations of extreme electron disequilibrium, such as within low-density regions at high energies and small field sizes, this represents a significant improvement over many existing techniques.