International perspectives on quality assurance and new techniques in radiation medicine: outcomes of an IAEA conference.

The International Atomic Energy Agency organized an international conference called, "Quality Assurance and New Techniques in Radiation Medicine" (QANTRM). It dealt with quality assurance (QA) in all aspects of radiation medicine (diagnostic radiology, nuclear medicine, and radiotherapy) at the international level. Participants discussed QA issues pertaining to the implementation of new technologies and the need for education and staff training. The advantage of developing a comprehensive and harmonized approach to QA covering both the technical and the managerial issues was emphasized to ensure the optimization of benefits to patient safety and effectiveness. The necessary coupling between medical radiation imaging and radiotherapy was stressed, particularly for advanced technologies. However, the need for a more systematic approach to the adoption of advanced technologies was underscored by a report on failures in intensity-modulated radiotherapy dosimetry auditing tests in the United States, which could imply inadequate implementation of QA for these new technologies. A plenary session addressed the socioeconomic impact of introducing advanced technologies in resource-limited settings. How shall the dual gaps, one in access to basic medical services and the other in access to high-quality modern technology, be addressed?

The IAEA/WHO TLD postal dose quality audits for radiotherapy: a perspective of dosimetry practices at hospitals in developing countries.

BACKGROUND AND PURPOSE: The IAEA/WHO TLD postal programme for external audits of the calibration of high-energy photon beams used in radiotherapy has been in operation since 1969. This work presents a survey of the 1317 TLD audits carried out during 1998-2001. The TLD results are discussed from the perspective of the dosimetry practices in hospitals in developing countries, based on the information provided by the participants in their TLD data sheets. MATERIALS AND METHODS: A detailed analysis of the TLD data sheets is systematically performed at the IAEA. It helps to trace the source of any discrepancy between the TLD measured dose and the user stated dose, and also provides information on equipment, dosimetry procedures and the use of codes of practice in the countries participating in the IAEA/WHO TLD audits. RESULT: The TLD results are within the 5% acceptance limit for 84% of the participants. The results for accelerator beams are typically better than for Co-60 units. Approximately 75% of participants reported dosimetry data, including details on their procedure for dose determination from ionisation chamber measurements. For the remaining 25% of hospitals, who did not submit these data, the results are poorer than the global TLD results. Most hospitals have Farmer type ionisation chambers calibrated in terms of air kerma by a standards laboratory. Less than 10% of the hospitals use new codes of practice based on standards of absorbed dose to water. CONCLUSION: Despite the differences in dosimetry equipment, traceability to different standards laboratories and uncertainties arising from the use of various dosimetry codes of practice, the determination of absorbed dose to water for photon beams typically agrees within 2% among hospitals. Correct implementation of any of the dosimetry protocols should ensure that significant errors in dosimetry are avoided.

An investigation of the photon energy dependence of the EPR alanine dosimetry system.

The electron paramagnetic resonance (EPR) alanine dosimetry system is based on EPR measurements of radicals formed in alanine by ionizing radiation. The system has been studied to determine its energy dependence for photons in the 10-30 MV region relative to those of 60Co and to find out if the system would be suitable for dosimetry comparisons. The irradiations were carried out at the National Research Council, Ottawa, Canada and the doses ranged from 8 to 54 Gy. The EPR measurements were performed at the University of Oslo, Norway. The ratio of the slope of the alanine reading versus dose-to-water curve for a certain linac photon beam quality and the corresponding slope for a reference 60Co gamma-radiation gives an experimental measure of the relative dose-to-water response of the EPR alanine dosimetry system. For calculating the linear regression coefficients of these alanine reading versus dose curves, the method of weighted least squares was used. This method is assumed to produce more accurate regression coefficients when applied to EPR dosimetry than the common method of standard least squares. The overall uncertainty on the ratio of slopes was between 0.5 and 0.6% for all three linac energies. The relative response for all the linac beams compared to cobalt was less than unity: by about 0.5% for the 20 and 30 MV points but by more than 1% for the 10 MV point. The given standard uncertainties negate concluding that there is any significant internal variation in the measured response as a function of beam quality between the three linac energies. Thus, we calculated the average dose response for all three energies and found that the alanine response is 0.8% (+/-0.5%) lower for high energy x-rays than for 60Co gamma-rays. This result indicates a small energy dependence in the alanine response for the high-energy photons relative to 60Co which may be significant. This result is specific to our dosimetry system (alanine with 20% polyethylene binder pressed into a particular shape) including its waterproofing sleeve of PMMA (2 mm thick); however, we expect that this result may apply to other similar detectors.

Protocols for the dosimetry of high-energy photon and electron beams: a comparison of the IAEA TRS-398 and previous international codes of practice. International Atomic Energy Agency.

A new international Code of Practice for radiotherapy dosimetry co-sponsored by several international organizations has been published by the IAEA, TRS-398. It is based on standards of absorbed dose to water, whereas previous protocols (TRS-381 and TRS-277) were based on air kerma standards. To estimate the changes in beam calibration caused by the introduction of TRS-398, a detailed experimental comparison of the dose determination in reference conditions in high-energy photon and electron beams has been made using the different IAEA protocols. A summary of the formulation and reference conditions in the various Codes of Practice, as well as of their basic data, is presented first. Accurate measurements have been made in 25 photon and electron beams from 10 clinical accelerators using 12 different cylindrical and plane-parallel chambers, and dose ratios under different conditions of TRS-398 to the other protocols determined. A strict step-by-step checklist was followed by the two participating clinical institutions to ascertain that the resulting calculations agreed within tenths of a per cent. The maximum differences found between TRS-398 and the previous Codes of Practice TRS-277 (2nd edn) and TRS-381 are of the order of 1.5-2.0%. TRS-398 yields absorbed doses larger than the previous protocols, around 1.0% for photons (TRS-277) and for electrons (TRS-381 and TRS-277) when plane-parallel chambers are cross-calibrated. For the Markus chamber, results show a very large variation, although a fortuitous cancellation of the old stopping powers with the ND,w/NK ratios makes the overall discrepancy between TRS-398 and TRS-277 in this case smaller than for well-guarded plane-parallel chambers. Chambers of the Roos-type with a 60Co ND,w calibration yield the maximum discrepancy in absorbed dose, which varies between 1.0% and 1.5% for TRS-381 and between 1.5% and 2.0% for TRS-277. Photon beam calibrations using directly measured or calculated TPR20,10 from a percentage dose data at SSD = 100 cm were found to be indistinguishable. Considering that approximately 0.8% of the differences between TRS-398 and the NK-based protocols are caused by the change to the new type of standards, the remaining difference in absolute dose is due either to a close similarity in basic data or to a fortuitous cancellation of the discrepancies in data and type of chamber calibration. It is emphasized that the NK-ND,air and ND,w formalisms have very similar uncertainty when the same criteria are used for both procedures. Arguments are provided in support of the recommendation for a change in reference dosimetry based on standards of absorbed dose to water.