Interfractional dose accumulation for MR-guided liver SBRT: Variation among algorithms is highly patient- and fraction-dependent.

BACKGROUND AND PURPOSE: Daily plan adaptations could take the dose delivered in previous fractions into account. Due to high dose delivered per fraction, low number of fractions, steep dose gradients, and large interfractional organ deformations, this might be particularly important for liver SBRT. This study investigates inter-algorithm variation of interfractional dose accumulation for MR-guided liver SBRT. MATERIALS AND METHODS: We assessed 27 consecutive MR-guided liver SBRT treatments of 67.5 Gy in three (n = 15) or 50 Gy in five fractions (n = 12), both prescribed to the GTV. We calculated fraction doses on daily patient anatomy, warped these doses to the simulation MRI using seven different algorithms, and accumulated the warped doses. Thus, we obtained differences in planned doses and warped or accumulated doses for each algorithm. This enabled us to calculate the inter-algorithm variations in warped doses per fraction and in accumulated doses per treatment course. RESULTS: The four intensity-based algorithms were more consistent with planned PTV dose than affine or contour-based algorithms. The mean (range) variation of the dose difference for PTV D95% due to dose warping by these intensity-based algorithms was 10.4 percentage points (0.3 to 43.7) between fractions and 8.6 (0.3 to 24.9) between accumulated treatment doses. As seen by these ranges, the variation was very dependent on the patient and the fraction being analyzed. Nevertheless, no correlations between patient or plan characteristics on the one hand and inter-algorithm dose warping variation on the other hand was found. CONCLUSION: Inter-algorithm dose accumulation variation is highly patient- and fraction-dependent for MR-guided liver SBRT. We advise against trusting a single algorithm for dose accumulation in liver SBRT.

Residential Radon Exposure and Skin Cancer Incidence in a Prospective Danish Cohort.

BACKGROUND: Although exposure to UV radiation is the major risk factor for skin cancer, theoretical models suggest that radon exposure can contribute to risk, and this is supported by ecological studies. We sought to confirm or refute an association between long-term exposure to residential radon and the risk for malignant melanoma (MM) and non-melanoma skin cancer (NMSC) using a prospective cohort design and long-term residential radon exposure. METHODS: During 1993-1997, we recruited 57,053 Danish persons and collected baseline information. We traced and geocoded all residential addresses of the cohort members and calculated radon concentrations at each address lived in from 1 January 1971 until censor date. Cox proportional hazards models were used to estimate incidence rate-ratios (IRR) and confidence intervals (CI) for the risk associated with radon exposure for NMSC and MM, and effect modification was assessed. RESULTS: Over a mean follow-up of 13.6 years of 51,445 subjects, there were 3,243 cases of basal cell carcinoma (BCC), 317 cases of squamous cell carcinoma (SCC) and 329 cases of MM. The adjusted IRRs per 100 Bq/m3 increase in residential radon levels for BCC, SCC and MM were 1.14 (95% CI: 1.03, 1.27), 0.90 (95% CI: 0.70, 1.37) and 1.08 (95% CI: 0.77, 1.50), respectively. The association between radon exposure and BCC was stronger among those with higher socio-economic status and those living in apartments at enrollment. CONCLUSION AND IMPACT: Long-term residential radon exposure may contribute to development of basal cell carcinoma of the skin. We cannot exclude confounding from sunlight and cannot conclude on causality, as the relationship was stronger amongst persons living in apartments and non-existent amongst those living in single detached homes.

Medical reference dosimetry using EPR measurements of alanine: development of an improved method for clinical dose levels.

BACKGROUND: Electron spin resonance (EPR) is used to determine the absorbed dose of alanine dosimeters exposed to clinical photon beams in a solid-water phantom. Alanine is potentially suitable for medical reference dosimetry, because of its near water equivalence over a wide energy spectrum, low signal fading, non-destructive measurement and small dosimeter size. MATERIAL AND METHODS: A Bruker EMX-micro EPR spectrometer with a rectangular cavity and a measurement time of two minutes per dosimeter was used for reading of irradiated alanine dosimeters. Under these conditions a new algorithm based on scaling of known spectra was developed to extract the alanine signal. RESULTS: The dose accuracy, including calibration uncertainty, is less than 2% (k=1) above 4 Gy (n=4). The measurement uncertainty is fairly constant in absolute terms (approximately 30 mGy) and the relative uncertainty therefore rises for dose measurements below 4 Gy. Typical reproducibility is <1% (k=1) above 10 Gy and <2% between 4 and 10 Gy. Below 4 Gy the uncertainty is higher. A depth dose curve measurement was performed in a solid-water phantom irradiated to a dose of 20 Gy at the maximum dose point (d(max)) in 6 and 18 MV photon beams. The typical difference between the dose measured with alanine in solid water and the dose measured with an ion chamber in a water tank was about 1%. A difference of 2% between 6 and 18 MV was found, possibly due to non-water equivalence of the applied phantom. DISCUSSION: Compared to previously published methods the proposed algorithm can be applied without normalisation of phase shifts caused by changes in the g-value of the cavity. The study shows that alanine dosimetry is a suitable candidate for medical reference dosimetry especially for quality control applications.