Experimental Comparison of Fiducial Markers Used in Proton Therapy: Study of Different Imaging Modalities and Proton Fluence Perturbations Measured With CMOS Pixel Sensors.

Fiducial markers are used for image guidance to verify the correct positioning of the target for the case of tumors that can suffer interfractional motion during proton therapy. The markers should be visible on daily imaging, but at the same time, they should produce minimal streak artifacts in the CT scans for treatment planning and induce only slight dose perturbations during particle therapy. In this work, these three criteria were experimentally investigated at the Heidelberg Ion Beam Therapy Center. Several small fiducial markers with different geometries and materials (gold, platinum, and carbon-coated ZrO2) were evaluated. The streak artifacts on treatment planning CT were measured with and without iMAR correction, showing significantly smaller artifacts from markers lighter than 6 mg and a clear improvement with iMAR correction. Daily imaging as X-ray projections and in-room mobile CT were also performed. Markers heavier than 6 mg showed a better contrast in the X-ray projections, whereas on the images from the in-room mobile CT, all markers were clearly visible. In the other part of this work, fluence perturbations of proton beams were measured for the same markers by using a tracker system of several high spatial resolution CMOS pixel sensors. The measurements were performed for single-energy beams, as well as for a spread-out Bragg peak. Three-dimensional fluence distributions were computed after reconstructing all particle trajectories. These measurements clearly showed that the ZrO2 markers and the low-mass gold/platinum markers (0.35mm diameter) induce perturbations being 2-3 times lower than the heavier gold or platinum markers of 0.5mm diameter. Monte Carlo simulations, using the FLUKA code, were used to compute dose distributions and showed good agreement with the experimental data after adjusting the phase space of the simulated proton beam compared to the experimental beam.

Evaluation of different fiducial markers for image-guided radiotherapy and particle therapy.

Modern radiotherapy (RT) techniques are widely used in the irradiation of moving organs. A crucial step in ensuring the correct position of a target structure directly before or during treatment is daily image guidance by computed tomography (CT) or X-ray radiography (image-guided radiotherapy, IGRT). Therefore, combinations of modern irradiation devices and imaging, such as on-board imaging (OBI) with X-rays, or in-room CT such as the tomotherapy system, have been developed. Moreover, combinations of linear accelerators and in-room CT-scanners have been designed. IGRT is of special interest in hypofractionated and radiosurgical treatments where high single doses are applied in the proximity of critical organs at risk. Radiographically visible markers in or in close proximity to the target structure may help to reproduce the position during RT and could therefore be used as external surrogates for motion monitoring. Criteria sought for fiducial markers are (i) visibility in the radiologic modalities involved in radiotherapeutic treatment planning and image guidance, such as CT and kilovoltage (kV) OBI), (ii) low production of imaging artifacts, and (iii) low perturbation of the therapeutic dose to the target volume. Photon interaction with interstitial markers has been shown to be not as important as in particle therapy, where interaction of the particle beam, especially with metal markers, can have a significant impact on treatment. This applies especially with a scanned ion beam. Recently we commenced patient recruitment at our institution within the PROMETHEUS trial, which evaluates a hypofractionation regime, starting with 4 x 10 Gy (RBE), for patients with hepatocellular carcinoma. The aim of this work is, therefore, to evaluate potential implantable fiducial markers for enabling precise patient and thus organ positioning in scanned ion beams. To transfer existing knowledge of marker application from photon to particle therapy, we used a range of commercially available markers of different forms and sizes, consisting of carbon and gold materials, and evaluated them for their potential use in the clinical setup with scanned ion beams at our institution. All markers were implanted in a standardized Alderson phantom and were examined using CT scans and orthogonal kV OBI in our clinical routine protocol. Impact on beam perturbation downstream of the markers in the plateau region of a spread-out Bragg peak (SOBP) was estimated by using radiographic films for clinical proton and carbon ion beams of high and low energies. All tested markers achieved good visibility in CT and kV OBI. Disturbances due to artifacts and dose perturbation were highest in the arbitrarily folded gold and the thickest gold marker, but especially low in the carbon marker. Dose perturbation was highest in the arbitrarily folded gold marker. In summary, the analyzed markers offer promising potential for identifying target structures in our treatment setup at HIT and will soon be used in clinical routine. However, a careful choice of marker, depending on the tumor localization and irradiation strategy, will need to be made.

Monte Carlo simulations on the water-to-air stopping power ratio for carbon ion dosimetry.

Many papers discussed the I value for water given by the ICRU, concluding that a value of about 80 +/- 2 eV instead of 67.2 eV would reproduce measured ion depth-dose curves. A change in the I value for water would have an effect on the stopping power and, hence, on the water-to-air stopping power ratio, which is important in clinical dosimetry of proton and ion beams. For energies ranging from 50 to 330 MeV/u and for one spread out Bragg peak, the authors compare the impact of the I value on the water-to-air stopping power ratio. The authors calculate ratios from different ICRU stopping power tables and ICRU reports. The stopping power ratio is calculated via track-length dose calculation with SHIELD-HIT07. In the calculations, the stopping power ratio is reduced to a value of 1.119 in the plateau region as compared to the cited value of 1.13 in IAEA TRS-398. At low energies the stopping power ratio increases by up to 6% in the last few tenths of a mm toward the Bragg peak. For a spread out Bragg peak of 13.5 mm width at 130 mm depth, the stopping power ratio increases by about 1% toward the distal end.