Toward a statistically relevant calibration end point for prostate seed implants.

Interstitial brachytherapy for carcinoma of the prostate is achieved through the use of a configuration of radioactive seeds placed in a manner that delivers a customized, reasonably uniform dose to the target volume. Accurate dose delivery depends on both precise seed placement and reliable seed strength in the implanted configuration. This study assumes the independence of the two issues, and quantifies the reduction in the minimum dose to the surface of the gland due only to variability in individual seed strengths. Current AAPM guidelines pertaining to the acceptable limits on seed-to-seed variability are prudent for small configurations of seeds, yet are likely to be overly stringent for applications such as prostate seed implantation. In this study we determine the reduction in the minimum peripheral dose (mPD) caused by the introduction of source strength variability, and provide statistical insight into this effect. It is concluded that the current guidelines limit the reduction in mPD to < or =0.4% relative to the prescription value, for an average configuration, due to the inclusion of strength variability. The maximum observed reduction in mPD would be < or =1.5%. This value is an order of magnitude lower than the recommendations of the AAPM Task Group 40 for the overall accuracy of brachytherapy procedures, which suggests that seed strength variability is of limited concern and that constraints on this factor should perhaps be reevaluated.

Characterization of the dose perturbation by stents as a function of X-ray beam energy.

PURPOSE: External beam irradiation of coronary arteries has been shown to be detrimental in an animal model for the prevention of neointimal hyperplasia in the presence of stents when orthovoltage x-ray beams are used. The present study investigated the effect of beam energy on the dose distribution in the wall of the artery in the presence of stents. MATERIALS AND METHODS: We used 250-kVp x-rays and 6-MV x-rays to irradiate a stent placed in a homogeneous phantom. Radiochromic film densitometry and Monte Carlo calculations were used to measure and to simulate the dose distribution in the proximity of the stent. RESULT: External beam irradiation not only failed to prevent neointimal hyperplasia, but actually accentuated the neointimal response to a prompt mechanical injury in the artery. The photoelectric effect, which dominates low-energy x-ray interactions, produces recoil electrons in the stent, which enhance the dose surrounding the intima. The photoelectrons generated in nickel and iron have an extremely short range in normal tissue, approximately 0.1 mm. Initial estimates of orthovoltage x-ray interactions with the stent indicate a dose enhancement in the orthovoltage range by a factor of 2-6 due to the rise in the photoelectric cross section in this energy range depending on the elemental composition of the stent. Film densitometry verifies this dose enhancement. The Monte Carlo calculation yields a dose enhancement and the dose fall-off with distance from the stent when irradiated with orthovoltage x-rays. Conversely when the tissue and stent are irradiated with megavoltage x-rays, the dose enhancement in this region is a factor of 1.15 in close proximity to the stent and 1.0 at distances greater than 0.1 mm. The 6-MV photon interactions in tissue and Ni/Ti are predominantly through Compton scattering. The Compton effect is dependent on the electron density in the medium, in contrast to the atomic number, which is more relevant for photoelectric absorption. The dose estimates for megavoltage x-rays adjacent to the stent are complicated by the lack of charged particle equilibrium. CONCLUSIONS: There is a limited but definite increase in the dose delivery to the arterial wall when stents are irradiated with orthovoltage x-ray energies. This increase may explain the negative response in other studies. The presence of the stent does perturb the character and magnitude of the dose in the normal arterial wall as a function of beam quality.

Quality assurance in linac-based stereotactic radiosurgery and radiotherapy.

Stereotactic Radiosurgery demands extraordinary attention to quality assurance issues. This is related to the high accuracy needed to perform a successful procedure, accuracy demanded by the proximity of the target lesion to neighboring fragile and eloquent structures in the head and large doses delivered. The nature of the linac-based radiosurgery procedure is that of a series of steps, each linked together and requiring quality control, for if one step is faulty the final result will be equally faulty. The salient points associated with the quality assurance of each step are laid out in this article. Implementation of a linac-based radiosurgery program in an institution must be well thought out and must be a team effort, involving expertise in medical physics, radiological imaging, radiation oncology, and specially trained radiation therapists in order to be successful and safe.