Poster - Thur Eve - 46: The upcoming international code of practice for small static photon field dosimetry.

The increased use of small photon fields in stereotactic and intensity-modulated radiotherapy has raised the need for standardizing the dosimetry of such fields using procedures consistent with those for conventional radiotherapy. An international working group, established by the IAEA in collaboration with AAPM and IPEM, is finalising a Code of Practice for the dosimetry of small static photon fields. Procedures for reference dosimetry in nonstandard machine specific reference (msr) fields are provided following the formalism of Alfonso et al. (Med. Phys. 35: 5179; 2008). Reference dosimetry using ionization chambers in machines that cannot establish a conventional 10 cm × 10 cm reference field is based on either a direct calibration in the msr field traceable to primary standards, a calibration in a reference field and a generic correction factor or the product of a correction factor for a virtual reference field and a correction factor for the difference between the msr and virtual fields. For the latter method, procedures are provided for determining the beam quality in non-reference conditions. For the measurement of field output factors in small fields, procedures for connecting large field measurements using ionization chambers to small field measurements using high-resolution detectors such as diodes, diamond, liquid ion chambers, organic scintillators and radiochromic film are given. The Code of Practice also presents consensus data on correction factors for use in conjunction with measured, detector-specific output factors. Further research to determine missing data according to the proposed framework will be strongly encouraged by publication of this document.

A 4 MV flattening filter-free beam: commissioning and application to conformal therapy and volumetric modulated arc therapy.

Recent studies have indicated that radiotherapy treatments undertaken on a flattening filter-free (FFF) linear accelerator have a number of advantages over treatments undertaken on a conventional linear accelerator. In addition, 4 MV photon beams may give improved isodose coverage for some treatment volumes at air/tissue interfaces, compared to when utilizing the clinical standard of 6 MV photons. In order to investigate these benefits, FFF beams were established on an Elekta Beam Modulator linear accelerator for 4 MV photons. Commissioning beam data were obtained for open and wedged fields. The measured data were then imported into a treatment planning system and a beam model was commissioned. The beam model was optimized to improve dose calculations at shallow, clinically relevant depths. Following verification, the beam model was utilized in a treatment planning study, including volumetric modulated arc therapy, for a selection of lung, breast/chest wall and larynx patients. Increased dose rates of around 800 MU min(-1) were recorded for open fields (relative to 320 MU min(-1) for filtered open fields) and reduced head scatter was inferred from output factor measurements. Good agreement between planned and delivered dose was observed in verification of treatment plans. The planning study indicated that with a FFF beam, equivalent (and in some cases improved) isodose profiles could be achieved for small lung and larynx treatment volumes relative to 4 MV filtered treatments. Furthermore, FFF treatments with wedges could be replicated using open fields together with an 'effective wedge' technique and isocentre shift. Clinical feasibility of a FFF beam was therefore demonstrated, with beam modelling, treatment planning and verification being successfully accomplished.

Practical experience of using the IPEM 2003 electron code of practice.

From 1 January 2007, the Institute of Physics and Engineering in Medicine (IPEM) 2003 code of practice (COP) for electron dosimetry replaces the old air kerma-based Institute of Physics and Engineering in Medicine and Biology 1996 COP as the recommended protocol for the UK. The IPEM 2003 COP requires a secondary standard ionisation chamber calibrated directly in terms of absorbed dose to water. This paper examines the differences between the new and old COP and indicates that the dose measured using the 2003 COP appears to be greater than that using the 1996 COP by approximately 2+/-1%, based on a survey of radiotherapy centres in the UK. The paper also compares the characteristics of the NACP (Scanditronix) and Roos (PTW) chambers recommended by the 2003 COP. No practical difference was found between adopting the NACP or Roos chambers as a secondary standard chamber.

A new formalism for reference dosimetry of small and nonstandard fields.

The use of small fields in radiotherapy techniques has increased substantially, in particular in stereotactic treatments and large uniform or nonuniform fields that are composed of small fields such as for intensity modulated radiation therapy (IMRT). This has been facilitated by the increased availability of standard and add-on multileaf collimators and a variety of new treatment units. For these fields, dosimetric errors have become considerably larger than in conventional beams mostly due to two reasons; (i) the reference conditions recommended by conventional Codes of Practice (CoPs) cannot be established in some machines and (ii) the measurement of absorbed dose to water in composite fields is not standardized. In order to develop standardized recommendations for dosimetry procedures and detectors, an international working group on reference dosimetry of small and nonstandard fields has been established by the International Atomic Energy Agency (IAEA) in cooperation with the American Association of Physicists in Medicine (AAPM) Therapy Physics Committee. This paper outlines a new formalism for the dosimetry of small and composite fields with the intention to extend recommendations given in conventional CoPs for clinical reference dosimetry based on absorbed dose to water. This formalism introduces the concept of two new intermediate calibration fields: (i) a static machine-specific reference field for those modalities that cannot establish conventional reference conditions and (ii) a plan-class specific reference field closer to the patient-specific clinical fields thereby facilitating standardization of composite field dosimetry. Prior to progressing with developing a CoP or other form of recommendation, the members of this IAEA working group welcome comments from the international medical physics community on the formalism presented here.

Addendum to the IPEMB code of practice for the determination of absorbed dose for x-rays below 300 kV generating potential (0.035 mm Al-4 mm Cu HVL).

This addendum to the code of practice for the determination of absorbed dose for x-rays below 300 kV has recently been approved by the IPEM and introduces three main changes: (i) Due to a lack of available data the original code recommended a value of unity for k(ch) in the very-low-energy range (0.035-1.0 mm Al HVL). A single table of k(ch) values, ranging from 1.01 to 1.07, applicable to both designated chamber types is now presented. (ii) For medium-energy x-rays (0.5-4 mm Cu HVL) methods are given to determine the absorbed dose to water either at 2 cm depth or at the surface of a phantom depending on clinical needs. Determination of the dose at the phantom surface is derived from an in-air measurement and by extending the low-energy range up to 4 mm Cu HVL. Relevant backscatter factors and ratios of mass energy absorption coefficients are given in the addendum. (iii) Relative dosimetry: although not normally forming part of a dosimetry code of practice a brief review of the current literature on this topic has been added as an appendix. This encompasses advice on techniques for measuring depth doses, applicator factors for small field sizes, dose fall off with increasing SSD and choice of appropriate phantom materials and ionization chambers.

Air kerma calibration factors and chamber correction values for PTW soft x-ray, NACP and Roos ionization chambers at very low x-ray energies.

This paper evaluates the characteristics of ionization chambers for the measurement of absorbed dose to water using very low-energy x-rays. The values of the chamber correction factor, k(ch), used in the IPEMB 1996 code of practice for the UK secondary standard ionization chambers (PTW type M23342 and PTW type M23344), the Roos (PTW type 34001) and NACP electron chambers are derived. The responses in air of the small and large soft x-ray chambers (PTW type M23342 and PTW type M23344) and the NACP and Roos electron ionization chambers were compared. Besides the soft x-ray chambers, the NACP and Roos chambers can be used for very low-energy x-ray dosimetry provided that they are used in the restricted energy range for which their response does not change by more than 5%. The chamber correction factor was found by comparing the absorbed dose to water determined using the dosimetry protocol recommended for low-energy x-rays with that for very low-energy x-rays. The overlap energy range was extended using data from Grosswendt and Knight. Chamber correction factors given in this paper are chamber dependent, varying from 1.037 to 1.066 for a PTW type M23344 chamber, which is very different from a value of unity given in the IPEMB code. However, the values of k(ch) determined in this paper agree with those given in the DIN standard within experimental uncertainty. The authors recommend that the very low-energy section of the IPEMB code is amended to include the most up-to-date values of k(ch).

Investigation of the chamber correction factor (k(ch)) for the UK secondary standard ionization chamber (NE2561/NE2611) using medium-energy x-rays.

This paper evaluates the characteristics of ionization chambers for the measurement of absorbed dose to water for medium-energy x-rays. The values of the chamber correction factor, k(ch), used in the IPEMB code of practice for the UK secondary standard (NE2561/NE2611) ionization chamber are derived and their constituent factors examined. The comparison of the chambers' responses in air revealed that of the chambers tested only the NE2561, NE2571 and NE2505 exhibit a flat (within 5%) energy response in air. Under no circumstances should the NACP, Sanders electron chamber, or any chamber that has a wall made of high atomic number material, be used for medium-energy x-ray dosimetry. The measurements in water reveal that a chamber that has a substantial housing, such as the PTW Grenz chamber, should not be used to measure absorbed dose to water in this energy range. The value of k(ch) for an NE2561 chamber was determined by measuring the absorbed dose to water and comparing it with that for an NE2571 chamber, for which k(ch) data have been published. The chamber correction factor varies from 1.023 +/- 0.03 to 1.018 +/- 0.001 for x-ray beams with HVL between 0.15 and 4 mm Cu. The values agree with that for an NE2571 chamber within the experimental uncertainty. The corrections due to the stem, waterproof sleeve and replacement of the phantom material by the chamber for an NE2561 chamber are described.

An alternative beam quality index for medium-energy x-ray dosimetry.

To determine absorbed dose to water it is essential that the radiation quality of the x-ray beam is known accurately. The unique method of defining the beam quality is to acquire a detailed knowledge of the photon spectrum at the point of measurement in water, but this is impractical. The aim of this work was to investigate a quality index that uniquely defines the ratio of mass-energy absorption coefficients of water to air at 2 cm deep in water ([(mu en/rho)w/a]z = 2,phi). Three parameters, HVL, mean energy at 2 cm deep in water and the ratio of the doses at 2 and 5 cm deep in water (D2/D5) were investigated as functions of [(mu en/rho)w/a]z = 2,phi. The quality index that best defines [(mu en/rho)w/a]z = 2,phi is the ratio of doses at 2 and 5 cm depth in water.

An ice calorimeter for photon dosimetry.

A prototype absorbed-dose ice calorimeter has been constructed of ice made with triple-distilled water. The calorimeter was formed by sandwiching a thermistor between two blocks of ice. Initial measurements in a 60Co gamma-ray beam show that ice calorimetry is feasible, giving a signal to noise ratio of about 300 for a dose of 5 Gy.

Prostate specific antigen--a screening test for prostatic cancer?

A series of 287 patients referred by their family doctors with symptoms of bladder outflow obstruction were asked to attend the hospital for "pre-clinic" screening for carcinoma of prostate (CaP). Blood samples were collected from 211 patients and analysed for serum prostate specific antigen (PSA) and prostatic acid phosphatase (PAP). Thirty-six patients had a serum PSA greater than 10 micrograms/l and 7 had PAP levels greater than 5 iu/l. In no instance was the PAP elevated without an associated increase in PSA concentration. Patients with raised markers underwent further investigations which included prostatic biopsy and/or resection; 17 patients were proved to have carcinoma of the prostate, 9 of whom had distant metastases. The specificity of PSA for detecting prostate cancer in this study was 90% with a sensitivity of 89.5%, in contrast to values for PAP of 100% and 36.8%. The routine use of PAP as a marker for prostatic cancer should be abandoned. The use of PSA as a screening test in a group of patients with prostatism appears justified, but with a positive predictive value of only 47%, its use in a mass unselected screening programme is not recommended.