A method for checking high dose rate treatment times for vaginal applicators.

A method is presented for checking the treatment time calculation for high dose rate (HDR) vaginal cylinder treatments. The method represents an independent check of the HDR planning system and can take into account nonuniform isodose line coverage around the cylinder. Only the air kerma strength of the source and information that is available from the written directive are required. The maximum discrepancy for a representative set of cylinder plans done on a Nucletron unit was 5%. A working HTML JavaScript program is included in the Appendix.

Clinically evident fat necrosis in women treated with high-dose-rate brachytherapy alone for early-stage breast cancer.

PURPOSE: To investigate the incidence of and variables associated with clinically evident fat necrosis in women treated on a protocol of high-dose-rate (HDR) brachytherapy alone without external-beam whole-breast irradiation for early-stage breast carcinoma. METHODS AND MATERIALS: From 6/1997 until 8/1999, 30 women diagnosed with Stage I or II breast carcinoma underwent surgical excision and postoperative irradiation via HDR brachytherapy implant as part of a multi-institutional clinical Phase I/II protocol. Patients eligible included those with T1, T2, N0, N1 (< or = 3 nodes positive), M0 tumors of nonlobular histology with negative surgical margins, no extracapsular lymph-node extension, and a negative postexcision mammogram. Brachytherapy catheters were placed at the initial excision, re-excision, or at the time of axillary sampling. Direct visualization, surgical clips, ultrasound, or CT scans assisted in delineating the target volume defined as the excision cavity plus 2-cm margin. High activity (192)Ir (3-10 Ci) was used to deliver 340 cGy per fraction, 2 fractions per day, for 5 consecutive days to a total dose of 34 Gy to the target volume. Source position and dwell times were calculated using standard volume optimization techniques. Dosimetric analyses were performed with three-dimensional postimplant dose and volume reconstructions. The median follow-up of all patients was 24 months (range, 12-36 months). RESULTS: Eight patients (crude incidence of 27%) developed clinically evident fat necrosis postimplant in the treated breast. Fat necrosis was determined by clinical presentation including pain and swelling in the treated volume, computed tomography, and/or biopsy. All symptomatic patients (7 of 8 cases) were successfully treated with 3 to 12 months of conservative management. Continuous variables that were found to be associated significantly with fat necrosis included the number of source dwell positions (p = 0.04), and the volume of tissue which received fractional doses of 340 cGy, 510 cGy, and 680 cGy (p = 0.03, p = 0.01, and p = 0.01, respectively). Other continuous variables including patient age, total excised tissue volume, tumor size, number of catheters, number of days the catheters were in place, planar separation, dose homogeneity index (DHI), and uniformity index (UI) were not significant. Discrete variables including the presence/absence of DCIS, sentinel versus full axillary nodal assessment, receptor status, presence/absence of diabetes, and the use of chemotherapy or hormone therapy were not found to have a significant association with the risk of fat necrosis. CONCLUSIONS: In this study of HDR brachytherapy of the breast tumor excision cavity plus margin, treatment was planned and delivered in accordance with the dosimetric parameters of the protocol resulting in a high degree of target volume dose homogeneity. Nonetheless, at a median follow-up of 24 months, a high rate of clinically definable fat necrosis occurred. The overall implant volume as reflected in the number of source dwell positions and the volume of breast tissue receiving fractional doses of 340, 510, and 680 cGy were significantly associated with fat necrosis. Future dosimetric optimization algorithms for HDR breast brachytherapy will need to include these factors to minimize the risk of fat necrosis.

Cosmetic outcome in patients receiving an interstitial implant as part of breast-conservation therapy.

PURPOSE: To study factors related to breast cosmetic outcome in patients treated with an interstitial implant as part of breast-conservation therapy. MATERIALS AND METHODS: One hundred fifty-six patients with stage I or II breast carcinoma who received 50 Gy of external-beam irradiation followed by a 20-Gy interstitial boost were examined. The dose homogeneity index (DHI) was calculated for each evaluable implant and was examined in light of other patient-, treatment-, and tumor-related variables previously demonstrated to affect cosmesis. RESULTS: Of the variables examined, both the DHI (P = .021) and the total excision volume (P = .019) were significantly related to cosmetic outcome (excellent vs less than excellent) in a univariate model. In the multivariate analysis, only the total excision volume remained significant (P = .032). The mean total excision volume +/- SD in patients with excellent cosmetic outcome (81.8 cm3 +/- 84.0) was significantly less than that in patients with less than excellent cosmetic outcome (120 cm3 +/- 84). The probability of excellent cosmetic outcome linearly increased with an increase in DHI. The mean DHI was 0.74 +/- 0.12 for the cases with excellent cosmetic outcome and 0.68 +/- 0.10 for those with less than excellent cosmetic outcome. CONCLUSION: To achieve optimal cosmesis, DHI should be maximized. The volume of tissue removed, however, remains the most significant determinant.

A technique for accurate planning of stereotactic brain implants prior to head ring fixation.

PURPOSE: A two-step procedure is described for accurate planning of stereotactic brain implants prior to head-ring fixation. METHODS AND MATERIALS: Approximately 2 weeks prior to implant a CT scan without the head ring is performed for treatment-planning purposes. An entry point and a reference point, both marked with barium and later tattooed, facilitate planning and permit correlation of the images with a later CT scan. A plan is generated using a conventional treatment-planning system to determine the number and activity of I-125 seeds required and the position of each catheter. I-125 seed anisotropy is taken into account by means of a modification to the treatment planning program. On the day of the implant a second CT scan is performed with the head ring affixed to the skull and with the same points marked as in the previous scan. The planned catheter coordinates are then mapped into the coordinate system of the second CT scan by means of a manual translational correction and a computer-calculated rotational correction derived from the reference point coordinates in the two scans. RESULTS: The rotational correction algorithm was verified experimentally in a Rando phantom before it was used clinically. For analysis of the results with individual patients a third CT scan is performed 1 day following the implant and is used for calculating the final dosimetry. CONCLUSION: The technique that is described has two important advantages: 1) the number and activity of seeds required can be accurately determined in advance; and 2) sufficient time is allowed to derive the best possible plan.

Factors determining outcome in patients treated with interstitial implantation as a radiation boost for breast conservation therapy.

PURPOSE: To evaluate the relative utility of interstitial implant as a technique for tumor bed dose escalation and assess technical factors related to outcome. METHODS AND MATERIALS: From 1982-1994, a prospectively applied institutional policy of margin-directed boost dose escalation to the tumor bed was followed whereby interstitial implantation was commonly employed for a final margin status (FMS) < or = 2 mm. There were 509 treated breasts, of which 127 received an implant boost. For purposes of comparison, cases were broadly classed as "implant" (all FMS < or = 2 mm) and "nonimplant" (FMS < or = 2 mm or FMS > 2 mm). The implant target volume was determined at completion of whole breast irradiation by clinical assessment. All implants were constructed in accordance with a preplanning algorithm designed to maximize dose homogeneity within a prescription isodose goal of 0.50 Gy/h for 40 h. Local control and cosmetic outcome were evaluated with respect to extent of tumor, histopathology, FMS, extent of surgery, and systemic adjuvant therapy. Implant quality was assessed using four calculated parameters: strand separation quotient (SSQ), planar separation quotient (PSQ), global separation quotient (GSQ), and dose homogeneity index (DHI). The mean implant volume was 48.3 +/- 20 cc, the mean prescribed dose rate was 0.46 +/- 0.08 Gy/h, and the mean total implant dose was 19.94 +/- 1.52 Gy. RESULTS: Cosmetic outcome was good/excellent in 90% of implant and 83% of all nonimplant cases, which was not statistically different. Cosmesis was significantly superior with implant when compared to nonimplant cases receiving an external boost of 20 Gy. Logistic regression analyses of implant cases revealed that reexcision volume and decreased DHI were associated with adverse cosmesis. There were 10 local failures in the implanted patients (4 within the prescribed isodose volume, 5 at the periphery, and 1 elsewhere in the breast). The local failure rate at 5 and 7 years in the implanted group was 3.9 and 9.0%, respectively, compared to nonimplant cases with a margin < or = 2 mm of 3.2 and 3.2%, respectively. These differences were not significant. The crude local failure rate in patients with an associated DCIS component was 12% a compared to 3% in patients with pure invasive histology (p = 0.06). A proportional hazards survival model revealed a significant association of local failure with the performance of a reexcision and young age. CONCLUSION: We conclude that interstitial implant boost for breast conserving irradiation is associated with cosmesis that is superior than the same nominal dose of external beam boost, although this is highly dependent upon the technical quality of the source position and the relative uniformity of dose deposition. Breast implantation results in a rate of local control no better than dose-matched external beam boost in patients with a final margin < or = 2 mm. Local control with implantation might be further enhanced by increasing implant volume and/or improved target localization.

Algorithms for the process management of sealed source brachytherapy.

Incidents and misadministrations suggest that brachytherapy may benefit from clarification of the quality management program and other mandates of the U.S. Nuclear Regulatory Commission. To that end, flowcharts of step by step subprocesses were developed and formatted with dedicated software. The overall process was similarly organized in a complex flowchart termed a general process map. Procedural and structural indicators associated with each flowchart and map were critiqued and pre-existing documentation was revised. "Step-regulation tables" were created to refer steps and subprocesses to Nuclear Regulatory Commission rules and recommendations in their sequences of applicability. Brachytherapy algorithms were specified as programmable, recursive processes, including therapeutic dose determination and monitoring doses to the public. These algorithms are embodied in flowcharts and step-regulation tables. A general algorithm is suggested as a template from which other facilities may derive tools to facilitate process management of sealed source brachytherapy.

The use of scattering foil compensators in electron beam therapy.

PURPOSE: This study was undertaken to show that scattering foils could be used as electron beam compensators. METHODS AND MATERIALS: Two scattering foils were designed to improve the dose homogeneity when a curved surface is irradiated with electrons. One scattering foil, constructed of mylar, was designed for use with a single 6 MeV electron field. The second scattering foil, constructed of lead, was designed to homogenize the dose along the matchline of two abutting electron fields. Measurements with the second compensator were made at energies of 6, 9, and 12 MeV. The compensators were mounted over the topmost opening of the electron cone. A simple method for modeling the effect of the second compensator using a conventional treatment planning system was also evaluated. RESULTS: When the mylar compensator was placed atop the 25 x 25 cm cone and a Rando phantom irradiated with 6 MeV electrons, the dose at the field edges was increased by about 10%. Use of the lead foil compensator for two abutting fields gave a highly uniform dose along the matchline, without perturbing the isodoses at depth or at the other field edges. Measured hot spots in the Rando phantom for 6 and 9 MeV electrons were 104 and 108%, respectively. The effect of the lead foil compensator was successfully modeled on a conventional treatment planning system by summing beams of different field sizes. CONCLUSIONS: Both compensators were effective in improving the dose homogeneity within the target volume.

An isodose shift technique for obliquely incident electron beams.

It is well known that when an electron beam is incident obliquely on the surface of a phantom, the depth dose curve measured normal to the surface is shifted toward the surface. Based on geometrical arguments alone, the depth of the nth isodose line for an electron beam incident at an angle theta should be equal to the product of cos theta and the depth of the nth isodose line at normal incidence. This method, however, ignores the effects of scatter and can lead to significant errors in isodose placement for beams at large angles of incidence. A semi-empirical functional relationship and a table of isodose shift factors have been developed with which one may easily calculate the depth of any isodose line for beams at incident angles of 0 degrees to 60 degrees. The isodose shift factors are tabulated in terms of beam energy (6-22 MeV) and isodose line (10%-90%) and are shown to be relatively independent of beam size and incident angle for angles less than 60 degrees. Extensive measurements have been made on a Varian Clinac 2500 linear accelerator with a parallel-plate chamber and polystyrene phantom. The dependence of the chamber response on beam angulation has been checked, and the scaling factor of the polystyrene phantom has been determined to be equal to 1.00.

A dose homogeneity index for evaluating 192Ir interstitial breast implants.

To evaluate and optimize dose homogeneity of 192Ir interstitial breast implants, we define a quantity, the dose homogeneity index (DHI), as follows: DHI = [V(TDR)--V(HDR)]/V(TDR), where V(TDR) denotes the total treatment volume enclosed by the prescribed treatment dose rate (TDR) and V(HDR) denotes the volume enclosed by high-dose rate (HDR), which is 1.5 X TDR or greater. We have used the DHI to examine and compare 192Ir double-plane implants of various sizes planned by the Memorial system or the Tufts system. Criteria have been suggested for the number of planes required for implants in a given treatment volume. Anderson's volume-dose histogram with inverse square suppression is adopted for illustration.

Photon activation analysis as a new technique for body composition studies.

A study was undertaken to demonstrate the usefulness of the recently developed photon activation analysis (PAA) technique for in vivo body composition studies. PAA can be used for direct measurement of total-body oxygen, nitrogen, and carbon. Sequential measurements were made on rats fed diets of 0%, 4.2%, or 20% protein for 6 1/2 wk, and significant changes in body composition were noted. In addition, rats of different ages, strains, nutritional states, and degrees of obesity were included in a comparison of PAA results in vivo with results from chemical analysis after sacrifice of the animals. High positive correlations were found between PAA measurements of carbon and chemical analysis measurements of fat and between PAA measurements of oxygen and chemical analysis measurements of total-body water. A low positive correlation was found between PAA measurements of nitrogen and chemical analysis measurements of protein.

Measurement of total-body oxygen, nitrogen, and carbon in vivo by photon activation analysis.

A method has been developed to measure total-body oxygen, nitrogen, and carbon in vivo using the x-ray beam of a 45-MV betatron and a whole-body counter. Following x-ray irradiation of living tissue, the positron emitting activation products 15O, 11C, and 13N are produced. The decay of these radionuclides has been measured in both phantoms and animals, and a computer curve-fitting algorithm used to resolve the decay curve into separate contributions from 15O, 11C, and 13N. The decay curve was corrected for interfering activity from 30P, 38K, and 34mCl, and in the case of live animals, also corrected for a substantial fraction of 11C lost through exhalation. Activation uniformity profiles have been measured for phantoms up to 30 cm in thickness. With a radiation dose of 20 cGy, total-body O, N, and C were measured in dead rats with estimated accuracies of +/- 1.4%, +/- 4.5%, and +/- 1.5% [1 standard deviation (SD)], respectively. With a radiation dose of 40 cGy, total-body O, N, and C were measured in living rats with estimated accuracies of +/- 1.4%, +/- 6.9%, and +/- 1.5% (1 SD), respectively. It is anticipated that total-body O, N, and C similarly could be measured in human subjects with a radiation dose of 1-2 cGy and with accuracies comparable to those obtained in rats. Although most of the measurements were made using a beam energy of 45 MV, we have shown that useful results may be achievable with a beam energy as low as 25 MV. This accurate, convenient, and safe technique for total-body O, C, and N measurement should have applications in the study of nutritional status in health and disease, both in human subjects and in animals.

Improved "nonisolated-sensor" solid polystyrene calorimeter.

A "nonisolated-sensor" solid polystyrene calorimeter is described which permits absorbed dose measurements with precision of less than 0.3% (standard error of the mean). The accuracy for obtaining absolute absorbed dose was estimated by comparisons with cavity ionization measurements. The calculation of absorbed dose with ionization chambers was carried out based upon the TG-21 AAPM dosimetry protocol. Measurements in a 60Co gamma-ray field with three different polystyrene parallel-plate ion chambers in a polystyrene phantom did not differ by more than 1.5% from that obtained with the polystyrene calorimeter. Measurements taken over a period of 247 days are compared with the expected values on the basis of the decay 60Co. The calorimeter system, with its capability of acquiring, printing, storing, plotting, and analyzing the data by computer, is described.