Radiochromic film-based quality assurance for CT-based high-dose-rate brachytherapy

PURPOSE

In the past, film dosimetry was developed into a powerful tool for external beam radiotherapy treatment verification and quality assurance. The objective of this work was the development and clinical testing of the EBT3 model GafChromic film based brachytherapy quality assurance (QA) system.

METHODS AND MATERIALS

Retrospective dosimetry study was performed to test a patient-specific QA system for preoperative endorectal brachytherapy that uses a radiochromic film dosimetry system. A dedicated phantom for brachytherapy applicator used for rectal cancer treatment was fabricated enabling us to compare calculated-to-measured dose distributions. Starting from the same criteria used for external beam intensity-modulated radiation therapy QA (3%, 3 mm), passing criteria for high- and low-dose gradient regions were subsequently determined. Finally, we investigated the QA system's sensitivity to controlled source positional errors on selected patient plans.

RESULTS

In low-dose gradient regions, measured dose distributions with criteria of 3%, 3 mm barely passed the test, as they showed 95% passing pixels. However, in the high-dose gradient region, a more stringent condition could be established. Both criteria of 2%, 3 mm and 3%, 2 mm with gamma function calculated using normalization to the same absolute dose value in both measured and calculated dose distributions, and matrix sizes rescaled to match each other showed more than 95% of pixels passing, on average, for 15 patient plans analyzed.

CONCLUSIONS

Although the necessity of the patient-specific brachytherapy QA needs yet to be justified, we described a radiochromic film dosimetry-based QA system that can be a part of the brachytherapy commissioning process, as well as yearly QA program.

The Effect of Radiotherapy on Gentamicin Ototoxicity

Objective

Patients undergoing radiotherapy (RT) often present with serious bacterial infections requiring the use of antibiotic treatment. Gentamicin is a commonly used aminoglycoside antibiotic, whose ototoxicity remains a major problem in clinical use. The objective of this study was to determine whether radiation exposure can influence gentamicin-induced ototoxicity.

Study Design

Prospective animal study.

Setting

Animal care facilities of the Montreal Children’s Hospital Research Institute.

Methods

Sixteen guinea pigs received low-dose RT unilaterally for 4 weeks (total: 48 Gy). Animals then received low or high doses of gentamicin (40 mg/kg/d and 80 mg/kg/d) for 10 days. The ears were divided into 4 groups: gentamicin 40 mg, gentamicin 80 mg, gentamicin 40 mg + RT, and gentamicin 80 + RT. Auditory brainstem responses and distortion products otoacoustic emissions were assessed at baseline and before and after gentamicin treatment. Cochlear morphology using light and scanning electron microscopy were evaluated.

Results

High-dose gentamicin caused significant auditory brainstem response threshold shifts ( P = .020), with greater hearing loss in the irradiated ear (difference of 23.6 + 7.5 dB). All animals exposed to high-dose gentamicin had head tilts toward the radiated side. Cochlear morphology revealed the greatest hair cell damage in the gentamicin 80 + RT group followed by gentamicin 80.

Conclusion

Results suggest that radiation can exacerbate the ototoxicity of gentamicin at high doses.

Characterization of calibration curves and energy dependence GafChromic™ XR-QA2 model based radiochromic film dosimetry system

PURPOSE

The authors investigated the energy response of XR-QA2 GafChromic™ film over a broad energy range used in diagnostic radiology examinations. The authors also made an assessment of the most suitable functions for both reference and relative dose measurements.

METHODS

Pieces of XR-QA2 film were irradiated to nine different values of air kerma in air, following reference calibration of a number of beam qualities ranging in HVLs from 0.16 to 8.25 mm Al, which corresponds to effective energy range from 12.7 keV to 56.3 keV. For each beam quality, the authors tested three functional forms (rational, linear exponential, and power) to assess the most suitable function by fitting the delivered air kerma in air as a function of film response in terms of reflectance change. The authors also introduced and tested a new parameter χ = netΔR·e(m netΔR) that linearizes the inherently nonlinear response of the film.

RESULTS

The authors have found that in the energy range investigated, the response of the XR-QA2 based radiochromic film dosimetry system ranges from 0.222 to 0.420 in terms of netΔR at K(air)(air) = 8 cGy. For beam qualities commonly used in CT scanners (4.03-8.25 mm Al), the variation in film response (netΔR at K(air)(air) = 8 cGy) amounts to ± 5%, while variation in K(air)(air) amounts to ± 14%.

CONCLUSIONS

Results of our investigation revealed that the use of XR-QA2 GafChromic™ film is accompanied by a rather pronounced energy dependent response for beam qualities used for x-ray based diagnostic imaging purposes. The authors also found that the most appropriate function for the reference radiochromic film dosimetry would be the power function, while for the relative dosimetry one may use the exponential response function that can be easily linearized.

Effective spatially fractionated GRID radiation treatment planning for a passive grid block

OBJECTIVE

To commission a grid block for spatially fractionated grid radiation therapy (SFGRT) treatments and describe its clinical implementation and verification through the record and verify (R&V) system.

METHODS

SFGRT was developed as a treatment modality for bulky tumours that cannot be easily controlled with conventionally fractionated radiation. Treatment is delivered in the form of open-closed areas. Currently, SFGRT is performed by either using a commercially available grid block or a multileaf collimator (MLC) of a linear accelerator. In this work, 6-MV photon beam was used to study dosimetric characteristics of the grid block. We inserted the grid block into a commercially available treatment planning system (TPS), and the feasibility of delivering such treatment plans on a linear accelerator using a R&V system was verified. Dose measurements were performed using a miniature PinPoint(TM) ion chamber (PTW, Freiburg, Germany) in a water phantom and radiochromic film within solid water slabs. PinPoint ion chamber was used to measure the output factors, percentage depth dose (PDD) curves and beam profiles at two depths, depth of maximum dose (zmax) and 10 cm. Film sheets were used to measure dose profiles at zmax and 10-cm depth.

RESULTS

The largest observed percentage difference between output factors for the grid block technique calculated by the TPS and measured with the PinPoint ion chamber was 3.6% for the 5 × 5-cm(2) field size. Relatively significant discrepancies between measured and calculated PDD values appear only in the build-up region, which was found to amount to <4%, while a good agreement (differences <2%) at depths beyond zmax was observed. Dose verification comparisons performed between calculated and measured dose distributions were in clinically acceptable agreements. When comparing the MLC-based with the grid block technique, the advantage of treating large tumours with a single field reduces treatment time by at least 3-5 times, having significant impact on patient throughput.

CONCLUSION

The proposed method supports and helps to standardize the clinical implementation of the grid block in a safer and more accurate way.

ADVANCES IN KNOWLEDGE

This work describes the method to implement treatment planning for the grid block technique in radiotherapy departments.

Radiochromic film based dosimetry of image-guidance procedures on different radiotherapy modalities

In this work we compare doses from imaging procedures performed on today's state‐of‐the‐art integrated imaging systems using a reference radiochromic film dosimetry system. Skin dose and dose profile measurements from different imaging systems were performed using radiochromic films at different anatomical sites on a humanoid RANDO phantom. EBT3 film was used to measure imaging doses from a TomoTherapy MVCT system, while XRQA2 film was used for dose measurements from kilovoltage imaging systems (CBCT on 21eX and TrueBeam Varian linear accelerators and CyberKnife stereoscopic orthogonal imagers). Maximum measured imaging doses in cGy at head, thorax, and pelvis regions were respectively 0.50, 1.01, and 4.91 for CBCT on 21eX, 0.38, 0.84, and 3.15 for CBCT on TrueBeam, 4.33, 3.86, and 6.50 for CyberKnife imagers, and 3.84, 1.90, and 2.09 for TomoTherapy MVCT. In addition, we have shown how an improved calibration system of XRQA2 film can achieve dose uncertainty level of better than 2% for doses above 0.25 cGy. In addition to simulation‐based studies in literature, this study provides the radiation oncology team with data necessary to aid in their decision about imaging frequency for image‐guided radiation therapy protocols.

PACS number: 87.53.Bn, 87.55.Qr, 87.56.Fc

Direction-modulated brachytherapy for high-dose-rate treatment of cervical cancer. I: theoretical design

PURPOSE

To demonstrate that utilization of the direction-modulated brachytherapy (DMBT) concept can significantly improve treatment plan quality in the setting of high-dose-rate (HDR) brachytherapy for cervical cancer.

METHODS AND MATERIALS

The new, MRI-compatible, tandem design has 6 peripheral holes of 1.3-mm diameter, grooved along a nonmagnetic tungsten-alloy rod (ρ = 18.0 g/cm(3)), enclosed in Delrin tubing (polyoxymethylene, ρ = 1.41 g/cm(3)), with a total thickness of 6.4 mm. The Monte Carlo N-Particle code was used to calculate the anisotropic (192)Ir dose distributions. An in-house-developed inverse planning platform, geared with simulated annealing and constrained-gradient optimization algorithms, was used to replan 15 patient cases (total 75 plans) treated with a conventional tandem and ovoids (T&O) applicator. Prescription dose was 6 Gy. For replanning, we replaced the conventional tandem with that of the new DMBT tandem for optimization but left the ovoids in place and kept the dwell positions as originally planned. All DMBT plans were normalized to match the high-risk clinical target volume V100 coverage of the T&O plans.

RESULTS

In general there were marked improvements in plan quality for the DMBT plans. On average, D2cc for the bladder, rectum, and sigmoid were reduced by 0.59 ± 0.87 Gy (8.5% ± 28.7%), 0.48 ± 0.55 Gy (21.1% ± 27.2%), and 0.10 ± 0.38 Gy (40.6% ± 214.9%) among the 75 plans, with best single-plan reductions of 3.20 Gy (40.8%), 2.38 Gy (40.07%), and 1.26 Gy (27.5%), respectively. The high-risk clinical target volume D90 was similar, with 6.55 ± 0.96 Gy and 6.59 ± 1.06 Gy for T&O and DMBT, respectively.

CONCLUSIONS

Application of the DMBT concept to cervical cancer allowed for improved organ at risk sparing while achieving similar target coverage on a sizeable patient population, as intended, by maximally utilizing the anatomic information contained in 3-dimensional imaging. A series of mechanical and clinical validations are to be followed.

Safety and otoprotection of metformin in radiation-induced sensorineural hearing loss in the guinea pig

OBJECTIVE

There is currently no treatment available to prevent radiation-induced sensorineural hearing loss. Metformin has antineoplastic effects and is able to regulate the mitochondrial production of reactive oxygen species after cellular stress, which is one of the mechanisms involved in apoptosis after radiation damage. The objective of this study was to determine the safety and radioprotective properties of metformin against radiation-induced cochlear damage both in vitro and in vivo.

STUDY DESIGN

In vitro and prospective animal study.

SETTING

Animal Care Facilities of the Montreal Children's Hospital Research Institute.

METHODS

Cultured auditory hair cells (HEI-OC1) were exposed to different concentrations of metformin to determine its safety. Cells were incubated with different metformin concentrations and subjected to radiation. Cell viability after experiments was determined with the 3-(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium (MTS) assay. Sixteen guinea pigs were divided in 2 groups: drinking tap water (n = 8) and drinking water containing metformin (n = 8). The animals were unilaterally irradiated for 20 days (total dose 70 Gy), and the ears were divided in 4 groups: control (n = 8), irradiated (n = 8), metformin (n = 8), and experimental (n = 8). Auditory brainstem responses were assessed before and 1, 6, and 16 weeks after completion of radiotherapy.

RESULTS

Metformin was not cytotoxic or radioprotective in cultured auditory hair cells. Experimental ears had less hearing loss than radiated ones; however, differences were not statistically significant (P > .05).

CONCLUSION

Metformin is not ototoxic or radioprotective in vitro or in vivo. Ears solely subjected to metformin had better hearing thresholds than the rest of the groups.