Recommendations for clinical electron beam dosimetry: supplement to the recommendations of Task Group 25

Dosimetric characterization of a rigid, surface-contour-specific thermoplastic bolus material

A dosimetric analysis of a commercially available thermoplastic sheet bolus, Klarity EZ Bolus^TM, was completed. Attenuation characteristics were evaluated using different configurations of a rectilinear water-mimicking plastic phantom irradiated by a high-energy linear accelerator using three photon energies, five electron energies. These results were compared with data obtained during the linear accelerator commissioning process to determine depths of water that attenuated beams similarly. CT scans of the flat, unmolded sheet bolus, as well as of the bolus molded to a cylindrical phantom, were analyzed. The product was found to form a durable and rigid, contour-specific bolus with a water-equivalent thickness of approximately 6 mm for a single sheet, and 11 mm for two sheets in tandem.

Production of patient-specific electron beam aperture cut-outs using a low-cost, multi-purpose 3D printer

Electron beam collimators for non‐standard field sizes and shapes are typically fabricated using Styrofoam molds to cast the aperture cut‐out. These molds are often produced using a dedicated foam cutter, which may be expensive and only serves a single purpose. An increasing number of radiotherapy departments, however, has a 3D printer on‐site, to create a wide range of custom‐made treatment auxiliaries, such as bolus and dosimetry phantoms. The 3D printer can also be used to produce patient‐specific aperture cut‐outs, as elaborated in this note. Open‐source programming language was used to automatically generate the mold's shape in a generic digital file format readable by 3D printer software. The geometric mold model has the patient's identification number integrated and is to be mounted on a uniquely fitting, reusable positioning device, which can be 3D printed as well. This assembly likewise fits uniquely onto the applicator tray, ensuring correct and error‐free alignment of the mold during casting of the aperture. For dosimetric verification, two aperture cut‐outs were cast, one using a conventionally cut Styrofoam mold and one using a 3D printed mold. Using these cut‐outs, the clinical plan was delivered onto a phantom, for which the transversal dose distributions were measured at 2 cm depth using radiochromic film and compared using gamma‐index analysis. An agreement score of 99.9% between the measured 2D dose distributions was found in the (10%–80%) dose region, using 1% (local) dose‐difference and 1.0 mm distance‐to‐agreement acceptance criteria. The workflow using 3D printing has been clinically implemented and is in routine use at the author's institute for all patient‐specific electron beam aperture cut‐outs. It allows for a standardized, cost‐effective, and operator‐friendly workflow without the need for dedicated equipment. In addition, it offers possibilities to increase safety and quality of the process including patient identification and methods for accurate mold alignment.

Practical lookup tables for ensuring target coverage in a clinical setup for skin cancer electron therapy

Aim

To create practical lookup tables containing percent depth dose (PDD) and profile parameters of electron beams and to demonstrate clinical application of the lookup tables to skin cancer treatment to ensure target coverage in a clinical setup.

Materials and methods

For 6 and 9 MeV electron energies, PDDs and profiles at clinically relevant depths [i.e., R95 (distal depth of 95% maximum dose), R90, R85 and R80] were measured in water at 100 cm source-to-surface distance for an 10×10 cm2 open field and circular cutouts with diameters of 4, 5, 6, 7 and 8 cm. Then PDD parameters along with profile parameters such as width of isodose lines and penumbra at the clinically relevant depths were determined. Output factors for the cutouts were measured at dmax in water and solid water.

Results

With PDD and profile parameters, dosimetry lookup tables were generated. Based upon the lookup tables, target coverage at prescribed depths was retrospectively reviewed for three skin cancer cases. The lookup tables suggested larger cutouts for adequate target coverage.

Findings

Dosimetry lookup tables for electron beam therapy should include profile parameters at clinically relevant depths and be provided to clinicians to ensure target coverage in a clinical setup.

COMP report: CPQR technical quality control guidelines for major dosimetry equipment

The Canadian Organization of Medical Physicists (COMP), in close partnership with the Canadian Partnership for Quality Radiotherapy (CPQR) has developed a series of Technical Quality Control (TQC) guidelines for radiation treatment equipment. These guidelines outline the performance objectives that equipment should meet to ensure an acceptable level of radiation treatment quality. The TQC guidelines have been rigorously reviewed and field tested in a variety of Canadian radiation treatment facilities. The development process enables rapid review and update to keep the guidelines current with changes in technology (the most update version of this guideline can be found on the CPQR website). This article provides guidelines for quality control testing of major dosimetry equipment.

Comparison of measured electron energy spectra for six matched, radiotherapy accelerators

This study compares energy spectra of the multiple electron beams of individual radiotherapy machines, as well as the sets of spectra across multiple matched machines. Also, energy spectrum metrics are compared with central‐axis percent depth‐dose (PDD) metrics.

Methods

A lightweight, permanent magnet spectrometer was used to measure energy spectra for seven electron beams (7–20 MeV) on six matched Elekta Infinity accelerators with the MLCi2 treatment head. PDD measurements in the distal falloff region provided R₅₀ and R_80–20 metrics in Plastic Water^®, which correlated with energy spectrum metrics, peak mean energy (PME) and full‐width at half maximum (FWHM).

Results

Visual inspection of energy spectra and their metrics showed whether beams on single machines were properly tuned, i.e., FWHM is expected to increase and peak height decrease monotonically with increased PME. Also, PME spacings are expected to be approximately equal for 7–13 MeV beams (0.5‐cm R₉₀ spacing) and for 13–16 MeV beams (1.0‐cm R₉₀ spacing). Most machines failed these expectations, presumably due to tolerances for initial beam matching (0.05 cm in R₉₀; 0.10 cm in R_80–20) and ongoing quality assurance (0.2 cm in R₅₀). Also, comparison of energy spectra or metrics for a single beam energy (six machines) showed outlying spectra. These variations in energy spectra provided ample data spread for correlating PME and FWHM with PDD metrics. Least‐squares fits showed that R₅₀ and R_80–20 varied linearly and supralinearly with PME, respectively; however, both suggested a secondary dependence on FWHM. Hence, PME and FWHM could serve as surrogates for R₅₀ and R_80–20 for beam tuning by the accelerator engineer, possibly being more sensitive (e.g., 0.1 cm in R_80–20 corresponded to 2.0 MeV in FWHM).

Conclusions

Results of this study suggest a lightweight, permanent magnet spectrometer could be a useful beam‐tuning instrument for the accelerator engineer to (a) match electron beams prior to beam commissioning, (b) tune electron beams for the duration of their clinical use, and (c) provide estimates of PDD metrics following machine maintenance. However, a real‐time version of the spectrometer is needed to be practical.

FMEA of manual and automated methods for commissioning a radiotherapy treatment planning system

PURPOSE

To evaluate the level of risk involved in treatment planning system (TPS) commissioning using a manual test procedure, and to compare the associated process-based risk to that of an automated commissioning process (ACP) by performing an in-depth failure modes and effects analysis (FMEA).

METHODS

The authors collaborated to determine the potential failure modes of the TPS commissioning process using (a) approaches involving manual data measurement, modeling, and validation tests and (b) an automated process utilizing application programming interface (API) scripting, preloaded, and premodeled standard radiation beam data, digital heterogeneous phantom, and an automated commissioning test suite (ACTS). The severity (S), occurrence (O), and detectability (D) were scored for each failure mode and the risk priority numbers (RPN) were derived based on TG-100 scale. Failure modes were then analyzed and ranked based on RPN. The total number of failure modes, RPN scores and the top 10 failure modes with highest risk were described and cross-compared between the two approaches. RPN reduction analysis is also presented and used as another quantifiable metric to evaluate the proposed approach.

RESULTS

The FMEA of a MTP resulted in 47 failure modes with an RPN_ave of 161 and S_ave of 6.7. The highest risk process of "Measurement Equipment Selection" resulted in an RPN_max of 640. The FMEA of an ACP resulted in 36 failure modes with an RPN_ave of 73 and S_ave of 6.7. The highest risk process of "EPID Calibration" resulted in an RPN_max of 576.

CONCLUSIONS

An FMEA of treatment planning commissioning tests using automation and standardization via API scripting, preloaded, and pre-modeled standard beam data, and digital phantoms suggests that errors and risks may be reduced through the use of an ACP.

Determination of Initial Beam Parameters of Varian 2100 CD Linac for Various Therapeutic Electrons Using PRIMO

The aim of the present research was to establish primary characteristics of electron beams for a Varian 2100C/D linear accelerator with recently developed PRIMO Monte Carlo software and to verify relations between electron energy and dose distribution. To maintain conformity of simulated and measured dose curves within 1%/1mm, mean energy, Full Width at Half Maximum (FWHM) of energy and focal spot FWHM of initial beam were changed iteratively. Mean and most probable energies were extracted from validated phase spaces and compared with related empirical equation results. To explain the importance of correct estimation of primary energy on a clinical case, computed tomography images of a thorax phantom were imported in PRIMO. Dose distributions and dose volume histogram (DVH) curves were compared between validated and artificial cases with overestimated energy. Initial mean energies were obtained of 6.68, 9.73, 13.2 and 16.4 MeV for 6, 9, 12 and 15 nominal energies, respectively. Energy FWHM reduced with increase in energy. Three mm focal spot FWHM for 9 MeV and 4 mm for other energies made proper matches of simulated and measured profiles. In addition, the maximum difference of calculated mean electrons energy at the phantom surface with empirical equation was 2.2 percent. Finally, clear differences in DVH curves of validated and artificial energy were observed as heterogeneity indexes were 0.15 for 7.21 MeV and 0.25 for 6.68 MeV. The Monte Carlo model presented in PRIMO for Varian 2100 CD was precisely validated. IAEA polynomial equations estimated mean energy more accurately than a known linear one. Small displacement of R50 changed DVH curves and homogeneity indexes. PRIMO is a user-friendly software which has suitable capabilities to calculate dose distribution in water phantoms or computerized tomographic volumes accurately.

A dosimetric comparison of copper and Cerrobend electron inserts

The purpose of this work was to evaluate differences in dose resulting from the use of copper aperture inserts compared to lead‐alloy (Cerrobend) aperture inserts for electron beam therapy. Specifically, this study examines if copper aperture inserts can be used clinically with the same commissioning data measured using lead‐alloy aperture inserts. The copper inserts were acquired from .decimal, LLC and matching lead‐alloy, Cerrobend inserts were constructed in‐house for 32 combinations of nine square insert field sizes (2×2 to 20×20 cm2) and five applicator sizes (6×6 to 25×25 cm2). Percent depth‐dose and off‐axis relative dose profiles were measured using an electron diode in water for select copper and Cerrobend inserts for a subset of applicators (6×6,10×10,25×25 cm2) and energies (6, 12, 20 MeV) at 100 and 110 cm source‐to‐surface distances (SSD) on a Varian Clinac 21EX accelerator. Dose outputs were measured for all field size‐insert combinations and five available energies (6−20 MeV) at 100 cm SSD and for a smaller subset at 110 cm SSD. Using these data, 2D planar absolute dose distributions were generated and compared. Criteria for agreement were ±2% of maximum dose or 1 mm distance‐to‐agreement for 99% of points. A gamma analysis of the beam dosimetry showed 94 of 96 combinations of insert size, applicator, energy, and SSD were within the 2%/1 mm criteria for >99% of points. Outside the field, copper inserts showed less bremsstrahlung dose under the insert compared to Cerrobend (greatest difference was 2.5% at 20 MeV and 100 cm SSD). This effect was most prominent at the highest energies for combinations of large applicators with small field sizes, causing some gamma analysis failures. Inside the field, more electrons scattered from the collimator edge of copper compared to Cerrobend, resulting in an increased dose at the field edge for copper at shallow depths (greatest increase was 1% at 20 MeV and 100 cm SSD). Dose differences decreased as the SSD increased, with no gamma failures at 110 cm SSD. Inserts for field sizes ≥6×6cm2 at any energy, or for small fields (≤4×4cm2) at energies <20 MeV, showed dosimetric differences less than 2%/1 mm for more than 99% of points. All areas of comparison criteria failures were from lower out‐of‐field dose under copper inserts due to a reduction in bremsstrahlung production, which is clinically beneficial in reducing dose to healthy tissue outside of the planned treatment volume. All field size‐applicator size‐energy combinations passed 3%/1 mm criteria for 100% of points. Therefore, it should be clinically acceptable to utilize copper insets with dose distributions measured with Cerrobend inserts for treatment planning dose calculations and monitor unit calculations.

PACS number(s): 87.56.jk

Permanent-magnet energy spectrometer for electron beams from radiotherapy accelerators

PURPOSE

The purpose of this work was to adapt a lightweight, permanent magnet electron energy spectrometer for the measurement of energy spectra of therapeutic electron beams.

METHODS

An irradiation geometry and measurement technique were developed for an approximately 0.54-T, permanent dipole magnet spectrometer to produce suitable latent images on computed radiography (CR) phosphor strips. Dual-pinhole electron collimators created a 0.318-cm diameter, approximately parallel beam incident on the spectrometer and an appropriate dose rate at the image plane (CR strip location). X-ray background in the latent image, reduced by a 7.62-cm thick lead block between the pinhole collimators, was removed using a fitting technique. Theoretical energy-dependent detector response functions (DRFs) were used in an iterative technique to transform CR strip net mean dose profiles into energy spectra on central axis at the entrance to the spectrometer. These spectra were transformed to spectra at 95-cm source to collimator distance (SCD) by correcting for the energy dependence of electron scatter. The spectrometer was calibrated by comparing peak mean positions in the net mean dose profiles, initially to peak mean energies determined from the practical range of central-axis percent depth-dose (%DD) curves, and then to peak mean energies that accounted for how the collimation modified the energy spectra (recalibration). The utility of the spectrometer was demonstrated by measuring the energy spectra for the seven electron beams (7-20 MeV) of an Elekta Infinity radiotherapy accelerator.

RESULTS

Plots of DRF illustrated their dependence on energy and position in the imaging plane. Approximately 15 iterations solved for the energy spectra at the spectrometer entrance from the measured net mean dose profiles. Transforming those spectra into ones at 95-cm SCD increased the low energy tail of the spectra, while correspondingly decreasing the peaks and shifting them to slightly lower energies. Energy calibration plots of peak mean energy versus peak mean position of the net mean dose profiles for each of the seven electron beams followed the shape predicted by the Lorentz force law for a uniform z-component of the magnetic field, validating its being modeled as uniform (0.542 ± 0.027 T). Measured Elekta energy spectra and their peak mean energies correlated with the 0.5-cm (7-13 MeV) and the 1.0-cm (13-20 MeV) R90 spacings of the %DD curves. The full-width-half-maximum of the energy spectra decreased with decreasing peak mean energy with the exception of the 9-MeV beam, which was anomalously wide. Similarly, R80-20 decreased linearly with peak mean energy with the exception of the 9 MeV beam. Both were attributed to suboptimal tuning of the high power phase shifter for the recycled radiofrequency power reentering the traveling wave accelerator.

CONCLUSIONS

The apparatus and analysis techniques of the authors demonstrated that an inexpensive, lightweight, permanent magnet electron energy spectrometer can be used for measuring the electron energy distributions of therapeutic electron beams (6-20 MeV). The primary goal of future work is to develop a real-time spectrometer by incorporating a real-time imager, which has potential applications such as beam matching, ongoing beam tune maintenance, and measuring spectra for input into Monte Carlo beam calculations.

Development of an accurate EPID-based output measurement and dosimetric verification tool for electron beam therapy

PURPOSE

To develop an efficient and robust tool for output measurement and absolute dose verification of electron beam therapy by using a high spatial-resolution and high frame-rate amorphous silicon flat panel electronic portal imaging device (EPID).

METHODS

The dosimetric characteristics of the EPID, including saturation, linearity, and ghosting effect, were first investigated on a Varian Clinac 21EX accelerator. The response kernels of the individual pixels of the EPID to all available electron energies (6, 9, 12, 16, and 20 MeV) were calculated by using Monte Carlo (MC) simulations, which formed the basis to deconvolve an EPID raw images to the incident electron fluence map. The two-dimensional (2D) dose distribution at reference depths in water was obtained by using the constructed fluence map with a MC simulated pencil beam kernel with consideration of the geometric and structural information of the EPID. Output factor measurements were carried out with the EPID at a nominal source-surface distance of 100 cm for 2 × 2, 3 × 3, 6 × 6, 10 × 10, and 15 × 15 cm(2) fields for all available electron energies, and the results were compared with that measured in a solid water phantom using film and a Farmer-type ion chamber. The dose distributions at a reference depth specific to each energy and the flatness and symmetry of the 10 × 10 cm(2) electron beam were also measured using EPID, and the results were compared with ion chamber array and water scan measurements. Finally, three patient cases with various field sizes and irregular cutout shapes were also investigated.

RESULTS

EPID-measured dose changed linearly with the monitor units and showed little ghosting effect for dose rate up to 600 MU/min. The flatness and symmetry measured with the EPID were found to be consistent with ion chamber array and water scan measurements. The EPID-measured output factors for standard square fields of 2 × 2, 3 × 3, 6 × 6, 10 × 10, 15 × 15 cm(2) agreed with film and ion chamber measurements. The average discrepancy between EPID and ion chamber/film measurements was 0.81% ± 0.60% (SD) and 1.34% ± 0.75%, respectively. For the three clinical cases, the difference in output between the EPID- and ion chamber array measured values was found to be 1.13% ± 0.11%, 0.54% ± 0.10%, and 0.74% ± 0.11%, respectively. Furthermore, the γ-index analysis showed an excellent agreement between the EPID- and ion chamber array measured dose distributions: 100% of the pixels passed the criteria of 3%/3 mm. When the γ-index was set to be 2%/2 mm, the pass rate was found to be 99.0% ± 0.07%, 98.2% ± 0.14%, and 100% for the three cases.

CONCLUSIONS

The EPID dosimetry system developed in this work provides an accurate and reliable tool for routine output measurement and dosimetric verification of electron beam therapy. Coupled with its portability and ease of use, the proposed system promises to replace the current film-based approach for fast and reliable assessment of small and irregular electron field dosimetry.

Electron beam energy QA - a note on measurement tolerances

Monthly QA is recommended to verify the constancy of high‐energy electron beams generated for clinical use by linear accelerators. The tolerances are defined as 2%/2 mm in beam penetration according to AAPM task group report 142. The practical implementation is typically achieved by measuring the ratio of readings at two different depths, preferably near the depth of maximum dose and at the depth corresponding to half the dose maximum. Based on beam commissioning data, we show that the relationship between the ranges of energy ratios for different electron energies is highly nonlinear. We provide a formalism that translates measurement deviations in the reference ratios into change in beam penetration for electron energies for six Elekta (6‐18 MeV) and eight Varian (6‐22 MeV) electron beams. Experimental checks were conducted for each Elekta energy to compare calculated values with measurements, and it was shown that they are in agreement. For example, for a 6 MeV beam a deviation in the measured ionization ratio of ±15% might still be acceptable (i.e., be within ±2 mm), whereas for an 18 MeV beam the corresponding tolerance might be ±6%. These values strongly depend on the initial ratio chosen. In summary, the relationship between differences of the ionization ratio and the corresponding beam energy are derived. The findings can be translated into acceptable tolerance values for monthly QA of electron beam energies.

PACS number(s): 87.55, 87.56

Evaluation of various boluses in dose distribution for electron therapy of the chest wall with an inward defect

Delivering radiotherapy to the postmastectomy chest wall can be achieved using matched electron fields. Surgical defects of the chest wall change the dose distribution of electrons. In this study, the improvement of dose homogeneity using simple, nonconformal techniques of thermoplastic bolus application on a defect is evaluated. The proposed phantom design improves the capability of film dosimetry for obtaining dose profiles of a patient's anatomical condition. A modeled electron field of a patient with a postmastectomy inward surgical defect was planned. High energy electrons were delivered to the phantom in various settings, including no bolus, a bolus that filled the inward defect (PB0), a uniform thickness bolus of 5 mm (PB1), and two 5 mm boluses (PB2). A reduction of mean doses at the base of the defect was observed by any bolus application. PB0 increased the dose at central parts of the defect, reduced hot areas at the base of steep edges, and reduced dose to the lung and heart. Thermoplastic boluses that compensate a defect (PB0) increased the homogeneity of dose in a fixed depth from the surface; adversely, PB2 increased the dose heterogeneity. This study shows that it is practical to investigate dose homogeneity profiles inside a target volume for various techniques of electron therapy.

Experimental assessment of out-of-field dose components in high energy electron beams used in external beam radiotherapy

The purpose of this work was to experimentally investigate the out-of-field dose in a water phantom, with several high energy electron beams used in external beam radiotherapy (RT). The study was carried out for 6, 9, 12, and 18 MeV electron beams, on three different linear accelerators, each equipped with a specific applicator. Measurements were performed in a water phantom, at different depths, for different applicator sizes, and off-axis distances up to 70 cm from beam central axis (CAX). Thermoluminescent powder dosimeters (TLD-700) were used. For given cases, TLD measurements were compared to EBT3 films and parallel-plane ionization chamber measurements. Also, out-of-field doses at 10 cm depth, with and without applicator, were evaluated. With the Siemens applicators, a peak dose appears at about 12-15 cm out of the field edge, at 1 cm depth, for all field sizes and energies. For the Siemens Primus, with a 10 × 10 cm(²) applicator, this peak reaches 2.3%, 1%, 0.9% and 1.3% of the maximum central axis dose (Dmax) for 6, 9, 12 and 18 MeV electron beams, respectively. For the Siemens Oncor, with a 10 × 10 cm(²) applicator, this peak dose reaches 0.8%, 1%, 1.4%, and 1.6% of Dmax for 6, 9, 12, and 14 MeV, respectively, and these values increase with applicator size. For the Varian 2300C/D, the doses at 12.5 cm out of the field edge are 0.3%, 0.6%, 0.5%, and 1.1% of Dmax for 6, 9, 12, and 18 MeV, respectively, and increase with applicator size. No peak dose is evidenced for the Varian applicator for these energies. In summary, the out-of-field dose from electron beams increases with the beam energy and the applicator size, and decreases with the distance from the beam central axis and the depth in water. It also considerably depends on the applicator types. Our results can be of interest for the dose estimations delivered in healthy tissues outside the treatment field for the RT patient, as well as in studies exploring RT long-term effects.

AAPM Medical Physics Practice Guideline 5.a.: Commissioning and QA of Treatment Planning Dose Calculations - Megavoltage Photon and Electron Beams

The American Association of Physicists in Medicine (AAPM) is a nonprofit professional society whose primary purposes are to advance the science, education and professional practice of medical physics. The AAPM has more than 8,000 members and is the principal organization of medical physicists in the United States. The AAPM will periodically define new practice guidelines for medical physics practice to help advance the science of medical physics and to improve the quality of service to patients throughout the United States. Existing medical physics practice guidelines will be reviewed for the purpose of revision or renewal, as appropriate, on their fifth anniversary or sooner. Each medical physics practice guideline represents a policy statement by the AAPM, has undergone a thorough consensus process in which it has been subjected to extensive review, and requires the approval of the Professional Council. The medical physics practice guidelines recognize that the safe and effective use of diagnostic and therapeutic radiology requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published practice guidelines and technical standards by those entities not providing these services is not authorized. The following terms are used in the AAPM practice guidelines:• Must and Must Not: Used to indicate that adherence to the recommendation is considered necessary to conform to this practice guideline.• Should and Should Not: Used to indicate a prudent practice to which exceptions may occasionally be made in appropriate circumstances.

Spectroscopic separation of Čerenkov radiation in high-resolution radiation fiber dosimeters

We have investigated Čerenkov radiation generated in phosphor-based optical fiber dosimeters irradiated with clinical electron beams. We fabricated two high-spatial resolution fiber-optic probes, with 200 and 400 μm core diameters, composed of terbium-based phosphor tips. A generalizable spectroscopic method was used to separate Čerenkov radiation from the transmitted signal by the fiber based on the assumption that the recorded signal is a linear superposition of two basis spectra: characteristic luminescence of the phosphor medium and Čerenkov radiation. We performed Monte Carlo simulations of the Čerenkov radiation generated in the fiber and found a strong dependence of the recorded Čerenkov radiation on the numerical aperture of the fiber at shallow phantom depths; however, beyond the depth of maximum dose that dependency is minimal. The simulation results agree with the experimental results for Čerenkov radiation generated in fibers. The spectroscopic technique used in this work can be used for development of high-spatial resolution fiber micro dosimeters and for optical characterization of various scintillating materials, such as phosphor nanoparticles, in ionizing radiation fields of high energy.

Assessment of Eclipse electron Monte Carlo output prediction for various topologies

Monte Carlo simulation is deemed to be the leading algorithm for accurate dose calculation with electron beams. Patient anatomy (contours and tissue densities) as well as irradiation geometry is accounted for. The accuracy of the Monitor Unit (MU) determination is one essential aspect of a treatment planning system. Patient‐specific quality assurance of a Monte Carlo plan usually involves verification of the MUs with an independent simpler calculation approach, in which flat geometry is to be assumed. The magnitude of the discrepancies between flat and varied surfaces for a few scenarios has been investigated in this study. The ability to predict MUs for various surface topologies by the commercial electron Monte Carlo implementation from Varian Eclipse system (Eclipse eMC) has been evaluated and compared to the Generalized Gaussian Pencil Beam (GGPB) algorithm. Ten phantoms with different topologies were constructed of water‐equivalent material. Measurements with a parallel plate ionization chamber were performed using these phantoms to gauge their relative impact on outputs for 6, 9, 12, 16, and 20 MeV electron beams from a Varian TrueBeam with cone sizes ranging from 6×6 cm2 to 25×25 cm2. The corresponding Monte Carlo simulations of the measured geometries were carried out using the CT scans of these phantoms. The results indicated that the Eclipse eMC algorithm can predict these output changes within 3% for most scenarios. However, at the lowest energy, the discrepancy was the greatest, up to 6%. In comparison, the Eclipse GGPB algorithm had much worse agreement, with discrepancies up to 17% at the lowest energies.

PACS numbers: 87.55.K‐, 87.55.km

Parameterization of electron beam output factor

Electron beam dose distribution is dependent on the beam energy and complicated trajectory of particles. Recent treatment planning systems using Monte Carlo calculation algorithm provide accurate dose calculation. However, double check of monitor units (MUs) based on an independent algorithm is still required. In this study, we have demonstrated single equation that reproduces the measured relative output factor (ROF) that can be used for MU calculation for electron radiotherapy. Electron beams generated by an iX (Varian Medical Systems) and a PRIMUS (Siemens) accelerator were investigated. For various energies of electron beams, the ROF at respective dmax were measured using diode detector in a water phantom at SSD of 100 cm. Curve fitting was performed with an exponential generalized equation ROF = α(β - e(-γR)) including three variables (α, β, γ) as a function of field radius and electron energy. The correlation coefficients between the ROF measured and that calculated by the equation were greater than 0.998. For ROF of Varian electron beams, the average values of all fitting formulas were applied for two of the constants; α and β. The parameter γ showed good agreement with the quadratic approximation as a function of mean energy at surface (E0). The differences between measured and calculated ROF values were within ± 3% for beams with cutout radius of ≥ 1.5 cm for electron beams with energies from 6 MeV to 15 MeV. The proposed formula will be helpful for double-check of MUs, as it requires minimal efforts for MU calculation.

Real-time simulator for designing electron dual scattering foil systems

The purpose of this work was to develop a user friendly, accurate, real-time com- puter simulator to facilitate the design of dual foil scattering systems for electron beams on radiotherapy accelerators. The simulator allows for a relatively quick, initial design that can be refined and verified with subsequent Monte Carlo (MC) calculations and measurements. The simulator also is a powerful educational tool. The simulator consists of an analytical algorithm for calculating electron fluence and X-ray dose and a graphical user interface (GUI) C++ program. The algorithm predicts electron fluence using Fermi-Eyges multiple Coulomb scattering theory with the reduced Gaussian formalism for scattering powers. The simulator also estimates central-axis and off-axis X-ray dose arising from the dual foil system. Once the geometry of the accelerator is specified, the simulator allows the user to continuously vary primary scattering foil material and thickness, secondary scat- tering foil material and Gaussian shape (thickness and sigma), and beam energy. The off-axis electron relative fluence or total dose profile and central-axis X-ray dose contamination are computed and displayed in real time. The simulator was validated by comparison of off-axis electron relative fluence and X-ray percent dose profiles with those calculated using EGSnrc MC. Over the energy range 7-20 MeV, using present foils on an Elekta radiotherapy accelerator, the simulator was able to reproduce MC profiles to within 2% out to 20 cm from the central axis. The central-axis X-ray percent dose predictions matched measured data to within 0.5%. The calculation time was approximately 100 ms using a single Intel 2.93 GHz processor, which allows for real-time variation of foil geometrical parameters using slider bars. This work demonstrates how the user-friendly GUI and real-time nature of the simulator make it an effective educational tool for gaining a better understanding of the effects that various system parameters have on a relative dose profile. This work also demonstrates a method for using the simulator as a design tool for creating custom dual scattering foil systems in the clinical range of beam energies (6-20 MeV). 

Review on the characteristics of radiation detectors for dosimetry and imaging

The enormous advances in the understanding of human anatomy, physiology and pathology in recent decades have led to ever-improving methods of disease prevention, diagnosis and treatment. Many of these achievements have been enabled, at least in part, by advances in ionizing radiation detectors. Radiology has been transformed by the implementation of multi-slice CT and digital x-ray imaging systems, with silver halide films now largely obsolete for many applications. Nuclear medicine has benefited from more sensitive, faster and higher-resolution detectors delivering ever-higher SPECT and PET image quality. PET/MR systems have been enabled by the development of gamma ray detectors that can operate in high magnetic fields. These huge advances in imaging have enabled equally impressive steps forward in radiotherapy delivery accuracy, with 4DCT, PET and MRI routinely used in treatment planning and online image guidance provided by cone-beam CT. The challenge of ensuring safe, accurate and precise delivery of highly complex radiation fields has also both driven and benefited from advances in radiation detectors. Detector systems have been developed for the measurement of electron, intensity-modulated and modulated arc x-ray, proton and ion beams, and around brachytherapy sources based on a very wide range of technologies. The types of measurement performed are equally wide, encompassing commissioning and quality assurance, reference dosimetry, in vivo dosimetry and personal and environmental monitoring. In this article, we briefly introduce the general physical characteristics and properties that are commonly used to describe the behaviour and performance of both discrete and imaging detectors. The physical principles of operation of calorimeters; ionization and charge detectors; semiconductor, luminescent, scintillating and chemical detectors; and radiochromic and radiographic films are then reviewed and their principle applications discussed. Finally, a general discussion of the application of detectors for x-ray nuclear medicine and ion beam imaging and dosimetry is presented.

Determination of relative ion chamber calibration coefficients from depth-ionization measurements in clinical electron beams

A method is presented to obtain ion chamber calibration coefficients relative to secondary standard reference chambers in electron beams using depth-ionization measurements. Results are obtained as a function of depth and average electron energy at depth in 4, 8, 12 and 18 MeV electron beams from the NRC Elekta Precise linac. The PTW Roos, Scanditronix NACP-02, PTW Advanced Markus and NE 2571 ion chambers are investigated. The challenges and limitations of the method are discussed. The proposed method produces useful data at shallow depths. At depths past the reference depth, small shifts in positioning or drifts in the incident beam energy affect the results, thereby providing a built-in test of incident electron energy drifts and/or chamber set-up. Polarity corrections for ion chambers as a function of average electron energy at depth agree with literature data. The proposed method produces results consistent with those obtained using the conventional calibration procedure while gaining much more information about the behavior of the ion chamber with similar data acquisition time. Measurement uncertainties in calibration coefficients obtained with this method are estimated to be less than 0.5%. These results open up the possibility of using depth-ionization measurements to yield chamber ratios which may be suitable for primary standards-level dissemination.

Dosimetric comparison of 4 MeV and 6 MeV electron beams for total skin irradiation

BACKGROUND

In this study, dosimetric aspects of TSEI consisting of a 4 MeV beam with no spoiler were investigated in comparison to a nominal 6 MeV beam with spoiler, and the potential for clinical applications was evaluated.

METHODS

The TSEI technique is based on the Stanford technique, which utilizes a beam configuration of six-dual fields. MOSFETs were used to measure the optimal gantry angle, profile uniformity, and absolute dose at the calibration point. The depth dose curve of the central axis was measured in the treatment plane using EBT2 film. Photon contamination was measured as the dose at 5 cm depth in a solid water phantom relative to the maximum dose using a parallel plate ion chamber. A MOSFET dosimeter placed on the surface of a humanoid phantom, and EBT2 films inserted into a humanoid phantom were used to verify the TSEI commissioning.

RESULTS

Dosimetric aspects of the 4 MeV TSEI beam, such as profile uniformity (±10%) and relative photon contamination (<0.001%), were comparable to those of a 6 MeV TSEI beam. The relative depth dose of the 4 MeV electrons was 81.4% at the surface and 100% at 0.4 cm. For the 6 MeV electrons, the relative depth dose was 93.4% at the surface and 100% from 0.2 cm to 0.4 cm. The calculated B-factor of the 4 MeV TSEI beam was 1.55, and 1.53 for the 6 MeV TSEI. 80% of the prescribed dose was obtained at 0.22 cm depth for the 4 MeV TSEI beam and 0.53 cm for the 6 MeV TSEI beam in the humanoid phantom measurement.

CONCLUSIONS

The suggested 4 MeV beam for TSEI could be applied to shallow depth skin diseases and to electron boost as second treatment course.

Design and production of 3D printed bolus for electron radiation therapy

This is a proof‐of‐concept study demonstrating the capacity for modulated electron radiation therapy (MERT) dose distributions using 3D printed bolus. Previous reports have involved bolus design using an electron pencil beam model and fabrication using a milling machine. In this study, an in‐house algorithm is presented that optimizes the dose distribution with regard to dose coverage, conformity, and homogeneity within the planning target volume (PTV). The algorithm takes advantage of a commercial electron Monte Carlo dose calculation and uses the calculated result as input. Distances along ray lines from the distal side of 90% isodose line to distal surface of the PTV are used to estimate the bolus thickness. Inhomogeneities within the calculation volume are accounted for using the coefficient of equivalent thickness method. Several regional modulation operators are applied to improve the dose coverage and uniformity. The process is iterated (usually twice) until an acceptable MERT plan is realized, and the final bolus is printed using solid polylactic acid. The method is evaluated with regular geometric phantoms, anthropomorphic phantoms, and a clinical rhabdomyosarcoma pediatric case. In all cases the dose conformity are improved compared to that with uniform bolus. For geometric phantoms with air or bone inhomogeneities, the dose homogeneity is markedly improved. The actual printed boluses conform well to the surface of complex anthropomorphic phantoms. The correspondence of the dose distribution between the calculated synthetic bolus and the actual manufactured bolus is shown. For the rhabdomyosarcoma patient, the MERT plan yields a reduction of mean dose by 38.2% in left kidney relative to uniform bolus. MERT using 3D printed bolus appears to be a practical, low‐cost approach to generating optimized bolus for electron therapy. The method is effective in improving conformity of the prescription isodose surface and in sparing immediately adjacent normal tissues.

PACS number: 81.40.Wx

Total skin electron beam therapy using an inclinable couch on motorized table and a compensating filter

Total skin electron beam is a specialized technique that involves irradiating the entire skin from the skin surface to only a few millimetres in depth. In the Stanford technique, the patient is in a standing position and six different directional positions are used during treatment. Our technique uses large electron beams in six directions with an inclinable couch on motorized table and a compensating filter was also used to spread the electron beam and move its intensity peak. Dose uniformity measurements were performed using Gafchromic films which indicated that the surface dose was 2.04 ± 0.05 Gy. This technique can ensure the dose reproducibility because the patient is fixed in place using an inclinable couch on a motorized table.

Monitor unit calculations for external photon and electron beams: Report of the AAPM Therapy Physics Committee Task Group No. 71

A protocol is presented for the calculation of monitor units (MU) for photon and electron beams, delivered with and without beam modifiers, for constant source-surface distance (SSD) and source-axis distance (SAD) setups. This protocol was written by Task Group 71 of the Therapy Physics Committee of the American Association of Physicists in Medicine (AAPM) and has been formally approved by the AAPM for clinical use. The protocol defines the nomenclature for the dosimetric quantities used in these calculations, along with instructions for their determination and measurement. Calculations are made using the dose per MU under normalization conditions, D'0, that is determined for each user's photon and electron beams. For electron beams, the depth of normalization is taken to be the depth of maximum dose along the central axis for the same field incident on a water phantom at the same SSD, where D'0 = 1 cGy/MU. For photon beams, this task group recommends that a normalization depth of 10 cm be selected, where an energy-dependent D'0 ≤ 1 cGy/MU is required. This recommendation differs from the more common approach of a normalization depth of dm, with D'0 = 1 cGy/MU, although both systems are acceptable within the current protocol. For photon beams, the formalism includes the use of blocked fields, physical or dynamic wedges, and (static) multileaf collimation. No formalism is provided for intensity modulated radiation therapy calculations, although some general considerations and a review of current calculation techniques are included. For electron beams, the formalism provides for calculations at the standard and extended SSDs using either an effective SSD or an air-gap correction factor. Example tables and problems are included to illustrate the basic concepts within the presented formalism.

Evaluation of a new commercial Monte Carlo dose calculation algorithm for electron beams

PURPOSE

In this report the authors present the validation of a Monte Carlo dose calculation algorithm (XiO EMC from Elekta Software) for electron beams.

METHODS

Calculated and measured dose distributions were compared for homogeneous water phantoms and for a 3D heterogeneous phantom meant to approximate the geometry of a trachea and spine. Comparisons of measurements and calculated data were performed using 2D and 3D gamma index dose comparison metrics.

RESULTS

Measured outputs agree with calculated values within estimated uncertainties for standard and extended SSDs for open applicators, and for cutouts, with the exception of the 17 MeV electron beam at extended SSD for cutout sizes smaller than 5 × 5 cm(2). Good agreement was obtained between calculated and experimental depth dose curves and dose profiles (minimum number of measurements that pass a 2%/2 mm agreement 2D gamma index criteria for any applicator or energy was 97%). Dose calculations in a heterogeneous phantom agree with radiochromic film measurements (>98% of pixels pass a 3 dimensional 3%/2 mm γ-criteria) provided that the steep dose gradient in the depth direction is considered.

CONCLUSIONS

Clinically acceptable agreement (at the 2%/2 mm level) between the measurements and calculated data for measurements in water are obtained for this dose calculation algorithm. Radiochromic film is a useful tool to evaluate the accuracy of electron MC treatment planning systems in heterogeneous media.

A systematic approach to statistical analysis in dosimetry and patient-specific IMRT plan verification measurements

PURPOSE

In the presence of random uncertainties, delivered radiation treatment doses in patient likely exhibit a statistical distribution. The expected dose and variance of this distribution are unknown and are most likely not equal to the planned value since the current treatment planning systems cannot exactly model and simulate treatment machine. Relevant clinical questions are 1) how to quantitatively estimate the expected delivered dose and extrapolate the expected dose to the treatment dose over a treatment course and 2) how to evaluate the treatment dose relative to the corresponding planned dose. This study is to present a systematic approach to address these questions and to apply this approach to patient-specific IMRT (PSIMRT) plan verifications.

METHODS

The expected delivered dose in patient and variance are quantitatively estimated using Student T distribution and Chi Distribution, respectively, based on pre-treatment QA measurements. Relationships between the expected dose and the delivered dose over a treatment course and between the expected dose and the planned dose are quantified with mathematical formalisms. The requirement and evaluation of the pre-treatment QA measurement results are also quantitatively related to the desired treatment accuracy and to the to-be-delivered treatment course itself. The developed methodology was applied to PSIMRT plan verification procedures for both QA result evaluation and treatment quality estimation.

RESULTS

Statistically, the pre-treatment QA measurement process was dictated not only by the corresponding plan but also by the delivered dose deviation, number of measurements, treatment fractionation, potential uncertainties during patient treatment, and desired treatment accuracy tolerance. For the PSIMRT QA procedures, in theory, more than one measurement had to be performed to evaluate whether the to-be-delivered treatment course would meet the desired dose coverage and treatment tolerance.

CONCLUSION

By acknowledging and considering the statistical nature of multi-fractional delivery of radiation treatment, we have established a quantitative methodology to evaluate the PSIMRT QA results. Both the statistical parameters associated with the QA measurement procedure and treatment course need to be taken into account to evaluate the QA outcome and to determine whether the plan is acceptable and whether additional measures should be taken to reduce treatment uncertainties. The result from a single QA measurement without the appropriate statistical analysis can be misleading. When the required number of measurements is comparable to the planned number of fractions and the variance is unacceptably high, action must be taken to either modify the plan or adjust the beam delivery system.

Water equivalence evaluation of PRESAGE(®) formulations for megavoltage electron beams: a Monte Carlo study

To investigate the radiological water equivalency of three different formulations of the radiochromic, polyurethane based dosimeter PRESAGE(®) for three dimensional (3D) dosimetry of electron beams. The EGSnrc/BEAMnrc Monte Carlo package was used to model 6-20 MeV electron beams and calculate the corresponding doses delivered in the three different PRESAGE(®) formulations and water. The depth of 50 % dose and practical range of electron beams were determined from the depth dose calculations and scaling factors were calculated for these electron beams. In the buildup region, a 1.0 % difference in dose was found for all PRESAGE(®) formulations relative to water for 6 and 9 MeV electron beams while the difference was negligible for the higher energy electron beams. Beyond the buildup region (at a depth range of 22-26 mm for the 6 MeV beam and 38 mm for the 9 MeV beam), the discrepancy from water was found to be 5.0 % for the PRESAGE(®) formulations with lower halogen content than the original formulation, which was found to have a discrepancy of up to 14 % relative to water. For a 16 MeV electron beam, the dose discrepancy from water increases and reaches about 7.0 % at 70 mm depth for the lower halogen content PRESAGE(®) formulations and 20 % at 66 mm depth for the original formulation. For the 20 MeV electron beam, the discrepancy drops to 6.0 % at 90 mm depth for the lower halogen content formulations and 18 % at 85 mm depth for the original formulation. For the lower halogen content PRESAGE(®), the depth of 50 % dose and practical range of electrons differ from water by up to 3.0 %, while the range of differences from water is between 6.5 and 8.0 % for the original PRESAGE(®) formulation. The water equivalent depth scaling factor required for the original formulation of PRESAGE(®) was determined to be 1.07-1.08, which is larger than that determined for the lower halogen content formulations (1.03) over the entire beam energy range of electrons. All three of the PRESAGE(®) formulations studied require a depth scaling factor to convert depth in PRESAGE(®) to water equivalent depth for megavoltage electron beam dosimetry. Compared to the original PRESAGE(®) formulation, the lower halogen content formulations require a significantly smaller scaling factor and are thus recommended over the original PRESAGE(®) formulation for electron beam dosimetry.

Scrotal irradiation in primary testicular lymphoma: review of the literature and in silico planning comparative study

We examined adjuvant irradiation of the scrotum in primary testicular lymphoma (PTL) by means of a literature review in MEDLINE, a telephone survey among Dutch institutes, and an in silico planning comparative study on scrotal irradiation in PTL. We did not find any uniform adjuvant irradiation technique assuring a safe planning target volume (PTV) coverage in published reports, and the definition of the clinical target volume is unclear. Histopathologic studies of PTL show a high invasion rate of the tunica albuginea, the epididymis, and the spermatic cord. In retrospective studies, a prescribed dose of at least 30 Gy involving the scrotum is associated with best survival. The majority of Dutch institutes irradiate the whole scrotum without using a planning computed tomography scan, with a single electron beam and a total dose of 30 Gy. The in silico planning comparative study showed that all evaluated approaches met a D(95%) scrotal dose of at least 85% of the prescription dose, without exceeding the dose limits of critical organs. Photon irradiation with 2 oblique beams using wedges resulted in the best PTV coverage, with a mean value of 95% of the prescribed dose, with lowest maximum dose. Adjuvant photon or electron irradiation of the whole scrotum including the contralateral testicle with a minimum dose of 30 Gy is recommended in PTL. Computed tomography-based radiation therapy treatment planning with proper patient positioning and position verification guarantees optimal dose coverage.

On-line optimization of intraoperative electron beam radiotherapy of the breast

PURPOSE

To optimize the dose delivery to the breast lumpectomy target treated with intraoperative electron beam radiotherapy (IOERT).

MATERIALS AND METHODS

Two tools have been developed in our MU calculation software NEMO X to improve the dose homogeneity and the in-vivo dosimetry effectiveness for IOERT treatments. Given the target (tumor bed) thickness measured by the surgeon, NEMO X can provide auto dose normalization to cover 95% of the target volume with 95% of the prescription dose (PD) and a "best guess" of the expected dosimeter dose (EDD) for a deep seated in-vivo dosimeter. The tools have been validated with the data of 91 patients treated with IOERT on a LIAC mobile accelerator. In-vivo dosimetry has been performed with microMOSFETs positioned on the shielding disk inserted between the tumor bed and the chest wall.

RESULTS

On average the auto normalization showed to provide better results if compared to conventional normalization rules in terms of mean target dose (|MTD-PD|/PD ≤ 5% in 95% vs. 53% of pts) and V107 percentage (left angle bracket V107 right angle bracket =19% vs. 32%). In-vivo dosimetry MOSFET dose (MD) showed a better correlation with the EDD guessed by our tool than just by assuming that EDD=PD (|MD-EDD|/EDD ≤ 5% in 57 vs. 26% of pts).

CONCLUSIONS

NEMO X provides two useful tools for the on-line optimization of the dose delivery in IOERT. This optimization can help to reduce unnecessary large over-dosage regions and allows introducing reliable action levels for in-vivo dosimetry.

Sterilization with electron beam irradiation influences the biomechanical properties and the early remodeling of tendon allografts for reconstruction of the anterior cruciate ligament (ACL)

Although allografts for anterior cruciate ligament (ACL) replacement have shown advantages compared to autografts, their use is limited due to the risk of disease transmission and the limitations of available sterilization methods. Gamma sterilization has shown detrimental effects on graft properties at the high doses required for sufficient pathogen inactivation. In our previous in vitro study on human patellar tendon allografts, Electron beam (Ebeam) irradiation showed less detrimental effects compared to gamma sterilization (Hoburg et al. in Am J Sports Med 38(6):1134-1140, 2010). To investigate the biological healing and restoration of the mechanical properties of a 34 kGy Ebeam treated tendon allograft twenty-four sheep underwent ACL replacement with either a 34 kGy Ebeam treated allograft or a non-sterilized fresh frozen allograft. Biomechanical testing of stiffness, ultimate failure load and AP-laxity as well as histological analysis to investigate cell, vessel and myofibroblast-density were performed after 6 and 12 weeks. Native sheep ACL and hamstring tendons (HAT, each n = 9) served as controls. The results of a previous study analyzing the remodeling of fresh frozen allografts (n = 12) and autografts (Auto, n = 18) with the same study design were also included in the analysis. Statistics were performed using Mann-Whitney U test followed by Bonferroni-Holm correction. Results showed significantly decreased biomechanical properties during the early remodeling period in Ebeam treated grafts and this was accompanied with an increased remodeling activity. There was no recovery of biomechanical function from 6 to 12 weeks in this group in contrast to the results observed in fresh frozen allografts and autografts. Therefore, high dose Ebeam irradiation investigated in this paper cannot be recommended for soft tissue allograft sterilization.

Inactivation Effect of Standard and Fractionated Electron Beam Irradiation on Enveloped and Non-Enveloped Viruses in a Tendon Transplant Model

BACKGROUND: For increasing allograft tendon safety in reconstructive surgery, an effective sterilization method achieving sterility assurance including viruses without impairing the grafts properties is needed. Fractionated Electron Beam (Ebeam) has shown promising in vitro results. The proof of sufficient virus inactivation is a central part of the process validation. METHODS: The Ebeam irradiation of the investigated viruses was performed in an optimized manner (oxygen content < 0.1%, -78 °C). Using principles of a tendon model the virus inactivation kinetics for HIV-2, HAV, pseudorabies virus (PRV) and porcine parvovirus (PPV) were calculated as TCID(50)/ml and D(10) value (kGy) for the fractionated (10 × 3.4 kGy) and the standard (1 × 34 kGy) Ebeam irradiation. RESULTS: All viruses showed comparable D(10) values for both Ebeam treatments. For sufficient virus titer reduction of 4 log(10) TCID(50)/ml, a dose of 34 kGy of the fractionated Ebeam irradiation was necessary in case of HIV-2, which was the most resistant virus investigated in this study. CONCLUSION: The fractionated and the standard Ebeam irradiation procedure revealed comparable and sufficient virus inactivation capacities. In combination with the known good biomechanical properties of fractionated Ebeam irradiated tendons, this method could be a safe and effective option for the terminal sterilization of soft tissue allografts.

Fractionation of high-dose electron beam irradiation of BPTB grafts provides significantly improved viscoelastic and structural properties compared to standard gamma irradiation

PURPOSE

Irradiation >30 kGy is required to achieve sterility against bacterial and viral pathogens in ACL allograft sterilization. However, doses >20 kGy substantially reduce the structural properties of soft-tissue grafts. Fractionation of irradiation doses is a standard procedure in oncology to reduce tissue damage but has not been applied in tissue graft sterilization.

METHODS

Forty-four human 10-mm wide bone-patellar-tendon-bone grafts were randomized into four groups of sterilization with (1) 34 kGy of ebeam (2) 34 kGy gamma (3) 34 kGy fractionated ebeam, and (4) non sterilized controls. Graft´s biomechanical properties were evaluated at time zero. Biomechanical properties were analyzed during cyclic and load-to-failure testing.

RESULTS

Fractionation of ebeam irradiation resulted in significantly higher failure loads (1,327 ± 305) than with one-time ebeam irradiation (1,024 ± 204; P = 0.008). Compared to gamma irradiation, significantly lower strain (2.9 ± 1.5 vs. 4.6 ± 2.0; P = 0.008) and smaller cyclic elongation response (0.3 ± 0.2 vs. 0.6 ± 0.4; P = 0.05), as well as higher failure loads (1,327 ± 305 vs. 827 ± 209; P = 0.001), were found. Compared to non-irradiated BPTB grafts, no significant differences were found for any of the biomechanical parameters. Non-irradiated controls had significantly lower cyclic elongation response and higher failure loads than ebeam and gamma irradiation.

CONCLUSIONS

In this study, it was found that fractionation of high-dose electron beam irradiation facilitated a significant improvement of viscoelastic and structural properties of BPTB grafts compared to ebeam and gamma irradiation alone, while maintaining levels of non-irradiated controls. Therefore, this technique might pose an important alternative to common methods for sterilization of soft-tissue allografts.

Verification of monitor unit calculations for non-IMRT clinical radiotherapy: report of AAPM Task Group 114

The requirement of an independent verification of the monitor units (MU) or time calculated to deliver the prescribed dose to a patient has been a mainstay of radiation oncology quality assurance. The need for and value of such a verification was obvious when calculations were performed by hand using look-up tables, and the verification was achieved by a second person independently repeating the calculation. However, in a modern clinic using CT/MR/PET simulation, computerized 3D treatment planning, heterogeneity corrections, and complex calculation algorithms such as convolution/superposition and Monte Carlo, the purpose of and methodology for the MU verification have come into question. In addition, since the verification is often performed using a simpler geometrical model and calculation algorithm than the primary calculation, exact or almost exact agreement between the two can no longer be expected. Guidelines are needed to help the physicist set clinically reasonable action levels for agreement. This report addresses the following charges of the task group: (1) To re-evaluate the purpose and methods of the "independent second check" for monitor unit calculations for non-IMRT radiation treatment in light of the complexities of modern-day treatment planning. (2) To present recommendations on how to perform verification of monitor unit calculations in a modern clinic. (3) To provide recommendations on establishing action levels for agreement between primary calculations and verification, and to provide guidance in addressing discrepancies outside the action levels. These recommendations are to be used as guidelines only and shall not be interpreted as requirements.

Electron arc therapy for bilateral chest wall irradiation: treatment planning and dosimetric study

AIMS

The treatment of patients with synchronous bilateral breast cancer is a challenge. We present a report of dosimetric data of patients with bilateral chest walls as the target treated with electron arc therapy.

MATERIALS AND METHODS

Ten consecutive patients who had undergone electron arc therapy to the bilateral chest wall for breast cancer were analysed. After positioning and immobilisation, patients underwent computed tomography scans from the neck to the upper abdomen. Electron arc plans were generated using the PLATO RTS (V1.8.2 Nucletron) treatment planning system. Electron energy was chosen depending upon the depth and thickness of the planning target volume (PTV). For all patients, the arc angle ranged between 80 and 280° (start angle 80°, stop angle 280°). The homogeneity index, coverage index and doses to organs at risk were evaluated. The patient-specific output factor and thermoluminescence dosimetry (TLD) measurements were carried out for all patients. The total planned dose to the PTV was 50Gy/25 fractions/5 weeks.

RESULTS

The mean PTV (± standard deviation) was 568.9 (±116)cm(3). The mean PTV coverage was 89 (±5.8)% of the prescribed dose. For the right lung, the mean values of D(1) and D(10) were 46 (±7.6) and 30 (±9)Gy, respectively. For the left lung, the mean values of D(1) and D(10) were 45 (±7) and 27 (±8)Gy, respectively. For the heart, the mean values of D(1), D(5) and D(10) were 21 (±15), 13.5 (±12) and 9 (±9)Gy, respectively. The mean values of TLD at various pre-specified locations on the chest wall surface were 1.84, 1.82, 1.82, 1.89 and 1.78Gy, respectively

CONCLUSION

The electron arc technique for treating the bilateral chest wall is a feasible and pragmatic technique. This technique has the twin advantages of adequate coverage of the target volume and sparing of adjacent normal structures. However, compared with other techniques, it needs a firm quality assurance protocol for dosimetry and treatment delivery.