In vivo proton range verification: a review

Time-resolved diode dosimetry calibration through Monte Carlo modeling for in vivo passive scattered proton therapy range verification

Purpose

Our group previously introduced an in vivo proton range verification methodology in which a silicon diode array system is used to correlate the dose rate profile per range modulation wheel cycle of the detector signal to the water‐equivalent path length (WEPL) for passively scattered proton beam delivery. The implementation of this system requires a set of calibration data to establish a beam‐specific response to WEPL fit for the selected ‘scout’ beam (a 1 cm overshoot of the predicted detector depth with a dose of 4 cGy) in water‐equivalent plastic. This necessitates a separate set of measurements for every ‘scout’ beam that may be appropriate to the clinical case. The current study demonstrates the use of Monte Carlo simulations for calibration of the time‐resolved diode dosimetry technique.

Methods

Measurements for three ‘scout’ beams were compared against simulated detector response with Monte Carlo methods using the Tool for Particle Simulation (TOPAS). The ‘scout’ beams were then applied in the simulation environment to simulated water‐equivalent plastic, a CT of water‐equivalent plastic, and a patient CT data set to assess uncertainty.

Results

Simulated detector response in water‐equivalent plastic was validated against measurements for ‘scout’ spread out Bragg peaks of range 10 cm, 15 cm, and 21 cm (168 MeV, 177 MeV, and 210 MeV) to within 3.4 mm for all beams, and to within 1 mm in the region where the detector is expected to lie.

Conclusion

Feasibility has been shown for performing the calibration of the detector response for three ‘scout’ beams through simulation for the time‐resolved diode dosimetry technique in passive scattered proton delivery.

Use of a LYSO-based Compton camera for prompt gamma range verification in proton therapy

PURPOSE

A Compton camera (CC), which measures prompt gammas (PGs) emitted during proton therapy, is a potentially useful imaging device for proton range verification. The aim of this study was to evaluate how well the reconstructed PG images obtained from various two-stage CC configurations reproduce the distal falloff of the PG emission.

METHODS

We conducted Monte Carlo simulations to evaluate different two-stage CCs positioned orthogonal to a proton pencil beam irradiating a water phantom. The results were compared with those obtained for a three-stage CC. In particular, all detectors were made of lutetium-yttrium orthosilicate (LYSO) crystals.

RESULTS

We found that: (a) the position resolution of the detector led to more uncertainty in predicting the depth of maximum emission and distal falloff positions than did the energy resolution of the detector; (b) reducing the thickness of the absorber detector reduces the effect of position resolution on the quality of reconstructed images and improves falloff position estimates; (c) incomplete absorption of PGs can be filtered by restricting incident gamma energies to known PG energy spectral peaks; and (d) there is greater bias and less accuracy in predicting distal falloff positions with the three-stage CC compared with the two-stage CC.

CONCLUSIONS

This study demonstrates the feasibility of using various CC designs and event selection methods to improve the imaging of PG rays. In our designed two-stage CCs, the thin LYSO-based absorber can provide better predictions of the distal falloff positions than the thick one. Compared to three-stage CCs, two-stage CCs are less biased and provide more accurate range verification.

Submillimeter ionoacoustic range determination for protons in water at a clinical synchrocyclotron

Proton ranges in water between 145 MeV to 227 MeV initial energy have been measured at a clinical superconducting synchrocyclotron using the acoustic signal induced by the ion dose deposition (ionoacoustic effect). Detection of ultrasound waves was performed by a very sensitive hydrophone and signals were stored in a digital oscilloscope triggered by secondary prompt gammas. The ionoacoustic range measurements were compared to existing range data from a calibrated range detector setup on-site and agreement of better than 1 mm was found at a Bragg peak dose of about 10 Gy for 220 MeV initial proton energy, compatible with the experimental errors. Ionoacoustics has thus the potential to measure the Bragg peak position with submillimeter accuracy during proton therapy, possibly correlated with ultrasound tissue imaging.

Three dimensional reconstruction of therapeutic carbon ion beams in phantoms using single secondary ion tracks

Carbon ion beam radiotherapy enables a very localised dose deposition. However, even small changes in the patient geometry or positioning errors can significantly distort the dose distribution. A live, non-invasive monitoring system of the beam delivery within the patient is therefore highly desirable, and could improve patient treatment. We present a novel three-dimensional method for imaging the beam in the irradiated object, exploiting the measured tracks of single secondary ions emerging under irradiation. The secondary particle tracks are detected with a TimePix stack-a set of parallel pixelated semiconductor detectors. We developed a three-dimensional reconstruction algorithm based on maximum likelihood expectation maximization. We demonstrate the applicability of the new method in the irradiation of a cylindrical PMMA phantom of human head size with a carbon ion pencil beam of [Formula: see text] MeV u^-1. The beam image in the phantom is reconstructed from a set of nine discrete detector positions between [Formula: see text] and [Formula: see text] from the beam axis. Furthermore, we demonstrate the potential to visualize inhomogeneities by irradiating a PMMA phantom with an air gap as well as bone and adipose tissue surrogate inserts. We successfully reconstructed a three-dimensional image of the treatment beam in the phantom from single secondary ion tracks. The beam image corresponds well to the beam direction and energy. In addition, cylindrical inhomogeneities with a diameter of [Formula: see text] cm and density differences down to [Formula: see text] g cm^-3 to the surrounding material are clearly visualized. This novel three-dimensional method to image a therapeutic carbon ion beam in the irradiated object does not interfere with the treatment and requires knowledge only of single secondary ion tracks. Even with detectors with only a small angular coverage, the three-dimensional reconstruction of the fragmentation points presented in this work was found to be feasible.

Visualization of air and metal inhomogeneities in phantoms irradiated by carbon ion beams using prompt secondary ions

PURPOSE

Non-invasive methods for monitoring of the therapeutic ion beam extension in the patient are desired in order to handle deteriorations of the dose distribution related to changes of the patient geometry. In carbon ion radiotherapy, secondary light ions represent one of potential sources of information about the dose distribution in the irradiated target. The capability to detect range-changing inhomogeneities inside of an otherwise homogeneous phantom, based on single track measurements, is addressed in this paper.

METHODS

Air and stainless steel inhomogeneities, with PMMA equivalent thickness of 10mm and 4.8mm respectively, were inserted into a PMMA-phantom at different positions in depth. Irradiations of the phantom with therapeutic carbon ion pencil beams were performed at the Heidelberg Ion Beam Therapy Center. Tracks of single secondary ions escaping the phantom under irradiation were detected with a pixelized semiconductor detector Timepix. The statistical relevance of the found differences between the track distributions with and without inhomogeneities was evaluated.

RESULTS

Measured shifts of the distal edge and changes in the fragmentation probability make the presence of inhomogeneities inserted into the traversed medium detectable for both, 10mm air cavities and 1mm thick stainless steel. Moreover, the method was shown to be sensitive also on their position in the observed body, even when localized behind the Bragg-peak.

CONCLUSIONS

The presented results demonstrate experimentally, that the method using distributions of single secondary ion tracks is sensitive to the changes of homogeneity of the traversed material for the studied geometries of the target.

Prompt Gamma Imaging for In Vivo Range Verification of Pencil Beam Scanning Proton Therapy

PURPOSE

To report the first clinical results and value assessment of prompt gamma imaging for in vivo proton range verification in pencil beam scanning mode.

METHODS AND MATERIALS

A stand-alone, trolley-mounted, prototype prompt gamma camera utilizing a knife-edge slit collimator design was used to record the prompt gamma signal emitted along the proton tracks during delivery of proton therapy for a brain cancer patient. The recorded prompt gamma depth detection profiles of individual pencil beam spots were compared with the expected profiles simulated from the treatment plan.

RESULTS

In 6 treatment fractions recorded over 3 weeks, the mean (± standard deviation) range shifts aggregated over all spots in 9 energy layers were -0.8 ± 1.3 mm for the lateral field, 1.7 ± 0.7 mm for the right-superior-oblique field, and -0.4 ± 0.9 mm for the vertex field.

CONCLUSIONS

This study demonstrates the feasibility and illustrates the distinctive benefits of prompt gamma imaging in pencil beam scanning treatment mode. Accuracy in range verification was found in this first clinical case to be better than the range uncertainty margin applied in the treatment plan. These first results lay the foundation for additional work toward tighter integration of the system for in vivo proton range verification and quantification of range uncertainties.

Beam-on imaging of short-lived positron emitters during proton therapy

In vivo dose delivery verification in proton therapy can be performed by positron emission tomography (PET) of the positron-emitting nuclei produced by the proton beam in the patient. A PET scanner installed in the treatment position of a proton therapy facility that takes data with the beam on will see very short-lived nuclides as well as longer-lived nuclides. The most important short-lived nuclide for proton therapy is ¹²N (Dendooven et al 2015 Phys. Med. Biol. 60 8923-47), which has a half-life of 11 ms. The results of a proof-of-principle experiment of beam-on PET imaging of short-lived ¹²N nuclei are presented. The Philips Digital Photon Counting Module TEK PET system was used, which is based on LYSO scintillators mounted on digital SiPM photosensors. A 90 MeV proton beam from the cyclotron at KVI-CART was used to investigate the energy and time spectra of PET coincidences during beam-on. Events coinciding with proton bunches, such as prompt gamma rays, were removed from the data via an anti-coincidence filter with the cyclotron RF. The resulting energy spectrum allowed good identification of the 511 keV PET counts during beam-on. A method was developed to subtract the long-lived background from the ¹²N image by introducing a beam-off period into the cyclotron beam time structure. We measured 2D images and 1D profiles of the ¹²N distribution. A range shift of 5 mm was measured as 6  ±  3 mm using the ¹²N profile. A larger, more efficient, PET system with a higher data throughput capability will allow beam-on ¹²N PET imaging of single spots in the distal layer of an irradiation with an increased signal-to-background ratio and thus better accuracy. A simulation shows that a large dual panel scanner, which images a single spot directly after it is delivered, can measure a 5 mm range shift with millimeter accuracy: 5.5  ±  1.1 mm for 1  ×  10⁸ protons and 5.2  ±  0.5 mm for 5  ×  10⁸ protons. This makes fast and accurate feedback on the dose delivery during treatment possible.

Feasibility study of using fall-off gradients of early and late PET scans for proton range verification

PURPOSE

While positron emission tomography (PET) allows for the imaging of tissues activated by proton beams in terms of monitoring the therapy administered, most endogenous tissue elements are activated by relatively high-energy protons. Therefore, a relatively large distance off-set exists between the dose fall-off and activity fall-off. However, ¹⁶ O(p,2p,2n)¹³ N has a relatively low energy threshold which peaks around 12 MeV and also a residual proton range that is approximately 1 to 2 mm. In this phantom study, we tested the feasibility of utilizing the ¹³ N production peak as well as the differences in activity fall-off between early and late PET scans for proton range verification. One of the main purposes for this research was developing a proton range verification methodology that would not require Monte Carlo simulations.

METHODS AND MATERIALS

Both monoenergetic and spread-out Bragg peak beams were delivered to two phantoms - a water-like gel and a tissue-like gel where the proton ranges came to be approximately 9.9 and 9.1 cm, respectively. After 1 min of postirradiation delay, the phantoms were scanned for a period of 30 min using an in-room PET. Two separate (Early and Late) PET images were reconstructed using two different postirradiation delays and acquisition times; Early PET: 1 min delay and 3 min acquisition, Late PET: 21 min delay and 10 min acquisition. The depth gradients of the PET signals were then normalized and plotted as functions of depth. The normalized gradient of the early PET images was subtracted from that of the late PET images, to observe the ¹³ N activity distribution in relation to depth. Monte Carlo simulations were also conducted with the same set-up as the measurements stated previously.

RESULTS

The subtracted gradients show peaks at 9.4 and 8.6 cm in water-gel and tissue-gel respectively for both pristine and SOBP beams. These peaks are created in connection with the sudden change of ¹³ N signals with depth and consistently occur 2 mm upstream to where ¹³ N signals were most abundantly created (9.6 and 8.8 cm in water-gel and tissue-gel, respectively). Monte Carlo simulations provided similar results as the measurements.

CONCLUSIONS

The subtracted PET signal gradient peaks and the proton ranges for water-gel and tissue-gel show distance off-sets of 4 to 5 mm. This off-set may potentially be used for proton range verification using only the PET measured data without Monte Carlo simulations. More studies are necessary to overcome various limitations, such as perfusion-driven washout, for the feasibility of this technique in living patients.

An analysis of beam parameters on proton-acoustic waves through an analytic approach

It has been reported that acoustic waves are generated when a high-energy pulsed proton beam is deposited in a small volume within tissue. One possible application of proton-induced acoustics is to get real-time feedback for intra-treatment adjustments by monitoring such acoustic waves. A high spatial resolution in ultrasound imaging may reduce proton range uncertainty. Thus, it is crucial to understand the dependence of the acoustic waves on the proton beam characteristics. In this manuscript, firstly, an analytic solution for the proton-induced acoustic wave is presented to reveal the dependence of the signal on the beam parameters; then it is combined with an analytic approximation of the Bragg curve. The influence of the beam energy, pulse duration and beam diameter variation on the acoustic waveform are investigated. Further analysis is performed regarding the Fourier decomposition of the proton-acoustic signals. Our results show that the smaller spill time of the proton beam upsurges the amplitude of the acoustic wave for a constant number of protons, which is hence beneficial for dose monitoring. The increase in the energy of each individual proton in the beam leads to the spatial broadening of the Bragg curve, which also yields acoustic waves of greater amplitude. The pulse duration and the beam width of the proton beam do not affect the central frequency of the acoustic wave, but they change the amplitude of the spectral components.

Experimental evaluation of x-ray acoustic computed tomography for radiotherapy dosimetry applications

PURPOSE

The aim of this work was to experimentally demonstrate the feasibility of x-ray acoustic computed tomography (XACT) as a dosimetry tool in a clinical radiotherapy environment.

METHODS

The acoustic waves induced following a single pulse of linear accelerator irradiation in a water tank were detected with an immersion ultrasound transducer. By rotating the collimator and keeping the transducer stationary, acoustic signals at varying angles surrounding the field were detected and reconstructed to form an XACT image. Simulated XACT images were obtained using a previously developed simulation workflow. Profiles extracted from experimental and simulated XACT images were compared to profiles measured with an ion chamber. A variety of radiation field sizes and shapes were investigated.

RESULTS

XACT images resembling the geometry of the delivered radiation field were obtained for fields ranging from simple squares to more complex shapes. When comparing profiles extracted from simulated and experimental XACT images of a 4 cm × 4 cm field, 97% of points were found to pass a 3%/3 mm gamma test. Agreement between simulated and experimental XACT images worsened when comparing fields with fine details. Profiles extracted from experimental XACT images were compared to profiles obtained through clinical ion chamber measurements, confirming that the intensity of XACT images is related to deposited radiation dose. Seventy-seven percent of the points in a profile extracted from an experimental XACT image of a 4 cm × 4 cm field passed a 7%/4 mm gamma test when compared to an ion chamber measured profile. In a complicated puzzle-piece shaped field, 86% of the points in an XACT extracted profile passed a 7%/4 mm gamma test.

CONCLUSIONS

XACT images with intensity related to the spatial distribution of deposited dose in a water tank were formed for a variety of field sizes and shapes. XACT has the potential to be a useful tool for absolute, relative and in vivo dosimetry.

INSIDE in-beam positron emission tomography system for particle range monitoring in hadrontherapy

The quality assurance of particle therapy treatment is a fundamental issue that can be addressed by developing reliable monitoring techniques and indicators of the treatment plan correctness. Among the available imaging techniques, positron emission tomography (PET) has long been investigated and then clinically applied to proton and carbon beams. In 2013, the Innovative Solutions for Dosimetry in Hadrontherapy (INSIDE) collaboration proposed an innovative bimodal imaging concept that combines an in-beam PET scanner with a tracking system for charged particle imaging. This paper presents the general architecture of the INSIDE project but focuses on the in-beam PET scanner that has been designed to reconstruct the particles range with millimetric resolution within a fraction of the dose delivered in a treatment of head and neck tumors. The in-beam PET scanner has been recently installed at the Italian National Center of Oncologic Hadrontherapy (CNAO) in Pavia, Italy, and the commissioning phase has just started. The results of the first beam test with clinical proton beams on phantoms clearly show the capability of the in-beam PET to operate during the irradiation delivery and to reconstruct on-line the beam-induced activity map. The accuracy in the activity distal fall-off determination is millimetric for therapeutic doses.

Towards clinical application: prompt gamma imaging of passively scattered proton fields with a knife-edge slit camera

Prompt γ-ray imaging with a knife-edge shaped slit camera provides the possibility of verifying proton beam range in tumor therapy. Dedicated experiments regarding the characterization of the camera system have been performed previously. Now, we aim at implementing the prototype into clinical application of monitoring patient treatments. Focused on this goal of translation into clinical operation, we systematically addressed remaining challenges and questions. We developed a robust energy calibration routine and corresponding quality assurance protocols. Furthermore, with dedicated experiments, we determined the positioning precision of the system to 1.1 mm (2σ). For the first time, we demonstrated the application of the slit camera, which was intentionally developed for pencil beam scanning, to double scattered proton beams. Systematic experiments with increasing complexity were performed. It was possible to visualize proton range shifts of 2-5 mm with the camera system in phantom experiments in passive scattered fields. Moreover, prompt γ-ray profiles for single iso-energy layers were acquired by synchronizing time resolved measurements to the rotation of the range modulator wheel of the treatment system. Thus, a mapping of the acquired profiles to different anatomical regions along the beam path is feasible and additional information on the source of potential range shifts can be obtained. With the work presented here, we show that an application of the slit camera in clinical treatments is possible and of potential benefit.

Clinical Implementation of Dual-energy CT for Proton Treatment Planning on Pseudo-monoenergetic CT scans

PURPOSE

To determine whether a standardized clinical application of dual-energy computed tomography (DECT) for proton treatment planning based on pseudomonoenergetic CT scans (MonoCTs) is feasible and increases the precision of proton therapy in comparison with single-energy CT (SECT).

METHODS AND MATERIALS

To define an optimized DECT protocol, CT scan settings were analyzed experimentally concerning beam hardening, image quality, and influence on the heuristic conversion of CT numbers into stopping-power ratios (SPRs) and were compared with SECT scans with identical CT dose. Differences in range prediction and dose distribution between SECT and MonoCT were quantified for phantoms and a patient.

RESULTS

Dose distributions planned on SECT and MonoCT datasets revealed mean range deviations of 0.3 mm, γ passing rates (1%, 1 mm) greater than 99.9%, and no clinically relevant changes in dose-volume histograms. However, image noise and CT-related uncertainties could be reduced by MonoCT compared with SECT, which resulted in a slightly decreased dependence of SPR prediction on beam hardening. Consequently, DECT was clinically implemented at the University Proton Therapy Dresden in 2015. Until October 2016, 150 patients were treated based on MonoCTs, and more than 950 DECT scans of 351 patients were acquired during radiation therapy.

CONCLUSIONS

A standardized clinical use of MonoCT for treatment planning is feasible, leads to improved image quality and SPR prediction, extends diagnostic variety, and enables a stepwise clinical implementation of DECT toward a physics-based, patient-specific, nonheuristic SPR determination. Further reductions of CT-related uncertainties, as expected from such SPR approaches, can be evaluated on the resulting DECT patient database.

Experimental observation of acoustic emissions generated by a pulsed proton beam from a hospital-based clinical cyclotron

PURPOSE

To measure the acoustic signal generated by a pulsed proton spill from a hospital-based clinical cyclotron.

METHODS

An electronic function generator modulated the IBA C230 isochronous cyclotron to create a pulsed proton beam. The acoustic emissions generated by the proton beam were measured in water using a hydrophone. The acoustic measurements were repeated with increasing proton current and increasing distance between detector and beam.

RESULTS

The cyclotron generated proton spills with rise times of 18 μs and a maximum measured instantaneous proton current of 790 nA. Acoustic emissions generated by the proton energy deposition were measured to be on the order of mPa. The origin of the acoustic wave was identified as the proton beam based on the correlation between acoustic emission arrival time and distance between the hydrophone and proton beam. The acoustic frequency spectrum peaked at 10 kHz, and the acoustic pressure amplitude increased monotonically with increasing proton current.

CONCLUSIONS

The authors report the first observation of acoustic emissions generated by a proton beam from a hospital-based clinical cyclotron. When modulated by an electronic function generator, the cyclotron is capable of creating proton spills with fast rise times (18 μs) and high instantaneous currents (790 nA). Measurements of the proton-generated acoustic emissions in a clinical setting may provide a method for in vivo proton range verification and patient monitoring.

Nuclear physics in particle therapy: a review

Charged particle therapy has been largely driven and influenced by nuclear physics. The increase in energy deposition density along the ion path in the body allows reducing the dose to normal tissues during radiotherapy compared to photons. Clinical results of particle therapy support the physical rationale for this treatment, but the method remains controversial because of the high cost and of the lack of comparative clinical trials proving the benefit compared to x-rays. Research in applied nuclear physics, including nuclear interactions, dosimetry, image guidance, range verification, novel accelerators and beam delivery technologies, can significantly improve the clinical outcome in particle therapy. Measurements of fragmentation cross-sections, including those for the production of positron-emitting fragments, and attenuation curves are needed for tuning Monte Carlo codes, whose use in clinical environments is rapidly increasing thanks to fast calculation methods. Existing cross sections and codes are indeed not very accurate in the energy and target regions of interest for particle therapy. These measurements are especially urgent for new ions to be used in therapy, such as helium. Furthermore, nuclear physics hardware developments are frequently finding applications in ion therapy due to similar requirements concerning sensors and real-time data processing. In this review we will briefly describe the physics bases, and concentrate on the open issues.

Monitoring of Hadrontherapy Treatments by Means of Charged Particle Detection

The interaction of the incoming beam radiation with the patient body in hadrontherapy treatments produces secondary charged and neutral particles, whose detection can be used for monitoring purposes and to perform an on-line check of beam particle range. In the context of ion-therapy with active scanning, charged particles are potentially attractive since they can be easily tracked with a high efficiency, in presence of a relatively low background contamination. In order to verify the possibility of exploiting this approach for in-beam monitoring in ion-therapy, and to guide the design of specific detectors, both simulations and experimental tests are being performed with ion beams impinging on simple homogeneous tissue-like targets (PMMA). From these studies, a resolution of the order of few millimeters on the single track has been proven to be sufficient to exploit charged particle tracking for monitoring purposes, preserving the precision achievable on longitudinal shape. The results obtained so far show that the measurement of charged particles can be successfully implemented in a technology capable of monitoring both the dose profile and the position of the Bragg peak inside the target and finally lead to the design of a novel profile detector. Crucial aspects to be considered are the detector positioning, to be optimized in order to maximize the available statistics, and the capability of accounting for the multiple scattering interactions undergone by the charged fragments along their exit path from the patient body. The experimental results collected up to now are also valuable for the validation of Monte Carlo simulation software tools and their implementation in Treatment Planning Software packages.

Ionoacoustic tomography of the proton Bragg peak in combination with ultrasound and optoacoustic imaging

Ions provide a more advantageous dose distribution than photons for external beam radiotherapy, due to their so-called inverse depth dose deposition and, in particular a characteristic dose maximum at their end-of-range (Bragg peak). The favorable physical interaction properties enable selective treatment of tumors while sparing surrounding healthy tissue, but optimal clinical use requires accurate monitoring of Bragg peak positioning inside tissue. We introduce ionoacoustic tomography based on detection of ion induced ultrasound waves as a technique to provide feedback on the ion beam profile. We demonstrate for 20 MeV protons that ion range imaging is possible with submillimeter accuracy and can be combined with clinical ultrasound and optoacoustic tomography of similar precision. Our results indicate a simple and direct possibility to correlate, in-vivo and in real-time, the conventional ultrasound echo of the tumor region with ionoacoustic tomography. Combined with optoacoustic tomography it offers a well suited pre-clinical imaging system.

Thermoacoustic range verification using a clinical ultrasound array provides perfectly co-registered overlay of the Bragg peak onto an ultrasound image

The potential of particle therapy due to focused dose deposition in the Bragg peak has not yet been fully realized due to inaccuracies in range verification. The purpose of this work was to correlate the Bragg peak location with target structure, by overlaying the location of the Bragg peak onto a standard ultrasound image. Pulsed delivery of 50 MeV protons was accomplished by a fast chopper installed between the ion source and the cyclotron inflector. The chopper limited the train of bunches so that 2 Gy were delivered in [Formula: see text]. The ion pulse generated thermoacoustic pulses that were detected by a cardiac ultrasound array, which also produced a grayscale ultrasound image. A filtered backprojection algorithm focused the received signal to the Bragg peak location with perfect co-registration to the ultrasound images. Data was collected in a room temperature water bath and gelatin phantom with a cavity designed to mimic the intestine, in which gas pockets can displace the Bragg peak. Phantom experiments performed with the cavity both empty and filled with olive oil confirmed that displacement of the Bragg peak due to anatomical change could be detected. Thermoacoustic range measurements in the waterbath agreed with Monte Carlo simulation within 1.2 mm. In the phantom, thermoacoustic range estimates and first-order range estimates from CT images agreed to within 1.5 mm.

Modeling of body tissues for Monte Carlo simulation of radiotherapy treatments planned with conventional x-ray CT systems

In the conventional procedure for accurate Monte Carlo simulation of radiotherapy, a CT number given to each pixel of a patient image is directly converted to mass density and elemental composition using their respective functions that have been calibrated specifically for the relevant x-ray CT system. We propose an alternative approach that is a conversion in two steps: the first from CT number to density and the second from density to composition. Based on the latest compilation of standard tissues for reference adult male and female phantoms, we sorted the standard tissues into groups by mass density and defined the representative tissues by averaging the material properties per group. With these representative tissues, we formulated polyline relations between mass density and each of the following; electron density, stopping-power ratio and elemental densities. We also revised a procedure of stoichiometric calibration for CT-number conversion and demonstrated the two-step conversion method for a theoretically emulated CT system with hypothetical 80 keV photons. For the standard tissues, high correlation was generally observed between mass density and the other densities excluding those of C and O for the light spongiosa tissues between 1.0 g cm(-3) and 1.1 g cm(-3) occupying 1% of the human body mass. The polylines fitted to the dominant tissues were generally consistent with similar formulations in the literature. The two-step conversion procedure was demonstrated to be practical and will potentially facilitate Monte Carlo simulation for treatment planning and for retrospective analysis of treatment plans with little impact on the management of planning CT systems.

Characterizing proton-activated materials to develop PET-mediated proton range verification markers

Conventional proton beam range verification using positron emission tomography (PET) relies on tissue activation alone and therefore requires particle therapy PET whose installation can represent a large financial burden for many centers. Previously, we showed the feasibility of developing patient implantable markers using high proton cross-section materials ((18)O, Cu, and (68)Zn) for in vivo proton range verification using conventional PET scanners. In this technical note, we characterize those materials to test their usability in more clinically relevant conditions. Two phantoms made of low-density balsa wood (~0.1 g cm(-3)) and beef (~1.0 g cm(-3)) were embedded with Cu or (68)Zn foils of several volumes (10-50 mm(3)). The metal foils were positioned at several depths in the dose fall-off region, which had been determined from our previous study. The phantoms were then irradiated with different proton doses (1-5 Gy). After irradiation, the phantoms with the embedded foils were moved to a diagnostic PET scanner and imaged. The acquired data were reconstructed with 20-40 min of scan time using various delay times (30-150 min) to determine the maximum contrast-to-noise ratio. The resultant PET/computed tomography (CT) fusion images of the activated foils were then examined and the foils' PET signal strength/visibility was scored on a 5 point scale by 13 radiologists experienced in nuclear medicine. For both phantoms, the visibility of activated foils increased in proportion to the foil volume, dose, and PET scan time. A linear model was constructed with visibility scores as the response variable and all other factors (marker material, phantom material, dose, and PET scan time) as covariates. Using the linear model, volumes of foils that provided adequate visibility (score 3) were determined for each dose and PET scan time. The foil volumes that were determined will be used as a guideline in developing practical implantable markers.

A simulation study investigating a Cherenkov material for use with the prompt gamma range verification in proton therapy

In vivo range verification methods will reveal information about the penetration depth into a patient for an incident proton beam. The prompt gamma (PG) method is a promising in vivo technique that has been shown to yield this range information by measuring the escaping MeV photons given a suitable detector system. The majority of current simulations investigating PG detectors utilize common scintillating materials ideal for photons within a low neutron background radiation field using complex geometries or novel designs. In this work we simulate a minimal detector system using a material ideal for MeV photon detection in the presence of a significant neutron field based on the Cherenkov phenomenon. The response of this selected material was quantified for the escaping particles commonly found in proton therapy applications and the feasibility of using the PG technique for this detector material was studied. Our simulations found that the majority of the range information can be determined by detecting photons emitted with a timing window less than ∼50 ns after the interaction of the proton beam with the water phantom and with an energy threshold focusing on the energy range of the de-excitation of 16O photons (∼6 MeV). The Cherenkov material investigated is able to collect these photons and estimate the range with timescales on the order of tens of nanoseconds as well as greatly suppress the signal due to neutron.

Review of 3D image data calibration for heterogeneity correction in proton therapy treatment planning

Correct modelling of the interaction parameters of patient tissues is of vital importance in proton therapy treatment planning because of the large dose gradients associated with the Bragg peak. Different 3D imaging techniques yield different information regarding these interaction parameters. Given the rapidly expanding interest in proton therapy, this review is written to make readers aware of the current challenges in accounting for tissue heterogeneities and the imaging systems that are proposed to tackle these challenges. A summary of the interaction parameters of interest in proton therapy and the current and developmental 3D imaging techniques used in proton therapy treatment planning is given. The different methods to translate the imaging data to the interaction parameters of interest are reviewed and a summary of the implementations in several commercial treatment planning systems is presented.

Evaluation of proton inelastic reaction models in Geant4 for prompt gamma production during proton radiotherapy

During proton beam radiotherapy, discrete secondary prompt gamma rays are induced by inelastic nuclear reactions between protons and nuclei in the human body. In recent years, the Geant4 Monte Carlo toolkit has played an important role in the development of a device for real time dose range verification purposes using prompt gamma radiation. Unfortunately the default physics models in Geant4 do not reliably replicate the measured prompt gamma emission. Determining a suitable physics model for low energy proton inelastic interactions will boost the accuracy of prompt gamma simulations. Among the built-in physics models, we found that the precompound model with a modified initial exciton state of 2 (1 particle, 1 hole) produced more accurate discrete gamma lines from the most important elements found within the body such as 16O, 12C and 14N when comparing them with the available gamma production cross section data. Using the modified physics model, we investigated the prompt gamma spectra produced in a water phantom by a 200 MeV pencil beam of protons. The spectra were attained using a LaBr3 detector with a time-of-flight (TOF) window and BGO active shield to reduce the secondary neutron and gamma background. The simulations show that a 2 ns TOF window could reduce 99% of the secondary neutron flux hitting the detector. The results show that using both timing and active shielding can remove up to 85% of the background radiation which includes a 33% reduction by BGO subtraction.

Compton Camera and Prompt Gamma Ray Timing: Two Methods for In Vivo Range Assessment in Proton Therapy

Proton beams are promising means for treating tumors. Such charged particles stop at a defined depth, where the ionization density is maximum. As the dose deposit beyond this distal edge is very low, proton therapy minimizes the damage to normal tissue compared to photon therapy. Nevertheless, inherent range uncertainties cast doubts on the irradiation of tumors close to organs at risk and lead to the application of conservative safety margins. This constrains significantly the potential benefits of protons over photons. In this context, several research groups are developing experimental tools for range verification based on the detection of prompt gammas, a nuclear by-product of the proton irradiation. At OncoRay and Helmholtz-Zentrum Dresden-Rossendorf, detector components have been characterized in realistic radiation environments as a step toward a clinical Compton camera. On the one hand, corresponding experimental methods and results obtained during the ENTERVISION training network are reviewed. On the other hand, a novel method based on timing spectroscopy has been proposed as an alternative to collimated imaging systems. The first tests of the timing method at a clinical proton accelerator are summarized, its applicability in a clinical environment for challenging the current safety margins is assessed, and the factors limiting its precision are discussed.

Experimental depth dose curves of a 67.5 MeV proton beam for benchmarking and validation of Monte Carlo simulation

PURPOSE

To measure depth dose curves for a 67.5 ± 0.1 MeV proton beam for benchmarking and validation of Monte Carlo simulation.

METHODS

Depth dose curves were measured in 2 beam lines. Protons in the raw beam line traversed a Ta scattering foil, 0.1016 or 0.381 mm thick, a secondary emission monitor comprised of thin Al foils, and a thin Kapton exit window. The beam energy and peak width and the composition and density of material traversed by the beam were known with sufficient accuracy to permit benchmark quality measurements. Diodes for charged particle dosimetry from two different manufacturers were used to scan the depth dose curves with 0.003 mm depth reproducibility in a water tank placed 300 mm from the exit window. Depth in water was determined with an uncertainty of 0.15 mm, including the uncertainty in the water equivalent depth of the sensitive volume of the detector. Parallel-plate chambers were used to verify the accuracy of the shape of the Bragg peak and the peak-to-plateau ratio measured with the diodes. The uncertainty in the measured peak-to-plateau ratio was 4%. Depth dose curves were also measured with a diode for a Bragg curve and treatment beam spread out Bragg peak (SOBP) on the beam line used for eye treatment. The measurements were compared to Monte Carlo simulation done with geant4 using topas.

RESULTS

The 80% dose at the distal side of the Bragg peak for the thinner foil was at 37.47 ± 0.11 mm (average of measurement with diodes from two different manufacturers), compared to the simulated value of 37.20 mm. The 80% dose for the thicker foil was at 35.08 ± 0.15 mm, compared to the simulated value of 34.90 mm. The measured peak-to-plateau ratio was within one standard deviation experimental uncertainty of the simulated result for the thinnest foil and two standard deviations for the thickest foil. It was necessary to include the collimation in the simulation, which had a more pronounced effect on the peak-to-plateau ratio for the thicker foil. The treatment beam, being unfocussed, had a broader Bragg peak than the raw beam. A 1.3 ± 0.1 MeV FWHM peak width in the energy distribution was used in the simulation to match the Bragg peak width. An additional 1.3-2.24 mm of water in the water column was required over the nominal values to match the measured depth penetration.

CONCLUSIONS

The proton Bragg curve measured for the 0.1016 mm thick Ta foil provided the most accurate benchmark, having a low contribution of proton scatter from upstream of the water tank. The accuracy was 0.15% in measured beam energy and 0.3% in measured depth penetration at the Bragg peak. The depth of the distal edge of the Bragg peak in the simulation fell short of measurement, suggesting that the mean ionization potential of water is 2-5 eV higher than the 78 eV used in the stopping power calculation for the simulation. The eye treatment beam line depth dose curves provide validation of Monte Carlo simulation of a Bragg curve and SOBP with 4%/2 mm accuracy.

How proton pulse characteristics influence protoacoustic determination of proton-beam range: simulation studies

The unique dose deposition of proton beams generates a distinctive thermoacoustic (protoacoustic) signal, which can be used to calculate the proton range. To identify the expected protoacoustic amplitude, frequency, and arrival time for different proton pulse characteristics encountered at hospital-based proton sources, the protoacoustic pressure emissions generated by 150 MeV, pencil-beam proton pulses were simulated in a homogeneous water medium. Proton pulses with Gaussian widths ranging up to 200 μs were considered. The protoacoustic amplitude, frequency, and time-of-flight (TOF) range accuracy were assessed. For TOF calculations, the acoustic pulse arrival time was determined based on multiple features of the wave. Based on the simulations, Gaussian proton pulses can be categorized as Dirac-delta-function-like (FWHM < 4 μs) and longer. For the δ-function-like irradiation, the protoacoustic spectrum peaks at 44.5 kHz and the systematic error in determining the Bragg peak range is <2.6 mm. For longer proton pulses, the spectrum shifts to lower frequencies, and the range calculation systematic error increases (⩽ 23 mm for FWHM of 56 μs). By mapping the protoacoustic peak arrival time to range with simulations, the residual error can be reduced. Using a proton pulse with FWHM = 2 μs results in a maximum signal-to-noise ratio per total dose. Simulations predict that a 300 nA, 150 MeV, FWHM = 4 μs Gaussian proton pulse (8.0 × 10(6) protons, 3.1 cGy dose at the Bragg peak) will generate a 146 mPa pressure wave at 5 cm beyond the Bragg peak. There is an angle dependent systematic error in the protoacoustic TOF range calculations. Placing detectors along the proton beam axis and beyond the Bragg peak minimizes this error. For clinical proton beams, protoacoustic detectors should be sensitive to <400 kHz (for -20 dB). Hospital-based synchrocyclotrons and cyclotrons are promising sources of proton pulses for generating clinically measurable protoacoustic emissions.

Assessment of Geant4 Prompt-Gamma Emission Yields in the Context of Proton Therapy Monitoring

Monte Carlo tools have been long used to assist the research and development of solutions for proton therapy monitoring. The present work focuses on the prompt-gamma emission yields by comparing experimental data with the outcomes of the current version of Geant4 using all applicable proton inelastic models. For the case in study and using the binary cascade model, it was found that Geant4 overestimates the prompt-gamma emission yields by 40.2 ± 0.3%, even though it predicts the prompt-gamma profile length of the experimental profile accurately. In addition, the default implementations of all proton inelastic models show an overestimation in the number of prompt gammas emitted. Finally, a set of built-in options and physically sound Geant4 source code changes have been tested in order to try to improve the discrepancy observed. A satisfactory agreement was found when using the QMD model with a wave packet width equal to 1.3 fm².

Experimental investigation of irregular motion impact on 4D PET-based particle therapy monitoring

Particle therapy positron emission tomography (PT-PET) is an in vivo and non-invasive imaging technique to monitor treatment delivery in particle therapy. The inevitable patient respiratory motion during irradiation causes artefacts and inaccurate activity distribution in PET images. Four-dimensional (4D) maximum likelihood expectation maximisation (4D MLEM) allows for a compensation of these effects, but has up to now been restricted to regular motion for PT-PET investigations. However, intra-fractional motion during treatment might differ from that during acquisition of the 4D-planning CT (e.g. amplitude variation, baseline drift) and therefore might induce inaccurate 4D PET reconstruction results. This study investigates the impact of different irregular analytical one-dimensional (1D) motion patterns on PT-PET imaging by means of experiments with a radioactive source and irradiated moving phantoms. Three sorting methods, namely phase sorting, equal amplitude sorting and event-based amplitude sorting, were applied to manage the PET list-mode data. The influence of these sorting methods on the motion compensating algorithm has been analysed. The event-based amplitude sorting showed a superior performance and it is applicable for irregular motions with ⩽ 4 mm amplitude elongation and drift. For motion with 10 mm baseline drift, the normalised root mean square error was as high as 10.5% and a 10 mm range deviation was observed.