Thermoluminescence dosimetry for in-vivo verification of high dose rate brachytherapy for prostate cancer

Feasibility of using micro silica bead TLDs for in-Vivo dosimetry of CT-based HDR prostate brachytherapy: An experimental and simulation study

PURPOSE

Feasibility of silica-based dosimeters for IVD of HDR prostate brachytherapy.

MATERIAL AND METHODS

Plastic dosimeter holders and a water-fillable prostate phantom were built in-house. Interstitial prostate brachytherapy and Monte Carlo simulations were performed. The treatment planning, Monte-Carlo simulation, and dosimetry results were compared.

RESULTS

The relative differences between TLD-TPS, TLD-MCNP, and TPS-MCNP were 0.2-6.9 %, 0.5-6.5 %, and 0.6-6.3 %, respectively.

CONCLUSION

Micro-silica bead dosimeters can perform offline in situ quality assurance in HDR prostate brachytherapy.

3D in vivo dosimetry of HDR gynecological brachytherapy using micro silica bead TLDs

Purpose

This study aimed to evaluate the feasibility of defining an in vivo dosimetry (IVD) protocol as a patient‐specific quality assurance (PSQA) using the bead thermoluminescent dosimeters (TLDs) for point and 3D IVD during brachytherapy (BT) of gynecological (GYN) cancer using ⁶⁰Co high‐dose‐rate (HDR) source.

Methods

The 3D in vivo absorbed dose verification within the rectum and bladder as organs‐at‐risk was performed by bead TLDs for 30 GYN cancer patients. For rectal wall dosimetry, 80 TLDs were placed in axial arrangements around a rectal tube covered with a layer of gel. Ten beads were placed inside the Foley catheter to get the bladder‐absorbed dose. Beads TLDs were localized and defined as control points in the treatment planning system (TPS) using CT images of the patients. Patients were planned and treated using the routine BT protocol. The experimentally obtained absorbed dose map of the rectal wall and the point dose of the bladder were compared to the TPSs predicted absorbed dose at these control points.

Results

Relative difference between TPS and TLDs results were −8.3% ± 19.5% and −7.2% ± 14.6% (1SD) for rectum‐ and bladder‐absorbed dose, respectively. Gamma analysis was used to compare the calculated with the measured absorbed dose maps. Mean gamma passing rates of 84.1%, 90.8%, and 92.5% using the criteria of 3%/2 mm, 3%/3 mm, and 4%/2 mm were obtained, respectively. Eventually, a “considering level” of at least 85% as pass rate with 4%/2‐mm criteria was recommended.

Conclusions

A 3D IVD protocol employing bead TLDs was presented to measure absorbed doses delivered to the rectum and bladder during GYN HDR‐BT as a reliable PSQA method. 3D rectal absorbed dose measurements were performed. Differences between experimentally measured and planned absorbed dose maps were presented in the form of a gamma index, which may be used as a warning for corrective action.

Brachytherapy treatment verification using gamma radiation from the internal treatment source combined with an imaging panel-a phantom study

Brachytherapy has an excellent clinical outcome for different treatment sites. However,in vivotreatment verification is not performed in the majority of hospitals due to the lack of proper monitoring systems. This study investigates the use of an imaging panel (IP) and the photons emitted by a high dose rate (HDR)¹⁹²Ir source to track source motion and obtain some information related to the patient anatomy. The feasibility of this approach was studied by monitoring the treatment delivery to a 3D printed phantom that mimicks a prostate patient. A 3D printed phantom was designed with a template for needle insertion, a cavity ('rectum') to insert an ultrasound probe, and lateral cavities used to place tissue-equivalent materials. CT images were acquired to create HDR¹⁹²Ir treatment plans with a range of dwell times, interdwell distances and needle arrangements. Treatment delivery was verified with an IP placed at several positions around the phantom using radiopaque markers on the outer surface to register acquired IP images with the planning CT. All dwell positions were identified using acquisition times ≤0.11 s (frame rates ≥ 9 fps). Interdwell distances and dwell positions (in relation to the IP) were verified with accuracy better than 0.1 cm. Radiopaque markers were visible in the acquired images and could be used for registration with CT images. Uncertainties for image registration (IP and planning CT) between 0.1 and 0.4 cm. The IP is sensitive to tissue-mimicking insert composition and showed phantom boundaries that could be used to improve treatment verification. The IP provided sufficient time and spatial resolution for real-time source tracking and allows for the registration of the planning CT and IP images. The results obtained in this study indicate that several treatment errors could be detected including swapped catheters, incorrect dwell times and dwell positions.

THERMOLUMINESCENCE DOSIMETRY (TLD) IN MEDICINE: FIVE 'W'S AND ONE HOW

Thermoluminescence dosimetry (TLD) has a long history of applications in medicine. However, despite its versatility and sensitivity its use is anecdotally diminishing, at least in part due to the complexity and work intensity of a quality TLD service. The present paper explores the role of TLD in medicine using a common inquiry methodology (5W1H) which systematically asks 'Who, What, When, Where, Why and How' to identify what role TLD could and should play in medical applications.

Feasibility of improving patient's safety with in vivo dose tracking in intracavitary and interstitial HDR brachytherapy

PURPOSE

The in vivo dosimetric monitoring in HDR brachytherapy is important for improving patient safety. However, there are very limited options available for clinical application. In this study, we present a new in vivo dose measurement system with a plastic scintillating detector (PSD) for GYN HDR brachytherapy.

METHODS

An FDA approved PSD system, called OARtrac (AngioDynamics, Latham, NY), was used with various applicators for in vivo dose measurements for GYN patients. An institutional workflow was established for the clinical implementation of the dosimetric system. Action levels were proposed based on the measurement and system uncertainty for measurement deviations. From October 2018 to September 2019, a total of 75 measurements (48 fractions) were acquired from 14 patients who underwent HDR brachytherapy using either a multichannel cylinder, Venezia applicator, or Syed-Neblett template. The PSDs were placed in predetermined catheters/channels. A planning CT was acquired for treatment planning in Oncentra (Elekta, Version-4.5.2) TPS. The PSDs were contoured on the CT images, and the PSD D_90% values were used as the expected doses for comparison with the measured doses.

RESULTS

The mean difference from patient measurements was -0.22% ± 5.98%, with 26% being the largest deviation from the expected value (Syed case). Large deviations were observed when detectors were placed in the area where dose rates were less than 1 cGy/s.

CONCLUSIONS

The establishment of clinical workflow for the in vivo dosimetry for both the intracavitary and interstitial GYN HDR brachytherapy will potentially improve the safety of the patient treatment.

In vivo dosimetry in brachytherapy: Requirements and future directions for research, development, and clinical practice

Brachytherapy can deliver high doses to the target while sparing healthy tissues due to its steep dose gradient leading to excellent clinical outcome. Treatment accuracy depends on several manual steps making brachytherapy susceptible to operational mistakes. Currently, treatment delivery verification is not routinely available and has led, in some cases, to systematic errors going unnoticed for years. The brachytherapy community promoted developments in in vivo dosimetry (IVD) through research groups and small companies. Although very few of the systems have been used clinically, it was demonstrated that the likelihood of detecting deviations from the treatment plan increases significantly with time-resolved methods. Time–resolved methods could interrupt a treatment avoiding gross errors which is not possible with time-integrated dosimetry. In addition, lower experimental uncertainties can be achieved by using source-tracking instead of direct dose measurements. However, the detector position in relation to the patient anatomy remains a main source of uncertainty. The next steps towards clinical implementation will require clinical trials and systematic reporting of errors and near-misses. It is of utmost importance for each IVD system that its sensitivity to different types of errors is well understood, so that end-users can select the most suitable method for their needs. This report aims to formulate requirements for the stakeholders (clinics, vendors, and researchers) to facilitate increased clinical use of IVD in brachytherapy. The report focuses on high dose-rate IVD in brachytherapy providing an overview and outlining the need for further development and research.

Experimental Determination of Radial Dose Function and Anisotropy Function of GammaMed Plus 192Ir High-Dose-Rate Brachytherapy Source in a Bounded Water Phantom and its Comparison with egs_brachy Monte Carlo Simulation

OBJECTIVE

The aim of the present study is to experimentally measure the radial dose function g(r) and anisotropy function F(r,θ) of GammaMed Plus 192Ir high-dose-rate source in a bounded water phantom using thermoluminescent dosimeter (TLD) and film dosimetry and compare the obtained results with egs_brachy Monte Carlo (MC)-calculated values for the same geometry.

MATERIALS AND METHODS

The recently developed egs_brachy is a fast Electron Gamma Shower National Research Council of Canada MC application which is intended for brachytherapy applications. The dosimetric dataset recommended by Task Group 43 update (TG43U1) is calculated using egs_brachy for an unbounded phantom. Subsequently, radial dose function g(r) and anisotropy function F(r,θ) are measured experimentally in a bounded water phantom using TLD-100 and Gafchromic EBT2 film.

RESULTS

The TG43U1 dosimetric parameters were determined using the egs_brachy MC calculation and compared with published data which are found to be in good agreement within 2%. The experimentally measured g(r) and F(r,θ) and its egs_brachy MC code-calculated values for a bounded phantom geometry are found to be good in agreement within the acceptable experimental uncertainties of 3%.

CONCLUSION

Our experimental phantom size represents the average patient width of 30 cm; hence, results are closer to scattering conditions in clinical situations. The experimentally measured g(r) and F(r,θ) and egs_brachy MC calculations for bounded geometry are well in agreement within experimental uncertainties. Further, the confidence level of our comparative study is enhanced by validating the egs_brachy MC code for the unbounded phantom with respect to consensus data.

[Dosimetric verification of MammoSite treatment plans using Monte Carlo simulations and measurements with a 2D ionization chamber array]

The surgical removal of a breast tumour is often followed by postoperative irradiation of the surrounding tissue with a radioactive source (brachytherapy). When performing the MammoSite procedure, a spherical silicone balloon is inserted and filled with a NaCl solution. In a period of about five days in several sessions an iridium-192 source with high activity travels through a catheter into the balloon (afterloading) to irradiate the tumour cells remaining in the cavity. In this study, dose distributions of a MammoSite applicator are investigated based on measurements with a 2D detector array, Monte Carlo simulations and calculations with BrachyVision. The focus is set on the 2D detector array and its possible application in the verification process in 3D brachytherapy treatment planning. The measured dose distributions conform well to the doses of BrachyVision with deviations of less than 5% within the clinically relevant field range. The deviations of the measured and calculated distributions from the simulation results are below 3%. The 2D detector array allows a new verification method for MammoSite treatment plans with sufficient accuracy. Future verifications can be performed without additional Monte Carlo simulations.

Web of Science, Scopus, and Google Scholar citation rates: a case study of medical physics and biomedical engineering: what gets cited and what doesn't?

There are often differences in a publication's citation count, depending on the database accessed. Here, aspects of citation counts for medical physics and biomedical engineering papers are studied using papers published in the journal Australasian physical and engineering sciences in medicine. Comparison is made between the Web of Science, Scopus, and Google Scholar. Papers are categorised into subject matter, and citation trends are examined. It is shown that review papers as a group tend to receive more citations on average; however the highest cited individual papers are more likely to be research papers.

In vivo TLD dose measurements in catheter-based high-dose-rate brachytherapy

Routine in vivo dosimetry is well established in external beam radiotherapy; however, it is restricted mainly to detection of gross errors in high-dose-rate (HDR) brachytherapy due to complicated measurements in the field of steep dose gradients in the vicinity of radioactive source and high uncertainties. The results of in vivo dose measurements using TLD 100 mini rods and TLD 'pin worms' in catheter-based HDR brachytherapy are provided in this paper alongside with their comparison with corresponding dose values obtained using calculation algorithm of the treatment planning system. Possibility to perform independent verification of treatment delivery in HDR brachytherapy using TLDs is discussed.

An investigation into the accuracy of Acuros(TM) BV in heterogeneous phantoms for a (192)Ir HDR source using LiF TLDs

The aim of this study was to evaluate the accuracy of the new Acuros(TM) BV algorithm using well characterized LiF:Mg,Ti TLD 100 in heterogeneous phantoms. TLDs were calibrated using an (192)Ir source and the AAPM TG-43 calculated dose. The Tölli and Johansson Large Cavity principle and Modified Bragg Gray principle methods confirm the dose calculated by TG-43 at a distance of 5 cm from the source to within 4 %. These calibrated TLDs were used to measure the dose in heterogeneous phantoms containing air, stainless steel, bone and titanium. The TLD results were compared with the AAPM TG-43 calculated dose and the Acuros calculated dose. Previous studies by other authors have shown a change in TLD response with depth when irradiated with an (192)Ir source. This TLD depth dependence was assessed by performing measurements at different depths in a water phantom with an (192)Ir source. The variation in the TLD response with depth in a water phantom was not found to be statistically significant for the distances investigated. The TLDs agreed with Acuros(TM) BV within 1.4 % in the air phantom, 3.2 % in the stainless steel phantom, 3 % in the bone phantom and 5.1 % in the titanium phantom. The TLDs showed a larger discrepancy when compared to TG-43 with a maximum deviation of 9.3 % in the air phantom, -11.1 % in the stainless steel phantom, -14.6 % in the bone phantom and -24.6 % in the titanium phantom. The results have shown that Acuros accounts for the heterogeneities investigated with a maximum deviation of -5.1 %. The uncertainty associated with the TLDs calibrated in the PMMA phantom is ±8.2 % (2SD).

Physics-aspects of dose accuracy in high dose rate (HDR) brachytherapy: source dosimetry, treatment planning, equipment performance and in vivo verification techniques

This study provides a review of recent publications on the physics-aspects of dosimetric accuracy in high dose rate (HDR) brachytherapy. The discussion of accuracy is primarily concerned with uncertainties, but methods to improve dose conformation to the prescribed intended dose distribution are also noted. The main aim of the paper is to review current practical techniques and methods employed for HDR brachytherapy dosimetry. This includes work on the determination of dose rate fields around brachytherapy sources, the capability of treatment planning systems, the performance of treatment units and methods to verify dose delivery. This work highlights the determinants of accuracy in HDR dosimetry and treatment delivery and presents a selection of papers, focusing on articles from the last five years, to reflect active areas of research and development. Apart from Monte Carlo modelling of source dosimetry, there is no clear consensus on the optimum techniques to be used to assure dosimetric accuracy through all the processes involved in HDR brachytherapy treatment. With the exception of the ESTRO mailed dosimetry service, there is little dosimetric audit activity reported in the literature, when compared with external beam radiotherapy verification.

A phantom study of an in vivo dosimetry system using plastic scintillation detectors for real-time verification of 192Ir HDR brachytherapy

PURPOSE

The goal of the present work was to evaluate the accuracy of a plastic scintillation detector (PSD) system to perform in-phantom dosimetry during 192Ir high dose rate (HDR) brachytherapy treatments.

METHODS

A PSD system capable of stem effect removal was built. A red-green-blue photodiode connected to a dual-channel electrometer was used to detect the scintillation light emitted from a green scintillation component and transmitted along a plastic optical fiber. A clinically relevant prostate treatment plan was built using the HDR brachytherapy treatment planning system. An in-house fabricated template was used for accurate positioning of the catheters, and treatment delivery was performed in a water phantom. Eleven catheters were inserted and used for dose delivery from 192Ir radioactive source, while two others were used to mimic dosimetry at the rectum wall and in the urethra using a PSD. The measured dose and dose rate data were compared to the expected values from the planning system. The importance of removing stem effects from in vivo dosimetry using a PSD during 192Ir HDR brachytherapy treatments was assessed. Applications for dwell position error detection and temporal verification of the treatment delivery were also investigated.

RESULTS

In-phantom dosimetry measurements of the treatment plan led to a ratio to the expected dose of 1.003 +/- 0.004 with the PSD at different positions in the urethra and 1.043 +/- 0.003 with the PSD inserted in the rectum. Verification for the urethra of dose delivered within each catheter and at specific dwell positions led to average measured to expected ratios of 1.015 +/- 0.019 and 1.014 +/- 0.020, respectively. These values at the rectum wall were 1.059 +/- 0.045 within each catheter and 1.025 +/- 0.028 for specific dwell positions. The ability to detect positioning errors of the source depended of the tolerance on the difference to the expected value. A 5-mm displacement of the source was detected by the PSD system from 78% to 100% of the time depending on the acceptable range value. The implementation of a stem effect removal technique was shown to be necessary, particularly when calculating doses at specific dwell positions, and allowed decreasing the number of false-error detections-the detection of an error when it should not be the case--from 19 to 1 for a 5% threshold out of 43 measurements. The use of the PSD system to perform temporal verification of elapsed time by the source in each catheter--generally on the order of minutes--was shown to be in agreement within a couple of seconds with the treatment plan

CONCLUSIONS

We showed that the PSD system used in this study, which was capable of stem effect removal, can perform accurate dosimetry during 192Ir HDR brachytherapy treatment in a water phantom. The system presented here shows some clear advantages over previously proposed dosimetry systems for HDR brachytherapy, and it has the potential for various online verifications of treatment delivery quality.

Technical note: removing the stem effect when performing Ir-192 HDR brachytherapy in vivo dosimetry using plastic scintillation detectors: a relevant and necessary step

PURPOSE

The purpose of this study was to investigate whether or not a stem effect removal technique is necessary when performing Ir-192 HDR brachytherapy in vivo dosimetry using a scintillation detector.

METHODS

A red-green-blue photodiode connected to a multichannel electrometer was used to detect the light emitted from a plastic scintillation detector (PSD) during irradiation with an Ir-192 HDR brachytherapy source. Accuracy in dose measurement was compared with and without the use of stem effect removal techniques. Monochromatic and polychromatic filtration techniques were studied. An in-house template was built for accurate positioning of catheters in which the source and the PSD were inserted. Dose distribution was measured up to 5 cm from source to detector in the radial and longitudinal directions.

RESULTS

The authors found the stem effect to be particularly important when the source was close to the optical fiber guide and far from the scintillation component of the detector. It can account for up to (72 +/- 3)% of the signal under clinically relevant conditions. The polychromatic filtration outperformed the monochromatic filtration as well as the absence of filtration in regard to dose measurement accuracy.

CONCLUSIONS

It is necessary to implement a stem effect removal technique when building a PSD for in vivo dosimetry during Ir-192 HDR brachytherapy. The PSD that the authors have developed for this study would be suitable for such an application.

An in vivo investigative protocol for HDR prostate brachytherapy using urethral and rectal thermoluminescence dosimetry

PURPOSE

To develop an in vivo dosimetry based investigative action level relevant for a corrective protocol for HDR brachytherapy boost treatment.

METHODS AND MATERIALS

The dose delivered to points within the urethra and rectum was measured using TLD in vivo dosimetry in 56 patients. Comparisons between the urethral and rectal measurements and TPS calculations showed differences, which are related to the relative position of the implant and TLD trains, and allowed shifts of implant position relative to the prostate to be estimated.

RESULTS AND CONCLUSIONS

Analysis of rectal dose measurements is consistent with implant movement, which was previously only identified with the urethral data. Shift corrected doses were compared with results from the TPS. Comparison of peak doses to the urethra and rectum has been assessed against the proposed corrective protocol to limit overdosing these critical structures. An initial investigative level of 20% difference between measured and TPS peak dose was established, which corresponds to 1/3 of patients which was practical for the caseload. These patients were assessed resulting in corrective action being applied for one patient. Multiple triggering for selective investigative action is outlined. The use of a single in vivo measurement in the first fraction optimizes patient benefit at acceptable cost.