Feasibility of 18-MV grid therapy from radiation protection aspects: unwanted dose and fatal cancer risk caused by photoneutrons and scattered photons

Dose equivalent consideration from neutron contamination in modified radiotherapy vault: a Monte Carlo study

Laminated barriers incorporating metal sheets provide effective protection for space-restricted radiotherapy centers. This study aimed to assess photoneutron contamination in smaller vaults protected by different compositions of multilayer barriers during simulated pelvic radiotherapy with 18 MV photon beams. Monte Carlo Simulations of 18 MV LINAC (Varian 2100 C/D) and Medical Internal Radiation Dose (MIRD) phantom were used to assess photoneutron contamination within reconstructed vaults incorporating different combinations of metal sheet and borated polyethylene (BPE) during pelvic radiotherapy. The findings highlight a 3.27 and 2.91 times increase in ambient neutron doseHn*(10) along the maze of reconstructed vaults that use lead and steel sheets, respectively, compared to concrete. TheHn*(10) outside the treatment room increased after incorporating a metal sheet, but it remained within the permissible limit of 20μSv/week for uncontrolled areas adjacent to the LINAC bunker, even with a workload of 1000Gy/week. Neutron equivalent doses in the patient's organs ranged from 0.22 to 0.96 mSv Gy-1. There is no notable distinction in the organ's neutron equivalent dose, fatal cancer risk, secondary radiation-induced cancer risk, and cancer mortality for various laminated barrier compositions. Furthermore, the use of metal sheets for vault wall reconstruction keeps the variation in cancer risk induced by photoneutrons below 6%, while risks of fatal cancer and cancer mortality vary less than 11%. While the metal portion of the laminated barrier raises the neutron dose, the addition of a BPE plate reduces concerns of increased effective dose and secondary malignancy risk.

Beam quality and the mystery behind the lower percentage depth dose in grid radiation therapy

Grid therapy recently has been picking momentum due to favorable outcomes in bulky tumors. This is being termed as Spatially Fractionated Radiation Therapy (SFRT) and lattice therapy. SFRT can be performed with specially designed blocks made with brass or cerrobend with repeated holes or using multi-leaf collimators where dosimetry is uncertain. The dosimetric challenge in grid therapy is the mystery behind the lower percentage depth dose (PDD) in grid fields. The knowledge about the beam quality, indexed by TPR20/10 (Tissue Phantom Ratio), is also necessary for absolute dosimetry of grid fields. Since the grid may change the quality of the primary photons, a new [Formula: see text] should be evaluated for absolute dosimetry of grid fields. A Monte Carlo (MC) approach is provided to resolving the dosimetric issues. Using 6 MV beam from a linear accelerator, MC simulation was performed using MCNPX code. Additionally, a commercial grid therapy device was used to simulate the grid fields. Beam parameters were validated with MC model for output factor, depth of maximum dose, PDDs, dose profiles, and TPR20/10. The electron and photon spectra were also compared between open and grid fields. The dmax is the same for open and grid fields. The PDD with grid is lower (~ 10%) than the open field. The difference in TPR20/10 of open and grid fields is observable (~ 5%). Accordingly, TPR20/10 is still a good index for the beam quality in grid fields and consequently choose the correct [Formula: see text] in measurements. The output factors for grid fields are 0.2 lower compared to open fields. The lower depth dose with grid therapy is due to lower depth fluence with scatter radiation but it does not impact the dosimetry as the calibration parameters are insensitive to the effective beam energies. Thus, standard dosimetry in open beam based on international protocol could be used.

Association between radiotherapy and risk of second primary malignancies in patients with resectable lung cancer: a population-based study

BACKGROUND

The most common form of treatment for non-metastatic lung cancer is surgery-based combination therapy, which may also include adjuvant radiotherapy or chemotherapy. Second primary malignancies (SPMs) are uncommon but significant radiation side effects in patients with resectable lung cancer, and SPMs have not been adequately investigated. Our study aims to assess the correlations of radiotherapy with the development of SPMs in patients with resectable lung cancer.

METHODS

We screened for any primary malignancy that occurred more than five years after the diagnosis of resectable lung cancer. Based on the large cohort of the Surveillance, Epidemiology and End Results database, radiotherapy-correlated risks were estimated using the Poisson regression analysis and the cumulative incidence of SPMs was calculated using Fine-Gray competing risk regression analysis.

RESULTS

Among the 62,435 patients with non-metastatic lung cancer undergoing surgery, a total of 11,341 (18.16%) patients have received radiotherapy. Our findings indicated that radiotherapy was substantially related to a high risk of main second solid malignancies (RR = 1.21; 95%CI, 1.08 to 1.35) and a negligible risk of main second hematologic malignancies (RR = 1.08; 95%CI, 0.84 to 1.37). With the greatest number of patients, the risk of acquiring a second primary gastrointestinal cancer was the highest overall (RR = 1.77; 95 percent CI, 1.44 to 2.15). The cumulative incidence and standardized incidence ratios of SPMs revealed similar findings. Furthermore, the young and the elderly may be more vulnerable, and the highest risk of acquiring most SPMs was seen more than ten years after lung cancer diagnosis. Additionally, more attention should be paid to the second primary gastrointestinal cancer in young individuals with resectable lung cancer.

CONCLUSION

After receiving radiotherapy, an increased risk of developing second primary solid and gastrointestinal cancers was observed for patients with resectable lung cancer. The prevention of SPMs associated with radiotherapy requires further attention.

How much should you worry about contaminant neutrons in spatially fractionated grid radiation therapy?

Neutron contamination in radiation therapy is of concern in treatment with high-energy photons (> 10 MV). With the development of new radiotherapy modalities such as spatially fractionated grid radiation therapy (SFGRT) or briefly grid radiotherapy, more studies are required to evaluate the risks associated with neutron contamination. In 15 MV SFGRT, high-Z materials such as lead and cerrobend are used as the block on the tray of linear accelerator (linac) which can probably increase the photoneutron production. On the other hand, the high-dose fractions (10-20 Gy) used in SFGRT can induce high neutron contamination. The current study was devoted to addressing these concerns via compression of neutron fluence (Φn) and ambient dose equivalent ([Formula: see text]) at the patient table and inside the maze between SFGRT and conventional fractionated radiation therapy (CFRT). The main components of the 15 MV Siemens Primus equipped with different grids and located inside a typical radiotherapy bunker were simulated by the MCNPX® Monte Carlo code. Evidence showed that the material used for grid construction does not significantly increase neutron contamination inside the maze. However, at the end of the maze, neutron contamination in SFGRT is significantly higher than in CFRT. In this regard, a delay time of 15 minutes after SFGRT is recommended for all radiotherapy staff before entering the maze. It can be also concluded that [Formula: see text] at the patient table is at least 10 times more pronounced than inside the maze. Therefore, the patient is more at risk of neutrons compared to the staff. The [Formula: see text] at the isocenter in SFGRT with grids made of lead and cerrobend was nearly equal to CFRT. Nevertheless, it was dramatically lower than in CFRT by 30% if the brass grid is used. Accordingly, SFGRT with the brass grid is recommended, from radiation protection aspects.

Semi-experimental assessment of neutron equivalent dose and secondary cancer risk for off-field organs in glioma patients undergoing 18-MV radiotherapy

Neutron contamination as a source of out-of-field dose in radiotherapy is still of concern. High-energy treatment photons have the potential to overcome the binding energy of neutrons inside the nuclei. Fast neutrons emitting from the accelerator head can directly reach the patient’s bed. Considering that modern radiotherapy techniques can increase patient survival, concerns about unwanted doses and the lifetime risk of fatal cancer remain strong or even more prominent, especially in young adult patients. The current study addressed these concerns by quantifying the dose and risk of fatal cancer due to photo-neutrons for glioma patients undergoing 18-MV radiotherapy. In this study, an NRD model rem-meter detector was used to measure neutron ambient dose equivalent, H*(10), at the patient table. Then, the neutron equivalent dose received by each organ was estimated concerning the depth of each organ and by applying depth dose corrections to the measured H*(10). Finally, the effective dose and risk of secondary cancer were determined using NCRP 116 coefficients. Evidence revealed that among all organs, the breast (0.62 mSv/Gy) and gonads (0.58 mSv/Gy) are at risk of photoneutrons more than the other organs in such treatments. The neutron effective dose in the 18-MV conventional radiotherapy of the brain was 13.36 mSv. Among all organs, gonads (6.96 mSv), thyroid (1.86 mSv), and breasts (1.86 mSv) had more contribution to the effective dose, respectively. The total secondary cancer risk was estimated as 281.4 cases (per 1 million persons). The highest risk was related to the breast and gonads with 74.4 and, 34.8 cases per 1 million persons, respectively. Therefore, it is recommended that to prevent late complications (secondary cancer and genetic effects), these organs should be shielded from photoneutrons. This procedure not only improves the quality of the patient’s personal life but also the healthy childbearing in the community.