In vivo skin dose measurement using MOSkin detectors in tangential breast radiotherapy

Implementation of OSL nanoDot dosimetry in different treatment techniques for head and neck cancer

In recent decades, technological advances have been made in the field of radiotherapy and with it the emergence of new dosimetric systems for their calibration and commissioning, among other uses. Such is the case of the measurement in the build-up region, where there is no charged-particle equilibrium, which is reflected in the increase in surface dose for patient treatments and potential skin toxicities as a secondary effect. This study utilizes optically stimulated dosemeters (nanoDot) and the radiochromic film (EBT3) to measure skin doses in patients with head and neck cancer who received radiotherapy. Accurately depicting 15 patients with different diagnoses from 3 linear accelerators using 3D, intensity modulated radiation therapy, or volumetric arc therapy/RapidArc technology, these results were compared with those calculated in the treatment planning system (TPS) and obtaining a percentage of variation for the EBT3 ranged from 0.30% to 6.15%, while that observed for the nanoDot was from 0.51% to 4.88%. This difference may be attributed to the reproducibility of placement in patients. Therefore, for clinical use, nanoDot dosemeters are a viable alternative for in vivo dosimetry where rapid validation of planning system results is required.

Electron streaming dose measurements and calculations on a 1.5 T MR-Linac

PURPOSE

To evaluate the accuracy of different dosimeters and the treatment planning system (TPS) for assessing the skin dose due to the electron streaming effect (ESE) on a 1.5 T magnetic resonance (MR)-linac.

METHOD

Skin dose due to the ESE on an MR-linac (Unity, Elekta) was investigated using a solid water phantom rotated 45° in the x-y plane (IEC61217) and centered at the isocenter. The phantom was irradiated with 1 × 1, 3 × 3, 5 × 5, 10 × 10, and 22 × 22 cm2 fields, gantry at 90°. Out-of-field doses (OFDs) deposited by electron streams generated at the entry and exit surface of the angled phantom were measured on the surface of solid water slabs placed ±20.0 cm from the isocenter along the x-direction. A high-resolution MOSkin™ detector served as a benchmark due to its shallower depth of measurement that matches the International Commission on Radiological Protection (ICRP) recommended depth for skin dose assessment (0.07 mm). MOSkin™ doses were compared to EBT3 film, OSLDs, a diamond detector, and the TPS where the experimental setup was modeled using two separate calculation parameters settings: a 0.1 cm dose grid with 0.2% statistical uncertainty (0.1 cm, 0.2%) and a 0.2 cm dose grid with 3.0% statistical uncertainty (0.2 cm, 3.0%).

RESULTS

OSLD, film, the 0.1 cm, 0.2%, and 0.2 cm, 3.0% TPS ESE doses, underestimated skin doses measured by the MOSkin™ by as much as -75.3%, -7.0%, -24.7%, and -41.9%, respectively. Film results were most similar to MOSkin™ skin dose measurements.

CONCLUSIONS

These results show that electron streams can deposit significant doses outside the primary field and that dosimeter choice and TPS calculation settings greatly influence the reported readings. Due to the steep dose gradient of the ESE, EBT3 film remains the choice for accurate skin dose assessment in this challenging environment.

High-resolution entry and exit surface dosimetry in a 1.5 T MR-linac

The magnetic field of a transverse MR-linac alters electron trajectories as the photon beam transits through materials, causing lower doses at flat entry surfaces and increased doses at flat beam-exiting surfaces. This study investigated the response of a MOSFET detector, known as the MOSkin™, for high-resolution surface and near-surface percentage depth dose measurements on an Elekta Unity. Simulations with Geant4 and the Monaco treatment planning system (TPS), and EBT-3 film measurements, were also performed for comparison. Measured MOSkin™ entry surface doses, relative to D_max, were (9.9 ± 0.2)%, (10.1 ± 0.3)%, (11.3 ± 0.6)%, (12.9 ± 1.0)%, and (13.4 ± 1.0)% for 1 × 1 cm², 3 × 3 cm², 5 × 5 cm², 10 × 10 cm², and 22 × 22 cm² fields, respectively. For the investigated fields, the maximum percent differences of Geant4, TPS, and film doses extrapolated and interpolated to a depth suitable for skin dose assessment at the beam entry, relative to MOSkin™ measurements at an equivalent depth were 1.0%, 2.8%, and 14.3%, respectively, and at a WED of 199.67 mm at the beam exit, 3.2%, 3.7% and 5.7%, respectively. The largest measured increase in exit dose, due to the electron return effect, was 15.4% for the 10 × 10 cm² field size using the MOSkin™ and 17.9% for the 22 × 22 cm² field size, using Geant4 calculations. The results presented in the study validate the suitability of the MOSkin™ detector for transverse MR-linac surface dosimetry.

Evaluation of skin dose and skin toxicity in patients undergoing intraoperative radiotherapy for early breast cancer

PURPOSE

This study aims to evaluate in vivo skin dose delivered by intraoperative radiotherapy (IORT) and determine the factors associated with an increased risk of radiation-induced skin toxicity.

METHODOLOGY

A total of 21 breast cancer patients who underwent breast-conserving surgery and IORT, either as IORT alone or IORT boost plus external beam radiotherapy (EBRT), were recruited in this prospective study. EBT3 film was calibrated in water and used to measure skin dose during IORT at concentric circles of 5 mm and 40 mm away from the applicator. For patients who also had EBRT, the maximum skin dose was estimated using the radiotherapy treatment planning system. Mid-term skin toxicities were evaluated at 3 and 6 months post-IORT.

RESULTS

The average skin dose at 5 mm and 40 mm away from the applicator was 3.07 ± 0.82 Gy and 0.99 ± 0.28 Gy, respectively. Patients treated with IORT boost plus EBRT received an additional skin dose of 41.07 ± 1.57 Gy from the EBRT component. At 3 months post-IORT, 86% of patients showed no evidence of skin toxicity. However, the number of patients suffering from skin toxicity increased from 15% to 38% at 6 months post-IORT. We found no association between the IORT alone or with the IORT boost plus EBRT and skin toxicity. Older age was associated with increased risk of skin toxicities. A mathematical model was derived to predict skin dose.

CONCLUSION

EBT3 film is a suitable dosimeter for in vivo skin dosimetry in IORT, providing patient-specific skin doses. Both IORT alone and IORT boost techniques resulted in similar skin toxicity rates.

Low-intensity ultrasound combined with allogenic adipose-derived mesenchymal stem cells (AdMSCs) in radiation-induced skin injury treatment

Mesenchymal stem cells are mechano-sensitive cells with the potential to restore the function of damaged tissues. Low-intensity ultrasound has been increasingly considered as a bioactive therapeutic apparatus. Optimizing transplantation conditions is a critical aim for radiation-induced skin tissue injury. Therefore, the therapeutic function of adipose-derived mesenchymal stem cells to ultrasound stimulus was examined based on the mechanical index (MI). Mesenchymal stem cells were isolated from the adipose tissues of mature guinea pigs. An ultrasound system (US) was constructed with a 40 kHz frequency. The radiation-induced skin injury model was produced on the abdominal skin of guinea pigs by 60 Gy of radiation. Then, they were divided to 7 groups (n = 42): control, sham, US (MI = 0.7), AdMSCs injection, US AdMSCs (AdMSCs, under US with MI = 0.2), AdMSCs + US (AdMSCs transplantation and US with MI = 0.7) and US AdMSCs + US (combining the last two groups). The homing of stem cells was verified with fluorescence imaging. The groups were followed with serial photography, ultrasound imaging, tensiometry, and histology. The thickness of the skin was analyzed. Functional changes in skin tissue were evaluated with Young's modulus (kPa). One-way ANOVA tests were performed to analyze differences between treatment protocols (p < 0.05). The results of Kumar's score showed that radiation injury was significantly lower in the treatment groups of US AdMSCs and US AdMSCs + US than other groups after 14 days (p < 0.05). There was a significant difference in skin thickness between treatment groups with control, sham, and US groups after 60 Gy radiation and were closer to the thickness of healthy skin. Young's modulus in US AdMSCs + US, US AdMSCs, and AdMSCs + US groups demonstrated a significant difference with the other groups (p < 0.05). Young's modulus in US AdMSCs + US and US AdMSCs treatment groups were closer to Young's modulus of the healthy skin. The histological results confirmed the improvement of acute radiation damage in the combined treatment method, especially in US AdMSCs + US and US AdMSCs groups with increasing the epithelialization and formation of collagen. An ultrasonic treatment plan based on a mechanical index of the target medium could be used to enhance stem cell therapy.

Surface dose and acute skin reactions in external beam breast radiotherapy

The biologically relevant depth for acute skin reactions in radiotherapy is 70 µm. The dose at this depth is difficult to measure or calculate and can be quite different than the dose at a depth of as little as 1 mm. For breast radiotherapy with medial and lateral tangential beams, the skin dose depends on both the contribution from the entrance beam and the exit beam. The skin dose has been estimated in a breast model hemi-ellipse accounting for field size, beam energy, obliquity, lack of backscatter, fractionation, size and shape of the hemi-ellipse. The dose has been held constant along the axis of symmetry of the hemi-ellipse by introducing modulation as in clinical IMRT practice. Dose distributions have been computed as a function of the polar angle from the center of the hemi-ellipse. The exit dose always dominates the entrance dose for all realistic parameters. As a result, the surface dose is higher for 18 MV than 6 MV over the entire surface for all reasonable sizes and shapes of the hemi-ellipse. The results of these calculations suggest that substituting an 18 MV beam for a 6 MV beam to achieve greater skin sparing may have just the opposite effect. The ratio of the surface dose to the mid-depth dose ranges from about 35% at polar angle 0^o to up to 70% at polar angle 80^o. The dose rises sharply at angles above 30^o. The surface dose rises moderately at all angles as the size of the hemi-ellipse increases. The effect of shape is somewhat complex: as the breast becomes flatter, doses at intermediate angles increase, but doses at small and large angles decrease. The biologically effective dose for erythema and moist desquamation is about 2 to 3 Gy higher at all polar angles for conventional fractionation (2.00 Gy × 25 fractions) than for hypofractionation (2.66 Gy × 16).

In vivo dosimetry using MOSkin detector during Cobalt-60 high-dose-rate (HDR) brachytherapy of skin cancer

The MOSkin, a metal-oxide semiconductor field-effect transistor based detector, is suitable for evaluating skin dose due to its water equivalent depth (WED) of 0.07 mm. This study evaluates doses received by target area and unavoidable normal skin during a the case of skin brachytherapy. The MOSkin was evaluated for its feasibility as detector of choice for in vivo dosimetry during skin brachytherapy. A high-dose rate Cobalt-60 brachytherapy source was administered to the tumour located at the medial aspect of the right arm, complicated with huge lymphedema thus limiting the arm motion. The source was positioned in the middle of patients' right arm with supine, hands down position. A 5 mm lead and 5 mm bolus were sandwiched between the medial aspect of the arm and lateral chest to reduce skin dose to the chest. Two calibrated MOSkin detectors were placed on the target and normal skin area for five treatment sessions for in vivo dose monitoring. The mean dose to the target area ranged between 19.9 and 21.1 Gy and was higher in comparison with the calculated dose due to contribution of backscattered dose from lead. The mean measured dose at normal skin chest area was 1.6 Gy (1.3-1.9 Gy), less than 2 Gy per fraction. Total dose in EQD₂ received by chest skin was much lower than the recommended skin tolerance. The MOSkin detector presents a reliable real-time dose measurement. This study has confirmed the applicability of the MOSkin detector in monitoring skin dose during brachytherapy treatment due to its small sensitive volume and WED 0.07 mm.

Passive radiofrequency x-ray dosimeter tag based on flexible radiation-sensitive oxide field-effect transistor

Distributed x-ray radiation dosimetry is crucial in diverse security areas with significant environmental and human impacts such as nuclear waste management, radiotherapy, or radioprotection devices. We present a fast, real-time dosimetry detection system based on flexible oxide thin-film transistors that show a quantitative shift in threshold voltage of up to 3.4 V/gray upon exposure to ionizing radiation. The transistors use indium-gallium-zinc-oxide as a semiconductor and a multilayer dielectric based on silicon oxide and tantalum oxide. Our measurements demonstrate that the threshold voltage shift is caused by the accumulation of positive ionization charge in the dielectric layer due to high-energy photon absorption in the high-Z dielectric. The high mobility combined with a steep subthreshold slope of the transistor allows for fast, reliable, and ultralow-power readout of the deposited radiation dose. The order-of-magnitude variation in transistor channel impedance upon exposure to radiation makes it possible to use a low-cost, passive radiofrequency identification sensor tag for its readout. In this way, we demonstrate a passive, programmable, wireless sensor that reports in real time the excess of critical radiation doses.

Semiconductor real-time quality assurance dosimetry in brachytherapy

With the increase in complexity of brachytherapy treatments, there has been a demand for the development of sophisticated devices for delivery verification. The Centre for Medical Radiation Physics (CMRP), University of Wollongong, has demonstrated the applicability of semiconductor devices to provide cost-effective real-time quality assurance for a wide range of brachytherapy treatment modalities. Semiconductor devices have shown great promise to the future of pretreatment and in vivo quality assurance in a wide range of brachytherapy treatments, from high-dose-rate (HDR) prostate procedures to eye plaque treatments. The aim of this article is to give an insight into several semiconductor-based dosimetry instruments developed by the CMRP. Applications of these instruments are provided for breast and rectal wall in vivo dosimetry in HDR brachytherapy, urethral in vivo dosimetry in prostate low-dose-rate (LDR) brachytherapy, quality assurance of HDR brachytherapy afterloaders, HDR pretreatment plan verification, and real-time verification of LDR and HDR source dwell positions.