Out-of-field doses from secondary radiation produced in proton therapy and the associated risk of radiation-induced cancer from a brain tumor treatment

Range shifter contribution to neutron exposure of patients undergoing proton pencil beam scanning

BACKGROUND

Superficial targets require the use of the lowest energies within the available energy range in proton pencil-beam scanning (PBS) technique. However, the lower efficiency of the energy selection system at these energies and the requirement of a greater number of layers may represent disadvantages for this approach. The alternative is to use a range shifter (RS) at nozzle exit. However, one of the concerns of using this beamline element is that it becomes an additional source of neutrons that could irradiate organs situated far from the target.

PURPOSE

The purpose of this study is to assess the increase in neutron dose due to the RS in proton PBS technique. Additionally, an analytical model for the neutron production is tested.

METHODS

Two clinical plans, designed to achieve identical target coverage, were created for an anthropomorphic phantom. These plans consisted of a lateral field delivering an absorbed dose of 60 Gy (RBE) to the target. One of the plans employed the RS. The MCNP code was used to simulate the plans, evaluating the distribution of neutron dose equivalent (Hn) and the equivalent dose in organ. In the plan with the RS plan, neutron production from both the patient and the RS were assessed separately. Hn values were also fitted versus the distance to field edge using a Gaussian function.

RESULTS

Hn per prescription dose, in the plan using the RS, ranged between 1.4 and 3.7 mSv/Gy at the field edge, whereas doses at 40 cm from the edge ranged from 9.9 to 32 μSv/Gy. These values are 1.2 to 10 times higher compared to those obtained without the RS. Both this factor and the contribution of neutrons originating from the RS increases with the distance from field edge. A triple-Gaussian function was able to reproduce the equivalent dose in organs within a factor of 2, although underestimating the values.

CONCLUSIONS

The dose deposited in the patient by the neutrons originating from the RS predominantly affects areas away from the target (beyond approximately 25 cm from field edge), resulting in a neutron dose equivalent of the order of mSv. This indicates an overall low neutron contribution from the use of RS in PBS.

Range-shifter effects on the stray field in proton therapy measured with the variance–covariance method

Measurements in the stray radiation field from a proton therapy pencil beam at energies 70 and 146 MeV were performed using microdosimetric tissue-equivalent proportional counters (TEPCs). The detector volumes were filled with a propane-based tissue-equivalent gas at low pressure simulating a mean chord length of 2 μm in tissue. Investigations were performed with and without a beam range shifter, and with different air gaps between the range shifter and a solid water phantom. The absorbed dose, the dose-mean lineal energy, and the dose equivalent were determined for different detector positions using the variance–covariance method. The influence from beam energy, detector- and range-shifter positions on absorbed dose, LET, and dose equivalent were investigated. Monte Carlo simulations of the fluence, detector response, and absorbed dose contribution from different particles were performed with MCNP 6.2. The simulated dose response for protons, neutrons, and photons were compared with, and showed good agreement with, previously published experimental data. The simulations also showed that the TEPC absorbed dose agrees well with the ambient absorbed dose for neutron energies above 20 MeV. The results illustrate that changes in both dose and LET variations in the stray radiation field can be identified from TEPC measurements using the variance–covariance method. The results are in line with the changes seen in the simulated relative dose contributions from different particles associated with different proton energies and range-shifter settings. It is shown that the proton contribution scattered directly from the range shifter dominates in some situations, and although the LET of the radiation is decreased, the ambient dose equivalent is increased up to a factor of 3.

Out-of-Field Doses Produced by a Proton Scanning Beam Inside Pediatric Anthropomorphic Phantoms and Their Comparison With Different Photon Modalities

Since 2010, EURADOS Working Group 9 (Radiation Dosimetry in Radiotherapy) has been involved in the investigation of secondary and scattered radiation doses in X-ray and proton therapy, especially in the case of pediatric patients. The main goal of this paper is to analyze and compare out-of-field neutron and non-neutron organ doses inside 5- and 10-year-old pediatric anthropomorphic phantoms for the treatment of a 5-cm-diameter brain tumor. Proton irradiations were carried out at the Cyclotron Centre Bronowice in IFJ PAN Krakow Poland using a pencil beam scanning technique (PBS) at a gantry with a dedicated scanning nozzle (IBA Proton Therapy System, Proteus 235). Thermoluminescent and radiophotoluminescent dosimeters were used for non-neutron dose measurements while secondary neutrons were measured with track-etched detectors. Out-of-field doses measured using intensity-modulated proton therapy (IMPT) were compared with previous measurements performed within a WG9 for three different photon radiotherapy techniques: 1) intensity-modulated radiation therapy (IMRT), 2) three-dimensional conformal radiation therapy (3D CDRT) performed on a Varian Clinac 2300 linear accelerator (LINAC) in the Centre of Oncology, Krakow, Poland, and 3) Gamma Knife surgery performed on the Leksell Gamma Knife (GK) at the University Hospital Centre Zagreb, Croatia. Phantoms and detectors used in experiments as well as the target location were the same for both photon and proton modalities. The total organ dose equivalent expressed as the sum of neutron and non-neutron components in IMPT was found to be significantly lower (two to three orders of magnitude) in comparison with the different photon radiotherapy techniques for the same delivered tumor dose. For IMPT, neutron doses are lower than non-neutron doses close to the target but become larger than non-neutron doses further away from the target. Results of WG9 studies have provided out-of-field dose levels required for an extensive set of radiotherapy techniques, including proton therapy, and involving a complete description of organ doses of pediatric patients. Such studies are needed for validating mathematical models and Monte Carlo simulation tools for out-of-field dosimetry which is essential for dedicated epidemiological studies which evaluate the risk of second cancers and other late effects for pediatric patients treated with radiotherapy.

Microdosimetric measurements as a tool to assess potential in-field and out-of-field toxicity regions in proton therapy

Relative biological effectiveness (RBE) variations are thought to be one of the primary causes of unexpected normal-tissue toxicities during tumor treatments with charged particles. Unlike carbon therapy, where treatment planning is optimized on the basis of the RBE-weighted dose, a constant RBE value of 1.1 is currently used in proton therapy. Assuming a uniform value can lead to under- or over-dosage, not just to the tumor but also to surrounding normal tissue. RBE changes have been linked with dose/fraction, the biological endpoint and beam properties. Understanding radiation quality and the associated RBE can improve the prediction of normal-tissue toxicities. In this study, we exploited microdosimetry for characterizing radiation quality in proton therapy in-field, and off-beam at 20 (beam edge), 50 (close out-of-field) and 100 (far out-of-field) mm from the beam center. We measured the lineal energy y spectra in a water phantom irradiated with 152 MeV protons, from which beam quality as well as the physical dose could be obtained. Taking advantage of the linear quadratic model and a modified version of the microdosimetric kinetic model, the microdosimetric data were combined with radiobiological parameters (α and β) of human salivary gland tumor cells for assessing cell survival RBE and RBE-weighted dose. The results indicate that if a dose of 60 Gy is delivered to the peak, the beam edge receives up to 6 Gy while the close and far out-of-field regions receive doses on the order of 10^-3 Gy and 10^-4 Gy, respectively. The RBE estimate in-beam shows large variations, ranging from 1.0 ± 0.2 at the entrance channel to 2.51 ± 0.15 at the tail. The beam edge follows a similar trend but the RBE calculated at the Bragg peak depth is 2.27 ± 0.17, i.e. twice the RBE in-beam (1.05 ± 0.15). Out-of-field, the estimated RBE is always significantly higher than 1.1 and increases with increasing lateral distance, reaching the overall highest value of 3.4 ± 0.3 at a depth of 206 mm and a lateral distance of 10 mm. The combination of RBE and dose into the biological dose points to the beam edge and the end-of-range in-beam as the areas with the highest risk of potential toxicities.

Clinical commissioning of intensity-modulated proton therapy systems: Report of AAPM Task Group 185

Proton therapy is an expanding radiotherapy modality in the United States and worldwide. With the number of proton therapy centers treating patients increasing, so does the need for consistent, high-quality clinical commissioning practices. Clinical commissioning encompasses the entire proton therapy system's multiple components, including the treatment delivery system, the patient positioning system, and the image-guided radiotherapy components. Also included in the commissioning process are the x-ray computed tomography scanner calibration for proton stopping power, the radiotherapy treatment planning system, and corresponding portions of the treatment management system. This commissioning report focuses exclusively on intensity-modulated scanning systems, presenting details of how to perform the commissioning of the proton therapy and ancillary systems, including the required proton beam measurements, treatment planning system dose modeling, and the equipment needed.