An on-site dosimetry audit for high-energy electron beams

Intraoperative electron beam intercomparison of 6 sites using mailed thermoluminescence dosimetry: Absolute dose and energy

PURPOSE

In 2018, the Netherlands Commission on Radiation Dosimetry subcommittee on IORT initiated a limited intercomparison of electron IORT (IOERT) in Belgium and The Netherlands. The participating institutions have enough variability in age, type of equipment, and in dose calibration protocols.

METHODS

In this study, three types of IOERT-dedicated mobile accelerators were represented: Mobetron 2000, LIAC HWL and LIAC. Mobetron produces electron beams with energies of 6, 9 and 12 MeV, while LIAC HWL and LIAC can deliver 6, 8, 10 and 12 MeV electron beams. For all energies, the reference beam (10 cm diameter, 0° incidence) and 5 cm diameter beams were measured, as these smaller beams are used more frequently in clinic. The mailed TLD service from the Radiation Dosimetry Services (RDS, Houston, USA) has been used. Following RDS' standard procedures, each beam was irradiated to 300 cGy at dmax with TLDs around dmax and around depth of 50 % dose (R50). Absolute dose at 100 % and beam energy, expressed as R50, could be verified in this way.

RESULTS

All absolute doses and energies under reference conditions were well within RDS-stated uncertainties: dose deviations were <5 % and deviations in R50 were <5 mm. For the small 5 cm beams, all results were also within acceptance levels except one absolute dose value. Deviations were not significantly dependent on manufacturer, energy, diameter and calibration protocol.

CONCLUSIONS

All absolute dose values, except one of a non-reference beam, and all energy values were well within the measurement accuracy of RDS TLDs.

IAEA/WHO postal dosimetry audit methodology for electron beams using radio photoluminescent dosimeters

BACKGROUND

Independent dosimetry audits are an important intervention in radiotherapy for quality assurance. Electron beams, used for superficial radiotherapy treatments, must also be tested in dosimetry audits as part of a good quality assurance program to help prevent clinical errors.

PURPOSE

To establish a new service for IAEA/WHO postal dosimetry audits in electron beams using RPL dosimeters.

METHODS

A novel postal audit methodology employing a PMMA holder system for RPLDs was developed. The associated correction factors including holder dependence, energy dependence, dose response non-linearity, and fading were obtained and tested in a multi-center (n = 12) pilot study. A measurement uncertainty budget was estimated and employed in analyzing the irradiated dosimeters.

RESULTS

Holder and energy correction factors ranged from 1.004 to 1.010 and 1.019 to 1.059 respectively across the energy range. The non-linearity and fading correction models used for photon beams were tested in electron beams and did not significantly increase measurement uncertainty. The mean dose ratio ± SD of the multi-center study was 1.001 ± 0.011. The overall uncertainty budget was estimated as ± 1.42% (k = 1).

CONCLUSIONS

A methodology for IAEA/WHO postal dosimetry audits in electron beams was developed and validated in a multi-center study and is now made available to radiotherapy centers as a routine service.

The QuADRANT study: Current status and recommendations for improving uptake and implementation of clinical audit of medical radiological procedures in Europe. The radiotherapy perspective

BACKGROUND

QuADRANT was a research project funded by the European Commission to evaluate clinical audit uptake and implementation across Europe, with an emphasis on clinical audit as mandated within the BSSD (Basic Safety Standards Directive).

AIM

Focusing on the QuADRANT objectives - to obtain an overview of European clinical audit activity; identify good practices, resources, barriers and challenges; provide guidance and recommendations going forwards; identify the potential for European Union action on quality and safety focusing on the field of radiotherapy.

RESULTS

A pan-European survey, expert interviews and a literature review conducted within the framework of the QuADRANT project indicated that developments in national clinical audit infrastructure are required. While in radiotherapy, there is a strong tradition and high level of experience of dosimetry audits and well-established practice through the IAEA's QUATRO audits, few countries have a well-established comprehensive clinical audit programme or international/national initiatives on tumour specific clinical audits. Even if sparse, the experience from countries with established system of quality audits can be used as role-models for national professional societies to promote clinical audit implementation. However, resource allocation and national prioritisation of clinical audit are needed in many countries. National and international societies should take the initiative to promote and facilitate training and resources (guidelines, experts, courses) for clinical audits. Enablers used to enhance clinical audit participation are not widely employed. Development of hospital accreditation programmes can facilitate clinical audit uptake. An active and formalised role for patients in clinical audit practice and policy development is recommended. Because there is a persisting variation in European awareness of BSSD clinical audit requirements, work is needed to improve dissemination of information on the legislative requirements relating to clinical audit in the BSSD and in relation to inspection processes. The aim is to ensure these include clinical audit and that they encompass all clinics and specialties involved in medical applications using ionising radiation.

CONCLUSION

QuADRANT provided an overarching view of clinical audit practice in Europe, with all its related aspects. Unfortunately, it showed that the awareness of the BSSD requirements for clinical audit are highly variable. Therefore, there is an urgent need to dedicate efforts towards ensuring that regulatory inspections also incorporate an assessment of clinical audit program(s), affecting all aspects of clinical work and specialties involved in patient exposure to ionising radiation.

Comparison of Dosimetry Protocols for Electron Beam Radiotherapy Calibrations and Measurement Uncertainties

This paper presents guidelines for the calibration of radiation beams that were issued by the International Atomic Energy Agency (IAEA TRS 398), the American Association of Physicists in Medicine (AAPM TG 51) and the German task group (DIN 6800-2). These protocols are based on the use of an ionization chamber calibrated in terms of absorbed dose to water in a standard laboratory’s reference quality beam, where the previous protocols were based on air kerma standards. This study aims to determine uncertainties in dosimetry for electron beam radiotherapy using internationally established high-energy radiotherapy beam calibration standards. Methods: D_w was determined in 6-, 12- and 18 MeV electron energies under reference conditions using three cylindrical and two plane-parallel ion chambers in concert with the IAEA TRS 398, AAPM TG 51 and DIN 6800-2 absorbed dose protocols. From mean measured D_w values, the ratio TRS 398/TG 51 was found to vary between 0.988 and 1.004, while for the counterpart TRS 398/DIN 6800-2 and TG 51/DIN 6800-2, the variation ranges were 0.991–1.003 and 0.997–1.005, respectively. For the cylindrical chambers, the relative combined uncertainty (k = 1) in absorbed dose measurements was 1.44%, while for the plane-parallel chambers, it ranged from 1.53 to 1.88%. Conclusions: A high degree of consistency was demonstrated among the three protocols. It is suggested that in the use of the presently determined dose conversion factors across the three protocols, dose intercomparisons can be facilitated between radiotherapy centres.

Dosimetric end-to-end tests in a national audit of 3D conformal radiotherapy

BACKGROUND AND PURPOSE

Independent dosimetry audits improve quality and safety of radiation therapy. This work reports on design and findings of a comprehensive 3D conformal radiotherapy (3D-CRT) Level III audit.

MATERIALS AND METHODS

The audit was conducted as onsite audit using an anthropomorphic thorax phantom in an end-to-end test by the Australian Clinical Dosimetry Service (ACDS). Absolute dose point measurements were performed with Farmer-type ionization chambers. The audited treatment plans included open and half blocked fields, wedges and lung inhomogeneities. Audit results were determined as Pass Optimal Level (deviations within 3.3%), Pass Action Level (greater than 3.3% but within 5%) and Out of Tolerance (beyond 5%), as well as Reported Not Scored (RNS). The audit has been performed between July 2012 and January 2018 on 94 occasions, covering approximately 90% of all Australian facilities.

RESULTS

The audit pass rate was 87% (53% optimal). Fifty recommendations were given, mainly related to planning system commissioning. Dose overestimation behind low density inhomogeneities by the analytical anisotropic algorithm (AAA) was identified across facilities and found to extend to beam setups which resemble a typical breast cancer treatment beam placement. RNS measurements inside lung showed a variation in the opposite direction: AAA under-dosed a target beyond lung and over-dosed the lung upstream and downstream of the target. Results also highlighted shortcomings of some superposition and convolution algorithms in modelling large angle wedges.

CONCLUSIONS

This audit showed that 3D-CRT dosimetry audits remain relevant and can identify fundamental global and local problems that also affect advanced treatments.