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Cases C, Oses G, Herreros A, Tarrats-Rosell J, Moreno S, Mollà M. On the need of in vivo verifications as quality control for intraoperative electron radiotherapy in breast cancer. Clin Transl Oncol 2024; 26:1623-1629. [PMID: 38267659 DOI: 10.1007/s12094-023-03378-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 12/20/2023] [Indexed: 01/26/2024]
Abstract
INTRODUCTION Intraoperative electron radiotherapy (IOERT) is a technique aiming to deliver radiotherapy during oncological surgery. In breast IOERT, the applicator and shielding disc placement are correlated with organs at risk (OAR) irradiation, in vivo verification of these parameters is scarcely reported. The aim of our study is to report and analyze possible causes of the misalignment using radiochromic films and compare our results to others reported in the bibliography. METHODS From November 2019 to April 2023, in vivo verifications were performed for 33 patients. IOERT was performed using a LIAC 10 MeV (Sordina, Italy) electron accelerator. We attached a radiochromic film to the upper side of the polytetrafluoroethylene cover of the shielding disc. The percentage of the irradiation area outside the disc was recorded and various parameters (applicator angulations, prescription depth, tumor location and breast size) were analyzed to find possible correlations. RESULTS For 29 patients, 20 Gy were prescribed while 10 Gy were prescribed to 4 patients. The average irradiated area outside the disc was 19% (0-56%) corresponding to a surface of 4.5 cm2 (0-17.4 cm2). The applicator of 5 cm was used for most of the patients. The mean prescription depth was 1.4 cm (0.5-2.5 cm). We found no correlation between the analyzed parameters and misalignment. CONCLUSION This study confirms the presence and magnitude of the misalignments. We strongly recommend in vivo verifications as a quality check during IOERT procedures. The misalignment has no correlation with tumor localization parameters, so the solution could be based on technical improvements of the applicator.
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Affiliation(s)
- Carla Cases
- Department of Radiation Oncology, Hospital Clínic, Carrer de Villarroel 170, 08036, Barcelona, Spain.
| | - Gabriela Oses
- Department of Radiation Oncology, Hospital Clínic, Carrer de Villarroel 170, 08036, Barcelona, Spain
| | - Antonio Herreros
- Department of Radiation Oncology, Hospital Clínic, Carrer de Villarroel 170, 08036, Barcelona, Spain
- Department of Clinical Foundations, University of Barcelona, Barcelona, Spain
| | - Jordi Tarrats-Rosell
- Department of Radiation Oncology, Hospital Clínic, Carrer de Villarroel 170, 08036, Barcelona, Spain
| | - Sara Moreno
- Department of Radiation Oncology, Hospital Clínic, Carrer de Villarroel 170, 08036, Barcelona, Spain
| | - Meritxell Mollà
- Department of Radiation Oncology, Hospital Clínic, Carrer de Villarroel 170, 08036, Barcelona, Spain
- Department of Clinical Foundations, University of Barcelona, Barcelona, Spain
- Translational Genomics and Targeted Therapies in Solid Tumors, Institute for Biomedical Research August Pi i Sunyer (IDIBAPS), Barcelona, Spain
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Baghani HR, Robatjazi M. Evaluating the induced photon contamination by different breast IOERT shields using Monte Carlo simulation. J Appl Clin Med Phys 2023; 24:e14098. [PMID: 37461859 PMCID: PMC10647956 DOI: 10.1002/acm2.14098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 06/25/2023] [Accepted: 07/05/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Avoiding the underlying healthy tissue over-exposure during breast intraoperative electron radiotherapy (IOERT) is owing to the use of some dedicated radioprotection disks during patient irradiation. The originated contaminant photons from some widely used double-layered shielding disks including PMMA+Cu, PTFE+steel, and Al+Pb configurations during the breast IOERT have been evaluated through a Monte Carlo (MC) simulation approach. METHODS Produced electron beam with energies of 6, 8, 10, and 12 MeV by a validated MC model of Liac12 dedicated IOERT accelerator was used for disk irradiations. Each of above-mentioned radioprotection disks was simulated inside a water phantom, so that the upper disk surface was positioned at R90 depth of each considered electron energy. Simulations were performed by MCNPX (version 2.6.0) MC code. Then, the energy spectra of the contaminant photons at different disk surfaces (upper, middle, and lower one) and relevant contaminant dose beneath the studied disks were determined and compared. RESULTS None of studied shielding disks show significant photon contamination up to 10 MeV electron energy, so that the induced photon dose by the contaminant X-rays was lower than those observed in the disk absence under the same conditions. In return, the induced photon dose at a close distance to the lower disk surface exceeded from calculated values in the disk absence at 12 MeV electron energy. The best performance in contaminant dose reduction at the energy range of 6-10 MeV belonged to the Al+Pb disk, while the PMMA+Cu configuration showed the best performance in this regard at 12 MeV energy. CONCLUSION Finally, it can be concluded that all studied shielding disks not only don't produce considerable photon contamination but also absorb the originated X-rays from electron interactions with water at the electron energy range of 6-10 MeV. The only concern is related to 12 MeV energy where the induced photon dose exceeds the dose values in the disk absence. Nevertheless, the administered dose by contaminant photons to underlying healthy tissues remains beneath the tolerance dose level by these organs at the entire range of studied electron energies.
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Affiliation(s)
| | - Mostafa Robatjazi
- Medical Physics and Radiological Sciences DepartmentSabzevar University of Medical SciencesSabzevarIran
- Non‐communicable Disease Research CenterSabzevar University of Medical SciencesSabzevarIran
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Petoukhova A, Snijder R, Vissers T, Ceha H, Struikmans H. In vivodosimetry in cancer patients undergoing intraoperative radiation therapy. Phys Med Biol 2023; 68:18TR01. [PMID: 37607566 DOI: 10.1088/1361-6560/acf2e4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 08/22/2023] [Indexed: 08/24/2023]
Abstract
In vivodosimetry (IVD) is an important tool in external beam radiotherapy (EBRT) to detect major errors by assessing differences between expected and delivered dose and to record the received dose by individual patients. Also, in intraoperative radiation therapy (IORT), IVD is highly relevant to register the delivered dose. This is especially relevant in low-risk breast cancer patients since a high dose of IORT is delivered in a single fraction. In contrast to EBRT, online treatment planning based on intraoperative imaging is only under development for IORT. Up to date, two commercial treatment planning systems proposed intraoperative ultrasound or in-room cone-beam CT for real-time IORT planning. This makes IVD even more important because of the possibility for real-time treatment adaptation. Here, we summarize recent developments and applications of IVD methods for IORT in clinical practice, highlighting important contributions and identifying specific challenges such as a treatment planning system for IORT. HDR brachytherapy as a delivery technique was not considered. We add IVD for ultrahigh dose rate (FLASH) radiotherapy that promises to improve the treatment efficacy, when compared to conventional radiotherapy by limiting the rate of toxicity while maintaining similar tumour control probabilities. To date, FLASH IORT is not yet in clinical use.
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Affiliation(s)
- Anna Petoukhova
- Haaglanden Medical Centre , Department of Medical Physics, Leidschendam, The Netherlands
| | - Roland Snijder
- Haaglanden Medical Centre , Department of Medical Physics, Leidschendam, The Netherlands
| | - Thomas Vissers
- Haaglanden Medical Centre , Medical Library, Leidschendam, The Netherlands
| | - Heleen Ceha
- Haaglanden Medical Centre , Department of Radiation Oncology, Leidschendam, The Netherlands
| | - Henk Struikmans
- Haaglanden Medical Centre , Department of Radiation Oncology, Leidschendam, The Netherlands
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Lozares-Cordero S, Bermejo-Barbanoj C, Badías-Herbera A, Ibáñez-Carreras R, Ligorred-Padilla L, Ponce-Ortega JM, González-Pérez V, Gandía-Martínez A, Font-Gómez JA, Blas-Borroy O, González-Ibáñez D. An open-source development based on photogrammetry for a real-time IORT treatment planning system. Phys Med 2023; 112:102622. [PMID: 37331081 DOI: 10.1016/j.ejmp.2023.102622] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 06/02/2023] [Accepted: 06/06/2023] [Indexed: 06/20/2023] Open
Abstract
PURPOSE This study presents a treatment planning system for intraoperative low-energy photon radiotherapy based on photogrammetry from real images of the surgical site taken in the operating room. MATERIAL AND METHODS The study population comprised 15 patients with soft-tissue sarcoma. The system obtains the images of the area to be irradiated with a smartphone or tablet, so that the absorbed doses in the tissue can be calculated from the reconstruction without the need for computed tomography. The system was commissioned using 3D printing of the reconstructions of the tumor beds. The absorbed doses at various points were verified using radiochromic films that were suitably calibrated for the corresponding energy and beam quality. RESULTS The average reconstruction time of the 3D model from the video sequence in the 15 patients was 229,6±7,0 s. The entire procedure, including video capture, reconstruction, planning, and dose calculation was 520,6±39,9 s. Absorbed doses were measured on the 3D printed model with radiochromic film, the differences between these measurements and those calculated by the treatment planning system were 1.4% at the applicator surface, 2.6% at 1 cm, 3.9% at 2 cm and 6.2% at 3 cm. CONCLUSIONS The study shows a photogrammetry-based low-energy photon IORT planning system, capable of obtaining real-time images inside the operating room, immediately after removal of the tumor and immediately before irradiation. The system was commissioned with radiochromic films measurements in 3D-printed model.
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Affiliation(s)
- Sergio Lozares-Cordero
- Physics and Radiation Protection Department, Miguel Servet University Hospital, Zaragoza, Spain.
| | | | - Alberto Badías-Herbera
- Higher Technical School of Industrial Engineering, Polytechnic University of Madrid, Spain
| | | | - Luis Ligorred-Padilla
- Esophagogastric Surgery and Sarcoma Unit (Department of General and Gastrointestinal Surgery), Miguel Servet University Hospital, Zaragoza, Spain
| | | | | | | | - José Antonio Font-Gómez
- Physics and Radiation Protection Department, Miguel Servet University Hospital, Zaragoza, Spain
| | - Olga Blas-Borroy
- Engineering and Maintenance Service, Miguel Servet University Hospital, Zaragoza, Spain
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5
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Investigation of isotropic radiation of low energy X-ray intra-operative radiotherapy by MAGAT gel dosimeter. Radiat Phys Chem Oxf Engl 1993 2021. [DOI: 10.1016/j.radphyschem.2021.109648] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Lozares S, Font JA, Gandía A, Campos A, Flamarique S, Ibáñez R, Villa D, Alba V, Jiménez S, Hernández M, Casamayor C, Vicente I, Hernando E, Rubio P. In vivo dosimetry in low-voltage IORT breast treatments with XR-RV3 radiochromic film. Phys Med 2021; 81:173-181. [PMID: 33465753 DOI: 10.1016/j.ejmp.2020.12.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 12/12/2020] [Accepted: 12/16/2020] [Indexed: 12/30/2022] Open
Abstract
PURPOSE The objectives of the study were to establish a procedure for in vivo film-based dosimetry for intraoperative radiotherapy (IORT), evaluate the typical doses delivered to organs at risk, and verify the dose prescription. MATERIALS AND METHODS In vivo dose measurements were studied using XR-RV3 radiochromic films in 30 patients with breast cancer undergoing IORT using the Axxent® device (Xoft Inc.). The stability of the radiochromic films in the energy ranges used was verified by taking measurements at different depths. The stability of the scanner response was tested, and 5 different calibration curves were constructed for different beam qualities. Six pieces of film were placed in each of the 30 patients. All the pieces were correctly sterilized and checked to ensure that the process did not affect the outcome. All calibration and dose measurements were analyzed using the Radiochromic.com software application. RESULTS The doses were measured for 30 patients. The doses in contact with the applicator (prescription zone) were 19.8 ± 0.9 Gy. In the skin areas, the doses were as follows: 1-2 cm from the applicator, 1.86 ± 0.77 Gy; 2-5 cm, 0.73 ± 0.14 Gy; and greater than 5 cm, 0.28 ± 0.17 Gy. The dose delivered to the pectoral muscle (tungsten shielding disc) was 0.51 ± 0.27 Gy. CONCLUSIONS The study demonstrated the viability of XR-RV3 films for in vivo dose measurement in the dose and energy ranges applied in a complex procedure, such as breast IORT. The doses in organs at risk were far below the tolerances for cases such as those studied.
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Affiliation(s)
- Sergio Lozares
- Medical Physics Department. Miguel Servet University Hospital Zaragoza, Spain.
| | - Jose A Font
- Medical Physics Department. Miguel Servet University Hospital Zaragoza, Spain
| | - Almudena Gandía
- Medical Physics Department. Miguel Servet University Hospital Zaragoza, Spain
| | - Arantxa Campos
- Radiation Oncology Department. Miguel Servet University Hospital Zaragoza, Spain
| | - Sonia Flamarique
- Radiation Oncology Department. Miguel Servet University Hospital Zaragoza, Spain
| | - Reyes Ibáñez
- Radiation Oncology Department. Miguel Servet University Hospital Zaragoza, Spain
| | - David Villa
- Medical Physics Department. Miguel Servet University Hospital Zaragoza, Spain
| | - Verónica Alba
- Medical Physics Department. Miguel Servet University Hospital Zaragoza, Spain
| | - Sara Jiménez
- Medical Physics Department. Miguel Servet University Hospital Zaragoza, Spain
| | - Mónica Hernández
- Medical Physics Department. Miguel Servet University Hospital Zaragoza, Spain
| | - Carmen Casamayor
- Endocrine, Bariatric and Breast Surgery Unit. General and Digestive Surgery Department. Miguel Servet University Hospital Zaragoza, Spain
| | - Isabel Vicente
- Breast Unit. Gynaecology Department. Miguel Servet University Hospital Zaragoza, Spain
| | - Ernesto Hernando
- Endocrine, Bariatric and Breast Surgery Unit. General and Digestive Surgery Department. Miguel Servet University Hospital Zaragoza, Spain
| | - Patricia Rubio
- Breast Unit. Gynaecology Department. Miguel Servet University Hospital Zaragoza, Spain
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Zoljalali Moghaddam SH, Baghani HR, Mahdavi SR. Construction and performance evaluation of a buildup bolus for breast intraoperative electron radiotherapy. Radiat Phys Chem Oxf Engl 1993 2020. [DOI: 10.1016/j.radphyschem.2020.108952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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8
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Avanzo M, Dassie A, Chandra Acharya P, Chiovati P, Pirrone G, Avigo C, Barresi L, Dang Quoc S, Fiagbedzi E, Navarria F, Palazzari E, Bertola G, De Paoli A, Stancanello J, Sartor G. Electron radiotherapy (IOERT) for applications outside of the breast: Dosimetry and influence of tissue inhomogeneities. Phys Med 2020; 69:82-89. [PMID: 31841774 DOI: 10.1016/j.ejmp.2019.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 11/17/2019] [Accepted: 12/04/2019] [Indexed: 12/12/2022] Open
Abstract
PURPOSE The purpose of study is to investigate the dosimetry of electron intraoperative radiotherapy (IOERT) of the Intraop Mobetron 2000 mobile LINAC in treatments outside of the breast. After commissioning and external validation of dosimetry, we report in vivo results of measurements for treatments outside the breast in a large patient cohort, and investigate if the presence of inhomogeneities can affect in vivo measurements. METHODS AND MATERIALS Applicator factors and profile curves were measured with a stereotactic diode. The applicators factors of the 6 cm flat and beveled applicators were also confirmed with radiochromic films, parallel-plate ion chamber and by an external audit performed with ThermoLuminescent Dosimeters (TLDs). The influence of bone on dose was investigated by using radiochromic films attached to an insert equivalent to cortical bone, immersed in the water phantom. In vivo dosimetry was performed on 126 patients treated with IOERT using metal oxide-silicon semiconductor field effect transistors (MOSFETs) placed on the tumor bed. RESULTS Relatively small differences were found among different detectors for measurements of applicator factors. In the external audit, the agreement with the TLD was mostly within ±0.2%. The largest increase of dose due to the presence of cortical bone insert was +6.0% with energy 12 MeV and 3 cm applicator. On average, in vivo dose was significantly (+3.1%) larger than prescribed dose. CONCLUSION IOERT in applications outside the breast results in low discrepancies between in vivo and prescribed doses, which can be also explained with the presence of tissue inhomogeneity.
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Affiliation(s)
- Michele Avanzo
- Department of Medical Physics, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, 33081 Aviano, Italy.
| | - Andrea Dassie
- Department of Medical Physics, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, 33081 Aviano, Italy
| | | | - Paola Chiovati
- Department of Medical Physics, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, 33081 Aviano, Italy
| | - Giovanni Pirrone
- Department of Medical Physics, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, 33081 Aviano, Italy
| | - Cinzia Avigo
- Medical Physics, ULSS 1 Dolomiti- S. Martino Hospital, Medical Physics Department, Belluno, Italy
| | - Loredana Barresi
- Department of Medical Physics, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, 33081 Aviano, Italy
| | - Soai Dang Quoc
- Medicinal Supplies, Medical Physics Division, Hanoi Oncology Hospital, Hanoi, Vietnam
| | | | - Federico Navarria
- Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, 33081 Aviano, Italy
| | - Elisa Palazzari
- Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, 33081 Aviano, Italy
| | - Giulio Bertola
- Surgical Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, 33081 Aviano, Italy
| | - Antonino De Paoli
- Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, 33081 Aviano, Italy
| | | | - Giovanna Sartor
- Department of Medical Physics, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, 33081 Aviano, Italy
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A Plasma Focus device as ultra-high dose rate pulsed radiation source. Part I: Primary electron beam characterization. Radiat Phys Chem Oxf Engl 1993 2019. [DOI: 10.1016/j.radphyschem.2019.02.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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10
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Baghani HR, Robatjazi M, Mahdavi SR, Nafissi N, Akbari ME. Breast intraoperative electron radiotherapy: Image-based setup verification and in-vivo dosimetry. Phys Med 2019; 60:37-43. [PMID: 31000084 DOI: 10.1016/j.ejmp.2019.03.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 02/25/2019] [Accepted: 03/19/2019] [Indexed: 10/27/2022] Open
Abstract
INTRODUCTION Single fraction nature of intraoperative radiotherapy highly demands a quality assurance procedure to qualify both beam setup and treatment delivery. The aim of this study is to evaluate the treatment setup during breast intraoperative electron radiotherapy (IOERT) and in-vivo dose delivery verification. MATERIALS AND METHODS Twenty-five breast cancer patients were enrolled and setup verification for each case was performed using C-arm imaging. The received dose by surface and distal end of target was measured by EBT2 film. The significance level of difference between obtained dosimetry results and predicted ones was evaluated by the T statistical test. RESULTS Acquired C-arm images in two different oblique views revealed any misalignment between the applicator and shielding disk. The mean difference between the measured surface dose and expected one was 1.8% ± 1.2 (p = 0.983) while a great disagreement, 11.1% ± 1.5 (p < 0.001), was observed between the measured distal end dose and expected one. This discrepancy is mainly correlated to the backscattering effect from the shielding disk. Target depth nonuniformities can also contribute to this remarkable difference. CONCLUSION Employing the intraoperative imaging for IOERT setup verification can considerably improve the treatment quality. Therefore, it is suggested to implement this imaging procedure as a part of treatment quality assurance. Favorable agreement between the predicted and measured surface doses demonstrates the applicability of EBT2 film for dose delivery verification. The results of in-vivo dosimetry showed that the electron backscattering from employed shielding disk can affect the received dose by the distal end of tumor bed.
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Affiliation(s)
- Hamid Reza Baghani
- Physics Department, Hakim Sabzevari University, Shohada-e Hastei Blvd, P.O. 9617976487, Sabzevar, Iran.
| | - Mostafa Robatjazi
- Department of Medical Physics and Radiological Sciences, Sabzevar University of Medical Sciences, Shohada-e Hastei Blvd, Sabzevar University of Medical Sciences Campus, P.O. 9617913112, Sabzevar, Iran; Vasei Radiotherapy & Oncology Center, Vasei Hospital, P.O. 9617913113, Sabzevar, Iran.
| | - Seied Rabi Mahdavi
- Department of Medical Physics, Iran University of Medical Sciences. Hemmat Exp. Way, Faculty of Medicine, P.O. 14496141525, Tehran, Iran
| | - Nahid Nafissi
- Department of Breast Surgery, Iran University of Medical Sciences. Hemmat Exp. Way, Faculty of Medicine, P.O. 14496141525, Tehran, Iran
| | - Mohammad Esmail Akbari
- Cancer Research Center, Shahid Beheshti University of Medical Sciences, Shohadaye Tajrrish Hospital, Tajrish Sq., P.O. 19996 14414, Tehran, Iran
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García-Vázquez V, Sesé-Lucio B, Calvo FA, Vaquero JJ, Desco M, Pascau J. Surface scanning for 3D dose calculation in intraoperative electron radiation therapy. Radiat Oncol 2018; 13:243. [PMID: 30526626 PMCID: PMC6286593 DOI: 10.1186/s13014-018-1181-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 11/12/2018] [Indexed: 02/03/2023] Open
Abstract
Background Dose calculations in intraoperative electron radiation therapy (IOERT) rely on the conventional assumption of water-equivalent tissues at the applicator end, which defines a flat irradiation surface. However, the shape of the irradiation surface modifies the dose distribution. Our study explores, for the first time, the use of surface scanning methods for three-dimensional dose calculation of IOERT. Methods Two different three-dimensional scanning technologies were evaluated in a simulated IOERT scenario: a tracked conoscopic holography sensor (ConoProbe) and a structured-light three-dimensional scanner (Artec). Dose distributions obtained from computed tomography studies of the surgical field (gold standard) were compared with those calculated under the conventional assumption or from pseudo-computed tomography studies based on surfaces. Results In the simulated IOERT scenario, the conventional assumption led to an average gamma pass rate of 39.9% for dose values greater than 10% (two configurations, with and without blood in the surgical field). Results improved when considering surfaces in the dose calculation (88.5% for ConoProbe and 92.9% for Artec). Conclusions More accurate three-dimensional dose distributions were obtained when considering surfaces in the dose calculation of the simulated surgical field. The structured-light three-dimensional scanner provided the best results in terms of dose distributions. The findings obtained in this specific experimental setup warrant further research on surface scanning in the IOERT context owing to the clinical interest of improving the documentation of the actual IOERT scenario.
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Affiliation(s)
- Verónica García-Vázquez
- Instituto de Investigación Sanitaria Gregorio Marañón. Calle Doctor Esquerdo, 46, 28007, Madrid, Spain.
| | - Begoña Sesé-Lucio
- Instituto de Investigación Sanitaria Gregorio Marañón. Calle Doctor Esquerdo, 46, 28007, Madrid, Spain
| | - Felipe A Calvo
- Instituto de Investigación Sanitaria Gregorio Marañón. Calle Doctor Esquerdo, 46, 28007, Madrid, Spain.,Departamento de Oncología, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain.,Clínica Universidad de Navarra, Madrid, Spain
| | - Juan J Vaquero
- Instituto de Investigación Sanitaria Gregorio Marañón. Calle Doctor Esquerdo, 46, 28007, Madrid, Spain.,Departamento de Bioingeniería e Ingeniería Aeroespacial, Universidad Carlos III de Madrid, Madrid, Spain
| | - Manuel Desco
- Instituto de Investigación Sanitaria Gregorio Marañón. Calle Doctor Esquerdo, 46, 28007, Madrid, Spain.,Departamento de Bioingeniería e Ingeniería Aeroespacial, Universidad Carlos III de Madrid, Madrid, Spain.,Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain.,Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain
| | - Javier Pascau
- Instituto de Investigación Sanitaria Gregorio Marañón. Calle Doctor Esquerdo, 46, 28007, Madrid, Spain.,Departamento de Bioingeniería e Ingeniería Aeroespacial, Universidad Carlos III de Madrid, Madrid, Spain.,Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain
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In vivo dosimetry with MOSFETs and GAFCHROMIC films during electron IORT for Accelerated Partial Breast Irradiation. Phys Med 2017; 44:26-33. [DOI: 10.1016/j.ejmp.2017.11.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Revised: 10/19/2017] [Accepted: 11/04/2017] [Indexed: 11/22/2022] Open
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Heidarloo N, Baghani HR, Aghamiri SMR, Mahdavi SR, Akbari ME. Commissioning of beam shaper applicator for conformal intraoperative electron radiotherapy. Appl Radiat Isot 2017; 123:69-81. [DOI: 10.1016/j.apradiso.2017.02.039] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Revised: 02/04/2017] [Accepted: 02/23/2017] [Indexed: 11/27/2022]
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Abstract
Literature was reviewed to assess the physical aspects governing the present and emerging technologies used in intraoperative radiation therapy (IORT). Three major technologies were identified: treatment with electrons, treatment with external generators of kV X-rays and electronic brachytherapy. Although also used in IORT, literature on brachytherapy with radioactive sources is not systematically reviewed since an extensive own body of specialized literature and reviews exists in this field. A comparison with radioactive sources is made in the use of balloon catheters for partial breast irradiation where these are applied in almost an identical applicator technique as used with kV X-ray sources. The physical constraints of adaption of the dose distribution to the extended target in breast IORT are compared. Concerning further physical issues, the literature on radiation protection, commissioning, calibration, quality assurance (QA) and in-vivo dosimetry of the three technologies was reviewed. Several issues were found in the calibration and the use of dosimetry detectors and phantoms for low energy X-rays which require further investigation. The uncertainties in the different steps of dose determination were estimated, leading to an estimated total uncertainty of around 10-15% for IORT procedures. The dose inhomogeneity caused by the prescription of electrons at 90% and by the steep dose gradient of kV X-rays causes additional deviations from prescription dose which must be considered in the assessment of dose response in IORT.
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Affiliation(s)
- Frank W Hensley
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
- , Present address: Birkenweg 35, 69221, Dossenheim, Germany.
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15
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Intraoperative Radiotherapy with Electrons (ELIOT). Breast Cancer 2017. [DOI: 10.1007/978-3-319-48848-6_56] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Costa F, Sarmento S, Gomes D, Magalhães H, Arrais R, Moreira G, Cruz MF, Silva JP, Santos L, Sousa O. In vivo dosimetry using Gafchromic films during pelvic intraoperative electron radiation therapy (IOERT). Br J Radiol 2016; 89:20160193. [PMID: 27188847 DOI: 10.1259/bjr.20160193] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To characterize in vivo dose distributions during pelvic intraoperative electron radiation therapy (IOERT) for rectal cancer and to assess the alterations introduced by irregular irradiation surfaces in the presence of bevelled applicators. METHODS In vivo measurements were performed with Gafchromic films during 32 IOERT procedures. 1 film per procedure was used for the first 20 procedures. The methodology was then optimized for the remaining 12 procedures by using a set of 3 films. Both the average dose and two-dimensional dose distributions for each film were determined. Phantom measurements were performed for comparison. RESULTS For flat and concave surfaces, the doses measured in vivo agree with expected values. For concave surfaces with step-like irregularities, measured doses tend to be higher than expected doses. Results obtained with three films per procedure show a large variability along the irradiated surface, with important differences from expected profiles. These results are consistent with the presence of surface hotspots, such as those observed in phantoms in the presence of step-like irregularities, as well as fluid build-up. CONCLUSION Clinical dose distributions in the IOERT of rectal cancer are often different from the references used for prescription. Further studies are necessary to assess the impact of these differences on treatment outcomes. In vivo measurements are important, but need to be accompanied by accurate imaging of positioning and irradiated surfaces. ADVANCES IN KNOWLEDGE These results confirm that surface irregularities occur frequently in rectal cancer IOERT and have a measurable effect on the dose distribution.
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Affiliation(s)
- Filipa Costa
- 1 Medical Physics, Radiobiology and Radiation Protection Group, IPO Porto Research Center (CI-IPOP), Portuguese Oncology Institute of Porto (IPO Porto), Porto, Portugal
| | - Sandra Sarmento
- 1 Medical Physics, Radiobiology and Radiation Protection Group, IPO Porto Research Center (CI-IPOP), Portuguese Oncology Institute of Porto (IPO Porto), Porto, Portugal.,2 Medical Physics Department, Portuguese Oncology Institute of Porto (IPO Porto), Porto, Portugal
| | - Dora Gomes
- 3 Radiation Oncology Department, Portuguese Oncology Institute of Porto (IPO Porto), Porto, Portugal
| | - Helena Magalhães
- 3 Radiation Oncology Department, Portuguese Oncology Institute of Porto (IPO Porto), Porto, Portugal
| | - Rosário Arrais
- 3 Radiation Oncology Department, Portuguese Oncology Institute of Porto (IPO Porto), Porto, Portugal
| | - Graciete Moreira
- 4 UCA, Portuguese Oncology Institute of Porto (IPO Porto), Porto, Portugal
| | - Maria Fátima Cruz
- 4 UCA, Portuguese Oncology Institute of Porto (IPO Porto), Porto, Portugal
| | - José Pedro Silva
- 5 Surgical Oncology Department, Portuguese Oncology Institute of Porto (IPO Porto), Porto, Portugal
| | - Lúcio Santos
- 5 Surgical Oncology Department, Portuguese Oncology Institute of Porto (IPO Porto), Porto, Portugal.,6 Experimental Pathology and Therapeutics Group, IPO Porto Research Center (CI-IPOP), Portuguese Oncology Institute of Porto (IPO Porto), Porto, Portugal
| | - Olga Sousa
- 3 Radiation Oncology Department, Portuguese Oncology Institute of Porto (IPO Porto), Porto, Portugal
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López-Tarjuelo J, Morillo-Macías V, Bouché-Babiloni A, Boldó-Roda E, Lozoya-Albacar R, Ferrer-Albiach C. Implementation of an intraoperative electron radiotherapy in vivo dosimetry program. Radiat Oncol 2016; 11:41. [PMID: 26980076 PMCID: PMC4793509 DOI: 10.1186/s13014-016-0621-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 03/11/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intraoperative electron radiotherapy (IOERT) is a highly selective radiotherapy technique which aims to treat restricted anatomic volumes during oncological surgery and is now the subject of intense re-evaluation. In vivo dosimetry has been recommended for IOERT and has been identified as a risk-reduction intervention in the context of an IOERT risk analysis. Despite reports of fruitful experiences, information about in vivo dosimetry in intraoperative radiotherapy is somewhat scarce. Therefore, the aim of this paper is to report our experience in developing a program of in vivo dosimetry for IOERT, from both multidisciplinary and practical approaches, in a consistent patient series. We also report several current weaknesses. METHODS Reinforced TN-502RDM-H mobile metal oxide semiconductor field effect transistors (MOSFETs) and Gafchromic MD-55-2 films were used as a redundant in vivo treatment verification system with an Elekta Precise fixed linear accelerator for calibrations and treatments. In vivo dosimetry was performed in 45 patients in cases involving primary tumors or relapses. The most frequent primary tumors were breast (37 %) and colorectal (29 %), and local recurrences among relapses was 83 %. We made 50 attempts to measure with MOSFETs and 48 attempts to measure with films in the treatment zones. The surgical team placed both detectors with supervision from the radiation oncologist and following their instructions. RESULTS The program was considered an overall success by the different professionals involved. The absorbed doses measured with MOSFETs and films were 93.8 ± 6.7 % and 97.9 ± 9.0 % (mean ± SD) respectively using a scale in which 90 % is the prescribed dose and 100 % is the maximum absorbed dose delivered by the beam. However, in 10 % of cases we experienced dosimetric problems due to detector misalignment, a situation which might be avoided with additional checks. The useful MOSFET lifetime length and the film sterilization procedure should also be controlled. CONCLUSIONS It is feasible to establish an in vivo dosimetry program for a wide set of locations treated with IOERT using a multidisciplinary approach according to the skills of the professionals present and the detectors used; oncological surgeons' commitment is key to success in this context. Films are more unstable and show higher uncertainty than MOSFETs but are cheaper and are useful and convenient if real-time treatment monitoring is not necessary.
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Affiliation(s)
- Juan López-Tarjuelo
- Servicio de Radiofísica y Protección Radiológica, Consorcio Hospitalario Provincial de Castellón, Avda. Dr. Clará, nº 19, Castellón de la Plana, 12004, Castellón, Spain.
| | - Virginia Morillo-Macías
- Servicio de Oncología Radioterápica, Consorcio Hospitalario Provincial de Castellón, Castellón de la Plana, Spain
- Unitat predepartamental de Medicina, Facultat de Ciències de la Salut, Universitat Jaume I, Avda. Vicent Sos Baynat, s/n, Castellón de la Plana, 12071, Castellón, Spain
| | - Ana Bouché-Babiloni
- Servicio de Oncología Radioterápica, Consorcio Hospitalario Provincial de Castellón, Castellón de la Plana, Spain
| | - Enrique Boldó-Roda
- Unidad de Cirugía Oncológica, Servicio de Cirugía, Consorcio Hospitalario Provincial de Castellón, Castellón de la Plana, Spain
| | - Rafael Lozoya-Albacar
- Unidad de Cirugía Oncológica, Servicio de Cirugía, Consorcio Hospitalario Provincial de Castellón, Castellón de la Plana, Spain
| | - Carlos Ferrer-Albiach
- Servicio de Oncología Radioterápica, Consorcio Hospitalario Provincial de Castellón, Castellón de la Plana, Spain
- Departamento de Medicina y Cirugía, Facultad de Ciencias de la Salud, Universidad Cardenal Herrera-CEU, C/ Grecia 31, Castellón de la Plana, 12006, Castellón, Spain
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Assessment of clinically relevant dose distributions in pelvic IOERT using Gafchromic EBT3 films. Phys Med 2015; 31:692-701. [DOI: 10.1016/j.ejmp.2015.05.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 05/06/2015] [Accepted: 05/20/2015] [Indexed: 11/21/2022] Open
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Liuzzi R, Savino F, D’Avino V, Pugliese M, Cella L. Evaluation of LiF:Mg,Ti (TLD-100) for Intraoperative Electron Radiation Therapy Quality Assurance. PLoS One 2015; 10:e0139287. [PMID: 26427065 PMCID: PMC4591127 DOI: 10.1371/journal.pone.0139287] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 09/09/2015] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Purpose of the present work was to investigate thermoluminescent dosimeters (TLDs) response to intraoperative electron radiation therapy (IOERT) beams. In an IOERT treatment, a large single radiation dose is delivered with a high dose-per-pulse electron beam (2-12 cGy/pulse) during surgery. To verify and to record the delivered dose, in vivo dosimetry is a mandatory procedure for quality assurance. The TLDs feature many advantages such as a small detector size and close tissue equivalence that make them attractive for IOERT as in vivo dosimeters. METHODS LiF:Mg,Ti dosimeters (TLD-100) were irradiated with different IOERT electron beam energies (5, 7 and 9 MeV) and with a 6 MV conventional photon beam. For each energy, the TLDs were irradiated in the dose range of 0-10 Gy in step of 2 Gy. Regression analysis was performed to establish the response variation of thermoluminescent signals with dose and energy. RESULTS The TLD-100 dose-response curves were obtained. In the dose range of 0-10 Gy, the calibration curve was confirmed to be linear for the conventional photon beam. In the same dose region, the quadratic model performs better than the linear model when high dose-per-pulse electron beams were used (F test; p<0.05). CONCLUSIONS This study demonstrates that the TLD dose response, for doses ≤10 Gy, has a parabolic behavior in high dose-per-pulse electron beams. TLD-100 can be useful detectors for IOERT patient dosimetry if a proper calibration is provided.
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Affiliation(s)
- Raffaele Liuzzi
- Institute of Biostructure and Bioimaging, National Research Council (CNR), Naples, Italy
| | - Federica Savino
- Department of Physics, Federico II University, Naples, Italy
| | - Vittoria D’Avino
- Institute of Biostructure and Bioimaging, National Research Council (CNR), Naples, Italy
| | | | - Laura Cella
- Institute of Biostructure and Bioimaging, National Research Council (CNR), Naples, Italy
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López-Tarjuelo J, Morillo-Macías V, Bouché-Babiloni A, Ferrer-Albiach C, Santos-Serra A. Defining Action Levels for In Vivo Dosimetry in Intraoperative Electron Radiotherapy. Technol Cancer Res Treat 2015; 15:453-9. [PMID: 26025385 DOI: 10.1177/1533034615588196] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 04/23/2015] [Indexed: 11/15/2022] Open
Abstract
In vivo dosimetry is recommended in intraoperative electron radiotherapy (IOERT). To perform real-time treatment monitoring, action levels (ALs) have to be calculated. Empirical approaches based on observation of samples have been reported previously, however, our aim is to present a predictive model for calculating ALs and to verify their validity with our experimental data. We considered the range of absorbed doses delivered to our detector by means of the percentage depth dose for the electron beams used. Then, we calculated the absorbed dose histograms and convoluted them with detector responses to obtain probability density functions in order to find ALs as certain probability levels. Our in vivo dosimeters were reinforced TN-502RDM-H mobile metal-oxide-semiconductor field-effect transistors (MOSFETs). Our experimental data came from 30 measurements carried out in patients undergoing IOERT for rectal, breast, sarcoma, and pancreas cancers, among others. The prescribed dose to the tumor bed was 90%, and the maximum absorbed dose was 100%. The theoretical mean absorbed dose was 90.3% and the measured mean was 93.9%. Associated confidence intervals at P = .05 were 89.2% and 91.4% and 91.6% and 96.4%, respectively. With regard to individual comparisons between the model and the experiment, 37% of MOSFET measurements lay outside particular ranges defined by the derived ALs. Calculated confidence intervals at P = .05 ranged from 8.6% to 14.7%. The model can describe global results successfully but cannot match all the experimental data reported. In terms of accuracy, this suggests an eventual underestimation of tumor bed bleeding or detector alignment. In terms of precision, it will be necessary to reduce positioning uncertainties for a wide set of location and treatment postures, and more precise detectors will be required. Planning and imaging tools currently under development will play a fundamental role.
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Affiliation(s)
- Juan López-Tarjuelo
- Servicio de Radiofísica y Protección Radiológica, Consorcio Hospitalario Provincial de Castellón, Castellón de la Plana, Spain
| | - Virginia Morillo-Macías
- Servicio de Oncología Radioterápica, Consorcio Hospitalario Provincial de Castellón, Castellón de la Plana, Spain
| | - Ana Bouché-Babiloni
- Servicio de Oncología Radioterápica, Consorcio Hospitalario Provincial de Castellón, Castellón de la Plana, Spain
| | - Carlos Ferrer-Albiach
- Servicio de Oncología Radioterápica, Consorcio Hospitalario Provincial de Castellón, Castellón de la Plana, Spain Facultad de Medicina, Universidad Cardenal Herrera-CEU, Castellón de la Plana, Spain
| | - Agustín Santos-Serra
- Servicio de Radiofísica y Protección Radiológica, Consorcio Hospitalario Provincial de Castellón, Castellón de la Plana, Spain
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Baghani HR, Aghamiri SMR, Mahdavi SR, Akbari ME, Mirzaei HR. Comparing the dosimetric characteristics of the electron beam from dedicated intraoperative and conventional radiotherapy accelerators. J Appl Clin Med Phys 2015; 16:5017. [PMID: 26103175 PMCID: PMC5690101 DOI: 10.1120/jacmp.v16i2.5017] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 11/11/2014] [Accepted: 10/31/2014] [Indexed: 11/28/2022] Open
Abstract
The specific design of the mobile dedicated intraoperative radiotherapy (IORT) accelerators and different electron beam collimation system can change the dosimetric characteristics of electron beam with respect to the conventional accelerators. The aim of this study is to measure and compare the dosimetric characteristics of electron beam produced by intraoperative and conventional radiotherapy accelerators. To this end, percentage depth dose along clinical axis (PDD), transverse dose profile (TDP), and output factor of LIAC IORT and Varian 2100C/D conventional radiotherapy accelerators were measured and compared. TDPs were recorded at depth of maximum dose. The results of this work showed that depths of maximum dose, R90,R50, and RP for LIAC beam are lower than those of Varian beam. Furthermore, for all energies, surface doses related to the LIAC beam are substantially higher than those of Varian beam. The symmetry and flatness of LIAC beam profiles are more desirable compared to the Varian ones. Contrary to Varian accelerator, output factor of LIAC beam substantially increases with a decrease in the size of the applicator. Dosimetric characteristics of beveled IORT applicators along clinical axis were different from those of the flat ones. From these results, it can be concluded that dosimetric characteristics of intraoperative electron beam are substantially different from those of conventional clinical electron beam. The dosimetric characteristics of the LIAC electron beam make it a useful tool for intraoperative radiotherapy purposes. PACS number: 87.56.‐v, 87.56.bd
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Robatjazi M, Mahdavi SR, Takavr A, Baghani HR. Application of Gafchromic EBT2 film for intraoperative radiation therapy quality assurance. Phys Med 2015; 31:314-9. [PMID: 25703011 DOI: 10.1016/j.ejmp.2015.01.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2014] [Revised: 01/29/2015] [Accepted: 01/31/2015] [Indexed: 10/24/2022] Open
Abstract
PURPOSE Intraoperative radiation therapy (IORT) using electron beam is commonly done by mobile dedicated linacs that have a variable range of electron energies. This paper focuses on the evaluation of the EBT2 film response in the green and red colour channels for IORT quality assurance (QA). METHODS The calibration of the EBT2 films was done in two ranges; 0-8 Gy for machine QA by red channel and 8-24 Gy for patient-specific QA by green channel analysis. Irradiation of calibration films and relative dosimetries were performed in a water phantom. To evaluate the accuracy of the film response in relative dosimetry, gamma analysis was used to compare the results of the Monte Carlo simulation and ionometric dosimetry. Ten patients with early stage breast cancer were selected for in-vivo dosimetry using the green channel of the EBT2 film. RESULTS The calibration curves were obtained by linear fitting of the green channel and a third-order polynomial function in the red channel (R2=0.99). The total dose uncertainty was up to 4.2% and 4.7% for the red and green channels, respectively. There was a good agreement between the relative dosimetries of films by the red channel, Monte Carlo simulations and ionometric values. The mean dose difference of the in-vivo dosimetry by green channel of this film and the expected values was about 1.98% ± 0.75. CONCLUSION The results of this study showed that EBT2 film can be considered as an appropriate tool for machine and patient-specific QA in IORT.
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Affiliation(s)
- Mostafa Robatjazi
- Department of Medical Physics, Tehran University of Medical Science, Poursina St, 1417614411 Tehran, Iran
| | - Seied Rabi Mahdavi
- Department of Medical Physics, Iran University of Medical Science, Hemmat Exp. Way, 14496141525 Tehran, Iran.
| | - Abbas Takavr
- Department of Medical Physics, Tehran University of Medical Science, Poursina St, 1417614411 Tehran, Iran
| | - Hamid Reza Baghani
- Department of Radiation Medicine, Shahid Beheshti University, Daneshjoo St, Velenjak, 1983963113 Tehran, Iran
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Intraoperative full-dose of partial breast irradiation with electrons delivered by standard linear accelerators for early breast cancer. Int J Breast Cancer 2015; 2014:568136. [PMID: 25587452 PMCID: PMC4281392 DOI: 10.1155/2014/568136] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 11/25/2014] [Indexed: 02/01/2023] Open
Abstract
Purpose. To assess feasibility, efficacy, toxicity, and cosmetic results of intraoperative radiotherapy (IORT) with electrons delivered by standard linear accelerators (Linacs) during breast conserving surgeries for early infiltrating breast cancer (BC) treatment. Materials and Methods. A total of 152 patients with invasive ductal carcinoma (T ≤ 3.0 cm) at low risk for local relapses were treated. All had unicentric lesions by imaging methods and negative sentinel node. After a wide local excision, 21 Gy were delivered on the parenchyma target volume with electron beams. Local recurrences (LR), survival, toxicity, and cosmetic outcomes were analyzed. Results. The median age was 58.3 years (range 40–85); median follow-up was 50.7 months (range 12–101.5). There were 5 cases with LR, 2 cases with distant metastases, and 2 cases with deaths related to BC. The cumulative incidence rates of LR, distant metastases, and BC death were 3.2%, 1.5%, and 1.5%, respectively. Complications were rare, and the cosmetic results were excellent or good in most of the patients. Conclusions. IORT with electrons delivered by standard Linacs is feasible, efficient, and well tolerated and seems to be beneficial for selected patients with early infiltrating BC.
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Baghani HR, Aghamiri SMR, Mahdavi SR, Robatjazi M, Zadeh AR, Akbari ME, Mirzaei HR, Nafissi N, Samsami M. Dosimetric evaluation of Gafchromic EBT2 film for breast intraoperative electron radiotherapy verification. Phys Med 2014; 31:37-42. [PMID: 25231546 DOI: 10.1016/j.ejmp.2014.08.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 08/16/2014] [Accepted: 08/18/2014] [Indexed: 11/16/2022] Open
Abstract
PURPOSE Quality assurance (QA) is one of the most important issues that should be addressed for intraoperative electron radiotherapy (IOERT), which is not benefiting from image-based treatment planning system. The aim of this study is to evaluate the dosimetric characteristics of Gafchromic EBT2 film for breast IOERT QA procedure. METHODS Due to the fact that some dedicated accelerators are being used for IOERT, dependence of the film response to energy, field size, dose rate and incidence angle of electron beam from the LIAC IOERT accelerator was studied. Then, film response curve to breast IOERT doses was obtained and its accuracy was evaluated and justified through comparison to the results of ionometric dosimetry. RESULTS The results of this study indicated that there are no significant differences between the film responses at different energies of 6, 8, 10 and 12 MeV (P-value = 0.99). Similarly, no field size dependency was found when evaluating the response of the film to different field sizes ranging from 4 to 10 cm (P-value = 0.94). Film response was found to be independent of the dose rate of intraoperative electron beam (P-value = 0.12). Film response variations with changing the beam incidence angle were not significant (P-value > 0.8). Calibration curve at the dose range of 8-24 Gy had an acceptable accuracy. The difference between the results of film dosimetry and ionometric dosimetry was around 5% which was in agreement with the results of dose uncertainty estimation. CONCLUSION The EBT2 film was found to be a potentially appropriate tool for breast IOERT verification.
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Affiliation(s)
- Hamid Reza Baghani
- Department of Radiation Medicine, Shahid Beheshti University, Daneshjoo St, Velenjak 1983963113, Tehran, Iran
| | - S Mahmoud Reza Aghamiri
- Department of Radiation Medicine, Shahid Beheshti University, Daneshjoo St, Velenjak 1983963113, Tehran, Iran.
| | - S Rabi Mahdavi
- Department of Medical Physics, Iran University of Medical Science, Hemmat Exp.Way 14496141525, Tehran, Iran
| | - Mostafa Robatjazi
- Department of Medical Physics, Tehran University of Medical Science, Poursina St 1417614411, Tehran, Iran
| | - Arezo Rahim Zadeh
- Department of Medical Radiation, Islamic Azad University, Science and Research Branch, Hesark Blvd 1477893855, Tehran, Iran
| | - Mohammad Esmail Akbari
- Cancer Research Center, Shahid Beheshti University of Medical Science, Shahrdari St 1985717443, Tehran, Iran
| | - Hamid Reza Mirzaei
- Cancer Research Center, Shahid Beheshti University of Medical Science, Shahrdari St 1985717443, Tehran, Iran
| | - Nahid Nafissi
- Cancer Research Center, Shahid Beheshti University of Medical Science, Shahrdari St 1985717443, Tehran, Iran
| | - Majid Samsami
- Cancer Research Center, Shahid Beheshti University of Medical Science, Shahrdari St 1985717443, Tehran, Iran
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López-Tarjuelo J, Bouché-Babiloni A, Morillo-Macías V, de Marco-Blancas N, Santos-Serra A, Quirós-Higueras JD, Ferrer-Albiach C. In vivo dosimetry in intraoperative electron radiotherapy: microMOSFETs, radiochromic films and a general-purpose linac. Strahlenther Onkol 2014; 190:1060-5. [PMID: 24965479 DOI: 10.1007/s00066-014-0689-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 05/13/2014] [Indexed: 11/26/2022]
Abstract
INTRODUCTION In vivo dosimetry is desirable for the verification, recording, and eventual correction of treatment in intraoperative electron radiotherapy (IOERT). Our aim is to share our experience of metal oxide semiconductor field-effect transistors (MOSFETs) and radiochromic films with patients undergoing IOERT using a general-purpose linac. MATERIALS AND METHODS We used MOSFETs inserted into sterile bronchus catheters and radiochromic films that were cut, digitized, and sterilized by means of gas plasma. In all, 59 measurements were taken from 27 patients involving 15 primary tumors (seven breast and eight non-breast tumors) and 12 relapses. Data were subjected to an outliers' analysis and classified according to their compatibility with the relevant doses. Associations were sought regarding the type of detector, breast and non-breast irradiation, and the radiation oncologist's assessment of the difficulty of detector placement. At the same time, 19 measurements were carried out at the tumor bed with both detectors. RESULTS MOSFET measurements ([Formula: see text] = 93.5 %, sD = 6.5 %) were not significantly shifted from film measurements ([Formula: see text] = 96.0 %, sD = 5.5 %; p = 0.109), and no associations were found (p = 0.526, p = 0.295, and p = 0.501, respectively). As regards measurements performed at the tumor bed with both detectors, MOSFET measurements ([Formula: see text] = 95.0 %, sD = 5.4 % were not significantly shifted from film measurements ([Formula: see text] = 96.4 %, sD = 5.0 %; p = 0.363). CONCLUSION In vivo dosimetry can produce satisfactory results at every studied location with a general-purpose linac. Detector choice should depend on user factors, not on the detector performance itself. Surgical team collaboration is crucial to success.
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Affiliation(s)
- Juan López-Tarjuelo
- Servicio de Radiofísica y Protección Radiológica, Consorcio Hospitalario Provincial de Castellón, Avenida Dr. Clará, nº 19, 12002, Castellón de la Plana, Spain,
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Severgnini M, de Denaro M, Bortul M, Vidali C, Beorchia A. In vivo dosimetry and shielding disk alignment verification by EBT3 GAFCHROMIC film in breast IOERT treatment. J Appl Clin Med Phys 2014; 16:5065. [PMID: 25679150 PMCID: PMC5689990 DOI: 10.1120/jacmp.v16i1.5065] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 09/10/2014] [Accepted: 09/03/2014] [Indexed: 11/23/2022] Open
Abstract
Intraoperative electron radiation therapy (IOERT) cannot usually benefit, as conventional external radiotherapy, from software systems of treatment planning based on computed tomography and from common dose verify procedures. For this reason, in vivo film dosimetry (IVFD) proves to be an effective methodology to evaluate the actual radiation dose delivered to the target. A practical method for IVFD during breast IOERT was carried out to improve information on the dose actually delivered to the tumor target and on the alignment of the shielding disk with respect to the electron beam. Two EBT3 GAFCHROMIC films have been positioned on the two sides of the shielding disk in order to obtain the dose maps at the target and beyond the disk. Moreover the postprocessing analysis of the dose distribution measured on the films provides a quantitative estimate of the misalignment between the collimator and the disk. EBT3 radiochromic films have been demonstrated to be suitable dosimeters for IVD due to their linear dose-optical density response in a narrow range around the prescribed dose, as well as their capability to be fixed to the shielding disk without giving any distortion in the dose distribution. Off-line analysis of the radiochromic film allowed absolute dose measurements and this is indeed a very important verification of the correct exposure to the target organ, as well as an estimate of the dose to the healthy tissue underlying the shielding. These dose maps allow surgeons and radiation oncologists to take advantage of qualitative and quantitative feedback for setting more accurate treatment strategies and further optimized procedures. The proper alignment using elastic bands has improved the absolute dose accuracy and the collimator disk alignment by more than 50%.
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Affiliation(s)
- Mara Severgnini
- Department of Medical Physics, A.O.U. "Ospedali Riuniti" di Trieste, Italy.
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Avanzo M, Drigo A, Ren Kaiser S, Roggio A, Sartor G, Chiovati P, Franchin G, Mascarin M, Capra E. Dose to the skin in helical tomotherapy: Results of in vivo measurements with radiochromic films. Phys Med 2013; 29:304-11. [DOI: 10.1016/j.ejmp.2012.04.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2011] [Revised: 04/10/2012] [Accepted: 04/14/2012] [Indexed: 12/21/2022] Open
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Deneve JL, Hoefer RA, Harris EER, Laronga C. Accelerated Partial Breast Irradiation: A Review and Description of an Early North American Surgical Experience with the Intrabeam Delivery System. Cancer Control 2012; 19:295-308. [DOI: 10.1177/107327481201900406] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Jeremiah L. Deneve
- Department of Women's Oncology H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Richard A. Hoefer
- Dorothy G. Hoefer Comprehensive Breast Center, Sentara Cancer Network, Newport News, Virginia
| | - Eleanor E. R. Harris
- Radiation Oncology Program at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Christine Laronga
- Department of Women's Oncology H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
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Avanzo M, Rink A, Dassie A, Massarut S, Roncadin M, Borsatti E, Capra E. In vivodosimetry with radiochromic films in low-voltage intraoperative radiotherapy of the breast. Med Phys 2012; 39:2359-68. [DOI: 10.1118/1.3700175] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Ciocca M, Cantone MC, Veronese I, Cattani F, Pedroli G, Molinelli S, Vitolo V, Orecchia R. Application of failure mode and effects analysis to intraoperative radiation therapy using mobile electron linear accelerators. Int J Radiat Oncol Biol Phys 2011; 82:e305-11. [PMID: 21708432 DOI: 10.1016/j.ijrobp.2011.05.010] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2010] [Revised: 04/26/2011] [Accepted: 05/10/2011] [Indexed: 11/25/2022]
Abstract
PURPOSE Failure mode and effects analysis (FMEA) represents a prospective approach for risk assessment. A multidisciplinary working group of the Italian Association for Medical Physics applied FMEA to electron beam intraoperative radiation therapy (IORT) delivered using mobile linear accelerators, aiming at preventing accidental exposures to the patient. METHODS AND MATERIALS FMEA was applied to the IORT process, for the stages of the treatment delivery and verification, and consisted of three steps: 1) identification of the involved subprocesses; 2) identification and ranking of the potential failure modes, together with their causes and effects, using the risk probability number (RPN) scoring system, based on the product of three parameters (severity, frequency of occurrence and detectability, each ranging from 1 to 10); 3) identification of additional safety measures to be proposed for process quality and safety improvement. RPN upper threshold for little concern of risk was set at 125. RESULTS Twenty-four subprocesses were identified. Ten potential failure modes were found and scored, in terms of RPN, in the range of 42-216. The most critical failure modes consisted of internal shield misalignment, wrong Monitor Unit calculation and incorrect data entry at treatment console. Potential causes of failure included shield displacement, human errors, such as underestimation of CTV extension, mainly because of lack of adequate training and time pressures, failure in the communication between operators, and machine malfunctioning. The main effects of failure were represented by CTV underdose, wrong dose distribution and/or delivery, unintended normal tissue irradiation. As additional safety measures, the utilization of a dedicated staff for IORT, double-checking of MU calculation and data entry and finally implementation of in vivo dosimetry were suggested. CONCLUSIONS FMEA appeared as a useful tool for prospective evaluation of patient safety in radiotherapy. The application of this method to IORT lead to identify three safety measures for risk mitigation.
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Affiliation(s)
- Mario Ciocca
- Unit of Medical Physics, Centro Nazionale di Adroterapia Oncologica Foundation, via Campeggi, 27100 Pavia, Italy.
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31
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Practical use of Gafchromic® EBT films in electron beams for in-phantom dose distribution measurements and monitor units verification. Phys Med 2011; 27:81-8. [DOI: 10.1016/j.ejmp.2010.04.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2009] [Revised: 01/29/2010] [Accepted: 04/28/2010] [Indexed: 11/21/2022] Open
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Veronesi U, Orecchia R, Luini A, Galimberti V, Zurrida S, Intra M, Veronesi P, Arnone P, Leonardi MC, Ciocca M, Lazzari R, Caldarella P, Rotmensz N, Sangalli C, Sances D, Maisonneuve P. Intraoperative radiotherapy during breast conserving surgery: a study on 1,822 cases treated with electrons. Breast Cancer Res Treat 2010; 124:141-51. [DOI: 10.1007/s10549-010-1115-5] [Citation(s) in RCA: 172] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2010] [Accepted: 08/04/2010] [Indexed: 12/23/2022]
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Gerbi BJ, Antolak JA, Deibel FC, Followill DS, Herman MG, Higgins PD, Huq MS, Mihailidis DN, Yorke ED, Hogstrom KR, Khan FM. Recommendations for clinical electron beam dosimetry: supplement to the recommendations of Task Group 25. Med Phys 2009; 36:3239-79. [PMID: 19673223 DOI: 10.1118/1.3125820] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
The goal of Task Group 25 (TG-25) of the Radiation Therapy Committee of the American Association of.Physicists in Medicine (AAPM) was to provide a methodology and set of procedures for a medical physicist performing clinical electron beam dosimetry in the nominal energy range of 5-25 MeV. Specifically, the task group recommended procedures for acquiring basic information required for acceptance testing and treatment planning of new accelerators with therapeutic electron beams. Since the publication of the TG-25 report, significant advances have taken place in the field of electron beam dosimetry, the most significant being that primary standards laboratories around the world have shifted from calibration standards based on exposure or air kerma to standards based on absorbed dose to water. The AAPM has published a new calibration protocol, TG-51, for the calibration of high-energy photon and electron beams. The formalism and dosimetry procedures recommended in this protocol are based on the absorbed dose to water calibration coefficient of an ionization chamber at 60Co energy, N60Co(D,w), together with the theoretical beam quality conversion coefficient k(Q) for the determination of absorbed dose to water in high-energy photon and electron beams. Task Group 70 was charged to reassess and update the recommendations in TG-25 to bring them into alignment with report TG-51 and to recommend new methodologies and procedures that would allow the practicing medical physicist to initiate and continue a high quality program in clinical electron beam dosimetry. This TG-70 report is a supplement to the TG-25 report and enhances the TG-25 report by including new topics and topics that were not covered in depth in the TG-25 report. These topics include procedures for obtaining data to commission a treatment planning computer, determining dose in irregularly shaped electron fields, and commissioning of sophisticated special procedures using high-energy electron beams. The use of radiochromic film for electrons is addressed, and radiographic film that is no longer available has been replaced by film that is available. Realistic stopping-power data are incorporated when appropriate along with enhanced tables of electron fluence data. A larger list of clinical applications of electron beams is included in the full TG-70 report available at http://www.aapm.org/pubs/reports. Descriptions of the techniques in the clinical sections are not exhaustive but do describe key elements of the procedures and how to initiate these programs in the clinic. There have been no major changes since the TG-25 report relating to flatness and symmetry, surface dose, use of thermoluminescent dosimeters or diodes, virtual source position designation, air gap corrections, oblique incidence, or corrections for inhomogeneities. Thus these topics are not addressed in the TG-70 report.
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Affiliation(s)
- Bruce J Gerbi
- University of Minnesota, Minneapolis, Minnesota 55455, USA.
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Ciocca M, Pedroli G, Orecchia R, Guido A, Cattani F, Cambria R, Veronesi U. Radiation survey around a Liac mobile electron linear accelerator for intraoperative radiation therapy. J Appl Clin Med Phys 2009; 10:131-138. [PMID: 19458597 PMCID: PMC5720457 DOI: 10.1120/jacmp.v10i2.2950] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2008] [Revised: 02/06/2009] [Accepted: 02/05/2009] [Indexed: 11/23/2022] Open
Abstract
The aim of this study was to perform a detailed analysis of the air kerma values around a Liac mobile linear accelerator working in a conventional operating room (OR) for IORT. The Liac delivers electron beams at 4, 6, 8 and 10 MeV. A radiation survey to determine photon leakage and scatter consisted of air kerma measurements on a spherical surface of 1.5 m radius, centered on the titanium exit window of the accelerating structure. Measurements were taken using a 30 cm3 calibrated cylindrical ion chamber in three orthogonal planes, at the maximum electron energy. For each point, 10 Gy was delivered. At selected points, the quality of x‐ray radiation was determined by using lead sheets, and measurements were performed for all energies to investigate the energy dependence of stray radiation. The photon scatter contribution from the metallic internal patient‐shielding in IORT, used to protect normal tissues underlying the target, was also evaluated. At seven locations outside the OR, the air kerma values derived from in‐room measurements were compared to measurements directly performed using a survey meter. The results, for a delivered dose of 10 Gy, showed that the air kerma values ranged from approximately 6 μGy (upper and rear sides of the Liac) to 320 μGy (lateral to beam stopper) in the two orthogonal vertical planes, while values lower than 18 μGy were found in the horizontal plane. At 10 MeV, transmission behind 1 cm lead shield was found to be 42%. The use of internal shielding appeared to increase the photon scatter only slightly. Air kerma values outside the OR were generally lower than 1 mGy for an annual workload of 200 patients. Thus, the Liac can safely work in a conventional OR, while the need for additional shielding mainly depends on patient workload. Our data can be useful for centers planning to implement an IORT program using a mobile linear accelerator, permitting radiation safety personnel to estimate in advance the shielding required for a particular workload. PACS number: 87.55.ne, 87.56.bd
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Affiliation(s)
- Mario Ciocca
- Unit of Medical Physics, European Institute of Oncology, Milano, Italy
| | - Guido Pedroli
- Unit of Medical Physics, European Institute of Oncology, Milano, Italy
| | - Roberto Orecchia
- Division of Radiation Oncology, European Institute of Oncology, Milano, Italy.,Faculty of Medicine, Università degli Studi di Milano, Milano, Italy
| | - Andrea Guido
- Division of Radiation Oncology, European Institute of Oncology, Milano, Italy
| | - Federica Cattani
- Unit of Medical Physics, European Institute of Oncology, Milano, Italy
| | - Raffaella Cambria
- Unit of Medical Physics, European Institute of Oncology, Milano, Italy
| | - Umberto Veronesi
- Scientific Direction, European Institute of Oncology, Milano, Italy
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35
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Veronesi U, Orecchia R, Luini A, Galimberti V, Gatti G, Intra M, Veronesi P, Leonardi MC, Ciocca M, Lazzari R, Caldarella P, Rotmensz N, Sangalli C, Silva LS, Sances D. Full-dose intra-operative radiotherapy with electrons (ELIOT) during breast-conserving surgery: experience with 1246 cases. Ecancermedicalscience 2008; 2:65. [PMID: 22275962 PMCID: PMC3234040 DOI: 10.3332/ecms.2008.65] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2008] [Indexed: 11/30/2022] Open
Abstract
Background: Previous studies showed that after breast-conserving surgery for breast cancer, radiotherapy may be applied to the portion of the breast where the primary tumour was removed (partial breast irradiation (PBI), avoiding the irradiation of the whole breast. We developed a procedure of PBI consisting of a single high dose of radiotherapy of 21 Gy with electrons equivalent to 58–60 Gy in fractionated doses, delivered during the surgical session by a mobile linear accelerator, positioned close to the operating table. Patients and methods: From July 1999 to December 2006, 1246 patients with primary carcinoma of less than 2.5-cm maximum diameter, mostly over 48 years, were treated with electron intra-operative radiotherapy (ELIOT) at a single dose of 21 Gy. Results: After a follow-up from 0.3 to 94.7 months (median 26), 24 (1.9%) patients showed a local recurrence and 22 developed distant metastases. Sixteen patients died, seven from breast carcinoma and nine from others causes. The five-year crude survival was 96.5%. Six (0.5%) developed severe breast fibrosis, which resolved in 2–3 years. An additional 40 patients suffered for mild fibrosis. Cosmetic results were good. Conclusions: Electron intra-operative radiotherapy is a safe method for treating conservatively operated breasts and avoids the long period of post-operative radiotherapy, greatly improving the quality of life and reduces the cost of radiotherapy. ELIOT markedly reduces the radiation to normal surrounding tissues and deep organs. Results on short- and medium-term toxicity are good. Data on local control are encouraging.
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Affiliation(s)
- U Veronesi
- Scientific Director, European Institute of Oncology, Milan, Italy.
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36
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Soriani A, Landoni V, Marzi S, Iaccarino G, Saracino B, Arcangeli G, Benassi M. Setup verification and in vivo dosimetry during intraoperative radiation therapy (IORT) for prostate cancer. Med Phys 2007; 34:3205-10. [PMID: 17879783 DOI: 10.1118/1.2750965] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
The purpose of this study was to check the setup and dose delivered to the patients during intraoperative electron beam radiation therapy (IORT) for prostate cancer. Twenty eight patients underwent IORT after radical prostatectomy for prostate cancer by means of a dedicated mobile accelerator, Novac7 (by Hitesys, SpA, Italy). A 9 MeV electron beam at high dose per pulse was used. Eighteen patients received IORT at escalating doses of 16, 18, and 20 Gy at 85% isodose, six patients for each dose level. Further, ten patients received 20 Gy at 85% isodose. The electron applicator position was checked in all cases by means of two orthogonal images obtained with brilliance intensifier. Target and organ at risk doses were measured in vivo by a MOSFETs dosimetry system. MOSFETs and microMOSFET dosimeters were inserted into sterile catheters and directly positioned into the rectal lumen, for ten patients, and into the bladder to urethra anastomosis, in the last 14 cases. Verification at 0 degree led to very few adjustments of setup while verifications at 90 degrees often suggested to bring the applicator closer to the target. In vivo dosimetry showed an absorbed dose into the rectum wall < or =1% of the total dose. The average dose value inside the anastomosis, for the 12 patients analyzed, was 23.7 Gy with a standard deviation of +/-7.6%, when the prescription was 20 Gy at 85% isodose. Using a C-arm mobile image intensifier, it is possible to assess if the positioning is correct and safe. Radio-opaque clips and liquid were necessary to obtain good visible images. In vivo MOSFETs dosimetry is feasible and reliable. A satisfactory agreement between measured and expected doses was found.
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Affiliation(s)
- Antonella Soriani
- Laboratory of Medical Physics, Istituto Regina Elena, via Elio Chianesi 53, 00144, Roma, Italy.
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Abstract
Breast-conserving treatment is considered the standard therapy for most early-stage breast cancer and has given excellent results. That notwithstanding in the last years, several institutions are trying to revisit the adjuvant radiation treatment setting, especially with respect to possible changes in overall treatment time and target volume within the philosophy of modern partial breast irradiation. Up to date, no conclusive data are available on the possible role of partial breast irradiation in early-stage breast cancer but in this paper, we review the rationale and the researches currently being undertaken within the framework of this approach, trying to answer whether, in spite of the absence of the randomized evidence of the equivalence between whole and partial breast irradiation, could be already possible to suggest this treatment modality in the daily clinical practice, at least in some selected cases.
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Affiliation(s)
- R Orecchia
- Department of Radio-Oncology, European Institute of Oncology, Milan, Italy.
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38
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Bernier J, Viale G, Orecchia R, Ballardini B, Richetti A, Bronz L, Franzetti-Pellanda A, Intra M, Veronesi U. Partial irradiation of the breast: Old challenges, new solutions. Breast 2006; 15:466-75. [PMID: 16439129 DOI: 10.1016/j.breast.2005.11.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2005] [Revised: 11/10/2005] [Accepted: 11/17/2005] [Indexed: 10/25/2022] Open
Abstract
Breast-conserving treatment, characteristically consisting of surgical removal of the tumor and post-operative whole breast irradiation, is nowadays considered as the standard therapeutic approach for most women with stage I/II, invasive breast cancer. Recently, a number of institutions started investigating the feasibility and safety of novel approaches in radiotherapy, modulating concomitantly treatment time and irradiation volume. Whilst this strategy is still under investigation, recent clinical studies on accelerated partial breast irradiation with intra-operative radiotherapy or high conformality irradiation strongly suggest that the way patients with early breast cancer are irradiated should be revisited.
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Affiliation(s)
- J Bernier
- Department of Radio-Oncology and Breast Unit, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland.
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Beddar AS, Biggs PJ, Chang S, Ezzell GA, Faddegon BA, Hensley FW, Mills MD. Intraoperative radiation therapy using mobile electron linear accelerators: report of AAPM Radiation Therapy Committee Task Group No. 72. Med Phys 2006; 33:1476-89. [PMID: 16752582 DOI: 10.1118/1.2194447] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Intraoperative radiation therapy (IORT) has been customarily performed either in a shielded operating suite located in the operating room (OR) or in a shielded treatment room located within the Department of Radiation Oncology. In both cases, this cancer treatment modality uses stationary linear accelerators. With the development of new technology, mobile linear accelerators have recently become available for IORT. Mobility offers flexibility in treatment location and is leading to a renewed interest in IORT. These mobile accelerator units, which can be transported any day of use to almost any location within a hospital setting, are assembled in a nondedicated environment and used to deliver IORT. Numerous aspects of the design of these new units differ from that of conventional linear accelerators. The scope of this Task Group (TG-72) will focus on items that particularly apply to mobile IORT electron systems. More specifically, the charges to this Task Group are to (i) identify the key differences between stationary and mobile electron linear accelerators used for IORT, (ii) describe and recommend the implementation of an IORT program within the OR environment, (iii) present and discuss radiation protection issues and consequences of working within a nondedicated radiotherapy environment, (iv) describe and recommend the acceptance and machine commissioning of items that are specific to mobile electron linear accelerators, and (v) design and recommend an efficient quality assurance program for mobile systems.
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Affiliation(s)
- A Sam Beddar
- Department of Radiation Physics, Division of Radiation Oncology, Unit 94, The University of Texas M.D. Anderson Cancer Center, Houston, Texas 77030, USA.
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Calvo FA, Meirino RM, Orecchia R. Intraoperative radiation therapy first part: rationale and techniques. Crit Rev Oncol Hematol 2006; 59:106-15. [PMID: 16844383 DOI: 10.1016/j.critrevonc.2005.11.004] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2005] [Revised: 11/17/2005] [Accepted: 11/17/2005] [Indexed: 11/15/2022] Open
Abstract
Intraoperative radiotherapy (IORT) is a technique where a high, single-fraction radiation dose is delivered during a surgical procedure to macroscopic tumours or tumour beds with minimal exposure of surroundings tissues which are displaced and shielded during the procedure. In this paper, the rationale for and use of IORT, both with electron beams (IOERT) and high-dose-rate brachytherapy (HDR-IORT) are discussed. For most tumours, the likelihood of obtaining local control (LC) improves when increasing doses can be administered. In many clinical situations, however, the dose that can be delivered safely to the tumour target is limited by the risk of damaging normal tissues. Special consideration is therefore given on this paper to the relationship between dose, LC and possible complications. Criteria for patient's selection and evaluation and information on sequencing and techniques are presented as well as some considerations on the need for a proper programme on quality assurance and periodical reporting of data.
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Affiliation(s)
- Felipe A Calvo
- Hospital General Universitario Gregorio Marañon, Madrid, Spain.
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41
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Ciocca M, Piazzi V, Lazzari R, Vavassori A, Luini A, Veronesi P, Galimberti V, Intra M, Guido A, Tosi G, Veronesi U, Orecchia R. Real-time in vivo dosimetry using micro-MOSFET detectors during intraoperative electron beam radiation therapy in early-stage breast cancer. Radiother Oncol 2006; 78:213-6. [PMID: 16359743 DOI: 10.1016/j.radonc.2005.11.011] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2005] [Revised: 10/17/2005] [Accepted: 11/23/2005] [Indexed: 11/24/2022]
Abstract
PURPOSE In a previous paper we reported the results of off-line in vivo measurements using radiochromic films in IOERT. In the present study, a further step was made, aiming at the improvement of the effectiveness of in vivo dosimetry, based on a real-time check of the dose. MATERIALS AND METHODS Entrance dose was determined using micro-MOSFET detectors placed inside a thin, sterile, transparent catheter. The epoxy side of the detector was faced towards the beam to minimize the anisotropy. Each detector was plugged into a bias supply (standard sensitivity) and calibrated at 5 Gy using 6 MeV electrons produced by a conventional linac. Detectors were characterized in terms of linearity, precision and dose per pulse dependence. No energy and temperature dependence was found. The sensitivity change of detectors was about 1% per 20 Gy accumulated dose. Correction factors to convert surface to entrance dose were determined for each combination of energy and applicator. From November 2004 to May 2005, in vivo dosimetry was performed on 45 patients affected by early-stage breast cancer, who underwent IOERT to the tumour bed. IOERT was delivered using electrons (4-10 MeV) at high dose per pulse, produced by either a Novac7 or a Liac mobile linac. RESULTS The mean ratio between measured and expected dose was 1.006+/-0.035 (1 SD), in the range 0.92-1.1. The procedure uncertainty was 3.6%. Micro-MOSFETs appeared suitable for in vivo dosimetry in IOERT, although some unfavourable aspects, like the limited lifetime and the anisotropy with no build-up, were found. Prospectively, a real-time action level (+/-6%) on dose discrepancy was defined. CONCLUSIONS Excellent agreement between measured and expected doses was found. Real-time in vivo dosimetry appeared feasible, reliable and more effective than the method previously published.
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Affiliation(s)
- Mario Ciocca
- Department of Medical Physics, European Institute of Oncology, Milano, Italy.
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Orecchia R, Ciocca M, Tosi G, Franzetti S, Luini A, Gatti G, Veronesi U. Intraoperative electron beam radiotherapy (ELIOT) to the breast: A need for a quality assurance programme. Breast 2005; 14:541-6. [PMID: 16242331 DOI: 10.1016/j.breast.2005.08.038] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Intraoperative radiotherapy (IORT) is a technique in which a high, single-fraction radiation dose is delivered directly to the tumour bed during a surgical intervention, after the removal of a neoplastic mass. IORT has been recently used in early stage cancer as an exclusive radiation modality, rather than as a boost, especially for breast tumours, in particular at the European Institute of Oncology in Milan, where the technique has been called electron intraoperative therapy (ELIOT). Our studies on more than 1000 patients have demonstrated the feasibility of the technique and it is expected that its application will become more widespread in the immediate future. It is important to emphasise that ELIOT relies not only on new technological developments, but also on a multidisciplinary team with clear roles and responsibilities, the establishment of a programme of quality assurance with appropriate guidelines and a comprehensive staff development programme.
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Affiliation(s)
- R Orecchia
- Radiation Oncology Department, European Institute of Oncology, University of Milan, Via Ripamonti 435 20141 Milan, Italy.
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Veronesi U, Orecchia R, Luini A, Galimberti V, Gatti G, Intra M, Veronesi P, Leonardi MC, Ciocca M, Lazzari R, Caldarella P, Simsek S, Silva LS, Sances D. Full-dose intraoperative radiotherapy with electrons during breast-conserving surgery: experience with 590 cases. Ann Surg 2005; 242:101-6. [PMID: 15973107 PMCID: PMC1357710 DOI: 10.1097/01.sla.0000167927.82353.bc] [Citation(s) in RCA: 119] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Previous studies show that local recurrences after breast-conserving treatment occur in the site of the primary tumor. The need for postoperative radiotherapy on the whole breast is challenged in favor of radiotherapy limited to the area of the breast at high risk of recurrence. The new mobile linear accelerators easily moved close to the operating table to allow the full-dose irradiation during surgery. PATIENTS AND METHODS From July 1999 to December 2003, 590 patients affected by unifocal breast carcinoma up to a diameter of 2.5 cm received wide resection of the breast followed by intraoperative radiotherapy with electrons (ELIOT). Most patients received 21 Gy intraoperatively, biologically equivalent to 58 to 60 Gy in standard fractionation. Patients were evaluated 1, 3, 6, and 12 months after surgery, and thereafter every 6 months, to look for early, intermediate, late complications, and other events. RESULTS After a follow-up from 4 to 57 months (mean, 24 months; median, 20 months), 19 patients (3.2%) developed breast fibrosis, mild in 18, severe in 1, which resolved within 24 months. Three patients (0.5%) developed local recurrences, 3 patients ipsilateral carcinomas in other quadrants and other 5 patients contralateral breast carcinoma. One patient (0.2%) died of distant metastases. CONCLUSIONS ELIOT is a safe method for treating conservatively operated breasts, avoids the long period of postoperative radiotherapy, and reduces drastically the cost of radiotherapy. ELIOT reduces radiation to normal tissues and organs. Results on short-term and middle-term toxicity up to 5 years of follow-up are good. Data on local control are encouraging.
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Affiliation(s)
- Umberto Veronesi
- Istituto Europeo di Oncologia, Division of Radiotherapy, Istituto Europeo di Oncologia, Milan, Italy.
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Abstract
Intraoperative radiotherapy (IORT) has been used for many years for treating patients with various locally-advanced malignancies, usually combined with external-beam radiation therapy (EBRT). Long-term results confirm that IORT improves local control, which is generally associated with increased survival. Recently, electron-beam IORT has been used as the sole treatment for patients with earlier-stage cancers, especially for breast tumors, with extremely promising results. Most of this work has been done at the European Institute of Oncology in Milan. We report the rationale and techniques of the use of electron intraoperative treatment (ELIOT) and the results of our different clinical studies. In our opinion, ELIOT may be an excellent alternative to EBRT for the treatment of patients with early-stage breast cancer. However, intensive long-term follow-up is needed to fully evaluate local control and possible side effects.
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Affiliation(s)
- Roberto Orecchia
- Department of Radiation Oncology, European Institute of Oncology, University of Milan, Italy.
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Chiu-Tsao ST, Duckworth T, Zhang C, Patel NS, Hsiung CY, Wang L, Shih JA, Harrison LB. Dose response characteristics of new models of GAFCHROMIC films: Dependence on densitometer light source and radiation energy. Med Phys 2004; 31:2501-8. [PMID: 15487731 DOI: 10.1118/1.1767103] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
This paper presents a systematic study of the dose response characteristics of two new models and one commonly used model of GAFCHROMIC film: HS, XR-T, and MD55-2, respectively. We irradiated these film models with three different radiation sources: I-125, Ir-192, and 6 MV photon beam (6 MVX). We scanned the films with three different densitometers: a He-Ne laser with a wavelength of 633 nm, a spot densitometer with a wavelength of 671 nm, and a CCD camera densitometer with interchangeable LED boxes with wavelengths of 665 nm (red), 520 nm (green), and 465 nm (blue). We compared the film sensitivities in terms of net optical density (NOD) per unit dose in Gy. The sensitivity of each film model depends on radiation energy and the densitometer light source. Using He-Ne laser based densitometer as a reference standard, we found the sensitivities (NOD/Gy) for the red lights of wavelengths, 671 nm and 665 nm, are higher by factors of about 2.5 and 2, respectively. The sensitivities for green (520 nm) and blue (465 nm) lights are lower than that for He-Ne laser (633 nm) by factors of about 2 and 4, respectively. The energy dependence of the sensitivity varies with the film model, but is similar for all densitometer light sources. Comparing I-125 to Ir-192 and 6MVX, we note that (a) model XR-T is about eight times more sensitive, and (b) models HS and MD55-2 are about 40% less sensitive. Relative to MD55-2, XR-T is 12 times more sensitive for I-125 but comparable for Ir-192 and 6MVX, whereas HS is 2 to 3 times more sensitive in all cases. This set of results can serve as useful information for making decisions in selecting the film model and compatible densitometer to achieve the best accuracy of dosimetry in the appropriate dose range.
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Affiliation(s)
- Sou-Tung Chiu-Tsao
- Beth Israel Medical Center and St. Luke's-Roosevelt Hospital Center, New York, New York 10003, USA.
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