Monte Carlo calculations and measurements of absorbed dose per monitor unit for the treatment of uveal melanoma with proton therapy

A generalized model for monitor units determination in ocular proton therapy using machine learning: A proof-of-concept study

Objective.Determining and verifying the number of monitor units is crucial to achieving the desired dose distribution in radiotherapy and maintaining treatment efficacy. However, current commercial treatment planning system(s) dedicated to ocular passive eyelines in proton therapy do not provide the number of monitor units for patient-specific plan delivery. Performing specific pre-treatment field measurements, which is time and resource consuming, is usually gold-standard practice. This proof-of-concept study reports on the development of a multi-institutional-based generalized model for monitor units determination in proton therapy for eye melanoma treatments.Approach.To cope with the small number of patients being treated in proton centers, three European institutes participated in this study. Measurements data were collected to address output factor differences across the institutes, especially as function of field size, spread-out Bragg peak modulation width, residual range, and air gap. A generic model for monitor units prediction using a large number of 3748 patients and broad diversity in tumor patterns, was evaluated using six popular machine learning algorithms: (i) decision tree; (ii) random forest, (iii) extra trees, (iv) K-nearest neighbors, (v) gradient boosting, and (vi) the support vector regression. Features used as inputs into each machine learning pipeline were: Spread-out Bragg peak width, range, air gap, fraction and calibration doses. Performance measure was scored using the mean absolute error, which was the difference between predicted and real monitor units, as collected from institutional gold-standard methods.Main results.Predictions across algorithms were accurate within 3% uncertainty for up to 85.2% of the plans and within 10% uncertainty for up to 98.6% of the plans with the extra trees algorithm.Significance.A proof-of-concept of using machine learning-based generic monitor units determination in ocular proton therapy has been demonstrated. This could trigger the development of an independent monitor units calculation tool for clinical use.

A torus source and its application for non-primary radiation evaluation

Objective. Non-primary radiation doses to normal tissues from proton therapy may be associated with an increased risk of secondary malignancies, particularly in long-term survivors. Thus, a systematic method to evaluate if the dose level of non-primary radiation meets the IEC standard requirements is needed.Approach. Different from the traditional photon radiation therapy system, proton therapy systems are composed of several subsystems in a thick bunker. These subsystems are all possible sources of non-primary radiation threatening the patient. As a case study, 7 sources in the P-Cure synchrotron-based proton therapy system are modeled in Monte Carlo (MC) code: tandem injector, injection, synchrotron ring, extraction, beam transport line, scanning nozzle and concrete reflection/scattering. To accurately evaluate the synchrotron beam loss and non-primary dose, a new model called the torus source model is developed. Its parametric equations define the position and direction of the off-orbit particle bombardment on the torus pipe shell in the Cartesian coordinate system. Non-primary doses are finally calculated by several FLUKA simulations.Main results. The ratios of summarized non-primary doses from different sources to the planned dose of 2 Gy are all much smaller than the IEC requirements in both the 15-50 cm and 50-200 cm regions. Thus, the P-Cure synchrotron-based proton therapy system is clean and patient-friendly, and there is no need an inner shielding concrete between the accelerator and patient.Significance. Non-primary radiation dose level is a very important indicator to evaluate the quality of a PT system. This manuscript provides a feasible MC procedure for synchrotron-based proton therapy with new beam loss model. Which could help people figure out precisely whether this level complies with the IEC standard before the system put into clinical treatment. What' more, the torus source model could be widely used for bending magnets in gantries and synchrotrons to evaluate non-primary doses or other radiation doses.

Stray neutron radiation exposures from proton therapy: physics-based analytical models of neutron spectral fluence, kerma and absorbed dose

Objective. Patients who receive proton beam therapy are exposed to unwanted stray neutrons. Stray radiations increase the risk of late effects in normal tissues, such as second cancers and cataracts, and may cause implanted devices such as pacemakers to malfunction. Compared to therapeutic beams, little attention has been paid to modeling stray neutron exposures. In the past decade, substantial progress was made to develop semiempirical models of stray neutron dose equivalent, but models to routinely calculate neutron absorbed dose and kerma are still lacking. The objective of this work was to develop a new physics based analytical model to calculate neutron spectral fluence, kerma, and absorbed dose in a water phantom. Approach. We developed the model using dosimetric data from Monte Carlo simulations and neutron kerma coefficients from the literature. The model explicitly considers the production, divergence, scattering, and attenuation of neutrons. Neutron production was modeled for 120–250 MeV proton beams impinging on a variety of materials. Fluence, kerma and dose calculations were performed in a 30 × 180 × 44 cm3 phantom at points up to 43 cm in depth and 80 cm laterally. Main Results. Predictions of the analytical model agreed reasonably with corresponding values from Monte Carlo simulations, with a mean difference in average energy deposited of 20%, average kerma coefficient of 21%, and absorbed dose to water of 49%. Significance. The analytical model is simple to implement and use, requires less configuration data that previously reported models, and is computationally fast. This model appears potentially suitable for integration in treatment planning system, which would enable risk calculations in prospective and retrospective cases, providing a powerful tool for epidemiological studies and clinical trials.

Evaluation of the dosimetric effect of scattered protons in clinical practice in passive scattering proton therapy

The present study verified and evaluated the dosimetric effects of protons scattered from a snout and an aperture in clinical practice, when a range compensator was included. The dose distribution calculated by a treatment planning system (TPS) was compared with the measured dose distribution and the dose distribution calculated by Monte Carlo simulation at several depths. The difference between the measured and calculated results was analyzed using Monte Carlo simulation with filtration of scattering in the snout and aperture. The dependence of the effects of scattered protons on snout size, beam range, and minimum thickness of the range compensator was also investigated using the Monte Carlo simulation. The simulated and measured results showed that the additional dose compared with the results calculated by the TPS at shallow depths was mainly due to protons scattered by the snout and aperture. This additional dose was filtered by the structure of the range compensator so that it was observed under the thin region of the range compensator. The maximum difference was measured at a depth of 16 mm (8.25%), with the difference decreasing with depth. Analysis of protons contributing to the additional dose showed that the contribution of protons scattered from the snout was greater than that of protons scattered from the aperture when a narrow snout was used. In the Monte Carlo simulation, this effect of scattered protons was reduced when wider snouts and longer‐range proton beams were used. This effect was also reduced when thicker range compensator bases were used, even with a narrow snout. This study verified the effect of scattered protons even when a range compensator was included and emphasized the importance of snout‐scattered protons when a narrow snout is used for small fields. It indicated that this additional dose can be reduced by wider snouts, longer range proton beams, and thicker range compensator bases. These results provide a better understanding of the additional dose from scattered protons in clinical practice.

Automatic phase space generation for Monte Carlo calculations of intensity modulated particle therapy

Monte Carlo (MC) is generally considered as the most accurate dose calculation tool for particle therapy. However, a proper description of the beam particle kinematics is a necessary input for a realistic simulation. Such a description can be stored in phase space (PS) files for different beam energies. A PS file contains kinetic information such as energies, positions and travelling directions for particles traversing a plane perpendicular to the beam direction. The accuracy of PS files plays a critical role in the performance of the MC method for dose calculations. A PS file can be generated with a set of parameters describing analytically the beam kinematics. However, determining such parameters can be tedious and time consuming. Thus, we have developed an algorithm to obtain those parameters automatically and efficiently. In this paper, we presented such an algorithm and compared dose calculations using PS automatically generated for the Shanghai Proton and Heavy Ion Center (SPHIC) with measurements. The gamma-index for comparing calculated depth dose distributions (DDD) with measurements are above 96.0% with criterion 0.6%/0.6 mm. For each single energy, the mean difference percentage between calculated lateral spot sizes at 5 different locations along beam direction and measurements are below 3.5%.

Comparison of Monte Carlo and analytical dose computations for intensity modulated proton therapy

To evaluate the effect of approximations in clinical analytical calculations performed by a treatment planning system (TPS) on dosimetric indices in intensity modulated proton therapy. TPS calculated dose distributions were compared with dose distributions as estimated by Monte Carlo (MC) simulations, calculated with the fast dose calculator (FDC) a system previously benchmarked to full MC. This study analyzed a total of 525 patients for four treatment sites (brain, head-and-neck, thorax and prostate). Dosimetric indices (D02, D05, D20, D50, D95, D98, EUD and Mean Dose) and a gamma-index analysis were utilized to evaluate the differences. The gamma-index passing rates for a 3%/3 mm criterion for voxels with a dose larger than 10% of the maximum dose had a median larger than 98% for all sites. The median difference for all dosimetric indices for target volumes was less than 2% for all cases. However, differences for target volumes as large as 10% were found for 2% of the thoracic patients. For organs at risk (OARs), the median absolute dose difference was smaller than 2 Gy for all indices and cohorts. However, absolute dose differences as large as 10 Gy were found for some small volume organs in brain and head-and-neck patients. This analysis concludes that for a fraction of the patients studied, TPS may overestimate the dose in the target by as much as 10%, while for some OARs the dose could be underestimated by as much as 10 Gy. Monte Carlo dose calculations may be needed to ensure more accurate dose computations to improve target coverage and sparing of OARs in proton therapy.

ADVANTAGES OF MCNPX-BASED LATTICE TALLY OVER MESH TALLY IN HIGH-SPEED MONTE CARLO DOSE RECONSTRUCTION FOR PROTON RADIOTHERAPY

Monte Carlo simulations are increasingly used to reconstruct dose distributions in radiotherapy research studies. Many studies have used the MCNPX Monte Carlo code with a mesh tally for dose reconstructions. However, when the number of voxels in the simulated patient anatomy is large, the computation time for a mesh tally can become prohibitively long. The purpose of this work was to test the feasibility of using lattice tally instead of mesh tally for whole-body dose reconstructions. We did this by comparing the dosimetric accuracy and computation time of lattice tallies with those of mesh tallies for craniospinal proton irradiation. The two tally methods generated nearly identical dosimetric results, within 1% in dose and within 1 mm distance-to-agreement for 99% of the voxels. For a typical craniospinal proton treatment field, simulation speed was 4 to 17 times faster using the lattice tally than using the mesh tally, depending on the numbers of proton histories and voxels. We conclude that the lattice tally is an acceptable substitute for the mesh tally in dose reconstruction, making it a suitable potential candidate for clinical treatment planning.

Water or realistic compositions in proton radiotherapy? An analytical study

PURPOSE

Pre-clinical tests and simulation studies for radiotherapy are generally carried out using water or simplified materials. Investigating the effects of defining compositionally realistic media in proton transport studies was the objective of this work. Accurate modeling of the Bragg curve is a fundamental requirement for such a study.

METHODS AND MATERIALS

An equation previously validated by experiments provides an appropriate analytical method for proton dose calculation in depth of the target. Owing to the dependency on protons ranges and the probability of undergoing non-elastic nuclear interactions (NNI), this formula comprises three parameters with values specified for initial proton energy and for the target material. As a result, knowledge of the depth-dose distribution using this analytical model is limited to the materials for which the data has been provided in nuclear data tables. In this study, we used our general formulas for calculating the protons ranges and the probability of undergoing NNI in desired compounds and mixtures with an arbitrary number of constituent elements. Furthermore, the protons dose distribution in the depth of these targets was leading off with determining the parameters appeared in the employed model using our mathematically easy to handle relations. For a number of tissues which may be of interest in proton radiotherapy studies but are missing in reference data tables, the mentioned parameters were calculated. Moreover, the resultant values for the protons ranges and the probability of undergoing NNIs were compared with those in water.

RESULTS

The results showed that the differences between the position of Bragg peaks in water and realistic media considered in this study were energy dependent, and ranged between a few millimeters. For proton beams of arbitrary chosen initial energies, the maximum dose delivered to the realistic media varied between about -0.02-4.42% in comparison with that to water.

CONCLUSIONS

The effects observed (both in penetration and in the magnitude of the Bragg peaks) may be overshadowed by the different dose prescriptions depending on the quality of the treatment planning system, and dosimetry protocols used at the various therapy centers.

Evaluation of monitor unit calculation based on measurement and calculation with a simplified Monte Carlo method for passive beam delivery system in proton beam therapy

Calibrating the dose per monitor unit (DMU) for individual patients is important to deliver the prescribed dose in radiation therapy. We have developed a DMU calculation method combining measurement data and calculation with a simplified Monte Carlo method for the double scattering system in proton beam therapy at the National Cancer Center Hospital East in Japan. The DMU calculation method determines the clinical DMU by the multiplication of three factors: a beam spreading device factor FBSD, a patient‐specific device factor FPSD, and a field‐size correction factor FFS(A). We compared the calculated and the measured DMU for 75 dose fields in clinical cases. The calculated DMUs were in agreement with measurements in ±1.1% for all of 25 fields in prostate cancer cases, and in ±3% for 94% of 50 fields in head and neck (H&N) and lung cancer cases, including irregular shape fields and small fields. Although the FBSD in the DMU calculations is dominant as expected, we found that the patient‐specific device factor and field‐size correction also contribute significantly to the calculated DMU. This DMU calculation method will be able to substitute the conventional DMU measurement for the majority of clinical cases with a reasonable calculation time required for clinical use.

PACS number: 87.55.kh

Range Verification Methods in Particle Therapy: Underlying Physics and Monte Carlo Modeling

Hadron therapy allows for highly conformal dose distributions and better sparing of organs-at-risk, thanks to the characteristic dose deposition as function of depth. However, the quality of hadron therapy treatments is closely connected with the ability to predict and achieve a given beam range in the patient. Currently, uncertainties in particle range lead to the employment of safety margins, at the expense of treatment quality. Much research in particle therapy is therefore aimed at developing methods to verify the particle range in patients. Non-invasive in vivo monitoring of the particle range can be performed by detecting secondary radiation, emitted from the patient as a result of nuclear interactions of charged hadrons with tissue, including β (+) emitters, prompt photons, and charged fragments. The correctness of the dose delivery can be verified by comparing measured and pre-calculated distributions of the secondary particles. The reliability of Monte Carlo (MC) predictions is a key issue. Correctly modeling the production of secondaries is a non-trivial task, because it involves nuclear physics interactions at energies, where no rigorous theories exist to describe them. The goal of this review is to provide a comprehensive overview of various aspects in modeling the physics processes for range verification with secondary particles produced in proton, carbon, and heavier ion irradiation. We discuss electromagnetic and nuclear interactions of charged hadrons in matter, which is followed by a summary of some widely used MC codes in hadron therapy. Then, we describe selected examples of how these codes have been validated and used in three range verification techniques: PET, prompt gamma, and charged particle detection. We include research studies and clinically applied methods. For each of the techniques, we point out advantages and disadvantages, as well as clinical challenges still to be addressed, focusing on MC simulation aspects.

An analytical model of leakage neutron equivalent dose for passively-scattered proton radiotherapy and validation with measurements

Exposure to stray neutrons increases the risk of second cancer development after proton therapy. Previously reported analytical models of this exposure were difficult to configure and had not been investigated below 100 MeV proton energy. The purposes of this study were to test an analytical model of neutron equivalent dose per therapeutic absorbed dose (H/D) at 75 MeV and to improve the model by reducing the number of configuration parameters and making it continuous in proton energy from 100 to 250 MeV. To develop the analytical model, we used previously published H/D values in water from Monte Carlo simulations of a general-purpose beamline for proton energies from 100 to 250 MeV. We also configured and tested the model on in-air neutron equivalent doses measured for a 75 MeV ocular beamline. Predicted H/D values from the analytical model and Monte Carlo agreed well from 100 to 250 MeV (10% average difference). Predicted H/D values from the analytical model also agreed well with measurements at 75 MeV (15% average difference). The results indicate that analytical models can give fast, reliable calculations of neutron exposure after proton therapy. This ability is absent in treatment planning systems but vital to second cancer risk estimation.

Optimization of a general-purpose, actively scanned proton beamline for ocular treatments: Geant4 simulations

The Italian National Center for Hadrontherapy (CNAO, Centro Nazionale di Adroterapia Oncologica), a synchrotron‐based hospital facility, started the treatment of patients within selected clinical trials in late 2011 and 2012 with actively scanned proton and carbon ion beams, respectively. The activation of a new clinical protocol for the irradiation of uveal melanoma using the existing general‐purpose proton beamline is foreseen for late 2014. Beam characteristics and patient treatment setup need to be tuned to meet the specific requirements for such a type of treatment technique. The aim of this study is to optimize the CNAO transport beamline by adding passive components and minimizing air gap to achieve the optimal conditions for ocular tumor irradiation. The CNAO setup with the active and passive components along the transport beamline, as well as a human eye‐modeled detector also including a realistic target volume, were simulated using the Monte Carlo Geant4 toolkit. The strong reduction of the air gap between the nozzle and patient skin, as well as the insertion of a range shifter plus a patient‐specific brass collimator at a short distance from the eye, were found to be effective tools to be implemented. In perspective, this simulation toolkit could also be used as a benchmark for future developments and testing purposes on commercial treatment planning systems.

PACS numbers: 21.30Fe, 24.10.Lx, 29.20.dk, 29.27.Eg, 29.85.Fj

Effects of defining realistic compositions of the ocular melanoma on proton therapy

BACKGROUND

Recent studies in eye plaque brachytherapy have shown a considerable difference between the dosimetric results using water phantom and a model of human eye containing realistic materials. In spite of this fact, there is a lack of simulation studies based on such a model in proton therapy literatures. In the presented work, the effect of utilizing an eye model with ocular media on proton therapy is investigated using the MCNPX Monte Carlo Code.

METHODS

Two different eye models are proposed to study the effect of defining realistic materials on dose deposition due to utilizing pencil beam scanning (PBS) method for proton therapy of ocular melanoma. The first model is filled with water, and the second one contains the realistic materials of tumor and vitreous. Spread out Bragg peaks (SOBP) are created to cover a typical tumor volume. Moreover, isodose curves are figured in order to evaluate planar variations of absorbed dose in two models.

RESULTS

The results show that the maximum delivered dose in ocular media is approximately 12-32% more than in water phantom. Also it is found that using the optimized weighted beams in water phantom leads to disturbance of uniformity of SOBP in ocular media.

CONCLUSION

Similar to the results reported in eye brachytherapy published papers, considering the ocular media in simulation studies leads to a more realistic assessment of sufficiency of the designed proton beam in tissue. This effect is of special importance in creating SOBP, as well as in delivered dose in the tumor boundaries in proton pencil beam scanning method.

Monte Carlo and analytical model predictions of leakage neutron exposures from passively scattered proton therapy

PURPOSE

Stray neutron radiation is of concern after radiation therapy, especially in children, because of the high risk it might carry for secondary cancers. Several previous studies predicted the stray neutron exposure from proton therapy, mostly using Monte Carlo simulations. Promising attempts to develop analytical models have also been reported, but these were limited to only a few proton beam energies. The purpose of this study was to develop an analytical model to predict leakage neutron equivalent dose from passively scattered proton beams in the 100-250-MeV interval.

METHODS

To develop and validate the analytical model, the authors used values of equivalent dose per therapeutic absorbed dose (H∕D) predicted with Monte Carlo simulations. The authors also characterized the behavior of the mean neutron radiation-weighting factor, wR, as a function of depth in a water phantom and distance from the beam central axis.

RESULTS

The simulated and analytical predictions agreed well. On average, the percentage difference between the analytical model and the Monte Carlo simulations was 10% for the energies and positions studied. The authors found that wR was highest at the shallowest depth and decreased with depth until around 10 cm, where it started to increase slowly with depth. This was consistent among all energies.

CONCLUSION

Simple analytical methods are promising alternatives to complex and slow Monte Carlo simulations to predict H∕D values. The authors' results also provide improved understanding of the behavior of wR which strongly depends on depth, but is nearly independent of lateral distance from the beam central axis.

Benchmark measurements and simulations of dose perturbations due to metallic spheres in proton beams

Monte Carlo simulations are increasingly used for dose calculations in proton therapy due to its inherent accuracy. However, dosimetric deviations have been found using Monte Carlo code when high density materials are present in the proton beam line. The purpose of this work was to quantify the magnitude of dose perturbation caused by metal objects. We did this by comparing measurements and Monte Carlo predictions of dose perturbations caused by the presence of small metal spheres in several clinical proton therapy beams as functions of proton beam range, spread-out Bragg peak width and drift space. Monte Carlo codes MCNPX, GEANT4 and Fast Dose Calculator (FDC) were used. Generally good agreement was found between measurements and Monte Carlo predictions, with the average difference within 5% and maximum difference within 17%. The modification of multiple Coulomb scattering model in MCNPX code yielded improvement in accuracy and provided the best overall agreement with measurements. Our results confirmed that Monte Carlo codes are well suited for predicting multiple Coulomb scattering in proton therapy beams when short drift spaces are involved.

Effect of inhomogeneity in a patient's body on the accuracy of the pencil beam algorithm in comparison to Monte Carlo

The pencil beam algorithm (PBA) is reasonably accurate and fast. It is, therefore, the primary method used in routine clinical treatment planning for proton radiotherapy; still, it needs to be validated for use in highly inhomogeneous regions. In our investigation of the effect of patient inhomogeneity, PBA was compared with Monte Carlo (MC). A software framework was developed for the MC simulation of radiotherapy based on Geant4. Anatomical sites selected for the comparison were the head/neck, liver, lung and pelvis region. The dose distributions calculated by the two methods in selected examples were compared, as well as a dose volume histogram (DVH) derived from the dose distributions. The comparison of the off-center ratio (OCR) at the iso-center showed good agreement between the PBA and MC, while discrepancies were seen around the distal fall-off regions. While MC showed a fine structure on the OCR in the distal fall-off region, the PBA showed smoother distribution. The fine structures in MC calculation appeared downstream of very low-density regions. Comparison of DVHs showed that most of the target volumes were similarly covered, while some OARs located around the distal region received a higher dose when calculated by MC than the PBA.

First steps towards a fast-neutron therapy planning program

BACKGROUND

The Monte Carlo code GEANT4 was used to implement first steps towards a treatment planning program for fast-neutron therapy at the FRM II research reactor in Garching, Germany. Depth dose curves were calculated inside a water phantom using measured primary neutron and simulated primary photon spectra and compared with depth dose curves measured earlier. The calculations were performed with GEANT4 in two different ways, simulating a simple box geometry and splitting this box into millions of small voxels (this was done to validate the voxelisation procedure that was also used to voxelise the human body).

RESULTS

In both cases, the dose distributions were very similar to those measured in the water phantom, up to a depth of 30 cm. In order to model the situation of patients treated at the FRM II MEDAPP therapy beamline for salivary gland tumors, a human voxel phantom was implemented in GEANT4 and irradiated with the implemented MEDAPP neutron and photon spectra. The 3D dose distribution calculated inside the head of the phantom was similar to the depth dose curves in the water phantom, with some differences that are explained by differences in elementary composition. The lateral dose distribution was studied at various depths. The calculated cumulative dose volume histograms for the voxel phantom show the exposure of organs at risk surrounding the tumor.

CONCLUSIONS

In order to minimize the dose to healthy tissue, a conformal treatment is necessary. This can only be accomplished with the help of an advanced treatment planning system like the one developed here. Although all calculations were done for absorbed dose only, any biological dose weighting can be implemented easily, to take into account the increased radiobiological effectiveness of neutrons compared to photons.

Clinical implementation of a GPU-based simplified Monte Carlo method for a treatment planning system of proton beam therapy

We implemented the simplified Monte Carlo (SMC) method on graphics processing unit (GPU) architecture under the computer-unified device architecture platform developed by NVIDIA. The GPU-based SMC was clinically applied for four patients with head and neck, lung, or prostate cancer. The results were compared to those obtained by a traditional CPU-based SMC with respect to the computation time and discrepancy. In the CPU- and GPU-based SMC calculations, the estimated mean statistical errors of the calculated doses in the planning target volume region were within 0.5% rms. The dose distributions calculated by the GPU- and CPU-based SMCs were similar, within statistical errors. The GPU-based SMC showed 12.30-16.00 times faster performance than the CPU-based SMC. The computation time per beam arrangement using the GPU-based SMC for the clinical cases ranged 9-67 s. The results demonstrate the successful application of the GPU-based SMC to a clinical proton treatment planning.

Maximum kinetic energy considerations in proton stereotactic radiosurgery

The purpose of this study was to determine the maximum proton kinetic energy required to treat a given percentage of patients eligible for stereotactic radiosurgery (SRS) with coplanar arc‐based proton therapy, contingent upon the number and location of gantry angles used. Treatment plans from 100 consecutive patients treated with SRS at the University of Wisconsin Carbone Cancer Center between June of 2007 and March of 2010 were analyzed. For each target volume within each patient, in‐house software was used to place proton pencil beam spots over the distal surface of the target volume from 51 equally‐spaced gantry angles of up to 360°. For each beam spot, the radiological path length from the surface of the patient to the distal boundary of the target was then calculated along a ray from the gantry location to the location of the beam spot. This data was used to generate a maximum proton energy requirement for each patient as a function of the arc length that would be spanned by the gantry angles used in a given treatment. If only a single treatment angle is required, 100% of the patients included in the study could be treated by a proton beam with a maximum kinetic energy of 118 MeV. As the length of the treatment arc is increased to 90°, 180°, 270°, and 360°, the maximum energy requirement increases to 127, 145, 156, and 179 MeV, respectively. A very high percentage of SRS patients could be treated at relatively low proton energies if the gantry angles used in the treatment plan do not span a large treatment arc. Maximum proton kinetic energy requirements increase linearly with size of the treatment arc.

PACS numbers: 87.55.‐x, 87.53.Ly, 87.53.Bn

Application of a fast proton dose calculation algorithm to a thorax geometry

Treatment planning in proton therapy requires the calculation of absorbed dose distributions on beam shaping components and the patient anatomy. Analytical pencil-beam dose algorithms commonly used are not always accurate enough. The Monte Carlo approach is more accurate but extremely computationally intensive. The Fast Dose Calculator, a track-repeating algorithm, has been proposed as an alternative fast and accurate dose calculation. In this work FDC is applied to a proton therapy patient thoracic anatomy.

Assessment of targeting accuracy of a low-energy stereotactic radiosurgery treatment for age-related macular degeneration

Age-related macular degeneration (AMD), a leading cause of blindness in the United States, is a neovascular disease that may be controlled with radiation therapy. Early patient outcomes of external beam radiotherapy, however, have been mixed. Recently, a novel multimodality treatment was developed, comprising external beam radiotherapy and concomitant treatment with a vascular endothelial growth factor inhibitor. The radiotherapy arm is performed by stereotactic radiosurgery, delivering a 16 Gy dose in the macula (clinical target volume, CTV) using three external low-energy x-ray fields while adequately sparing normal tissues. The purpose of our study was to test the sensitivity of the delivery of the prescribed dose in the CTV using this technique and of the adequate sparing of normal tissues to all plausible variations in the position and gaze angle of the eye. Using Monte Carlo simulations of a 16 Gy treatment, we varied the gaze angle by ±5° in the polar and azimuthal directions, the linear displacement of the eye ±1 mm in all orthogonal directions, and observed the union of the three fields on the posterior wall of spheres concentric with the eye that had diameters between 20 and 28 mm. In all cases, the dose in the CTV fluctuated <6%, the maximum dose in the sclera was <20 Gy, the dose in the optic disc, optic nerve, lens and cornea were <0.7 Gy and the three-field junction was adequately preserved. The results of this study provide strong evidence that for plausible variations in the position of the eye during treatment, either by the setup error or intrafraction motion, the prescribed dose will be delivered to the CTV and the dose in structures at risk will be kept far below tolerance doses.

A GPU implementation of a track-repeating algorithm for proton radiotherapy dose calculations

An essential component in proton radiotherapy is the algorithm to calculate the radiation dose to be delivered to the patient. The most common dose algorithms are fast but they are approximate analytical approaches. However their level of accuracy is not always satisfactory, especially for heterogeneous anatomical areas, like the thorax. Monte Carlo techniques provide superior accuracy; however, they often require large computation resources, which render them impractical for routine clinical use. Track-repeating algorithms, for example the fast dose calculator, have shown promise for achieving the accuracy of Monte Carlo simulations for proton radiotherapy dose calculations in a fraction of the computation time. We report on the implementation of the fast dose calculator for proton radiotherapy on a card equipped with graphics processor units (GPUs) rather than on a central processing unit architecture. This implementation reproduces the full Monte Carlo and CPU-based track-repeating dose calculations within 2%, while achieving a statistical uncertainty of 2% in less than 1 min utilizing one single GPU card, which should allow real-time accurate dose calculations.

Development and verification of an analytical algorithm to predict absorbed dose distributions in ocular proton therapy using Monte Carlo simulations

Proton beam radiotherapy is an effective and non-invasive treatment for uveal melanoma. Recent research efforts have focused on improving the dosimetric accuracy of treatment planning and overcoming the present limitation of relative analytical dose calculations. Monte Carlo algorithms have been shown to accurately predict dose per monitor unit (D/MU) values, but this has yet to be shown for analytical algorithms dedicated to ocular proton therapy, which are typically less computationally expensive than Monte Carlo algorithms. The objective of this study was to determine if an analytical method could predict absolute dose distributions and D/MU values for a variety of treatment fields like those used in ocular proton therapy. To accomplish this objective, we used a previously validated Monte Carlo model of an ocular nozzle to develop an analytical algorithm to predict three-dimensional distributions of D/MU values from pristine Bragg peaks and therapeutically useful spread-out Bragg peaks (SOBPs). Results demonstrated generally good agreement between the analytical and Monte Carlo absolute dose calculations. While agreement in the proximal region decreased for beams with less penetrating Bragg peaks compared with the open-beam condition, the difference was shown to be largely attributable to edge-scattered protons. A method for including this effect in any future analytical algorithm was proposed. Comparisons of D/MU values showed typical agreement to within 0.5%. We conclude that analytical algorithms can be employed to accurately predict absolute proton dose distributions delivered by an ocular nozzle.

Maximum proton kinetic energy and patient-generated neutron fluence considerations in proton beam arc delivery radiation therapy

Several compact proton accelerator systems for use in proton therapy have recently been proposed. Of paramount importance to the development of such an accelerator system is the maximum kinetic energy of protons, immediately prior to entry into the patient, that must be reached by the treatment system. The commonly used value for the maximum kinetic energy required for a medical proton accelerator is 250 MeV, but it has not been demonstrated that this energy is indeed necessary to treat all or most patients eligible for proton therapy. This article quantifies the maximum kinetic energy of protons, immediately prior to entry into the patient, necessary to treat a given percentage of patients with rotational proton therapy, and examines the impact of this energy threshold on the cost and feasibility of a compact, gantry-mounted proton accelerator treatment system. One hundred randomized treatment plans from patients treated with IMRT were analyzed. The maximum radiological pathlength from the surface of the patient to the distal edge of the treatment volume was obtained for 180 degrees continuous arc proton therapy and for 180 degrees split arc proton therapy (two 90 degrees arcs) using CT# profiles from the Pinnacle (Philips Medical Systems, Madison, WI) treatment planning system. In each case, the maximum kinetic energy of protons, immediately prior to entry into the patient, that would be necessary to treat the patient was calculated using proton range tables for various media. In addition, Monte Carlo simulations were performed to quantify neutron production in a water phantom representing a patient as a function of the maximum proton kinetic energy achievable by a proton treatment system. Protons with a kinetic energy of 240 MeV, immediately prior to entry into the patient, were needed to treat 100% of patients in this study. However, it was shown that 90% of patients could be treated at 198 MeV, and 95% of patients could be treated at 207 MeV. Decreasing the proton kinetic energy from 250 to 200 MeV decreases the total neutron energy fluence produced by stopping a monoenergetic pencil beam in a water phantom by a factor of 2.3. It is possible to significantly lower the requirements on the maximum kinetic energy of a compact proton accelerator if the ability to treat a small percentage of patients with rotational therapy is sacrificed. This decrease in maximum kinetic energy, along with the corresponding decrease in neutron production, could lower the cost and ease the engineering constraints on a compact proton accelerator treatment facility.

Monte Carlo modelling of the treatment line of the Proton Therapy Center in Orsay

This paper presents the main results of a Monte Carlo simulation describing the Orsay Proton Therapy Center (CPO) beam line. The project aimed to obtain a prediction of the dose distribution in a water phantom within 2% accuracy in the dose value and a 2 mm of range. The simulation tool used was MCNPX, version 2.5.0, and included all the elements of the CPO beam line. A new algorithm of multiple Coulomb scattering has been incorporated in MCNPX, resulting in a better prediction of the spatial dose distribution and absolute values of the deposited energy. The simulations of 3D dose profiles in water show a very good agreement with measured data to within 2%. We first performed a comparative analysis of the dosimetry in heterogeneous phantoms between the pencil beam algorithm and MCNPX. The simulations give a better agreement with experimental data compared to the pencil beam approach. In a second phase, we simulated the patient-dependent fields along with the spatial dose distributions in a water phantom. The simulated response of a Pixel chamber located 2 m upstream of the water phantom revealed a good agreement with the measured data to within 1%. The results presented herein support the applicability of Monte Carlo models for absolute dosimetry and for design purposes regarding existing and new beam lines at CPO. This work completes a series of publications reporting the progress in the development of a Monte Carlo simulation tool for the CPO beam line dedicated for the treatment of head and neck tumours.

Stray radiation dose and second cancer risk for a pediatric patient receiving craniospinal irradiation with proton beams

Proton beam radiotherapy unavoidably exposes healthy tissue to stray radiation emanating from the treatment unit and secondary radiation produced within the patient. These exposures provide no known benefit and may increase a patient's risk of developing a radiogenic cancer. The aims of this study were to calculate doses to major organs and tissues and to estimate second cancer risk from stray radiation following craniospinal irradiation (CSI) with proton therapy. This was accomplished using detailed Monte Carlo simulations of a passive-scattering proton treatment unit and a voxelized phantom to represent the patient. Equivalent doses, effective dose and corresponding risk for developing a fatal second cancer were calculated for a 10-year-old boy who received proton therapy. The proton treatment comprised CSI at 30.6 Gy plus a boost of 23.4 Gy to the clinical target volume. The predicted effective dose from stray radiation was 418 mSv, of which 344 mSv was from neutrons originating outside the patient; the remaining 74 mSv was caused by neutrons originating within the patient. This effective dose corresponds to an attributable lifetime risk of a fatal second cancer of 3.4%. The equivalent doses that predominated the effective dose from stray radiation were in the lungs, stomach and colon. These results establish a baseline estimate of the stray radiation dose and corresponding risk for a pediatric patient undergoing proton CSI and support the suitability of passively-scattered proton beams for the treatment of central nervous system tumors in pediatric patients.

Effective Dose from Stray Radiation for a Patient Receiving Proton Therapy for Liver Cancer

Because of its advantageous depth-dose relationship, proton radiotherapy is an emerging treatment modality for patients with liver cancer. Although the proton dose distribution conforms to the target, healthy tissues throughout the body receive low doses of stray radiation, particularly neutrons that originate in the treatment unit or in the patient. The aim of this study was to calculate the effective dose from stray radiation and estimate the corresponding risk of second cancer fatality for a patient receiving proton beam therapy for liver cancer. Effective dose from stray radiation was calculated using detailed Monte Carlo simulations of a double-scattering proton therapy treatment unit and a voxelized human phantom. The treatment plan and phantom were based on CT images of an actual adult patient diagnosed with primary hepatocellular carcinoma. For a prescribed dose of 60 Gy to the clinical target volume, the effective dose from stray radiation was 370 mSv; 61% of this dose was from neutrons originating outside of the patient while the remaining 39% was from neutrons originating within the patient. The excess lifetime risk of fatal second cancer corresponding to the total effective dose from stray radiation was 1.2%. The results of this study establish a baseline estimate of the stray radiation dose and corresponding risk for an adult patient undergoing proton radiotherapy for liver cancer and provide new evidence to corroborate the suitability of proton beam therapy for the treatment of liver tumors.

Neutron production from beam-modifying devices in a modern double scattering proton therapy beam delivery system

In this work the neutron production in a passive beam delivery system was investigated. Secondary particles including neutrons are created as the proton beam interacts with beam shaping devices in the treatment head. Stray neutron exposure to the whole body may increase the risk that the patient develops a radiogenic cancer years or decades after radiotherapy. We simulated a passive proton beam delivery system with double scattering technology to determine the neutron production and energy distribution at 200 MeV proton energy. Specifically, we studied the neutron absorbed dose per therapeutic absorbed dose, the neutron absorbed dose per source particle and the neutron energy spectrum at various locations around the nozzle. We also investigated the neutron production along the nozzle's central axis. The absorbed doses and neutron spectra were simulated with the MCNPX Monte Carlo code. The simulations revealed that the range modulation wheel (RMW) is the most intense neutron source of any of the beam spreading devices within the nozzle. This finding suggests that it may be helpful to refine the design of the RMW assembly, e.g., by adding local shielding, to suppress neutron-induced damage to components in the nozzle and to reduce the shielding thickness of the treatment vault. The simulations also revealed that the neutron dose to the patient is predominated by neutrons produced in the field defining collimator assembly, located just upstream of the patient.

Assessment of the accuracy of an MCNPX-based Monte Carlo simulation model for predicting three-dimensional absorbed dose distributions

In recent years, the Monte Carlo method has been used in a large number of research studies in radiation therapy. For applications such as treatment planning, it is essential to validate the dosimetric accuracy of the Monte Carlo simulations in heterogeneous media. The AAPM Report no 105 addresses issues concerning clinical implementation of Monte Carlo based treatment planning for photon and electron beams, however for proton-therapy planning, such guidance is not yet available. Here we present the results of our validation of the Monte Carlo model of the double scattering system used at our Proton Therapy Center in Houston. In this study, we compared Monte Carlo simulated depth doses and lateral profiles to measured data for a magnitude of beam parameters. We varied simulated proton energies and widths of the spread-out Bragg peaks, and compared them to measurements obtained during the commissioning phase of the Proton Therapy Center in Houston. Of 191 simulated data sets, 189 agreed with measured data sets to within 3% of the maximum dose difference and within 3 mm of the maximum range or penumbra size difference. The two simulated data sets that did not agree with the measured data sets were in the distal falloff of the measured dose distribution, where large dose gradients potentially produce large differences on the basis of minute changes in the beam steering. Hence, the Monte Carlo models of medium- and large-size double scattering proton-therapy nozzles were valid for proton beams in the 100 MeV-250 MeV interval.