Radiation safety survey on a flattening filter-free medical accelerator

Linear accelerator bunker shielding for stereotactic radiotherapy

Shielding protocols such as NCRP 151, IAEA SRS 47 and IPEM 47 are commonly used for the design of radiotherapy facilities. Some work has been accomplished in updating the basic formula with the advent of IMRT but little consideration has been made for unflattened beams and stereotactic techniques apart from for facilities housing devices like the CyberKnife. The inevitable scenario of a stereotactic-only linear accelerator was considered in this study. The necessary shielding requirements were determined based on stereotactic data from a year's worth treatments from one clinic as well as further measurements of leakage, scatter and use factors. These values were compared to recommendations in the literature. While tenth value layer amounts, workload and barrier widths could be kept at the status quo, major changes could be made to the parameters of leakage, scatter and use factors while still maintaining safety. Some differences could also be seen for the use of IMRT factors. Current shielding protocols were found to inadequately describe methodology for the shielding of a stereotactic-only radiotherapy linac bunker, producing overly-conservative wall thicknesses which is in disagreement with the principles of ICRP.

Photon dose at the maze entrance door: The comparison of flattening filter and flattening filter free working modes

In recent years, field flattening free accelerators have been introduced in therapy practice. One of the objective of these measurements was to establish if the maze door, designed for accelerators operating with flattening filter can provide adequate shielding in field flattening free mode of operation. Linac installed in this standard one band maze vault is equipped to operate at 6 MV with field flattening filter and in field flattening free mode of operation. Series of measurements of the photon dose at the maze door (with different jaws openings and gantry positions) were performed in both operation modes with and without water canister to mimic standard therapy conditions. In this paper results of photon dose measurements, performed at the maze door of the therapy linear accelerator vault are presented in order to compare photon dose in flattening filter and flattening filter free operation modes. It was obtained that in field flattening free mode of operation, the dose at the maze door is always lower than the dose measured in standard mode of operation with the field flattening filter. In the case when FFF therapy practice should start in some existing therapy vault, no additional shielding measures need to be added at the existing maze door.

A REVIEW ON THE RADIATION THERAPY TECHNOLOGIST RECEIVED DOSE FROM INDUCED ACTIVATION IN HIGH-ENERGY MEDICAL LINEAR ACCELERATORS

Despite all advantages for using high-energy photons for radiotherapy, high-energy photon beams (≥10 MV) induce photonuclear and neutron capture interactions, which result in producing radionuclide byproducts inside the Linac head and bunker, exposing radiation therapy technologists (RTTs) and patients to excessive dose. By the use of higher photon energy, greater number of monitor unit, greater field size and adding treatment accessories, induced dose rate become greater in the isocenter mainly due to activation of high-Z materials inside the Linac head. Activated radionuclides disintegrate with γ, β+ and β- rays with half-lives between 2 min up to more than 5 years. Several researches estimated additional exposure to an RTT depend on treatment strategies, beam energy, and delay time before entrance to the treatment room between 0.1 and 4.9 mSv/y and proposed at least 2 min delay before entrance to the treatment room after treatments with high-energy photon beams.

Measurement and comparison of head scatter factor for 7 MV unflattened (FFF) and 6 MV flattened photon beam using indigenously designed columnar mini phantom

AIM

To measure and compare the head scatter factor for 7 MV unflattened and 6 MV flattened photon beam using a home-made designed mini phantom.

BACKGROUND

The head scatter factor (Sc) is one of the important parameters for MU calculation. There are multiple factors that influence the Sc values, like accelerator head, flattening filter, primary and secondary collimators.

MATERIALS AND METHODS

A columnar mini phantom was designed as recommended by AAPM Task Group 74 with high and low atomic number material for measurement of head scatter factors at 10 cm and d max dose water equivalent thickness.

RESULTS

The Sc values measured with high-Z are higher than the low-Z mini phantoms observed for both 6MV-FB and 7MV-UFB photon energies. Sc values of 7MV-UFB photon beams were smaller than those of the 6MV-FB photon beams (0.6-2.2% (Primus), 0.2-1.4% (Artiste) and 0.6-3.7% (Clinac iX (2300CD))) for field sizes ranging from 10 cm × 10 cm to 40 cm × 40 cm. The SSD had no influence on head scatter for both flattened and unflattened beams. The presence of wedge filters influences the Sc values. The collimator exchange effects showed that the opening of the upper jaw increases Sc irrespective of FF and FFF.

CONCLUSIONS

There were significant differences in Sc values measured for 6MV-FB and unflattened 7MV-UFB photon beams over the range of field sizes from 10 cm × 10 cm to 40 cm × 04 cm. Different results were obtained for measurements performed with low-Z and high-Z mini phantoms.

Flattening filter-free accelerators: a report from the AAPM Therapy Emerging Technology Assessment Work Group

This report describes the current state of flattening filter‐free (FFF) radiotherapy beams implemented on conventional linear accelerators, and is aimed primarily at practicing medical physicists. The Therapy Emerging Technology Assessment Work Group of the American Association of Physicists in Medicine (AAPM) formed a writing group to assess FFF technology. The published literature on FFF technology was reviewed, along with technical specifications provided by vendors. Based on this information, supplemented by the clinical experience of the group members, consensus guidelines and recommendations for implementation of FFF technology were developed. Areas in need of further investigation were identified. Removing the flattening filter increases beam intensity, especially near the central axis. Increased intensity reduces treatment time, especially for high‐dose stereotactic radiotherapy/radiosurgery (SRT/SRS). Furthermore, removing the flattening filter reduces out‐of‐field dose and improves beam modeling accuracy. FFF beams are advantageous for small field (e.g., SRS) treatments and are appropriate for intensity‐modulated radiotherapy (IMRT). For conventional 3D radiotherapy of large targets, FFF beams may be disadvantageous compared to flattened beams because of the heterogeneity of FFF beam across the target (unless modulation is employed). For any application, the nonflat beam characteristics and substantially higher dose rates require consideration during the commissioning and quality assurance processes relative to flattened beams, and the appropriate clinical use of the technology needs to be identified. Consideration also needs to be given to these unique characteristics when undertaking facility planning. Several areas still warrant further research and development. Recommendations pertinent to FFF technology, including acceptance testing, commissioning, quality assurance, radiation safety, and facility planning, are presented. Examples of clinical applications are provided. Several of the areas in which future research and development are needed are also indicated.

PACS number: 87.53.‐j, 87.53.Bn, 87.53.Ly, 87.55.‐x, 87.55.N‐, 87.56.bc

Ambient dose and dose rate measurements in the vicinity of Elekta Precise accelerators for radiation therapy

In radiation therapy, commercially available medical linear accelerators (LINACs) are used. At high primary beam energies in the 10-MeV range, the leakage dose of the accelerator head and the backscatter from the room walls, the air and the patient become more important. Therefore, radiation protection measurements of photon dose rates in the treatment room and in the maze are performed to quantify the radiation field. Since the radiation of the LINACs is usually pulsed with short radiation pulse durations in the microsecond range, there are problems with electronic dose (rate) meters commonly used in radiation protection. In this paper measurements with ionisation chambers are presented and electronic dosemeters are used for testing at selected positions. The measured time-averaged dose rate ranges from a few microsieverts per hour in the maze to some millisieverts per hour in the vicinity of the accelerator head and up to some sieverts per hour in the blanked primary beam and several hundred sieverts per hour in the direct primary beam.

Potential hazard due to induced radioactivity secondary to radiotherapy: the report of task group 136 of the American Association of Physicists in Medicine

External-beam radiation therapy mostly uses high-energy photons (x-rays) produced by medical accelerators, but many facilities now use proton beams, and a few use fast-neutron beams. High-energy photons offer several advantages over lower-energy photons in terms of better dose distributions for deep-seated tumors, lower skin dose, less sensitivity to tissue heterogeneities, etc. However, for beams operating at or above 10 MV, some of the materials in the accelerator room and the radiotherapy patient become radioactive due primarily to photonuclear reactions and neutron capture, exposing therapy staff and patients to unwanted radiation dose. Some recent advances in radiotherapy technology require treatments using a higher number of monitor units and monitor-unit rates for the same delivered dose, and compared to the conventional treatment techniques and fractionation schemes, the activation dose to personnel can be substantially higher. Radiotherapy treatments with proton and neutron beams all result in activated materials in the treatment room. In this report, the authors review critically the published literature on radiation exposures from induced radioactivity in radiotherapy. They conclude that the additional exposure to the patient due to induced radioactivity is negligible compared to the overall radiation exposure as a part of the treatment. The additional exposure to the staff due to induced activity from photon beams is small at an estimated level of about 1 to 2 mSv y. This is well below the allowed occupational exposure limits. Therefore, the potential hazard to staff from induced radioactivity in the use of high-energy x-rays is considered to be low, and no specific actions are considered necessary or mandatory. However, in the spirit of the "As Low as Reasonably Achievable (ALARA)" program, some reasonable steps are recommended that can be taken to reduce this small exposure to an even lower level. The dose reduction strategies suggested should be followed only if these actions are considered reasonable and practical in the individual clinics. Therapists working with proton beam and neutron beam units handle treatment devices that do become radioactive, and they should wear extremity monitors and make handling apertures and boluses their last task upon entering the room following treatment. Personnel doses from neutron-beam units can approach regulatory limits depending on the number of patients and beams, and strategies to reduce doses should be followed.

Comparison of Head Scatter Factor for 6MV and 10MV flattened (FB) and Unflattened (FFF) Photon Beam using indigenously Designed Columnar Mini Phantom

To measure and compare the head scatter factor for flattened (FB) and unflattened (FFF) of 6MV and 10MV photon beam using indigenously designed mini phantom. A columnar mini phantom was designed as recommended by AAPM Task Group 74 with low and high atomic number materials at 10 cm (mini phantom) and at approximately twice the depth of maximum dose water equivalent thickness (brass build-up cap). Scatter in the accelerator (Sc) values of 6MV-FFF photon beams are lesser than that of the 6MV-FB photon beams (0.66-2.8%; Clinac iX, 2300CD) and (0.47-1.74%; True beam) for field sizes ranging from 10 × 10 cm² to 40 × 40 cm². Sc values of 10MV-FFF photon beams are lesser (0.61-2.19%; True beam) than that of the 10MV-FB photons beams for field sizes ranging from 10 × 10 cm² to 40 × 40 cm². The SSD had no influence on head scatter for both flattened and unflattened beams and irrespective of head design of the different linear accelerators. The presence of field shaping device influences the Sc values. The collimator exchange effect reveals that the opening of the upper jaw increases Sc irrespective of FB or FFF photon beams and different linear accelerators, and it is less significant in FFF beams. Sc values of 6MV-FB square field were in good agreement with that of AAPM, TG-74 published data for Varian (Clinac iX, 2300CD) accelerator. Our results confirm that the removal of flattening filter decreases in the head scatter factor compared to flattened beam. This could reduce the out-of-field dose in advanced treatment delivery techniques.

Fidelity of dose delivery at high dose rate of volumetric modulated arc therapy in a truebeam linac with flattening filter free beams

The purpose of this study is to assess fidelity of radiation delivery between high and low dose rates of the flattening filter free (FFF) modes of a new all-digital design medical linear accelerator (Varian TrueBeam™), particularly for plans optimized for volumetric modulated arc therapy (VMAT). Measurements were made for the two energies of flattening filter free photon beams with a Varian TrueBeam™ linac: 6 MV (6 XFFF) at 400 and 1400 MU/min, and 10 MV (10 XFFF) at 400 and 2400 MU/min. Data acquisition and analysis was performed with both ionization chambers and diode detector system Delta(4), for square radiation fields and for 8 VMAT treatment plans optimized for SBRT treatment of lung tumors. For the square fields, a percent dose difference between high and low dose rate of the order of 0.3-0.4% for both photon energies was seen with the ionization chambers, while the contribution to the difference from ion recombination was found to be negligible. For both the VMAT and square-field deliveries, the Delta(4) showed the same average percent dose difference between the two dose rates of ~0.8% and ~0.6% for 10 MV and 6 MV, respectively, with the lower dose rate values giving the greater measured dose compared to the high dose rate. Thus, the VMAT deliveries introduced negligible dose differences between high and low dose rate. Finally, reproducibility of dose measurements was good for both energies.

Definition of parameters for quality assurance of flattening filter free (FFF) photon beams in radiation therapy

PURPOSE

Flattening filter free (FFF) beams generated by medical linear accelerators have recently started to be used in radiotherapy clinical practice. Such beams present fundamental differences with respect to the standard filter flattened (FF) beams, making the generally used dosimetric parameters and definitions not always viable. The present study will propose possible definitions and suggestions for some dosimetric parameters for use in quality assurance of FFF beams generated by medical linacs in radiotherapy.

METHODS

The main characteristics of the photon beams have been analyzed using specific data generated by a Varian TrueBeam linac having both FFF and FF beams of 6 and 10 MV energy, respectively.

RESULTS

Definitions for dose profile parameters are suggested starting from the renormalization of the FFF with respect to the corresponding FF beam. From this point the flatness concept has been translated into one of "unflatness" and other definitions have been proposed, maintaining a strict parallelism between FFF and FF parameter concepts.

CONCLUSIONS

Ideas for quality controls used in establishing a quality assurance program when introducing FFF beams into the clinical environment are given here, keeping them similar to those used for standard FF beams. By following the suggestions in this report, the authors foresee that the introduction of FFF beams into a clinical radiotherapy environment will be as safe and well controlled as standard beam modalities using the existing guidelines.

Health physics aspects in treatment rooms after 18-MV X-ray irradiations

Delayed activation products contribute to the exposure of the staff operating high-energy accelerators. Induced activity was studied in a treatment room following 18-MV X-ray irradiations using a hand-held system that allows both dose rate measurements and spectroscopic analysis. The major activation products and the corresponding nuclear reactions were identified. At the majority of the studied locations, β(+) emitters were the main short-term dose contributors. The time variation of the absorbed dose rate in a treatment room during the first 20-min post-irradiation was represented by the sum of two exponential components with half-lives of 1-2 min and either 4 or 10 min, depending on the location in the room. Components with a half-life of hours or days contribute <1 % to the initial dose rate. The activation of some accessories, such as iron filters and portal imagers, deserve special attention. The collection of such data with the proposed method allows the development of optimised working protocols at each treatment room.

Current status and future perspective of flattening filter free photon beams

PURPOSE

Flattening filters (FFs) have been considered as an integral part of the treatment head of a medical accelerator for more than 50 years. The reasons for the longstanding use are, however, historical ones. Advanced treatment techniques, such as stereotactic radiotherapy or intensity modulated radiotherapy have stimulated the interest in operating linear accelerators in a flattening filter free (FFF) mode. The current manuscript reviews treatment head physics of FFF beams, describes their characteristics and the resulting potential advantages in their medical use, and closes with an outlook.

METHODS

A number of dosimetric benefits have been determined for FFF beams, which range from increased dose rate and dose per pulse to favorable output ratio in-air variation with field size, reduced energy variation across the beam, and reduced leakage and out-of-field dose, respectively. Finally, the softer photon spectrum of unflattened beams has implications on imaging strategies and radiation protection.

RESULTS

The dosimetric characteristics of FFF beams have an effect on treatment delivery, patient comfort, dose calculation accuracy, beam matching, absorbed dose determination, treatment planning, machine specific quality assurance, imaging, and radiation protection. When considering conventional C-arm linacs in a FFF mode, more studies are needed to specify and quantify the clinical advantages, especially with respect to treatment plan quality and quality assurance.

CONCLUSIONS

New treatment units are already on the market that operate without a FF or can be operated in a dedicated clinical FFF mode. Due to the convincing arguments of removing the FF, it is expected that more vendors will offer dedicated treatment units for advanced photon beam therapy in the near future. Several aspects related to standardization, dosimetry, treatment planning, and optimization need to be addressed in more detail in order to facilitate the clinical implementation of unflattened beams.

Treatment planning and delivery of IMRT using 6 and 18MV photon beams without flattening filter

In light of the increasing use of intensity modulated radiation therapy (IMRT) in modern radiotherapy practice, the use of a flattening filter may no longer be necessary. Commissioning data have been measured for a Varian 23EX linear accelerator with 6 and 18 MV photon energies without a flattening filter. Measurements collected for the commissioning of the linac included percent depth dose curves and profiles for field sizes ranging from 2 x 2 to 40 x 40 cm(2) as defined by the jaws and multileaf collimator. Machine total scatter factors were measured and calculated. Measurements were used to model the unflattened beams with the Pinnacle(3) treatment planning system. IMRT plans for prostate, lung, brain and head and neck cancer cases were generated using the flattening filter and flattening filter-free beams. From our results, no difference in the quality of the treatment plans between the flat and unflattened photon beams was noted. There was however a significant decrease in the number of monitor units required for unflattened beam treatment plans due to the increase in linac output-approximately two times and four times higher for the 6 and 18 MV, respectively.

A Monte Carlo study on neutron and electron contamination of an unflattened 18-MV photon beam

Recent studies on flattening filter (FF) free beams have shown increased dose rate and less out-of-field dose for unflattened photon beams. On the other hand, changes in contamination electrons and neutron spectra produced through photon (E>10 MV) interactions with linac components have not been completely studied for FF free beams. The objective of this study was to investigate the effect of removing FF on contamination electron and neutron spectra for an 18-MV photon beam using Monte Carlo (MC) method. The 18-MV photon beam of Elekta SL-25 linac was simulated using MCNPX MC code. The photon, electron and neutron spectra at a distance of 100 cm from target and on the central axis of beam were scored for 10 x 10 and 30 x 30 cm(2) fields. Our results showed increase in contamination electron fluence (normalized to photon fluence) up to 1.6 times for FF free beam, which causes more skin dose for patients. Neuron fluence reduction of 54% was observed for unflattened beams. Our study confirmed the previous measurement results, which showed neutron dose reduction for unflattened beams. This feature can lead to less neutron dose for patients treated with unflattened high-energy photon beams.