An EGSnrc Monte Carlo study of the microionization chamber for reference dosimetry of narrow irregular IMRT beamlets

Validation of Microionization Chambers in Small-field Dosimetry

Aim

This study aims to validate the Razor Nano Chamber (RNC) and Razor Chamber (RC) dosimetric characteristics in a small field. The dosimetric parameters of the two chambers were compared.

Materials and Methods

The chamber characteristics of leakage (pre and post), stability, energy dependency, dose linearity, dose rate effect, stem effect, angular dependency, ion recombination effect, and polarity effect were studied. Relative dose measurements of the percentage depth dose, profile measurement, and output factor (OF) measurements were performed for small fields. All measurements were performed in a Theratron 780E telecobalt unit and an Elekta Versa HD™ Linear Accelerator.

Results and Discussion

The measured pre- and postirradiation leakage and energy dependency were within 0.5% of the acceptable limit. In the stability check, the standard error and standard error of mean were 0.047% and 0.068%, respectively, for both RNC and RC. The deviation in the angular responses of the RNC and RC ion chambers was negligible. In the ion recombination measurements, both the RNC and RC were overestimated for the 10 flattening filter-free photon beam. In small fields, there were no significant differences in the kpol values for either chamber. The RNC showed good agreement in the relative dose measurements compared to the RC.

Conclusion

RNC and RC showed good agreement in small-field dosimetry. The RNC angular dependency and OF showed a superior response compared to the RC because of the small volume spherical shape and high spatial resolution, which gives a reduced penumbra and no volume averaging effect.

Cylindrical ionization chamber response in static and dynamic 6 and 15 MV photon beams

Purpose.To investigate the response of the CC13 ionization chamber under non-reference photon beam conditions, focusing on penumbra and build-up regions of static fields and on dynamic intensity-modulated beams.Methods. Measurements were performed in 6 MV 100 × 100, 20 × 100, and 20 × 20 mm²static fields. Monte Carlo calculations were performed for the static fields and for 6 and 15 MV dynamic beam sequences using a Varian multi-leaf collimator. The chamber was modelled using EGSnrc egs_chamber software. Conversion factors were calculated by relating the absorbed dose to air in the chamber air cavity to the absorbed dose to water. Correction and point-dose correction factors were calculated to quantify the conversion factor variations.Results. The correction factors for positions on the beam central axis and at the penumbra centre were 0.98-1.02 for all static fields and depths investigated. The largest corrections were obtained for chamber positions beyond penumbra centre in the off-axis direction. Point-dose correction factors were 0.54-0.71 at 100 mm depth and their magnitude increased with decreasing field size and measurement depth. Factors of 0.99-1.03 were obtained inside and near the integrated penumbra of the dynamic field at 100 mm depth, and of 0.92-0.94 beyond the integrated penumbra centre. The variations in the ionization chamber response across the integrated dynamic penumbra qualitatively followed the behaviour across penumbra of static fields.Conclusions. Without corrections, the CC13 chamber was of limited usefulness for profile measurements in 20-mm-wide fields. However, measurements in dynamic small irregular beam openings resembling the conditions of pre-treatment patient quality assurance were feasible. Uncorrected ionization chamber response could be applied for dose verification at 100 mm depth inside and close to large gradients of dynamically accumulating high- and low-dose regions assuming 3% tolerance between measured and calculated doses.

Monte Carlo methods for device simulations in radiation therapy

Monte Carlo (MC) simulations play an important role in radiotherapy, especially as a method to evaluate physical properties that are either impossible or difficult to measure. For example, MC simulations (MCSs) are used to aid in the design of radiotherapy devices or to understand their properties. The aim of this article is to review the MC method for device simulations in radiation therapy. After a brief history of the MC method and popular codes in medical physics, we review applications of the MC method to model treatment heads for neutral and charged particle radiation therapy as well as specific in-room devices for imaging and therapy purposes. We conclude by discussing the impact that MCSs had in this field and the role of MC in future device design.

Neutron contamination in radiotherapy processes: a review study

Using high-energy photon beams is one of the most practical methods in radiotherapy treatment of cases in deep site located tumors. In such treatments, neutron contamination induced through photoneutron interaction of high energy photons (>8 MeV) with high Z materials of LINAC structures is the most crucial issue which should be considered. Generated neutrons will affect shielding calculations and cause extra doses to the patient and the probability of increase induced secondary cancer risks. In this study, different parameters of neutron production in radiotherapy processes will be reviewed.

Report of AAPM Task Group 155: Megavoltage photon beam dosimetry in small fields and non-equilibrium conditions

Small-field dosimetry used in advance treatment technologies poses challenges due to loss of lateral charged particle equilibrium (LCPE), occlusion of the primary photon source, and the limited choice of suitable radiation detectors. These challenges greatly influence dosimetric accuracy. Many high-profile radiation incidents have demonstrated a poor understanding of appropriate methodology for small-field dosimetry. These incidents are a cause for concern because the use of small fields in various specialized radiation treatment techniques continues to grow rapidly. Reference and relative dosimetry in small and composite fields are the subject of the International Atomic Energy Agency (IAEA) dosimetry code of practice that has been published as TRS-483 and an AAPM summary publication (IAEA TRS 483; Dosimetry of small static fields used in external beam radiotherapy: An IAEA/AAPM International Code of Practice for reference and relative dose determination, Technical Report Series No. 483; Palmans et al., Med Phys 45(11):e1123, 2018). The charge of AAPM task group 155 (TG-155) is to summarize current knowledge on small-field dosimetry and to provide recommendations of best practices for relative dose determination in small megavoltage photon beams. An overview of the issue of LCPE and the changes in photon beam perturbations with decreasing field size is provided. Recommendations are included on appropriate detector systems and measurement methodologies. Existing published data on dosimetric parameters in small photon fields (e.g., percentage depth dose, tissue phantom ratio/tissue maximum ratio, off-axis ratios, and field output factors) together with the necessary perturbation corrections for various detectors are reviewed. A discussion on errors and an uncertainty analysis in measurements is provided. The design of beam models in treatment planning systems to simulate small fields necessitates special attention on the influence of the primary beam source and collimating devices in the computation of energy fluence and dose. The general requirements for fluence and dose calculation engines suitable for modeling dose in small fields are reviewed. Implementations in commercial treatment planning systems vary widely, and the aims of this report are to provide insight for the medical physicist and guidance to developers of beams models for radiotherapy treatment planning systems.

Reference dosimetry of modulated and dynamic photon beams

In the late 1980s, a new technique was proposed that would revolutionize radiotherapy. Now referred to as intensity-modulated radiotherapy, it is at the core of state-of-the-art photon beam delivery techniques, such as helical tomotherapy and volumetric modulated arc therapy. Despite over two decades of clinical application, there are still no established guidelines on the calibration of dynamic modulated photon beams. In 2008, the IAEA-AAPM work group on nonstandard photon beam dosimetry published a formalism to support the development of a new generation of protocols applicable to nonstandard beam reference dosimetry (Alfonso et al 2008 Med. Phys. 35 5179-86). The recent IAEA Code of Practice TRS-483 was published as a result of this initiative and addresses exclusively small static beams. But the plan-class specific reference calibration route proposed by Alfonso et al (2008 Med. Phys. 35 5179-86) is a change of paradigm that is yet to be implemented in radiotherapy clinics. The main goals of this paper are to provide a literature review on the dosimetry of nonstandard photon beams, including dynamic deliveries, and to discuss anticipated benefits and challenges in a future implementation of the IAEA-AAPM formalism on dynamic photon beams.

Monte Carlo simulations in radiotherapy dosimetry

BACKGROUND

The use of the Monte Carlo (MC) method in radiotherapy dosimetry has increased almost exponentially in the last decades. Its widespread use in the field has converted this computer simulation technique in a common tool for reference and treatment planning dosimetry calculations.

METHODS

This work reviews the different MC calculations made on dosimetric quantities, like stopping-power ratios and perturbation correction factors required for reference ionization chamber dosimetry, as well as the fully realistic MC simulations currently available on clinical accelerators, detectors and patient treatment planning.

CONCLUSIONS

Issues are raised that include the necessity for consistency in the data throughout the entire dosimetry chain in reference dosimetry, and how Bragg-Gray theory breaks down for small photon fields. Both aspects are less critical for MC treatment planning applications, but there are important constraints like tissue characterization and its patient-to-patient variability, which together with the conversion between dose-to-water and dose-to-tissue, are analysed in detail. Although these constraints are common to all methods and algorithms used in different types of treatment planning systems, they make uncertainties involved in MC treatment planning to still remain "uncertain".

CPU time optimization and precise adjustment of the Geant4 physics parameters for a VARIAN 2100 C/D gamma radiotherapy linear accelerator simulation using GAMOS

We have verified the GAMOS/Geant4 simulation model of a 6 MV VARIAN Clinac 2100 C/D linear accelerator by the procedure of adjusting the initial beam parameters to fit the percentage depth dose and cross-profile dose experimental data at different depths in a water phantom. Thanks to the use of a wide range of field sizes, from 2  ×  2 cm² to 40  ×  40 cm², a small phantom voxel size and high statistics, fine precision in the determination of the beam parameters has been achieved. This precision has allowed us to make a thorough study of the different physics models and parameters that Geant4 offers. The three Geant4 electromagnetic physics sets of models, i.e. Standard, Livermore and Penelope, have been compared to the experiment, testing the four different models of angular bremsstrahlung distributions as well as the three available multiple-scattering models, and optimizing the most relevant Geant4 electromagnetic physics parameters. Before the fitting, a comprehensive CPU time optimization has been done, using several of the Geant4 efficiency improvement techniques plus a few more developed in GAMOS.

Dosimetric characterization and behaviour in small X-ray fields of a microchamber and a plastic scintillator detector

OBJECTIVE

The aim of this work was to investigate the main dosimetric characteristics and the performance of an A26 Exradin ionization microchamber (A26 IC) and a W1 Exradin plastic scintillation detector (W1 PSD) in small photon beam dosimetry for treatment planning system commissioning and quality assurance programme.

METHODS

Detector characterization measurements (short-term stability, dose linearity, angular dependence and energy dependence) were performed in water for field sizes up to 10 × 10 cm². Polarity effect (P_pol) was examined for the A26 IC. The behaviour of the detectors in small field relative dosimetry [percentage depth dose, dose profiles often called the off-axis ratio and output factors (OFs)] was investigated for field sizes ranging from 1 × 1 to 3 × 3 cm².

RESULTS

Results were compared with those obtained with other detectors we already use for small photon beam dosimetry. A26 IC and W1 PSD showed a linear dose response. While the A26 IC showed no energy dependence, the W1 PSD showed energy dependence within 2%; no angular dependence was registered. P_pol values for A26 IC were below 0.9% (0.5% for field size >2 × 2 cm²). A26 IC and W1 PSD depth-dose curves and lateral profiles agreed with those obtained with an EDGE diode. No differences were observed among the detectors in OF measurement for field sizes larger than 1 × 1 cm², with average differences <1%. For field sizes <1 × 1 cm², the effective volume of ionization chamber and non-water equivalence of EDGE diode become significant. A26 IC OF values were significantly lower than EDGE diode and W1 PSD values, with percentage differences of about -23 and -13% for the smallest field, respectively. W1 PSD OF values lay between ion chambers and diode values, with a maximum percentage difference of about -10% with respect to the EDGE diode, for a 6 × 6-mm² field size.

CONCLUSION

The results of our investigation confirm that A26 IC and W1 PSD could play an important role in small field relative dosimetry. Advances in knowledge: Dosimetric characteristics of Exradin A26 ionization microchamber and W1 plastic scintillation detector for small field dosimetry.

Determination of small-field correction factors for cylindrical ionization chambers using a semiempirical method

A semiempirical method based on the averaging effect of the sensitive volumes of different air-filled ionization chambers (ICs) was employed to approximate the correction factors for beam quality produced from the difference in the sizes of the reference field and small fields.We measured the output factors using several cylindrical ICs and calculated the correction factors using a mathematical method similar to deconvolution; in the method, we modeled the variable and inhomogeneous energy fluence function within the chamber cavity. The parameters of the modeled function and the correction factors were determined by solving a developed system of equations as well as on the basis of the measurement data and the geometry of the chambers. Further, Monte Carlo (MC) computations were performed using the Monaco® treatment planning system to validate the proposed method.The determined correction factors () were comparable to the values derived from the MC computations performed using Monaco®. For example, for a 6 MV photon beam and a field size of 1  ×  1 cm2, was calculated to be for a PTW 31010 chamber and for a PTW 31016 chamber. On the other hand, the values determined from the MC computations were 1.121 and 1.031, respectively; the difference between the proposed method and the MC computation is less than 2%. In addition, we determined the values for PTW 30013, PTW 31010, PTW 31016, IBA FC23-C, and IBA CC13 chambers as well.We devised a method for determining from both the measurement of the output factors and model-based mathematical computation. The proposed method can be useful in case the MC simulation would not be applicable for the clinical settings.

Experimental determination of the lateral dose response functions of detectors to be applied in the measurement of narrow photon-beam dose profiles

This study aims at the experimental determination of the detector-specific 1D lateral dose response function K(x) and of its associated rotational symmetric counterpart K(r) for a set of high-resolution detectors presently used in narrow-beam photon dosimetry. A combination of slit-beam, radiochromic film, and deconvolution techniques served to accomplish this task for four detectors with diameters of their sensitive volumes ranging from 1 to 2.2 mm. The particular aim of the experiment was to examine the existence of significant negative portions of some of these response functions predicted by a recent Monte-Carlo-simulation (Looe et al 2015 Phys. Med. Biol. 60 6585-607). In a 6 MV photon slit beam formed by the Siemens Artiste collimation system and a 0.5 mm wide slit between 10 cm thick lead blocks serving as the tertiary collimator, the true cross-beam dose profile D(x) at 3 cm depth in a large water phantom was measured with radiochromic film EBT3, and the detector-affected cross-beam signal profiles M(x) were recorded with a silicon diode, a synthetic diamond detector, a miniaturized scintillation detector, and a small ionization chamber. For each detector, the deconvolution of the convolution integral M(x)  =  K(x)  ∗  D(x) served to obtain its specific 1D lateral dose response function K(x), and K(r) was calculated from it. Fourier transformations and back transformations were performed using function approximations by weighted sums of Gaussian functions and their analytical transformation. The 1D lateral dose response functions K(x) of the four types of detectors and their associated rotational symmetric counterparts K(r) were obtained. Significant negative curve portions of K(x) and K(r) were observed in the case of the silicon diode and the diamond detector, confirming the Monte-Carlo-based prediction (Looe et al 2015 Phys. Med. Biol. 60 6585-607). They are typical for the perturbation of the secondary electron field by a detector with enhanced electron density compared with the surrounding water. In the cases of the scintillation detector and the small ionization chamber, the negative curve portions of K(x) practically vanish. It is planned to use the measured functions K(x) and K(r) to deconvolve clinical narrow-beam signal profiles and to correct the output factor values obtained with various high-resolution detectors.

Clinical and dosimetric implications of intensity-modulated radiotherapy for early-stage glottic carcinoma

Conventional parallel-opposed radiotherapy (PORT) is the established standard technique for early-stage glottic carcinoma. However, case reports have reported the utility of intensity-modulated radiotherapy (IMRT) and volumetric-modulated arc therapy (VMAT) with or without image guidance (image-guided radiotherapy, IGRT) in select patients. The proposed advantages of IMRT/VMAT include sparing of the carotid artery, thyroid gland, and the remaining functional larynx, although these benefits remain unclear. The following case study presents a patient with multiple vascular comorbidities treated with VMAT for early-stage glottic carcinoma. A detailed explanation of the corresponding treatment details, dose-volume histogram (DVH) analysis, and a review of the relevant literature are provided. Conventional PORT remains the standard of care for early-stage glottic carcinoma. IMRT or VMAT may be beneficial for select patients, although great care is necessary to avoid a geographical miss. Clinical data supporting the benefit of CRT are lacking. Therefore, these techniques should be used with caution and only in selected patients.

Step-and-Shoot IMRT by Siemens Beams: An EPID Dosimetry Verification During Treatment

PURPOSE

This work reports the extension of a semiempirical method based on the correlation ratios to convert electronic portal imaging devices transit signals into in vivo doses for the step-and-shoot intensity-modulated radiotherapy Siemens beams. The dose reconstructed at the isocenter point Diso, compared to the planned dose, Diso,TPS, and a γ-analysis between 2-dimensional electronic portal imaging device images obtained day to day, seems to supply a practical method to verify the beam delivery reproducibility.

METHOD

The electronic portal imaging device images were obtained by the superposition of many segment fields, and the algorithm for the Diso reconstruction for intensity-modulated radiotherapy step and shoot was formulated using a set of simulated intensity-modulated radiotherapy beams. Moreover, the in vivo dose-dedicated software was integrated with the record and verify system of the centers.

RESULTS

Three radiotherapy centers applied the in vivo dose procedure at 30 clinical intensity-modulated radiotherapy treatments, each one obtained with 5 or 7 beams, and planned for patients undergoing radiotherapy for prostatic tumors. Each treatment beam was checked 5 times, obtaining 900 tests of the ratios R = Diso/Diso,TPS. The average R value was equal to 1.002 ± 0.056 (2 standard deviation), while the mean R value for each patient was well within 5%, once the causes of errors were removed. The γ-analysis of the electronic portal imaging device images, with 3% 3 mm acceptance criteria, showed 90% of the tests with Pγ < 1 ≥ 95% and γmean ≤ 0.5. The off-tolerance tests were found due to incorrect setup or presence of morphological changes. This preliminary experience shows the great utility of obtaining the in vivo dose results in quasi real time and close to the linac, where the radiotherapy staff may immediately spot possible causes of errors. The in vivo dose procedure presented here is one of the objectives of a project, for the development of practical in vivo dose procedures, financially supported by the Istituto Nazionale di Fisica Nucleare.

Variation of kQclin,Qmsr (fclin,fmsr) for the small-field dosimetric parameters percentage depth dose, tissue-maximum ratio, and off-axis ratio

PURPOSE

Evaluate the ability of different dosimeters to correctly measure the dosimetric parameters percentage depth dose (PDD), tissue-maximum ratio (TMR), and off-axis ratio (OAR) in water for small fields.

METHODS

Monte Carlo (MC) simulations were used to estimate the variation of kQclin,Qmsr (fclin,fmsr) for several types of microdetectors as a function of depth and distance from the central axis for PDD, TMR, and OAR measurements. The variation of kQclin,Qmsr (fclin,fmsr) enables one to evaluate the ability of a detector to reproduce the PDD, TMR, and OAR in water and consequently determine whether it is necessary to apply correction factors. The correctness of the simulations was verified by assessing the ratios between the PDDs and OARs of 5- and 25-mm circular collimators used with a linear accelerator measured with two different types of dosimeters (the PTW 60012 diode and PTW PinPoint 31014 microchamber) and the PDDs and the OARs measured with the Exradin W1 plastic scintillator detector (PSD) and comparing those ratios with the corresponding ratios predicted by the MC simulations.

RESULTS

MC simulations reproduced results with acceptable accuracy compared to the experimental results; therefore, MC simulations can be used to successfully predict the behavior of different dosimeters in small fields. The Exradin W1 PSD was the only dosimeter that reproduced the PDDs, TMRs, and OARs in water with high accuracy. With the exception of the EDGE diode, the stereotactic diodes reproduced the PDDs and the TMRs in water with a systematic error of less than 2% at depths of up to 25 cm; however, they produced OAR values that were significantly different from those in water, especially in the tail region (lower than 20% in some cases). The microchambers could be used for PDD measurements for fields greater than those produced using a 10-mm collimator. However, with the detector stem parallel to the beam axis, the microchambers could be used for TMR measurements for all field sizes. The microchambers could not be used for OAR measurements for small fields.

CONCLUSIONS

Compared with MC simulation, the Exradin W1 PSD can reproduce the PDDs, TMRs, and OARs in water with a high degree of accuracy; thus, the correction used for converting dose is very close to unity. The stereotactic diode is a viable alternative because it shows an acceptable systematic error in the measurement of PDDs and TMRs and a significant underestimation in only the tail region of the OAR measurements, where the dose is low and differences in dose may not be therapeutically meaningful.

Monte Carlo investigation of collapsed versus rotated IMRT plan verification

IMRT QA requires, among other tests, a time-consuming process of measuring the absorbed dose, at least to a point, in a high-dose, low-dose-gradient region. Some clinics use a technique of measuring this dose with all beams delivered at a single gantry angle (collapsed delivery), as opposed to the beams delivered at the planned gantry angle (rotated delivery). We examined, established, and optimized Monte Carlo simulations of the dosimetry for IMRT verification of treatment plans for these two different delivery modes (collapsed versus rotated). The results of the simulations were compared to the treatment planning system dose calculations for the two delivery modes, as well as to measurements taken. This was done in order to investigate the validity of the use of a collapsed delivery technique for IMRT QA. The BEAMnrc, DOSXYZnrc, and egs_chamber codes were utilized for the Monte Carlo simulations along with the MMCTP system. A number of different plan complexity metrics were also used in the analysis of the dose distributions in a bid to qualify why verification in a collapsed delivery may or may not be optimal for IMRT QA. Following the Alfonso et al. formalism, the kfclin,frefQclin,Q correction factor was calculated to correct the deviation of small fields from the reference conditions used for beam calibration. We report on the results obtained for a cohort of 20 patients. The plan complexity was investigated for each plan using the complexity metrics of homogeneity index, conformity index, modulation complexity score, and the fraction of beams from a particular plan that intersect the chamber when performing the QA. Rotated QA gives more consistent results than the collapsed QA technique. The kfclin,frefQclin,Qfactor deviates less from 1 for rotated QA than for collapsed QA. If the homogeneity index is less than 0.05 then the kfclin,frefQclin,Q factor does not deviate from unity by more than 1%. A value this low for the homogeneity index can only be obtained with the rotated QA technique.

aSi-EPID transit signal calibration for dynamic beams: a needful step for the IMRT in vivo dosimetry

This work reports a method based on correlation functions to convert EPID transit signals into in vivo dose values at the isocenter point, D_iso, of dynamic IMRT beams supplied by Varian linac. Dose reconstruction for intensity-modulated beams required significant corrections of EPID response, due to the X-ray component transmitted through multileaf collimator. The algorithm was formulated using a set of simulated IMRT beams. The beams were parameterized by means of a fluence inhomogeneity index, FI, introduced to describe the degree of beam modulation with respect to open beams. This way, all dosimetric parameters involved in D_iso reconstruction algorithm, such as the correlation functions, the correction factor for EPID to phantom distance and the modulated tissue maximum ratios, were determined as a function of the FI index. Clinical IMRT beams were used to irradiate a homogeneous phantom, and for each beam, the agreement between the reconstructed dose, D_iso, and the dose computed by TPS, D_iso,TPS, was well within 5 %. Moreover, the average ratios, R, between the D_iso, and D_iso,TPS, resulted equal to 1.002 ± 0.030. Thirty-five IMRT fields of 5 different patients undergoing radiotherapy for head–neck tumors were tested and the results were displayed on a computer screen after 2 min from the end of the treatment. However, 350 in vivo tests supplied an average ratio R equal to 1.004 ± 0.040. The in vivo dosimetry procedure here presented is among the objectives of a National Project financially supported by the Istituto Nazionale di Fisica Nucleare for the development of in vivo dosimetry procedures (Piermattei et al. in Nucl Instrum Methods Phys Res B 274:42–50, 2012) connected to the Record–Verify system of the radiotherapy center.

A contemporary review of stereotactic radiotherapy: inherent dosimetric complexities and the potential for detriment

OBJECTIVE

The advantages of highly localised, conformal treatments achievable with stereotactic radiotherapy (SRT) are increasingly being extended to extracranial sites as stereotactic body radiotherapy with advancements in imaging and beam collimation. One of the challenges in stereotactic treatment lies in the significant complexities associated with small field dosimetry and dose calculation. This review provides a comprehensive overview of the complexities associated with stereotactic radiotherapy and the potential for detriment.

METHODS

This study is based on a comprehensive review of literature accessible via PubMed and other sources, covering stereotactic radiotherapy, small-field dosimetry and dose calculation.

FINDINGS

Several key issues were identified in the literature. They pertain to dose prescription, dose measurement and dose calculation within and beyond the treatment field. Field-edge regions and penumbrae occupy a significant portion of the total field size. Spectral and dosimetric characteristics are difficult to determine and are compounded by effects of tissue inhomogeneity. Measurement of small-fields is made difficult by detector volume averaging and energy response. Available dosimeters are compared, and emphasis is given to gel dosimetry which offers the greatest potential for three-dimensional small-field dosimetry. The limitations of treatment planning system algorithms as applied to small-fields (particularly in the presence of heterogeneities) is explained, and a review of Monte Carlo dose calculation is provided, including simplified treatment planning implementations. Not incorporated into treatment planning, there is evidence that far from the primary field, doses to patients (and corresponding risks of radiocarcinogenesis) from leakage/scatter in SRT are similar to large fields.

CONCLUSIONS

Improved knowledge of dosimetric issues is essential to the accurate measurement and calculation of dose as well as the interpretation and assessment of planned and delivered treatments. This review highlights such issues and the potential benefit that may be gained from Monte Carlo dose calculation and verification via three-dimensional dosimetric methods (such as gel dosimetry) being introduced into routine clinical practice.

Statistical analysis of IMRT dosimetry quality assurance measurements for local delivery guideline

Purpose

To establish our institutional guideline for IMRT delivery, we statistically evaluated the results of dosimetry quality assurance (DQA) measurements and derived local confidence limits using the concept confidence limit of |mean|+1.96σ.

Materials and methods

From June 2006 to March 2009, 206 patients with head and neck cancer, prostate cancer, liver cancer, or brain tumor were treated using LINAC-based IMRT technique. In order to determine site specific DQA tolerances at a later stage, a hybrid plan with the same fluence maps as in the treatment plan was generated on CT images of a cylindrical phantom of acryl. Points of measurement using a 0.125 cm³ ion-chamber were typically located in the region of high and uniform doses. The planar dose distributions perpendicular to the central axis were measured by using a diode array in solid water with all fields delivered, and assessed using gamma criteria of 3%/3 mm. The mean values and standard deviations were used to develop the local confidence and tolerance limits. The dose differences and gamma pass rates for the different treatment sites were also evaluated in terms of total monitor uints (MU), MU/cGy, and the number of PTV's pieces.

Results

The mean values and standard deviations of ion-chamber dosimetry differences between calculated and measured doses were -1.6 ± 1.2% for H&N cancer, -0.4 ± 1.2% for prostate and abdominal cancer, and -0.6 ± 1.5% for brain tumor. Most of measured doses (92.2%) agreed with the calculated doses within a tolerance limit of ±3% recommended in the literature. However, we found some systematic under-dosage for all treatment sites. The percentage of points passing the gamma criteria, averaged over all treatment sites was 97.3 ± 3.7%. The gamma pass rate and the agreement of ion-chamber dosimetry generally decreased with increasing the number of PTV's pieces, the degree of modulation (MU/cGy), and the total MU beyond 700. Our local confidence limits were comparable to those of AAPM TG 119 and ESTRO guidelines that were provided as a practical baseline for center-to-center commissioning comparison. Thus, our institutional confidence and action limits for IMRT delivery were set into the same levels of those guidelines.

Discussion and Conclusions

The systematic under-dosage were corrected by tuning up the MLC-related factors (dosimetric gap and transmission) in treatment planning system (TPS) and further by incorporating the tongue-and groove effect into TPS. Institutions that have performed IMRT DQA measurements over a certain period of time need to analyze their accrued DQA data. We confirmed the overall integrity of our IMRT system and established the IMRT delivery guideline during this procedure. Dosimetric corrections for the treatment plans outside of the action level can be suggested only with such rigorous DQA and statistical analysis.

On the p(dis) correction factor for cylindrical chambers

The authors of a recent paper (Wang and Rogers 2009 Phys. Med. Biol. 54 1609) have used the Monte Carlo method to simulate the 'classical' experiment made more than 30 years ago by Johansson et al (1978 National and International Standardization of Radiation Dosimetry (Atlanta 1977) vol 2 (Vienna: IAEA) pp 243-70) on the displacement (or replacement) perturbation correction factor p(dis) for cylindrical chambers in 60Co and high-energy photon beams. They conclude that an 'unreasonable normalization at dmax' of the ionization chambers response led to incorrect results, and for the IAEA TRS-398 Code of Practice, which uses ratios of those results, 'the difference in the correction factors can lead to a beam calibration deviation of more than 0.5% for Farmer-like chambers'. The present work critically examines and questions some of the claims and generalized conclusions of the paper. It is demonstrated that for real, commercial Farmer-like chambers, the possible deviations in absorbed dose would be much smaller (typically 0.13%) than those stated by Wang and Rogers, making the impact of their proposed values negligible on practical high-energy photon dosimetry. Differences of the order of 0.4% would only appear at the upper extreme of the energies potentially available for clinical use (around 25 MV) and, because lower energies are more frequently used, the number of radiotherapy photon beams for which the deviations would be larger than say 0.2% is extremely small. This work also raises concerns on the proposed value of pdis for Farmer chambers at the reference quality of 60Co in relation to their impact on electron beam dosimetry, both for direct dose determination using these chambers and for the cross-calibration of plane-parallel chambers. The proposed increase of about 1% in p(dis) (compared with TRS-398) would lower the kQ factors and therefore Dw in electron beams by the same amount. This would yield a severe discrepancy with the current good agreement between electron dosimetry based on an electron cross-calibrated plane-parallel chamber (against a Farmer) or on a directly 60Co calibrated plane-parallel chamber, which is not likely to be in error by 1%. It is suggested that the influence of the 60Co source spectrum used in the simulations may not be negligible for calculations aimed at an uncertainty level of 0.1%.

Dosimetry of a small air cavity for clinical electron beams: A Monte Carlo study

This study investigated dosimetric changes in a water phantom when a small air cavity was presented at the central axis of a clinical electron beam. We used 6-, 9-, and 16-MeV electron beams with a 10 x 10 cm(2) applicator and cutout produced by a Varian 21 EX linear accelerator. Percentage depth doses (PDDs) for different depths (0.5-7 cm), thicknesses (2-10 mm), and widths (1-5 cm) of air cavities were calculated using Monte Carlo simulations (EGSnrc code) validated by film measurements. By comparing PDDs of phantoms with and without the air cavity, it was found that when the depth or thickness of cavity was changed, the PDD curve below the cavity was shifted with a distance equal to the thickness of the cavity. However, when the width of the air cavity was changed, both the PDD curve and its slope within and below the cavity were changed. A larger width of the air cavity resulted in a shallower PDD curve within the cavity. The slope of the PDD curve below the cavity tended towards a value as the width of the air cavity was increased to 3-5 cm for the 6-, 9-, and 16-MeV electron beams. The dependence of the depth dose on the width of the air cavity is a result of the contribution of the electron side scattering in the water surrounding the cavity. The change in depth dose resulting from the presence of an air cavity can cause discrepancies between the calculated and actual dose during radiotherapy, unless the effects of the air cavity are properly characterized during treatment planning. From the dosimetry data in this study, neglecting an air cavity of 1-cm thickness in the build-up region of a 6-MeV electron beam resulted in a delivered dose 10-12% larger than the original prescription. Delivered doses 3% and 6% higher than the prescribed dose were observed when doses were prescribed at R(80) for a 16-MeV electron beam. These results were obtained by neglecting air cavities with thicknesses equal to 2 and 4 mm, respectively, at a depth of 5 cm.

Characterization and clinical evaluation of a novel IMRT quality assurance system

Intensity-modulated radiation therapy (IMRT) is a complex procedure that involves the delivery of complex intensity patterns from various gantry angles. Due to the complexity of the treatment plans, the standard-of-care is to perform measurement based patient-specific quality assurance (QA). IMRT QA is traditionally done with film for relative dose in a plane and an ion chamber for absolute dose. This is a laborious and time-consuming process. In this work, we characterized, commissioned, and evaluated the QA capabilities of a novel commercial IMRT device Delta4, (Scandidos, Uppsala, Sweden). This device consists of diode matrices in 2 orthogonal planes inserted in a cylindrical acrylic phantom that is 22 cm in diameter. Although the system has detectors in only 2 planes, it provides a novel interpolation algorithm that is capable of estimating doses at points where no detectors are present. Each diode is sampled per beam pulse so that the dose distribution can be evaluated on segment-by-segment, beam-by-beam, or as a composite plan from a single set of measurements. The end user can calibrate the system to perform absolute dosimetry eliminating the need for additional ion chamber measurements. The patient's IMRT plan is imported into the device over the hospital LAN and the results of measurements can be displayed as gamma profiles, distance-to-agreement maps, dose difference maps, or the measured dose distribution can be superimposed of the patient's anatomy to display an as-delivered plan. We evaluated the system's reproducibility, stability, pulse-rate dependence, dose-rate dependence, angular dependence, linearity of dose response and energy response using carefully planned measurements. We also validated the system's interpolation algorithm by measuring a complex dose distribution from an IMRT treatment. Several simple and complex isodose distributions planned using a treatment planning system were delivered to the QA device; the planned and measured dose distributions were then compared and analyzed. In addition, the dose distributions measured by conventional IMRT QA, which uses an ion chamber and film, were compared. We found that this device is accurate and reproducible and that its interpolation algorithm is valid. In addition the supplied software and network interface allow a streamlined IMRT QA process.