Acceptance, commissioning and clinical use of the WOmed T-200 kilovoltage X-ray therapy unit

Determination of kilovoltage x-ray therapy depth doses with open-ended applicators

The purpose of this work was to determine percentage depth dose (PDD) curves for kilovoltage x-rays from the WOmed-T105 unit, with open-ended steel applicators and beam qualities ranging from 0.5 to 4.2 mm Al. Measurements were made with parallel plate chambers in a water phantom, with extrapolation based on a fifth order polynomial used to estimate the surface dose. Measurements were also made with parallel plate chambers in a plastic water phantom, with thin plastic sheets used to obtain detailed measurements at shallow depths (less than 1 mm). Monte Carlo simulations were performed using the EGSnrc package, with two different sources as input: a SpekPy simulation of the x-ray beam and a full simulation of the x-ray tube, treatment head and applicators. Results showed that all four methods (two measurements and two simulations) agreed within the measurement uncertainty at depths greater than 2 mm. At shallow depths, significant differences were noted. At depths less than 0.1 mm, the full Monte Carlo simulation and the solid water measurements showed a sharp spike in surface dose which is attributed to electron contamination, which was not seen in the SpekPy Monte Carlo simulation or the extrapolated water measurements. At depths between 0.1 mm and 2 mm, beyond the range of contaminant electrons, the extrapolated water measurements underestimate the dose by up to 13% compared to the full Monte Carlo simulation and the solid water measurements, attributed to fluorescent photons generated in the applicators. This work demonstrates that for open-ended applicators, measurement of depth doses in water with extrapolation of surface dose has the potential to significantly underestimate the dose at shallow depths between the surface and 2 mm, even after eliminating electron contamination from the beam.

The assessment of the clinical impact of using a single set of radiotherapy planning data for two kilovoltage therapy units

Kilovoltage therapy units are used for superficial radiotherapy treatment delivery. Peer reviewed studies for MV linear accelerators describe tolerances to dosimetrically match multiple linear accelerators enabling patient treatment on any matched machine. There is an absence of literature on using a single planning data set for multiple kilovoltage units which have limited ability for beam adjustment. This study reviewed kilovoltage dosimetry and treatment planning scenarios to evaluate the feasibility of using ACPSEM annual QA tolerances to determine whether two units (of the same make and model) were dosimetrically matched. The dosimetric characteristics, such as measured half value layer (HVL), percentage depth dose (PDD), applicator factor and output variation with stand-off distance for each kV unit were compared to assess the agreement. Independent planning data based on the measured HVL for each beam energy from each kV unit was prepared. Monitor unit (MU) calculations were performed using both sets of planning data for approximately 200 clinical scenarios and compared with an overall agreement between units of < 2%. Additionally, a dosimetry measurement comparison was completed at each site for a subset of nine scenarios. All machine characterisation measurements were within the ACPSEM Annual QA tolerances, and dosimetric testing was within 2.5%. This work demonstrates that using a single set of planning data for two kilovoltage units is feasible, resulting in a clinical impact within published uncertainty.

SSRMP Recommendations No 9: Reference dosimetry in low and medium energy x-ray beams

The SSRMP recommendations on reference dosimetry in kilovolt beams as used in radiation therapy were revised to establish current practice in Switzerland. The recommendations specify the dosimetry formalism, reference class dosimeter systems and conditions used for the calibration of low and medium energy x-ray beams. Practical guidance is provided on the determination of the beam quality specifier and all corrections required for converting instrument readings to absorbed dose to water. Guidance is also provided on the determination of relative dose under non-reference conditions and on the cross calibration of instruments. The effect of lack of electron equilibrium and influence of contaminant electrons when using thin window plane parallel chambers at x-ray tube potentials higher than 50kV is elaborated in an appendix. In Switzerland the calibration of the reference system used for dosimetry is regulated by law. METAS and IRA are the authorities providing this calibration service to the radiotherapy departments. The last appendix of these recommendations summarise this calibration chain.

Machine characterization and central axis depth dose data of a superficial x-ray radiotherapy unit

Objectives. The purpose of this study is to present data from the clinical commissioning of an Xstrahl 150 x-ray unit used for superficial radiotherapy,Methods. Commissioning tasks included vendor acceptance tests, timer reproducibility, linearity and end-effect measurements, half-value layer (HVL) measurements, inverse square law verification, head-leakage measurements, and beam output calibration. In addition, percent depth dose (PDD) curves were determined for different combinations of filter/kV settings and applicators. Automated PDD water phantom scans were performed utilizing four contemporary detectors: a microDiamond detector, a microSilicon detector, an EDGE detector, and a PinPoint ionization chamber. The measured PDD data were compared to the published values in BJR Supplement 25,Results. The x-ray unit's mechanical, safety, and radiation characteristics were within vendor-stated specifications. Across sixty commissioned x-ray beams, the PDDs determined in water using solid state detectors were in excellent agreement with the BJR 25 data. For the lower (<100 kVp) and medium-energy (≥100 kVp) superficial beams the average agreement was within [-3.6,+0.4]% and [-3.7,+1.4]% range, respectively. For the high-energy superficial (low-energy orthovoltage) x-rays at 150 kVp, the average difference for the largest 20 × 20 cm²collimator was (-0.7 ± 1.0)%,Conclusions. This study presents machine characterization data collected for clinical use of a superficial x-ray unit. Special focus was placed on utilizing contemporary detectors and techniques for the relative PDD measurements using a motorized water phantom. The results in this study confirm that the aggregate values published in the BJR 25 report still serve as a valid benchmark when comparing data from site-specific measurements, or the reference data for clinical utilization without such measurements,Advances in knowledge. This paper presents comprehensive data from the acceptance and commissioning of a modern kilovoltage superficial x-ray radiotherapy machine. Comparisons between the PDD data measured in this study using different detectors and BJR 25 data are highlighted.

Use of a PLA sleeve to remove electron enhancement in superficial X-ray therapy

A newly installed superficial X-ray unit was found to produce enhanced electron dose at the skin surface. The ACPSEM kilovoltage dosimetry recommendations suggest using nail varnish within the treatment cones as a method to reduce this dose. In this study, a 3D PLA sleeve was produced and used as an alternative to the nail varnish for energies between 55 and 100 kV. Further, plastic wrap was also investigated as an alternative method to reduce dose. It was found that a 1 mm printed sleeve, inserted into the treatment cone sufficiently reduced the enhanced dose as measured with a thin-window Exradin chamber to within 3.3% of the dose measured with a Farmer-type ionisation chamber. The use of plastic wrap also reduced the enhanced dose, but impracticalities in its use make it non-viable for routine clinical use.

On the use of EBT3 film for relative dosimetry of kilovoltage X ray beams

EBT3 films were evaluated for relative dosimetry in water, in the energy range of therapeutic kV X ray beams. A film batch was calibrated in air for all nine beam qualities of a clinical unit (XStrahl 200). Monte Carlo (MC) simulations using MCNP v.6 facilitated the calculation of the film absorbed dose (f), and beam quality (k_bq) energy dependences in air. Results were found in agreement with corresponding data in the literature. Film samples from the same batch were irradiated in water along the central beam axis for each beam quality. Experimental percentage depth dose (PDD) results obtained using calibration data in air showed quality and depth dependent differences from corresponding MC simulations. These differences increased beyond film dosimetry uncertainty (<3.3%), reaching up to 8% at increased depth. The observed differences reduced only slightly when spectral variation as a function of measurement point was accounted for, using photon effective energy. PDD measurements and corresponding MC results facilitated the determination of f and k_bq in water. Results showed that the origin of the observed differences between experimental and MC PDD results is the difference between film response in air and water, as a result of radiation field perturbation from the film oriented along the central beam axis. This implies a directional dependence of film response which necessitates that the angular distribution of photons impinging on the film is the same in the calibration and measurement geometries.

Off-axis dose distribution with stand-in and stand-off configurations for superficial radiotherapy treatments

Current practice when delivering dose for superficial skin radiotherapy is to adjust the monitor units so that the prescribed dose is delivered to the central axis of the superficial unit applicator. Variations of source‐to‐surface distance due to patient’s anatomy protruding into the applicator or extending away from the applicator require adjustments to the monitor units using the inverse square law. Off‐axis dose distribution varies significantly from the central axis dose and is not currently being quantified. The dose falloff at the periphery of the field is not symmetrical in the anode–cathode axis due to the heel effect. This study was conducted to quantify the variation of dose across the surface being treated and model a simple geometric shape to estimate a patient’s surface with stand‐in and stand‐off. Isodose plots and color‐coded dose distribution maps were produced from scans of GAFChromic EBT‐3 film irradiated by a Gulmay D3300 orthovoltage x‐ray therapy system. It was clear that larger applicators show a greater dose falloff toward the periphery than smaller applicators. Larger applicators were found to have a lower percentage of points above 90% of central axis dose (SA90). Current clinical practice does not take this field variation into account. Stand‐in can result in significant dose falloff off‐axis depending on the depth and width of the protrusion, while stand‐off can result in a flatter field due to the high‐dose region near the central axis being further from the source than the peripheral regions. The central axis also received a 7% increased or decreased dose for stand‐in or stand‐off, respectively.

Excessive applicator radiation leakage for a common therapeutic kilovoltage system

OBJECTIVE:

The objective of this work is to characterise out- of- field leakage radiation emanating from clinical applicators of the WOmed T-200 kilovoltage therapy machine.

METHODS:

To identify points of leakage, radiosensitive film was affixed to the walls and base plate of each applicator. Quantitative assessment of leakage radiation was conducted with a 0.23 cm3 ionisation chamber following the International Electrotechnical Commission standard. Film was also used to illustrate leakage distribution in the patient plane. Angular and energy dependences of the leakage radiation were quantified as well as a two-dimensional leakage profile in the plane parallel to one applicator.

RESULTS:

Leakage was found when the diameter of primary collimator of the kV tube exceeded the external dimension of the applicator wall. In the patient plane all applicators showed similar leakage rates with the leakage distribution dependent upon applicator design. Mean patient plane leakage was 1.37% of central axis air kerma rate, exceeding the 0.5% limit specified in the standard. Leakage was shown to be profoundly energy dependent with maximum leakage of 11.8% for the 200 kV beam, 1.3% for 150 kV and 0.2% for 100 kV. Angular dependence measurements showed a 10.3% change in leakage between the minimum and maximum positions.

CONCLUSION

The combination of shielding thickness, primary collimator design and applicator dimensions permits unwanted radiation to contribute dose outside the treatment field when energies ≥150 kV are used.

ADVANCES IN KNOWLEDGE:

Even carefully designed modern kv therapy systems can exhibit leakage in some areas. Thorough assessment of leakage is needed prior to release for clinical use.

Current status of kilovoltage (kV) radiotherapy in the UK: installed equipment, clinical workload, physics quality control and radiation dosimetry

OBJECTIVE

To assess the status and practice of kilovoltage (kV) radiotherapy in the UK.

METHODS

96% of the radiotherapy centres in the UK responded to a comprehensive survey. An analysis of the installed equipment base, patient numbers, clinical treatment sites, quality control (QC) testing and radiation dosimetry processes were undertaken.

RESULTS

73% of UK centres have at least one kV treatment unit, with 58 units installed across the UK. Although 35% of units are over 10 years old, 39% units have been installed in the last 5 years. Approximately 6000 patients are treated with kV units in the UK each year, the most common site (44%) being basal cell carcinoma. A benchmark of QC practice in the UK is presented, against which individual centres can compare their procedures, frequency of testing and acceptable tolerance values. We propose the use of internal "notification" and "suspension" levels for analysis. All surveyed centres were using recommended Codes of Practice for kV dosimetry in the UK; approximately the same number using in-air and in-water methodologies for medium energy, with two-thirds of all centres citing "clinical relevance" as the reason for choice of code. 64% of centres had hosted an external dosimetry audit within the last 3 years, with only one centre never being independently audited. The majority of centres use locally measured applicator factors and published backscatter factors for treatments. Monitor unit calculations are performed using software in only 36% of centres.

CONCLUSION

A comprehensive review of current kV practice in the UK is presented. Advances in knowledge: Data and discussion on contemporary kV radiotherapy in the UK, with a particular focus on physics aspects.