An IAEA survey of radiotherapy practice including quality assurance extent and depth

Background: The IAEA recommends a quality assurance program in radiotherapy to ensure safe and effective treatments. In this study, radiotherapy departments were surveyed on their current practice including the extent and depth of quality assurance activities.Methods: Radiotherapy departments were voluntarily surveyed in three stages, firstly, in basic facility information, secondly, in quality assurance activities and treatment techniques, and thirdly, in a snapshot of quality assurance, departmental and treatment activities.Results: The IAEA received completed surveys from 381 radiotherapy departments throughout the world with 100 radiotherapy departments completing all three surveys. Dominant patterns were found in linac-based radiotherapy with access to treatment planning systems for 3D-CRT and 3D imaging. Staffing levels for major staff groups were on average in the range recommended by the IAEA. The modal patient workload per EBRT unit was as expected in the range of 21-30 patients per day, however significant instances of high workload (more than 50 patients per day per treatment unit) were reported. Staffing levels were found to correlate with amount of treatment equipment and patient workload. In a self-assessment of quality assurance performance, most radiotherapy departments reported that they would perform at least 60% of the quality assurance activities itemized in the second survey, with particular strength in equipment quality control. In a snapshot survey of quality assurance performance, again equipment quality control practice was well developed, particularly for the treatment equipment.Conclusions: The IAEA surveys provide a snapshot of current radiotherapy practice including quality assurance activities.

Testing of a treatment planning system with beam data from IAEA TECDOC 1540

Quality assurance of external-beam treatment-planning systems is recommended, and this can be partly achieved with predefined type tests. The beam data and test geometries of IAEA TECDOC 1540 have been used to test the analytical anisotropic algorithm (AAA) and pencil-beam convolution (PBC) algorithm of the Varian Eclipse treatment planning system. Beam models were created in Eclipse for 6 MV, 10 MV and 18 MV from the available beam data. Twelve test geometries were re-created in Eclipse, and the differences between Eclipse dose calculations and dose measurements were recorded. The AAA algorithm generally performed better than the PBC algorithm for the 12 tests, but both algorithms did not meet predefined tolerances for asymmetric wedge fields. An in-house monitor unit check program based on collimator and phantom scatter factors with tissue-phantom ratios was also tested and its calculations were found to agree with measurements to within 3.2% for on-axis points.

Investigation of vacuum pumping on the dose response of the MAGAS normoxic polymer gel dosimeter

The effect of vacuum pumping on the dose response of the MAGAS polymer gel dosimeter has been investigated. A delay of several days post-manufacture before irradiation was previously necessary due to the slow oxygen scavenging of ascorbic acid. The MAGAS polymer gel dosimeter was vacuum pumped before gelation to remove dissolved oxygen. The MAGAS polymer gel dosimeter was poured into glass screw-top vials, which were irradiated at various times, post-manufacture to a range of doses. Magnetic resonance imaging techniques were used to determine the R2-dose response and R2-dose sensitivity of the MAGAS polymer gel. The results were compared with a control batch of MAGAS polymer gel that was not vacuum pumped. It was shown that vacuum pumping on the MAGAS polymer gel solution immediately prior to sealing in glass screw-top vials initially increases the R2-dose response and R2-dose sensitivity of the dosimeter. An increase in the R2-dose response and R2-dose sensitivity was observed with increasing time between manufacture and irradiation. Over the range of post-manufacture irradiation times investigated, the greatest R2-dose response and R2-dose sensitivity occurred at 96 hours.

Output factor measurements for a kilovoltage x-ray therapy unit

Output factors at the surface for treatment cones and lead cut-outs have been measured for a Pantak Therapax SXT 150 superficial therapy unit with x-ray beam qualities from 1 to 13 mm A1 HVL. A variety of phantom materials and two ionisation chambers were tested for their suitability in output factor and percentage depth dose measurement. Solid water proved a useful water-equivalent phantom material with discrepancies between measurements in water and solid water less than 2.3% for percentage depth dose and less than 0.6% for output factors. Larger measurement discrepancies were found for Plastic Water and Perspex. A PTW Markus chamber was found to compare well with a NE 2532/3 low energy chamber in percentage depth dose measurement, but discrepancies arose between the chambers in output factor measurements, up to 5% for small field sizes. Measurements indicated that the Markus chamber had an energy dependent response in the kilovoltage range, which could account for the discrepancy in output factor measurement.

Tin foil as bolus material for therapeutic electron beams from the Varian Clinac 2100C/D

Tin foils of sub-millimetre thickness have been investigated as bolus material for therapeutic electron beams from the Varian Clinac 2100C/D linear accelerator. Measurements with ionisation chamber and radiographic film in Plastic Water or water were performed under tin foil bolus to determine surface dose, therapeutic ranges, output factor correction, penumbra and dose outside the field edge. Appropriate thicknesses of tin foil for 90% dose at the surface were found to be approximately 0.3 mm for 6 MeV, and 0.4 mm for 9 MeV and 12 MeV. Enhanced therapeutic interval with tin foil bolus over water-equivalent bolus has previously been reported, but was found not to be evident for 12 MeV and for a small (4 x 4 cm2) 9 MeV field. The penumbra width of fields with tin foil and water-equivalent bolus were found to be within 2 mm, while the doses at 1 cm outside the field edge were within 1.5% of peak dose. Output factor corrections for fields with tin foil were measured as within 2% of unity. Air gaps between the tin foil and phantom surface up to 5 mm were observed to have minimal effect on output correction factor, relative surface dose, and therapeutic range.

Effect of saccharide additives on response of ferrous-agarose-xylenol orange radiotherapy gel dosimeters

Glucose, sucrose, starch, and locust bean gum have been used as additives to the ferrous-agarose-xylenol orange (FAX) gel dosimeter. The saccharide enhanced dosimeters were found to have a higher dose sensitivity over a standard FAX gel as measured by both optical density change and magnetic resonance imaging (MRI). With optical density measurement, OD-dose sensitivity increases were up to 55% for glucose, 122% for sucrose and 43% for starch, while locust bean gum did not give a consistent response. With MRI, R1-dose sensitivity increases were up to 178% with sucrose addition. The FAX gel with sucrose was studied in greatest detail. The OD-dose sensitivity dependence on cooling rate was reduced for the sucrose FAX gel over the standard FAX gel, which has significant implications for uniform dose sensitivity in large gel phantoms. The thermal oxidation rate in the sucrose FAX gel was up to 2.3 times higher than in the standard gel. The OD-dose sensitivity of oxygenated sucrose FAX gels was 4.3 times greater than standard FAX gels, while continued enhancement in OD-dose sensitivity with increased sucrose concentrations beyond 2.0 g/l was found only for the oxygenated sucrose FAX gels. Both the molar absorption coefficient of the ferric ion-xylenol orange complex at 543 nm and gel pH were not affected by the presence of sucrose, with the implication that the higher OD-dose sensitivity of gels with saccharides is due to increased chain reaction production of ferric ions.

A basic study of some normoxic polymer gel dosimeters

Polymer gel dosimeters offer a wide range of potential applications in the three-dimensional verification of complex dose distribution such as in intensity-modulated radiotherapy (IMRT). Until now, however, polymer gel dosimeters have not been widely used in the clinic. One of the reasons is that they are difficult to manufacture. As the polymerization in polymer gels is inhibited by oxygen, all free oxygen has to be removed from the gels. For several years this was achieved by bubbling nitrogen through the gel solutions and by filling the phantoms in a glove box that is perfused with nitrogen. Recently another gel formulation was proposed in which oxygen is bound in a metallo-organic complex thus removing the problem of oxygen inhibition. The proposed gel consists of methacrylic acid, gelatin, ascorbic acid, hydroquinone and copper(II)sulphate and is given the acronym MAGIC gel dosimeter. These gels are fabricated under normal atmospheric conditions and are therefore called 'normoxic' gel dosimeters. In this study, a chemical analysis on the MAGIC gel was performed. The composition of the gel was varied and its radiation response was evaluated. The role of different chemicals and the reaction kinetics are discussed. It was found that ascorbic acid alone was able to bind the oxygen and can thus be used as an anti-oxidant in a polymer gel dosimeter. It was also found that the anti-oxidants N-acetyl-cysteine and tetrakis(hydroxymethyl)phosphonium were effective in scavenging the oxygen. However, the rate of oxygen scavenging is dependent on the anti-oxidant and its concentration with tetrakis(hydroxymethyl)phosphonium being the most reactive anti-oxidants. Potentiometric oxygen measurements in solution provide an easy way to get a first impression on the rate of oxygen scavenging. It is shown that cupper(II)sulphate operates as a catalyst in the oxidation of ascorbic acid. We, therefore, propose some new normoxic gel formulations that have a less complicated chemical formulation than the MAGIC gel.

Dose-response stability and integrity of the dose distribution of various polymer gel dosimeters

In this study the stability of different polymer gel dosimeters is investigated. Further to a previous chemical stability study on a (6%T, 50%C) PAG gel, the change in slope and intercept of the linear part of the R2-dose plot is recorded with time for different gel formulations. In addition to this R2-dose-response stability study, the dose edge of a half-blocked field was recorded with time. Three different PAG type polymer gels, a hydroxyethyl acrylate (HEA) gel and two different normoxic polymer gels were investigated. In the PAG type polymer gels, the relative concentration of gelatin and comonomers was varied in order to study the influence of the different components, that constitute the dosimeter, on the stability. It is shown that the R2-dose-response stability is largely determined by the chemical composition of the gel dosimeters. All the PAG gel dosimeters and the normoxic gel dosimeters are found to preserve the integrity of the dose distribution up to 22 days after irradiation. The half-life of the change in dose sensitivity of a MAGIC gel is found to be 18 h compared to 5.7 h for a (6%T, 50%C) PAG gel. A maximum relative decrease in dose sensitivity of 21% was noted for the MAGIC gel compared to an increase of 50% for a (6%T, 50%C) PAG gel. A loss of integrity of the dose distribution was found in the HEA gel.

Optimum particle size of corn and hard and soft sorghum for nursery pigs

A total of 240 weanling pigs (22 d of age and 5.3 kg average BW) were used to determine the effects of particle size of corn and two sorghum hybrids on diet processing, growth performance, apparent digestibility of nutrients, and morphology of the stomach and intestines in weanling pigs. Treatments were corn, hard endosperm sorghum, and soft endosperm sorghum milled to particle sizes (geometric mean) of 900, 700, 500, and 300 microns, in a 3 x 4 factorial arrangement. All diets were pelleted and the pigs were allowed to consume feed and water on an ad libitum basis. As particle size was reduced, production rate (tons/hour) decreased and energy required to mill (kilowatt hours/ton) increased. Corn required more energy to mill and had a lower production rate than the sorghums. For d 0 to 14, ADG and gain/feed increased linearly (P < .009 and P < .002, respectively) as particle size was decreased to 300 microns. However, there was a grain source x particle size interaction; pigs fed corn responded to particle size reduction more than pigs fed the sorghums (P < .04). For d 0 to 35, pigs fed diets with corn grew 23% faster and were 6% more efficient (P < .001) than pigs fed diets with sorghum. Gain/feed responded quadratically to reduction of particle size (P < .01), with maximum gain/feed at 500 microns for all grains. Lowest cost of gain (including milling and ingredient costs) was achieved at 500 to 700 microns for corn and 500 microns for the hard and soft sorghums. These data suggest that response to reducing particle size is greatest during the first 2 wk postweaning and that optimal particle size for corn and sorghums increases with age of nursery pigs.