Analysis of dose heterogeneity using a subvolume-DVH

The dose-volume histogram (DVH) is universally used in radiation therapy for its highly efficient way of summarizing three-dimensional dose distributions. An apparent limitation that is inherent to standard histograms is the loss of spatial information, e.g. it is no longer possible to tell where low- and high-dose regions are, and whether they are connected or disjoint. Two methods for overcoming the spatial fragmentation of low- and high-dose regions are presented, both based on the gray-level size zone matrix, which is a two-dimensional histogram describing the frequencies of connected regions of similar intensities. The first approach is a quantitative metric which can be likened to a homogeneity index. The large cold spot metric (LCS) is here defined to emphasize large contiguous regions receiving too low a dose; emphasis is put on both size, and deviation from the prescribed dose. In contrast, the subvolume-DVH (sDVH) is an extension to the standard DVH and allows for a qualitative evaluation of the degree of dose heterogeneity. The information retained from the two-dimensional histogram is overlaid on top of the DVH and the two are presented simultaneously. Both methods gauge the underlying heterogeneity in ways that the DVH alone cannot, and both have their own merits - the sDVH being more intuitive and the LCS being quantitative

Breathing-motion induced interplay effects for stereotactic body radiotherapy of liver tumours using flattening-filter free volumetric modulated arc therapy

The purpose of this study was to investigate breathing-motion induced interplay effects for stereotactic body radiotherapy (SBRT) of liver tumours treated with flattening-filter free (FFF) volumetric modulated arc therapy (VMAT). Ten patients previously treated with liver SBRT were included in this study. All patients had four-dimensional computed tomography (4DCT) scans acquired prior to treatment. The 4DCT was sorted into 8-10 phases covering an equal time interval. A FFF VMAT plan was created for one fraction in the mid-ventilation phase for each patient. To generate dose distributions including both interplay effects and dose blurring, a sub-plan was calculated for each phase. The total dose distributions were accumulated to the mid-ventilation phase using the deformed vector fields (DVF) from deformable image registration between the corresponding CT and the mid-ventilation phase CT. A blurred dose distribution, not including interplay effects, was also obtained by distributing the delivery of the whole plan uniformly on all phases, and was similarly accumulated to the mid-ventilation phase. To isolate interplay effects, this blurred dose distribution was subtracted from the total dose distribution with interplay effects. The near minimum dose (D 98%), mean dose (D mean), heterogeneity index (HI), and the near minimum dose difference (ΔD 98%) between the accumulated dose distributions with and without interplay effects were calculated within the gross tumour volume (GTV) for each patient. Comparing the accumulated dose distributions with and without interplay effects, the D 98% decreased for nine of the ten patients and the HI increased for all patients. The median and minimum differences in D 98% were -2.1% and -5.0% (p = 0.006), respectively, and the median HI significantly increased from 6.2% to 12.2% (p = 0.002). The median ΔD 98% was -4.0% (range -7% to -1.5%). In conclusion, statistically significant breathing-induced interplay effects were observed for a single fraction of FFF VMAT liver SBRT, resulting in heterogeneous dose distributions within the GTV

Tissue-phantom ratios from percentage depth doses

When converting fractional (percentage) depth doses to tissue-phantom ratios, one must use a factor that accounts for the different source-to-point distances. Two minor correction factors are also involved. One is the ratio of total to primary dose at the two different distances from the source, for the same depth and field size. This factor is usually ignored. It was determined experimentally that this can introduce up to 1.5% error at 6 MV. The second correction factor reflects differences related to scattered photons and electrons at the depth of normalization in the two geometries. This correction is accounted for in published conversion procedures. It was found to be less than 1% provided the normalization depth is sufficient for electron equilibrium, which occurs first well beyond the depth of maximum dose. One may avoid electron-equilibrium problems by using an interim normalization depth that provides electron equilibrium with some margin, renormalizing to a shallower depth if desired. With this precaution, the accuracy when measured fractional depth doses were converted to tissue-phantom ratios was comparable to that of directly measured tissue-phantom ratios even when the correction factors were ignored

SU‐E‐T‐809 : A Grading‐Study Based Tool to Assist in the Choice of Treatment Modality

Purpose: It is common for radiation oncologists (ROs) today to have a mixed arsenal of radiotherapy treatment modalities at their disposal. To optimize a clinic's use of its different treatment modalities, while at the same time giving every patient an optimal treatment, is not a trivial task. The purpose of this study was to give ROs a tool to choose between available modalities. This would help to ensure that the most advanced modality is available for the patients that really benefits from this treatment, and allow for a more optimal use of the clinic's assets. This study included different modalities such as 3DCRT, step‐and‐shoot IMRT, and helical tomotherapy. Methods: Twenty‐three patients that had received treatment for tumours in different anatomical regions with the tomotherapy system were chosen. All tomotherapy plans were converted into seven‐beam step‐ and‐shoot IMRT plans using the treatment planning system SharePlan. When feasible, conventional 3DCRT plans were also created by our most experienced planner. A side‐by‐side demonstration of every patient's plans was performed. Ten experienced ROs were individually asked to compare and grade the plans. The results were statistically analysed by using Sign test. Results: The results show that for all regions combined, the TT plans were considered somewhat better than the IMRT plans and much better than the 3DCRT plans (p<0.05). Divided into the different anatomical regions, however, the perceived superiority of the TT plans, as compared to step‐and‐shoot IMRT, was only significant for the patients treated in the abdominal and pelvic region. Conclusions: Based on the ROs grading scores obtained in the present study, priority for treatment with the TT system should be given to patients with tumours in the abdominal and pelvic region. Other factors, such as the overall treatment time and the machine occupancy, may also be important for the final choice of treatment

Development of dosimetric procedures for experimental ultrahigh dose rate irradiation at a clinical linear accelerator

As radiotherapy using ultra-high dose rates has gained new interest, the dosimetric challenges arising at these conditions needs to be addressed. Ionization chambers suffer from a large decrease in ion collection efficiency due to ion recombination, making on-line dosimetry difficult. In this work we present experimental setups and dosimetric procedures for FLASH irradiation of cells, zebrafish embryos and small animals using a 10 MeV electron beam at a modified clinical linear accelerator, and describe the dosimetric steps required to initiate clinical trials. The dosimetric equipment used for our pre-clinical experiments consisted of radiochromic film, thermoluminescent dosimeters, a Farmer-type ionization chamber and phantom material mimicking the experimental setup for irradiation. In preparation for small animal irradiation, dose profiles and depth dose curves were measured for all collimator sizes. The average dose rates were ≥620 Gy/s, ≥640 Gy/s and ≥400 Gy/s for cells, zebrafish embryos and small animals, respectively

Dose integration and dose rate characteristics of a NiPAM polymer gel MRI dosimeter system

The normoxic polymer gel dosimeter based on N-isopropyl acrylamide (NiPAM) is a promising full 3D-dosimeter with high spatial resolution and near tissue equivalency. NiPAM gel samples were irradiated to different doses using a linear accelerator. The absorbed dose was evaluated using MRI and statistical significance of the analysed data was calculated. The analysis was carried out using an in-house developed software. It was found that the gel dosimeter responded linearly to the absorbed dose. The gel exhibited a dose rate dependence, as well as a dependence on the sequential beam irradiation scheme. A higher dose rate, as well as a higher dose per sequential beam, resulted in a lower dose response