Time resolved dose rate distributions in brachytherapy

Purpose To investigate the biological significance of introducing time-resolved dose rate distributions (TR-DRD) in brachytherapy. Materials and methods The treatment plan of a head and neck patient treated with pulsed-dose-rate (PDR) brachytherapy was considered. The TR-DRD was calculated on the basis of a Monte Carlo generated single source dose rate matrix taking into account the dose rate per source dwell position. Biologically Effective Dose (BED) was obtained considering either the mean dose rate per pulse (analytical method) or the TR-DRD (numerical method). Corresponding Tumor Control Probabilities (TCP) were calculated and compared for various PDR schemes and repair half-times from the literature. The dose of the biologically equivalent high-dose-rate (HDR) treatment schedule was also evaluated. Results The analytical method presents an overall BED underestimation (up to 2%) relative to TR-DRD results. This is associated with an analytical-based TCP underestimation which increases with dose/pulse, pulse duration and period time and decreases with total dose. The half-time of repair seems to have the largest impact on the TCP calculations, with significant differences (up to 39.1%) corresponding to the shorter repair half-times. Regarding the equivalent HDR treatment schedule, the analytical method resulted to a HDR isoeffective dose underestimation lower than 2.2% and thus does not warrant any change in the derivation of the equivalent HDR scheme. Conclusion TR-DRD data should be taken into account for PDR biological effectiveness estimations, especially for short tissue repair half-times. This does not appear however to influence dose prescription of the equivalent HDR treatment schedule for mobile tongue carcinoma. © 2017 Associazione Italiana di Fisica Medic

On the use of a novel Ferrous Xylenol-orange gelatin dosimeter for HDR brachytherapy commissioning and quality assurance testing

Purpose: To evaluate a commercially available Ferrous-Xylenol Orange-Gel (FXG) dosimeter (TrueView™) coupled with Optical-Computed Tomography (OCT) read out, for 3D dose verification in an Ir-192 superficial brachytherapy application. Methods: Two identical polyethylene containers filled with gel from the same batch were used. One was irradiated with an 18 MeV electron field to examine the dose-response linearity and obtain a calibration curve. A flap surface applicator was attached to the other to simulate treatment of a skin lesion. The dose distribution in the experimental set up was calculated with the TG-43 and the model based dose calculation (MBCA) algorithms of a commercial treatment planning system (TPS), as well as Monte Carlo (MC) simulation using the MCNP code. Measured and calculated dose distributions were spatially registered and compared. Results: Apart from a region close to the container's neck, where gel measurements exhibited an over-response relative to MC calculations (probably due to stray light perturbation), an excellent agreement was observed between measurements and simulations. More than 97% of points within the 10% isodose line (80 cGy) met the gamma index criteria established from uncertainty analysis (5%/2 mm). The corresponding passing rates for the comparison of experiment to calculations using the TG-43 and MBDCA options of the TPS were 57% and 92%, respectively. Conclusion: TrueView™ is suitable for the quality assurance of demanding radiotherapy applications. Experimental results of this work confirm the advantage of the studied MBDCA over TG-43, expected from the improved account of scatter radiation in the treatment geometry. © 2017 Associazione Italiana di Fisica Medic

Dosimetric and radiobiological comparison of TG-43 and Monte Carlo calculations in 192Ir breast brachytherapy applications

Purpose To investigate the clinical significance of introducing model based dose calculation algorithms (MBDCAs) as an alternative to TG-43 in 192Ir interstitial breast brachytherapy. Materials and methods A 57 patient cohort was used in a retrospective comparison between TG-43 based dosimetry data exported from a treatment planning system and Monte Carlo (MC) dosimetry performed using MCNP v. 6.1 with plan and anatomy information in DICOM-RT format. Comparison was performed for the target, ipsilateral lung, heart, skin, breast and ribs, using dose distributions, dose-volume histograms (DVH) and plan quality indices clinically used for plan evaluation, as well as radiobiological parameters. Results TG-43 overestimation of target DVH parameters is statistically significant but small (less than 2% for the target coverage indices and 4% for homogeneity indices, on average). Significant dose differences (>5%) were observed close to the skin and at relatively large distances from the implant leading to a TG-43 dose overestimation for the organs at risk. These differences correspond to low dose regions (<50% of the prescribed dose), being less than 2% of the prescribed dose. Detected dosimetric differences did not induce clinically significant differences in calculated tumor control probabilities (mean absolute difference <0.2%) and normal tissue complication probabilities. Conclusion While TG-43 shows a statistically significant overestimation of most indices used for plan evaluation, differences are small and therefore not clinically significant. Improved MBDCA dosimetry could be important for re-irradiation, technique inter-comparison and/or the assessment of secondary cancer induction risk, where accurate dosimetry in the whole patient anatomy is of the essence. © 2016 Associazione Italiana di Fisica Medic

Characterization of a novel 3D printed patient specific phantom for quality assurance in cranial stereotactic radiosurgery applications

In single-isocenter stereotactic radiosurgery/radiotherapy (SRS/SRT) intracranial applications, multiple targets are being treated concurrently, often involving non-coplanar arcs, small photon beams and steep dose gradients. In search for more rigorous quality assurance protocols, this work presents and evaluates a novel methodology for patient-specific pre-treatment plan verification, utilizing 3D printing technology. In a patient's planning CT scan, the external contour and bone structures were segmented and 3D-printed using high-density bone-mimicking material. The resulting head phantom was filled with water while a film dosimetry insert was incorporated. Patient and phantom CT image series were fused and inspected for anatomical coherence. HUs and corresponding densities were compared in several anatomical regions within the head. Furthermore, the level of patient-to-phantom dosimetric equivalence was evaluated both computationally and experimentally. A single-isocenter multi-focal SRS treatment plan was prepared, while dose distributions were calculated on both CT image series, using identical calculation parameters. Phantom- and patient-derived dose distributions were compared in terms of isolines, DVHs, dose-volume metrics and 3D gamma index (GI) analysis. The phantom was treated as if the real patient and film measurements were compared against the patient-derived calculated dose distribution. Visual inspection of the fused CT images suggests excellent geometric similarity between phantom and patient, also confirmed using similarity indices. HUs and densities agreed within one standard deviation except for the skin (modeled as 'bone') and sinuses (water-filled). GI comparison between the calculated distributions resulted in passing rates better than 97% (1%/1 mm). DVHs and dose-volume metrics were also in satisfying agreement. In addition to serving as a feasibility proof-of-concept, experimental absolute film dosimetry verified the computational study results. GI passing rates were above 90%. Results of this work suggest that employing the presented methodology, patient-equivalent phantoms (except for the skin and sinuses areas) can be produced, enabling literally patient-specific pre-treatment plan verification in intracranial applications. © 2019 Institute of Physics and Engineering in Medicine

Dosimetric performance of the Elekta Unity MR-linac system: 2D and 3D dosimetry in anthropomorphic inhomogeneous geometry

Following the clinical introduction of the Elekta Unity MR-linac, there is an urgent need for development of dosimetry protocols and tools, not affected by the presence of a magnetic field. This work presents a benchmarking methodology comprising 2D/3D passive dosimetry and involving on-couch adaptive treatment planning, a unique step in MR-linac workflows. Two identical commercially available 3D-printed head phantoms (featuring realistic bone anatomy and MR/CT contrast) were employed. One phantom incorporated a film dosimetry insert, while the second was filled with polymer gel. Gel dose-response characteristics were evaluated under the Unity irradiation and read-out conditions, using vials and a cubic container filled with gel from the same batch. Treatment plan for the head phantoms involved a hypothetical large C-shape brain lesion, partly surrounding the brainstem. An IMRT step-and-shoot 7-beam plan was employed. Pre-treatment on-couch MR-images were acquired in order for the treatment planning system to calculate the virtual couch shifts and perform adaptive planning. Absolute 2D and relative 3D measurements were compared against calculations related to both adapted and original plans. Real-time dose accumulation monitoring in the gel-filled phantom was also performed. Results from the vials and cubic container suggest that gel dose-response is linear in the dose range investigated and signal integrity is mature at the read-out timings considered. Head phantom 2D and 3D measurements agreed well with calculations with 3D gamma index passing rates above 90% in all cases, even with the most stringent criteria used (2 mm/2%). By exploiting the 3D information provided by the gel, comparison also involved DVHs, dose-volume and plan quality metrics, which also reflected the agreement between adapted and delivered plans within ±4%. No considerable discrepancies were detected between adapted and original plans. A novel methodology was developed and implemented, suitable for QA procedures in Unity. TPS calculations were validated within the experimental uncertainties involved. © 2019 Institute of Physics and Engineering in Medicine

On the development of a comprehensive MC simulation model for the Gamma Knife Perfexion radiosurgery unit

This work presents a comprehensive Monte Carlo (MC) simulation model for the Gamma Knife Perfexion (PFX) radiosurgery unit. Model-based dosimetry calculations were benchmarked in terms of relative dose profiles (RDPs) and output factors (OFs), against corresponding EBT2 measurements. To reduce the rather prolonged computational time associated with the comprehensive PFX model MC simulations, two approximations were explored and evaluated on the grounds of dosimetric accuracy. The first consists in directional biasing of the 60Co photon emission while the second refers to the implementation of simplified source geometric models. The effect of the dose scoring volume dimensions in OF calculations accuracy was also explored. RDP calculations for the comprehensive PFX model were found to be in agreement with corresponding EBT2 measurements. Output factors of 0.819 ± 0.004 and 0.8941 ± 0.0013 were calculated for the 4 mm and 8 mm collimator, respectively, which agree, within uncertainties, with corresponding EBT2 measurements and published experimental data. Volume averaging was found to affect OF results by more than 0.3% for scoring volume radii greater than 0.5 mm and 1.4 mm for the 4 mm and 8 mm collimators, respectively. Directional biasing of photon emission resulted in a time efficiency gain factor of up to 210 with respect to the isotropic photon emission. Although no considerable effect on relative dose profiles was detected, directional biasing led to OF overestimations which were more pronounced for the 4 mm collimator and increased with decreasing emission cone half-angle, reaching up to 6% for a 5 angle. Implementation of simplified source models revealed that omitting the sources' stainless steel capsule significantly affects both OF results and relative dose profiles, while the aluminum-based bushing did not exhibit considerable dosimetric effect. In conclusion, the results of this work suggest that any PFX simulation model should be benchmarked in terms of both RDP and OF results. © 2016 Institute of Physics and Engineering in Medicine

On the experimental validation of model-based dose calculation algorithms for 192Ir HDR brachytherapy treatment planning

There is an acknowledged need for the design and implementation of physical phantoms appropriate for the experimental validation of model-based dose calculation algorithms (MBDCA) introduced recently in 192Ir brachytherapy treatment planning systems (TPS), and this work investigates whether it can be met. A PMMA phantom was prepared to accommodate material inhomogeneities (air and Teflon), four plastic brachytherapy catheters, as well as 84 LiF TLD dosimeters (MTS-100M 1 × 1 × 1 mm3 microcubes), two radiochromic films (Gafchromic EBT3) and a plastic 3D dosimeter (PRESAGE). An irradiation plan consisting of 53 source dwell positions was prepared on phantom CT images using a commercially available TPS and taking into account the calibration dose range of each detector. Irradiation was performed using an 192Ir high dose rate (HDR) source. Dose to medium in medium, , was calculated using the MBDCA option of the same TPS as well as Monte Carlo (MC) simulation with the MCNP code and a benchmarked methodology. Measured and calculated dose distributions were spatially registered and compared. The total standard (k = 1) spatial uncertainties for TLD, film and PRESAGE were: 0.71, 1.58 and 2.55 mm. Corresponding percentage total dosimetric uncertainties were: 5.4-6.4, 2.5-6.4 and 4.85, owing mainly to the absorbed dose sensitivity correction and the relative energy dependence correction (position dependent) for TLD, the film sensitivity calibration (dose dependent) and the dependencies of PRESAGE sensitivity. Results imply a LiF over-response due to a relative intrinsic energy dependence between 192Ir and megavoltage calibration energies, and a dose rate dependence of PRESAGE sensitivity at low dose rates (<1 Gy min-1). Calculations were experimentally validated within uncertainties except for MBDCA results for points in the phantom periphery and dose levels <20%. Experimental MBDCA validation is laborious, yet feasible. Further work is required for the full characterization of dosimeter response for 192Ir and the reduction of experimental uncertainties. © 2017 Institute of Physics and Engineering in Medicine

Evaluation of patient-specific MR distortion correction schemes for improved target localization accuracy in SRS

Purpose: This work aims at promoting target localization accuracy in cranial stereotactic radiosurgery (SRS) applications by focusing on the correction of sequence-dependent (also patient induced) magnetic resonance (MR) distortions at the lesion locations. A phantom-based quality assurance (QA) methodology was developed and implemented for the evaluation of three distortion correction techniques. The same approach was also adapted to cranial MR images used for SRS treatment planning purposes in single or multiple brain metastases cases. Methods: A three-dimensional (3D)-printed head phantom was filled with a 3D polymer gel dosimeter. Following treatment planning and dose delivery, volumes of radiation-induced polymerization served as hypothetical lesions, offering adequate MR contrast with respect to the surrounding unirradiated areas. T1-weighted (T1w) MR imaging was performed at 1.5 T using the clinical scanning protocol for SRS. Additional images were acquired to implement three distortion correction methods; the field mapping (FM), mean image (MI) and signal integration (SI) techniques. Reference lesion locations were calculated as the averaged centroid positions of each target identified in the forward and reverse read gradient polarity MRI scans. The same techniques and workflows were implemented for the correction of contrast-enhanced T1w MR images of 10 patients with a total of 27 brain metastases. Results: All methods employed in the phantom study diminished spatial distortion. Median and maximum distortion magnitude decreased from 0.7 mm (2.10 ppm) and 0.8 mm (2.36 ppm), respectively, to <0.2 mm (0.61 ppm) at all target locations, using any of the three techniques. Image quality of the corrected images was acceptable, while contrast-to-noise ratio slightly increased. Results of the patient study were in accordance with the findings of the phantom study. Residual distortion in corrected patient images was found to be <0.3 mm in the vast majority of targets. Overall, the MI approach appears to be the most efficient correction method from the three investigated. Conclusions: In cranial SRS applications, patient-specific distortion correction at the target location(s) is feasible and effective, despite the expense of longer imaging time since additional MRI scan(s) need to be performed. A phantom-based QA methodology was developed and presented to reassure efficient implementation of correction techniques for sequence-dependent spatial distortion. © 2020 American Association of Physicists in Medicin

Dosimetric impact of rotational errors on the quality of VMAT-SRS for multiple brain metastases: Comparison between single- and two-isocenter treatment planning techniques

Purpose: In the absence of a 6D couch and/or assuming considerable intrafractional patient motion, rotational errors could affect target coverage and OAR-sparing especially in multiple metastases VMAT-SRS cranial cases, which often involve the concurrent irradiation of off-axis targets. This work aims to study the dosimetric impact of rotational errors in such applications, under a comparative perspective between the single- and two-isocenter treatment techniques. Methods: Ten patients (36 metastases) were included in this study. Challenging cases were only considered, with several targets lying in close proximity to OARs. Two multiarc VMAT plans per patient were prepared, involving one and two isocenters, serving as the reference plans. Different degrees of angular offsets at various orientations were introduced, simulating rotational errors. Resulting dose distributions were evaluated and compared using commonly employed dose-volume and plan quality indices. Results: For single-isocenter plans and 1⁰ rotations, plan quality indices, such as coverage, conformity index and D95%, deteriorated significantly (>5%) for distant targets from the isocenter (at> 4–6 cm). Contrarily, for two-isocenter plans, target distances to nearest isocenter were always shorter (≤4 cm), and, consequently, 1⁰ errors were well-tolerated. In the most extreme case considered (2⁰ around all axes) conformity index deteriorated by on-average 7.2%/cm of distance to isocenter, if one isocenter is used, and 2.6%/cm, for plans involving two isocenters. The effect is, however, strongly associated with target volume. Regarding OARs, for single-isocenter plans, significant increase (up to 63%) in Dmax and D0.02cc values was observed for any angle of rotation. Plans that could be considered clinically unacceptable were obtained even for the smallest angle considered, although rarer for the two-isocenter planning approach. Conclusion: Limiting the lesion-to-isocenter distance to ≤4 cm by introducing additional isocenter(s) appears to partly mitigate severe target underdosage, especially for smaller target sizes. If OAR-sparing is also a concern, more stringent rotational error tolerances apply. © 2020 The Authors. Journal of Applied Clinical Medical Physics published by Wiley Periodicals, Inc. on behalf of American Association of Physicists in Medicine