Isoeffective dose: a concept for biological weighting of absorbed dose in proton and heavier-ion therapies

When reporting radiation therapy procedures, International Commission on Radiation Units and Measurements (ICRU) recommends specifying absorbed dose at/in all clinically relevant points and/or volumes. In addition, treatment conditions should be reported as completely as possible in order to allow full understanding and interpretation of the treatment prescription. However, the clinical outcome does not only depend on absorbed dose but also on a number of other factors such as dose per fraction, overall treatment time and radiation quality radiation biology effectiveness (RBE). Therefore, weighting factors have to be applied when different types of treatments are to be compared or to be combined. This had led to the concept of 'isoeffective absorbed dose', introduced by ICRU and International Atomic Energy Agency (IAEA). The isoeffective dose D(IsoE) is the dose of a treatment carried out under reference conditions producing the same clinical effects on the target volume as those of the actual treatment. It is the product of the total absorbed dose (in gray) used and a weighting factor W(IsoE) (dimensionless): D(IsoE)=D×W(IsoE). In fractionated photon-beam therapy, the dose per fraction and the overall treatment time (in days) are the two main parameters that the radiation oncologist has the freedom to adjust. The weighting factor for an alteration of the dose per fraction is commonly evaluated using the linear-quadratic (α/β) model. For therapy with protons and heavier ions, radiation quality has to be taken into account. A 'generic proton RBE' of 1.1 for clinical applications is recommended in a joint ICRU-IAEA Report [ICRU (International Commission on Radiation Units and Measurements) and IAEA (International Atomic Energy Agency). Prescribing, recording and reporting proton-beam therapy. ICRU Report 78, jointly with the IAEA, JICRU, 7(2) Oxford University Press (2007)]. For heavier ions (e.g. carbon ions), the situation is more complex as the RBE values vary markedly with particle type, energy and depth in tissue.

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%.

IAEA's role in the global management of cancer-focus on upgrading radiotherapy services

The International Atomic Energy Agency (IAEA) is an intergovernmental organization composed by 138 Member States within the United Nations. It has a mandate to seek to accelerate and enlarge the contribution of atomic energy to peace, health and prosperity throughout the world. Within the IAEA structure, the Division of Human Health contributes to the enhancement of the capabilities in Member States to address needs related to prevention, diagnosis and treatment of health problems through the development and application of nuclear and radiation techniques within a framework of quality assurance. In view of the increasing cancer incidence rates in developing countries the activities in improving management of cancer have become increasingly important. This review will outline the IAEA's role in cancer management focusing on activities related to improving radiotherapy worldwide.

On the clinical spatial resolution achievable with protons and heavier charged particle radiotherapy beams

The 'sub-millimetre precision' often claimed to be achievable in protons and light ion beam therapy is analysed using the Monte Carlo code SHIELD-HIT for a broad range of energies. Based on the range of possible values and uncertainties of the mean excitation energy of water and human tissues, as well as of the composition of organs and tissues, it is concluded that precision statements deserve careful reconsideration for treatment planning purposes. It is found that the range of I-values of water stated in ICRU reports 37, 49 and 73 (1984, 1993 and 2005) for the collision stopping power formulae, namely 67 eV, 75 eV and 80 eV, yields a spread of the depth of the Bragg peak of protons and heavier charged particles (carbon ions) of up to 5 or 6 mm, which is also found to be energy dependent due to other energy loss competing interaction mechanisms. The spread is similar in protons and in carbon ions having analogous practical range. Although accurate depth-dose distribution measurements in water can be used at the time of developing empirical dose calculation models, the energy dependence of the spread causes a substantial constraint. In the case of in vivo human tissues, where distribution measurements are not feasible, the problem poses a major limitation. In addition to the spread due to the currently accepted uncertainties of their I-values, a spread of the depth of the Bragg peak due to the varying compositions of soft tissues is also demonstrated, even for cases which could be considered practically identical in clinical practice. For these, the spreads found were similar to those of water or even larger, providing support to international recommendations advising that body-tissue compositions should not be given the standing of physical constants. The results show that it would be necessary to increase the margins of a clinical target volume, even in the case of a water phantom, due to an 'intrinsic basic physics uncertainty', adding to those margins usually considered in normal clinical practice due to anatomical or therapeutic strategy reasons. Individualized patient determination of tissue composition along the complete beam path, rather than CT Hounsfield numbers alone, would also probably be required even to reach 'sub-centimetre precision'.

Configuration of the electron transport algorithm of PENELOPE to simulate ion chambers

The stability of the electron transport algorithm implemented in the Monte Carlo code PENELOPE with respect to variations of its step length is analysed in the context of the simulation of ion chambers used in photon and electron dosimetry. More precisely, the degree of violation of the Fano theorem is quantified (to the 0.1% level) as a function of the simulation parameters that determine the step size. To meet the premises of the theorem, we define an infinite graphite phantom with a cavity delimited by two parallel planes (i.e., a slab) and filled with a 'gas' that has the same composition as graphite but a mass density a thousand-fold smaller. The cavity walls and the gas have identical cross sections, including the density effect associated with inelastic collisions. Electrons with initial kinetic energies equal to 0.01, 0.1, 1, 10 or 20 MeV are generated in the wall and in the gas with a uniform intensity per unit mass. Two configurations, motivated by the design of pancake- and thimble-type chambers, are considered, namely, with the initial direction of emission perpendicular or parallel to the gas-wall interface. This version of the Fano test avoids the need of photon regeneration and the calculation of photon energy absorption coefficients, two ingredients that are common to some alternative definitions of equivalent tests. In order to reduce the number of variables in the analysis, a global new simulation parameter, called the speedup parameter (a), is introduced. It is shown that setting a = 0.2, corresponding to values of the usual PENELOPE parameters of C1 = C2 = 0.02 and values of WCC and WCR that depend on the initial and absorption energies, is appropriate for maximum tolerances of the order of 0.2% with respect to an analogue, i.e., interaction-by-interaction, simulation of the same problem. The precise values of WCC and WCR do not seem to be critical to achieve this level of accuracy. The step-size dependence of the absorbed dose is explained in the light of the properties of PENELOPE's transport mechanics. This work is intended to help users to adopt an optimal configuration that guarantees both a high-accuracy calculation of the absorbed dose and a reasonably short computing time.

Calculation of stopping power ratios for carbon ion dosimetry

Water-to-air stopping power ratio calculations for the ionization chamber dosimetry of clinical carbon ion beams with initial energies from 50 to 450 MeV/u have been performed using the Monte Carlo technique. To simulate the transport of a particle in water the computer code SHIELD-HIT v2 was used, which is a newly developed version where substantial modifications were implemented on its predecessor SHIELD-HIT v1 (Gudowska et al 2004 Phys. Med. Biol. 49 1933-58). The code was completely rewritten replacing formerly used single precision variables with double precision variables. The lowest particle transport specific energy was decreased from 1 MeV/u down to 10 keV/u by modifying the Bethe-Bloch formula, thus widening its range for medical dosimetry applications. In addition, the code includes optionally MSTAR and ICRU-73 stopping power data. The fragmentation model was verified and its parameters were also adjusted. The present code version shows excellent agreement with experimental data. It has been used to compute the physical quantities needed for the calculation of stopping power ratios, s(water,air), of carbon beams. Compared with the recommended constant value given in the IAEA Code of Practice, the differences found in the present investigations varied between 0.5% and 1% at the plateau region, respectively for 400 MeV/u and 50 MeV/u beams, and up to 2.3% in the vicinity of the Bragg peak for 50 MeV/u.

The RBE issues in ion-beam therapy: conclusions of a joint IAEA/ICRU working group regarding quantities and units

This paper summarises the conclusions of a working group established jointly by the International Atomic Energy Agency (IAEA) and the International Commission on Radiation Units and Measurements (ICRU) to address some of the relative biological effectiveness (RBE) issues encountered in ion-beam therapy. Special emphasis is put on the selection and definition of the involved quantities and units. The isoeffective dose, as introduced here for radiation therapy applications, is the dose that delivered under reference conditions would produce the same clinical effects as the actual treatment in a given system, all other conditions being identical. It is expressed in Gy. The reference treatment conditions are: photon irradiation, 2 Gy per fraction, 5 daily fractions a week. The isoeffective dose D(IsoE) is the product of the physical quantity absorbed dose D and a weighting factor W(IsoE). W(IsoE) is an inclusive weighting factor that takes into account all factors that could influence the clinical effects like dose per fraction, overall time, radiation quality (RQ), biological system and effects. The numerical value of W(IsoE) is selected by the radiation-oncology team for a given patient (or treatment protocol). It is part of the treatment prescription. Evaluation of the influence of RQ on W(IsoE) raises complex problems because of the clinically significant RBE variations with biological effect (late vs. early) and position in depth in the tissues which is a problem specific to ion-beam therapy. Comparison of the isoeffective dose with the equivalent dose frequently used in proton- and ion-beam therapy is discussed.

Electron beam quality correction factors for plane-parallel ionization chambers: Monte Carlo calculations using the PENELOPE system

Simulations of three plane-parallel ionization chambers have been used to determine directly the chamber- and quality-dependent factors fc,Q, instead of the product (Sw,air p)Q, and kQ,Q0 (or kQ,Q,int) for a broad range of electron beam qualities (4-20 MeV) using divergent monoenergetic beams and phase-space data from two accelerators. An original calculation method has been used which circumvents the weakness of the so far assumed independence between stopping-power ratios and perturbation factors. Very detailed descriptions of the geometry and materials of the chambers have been obtained from the manufacturers, and prepared as input to the PENELOPE 2003 Monte Carlo system using a computer code that includes correlated sampling and particle splitting. Values of the beam quality factors have been determined for the case of an electron reference beam. The calculated values have been compared with those in the IAEA TRS-398 dosimetry protocol and the differences analysed. The results for a NACP-02 chamber show remarkably good agreement with TRS-398 at high electron beam qualities but differ slightly at low energies. Arguments to explain the differences include questioning the undemonstrated assumption that the NACP is a 'perturbation-free' chamber even at very low electron beam energies. Results for Wellhöfer PPC-40 and PPC-05 chambers cannot be compared with data from others for these chambers because no calculations or reliable experimental data exist. It has been found that the results for the PPC-40 are very close to those of a Roos chamber, but the values for the PPC-05 are considerably different from those of a Markus chamber, and rather approach those of a Roos chamber. Results for monoenergetic electrons and accelerator phase-space data have been compared to assess the need for detailed and costly simulations, finding very small differences. This questions the emphasis given in recent years to the use of 'realistic' source data for accurate electron beam dosimetry.

Ion beam transport in tissue-like media using the Monte Carlo code SHIELD-HIT

The development of the Monte Carlo code SHIELD-HIT (heavy ion transport) for the simulation of the transport of protons and heavier ions in tissue-like media is described. The code SHIELD-HIT, a spin-off of SHIELD (available as RSICC CCC-667), extends the transport of hadron cascades from standard targets to that of ions in arbitrary tissue-like materials, taking into account ionization energy-loss straggling and multiple Coulomb scattering effects. The consistency of the results obtained with SHIELD-HIT has been verified against experimental data and other existing Monte Carlo codes (PTRAN, PETRA), as well as with deterministic models for ion transport, comparing depth distributions of energy deposition by protons, 12C and 20Ne ions impinging on water. The SHIELD-HIT code yields distributions consistent with a proper treatment of nuclear inelastic collisions. Energy depositions up to and well beyond the Bragg peak due to nuclear fragmentations are well predicted. Satisfactory agreement is also found with experimental determinations of the number of fragments of a given type, as a function of depth in water, produced by 12C and 14N ions of 670 MeV u(-1), although less favourable agreement is observed for heavier projectiles such as 16O ions of the same energy. The calculated neutron spectra differential in energy and angle produced in a mimic of a Martian rock by irradiation with 12C ions of 290 MeV u(-1) also shows good agreement with experimental data. It is concluded that a careful analysis of stopping power data for different tissues is necessary for radiation therapy applications, since an incorrect estimation of the position of the Bragg peak might lead to a significant deviation from the prescribed dose in small target volumes. The results presented in this study indicate the usefulness of the SHIELD-HIT code for Monte Carlo simulations in the field of light ion radiation therapy.

Advances in the determination of absorbed dose to water in clinical high-energy photon and electron beams using ionization chambers

During the last two decades, absorbed dose to water in clinical photon and electron beams was determined using dosimetry protocols and codes of practice based on radiation metrology standards of air kerma. It is now recommended that clinical reference dosimetry be based on standards of absorbed dose to water. Newer protocols for the dosimetry of radiotherapy beams, based on the use of an ionization chamber calibrated in terms of absorbed dose to water, N(D,w), in a standards laboratory's reference quality beam, have been published by several national or regional scientific societies and international organizations. Since the publication of these protocols multiple theoretical and experimental dosimetry comparisons between the various N(D,w) based recommendations, and between the N(D,w) and the former air kerma (NK) based protocols, have been published. This paper provides a comprehensive review of the dosimetry protocols based on these standards and of the intercomparisons of the different protocols published in the literature, discussing the reasons for the observed discrepancies between them. A summary of the various types of standards of absorbed dose to water, together with an analysis of the uncertainties along the various steps of the dosimetry chain for the two types of formalism, is also included. It is emphasized that the NK-N(D,air) and N(D,w) formalisms have very similar uncertainty when the same criteria are used for both procedures. Arguments are provided in support of the recommendation for a change in reference dosimetry based on standards of absorbed dose to water.

Positron flight in human tissues and its influence on PET image spatial resolution

The influence of the positron distance of flight in various human tissues on the spatial resolution in positron emission tomography (PET) was assessed for positrons from carbon-11, nitrogen-13, oxygen-15, fluorine-18, gallium-68 and rubidium-82. The investigation was performed using the Monte Carlo code PENELOPE to simulate the transport of positrons within human compact bone, adipose, soft and lung tissue. The simulations yielded 3D distributions of annihilation origins that were projected on the image plane in order to assess their impact on PET spatial resolution. The distributions obtained were cusp-shaped with long tails rather than Gaussian shaped, thus making conventional full width at half maximum (FWHM) measures uncertain. The full width at 20% of the maximum amplitude (FW20M) of the annihilation distributions yielded more appropriate values for root mean square addition of spatial resolution loss components. Large differences in spatial resolution losses due to the positron flight in various human tissues were found for the selected radionuclides. The contribution to image blur was found to be up to three times larger in lung tissue than in soft tissue or fat and five times larger than in bone tissue. For (18)F, the spatial resolution losses were 0.54 mm in soft tissue and 1.52 mm in lung tissue, compared with 4.10 and 10.5 mm, respectively, for (82)Rb. With lung tissue as a possible exception, the image blur due to the positron flight in all human tissues has a minor impact as long as PET cameras with a spatial resolution of 5-7 mm are used in combination with (18)F-labelled radiopharmaceuticals. However, when ultra-high spatial resolution PET cameras, with 3-4 mm spatial resolution, are applied, especially in combination with other radionuclides, the positron flight may enter as a limiting factor for the total PET spatial resolution--particularly in lung tissue.

The IAEA/WHO TLD postal dose quality audits for radiotherapy: a perspective of dosimetry practices at hospitals in developing countries

BACKGROUND AND PURPOSE

The IAEA/WHO TLD postal programme for external audits of the calibration of high-energy photon beams used in radiotherapy has been in operation since 1969. This work presents a survey of the 1317 TLD audits carried out during 1998-2001. The TLD results are discussed from the perspective of the dosimetry practices in hospitals in developing countries, based on the information provided by the participants in their TLD data sheets.

MATERIALS AND METHODS

A detailed analysis of the TLD data sheets is systematically performed at the IAEA. It helps to trace the source of any discrepancy between the TLD measured dose and the user stated dose, and also provides information on equipment, dosimetry procedures and the use of codes of practice in the countries participating in the IAEA/WHO TLD audits.

RESULT

The TLD results are within the 5% acceptance limit for 84% of the participants. The results for accelerator beams are typically better than for Co-60 units. Approximately 75% of participants reported dosimetry data, including details on their procedure for dose determination from ionisation chamber measurements. For the remaining 25% of hospitals, who did not submit these data, the results are poorer than the global TLD results. Most hospitals have Farmer type ionisation chambers calibrated in terms of air kerma by a standards laboratory. Less than 10% of the hospitals use new codes of practice based on standards of absorbed dose to water.

CONCLUSION

Despite the differences in dosimetry equipment, traceability to different standards laboratories and uncertainties arising from the use of various dosimetry codes of practice, the determination of absorbed dose to water for photon beams typically agrees within 2% among hospitals. Correct implementation of any of the dosimetry protocols should ensure that significant errors in dosimetry are avoided.

Ionization chamber dosimetry of small photon fields: a Monte Carlo study on stopping-power ratios for radiosurgery and IMRT beams

Absolute dosimetry with ionization chambers of the narrow photon fields used in stereotactic techniques and IMRT beamlets is constrained by lack of electron equilibrium in the radiation field. It is questionable that stopping-power ratio in dosimetry protocols, obtained for broad photon beams and quasi-electron equilibrium conditions, can be used in the dosimetry of narrow fields while keeping the uncertainty at the same level as for the broad beams used in accelerator calibrations. Monte Carlo simulations have been performed for two 6 MV clinical accelerators (Elekta SL-18 and Siemens Mevatron Primus), equipped with radiosurgery applicators and MLC. Narrow circular and Z-shaped on-axis and off-axis fields, as well as broad IMRT configured beams, have been simulated together with reference 10 x 10 cm2 beams. Phase-space data have been used to generate 3D dose distributions which have been compared satisfactorily with experimental profiles (ion chamber, diodes and film). Photon and electron spectra at various depths in water have been calculated, followed by Spencer-Attix (delta = 10 keV) stopping-power ratio calculations which have been compared to those used in the IAEA TRS-398 code of practice. For water/air and PMMA/air stopping-power ratios, agreements within 0.1% have been obtained for the 10 x 10 cm2 fields. For radiosurgery applicators and narrow MLC beams, the calculated s(w,air) values agree with the reference within +/-0.3%, well within the estimated standard uncertainty of the reference stopping-power ratios (0.5%). Ionization chamber dosimetry of narrow beams at the photon qualities used in this work (6 MV) can therefore be based on stopping-power ratios data in dosimetry protocols. For a modulated 6 MV broad beam used in clinical IMRT, s(w,air) agrees within 0.1% with the value for 10 x 10 cm2, confirming that at low energies IMRT absolute dosimetry can also be based on data for open reference fields. At higher energies (24 MV) the difference in s(w,air) was up to 1.1%, indicating that the use of protocol data for narrow beams in such cases is less accurate than at low energies, and detailed calculations of the dosimetry parameters involved should be performed if similar accuracy to that of 6 MV is sought.

Calculations of electron fluence correction factors using the Monte Carlo code PENELOPE

In electron-beam dosimetry, plastic phantom materials may be used instead of water for the determination of absorbed dose to water. A correction factor phi(water)plastic is then needed for converting the electron fluence in the plastic phantom to the fluence at an equivalent depth in water. The recommended values for this factor given by AAPM TG-25 (1991 Med. Phys. 18 73-109) and the IAEA protocols TRS-381 (1997) and TRS-398 (2000) disagree, in particular at large depths. Calculations of the electron fluence have been done, using the Monte Carlo code PENELOPE, in semi-infinite phantoms of water and common plastic materials (PMMA, clear polystyrene, A-150, polyethylene, Plastic water and Solid water (WT1)). The simulations have been carried out for monoenergetic electron beams of 6, 10 and 20 MeV, as well as for a realistic clinical beam. The simulated fluence correction factors differ from the values in the AAPM and IAEA recommendations by up to 2%, and are in better agreement with factors obtained by Ding et al (1997 Med. Phys. 24 161-76) using EGS4. Our Monte Carlo calculations are also in good accordance with phi(water)plastic values measured by using an almost perturbation-free ion chamber. The important interdependence between depth- and fluence-scaling corrections for plastic phantoms is discussed. Discrepancies between the measured and the recommended values of phi(water)plastic may then be explained considering the different depth-scaling rules used.

Secondary particle production in tissue-like and shielding materials for light and heavy ions calculated with the Monte-Carlo code SHIELD-HIT

The Monte Carlo code SHIELD has been modified into a version named SHIELD-HIT which extends the transport of hadron cascades in shielding materials to that of ions in tissue-like materials, and includes ion energy-loss straggling, multiple scattering, track-length calculations and production of secondary particles, which includes all generations, for ion interactions with the media. Calculations using SHIELD-HIT have been performed for 1H, 12C and 26Fe ions with energies up to 1000 MeV/u transported through water, soft tissue and aluminium. These have been validated by comparing Monte Carlo results with experimental data and results from other Monte Carlo codes for ion transport. Good agreement has been found for depth-dose distributions of protons and 12C ions in water up to depths well beyond the Bragg peak, where nuclear fragmentation effects dominate and for the production of secondary particles at different depths. Detailed track-length fluence spectra of secondary particles have been calculated for various combinations of projectiles and targets of interest for space radiation and radiotherapy applications. The secondary particle spectra in water from carbon ions have been used for calculations of stopping-power ratios for ionization chamber dosimetry, confirming the values recommended by the IAEA Code of Practice for radiotherapy dosimetry with heavy ions.

Protocols for the dosimetry of high-energy photon and electron beams: a comparison of the IAEA TRS-398 and previous international codes of practice. International Atomic Energy Agency

A new international Code of Practice for radiotherapy dosimetry co-sponsored by several international organizations has been published by the IAEA, TRS-398. It is based on standards of absorbed dose to water, whereas previous protocols (TRS-381 and TRS-277) were based on air kerma standards. To estimate the changes in beam calibration caused by the introduction of TRS-398, a detailed experimental comparison of the dose determination in reference conditions in high-energy photon and electron beams has been made using the different IAEA protocols. A summary of the formulation and reference conditions in the various Codes of Practice, as well as of their basic data, is presented first. Accurate measurements have been made in 25 photon and electron beams from 10 clinical accelerators using 12 different cylindrical and plane-parallel chambers, and dose ratios under different conditions of TRS-398 to the other protocols determined. A strict step-by-step checklist was followed by the two participating clinical institutions to ascertain that the resulting calculations agreed within tenths of a per cent. The maximum differences found between TRS-398 and the previous Codes of Practice TRS-277 (2nd edn) and TRS-381 are of the order of 1.5-2.0%. TRS-398 yields absorbed doses larger than the previous protocols, around 1.0% for photons (TRS-277) and for electrons (TRS-381 and TRS-277) when plane-parallel chambers are cross-calibrated. For the Markus chamber, results show a very large variation, although a fortuitous cancellation of the old stopping powers with the ND,w/NK ratios makes the overall discrepancy between TRS-398 and TRS-277 in this case smaller than for well-guarded plane-parallel chambers. Chambers of the Roos-type with a 60Co ND,w calibration yield the maximum discrepancy in absorbed dose, which varies between 1.0% and 1.5% for TRS-381 and between 1.5% and 2.0% for TRS-277. Photon beam calibrations using directly measured or calculated TPR20,10 from a percentage dose data at SSD = 100 cm were found to be indistinguishable. Considering that approximately 0.8% of the differences between TRS-398 and the NK-based protocols are caused by the change to the new type of standards, the remaining difference in absolute dose is due either to a close similarity in basic data or to a fortuitous cancellation of the discrepancies in data and type of chamber calibration. It is emphasized that the NK-ND,air and ND,w formalisms have very similar uncertainty when the same criteria are used for both procedures. Arguments are provided in support of the recommendation for a change in reference dosimetry based on standards of absorbed dose to water.

Photon quality correction factors for ionization chambers in an epithermal neutron beam

Photon quality correction factors (kQy) for ionization chamber photon dosimetry in an epithermal neutron beam were determined according to a modified absorbed dose to water formalism which was extended to mixed radiation fields. We have studied two commercially available ionization chambers in the epithermal neutron beam optimized for BNCT at the facility at Studsvik, Sweden. One of the chambers is nominally neutron insensitive; a magnesium-walled detector flushed with pure argon gas (denoted by Mg/Ar). The second chamber has approximately the same sensitivity for neutrons and photons; it is considered a 'tissue equivalent' detector, with A-150 walls flushed with methane-based tissue-equivalent gas (denoted by TE/TE). The kQy-factors in epithermal neutron beams have previously been assumed to be equal to unity or estimated from measurements in clinical accelerator produced photon beams. In this work the kQy-factors have been determined from absorbed dose calculations using cavity theory together with Monte Carlo derived electron fluences obtained with the MCNP4c system for water and PMMA phantoms. The calculated quality correction factors differ substantially from unity, being in the order of 10% for the Mg/Ar detector at shallow phantom depths, and between 2 and 4% for other depths and for the TE/TE chamber.

Performance analysis and determination of the p(wall) correction factor for 60Co gamma-ray beams for Wellhöfer Roos-type plane-parallel chambers

The wall perturbation correction factor p(wall) in 60Co for Wellhöfer Roos-type plane-parallel ionization chambers is determined experimentally and compared with the results of a previous study using PTW-Roos chambers (Palm et al 2000 Phys. Med. Biol. 45 971-81). Five ionization chambers of the type Wellhöfer PPC-35 (or its equivalent PPC-40) are used for the analysis. Wall perturbation correction factors are obtained by assuming N(D,air) chamber factors determined by cross-calibration in a high-energy electron and in a 60Co gamma-ray beam to be equal, and by assigning any differences to the wall perturbation factor. The procedure yields a p(wall) value of 1.018 (u(c) = 0.010), which is slightly higher than the value 1.014 (u(c) = 0.010) formerly obtained for the PTW-Roos chambers using the N(D,air) method. The chamber-to-chamber variation in p(wall) for the Wellhöfer-Roos chambers is found to be very small, with a maximum difference of 0.3%. The effect of using new p(cav) values for graphite-walled Farmer-type chambers used in water in electron beams is to decrease p(wall) by approximately 0.5%. The long- and short-term stability of the Roos-type chambers manufactured by Wellhöfer is investigated by measurements at the IAEA Dosimetry Laboratory in Vienna, Austria, and at the Sahlgrenska University Hospital in Göteborg, Sweden. Calibrations made at the IAEA over several months show variations in the N(D,w) calibration factors larger than expected. based on previous experiences with PTW-Roos chambers. Measurements of the short-term stability of the Wellhöfer-Roos chambers show a marked increase in chamber response for the time the chambers are immersed in water, pointing to a possible problem in the chamber design. As a consequence of these findings, Wellhöfer is currently working on a re-design of the chamber to solve the stability problem.

Study of a selection of 10 historical types of dosemeter: variation of the response to Hp(10) with photon energy and geometry of exposure

An international collaborative study of cancer risk among workers in the nuclear industry is tinder way to estimate direetly the cancer risk following protracted low-dose exposure to ionising radiation. An essential aspect of this study is the characterisation and quantification of errors in available dose estimates. One major source of errors is dosemeter response in workplace exposure conditions. Little information is available on energy and geometry response for most of the 124 different dosemeters used historically in participating facilities. Experiments were therefore set up to assess this. using 10 dosemeter types representative of those used over time. Results show that the largest errors were associated with the response of early dosemeters to low-energy photon radiation. Good response was found with modern dosemeters. even at low energy. These results are being used to estimate errors in the response for each dosemeter type, used in the participating facilities, so that these can be taken into account in the estimates of cancer risk.

Comparison of the IAEA TRS-398 and AAPM TG-51 absorbed dose to water protocols in the dosimetry of high-energy photon and electron beams

The International Atomic Energy Agency (IAEA TRS-398) and the American Association of Physicists in Medicine (AAPM TG-51) have published new protocols for the calibration of radiotherapy beams. These protocols are based on the use of an ionization chamber calibrated in terms of absorbed dose to water in a standards laboratory's reference quality beam. This paper compares the recommendations of the two protocols in two ways: (i) by analysing in detail the differences in the basic data included in the two protocols for photon and electron beam dosimetry and (ii) by performing measurements in clinical photon and electron beams and determining the absorbed dose to water following the recommendations of the two protocols. Measurements were made with two Farmer-type ionization chambers and three plane-parallel ionization chamber types in 6, 18 and 25 MV photon beams and 6, 8, 10, 12, 15 and 18 MeV electron beams. The Farmer-type chambers used were NE 2571 and PTW 30001, and the plane-parallel chambers were a Scanditronix-Wellhöfer NACP and Roos, and a PTW Markus chamber. For photon beams, the measured ratios TG-51/TRS-398 of absorbed dose to water Dw ranged between 0.997 and 1.001, with a mean value of 0.999. The ratios for the beam quality correction factors kQ were found to agree to within about +/-0.2% despite significant differences in the method of beam quality specification for photon beams and in the basic data entering into kQ. For electron beams, dose measurements were made using direct N(D,w) calibrations of cylindrical and plane-parallel chambers in a 60Co gamma-ray beam, as well as cross-calibrations of plane-parallel chambers in a high-energy electron beam. For the direct N(D,w) calibrations the ratios TG-51/TRS-398 of absorbed dose to water Dw were found to lie between 0.994 and 1.018 depending upon the chamber and electron beam energy used, with mean values of 0.996, 1.006, and 1.017, respectively, for the cylindrical, well-guarded and not well-guarded plane-parallel chambers. The Dw ratios measured for the cross-calibration procedures varied between 0.993 and 0.997. The largest discrepancies for electron beams between the two protocols arise from the use of different data for the perturbation correction factors p(wall) and p(dis) of cylindrical and plane-parallel chambers, all in 60Co. A detailed analysis of the reasons for the discrepancies is made which includes comparing the formalisms, correction factors and the quantities in the two protocols.

Reference dosimetry in clinical high-energy electron beams: comparison of the AAPM TG-51 and AAPM TG-21 dosimetry protocols

A comparison of the determination of absorbed dose to water in reference conditions with high-energy electron beams (Enominal of 6, 8, 10, 12, 15, and 18 MeV) following the recommendations given in the AAPM TG-51 and in the original TG-21 dosimetry protocols has been made. Six different ionization chamber types have been used, two Farmer-type cylindrical (PTW 30001, PMMA wall; NE 2571, graphite wall) and four plane parallel (PTW Markus, and Scanditronix-Wellhöfer NACP, PPC-05 and Roos PPC-40). Depending upon the cylindrical chamber type used and the beam energy, the doses at dmax determined with TG-51 were higher than with TG-21 by about 1%-3%. Approximately 1% of this difference is due to the differences in the data given in the two protocols; another 1.1%-1.2% difference is due to the change of standards, from air-kerma to absorbed dose to water. For plane-parallel chambers, absorbed doses were determined by using two chamber calibration methods: (i) direct use of the ADCL calibration factors N(60Co)D,w and Nx for each chamber type in the appropriate equations for dose determination recommended by each protocol, and (ii) cross-calibration techniques in a high-energy electron beam, as recommended by TG-21, TG-39, and TG-51. Depending upon the plane-parallel chamber type used and the beam energy, the doses at dmax determined with TG-51 were higher than with TG-21 by about 0.7%-2.9% for the direct calibration procedures and by 0.8%-3.2% for the cross-calibration techniques. Measured values of photon-electron conversion kecal, for the NACP and Markus chambers were found to be 0.3% higher and 1.7% lower than the corresponding values given in TG-51. For the PPC-05 and PPC-40 (Roos) chamber types, the values of kecal were measured to be 0.889 and 0.893, respectively. The uncertainty for the entire calibration chain, starting from the calibration of the ionization chamber in the standards laboratory to the determination of absorbed dose to water in the user beam, has been analyzed for the two formalisms. For cylindrical chambers, the observed differences between the two protocols are within the estimated combined uncertainty of the ratios of absorbed doses for 6 and 8 MeV; however, at higher energies (10< or =E< or =18 MeV), the differences are larger than the estimated combined uncertainties by about 1%. For plane-parallel chambers, the observed differences are within the estimated combined uncertainties for the direct calibration technique; for the cross-calibration technique the differences are within the uncertainty estimates at low energies whereas they are comparable to the uncertainty estimates at higher energies. A detailed analysis of the reasons for the discrepancies is made which includes comparing the formalisms, correction factors, and quantities in the two protocols, as well as the influence of the implementation of the different standards for chamber calibration.

Aspects of MR image distortions in radiotherapy treatment planning

BACKGROUND

Registration of computed tomography (CT) and magnetic resonance (MR) images are commonly performed to define the different target regions used in radiotherapy treatment planning (RTTP). The accuracy of target definition will then depend on the spatial accuracy of the CT and MR data, and on the technique used to register the images. CT images are usually regarded as geometrically correct, while MR images are known to suffer from geometric distortion. The aim of this paper is to discuss the possible impact of MR image distortions in the radiotherapy treatment planning process.

METHODS

The origin, magnitude, and relative impact of the different sources of geometric distortions that affect the MR image data at different magnetic fields and for different acquisition settings are described. Techniques for distortion correction are reviewed, and their limitations are outlined. The sensitivity of image registration techniques to the presence of geometric distortions in the MR data is discussed. Finally, an overview of image registration techniques used and results obtained in clinical radiotherapy treatment planning applications is given.

RESULTS

Spatial distortions in MR images vary with field strength and with the image acquisition protocol. The spatial accuracy generally decreases with distance from the magnet isocenter. Distortion correction techniques based on phantom evaluations cannot adequately model patient-induced distortions.

CONCLUSION

Image protocols with high gradient bandwidths should be used to reduce the spatial distortions in MR images. Correction techniques based only on phantom measurements could be sufficient at low magnetic fields, while at higher fields additional corrections of patient-related distortions might be needed. Registration techniques based on matching of Landmark points located far from the magnet isocenter are especially prone to MR distortions.

Reference dosimetry in clinical high-energy photon beams: comparison of the AAPM TG-51 and AAPM TG-21 dosimetry protocols

Task Group 51 (TG-51) of the Radiation Therapy Committee of the American Association of Physicists in Medicine (AAPM) has recently developed a new protocol for the calibration of high-energy photon and electron beams used in radiation therapy. The formalism and the dosimetry procedures recommended in this protocol are based on the use of an ionization chamber calibrated in terms of absorbed dose-to-water in a standards laboratory's 60Co gamma ray beam. This is different from the recommendations given in the AAPM TG-21 protocol, which are based on an exposure calibration factor of an ionization chamber in a 60Co beam. The purpose of this work is to compare the determination of absorbed dose-to-water in reference conditions in high-energy photon beams following the recommendations given in the two dosimetry protocols. This is realized by performing calibrations of photon beams with nominal accelerating potential of 6, 18 and 25 MV, generated by an Elekta MLCi and SL25 series linear accelerator. Two widely used Farmer-type ionization chambers having different composition, PTW 30001 (PMMA wall) and NE 2571 (graphite wall), were used for this study. Ratios of AAPM TG-51 to AAPM TG-21 doses to water are found to be 1.008, 1.007 and 1.009 at 6, 18 and 25 MV, respectively when the PTW chamber is used. The corresponding results for the NE chamber are 1.009, 1.010 and 1.013. The uncertainties for the ratios of the absorbed dose determined by the two protocols are estimated to be about 1.5%. A detailed analysis of the reasons for the discrepancies is made which includes comparing the formalisms, correction factors and quantities in the two protocols, as well as the influence of the implementation of the different standards for chamber calibration. The latter has been found to have a considerable influence on the differences in clinical dosimetry, even larger than the adoption of the new data and recommended procedures, as most intrinsic differences cancel out due to the adoption of the new formalism.

Comparison of dosimetry recommendations for clinical proton beams

The formalism and data in the two most recent dosimetry recommendations for clinical proton beams, ICRU Report 59 and the forthcoming IAEA Code of Practice, are compared. Chamber calibrations in terms of air kerma and absorbed dose to water are considered, including five different cylindrical ionization chamber types commonly used in proton beam dosimetry. The methodology for both types of calibration for ionization chambers is described in ICRU Report 59. The procedure based on air kerma calibrations is compared with an alternative formalism based on IAEA Codes of Practice (TRS-277, TRS-381), modified for proton beams. The new IAEA Code of Practice is exclusively based on calibrations in terms of absorbed dose to water and a direct comparison with ICRU Report 59 recommendations is made. Common to the two formalisms are the fundamental quantities Wair and w(air) and their atmospheric conditions of applicability. The difference in the recommended values of the ratio w(air)/Wair (protons to 60Co) is as large as 2.3%. The use of Wair and w(air) values for dry air (IAEA) and for ambient air (ICRU) is a contribution to the discrepancy, and the ICRU usage is questioned. For air kerma based chamber calibrations, ICRU Report 59 does not take into account the effect of different compositions of the build-up cap and chamber wall on the calibration beam quality. For the chamber types included in the study, this introduces discrepancies of up to 1.1%. Combined with differences in the recommended basic data, discrepancies in absorbed dose determination in proton beams of up to 2.1% are found. For the absorbed dose to water based formalism, differences in the formalism, notably the omission of perturbation factors for 60Co in ICRU 59, and data yield discrepancies in calculated kQ factors, and in absorbed dose determinations, between -1.5% and +2.6%, depending on the chamber type and the proton beam quality.

A comparison between calculated and experimental kQ photon beam quality correction factors

To validate the calculated values of kQ for high-energy photon beams given in the International Code of Practice for radiotherapy dosimetry based on water-absorbed-dose standards, a comparison with experimental values derived in standards laboratories and in clinical beams has been made. The study includes a compilation of experimental values for ionization chambers of the type NE2561/2611, NE2571, PTW30001 and PR06. The energy dependence of the G(Fe3+) ratio of high-energy x-rays to 60Co gamma-rays by Klassen et al is taken into account for all the Fricke-derived values. For three of the chamber types analysed, the comparison shows that the calculated values are a very good estimate of the average values of kQ in the entire range of photon beam qualities available for clinical use. For the NE2571 chamber type a difference which increases with energy between calculated and experimental kQ factors has been observed; however, the largest difference with a fit describing the entire set of experimental data is always smaller than 0.4%. It is concluded that if the recommendation of the Code of Practice for an individual calibration of the user's chamber at a range of photon beam qualities is not available, the use of calculated kQ factors will yield absorbed dose to water determinations accurate within the uncertainty limits of the majority of experimental data available. The good agreement between calculated and measured values, obtained for practically all the experimental data using TPR(20,10) as photon beam quality specifier, is not satisfied in some cases for two high-energy soft beams used at the Canadian NRC. There appears to be no justification for a change to a different photon beam quality specifier solely on the grounds that such a limited set of data is not described by the same distributions as the rest of the experimental data.

Calibration of plane-parallel chambers and determination of p(wall) for the NACP and Roos chambers for 60Co gamma-ray beams

Procedures for the calibration and use of plane-parallel ionization chambers in high-energy electron and photon beams have been given in the international code of practice IAEA TRS-381. In the present work, plane-parallel ionization chambers of the type PTW-34001 Roos and Scanditronix NACP02 have been calibrated using two N(K)-based procedures. For the NACP chamber the difference between the N(D,air) chamber factors determined in an electron beam and in a 60Co gamma-ray beam, respectively, is of the same magnitude as the experimental uncertainty. Results for the PTW Roos chambers, however, do not agree, in accordance with recent findings of other authors. The value determined in a 60Co gamma-ray beam is questioned and the reason for the discrepancy assigned to the correction factor for the perturbation due to the chamber wall, p(wall). New values of p(wall) have been experimentally determined by comparing absorbed dose measurements based on air-kerma and absorbed dose to water calibration procedures. A new p(wall) factor for the Roos chamber in 60Co gamma-ray beams in water (1.009+/-0.6%) was derived as the weighted average of the different determinations. The value is not significantly higher than the p(wall) factor given in TRS-381 (1.003+/-1.5%), but the combined standard uncertainty is reduced. The chamber to chamber variation for six commercial PTW Roos chambers and a Roos prototype was found to be very small.

Determination of absorbed dose to water in reference conditions for radiotherapy kilovoltage x-rays between 10 and 300 kV: a comparison of the data in the IAEA, IPEMB, DIN and NCS dosimetry protocols

A comparison of four of the most commonly used dosimetry protocols for the determination of absorbed dose to water in therapeutic kilovoltage x-rays using an ionization chamber (IAEA TRS-277, IPEMB, DIN and NCS) has been carried out. Owing to the different energy ranges and HVLs recommended by each protocol, backscatter factors, water-to-air mass energy absorption coefficient ratios and perturbation correction factors have been recast to a common quality range that all protocols satisfy individually to make a comparison possible. The results of the comparison show that in the sometimes reduced quality range originally included by the different protocols, determinations of absorbed dose to water at all beam qualities agree to within +/-1.0% with that obtained using the second edition of the IAEA TRS-277 code of practice (1997). The extrapolation of data to a common beam quality range practically preserves the agreement for all the protocols except for that issued by the NCS at the extremes of the range, where differences of up to 1.8% and 1.4% have been found for low and medium energies respectively. In all cases the DIN protocol yields very good agreement with TRS-277.

On the beam quality specification of high-energy photons for radiotherapy dosimetry

An overview of common photon beam quality specifiers used in radiotherapy dosimetry introduces a reasoned discussion on the advantages and disadvantages of TPR20,10 and PDD(10)x. It is shown that some of the potential advantages of PDD(10)x are also present in other well known beam quality specifiers such as d80. However, all PDD-based beam quality indices, including PDD(10)x, are subject to electron contamination and their determination is affected by practical limitations. The proposed filtration of contaminant electrons by Kosunen and Rogers [Med. Phys. 20, 1181-1188 (1993)] and by Li and Rogers [Med. Phys. 21, 791-798 (1994)] is questioned, not only with regard to the adequacy of using lead as an electron filter, but also in relation to its efficiency (if there were no contamination, restrictions for beam calibrations at dmax would be removed) and practical measurement. It is argued that (i) there is no unique beam quality specifier that works satisfactorily in all possible conditions, for the entire energy range of photon energies used in radiotherapy and all possible accelerators used in hospitals and in standards laboratories, and (ii) TPR20,10 remains to be the most appropriate specifier for clinical photon beams as it has less practical drawbacks than PDD-based quality indices. The final impact on clinical photon beam dosimetry resulting from the use of different photon beam quality specifiers, is that they are not expected to yield a significant change (i.e., more than 0.5% and in most cases well within 0.2%) in the absorbed dose to water in reference conditions for most clinical beams.

The IAEA/WHO TLD postal programme for radiotherapy hospitals

BACKGROUND AND PURPOSE

Since 1969 the International Atomic Energy Agency (IAEA), together with the World Health Organization (WHO), has performed postal TLD audits to verify the calibration of radiotherapy beams in developing countries.

MATERIALS AND METHODS

A number of changes have recently been implemented to improve the efficiency of the IAEA/WHO TLD programme. The IAEA has increased the number of participants and reduced significantly the total turn-around time to provide results to the hospitals within the shortest possible time following the TLD irradiations. The IAEA has established a regular follow-up programme for hospitals with results outside acceptance limits of +/- 5%.

RESULTS

The IAEA has, over 30 years, verified the calibration of more than 3300 clinical photon beams at approximately 1000 radiotherapy hospitals. Only 65% of those hospitals who receive TLDs for the first time have results within the acceptance limits, while more than 80% of the users that have benefited from a previous TLD audit are successful. The experience of the IAEA in TLD audits has been transferred to the national level. The IAEA offers a standardized TLD methodology, provides guidelines and gives technical back-up to the national TLD networks.

CONCLUSION

The unsatisfactory status of the dosimetry for radiotherapy, as noted in the past, is gradually improving; however, the dosimetry practices in many hospitals in developing countries need to be revised in order to reach adequate conformity to hospitals that perform modern radiotherapy in Europe, USA and Australia.

Calculation of absorbed dose and biological effectiveness from photonuclear reactions in a bremsstrahlung beam of end point 50 MeV

The absorbed dose due to photonuclear reactions in soft tissue, lung, breast, adipose tissue and cortical bone has been evaluated for a scanned bremsstrahlung beam of end point 50 MeV from a racetrack accelerator. The Monte Carlo code MCNP4B was used to determine the photon source spectrum from the bremsstrahlung target and to simulate the transport of photons through the treatment head and the patient. Photonuclear particle production in tissue was calculated numerically using the energy distributions of photons derived from the Monte Carlo simulations. The transport of photoneutrons in the patient and the photoneutron absorbed dose to tissue were determined using MCNP4B; the absorbed dose due to charged photonuclear particles was calculated numerically assuming total energy absorption in tissue voxels of 1 cm3. The photonuclear absorbed dose to soft tissue, lung, breast and adipose tissue is about (0.11-0.12)+/-0.05% of the maximum photon dose at a depth of 5.5 cm. The absorbed dose to cortical bone is about 45% larger than that to soft tissue. If the contributions from all photoparticles (n, p, 3He and 4He particles and recoils of the residual nuclei) produced in the soft tissue and the accelerator, and from positron radiation and gammas due to induced radioactivity and excited states of the nuclei, are taken into account the total photonuclear absorbed dose delivered to soft tissue is about 0.15+/-0.08% of the maximum photon dose. It has been estimated that the RBE of the photon beam of 50 MV acceleration potential is approximately 2% higher than that of conventional 60Co radiation.