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Sethi A, Gros S, Brodin P, Ghavidel B, Chai X, Popovic M, Tomé WA, Trichter S, Yang X, Zhang H, Uhl V. Intraoperative radiation therapy with 50 kV x-rays: A multi-institutional review. J Appl Clin Med Phys 2024; 25:e14272. [PMID: 38279520 DOI: 10.1002/acm2.14272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/16/2023] [Accepted: 01/01/2024] [Indexed: 01/28/2024] Open
Abstract
This report covers clinical implementation of a low kV intraoperative radiation therapy (IORT) program with the INTRABEAM® System (Carl Zeiss Meditec AG, Jena, Germany). Based on collective user experience from eight institutions, we discuss best methods of INTRABEAM quality assurance (QA) tests, commissioning measurements, clinical workflow, treatment planning, and potential avenues for research. The guide provides pertinent background information and clinical justification for IORT. It describes the INTRABEAM system and commissioning measurements along with a TG100 risk management analysis to ensure safety and accuracy of the IORT program. Following safety checks, dosimetry measurements are performed for verification of field flatness and symmetry, x-ray output, and depth dose. Also discussed are dose linearity checks, beam isotropy, ion chamber measurements, calibration protocols, and in-vivo dosimetry with optically stimulated luminescence dosimeters OSLDs, and radiochromic film. Emphasis is placed on the importance of routine QA procedures (daily, monthly, and annual) performed at regular intervals for a successful IORT program. For safe and accurate dose delivery, tests of important components of IORT clinical workflow are emphasized, such as, dose prescription, pre-treatment QA, treatment setup, safety checks, radiation surveys, and independent checks of delivered dose. Challenges associated with in-vivo dose measurements are discussed, along with special treatment procedures and shielding requirements. The importance of treatment planning in IORT is reviewed with reference to a Monte Carlo-based commercial treatment planning system highlighting its main features and limitations. The report concludes with suggested topics for research including CT-based image-guided treatment planning and improved prescription dose accuracy. We hope that this multi-institutional report will serve as a guidance document on the clinical implementation and use of INTRABEAM IORT.
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Affiliation(s)
- Anil Sethi
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois, USA
| | - Sebastien Gros
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois, USA
| | - Patrik Brodin
- Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Beth Ghavidel
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Xuedong Chai
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California, USA
| | - Marija Popovic
- Department of Medical Physics, McGill University Health Center, Montreal, Quebec, Canada
| | - Wolfgang Axel Tomé
- Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Samuel Trichter
- Department of Radiation Oncology, Weill Cornell Medical Center, New York-Presbyterian Hospital, New York, New York, USA
| | - Xiaofeng Yang
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Hualin Zhang
- Department of Radiation Oncology, University of Southern California, Los Angeles, California, USA
| | - Valery Uhl
- Department of Radiation Oncology, Summit Medical Center, Emeryville, California, USA
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Ayala Alvarez DS, Watson PGF, Popovic M, Heng VJ, Evans MDC, Panet-Raymond V, Seuntjens J. Evaluation of Dosimetry Formalisms in Intraoperative Radiation Therapy of Glioblastoma. Int J Radiat Oncol Biol Phys 2023; 117:763-773. [PMID: 37150259 DOI: 10.1016/j.ijrobp.2023.04.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 03/21/2023] [Accepted: 04/29/2023] [Indexed: 05/09/2023]
Abstract
PURPOSE The intraoperative radiotherapy in newly diagnosed glioblastoma multiforme (INTRAGO) clinical trial assesses survival in patients with glioblastoma treated with intraoperative radiation therapy (IORT) using the INTRABEAM. Treatment planning for INTRABEAM relies on vendor-provided in-water depth dose curves obtained according to the TARGeted Intraoperative radioTherapy (TARGIT) dosimetry protocol. However, recent studies have shown discrepancies between the estimated TARGIT and delivered doses. This work evaluates the effect of the choice of dosimetry formalism on organs at risk (OAR) doses. METHODS AND MATERIALS A treatment planning framework for INTRABEAM was developed to retrospectively calculate the IORT dose in 8 INTRAGO patients. These patients received an IORT prescription dose of 20 to 30 Gy in addition to external beam radiation therapy. The IORT dose was obtained using (1) the TARGIT method; (2) the manufacturer's V4.0 method; (3) the CQ method, which uses an ionization chamber Monte Carlo (MC) calculated factor; (4) MC dose-to-water; and (5) MC dose-to-tissue. The IORT dose was converted to 2 Gy fractions equivalent dose. RESULTS According to the TARGIT method, the OAR dose constraints were respected in all cases. However, the other formalisms estimated a higher mean dose to OARs and revealed 1 case where the constraint for the brain stem was exceeded. The addition of the external beam radiation therapy and TARGIT IORT doses resulted in 10 cases of OARs exceeding the dose constraints. The more accurate MC calculation of dose-to-tissue led to the highest dosimetric differences, with 3, 3, 2, and 2 cases (out of 8) exceeding the dose constraint to the brain stem, optic chiasm, optic nerves, and lenses, respectively. Moreover, the mean cumulative dose to brain stem exceeded its constraint of 66 Gy with the MC dose-to-tissue method, which was not evident with the current INTRAGO clinical practice. CONCLUSIONS The current clinical approach of calculating the IORT dose with the TARGIT method may considerably underestimate doses to nearby OARs. In practice, OAR dose constraints may have been exceeded, as revealed by more accurate methods.
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Affiliation(s)
| | | | | | - Veng Jean Heng
- Department of Physics and Medical Physics Unit, McGill University, Montreal, QC, Canada
| | | | - Valerie Panet-Raymond
- Department of Radiation Oncology, McGill University Health Centre, Montreal, QC, Canada
| | - Jan Seuntjens
- Medical Physics Unit and; Princess Margaret Cancer Centre, Radiation Medicine Program, University Health Network, Toronto, ON, Canada
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Can S, Atilla Ö, Karaçetin D. Calculated and measured radiation dose for the low energy xoft axxent eBT X-ray source. BMC Res Notes 2023; 16:25. [PMID: 36855193 PMCID: PMC9976427 DOI: 10.1186/s13104-023-06287-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 02/08/2023] [Indexed: 03/02/2023] Open
Abstract
PURPOSE In this study, it was aimed to evaluate the functionality to deliver different prescription dose except 20 Gy for the Xoft Axxent Ebt (electronic Brachytherapy) system and analyzing the system in terms of radiation dosimetry in water and 0.9% isotonic Sodium Chloride (NaCl) solution. MATERIALS AND METHODS In the Xoft Axxent eBT, different prescription dose in single fraction were calculated for different balloon applicator volumes based on source position and irradiation times. EBT-XD Gafchromic film was calibrated at 6MV photon energy. A balloon applicator filled with 0.9% isotonic NaCl solution was used to deliver a radiation dose of 20 Gy, 16 Gy, 10 Gy on the applicator surface. Then the balloon applicator was filled with water and the same measurements were repeated. Finally, the balloon applicator was irradiated by positioning it at different distances in the water phantom to simulate the isodose contour. RESULTS At the time the balloon applicator was filled with water and 0,9% NaCl solution, the difference between the planned dose and the absorbed dose was ~ 2% vs. 15% for 30 cc, ~ 5% vs. 14% for 35 cc and ~ 3,5% vs. 10% for 40 cc respectively. Finally, the absorbed dose at a distance of 1 cm from the applicator surface was measured as 9.63 Gy. CONCLUSION In this study, it was showed that different prescription dose could be possible to deliver in the Xoft Axxent eBT system based on the standard plan. In addition, the absorbed dose was higher than the planned dose depending on the effective atomic number of NaCl solution comparing to water due to photoelectric effect in low energy photons. By measuring the dose distributions at different distances from the balloon applicator surface, the absorbed dose in tissue equivalent medium was determined and the isodose contours characteristics was simulated.
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Affiliation(s)
- Sümeyra Can
- Basaksehir Cam and Sakura City Hospital Radiation Oncology Department, 34480, Basaksehir Istanbul, Turkey.
| | - Özge Atilla
- Basaksehir Cam and Sakura City Hospital Radiation Oncology Department, 34480 Basaksehir Istanbul, Turkey
| | - Didem Karaçetin
- Basaksehir Cam and Sakura City Hospital Radiation Oncology Department, 34480 Basaksehir Istanbul, Turkey
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Nasir Z, Probst L, Schneider F, Clausen S, Bürgy D, Glatting G, Nwankwo O. Organ absorbed doses in the IORT treatment of breast cancer with the INTRABEAM device: a Monte-Carlo study. Biomed Phys Eng Express 2023; 9. [PMID: 36745910 DOI: 10.1088/2057-1976/acb941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 02/06/2023] [Indexed: 02/08/2023]
Abstract
Purpose: The current prescription and the assessment of the delivered absorbed dose in intraoperative radiation therapy (IORT) with the INTRABEAM system rely mainly on depth-dose measurements in water. The accuracy of this approach is limited because tissue heterogeneity is ignored. It is also difficult to accurately determine the dose delivered to the patient experimentally as the steep dose gradient is highly sensitive to geometric errors. Our goal is to determine the dose to the target volume and the organs at risk of a clinical breast cancer patient from treatment with the system.Methods: A homogeneous water-equivalent CT dataset was derived from the preoperative CT scan of a patient by setting all materials in the patient volume as water-equivalent. This homogeneous CT data represents the current assumption of a homogenous patient, while the original CT data is considered the ground truth. An in-house Monte Carlo algorithm was used to simulate the delivered dose in both setups for a prescribed treatment dose of 20 Gy to the surface of the 3.5 cm diameter spherical applicator.Results: The doses received by 2% (D2%) of the target volume for the homogeneous and heterogeneous geometries are 16.26 Gy and 9.33 Gy, respectively. The D2% for the heart are 0.035 Gy and 0.119 Gy for the homogeneous and heterogeneous geometries, respectively. This trend is also observed for the other organs at risk.Conclusions: The assumption of a homogeneous patient overestimates the dose to the target volume and underestimates the doses to the organs at risk.
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Affiliation(s)
- Zulfa Nasir
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University. Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.,Department of Physics, Faculty of Mathematics and Natural Sciences, Riau University, Bina Widya Campus, Pekanbaru, 28293, Riau, Indonesia
| | - Luis Probst
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University. Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Frank Schneider
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University. Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Sven Clausen
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University. Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Daniel Bürgy
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University. Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Gerhard Glatting
- Medical Radiation Physics, Department of Nuclear Medicine, Ulm University, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Obioma Nwankwo
- Strahlentherapie Rhein/Pfalz, Praxis für Strahlentherapie Neustadt, Stiftstraße 15, 67434 Neustadt, Germany
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Refaat T, Gros SE, Small W. The case for risk-stratified IORT for early breast cancer. Brachytherapy 2022; 21:719-722. [PMID: 36167653 DOI: 10.1016/j.brachy.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 08/17/2022] [Indexed: 12/14/2022]
Affiliation(s)
- Tamer Refaat
- Department of Radiation Oncology, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago, Maywood, IL
| | - Sebastien E Gros
- Department of Radiation Oncology, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago, Maywood, IL
| | - William Small
- Department of Radiation Oncology, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago, Maywood, IL.
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Mohammad Rafiei M, Parsaei S, Kaur P, Singh KJ, Büyükyıldız M, Kurudirek M. A Monte Carlo investigation of some important radiation parameters and tissue equivalency for photons below 1 keV in human tissues. Biomed Phys Eng Express 2022; 8. [PMID: 34902852 DOI: 10.1088/2057-1976/ac428f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 12/13/2021] [Indexed: 11/11/2022]
Abstract
The attenuation coefficients are important input values in estimating not only the dose and exposure in radiotherapy and medical imaging, but also in the proper design of photon shields. While studies are widely available above 1 keV, the attenuation coefficients of human tissues for photon energies less than 1 keV have not been studied yet. In this study, the attenuation coefficients of water and some human tissues were estimated for low energy photons using the MCNP6.1 code in the energy region 0.1 keV-1 keV. Mass attenuation coefficients were estimated at photon energies of 100, 150, 200, 250, 300, 350, 400, 450, 500, 550, 600, 650, 700, 750, 800, 850, 900, 950 and 1000 eV for water and ten human tissues (Soft, Breast, Lung, Bone, Brain, Eye lens, Ovary, Skin, Thyroid and Prostate). Results were compared with those available in literature and a fairly good agreement has been obtained. These data were then used to calculate the mean free path, half value layer, tenth value layer, effective atomic number and specific gamma-ray constant (useful for calculation of dose rate) as well. Moreover, for comparison the effective atomic number of the water has been obtained using the results of this work and using the data available in NIST database from 0.1 to 1 keV. In addition, the human tissues were compared with some tissue equivalent materials in terms of effective atomic number and specific gamma-ray constant to study the tissue equivalency from the results, the muscle-equivalent liquid with sucrose has been found to be the best tissue equivalent material for soft tissue, eye lens and brain with relative difference below 4.1%.
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Affiliation(s)
| | - Sara Parsaei
- Faculty of Physics, Shahid Bahonar University of Kerman, Kerman, Iran
| | - Parminder Kaur
- Department of Physics, Guru Nanak Dev University, Amritsar, 143005, India
| | - K J Singh
- Department of Physics, Guru Nanak Dev University, Amritsar, 143005, India
| | - Mehmet Büyükyıldız
- Department of Physics, Faculty of Engineering and Natural Sciences, Bursa Technical University, Bursa, Turkey
| | - Murat Kurudirek
- Technical Sciences Vocational College, Department of Electricity and Energy, Ataturk University, Erzurum, Turkey
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Wong JHD, Zaili Z, Abdul Malik R, Bustam AZ, Saad M, Jamaris S, Mosiun JA, Mohd Taib NA, Ung NM, See M. Evaluation of skin dose and skin toxicity in patients undergoing intraoperative radiotherapy for early breast cancer. J Appl Clin Med Phys 2021; 22:139-147. [PMID: 34254425 PMCID: PMC8364274 DOI: 10.1002/acm2.13338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
PURPOSE This study aims to evaluate in vivo skin dose delivered by intraoperative radiotherapy (IORT) and determine the factors associated with an increased risk of radiation-induced skin toxicity. METHODOLOGY A total of 21 breast cancer patients who underwent breast-conserving surgery and IORT, either as IORT alone or IORT boost plus external beam radiotherapy (EBRT), were recruited in this prospective study. EBT3 film was calibrated in water and used to measure skin dose during IORT at concentric circles of 5 mm and 40 mm away from the applicator. For patients who also had EBRT, the maximum skin dose was estimated using the radiotherapy treatment planning system. Mid-term skin toxicities were evaluated at 3 and 6 months post-IORT. RESULTS The average skin dose at 5 mm and 40 mm away from the applicator was 3.07 ± 0.82 Gy and 0.99 ± 0.28 Gy, respectively. Patients treated with IORT boost plus EBRT received an additional skin dose of 41.07 ± 1.57 Gy from the EBRT component. At 3 months post-IORT, 86% of patients showed no evidence of skin toxicity. However, the number of patients suffering from skin toxicity increased from 15% to 38% at 6 months post-IORT. We found no association between the IORT alone or with the IORT boost plus EBRT and skin toxicity. Older age was associated with increased risk of skin toxicities. A mathematical model was derived to predict skin dose. CONCLUSION EBT3 film is a suitable dosimeter for in vivo skin dosimetry in IORT, providing patient-specific skin doses. Both IORT alone and IORT boost techniques resulted in similar skin toxicity rates.
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Affiliation(s)
- Jeannie Hsiu Ding Wong
- Department of Biomedical ImagingFaculty of MedicineUniversity of MalayaKuala LumpurMalaysia
| | - Zainor Zaili
- Department of Biomedical ImagingFaculty of MedicineUniversity of MalayaKuala LumpurMalaysia
| | - Rozita Abdul Malik
- Clinical Oncology UnitFaculty of MedicineUniversity of MalayaKuala LumpurMalaysia
| | - Anita Zarina Bustam
- Clinical Oncology UnitFaculty of MedicineUniversity of MalayaKuala LumpurMalaysia
| | - Marniza Saad
- Clinical Oncology UnitFaculty of MedicineUniversity of MalayaKuala LumpurMalaysia
| | - Suniza Jamaris
- Breast Surgery UnitDepartment of Medicine, Faculty of MedicineUniversity of MalayaKuala LumpurMalaysia
- Department of Surgery, Faculty of MedicineUniversity of MalayaKuala LumpurMalaysia
| | - Joanne Aisha Mosiun
- Department of Surgery, Faculty of MedicineUniversity of MalayaKuala LumpurMalaysia
| | - Nur Aishah Mohd Taib
- Breast Surgery UnitDepartment of Medicine, Faculty of MedicineUniversity of MalayaKuala LumpurMalaysia
| | - Ngie Min Ung
- Clinical Oncology UnitFaculty of MedicineUniversity of MalayaKuala LumpurMalaysia
| | - Mee‐Hoong See
- Breast Surgery UnitDepartment of Medicine, Faculty of MedicineUniversity of MalayaKuala LumpurMalaysia
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