Benchmark measurements and simulations of dose perturbations due to metallic spheres in proton beams

Carbon ion radiotherapy using fiducial markers for prostate cancer in Osaka HIMAK: Treatment planning

PURPOSE

Carbon ion radiotherapy for prostate cancer was performed using two fine needle Gold Anchor (GA) markers for patient position verification in Osaka Heavy Ion Medical Accelerator in Kansai (Osaka HIMAK). The present study examined treatment plans for prostate cases using beam-specific planning target volume (bsPTV) based on the effect of the markers on dose distribution and analysis of target movements.

MATERIALS AND METHODS

Gafchromic EBT3 film was used to measure dose perturbations caused by markers. First, the relationships between the irradiated film density and absolute dose with different linear energy transfer distributions within a spread-out Bragg peak (SOBP) were confirmed. Then, to derive the effect of markers, two types of markers, including GA, were placed at the proximal, center, and distal depths within the same SOBP, and dose distributions behind the markers were measured using the films. The amount of internal motion of prostate was derived from irradiation results and analyzed to determine the margins of the bsPTV.

RESULTS

The linearity of the film densities against absolute doses was constant within the SOBP and the amount of dose perturbations caused by the markers was quantitatively estimated from the film densities. The dose perturbation close behind the markers was smallest (<10% among depths within the SOBP regardless of types of markers) and increased with depth. The effect of two types of GAs on dose distributions was small and could be ignored in the treatment planning. Based on the analysis results of internal motions of prostate, required margins of the bsPTV were found to be 8, 7, and 7 mm in left-right (LR), anterior-posterior (AP), and superior-inferior (SI) directions, respectively.

CONCLUSION

We evaluated the dose reductions caused by markers and determined the margins of the bsPTV, which was applied to the treatment using fiducial markers, using the analysis results of prostate movements.

Biological impact of dosimetric perturbations of a fiducial marker and the daily number of fields in proton therapy for prostate cancer

The purpose of this study was to estimate the biological impact of dosimetric perturbations of a fiducial marker and the daily number of fields in proton therapy for prostate cancer. Using a linear-quadratic model, normalized total doses (NTDs) of points where deposited dose was reduced from the prescribed dose by dosimetric perturbation of a fiducial marker were calculated in two hypothetical prostate cancer treatment schedules: a) irradiation of both parallel-opposed lateral fields and b) irradiation of alternate field in each daily treatment. The impact of hypofractionation and sublethal damage repair between irradiation on NTD was also estimated. The NTD of two fields/day schedule becomes lower than that of one field/day schedule. The difference becomes larger as dose reduction from one of two fields becomes more enhanced. The NTD reduction from the total dose in the two fields/day schedule is largest (30% of total dose) where the dose from one beam is completely lost by a fiducial marker. In contrast, the NTD reduction from the total dose in the one field/day schedule is largest (9% of total dose) where the half dose from one beam is decreased by a fiducial marker. In addition, the NTD reduction becomes larger as the fractional dose increases in a hypofractionated regimen, and when the effect of sublethal damage repair was incorporated. These influences become significant in prostate cancer since the radiobiological sensitivity α/β of prostate cancer is lower than other cancer types and normal tissues late complication. Treating with one alternate field in a daily treatment can improve a deteriorating treatment effect by dosimetric distortion of a fiducial marker in prostate cancer treatment. However, the choice of the number of beams in a fraction must also be determined by considering the sparing of normal tissues and patient-specific status.

Dose perturbation caused by metallic port in breast tissue expander in proton beam therapy

Proton beam treatment is being looked favourably now in breast treatment. Tissue expanders are often placed after mastectomy that contains metallic port for saline injection which produces dose perturbations in proton beam therapy with uncertain dosimetry. Dose perturbation for a stainless-steel injection port from a breast implant is investigated in this study. Measurements, Monte-Carlo simulation, and calculated dose distribution of plans based on kVCT and MVCT images are compared. Treatment plans are performed on kVCT and MVCT images to observe the effect of metal artifact from the breast implant. The kVCT based plan underestimates the beam range due to the overestimated water equivalent thickness of the metal ports as a result of image degradation. Compared to the measurement with metal port in the proton beam, the MVCT-based treatment planning provides more accurate dose calculation than the kVCT-based results. The dose perturbation factor calculated from MVCT planning is within 10% of the measurement results while HU corrected kVCT plan still shows dose difference as large as 100% due to the incorrect range pull back calculation caused by the misrepresentation of the volume between the plastic cap and the stainless-steel base. The dose enhancement observed at the metal and solid water interface is as large as 15%, which needs to be accounted for in the planning process if there is a clinical concern. Dose reduction as large as 16% is observed with depth from 1 cm to 4 cm underneath the thickest part of the metallic port whereas lateral dose perturbation is also seen up to 7 mm. The measurement data are supported by the Monte-Carlo simulated results with a maximum dose difference of 6%. It is concluded that if proton beam is used with metallic port, MVCT imaging data is recommended. In lieu of MVCT, DECT, CT scanner with metal artifact reduction software or in the very least, extended HU range should be used to reduce the streaking artifact as well as to produce a more accurate image of the metallic port.

The physics of proton therapy

The physics of proton therapy has advanced considerably since it was proposed in 1946. Today analytical equations and numerical simulation methods are available to predict and characterize many aspects of proton therapy. This article reviews the basic aspects of the physics of proton therapy, including proton interaction mechanisms, proton transport calculations, the determination of dose from therapeutic and stray radiations, and shielding design. The article discusses underlying processes as well as selected practical experimental and theoretical methods. We conclude by briefly speculating on possible future areas of research of relevance to the physics of proton therapy.

Inter-Institutional Comparison of Personalized Risk Assessments for Second Malignant Neoplasms for a 13-Year-Old Girl Receiving Proton versus Photon Craniospinal Irradiation

Children receiving radiotherapy face the probability of a subsequent malignant neoplasm (SMN). In some cases, the predicted SMN risk can be reduced by proton therapy. The purpose of this study was to apply the most comprehensive dose assessment methods to estimate the reduction in SMN risk after proton therapy vs. photon therapy for a 13-year-old girl requiring craniospinal irradiation (CSI). We reconstructed the equivalent dose throughout the patient’s body from therapeutic and stray radiation and applied SMN incidence and mortality risk models for each modality. Excluding skin cancer, the risk of incidence after proton CSI was a third of that of photon CSI. The predicted absolute SMN risks were high. For photon CSI, the SMN incidence rates greater than 10% were for thyroid, non-melanoma skin, lung, colon, stomach, and other solid cancers, and for proton CSI they were non-melanoma skin, lung, and other solid cancers. In each setting, lung cancer accounted for half the risk of mortality. In conclusion, the predicted SMN risk for a 13-year-old girl undergoing proton CSI was reduced vs. photon CSI. This study demonstrates the feasibility of inter-institutional whole-body dose and risk assessments and also serves as a model for including risk estimation in personalized cancer care.