Dosimetric characterization of CyberKnife radiosurgical photon beams using polymer gels

Validation of complex radiotherapy techniques using polymer gel dosimetry

Modern radiotherapy delivers highly conformal dose distributions to irregularly shaped target volumes while sparing the surrounding normal tissue. Due to the complex planning and delivery techniques, dose verification and validation of the whole treatment workflow by end-to-end tests became much more important and polymer gel dosimeters are one of the few possibilities to capture the delivered dose distribution in 3D. The basic principles and formulations of gel dosimetry and its evaluation methods are described and the available studies validating device-specific geometrical parameters as well as the dose delivery by advanced radiotherapy techniques, such as 3D-CRT/IMRT and stereotactic radiosurgery treatments, the treatment of moving targets, online-adaptive magnetic resonance-guided radiotherapy as well as proton and ion beam treatments, are reviewed. The present status and limitations as well as future challenges of polymer gel dosimetry for the validation of complex radiotherapy techniques are discussed.

Small field output factor measurement and verification for CyberKnife robotic radiotherapy and radiosurgery system using 3D polymer gel, ionization chamber, diode, diamond and scintillator detectors, Gafchromic film and Monte Carlo simulation

The dosimetry of small fields has become tremendously important with the advent of intensity-modulated radiation therapy (IMRT) and stereotactic radiosurgery, where small field segments or very small fields are used to treat tumors. With high dose gradients in the stereotactic radiosurgery or radiotherapy treatment, small field dosimetry becomes challenging due to the lack of lateral electronic equilibrium in the field, x-ray source occlusion, and detector volume averaging. Small volume and tissue-equivalent detectors are recommended to overcome the challenges. With the lack of a perfect radiation detector, studies on available detectors are ongoing with reasonable disagreement and uncertainties. The joint IAEA and AAPM international code of practice (CoP) for small field dosimetry, TRS 483 (Alfonso et al., 2017) provides guidelines and recommendations for the dosimetry of small static fields in external beam radiotherapy. The CoP provides a methodology for field output factor (FOF) measurements and use of field output correction factors for a series of small field detectors and strongly recommends additional measurements, data collection and verification for CyberKnife (CK) robotic stereotactic radiotherapy/radiosurgery system using the listed detectors and more new detectors so that the FOFs can be implemented clinically. The present investigation is focused on using 3D gel along with some other commercially available detectors for the measurement and verification of field output factors (FOFs) for the small fields available in the CK system. The FOF verification was performed through a comparison with published data and Monte Carlo simulation. The results of this study have proved the suitability of an in-house developed 3D polymer gel dosimeter, several commercially available detectors, and Gafchromic films as a part of small field dosimetric measurements for the CK system.

Geometric distortion assessment in 3T MR images used for treatment planning in cranial Stereotactic Radiosurgery and Radiotherapy

Magnetic Resonance images (MRIs) are employed in brain Stereotactic Radiosurgery and Radiotherapy (SRS/SRT) for target and/or critical organ localization and delineation. However, MRIs are inherently distorted, which also impacts the accuracy of the Magnetic Resonance Imaging/Computed Tomography (MRI/CT) co-registration process. In this phantom-based study, geometric distortion is assessed in 3T T2-weighted images (T2WIs), while the efficacy of an MRI distortion correction technique is also evaluated. A homogeneous polymer gel-filled phantom was CT-imaged before being irradiated with 26 4-mm Gamma Knife shots at predefined locations (reference control points). The irradiated phantom was MRI-scanned at 3T, implementing a T2-weighted protocol suitable for SRS/SRT treatment planning. The centers of mass of all shots were identified in the 3D image space by implementing an iterative localization algorithm and served as the evaluated control points for MRI distortion detection. MRIs and CT images were spatially co-registered using a mutual information algorithm. The inverse transformation matrix was applied to the reference control points and compared with the corresponding MRI-identified ones to evaluate the overall spatial accuracy of the MRI/CT dataset. The mean image distortion correction technique was implemented, and resulting MRI-corrected control points were compared against the corresponding reference ones. For the scanning parameters used, increased MRI distortion (>1mm) was detected at areas distant from the MRI isocenter (>5cm), while median radial distortion was 0.76mm. Detected offsets were slightly higher for the MRI/CT dataset (0.92mm median distortion). The mean image distortion correction improves geometric accuracy, but residual distortion cannot be considered negligible (0.51mm median distortion). For all three datasets studied, a statistically significant positive correlation between detected spatial offsets and their distance from the MRI isocenter was revealed. This work contributes towards the wider adoption of 3T imaging in SRS/SRT treatment planning. The presented methodology can be employed in commissioning and quality assurance programmes of corresponding treatment workflows.

Target localization accuracy in frame‐based stereotactic radiosurgery: Comparison between MR‐only and MR/CT co‐registration approaches

Purpose

In frame‐based Gamma Knife (GK) stereotactic radiosurgery two treatment planning workflows are commonly employed; one based solely on magnetic resonance (MR) images and the other based on magnetic resonance/computed tomography (MR/CT) co‐registered images. In both workflows, target localization accuracy (TLA) can be deteriorated due to MR‐related geometric distortions and/or MR/CT co‐registration uncertainties. In this study, the overall TLA following both clinical workflows is evaluated for cases of multiple brain metastases.

Methods

A polymer gel‐filled head phantom, having the Leksell stereotactic headframe attached, was CT‐imaged and irradiated by a GK Perfexion unit. A total of 26 4‐mm shots were delivered at 26 locations directly defined in the Leksell stereotactic space (LSS), inducing adequate contrast in corresponding T2‐weighted (T2w) MR images. Prescribed shot coordinates served as reference locations. An additional MR scan was acquired to implement the “mean image” distortion correction technique. The TLA for each workflow was assessed by comparing the radiation‐induced target locations, identified in MR images, with corresponding reference locations. Using T1w MR and CT images of 15 patients (totaling 81 lesions), TLA in clinical cases was similarly assessed, considering MR‐corrected data as reference. For the MR/CT workflow, both global and region of interest (ROI)‐based MR/CT registration approaches were studied.

Results

In phantom measurements, the MR‐corrected workflow demonstrated unsurpassed TLA (median offset of 0.2 mm) which deteriorated for MR‐only and MR/CT workflows (median offsets of 0.8 and 0.6 mm, respectively). In real‐patient cases, the MR‐only workflow resulted in offsets that exhibit a significant positive correlation with the distance from the MR isocenter, reaching 1.1 mm (median 0.6 mm). Comparable results were obtained for the MR/CT‐global workflow, although a maximum offset of 1.4 mm was detected. TLA was improved with the MR/CT‐ROI workflow resulting in median/maximum offsets of 0.4 mm/1.1 mm.

Conclusions

Subpixel TLA is achievable in all workflows. For the MR/CT workflow, a ROI‐based MR/CT co‐registration approach could considerably increase TLA and should be preferred instead of a global registration.

Fricke gel xylenol orange dosimeter layers for stereotactic radiosurgery: A preliminary approach

Investigations regarding the feasibility, reliability, and accuracy of Fricke gel dosimeter layers for stereotactic radiosurgery are presented. A representative radiosurgery plan consisting of two targets has been investigated. Absorbed dose distributions measured using radiochromic films and gelatin Fricke Gel dosimetry in layers have been compared with dose distributions calculated by using a treatment planning system and Monte Carlo simulations. The different dose distributions have been compared by means of the gamma index demonstrating that gelatin Fricke gel dosimeter layers showed agreements of 100%, 100%, and 93%, with dose and distance tolerances of 2% and 2 mm, with respect to film dosimetry, treatment planning system and Monte Carlo simulations, respectively. The capability of the developed system for three-dimensional dose mapping was shown, obtaining promising results when compared with well-established dosimetry methods. The obtained results support the viability of Fricke gel dosimeter layers analyzed by optical methods for stereotactic radiosurgery.

Report of AAPM Task Group 155: Megavoltage photon beam dosimetry in small fields and non-equilibrium conditions

Small-field dosimetry used in advance treatment technologies poses challenges due to loss of lateral charged particle equilibrium (LCPE), occlusion of the primary photon source, and the limited choice of suitable radiation detectors. These challenges greatly influence dosimetric accuracy. Many high-profile radiation incidents have demonstrated a poor understanding of appropriate methodology for small-field dosimetry. These incidents are a cause for concern because the use of small fields in various specialized radiation treatment techniques continues to grow rapidly. Reference and relative dosimetry in small and composite fields are the subject of the International Atomic Energy Agency (IAEA) dosimetry code of practice that has been published as TRS-483 and an AAPM summary publication (IAEA TRS 483; Dosimetry of small static fields used in external beam radiotherapy: An IAEA/AAPM International Code of Practice for reference and relative dose determination, Technical Report Series No. 483; Palmans et al., Med Phys 45(11):e1123, 2018). The charge of AAPM task group 155 (TG-155) is to summarize current knowledge on small-field dosimetry and to provide recommendations of best practices for relative dose determination in small megavoltage photon beams. An overview of the issue of LCPE and the changes in photon beam perturbations with decreasing field size is provided. Recommendations are included on appropriate detector systems and measurement methodologies. Existing published data on dosimetric parameters in small photon fields (e.g., percentage depth dose, tissue phantom ratio/tissue maximum ratio, off-axis ratios, and field output factors) together with the necessary perturbation corrections for various detectors are reviewed. A discussion on errors and an uncertainty analysis in measurements is provided. The design of beam models in treatment planning systems to simulate small fields necessitates special attention on the influence of the primary beam source and collimating devices in the computation of energy fluence and dose. The general requirements for fluence and dose calculation engines suitable for modeling dose in small fields are reviewed. Implementations in commercial treatment planning systems vary widely, and the aims of this report are to provide insight for the medical physicist and guidance to developers of beams models for radiotherapy treatment planning systems.

Clinical radiotherapy application of N-vinylpyrrolidone-containing 3D polymer gel dosimeters with remote external MR-reading

PURPOSE

Advanced 3D dosimetry is required for verifications of complex dose distributions in modern radiotherapy. Two 3D polymer gel dosimeters, coupled with magnetic resonance (MR) imaging (3 T MRI) readout and data processing with polyGeVero® software, were tested for the verification of calculated 3D dose distributions by a treatment planning system (TPS) and ArcCHECK®-3DVH®, related to eradication of a lung tumour.

METHODS

N-vinylpyrrolidone-containing 3D polymer gel dosimeters were used: VIC (containing ascorbic acid and copper sulfate pentahydrate) and VIC-T (containing tetrakis(hydroxymethyl)phosphonium chloride). Three remote centers were involved in the dosimeters preparation and irradiation (Poland), and MRI (Austria). Cross beam calibration of the dosimeters and verification of a 3D dose distribution calculated with an Eclipse External Beam TPS and ArcCHECK®-3DVH® were performed. The 3D-to-3D comparisons of the VIC and VIC-T with TPS and ArcCHECK®-3DVH® along with ArcCHECK®-3DVH® versus TPS dose matrixes were performed with the aid of the polyGeVero® by analyzing dose profiles, isodoses lines, gamma index, gamma angle, dose difference, and related histograms.

RESULTS

The measured MR-relaxation rate (R₂ = 1/T₂) for the dosimeters relates to the dose, as follows: R₂ = 0.0928 ± 0.0008 [Gy^-1 s^-1] × D [Gy] + 2.985 ± 0.012 [s^-1] (VIC) and 0.1839 ± 0.0044 [Gy^-1 s^-1] × D [Gy] + 2.519 ± 0.053 [s^-1] (VIC-T). The 3D-to-3D comparisons revealed a good agreement between the measured and calculated 3D dose distributions.

CONCLUSIONS

VIC and VIC-T with 3T MRI readout and polyGeVero® showed potential for verifications of calculated irradiation plans. The results obtained suggest the implementation of the irradiation plan for eradication of the lung tumour.

Comparison of detector performance in small 6 MV and 6 MV FFF beams using a Versa HD accelerator

1. BACKGROUND & PURPOSE

Investigate the applicability of a series of detectors in small field dosimetry and the possible differences between their responses to FF and FFF beams. This work extends upon the series of detectors used by other authors to also include metal-oxide-semiconductor field-effect transistors (MOSFETs) detectors and radiochromic film. We also included a later correction of output factors (OFs) recommended by the recently published IAEA´s code of practice TRS 483 on dosimetry of small static fields used in external beam radiotherapy.

2. MATERIALS & METHODS

The OFs, profiles, and PDDs of 6 MV and 6 MV FFF beams were measured with 11 different detectors using field sizes between 0.6 × 0.6 cm2 and 10 × 10 cm2.

3. RESULTS

The OFs of the FFF beams were lower than those of the FF beams for field sizes larger than 3 × 3 cm2 but higher for field sizes smaller than 3 × 3 cm2. After applying the IAEA´s TRS 483 corrections, the final OFs were compatible with our initial results when considering uncertainties involved. Small-volume detectors are preferable for measuring the penumbra of these small fields where this attribute is higher in the crossline direction than in the inline direction. The R100 of equivalent-quality FFF beams was higher compared to the corresponding flattened beams.

4. CONCLUSIONS

We observed no difference for the dose responses between 6 MV and 6 MV FFF beams for any of the detectors. OF results, profiles and PDDs were clearly consistent with the previously published literature regarding the Versa HD linac. Correcting our first OFs, taken as ratio of detector charges, with the IAEA´s TRS 483 corrections to obtain the final OFs, did not make the former significantly different.

Quality assurance of Cyberknife robotic stereotactic radiosurgery using an angularly independent silicon detector

Purpose

The aim of this work was to evaluate the use of an angularly independent silicon detector (edgeless diodes) developed for dosimetry in megavoltage radiotherapy for Cyberknife in a phantom and for patient quality assurance (QA).

Method

The characterization of the edgeless diodes has been performed on Cyberknife with fixed and IRIS collimators. The edgeless diode probes were tested in terms of basic QA parameters such as measurements of tissue‐phantom ratio (TPR), output factor and off‐axis ratio. The measurements were performed in both water and water‐equivalent phantoms. In addition, three patient‐specific plans have been delivered to a lung phantom with and without motion and dose measurements have been performed to verify the ability of the diodes to work as patient‐specific QA devices. The data obtained by the edgeless diodes have been compared to PTW 60016, SN edge, PinPoint ionization chamber, Gafchromic EBT3 film, and treatment planning system (TPS).

Results

The TPR measurement performed by the edgeless diodes show agreement within 2.2% with data obtained with PTW 60016 diode for all the field sizes. Output factor agrees within 2.6% with that measured by SN EDGE diodes corrected for their field size dependence. The beam profiles’ measurements of edgeless diodes match SN EDGE diodes with a measured full width half maximum (FWHM) within 2.3% and penumbra widths within 0.148 mm. Patient‐specific QA measurements demonstrate an agreement within 4.72% in comparison with TPS.

Conclusion

The edgeless diodes have been proved to be an excellent candidate for machine and patient QA for Cyberknife reproducing commercial dosimetry device measurements without need of angular dependence corrections. However, further investigation is required to evaluate the effect of their dose rate dependence on complex brain cancer dose verification.

Substituting gelatine with Pluronic F-127 matrix in 3D polymer gel dosimeters can improve nuclear magnetic resonance, thermal and optical properties

This work discusses the substitution of a gelatine physical gel matrix with a matrix made of poly(ethylene oxide)-block-poly(propylene oxide)-block-poly(ethylene oxide) (Pluronic F-127) in five 3D radiotherapy polymer gel dosimeters: MAGAT, PAGAT, NIPAM, VIPAR^nd (VIP) and VIPAR^CT (VIC). The current research outcomes showed that not each polymer gel dosimeter could be manufactured with Pluronic F-127. Two of the polymer gel dosimeters (PAGAT and VIP) containing the Pluronic F-127 matrix allowed for some proper dose response for radiotherapy dosimetry (a response to a dose range of e.g. 0‒50 Gy). The new best performing Pluronic-based polymer gel dosimeters were characterised by improved nuclear magnetic resonance properties, when being compared to gels with gelatine matrix at the same monomer content. These are: (i) a ~33% higher dose sensitivity; (ii) a comparable or slightly higher linear and dynamic dose range and (iii) a lower (new VIP composition, VIP3) or equivocal (new PAGAT composition, PAGAT2-Pluronic) dose threshold. However, there might be optimised gelatine based polymer dosimeters demonstrating even better sensitivity. UV-vis spectrophotometry measurements revealed that Pluronic matrices ensure six-times lower (VIP3-Pluronic) and eight-times lower (PAGAT2-Pluronic) absorbance (at 400 nm) of non-irradiated gels compared to gelatine matrices, which makes the new polymer gel dosimeters optically improved in comparison to their corresponding gelatine-based compositions. The differences in absorption reduce for higher wavelengths. Differential scanning calorimetry measurements revealed the following temperature stability ranges for the gels: (i) VIP with gelatine matrix: 0 °C‒26 °C, (ii) VIP3 with Pluronic matrix: 13.8 °C-55.2 °C, (iii) PAGAT2 with gelatine matrix: 0 °C-80 °C and (iv) PAGAT2 with Pluronic matrix: 21.4 °C-55.2 °C. In conclusion, Pluronic F-127 is an attractive co-polymer to serve as a substitute for the gelatine matrix in some 3D polymer gel dosimeters.

Different Dosimeters/Detectors Used in Small-Field Dosimetry: Pros and Cons

With the advent of complex and precise radiation therapy techniques, the use of relatively small fields is needed. Using such field sizes can cause uncertainty in dosimetry; therefore, special attention is required both in dose calculations and measurements. There are several challenges in small-field dosimetry such as the steep gradient of the radiation field, volume averaging effect, lack of charged particle equilibrium, partial occlusion of radiation source, beam alignment, and unable to use a reference dosimeter. Due to these challenges, special dosimeters are needed for small-field dosimetry, and this review article discusses this topic.

Investigating the Electronic Portal Imaging Device for Small Radiation Field Measurements

Purpose:

With the advent of state-of-the-art treatment technologies, the use of small fields has increased, and dosimetry in small fields is highly challenging. In this study, the potential use of Varian electronic portal imaging device (EPID) for small field measurements was explored for 6 and 15 MV photon beams.

Materials and Methods:

The output factors and profiles were measured for a range of jaw-collimated square field sizes starting from 0.8 cm × 0.8 cm to 10 cm × 10 cm using EPID. For evaluation purpose, reference data were acquired using Exradin A16 microionization chamber (0.007 cc) for output factors and stereotactic field diode for profile measurements in a radiation field analyzer.

Results:

The output factors of EPID were in agreement with the reference data for field sizes down to 2 cm × 2 cm and for 2 cm × 2 cm; the difference in output factors was +2.06% for 6 MV and +1.56% for 15 MV. For the lowest field size studied (0.8 cm × 0.8 cm), the differences were maximum; +16% for 6 MV and +23% for 15 MV photon beam. EPID profiles of both energies were closely matching with reference profiles for field sizes down to 2 cm × 2 cm; however, penumbra and measured field size of EPID profiles were slightly lower compared to its counterpart.

Conclusions:

EPID is a viable option for profile and output factor measurements for field sizes down to 2 cm × 2 cm in the absence of appropriate small field dosimeters.

Stereotactic radiosurgery alone for multiple brain metastases? A review of clinical and technical issues

Over the past three decades several randomized trials have enabled evidence-based practice for patients presenting with limited brain metastases. These trials have focused on the role of surgery or stereotactic radiosurgery (SRS) with or without whole brain radiation therapy (WBRT). As a result, it is clear that local control should be optimized with surgery or SRS in patients with optimal prognostic factors presenting with up to 4 brain metastases. The routine use of adjuvant WBRT remains debatable, as although greater distant brain control rates are observed, there is no impact on survival, and modern outcomes suggest adverse effects from WBRT on patient cognition and quality of life. With dramatic technologic advances in radiation oncology facilitating the adoption of SRS into mainstream practice, the optimal management of patients with multiple brain metastases is now being put forward. Practice is evolving to SRS alone in these patients despite a lack of level 1 evidence to support a clinical departure from WBRT. The purpose of this review is to summarize the current state of the evidence for patients presenting with limited and multiple metastases, and to present an in-depth analysis of the technology and dosimetric issues specific to the treatment of multiple metastases.

Three-dimensional radiation dosimetry using polymer gel and solid radiochromic polymer: From basics to clinical applications

Accurate dose measurement tools are needed to evaluate the radiation dose delivered to patients by using modern and sophisticated radiation therapy techniques. However, the adequate tools which enable us to directly measure the dose distributions in three-dimensional (3D) space are not commonly available. One such 3D dose measurement device is the polymer-based dosimeter, which changes the material property in response to radiation. These are available in the gel form as polymer gel dosimeter (PGD) and ferrous gel dosimeter (FGD) and in the solid form as solid plastic dosimeter (SPD). Those are made of a continuous uniform medium which polymerizes upon irradiation. Hence, the intrinsic spatial resolution of those dosimeters is very high, and it is only limited by the method by which one converts the dose information recorded by the medium to the absorbed dose. The current standard methods of the dose quantification are magnetic resonance imaging, optical computed tomography, and X-ray computed tomography. In particular, magnetic resonance imaging is well established as a method for obtaining clinically relevant dosimetric data by PGD and FGD. Despite the likely possibility of doing 3D dosimetry by PGD, FGD or SPD, the tools are still lacking wider usages for clinical applications. In this review article, we summarize the current status of PGD, FGD, and SPD and discuss the issue faced by these for wider acceptance in radiation oncology clinic and propose some directions for future development.

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 (60)Co 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.

Variation of kQclin,Qmsr (fclin,fmsr) for the small-field dosimetric parameters percentage depth dose, tissue-maximum ratio, and off-axis ratio

PURPOSE

Evaluate the ability of different dosimeters to correctly measure the dosimetric parameters percentage depth dose (PDD), tissue-maximum ratio (TMR), and off-axis ratio (OAR) in water for small fields.

METHODS

Monte Carlo (MC) simulations were used to estimate the variation of kQclin,Qmsr (fclin,fmsr) for several types of microdetectors as a function of depth and distance from the central axis for PDD, TMR, and OAR measurements. The variation of kQclin,Qmsr (fclin,fmsr) enables one to evaluate the ability of a detector to reproduce the PDD, TMR, and OAR in water and consequently determine whether it is necessary to apply correction factors. The correctness of the simulations was verified by assessing the ratios between the PDDs and OARs of 5- and 25-mm circular collimators used with a linear accelerator measured with two different types of dosimeters (the PTW 60012 diode and PTW PinPoint 31014 microchamber) and the PDDs and the OARs measured with the Exradin W1 plastic scintillator detector (PSD) and comparing those ratios with the corresponding ratios predicted by the MC simulations.

RESULTS

MC simulations reproduced results with acceptable accuracy compared to the experimental results; therefore, MC simulations can be used to successfully predict the behavior of different dosimeters in small fields. The Exradin W1 PSD was the only dosimeter that reproduced the PDDs, TMRs, and OARs in water with high accuracy. With the exception of the EDGE diode, the stereotactic diodes reproduced the PDDs and the TMRs in water with a systematic error of less than 2% at depths of up to 25 cm; however, they produced OAR values that were significantly different from those in water, especially in the tail region (lower than 20% in some cases). The microchambers could be used for PDD measurements for fields greater than those produced using a 10-mm collimator. However, with the detector stem parallel to the beam axis, the microchambers could be used for TMR measurements for all field sizes. The microchambers could not be used for OAR measurements for small fields.

CONCLUSIONS

Compared with MC simulation, the Exradin W1 PSD can reproduce the PDDs, TMRs, and OARs in water with a high degree of accuracy; thus, the correction used for converting dose is very close to unity. The stereotactic diode is a viable alternative because it shows an acceptable systematic error in the measurement of PDDs and TMRs and a significant underestimation in only the tail region of the OAR measurements, where the dose is low and differences in dose may not be therapeutically meaningful.

Comparative analysis between 5 mm and 7.5 mm collimators in CyberKnife radiosurgery for trigeminal neuralgia

Trigeminal neuralgia (TN) is treated in CyberKnife (Accuray Inc, Sunnyvale, USA) with the 5 mm collimator whose dosimetric inaccuracy is higher than the other available collimators. The 7.5 mm collimator which is having less dosimetric uncertainty can be an alternative for 5 mm collimator provided the dose distribution with 7.5 mm collimator is acceptable. Aim of this study is to analyze the role of 7.5 mm collimator in CyberKnife treatment plans of TN. The treatment plans with 5 mm collimators were re-optimized with 7.5 mm collimator and a bi-collimator system (5 mm and 7.5 mm). The treatment plans were compared for target coverage, brainstem doses, and the dose to normal tissues. The target and brainstem doses were comparable. However, the conformity indices were 2.31 ± 0.52, 2.40 ± 0.87 and 2.82 ± 0.51 for 5 mm, bi-collimator (5mm and 7.5 mm), 7.5 mm collimator plans respectively. This shows the level of dose spillage in 7.5 mm collimator plans. The 6 Gy dose volumes in 7.5 mm plans were 1.53 and 1.34 times higher than the 5 mm plan and the bi-collimator plans respectively. The treatment time parameters were lesser for 7.5 mm collimators. Since, the normal tissue dose is pretty high in 7.5 mm collimator plans, the use of it in TN plans can be ruled out though the treatment time is lesser for these 7.5 mm collimator plans.

Assessment and characterization of the total geometric uncertainty in Gamma Knife radiosurgery using polymer gels

PURPOSE

This work proposes and implements an experimental methodology, based on polymer gels, for assessing the total geometric uncertainty and characterizing its contributors in Gamma Knife (GK) radiosurgery.

METHODS

A treatment plan consisting of 26, 4-mm GK single shot dose distributions, covering an extended region of the Leksell stereotactic space, was prepared and delivered to a polymer gel filled polymethyl methacrylate (PMMA) head phantom (16 cm diameter) used to accurately reproduce every link in the GK treatment chain. The center of each shot served as a "control point" in the assessment of the GK total geometric uncertainty, which depends on (a) the spatial dose delivery uncertainty of the PERFEXION GK unit used in this work, (b) the spatial distortions inherent in MR images commonly used for target delineation, and (c) the geometric uncertainty contributor associated with the image registration procedure performed by the Leksell GammaPlan (LGP) treatment planning system (TPS), in the case that registration is directly based on the apparent fiducial locations depicted in each MR image by the N-shaped rods on the Leksell localization box. The irradiated phantom was MR imaged at 1.5 T employing a T2-weighted pulse sequence. Four image series were acquired by alternating the frequency encoding axis and reversing the read gradient polarity, thus allowing the characterization of the MR-related spatial distortions.

RESULTS

MR spatial distortions stemming from main field (B0) inhomogeneity as well as from susceptibility and chemical shift phenomena (also known as sequence dependent distortions) were found to be of the order of 0.5 mm, while those owing to gradient nonlinearities (also known as sequence independent distortions) were found to increase with distance from the MR scanner isocenter extending up to 0.47 mm at an Euclidean distance of 69.6 mm. Regarding the LGP image registration procedure, the corresponding average contribution to the total geometric uncertainty ranged from 0.34 to 0.80 mm. The average total geometric uncertainty, which also includes the GK spatial dose delivery uncertainty, was found equal to (0.88 ± 0.16), (0.88 ± 0.26), (1.02 ± 0.09), and (1.15 ± 0.24) mm for the MR image series acquired with the read gradient polarity (direction) set toward right, left, posterior, and anterior, respectively.

CONCLUSIONS

The implemented methodology seems capable of assessing the total geometric uncertainty, as well as of characterizing its contributors, ascribed to the entire GK treatment delivery (i.e., from MR imaging to GK dose delivery) for an extended region of the Leksell stereotactic space. Results obtained indicate that the selection of both the frequency encoding axis and the read gradient polarity during MRI acquisition may affect the magnitude as well as the spatial components of the total geometric uncertainty.

Optical scanner for 3D radiotherapy polymer gel dosimetry

Sophisticated techniques employed in radiotherapy for irradiation of tumours require comprehensive dosimetry allowing for precise, high resolution measurements of radiation dose distribution in three dimensions and verification of treatment planning systems. Polymer gel dosimetry has been shown to be a unique technique for three-dimensional high resolution measurements of absorbed radiation dose distributions. If exposed to ionizing radiation, radical polymerisation and crosslinking of monomeric components take place in a 3D polymer gel dosimeter, leading to the formation of large polymeric structures that scatter visible light. This feature allows for optical observation of the effects of the absorbed dose and its distribution. Presently, magnetic resonance imaging is employed the most often for analysis of 3D polymer gel dosimeters. However, much attention is also being given to the development of optical computed tomography since this technique is hoped to serve as a substitute for expensive and not easily available magnetic resonance imaging. The optical scanner presented in this work consists of a laser diode, a scanning system and a signal detector. A 3D polymer gel dosimeter is measured in an immersion liquid in order to reduce deflection of the light from the dosimeter phantom. The very first results were obtained with the newly constructed scanner for PABIGnx 3D polymer gel dosimeter, which was inhomogeneously irradiated with 192Ir brachytherapy source. The results have been contrasted with those for magnetic resonance imaging and are presented in this work together with the description of the optical scanner. Currently, optimization of the optical scanner is performed.

Dose linearity and monitor unit stability of a G4 type cyberknife robotic stereotactic radiosurgery system

Dose linearity studies on conventional linear accelerators show a linearity error at low monitor units (MUs). The purpose of this study was to establish the dose linearity and MU stability characteristics of a cyberknife (Accuray Inc., USA) stereotactic radiosurgery system. Measurements were done at a depth of 5 cm in a stereotactic dose verification phantom with a source to surface distance of 75 cm in a Generation 4 (G4) type cyberknife system. All the 12 fixed-type collimators starting from 5 to 60 mm were used for the dose linearity study. The dose linearity was examined in small (1–10), medium (15–100) and large (125–1000) MU ranges. The MU stability test was performed with 60 mm collimator for 10 MU and 20 MU with different combinations. The maximum dose linearity error of –38.8% was observed for 1 MU with 5 mm collimator. Dose linearity error in the small MU range was considerably higher than in the medium and large MU ranges. The maximum error in the medium range was –2.4%. In the large MU range, the linearity error varied between –0.7% and 1.2%. The maximum deviation in the MU stability was –3.03%.

A contemporary review of stereotactic radiotherapy: inherent dosimetric complexities and the potential for detriment

OBJECTIVE

The advantages of highly localised, conformal treatments achievable with stereotactic radiotherapy (SRT) are increasingly being extended to extracranial sites as stereotactic body radiotherapy with advancements in imaging and beam collimation. One of the challenges in stereotactic treatment lies in the significant complexities associated with small field dosimetry and dose calculation. This review provides a comprehensive overview of the complexities associated with stereotactic radiotherapy and the potential for detriment.

METHODS

This study is based on a comprehensive review of literature accessible via PubMed and other sources, covering stereotactic radiotherapy, small-field dosimetry and dose calculation.

FINDINGS

Several key issues were identified in the literature. They pertain to dose prescription, dose measurement and dose calculation within and beyond the treatment field. Field-edge regions and penumbrae occupy a significant portion of the total field size. Spectral and dosimetric characteristics are difficult to determine and are compounded by effects of tissue inhomogeneity. Measurement of small-fields is made difficult by detector volume averaging and energy response. Available dosimeters are compared, and emphasis is given to gel dosimetry which offers the greatest potential for three-dimensional small-field dosimetry. The limitations of treatment planning system algorithms as applied to small-fields (particularly in the presence of heterogeneities) is explained, and a review of Monte Carlo dose calculation is provided, including simplified treatment planning implementations. Not incorporated into treatment planning, there is evidence that far from the primary field, doses to patients (and corresponding risks of radiocarcinogenesis) from leakage/scatter in SRT are similar to large fields.

CONCLUSIONS

Improved knowledge of dosimetric issues is essential to the accurate measurement and calculation of dose as well as the interpretation and assessment of planned and delivered treatments. This review highlights such issues and the potential benefit that may be gained from Monte Carlo dose calculation and verification via three-dimensional dosimetric methods (such as gel dosimetry) being introduced into routine clinical practice.

A variable echo-number method for estimating R2 in MRI-based polymer gel dosimetry

PURPOSE

Spin-spin relaxation rate R2 is commonly used to quantify absorbed dose for magnetic resonance imaging (MRI)-based polymer gel dosimetry. R2 is estimated by applying a parameter fitting algorithm to a train of spin-echo signals. However, a careless application of a large number of echoes can result in anomalous R2 values because the echo signal intensity decreases to the background signal offset level for a long echo time. In this article, the authors proposed and evaluated a variable echo-number (VAREC) method to remedy the problem.

METHODS

The VAREC algorithm uses only echo signals, whose intensities are greater than a preset threshold. Here, the threshold is defined as the standard deviation of Gaussian noise times a multiplier alpha. The authors implemented three R2 estimation methods in an in-house program: The nonlinear least-squares algorithm (NLLS), the VAREC method, and the maximum likelihood estimator with the Rician signal intensity distribution (MLE_R). Those methods were used to estimate the R2 values of test phantoms with known R2 values and BANG3-type polymer gels, which were irradiated to 12 different doses ranging from 0 to 50 Gy. The R2 values were measured by using a 32-echo CPMG pulse sequence on 3 T MRI scanners. The R2 values of the VAREC method were compared with those of NLLS and MLE_R.

RESULTS

The R2 values of the NLLS method incorrectly decreased to the zero-dose level for doses greater than 10 Gy. The R2 values of the VAREC method with alpha=2 agreed with those of MLE_R within the measurement uncertainty. The uncertainties of the R2 values were the smallest for alpha=2 or 3 among various alpha values.

CONCLUSIONS

The VAREC algorithm is simple, fast, and robust for the R2 estimation. The authors recommend this method with alpha=2 or 3 for R2 estimation using multispin echo MRI protocols.

A new optical-CT apparatus for 3-D radiotherapy dosimetry: is free space scanning feasible?

In this paper, we present a new optical computed tomography (Optical-CT) scanner for the verification of the radiation dose schemes delivered in modern radiotherapy applications. The optical-CT scanner is capable of providing rapid relative 3-D dosimetry with high spatial resolution with the use of normoxic N-Vinylpyrrolidone based polymer gel dosimeter. The scanner employs a diffuse uncollimated light illumination beam, a computer controlled motorized rotation stage and a charge-coupled device (CCD) camera. Various test experiments were performed to determine the performance characteristics of the optical-CT apparatus. Attenuation coefficient (micro) versus dose calibration data were generated from two calibration experiments using gel containers of two different diameters. All irradiations were performed using a 6 MV linear accelerator. A comparison of the reconstructed images between optical-CT scans using refractive index (RI) matching fluid and corresponding scans performed in free space was demonstrated. The dose readout of a test irradiation model was found to be in good agreement with independent readout performed by MR imaging. The findings presented in this study suggest that polymer dosimeters combined with the new optical-CT scanner constitute a potentially feasible method capable of measuring complex 3-D dose distributions with high resolution and in a wide dose range.

Toward acquiring comprehensive radiosurgery field commissioning data using the PRESAGE/optical-CT 3D dosimetry system

Achieving accurate small field dosimetry is challenging. This study investigates the utility of a radiochromic plastic PRESAGE read with optical-CT for the acquisition of radiosurgery field commissioning data from a Novalis Tx system with a high-definition multileaf collimator (HDMLC). Total scatter factors (Sc, p), beam profiles, and penumbrae were measured for five different radiosurgery fields (5, 10, 20, 30 and 40 mm) using a commercially available optical-CT scanner (OCTOPUS, MGS Research). The percent depth dose (PDD), beam profile and penumbra of the 10 mm field were also measured using a higher resolution in-house prototype CCD-based scanner. Gafchromic EBT film was used for independent verification. Measurements of Sc, p made with PRESAGE and film agreed with mini-ion chamber commissioning data to within 4% for every field (range 0.2-3.6% for PRESAGE, and 1.6-3.6% for EBT). PDD, beam profile and penumbra measurements made with the two PRESAGE/optical-CT systems and film showed good agreement with the high-resolution diode commissioning measurements with a competitive resolution (0.5 mm pixels). The in-house prototype optical-CT scanner allowed much finer resolution compared with previous applications of PRESAGE. The advantages of the PRESAGE system for small field dosimetry include 3D measurements, negligible volume averaging, directional insensitivity, an absence of beam perturbations, energy and dose rate independence.

Sensitivity calibration procedures in optical-CT scanning of BANG 3 polymer gel dosimeters

The dose response of the BANG 3 polymer gel dosimeter (MGS Research Inc., Madison, CT) was studied using the OCTOPUS laser CT scanner (MGS Research Inc., Madison, CT). Six 17 cm diameter and 12 cm high Barex cylinders, and 18 small glass vials were used to house the gel. The gel phantoms were irradiated with 6 and 10 MV photons, as well as 12 and 16 MeV electrons using a Varian Clinac 2100EX. Three calibration methods were used to obtain the dose response curves: (a) Optical density measurements on the 18 glass vials irradiated with graded doses from 0 to 4 Gy using 6 or 10 MV large field irradiations; (b) optical-CT scanning of Barex cylinders irradiated with graded doses (0.5, 1, 1.5, and 2 Gy) from four adjacent 4 x 4 cm2 photon fields or 6 x 6 cm2 electron fields; and (c) percent depth dose (PDD) comparison of optical-CT scans with ion chamber measurements for 6 x 6 cm2, 12 and 16 MeV electron fields. The dose response of the BANG3 gel was found to be linear and energy independent within the uncertainties of the experimental methods (about 3%). The slopes of the linearly fitted dose response curves (dose sensitivities) from the four field irradiations (0.0752 +/- 3%, 0.0756 +/- 3%, 0.0767 +/- 3%, and 0.0759 +/- 3% cm(-1) Gy(-1)) and the PDD matching methods (0.0768 +/- 3% and 0.0761 +/- 3% cm(-1) Gy(-1)) agree within 2.2%, indicating a good reproducibility of the gel dose response within phantoms of the same geometry. The dose sensitivities from the glass vial approach are different from those of the cylindrical Barex phantoms by more than 30%, owing probably to the difference in temperature inside the two types of phantoms during gel formation and irradiation, and possible oxygen contamination of the glass vial walls. The dose response curve obtained from the PDD matching approach with 16 MeV electron field was used to calibrate the gel phantom irradiated with the 12 MeV, 6 x 6 cm2 electron field. Three-dimensional dose distributions from the gel measurement and the Eclipse planning system (Varian Corporation, Palo Alto, CA) were compared and evaluated using 3% dose difference and 2 mm distance-to-agreement criteria.

Three-dimensional dosimetry of small megavoltage radiation fields using radiochromic gels and optical CT scanning

The dosimetry of small fields as used in stereotactic radiotherapy, radiosurgery and intensity-modulated radiation therapy can be challenging and inaccurate due to partial volume averaging effects and possible disruption of charged particle equilibrium. Consequently, there exists a need for an integrating, tissue equivalent dosimeter with high spatial resolution to avoid perturbing the radiation beam and artificially broadening the measured beam penumbra. In this work, radiochromic ferrous xylenol-orange (FX) and leuco crystal violet (LCV) micelle gels were used to measure relative dose factors (RDFs), percent depth dose profiles and relative lateral beam profiles of 6 MV x-ray pencil beams of diameter 28.1, 9.8 and 4.9 mm. The pencil beams were produced via stereotactic collimators mounted on a Varian 2100 EX linear accelerator. The gels were read using optical computed tomography (CT). Data sets were compared quantitatively with dosimetric measurements made with radiographic (Kodak EDR2) and radiochromic (GAFChromic EBT) film, respectively. Using a fast cone-beam optical CT scanner (Vista), corrections for diffusion in the FX gel data yielded RDFs that were comparable to those obtained by minimally diffusing LCV gels. Considering EBT film-measured RDF data as reference, cone-beam CT-scanned LCV gel data, corrected for scattered stray light, were found to be in agreement within 0.5% and -0.6% for the 9.8 and 4.9 mm diameter fields, respectively. The validity of the scattered stray light correction was confirmed by general agreement with RDF data obtained from the same LCV gel read out with a laser CT scanner that is less prone to the acceptance of scattered stray light. Percent depth dose profiles and lateral beam profiles were found to agree within experimental error for the FX gel (corrected for diffusion), LCV gel (corrected for scattered stray light), and EBT and EDR2 films. The results from this study reveal that a three-dimensional dosimetry method utilizing optical CT-scanned radiochromic gels allows for the acquisition of a self-consistent volumetric data set in a single exposure, with sufficient spatial resolution to accurately characterize small fields.