Management of radiotherapy patients with implanted cardiac pacemakers and defibrillators: A Report of the AAPM TG-203†

Managing radiotherapy patients with implanted cardiac devices (implantable cardiac pacemakers and implantable cardioverter-defibrillators) has been a great practical and procedural challenge in radiation oncology practice. Since the publication of the AAPM TG-34 in 1994, large bodies of literature and case reports have been published about different kinds of radiation effects on modern technology implantable cardiac devices and patient management before, during, and after radiotherapy. This task group report provides the framework that analyzes the potential failure modes of these devices and lays out the methodology for patient management in a comprehensive and concise way, in every step of the entire radiotherapy process.

Performance characterization of a 3D liquid scintillation detector for discrete spot scanning proton beam systems

Existing systems for proton beam dosimetry are limited in their ability to provide a complete, accurate, and detailed account of volumetric dose distribution. In this work, we describe the design and development of a portable, fast, and reusable liquid scintillator-based three-dimensional (3D) optical detection system for use in proton therapy. Our long-term goal is to use this system clinically for beam characterization, dosimetry, and quality assurance studies of discrete spot scanning proton beam systems. The system used a 20  ×  20  ×  20 cm³ liquid scintillator volume. Three mutually orthogonal cameras surrounding this volume captured scintillation photons emitted in response to the proton beams. The cameras exhibited a mean spatial resolution of 0.21 mm over the complete detection volume and a temporal resolution of 11 ms. The system is shown to be capable of capturing all 94 beam energies delivered by a synchrotron and performing rapid beam range measurements with a mean accuracy of 0.073  ±  0.030 mm over all energies. The range measurement uncertainty for doses less than 1 cGy was found to be  ±0.355 mm, indicating high precision for low dose detection. Finally, we demonstrated that using multiple cameras allowed for the precise locations of the delivered beams to be tracked in 3D. We conclude that this detector is capable of real-time and accurate tracking of dynamic spot beam deliveries in 3D. The high-resolution light profiles it generates will be useful for future 3D construction of dose maps.

Pitfalls of tungsten multileaf collimator in proton beam therapy

PURPOSE

Particle beam therapy is associated with significant startup and operational cost. Multileaf collimator (MLC) provides an attractive option to improve the efficiency and reduce the treatment cost. A direct transfer of the MLC technology from external beam radiation therapy is intuitively straightforward to proton therapy. However, activation, neutron production, and the associated secondary cancer risk in proton beam should be an important consideration which is evaluated.

METHODS

Monte Carlo simulation with FLUKA particle transport code was applied in this study for a number of treatment models. The authors have performed a detailed study of the neutron generation, ambient dose equivalent [H∗(10)], and activation of a typical tungsten MLC and compared with those obtained from a brass aperture used in a typical proton therapy system. Brass aperture and tungsten MLC were modeled by absorber blocks in this study, representing worst-case scenario of a fully closed collimator.

RESULTS

With a tungsten MLC, the secondary neutron dose to the patient is at least 1.5 times higher than that from a brass aperture. The H∗(10) from a tungsten MLC at 10 cm downstream is about 22.3 mSv/Gy delivered to water phantom by noncollimated 200 MeV beam of 20 cm diameter compared to 14 mSv/Gy for the brass aperture. For a 30-fraction treatment course, the activity per unit volume in brass aperture reaches 5.3 × 10⁴ Bq cm(-3) at the end of the last treatment. The activity in brass decreases by a factor of 380 after 24 h, additional 6.2 times after 40 days of cooling, and is reduced to background level after 1 yr. Initial activity in tungsten after 30 days of treating 30 patients per day is about 3.4 times higher than in brass that decreases only by a factor of 2 after 40 days and accumulates to 1.2 × 10⁶ Bq cm(-3) after a full year of operation. The daily utilization of the MLC leads to buildup of activity with time. The overall activity continues to increase due to (179)Ta with a half-life of 1.82 yr and thus require prolonged storage for activity cooling. The H∗(10) near the patient side of the tungsten block is about 100 μSv/h and is 27 times higher at the upstream side of the block. This would lead to an accumulated dose for therapists in a year that may exceed occupational maximum permissible dose (50 mSv/yr). The value of H∗(10) at the upstream surface of the tungsten block is about 220 times higher than that of the brass.

CONCLUSIONS

MLC is an efficient way for beam shaping and overall cost reduction device in proton therapy. However, based on this study, tungsten seems to be not an optimal material for MLC in proton beam therapy. Usage of tungsten MLC in clinic may create unnecessary risks associated with the secondary neutrons and induced radioactivity for patients and staff depending on the patient load. A careful selection of material for manufacturing of an optimal MLC for proton therapy is thus desired.