Dose buildup for obliquely incident photon beams

Skin dose in radiation treatment of the left breast: Analysis in the context of prone versus supine treatment technique

PURPOSE

To determine how the skin dose varies in patients receiving radiation treatment for breast cancer in the prone and supine positions.

METHODS

Fifty patients were scanned in the prone and supine positions. A radiation treatment plan was created for the left breast using a 6-MV beam for a prescribed dose of 42.66 Gy in 16 fractions. The dose was calculated using 1- and 2.5-mm calculation grid sizes and the surface dose was compared in both techniques.

RESULTS

The median gantry angles relative to the skin surface at the central axis were 8 and 52 degrees for treatment in the prone and supine positions, respectively. The mean dose difference between the prone and supine techniques was statistically significant from 3- to 5-mm depth for both grid sizes. For the 1-mm calculation grid size, the doses at 3-, 4-, and 5-mm depths in the prone and supine techniques were 87.80% and 89.10% (P < 0.003), 91.92% and 94.50% (P < 0.00), and 95.30% and 98.20% (P < 0.00), respectively; for the 2.5-mm grid size, the respective doses were 87.10% and 88.59% (P < 0.00), 91.60% and 94.63% (P < 0.00), and 95.10% and 97.80% (P < 0.00), respectively.

CONCLUSIONS

This study demonstrates that the prone technique facilitates a relatively lower skin dose than the supine technique. This observation is probably due to the beam angle. The beam is more perpendicular to the skin surface in the prone technique, whereas it is more tangential in the supine technique, which may deliver a higher skin dose. Thus, the dose to the skin should be evaluated in the prone technique, and if desired, the skin dose could be carefully augmented via a bolus or beam spoiler.

Skin dose in chest wall radiotherapy with bolus: a Monte Carlo study

Monte Carlo simulations are used to investigate skin dose resulting from chest wall radiotherapy with bolus. A simple model of a female thorax is developed, which includes a 2 mm-thick skin layer. Two representative 6 MV source models are considered: a tangents source model consisting of a parallel opposed pair of medial and lateral fields and subfields, and an arc source model. Tissue equivalent (TE) boluses (thicknesses of 3, 5 and 10 mm) and brass mesh bolus are considered. Skin dose distributions depend on incident photon obliquity: for tangents, radiation is incident more obliquely, resulting in longer path lengths through the bolus and higher skin dose compared to the arc source model in most cases. However, for thicker TE boluses, attenuation of oblique photons becomes apparent. Brass bolus and 3 mm TE bolus result in similar mean skin dose. This relatively simple computational model allows for consideration of different bolus thicknesses, materials and usage schedules based on desired skin dose and choice of either tangents or an arc beam technique. For example, using a 5 mm TE bolus every second treatment would result in mean skin doses of 89% and 85% for tangents and the arc source model, respectively. The hot spot metric D[Formula: see text] would be 103% and 99%, respectively.

Surface dose and acute skin reactions in external beam breast radiotherapy

The biologically relevant depth for acute skin reactions in radiotherapy is 70 µm. The dose at this depth is difficult to measure or calculate and can be quite different than the dose at a depth of as little as 1 mm. For breast radiotherapy with medial and lateral tangential beams, the skin dose depends on both the contribution from the entrance beam and the exit beam. The skin dose has been estimated in a breast model hemi-ellipse accounting for field size, beam energy, obliquity, lack of backscatter, fractionation, size and shape of the hemi-ellipse. The dose has been held constant along the axis of symmetry of the hemi-ellipse by introducing modulation as in clinical IMRT practice. Dose distributions have been computed as a function of the polar angle from the center of the hemi-ellipse. The exit dose always dominates the entrance dose for all realistic parameters. As a result, the surface dose is higher for 18 MV than 6 MV over the entire surface for all reasonable sizes and shapes of the hemi-ellipse. The results of these calculations suggest that substituting an 18 MV beam for a 6 MV beam to achieve greater skin sparing may have just the opposite effect. The ratio of the surface dose to the mid-depth dose ranges from about 35% at polar angle 0^o to up to 70% at polar angle 80^o. The dose rises sharply at angles above 30^o. The surface dose rises moderately at all angles as the size of the hemi-ellipse increases. The effect of shape is somewhat complex: as the breast becomes flatter, doses at intermediate angles increase, but doses at small and large angles decrease. The biologically effective dose for erythema and moist desquamation is about 2 to 3 Gy higher at all polar angles for conventional fractionation (2.00 Gy × 25 fractions) than for hypofractionation (2.66 Gy × 16).

Effect of VERO pan-tilt motion on the dose distribution

Tumor tracking is an option for intra-fractional motion management in radiotherapy. The VERO gimbal tracking system creates a unique beam geometry and understanding the effect of the gimbal motion in terms of dose distribution is important to assess the dose deviation from the reference conditions. Beam profiles, output factors (OF) and percentage depth doses (PDD) were measured and evaluated to investigate this effect. In order to find regions affected by the pan-tilt motion, synthesized 2D dose distributions were generated. An evaluation of the 2D dose distribution with the reference position was done using dose difference criteria 1%-4%. The OF and point dose at central axis were measured and compared with the reference position. Furthermore, the PDDs were measured using a special monitoring approach to filtering inaccurate points during the acquisition. Beam profiles evaluation showed that the effect of pan-tilt at inline direction was stronger than at the crossline direction. The maximum average deviation of the full width half maximum (FWHM), flatness, symmetry, penumbra left and right were 0.39 ± 0.25 mm, 0.62 ± 0.50%, 0.76 ± 0.59%, 0.22 ± 0.16 mm, and 0.19 ± 0.15 mm respectively. The ÔF and the measured dose average deviation were <0.5%. The mechanical accuracies during the PDD measurements were 0.28 ± 0.09 mm and 0.21 ± 0.09 mm for pan and tilt and pan or tilt position. The PDD average deviations were 0.58 ± 0.26 % and 0.54 ± 0.25 % for pan-or-tilt and pan-and-tilt position respectively. All the results showed that the deviation at pan and tilt position are higher than pan or tilt. The most influences were observed for the penumbra region and the shift of radiation beam path.

Measurement of skin surface dose distributions in radiation therapy using poly(vinyl alcohol) cryogel dosimeters

In external beam radiation therapy (EBRT), skin dose measurement is important to evaluate dose coverage of superficial target volumes. Treatment planning systems (TPSs) are often inaccurate in this region of the patient, so in vivo measurements are necessary for skin surface dose estimation. In this work, superficial dose distributions were measured using radiochromic translucent poly(vinyl alcohol) cryogels. The cryogels simultaneously served as bolus material, providing the necessary buildup to achieve the desired superficial dose. The relationship between dose to the skin surface and dose measured with the bolus was established using a series of oblique irradiations with gantry angles ranging from 0° to 90°. EBT-2 Gafchromic film was placed under the bolus, and the ratio of bolus-film dose was determined ranging from 0.749 ± 0.005 to 0.930 ± 0.002 for 0° and 90° gantry angles, respectively. The average ratio over 0-67.5° (0.800 ± 0.064) was used as the single correction factor to convert dose in bolus to dose to the skin surface. The correction factor was applied to bolus measurements of skin dose from head and neck intensity-modulated radiation therapy (IMRT) treatments delivered to a RANDO phantom. The resulting dose distributions were compared to film measurements using gamma analysis with a 3%/3 mm tolerance and a 10% threshold. The minimum gamma pass rate was 95.2% suggesting that the radiochromic bolus may provide an accurate estimation of skin surface dose using a simple correction factor. This study demonstrates the suitability of radiochromic cryogels for superficial dose measurements in megavoltage photon beams.

Increased dose near the skin due to electromagnetic surface beacon transponder

The purpose of this study was to evaluate the increased dose near the skin from an electromagnetic surface beacon transponder, which is used for localization and tracking organ motion. The bolus effect due to the copper coil surface beacon was evaluated with radiographic film measurements and Monte Carlo simulations. Various beam incidence angles were evaluated for both 6 MV and 18 MV experimentally. We performed simulations using a general‐purpose Monte Carlo code MCNPX (Monte Carlo N‐Particle) to supplement the experimental data. We modeled the surface beacon geometry using the actual mass of the glass vial and copper coil placed in its L‐shaped polyethylene terephthalate tubing casing. Film dosimetry measured factors of 2.2 and 3.0 enhancement in the surface dose for normally incident 6 MV and 18 MV beams, respectively. Although surface dose further increased with incidence angle, the relative contribution from the bolus effect was reduced at the oblique incidence. The enhancement factors were 1.5 and 1.8 for 6 MV and 18 MV, respectively, at an incidence angle of 60°. Monte Carlo simulation confirmed the experimental results and indicated that the epidermal skin dose can reach approximately 50% of the dose at dmax at normal incidence. The overall effect could be acceptable considering the skin dose enhancement is confined to a small area (∼1 cm2), and can be further reduced by using an opposite beam technique. Further clinical studies are justified in order to study the dosimetric benefit versus possible cosmetic effects of the surface beacon. One such clinical situation would be intact breast radiation therapy, especially large‐breasted women.

PACS number: 87.53

Superficial dosimetry imaging based on Čerenkov emission for external beam radiotherapy with megavoltage x-ray beam

PURPOSE

Čerenkov radiation emission occurs in all tissue, when charged particles (either primary or secondary) travel at velocity above the threshold for the Čerenkov effect (about 220 KeV in tissue for electrons). This study presents the first examination of optical Čerenkov emission as a surrogate for the absorbed superficial dose for MV x-ray beams.

METHODS

In this study, Monte Carlo simulations of flat and curved surfaces were studied to analyze the energy spectra of charged particles produced in different regions near the surfaces when irradiated by MV x-ray beams. Čerenkov emission intensity and radiation dose were directly simulated in voxelized flat and cylindrical phantoms. The sampling region of superficial dosimetry based on Čerenkov radiation was simulated in layered skin models. Angular distributions of optical emission from the surfaces were investigated. Tissue mimicking phantoms with flat and curved surfaces were imaged with a time domain gating system. The beam field sizes (50 × 50-200 × 200 mm(2)), incident angles (0°-70°) and imaging regions were all varied.

RESULTS

The entrance or exit region of the tissue has nearly homogeneous energy spectra across the beam, such that their Čerenkov emission is proportional to dose. Directly simulated local intensity of Čerenkov and radiation dose in voxelized flat and cylindrical phantoms further validate that this signal is proportional to radiation dose with absolute average discrepancy within 2%, and the largest within 5% typically at the beam edges. The effective sampling depth could be tuned from near 0 up to 6 mm by spectral filtering. The angular profiles near the theoretical Lambertian emission distribution for a perfect diffusive medium, suggesting that angular correction of Čerenkov images may not be required even for curved surface. The acquisition speed and signal to noise ratio of the time domain gating system were investigated for different acquisition procedures, and the results show there is good potential for real-time superficial dose monitoring. Dose imaging under normal ambient room lighting was validated, using gated detection and a breast phantom.

CONCLUSIONS

This study indicates that Čerenkov emission imaging might provide a valuable way to superficial dosimetry imaging in real time for external beam radiotherapy with megavoltage x-ray beams.

Superficial dosimetry imaging of Čerenkov emission in electron beam radiotherapy of phantoms

Čerenkov emission is generated from ionizing radiation in tissue above 264 keV energy. This study presents the first examination of this optical emission as a surrogate for the absorbed superficial dose. Čerenkov emission was imaged from the surface of flat tissue phantoms irradiated with electrons, using a range of field sizes from 6 cm × 6 cm to 20 cm × 20 cm, incident angles from 0° to 50°, and energies from 6 to 18 MeV. The Čerenkov images were compared with the estimated superficial dose in phantoms from direct diode measurements, as well as calculations by Monte Carlo and the treatment planning system. Intensity images showed outstanding linear agreement (R(2) = 0.97) with reference data of the known dose for energies from 6 to 18 MeV. When orthogonal delivery was carried out, the in-plane and cross-plane dose distribution comparisons indicated very little difference (± 2-4% differences) between the different methods of estimation as compared to Čerenkov light imaging. For an incident angle 50°, the Čerenkov images and Monte Carlo simulation show excellent agreement with the diode data, but the treatment planning system had a larger error (OPT = ± 1~2%, diode = ± 2~3%, TPS = ± 6-8% differences) as would be expected. The sampling depth of superficial dosimetry based on Čerenkov radiation has been simulated in a layered skin model, showing the potential of sampling depth tuning by spectral filtering. Taken together, these measurements and simulations indicate that Čerenkov emission imaging might provide a valuable method of superficial dosimetry imaging from incident radiotherapy beams of electrons.

Dosimetric verification of surface and superficial doses for head and neck IMRT with different PTV shrinkage margins

PURPOSE

Dosimetric uncertainty in the surface and superficial regions is still a major concern for radiation therapy and becomes more important when using the inverse planning algorithm for IMRT. The purpose of this study was to measure dose distributions and to evaluate the calculation accuracy in the superficial region for different planning target volume (PTV) shrinkage methods for head and neck IMRT plans.

METHODS

A spherical polystyrene phantom 160 mm in diameter (ball phantom) was used to simulate the shape of the head. Strips of superflab bolus with thicknesses of 3.5 and 7.0 mm were spread on the surface of the ball phantom. Three sets of CT images were acquired for the ball phantom without and with the bolus. The hypothetical clinical target volume (CTV) and critical structures (spinal cord and parotid glands) were outlined on each set of CT images. The PTVs were initially created by expanding an isotropic 3 mm margin from the CTV and then margins of 0, 3, and 5 mm were shrunk from the phantom surface for dosimetric analysis. Seven-field IMRT plans with a prescribed dose of 180 cGy and same dose constraints were designed using an Eclipse treatment planning system. Superficial doses at depths of 0, 3.5, and 7.0 mm and at seven beam axis positions (gantry angles of 0 degrees, 30 degrees, 60 degrees, 80 degrees, 330 degrees, 300 degrees, and 280 degrees) were measured for each PTV shrinkage margin using 0.1 mm ultrathin thermoluminescent dosimeters. For each plan, the measured doses were compared to the calculated doses.

RESULTS

The PTV without shrinkage had the highest intensity and the steepest dose gradient in the superficial region. The mean measured doses for different positions at depths of 0, 3.5, and 7.0 mm were 106 +/- 18, 185 +/- 16, and 188 +/- 12 cGy, respectively. For a PTV with 3 mm shrinkage, the mean measured doses were 94 +/- 13, 183 +/- 8, and 191 +/- 8 cGy. For a PTV with 5 mm shrinkage, the mean measured doses were 86 +/- 11, 173 +/- 8, and 187 +/- 5 cGy. The comparisons indicated that more than 73.3% of the calculated points are with doses lower than the measured points and the difference of the dose becomes more significant in the shallower region. At 7.0 mm depth, the average difference between calculations and measurements was 2.5% (maximum 5.5%).

CONCLUSIONS

Application of the PTV shrinkage method should take into account the calculation inaccuracy, tumor coverage, and possible skin reaction. When the tumor does not invade the superficial region, an adequate shrinkage margin from the surface is helpful for reducing the skin reaction. As the tumor invades the superficial region, adding a bolus is a method better than only contouring PTV with skin inclusion.

Dose discrepancies in the buildup region and their impact on dose calculations for IMRT fields

PURPOSE

Dose accuracy in the buildup region for radiotherapy treatment planning suffers from challenges in both measurement and calculation. This study investigates the dosimetry in the buildup region at normal and oblique incidences for open and IMRT fields and assesses the quality of the treatment planning calculations.

METHODS

This study was divided into three parts. First, percent depth doses and profiles (for 5 x 5, 10 x 10, 20 x 20, and 30 x 30 cm2 field sizes at 0 degrees, 45 degrees, and 70 degrees incidences) were measured in the buildup region in Solid Water using an Attix parallel plate chamber and Kodak XV film, respectively. Second, the parameters in the empirical contamination (EC) term of the convolution/ superposition (CVSP) calculation algorithm were fitted based on open field measurements. Finally, seven segmental head-and-neck IMRT fields were measured on a flat phantom geometry and compared to calculations using gamma and dose-gradient compensation (C) indices to evaluate the impact of residual discrepancies and to assess the adequacy of the contamination term for IMRT fields.

RESULTS

Local deviations between measurements and calculations for open fields were within 1% and 4% in the buildup region for normal and oblique incidences, respectively. The C index with 5%/1 mm criteria for IMRT fields ranged from 89% to 99% and from 96% to 98% at 2 mm and 10 cm depths, respectively. The quality of agreement in the buildup region for open and IMRT fields is comparable to that in nonbuildup regions.

CONCLUSIONS

The added EC term in CVSP was determined to be adequate for both open and IMRT fields. Due to the dependence of calculation accuracy on (1) EC modeling, (2) internal convolution and density grid sizes, (3) implementation details in the algorithm, and (4) the accuracy of measurements used for treatment planning system commissioning, the authors recommend an evaluation of the accuracy of near-surface dose calculations as a part of treatment planning commissioning.

Build-up and surface dose measurements on phantoms using micro-MOSFET in 6 and 10MV x-ray beams and comparisons with Monte Carlo calculations

This work is intended to investigate the application and accuracy of micro-MOSFET for superficial dose measurement under clinically used MV x-ray beams. Dose response of micro-MOSFET in the build-up region and on surface under MV x-ray beams were measured and compared to Monte Carlo calculations. First, percentage-depth-doses were measured with micro-MOSFET under 6 and 10 MV beams of normal incidence onto a flat solid water phantom. Micro-MOSFET data were compared with the measurements from a parallel plate ionization chamber and Monte Carlo dose calculation in the build-up region. Then, percentage-depth-doses were measured for oblique beams at 0 degrees-80 degrees onto the flat solid water phantom with micro-MOSFET placed at depths of 2 cm, 1 cm, and 2 mm below the surface. Measurements were compared to Monte Carlo calculations under these settings. Finally, measurements were performed with micro-MOSFET embedded in the first 1 mm layer of bolus placed on a flat phantom and a curved phantom of semi-cylindrical shape. Results were compared to superficial dose calculated from Monte Carlo for a 2 mm thin layer that extends from the surface to a depth of 2 mm. Results were (1) Comparison of measurements with MC calculation in the build-up region showed that micro-MOSFET has a water-equivalence thickness (WET) of 0.87 mm for 6 MV beam and 0.99 mm for 10 MV beam from the flat side, and a WET of 0.72 mm for 6 MV beam and 0.76 mm for 10 MV beam from the epoxy side. (2) For normal beam incidences, percentage depth dose agree within 3%-5% among micro-MOSFET measurements, parallel-plate ionization chamber measurements, and MC calculations. (3) For oblique incidence on the flat phantom with micro-MOSFET placed at depths of 2 cm, 1 cm, and 2 mm, measurements were consistent with MC calculations within a typical uncertainty of 3%-5%. (4) For oblique incidence on the flat phantom and a curved-surface phantom, measurements with micro-MOSFET placed at 1.0 mm agrees with the MC calculation within 6%, including uncertainties of micro-MOSFET measurements of 2%-3% (1 standard deviation), MOSFET angular dependence of 3.0%-3.5%, and 1%-2% systematical error due to phantom setup geometry asymmetry. Micro-MOSFET can be used for skin dose measurements in 6 and 10 MV beams with an estimated accuracy of +/- 6%.

Feasibility study of helical tomotherapy for total body or total marrow irradiationa)

Total body radiation (TBI) has been used for many years as a preconditioning agent before bone marrow transplantation. Many side effects still plague its use. We investigated the planning and delivery of total body irradiation (TBI) and selective total marrow irradiation (TMI) and a reduced radiation dose to sensitive structures using image-guided helical tomotherapy. To assess the feasibility of using helical tomotherapy, (A) we studied variations in pitch, field width, and modulation factor on total body and total marrow helical tomotherapy treatments. We varied these parameters to provide a uniform dose along with a treatment times similar to conventional TBI (15-30 min). (B) We also investigated limited (head, chest, and pelvis) megavoltage CT (MVCT) scanning for the dimensional pretreatment setup verification rather than total body MVCT scanning to shorten the overall treatment time per treatment fraction. (C) We placed thermoluminescent detectors (TLDs) inside a Rando phantom to measure the dose at seven anatomical sites, including the lungs. A simulated TBI treatment showed homogeneous dose coverage (+/-10%) to the whole body. Doses to the sensitive organs were reduced by 35%-70% of the target dose. TLD measurements on Rando showed an accurate dose delivery (+/-7%) to the target and critical organs. In the TMI study, the dose was delivered conformally to the bone marrow only. The TBI and TMI treatment delivery time was reduced (by 50%) by increasing the field width from 2.5 to 5.0 cm in the inferior-superior direction. A limited MVCT reduced the target localization time 60% compared to whole body MVCT. MVCT image-guided helical tomotherapy offers a novel method to deliver a precise, homogeneous radiation dose to the whole body target while reducing the dose significantly to all critical organs. A judicious selection of pitch, modulation factor, and field size is required to produce a homogeneous dose distribution along with an acceptable treatment time. In addition, conformal radiation to the bone marrow appears feasible in an external radiation treatment using image-guided helical tomotherapy.

Surface buildup dose dependence on photon field delivery technique for IMRT

The more complex delivery techniques required for implementation of intensity‐modulated radiotherapy (IMRT) based on inverse planning optimization have changed the relationship between dose at depth and dose at buildup regions near the surface. Surface buildup dose is dependent on electron contamination primarily from the unblocked view of the flattening filter and secondarily from air and collimation systems. To evaluate the impact of beam segmentation on buildup dose, measurements were performed with 10×10 cm2 fields, which were delivered with 3 static 3.5×10 cm2 or 3×10 cm2 strips, 5 static 2×10 cm2 strips, 10 static 1×10 cm2 strips, and 1.1×10 cm2 dynamic delivery, compared with a 10×10 cm2 open field. Measurements were performed in water and Solid Water using parallel plate chambers, a stereotactic diode, and thermoluminescent dosimeters (TLDs) for a 6 MV X‐ray beam. Depth doses at 2 mm depth (relative to dose at 10 cm depth) were lower by 6%, 7%, 11%, and 10% for the above field delivery techniques, respectively, compared to the open field. These differences are most influenced by differences in multileaf collimator (MLC) transmission contributing to the useful beam. An example IMRT field was also studied to assess variations due to delivery technique (static vs. dynamic) and intensity level. Buildup dose is weakly dependent on the multileaf delivery technique for efficient IMRT fields.

PACS numbers: 87.53.‐j, 87.53.Dq

A method to check the accuracy of dose computation using quality index: application to scatter contribution in high energy photon beams

Computerized dose calculation verification is a relevant component of radiotherapy treatment planning quality assurance. The usual procedure is to compare measurements to computations for several standard situations. As cases become more complex, special test phantoms and beam arrangements must be used, and an experimental procedure must be carefully established. In this paper we follow a new methodology to prepare a set of reference data that may be used to verify the accuracy of dose calculations involving changes in the scatter component of photon beams. The advantage of this methodology is that local measurements are not required. A quantitative evaluation of dose modifications was performed by means of correction factors (CF). For this purpose, three geometrical configurations were designed (asymmetric, symmetric, and reference) where the primary component was kept constant and the scatter component was varied by changing the height (h) of lateral columns. Measurements were performed in polystyrene phantoms for seven photon beam energies. CF were derived as the ratio of the absolute dose measured at the point of interest to the absolute dose for the reference configuration, for the asymmetric and symmetric configurations, respectively. They were expressed as a function of beam quality (QI). We have verified that, for all configurations studied, CF decrease with QI. For h = 15 cm, CF remain practically constant, whatever machine technology is used [the mean values of CF for the asymmetric and symmetric cases are CFa= 1.028 (0.2% 1 s.d.) and CFs= 1.058 (0.4% 1 s.d.)]. We have developed a test protocol and we have chosen those configurations corresponding to h = 15 cm because they both present greater values of the CF and lower standard deviations. The direct application of the method is straightforward. The user can reproduce on his local TPS the three experimental configurations described in the test protocol, and then compute CF which can be compared to our reference data set for any beam quality.

Is machine energy (4-8 MV) associated with outcome for stage I-II breast cancer patients?

PURPOSE

To assess the relationship between machine energy (4-8 MV) and treatment outcome in patients treated with conservative surgery and radiation therapy.

METHODS AND MATERIALS

Between 1968 and 1985, 1624 patients were treated for clinical Stage I or II invasive breast cancer. The study population was limited to 1380 patients who underwent complete gross excision and received greater than or equal to 60 Gy to the tumor bed. Of these, 1125 were treated on a 4 MV, 153 on a 6 MV, and 102 on an 8 MV linear accelerator. Patients were selected for treatment on the 8 MV machine based on chest wall separations greater than 24 cm. Of patients treated on the 8 MV, netting was used for 42% and bolus was used for 26%. The median dose with bolus was 14 Gy in seven fractions (range: 2-34.2 Gy). Patients treated on the 8 MV accelerator were older, had a higher percentage of clinical T2 tumors, a higher percentage of pathologically positive nodes, and a lower incidence of extensive intraductal component (EIC). Median follow-up times were 130, 153, and 102 months, respectively, for survivors treated on the 4, 6, and 8 MV machines.

RESULTS

We analyzed the site and 5-year crude incidence of first failure by machine energy and found the pattern of first failure site (local, nodal, or distant) to be virtually identical for each energy group. Of the local failures, 12 were in the skin of the treated breast, and these failures were evenly distributed by machine energy. We performed a multivariate analysis to adjust for factors known to predict for treatment failure. When adjusted for these other variables, machine energy was not associated with an increased (or decreased) risk of recurrence (RR for 8 MV vs. 4 MV = 0.94, p = 0.7; RR for 6 MV vs. 4 MV = 1.0, p = 0.9). We also analyzed the nature and incidence of treatment complications (rib fracture, radiation pneumonitis, soft tissue necrosis, and brachial plexopathy) and found no significant differences among the three treatment groups when stratified by treatment technique (tangents only vs. three-field). There was also no significant difference in cosmetic outcome at 5 years among the three groups.

CONCLUSIONS

We conclude that machine energy over the range of 4 to 8 MV does not significantly affect treatment outcome. Specifically, it was feasible to treat patients with large chest wall separations using an 8 MV machine without an increase in skin recurrences and with the improved dose homogeneity afforded by 8 MV machines as compared with those of lower energies.

Radiochromic film as a radiotherapy surface-dose detector

Radiochromic film is shown to be a useful surface-dose detector for radiotherapy x-ray beams. Central-axis percentage surface-dose results as measured by Gafchromic film for a 6 MVp x-ray beam produced by a Varian 2100C Linac at 100 cm SSD are 16%, 25%, 35%, 41% for 10, 20, 30 and 40 cm square field sizes, respectively. Using a simple, uniform light source and a CCD camera connected to an image analysis system, quantitative 3D surface doses are accurately attainable in real time as either numerical data, a black-and-white image or a colour-enhanced image.

Effects of beam modifiers and immobilization devices on the dose in the build-up region

PURPOSE

To analyze the effect that immobilization devices used in conjunction with beam modifiers may have on the dose to the skin and build-up region.

METHODS AND MATERIALS

Central axis depth dose measurements were made in a polystyrene phantom in the build-up regions using the 6 and 15 MV photon beams, at two different source-to-phantom distances, and various field sizes. The effects of acrylic blocking trays, lead wedges, and cerrobend blocks were assessed in conjunction with the enhancement of dose in the build-up region due to immobilizing devices using plaster and thermoplastic casting materials of different thicknesses.

RESULTS

For the 6 MV photons, solid (3 mm) thermoplastic casting material was found to have the greatest effect on surface dose: for a 12 x 12 cm field we measured 79% of maximum dose when treating through the material versus 22% of maximum dose when no beam modifiers or immobilization devices are used. Measurements were also made to evaluate the effect of the immobilization of patients receiving three-dimensional conformal treatments using a 15 MV photon beam.

CONCLUSIONS

The relevance of these results to treatments in the pelvis, breast, and head and neck regions is discussed. For 6 MV beams, special consideration should be given if the need arises to treat through the immobilization device, as unacceptable skin reactions may result.