[Does radiation therapy for prostate cancer increase the risk of second cancers?]

PURPOSE

The increased risk of second cancer after prostate radiotherapy is a debated clinical concern. The objective of the study was to assess the risk of occurrence of second cancers after prostate radiation therapy based on the analysis the literature, and to identify potential factors explaining the discrepancies in results between studies.

MATERIALS AND METHODS

A review of the literature was carried out, comparing the occurrence of second cancers in patients all presenting with prostate cancer, treated or not by radiation.

RESULTS

This review included 30 studies reporting the occurrence of second cancers in 2,112,000 patients treated or monitored for localized prostate cancer, including 1,111,000 by external radiation therapy and 103,000 by brachytherapy. Regarding external radiation therapy, the average follow-up was 7.3years. The majority of studies (80%) involving external radiation therapy, compared to no external radiation therapy, showed an increased risk of second cancers with a hazard ratio ranging from 1.13 to 4.9, depending on the duration of the follow-up. The median time to the occurrence of these second cancers after external radiotherapy ranged from 4 to 6years. An increased risk of second rectal and bladder cancer was observed in 52% and 85% of the studies, respectively. Considering a censoring period of more than 10 years after irradiation, 57% and 100% of the studies found an increased risk of rectal and bladder cancer, without any impact in overall survival. Studies of brachytherapy did not show an increased risk of second cancer. However, these comparative studies, most often old and retrospective, had many methodological biases.

CONCLUSION

Despite numerous methodological biases, prostate external radiation therapy appears associated with a moderate increase in the risk of second pelvic cancer, in particular bladder cancer, without impacting survival. Brachytherapy does not increase the risk of a second cancer.

Radiation dose evaluation to organs in neonatal patients by field size during potable X-ray examination in incubators: A Monte Carlo simulation study

BACKGROUND

Neonatal patients located in incubators are exposed to as many as 159 radiographs until discharge. To reduce the dose exposed to the patient, factors that may cause unnecessary exposure to the patient were judged. When conducting portable X-rays of neonatal patients located in an incubator, it is not easy to determine the exact field size because collimation light is exposed on the acrylic plate, an incubator canopy, and the resulting shadow is reflected on the patient's body.

OBJECTIVE

This study aims to measure the organ dose exposed to the patient according to the field size when a portable radiograph is given to a neonatal patient in a neonatal intensive care unit (NICU) incubator.

METHODS

To identify the absorbed organ dose depending on the radiation field size during portable X-ray examination of neonatal patient, a Monte Carlo N-Particle (MCNP) simulation, a SpeckCalc program, and a neonatal phantom from the ICRP 89 are applied for the calculation. According to the minimal field size (MinFS) standards of the European Commission (EC), the smaller field size is intended to measure tightly from the top of the lung apices to the bottom of the genitals; a larger field size is also calculated by adding 6 cm in width and length.

RESULTS

Compared to the hospital C condition from the previous study, the larger and smaller field sizes are decreased by an average of 45% and 67%, respectively. Study results also show a 42% reduction in smaller field size compared to the larger field size.

CONCLUSION

When taking chest and abdomen radiographic images of neonatal patients in incubators, appropriate field sizes are required to prevent inappropriate dose absorption for non-thoracic organs.

Dosimetry and radioprotection evaluations of very high energy electron beams

Very high energy electrons (VHEEs) represent a promising alternative for the treatment of deep-seated tumors over conventional radiotherapy (RT), owing to their favourable dosimetric characteristics. Given the high energy of the electrons, one of the concerns has been the production of photoneutrons. In this article we explore the consequence, in terms of neutron yield in a water phantom, of using a typical electron applicator in conjunction with a 2 GeV and 200 MeV VHEE beam. Additionally, we evaluate the resulting ambient neutron dose equivalent at various locations between the phantom and a concrete wall. Through Monte Carlo (MC) simulations it was found that an applicator acts to reduce the depth of the dose build-up region, giving rise to lower exit doses but higher entrance doses. Furthermore, neutrons are injected into the entrance region of the phantom. The highest dose equivalent found was approximately 1.7 mSv/Gy in the vicinity of the concrete wall. Nevertheless, we concluded that configurations of VHEEs studied in this article are similar to conventional proton therapy treatments in terms of their neutron yield and ambient dose equivalent. Therefore, a clinical implementation of VHEEs would likely not warrant additional radioprotection safeguards compared to conventional RT treatments.

Risk of radiation-induced second malignant neoplasms from photon and proton radiotherapy in paediatric abdominal neuroblastoma

BACKGROUND AND PURPOSE

State-of-the-art radiotherapy modalities have the potential of reducing late effects of treatment in childhood cancer survivors. Our aim was to investigate the carcinogenic risk associated with 3D conformal (photon) radiation (3D-CRT), intensity modulated arc therapy (IMAT) and pencil beam scanning proton therapy (PBS-PT) in the treatment of paediatric abdominal neuroblastoma.

MATERIALS AND METHODS

The risk of radiation-induced second malignant neoplasm (SMN) was estimated using the concept of organ equivalent dose (OED) for eleven organs (lungs, rectum, colon, stomach, small intestine, liver, bladder, skin, central nervous system (CNS), bone, and soft tissues). The risk ratio (RR) between radiotherapy modalities and lifetime absolute risks (LAR) were reported for twenty abdominal neuroblastoma patients (median, 4y; range, 1-9y) historically treated with 3D-CRT that were also retrospectively replanned for IMAT and PBS-PT.

RESULTS

The risk of SMN due to primary radiation was reduced in PBS-PT against 3D-CRT and IMAT for most patients and organs. The RR across all organs ranged from 0.38 ± 0.22 (bladder) to 0.98 ± 0.04 (CNS) between PBS-PT and IMAT, and 0.12 ± 0.06 (rectum and bladder) to 1.06 ± 0.43 (bone) between PBS-PT and 3D-CRT. The LAR for most organs was within 0.01-1% (except the colon) with a cumulative risk of 21 ± 13%, 35 ± 14% and 35 ± 16% for PBS-PT, IMAT and 3D-CRT, respectively.

CONCLUSIONS

PBS-PT was associated with the lowest risk of radiation-induced SMN compared to IMAT and 3D-CRT in abdominal neuroblastoma treatment. Other clinical endpoints and plan robustness should also be considered for optimal plan selection.

NOVEL 'PHOTONEUTRON VOLUME DOSE EQUIVALENT' HYPOTHESIS AND METHODOLOGY FOR SECOND PRIMARY CANCER RISK ESTIMATION IN HIGH-ENERGY X-RAY MEDICAL ACCELERATORS

A novel 'photoneutron (PN) volume dose equivalent' methodology was hypothesized and applied for the first time for estimating PN second primary cancer (PN-SPC) risks in high-energy X-ray medical accelerators. Novel position-sensitive mega-size polycarbonate dosimeters with 10B converter (with or without cadmium covers) were applied for determining fast, epithermal and thermal PN dose equivalents at positions on phantom surface and depths. The methodology was applied to sites of tumors such as brain, stomach and prostate in 47 patients. The PN-SPC risks were estimated for specific organs/tissues using linear International Commission on Radiological Protection cancer risks and were compared with some available data. The corresponding PN-SPC risk estimates ranged from 1.450 × 10-3 to 1.901 cases per 10 000 persons per Gray. The method was applied to 47 patients for estimating PN-SPC risks in patients undergoing radiotherapy. The PN-SPC risk estimates well match those calculated by simulation but are comparatively different from those estimated by 'PN point dose equivalent' methods, as expected.

A Monte Carlo study of neutron contamination in presence of circular cones during stereotactic radiotherapy with 18 MV photon beams

High-energy photons are being used to treat different kinds of cancer, but it may increase the rate of secondary cancers due to the neutron contamination as well as over exposing of patients and medical staffs in radiation therapy Takam, Bezak, Marcu, and Yeoh, 2011, Radiation Research, 176, 508-520. Due to some difficulties in experimental measurements of neutron contamination, Monte Carlo method is an efficient tool to investigate dose parameters and characteristics in new techniques. The 18-MV photon beam of linac and circular cones have been simulated by MCNP5 code. Various parameters of photon and neutron including mean energy, flux, KERMA, the number of particles crossing a surface at a distance of 100 cm (SSD = 100 cm) as well as the change in photon and neutron spectrum as well as in intensity through the transmission in the circular collimators have been investigated. The results of this study show that the use of a circular collimator decreases neutron dose in the central axis, which is an advantage, but neutron contamination inducing small neutron dose is distributed all over the space. On the surface of phantom, photon dose rate is approximately equal to 3.41E7 (mGy/mA.min) for different collimators, but the neutron dose rate is 1.64E2 (mGy/ mA.min), 2.03E2 (mGy/ mA.min) and 2.52E2 (mGy/mA.min) for diameters of 12, 20 and 40 mm, respectively and it decreases by decreasing the diameter of the collimator. The neutron dose rate decreases from 9.68E7 and 9.74E7 (mGy/min.mA) for open field size 33 cm² and 55 cm² to 1.64E2 (mGy/min.mA), 2.02E2 (mGy/min.mA) and 2.52E2 (mGy/min.mA) for collimator diameter of 12 mm, 20 mm and 40 mm. It can be concluded that the use of circular collimators has an advantage of reducing neutron dose in the central axis. It should be mentioned that the off-axis neutron dose surrounding the collimator can be eliminated using an external neutron shield without perturbing the treatment field.

Whole-body dose equivalent including neutrons is similar for 6 MV and 15 MV IMRT, VMAT, and 3D conformal radiotherapy

PURPOSE

This study investigates the difference in whole-body dose equivalent between 6 and 15 MV image-guided radiotherapy (IGRT) for the treatment of a rhabdomyosarcoma in the prostate.

METHODS

A previously developed model for stray radiation of the primary beam was improved and used to calculate the photon dose and photon energy in the out-of-field region for a radiotherapy patient. The dose calculated by the treatment planning system was fused with the model-calculated out-of-field dose, resulting in a whole-body photon dose distribution. The peripheral neutron dose equivalent was calculated using an analytical model from the literature. A daily cone beam CT dose was added to the neutron and photon dose equivalents. The calculated 3D dose distributions were compared to independent measurements conducted with thermoluminescence dosimeters and an anthropomorphic phantom. The dose contributions from the IGRT treatments of three different techniques applied with two nominal X-ray energies were compared using dose equivalent volume histograms (DEVHs).

RESULTS

The calculated and measured out-of-field whole-body dose equivalents for the IGRT treatments agreed within (9 ± 10) % (mean and type A SD). The neutron dose equivalent was a minor contribution to the total out-of-field dose up to 50 cm from the isocenter. Further from the isocenter, head leakage was dominating inside the patient body, whereas the neutron dose equivalent contribution was important close to the surface. There were small differences between the whole-body DEVHs of the 6 and 15 MV treatments applied with the same technique, although the single scatter contributions showed large differences. Independent of the beam energy, the out-of-field dose of the volumetric-modulated arc therapy (VMAT) treatment was significantly lower than the dynamic intensity-modulated radiation therapy (IMRT) treatment.

CONCLUSION

The calculated whole-body dose helped to understand the importance of the dose contributions in different areas of the patient. Regarding radiation protection of the patient for IGRT treatments, the choice of beam energy is not important, whereas the treatment technique has a large influence on the out-of-field dose. If the patient is treated with intensity-modulated beams, VMAT should be used instead of dynamic IMRT in terms of radiation protection of the patient. In general, the developed models for photon and neutron dose equivalent calculation can be used for any patient geometry, tumor location, and linear accelerator.

Excessive applicator radiation leakage for a common therapeutic kilovoltage system

OBJECTIVE:

The objective of this work is to characterise out- of- field leakage radiation emanating from clinical applicators of the WOmed T-200 kilovoltage therapy machine.

METHODS:

To identify points of leakage, radiosensitive film was affixed to the walls and base plate of each applicator. Quantitative assessment of leakage radiation was conducted with a 0.23 cm3 ionisation chamber following the International Electrotechnical Commission standard. Film was also used to illustrate leakage distribution in the patient plane. Angular and energy dependences of the leakage radiation were quantified as well as a two-dimensional leakage profile in the plane parallel to one applicator.

RESULTS:

Leakage was found when the diameter of primary collimator of the kV tube exceeded the external dimension of the applicator wall. In the patient plane all applicators showed similar leakage rates with the leakage distribution dependent upon applicator design. Mean patient plane leakage was 1.37% of central axis air kerma rate, exceeding the 0.5% limit specified in the standard. Leakage was shown to be profoundly energy dependent with maximum leakage of 11.8% for the 200 kV beam, 1.3% for 150 kV and 0.2% for 100 kV. Angular dependence measurements showed a 10.3% change in leakage between the minimum and maximum positions.

CONCLUSION

The combination of shielding thickness, primary collimator design and applicator dimensions permits unwanted radiation to contribute dose outside the treatment field when energies ≥150 kV are used.

ADVANCES IN KNOWLEDGE:

Even carefully designed modern kv therapy systems can exhibit leakage in some areas. Thorough assessment of leakage is needed prior to release for clinical use.

Simultaneous induction of dispersed and clustered DNA lesions compromises DNA damage response in human peripheral blood lymphocytes

Due to its ability to induce DNA damage in a space and time controlled manner, ionising radiation is a unique tool for studying the mechanisms of DNA repair. The biological effectiveness of ionising radiation is related to the ionisation density which is defined by the linear energy transfer (LET). Alpha particles are characterised by high LET, while X-rays by low LET values. An interesting question is how cells react when exposed to a mixed beam of high and low LET radiation. In an earlier study carried out with human peripheral blood lymphocytes (PBL) we could demonstrate that alpha radiation X-rays interact in producing more chromosomal aberrations than expected based on additivity. The aim of the present investigation was to look at the mechanism of the interaction, especially with respect to the question if it is due to an augmented level of initial damage or impaired DNA repair. PBL were exposed to various doses of alpha particles, X-rays and mixed beams. DNA damage and the kinetics of damage repair was quantified by the alkaline comet assay. The levels of phosphorylated, key DNA damage response (DDR) proteins ATM, p53 and DNA-PK were measured by Western blotting and mRNA levels of 6 damage-responsive genes were measured by qPCR. Alpha particles and X-rays interact in inducing DNA damage above the level predicted by assuming additivity and that the repair of damage occurs with a delay. The activation levels of DDR proteins and mRNA levels of the studied genes were highest in cells exposed to mixed beams. The results substantiate the idea that exposure to mixed beams presents a challenge for the cellular DDR system.

Neutron track length estimator for GATE Monte Carlo dose calculation in radiotherapy

The out-of-field dose in radiation therapy is a growing concern in regards to the late side-effects and secondary cancer induction. In high-energy x-ray therapy, the secondary neutrons generated through photonuclear reactions in the accelerator are part of this secondary dose. The neutron dose is currently not estimated by the treatment planning system while it appears to be preponderant for distances greater than 50 cm from the isocenter. Monte Carlo simulation has become the gold standard for accurately calculating the neutron dose under specific treatment conditions but the method is also known for having a slow statistical convergence, which makes it difficult to be used on a clinical basis. The neutron track length estimator, a neutron variance reduction technique inspired by the track length estimator method has thus been developped for the first time in the Monte Carlo code GATE to allow a fast computation of the neutron dose in radiotherapy. The details of its implementation, as well as the comparison of its performances against the analog MC method, are presented here. A gain of time from 15 to 400 can be obtained by our method, with a mean difference in the dose calculation of about 1% in comparison with the analog MC method.

MONTE CARLO SIMULATION OF OUT-OF-FIELD ORGAN DOSES AND CANCER RISK IN TANZANIA FOR RADIATION THERAPY OF UNILATERAL RETINOBLASTOMA USING A 60Co UNIT

The use of 60Co teletherapy unit for the treatment of unilateral retinoblastoma (Rb) patients is a very common procedure in many developing countries including Tanzania. The aim of this study was to estimate organ-specific absorbed doses from an external beam radiation therapy 60Co unit for unilateral Rb and to assess the risks of the patients developing a secondary primary cancer. The absorbed dose estimations were based on a Monte Carlo method and a set of age-dependent computational male phantoms. The estimated doses were used to calculate the secondary cancer risks in out-of-field organs using the Biological Effects of Ionising Radiation VII risk models. The survival information and baseline cancer risks were based on relevant statistics for the Tanzanian population. The resulting out-of-field organ doses data showed that organs which are close to the target volume, such as the brain, salivary glands and thyroid glands, received the highest absorbed dose from scattered photons during the treatment of Rb. It was also found that the resulting photons dose to specific organs depends on the patient's age. Younger patients are more sensitive to radiation and also received higher dose contributions from the treatment head due to a larger part of the body exposed to the photon radiation. In all sites considered, the overall risks associated with radiation-induced secondary cancer were relatively lower than the baseline risks. Thus, the results in this article can help to provide good estimations of radiation-induced secondary cancer after radiation treatment of unilateral Rb using 60Co teletherapy unit in Tanzania and other developing countries.

Live Dynamics of 53BP1 Foci Following Simultaneous Induction of Clustered and Dispersed DNA Damage in U2OS Cells

Cells react differently to clustered and dispersed DNA double strand breaks (DSB). Little is known about the initial reaction to simultaneous induction of DSBs with different complexities. Here, we used live cell microscopy to analyse the behaviour of 53BP1-GFP (green fluorescence protein) foci formation at DSBs induced in U2OS cells by alpha particles, X-rays or mixed beams over a 75 min period post irradiation. X-ray-induced foci rapidly increased and declined over the observation interval. After an initial increase, mixed beam-induced foci remained at a constant level over the observation interval, similarly as alpha-induced foci. The average areas of radiation-induced foci were similar for mixed beams and X-rays, being significantly smaller than those induced by alpha particles. Pixel intensities were highest for mixed beam-induced foci and showed the lowest level of variability over time as compared to foci induced by alphas and X-rays alone. Finally, mixed beam-exposed foci showed the lowest level of mobility as compared to alpha and X-ray exposure. The results suggest paralysation of chromatin around foci containing clustered DNA damage.

Interaction of low and high LET radiation in TK6 cells-mechanistic aspects and significance for radiation protection

Most environmental, occupational and medical exposures to ionising radiation are associated with a simultaneous action of different radiation types. An open question remains whether radiations of different qualities interact with each other to yield effects stronger than expected based on the assumption of additivity. It is possible that DNA damage induced by high linear energy transfer (LET) radiation will lead to an opening of the chromatin structure making the DNA more susceptible to attack by reactive oxygen species (ROS) generated by the low LET radiation. In such case, the effect of mixed beams should be strongly expressed in cells that are sensitive to ROS. The present investigation was carried out to test if cells with an impaired capacity to handle oxidative stress are particularly sensitive to the effect of mixed beams of alpha particles and x-rays. Clonogenic cell survival curves and mutant frequencies were analysed in TK6 wild type (wt) cells and in TK6 cells with a knocked down hMYH glycosylase. The results showed a synergistic effect of mixed beams on clonogenic cell survival of TK6^wt but not TK6^MYH- cells. The frequencies of mutants showed a high degree of interexperimental variability without any indications for synergistic effects of mixed beams. TK6^MYH- cells were generally more tolerant to radiation exposure with respect to clonogenic cell survival but showed a strong increase in mutant frequency. The results demonstrate that exposure of wt cells to a mixed beam of alpha particles and x-rays leads to a detrimental effect which is stronger than expected based on the assumption of additivity. The role of oxidative stress in the reaction of cells to mixed beams remains unclear.

Treatment of breast cancer with simultaneous integrated boost in hybrid plan technique : Influence of flattening filter-free beams

OBJECTIVE

The present study compares in silico treatment plans using hybrid plan technique during hypofractionated radiation of mammary carcinoma with simultaneous integrated boost (SIB). The influence of 6 MV photon radiation in flattening filter free (FFF) mode against the clinical standard flattening filter (FF) mode is to be examined.

PATIENTS AND METHODS

RT planning took place with FF and FFF radiation plans for 10 left-sided breast cancer patients. Hybrid plans were realised with two tangential IMRT fields and one VMAT field. The dose prescription was in line with the guidelines in the ARO-2010-01 study. The dosimetric verification took place with a manufacturer-independent measurement system.

RESULTS

Required dose prescriptions for the planning target volumes (PTV) were achieved for both groups. The average dose values of the ipsi- and contralateral lung and the heart did not differ significantly. The overall average incidental dose to the left anterior descending artery (LAD) of 8.24 ± 3.9 Gy in the FFF group and 9.05 ± 3.7 Gy in the FF group (p < 0.05) were found. The dosimetric verifications corresponded to the clinical requirements. FFF-based RT plans reduced the average treatment time by 17 s/fraction.

CONCLUSION

In comparison to the FF-based hybrid plan technique the FFF mode allows further reduction of the average LAD dose for comparable target volume coverage without adverse low-dose exposure of contralateral structures. The combination of hybrid plan technique and 6 MV photon radiation in the FFF mode is suitable for use with hypofractionated dose schemes. The increased dose rate allows a substantial reduction of treatment time and thus beneficial application of the deep inspiration breath hold technique.

Monte Carlo simulation of secondary radiation exposure from high-energy photon therapy using an anthropomorphic phantom

The development of intensity-modulated radiotherapy treatments delivering large amounts of monitor units (MUs) recently raised concern about higher risks for secondary malignancies. In this study, optimised combinations of several variance reduction techniques (VRTs) have been implemented in order to achieve a high precision in Monte Carlo (MC) radiation transport simulations and the calculation of in- and out-of-field photon and neutron dose-equivalent distributions in an anthropomorphic phantom using MCNPX, v.2.7. The computer model included a Varian Clinac 2100C treatment head and a high-resolution head phantom. By means of the applied VRTs, a relative uncertainty for the photon dose-equivalent distribution of <1 % in-field and 15 % in average over the rest of the phantom could be obtained. Neutron dose equivalent, caused by photonuclear reactions in the linear accelerator components at photon energies of approximately >8 MeV, has been calculated. Relative uncertainty, calculated for each voxel, could be kept below 5 % in average over all voxels of the phantom. Thus, a very detailed neutron dose distribution could be obtained. The achieved precision now allows a far better estimation of both photon and especially neutron doses out-of-field, where neutrons can become the predominant component of secondary radiation.

PHITS simulations of absorbed dose out-of-field and neutron energy spectra for ELEKTA SL25 medical linear accelerator

Monte Carlo (MC) based calculation methods for modeling photon and particle transport, have several potential applications in radiotherapy. An essential requirement for successful radiation therapy is that the discrepancies between dose distributions calculated at the treatment planning stage and those delivered to the patient are minimized. It is also essential to minimize the dose to radiosensitive and critical organs. With MC technique, the dose distributions from both the primary and scattered photons can be calculated. The out-of-field radiation doses are of particular concern when high energy photons are used, since then neutrons are produced both in the accelerator head and inside the patients. Using MC technique, the created photons and particles can be followed and the transport and energy deposition in all the tissues of the patient can be estimated. This is of great importance during pediatric treatments when minimizing the risk for normal healthy tissue, e.g. secondary cancer. The purpose of this work was to evaluate 3D general purpose PHITS MC code efficiency as an alternative approach for photon beam specification. In this study, we developed a model of an ELEKTA SL25 accelerator and used the transport code PHITS for calculating the total absorbed dose and the neutron energy spectra infield and outside the treatment field. This model was validated against measurements performed with bubble detector spectrometers and Boner sphere for 18 MV linacs, including both photons and neutrons. The average absolute difference between the calculated and measured absorbed dose for the out-of-field region was around 11%. Taking into account a simplification for simulated geometry, which does not include any potential scattering materials around, the obtained result is very satisfactorily. A good agreement between the simulated and measured neutron energy spectra was observed while comparing to data found in the literature.

Risk of second cancers according to radiation therapy technique and modality in prostate cancer survivors

PURPOSE

Radiation therapy (RT) techniques for prostate cancer are evolving rapidly, but the impact of these changes on risk of second cancers, which are an uncommon but serious consequence of RT, are uncertain. We conducted a comprehensive assessment of risks of second cancer according to RT technique (>10 MV vs ≤10 MV and 3-dimensional [3D] vs 2D RT) and modality (external beam RT, brachytherapy, and combined modes) in a large cohort of prostate cancer patients.

METHODS AND MATERIALS

The cohort was constructed using the Surveillance Epidemiology and End Results-Medicare database. We included cases of prostate cancer diagnosed in patients 66 to 84 years of age from 1992 to 2004 and followed through 2009. We used Poisson regression analysis to compare rates of second cancer across RT groups with adjustment for age, follow-up, chemotherapy, hormone therapy, and comorbidities. Analyses of second solid cancers were based on the number of 5-year survivors (n=38,733), and analyses of leukemia were based on number of 2-year survivors (n=52,515) to account for the minimum latency period for radiation-related cancer.

RESULTS

During an average of 4.4 years' follow-up among 5-year prostate cancer survivors (2DRT = 5.5 years; 3DRT = 3.9 years; and brachytherapy = 2.7 years), 2933 second solid cancers were diagnosed. There were no significant differences in second solid cancer rates overall between 3DRT and 2DRT patients (relative risk [RR] = 1.00, 95% confidence interval [CI]: 0.91-1.09), but second rectal cancer rates were significantly lower after 3DRT (RR = 0.59, 95% CI: 0.40-0.88). Rates of second solid cancers for higher- and lower-energy RT were similar overall (RR = 0.97, 95% CI: 0.89-1.06), as were rates for site-specific cancers. There were significant reductions in colon cancer and leukemia rates in the first decade after brachytherapy compared to those after external beam RT.

CONCLUSIONS

Advanced treatment planning may have reduced rectal cancer risks in prostate cancer survivors by approximately 3 cases per 1000 after 15 years. Despite concerns about the neutron doses, we did not find evidence that higher energy therapy was associated with increased second cancer risks.

Ambient dose and dose rate measurements in the vicinity of Elekta Precise accelerators for radiation therapy

In radiation therapy, commercially available medical linear accelerators (LINACs) are used. At high primary beam energies in the 10-MeV range, the leakage dose of the accelerator head and the backscatter from the room walls, the air and the patient become more important. Therefore, radiation protection measurements of photon dose rates in the treatment room and in the maze are performed to quantify the radiation field. Since the radiation of the LINACs is usually pulsed with short radiation pulse durations in the microsecond range, there are problems with electronic dose (rate) meters commonly used in radiation protection. In this paper measurements with ionisation chambers are presented and electronic dosemeters are used for testing at selected positions. The measured time-averaged dose rate ranges from a few microsieverts per hour in the maze to some millisieverts per hour in the vicinity of the accelerator head and up to some sieverts per hour in the blanked primary beam and several hundred sieverts per hour in the direct primary beam.

Constituent components of out-of-field scatter dose for 18-MV intensity modulated radiation therapy versus 3-dimensional conformal radiation therapy: a comparison with 6-MV and implications for carcinogenesis

PURPOSE

To characterize and compare the components of out-of-field dose for 18-MV intensity modulated radiation therapy (IMRT) versus 3-dimensional conformal radiation therapy (3D-CRT) and their 6-MV counterparts and consider implications for second cancer induction.

METHODS AND MATERIALS

Comparable plans for each technique/energy were delivered to a water phantom with a sloping wall; under full scatter conditions; with field edge abutting but outside the bath to prevent internal/phantom scatter; and with shielding below the linear accelerator head to attenuate head leakage. Neutron measurements were obtained from published studies.

RESULTS

Eighteen-megavolt IMRT produces 1.7 times more out-of-field scatter than 18-MV 3D-CRT. In absolute terms, however, differences are just approximately 0.1% of central axis dose. Eighteen-megavolt IMRT reduces internal/patient scatter by 13%, but collimator scatter (C) is 2.6 times greater than 18-MV 3D-CRT. Head leakage (L) is minimal. Increased out-of-field photon scatter from 18-MV IMRT carries out-of-field second cancer risks of approximately 0.2% over and above the 0.4% from 18-MV 3D-CRT. Greater photoneutron dose from 18-MV IMRT may result in further maximal, absolute increased risk to peripheral tissue of approximately 1.2% over 18-MV 3D-CRT. Out-of-field photon scatter remains comparable for the same modality irrespective of beam energy. Machine scatter (C+L) from 18 versus 6 MV is 1.2 times higher for IMRT and 1.8 times for 3D-CRT. It is 4 times higher for 6-MV IMRT versus 3D-CRT. Reduction in internal scatter with 18 MV versus 6 MV is 27% for 3D-CRT and 29% for IMRT. Compared with 6-MV 3D-CRT, 18-MV IMRT increases out-of-field second cancer risk by 0.2% from photons and adds 0.28-2.2% from neutrons.

CONCLUSIONS

Out-of-field photon dose seems to be independent of beam energy for both techniques. Eighteen-megavolt IMRT increases out-of-field scatter 1.7-fold over 3D-CRT because of greater collimator scatter despite reducing internal/patient scatter. Out-of-field carcinogenic risk is thus increased (but improved in-field dose conformity may offset this). Potentially increased carcinogenic risk should be weighed against any benefit 18-MV IMRT may provide.

Measurements of the neutron dose equivalent for various radiation qualities, treatment machines and delivery techniques in radiation therapy

In radiation therapy, high energy photon and proton beams cause the production of secondary neutrons. This leads to an unwanted dose contribution, which can be considerable for tissues outside of the target volume regarding the long term health of cancer patients. Due to the high biological effectiveness of neutrons in regards to cancer induction, small neutron doses can be important. This study quantified the neutron doses for different radiation therapy modalities. Most of the reports in the literature used neutron dose measurements free in air or on the surface of phantoms to estimate the amount of neutron dose to the patient. In this study, dose measurements were performed in terms of neutron dose equivalent inside an anthropomorphic phantom. The neutron dose equivalent was determined using track etch detectors as a function of the distance to the isocenter, as well as for radiation sensitive organs. The dose distributions were compared with respect to treatment techniques (3D-conformal, volumetric modulated arc therapy and intensity-modulated radiation therapy for photons; spot scanning and passive scattering for protons), therapy machines (Varian, Elekta and Siemens linear accelerators) and radiation quality (photons and protons). The neutron dose equivalent varied between 0.002 and 3 mSv per treatment gray over all measurements. Only small differences were found when comparing treatment techniques, but substantial differences were observed between the linear accelerator models. The neutron dose equivalent for proton therapy was higher than for photons in general and in particular for double-scattered protons. The overall neutron dose equivalent measured in this study was an order of magnitude lower than the stray dose of a treatment using 6 MV photons, suggesting that the contribution of the secondary neutron dose equivalent to the integral dose of a radiotherapy patient is small.

Gamma-H2AX foci in cells exposed to a mixed beam of X-rays and alpha particles

Background

Little is known about the cellular effects of exposure to mixed beams of high and low linear energy transfer radiation. So far, the effects of combined exposures have mainly been assessed with clonogenic survival or cytogenetic methods, and the results are contradictory. The gamma-H2AX assay has up to now not been applied in this context, and it is a promising tool for investigating the early cellular response to mixed beam irradiation.

Purpose

To determine the dose response and repair kinetics of gamma-H2AX ionizing radiation-induced foci in VH10 human fibroblasts exposed to mixed beams of ²⁴¹Am alpha particles and X-rays.

Results

VH10 human fibroblasts were irradiated with each radiation type individually or both in combination at 37°C. Foci were scored for repair kinetics 0.5, 1, 3 and 24 h after irradiation (one dose per irradiation type), and for dose response at the 1 h time point. The dose response effect of mixed beam was additive, and the relative biological effectiveness for alpha particles (as compared to X-rays) was of 0.76 ± 0.52 for the total number of foci, and 2.54 ± 1.11 for large foci. The repair kinetics for total number of foci in cells exposed to mixed beam irradiation was intermediate to that of cells exposed to alpha particles and X-rays. However, for mixed beam-irradiated cells the frequency and area of large foci were initially lower than predicted and increased during the first 3 hours of repair (while the predicted number and area did not).

Conclusions

The repair kinetics of large foci after mixed beam exposure was significantly different from predicted based on the effect of the single dose components. The formation of large foci was delayed and they did not reach their maximum area until 1 h after irradiation. We hypothesize that the presence of low X-ray-induced damage engages the DNA repair machinery leading to a delayed DNA damage response to the more complex DNA damage induced by alpha particles.

Micronuclei in human peripheral blood lymphocytes exposed to mixed beams of X-rays and alpha particles

The purpose of this study was to analyse the cytogenetic effect of exposing human peripheral blood lymphocytes (PBL) to a mixed beam of alpha particles and X-rays. Whole blood collected from one donor was exposed to different doses of alpha particles ((241)Am), X-rays and a combination of both. All exposures were carried out at 37 °C. Three independent experiments were performed. Micronuclei (MN) in binucleated PBL were scored as the endpoint. Moreover, the size of MN was measured. The results show that exposure of PBL to a mixed beam of high and low linear energy transfer radiation led to significantly higher than expected frequencies of MN. The measurement of MN size did not reveal any differences between the effect of alpha particles and mixed beam. In conclusion, a combined exposure of PBL to alpha particles and X-rays leads to a synergistic effect as measured by the frequency of MN. From the analysis of MN distributions, we conclude that the increase was due to an impaired repair of X-ray-induced DNA damage.

Out-of-field dose measurements in a water phantom using different radiotherapy modalities

This investigation focused on the characterization of the lateral dose fall-off following the irradiation of the target with photons, protons and carbon ions. A water phantom was irradiated with a rectangular field using photons, passively delivered protons as well as scanned protons and carbon ions. The lateral dose profile in the depth of the maximum dose was measured using an ion chamber, a diamond detector and thermoluminescence detectors TLD-600 and TLD-700. The yield of thermal neutrons was estimated for all radiation types while their complete spectrum was measured with bubble detectors during the irradiation with photons. The peripheral dose delivered by photons is significantly higher compared to both protons and carbon ions and exceeds the latter by up to two orders of magnitude at distances greater than 50 mm from the field. The comparison of passive and active delivery techniques for protons shows that, for the chosen rectangular target shape, the former has a sharper penumbra whereas the latter has a lower dose in the far-out-of-field region. When comparing scanning treatments, carbon ions present a sharper dose fall-off than protons close to the target but increasing peripheral dose with increasing incident energy. For photon irradiation, the contribution to the out-of-field dose of photoneutrons appears to be of the same order of magnitude as the scattered primary beam. Charged particles show a clear supremacy over x-rays in achieving a higher dose conformality around the target and in sparing the healthy tissue from unnecessary radiation exposure. The out-of-field dose for x-rays increases with increasing beam energy because of the production of biologically harmful neutrons.

Internal scatter, the unavoidable major component of the peripheral dose in photon-beam radiotherapy

In clinical photon beams, the dose outside the geometrical field limits is produced by photons originating from (i) head leakage, (ii) scattering at the beam collimators and the flattening filter (head scatter) and (iii) scattering from the directly irradiated region of the patient or phantom (internal scatter). While the first two components can be modified, e.g. by reinforcement of shielding components or by re-modeling the filter system, internal scatter remains an unavoidable contributor to the peripheral dose. Its relative magnitude compared to the other components, its numerical variation with beam energy, field size and off-axis distance as well as its spectral distribution are evaluated in this study. We applied a detailed Monte Carlo (MC) model of our 6/15 MV Siemens Primus linear accelerator beam head, provided with ideal head leakage shielding conditions (multi-leaf collimator without gaps) to assess the head scatter contribution. Experimental values obtained under real shielding conditions were used to evaluate the head leakage contribution. It was found that the MC-computed internal scatter doses agree with the results of our previous measurements, that internal scatter is the major contributor to the peripheral dose in the near periphery while head leakage prevails in the far periphery, and that the lateral decline of the internal scatter dose can be represented by the sum of two exponentials, with an asymptotic tenth value of 18 to 19 cm. Internal scatter peripheral doses from various elementary beams are additive, so that their sum increases approximately in proportion with field size. The ratio between normalized internal scatter doses at 6 and 15 MV is approximately 2:1. The energy fluence spectra of the internal scatter component at all points of interest outside the field have peaks near 500 keV. The fact that the energy-shifted internal scatter constitutes the major contributor to the dose in the near periphery has a general bearing for dosimetry, i.e. for energy-dependent detector responses and dose conversion factors, for the relative biological effectiveness and for second primary malignancy risk estimates in the peripheral region.