Physics-aspects of dose accuracy in high dose rate (HDR) brachytherapy: source dosimetry, treatment planning, equipment performance and in vivo verification techniques

Quantitative study on dose distribution of Freiburg flap for keloid high-dose-rate brachytherapy based on MatriXX

PURPOSE

To quantify the dose distribution effect of insufficient scattering conditions in keloid HDR brachytherapy with Freiburg fFlap (FF) applicator.

MATERIALS AND METHODS

A phantom composed of FF applicator, MatriXX and solid water slices was designed and scanned for treatment planning. Bolus with different thicknesses were covered to offer different scatter conditions. Planar dose distributions were measured by MatriXX. The maximum value (Max), average value (Avg) and γ passing rate (3 mm/3%) were evaluated by the software MyQA Platform.

RESULTS

The maximum and average doses measured by MatriXX were lower than the calculated values. The difference increased as field size decreased. The Max value, found at 0.86 cm level in the two tube case, was -20.0%, and the avg value was -11.9%. All the γ values were less than 95%. This difference gradually decreased with increasing bolus thickness and the γ values were significantly improved.

CONCLUSION

MatriXX could be used for dose verification of HDR brachytherapy with an FF applicator. When the FF applicator was applied for keloid, insufficient scattering conditions would cause an insufficient target dose. This difference could be reduced by covering the bolus with different thicknesses on the applicator. The smaller the field, the thicker the bolus required.

Dose perturbation effects by metal hip prosthesis in gynaecological 192Ir HDR brachytherapy

The present study was conducted to elucidate the effects of hip prostheses in ¹⁹²Ir HDR brachytherapy and determine dose uncertainties introduced by the treatment planning. A gynaecological phantom irradiated using Nucletron ¹⁹²Ir microSelectron HDR source was modeled using MCNP5 code. Three hip materials considered in this study were water, bone, and metal prosthesis. According to the obtained results, a dose perturbation was observed within the medium with a higher atomic number, which reduced the dose to the nearby region.

Validation of automated post-adjustments of HDR prostate brachytherapy treatment plans by quantitative measures and oncologist observer study

PURPOSE

The aim was to evaluate a postprocessing optimization algorithm's ability to improve the spatial properties of a clinical treatment plan while preserving the target coverage and the dose to the organs at risk. The goal was to obtain a more homogenous treatment plan, minimizing the need for manual adjustments after inverse treatment planning.

MATERIALS AND METHODS

The study included 25 previously treated prostate cancer patients. The treatment plans were evaluated on dose-volume histogram parameters established clinical and quantitative measures of the high dose volumes. The volumes of the four largest hot spots were compared and complemented with a human observer study with visual grading by eight oncologists. Statistical analysis was done using ordinal logistic regression. Weighted kappa and Fleiss' kappa were used to evaluate intra- and interobserver reliability.

RESULTS

The quantitative analysis showed that there was no change in planning target volume (PTV) coverage and dose to the rectum. There were significant improvements for the adjusted treatment plan in: V150% and V200% for PTV, dose to urethra, conformal index, and dose nonhomogeneity ratio. The three largest hot spots for the adjusted treatment plan were significantly smaller compared to the clinical treatment plan. The observers preferred the adjusted treatment plan in 132 cases and the clinical in 83 cases. The observers preferred the adjusted treatment plan on homogeneity and organs at risk but preferred the clinical plan on PTV coverage.

CONCLUSIONS

Quantitative analysis showed that the postadjustment optimization tool could improve the spatial properties of the treatment plans while maintaining the target coverage.

A review article on the dosimetry in intraluminal HDR brachytherapy of lung carcinoma

Lung cancer is one of the most common cancers in the world. Intraluminal brachytherapy (BT) is one of the most adopted treatment modalities for lung malignancies with Ir-192 source in radiotherapy. In intraluminal BT, treatment delivery is required to be very accurate and precise with respect to the plan created in the treatment planning system (TPS). The BT dosimetry is necessary for better treatment outcomes. Therefore in this review article, some relevant studies were identified and analyzed for dosimetric outcomes in intraluminal BT in lung malignancies. The dosimetry in BT for plan verification is not presently in practice, which needs to be performed to check the variation between the planned and measured doses. The necessary dosimetric work done by the various researchers in intraluminal BT such as the Monte Carlo CYLTRAN code was used to calculate and measure the dose rate in any medium. Anthropomorphic phantom was used to measure doses at some distance from the source with Thermo luminescence dosimeters (TLDs). The dosimetric influence of air passage in the bronchus was evaluated with the GEANT4 Monte Carlo method. A pinpoint chamber was used to measure and quantify the impact of inhomogeneity in wax phantom for the Ir-192 source. The Gafchromic films and Monte Carlo methods were used to find the phantom and heterogeneities, which were found to underestimate the dose for the lungs and overestimated for the bones in TPS. The exact tool to quantify the variation in planned and delivered doses should be cost-effective and easy to use possibly with tissue equivalent phantoms and Gafchromic films in lung malignancies treatment.

Validation of accordance of ArcCHECK diode detector output with Monte Carlo simulation in brachytherapy

There are several accepted methods to verify External Beam Radiation Therapy (EBRT) treatment plans, but there is no standard way to check the quality of a brachytherapy treatment plan.

PURPOSE

This feasibility study assesses whether the ArcCHECK EBRT radiation detector can also be used to verify Treatment Planning System software quality check procedures for brachytherapy.

METHODS AND MATERIALS

ArcCHECK is a three-dimensional matrix of 1386 semiconductor diodes, arranged spirally around an internal cylindrical space that is 32 cm long and 15 cm in diameter. The detector makes it possible to reproduce the distribution of sources in a planned EBRT procedure (energy range 6-22 MeV) using an appropriate phantom. Detector responses are displayed as a two-dimensional dose distribution map on the diode surface. In this pilot brachytherapy study, we determined values that characterized the output of the detectors to a simulated Ir-192 radiation source with an energy range of approximately 9-1378 keV, and compared this to the actual signal recorded by an ArcCHECK detector. Experimental treatment plan measurement was performed using a standard Elekta micro-Selectron-v2 unit equipped with an iridium-192 source. To avoid unit inconsistencies, the signal from each of the diodes and the simulation results were normalized to the maximum value, with similar statistical parameters.

RESULTS

The difference between diode indications in the simulation and the actual measurement was analyzed statistically to show the degree of general inconsistency between them. The average difference for diode pairs here is equal 1,07%, with standard deviation 3, 95%.

CONCLUSION

The results obtained represent the first quantitative evidence of potential usefulness of the ArcCHECK detector in brachytherapy Treatment Planning System software QC verification.

Borosilicate glass 60Co high dose rate brachytherapy thermoluminescence dosimetry

Brachytherapy is commonly used in treatment of cervical, prostate, breast and skin cancers, also for oral cancers, typically via the application of sealed radioactive sources that are inserted within or alongside the area to be treated. A particular aim of the various brachytherapy techniques is to accurately transfer to the targeted tumour the largest possible dose, at the same time minimizing dose to the surrounding normal tissue, including organs at risk. The dose fall-off with distance from the sources is steep, the dose gradient representing a prime factor in determining the dose distribution, also representing a challenge to the conduct of measurements around sources. Amorphous borosilicate glass (B₂O₃) in the form of microscope cover slips is recognized to offer a practicable system for such thermoluminescence dosimetry (TLD), providing for high-spatial resolution (down to < 1 mm), wide dynamic dose range, good reproducibility and reusability, minimal fading, resistance to water and low cost. Herein, investigation is made of the proposed dosimeter using a 1.25 MeV High Dose Rate (HDR) ⁶⁰Co brachytherapy source, characterizing dose response, sensitivity, linearity index and fading. Analysis of the TL glow curves were obtained using the T_max-T_stop method and first-order kinetics using GlowFit software, detailing the frequency factors and activation energy.

Photonic crystal fibre as a potential medium for radiotherapy dosimetry

Present study concerns the key thermoluminescence (TL) properties of photonic crystal fibres (PCFs), seeking development of alternatively structured TL materials that are able to offer a advantages over existing passive dosimeters. In terms of their internal structure and light guiding properties the PCFs, collapsed and structured, differ significantly from that of conventional optical fibres. To investigate the dosimetric parameters of the PCFs use was made of a linear accelerator producing a 6 MV photon beam, delivering doses ranging from 0.5 Gy to 8 Gy. The parameters studied included TL response, linearity index, glow curves, relative sensitivity and TL signal fading, the results being compared against those obtained using TLD-100 chips. At 4 Gy photon dose the Ge-doped collapsed PCFs were found to provide a response 27 × that of structured PCF, also giving a TL yield similar to that of standard TLD-100 chips. Over post-irradiation periods of 15 and 30 days collapsed PCF TL signal fading were 8% and 17% respectively, with corresponding values of 37% and 64% for the structured PCF. Trapping parameters including the order of kinetics (b), activation energy (E) and frequency factor (s^-1) were assessed with Chen's peak shape method. Lifetime of trapping centre was found to be (2.36 E+03) s and (9.03 E +01) s regarding the collapsed and structured PCF respectively with 6 Gy of photon beam. For the Ge-doped collapsed PCF, the high TL yield, sensitivity and low fading provide the basis of a highly promising system of TLD for radiotherapy applications.

Evaluation of exit skin dose for intra-cavitary brachytherapy treatments by the BEBIG 60Co machine using thermoluminescent dosimeters

Purpose:

This study aims to evaluate the application of the exit skin dose (ESD) in verifying the accuracy of intra-cavitary brachytherapy treatments performed by the BEBIG 60Co machine using thermoluminescent dosimeters (TLDs).

Materials and methods:

Eleven patients who were treated for gynaecological (GYN) malignancy by high-dose-rate (HDR) brachytherapy machine have been considered in this study. A combination of tandem, cylinder and interstitial needles was applied for eight patients while tandem ovoid (TO) applicators were used for the rest (three patients). In order to measure ESD, thermoluminescent dosimetry was performed for each patient. TLDs were placed precisely on the patient’s skin along her symphysis pubis bone (anterior) and left (L)/right (R) sides of her pelvic. Positioning of the dosimeter was accurately determined using fiducial markers in computed tomography (CT) scan imaging, prior to the treatment. Finally, a comparison was made between the calculated dose from the treatment planning system (TPS) and the dose measured by TLDs.

Results:

About 90% of all cases showed a good agreement (while considering TLD uncertainty ∼5·5%) between TPS dose calculations and TLD measurements. The measured mean values of ESD received to anterior, left and right positions were 56·72, 12·18 and 12·82 cGy, respectively. For three patients, differences up to 11·9% were detected.

Conclusion:

To conclude, ESD measurement method can be a suitable practical approach for verifying the accuracy of GYN HDR treatment delivery.

An audit of high dose-rate prostate brachytherapy treatment planning at six Swedish clinics

Purpose

High dose-rate prostate brachytherapy has been implemented in Sweden in the late 1980s and early 1990s in six clinics using the same schedule: 20 Gy in two fractions combined with 50 Gy in 25 fractions with external beam radiation therapy. Thirty years have passed and during these years, various aspects of the treatment process have developed, such as ultrasound-guided imaging and treatment planning system. An audit was conducted, including a questionnaire and treatment planning, which aimed to gather knowledge about treatment planning methods in Swedish clinics.

Material and methods

A questionnaire and a treatment planning case (non-anatomical images) were sent to six Swedish clinics, in which high-dose-rate prostate brachytherapy is performed. Treatment plans were compared using dosimetric indices and equivalent 2 Gy doses (EQD₂). Treatment planning system report was used to compare dwell positions and dwell times.

Results

For all the clinics, the planning aim for the target was 10.0 Gy, but the volume to receive the dose differed from 95% to 100%. Dose constraints for organs at risk varied with up to 2 Gy. The dose to 90% of target volume ranged from 10.0 Gy to 11.1 Gy, equivalent to 26.0 Gy EQD₂ and 31.3 Gy EQD₂, respectively. Dose non-homogeneity ratio differed from 0.18 to 0.32 for clinical target volume (CTV) in treatment plans and conformity index ranged from 0.52 to 0.59 for CTV.

Conclusions

Dose constraints for the organs at risk are showing a larger variation than that reflected in compared treatments plans. In all treatment plans in our audit, at least 10 Gy was administered giving a total treatment of 102 Gy EQD₂, which is in the upper part of the prescription doses published in the GEC/ESTRO recommendations.

Positional and angular tracking of HDR 192 Ir source for brachytherapy quality assurance using radiochromic film dosimetry

PURPOSE

To quantify and verify the dosimetric impact of high-dose rate (HDR) source positional uncertainty in brachytherapy, and to introduce a model for three-dimensional (3D) position tracking of the HDR source based on a two-dimensional (2D) measurement. This model has been utilized for the development of a comprehensive source quality assurance (QA) method using radiochromic film (RCF) dosimetry including assessment of different digitization uncertainties.

METHODS

An algorithm was developed and verified to generate 2D dose maps of the mHDR-V2 ¹⁹² Ir source (Elekta, Veenendaal, Netherlands) based on the AAPM TG-43 formalism. The limits of the dosimetric error associated with source (0.9 mm diameter) positional uncertainty were evaluated and experimentally verified with EBT3 film measurements for 6F (2.0 mm diameter) and 4F (1.3 mm diameter) size catheters at the surface (4F, 6F) and 10 mm further (4F only). To quantify this uncertainty, a source tracking model was developed to incorporate the unique geometric features of all isodose lines (IDLs) within any given 2D dose map away from the source. The tracking model normalized the dose map to its maximum, then quantified the IDLs using blob analysis based on features such as area, perimeter, weighted centroid, elliptic orientation, and circularity. The Pearson correlation coefficients (PCCs) between these features and source coordinates (x, y, z, θ_y , θ_z ) were calculated. To experimentally verify the accuracy of the tracking model, EBT3 film pieces were positioned within a Solid Water® (SW) phantom above and below the source and they were exposed simultaneously.

RESULTS

The maximum measured dosimetric variations on the 6F and 4F catheter surfaces were 39.8% and 36.1%, respectively. At 10 mm further, the variation reduced to 2.6% for the 4F catheter which is in agreement with the calculations. The source center (x, y) was strongly correlated with the low IDL-weighted centroid (PCC = 0.99), while the distance to source (z) was correlated with the IDL areas (PCC = 0.96) and perimeters (PCC = 0.99). The source orientation θ_y was correlated with the difference between high and low IDL-weighted centroids (PCC = 0.98), while θ_z was correlated with the elliptic orientation of the 60-90% IDLs (PCC = 0.97) for a maximum distance of z = 5 mm. Beyond 5 mm, IDL circularity was significant, therefore limiting the determination of θ_z (PCC ≤ 0.48). The measured positional errors from the film sets above and below the source indicated a source position at the bottom of the catheter (-0.24 ± 0.07 mm).

CONCLUSIONS

Isodose line features of a 2D dose map away from the HDR source can reveal its spatial coordinates. RCF was shown to be a suitable dosimeter for source tracking and dosimetry. This technique offers a novel source QA method and has the potential to be used for QA of commercial and customized applicators.

Is adaptive treatment planning in multi-catheter interstitial breast brachytherapy necessary?

PURPOSE

For 55 patients treated with interstitial multi-catheter breast brachytherapy the need for adaptive treatment planning was assessed.

METHODS AND MATERIALS

For all patients a treatment planning computed tomography (CT) and a follow-up CT were acquired and used for the retrospective evaluation. Keeping dwell time and dwell positions constant, the treatment plan assessed directly after catheter implantation was compared to the situation 48 h after implantation. Both manual catheter reconstructions, based on the planning and follow-up CT, were rigid registered to each other and the resulting deviations analyzed, like the difference between corresponding dwell positions (ΔDP) or the discrete Fréchet distance. Further, the dosimetric changes, e.g., coverage index (ΔCI), conformal index (ΔCOIN) and dose non-uniformity ratio (ΔDNR) were considered for a deformed planning target volume (PTV) and the rigid warped PTV structure. The PTV was deformed according to the vector field estimated between the two acquired CTs.

RESULTS

Over all patients with rigid aligned CTs a mean ΔDP, ΔCI, ΔCOIN and ΔDNR were determined to 2.41 ± 1.73 mm, 3.10 ± 3.17%, 0.009 ± 0.007 and 0.036 ± 0.040, respectively. Considering the deformed PTV ΔCI was estimated to 5.05 ± 4.14%.

CONCLUSION

In conclusion, in 4% of the cases re-planning would have been beneficial to ensure the planned dose delivery. Large PTV changes or large DP deviations were found to be the main reasons for dosimetric variations.

An automated dose verification software for brachytherapy

Purpose

To report an implementation method and the results of independent brachytherapy dose verification software (DVS).

Material and methods

The DVS was developed based on Visual C++ and adopted a modular structure design. The DICOM RT files exported from a treatment planning system (TPS) were automatically loaded into the DVS. The DVS used the TG-43 formalism for dose calculation. A total of 15 cervical cancer patients who underwent brachytherapy were retrospectively selected to test the DVS. Dosimetric parameters and γ analysis (0.1 cm, 5%) were used to evaluate the dose differences between the DVS and the TPS.

Results

Compared with the TPS dose, the γ pass rates of the dose calculated by the DVS were higher than 98%. For the clinical target volume (CTV), the dosimetric differences were less than 0.63% for D_90% and D_100%. For the bladder, rectum, and sigmoid, the agreement of D_0.1cc, D_1cc, and D_2cc were within a 0.78% level.

Conclusions

With minimal human-computer interactions, the DVS can verify the accuracy of doses calculated by the TPS.

Quality Assurance Procedures based on Dosimetric, Gamma Analysis as a Fast Reliable Tool for Commissioning Brachytherapy Treatment Planning Systems

Background

Fast and easily repeatable methods for commissioning procedures for brachytherapy (BT) treatment planning systems (TPS) are needed. Radiochromic film dosimetry with gamma analysis is widely used in external beam quality assurance (QA) procedures and planar film dosimetry is also increasingly used for verification of the dose distribution in BT applications. Using the gamma analysis method for comparing calculated and measured dose data could be used for commissioning procedures of the newly developed TG-186 and MBDCA calculation algorithms. The aim of this study was dosimetric verification of the calculation algorithm used in TPS when the CT/MRI ring applicator is used.

Materials and methods

Ring applicators with 26 and 30 mm diameters and a 60 mm intra-uterine tube with 60° angle were used for verification. Gafchromic® EBT films were used as dosimetric media. Dose grids, corresponding to each plane (dosimetric film location), were exported from the TPS as a raw data. Gafchromic® films were digitized after irradiation. gamma analysis of the data were performed using the OMNI Pro I’mRT® system, as recommended by the AAPM TG-119 rapport criterion for gamma analysis of 3%, 3 mm and a level of 95%.

Results

For the 26 mm and 30 mm rings, the average gamma ranged, respectively, from 0.1 to 0.44 and from 0.1 to 0.27. In both cases, 99% of the measured points corresponded with the calculated data.

Conclusions

This analysis showed excellent agreement between the dose distribution calculated with the TPS and the doses measured by Gafchromic films. This finding confirms the viability of using film dosimetry in BT.

Brachytherapy patient safety events in an academic radiation medicine program

PURPOSE

To describe the incidence and type of brachytherapy patient safety events over 10 years in an academic brachytherapy program.

METHODS AND MATERIALS

Brachytherapy patient safety events reported between January 2007 and August 2016 were retrieved from the incident reporting system and reclassified using the recently developed National System for Incident Reporting in Radiation Treatment taxonomy. A multi-incident analysis was conducted to identify common themes and key learning points.

RESULTS

During the study period, 3095 patients received 4967 brachytherapy fractions. An additional 179 patients had MR-guided prostate biopsies without treatment as part of an interventional research program. A total of 94 brachytherapy- or biopsy-related safety events (incidents, near misses, or programmatic hazards) were identified, corresponding to a rate of 2.8% of brachytherapy patients, 1.7% of brachytherapy fractions, and 3.4% of patients undergoing MR-guided prostate biopsy. Fifty-one (54%) events were classified as actual incidents, 29 (31%) as near misses, and 14 (15%) as programmatic hazards. Two events were associated with moderate acute medical harm or dosimetric severity, and two were associated with high dosimetric severity. Multi-incident analysis identified five high-risk activities or clinical scenarios as follows: (1) uncommon, low-volume or newly implemented brachytherapy procedures, (2) real-time MR-guided brachytherapy or biopsy procedures, (3) use of in-house devices or software, (4) manual data entry, and (5) patient scheduling and handoffs.

CONCLUSIONS

Brachytherapy is a safe treatment and associated with a low rate of patient safety events. Effective incident management is a key element of continuous quality improvement and patient safety in brachytherapy.

In vivo dosimetry in gynecological applications-A feasibility study

PURPOSE

To investigate the feasibility of in vivo dosimetry using microMOSFET dosimeters in patients treated with brachytherapy using two types of gynecological applicators.

METHODS AND MATERIALS

In this study, a microMOSFET was placed in an empty needle of an Utrecht Interstitial Fletcher applicator or MUPIT (Martinez Universal Perineal Interstitial Template) applicator for independent verification of treatment delivery. Measurements were performed in 10 patients, with one to three microMOSFETs per applicator and repeated for one to four fractions, resulting in 50 in vivo measurements. Phantom measurements were used to determine characteristics of the microMOSFETs.

RESULTS

Phantom measurements showed a linear relationship between dose and microMOSFET threshold voltage, and a calibration coefficient (mV/cGy) was determined. Reproducibility of repeated 50 cGy irradiations was 2% (1 standard deviation). Distance and angle dependencies were measured and correction factors were determined. Subsequently, three microMOSFETs were placed in a phantom to measure a validation plan. The difference between predicted and measured dose was less than the measurement uncertainty (±9%, 2 standard deviations). In vivo measurements were corrected for distance and angle dependencies. Differences between predicted and measured dose in the patients were smaller than the measurement uncertainty for the majority of the measurements.

CONCLUSIONS

In vivo dosimetry using microMOSFETs in MUPIT and Utrecht Interstitial Fletcher applicators has proved to be feasible. Reimaging should be performed after detection of differences larger than 10% between predicted and measured dose to verify the applicator configuration. Movement of the applicator relative to the target or organs at risk is undetectable with this method.

Iridium-Knife: Another knife in radiation oncology

PURPOSE

Intratarget dose escalation with superior conformity is a defining feature of three-dimensional (3D) iridium-192 (¹⁹²Ir) high-dose-rate (HDR) brachytherapy (BRT). In this study, we analyzed the dosimetric characteristics of interstitial ¹⁹²Ir HDR BRT for intrathoracic and cerebral malignancies. We examined the dose gradient sharpness of HDR BRT compared with that of linear accelerator-based stereotactic radiosurgery and stereotactic body radiation therapy, usually called X-Knife, to demonstrate that it may as well be called a Knife.

METHODS AND MATERIALS

Treatment plans for 10 patients with recurrent glioblastoma multiforme or intrathoracic malignancies, five of each entity, treated with X-Knife (stereotactic radiosurgery for glioblastoma multiforme and stereotactic body radiation therapy for intrathoracic malignancies) were replanned for simulated HDR BRT. For 3D BRT planning, we used identical structure sets and dose prescription as for the X-Knife planning. The indices for qualitative treatment plan analysis encompassed planning target volume coverage, conformity, dose falloff gradient, and the maximum dose-volume limits to different organs at risk.

RESULTS

Volume coverage in HDR plans was comparable to that calculated for X-Knife plans with no statistically significant difference in terms of conformity. The dose falloff gradient-sharpness-of the HDR plans was considerably steeper compared with the X-Knife plans.

CONCLUSIONS

Both 3D ¹⁹²Ir HDR BRT and X-Knife are effective means for intratarget dose escalation with HDR BRT achieving at least equal conformity and a steeper dose falloff at the target volume margin. In this sense, it can reasonably be argued that 3D ¹⁹²Ir HDR BRT deserves also to be called a Knife, namely Iridium-Knife.

3D image-based adapted high-dose-rate brachytherapy in cervical cancer with and without interstitial needles: measurement of applicator shift between imaging and dose delivery

Purpose

Using 3D image-guided adaptive brachytherapy for cervical cancer treatment, it often means that patients are transported and moved during the treatment procedure. The purpose of this study was to determine the intra-fractional longitudinal applicator shift in relation to the high risk clinical target volume (HR-CTV) by comparing geometries at imaging and dose delivery for patients with and without needles.

Material and methods

Measurements were performed in 33 patients (71 fractions), where 25 fractions were without and 46 were with interstitial needles. Gold markers were placed in the lower part of the cervix as a surrogate for HR-CTV, enabling distance measurements between HR-CTV and the ring applicator. Shifts of the applicator relative to the markers were determined using planning computed tomography (CT) images used for planning, and the radiographs obtained at dose delivery. Differences in the physical D₉₀ for HR-CTV due to applicator shifts were simulated individually in the treatment planning system to provide the relative dose variation.

Results

The maximum distances of the applicator shifts, in relation to the markers, were 3.6 mm (caudal), and –2.5 mm (cranial). There was a significant displacement of –0.7 mm (SD = 0.9 mm) without needles, while with needles there was no significant shift. The relative dose variation showed a significant increase in D₉₀ HR-CTV of 1.6% (SD = 2.6%) when not using needles, and no significant dose variation was found when using needles.

Conclusions

The results from this study showed that there was a small longitudinal displacement of the ring applicator and a significant difference in displacement between using interstitial needles or not.

Film based verification of calculation algorithms used for brachytherapy planning-getting ready for upcoming challenges of MBDCA

Purpose

Well-known defect of TG-43 based algorithms used in brachytherapy is a lack of information about interaction cross-sections, which are determined not only by electron density but also by atomic number. TG-186 recommendations with using of MBDCA (model-based dose calculation algorithm), accurate tissues segmentation, and the structure's elemental composition continue to create difficulties in brachytherapy dosimetry. For the clinical use of new algorithms, it is necessary to introduce reliable and repeatable methods of treatment planning systems (TPS) verification. The aim of this study is the verification of calculation algorithm used in TPS for shielded vaginal applicators as well as developing verification procedures for current and further use, based on the film dosimetry method.

Material and methods

Calibration data was collected by separately irradiating 14 sheets of Gafchromic^® EBT films with the doses from 0.25 Gy to 8.0 Gy using HDR ¹⁹²Ir source. Standard vaginal cylinders of three diameters were used in the water phantom. Measurements were performed without any shields and with three shields combination. Gamma analyses were performed using the VeriSoft^® package.

Results

Calibration curve was determined as third-degree polynomial type. For all used diameters of unshielded cylinder and for all shields combinations, Gamma analysis were performed and showed that over 90% of analyzed points meets Gamma criteria (3%, 3 mm).

Conclusions

Gamma analysis showed good agreement between dose distributions calculated using TPS and measured by Gafchromic films, thus showing the viability of using film dosimetry in brachytherapy.

To determine the source dwell positions of HDR brachytherapy using 2D 729 ion chamber array

The purpose of this study was to determine the dwell position of a high-dose-rate (HDR) brachytherapy Ir-192 source using a PTW Seven29 2D detector array. A Nucletron Microselectron HDR device and 2D array ionisation chamber, equipped with 729 ionisation chambers uniformly arranged in a 27×27 matrix with an active array area of 27×27 cm2, were used for this study. Different dwell positions were assigned in the HDR machine. Rigid interstitial needles and a vaginal applicator were positioned on the 2D array, which was then exposed according to the programmed dwell positions. Subsequently, the positional accuracy of the source position was analysed. This process was repeated for different dwell positions. The results were analysed using an in-house-developed Excel programme. Different random dwell position checks as well as dwell position measurements were performed using a radiochromic film. The dwell positions measured by the 2D array were found to be in good agreement with those measured by the film. The standard deviations between the doses obtained from the different dwell positions were 0·191828, 0·329973, 0·370632 and 0·779939, whereas the corresponding standard deviations of the doses at the vaginal cylinder were 0·60303, 0·242808, 0·242808 and 0·065309. When the planned and measured dwell positions were plotted, a linear relationship was obtained.

The impact of activating source dwell positions outside the CTV on the dose to treated normal tissue volumes in TRUS guided 3D conformal interstitial HDR brachytherapy of prostate cancer

Purpose

Dose coverage is crucial for successful treatment in mono-brachytherapy. Since few and very high dose fractions are used, there is an important balance between dwell positioning outside the clinical target volume (CTV) and possible damage on adjacent normal tissue. The purpose of this study was to evaluate the possibility of having dwell positions close to the CTV surface, while maintaining an acceptable dose distribution, and to investigate the robustness in terms of known geometrical uncertainties of the implant.

Material and methods

This study included 37 patients who had received brachytherapy for prostate cancer as a monotherapy with the following schedules: 2 × 14 Gy or 3 × 11 Gy, each fraction separated by two weeks. The source dwell positions were activated 5 mm outside CTV. New optimizations were simulated for dwell positions at 3, 2, 1, and 0 mm. Inverse and graphical optimization were applied according to the relative dose constraints: V_{100 CTV} ≥ 97%, D_{max, urethra} ≤ 110%, and D_{10 rectal mucosa} ≤ 65%. The V_{100, normal tissue} outside CTV was used to evaluate dose variations caused by different dwell positions. Prostate geometries and dose distributions for the different dwell positions outside the CTV were used to investigate the impact on the CTV dose distribution due to geometrical uncertainties.

Results

Both V_{100, CTV}, and V_{100, normal tissue} decreased, 98.6% to 92.2%, and 17 cm³ to 9.0 cm³, for dwell activation from 5 mm to 0 mm. The evaluation of both simulated longitudinal geometrical uncertainties and different source dwell activations implied that V_{100, CTV} ranged from 98.6% to 86.3%.

Conclusions

It is possible to reduce the V_{100, normal tissue} by decreasing the source dwell positions outside the CTV from 5 to 3 mm, while maintaining dose constraints. In combination with the estimated geometrical uncertainties, however, the source dwell positions need to be 5 mm from the surface in order to maintain a robust implant.

Evaluation and implementation of triple-channel radiochromic film dosimetry in brachytherapy

The measurement of dose distributions in clinical brachytherapy, for the purpose of quality control, commissioning or dosimetric audit, is challenging and requires development. Radiochromic film dosimetry with a commercial flatbed scanner may be suitable, but careful methodologies are required to control various sources of uncertainty. Triple‐channel dosimetry has recently been utilized in external beam radiotherapy to improve the accuracy of film dosimetry, but its use in brachytherapy, with characteristic high maximum doses, steep dose gradients, and small scales, has been less well researched. We investigate the use of advanced film dosimetry techniques for brachytherapy dosimetry, evaluating uncertainties and assessing the mitigation afforded by triple‐channel dosimetry. We present results on postirradiation film darkening, lateral scanner effect, film surface perturbation, film active layer thickness, film curling, and examples of the measurement of clinical brachytherapy dose distributions. The lateral scanner effect in brachytherapy film dosimetry can be very significant, up to 23% dose increase at 14 Gy, at ± 9 cm lateral from the scanner axis for simple single‐channel dosimetry. Triple‐channel dosimetry mitigates the effect, but still limits the useable width of a typical scanner to less than 8 cm at high dose levels to give dose uncertainty to within 1%. Triple‐channel dosimetry separates dose and dose‐independent signal components, and effectively removes disturbances caused by film thickness variation and surface perturbations in the examples considered in this work. The use of reference dose films scanned simultaneously with brachytherapy test films is recommended to account for scanner variations from calibration conditions. Postirradiation darkening, which is a continual logarithmic function with time, must be taken into account between the reference and test films. Finally, films must be flat when scanned to avoid the Callier‐like effects and to provide reliable dosimetric results. We have demonstrated that radiochromic film dosimetry with GAFCHROMIC EBT3 film and a commercial flatbed scanner is a viable method for brachytherapy dose distribution measurement, and uncertainties may be reduced with triple‐channel dosimetry and specific film scan and evaluation methodologies.

PACS numbers: 87.55.Qr, 87.56.bg, 87.55.km

An investigation of a PRESAGE® in vivo dosimeter for brachytherapy

Determining accurate in vivo dosimetry in brachytherapy treatment with high dose gradients is challenging. Here we introduce, investigate, and characterize a novel in vivo dosimeter and readout technique with the potential to address this problem. A cylindrical (4 mm × 20 mm) tissue equivalent radiochromic dosimeter PRESAGE® in vivo (PRESAGE®-IV) is investigated. Two readout methods of the radiation induced change in optical density (OD) were investigated: (i) volume-averaged readout by spectrophotometer, and (ii) a line profile readout by 2D projection imaging utilizing a high-resolution (50 micron) telecentric optical system. Method (i) is considered the gold standard when applied to PRESAGE® in optical cuvettes. The feasibility of both methods was evaluated by comparison to standard measurements on PRESAGE® in optical cuvettes via spectrophotometer. An end-to-end feasibility study was performed by a side-by-side comparison with TLDs in an (192)Ir HDR delivery. 7 and 8 Gy was delivered to PRESAGE®-IV and TLDs attached to the surface of a vaginal cylinder. Known geometry enabled direct comparison of measured dose with a commissioned treatment planning system. A high-resolution readout study under a steep dose gradient region showed 98.9% (5%/1 mm) agreement between PRESAGE®-IV and Gafchromic® EBT2 Film. Spectrometer measurements exhibited a linear dose response between 0-15 Gy with sensitivity of 0.0133 ± 0.0007 ΔOD/(Gy ⋅ cm) at the 95% confidence interval. Method (ii) yielded a linear response with sensitivity of 0.0132 ± 0.0006 (ΔOD/Gy), within 2% of method (i). Method (i) has poor spatial resolution due to volume averaging. Method (ii) has higher resolution (∼1 mm) without loss of sensitivity or increased noise. Both readout methods are shown to be feasible. The end-to-end comparison revealed a 2.5% agreement between PRESAGE®-IV and treatment plan in regions of uniform high dose. PRESAGE®-IV shows promise for in vivo dose verification, although improved sensitivity would be desirable. Advantages include high-resolution, convenience and fast, low-cost readout.

Dosimetric audit in brachytherapy

Dosimetric audit is required for the improvement of patient safety in radiotherapy and to aid optimization of treatment. The reassurance that treatment is being delivered in line with accepted standards, that delivered doses are as prescribed and that quality improvement is enabled is as essential for brachytherapy as it is for the more commonly audited external beam radiotherapy. Dose measurement in brachytherapy is challenging owing to steep dose gradients and small scales, especially in the context of an audit. Several different approaches have been taken for audit measurement to date: thimble and well-type ionization chambers, thermoluminescent detectors, optically stimulated luminescence detectors, radiochromic film and alanine. In this work, we review all of the dosimetric brachytherapy audits that have been conducted in recent years, look at current audits in progress and propose required directions for brachytherapy dosimetric audit in the future. The concern over accurate source strength measurement may be essentially resolved with modern equipment and calibration methods, but brachytherapy is a rapidly developing field and dosimetric audit must keep pace.

Effect of tissue composition on dose distribution in brachytherapy with various photon emitting sources

Purpose

The aim of this study is to compare the dose in various soft tissues in brachytherapy with photon emitting sources.

Material and methods

¹⁰³Pd, ¹²⁵I, ¹⁶⁹Yb, ¹⁹²Ir brachytherapy sources were simulated with MCNPX Monte Carlo code, and their dose rate constant and radial dose function were compared with the published data. A spherical phantom with 50 cm radius was simulated and the dose at various radial distances in adipose tissue, breast tissue, 4-component soft tissue, brain (grey/white matter), muscle (skeletal), lung tissue, blood (whole), 9-component soft tissue, and water were calculated. The absolute dose and relative dose difference with respect to 9-component soft tissue was obtained for various materials, sources, and distances.

Results

There was good agreement between the dosimetric parameters of the sources and the published data. Adipose tissue, breast tissue, 4-component soft tissue, and water showed the greatest difference in dose relative to the dose to the 9-component soft tissue. The other soft tissues showed lower dose differences. The dose difference was also higher for ¹⁰³Pd source than for ¹²⁵I, ¹⁶⁹Yb, and ¹⁹²Ir sources. Furthermore, greater distances from the source had higher relative dose differences and the effect can be justified due to the change in photon spectrum (softening or hardening) as photons traverse the phantom material.

Conclusions

The ignorance of soft tissue characteristics (density, composition, etc.) by treatment planning systems incorporates a significant error in dose delivery to the patient in brachytherapy with photon sources. The error depends on the type of soft tissue, brachytherapy source, as well as the distance from the source.

Comparison of methods for the measurement of radiation dose distributions in high dose rate (HDR) brachytherapy: Ge-doped optical fiber, EBT3 Gafchromic film, and PRESAGE® radiochromic plastic

PURPOSE

Dose distribution measurement in clinical high dose rate (HDR) brachytherapy is challenging, because of the high dose gradients, large dose variations, and small scale, but it is essential to verify accurate treatment planning and treatment equipment performance. The authors compare and evaluate three dosimetry systems for potential use in brachytherapy dose distribution measurement: Ge-doped optical fibers, EBT3 Gafchromic film with multichannel analysis, and the radiochromic material PRESAGE(®) with optical-CT readout.

METHODS

Ge-doped SiO2 fibers with 6 μm active core and 5.0 mm length were sensitivity-batched and their thermoluminescent properties used via conventional heating and annealing cycles. EBT3 Gafchromic film of 30 μm active thickness was calibrated in three color channels using a nominal 6 MV linear accelerator. A 48-bit transmission scanner and advanced multichannel analysis method were utilized to derive dose measurements. Samples of the solid radiochromic polymer PRESAGE(®), 60 mm diameter and 100 mm height, were analyzed with a parallel beam optical CT scanner. Each dosimetry system was used to measure the dose as a function of radial distance from a Co-60 HDR source, with results compared to Monte Carlo TG-43 model data. Each system was then used to measure the dose distribution along one or more lines through typical clinical dose distributions for cervix brachytherapy, with results compared to treatment planning system (TPS) calculations. Purpose-designed test objects constructed of Solid Water and held within a full-scatter water tank were utilized.

RESULTS

All three dosimetry systems reproduced the general shape of the isolated source radial dose function and the TPS dose distribution. However, the dynamic range of EBT3 exceeded those of doped optical fibers and PRESAGE(®), and the latter two suffered from unacceptable noise and artifact. For the experimental conditions used in this study, the useful range from an isolated HDR source was 5-40 mm for fibers, 3-50 mm for EBT3, and 4-21 mm for PRESAGE(®). Fibers demonstrated some over-response at very low dose levels, suffered from volume averaging effects in the dose distribution measurement, and exhibited up to 9% repeatability variation over three repeated measurements. EBT3 demonstrated excellent agreement with Monte Carlo and TPS dose distributions, with up to 3% repeatability over three measurements. PRESAGE(®) gave promising results, being the only true 3D dosimeter, but artifacts and noise were apparent.

CONCLUSIONS

The comparative response of three emerging dosimetry systems for clinical brachytherapy dose distribution measurement has been investigated. Ge-doped optical fibers have excellent spatial resolution for single-direction measurement but are currently too large for complex dose distribution assessment. The use of PRESAGE(®) with optical-CT readout gave promising results in the measurement of true 3D dose distributions but further development work is required to reduce noise and improve dynamic range for brachytherapy dose distribution measurements. EBT3 Gafchromic film with multichannel analysis demonstrated accurate and reproducible measurement of dose distributions in HDR brachytherapy. Calibrated dose measurements were possible with agreement within 1.5% of TPS dose calculations. The suitability of EBT3 as a dosimeter for 2D quality control or commissioning work has been demonstrated.

A survey of quality control practices for high dose rate (HDR) and pulsed dose rate (PDR) brachytherapy in the United Kingdom

PURPOSE

A survey of quality control (QC) currently undertaken in UK radiotherapy centres for high dose rate (HDR) and pulsed dose rate (PDR) brachytherapy has been conducted. The purpose was to benchmark current accepted practice of tests, frequencies and tolerances to assure acceptable HDR/PDR equipment performance. It is 20 years since a similar survey was conducted in the UK and the current review is timed to coincide with a revision of the IPEM Report 81 guidelines for quality control in radiotherapy.

MATERIAL AND METHODS

ALL RADIOTHERAPY CENTRES IN THE UK WERE INVITED BY EMAIL TO COMPLETE A COMPREHENSIVE QUESTIONNAIRE ON THEIR CURRENT BRACHYTHERAPY QC PRACTICE, INCLUDING: equipment type, patient workload, source calibration method, level of image guidance for planning, prescribing practices, QC tests, method used, staff involved, test frequencies, and acceptable tolerance limits.

RESULTS

Survey data was acquired between June and August 2012. Of the 64 centres invited, 47 (73%) responded, with 31 centres having brachytherapy equipment (3 PDR) and fully completing the survey, 13 reporting no HDR/PDR brachytherapy, and 3 intending to commence HDR brachytherapy in the near future. All centres had comprehensive QC schedules in place and there was general agreement on key test frequencies and tolerances. Greatest discord was whether source strength for treatment planning should be derived from measurement, as at 58% of centres, or from the certified value, at 42%. IPEM Report 81 continues to be the most frequently cited source of QC guidance, followed by ESTRO Booklet No. 8.

CONCLUSIONS

A comprehensive survey of QC practices for HDR/PDR brachytherapy in UK has been conducted. This is a useful reference to which centres may benchmark their own practice. However, individuals should take a risk-assessment based approach, employing full knowledge of local equipment, clinical procedures and available test equipment in order to determine individual QC needs.