In-vivo Dosimetry Method Research Articles

Time-resolved clinical dose volume metrics, calculations and predictions based on source tracking measurements and uncertainties to aid treatment verification and error detection for HDR brachytherapy—a proof-of-principle study

Objective. High-dose-rate (HDR) brachytherapy lacks routinely available treatment verification methods. Real-time tracking of the radiation source during HDR brachytherapy can enhance treatment verification capabilities. Recent developments in source tracking allow for measurement of dwell times and source positions with high accuracy. However, more clinically relevant information, such as dose discrepancies, is still needed. To address this, a real-time dose calculation implementation was developed to provide more relevant information from source tracking data. A proof-of-principle of the developed tool was shown using source tracking data obtained from a 3D-printed anthropomorphic phantom. Approach. Software was developed to calculate dose-volume-histograms (DVH) and clinical dose metrics from experimental HDR prostate treatment source tracking data, measured in a realistic pelvic phantom. Uncertainty estimation was performed using repeat measurements to assess the inherent dose measuring uncertainty of the in vivo dosimetry (IVD) system. Using a novel approach, the measurement uncertainty can be incorporated in the dose calculation, and used for evaluation of cumulative dose and clinical dose-volume metrics after every dwell position, enabling real-time treatment verification. Main results. The dose calculated from source tracking measurements aligned with the generated uncertainty bands, validating the approach. Simulated shifts of 3 mm in 5/17 needles in a single plan caused DVH deviations beyond the uncertainty bands, indicating errors occurred during treatment. Clinical dose-volume metrics could be monitored in a time-resolved approach, enabling early detection of treatment plan deviations and prediction of their impact on the final dose that will be delivered in real-time. Significance. Integrating dose calculation with source tracking enhances the clinical relevance of IVD methods. Phantom measurements show that the developed tool aids in tracking treatment progress, detecting errors in real-time and post-treatment evaluation. In addition, it could be used to define patient-specific action limits and error thresholds, while taking the uncertainty of the measurement system into consideration.

A Method for <i>In Vivo</i> Dosimetry Using an Electronic Portal Imaging Device

The implementation of advanced radiotherapy techniques such as Intensity-Modulated RadiationTherapy (IMRT) and Volumetric Modulated Arc Therapy (VMAT) allows much more accuratecontrol of the irradiation area and more conformal dose delivery. Since these treatments are characterizedby high dose gradients and hence small error margins, they also require advanced and highlyeffective treatment verification techniques. Fortunately, an imaging modality, originally intended forset-up verifications, called the Electronic Portal Imaging Device (EPID) was reported to have hugepotential for dosimetry and treatment verification applications. However, methods and algorithmspreviously developed for EPID dosimetry are not yet widely adopted in cancer centers due to complexitiesin the implementation. These motivate more investigation and development of new methodsto encourage cancer centers to practice EPID dosimetry and improve patient safety.This research generally aims to develop an in-vivo dosimetry method that can be used in the future toapproximate the actual dose delivered inside the target by utilizing the transmitted fluence detectedby the EPID. In this study, Monte Carlo simulations are carried out using the Geant4 Application forTomographic Emission (GATE) to implement a virtual set-up composed of a water target irradiatedwith a monoenergetic 2 MeV photon beam and an EPID model to detect the total transmitted fluence.A mathematical model has been proposed to calculate the target absorbed dose by utilizing the transmittedprimary fluence. This involves back-projection of the transmitted fluence to determine fluencevalues at certain depths inside the irradiated homogeneous medium. This is followed by the calculationof the collision kerma using the back-projected fluence and the values of the linear attenuation coefficientand mass energy absorption coefficient in the National Institute of Standards and Technology(NIST) database. The results show accurate prediction of the fluence values inside the target, calculationof the corresponding values of the collision kerma, and determination of the proportionalityconstant β that relates the collision kerma to the target absorbed dose.

In vivo dosimetry in external beam photon radiotherapy: Requirements and future directions for research, development, and clinical practice.

External beam radiotherapy with photon beams is a highly accurate treatment modality, but requires extensive quality assurance programs to confirm that radiation therapy will be or was administered appropriately. In vivo dosimetry (IVD) is an essential element of modern radiation therapy because it provides the ability to catch treatment delivery errors, assist in treatment adaptation, and record the actual dose delivered to the patient. However, for various reasons, its clinical implementation has been slow and limited. The purpose of this report is to stimulate the wider use of IVD for external beam radiotherapy, and in particular of systems using electronic portal imaging devices (EPIDs). After documenting the current IVD methods, this report provides detailed software, hardware and system requirements for in vivo EPID dosimetry systems in order to help in bridging the current vendor-user gap. The report also outlines directions for further development and research. In vivo EPID dosimetry vendors, in collaboration with users across multiple institutions, are requested to improve the understanding and reduce the uncertainties of the system and to help in the determination of optimal action limits for error detection. Finally, the report recommends that automation of all aspects of IVD is needed to help facilitate clinical adoption, including automation of image acquisition, analysis, result interpretation, and reporting/documentation. With the guidance of this report, it is hoped that widespread clinical use of IVD will be significantly accelerated.

Setup in a Clinical Workflow and Results of In Vivo Dosimetry Procedure in an Overload Radiation Therapy Department

High conformal techniques, as intensity modulated radiation therapy (IMRT) and volumetric modulated arc therapy (VMAT) are widely used in overloaded radiotherapy departments. In vivo dosimetric screening appears to be essential in this environment to avoid important dosimetric errors. The work reports the results of the assessment of an in vivo dosimetry (IVD) procedure in a surcharged clinical workflow, analyses the causes that could be responsible of dosimetric disagreements between the delivered and planned treatments and evaluates the added workload needed for the whole procedure. An IVD method based on the results of an electronic portal imaging device (EPID) was used. A total of 3484 IVD tests were performed for 150 patients treated for head and neck, abdomen, pelvis, breast and thorax tumors with IMRT and VMAT techniques. Two types of tests were considered: the ratio R between the reconstructed and planned isocenter doses and a transit dosimetry based on the γ-analysis of the electronic portal images. The tests were considered in tolerance if R is within 5%, γ% >90% (i.e. the percentage of points with γ <1 is greater than 90%) and if γ mean ≤ 0.4. Therefore, within the EPID irradiated area, a maximum of 10% of the points in disagreement were accepted, while the weight of the discrepancy was supplied by the distribution of the γ values, characterized by a mean value lower than 0.4. If even only one of these indices was outside the tolerance level, the reason was investigated and corrected prior to the next fraction and the IVD test was repeated. The time needed for each step of the IVD procedure was registered. IMRT and VMAT treatments for pelvis, abdomen and head and neck presented 10% of the tests out of the tolerance level, while IMRT treatments for the breast and thorax regions accounted for up to 25%. Of the off-tolerance tests, 90% were due to inadequate standard quality controls that can lead to errors in the patient setup. The remaining 10% of the tests out of the tolerance level, were mainly ascribable to patient morphological changes as different filling of bladder and rectum for pelvis treatments, tumor shrinkage for head and neck, but also loss of weight. For breast and thorax treatments, the patient positioning was the main cause of the out of tolerance of the γ analysis. Once corrected the cause of the errors, the percentage of patients ending the treatment with each mean index within the tolerance level tends towards 100% for every region treated and technique used. An average time of 42 minutes/day was sufficient to monitor a daily workload of 60 patients in treatment. IVD performed with an electronic portal imaging device is feasible in an overloaded department. Its use enables the timely realignment of the treatment quality indices within the tolerance level in order to achieve 100% of patient’s final treatment compliant with the one prescribed.

Experimental method of in-vivo dosimetry without build-up device on the skin for external beam radiotherapy

Accurate dose delivery is crucial to the success of modern radiotherapy. To evaluate the dose actually delivered to patients, in-vivo dosimetry (IVD) is generally performed during radiotherapy to measure the entrance doses. In IVD, a build-up device should be placed on top of an in-vivo dosimeter to satisfy the electron equilibrium condition. However, a build-up device made of tissue-equivalent material or metal may perturb dose delivery to a patient, and requires an additional laborious and time-consuming process. We developed a novel IVD method using a look-up table of conversion ratios instead of a build-up device. We validated this method through a monte-carlo simulation and 31 clinical trials. The mean error of clinical IVD is 3.17% (standard deviation: 2.58%), which is comparable to that of conventional IVD methods. Moreover, the required time was greatly reduced so that the efficiency of IVD could be improved for both patients and therapists.

Quasi real time in vivo dosimetry for VMAT.

Results about the feasibility of a method for quasi real time in vivo dosimetry (IVD) at the isocenter point for volumetric modulated arc therapy (VMAT) are here reported. The method is based on correlations between the EPID signal and the dose on the beam central axis. Moreover, the γ-analysis of EPID images was adopted to verify off-axis reproducibility of fractionated plan delivery. An algorithm to reconstruct in vivo the isocenter dose, D(iso), for RapidArc treatments has been developed. 20 VMAT plans, optimized with two opposite arcs, for prostate, pancreas, and head treatments have been delivered by a Varian linac both to a conic PMMA phantom with elliptical section and to patients. The ratios R between reconstructed D(iso) and the planned doses were determined for phantom and patient irradiations adopting an acceptance criterion of ±5%. In total, 40 phantom checks and 400 patient checks were analyzed. Moreover, 3% and 3 mm criteria were adopted for portal image γ-analysis to assess patient irradiation reproducibility. The average ratio R, between reconstructed and planned doses for the PMMA phantom irradiations was equal to 1.007 ± 0.024. When the IVD method was applied to the 20 patients, the average R ratio was equal to 1.003 ± 0.017 and 96% of the tests were within the acceptance criteria. The portal image γ-analysis supplied 88% of the tests within the pass rates γ(mean) ≤ 0.4 and P(γ<1) ≥ 98%. All the warnings were understood comparing the CT and the cone beam CT images and in one case a patient's setup error was detected and corrected for the successive fractions. This preliminary experience suggests that the method is able to detect dosimetric errors in quasi real time at the end of the therapy session. The authors intend to extend this procedure to other pathologies with the integration of in-room imaging verification by cone beam CT.

Clinical results of an EPID-based in-vivo dosimetry method for pelvic cancers treated by intensity-modulated radiation therapy

The purpose of our work was to investigate the feasibility of using an EPID-based in-vivo dosimetry method initially designed for conformal fields on pelvic dynamic IMRT fields. The method enables a point dose delivered to the patient to be calculated from the transit signal acquired with an electronic portal imaging device (EPID). After defining a set of correction factors allowing EPID pixel values to be converted into absolute doses, several tests on homogeneous water-equivalent phantoms were performed to estimate the validity of the method in reference conditions. The effects of different treatment parameters, such as delivered dose, field size dependence and patient thickness were also studied. The model was first evaluated on a group of 53 patients treated by 3D conformal radiotherapy (3DCRT) and then on 92 patients treated by IMRT, both for pelvic cancers. For each measurement, the dose was reconstructed at the isocenter (DREC) and compared with the dose calculated by our treatment planning system (DTPS). Excellent agreement was found between DREC and DTPS for both techniques. For 3DCRT treatments, the mean deviation between DREC and DTPS for the 211 in-vivo dose verifications was equal to −1.0 ± 2.2% (1SD). Concerning IMRT treatments, the averaged deviation for the 418 fields verified was equal to −0.3 ± 2.6% (1SD) proving that the method is able to reconstruct a dose for dynamic IMRT pelvic fields. Based on these results, tolerance criteria and action levels were established before its implementation in clinical routine.

Feasibility Study of In Vivo Transit Dosimetry for IMRT Patients

The ultimate goal of IMRT QA should be to verify that the correct dose has been delivered to the patient. The purpose of this study is to evaluate for feasibility and reliability of volumetric transit dosimetry as a routine in-vivo dosimetry method during the actual patient treatment for different sites.

Correlation functions for Elekta aSi EPIDs used as transit dosimeter for open fields

In‐vivo dosimetry techniques are currently being applied only by a few Centers because they require time‐consuming implementation measurements, and workload for detector positioning and data analysis. The transit in‐vivo dosimetry performed by the electronic portal imaging device (EPID) avoids the problem of solid‐state detector positioning on the patient. Moreover, the dosimetric characterization of the recent Elekta aSi EPIDs in terms of signal stability and linearity make these detectors useful for the transit in‐vivo dosimetry with 6, 10 and 15 MV photon beams. However, the implementation of the EPID transit dosimetry requires several measurements. Recently, the present authors have developed an in‐vivo dosimetry method for 3D CRT based on correlation functions defined by the ratios between the transit signal, st(w,L), by the EPID and the phantom midplane dose, Dm(w,L), at the source to axis distance (SAD) as a function of the phantom thickness, w, and the square field dimensions, L. When the phantom midplane was positioned at distance, d, from the SAD, the ratios st(w,L)/st'(d,w,L) were used to take into account the variation of the scattered photon contributions on the EPID as a function of d and L.The aim of this paper is the implementation of a procedure that uses generalized correlation functions obtained by nine Elekta Precise linac beams. The procedure can be used by other Elekta Precise linacs equipped with the same aSi EPIDs, assuming the stabilities of the beam output factors and the EPID signals. The procedure here reported avoids measurements in solid water equivalent phantoms needed to implement the in‐vivo dosimetry method in the radiotherapy department. A tolerance level ranging between ±5% and ±6% (depending on the type of tumor) was estimated for the comparison between the reconstructed isocenter dose, Diso, and the computed dose, Diso,TPS, by the treatment planning system (TPS).PACS number: 87.55.Qr; 87.56.Fc

Build-up modification of commercial diodes for entrance dose measurements in ‘higher energy’ photon beams

Background and Purpose: Several commercially available p-type diodes do not provide sufficient build-up for in-vivo dosimetry in ‘higher’ energy photon beams, and only limited information could be found in the literature describing the correction factor variation and/or the achievable accuracy for in-vivo dosimetry methods in this energy range. The first aim of this study is to assess and analyze the variation of diode correction factors for entrance dose measurements at higher photon energies. In a second step the total build up thickness of the diode has been modified in order to minimize the correction factor variation. Materials and Methods: Diode correction factors accounting for non-reference conditions (field size, source surface distance, tray, wedge, and block) are determined in 18–25 MV photon beams provided by different treatment units for Scanditronix p-type diodes recommended for higher energy photon beams: old type and new type EDP-20, and EDP-30 diodes. Hemispherical build-up caps of different materials (copper, iron, lead) are used to increase the total build-up thickness. Perturbation effects with and without additional build-up caps are assessed for the three diode types. Results: For unmodified diodes field size correction factors (C FS) vary between 1.7% and 6%, dependent on diode type and treatment unit. For example, for an old type EDP-20 the C FS variation at 18 MV is much higher on a GE linac (5%) as compared to the Philips machine (1.7%). Depending on diode type, this variation can be reduced to 1–2% when adding additional build-up. The variation of source to surface distance correction factors is almost independent of build-up thickness. By adding additional build-up the influence of trays and blocks can be almost eliminated. Conclusions: The correction factor variation of unmodified diodes reflects the variation of the electron contamination with treatment geometry. A total build-up thickness of 3O mm is found to be the ‘best compromise’ for the three types of diodes investigated when measuring entrance doses in the energy range between 18 and 25 MV.