Kilovoltage X-ray Research Articles

Characterization of kilovoltage x-ray image guidance system with a novel post-processing algorithm on a new slip ring-mounted radiotherapy system.

This study evaluates the performance of a kilovoltage x-ray image-guidance system equipped with a novel post-processing optimization algorithm on the newly introduced TAICHI linear accelerator (Linac). A comparative study involving image quality tests and radiation dose measurements was conducted across six scanning protocols of the kV-cone beam computed tomography (CBCT) system on the TAICHI Linac. The performance assessment utilized the conventional Feldkamp-Davis-Kress (FDK) algorithm and a novel Non-Local Means denoising and adaptive scattering correction (NLM-ASC) algorithm. Image quality metrics, including spatial resolution, contrast-to-noise ratio (CNR), and signal-to-noise ratio (SNR), were evaluated using a Catphan 604 phantom. Radiation doses for low-dose and standard protocols were measured using a computed tomography dose index (CTDI) phantom, with comparative measurements from the Halcyon Linac's iterative CBCT (iCBCT). The NLM-ASC algorithm significantly improved image quality, achieving a 300%-1000% increase in CNR and SNR over the FDK-only images and it also showed a 100%-200% improvement over the iCBCT images from Halcyon's head protocol. The optimized low-dose protocols yielded higher image quality than the standard FDK protocols, indicating potential for reduced radiation exposure. Clinical implementation confirmed the TAICHI system's utility for precise and adaptive radiotherapy. The kV-IGRT system on the TAICHI Linac, with its novel post-processing algorithm, demonstrated superior image quality suitable for routine clinical use, effectively reducing image noise without compromising other quality metrics.

Response characterization of radiochromic OC-1 films in photon, electron, and proton beams.

Radiochromic film (RCF) dosimeters with their high spatial resolution and tissue equivalent properties are conveniently used for two-dimensional and small-field dosimetry. OC-1 is a new model of RCF dosimeter that was commercially introduced recently. Due to its novelty there is a need to characterize its response in various radiation beam types. To study the response of OC-1 RCFs to megavoltage clinical x-ray, electron, and proton beams, as well as kilovoltage x-ray beams used in a small animal research irradiator. OC-1 RCFs were cut into ∼4×4 cm2 pieces. RCF samples were irradiated at various dose levels in the range 0.5-120Gy using different modalities; a small animal radiation research platform (SARRP) (220 kVp), a medical linear accelerator (6 MV, 10 MV, 15 MV, 6 MV FFF, 10 MV FFF photon beams, as well as 6 and 20 MeV electron beams), and a gantry-mounted proton therapy synchrocyclotron. In order to study any dependency on the fractionation scheme, same dose was delivered at several fractions to a set of films. Different dose rates in the range 200-600 MU/min were delivered to a set of films to investigate any dose rate dependency. The films were scanned pre-irradiation and at 48h post-irradiation using a flatbed scanner. The net optical density (OD) was measured for red, green, and blue color channel for each film. The orientation dependency was studied by scanning the films at eight different orientations. In order to study the temporal evolution of the response of the films, film samples were irradiated at 10 and 50Gy using 6 MV photon beams and were scanned upon irradiation at certain time intervals up to 3 months. The spectral response of the films were studied over the visible range using a spectrometer. For megavoltage photon, electron, and plateau region of the proton beams, we did not observe a significant dependency on the beam quality, dose rate, and fractionation scheme. At the kV beam, an unusual over-response was observed in the films' net OD. An orientation dependency in the response of the films with a sinusoidal trend was observed. The response of the films increased with time following a double or triple exponential trend. The spectral absorption peaks were blue-shifted with dose. OC-1 RCFs were found to be reliable dosimeters with no significant energy dependency in MV range for photon and electron beams including the FFF beams. They over-respond when irradiated bykV x-ray beams compared to MV x-ray beams. Caution must be exercised to maintain the orientation of the films when scanning. Due to the temporal growth in the net OD of the films, same post-irradiation time interval must be used for scanning the calibration and test films.

Ligand Shell Thickness of PEGylated Gold Nanoparticles Controls Cellular Uptake and Radiation Enhancement.

The drive to improve the safety and efficacy of radiotherapies for cancers has prompted the development of nanomaterials that can locally amplify the radiation dose at a tumor without damaging the surrounding healthy tissue. Gold nanoparticles (Au NPs), in particular, exhibit promising radiosensitizing properties under kilovolt X-ray exposure, although the precise mechanism behind this enhancement is not fully understood. While most studies recognize the involvement of factors such as core composition, size, shape, and ligand chemistry in the effectiveness of Au NPs for radiation-induced cancer treatment, there is a scarcity of direct assessments that connect the photophysical properties of the nanomaterial with the observed cellular or biological outcomes. Despite previous evidence of low-energy electron (LEE) emission from Au NPs and their potential to initiate biological damage, to our knowledge, no studies directly correlate the secondary LEE emission with radiation-induced cell death. In this study we assessed Au NPs functionalized with polyethylene glycol (PEG) ligands of varying molecular weights and lengths (1, 5, and 20 kDa PEG) as potential radiosensitizers of A549 lung cancer cells using kilovolt X-ray source potentials (33-130 kVp). We assessed NP internalization using mass cytometry, radiation dose enhancement using clonogenic survival assays, and secondary LEE emission using a retarding field analyzer. Results reveal a statistically significant difference in cellular uptake and radiation dose enhancement for 5 kDa PEG-Au NPs compared to formulations using 1 and 20 kDa PEG, while analysis of secondary LEE emission spectra demonstrated that differences in the length of the PEG ligand did not cause statistically significant attenuation of secondary LEE flux. Consequently, we inferred increased cellular uptake of NPs to be the cause for the observed enhancement in radiosensitivity for 5 kDa PEGylated Au NPs. The approach used in this study establishes a more complete workflow for designing and characterizing the performance of nanomaterial radiosensitizers, allowing for quantification of secondary LEEs and cellular uptake, and ultimately correlation with localized dose enhancement that leads to cell death.

Dosimetry and Monte Carlo modelling of the Papillon+ contact X-ray brachytherapy device

PurposeThis study aimed to develop and validate a Monte Carlo (MC) model for the Papillon+ contact x-ray brachytherapy (CXB) device, producing 50 kilovolt (kV) x-rays, specifically focusing on its application with a 25 mm diameter rectal applicator for contact therapy. Material and methodsThe validation process involved depth dose and transverse dose profile measurements using EBT3 gafchromic films positioned in a Plastic Water Low Energy Range phantom. The half-value layer (HVL) was further measured and derived from the simulated x-ray spectra. ResultsExcellent agreement within ± 2 % was achieved between the measured and simulated on-axis depth dose curves for the 25 mm rectal applicator. Transverse dose profile measurements showed a high level of agreement between the simulation and measurements, on average 3.1 % in contact with the applicator at the surface of the phantom and on average 1.7 % at 10 mm depth. A close agreement within 5.5 % was noticed concerning the HVL between the measurement and simulation. The simulated gamma spectra and 2D-dose distribution demonstrated a soft x-ray energy spectrum and a uniform dose distribution in contact with the applicator. ConclusionsAn MC model was successfully developed for the Papillon+ eBT device with a 25 mm diameter rectal applicator. The validated model, with its demonstrated accuracy in depth dose and transverse dose profile simulations, is a valuable tool for quality assurance and patient safety and, in a later phase, may be used for treatment planning, dose calculations and tissue inhomogeneity corrections.

Determination of kilovoltage x-ray therapy depth doses with open-ended applicators.

The purpose of this work was to determine percentage depth dose (PDD) curves for kilovoltage x-rays from the WOmed-T105 unit, with open-ended steel applicators and beam qualities ranging from 0.5 to 4.2mm Al. Measurements were made with parallel plate chambers in a water phantom, with extrapolation based on a fifth order polynomial used to estimate the surface dose. Measurements were also made with parallel plate chambers in a plastic water phantom, with thin plastic sheets used to obtain detailed measurements at shallow depths (less than 1mm). Monte Carlo simulations were performed using the EGSnrc package, with two different sources as input: a SpekPy simulation of the x-ray beam and a full simulation of the x-ray tube, treatment head and applicators. Results showed that all four methods (two measurements and two simulations) agreed within the measurement uncertainty at depths greater than 2mm. At shallow depths, significant differences were noted. At depths less than 0.1mm, the full Monte Carlo simulation and the solid water measurements showed a sharp spike in surface dose which is attributed to electron contamination, which was not seen in the SpekPy Monte Carlo simulation or the extrapolated water measurements. At depths between 0.1mm and 2mm, beyond the range of contaminant electrons, the extrapolated water measurements underestimate the dose by up to 13% compared to the full Monte Carlo simulation and the solid water measurements, attributed to fluorescent photons generated in the applicators. This work demonstrates that for open-ended applicators, measurement of depth doses in water with extrapolation of surface dose has the potential to significantly underestimate the dose at shallow depths between the surface and 2mm, even after eliminating electron contamination from the beam.

A study of polarity effect for various ionization chambers in kilovoltage x-ray beams.

Ionization chambers play an essential role in dosimetry measurements for kilovoltage (kV) x-ray beams. Despite their widespread use, there is limited data on the absolute values for the polarity correction factors across a range of commonly employed ionization chambers. This study aimed to investigate the polarity effects for five different ionization chambers in kV x-ray beams. Two plane-parallel chambers being the Advanced Markus and Roos and three cylindrical chambers; 3D PinPoint, Semiflex and Farmer chamber (PTW, Freiburg, Germany), were employed to measure the polarity correction factors. The kV x-ray beams were produced from an Xstrahl 300 unit (Xstrahl Ltd., UK). All measurements were acquired at 2cm depth in a PTW-MP1 water tank for beams between 60 kVp (HVL 1.29mm Al) and 300 kVp (HVL 3.08mm Cu), and field sizes of 2-10cm diameter for 30cm focus-source distance (FSD) and 4 × 4 cm2 - 20 × 20 cm2 for 50cm FSD. The ionization chambers were connected to a PTW-UNIDOS electrometer, and the polarity effect was determined using the AAPM TG-61 code of practice methodology. The study revealed significant polarity effects in ionization chambers, especially in those with smaller volumes. For the plane-parallel chambers, the Advanced Markus chamber exhibited a maximum polarity effect of 2.5%, whereas the Roos chamber showed 0.3% at 150 KVp with the 10cm circular diameter open-ended applicator. Among the cylindrical chambers at the same beam energy and applicator, the Pinpoint chamber exhibited a 3% polarity effect, followed by Semiflex with 1.7%, and Farmer with 0.4%. However, as the beam energy increased to 300 kVp, the polarity effect significantly increased reaching 8.5% for the Advanced Markus chamber and 13.5% for the PinPoint chamber at a 20 × 20 cm2 field size. Notably, the magnitude of the polarity effect increased with both the field size and beam energy, and was significantly influenced by the size of the chamber's sensitive volume. The findings demonstrate that ionization chambers can exhibit substantial polarity effects in kV x-ray beams, particularly for those chambers with smaller volumes. Therefore, it is important to account for polarity corrections when conducting relative dose measurements in kV x-ray beams to enhance the dosimetry accuracy and improve patient dose calculations.

Dosimetric validation of SmART-RAD Monte Carlo modelling for x-ray cabinet radiobiology irradiators

Objective. Accuracy and reproducibility in the measurement of radiation dose and associated reporting are critically important for the validity of basic and preclinical radiobiological studies performed with kilovolt x-ray radiation cabinets. This is essential to enable results of radiobiological studies to be repeated, as well as enable valid comparisons between laboratories. In addition, the commonly used single point dose value hides the 3D dose heterogeneity across the irradiated sample. This is particularly true for preclinical rodent models, and is generally difficult to measure directly. Radiation transport simulations integrated in an easy to use application could help researchers improve quality of dosimetry and reporting. Approach. This paper describes the use and dosimetric validation of a newly-developed Monte Carlo (MC) tool, SmART-RAD, to simulate the x-ray field in a range of standard commercial x-ray cabinet irradiators used for preclinical irradiations. Comparisons are made between simulated and experimentally determined dose distributions for a range of configurations to assess the potential use of this tool in determining dose distributions through samples, based on more readily available air-kerma calibration point measurements. Main results. Simulations gave very good dosimetric agreement with measured depth dose distributions in phantoms containing both water and bone equivalent materials. Good spatial and dosimetric agreement between simulated and measured dose distributions was obtained when using beam-shaping shielding. Significance. The MC simulations provided by SmART-RAD provide a useful tool to go from a limited number of dosimetry measurements to detailed 3D dose distributions through a non-homogeneous irradiated sample. This is particularly important when trying to determine the dose distribution in more complex geometries. The use of such a tool can improve reproducibility and dosimetry reporting in preclinical radiobiological research.

Development of lead-free metal carbides and ceramic decorated HDPE composites for low energy X-ray shielding applications

Materials with high atomic numbers are effective for shielding ionizing radiation. However, some, such as lead, are toxic, and their disposal causes environmental damage. Polymer composites are a good choice for radiation shielding because they are environmentally friendly, lightweight and non-toxic. This study investigated the possibility of using high-density polyethylenhe (HDPE) composites doped with three different materials comprising the carbide (such as tungsten carbide, and molybdenum carbide) and ceramic (silicon carbide) as a kilo-voltage radiation shield. The linear attenuation coefficients of the composites ranged from 0.21 to 2.82cm−1. The measured results are in good agreement with XCOM with an average error of 13.82%. Through meticulous empirical analysis, including the assessment of linear and mass attenuation coefficients, half-value layer (HVL), and mean free path (MFP), our findings suggest that HDPE composites doped with 15% MoC present the most promising configuration for low-energy X-ray shielding (30–50 keV). This work concludes that HDPE composites decorated with MoC and W could be used as an alternative and environment-friendly material for shielding of kilo-voltage X-rays in medical diagnostics and research environments.

Dual-energy computed tomography imaging with megavoltage and kilovoltage X-ray spectra.

Single-energy computed tomography (CT) often suffers from poor contrast yet remains critical for effective radiotherapy treatment. Modern therapy systems are often equipped with both megavoltage (MV) and kilovoltage (kV) X-ray sources and thus already possess hardware for dual-energy (DE) CT. There is unexplored potential for enhanced image contrast using MV-kV DE-CT in radiotherapy contexts. A single-line integral toy model was designed for computing basis material signal-to-noise ratio (SNR) using estimation theory. Five dose-matched spectra (3kV, 2 MV) and three variables were considered: spectral combination, spectral dose allocation, and object material composition. The single-line model was extended to a simulated CT acquisition of an anthropomorphic phantom with and without a metal implant. Basis material sinograms were computed and synthesized into virtual monoenergetic images (VMIs). MV-kV and kV-kV VMIs were compared with single-energy images. The 80kV-140kV pair typically yielded the best SNRs, but for bone thicknesses , the detunedMV-80kV pair surpassed it. Peak MV-kV SNR was achieved with dose allocated to the MV spectrum. In CT simulations of the pelvis with a steel implant, MV-kV VMIs yielded a higher contrast-to-noise ratio (CNR) than single-energy CT and kV-kV DE-CT. Without steel, the MV-kV VMIs produced higher contrast but lower CNR than single-energy CT. This work analyzes MV-kV DE-CT imaging and assesses its potential advantages. The technique may be used for metal artifact correction and generation of VMIs with higher native contrast than single-energy CT. Improved denoising is generally necessary for greater CNR without metal.

A review of small animal dosimetry techniques: image-guided and spatially fractionated therapy

Research in small animal radiotherapy is a crucial step in clinical translation of novel radiotherapy techniques, either delivered as stand-alone treatment or in combination with other treatments, such as chemotherapy and immunotherapy. In order to efficiently translate preclinical findings to the clinical setting, preclinical radiotherapy must replicate clinical therapy in terms of mode of delivery as well as dose delivery accuracy as closely as possible. In this review article, we focused on the description of dosimetry tools for radiotherapy of small animals delivered with kilovoltage x-ray beams on image-guided irradiators and in a spatially-fractionated manner by means of microbeam therapy. The specifics of dosimetry of kilovoltage x-ray beam deliveries with small, often sub-millimeter, beams are highlighted, and suitable dosimeters, phantoms, and dose measurement and calculation techniques are reviewed. Future directions for accurate real-time high spatial resolution dosimetry of small animal irradiations are also discussed.

Kilovoltage X-ray beam quality effect on the relative response of alanine pellet dosemeters.

Determination of beam quality correction factors is crucial for performing accurate alanine pellet dosimetry in non-reference fields. For some complex irradiation geometries, interpolation from literature data is more convenient than an experimental approach to establish these factors. Here we investigate the validity of extracting quality correction factors from literature data based on information on beam qualifiers such as half-value layer (HVL) or effective energy ${E}_{\text{eff}}$. A combination of Monte Carlo calculated dose ratios and a microdosimetric assessment of the relative efficiency allows for numerical evaluation of quality correction factors for a wide array of X-ray qualities. The computational analysis demonstrates that the average energy of the X-ray beam is optimal for characterizing the relative response. Special care should be taken when using the common X-ray beam qualifiers HVL or ${E}_{\text{eff}}$ to determine quality correction factors from literature data.

Superficial kilovoltage x-ray radiotherapy for the treatment of cutaneous mast cell tumors on the head in three dogs and one cat: a limited retrospective case series.

To report preliminary findings of hypofractionated superficial radiotherapy for treatment of cutaneous mast cell tumors (MCTs) and report the acute and late toxicity associated with its use. 3 dogs and 1 cat. In this retrospective study, medical records from January 2021 through July 2022 were searched for animals that received superficial radiation therapy for MCTs of the head. 4 patients with 5 MCTs were included. Three of the masses were periocular and required protection of the globe with a tungsten eye shield. One patient did not complete the intended protocol due to diffuse metastatic spread noted after the second fraction. Of the 3 patients that completed their protocol, 100% had a complete response. Two canine patients were treated adjunctively with toceranib. Two of the 4 patients experienced grade 1 acute veterinary radiation therapy oncology group (VRTOG) toxicity, and the 3 patients that completed their protocol experienced grade 1 late VRTOG toxicity. No radiation effects were documented to the cornea or lens in any patient. Superficial radiation therapy was effective in our limited study population, and patients experienced minimal side effects for treatment of cutaneous MCTs.

FLASH Effects Induced by Orthovoltage X-Rays

This work describes the first implementation and in vivo study of ultrahigh-dose-rate radiation (>37 Gy/s; FLASH) effects induced by kilovoltage (kV) x-ray from a rotating-anode x-ray source. A high-capacity rotating-anode x-ray tube with an 80-kW generator was implemented for preclinical FLASH radiation research. A custom 3-dimensionally printed immobilization and positioning tool was developed for reproducible irradiation of a mouse hind limb. Calibrated Gafchromic (EBT3) film and thermoluminescent dosimeters (LiF:Mg,Ti) were used for in-phantom and in vivo dosimetry. Healthy FVB/N and FVBN/C57BL/6 outbred mice were irradiated on 1 hind leg to doses up to 43 Gy at FLASH (87 Gy/s) and conventional (CONV; <0.05 Gy/s) dose rates. The radiation doses were delivered using a single pulse with the widths up to 500 ms and 15 minutes at FLASH and CONV dose rates. Histologic assessment of radiation-induced skin damage was performed at 8 weeks posttreatment. Tumor growth suppression was assessed using a B16F10 flank tumor model in C57BL6J mice irradiated to 35 Gy at both FLASH and CONV dose rates. FLASH-irradiated mice experienced milder radiation-induced skin injuries than CONV-irradiated mice, visible by 4 weeks posttreatment. At 8 weeks posttreatment, normal tissue injury was significantly reduced in FLASH-irradiated animals compared with CONV-irradiated animals for histologic endpoints including inflammation, ulceration, hyperplasia, and fibrosis. No difference in tumor growth response was observed between FLASH and CONV irradiations at 35 Gy. The normal tissue sparing effects of FLASH irradiations were observed only for high-severity endpoint of ulceration at 43 Gy, which suggests the dependency of biologic endpoints to FLASH radiation dose. Rotating-anode x-ray sources can achieve FLASH dose rates in a single pulse with dosimetric properties suitable for small-animal experiments. We observed FLASH normal tissue sparing of radiation toxicities in mouse skin irradiated at 35 Gy with no sacrifice to tumor growth suppression. This study highlights an accessible new modality for laboratory study of the FLASH effect.

PO-1754 Effective point of measurement of cylindrical ionization chambers in kilovoltage x-ray beams

PO-1754 Effective point of measurement of cylindrical ionization chambers in kilovoltage x-ray beams

Factory quality assurance of passive radiotherapy intensity modulators for electrons using kilovoltage x-ray imaging.

This work developed an x-ray-based method for performing factory quality assurance (QA) of Passive Radiotherapy Intensity Modulators for Electrons (PRIME) device fabrication. This method measures errors in position, diameter, and orientation of cylindrical island blocks on a hexagonal grid that comprises PRIME devices and the impact of such errors on the underlying intensity distribution. X-ray images were acquired of six PRIME devices, which modeled three error cases (small random, large random, and systematic errors) for two island block diameters (0.158 and 0.352cm). Island blocks in each device, 0.6cm long tungsten cylinders of constant diameter, were spaced 0.6cm on a hexagonal grid over approximately 8cm square. Using a 50 kVp x-ray image, each island block projected a racetrack, whose perimeter was fit to a function that allowed determination of its position, diameter, and angular orientation (θ, ϕ). These measured parameters were input into a pencil beam algorithm (PBA) dose calculation performed in water (16 MeV, SSD=103cm) for each device. PBA calculated intensity distributions using measured and planned (exact) island block parameters were compared. Θ distributions for the 0.158 and 0.352cm devices were nearly identical for each error case, with θ values for most island blocks being within 3.2°, 8.5°, and 7.5° for the small random, large random, and systematic error PRIME devices, respectively. Corresponding intensity differences between using measured and planned island block parameters were within 1.0% and 2.8% (small random), 2.2% and 4.8% (large random), and 3.2% and 6.7% (systematic) for the 0.158 and 0.352cm devices, respectively. This approach provides a viable and economical method for factory QA of fabricated PRIME devices by determining errors in their planned intensity distribution from which their quality can be assessed prior to releasing to the customer.

Technical note: Energy dependence of the Gafchromic EBT4 film: Dose-response curves for 70kV, 6MV, 6MV FFF, 10MV FFF, and 15MV x-ray beams.

EBT4 was newly released for radiotherapy quality assurance to improve the signal-to-noise ratio in radiochromic film dosimetry. It is important to know its dose-response characteristics before its use in the clinic. This study aims to investigate and compare the dose-response curves of the Gafchromic EBT4 film for megavoltage and kilovoltage x-ray beams with different dose levels, scanning spatial resolutions, and sizes of region of interest (ROI). EBT4 film (Lot#07052201) calibration strips (3.5×20cm2 ) were exposed to a 10×10cm2 open field at doses of 0, 63, 125, 500, 750, 1000cGy using 6MV photon beam. EBT4 film strips from the same lot were then exposed to each x-ray beam (6MV, 6MV FFF, 10MV FFF, 15MV, and 70kV) at six dose values (50, 100, 300, 600, 800, 1000cGy). A full sheet (25×20cm2 ) of EBT4 film was irradiated at each energy with 300cGy for profile comparison with the treatment planning calculation. At two different spatial resolutions of 72 and 300dpi, each film piece was scanned three consecutive times in the center of an Epson 10000XL flatbed scanner in 48-bit color. The scanned images were analyzed using FilmQA Pro. For each scanned image, an ROI of 2×2cm2 at the field center was selected to obtain the average pixel value with its standard deviation in the ROI. An additional ROI of 1cm diameter circle was also used to evaluate the impact of ROI shape and size, especially for FFF beams. The dose value, average dose-response value, and associated uncertainty were determined for each energy and relative responses were analyzed. The Student's t-test was performed to evaluate the statistical significance of the dose-response values with different color channels, ROI shapes, and spatial resolutions. The dose-response curves for the five x-ray energies were compared in three color channels. Weak energy dependence was found among the megavoltage beams. No significant differences (average ∼1.1%) were observed for all doses in this study among 6 MV, 6 MV FFF, 10 MV FFF, and 15 MV beams, regardless of spatial resolution and color channel. However, a statistically significant difference in dose-response was observed up to 12% between 70kV and 6MV beams. The dose-response curves for Gafchromic EBT4 films were nearly independent of the energy of the photon beams among 6MV, 6MV FFF, 10MV FFF, and 15MV. For very low-energy photons (e.g., 70kV), a separate calibration from the same low-energy x-ray is necessary.

Improving animal-specific radiotherapy quality assurance for kilovoltage X-ray radiotherapy using a 3D printed dog skull water phantom.

Accurate dose assessment during animal radiotherapy is beneficial for veterinary medicine and medical education. To visualize the radiation treatment distribution of orthovoltage X-ray equipment in clinical practice using Monte Carlo simulations and create a dog skull water phantom for animal-specific radiotherapy. EGSnrc-based BEAMnrc and DOSXYZnrc codes were used to simulate orthovoltage dose distributions. At 10, 20, 30, 40, 50, and 80 mm in a water phantom, the depth dose was measured with waterproof Farmer dosimetry chambers, and the diagonal off-axis ratio was measured with Gafchromic EBT3 film to simulate orthovoltage dose distributions. Energy differences between orthovoltage and linear accelerated radiotherapy were assessed with a heterogeneous bone and tissue virtual phantom. The animal-specific phantom for radiotherapy quality assurance (QA) was created from CT scans of a dog and printed with a three-dimensional printer using polyamide 12 nylon, with insertion points for dosimetry chambers and Gafchromic EBT3 film. Monte Carlo simulated and measured dose distributions differed by no more than 2.0% along the central axis up to a depth of 80 mm. The anode heel effect occurred in shallow areas. The orthovoltage radiotherapy percentage depth dose in bone was >40%. Build-up was >40%, with build-down after bone exit, whereas linear accelerator radiotherapy absorption changed little in the bone. A highly water-impermeable, animal-specific dog skull water phantom could be created to evaluate dose distribution. Animal-specific water phantoms and Monte Carlo simulated pre-treatment radiotherapy are useful QA for orthovoltage radiotherapy and yield a visually familiar phantom that will be useful for veterinary medical education.

Explainability and controllability of patient-specific deep learning with attention-based augmentation for markerless image-guided radiotherapy.

We reported the concept of patient-specific deep learning (DL) for real-time markerless tumor segmentation in image-guided radiotherapy (IGRT). The method was aimed to control the attention of convolutional neural networks (CNNs) by artificial differences in co-occurrence probability (CoOCP) in training datasets, that is, focusing CNN attention on soft tissues while ignoring bones. However, the effectiveness of this attention-based data augmentation has not been confirmed by explainable techniques. Furthermore, compared to reasonable ground truths, the feasibility of tumor segmentation in clinical kilovolt (kV) X-ray fluoroscopic (XF) images has not been confirmed. The first aim of this paper was to present evidence that the proposed method provides an explanation and control of DL behavior. The second purpose was to validate the real-time lung tumor segmentation in clinical kV XF images for IGRT. This retrospective study included 10 patients with lung cancer. Patient-specific and XF angle-specific image pairs comprising digitally reconstructed radiographs (DRRs) and projected-clinical-target-volume (pCTV) images were calculated from four-dimensional computer tomographic data and treatment planning information. The training datasets were primarily augmented by random overlay (RO) and noise injection (NI): RO aims to differentiate positional CoOCP in soft tissues and bones, and NI aims to make a difference in the frequency of occurrence of local and global image features. The CNNs for each patient-and-angle were automatically optimized in the DL training stage to transform the training DRRs into pCTV images. In the inference stage, the trained CNNs transformed the test XF images into pCTV images, thus identifying target positions and shapes. The visual analysis of DL attention heatmaps for a test image demonstrated that our method focused CNN attention on soft tissue and global image features rather than bones and local features. The processing time for each patient-and-angle-specific dataset in the training stage was ∼30min, whereas that in the inference stage was 8ms/frame. The estimated three-dimensional 95 percentile tracking error, Jaccard index, and Hausdorff distance for 10 patients were 1.3-3.9mm, 0.85-0.94, and 0.6-4.9mm, respectively. The proposed attention-based data augmentation with both RO and NI made the CNN behavior more explainable and more controllable. The results obtained demonstrated the feasibility of real-time markerless lung tumor segmentation in kV XF images for IGRT.

A novel multichannel deep learning model for fast denoising of Monte Carlo dose calculations: preclinical applications

Objective. In preclinical radiotherapy with kilovolt (kV) x-ray beams, accurate treatment planning is needed to improve the translation potential to clinical trials. Monte Carlo based radiation transport simulations are the gold standard to calculate the absorbed dose distribution in external beam radiotherapy. However, these simulations are notorious for their long computation time, causing a bottleneck in the workflow. Previous studies have used deep learning models to speed up these simulations for clinical megavolt (MV) beams. For kV beams, dose distributions are more affected by tissue type than for MV beams, leading to steep dose gradients. This study aims to speed up preclinical kV dose simulations by proposing a novel deep learning pipeline. Approach. A deep learning model is proposed that denoises low precision (∼106 simulated particles) dose distributions to produce high precision (109 simulated particles) dose distributions. To effectively denoise the steep dose gradients in preclinical kV dose distributions, the model uses the novel approach to use the low precision Monte Carlo dose calculation as well as the Monte Carlo uncertainty (MCU) map and the mass density map as additional input channels. The model was trained on a large synthetic dataset and tested on a real dataset with a different data distribution. To keep model inference time to a minimum, a novel method for inference optimization was developed as well. Main results. The proposed model provides dose distributions which achieve a median gamma pass rate (3%/0.3 mm) of 98% with a lower bound of 95% when compared to the high precision Monte Carlo dose distributions from the test set, which represents a different dataset distribution than the training set. Using the proposed model together with the novel inference optimization method, the total computation time was reduced from approximately 45 min to less than six seconds on average. Significance. This study presents the first model that can denoise preclinical kV instead of clinical MV Monte Carlo dose distributions. This was achieved by using the MCU and mass density maps as additional model inputs. Additionally, this study shows that training such a model on a synthetic dataset is not only a viable option, but even increases the generalization of the model compared to training on real data due to the sheer size and variety of the synthetic dataset. The application of this model will enable speeding up treatment plan optimization in the preclinical workflow.

Treatment Planning in Intraoperative Radiation Therapy (IORT): Where Should We Go?

Simple SummaryIntraoperative radiation therapy is evolving towards new treatment regimens, including ultrahigh dose rates, while in-room imaging systems are increasingly being used for treatment planning and verification. Furthermore, the combination of multiple treatment modalities is being investigated and suggested in some studies, with the aim to improve clinical outcomes. This evolution calls for newly designed treatment planning systems in which several features shall be integrated. In this article, an attempt is made to identify emerging needs and foresee the possible evolution of treatment planning technology and strategies for intraoperative radiation therapy in the near future.As opposed to external beam radiation therapy (EBRT), treatment planning systems (TPS) dedicated to intraoperative radiation therapy (IORT) were not subject to radical modifications in the last two decades. However, new treatment regimens such as ultrahigh dose rates and combination with multiple treatment modalities, as well as the prospected availability of dedicated in-room imaging, call for important new features in the next generation of treatment planning systems in IORT. Dosimetric accuracy should be guaranteed by means of advanced dose calculation algorithms, capable of modelling complex scattering phenomena and accounting for the non-tissue equivalent materials used to shape and compensate electron beams. Kilovoltage X-ray based IORT also presents special needs, including the correct description of extremely steep dose gradients and the accurate simulation of applicators. TPSs dedicated to IORT should also allow real-time imaging to be used for treatment adaptation at the time of irradiation. Other features implemented in TPSs should include deformable registration and capability of radiobiological planning, especially if unconventional irradiation schemes are used. Finally, patient safety requires that the multiple features be integrated in a comprehensive system in order to facilitate control of the whole process.