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Dosimetric effects of weight loss or gain during volumetric modulated arc therapy and intensity-modulated radiation therapy for prostate cancer

Weight loss or gain during the course of radiation therapy for prostate cancer can alter the planned dose to the target volumes and critical organs. Typically, source-to-surface distance (SSD) measurements are documented by therapists on a weekly basis to ensure that patients' exterior surface and isocenter-to-skin surface distances remain stable. The radiation oncology team then determines whether the patient has undergone a physical change sufficient to require a new treatment plan. The effect of weight change (SSD increase or decrease) on intensity-modulated radiation therapy (IMRT) or volumetric modulated arc therapy (VMAT) dosimetry is not well known, and it is unclear when rescanning or replanning is needed. The purpose of this study was to determine the effects of weight change (SSD increase or decrease) on IMRT or VMAT dose delivery in patients with prostate cancer and to determine the SSD change threshold for replanning. Whether IMRT or VMAT provides better dose stability under weight change conditions was also determined. We generated clinical IMRT and VMAT prostate and seminal vesicle treatment plans for varying SSDs for 10 randomly selected patients with prostate cancer. The differences due to SSD change were quantified by a specific dose change for a specified volume of interest. The target mean dose, decreased or increased by 2.9% per 1-cm SSD decrease or increase in IMRT and by 3.6% in VMAT. If the SSD deviation is more than 1 cm, the radiation oncology team should determine whether to continue treatment without modifications, to adjust monitor units, or to resimulate and replan.

61 RADIATION PROTECTION AND DOSIMETRY↗

Volumetric-modulated arc therapy in postprostatectomy radiotherapy patients: A planning comparison study

The purpose of this study was to compare postprostatectomy planning for volumetric-modulated arc therapy (VMAT) with both single arc (SA) and double arcs (DA) against dynamic sliding window intensity-modulated radiotherapy (IMRT). Ten cases were planned with IMRT, SA VMAT, and DA VMAT. All cases were planned to achieve a minimum dose of 68 Gy to 95% of the planning target volume (PTV) and goals to limit rectal volume >40 Gy to 35% and >65 Gy to 17%, and bladder volumes >40 Gy to 50% and >65 Gy to 25%. Plans were averaged across the 10 patients and compared for mean dose, conformity, homogeneity, rectal and bladder doses, and monitor units. The mean dose to the clinical target volume and PTV was significantly higher (p<0.05) for SA compared with DA or IMRT. The homogeneity index was not significantly different: SA = 0.09; DA = 0.08; and IMRT = 0.07. The rectal V40 was lowest for the DA plan. The rectal V20 was significantly lower (p<0.05) for both the VMAT plans compared with IMRT. There were no significant differences for bladder V40 or rectal and bladder V65. The IMRT plans required 1400 MU compared with 745 for DA and 708 for SA. This study shows that for equivalent dose coverage, SA and DA VMAT plans result in higher mean doses to the clinical target volume and PTV. This greater dose heterogeneity is balanced by improved low-range rectal doses and halving of the monitor units.

61 RADIATION PROTECTION AND DOSIMETRY↗

Establishing an optimized patient-specific verification program for volumetric modulated arc therapy

Quality assurance (QA) of volumetric modulated arc therapy (VMAT) increases the workload significantly. We compared the results from 4 verification methods to establish an efficient VMAT QA. Planning for VMAT treatments was carried out for 40 consecutive patients. Pretreatment verifications were carried out with ion chamber array Physikalish-Technische Werkstätten (PTW729), electronic portal dosimetry (EPID), ion chamber measurements, and independent dose calculation with Diamond program. 2D analyses were made using the gamma analysis (3 mm distance to agreement and 3% dose difference relative to maximum, 10% dose threshold). Average point dose difference calculated by Eclipse relative to ion chamber measurements and Diamond were 0.1%±0.9% and 0.6%±2.2%, respectively. Average pass rate for PTW729 was 99.2%±1.9% and 98.3%±1.3% for EPID. The total required time (linac occupancy time given in parentheses) for each QA method was: PTW729 43.5 minutes (26.5 minutes), EPID 14.5 minutes (2.5 minutes), ion chamber 34.5 minutes (26.5 minutes), and Diamond 12.0 minutes (0 minute). The results were consistent and allowed us to establish an optimized protocol, considering safety and accuracy as well as workload, consisting of 2 verification methods: EPID 2D analysis and independent dose calculation.

61 RADIATION PROTECTION AND DOSIMETRY↗

Implementation and evaluation of modified dynamic conformal arc (MDCA) technique for lung SBRT patients following RTOG protocols

To implement modified dynamic conformal arc (MDCA) technique and Radiation Therapy Oncology Group (RTOG) protocols in our clinic for stereotactic body radiation therapy (SBRT) treatment of patients with Stage I/II non–small cell lung cancer. Five patients with non–small cell lung cancer have been treated with SBRT. All the patients were immobilized using CIVCO Body Pro-Lok system and scanned using GE 4-slice computed tomography. The MDCA technique that was previously published was adopted as our planning technique, and RTOG protocols for the lung SBRT were followed. The patients were treated on Novalis Tx system with cone-beam computed tomography imaging guidance. All the patient plans passed the RTOG criteria. The conformal index ranges from 0.99 to 1.12 for the planning target volume, and the biological equivalent dose for the planning target volume is overall 100 Gy. Critical structures (lung, spinal cord, brachial plexus, skin, and chest wall) also meet RTOG protocols or published data. A 6-month follow-up of one of the patients shows good local disease control. We have successfully implemented the MDCA technique into our clinic for the lung SBRT program. It shows that the MDCA is useful and efficient for the lung SBRT planning, with the plan quality meeting the RTOG protocols.

61 RADIATION PROTECTION AND DOSIMETRY↗

Feasibility study of volumetric modulated arc therapy with constant dose rate for endometrial cancer

To investigate the feasibility, efficiency, and delivery accuracy of volumetric modulated arc therapy with constant dose rate (VMAT-CDR) for whole-pelvic radiotherapy (WPRT) of endometrial cancer. The nine-field intensity-modulated radiotherapy (IMRT), VMAT with variable dose-rate (VMAT-VDR), and VMAT-CDR plans were created for 9 patients with endometrial cancer undergoing WPRT. The dose distribution of planning target volume (PTV), organs at risk (OARs), and normal tissue (NT) were compared. The monitor units (MUs) and treatment delivery time were also evaluated. For each VMAT-CDR plan, a dry run was performed to assess the dosimetric accuracy with MatriXX from IBA. Compared with IMRT, the VMAT-CDR plans delivered a slightly greater V{sub 20} of the bowel, bladder, pelvis bone, and NT, but significantly decreased the dose to the high-dose region of the rectum and pelvis bone. The MUs decreased from 1105 with IMRT to 628 with VMAT-CDR. The delivery time also decreased from 9.5 to 3.2 minutes. The average gamma pass rate was 95.6% at the 3%/3 mm criteria with MatriXX pretreatment verification for 9 patients. VMAT-CDR can achieve comparable plan quality with significant shorter delivery time and smaller number of MUs compared with IMRT for patients with endometrial cancer undergoing WPRT. It can be accurately delivered and be an alternative to IMRT on the linear accelerator without VDR capability.

61 RADIATION PROTECTION AND DOSIMETRY↗

On the possible benefits of a hybrid VMAT technique in the treatment of non–small cell lung cancer

To assess, using clinical cases, the potential of a hybrid technique for the treatment of non–small cell lung cancer (NSCLC)-blending volumetric-modulated arc therapy (VMAT) and conformal radiation therapy (CRT) fields, and to consider potential issues with implementation of such a technique. Eight clinical cases already treated with CRT were used for a planning study comparing target coverage and organs at risk (OAR) sparing between CRT and hybrid VMAT (VMATh). Quality assurance (QA) implications of the resultant hybrid plans are discussed. The hybrid technique resulted in superior target conformity or improved sparing of OAR or both. The hybrid technique shows promise, but the QA implications of motion at treatment need careful consideration.

61 RADIATION PROTECTION AND DOSIMETRY↗

Experience with the CyberKnife for intracranial stereotactic radiosurgery: Analysis of dosimetry indices

We evaluated coverage, dose homogeneity, dose conformity, and dose gradient in CyberKnife VSI treatment plans. Several dosimetric indices were calculated, and the results were compared with those of previous publications. The effect of target volume on the radiosurgical treatment indices selected was also investigated. The study population comprised the first 40 patients treated at our department from March 2011 to September 2012. Dosimetric indices were calculated and compared with published results for other frame-based and frameless intracranial stereotactic radiotherapy techniques. A comparison of the indices confirmed the ability of the CyberKnife VSI system to provide very high-quality dosing plans. The results were independent of target volume for coverage, homogeneity, and dose conformity. However, a dependence on target volume was observed for the dose-gradient indices analyzed. Based on the indices proposed, CyberKnife provides very good treatment plans and compares favorably with other techniques in most cases. However, greater consensus on the radiosurgery indices calculated would be desirable to facilitate comparison of the various techniques or the same techniques when applied by different users.

61 RADIATION PROTECTION AND DOSIMETRY↗

Covariance Propagation in Spectral Indices

The dosimetry community has a history of using spectral indices to support neutron spectrum characterization and cross section validation efforts. An important aspect to this type of analysis is the proper consideration of the contribution of the spectrum uncertainty to the total uncertainty in calculated spectral indices (SIs). This paper identifies deficiencies in the traditional treatment of the SI uncertainty, provides simple bounds to the spectral component in the SI uncertainty estimates, verifies that these estimates are reflected in actual applications, details a methodology that rigorously captures the spectral contribution to the uncertainty in the SI, and provides quantified examples that demonstrate the importance of the proper treatment the spectral contribution to the uncertainty in the SI.

73 NUCLEAR PHYSICS AND RADIATION PHYSICS↗

Leveraging Radiofrequency Identification Success Beyond Hazardous Material Inventory Management at a National Laboratory

Effective inventory management can be overshadowed by conflicting priorities in organizational procedures, particularly in research-focused institutions such as national laboratories that handle expensive, delicate, and hazardous materials. Here, this study investigated the potential of radiofrequency identification (RFID) technology, currently used for hazardous chemical inventory, in applications with higher metal interference and absorption, specifically pressure release device (PRD) compliance and nuclear container management, at Lawrence Livermore National Laboratory (LLNL). This study was done to document best practices to enhance inventory identification speeds for inventory reconciliation and inventory recall and to explore optimal configurations for RFID implementation compared to traditional manual methods of equipment management. Tests were conducted to determine the ideal RFID tag orientation (read at angles of 0°, 90°, and 270°), various container layouts (linear, separated, curved, operational), and ID methods such as manual, barcode, and RFID performing three trials per method per orientation. Results indicated that 0° was the optimal read angle for minimizing metallic interference, and the operational and curved arrangements significantly outperformed the linear and separated configurations in read speed. 3D printed mounts were developed and tested, increasing the read range of the RFID reader by up to 235% in cases of high metallic interference. The RFID technology demonstrated an average speed increase of 65% over a simplified manual identification, which supports the conclusion that RFID is a more efficient method for large hazardous inventory management and equipment reconciliation. Additionally, capturing meta-data, such as location and date, can be used to query for inventory recall and automated updating of record information.

42 ENGINEERING↗

Preliminary analysis of TREAT free-field experiments using openmc

This work analyses activation calculations for dosimetry materials during a steady-state irradiation in the Transient Reactor Test (TREAT) reactor core. Hence, we developed a workflow based on the Monte Carlo code OpenMC alongside a custom depletion solver. The irradiation-induced activity as a function of time is computed, and several sensitivity studies are performed to evaluate uncertainty. This study has shown activity computations are sensitive to flux amplitude, irradiation time, atoms quantity and microscopic cross sections. Stochastic uncertainties have been propagated to evaluate the activity uncertainty for each dosimetry material. Most uncertainties are below our target of 3%, which demonstrates OpenMC as a powerful predictive and analysis tool. The precise results obtained through this newly developed computation scheme will be used in future experiments to characterize quantities of interest when operating the TREAT reactor in new configurations.

22 GENERAL STUDIES OF NUCLEAR REACTORS↗

Enhancement of radiation detection performance with reduction of EH 6/7 deep levels in n-type 4H–SiC through thermal oxidation

We report the effect of EH 6/7 electron trap centers alone on the performance of high-resolution radiation detectors fabricated on n-type 4H–SiC epitaxial layers. A Schottky barrier detector (SBD) and a metal-oxide-semiconductor (MOS) capacitor detector fabricated using two sister samples derived from the same 50 μm 4H–SiC parent wafer exhibited widely different energy resolutions of 0.4% and 0.9% for 5486 keV alpha particles. An equivalent noise charge model analysis ruled out the effect of the detector capacitance and the leakage current on the resolution of the detectors. Deep level transient spectroscopic studies revealed the presence of two trapping centers in each detector within the temperature scan range 240–800 K. The Z 1/2 center, a potential electron trap, was detected in both the detectors in equal concentration, which suggested that the observed difference in the energy resolution is due to the presence of the other defect, the EH 6/7 center, in the SBD. The capture cross section of the EH 6/7 center was calculated to be three orders of magnitude higher than the second defect [a carbon antisite vacancy (CAV) center] observed in the MOS detector with an activation energy of 1.10 eV, which accounted for the enhanced electronic trapping in the SBD leading to its poor energy resolution. It has been proposed that the EH 6/7 centers in the SBD have likely been reconfigured to CAV pairs during the thermal growth of the silicon dioxide layer in the MOS detector. The proposed formation mechanism of CAV, a stable qubit state for quantum information processing, addresses the outstanding questions related to the role of defect dynamics in their formation.

61 RADIATION PROTECTION AND DOSIMETRY↗

Cytogenetic follow-up studies on humans with internal and external exposure to ionizing radiation

Cells exposed to ionizing radiation have a wide spectrum of DNA lesions that include DNA single-strand breaks, DNA double-strand breaks (DSBs), oxidative base damage and DNA-protein crosslinks. Among them, DSB is the most critical lesion, which when mis-repaired leads to unstable and stable chromosome aberrations. Currently, chromosome aberration analysis is the preferred method for biological monitoring of radiation-exposed humans. Here, stable chromosome aberrations, such as inversions and balanced translocations, persist in the peripheral blood lymphocytes of radiation-exposed humans for several years and, therefore, are potentially useful tools to prognosticate the health risks of radiation exposure, particularly in the hematopoietic system. In this review, we summarize the cytogenetic follow-up studies performed by REAC/TS (Radiation Emergency Assistance Center/Training site, Oak Ridge, USA) on humans exposed to internal and external radiation. In the light of our observations as well as the data existing in the literature, this review attempts to highlight the importance of follow-up studies for predicting the extent of genomic instability and its impact on delayed health risks in radiation-exposed victims.

61 RADIATION PROTECTION AND DOSIMETRY↗

Dose Reconstruction for the Million Worker Study: Status and Guidelines

The primary aim of the epidemiologic study of one million U.S. radiation workers and veterans (the Million-Worker study) is to provide scientifically valid information on the level of radiation risk when exposures are received gradually over time, and not acutely as was the case for Japanese atomic bomb survivors. The primary outcome of the epidemiological study is cancer mortality but other causes of death such as cardiovascular disease and cerebrovascular disease will be evaluated. The success of the study is tied to the validity of the dose reconstruction approaches to provide unbiased estimates of organ-specific radiation absorbed doses and their accompanying uncertainties. The dosimetry aspects for the Million-Worker study are challenging in that they address diverse exposure scenarios for diverse occupational groups being studied over a period of up to 70 years. The dosimetric issues differ among the varied exposed populations that are considered: atomic veterans, DOE workers exposed to both penetrating radiation and intakes of radionuclides, nuclear power plant workers, medical radiation workers, and industrial radiographers. While a major source of radiation exposure to the study population comes from external gamma-ray or x-ray sources, for certain of the study groups there is a meaningful component of radionuclide intakes that require internal radiation dosimetry measures. Scientific Committee 6-9 has been established by NCRP to produce a report on the comprehensive organ dose assessment (including uncertainty analysis) for the Million-Worker study. The Committee’s report will cover the specifics of practical dose reconstruction for the ongoing epidemiologic studies with uncertainty analysis discussions and will be a specific application of the guidance provided in NCRP Reports 158, 163, 164, and 171. The main role of the Committee is to provide guidelines to the various groups of dosimetrists involved in the various components of the Million-Worker study to make sure that certain dosimetry criteria are respected: calculation of annual absorbed doses in the organs of interest, separation of low-LET and high-LET components, evaluation of uncertainties, and quality assurance and quality control. Lastly, we recognize that the Million-Worker study and its approaches to dosimetry are a work in progress and that there will be flexibility and changes in direction as new information is obtained, both with regard to dosimetry and with regard to the epidemiologic features of the study components.

59 BASIC BIOLOGICAL SCIENCES↗

Radon-222 Charcoal Canister Steady State Model Calibrations Performed in a Highly Controlled Environmental Chamber and a Natural Indoor Environment

Charcoal canisters are a common method of 222 Rn screening. The calibrations of different batches of activated charcoal used in different canister designs are typically performed in large volume controlled environmental chambers with known and controlled radon concentration, temperature, and humidity. Radon screening could be facilitated in locations without ready access to environmental chambers if canisters could be accurately calibrated and undergo quality control in less controlled environments. This study compares charcoal canister calibrations from a highly controlled radon chamber with calibrations from a basement storage area experiencing temporally varying radon. In addition, the impacts of exposure time and spectral region of interest selection on calibration accuracy are investigated by comparing calibrations calculated using three different choices. Approximately 30 mo after calibrations were completed, groups of canisters were exposed for different durations of time to investigate measurement accuracy and calibration validity over an extended time. A digital simulation of charcoal canister kinetics was also performed to establish limits on how stable radon must be in a space for equilibrium-based calibration to be performed there. Overall, the accuracy of measurements using calibrations from each space differed by less than 10% after 2 d exposure time, showing that carefully controlled conditions are not necessary for the accurate calibration of charcoal canisters. Furthermore, measurement accuracy differed by less than 2% for different spectral region selections. Accuracy improved slightly with canister exposure duration. Simulations suggest that radon instability is most tolerable near the beginning of canister calibration exposures, but this merits further experimental study.

07 ISOTOPE AND RADIATION SOURCES↗

Gafchromic EBT2 film dosimetry in reflection mode with a novel plan-based calibration method

Purpose:A dosimetric system formed by Gafchromic EBT2 radiochromic film and Epson Expression 10000XL flatbed scanner was commissioned for dosimetry. In this paper, several open questions concerning the commissioning of radiochromic films for dosimetry were addressed: (a) is it possible to employ this dosimetric system in reflection mode; (b) if so, can the methods used in transmission mode also be used in reflection mode; (c) is it possible to obtain accurate absolute dose measurements with Gafchromic EBT2 films; (d) which calibration method should be followed; (e) which calibration models should be used; and (f) does three-color channel dosimetry offer a significant improvement over single channel dosimetry. The purpose of this paper is to help clarify these questions. Methods: In this study, films were scanned in reflection mode, the effect of surrounding film was evaluated and the feasibility of EBT2 film dosimetry in reflection mode was studied. EBT2's response homogeneity has been reported to lead to excessive dose uncertainties. To overcome this problem, a new plan-based calibration method was implemented. Plan-based calibration can use every pixel and each of the three color channels of the scanned film to obtain the parameters of the calibration model. A model selection analysis was conducted to select lateral correction and sensitometric curve models. The commonly used calibration with fragments was compared with red-channel plan-based calibration and with three-channel plan-based calibration. Results: No effect of surrounding film was found in this study. The film response inhomogeneity in EBT2 films was found to be important not only due to differences in the fog but also due to differences in sensitivity. The best results for lateral corrections were obtained using absolute corrections independent of the dose. With respect to the sensitometric curves, an empirical polynomial fit of order 4 was found to obtain results equivalent to a gamma-distributed single hit model based on physical assumptions. Three-channel dosimetry was found to be substantially superior to red-channel dosimetry. Conclusions: Reflection mode with Gafchromic EBT2 radiochromic film was found to be a viable alternative to transmission mode. The same methods that are used in transmission mode can be followed in reflection mode. A novel plan-based method was developed for calibration and multichannel dosimetry. This novel method offers increased robustness against film response inhomogeneities and reduces considerably the time required for calibration.

60 APPLIED LIFE SCIENCES↗

SU-E-P-01: An Informative Review On the Role of Diagnostic Medical Physicist in the Academic and Private Medical Centers

Purpose: The role of physicist in the academic and private hospital environment continues to evolve and expand. This becomes more obvious with the newly revised requirements of the Joint Commission (JC) on imaging modalities and the continued updated requirements of ACR accreditation for medical physics (i.e., starting in June 2014, a physicists test will be needed before US accreditation). We provide an informative review on the role of diagnostic medical physicist and hope that our experience will expedite junior physicists in understanding their role in medical centers, and be ready to more opportunities. Methods: Based on our experience, diagnostic medical physicists in both academic and private medical centers perform several clinical functions. These include providing clinical service and physics support, ensuring that all ionizing radiation devices are tested and operated in compliance with the State and Federal laws, regulations and guidelines. We also discuss the training and education required to ensure that the radiation exposure to patients and staff is as low as reasonably achievable. We review the overlapping roles of medical and health physicist in some institutions. Results: A detailed scheme on the new requirements (effective 7/1/2014) of the JC is provided. In 2015, new standards for fluoroscopy, cone beam CT and the qualifications of staff will be phased in. A summary of new ACR requirements for different modalities is presented. Medical physicist have other duties such as sitting on CT and fluoroscopy committees for protocols design, training of non-radiologists to meet the new fluoroscopy rules, as well as helping with special therapies such as Yittrium 90 cases. Conclusion: Medical physicists in both academic and private hospitals are positioned to be more involved and prominent. Diagnostic physicists need to be more proactive to involve themselves in the day to day activities of the radiology department.

60 APPLIED LIFE SCIENCES↗