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to new paradigms in radiotherapy combined with systemic treatment.
Novel dosimetry methods
69 speaker
3D DOSIMETRY SYSTEMS - GELS, EPIDS AND OTHERS
M. Duchateau1 , D. Verellen1 , T. Depuydt1 , K. Tournel1 , T. Reynders1 , T.
Gevaert1 , K. Leysen1 , A. Gulyban1 , K. Poels1 , M. De Ridder1
1 general quality assurance equipment for external-beam radiotherapy (for ex-
UZ B RUSSEL O NCOLOGY C ENTRE, Radiotherapy, Jette, Belgium
Treatment modalities are becoming more and more complex in order to en-
able advanced patient treatments with a higher dose to the tumor while spar-
ing the organs at risk. The last couple of years a lot of new treatment tech-
niques and modalities became commercially available such as Intensity mod-
ulated radiotherapy (IMRT), Helical Tomotherapy, gated treatments, tumor
tracking, VMAT, RapidArc, IMAT, dynamic delivery techniques (leafs, gantry
and couch), atness lter free (FFF) designs, etc..
Although the compliance rate for beam calibration is improving and near 98%
for both photon and electron beams, increasing treatment complexity leads
to more technically advanced components in the treatment chain, possibly in-
ducing discrepancies. Credential audit results from the Radiological Physics
Center (RPC) indicate that roughly 30% of the institutions failed to deliver an
IMRT dose distribution to a head and neck phantom that agrees with their own
treatment plan to within 7% or 4mm. So, even though the use of advanced
dosimetry equipment for QA is wide spread, it seams that a lot of caveats are
still present in the QA chain of advanced treatment techniques.
The choice of a specic QA system depends on the number of treatment pa-
rameters to be veried and the extensiveness of the desired QA process. For
this choice the use of the conceptual pyramid was proposed by De Wagter
et al. In this conceptual pyramid the treatment chain is divided into 4 levels
of specicity, all based on the stability of the underlying levels. On top of the
pyramid (level 4) we can nd the 3D dosimetry of the entire treatment delivery.
Descending brings us to level 3 where we nd the 1D-2D dosimetry of individ-
ual beam components. Level 2 is the planning system and data consistency
QA level and at the ground level (level 1) we nd the machine QA level.The
best way to use the conceptual pyramid is the top down approach where a
3D dosimetry of the entire treatment is delivered to a phantom. When the re-
sults show discrepancies, lower levels of the pyramid should be sought to nd
answers. 3D dose distributions are QAed using different types of dosimeters
such as; lm (EDR2 and EBT2), diode arrays, ionization chamber arrays,
EPID detectors, MVCT imaging detectors, etc...
Is this talk we will try to give a general overview of dosimetry techniques used
to QA 3D dose distributions and we will try to answer some questions:
- What techniques are used and are the QA tools keeping up with the rapid
evolutions of the treatment machine manufacturers ?
- How are they applied in the different levels of the conceptual pyramid ?
- Is 3D really 3D ?
- Where do they stand compared to the ideal dosimeter ?
- What are the pros and cons of each group of dosimeters ?
- How do they t in the workow ?
70 speaker
ONLINE LUMINESCENCE DOSIMETRY
C. E. Andersen1
1
R IS N ATIONAL L ABORATORY, T ECHNICAL U NIVERSITY OF D ENMARK,
Department of Medical Physics, Roskilde, Denmark
Radioluminescence (RL) and optically stimulated luminescence (OSL) from
certain phosphors can be used for dosimetry in diagnostic and therapeutic
radiology, and RL/OSL dosimetry is an active area of research for several
groups. The objective of this work was to outline and review the current sta-
tus of this eld. RL/OSL dosimetry is entirely based on optical signals, and
it is therefore possible to perform online real-time read out using thin optical
ber cables and remotely placed instrumentation. Fiber-coupled RL dosime-
try can be carried out on the basis of a fraction of a mg of plastic scintillator
material attached to a 10-20 m long optical ber cables of plastic. During
irradiation, such a dosimeter probe spontaneously emits RL in proportion to
the instantaneous dose rate at the point of the scintillator. The luminescence
intensity can be detected with photomultiplier tubes, CCD cameras or other
highly sensitive photodetectors. Some crystalline inorganic phosphors, such
as carbon-doped aluminium oxide (Al2O3:C) have the ability to store charge
produced in the crystal during irradiations. The stored charge may later be
released by ber-guided laser light under emission of OSL. This OSL sig-
nal therefore reects the passively integrated dose since the dosimeter was
last read out. In contrast to thermoluminescence dosimetry, ber-coupled
OSL dosimetry may be performed in vivo while the dosimeter is still in the
patient. Some of the attractive features of RL/OSL dosimetry was found to
be: sub-mm detector size, high dynamic range (below a mGy to several Gy),
and absence of electrical wires or other electronics in the dosimeter probe
S YMPOSIUM
heads. RL dosimetry based on plastic scintillators were found to be of par-
ticular interest due to their direct water equivalence (i.e. such detectors do
not cause signicant perturbation of the radiation eld in a water phantom
or a patient) and they have a fast (ns) time-response which allows for dose-
per-pulse measurements in linear accelerator beams. The prime challenges
with RL/OSL dosimetry was found to be ionization quenching (i.e. lack of
proportionality between absorbed energy in the detector and light output for
highly dense ionizations) and interference by light signals generated in the op-
tical ber cable during irradiations. The most promising uses of ber-coupled
RL/OSL dosimetry seemed to be online time-resolved in vivo dosimetry (es-
pecially for remotely afterloaded brachytherapy and diagnostic radiology) and
ample, scintillator arrays tailored for measurements in small elds or dynamic
treatments).
71 speaker
LITHIUM FORMATE EPR DOSIMETRY FOR DOSIMETRY VERIFICA-
TIONS IN RADIOTHERAPY
S. Olsson1
1
L INKPING U NIVERSITY H OSPITAL, Radiation Physics, Linkping, Sweden
Electron paramagnetic resonance (EPR) dosimetry with alanine is becom-
ing more and more appreciated as a dosimetry method in radiotherapy due
to its broad linear dose range and low energy dependence. The alternative
dosimeter material lithium formate has a sensitivity that is at least a factor of
two higher than alanine. In addition, the material is even more tissue equiva-
lent than alanine regarding mass energy absorption coefcient and stopping
power, which makes the signal more independent of beam quality. The de-
pendence of linear energy transfer (LET) of the signal is an important aspect
both for applications with heavy particles and for brachytherapy applications
with low photon energies. For photons, a small LET dependence, 5-6%, for
energies below 100 keV has been found, but there are no signs of any dose
rate dependence. For high LET beams, a strong LET dependence of the
signal have been observed, comparable to earlier results for alanine and am-
monium tartrate. Another feature of lithium formate is that the spectrum has
only one peak whereas alanine has ve. This makes the material possible to
use for EPR imaging where a 2D or 3D dose distribution in a small volume
can be obtained with a high spatial resolution.
However, the suitability for applications such as dosimetry audits, measure-
ments under non-reference conditions and brachytherapy also includes more
practical aspects. One is the possibility to make pellets. The material can
be pressed to pellets manually, but more work is needed to develop an au-
tomated process. Another practical aspect is how the signal is affected by
humidity as well as storing and readout temperature. The time dependence
of the signal is affected primarily by air humidity in a complex process that
is not yet fully explored. The inuence of short-time storing temperature has
been tested and found to be insignicant in the range -20 C to +40 C. A
more thorough study of the time dependence is initiated, primarily to nd
a robust method for dosimetry audits with measurements in non-reference
conditions. A pilot-study with such a system for dosimetry audits has been
performed with promising results. Lithium formate has also successfully been
tested for applications such as pre treatment verication of an IMRT plan and
phantom measurements in stereotactic radiosurgery, as well as for measure-
ments around 192 Ir brachytherapy sources.
Once the manufacturing and time dependence issues are solved, EPR
dosimetry with lithium formate will be valuable as a complement to other clin-
ical dosimetry methods.
From conventional to advance practice on miscel-
laneous treatments
72 speaker
CURRENT STATUS ON TOTAL SKIN ELECTRON IRRADIATION
S. Hynds1 , D. Irvine2 , R. Houston1 , P. Henry1 , S. Stranex1 , J. McAleer1 , J.
OSullivan1 3
1
B ELFAST C ITY H OSPITAL, Radiotherapy Department, Belfast, United
Kingdom
2
B ELFAST C ITY H OSPITAL, Medical Physics Department, Belfast, United
Kingdom
3
C ENTRE FOR C ANCER R ESEARCH & C ELL B IOLOGY, Q UEEN S U NIVER -
SITY B ELFAST, Belfast, United Kingdom
Introduction: Total Skin Electron Beam Therapy (TSEBT) has been used for
many years in the palliation of Cutaneous T Cell Lymphoma (CTCL) such as
Mycosis Fungoides. This rare condition often presents clinically with multiple
cutaneous lesions, severe itch and skin ulceration. The aim of the TSEBT
technique is to uniformly deliver a specied dose over the entire skin surface
to a depth of approx. 8mm to avoid penetration to bone marrow and other or-
gans. The Northern Ireland Cancer Centre, Belfast is the only site that offers
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patients the TSEBT technique on the island of Ireland, with a total number of
36 patients treated since 1993. The aim of this review is to report the changes
to our technique in the past 4 years.
Methods: In March 2006, due to the transfer of clinical services, the TSEBT
technique was re-commissioned on 2 Varian 2100CD Linacs. The original
modied version of the Stanford system consisted of 6 static elds which did
not fully comply with the EORTC guidelines published in 2002. The TSEBT
technique was changed to a dual angled beam Stanford system with 6 patient
positions per appointment and treatment delivered with 12 beams (2 beams
per eld). This presentation will describe in detail the changes implemented
at the N.I. Cancer Centre, Belfast.
Results: In total 4 patients have been treated with the dual angled beam
Stanford technique since 2007, 1 patient died shortly after nishing treatment
and 3 are alive with disease.
The dose and fractionation has changed in line with the EORTC guidelines
from 20Gy in 10 fractions or 36 Gy in 18 fractions to 30Gy in 20 fractions over
5 weeks, treating 4 days per week. An in-house treatment stand has been
developed to raise the patient 20cms above the ground into the central part
of the beam and to provide patient support. A 3mm Polycarbonate degrader
mounted on casters is placed in front of the patient stand during treatment to
achieve the required beam energy.
Conclusions: The EORTC guidelines for TSEBT published in 2002 changed
our local clinical protocol in terms of dose, fractionation/overall treatment time,
QA procedures and treatment set-up. The dual angled beam Stanford tech-
nique in Belfast conforms to these guidelines in terms of beam characteristics,
uniformity and x-ray contamination levels.
et al Treatment of children with medulloblastomas (MB) with reduced-dose
CSA RT and adjuvant chemotherapy: A CCG Study. J Clin Oncol. 1999
Jul;17(7):2127-36) The quality of the radiotherapy delivered may be a major
contributing factor to outcome and thus a technique which is able to verify
eld matches, effect a moving gap and compensate for the inhomogeneity
involved in treating the entire length of the spine while being tolerable for the
patient is still a goal for some centres. Results: Conventional techniques
consisting of overlapped posterior photon elds, with boost elds to provide
additional dose homogeneity, conform poorly to the target volume. This is
overcome with helical tomotherapy, although at the expense of a larger vol-
ume of normal tissue irradiated to a low dose (Parker et al. Standard and
nonstandard craniospinal radiotherapy using helical TomoTherapy. Int J Ra-
diat Oncol Biol Phys. 2010;77(3):926-3). Tomotherapy also eliminates the
need for matched elds. Proton therapy avoids irradiating large volumes of
the patient to low dose, but still requires eld matching (St. Clair et al. Advan-
tage of protons compared to conventional X-ray or IMRT in the treatment of a
pediatric patient with MB. Int J Radiat Oncol Biol Phys. 2004;58(3):727-34).
VMAT offers a practical solution, based on a linac, which does not require
eld matching (Lee et al. Development and evaluation of multiple isocentric
VMAT technique for CSA RT planning. Int J Radiat Oncol Biol Phys. in press).
Recent research towards helical VMAT also promises to provide a simple and
efcient delivery solution.Conclusion: Crucially more centres delivering CSA
RT do so with a supine technique, and for those achieving this, improving ac-
curacy, verication and reduced OAR dose is the next step. Patient comfort
and tolerability are much improved with the supine technique, but it is still
challenging for some due to technical restrictions.

73 speaker

IMMOBILISATION METHODS IN SARCOMA TREATMENTS

C. Dickie1
1
P RINCESS M ARGARET H OSPITAL, Radiation Technology, Toronto, Canada

Rarity of sarcoma in addition to heterogeneity of anatomic site provides

unique challenges in the management of this disease. Improvement in the
accuracy of immobilization methods parallels the advance of modern exter-
nal beam radiotherapy approaches.
The objective of this lecture is to provide an overview of sarcoma immobiliza-
tion methods from conventional radiotherapy to advanced practice, focusing
on common problems encountered while attempting to minimize set up un-
certainty related to sarcoma treatment.
The treatment paradigm for sarcoma has evolved from conventional two or
three eld techniques to highly conformal targeted therapy using online 3D
daily image guidance with evidence based error margins and dose objectives
for critical structure avoidance. Effective limb immobilization is an essen-
tial element of accurate and precise radiotherapy targeting. Immobilization
methods used within our institution have included sand bags, thermoplastic
moulds, polystyrene-lled cradles and an innovative custom device. Goals
for limb immobilization in the modern era should include patient comfort for
lengthy treatment and imaging procedures, limb stability in all cardinal direc-
tions, rotational reproducibility, reduction of the random and systematic set up
error, and user friendliness/durability for efcient workow.
The development of patented inventions such as a versatile extremity im-
mobilization device and a linear accelerator bed extension to accommodate
complex asymmetrical patient setups and variable anatomical tumour presen-
tation will also be discussed.

74 speaker

AN OVERVIEW OF CSA RT; PAST, PRESENT AND FUTURE DEVEL-

OPMENTS
H. Taylor1 , Y. Lee2 , J. Bedford2 , F. Saran3
1
T HE R OYAL M ARSDEN NHS F OUNDATION T RUST, Radiotherapy Dept.,
Sutton, United Kingdom
2
R OYAL M ARSDEN H OSPITAL T RUST & I NSTITUTE OF C ANCER R ESEARCH,
Physics Dept., London, United Kingdom
3
T HE R OYAL M ARSDEN NHS F OUNDATION T RUST, Radiotherapy Dept,
Sutton, United Kingdom

This presentation will review the indications for Cranio-spinal Axis (CSA) RT
and then provide a brief history of the technique. It will concentrate predom-
inantly on recent developments of a supine CT planned technique and then
discuss novel techniques being studied or implemented currently. Their ob-
jectives are to decrease the acute side-effects and late effects of radiation
without reducing survival in both paediatric and adult CSA RT. A comfortable,
reproducible position for the patient is required, and an elegant solution to the
inherent problem of matching elds and reducing dose to OAR such as the
heart, thyroid and abdomen.Methods: Radiotherapy of the CSA is indicated
in primary tumours with a high propensity to spread through the CSF (e.g.
PNETs, ependymoma). Over the last 2 decades a reduction in dose to the
CSA has been possible due to the addition of adjuvant chemotherapy. Many
groups have looked at this with the Packer regimen being developed in the
mid 1990s reducing CSA dose to 23.4Gy for Standard risk disease. (Packer