State of the art of in vivo dosimetry

Ben Mijnheer

Why in vivo dosimetry during radiotherapy?

To reduce the risk of serious accidents.

so what?
major accidents do happen...rarely

UT B

they send a shock wave to radiotherapy departments all over the world

 At NKI-AVL 300 patients are treated per day Systematic errors affect large patient groups

1908.

Why in vivo dosimetry during radiotherapy?

To reduce the risk of serious accidents. To ensure the patient was treated as planned.

Why in vivo dosimetry during radiotherapy?

To reduce the risk of serious accidents. To ensure the patient was treated as planned. For legal reasons.

Dosimetry in radiotherapy
0D
dose (cGy)
220 215 210 205 200 195 1 2 3 4 5 6 7 8

1D

2D

points, lines, planes

patient #

in phantoms

not often in vivo

Definition of in vivo dosimetry

In vivo dosimetry can be done in two ways: a suitable probe can be inserted into the patient to measure the dose directly but invasively, or a detector can be placed against or at some distance from the patient to measure the dose non-invasively. In the latter case the dose inside the patient is calculated with a suitable mathematical model, using the dose measured at the position of the detector. The use of dosimeters positioned on the skin or behind a patient belongs to the second category of in vivo dosimetry.

Techniques of in vivo dosimetry

Entrance dose measurements serve to check the monitor unit (time) calculation, the patient set-up, the presence of a wedge and the machine performance. Exit dose measurements serve in addition to check the influence of the patient on the dose calculation (presence of inhomogeneities, missing tissue.). In some special situations it is possible to apply intracavitary in vivo dosimetry.

Detectors most often used for in vivo dosimetry purposes

Diodes Thermoluminescense detectors (TLDs) Metal Oxide Field Effect Transistors (MOSFETs) Electronic Portal Imaging Devices (EPIDs)

In vivo dosimetry using diodes

Derivation of absorbed dose to water, D, from diode reading, R

D = R . ND . i ki
where ND is the absorbed dose to water calibration factor of the diode under reference conditions, ki are factors that correct for the change in diode response with field size, SSD, the presence of a wedge, temperature and patient thickness (only for exit dose).

Derivation of midline dose from entrance and/or exit dose

In vivo dosimetry of breast cancer

Copenhagen:

In vivo dosimetry of breast cancer

Copenhagen: Entrance dose measurements of mastectomy patients showed a 3.5% systematic deviation from the expected value. An investigation of possible causes revealed errors in the output factors used to calculate monitor units in quarter fields (3/4 blocked field).

Three-field 3D-CRT technique at NKI-AVL

8 MV

18 MV

18 MV

First patients were planned with a 2D treatment planning system. From 1993 on, patients were planned with a 3D treatment planning system (U-MPlan) using a home-made MU calculation programme.

IVD results 3D-CRT prostate treatments

5.0

Deviation (%)

2.5

0.0

-2.5

-5.0 0 50 100 150 200 250 300

Patient number

Thermoluminescent dosimeters

Mainly used for in vivo dosimetry in special cases, for example complicated geometries, dose at organs at risk and total body irradiation (TBI)

In vivo dose verification of IMRT of head and neck cancer patients using TLD rods

(P.E. Engstrm, et al., Acta Oncol. 44, 572-578, 2005)

MOSFET dosimeters

Electronic chip of silicon Sensitive area 0.2 mm x 0.2 mm Epoxy coating 5 dosimeters connect to 1 bias box Post-irradiation readout Reproducibility 1.5 to 2% (1 SD)

In vivo dose verification of TBI using TLD and MOSFETs

(E. Bloemen-van Gurp et al., Int. J. Radiat. Oncol. Biol. Phys. 69:1297-1304, 2007)

In vivo dose verification of TBI using TLD and MOSFETs

260.0 250.0 240.0 230.0 220.0 210.0 200.0 190.0 180.0 170.0 160.0 1 2 3 4 5

Midline dose (cGy)

MOSFET TLD
TPS

Location

(E. Bloemen-van Gurp et al., Int. J. Radiat. Oncol. Biol. Phys. 69:1297-1304, 2007)

MOSFETs compared to diodes

MOSFETs differ from diodes in that they show no sensitivity variation with temperature and with accumulated dose. However, these factors do not overcome other shortcomings such as their less good intrinsic precision and their short lifetime. Because of their short lifetime, 50 Gy in the high sensitivity mode, extensive calibration work cannot be performed.

Amorphous silicon (a-Si) type of Electronic Portal Imaging Device (EPID)

Portal imaging

Back-project to dose grid from transit images

1. 2. 3.
dose calculation algorithm EPID

measure open and transit EPID dose image estimate and subtract EPID and patient/phantom scatter back-project primary dose to multiple planes to form dose grid using CT data total dose = primary + patient scatter (based on transmission)
Med Phys (30) 2003 Proc 9th EPI 2006 ESTRO 25 2006

4.

Louwe Wendling

2D in vivo dosimetry using EPIDs

5-field IMRT prostate cancer treatment 18 MV beam TPS: Pinnacle 3D -evaluation with 3% of dose at isoc. 3 mm DTA

Within 20% isodose line of plan (including build-up regions): mean -value = 0.58; SD = 0.41 percentage of points with a -value 1 = 95%

Patient record of -evaluation

Per field: mean max (1%) % points <1 isoc dose Per fraction isoc dose Warning: yellow Error: orange

Patient record of -evaluation

Per field: mean max (1%) % points <1 isoc dose

O O

Per fraction isoc dose Warning: yellow Error: orange

Large scale clinical IMRT verification

Current situation: all IMRT treatments are verified by means of EPID dosimetry (in vivo / pre-treatment) pilot study breast & lung Goal for 2008: all curative treatments will be performed using IMRT techniques and verified by means of EPID dosimetry (in vivo / pre-treatment) Goal 01-2009: In vivo EPID dosimetry will be fully implemented

Overview of patient groups at NKI-AVL

Site Prostate Rectum Head & neck Skull / liver Gynecology Other (IMRT) Breast Lung Verification in vivo in vivo in vivo in vivo pre-treatment pre-treatment in preparation in preparation Patients per year 230 200 250 60 70 90 700 400 2000 Time needed : pre-treatment 100 min in vivo 45 min (15 + 10 / fraction)

Future: 3D approach
1) calculate plan 2) measure EPID dose 3) reconstruct dose in many planes for all gantry angles

patient (CT)

4) compare plan and reconstructed patient dose

Furure: 3D in vivo dose reconstruction

5-field IMRT prostate cancer treatment 18 MV beam 3D -evaluation with criteria: 3% of dose at isoc. and 3 mm DTA CT dose -index

Conclusions in vivo dosimetry (1)

If a high accuracy in dose delivery is required, such as in conformal radiotherapy or IMRT, and to avoid accidents, it is highly recommended to perform in vivo dosimetry during a few treatment sessions.

Conclusions in vivo dosimetry (1)

If a high accuracy in dose delivery is required, such as in conformal radiotherapy or IMRT, and to avoid accidents, it is highly recommended to perform in vivo dosimetry during a few treatment sessions. The permanent availability of EPIDs on accelerators makes them attractive tools for in vivo dose verification.

Conclusions in vivo dosimetry (2)

If performed properly, the workload involved with in vivo dosimetry is limited and errors of a few percent can be detected.

Conclusions in vivo dosimetry (2)

If performed properly, the workload involved with in vivo dosimetry is limited and errors of a few percent can be detected. Corrections of a systematic error traced by means of in vivo dosimetry will not only benefit the treatment of a specific patient or patient group, but will improve the quality of many future patient treatments.

Many thanks for your attention