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The effect of the jaw configuration and the presence and configuration of the tertiary multileaf collimator (MLC) on the secondary neutron spectra for an 18 MV Varian 21EX linear accelerator (linac) is investigated in detail. The authors report the measured spectra for four collimator (jaw-and-MLC) configurations. These configurations represent the extreme settings of the jaws and MLC and should therefore describe the range of possible fluence and spectra that may be encountered during use of this linac. In addition to measurements, a Monte Carlo model was used to simulate the four collimator configurations and calculate the energy spectra and fluence at the same location as it was measured. The Monte Carlo model was also used to calculate the sources of neutron production in the linac head for each collimator configuration. They found that photoneutron production in the linac treatment head is dominated by the order in which the primary photon beam intercepts the high-Z material. The primary collimator, which has the highest position in the linac head (in a fixed location), is the largest source of secondary neutrons. Thereafter, the collimator configuration plays a role in where the neutrons originate. For instance, if the jaws are closed, they intercept the beam and contribute substantially to the secondary neutron production. Conversely, if the jaws are open, the MLC plays a larger role in neutron production (assuming, of course, that it intercepts the beam). They found that different collimator configurations make up to a factor of 2 difference in the ambient dose equivalent.

Neutrons are by-products of high-energy radiation therapy and a source of dose to normal tissues. Thus, the presence of neutrons increases a patient’s risk of radiation-induced secondary cancer. Although neutrons have been thoroughly studied in air, little research has been focused on neutrons at depths in the patient where radiosensitive structures may exist, resulting in wide variations in neutron dose equivalents between studies. In this study, we characterized properties of neutrons produced during high-energy radiation therapy as a function of their depth in tissue and for different field sizes and different source-to-surface distances (SSD). We used a previously developed Monte Carlo model of an accelerator operated at 18 MV to calculate the neutron fluences, energy spectra, quality factors, and dose equivalents in air and in tissue at depths ranging from 0.1 to 25 cm. In conjunction with the sharply decreasing dose equivalent with increased depth in tissue, the authors found that the neutron energy spectrum changed drastically as a function of depth in tissue. The neutron fluence decreased gradually as the depth increased, while the average neutron energy decreased sharply with increasing depth until a depth of approximately 7.5 cm in tissue, after which it remained nearly constant. There was minimal variation in the quality factor as a function of depth. At a given depth in tissue, the neutron dose equivalent increased slightly with increasing field size and decreasing SSD; however, the percentage depth-dose equivalent curve remained constant outside the primary photon field. Because the neutron dose equivalent, fluence, and energy spectrum changed substantially with depth in tissue, we concluded that when the neutron dose equivalent is being determined at a depth within a patient, the spectrum and quality factor used should be appropriate for depth rather than for in-air conditions. Alternately, an appropriate percent depth-dose equivalent curve should be used to correct the dose equivalent at the patient surface.

Neutron production is an unwanted result of high-energy radiation therapy and results in secondary exposure of patients and radiation therapists to radiation. Recent studies have shown that delivering therapy using a standard medical accelerator with the flattening filter removed may reduce neutron fluence by nearly 70% over the course of prostate intensity-modulated radiation therapy (IMRT). In the current study, the 197Au Bonner sphere technique was used to compare the neutron spectrum produced when the filter is present and when it is absent. In addition, the following was calculated: (1) the neutron-shielding parameters of source strength and ambient dose equivalent (H0) and (2) using the Monte Carlo technique, the sources of neutron production in the accelerator head. It was found that the neutron spectrum was nearly constant, regardless of the presence of the flattening filter; however, the total fluence and ambient dose equivalent over the course of prostate IMRT were more than 70% lower when the filter was removed. Similarly, shielding parameters were lower when the filter was removed. Finally, the primary collimator and jaws accounted for the majority of neutron production, both with and without the flattening filter; however, with the flattening filter removed, the upper jaw accounted for much more neutron production relative to when the filter was present. Ultimately, removal of the flattening filter may offer several clinical advantages, including a reduction in the dose from neutrons to the patient and to radiation personnel.

Purpose To evaluate the photon and neutron out-of-field dose equivalents from 6- and 18-MV intensity-modulated radiation therapy (IMRT) and to investigate the impact of the differences on the associated risk of induced second malignancy using a Monte Carlo model. Methods and materials A Monte Carlo model created with MCNPX was used to calculate the out-of-field photon dose and neutron dose equivalent from simulated IMRT of the prostate conducted at beam energies of 6 and 18 MV. The out-of-field dose equivalent was calculated at the locations of sensitive organs in an anthropomorphic phantom. Based on these doses, the risk of secondary malignancy was calculated based on organ-, gender-, and age-specific risk coefficients for a 50-year-old man. Results The Monte Carlo model predicted much lower neutron dose equivalents than had been determined previously. Further analysis illuminated the large uncertainties in the neutron dose equivalent and demonstrated the need for better determination of this value, which plays a large role in estimating the risk of secondary malignancies. The Monte Carlo calculations found that the differences in the risk of secondary malignancies conferred by high-energy IMRT versus low-energy IMRT are minimal and insignificant, contrary to prior findings. Conclusions The risk of secondary malignancy associated with high-energy radiation therapy may not be as large as previously reported, and likely should not deter the use of high-energy beams. However, the large uncertainties in neutron dose equivalents at specific locations within the patient warrant further study so that the risk of secondary cancers can be estimated with greater accuracy.

Dose rates at several locations outside a treatment room were measured for 6 and 18 MV photon beams from a Varian Clinac 21EX accelerator operated with and without a flattening filter. Also, dose rates in the treatment room due to activation were measured at 18 MV. An analysis of the measured data is presented. The results suggest that substantial reduction in doses outside the treatment room and lower activation can be achieved with a flattening-filter free accelerator.

The American Association of Physicists in Medicine Radiation Therapy Committee Task Group 36 report (TG-36) provides guidelines for managing radiation therapy of pregnant patients. Included in the report are data that can be used to estimate the dose to the fetus. The purpose of this study is to evaluate the accuracy of these fetal dose estimates as compared to clinically measured values. TG-36 calculations were performed and compared with measurements of the fetal dose made in vivo or in appropriately-designed phantoms. Calculation and measurement data was collected for eight pregnant patients who underwent radiation therapy at the MD Anderson Cancer Center as well as for several fetal dose studies in the literature. The maximum measured unshielded fetal dose was 47 cGy, which was 1.5% of the prescription dose. For all cases, TG-36 calculations and measured fetal doses differed by up to a factor of 3--the ratio of the calculated to measured dose ranged from 0.34 to 2.93. On average, TG-36 calculations underestimated the measured dose by 31%. No significant trends in the relationship between the calculated and measured fetal doses were found based on the distance from, or the size of, the treatment field.

Purpose: To assess the perception of TG-142 tolerance level dose delivery failures in IMRT and the application of FMEA process to this specific aspect of IMRT. Methods: An online survey was distributed to medical physicists worldwide that briefly described 11 different failure modes (FMs) covered by basic quality assurance in step- and-shoot IMRT at or near TG-142 tolerance criteria levels. For each FM, respondents estimated the worst case H&N patient percent dose error and FMEA scores for Occurrence, Detectability, and Severity. Demographic data was also collected. Results: 181 individual and three group responses were submitted. 84% were from North America. Most (76%) individual respondents performed at least 80% clinical work and 92% were nationally certified. Respondent medical physics experience ranged from 2.5–45 years (average 18 years). 52% of individual respondents were at least somewhat familiar with FMEA, while 17% were not familiar. Several IMRT techniques, treatment planning systems and linear accelerator manufacturers were represented. All FMs received widely varying scores ranging from 1–10 for occurrence, at least 1–9 for detectability, and at least 1–7 for severity. Ranking FMs by RPN scores also resulted in large variability, with each FM being ranked both most risky (1st ) and least risky (11th) by different respondents. On average MLC modeling had the highest RPN scores. Individual estimated percent dose errors and severity scores positively correlated (p

Purpose: To validate a secondary treatment planning system (sTPS) for use by the Imaging & Radiation Oncology Core-Houston (IROC-H). The TPS will recalculate phantom irradiations submitted by institutions to IROC-H and compare plan results of the institution to the sTPS. Methods: In-field dosimetric data was collected by IROC-H for numerous linacs at 6, 10, 15, and 18 MV. The data was aggregated and used to define reference linac classes; each class was then modeled in the sTPS (Mobius3D) by matching the in-field characteristics. Fields used to collect IROC-H data were recreated and recalculated using Mobius3D. The same dosimetric points were measured in the recalculation and compared to the initial collection data. Additionally, a 6MV Monte Carlo beam configuration was used to compare penumbrae in the Mobius3D models. Finally, a handful of IROC-H head and neck phantoms were recalculated using Mobius3D. Results: Recalculation and quantification of differences between reference data and Mobius3D values resulted in a relative matching score of 12.45 (0 is a perfect match) for the default 6MV Mobius3D beam configuration. By adjusting beam configuration options, iterations resulted in scores of 8.45, 6.32, and 3.52, showing that customization could have a dramatic effect on beam configuration. After in-field optimization, penumbra was compared between Monte Carlo and Mobius3D for the reference fields. For open jaw fields, FWHM field widths and penumbra widths were different by

Purpose: To highlight the IROC Houston on-site dosimetry audit program, and to investigate the impact of clinical conditions on the frequency of errors/recommendations noted by IROC Houston. Methods: The results of IROC Houston on-site audits from 2000-present were abstracted and compared to clinical parameters, this included 409 institutions and 1020 linacs. In particular, we investigated the frequency of recommendations versus year, and the impact of repeat visits on the number of recommendations. We also investigated the impact on the number of recommendations of several clinical parameters: the number and age of the linacs, the linac/TPS combination, and the scope of the QA program. Results: The number of recommendations per institution (3.1 average) has shown decline between 2000 and present, although the number of recommendations per machine (0.89) has not changed. Previous IROC Houston site visits did not Result in fewer recommendations on a repeat visit, but IROC Houston tests have changed substantially during the last 15 years as radiotherapy technology has changed. There was no impact on the number of recommendations based on the number of machines at the institution or the age of a given machine. The fewest recommendations were observed for Varian-Eclipse combinations (0.71 recs/machine), while Elekta- Pinnacle combinations yielded the most (1.62 recs/machine). Finally, in the TG-142 era (post-2010), those institutions that had a QA recommendation (n=77) had significantly more other recommendations (1.83 per institution) than those that had no QA rec (n=12, 1.33 per institution). Conclusion: Establishing and maintaining a successful radiotherapy program is challenging and areas of improvement can routinely be identified. Clinical conditions such as linac-TPS combinations and the establishment of a good QA program impact the frequency of errors/deficiencies identified by IROC Houston during their on-site review process.

Purpose: To investigate two strategies for reducing dose calculation errors near metal implants: use of CT metal artifact reduction methods and implementation of metal-based energy deposition kernels in the convolution/superposition (C/S) method. Methods: Radiochromic film was used to measure the dose upstream and downstream of titanium and Cerrobend implants. To assess the dosimetric impact of metal artifact reduction methods, dose calculations were performed using baseline, uncorrected images and metal artifact reduction Methods: Philips O-MAR, GE’s monochromatic gemstone spectral imaging (GSI) using dual-energy CT, and GSI imaging with metal artifact reduction software applied (MARs).To assess the impact of metal kernels, titanium and silver kernels were implemented into a commercial collapsed cone C/S algorithm. Results: The CT artifact reduction methods were more successful for titanium than Cerrobend. Interestingly, for beams traversing the metal implant, we found that errors in the dimensions of the metal in the CT images were more important for dose calculation accuracy than reduction of imaging artifacts. The MARs algorithm caused a distortion in the shape of the titanium implant that substantially worsened the calculation accuracy. In comparison to water kernel dose calculations, metal kernels resulted in better modeling of the increased backscatter dose at the upstream interface but decreased accuracy directly downstream of the metal. We also found that the success of metal kernels was dependent on dose grid size, with smaller calculation voxels giving better accuracy. Conclusion: Our study yielded mixed results, with neither the metal artifact reduction methods nor the metal kernels being globally effective at improving dose calculation accuracy. However, some successes were observed. The MARs algorithm decreased errors downstream of Cerrobend by a factor of two, and metal kernels resulted in more accurate backscatter dose upstream of metals. Thus, these two strategies do have the potential to improve accuracy for patients with metal implants in certain scenarios. This work was supported by Public Health Service grants CA 180803 and CA 10953 awarded by the National Cancer Institute, United States of Health and Human Services, and in part by Mobius Medical Systems.

Purpose: To compare the CT Number (CTN) to Relative Linear Stopping Power (RLSP) conversion curves used by 14 proton institutions in their dose calculations. Methods: The proton institution’s CTN to RLSP conversion curves were collected by the Imaging and Radiation Oncology Core (IROC) Houston QA Center during its on-site dosimetry review audits. The CTN values were converted to scaled CT Numbers. The scaling assigns a CTN of 0 to air and 1000 to water to allow intercomparison. The conversion curves were compared and the mean curve was calculated based on institutions’ predicted RLSP values for air (CTN 0), lung (CTN 250), fat (CTN 950), water (1000), liver (CTN 1050), and bone (CTN 2000) points. Results: One institution’s curve was found to have a unique curve shape between the scaled CTN of 1025 to 1225. This institution modified its curve based on the findings. Another institution had higher RLSP values than expected for both low and high CTNs. This institution recalibrated their two CT scanners and the new data placed their curve closer to the mean of all institutions. After corrections were made to several conversion curves, four institutions still fall outside 2 standard deviations at very low CTNs (100–200), and two institutions fall outside between CTN 850–900. The largest percent difference in RLSP values between institutions for the specific tissues reviewed was 22% for the lung point. Conclusion: The review and comparison of CTN to RLSP conversion curves allows IROC Houston to identify any outliers and make recommendations for improvement. Several institutions improved their clinical dose calculation accuracy as a Result of this review. There is still area for improvement, particularly in the lung area of the curve. The IROC Houston QA Center is supported by NCI grant CA180803.

Purpose: To describe the extent of IROC Houston’s (formerly the RPC) QA activities and audit results for radiotherapy institutions outside of North America (NA). Methods: The IROC Houston’s QA program components were designed to audit the radiation dose calculation chain from the NIST traceable reference beam calibration, to inclusion of dosimetry parameters used to calculate tumor doses, to the delivery of the radiation dose. The QA program provided to international institutions includes: 1) remote TLD/OSLD audit of machine output, 2) credentialing for advanced technologies, and 3) review of patient treatment records. IROC Houston uses the same standards and acceptance criteria for all of its audits whether for North American or international sites. Results: IROC Houston’s QA program has reached out to radiotherapy sites in 43 different countries since 2013 through their participation in clinical trials. In the past two years, 2,778 international megavoltage beam outputs were audited with OSLD/TLD. While the average IROC/Inst ratio is near unity for all sites monitored, there are international regions whose results are significantly different from the NA region. In the past 2 years, 477 and 87 IMRT H&N phantoms were irradiated at NA and international sites, respectively. Regardless of the OSLD beam audit results, the overall pass rate (87 percent) for all international sites (no region separation) is equal to the NA sites. Of the 182 international patient charts reviewed, 10.7 percent of the dose calculation points did not meet our acceptance criterion as compared to 13.6 percent for NA sites. The lower pass rate for NA sites results from a much larger brachytherapy component which has been shown to be more error prone. Conclusion: IROC Houston has expanded its QA services worldwide and continues a long history of improving radiotherapy dose delivery in many countries. Funding received for QA audit services from the Korean GOG, DAHANCA, EORTC, ICON and CMIC Group

The introduction of advanced techniques and technology in radiotherapy has greatly improved our ability to deliver highly conformal tumor doses while minimizing the dose to the adjacent organs at risk. Despite these tremendous improvements there remains a general concern about doses to normal tissues outside the target volume. As patients live longer after treatment, there is increased opportunity for late effects including second cancers and cardiac toxicity to manifest. Complicating the management of these issues, there are unique challenges with measuring, calculating, and reducing non-target doses that many medical physicists may have limited experience with. Task Group (TG) 158, measurement and calculation of doses outside the treatment volume from external-beam radiation therapy was created to provide guidance for physicists in terms of assessing and managing non-target doses. This education session would highlight the major topics included TG-158. The principal objective for this session will be to provide guidance for medical physicists in terms of assessing and managing non-target doses. Learning Objectives: 1. To highlight major concerns with non-target radiation and provide a rough estimate of doses associated with different treatment approaches in clinical practice. 2. To discuss (a) uses of dosimeters and phantoms for measuring photon, electron, and neutron doses and (b) the use of calculation techniques (including Monte Carlo) for dosimetric evaluations. 3. To highlight techniques that may be considered for reducing non-target doses and summarize TG158 recommendations for both clinical and research practice.

Purpose: Accurately determining out-of-field doses when using electron beam radiotherapy is of importance when treating pregnant patients or patients with implanted electronic devices. Scattered doses outside of the applicator field in electron beams have not been broadly investigated, especially since manufacturers have taken different approaches in applicator designs. Methods: In this study, doses outside of the applicator field were measured for electron beams produced by a 10×10 applicator on two Varian 21iXs operating at 6, 9, 12, 16, and 20 MeV, a Varian TrueBeam operating at 6, 9, 12, 16, and 20 MeV, and an Elekta Versa HD operating at 6, 9, 12 and 15 MeV. Peripheral dose profiles and percent depth doses were measured in a Wellhofer water phantom at 100 cm SSD with a Farmer ion chamber. Doses were compared to peripheral photon doses from AAPM’s Task Group #36 report. Results: Doses were highest for the highest electron energies. Doses typically decreased with increasing distance from the field edge but showed substantial increases over some distance ranges. Substantial dose differences were observed between different accelerators; the Elekta accelerator had much higher doses than any Varian unit examined. Surprisingly, doses were often similar to, and could be much higher than, doses from photon therapy. Doses decreased sharply with depth before becoming nearly constant; the dose was found to decrease to a depth of approximately E(MeV)/4 in cm. Conclusion: The results of this study indicate that proper shielding may be very important when utilizing electron beams, particularly on a Versa HD, while treating pregnant patients or those with implanted electronic devices. Applying a water equivalent bolus of Emax(MeV)/4 thickness (cm) on the patient would reduce fetal dose drastically for all clinical energies and is a practical solution to manage the potentially high peripheral doses seen from modern electron beams. Funding from NIH Grant number: #CA180803

Dose to the patient outside of the treatment field is important when evaluating the outcome of radiotherapy treatments. However, determining out-of-field doses for any particular treatment plan currently requires either time-consuming measurements or calculated estimations that may be highly uncertain. A Monte Carlo model may allow these doses to be determined quickly, accurately, and with a great degree of flexibility. MCNPX was used to create a Monte Carlo model of a Varian Clinac 2100 accelerator head operated at 6 MV. Simulations of the dose out-of-field were made and measurements were taken with thermoluminescent dosimeters in an acrylic phantom and with an ion chamber in a water tank to validate the Monte Carlo model. Although local differences between the out-of-field doses calculated by the model and those measured did exceed 50% at some points far from the treatment field, the average local difference was only 16%. This included a range of doses as low as 0.01% of the central axis dose, and at distances in excess of 50 cm from the central axis of the treatment field. The out-of-field dose was found to vary with field size and distance from the central axis, but was almost independent of the depth in the phantom except where the dose increased substantially at depths less than dmax. The relationship between dose and kerma was also investigated, and kerma was found to be a good estimate of dose (within 3% on average) except near the surface and in the field penumbra. Our Monte Carlo model was found to well represent typical Varian 2100 accelerators operated at 6 MV.

Several studies have shown that removal of the flattening filter from the treatment head of a clinical accelerator increases the dose rate and changes the lateral profile in radiation therapy with photons. However, the multileaf collimator (MLC) used to shape the field was not taken into consideration in these studies. We therefore investigated the effect of the MLC on flattened and unflattened beams. To do this, we performed measurements on a Varian Clinac 21EX and MCNPX Monte Carlo simulations to analyze the physical properties of the photon beam. We compared lateral profiles, depth dose curves, MLC leakages, and total scatter factors for two energies (6 and 18 MV) of MLC-shaped fields and jaw-shaped fields. Our study showed that flattening filter-free beams shaped by a MLC differ from the jaw-shaped beams. Similar differences were also observed for flattened beams. Although both collimating methods produced identical depth dose curves, the penumbra size and the MLC leakage were reduced in the softer, unflattened beam and the total scatter factors showed a smaller field size dependence.

Purpose: The significance of risk estimates for fatal secondary malignancies caused by out-of-field radiation exposure remains unresolved because the uncertainty in calculated risk estimates has not been established. This work examines the uncertainty in absolute risk estimates and in the ratio of risk estimates between different treatment modalities. Methods and Materials: Clinically reasonable out-of-field doses and calculated risk estimates were taken from the literature for several prostate treatment modalities, including intensity-modulated radiotherapy (IMRT), and were recalculated using the most recent risk model. The uncertainties in this risk model and uncertainties in the linearity of the dose-response model were considered in generating 90% confidence intervals for the uncertainty in the absolute risk estimates and in the ratio of the risk estimates. Results: The absolute risk estimates of fatal secondary malignancy were associated with very large uncertainties, which precluded distinctions between the risks associated with the different treatment modalities considered. However, a much smaller confidence interval exists for the ratio of risk estimates, and this ratio between different treatment modalities may be statistically significant when there is an effective dose equivalent difference of at least 50%. Such a difference may exist between clinically reasonable treatment options, including 6-MV IMRT versus 18-MV IMRT for prostate therapy. Conclusion: The ratio of the risk between different treatment modalities may be significantly different. Consequently risk models and associated risk estimates may be useful and meaningful for evaluating different treatment options. The calculated risk of secondary malignancy should be considered in the selection of an optimal treatment plan.

In conventional clinical linear accelerators, the flattening filter scatters and absorbs a large fraction of primary photons. Increasing the beam-on time, which also increases the out-of-field exposure to patients, compensates for the reduction in photon fluence. In recent years, intensity modulated radiation therapy has been introduced, yielding better dose distributions than conventional three-dimensional conformal therapy. The drawback of this method is the further increase in beam-on time. An accelerator with the flattening filter removed, which would increase photon fluence greatly, could deliver considerably higher dose rates. The objective of the present study is to investigate the dosimetric properties of 6 and 18 MV photon beams from an accelerator without a flattening filter. The dosimetric data were generated using the Monte Carlo programs BEAMnrc and DOSXYZnrc. The accelerator model was based on the Varian Clinac 2100 design. We compared depth doses, dose rates, lateral profiles, doses outside collimation, total and collimator scatter factors for an accelerator with and without a flatteneing filter. The study showed that removing the filter increased the dose rate on the central axis by a factor of 2.31 (6 MV) and 5.45 (18 MV) at a given target current. Because the flattening filter is a major source of head scatter photons, its removal from the beam line could reduce the out-of-field dose.

Basic dosimetric properties of 6 MV and 18 MV photon beams from a Varian Clinac 21EX accelerator operating without the flattening filter have been measured. These include dose rate data, depth dose dependencies and lateral profiles in a water phantom, total scatter factors and transmission factors of a multileaf collimator. The data are reviewed and compared with measurements for the flattened beams. The unflattened beams have the following: a higher dose rate by factors of 2.3 (6 MV) and 5.5 (18 MV) on the central axis; lower out-of-field dose due to reduced head scatter and softer spectra; less variation of the total scatter factor with field size; and less variation of the shape of lateral dose profiles with depth. The findings suggest that with a flattening filter free accelerator better radiation treatments can be developed, with shorter delivery times and lower doses to normal tissues and organs.

Our purpose in this work was to validate a very detailed Monte Carlo model, developed in MCNPX, of a Millennium 120 multileaf collimator integrated into a Varian Clinac 21EX treatment head. The Monte Carlo results were compared with measurements for both the 6-MV and 18-MV photon modes. The following comparisons were performed: depth-dose curves, lateral profiles, multileaf collimator leakage, the tongue-and-grove test, and the round leaf-end test. The good agreement between the Monte Carlo simulations and measurements showed that our model is accurate. Consequently, the benchmarks provided by our study can be used in future Monte Carlo studies.

Purpose: To develop a quantitative image feature model to predict non‐small cell lung cancer (NSCLC) volume shrinkage from standard of care pre‐treatment CT images. Methods: 64 stage II‐IIIB NSCLC patients with similar treatments were all imaged using the same CT scanner and protocol. For each patient, the planning gross tumour volume (GTV) was deformed onto the week six treatment image, and tumour shrinkage was quantified as the deformed GTV volume divided by the planning GTV volume. Geometric, intensity histogram, absolute gradient image, co‐occurrence matrix, and run‐length matrix 3D quantitative image features were extracted multiple times from each planning GTV using a variety of feature extraction parameters. Prediction models were generated using principal component regression with simulated annealing subset selection; performance was quantified using the mean squared error (MSE) between the predicted and observed tumour shrinkages. Cross validation and permutation tests were used to validate the results. Results: The optimal model gave a strong correlation between the observed and predicted shrinkages with r=0.81 and MSE =0.0086. Compared to predictions based on the mean population shrinkage (i.e. predicted shrinkage = mean shrinkage; MSE =0.0251) this resulted a 2.92 fold reduction in MSE. That is, the tumor shrinkage uncertainty was reduced by a factor of approximately three. Conclusion: A quantitative image feature model can use existing CT images to successfully predict tumour shrinkage and provide additional information for clinical decisions regarding patient risk stratification, treatment, and prognosis.

Purpose: Out-of-field radiation doses to normal tissues may be associated with an increased risk of secondary malignancies, particularly in long-term survivors. Step-and-shoot intensity-modulated radiation therapy (IMRT), an increasingly popular treatment modality, yields higher out-of-field doses than do conventional treatments, because of an increase in required monitor units (beam-on time). Methods: We used published risk coefficients (NRCP Report 116) and out-of-field dose equivalents to multiple organ sites to estimate a conservative maximal risk of fatal secondary malignancy associated with 6 IMRT approaches and 1 conventional external-beam approach for prostate cancer. Results: Depending on treatment energy, the IMRT treatments required 3.5–4.9 times as many monitor units to deliver as did the conventional treatment. The conservative maximum risk of fatal second malignancy was 1.7% for conventional radiation, 2.1% for IMRT using 10-MV X-rays, and 5.1% for IMRT using 18-MV X-rays. Intermediate risks were associated with IMRT using 6-MV X-rays: 2.9% for treatment with the Varian accelerator and 3.7% for treatment with the Siemens accelerator, as well as using 15-MV X-rays: 3.4% (Varian) and 4.0% (Siemens). Conclusion: The risk of fatal secondary malignancy differed substantially between IMRT and conventional radiation therapy for prostate cancer, as well as between different IMRT approaches. Perhaps this risk should be considered when choosing the optimal treatment technique and delivery system for patients who will undergo prostate radiation.

Purpose: To measure the photon and neutron out-of-treatment-field dose equivalents to various organs from different treatment strategies (conventional vs. intensity-modulated radiation therapy [IMRT]) at different treatment energies and delivered by different accelerators. Methods and Materials: Independent measurements were made of the photon and neutron out-of-field dose equivalents resulting from one conventional and six IMRT treatments for prostate cancer. The conventional treatment used an 18-MV beam from a Clinac 2100; the IMRT treatments used 6-MV, 10-MV, 15-MV, and 18-MV beams from a Varian Clinac 2100 accelerator and 6-MV and 15-MV beams from a Siemens Primus accelerator. Photon doses were measured with thermoluminescent dosimeters in a Rando phantom, and neutron fluence was measured with gold foils. Dose equivalents to the colon, liver, stomach, lung, esophagus, thyroid, and active bone marrow were determined for each treatment approach. Results: For each treatment approach, the relationship between dose equivalent per MU, distance from the treatment field, and depth in the patient was examined. Photon dose equivalents decreased approximately exponentially with distance from the treatment field. Neutron dose equivalents were independent of distance from the treatment field and decreased with increasing tissue depth. Neutrons were a significant contributor to the out-of field dose equivalent for beam energies ≥15 MV. Conclusions: Out-of-field photon and neutron dose equivalents can be estimated to any point in a patient undergoing a similar treatment approach from the distance of that point to the central axis and from the tissue depth. This information is useful in determining the dose to critical structures and in evaluating the risk of associated carcinogenesis.

Purpose: To develop and evaluate a modified anthropomorphic head phantom for evaluation of stereotactic radiosurgery(SRS) dose planning and delivery. Methods: A phantom was constructed from a water equivalent, plastic, head‐shaped shell. The original phantom design, with only a spherical target, was modified to include a nonspherical target (pituitary) and an adjacent organ at risk (OAR) (optic chiasm), within 2 mm, simulating the anatomy encountered when treating acromegaly. The target and OAR spatial proximity provided a more realistic treatment planning and dose delivery exercise. A separate dosimetry insert contained two TLD for absolute dosimetry and radiochromic film, in the sagittal and coronal planes, for relative dosimetry. The prescription was 25Gy to 90% of the GTV with >= 10% of the OAR volume receiving >= 8Gy. The modified phantom was used to test the rigor of the treatment planning process, dosimeter reproducibility, and measured dose delivery agreement with calculated doses using a Gamma Knife, CyberKnife, and linear accelerator based radiosurgery systems. Results:TLD results from multiple irradiations using either a CyberKnife or Gamma Knife agreed with the calculated target dose to within 4.7% with a maximum coefficient of variation of+/−2.0%. Gamma analysis in the coronal and sagittal film planes showed an average passing rate of 99.3% and 99.5% using +/−5%/3mm criteria, respectively. A treatment plan for linac delivery was developed meeting the prescription guidelines. Dosimeter reproducibility and dose delivery agreement for the linac is expected to have results similar to the results observed with the CyberKnife and Gamma Knife. Conclusions: A modified anatomically realistic SRS phantom was developed that provided a realistic clinical planning and delivery challenge that can be used to credential institutions wanting to participate in NCI funded clinical trials. Work supported by PHS CA010953, CA081647, CA21661 awarded by NCI. DHHS

Second Cancers are the most common late effect among long‐term cancer survivors. Radiation has been a known risk factor for cancer induction based on atomic bomb survivor follow‐up. Over the last few decades, there has also been increasing data on second cancers in medically exposed populations, particularly radiotherapy patients. As treatments become more successful and patients survive longer after treatment, long‐term patient health considerations must play an increasing role in the selection of treatment. To this end, it is important that the field of medical physics become well educated in issues related to long‐term radiotherapy sequelae, including second cancers. The session chair will give an overview of retrospective dose reconstruction method commonly used in these large cohort studies second cancers in patients treated with radiation therapy. Understanding the dosimetry in these studies will provide a better understanding of the results of the studies, the dose response models, and gaps in knowledge regarding dose volume effects. In the remainder of the presentation, the speaker will focus on the current state of knowledge of second cancers, specifically focusing on information and limitations of the available literature. This will include the magnitude of risk of second cancers, including the impact of different demographics. It will also include etiological discussions, focusing on the risk attributable to radiation. This presentation will include the available data on the dose response of second cancers, including the large uncertainties inherent to both low and high dose regions. It will also highlight dosimetry for advanced radiotherapy techniques, and what associated doses might mean for the second cancer risk. Finally, the presentation will discuss examples of how second cancer risk can be reduced in routine clinical practice. Learning Objectives: increase the knowledge of clinical medical physicists regarding radiation‐ induced second cancers as well as stimulate further research in this broad and increasingly important area. Learning Objectives: 1. To provide general overview of the dose reconstruction methods used in epidemiological retrospective cohort studies of radiation related late effects. 2. To improve the understanding of the magnitude of the second cancer risk faced by radiotherapy patients. 3. To improve the understanding of the etiology of second cancers. 4. To present an overview of current knowledge on dose response for radiation induced second cancers. 5. To discuss the impact of advanced radiotherapy techniques on the risk of second cancers 6. To provide examples of how second cancer risk can be reduced in routine clinical practice.

Purpose: As clinics begin to use 3D quality assurance (QA) metrics, an investigation into appropriate action limits is required. This can be accomplished by comparing results of the 3D metric to the existing 2D metric. To investigate this, we compared 2D and 3D gamma analysis results to determine 3D gamma action limits that would Result in comparable 2D QA outcomes. Methods: 2D and 3D gamma QA analysis results for ten clinical IMRT patients using a variety of distance‐to‐agreements (DTA), dose‐thresholds, and interpolated slice thicknesses were chosen for this study. Clinical treatment planning system (TPS)‐calculated dose (evaluated) distribution and Monte Carlo‐calculated (reference) dose distribution were compared using DoseLab (Mobius Medical Systems) gamma analysis software that calculates 2‐ and 3‐dimensional gamma index for a given DTA. Each comparison evaluated the 2‐ and 3‐D average gamma and percent of pixels passing for the following acceptance criteria: ±5%/5mm, 3%/3mm, 2%/2mm, and 1%/1mm using 1 mm slice thicknesses (no dose threshold used). The effect of low‐dose thresholds and slice thickness was also evaluated. Results: The percent of pixels passing for each DTA was better for 3D as compared to the 2D analysis (2D vs 3D): 99.8% vs. 99.9% for 5%/5mm, 99.0% vs. 99.7% for 3%/3mm, 96.4% vs. 98.4% for 2%/2mm, and 79.3% vs. 83.4% for 1%/1mm. Using the low‐dose threshold resulted in worse gamma for both 2D and 3D gamma. However, similar to the no‐threshold results, use of dose threshold resulted in worse agreement for 2D than 3D for all DTA (4.1% decrease compared to 1.7% at 15% low‐dose threshold). No appreciable differences in gamma were observed as a function of slice thickness. Conclusions: Clinical use of 3D gamma analysis requires use of action limits (% of pixel passing and γ values) that are more stringent than 2D for comparable QA results.

Purpose: The authors investigated the performance of several patient-specific intensity-modulated radiation therapy (IMRT) quality assurance (QA) dosimeters in terms of their ability to correctly identify dosimetrically acceptable and unacceptable IMRT patient plans, as determined by an in-house-designed multiple ion chamber phantom used as the gold standard. A further goal was to examine optimal threshold criteria that were consistent and based on the same criteria among the various dosimeters. Methods: The authors used receiver operating characteristic (ROC) curves to determine the sensitivity and specificity of (1) a 2D diode array undergoing anterior irradiation with field-by-field evaluation, (2) a 2D diode array undergoing anterior irradiation with composite evaluation, (3) a 2D diode array using planned irradiation angles with composite evaluation, (4) a helical diode array, (5) radiographic film, and (6) an ion chamber. This was done with a variety of evaluation criteria for a set of 15 dosimetrically unacceptable and 9 acceptable clinical IMRT patient plans, where acceptability was defined on the basis of multiple ion chamber measurements using independent ion chambers and a phantom. The area under the curve (AUC) on the ROC curves was used to compare dosimeter performance across all thresholds. Optimal threshold values were obtained from the ROC curves while incorporating considerations for cost and prevalence of unacceptable plans. Results: Using common clinical acceptance thresholds, most devices performed very poorly in terms of identifying unacceptable plans. Grouping the detector performance based on AUC showed two significantly different groups. The ion chamber, radiographic film, helical diode array, and anterior-delivered composite 2D diode array were in the better-performing group, whereas the anterior-delivered field-by-field and planned gantry angle delivery using the 2D diode array performed less well. Additionally, based on the AUCs, there was no significant difference in the performance of any device between gamma criteria of 2%/2 mm, 3%/3 mm, and 5%/3 mm. Finally, optimal cutoffs (e.g., percent of pixels passing gamma) were determined for each device and while clinical practice commonly uses a threshold of 90% of pixels passing for most cases, these results showed variability in the optimal cutoff among devices. Conclusions: IMRT QA devices have differences in their ability to accurately detect dosimetrically acceptable and unacceptable plans. Field-by-field analysis with a MapCheck device and use of the MapCheck with a MapPhan phantom while delivering at planned rotational gantry angles resulted in a significantly poorer ability to accurately sort acceptable and unacceptable plans compared with the other techniques examined. Patient-specific IMRT QA techniques in general should be thoroughly evaluated for their ability to correctly differentiate acceptable and unacceptable plans. Additionally, optimal agreement thresholds should be identified and used as common clinical thresholds typically worked very poorly to identify unacceptable plans.

Medical physicists rarely have had exposure to teaching methodologies during their education. Our teaching methodologies are often based on copying the lecturing styles of effective teachers we have experienced. Consequently, it is rare that we make radical changes in our teaching methodologies. In recent years, new methodologies have been introduced that depart from the traditional lecture format. Some of these methodologies include Flipped Learning, Project-Based Learning, and Peer Instruction. In all cases, students acquire information outside of class, either through readings or recorded lectures. In Flipped Learning, students use class time to solve problems and discuss information acquired prior to class. In Project-Based Learning, students are assigned a project and acquire their understanding of the subject material by completing the project using a team approach. In Peer Instruction, students use class time to answer conceptual questions and assist each other in achieving conceptual understanding of the course material. In all cases, the course instructor serves as a guide to assist the student with their learning rather than as a presenter of information.In this course, several medical physicists will describe how these techniques are actually implemented in courses that they teach with the goal of providing attendees with models that attendees might use in their teaching. Learning Objectives: 1. Identify novel teaching methodologies such as Flipped Learning, Project-Based Learning, and Peer Instruction. 2. Be able to incorporate these teaching methodologies into their classes. 3. Identify various tools to aid in teaching such as Camtasia, Facebook, and SurveyMonkey

Purpose: Optically stimulated luminescent dosimeters (OSLD) are an increasingly popular dosimeter for research and clinical applications. It is also used by the Radiological Physics Center for remote auditing of machine output. In this work we robustly calculated the reproducibility and uncertainty of the OSLD nanoDot. Methods: For the RPC dose calculation, raw readings are corrected for depletion, element sensitivity, fading, linearity, and energy. System calibration is determined for the experimental OSLD irradiated at different institutions by using OSLD irradiated by the RPC under reference conditions (i.e., standards): 1 Gy in a Cobalt beam. The intra-dot and inter-dot reproducibilities (coefficient of variation) were determined from the history of RPC readings of these standards. The standard deviation of the corrected OSLD signal was then calculated analytically using a recursive formalism that did not rely on the normality assumption of the underlying uncertainties, or on any type of mathematical approximation. This analytical uncertainty was compared to that empirically estimated from >45,000 RPC beam audits. Results: The intra-dot variability was found to be 0.59%, with only a small variation between readers. Inter-dot variability was found to be 0.85%. The uncertainty in each of the individual correction factors was empirically determined. When the raw counts from each OSLD were adjusted for the appropriate correction factors, the analytically determined coefficient of variation was 1.8% over a range of institutional irradiation conditions that are seen at the RPC. This is reasonably consistent with the empirical observations of the RPC, where the coefficient of variation of the measured beam outputs is 1.6% (photons) and 1.9% (electrons). Conclusion: OSLD nanoDots provide sufficiently good precision for a wide range of applications, including the RPC remote monitoring program for megavoltage beams. This work was supported by PHS grant CA10953 awarded by the NIH (DHHS).

Purpose: To develop a comprehensive end-to-end test for Varian's TrueBeam linear accelerator for head and neck IMRT using a custom phantom designed to utilize multiple dosimetry devices. Purpose: To commission a multiple-source Monte Carlo model of Elekta linear accelerator beams of nominal energies 6MV and 10MV. Methods: A three source, Monte Carlo model of Elekta 6 and 10MV therapeutic x-ray beams was developed. Energy spectra of two photon sources corresponding to primary photons created in the target and scattered photons originating in the linear accelerator head were determined by an optimization process that fit the relative fluence of 0.25 MeV energy bins to the product of Fatigue-Life and Fermi functions to match calculated percent depth dose (PDD) data with that measured in a water tank for a 10x10cm2 field. Off-axis effects were modeled by a 3rd degree polynomial used to describe the off-axis half-value layer as a function of off-axis angle and fitting the off-axis fluence to a piecewise linear function to match calculated dose profiles with measured dose profiles for a 40×40cm2 field. The model was validated by comparing calculated PDDs and dose profiles for field sizes ranging from 3×3cm2 to 30×30cm2 to those obtained from measurements. A benchmarkingmore » study compared calculated data to measurements for IMRT plans delivered to anthropomorphic phantoms. Results: Along the central axis of the beam 99.6% and 99.7% of all data passed the 2%/2mm gamma criterion for 6 and 10MV models, respectively. Dose profiles at depths of dmax, through 25cm agreed with measured data for 99.4% and 99.6% of data tested for 6 and 10MV models, respectively. A comparison of calculated dose to film measurement in a head and neck phantom showed an average of 85.3% and 90.5% of pixels passing a 3%/2mm gamma criterion for 6 and 10MV models respectively. Conclusion: A Monte Carlo multiple-source model for Elekta 6 and 10MV therapeutic x-ray beams has been developed as a quality assurance tool for clinical trials.« less

Purpose: To analyze results of IROC Houston QA center's (RPC) H&N and prostate IMRT phantoms to determine the effect that tightening criteria would have on the phantom pass rate. Methods: IROC Houston's anthropomorphic H&N and prostate phantoms are used to credential institution's to participate in NCI clinical trials that allow the use of IMRT. The phantoms are shipped to institutions where they are filled with water and undergo imaging, treatment planning, and irradiation as a patient would. Each phantom houses targets and organs at risk. They also hold film and TLD. Dosimeter results are compared to the institution's treatment plan using the criteria of 7% for PTV TLD doses and ≥85% pixels must pass 7%/4 mm global gamma analyses. Pass rates for the H&N and prostate phantoms were recalculated using the following tighter criteria options: 1) 5% TLD and 85% pixels 7%/4 gamma2) 5% TLD and 90% pixels 7%/4 gamma3) 5% TLD and 85% pixels 5%/4 gammaGamma analysis was repeated for the 30 most recent irradiations of each phantom to estimate results for criteria 3. Results: Pass rates using current criteria for the H&N and prostate phantoms are 84% and 85% respectively. Pass rates since gamma criteria were introduced in 2012 are 90% and 87%. Criteria 1 applied to all irradiations drops pass rates to 78% and 82%. Applying it to only irradiations with gamma results give 77% and 84%. Applying criteria 2 to only phantoms with gamma results drops pass rates to 80% and 74% and they fall to 83% and 67% respectively using criteria 3. Conclusion: Applying tighter criteria to phantom results has potential to increase quality in clinical trials. The results of the 30 most recent irradiations indicate that there may be room to tighten H&N phantom criteria in the future. Work supported by PHS grant CA10953 and CA081647 (NCI, DHHS).

Purpose: Accurate data of linear accelerator radiation characteristics is important for treatment planning system commissioning as well as regular quality assurance of the machine. The RPC has performed site visits of numerous machines . Data gathered from Varian machines from the past 15 years are presented. The data collected can be used as a secondary check or when commissioning a new machine to verify that values are reasonable. Methods: Data from the past 15 years of RPC site visits was compiled and analyzed. Data was composed from measurements from approximately 400 Varian machines. Each dataset consists of several point measurements at various locations in a water phantom to measure percentage depth dose, output factors, including small MLC fields, off-axis factors, and wedge factors if applicable. Common statistical values are presented for each machine type. Where applicable, data was compared to other reference data given by the vendor or a select number of previous researchers. Results: Data is separated by energy and parameter and then analyzed by machine class. Data distributions of the parameter data were normal except occasionally at the tails. Distributions of the data for each class and parameter are tabulated to give not simply a singular reference value, but metrics about the distribution: 5th and 95th percentile values and the standard deviation as well as the median. Conclusion: The RPC has collected numerous data on Varian linacs and presented the finding of the past 15 years. The data can be used as a reference data set for physicists to compare against. A linac that deviates from the values does not necessarily indicate there is a problem as long as the treatment planning system correlates to the machine. Comparison of linac and treatment planning system data to external reference data can prevent serious treatment errors.

Purpose: The RPC, established in 1968 has contributed to the development, conduct, and QA of NCI funded multi-institutional cooperative group clinical trials and institutions, primarily in the USA/Canada and 242 other countries, participating in trials. Methods: The RPC QA program components were designed to audit the radiation dose calculation chain from the NIST traceable reference beam calibration, to inclusion of dosimetry parameters used to calculate tumor doses, to the delivery of the radiation dose. The QA program included: 1) remote TLD/OSLD audit of machine output, 2) on-site dosimetry review visits, 3) credentialing for advanced technologies, and 4) review of patient treatment records. The RPC presented and published their findings to the radiation oncology community. Results: The number of institutions monitored by the RPC increased from around 1200 in the late 90s, to ∼2000 in 2013. There were over 4000 megavoltage therapy machines and ∼28,000 therapy beams in the 1991 institutions monitored by the RPC by the end of 2013. Within the 14,000 photon, electron and proton beam outputs remotely monitored with TLD/OSLD annually, between 10-20% of the institutions have one or more beams outside the RPC 5% criterion. Dosimetry site visits to photon and proton centers continue to result in 2-4 recommendations affecting key dosimetry parameters that impact patient treatment times. One in four patient treatment records reviewed by the RPC have their dose data corrected by >5% before trial groups use them for outcomes analysis. Twelve of fourteen clinically active proton centers are approved to participate in NCI funded clinical trials. The RPC published 222 peer reviewed articles since 1972. Conclusion: Findings from the RPC suggest that human errors continue to play a role in radiotherapy discrepancies and without the RPC independent QA program, the number of undetected errors and time elapsed before their discovery would have been greater. Work supported by MGH C06 CA059267 and grants CA10953, CA081647 awarded by NCI, DHHS.

Purpose: To evaluate the ability of a selection of patient-specific QA methods to accurately classify IMRT plans as acceptable or unacceptable based on a multiple ion chamber (MIC) phantom. Methods: Twenty-four IMRT plans were selected (20 previously failed the institutional QA), and were measured on a MIC phantom to assess their dosimetric acceptability. These same plans were then measured using film (Kodak EDR2) and ion chamber (Wellhofer cc04), ArcCheck (Sun Nuclear), and MapCheck (Sun Nuclear) (delivered AP field-by-field, AP composite, and with original gantry angles). All gamma analyses were performed at 2%/2mm, 3%/3mm, and 5%/3mm. By using the MIC results as a gold standard, the sensitivity and specificity were calculated across a range of cut-off thresholds (% pixels passing for gamma analysis, and % dose difference for ion chamber), and were used to form ROC curves. Area under the curve (AUC) was used as a metric to quantify the performance of the various QA methods. Results: Grouping device’s AUC’s revealed two statistically significant different groups: ion chamber (AUC of 0.94), AP composite MapCheck (AUC of 0.85), ArcCheck (AUC of 0.84), and film (AUC of 0.82) were in the better performing group, while original gantry angles and AP field-by-field MapCheck (AUC of 0.65 and 0.66, respectively) matched less well with the gold standard results. Optimal cut-offs were also assessed using the ROC curves. We found that while often 90% of pixels passing is used as a criteria, the differing sensitivities of QA methods can lead to device and methodology-based optimal cutoff thresholds. Conclusion: While many methods exist to perform the same task of patient-specific IMRT QA, they utilize different strategies. This work has shown that there are inconsistencies in these methodologies in terms of their sensitivity and specificity to dosimetric acceptability. This work was supported by Public Health Service grants CA010953, CA081647, and CA21661 awarded by the National Cancer Institute, United States Department of Health and Human Services.

Purpose: Failure modes and effects analysis (FMEA) is a subjective risk mitigation technique that has not been applied to physics-specific quality management practices. There is a need for quantitative FMEA data as called for in the literature. This work focuses specifically on quantifying FMEA severity scores for physics components of IMRT delivery and comparing to subjective scores. Methods: Eleven physical failure modes (FMs) for head and neck IMRT dose calculation and delivery are examined near commonly accepted tolerance criteria levels. Phantom treatment planning studies and dosimetry measurements (requiring decommissioning in several cases) are performed to determine the magnitude of dose delivery errors for the FMs (i.e., severity of the FM). Resultant quantitative severity scores are compared to FMEA scores obtained through an international survey and focus group studies. Results: Physical measurements for six FMs have resulted in significant PTV dose errors up to 4.3% as well as close to 1 mm significant distance-to-agreement error between PTV and OAR. Of the 129 survey responses, the vast majority of the responders used Varian machines with Pinnacle and Eclipse planning systems. The average years of experience was 17, yet familiarity with FMEA less than expected. Survey reports perception of dose delivery error magnitudemore » varies widely, in some cases 50% difference in dose delivery error expected amongst respondents. Substantial variance is also seen for all FMs in occurrence, detectability, and severity scores assigned with average variance values of 5.5, 4.6, and 2.2, respectively. Survey shows for MLC positional FM(2mm) average of 7.6% dose error expected (range 0–50%) compared to 2% error seen in measurement. Analysis of ranking in survey, treatment planning studies, and quantitative value comparison will be presented. Conclusion: Resultant quantitative severity scores will expand the utility of FMEA for radiotherapy and verify accuracy of FMEA results compared to highly variable subjective scores.« less

Purpose: As clinics begin to use 3D metrics for intensity-modulated radiation therapy (IMRT) quality assurance; these metrics will often produce results different from those produced by their 2D counterparts. 3D and 2D gamma analyses would be expected to produce different values, because of the different search space available. We compared the results of 2D and 3D gamma analysis (where both datasets were generated the same way) for clinical treatment plans. Methods: 50 IMRT plans were selected from our database and recalculated using Monte Carlo. Treatment planning system-calculated (“evaluated”) and Monte Carlo-recalculated (“reference”) dose distributions were compared using 2D and 3D gamma analysis. This analysis was performed using a variety of dose-difference (5%, 3%, 2%, and 1%) and distance-to-agreement (5, 3, 2, and 1 mm) acceptance criteria, low-dose thresholds (5%, 10%, and 15% of the prescription dose), and data grid sizes (1.0, 1.5, and 3.0 mm). Each comparison was evaluated to determine the average 2D and 3D gamma and percentage of pixels passing gamma.Results: Average gamma and percentage of passing pixels for each acceptance criterion demonstrated better agreement for 3D than for 2D analysis for every plan comparison. Average difference in the percentage of passing pixels between the 2D and 3D analyses with no low-dose threshold ranged from 0.9% to 2.1%. Similarly, using a low-dose threshold resulted in a differences ranging from 0.8% to 1.5%. No appreciable differences in gamma with changes in the data density (constant difference: 0.8% for 2D vs. 3D) were observed.Conclusion: We found that 3D gamma analysis resulted in up to 2.9% more pixels passing than 2D analysis. Factors such as inherent dosimeter differences may be an important additional consideration to the extra dimension of available data that was evaluated in this study.------------------------------------Cite this article as: Pulliam KB, Huang JY, Bosca R, Followill D, Kry SF. 2D vs. 3D gamma analysis: Establishment of comparable clinical action limits. Int J Cancer Ther Oncol 2014; 2(2):020231. DOI: 10.14319/ijcto.0202.31

Purpose:Monte Carlo methods have been used extensively to calculate radiation does to organs both in‐field and far‐field. However, particularly for out‐of‐field dose calculations, this process has relied on the very time consuming and potentially error‐prone manual conversion of radiation field parameters and CT datum to a Monte Carlo input format. The purpose of this study was to develop computational infrastructure to automate a Monte Carlo‐based dose calculation algorithm for a previously modeled and benchmarked Varian 2100 linear accelerator operating at 6 MV. This system would be suitable for in‐field and out‐of‐field calculations. Method and Materials: A computer program was written using a Digital Imaging and Communications Tool Kit (DCMTK) to extract patient position data and radiation field parameters from a photonradiation therapy (RT) file and, based on this data, set the MCNPX simulation geometry for the modeled linear accelerator. A shell script was written to automate extraction, writing MCNPX geometry input files and submission of simulations to a computer cluster. The accuracy of the automation process was tested by examining the accuracy of the in‐field dose from an eight‐field, intensity modulated radiotherapy plan. Each field corresponded to a different gantry angle and set of control points. For each field, simulated depth‐dose curves and cross‐filed dose profiles at isocenter were compared with dose profiles calculated from Varian treatment planning software (Eclipse). Results: In‐field dose profiles calculated from the automated system agreed within 4% to dose profiles calculated using the Eclipse. Statistical uncertainty of simulated in‐field dose profiles was at most 4%. Conclusion: The automated dose calculation system accurately extracted the complex treatment geometry parameters, and successfully incorporated them into the Monte Carlo framework. This process substantially reduces the time required, and potential for error, for conducting Monte Carlo simulations within or outside the treatment field.

Purpose: To evaluate two commercially available Head‐and‐Neck immobilization devices for daily treatment setup and their correlations to anatomy changes. The study represents an early implementation experience with the Orfit mask, which was new to our clinic. Method and Materials: Twenty‐one patients enrolled in an in‐house adaptive radiotherapy protocol 3171 using daily CT guided treatment were randomly assigned to one of two different thermoplastic masks: 5‐Point Efficast mask from Orfit (ORFIT Industries, Jericho, NY) or the extended S‐Board mask from Civco (CIVCO/MedTec, Orange City, IA). The daily setup displacements in each of the antero‐posterior(AP), supero‐inferior(SI), and medio‐lateral(ML) direction were determined using a 3D rigid image registration technique with the C2 vertebral body as the bony landmark. Systematic and random setup errors were computed for each group. The Pearson product‐moment correlation coefficient was used to determine the correlation between parotid shrinkage and the magnitudes of 3D displacements. Results: The random errors in AP, SI, and ML directions for Orfit mask (10 patients) were 0.13, 0.12, 0.11cm, and 0.12, 0.16, 0.11cm for the Civco mask (11 patients), respectively. The systematic errors were 0.20, 0.12, 0.16 cm for the Orfit mask, and 0.16, 0.16, 0.13 cm for the Civco mask, respectively. The Orfit mask significantly reduced the setup error in SI direction. However, in the AP and ML directions the systematic error increased with the Orfit mask, although the random errors were similar. The magnitude of the total (3D) shift was found to be correlated with the percent of parotid shrinkage for the Civco mask (p=0.026), but not for the Orfit mask. Conclusion: Although the Orfit mask reduced setup error in SI direction due to its head rest design, setup errors in AP and ML directions increased mainly due to increased systematic mask preparation errors. User training may be important.

Purpose: To investigate characteristics of optically‐stimulated luminescent detectors (OSLDs) to protons thus allowing comparison to thermoluminescent detectors and implementation into a quality assurance program. Methods & Materials: The OSLDs used were aluminum oxide (Al2O3) nanodots (Landauer Inc. Glenwood IL) measuring 10×10×2 mm3. A 20(L)×20(W)×0.5(H) cm3 volume of solid water was fabricated with pockets to allow OSLDs and TLDs to be irradiated simultaneously and perpendicular to the beam. Irradiations were performed at a 5 cm depth for photons and in the center of a 10 cm SOBP for a 200 MeV proton beam. Additionally the Radiological Physics Center's (RPC) anthropomorphic pelvic phantom was used to test the angular dependence of OSLDs for photons and protons. A cylindrical insert in the phantom allows the dosimeters to be rotated to any angle with a fixed gantry angle. OSLDs were irradiated at 8 angles between 0 and 360 degrees. OSLDs were read out with a Landauer Microstar reader. Results:Dose response measurements indicate for photons that at angles where the dosimeter is near parallel with the radiation beam response is slightly reduced. Results in protons do not seem to show significant angular dependence. OSLDs and TLDs are comparable within 3% for both photons and protons during perpendicular measurements. Conclusion: OSLDs and TLDs are comparable dosimeters in 6 MV photon and 200 MeV protons beams in a perpendicular irradiation. Preliminary results show that OSLDs might have some angular dependence to photons but not protons. With angular dependence characteristics defined OSLDs can be implemented into multiple‐field treatment plans in photons and protons and used in the RPC's quality assurance program.

Purpose: Validation and benchmarking of a newly‐developed measurement‐drivensource model based on Monte Carlo calculations. Method and Materials: A measurement‐driven model using the Dose Planning Method DPM dose calculation algorithm is being developed for use with Varian, Elekta, and Siemens 6 MV and 10 MV photon beams. The present work details the validation and benchmarking for the Varian 6 MV beam. The multi‐source model consists of a primary photon point source, an extra‐focal exponential disk source, and an electron contamination uniform disk source. The model accounts for fluence and off‐axis energy effects due to the flattening filter. Dose calculations for field sizes from 4 cm by 4 cm to 40 cm by 40 cm were performed and tested against the basic beam data measurements. In addition, an IMRT homogeneous plan, a stereotactic lung plan, and an IMRTlung plan were delivered to anthropomorphic phantoms housing TLD and radiographic film dosimeters for benchmark evaluations. Results: Comparisons between calculation and measurement of the PDD and dose profiles for all square field size configurations showed agreement within 2%/2 mm for 90% of the data tested. General agreement at the level of 3%/2mm for 85% of the data tested was found in both of the lung treatment plans. However, calculation of the highly modulated IMRT homogeneous plan showed an underestimation of dose of up to 8% locally in the center of the PTV. Conclusion: This work demonstrates a source model that is robust for the Varian 6 MV photon beam; however, only a simple MLC model that did not include the effects of the rounded leaf ends and interleaf leakage was used. We are currently evaluating a detailed MLC model to improve the agreement with measurement. Conflict of Interest: Work supported by PHS CA010953, CA081647, and R01 CA85181 awarded by NCI, DHHS

As new treatment modalities in RadiationOncology such as Intensity Modulated Radiation Therapy(IMRT) and Proton Therapy (PT) become more widely used, improved target coverage and lower doses to surrounding normal tissues are achieved at the expense of higher out‐of‐field doses to distant normal tissues. These higher out‐of‐field normal tissuedoses are the result of increased X ray leakage radiation from longer beam‐on times associated with IMRT and neutron leakage radiation associated with high energy X ray beams (>10 MV) and protons.IMRT beam‐on times can be 4–6 times that of conventional 3D treatments and neutrons produced by the high‐energy X rays and protons striking a patient have a high relative biological effectiveness (RBE). Measurement of the increased X ray and neutron leakage radiation is crucial if one is to assess any additional risks to the patient that might result from the higher out‐of‐field radiationdoses from these new treatment modalities. A variety of dosimeters, large volume ion chambers, diodes, survey meters, small volume ion chambers and thermoluminescent dosimeters(TLD), have been used to measure the X ray leakage in the treatment room and in the patient plane. TLD, because of its spatial resolution and ability to precisely measure low doses associated with leakage radiation, appears to be the preferable dosimeter.Neutrons are measured with bubble detectors, neutron meters utilizing a BF3 proportional counter, 197Au foil based activation either with a Bonner Sphere system/moderator or LiI dosimeters in Bonner Spheres. The gold activation technique has a calibration directly traceable to NIST and is the detector of choice for X ray produced neutrons. Due to the limited amount of neutron leakage measurement data around proton machines the ideal dosimeter has yet to be determined for this type of measurement. The measured dose‐equivalent values in an anthropomorphic phantom for X ray leakage from an X ray accelerator decrease with increased distance from central axis (CAX) in the patient plane by a factor of 3 to 10, depending on the delivery mode and accelerator type. IMRTtreatments on a Siemens machine results in higher dose‐equivalents than the same energies on a Varian machine. Neutron measurements in the patient plane were approximately the same despite the distance from the CAX. Overall, the total dose‐equivalent, X ray and neutrondose, decrease with distance from CAX with the Varian IMRT having the greatest decrease. Measured neutrondose‐equivalents from proton therapy strongly depend on the delivery apparatus and decrease with distance from the nozzle. This lecture will provide an overview of the measurement techniques for X ray and neutron leakage radiation from both X ray and proton therapy machines and the resulting measured dose‐equivalent values from which the risk of secondary cancers can be estimated. Educational Objectives: 1. Understand the various techniques used to accurately measure X ray and neutron leakage radiation in the patient plane. 2. Understand the magnitude of the dose‐equivalent in the patient plane from the various X ray accelerators and from proton therapy.

Purpose: To compare the secondary neutron spectra in accelerators with different multileaf collimator(MLC) configurations. The addition of MLC, have lead to design modifications in modern linear accelerators; Elekta has replaced upper collimating jaws with MLC, Siemens has replaced lower jaws with MLC, Varian added tertiary level MLC.Method and Materials: Measurements were made of the neutron fluence and energy spectra for several modern accelerators. The detector consisted of 197Au activation foils, which were placed on the surface of the holder and inserted into Bonner Spheres. An HPGe detector was used to measure counts under the 411keV photopeak for each foil. Data were unfolded with the MXD_FC33 code with a response matrix specifically calculated for this measurement system using MCNP5. In this investigation, neutron spectra, fluence per MU, and ambient dose equivalent are reported for 18MV x‐ray beams generated by Varian 21EX, Siemens Oncor, and Elekta Precise accelerators. The impact of the jaw and MLC configuration were further studied for the Varian 21EX by taking measurements following the complete removal of the MLC.Results:Jaws and MLC closed: similar spectra for the Siemens and Elekta but the Varian spectrum has a lower energy distribution. Varian X and Y jaws closed: With MLC in place, less neutrons are detected and spectrum shifts to lower energies (compared to MLC removed). MLC attenuates neutrons created higher in treatment head. Varian X and Y jaws retracted: With MLC in place more neutrons are detected and the spectra shifts to lower energies (compared to MLC removed). The MLC attenuate neutrons created higher in treatment head but MLC become the primary source of contamination neutrons when jaws retracted. Conclusion: Secondary neutron spectra are different in accelerators with different MLC configurations. This difference translates to a difference in ambient dose equivalent to patients receiving high‐energy radiation therapy.