Tumors in thoracic and upper abdomen regions such as lungs, liver, pancreas, esophagus, and breast move due to respiration. Respiration-induced motion introduces uncertainties in radiotherapy treatments of these sites and is regarded as a significant bottleneck in achieving highly conformal dose distributions. Recent developments in radiation therapy have resulted in (i) motion-encompassing, (ii) respiratory gating, and (iii) tracking methods for adapting the radiation beam aperture to account for the respiration-induced target motion. The purpose of this review is to discuss the magnitude, impact, and management of respiration-induced tumor motion.

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Introduction: Different techniques of radiation therapy have been studied to reduce the cardiac dose in left breast cancer. Aim: In this prospective dosimetric study, the doses to heart as well as other organs at risk (OAR) were compared between free-breathing (FB) and deep inspiratory breath hold (DIBH) techniques in intensity modulated radiotherapy (IMRT) and opposed-tangent three-dimensional radiotherapy (3DCRT) plans. Materials and Methods: Fifteen patients with left-sided breast cancer underwent computed tomography simulation and images were obtained in both FB and DIBH. Radiotherapy plans were generated with 3DCRT and IMRT techniques in FB and DIBH images in each patient. Target coverage, conformity index, homogeneity index , and mean dose to heart (Heart D_mean), left lung, left anterior descending artery (LAD) and right breast were compared between the four plans using the Wilcoxon signed rank test. Results: Target coverage was adequate with both 3DCRT and IMRT plans, but IMRT plans showed better conformity and homogeneity. A statistically significant dose reduction of all OARs was found with DIBH. 3DCRT_DIBHdecreased the Heart D_meanby 53.5% (7.1 vs. 3.3 Gy) and mean dose to LAD by 28% compared to 3DCRT_FB. IMRT further lowered mean LAD dose by 18%. Heart D_meanwas lower with 3DCRT_DIBHover IMRT_DIBH (3.3 vs. 10.2 Gy). Mean dose to the contralateral breast was also lower with 3DCRT over IMRT (0.32 vs. 3.35 Gy). Mean dose and the V₂₀of ipsilateral lung were lower with 3DCRT_DIBHover IMRT_DIBH (13.78 vs. 18.9 Gy) and (25.16 vs. 32.95%), respectively. Conclusions: 3DCRT_DIBHprovided excellent dosimetric results in patients with left-sided breast cancer without the need for IMRT.

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Purpose: This study focuses on incorporation of a solitary dynamic portal (SDP) in conformal planning for postmastectomy radiotherapy (PMRT) with nodal regions with an intention to overcome the treatment planning limitations imposed by conventional techniques. Materials and Methods: Twenty-four patients who underwent surgical mastectomy followed by PMRT were included in this study. Initially, a treatment plan comprising tangential beams fitted to beam's-eye-view (BEV) of chest wall (CW) and a direct anterior field fitted to BEV of nodal region, both sharing a single isocenter was generated using Eclipse treatment planning system. Multiple field-in-fields with optimum beam weights (5% per field) were added primarily from the medial tangent, fitted to BEV of entire target volume, and finally converted into a dynamic portal. Dosimetric analysis for the treatment plans and fluence verification for the dynamic portals were performed. Results and Discussion: Conformal plans with SDP showed excellent dose coverage (V_95%>95%), higher degree of tumor dose conformity (≤1.25) and homogeneity (≤0.12) without compromising the organ at risk sparing for PMRT with nodal region. Treatment plans with SDP considerably reduced the lower isodose spread to the ipsilateral lung, heart, and healthy tissue without affecting the dose homogeneity. Further, gamma evaluation showed more than 96% pixel pass rate for standard 3%/3 mm dose difference and distance-to-agreement criteria. Moreover, this plan offers less probability of “geometrical miss” at the highly irregular CW with regional nodal radiotherapy. Conclusion: Hybrid conformal plans with SDP would facilitate improved dose distribution and reduced uncertainty in delivery and promises to be a suitable treatment option for complex postmastectomy CW with regional nodal irradiation.

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Introduction: The aim of this work is to verify the use of radiochromic film in the quality assurance (QA) of volumetric-modulated arc therapy (VMAT) lung stereotactic body radiation therapy (SBRT) plans and compare the results with those obtained using an ion chamber array. Materials and Methods: QA was performed for 14 plans using a two-dimensional-array seven29 and EBT3 film. Dose values per session ranged between 7.5 Gy and 18 Gy. The multichannel method was used to obtain a dose map for film. Results: The results obtained were compared with treatment planning system calculated profiles through gamma analysis. Passing criteria were 3%/3 mm, 2%/2 mm and 3%/1.5 mm with maximum and local dose (LD) normalization. Mean gamma passing rate (GPR) (percentage of points presenting a gamma function value of <1) was obtained and compared. Calibration curves were obtained for each color channel within the dose range 0–16 Gy. Mean GPR values for film were >98.9% for all criteria when normalizing per maximum dose. When using LD, normalization was >92.7%. GPR values for the array were lower for all criteria; this difference being statistically significant when normalizing at LD, reaching 12% for the 3%/1.5 mm criterion. Conclusion: Both detectors provide satisfactory results for the QA of plans for VMAT lung SBRT. The film provided greater mean GPR values, afforded greater spatial resolution and was more efficient overall.

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Dedicated rapid access palliative radiation therapy improves patients' access to care, allowing more timely treatment which would positively impact on quality of life. The TomoTherapy (Accuray, Sunnyvale, CA) system provides megavoltage (MV) fan-beam computed tomography (FBCT) as the image guidance technique, and a module called “statRT” that allows the use of these MV FBCT images for direct planning. The possibility of using this imaging modality for palliative radiotherapy treatment planning is assessed against accepted planning CT standards by performing tests following AAPM TG 66 and an end-to-end measurement. Results have shown that MV FBCT images acquired by TomoTherapy are of sufficient quality for the purpose of target delineation and dose calculation for palliative treatments. Large image noise and extended scan acquisition time are the two main drawbacks, so this imaging modality should only be used for palliative treatments at areas with well-known, easily distinguishable, and relatively immobile targets such as spine and whole brain.

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To ensure the safe operation of mammography units, acceptance tests and quality assurance (QA) protocols have been developed by the American Association of Physicists in Medicine (AAPM), Engineers Registration Board, and International Atomic Energy Agency. Eight mammography units manufactured by five different manufacturers located in hospitals in our region were investigated following the AAPM and Atomic Energy Regulatory Board (AERB) protocols using a solid-state dosimeter-based PTW-NOMEX Multimeter and a metal-oxide-semiconductor field-effect transistor. This study evaluated different operating parameters through mechanical test, accelerating voltage (kVp) accuracy test, machine output measurement, half-value layer measurement, calibration of compression device, image quality assessment, measurement of leakage radiation, radiation survey, and average glandular dose (AGD) measurements using stereotactic needle biopsy phantom. The results show that out of eight mammography units, only a single mammography unit (U-1) passed all QA tests and 2 units passed 7 tests, 2 units passed 6 tests, and 3 units passed 5 tests out of 8 QA tests. In unit 5, the AGD value was 4 and 1.93 mGy before and after service, respectively. QA programs as recommended by AAPM and AERB should be carried out periodically to ensure safety in breast cancer screening. This work points to the importance of the regulation and effective compliance and also help in both improving the QA and reduce the glandular dose received by the patients.

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Purpose: This study aims to investigate the factors that reduce fetal dose in pregnant patients with breast cancer throughout their radiation treatment. Two main factors in a standard radiation oncology center are considered as the treatment planning systems (TPSs) and simple shielding for intensity modulated radiation therapy technique. Materials and Methods: TPS factor was evaluated with two different planning algorithms: Anisotropic analytical algorithm and Acuros XB (external beam). To evaluate the shielding factor, a standard radiological purpose lead apron was chosen. For both studies, thermoluminescence dosimeters were used to measure the point dose, and an Alderson RANDO-phantom was used to simulate a female pregnant patient in this study. Thirteen measurement points were chosen in the 32^nd slice of the phantom to cover all possible locations of a fetus up to 8^th week of gestation. Results: The results show that both of the TPS algorithms are incapable of calculating the fetal doses, therefore, unable to reduce them at the planning stage. Shielding with a standard lead apron, however, showed a slight radiation protection (about 4.7%) to the fetus decreasing the mean fetal dose from 84.8 mGy to 80.8 mGy, which cannot be disregarded in case of fetal irradiation. Conclusions: Using a lead apron for shielding the abdominal region of a pregnant patient during breast irradiation showed a minor advantage; however, its possible side effects (i.e., increased scattered radiation and skin dose) should also be investigated further to solidify its benefits.

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The International Atomic Energy Agency Technical Reports Series-398 code of practice for dosimetry recommends measuring photon percentage depth dose (PDD) curves with parallel-plate chambers. This code of practice was published before flattening filter-free (FFF) beams were widely used in clinical linear accelerators. The choice of detector for PDD measurements needs to be reassessed for FFF beams given the physical differences between FFF beams and flattened ones. The present study compares PDD curves for FFF beams of nominal energies 6 MV, 6 FFF, 10 MV, and 10 FFF from a Varian TrueBeam linear accelerator (Varian Medical Systems, Palo Alto, USA) acquired with Scanditronix photon diodes, two scanning type chambers (both PTW 31010 Semiflex), two small volume chambers (Wellhofer CC04 and PTW 31016 PinPoint 3D), PTW 34001 Roos, Scanditronix Roos, and NACP 02 parallel-plate chambers. Results show that parallel-plate ion chambers can be used for photon PDD measurements, although for better accuracy, recombination effects should be taken into account.

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The purpose of this study was to evaluate the impact of selected configuration parameters that govern multileaf collimator (MLC) transmission and rounded leaf offset in a commercial treatment planning system (TPS) (Pinnacle³, Philips Medical Systems, Andover, MA, USA) on the accuracy of intensity-modulated radiation therapy (IMRT) dose calculation. The MLC leaf transmission factor was modified based on measurements made with ionization chambers. The table of parameters containing rounded-leaf-end offset values was modified by measuring the radiation field edge as a function of leaf bank position with an ionization chamber in a scanning water-tank dosimetry system and comparing the locations to those predicted by the TPS. The modified parameter values were validated by performing IMRT quality assurance (QA) measurements on 19 gantry-static IMRT plans. Planar dose measurements were performed with radiographic film and a diode array (MapCHECK2) and compared to TPS calculated dose distributions using default and modified configuration parameters. Based on measurements, the leaf transmission factor was changed from a default value of 0.001 to 0.005. Surprisingly, this modification resulted in a small but statistically significant worsening of IMRT QA gamma-index passing rate, which revealed that the overall dosimetric accuracy of the TPS depends on multiple configuration parameters in a manner that is coupled and not intuitive because of the commissioning protocol used in our clinic. The rounded leaf offset table had little room for improvement, with the average difference between the default and modified offset values being −0.2 ± 0.7 mm. While our results depend on the current clinical protocols, treatment unit and TPS used, the methodology used in this study is generally applicable. Different clinics could potentially obtain different results and improve their dosimetric accuracy using our approach.

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Helical tomotherapy with its advanced method of intensity-modulated radiation therapy delivery has been used clinically for over 20 years. The standard delivery quality assurance procedure to measure the accuracy of delivered radiation dose from each treatment plan to a phantom is time-consuming. RadCalc^®, a radiotherapy dose verification software, has released specifically for beta testing a module for tomotherapy plan dose calculations. RadCalc^®'s accuracy for tomotherapy dose calculations was evaluated through examination of point doses in ten lung and ten prostate clinical plans. Doses calculated by the TomoHDA™ tomotherapy treatment planning system were used as the baseline. For lung cases, RadCalc^® overestimated point doses in the lung by an average of 13%. Doses within the spinal cord and esophagus were overestimated by 10%. Prostate plans showed better agreement, with overestimations of 6% in the prostate, bladder, and rectum. The systematic overestimation likely resulted from limitations of the pencil beam dose calculation algorithm implemented by RadCalc^®. Limitations were more severe in areas of greater inhomogeneity and less prominent in regions of homogeneity with densities closer to 1 g/cm³. Recommendations for RadCalc^® dose calculation algorithms and anatomical representation were provided based on the results of the study.

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Cone-beam computed tomography (CBCT) images are presently used for geometric verification for daily patient positioning. In this work, we have compared the images of CBCT with the images of conventional fan beam CT (FBCT) in terms of image quality and Hounsfield units (HUs). We also compared the dose calculated using CBCT with that of FBCT. Homogenous RW3 plates and Catphan phantom were scanned by FBCT and CBCT. In RW3 and Catphan phantom, percentage depth dose (PDD), profiles, isodose distributions (for intensity modulated radiotherapy plans), and calculated dose volume histograms were compared. The HU difference was within ± 20 HU (central region) and ± 30 HU (peripheral region) for homogeneous RW3 plates. In the Catphan phantom, the difference in HU was ± 20 HU in the central area and peripheral areas. The HU differences were within ± 30 HU for all HU ranges starting from −1000 to 990 in phantom and patient images. In treatment plans done with simple symmetric and asymmetric fields, dose difference (DD) between CBCT plan and FBCT plan was within 1.2% for both phantoms. In intensity modulated radiotherapy (IMRT) treatment plans, for different target volumes, the difference was <2%. This feasibility study investigated HU variation and dose calculation accuracy between FBCT and CBCT based planning and has validated inverse planning algorithms with CBCT. In our study, we observed a larger deviation of HU values in the peripheral region compared to the central region. This is due to the ring artifact and scatter contribution which may prevent the use of CBCT as the primary imaging modality for radiotherapy treatment planning. The reconstruction algorithm needs to be modified further for improving the image quality and accuracy in HU values. However, our study with TG-119 and intensity modulated radiotherapy test targets shows that CBCT can be used for adaptive replanning as the recalculation of dose with the anisotropic analytical algorithm is in full accord with conventional planning CT except in the build-up regions. Patient images with CBCT have to be carefully analyzed for any artifacts before using them for such dose calculations.

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Discretization errors due to the digitization of computed tomography images and the calculation grid are a significant issue in radiation therapy. Such errors have been quantitatively reported for a fixed multifield intensity-modulated radiation therapy using traditional linear accelerators. The aim of this study is to quantify the influence of the calculation grid size on the dose distribution in TomoTherapy. This study used ten treatment plans for prostate cancer. The final dose calculation was performed with “fine” (2.73 mm) and “normal” (5.46 mm) grid sizes. The dose distributions were compared from different points of view: the dose-volume histogram (DVH) parameters for planning target volume (PTV) and organ at risk (OAR), the various indices, and dose differences. The DVH parameters were used Dmax, D2%, D2cc, Dmean, D95%, D98%, and Dmin for PTV and Dmax, D2%, and D2cc for OARs. The various indices used were homogeneity index and equivalent uniform dose for plan evaluation. Almost all of DVH parameters for the “fine” calculations tended to be higher than those for the “normal” calculations. The largest difference of DVH parameters for PTV was Dmax and that for OARs was rectal D2cc. The mean difference of Dmax was 3.5%, and the rectal D2cc was increased up to 6% at the maximum and 2.9% on average. The mean difference of D95% for PTV was the smallest among the differences of the other DVH parameters. For each index, whether there was a significant difference between the two grid sizes was determined through a paired t-test. There were significant differences for most of the indices. The dose difference between the “fine” and “normal” calculations was evaluated. Some points around high-dose regions had differences exceeding 5% of the prescription dose. The influence of the calculation grid size in TomoTherapy is smaller than traditional linear accelerators. However, there was a significant difference. We recommend calculating the final dose using the “fine” grid size.

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