SmallFieldDosimetry forIMRT andRadiosurgery

JanSeuntjens,Ph.D.,FAAPM,FCCPM Professor&DirectorMedicalPhysics McGillUniversity Canada

ThursdayApril7

SEAAPM2011

Overview Smallfield radiotherapy

Background
Issuesanddefinitions

Measurementphysicsofsmallfields MeasurementphysicsofIMRT(composite) fields Newdosimetry ofsmallandIMRTfields statusreport Conclusions

ThursdayApril7 SEAAPM2011 2

Acknowledgments smallfield committees

IAEAcommittee
Palmans (Chair) Andreo Huq Mackie Ulrich Kilby Izewska Capote Alfonso Seuntjens

AAPMCommittees
TG178(Goetsch etal) TG155(Dasetal) WGDPCB

ICRUReportCommittee

ThursdayApril7

SEAAPM2011

Background
Technologicalimprovementsinconventional Linacs haveimprovedmechanicalaccuracyand stabilityaswellasdosimetric control IncreasedavailabilityoftertiaryMLCs on conventionalaccelerators(Brainlab M3,Novalis Tx) SpecializedmachinesforIGRTusingsmallfields orcombinationofsmallfields(GammaKnife, CyberKnife,TomoTherapy,Vero) Hastechnologygottenaheadofcomprehensionof basicdosimetry principles?
ThursdayApril7 SEAAPM2011 4

Summaryofsomechallengesinsmall fielddosimetry
Definitionoffieldsize? Difficultiesinaccuratemeasurements Modelingofsmallfielddosecalculationsin TPSs Calibrationprotocolreferenceconditions cannotbeachieved

ThursdayApril7

SEAAPM2011

IMRTversusSRS/SRT some nomenclature

nonstandard(a.k.a. noncompliant)fields: radiationfieldsforwhichreferencedosimetry cannotbereliablyperformedusingtheexisting protocols(AAPMTG51orIAEATRS398)
Smallfields(static)
Referenceconditionscannotbemet(10x 10cm2isnot available)

Composedfields(IMRT,stepandshootordynamic)
Deliveryconditionsarefarremovedfromcalibration conditions

ThursdayApril7

SEAAPM2011

Large differences in Output Factors among users/machines

Statisticsof45OutputFactorsfor 6mmand18mmsquarefieldsNovalis, SSD=100cm,depth=5cm,variousdetectors)

factorof2indose determination!

ThursdayApril7

FromWolfgangUllrich (BrainLab) SEAAPM2011

Physicsofsmallfields

ThursdayApril7

SEAAPM2011

Whatconstitutesmallfieldconditions?
Beamrelatedsmallfieldconditions
theexistenceoflateralchargedparticle disequilibrium partialgeometricalshieldingoftheprimary photonsourceasseenfromthepointof measurement

Detectorrelatedsmallfieldcondition
detectorsizecomparedtofieldsize

ThursdayApril7

SEAAPM2011

Whatconstitutesmallfieldconditions?
Beamrelatedsmallfieldconditions
theexistenceoflateralchargedparticle disequilibrium partialgeometricalshieldingoftheprimary photonsourceasseenfromthepointof measurement

Detectorrelatedsmallfieldcondition
detectorsizecomparedtofieldsize

ThursdayApril7

SEAAPM2011

10

Lateralchargedparticleloss
broadphotonfield narrowphotonfield

volume

volume

Asmallfield canbedefinedasafieldwithasizesmallerthan thelateralrange ofchargedparticles isameasureofthedegreeofequilibriumortransientequilibrium

ICRU,September2008 11

Lossoflateralchargedparticleequilibrium

ConceptofrLEE
Lietal.1995 MedPhys22:1167 70
ThursdayApril7 SEAAPM2011 12

Sourceocclusion

Largefieldconditions
ThursdayApril7 SEAAPM2011

Smallfieldconditions
(IPEMReport103)
13

Overlappingofbeampenumbras
definition offield size?

FromDasetal.2008MedPhys35:20615
ThursdayApril7 SEAAPM2011 14

Whatconstitutesmallfield conditions?
Beamrelatedsmallfieldconditions
theexistenceoflateralchargedparticle disequilibrium partialgeometricalshieldingoftheprimary photonsourceasseenfromthepointof measurement

Detectorrelatedsmallfieldcondition
detectorsizecomparedtofieldsize

ThursdayApril7

SEAAPM2011

15

Detectordependenceofoutputfactor

ThursdayApril7

FromDoblado etal.2007PhysMed23:5866
SEAAPM2011

16

Detectorissuesinsmallfielddosimetry
Energydependenceoftheresponse Perturbationeffects
Centralelectrode Walleffects Factthatcavityisairfilledinsteadofwater Volumeaveraging

Interactionoftheseeffectswithbeamfocal spotsize
ThursdayApril7 SEAAPM2011 17

Detectorrelatedsmallfieldcondition

Meltsner etal., Med Phys36:339 (2009)

Exradin A16outer diameter Exradin A16inner diameter

OnecouldclaimthattheGammaKnife 18or14mmdiameterfieldsarenot small(quasipointsource+electronequilibriumlengthabout6mm)

ThursdayApril7 SEAAPM2011 18

Measurementswithsmallfield detectors

Sauer&Wilbert MedPhys34,198388 (2007)

IC=PTW31010(0.125cm3) PiP =PTW31006(Pinpoint)

SES=sizeof equivalentsquare

ThursdayApril7

SEAAPM2011

19

WhydoweworryaboutCPEorTCPE?

ValidforCPEorTCPE. CorrectionfactorkQ wellknownfor: Q1 =Co60;Q2 =linac beamwithfield 10x 10cm2;z =10cm;SSDorSAD100cm

ThursdayApril7

SEAAPM2011

20

WhydoweworryaboutCPEorTCPE?
Forthemeasurementofabsorbeddose: InregionsofCPEandTCPE: SPRconversionisaccurate
Dosimetry accordingtoTG51orTRS398

InregionsofnonCPE: SPRconversionisnotaccurate and additional,sometimeslarge,correctionsareneeded,i.e.,

Dosimetry innarrowstereotacticfields

InregionsofrecomposedCPE (IMRT,Tomotherapy,etc): wedontknow(sincecompositionofCPEmaybedisturbedby detector,ormaynotbeperfect)

Dosimetry ofintensitymodulatedfields

ThursdayApril7

SEAAPM2011

21

Smallfielddosimetry

0.3% effect

SanchezDoblado etal Phys.Med.Biol. 48 20812099(2003)

22

Stoppingpowerratiowatertoair

Very small effects!

Eklund andAhnesj,PhysMedBiol 53:4231 (2008)

ThursdayApril7 SEAAPM2011 23

Narrow 1.5mmfield
1.70 1.60

Ratioofdosetowatertodoseto airaveragedovercavityvolume

Dw/Dair

Collectingelectrode diameter:1.5mm Separation:1mm

1.50 1.40 1.30 1.20

60%1.10
1.00 0.90 0.80 0 2

Stoppingpower ratiow/air

4 6 Offaxisdistance(mm)

Paskalev,Seuntjens,Podgorsak (2002)AAPMProc.Series13,Med. 24 Phys.Publishing,Madison,Wi,298 318.

Roleofdifferentperturbationfactors insmallfields

080915

PP31006andPP31016 chambers

Cropetal.,PhysMedBiol 54:2951(2009)
ThursdayApril7 SEAAPM2011 25

Offaxisbehaviourofcorrectionfactors
8mmx 8mmfield,10cmdepth(0.6mm,2mmspotsizes)

080915

Verysmalleffects!
Cropetal.,PhysMedBiol 54:2951(2009)
ThursdayApril7 SEAAPM2011 26

Offaxisbehaviourofcorrectionfactors
8mmx 8mmfield,10cmdepth(0.6mm,2mmspotsizes)

080915

Verylargeeffects!

Cropetal.,PhysMedBiol 54:2951(2009)
ThursdayApril7 SEAAPM2011 27

Summaryofmeasurementissuesin smallfields
Beamdependentissues
Beamfocalspotsizeplaysarole Lateraldisequilibrium Howdowemeasurebeamqualityinpractice?

Detectoreffects
Thereisnoidealdetector Volumeaveragingandperturbationeffects Correctionsdependonbeamfocalspotsize
ThursdayApril7 SEAAPM2011 28

PhysicsofIMRTfields

ThursdayApril7

SEAAPM2011

29

Compositenonstandardfields
Composedofmultiplesmallfields Thus:samedosimetric issuesasinsmallfields
Lateralchargedparticledisequilibrium Partialocclusionofsource Detectorresponseproblems,volumeaveraging, perturbations

Howcandosimetric accuracybeaffected?

ThursdayApril7

SEAAPM2011

30

Dosemeasurementsincompositefields
x NE = 0.973 s ( x NE ) = 0.022

xIC10 = 0.963 x PP = 0.944 s ( x PP ) = 0.035 s ( xIC10 ) = 0.024

Fraseretal(2009)JACMP10(4):24151
ThursdayApril7 SEAAPM2011 31

WhydoweworryaboutCPEorTCPE?
Forthemeasurementofabsorbeddose: InregionsofCPEandTCPE:SPRconversionisaccurate
Dosimetry accordingtoTG51orTRS398

InregionsofnonCPE:SPRconversionisnotaccurateand additional,sometimeslarge,correctionsareneeded,i.e.,
Dosimetry innarrowstereotacticfields

InregionsofrecomposedCPE (IMRT,Tomotherapy,etc): wedontknow(sincecompositionofCPEmaybedisturbedby detector,ormaynotbeperfect)

Dosimetry ofintensitymodulatedfields

ThursdayApril7

SEAAPM2011

32

Field name Static #1 Static #2 Static #3 Static #4 Static #5 Dynamic #1 Dynamic #2 Dynamic #3 Dynamic #4 Dynamic #5 Dynamic #6 Dynamic #7 Dynamic #8

CIMRT,6 MVmeasured 1.019 1.173 1.124 1.274 1.172 1.139 1.169 1.089 1.007 0.920 1.583 1.077 1.079
4.0% 6.1% 3.2% 6.0% 2.5% 3.0% 2.5% 3.9% 3.2% 5.4% 5.9% 5.7% 5.9%

CIMRT,6 MVcalculated 0.950 1.150 1.094 1.233 1.141 1.143 1.161 1.004 1.031 0.885 1.605 1.014 1.005

Difference 6.8% 1.9% 2.7% 3.2% 2.7% -0.3% 0.7% 7.8% -2.4% 3.8% -1.4% 5.9% 6.9%

Bouchard &Seuntjens,MedPhys31: 24532464(2004)

ThursdayApril7 SEAAPM2011 33

Exradin A12

Exradin A14

Gradientcorrectionduetovolumeaveragingisdominating
ThursdayApril7 SEAAPM2011 34

Issuewithreferencedosimetry conditions
Modality Most relevant static calibration field size 10 x 10 cm2 S&S or dynamic capabilities? Yes Yes Yes Yes

IMRT, SRS/SRT

TomoTherapy 5 x 20 cm2 CyberKnife GammaKnife 6 cm diameter 16 mm / 18 mm diameter

SEAAPM2011

ThursdayApril7

35

Newdosimetry ofsmalland IMRTfields

StatusReport

ThursdayApril7

SEAAPM2011

36

SeveralworkinggroupsandTGs
AAPMTG155 smallfieldrelativedosimetry AAPMTG178 GammaKnife dosimetry IAEAsmallfieldcommittee liaisedwith AAPMWGDPCB ICRUreportcommitteeonprescribingand reportingofstereotacticradiationtherapy IPEM Report103 DIN smallfieldsubcommittee
ThursdayApril7 SEAAPM2011 37

Upcomingguidelinesand recommendations
Newformalism Datafornewformalism Practicalissues
Smallfields:

ThursdayApril7

Beamquality Suitabledetectors Correctionfactors etc Beamquality Suitabledetectors Referencefieldcriteria Correctionfactors etc

SEAAPM2011 38

CompositefieldsIMRT:

Newformalism
TworelatedroutesforDw innonconventionalreference conditions,bothrequiringanextensionofconceptof referencefieldandmodifiedreferenceconditions Smallstaticfielddosimetry
intermediatemachinespecificreferencefield(msr) Recommendationsforcorrectionfactorstomeasuredoutputfactors

Compositefield IMRTdosimetry
planclassspecificreferencefield(pcsr) Apcsr fieldcanbea3Dirradiatedvolumeora4Ddeliverysequence. Thepcsr shouldbeascloseaspossibletoaclassofclinicalplansof interest,andprovideauniformdoseoveraregionexceedingthe dimensionsofareferencedetector

AlfonsoetalMedPhys35:5197(2008)
ThursdayApril7 SEAAPM2011 39

Staticsmallfields

ThursdayApril7

SEAAPM2011

40

REFERENCEDOSIMETRY

RELATIVEDOSIMETRY
fmsr , fref Qmsr ,Q

fmsr w,Qmsr

=M

fmsr Qmsr

ND,w,Q0 kQ,Q0 k

fclin w,Qclin

=D

fmsr w,Qmsr

fclin, fmsr Qclin,Qmsr

Broadbeam referencefieldfref

Machinespecific referencefield fmsr

Radiosurgical collimators

Clinical fclin

1.8cm

k
ND,w,Q0 kQ,Q0

f msr , f ref Qmsr ,Q

BrainLAB microMLC 10cmx10cm

Hypothetical referencefield fref

CyberKnife 6 cm GammaKnife 1.6/1.8cm Tomotherapy 5cmx 20cm

SEAAPM2011

f clin , f msr Qclin , Qmsr

M M

f clin Qclin f msr Qmsr

f clin f kQclin ,,Qmsr msr

k
Ionization chamber
ThursdayApril7

f msr , f ref Qmsr ,Q

41

Howtospecifybeamquality?
MultiplebeamsfromBJRSuppl 25

Sauer(2009)Med.Phys.36:4168
ThursdayApril7 SEAAPM2011 42

Beamqualityspecifier forTomotherapy

AAPMTG148 (Langen etal. 2010MedPhys 37:481753): dd(10)x[HTref]

ThursdayApril7

SEAAPM2011

43

Datafor

correctionfactorsaresmallforthelargerfieldmsr
ThursdayApril7 SEAAPM2011 44

Datafor(contd)
Tomotherapy msr field

Sterpin etal(2011 preliminarydata)

correctionfactorsaresmallforthelargerfieldmsr
ThursdayApril7 SEAAPM2011 45

Fieldoutputfactors
f f Qclin ,,Qmsr = clin msr f Dwclinclin ,Q f Dwmsrmsr ,Q f clin f f clin f clin M Qclin Dwclinclin M Qclin M Qclin f clin , f msr ,Q = f msr f msr = f msr kQclin ,Qmsr f msr M Qmsr Dw,Qmsr M Qmsr M Qmsr

f clin f kQclin ,,Qmsr msr

f f msr Dwclinclin M Qmsr ,Q = f msr f clin Dw,Qmsr M Qclin

f msr f clin f clin M Qmsr (1) M Qclin (2) M rel ,Qclin (2) = f clin f msr = f clin , f msr f clin kQclin ,Qmsr (2) M Qclin (1) M Qmsr (2) M rel ,Qclin (1)

f clin f kQclin ,,Qmsr (1) msr

ThursdayApril7

SEAAPM2011

46

Fieldoutputfactors CyberKnife:
Pantelis etal.2010MedPhys37:2369
1.050 1.000 0.950 0.900 M / M60 0.850 0.800 0.750 0.700 0.650 0.600 0
A16 PinPoint Diode 60008 Diode 60012 EDGE Alanine TLD EBT film Polymer gel
1.300 1.250 1.200 1.150 1.100 1.050 1.000 PinPoint Diode 60008 Diode 60012 EDGE Alanine TLD EBT film Polymer gel

0.70

(M/M 60)2/(M/M 60) 1

0.75

( M clin / Mref) * kclin,msr

M clin / M ref

0.65
10 diameter / mm 15 20

0.950 0 5 10 diam eter / m m

15

20

0.60
1.300 ratio of correction factors (MC or vol) 1.250 1.200 1.150 1.100

1.15 1.10
clin f clin f kQfclin ,,Qmsr (1) kQfclin ,,Qmsr ( 2) msr msr

PinPoint Diode 60008 Diode 60012 EDGE Alanine

0.55
Diode 60008 Diode 60012 EDGE

1.05 1.00 0.95 0.90 0.85

Diode 60008 Diode 60012 Polymer gel

0.50
ExrA16

TLD

PinPoint EBT film SHD

Polymer gel

USD

EDGE
1.050

alanine

TLD

EBT

GEL

detector 1.000
0.950

080915
PinPoint A16

47/25

10 diam eter / m m

15

20

Alanine

EDGE

TLD

EBT film

Gettingoutputfactordataformultiple detectortypes

ThursdayApril7

SauerandWilbert2007 SEAAPM2011 MedPhys34:19838

48

Outputfactors CyberKnife
couplingofbeamspotsizeanddetectorcorrectionfactors
DifferentFWHMprimarysource

f clin f clin f kQclin ,,Qmsr = a Qfclin ,,Qmsr + b msr msr

f clin , f msr Qclin ,Qmsr

f clin , f msr Qclin ,Qmsr

M msr clin f = Qfclin ,,Qmsr msr M clin

msr = 60 mm collimator

Qf

clin , f msr

clin ,Qmsr

Francescon etal2008MedPhys35:50413
ThursdayApril7 SEAAPM2011 49

IMRTfields

ThursdayApril7

SEAAPM2011

50

Newformalism
TworelatedroutesforDw innonconventionalreference conditions,bothrequiringanextensionofconceptof referencefieldandmodifiedreferenceconditions Smallstaticfielddosimetry
intermediatemachinespecificreferencefield(msr) Recommendationsforcorrectionfactorstomeasuredoutputfactors

Compositefield IMRTdosimetry
planclassspecificreferencefield(pcsr) Apcsr fieldcanbea3Dirradiatedvolumeora4Ddeliverysequence. Thepcsr shouldbeascloseaspossibletoaclassofclinicalplansof interest,andprovideauniformdoseoveraregionexceedingthe dimensionsofareferencedetector

AlfonsoetalMedPhys35:5197(2008)
ThursdayApril7 SEAAPM2011 51

REFERENCEDOSIMETRY

RELATIVEDOSIMETRY
f pcsr, fref Qpcsr,Q

f pcsr w,Qpcsr

=M

f pcsr Qpcsr

ND,w,Q0 kQ,Q0 k

fclin w,Qclin

=D

f pcsr w,Qpcsr

fclin, f pcsr Qclin,Qpcsr

Broadbeam referencefield

fref

f pcsr, fref Qpcsr,Q

(e.g.IMRTLinac)

Planclass specificreference field fpcsr

Clinical fclin
300 340 20 60

ND,w,Q0 kQ,Q0
Hypothetical referencefield

260 220 180

100 140

fmsr
e.g.9fieldprostate pcsr

f clin , f pcsr Qclin ,Q pcsr

f clin M Qclin

f pcsr Q pcsr

f clin , f pcsr Qclin ,Q pcsr

k
f msr , f ref Qmsr ThursdayApril7 ,Q

f pcsr , f msr Qpcsr ,Qmsr

(e.g.Tomotherapy 5cmx20cm) SEAAPM2011

Ionization chamber

52

Plan class specific reference fields

DynamicIMRTH&N Chungetal. 2010Med.Phys.37:240413 VMAT RosserandBedford2009 Phys.Med.Biol.54:70457061

TomoTherapy Bailatetal.2009 Med.Phys.36:38913896

ThursdayApril7

SEAAPM2011

53

pcsrfieldcorrectionfactors
1.03 1.02 1.01 k pcsr,ref 1.00 0.99 0.98
Rosser and Rosser and Bedford 2009 Bedford 2009 Bailat et al. Bailat et al. 2009 2009 Chung et al. Chung et al. 2010 2010

k=2

0.97 pcsr field

SuitableIMRTcalibrationfields?

Chungetal2011
ThursdayApril7 SEAAPM2011 55

Whatarepossiblecriteriaforsuitable IMRTcalibrationfields?

Chungetal2011
ThursdayApril7 SEAAPM2011 56

Conclusions
SmallandIMRTfielddosimetry canbecomplex
Thereareheftyperturbationeffectsthatcanhave significantimpactonreferencedosimetry procedures andoutputfactors Comparisonbetweendifferentdetectorsprovides valuableinformation

Insmallfielddosimetry
Machinespecificreferencefieldsdefined Dataoncorrectionfactorsisbeingcollected
ThursdayApril7 SEAAPM2011 57

Conclusions(contd)
InIMRT/compositefielddosimetry
Measurementuncertainties,referencedetectors Practicalcriteriaforthereferencefielddefinition arebeingdeveloped

Newdocumentswillbecomingoutproviding guidelinesonhowtobetterdealwiththese issues Continuededucationisneededandcanprevent complacency

ThursdayApril7 SEAAPM2011 58