IAEA Training Material on Radiation Protection in Radiotherapy

Radiation Protection in
Radiotherapy

Part 10
Good Practice including Radiation
Protection in EBT
Lecture 4: Treatment verification and reporting
The Problems:
 The correct dose of radiation shall be
delivered just to the target.
 The dose to surrounding structures shall be
as low as possible.
 Must be achieved on many occasions
(typically >30 treatment fractions)
 It must be verifiable
 Must be documented in a way that allows
others to understand all important factors of
the treatment performed
Radiation Protection in Radiotherapy Part 10, lecture 4: Treatment verification 2
Objectives
 To understand the different frames of reference used
in radiotherapy
 To be familiar with techniques which allow to verify
that the treatment is delivered to the appropriate
location
 To appreciate the need for reporting dose AND
volume in prescription and treatment reporting in
radiotherapy
 To be aware of the reports of the ICRU regarding
reporting of radiotherapy treatments

Radiation Protection in Radiotherapy Part 10, lecture 4: Treatment verification 3

Contents of lecture 4 in part
10
1. Sources of uncertainty
2. Methods to verify dose delivery
 portal films
 in vivo dosimetry

3. Prescription and reporting

Radiation Protection in Radiotherapy Part 10, lecture 4: Treatment verification 4

1. Sources of uncertainty
 Patient localization
 Organ motion
 Imaging (resolution, distortions,…)
 Definition of anatomy (outlines,…)
 Beam geometry
 Dose calculation
 Dose display and plan evaluation
 Plan implementation

Radiation Protection in Radiotherapy Part 10, lecture 4: Treatment verification 5

Patient localization
 The patient should be
positioned identically
during diagnostics (CT),
in simulation and 30+
times during treatment
 Sources of uncertainty:
 motion
 reliability of marks on
the skin
 couch sag

Radiation Protection in Radiotherapy Part 10, lecture 4: Treatment verification 6

Organ motion
 Affects most organs - particularly noticeable
for lung cancer, liver, prostate and other pelvic
malignancies
 Shown here is the difference in CT scan
between inhale and exhale position

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Imaging issues
 Partial volume effects
 Distortion (MR)
 Limited spatial resolution (PET)
 More discussion on these issues in the
companion course on diagnostic
radiology

Radiation Protection in Radiotherapy Part 10, lecture 4: Treatment verification 8

Target definition, outlining of
organs
 Decide where the
organ is and what
extend it has.
 Are the seminal
vesicles really
where they are
drawn here?

Radiation Protection in Radiotherapy Part 10, lecture 4: Treatment verification 9

Beam geometry and positioning

 Is the block exactly

where it should be?
 Is there gantry sag?

Radiation Protection in Radiotherapy Part 10, lecture 4: Treatment verification 10

Dose calculation
 There are many
different dose
calculation algorithms
 All have limitations (and
be it the long time
required to calculate the
dose)
 Must know what to trust

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Plan display and evaluation
 Comparison of competing plans...

Radiation Protection in Radiotherapy Part 10, lecture 4: Treatment verification 12

Implementation of the plan
 Transfer of data between
units

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2. Verification of dose delivery
 The plan looks great...
 However, one must ensure that during
treatment everything is matching the
treatment plan

ADAC
Radiation Protection in Radiotherapy Part 10, lecture 4: Treatment verification 14
In practice there are many
systems...

Diagnostic tools
Patient

Treatment
planning
Treatment unit

Radiation Protection in Radiotherapy Part 10, lecture 4: Treatment verification 15

Ensure different co-ordinate
systems match...

Diagnostic tools
Patient

Treatment
planning
Treatment unit

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Good practice
 Verify data transfer
 Use critical approach
 Verify treatment by comparing an image
taking during treatment with a reference
image taken either during simulation or
taken from the treatment planning
system

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Human errors in data transfer during the preparation
and delivery of radiation treatment affecting the final
result: "garbage in, garbage out"
Leunens, G; Verstraete, J; Van den Bogaert, W; Van Dam, J; Dutreix, A; van der Schueren, E
Department of Radiotherapy, University Hospital, St. Rafaël, Leuven, Belgium

Abstract
Due to the large number of steps and the number of persons involved in the preparation of a radiation
treatment, the transfer of information from one step to the next is a very critical point. Errors due to
inadequate transfer of information will be reflected in every next step and can seriously affect the final
result of the treatment. We studied the frequency and the sources of the transfer errors. A total number of
464 new treatments has been checked over a period of 9 months (January to October 1990). Erroneous data
transfer has been detected in 139/24,128 (less than 1%) of the transferred parameters; they affected 26%
(119/464) of the checked treatments. Twenty-five of these deviations could have led to large geographical
miss or important over- or underdosage (much more than 5%) of the organs in the irradiated volume, thus
increasing the complications or decreasing the tumour control probability, if not corrected. Such major
deviations, only occurring in 0.1% of the transferred parameters, affected 5% (25/464) of the new
treatments. The sources of these large deviations were nearly always human mistakes, whereas a
considerable number of the smaller deviations were, in fact, consciously taken decisions to deviate from the
Green Journal 1992: > 50 occasions of data transfer
intended treatment. Nearly half of the major deviations were introduced during input of the data in the
check-and-confirm system, demonstrating that a system aimed to prevent accidental errors, can lead to a
from one point to another for each patient!
considerable number of systematic errors if used as an uncontrolled set-up system. The results of this study
show that human mistakes can seriously affect the outcome of patient treatments.(ABSTRACT
TRUNCATED AT 250 WORDS) [Journal Article; In English; Netherlands]
Radiation Protection in Radiotherapy Part 10, lecture 4: Treatment verification 18
Most important comparison
 Reference from  Check film during
planning treatment
• Simulator film • Port film
• DRR • EPID

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Portal films
 Taken during (or
directly before)
treatment with:
 beam from the
treatment unit
 patient in treatment
position
 shielding in place

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Port films
 Usually taken before
or after treatment
 If the field itself does
not show enough
anatomy, a double
exposure technique
can be used:
Expose treatment field
Open collimators and expose the same film again

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In radiotherapy practice
 The risk from the additional exposure in
dual exposure technique portal images
is negligible compared to the risk not
treating the correct area in the patient...

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Electronic Portal Images
 A film less way to
verify field location
 Mounted on the
linac
 Different systems:
 ion chamber
 fluoroscopic screen
 semiconductor
arrays

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Electronic Portal Imaging
Devices - EPIDs
 Offered by all major  Easy use and
manufacturers positioning of the
 Has several system
advantages:  Allows on line
verification
 Multiple images (‘cine’)
can be taken during one
treatment
 Images available in
digital format

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Verification films/images
 Two different aims:
 Verify correct shielding
 Verify patient location

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Verify block shape and position

 should be done for every treatment field

at least once per course of radiotherapy

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Verify patient location
 Should be done using two images which give
adequate information on the location of the
target in respect to the treatment beam
geometry.
 These do not necessarily need to be
treatment fields (e.g. in case of IMRT or arcs)
 This verification should be repeated every
week during treatment for radical treatments

Radiation Protection in Radiotherapy Part 10, lecture 4: Treatment verification 27

Verify dose delivered to the
patient
 May be done in
customized
anthropomorphic
phantoms
 More likely using in Breasts modeled on a particular
patient to verify skin dose using
vivo dosimetry TLDs

Radiation Protection in Radiotherapy Part 10, lecture 4: Treatment verification 28

IN VIVO DOSIMETRY

ICRU report 24 (1976):

“An ultimate check of the actual
treatment given can only be made by
using in vivo dosimetry.”
Why do in vivo dosimetry
 Quality Assurance – Treatment Verification
 Measure because we don’t know
 Limitations of dose planning
 Patient movement
 Verify dose for the record
 Critical organs
 Legal aspects
 Clinical trials

Radiation Protection in Radiotherapy Part 10, lecture 4: Treatment verification 30

Challenges for in vivo dosimetry

 Typically low dose where the detectors

can be located
 Variation of detector response with
 Temperature
 Radiation Quality
 Direction of radiation
 Need to not interfere with therapeutic
objective

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Potential detectors
 Needed: High sensitivity, tissue
equivalence, high spatial resolution

TLD
Semiconductors (diodes, MOSFETs)
Radiochromic film
Others (alanine, gel dosimetry, …)

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In vivo exit dosimetry
 calculate exit
fluence
 determine what the
portfilm/EPID should
look like
 verify dose by
projecting back

Radiation Protection in Radiotherapy Part 10, lecture 4: Treatment verification 33

3. Prescription and reporting
 Prescription may be at the discretion of
individual clinicians, depending on equipment
available, experience and training
 Reporting must be uniform - any adequately
educated person must be able to understand
what happened to the patient in case of:
 need for a different clinician to continue treatment
 re-treatment of the patient
 clinical trials
 potential litigation

Radiation Protection in Radiotherapy Part 10, lecture 4: Treatment verification 34

Recommendations by the ICRU
 International
Commission on
Radiation Units and
Measurements
 ICRU reports provide
guidance on
prescribing, recording
and reporting

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The required dose information
 Should describe the treatment
concisely and unambiguously
 Gets more and more complex as
treatment approaches become more
complex

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The required dose information
 1950: Patient X: x
Gy in n fractions to y
tumour
 1993: ICRU 50,
appendix I

1999: ICRU 62 …plus

the same for OAR...

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Important
 Information includes dose AND volume
 Information is provided for target AND
normal structure
 Information includes dose AND
fractionation

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Dose Volume Histograms
 Dose and
Volume
information
 Example
from ICRU
report 62:
prostate
cancer

Radiation Protection in Radiotherapy Part 10, lecture 4: Treatment verification 39

Normal tissue information

rectum bladder femoral heads

Radiation Protection in Radiotherapy Part 10, lecture 4: Treatment verification 40

Normal tissue information

rectum bladder femoral heads

Quick Question: Why is there a ‘kink’ in the DVH for

the femoral heads at about half of the dose to the
prostate?

Radiation Protection in Radiotherapy Part 10, lecture 4: Treatment verification 41

Answer 1

3 60 Gy 2

4
 In a ‘four field box’ treatment two of the
four fields go through the femoral
heads...

Radiation Protection in Radiotherapy Part 10, lecture 4: Treatment verification 42

Record keeping required...
 BSS.appendix II.31 “… in radiation
therapy, a description of the planning
target volume, the dose to the centre of
the planning target volume and the
maximum and minimum doses
delivered to the planning target volume,
the doses to other relevant organs, the
dose fractionation, and the overall
treatment time; …”
Radiation Protection in Radiotherapy Part 10, lecture 4: Treatment verification 43
A final point
 The best localization is
void if it is the wrong
patient!!!
 Always check patient
identification prior to
treatment
 In practice this is a surprisingly
common problem - there are
many patients called ‘Mr Smith’
and patients may be confused
when presenting for treatment.
A photo in the treatment sheet
may also be useful

Radiation Protection in Radiotherapy Part 10, lecture 4: Treatment verification 44

Summary
 Optimization of radiotherapy includes the
optimization of radiation beam design
 Treatment verification using portal imaging is
essential
 In vivo dosimetry is a useful complementation of
portal imaging
 A large amount of information - including dose AND
volume - is required to describe a radiotherapy
treatment concisely
 Radiotherapy treatments should be reported
following international conventions

Radiation Protection in Radiotherapy Part 10, lecture 4: Treatment verification 45

Where to Get More Information
 International Commission on Radiation Units and
Measurements. ICRU report 50: Prescribing,
recording, and reporting photon beam therapy.
Bethesda. 1993.
 International Commission on Radiation Units and
Measurements. ICRU report 62: Prescribing,
recording, and reporting photon beam therapy
(Supplement to ICRU report 50). Bethesda 2000.

Radiation Protection in Radiotherapy Part 10, lecture 4: Treatment verification 46

Any questions?
 Question:

Please discuss the advantages (and

disadvantages) of electronic portal imaging as
compared to portal films for verification of patient
positioning during radiotherapy.
The answer should include:
 Advantages  Disadvantages
 No additional dose  High initial investment
required for most images costs
 Easy positioning of the  Dual exposures may be
system more difficult
 Allows on line verification  Image quality of many
 Multiple images (‘cine’) systems inferior to film
can be taken during one
treatment
 Images available in
digital format

Radiation Protection in Radiotherapy Part 10, lecture 4: Treatment verification 49