Comparison of dosimetric characteristics of physical and enhanced dynamic wedges

BackgroundWedge filters can be used as missing tissue compensators or wedge pairs to alter the shape of isodose curves so that two beams can be angled with a small hinge angle at a target volume without creating a hotspot.AimIn this study the dosimetric properties of Varian Enhanced Dynamic Wedge (EDW) and physical wedges (PW) were analyzed and compared.Materials and methodsIonometric measurements of open field output factor, physical wedge output factor, physical wedge factor and EDW factor for photon beams were carried out. A 3D scanning water phantom was used to scan depth dose and profiles for open and PW fields. The 2D ionization matrix was used to measure profiles of physical and EDW wedges. The isodose curves of physical and EDW angles were obtained using a therapy verification film.Results and discussionThe PW output factors of photons were compared with the open field output factors. The physical and EDW factors were compared. The difference in percentage depth dose for open and PW fields was observed for both photon beams. The measured isodose plots for physical and EDW were compared.ConclusionThe wedge field output factor increases with field size and wedge angle compared to that of the open field output factor. The number of MU to deliver a particular dose with the EDW field is less than that of the PW field due to a change in wedge factor. The dosimetric characteristics, like profile and isodose of EDW, closely match with that of the PW.     

Multienergetic verification of dynamic wedge angles in medical accelerators using multichannel linear array

Background

The aim of the modern radiotherapy is to get a homogenous dose distribution in PTV, which is obtained by using for example physical or dynamic wedges. The using of a physical wedge has provided such isodose distributions but their use resulted in detrimental dosimetric consequences, for example beam hardening effects and practical consequences of filter handling or possible misalignment. Linear accelerators are now equipped with collimator jaws systems and controlled by modern computers and it is possible to generate wedge shaped isodose distributions dynamically. Because of a more comfortable use of a dynamic wedge, there are alternatives to the standard physical wedge. During the treatment, different segments of the treatment field can be exposed to the primary beam at different intervals of time. This process of shrinking the field while modulating the collimator jaw velocity and dose rate creates the desired wedge-shaped isodose gradient across the treatment field. Dynamic wedges can replace physical wedges but they need more precise dosimetry and quality control procedures.

Aim

The aim of this study was to perform a multienergetic verification of dynamic wedge angles using the multichannel detector PTW LA48 linear array.

Material and methods

The measurements of angle value of dynamic wedges were performed for Clinac 2300 C/D accelerators (Varian). The accelerator was equipped with the EDW option for 6 MV and 15 MV photon beams. In this case, 7 wedge angle values were used: 10°, 15°, 20°, 25°, 30°, 45° and 60°. The dynamic wedges are realized by continuous movement of one collimator jaw. The field size is gradually reduced until the collimator is almost completely closed or the field increases, while the beam is on. The measurements were divided in two steps: in the first step, the dynamic wedges were verified with the recommended values and in the second step there the planned and measured angles of dynamic wedges were compared. Measurements were made by means of LA48 linear array of ionization chambers (PTW). The results of the measurements were compared with the reference profile produced by the treatment planning system ECLIPSE 8.5 (Varian).

Results

The results showed differences between measured and calculated angle of dynamic wedges. The differences were observed for both energies in the case of a small angle value. For energies 6 MV and 15 MV, almost all percentage difference between the measured and calculated profile was lower than 5%. The biggest difference was observed in the first step of measurements when the angle of Dynamic Wedge was verified. The comparison between the planned and measured angle value of Dynamic Wedge showed the difference between 0.1% and 4.5%.The difference for 6 MV for the angle value of 10° in orientation IN was 1.1% and for energy 15 MV in the same case the difference was 3.8%. Thinner wedges exhibit less difference.

Conclusion

It is necessary to provide comprehensive quality control procedure for enhanced dynamic wedges. Verification measurements should be an obligatory procedure in the recommendation for the testing of medical accelerators. These results are the preliminary results to provide measurements in other Polish Cancer Centres.     

Interplay effects during enhanced dynamic wedge deliveries

In this study the interplay effects for Enhanced Dynamic Wedge (EDW) treatments are experimentally investigated. Single and multiple field EDW plans for different wedge angles were delivered to a phantom and detector on a moving platform, with various periods, amplitudes for parallel and perpendicular motions. A four field 4D CT planned lung EDW treatment was delivered to a dummy tumor over four fractions. For the single field parallel case the amplitude and the period of motion both affect the interplay resulting in the appearance of a step function and penumbral cut off with the discrepancy worst where collimator-tumor speed is similar. For perpendicular motion the amplitude of tumor motion is the only dominant factor. For large wedge angle the dose discrepancy is more pronounced compared to the small wedge angle for the same field size and amplitude-period values. For a small field size i.e. 5 × 5 cm² the loss of wedged distribution was observed for both 60° and 15° wedge angles for parallel and perpendicular motions. Film results from 4D CT planned delivery displayed a mix of over and under dosages over 4 fractions, with the gamma pass rate of 40% for the averaged film image at 3%/1 mm DTA (Distance to Agreement). Amplitude and period of the tumor motion both affect the interplay for single and multi-field EDW treatments and for a limited (4 or 5) fraction delivery there is a possibility of non-averaging of the EDW interplay.     

Study of 2D ion chamber array for angular response and QA of dynamic MLC and pretreatment IMRT plans

AimTo study of 2 Dimensional ion chamber array for angular response and its utility for quality assurance of dynamic multileaf collimator and pretreatment intensity modulated radiotherapy plans.Materials and MethodsThe MLC QA test patterns and IMRT plans were executed on 2D ion chamber array having 1020 vented pixel ionization chambers. The dynamic MLC QA test patterns were chair test, x–wedge, pyramid, open swipe field, garden fence and picket fence. Performance of Dynamic wedges was compared with physical wedges. For IMRT verification, five patients with localized prostate carcinoma were planned using dynamic IMRT technique. Angular response of MatriXX was measured by exposing the system from different gantry angles.ResultsDynamic MLC QA tests such as chair, x-wedge, pyramid, and open swipe field were successfully verified. MatriXX was not able to recognize the bar pattern of picket test and garden fence test. The response of MatriXX gradually decreases from 0° to 180° angles and it was 7.7% less at 180° angle. The dynamic wedge profiles were matching with corresponding physical wedge profiles. For pretreatment IMRT QA, the average dose difference between planned and measured dose was 1.26% with standard deviation of 1.06.ConclusionI'mRT MatriXX can be used for routine dynamic MLC and IMRT pretreatment QA but care should be taken while taking measurements in penumbra region because of its limited spatial resolution.     

Quality assurance of Siemen's virtual wedgeTMby using film dosimetry

A film dosi netry method is proposed for measuring the non-uniform dose distribution generated by Virtual Wedges of a 6 MV Siemens Pr mus accelerator. This method was chosen due to the dose integration capabilities and the improved spatial resolution that films offer, giving the opportunity of measuring dose distribution in a single beam irradiation. Dose profiles were obtained and analyzed using a 16-bit Vidar film scanner and OmniPro-Accept software. Results were compared with corresponding ones measured with an array ionization chamber for both virtual and conventional wedges. A good agreement was found between the two methods for all the examined wedge angles. This study shows that film, dosimetry can be incorporated in a monthly quality asseurance program for virtual wedges in order to reduce the required effort.     

Lateral wedge with medial only cardiac shielding (LEMONADE) technique in left chest wall adjuvant radiotherapy

BackgroundThis dosimetric study compared lateral wedge with medial only cardiac shielding (LEMONADE) technique, for left chest wall (LCW) irradiation against three other commonly used techniques.Materials and methodsDosimetric parameters of 22 consecutive LBC patients treated using the P1 (LEMONADE technique) were compared with 3 other virtually reconstructed plans : no cardiac shielding with paired wedges; P2 (paired wedges and medial only Y-direction shielding) and P3 (paired wedges and bilateral Y-direction shielding).ResultsP1 showed better target volume (TV) coverage with the mean 90% isodose coverage of 85.59% ± 5.44 compared to 78.90% ± 8.59 and 74.22% ± 9.50 for P2 and P3, respectively. Compared to no cardiac shielding, for a 4.65% drop in TV coverage the V26Gy of heart dropped from 6.68% to a negligible 0.85% for P1. TV receiving < 30Gy is also significantly lesser for P1 compared to P2 and P3 (5.42% vs 10.64% and 15.8%), whilst there is a small difference of 2.75% between no cardiac shielding and P1.ConclusionWith the improvement in BC survival rate, cardiac toxicity associated with adjuvant irradiation for LBC is a major concern. P1 (LEMONADE) technique has a good compromise between cardiac sparing and target coverage and should suffice for most LCW irradiations. Furthermore, the LEMONADE technique is a simple, reproducible and involves fast planning for cardiac sparing, which is ideal for under-resourced departments with heavy workload.     

High throughput film dosimetry in homogeneous and heterogeneous media for a small animal irradiator

PurposeWe have established a high-throughput Gafchromic film dosimetry protocol for narrow kilovoltage beams in homogeneous and heterogeneous media for small-animal radiotherapy applications. The kV beam characterization is based on extensive Gafchromic film dosimetry data acquired in homogeneous and heterogeneous media. An empirical model is used for parameterization of depth and off-axis dependence of measured data.MethodsWe have modified previously published methods of film dosimetry to suit the specific tasks of the study. Unlike film protocols used in previous studies, our protocol employs simultaneous multi-channel scanning and analysis of up to nine Gafchromic films per scan. A scanner and background correction were implemented to improve accuracy of the measurements. Measurements were taken in homogeneous and inhomogeneous phantoms at 220 kVp and a field size of 5 × 5 mm². The results were compared against Monte Carlo simulations.ResultsDose differences caused by variations in background signal were effectively removed by the corrections applied. Measurements in homogeneous phantoms were used to empirically characterize beam data in homogeneous and heterogeneous media. Film measurements in inhomogeneous phantoms and their empirical parameterization differed by about 2%–3%. The model differed from MC by about 1% (water, lung) to 7% (bone). Good agreement was found for measured and modelled off-axis ratios.ConclusionsEBT2 films are a valuable tool for characterization of narrow kV beams, though care must be taken to eliminate disturbances caused by varying background signals. The usefulness of the empirical beam model in interpretation and parameterization of film data was demonstrated.     

The influence of physical wedges on penumbra and in-field dose uniformity in ocular proton beams

A physical wedge may be partially introduced into a proton beam when treating ocular tumours in order to improve dose conformity to the distal border of the tumour and spare the optic nerve. Two unwanted effects of this are observed: a predictable broadening of the beam penumbra on the wedged side of the field and, less predictably, an increase in dose within the field along a relatively narrow volume beneath the edge (toe) of the wedge, as a result of small-angle proton scatter. Monte Carlo simulations using MCNPX and direct measurements with radiochromic (GAFCHROMIC^® EBT2) film were performed to quantify these effects for aluminium wedges in a 60 MeV proton beam as a function of wedge angle and position of the wedge relative to the patient. For extreme wedge angles (60° in eye tissue) and large wedge-to-patient distances (70 mm in this context), the 90–10% beam penumbra increased from 1.9 mm to 9.1 mm. In-field dose increases from small-angle proton scatter were found to contribute up to 21% additional dose, persisting along almost the full depth of the spread-out-Bragg peak. Profile broadening and in-field dose enhancement are both minimised by placing the wedge as close as possible to the patient. Use of lower atomic number wedge materials such as PMMA reduce the magnitude of both effects as a result of a reduced mean scattering angle per unit energy loss; however, their larger physical size and greater variation in density are undesirable.     

Comparison of peripheral dose measurements using Ionization chamber and MOSFET detector

BackgroundIn radiation therapy, the peripheral dose (PD) – the dose outside the geometric boundaries of the radiation field – is of clinical importance. A metal oxide semiconductor field effect transistor (MOSFET) detector is used to estimate the peripheral dose.AimThe aim of this study is to investigate the ability of a MOSFET dosimetry system to accurately measure doses in peripheral regions of high energy X-ray beams.Materials & MethodsThe accuracy of the MOSFET system is evaluated by comparing peripheral region dose measurement with the results of standard ionization chamber measurements. Furthermore, the measurement of PD using a MOSFET detector helps us to keep the tolerance dose of any critical organ closer to the treatment field within the acceptable limits. The measurements were carried out using a 0.6 cc Farmer type ionization chamber and MOSFET 20 dosimetry system for field sizes ranging from 5 × 5 cm² to 20 × 20 cm² at three depths of 1.5 cm, 5 cm and 10 cm in a blue water phantom. PD were measured at distances varying from 1 cm to 30 cm from the field edges along the x axis for the open fields, with collimator rotation and with beam modifiers like 15 degree, 30 degree and 45 degree wedges.ResultsThe results show a good agreement of measured dose by both methods for various field sizes, collimator rotation and wedges.ConclusionThe MOSFET detector has a compact construction, provides instant readout, is of minimal weight and can be used on any surface.     

Validation of Monte carlo Geant4 multithreading code for a 6 MV photon beam of varian linac on the grid computing

AimTo evaluate the computation time efficiency of the multithreaded code (G4Linac-MT) in the dosimetry application, using the high performance of the HPC-Marwan grid to determine with high accuracy the initial parameters of the 6 MV photon beam of Varian CLINAC 2100C.BackgroundThe difficulty of Monte Carlo methods is the long computation time, this is one of the disadvantages of the Monte Carlo methods.Materials and methodsCalculations are performed by the multithreaded code G4Linac-MT and Geant4.10.04.p02 using the HPC-Marwan computing grid to evaluate the computing speed for each code. The multithreaded version is tested in several CPUs to evaluate the computing speed according to the number of CPUs used. The results were compared to the measurements using different types of comparisons, TPR_20.10, penumbra, mean dose error and gamma index.ResultsThe results obtained for this work indicate a much higher computing time saving for the G4Linac-MT version compared to the Geant4.10.04 version, the computing time decreases with the number of CPUs used, can reach about 12 times if 64CPUs are used. After optimization of the initial electron beam parameters, the results of the dose simulations obtained for this work are in very good agreement with the experimental measurements with a mean dose error of up to 0.41% on the PDDs and 1.79% on the lateral dose.ConclusionsThe gain in computation time leads us to perform Monte Carlo simulations with a large number of events which gives a high accuracy of the dosimetry results obtained in this work.     

Validation of Dolphin dosimetry in three dimensional patient-specific quality assurance programme

AimThe aim of this study is to commission and validate Dolphin-Compass dosimetry as a patient-specific Quality Assurance (QA) device.BackgroundThe advancement of radiation therapy in terms of highly conformal delivery techniques demands a novel method of patient-specific QA. Dolphin-Compass system is a dosimetry solution capable of doing different QA in radiation therapy.Materials and methodsDolphin, air-vented ionization detector array mounted on Versa-HD Linear Accelerator (LINAC) was used for measurements. The Compass is a dose computation algorithm which requires modelling of LINAC head similar to other Treatment Planning Systems (TPS). The dosimetry system was commissioned after measuring the required beam data. The validation was performed by comparison of treatment plans generated in Monaco TPS against the measurement data. Different types of simple, complex, static and dynamic radiation fields and highly conformal treatment plans of patients were used in this study.ResultsFor all field sizes, point doses obtained from Dolphin-Compass dosimetry were in good agreement with the corresponding TPS calculated values in most of the regions, except the penumbra, outside field and at build-up depth. The results of gamma passing rates of measurements by using different Multi-leaf Collimator patterns and Intensity Modulated Radiation Therapy fluence were also found to be in good correlation with the corresponding TPS values.ConclusionsThe commissioning and validation of dosimetry was performed with the help of various fields, MLC patterns and complex treatment plans. The present study also evaluated the efficiency of the 3D dosimetry system for the QA of complex treatment plans.     

Evaluation of Gafchromic® EBT3 films characteristics in therapy photon,electron and proton beams

PurposeTo evaluate the uncertainties and characteristics of radiochromic film-based dosimetry system using the EBT3 model Gafchromic^® film in therapy photon, electron and proton beams.Material and methodsEBT3 films were read using an EPSON Expression 10000XL/PRO scanner. They were irradiated in five beams, an Elekta SL25 6 MV and 18 MV photon beam, an IBA 100 MeV 5 × 5 cm² proton beam delivered by pencil-beam scanning, a 60 MeV fixed proton beam and an Elekta SL25 6 MeV electron beam. Reference dosimetry was performed using a FC65-G chamber (Elekta beam), a PPC05 (IBA beam) and both Markus 1916 and PPC40 Roos ion-chambers (60 MeV proton beam). Calibration curves of the radiochromic film dosimetry system were acquired and compared within a dose range of 0.4–10 Gy. An uncertainty budget was estimated on films irradiated by Elekta SL25 by measuring intra-film and inter-film reproducibility and uniformity; scanner uniformity and reproducibility; room light and film reading delay influences.ResultsThe global uncertainty on acquired optical densities was within 0.55% and could be reduced to 0.1% by placing films consistently at the center of the scanner. For all beam types, the calibration curves are within uncertainties of measured dose and optical densities. The total uncertainties on calibration curve due to film reading and fitting were within 1.5% for photon and proton beams. For electrons, the uncertainty was within 2% for dose superior to 0.8 Gy.ConclusionsThe low combined uncertainty observed and low beam and energy-dependence make EBT3 suitable for dosimetry in various applications.     

Monte Carlo transport of swift protons and light ions in water: The influence of excitation cross sections,relativistic effects,and Auger electron emission in w-values

PurposeTo develop a particle transport code to compute w-values and stopping power of swift ions in liquid water and gases of interest for reference dosimetry in hadrontherapy. To analyze the relevance of inelastic and post-collisional processes considered.MethodsThe Monte Carlo code MDM was extended to the case of swift ion impact on liquid water (MDM-Ion). Relativistic corrections in the inelastic cross sections and the post-collisional Auger emission were considered. The effects of introducing different electronic excitation cross sections were also studied.ResultsThe stopping power of swift ions on liquid water, calculated with MDM-Ion, are in excellent agreement with recommended data. The w-values show a strong dependence on the electronic excitation cross sections and on the Auger electron emission. Comparisons with other Monte Carlo codes show the relevance of both the processes considered and of the cross sections employed. W and w-values for swift electron, proton, and carbon ions calculated with the MDM and MDM-Ion codes are in very close agreement with each other and with the 20.8 eV experimental value.ConclusionWe found that w-values in liquid water are independent of ion charge and energy, as assumed in reference dosimetry for hadrontherapy from sparse experimental results for electron and ion impact on gases. Excitation cross sections and Auger emission included in Monte Carlo codes are critical in w-values calculations. The computation of this physical parameter should be used as a benchmark for micro-dosimetry investigations, to assess the reliability of the cross sections employed.     

Characterization of a commercial scintillation detector for 2-D dosimetry in scanned proton and carbon ion beams

IntroductionPencil beam scanning technique used at CNAO requires beam characteristics to be carefully assessed and periodically checked to guarantee patient safety. This study aimed at characterizing the Lynx® detector (IBA Dosimetry) for commissioning and periodic quality assurance (QA) for proton and carbon ion beams, as compared to EBT3 films, currently used for QA checks.Methods and materialsThe Lynx® is a 2-D high-resolution dosimetry system consisting of a scintillating screen coupled with a CCD camera, in a compact light-tight box. The scintillator was preliminarily characterized in terms of short-term stability, linearity with number of particles, image quality and response dependence on iris setting and beam current; Lynx® was then systematically tested against EBT3 films. The detector response dependence on radiation LET was also assessed.ResultsPreliminary results have shown that Lynx is suitable to be used for commissioning and QA checks for proton and carbon ion scanning beams; the cross-check with EBT3 films showed a good agreement between the two detectors, for both single spot and scanned field measurements. The strong LET dependence of the scintillator due to quenching effect makes Lynx® suitable only for relative 2-D dosimetry measurements.ConclusionLynx® appears as a promising tool for commissioning and periodic QA checks for both protons and carbon ion beams. This detector can be used as an alternative of EBT3 films, allowing real-time measurements and analysis, with a significant time sparing.     

Multiple-source models for electron beams of a medical linear accelerator using BEAMDP computer code

AimThe aim of this work was to develop multiple-source models for electron beams of the NEPTUN 10PC medical linear accelerator using the BEAMDP computer code.BackgroundOne of the most accurate techniques of radiotherapy dose calculation is the Monte Carlo (MC) simulation of radiation transport, which requires detailed information of the beam in the form of a phase-space file. The computing time required to simulate the beam data and obtain phase-space files from a clinical accelerator is significant. Calculation of dose distributions using multiple-source models is an alternative method to phase-space data as direct input to the dose calculation system.Materials and methodsMonte Carlo simulation of accelerator head was done in which a record was kept of the particle phase-space regarding the details of the particle history. Multiple-source models were built from the phase-space files of Monte Carlo simulations. These simplified beam models were used to generate Monte Carlo dose calculations and to compare those calculations with phase-space data for electron beams.ResultsComparison of the measured and calculated dose distributions using the phase-space files and multiple-source models for three electron beam energies showed that the measured and calculated values match well each other throughout the curves.ConclusionIt was found that dose distributions calculated using both the multiple-source models and the phase-space data agree within 1.3%, demonstrating that the models can be used for dosimetry research purposes and dose calculations in radiotherapy.     

Design,implementation and validation of a motorized wedge filter for a telecobalt machine (Bhabhatron-II)

A universal wedge filter of 15W × 20 cm² and 60° nominal wedge angle is designed and placed between the collimating jaws and penumbra trimmers inside the treatment head. A pneumatically driven actuating mechanism toggles the wedge between the wedge IN position and wedge OUT position. The effective wedge angles were determined using an analytical formula. An accumulated wedge profile at a depth of 10 cm which was measured using a 2D profiler and dose values at depths of 10 cm and 20 cm for the same experimental setup were used as input parameters in the formula used for determining effective wedge angles. The relationship between the wedge beam weight and effective wedge angle was established. The planned wedge angles were compared with the measured wedge angles and the differences are found to be less than 2° throughout the range of field sizes. Planned doses for various field sizes and wedge angles were measured for verification and the differences were found to be less than 1.8%. This study established that the relationship between the beam weights and effective wedge angles implemented for the motorized wedge filter of medical linacs is not directly applicable for the motorized wedge filter of Telecobalt.     

A patient immobilization device for prone breast radiotherapy: Dosimetric effects and inclusion in the treatment planning system

PurposeTo assess the dosimetric impact of a patient positioning device for prone breast radiotherapy and assess the accuracy of a treatment planning system (TPS) in predicting this impact.MethodsBeam attenuation and build-up dose perturbations, quantified by ionization chamber and radiochromic film dosimetry, were evaluated for 3 components of the patient positioning device: the carbon fiber baseplate, the support cushions and the support wedge for the contralateral breast. Dose calculations were performed using the XVMC dose engine implemented in the Monaco TPS. All components were included during planning CT acquisition.ResultsBeam attenuation amounted to 7.57% (6 MV) and 5.33% (15 MV) for beams obliquely intersecting the couchtop–baseplate combination. Beams traversing large sections of the support wedge were attenuated by 12.28% (6 MV) and 9.37% (15 MV). For the support cushion foam, beam attenuation remained limited to 0.11% (6 MV) and 0.08% (15 MV) per centimeter thickness. A substantial loss of dose build-up was detected when irradiating through any of the investigated components. TPS dose calculations accurately predicted beam attenuation by the baseplate and support wedge. A manual density overwrite was needed to model attenuation by the support cushion foam. TPS dose calculations in build-up regions differed considerably from measurements for both open beams and beams traversing the device components.ConclusionsIrradiating through the components of the positioning device resulted in a considerable degradation of skin sparing. Inclusion of the device components in the treatment planning CT allowed to accurately model the most important attenuation effect, but failed to accurately predict build-up doses.     

Monte Carlo simulation using PRIMO code as a tool for checking the credibility of commissioning and quality assurance of 6 MV TrueBeam STx varian LINAC

AimTo validate and implement Monte Carlo simulation using PRIMO code as a tool for checking the credibility of measurements in LINAC initial commissioning and routine Quality Assurance (QA). Relative and absolute doses of 6 MV photon beam from TrueBeam STx Varian Linear Accelerator (LINAC) were simulated and validated with experimental measurement, Analytical Anisotropic Algorithm (AAA) calculation, and golden beam.Methods and MaterialsVarian phase-space files were imported to the PRIMO code and four blocks of jaws were simulated to determine the field size of the photon beam. Water phantom was modeled in the PRIMO code with water equivalent density. Golden beam data, experimental measurement, and AAA calculation results were imported to PRIMO code for gamma comparison.ResultsPRIMO simulations of Percentage Depth Dose (PDD) and in-plane beam profiles had good agreement with experimental measurements, AAA calculations and golden beam. However, PRIMO simulations of cross-plane beam profiles have a better agreement with AAA calculation and golden beam than the experimental measurement. Furthermore, PRIMO simulations of absolute dose agreed well with experimental results with ±0.8% uncertainty.ConclusionThe PRIMO code has good accuracy and is appropriate for use as a tool to check the credibility of beam scanning and output measurement in initial commissioning and routine QA.     

Robust inference for the stepped wedge design

Stepped wedge designed trials are a type of cluster-randomized study in which the intervention is introduced to each cluster in a random order over time. This design is often used to assess the effect of a new intervention as it is rolled out across a series of clinics or communities. Based on a permutation argument, we derive a closed-form expression for an estimate of the intervention effect, along with its standard error, for a stepped wedge design trial. We show that these estimates are robust to misspecification of both the mean and covariance structure of the underlying data-generating mechanism, thereby providing a robust approach to inference for the intervention effect in stepped wedge designs. We use simulations to evaluate the type 1 error and power of the proposed estimate and to compare the performance of the proposed estimate to the optimal estimate when the correct model specification is known. The limitations, possible extensions, and open problems regarding the method are discussed.     

Assessment of skin dose in breast cancer radiotherapy: on-phantom measurement and Monte Carlo simulation

AimThe main purpose of the present study is assessment of skin dose in breast cancer radiotherapy.BackgroundAccurate assessment of skin dose in radiotherapy can provide useful information for clinical considerations.Materials and methodsA RANDO phantom was irradiated using a 6 MV Siemens Primus linac with medial and tangential radiotherapy fields for simulating breast cancer treatment. Dosimetry was also performed on various positions across the fields using an EBT3 radiochromic film. Similar conditions of measurement on the RANDO phantom including field size, irradiation angle, number of fields, etc. were subsequently simulated via the Monte Carlo N-Particle Transport code (MCNP). Ultimately, dose values for corresponding points from both methods were compared.ResultsConsidering dosimetry using radiochromic films on the RANDO phantom, there were points having underdose and overdose based on the prescribed dose and skin tolerance levels. In this respect, 81.25% and 18.75% of the points had underdose and overdose, respectively. In some cases, several differences were observed between the measurement and the MCNP simulation results associated with skin dose.ConclusionBased on the results of the points which had underdose, it was suggested that a bolus should be used for the given points. With regard to overdose points, it was advocated to consider skin tolerance dose in treatment planning. Differences between the measurement and the MCNP simulation results might be due to voxel size of tally cells in simulations, effect of beam’s angle of incidence, validation time of linac’s head, lack of electronic equilibrium in the build-up region, as well as MCNP tally type.