Skin dose assessment in interventional radiology

For long, complex procedures in interventional radiology (IR) or in interventional cardiology (IC), the skin dose can be high and induce skin injuries. To improve patient follow-up, it is essential to measure and locate the peak skin dose (PSD). PSD can be measured using dosimeters or computed by skin dose calculation software solutions. Recently, a study was published (e.g. Malchair F et al Phys Med 2020; 80:75–83) listing all the software solutions developed and available and compared them in operation as regards accuracy of the calculated PSD and generated dose map. Similarities and differences exist between these different software packages, which are discussed here. The accuracy of PSD calculated on phantom studies with these software solutions are within ± 25% and poorer in patient studies. Improvements are therefore required for manufacturers of both software and IR systems. The medical physicists also have an important role to play in setting up and monitoring the dose in these software solutions to ensure the accuracy of the calculated PSD.     

Review of skin dose calculation software in interventional cardiology

PurposeIn interventional cardiology, patients may be exposed to high doses to the skin resulting in skin burns following single or multiple procedures. Reviewing and analysing available software (online or offline) may help medical physicists assessing the maximum skin dose to the patient together with the dose distribution during (or after) these procedures.Method and resultsCapabilities and accuracy of available software were analysed through an extensive bibliography search and contacts with both vendor and authors. Their markedly differed among developers.In total, 22 software were identified and reviewed according to their algorithms and their capabilities. Special attention was dedicated to their main features and limitations of interest for the intended clinical use.While the accuracy of the 12 software products validated with measurements on phantoms was acceptable (within ± 25%), the agreement was poor for the two products validated on patients (within ± 43% and ± 76%, respectively). In addition, no software has been validated on angiographic units from all manufacturers, though several software developers claimed vendor-independent transportability. Only one software allows for multiple procedures dose calculation.ConclusionLarge differences among vendors made it clear that work remains to be done before an accurate and reliable skin dose mapping is available for all patients.     

Overview of commercial treatment planning systems for targeted radionuclide therapy

IntroductionTargeted Radionuclide Therapy (TRT) is a branch of cancer medicine dealing with the therapeutic use of radioisotopes associated with biological vectors accumulating in the tumors/targets, indicated as Molecular Radiotherapy (MRT), or directly injected into the arteries that supply blood to liver tumour vasculature, indicated as Selective RT (SRT). The aim of this work is to offer a panoramic view on the increasing number of commercially-available TRT treatment planning systems (TPSs).Materials and methodsA questionnaire was sent to manufacturers' representatives. Academic software were not considered. Questions were grouped as follows: general information, clinical workflow, calibration procedure, image processing/reconstruction, image registration and segmentation tools, time-activity curve (TAC) fitting and absorbed dose calculation.ResultsAll software reported have CE-marking. TPSs were divided between SRT-dedicated software [4] and MRT [5] dosimetry software. In SRT, since no kinetic process is involved, absorbed dose calculation does not require TAC fitting, and image registration is not fully developed in all TPS. All software requires a radionuclide-specific calibration. In SRT, a relative image calibration can be obtained by scaling the counts to a known activity. Automated VOI contouring and rigid/deformable propagation between different acquisitions time-points is implemented in most TPSs, although DICOM export is rare. Different TAC fits are available depending on the number of time-points. Voxel S-value and Local deposition methods are the most frequent dosimetric approaches; dose-voxel kernel convolution and semi-Monte Carlo method are also available.ConclusionsAvailable TPSs allows performing personalized dosimetry in clinical practice. Individual variations in methodology/algorithms must be considered in the standardisation/harmonization processes.     

Accuracy of skin dose mapping in interventional cardiology: Comparison of 10 software products following a common protocol

PurposeOnline and offline software products can estimate the maximum skin dose (MSD) delivered to the patient during interventional cardiology procedures. The capabilities and accuracy of several skin dose mapping (SDM) software products were assessed on X-ray systems from the main manufacturers following a common protocol.MethodsSkin dose was measured on four X-ray systems following a protocol composed of nine fundamental irradiation set-ups and three set-ups simulating short, clinical procedures. Dosimeters/multimeters with semiconductor-based detectors, radiochromic films and thermoluminescent dosimeters were used. Results were compared with up to eight of 10 SDM products, depending on their compatibility.ResultsThe MSD estimates generally agreed with the measurements within ± 40% for fundamental irradiation set-ups and simulated procedures. Only three SDM products provided estimates within ± 40% for all tested configurations on at least one compatible X-ray system. No SDM product provided estimates within ± 40% for all combinations of configurations and compatible systems. The accuracy of the MSD estimate for lateral irradiations was variable and could be poor (up to 66% underestimation). Most SDM products produced maps which qualitatively represented the dimensions, the shape and the relative position of the MSD region. Some products, however, missed the MSD region when situated at the intersection of multiple fields, which is of radiation protection concern.ConclusionsIt is very challenging to establish a common protocol for quality control (QC) and acceptance testing because not all information necessary for accurate MSD calculation is available or standardised in the radiation dose structured reports (RDSRs).     

GWAPower: a statistical power calculation software for genome-wide association studies with quantitative traits

Background

In designing genome-wide association (GWA) studies it is important to calculate statistical power. General statistical power calculation procedures for quantitative measures often require information concerning summary statistics of distributions such as mean and variance. However, with genetic studies, the effect size of quantitative traits is traditionally expressed as heritability, a quantity defined as the amount of phenotypic variation in the population that can be ascribed to the genetic variants among individuals. Heritability is hard to transform into summary statistics. Therefore, general power calculation procedures cannot be used directly in GWA studies. The development of appropriate statistical methods and a user-friendly software package to address this problem would be welcomed.

Results

This paper presents GWAPower, a statistical software package of power calculation designed for GWA studies with quantitative traits, where genetic effect is defined as heritability. Based on several popular one-degree-of-freedom genetic models, this method avoids the need to specify the non-centrality parameter of the F-distribution under the alternative hypothesis. Therefore, it can use heritability information directly without approximation. In GWAPower, the power calculation can be easily adjusted for adding covariates and linkage disequilibrium information. An example is provided to illustrate GWAPower, followed by discussions.

Conclusions

GWAPower is a user-friendly free software package for calculating statistical power based on heritability in GWA studies with quantitative traits. The software is freely available at: http://dl.dropbox.com/u/10502931/GWAPower.zip     

A new colorimetric DPPH• scavenging activity method with no need for a spectrophotometer applied on synthetic and natural antioxidants and medicinal herbs

2,2-Diphenyl-1-picrylhydrazyl (DPPH^?) radical scavenging, the most commonly used antioxidant method with more than seventeen thousand articles cited, is very practical; however, as with most assays, it has the major disadvantage of dependence on a spectrophotometer. To overcome this drawback, the colorimetric determination of the antioxidant activity using a scanner and freely available Image J software was developed. In this new method, the mixtures of solutions of DPPH^? and standard antioxidants or extracts of common medicinal herbs were dropped onto TLC plates, after an incubation period. The spot images were evaluated with Image J software to determine CSC₅₀ values, the sample concentrations providing 50% colour reduction, which were very similar with the SC₅₀ values obtained with spectrophotometric method. The advantages of the new method are the use of lower amounts of reagents and solvents, no need for costly spectrophotometers, and thus significantly lowered costs, and convenient implementation in any environment and situation.     

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.     

Validation of a dose tracking software for skin dose map calculation in interventional radiology

PurposeValidate the skin dose software within the radiation dose index monitoring system NEXO[DOSE]® (Bracco Injeneering S.A., Lausanne, Switzerland). It provides the skin dose distribution in interventional radiology (IR) procedures.MethodsTo determine the skin dose distribution and the Peak Skin Dose (PSD) in IR procedures, the software uses exposure and geometrical parameters taken from the radiation dose structured report and additional information specific to each angiographic system. To test the accuracy of the software, GafChromic® XR-RV3 films, wrapped under a cylindrical PMMA phantom, were irradiated with different setups. Calculations and films results are compared in terms of absolute dose and geometric accuracy, using two angiographic systems (Philips Integris Allura FD20, Siemens AXIOM-ArtisZeego).ResultsCalculated and film measured PSD values agree with an average difference of 7% ± 5%. The discrepancies in dose evaluation increase up to 33% in lower dose regions, because the algorithm does not consider the out-of-field scatter contribution of the neighboring fields, which is more significant in these areas. Regarding the geometric accuracy, the differences between the simulated dose spatial distributions and the measured ones are<3 mm (4%) in simple tests and 5 mm (5%) in setups closer to clinical practice. Moreover, similar results are obtained for the two studied angiographic system vendors.ConclusionsNEXO[DOSE]® provides an accurate skin dose distribution and PSD estimate. It will allow faster and more accurate monitoring of patient follow-up in the future.     

Institutional experience with a rotational total skin electron irradiation (RTSEI) technique—A three decade review (1981–2012)

Total skin electron irradiation (TSEI) for patients with cutaneous lymphomas is technically challenging, and numerous approaches have been developed to overcome the many field matching problems associated with such a large and complex treatment volume. Since 1981 we have delivered TSEI using a rotational total skin electron irradiation (RTSEI) technique in conjunction with patch, treat and boost fields in order to provide complete skin and dose coverage. Initially we used a 6 MeV electron beam at an extended source-skin distance (SSD) on a modified linear accelerator. More recently we began using a high dose rate electron mode on a commercially available linear accelerator. The RTSEI technique allows the delivery of a seamless surface dose to the majority of the patient''s skin surface in a single treatment. In this review paper we present our three-decade experience with the technical development, dosimetry, treatment delivery and clinical outcomes of our RTSEI technique.     

Concentration modulated skin marker for radiotherapy treatment planning process

Background and purposeFor conformal radiotherapy, it is feasible to achieve high accuracy in contouring the outline of the target volume in treatment planning process. In contouring process, target volume is occasionally defined by means of either surgical clips or skin marker during patient anatomical data acquisition. Treatment planning systems are predicting invalid radiation dose distributions by using surgical clips and skin marker within the patient. Purpose of this study is the production of new skin marker which affects less dose distributions of electron beam.Materials and methodsThe influences of lead and commercial markers on dose calculations in a 3D treatment planning systems were investigated in terms of electron beam energy and dose profile depth. Dose deviation with commercial marker was observed to smaller than lead marker. However this dose deviation was still at big value. In order to reduce of this value, barium sulfate suspension and ultrasound gel were mixed with different volumetric ratio. With the purpose of acception the most suitable marker for radiation therapy, obtained new suspensions were investigated in terms of visibility and dose deviation.ResultsB:G/1:10 marker was determined to cause optimum visibility and the lowest dose deviation on dose calculations in terms of electron beam energy and dose profile depth.ConclusionsAppropriate marker, mixture of substances such as barium sulfate suspension and ultrasound gel can be produced. This marker is both ease of usage and practical and economical. Each clinic can prepare marker which is peculiar to suspension with different concentration of substance for specific visibility. But, it should be taken into account resultant dose deviation to beam calculation depending on barium sulfate concentration.     

Differential dose contributions on total dose distribution of 125I brachytherapy source

This work provides an improvement of the approach using Monte Carlo simulation for the Amersham Model 6711 ¹²⁵I brachytherapy seed source, which is well known by many theoretical and experimental studies. The source which has simple geometry was researched with respect to criteria of AAPM Tg-43 Report. The approach offered by this study involves determination of differential dose contributions that come from virtual partitions of a massive radioactive element of the studied source to a total dose at analytical calculation point. Some brachytherapy seeds contain multi-radioactive elements so the dose at any point is a total of separate doses from each element. It is momentous to know well the angular and radial dose distributions around the source that is located in cancerous tissue for clinical treatments. Interior geometry of a source is effective on dose characteristics of a distribution. Dose information of inner geometrical structure of a brachytherapy source cannot be acquired by experimental methods because of limits of physical material and geometry in the healthy tissue, so Monte Carlo simulation is a required approach of the study. EGSnrc Monte Carlo simulation software was used. In the design of a simulation, the radioactive source was divided into 10 rings, partitioned but not separate from each other. All differential sources were simulated for dose calculation, and the shape of dose distribution was determined comparatively distribution of a single-complete source. In this work anisotropy function was examined also mathematically.     

Establishment of trigger levels to steer the follow-up of radiation effects in patients undergoing fluoroscopically-guided interventional procedures in Belgium

The accumulated dose to the skin of the patient during fluoroscopically-guided procedures can exceed the thresholds for tissue reactions. In practice, interventionalists have no direct information about the local procedure-related skin doses in their patient, causing suboptimal or delayed treatment. In current study, the accumulated Kerma-Area-Product (KAP) values were registered, as well as the reference air kerma (K_a,r) values, if available, for almost 200 cases undergoing seven different procedures. A sheet filled with 50 thermoluminescent dosemeters was wrapped around each patient to measure the peak skin dose. In a significant part of the Transjugular Intrahepatic Portosystemic Shunt (TIPSS) procedures, chemo-embolizations of the liver and cerebral embolizations, the threshold values for deterministic skin damage (2 Gy) were attained. Trigger values in terms of KAP, corresponding to a peak skin dose of 2 Gy, were determined. In general, our results comply reasonably well with the values proposed in the NCRP 168 report, with a KAP value of 425 Gy cm² and a K_a,r value of 3 Gy, corresponding to a peak skin dose of 3 Gy. Only for the TIPSS procedure a considerably lower value of 2 Gy was obtained at the published K_a,r and for the RF ablations we obtained a considerably lower value of 250 Gy cm² in terms of KAP.     

Climate change and human skin cancer.

As part of an inventory of potential interactions between effects of ozone depletion and climate change, a possible effect of ambient temperature on sun-induced skin cancers was suggested. Mouse experiments had shown that increased room temperature enhanced ultraviolet (UV) radiation-induced carcinogenesis; the effective UV dose was increased by 3-7% per degrees C. The present investigation was aimed at studying a possible temperature effect on human skin cancer. Existing data on the incidence of human skin cancer were analyzed, as available from two special surveys of non-melanoma skin cancer in the United States. The incidence of non-melanoma skin cancer in the ten regions surveyed not only correlated significantly with the ambient UV dose but also with the average daily maximum temperature in summer. For squamous cell carcinoma the incidence was higher by 5.5% (SE 1.6%) per degrees C and for basal cell carcinoma by 2.9% (SE 1.4%) per degrees C. These values correspond to an increase of the effective UV dose by about 2% per degrees C. Although the precise nature of this correlation with temperature requires further studies, it can be concluded that the temperature rises coming with climate change can indeed amplify the induction of non-melanoma skin cancers by UV radiation in human populations.     

Enhancement of Skin Permeation and Skin Immunization of Ovalbumin Antigen <Emphasis Type="Italic">via</Emphasis> Microneedles

The purpose of this study was to evaluate the use of different types of microneedles and doses of ovalbumin antigen for in vitro skin permeation and in vivo immunization. In vitro skin permeation experiments and confocal laser scanning microscopy revealed that hollow microneedles had a superior enhancing effect on skin permeation compared with a solid microneedle patch and untreated skin by efficiently delivering ovalbumin-fluorescein conjugate into the deep skin layers. The flux and cumulative amount of ovalbumin-fluorescein conjugate at 8 h after administering with various conditions could be ranked as follows: hollow MN; high dose?>?medium dose?>?low dose?>?MN patch; high dose?>?medium dose?>?low dose?>?untreated skin; high dose?>?medium dose?>?low dose?>?without ovalbumin-fluorescein conjugate. As the dose of ovalbumin-fluorescein conjugate was increased to 500 μg, the antigen accumulated in the skin to a greater extent, as evidenced by the increasing green fluorescence intensity. When the hollow microneedle was used for the delivery of ovalbumin into the skin of mice, it was capable of inducing a stronger immunoglobulin G immune response than conventional subcutaneous injection at the same antigen dose. Immunoglobulin G levels in the hollow MN group were 5.7, 11.6, and 13.3 times higher than those of the subcutaneous injection group for low, medium, and high doses, respectively. Furthermore, the mice immunized using the hollow microneedle showed no signs of skin infection or pinpoint bleeding. The results suggest that the hollow MN is an efficient device for delivering the optimal dose of antigen via the skin for successful immunization.     

Skin dose in radiation treatment of the left breast: Analysis in the context of prone versus supine treatment technique

PurposeTo determine how the skin dose varies in patients receiving radiation treatment for breast cancer in the prone and supine positions.MethodsFifty patients were scanned in the prone and supine positions. A radiation treatment plan was created for the left breast using a 6-MV beam for a prescribed dose of 42.66 Gy in 16 fractions. The dose was calculated using 1- and 2.5-mm calculation grid sizes and the surface dose was compared in both techniques.ResultsThe median gantry angles relative to the skin surface at the central axis were 8 and 52 degrees for treatment in the prone and supine positions, respectively. The mean dose difference between the prone and supine techniques was statistically significant from 3- to 5-mm depth for both grid sizes. For the 1-mm calculation grid size, the doses at 3-, 4-, and 5-mm depths in the prone and supine techniques were 87.80% and 89.10% (P < 0.003), 91.92% and 94.50% (P < 0.00), and 95.30% and 98.20% (P < 0.00), respectively; for the 2.5-mm grid size, the respective doses were 87.10% and 88.59% (P < 0.00), 91.60% and 94.63% (P < 0.00), and 95.10% and 97.80% (P < 0.00), respectively.ConclusionsThis study demonstrates that the prone technique facilitates a relatively lower skin dose than the supine technique. This observation is probably due to the beam angle. The beam is more perpendicular to the skin surface in the prone technique, whereas it is more tangential in the supine technique, which may deliver a higher skin dose. Thus, the dose to the skin should be evaluated in the prone technique, and if desired, the skin dose could be carefully augmented via a bolus or beam spoiler.     

SoFAR: software for fully automatic evaluation of real-time PCR data

Quantitative real-time PCR has proven to be an extremely useful technique in life sciences for many applications. Although a lot of attention has been paid to the optimization of the assay conditions, the analysis of the data acquired is often done with software tools that do not make optimum use of the information provided by the data. Particularly, this is the case for high-throughput analysis, which requires a careful characterization and interpretation of the complete data by suitable software. Here we present a software solution for the robust, reliable, accurate, and fast evaluation of real-time PCR data, called SoFAR. The software automatically evaluates the data acquired with the LightCycler system. It applies new algorithms for an adaptive background correction of signal trends, the calculation of the effective signal noise, the automated identification of the exponential phases, the adaptive smoothing of the raw data, and the correction of melting curve data. Finally, it provides information regarding the validity of the results obtained. The SoFAR software minimizes the time required for evaluation and increases the accuracy and reliability of the results. The software is available upon request.     

Macintosh sequence analysis software

The analysis of information in nucleotide and amino acid sequence data from an investigator’s own laboratory, or from the ever-growing worldwide databases, is critically dependent on well planned and written software. Although the most powerful packages previously have been confined to workstations, there has been a dramatic increase over the last few years in the sophistication of the programs available for personal computers, as the speed and power of these have increased. A wide choice of software is available for the Macintosh, including the LaserGene suite of programs from DNAStar. This review assesses the strengths and weaknesses of LaserGene and concludes that it provides a useful and comprehensive range of sequence analysis tools.     

In vivo skin dose measurement using MOSkin detectors in tangential breast radiotherapy

The purpose of this study is to measure patient skin dose in tangential breast radiotherapy. Treatment planning dose calculation algorithm such as Pencil Beam Convolution (PBC) and in vivo dosimetry techniques such as radiochromic film can be used to accurately monitor radiation doses at tissue depths, but they are inaccurate for skin dose measurement. A MOSFET-based (MOSkin) detector was used to measure skin dose in this study. Tangential breast radiotherapies (“bolus” and “no bolus”) were simulated on an anthropomorphic phantom and the skin doses were measured. Skin doses were also measured in 13 patients undergoing each of the techniques. In the patient study, the EBT2 measurements and PBC calculation tended to over-estimate the skin dose compared with the MOSkin detector (p < 0.05) in the “no bolus radiotherapy”. No significant differences were observed in the “bolus radiotherapy” (p > 0.05). The results from patients were similar to that of the phantom study. This shows that the EBT2 measurement and PBC calculation, while able to predict accurate doses at tissue depths, are inaccurate in predicting doses at build-up regions. The clinical application of the MOSkin detectors showed that the average total skin doses received by patients were 1662 ± 129 cGy (medial) and 1893 ± 199 cGy (lateral) during “no bolus radiotherapy”. The average total skin doses were 4030 ± 72 cGy (medial) and 4004 ± 91 cGy (lateral) for “bolus radiotherapy”. In some cases, patient skin doses were shown to exceed the dose toxicity level for skin erythema. Hence, a suitable device for in vivo dosimetry is necessary to accurately determine skin dose.     

Dose distribution comparison in volumetric-modulated arc therapy plans for head and neck cancers with and without an external body contour extended technique

AimThis study compared volumetric-modulated arc therapy (VMAT) plans for head and neck cancers with and without an external body contour extended technique (EBCT).BackgroundDose calculation algorisms for VMAT have limitations in the buildup region.Materials and methodsThree VMAT plans were enrolled, with one case having a metal artifact from an artificial tooth. The proper dose was calculated using Eclipse version 11.0. The body contours were extended 2 cm outward from the skin surface in three-dimensional space, and the dose was recalculated with an anisotropic analytical algorithm (AAA) and Acuros XB (AXB). Monitor units (MUs) were set, and the dose distributions in the planning target volume (PTV), clinical target volume, and organ at risk (OAR) and conformity index (CI) with and without an EBCT were compared. The influence of a metal artifact outside of the thermoplastic head mask was also compared.ResultsThe coverage of PTV by the 95% dose line near the patient’s skin was increased drastically by using an EBCT. Plan renormalization had a negligible impact on MUs and doses delivered to OARs. CI of PTV with a 6-MV photon beam was closer to 1 than that with a 10-MV photon beam when both AAA and AXB were used in all cases. Metal artifacts outside the head mask had no effect on dose distribution.ConclusionsAn EBCT is needed to estimate the proper dose at object volumes near the patient’s skin and can improve the accuracy of the calculated dose at target volumes.