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Objective . In this experimental work we compared the determination of absorbed dose to water using four ionization chambers (ICs), a PTW-34045 Advanced Markus, a PTW-34001 Roos, an IBA-PPC05 and a PTW-30012 Farmer, irradiated under the same conditions in one continuous- and in two pulsed-scanned proton beams. Approach . The ICs were positioned at 2 cm depth in a water phantom in four square-field single-energy scanned-proton beams with nominal energies between 80 and 220 MeV and in the middle of 10 × 10 × 10 cm 3 dose cubes centered at 10 cm or 12.5 cm depth in water. The water-equivalent thickness (WET) of the entrance window and the effective point of measurement was considered when positioning the plane parallel (PP) ICs and the cylindrical ICs, respectively. To reduce uncertainties, all ICs were calibrated at the same primary standards laboratory. We used the beam quality ( k Q ) correction factors for the ICs under investigation from IAEA TRS-398, the newly calculated Monte Carlo (MC) values and the anticipated IAEA TRS-398 updated recommendations. Main results . Dose differences among the four ICs ranged between 1.5% and 3.7% using both the TRS-398 and the newly recommended k Q values. The spread among the chambers is reduced with the newly k Q values. The largest differences were observed between the rest of the ICs and the IBA-PPC05 IC, obtaining lower dose with the IBA-PPC05. Significance . We provide experimental data comparing different types of chambers in different proton beam qualities. The observed dose differences between the ICs appear to be related to inconsistencies in the determination of the k Q values. For PP ICs, MC studies account for the physical thickness of the entrance window rather than the WET. The additional energy loss that the wall material invokes is not negligible for the IBA-PPC05 and might partially explain the low k Q values determined for this IC. To resolve this inconsistency and to benchmark MC values, k Q values measured using calorimetry are needed., (© 2024 Institute of Physics and Engineering in Medicine.)

Background and Purpose: This work reports on the results of a survey performed on the use of computed tomography (CT) imaging for motion management, surface guidance devices, and their quality assurance (QA). Additionally, it details the collected user insights regarding professional needs in CT for radiotherapy. The purpose of the survey is to understand current practice, professional needs and future directions in the field of fan-beam CT in radiation therapy (RT)., Materials and Methods: An online institutional survey was conducted between 1-Sep-2022 and 10-Oct-2022 among medical physics experts at Belgian and Dutch radiotherapy institutions, to assess the current status, challenges, and future directions of motion management and surface image-guided radiotherapy. The survey consisted of a maximum of 143 questions, with the exact number depending on participants' responses., Results: The response rate was 66 % (31/47). Respiratory management was reported as standard practice in all but one institution; surface imaging during CT-simulation was reported in ten institutions. QA procedures are applied with varying frequencies and methodologies, primarily with commercial anatomy-like phantoms. Surface guidance users report employing commercial static and dynamic phantoms. Four main subjects are considered clinically important by the respondents: surface guidance, CT protocol optimisation, implementing gated imaging (4DCT, breath-hold), and a tattoo-less workflow., Conclusions: The survey highlights the scattered pattern of QA procedures for respiratory motion management, indicating the need for well-defined, unambiguous, and practicable guidelines. Surface guidance is considered one of the most important techniques that should be implemented in the clinical radiotherapy simulation workflow., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Author(s).)

Background and Purpose: To obtain an understanding of current practice, professional needs and future directions in the field of fan-beam CT in RT, a survey was conducted. This work presents the collected information regarding the use of CT imaging for dose calculation and structure delineation., Materials and Methods: An online institutional survey was distributed to medical physics experts employed at Belgian and Dutch radiotherapy institutions to assess the status, challenges, and future directions of QA practices for fan-beam CT. A maximum of 143 questions covered topics such as CT scanner availability, CT scanner specifications, QA protocols, treatment simulation workflow, and radiotherapy dose calculation. Answer forms were collected between 1-Sep-2022 and 10-Oct-2022., Results: A 66 % response rate was achieved, yielding data on a total of 58 CT scanners. For MV photon therapy, all single-energy CT scans are reconstructed in Hounsfield Units for delineation or dose calculation, and a direct- or stoichiometric method was used to convert CT numbers for dose calculation. Limited use of dual-energy CT is reported for photon (N = 3) and proton dose calculations (N = 1). For brachytherapy, most institutions adopt water-based dose calculation, while approximately 26 % of the institutions take tissue heterogeneity into account. Commissioning and regular QA include eleven tasks, which are performed by two or more professions (29/31) with varying frequencies., Conclusions: Dual usage of a planning CT limits protocol optimization for both tissue characterization and delineation. DECT has been implemented only gradually. A variation of QA testing frequencies and tests are reported., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Author(s).)

Background and Purpose: Studies have shown large variations in stopping-power ratio (SPR) prediction from computed tomography (CT) across European proton centres. To standardise this process, a step-by-step guide on specifying a Hounsfield look-up table (HLUT) is presented here., Materials and Methods: The HLUT specification process is divided into six steps: Phantom setup, CT acquisition, CT number extraction, SPR determination, HLUT specification, and HLUT validation. Appropriate CT phantoms have a head- and body-sized part, with tissue-equivalent inserts in regard to X-ray and proton interactions. CT numbers are extracted from a region-of-interest covering the inner 70% of each insert in-plane and several axial CT slices in scan direction. For optimal HLUT specification, the SPR of phantom inserts is measured in a proton beam and the SPR of tabulated human tissues is computed stoichiometrically at 100 MeV. Including both phantom inserts and tabulated human tissues increases HLUT stability. Piecewise linear regressions are performed between CT numbers and SPRs for four tissue groups (lung, adipose, soft tissue, and bone) and then connected with straight lines. Finally, a thorough but simple validation is performed., Results: The best practices and individual challenges are explained comprehensively for each step. A well-defined strategy for specifying the connection points between the individual line segments of the HLUT is presented. The guide was tested exemplarily on three CT scanners from different vendors, proving its feasibility., Conclusion: The presented step-by-step guide for CT-based HLUT specification with recommendations and examples can contribute to reduce inter-centre variations in SPR prediction., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Authors. Published by Elsevier B.V. All rights reserved.)

Objective. Protons offer a more conformal dose delivery compared to photons, yet they are sensitive to anatomical changes over the course of treatment. To minimize range uncertainties due to anatomical variations, a new CT acquisition at every treatment session would be paramount to enable daily dose calculation and subsequent plan adaptation. However, the series of CT scans results in an additional accumulated patient dose. Reducing CT radiation dose and thereby decreasing the potential risk of radiation exposure to patients is desirable, however, lowering the CT dose results in a lower signal-to-noise ratio and therefore in a reduced quality image. We hypothesized that the signal-to-noise ratio provided by conventional CT protocols is higher than needed for proton dose distribution estimation. In this study, we aim to investigate the effect of CT imaging dose reduction on proton therapy dose calculations and plan optimization. Approach. To verify our hypothesis, a CT dose reduction simulation tool has been developed and validated to simulate lower-dose CT scans from an existing standard-dose scan. The simulated lower-dose CTs were then used for proton dose calculation and plan optimization and the results were compared with those of the standard-dose scan. The same strategy was adopted to investigate the effect of CT dose reduction on water equivalent thickness (WET) calculation to quantify CT noise accumulation during integration along the beam. Main results. The similarity between the dose distributions acquired from the low-dose and standard-dose CTs was evaluated by the dose-volume histogram and the 3D Gamma analysis. The results on an anthropomorphic head phantom and three patient cases indicate that CT imaging dose reduction up to 90% does not have a significant effect on proton dose calculation and plan optimization. The relative error was employed to evaluate the similarity between WET maps and was found to be less than 1% after reducing the CT imaging dose by 90%. Significance. The results suggest the possibility of using low-dose CT for proton therapy dose estimation, since the dose distributions acquired from the standard-dose and low-dose CTs are clinically equivalent., (© 2022 Institute of Physics and Engineering in Medicine.)

Purpose: One of the main sources of uncertainty in proton therapy is the conversion of the Hounsfield Units of the planning CT to (relative) proton stopping powers. Proton radiography provides range error maps but these can be affected by other sources of errors as well as the CT conversion (e.g., residual misalignment). To better understand and quantify range uncertainty, it is desirable to measure the individual contributions and particularly those associated to the CT conversion., Methods: A workflow is proposed to carry out an assessment of the CT conversion solely on the basis of proton radiographs of real tissues measured with a multilayer ionization chamber (MLIC). The workflow consists of a series of four stages: (a) CT and proton radiography acquisitions, (b) CT and proton radiography registration in postprocessing, (c) sample-specific validation of the semi-empirical model both used in the registration and to estimate the water equivalent path length (WEPL), and (d) WEPL error estimation. The workflow was applied to a pig head as part of the validation of the CT calibration of the proton therapy center PARTICLE at UZ Leuven, Belgium., Results: The CT conversion-related uncertainty computed based on the well-established safety margin rule of 1.2 mm + 2.4% were overestimated by 71% on the pig head. However, the range uncertainty was very much underestimated where cavities were encountered by the protons. Excluding areas with cavities, the overestimation of the uncertainty was 500%. A correlation was found between these localized errors and HUs between -1000 and -950, suggesting that the underestimation was not a consequence of an inaccurate conversion but was probably rather due to the resolution of the CT leading to material mixing at interfaces. To reduce these errors, the CT calibration curve was adapted by increasing the HU interval corresponding to the air up to -950., Conclusion: The application of the workflow as part of the validation of the CT conversion to RSPs showed an overall overestimation of the expected uncertainty. Moreover, the largest WEPL errors were found to be related to the presence of cavities which nevertheless are associated with low WEPL values. This suggests that the use of this workflow on patients or in a generalized study on different types of animal tissues could shed sufficient light on how the contributions to the CT conversion-related uncertainty add up to potentially reduce up to several millimeters the uncertainty estimations taken into account in treatment planning. All the algorithms required to perform the workflow were implemented in the computational tool named openPR which is part of openREGGUI, an open-source image processing platform for adaptive proton therapy., (© 2020 American Association of Physicists in Medicine.)

Maximum likelihood expectation-maximization (MLEM) is a popular algorithm to reconstruct the activity image in positron emission tomography. This paper introduces a "fundamental equality" for the MLEM complete data from which two key properties easily follow that allows us to: 1) prove in an elegant and compact way the convergence of MLEM for a forward model with fixed background (i.e., counts such as random and scatter coincidences) and 2) generalize this proof for the MLEM-3 algorithm. Moreover, we give necessary and sufficient conditions for the solution to be unique.

The 'simultaneous maximum-likelihood attenuation correction factors' (sMLACF) algorithm presented here, is an iterative algorithm to calculate the maximum-likelihood estimate of the activity λ and the attenuation factors a in time-of-flight positron emission tomography, and this from emission data only. Hence sMLACF is an alternative to the MLACF algorithm. sMLACF is derived using the generalized expectation-maximization principle by introducing an appropriate set of complete data. The resulting iteration step yields a simultaneous update of λ and a which, in addition, enforces in a natural way the constraints [Formula: see text] where [Formula: see text] is a fixed lower bound that ensures the boundedness of the reconstructed activities. Some properties-like the monotonic increase of the likelihood and the asymptotic regularity of the estimated [Formula: see text]-of sMLACF are proven. Comparison of sMLACF with MLACF for two data sets reveals that both algorithms show very similar results, although sMLACF converges slower.

Scatter correction is typically done using a simulation of the single scatter, which is then scaled to account for multiple scatters and other possible model mismatches. This scaling factor is determined by fitting the simulated scatter sinogram to the measured sinogram, using only counts measured along LORs that do not intersect the patient body, i.e. 'scatter-tails'. Extending previous work, we propose to scale the scatter with a plane dependent factor, which is determined as an additional unknown in the maximum likelihood (ML) reconstructions, using counts in the entire sinogram rather than only the 'scatter-tails'. The ML-scaled scatter estimates are validated using a Monte-Carlo simulation of a NEMA-like phantom, a phantom scan with typical contrast ratios of a 68 Ga-PSMA scan, and 23 whole-body 18 F-FDG patient scans. On average, we observe a 12.2% change in the total amount of tracer activity of the MLEM reconstructions of our whole-body patient database when the proposed ML scatter scales are used. Furthermore, reconstructions using the ML-scaled scatter estimates are found to eliminate the typical 'halo' artifacts that are often observed in the vicinity of high focal uptake regions.

Background: The different bariatric surgery techniques that alter the digestive anatomy also modify the gastric absorption surface. Since alcohol is a substance that is mainly metabolized in the stomach, the goal of this study was to determine alcohol absorption before and after a laparoscopic sleeve gastrectomy (LSG) in the same patients., Methods: Studies were carried out on 12 morbidly obese patients who underwent a LSG (eight men and four women). Each patient was given 3.6 ml of red wine to drink at 14% for each liter of body water mass. Alcotest values (Alcoscan Alcomate AL-6000) were measured 10 min after the wine dose had been consumed. Measurements were then repeated every 5 min until the alcohol had been completely eliminated from the bloodstream. During the postoperatory period (median of 2.3 months), the measurement was repeated with the total dose per kg adjusted to the new water body mass. The results were measured with a nonparametric analysis for repeated samples., Results: The maximum average peak of the Alcotest was 2.02 g/l during the postoperative period compared to 0.87 g/l during the preoperative period (p = 0.001 Wilcoxon). At 175 min, the blood alcohol level value reaches zero (0) in all pre-operatory patients, while after surgery, an average value of 0.26 g/l was observed (p = 0.027 Wilcoxon). After 4 h, an Alcotest average of 0.20 g/l was observed in these patients., Conclusion: Alcohol absorption was considerably modified after LSG with higher and longer blood alcohol values for equivalent amounts of alcohol.