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Background: While IAEA's TRS‐483 code of practice is adapted for the calibration of CyberKnife machines, AAPM's TG‐51 is still the protocol recommended by the manufacturer for their calibration. The differences between both protocols could lead to differences in absorbed dose to water during the calibration process. Purpose: The aims of this work are to evaluate the difference resulting from the application of TG‐51 (including the manufacturer's adaptations) and TRS‐483 in terms of absorbed dose to water for a CyberKnife M6, and to evaluate the consistency of TRS‐483. Methods: Measurements are performed on a CyberKnife M6 unit under machine‐specific reference conditions using a calibrated Exradin A12 ionization chamber. Monte Carlo (MC) simulations are performed to estimate kQmsr,Q0fmsr,fref$k_{Q_{\mathrm{msr}},Q_0}^{f_{\mathrm{msr}},f_{\mathrm{ref}}}$ and kvol$k_{\text{vol}}$ using a fully modeled detector and an optimized CyberKnife M6 beam model. The latter is also estimated experimentally. Differences between the adapted TG‐51 and TRS‐483 protocols are identified and their impact is quantified. Results: When using an in‐house experimentally‐evaluated volume averaging correction factor, a difference of 0.11% in terms of absorbed dose to water per monitor unit is observed when applying both protocols. This disparity is solely associated to the difference in beam quality correction factor. If a generic volume averaging correction factor is used during the application of TRS‐483, the difference in calibration increases to 0.14%. In both cases, the disparity is not statistically significant according to TRS‐483's reported uncertainties on their beam quality correction factor (i.e., 1%). MC results lead to kQmsr,Q0fmsr,fref=1.0004±0.0002$k_{Q_{\mathrm{msr}},Q_0}^{f_{\mathrm{msr}},f_{\mathrm{ref}}}=1.0004\pm 0.0002$ and kvol=1.0072±0.0009$k_{\text{vol}}=1.0072\pm 0.0009$. Results illustrate that the generic beam quality correction factor provided in the TRS‐483 might be overestimated by 0.36% compared to our specific model and that this overestimation could be due to the volume averaging component. Conclusions: For clinical reference dosimetry of the CyberKnife M6, the application of TRS‐483 is found to be consistent with TG‐51. [ABSTRACT FROM AUTHOR]

Background: Target motion in the course of radiotherapy is one of the largest factors affecting the treatment quality of highly dynamic sites such as lung. A critical component of real‐time motion management is not only the prediction of tumor location at a future point in time but assessment of positional uncertainty for the purposes of margin adjustment and optimization of validation schemes. Purpose: In this study, we propose to investigate the ability of a confidence estimator to accurately reflect the reliability of individual target position predictions and prospectively detect large prediction errors by relying exclusively on a surrogate signal. Methods: This work uses a Bayesian framework for indirect tracking. While constant covariance estimates are commonly used to express the uncertainty of the models involved, in this study new adaptive estimates are derived from the surrogate behavior to reflect increasing uncertainty when the breathing conditions differ from the reference conditions observed during the training step. The accuracy of the resulting 95% predicted confidence regions (CRs) is evaluated on nine breathing sequences involving changes of respiratory types (free, thoracic, abdominal, deep). The breathing motions are collected simultaneously from a lung target and two different surrogate signals (an external marker and an anatomical location within the liver). Receiver operating characteristic (ROC) analysis is performed to evaluate the ability of the predicted uncertainty to prospectively detect large prediction errors. Results: Higher CR accuracy is obtained when using the proposed adaptive estimates over using constant estimations: on average over the cohort, the proportion of actual target positions lying within the 95% CR is increased by 40 and 35 p.p. with the internal and external surrogates. The time‐dependent inflation of the CR width tends to match the magnitude variation of the prediction errors: the adaptive CR effectively enlarges when the target position cannot be predicted reliably, which corresponds to potentially high prediction errors. More precisely, the ROC analysis indicates that the proposed uncertainty estimate can detect if prediction errors are greater than 5 mm with on average high sensitivity (90%) and modest specificity (54% and 47% from internal and external surrogates, respectively). Conclusions: While relying exclusively on the surrogate motion characteristics being continuously monitored, the Bayesian framework coupled to adaptive uncertainty estimations can provide reliable CR able to detect large prediction errors. The findings of this study could be further used to automatically trigger risk management mechanisms prospectively. [ABSTRACT FROM AUTHOR]

Purpose: Silicon diodes are often the detector of choice for relative dose measurements, particularly in the context of radiotherapy involving small photon beams. However, a major drawback lies in their dose‐rate dependency. Although ionization chambers are often too large for small field output factor (OF) measurements, they are valuable instruments to provide reliable percent‐depth dose (PDD) curves in reference beams. The aim of this work is to propose a practical and accurate method for the characterization of silicon diode dose‐rate dependence correction factors using ionization chamber measurements as a reference. Methods: The robustness of ionization chambers for PDD measurements is used to quantify the dose‐rate dependency of a diode detector. A mathematical formalism, which exploits the error induced in percent‐depth ionization (PDI) curves for diodes by their dose‐rate dependency, is developed to derive a dose‐rate correction factor applicable to diode relative measurements. The method is based on the definition of the recombination correction factor given in the addendum to TG 51 and is applied to experimental measurements performed on a CyberKnife M6 radiotherapy unit using a PTW 60012 diode detector. A measurement‐based validation is provided by comparing corrected PDI curves to measurements performed with a PTW 60019 diamond detector, which does not exhibit dose‐rate dependence. Results: Results of dose‐rate correction factors for PDI curves, off‐axis ratios (OARs), tissue‐phantom ratios, and small field OFs are coherent with the expected behavior of silicon diode detectors. For all considered setups and field sizes, the maximum correction and the maximum impact of the uncertainties induced by the correction are obtained for OARs for the 60 mm collimator, with a correction of 2.5% and an uncertainty of 0.34%. For OFs, corrections range from 0.33% to 0.82% for all field sizes considered, and increase with the reduction of the field size. Comparison of PDI curves corrected for dose‐rate and for in‐depth beam quality variations illustrates excellent agreement with measurements performed using the diamond detector. Conclusion: The proposed method allows the efficient and precise correction of the dose‐rate dependence of silicon diode detectors in the context of clinical relative dosimetry. [ABSTRACT FROM AUTHOR]

Purpose: The goal of this work is to propose a new multichannel method correcting for systematic thickness disturbances and to evaluate its precision in relevant radiation dosimetry applications. Methods: The eigencolor ratio technique is introduced and theoretically developed to provide a method correcting for thickness disturbances. The method is applied to EBT3 GafchromicTM film irradiated with cobalt‐60 and 6 MV photon beams and digitized with an Epson 10000XL photo scanner. Dose profiles and output factors of different field sizes are measured and analyzed. Variance analysis of the previous method of Bouchard et al. ["On the characterization and uncertainty analysis of radiochromic film dosimetry" Med Phys. 2009;36:1931‐1946] is adapted to the new approach. Uncertainties are predicted for relevant applications. Results: Results show that systematic disturbances attributed to thickness variations are efficiently corrected. The method is shown efficient to identify and correct for dark spots which cause systematic errors in single‐channel distributions. Applications of the method in the context of relative dosimetry yields standard uncertainties ranging between 0.8% and 1.9%, depending on the region of interest (ROI) size and the film irradiation. Variance analysis predicts that uncertainty levels between 0.3% and 0.6% are achievable with repeated measurements. Uncertainties are found to vary with absorbed dose and ROI size. Conclusions: The proposed multichannel method is efficient for accurate dosimetry, reaching uncertainty levels comparable to previous publications with EBT film. The method is also promising for applications beyond clinical QA, such as machine characterization and other advanced dosimetry applications. [ABSTRACT FROM AUTHOR]

Purpose: The stoichiometric calibration method for dual‐energy CT (DECT) proposed by Bourque et al. (Phys Med Biol. 59:2059; 2014), which provides estimators of the electron density and the effective atomic number, is adapted to a maximum a posteriori (MAP) framework to increase the model's robustness to noise and biases in CT data, specifically for human tissues. Robust physical parameter estimation from noisy DECT scans is required to maximize the precision of quantities used for radiotherapy treatment planning such as the proton stopping power (SPR). Methods: Estimation of electron density and effective atomic number is performed by constraining their variation to the natural range of values expected for human tissues, while maximizing attenuation data fidelity. The MAP framework is first compared against the original method using theoretical CT numbers with Gaussian noise. The quantitative accuracy of the MAP framework is then validated experimentally on the Gammex 467 phantom. Then, using two clinical datasets, the advantages of the approach are experimentally evaluated, qualitatively, and quantitatively. Results: The theoretical study shows that the root‐mean‐square error on the electron density, the effective atomic number and the SPR are, respectively, reduced from 2.3 to 1.5, 5.7 to 3.2 and 2.8 to 1.7% with the adapted framework, when analyzing soft tissues and bone together. The experimental validation study shows that the standard deviation in Gammex inserts can be reduced, on average, by factors of 1.4 (electron density), 2.7 (effective atomic number), and 1.9 (SPR), while the quantitative accuracy of the three physical parameters is preserved, on average. Evaluation on clinical datasets show apparent noise reduction in maps of all estimated physical quantities, and suggests that the MAP framework has increased robustness to beam hardening and photon starvation artifacts. Mean values for the electron density, the effective atomic number, and the SPR averaged in four uniform regions of interest (brain, muscle, adipose, and cranium), respectively, differ by 0.7, 1.8, and 0.9% between both frameworks. The standard deviation in the same regions of interest is also reduced, on average, by factors of 1.8, 6.6, and 3.2 with the MAP framework. Differences in mean value and standard deviations are statistically significant. Conclusion: Theoretical and experimental results suggest that the MAP framework produces more accurate and precise estimates of the electron density and SPR. Thus, the present approach limits the propagation of noise in DECT attenuation data to radiotherapy‐related parameters maps such as the SPR and the electron density. Using a MAP framework with DECT for radiotherapy treatment planning can help maximizing the precision of dose calculation. The method also provides more precise estimates of the effective atomic number. The MAP methodology is presented in a general way such that it can be adapted to any DECT image‐based tissue characterization method. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the quantitative imaging performance of a spectral photon‐counting computed tomography (SPCCT) scanner for radiotherapy applications. An experimental comparison of the quantitative performance of a Siemens dual‐energy CT (DECT) and a MARS SPCCT scanner is performed to estimate physical properties relevant to radiotherapy of human substitute materials and contrast agent solutions. In human substitute materials, the accuracy of quantities relevant to photon therapy, proton therapy, and Monte‐Carlo simulations, such as the electron density, proton stopping power, and elemental composition is evaluated. For contrast agent solutions, the accuracy of the contrast agent concentrations and the virtual non‐contrast (VNC) electron density is evaluated. Methods: Human tissue substitute phantoms (Gammex 467 and 472) as well as diluted solutions of contrast agents (iodine and gadolinium based) are scanned with two commercial systems: a Siemens dual‐source CT (SOMATOM Definition Flash, Siemens Healthineers, Forchheim, Germany) and a MARS spectral photon‐counting micro‐CT (MARS V5.2, MARS Bioimaging Ltd., Christchurch, New Zealand). Material decomposition is performed in a maximum a posteriori framework with an optimized material basis tailored to characterize either human substitute materials or contrast agents in the context of experimental multi‐energy CT data. Results: The root‐mean‐square error (RMSE) of the electron density calculated over all Gammex inserts is reduced from 1.09 to 0.89% when going from DECT to SPCCT. For the proton stopping power, the RMSE is reduced from 1.92 to 0.89%. Elemental mass fractions of hydrogen, carbon, nitrogen, oxygen, and calcium are more accurately estimated with the MARS scanner. The RMSE on the iodine‐based contrast agents concentration is reduced from 0.27 to 0.12 mg/mL with SPCCT, and the VNC electron density from 0.40 to 0.22%. Conclusion: In the present phantom study, a MARS photon‐counting scanner provides superior accuracy compared to a Siemens SOMATOM Definition Flash DECT scanner to quantify physical parameters relevant to radiotherapy. This work experimentally demonstrates the benefits of using more energies to characterize human tissue equivalent materials. This highlights the potential of SPCCT for particle therapy, where more accurate tissue characterization is needed, as well as for Monte‐Carlo based planning, which requires accurate elemental mass fractions. [ABSTRACT FROM AUTHOR]

Purpose: In all recent protocols for the reference dosimetry of clinical proton beams, ionization chamber perturbation factors are assumed to be unity. In this work, such factors were computed using the FLUKA Monte Carlo code for three ionization chamber types, with particular attention to the influence of nuclear interactions. Methods: The accuracy of the transport algorithms implemented in FLUKA was first evaluated by performing a Fano cavity test. Ionization chamber perturbation factors were computed for the PTW‐34001 Roos® and the PTW‐34070 and PTW‐34073 Bragg peak® chambers for proton beams of 60–250 MeV using the same transport parameters that were needed to pass the Fano test. Results: FLUKA was found to pass the Fano test within 0.15%. Ionization chamber simulation results show that the presence of the air cavity and the wall results in dose perturbations of the order of 0.6% and 0.8%, respectively. The perturbation factors are shown to be energy dependent and nuclear interactions must be taken into account for accurate calculation of the ionization chamber's response. Conclusion: Ionization chamber perturbations can amount to 1% in high‐energy proton beams and therefore need to be considered in dosimetry procedures. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to develop and validate accurate methods for determining iodine content and virtual noncontrast maps of physical parameters, such as electron density, in the context of radiotherapy. Methods: A simulation environment is developed to compare three methods allowing extracting iodine content and virtual noncontrast composition: (a) two‐material decomposition, (b) three‐material decomposition with the conservation of volume constraint, and (c) eigentissue decomposition. The simulation allows comparing the performance of the methods using iodine‐based contrast agent contents in tissues from a reference dataset with variable density and elemental composition. The comparison is performed in two ways: (a) with a priori knowledge on the composition of the targeted tissue, and (b) without a priori knowledge on the base tissue. The three methods are tested with patient images scanned with dual‐energy CT and iodine‐based contrast agent. An experimental calibration adapted to the presence of iodine is performed by imaging tissue equivalent materials and diluted contrast agent solutions with known atomic composition. Results: Results show that in the case of known a priori on the composition of the targeted tissue, the two‐material decomposition is robust to variable densities and atomic compositions without biasing the results. In the absence of a priori knowledge on the target tissue composition, the eigentissue decomposition method yields minimal bias and higher robustness to variations. Results from the experimental calibration and the images of two patients show that the extracted quantities are accurate and the bias is negligible for both methods with respect to clinical applications in their respective scope of use. For the patient imaged with a contrast agent, virtual noncontrast electron densities are found in good agreement with values extracted from the scan without contrast agent. Conclusion: This study identifies two accurate methods to quantify iodine‐based contrast agents and virtual noncontrast composition images with dual‐energy CT. One is the two‐material decomposition with a priori knowledge of the constituent components focused on organ‐specific applications, such as kidney or lung function assessment. The other method is the eigentissue decomposition and is useful for general radiotherapy applications, such as treatment planning where accurate dose calculations are needed in the absence of contrast agent. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this work is to evaluate the performance of dual‐energy CT (DECT) for determining proton stopping power ratios (SPRs) in an experimental environment and to demonstrate its potential advantages over conventional single‐energy CT (SECT) in clinical conditions. Methods: Water equivalent range (WER) measurements of 12 tissue‐equivalent plastic materials and 12 fresh animal tissue samples are performed in a 195 MeV broad proton beam using the dose extinction method. SECT and DECT scans of the samples are performed with a dual‐source CT scanner (Siemens SOMATOM Definition Flash). The methods of Schneider et al. (1996), Bourque et al. (2014), and Lalonde et al. (2017) are used to predict proton SPR on SECT and DECT images. From predicted SPR values, the WER of the proton beam through the sample is predicted for SECT and DECT using Monte Carlo simulations and compared to the measured WER. Results: For homogeneous tissue‐equivalent plastic materials, results with DECT are consistent with experimental measurements and show a systematic reduction of SPR uncertainty compared to SECT, with root‐mean‐square errors of 1.59% versus 0.61% for SECT and DECT, respectively. Measurements with heterogeneous animal samples show a clear reduction of the bias on range predictions in the presence of bones, with −0.88% for SECT versus −0.58% and −0.14% for both DECT methods. An uncertainty budget allows isolating the effect of CT number conversion to SPR and predicts improvements by DECT over SECT consistently with theoretical predictions, with 0.34% and 0.31% for soft tissues and bones in the experimental setup compared to 0.34% and 1.14% with the theoretical method. Conclusions: The present work uses experimental measurements in a realistic clinical environment to show potential benefits of DECT for proton therapy treatment planning. Our results show clear improvements over SECT in tissue‐equivalent plastic materials and animal tissues. Further work towards using Monte Carlo simulations for treatment planning with DECT data and a more detailed investigation of the uncertainties on I‐value and limitations on the Bragg additivity rule could potentially further enhance the benefits of this imaging technology for proton therapy. [ABSTRACT FROM AUTHOR]

Purpose: To propose a new formalism allowing the characterization of human tissues from multienergy computed tomography (MECT) data affected by noise and to evaluate its performance in estimating proton stopping powers (SPR). Methods: A recently published formalism based on principal component analysis called eigentissue decomposition (ETD) is adapted to the context of noise using a Bayesian estimator. The method, named Bayesian ETD, uses the maximum a posteriori fractions of eigentissues in each voxel to determine physical parameters relevant for proton beam dose calculation. Simulated dual-energy computed tomography (DECT) data are used to evaluate the performance of the proposed method to estimate SPR and to compare it to the initially proposed maximum-likelihood ETD and to a state-of-the-art ρe − Z formalism. To test the robustness of each method towards clinical reality, three different levels of noise are implemented, as well as variations in elemental composition and density of reference tissues. The impact of using more than two energy bins to determine SPR is also investigated by simulating MECT data using two to five energy bins. Finally, the impact of using MECT over DECT for range prediction is evaluated using a probabilistic model. Results: For simulated DECT data of reference tissues, the Bayesian ETD approach systematically gives lower root-mean-square (RMS) errors with negligible bias. For a medium level of noise, the RMS errors on SPR are found to be 2.78%, 2.76% and 1.53% for ρe − Z, maximum-likelihood ETD, and Bayesian ETD, respectively. When variations are introduced to the elemental composition and density, all implemented methods give similar performances at low noise. However, for a medium noise level, the proposed Bayesian method outperforms the two others with a RMS error of 1.94%, compared to 2.79% and 2.78% for ρe − Z and maximum-likelihood ETD, respectively. When more than two energy spectra are used, the Bayesian ETD is able to reduce RMS error on SPR using up to five energy bins. In terms of range prediction, Bayesian ETD with four energy bins in realistic conditions reduces proton beam range uncertainties by a factor of up to 1.5 compared to ρe − Z. Conclusion: The Bayesian ETD is shown to be more robust against noise than similar methods and a promising approach to extract SPR from noisy DECT data. In the advent of commercially available multi-energy CT or photon-counting CT scanners, the Bayesian ETD is expected to allow extracting more information and improve the precision of proton therapy beyond DECT. [ABSTRACT FROM AUTHOR]

Purpose: There is an increasing interest in the evaluation of lung function from physiological images in radiation therapy treatment planning to reduce the extent of postradiation toxicities. The purpose of this work was to retrieve reliable functional information from contrast-enhanced dualenergy computed tomography (DECT) for new applications in radiation therapy. The functional information obtained by DECT is also compared with other methods using single-energy CT (SECT) and single-photon emission computed tomography (SPECT) with CT. The differential function between left and right lung, as well as between lobes is computed for all methods. Methods: Five lung cancer patients were retrospectively selected for this study; each underwent a SPECT/CT scan and a contrast-injected DECT scan, using 100 and 140 Sn kVp. The DECT images are postprocessed into iodine concentration maps, which are further used to determine the perfused blood volume. These maps are calculated in two steps: (a) a DECT stoichiometric calibration adapted to the presence of iodine and followed by (b) a two-material decomposition technique. The functional information from SECT is assumed proportional to the HU numbers from a mixed CT image. The functional data from SPECT/CT are considered proportional to the number of counts. A radiation oncologist segmented the entire lung volume into five lobes on both mixed CT images and low-dose CT images from SPECT/CT to allow a regional comparison. The differential function for each subvolume is computed relative to the entire lung volume. Results: The differential function per lobe derived from SPECT/CT correlates strongly with DECT (Pearson’s coefficient r = 0.91) and moderately with SECT (r = 0.46). The differential function for the left lung shows a mean difference of 7% between SPECT/CT and DECT; and 17% between SPECT/CT and SECT. The presence of nonfunctional areas, such as localized emphysema or a lung tumor, is reflected by an intensity drop in the iodine concentration maps. Functional dose volume histograms (fDVH) are also generated for two patients as a proof of concept. Conclusion: The extraction of iodine concentration maps from a contrast-enhanced DECT scan is achieved to compute the differential function for each lung subvolume and good agreement is found in respect to SPECT/CT. One promising avenue in radiation therapy is to include such functional information during treatment planning dose optimization to spare functional lung tissues. [ABSTRACT FROM AUTHOR]

Purpose Dual-energy CT ( DECT) promises improvements in estimating stopping power ratios ( SPRs) for proton therapy treatment planning. Although several comparable mathematical formalisms have been proposed in literature, the optimal techniques to characterize human tissue SPRs with DECT in a clinical environment are not fully established. The aim of this work is to compare the most robust DECT methods against conventional single-energy CT ( SECT) in conditions reproducing a clinical environment, where CT artifacts and noise play a major role on the accuracy of these techniques. Methods Available DECT tissue characterization methods are investigated and their ability to predict SPRs is compared in three contexts: (a) a theoretical environment using the XCOM cross section database; (b) experimental data using a dual-source CT scanner on a calibration phantom; (c) simulations of a virtual humanoid phantom with the ImaSim software. The latter comparison accounts for uncertainties caused by CT artifacts and noise, but leaves aside other sources of uncertainties such as CT grid size and the I-values. To evaluate the clinical impact, a beam range calculation model is used to predict errors from the probability distribution functions determined with ImaSim simulations. Range errors caused by SPR errors in soft tissues and bones are investigated. Results Range error estimations demonstrate that DECT has the potential of reducing proton beam range uncertainties by 0.4% in soft tissues using low noise levels of 12 and 8 HU in DECT, corresponding to 7 HU in SECT. For range uncertainties caused by the transport of protons through bones, the reduction in range uncertainties for the same levels of noise is found to be up to 0.6 to 1.1 mm for bone thicknesses ranging from 1 to 5 cm, respectively. We also show that for double the amount noise, i.e., 14 HU in SECT and 24 and 16 HU for DECT, the advantages of DECT in soft tissues are lost over SECT. In bones however, the reduction in range uncertainties is found to be between 0.5 and 0.9 mm for bone thicknesses ranging from 1 to 5 cm, respectively. Conclusion DECT has a clear potential to improve proton beam range predictions over SECT in proton therapy. However, in the current state high levels of noise remain problematic for DECT characterization methods and do not allow getting the full benefits of this technology. Future work should focus on adapting DECT methods to noise and investigate methods based on raw-data to reduce CT artifacts. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to determine fluence corrections necessary to convert absorbed dose to graphite, measured by graphite calorimetry, to absorbed dose to water. Fluence corrections were obtained from experiments and Monte Carlo simulations in low- and high-energy proton beams. Methods: Fluence corrections were calculated to account for the difference in fluence between water and graphite at equivalent depths. Measurements were performed with narrow proton beams. Plane-parallel-plate ionization chambers with a large collecting area compared to the beam diameter were used to intercept the whole beam. High- and low-energy proton beams were provided by a scanning and double scattering delivery system, respectively. A mathematical formalism was established to relate fluence corrections derived from Monte Carlo simulations, using the fluka code [A. Ferrari et al., "fluka: A multi-particle transport code," in CERN 2005-10, INFN/TC 05/11, SLAC-R-773 (2005) and T. T. Böhlen et al., "The fluka Code: Developments and challenges for high energy and medical applications," Nucl. Data Sheets 120, 211-214 (2014)], to partial fluence corrections measured experimentally. Results: A good agreement was found between the partial fluence corrections derived by Monte Carlo simulations and those determined experimentally. For a high-energy beam of 180 MeV, the fluence corrections from Monte Carlo simulations were found to increase from 0.99 to 1.04 with depth. In the case of a low-energy beam of 60 MeV, the magnitude of fluence corrections was approximately 0.99 at all depths when calculated in the sensitive area of the chamber used in the experiments. Fluence correction calculations were also performed for a larger area and found to increase from 0.99 at the surface to 1.01 at greater depths. Conclusions: Fluence corrections obtained experimentally are partial fluence corrections because they account for differences in the primary and part of the secondary particle fluence. A correction factor, F(d), has been established to relate fluence corrections defined theoretically to partial fluence corrections derived experimentally. The findings presented here are also relevant to water and tissue-equivalent-plastic materials given their carbon content. [ABSTRACT FROM AUTHOR]

Purpose: To quantify detector perturbation effects in megavoltage small photon fields and support the theoretical explanation on the nature of quality correction factors in these conditions. Methods: In this second paper, a modern approach to radiation dosimetry is defined for any detector and applied to small photon fields. Fano's theorem is adapted in the form of a cavity theory and applied in the context of nonstandard beams to express four main effects in the form of perturbation factors. The pencil-beam decomposition method is detailed and adapted to the calculation of perturbation factors and quality correction factors. The approach defines a perturbation function which, for a given field size or beam modulation, entirely determines these dosimetric factors. Monte Carlo calculations are performed in different cavity sizes for different detection materials, electron densities, and extracameral components. Results: Perturbation effects are detailed with calculated perturbation functions, showing the relative magnitude of the effects as well as the geometrical extent to which collimating or modulating the beam impacts the dosimetric factors. The existence of a perturbation zone around the detector cavity is demonstrated and the approach is discussed and linked to previous approaches in the literature to determine critical field sizes. Conclusions: Monte Carlo simulations are valuable to describe pencil beam perturbation effects and detail the nature of dosimetric factors in megavoltage small photon fields. In practice, it is shown that dosimetric factors could be avoided if the field size remains larger than the detector perturbation zone. However, given a detector and beam quality, a full account for the detector geometry is necessary to determine critical field sizes. [ABSTRACT FROM AUTHOR]

Purpose: To explain the reasons for significant quality correction factors in megavoltage small photon fields and clarify the underlying concepts relevant to dosimetry under such conditions. Methods: The validity of cavity theory and the requirement of charged particle equilibrium (CPE) are addressed from a theoretical point of view in the context of nonstandard beams. Perturbation effects are described into four main subeffects, explaining their nature and pointing out their relative importance in small photon fields. Results: It is demonstrated that the failure to meet classical cavity theory requirements, such as CPE, is not the reason for significant quality correction factors. On the contrary, it is shown that the lack of CPE alone cannot explain these corrections and that what matters most, apart from volume averaging effects, is the relationship between the lack of CPE in the small field itself and the density of the detector cavity. The density perturbation effect is explained based on Fano's theorem, describing the compensating effect of two main contributions to cavity absorbed dose. Using the same approach, perturbation effects arising from the difference in atomic properties of the cavity medium and the presence of extracameral components are explained. Volume averaging effects are also discussed in detail. Conclusions: Quality correction factors of small megavoltage photon fields are mainly due to differences in electron density between water and the detector medium and to volume averaging over the detector cavity. Other effects, such as the presence of extracameral components and differences in atomic properties of the detection medium with respect to water, can also play an accentuated role in small photon fields compared to standard beams. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the reliability of common sinogram-based DECT reconstruction methods for radiotherapy tissue characterization and to evaluate the advantage of combining them with a stoichiometric calibration. Methods: The sinogram-based DECT method defined by Alvarez and Macovski ["Energy-selective reconstructions in x-ray computerized tomography," Phys. Med. Biol. 21, 733-744 (1976)] is adapted to the XCOM photon cross sections database and also generalized to a two-material decomposition method. A theoretical framework is developed using a test phantom containing human tissue compositions for comparing the sinogram-based methods and the calibration-based method, being defined as the application of the stoichiometric calibration technique of Bourque et al. ["A stoichiometric calibration method for dual energy computed tomography," Phys. Med. Biol. 59, 2059-2088 (2014)] on monoenergetic images being generated with a sinogram-based method. Applying a bias correction to the sinogram-based method, its performance in extracting human tissue parameters in the presence of noise as well as by altering the photon energy spectrum is compared to the calibration-based method. Results: In the absence of noise and without spectrum alteration, the calibration-based method is found to have no benefit on the sinogram-based method. However, the calibration-based method is shown to be potentially more reliable than bias-corrected sinogram-based methods in situations comparable to the clinical environment, where noise is present and the photon energy spectra can differ from what is used during image reconstruction. In determining electron density, the performance of all methods is comparable in the presence of noise only. Moreover, combined with heavy spectrum alteration, the mean errors on electron density are found higher in sinogram-based methods in comparison with the calibration-based method, with 1.2% versus 0.2%. In the presence of significant noise, bias-corrected sinogram-based methods yield mean errors on effective atomic number of about 2.5%, as compared to 0.5% for the calibration-based method. When combined with heavy spectrum alteration, bias-corrected sinogram-based methods can lead to error of up to 4% on the effective atomic number versus 1.8% for the calibration-based method. Conclusions: While sinogram-based methods have the advantage of eliminating beam hardening effects, results of this study suggest improvements in the accuracy and reliability of extracting tissue parameters by applying the DECT stoichiometric calibration of Bourque et al. to monoenergetic images being generated with such DECT reconstruction methods. [ABSTRACT FROM AUTHOR]

Purpose: In the scope of reference dosimetry of radiotherapy beams, Monte Carlo (MC) simulations are widely used to compute ionization chamber dose response accurately. Uncertainties related to the transport algorithm can be verified performing self-consistency tests, i.e., the so-called 'Fano cavity test.' The Fano cavity test is based on the Fano theorem, which states that under charged particle equilibrium conditions, the charged particle fluence is independent of the mass density of the media as long as the cross-sections are uniform. Such tests have not been performed yet for MC codes simulating proton transport. The objectives of this study are to design a new Fano cavity test for proton MC and to implement the methodology in two MC codes: Geant4 and PENELOPE extended to protons (PENH). Methods: The new Fano test is designed to evaluate the accuracy of proton transport. Virtual particles with an energy of E0 and a mass macroscopic cross section of [ABSTRACT FROM AUTHOR]

Purpose: In the scope of intensity modulated radiation therapy (IMRT) dosimetry using ionization chambers, quality correction factors of plan-class-specific reference (PCSR) fields are theoretically investigated. The symmetry of the problem is studied to provide recommendable criteria for composite beam deliveries where correction factors are minimal and also to establish a theoretical limit for PCSR delivery kQ factors. Methods: The concept of virtual symmetric collapsed (VSC) beam, being associated to a given modulated composite delivery, is defined in the scope of this investigation. Under symmetrical measurement conditions, any composite delivery has the property of having a kQ factor identical to its associated VSC beam. Using this concept of VSC, a fundamental property of IMRT kQ factors is demonstrated in the form of a theorem. The sensitivity to the conditions required by the theorem is thoroughly examined. Results: The theorem states that if a composite modulated beam delivery produces a uniform dose distribution in a volume Vcyl which is symmetric with the cylindrical delivery and all beams fulfills two conditions in Vcyl: (1) the dose modulation function is unchanged along the beam axis, and (2) the dose gradient in the beam direction is constant for a given lateral position; then its associated VSC beam produces no lateral dose gradient in Vcyl, no matter what beam modulation or gantry angles are being used. The examination of the conditions required by the theorem lead to the following results. The effect of the depth-dose gradient not being perfectly constant with depth on the VSC beam lateral dose gradient is found negligible. The effect of the dose modulation function being degraded with depth on the VSC beam lateral dose gradient is found to be only related to scatter and beam hardening, as the theorem holds also for diverging beams. Conclusions: The use of the symmetry of the problem in the present paper leads to a valuable theorem showing that kQ factors of composite IMRT beam deliveries are close to unity under specific conditions. The theoretical limit kQpcsr,Qmsrfpcsr,fmsr=1 is determined based on the property of PCSR deliveries to provide a uniform dose in the target volume. The present approach explains recent experimental observations and proposes ideal conditions for IMRT reference dosimetry. The result of this study could potentially serve as a theoretical basis for reference dosimetry of composite IMRT beam deliveries or for routine IMRT quality assurance. [ABSTRACT FROM AUTHOR]

Purpose: In a recent paper by Bouchard et al. [Med. Phys. 36(10), 4654-4663 (2009)], a theoretical model of quality correction factors for idealistic so-called plan-class specific reference (PCSR) fields was proposed. The reasoning was founded on the definition of PCSR fields made earlier by Alfonso et al. [Med. Phys. 35(11), 5179-5186 (2008)], requiring the beam to achieve charged particle equilibrium (CPE), in a time-averaged sense, in the reference medium. The relation obtained by Bouchard et al. was derived using Fano's theorem (1954) which states that if CPE is established in a given medium, the dose is independent of point-to-point density variations. A potential misconception on the achievability of the condition required by Fano (1954) might be responsible for false practical conclusions, both in the definition of PCSR fields as well as the theoretical model of quality correction factor. Methods: In this paper, the practical achievability of CPE in external beams is treated in detail. The fact that this condition is not achievable in single or composite deliveries is illustrated by an intuitive method and is also formally demonstrated. Conclusions: Fano's theorem is not applicable in external beam radiation dosimetry without (virtually) removing attenuation effects, and therefore, the relation conditionally defined by Bouchard et al. (2009) cannot be valid in practice. A definition of PCSR fields in the recent formalism for nonstandard beams proposed by Alfonso et al. (2008) should be modified, revising the criterion of CPE condition. The authors propose reconsidering the terminology used to describe standard and nonstandard beams. The authors argue that quality correction factors of intensity modulated radiation therapy PCSR fields (i.e., kQpcsr,Qfpcsr,fref) could be unity under ideal conditions, but it is concluded that further investigation is necessary to confirm that hypothesis. [ABSTRACT FROM AUTHOR]

Purpose: Monte Carlo methods are considered as the gold standard for dosimetric computations in radiotherapy. Their execution time is, however, still an obstacle to the routine use of Monte Carlo packages in a clinical setting. To address this problem, a completely new, and designed from the ground up for the GPU, Monte Carlo dose calculation package for voxelized geometries is proposed: GPUMCD. Method: GPUMCD implements a coupled photon-electron Monte Carlo simulation for energies in the range of 0.01-20 MeV. An analog simulation of photon interactions is used and a class II condensed history method has been implemented for the simulation of electrons. A new GPU random number generator, some divergence reduction methods, as well as other optimization strategies are also described. GPUMCD was run on a NVIDIA GTX480, while single threaded implementations of EGSnrc and DPM were run on an Intel Core i7 860. Results: Dosimetric results obtained with GPUMCD were compared to EGSnrc. In all but one test case, 98% or more of all significant voxels passed the gamma criteria of 2%-2 mm. In terms of execution speed and efficiency, GPUMCD is more than 900 times faster than EGSnrc and more than 200 times faster than DPM, a Monte Carlo package aiming fast executions. Absolute execution times of less than 0.3 s are found for the simulation of 1M electrons and 4M photons in water for monoenergetic beams of 15 MeV, including GPU-CPU memory transfers. Conclusion: GPUMCD, a new GPU-oriented Monte Carlo dose calculation platform, has been compared to EGSnrc and DPM in terms of dosimetric results and execution speed. Its accuracy and speed make it an interesting solution for full Monte Carlo dose calculation in radiation oncology. [ABSTRACT FROM AUTHOR]

Purpose: To establish accurate experimental dosimetry techniques for reference dose measurements in nonstandard composite fields. Methods: A cylindrical PMMA phantom filled with water was constructed, at the center of which reference absorbed dose to water for a head and neck IMRT delivery was measured. Based on the proposed new formalism for reference dosimetry of nonstandard fields [Alfonso et al., Med. Phys. 35, 5179–5186 (2008)], a candidate plan-class specific reference (pcsr) field for a typical head and neck IMRT delivery was created on the CT images of the phantom. The absorbed dose to water in the pcsr field normalized to that in a reference 10×10 cm2 field was measured using three radiation detectors: Gafchromic® EBT films, a diamond detector, and a guarded liquid-filled ionization chamber developed in-house (GLIC-03). Pcsr correction factors kQpcsr,Qfpcsr,fref were determined for five different types of air-filled ionization chambers (Exradin A12, NE2571, Exradin A1SL, Exradin A14, and PinPoint® 31006) in a fully rotated delivery and in a delivery with the same MLC settings and weights but from a single gantry angle (a collapsed delivery). Results: The combined standard uncertainty in measuring the correction factor kQpcsr,Qfpcsr,fref using the three dosimetry techniques was 0.3%. For all the air-filled ionization chambers and the pcsr field tested, the correction factor was not different from unity by more than ±0.8%. For the fully rotated delivery, the correction factors were in a narrow range of 0.9955–0.9986, while in the collapsed delivery, they were in a slightly broader range of 0.9922–1.0048. In the collapsed delivery, the Farmer-type chambers (Exradin A12 and NE2571) had very similar correction factors (0.9922 and 0.9931, respectively), whereas the correction factors for the smaller chambers showed more distinct chamber-type dependence. Conclusions: The authors have established three experimental dosimetry techniques that allow reference measurements of nonstandard field correction factors kQpcsr,Qfpcsr,fref for air-filled ionization chambers at the 0.3% 1σ uncertainty level. These techniques can be used to determine criteria for the selection of plan-class specific reference fields and ultimately improve clinical reference dosimetry of nonstandard fields. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study is to determine the effect on the measured optical density of scanning on either side of a Gafchromic EBT and EBT2 film using an Epson (Epson Canada Ltd., Toronto, Ontario) 10000XL flat bed scanner. Methods: Calibration curves were constructed using EBT2 film scanned in landscape orientation in both reflection and transmission mode on an Epson 10000XL scanner. Calibration curves were also constructed using EBT film. Potential errors due to an optical density difference from scanning the film on either side (“face up” or “face down”) were simulated. Results: Scanning the film face up or face down on the scanner bed while keeping the film angular orientation constant affects the measured optical density when scanning in reflection mode. In contrast, no statistically significant effect was seen when scanning in transmission mode. This effect can significantly affect relative and absolute dose measurements. As an application example, the authors demonstrate potential errors of 17.8% by inverting the film scanning side on the gamma index for 3%—3 mm criteria on a head and neck intensity modulated radiotherapy plan, and errors in absolute dose measurements ranging from 10% to 35% between 2 and 5 Gy. Conclusions: Process consistency is the key to obtaining accurate and precise results in Gafchromic film dosimetry. When scanning in reflection mode, care must be taken to place the film consistently on the same side on the scanner bed. [ABSTRACT FROM AUTHOR]

Purpose: For the purpose of nonstandard beam reference dosimetry, the current concept of reporting absorbed dose at a point in water located at a representative position in the chamber volume is investigated in detail. As new nonstandard beam reference dosimetry protocols are under development, an evaluation of the role played by the definition of point of measurement could lead to conceptual improvements prior to establishing measurement procedures. Methods: The present study uses the current definition of reporting absorbed dose to calculate ionization chamber perturbation factors for two cylindrical chamber models (Exradin A12 and A14) using the Monte Carlo method. The EGSnrc based user-code EGS_chamber is used to calculate chamber dose responses of 14 IMRT beams chosen to cause considerable dose gradients over the chamber volume as previously used by Bouchard and Seuntjens [“Ionization chamber-based reference dosimetry of intensity modulated radiation beams,” Med. Phys. 31(9), 2454–5465 (2004)]. Results: The study shows conclusively the relative importance of each physical effect involved in the nonstandard beam correction factors of 14 IMRT beams. Of all correction factors involved in the dosimetry of the beams studied, the gradient perturbation correction factor has the highest magnitude, on average, 11% higher compared to reference conditions for the Exradin A12 chamber and about 5% higher for the Extradin A14 chamber. Other perturbation correction factors (i.e., Pwall, Pstem, and Pcel) are, on average, less than 0.8% different from reference conditions for the chambers and beams studied. The current approach of reporting measured absorbed dose at a point in water coinciding with the location of the centroid of the chamber is the main factor responsible for large correction factors in nonstandard beam deliveries (e.g., intensity modulated radiation therapy) reported in literature. Conclusions: To reduce or eliminate the magnitude of perturbation correction factors in nonstandard beam reference dosimetry, two possible ways to report absorbed dose are suggested: (1) Reporting average dose to the sensitive volume of the chamber filled with water, combined with removing the reference field implicit gradient effect when measuring output factors, and (2) reporting average dose to the chamber itself during output factor verifications. The first option could be adopted if clinical beam correction factors are negligible. The second option could simplify quality assurance procedures when correction factors are not negligible and have to be calculated using Monte Carlo simulations. [ABSTRACT FROM AUTHOR]

Radiochromic film is a dosimeter of choice in applications requiring high spatial resolution, two dimensional measurements, or minimum perturbation of the beam fluence. Since the measurement uncertainty in Gafchromic film dosimetry is thought to be significant compared to that of ionization chambers, a rigorous method to evaluate measurement uncertainties is desired. This article provides a method that takes into account the correlation between fit parameters as well as single dose values in order to obtain accurate uncertainties in absolute and relative measurements. A complete portrait of all sources of uncertainty in Gafchromic film dosimetry is given. The parametrization of variance as a function of the number of averaged pixels is obtained in order to accurately predict the uncertainty as a function of the size of the region of interest. The choice of functional form for the sensitometric curve is based on four criteria and a convergence of global net optical density uncertainty to 0.0013 is demonstrated. A minimum number of 12 points is recommended to characterize the sensitometric curve to a sufficient precision on the uncertainty estimation. Uncertainty levels of 0.9% on absolute dose measurements and 0.45% on relative measurements are achieved using a 12-point calibration curve with 220 cGy and repeating measurements five times. Uncertainties of 0.8% and 0.4% are achievable when using 35 points during film characterization. Ignoring covariance terms is shown to lead to errors in the estimation of uncertainty. [ABSTRACT FROM AUTHOR]