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Cone beam CT is integral to most modern radiotherapy treatments. The application of daily and repeat CBCT imaging can lead to high imaging doses over a large volume of tissue that extends beyond the treatment site. Hence, it is important to ensure exposures are optimised to keep doses as low as reasonably achievable, whilst ensuring images are suitable for the clinical task. This IPEM topical report presents the results of the first UK survey of dose indices in radiotherapy CBCT. Dose measurements, as defined by the cone beam dose index (CBDIw), were collected along with protocol information for seven treatment sites. Where a range of optimised protocols were available in a centre, a sample of patient data demonstrating the variation in protocol use were requested. Protocol CBDIw values were determined from the average dosimetry data for each type of linear accelerator, and median CBDIw and scan length were calculated for each treatment site at each centre. Median CBDIw values were compared and summary statistics derived that enable the setting of national dose reference levels (DRLs). A total of 63 UK radiotherapy centres contributed data. The proposed CBDIw DRLs are; prostate 20.6 mGy, gynaecological 20.8 mGy, breast 5.0 mGy, 3D-lung 6.0 mGy, 4D-lung 11.8 mGy, brain 3.5 mGy and head/neck 4.2 mGy. However, large differences between models of imaging system were noted. Where centres had pro-active optimisation strategies in place, such as sized based protocols with selection criteria, dose reductions on the 'average' patient were possible compared with vendor defaults. Optimisation of scan length was noted in some clinical sites, with Elekta users tending to fit different collimators for prostate imaging (relatively short) compared with gynaecological treatments (longest). This contrasts with most Varian users who apply the default scan length in most cases. [ABSTRACT FROM AUTHOR]

Featured Application: The research provides data on practices in imaging employed in radiotherapy services in countries with different levels of income and development. The information will be used in deciding on recommendations to encourage optimization of radiological protection for imaging by radiotherapy facilities and in evaluating what additional dosimetry features might be included on cone beam CT facilities incorporated into radiotherapy equipment. These will be included in a publication on radiological protection aspects of imaging in radiotherapy being prepared by the International Commission on Radiological Protection (ICRP). Dramatic improvements in radiotherapy equipment have allowed radiation fields to be conformed to tumours for more accurate treatment. Successful delivery often requires imaging at every treatment fraction, a method known as image guided radiation therapy (IGRT). But increased X-ray imaging exposes patients to doses that carry risks of inducing second cancers in normal tissues. Therefore, reductions in high-dose treatment margins achieved with IGRT must be balanced against detriments from greater imaging doses. ICRP Task Group 116 has been set up to prepare guidance on radiological protection aspects of IGRT. Factors affecting the optimization of radiological protection are the modalities used, the frequency of imaging, the image acquisition parameters influencing image quality and radiation dose, and the volume of normal tissue included in the images. The Task Group has undertaken two projects: (1) a snapshot survey of radiotherapy imaging practices across six continents, which has shown that use of kV cone beam CT (CBCT) increases with Human Development Index for the country; and (2) a project looking at ways for measuring CBCT doses that could be applied more widely. The results highlight the need for raising awareness of imaging doses, and development of the dose quantities displayed on imaging equipment used in radiotherapy. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to develop size-based radiotherapy kilovoltage cone beam CT (CBCT) protocols for the pelvis. Methods: Image noise was measured in an elliptical phantom of varying size for a range of exposure factors. Based on a previously defined "small pelvis" reference patient and CBCT protocol, appropriate exposure factors for small, medium, large and extra-large patients were derived which approximate the image noise behaviour observed on a Philips CT scanner (Philips Medical Systems, Best, Netherlands) with automatic exposure control (AEC). Selection criteria, based on maximum tube current-time product per rotation selected during the radiotherapy treatment planning scan, were derived based on an audit of patient size. Results: It has been demonstrated that 110?kVp yields acceptable image noise for reduced patient dose in pelvic CBCT scans of small, medium and large patients, when compared with manufacturer's default settings (125?kVp). Conversely, extra-large patients require increased exposure factors to give acceptable images. 57% of patients in the local population now receive much lower radiation doses, whereas 13% require higher doses (but now yield acceptable images). Conclusion: The implementation of size-based exposure protocols has significantly reduced radiation dose to the majority of patients with no negative impact on image quality. Increased doses are required on the largest patients to give adequate image quality. Advances in knowledge: The development of size-based CBCT protocols that use the planning CT scan (with AEC) to determine which protocol is appropriate ensures adequate image quality whilst minimizing patient radiation dose. [ABSTRACT FROM AUTHOR]