Biomedical subjects
A Dutreix
Publications and source records attributed to A Dutreix.
Quality assurance network in central Europe. External audit on output calibration for photon beams.
The EROPAQ project for TLD monitoring of photon beams started in June 1994 with the set-up of the TLD system: calibration, reading and evaluation procedures. The acceptance level of +/- 3% was set for the TLD intercomparisons. The policy of the project was to check all beams in 47 participating radiotherapy centres and to recheck all the beams in those centres, where a deviation exceeding +/- 3% occurred in one or more of the beams. Out of 129 beams checked, 100 beams (78%) were found within the +/- 3% limit. Eleven beams show deviations larger than +/- 6%, and immediate corrective action was undertaken. Out of 47 centres checked, 22 did not participate in any external audit in a preceding 5 years. In these centres 68% (34/50) of the total number of gamma and x-ray beams checked but only 59% (20/34) of gamma beams were within the acceptance level, while in the 25 centres, which participated in an external audit before, these figures were 84% (66/79) and 88% (35/40) respectively. The sources of discrepancies were thoroughly investigated, discussed with the participants and the errors corrected. Poor results were in several cases associated with very old design of radiotherapy units and old dosimetry systems, equipped with inadequate ionization chambers. In several centres, an insufficient training of the physicists in clinical dosimetry was observed. Thanks to the corrective action, a great improvement of calibration of the beams was achieved. Standard deviation of the distribution of the results for all x and gamma beams checked decreased from SD = 7.4% at the first check to SD = 2.5% at the second check.
Importance of in vivo dosimetry as part of a quality assurance program in tangential breast treatments.
PURPOSE: The investigation of the accuracy and reproducibility in the daily dose delivered in tangential breast treatments with in vivo dose measurements. METHODS AND MATERIALS: In vivo dose measurements performed on the tangential treatment fields of 35 breast cancer patients are analysed for three units: a 6 MV linear accelerator, an old Cobalt unit and a new Cobalt unit. The results are plotted in frequency distributions. Deviations on the mean are often the expression of a systematic error in one of the core procedures of a department. A large spread of the results around the mean indicates a high burden of random set-up errors and/or systematic errors in individual patients. The reproducibility in dose delivery is studied by comparing repetitive checks to their respective mean for investigation of random day-to-day variation. RESULTS: A small systematic error on the entrance dose (+ 1.4%) is detected on the old Cobalt unit due to a discrepancy between measured and published percentage depth dose values. An unexpected systematic overdosage (+ 6%) is detected after implementation of a new software for dose calculation, proving that treatment quality is a process needing continuous monitoring. The transmission measurements demonstrate a systematic error in dose delivery of 1.5 to 3% due to the assumption that the breast is water equivalent when calculating the dose. The large spread of the transmission measurements (sa = 7.7%) shows that the weakest point in the treatment preparation chain is inaccurate acquisition of external body contours, leading to systematic errors in dose delivery for specific patients. The standard deviation for the reproducibility is 3.1% for the old Cobalt unit, vs. 1.6% on the other units, demonstrating the influence of staffing and mechanical characteristics of the units on daily precision in dose delivery. CONCLUSION: In vivo dosimetry is an important tool in a departmental quality assurance program to detect systematic errors in dose delivery, to identify inadequate treatment situations, to investigate weak points in the chain of treatment preparation and to ensure accurate dose delivery for individual patients. The predictive value of a single check for the accuracy in dose delivery during the whole treatment series is high for reproducible treatment methodologies.
Quality control of radiotherapy centres in Europe: beam calibration.
A European Quality Assurance Network for external radiotherapy was set up. In this, several countries participated on a voluntary basis to elaborate common protocols, using joint infrastructure. The support for the co-ordination of the project was given by the EC committee 'Europe Against Cancer'. In the first step of the programme, beam outputs and beam qualities are checked with mailed thermoluminescent dosimeters following the protocol prepared by the IAEA. The results concerning 125 beams from 66 centres are analysed. Twenty-two beams presented minor deviations (3-6%) and 15 beams (4/48 60Co beams and 11/77 X-ray beams) from 11 centres presented major deviations (> or = 6%). The analysis shows that 16/22 minor deviations and all major deviations have been detected in centres which have not benefited from an external check during the last 5 years. In 14 out of 15 large deviations, the measured dose was smaller than the stated dose. In most centres with major deviation the physicists did not have the necessary experience and did not regularly calibrate the beams. In 6 out of 11 centres there was no dosimeter or the dosimeter available had not been calibrated recently. In 3 centres, the physicist did not give any explanation.
Reliability of clinical port films for measuring dose inhomogeneities in radiotherapy for head and neck tumours.
Reproducibility and reliability of film dosimetry are evaluated in clinical circumstances. Optical densities were read on 82 routinely taken verification films of Ear-Nose-Throat (ENT) treatment fields and corrected with the sensitometric curve to obtain relative dose values. Off-axis ratios measured on 10 successive films of one specific field were compared with each other and show a good reproducibility (s = 1.7%). Reliability was assessed by comparing 82 off-axis ratios obtained on the films with off-axis ratios obtained by simultaneously performed diode measurements. Only small relative differences were detected (mean = 1.1%, s = 3.0).
Midplane dose determination using in vivo dose measurements in combination with portal imaging.
The possibility of using portal films in combination with semiconductor in vivo measurements for midplane dose distribution is investigated. A general algorithm, using measured entrance and exit doses and available beam data of the Linac, is proposed to derive the midplane dose for symmetrical inhomogeneities. Experimental verification of the algorithm with phantom measurements is performed for different kinds of inhomogeneities (Al, air and cork) and phantom thicknesses from 13 cm to 30 cm. When using only the entrance dose and the exit dose, provided by the diodes on the beam axis, the algorithm predicts for the different inhomogeneities midplane doses in all cases within 1% of the midplane doses measured with an ionization chamber. When using the portal film in combination with entrance and exit dose measurements to estimate the midplane dose in an off-axis position, the calculated midplane doses are within 3% of the midplane doses measured with an ionization chamber. The midplane doses calculated with the algorithm are compared to the midplane doses obtained with simplified calculation methods, i.e. the arithmetical mean and the geometrical mean of the measured entrance and exit doses. The geometrical mean especially seems to give acceptable results (within 5%) and can as such be used as an easy rule of thumb to estimate roughly the midplane dose. Finally, critical considerations on the validity and the precision of the proposed algorithm are given. The present results confirm the possibility of using the portal film for midplane dose distribution determination at the patient level.
A model for calculating the costs of in vivo dosimetry and portal imaging in radiotherapy departments.
The costs of in vivo dosimetry and portal imaging in radiotherapy are estimated, on the basis of a detailed overview of the activities involved in both quality assurance techniques. These activities require the availability of equipment, the use of material and workload. The cost calculations allow to conclude that for most departments in vivo dosimetry with diodes will be a cheaper alternative than in vivo dosimetry with TLD-meters. Whether TLD measurements can be performed cheaper with an automatic reader (with a higher equipment cost, but lower workload) or with a semi-automatic reader (lower equipment cost, but higher workload), depends on the number of checks in the department. LSP-systems (with a very high equipment cost) as well as on-line imaging systems will be cheaper portal imaging techniques than conventional port films (with high material costs) for large departments, or for smaller departments that perform frequent volume checks.
Characteristics of contamination electrons in high energy photon beams.
A simple method to estimate the contribution of contaminating electrons to the dose, and to evaluate their dosimetric characteristics is proposed. The method is based on a normalisation of the tissue--maximum ratio curves to a constant primary photon fluence. The contribution of the contaminating electrons to the dose is calculated by subtracting the dose relative to a small field from the dose relative to the field under consideration. The method includes the determination of the mean energy, the linear apparent attenuation coefficient, the 50% range and the maximum range of the contaminating electrons. The extrapolated surface dose normalised to a constant primary photon fluence has been found to be constant for a constant collimator opening whatever may be the source distance.
Accuracy in mantle field irradiations: irradiated volume and daily dose.
Accuracy of patient positioning and dose delivery in mantle field irradiations was investigated on 29 patients treated between August 1990 and December 1991. Patients were treated in two different centers, University Hospital St. Rafaël in Leuven and Institut Gustave Roussy in Villejuif, where different techniques and procedures were used. Measurements were performed on 341 portal films and entrance doses were measured in 518 treatment set-ups. The impact of systematic errors occurring during treatment preparation and day-to-day variations on the accuracy of treatment execution were separately analysed. Daily reproducibility, defined as the deviation from the respective mean measured value for a treatment was demonstrated to be good for both the treated volume and the delivered dose and no difference between the two techniques was shown. Comparing the successive portal films of individual patients (reproducibility of a treatment, once it has started), only small day-to-day variations are found: the SD is 3.4 mm for craniocaudal movements and 2.6 mm for lateral movements. For dose delivery very narrow distributions are obtained with SDs of, respectively, 1.5% and 1.85% for the Leuven and the Villejuif group. This suggests that the position of the patient, which is often thought as the critical point in this complex set-up can be done in a very accurate way, regardless of the position used. To assess the global accuracy of the treatment, the actually treated volume and delivered dose were compared with the planned values. Apart from reproducibility this also takes into account the whole preparatory procedure between planning and the start of the therapy (first session).(ABSTRACT TRUNCATED AT 250 WORDS)
Black and white in accuracy assessment of megavoltage images: the medical decision is often grey.
Using different criteria for acceptance of the portal film taken at the first treatment session, a comparison was made of the relevance of the information obtained from such a single check for the subsequent irradiations. A total number of 234 verification films have been taken on 29 fields for 27 head and neck patients. Patients were immobilised with individual plastic masks fixed to the couch and treated on a 6-MV linac fitted with an automatic verification system. Field alignment was checked with a measurement in the anteroposterior (AP) and craniocaudal (CC) direction on each film. Referring to the simulated field, this group of patients was treated with excellent average precision (mean, -0.7 mm) and reasonable spread (s = 5 mm). The percentage of 'large' deviations (> or = 6 mm) occurring during the whole treatment course is proportional to the upper limit of deviation accepted in the first assessed field (for an upper limit < 6 mm): it goes progressively up from 5% (AP-CC direction) to 17% (AP) and 13% (CC) for accepted magnitudes of deviation going from 2 mm to 6 mm in the first film. As the reproducibility of the different treatment series (s = 2 mm) is independent of the upper level of error accepted on the first film, this means that errors are mainly systematic errors coming from the transfer of the simulation unit to the treatment unit. Precision in a series of set-ups is always expressed by a Gaussian curve.(ABSTRACT TRUNCATED AT 250 WORDS)
Preliminary results of a quality assurance network for radiotherapy centres in Europe.
Based on the IAEA/WHO experience in mailed dosimetry, a Quality Assurance (QA) Network, sponsored by the EC committee "Europe Against Cancer", has been set up in 1991 for European centres, not involved in clinical research. Besides a survey of radiotherapy infrastructure, the project includes three measurement steps: primarily a check of beam output and quality in reference conditions with a mailed TLD-procedure, in a second step the mailed verification of other beam data and dose calculation procedures with a multipurpose phantom and finally in vivo dosimetry at the individual patient levels with mailed dosimeters. The results of infrastructure show good agreement with the data previously published by EORTC for research centres. Until January 1993, a total number of 37 centres (49 X-ray beams and 28 cobalt beams) from Belgium, France, Italy, The Netherlands, Sweden and The Czech and Slovak Republics have participated in the first measurement step. Deviations > 3% and < 6% from the stated dose are found in 17 out of the 79 checked beams. A deviation < 6% from the stated dose is detected in only 1 out of the 28 cobalt beams, but in 7 of the 49 X-ray beams. The large majority of the beams (23/25) with deviations > 3% belong to centres not having participated in external audits in the previous 5 years. A pilot study for the second step shows larger deviations in non reference conditions, especially for off-axis points and for oblique phantom surface. The third step has yet to be implemented.(ABSTRACT TRUNCATED AT 250 WORDS)
Quality assurance procedures in radiotherapy. Economic criteria to support decision making.
This paper details the costs of two types of quality assurance activities in radiotherapy: in vivo dosimetry, intended to check the delivered dose, and portal imaging to check the treated volume. For both activities, either on-line or off-line techniques may be used. Describing the costs allows the calculation of which techniques are most cost-efficient for different radiotherapy departments.
A method for dose calculation for high energy photon beams based on measurements performed at reference depth.
An algorithm is proposed to calculate the dose per monitor unit at any point along the beam axis for blocked or unblocked fields. The proposed formalism takes into consideration the beam measurements performed at the reference depth as recommended by most dosimetry protocols (5 cm or 10 cm depending on the beam quality). The only parameters which cannot be measured at the reference depth are the peak scatter factors, but they appear only as a ratio of two peak scatter factors for two slightly different field sizes. A correction factor is proposed when the distance of one shielding block to the beam axis is smaller than 5 cm. An agreement better than 1% has been obtained between calculations and measurements in the range of beam qualities, distances to the source and field sizes defined by typical collimators or shielding blocks, usually encountered in clinical practice.
Quality control at the patient level: action or retrospective introspection.
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Are port films reliable for in vivo exit dose measurements?
The possibility of using conventional port films as an in vivo method for obtaining relative exit dose distribution in patients is evaluated. Kodak "Verification" films in "Localization" cassettes are positioned in the usual clinical conditions behind an homogeneous polystyrene phantom as well as behind a phantom containing air, wood and aluminium inhomogeneities. Taking beam divergency into account the densitometric profiles are projected back to the exit side of the phantom. They are compared to the profiles obtained with an ionization chamber used under full backscatter conditions. The agreement between the off-axis ratios determined with either method are mostly better than 2% and never exceed 5%. These phantom measurements are completed by a comparison between off-axis ratios determined on a port film for a head and neck patient and those obtained by diode dosimetry applied on the patient at the exit side of the beam. A similar agreement as between film and ion chamber on the phantoms is obtained. These encouraging results illustrate the possibilities of using conventional port films for in vivo dosimetry.
Assessment of dose inhomogeneity at target level by in vivo dosimetry: can the recommended 5% accuracy in the dose delivered to the target volume be fulfilled in daily practice?
The inhomogeneity of the dose delivered to the target volume due to irregular body surface and tissue densities remains in many cases unknown, since the dose distribution is calculated for most radiation treatments in only one transverse section and assuming the patient to be water equivalent. In the present study, the transmission and the target absorbed dose homogeneity is assessed for 11 head-and-neck cancer treatments by in vivo measurements with silicon diodes. Besides the dose to the specification point, the dose delivered to 2-4 off-axis points in the midline sagittal plane is estimated from entrance and exit dose measurements. Simultaneously made portal films allow to identify the anatomical structures passed by the beam before reaching the exit diode. The mean deviation from the expected transmission is -6.8% for bone, +6% for air cavities and -2.5% for soft tissue. At the midplane, the mean deviations from the expected target dose are respectively -3.5%, +2.3% and -1.9%. The deviations from the prescribed dose are larger than 5% in 12 out of the 39 target points. The accuracy requirement in target dose delivery of plus or minus 5%, as proposed by ICRU, cannot be fulfilled in 7 out of the 11 patients and is mostly due to irregular body contour and tissue densities. As only a limited number of points are considered, the inhomogeneity in the dose delivered throughout the whole irradiated volume is underestimated as is illustrated from the exit dose profiles obtained from the portal image.(ABSTRACT TRUNCATED AT 250 WORDS)
Combined radiotherapy and surgery: local control and complications in early carcinoma of the uterine cervix--the Villejuif experience, 1975-1984.
From January 1975 to December 1984, 441 patients were treated by combined radiotherapy and surgery at the Institut Gustave Roussy (IGR) for Stage IB (288) and II (proximal) (103) carcinoma of the uterine cervix. Standard treatment consisted of pre-operative utero-vaginal brachytherapy (60 Gy) using a mould technique followed by a colpo-hysterectomy and external iliac lymphadenectomy. Overall 5 year actuarial survival for the whole population was 87% and disease-free survival 85%. Loco-regional relapse occurred in 23 patients (5%). Of these, 12 were central pelvic failures, 8 regional failures and 3 combined central and regional failures. There were 36 systemic relapses (8%) of which 12 relapsed concurrently in the pelvis. Five year actuarial pelvic disease-free, disease-free and overall survival was 87, 85 and 87%, respectively, for the whole population. 340 patients developed one or more complications [Grade 1: 198/441 (44%), Grade 2: 121/441 (27%) and Grade 3 or 4: 21/441 (4.7%)]. Five year actuarial survival for the whole population was poorer for histologically node positive than for node negative (89 vs. 55%, p less than 0.0001). Pre-operative brachytherapy followed by surgery can provide good local control with acceptable morbidity in early cervical cancer.
Influence of shielding blocks on the output of photon beams as a function of energy and type of treatment unit.
The influence of field-defining shielding blocks on the output of a cobalt unit and of seven different accelerators (one with dual energy output) has been investigated. The quality indices range from 0.57 (cobalt-60) to 0.79. The loss in output due to shielding blocks has been calculated taking into account loss in phantom scatter only. Comparison with experimental results shows that the calculation algorithm is correct in most of the clinical conditions. However, for quality indices of 0.70 and higher, for blocks close to the central beam axis, an overestimation of the output by the algorithm has been found. The maximum deviation observed is about 5% for the highest energy and for block positions corresponding to those applied, e.g. for inverted Y-fields with narrow lumbo-aortic block spacing.