Current Status of Electronic Brachytherapy Dosimetry

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1 Current Status of Electronic Brachytherapy Dosimetry 2014 NCCAAPM Fall Meeting La Crosse, WI Wes Culberson, PhD, DABR University of Wisconsin Madison University of Wisconsin Medical Radiation Research Center (UWMRRC) October 24, 2014

2 Current Status of Electronic Brachytherapy Dosimetry 2014 NCCAAPM Fall Meeting La Crosse, WI Wes Culberson, PhD, DABR University of Wisconsin Madison University of Wisconsin Medical Radiation Research Center (UWMRRC) October 24, 2014

3 Disclosures UWMRRC receives research support from Xoft, a subsidiary of icad 3of 43

4 Outline 1. Electronic Brachytherapy Rationale 2. Overview of Commercial Systems 3. Dosimetry Protocols 4. Establishment of NIST-traceable Standards 5. Current Research in the UWMRRC 4of 43

5 Uses for a Miniature X-Ray Tubes Imaging x-ray radiography Handheld x-ray spectrometers Vacuum applications Electronic brachytherapy (ebt) The Amp TeK Mini-X Image from a 60kVp research x-ray tube based on carbon nanotube field emitters in Korea 5of 43

6 Electronic Brachytherapy (EBT) Rationale Miniature x-ray sources delivering therapeutic doses of radiation Brehmsstrahlung x-rays created by targeting electrons onto a high- Z target (usually gold or tungsten) No radionuclides used, thus different regulatory requirements (no radioactive materials license needed) Commercial units have energies ranging from 30 90kVp Adjustable dose rates / tube currents Less shielding required due to low energies (compared to 192 Ir at least) Developed in the late 1980s, ~10 companies have pursued since then 6of 43

7 Two Main Applications Surface (i.e. skin) Interstitial, intracavitary, and intraluminary 7of 43

8 Carl Zeiss INTRABEAM Oberkochen, Germany 30, 40, and 50kVp at 40 A FDA cleared for intracranial, IORT, skin, and partial breast applications (using a balloon applicator) Gold target 1.2 Gy/min at surface of 1.5cm applicator Images courtesy of 8of 43

9 Elekta Nucletron Esteya Stockholm, Sweden 70 kvp x-ray source + flattening filter Runs at ma FDA cleared for surface treatments in Gy/min at skin surface Images courtesy of 9of 43

10 Xoft Axxent Freemont, CA Disposable 40kVp or 50kVp source FDA cleared for PBI, skin, and cervical (anywhere in or on the body where radiation is indicated ) 300 A 1 Gy/min at 3cm Originally designed as an alternative to HDR 192 Ir Images courtesy of 10 of 43

11 Xstrahl Surrey, UK Not FDA cleared Photographs of Xstrahl exhibit booth at ASTRO Annual Meeting of 43

12 Advance X-ray Technology Birmingham, MI X-ray Scalpel Not FDA cleared Microfocus x-ray tube coupled to a capillary optics collimator connected to an insertable tip with a metal target Up to 20.2 kvp 20Gy/min Gutman et al., Phys Med Biol 49, (2004) 12 of 43

13 Carbon Nanotube Field Emitters Up to 70kVp Being developed in Korea Heo, Kim, Ha, and Cho, A Vacuum-sealed miniature x-ray tube based on carbon nanotube field emitters, Nanoscale Research Letters 7: 258, of 43

14 Definition of Brachytherapy Distance? Literal Latin translation of brachytherapy is near or shortdistance therapy Historically, brachytherapy sources have either been implanted interstitially (inside) or directly on the surface ebt units can be implemented interstitially or for surface treatments, but typically are not directly on the surface ebt nominal SSDs are ~2.5cm 6cm Grenz Ray Contact Therapy SSD<2cm Brachytherapy Superficial, SSD 15-25cm source 0cm 6cm SSD 14 of 43

15 AAPM Protocols None specifically for ebt Concepts based on existing reports TG-43: Brachytherapy dosimetry formalism (1995, 2004) TG-56: Code of practice for brachytherapy (1997) TG-59: HDR treatment delivery (1998) TG-61: Protocol for calibration of kv beams 15 of 43

16 Dosimetry Protocols AAPM TG43 For low-energy LDR and HDR interstitial sources Source strength is air-kerma strength, S K Uses the average of Monte Carlo calculations and measured values to determine the 3-D dose distributions Uses lookup tables or functions to apply these results 16 of 43

17 Dosimetry Protocols AAPM TG61 (40-300kVp) X-ray tube output standard (measured with a NIST FAC and subsequently transferred by the ADCLs) is air kerma, K air Physicists can use the in-air (<100 kvp) or in-phantom (>100 kvp) measurement method Beam quality corrections based on the measured x-ray tube HVL Conversion from air-kerma to dose to water achieved by fundamental formulas (mass energy-absorption coefficients, BSFs, etc) Uses PDDs to scale the dose 17 of 43

18 Dosimetry for Surface Compatibility of AAPM TG61 Applications Measuring air kerma, K air, is possible Distances are very close: effective point of measurement in the chamber needs to be considered. Stem effect normally close to unity since irradiation conditions are similar to calibration conditions. For ebt, Monte Carlo based corrections are necessary 18 of 43

19 Dosimetry for Surface Applications Modified TG61 protocol Fulkerson et al equations 3 and 4 R.K.Fulkerson, J.A. Micka, L.A. DeWerd, Dosimetric characterization and output for conical brachytherapy surface applicators. Part 1. Electronic brachytherapy source, Medical physics, 2014, Vol.41(2), pp Special holders designed 19 of 43

20 Dosimetry for Interstitial, Intraluminary, and Intracavitary Compatibility with TG43 Air-kerma rate vs air-kerma strength S K defined in vacuo Must correct for attenuation in air Calculated Xoft Axxent spectrum by Dr. Steve Davis 2009 Difficult to rotate the source Energies too high for NIST WAFAC PMMA holder 20 of 43

21 Dosimetry for Interstitial, Intraluminary, and Intracavitary Dr. Steve Davis measured and calculated the air-kerma strength of an electronic brachytherapy source for his PhD dissertation and determined k=2 uncertainties of 14% Correcting measurement for filtration in air to account for the entire spectrum Large uncertainties were due to source-to-source variations and uncertainties in the Monte Carlo simulations Low energies aren t clinically relevant, much as in the 4.5 kev Ti x-rays around common LDR I-125 and Pd-103 sources Filter - air 21 of 43

22 Establishing NIST-Traceable Standards Xoft, Inc. source had a contract with the UWMRRC and subsequently NIST to establish standards for the S700 source Initially, went with the AAPM TG43 approach Sk difficult to measure Used a hybrid TG43 formalism with 1m as the source strength metric Conversion to dose is achieved with a conversion coefficient Source strength based on air-kerma rate at 1m in air (not in vacuo) measured with the UW Attix FAC Conversion to absorbed dose to water based on measurements and Monte Carlo calculations at UWMRRC In 2014, NIST introduced a new source strength metric of air-kerma rate in air at 50cm 22 of 43

23 The NIST Standard for the XOFT Axxent S700 Source Introduced in 2013 Lamperti Free-Air Chamber (FAC) Originally intended to swing the FAC around the source Now fixed FAC position FAC X-ray source HPGe spectrometer Image from NIST.gov 23 of 43

24 UW Attix FAC UWMRRC also measured the output with the Attix FAC and compared with NIST Collimation slightly different than Lamperti FAC Measured at four cardinal angles 24 of 43

25 NIST and UW FAC Agreement Xoft Axxent S700 Sources Round s/n UW FAC (Gy/s) NIST FAC (Gy/s) % Diff E E % E E % E E % E E % E E % E E % E E % E E % E E % E E % Measurement angles and air attenuation corrections are likely main sources of discrepancy in the first two rounds 25 of 43

26 Azimuthal Angular Dependence Attix FAC FAC results as a function of angle Source s/n ebt source (top view) Azimuthal Angle Attix FAC Response Relative to Zero Degrees of 43

27 Calibration of Well Chambers Since clinical users don t have a FAC, must use well chamber Should provide a consistent transfer of AKR to charge readings in the well chamber Should give clinically relevant measure of source strength 4π geometry Filter out the low energies (like air and tissue) 27 of 43

28 The Well Chamber Standard Imaging HDR 1000 Plus with a specific insert with ~3mm thick Al holder filters out the lower energies Uses a plastic standoff to position the source in the sweet spot (point of maximum response) SNR Great! ~100nA ionization current for Xoft Axxent S700 source (with special insert) For reference, well chamber current an LDR seed in its normal insert is ~9 pa and the UW VAFAC is ~50fA 28 of 43

29 The Well Chamber 29 of 43

30 Setting up an ADCL Service Typical well chamber calibration coefficients Primary air-kerma measurement performed by NIST on FAC for multiple sources Sources sent to a ADCL and measured in a well chamber. Ratios of air-kerma to well chamber current used as calibration coefficient Hoping for tight range of coefficients Coefficients will vary slightly for LDR sources (+/- 2%) due to internal construction of sources 30 of 43

31 Source-to-Source Variations Not all tungsten targets made the same, especially for these sizes Effects of spectral differences Will affect conversion from AKR to dose to water Low energy component of spectrum will be the main issue 31 of 43

32 Initial UWADCL Well Chamber Results Xoft Axxent Sources Average of Round 3 values used as the final cal coefficient 32 of 43

33 Implementation of a New Standard UWADCL calibrations for the XOFT Axxent Model S700 source approved by AAPM CLA in summer, 2014 Slight modification of TG43 is needed to accommodate the new source strength metric of AKR at 50cm in air Manuscript submitted by DeWerd et al. to Medical Physics Journal Proposes a formalism to use the new NIST standard Proposes the Dose Conversion Coefficient, χ Proposes applicator specific values (not in TG43) 33 of 43

34 Current Research in the UWMRRC Measurement of dose surrounding ebt sources Applicators and their effect on ebt dosimetry Relative biological effectiveness (RBE) 34 of 43

35 Measuring Dose Around an ebt Source Photograph courtesy of Sam Simiele 35 of 43 35

36 Applicators Common for brachytherapy intracavitary treatments For 192 Ir, metal applicators disrupt the dose distribution minimally Electronic brachytherapy will attenuate by a factor of 8! All lookup values should be applicator specific 36 of 43

37 Applicators 37 of 43

38 Measured vs Calculated Results Active area of research at UWMRRC by Sam Simiele Both bare and in applicator results show substantial disagreement between measured and predicted dose distributions Difficult to identify the source of the discrepancy Monte Carlo? TLD energy dependence? 38 of 43

39 RBE of ebt is under scrutiny RBE Lower energy, longer treatment times (~10-15 min for IORT) 192 Ir Xoft Axxent 39 of 43

40 RBE Recall, RBE depends on LET LET of 10keV x-rays is 10x higher than 1MeV x-rays RBE decreases with depth due to beam hardening Estimated to vary by a factor of 1.5 by Brenner et al of 43

41 Conclusions Recent years have seen a surge of new ebt manufacturers Current AAPM dosimetry protocols need revisions before being implemented for ebt NIST-traceable air-kerma standards have been established for the Xoft Axxent Model S700 source Research is underway in the UWMRRC to solve some of the remaining challenges 41 of 43

42 Acknowledgements UWMRRC students and staff UWADCL customers for their continued support 42 of 43

43 Questions 43 of 43

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