SonjaDieterich,PhD,DABR

StanfordUniversityHospital
EllenWilcox,PhD
StFrancisHospital,CT
CarloCavedon,D.S.
Ospedale SanBartolo,Vicenza,Italy
WithslidesfromRemyDurand,Huaying Ji,JosephNovotny

ConflictofInterest
SonjaDieterich hasaconsultingagreementwith

Cyberheart Inc.

LearningObjectives
Describethebasicconceptsofsmallfieldreference

dosimetry
Knowwhichdetectorsareappropriatetouse
Learntherightquestionstoaskwhenyouseeaplan
Beawareofwholebodydose

90% of attention goes to:

90%ofattentiongoesto:
SpatialAccuracy
Robotpointingaccuracy(calibrationverification):0.2mm

0.3mm
Closertoclinicalreality:Endtoend(E2E)
ManufacturerE2Espec:<0.95mm
Myclinic:0.3mm 0.7mm
IstarttoinvestigateifE2E>0.7mm
OlderpaperbyYuetal (E2E
(E2E=1.1mm)
1.1mm)

had2mmslice thickness
Knowndependencyofspatialaccuracyvs.slicethickness

1mmor1.25mmiscurrentlystandardslicethickness

Thinkofdosimetricaccuracyas
y
shiftingisodoselines

WhyisDosimetryimportant?
Inthebrain:
PreSRSAVMembolizationwithOnyxorglue
Nearcavitiesorsuperficialtumors
SRShasmovedoutsidethebrain:
Lung
L
Tspine
OurSmallFieldsaregettingsmaller
WhatistheWBdosefor85(!)lesions?

T bl f C
TableofContents
ReferenceDosimetry
Whatisasmallfield?
ThenewIAEAframeworkforSRSfields
Relative(Patient)Dosimetry
Dosecalculationalgorithms
Invivodosimetry
v vo dos et y
Wholebodydose

WhatisaSmallField?
Smallchangeswithtime:
Nolaterale equilibrium(quick:whatisthatfor6MV?)
<10mm
<4mm?
Challenges:
Ch ll
Howtobuildacollimator
Focalspotsizelargecomparedtocollimator
Inversesquarelawbreakingdown
Detectorresolution

WhyMicrobeams?
Functionaltargets:
Epilepsy,Parkinsons(fornon
DBScandidates))
Neurology:Facetblocks,
hyperhydrosis
Intractablepain(palliative,
capsulotomy)
ObsessiveCompulsiveDisorder
Intractable,severedepression
Intractable severedepression
(fMRI:hyperactivityofBrodmann
25)
Smallanimalapplications

R f
d
f
d d fi ld
Referencedosefornonstandardfields
TG51presentations: Musthave10cmx10cmfield
Gammaknife?Cyberknife?Tomotherapy?
y
py
Thesefieldsarenotflatoverdetectorvolume
IAEAandAAPMtaskgroupsonsmallfielddosimetry

The IAEA concept

TheIAEAconcept

(TG51)60mmconeforCK
Standardbeamdataacquisition(TPR,OCR)forCK:

80cmSAD

Howtoobtain100cmSSD?
Easy:moverobotup(byhowmuch?)

HowtoobtainkQ?
Noflatteningfilter
N fl tt i filt noproblem(seeDWORogers)
bl ( DWOR
)
Howtohandlegradientcorrections?

TG51output=1.0153cGy/MUatdmax
TG21output=1.0162cGy/MUatd
p
y/
y
max sameday
15

EffectsofDetectorSizeon
ReferenceDosimetry
1.2

0.8

plan

0.6

BeamData

0.4

0.2

0
30

-20

-10

10

No flattening filter: round edges

Length of Farmer ~ 2 cm

20

30

PracticalProcedure(1)
MoverobotuptoextendSSDto100cm.
Eqv
q square=0.9
q
9 Eqv
q circle*
Eqv square=0.9 6 100/80=6.75cm@100cmSSD
Measure%dd(10,6.75,100)withCyberKnife.
%dd(
)
h b
f
Compare%dd(10,6.75,100)withlocalorreferencedata

(e.g.BJRsup25
(e
g BJRsup25)
*

Day MJ & Aird EGA in BJR sup 25, 1996, p138-153

Jordan TJ in in BJR sup 25, 1996, p62 - 110

17

PracticalProcedure(2)
Takethecorresponding%dd(10,10,100)fromthe

referencedataset.
ObtainkQ with%dd(10,10,100).
ObtainPgr(10,10,100)fromreferencedata.
(10 10 100)fromreferencedata
ChangecalibrationconditiontoCyberKnife calibration

condition(SSDsetuptoSADsetup).
condition(SSDsetuptoSADsetup)

18

PracticalProcedure(3)
PerformmeasurementbaseduponstandardTG51

procedure.
MeasurePgr(CK)atthemeasurementpoint.
(CK)atthemeasurementpoint
Calculatedosetodmax:

DwQ

M N DQ, w
%dd

or TPR

M M raw P

Q
D,w

Co 60
D,w

kQ

Pgr (CK )
Pgr (10,10,100)

19

Example
1.
2.
3
3.
4.
5.
6.
7.
8.
9.

100cmSSD60mmcone,%dd(10,6.75,100)=64.02%.
SSD6

%dd( 6
) 6
%
%dd(10,10,100)=65.4%*.
Withthis%dd(10 10 100) kQ=0.9928.
Withthis%dd(10,10,100),k
=0 9928
Pgr(10,10,100)=0.9897*.
78.5cmSSD,60mmcone,%dd(10,5.3,78.5)=59.43%.
78.5
c SS , 60
co e, %dd( 0,5.3,78.5) 59.43%.
Pgr(10,5.3,78.5)=0.9878
CyberKnife newkQ =0.9909
TG51output=1.0153cGy/MUatdmax
TG21output=1.0162cGy/MUatdmax sameday
* Calculated from BJR data.
20

Back to: The IAEA concept

Backto:TheIAEAconcept

Example for a device: GK

Exampleforadevice:GK

Measuringeachfieldnotpossible
EvenwithPerfexion,8segments
Planclass:Isocentric,allbeams,defined
,
,

collimator

GKPlanClassSpecificReference
p
Calibration

VerificationofDoseCalculation

SuitableDetectors?
Plus:
Plus
BANGgels
Diamond
OLD

UncertaintiesforOutputFactors
Errorbarsgettinglarger
below20mm
MCofbeam
MC f b
MCofdetectors

Fi ld
D
Si
Fieldvs.DetectorSize
1.000

1.5cm
1 5cm depth
0.800

0.600

Widthofa
Wid h f

5c

7.5c

10c

12.5c

15c

site 5c

site 7.5c

site 10c

site 12.5c

site 15c

0.400

0.200

0 000
0.000
0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

PTW60012diode
comparedtosmall
collimatorOARs

Al ith i ( ld ) C i l SRS
Algorithmsin(older)CranialSRS
y
Aheadisverysimilartoa
sphere(surface
corrections!)
Fairlyhomogeneous
Nasopharynx
AVMembolizations

Densitycanbe

approximatedbyH
i t db H2O
(hencenoCTusedon
GammaKnife)

NeedforbetteralgorithmsinSRS
Mostsystemsusedpathlengthcorrection
Narrowbeams:
fielddimensionssmallerthenmaximumrangeof
secondaryelectrons
Steepdosegradients
Getsexacerbatedbytissueheterogeneity
Betteralternative:
Collapsedconeconvolutionsuperposition
MonteCarlo

Example:
Example:
6MVPhotonMonteCarlo
UseMCinalllungcases,Tspine,Head&Neck
Brain:supraorbital,pituitary,<1.5cmtoskin,embolized

AVM
Recalculationorreoptimization
Older(e.g.Raytracing)algorithms:
+8%14%offforRPClungphantom(RTOG0236)
Dosedifferencemaybemuchhigherforsmalllesions
D diff

b
hhi h f
lll i
( t %!)
(upto40%!)
Dosedifferenceofvarying%knownissueforall olderTx planning

algorithmsincombinationwithsmallbeams,not limitedto
C b k if
Cyberknife

ExampleI:DosimetryforSBRT
a p e : os et y o S

ExampleII:DosimetryforSBRT
a p e : os et y o S

Independent verification of MC
IndependentverificationofMC

RecentlygotapprovedforRTOG0618
RTOG0618=RTOG0236+inhomogeneity
3
g
y

corrections
Doneonamotionplatform
June 11, 2009

9th ISRS Congress, Seoul, Korea 2009

WhyInVivoDosimetry?
Why?

Challenges?

FramelessSRS

Fieldsize:noexitfieldfor

di d l
diodeplacement
SBRT:
Imaging:NospaceforEPID
Gating/ABC
(GammaKnife)
Motion
Motionadaptivewith
adaptivewith
Synchrony
Nonisocentricity
(Cyberknife)
Motionadaptivewithmoving
MLC
C
Fieldmatchingfor
retreatments

Justoneideaforinvivo
Antennaisverysimilartoagoldseed
Invasiveproceduretoimplantmarker
Implantable Dosimeter

11.25
25 mm CT slice thickness
Looks like two closely placed
fiducials!
Not uncommon in patients

01/26/2007

6th Annual Cyberknife Users Meeting

39

Whyisitimportant?
Wearetreatingbenign&functionalcases
Longsurvival
Pediatrics(protons!)
MUperdelivereddose
Theissues:
Whatistheerrorbaronsecondarycancerrisk?
Absolutevs.relativerisk
Absolutevs relativerisk
Delayedradiationresponse
Riskoftreatingvs.notreatment/othertreatments
Differenceinrisktolerance(e.g.RadOnc
Diff
i i k l
( R dO vs.Neurosurgeon)
N
)

GK: Extracranial DoseforSingle

Dose for Single
GK:Extracranial
Isocenter

Travel home safely!

Travelhomesafely!