Patient Received Dose From Daily Cone Beam Imaging Alison Malavite 12/02/2013

Cone-beam computerized tomography (CBCT) systems incorporated in the gantry of a linear accelerator can be utilized to obtain volumetric images of a patient to verify treatment position. Using CBCT, patient positioning may be precisely determined and then adjusted so the intended treatment may be delivered to the planned target volume. However, while imaging of a patient is beneficial in determining accurate set-up positions before beaming on, dose due to this single volumetric imaging acquisition on a repeated daily basis can potentially add up to a substantial dose to normal tissues. If daily cone-beam dose significantly accumulates during a patients treatment course, then increased negative radiobiological effects to normal tissue surrounding the target volume may transpire. The purpose of this study is to quantitatively evaluate the dose from on board imaging (OBI) cone-beam systems, determine measurements to the whole body, and assess techniques to reduce this imaging dose. According to researchers from the University of California San Diego, radiation doses received by patients that undergo daily image-guided cone-beam computed tomography have become an increased clinical concern1. Therefore, in order to evaluate the given CBCT dose from such OBI systems, water phantom dose measurements, 25 brain cancer patient measurements and 25 prostate cancer patient measurements were studied in order to determine the doses deposited within them1. Over the years, research has been conducted using thermoluminescent dosimeters (TLDs) and ion chambers to assess the CBCT dose in water phantoms and anthropomorphic phantoms1. The issue with the acquired results is that they cannot be directly interpreted to real individual patient cases and anatomy. Therefore, Montanari conducted actual patient studies utilizing current CBCT protocols1. Firstly, results

showed that the dose distribution is highly non-homogeneous as it penetrates through an actual patients body1. Mean dose to critical organs were found to be significantly variable from patient to patient1. Furthermore, the highest computed dose inside each organ was much higher, 1 to 3 times respectively, than the calculated mean of the organ and 8 times higher to the entire body1. The accuracy of the results were calculated compared to dose measurements1. Overall, the mean dose accumulated was higher in actual patients than when measured through phantoms, however the doses amounted to still be small, in the order of mGy or cGy1. During a long treatment course, these results may be useful to manage any side effects that could occur to such accumulations, but in short stereotactic treatment courses, these results may be negligible depending on the patients individual body type and physicians concern. As important as it is to verify patient positioning to treat the planned target volume as conformal as possible, it is also essential to limit the dose to the surrounding normal tissues of a patient. Utilizing CBCT technology to improve patient positioning accuracy also contributes to increasing a patients integral dose2. In a study conducted by researchers in Switzerland, this dose was measured. In an anthropomorphic phantom, imaging dose distribution measurements to the whole-body were recorded through the use of 184 thermoluminescent dosimeters2. The effective dose and average organ dose were calculated and compared to the effective dose from therapeutic stray radiation outside the planned treatment volume2. Results showed that imaging dose additionally to treatment stray dose from kilovoltage (KV) or megavoltage (MV) CBCT varied between 8 and 46 mSv, 5% and 30% respectively2. Whereas additional effective imaging dose outside of the treated volume from 2 planar KV images ranged less than

0.4 mSv2. Similar to conclusions made in the previous study, megavoltage or kilovoltage cone beam computed tomography should be utilized on an individual patient basis or protocol2. While weighing the costs of CBCT such as increasing the dose distributed to normal surrounding tissues, which increases the possibility of creating adverse side effects in such tissues, the costs of not using CBCTs would be more detrimental due to the loss of dose accuracy. Researchers Ding and Munro conducted a study in search of image guidance techniques that reduce such imaging dose3. Monte Carlo techniques and treatment planning systems were used to measure dose deposited in anatomic areas of the head, chest and pelvis3. The following measured techniques results are in the order of highest dose to anatomic structures to lowest: 6 MV portal imaging, Varian OBI CBCT, Varian TrueBeam CBCT, and kV radiographs3. In the same order, results show doses for the 50% volumes (D50) from the dose volume histgograms (DVHs) to critical organs in the head, chest and pelvis3. In the head, the left and right eyes received 4.3-4.8 cGy, 0.05-0.06 cGy, 0.04-0.05 cGy, and 0.12 cGy3. In addition, doses to the eyes can be reduced further from 0.12 cGy when using right and AP kV radiographs to 0.008-0.017 cGy when reorienting the kV beam direction to right and PA3. Furthermore, the dose of 0.008-0.017 cGy when using a right and PA beam orientation can be reduced to 0.003 cGy when using a full-fan bow-tie filter in the beam to minimally attenuate the center of the kV field along with the right and PA radiograph 3. The results were as follows for the D50 to the heart of the chest: 3.5 cGy, 0.42 cGy, 0.2 cGy, and 0.07 cGy3. As shown with the doses to the head, when using full-fan bow-tie filters in the chest, organ exposure can be further reduced with kV radiographs by 15-

70% of their original values3. D50 to the bladder for the pelvis are: 3.3 cGy, 1.6 cGy, 1.0 cGy, and 0.07 cGy3. Researchers also found that if a full-fan bow-tie filter is not used while imaging with a kV CBCT technique, organ exposure can increase by 2-4 times in the pelvis3. Overall, findings indicated that portal imaging with an MV technique resulted in 2-10 times higher organ dose than when using a kV energy3. Also, kV imaging doses can be further reduced by: 1) reorienting the beam direction for radiographs to a PA and right lateral view instead of an AP and right lateral exposure for the head (this reduces the dose by ~7 times), and 2) rotating the kV source behind the head instead of across the face for CBCT to reduce the organ exposure by a factor of ~33. Lastly, bow-tie filters can be used to reduce dose to the skin surface and superficial organs 3. In a treatment situation where the doctor prescribes a daily cone beam, field sizes can be reduced to decrease the volume of tissue irradiated, CBCT settings can be adjusted on an individual patient size basis, and beam directions that will minimize imaging dose along with full-fan bow-tie filters will lower the daily dose received by the patient from imaging orders3. With the increase in dose conformity to tumors, patient-positioning accuracy is essential so target volumes are not missed and minimal margins can be drawn. However, in order to position patients so external and internal landmarks coincide, imaging is required. With tumors that are close to critical organs such as in the head, chest and pelvis, margins are tighter and require daily cone beam acquisitions. According to the research reviewed above, doses to the patient are a bit higher than originally calculated through the use of phantoms due to high dose deposits inside of organs1. Also, unlike the actual treatments that are highly conformal to the tumor, CBCT

imaging scatters dose to the entire body2. However, techniques can be employed so that this total body dose is limited as much as possible 3. The main flaw with the research I noticed was that dose measurements were not all done on the same phantoms or patients. Each study obviously conducted their measurements with different tools so if there were any mechanical discrepancies between each institutes calibration, those discrepancies would reflect in their results. Potential steps to improve this problem would be to re-conduct all of the research at one facility so this bias between systems would not be existent.

Bibliography

1) Montanari D, Scolari E, Silvestri C, et al. Comprehensive Evaluations of Cone-beam CT dose in Image-guided Radiation Therapy via GPU-based 5 Monte Carlo simulations. Medical Physics. 2013; 1-19. http://arxiv.org/pdf/1309.5044v1.pdf . Published September 19, 2013. Accessed November 28, 2013.

2) Halg RA, Besserer J, Schneider U. Systematic measurements of whole-body imaging dose distributions in image-guided radiation therapy. Medical Physics. 2012;39(12);7650-7661. doi:10.1118. http://scitation.aip.org.proxy.lib.ohiostate.edu/docserver/fulltext/aapm/journal/medphys/39/12/1.4758065.pdf?expires=13857 57602&id=id&accname=407186&checksum=95B7EE741A859380E881F94C835240B8 .Published December 3, 1012. Accessed November 28, 2013.

3) Ding GX, Munro P. Radiation exposure to patients from image guidance procedures and techniques to reduce the imaging dose. Radiotherapy and Oncology. 2013;(108);91-98. http://journals.ohiolink.edu/ejc/pdf.cgi/Ding_George_X.pdf?issn=01678140&issue=v108i 0001&article=91_retpfittrtid .Published May 9, 2013. Accessed November 28, 2013.