Total Skin Electron Therapy

Wednesday, October 12th, 2011 Michael S. Curry, M.S.

TSET
TG-30
Introduction Requirements Techniques LINAC Operating Conditions Dosimetry and Instrumentation Patient Considerations

Commissioning TSET at MDACCO

Introduction to TSET
Diseases most commonly treated (require shallow Tx depths)
Cutaneous T-cell Lymphomas
Micosis Fungoides Sezary syndrome (less so than Micosis Fungoides)

Less commonly treated diseases

Kaposis sarcoma

Dose Scheme (TG-30):

Requirements
Beam
Specification of:
Field size, penetration, energy, depth, dose rate, field flatness in treatment plane, X-ray background, and the need and nature of boost fields

Room
Careful consideration of:
Space, shielding, ventilation, electron ranges

Beam Requirements
Field size 200 cm high by 80 cm wide Penetration depth Varies with stage, type of disease, and over the body surface Typically 5 15mm or more at the 50% isodose line Energy 3 to 7 MeV at patient treatment plane 4 to 10 MeV at beam exit window Dose rate In order to reduce Tx time high dose rates are desirable Range from 0.25 Gy/min to several Gy/min

Beam Requirements
Field flatness in the treatment plane Vertical uniformity of +-8%, Horizontal Uniformity of +-4% over the central 160 cm x 60 cm area X-ray background Penetrating and forward directed Exposes most of body and should be ALARA Can be reduced by angling beams such that the x-ray peaks lie outside the body Desired to be 1% or less averaged over the entire body (typically 1-4%) EORTC spec < 5% Need and nature of boost fields Some body areas are unintentionally shielded by other body sections or inadequately exposed due to limitations of beam geometry

Profiles
Left: 6E 10x10 surface Right: 6E HDTSE (no cone, 10x10 XY jaws)

Room Requirements
Space
In order to provide good dose uniformity large distances are needed Typically 2-7m from scatterer and patient (depending on technique)

Ventilation
TSET involves significant ozone production from ionizing large volumes of air in the treatment room Frequent exchange of air is essential for confining ozone exposure

Shielding
Typically MV X-ray shielding is adequate, but should measure Electron Ranges
Max track length range of ~0.5 g/cm2 per MeV (~4 m/MeV) in air Range is typically not in direction of beam, most stop far short of this

Bremsstrahlung

Techniques
Why do we need special techniques, are large AP/PA fields not sufficient?
No, they are not sufficient:
Patients body shape is not flat Dose uniformity impossible with AP/PA

Techniques

Flat = good Round = bad

Techniques
How do you treat curved surfaces?
Multiple fields Electron arcs

Techniques
Prior to use of LINACs
Beta Particles
Beta-particle beams used Sr/Y-90 with Emax=2.18 MeV Use 10% isodose line and deliver 2Gy/fx in 15 min fx by scannins over a patient surface 60 cm x 180 cm

Narrow rectangular beams

Use Van de Graaf accelerators in fixed positions with vertically downward beams Patient translated horizontally on a motor driven couch under the 1.5 to 4.5 MeV beam

Techniques
Used with LINACs
Scattered single beam
6.5 MeV beam with 0.15mm thick titanium scattering foil placed 10 cm from accelerator window Shaped polystryrene beam-flattening filter mounted on front of treatment head Producing a flattened 4 MeV beam at the Tx plane

Pair of parallel beams

2 horizontal parallel beams with axes contained in a vertical plane (axes seperation=150cm) with Tx distance of 2m 8MeV linac with carbon energy degraders just beyond exit window Adjusting thicknesses adjusts depth of penetration in patient X-ray background=2%

Pair of angled beams

Stanford Technique

Stanford Technique
Most commonly used technique Utilizes 6 dual fields
Each dual field is comprised of two angled beams
Typically 18 to 20 from 270 or 90 gantry position

The 6 fields correspond to 6 different patient treatment positions

Provides acceptable dose uniformity

3 sets of dual fields treated per day

Stanford Technique

Stanford Technique

Stanford Technique

Mayo Clinic Jacksonville TSET Technique

IMPAC Rx and Tx fields Each day 6 fields (upper and lower of 3 fields), e.g. 1U,1D,2U,2D,3U,3D

Mayo Clinic Jacksonville TSET Technique

University of Iowa TSET Technique

University of Iowa TSET Technique

Tray allows 40 x 40cm field size

University of Iowa TSET Technique

EORTC: R80 > 4mm, R20 < 2cm

University of Iowa TSET Technique

University of Iowa TSET Technique

Techniques
Used with LINACs
Pendulum-arc
8 MeV beam with the gantry rotated continuously during treatment in a 50 arc (six fields) Arc starts from an initial angle with CAX above the head and ends with CAX below the feet Degrader: large 1 cm thick plexiglass sheet 5cm from the patient Provides large angle electron scattering near the patient

Patient Rotation
Use single horizontal 6 MeV beam (3.5 MeV at Tx plane) with a scatterer near the exit window and a 7 m treatment distance X-ray background = 2.2% Reduced setup and Tx times as well as simplified beam matching Self shielding by limbs is unavoidable

Pendulum Arc

Patient Rotation

LINAC Operating Conditions

LINAC operating perameters
Stable, Repeatable operating energy is essential
Energy changes can shift large SSD fields laterally and change dose calibration and uniformity

High average beam current (100 times normal electron beam) for high dose rate (>1Gy/min) at Tx plane

Beam scatterer-energy degraders

Scatterers are thin materials used to spread out the beam Energy degraders are thick materials used to reduce beam energy at the Tx plane Can be placed internally in the Tx head or externally
Location and Materials used are important in determining dose rate

X-ray background is least when scattererdegrader is close to patient (~15mm from pt)

LINAC Operating Conditions

Beam Monitoring
Typically monitor electron fluence rate or dose rate at Dmax Monitor response should be directly proportional to parameter of interest Acceptable monitors include:
Built-in transmission ion chambers, secondary electron emission monitors, and electromagnetic induction monitors

Should be placed where beam exits accelerator A common combination for TSET monitoring:
a full-beam transmission ionization chamber at or within the treatment head a sampling chamber or electron collector placed at or near the patient Tx plane but not in line with the patient

Dosimetry and Instrumentation

Methods
Acceptable detectors:
ion chambers, film, TLD, Fricke dosimeters, electron collectors, and faraday cups

Ion chambers (small thimble or small volume/thin window p-p) are recommended for scanning in a water tank If film is used with solid water, no air gaps should be present
Might be difficult if film is in a package

Phantoms
Square water phantoms are recommended for depth dose data Otherwise, layered, flat phantoms made of conducting plastics or thin laminae of polystyrene with conductive graphite coatings are recommended for depth dose and buildup data Elliptical, oval or cylindrical phantoms are recommended for simulating a patients body

Dosimetry and Instrumentation

Measurements
Energy
Determined from depth ionization curve and the range-energy relationship given in section 2.1 of TG-30:

Fluence
Evacuated Faraday cup with collimator placed over the aperture Electron fluence is determined from the charge collected and the area of the collimator This fluence can be used to estimate entrance surface dose

Depth dose
Using a parallel-plate chamber overlayed with varying thicknesses of polystyrene EORTC: R80 > 4mm, R20 < 2cm

Dosimetry and Instrumentation

Calibration Point Dose Measurements
TG-30 recommends that TSET absorbed dose be evaluated at a point (0,0,0) see figure The TG-21 protocol should be followed for calibration using data for electron energy of 0 determined from R50 ( ) A p-p chamber with known Ngas is recommended The chamber surface should be placed at dmax using polystyrene The rest of the chamber should also be surrounded with polystyrene
1 cm posteriorly and 5 cm radially

Expose the chamber to a single dual-field

Dosimetry and Instrumentation

Treatment Skin Dose Measurements
Treatment skin dose is defined as the dose along a circle at or near the surface of a cylindrical polystyrene phantom 30 cm in diameter and 30 cm high which has been irradiated as a hypothetical patient with all 6 dual fields.
During irradiation the phantom is outfitted with appropriate dosimeters These dosimeters are calibrated with a single dual field Therefore calibration point dose is related to treatment skin dose by a factor B (typical values between 2.5 and 3.1)

Patient Considerations
Positioning
Patient should be positioned to minimize self shielding

Support devices
Patients may have trouble standing Should be prepared with multiple alternative positioning methods

Shielding
Lenses of the eyes can be shielded by placing high Z material either over or under the eye lids Finger and toe nails can be shielded with thin sheets of lead cut to size

Shielding

University of Iowa TSET Shielding

Patient Considerations
Boost Fields
Typically the Soles of the feet, the perineal area, the dorsal surface of the penis, peri-anal skin, and the inframammary region of large breasted women Areas requiring a boost are determined by in-vivo dosimetry

In-vivo dose measurements

Important for 2 reasons:
1. determination of the distribution of dose to the patient's skin 2. verifying that the prescribed dose to the patient's skin is correct

In-vivo dosimeters include:

Ion chambers, diodes, film, TLDs, OSLs, MOSFETs Ion chambers and diodes are impractical due to the number required (at least 40) TG-30 recommends TLDs for In-vivo dosimetry (could argue for OSL or MOSFET too)

Boost Fields

Commissioning
LINAC must be capable Room must be large enough Determine a Beam monitoring approach Decide on a technique Build or purchase patient support system Create a written procedure for changing from conventional modalities to TSET and back to conventional Determine an In-vivo dosimetry protocol

TSET at MDACCO
IX Vault Patient Support System Stanford Technique In-Vivo Dosimetry system

In-Vivo Dosimetry system

Landauer OSL system (InLight microStar)
Carbon-doped aluminum oxide (Al2O3:C) Similar to TLD except use LED light for stimulation instead of heat
The light used is of a specific wavelength

The stimulation process doesnt anneal the OSL

OSL can be read multiple times and or stored as record of delivered dose

Independent of energy for 6 and 18 MV beams Response increases linearly with dose rate Time resolution = 0.1s, Spatial resolution <0.5mm Readings compare well with TPS calculations

Review
What is TSET e- beam energy?
Nominal? 9 MeV At pt surface? 4 MeV

What are differences between clinical e- beam and TSET beam? Higher dose rates; Larger Field Sizes; No Cones What are common Tx indications for TSET?
T-cell Lymphoma (micosis fungoides) Doses? 36Gy in 9 fx

Describe one technique for delivering TSET.

Stanford Technique