Upload
others
View
1
Download
0
Embed Size (px)
Citation preview
1
Skin Applicators: Radionuclide based (Valencia) &
electronic (Esteya)
J. Perez-Calatayud, C. Candela, T. García, J. Bautista, V. Carmona, F. Lliso, J. Gimeno, J. Richart, R. Ballester, O. Pons, R. Botella, F. Celada, M. Hernández, A. Ballesta, S. Rodríguez, M. Santos, A. Tormo, F. Ballester
Manchester Clinical Workshop, Jan 21-22, 2016
Disclosure
Research support received from:
• Elekta-Nucletron: Valencia Applicators, Freiburg flap, QA tools, MRI dummies, MC sources, electronic BT: ESTEYA
• PTW: Well chamber inserts, QA tools
La Fe Hospital& Valencia University & Benidorm ITIC
2
3
Content
• Background
• Valencia vs Leipzig
• Esteya vs Valencia
• Commissioning
• QA & Periodic test
• Clinical implementation
• Conclusions
4
Skin radiotherapy
Small PTV cases: (area < 3 cm) and depth <3-4 mm
Difficulties using electrons (bolus, specific dosimetry)
Difficulties using flaps & moulds
Brachytherapy Skin applicators
Treatment planning & delivery simpler
High protection surrounding tissue
Radionuclide HDR Applicators (Leipzig & Valencia)
Electronic BT Applicators (Xoft & Esteya)
5
Leipzig Applicattors
Courtesy: Varian
Court
esy:
Nucle
tron-E
lekta
Cup-shaped of tungstenHorizontal and VerticalDiameters 1 cm, 2 cm, 3 cm
Plastic cap 1 mm, to reduce skin dose due to electrons
6
Leipzig vs Valencia (Elekta)
Lateral homogeneity, penumbra, and useful beam are improved
longer treatment time
Granero et al 2008
Valencia App: new design
Extra shield to reduce tip dose
Granero, Perez-Calatayud, Ballester, Ouhib EJMP 2012
lateral nose eye dose
Same absolute dose distribution as in previous models
7
8
Plastic cap: To avoid electron contamination
Valencia Applicators: Cap
9
Plastic cap:To avoid electron contamination
Applicators: Clinical implementation
Granero et al (accepted Med Phys)
10
In Progress: New Valencia
Esteya (Elekta)
Designed to obtain dose distributionssimilar to Valencia App
X-ray source 69.5 kV
Adjustable arm
10-30 mm App
Console includes: patientadministration, control Unit (timers, interlocks,…) QA and treatment planning
After dose per fraction, depth and applicator size are selected, the system presents automatically thetreatment time ¡
11
!
Esteya vs. Valencia PROFILES
12Penumbra: 1.1 mm vs. 1.9 mm
Esteya vs. Valencia PROFILES
Esteya (3 cm colimator)
Valencia applicator (H3)
SSD 6 cm
SSD 1.6 cm
13
Esteya vs. Valencia PDD & Output
14
Gradient
Valencia
Esteya
7 Gy treatment time Esteya Valencia H3
App 3 cm @ 3 mm 153s 449-898 s
12% / mm
8% / mm
Garcia et al 2014
Esteya Leackage
15
Leackage < 2 Gy/s < 0.01% of the delivered dose
Garcia et al 2014
Esteya shielding requirements
16
Work in progress
B. Ibañez, J. Bautista, C. Candela, J. Richart, I. Villaescusa, F. Ballester, J. Perez-
Calatayud. AAPM Annual Meeting Anaheim 2015. Med Phys 42(6) 3495
Exp derived scatter and leackage + 5 cm tissue attenuation
Primary
Secondary
0.82 mm Pb
0.34 mm Pb
1.61 mm Pb
0.71 mm Pb
W: 20 fx/day, 7 Gy/fx
d=1.5 m
T=1
U=1
P=0.02 mGy/week
NCRP-145
Commissioning VALENCIA
Data for clinical use
17EXP validated Monte Carlo
PDD & Output
Granero et al 2008
Valencia H3
http://www.uv.es/braphyqsF. Ballester
Commissioning VALENCIASID & Flatness & Symmetry
18
FILM
MULTICHAMBER ARRAY
1319 mm
1320 mm
1321 mm
Commissioning VALENCIA
19
FILM
MULTICHAMBER ARRAY
1319 mm1321 mm
SID & Flatness & Symmetry
Commissioning VALENCIA
MC Output check
20
Small volume chambercalibrated Co-60 (eg PTW
Markus or PTW PinPoint)
CF reference values for HDR 1000Plus (SI) and TM3304 (PTW)
Perez-Calatayud 2006
Granero 2008
Granero 2012
Commissioning VALENCIA
21
CF reference values for HDR 1000Plus (SI) and TM3304 (PTW)
Perez-Calatayud 2006
Granero 2008
Granero 2012
Commissioning VALENCIA
22
CF reference values for HDR 1000Plus (SI) and TM3304 (PTW)
Perez-Calatayud 2006
Granero 2008
Granero 2012
Revised according to Comments Gotts MP 2012
Reply Med Phys April 2012
Commissioning VALENCIA
23
TPS implementation
Not possible on TG-43 based TPSLibrary plan: 1 dwell position +1 dose point in which the dose rate is equal to the output
Commissioning VALENCIA
24
TPS implementation
Library plan: 1 dwell position +1 dose point in which the dose rate is equal to the output
F is used for PDD
F=1 when prescription is done at 3 mm
Data for clinical use
25Automatic treatment time calculation
PDD & Output not accesible to user
Esteya
App size + depth + dose
Commissioning ESTEYAFlatness & Symmetry
26
FILM
MULTICHAMBER ARRAY
TG profileLR profile
Commissioning ESTEYA
HVL
27
Set-up according TG-61 and TRS-398
Aluminium slabs
Barracuda (solid state) and 0.6 cc farmer
1.88 mm Al 2.09 mm Al
Garcia et al 2014 Candela-Juan et al 2015
Esteya
X-ray Tube
Al slabs
Detector
55 cm
50 cm
To quantify the quality for theselection of the correctionfactors.
Goals
Methodology
Commissioning Virtual Focus
28
Esteya and A20
2
0
0 0
1 1 1
( )
cd
c d c
SSD dx x d
SSD d d x x SSD d x
Nominal
Measured
To apply the inverse square law from the effective measuring point of the chamber to the surface
60 mm
59.0 ± 0.7 mm
Candela-Juan et al 2015
xd : reading of the chamber when its top surface is placed at
a distance d from the collimator surface.
x0 : reading of the chamber for d = 0.
dc : depth of the effective point of measurement.
SSD : source to applicator surface distance.
considering dc = 1.8 mm
Commissioning
PDD
Soft X-ray paralell-plate chamber. PTW T34013: 0.0053 cc volume, entrance window thickness 0.03 mm, active diameter 1.7 mm
Plastic water Low Range (CIRS), density 1.03 g/cc.
Typical PDD range for all App: 1% (3 mm) 4% (10 mm)
Garc
ia e
t al 2014
Esteya
29
Commissioning
Absolute surface dose rate
Method I Measure in solid water with a chamber calibrated in absorbed dose to water
30
0.005 cm3 Soft X-ray chamberType 34013
dc=0.25 mm
Commissioning
Absolute surface dose rate
Traceable to PTB (Germany)
0.005 cm3 Soft X-ray chamber, Type 34013
(k=2)
Calibrated with beam size Ø = 3 cm, with SSD = 75 cm.
Commissioning
Absolute surface dose rate
Method I Measure in solid water with a chamber calibrated in absorbed dose to water
32
TRS-398
0.25 mm for T34013 (PTW)
6 cm (Esteya) 1.00 for T34013
From calibration certificate
KpT
Kion
Kpol
Kelec
1.000 More direct and robust¡¡
Commissioning
Absolute surface dose rate
Caution: Equivalence plastic water with liquid water
33
Hill et
al 2010
Difference (%) in the dose to a small voxel of water located on the surface of
the phantom material relative to the surface dose in a water phantom
CIRS Plastic Water Low Range: 0.2%
Candela-Juan et al 2015b using MC Penelope with Esteya spectrum
Hill et al 2014
Summary suitable/unsuitable
phantoms for kV dosimetry
Commissioning
Absolute surface dose rate
Method II Measure in air with a chamber calibrated in air kerma
34
0.074 cm3 Exradin A20
Commissioning
Absolute surface dose rate
35
±1% (k = 2)
ADCL Wisconsin USA
No available the calibration in water
Calibrated with beam size 10x10 cm2, with SSD = 100
cm.
Commissioning
Absolute surface dose rate
Method II Measure in air with a chamber calibrated in air kerma
36
TG-61
From Table V TG-61
Depends of: SSD, Ø, HVL
KpT
Kion
Kpol
Kelec
1.000
From calibration certificate
1.80 mm for A20 (SI)
6 cm (Esteya) 1.00 for A20
From Table IV TG-61
Depends of HVL
37
T34013 chamber in plastic water
T34013 chamber in air
Exradin A20 chamber in air
Med Phys 2015
Relative difference (%) between the surface dose rates measured and
the surface dose rates included in the Esteya console.
(±2.3%) (±2.7%) (±2.5%) (k=1)
Commissioning
Timer
38
Tests
Reproducibility
Accuracy
Linearity
Surface dose, D (Gy) Intensity
D > 4 Gy 1.6 mA
2Gy < D ≤ 4 Gy 1.0 mA
D ≤ 2 Gy 0.5 mA
IONIZATION CHAMBER
Material
JCB 2015JCB 2014
Commissioning ESTEYA
39
Applicator interlocks
Indicators
Door interlock (if required)
Radiation area monitor (if required)
Emergency buttons
Arm movements
Console calculation
Timer: reproducibility and accuracy
Timer: main power interruption
QA & Periodic test Valencia
40
Independent calculation
Each calculated plan
41
Weekly Chart QA
QA & Periodic test Valencia
QA & Periodic test Valencia
42
Source To Indexer Distance
Flatness & Symmetry & Penumbra
Output
HDR Ir-192 Source ex change (approx 3-4 moths)
QA & Periodic test ESTEYA
43
Independent calculation
Each calculated plan
QA & Periodic test ESTEYA
44
Weekly Chart QA
45
Periodic tests ESTEYA
Esteya
Self-test
Indicators, interlocks and emergency buttons
Visual inspection of applicators
Output, flatness, PDD constancy
Each treatment day
TG-40 AAPM
TG-56 AAPM
TG-158 AAPM
ESTRO Booklet 8
Eaton 2015 (eBT review)
Manufacturer
Diode QA tool
Specific to daily evaluate constancy of output, flatness, symetry and PDD: 26 diodes
Periodic testQA tool
OK:
Surface Dose Rate Change < 2%
PDD 5 mm Change < 2%
All 9 flatness changes < 2%
Measured radiation time is within 1% of the planned radiation time
Esteya
In our center, change in surface dose rate: +0.5% after 1 year
47
Periodic tests
Flatness & symmetry for the 30 mm app
Output and PDD (0 and 3 mm depth) for the30 mm app, with ionization chamber
Monthly Quarterly
3%
2%
Semiannual Annual
Flatness, Output and PDD (0 and 3 mm depth) for ALL app.
2%
JCB 2015
TG-253 (AAPM-ESTRO) Surface Brachytherapy
R. Fulkerson, J. Perez-Calatayud, F. Ballester, I. Buzurovic, D. Harrington, Y. Kim, Y. Niatsetski, Z. Ouhib, S. Pai, M. Rivard, Y. Romg, T. Rusch, FA Siebert, B. Thomadsen, F. Weigand
Societal Recommendations
“Aspects of Dosimetry and Clinical Practice of Skin Brachytherapy: The
American Brachytherapy Society Working Group Report”
Z. Ouhib, M. Kasper, J. Perez-Calatayud , S. Rodriguez, A. Bhatnagar, S.
Pai, J. Strasswimmer.
Brachytherapy 2015
Recommendations Commissioning and QM program for surface brachytherapy
Methods, detectors, traceability, periodic test: frequency & tolerance, and QM under the TG-100 (FMEA) perspective
Future TG-253 Recommendations
TG-100 FMEA approach
Future TG-253 Recommendations
Clinical implementation
HFUS
51
Depth determination
Superficial Nodular
High resolution B-scan with 18 mHzhand-held transducer (Siemens AcusonS2000). Gel pad 2 cm x 9 cm (Aquaflex)
Clinical implementationUS vs. punch biopsy
52
Depth determination
Superficial Nodular
3 mm diameter punch biopsy on thedeepest site estimated clinically. Depthevaluated with Leica DMD108 digitalmicroimaging network
Ballester, JCB in press
prescribe at 3 mm depth when HFUS measurements give values smaller than this umbral one
53
US for depth evaluation and follow-up
Longport Episcan 35MHz
Courtesy Dr E. AllenChristie Hospital
?
Project in evaluation La Fe: US vs OCT vs MRI vs Biopsy
Clinical implementation
Templates: useful beam and outer app contour 54
Patient marking
Clinical implementation
Templates LA FE: useful beam and outer app contour
55
Patient marking
Available FREE under request to [email protected] to the funding of Elekta (from April 2016)
56
Set-up
Applicators: Clinical implementation
10%/mm
Good contact without gaps
Clinical implementation
Valencia
57
Patient Set-up
Protective condom
Clinical implementation
Esteya
58
Patient Set-up
Plastic wrap
Esteya arm with freedomdegrees and approach tool
Clinical implementation
59
Patient Set-up
Approach tool to get full contact
BT skin Apps are very efficient with respect to treatment planning and delivery. Applicator shielding results in high protection of surrounding tissue.
Commissioning and QA procedure is well established.
Esteya is a new electronic brachytherapy system. Compared with the Valencia App there are improvements of penumbra, treatment time, gradient on PTV, leakage.
The low energy and tungsten shielding allows treatment in a minimally shielded environment.
Clinical implementation of both Valencia & Esteya are well established and allow to use a hypofractionated protocol
Conclusions
61
References Valencia Group I
“Design and evaluation of a HDR skin applicator flatering filter” D. Granero, J. Perez-Calatayud,
J. Gimeno, F. Ballester, E. Casal, V. Crispin, R. van der Laarse. Med. Phys. 35(2) 495-503
(2008)
"Dosimetric evaluation of internal shielding in a high dose rate skin applicator" F. Lliso, D.
Granero, J. Perez-Calatayud, V. Carmona, Ma Carmen Pujades, F. Ballester. J. Contemp
Brachyther 3(1) 32-35 (2011)
"Correspondence: Reply to “Comments on “Correspondence factor for Nucletron surface
applicators”"”
D. Granero, J. Perez-Calatayud, F. Ballester, V. Crispin, E. Casal, J. Gimeno, R. vd Laarse Med
Phys 39(4) . 2310-2311 (2012)
"Radiation leakage study for the Valencia applicators" D. Granero, J. Perez-Calatayud, F.
Ballester, Z. Ouhib.
E. Journal Med. Phys. 29, 60-64 (2013)
"Dosimetric characteristics of a new unit for electronic skin brachytherapy" T. Garcia-Martinez,
J-P. Chan, J. Perez-Calatayud, F. Ballester J. Contemp Brachyther 6(1) 1-9 (2014)
"Non-melanoma skin cancer treated with HDR Valencia applicator: clinical outcomes" A. Tormo,
F. Celada, S. Rodriguez, R. Botella, A. Ballesta, M. Kasper, Z. Ouhib, M. Santos, J. Perez-
Calatayud..J. Contemp Brachyther 6(2) 167-172 (2014)
62
References Valencia Group II
"Clinical implementation of a new electronic brachytherapy system for skin brachytherapy" O.
Pons, R. Ballester, F. Celada, C. Candela, T. Garcia, M. Llavador, R. Botella, C. Barker, A.
Ballesta, A. Tormo, S. Rodriguez, J. Perez-Calatayud..J. Contemp Brachyther 6(4) 417-423
(2014)
"Depth determination of skin cancers treated with superficial brachytherapy: ultrasound vs
histopathology"
R. Ballester, O. Pons, M. Llavador, R. Botella, A. Ballesta, A. Tormo, F. Celada, S. Rodriguez,
M. Santos, F. Ballester, J. Perez-Calatayud. J. Contemp Brachyther 6(4) 417-423 (2014)
"Commissioning and periodic test of the Esteya electronic brachytherapy system" C. Candela-
Juan, Y. Niatsetski, Z. Ouhib, F. Ballester, J. Vijande, J. Perez-Calatayud.J. Contemp Brachyther
7(2) 189-195 (2015)
“Efficacy and safety of electronic brachytherapy for superficial and nodular basal cell
carcinoma“.R. Ballester, O. Pons, C. Candela-Juan, F. Celada, B. de Unamuno, M. Llavador, A.
Ballesta, C. Barker, A. Tormo, R. Botella, J. Perez-Calatayud. J. Contemp Brachyther 7(3) 1-8
(2015)
"Comparison and uncertainty evaluation of different calibration protocols and ionization
chambers for low-energy surface brachytherapy dosimetry”. C. Candela-Juan, J. Vijande, T.
García-Martínez, Y. Niatsetski, G. Nauta, J. Schuurman, Z. Ouhib, F. Ballester, and J. Perez-
Calatayud.. Med. Phys. 42 (2015) 4954-4964