| Περίληψη: | The risk of secondary cancer associated with low doses of ionizing radiation, is gaining new interest every day, especially in long term surviving patients. The unavoidable amount of the scattered dose, which is absorbed by radiosensitive tissues/organs away from the irradiated treatment site, known as peripheral dose (PD), is the outcome of secondary irradiation sources while it influences the treatment parameters. Since the associated cancer risk is likely to be much lower but not insignificant from such low doses this may affect the choice of treatment options adopted. In this study, we performed measurements in a water phantom in order to indicate the trends of the PD from conventional radiotherapy and to demonstrate the influence of typical treatment parameters, such as the distance, the depth, the field size and the energy using the mobileMOSFET dose verification system. The PD is given as a function of the above treatment parameters and a comparison was made with an ionization chamber. In the same way measurements are presented in an anthropomorphic phantom and a comparison of the results between the mobileMOSFET dose verification system and the treatment planning software is given. Finally, the PD measurements were performed in preselected areas outside the treatment field in patients undergoing 3D conformal radiotherapy treatment and since, modern treatment modalities such as the stereotactic radiosurgery/radiotherapy (SRS/SRT) procedures consolidate more and more in the treatment of benign and malignant disease, we investigated the PD in patients undergoing intracranial and extracranial treatment with Cyberknife, before and after the shielding upgrade, and demonstrated the influence of the monitor units (MU) and the size of the collimator. A discussion for the potential of stochastic radiation induced effects with both treatment modalities is also given.
Peripheral dose (PD) is strongly dependent upon the irradiation parameters selected during the treatment planning procedure such as the distance, the depth, the field size and the energy of the photon beam. More specifically, PD decreases almost exponentially with the increase of distance. Close to the edge of the field, the internal scattered radiation from the patient is the predominant source of secondary scattered dose. As the distance from the field edge increases, the radiation scattered by the collimator, and the machine leakage become predominant. On the other hand, the PD is higher near the surface and drops to a minimum at the depth of dmax, and then the PD tends to become constant with depth. Closer to the field edge, where internal scatter from the phantom dominates, the PD increases with depth, because the ratio of the scatter to primary increases with depth. A few centimetres away from the field, where collimator scatter and leakage dominate, the PD decreases with depth, due to the attenuation by the water. Finally, PD is significantly higher for larger field sizes, due to the increase of the scattering volume and as the energy increase the PD increases too.
According the results of PD measurements with the 3D conformal radiotherapy treatment, the mean PD in the thyroid gland, expressed as a percentage of the prescribed dose (%TD), was 1.43 %, 9.85 %, 7.27% and 2.02 %, corresponding to whole brain irradiation, mediastinum treatment, and breast treatment with and without the irradiation of supraclavicular and axillary nodes, respectively. The risk of radiation induced cancer to the thyroid gland was estimated to be at levels of 0.18 %, 1.19 %, 1.18 % and 0.33 % respectively. The mean PD of the breast, expressed as a % TD, was 5.90 %, 2.59 % and 3.14% corresponding to mediastimun treatment and breast treatment with and without the irradiation of supraclavicular and axillary nodes, respectively. The risk to the breast was estimated to be at levels of 3.97 %, 1.76 % and 1.45%, in mediastinum and breast treatment, with and without the supraclavicular irradiation, respectively. Although the results indicate that there is not an increased risk of secondary cancer in the thyroid gland and the breast after conventional radiotherapy (3D CRT), the significance of this risk has to be considered taking into account the existing pathology and the age of the patient as also further studies are needed to determine the weight of each contributor to the peripheral dose as also.
As a concern, the results of the PD measurements during Cyberknife treatment, the mean preshielding PD, as a percentage of the prescribed dose (% TD) was 2.32 %, 0.63 % and 0.48 %, in the thyroid gland, the umbilicus and the pubic symphysis, respectively, since in the preshielding measurements the nipple was not monitored. The mean postshielding PD was 2.06 %, 0.65 %, 0.59 %, and 0.47 %, in the thyroid gland, the nipple, the umbilicus and the pubic symphysis, respectively. The risk for inducing secondary cancers can be considered low for the organs studied, by taking into account the existing pathology of the patients undergoing Cyberknife treatment. However, it should not be completely disregarded, especially in long term surviving patients, who are being treated for benign diseases or for curatively non metastatic malignancies.
We also concluded that the increase of the collimator size during Cyberknife treatment corresponds to an increase of the PD and becomes less significant at larger distances, indicating that at these distances the PD is predominate due to the head leakage and the collimator scatter. Weighting the effect of the number of monitor units and the collimator size can be effectively used during the optimization procedure of Cyberknife in order to choose the most suitable treatment plan that will deliver the maximum dose to the tumor, while being compatible with the dose constraints for the surrounding organs at risk. Attention is required in defining the thyroid gland as a structure of avoidance in the treatment plan especially in patients with benign diseases.
The most important advantages of the mobileMOSFET dosimeter are its small size, as it can be easily placed on the patient’s skin and the almost direct estimation of the dose during exposure. Moreover, its sensitivity and reproducibility make it suitable for measurements of low PD, as it provides an adequate measure of dose at low dose levels for high-energy photon beam irradiations used for therapy applications. However, attention should be given to the utilized Calibration Factor (CF), since its sensitivity is affected by the accumulated dose during its lifetime.
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