IMRT uses non-uniform beam intensities within a radiation field to provide patient-specific dose shaping, resulting in a dose distribution that conforms tightly to the planning target volume (PTV). Unavoidable geometric uncertainty arising from patient repositioning and internal organ motion can lead to lower conformality index (CI), a decrease in tumor control probability (TCP) and an increase in normal tissue complication probability (NTCP). The CI of the IMRT plan depends heavily on steep dose gradients between the PTV and organ at risk (OAR). Geometric uncertainties reduce the planned dose gradients and result in a less steep or “blurred” dose gradient. The blurred dose gradients can be maximized by constraining the dose objective function in the static IMRT plan or by reducing geometric uncertainty during treatment with corrective verification imaging. Internal organ motion and setup error were evaluated simultaneously for 118 individual patients with implanted fiducials and MV electronic portal imaging (EPI). The Gaussian PDF is patient specific and group standard deviation (SD) should not be used for accurate treatment planning for individual patients. Frequent verification imaging should be employed in situations where geometric uncertainties are expected. The dose distribution including geometric uncertainties was determined from integration of the convolution of the static dose gradient with the PDF. Local maximum dose gradient (LMDG) was determined via optimization of dose objective function by manually adjusting DVH control points or selecting beam numbers and directions during IMRT treatment planning. EUDf is a useful QA parameter for interpreting the biological impact of geometric uncertainties on the static dose distribution. The EUDf has been used as the basis for the time-course NTCP evaluation in the thesis. Relative NTCP values are useful for comparative QA checking by normalizing known complications (e.g. reported in the RTOG studies) to specific DVH control points. For prostate cancer patients, rectal complications were evaluated from specific RTOG clinical trials and detailed evaluation of the treatment techniques. Treatment plans that did not meet DVH constraints represented additional complication risk. Geometric uncertainties improved or worsened rectal NTCP depending on individual internal organ motion within patient.

IMRT uses non-uniform beam intensities within a radiation field to provide patient-specific dose shaping, resulting in a dose distribution that conforms tightly to the planning target volume (PTV). Unavoidable geometric uncertainty arising from patient repositioning and internal organ motion can lead to lower conformality index (CI), a decrease in tumor control probability (TCP) and an increase in normal tissue complication probability (NTCP). The CI of the IMRT plan depends heavily on steep dose gradients between the PTV and organ at risk (OAR). Geometric uncertainties reduce the planned dose gradients and result in a less steep or “blurred” dose gradient. The blurred dose gradients can be maximized by constraining the dose objective function in the static IMRT plan or by reducing geometric uncertainty during treatment with corrective verification imaging. Internal organ motion and setup error were evaluated simultaneously for 118 individual patients with implanted fiducials and MV electronic portal imaging (EPI). The Gaussian PDF is patient specific and group standard deviation (SD) should not be used for accurate treatment planning for individual patients. Frequent verification imaging should be employed in situations where geometric uncertainties are expected. The dose distribution including geometric uncertainties was determined from integration of the convolution of the static dose gradient with the PDF. Local maximum dose gradient (LMDG) was determined via optimization of dose objective function by manually adjusting DVH control points or selecting beam numbers and directions during IMRT treatment planning. EUDf is a useful QA parameter for interpreting the biological impact of geometric uncertainties on the static dose distribution. The EUDf has been used as the basis for the time-course NTCP evaluation in the thesis. Relative NTCP values are useful for comparative QA checking by normalizing known complications (e.g. reported in the RTOG studies) to specific DVH control points. For prostate cancer patients, rectal complications were evaluated from specific RTOG clinical trials and detailed evaluation of the treatment techniques. Treatment plans that did not meet DVH constraints represented additional complication risk. Geometric uncertainties improved or worsened rectal NTCP depending on individual internal organ motion within patient.

This thesis details the measurement and simulation of patient skin doses arising from X-ray exposure during interventional cardiology procedures. Interventional cardiology procedures can be long and complex resulting in high skin doses, to the extent that radiation burns may be produced. Twenty patients were used in the study consisting of 10 coronary angiogram and 10 coronary angioplasty procedures. Radiochromic films were used to measure skin dose directly. The Gafchromic® XR-RV2 film was chosen for its suitability for this project. The key characteristics of this film were experimentally determined including: dose response, energy dependence, polarisation and post-exposure growth. The dose range was found to be ideally suited for the doses encountered in this study. Energy dependence was found to be ~14% between 60 and 125 kVp at 1 Gy and introduced an unavoidable uncertainty into dose calculations from unknown beam energies. Document scanner characteristics were also been investigated and a scanning protocol is determined. A mathematical model was created to use the geometry and exposure information encoded into acquisition files to reconstruct dose and dose distributions. The model requires a set of study files encoded according to the DICOM format, as well as user input for fluoroscopic estimations. The output is a dose map and dose summary. Simulation parameters were varied and results compared with film measurements to provide the most accurate model. From the data collected the relation between dose area product, maximum skin dose and fluoroscopic time were also investigated. The results demonstrated that a model based on acquisition information can accurately predict maximum skin dose and provide useful geometrical information. The model is currently being developed into a standalone program for use by the Medical Physics and Bioengineering department.

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To estimate the delivered dose to the patient during intra-fraction or throughout the whole treatment, it is important to determine the contribution of dose accumulated at different patient geometries to the overall dose. Dose mapping utilizes deformable image registration to map doses deposited on patient geometries at different times. Inputs to the dose mapping process are the irradiated and reference images, the displacement vector field, and a dose mapping algorithm. Thus accuracy of the mapped dose depends on the DVF and dose mapping algorithm. Dose mapping had been the subject of many research studies however, up to now there is no gold standard DIR or dose mapping algorithm. This thesis compares current dose mapping algorithms under different conditions such as choosing the planning target and dose grid size, and introduces new tool to estimate the required spatial accuracy of a DVF. 11 lung patients were used for this thesis work. IMRT plans were generated on the end of inhale breathing phases with 66 Gy as the prescription dose. Demons DVF’s were generated using the Pinnacle treatment planning system DIR interface. Dtransform, Tri-linear with sub-voxel division, and Pinnacle dose mapping algorithms were compared to energy transfer with mass sub-voxel mapping. For breathing phase 50% on 11 patients, tissue density gradients were highest around the edge of the tumor compared to the CTV and the PTV edge voxels. Thus treatment plans generated with margin equal to zero on the tumor might yield the highest dose mapping error (DME). For plans generated on the tumor, there was no clinical effect of DME on the MLD, lung V20, and Esophagus volume indices. Statistically, MLD and lung V20 DME were significant. Two patients had D98 Pinnacle-DME of 4.4 and 1.2 Gy. In high dose gradient regions DVF spatial accuracy of ~ 1 mm is needed while 8 to 10 mm DVF accuracy can be tolerated before introducing any considerable dose mapping errors inside the CTV. By using ETM with mass sub-voxel mapping and adapting the reported DVF accuracy, the findings of this thesis have the potential to increase the accuracy of 4D lung planning.

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg in partial fulfillment of the requirements for the degree of MSc (Dent) / A comparison of radiation doses to selected vital organs in the maxillo-facial region at three different settings on the Galileos cone-beam computed tomography (CBCT) machine in the Wits Dental Hospital, was conducted with the courtesy of the Department of Medical Physics of the Charlotte Maxeke Johannesburg Academic Hospital. The study made use of the RANDO phantom and TLD- 100 detector chips, which provided detailed mapping of the dose distribution from the Galileos CBCT machine. Sixty-two Sanford® lithium fluoride dosimeters- (TLD- 100) were irradiated using a calibrated known x-ray source after having undergone a recommended annealing cycle. The data showed great consistency in the results. Association between the different imaging modalities was further investigated using Kruskal-Wallis equality-of-populations rank test and Chi-squared test. A p-value of <0.05 was considered statistically significant. Since there do not appear to be major differences between the radiation doses for the different settings of the Galileos CBCT machine, the author recommends the use of the combined setting at all times for optimum image quality.