Graduation date: 1999

External radiotherapy is a common treatment technique for cancer. It has been shown that radiation therapy is a both clinically and economically effective treatment for many types of cancer, even though the equipment is expensive. The technology is in constant evolution and more and more sophisticated and complex techniques are introduced. One of the main tasks for physicists at a radiotherapy department is quality control, i.e. making sure that the treatments are delivered in accordance with the dosimetric intentions. Over dosage of radiation can lead to severe side effects, while under dosage reduces the probability for patient cure. The present thesis is mainly focused on the verification of the calculated dose. Requirements for independent dose calculation software are identified and the procedures using such software are described. In the publications included in the thesis an algorithm specially developed for verification of dose calculations is described and tested. The calculation uncertainties connected with the described algorithm are investigated and modeled. A brief analysis of the quality assurance procedures available and used in external radiotherapy is also included in the thesis. The main conclusion of the thesis is that independent verification of the dose calculations is feasible in an efficient and cost effective quality control system. The independent calculations do not only serve as a protection against accidents, but can also be the basis for comparisons of the dose calculation performance at different clinics.

Radioiodine has been used in nuclear medicine for the treatment of thyroid diseases such as Thyroid Cancer and Thyrotoxicosis for many years. The treatment renders the patient radioactive. To minimize the dose to the patients’ relatives and the general public, restric-tions are imposed on the behaviour of the patient. This project presents the person dose equivalents actually received by family members of radioiodine patients following such restrictions. The family members wore hospital ID-bands on left and right wrists for up to four weeks. Each ID-band contained two LiF: Mg, Ti Thermo Luminescence Dosimeters (TLD) calibrated to measure air kerma. The TLDs were analysed and a total person dose equivalent received by the relative was calculated from the measured air kerma values. The results were compared to the dose constraints imposed by The Swedish Radiation Protection Authority (SSI FS 2000:3) in order to confirm that the new set of restrictions used at Karolinska University Hospital Huddinge maintains the dose to family members below the applicable limits. A total number of 22 relatives were recruited, 8 elderly, 7 adults and 7 children. Of the recruited relatives 4 (2 adults, 2 children) were excluded from the study as they had lost their dosimeter ID-bands or had other reasons not to participate in the study. This leaves the number of relatives used for data analysis at 18 individuals (8 elderly, 5 adults and 5 children) with a min age of 10 years and max age of 80 years. The observed average person dose equivalent of 0.43 mSv (max, 1.27; min, 0.12) indi-cates that the new method of individualised restriction used at Karolinska University Hospital Huddinge work as desired in keeping the dose to family members at an accept-able level. The accuracy of the clinical study has been shown to depend greatly on the method by which the dose is investigated but also on the properties of the TLD material used. There is a potential underestimation of air kerma due to fading of up to 30 %. In addition there are contributing uncertainties from both the calibration method and the conversion to person dose equivalent with the combined uncertainty estimated to be 14%.

The International Atomic Energy Agency (IAEA) and the World Health Organisation (WHO) operate the IAEA/WHO TLD postal dose audit programme. The purpose of the programme is to verify the beam calibration in radiotherapy centres in developing countries and to check the Secondary Standards Dosimetry Laboratories (SSDLs). Thermoluminescence dosimeters (TLDs) are used as transfer dosimeters and the evaluation of these are done at the IAEA Dosimetry Laboratory. In the present work the uncertainties in the process of dose determination from TLD readings have been evaluated. The analysis comprises the TLD reading reproducibility, uncertainties in the calibration coefficient, and uncertainties in factors correcting for fading of TL signal, influence of TLD holder, energy response and dose response non-linearity. The individual uncertainties were combined to estimate the total uncertainty in the evaluated dose from TLD readings. Experimental data from 2001-2005 were used in the analysis. The total uncertainty has been estimated to be 1.2 % for irradiations with 60Co -rays and 1.6 % for irradiations with high-energy X-rays. Results from irradiations by the Bureau International des Poids et Mesures (BIPM), Primary Standard Dosimetry Laboratories (PSDLs), Secondary Standard Dosimetry Laboratories (SSDLs) and reference centres compare favourably with the estimated uncertainties. The largest uncertainty components are in the energy correction factor (for high-energy X-rays) with a value of 1.1 % and in the dose response non-linearity correction factor with a value of 0.9 %. It has been shown that the acceptance limits of 5 % for TLD results of hospitals and 3.5 % for SSDLs are justified when related to the uncertainties in the dose calculations and the uncertainty in the determination of absorbed dose to water at the centre, as discussed in IAEA TRS-398 (IAEA, 2000), provided that it is followed.

The dose distribution around brachytherapy (BT) sources is characterized by steep dose gradients and an energy spectrum varying rapidly with depth in water around the source. These two properties make experimental verification of the dose distribution difficult, and put high demands on the dosimetry system in use regarding precision, size and energy dependence. The American Association of Physicists in Medicine (AAPM) recommends lithium fluoride (LiF) thermo-luminescence dosimetry (TLD) to be used for verification measurements, as it is the only dosimetry system meeting the requirements, but still the total combined uncertainty in dose-rate determination is as high as 7-9 % (1 σ). Lithium formate is a new dosimetry material that is less energy dependent than LiF, but more sensitive than the most common EPR (electron paramagnetic resonance) dosimetry material, alanine. In order to evaluate lithium formate EPR for BT dosimetry, dosimeters were produced for experimental dose determination around BT source 192Ir. The dosimeters were calibrated against an ionization chamber in a high energy photon beam. Dose to water was determined at 1, 3 and 5 cm radial distance from the source, which was stepped along a straight line in a PMMA phantom. The experiments were performed twice using 4 dosimeters per distance and experiment. Methods to correct for energy dependence were developed and evaluated. The uncertainty in measured dose was estimated. The experimental dose values agreed with the values from the treatment planning system with a maximum deviation of 3.3 %, and an average 1 σ uncertainty of 3 % at 3 and 5 cm and 5 % at 1cm. Uncertainty in radial distance from the source as well as source calibration were the dominating contributions to the total combined uncertainty. Lithium formate EPR has been shown to be a promising alternative to LiF TLD for BT dosimetry.

Dosimetric characteristics of a CVD single crystal diamond detector have been evaluated. Detector stability, linearity, optimal bias, temperature dependence, directional dependence, priming and pre-irradiation behaviour, depth dose curves and dose profiles were investigated. The optimal bias was determined to be 50 V. The detector stability measurement showed a too large variation for absolute dosimetry in a day to day measurement, but acceptable variation during one and the same day. The linearity constant, , in the relation between signal and dose rate, (Fowler 1966), was determined to 0.978 and 0.953 for two detectors. The sub-linearity was also observed in the depth dose curves and could be eliminated with a correction method. The diamond detector showed smaller temperature dependence than the EFD silicon diode. The directional dependency was, <1 %, up to at least ± 15˚ and therefore no angular correction is needed. A priming dose of 0.6 Gy was determined, which is considerably smaller than for existing detectors on the market. After pre-irradiation with electrons (8 and 18 MeV) a large and permanent desensitization of up to 31 % / 500 Gy was detected. This is in contradiction to what previous published articles claim. 15 MV photons also reduced the sensitivity of the detector, but no evidence that 5 MV photons do has been found. A 50 Gy dose of 180 MeV protons did not reduce the sensitivity either. The detector dose rate linearity was improved by electron pre-irradiation. The dose profile penumbras of the diamond detector were, for the most part, smaller than the RK ionization chamber, indicating a better spatial resolution.

The aim of this project is to keep the x-ray exposure of the patient as low as reasonably achievable while improving the diagnostic image quality for the radiologist. The means to achieve these goals is to develop and evaluate an ecient adaptive ltering (denoising/image enhancement) method that fully explores true 4D image acquisition modes. The proposed prototype system uses a novel lter set having directional lter responses being monomials. The monomial lter concept is used both for estimation of local structure and for the anisotropic adaptive ltering. Initial tests on clinical 4D CT-heart data with ECG-gated exposure has resulted in a signicant reduction of the noise level and an increased detail compared to 2D and 3D methods. Another promising feature is that the reconstruction induced streak artifacts which generally occur in low dose CT are remarkably reduced in 4D.

The county of Dalarna is at present carrying through a process of digitalization where traditional x-ray film is being replaced with digital detectors. Earlier used methods for dose optimization turned out not being sufficient. This report presents a method to harmonize dose levels between x- ray sites equipped with Fujifilm imaging plate systems. An exposure index, S, related to the dose level of the examination is computed to every x-ray image. S turned out to be inversely proportional to the detector dose used at the examination. Detector dose is also the one simulated factor that doubtlessly affects S the most.There are however a lot of parameters, e.g difference between patients, that are not easily simulated even though they still have considerable affect. The method for harmonizing dose levels between x-ray sites are based on statistics of collected S-values for a kind of examination. The average of the collected S-values levels variations and is a more solid measure of the dose level for the examination. By means of this method the dose level of frontal images of the lungs at a site have been reduced by 30 per cent without endanger the diagnostic security.

<p>The purpose of this research was to verify experimentally the buildup region dose calculation for Pinnacle³ (version 9.0), a commercial treatment planning system, commissioned and in use at the Saskatoon Cancer Center. To achieve this, buildup dose measurements using Attix parallel-plate ionization chamber and calculations by Pinnacle³, for a variety of clinical setups, were compared. The clinical setups involved 6 MV and 15 MV photon beams, open fields, enhanced dynamic wedges, physical wedges, block tray, 85, 100 and 120 cm source-to-surface distances (SSDs), and field sizes 3 x 3, 4 x 4, 5 x 5, 8 x 8, 10 x 10, 12 x 12, 15 x 15, 20 x 20, 30 x 30 cm². The dose difference (DD) and distance-to-agreement (DTA) were used to evaluate the discrepancy between measured and calculated dose values. Significant discrepancies between measured and calculated buildup dose values were observed because the modeling in Pinnacle³ is based on measurements made using a cylindrical ionization chamber. Based on the criteria of DD less than 2% or DTA less than 2 mm, 93.7% of 1,710 dose points for the 6 MV photon beam passed while for the 15 MV photon beam, 96.1% of the 2,244 dose points passed. The dose points that did not pass these criteria were mostly for open fields, block tray fields, fields with physical wedges of 15 degrees and 30 degrees and for fields with shorter source-to-surface distances. This is attributed to the high electron contamination associated with these fields. The low levels of discrepancies between measured and calculated dose values for the 15 MV beam as compared to those of the 6 MV beam need further investigations. The good agreement between measured and calculated dose values after remodeling the Electron Contamination in Pinnacle³ based on Attix chamber measurements is an indication that the Electron Contamination equation in Pinnacle³ may be adequate for modeling of electron contamination in the buildup dose region. The disagreement between Attix chamber and EBT 2 film measured buildup dose values was less than 3% for 89.9% of the buildup dose measurements compared. It is recommended to use a good parallel plate ionization chamber, such as the Attix chamber, for measurements in the buildup region.</p>

Background: Evidence on aerosol delivery via tracheostomy is lacking. The purpose of this study was to evaluate the effect of aerosol device and administration technique on drug delivery in a simulated spontaneously breathing pediatric model with tracheostomy. Methods: Delivery efficiencies during spontaneous breathing with assisted and unassisted administration techniques were compared using the jet nebulizer (JN- MicroMist), vibrating mesh nebulizer (VMN- Aeroneb Solo) and pressurized metered-dose inhaler (pMDI- ProAirHFA). The direct administration of aerosols in spontaneously breathing patients (unassisted technique) was compared to administration of aerosol therapy via a manual resuscitation bag (assisted technique) attached to the aerosol delivery device and synchronized with inspiration. An in-vitro lung model consisted of an uncuffed tracheostomy tube (4.5 mmID) was attached to a collecting filter (Respirgard) which was connected to a dual-chamber test lung (TTL) and a ventilator (Hamilton). The breathing parameters of a 2 years-old child were set at an RR of 25 breaths/min, a Vt of 150 mL, a Ti of 0.8 sec and PIF of 20 L/min. Albuterol sulfate was administered with each nebulizer (2.5 mg/3 ml) and pMDI with spacer (4 puffs, 108 µg/puff). Each aerosol device was tested five times with both administration techniques (n=5). Drug collected on the filter was eluted with 0.1 N HCl and analyzed via spectrophotometry. Results: The amount of aerosol deposited in the filter was quantified and expressed as inhaled mass and inhaled mass percent. The pMDI with spacer had the highest inhaled mass percent, while the VMN had the highest inhaled mass. The results of this study also found that JN had the least efficient aerosol device used in this study. The trend of higher deposition with unassisted versus assisted administration of aerosol was not significant (p>0.05). Conclusions: Drug deposited distal to the tracheostomy tube with JN was lesser than either VMN or pMDI. Delivery efficiency was similar with unassisted and assisted aerosol administration technique in this in vitro pediatric model.