Handbook of Radiotherapy Physics

Description

From the essential background physics and radiobiology to the latest imaging and treatment modalities, the updated second edition of Handbook of Radiotherapy Physics: Theory and Practice covers all aspects of the subject. In Volume I, Part A includes the Interaction of Radiation with Matter- charged particles and photons - and the Fundamentals of Dosimetry- with an extensive section on small-field physics. Part B covers Radiobiologywith increased emphasis on hypofractionation. Part C describes Equipment for Imaging and Therapyincluding MR-guided linear accelerators. Part D on Dose Measurementincludes chapters on ionisation chambers, solid-state detectors, film and gels, as well as a detailed description and explanation of Codes of Practice for Reference Dose Determination including detector correction factors in small fields. Part E describes the properties of Clinical (external) Beams. The various methods (or ''algorithms'') for Computing Doses in Patientsirradiated by photon, electron and proton beams are described in Part F with increased emphasis on Monte-Carlo-based and grid-based deterministic algorithms. In Volume 2, Part G covers all aspects of Treatment Planningincluding CT-, MR- and Radionuclide-based patient imaging, Intensity-Modulated Photon beams, Electron and Proton Beams, Stereotactic and Total Body Irradiation and the use of the dosimetric and radiobiological metrics TCP and NTCP for plan evaluation and optimisation. Quality Assurance fundamentals with application to equipment and processes is covered in Part H. Radionuclides, equipment and methods for Brachytherapyand Targeted Molecular Therapyare covered in Parts I and J respectively. Finally, Part K is devoted to Radiation Protection of the public, staff and patients. Extensive tables of Physical Constants, Photon, Electron and Proton Interaction data, andtypicalPhoton Beam and Radionuclide dataare given in Part L. Edited by recognised authorities in the field, with the individual chapters written by renowned specialists, this second edition ofHandbook of Radiotherapy Physicsprovides the essential up-to-date theoretical and practical knowledge to deliver safe and effective radiotherapy. It will be of interest to clinical and research medical physicists, radiation oncologists, radiation technologists, PhD and Masters students. scribes the properties of Clinical (external) Beams. The various methods (or ''algorithms'') for Computing Doses in Patientsirradiated by photon, electron and proton beams are described in Part F with increased emphasis on Monte-Carlo-based and grid-based deterministic algorithms. In Volume 2, Part G covers all aspects of Treatment Planningincluding CT-, MR- and Radionuclide-based patient imaging, Intensity-Modulated Photon beams, Electron and Proton Beams, Stereotactic and Total Body Irradiation and the use of the dosimetric and radiobiological metrics TCP and NTCP for plan evaluation and optimisation. Quality Assurance fundamentals with application to equipment and processes is covered in Part H. Radionuclides, equipment and methods for Brachytherapyand Targeted Molecular Therapyare covered in Parts I and J respectively. Finally, Part K is devoted to Radiation Protection of the public, staff and patients. Extensive tables of Physical Constants, Photon, Electron and Proton Interaction data, andtypicalPhoton Beam and Radionuclide dataare given in Part L. Edited by recognised authorities in the field, with the individual chapters written by renowned specialists, this second edition ofHandbook of Radiotherapy Physicsprovides the essential up-to-date theoretical and practical knowledge to deliver safe and effective radiotherapy. It will be of interest to clinical and research medical physicists, radiation oncologists, radiation technologists, PhD and Masters students. ation Protection of the public, staff and patients. Extensive tables of Physical Constants, Photon, Electron and Proton Interaction data, andtypicalPhoton Beam and Radionuclide dataare given in Part L. Edited by recognised authorities in the field, with the individual chapters written by renowned specialists, this second edition ofHandbook of Radiotherapy Physicsprovides the essential up-to-date theoretical and practical knowledge to deliver safe and effective radiotherapy. It will be of interest to clinical and research medical physicists, radiation oncologists, radiation technologists, PhD and Masters students. Cover Volume 01 Half Title Title Page Copyright Page Table of Contents Preface to the Second Edition The Editors List of Contributors to the Second Edition Notes for Readers Part A Fundamentals Chapter 1 Structure of Matter 1.1 The Concept of the Atom 1.2 The Atomic Structure 1.2.1 Building Up the Models 1.2.2 Schematic Description of the Atomic Structure 1.2.2.1 The Nucleus 1.2.2.2 The Peripheral Electrons/Electronic Shells 1.2.2.3 The Global Atom 1.2.3 Atomic Structure Interpretation According to the Wave-Mechanical Model 1.2.3.1 Peripheral Electrons 1.2.3.2 Electronic Status 1.2.3.3 The Nucleus 1.2.4 Nomenclature 1.3 Binding Energies in Atoms and Molecules 1.3.1 Energy and Matter 1.3.1.1 Energy of Particles with Mass 1.3.1.2 Energy of Photons 1.3.2 Binding Energies in Atoms 1.3.2.1 Mass Defect 1.3.2.2 Electron Binding Energy and Energy Levels of the Atomic Shells 1.3.3 Binding Energies in Molecules 1.4 Perturbation of Binding Energies 1.4.1 Excitation 1.4.2 Ionisation 1.4.3 Equilibrium Recovery: Fluorescence 1.4.4 Equilibrium Recovery: Auger Effect 1.5 Examples of Atoms and Molecules of Interest for Radiation Physics Chapter 2 Radioactivity 2.1 Stable Nucleus: Nuclear Energy Structure 2.1.1 Nuclear Energy Levels 2.1.2 Abundance of Stable Nuclei as a Function of the Number of Protons and Neutrons 2.1.3 Influence of N/Z on Stability 2.2 Nuclear Instability: Radioactivity 2.2.1 Definition of Radioactivity 2.2.2 Radioactive Transformations Associated with Strong Interactions 2.2.2.1 α Radioactivity 2.2.2.2 Spontaneous Fission 2.2.3 Radioactive Transformations Associated with the Electrostatic Force 2.2.3.1 Nuclear Isomerism (or . Radioactivity 2.2.3.2 γ Emission and Internal Conversion 2.2.4 Radioactive Transformations Associated with the Weak Interaction 2.2.4.1 ß– Radioactivity 2.2.4.2 ß+ Radioactivity 2.2.4.3 General Aspects of ß Decay 2.2.4.4 Electron Capture 2.2.5 Artificial Radioactivity 2.3 Quantification of Radioactivity 2.3.1 Activity: Quantity and Unit 2.3.2 Radioactive Disintegration and Decay 2.3.2.1 Law of Radioactive Decay 2.3.2.2 Half-life of a Radioactive Nuclide 2.3.2.3 Specific Activity 2.3.2.4 Equilibrium with Radioactive Daughter Products 2.4 Production of Radioactive Sources through the Activation Process 2.4.1 Standard Production of Artificial Radionuclides 2.4.2 Unintentional Activation Chapter 3 Interactions of Charged Particles with Matter 3.1 Introduction 3.2 Electronic Losses 3.2.1 Theory 3.2.2 Electronic Stopping Power 3.2.3 The Density or Polarisation Effect 3.2.4 Electronic Stopping-Power Data for Electrons in Materials of Medical Interest 3.2.5 Restricted Stopping Power 3.2.6 Electronic Stopping Power for Heavy Charged Particles 3.3 Nuclear Interactions 3.4 Radiative Losses (Bremsstrahlung 3.4.1 Theory 3.4.2 Radiative Stopping Power 3.4.3 Radiation Yield 3.4.4 Angular Distribution of Bremsstrahlung Photons 3.5 Total Energy Losses 3.5.1 Total Stopping Power 3.5.2 Energy-Loss Straggling 3.5.3 Continuous-Slowing-Down-Approximation (CSDA) Range 3.5.4 Tabulated Stopping-Power Data 3.6 Elastic Nuclear Scattering 3.6.1 General 3.6.2 Elastic Nuclear Scattering of Protons 3.7 Application to Electron and Proton Depth–Dose Curves 3.8 Electron-Positron Annihilation Chapter 4 Interactions of Uncharged Particles with Matter 4.1 Introduction 4.2 Photon Interaction Cross Sections 4.2.1 Interaction Cross Sections 4.2.2 Differential Scattering Cross Sections 4.3 Photon Interaction Processes 4.3.1 Photoelectric Absorption 4.3.2 Compton Interaction and Scattering Processes 4.3.2.1 Incoherent (Inelastic) Scattering 4.3.2.2 Coherent (Elastic) Scattering 4.3.3 Pair and Triplet Production 4.3.4 Nuclear Photoeffect 4.3.5 The Total Atomic Cross Section 4.4 Neutron Interactions 4.4.1 General Aspects 4.4.2 Elastic Scattering 4.4.3 Neutron Capture 4.5 Macroscopic Behaviour 4.5.1 Photon Beam Attenuation and Attenuation Coefficients 4.5.2 Neutron Beam Attenuation 4.5.3 Photon Energy-Transfer and Energy-Absorption Coefficients 4.5.4 Neutron Energy Transfer 4.6 Sources of Interaction Data Chapter 5 Principles and Basic Concepts in Radiation Dosimetry 5.1 Introduction 5.2 The Stochastic Nature of Energy Deposition 5.3 Definitions of Dosimetric Quantities 5.3.1 Absorbed Dose 5.3.2 Kerma (and Exposure 5.3.3 Particle Fluence 5.3.4 Energy Fluence 5.3.5 Planar Fluence 5.3.6 Fluence Rate 5.4 Relations between Fluence and Dosimetric Quantities for Photons 5.4.1 Relation between Photon Fluence and Kerma 5.4.2 Relation between Kerma and Absorbed Dose 5.5 Charged-Particle Equilibrium (CPE); Partial CPE 5.6 Relation between Fluence and Dose for Charged Particles 5.6.1 Stopping Power and CEMA 5.6.2 Delta-Ray Equilibrium 5.7 Cavity Theory 5.7.1 Introduction 5.7.2 The Fano Theorem 5.7.3 Cavity Theory for ‘Large’ Photon Detectors 5.7.4 Bragg–Gray Cavity Theory 5.7.4.1 Introduction 5.7.4.2 Theory 5.7.4.3 When Does a Detector Behave in a Bragg–Gray Manner 5.7.4.4 Bragg-Gray (Unrestricted) Stopping-Power Ratios, Water-to-Detector 5.7.4.5 Is a Low-density Cavity in a Medium Irradiated by Kilovoltage X-Rays a Bragg–Gray Cavity 5.7.5 The Spencer–Attix Modification of Bragg–Gray Theory 5.7.5.1 Introduction 5.7.5.2 Theory 5.7.5.3 Practical Implications of Spencer–Attix Theory 5.7.6 Departures from ‘Perfect’ Bragg–Gray Behaviour For Ionisation Chambers 5.7.6.1 Introduction 5.7.6.2 The Various Sources of Ion-Chamber Perturbation 5.7.7 General or ‘Burlin’ Cavity Theory 5.7.8 The Response of a Detector as it Varies from ‘Bragg–Gray’ to ‘Large Photon 5.8 The Special Case of Small, Non-equilibrium, Megavoltage Photon Fields 5.8.1 Introduction 5.8.2 Absorbed Dose in a Uniform Medium Irradiated by a Small Photon Field 5.8.3 Detector Response in Small Photon Fields 5.8.3.1 General 5.8.3.2 Response as a Function of Detector Type 5.8.3.3 Small-Field Perturbation Factor for Air-filled Ionisation Chambers 5.8.3.4 The Physics of ‘Bragg–Gray Breakdown’ in Small Fields 5.8.4 Mass-density Compensation to Improve Small-field Detector Response References Part B Radiobiology Chapter 6 Radiobiology of Tumours 6.1 The Concept of Clonogenic Cells 6.2 Clonogenic Assays 6.3 Cell Survival Curves 6.4 The Relationship between Cell Survival and Gross Tumour Response 6.4.1 Tumour Growth Delay 6.4.2 Local Tumour Control 6.4.3 Selectivity Is the Name of the Game 6.5 Why Cells Die When They Are Irradiated 6.6 Cellular Recovery from Radiation Damage 6.7 Variation of Cell Killing through the Cell Cycle 6.8 The Importance of Oxygen 6.9 Hypoxia in Tumours 6.9.1 Hypoxic Fraction 6.9.2 Reoxygenation 6.10 Tumour Dose Response 6.11 Radiosensitivity of Human Tumour Cells 6.11.1 Radiosensitivity and Clinical Outcome 6.11.2 Cell Survival Curves for Human Tumour Cells 6.11.3 Departures from LQ for Doses below 1 Gy 6.11.4 Challenges to the LQ Model 6.11.5 Radiation Quality (LET) and Relative Biological Effectiveness (RBE 6.12 Experimental Tumour Systems 6.13 The 5 Rs of Radiobiology Chapter 7 Radiobiology of Normal Tissues 7.1 Normal-Tissue Reactions to Radiotherapy 7.2 What Determines the Severity of Normal-Tissue Damage 7.2.1 Controllable Factors 7.2.2 Uncontrollable Factors 7.3 The Proliferative Structure of Tissues 7.4 Early- and Late-Responding Tissues 7.4.1 Early-Responding Tissues 7.4.2 Late-Responding Tissues 7.5 Concepts of Normal-Tissue Tolerance and Therapeutic Gain 7.6 Steepness of Dose–Response Curves 7.6.1 Basic Properties of Dose–Response Curves 7.6.2 What Determines the Steepness of Dose–Response Curves 7.7 Radiation Pathology 7.7.1 Stochastic Effects 7.7.2 Nonstochastic Effects 7.7.2.1 Skin and Mucosae 7.7.2.2 Lung 7.7.2.3 Brain and Spinal Cord 7.8 Quantification of Normal-Tissue Damage 7.8.1 Visual Scoring Methods 7.8.2 Assays of Tissue Function 7.8.3 Stem-Cell Cloning Techniques 7.9 The Volume Effect 7.9.1 Introduction 7.9.2 Basis of the Volume Effect 7.10 Predicting Risk of Toxicity 7.10.1 Measuring Normal-Tissue Radiosensitivity 7.10.2 The Genetic Basis of Normal-Tissue Radiosensitivity 7.10.3 Measuring Radiosensitivity 7.10.4 Clinical Models Predicting Risk of Toxicity Chapter 8 Dose Fractionation in Radiotherapy 8.1 Why we Fractionate in Radiotherapy 8.2 Historical Approaches to Fractionation 8.2.1 The Approaches of Strandqvist and Ellis 8.2.2 The Contribution of Experimental Radiobiology 8.3 The Fractionation Response of Early- and Late-Responding Tissues 8.3.1 The Linear-Quadratic Approach to Fractionation 8.3.2 Rationale of the LQ Approach 8.3.3 Hypofractionation 8.4 The Normal-Tissue Volume Effect and the ‘Effective’ a/b Ratio 8.5 Effect of Overall Treatment Time 8.6 Hyperfractionation and Accelerated Fractionation 8.6.1 Hyperfractionation 8.6.2 Accelerated Fractionation 8.6.3 Hybrid Schedules and Clinical Examples 8.6.4 Inter-Fraction Interval for Multiple Fractions per Day 8.7 How to Respond to Gaps in Treatment 8.7.1 Introduction 8.7.2 Gap Compensation 8.7.2.1 Repopulation 8.7.2.2 The Repopulation Process 8.7.2.3 Effect of Gaps in Treatment 8.7.2.4 Values of Model Parameters 8.7.3 Worked Example 8.7.4 Summary 8.8 Effect of Dose Rate 8.8.1 Low Dose Rate 8.8.2 Variable Dose Rate 8.8.3 Accounting for Dose Rate in the LQ Expression 8.8.4 Ultra High Dose Rate or ‘Flash’ Radiotherapy References Part C Equipment Chapter 9 Equipment for Patient Data Acquisition 9.1 Introduction 9.2 Cone-Beam Simulators 9.2.1 Radiographic and Fluoroscopic Mode 9.2.2 Cone-Beam CT Mode 9.3 CT Scanners 9.3.1 X-Ray Tube and Generator, Detectors 9.3.2 Aperture 9.3.3 Field of View (FOV 9.3.4 Patient Support Table 9.3.5 Summary 9.4 MRI Equipment 9.4.1 Bore Design and Main Magnetic Field 9.4.2 Other Components 9.4.3 Specificities of MRI Scanners Dedicated to Radiotherapy 9.5 PET/CT Scanners 9.5.1 From Single-Photon Emission Imaging to Positron Emission Tomography 9.5.2 Main Characteristics of PET Scanners 9.5.2.1 General 9.5.2.2 Gamma Detection 9.5.2.3 Data Acquisition and Image Reconstruction 9.5.3 Hybrid PET/CT Equipment 9.5.3.1 Rationale 9.5.3.2 Practical Design and Implementation of PET/CT Scanners 9.6 Additional Equipment for Patient Positioning 9.6.1 Lasers 9.6.2 Patient Immobilisation Devices 9.6.3 Equipment for Respiratory Motion Management 9.6.3.1 Gating Techniques 9.6.3.2 Breath-Hold Techniques 9.6.3.3 Tracking Methods 9.6.4 Optical Surface Imaging Devices Chapter 10 Kilovoltage X-Ray Units 10.1 Introduction 10.2 Principles of X-Ray Generation 10.2.1 X-Ray Production 10.2.2 The X-Ray Spectrum 10.3 Practical X-Ray Generators 10.3.1 The X-Ray Tube 10.3.1.1 Metal–Ceramic Tube Design 10.3.1.2 Contact Therapy Tubes 10.3.1.3 Miniature Tubes 10.3.1.4 Target Angle and Radiation Distribution in Air 10.3.2 X-Ray Tube Housing 10.3.3 Tube Cooling System 10.3.4 HT Generator and Rectification 10.4 Ancillary Equipment 10.4.1 Tube Support Stand 10.4.2 System Control Unit and User Interface 10.4.3 Machine Interlocks 10.5 Beam Filtration 10.5.1 Superficial Energies 10.5.2 Orthovoltage Energies 10.5.3 Filter Box 10.6 Beam Collimation and Applicators 10.6.1 Superficial Applicators 10.6.2 Orthovoltage Applicators 10.6.3 Contact Therapy Applicators 10.7 Electronic Brachytherapy Equipment 10.7.1 Clinical Systems 10.7.2 Interoperative Applicators 10.7.3 Surface Applicators Chapter 11 Traditional Linear Accelerators 11.1 Introduction 11.2 Principles of Electron Linear Accelerators 11.2.1 Electron Acceleration at Megavoltage Energies 11.2.2 An Early Charged Particle Accelerator 11.2.3 Modern Accelerators 11.2.3.1 Electron Bunching 11.2.3.2 Electron Mass Increase 11.2.3.3 Relationship between Electron Beam Energy and Beam Current 11.2.3.4 Summary of the Electron Accelerating Waveguide Principles 11.2.4 Travelling and Standing Wave Accelerating Structures 11.2.5 Microwave Generation and Transmission 11.2.5.1 Klystrons 11.2.5.2 Magnetrons 11.2.6 Transmission Waveguides 11.2.7 Electron Sources 11.2.7.1 The Electron Gun 11.2.8 Controlling the Inputs to the Accelerating Waveguide 11.2.8.1 Gun Driver and HV Supply 11.2.8.2 Gun Filament Supply 11.2.8.3 Modulator 11.2.8.4 The Hydrogen Thyratron 11.2.9 Accelerating Waveguides 11.2.9.1 Standing Wave Accelerating Waveguides 11.2.9.2 Control of Microwave Power 11.2.9.3 Coupling of Cavities in the Standing Wave Accelerating Waveguide 11.2.9.4 Control of Electron Energies in the Standing Wave Accelerating Waveguide 11.2.9.5 Summary of the Properties of a Standing Wave Accelerating System 11.2.9.6 Travelling Wave Accelerating Waveguides 11.2.9.7 Summary of the Properties of a Travelling Wave Accelerating System 11.2.9.8 Vacuum Windows 11.2.9.9 Relationship between Electron Energy, Beam Current and X-Ray Dose Rate 11.2.9.10 Summary of Electron Acceleration Technologies Used in Medical Linacs 11.2.10 Beam Transport 11.2.10.1 Beam Steering and Alignment in the Waveguide 11.2.10.2 Beam Transport 11.2.10.3 Research Beam Option 11.2.11 Beam Bending Systems 11.2.11.1 90° Bending 11.2.11.2 Slalom (112.5°) Bending Magnet 11.2.11.3 Pretzel (270°) Bending Magnet 11.2.11.4 Physics of Electron Beam Bending 11.2.11.5 Energy Monitoring in the Beam Transport System 11.2.11.6 Shielding of the Beam Transport System 11.2.12 X-Ray Production – the Transmission Target 11.3 Shaping the Beam Profile 11.3.1 Primary Collimator 11.3.2 Flattening Filter 11.3.3 Flattening Filter Free Beams 11.3.4 Electron Beam Modification and Shaping 11.4 Beam Monitoring and Dosimetry Control Systems 11.4.1 Principles of Beam Monitoring 11.4.2 The Beam Monitor 11.4.3 Beam Monitor Calibration and Linac Control 11.4.4 Dose and Dose Rate Control 11.4.5 Pulsed Dose Delivery in the Linac 11.4.6 Power Considerations in the Linac 11.4.7 Beam Steering with Beam Monitor Signals 11.5 X-Ray Beam Modification and Shaping and Beam Indication 11.5.1 Rectangular Field Shaping 11.5.2 The Multi-Leaf Collimator (MLC 11.5.2.1 Type A MLC 11.5.2.2 Type B MLC 11.5.2.3 Type C MLC 11.5.2.4 Type D MLC 11.5.2.5 Leaf End Shaping 11.5.2.6 Inter-Leaf Leakage and the Tongue-and-Groove Effect 11.5.2.7 Comparison of MLC Technologies 11.5.3 Rotating and Non-Rotating Sections of the Treatment Head 11.5.3.1 The Light Field and the Optical Distance Indicator 11.6 Properties of the X-Ray Field 11.6.1 Penumbra 11.6.2 Field Size 11.6.3 Field Flatness 11.6.4 Field Symmetry 11.6.5 Control of Flatness and Symmetry 11.6.6 Wedged Beam Profiles 11.6.6.1 External Physical Wedges 11.6.6.2 Internal Physical Wedges 11.6.6.3 Dynamic or Flying Wedge 11.6.6.4 Effect of Field Size and Field Asymmetry on Wedge Profiles 11.7 Linac Control and Interlock Systems 11.7.1 Linac Operational States 11.7.1.1 OFF State 11.7.1.2 STANDBY State 11.7.1.3 PREPARATORY state 11.7.1.4 READY state 11.7.1.5 RADIATION-ON state 11.7.1.6 Emergency Stop Actions 11.7.2 The Linac Interlock and Verification Systems 11.7.3 Control Monitoring and Actions Independent of the Linac Control System 11.7.4 Linac Control of Dynamic Treatments 11.7.4.1 The Dynamic Wedge 11.7.4.2 The Difference between Static and Dynamic Treatment Beams 11.7.4.3 Multi-Parameter Treatments 11.7.5 Control of Special Treatment Modes 11.8 Linac Ancillary Systems 11.8.1 Vacuum System 11.8.2 Water Cooling System 11.8.3 Gas Pressure System 11.8.4 Air for Pneumatic Systems 11.8.5 Electrical Supply 11.8.5.1 Electrical Backup Supply 11.8.5.2 Electrical Safety 11.8.6 Ventilation and Air Conditioning 11.9 Linac Isocentre, Configurations and Beam Modification Options 11.9.1 Linac Isocentre 11.9.2 Accelerator Mountings 11.9.2.1 Gantry Stand Configuration 11.9.2.2 Drum Gantry Configuration 11.9.2.3 Enclosed Gantries Chapter 12 Machines with Radionuclide Sources 12.1 Introduction 12.2 Mechanical Construction 12.2.1 Teletherapy Cobalt Units 12.2.1.1 The Source 12.2.1.2 The Head 12.2.1.3 Gantry 12.2.1.4 Beam Modifiers 12.2.2 Gamma Knife 12.2.2.1 Introduction 12.2.2.2 Models of Gamma Knife – Treatment Process 12.3 Installation of Cobalt Sources 12.3.1 Teletherapy Machines 12.3.1.1 Source Specification 12.3.1.2 Preparation 12.3.1.3 Installation 12.3.2 Gamma Knife Sources and Source Loading 12.4 Safety 12.4.1 Leakage 12.4.2 Area Radiation Monitors 12.4.3 Wipe Tests 12.4.4 Local Rules 12.4.5 Mechanical Safety 12.5 Quality Assurance 12.5.1 Definitive Calibration 12.5.1.1 Teletherapy Issues 12.5.1.2 Gamma Knife Issues 12.5.2 Gamma Knife Quality Assurance 12.5.2.1 Relative Output Factors 12.5.2.2 Sector Uniformity 12.5.2.3 Dose Profiles and Distributions 12.5.2.4 Positioning Accuracy 12.6 Radiosurgery Treatment with the Gamma Knife 12.6.1 Frame Application 12.6.2 Imaging 12.6.3 Treatment Planning 12.6.3.1 The Treatment Planning Process 12.6.3.2 Treatment Planning Algorithm 12.6.3.3 Plan Evaluation 12.6.4 Treatment Delivery 12.6.4.1 Framed Patient 12.6.4.2 Thermoplastic Mask Treatment Using Icon Chapter 13 In-Room Imaging Devices Used for Treatment 13.1 Introduction 13.2 Historical Perspective of EPIDs 13.2.1 Earlier Systems: Fluorescent Screens and Scanning Diodes 13.2.2 Matrix Ionisation Chamber 13.2.3 Amorphous Silicon Arrays 13.3 Imaging Modalities 13.3.1 Portal Imaging 13.3.2 Megavoltage Imaging Cone-Beam CT (CBCT) Systems 13.3.3 Gantry-Mounted kV Systems 13.3.4 Floor- and Ceiling-Mounted Systems 13.4 Imaging Dose Considerations 13.5 EPID Portal Dosimetry Chapter 14 CyberKnife, TomoTherapy and MR-Guided Linear Accelerators 14.1 Introduction 14.2 CyberKnife 14.2.1 Design and Hardware 14.2.2 Set-Up Algorithms 14.2.2.1 Intra-Cranial Treatment 14.2.2.2 Extra-Cranial Treatments 14.2.3 Treatment Planning 14.3 TomoTherapy 14.3.1 Introduction 14.3.2 TomoTherapy Treatment 14.3.3 TomoTherapy Imaging 14.3.4 Treatment Planning 14.3.5 TomoTherapy as an Integrated Treatment Delivery System 14.4 MR-Guided Linear Accelerator 14.4.1 Introduction 14.4.2 A Brief History of the Development of the MR-Linac Concept 14.4.3 Overview of the Challenge of the MR-Linac Integration 14.4.3.1 Magnetic Shielding 14.4.3.2 Radiofrequency Shielding 14.4.3.3 Software Components 14.4.4 Progress of the Clinical Implementation of MR-Guided Radiotherapy 14.4.4.1 MR-Cobalt System 14.4.4.2 MR-Linac Systems 14.4.5 Conclusion Chapter 15 Accelerators for Protons and Other Heavy Charged Particles 15.1 Introduction 15.2 Types of Accelerators for Proton Therapy 15.2.1 Circular Accelerators 15.2.1.1 The Cyclotron 15.2.1.2 The Synchrocyclotron 15.2.1.3 The Isochronous Cyclotron 15.2.1.4 The Synchrotron 15.2.2 Linear Accelerators 15.2.2.1 Dielectric Wave Linear Accelerators (DWAs 15.3 Types of Accelerator for Therapy with Heavy Ions 15.3.1 Synchrotron Facilities for Carbon-Ion Therapy 15.3.2 Cyclotron Facilities for Carbon-Ion Therapy 15.3.3 Linac Facilities for Carbon-Ion Therapy 15.4 New On-Going Developments in Accelerators 15.4.1 Laser-Based Particle Accelerators 15.4.2 Fixed Field Alternating Gradient Particle Accelerators 15.5 General Technical Design Considerations 15.5.1 Extraction 15.5.2 Vacuum and Cryogenic Systems 15.5.3 Ironless Magnetic Circuits 15.6 Beam Transport 15.7 Economic and Functional Aspects 15.7.1 Capital Costs 15.7.2 Running Costs 15.7.3 Treatment Capacity 15.7.4 Cost of Treatment 15.8 Perspectives References Part D Dose Measurement Chapter 16 Ionisation Chambers 16.1 Introduction 16.2 Physical and Operational Principles 16.2.1 Influence of the Applied Voltage – the Ionisation Region 16.2.2 Chamber Design 16.2.3 Insulators and Guard Rings 16.2.4 Electrometers 16.2.5 Cables and Connectors 16.3 Types of Chambers 16.3.1 Free-Air Chambers 16.3.2 Cavity Chambers 16.3.2.1 Desirable Properties of Cavity Chambers – Perturbation Corrections 16.3.2.2 Cylindrical Chambers 16.3.2.3 Plane-Parallel Chambers 16.3.3 Transmission Monitor Chambers 16.4 Determination of the Charge Produced 16.4.1 Recombination 16.4.1.1 Initial and General Recombination 16.4.1.2 Collection Efficiency: Boag’s Theory 16.4.1.3 Collection Efficiency: the Two-Voltage Method 16.4.2 Polarity Effect 16.4.3 Stabilisation and Pre-Irradiation 16.4.4 Leakage and Stem Effect 16.4.5 Correction for the Changes in the Mass of Air within the Cavity Chapter 17 Solid-State Dose Measuring Devices 17.1 Introduction 17.2 Thermoluminescent Dosimetry (TLD) 17.2.1 Principles of TL Dosimetry 17.2.2 Detectors 17.2.3 Readers 17.2.4 Dosimetric Properties and Influence Factors 17.2.4.1 Reproducibility 17.2.4.2 Background Signal 17.2.4.3 Detection Threshold 17.2.4.4 Fading 17.2.4.5 Mass 17.2.4.6 Dose 17.2.4.7 Dose-Rate 17.2.4.8 Temperature 17.2.4.9 Energy 17.2.4.10 Directional Effect 17.3 Diode Dosimetry 17.3.1 Principles of Diode Dosimetry 17.3.2 Detectors 17.3.3 Electrometers 17.3.4 Dosimetric Properties and Influence Factors 17.3.4.1 Repeatability and Reproducibility 17.3.4.2 Signal Stability after Irradiation 17.3.4.3 Detection Threshold 17.3.4.4 Background Signal 17.3.4.5 Dose 17.3.4.6 Dose-Rate 17.3.4.7 Temperature 17.3.4.8 Energy 17.3.4.9 Directional Effect 17.4 MOSFET Dosimetry 17.4.1 Principles of MOSFETS Dosimetry 17.4.2 Detectors 17.4.3 Electrometers 17.4.4 Dosimetric Properties and Influence Factors 17.4.4.1 Repeatability and Reproducibility 17.4.4.2 Fading 17.4.4.3 Sensitivity 17.4.4.4 Background Signal 17.4.4.5 Dose 17.4.4.6 Dose-Rate 17.4.4.7 Temperature 17.4.4.8 Energy 17.4.4.9 Directional Effect 17.5 Optically Stimulated Luminescence Dosimetry 17.5.1 Principles of OSL Dosimetry 17.5.2 Detectors 17.5.3 Readers 17.5.4 Dosimetric Properties and Influence Factors 17.5.4.1 Reproducibility 17.5.4.2 Fading 17.5.4.3 Background Signal 17.5.4.4 Dose 17.5.4.5 Dose-Rate 17.5.4.6 Energy 17.5.4.7 Directional Effect 17.6 Diamond Detectors Dosimetry 17.6.1 Principles of Diamond Dosimetry 17.6.2 Detectors 17.6.3 Dosimetric Properties and Influence Factors 17.6.3.1 Reproducibility and Consistency of Detector Responses 17.6.3.2 Sensitivity 17.6.3.3 Background Signal 17.6.3.4 Dose 17.6.3.5 Dose-Rate 17.6.3.6 Temperature 17.6.3.7 Energy 17.6.3.8 Directional Effect Chapter 18 Two-dimensional and Three-dimensional Dosimetry 18.1 Introduction 18.2 Radiographic Silver Halide Film 18.2.1 General 18.2.2 The Latent Image 18.2.3 Film Processing 18.2.4 Film Blackening and Optical Density 18.3 Radiochromic Film 18.3.1 General 18.3.2 Energy Dependence 18.3.3 Optical Density 18.3.4 2D Film Readout 18.3.5 Readout Protocol 18.4 Radiation-Sensitive Gels and Plastics 18.4.1 Principles of 3D Gel and Plastics Dosimetry 18.4.2 3D Dosimetry Materials 18.4.2.1 Fricke Gels 18.4.2.2 Polymer Gels 18.4.2.3 Comparison of Fricke and Polymer Gels 18.4.2.4 Radiochromic Plastics 18.4.3 Readout Techniques 18.4.3.1 Magnetic Resonance Imaging 18.4.3.2 X-Ray Computed Tomography 18.4.3.3 Optical Computed Tomography 18.5 Computed Radiography (CR) Plates for Dosimetry 18.5.1 Principle 18.5.2 CR Dosimetry Advantages 18.5.3 CR Dosimetry Challenges 18.6 Diode and Ionisation Chamber Arrays 18.6.1 Description 18.6.2 Detector Size and Spacing 18.6.3 Energy Dependence 18.6.4 Dose Rate and SSD Dependence 18.6.5 Directional and Field Size Dependence 18.6.6 Transmission Detectors 18.7 Electronic Portal Imaging Devices 18.7.1 General 18.7.2 Fundamentals of EPID Design 18.7.3 EPIDs as Dosimeters Chapter 19 Reference Dose Determination under Reference Conditions 19.1 Introduction 19.2 Codes of Practice Based on Absorbed-Dose-to-Water Calibration 19.2.1 Rationale for Absorbed-Dose-to-Water Calibration 19.2.2 Absorbed-Dose-to-Water Primary Standards 19.2.2.1 Calorimetric Primary Standards 19.2.2.2 Fricke-(Ferrous Sulphate)-Dosimeter-Based Primary Standards 19.2.2.3 Ionometric Primary Standards of Absorbed Dose 19.2.3 Calibration Formalism and Coefficients 19.2.3.1 Calibration at the Standards Dosimetry Laboratory 19.2.3.2 Conversion Factor For the Radiation Quality of the Beam, kQ ,Q0 19.2.3.3 Cross-Calibration of Dosimeters in Electron Beams 19.2.4 Options for Determination of Calibration Coefficients and Conversion Factors 19.2.5 Source of Data for Conversion Factors kQ 19.2.6 Uncertainties in Reference Absorbed Dose Determination 19.3 Codes of Practice Based on an Air Kerma Calibration in a 60Co Gamma-Ray Beam 19.3.1 Background 19.3.2 Determination of the Air Kerma Calibration Coefficient 19.3.3 From Air Kerma to Dose to the Air of the Cavity 19.3.4 Determining the Absorbed Dose to Water from the Dose in the Air Cavity 19.4 Quantities Common to Absorbed-Dose-to-Water and Air-Kerma-Based Codes of Practice 19.4.1 Stopping-Power Ratios 19.4.1.1 General 19.4.1.2 Stopping-Power Ratios for Electron Beams 19.4.1.3 Stopping-Power Ratios for Photon Beams 19.4.2 Perturbation Correction Factors 19.4.2.1 Introduction 19.4.2.2 The Displacement Effect (pdis or Peff shift 19.4.2.3 The Effect of the Chamber Wall (pwall 19.4.2.4 The Electron-fluence (In-)Scattering Effect (pcav 19.4.2.5 The Effect of the Central Electrode Composition (pcel 19.4.2.6 The ‘Hidden’ Components of the Conversion Factor kQ 19.4.3 Mean Energy Expended in Air Per Ion Pair 19.4.4 Beam Quality Specification 19.4.4.1 Megavoltage Photon Beams 19.4.4.2 Electron Beams 19.4.5 Differences in Nomenclature between the IAEA and North American Dosimetry Protocols 19.5 Small, Sub-Equilibrium Megavoltage Photon Fields 19.5.1 The Rationale for a Small-Field Code of Practice 19.5.2 Characteristics of Small-Field Dosimetry 19.5.2.1 The Machine-Specific Reference Field 19.5.2.2 Beam Quality Specification for Small Fields 19.5.2.3 The Charged-Particle Equilibrium Lateral Range (rCPE 19.5.3 Determination of the Reference Dose to Water in the Machine-Specific Reference Field 19.5.3.1 General 19.5.3.2 Options for the Determination of Calibration Coefficients and Conversion Factors 19.5.3.3 Determination of the Beam-Quality Conversion Factors 19.5.4 Determination of the Field Output Factor 19.6 Flattening-Filter-Free (FFF) Photon Beams 19.6.1 Characteristics of FFF Beams 19.6.2 Volume Averaging Correction 19.6.3 Beam-Quality Conversion Factors 19.7 Photon Beams in the Presence of Magnetic Fields 19.8 Kilovoltage X-Ray Beams 19.8.1 Introduction 19.8.2 Fundamentals of kV X-Ray Dosimetry 19.8.3 Introduction to Air-Kerma-Based kV X-Ray Codes of Practice 19.8.4 The Backscatter Method (Low Energies – Approximately 50 kV to 160 kV 19.8.5 The In-Phantom Method (Medium Energies – Approximately 160 kV to 300 kV 19.8.6 Very Low Energies (approximately 8 kV to 50 kV 19.8.7 Absorbed-Dose-to-Water Calibration 19.8.8 A Comparison of Reference Dose Determination between Different Codes of Practice 19.9 Proton and Heavy Charged-Particle Beams 19.10 Phantoms for Dose Determination in Reference Conditions 19.10.1 Introduction 19.10.2 Megavoltage X-Ray and 60Co .-Ray Beams 19.10.3 Electron Beams 19.10.4 Kilovoltage X-Ray Beams 19.10.5 Protons and Heavier Charged Particles Chapter 20 Relative Dose Measurements 20.1 Introduction 20.1.1 Rationale for Absolute and Relative Dose Measurements 20.1.2 Pre-Measurement Preparation 20.1.3 Choice of Phantoms 20.1.3.1 Water Phantoms 20.1.3.2 Solid Phantoms 20.1.3.3 Phantom Sizes 20.1.4 General Principles for Relative Dose Measurements 20.1.5 Choice of Detectors 20.1.5.1 Ionisation Chambers 20.1.5.2 Small Field Chambers 20.1.5.3 Diodes 20.1.5.4 Diamonds 20.1.6 Beam Quality 20.2 Measurements in Photon Beams 20.2.1 Virtual Source Position 20.2.2 Relative Depth Doses 20.2.3 Build-Up Region 20.2.4 Off-Axis Profiles 20.2.5 Field Output Factors 20.2.6 Wedge Dosimetry 20.2.7 Secondary Blocking and Attenuators 20.2.8 Asymmetric Independent Jaws 20.2.9 Multi-Leaf Collimators 20.2.10 Intensity-Modulated Radiation Therapy (IMRT 20.3 Measurements in Charged Particle Beams 20.3.1 Virtual Source Position and Angular Spread 20.3.2 Relative Depth Doses and Off-Axis Profiles 20.3.3 Output Factors References Part E Clinical Beams Chapter 21 The Framework Relating Measurements to Calculation of Delivered Dose 21.1 Introduction 21.2 Control of Dose Delivery: The Monitor Unit Concept 21.2.1 Kilovoltage X-Ray Units 21.2.2 Linear Accelerators 21.2.3 CyberKnife and TomoTherapy 21.2.4 Cobalt-60 Units 21.3 Relative Dose Distributions 21.3.1 Variation of Dose with Distance from the Source 21.3.2 Variation of Dose with Depth within the Patient 21.3.3 Effect of Field Size and Shape 21.3.4 Effect of Distance from the Central Axis 21.3.5 Composition of Patient Tissue 21.4 Representation of Dose Distributions: Isodose Curves and Surfaces Chapter 22 Kilovoltage X-Ray Beams 22.1 Introduction 22.2 Beam Quality 22.2.1 Energy Spectrum and Role of Filtration 22.2.2 Half-value Layer 22.3 Depth-dose Characteristics 22.4 Dose Distribution 22.5 Beam Shaping 22.6 Dose Calculations for Kilovoltage X-Rays 22.6.1 Backscatter Factors 22.6.2 Applicator Factors 22.6.3 Cut-out Factors 22.6.4 Example of Monitor Units (or Treatment Time) Calculation 22.7 Contact Therapy Chapter 23 High-Energy Photon Beams 23.1 Introduction 23.2 Beam Quality 23.2.1 Linear Accelerators 23.2.2 Cobalt Units 23.3 Characteristics of Photon Beams 23.3.1 Dose Build-Up 23.3.2 Variation of Dose with Depth 23.3.2.1 Effect of Energy 23.3.2.2 Effect of Field Size 23.3.2.3 Effect of Source–Skin Distance 23.3.3 Off-Axis Dose Distribution 23.3.3.1 Linear Accelerators 23.3.3.2 Cobalt Beams 23.3.4 Isodose Distributions 23.4 Influence of Patient Shape and Composition 23.4.1 Effect of Oblique Incidence 23.4.2 Inhomogeneities 23.5 Beam Delineation 23.5.1 Standard Collimators 23.5.2 Enhanced Beam Shaping 23.5.3 Blocks 23.5.4 Multi-Leaf Collimators 23.6 Beam Modulation Techniques 23.6.1 Mechanical Fixed or Motorised Wedge Filters 23.6.1.1 Wedge Angle and Wedge Factor 23.6.1.2 Design of Mechanical Wedge Filters 23.6.1.3 Dosimetry Considerations for Wedge Filters 23.6.2 Dynamic Wedges 23.6.3 Tissue Compensators 23.6.4 Intensity Modulation with the MLC 23.7 Flattening Filter Free Beams 23.7.1 Rationale 23.7.2 Profiles of FFF Beams 23.7.3 Surface Dose 23.7.4 Depth Dose Chapter 24 Electron Beams 24.1 Introduction 24.2 Depth-Dose Characteristics of Electron Beams 24.2.1 Spectrum at the Patient Surface 24.2.2 General Shape of the Depth-Dose Curve 24.2.3 Variation with Beam Energy 24.2.4 Variation with Field Size 24.2.5 Variation with Field Shape 24.2.6 Variation with Source–Skin Distance (SSD 24.2.7 Variation with Oblique Incidence 24.3 Isodoses 24.3.1 General Characteristics 24.3.2 Electron-Beam Flatness and Symmetry 24.3.3 Electron-Beam Penumbra 24.3.4 Variation of Isodoses with Field Size 24.3.5 Variation of Isodoses with SSD 24.3.6 Variation of Isodoses with Oblique Incidence 24.4 Field Shaping/Shielding 24.4.1 Field Shaping 24.4.2 Internal Shielding/Backscattered Electrons 24.5 Bolus/Energy Degraders 24.6 Electron Scatter Effects 24.7 Output Factors and Monitor Unit Calculations Chapter 25 Proton and Other Heavy Charged-Particle Beams 25.1 Introduction 25.2 In-Depth Dose Variation – the Pristine Bragg Curve 25.3 Passive Beam Shaping 25.3.1 Choice of Materials for Beam Modifier Devices 25.3.2 Passive Spread-Out of the Bragg peak (SOBP 25.3.3 Passive Energy Compensation for the Distal Shape of the Target Volume 25.3.4 Passive Lateral Beam Shaping 25.4 Dynamic Techniques of Beam Shaping 25.5 Output Factors and Monitor Unit Calculations 25.5.1 Definition of the Output Factor 25.5.2 Output Factors in Scattered Beams 25.5.3 Scanned Fields References Part F Patient Dose Calculation Methods Chapter 26 Parameters and Methodology for Point Dose Calculation in Photon Beams 26.1 Introduction 26.2 Parameters for Dose Calculations 26.2.1 Notation and Conventions 26.2.2 Percent Depth Dose (PDD 26.2.3 Tissue Air Ratio (TAR 26.2.4 Peak Scatter Factor (PSF 26.2.5 Zero-Field Tissue Air Ratio (TAR0 26.2.6 Scatter-Air Ratio (SAR 26.2.7 Tissue Phantom Ratio (TPR 26.2.8 Equivalent Square (ESQ 26.2.9 Field Output Factor (Scp 26.2.10 Collimator Scatter Correction Factor (Sc 26.2.11 Collimator Exchange Effect 26.2.12 Phantom Scatter Correction Factor (Sp 26.2.13 Wedge Transmission Factor 26.2.14 Off-axis Ratio 26.2.15 Inverse Square Law 26.3 Derivation of the Dose on the Central Axis 26.3.1 The Reference Dose 26.3.2 The Dose at Point P on the Beam Axis 26.3.2.1 General 26.3.2.2 TPR method for Isocentric Reference Dose Definition 26.3.2.3 PDD method for SSD Reference Dose Definition 26.3.2.4 TPR Method for SSD Reference Dose Definition 26.4 Relationships between Dosimetric Quantities 26.4.1 TPR from PDD 26.4.2 PDD from One SSD to Another (TPR Method 26.4.3 Phantom Scatter Correction Factor Sp from TAR 26.5 Monitor Unit Calculations 26.5.1 General Methodology 26.5.2 Calibration Conventions 26.5.3 From Prescribed Dose to Monitor Unit Setting 26.5.4 Calculations for Rectangular Fields at the Standard Distance 26.5.4.1 Isocentric Treatment (Isocentric Calibration 26.5.4.2 Fixed SSD Treatment (SSD Calibration–PDD Method 26.5.4.3 Fixed SSD Treatment (SSD Calibration–TPR Method 26.5.5 Calculations for Modified Beams 26.5.5.1 Wedge Filters 26.5.5.2 Asymmetric Fields and Off-axis Calculation Points 26.5.5.3 Corrections for Inhomogeneities Chapter 27 Framework for Computation of Patient Dose Distribution 27.1 General Requirements 27.1.1 Accuracy 27.1.2 Speed 27.1.3 Combining Beam and Patient Data 27.2 Geometrical Issues 27.2.1 Density Scaling 27.2.2 Coordinate Transformation 27.2.3 Bitmap versus Vector-Based Geometry 27.3 Dose Issues 27.3.1 Calibration of Dose Calculation Algorithms 27.3.2 Dose to Water versus Dose to Tissue 27.4 Algorithm Classification Chapter 28 Photon Beams: Broad-Beam and Superposition Methods 28.1 Physical Background 28.2 Broad-Beam (Empirical) Methods 28.2.1 Simple Beams in Water 28.2.1.1 Tabulated Beam Data Representations 28.2.1.2 Analytical Beam Representations 28.2.2 Improvement of Off-Axis Calculations and Corrections for Wedge Filters 28.2.3 Correction for Patient Shape 28.2.3.1 The Effective Source–Skin Distance (SSD) Method 28.2.3.2 The Method Based on Tissue Phantom Ratio (TPR 28.2.4 Correction for Patient Inhomogeneities 28.2.4.1 The Effective-Depth TAR Correction Method 28.2.4.2 The Power-Law Correction (Batho Correction 28.2.4.3 Beam-Subtraction Method 28.2.4.4 Equivalent-Tissue-Air-Ratio (ETAR) Correction 28.2.5 Limitations and Drawbacks of Broad-Beam Methods 28.3 The Superposition Principle 28.4 Primary-Scatter Separation 28.4.1 Principle of the Method (Clarkson integration 28.4.2 Application to Cobalt-60 and Medium-Energy X-Ray Beams 28.4.2.1 In-Phantom Basic Measurements 28.4.2.2 ‘In-Air’ Beam Profiles 28.4.2.3 Intensity Modulation 28.4.2.4 Inhomogeneities 28.4.3 Extension to Higher Energies 28.5 Convolution/Superposition of Kernels 28.5.1 General Principle 28.5.2 Determination of the Energy Fluence and Terma at point P' (distant from P 28.5.2.1 Origin and Energy Distribution of the Photons 28.5.2.2 Modelling the Energy Fluence Incident on the Patient 28.5.2.3 Computing the Terma Distribution in the Patient 28.5.3 Convolution/Superposition of Energy Deposition Kernels 28.5.3.1 In-Water Energy Deposition Point Kernels 28.5.3.2 Beam Divergence and Tilting of the Kernels 28.5.3.3 Kernel Scaling According to Tissue Density and Tissue Inhomogeneities 28.5.3.4 Surface Electron Contamination and Exit Dose 28.5.4 Practical Implementation 28.5.5 Pencil-Beam Approach 28.5.5.1 General Principle 28.5.5.2 Determination of the Pencil-Beam Kernels 28.5.5.3 Some Practical Implementations 28.5.5.4 Inhomogeneities and Other Limitations 28.5.6 The Analytical Anisotropic Algorithm (AAA Chapter 29 Charged-Particle Beams: The Pencil-Beam Approach 29.1 Introduction 29.2 The Fermi–Eyges Pencil-Beam Algorithm (Hogstrom Model 29.2.1 General 29.2.2 Theory of the Fermi–Eyges Pencil-Beam Model 29.2.3 Adaptation of Fermi–Eyges Theory to the Treatment Situation 29.2.3.1 Modelling Electron Scattering 29.2.3.2 Incorporation of Measured Depth-Dose Curves 29.2.3.3 The Air-fluence Weighting Factor, Fair 29.2.3.4 The Final Expression for the Elementary Pencil 29.2.3.5 The Photon Dose 29.2.3.6 Practical Implementation for an Inhomogeneous Patient 29.2.4 Input Data 29.2.4.1 Measured Depth-Dose Distributions 29.2.4.2 Dose Profiles 29.2.4.3 The mean Energy at the Surface, E0 29.2.4.4 The Initial Angular Spread, s.x 29.2.4.5 The Penumbra Adjustment Factor, FMCS 29.3 Limitations of the Fermi–Eyges Pencil-Beam Model 29.4 Other Electron-Beam Algorithms 29.5 Tests of Electron Pencil-Beam Treatment Planning 29.6 Proton-Beam Algorithms 29.6.1 The Effect of Inhomogeneities 29.6.2 Methods of Proton Dose Computation in Patients 29.6.2.1 Ray Tracing 29.6.2.2 Pencil Beams Chapter 30 Monte-Carlo and Grid-Based-Deterministic Models for Patient Dose Computation 30.1 Introduction 30.2 The Monte-Carlo (MC) Method 30.2.1 Historical Background 30.2.2 Application to Radiation Transport 30.2.3 Simulation of Photon Transport 30.2.4 Simulation of Electron (or Positron) Transport 30.2.5 Coupled Photon–Electron Transport 30.2.6 Mathematical Techniques in Monte-Carlo Simulation 30.2.6.1 Random Number Generation 30.2.6.2 Elementary Sampling Theory 30.2.6.3 Displacements and Rotations 30.2.6.4 Estimating Means and Variances 30.2.6.5 Variance Reduction Techniques 30.2.7 Examples of Radiation Transport Simulation 30.3 Monte-Carlo-Based Patient-Dose Computation 30.3.1 Rationale 30.3.2 Monte-Carlo Radiation Transport Codes 30.3.3 Treatment-Machine Simulation 30.3.4 Simulation of the Dose Distribution in the Patient 30.3.5 Monte-Carlo Treatment Planning Implementations 30.3.6 Special Features of Monte-Carlo-Based Patient Dose Computation 30.3.6.1 Dose in Grays per Monitor Unit 30.3.6.2 Dose to Medium or Dose to Water 30.3.6.3 Computer Hardware Considerations 30.3.7 Future Of Monte-Carlo-Based Patient Dose Calculation 30.4 Grid-Based Deterministic Solutions of Radiation Transport 30.4.1 The Boltzmann Transport Equation 30.4.1.1 General Form of the Equation 30.4.1.2 Specific Form for Megavoltage Photon Beams 30.4.2 Grid-Based Solver of the Boltzmann Equation – the Acuros Implementation 30.4.3 Acuros Benchmarking References General Index Volume 02 Half Title Title Page Copyright Page Table of Contents Preface to the Second Edition The Editors List of Contributors to the Second Edition Notes for Readers Part G Treatment Planning Chapter 31 Target and Organ at Risk DefinitionDose Prescription and Reporting 31.1 Introduction 31.2 Definition of Volumes 31.2.1 The Reports of the International Commission on Radiation Units and Measurements (ICRU 31.2.2 Gross Tumour Volume (GTV 31.2.3 Clinical Target Volume (CTV 31.2.4 Internal Target Volume (ITV) and Set-Up Margin (SM 31.2.5 Planning Target Volume (PTV 31.2.6 Organ at Risk (OAR 31.2.7 Planning Organ-at-Risk Volume (PRV 31.2.8 Treated Volume (TV 31.2.9 Remaining Volume at Risk (RVR 31.3 Clinical Issues in Target Definition 31.3.1 Poor Organ/Tumour Definition 31.3.2 Inter-observer Variation 31.3.3 Internal Organ Movements 31.4 Prescribing and Reporting Dose 31.4.1 Levels for Prescribing and Reporting 31.4.2 The Conventional ICRU Reference Point 31.4.3 Dose-volume Considerations in the Target 31.4.4 Stereotactic Treatments with Small Photon Beams 31.4.5 Dose-volume Considerations in Organs at Risk 31.4.6 Other Information to Be Reported 31.4.7 Planning Aims versus Dose Prescription Chapter 32 Computed Tomography Imaging in Radiotherapy 32.1 Introduction 32.2 CT Scanners Used in Radiotherapy 32.2.1 Principle and Determination of Hounsfield Units (HU 32.2.2 Image Display – Window Width and Level 32.2.3 Terminology 32.2.4 Specific Features 32.2.4.1 General Performance 32.2.4.2 CT Aperture 32.2.4.3 Flat Table Top 32.2.4.4 Patient-Positioning Lasers 32.3 The CT Imaging Process for Radiotherapy Planning 32.3.1 Planning CT Workflow 32.3.1.1 General Workflow 32.3.1.2 Data Exchange 32.3.1.3 Integrated Virtual Simulation 32.3.2 Patient Orientation 32.3.3 Patient Reference Coordinate System 32.3.3.1 DICOM Image Coordinate System and DICOM Image Origin 32.3.3.2 TPS System of Coordinates, CT Origin and Plan Origin 32.3.4 Acquisition and Reconstruction Parameters 32.3.5 Contrast-Enhanced CT 32.3.6 Examples of Specific Protocols 32.3.6.1 Breast Tumours and Cardiac Issues 32.3.6.2 Lung, Thorax and Abdomen – Respiration Management 32.3.6.3 Head-and-Neck and Pelvic Sites – Adaptive Radiotherapy 32.3.6.4 Paediatrics 32.3.6.5 Implanted Markers and Metallic Artefacts 32.3.6.6 Proton Therapy Planning 32.4 Special Issues 32.4.1 CT Numbers Calibration and Tissue Assignment 32.4.1.1 Conventional Calibration Method for Assessment of Tissue Density 32.4.1.2 The Stoichiometric Method 32.4.1.3 Tissue Assignment 32.4.2 CT Artefacts 32.4.2.1 Motion and Metal Artefacts 32.4.2.2 Treatment Planning in Presence of Metal Artefacts 32.4.2.3 Perspectives in Reduction of Metal Artefacts 32.4.3 Respiration Management 32.4.3.1 Breathing-Related Treatment Strategies 32.4.3.2 Using Standard (3D) CT – Free Breathing and Breath-Hold Options 32.4.3.3 4D Respiration-Correlated CT 32.4.3.4 4D Treatment Planning 32.4.3.5 Prospective Image Acquisition for Gated Treatment 32.4.4 Optimising Patient CT Dose Chapter 33 Magnetic Resonance Imaging in Treatment Planning 33.1 Introduction 33.2 Principles of Magnetic Resonance Imaging 33.3 Rationale for the Use of MRI in Treatment Planning 33.4 Contrast Agents and Specialised MR Sequences 33.4.1 Dynamic Contrast Enhanced (DCE) MRI 33.4.2 Blood Oxygenation Level-Dependent (BOLD) MR Sequences 33.4.3 Diffusion-Weighted (DW) MRI 33.4.4 Magnetic Resonance Spectroscopy (MRS 33.4.5 Ultrasmall Superparamagnetic Iron Oxide (USPIO) Particles 33.5 Problems with the Use of MRI in Treatment Planning 33.5.1 Electron Density Information 33.5.2 Imaging of Bone 33.5.3 Magnetic Resonance Image Distortion 33.5.3.1 System-Related Distortions 33.5.3.2 Object-Induced Distortions 33.5.3.3 Magnetic Resonance Correction of Image Distortion 33.6 Other Considerations Affecting Use of MRI for Treatment Planning 33.6.1 General Considerations 33.6.2 Motion 33.7 Methods to Allow the Use of MRI in Treatment Planning 33.7.1 Image Registration 33.7.2 MR-Alone Planning 33.8 Clinical Sites of MRI Applications in Treatment Planning 33.8.1 Brain 33.8.2 Head and Neck 33.8.3 Lymphoma 33.8.4 Pelvis 33.8.5 Rectum 33.8.6 Brachytherapy Chapter 34 Radionuclide Imaging in Treatment Planning 34.1 Introduction 34.2 Selection of Radionuclides and Radiopharmaceuticals 34.2.1 Radiopharmaceuticals for PET Imaging 34.2.2 Radiopharmaceuticals for SPECT Imaging 34.3 Quantitative Aspects of Hybrid Emission Imaging 34.3.1 Quantitative Parameters 34.3.2 Attenuation and Scatter Corrections 34.3.3 Partial-Volume Effect 34.3.4 Delineation of the Target Volume 34.3.5 Image Registration Issues 34.3.6 Comparison and Stability of Performance 34.4 PET Imaging Sequences 34.4.1 PET Static Imaging 34.4.2 PET Dynamic Imaging 34.4.3 Four-Dimensional (4D) PET imaging 34.5 SPECT Imaging 34.6 Functional Imaging and Radiomics 34.6.1 Multimodality Imaging for Improved Planning 34.6.2 Tissue Characterisation with Radiomics for Optimal Dose Delivery Chapter 35 Image Registration, Segmentation and Virtual Simulation 35.1 Introduction 35.2 Image Registration 35.2.1 Fundamentals of Multimodality Image Registration 35.2.2 Extrinsic Methods of Image Registration 35.2.3 Intrinsic Methods of Image Registration 35.2.3.1 Landmark-based registration 35.2.3.2 Structure-based registration 35.2.3.3 Voxel-based registration 35.2.3.4 Deformable registration 35.2.4 Evaluation of Registered Images 35.3 Image Segmentation 35.3.1 Volumes of Interest – Structures 35.3.2 Tools for Delineation of Structures 35.3.3 Structure Editing – Application of Margins 35.3.4 Consensus Guidelines – Atlas-Based Segmentation 35.4 Virtual Simulation and Three Dimensional Conformal Radiotherapy 35.4.1 Principle of Virtual Simulation 35.4.2 Beam Axis Direction – the Beam’s-Eye View concept 35.4.3 Field Shaping 35.4.4 Digitally Reconstructed Radiographs (DRRs 35.4.5 Tangential Beams for Breast Treatment Chapter 36 Photon-Beam Forward Planning Techniques 36.1 Introduction 36.2 Single-Beam Treatments 36.2.1 Kilovoltage Beams 36.2.2 Megavoltage Beams 36.3 Two-beam Arrangements 36.3.1 Parallel Opposed Pair 36.3.2 Beam Weighting 36.3.3 Wedge Filters 36.3.4 Segmented Fields 36.3.5 Tangential Beams 36.3.6 Wedged Pair Beams 36.3.7 Photon and Electron Beams 36.4 Multiple Coplanar Beams 36.4.1 Three-Beam Arrangements 36.4.2 Four-Beam Arrangements 36.4.3 Arrangements with More than Four Beams 36.5 Non-coplanar Beams 36.6 Fixed Source–Surface Distance Beams vs. Isocentric Treatments 36.7 Extended Source–Surface Distances 36.8 Matching Fields 36.8.1 Abutting Fields with Parallel Axes 36.8.2 Matching Single Fields to Parallel Opposed Pairs 36.8.3 Matching Adjacent Beams in Inclined Planes 36.8.4 Matching Electron to Photon Fields Chapter 37 Intensity-Modulated Radiation Therapy and Inverse Planning 37.1 Introduction 37.1.1 The Limit of Three-Dimensional Conformal Radiotherapy (3D-CRT 37.1.2 The Principle of Intensity-Modulated Radiation Therapy (IMRT 37.1.3 The Process of IMRT 37.2 Inverse Planning Methods 37.2.1 General Goal 37.2.2 What Can Be Optimised 37.2.2.1 Beam Fluence 37.2.2.2 Beam Direction 37.2.2.3 Volumetric Modulated Arc Therapy 37.2.3 Intensity Modulation – Optimisation Criteria 37.2.3.1 Objectives 37.2.3.2 Importance Factors 37.2.3.3 Cost Functions 37.2.4 Optimisation Algorithms 37.2.4.1 Constructing and Minimising the Cost Function 37.2.4.2 Gradient Descent Methods 37.2.4.3 Simulated Annealing 37.2.4.4 Dose Calculation Issues 37.2.4.5 Multicriteria Optimisation and Pareto-Optimal Solutions 37.3 Generation of Deliverable Beams 37.3.1 Beam Delivery Techniques and Sequencers 37.3.1.1 Role of Sequencers 37.3.1.2 Step and Shoot 37.3.1.3 Sliding Window 37.3.2 Machine-Related Constraints 37.3.2.1 Minimum Leaf Separation and Interdigitation 37.3.2.2 Tongue-and-Groove Effect 37.3.2.3 Leaf Overtravel 37.3.2.4 Leaf Speed 37.3.2.5 Dose per Segment 37.3.2.6 Gantry Constraints 37.3.3 Recomputation of the Dose Distribution – MLC-Related Dosimetric Parameters 37.3.4 Direct Aperture Optimisation 37.3.5 Volumetric Modulated Arc Therapy (VMAT 37.4 Alternative Beam Delivery Systems 37.4.1 TomoTherapy 37.4.2 CyberKnife 37.5 Practical IMRT Planning 37.5.1 Forward IMRT Planning 37.5.1.1 IMRT as Replacement for Compensators 37.5.1.2 Field-in-Field 37.5.2 Clinical Inverse Planning 37.5.2.1 IMRT Structures for Optimisation 37.5.2.2 Skin Flash Issues 37.5.2.3 Dose Objectives 37.5.2.4 Importance Factors 37.5.2.5 Class Solutions 37.5.2.6 Simultaneous Integrated Boosts 37.5.3 VMAT Issues 37.5.4 Deliverability Issues 37.5.4.1 Robust Optimisation 37.5.4.2 Machine Deliverability Issues 37.5.4.3 Moving Targets – the Interplay Effect 37.5.5 Enhanced Automated Planning 37.5.6 Evaluating IMRT Plans and IMRT Dose Reporting 37.6 Site-Specific Treatment Planning Issues 37.6.1 Prostate IMRT 37.6.2 Head and Neck IMRT 37.6.3 Breast IMRT 37.6.3.1 Forward Planning 37.6.3.2 Inverse Planning 37.6.4 Lung IMRT – Motion and Low Density Issues 37.7 Implementation of IMRT 37.7.1 Commissioning 37.7.2 Training Chapter 38 Electron-Beam Treatment Planning Techniques 38.1 Introduction 38.2 Checklist for Electron Treatment Planning 38.3 Field Size and Coverage of the Target Volume 38.4 Examples of Electron Planning 38.4.1 Example A: Standard Single Beam Treatment 38.4.2 Example B: Use of Internal Shielding 38.4.3 Example C: Single Beam with Surface Irregularities 38.4.4 Example D: Single Beam with Obliquity 38.5 Field Matching 38.6 Special Electron Techniques 38.6.1 Electron Arc Therapy 38.6.2 Matched Photon and Electron Beams 38.6.3 Modulated Electron Radiotherapy 38.7 Inhomogeneities and Electron Planning Algorithms 38.8 Prescribing and Reporting Electron Therapy Chapter 39 Proton-Beam Treatment Planning Techniques 39.1 Introduction 39.2 Fundamentals of Proton Beam Planning 39.2.1 Planning for Passive-Scattering Proton Therapy 39.2.1.1 Plan Design 39.2.1.2 Beam Angle Selection 39.2.1.3 Aperture Design 39.2.1.4 Range Compensator Design 39.2.1.5 Selection of Range and Modulation 39.2.1.6 Beam Patching 39.2.1.7 Mixed Modalities 39.2.2 Planning for Active-Scanning Proton Therapy 39.2.2.1 Plan Design 39.2.2.2 Beam Angle Selection 39.2.2.3 Robustness of Multiple-Beam Plans 39.2.2.4 Options for Optimisation of the Dose Distribution: SFUD, SFO and IMPT 39.2.2.5 Uncertainties and Margins 39.3 Clinical Examples 39.3.1 Intracranial Targets 39.3.2 Prostate 39.3.3 Head and Neck 39.3.4 Cranio-Spinal Tumours 39.3.5 Ophthalmic Applications 39.3.6 Proton Radiosurgery 39.4 Special Issues 39.4.1 The RBE-Weighted Dose Concept 39.4.2 Dealing with Metal Implants 39.4.2.1 Accounting for the Perturbations from Metal Implants 39.4.2.2 Accounting for Streak Artefacts 39.4.3 Motion – Interplay Effect 39.4.4 Inter-Fraction Anatomical Changes – Adaptive Proton Therapy 39.4.4.1 Minimising the Impact of Anatomical Changes 39.4.4.2 Assessing the Impact of the Changes 39.4.4.3 Adapting the Plan Chapter 40 Intracranial and Body Stereotactic Radiotherapy 40.1 Introduction 40.2 Equipment Used for Stereotactic Treatments 40.2.1 Intracranial Stereotactic Radiosurgery (SRS) and Radiotherapy (SRT 40.2.2 Multipurpose Equipment for Stereotactic Radiotherapy 40.3 Stereotactic Frames for Intracranial SRS and SRT 40.3.1 Neurosurgical Invasive Frames 40.3.2 Relocatable Frames 40.4 Fiducial Systems for Intracranial SRS and SRT 40.5 Stereotactic Body Radiation Therapy (SBRT) for Extracranial Sites 40.5.1 From Intracranial SRT to SBRT 40.5.2 Patient Fixation 40.6 Treatment Planning and Beam Commissioning 40.7 Optimisation of Dose Distribution 40.8 Patient Set-Up and treatment 40.9 Accuracy, Dose Prescription and Reporting 40.10 Quality Assurance Chapter 41 Total Body Irradiation 41.1 Clinical Goals 41.2 Dose and Dose Rate 41.3 Dose Specification 41.4 Available Techniques 41.4.1 Specialised Facilities 41.4.2 Horizontal Beam Techniques 41.4.3 Techniques with the Patient Lying beneath the Accelerator 41.4.4 Intensity Modulated Techniques 41.5 Dose Calculation and Dosimetry 41.5.1 General Considerations 41.5.2 Choice of Energy 41.5.3 Dose Measurement 41.5.4 Dose Calculation 41.5.5 Compensation 41.6 Dosimetric Accuracy Chapter 42 Total Skin Electron Irradiation 42.1 Introduction 42.2 General Clinical and Patient-Related Problems 42.3 Techniques of Irradiation 42.3.1 The Stanford Technique 42.3.2 The Rotational Technique 42.3.3 Patient Lying Down 42.4 Beam Characteristics 42.4.1 Beam Energy 42.4.2 X-Ray Contamination 42.4.3 Dose Rate and Treatment Time 42.5 Beam Calibration and Dose Measurements 42.6 Practical Implementation 42.7 Quality Assurance Chapter 43 Dose Evaluation of Treatment Plans 43.1 Introduction 43.2 Isodose Display 43.3 Dose-Volume Analysis 43.3.1 Definition and Application of Dose-Volume Histogram 43.3.2 Methods for Dose-Volume Histogram Calculation 43.3.2.1 Sampling Methods 43.3.2.2 Dose Binning and Graphical Representation 43.3.2.3 Boolean Operations on Structures for Dose-Volume Histogram Calculations 43.4 Dose-Volume Metrics 43.5 Conformity and Homogeneity Indices 43.5.1 Conformity 43.5.1.1 General Definition 43.5.1.2 Intracranial Stereotactic Treatments 43.5.1.3 Stereotactic Body Radiation Therapy (SBRT 43.5.2 Homogeneity 43.6 Limitations of Dose-Volume Histograms 43.7 Clinical Use of Dose-Volume Analysis 43.7.1 Correlation between Dose-Volume Metrics and Clinical Outcome 43.7.2 Tools for Comparison of Dose-Volume Histograms 43.7.3 Knowledge-Based Radiotherapy Planning Chapter 44 Radiobiological Evaluation and Optimisation of Treatment Plans 44.1 Introduction 44.2 Modelling the Probability of Tumour Control (TCP) 44.2.1 Introduction 44.2.2 Desirable Properties of a TCP Model 44.2.3 Empirical vs. Mechanistic Approaches 44.2.4 The ‘No Surviving Clonogen’ Hypothesis and Poisson Statistics 44.2.5 The Linear-Quadratic Expression for Surviving Fraction, Incorporating Fractionation 44.2.6 The ‘Standard Model’ for Tumour Control Probability 44.2.7 The Slope of Theoretical vs. Clinical TCP vs. Dose Curves 44.2.8 The ‘Marsden’ Population TCP Model; Relationship between N0, a _ and s a 44.2.9 The Relationship between N0, a _ and s a 44.2.9.1 Incorporating Heterogeneous Doses: Voxel-Based and DVH-Based Formalisms 44.2.9.2 Application to Inhomogeneous Doses in Radiotherapy Treatment Plans 44.2.10 The Complete Expression for the ‘Marsden’ Mechanistic Population-TCP Model 44.2.11 Modification for Clonogen Repopulation during Treatment 44.2.12 The Effect of Tumour Dose Heterogeneity on TCP 44.2.13 Which Target Volume Should Be Used to Estimate TCP 44.2.14 Application of the TCP Model to Patient Data 44.3 Normal-Tissue Complication Probability (NTCP) 44.3.1 Pathogenesis of Radiotherapy Side Effects 44.3.1.1 Tissue Damage 44.3.1.2 Organ Failure 44.3.2 Organ Architecture Models 44.3.2.1 Functional Subunits 44.3.2.2 The Critical-Element Model 44.3.2.3 The Critical Volume/Parallel-Architecture Model 44.3.2.4 The Relative Seriality Model 44.3.3 Empirical Dose-Volume-Response Modelling 44.3.3.1 Sigmoid Population Response Curves 44.3.3.2 The LKB Model – Homogeneous Irradiation 44.3.3.3 The LKB Model – Inhomogeneous Irradiation 44.3.3.4 Alternative Definitions of EUD 44.3.3.5 The Critical Volume Model 44.3.4 Relationships between Dose-Volume-Response Models 44.3.5 Limitations of Empirical DVH-Based Models 44.3.6 Incorporating Non-Dosimetric Variables 44.3.7 Effect of Fraction Size 44.3.8 Parameter Fitting 44.3.8.1 The Maximum Likelihood Method 44.3.8.2 Confidence Intervals for NTCP Estimates 44.3.9 Model Performance 44.3.9.1 Bootstrap Analysis 44.3.10 Advanced Statistical Models 44.3.11 NTCP Parameter Values for Clinical Endpoints 44.3.11.1 Ano-Rectal Complications 44.3.11.2 Radiation-Induced Liver Disease (Radiation Hepatitis 44.3.11.3 Radiation Pneumonitis 44.4 Use of TCP and NTCP Models in Radiotherapy Treatment Planning 44.4.1 Data Management 44.4.2 Quality Assurance of Radiobiological Models 44.4.3 Radiobiological Optimisation 44.4.4 The Different ‘Levels’ of Radiobiological Optimisation 44.4.4.1 Isotoxic Prescription Dose Individualisation (Level I 44.4.4.2 Isotoxically-Based Individualisation of the Number of Fractions (Level II 44.4.4.3 Inverse Planning Based on TCP, NTCP and EUD (Level III 44.4.4.4 Patient-Specific Information from Functional Imaging added to Radiobiological Inverse Planning (Level IV 44.4.4.5 Individual Patient ‘Biology’, e.g. from Genomics, added to any of the Previous Levels (Level V References Part H Quality Assurance Chapter 45 Quality and Safety Management 45.1 Introduction 45.2 Definitions 45.2.1 Quality Control (QC) 45.2.2 Quality Assurance (QA) 45.2.3 Quality Management (QM) 45.2.4 Quality Audit 45.2.5 Safety 45.2.6 Accuracy, Precision and Tolerance 45.2.6.1 Uncertainty in Measurement 45.2.6.2 Coverage Factor 45.2.6.3 Repeatability and Reproducibility 45.2.6.4 Precision and Accuracy 45.2.6.5 Tolerance and Action Level 45.3 Requirements of a Quality Management System in Radiotherapy 45.3.1 General Requirements 45.3.2 Process Approach 45.3.3 Continual Improvement 45.3.4 Audit 45.3.5 Documentation 45.3.6 Training 45.4 Required Accuracy in Radiotherapy 45.4.1 Dose–Effect Relationships 45.4.2 Required Accuracy in Absorbed Dose Delivery 45.4.3 Required Accuracy in Absorbed Dose Distributions 45.4.4 Required Geometric Accuracy in Radiotherapy 45.4.5 Overall Accuracy Requirements 45.5 Accuracy Currently Achievable 45.5.1 General 45.5.2 Estimation of Achievable Uncertainties on Delivered Dose 45.5.2.1 General Principle 45.5.2.2 Reference Dose Uncertainties 45.5.2.3 Relative Dose Uncertainties 45.5.2.4 Dose Calculation Uncertainties 45.5.2.5 Uncertainties in Dose Delivery 45.5.2.6 Overall Uncertainty 45.5.2.7 Uncertainty in Brachytherapy 45.5.2.8 Acceptable Deviation on Delivered Dose 45.5.3 Estimation of Achievable Geometric Uncertainties 45.6 Radiation Incidents 45.6.1 Terminology of Radiation Incidents 45.6.2 Learning from Experience and Reporting Incidents 45.6.3 Risk Assessment 45.6.4 Corrective and Preventive Actions 45.7 Contribution of Medical Physicists to the Radiotherapy Quality System 45.7.1 Roles and Responsibilities in Radiotherapy 45.7.2 Document and Record Management 45.7.3 From Equipment Acquisition to Clinical Use 45.7.3.1 Specification 45.7.3.2 Acceptance 45.7.3.3 Commissioning 45.7.4 Initial and On-Going Quality Control (QC) of Equipment 45.7.4.1 The QC Procedures 45.7.4.2 Monitoring the Quality Control Results 45.7.5 Patient-Specific Quality Assurance (QA 45.7.6 Tools and Software for QA 45.8 Quality Control of Clinical Trials Chapter 46 Quality Control of High-Energy External Beams 46.1 Introduction 46.1.1 Quality Control of Linear Accelerators and Cobalt Machines 46.1.1.1 New Technologies/Techniques 46.1.2 Responsibilities 46.1.3 Tolerances 46.2 Isocentric Treatment Machines 46.2.1 Mechanical Alignment of Isocentric Machines 46.2.1.1 Optical Alignment Checks 46.2.1.2 Definitive Mechanical Isocentre Assessment 46.2.1.3 Isocentric Couch Rotation Axis 46.2.1.4 Establishment of the Vertical Axis 46.2.1.5 Six Degrees of Freedom (6DoF) Couch Tops 46.2.1.6 Considerations Relating to the Mechanical Isocentre 46.2.2 Use of Film in Quality Assurance 46.2.3 Radiation Beam Alignment 46.2.3.1 Radiation Isocentre 46.2.3.2 Radiation and Light Field Coincidence 46.2.3.3 Considerations Relating to Radiation Alignment of the Beam 46.2.3.4 Interpretation of Alignment Checks 46.3 Alignment and Quality Control of Multi-Leaf Collimators 46.3.1 Leaf Calibration 46.3.2 Alignment of the MLC to the Treatment-Machine Axes 46.3.3 Leakage between Leaves 46.3.4 Variation with Gantry Angle 46.3.5 QA for IMRT 46.3.5.1 Relative Spatial Position of Opposing Leaves 46.3.5.2 Dynamic Leaf Movements and Dose Delivery 46.3.5.3 Mechanical Integrity 46.3.5.4 Beam Output and Symmetry 46.3.5.5 Interleaf Leakage and Transmission 46.3.5.6 Small Field Dosimetry 46.3.6 QA for Rotational IMRT 46.3.7 Static IMRT Test Protocols 46.3.8 VMAT Protocols 46.3.9 External Audit 46.3.10 Commercial Measurement Phantoms for IMRT QC 46.3.11 MLC Log Files 46.4 Flatness and Symmetry of Photon Beams 46.4.1 Quality Control of Flatness and Symmetry 46.4.2 Adjustment of Photon Beam Flatness and Symmetry 46.5 X-ray Beam Energy 46.6 Quality Control of Electron Beams 46.6.1 Electron Beam Flatness and Symmetry 46.6.2 Electron Beam Energy 46.6.2.1 Energy Selection 46.6.2.2 Quality Control of Electron Energy 46.6.3 Applicator Factors 46.7 Measurement of Percentage Depth Dose 46.8 Quality Control of Treatment Unit Output 46.8.1 Strategies for Quality Control of Treatment Unit Dose Calibration 46.8.1.1 Definitive Calibration 46.8.1.2 Routine Calibration 46.8.1.3 Constancy Checks 46.8.1.4 Frequency of Checks 46.8.2 Use of Ionisation Chambers for Output Calibration 46.8.3 Practical Issues in Photon Calibrations 46.8.4 Calibration of Units Controlled by a Timer 46.8.5 Electron Output 46.9 Special Situations 46.9.1 Machines That Cannot Create a 10 cm Square Field 46.9.2 Flattening Filter Free Beams 46.10 Checks on Dosimeters 46.10.1 Ionisation Chambers 46.10.2 Thermoluminescent Dosimeters 46.10.3 Diodes 46.10.4 Constancy Devices 46.10.5 Testing of Diode or Ionisation Chamber Arrays 46.11 Phantoms and Phantom Materials 46.12 Quality Assurance of Imaging Devices 46.12.1 Mechanical Stability 46.12.2 Application/Software Checks 46.12.3 Image Quality Assessment 46.12.3.1 Subjective Image Analysis 46.12.3.2 Objective Image Analysis 46.12.4 Imaging Dose 46.12.5 Quality Control of Image Data Chapter 47 Quality Assurance of the Treatment Planning Process 47.1 The Treatment Planning Process 47.1.1 Definition of Treatment Planning 47.1.2 Equipment and Data Exchange 47.1.3 Quality Assurance in Treatment Planning 47.1.4 Risk Analysis of the Treatment Planning Process 47.2 Quality Assurance of Patient Data Acquisition 47.2.1 Quality Assurance of Equipment Used for Patient Data Acquisition 47.2.2 Procedures for Patient Data Acquisition 47.2.3 Transferring Data to the Planning System 47.3 Treatment Planning Systems 47.3.1 Hardware 47.3.2 Software Functions 47.3.3 Accuracy and Tolerances 47.3.3.1 Expressing Deviations and Setting Tolerances 47.3.3.2 Acceptance Criteria: Confidence Limit Concept 47.3.3.3 Global Assessment of Dose Distributions: the Gamma Index 47.4 Implementation of Treatment Planning Systems 47.4.1 The Specification and Purchase Process 47.4.2 Acceptance of a Treatment Planning System 47.5 Commissioning a Treatment Planning System 47.5.1 Aim of Commissioning 47.5.2 Construction of the Beam Data Library 47.5.2.1 Data Related to Identification of the Equipment 47.5.2.2 Geometrical Data 47.5.2.3 Dosimetric Data 47.5.3 Verification of the Non-Dosimetric Features 47.5.3.1 Anatomical Data 47.5.3.2 Beam Definition and Representation 47.5.4 Verification of the Dosimetric Features 47.5.4.1 Accuracy Assessment for Simple Situations Using Reference Data 47.5.4.2 Accuracy Assessment for Patient-Related Perturbations 47.5.4.3 Accuracy Assessment for Intensity-Modulated Radiation Therapy 47.5.5 End-to-End Assessment of a Treatment Planning System 47.6 Periodic Checks of the Treatment Planning System 47.6.1 Regular Quality Control Checks 47.6.2 After Changes to the Beam Data Library 47.6.3 After a New Software Release 47.6.4 Replacement of an Existing Treatment Planning System 47.7 Patient-specific Pre-Treatment Quality Assurance 47.7.1 Independent Plan Review 47.7.2 Independent Calculation of Monitor Units 47.7.3 In-Phantom Verification of IMRT Plans Chapter 48 Quality Assurance of Treatment Delivery 48.1 Verification of Beam Parameters and Treatment Scheduling 48.1.1 Recording and Verification in External Beam Radiotherapy 48.1.2 Monitoring of Treatment Machine Control Systems 48.1.3 Implementation of the Record and Verification System 48.1.3.1 Workflow in the Radiotherapy Department 48.1.3.2 Data Entry and Checking 48.1.3.3 Data Retrieval 48.1.3.4 Computer-Assisted Setup 48.1.3.5 Record Keeping 48.1.4 System Management 48.1.4.1 Passwords 48.1.4.2 Tolerance Tables 48.1.4.3 Backup and Archiving 48.1.4.4 System Resilience 48.1.5 Error Control 48.1.5.1 Types of Error and Measures to Avoid Them 48.1.5.2 Training Requirements 48.1.5.3 Use of Override Facilities 48.1.6 Quality Assurance of the Record and Verify Systems 48.1.7 The Networked Department 48.1.7.1 Dedicated Radiotherapy Network 48.1.7.2 Integration with Hospital Information System 48.2 Verification of Patient Positioning 48.2.1 Historical Background 48.2.2 Initial Patient Setup 48.2.3 Verification Based on Portal Images of the Treatment Field 48.2.3.1 General Principle 48.2.3.2 Matching Structures and Registration Methods 48.2.4 Verification Based on Specific Setup Beams 48.2.4.1 Rationale for Orthogonal Setup Beams 48.2.4.2 Registration Using Matching Structures 48.2.4.3 Using Implanted Markers 48.2.5 Verification Based on 3D Volumetric Imaging 48.2.5.1 Cone-beam Computed Tomography (CBCT 48.2.5.2 Megavoltage CT imaging (MVCT 48.2.6 Verification with Non-Ionising Radiation Imaging 48.2.6.1 Ultrasound 48.2.6.2 Magnetic Resonance Imaging 48.2.7 Methods for Correcting Misalignment 48.2.8 Strategy for Patient Setup Corrections 48.2.8.1 General Principles 48.2.8.2 Basis for CTV to PTV Margins 48.2.8.3 Off-Line Correction Protocols 48.2.8.4 On-Line Correction Protocols 48.2.9 Intra-Fraction Real-Time Movement Detection 48.2.9.1 External Movement Detection 48.2.9.2 Internal Movement Detection 48.2.9.3 Respiratory Management 48.2.10 Dose Issues 48.3 In Vivo Verification of Dose Delivery 48.3.1 Introduction 48.3.2 Choice of Detectors 48.3.2.1 Detectors for Point Dosimetry 48.3.2.2 Detectors for Transit Dosimetry 48.3.3 Methodology for Point Dosimetry 48.3.3.1 Calibration Procedure and Correction Factors for Photon Beams 48.3.3.2 Skin Dose Measurements 48.3.3.3 Entrance Dose Measurements 48.3.3.4 Exit Dose Measurements 48.3.3.5 Target and Midplane Doses 48.3.3.6 Intracavitary and Interstitial Dose Measurements 48.3.4 Methodology for EPID-Based Transit Dosimetry 48.3.4.1 EPID Calibration 48.3.4.2 Back-Projection to Calculate the Dose inside the Patient 48.3.5 Clinical Application in External Radiotherapy 48.3.5.1 Target Dose Verification in External Beam Radiotherapy 48.3.5.2 Dose to Organs-at-Risk Close to or Outside the Irradiation Field 48.3.5.3 Intraoperative Irradiation 48.3.6 Proton Range Verification 48.4 Adaptive Radiotherapy 48.4.1 Rationale 48.4.2 Online Adaptation – the Goal 48.4.3 Adaptive Strategies 48.4.4 A Process for Plan Adaptation 48.4.5 Quality and Safety Issues Chapter 49 Data Communication with DICOM 49.1 Introduction 49.2 Elements of the Standard 49.2.1 The Data Format 49.2.2 Data Organisation 49.2.3 DICOM Actions (Service Classes 49.2.4 DICOM Identifiers (Unique Identifiers 49.2.5 Data Communication 49.2.5.1 Users and Providers 49.2.5.2 DICOM Data Transfer 49.2.6 The DICOM Conformance Statement 49.2.7 Data Translation and Quality Assurance 49.3 DICOM Applied to Diagnostic Image Data 49.3.1 DICOM Worklist 49.3.2 Media Storage 49.3.3 Magnetic Resonance Images 49.3.3.1 DICOM Issues with MR Functional Sequences Useful for Radiotherapy Treatment Planning 49.3.3.2 MR Series Acquisitions in Non-Transaxial Planes 49.3.3.3 MR-Based Radiotherapy Planning without CT Scans 49.3.4 DICOM Print Function 49.4 Radiotherapy Data Objects 49.4.1 DICOM RT Structure Set 49.4.2 DICOM RT Plan 49.4.3 DICOM RT Dose 49.4.4 DICOM RT Image 49.4.5 DICOM Spatial Registration Object 49.4.6 DICOM RT Treatment Record 49.4.7 DICOM RT Brachytherapy Application Setups 49.4.8 Other Data Formats 49.4.9 DICOM RT Dependencies 49.5 Data Visualisation in the Radiotherapy Process 49.5.1 Target Volumes 49.5.2 Planning Radiotherapy Image Viewing 49.5.3 Dose Planning 49.5.4 Dose Plan Viewing 49.5.5 Treatment Verification Image Viewing 49.5.6 Recording Approval 49.6 De-identification of DICOM Data 49.7 Quality-Assurance-Related Issues 49.8 Second Generation RT Objects References Part I Brachytherapy Chapter 50 Brachytherapy Clinical Introduction 50.1 History and Rationale for Brachytherapy 50.2 Intracavitary Brachytherapy 50.3 Interstitial Brachytherapy 50.4 Intraluminal Brachytherapy 50.5 Superficial Brachytherapy 50.6 Ophthalmic Applicators 50.7 Integration of Brachytherapy with External-Beam Radiotherapy 50.8 Dose-Rate Effects 50.9 Developments Chapter 51 Calibration and Quality Assurance of Sources 51.1 Introduction 51.2 Particular Sources 51.2.1 Radium-226 51.2.2 Radon-222 51.2.3 Caesium-137 51.2.4 Iridium-192 51.2.5 Cobalt-60 51.2.6 Gold-198 51.2.7 Iodine-125 51.2.8 Beta Sources: Strontium-90, Yttrium-90, Ruthenium-106 and Phosphorus-32 51.2.9 Other Sources 51.2.9.1 Palladium-103 51.2.9.2 Samarium-145 51.2.9.3 Americium-241 51.2.9.4 Ytterbium-169 51.2.9.5 Californium-252 51.2.9.6 Caesium-131 51.2.9.7 Thulium-170 51.3 Specification of Brachytherapy Source Strength 51.4 Calibration of Brachytherapy Sources 51.4.1 Long-Half-Life Sources of Low Activity (226Ra, 137Cs and 60Co 51.4.2 Sources Used in Automatic Afterloading Systems (137Cs, 192Ir and 60Co 51.4.3 Short-Half-Life Sources of Low Activity such as 198Au, 192Ir and 125I Sources 51.4.4 Ophthalmic Applicators 51.4.4.1 Beta-ray Applicators 51.4.4.2 Photon-emitting Seed-Based Applicators 51.5 Quality Assurance of Sealed Sources 51.5.1 Leakage and Contamination Checks 51.5.2 Radiography and Autoradiography Chapter 52 Afterloading Equipment for Brachytherapy 52.1 Introduction 52.2 Manual Afterloading 52.3 Remote-Controlled Afterloading 52.3.1 Low and Medium Dose Rates 52.3.2 High Dose Rates 52.3.3 Pulsed Dose Rate 52.4 Applicators 52.4.1 Gynaecological Applicators 52.4.2 Needles 52.4.3 Rectal Applicators 52.4.4 Bronchial Applicators 52.4.5 Oesophageal Applicators 52.4.6 Nasopharynx and Oropharynx 52.4.7 Breast Treatment 52.4.8 Skin Applicators 52.5 Quality Assurance for Afterloading Systems 52.5.1 Source Positioning 52.5.2 Machine Function 52.5.3 Facility Checks 52.5.4 Emergency Procedures 52.5.5 Other Considerations Chapter 53 Dose Calculation for Brachytherapy Sources 53.1 Introduction 53.2 Traditional Analytical Calculation Methods 53.2.1 Dose from a Point Source 53.2.2 Extension to a Line Source 53.3 The AAPM Task Group 43 Approach 53.3.1 Overview of the TG-43 Reports 53.3.2 The TG-43 Formalism 53.3.3 Application of TG-43 to 192Ir Dosimetry 53.3.4 Application of TG-43 to 125I Dosimetry 53.3.4.1 Changes to 125I Seed Calibration 53.3.4.2 Seed Orientation 53.3.5 Corrections to TG-43 Calculation 53.3.5.1 Shielding by Other Sources 53.3.5.2 Applicator Shielding 53.3.5.3 Inhomogeneity Corrections 53.3.6 Sources of TG-43 Data 53.4 Model-based Dose Calculation 53.4.1 Choice of Medium 53.4.2 Transition Issues 53.5 Decay Correction 53.6 Conversion Factors between Units 53.6.1 The Roentgen 53.6.2 Radium Equivalence 53.6.3 Activity Units Chapter 54 Brachytherapy Treatment Planning 54.1 Interstitial Implants 54.1.1 Introduction 54.1.2 Paris Predictive Dose-Planning System 54.1.2.1 Basic Principles 54.1.2.2 Contribution from Individual Sources 54.1.2.3 Single and Multiple Planar Implants 54.1.2.4 Nonplanar Implants 54.1.2.5 Dose Specification and Calculation 54.1.3 Dose Calculation for Real Implants 54.1.4 ICRU Recommendations on Dose and Volume Specification in Interstitial Brachytherapy 54.1.4.1 Description of Volumes 54.1.4.2 Reference Dose 54.1.4.3 High- and Low-Dose Volumes 54.1.4.4 Dose Uniformity 54.1.4.5 Implant Duration 54.2 Gynaecological Intracavitary Treatments 54.2.1 Introduction 54.2.2 Historical Background: Manchester Radium System 54.2.3 Extension of the Manchester System to Remote Afterloading 54.2.3.1 Geometrical Considerations 54.2.3.2 Early Approaches to Optimisation 54.2.4 HDR Treatment of Gynaecological Carcinomas 54.2.4.1 Treatment of Carcinoma of the Cervix 54.2.4.2 Optimisation 54.2.4.3 Treatment of Endometrial or Vaginal Carcinoma 54.2.4.4 Combination of Intracavitary and External-Beam Therapy 54.2.5 ICRU Recommendations on Gynaecological Brachytherapy 54.2.5.1 Definition of Volumes 54.2.5.2 Dose to the Bladder 54.2.5.3 Dose to the Rectum 54.2.5.4 Sigmoid Point 54.2.5.5 Vaginal Dose 54.2.5.6 Dose to the Pelvic Structures 54.2.5.7 Total Reference Air Kerma 54.2.5.8 Reporting 54.2.5.9 Time-Dose Pattern 54.3 High-Dose-Rate Techniques for Non Gynaecological Sites 54.3.1 Carcinoma of the Bronchus and Oesophagus 54.3.2 Carcinoma of the Nasopharynx 54.3.3 Carcinoma of the Breast 54.3.4 Specialised Moulds and Applicators 54.4 Prostate Brachytherapy 54.4.1 Introduction 54.4.2 Low-dose-rate Permanent Seed Prostate Brachytherapy 54.4.2.1 Treatment Planning 54.4.2.2 Source Implantation 54.4.2.3 Post-implant Dose Calculation 54.4.3 High-dose-rate Iridium-192 Remote Afterloading Prostate Brachytherapy 54.4.3.1 Technique Description 54.4.3.2 Implant Procedure 54.4.3.3 Uncertainties in HDR Prostate Brachytherapy 54.4.4 Focal Prostate Brachytherapy 54.4.5 Salvage Prostate Brachytherapy 54.5 Dose-planning Considerations for Brachytherapy in General 54.5.1 Sealed Source Dose Calculation 54.5.2 Radiographic Methods of Implant Reconstruction 54.5.2.1 Planar Imaging Methods 54.5.2.2 3D Imaging Methods 54.5.3 Computerised Dose Planning 54.6 Optimisation in Afterloading Brachytherapy 54.6.1 Comparison with External-Beam Therapy 54.6.2 Approaches to Optimisation in Brachytherapy 54.6.3 Surface Optimisation 54.6.4 Volume Optimisation 54.6.5 Inverse Optimisation Techniques 54.6.6 Dose-volume Analysis 54.7 Quality Assurance of Brachytherapy Treatment Planning Systems Chapter 55 Radiobiology of Brachytherapy 55.1 Introduction 55.2 a/b Ratios 55.3 Repair Rates (µ Values 55.4 The Concept of Biological Dose 55.4.1 Effect of Cellular Repopulation on Biological Dose 55.4.2 Fractionated-High-Dose-Rate (FHDR) Brachytherapy 55.4.3 Dose-rate Effects 55.4.4 Continuous-Low-Dose-Rate (CLDR) and Permanent Implant Brachytherapy 55.5 The Concept of Equivalence 55.6 Inter-Comparisons between CLDR and FHDR 55.7 Pulsed Brachytherapy 55.8 The Influence of Dose Gradients on Biological Response 55.9 Consequences of Dynamic Changes during the Course of a Brachytherapy Treatment 55.10 The RBE in Brachytherapy References Part J Therapy with Unsealed Sources Chapter 56 Radionuclide Selection for Targeted Molecular Radiotherapy 56.1 Introduction 56.2 Beta Emitters 56.3 Auger-Electron Emitters 56.4 Alpha Emitters 56.5 Imaging and Therapy Pairs for Theragnostics Chapter 57 Targeted Molecular Radiotherapy – Clinical Considerations and Dosimetry* 57.1 Introduction 57.2 Targeting and Range of Treatments with Radionuclides 57.2.1 Metabolic Processes 57.2.2 Peptides 57.2.3 Bone-Seeking Agents 57.2.4 Antibodies 57.2.5 Intra-Arterial Infusion 57.3 Dosimetry for Molecular Radiotherapy (MRT 57.3.1 The MIRD Formalism 57.3.2 Whole-Body Dosimetry 57.3.3 Normal-Organ Dosimetry 57.3.4 Tumour Dosimetry 57.3.5 Voxel Dosimetry 57.4 Quantitative Imaging 57.5 Treatment Planning 57.5.1 The Radionuclide 57.5.2 The Radiopharmaceutical 57.5.3 Level of Administration 57.5.4 Frequency of Administration 57.5.5 Absorbed Doses and Biodistribution 57.6 The Radiobiology of Targeted Molecular Radiotherapy 57.7 Future Prospects References Part K Radiation Protection in Radiotherapy Chapter 58 Theoretical Background to Radiation Protection 58.1 Basic Concepts 58.1.1 Deterministic and Stochastic Effects 58.1.2 Equivalent Dose 58.1.3 Effective Dose 58.2 Risk Estimation 58.2.1 Sources of Data for Risk Estimates 58.2.2 Hereditary Effects 58.2.3 Dose and Dose-Rate Effectiveness Factor 58.2.4 Low Dose Threshold Theories 58.2.5 Relative and Absolute Risks 58.2.6 Effect of Age at Exposure and Lifetime Risk 58.2.7 The Concept of Detriment 58.2.8 Risk Coefficients for Whole-Body Irradiation 58.2.9 Risk Coefficients for Partial Body Irradiation 58.2.10 Effect of Radiation on the Developing Foetus and Children 58.2.11 Estimation of Doses from Internal Radionuclides 58.3 Principles of Radiation Protection 58.3.1 Classification of Exposure 58.3.2 Basis for Dose Regulation 58.3.3 Limitation of Dose to Staff 58.3.4 Limitation of Dose to the General Public 58.3.5 Dose Constraints 58.3.6 Risk Assessment 58.3.7 Cost–Benefit Calculation Chapter 59 Radiation Protection Regulation 59.1 The Regulatory Framework 59.2 Protection of Staff and the Public 59.2.1 Designated Areas 59.2.2 Local Rules 59.2.3 Dose Limits for Staff and Public 59.2.3.1 Employees (Radiation Workers 59.2.3.2 Other Persons (Members of the Public 59.2.3.3 Classification and Monitoring of Staff 59.2.3.4 Dose Limitation in Special Situations: Carers and Comforters 59.2.4 Radiation Protection Expert (or Radiation Protection Adviser 59.2.5 Risk Assessment 59.2.6 Critical Examination of Equipment 59.2.7 Accidental and Unintended Exposures 59.3 Protection of the Patient 59.3.1 Justification of Medical Exposures 59.3.2 Optimisation of Exposures 59.3.3 Diagnostic Reference Levels 59.3.4 Medical Physics Expert 59.3.5 Other Requirements 59.4 Licensing Arrangements 59.4.1 Storage of Radioactive Material 59.4.2 Disposal of Radioactive Waste 59.4.3 Administration of Radioactive Substances 59.5 Transport of Radioactive Substances Chapter 60 Radiation Protection of Staff and the Public 60.1 Design of External Beam Treatment Facilities 60.1.1 Components of Radiation 60.1.1.1 Primary Radiation 60.1.1.2 Leakage Radiation 60.1.1.3 Scattered Radiation 60.1.1.4 Neutrons and Induced Radioactivity 60.1.2 Barrier Attenuation 60.1.3 Treatment-Room Design Calculations 60.1.3.1 General Principles 60.1.3.2 Dose-Rate Considerations 60.1.3.3 Primary Barriers 60.1.3.4 Secondary Barriers 60.1.3.5 Room Entrances: Protection against Scattered Radiation 60.1.3.6 Room Entrances: Protection against Neutrons 60.1.3.7 Skyshine 60.1.4 Choice of Materials 60.1.5 Interlocks and Other Issues 60.1.6 Upgrading Existing Treatment Rooms 60.1.7 Protection Surveys 60.2 Design of Facilities for Sealed and Unsealed Source Therapy 60.2.1 Remote Afterloading 60.2.2 Facilities for Unsealed Source Therapy 60.3 Equipment and Source Handling 60.3.1 Afterloading Equipment 60.3.2 Manipulation of Low-activity Brachytherapy Sources 60.3.3 Unsealed Sources 60.3.3.1 Dispensing and Handling of Unsealed Radioactive Substances 60.3.3.2 Monitors for Working with Unsealed Radioisotopes 60.3.3.3 Monitoring of Staff Working with Unsealed Radioactive Substances 60.3.3.4 Contingency Arrangements 60.4 Management of Patients Treated with Radionuclides 60.4.1 Automatic Afterloading 60.4.2 Radionuclide Patients in Hospital 60.4.2.1 Managing External Dose Rates 60.4.2.2 Managing Contamination 60.4.3 Patients Leaving Hospital 60.4.4 Advice to Patients and Carers 60.4.5 Death of Patients Containing Radioactive Materials Chapter 61 Radiation Protection of the Patient 61.1 Introduction 61.2 Non-Target Doses to Patients 61.2.1 Computed Tomography (CT) Scanning 61.2.2 Doses Associated with the Verification of Radiotherapy Treatment 61.2.2.1 Megavoltage CT 61.2.2.2 Kilovoltage Cone-Beam CT 61.2.2.3 Megavoltage Planar Imaging 61.2.2.4 Kilovoltage Planar Imaging 61.2.3 Out-of-Field Doses 61.3 Tissue Reactions 61.4 Radiotherapy of Patients of Child-Bearing Age 61.4.1 External-Beam Therapy of Potentially Pregnant Women 61.4.2 Unsealed Source Therapy of Pregnant or Nursing Mothers 61.4.3 Irradiation of the Gonads 61.5 Second Cancer Risk to Individual Patients from Radiotherapy 61.5.1 Second Cancer Risk Estimation 61.5.2 Impact of Treatment Modality on Cancer Induction 61.5.3 Contribution of Imaging Dose to Cancer Induction 61.6 Epidemiological Studies of Population Risks of Second Cancers after Radiotherapy 61.7 Implantable Electronic Devices Appendix K1: A Regulatory Framework (UK example) K1.1 Introduction K1.2 Ionising Radiations Regulations 2017 K1.2.1 Registration and Licensing K1.2.2 Dose Limits K1.2.3 Investigations K1.2.4 Control of Areas K1.2.5 Equipment K1.2.6 Radiation Protection Adviser K1.2.7 Radiation Protection Supervisors K1.2.8 Training K1.2.9 Outside Workers K1.3 Ionising Radiation (Medical Exposure) Regulations 2017 K1.3.1 Definition of Roles K1.3.2 Medical Physics Expert K1.3.3 Justification K1.3.4 Optimisation K1.3.5 Carers and Comforters K1.3.6 Investigation of Errors K1.3.7 Training K1.3.8 Equipment K1.3.9 Quality Assurance K1.3.10 Enforcing Authority K1.4 Administration of Radioactive Substances to Patients K1.4.1 Research Exposures K1.5 Radiation (Emergency Preparedness and Public Information) Regulations 2001 K1.6 Environment Protection Regulation: Control of Sources and Waste Disposal K1.7 The Carriage of Dangerous Goods Regulations 2009 Appendix K2: Example Wall Thickness Calculations Appendix K3: Example Local Rules for Handling Radioactive Sources References Part L Data Tables Tables L1: Physical Constants and Useful Data Tables L2: Charged Particle Stopping Power and Range Tables L3: Photon Interaction Coefficients Tables L4: Typical Megavoltage Photon Beam Data Table L5: Radionuclide Data References General Index