On the acceptance, commissioning, and quality assurance of electron FLASH units.

commissioning electron FLASH ultra‐high dose rate

Journal

Medical physics
ISSN: 2473-4209
Titre abrégé: Med Phys
Pays: United States
ID NLM: 0425746

Informations de publication

Date de publication:
27 Oct 2024
Historique:
revised: 04 10 2024
received: 29 05 2024
accepted: 07 10 2024
medline: 27 10 2024
pubmed: 27 10 2024
entrez: 27 10 2024
Statut: aheadofprint

Résumé

FLASH or ultra-high dose rate (UHDR) radiation therapy (RT) has gained attention in recent years for its ability to spare normal tissues relative to conventional dose rate (CDR) RT in various preclinical trials. However, clinical implementation of this promising treatment option has been limited because of the lack of availability of accelerators capable of delivering UHDR RT. Commercial options are finally reaching the market that produce electron beams with average dose rates of up to 1000 Gy/s. We established a framework for the acceptance, commissioning, and periodic quality assurance (QA) of electron FLASH units and present an example of commissioning. A protocol for acceptance, commissioning, and QA of UHDR linear accelerators was established by combining and adapting standards and professional recommendations for standard linear accelerators based on the experience with UHDR at four clinical centers that use different UHDR devices. Non-standard dosimetric beam parameters considered included pulse width, pulse repetition frequency, dose per pulse, and instantaneous dose rate, together with recommendations on how to acquire these measurements. The 6- and 9-MeV beams of an UHDR electron device were commissioned by using this developed protocol. Measurements were acquired with a combination of ion chambers, beam current transformers (BCTs), and dose-rate-independent passive dosimeters. The unit was calibrated according to the concept of redundant dosimetry using a reference setup. This study provides detailed recommendations for the acceptance testing, commissioning, and routine QA of low-energy electron UHDR linear accelerators. The proposed framework is not limited to any specific unit, making it applicable to all existing eFLASH units in the market. Through practical insights and theoretical discourse, this document establishes a benchmark for the commissioning of UHDR devices for clinical use.

Sections du résumé

BACKGROUND AND PURPOSE OBJECTIVE
FLASH or ultra-high dose rate (UHDR) radiation therapy (RT) has gained attention in recent years for its ability to spare normal tissues relative to conventional dose rate (CDR) RT in various preclinical trials. However, clinical implementation of this promising treatment option has been limited because of the lack of availability of accelerators capable of delivering UHDR RT. Commercial options are finally reaching the market that produce electron beams with average dose rates of up to 1000 Gy/s. We established a framework for the acceptance, commissioning, and periodic quality assurance (QA) of electron FLASH units and present an example of commissioning.
METHODS METHODS
A protocol for acceptance, commissioning, and QA of UHDR linear accelerators was established by combining and adapting standards and professional recommendations for standard linear accelerators based on the experience with UHDR at four clinical centers that use different UHDR devices. Non-standard dosimetric beam parameters considered included pulse width, pulse repetition frequency, dose per pulse, and instantaneous dose rate, together with recommendations on how to acquire these measurements.
RESULTS RESULTS
The 6- and 9-MeV beams of an UHDR electron device were commissioned by using this developed protocol. Measurements were acquired with a combination of ion chambers, beam current transformers (BCTs), and dose-rate-independent passive dosimeters. The unit was calibrated according to the concept of redundant dosimetry using a reference setup.
CONCLUSION CONCLUSIONS
This study provides detailed recommendations for the acceptance testing, commissioning, and routine QA of low-energy electron UHDR linear accelerators. The proposed framework is not limited to any specific unit, making it applicable to all existing eFLASH units in the market. Through practical insights and theoretical discourse, this document establishes a benchmark for the commissioning of UHDR devices for clinical use.

Identifiants

pubmed: 39462477
doi: 10.1002/mp.17483
doi:

Types de publication

Journal Article

Langues

eng

Sous-ensembles de citation

IM

Subventions

Organisme : National Cancer Institute of the National Institutes of Health
ID : R01CA266673
Organisme : University Cancer Foundation via the Institutional Research Grant program at MD Anderson Cancer Center
Organisme : MD Anderson's Division of Radiation Oncology
Organisme : National Cancer Institute of the National Institutes of Health Cancer Center Support Grant
ID : P30CA016672
Organisme : UTHealth Innovation for Cancer Prevention Research Training Program Pre-doctoral Fellowship
Organisme : Cancer Prevention and Research Institute of Texas
ID : #RP210042

Informations de copyright

© 2024 The Author(s). Medical Physics published by Wiley Periodicals LLC on behalf of American Association of Physicists in Medicine.

Références

Bourhis J, Montay‐Gruel P, Gonçalves Jorge P, et al. Clinical translation of FLASH radiotherapy: why and how? Radiother Oncol. 2019;139:11‐17.
Favaudon V, Caplier L, Monceau V, et al. Ultrahigh dose‐rate FLASH irradiation increases the differential response between normal and tumor tissue in mice. Sci Transl Med. 2014;6(245):245ra93.
Montay‐Gruel P, Bouchet A, Jaccard M, et al. X‐rays can trigger the FLASH effect: ultra‐high dose‐rate synchrotron light source prevents normal brain injury after whole brain irradiation in mice. Radiother Oncol. 2018;129(3):582‐588.
Wu YNH, Breitkreutz DY, Mascia AE, et al. Technological basis for clinical trials in FLASH radiation therapy: a review. Appl Rad Oncol. 2021;10(2):6‐14.
Schler E, Acharya M, Montay‐Gruel P, Loo BW Jr, Vozenin MC, Maxim PG. Ultra‐high dose rate electron beams and the FLASH effect: from preclinical evidence to a new radiotherapy paradigm. Med Phys. 2022;49(3):2082‐2095.
Matuszak N, Suchorska WM, Milecki P, et al. FLASH radiotherapy: an emerging approach in radiation therapy. Rep Pract Oncol Radiother. 2022;27(2):344‐351.
Ronga MG, Cavallone M, Patriarca A, et al. Back to the future: very high‐energy electrons (VHEEs) and their potential application in radiation therapy. Cancers (Basel). 2021;13(19):4942.
Whitmore L, Mackay RI, van Herk M, Jones JK, Jones RM. Focused VHEE (very high energy electron) beams and dose delivery for radiotherapy applications. Sci Rep. 2021;11(1):14013.
Faillace L, Alesini D, Bisogni G, et al. Perspectives in linear accelerator for FLASH VHEE: study of a compact C‐band system. Phys Med. 2022;104:149‐159.
Wanstall HC, Korysko P, Farabolini W, et al. VHEE FLASH sparing effect measured at CLEAR, CERN with DNA damage of pBR322 plasmid as a biological endpoint. Sci Rep. 2024;14(1):14803.
Schuler E, Trovati S, King G, et al. Experimental platform for ultra‐high dose rate FLASH irradiation of small animals using a clinical linear accelerator. Int J Radiat Oncol. 2017;97(1):195‐203.
Kim MM, Darafsheh A, Schuemann J, et al. Development of ultra‐high dose‐rate (FLASH) particle therapy. IEEE Trans Radiat Plasma Med Sci. 2022;6(3):252‐262. [published online ahead of print 2022/09/13].
Lempart M, Blad B, Adrian G, et al. Modifying a clinical linear accelerator for delivery of ultra‐high dose rate irradiation. Radiother Oncol. 2019;139:40‐45.
Moeckli R, Goncalves Jorge P, Grilj V, et al. Commissioning of an ultra‐high dose rate pulsed electron beam medical LINAC for FLASH RT preclinical animal experiments and future clinical human protocols. Med Phys. 2021;48(6):3134‐3142.
Oesterle R, Goncalves Jorge P, Grilj V, et al. Implementation and validation of a beam‐current transformer on a medical pulsed electron beam LINAC for FLASH‐RT beam monitoring. J Appl Clin Med Phys. 2021;22(11):165‐171.
Liu K, Palmiero A, Chopra N, et al. Dual beam‐current transformer design for monitoring and reporting of electron ultra‐high dose rate (FLASH) beam parameters. J Appl Clin Med Phys. 2023;24(2):e13891.
Jaccard M, Duran MT, Petersson K, et al. High dose‐per‐pulse electron beam dosimetry: commissioning of the Oriatron eRT6 prototype linear accelerator for preclinical use. Med Phys. 2018;45(2):863‐874.
FLASHKNiFETHERYQ. Accessed February 23, 2024. https://www.flashknife‐project.com/project/
Oh K, Gallagher KJ, Yan Y, Zhou S. Commissioning and initial validation of Eclipse eMC algorithm for the electron FLASH research extension (FLEX) system for pre‐clinical studies. J Appl Clin Med Phys. 2024;25(5):e14289.
ElectronFlash SIT‐Sordina IORT Technologies. Accessed February 23, 2024. https://www.soiort.com/flash‐rt‐technology/
Gerbi BJ, Antolak JA, Deibel FC, et al. Recommendations for clinical electron beam dosimetry: supplement to the recommendations of Task Group 25. Med Phys. 2009;36(7):3239‐3279.
Klein EE, Hanley J, Bayouth J, et al. Task Group 142 report: quality assurance of medical accelerators. Med Phys. 2009;36(9):4197‐4212.
Beddar AS, Biggs PJ, Chang S, et al. Intraoperative radiation therapy using mobile electron linear accelerators: report of AAPM Radiation Therapy Committee Task Group No. 72. Med Phys. 2006;33(5):1476‐1489.
International Electrotechnical Commission. Medical electrical equipment, Medical Electron Accelerators: Functional performance characteristics. IEC‐60976 Edition 2.0, 2007‐10.
International Electrotechnical Commission. Medical electrical equipment—Medical electron accelerators—Guidelines for functional performance characteristics. Technical report IEC 60977. 2008.
Structural Shielding Design and Evaluation for Megavoltage X‐and Gamma‐Ray Radiotherapy Facilities. National Council on Radiation Protection and Measurements (NCRP), Report 151, 2005.
Poirier Y, Mossahebi S, Becker SJ, et al. Radiation shielding and safety implications following linac conversion to an electron FLASH‐RT unit. Med Phys. 2021;48(9):5396‐5405.
Cetnar AJ, Jain S, Gupta N, Chakravarti A. Technical note: commissioning of a linear accelerator producing ultra‐high dose rate electrons. Med Phys. 2024;51(2):1415‐1420.
Præstegaard LH. Radiation safety of ultra‐high dose rate electron accelerators for FLASH radiotherapy. Med Phys. 2024;51:6206‐6219.
Karsch L, Beyreuther E, Burris‐Mog T, et al. Dose rate dependence for different dosimeters and detectors: tLD, OSL, EBT films, and diamond detectors. Med Phys. 2012;39(5):2447‐2455.
Niroomand‐Rad A, Chiu‐Tsao ST, Grams MP, et al. Report of AAPM Task Group 235 Radiochromic Film Dosimetry: an update to TG‐55. Med Phys. 2020;47(12):5986‐6025.
Bazalova‐Carter M, Liu M, Palma B, et al. Comparison of film measurements and Monte Carlo simulations of dose delivered with very high‐energy electron beams in a polystyrene phantom. Med Phys. 2015;42(4):1606‐1613.
Gondré M, Jorge PG, Vozenin M‐C, et al. Optimization of alanine measurements for fast and accurate dosimetry in FLASH radiation therapy. Radiat Res. 2020;194(6):573‐579.
Marinelli M, di Martino F, Del Sarto D, et al. A diamond detector based dosimetric system for instantaneous dose rate measurements in FLASH electron beams. Phys Med Biol. 2023;68(17):175011.
Jorge PG, Jaccard M, Petersson K, et al. Dosimetric and preparation procedures for irradiating biological models with pulsed electron beam at ultra‐high dose‐rate. Radiother Oncol. 2019;139:34‐39.
Liu K, Holmes S, Khan AU, et al. Development of novel ionization chambers for reference dosimetry in electron FLASH radiotherapy. Med Phys. 2024;1‐15.
Gómez F, Gonzalez‐Castaño DM, Fernández NG, et al. Development of an ultra‐thin parallel plate ionization chamber for dosimetry in FLASH radiotherapy. Med Phys. 2022;49(7):4705‐4714.
Nath R, Biggs PJ, Bova FJ, et al. AAPM code of practice for radiotherapy accelerators: report of AAPM Radiation Therapy Task Group No. 45. Med Phys. 1994;21(7):1093‐1121.
Wootton P, Almond PR, Holt JG, et al. Code of practice for x‐ray therapy linear accelerators. Med Phys. 1975;2(3):110‐121.
Das IJ, Cheng C‐W, Watts RJ, et al. Accelerator beam data commissioning equipment and procedures: report of the TG‐106 of the Therapy Physics Committee of the AAPM. Med Phys. 2008;35(9):4186‐4215.
Beddar AS. Stability of a mobile electron linear accelerator system for intraoperative radiation therapy. Med Phys. 2005;32(10):3128‐3131.
Krauss RF, Balik S, Cirino ET, et al. AAPM Medical Physics Practice Guideline 8.b: linear accelerator performance tests. J Appl Clin Med Phys. 2023;24(11):e14160.
Oesterle R, Gonçalves Jorge P, Grilj V, et al. Implementation and validation of a beam‐current transformer on a medical pulsed electron beam LINAC for FLASH‐RT beam monitoring. J Appl Clin Med Phys. 2021;22(11):165‐171.
Petersson K, Jaccard M, Germond JF, et al. High dose‐per‐pulse electron beam dosimetry—A model to correct for the ion recombination in the Advanced Markus ionization chamber. Med Phys. 2017;44(3):1157‐1167.
Jaccard M, Petersson K, Buchillier T, et al. High dose‐per‐pulse electron beam dosimetry: usability and dose‐rate independence of EBT3 Gafchromic films. Med Phys. 2017;44(2):725‐735.
Arjomandy B, Tailor R, Zhao L, Devic S. EBT2 film as a depth‐dose measurement tool for radiotherapy beams over a wide range of energies and modalities. Med Phys. 2012;39(2):912‐921.
Liu K, Jorge PG, Tailor R, Moeckli R, Schüler E. Comprehensive evaluation and new recommendations in the use of Gafchromic EBT3 film. Med Phys. 2023;50(11):7252‐7262.
Liu K, Velasquez B, Schuler E. Technical note: high‐dose and ultra‐high dose rate (UHDR) evaluation of Al(2) O(3) :c optically stimulated luminescent dosimeter nanoDots and powdered LiF:mg,Ti thermoluminescent dosimeters for radiation therapy applications. Med Phys. 2023;51(3):2311‐2319. doi:10.1002/mp.16832
Kry SF, Alvarez P, Cygler JE, et al. AAPM TG 191: clinical use of luminescent dosimeters: tLDs and OSLDs. Med Phys. 2020;47(2):e19‐e51.
Wootton LS, Meyer J, Kim E, Phillips M. Commissioning, clinical implementation, and performance of the Mobetron 2000 for intraoperative radiation therapy. J Appl Clin Med Phys. 2017;18(1):230‐242.
Almond PR, Biggs PJ, Coursey BM, et al. AAPM's TG‐51 protocol for clinical reference dosimetry of high‐energy photon and electron beams. Med Phys. 1999;26(9):1847‐1870.
Das IJ, Cheng CW, Watts RJ, et al. Accelerator beam data commissioning equipment and procedures: report of the TG‐106 of the Therapy Physics Committee of the AAPM. Med Phys. 2008;35(9):4186‐4215.
Levy K, Natarajan S, Wang J, et al. Abdominal FLASH irradiation reduces radiation‐induced gastrointestinal toxicity for the treatment of ovarian cancer in mice. Sci Rep. 2020;10(1):21600.
Borca VC, Pasquino M, Russo G, et al. Dosimetric characterization and use of GAFCHROMIC EBT3 film for IMRT dose verification. J Appl Clin Med Phys. 2013;14(2):158‐171.
Palmer AL, Dimitriadis A, Nisbet A, Clark CH. Evaluation of Gafchromic EBT‐XD film, with comparison to EBT3 film, and application in high dose radiotherapy verification. Phys Med Biol. 2015;60(22):8741‐8752.
Marroquin EY, Herrera Gonzalez JA, Camacho Lopez MA, Barajas JE, Garcia‐Garduno OA. Evaluation of the uncertainty in an EBT3 film dosimetry system utilizing net optical density. J Appl Clin Med Phys. 2016;17(5):466‐481.
Leon‐Marroquin EY, Mulrow D, Darafsheh A, Khan R. Response characterization of EBT‐XD radiochromic films in megavoltage photon and electron beams. Med Phys. 2019;46(9):4246‐4256.
Romano F, Bailat C, Jorge PG, Lerch MLF, Darafsheh A. Ultra‐high dose rate dosimetry: challenges and opportunities for FLASH radiation therapy. Med Phys. 2022;49(7):4912‐4932.
Goncalves Jorge P, Grilj V, Bourhis J, et al. Technical note: validation of an ultrahigh dose rate pulsed electron beam monitoring system using a current transformer for FLASH preclinical studies. Med Phys. 2022;49(3):1831‐1838.
Baikalov A, Tho D, Liu K, Bartzsch S, Beddar S, Schüler E, Characterization of a novel time‐resolved, real‐time scintillation dosimetry system for ultra‐high dose rate radiation therapy applications. arXiv:2403.03142. 2024.
Liu K, Holmes S, Hooten B, Schüler E, Beddar S. Evaluation of ion chamber response for applications in electron FLASH radiotherapy. Med Phys. 2024;51(1):494‐508.
Liu K, Holmes S, Schüler E, Beddar S. A comprehensive investigation of the performance of a commercial scintillator system for applications in electron FLASH radiotherapy. Med Phys. 2024;51(6):4504‐4512.
Verona Rinati G, Felici G, Galante F, et al. Application of a novel diamond detector for commissioning of FLASH radiotherapy electron beams. Med Phys. 2022;49(8):5513‐5522.
Vanreusel V, Gasparini A, Galante F, et al. Point scintillator dosimetry in ultra‐high dose rate electron “FLASH” radiation therapy: a first characterization. Phys Med. 2022;103:127‐137.

Auteurs

Allison Palmiero (A)

Department of Radiation Oncology, James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, Ohio, USA.

Kevin Liu (K)

Division of Radiation Oncology, Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
Graduate School of Biomedical Sciences, The University of Texas, Houston, Texas, USA.

Julie Colnot (J)

INSERM U1030, Gustave Roussy, Université Paris-Saclay, Villejuif, France.

Nitish Chopra (N)

Division of Radiation Oncology, Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.

Denae Neill (D)

Division of Radiation Oncology, Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.

Luke Connell (L)

Division of Radiation Oncology, Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
Graduate School of Biomedical Sciences, The University of Texas, Houston, Texas, USA.

Brett Velasquez (B)

Division of Radiation Oncology, Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.

Albert C Koong (AC)

Division of Radiation Oncology, Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.

Steven H Lin (SH)

Division of Radiation Oncology, Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.

Peter Balter (P)

Division of Radiation Oncology, Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.

Ramesh Tailor (R)

Division of Radiation Oncology, Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.

Charlotte Robert (C)

INSERM U1030, Gustave Roussy, Université Paris-Saclay, Villejuif, France.

Jean-François Germond (JF)

Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland.

Patrik Gonçalves Jorge (P)

Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland.

Reiner Geyer (R)

Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland.

Sam Beddar (S)

Division of Radiation Oncology, Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
Graduate School of Biomedical Sciences, The University of Texas, Houston, Texas, USA.

Raphael Moeckli (R)

Institute of Radiation Physics, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland.

Emil Schüler (E)

Division of Radiation Oncology, Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
Graduate School of Biomedical Sciences, The University of Texas, Houston, Texas, USA.

Classifications MeSH