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- Ardenfors, Oscar, 1985-
(author)
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Out-of-field doses from proton therapy and doses from CBCT imaging : Risk of radiation-induced second cancer from modern radiotherapy
- 2018
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Doctoral thesis (other academic/artistic)abstract
- The use of ionizing radiation for treatment of cancer diseases is continuously increasing as patient survival is improving and new treatment techniques are emerging. While this development is beneficial for curing primary tumors, concerns have been raised regarding the unwanted dose contribution to healthy tissues of patients and the associated risk of radiation-induced second cancer (RISC). This is especially important for younger patients receiving radiotherapy more often than before and for whom the risk of developing RISC is elevated in comparison to the typical adult radiotherapy patient. In order to estimate the risk of RISC associated with modern radiotherapy and imaging, the associated radiation doses must be determined.Patients undergoing radiotherapy receive in-field doses from the primary beam but also out-of-field doses originating from secondary radiation produced in the beamline and within the patient. Over the last years, the use of proton pencil beam scanning (PBS) therapy has rapidly increased due to its potential to reduce the in-field doses to healthy tissues in comparison to photon therapy. One of the drawbacks with proton therapy is the production of neutrons capable of travelling large distances and depositing out-of-field doses to organs located far from the primary treatment field. The dose reduction associated with proton PBS therapy could consequently be affected by the out-of-field doses originating from secondary radiation.The sharp dose gradients associated with modern treatment techniques, such as photon intensity-modulated radiotherapy (IMRT) and proton PBS therapy require more frequent and accurate patient imaging in comparison to conventional treatment techniques such as three-dimensional conformal radiotherapy (CRT). Setup verification images could be acquired with cone-beam computed tomography (CBCT) producing three-dimensional patient images at the cost of an increased patient dose in comparison to planar x-ray imaging. Concerns have been raised regarding the cumulative patient doses from repeated CBCT imaging versus the dose-saving benefits associated with modern radiotherapy techniques like IMRT and proton PBS.In this thesis, a study on the in-field and out-of-field doses to healthy tissues from photon IMRT and CRT treatments of head and neck tumors showed that the risk of RISC was unaffected by the employed treatment technique and indicated that the lifetime risk of cancer induction was of the order of 1-2%.Results from measurements and Monte Carlo simulations showed that the out-of-field absorbed doses and equivalent doses associated with proton PBS treatments of brain tumors were up to 60 µGy/Gy and 150 µSv/Gy, respectively. The risk of RISC associated with these out-of-field doses was in the range of approximately one induced cancer in ten thousand treated patients. A simulation study on the doses from a proton gantry-mounted CBCT system showed that repeated CBCT imaging could result in cumulative organ doses of almost 2 Gy. The conclusion from these studies is that the dose-sparing effects of proton PBS therapy are not overshadowed by the out-of-field doses originating from secondary radiation for brain tumor treatments, but that the cumulative doses from repeated CBCT imaging could have a relevant impact on the overall dose reduction.
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| 2. |
- Flejmer, Anna M.
(author)
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Radiation burden from modern radiation therapy techniques including proton therapy for breast cancer treatment - clinical implications
- 2016
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Doctoral thesis (other academic/artistic)abstract
- The purpose of this thesis was to study the clinical implications of modern radiotherapy techniques for breast cancer treatment. This was investigated in several individual studies.Study I investigated the implications of using the analytical anisotropic algorithm (AAA) from the perspective of clinical recommendations for breast cancer radiotherapy. Pencil beam convolution plans of 40 breast cancer patients were recalculated with AAA. The latter plans had a significantly worse coverage of the planning target volume (PTV) with the 93% isodose, higher maximum dose in hotspots, higher volumes of the ipsilateral lung receiving doses below 25 Gy and smaller volumes with doses above 25 Gy. AAA also predicted lower doses to the heart.Study II investigated the implications of using the irregular surface compensator (ISC), an electronic compensation algorithm, in comparison to three‐dimensional conformal radiotherapy (3D‐CRT) for breast cancer treatment. Ten breast cancer patients were planned with both techniques. The ISC technique led to better coverage of the clinical target volume of the tumour bed (CTV‐T) and PTV in almost all patients with significant improvement in homogeneity.Study III investigated the feasibility of using scanning pencil beam proton therapy for regional and loco‐regional breast cancer with comparison of ISC photon planning. Ten patients were included in the study, all with dose heterogeneity in the target and/or hotspots in the normal tissues outside the PTV. The proton plans showed comparable or better CTV‐T and PTV coverage, with large reductions in the mean doses to the heart and the ipsilateral lung.Study IV investigated the added value of enhanced inspiration gating (EIG) for proton therapy. Twenty patients were planned on CT datasets acquired during EIG and freebreathing (FB) using photon 3D‐CRT and scanning proton therapy. Proton spot scanning has a high potential to reduce the irradiation of organs‐at‐risk for most patients, beyond what could be achieved with EIG and photon therapy, especially in terms of mean doses to the heart and the left anterior descending artery.Study V investigated the impact of physiological breathing motion during proton radiotherapy for breast cancer. Twelve thoracic patients were planned on CT datasets during breath‐hold at inhalation phase and breath‐hold at exhalation phase. Between inhalation and exhalation phase there were very small differences in dose delivered to the target and cardiovascular structures, with very small clinical implication.The results of these studies showed the potential of various radiotherapy techniques to improve the quality of life for breast cancer patients by limiting the dose burden for normal tissues.
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