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SU-E-I-41: Dictionary Learning Based Quantitative Reconstruction for Low-Dose Dual-Energy CT (DECT)

Purpose: DECT collects two sets of projection data under higher and lower energies. With appropriates composition methods on linear attenuation coefficients, quantitative information about the object, such as density, can be obtained. In reality, one of the important problems in DECT is the radiation dose due to doubled scans. This work is aimed at establishing a dictionary learning based reconstruction framework for DECT for improved image quality while reducing the imaging dose. Methods: In our method, two dictionaries were learned respectively from the high-energy and lowenergy image datasets of similar objects under normal dose in advance. The linear attenuation coefficient was decomposed into two basis components with material based composition method. An iterative reconstruction framework was employed. Two basis components were alternately updated with DECT datasets and dictionary learning based sparse constraints. After one updating step under the dataset fidelity constraints, both high-energy and low-energy images can be obtained from the two basis components. Sparse constraints based on the learned dictionaries were applied to the high- and low-energy images to update the two basis components. The iterative calculation continues until a pre-set number of iteration was reached. Results: We evaluated the proposed dictionary learning method with dual energy images collected using a DECT scanner. We re-projected the projection data with added Poisson noise to reflect the low-dose situation. The results obtained by the proposed method were compared with that obtained using FBP based method and TV based method. It was found that the proposed approach yield better results than other methods with higher resolution and less noise. Conclusion: The use of dictionary learned from DECT images under normal dose is valuable and leads to improved results with much lower imaging dose.

60 APPLIED LIFE SCIENCES↗

Note: On the generation of sub-300 keV flash-X-rays using rod-pinch diode: An experimental investigation

Generation of flash X-rays (FXRs) at less than 500 keV is described with emphasis on experimental investigation. The pulser is a Tesla transformer-Water transmission line based pulsed power generator operating in double resonance mode to power a rod-pinch diode. The configuration of aspect ratio reported here falls much below the normally reported ratios for the rod-pinch diode operation. Experimental investigation at such low pulsed voltage has revealed “flowering” of the anode tip and “pitting” of the perspex window. A possible explanation in terms of Lorentz body force is discussed rather than the pinch mechanism generally suggested in literature. The experimental investigation for the FXR generation is corroborated by measuring the radiation dose using CaSO{sub 4} (Dy) thermo luminescent dosimeters.

46 INSTRUMENTATION RELATED TO NUCLEAR SCIENCE AND ↗

Three independent one-dimensional margins for single-fraction frameless stereotactic radiosurgery brain cases using CBCT

Purpose: Setting a proper margin is crucial for not only delivering the required radiation dose to a target volume, but also reducing the unnecessary radiation to the adjacent organs at risk. This study investigated the independent one-dimensional symmetric and asymmetric margins between the clinical target volume (CTV) and the planning target volume (PTV) for linac-based single-fraction frameless stereotactic radiosurgery (SRS).Methods: The authors assumed a Dirac delta function for the systematic error of a specific machine and a Gaussian function for the residual setup errors. Margin formulas were then derived in details to arrive at a suitable CTV-to-PTV margin for single-fraction frameless SRS. Such a margin ensured that the CTV would receive the prescribed dose in 95% of the patients. To validate our margin formalism, the authors retrospectively analyzed nine patients who were previously treated with noncoplanar conformal beams. Cone-beam computed tomography (CBCT) was used in the patient setup. The isocenter shifts between the CBCT and linac were measured for a Varian Trilogy linear accelerator for three months. For each plan, the authors shifted the isocenter of the plan in each direction by ±3 mm simultaneously to simulate the worst setup scenario. Subsequently, the asymptotic behavior of the CTV V{sub 80%} for each patient was studied as the setup error approached the CTV-PTV margin.Results: The authors found that the proper margin for single-fraction frameless SRS cases with brain cancer was about 3 mm for the machine investigated in this study. The isocenter shifts between the CBCT and the linac remained almost constant over a period of three months for this specific machine. This confirmed our assumption that the machine systematic error distribution could be approximated as a delta function. This definition is especially relevant to a single-fraction treatment. The prescribed dose coverage for all the patients investigated was 96.1%± 5.5% with an extreme 3-mm setup error in all three directions simultaneously. It was found that the effect of the setup error on dose coverage was tumor location dependent. It mostly affected the tumors located in the posterior part of the brain, resulting in a minimum coverage of approximately 72%. This was entirely due to the unique geometry of the posterior head.Conclusions: Margin expansion formulas were derived for single-fraction frameless SRS such that the CTV would receive the prescribed dose in 95% of the patients treated for brain cancer. The margins defined in this study are machine-specific and account for nonzero mean systematic error. The margin for single-fraction SRS for a group of machines was also derived in this paper.

61 RADIATION PROTECTION AND DOSIMETRY↗

Value of Duplex Ultrasound Assistance for Thromboaspiration and Dilation of Thrombosed Native Arterio-Venous Fistulae

Purpose: To evaluate the value of duplex ultrasound assistance during thromboaspiration of thrombosed arteriovenous fistulae for haemodialysis. Materials and Methods: We prospectively studied 54 thrombosed native fistulae (23 with total thrombosis and 31 with partial thrombosis), in which we performed manual thromboaspiration guided by ultrasonography associated with fluoroscopy. Results: The fistulae were located in the forearm (n = 39) or in the upper arm (n = 15) of 46 patients. Mean patient age was 65 years, and hypertension was the most common risk factor (74 %). Mean access age was 928 days (range 69-2,290), and most fistulae were on the left side (41 cases, 75.92 %). The success rate was 83 % in the total thrombosis group and 100 % in the partial thrombosis group. Including initial failures, the respective primary patency rates in the total thrombosis group and the partial thrombosis group were, respectively, 83 {+-} 8 % (n = 20) and 87 {+-} 6 % (n = 28) at 1 month, 39 {+-} 10 % (n = 10) and 61 {+-} 8 % (n = 20) at 6 months, and 17 {+-} 8 % (n = 5) and 26 {+-} 8 % (n = 9) at 1 year. The mean decrease of fluoroscopy time with ultrasound was 3 min (range 1-5). The mean decrease of radiation dose was 2.6 Gy cm Superscript-Two (range 0.9-4.3]. Conclusion: Ultrasound is a feasible and useful tool in the management of thrombosed native fistulae, thus decreasing radiation exposure, and has no detrimental effect on success rates.

62 RADIOLOGY AND NUCLEAR MEDICINE↗

CT based computerized identification and analysis of human airways: A review

As one of the most prevalent chronic disorders, airway disease is a major cause of morbidity and mortality worldwide. In order to understand its underlying mechanisms and to enable assessment of therapeutic efficacy of a variety of possible interventions, noninvasive investigation of the airways in a large number of subjects is of great research interest. Due to its high resolution in temporal and spatial domains, computed tomography (CT) has been widely used in clinical practices for studying the normal and abnormal manifestations of lung diseases, albeit there is a need to clearly demonstrate the benefits in light of the cost and radiation dose associated with CT examinations performed for the purpose of airway analysis. Whereas a single CT examination consists of a large number of images, manually identifying airway morphological characteristics and computing features to enable thorough investigations of airway and other lung diseases is very time-consuming and susceptible to errors. Hence, automated and semiautomated computerized analysis of human airways is becoming an important research area in medical imaging. A number of computerized techniques have been developed to date for the analysis of lung airways. In this review, we present a summary of the primary methods developed for computerized analysis of human airways, including airway segmentation, airway labeling, and airway morphometry, as well as a number of computer-aided clinical applications, such as virtual bronchoscopy. Both successes and underlying limitations of these approaches are discussed, while highlighting areas that may require additional work.

62 RADIOLOGY AND NUCLEAR MEDICINE↗

Imaging dose in breast radiotherapy: does breast size affect the dose to the organs at risk and the risk of secondary cancer to the contralateral breast?

Correct target positioning is crucial for accurate dose delivery in breast radiotherapy resulting in utilisation of daily imaging. However, the radiation dose from daily imaging is associated with increased probability of secondary induced cancer. The aim of this study was to quantify doses associated with three imaging modalities and investigate the correlation of dose and varying breast size in breast radiotherapy. Planning computed tomography (CT) data sets of 30 breast cancer patients were utilised to simulate the dose received by various organs from a megavoltage computed tomography (MV-CT), megavoltage electronic portal image (MV-EPI) and megavoltage cone-beam computed tomography (MV-CBCT). The mean dose to organs adjacent to the target volume (contralateral breast, lungs, spinal cord and heart) were analysed. Pearson correlation analysis was performed to determine the relationship between imaging dose and primary breast volume and the lifetime attributable risk (LAR) of induced secondary cancer was calculated for the contralateral breast. The highest contralateral breast mean dose was from the MV-CBCT (1.79 Gy), followed by MV-EPI (0.22 Gy) and MV-CT (0.11 Gy). A similar trend was found for all organs at risk (OAR) analysed. The primary breast volume inversely correlated with the contralateral breast dose for all three imaging modalities. As the primary breast volume increases, the likelihood of a patient developing a radiation-induced secondary cancer to the contralateral breast decreases. MV-CBCT showed a stronger relationship between breast size and LAR of developing a radiation-induced contralateral breast cancer in comparison with the MV-CT and MV-EPI. For breast patients, imaging dose to OAR depends on imaging modality and treated breast size. When considering the use of imaging during breast radiotherapy, the patient's breast size and contralateral breast dose should be taken into account.

62 RADIOLOGY AND NUCLEAR MEDICINE↗

Anisotropic mechanical properties of zircon and the effect of radiation damage

Our study provides new insights into the relationship between radiation-dose-dependent structural damage, due to natural U and Th impurities, and the anisotropic mechanical properties (Poisson s ratio, elastic modulus and hardness) of zircon. Natural zircon samples from Sri Lanka (see Muarakami et al. 1991) and synthetic samples, covering a dose range of zero up to 6.8 x 10 18 -decays/g, have been studied by nanoindentation. Measurements along the [100] crystallographic direction and calculations, based on elastic stiffness constants determined by zkan (1976), revealed a general radiation-induced decrease in stiffness (~ 54 %) and hardness (~ 48 %) and an increase of the Poisson s ratio (~ 54 %) with increasing dose. Additional indentations on selected samples along the [001] allowed one to follow the amorphization process to the point that the mechanical properties are isotropic. This work shows that the radiation-dose-dependent changes of the mechanical properties of zircon can be directly correlated with the amorphous fraction as determined by previous investigations with local and global probes (Rios et al. 2000a; Farnan and Salje 2001; Zhang and Salje 2001). This agreement, revealed by the different methods, indicates a huge influence of structural and even local phenomena on the macroscopic mechanical properties.

36 MATERIALS SCIENCE↗

Clinical Outcomes and Late Endocrine, Neurocognitive, and Visual Profiles of Proton Radiation for Pediatric Low-Grade Gliomas

Purpose/Objective(s): Primary low-grade gliomas are common brain tumors of childhood, many of which require radiation therapy (RT) as definitive treatment. Increased conformality of RT could decrease the incidence and severity of late effects. We report our experience with 32 pediatric patients treated with proton RT. Methods and Materials: Thirty-two pediatric patients with low-grade gliomas of the brain or spinal cord were treated with proton RT from 1995 to 2007. Sixteen patients received at least 1 regimen of chemotherapy before definitive RT. The median radiation dose was 52.2 Gy{sub RBE} (48.6-54 Gy{sub RBE}). Results: The median age at treatment was 11.0 years (range, 2.7-21.5 years), with a median follow-up time of 7.6 years (range, 3.2-18.2 years). The 6-year and 8-year rates of progression-free survival were 89.7% and 82.8%, respectively, with an 8-year overall survival of 100%. For the subset of patients who received serial neurocognitive testing, there were no significant declines in Full-Scale Intelligence Quotient (P=.80), with a median neurocognitive testing interval of 4.5 years (range, 1.2-8.1 years) from baseline to follow-up, but subgroup analysis indicated some significant decline in neurocognitive outcomes for young children (<7 years) and those with significant dose to the left temporal lobe/hippocampus. The incidence of endocrinopathy correlated with a mean dose of ≥40 Gy{sub RBE} to the hypothalamus, pituitary, or optic chiasm. Stabilization or improvement of visual acuity was achieved in 83.3% of patients at risk for radiation-induced injury to the optic pathways. Conclusions: This report of late effects in children with low-grade gliomas after proton RT is encouraging. Proton RT appears to be associated with good clinical outcome, especially when the tumor location allows for increased sparing of the left temporal lobe, hippocampus, and hypothalamic-pituitary axis.

62 RADIOLOGY AND NUCLEAR MEDICINE↗

A prospective follow-up study of the association of radiation exposure with fatal and non-fatal stroke among atomic bomb survivors in Hiroshima and Nagasaki (1980–2003)

Use of medical radiotherapy has increased markedly in recent decades. Whether the consequence includes an increased risk of cardiovascular disease remains to be determined. The purpose of this study was to examine the association between radiation exposure and the incidence of stroke among Japanese atomic bomb survivors. Radiation exposure from the atomic bombing was assessed in 9515 subjects (34.8% men) with 24-year follow-up from 1980. Subjects were free of prevalent stroke when follow-up began. Stroke events and the underlying cause of death were reviewed to confirm the first-ever stroke. Subtypes (ischaemic and haemorrhagic events) were categorised based on established criteria according to the definitions of typical/atypical stroke symptoms. Overall mean radiation dose (±SD) in units of gray (Gy) was 0.38±0.58 (range: 0–3.5). During the study period, 235 haemorrhagic and 607 ischaemic events were identified. For men, after adjusting for age and concomitant risk factors, the risk of haemorrhagic stroke rose consistently from 11.6 to 29.1 per 10 000 person-years as doses increased from <0.05 to ≥2 Gy (p=0.009). Incidence also rose within the dose range <1 Gy (p=0.004) with no dose threshold. In women, the risk of haemorrhagic stroke rose with increasing radiation exposure but not until doses reached a threshold of 1.3 Gy (95% CI 0.5 to 2.3). Among women, for doses <1.3 Gy, differences in stroke risk were modest (13.5 per 10 000 person-years), while it increased to 20.3 per 10 000 person-years for doses that ranged from 1.3 to <2.2 Gy and to 48.6 per 10 000 person-years for doses that were higher (p=0.002). In both sexes, dose was unrelated to ischaemic stroke. While the risk of haemorrhagic stroke increases with rising radiation exposure for both sexes, effects in women are less apparent until doses exceed a threshold at 1.3 Gy.

60 APPLIED LIFE SCIENCES↗

A Population-Based Comparative Effectiveness Study of Radiation Therapy Techniques in Stage III Non-Small Cell Lung Cancer

Purpose: Concerns have been raised about the potential for worse treatment outcomes because of dosimetric inaccuracies related to tumor motion and increased toxicity caused by the spread of low-dose radiation to normal tissues in patients with locally advanced non-small cell lung cancer (NSCLC) treated with intensity modulated radiation therapy (IMRT). We therefore performed a population-based comparative effectiveness analysis of IMRT, conventional 3-dimensional conformal radiation therapy (3D-CRT), and 2-dimensional radiation therapy (2D-RT) in stage III NSCLC. Methods and Materials: We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare database to identify a cohort of patients diagnosed with stage III NSCLC from 2002 to 2009 treated with IMRT, 3D-CRT, or 2D-RT. Using Cox regression and propensity score matching, we compared survival and toxicities of these treatments. Results: The proportion of patients treated with IMRT increased from 2% in 2002 to 25% in 2009, and the use of 2D-RT decreased from 32% to 3%. In univariate analysis, IMRT was associated with improved overall survival (OS) (hazard ratio [HR] 0.90, P=.02) and cancer-specific survival (CSS) (HR 0.89, P=.02). After controlling for confounders, IMRT was associated with similar OS (HR 0.94, P=.23) and CSS (HR 0.94, P=.28) compared with 3D-CRT. Both techniques had superior OS compared with 2D-RT. IMRT was associated with similar toxicity risks on multivariate analysis compared with 3D-CRT. Propensity score matched model results were similar to those from adjusted models. Conclusions: In this population-based analysis, IMRT for stage III NSCLC was associated with similar OS and CSS and maintained similar toxicity risks compared with 3D-CRT.

62 RADIOLOGY AND NUCLEAR MEDICINE↗

WE-DE-BRA-10: Development of a Novel Scanning Beam Low-Energy Intraoperative Radiation Therapy (SBIORT) System for Pancreatic Cancer

Purpose: Developing a compact collimator system and validating a 3D surface imaging module for a scanning beam low-energy x-ray radiation therapy (SBIORT) system that enables delivery of non-uniform radiation dose to targets with irregular shapes intraoperatively. Methods: SBIORT consists of a low energy x-ray source, a custom compact collimator module, a robotic arm, and a 3D surface imaging module. The 3D surface imaging system (structure sensor) is utilized for treatment planning and motion monitoring of the surgical cavity. SBIORT can deliver non-uniform dose distributions by dynamically moving the x-ray source assembly along optimal paths with various collimator apertures. The compact collimator utilizes a dynamic shutter mechanism to form a variable square aperture. The accuracy and reproducibility of the collimator were evaluated using a high accuracy encoder and a high resolution camera platform. The dosimetrical characteristics of the collimator prototype were evaluated using EBT3 films with a Pantak Therapax unit. The accuracy and clinical feasibility of the 3D imaging system were evaluated using a phantom and a cadaver cavity. Results: The SBIORT collimator has a compact size: 66 mm diameter and 10 mm thickness with the maximum aperture of 20 mm. The mechanical experiment indicated the average accuracy of leaf position was 0.08 mm with a reproducibility of 0.25 mm at 95% confidence level. The dosimetry study indicated the collimator had a penumbra of 0.35 mm with a leaf transmission of 0.5%. 3D surface scans can be acquired in 5 seconds. The average difference between the acquired 3D surface and the ground truth is 1 mm with a standard deviation of 0.6 mm. Conclusion: This work demonstrates the feasibility of the compact collimator and 3D scanning system for the SBIORT. SBIORT is a way of delivering IORT with a compact system that requires minimum shielding of the procedure room. This research is supported by the University of Iowa Internal Funding Initiatives.

60 APPLIED LIFE SCIENCES↗

Early Cognitive Outcomes Following Proton Radiation in Pediatric Patients With Brain and Central Nervous System Tumors

Purpose: To report, from a longitudinal study, cognitive outcome in pediatric patients treated with proton radiation therapy (PRT) for central nervous system (CNS) tumors. Methods and Materials: Sixty patients receiving PRT for medulloblastoma (38.3%), gliomas (18.3%), craniopharyngioma (15.0%), ependymoma (11.7%), and other CNS tumors (16.7%) were administered age-appropriate measures of cognitive abilities at or near PRT initiation (baseline) and afterward (follow-up). Patients were aged ≥6 years at baseline to ensure consistency in neurocognitive measures. Results: Mean age was 12.3 years at baseline; mean follow-up interval was 2.5 years. Treatment included prior surgical resection (76.7%) and chemotherapy (61.7%). Proton radiation therapy included craniospinal irradiation (46.7%) and partial brain radiation (53.3%). At baseline, mean Wechsler Full Scale IQ was 104.6; means of all 4 Index scores were also in the average range. At follow-up, no significant change was observed in mean Wechsler Full Scale IQ, Verbal Comprehension, Perceptual Reasoning/Organization, or Working Memory. However, Processing Speed scores declined significantly (mean 5.2 points), with a significantly greater decline for subjects aged <12 years at baseline and those with the highest baseline scores. Cognitive outcome was not significantly related to gender, extent of radiation, radiation dose, tumor location, histology, socioeconomic status, chemotherapy, or history of surgical resection. Conclusions: Early cognitive outcomes after PRT for pediatric CNS tumors are encouraging, compared with published outcomes from photon radiation therapy.

62 RADIOLOGY AND NUCLEAR MEDICINE↗

MO-C-18A-01: Advances in Model-Based 3D Image Reconstruction

Recent years have seen the emergence of CT image reconstruction techniques that exploit physical models of the imaging system, photon statistics, and even the patient to achieve improved 3D image quality and/or reduction of radiation dose. With numerous advantages in comparison to conventional 3D filtered backprojection, such techniques bring a variety of challenges as well, including: a demanding computational load associated with sophisticated forward models and iterative optimization methods; nonlinearity and nonstationarity in image quality characteristics; a complex dependency on multiple free parameters; and the need to understand how best to incorporate prior information (including patient-specific prior images) within the reconstruction process. The advantages, however, are even greater – for example: improved image quality; reduced dose; robustness to noise and artifacts; task-specific reconstruction protocols; suitability to novel CT imaging platforms and noncircular orbits; and incorporation of known characteristics of the imager and patient that are conventionally discarded. This symposium features experts in 3D image reconstruction, image quality assessment, and the translation of such methods to emerging clinical applications. Dr. Chen will address novel methods for the incorporation of prior information in 3D and 4D CT reconstruction techniques. Dr. Pan will show recent advances in optimization-based reconstruction that enable potential reduction of dose and sampling requirements. Dr. Stayman will describe a “task-based imaging” approach that leverages models of the imaging system and patient in combination with a specification of the imaging task to optimize both the acquisition and reconstruction process. Dr. Samei will describe the development of methods for image quality assessment in such nonlinear reconstruction techniques and the use of these methods to characterize and optimize image quality and dose in a spectrum of clinical applications. Learning Objectives: Learn the general methodologies associated with model-based 3D image reconstruction. Learn the potential advantages in image quality and dose associated with model-based image reconstruction. Learn the challenges associated with computational load and image quality assessment for such reconstruction methods. Learn how imaging task can be incorporated as a means to drive optimal image acquisition and reconstruction techniques. Learn how model-based reconstruction methods can incorporate prior information to improve image quality, ease sampling requirements, and reduce dose.

60 APPLIED LIFE SCIENCES↗

Comparison of structural properties of pristine and gamma irradiated single-wall carbon nanotubes: Effects of medium and irradiation dose

A systematic study of the gamma irradiation effects on single wall carbon nanotube (SWCNT) structure was conducted. Nanotubes were exposed to different doses of gamma irradiation in three media. Irradiation was carried out in air, water and aqueous ammonia. Thermogravimetric analysis (TGA), Fourier transform infrared spectroscopy (FTIR), elemental analysis (EA) and Raman spectroscopy confirmed the changes in the SWCNT structure. TGA measurements showed the highest percentage of introduced groups for the SWCNTs irradiated with 100 kGy. FTIR spectroscopy provided evidence for the attachment of hydroxyl, carboxyl and nitrile functional groups to the SWCNT sidewalls. Those groups were confirmed by EA. All irradiated SWCNTs had hydroxyl and carboxyl groups irrelevant to media used for irradiation, but nitrile functional groups were only identified in SWCNTs irradiated in aqueous ammonia. Raman spectroscopy indicated that the degree of disorder in the carbon nanotube structure correlates with the irradiation dose. For the nanotubes irradiated with the dose of 100 kGy, the Raman I{sub D}/I{sub G} ratio was three times higher than for the pristine ones. Atomic force microscopy showed a 50% decrease in nanotube length at a radiation dose of 100 kGy. Scanning and transmission electron microscopies showed significant changes in the morphology and structure of gamma irradiated SWCNTs. - Highlights: Black-Right-Pointing-Pointer Gamma irradiation causes SWCNT covalent functionalization. Black-Right-Pointing-Pointer Type of covalently attached groups to SWCNT surface depends on irradiation medium. Black-Right-Pointing-Pointer The SWCNT shortening level increases with applied irradiation dose. Black-Right-Pointing-Pointer The average length of carbon nanotubes decreased by 50% at the highest dose. Black-Right-Pointing-Pointer The diameter of SWCNT bundles becomes small as irradiation dose rises.

36 MATERIALS SCIENCE↗

SU-E-T-594: Out-Of-Field Neutron and Gamma Dose Estimated Using TLD-600/700 Pairs in the Wobbling Proton Therapy System

Purpose: Secondary fast neutrons and gamma rays are mainly produced due to the interaction of the primary proton beam with the beam delivery nozzle. These secondary radiation dose to patients and radiation workers are unwanted. The purpose of this study is to estimate the neutron and gamma dose equivalent out of the treatment volume during the wobbling proton therapy system. Methods: Two types of thermoluminescent (TL) dosimeters, TLD-600 ({sup 6}LiF: Mg, Ti) and TLD-700 ({sup 7}LiF: Mg, Ti) were used in this study. They were calibrated in the standard neutron and gamma sources at National Standards Laboratory. Annealing procedure is 400°C for 1 hour, 100°C for 2 hours and spontaneously cooling down to the room temperature in a programmable oven. Two-peak method (a kind of glow curve analysis technique) was used to evaluate the TL response corresponding to the neutron and gamma dose. The TLD pairs were placed outside the treatment field at the neutron-gamma mixed field with 190-MeV proton beam produced by the wobbling system through the polyethylene plate phantom. The results of TLD measurement were compared to the Monte Carlo simulation. Results: The initial experiment results of calculated dose equivalents are 0.63, 0.38, 0.21 and 0.13 mSv per Gy outside the field at the distance of 50, 100, 150 and 200 cm. Conclusion: The TLD-600 and TLD-700 pairs are convenient to estimate neutron and gamma dosimetry during proton therapy. However, an accurate and suitable glow curve analysis technique is necessary. During the wobbling system proton therapy, our results showed that the neutron and gamma doses outside the treatment field are noticeable. This study was supported by the grants from the Chang Gung Memorial Hospital (CMRPD1C0682)

61 RADIATION PROTECTION AND DOSIMETRY↗

Dose optimization in cardiac x-ray imaging

Purpose: The aim of this research was to optimize x-ray image quality to dose ratios in the cardiac catheterization laboratory. This study examined independently the effects of peak x-ray tube voltage (kVp), copper (Cu), and gadolinium (Gd) x-ray beam filtration on the image quality to radiation dose balance for adult patient sizes.Methods: Image sequences of polymethyl methacrylate (PMMA) phantoms representing two adult patient sizes were captured using a modern flat panel detector based x-ray imaging system. Tin and copper test details were used to simulate iodine-based contrast medium and stents/guide wires respectively, which are used in clinical procedures. Noise measurement for a flat field image and test detail contrast were used to calculate the contrast to noise ratio (CNR). Entrance surface dose (ESD) and effective dose measurements were obtained to calculate the figure of merit (FOM), CNR{sup 2}/dose. This FOM determined the dose efficiency of x-ray spectra investigated. Images were captured with 0.0, 0.1, 0.25, 0.4, and 0.9 mm Cu filtration and with a range of gadolinium oxysulphide (Gd{sub 2}O{sub 2}S) filtration.Results: Optimum x-ray spectra were the same for the tin and copper test details. Lower peak tube voltages were generally favored. For the 20 cm phantom, using 2 Lanex Fast Back Gd{sub 2}O{sub 2}S screens as x-ray filtration at 65 kVp provided the highest FOM considering ESD and effective dose. Considering ESD, this FOM was only marginally larger than that from using 0.4 mm Cu at 65 kVp. For the 30 cm phantom, using 0.25 mm copper filtration at 80 kVp was most optimal; considering effective dose the FOM was highest with no filtration at 65 kVp.Conclusions: These settings, adjusted for x-ray tube loading limits and clinically acceptable image quality, should provide a useful option for optimizing patient dose to image quality in cardiac x-ray imaging. The same optimal x-ray beam spectra were found for both the tin and copper details, suggesting that iodine contrast based imaging and visualization of interventional devices could potentially be optimized for dose using similar x-ray beam spectra.

62 RADIOLOGY AND NUCLEAR MEDICINE↗

Long-term Survival and Toxicity in Patients Treated With High-Dose Intensity Modulated Radiation Therapy for Localized Prostate Cancer

Purpose: To report long-term survival and toxicity outcomes with the use of high-dose intensity modulated radiation therapy (IMRT) to 86.4 Gy for patients with localized prostate cancer. Methods and Materials: Between August 1997 and December 2008, 1002 patients were treated to a dose of 86.4 Gy using a 5-7 field IMRT technique. Patients were stratified by prognostic risk group based on National Comprehensive Cancer Network risk classification criteria. A total of 587 patients (59%) were treated with neoadjuvant and concurrent androgen deprivation therapy. The median follow-up for the entire cohort was 5.5 years (range, 1-14 years). Results: For low-, intermediate-, and high-risk groups, 7-year biochemical relapse-free survival outcomes were 98.8%, 85.6%, and 67.9%, respectively (P<.001), and distant metastasis-free survival rates were 99.4%, 94.1%, and 82.0% (P<.001), respectively. On multivariate analysis, T stage (P<.001), Gleason score (P<.001), and >50% of initial biopsy positive core (P=.001) were predictive for distant mestastases. No prostate cancer-related deaths were observed in the low-risk group. The 7-year prostate cancer-specific mortality (PCSM) rates, using competing risk analysis for intermediate- and high-risk groups, were 3.3% and 8.1%, respectively (P=.008). On multivariate analysis, Gleason score (P=.004), percentage of biopsy core positivity (P=.003), and T-stage (P=.033) were predictive for PCSM. Actuarial 7-year grade 2 or higher late gastrointestinal and genitourinary toxicities were 4.4% and 21.1%, respectively. Late grade 3 gastrointestinal and genitourinary toxicity was experienced by 7 patients (0.7%) and 22 patients (2.2%), respectively. Of the 427 men with full potency at baseline, 317 men (74%) retained sexual function at time of last follow-up. Conclusions: This study represents the largest cohort of patients treated with high-dose radiation to 86.4 Gy, using IMRT for localized prostate cancer, with the longest follow-up to date. Our findings indicate that this treatment results in excellent clinical outcomes with acceptable toxicity.

62 RADIOLOGY AND NUCLEAR MEDICINE↗