- Dosimetry of Small Static Fields Used in External Beam Radiotherapy: An International Code of Practice for Reference and Relative Dose Determination Prepared Jointly by the IAEA and AAPM, Technical Report |Series No. 483, 2017 (IAEA)
- IPEM Report 103, Small field MV photon dosimetry, Institute of Physics and Engineering in Medicine, 2010
- Alfonso R., Andreo P., et al., A new formalism for reference dosimetry of small and nonstandard fields, Med Phys 35 (2008) 5179
- Handling small fields and segment in a TPS
- Online E-learning Course on IAEA/AAPM Code of Practice for the Dosimetry of Static and Small Photon Fields
Small and non standard fields
The use of small fields in radiotherapy techniques has increased substantially, in particular in stereotactic treatments and large uniform or non-uniform fields that are composed of small fields such as for IMRT. This has been facilitated by the increased availability of standard and add-on multileaf collimators and a variety of new treatment units, such as GammaKnife (Leksell GammaKnife®, Elekta Instrument AB, Stockholm, Sweden), CyberKnife® Robotic Radiosurgery System and TomoTherapy® Hi-Art® (Accuray Inc., Sunnyvale, CA).
A number of dosimetry incidents have been reported due to the misunderstanding of small field dosimetry. For example in 2007, an inappropriate detector was used to commission the 6 mm × 6 mm photon field defined by a microMLC (Novalis Tx, BrainLAB) leading to incorrect data being entered into the treatment planning system and to the mistreatment of 145 patients within a period of a year. The mistake was discovered by the manufacturer through a corroboration of the data measured worldwide by its users.
Small photon fields differ from conventional broad reference fields in their lateral dimensions causing the penumbrae at both sides of the field to overlap and most commonly used detectors to be large relative to the field size.
Three physical conditions, of which one, two or all are fulfilled, determine if an external photon beam is small: (i) there is a loss of charged particle equilibrium, (ii) partial occlusion of the primary photon source by the collimating devices takes place and (iii) the size of the detector compared to the beam dimensions is large.
In addition, dosimetric errors are larger than in conventional beams mostly due to two reasons: (i) the reference conditions recommended by conventional Codes of Practice cannot be realised in some machines and (ii) the measurement procedures for absorbed dose determination in small and composite fields is not standardized.
No ideal detector exists for small field dosimetry so it is recommended to use two or three different types of detector suitable for a particular measurement to improve assurance against unacceptable dose errors by means of redundancy in the results.
Introduction to References
There have been a number of publications over the years outlining the problems associated with using small fields in radiotherapy. These are too numerous to mention here but a summary was presented in 2010 by an IPEM working group.
Alfonso et al. addressed the problem of absolute small field dosimetry by presenting formalism for the dosimetry of small and composite fields. The concept of two new intermediate calibration fields was introduced: (i) a static machine-specific reference field for those modalities that cannot establish conventional reference conditions and (ii) a plan-class specific reference field closer to the patient-specific clinical fields thereby facilitating standardization of composite field dosimetry.
Accurate calculation of dose by treatment planning system (TPS) software depends on the quality of the measured basic data and the accuracy of the beam models. A webinar is made available at this link that presents the challenges when modelling dose in small photon fields. The webinar delivered by Mr John Byrne (UK), does not offer solutions to all the questions raised but emphasises that, for small field work, the configuration of beam models, and more so accurate geometric and dosimetric input data, requires special attention. It is the topic of future research work to address the challenges raised in this Webinar and other questions related to the application of small field dosimetry when used in the clinic.
On-going IAEA/AAPM work on small field dosimetry
The IAEA and AAPM have formed a working group on small field dosimetry whose remit is to produce a Code of Practice based on the Alfonso formalism. The code has been published in November 2017 and available for download through a link on this page.