Regional (AFRA) Training Course on

Small Field Dosimetry

Johannesburg, South Africa

6 – 10 October 2016

Dosimetric Errors of Radiotherapy Techniques

Involving Small Fields
Godfrey Azangwe, PhD, MInstP, MIPEM, MAAPM
Senior Lecturer, National University of Science &Technology
Bulawayo, Zimbabwe

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International Atomic Energy Agency
Outline

• Trends in RT
• Techniques involving small fields
• Examples of errors
• Error Prevention/Reduction

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Trends in RT

• New technologies are being introduced in

radiation therapy, principally aimed at
improving the treatment outcome
• Highly conformal dose distribution allows for
a dose escalation to the target volume
without increase of the radiation dose to
normal tissues.

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Trends in RT

• 10 years after a new concept for the delivery

of dynamic conformal radiotherapy was
described (Mackie et al. 1993), a
Tomotherapy unit was put into clinical
operation, and five years after the first
clinical prototype, more than 200
Tomotherapy machines are operating
throughout the world.

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Trends in RT

• Rotational treatments are being

implemented on more “traditional”
accelerators “Volumetric Arc Therapy”
techniques (VMAT) with the trade name
depending on the manufacturer
• What is a “standard” radiotherapy machine?
• IMRT capable machines now becoming
“standard”

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Trends in RT

• There is a danger of not ensuring the

availability of appropriate technical, scientific
and medical resources for the safe
introduction of these new approaches
• Risk of accidental exposure as a
consequence of this evolution in technology
can be reduced by appropriate efforts on
education and availability of appropriate
equipment
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New technology

• “New” technologies include:

• Increased use of MLCs
• Intensity modulated radiation therapy (IMRT)
• Arc therapy (IMAT, VMAT)
• Tomotherapy
• Image guided radiation therapy (IGRT)
• Gated radiation therapy
• Radiosurgery
• …
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New technology

• New technologies involve:

• Increased use of small fields
• Increased reliance on complex information
management system
• Increase requirements to have matching
dosimetry systems to verify accurate dose
delivery

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Errors in RT

“Radiotherapy is widely known to be one of

the safest areas of modern medicine, yet, for
some, this essential treatment can bring harm,
personal tragedy and even death”

Radiotherapy Risk Profile, WHO (2008)

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Errors in RT

• The literature in the area of radiation safety

is limited, and relates mainly to developed
countries, or is the result of investigations of
major errors.

Radiotherapy Risk Profile, WHO (2008)

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Radiotherapy treatment process

Radiotherapy Risk Profile, WHO (2008)

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Errors in RT

• The potential for errors in radiotherapy is

high, as it involves a complete patient
pathway with many links in the chain

Radiotherapy Risk Profile, WHO (2008)

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Errors in RT

An error is a failure to carry out a planned

action as intended or application of an
incorrect plan, and may manifest by doing the
wrong thing (an error of commission) or by
failing to do the right thing (an error of
omission), at either the planning or execution
phase.

http://www.who.int/patientsafety/implementation/taxonomy/publications/en/
Radiotherapy Risk Profile, WHO (2008)

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Errors in RT

• Summary of all widely reported major

radiotherapy incidents that led to significant
adverse events to patients (such as radiation
injury and death) and which have occurred
in the last three decades (1976-2007)

Radiotherapy Risk Profile, WHO (2008)

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Errors in RT

• The number of incidents that occurred:

• in the planning stage was 1702 (55%)
• of the remaining 45%,
• incidents were due to errors that occurred during the
introduction of new systems and/or equipment such as
megavoltage machines (25%),
• errors in treatment delivery (10%),
• information transfer (9%) or in multiple stages (1%).

Radiotherapy Risk Profile, WHO (2008)

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Errors in RT

Radiotherapy Risk Profile, WHO (2008)

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Errors in RT

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Errors in RT

• No detailed reports on radiotherapy-related

adverse events were available from Asia or Africa

• IAEA publications on TLD audits reported that

facilities that operate radiotherapy services without
qualified staff or without dosimetry equipment have
poorer results than those facilities that are properly
staffed and equipped (Izewska et al., 2003
Izewska et al., 2006)

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Errors in RT

• Report points out that in the early 1990s

major radiotherapy incidents occurred
mainly due to inexperience in using new
equipment and technology during
radiotherapy treatment

• As a region we should avoid this and learn

from mistakes of the past.

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Errors in conventional RT

• Publication ICRP 86 (ICRP 2000) points out

that most severe accidental exposures
occurred in radiation therapy departments
where a Quality Assurance (QA) programme
was not in place, or if it existed, it was not
fully implemented and/or verifications were
omitted

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Errors in conventional RT

• Weaknesses identified from accidental

exposures with conventional technology are:
• insufficient education and training, including
poor understanding of the physics of the
treatment equipment and treatment planning
systems,
• absence of appropriate acceptance and
commissioning procedures,
• misunderstanding instructions for users, verbally
communicated instructions,
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Errors in conventional RT

• Weaknesses identified from accidental

exposures with conventional technology are:
• omission of some of the checks of the quality
control programmes,
• changing a procedure without validation,
• resuming treatments after a major repair without
notifying the responsible person for beam
verification,
• poor notification of unusual tissue reactions and
• poor patient follow up.
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Calibration problems of small-fields

• Inappropriate detector size used when

commissioning micro-multileaf collimators
(Derreumaux, 2008).
• In April of 2006, a hospital physicist
commissioned a new stereotactic unit capable of
operating with micro-multileaf collimators (3 mm
leaf-width at isocentre) or conical standard
collimators.
• With the unit it was possible to shape clinically
usable fields down to 6 mm x 6 mm.
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Calibration problems of small-fields

• Inappropriate detector size used when

commissioning micro-multileaf collimators
(Derreumaux, 2008).
• It is necessary to measure the beam dose
characteristics down to this field size
• The beam data is subsequently used for
treatment planning purposes
• Data collected for the micro-multileaf collimator
is handled separately from data collected for
standard collimators.
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Calibration problems of small-fields

• Inappropriate detector size used when

commissioning micro-multileaf collimators
(Derreumaux, 2008).
• The physicist at the hospital used a Farmer 0.6
cm ionisation chamber, which is too large for
this type of measurements.
• This caused the wrong absorbed dose to be
administered when these fields were used with a
maximum overdose of ~200%.

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Two Major Categories in SRS/SBRT

• Commissioning
• Small field measurements
• Absolute calibration
• Treatment parameter transfer
• –SRS Cones
• Wrong side/site treatments

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Two Major Categories in SRS/SBRT

• Commissioning
• Small field measurements
• Absolute calibration
• Treatment parameter transfer
• –SRS Cones
• Wrong side/site treatments

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Errors

Newspaper articles/
TV News
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Errors

Newspaper articles/
TV News
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Errors

Newspaper articles/
TV News
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Errors

patient received 39 Gy / 3 fractions

Computer crash

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Errors

October 2007, USA: Gamma Knife treatment facility

Patient was set up for MRT imaging
• Standard practice is to position the patient “head first”
• The patient was positioned “head first”, but “feet first” scan
technique was chosen on the unit The axial images were
therefore reversed left-to-right
• The physicist did not see the mistake when importing images into
the TPS
• The error resulted in an 18 mm shift of isocentre across the
midline of the brain

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Error Reporting

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Sources of information

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References
• ASTRO. Safety is no Accident: A Framework for
Quality Radiation Oncology and Care. American
Society for Radiation Oncology (2012).
• Towards Safer Radiotherapy. BIR, IPEM, National
Patient Safety Agency Society, College of
Radiographers, The Royal College of Radiologists
(2008).
• Radiotherapy Risk Profile: Technical Manual. WHO
(2008).
• Bogdanich W, Ruiz RR. Radiation errors in Missouri,
New York Times.
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Where to Get More Information?
• AAPM Task Group 101
• Target Safely – IMRT Safety White Paper
• Target Safely – SBRT/SRS Safety White
Paper
• ASTRO – Safety is no accident – A
framework for quality radiation oncology and
care
• IPEM 103
• IAEA
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