This document is the report of a task group of the Radiation Therapy Committee of the AAPM and has been prepared primarily to advise hospital physicists involved in external beam treatment of patients with pelvic malignancies who have high atomic number (Z) hip prostheses. The purpose of the report is to make the radiation oncology community aware of the problems arising from the presence of these devices in the radiation beam, to quantify the dose perturbations they cause, and, finally, to provide recommendations for treatment planning and delivery. Some of the data and recommendations are also applicable to patients having implanted high-Z prosthetic devices such as pins, humeral head replacements. The scientific understanding and methodology of clinical dosimetry for these situations is still incomplete. This report is intended to reflect the current state of scientific understanding and technical methodology in clinical dosimetry for radiation oncology patients with high-Z hip prostheses.

In vivo dosimetry (IVD) is in use in external beam radiotherapy (EBRT) to detect major errors, to assess clinically relevant differences between planned and delivered dose, to record dose received by individual patients, and to fulfill legal requirements. After discussing briefly the main characteristics of the most commonly applied IVD systems, the clinical experience of IVD during EBRT will be summarized. Advancement of the traditional aspects of in vivo dosimetry as well as the development of currently available and newly emerging noninterventional technologies are required for large-scale implementation of IVD in EBRT. These new technologies include the development of electronic portal imaging devices for 2D and 3D patient dosimetry during advanced treatment techniques, such as IMRT and VMAT, and the use of IVD in proton and ion radiotherapy by measuring the decay of radiation-induced radionuclides. In the final analysis, we will show in this Vision 20∕20 paper that in addition to regulatory compliance and reimbursement issues, the rationale for in vivo measurements is to provide an accurate and independent verification of the overall treatment procedure. It will enable the identification of potential errors in dose calculation, data transfer, dose delivery, patient setup, and changes in patient anatomy. It is the authors' opinion that all treatments with curative intent should be verified through in vivo dose measurements in combination with pretreatment checks.

Optically stimulated luminescent detectors, which are widely used in radiation protection, offer a number of potential advantages for application in radiation therapy dosimetry. Their introduction into this field has been somewhat hampered by the lack of information on their radiation response in megavoltage beams. Here the response of a commercially available optically stimulated luminescent detector (OSLD) is determined as a function of energy, absorbed dose to water, and linear energy transfer (LET). The detector response was measured as a function of energy for absorbed doses from 0.5 to 4.0 Gy over the following ranges: 125 kVp to 18 MV for photons, 6-20 MeV for electrons, 50-250 MeV for protons, and 290 MeV/u for the carbon ions. For the low LET beams, the response of the detector was linear up to 2 Gy with supralinearity occurring at higher absorbed doses. For the kilovoltage photons, the detector response relative to 6 MV increased with decreasing energy due to the higher atomic number of aluminum oxide (11.2) relative to water (7.4). For the megavoltage photons and electrons, the response was independent of energy. The response for protons was also independent of energy, but it was about 6% higher than its response to 6 MV photons. For the carbon ions, the dose response was linear for a given LET from 0.5 to 4.0 Gy, and no supralinearity was observed. However, it did exhibit LET dependence on the response relative to 6 MV photons decreasing from 1.02 at 1.3 keV/microm to 0.41 at 78 keV/microm. These results provide additional information on the dosimetric properties for this particular OSL detector and also demonstrate the potential for their use in photon, electron, and proton radiotherapy dosimetry with a more limited use in high LET radiotherapy dosimetry.

Thermoluminescent dosimeters (TLD) and optically stimulated luminescent dosimeters (OSLD) are practical, accurate, and precise tools for point dosimetry in medical physics applications. The charges of Task Group 191 were to detail the methodologies for practical and optimal luminescence dosimetry in a clinical setting. This includes: (a) to review the variety of TLD/OSLD materials available, including features and limitations of each; (b) to outline the optimal steps to achieve accurate and precise dosimetry with luminescent detectors and to evaluate the uncertainty induced when less rigorous procedures are used; (c) to develop consensus guidelines on the optimal use of luminescent dosimeters for clinical practice; and (d) to develop guidelines for special medically relevant uses of TLDs/OSLDs such as mixed photon/neutron field dosimetry, particle beam dosimetry, and skin dosimetry. While this report provides general guidelines for TLD and OSLD processes, the report provides specific details for TLD‐100 and nanoDotTM dosimeters because of their prevalence in clinical practice.

Managing radiotherapy patients with implanted cardiac devices (implantable cardiac pacemakers and implantable cardioverter‐defibrillators) has been a great practical and procedural challenge in radiation oncology practice. Since the publication of the AAPM TG‐34 in 1994, large bodies of literature and case reports have been published about different kinds of radiation effects on modern technology implantable cardiac devices and patient management before, during, and after radiotherapy. This task group report provides the framework that analyzes the potential failure modes of these devices and lays out the methodology for patient management in a comprehensive and concise way, in every step of the entire radiotherapy process.

Abbreviations: %dd(10) x , The photon component of the percent depth dose at 10 cm depth in water for a 10 cm 2 × 10 cm 2 field; L∕ w air , Restricted mass collision stopping power ratio of water to air; en ∕ , Spectrum-averaged mass energy-absorption coefficient; AAPM, American Association of Physicists in Medicine; CPE, Charged Particle Equilibrium; DLG, Dosimetric leaf gap; D f msr w,Q msr , Absorbed dose to water at the reference depth z ref in water in the absence of the detector in a field specified by f msr and beam quality Q msr .; f clin , Clinical (clin) non-reference radiation field; f msr , Machine-specific reference (msr) field; f ref , Reference field (ref) specified in dosimetry protocols for which the calibration coefficient of an ionization chamber in terms of absorbed dose to water is provided by a standards laboratory; FWHM, Full-width at half-maximum; GUM, Guide to the expression of Uncertainty in Measurements.; IAEA, International Atomic Energy Agency; ICRU, International Commission on Radiation Units and Measurements; IMRT, Intensity-modulated radiation therapy; k Q,Q 0 , The beam-quality correction factor, which corrects for the differences between the response of an ionization chamber in the reference beam of quality Q o used for calibrating the chamber and the beam of quality Q (defined as k Q . in TG-51 4 ); k f ref Q,Q 0 , Correction factor that accounts for the differences between the response of a detector in field f ref in a beam of quality Q and reference beam quality Q 0 as defined in TRS-483. 1 and Palmans et al 2 ; k fclin,fmsr Qclin,Q msr , The detector-specific correction factor that accounts for the difference between the responses of the detector in fields f clin in a beam of quality Q clin and in fields f msr in beam of quality Q msr as defined by Alfonso et al. 3 ; LCPE, Lateral charged particle equilibrium; M fmsr Qmsr , Detector reading in field f msr and beam quality Q msr corrected for influence of changes in pressure and temperature, incomplete charge collection, polarity effect and electrometer correction factor (TRS-483 1 ); MU, Monitor unit; N D,w,Q 0 , This is N D,w in TG-51, 4 and defined as the calibration coefficient in terms of absorbed dose to water for an ionization chamber at a reference beam of quality,Q 0 and field size f ref ; N f ref D,w,Q 0

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For intensity modulated radiation therapy (IMRT) treatments 6 MV photons are typically used, however, for deep seated tumors in the pelvic region, higher photon energies are increasingly being employed. IMRT treatments require more monitor units (MU) to deliver the same dose as conformal treatments, causing increased secondary radiation to tissues outside the treated area from leakage and scatter, as well as a possible increase in the neutron dose from photon interactions in the machine head. Here we provide in vivo patient and phantom measurements of the secondary out-of-field photon radiation and the neutron dose equivalent for 18 MV IMRT treatments. The patients were treated for prostate cancer with 18 MV IMRT at institutions using different therapy machines and treatment planning systems. Phantom exposures at the different facilities were used to compare the secondary photon and neutron dose equivalent between typical IMRT delivered treatment plans with a six field three-dimensional conformal radiotherapy (3DCRT) plan. For the in vivo measurements LiF thermoluminescent detectors (TLDs) and Al2O3 detectors using optically stimulated radiation were used to obtain the photon dose and CR-39 track etch detectors were used to obtain the neutron dose equivalent. For the phantom measurements a Bonner sphere (25.4 cm diameter) containing two types of TLDs (TLD-600 and TLD-700) having different thermal neutron sensitivities were used to obtain the out-of-field neutron dose equivalent. Our results showed that for patients treated with 18 MV IMRT the photon dose equivalent is greater than the neutron dose equivalent measured outside the treatment field and the neutron dose equivalent normalized to the prescription dose varied from 2 to 6 mSv/Gy among the therapy machines. The Bonner sphere results showed that the ratio of neutron equivalent doses for the 18 MV IMRT and 3DCRT prostate treatments scaled as the ratio of delivered MUs. We also observed differences in the measured neutron dose equivalent among the three therapy machines for both the in vivo and phantom exposures.