Feasibility study of entrance and exit dose measurements at the contra lateral breast with alanine/electron spin resonance dosimetry in volumetric modulated radiotherapy of breast cancer.

The Physikalisch-Technische Bundesanstalt has established a secondary standard measurement system for the dose to water, D-W, based on alanine/ESR (Anton et al 2013 Phys. Med. Biol. 58 3259-82). The aim of this study was to test the established measurement system for the out-of-field measurements of inpatients with breast cancer. A set of five alanine pellets were affixed to the skin of each patient at the contra lateral breast beginning at the sternum and extending over the mammilla to the distal surface. During 28 fractions with 2.2 Gy per fraction, the accumulated dose was measured in four patients. A cone beam computer tomography (CBCT) scan was generated for setup purposes before every treatment. The reference CT dataset was registered rigidly and deformably to the CBCT dataset for 28 fractions. To take the actual alanine pellet position into account, the dose distribution was calculated for every fraction using the Acuros XB algorithm. The results of the ESR measurements were compared to the calculated doses. The maximum dose measured at the sternum was 19.9 Gy +/- 0.4 Gy, decreasing to 6.8 Gy +/- 0.2 Gy at the mammilla and 4.5 Gy +/- 0.1 Gy at the distal surface of the contra lateral breast. The absolute differences between the calculated and measured doses ranged from - 1.9 Gy to 0.9 Gy. No systematic error could be seen. It was possible to achieve a combined standard uncertainty of 1.63% for D-w = 5 Gy for the measured dose. The alanine/ESR method is feasible for in vivo measurements.