A new approach to account for the medium-dependent effect in model-based dose calculations for kilovoltage x-rays

This study presents a new approach to accurately account for the medium-dependent effect in model-based dose calculations for kilovoltage (kV) x-rays. This approach is based on the hypothesis that the correction factors needed to convert dose from model-based dose calculations to absorbed dose-to-medium depend on both the attenuation characteristics of the absorbing media and the changes to the energy spectrum of the incident x-rays as they traverse media with an effective atomic number different than that of water. Using Monte Carlo simulation techniques, we obtained empirical medium-dependent correction factors that take both effects into account. We found that the correction factors can be expressed as a function of a single quantity, called the effective bone depth, which is a measure of the amount of bone that an x-ray beam must penetrate to reach a voxel. Since the effective bone depth can be calculated from volumetric patient CT images, the medium-dependent correction factors can be obtained for model-based dose calculations based on patient CT images. We tested the accuracy of this new approach on 14 patients for the case of calculating imaging dose from kilovoltage cone-beam computed tomography used for patient setup in radiotherapy, and compared it with the Monte Carlo method, which is regarded as the 'gold standard'. For all patients studied, the new approach resulted in mean dose errors of less than 3%. This is in contrast to current available inhomogeneity corrected methods, which have been shown to result in mean errors of up to -103% for bone and 8% for soft tissue. Since there is a huge gain in the calculation speed relative to the Monte Carlo method (∼two orders of magnitude) with an acceptable loss of accuracy, this approach provides an alternative accurate dose calculation method for kV x-rays.