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Rahman, A.T.A.;  Mohyedin, M.Z.;  Zin, H.M.;  Adenan, M.Z. Radiotherapy Dosimetry Applications of PRESAGE. Encyclopedia. Available online: (accessed on 21 June 2024).
Rahman ATA,  Mohyedin MZ,  Zin HM,  Adenan MZ. Radiotherapy Dosimetry Applications of PRESAGE. Encyclopedia. Available at: Accessed June 21, 2024.
Rahman, Ahmad Taufek Abdul, Muhammad Zamir Mohyedin, Hafiz Mohd Zin, Mohd Zulfadli Adenan. "Radiotherapy Dosimetry Applications of PRESAGE" Encyclopedia, (accessed June 21, 2024).
Rahman, A.T.A.,  Mohyedin, M.Z.,  Zin, H.M., & Adenan, M.Z. (2022, July 19). Radiotherapy Dosimetry Applications of PRESAGE. In Encyclopedia.
Rahman, Ahmad Taufek Abdul, et al. "Radiotherapy Dosimetry Applications of PRESAGE." Encyclopedia. Web. 19 July, 2022.
Radiotherapy Dosimetry Applications of PRESAGE

PRESAGE is a commercial radiochromic polymer dosimeter that was introduced by John Adamovics. It exhibits several strong advantages compared to other polymer gel dosimeters. The implementation of PRESAGE dosimetry is useful for complex radiotherapy treatment verifications, which include VMAT, IMRT, radiosurgery, and brachytherapy. 

polymer dosimeter PRESAGE radiotherapy

1. Applications in Radiotherapy Dosimetry

Advances in radiotherapy have allowed the conformal delivery of a high radiation dose to a cancer target volume whilst sparing the dose to normal tissues through various IMRT techniques [1][2]. PRESAGE provides dose distribution in 3D that can be compared with the dose predicted from the radiotherapy treatment planning system (TPS). Gamma analysis is used to compare the delivered dose distribution to that planned by the TPS. The calculation is based on the distance to agreement (DTA) criteria and the dose difference criteria [3]. Recent studies show that PRESAGE has excellent gamma passing rates for various radiotherapy treatments [4][5][6][7][8][9][10][11][12].
PRESAGE was used with the Radiological Physics Center head and neck (RPC H&N) phantom for IMRT verification and was shown to have excellent intra-dosimeter consistency within 2%. The dosimeter is capable of producing a consistent response (by a difference within 2%) at three different 3D inserts. The PRESAGE also showed a gamma passing rate of more than 99% for 2%/2 mm criteria when the 4 mm ring profile around the edge was removed from the analysis. The presence of impurities caused errors at the particular points and was responsible for 1% of the failures [13]. Furthermore, the study also showed that the dosimeter measurement agreed well with the EBT film (98% pass rate) and the Eclipse dose calculations (94% pass rate) [14]. The dosimeter has post-irradiation stability for more than 90 h.
PRESAGE has also been shaped into an anthropomorphic breast for IMRT treatment verification and brachytherapy [15][16]. The study demonstrated that the dose measured by PRESAGE was within a 5% maximum difference when compared with the EBT2 film and the Pinnacle treatment planning system. The gamma passing when compared with the EBT2 film and Pinnacle TPS was 88.4% and 90.6%, respectively, at the 3%/3 mm criteria. The major failures took place at the 8 mm outer ring of the dosimeter. PRESAGE illustrated a 95% gamma passing rate if the ring was ignored [16]. PRESAGE has also been fabricated as a sheet and used for QA measurement. A study shows that the PRESAGE sheet is capable of producing a linear dose response with a negligible dose rate and energy dependence. It demonstrated a gamma passing rate of 99.7% when compared with the EBT3 films [17]. Another study shows that the PRESAGE sheet is capable of being reused six times after irradiation, with a consistent sensitivity within 5% [18]. These works have provided the applicability of PRESAGE as a fashionable phantom. The investigation of the feasibility of the PRESAGE breast phantom for other radiotherapy treatments was suggested.
Another study has developed a new formulation of PRESAGE, known as the DEA-1 formulation, to investigate its feasibility for IMRT and VMAT treatment verification. The study reported that PRESAGE shows deviation within 2% for VMAT and less than 2% for IMRT, as compared with the Eclipse calculations in the high-dose regions. The study also showed that the PRESAGE has average gamma passing rates of more than 98% for IMRT and around 92% for VMAT, when compared to the Eclipse calculations. Similar to the previous studies, the outer ring of the dosimeter was the major failure in the gamma passing rate and was left out in the gamma analysis [19].
PRESAGE has been utilised to investigate the effect of organ motion on IMRT treatment and shows a good agreement of more than 90% passing rates for 3%/2 mm criteria, with the noise being less than 0.5%. A significant deviation was observed in the form of stretching and shifting for organ motion treatment. [20]. A study showed that PRESAGE has a gamma passing rate of 98% for 3%/2 mm criteria in VMAT treatment [21]. PRESAGE has also been utilised in an RPC head and neck phantom for 3D-CRT and VMAT treatment, with the gamma passing rate of 99% when compared to the Pinnacle calculations for 5%/3 mm criteria [22].
PRESAGE has been used for the Imaging and Radiation Oncology Core (IROC) Houston Quality Assurance Center (IROC) head and neck phantom as a QA tool for VMAT treatment. The study demonstrated the feasibility of the dosimeter with gamma passing rates of 94.38% for 5%/3 mm [6]. One study reported that the gamma passing rates of PRESAGE were 99% for 3%/3 mm criteria when investigating the applicability of the dosimeter for organ motion in VMAT treatment. However, the difference of 15% in dose to PTV was observed [23]. In general, PRESAGE demonstrated useful properties when verifying several radiotherapy methods, including IMRT and VMAT.

2. The Challenge in Small Field Dosimetry

Another challenge in radiotherapy dosimetry is the treatment of a small volume of cancer target. The small field treatment uses a few mm beam apertures to irradiate a small volumetric target. A recent study shows that the PRESAGE is capable of obtaining a small-field megavoltage beam accurately [11]. PRESAGE has been used to make a measurement of a small field as small as 5 mm2. A study shows that PRESAGE has an accuracy of 99.8% at a field size of 20 mm2. The accuracy, however, is reduced as the field size is reduced. At 5 mm2, the accuracy of PRESAGE is 96.4%. When compared with the EBT film, PRESAGE has better accuracy at the large field size. At the small field size, the EBT film was observed to have better accuracy. This is due to the debris and small bubbles suspended in the PRESAGE matrix. In addition, the error also included the water inequivalence that may raise the equilibrium of the lateral electronics a little and affect the measured scatter factors [24][25]. Such errors can be improved through the development of PRESAGE formulation. The utilisation of PRESAGE in gamma knife radiosurgery has also been investigated. The study shows that PRESAGE has excellent agreement with the gamma knife output factors, with the average difference of 1.24%, which is suitable for performing quality assurance measurements for the radiosurgery gamma knife treatment system [26]Figure 1 shows an example of an SRS dose deposited in a PRESAGE dosimeter.
Figure 1. Projection image of PRESAGE irradiated with stereotactic radiosurgery (SRS) treatment. The image was captured with the in-house CMOS-OCT dosimetry system.

3. Application in Brachytherapy

PRESAGE has also been used in high-dose brachytherapy treatment. A current benchmark for the measurement of the absolute dose in brachytherapy is TLD. The main disadvantage of TLD is water inequivalence. The dose response of TLD depends on dose rate and beam energy. Thus, 3D dosimetry is required to enhance the accuracy and precision of absolute dose measurement in brachytherapy [27][28]. PRESAGE shows more accurate absolute dose measurement when compared with the TLD in brachytherapy treatment. A study shows that PRESAGE has a deviation of 0.7% from the treatment dose prediction. Meanwhile, the TLD has a deviation of 13.08%. In addition, PRESAGE also has a 98.9% agreement with the EBT2 film dose delivery in brachytherapy treatment [29]. Another study reported that PRESAGE provides an acceptable relative dose measurement for Ir-192 and Cs-137 brachytherapy sources [30]. PRESAGE has also demonstrated feasibility in the application to the anthropomorphic breast shape for measurement of the skin dose for accuracy verification in the brachytherapy treatment planning system [31].


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