Dosimetric control of conformal treatment of parotid gland tumours

The purpose of this study was to determine the dosimetric accuracy of the treatment of parotid gland tumours using 8 MV X-ray beams. These tumours are generally situated near the patient's skin. Entrance in vivo dose measurements with diodes were obtained for 20 patients during 5 sessions per patient, in the anterior-oblique and posterior-oblique wedged fields, on the central beam axis as well as in points situated in a cranial plane 2 or 3 cm off-axis. Phantom measurements were performed in order to determine the actual position of the 95% isodose surface. The measurements were compared with calculations performed with our three-dimensional treatment planning system. The reproducibility of the diode measurements on patients was found to be 1.4% (1 SD). The total accuracy in the entrance dose determination for the average of 2 measurements was 1.8% (1 SD). The central axis entrance dose for the anterior field was on average 1.5% +/- 3.2% (1 SD) higher than the calculated value. For the posterior field, the difference was 0.9% +/- 3.1% (1 SD). The deviations for the off-axis points were somewhat smaller, mainly due to overestimation of the block effect in the calculations. The value of the dose at the isocentre obtained by extrapolation of the measured entrance dose values, differed 0.3% +/- 2.1% from the calculations. The accuracy in dose determination at the isocentre was 2% (1 SD). After correction for the difference in prescribed and actual source-to-skin distance, the results showed good agreement with phantom measurements on a polystyrene phantom without inhomogeneities, performed both with diodes and an ionization chamber.(ABSTRACT TRUNCATED AT 250 WORDS)

Precise positioning of intracranial small tumors to the linear accelerator's isocenter, using a stereotactic radiotherapy computed tomography system (SRT-CT)

RT-CT was developed as a simulator using CT scan for radiotherapy. Following three-dimensional treatment planning using CT images, the treatment center and treatment fields are projected to the patients' surface by laser beam on the C arm. The prototype had an accuracy of 3 mm which was equivalent to conventional X-ray simulators but was not adequate for use in stereotactic radiotherapy. A new RT-CT system was developed to have a precise localization capability for stereotactic radiotherapy. Using this stereotactic RT-CT (SRT-CT) after three-dimensional planning, the treatment center is projected to the stereotactic frame automatically. In this study, the values of the x, y and z coordinates of the target center determined by SRT-CT are compared with those determined by the traditional method using CT localizing plates. The discrepancies were within 1.0 mm in 90% and 1.5 mm in 100% of 30 measurements in 16 patients. The disadvantages of SRT-CT may be that the accuracy of localization depends on the quality of calibration of laser beams. The traditional CT localizing method has superiority over SRT-CT because of its solid coordinates but its accuracy is vulnerable to alignment of CT fiducial marker plates. Therefore, the SRT-CT and traditional CT localizing methods would be complementary to each other for precise localization.

Wedge factor constituents of high-energy photon beams: head and phantom scatter dose components

The head and phantom scatter contribution to the output of a treatment machine have been determined for open and wedged 60Co gamma-ray beams and 4, 8, 16 and 25 MV X-ray beams, using an extended and a small-sized phantom. The wedge factor variation with field size and phantom depth have been analysed as a function of both scatter components. For the wedged beams a stronger increase of the head scatter contribution with field size, i.e. 4-9% for field sizes increasing from 5 cm x 5 cm to 20 cm x 20 cm, has been observed compared with open beams. This result indicates that the wedge factor variation with field size is related to a change of the primary photon fluence. Our study shows that the ratio of the head and phantom scatter contribution for the wedged and open beams remains unchanged for all beams except the 4 and 25 MV X-ray beam. This implies that, except for these latter energies, the variation of the wedge factor with phantom depth is determined by the wedge-induced change of the primary photon energy fluence. For the 4 and 25 MV X-ray beam it is shown that the wedge factor is also influenced by a change of the phantom scatter contribution. The wedge factor for the 25 MV X-ray beam is strongly influenced by the electron contamination for phantom depths up to 6 cm. For the 60Co and the 4 MV photon beam it is shown that the wedge factor decreases slightly with increasing source-to-skin distance due to a reduced contribution to the total dose from photons scattered in the wedge. For clinical use, an algorithm is given to calculate the wedge factor variation with field size and phantom depth.

A doubly achromatic asymmetric three-magnet 90 degrees deflection system

A doubly achromatic asymmetric three-magnet beam deflection system is described which is suitable for deflecting low energy electron linac beams with high energy spread through approximately 90 degrees. It consists of three dipoles: two small antisymmetric magnets and one approximately 90 degrees magnet. The doubly achromatic relations for the system are given. The configuration has the specific advantage over all other doubly achromatic systems of minimizing the magnet dimension in the direction opposite to the exit trajectory, and is particularly desirable in a high energy medical electron linac, for it reduces rotation radius of gantry of the machine.

The accuracy of field shape definition using standard shielding blocks and the consequences for field shape verification

The accuracy of field shaping using standard shielding blocks has been investigated in 157 fields in the thoracic region, the majority for treatment of lung cancer. Accuracy was defined as the width of the tolerance margin around the prescribed field outline that would be needed to accept the full megavoltage field boundary. The use of several positioning aids was evaluated, including a cardboard template that was created with the data already specified for field shape verification of megavoltage fields. Block positioning via tattoos on the skin gives large random field shape errors: assuming a tolerance margin of +/- 5 mm, approximately 50% of these fields would have to be rejected. When a transparent sheet with a drawing of the required field outline was used as positioning aid on the tray without an explicit quality control of the sheet itself approximately 24% of the fields would not be accepted because of an error in the sheet (systematic error) and approximately 20% because of a discrepancy in block position relative to the actual prescription of the sheet (random error). If block positioning is performed via a cardboard template of which the prescription was checked to be better than 3 mm measured in the plane of the isocentre, approximately 96% of the fields will be accepted assuming a tolerance margin of +/- 5 mm: the risk of misplacement of blocks appeared to be very low. Integration of prescription, preparation of the cardboard template, quality control of the template and verification of the megavoltage field shape results in an easy, accurate and reliable way of field shape definition using standard blocks.

Skin-sparing reduction effects of thermoplastics used for patient immobilization in head and neck radiotherapy

Skin-sparing benefits derived from the use of megavoltage photon beams can be strongly reduced when filters are inserted between the source and the patient. The use of plastic masks for immobilizing the patient is the most important cause of this reduction in head and neck treatments. The influence of thermoplastics, commercially available for patient immobilization systems (Orfit Raycast (Luxilon Ind. Co.), Posicast (Sinmed bv) and Optimold (WFR Aquaplast Corp.)), on the patient skin dose value has been investigated by using an NE2534 'Markus' chamber. Indicative measurements with moulded masks (carried out with 2-mm Orfit and 3.2-mm Optimold layers) show significant differences between masks moulded with the two thermoplastics.

Intra-operative radiation therapy for malignant brain tumors: rationale, method, and treatment results of cerebral glioblastomas

In radiation therapy for malignant brain tumours, the dose of radiation that can be safely delivered to a tumour is limited by the radiation tolerance of the adjacent normal brain tissue. Among various radiation modalities to produce local tumour eradication without unacceptable complications, we chose a large, single irradiation dose during the operation (intra-operative radiation therapy, IORT). In contrast to X-ray or Cobalt-60 gamma ray irradiation, IORT with a high-energy electron beam delivered by the Shimadzu 20 MeV betatron provides acceptable dose homogeneity with rapid fall-off of the radiation dose beyond the treatment volume. Thus, IORT has the advantage of precise demarcation of the target volume, minimum damage to surrounding normal tissues, and a high absorbed target dose (15-25 Gy in 5-10 min). On the basis of our experience with 170 patients treated by IORT, we established the treatment indications and method in patients with malignant brain tumours. IORT with a dose of 15-25 Gy was delivered to widely resected tumours followed by external radiation therapy. No acute or subacute complications were observed. Treatment results of 30 patients with glioblastoma treated by IORT (mean 18.3 Gy) combined with external radiation therapy (mean 58.5 Gy) resulted in a median survival of 119 weeks and a 2-year survival rate of 61%.

New treatment protocol by intra-operative radiation therapy for metastatic brain tumours

In patients with brain metastasis from lung cancer, we have been able to control local recurrence in approximately 80% of cases. But many of them tend to show brain atrophy with mental deterioration developing a few months after whole brain radiation. To prevent brain atrophy, we have attempted treating patients, whose metastasis was diagnosed as single, by intra-operative radiotherapy (IOR) alone following surgical resection. Among 43 patients, 19 patients who had no metastases other than the brain metastases, were chosen as subjects for active treatment (surgical resection+IOR). Their 1-year survival rate was 75%. Fourteen out of 27 patients with brain metastases from lung cancer received active treatment and their 1-year survival rate was 74%. This result was not inferior to our result of 71 patients who received surgical resection and whole brain irradiation. When no preventive whole brain irradiation was performed, patients were observed every 8 weeks by CT scan in order to ascertain tumour recurrence limited to the treated site or appearance of any new metastatic lesion remote from the treated site. Among all 43 patients, local recurrence was recognized in 7 cases and remote recurrence was observed in 7 cases. Within 6 months, local and remote recurrence was found in 3 cases each. These results were almost the same as those for the usual therapy (surgery plus whole brain irradiation). If such a new lesion is detected, additional radiation can be performed with the possibility of achieving complete remission.

A mono isocentric technique for breast and regional nodal therapy using dual asymmetric jaws

PURPOSE

Definitive radiation therapy for breast cancer with regional nodal involvement often introduces treatment of adjacent abutted regions. Many methods describe techniques to achieve an effective transverse plane match. Our facility recently adopted a matching technique using asymmetric jaws to beam-split all portals along the central axis plane. Our technique uses one isocenter to treat the opposed tangential breast fields, the supraclavicular port and the posterior axillary field.

METHODS AND MATERIALS

Our linear accelerator has four collimator jaws capable of being set independently. The longitudinal (Y) jaws beam-split all the portals at the match plane, namely the upper border of the tangential beams and the bottom border of the nodal fields. The transverse (X) jaws define the lateral borders of the nodal fields, and in a near beam-split fashion in conjunction with customized Cerrobend, block the lung for the tangential beams. The unique isocenter is chosen along the mid-bridge through the tangential match plane. Dosimetric qualities and calculational techniques of the asymmetric beams were analyzed with ionimetric water scans, ion chamber studies, and film. The match-line is clinically confirmed with composite port films.

RESULTS

Our dosimetric studies show asymmetric jaws provide nearly equivalent field edge definition and superior absorption in comparison with Cerrobend blocks. The use of one isocenter results in a reduction of in-room treatment time by a factor of two. The burden of lifting heavy Cerrobend blocks has been removed. A composite port film, which includes the medial tangential and supraclavicular ports, shows a perfect match-line in all cases. Similar composite port films taken with our previous technique of geometric matching with collimator and table angulation exhibit slight overlap or underdose regions in many cases.

CONCLUSION

Our treatment technique takes full advantage of dual asymmetric jaws to achieve a perfect match-line, necessitates only one isocenter and set-up point, and supplies more absorption in reference to lung and contralateral breast dose. The pure match-line is accompanied by the fact that the patient does not have to move in any direction.

Preliminary clinical performance of a scanning detector for rapid portal imaging

A scanning megavoltage imaging detector, with associated image storage and analysis facilities has been developed. This produces images of the treatment portals in under 10 seconds, in a digital format, facilitating rapid, quantitative image analysis. Image quality is comparable to, and at some sites improves upon, that available from film. Clinical problems in the use of megavoltage imaging include limited field of view, loss of information at the field edge due to penumbra effects, degradation of the image by bowel gas, and difficulties in the detection of soft tissue-air interfaces. Possible solutions to these problems are discussed. The imaging system has been used to assess the random errors occurring during routine para-aortic nodal irradiation. The errors detected are small, with over 95% of set-ups lying within +/- 4.5 mm of the mean daily position. No differences were detected in the magnitude of random errors between anterior and posterior treatment fields.

Evaluation and quality control of a commercial 3-D dose compensator system

A commercially available software/hardware system for automated design and fabrication of three-dimensional dose compensator molds has been tested for accuracy and precision as well as for its ability to provide adequate dose compensation at depth. To date, we have used this system to treat more than 50 patients with either head and neck or lung malignancies. In 19 head and neck patients (38 compensators) the use of a customized compensator resulted in an average reduction of dose variance in the target volume from 13.8% (range of 7%-21%) with uncompensated parallel-opposed fields to 4.5% (2%-7%) with custom-compensated parallel-opposed fields. A similar reduction was seen in the dose variation across lung tumor volumes. The custom compensators were also tested for accuracy of fabrication and positioning; both were found to be accurate within +/- 1 mm of the design specifications for all compensators tested. Last, the dosimetric properties of the compensators were studied. The ratios of measured open-beam dose profiles to measured compensated-beam dose profiles were compared with the ratio of similar profiles calculated with a treatment planning system. These ratios were equal within +/- 2.9%, thus providing evidence of the fidelity of the compensator to its design and the accuracy of the treatment planning algorithm that designs 34 each compensator.

Dosimetry of effective wedge fields produced by an internal wedge

A procedure is described to calculate the monitor unit ratios required to produce effective wedge fields having a desired wedge angle by combining an internal 60 degrees wedge with an open field. Complementary procedures are derived and demonstrated for calculating the effective wedge dose distributions with wedge angles of 15 degrees, 30 degrees, and 45 degrees using the central axis depth dose data and off-axis ratios of the open field and the 60 degrees wedged field. Measurements at five points on and off the central axis within each field and measurements of the effective wedge factor demonstrated that the calculated wedge distributions were correctly delivered to within 2% in all cases.

Description and evaluation of a new 3-D computerized treatment planning dose compensator system

Evaluation has been performed of compensators generated by means of a computerized three-dimensional treatment planning system that can utilize either digitized slice profiles or CT scans. Two methods of calculating compensator thickness are used: the modified Batho power law (dSAR) method for digitized profiles and the equivalent TAR (eqTAR) method for CT scans. This system not only compensates for patient surface contours but also compensates for internal inhomogeneities. In addition, any required wedging will be incorporated in the compensator generation. This system has been tested for a number of extreme cases with inhomogeneities and sloping contours. Good agreement was obtained between the measured and computer calculated dose profiles especially along the central axis of the beam. A "Profile Uniformity Index" was defined to quantify the goodness of dose compensation in three dimensions. Compensation using this system can achieve good dose uniformity within the target volume in all clinical cases and is definitely an improvement over systems based solely on tissue deficit.

Characterization of gypsum attenuators for radiotherapy dose modification

Gypsum has significant value as a compensator material for use with high energy x rays in radiation therapy. Compensator thickness may be calculated by using an effective attenuation coefficient (mu eff). Detailed measurements using narrow and broad beam geometry were collected to determine this effective attenuation coefficient as a function of energy (4-15 MV), field size, depth in tissue, and thickness of the compensator. An effective attenuation coefficient relation was defined using a least-square method. It was then determined that extrapolating the broad beam data to a 0 x 0 cm2 field size resulted in a good approximation to the measured narrow beam attenuation coefficient. The variations in surface dose produced by gypsum attenuators were compared to open beam results. For the energies studied, it was determined that the increase in surface dose was acceptable for clinical application.

Prospects for proton-beam radiotherapy

Proton beams are already being employed for radiation therapy in 15 centres worldwide and over a dozen more are planned. Good clinical results have been reported in uveal melanomas and in sarcomas of the skull base. Calculated dose distributions for the treatment of brain, lung, head and neck and pelvic tumours predict an improvement relative to multiple-field or conformal photon radiotherapy. Protons may well provide high-precision radiotherapy that will lead to improved treatment of certain tumours in specific anatomical locations.

Matching of electron and photon beams with a multi-leaf collimator

Multi-leaf collimators (MLCs) are offered as an accessory to many accelerators for radiation therapy. However, beam edges generated with these collimators are not as smooth as can be achieved with individually made blocks. The clinical drawbacks and benefits of this ripple were evaluated both for single field treatments and for combined adjacent fields of different beam qualities. In this investigation the MLC-collimated beams of the MM50 racetrack microtron were studied. The distance between the field edge and the 90% isodose was measured at the reference depth for four beam qualities (20 MV photons and 10, 20 and 50 MeV electrons). This distance was found to vary from approximately 6 mm for straight beam edges (i.e., all collimator leaves aligned) to approximately 2 mm from the tip of the leaves for a saw-tooth shaped beam edge. The over- and under-dosage in the joint between combined adjacent fields was found to be typically +/- 10% in small volumes. Improved clinical techniques using adjacent photon and electron fields with the same isocentre and source position (without moving the gantry) have been developed. For treatments of the breast, including the mammary chain, a uniform dose distribution was created with special attention given to the irradiation of the heart and lung outside the target volume. A method for head and neck treatments was optimised to give uniform dose distribution in the joint between the photon and electron fields and a method of treating the mediastinum, including the chest wall in front of the left lung, was analysed with respect to dose uniformity in the tumour and shielding of the lung.

The effect on tumour control probability of varying the setting of a multileaf collimator with respect to the planning target volume

The multileaf collimator (MLC) is being used increasingly to replace Cerrobend blocks when shaping radiation fields. When the MLC has a stepped edge in relation to the planning target volume (PTV) there might be concern that the MLC is not equivalent to the use of a block. This concern is countered by studying the effect on the tumour control probability of varying the distance between the stepped edge of the MLC and the contour of the PTV. It is observed that provided an adequate margin is added to the PTV when using the MLC the TCP is not reduced. The meaning of adequate has been accurately quantitated as being > or = 7 mm when the projected leaf width is 10 mm at the isocentre. This is the margin which when added to the outline of the planning target volume will ensure no reduction in TCP compared with the use of a block.

[A mathematical description of the relative dosage distributions of stereotactic collimator tubes in 6-MV photon radiation]

The relative dose distributions of small circular fields for 6 MV photons may be calculated using a simple mathematical model. This model has been developed for stereotactic collimators with cylindrical cross section and diameters between 5 mm and 30 mm. The model consists of the description of depth dose curves and off-axis dose distributions. The function for off-axis dose distributions is calculated by convolution of a simple profile function with a constant function. The width of the constant function is defined by beam geometry. In the result of integration only the width of the profile function is unknown, but it can be iteratively calculated. The agreement between measured and calculated dose distributions was tested at 5 cm and 20 cm depth in water and 100 cm source-to-surface distance using thermoluminescent dosimetry (TLD) and films, giving a resolution of 1 mm. The depth dose curve is described using the inverse square law and two exponential functions. The first of these functions contains the effective attenuation coefficient in the argument, the second describes the build-up. The increase of irradiated volume with increase of field diameter is accounted for using scatter-air ratios. The calculations were compared with TLD and ion-chamber measurements.

EORTC radiotherapy group quality assurance: mechanical checks and beam alignments of megavoltage equipment

In 1987 mechanical checks of megavoltage units and simulators were included in the on-site physics program of the EORTC. The results reported were obtained in 16 different centres and concern 23 accelerators, 14 cobalt units and 14 simulators. In general, the deviations observed for accelerators and simulators are smaller than for cobalt units. A single score, based on the deviations observed for the mechanical checks, is attributed to each centre.

Inhibitory effect of high energy shock waves and radiotherapy in vitro

Exposure of mice fibroblasts cell strain 3T3 to high energy shock waves and megavoltage radiotherapy resulted in a reduction in cell viability as determined by trypan-blue exclusion and H3-Thymidine incorporation assays. Electromagnetic shock waves have a higher cytotoxic effect on cell viability than megavoltage radiotherapy, at low and medium levels of energy. Megavoltage radiotherapy has a higher cytotoxic effect on cell viability at high levels of energy, as nucleoside incorporation reveals. The combination of electromagnetic shock waves and megavoltage radiotherapy delivered on cell cultures at medium levels of energy, did not enhance their cytotoxicity when it was compared with their high levels of energy individually.

The response characteristics of a newly designed plane-parallel ionization chamber in high-energy photon and electron beams

A new plane-parallel ionization chamber has been designed by Attix to overcome the shortcoming of previous commercially available parallel-plate ionization chambers for dosimetry in high-energy photon and electron beams in radiation oncology. This investigation details the performance characteristics of this new, commercially available plane-parallel chamber. The magnitude of the polarity effect in high-energy electron beams is shown to be less than 1% while the polarity effect in high-energy photon beams is lower than several other plane-parallel ionization chambers. The over response of the chamber in the buildup region of normally incident high-energy photon beams is less than 1% for 6- and 24-MV x rays while the response of the new chamber to obliquely incident x-ray beams was affected much less by the angle of beam incidence than the other chambers tested. These superior response characteristics are primarily due to the construction characteristics of the collecting electrode arrangement. The Attix chamber, with a wall diameter (w) of 40 mm and a plate separation (s) of 1 mm, has an aspect ratio, (w/s), of 40. This exceeds the previously reported design criterion of w/s > or = 25 required to properly measure surface and buildup dose in either conventional therapy beams or in beams that are highly contaminated.