Linac-based small-field radiotherapy for brain tumors

Small-field radiotherapy based on a 6-MeV linac and a conventional head mold is investigated as an alternative to radiosurgery with stereotactic frames. The system requires no additional device and allows fractionated treatment. The dose distributions obtained are comparable to those reported with a Gamma Unit. Overall positioning errors are within 2 mm. Using this approach, seven patients with brain tumors who could not have been treated otherwise, underwent fractionated radiotherapy with total accumulated doses ranging from 70 to 108 Gy. The treatment was tolerated well with no acute toxicity or adverse effect encountered during the follow-up period of 8-14 months. All of the patients remained free from disease progression in the treated volumes. Although the follow-up is brief, the preliminary results suggest that this is a simple and inexpensive but effective system for the treatment of small intracranial malignancies.

Time trend of patient setup deviations during pelvic irradiation using electronic portal imaging

An electronic portal imaging device (EPID) was used to detect patient setup displacement during the course of a 3-field pelvic irradiation of two groups of patients: 10 rectal and 10 prostate carcinomas. These patients were irradiated with conventional treatment techniques in routine clinical practice. A total of 469 portal images and 60 simulator films were used to determine the values of setup deviations in the X- Y- and Z-directions of a fixed coordinate system, corresponding to the medio-lateral, cranio-caudal and antero-posterior direction, respectively. The absolute displacement averaged over all setups and patients ranged between 0.4 mm and 1.4 mm with a standard deviation (S.D.) of 1.6-3.9 mm. The overall distribution along each direction could be separated into a distribution of random deviations (S.D.s ranging from 1.2 to 2.8 mm) around the mean deviation of each patient and a distribution of the means themselves: the distribution of systematic deviations (S.D.s ranging from 1.0 to 2.6 mm). Significant gradual displacement as a function of time was detected in 5 out of the 20 patients, 2 in the rectum and 3 in the prostate group. This "time trend" was found along each of the 3 directions specified. The magnitude of the time-dependent displacement throughout the course of treatment ranged between 4 and 11 mm. It can be concluded that for treatments requiring a high level of precision, portal images should be made and analyzed during the whole treatment course in order to detect and correct significant time trends.

Characterization of a multi-leaf collimator system

Commissioning measurements for a multi-leaf collimator installed on a dual energy accelerator with 6 and 15 MV photons are described. Detailed dosimetric characterization of the multi-leaf collimator is a requirement for modeling the collimator with treatment planning software. Measurements include a determination of the penumbra width, leaf transmission, between-leaf leakage, and localization of the leaf ends and sides. Standard radiographic film was used for the penumbra measurements, and separate experiments using radiochromic film and thermoluminescent dosimeters were performed to verify that distortions of the dose distribution at an edge due to changing energy sensitivity of silver bromide film are negligible. Films were analyzed with a scanning laser densitometer with a 210 micron spot. Little change in the penumbra edge distribution was noted for different positions of a leaf in the field. Experiments localizing the physical end of the leaves showed less than 1 mm deviation from the 50% decrement line. This small difference is attributed to the shaped end on the leaves. One side of a single leaf corresponded to the 50% decrement line, but the opposite face was aligned with a lower value. This difference is due to the tongue and groove used to decrease between-leaf leakage. For both energies, approximately 2% of photons incident on the multi-leaf collimator are transmitted and an additional 0.5% leakage occurs between the leaves. Alignment of the leaves to form a straight edge results in a penumbra profile which compares favorably with the standard technique of using alloy blocks. When the edge is stepped, the isodose lines follow the leaf pattern and the boundary is poorly defined compared to divergent blocks.

Initiation of multi-leaf collimator conformal radiation therapy

Clinical studies have been initiated in conformal radiotherapy using a computer controlled multi-leaf collimator. Quantitative dosimetry and treatment planning studies comparing field shaping by lead alloy blocks and the multi-leaf collimator demonstrate the clinical acceptability of the multi-leaf collimator. Sixteen patients with tumors in multiple sites have received some part of their treatments with both blocking systems. Studies of dosimetry and field shaping show that the multi-leaf collimator produces clinically acceptable blocking for most field shapes and disease sites. The 80-20% penumbra was characterized for a wide range of shaped beams. For straight edges perpendicular to the leaf travel, the penumbra of measured dose distributions from the multi-leaf collimator is equal to conventional divergent blocking. When the multi-leaf collimator leaves approach a contour at an angle, the penumbra increases. At forty-five degrees, the maximum angle of approach, the penumbra is approximately 4 mm wider than that for divergent blocks. Three-dimensional treatment planning demonstrates that equivalent dose distributions can be obtained from the two field shaping systems. The multi-leaf collimator can be used effectively and efficiently to treat a variety of disease sites. Its optimal utility may be in treating complex fields--five or more shaped coplanar or non-coplanar beams. It is well suited for conformal therapy applications.

The use of a multi-leaf collimator for conformal radiotherapy of carcinomas of the prostate and nasopharynx

We investigate the use of a multi-leaf collimator for conformal radiation therapy of carcinomas of the prostate and of the nasopharynx. Following verification of dose calculation algorithms for multi-leaf collimated fields using film dosimetry, we compute dose distributions for multi-field conformal treatment using fields shaped with either the multi-leaf collimator or conventional cerrobend blocks. We compare the two sets of treatment plans using graphical isodose displays, tissue specific dose volume histograms, tumor control probabilities, and normal tissue complication probabilities. We also incorporate setup errors into the calculated dose distributions to assess the effect of treatment uncertainties on the various criteria. Based on these comparisons, we conclude that for multi-field conformal radiotherapy for these two disease sites, the use of multi-leaf collimation is equivalent to that of conventional cerrobend blocks.

Photon beam characteristics on the MM50 racetrack microtron and a new approach for beam quality determination

The photon beams of the MM50 racetrack microtron have special characteristics which make them more suitable than conventional photon beams for precision radiation therapy with good dosimetric control. The beam flattening is obtained by the scanning of an elementary beam instead of using a flattening filter. This will give a number of advantages such as the possibility to optimize field flattening to individual field forms and field sizes. The radiation quality is the same across the whole beam, which gives smaller changes in dose profiles with depth and also makes it easier to perform careful dose planning. Beam collimation is mainly performed by a multileaf collimator and the special design of the treatment head gives nearly ideal characteristics for dose determination in an arbitrary point in the treatment fields. The output factor has been shown to depend almost solely on scattering within the treatment field. The conventional methods for beam quality characterization have been found less suitable at high energies and a new method based on HVL measurements in water is proposed.

Shaping of photon beams from electron linear accelerators in radiation therapy

The method of calculation of the bremmstrahlung yield and angular distributions based on the semianalytical model described by Kovalev [Vtoricnoe izlucenie uskoritelej elektronov (Atomizdat, Moscow, 1979)] was analyzed. The specially written computer program was used to optimize the geometry of the collimators and the flattening filter design for radiation therapy purposes. The x-ray beam shaping system thus designed was installed in the 4-MeV linear Limex accelerator working at the Cancer Center in Warsaw (Poland). By comparing the calculated beam distributions with the experimental data, the agreement between theory and measurements was found to be within about +/- 3%.

Assessment of a linear accelerator for segmented conformal radiation therapy

Segmented conformal radiation therapy is a new computer-controlled treatment technique under investigation in which the target volume is subdivided into thick transverse segments each of which is then treated individually by rectangular transverse abutting fields. In order to obtain uniform dose at abutments, the machine isocenter remains fixed in the patient and field edges are defined by independently moving focused collimator jaws to give matching geometric divergence. Mechanical variation in jaw and gantry positioning will create some dose variation at field abutments. Film dosimetry was used to study the radiation field positioning accuracy and precision of a commercial linear accelerator. A method of field position calibration was developed using multiple nonabutting fields exposed on the same radiograph. Verification of collimator jaw calibration measurements was performed using multiple abutting fields exposed on a single radiograph. Measurements taken over 5 months of clinical accelerator operation studied the effects of simple jaw motion, simple gantry motion, and combined jaw/gantry motion on jaw position precision and accuracy. The inherent precision and accuracy of radiation field positioning was found to be better than +/- 0.3 mm for both jaws with all types of motions except for the Y2 jaw under combined jaw/gantry motion. When the ability to deliver abutting beams was verified in clinical mode, the average dose variation at abutments was less than 6% at all gantry angles except for one. However, due to accelerator software limitations in clinical mode, the settings for collimator positions could not take advantage of the maximum accuracy of which the hardware is capable.(ABSTRACT TRUNCATED AT 250 WORDS)

[The improved determination of the dose rate in irregular photon fields]

A revised formula for calculation of dose per time or monitor unit ("dose rate") of irregular megavoltage photon beams is proposed. The formula considers additionally the shading by secondary shieldings of the plane source describing the scattered radiation in the head. Therefore, in addition to the primary output factor C(ac) as function of the equivalent square ac x ac of the collimator field size a secondary output factor S(as) is introduced denoted as function of the equivalent square as x as of the irregular field. S is determined using a satellite diaphragm formed of shielding blocks in combination with a totally opened collimator. In this definition, S includes both the effects of radiation scattered in tissue (phantom scatter factor PSF) and of missing photons from the plane source by the blocks (satellite diaphragm factor SAT). In the usual formula to calculate the "dose rate" (output) at reference point in depth t, PSF is replaced by S: D = D0 x C(ac) x [PSF(as)/PSF(ac)] x T x R(as,t). There T is representing the block tray factor and R(as,t) the tissue phantom ratio or relative depth dose, depending on the irradiation technique used. Thus the modified formula is given by D = D0 x C(ac) x [S(as)/S(ac)] x T x R(as,t). Measurements show that the revised formula provides an additional precision of up to 2% in the calculation of dose, depending on the type of accelerator respectively on the size of the plane source of scattered radiation.

Water-equivalent plastic scintillation detectors for high-energy beam dosimetry: II. Properties and measurements

The properties of a new scintillation detector system for use in dosimetry of high-energy beams in radiotherapy have been measured. The most important properties of these detectors are their hgh spatial resolution and their nearly water-equivalence. Measurements have shown that they have excellent reproducibility and stability, and a linear response versus dose-rate. It is also shown that they have better spatial resolution than ionization chambers and have much less energy or depth dependence in electron fields due to the removal of the influence of the polarization effect. Dose distributions in water, using miniature plastic scintillation detectors, have been measured for different high-energy photon and electron beams.

Water-equivalent plastic scintillation detectors for high-energy beam dosimetry: I. Physical characteristics and theoretical consideration

A minimally perturbing plastic scintillation detector has been developed for the dosimetry of high-energy beams in radiotherapy. The detector system consists of two identical parallel sets of radiation-resistant optical fibre bundles, each connected to independent photomultiplier tubes (PMTs). One fibre bundle is connected to a miniature water equivalent plastic scintillator and so scintillation as well as Cerenkov light generated in the fibres is detected at its PMT. The other 'background' bundle is not connected to the scintillator and so only Cerenkov light is detected by its PMT. The background signal is subtracted to yield only the signal from the scintillator. The water-equivalence of plastic scintillation detectors is studied for photon and electron beams in the radiotherapy range. Application of Burlin cavity theory shows that the energy dependence of such detectors is expected to be better than the commonly used systems (ionization chambers, LiF thermoluminescent dosimeters, film and Si diodes). It is also shown that they are not affected by temperature variations and exhibit much less radiation damage than either photon or electron diode detectors.

A megavoltage CT scanner for radiotherapy verification

We have further developed a system for generating megavoltage CT images immediately prior to the administration of external beam radiotherapy. The detector is based on the scanner of Simpson (Simpson et al 1982)--the major differences being a significant reduction in dose required for image formation, faster image formation and greater convenience of use in the clinical setting. Attention has been paid to the problem of ring artefacts in the images. Specifically, a Fourier-space filter has been applied to the sinogram data. After suitable detector calibration, it has been shown that the device operates close to its theoretical specification of 3 mm spatial resolution and a few percent contrast resolution. Ring artefacts continue to be a major source of image degradation. A number of clinical images have been presented. The next stage of this work is to use the system to make clinical measurements of patient set-up inaccuracies building on our work making such measurements from digital portal images (Evans et al 1992).

Radiotherapy treatment planning of basal meningiomas: improved tumor localization by correlation of CT and MR imaging data

A localization technique, based on three-dimensional CT and MR imaging data for precision radiotherapy of basal meningiomas, is presented. Indications for radiotherapy included unresected tumors, gross disease remaining despite surgery, and recurrences. The patient's head was fixed in a stereotactic localization system which is usable at the CT, MR and the linear accelerator installations. The geometrical distortion of MR imaging data was evaluated in three dimensions by phantom measurements. The geometrical distortion was "corrected" (reducing displacements to the size of a pixel) by calculations based on modelling the distortion as a fourth order two-dimensional polynomial. The target volume was defined in three-dimensional MR imaging data after application of 0.1 mmol/kg b.w. Gd-DTPA solution and transferred precisely from MR onto CT data to provide a map of the radiation attenuation coefficient for dose calculation. The superior soft tissue contrast of MR showed an excellent tumor delineation especially when the bony base of the skull obscured the target in CT images. Target volume, calculated dose distribution, and critical structures could be transferred between CT and MR imaging data and displayed as three-dimensional shaded structures for better assessment for matching of target volume and dose distribution. With the described planning system a more precise target definition of basal meningiomas was possible by integration of the superior tumor delineation in MR compared with CT.

Optimization by simulated annealing of three-dimensional, conformal treatment planning for radiation fields defined by a multileaf collimator: II. Inclusion of two-dimensional modulation of the x-ray intensity

Interest is rapidly growing in using multiple x-radiation fields defined by a multileaf collimator to achieve conformal radiotherapy. Three-dimensional treatment planning in such situations is in its infancy and most 3D planning systems provide no tools for optimizing therapy. A previous paper addressed how to calculate optimum beamweights when both the target volume and all or some parts of organs at risk were in the fields-of-view. This work allowed a maximum of two weights per field. The present paper extends this technique to allow each radiation port to be spatially modulated across the geometrically shaped field. An optimization method based on simulated annealing is presented. It is shown that including spatial modulation leads to a wider separation between the dose-volume histograms of the target volume and organs at risk. The improvement is quantified in terms of the tumour control probability at constant normal tissue complication probability. Possible limitations of the a posteriori applied biological model are discussed in detail.

Megavoltage grid total body irradiation of C3Hf/SED mice

The effect of a grid on whole-body megavoltage radiation tolerance in C3Hf/SED mice was studied. Adult mice were irradiated beneath a 50% megavoltage grid. LD50 (50% lethality) values were measured at ten and 30 days. LD50/30 day increased by a factor of 1.5 for mice receiving both single and two fraction irradiation beneath the grid. LD50/ten day increased by factors of 1.1 to 1.2 for single, two, and five fraction irradiation beneath the grid.

Optimized dynamic rotation with wedges

Dynamic rotation is a computer-controlled therapy technique utilizing an automated multileaf collimator in which the radiation beam shape changes dynamically as the treatment machine rotates about the patient so that at each instant the beam shape matches the projected shape of the target volume. In simple dynamic rotation, the dose rate remains constant during rotation. For optimized dynamic rotation, the dose rate is varied as a function of gantry angle. Optimum dose rate at each gantry angle is computed by linear programming. Wedges can be included in the optimized dynamic rotation therapy by using additional rotations. Simple and optimized dynamic rotation treatment plans, with and without wedges, for a pancreatic tumor have been compared using optimization cost function values, normal tissue complication probabilities, and positive difference statistic values. For planning purposes, a continuous rotation is approximated by static beams at a number of gantry angles equally spaced about the patient. In theory, the quality of optimized treatment planning solutions should improve as the number of static beams increases. The addition of wedges should further improve dose distributions. For the case studied, no significant improvements were seen for more than 36 beam angles. Open and wedged optimized dynamic rotations were better than simple dynamic rotation, but wedged optimized dynamic rotation showed no definitive improvement over open beam optimized dynamic rotation.

Routine clinical on-line portal imaging followed by immediate field adjustment using a tele-controlled patient couch

We have evaluated the fluoroscopic on-line portal imaging (OPI) system developed by Siemens (Beamview-1, Concord, CA, U.S.A.) in routine clinical radiotherapy, involving the treatment of 883 fields (559 patient set-ups for treatment) on 21 patients. The image was typically generated by delivering 10 monitor units when used in single exposure or 1-2 monitor units on a large open field followed by 8-10 monitor units on the actual field when double exposure was used. Comparison between the portal image and the simulator film was done by eye. A region of tolerance was drawn on the simulator film and the field edges on the portal image had to project within this region. If this criterion was not met, adjustments followed by verification portal images were done before the remaining field dose was delivered. If possible, these adjustments were performed by moving the patient couch by remote control. The image quality was insufficient for evaluation in 75/883 (8.5%) fields. The abovementioned criterion was not met in 95/808 (11.8%) of the evaluable fields (26/559 patient set-ups were not evaluable). Of the 533 evaluable patient set-ups, 92 had to be adjusted (17.2%) including three (pelvic irradiations) set-ups that were adjusted on both field irradiated during the same radiotherapy session. In one case an incorrect tray (with wrong blocks) was detected and replaced. In one case (a 5.5 x 6.0 cm rectangular larynx field) the x and y axis of the field were interswitched. In one case incorrect focusing of a block was shown by the portal image. To make adjustments, the couch longitudinal position was changed 20 times (range -10 to +15 mm). The lateral position was changed 73 times (range -15 to +16 mm). The height position was changes 6 times (range -7 to +6 mm). Diaphragma rotation changes were performed 5 times (1 degree). The fraction of treatment time that was related to the use of OPI was 30.7% median (mean 32.4%, S.D. 14.1%). The range was 4.1 to 78.6%. On the basis of calculations assuming no OPI would have been used, field treatment time was increased by a median of 44.2% (mean 55.8%; S.D. 41.2%) by using OPI. The fraction of monitor units (fraction of the dose) to generate a satisfactory image was 10% median.(ABSTRACT TRUNCATED AT 400 WORDS)

Influence of shielding blocks on the output of photon beams as a function of energy and type of treatment unit

The influence of field-defining shielding blocks on the output of a cobalt unit and of seven different accelerators (one with dual energy output) has been investigated. The quality indices range from 0.57 (cobalt-60) to 0.79. The loss in output due to shielding blocks has been calculated taking into account loss in phantom scatter only. Comparison with experimental results shows that the calculation algorithm is correct in most of the clinical conditions. However, for quality indices of 0.70 and higher, for blocks close to the central beam axis, an overestimation of the output by the algorithm has been found. The maximum deviation observed is about 5% for the highest energy and for block positions corresponding to those applied, e.g. for inverted Y-fields with narrow lumbo-aortic block spacing.

Design of parallel plate ion chambers for buildup measurements in megavoltage photon beams

Dose measurements in the buildup region of megavoltage photon beams are most commonly made using parallel plate ion chambers having fixed electrode separation. Fixed-separation chambers generally do not read correctly under such beam conditions because of the contribution to the chamber signal of electrons from the side walls. In this work it is shown that the side wall error can be very large and published correction formulas are not accurate for all beam conditions and chamber geometries. The principal focus of this study has been to determine the design features of a fixed-separation chamber that has negligible side wall error. The approach has been to study, in beams of 60Co, 6 MV, and 18 MV, the response of a specially built ion chamber in which several chamber parameters could be independently varied. The study has shown that the side wall error is primarily dependent on the ratio of the electrode separation to the wall diameter as well as on the wall density and wall angle. Based on these findings the design of a fixed-separation chamber is described which reads to within about 1% of the correct dose. Guidelines are also provided for assessing the suitability of current commercial fixed-separation ion chambers for buildup measurements.

Electron beam characteristics of the 50-MeV racetrack microtron

Electron beams in the MM50 racetrack microtron are generated by computer controlled scanning of a well-focused electron pencil beam. The treatment head is optimized to give a minimum of scatter between the source position and the collimator plane by a general minimization of all scattering material in the beam and by replacement of the air in the treatment head by helium, which has a much lower linear scattering power than air. A double-focused multileaf collimator with a 31-cm collimator to patient distance is used both for electron and photon collimation. In general, no extra electron collimation is needed for the standard SSD of 100 cm. To make irregular field collimation at a distance this far from the patient possible, a number of requirements have to be fulfilled regarding the virtual source position and the spatial and angular distribution of the initial electron beam. The virtual source position has been found to be at a fixed position for different irradiation parameters. This is important for the use of the light field in electron beam treatment but also for achieving a high degree of accuracy in the dosimetry. Scatter from the multileaf collimator has not been found to give any significant contribution to the radiation field or to the monitor output factor of the MM50. Experimental dose distribution data on the MM50 have been compared to data both from other types of treatment units and to Monte Carlo simulations.

Field matching of electron beams using plastic wedge penumbra generators

We describe the use of polystyrene wedges to match adjacent electron beams with improved dose uniformity. These wedges were designed to increase the penumbra width at the field junction from about 1.5 to about 3.5 cm, to achieve dose uniformity. Measurements using thermoluminescent dosimeters (TLD) and therapy localization film showed that the use of polystyrene wedges (penumbra generators) produced only a small increase (less than 3%) in the surface dose and a small increase (less than 1%) in the x-ray contamination. Without wedges at the field junction, lateral mismatching of beam edges by 2 or 3 mm may introduce high dose variations (120% or more or 50% or less). Similar 2-3 mm set-up errors did not cause more than +/- 5% dose variations when plastic wedges were used to match the fields. These wedges are particularly useful when matching fields of different beam energies or matching fields on curved surfaces, such as the chest wall.