Assessment of geometric treatment accuracy using time-lapse display of electronic portal images

During the past two years, several electronic portal imaging systems have been introduced to the market by therapy accelerator manufacturers and other vendors. While these systems differ substantially in their detection technology, they are all capable of displaying portal images on a video screen in near real-time, and of creating multiple static (or "movie") images during each treatment. Major questions confront the users of such systems as to the best utilization of this wealth of information, and to its value in comparison to traditional weekly portal film methods. Using an "in-house" video based system, a new technique was established to aid in the assessment of on-line images so that immediate "go/no-go" decisions can be made by the therapy technologist. A video "movie-loop" is displayed which consists of the static image of the initial (approved) set-up, and the current treatment image. Multiple images of successive treatments can also be viewed in this "time-lapse" display mode to provide a quick visual means for review of an entire course of therapy. The on-line imaging system hardware is composed of a combination copper-plate/fluorescent-screen detector, a front surface mirror angled at 45 degrees to remove the camera from the direct radiation beam, and a high sensitivity SIT video camera. This assembly is attached to a rigid base and mounted directly to the isocentric gantry. The geometry is fixed to within +/- 1 mm and assures the precise day-to-day reproducibility which is necessary for the success of the time-lapse display technique. Experience with this technique shows it to enhance the user's ability to notice small changes in patient's position with respect to the radiation field. Radiation treatment sites reviewed using this procedure were Hodgkin's (mantle), Lung, Brain and extremities. Shifts in patient position on the order of several millimeters were readily detectable, as will be demonstrated in this paper. Somewhat surprisingly, grosser movements (greater than 1 cm) were also noted despite overall technical excellence as assessed by weekly portal filming. The eye senses day-to-day movement with greater ease when the fields are seen in time-lapse display than when compared as discrete portal images. Ultimately, persistent movement appreciated on the time-lapse display can suggest the need for a change in patient set-up or immobilization technique.

Evaluation of multileaf collimator design for a photon beam

Various aspects of multileaf collimator (MLC) design are examined relative to clinical requirements. The characteristics studied included: (a) irregular field edge definition or "effective" penumbra, (b) optimum field coverage for the multileaf portion of the field, and (c) leaf velocity. A film dosimetry technique was developed to measure the rapid 2-dimensional change in dose at an edge defined by a multileaf collimator with the segments staggered. The method applies a correction factor which allows for the changing ratio of scattered to primary photons at the field edge so that the energy dependence of the film is corrected. Stepped lead alloy blocks were irradiated with 6 MV photons to obtain films simulating a double-focused multileaf collimator, and the results were compared to films of fields shaped with standard divergent blocks. The effect of the shape of the leaf face (the end of the leaf) on penumbra was also studied. Proper shaping of the leaf ends may eliminate the need to exactly match beam divergence so that the mechanical of the collimator system is simplified. Leaves having several different end shapes and moving horizontally to intercept a vertical beam were compared to the divergent design where a straight face moves along an arc. The measurements showed that the "effective" penumbra (measured as the distance from the 80 to 20% isodose lines) for the multileaf collimator is a function of the angle between the direction of leaf motion and the edge defined by the leaves. In addition, all leaf end shapes showed some increase in penumbra compared to standard divergent blocking and also had increasing penumbra width as they moved over or back from the field center line. A total of 459 treatment fields and six disease sites were examined to determine the percentage of fields potentially shaped by multileaf segments of specified length. This study showed 93% of the fields had lengths of 30 cm or less and 99% had widths of 25 cm or less. A study conducted to determine the required leaf velocity to shape various target volume configurations during complete rotation (at 1 RPM) showed that a leaf speed of at least 1.5 cm/sec at isocenter is needed for dynamic conformal treatment.

Weight consideration in the use of cerrobend beam blocks

The technique of using customized field blocking to protect sensitive normal tissue during megavoltage radiation treatment is common practice in modern radiation therapy. The introduction of CT-based treatment planning has revolutionized customized field shaping. We carried out a prospective evaluation of 54 cerrobend blocks during a one-month time period. The goals of this study were to analyze the specific block patterns and correlate these with field size, block weight, and field setup. Factors contributing to excessively large and heavy cerrobend blocks defined as > or = 20 lbs. were identified. Twenty-two percent of blocks were found to be excessively large and one-third of these were a consequence of planning decisions. A review of these situations suggests that alternative methods would have avoided the excessive weight. Concerns have been raised regarding the safety of large and heavy cerrobend blocks. These blocks were therefore analyzed in terms of tray sag and tray break-point. Our data suggest that within this clinical range of block weight, neither tray sag nor tray break-point are of significant concern.

Dose distributions of x-ray fields as shaped with multileaf collimators

Multileaf collimators (MLC) with various blade widths were simulated using standard cerrobend blocks, and three-dimensional dose computations were carried out to study the resultant radiation field edges. Film measurements made with 6 and 18 MV x-ray beams were compared with calculations that employed a three-dimensional Fourier convolution. A spatial accuracy of better than 3 mm was found in the 50% isodose line of the penumbral region with a calculation voxel size of 5 mm x 5 mm x 5 mm. The computer simulation was used to study the deviation of the calculated 50% isodose line from the desired geometric field edge using various MLC blade positions. The study suggests that multileaf collimation to the outside of the desired field edge will lead to overdose outside the field, whereas multileaf collimation to the inside of the desired field edge will lead to underdose inside the field. When the direction of travel of the leaves with respect to the field edge is near 45 degrees, the 50% isodose of a multileaf-collimated beam will fall close to the desired edge with no underdose when the leaf corners are allowed to insert into the desired field edge by 1.2 mm for 6 MV x-rays and 1.4 mm for 18 MV x-rays using a 1 cm wide leaf. These blade offsets account for the scattering of photons and electrons in the medium within the penumbral region.

[The sensitometric recording of verification films in high-volt therapy]

Film sensitometric determinations under high voltage conditions, i.e. under radiation at an energy of at least 1 MeV, are very time-consuming and material intensive, because, with increased dose of radiation, several films have to be exposed and densitometrically measured. These results then form the basis of the preparation of the density curve. This paper describes, how, by applying a special technique (so-called sensitometric double exposure method), film sensitometry under high voltage radiation conditions may be considerably simplified and shows how the necessary resources (i.e. step-wedge = stepped photometric absorption wedge) can be made quite simply. The method described uses film DOT-I and DOT-II by Dupont, whereby the exposure of the step wedge takes place on a linear accelerator with a photo energy of 10 MeV. The results show that with a target volume dose up to 1.5 Gy the DOT-II film yields the better results, while with doses above 1.5 Gy, usage of DOT-I film is recommended.

Dosimetric evaluation of a two-dimensional, arc electron, pencil-beam algorithm in water and PMMA

The accuracy of dose calculations from a pencil-beam algorithm developed specifically for arc electron beam therapy was evaluated at 10 and 15 MeV. Mid-arc depth-doses were measured for 0 degrees and 90 degrees arcs using 12 and 15 cm radius cylindrical water phantoms. Calculated depth-doses for the 90 degrees arced beams in the build-up region were as much as 3% less than measured values; the maximum dose was similar in magnitude but at a greater depth; and the therapeutic depth, R80, was 2-4 mm deeper. Calculated values of output (dose per monitor unit) at the depth of the maximum calculated dose were compared with measured values; for arcs ranging from 0-90 degrees, 12 and 15 cm radius water phantoms, and collimator widths of 4, 5 and 6 cm, results showed differences as great as 7%. Isodose countours for a 90 degrees arc were also measured in a 15 cm radius PMMA phantom. At the depth of maximum dose the algorithm predicted doses in the penumbral regions, both with and without collimation, which agreed within a few per cent of measured values. The largest discrepancies were 5%, which occurred in the penumbral portion of the depth-dose fall-off region. Differences between measurement and calculation are not believed to be clinically significant and are believed to be primarily due to the fact that the algorithm models neither large-angle scattering nor the effects of range straggling on the pencil-beam dose distribution.

Efficient fabrication of precise electron cut-outs

A time-saving method for creating accurate patient-personalized cerrobend cut-outs, utilized in electron beam therapy, is described--implemented by radiographic films taken during simulation. This technique is used frequently (but not exclusively) for the treatment of head and neck cancer, where isocentric lateral films taken for photon treatment also provide the information needed to define the posterior off-cord electron boost. The boost field is traced from the film and demagnified by xerox to the distance of the cone cut-out holder. A second simulation of the electron field is not necessary. Matching of the electron fields to the photon fields is accurate, consistent, and easy to define on the patient.

Fast evaluation of patient set-up during radiotherapy by aligning features in portal and simulator images

A new fast method is presented for the quantification of patient set-up errors during radiotherapy with external photon beams. The set-up errors are described as deviations in relative position and orientation of specified anatomical structures relative to specified field shaping devices. These deviations are determined from parameters of the image transformations that make their features in a portal image align with the corresponding features in a simulator image. Knowledge of some set-up parameters during treatment simulation is required. The method does not require accurate knowledge about the position of the portal imaging device as long as the positions of some of the field shaping devices are verified independently during treatment. By applying this method, deviations in a pelvic phantom set-up can be measured with a precision of 2 mm within 1 minute. Theoretical considerations and experiments have shown that the method is not applicable when there are out-of-plane rotations larger than 2 degrees or translations larger than 1 cm. Inter-observer variability proved to be a source of large systematic errors, which could be reduced by offering a precise protocol for the feature alignment.

Implementation of the three-field electron wraparound technique for extensive recurrent chest wall carcinoma: dosimetric and clinical considerations

Treatment of extensive recurrent chest wall carcinoma is a challenge for the radiation oncologist as well as the physics team responsible for setup, computer planning, and daily reproducibility. While electron arc therapy is desirable, unfortunately, most sites do not have this capability. The alternative method of treatment discussed here involves the use of a three-field electron wraparound technique for the chest wall when electron arc therapy is not available. This technique yields an excellent alternative treatment modality with flexibility to accommodate multiple electron energies to compensate for varying chest wall thickness. An additional anterior photon beam is used when skin lesions extend superiorly to the clavicle and along the proximal aspect of the arm. Computerized tomography (CT) interfaced radiotherapy computer planning is used to precisely calculate the sequential gantry angles, skin gaps for adjacent electron fields, and the appropriate junction moves to create a feathering effect of all overlap areas. Treatment aids include extensive shaping of electron and photon fields and the application of bolus material on all four fields. A Smithers Medical Products' Alpha Cradle is used to make this intricate setup possible, providing patient comfort and daily reproducibility for a more efficient treatment.

Technical considerations in the use of 3-D beam arrangements in the abdomen

The practical utilization of 3-D treatment planning to reduce doses to normal tissues in the abdomen is illustrated for irradiation of hepatic masses using fields with central axes rotated out of the transverse plane. The beams were arranged to go through the minimum amount of normal liver tissue, while exiting above or below a kidney. Although these beam arrangements were not coplanar with standard transverse body sections, they were designed for dose delivery through use of standard Megavoltage equipment. The planning process for these techniques illustrates the need for and use of several tools usually associated with 3-D treatment planning systems. Beam's eye-view planning with perspective display of the relevant anatomy in the projective beam geometry is required for designing the placement of focused blocks for these oblique fields. Three-dimensional volumetric dose calculations are required to evaluate dose distributions. Additionally, port-film-type radiographs, digitally reconstructed from the CT dataset, are found to be useful in understanding the correctness of simulation and verification films. The reduction in dose to normal tissues over that achievable using standard plans with beams entering the patient at right angles to the central axis of the body is illustrated using dose-volume histograms. These techniques have allowed the initiation of a radiation dose escalation protocol for tumors involving the liver and porta hepatis.

Pitfalls in dose calculation using a commercial treatment planning computer for Clinac-4 4MV x-ray beam

Dose calculations on a commercial treatment planning computer based on the storage of profile data along a principal axis for Clinac-4 4MV x-ray can lead to significant error in calculated dose in the corners of a large field. These errors are due to the unique nature of the lead flattening filter on Cl-4. A method is suggested to remedy this problem by storing profile data along a diagonal of a large field.

The design of megavoltage projection imaging systems: some theoretical aspects

This study investigates factors associated with the imaging of a patient using a high-energy radiotherapy treatment beam. Both single-stage (e.g., solid-state detector) and two-stage (e.g., scintillation screen plus TV) systems are considered. First an expression is derived that relates dose at the buildup depth in the object to the structure of the object, the scatter-to-primary signal-variance ratio and the differential-signal-to-noise ratio in the image. Second the number of bits required to digitize the image is derived. Third the effect of scattered radiation is investigated for photon counting, photopeak, and Compton detector types. Fourth the effect of noise in the detection process is considered. Finally, the relationship between x-ray source size, detector aperture, and image magnification is derived. The optimum magnification for given source size and detector aperture is discussed in terms of the system transfer function. The study indicates that at a primary beam energy of 2 MeV, a dose of 10(-3) cGy is required to detect reliably the presence of a bone section of area 10 x 10 mm and thickness 4 mm in 250 mm of soft tissue. For this example, it is also estimated that a digitization accuracy of 10 bits is required. The calculations indicate that for a Compton detector, the scatter-to-primary signal-variance ratio drops from a value of around 30% at the exit surface of the object to 5% at a distance of 80 cm from the object with a consequent small reduction in the dose required to form the image.

Effect of backscatter on cell survival for a clinical electron beam

Relative to homogeneous scattering conditions in tissue-like materials, a large increase in dose for clinical electron beams can occur upstream from high atomic number heterogeneities due to backscattered electrons. The degree of this dose increase is uncertain due to the unknown energy distribution of the backscattered electron fluence. Cell survival after irradiation was studied for Chinese hamster cells at the depth of maximum dose in a clinical 6 MeV electron beam under normal scattering conditions and with the addition of a lead backscatter. No significant difference in cell survival was found between the two geometries when the dose increase due to the backscattered electron fluence was approximated by the product of the measured ionization and the normal scattering stopping power ratio.

Dose rate in irregularly shaped high energy photon beams

A quick method of calculating the dose-rate distribution in irregularly shaped beams is presented. This method is partly based on the Cunningham model. The proposed modifications make it possible to avoid the scatter functions in favor of direct use of tissue-phantom ratios and field size coefficients. The problem has been evaluated for photons generated by 10 and 23 MV linacs. The calculated dose rates have been compared with measured ones, and good accuracy has been achieved.

A linear array, scintillation crystal-photodiode detector for megavoltage imaging

An imaging device has been developed to acquire images during external photon-beam radiotherapy treatments. It consists of a linear array of 128 zinc tungstate (ZnWO4) scintillation crystals each of which is individually optically coupled to a photodiode and associated electronics. The image is formed by scanning the linear array across the radiation field using a stepping motor under the control of a microcomputer. Image archive, display, and analysis are performed using a microVAX II computer. Results from a general theoretical analysis are presented before a detailed description of the particular detector construction. The mechanical design of the detector is such that the detector is automatically positioned to within a millimeter relative to the treatment source. This simplifies procedures for analyzing setup variations when comparing a treatment image to any other treatment, or planning, images. Image acquisition takes under 4 s with a contrast resolution of better than 1% at a spatial resolution of 2.5 mm in the object plane. The primary dose used to form these images is 0.55 cGy although the dose received by the patient will be closer to 25 cGy due to the linear scanning geometry and 3.8-s scan time that is used.

The effects of a universal wedge and beam obliquity upon the central axis dose buildup for 6-MV x rays

In a number of clinical situations, the dose to the skin and the superficial tissues is of concern. Both beam obliquity and a beam modifier will modify the dose delivered to these regions due to changes in the scattering geometry, scattered photon and secondary electron production, and changes in the energy spectrum of a polyenergetic beam. Some linear accelerators use a single universal wedge mounted within the treatment head. Because such a wedge is at an extended distance from the patient, its contribution to the beam contaminants incident to the skin will be limited. Measurements of the ionization in the buildup region have been performed in a polystyrene phantom irradiated with a 6-MV x-ray beam from a linear accelerator equipped with a universal wedge. The variation of the buildup dose with obliquity, universal wedging, and distance from the source has been measured for angles of incidence between 0 degrees and 60 degrees and for effective wedge angles between 0 degrees and 45 degrees. The results indicate that the percentage buildup has a much stronger dependence upon the angle of incidence than upon the effective wedge angle. For distances approaching the treatment head, it is shown that the universal wedge generates secondary electrons that elevate the surface dose, but that this contribution decreases with distance.

The use of an universal wedge for asymmetric fields

Beam collimators on newer linear accelerators may be collimated asymmetric to the central axis. The asymmetric beam has a non-flat profile adjusted to yield fields whose half widths are not symmetric about the central axis. While some treatment planning systems modify their programs to mimic the nonuniformity, ideally it is preferred to have a flat profile under the open beam. We have developed a universal wedge that can be used to flatten the field for a variety of jaw sizes and positions and energies for the Varian 2100C. The wedge flattens the field to +/- 3% over 80% of the field.

A head immobilization system for radiation simulation, CT, MRI, and PET imaging

An aquaplast mask/marker immobilization system for the routine radiation therapy treatment of head and neck disease is described. The system utilizes a commercially available thermoplastic mesh indexed and mounted to a rigid frame attached to the therapy couch. The apparatus is designed to permit CT, MRI, and PET diagnostic scans of the patient to be performed in the simulation and treatment position utilizing the same mask, thereby facilitating image correlation. Studies employing weekly simulation indicate that patient treatment position movement can be restricted to 3 mm over the course of treatment. This easily constructed system permits rapid mask formation to be performed on the treatment simulator, resulting in an immobilization device comparable to masks produced with vacuum-forming techniques. Details of construction, verification, and central axis CT, MRI, PET markers are offered.

Evaluation of radiosurgery techniques with cumulative dose volume histograms in linac-based stereotactic external beam irradiation

Radiosurgery at UCSF is performed with a 6-MV linear accelerator with tertiary collimation for improved small field definition. The dose delivery to the target relative to normal tissue is influenced by the number of arcs, the arc geometry, field size, and beam energy. The impact of arc number, arc geometry, and field size on the dose distribution from 6-MV X rays in a 16 cm spherical phantom has been evaluated through the use of cumulative dose volume histograms. Dose volume histograms were calculated for a) 1-5 and 10 arcs, and b) collimator sizes of 1.25, 2.0, and 3.0 cm. Differences between techniques were found at the 5-10% level for field sizes from 1.25 to 2.0 cm. It was shown that the finite dimension of the sphere and, by extension, head diminishes the differences between techniques for the larger field sizes. The effect of treating with two isocenters is also analyzed and an approach for improving the dose distribution is presented.

Physical aspects of the angle-beta concept in electron arc therapy

A technique for the determination of treatment parameters that are required to achieve a desired depth dose distribution in electron arc therapy is discussed and a method for calculating isodose distributions is presented. Both the treatment technique and the dose calculation method rely on the angle beta concept, which uniquely describes the dependence of the radial percentage depth doses in electron arc therapy on the nominal field width, isocenter depth, and virtual source-axis distance. The angle beta concept is discussed in detail and the electron pseudo-arc therapy technique used at McGill is described. Also presented is the method used to achieve dose homogeneity in target volumes treated with the pseudo-arc technique.

Analytic representation of the backscatter correction factor at the exit of high energy photon beams

In high energy X-ray beams, the dose calculated near the exit surface under electronic equilibrium conditions is generally overestimated since it is derived from measurements performed in water with large thickness of backscattering material. The resulting error depends on a number of parameters such as beam energy, field dimensions, thickness of overlying and underlying material. We have systematically measured for four different energies and for different combinations of the above parameters, the reduction of dose due to the lack of backscatter. This correction is expressed as a multiplicative factor, called "Backscatter Correction Factor" (BCF). This BCF is larger for lower energies, larger field sizes and larger depths. The BCF has been represented by an analytical expression which involves an exponential function of the backscattering thickness and linear relationships with depth, field size and beam quality index. Using this expression, the BCF can be calculated within 0.5% for any conditions in the energy range investigated.

Sensitivity of helium beam-modulator design to uncertainties in biological data

The goal in designing beam-modulating devices for heavy charged-particle therapy is to achieve uniform biological effects across the spread-peak region of the beam. To accomplish this, the linear-quadratic model for cell survival has been used to describe the biological response of the target cells to charged-particle radiation. In this paper, the sensitivity of the beam-modulator design in the high-dose region to the values of the linear-quadratic variables alpha and beta has been investigated for a 215-MeV/u helium beam, and implications for higher LET beams are discussed. The major conclusions of this work are that, for helium over the LET range of 2 to 16 keV/mu, uncertainties in measuring alpha and beta for a given cell type which are of the order of 20% or less have a negligible effect on the beam-modulator design (i.e., on the slope of the spread Bragg peak); uncertainties less than or equal to 10% in the dose-averaged LET at each depth are unimportant; and, if the linear-quadratic variables for the tumor differ from those used in the beam-modulator design by a constant factor between about 0.5 and 3, then the resultant nonuniformity in the photon-equivalent dose delivered to the tumor is within +/- 25%. It is also shown that for any ion, if the nominal values of alpha or beta used by the beam-modulator design program differ from their actual values by a constant factor, then the maximum errors possible in the beam-modulator design may be characterized by two limiting depth-dose curves such that the ratio of the dose at the proximal end of the spread Bragg curve to the dose at the distal end of the spread peak is given by alpha distal/alpha prox for the steepest curve, and square root of beta distal/beta prox for the flattest curve.

Design of beam-modulating devices for charged-particle therapy

The computer modeling program used to design beam-modulating devices for charged-particle therapy at Lawrence Berkeley Laboratory has been improved to allow a more realistic description of the beam. The original program used a single calculated Bragg peak to design the spread Bragg peak. The range of this curve was shifted so that Bragg curves of varying ranges could be superimposed. The new version of the program allows several measured Bragg curves with different ranges to be used as input, and interpolates between them to obtain the required data for the superposition calculation. The experimental configuration for measuring these input curves simulated therapy conditions. Seven beam-modulating propellers with spread Bragg-peak widths ranging from 2.2 to 14.4 cm were designed and constructed for a 215-MeV/u helium beam using this new design program. Depth-dose distributions produced by these new propellers were in good agreement with predicted distributions, and these propellers are currently being used clinically.