Low dose megavoltage cone beam computed tomography with an unflattened 4 MV beam from a carbon target

Current status and future perspective of flattening filter free photon beams

PURPOSE

Flattening filters (FFs) have been considered as an integral part of the treatment head of a medical accelerator for more than 50 years. The reasons for the longstanding use are, however, historical ones. Advanced treatment techniques, such as stereotactic radiotherapy or intensity modulated radiotherapy have stimulated the interest in operating linear accelerators in a flattening filter free (FFF) mode. The current manuscript reviews treatment head physics of FFF beams, describes their characteristics and the resulting potential advantages in their medical use, and closes with an outlook.

METHODS

A number of dosimetric benefits have been determined for FFF beams, which range from increased dose rate and dose per pulse to favorable output ratio in-air variation with field size, reduced energy variation across the beam, and reduced leakage and out-of-field dose, respectively. Finally, the softer photon spectrum of unflattened beams has implications on imaging strategies and radiation protection.

RESULTS

The dosimetric characteristics of FFF beams have an effect on treatment delivery, patient comfort, dose calculation accuracy, beam matching, absorbed dose determination, treatment planning, machine specific quality assurance, imaging, and radiation protection. When considering conventional C-arm linacs in a FFF mode, more studies are needed to specify and quantify the clinical advantages, especially with respect to treatment plan quality and quality assurance.

CONCLUSIONS

New treatment units are already on the market that operate without a FF or can be operated in a dedicated clinical FFF mode. Due to the convincing arguments of removing the FF, it is expected that more vendors will offer dedicated treatment units for advanced photon beam therapy in the near future. Several aspects related to standardization, dosimetry, treatment planning, and optimization need to be addressed in more detail in order to facilitate the clinical implementation of unflattened beams.

Characterization of linear accelerator X-ray source size using a laminated beam-spot camera

A laminated beam-spot camera of length 20 cm and effective cross-sectional area 2.5 cm × 3 cm was designed and constructed for the measurement of X-ray beam-spot sizes on different models of Siemens accelerators. With the accelerator gantry at 180° and camera positioned on an accessory tray holder, an XV film placed in contact with the camera at the distal end of it detected those X-rays that were transmitted through the camera. The FWHM of the detected X-ray intensity profile in the gun-target (G-T) direction or the orthogonal A-B direction was used as a measure of the beam-spot size in that direction. Siemens Mevatron MXEs exhibited a beam-spot size of 1.7 ± 0.2 mm in both the in-plane and cross-plane directions for 6 MV photon beams. The beam-spot size observed for a Mevatron MDX-2 was larger by up to 1 mm, and also was different for the in-plane and cross-plane directions. For Siemens PRIMUS accelerators, the beam-spot size in the in-plane direction was found to fall in the range 2.0-2.2 ± 0.2 mm, whereas the beam-spot size in the cross-plane direction fell within 1.7-1.9 ± 0.2 mm for 6, 10, and 18 MV photon beams. Assessment of long-term stability of the beam-spot size shows the spot size remains fairly stable over time.

Feasibility of using respiratory correlated mega voltage cone beam computed tomography to measure tumor motion

The purpose of this study was to test the feasibility of using respiratory correlated mega voltage cone‐beam computed tomography (MVCBCT), taken during patient localization, to quantify the size and motion of lung tumors. An imaging phantom was constructed of a basswood frame embedded with six different‐sized spherical pieces of paraffin wax. The Quasar respiratory motion phantom was programmed to move the imaging phantom using typical respiratory motion. The moving imaging phantom was scanned using various MVCBCT imaging parameters, including two beam line types, two protocols with different ranges of rotation and different imaging doses. A static phantom was also imaged as a control. For all the 3D volumetric images, the contours of the six spherical inserts were measured manually. Compared with the nominal sphere diameter, the average relative error in the size of the respiratory correlated MVCBCT spheres ranged from 5.3% to 12.6% for the four largest spheres, ranging in size from 3.6 cc to 29 cc. Larger errors were recorded for the two smallest inserts. The average relative error in motion was 5.1% smaller than the programmed amplitude of 3.0 cm. We are able to conclude that it is feasible to use respiratory correlated MVCBCT to quantify tumor motion for lung cancer patients.

PACS numbers: 87.19.Wx, 87.57.Q

Dosimetric effect of target expansion and setup uncertainty during radiation therapy in pediatric craniopharyngioma

PURPOSE

Investigate the effect of tumor change and setup uncertainties on target coverage for pediatric craniopharyngioma during RT.

METHODS AND MATERIALS

Fifteen pediatric patients with craniopharyngioma (mean 5.1 years) were included in this study. MRI was performed before and a median of six times during RT to monitor changes in the tumor volume. IMRT plans were created and compared to the CRT plan used for treatment. The role of adaptive therapy based on GTV changes was investigated. Dosimetric effects of interfraction and intrafraction motion were examined.

RESULTS

The mean of the maximal change in the GTV was 28.5% [-20.7% to 82.0%]. For the standard margin IMRT plans, the mean D(95) of the base plan on the base target was 53.6 Gy [53.1-54.1]. The mean D(95) of the base plans on the adaptive targets was 52.1 Gy [47.9-54.1]. The D(95) for the adaptive plan on the adaptive target was 53.8 Gy [53.4-54.3]. A linear regression equation of y=-0.12x , r(2)=0.70, was found for the percent change in D(95) of the PTV (y) vs. the percent change in the GTV (x). Inter and intrafraction motion did not affect the target coverage for standard and reduced margin plans.

CONCLUSIONS

The GTV of pediatric craniopharyngioma patients change size during therapy and adaptive planning is critical for conformal plans; therefore early and regular surveillance imaging is required.

Daily image-guided localization for neuroblastoma

The purpose was to quantify the setup margin for pediatric patients with neuro-blastoma using cone beam CT imaging (CBCT) and ultrasound localization. Ten patients, with a median age of 4.3 years (1.8 to 7.9) underwent daily pretreatment localization CBCT and every other day post-treatment CBCT to calculate interfractional and intrafraction movement. Localization was based on CBCT to treatment planning CT registration in the lumbar spine region. Each subject was treated in the supine position under IV general anesthesia using intensity-modulated radiation therapy. Patients were repositioned based on the daily pretreatment CBCT. Required setup margins based on inter- and intrafraction positioning errors were calculated based on weekly and daily imaging scenarios. Four patients had ultra-sound localization of the kidneys performed before the CBCT. Correlation between daily CBCT and ultrasound was investigated. A lateral, longitudinal and vertical setup margin of 5.4, 5.6, and 5.9 mm is required without daily CBCT. When daily CBCT was incorporated, the setup margin was reduced to 1.5, 2.1, and 1.7 mm. There was no correlation between the suggested ultrasound shifts and the shifts based on the CBCT. Daily localization based on CBCT of the lumbar spine can reduce the required setup margin for neuroblastoma patients, thereby reducing normal tissue exposure for this young patient population. The internal margin needs further investigation before PTV reduction can be made. Ultrasound localization was highly variable and not correlated to CBCT shifts.

Inter- and intrafractional positional uncertainties in pediatric radiotherapy patients with brain and head and neck tumors

PURPOSE

To estimate radiation therapy planning margins based on inter- and intrafractional uncertainty for pediatric brain and head and neck tumor patients at different imaging frequencies.

METHODS

Pediatric patients with brain (n = 83) and head and neck (n = 17) tumors (median age = 7.2 years) were enrolled on an internal review board-approved localization protocol and stratified according to treatment position and use of anesthesia. Megavoltage cone-beam CT (CBCT) was performed before each treatment and after every other treatment. The pretreatment offsets were used to calculate the interfractional setup uncertainty (SU), and posttreatment offsets were used to calculate the intrafractional residual uncertainty (RU). The SU and RU are the patient-related components of the setup margin (SM), which is part of the planning target volume (PTV). SU data was used to simulate four intervention strategies using different imaging frequencies and thresholds.

RESULTS

The SM based on all patients treated on this study was 2.1 mm (SU = 0.9 mm, RU = 1.9 mm) and varied according to treatment position (supine = 1.8 mm, prone = 2.6 mm) and use of anesthesia (with = 1.7 mm, without = 2.5 mm) because of differences in the RU. The average SU for a 2-mm threshold based on no imaging, once per week imaging, initial five images, and daily imaging was 3.6, 2.1, 2.2, and 0.9 mm, respectively.

CONCLUSION

On the basis of this study, the SM component of the PTV may be reduced to 2 mm for daily CBCT compared with 3.5 mm for weekly CBCT. Considering patients who undergo daily pretreatment CBCT, the SM is larger for those treated in the prone position or smaller for those treated under anesthesia because of differences in the RU.

Treatment head disassembly to improve the accuracy of large electron field simulation

PURPOSE

The purposes of this study are to improve the accuracy of source and geometry parameters used in the simulation of large electron fields from a clinical linear accelerator and to evaluate improvement in the accuracy of the calculated dose distributions.

METHODS

The monitor chamber and scattering foils of a clinical machine not in clinical service were removed for direct measurement of component geometry. Dose distributions were measured at various stages of reassembly, reducing the number of geometry variables in the simulation. The measured spot position and beam angle were found to vary with the beam energy. A magnetic field from the bending magnet was found between the exit window and the secondary collimators of sufficient strength to deflect electrons 1 cm off the beam axis at 100 cm from the exit window. The exit window was 0.05 cm thicker than manufacturer's specification, with over half of the increased thickness due to water pressure in the channel used to cool the window. Dose distributions were calculated with Monte Carlo simulation of the treatment head and water phantom using EGSnrc, a code benchmarked at radiotherapy energies for electron scatter and bremsstrahlung production, both critical to the simulation. The secondary scattering foil and monitor chamber offset from the collimator rotation axis were allowed to vary with the beam energy in the simulation to accommodate the deflection of the beam by the magnetic field, which was not simulated.

RESULTS

The energy varied linearly with bending magnet current to within 1.4% from 6.7 to 19.6 MeV, the bending magnet beginning to saturate at the highest beam energy. The range in secondary foil offset used to account for the magnetic field was 0.09 cm crossplane and 0.15 cm inplane, the range in monitor chamber offset was 0.14 cm crossplane and 0.07 cm inplane. A 1.5%/0.09 cm match or better was obtained to measured depth dose curves. Profiles measured at the depth of maximum dose matched the simulated profiles to 2.6% or better at doses of 80% or more of the dose on the central axis. The profiles along the direction of MLC motion agreed to within 0.16 cm at the edge of the field. There remained a mismatch for the lower beam energies at the edge of the profile that ran parallel to the direction of jaw motion of up to 1.4 cm for the 6 MeV beam, attributed to the MLC support block at the periphery of the field left out of the simulation and to beam deflection by the magnetic field. The possibility of using these results to perform accurate simulation without disassembly is discussed. Phase-space files were made available for benchmarking beam models and other purposes.

CONCLUSIONS

The match to measured large field dose distributions from clinical electron beams with Monte Carlo simulation was improved with more accurate source details and geometry details closer to manufacturer's specification than previously achieved.

Megavoltage planar and cone-beam imaging with low-Z targets: dependence of image quality improvement on beam energy and patient separation

PURPOSE

The purpose of this study is to investigate the improvement of megavoltage planar and cone-beam CT (CBCT) image quality with the use of low atomic number (Z) external targets in the linear accelerator.

METHODS

In this investigation, two experimental megavoltage imaging beams were generated by using either 3.5 or 7.0 MeV electrons incident on aluminum targets installed above the level of the carousel in a linear accelerator (2100EX, Varian Medical, Inc., Palo Alto, CA). Images were acquired using an amorphous silicon detector panel. Contrast-to-noise ratio (CNR) in planar and CBCT images was measured as a function of dose and a comparison was made between the imaging beams and the standard 6 MV therapy beam. Phantoms of variable diameter were used to examine the loss of contrast due to beam hardening. Porcine imaging was conducted to examine qualitatively the advantages of the low-Z target approach in CBCT.

RESULTS

In CBCT imaging CNR increases by factors as high as 2.4 and 4.3 for the 7.0 and 3.5 MeV/Al beams, respectively, compared to images acquired with 6 MV. Similar factors of improvement are observed in planar imaging. For the imaging beams, beam hardening causes a significant loss of the contrast advantage with increasing phantom diameter; however, for the 3.5 MeV/Al beam and a phantom diameter of 25 cm, a contrast advantage remains, with increases of contrast by factors of 1.5 and 3.4 over 6 MV for bone and lung inhale regions, respectively. The spatial resolution is improved slightly in CBCT images for the imaging beams. CBCT images of a porcine cranium demonstrate qualitatively the advantages of the low-Z target approach, showing greater contrast between tissues and improved visibility of fine detail.

CONCLUSIONS

The use of low-Z external targets in the linear accelerator improves megavoltage planar and CBCT image quality significantly. CNR may be increased by a factor of 4 or greater. Improvement of the spatial resolution is also apparent.

The accuracy of EGSnrc, Geant4 and PENELOPE Monte Carlo systems for the simulation of electron scatter in external beam radiotherapy

Three widely used Monte Carlo systems were benchmarked against recently published measurements of the angular distribution of 13 MeV and 20 MeV electrons scattered from foils of different atomic numbers and thicknesses. Source and geometry were simulated in detail to calculate electron fluence profiles 118.2 cm from the exit window. Results were compared to the measured fluence profiles and the characteristic angle where the fluence drops to 1/e of its maximum value. EGSnrc and PENELOPE results, on average, agreed with measurement within 1 standard deviation experimental uncertainty, with EGSnrc estimating slightly lower scatter than measurement and PENELOPE slightly higher scatter. Geant4.9.2 overestimated the characteristic angle for the lower atomic number foils by as much as 10%. Retuning of the scatter distributions in Geant4 led to a much better agreement with measurement, close to that achieved with the other codes. The 3% differences from measurement seen with all codes for at least some of the foils would result in clinically significant errors in the fluence profiles (2%/4 mm), given accurate knowledge of the electron source and treatment head geometry used in radiotherapy. Further improvement in simulation accuracy is needed to achieve 1%/1 mm agreement with measurement for the full range of beam energies, foil atomic number and thickness used in radiotherapy. EGSnrc would achieve this accuracy with an increase in thickness of the mylar sheets in the monitor chamber, PENELOPE with a decrease in thickness.

Image quality & dosimetric property of an investigational imaging beam line MV-CBCT

To measure and compare the contrast to noise ratio (CNR) as a function of dose for the CBCTs produced by the mega‐voltage (MV) imaging beam line (IBL) and the treatment beam line (TBL), and to compare the dose to target and various critical structures of pediatric patients for the IBL CBCT versus standard TBL orthogonal port films.

Two Siemens Oncor linear accelerators were modified at our institution such that the MV‐CBCT would operate under an investigational IBL rather than the standard 6MV TBL. Prior to the modification, several CBCTs of an electron density phantom were acquired with the TBL at various dose values. After the modification, another set of CBCTs of the electron density phantom were acquired for various doses using the IBL. The contrast to noise ratio (CNR) for each tissue equivalent insert was calculated. In addition, a dosimetric study of pediatric patients was conducted comparing the 1 cGy IBL CBCT and conventional TBL orthogonal pair port films.

The CNR for eight tissue equivalent inserts at five different dose settings for each type of CBCT was measured. The CNR of the muscle insert was 0.8 for a 5 cGy TBL CBCT, 1.1 for a 1.5 cGy IBL CBCT, and 2.8 for a conventional CT. The CNR of the trabecular bone insert was 2.9 for a 5 cGy TBL CBCT, 5.5 for a 1.5 cGy IBL CBCT, and 14.8 for a conventional CT. The IBL CBCT delivered approximately one‐fourth the dose to the target and critical structures of the patients as compared to the TBL orthogonal pair port films.

The IBL CBCT improves image quality while simultaneously reducing the dose to the patient as compared to the TBL CBCT. A 1 cGy IBL CBCT, which is used for bony anatomy localization, delivers one‐fourth the dose as compared to conventional ortho‐pair films.

PACS number: 87.57.Q, 87.57.cj, 87.53.Jw

Determination of electron energy, spectral width, and beam divergence at the exit window for clinical megavoltage x-ray beams

Monte Carlo simulations of x-ray beams typically take parameters of the electron beam in the accelerating waveguide to be free parameters. In this paper, a methodology is proposed and implemented to determine the energy, spectral width, and beam divergence of the electron source. All treatment head components were removed from the beam path, leaving only the exit window. With the x-ray target and flattener out of the beam, uncertainties in physical characteristics and relative position of the target and flattening filter, and in spot size, did not contribute to uncertainty in the energy. Beam current was lowered to reduce recombination effects. The measured dose distributions were compared with Monte Carlo simulation of the electron beam through the treatment head to extract the electron source characteristics. For the nominal 6 and 18 MV x-ray beams, the energies were 6.51 +/- 0.15 and 13.9 +/- 0.2 MeV, respectively, with the uncertainties resulting from uncertainties in the detector position in the measurement and in the stopping power in the simulations. Gaussian spectral distributions were used, with full widths at half maximum ranging from 20 +/- 4% at 6 MV to 13 +/- 4% at 18 MV required to match the fall-off portion of the percent-depth ionization curve. Profiles at the depth of maximum dose from simulations that used the manufacturer-specified exit window geometry and no beam divergence were 2-3 cm narrower than measured profiles. Two simulation configurations yielding the measured profile width were the manufacturer-specified exit window thickness with electron source divergences of 3.3 degrees at 6 MV and 1.8 degrees at 18 MV and an exit window 40% thicker than the manufacturer's specification with no beam divergence. With the x-ray target in place (and no flattener), comparison of measured to simulated profiles sets upper limits on the electron source divergences of 0.2 degrees at 6 MV and 0.1 degrees at 18 MV. A method of determining source characteristics without mechanical modification of the treatment head, and therefore feasible in clinics, is presented. The energies and spectral widths determined using this method agree with those determined with only the exit window in the beam path.