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

The use of intensity-modulated radiation therapy photon beams for improving the dose uniformity of electron beams shaped with MLC

Electrons are ideal for treating shallow tumors and sparing adjacent normal tissue. Conventionally, electron beams are collimated by cut-outs that are time-consuming to make and difficult to adapt to tumor shape throughout the course of treatment. We propose that electron cut-outs can be replaced using photon multileaf collimator (MLC). Two major problems of this approach are that the scattering of electrons causes penumbra widening because of a large air gap, and available commercial treatment planning systems (TPSs) do not support MLC-collimated electron beams. In this study, these difficulties were overcome by (1) modeling electron beams collimated by photon MLC for a commercial TPS, and (2) developing a technique to reduce electron beam penumbra by adding low-energy intensity-modulated radiation therapy (IMRT) photons (4 MV). We used blocks to simulate MLC shielding in the TPS. Inverse planning was used to optimize boost photon beams. This technique was applied to a parotid and a central nervous system (CNS) clinical case. Combined photon and electron plans were compared with conventional plans and verified using ion chamber, film, and a 2D diode array. Our studies showed that the beam penumbra for mixed beams with 90 cm source to surface distance (SSD) is comparable with electron applicators and cut-outs at 100 cm SSD. Our mixed-beam technique yielded more uniform dose to the planning target volume and lower doses to various organs at risk for both parotid and CNS clinical cases. The plans were verified with measurements, with more than 95% points passing the gamma criteria of 5% in dose difference and 5 mm for distance to agreement. In conclusion, the study has demonstrated the feasibility and potential advantage of using photon MLC to collimate electron beams with boost photon IMRT fields.

Dosimetric characteristics of an electron multileaf collimator for modulated electron radiation therapy

Modulated electron radiation therapy (MERT) has been proven as an effective way to deliver conformal dose distributions to shallow tumors while sparing distal critical structures and surrounding normal tissues. It had been shown that a dedicated electron multileaf collimator (eMLC) is necessary to reach the full potential of MERT. In this study, a manually-driven eMLC for MERT was investigated. Percentage depth dose (PDD) curves and profiles at different depths in a water tank were measured using ionization chamber and were also simulated using the Monte Carlo method. Comparisons have been performed between PDD curves and profiles collimated using the eMLC and conventional electron applicators with similar size of opening. Monte Carlo simulations were performed for all electron energies available (6, 9, 12, 15, 18 and 20 MeV) on a Varian 21EX accelerator. Monte Carlo simulation results were compared with measurements which showed good agreement (< 2%/1mm). The simulated dose distributions resulting from multiple static electron fields collimated by the eMLC agreed well with measurements. Further studies were carried out to investigate the properties of abutting electron beams using the eMLC, as it is an essential issue that needs to be addressed for optimizing the MERT outcome. A series of empirical formulas for abutting beams of different energies have been developed for obtaining the optimum gap sizes, which can highly improve the target dose uniformity.

Matching extended-SSD electron beams to multileaf collimated photon beams in the treatment of head and neck cancer

PURPOSE

Matching the penumbra of a 6 MeV electron beam to the penumbra of a 6 MV photon beam is a dose optimization challenge, especially when the electron beam is applied from an extended source-to-surface distance (SSD), as in the case of some head and neck treatments. Traditionally low melting point alloy blocks have been used to define the photon beam shielding over the spinal cord region. However, these are inherently time consuming to construct and employ in the clinical situation. Multileaf collimators (MLCs) provide a fast and reproducible shielding option but generate geometrically nonconformal approximations to the desired beam edge definition. The effects of substituting Cerrobend for the MLC shielding mode in the context of beam matching with extended-SSD electron beams are the subject of this investigation.

METHODS

Relative dose beam data from a Varian EX 2100 linear accelerator were acquired in a water tank under the 6 MeV electron beam at both standard and extended-SSD and under the 6 MV photon beam defined by Cerrobend and a number of MLC stepping regimes. The effect of increasing the electron beam SSD on the beam penumbra was assessed. MLC stepping was also assessed in terms of the effects on both the mean photon beam penumbra and the intraleaf dose-profile nonuniformity relative to the MLC midleaf. Computational techniques were used to combine the beam data so as to simulate composite relative dosimetry in the water tank, allowing fine control of beam abutment gap variation. Idealized volumetric dosimetry was generated based on the percentage depth-dose data for the beam modes and the abutment geometries involved. Comparison was made between each composite dosimetry dataset and the relevant ideal dosimetry dataset by way of subtraction.

RESULTS

Weighted dose-difference volume histograms (DDVHs) were produced, and these, in turn, summed to provide an overall dosimetry score for each abutment and shielding type/angle combination. Increasing the electron beam SSD increased the penumbra width (defined as the lateral distance of the 80% and 20% isodose contours) by 8-10 mm at the depths of 10-20 mm. Mean photon beam penumbra width increased with increased MLC stepping, and the mean MLC penumbra was approximately 1.5 times greater than that across the corresponding Cerrobend shielding. Intraleaf dose discrepancy in the direction orthogonal to the beam edge also increased with MLC stepping.

CONCLUSIONS

The weighted DDVH comparison techniques allowed the composite dosimetry resulting from the interplay of the abovementioned variables to be ranked. The MLC dosimetry ranked as good or better than that resulting from beam matching with Cerrobend for all except large field overlaps (-2.5 mm gap). The results for the linear-weighted DDVH comparison suggest that optimal MLC abutment dosimetry results from an optical surface gap of around 1 +/- 0.5 mm. Furthermore, this appears reasonably lenient to abutment gap variation, such as that arising from uncertainty in beam markup or other setup errors.

Developments in radiotherapy

A systematic assessment of radiotherapy for cancer was conducted by The Swedish Council on Technology Assessment in Health Care (SBU) in 2001. The assessment included a review of future developments in radiotherapy and an estimate of the potential benefits of improved radiotherapy in Sweden. The conclusions reached from this review can be summarized as: Successively better knowledge is available on dose-response relationships for tumours and normal tissues at different fractionation schedules and treated volumes. Optimization of dose levels and fractionation schedules should improve the treatment outcome. Improved treatment results may be expected with even more optimized fractionation schedules. The radiosensitivity of the tumour is dependent on the availability of free oxygen in the cells. The oxygen effect has been studied for a long time and new knowledge has emerged, but there is still no consensus on the best way to minimize its negative effect in the treatment of hypoxic tumours. Development in imaging techniques is rapid, improving accuracy in outlining targets and organs at risk. This is a prerequisite for advanced treatment planning. More accurate treatment can be obtained using all the computer techniques that are successively made available for calculating dose distributions, controlling the accelerator and multileaf collimator (MLC) and checking patient set-up. Optimized treatment plans can be achieved using inverse dose planning and intensity modulation radiation therapy (IMRT). Optimization algorithms based on biological data from clinical trials could be a part of future dose planning. New genetic markers might be developed that give a measure of the radiation responsiveness of tumours and normal tissue. This could lead to more individualized treatments. New types of radiation sources may be expected: protons, light ions, and improved beams (and compounds) for boron neutron capture therapy (BNCT). Proton accelerators with scanned-beam systems and energy modulation give good dose distribution. The results reported with carbon ions from Japan and Germany are promising. An interesting development is to verify the dose and position for the irradiated volume with PET on line. Safer margins are obtained and the treatment volume can thus be limited. Very large accelerators are needed to accelerate the carbon ions. Still, it should be possible to keep the costs per patient at the same level as those for other types of advanced radiotherapy, since far fewer treatments per patient are needed. It might also be possible to treat new groups of patients. Increased resources are needed to introduce all the currently available techniques. New types of particle accelerators require large investments and a new structure of radiotherapy in Sweden.

Optimized Dose Coverage of Regional Lymph Nodes in Breast Cancer: The Role of Intensity-Modulated Radiotherapy

PURPOSE

To determine whether the use of intensity-modulated radiotherapy (IMRT) would lead to improved dosimetry for the breast and regional nodes.

METHODS AND MATERIALS

Ten patients with left-sided breast cancer were selected. The clinical target volume included left breast and internal mammillary (IM), supraclavicular (SC), and axillary (AX) nodes. The critical structures included heart, right and left lungs, contralateral breast, esophagus, thyroid, and humeral head. Conventional and a series of IMRT plans were generated for comparison.

RESULTS

The average heart D(3) was reduced from 31.4 +/- 18.9 with three-dimensional conformal radiotherapy (3D-CRT) to 15 +/- 7.2 Gy with 9-field (9-FLD IMRT). The average left lung D(30) was also decreased from 27.9 +/- 11.5 Gy (3D-CRT) to 12.6 +/- 8.2 Gy (9-FLD IMRT). The average contralateral breast D(2) was reduced from 4.4 +/- 5.3 Gy (3D-CRT) to 1.8 +/- 1.2 Gy (4-FLD IMRT). Esophagus D(2) was increased from 9.3 +/- 8.1 Gy (3D-CRT) to 29.4 +/- 5.4 (9-FLD IMRT); thyroid D(50) was increased from 0.9 +/- 0.6 Gy (3D-CRT) to 11.9 +/- 6.6 (9-FLD IMRT); humeral head D(2) was increased from 36.1 +/- 13.1 Gy (3D-CRT) to 39.9 +/- 6.5 (9-FLD IMRT).

CONCLUSIONS

The use of IMRT improves breast and regional node coverage while decreasing doses to the lungs, heart, and contralateral breast when compared with 3D-CRT. Doses to esophagus, thyroid, and humeral head, however, were increased with IMRT.

Photon and electron collimator effects on electron output and abutting segments in energy modulated electron therapy

In energy modulated electron therapy a large fraction of the segments will be arranged as abutting segments where inhomogeneities in segment matching regions must be kept as small as possible. Furthermore, the output variation between different segments should be minimized and must in all cases be well predicted. For electron therapy with add-on collimators, both the electron MLC (eMLC) and the photon MLC (xMLC) contribute to these effects when an xMLC tracking technique is utilized to reduce the x-ray induced leakage. Two add-on electron collimator geometries have been analyzed using Monte Carlo simulations: One isocentric eMLC geometry with an isocentric clearance of 35 cm and air or helium in the treatment head, and one conventional proximity geometry with a clearance of 5 cm and air in the treatment head. The electron fluence output for 22.5 MeV electrons is not significantly affected by the xMLC if the shielding margins are larger than 2-3 cm. For small field sizes and 9.6 MeV electrons, the isocentric design with helium in the treatment head or shielding margins larger than 3 cm is needed to avoid a reduced electron output. Dose inhomogeneity in the matching region of electron segments is, in general, small when collimator positions are adjusted to account for divergence in the field. The effect of xMLC tracking on the electron output can be made negligible while still obtaining a substantially reduced x-ray leakage contribution. Collimator scattering effects do not interfere significantly when abutting beam techniques are properly applied.

HDR brachytherapy combined with 3-D conformal vs. IMRT in left-sided breast cancer patients including internal mammary chain: comparative analysis of dosimetric and technical parameters

Treatment of the internal mammary chain (IMC) with radiation therapy (RT) for patients with breast cancer remains a controversial issue. Different treatment techniques have been proposed, including oblique electrons, electron‐photon combination, and partially wide tangents (PWTs). However, the residual heart dose can remain significant mainly for left‐sided lesions. With PWTs and intensity‐modulated radiotherapy (IMRT), respiratory movement and errors in IMC localization remain a problem. The goal of this paper is to evaluate the impact of IMC brachytherapy (IMCBT) combined with 3D conformal radiotherapy (3DCRT) planning on heart, lung, and contralateral breast doses compared with IMRT. All plans including IMCBT plus 3DCRT were done on PLATO; IMRT plans were generated using the Cadplan‐Helios inverse treatment‐planning software module with the “sliding window&rdquo; technique. Dose‐volume histograms (DVHs) were calculated for all volumes of interest. Conformity and homogeneity index was also calculated for the planning target volume (PTV). Dose distribution in the surrounding normal tissue was evaluated. The mean conformity of the PTV was found to be 1.06 with IMCBT plus 3DCRT and 1.12 with IMRT. The mean homogeneity (HI95/107) was found to be 1.4 with IMCBT plus 3DCRT and 3.32 with IMRT. Using the IMCBT plus 3DCRT technique, the mean dose to the heart, contralateral breast, ipsilateral lung, and contralateral lung decreased with values of 32%, 6.76%, 20% and 5.52%, respectively, compared with IMRT. This novel technique of IMCBT plus 3DCRT can potentially reduce the dose to the heart and lungs. In addition, it rivals IMRT because of its unique advantages in localization, obviating the need for respiratory gating and maximum sparing of heart and other structures.

PACS numbers: 87.53.Jw, 87.53.Kn, 87.53.Mr, 87.53, 87.53.Tf

Can photon IMRT be improved by combination with mixed electron and photon techniques?

Conformal radiotherapy or intensity modulated radiotherapy (IMRT) commonly leads to a large integral dose in the patient. Electrons would reduce the integral dose but are not suitable for treating deep-seated tumours, owing to their limited penetration. By combining electron and photon beams, the dose distributions may be improved. In this study, the possibility is explored of using a mixture of electron and photon beams for a deep-seated target volume in the head and neck region. Treatment plans were made for five simulated head and neck cancer cases. Mixed electron and photon beam plans (MB) were constructed using a manual iterative procedure. Photon IMRT plans were optimized automatically. Both electron and photon beams were collimated by a computer controlled multi-leaf collimator (MLC). Both methods were able to produce clinically acceptable plans. Criteria for the target dose were met similarly by both as were the criteria for critical organs. The integral dose outside the planning target volume (PTV) showed a tendency to be lower with MB plans compared with photon IMRT plans. A mixed electron and photon technique has the potential to treat deep-seated tumours. It is reasonable to expect that if computerized optimization tools were coupled with the mixed electron and photon beam technique, treatment goals would be more readily achieved than if using solely pure photon IMRT.

Effects on electron beam penumbra using the photon MLC to reduce bremsstrahlung leakage for an add-on electron MLC

Electron IMRT treatments have the potential to reduce the integral dose due to the limited range of the electrons. However, bremsstrahlung produced in the scattering foils could penetrate an added electron MLC (eMLC), thus producing an unmodulated dose contribution that could become unacceptable in electron IMRT treatments. To limit this bremsstrahlung contribution, the photon MLC (xMLC) was used to track the eMLC, but with a margin to avoid penumbra widening through partial screening of the effective electron source. The purpose of this work was to study the effect of the photon-electron MLC tracking on the electron beam penumbra for different treatment head designs. Both isocentric designs and designs where the eMLC is used close to the patient (proximity geometry) have been analysed using Monte Carlo simulations. At 22.5 MeV energy, a tracking margin of 1 cm was enough to avoid penumbra degradation for a helium-filled isocentric geometry, while air-filled geometries (including proximity geometries) require a 2-3 cm margin. Illustrated by an example of a chest wall treatment by electron IMRT, the use of 1 cm tracking margin will reduce the collimator leakage contribution by a factor of 36 as compared to using a static setting of the photon collimator.

Dosimetry of a prototype retractable eMLC for fixed-beam electron therapy

An electron multileaf collimator (eMLC) has been designed that is unique in that it retracts to 37 cm from the isocenter [63-cm source-to-collimator distance (SCD)] and can be deployed to distances of 20 and 10 cm from the isocenter (80 and 90 cm SCD, respectively). It is expected to be capable of arc therapy at 63 cm SCD; isocentric, fixed-beam therapy at 80 cm SCD; and source-to-surface distance (SSD), fixed-beam therapy at 90 cm SCD. In all positions, its leaves could be used for unmodulated or intensity-modulated therapy. Our goal in the present work is to describe the general characteristics of the eMLC and to demonstrate that its leakage characteristics and dosimetry are adequate for SSD, fixed-beam therapy as an alternative to Cerrobend cutouts with applicators once the prototype's leaves are motorized. Our eMLC data showed interleaf electron leakage at 15 MeV to be less than 0.1% based on a 0.0025 cm manufacturing tolerance, and lateral electron leakage at 5 and 15 MeV to be less than 2%. X-ray leakage through the leaves was 1.6% at 15 MeV. Our data showed that beam penumbra was independent of direction and leaf position. The dosimetric properties of square fields formed by the eMLC were very consistent with those formed by Cerrobend inserts in the 20 x 20 cm2 applicator. Output factors exhibited similar field-size dependence. Airgap factors exhibited almost identical field-size dependence at two SSDs (105 and 110 cm), consistent with the common assumption that airgap factors are applicator independent. Percent depth-dose curves were similar, but showed variations up to 3% in the buildup region. The pencil-beam algorithm (PBA) fit measured data from the eMLC and applicator-cutout systems equally well, and the resulting two-dimensional (2-D) dose distributions, as predicted by the PBA, agreed well at common airgap distance. Simulating patient setups for breast and head and neck treatments showed that almost all fields could be treated using similar SSDs as when using applicators, although head and neck treatments require placing the patient's head on a head-holder treatment table extension. The results of this work confirmed our design goals and support the potential use of the eMLC design in the clinical setting. The eMLC should allow the same treatments as are typically delivered with the electron applicator-cutout system currently used for fixed-beam therapy.

Potential role of intensity-modulated photons and protons in the treatment of the breast and regional nodes

PURPOSE

To investigate, using comparative treatment planning, the potential improvements that could result through the use of intensity-modulated photons (intensity-modulated radiation therapy [IMRT]) and protons for the locoregional treatment of complex-target breast cancer.

METHODS AND MATERIALS

Using CT data from a breast cancer patient, treatment plans were computed using "standard" photon/electron, IMRT, and forward-planned proton techniques. A dose of 50 Gy was prescribed to the target volume consisting of the involved breast, internal mammary, supraclavicular, and axillary nodes. The standard plan was designed using 6-MV X-ray beams to the breast, axillary, and supraclavicular areas and a mixture of 6-MV X-rays and 12-MeV electrons for the internal mammary nodes. Two IMRT (IMX1 and IMX2) plans were calculated for nine evenly spaced beams using dose-volume constraints to the organs at risk. For plan IMX1, precedence was given to optimizing the reduction in lung and heart dose while preserving target dose homogeneity. For plan IMX2, an increased precedence was given to the lungs, heart, and contralateral breast to further reduce doses to these organs and to study the effect on target coverage. The proton plan consisted of two oblique, energy-modulated fields. Target dose homogeneity and the doses to neighboring organs were both considered when comparing the different plans.

RESULTS

For the standard plan, dose-volume histograms (DVHs) of the target volumes showed severe dose heterogeneity, whereas target coverage for the IMRT and proton plans was comparable. Lung DVHs for the standard and IMRT plans were also comparable, while the proton plan showed the best sparing over all dose levels. Mean doses to the ipsilateral lung for the three plans were found to be 17 Gy, 15 Gy, and 13 Gy for the standard, IMRT, and proton plans, respectively. For the heart, the IMRT plan delivered the highest mean dose (16 Gy), reflecting the extra dose delivered through this organ to spare the lungs. This was reduced somewhat by the standard plan (15 Gy), with the best sparing being provided by the proton plan (6 Gy). When the IMRT plan was reoptimized with an increased precedence to the normal tissues, the mean doses to all neighboring organs at risk could be reduced, but only at the cost of substantial target dose heterogeneity.

CONCLUSIONS

In comparison with the standard plan, IMRT photons have the potential to greatly improve the target dose homogeneity with only a small increase in the doses delivered to the neighboring critical structures. However, when attempting to further reduce doses to the critical structures, substantial loss of target dose homogeneity was found. In conclusion, only the two-field, energy-modulated proton plan had the potential to preserve target dose homogeneity while simultaneously minimizing the dose delivered to both lungs, heart, and the contralateral breast.

Multileaf collimation of electrons--clinical effects on electron energy modulation and mixed beam therapy depending on treatment head design

The aim of this study was to explore the possibilities of using multileaf-collimated electron beams for advanced radiation therapy with conventional scattering foil flattened beams. Monte Carlo simulations were performed with the aim to improve electron beam characteristics and enable isocentric multileaf collimation. The scattering foil positions, monitor chamber thickness, the MLC location and the amount of He in the treatment head were optimized for three common commercial accelerators. The performance of the three optimized treatment head designs was compared for different SSDs in air, at treatment depth in water and for some clinical cases. The effects of electron/photon beam matching including generalized random and static errors using Gaussian one-dimensional (1 D) error distributions, and also electron energy modulation, were studied at treatment depth in water. The modification of the treatment heads improved the electron beam characteristics and enabled the use of multileaf collimation in isocentric delivery of both electron and photon beams in a mixed beam IMRT procedure.

Electron beam collimation with focused and curved leaf end MLCs--experimental verification of Monte Carlo optimized designs

In general, electron beams from conventional accelerators using applicators with lead alloy inserts are not suitable for advanced conformal radiation therapy. However, interesting electron treatments have been demonstrated on a few advanced accelerators. These accelerators have been equipped with helium filled treatment heads and computer controlled MLCs that produce clinically useful energy modulated electron beams or mixed photon electron beams in an automated sequence. This study analyzes the characteristics of different MLC designs, curved and focused leaf ends in helium filled treatment heads, with respect to their effect on electron beams. In addition, this study analyzes the effects that different treatment head designs have on the output factor due to collimator scattering and shielding of secondary sources during treatment. The investigation of the different treatment head designs was performed with the Monte Carlo package BEAM and was verified by experimental methods. The results show that the difference between curved leaf ends and focused ends is negligible in most practical cases. The results also show the importance of scattering foil optimization in the optimization of parameters such as penumbra, virtual source position, and in the reduction of the output variation. In all cases, the experimental data verifies the calculations.

Investigation of the added value of high-energy electrons in intensity-modulated radiotherapy: four clinical cases

PURPOSE

Intensity-modulated radiotherapy (IMRT) with photon beams is currently pursued in many clinics. Theoretically, inclusion of intensity- and energy-modulated high-energy electron beams (15-50 MeV) offers additional possibilities to improve radiotherapy treatments of deep-seated tumors. In this study the added value of high-energy electron beams in IMRT treatments was investigated.

METHODS AND MATERIALS

In a comparative treatment planning study, conventional treatment plans and various types of IMRT plans were constructed for four clinical cases (cancer of the bladder, pancreas, chordoma of the sacrum, and breast). The conventional plans were used for the actual treatment of the patients. The IMRT plans were optimized using the Orbit optimization code (Löf et al., 2000) with a radiobiologic objective function. The IMRT plans were either photon or combined electron and photon beam plans, with or without dose homogeneity constraints assuming standard or increased radiosensitivities of organs at risk.

RESULTS

Large improvements in expected treatment outcome are found using IMRT plans compared to conventional plans, but differences in tumor control probability (TCP) and normal tissue complication probabilities (NTCP) values between IMRT plans with and without electrons are small. However, the use of electrons improves the dose-volume histograms for organs at risk, especially at lower dose levels (e.g., 0-40 Gy).

CONCLUSIONS

This preliminary study indicates that addition of higher energy electrons to IMRT can only marginally improve treatment outcome for the selected cases. The dose-volume histograms of organs at risk show improvements for IMRT with higher energy electrons, which may reduce tumor induction but does not substantially reduce NTCP.

A linear diode array (JFD-5) for match line in vivo dosimetry in photon and electron beams; evaluation for a chest wall irradiation technique

BACKGROUND AND PURPOSE

In vivo dosimetry using thermoluminiscence detectors (TLD) is routinely performed in our institution to determine dose inhomogeneities in the match line region during chest wall irradiation. However, TLDs have some drawbacks: online in vivo dosimetry cannot be performed; generally, doses delivered by the contributing fields are not measured separately; measurement analysis is time consuming. To overcome these problems, the Joined Field Detector (JFD-5), a detector for match line in vivo dosimetry based on diodes, has been developed. This detector and its characteristics are presented.

MATERIALS AND METHODS

The JFD-5 is a linear array of 5 p-type diodes. The middle three diodes, used to measure the dose in the match line region, are positioned at 5-mm intervals. The outer two diodes, positioned at 3-cm distance from the central diode, are used to measure the dose in the two contributing fields. For three JFD-5 detectors, calibration factors for different energies, and sensitivity correction factors for non-standard field sizes, patient skin temperature, and oblique incidence have been determined. The accuracy of penumbra and match line dose measurements has been determined in phantom studies and in vivo.

RESULTS

Calibration factors differ significantly between diodes and between photon and electron beams. However, conversion factors between energies can be applied. The correction factor for temperature is 0.35%/ degrees C, and for oblique incidence 2% at maximum. The penumbra measured with the JFD-5 agrees well with film and linear diode array measurements. JFD-5 in vivo match line dosimetry reproducibility was 2.0% (1 SD) while the agreement with TLD was 0.999+/-0.023 (1 SD).

CONCLUSION

The JFD-5 can be used for accurate, reproducible, and fast on-line match line in vivo dosimetry.

Testing of the stability of intensity modulated beams generated with dynamic multileaf collimation, applied to the MM50 racetrack microtron

Recently, we have published a method for the calculation of required leaf trajectories to generate optimized intensity modulated x-ray beams by means of dynamic multileaf collimation [Phys. Med. Biol. 43, 1171-1184 (1998)]. For the MM50 Racetrack Microtron it has been demonstrated that the dosimetric accuracy of this method, in combination with the dose calculation algorithm of the Cadplan 3D treatment planning system, is adequate for a clinical application (within 2% or 0.2 cm). Prior to initiating patient treatment with dynamic multileaf collimation (DMLC), tests have been performed to investigate the stability of DMLC fields generated at the MM50, (i) in time, (ii) subject to gantry rotation and (iii) in case of treatment interrupts, e.g., caused by an error detected by the treatment machine. The stability of relative dose profiles, normalized to a reference point in a relatively flat part of the modulated beam profile, was assessed from measurements with an electronic portal imaging device (EPID), with a linear diode array attached to the collimator and with film. The dose in the reference point was monitored using an ionization chamber. Tests were performed for several intensity modulated fields using 10 and 25 MV photon beams. Based on film measurements for sweeping 0.1 cm leaf gaps it was concluded that in an 80 days period the variation in leaf positioning was within 0.05 cm, without requiring any recalibration. For a uniform 10x10 cm2 field, realized dynamically by a scanning 0.4x10 cm2 slit beam, a maximum variation in slit width of 0.01 cm was derived from ionization chamber measurements, both in time and for gantry rotation. For a clinical example, the dose in the reference point reproduced within 0.2% (1 SD) over a period of 100 days. Apart from regions with very large dose gradients, variations in the relative beam profiles measured with the EPID were generally less than 1% (1 SD). For different gantry angles the dose profiles also reproduced within 1%, showing that gravity has a negligible influence. No significant deviations between uninterrupted and interrupted treatments could be observed, indicating that the effects of acceleration and deceleration of the leaves are negligible and that a DMLC treatment can be finished correctly after a treatment interrupt. Our previous and present studies have demonstrated that the dosimetric accuracy and stability of intensity modulated beams, generated at the MM50 by means of dynamic multileaf collimation, are adequate for clinical use. Patient treatment using dynamic multileaf collimation has been started in our clinic.

Chest wall irradiation with MLC-shaped photon and electron fields

PURPOSE

To improve the treatment technique for chest wall irradiation, using the multileaf collimator (MLC) of the MM50 Racetrack Microtron to shape both photon and electron beams, and to check the dose delivery in the match-line region of these fields for the routine and improved technique.

METHODS AND MATERIALS

Using diode and film phantom measurements, the optimal number of photon beam segments and their positions relative to the electron beam were determined. On phantoms, and during actual patient treatment using in vivo dosimetry, the dose homogeneity in the match-line region was determined for both the routine and improved techniques.

RESULTS

Three photon beam segments (9-mm gap, perfect match, and 9-mm overlap) were used to match the electron beam, resulting in minimum-maximum dose values in the match-line region of 88-109%, compared to 80-115% for the routine technique (2 photon beam segments). During patient treatment, the average minimum and maximum dose values were 95% and 115%, respectively, compared to 78% and 127%, respectively, for the routine technique. The interfraction variation in dose delivery was reduced from 11.0% (1 SD) to 4.6% (1 SD). The actual treatment time was reduced from 10 to 4.5 min.

CONCLUSION

Using the MLC of the MM50 to shape both photon and electron beams, an improved treatment technique for chest wall irradiation was developed, which is less labor intensive, faster, and yields a more homogeneous, and better reproducible dose delivery.

Determination of effective electron source size using multislit and pinhole cameras

Two independent methods have been utilized for determination of effective source sizes for 6, 12, and 20 MeV electron beams generated by a Varian 2100C linear accelerator. First, a multislit camera has been constructed using parallel aluminum plates and plastic strip spacers, similar to the beam-spot camera for the photon source imaging. Second, pinhole imaging was performed using a lead plate with a small hole on the central axis of the beam. The plate thickness and the hole diameter varied with electron energy. The cameras were positioned directly at the opening of the movable photon collimator. The size of the source distribution from each camera was characterized by its full width at half-maximum (FWHM) value. The measured values of FWHM are different for each camera because of their different imaging principles. For the multislit camera, the measured FWHM values were (6.3 +/- 0.4) cm for the 6 MeV beam, (3.6 +/- 0.4) cm for 12 MeV, and (2.7 +/- 0.4) cm for 20 MeV. For the pinhole camera the measured values of FWHM were (7.9 +/- 0.6) cm for 6 MeV, (4.5 +/- 0.4) cm for 12 MeV, and (3.0 +/- 0.4) cm for the 20 MeV beam. Additionally, the effective source position was derived from output measurements at different values of the SSD, which were fitted to the inverse square law.

An improved technique for breast cancer irradiation including the locoregional lymph nodes

PURPOSE

To find an irradiation technique for locoregional irradiation of breast cancer patients which, compared with a standard technique, improves the dose distribution to the internal mammary-medial supraclavicular (IM-MS) lymph nodes. The improved technique is intended to minimize the lung dose and reduce the dose to the heart.

METHODS AND MATERIALS

The standard technique consists of an anterior mixed electron/photon IM-MS field. In the improved technique, an oblique electron and an oblique asymmetric photon field are combined to irradiate the IM lymph nodes. To irradiate the MS lymph nodes, a combination of an anterior electron and an anterior asymmetric photon field is used. For both the standard and the improved technique, tangential photon fields are used to irradiate the breast. Three-dimensional (3D) treatment planning was performed for 8 patients with various breast sizes for these two techniques. Dose-volume histograms (DVHs) and normal tissue complication probabilities (NTCPs) were compared for both techniques. The field dimensions and energy of the standard technique were determined at simulation, whereas for the improved technique the fields were designed by CT-based treatment planning.

RESULTS

The dose in the breast planning target volume was essentially the same for both techniques. For the improved technique, combined with 3D localization information, an improvement in the IM-MS planning target coverage is seen. The volume within the 95% isodose surface was on average 25% (range, 0-64%) and 74% (range, 43-90%) for the standard and improved technique, respectively. The heart generally receives less dose with the improved technique. However, sometimes a small but acceptable increase in lung dose is found.

CONCLUSION

The improved technique, combined with localization information of the IM-MS lymph nodes, greatly improves the dose distribution in the planning target volume for a large group of patients without significantly increasing the dose to organs at risk.

Breast-conserving radiation therapy using combined electron and intensity-modulated radiotherapy technique

BACKGROUND AND PURPOSE

To explore the feasibility of a multi-modality breast-conserving radiation therapy treatment technique to reduce high dose to the ipsilateral lung and the heart when compared with the conventional treatment technique using two tangential fields.

MATERIALS AND METHODS

An electron beam with appropriate energy was combined with four intensity modulated photon beams. The direction of the electron beam was chosen to be tilted 10-20 degrees laterally from the anteroposterior direction. Two of the intensity-modulated photon beams had the same gantry angles as the conventional tangential fields, whereas the other two beams were rotated 15-25 degrees toward the anteroposterior directions from the first two photon beams. An iterative algorithm was developed which optimizes the weight of the electron beam as well as the fluence profiles of the photon beams for a given patient. Two breast cancer patients with early-stage breast tumors were planned with the new technique and the results were compared with those from 3D planning using tangential fields as well as 9-field intensity-modulated radiotherapy (IMRT) techniques.

RESULTS

The combined electron and IMRT plans showed better dose conformity to the target with significantly reduced dose to the ipsilateral lung and, in the case of the left-breast patient, reduced dose to the heart, than the tangential field plans. In both the right-sided and left-sided breast plans, the dose to other normal structures was similar to that from conventional plans and was much smaller than that from the 9-field IMRT plans. The optimized electron beam provided between 70 to 80% of the prescribed dose at the depth of maximum dose of the electron beam.

CONCLUSIONS

The combined electron and IMRT technique showed improvement over the conventional treatment technique using tangential fields with reduced dose to the ipsilateral lung and the heart. The customized beam directions of the four IMRT fields also kept the dose to other critical structures to a minimum.

Treatment head design for multileaf collimated high-energy electrons

This paper describes how a conventional treatment head can be modified for use of multileaf collimated electron beams. Automatic and dynamic beam delivery are possible for both electrons and photons by using the computer controlled multileaf collimator (MLC) for both photon and electron beams. Thereby, the electron beams can be mixed more freely into the treatment to take advantage of the specific depth modulation characteristics of electrons. The investigation was based on Monte Carlo calculations using the software package BEAM. The physical parameters used in this optimization were the beam penumbra and the virtual/effective point source position. These parameters are essential for shaping beams, beam matching and for dosimetry calculations. The optimization was carried out by modifying a number of parameters: replacing the air atmosphere in the treatment head with helium, adding a helium bag below the MLC, changing the position of the scattering foils, modifying the monitor chamber, and adjusting the position of the MLC. The beam characteristics for some of these designs were found to fulfil our criteria for clinically useful beams down to at least 9 MeV.

The effect of beam divergence on target coverage

The well-known fact that radiation beams diverge is frequently not considered during the treatment planning process. Complacency with respect to beam divergence can, in some situations, lead to inappropriate field design. In this review, the potential problems arising from failure to adequately account for beam divergence in treatment planning are outlined, and commonly encountered clinical examples are illustrated.

Clinical use of a simulation-multileaf collimator

BACKGROUND

At the University of Lübeck, radiotherapy is delivered by a 6/18-MV linear accelerator. Using the integrated multileaf collimator, irradiation of individually shaped treatment fields is possible in place of alloy blocks. Due to unsatisfactory pretherapeutic review of the radiation-field-specific multileaf collimator (MLC) configuration, we developed a simulation-multileaf collimator (SMLC) and assessed its feasibility at different tumor sites.

MATERIAL AND METHODS

The SMLC is made of a perspex carrier with 52 horizontal sliding leaves. The position of each leaf is calculated by a 3D treatment-planning computer. The technician manually adjusts the leaves according to the beams-eye-view plot of the planning computer. Consequently, the SMLC is mounted on the therapy simulator at a distance of 64.8 cm from the focus. The treatment fields and the position of the leaves are documented by X-ray films.

RESULTS

Using the SMLC, radiation oncologists are able to review exactly the leaf configuration of each MLC-shaped radiation field and to correlate the MLC-shaped radiation field with the treated volume, the organs at risk and the port films acquired by the Portal Vision system.

CONCLUSION

The SMLC is a new tool to review radiation planning that uses an MLC in daily routine. The use of the SMLC improves the documentation and the quality assurance. It accelerates the treatment field review at the linear accelerator by comparing the SMLC simulator films with the portal images.

Leaf trajectory calculation for dynamic multileaf collimation to realize optimized fluence profiles

An algorithm for the calculation of the required leaf trajectories to generate optimized intensity modulated beam profiles by means of dynamic multileaf collimation is presented. This algorithm iteratively accounts for leaf transmission and collimator scatter and fully avoids tongue-and-groove underdosage effects. Tests on a large number of intensity modulated fields show that only a limited number of iterations, generally less than 10, are necessary to minimize the differences between optimized and realized fluence profiles. To assess the accuracy of the algorithm in combination with the dose calculation algorithm of the Cadplan 3D treatment planning system, predicted absolute dose distributions for optimized fluence profiles were compared with dose distributions measured on the MM50 Racetrack Microtron and resulting from the calculated leaf trajectories. Both theoretical and clinical cases yield an agreement within 2%, or within 2 mm in regions with a high dose gradient, showing that the accuracy is adequate for clinical application.

Intensity modulation with electrons: calculations, measurements and clinical applications

Intensity modulation of electron beams is one step towards truly conformal therapy. This can be realized with the MM50 racetrack microtron that utilizes a scanning beam technique. By adjusting the scan pattern it is possible to obtain arbitrary fluence distributions. Since the monitor chambers in the treatment head are segmented in both x- and y-directions it is possible to verify the fluence distribution to the patient at any time during the treatment. Intensity modulated electron beams have been measured with film and a plane parallel chamber and compared with calculations. The calculations were based on a pencil beam method. An intensity distribution at the multileaf collimator (MLC) level was calculated by superposition of measured pencil beams over scan patterns. By convolving this distribution with a Gaussian pencil beam, which has propagated from the MLC to the isocentre, a fluence distribution at isocentre level was obtained. The agreement between calculations and measurements was within 2% in dose or 1 mm in distance in the penumbra zones. A standard set of intensity modulated electron beams has been developed. These beams have been implemented in a treatment planning system and are used for manual optimization. A clinical example (prostate) of such an application is presented and compared with a standard irradiation technique.

Electron wedges for radiation therapy

PURPOSE

Brain tumors can be advantageously treated with electron over photon radiation, by exploiting the rapid fall-off in dose with depth. This advantage could be further enhanced by utilizing multiple electron beams. However, in some beam configurations, wedged dose profiles would be necessary for the dose uniformity. Unlike photons, shaped pieces of material placed in electron beam severely degrade the energy, give additional scattering and, therefore, are suboptimal. The purpose of this study was to create wedged electron fields, using intensity modulation. The combination of electron wedges enables a more uniform coverage of brain tumors with a reduced dose to normal tissue.

METHODS AND MATERIALS

Intensity modulation was performed for 10 to 50 MeV electrons using a narrow scanning elementary beam of a racetrack Microtron accelerator, delivering radiation pulses with coordinates and intensities prescribed by a custom scan matrix. Dispensing more pulses (or longer pulses) within the field to increase the local dose, one can sharpen the penumbra at depth and generate wedged dose distributions of arbitrary angle as well as many other desired profiles. We modulated the electron beams, measured dose distributions using film in an anthropomorphic phantom, and compared the results with conventional techniques.

RESULTS

Intensity modulation of electron beams decreases the 50-90% penumbra at depth by 40% and increases the flatness by 80%. Wedged profiles at depth can be created for any angle up to about 70 degrees, depending on the beam energy. Multiple modulated electron beams give smaller 20-70% but larger 70-100% isodose regions than photon beams.

CONCLUSIONS

Electron beams can improve dose distributions in brain compared to the same number of photon beams, reducing the 20-70% isodoses region in normal tissue by 30%. Intensity modulation significantly improves the dose distribution from combined electron beams providing a sharper penumbra, better conformity, and reduced margin.

Radiotherapy of breast cancer after breast-conserving surgery: an improved technique using mixed electron-photon beams with a multileaf collimator

BACKGROUND AND PURPOSE

Loco-regional radiotherapy after breast cancer surgery significantly reduces the risk of recurrences. An increase of cardiac deaths for irradiated breast cancer patients has been reported in some studies, especially for women with tumours in the left breast. The aim of this study was to compare retrospectively the conventionally used technique using two opposed tangential photon beams with a modified technique using a combination of photon and electron beams to find an optimal technique with respect to dose homogeneity in the breast and surrounding regional lymph nodes and a minimal dose in the organs at risk.

MATERIALS AND METHODS

Thirty patients with stage II breast cancer who received different types of adjuvant systemic therapy were included in the investigation. Comparative dose planning of two techniques was performed, i.e. an isocentric technique with two photon beams with coplanar medial beam edges and a technique with one electron and three photon beams with a common isocentre for all beams aided by a multileaf collimator.

RESULTS

The mixed technique was selected for eight of 12 patients with left-sided breast cancers because of significantly lower doses to the heart. However, the decision-making was influenced by many factors such as dose coverage of the target volume combined with minimizing of the doses to the organs at risk and the contralateral breast.

CONCLUSION

The use of the mixed technique will optimize the loco-regional radiotherapy after breast-conserving surgery for many left-sided breast cancers.

Optimization of 3D conformal electron beam therapy in inhomogeneous media by concomitant fluence and energy modulation

The possibilities of using simultaneous fluence and energy modulation techniques in electron beam therapy to shape the dose distribution and almost eliminate the influences of tissue inhomogeneities have been investigated. By using a radiobiologically based optimization algorithm the radiobiological properties of the tissues can be taken into account when trying to find the best possible dose delivery. First water phantoms with differently shaped surfaces were used to study the effect of surface irregularities. We also studied water phantoms with internal inhomogeneities consisting of air or cortical bone. It was possible to improve substantially the dose distribution by fluence modulation in these cases. In addition to the fluence modulation the most suitable single electron energy in each case was also determined. Finally, the simultaneous use of several preselected electron beam energies was also tested, each with an individually optimized fluence profile. One to six electron energies were used, resulting in a slow improvement in complication-free cure with increasing number of beam energies. To apply these techniques to a more clinically relevant situation a post-operative breast cancer patient was studied. For simplicity this patient was treated with only one anterior beam portal to clearly illustrate the effect of inhomogeneities like bone and lung on the dose distribution. It is shown that by using fluence modulation the influence of dose inhomogeneities can be significantly reduced. When two or more electron beam energies with individually optimized fluence profiles are used the dose conformality to the internal target volume is further increased, particularly for targets with complex shapes.

Characteristics of scattered electron beams shaped with a multileaf collimator

Characteristics of dual-foil scattered electron beams shaped with a multileaf collimator (MLC) (instead of an applicator system) were studied. The electron beams, with energies between 10 and 25 MeV, were produced by a racetrack microtron using a dual-foil scattering system. For a range of field sizes, depth dose curves, profiles, penumbra width, angular spread in air, and effective and virtual source positions were compared. Measurements were made when the MLC alone provided collimation and when an applicator provided collimation. Identical penumbra widths were obtained at a source-to-surface distance of 85 cm for the MLC and 110 cm for the applicator. The MLC-shaped beams had characteristics similar to other machines which use trimmers or applicators to collimate scanned or scattered electron beams. Values of the effective source position and the angular spread parameter for the MLC beams were similar to those of the dual-foil scattered beams of the Varian Clinac 2100 CD and the scanned beams of the Sagittaire linear accelerators. A model, based on Fermi-Eyges multiple scattering theory, was adapted and applied successfully to predict penumbra width as a function of collimator-surface distance.

Exploration of new treatment modalities offered by high energy (up to 50 MeV) electrons and photons

BACKGROUND AND PURPOSE

A number of deep seated tumours are difficult to treat conformally with photon beams mainly due to the almost exponential dose decrease with depth.

MATERIALS AND METHODS

In order to improve the conformity of these treatments a number of useful characteristics of high energy (above 20 MeV) electron beams of the MM50 Racetrack Microtron have been systematically investigated and clinically applied.

RESULTS

A typical characteristic of electron beams with energies up to 20 MeV is the sharp dose fall-off with depth. At higher energies this effect is less pronounced but may be improved by adding a small fraction of photons with a matching dose gradient (wedge). With this technique, high energy electrons can be used close to sensitive organs down to 17 cm depth. Another physical characteristic of high energy electrons is the sharp penumbra at depths down to 4-5 cm and the possibility to use opposed electron beams in order to enhance the dose centrally or near the centre of a body. Skin sparing by delivering a part of the absorbed dose with photons through the same beam portal as the electrons has also been systematically studied. These characteristics of the high-energy electron beams have been utilised in the optimisation of some clinical treatments.

CONCLUSIONS

Electron beams in this high energy region give increased possibilities to achieve dose conformity. Enhanced conformity can be obtained especially if electrons and photons are combined to augment some specific characteristics of the electron beams.

Feasibility study of multileaf collimated electrons with a scattering foil based accelerator

BACKGROUND AND PURPOSE

There is an ever evolving process to improve the technical aspects of electron beam delivery. Both the foil/applicator and scanning electron beam systems have gone through recent upheavals. Concomitantly, multileaf collimators are now a staple method for collimating photons. We undertook a study of multileaf collimated electron beam (MLCEB) using a dual scattering foil system.

MATERIALS AND METHODS

We compared MLCEB with applicator collimated electron beams (AEB) by examining the dosimetric aspects of the two systems using 70 and 80 cm SSDs for the MLCEB, the minimum practical SSDs achievable. Percent depth dose, isodose profiles, output factors, leakage, surface dose, bremstrahlung, effective SSDs, etc. were measured using film and/or ion chamber. Clinical fields, such as posterior neck node (PNN), were compared. We also investigated the use of MLCEB for arc therapy using segments.

RESULTS

In all cases, the MLCEB performed inferior, as judged by isodoses, uniformity index (UI) and penumbra analysis. The 80 cm SSD (minimum for PNN), low energy, small fields, was the worst case. For a 6 MeV beam, the UI/penumbra was 0.823/10 mm for the AEB, and 0.561/29 mm for the MLCEB at 80 cm SSD. The PNN multileaf fields exhibited narrow 90% and 80% isodose lines, and wide 20% and 10% lines.

CONCLUSIONS

We conclude that multileaf for PNN fields could not be matched to adjacent off-cord photon fields. The "stair-stepping' effect associated with MLC photons was absent for electrons.

Matching of electron beams for conformal therapy of target volumes at moderate depths

The basic requirements for conformal electron therapy are an accelerator with a wide range of energies and field shapes. The beams should be well characterised in a full 3-D dose planning system which has been verified for the geometries of the current application. Differences in the basic design of treatment units have been shown to have a large influence on beam quality and dosimetry. Modern equipment can deliver electron beams of good quality with a high degree of accuracy. A race-track microtron with minimised electron scattering and a multi-leaf collimator (MLC) for electron collimating will facilitate the isocentric technique as a general treatment technique for electrons. This will improve the possibility of performing combined electron field techniques in order to conform the dose distribution with no or minimal use of a bolus. Furthermore, the isocentric technique will facilitate multiple field arrangements that decrease the problems with distortion of the dose distribution due to inhomogeneities, etc. These situations are demonstrated by clinical examples where isocentric, matched electron fields for treatment of the nose, thyroid and thoracic wall have been used.

Daily dosimetric quality control of the MM50 Racetrack Microtron using an electronic portal imaging device

The MM50 Racetrack Microtron, suited for advanced three-dimensional conformal radiotherapy techniques, is a complex machine in various respects. Therefore, for a number of gantry angles, daily quality control of the absolute output and fluence profiles of the scanned beams are mandatory. For the applied photon beams, a fast method for these daily checks, based on dosimetric measurements with the Philips SRI-100 Electronic Portal Imaging Device (EPID), has been developed and tested. Open beams are checked for four different gantry angles; for gantry angle 0, a wedged field is checked as well. Performing and analyzing the measurements takes about 10 min. The applied EPID has favourable characteristics for dosimetric quality control measurements: absolute output measurements reproduce within 0.5% (1 SD) and the reproducibility of relative (2D) beam profile measurements is 0.2% (1 SD). The day-to-day sensitivity stability over a period of one month is 0.6% (1 SD). Measured grey scale values are within 0.2% linear with the applied dose. The 2D fluence profile of the 25 MV photon beam of the MM50 is very stable in time: during a period of 5 months a maximum fluctuation of 2.2% has been observed. Once, a deviation in the cGy/MU-value of 6% was detected. There is no interlock in the MM50-system that would have prevented patient treatment with this strongly deviating output. Based on the results of this study and on clinical requirements regarding acceptability of deviations of beam characteristics, a protocol has been developed including action levels for additional investigations and, if necessary, adjustment of the beam characteristics.