Characterization of computer simulated radiotherapy beams for Monte-Carlo treatment planning

Monte Carlo methods for device simulations in radiation therapy

Monte Carlo (MC) simulations play an important role in radiotherapy, especially as a method to evaluate physical properties that are either impossible or difficult to measure. For example, MC simulations (MCSs) are used to aid in the design of radiotherapy devices or to understand their properties. The aim of this article is to review the MC method for device simulations in radiation therapy. After a brief history of the MC method and popular codes in medical physics, we review applications of the MC method to model treatment heads for neutral and charged particle radiation therapy as well as specific in-room devices for imaging and therapy purposes. We conclude by discussing the impact that MCSs had in this field and the role of MC in future device design.

An automated optimization strategy to design collimator geometry for small field radiation therapy systems

PURPOSE

To develop an automated optimization strategy to facilitate collimator design for small-field radiotherapy systems.

METHODS

We developed an objective function that links the dose profile characteristics (FWHM, penumbra, and central dose rate) and the treatment head geometric parameters (collimator thickness/radii, source-to-distal-collimator distance[SDC]) for small-field radiotherapy systems. We performed optimization using a downhill simplex algorithm. We applied this optimization strategy to a linac-based radiosurgery system to determine the optimal geometry of four pencil-beam collimators to produce 5, 10, 15, and 20mm diameter photon beams (from a 6.7MeV, 2.1mmFWHM electron beam). Two different optimizations were performed to prioritize minimum penumbra or maximum central dose rate for each beam size. We compared the optimized geometric parameters and dose distributions to an existing clinical system (CyberKnife).

RESULTS

When minimum penumbra was prioritized, using the same collimator thickness and SDC (40cm) as a CyberKnife system, the optimized collimator upstream and downstream radii agreed with the CyberKnife system within 3-14%, the optimized output factors agreed within 0-8%, and the optimized transverse and percentage depth dose profiles matched those of the CyberKnife with the penumbras agreeing within 2%. However, when maximum dose rate was prioritized, allowing both the collimator thickness and SDC to change, the central dose rate for larger collimator sizes (10, 15, 20mm) could be increased by about 1.5-2 times at the cost of 1.5-2 times larger penumbras. No further improvement in central dose rate for the 5mm beam size could be achieved.

CONCLUSIONS

We developed an automated optimization strategy to design the collimator geometry for small-field radiation therapy systems. Using this strategy, the penumbra-prioritized dose distribution and geometric parameters agree well with the CyberKnife system as an example, suggesting that this system was designed to prioritize sharp penumbra. This represents proof-of-principle that an automated optimization strategy may apply to more complex collimator designs with multiple optimization parameters.

Beam modeling and beam model commissioning for Monte Carlo dose calculation-based radiation therapy treatment planning: Report of AAPM Task Group 157

Dose calculation plays an important role in the accuracy of radiotherapy treatment planning and beam delivery. The Monte Carlo (MC) method is capable of achieving the highest accuracy in radiotherapy dose calculation and has been implemented in many commercial systems for radiotherapy treatment planning. The objective of this task group was to assist clinical physicists with the potentially complex task of acceptance testing and commissioning MC-based treatment planning systems (TPS) for photon and electron beam dose calculations. This report provides an overview on the general approach of clinical implementation and testing of MC-based TPS with a specific focus on models of clinical photon and electron beams. Different types of beam models are described including those that utilize MC simulation of the treatment head and those that rely on analytical methods and measurements. The trade-off between accuracy and efficiency in the various source-modeling approaches is discussed together with guidelines for acceptance testing of MC-based TPS from the clinical standpoint. Specific recommendations are given on methods and practical procedures to commission clinical beam models for MC-based TPS.

A fast jaw-tracking model for VMAT and IMRT Monte Carlo simulations

Modern radiotherapy techniques involve routine use of volumetric arc therapy (VMAT) and intensity modulated radiotherapy (IMRT) with jaw‐tracking – dynamic motion of the secondary collimators (jaws) in tandem with multi‐leaf collimators (MLCs). These modalities require accurate dose calculations for the purposes of treatment planning and dose verification. Monte Carlo (MC) methods for radiotherapy dose calculation are widely accepted as capable of achieving high accuracy. This paper presents an efficiency‐enhancement method for secondary collimator modeling, presented in the context of a tool for MC‐based dose second checks. The model constitutes an accuracy trade‐off in the source model for the sake of efficiency enhancement, but maintains the advantages of MC transport in patient heterogeneities. The secondary collimator model is called Flat‐Absorbing‐Jaw‐Tracking (FAJT). Transmission through and scatter from the secondary collimators is neglected, and jaws are modeled as perfectly absorbing planes. To couple the motion of secondary collimators with MLCs for jaw‐tracking, the FAJT model was built into the VCU‐MLC model. Gamma‐index analysis of the dose distributions from FAJT against the full BEAMnrc MC simulations showed over 99% pass rate for a range of open fields, two clinical IMRT, and one VMAT treatment plan, for 2%/2 mm criteria above 10%. Using FAJT, the simulation speed of the secondary collimators for open fields increased by a factor of 237, 1489, and 1395 for 4 × 4, 10 × 10, and 30 × 30 cm², respectively. In general, clinically oriented simulation times are reduced from “hours” to “minutes” on identical hardware. Results for nine representative clinical cases (seven with jaw‐tracking) are presented. The average 2%/2 mm γ‐test success rate above the 80% isodose was 96.8% when tested against the EPIDose electronic portal image‐based dose reconstruction method and 97.3% against the Eclipse analytical anisotropic algorithm.

CPU time optimization and precise adjustment of the Geant4 physics parameters for a VARIAN 2100 C/D gamma radiotherapy linear accelerator simulation using GAMOS

We have verified the GAMOS/Geant4 simulation model of a 6 MV VARIAN Clinac 2100 C/D linear accelerator by the procedure of adjusting the initial beam parameters to fit the percentage depth dose and cross-profile dose experimental data at different depths in a water phantom. Thanks to the use of a wide range of field sizes, from 2  ×  2 cm² to 40  ×  40 cm², a small phantom voxel size and high statistics, fine precision in the determination of the beam parameters has been achieved. This precision has allowed us to make a thorough study of the different physics models and parameters that Geant4 offers. The three Geant4 electromagnetic physics sets of models, i.e. Standard, Livermore and Penelope, have been compared to the experiment, testing the four different models of angular bremsstrahlung distributions as well as the three available multiple-scattering models, and optimizing the most relevant Geant4 electromagnetic physics parameters. Before the fitting, a comprehensive CPU time optimization has been done, using several of the Geant4 efficiency improvement techniques plus a few more developed in GAMOS.

A single-source photon source model of a linear accelerator for Monte Carlo dose calculation

PURPOSE

To introduce a new method of deriving a virtual source model (VSM) of a linear accelerator photon beam from a phase space file (PSF) for Monte Carlo (MC) dose calculation.

MATERIALS AND METHODS

A PSF of a 6 MV photon beam was generated by simulating the interactions of primary electrons with the relevant geometries of a Synergy linear accelerator (Elekta AB, Stockholm, Sweden) and recording the particles that reach a plane 16 cm downstream the electron source. Probability distribution functions (PDFs) for particle positions and energies were derived from the analysis of the PSF. These PDFs were implemented in the VSM using inverse transform sampling. To model particle directions, the phase space plane was divided into a regular square grid. Each element of the grid corresponds to an area of 1 mm2 in the phase space plane. The average direction cosines, Pearson correlation coefficient (PCC) between photon energies and their direction cosines, as well as the PCC between the direction cosines were calculated for each grid element. Weighted polynomial surfaces were then fitted to these 2D data. The weights are used to correct for heteroscedasticity across the phase space bins. The directions of the particles created by the VSM were calculated from these fitted functions. The VSM was validated against the PSF by comparing the doses calculated by the two methods for different square field sizes. The comparisons were performed with profile and gamma analyses.

RESULTS

The doses calculated with the PSF and VSM agree to within 3% /1 mm (>95% pixel pass rate) for the evaluated fields.

CONCLUSION

A new method of deriving a virtual photon source model of a linear accelerator from a PSF file for MC dose calculation was developed. Validation results show that the doses calculated with the VSM and the PSF agree to within 3% /1 mm.

A measurement-based generalized source model for Monte Carlo dose simulations of CT scans

The goal of this study is to develop a generalized source model for accurate Monte Carlo dose simulations of CT scans based solely on the measurement data without a priori knowledge of scanner specifications. The proposed generalized source model consists of an extended circular source located at x-ray target level with its energy spectrum, source distribution and fluence distribution derived from a set of measurement data conveniently available in the clinic. Specifically, the central axis percent depth dose (PDD) curves measured in water and the cone output factors measured in air were used to derive the energy spectrum and the source distribution respectively with a Levenberg-Marquardt algorithm. The in-air film measurement of fan-beam dose profiles at fixed gantry was back-projected to generate the fluence distribution of the source model. A benchmarked Monte Carlo user code was used to simulate the dose distributions in water with the developed source model as beam input. The feasibility and accuracy of the proposed source model was tested on a GE LightSpeed and a Philips Brilliance Big Bore multi-detector CT (MDCT) scanners available in our clinic. In general, the Monte Carlo simulations of the PDDs in water and dose profiles along lateral and longitudinal directions agreed with the measurements within 4%/1 mm for both CT scanners. The absolute dose comparison using two CTDI phantoms (16 cm and 32 cm in diameters) indicated a better than 5% agreement between the Monte Carlo-simulated and the ion chamber-measured doses at a variety of locations for the two scanners. Overall, this study demonstrated that a generalized source model can be constructed based only on a set of measurement data and used for accurate Monte Carlo dose simulations of patients' CT scans, which would facilitate patient-specific CT organ dose estimation and cancer risk management in the diagnostic and therapeutic radiology.

Energy Modulated Photon Radiotherapy: A Monte Carlo Feasibility Study

A novel treatment modality termed energy modulated photon radiotherapy (EMXRT) was investigated. The first step of EMXRT was to determine beam energy for each gantry angle/anatomy configuration from a pool of photon energy beams (2 to 10 MV) with a newly developed energy selector. An inverse planning system using gradient search algorithm was then employed to optimize photon beam intensity of various beam energies based on presimulated Monte Carlo pencil beam dose distributions in patient anatomy. Finally, 3D dose distributions in six patients of different tumor sites were simulated with Monte Carlo method and compared between EMXRT plans and clinical IMRT plans. Compared to current IMRT technique, the proposed EMXRT method could offer a better paradigm for the radiotherapy of lung cancers and pediatric brain tumors in terms of normal tissue sparing and integral dose. For prostate, head and neck, spine, and thyroid lesions, the EMXRT plans were generally comparable to the IMRT plans. Our feasibility study indicated that lower energy (<6 MV) photon beams could be considered in modern radiotherapy treatment planning to achieve a more personalized care for individual patient with dosimetric gains.

Intermediate Megavoltage Photon Beams for Improved Lung Cancer Treatments

The goal of this study is to evaluate the effects of intermediate megavoltage (3-MV) photon beams on SBRT lung cancer treatments. To start with, a 3-MV virtual beam was commissioned on a commercial treatment planning system based on Monte Carlo simulations. Three optimized plans (6-MV, 3-MV and dual energy of 3- and 6-MV) were generated for 31 lung cancer patients with identical beam configuration and optimization constraints for each patient. Dosimetric metrics were evaluated and compared among the three plans. Overall, planned dose conformity was comparable among three plans for all 31 patients. For 21 thin patients with average short effective path length (< 10 cm), the 3-MV plans showed better target coverage and homogeneity with dose spillage index R_50% = 4.68±0.83 and homogeneity index = 1.26±0.06, as compared to 4.95±1.01 and 1.31±0.08 in the 6-MV plans (p < 0.001). Correspondingly, the average/maximum reductions of lung volumes receiving 20 Gy (V_20Gy), 5 Gy (V_5Gy), and mean lung dose (MLD) were 7%/20%, 9%/30% and 5%/10%, respectively in the 3-MV plans (p < 0.05). The doses to 5% volumes of the cord, esophagus, trachea and heart were reduced by 9.0%, 10.6%, 11.4% and 7.4%, respectively (p < 0.05). For 10 thick patients, dual energy plans can bring dosimetric benefits with comparable target coverage, integral dose and reduced dose to the critical structures, as compared to the 6-MV plans. In conclusion, our study indicated that 3-MV photon beams have potential dosimetric benefits in treating lung tumors in terms of improved tumor coverage and reduced doses to the adjacent critical structures, in comparison to 6-MV photon beams. Intermediate megavoltage photon beams (< 6-MV) may be considered and added into current treatment approaches to reduce the adjacent normal tissue doses while maintaining sufficient tumor dose coverage in lung cancer radiotherapy.

An analytic linear accelerator source model for GPU-based Monte Carlo dose calculations

Recently, there has been a lot of research interest in developing fast Monte Carlo (MC) dose calculation methods on graphics processing unit (GPU) platforms. A good linear accelerator (linac) source model is critical for both accuracy and efficiency considerations. In principle, an analytical source model should be more preferred for GPU-based MC dose engines than a phase-space file-based model, in that data loading and CPU-GPU data transfer can be avoided. In this paper, we presented an analytical field-independent source model specifically developed for GPU-based MC dose calculations, associated with a GPU-friendly sampling scheme. A key concept called phase-space-ring (PSR) was proposed. Each PSR contained a group of particles that were of the same type, close in energy and reside in a narrow ring on the phase-space plane located just above the upper jaws. The model parameterized the probability densities of particle location, direction and energy for each primary photon PSR, scattered photon PSR and electron PSR. Models of one 2D Gaussian distribution or multiple Gaussian components were employed to represent the particle direction distributions of these PSRs. A method was developed to analyze a reference phase-space file and derive corresponding model parameters. To efficiently use our model in MC dose calculations on GPU, we proposed a GPU-friendly sampling strategy, which ensured that the particles sampled and transported simultaneously are of the same type and close in energy to alleviate GPU thread divergences. To test the accuracy of our model, dose distributions of a set of open fields in a water phantom were calculated using our source model and compared to those calculated using the reference phase-space files. For the high dose gradient regions, the average distance-to-agreement (DTA) was within 1 mm and the maximum DTA within 2 mm. For relatively low dose gradient regions, the root-mean-square (RMS) dose difference was within 1.1% and the maximum dose difference within 1.7%. The maximum relative difference of output factors was within 0.5%. Over 98.5% passing rate was achieved in 3D gamma-index tests with 2%/2 mm criteria in both an IMRT prostate patient case and a head-and-neck case. These results demonstrated the efficacy of our model in terms of accurately representing a reference phase-space file. We have also tested the efficiency gain of our source model over our previously developed phase-space-let file source model. The overall efficiency of dose calculation was found to be improved by ~1.3-2.2 times in water and patient cases using our analytical model.

A hybrid phase-space and histogram source model for GPU-based Monte Carlo radiotherapy dose calculation

In GPU-based Monte Carlo simulations for radiotherapy dose calculation, source modelling from a phase-space source can be an efficiency bottleneck. Previously, this has been addressed using phase-space-let (PSL) sources, which provided significant efficiency enhancement. We propose that additional speed-up can be achieved through the use of a hybrid primary photon point source model combined with a secondary PSL source. A novel phase-space derived and histogram-based implementation of this model has been integrated into gDPM v3.0. Additionally, a simple method for approximately deriving target photon source characteristics from a phase-space that does not contain inheritable particle history variables (LATCH) has been demonstrated to succeed in selecting over 99% of the true target photons with only ~0.3% contamination (for a Varian 21EX 18 MV machine). The hybrid source model was tested using an array of open fields for various Varian 21EX and TrueBeam energies, and all cases achieved greater than 97% chi-test agreement (the mean was 99%) above the 2% isodose with 1% / 1 mm criteria. The root mean square deviations (RMSDs) were less than 1%, with a mean of 0.5%, and the source generation time was 4-5 times faster. A seven-field intensity modulated radiation therapy patient treatment achieved 95% chi-test agreement above the 10% isodose with 1% / 1 mm criteria, 99.8% for 2% / 2 mm, a RMSD of 0.8%, and source generation speed-up factor of 2.5.

Automatic commissioning of a GPU-based Monte Carlo radiation dose calculation code for photon radiotherapy

Monte Carlo (MC) simulation is commonly considered as the most accurate method for radiation dose calculations. Commissioning of a beam model in the MC code against a clinical linear accelerator beam is of crucial importance for its clinical implementation. In this paper, we propose an automatic commissioning method for our GPU-based MC dose engine, gDPM. gDPM utilizes a beam model based on a concept of phase-space-let (PSL). A PSL contains a group of particles that are of the same type and close in space and energy. A set of generic PSLs was generated by splitting a reference phase-space file. Each PSL was associated with a weighting factor, and in dose calculations the particle carried a weight corresponding to the PSL where it was from. Dose for each PSL in water was pre-computed, and hence the dose in water for a whole beam under a given set of PSL weighting factors was the weighted sum of the PSL doses. At the commissioning stage, an optimization problem was solved to adjust the PSL weights in order to minimize the difference between the calculated dose and measured one. Symmetry and smoothness regularizations were utilized to uniquely determine the solution. An augmented Lagrangian method was employed to solve the optimization problem. To validate our method, a phase-space file of a Varian TrueBeam 6 MV beam was used to generate the PSLs for 6 MV beams. In a simulation study, we commissioned a Siemens 6 MV beam on which a set of field-dependent phase-space files was available. The dose data of this desired beam for different open fields and a small off-axis open field were obtained by calculating doses using these phase-space files. The 3D γ-index test passing rate within the regions with dose above 10% of dmax dose for those open fields tested was improved averagely from 70.56 to 99.36% for 2%/2 mm criteria and from 32.22 to 89.65% for 1%/1 mm criteria. We also tested our commissioning method on a six-field head-and-neck cancer IMRT plan. The passing rate of the γ-index test within the 10% isodose line of the prescription dose was improved from 92.73 to 99.70% and from 82.16 to 96.73% for 2%/2 mm and 1%/1 mm criteria, respectively. Real clinical data measured from Varian, Siemens, and Elekta linear accelerators were also used to validate our commissioning method and a similar level of accuracy was achieved.

Use of IAEA's phase-space files for the implementation of a clinical accelerator virtual source model

In the present work, phase-space data files (phsp) provided by the International Atomic Energy Agency (IAEA) for different accelerators were used in order to develop a Virtual Source Model (VSM) for clinical photon beams. Spectral energy distributions extracted from supplied phsp files were used to define the radiation pattern of a virtual extended source in a hybrid model which is completed with a virtual diaphragm used to simulate both electron contamination and the shape of the penumbra region. This simple virtual model was used as the radiation source for dosimetry calculations in a water phantom. The proposed model proved easy to build and test, and good agreement with clinical accelerators dosimetry measurements were obtained for different field sizes. Our results suggest this simple method could be useful for treatment planning systems (TPS) verification purposes.

A comprehensive procedure for characterizing arbitrary azimuthally symmetric photon beams

PURPOSE

A new Monte Carlo (MC) source model (SM) has been developed for azimuthally symmetric photon beams.

METHODS

The MC simulation tallied phase space file (PSF) is divided into two categories depending on the relationship of the particle track line to the beam central axis: multiple point source (MPS) and spatial mesh based surface source (SMBSS). To validate this SM, MCNPX2.6 was used to generate two PSFs for a 6 MV photon beam from a Varian 2100C/D linear accelerator.

RESULTS

PDDs and profiles were calculated using the SM and original PSF for different field sizes from 5 × 5 to 40 × 40 cm2. Agreement was within 2% of the maximum dose at 100 cm SSD and 2.5% of the maximum dose at 200 cm SSD for beam profiles at depths of 3.5 cm and 15 cm with respect to the original PSF. Differences between the source model and the PSF in the out-of-field regions were less than 0.5% of the profile maximum value at 100 cm SSD. Differences between measured and calculated points were less than 2% of the maximum dose or 2 mm distance to agreement (DTA) at 100 cm SSD.

CONCLUSIONS

This SM is unique in that it accounts for a higher level of energy dependence on the particle's direction and it is independent from accelerator components, unlike other published SMs. The model can be applied to any arbitrary azimuthally symmetric beam and has source biasing capabilities that significantly increase the simulation speed up to 3300 for certain field sizes.

GPU-based Monte Carlo radiotherapy dose calculation using phase-space sources

A novel phase-space source implementation has been designed for graphics processing unit (GPU)-based Monte Carlo dose calculation engines. Short of full simulation of the linac head, using a phase-space source is the most accurate method to model a clinical radiation beam in dose calculations. However, in GPU-based Monte Carlo dose calculations where the computation efficiency is very high, the time required to read and process a large phase-space file becomes comparable to the particle transport time. Moreover, due to the parallelized nature of GPU hardware, it is essential to simultaneously transport particles of the same type and similar energies but separated spatially to yield a high efficiency. We present three methods for phase-space implementation that have been integrated into the most recent version of the GPU-based Monte Carlo radiotherapy dose calculation package gDPM v3.0. The first method is to sequentially read particles from a patient-dependent phase-space and sort them on-the-fly based on particle type and energy. The second method supplements this with a simple secondary collimator model and fluence map implementation so that patient-independent phase-space sources can be used. Finally, as the third method (called the phase-space-let, or PSL, method) we introduce a novel source implementation utilizing pre-processed patient-independent phase-spaces that are sorted by particle type, energy and position. Position bins located outside a rectangular region of interest enclosing the treatment field are ignored, substantially decreasing simulation time with little effect on the final dose distribution. The three methods were validated in absolute dose against BEAMnrc/DOSXYZnrc and compared using gamma-index tests (2%/2 mm above the 10% isodose). It was found that the PSL method has the optimal balance between accuracy and efficiency and thus is used as the default method in gDPM v3.0. Using the PSL method, open fields of 4 × 4, 10 × 10 and 30 × 30 cm(2) in water resulted in gamma passing rates of 99.96%, 99.92% and 98.66%, respectively. Relative output factors agreed within 1%. An intensity modulated radiation therapy patient plan using the PSL method resulted in a passing rate of 97%, and was calculated in 50 s (per GPU) compared to 8.4 h (per CPU) for BEAMnrc/DOSXYZnrc.

Investigation of pulsed low dose rate radiotherapy using dynamic arc delivery techniques

There has been no consensus standard of care to treat recurrent cancer patients who have previously been irradiated. Pulsed low dose rate (PLDR) external beam radiotherapy has the potential to reduce normal tissue toxicities while still providing significant tumor control for recurrent cancers. This work investigates the dosimetry feasibility of PLDR treatment using dynamic arc delivery techniques. Five treatment sites were investigated in this study including breast, pancreas, prostate, head and neck, and lung. Dynamic arc plans were generated using the Varian Eclipse system and the RapidArc delivery technique with 6 and 10 MV photon beams. Each RapidArc plan consisted of two full arcs and the plan was delivered five times to achieve a daily dose of 200 cGy. The dosimetry requirement was to deliver approximately 20 cGy/arc with a 3 min interval to achieve an effective dose rate of 6.7 cGy min⁻¹. Monte Carlo simulations were performed to calculate the actual dose delivered to the planning target volume (PTV) per arc taking into account beam attenuation/scattering and intensity modulation. The maximum, minimum and mean doses to the PTV were analyzed together with the dose volume histograms and isodose distributions. The dose delivery for the five plans was validated using solid water phantoms inserted with an ionization chamber and film, and a cylindrical detector array. Two intensity-modulated arcs were used to efficiently deliver the PLDR plans that provided conformal dose distributions for treating complex recurrent cancers. For the five treatment sites, the mean PTV dose ranged from 18.9 to 22.6 cGy/arc. For breast, the minimum and maximum PTV dose was 8.3 and 35.2 cGy/arc, respectively. The PTV dose varied between 12.9 and 27.5 cGy/arc for pancreas, 12.6 and 28.3 cGy/arc for prostate, 12.1 and 30.4 cGy/arc for H&N, and 16.2 and 27.6 cGy/arc for lung. Advanced radiation therapy can provide superior target coverage and normal tissue sparing for PLDR reirradiation of recurrent cancers, which can be delivered using dynamic arc delivery techniques with ten full arcs and an effective dose rate of 6.7 ± 4.0 cGy min⁻¹.

Multiple-source models for electron beams of a medical linear accelerator using BEAMDP computer code

AIM

The aim of this work was to develop multiple-source models for electron beams of the NEPTUN 10PC medical linear accelerator using the BEAMDP computer code.

BACKGROUND

One of the most accurate techniques of radiotherapy dose calculation is the Monte Carlo (MC) simulation of radiation transport, which requires detailed information of the beam in the form of a phase-space file. The computing time required to simulate the beam data and obtain phase-space files from a clinical accelerator is significant. Calculation of dose distributions using multiple-source models is an alternative method to phase-space data as direct input to the dose calculation system.

MATERIALS AND METHODS

Monte Carlo simulation of accelerator head was done in which a record was kept of the particle phase-space regarding the details of the particle history. Multiple-source models were built from the phase-space files of Monte Carlo simulations. These simplified beam models were used to generate Monte Carlo dose calculations and to compare those calculations with phase-space data for electron beams.

RESULTS

Comparison of the measured and calculated dose distributions using the phase-space files and multiple-source models for three electron beam energies showed that the measured and calculated values match well each other throughout the curves.

CONCLUSION

It was found that dose distributions calculated using both the multiple-source models and the phase-space data agree within 1.3%, demonstrating that the models can be used for dosimetry research purposes and dose calculations in radiotherapy.

Ant colony algorithm implementation in electron and photon Monte Carlo transport: application to the commissioning of radiosurgery photon beams

PURPOSE

In this work, the authors describe an approach which has been developed to drive the application of different variance-reduction techniques to the Monte Carlo simulation of photon and electron transport in clinical accelerators.

METHODS

The new approach considers the following techniques: Russian roulette, splitting, a modified version of the directional bremsstrahlung splitting, and the azimuthal particle redistribution. Their application is controlled by an ant colony algorithm based on an importance map.

RESULTS

The procedure has been applied to radiosurgery beams. Specifically, the authors have calculated depth-dose profiles, off-axis ratios, and output factors, quantities usually considered in the commissioning of these beams. The agreement between Monte Carlo results and the corresponding measurements is within approximately 3%/0.3 mm for the central axis percentage depth dose and the dose profiles. The importance map generated in the calculation can be used to discuss simulation details in the different parts of the geometry in a simple way. The simulation CPU times are comparable to those needed within other approaches common in this field.

CONCLUSIONS

The new approach is competitive with those previously used in this kind of problems (PSF generation or source models) and has some practical advantages that make it to be a good tool to simulate the radiation transport in problems where the quantities of interest are difficult to obtain because of low statistics.

Monte Carlo source model for photon beam radiotherapy: photon source characteristics

A major barrier to widespread clinical implementation of Monte Carlo dose calculation is the difficulty in characterizing the radiation source within a generalized source model. This work aims to develop a generalized three-component source model (target, primary collimator, flattening filter) for 6- and 18-MV photon beams that match full phase-space data (PSD). Subsource by subsource comparison of dose distributions, using either source PSD or the source model as input, allows accurate source characterization and has the potential to ease the commissioning procedure, since it is possible to obtain information about which subsource needs to be tuned. This source model is unique in that, compared to previous source models, it retains additional correlations among PS variables, which improves accuracy at nonstandard source-to-surface distances (SSDs). In our study, three-dimensional (3D) dose calculations were performed for SSDs ranging from 50 to 200 cm and for field sizes from 1 x 1 to 30 x 30 cm2 as well as a 10 x 10 cm2 field 5 cm off axis in each direction. The 3D dose distributions, using either full PSD or the source model as input, were compared in terms of dose-difference and distance-to-agreement. With this model, over 99% of the voxels agreed within +/-1% or 1 mm for the target, within 2% or 2 mm for the primary collimator, and within +/-2.5% or 2 mm for the flattening filter in all cases studied. For the dose distributions, 99% of the dose voxels agreed within 1% or 1 mm when the combined source model-including a charged particle source and the full PSD as input-was used. The accurate and general characterization of each photon source and knowledge of the subsource dose distributions should facilitate source model commissioning procedures by allowing scaling the histogram distributions representing the subsources to be tuned.

Photon-beam subsource sensitivity to the initial electron-beam parameters

One limitation to the widespread implementation of Monte Carlo (MC) patient dose-calculation algorithms for radiotherapy is the lack of a general and accurate source model of the accelerator radiation source. Our aim in this work is to investigate the sensitivity of the photon-beam subsource distributions in a MC source model (with target, primary collimator, and flattening filter photon subsources and an electron subsource) for 6- and 18-MV photon beams when the energy and radial distributions of initial electrons striking a linac target change. For this purpose, phase-space data (PSD) was calculated for various mean electron energies striking the target, various normally distributed electron energy spread, and various normally distributed electron radial intensity distributions. All PSD was analyzed in terms of energy, fluence, and energy fluence distributions, which were compared between the different parameter sets. The energy spread was found to have a negligible influence on the subsource distributions. The mean energy and radial intensity significantly changed the target subsource distribution shapes and intensities. For the primary collimator and flattening filter subsources, the distribution shapes of the fluence and energy fluence changed little for different mean electron energies striking the target, however, their relative intensity compared with the target subsource change, which can be accounted for by a scaling factor. This study indicates that adjustments to MC source models can likely be limited to adjusting the target subsource in conjunction with scaling the relative intensity and energy spectrum of the primary collimator, flattening filter, and electron subsources when the energy and radial distributions of the initial electron-beam change.

Modelling of electron contamination in clinical photon beams for Monte Carlo dose calculation

The purpose of this work is to model electron contamination in clinical photon beams and to commission the source model using measured data for Monte Carlo treatment planning. In this work, a planar source is used to represent the contaminant electrons at a plane above the upper jaws. The source size depends on the dimensions of the field size at the isocentre. The energy spectra of the contaminant electrons are predetermined using Monte Carlo simulations for photon beams from different clinical accelerators. A 'random creep' method is employed to derive the weight of the electron contamination source by matching Monte Carlo calculated monoenergetic photon and electron percent depth-dose (PDD) curves with measured PDD curves. We have integrated this electron contamination source into a previously developed multiple source model and validated the model for photon beams from Siemens PRIMUS accelerators. The EGS4 based Monte Carlo user code BEAM and MCSIM were used for linac head sinulation and dose calculation. The Monte Carlo calculated dose distributions were compared with measured data. Our results showed good agreement (less than 2% or 2 mm) for 6, 10 and 18 MV photon beams.

Optimization of combined electron and photon beams for breast cancer

Recently, intensity-modulated radiation therapy and modulated electron radiotherapy have gathered a growing interest for the treatment of breast and head and neck tumours. In this work, we carried out a study to combine electron and photon beams to achieve differential dose distributions for multiple target volumes simultaneously. A Monte Carlo based treatment planning system was investigated, which consists of a set of software tools to perform accurate dose calculation, treatment optimization, leaf sequencing and plan analysis. We compared breast treatment plans generated using this home-grown optimization and dose calculation software for different treatment techniques. Five different planning techniques have been developed for this study based on a standard photon beam whole breast treatment and an electron beam tumour bed cone down. Technique 1 includes two 6 MV tangential wedged photon beams followed by an anterior boost electron field. Technique 2 includes two 6 MV tangential intensity-modulated photon beams and the same boost electron field. Technique 3 optimizes two intensity-modulated photon beams based on a boost electron field. Technique 4 optimizes two intensity-modulated photon beams and the weight of the boost electron field. Technique 5 combines two intensity-modulated photon beams with an intensity-modulated electron field. Our results show that technique 2 can reduce hot spots both in the breast and the tumour bed compared to technique 1 (dose inhomogeneity is reduced from 34% to 28% for the target). Techniques 3, 4 and 5 can deliver a more homogeneous dose distribution to the target (with dose inhomogeneities for the target of 22%, 20% and 9%, respectively). In many cases techniques 3, 4 and 5 can reduce the dose to the lung and heart. It is concluded that combined photon and electron beam therapy may be advantageous for treating breast cancer compared to conventional treatment techniques using tangential wedged photon beams followed by a boost electron field.

Modelling 6 MV photon beams of a stereotactic radiosurgery system for Monte Carlo treatment planning

The goal of this work is to build a multiple source model to represent the 6 MV photon beams from a Cyberknife stereotactic radiosurgery system for Monte Carlo treatment planning dose calculations. To achieve this goal, the 6 MV photon beams have been characterized and modelled using the EGS4/BEAM Monte Carlo system. A dual source model has been used to reconstruct the particle phase space at a plane immediately above the secondary collimator. The proposed model consists of two circular planar sources for the primary photons and the scattered photons, respectively. The dose contribution of the contaminant electrons was found to be in the order of 10(-3) of the total maximum dose and therefore has been omitted in the source model. Various comparisons have been made to verify the dual source model against the full phase space simulated using the EGS4/BEAM system. The agreement in percent depth dose (PDD) curves and dose profiles between the phase space and the source model was generally within 2%/1 mm for various collimators (5 to 60 mm in diameter) at 80 to 100 cm source-to-surface distances (SSD). Excellent agreement (within 1%/1 mm) was also found between the dose distributions in heterogeneous lung and bone geometry calculated using the original phase space and those calculated using the source model. These results demonstrated the accuracy of the dual source model for Monte Carlo treatment planning dose calculations for the Cyberknife system.

Monte Carlo modelling of external radiotherapy photon beams

An essential requirement for successful radiation therapy is that the discrepancies between dose distributions calculated at the treatment planning stage and those delivered to the patient are minimized. An important component in the treatment planning process is the accurate calculation of dose distributions. The most accurate way to do this is by Monte Carlo calculation of particle transport, first in the geometry of the external or internal source followed by tracking the transport and energy deposition in the tissues of interest. Additionally, Monte Carlo simulations allow one to investigate the influence of source components on beams of a particular type and their contaminant particles. Since the mid 1990s, there has been an enormous increase in Monte Carlo studies dealing specifically with the subject of the present review, i.e., external photon beam Monte Carlo calculations, aided by the advent of new codes and fast computers. The foundations for this work were laid from the late 1970s until the early 1990s. In this paper we will review the progress made in this field over the last 25 years. The review will be focused mainly on Monte Carlo modelling of linear accelerator treatment heads but sections will also be devoted to kilovoltage x-ray units and 60Co teletherapy sources.

A comparative dosimetric study on tangential photon beams, intensity-modulated radiation therapy (IMRT) and modulated electron radiotherapy (MERT) for breast cancer treatment

Recently, energy- and intensity-modulated electron radiotherapy (MERT) has garnered a growing interest for the treatment of superficial targets. In this work. we carried out a comparative dosimetry study to evaluate MERT, photon beam intensity-modulated radiation therapy (IMRT) and conventional tangential photon beams for the treatment of breast cancer. A Monte Carlo based treatment planning system has been investigated, which consists of a set of software tools to perform accurate dose calculation, treatment optimization, leaf sequencing and plan analysis. We have compared breast treatment plans generated using this home-grown treatment optimization and dose calculation software forthese treatment techniques. The MERT plans were planned with up to two gantry angles and four nominal energies (6, 9, 12 and 16 MeV). The tangential photon treatment plans were planned with 6 MV wedged photon beams. The IMRT plans were planned using both multiple-gantry 6 MV photon beams or two 6 MV tangential beams. Our results show that tangential IMRT can reduce the dose to the lung, heart and contralateral breast compared to conventional tangential wedged beams (up to 50% reduction in high dose volume or 5 Gy in the maximum dose). MERT can reduce the maximum dose to the lung by up to 20 Gy and to the heart by up to 35 Gy compared to conventional tangential wedged beams. Multiple beam angle IMRT can significantly reduce the maximum dose to the lung and heart (up to 20 Gy) but it induces low and medium doses to a large volume of normal tissues including lung, heart and contralateral breast. It is concluded that MERT has superior capabilities to achieve dose conformity both laterally and in the depth direction, which will be well suited for treating superficial targets such as breast cancer.

A quality assurance phantom for IMRT dose verification

This paper investigates a quality assurance (QA) phantom specially designed to verify the accuracy of dose distributions and monitor units (MU) calculated by clinical treatment planning optimization systems and by the Monte Carlo method for intensity-modulated radiotherapy (IMRT). The QA phantom is a PMMA cylinder of 30 cm diameter and 40 cm length with various bone and lung inserts. A procedure (and formalism) has been developed to measure the absolute dose to water in the PMMA phantom. Another cylindrical phantom of the same dimensions, but made of water, was used to confirm the results obtained with the PMMA phantom. The PMMA phantom was irradiated by 4, 6 and 15 MV photon beams and the dose was measured using an ionization chamber and compared to the results calculated by a commercial inverse planning system (CORVUS, NOMOS, Sewickley, PA) and by the Monte Carlo method. The results show that the dose distributions calculated by both CORVUS and Monte Carlo agreed to within 2% of dose maximum with measured results in the uniform PMMA phantom for both open and intensity-modulated fields. Similar agreement was obtained between Monte Carlo calculations and measured results with the bone and lung heterogeneity inside the PMMA phantom while the CORVUS results were 4% different. The QA phantom has been integrated as a routine QA procedure for the patient's IMRT dose verification at Stanford since 1999.

Monte Carlo simulation for MLC-based intensity-modulated radiotherapy

This article describes photon beam Monte Carlo simulation for multi leaf collimator (MLC)-based intensity-modulated radiotherapy (IMRT). We present the general aspects of the Monte Carlo method for the non-Monte Carloist with an emphasis given to patient-specific radiotherapy application. Patient-specific application of the Monte Carlo method can be used for IMRT dose verification, inverse planning, and forward planning in conventional conformal radiotherapy. Because it is difficult to measure IMRT dose distributions in heterogeneous phantoms that approximate a patient, Monte Carlo methods can be used to verify IMRT dose distributions that are calculated using conventional methods. Furthermore, using Monte Carlo as the dose calculation method for inverse planning results in better-optimized treatment plans. We describe both aspects and present our recent results to illustrate the discussion. Finally, we present current issues related to clinical implementation of Monte Carlo dose calculation. Monte Carlo is the most recent, and most accurate, method of radiotherapy dose calculation. It is currently in the process of being implemented by various treatment planning vendors and will be available for clinical use in the immediate future.

A Monte Carlo dose calculation tool for radiotherapy treatment planning

A Monte Carlo user code, MCDOSE, has been developed for radiotherapy treatment planning (RTP) dose calculations. MCDOSE is designed as a dose calculation module suitable for adaptation to host RTP systems. MCDOSE can be used for both conventional photon/electron beam calculation and intensity modulated radiotherapy (IMRT) treatment planning. MCDOSE uses a multiple-source model to reconstruct the treatment beam phase space. Based on Monte Carlo simulated or measured beam data acquired during commissioning, source-model parameters are adjusted through an automated procedure. Beam modifiers such as jaws, physical and dynamic wedges, compensators, blocks, electron cut-outs and bolus are simulated by MCDOSE together with a 3D rectilinear patient geometry model built from CT data. Dose distributions calculated using MCDOSE agreed well with those calculated by the EGS4/DOSXYZ code using different beam set-ups and beam modifiers. Heterogeneity correction factors for layered-lung or layered-bone phantoms as calculated by both codes were consistent with measured data to within 1%. The effect of energy cut-offs for particle transport was investigated. Variance reduction techniques were implemented in MCDOSE to achieve a speedup factor of 10-30 compared to DOSXYZ.

The MLC tongue-and-groove effect on IMRT dose distributions

We have investigated the tongue-and-groove effect on the IMRT dose distributions for a Varian MLC. We have compared the dose distributions calculated using the intensity maps with and without the tongue-and-groove effect. Our results showed that, for one intensity-modulated treatment field, the maximum tongue-and-groove effect could be up to 10% of the maximum dose in the dose distributions. For an IMRT treatment with multiple gantry angles (> or = 5), the difference between the dose distributions with and without the tongue-and-groove effect was hardly visible, less than 1.6% for the two typical clinical cases studied. After considering the patient setup errors, the dose distributions were smoothed with reduced and insignificant differences between plans with and without the tongue-and-groove effect. Therefore, for a multiple-field IMRT plan (> or = 5), the tongue-and-groove effect on the IMRT dose distributions will be generally clinically insignificant due to the smearing effect of individual fields. The tongue-and-groove effect on an IMRT plan with small number of fields (< 5) will vary depending on the number of fields in a plan (coplanar or non-coplanar), the MLC leaf sequences and the patient setup uncertainty, and may be significant (> 5% of maximum dose) in some cases, especially when the patient setup uncertainty is small (< or = 2 mm).

Comparison of RTP dose distributions in heterogeneous phantoms with the BEAM Monte Carlo simulation system

Therapeutic treatment plan evaluation is often based on examining the radiotherapy treatment planning (RTP) system dose distributions in the target and surrounding normal structures. To study the effects of tissue inhomogeneities on photon dose distributions, we compared FOCUS RTP system dose distributions from the measurement-based Clarkson and model-based MultiGrid Superposition (MGS) algorithms with those from the BEAM Monte Carlo code system in a set of heterogeneous phantoms. The phantom inhomogeneities mimic relevant clinical treatment sites, which include lung slab, lung-bone slab, bone-lung slab, mediastinum, and tumor geometries. The benchmark comparisons were performed in lung densities of 0.20 and 0.31 g/cm3, and a bone density of 2.40 g/cm3 for 5x5 cm2 and 10x10 cm2, 6- and 15-MV photon beams. Benchmark comparison results show that the MGS model and BEAM doses match better than 3% or 3 mm, and the MGS model is more accurate than the Clarkson model in all phantoms. The MGS model, unlike the Clarkson model, predicts the build-down and build-up of dose near tissue interfaces and penumbra broadening in lung associated with high energy beams. The Clarkson model overestimates the dose in lung by a maximum of 10% compared to BEAM. Dose comparisons suggest turning-off the effective path length inhomogeneity correction in the Clarkson model for lung treatments.

Validation of a Monte Carlo dose calculation tool for radiotherapy treatment planning

A new EGS4/PRESTA Monte Carlo user code, MCDOSE, has been developed as a routine dose calculation tool for radiotherapy treatment planning. It is suitable for both conventional and intensity modulated radiation therapy. Two important features of MCDOSE are the inclusion of beam modifiers in the patient simulation and the implementation of several variance reduction techniques. Before this tool can be used reliably for clinical dose calculation, it must be properly validated. The validation for beam modifiers has been performed by comparing the dose distributions calculated by MCDOSE and the well-benchmarked EGS4 user codes BEAM and DOSXYZ. Various beam modifiers were simulated. Good agreement in the dose distributions was observed. The differences in electron cutout factors between the results of MCDOSE and measurements were within 2%. The accuracy of MCDOSE with various variance reduction techniques was tested by comparing the dose distributions in different inhomogeneous phantoms with those calculated by DOSXYZ without variance reduction. The agreement was within 1.0%. Our results demonstrate that MCDOSE is accurate and efficient for routine dose calculation in radiotherapy treatment planning, with or without beam modifiers.

Monte Carlo verification of IMRT dose distributions from a commercial treatment planning optimization system

The purpose of this work was to use Monte Carlo simulations to verify the accuracy of the dose distributions from a commercial treatment planning optimization system (Corvus, Nomos Corp., Sewickley, PA) for intensity-modulated radiotherapy (IMRT). A Monte Carlo treatment planning system has been implemented clinically to improve and verify the accuracy of radiotherapy dose calculations. Further modifications to the system were made to compute the dose in a patient for multiple fixed-gantry IMRT fields. The dose distributions in the experimental phantoms and in the patients were calculated and used to verify the optimized treatment plans generated by the Corvus system. The Monte Carlo calculated IMRT dose distributions agreed with the measurements to within 2% of the maximum dose for all the beam energies and field sizes for both the homogeneous and heterogeneous phantoms. The dose distributions predicted by the Corvus system, which employs a finite-size pencil beam (FSPB) algorithm, agreed with the Monte Carlo simulations and measurements to within 4% in a cylindrical water phantom with various hypothetical target shapes. Discrepancies of more than 5% (relative to the prescribed target dose) in the target region and over 20% in the critical structures were found in some IMRT patient calculations. The FSPB algorithm as implemented in the Corvus system is adequate for homogeneous phantoms (such as prostate) but may result in significant under or over-estimation of the dose in some cases involving heterogeneities such as the air-tissue, lung-tissue and tissue-bone interfaces.

Electron spectra derived from depth dose distributions

The technique of extracting electron energy spectra from measured distributions of dose along the central axis of clinical electron beams is explored in detail. Clinical spectra measured with this simple spectroscopy tool are shown to be sufficient in accuracy and resolution for use in Monte Carlo treatment planning. A set of monoenergetic depth dose curves of appropriate energy spacing, precalculated with Monte Carlo for a simple beam model, are unfolded from the measured depth dose curve. The beam model is comprised of a point electron and photon source placed in vacuum with a source-to-surface distance of 100 cm. Systematic error introduced by this model affects the calculated depth dose curve by no more than 2%/2 mm. The component of the dose due to treatment head bremsstrahlung, subtracted prior to unfolding, is estimated from the thin-target Schiff spectrum within 0.3% of the maximum total dose (from electrons and photons) on the beam axis. Optimal unfolding parameters are chosen, based on physical principles. Unfolding is done with the public-domain code FERDO. Comparisons were made to previously published spectra measured with magnetic spectroscopy and to spectra we calculated with Monte Carlo treatment head simulation. The approach gives smooth spectra with an average resolution for the 27 beams studied of 16+/-3% of the mean peak energy. The mean peak energy of the magnetic spectrometer spectra was calculated within 2% for the AECL T20 scanning beam accelerators, 3% for the Philips SL25 scattering foil based machine. The number of low energy electrons in Monte Carlo spectra is estimated by unfolding with an accuracy of 2%, relative to the total number of electrons in the beam. Central axis depth dose curves calculated from unfolded spectra are within 0.5%/0.5 mm of measured and simulated depth dose curves, except near the practical range, where 1%/1 mm errors are evident.

Photon beam characterization and modelling for Monte Carlo treatment planning

Photon beams of 4, 6 and 15 MV from Varian Clinac 2100C and 2300C/D accelerators were simulated using the EGS4/BEAM code system. The accelerators were modelled as a combination of component modules (CMs) consisting of a target, primary collimator, exit window, flattening filter, monitor chamber, secondary collimator, ring collimator, photon jaws and protection window. A full phase space file was scored directly above the upper photon jaws and analysed using beam data processing software, BEAMDP, to derive the beam characteristics, such as planar fluence, angular distribution, energy spectrum and the fractional contributions of each individual CM. A multiple-source model has been further developed to reconstruct the original phase space. Separate sources were created with accurate source intensity, energy, fluence and angular distributions for the target, primary collimator and flattening filter. Good agreement (within 2%) between the Monte Carlo calculations with the source model and those with the original phase space was achieved in the dose distributions for field sizes of 4 cm x 4 cm to 40 cm x 40 cm at source surface distances (SSDs) of 80-120 cm. The dose distributions in lung and bone heterogeneous phantoms have also been found to be in good agreement (within 2%) for 4, 6 and 15 MV photon beams for various field sizes between the Monte Carlo calculations with the source model and those with the original phase space.

Electron beam modeling and commissioning for Monte Carlo treatment planning

A hybrid approach for commissioning electron beam Monte Carlo treatment planning systems has been studied. The approach is based on the assumption that accelerators of the same type have very similar electron beam characteristics and the major difference comes from the on-site tuning of the electron incident energy at the exit window. For one type of accelerator, a reference machine can be selected and simulated with the Monte Carlo method. A multiple source model can be built on the full Monte Carlo simulation of the reference beam. When commissioning electron beams from other accelerators of the same type, the energy spectra in the source model are tuned to match the measured dose distributions. A Varian Clinac 2100C accelerator was chosen as the reference machine and a four-source beam model was established based on the Monte Carlo simulations. This simplified beam model can be used to generate Monte Carlo dose distributions accurately (within 2%/2 mm compared to those calculated with full phase space data) for electron beams from the reference machine with various nominal energies, applicator sizes, and SSDs. Three electron beams were commissioned by adjusting the energy spectra in the source model. The dose distributions calculated with the adjusted source model were compared with the dose distributions calculated using the phase space data for these beams. The agreement is within 1% in most of cases and 2% in all situations. This preliminary study has shown the capability of the commissioning approach for handling large variation in the electron incident energy. The possibility of making the approach more versatile is also discussed.

Monte Carlo modelling of electron beams from medical accelerators

Monte Carlo simulation of radiation transport is considered to be one of the most accurate methods of radiation therapy dose calculation. With the rapid development of computer technology, Monte Carlo based treatment planning for radiation therapy is becoming practical. A basic requirement for Monte Carlo treatment planning is a detailed knowledge of the radiation beams from medical accelerators. A practical approach to obtain the above is to perform Monte Carlo simulation of radiation transport in the medical accelerator. Additionally, Monte Carlo modelling of the treatment machine head can also improve our understanding of clinical beam characteristics, help accelerator design and improve the accuracy of clinical dosimetry by providing more realistic beam data. This paper summarizes work over the past two decades on Monte Carlo simulation of clinical electron beams from medical accelerators.

Clinical implementation of a Monte Carlo treatment planning system

The purpose of this study was to implement the Monte Carlo method for clinical radiotherapy dose calculations. We used the EGS4/BEAM code to obtain the phase-space data for 6-20 MeV electron beams and 4, 6, and 15 MV photon beams for Varian Clinac 1800, 2100C, and 2300CD accelerators. A multiple-source model was used to reconstruct the phase-space data for both electron and photon beams, which retained the accuracy of the Monte Carlo beam data. The multiple-source model reduced the phase-space data storage requirement by a factor of 1000 and the accelerator simulation time by a factor of 10 or more. Agreement within 2% was achieved between the Monte Carlo calculations and measurements of the dose distributions in homogeneous and heterogeneous phantoms for various field sizes, source-surface distances, and beam modulations. The Monte Carlo calculated electron output factors were within 2% of the measured values for various treatment fields while the heterogeneity correction factors for various lung and bone phantoms were within 1% for photon beams and within 2% for electron beams. The EGS4/DOSXYZ Monte Carlo code was used for phantom and patient dose calculations. The results were compared to the dose distributions produced by a conventional treatment planning system and an intensity-modulated radiotherapy inverse-planning system. Significant differences (>5% in dose and >5 mm shift in isodose lines) were found between Monte Carlo calculations and the analytical calculations implemented in the commercial systems. Treatment sites showing the largest dose differences were for head and neck, lung, and breast cases.