Photon beam quality specification by narrow-beam transmission measurements

Current status and future perspective of flattening filter free photon beams

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Prediction of stopping-power ratios in flattening-filter free beams

PURPOSE

In recent years, there has been an increasing interest in flattening-filter free (FFF) beams. However, since the removal of the flattening filter will affect both the mean and the variance of the energy spectrum, current beam-quality specifiers may not be adequate for reference dosimetry in such beams. The purpose of this work was to investigate an alternative, more general beam-quality specifier.

METHODS

The beam-quality specifier used in this work was a combination of the kerma-weighted mean and the coefficient of variation of the linear attenuation coefficient in water. These parameters can in theory be determined from narrow-beam transmission measurements using a miniphantom "in-air," which is a measurement condition well suited also to small and nonstandard fields. The relation between the Spencer-Attix stopping-power ratios and this novel beam-quality specifier was described by a simple polynomial. For reference, the authors used Monte Carlo calculated spectra and stopping-power data for nine different beams, with and without flattening filter.

RESULTS

The polynomial coefficients were obtained by least-squares optimization. For all beams included in this investigation, the average of the differences between the predicted and the Monte Carlo calculated stopping-power ratios was 0.02 +/- 0.17% (1 SD) (including TomoTherapy and CyberKnife example beams).

CONCLUSIONS

An alternative dual-parameter beam-quality specifier was investigated. The evaluation suggests that it can be used successfully to predict stopping-power ratios in FFF as well as conventional beams, regardless of filtration.

Optimization of photon beam flatness for radiation therapy

In this work, we investigate the relation between lateral fluence/dose distributions and photon beam uniformity, possibly identifying ways to improve these characteristics. The calculations included treatment head scatter properties associated with three common types of linear accelerators in order to study their impact on the results. For 6 and 18 MV photon beams the lateral fluence distributions were optimized with respect to the resulting calculated flatness, as defined by the International Electrotechnical Commission (IEC), at 10 cm depth in six different field sizes. The limits proposed by IEC for maximum dose ratios ('horns') at the depth of dose maximum have also been accounted for in the optimization procedure. The conclusion was that typical head scatter variations among different types of linear accelerators have a very limited effect on the optimized results, which implies that the existing differences in measured off-axis dose distributions are related to non-equivalent optimization objectives. Finally, a comparison between the theoretically optimized lateral dose distributions and corresponding dose measurements for the three investigated accelerator types was performed. Although the measured data generally fall within the IEC requirements the optimized distributions show better results overall for the evaluated uniformity parameters, indicating that there is room for improved flatness performance in clinical photon beams.

Dose uncertainties in photon pencil kernel calculations at off-axis positions

The purpose of this study was to investigate the specific problems associated with photon dose calculations in points located at a distance from the central beam axis. These problems are related to laterally inhomogeneous energy fluence distributions and spectral variations causing a lateral shift in the beam quality, commonly referred to as off-axis softening (OAS). We have examined how the dose calculation accuracy is affected when enabling and disabling explicit modeling of these two effects. The calculations were performed using a pencil kernel dose calculation algorithm that facilitates modeling of OAS through laterally varying kernel properties. Together with a multi-source model that provides the lateral energy fluence distribution this generates the total dose output, i.e., the dose per monitor unit, at an arbitrary point of interest. The dose calculation accuracy was evaluated through comparisons with 264 measured output factors acquired at 5, 10, and 20 cm depth in four different megavoltage photon beams. The measurements were performed up to 18 cm from the central beam axis, inside square fields of varying size and position. The results show that calculations including explicit modeling of OAS were considerably more accurate, up to 4%, than those ignoring the lateral beam quality shift. The deviations caused by simplified head scatter modeling were smaller, but near the field edges additional errors close to 1% occurred. When enabling full physics modeling in the dose calculations the deviations display a mean value of -0.1%, a standard deviation of 0.7%, and a maximum deviation of -2.2%. Finally, the results were analyzed in order to quantify and model the inherent uncertainties that are present when leaving the central beam axis. The off-axis uncertainty component showed to increase with both off-axis distance and depth, reaching 1% (1 standard deviation) at 20 cm depth.

Modelling lateral beam quality variations in pencil kernel based photon dose calculations

Standard treatment machines for external radiotherapy are designed to yield flat dose distributions at a representative treatment depth. The common method to reach this goal is to use a flattening filter to decrease the fluence in the centre of the beam. A side effect of this filtering is that the average energy of the beam is generally lower at a distance from the central axis, a phenomenon commonly referred to as off-axis softening. The off-axis softening results in a relative change in beam quality that is almost independent of machine brand and model. Central axis dose calculations using pencil beam kernels show no drastic loss in accuracy when the off-axis beam quality variations are neglected. However, for dose calculated at off-axis positions the effect should be considered, otherwise errors of several per cent can be introduced. This work proposes a method to explicitly include the effect of off-axis softening in pencil kernel based photon dose calculations for arbitrary positions in a radiation field. Variations of pencil kernel values are modelled through a generic relation between half value layer (HVL) thickness and off-axis position for standard treatment machines. The pencil kernel integration for dose calculation is performed through sampling of energy fluence and beam quality in sectors of concentric circles around the calculation point. The method is fully based on generic data and therefore does not require any specific measurements for characterization of the off-axis softening effect, provided that the machine performance is in agreement with the assumed HVL variations. The model is verified versus profile measurements at different depths and through a model self-consistency check, using the dose calculation model to estimate HVL values at off-axis positions. A comparison between calculated and measured profiles at different depths showed a maximum relative error of 4% without explicit modelling of off-axis softening. The maximum relative error was reduced to 1% when the off-axis softening was accounted for in the calculations.

On beam quality and stopping power ratios for high-energy x-rays

The aim of this work is to quantitatively compare two commonly used beam quality indices, IPR(20/10) and %dd(10)x, with respect to their ability to predict stopping power ratios (water to air), s(w,air), for high-energy x-rays. In particular, effects due to a varied amount of filtration of the photon beam will be studied. A new method for characterizing beam quality is also presented, where the information we strive to obtain is the moments of the spectral distribution. We will show how the moments enter into a general description of the transmission curve and that it is possible to correlate the moments to s(w,air) with a unique and simple relationship. Comparisons with TPR(20/10) and %dd(10), show that the moments are well suited for beam quality specification in terms of choosing the correct s(w,air).

Transmission measurements in air using the ESTRO mini-phantom

The aim of this work is to study the possibility of using the ESTRO mini-phantom for transmission measurements of primary kerma in water at a point free in air. We discuss in-air measurements in general, with special attention given to in-air equivalent measurements using a water equivalent mini-phantom. The study includes four different photon energies (4, 6, 10 and 18 MV), where scoring of dose and primary kerma inside a mini-phantom in narrow beam geometry is performed with the Monte Carlo code EGS4. The results reveal that relative measurements (i.e. with and without a water absorber present) at 10 cm depth in a mini-phantom do not represent the variation of primary kerma in water at a point free in air (deviations as large as 7% at 4 MV are observed). Minimum deviations are obtained at depths somewhat larger than the depth of dose maximum. The observed deviations are due to a considerable beam hardening in the water absorber, which changes the amount of attenuation and scatter inside the mini-phantom.

Methods for beam data acquisition offered by a mini-phantom

Mini-phantoms are an important tool for measurement of basic head scatter parameters in high-energy photon beams, and recently they have also been used for beam quality specification. Therefore the feasibility and reliability of basic beam parameter acquisition using only a mini-phantom is checked in 6, 18 and 25 MV photon beams. These parameters include head scatter correction factors, phantom scatter correction factors, total scatter correction factors, wedge factors, off-axis ratios, as well as beam attenuation coefficients and beam hardening coefficients. In order to specify beam quality variations and beam quality modifications by a wedge, two different methods are compared: the first method uses a constant source to chamber distance of 1 m, the second method refers to narrow beam geometry. Mu values derived with two different beam quality specification methods show a systematic deviation. However, relative variations of the attenuation coefficient within the beam and the associated beam quality modifications observed with the two methods show good agreement in open and wedged beams. Phantom scatter correction factors are calculated from measured head scatter correction factors and total scatter correction factors as well as from attenuation coefficients. Measured and calculated phantom scatter correction factors agree within 1% with the values given in literature. For 18 and 25 MV photon beam, wedge factors measured in water or in the mini-phantom agree within 0.5%, but maximum deviations of approximately 1.5% are observed at 6 MV for the largest field sizes. It is demonstrated that the determination of several beam data related to full scatter conditions does not necessarily require the availability of a full scatter phantom. The mini-phantom is a reliable but very cheap and simple tool. It offers versatile possibilities to measure, check and verify basic beam parameters in high-energy photon beams.

A generic off-axis energy correction for linac photon beam dosimetry

Cooperative clinical trial group protocols frequently require off-axis point dose calculations. The Radiological Physics Center uses the calculative technique developed by Hanson et al. [Med. Phys. 7, 145-146 (1980); 7, 147-150 (1980)] to verify these calculations. In order to correct for off-axis energy changes, this technique requires off-axis half-value layer data, HVL, as a function of off-axis ray angle for the specific beam. This paper presents a formulism based on HVL mesurements on a limited number of therapy beams, which allows the calculation of an off-axis energy-correction factor for any clinical photon beam created by a linear accelerator using conventional flattening filters.

Relations between scatter factor, quality index and attenuation for x-ray beams

The relations between the attenuation factor, the normalized phantom scatter factor and the quality index are examined using a semiempirical formula for the dose on the central axis of an x-ray beam in water. The study is restricted to depths and field sizes sufficient for electron equilibrium. The results are compared with data in the recent literature. It is concluded that for x-ray beams in the energy range 4-25 MV the normalized scatter factors can be calculated from the dose-weighted average linear attenuation coefficient in water, determined from transmission measurements in a narrow-beam geometry or from the quality index.

Calculation of photon energy and dose distributions in a 50 MV scanned photon beam for different target configurations and scan patterns

A method to characterize the energy distribution in the whole photon field is valuable when designing an accelerator for choosing target and flattening filter or scan pattern. Another field of application is beam characterization for treatment planning systems or other dosimetric purposes. This work is focused on the energy distribution in different 50 MV bremsstrahlung beams with different scanning of electrons on three different targets. Fluence differential in energy and angle at the exit of each target has been determined by Monte Carlo calculations for a narrow beam. Data for broad beams were obtained by convolution of the narrow beams with different scan patterns. Photon energy fluence differential in energy at SSD 100 were thus found to be rather different for the targets studied. The results are presented as mean energy profiles and narrow beam half-value layer (HVL) in water. Two different experimental setups were used to measure HVL at the central axis and at off-axis positions. The two methods gave results which differ by 5%-6% and the calculated data where within these experimental results. In conclusion, the presented method for characterization of the photon field energy distribution is well within the experimental results and can thus be used to improve accelerator design or dosimetric calculations, e.g., for treatment planning.

Measurements of basic parameters in wedged high-energy photon beams using a mini-phantom

Basic dosimetric quantities necessary to specify wedged beans (beam quality, wedge factors, output ratios) are obtained by measurements performed in a narrow coaxial mini-phantom for 6, 18 and 15 MV photon beams. To express beam quality, an attenuation coefficient mu is derived from measurements in a mini-phantom at 20 and 10 cm depth. Wedge factors and output ratios are measured as a function of field size at 10 cm water-equivalent depth. In open beams one observes beam softening with increasing distance from the collimator axis for all energies. With an inserted wedge a beam hardening is observed at 6 MV. This beam hardening decreases at 18 MV while at 25 MV a slight beam softening is detected. Larger variations of output ratios with field sizes are observed with a wedge than without a wedge. An equivalent square formula for head-scatter factors can be used with a good accuracy for rectangular wedged fields. For irregular wedged fields a method is proposed to calculate the product of the output ratio and the wedge factor. Measurements and calculations agree within 1% for all irregular wedged fields checked.

Off-axis primary-dose measurements using a mini-phantom

The characterization of the incident photon beam is usually divided into its dependence on collimator setting (head-scatter factor) and off-axis position (primary off-axis ratio). These parameters are normally measured "in air" with a build-up cap thick enough to generate full dose build-up at the depth of dose maximum. In order to prevent any influence from contaminating electrons, it has been recommended that head-scatter measurements are carried out using a mini-phantom rather than a conventional build-up cap. Due to the volume of the mini-phantom, the effects from attenuation and scatter are not negligible. In relative head-scatter measurements these effects cancel and the head scatter is thus a good representation of the variation of the incident photon beam with collimator setting. However, in off-axis measurements, attenuation and scatter conditions vary due to beam softening and do not cancel in the calculation of the primary off-axis ratio. The purpose of the present work was to estimate the effects from attenuation and phantom scatter in order to determine their influence on primary off-axis ratio measurements. We have characterized the off-axis beam-softening effect by means of narrow-beam transmission measurements to obtain the effective attenuation coefficient as a function of off-axis position. We then used a semi-analytical expression for the phantom-scatter calculation that depends solely on this attenuation coefficient. The derived formalism for relative "in air" measurements using a mini-phantom is clear and consistent, which enables the user to separately calculate the effects from scatter and attenuation. For the investigated beam qualities, 6 and 18 MV, our results indicate that the effects from attenuation and scatter in the mini-phantom nearly cancel (the combined effect is less than 1%) within 12.5 cm from the central beam axis. Thus, no correction is needed when the primary off-axis ratio is measured with a mini-phantom.

The contribution of secondary heavy particles to the absorbed dose from high-energy photon beams

High-energy photon radiotherapy sources produce non-negligible numbers of secondary heavy particles (neutrons, protons and alphas) which contribute to the dose in a patient. They also present a radiation protection problem. The contribution of such particles to the absorbed dose in a tissue-like medium and to the equivalent dose is considered in this study experimentally. Track etch detectors were chosen as a basic type of measuring instrument: cellulose nitrate Kodak LR115 and polyallyldiglycol carbonate CR39 were used as detectors. Several methods of directly read datum (track density, track parameter, LET spectrum etc) interpretation have been analysed. It has been ascertained that the contribution of secondary heavy particles represents approximately 0.002 of the photon dose and 0.02 of the equivalent dose, both at 50 MeV as maximum photon energy. The contribution of a 20 MV bremsstrahlung beam is roughly one-fifth of that at 50 MV.

Theoretical and experimental determination of phantom scatter factors for photon fields with different radial energy variation

The output factor used for monitor unit determination in radiotherapy can be divided into two factors: the head scatter factor and the phantom scatter factor. Theoretical and experimental phantom scatter factors have been compared for different beam qualities between 4 MV and 50 MV and field sizes from 5 cm x 5 cm to 30 cm x 30 cm. The theoretical data were obtained through a convolution method based on Monte Carlo calculated energy spectra and dose kernels. The calculations have been performed both for accelerators with a rather large energy variation within the field and for accelerators with a constant energy distribution in the field. Deviations between theoretical and experimental data were found to be less than 1%.

Properties of liquid ionization chambers at LDR brachytherapy dose rates

Properties such as sensitivity, general recombination and reproducibility of liquid-filled parallel-plate ionization chambers for dosimetry in low-dose-rate brachytherapy radiation fields have been evaluated. Two different dielectric liquids, isooctane (C8H(1)8) and tetramethylsilane (Si(CH3)4), have been used as sensitive media in chambers having a coin-shaped sensitive volume of 3 mm in diameter and 1 mm thickness. An electric field strength of 300 kV m-1 was found to be optimal with respect to sensitivity, leakage current and general recombination. At absorbed dose rates from 0.1-100 mGy min-1 the ionization charge measurements at an irradiation time of 1 min showed a reproducibility better than 1%, and a general recombination not exceeding 0.5%. The calibration--absorbed dose to water against ionization charge at a 60Co reference source--did not show any significant change over an observation time of one year for any of the chambers.