Monte Carlo study of backscatter in a flattening filter free clinical accelerator

Commissioning and quality assurance of HalcyonTM 2.0 linear accelerator

BACKGROUND

Varian Medical Systems has introduced a new medical linear accelerator called HalcyonTM 2.0, which is based on the ring delivery system (RDS). It is a true IGRT machine having 6MV FFF photon energy. In addition to the planar and MV-CBCT imaging techniques it also has an option of ultra-fast kV-iCBCT which enhances the image reconstruction and improves the visualization of soft tissue. The field portals are shaped by a unique dual layer MLC with special stacked and staggered design which enables high modulation with low radiation leakage. Recently, we have commissioned our first Halcyon 2.0 machine. The aim of this work was to systematically investigate various parameters of a newly installed HalcyonTM 2.0 linear accelerator.

MATERIALS AND METHODS

Detailed measurements were conducted as per various guidelines. Also, the measurements were performed to fulfil the national regulatory requirements. Commissioning data of Halcyon 6 MV-FFF beam was performed in a water tank. For absolute measurements, a 0.6-cc waterproof Farmer chamber and electrometer were used. All relative measurements (PDDs, in-line, cross-line and angular profiles) were performed with 0.0125 cc point chamber.

RESULTS

All the tests were within the acceptable limit. Measured data were compared with factory data as well as the existing medical linear accelerator of the same category. The obtained results were quite satisfactory.

CONCLUSIONS

This study summarizes the commissioning experience with Halcyon linear accelerator. Evaluation of mechanical, radiation safety and dosimetric parameters were performed. The obtained parameters were well below the specified tolerance limits.

Beam flatness modulation for a flattening filter free photon beam utilizing a novel direct leaf trajectory optimization model

Flattening filter free (FFF) linear accelerators produce a fluence distribution that is forward peaked. Various dosimetric benefits, such as increased dose rate, reduced leakage and out of field dose has led to the growth of FFF technology in the clinic. The literature has suggested the idea of vendors offering dedicated FFF units where the flattening filter (FF) is removed completely and manipulating the beam to deliver conventional flat radiotherapy treatments. This work aims to develop an effective way to deliver modulated flat beam treatments, rather than utilizing a physical FF. This novel optimization model is an extension of the direct leaf trajectory optimization (DLTO) previously developed for volumetric modulated radiation therapy (VMAT) and is capable of accounting for all machine and multileaf collimator (MLC) dynamic delivery constraints, using a combination of linear constraints and a convex objective function. Furthermore, the tongue and groove (T&G) effect was also incorporated directly into our model without introducing nonlinearity to the constraints, nor nonconvexity to the objective function. The overall beam flatness, machine deliverability, and treatment time efficiency were assessed. Regular square fields, including field sizes of 10 × 10 cm² to 40 × 40 cm² were analyzed, as well as three clinical fields, and three arbitrary contours with "concave" features. Quantitative flatness was measured for all modulated FFF fields, and the results were comparable or better than their open FF counterparts, with the majority having a quantitative flatness of less than 3.0%. The modulated FFF beams, due to the included efficiency constraint, were able to achieve acceptable delivery time compared to their open FF counterpart. The results indicated that the dose uniformity and flatness for the modulated FFF beams optimized with the DLTO model can successfully match the uniformity and flatness of their conventional FF counterparts, and may even provide further benefit by taking advantage of the unique FFF beam characteristics.

Feasibility study of using flattening-filter-free photon beams to deliver conventional flat beams

Various dosimetric benefits such as increased dose rate, and reduced leakage and out of field dose have led to the growth of flattening-filter-free (FFF) technology in the clinic. In this study, we concentrate on investigating the feasibility of using FFF beams to deliver conventional flat beams, since completely getting rid of the flattening-filter module from the gantry head can not only simplify the gantry design but also decrease the workload on machine maintenance and quality assurance. Two intensity modulated radiotherapy techniques, step-and-shoot (S&S) and sliding window (SW), were used to generate flat beam profiles for 6 regular-shaped beams and 3 clinical beams while operating in FFF mode. The inverse plans were generated based on uniform dose optimization. Degree of flatness, MU efficiency, and beam delivery time for both methods were assessed. S&S technique is able to achieve a degree of flatness less than 2.5% for most field configurations. While SW technique was able to generate relatively flat beams for field sizes less than 18 × 18 cm². For all field configurations, S&S beams resulted in a longer delivery time compared to reference flat beams and SW beams. For field sizes less than 18 × 18 cm², SW modulated FFF beams resulted in a faster delivery time compared to reference flat beams. The ability to deliver conventional flat beams is not absent when operating in FFF mode. Utilizing beam modulation, FFF mode can achieve reasonable flat profiles and comparable efficiency to conventional flat beams. The ability to deliver most clinical treatments from the same treatment unit will allow for less quality assurance as well as maintenance, and completely eliminate the need for the flattening filter on modern linacs.

The effect of beam shape on physical parameters of head and neck simultaneous-integrated boost intensity-modulated radiation therapy

Aim

To evaluate the influence of the beam shape created by X-rays with "flat beams" and without "flattening-filter-free [FFF] beams" a flattening filter, and the isocenter locations for FFF beams on the treatment of a large irradiated volume for tumours.

Background

The increase of dose rate and the decrease of out-of-field dose can be expected for FFF beams and lead to effective and safety radiotherapy. On the other hand, the bell-shaped dose profile is thought to be a factor of negating these advantages.

Materials and methods

Treatment plans for 15 patients with head and neck cancer were created using XiO (Elekta, Stockholm AB, Sweden) in fixed-gantry step-and-shoot delivery under the same dose constraints. Seven fields of FFF beams with 7 MV and flat beams with 6 MV were used with the technique of intensity-modulated radiation therapy (IMRT). We compared the dose homogeneity and conformity of targets and dose constraints for organs as the plan quality and evaluated physical parameters: monitor unit (MU) values, number of segments and their locations from the isocenter in beam's-eye-view.

Results

No significant differences were found in the plan quality. The isocenter locations do not affect the physical parameters for FFF beams. It has been confirmed that the number of segments and MU values were 40% higher with FFF beams than with flat beams (p < 0.05).

Conclusion

This study demonstrates flat dose distribution is more suitable for IMRT with large and complex targets.

Photon dose at the maze entrance door: The comparison of flattening filter and flattening filter free working modes

In recent years, field flattening free accelerators have been introduced in therapy practice. One of the objective of these measurements was to establish if the maze door, designed for accelerators operating with flattening filter can provide adequate shielding in field flattening free mode of operation. Linac installed in this standard one band maze vault is equipped to operate at 6 MV with field flattening filter and in field flattening free mode of operation. Series of measurements of the photon dose at the maze door (with different jaws openings and gantry positions) were performed in both operation modes with and without water canister to mimic standard therapy conditions. In this paper results of photon dose measurements, performed at the maze door of the therapy linear accelerator vault are presented in order to compare photon dose in flattening filter and flattening filter free operation modes. It was obtained that in field flattening free mode of operation, the dose at the maze door is always lower than the dose measured in standard mode of operation with the field flattening filter. In the case when FFF therapy practice should start in some existing therapy vault, no additional shielding measures need to be added at the existing maze door.

Beam Characterization of 10-MV Photon Beam from Medical Linear Accelerator without Flattening Filter

Aim:

This work investigated the dosimetric properties of a 10-MV photon beam emitted from a medical linear accelerator (linac) with no flattening filter (FF). The aim of this study is to analyze the radiation fluence and energy emitted from the flattening filter free (FFF) linac using Monte Carlo (MC) simulations.

Materials and Methods:

The FFF linac was created by removing the FF from a linac in clinical use. Measurements of the depth dose (DD) and the off-axis profile were performed using a three-dimensional water phantom with an ionization chamber. A MC simulation for a 10-MV photon beam from this FFF linac was performed using the BEAMnrc code.

Results:

The off-axis profiles for the FFF linac exhibited a chevron-like distribution, and the dose outside the irradiation field was found to be lower for the FFF linac than for a linac with an FF (FF linac). The DD curves for the FFF linac included many contaminant electrons in the build-up region.

Conclusion:

Therefore, for clinical use, a metal filter is additionally required to reduce the effects of the electron contamination. The mean energy of the FFF linac was found to be lower than that of the FF linac owing to the absence of beam hardening caused by the FF.

Treatment of breast cancer with simultaneous integrated boost in hybrid plan technique : Influence of flattening filter-free beams

OBJECTIVE

The present study compares in silico treatment plans using hybrid plan technique during hypofractionated radiation of mammary carcinoma with simultaneous integrated boost (SIB). The influence of 6 MV photon radiation in flattening filter free (FFF) mode against the clinical standard flattening filter (FF) mode is to be examined.

PATIENTS AND METHODS

RT planning took place with FF and FFF radiation plans for 10 left-sided breast cancer patients. Hybrid plans were realised with two tangential IMRT fields and one VMAT field. The dose prescription was in line with the guidelines in the ARO-2010-01 study. The dosimetric verification took place with a manufacturer-independent measurement system.

RESULTS

Required dose prescriptions for the planning target volumes (PTV) were achieved for both groups. The average dose values of the ipsi- and contralateral lung and the heart did not differ significantly. The overall average incidental dose to the left anterior descending artery (LAD) of 8.24 ± 3.9 Gy in the FFF group and 9.05 ± 3.7 Gy in the FF group (p < 0.05) were found. The dosimetric verifications corresponded to the clinical requirements. FFF-based RT plans reduced the average treatment time by 17 s/fraction.

CONCLUSION

In comparison to the FF-based hybrid plan technique the FFF mode allows further reduction of the average LAD dose for comparable target volume coverage without adverse low-dose exposure of contralateral structures. The combination of hybrid plan technique and 6 MV photon radiation in the FFF mode is suitable for use with hypofractionated dose schemes. The increased dose rate allows a substantial reduction of treatment time and thus beneficial application of the deep inspiration breath hold technique.

Measurement and comparison of head scatter factor for 7 MV unflattened (FFF) and 6 MV flattened photon beam using indigenously designed columnar mini phantom

AIM

To measure and compare the head scatter factor for 7 MV unflattened and 6 MV flattened photon beam using a home-made designed mini phantom.

BACKGROUND

The head scatter factor (Sc) is one of the important parameters for MU calculation. There are multiple factors that influence the Sc values, like accelerator head, flattening filter, primary and secondary collimators.

MATERIALS AND METHODS

A columnar mini phantom was designed as recommended by AAPM Task Group 74 with high and low atomic number material for measurement of head scatter factors at 10 cm and d max dose water equivalent thickness.

RESULTS

The Sc values measured with high-Z are higher than the low-Z mini phantoms observed for both 6MV-FB and 7MV-UFB photon energies. Sc values of 7MV-UFB photon beams were smaller than those of the 6MV-FB photon beams (0.6-2.2% (Primus), 0.2-1.4% (Artiste) and 0.6-3.7% (Clinac iX (2300CD))) for field sizes ranging from 10 cm × 10 cm to 40 cm × 40 cm. The SSD had no influence on head scatter for both flattened and unflattened beams. The presence of wedge filters influences the Sc values. The collimator exchange effects showed that the opening of the upper jaw increases Sc irrespective of FF and FFF.

CONCLUSIONS

There were significant differences in Sc values measured for 6MV-FB and unflattened 7MV-UFB photon beams over the range of field sizes from 10 cm × 10 cm to 40 cm × 04 cm. Different results were obtained for measurements performed with low-Z and high-Z mini phantoms.

Comparison of Head Scatter Factor for 6MV and 10MV flattened (FB) and Unflattened (FFF) Photon Beam using indigenously Designed Columnar Mini Phantom

To measure and compare the head scatter factor for flattened (FB) and unflattened (FFF) of 6MV and 10MV photon beam using indigenously designed mini phantom. A columnar mini phantom was designed as recommended by AAPM Task Group 74 with low and high atomic number materials at 10 cm (mini phantom) and at approximately twice the depth of maximum dose water equivalent thickness (brass build-up cap). Scatter in the accelerator (Sc) values of 6MV-FFF photon beams are lesser than that of the 6MV-FB photon beams (0.66-2.8%; Clinac iX, 2300CD) and (0.47-1.74%; True beam) for field sizes ranging from 10 × 10 cm² to 40 × 40 cm². Sc values of 10MV-FFF photon beams are lesser (0.61-2.19%; True beam) than that of the 10MV-FB photons beams for field sizes ranging from 10 × 10 cm² to 40 × 40 cm². The SSD had no influence on head scatter for both flattened and unflattened beams and irrespective of head design of the different linear accelerators. The presence of field shaping device influences the Sc values. The collimator exchange effect reveals that the opening of the upper jaw increases Sc irrespective of FB or FFF photon beams and different linear accelerators, and it is less significant in FFF beams. Sc values of 6MV-FB square field were in good agreement with that of AAPM, TG-74 published data for Varian (Clinac iX, 2300CD) accelerator. Our results confirm that the removal of flattening filter decreases in the head scatter factor compared to flattened beam. This could reduce the out-of-field dose in advanced treatment delivery techniques.

An analytical formalism to calculate phantom scatter factors for flattening filter free (FFF) mode photon beams

Phantom Scatter Factors, Sp in the Khan formalism (Khan et al 1980 J. Radiat. Oncol. Biol. Phys. 6 745-51) describe medium-induced changes in photon-beam intensity as a function of size of the beam. According to the British Journal of Radiology, Supplement 25, megavoltage phantom scatter factors are invariant as a function of photon-beam energy. However, during the commissioning of an accelerator with flattening filter free (FFF) photon beams (Varian TrueBeam(TM) 6-MV FFF and 10-MV FFF), differences were noted in phantom scatter between the filtered beams and FFF-mode beams. The purpose of this work was to evaluate this difference and provide an analytical formalism to explain the phantom scatter differences between FFF-mode and the filtered mode. An analytical formalism was devised to demonstrate the source of phantom scatter differences between the filtered and the FFF-mode beams. The reason for the differences in the phantom scatter factors between the filtered and the FFF-mode beams is hypothesized to be the non-uniform beam profiles of the FFF-mode beams. The analytical formalism proposed here is based on this idea, taking the product of the filtered phantom scatter factors and the ratio of the off-axis ratio between the FFF-mode and the filtered beams. All measurements were performed using a Varian TrueBeam(TM) linear accelerator with photon energies of 6-MV and 10-MV in both filtered and FFF-modes. For all measurements, a PTW Farmer type chamber and a Scanditronix CC04 cylindrical ionization were used. The in-water measurements were made at depth dose maximum and 100 cm source-to-axis distance. The in-air measurements were done at 100 cm source-to-axis distance with appropriate build-up cap. From these measurements, the phantom scatter factors were derived for the filtered beams and the FFF-mode beams for both energies to be evaluated against the phantoms scatter factors calculated using the proposed algorithm. For 6-MV, the difference between the measured and the calculated FFF-mode phantom scatter factors ranged from -0.34% to 0.73%. The average per cent difference was -0.17% (1σ = 0.25%). For 10-MV, the difference ranged from -0.19% to 0.24%. The average per cent difference was -0.17% (1σ = 0.13%). An analytical formalism was presented to calculate the phantom scatter factors for FFF-mode beams using filtered phantom scatter factors as a basis. The overall differences between measurements and calculations were within ± 0.5% for 6-MV and ± 0.25% for 10-MV.

Commissioning and validation of BrainLAB cones for 6X FFF and 10X FFF beams on a Varian TrueBeam STx

Small field dosimetry is a challenging task. The difficulties of small field measurements, particularly stereotactic field size measurements, are highlighted by the large interinstitution variability that can be observed for circular cone collimator commissioning measurements. We believe the best way to improve the consistency of small field measurements is to clearly document and share the results of small field measurements. In this work we report on the commissioning and validation of a BrainLAB cone system for 6 MV and 10 MV flattening filter‐free (FFF) beams on a Varian TrueBeam STx. Commissioning measurements consisted of output factors, percent depth dose, and off‐axis factor measurements with a diode. Validation measurements were made in a polystyrene slab phantom at depths of 5 cm, 10 cm, and 15 cm using radiochromic film. Output factors for the 6xFFF cones are 0.689, 0. 790, 0.830, 0.871, 0.890, and 0.901 for 4 mm, 6 mm, 7.5 mm, 10 mm, 12.5 mm, and the 15 mm cones, respectively. Output factors for the 10xFFF cones are 0.566, 0. 699, 0.756, 0.826, 0.864, and 0.888 for 4 mm, 6 mm, 7.5 mm, 10 mm, 12.5 mm, and the 15 mm cones, respectively. The full width half maximum values of the off‐axis factors agreed with the nominal cone size to within 0.5 mm. Validation measurements showed an agreement of absolute dose between calculation and plan of ≤ 3.6%, and an agreement of field sizes of ≤ 0.3 mm in all cases. Radiochromic film validation measurements show reasonable agreement with beam models for circular collimators based on diode commissioning measurements.

PACS numbers: 87.53.Ly, 87.53.Bn, 87.56.nk, 87.55.D‐, 87.55.km

Monte Carlo investigation into feasibility and dosimetry of flat flattening filter free beams

Flattening filter free (FFF) beams due to their non-uniformity, are sub-optimal for larger field sizes. The purpose of this study was to investigate the incident electron beam distributions that would produce flat FFF (F4) beams without the use of a flattening filter (FF). Monte Carlo (MC) simulations with BEAMnrc and DOSXYZnrc codes have been performed to evaluate feasibility of this approach. The dose distributions in water for open 6 MV beams were simulated using the Varian 21EX linac head model, which will be called the FF model. The FF was then removed from the FF model, and MC simulations were performed using (1) 6 MeV electrons incident on the target and (2) a 6 MeV electron beam with electron angular distributions optimized to provide as flat dose profiles as possible. Configuration (1) represents FFF beam while configuration (2) allowed producing a F4 beam. Optimizations have also been performed to produce flattest profiles for a set of dose rates (DRs) in the range from 1.25 to 2.4 of the DR of FF beam. Profiles and percentage depth doses (PDDs) from 6 MV F4 beams have been calculated and compared to those from the FF beam. Calculated profiles demonstrated improved flatness of the FFF beams. In fact, up to field sizes within the circle of 35 cm diameter the flatness of F4 beam at dmax was better or comparable to that of FF beam. At 20 cm off-axis the dose increased from 52% for FFF to 92% for F4 beam. Also, profiles of F4 beams did not change considerably with depth. PDDs from F4 beams were similar to those of the FFF beam. The DR for the largest modeled (44 cm diameter) F4 beam was higher than the DR from FF beam by a factor of 1.25. It was shown that the DR can be increased while maintaining beam flatness, but at the cost of reduced field size.

Equivalent-quality unflattened photon beam modeling, planning, and delivery

The clinical application of the flattening filter‐free photon beam (FFF) has enjoyed greater use due to its advantage of reduced treatment time because of the increased dose rate. Its unique beam characteristics, along with the very high‐dose rate, require a thorough knowledge of the capability and accuracy in FFF beam modeling, planning, and delivery. This work verifies the feasibility of modeling an equivalent quality unflattened photon beam (eqUF), and the dosimetric accuracy in eqUF beam planning and delivery. An eqUF beam with a beam quality equivalent to a conventional 6 MV photon beam with the filter in place (WF) was modeled for the Pinnacle³ TPS and the beam model quality was evaluated by gamma index test. Results showed that the eqUF beam modeling was similar to that of the WF beam, as the overall passing rate of the 2%/2mm gamma index test was 99.5% in the eqUF beam model and 96% in the WF beam model. Hypofractionated IMRT plans were then generated with the same constraints using both WF and eqUF beams, and the similarity was evaluated by DVH comparison and generalized 3D gamma index test. The WF and eqUF plans showed no clinically significant differences in DVH comparison and, on average >98% voxels passed the 3%/3mm 3D gamma index test. Dosimetric accuracy in gated phantom delivery was verified by ion chamber and film measurements. All ion chamber measurements at the isocenter were within 1% of calculated values and film measurements passed the 3mm/3% gamma index test with an overall passing rate >95% in the high‐dose and low‐gradient region in both WF and eqUF cases. Treatment plan quality assurance (QA), using either measurement‐based or independent calculation‐based methods of ten clinically treated eqUF IMRT plans were analyzed. In both methods, the point dose differences were all within 2% difference. In the relative 2D dose distribution comparison, >95% points were within 3% dose difference or 3 mm DTA.

PACS number: 87.55.kh

Beam quality and dose perturbation of 6 MV flattening-filter-free linac

The aim of this study is twofold: (a) determination of the spectral differences for flattening-filter-free (FFF) versus standard (STD) linac under various clinical conditions, (b) based on an extensive list of clinically important beam configurations, identification of clinical scenarios that lead to higher macroscopic dose perturbations due to the presence of high-Z material. The focus is on dose enhancement due to contrast agents including high-Z elements such as gold or gadolinium. EGSnrc was used to simulate clinical beams under various irradiation conditions: open/IMRT/spit-IMRT fields, in/out-off-field areas, different depths and field sizes. Spectra were calculated and analyzed for about 80 beams and for a total of 480 regions. Quantitative differential effects in beam quality were characterized using energy-dependent and cumulative dose perturbation metrics. Analysis of the spectral database showed that even though the general trends for both linacs (FFF/STD) were the same, there were crucial differences. In general, the relative changes between different conditions were smaller for FFF spectra. This was because of the higher component of low-energy photons of the FFF linac, which already lead to higher dose enhancement than for the STD linac (photon energies were more "uniformly" distributed for FFF spectra and henceforth their perturbation resulted in lesser relative changes). For out-of-field FFF spectra and split-IMRT fields the strongest enhancement were observed (∼25 and ∼5 respectively). Different spectral scenarios lead to different dose enhancements, however, they scale with the higher effective-Z of the materials and were directly related to the lower range of the spectra (<200 keV).

Definition of parameters for quality assurance of flattening filter free (FFF) photon beams in radiation therapy

PURPOSE

Flattening filter free (FFF) beams generated by medical linear accelerators have recently started to be used in radiotherapy clinical practice. Such beams present fundamental differences with respect to the standard filter flattened (FF) beams, making the generally used dosimetric parameters and definitions not always viable. The present study will propose possible definitions and suggestions for some dosimetric parameters for use in quality assurance of FFF beams generated by medical linacs in radiotherapy.

METHODS

The main characteristics of the photon beams have been analyzed using specific data generated by a Varian TrueBeam linac having both FFF and FF beams of 6 and 10 MV energy, respectively.

RESULTS

Definitions for dose profile parameters are suggested starting from the renormalization of the FFF with respect to the corresponding FF beam. From this point the flatness concept has been translated into one of "unflatness" and other definitions have been proposed, maintaining a strict parallelism between FFF and FF parameter concepts.

CONCLUSIONS

Ideas for quality controls used in establishing a quality assurance program when introducing FFF beams into the clinical environment are given here, keeping them similar to those used for standard FF beams. By following the suggestions in this report, the authors foresee that the introduction of FFF beams into a clinical radiotherapy environment will be as safe and well controlled as standard beam modalities using the existing guidelines.

Beam properties and stability of a flattening-filter free 7 MV beam-an overview

PURPOSE

Several works have recently focused on flattening-filter-free (FFF) beams of linear accelerators of various companies (in particular, Varian and Elekta), but no overview as yet exists for the flattening-filter free 7XU beam (Siemens Artiste).

METHODS

Dosimetric properties of the 7XU beam were measured in May and September 2011. We present depth dose curves and beam profiles, output factors, and MLC transmission and assess the stability of the measurements. The 7XU beam was commissioned in the Pinnacle[superscript three] treatment planning system (TPS), and modeling results including the spectrum are presented.

RESULTS

The percent depth dose curve of the 7XU beam is similar to the flat 6X beam line, with a slightly smaller surface dose. The beam profiles show the characteristic shape of flattening-filter free beams, with deviations between measurements of generally less than 1%. The output factors of the 7XU beam decrease more slowly than for the 6X beam. The MLC transmission is comparable but slightly less for the 7XU beam. The 7XU beam can be adequately modeled by the Pinnacle[superscript three] TPS, with successful dosimetric verification. The spectrum of the 7XU beam has lower photon fluence up to approximately 2.5 MeV and higher fluence beyond, with a slightly higher mean energy.

CONCLUSIONS

The 7XU beam has been commissioned for clinical use after successful modeling, stability checks, and dosimetric verification.

Dosimetric properties of a beam quality-matched 6 MV unflattened photon beam

The purpose of this study was to report the characteristics of an equivalent quality unflattened (eqUF) photon beam in clinical implementation and to provide a generalized method to describe unflattened (UF) photon beam profiles. An unflattened photon beam with a beam quality equivalent to the corresponding flat 6 MV photon beam (WF) was obtained by removing the flattening filter from a Siemens ONCOR Avant‐Garde linear accelerator and adjusting the photon energy. A method independent from the WF beam profile was presented to describe UF beam profiles and other selected beam characteristics were examined. The short‐term beam stability was examined by dynamic beam profiles, recorded every 0.072 s in static and gated delivery, and the long‐term stability was evidenced by the five‐year clinical quality assurance records. The dose rate was raised fivefold using the eqUF beam. The depth of maximum dose (dmax) shifted 3 mm deeper, but the percent depth dose beyond dmax was very similar to that of the WF beam. The surface dose and out‐of‐field dose were lower, but the penumbra was slightly wider. The variation in head scatter and phantom scatter with changes in field size was smaller; the variation in the profile shape with change in depth was also smaller. The eqUF beam is stable 0.072 s after the beam is turned on, and the five‐year beam stability was comparable to that of the WF beam. A fivefold dose rate increase was observed in the eqUF beam with similar beam characteristics to other reported UF beam data except for a deeper dmax and a slightly wider penumbra. The initial and long‐term stability of the eqUF beam profile is on parity with the WF beam. The UF beam profile can be described in the generalized method independently without relying on the WF beam profile.

PACS number: 87.55.de

A modification of flattening filter free linac for IMRT

PURPOSE

This study investigates the benefits of a modified flattening filter free (FFF) linac over the standard (STD) linac equipped with the flattening filter. Energy and angular spread of the electron beam of the FFF linac were modified. Modification of FFF beam parameters is explored to maximize the monitor unit efficiency and to minimize the head scatter in IMRT delivery for large target volumes or targets lying away from the central axis.

METHODS

The EGSnrc code is used to model FFF and STD linacs and study basic beam properties for both linac types in various beam configurations. Increasing energy of FFF linac results in similar beam attenuation properties and maximized dose rate compared to STD linac. Matching beam attenuation properties allows a more direct exploration of beam flatness of FFF linac in regard to IMRT delivery, especially away from the central axis where the effective dose rate is considerably smaller than the one at the central axis. Flatness of open beam dose profile of FFF linac is improved by increasing the angular spread of the electron beam. The resulting dose rate within the treatment field and outside of the field (peripheral dose) are characterized and compared to the unmodified FFF and STD linacs,

RESULTS

In order to match beam penetration properties, the energy of FFF is adjusted from 6.5 to 8.0 MeV for small to medium field sizes and from 6.5 to 8.5 MeV for larger ones. Dose rate of FFF vs STD linac increased by a factor of 1.9 (6.5 MeV) and 3.4-4.1 (8.0-8.5 MeV). Adjusting the mean angular spread of the electron beam from 0 degrees to 5 degrees-10 degrees resulted in complete flattening of photon beam for field sizes between 10 x 10 cm2 and 15 x 15 cm2 and partial flattening for field sizes from 15 x 15 cm2 to 30 x 30 cm2. Values of angular spread > or =14 degrees are not recommended as they exceed the opening of the primary collimator, affecting the area at the edges of the field. FFF fields of sizes smaller than 6 x 6 cm2 are already flat and beam flattening is not necessary. Overall, the angular spread of 5 degrees-10 degrees is sufficient and can satisfactorily flatten open beam dose profiles even for larger field sizes. Increasing the electron beam angular spread amounts to a slight decrease of dose rate of FFF linac. However, for angular spread, 5 degrees-10 degrees dose rate factor of FFF vs STD is still about 1.6-2.6, depending on the field size (and the adjusted energy). Similarly, in case of peripheral dose, a moderate increase in dose can be observed for angular spread of 5 degrees-10 degrees and for field sizes 10 x 10 cm2 to 30 x 30 cm2. Lastly, beam flatness of not modified FFF linac can be conveniently described by an analytical function representing a ratio of STD vs FFF doses: 1 + b|r|(n).

CONCLUSIONS

A modified FFF beamline with increased energy and electron beam angular spread results in satisfactory flattened beam and high dose rate within the field. Peripheral dose remaining at similar (or smaller) level than that of STD linac for the same delivered dose within the treatment field.

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.

Treatment vault shielding for a flattening filter-free medical linear accelerator

The requirements for shielding a treatment vault with a Varian Clinac 2100 medical linear accelerator operated both with and without the flattening filter were assessed. Basic shielding parameters, such as primary beam tenth-value layers (TVLs), patient scatter fractions, and wall scatter fractions, were calculated using Monte Carlo simulations of 6, 10 and 18 MV beams. Relative integral target current requirements were determined from treatment planning studies of several disease sites with, and without, the flattening filter. The flattened beam shielding data were compared to data published in NCRP Report No. 151, and the unflattened beam shielding data were presented relative to the NCRP data. Finally, the shielding requirements for a typical treatment vault were determined for a single-energy (6 MV) linac and a dual-energy (6 MV/18 MV) linac. With the exception of large-angle patient scatter fractions and wall scatter fractions, the vault shielding parameters were reduced when the flattening filter was removed. Much of this reduction was consistent with the reduced average energy of the FFF beams. Primary beam TVLs were reduced by 12%, on average, and small-angle scatter fractions were reduced by up to 30%. Head leakage was markedly reduced because less integral target current was required to deliver the target dose. For the treatment vault examined in the current study, removal of the flattening filter reduced the required thickness of the primary and secondary barriers by 10-20%, corresponding to 18 m(3) less concrete to shield the single-energy linac and 36 m(3) less concrete to shield the dual-energy linac. Thus, a shielding advantage was found when the linac was operated without the flattening filter. This translates into a reduction in occupational exposure and/or the cost and space of shielding.

Energy spectra, sources, and shielding considerations for neutrons generated by a flattening filter-free Clinac

Neutron production is an unwanted result of high-energy radiation therapy and results in secondary exposure of patients and radiation therapists to radiation. Recent studies have shown that delivering therapy using a standard medical accelerator with the flattening filter removed may reduce neutron fluence by nearly 70% over the course of prostate intensity-modulated radiation therapy (IMRT). In the current study, the 197Au Bonner sphere technique was used to compare the neutron spectrum produced when the filter is present and when it is absent. In addition, the following was calculated: (1) the neutron-shielding parameters of source strength and ambient dose equivalent (H0) and (2) using the Monte Carlo technique, the sources of neutron production in the accelerator head. It was found that the neutron spectrum was nearly constant, regardless of the presence of the flattening filter; however, the total fluence and ambient dose equivalent over the course of prostate IMRT were more than 70% lower when the filter was removed. Similarly, shielding parameters were lower when the filter was removed. Finally, the primary collimator and jaws accounted for the majority of neutron production, both with and without the flattening filter; however, with the flattening filter removed, the upper jaw accounted for much more neutron production relative to when the filter was present. Ultimately, removal of the flattening filter may offer several clinical advantages, including a reduction in the dose from neutrons to the patient and to radiation personnel.

The characterization of unflattened photon beams from a 6 MV linear accelerator

Commissioning data have been measured for an Elekta Precise linear accelerator running at 6 MV without a flattening filter with the aim of studying the effects of flattening filter removal on machine operation and beam characterization. Modern radiotherapy practice now routinely relies on the use of fluence modifying techniques such as IMRT, i.e. the active production of non-flat beams. For these techniques the flattening filter should not be necessary. It is also possible that the increased intensity around the central axis associated with unflattened beams may be useful for conventional treatment planning by acting as a field-in-field or integrated boost technique. For this reason open and wedged field data are presented. Whilst problems exist in running the machine filter free clinically, this paper shows that in many ways the beam is actually more stable, exhibiting almost half the variation in field symmetry for changes in steering and bending currents. Dosimetric benefits are reported here which include a reduction in head scatter by approx. 70%, decreased penumbra (0.5 mm), lower dose outside of the field edge (11%) and a doubling in dose rate (2.3 times for open and 1.9 times for wedged fields). Measurements also show that reduced scatter also reduces leakage radiation by approx. 60%, significantly lowering whole body doses. The greatest benefit of filter-free use is perceived to be for IMRT where increased dose rate combined with reduced head scatter and leakage radiation should lead to improved dose calculation, giving simpler, faster and more accurate dose delivery with reduced dose to normal tissues.

Multibeam tomotherapy: a new treatment unit devised for multileaf collimation, intensity-modulated radiation therapy

A fully integrated system for treatment planning, application, and verification for automated multileaf collimator (MLC) based, intensity-modulated, image-guided, and adaptive radiation therapy (IMRT, IGRT and ART, respectively) is proposed. Patient comfort, which was the major development goal, will be achieved through a new unit design and short treatment times. Our device for photon beam therapy will consist of a new dual energy linac with five fixed treatment heads positioned evenly along one plane but one electron beam generator only. A minimum of moving parts increases technical reliability and reduces motion times to a minimum. Motion is allowed solely for the MLCs, the robotic patient table, and the small angle gantry rotation of +/- 36 degrees. Besides sophisticated electron beam guidance, this compact setup can be built using existing modules. The flattening-filter-free treatment heads are characterized by reduced beam-on time and contain apertures restricted in one dimension to the area of maximum primary fluence output. In the case of longer targets, this leads to a topographic intensity modulation, thanks to the combination of "step and shoot" MLC delivery and discrete patient couch motion. Owing to the limited number of beam directions, this multislice cone beam serial tomotherapy is referred to as "multibeam tomotherapy." Every patient slice is irradiated by one treatment head at any given moment but for one subfield only. The electron beam is then guided to the next head ready for delivery, while the other heads are preparing their leaves for the next segment. The "Multifocal MLC-positioning" algorithm was programmed to enable treatment planning and optimize treatment time. We developed an overlap strategy for the longitudinally adjacent fields of every beam direction, in doing so minimizing the field match problem and the effects of possible table step errors. Clinical case studies show for the same or better planning target volume coverage, better organ-at-risk sparing, and comparable mean integral dose to the normal tissue a reduction in treatment time by more than 50% to only a few minutes in comparison to high-quality 3-D conformal and IMRT treatments. As a result, it will be possible to incorporate features for better patient positioning and image guidance, while sustaining reasonable overall treatment times at the same time. The virtual multibeam tomotherapy design study TOM'5-CT contains a dedicated electron beam CT (TOM'AGE) and an objective optical topometric patient positioning system (TOPOS). Thanks to the wide gantry bore of 120 cm and slim gantry depths of 70 cm, patients can be treated very comfortably, in all cases tumor-isocentrically, as well as with noncoplanar beam arrangements as in stereotactic radiosurgery with a couch rotation of up to +/- 54 degrees. The TOM'5 treatment unit on which this theoretical concept is based has a stand-alone depth of 40 cm and an outer diameter of 245 cm; the focus-isocenter distance of the heads is 100 cm with a field size of 40 cm x 7 cm and 0.5 cm leaves, which operate perpendicular to the axis of table motion.

Reduced neutron production through use of a flattening-filter-free accelerator

PURPOSE

To measure and compare neutron fluence around an accelerator operating at 18 MV, both with the flattening filter present (FF mode) and absent (flattening-filter-free [FFF] mode).

METHODS AND MATERIALS

The neutron fluence was measured at several locations in the patient plane using gold foil activation in neutron moderators. Differences in neutron fluence between the FF and FFF mode were assessed in three frameworks: (1) measured per monitor unit of machine-on time, (2) determined per dose on the central axis, and (3) determined for a complete course of prostate intensity-modulated radiotherapy.

RESULTS

Neutron fluence per monitor unit was approximately 20% lower when the accelerator was operated in the FFF mode than when it was in FF mode. The total amount of neutron fluence that would be obtained during the entire course of prostate intensity-modulate radiotherapy was 69% lower when the accelerator was operated in the FFF mode than when it was in the FF mode. This reduction in neutron fluence would correspond to a drastic reduction in the neutron dose equivalent received by the patient as a byproduct of high-energy radiotherapy. It would also correspond to a reduction in activation within the treatment vault and subsequent exposure to radiation therapists.

CONCLUSION

When feasible, operating the accelerator without a FF will benefit both patients and radiation therapists by reducing the number of unwanted neutrons and resultant exposure. This reduces the risk of negative effects from such exposure (e.g., second cancers).