The optimum intensities for multiple static multileaf collimator field compensation

The stability of imaging biomarkers in radiomics: a framework for evaluation

This paper studies the sensitivity of a range of image texture parameters used in radiomics to: (i) the number of intensity levels, (ii) the method of quantisation to select the intensity levels and (iii) the use of an intensity threshold. 43 commonly used texture features were studied for the gross target volume outlined on the CT component of PET/CT scans of 50 patients with non-small cell lung carcinoma (NSCLC). All cases were quantised for all values between 4 and 128 intensity levels using four commonly used quantisation methods. All results were analysed with and without a threshold range of  -200 HU to 300 HU. Cases were ranked for each texture feature and for all quantisation methods with the Spearman's rank correlation coefficient determined to evaluate stability. Results showed large fluctuations in ranking, particularly for low numbers of levels, differences between quantisation methods and with the use of a threshold, with values Spearman's Rank Correlation for many parameters below 0.2. Our results demonstrated the sensitivity of radiomics features to the parameters used during analysis and highlight the risk of low reproducibility comparing studies with slightly different parameters. In terms of the lung cancer CT datasets, this study supports the use of 128 intensity levels, the same uniform quantiser applied to all scans and thresholding of the data. It also supports several of the features recommended in the literature for such studies such as skewness and kurtosis. A recommended framework is presented for curation of the data analysis process to ensure stability of results.

Advances in Treatment with Intensity-Modulated Conformal Radiotherapy

The modern practice of radiotherapy centres on the development of conformai radiotherapy, techniques to ensure the high-dose volume is tightly wrapped around the diseased tissue and excluded as far as possible from adjacent normal structures. The development of conformai radiotherapy is a chain of processes involving treatment planning, development of new methods to deliver radiation, verification of the accuracy of radiation delivery and improvement of biological outcome. This is an enormous field of activity. This invited review paper summarises some of the main elements of progress towards implementing intensity-modulated conformai radiotherapy. This is the newest and most exciting development and, when achieved clinically, will lead to a quantum leap in tumour control probability with a fixed level of normal tissue damage.

Computerized triplet beam orientation optimization for MRI-guided Co-60 radiotherapy

PURPOSE

Magnetic resonance imaging (MRI)-guided Co-60 provides daily and intrafractional MRI soft tissue imaging for improved target and critical organ tracking. To increase delivery efficiency, the system uses three Co-60 sources at 120° apart, allowing up to 600 cGy combined dose rate at isocenter. Despite the potential tripling in output, creating a delivery plan that uses all three sources is considerably unintuitive. Here, the authors computerize the triplet orientation optimization using column generation, an approach that was demonstrated effective in integrated beam orientation and fluence optimization for noncoplanar therapies. To achieve a better plan quality without increasing the treatment time, the authors then solve a fluence map optimization (FMO) problem while regularizing the fluence maps to reduce the number of deliverable MLC segments.

METHODS

Three patients-one prostate, one lung, and one head and neck boost plan (H&N_Boost)-were evaluated in this study. For each patient, the beamlet doses were calculated using Monte Carlo, under a 0.35 T magnetic field, for 180 equally spaced coplanar beams grouped into 60 triplets. The beamlet size is 1.05 × 0.5 cm determined by the MLC leaf thickness and step size. The triplets were selected using the column generation algorithm. The FMO problem was formulated using an L2-norm dose fidelity term and an L1-norm anisotropic total variation regularization term, which allows controlling the number of MLC segments, and hence the treatment time, with minimal degradation to the dose. The authors' Fluence Regularization and Optimized Selection of Triplets (FROST) plans were compared against the clinical treatment plans (CLNs) produced by an experienced dosimetrist. PTV homogeneity, max dose, mean dose, D95, D98, and D99 were evaluated. OAR max and mean doses, as well as R50, defined as the ratio of the 50% isodose volume over the planning target volume were investigated.

RESULTS

The mean PTV D95, D98, and D99 differ by +0.04%, +0.07%, and +0.25% of the prescription dose between planning methods. The mean PTV homogeneity was virtually same with values at 0.8788 (FROST) and 0.8812 (CLN). R50 decreased by 0.67 comparing FROST to CLN. On average, FROST reduced D_max and D_mean of OARs by 7.30% and 6.08% of the prescription dose, respectively. The manual CLN planning processes required numerous trial and error runs. The FROST plans on the other hand required minimal human intervention.

CONCLUSIONS

Efficient delivery of MRI-guided Co-60 therapy needs the output of multiple sources yet suffers from unintuitive and laborious manual beam selection processes. Computerized triplet orientation optimization improves both planning efficiency and plan dosimetry. The novel fluence map regularization provides additional controls over the number of MLC segments and treatment time.

Dose domain regularization of MLC leaf patterns for highly complex IMRT plans

PURPOSE

The advent of automated beam orientation and fluence optimization enables more complex intensity modulated radiation therapy (IMRT) planning using an increasing number of fields to exploit the expanded solution space. This has created a challenge in converting complex fluences to robust multileaf collimator (MLC) segments for delivery. A novel method to regularize the fluence map and simplify MLC segments is introduced to maximize delivery efficiency, accuracy, and plan quality.

METHODS

In this work, we implemented a novel approach to regularize optimized fluences in the dose domain. The treatment planning problem was formulated in an optimization framework to minimize the segmentation-induced dose distribution degradation subject to a total variation regularization to encourage piecewise smoothness in fluence maps. The optimization problem was solved using a first-order primal-dual algorithm known as the Chambolle-Pock algorithm. Plans for 2 GBM, 2 head and neck, and 2 lung patients were created using 20 automatically selected and optimized noncoplanar beams. The fluence was first regularized using Chambolle-Pock and then stratified into equal steps, and the MLC segments were calculated using a previously described level reducing method. Isolated apertures with sizes smaller than preset thresholds of 1-3 bixels, which are square units of an IMRT fluence map from MLC discretization, were removed from the MLC segments. Performance of the dose domain regularized (DDR) fluences was compared to direct stratification and direct MLC segmentation (DMS) of the fluences using level reduction without dose domain fluence regularization.

RESULTS

For all six cases, the DDR method increased the average planning target volume dose homogeneity (D95/D5) from 0.814 to 0.878 while maintaining equivalent dose to organs at risk (OARs). Regularized fluences were more robust to MLC sequencing, particularly to the stratification and small aperture removal. The maximum and mean aperture sizes using the DDR were consistently larger than those from DMS for all tested number of segments.

CONCLUSIONS

The fluence map to MLC segmentation conversion problem was formulated as a secondary optimization problem in the dose domain to minimize the smoothness-regularized dose discrepancy. The large scale optimization problem was solved using a primal-dual algorithm that transformed complicated fluences into maps that were more robust to the MLC segmentation and sequencing, affording fewer and larger segments with minimal degradation to dose distribution.

GENERALIZED GEOMETRIC APPROACHES FOR LEAF SEQUENCING PROBLEMS IN RADIATION THERAPY

The 3-D static leaf sequencing (SLS) problem arises in radiation therapy for cancer treatments, aiming to deliver a prescribed radiation dose to a target tumor accurately and efficiently. The treatment time and machine delivery error are two crucial factors to the solution (i.e., a treatment plan) for the SLS problem. In this paper, we prove that the 3-D SLS problem is NP-hard, and present the first ever algorithm for the 3-D SLS problem that can determine a tradeoff between the treatment time and machine delivery error (also called the "tongue-and-groove" error in medical literature). Our new 3-D SLS algorithm with error control gives the users (e.g., physicians) the option of specifying a machine delivery error bound, and subject to the given error bound, the algorithm computes a treatment plan with the minimum treatment time. We formulate the SLS problem with error control as computing a k-weight shortest path in a directed graph and build the graph by computing g-matchings and minimum cost flows. Further, we extend our 3-D SLS algorithm to all the popular radiotherapy machine models with different constraints. In our extensions, we model the SLS problems for some of the radiotherapy systems as computing a minimum g-path cover of a directed acyclic graph. We implemented our new 3-D SLS algorithm suite and conducted an extensive comparison study with commercial planning systems and well-known algorithms in medical literature. Some of our experimental results based on real medical data are presented.

GEOMETRIC ALGORITHMS FOR STATIC LEAF SEQUENCING PROBLEMS IN RADIATION THERAPY

The static leaf sequencing (SLS) problem arises in radiation therapy for cancer treatments, aiming to accomplish the delivery of a radiation prescription to a target tumor in the minimum amount of delivery time. Geometrically, the SLS problem can be formulated as a 3-D partition problem for which the 2-D problem of partitioning a polygonal domain (possibly with holes) into a minimum set of monotone polygons is a special case. In this paper, we present new geometric algorithms for a basic case of the 3-D SLS problem (which is also of clinical value) and for the general 3-D SLS problem. Our basic 3-D SLS algorithm, based on new geometric observations, produces guaranteed optimal quality solutions using O(1) Steiner points in polynomial time; the previously best known basic 3-D SLS algorithm gives optimal outputs only for the case without considering any Steiner points, and its time bound involves a multiplicative factor of a factorial function of the input. Our general 3-D SLS algorithm is based on our basic 3-D SLS algorithm and a polynomial time algorithm for partitioning a polygonal domain (possibly with holes) into a minimum set of x-monotone polygons, and has a fast running time. Experiments of our SLS algorithms and software in clinical settings have shown substantial improvements over the current most popular commercial treatment planning system and the most well-known SLS algorithm in medical literature. The radiotherapy plans produced by our software not only take significantly shorter delivery times, but also have a much better treatment quality. This proves the feasibility of our software and has led to its clinical applications at the Department of Radiation Oncology at the University of Maryland Medical Center. Some of our techniques and geometric procedures (e.g., for partitioning a polygonal domain into a minimum set of x-monotone polygons) are interesting in their own right.

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.

Improved stratification algorithms for step-and-shoot MLC delivery in intensity-modulated radiation therapy

In inverse planning for intensity-modulated radiotherapy (IMRT), the fluence distribution of each treatment beam is usually calculated in an optimization process. The delivery of the resulting treatment plan using multileaf collimators (MLCs) is performed either in the step-and-shoot or sliding window technique. For step-and-shoot delivery, the arbitrary beam fluence distributions have to be transformed into an applicable sequence of subsegments. In a stratification step the complexity of the fluence maps is reduced by assigning each beamlet to discrete intensity values, followed by the sequencing step that generates the subsegments. In this work, we concentrate on the stratification for step-and-shoot delivery. Different concepts of stratification are formally introduced. In addition to already used strategies that minimize the difference between original and stratified beam intensities, we propose an original stratification principle that minimizes the error of the resulting dose distribution. It could be shown that for a comparable total number of subsegments the dose-oriented stratification results in a better approximation of the original, unsequenced plan. The presented algorithm can replace the stratification routine in existing sequencer programs and can also be applied to interpolated plans that are generated in an interactive decision making process of multicriteria inverse planning programs.

A difference-matrix metaheuristic for intensity map segmentation in step-and-shoot IMRT delivery

At an intermediate stage of radiation treatment planning for IMRT, most commercial treatment planning systems for IMRT generate intensity maps that describe the grid of beamlet intensities for each beam angle. Intensity map segmentation of the matrix of individual beamlet intensities into a set of MLC apertures and corresponding intensities is then required in order to produce an actual radiation delivery plan for clinical use. Mathematically, this is a very difficult combinatorial optimization problem, especially when mechanical limitations of the MLC lead to many constraints on aperture shape, and setup times for apertures make the number of apertures an important factor in overall treatment time. We have developed, implemented and tested on clinical cases a metaheuristic (that is, a method that provides a framework to guide the repeated application of another heuristic) that efficiently generates very high-quality (low aperture number) segmentations. Our computational results demonstrate that the number of beam apertures and monitor units in the treatment plans resulting from our approach is significantly smaller than the corresponding values for treatment plans generated by the heuristics embedded in a widely use commercial system. We also contrast the excellent results of our fast and robust metaheuristic with results from an 'exact' method, branch-and-cut, which attempts to construct optimal solutions, but, within clinically acceptable time limits, generally fails to produce good solutions, especially for intensity maps with more than five intensity levels. Finally, we show that in no instance is there a clinically significant change of quality associated with our more efficient plans.

Use of intensity modulation for missing tissue compensation of pediatric spinal fields

Irradiation of the cranio‐spinal axis is often one of the treatment modalities of certain childhood cancers, e.g., medulloblastoma. In order to achieve a uniform dose to the spinal cord, missing tissue compensators are required. In the past, our practice was to fabricate compensators out of strips of lead. We report on the use of intensity modulated fields to achieve the desired compensation. Seven cases of pediatric cancer whose treatment involved irradiation of the cranio‐spinal axis had compensators designed using a beam intensity modulation method rather than making mechanical compensators. The compensators only adjusted for missing tissue along the spinal axis. Comparisons between calculated and measured doses were made at depth in phantoms and on the surface of the patient. The intensity modulated fields were delivered using a step‐and‐shoot delivery on an Elekta SL20 accelerator equipped with multileaf collimator. The intensity‐modulated compensators provided more flexibility in design than the physical compensator method. Finer intensity steps were achievable, more accurate dose distributions were able to be calculated, and adjustments during treatment, e.g., junction changes, were more easily implemented. Convolution/superposition dose calculations were within ±3% of measurements. Intensity modulated fields are a practical and more efficient method of delivering uniform doses to the spine in pediatric cancer treatments. They provide many advantages over mechanical compensators with regard to time and flexibility.

PACS number(s): 87.53.–j, 87.90.+y

Simulations for inverse radiation therapy treatment planning using a dynamic MLC algorithm

The inverse radiation treatment planning model for a dynamic multileaf collimator (MLC) is used to find the optimal solution of planning problem. The model for dynamic MLC is explained in Tervo et al (2003 Appl. Math. Comput. 135 227-50). The advantage of this model is that it optimizes leaf velocity parameters directly. Our algorithm uses a gradient-based local optimization method. Two patient cases, prostate carcinoma and tonsilla carcinoma, are studied. Field arrangements are pre-selected and velocity parameters for MLC leaves are optimized to obtain the prescribed dose in the patient space. In both simulated cases, high dose distribution conforms the planning target volume well and organs-at-risk are saved in most parts. Simulations show that the model has its functionality in patient treatments, although it is still formal and needs further development.

Forward planning using multileaf collimation as a replacement for patient tissue compensation

In treatment planning, a dosimetrist may encounter a technique that would best be treated by including some type of compensation to correct for tissue or depth variations throughout the field, allowing for a more homogeneous dose distribution. Recent innovations, such as intensity-modulated radiotherapy (IMRT), have been introduced in an effort to address these issues. In many institutions, however, the treatment planning capabilities available may not accommodate consideration of such new technologies. The treatment planner is therefore left to determine how to incorporate these concepts with the current technologies available. While compensation may be an option, this may not always be possible due to the position of the beam or to actual mechanical restraints. Some institutions may also lack the ability and equipment to consider compensation at all. The answer is forward planning IMRT. This concept combines current forward planning techniques with multiple asymmetrically blocked treatment fields, varying the intensity of the beam from a given orientation to produce the desired treatment plan.

A quality and efficiency analysis of the IMFAST segmentation algorithm in head and neck "step & shoot" IMRT treatments

The performance of segmentation algorithms used in IMFAST for "step & shoot" IMRT treatment delivery is evaluated for three head and neck clinical treatments of different optimization objectives. The segmentation uses the intensity maps generated by the in-house TPS PLANUNC using the index-dose minimization algorithm. The dose optimization objectives include PTV dose uniformity and dose volume histogram-specified critical structure sparing. The optimized continuous intensity maps were truncated into five and ten intensity levels and exported to IMFAST for MLC segments optimization. The MLC segments were imported back to PLUNC for dose optimization quality calculation. The five basic segmentation algorithms included in IMFAST were evaluated alone and in combination with either tongue and groove/match line correction or fluence correction or both. Two criteria were used in the evaluation: treatment efficiency represented by the total number of MLC segments and optimization quality represented by a clinically relevant optimization quality factor. We found that the treatment efficiency depends first on the number of intensity levels used in the intensity map and second the segmentation technique used. The standard optimal segmentation with fluence correction is a consistent good performer for all treatment plans studied. All segmentation techniques evaluated produced treatments with similar dose optimization quality values, especially when ten-level intensity maps are used.

Improved leaf sequencing reduces segments or monitor units needed to deliver IMRT using multileaf collimators

Leaf sequencing algorithms may use an unnecessary number of monitor units or segments to generate intensity maps for delivery of intensity modulated radiotherapy (IMRT) using multiple static fields. An integer algorithm was devised to generate a sequence with the fewest possible segments when the minimum number of monitor units are used. Special hardware related restrictions on leaf motion can be incorporated. The algorithm was tested using a benchmark map from the literature and clinical examples. Results were compared to sequences given by the routine of Bortfeld that minimizes monitor units by treating each row independently, and the areal or reducing routines that use fewer segments at the price of more monitor units. The Bortfeld algorithm used on average 58% more segments than provided by the integer algorithm with bidirectional motion and 32% more segments than did an integer algorithm admitting only unidirectional sequences. The areal algorithm used 48% more monitor units and the reducing algorithm used 23% more monitor units than did the bidirectional integer algorithm, while the areal and reducing algorithms used 23% more segments than did the integer algorithm. Improved leaf sequencing algorithms can allow more efficient delivery of static field IMRT. The integer algorithm demonstrates the efficiencies possible with an improved routine and opens a new avenue for development.

Implementing multiple static field delivery for intensity modulated beams

A clinically oriented two-dimensional intensity-modulated beam delivery method is implemented using multiple static segmented fields, i.e., the "step-and-shoot" approach. Starting with a desired al" intensity distribution, it creates a multiple-level intensity approximation, and then constructs a sequence of segmented fields to deliver the multiple-level intensities using multileaf collimator (MLC) and independent backup jaws. The approach starts with a simple grouping of all the nonzero intensity values into a minimum number of clusters for a user specified deviation tolerance for the ideal plan. The k-means clustering algorithm is then employed to find the optimal levels of intensity that minimize the discrepancies between the ideal and the approximated intensities, without violating the user specified deviation tolerance. The multiple-level intensities are then decomposed into a sequence of machine deliverable segments. Apart from the first segment for each gantry angle, all the other segments are arranged to minimize the total travel distance of the leaves. The first segment covers the entire irradiated area and is used for treatment verification by electronic portal imaging. The implementation issues due to the physical constraints of the MLCs are also addressed.

An intercomparison of IMRT delivery techniques: a case study for breast treatment

Intensity-modulated radiotherapy beams can be delivered using a multileaf collimator by one of two methods: either by superposition of a series of multiple-static fields, or by moving the collimators while the beam is on to produce 'dynamically' modulated beams. The leaf trajectories in this dynamic mode are given by a series of linear steps between control points defining each collimator position at known intervals throughout an exposure. The complexity of the resulting modulation is limited in the first case by the number of fields superposed and in the second case by the number of control points defined. Results are presented for an experimental study that investigates the effect of changing both the number of fields for the multiple-static technique, and the number of control points for a dynamic 'close-in' technique. All deliveries studied are clinical intensity-modulated breast fields. The effect of using a universal wedge in conjunction with the multileaf collimator is also studied, together with a comparison of the relative efficiency, time taken and the absolute dosimetric accuracy of the various delivery options. It is shown that all delivery techniques produce equivalent dose distributions when using 15 control points, with 10 control points being sufficient to produce an adequate breast compensator distribution. Except for the case of a four-control-point dynamic delivery, the universal wedge makes no significant difference to the dose distribution. However, it makes the delivery less efficient. The close-in interpreter consistently produces deliveries that are more efficient than the more conventional sliding-window technique and faster than the multiple-static-field technique. Finally the close-in technique is compared to the more 'standard' leaf-sweep technique and shown to be equivalent.

A variable fluence step clustering and segmentation algorithm for step and shoot IMRT

A step and shoot sequencer was developed that can be integrated into an IMRT optimization algorithm. The method uses non-uniform fluence steps and is adopted to the constraints of an MLC. It consists of a clustering, a smoothing and a segmentation routine. The performance of the algorithm is demonstrated for eight mathematical profiles of differing complexity and two optimized profiles of a clinical prostate case. The results in terms of stability, flexibility, speed and conformity fulfil the criteria for the integration into the optimization concept. The performance of the clustering routine is compared with another previously published one (Bortfeld et al 1994 Int. J. Radiat. Oncol. Biol. Ph.vs. 28 723-30) and yields slightly better results in terms of mean and maximum deviation between the optimized and the clustered protile. We discuss the specific attributes of the algorithm concerning its integration into the optimization concept.

The dosimetric consequences of inter-fractional patient movement on three classes of intensity-modulated delivery techniques in breast radiotherapy

BACKGROUND AND PURPOSE

A comparison between three classes of intensity-modulated delivery techniques was undertaken to examine the dosimetric consequences of using a multileaf collimator (MLC) reshaped on each imaged fraction as opposed to compensators designed on the first day of treatment potentially giving a treatment technique whose accuracy is thus degraded by movement.

MATERIALS AND METHODS

The effects of inter-fractional patient movement for a cohort of six breast patients were studied. Five treatment techniques were evaluated, two using a compensator, two using multiple static fields (MSF) and one using a dynamic multileaf collimator (DMLC). The compensated techniques consisted of (i) the use of compensators designed on day 1 only and used each fraction thereafter and (ii) the use of a compensator redesigned for each imaged fraction. The two MSF techniques were (i) a four-field-component design and (ii) a method where the fluence interval between the MLC field components was set so they were equivalent to the compensator ('quantized' MSF-MLC). The final technique investigated was the DMLC. Plans were produced for each of the five methods and a paired t-test was used to assess the reduction in the breast volume outside the dose range 95-105% between sets of pairs of techniques. An on-line correction strategy was simulated to determine the number of treatments that required intervention. The action levels were calculated using the difference between the volume outside the dose range 95-105% calculated for treatments where the DMLC was designed on day 1 only and for each imaged fraction. Differences of greater than 2%, greater than 5% and greater than 10% were investigated.

RESULTS

Thirty-five plans were evaluated for each technique. Results showed that a statistically significant mean reduction in the volume of the breast outside the dose range 95-105% could be achieved if the compensators were designed on each imaged fraction rather than on day 1 only (P=0.0045). When the comparison was made between the 'quantized' MSF-MLC and the technique where the compensators were designed on day 1 only, a statistically significant mean reduction in the volume of the breast tissue outside the dose range 95-105% was not achieved (P=0.21). Comparison of the DMLC technique to the technique where the compensators were designed on day 1 only results in a statistically significant mean reduction in the volume outside the dose range 95-105% (P=0.024). This corresponds to a mean reduction in the volume outside 95-105% dose of 1.94%. The 2% action level showed the greatest reduction in the volume outside 95-105% dose and intervention was only required in approximately one-third of the treatments investigated.

CONCLUSIONS

Redesigning MSFs for each imaged fraction did not provide a statistically significant mean reduction in the volume outside the dose range 95-105%. However, using the DMLC technique creates a statistically significant mean reduction in the volume outside the dose range 95-105%.

The delivery of intensity modulated radiotherapy to the breast using multiple static fields

BACKGROUND AND PURPOSE

To develop a method of using a multileaf collimator (MLC) to deliver intensity modulated radiotherapy (IMRT) for tangential breast fields, using an MLC to deliver a set of multiple static fields (MSFs).

MATERIALS AND METHODS

An electronic portal imaging device (EPID) is used to obtain thickness maps of medial and lateral tangential breast fields. From these IMRT deliveries are designed to minimize the volume of breast above 105% of prescribed dose. The deliveries are universally-wedged beams augmented with a set of low dose shaped irradiations. Dosimetric and planning QA of this method has been compared with the standard, wedged treatment and the corresponding treatment using physical compensators. Several options for delivering the MSF treatment are presented.

RESULTS

The MSF technique was found to be superior to the standard technique (P value=0.002) and comparable with the compensated technique. Both IMRT methods reduced the volume of breast above 105% dose from a mean value of 12.0% of the total breast volume to approximately 2.8% of the total breast volume.

CONCLUSIONS

This MSF method may be used to reduce the high dose volume in tangential breast irradiation significantly. This may have consequences for long-term side effects, particularly cosmesis.

Advances in three-dimensional conformal radiation therapy physics with intensity modulation

Intensity-modulated radiation therapy, a specific form of conformal radiation therapy, is currently attracting a lot of attention, and there are high expectations for this class of treatment techniques. Several new technologies are in development, but physicists are still working to improve the physical basis of radiation therapy.

Temporal resolution requirements for intensity modulated radiation therapy delivered by multileaf collimators

Intensity modulated radiation therapy may be delivered via dynamic control of a multileaf collimator by defining dynamic leaf trajectories at a series of control points which are spaced at arbitrary intervals throughout an exposure. Leaves move linearly between the positions defined at the control points and hence leaf motion is a linear approximation to the planned trajectories. When many control points are used, very complex modulations can be defined accurately. If too few are used, dose errors are introduced which depend on the complexity of the modulation and the number of control points chosen. Proposed intensity modulations, of varying complexity, have been converted to trajectory plans where the number of equally spaced control points varied between 11 and 99. In each case the fluence map generated by the resulting leaf motions was computed, and this was quantitatively compared with the desired modulation by calculating the root mean square (RMS) error. It is shown that in no case can the RMS error be significantly reduced by increasing the number of control points beyond 50. Guidelines are derived such that compensators and simple modulations may be very accurately delivered with about 20 control points, moderately complex modulations require 30-35 control points and very complex modulations 50 control points. A similar analysis of the step and shoot technique suggests that very accurate deliveries are always achieved with a maximum of 25 equally weighted static fields and reasonable accuracy with 15 fields.

Generation of discrete beam-intensity modulation by dynamic multileaf collimation under minimum leaf separation constraints

An algorithm to generate discrete beam-intensity modulation by dynamic multileaf collimation is presented which incorporates constraints on minimum allowed leaf separations. MLC positioning information is derived simultaneously for all leaf pairs and back-up diaphragms as they progress across the field. A feedback mechanism allows corrections to be applied to eliminate potential violations of minimum separation conditions and any underexposure in the interleaf tongue-and-groove region as they are encountered. The resulting motion correctly delivers the intended modulation and is physically realizable. Implementation of the algorithm is described. Results of the algorithm can also alternatively be interpreted as defining a series of static fields to deliver the same modulation.

Configuration options for intensity-modulated radiation therapy using multiple static fields shaped by a multileaf collimator. II: constraints and limitations on 2D modulation

This paper addresses the technique of using multiple static multileaf-collimator-shaped field components to create a two-dimensional intensity-modulated beam (2D IMB). It addresses the physical constraints on the problem of determining the optimum field-component leaf configurations under the circumstances that (i) the static field components are shaped by leaves alone and (ii) the 2D intensity distribution is delivered by exactly N field components when there are N rising-intensity equal-fluence increments in the 1D channel containing the maximum fluence in the 2D IMB. This corresponds to the least inefficient delivery. In general it is noted that an optimum solution (set of field-component leaf configurations) with zero tongue-and-groove underdose may not exist (depending on the distribution) and an exhaustive search for the set of leaf configurations with the minimum tongue-and-groove underdose is impossible for realistically sized problems. Against this background iterative methods to examine a limited search space are shown to yield an optimum solution with zero tongue-and-groove underdose for certain intensity distributions. These searches are not robust and can be defeated. The problem of finding an optimum solution may be generally insoluble for some 2D IMBs under the conditions (i) and (ii). If, however, a larger number of field components is permitted and/or the accelerator jaws may also be used, in addition to the multileaves, then an optimum solution with zero tongue-and-groove underdose can always be found with lower efficiency.