Evaluation of the analytical anisotropic algorithm in an extreme water-lung interface phantom using Monte Carlo dose calculations

Effect of modulation factor and low dose threshold level on gamma pass rates of single isocenter multi-target SRT treatment plans

PURPOSE

SRS MapCHECK (SMC) is a commercially available patient-specific quality assurance (PSQA) tool for stereotactic radiosurgery (SRS) applications. This study investigates the effects of degree of modulation, location off-axis, and low dose threshold (LDT) selection on gamma pass rates (GPRs) between SMC and treatment planning system, Analytical Anisotropic Algorithm (AAA), or Vancouver Island Monte Carlo (VMC++ algorithm) system calculated dose distributions.

METHODS

Volumetric-modulated arc therapy (VMAT) plans with modulation factors (MFs) ranging from 2.7 to 10.2 MU/cGy were delivered to SMC at isocenter and 6 cm off-axis. SMC measured dose distributions were compared against AAA and VMC++ via gamma analysis (3%/1 mm) with LDT of 10% to 80% using SNC Patient software.

RESULTS

Comparing on-axis SMC dose against AAA and VMC++ with LDT of 10%, all AAA-calculated plans met the acceptance criteria of GPR ≥ 90%, and only one VMC++ calculated plan was marginally outside the acceptance criteria with pass rate of 89.1%. Using LDT of 80% revealed decreasing GPR with increasing MF. For AAA, GPRs reduced from 100% at MF of 2.7 MU/cGy to 57% at MF of 10.2 MU/cGy, and for VMC++ calculated plans, the GPRs reduced from 89% to 60% in the same MF range. Comparison of SMC dose off-axis against AAA and VMC++ showed more pronounced reduction of GPR with increasing MF. For LDT of 10%, AAA GPRs reduced from 100% to 83% in the MF range of 2.7 to 9.8 MU/cGy, and VMC++ GPR reduced from 100% to 91% in the same range. With 80% LDT, GPRs dropped from 100% to 42% for both algorithms.

CONCLUSIONS

MF, dose calculation algorithm, and LDT selections are vital in VMAT-based SRT PSQA. LDT of 80% enhances sensitivity of gamma analysis for detecting dose differences compared to 10% LDT. To achieve better agreement between calculated and SMC dose, it is recommended to limit the MF to 4.6 MU/cGy on-axis and 3.6 MU/cGy off-axis.

Efficacy of flattening filter-free beams with the acuros XB algorithm in thoracic spine stereotactic body radiation therapy

This study aimed to determine the dosimetric value of flattening filter-free (FFF) beams compared to flattening filter (FF) beams using different algorithms in the treatment planning of thoracic spine stereotactic body radiation therapy (SBRT). A total of 120 plans were created for 15 patients using the Anisotropic Analytical Algorithm (AAA) and the Acuros External Beam (AXB) algorithm with FF and FFF beams at 6 MV and 10 MV energies. Various dosimetric parameters were evaluated, including target coverage, dose spillage, and organs-at-risk sparing of the spinal cord and esophagus. Treatment delivery parameters, such as the monitor units (MUs), modulation factors (MFs), beam-on time (BOT), and dose calculation time (DCT), were also collected. Significant differences were observed in the dosimetric parameters when AXB was used for all energies (P < 0.05). 6 XFFF energy was the best option for target coverage, dose spillage, and organs-at-risk sparing. In contrast, dosimetric parameters had no significant difference when using the AAA. The AAA and AXB calculations showed that the 6 XFFF beam had the shortest DCT. The treatment delivery parameters indicated that 10 XFF beam required the fewest MUs and MFs. In addition, the 10 XFFF beam demonstrated the shortest BOT. For effective treatment of the thoracic spine using SBRT, it is recommended to use the 10 XFFF beam because of the short BOT. Moreover, the AXB algorithm should be used because of its accurate dose calculation in regions with tissue heterogeneity.

Deep learning enables time-efficient soft tissue enhancement in CBCT: Proof-of-concept study for dentomaxillofacial applications

PURPOSE

The use of iterative and deep learning reconstruction methods, which would allow effective noise reduction, is limited in cone-beam computed tomography (CBCT). As a consequence, the visibility of soft tissues is limited with CBCT. The study aimed to improve this issue through time-efficient deep learning enhancement (DLE) methods.

METHODS

Two DLE networks, UNIT and U-Net, were trained with simulated CBCT data. The performance of the networks was tested with three different test data sets. The quantitative evaluation measured the structural similarity index measure (SSIM) and the peak signal-to-noise ratio (PSNR) of the DLE reconstructions with respect to the ground truth iterative reconstruction method. In the second assessment, a dentomaxillofacial radiologist assessed the resolution of hard tissue structures, visibility of soft tissues, and overall image quality of real patient data using the Likert scale. Finally, the technical image quality was determined using modulation transfer function, noise power spectrum, and noise magnitude analyses.

RESULTS

The study demonstrated that deep learning CBCT denoising is feasible and time efficient. The DLE methods, trained with simulated CBCT data, generalized well, and DLE provided quantitatively (SSIM/PSNR) and visually similar noise-reduction as conventional IR, but with faster processing time. The DLE methods improved soft tissue visibility compared to the conventional Feldkamp-Davis-Kress (FDK) algorithm through noise reduction. However, in hard tissue quantification tasks, the radiologist preferred the FDK over the DLE methods.

CONCLUSION

Post-reconstruction DLE allowed feasible reconstruction times while yielding improvements in soft tissue visibility in each dataset.

Evaluation of Radiation Treatment Planning Algorithms in IMRT and VMAT: A Comparative Dosimetric Study in Lung Equivalent Heterogeneous Medium

Background

In Radiotherapy, computation of dose is important since in a small field with heterogeneity, dose is usually computed with discrepancies.

Objective

The present study was aimed to evaluate the dosimetry of treatment planning algorithms in lung equivalent heterogeneous medium for Volumetric Modulated Arc Therapy (VMAT) with step and shoot Intensity-Modulated Radiation Therapy (ss-IMRT), and dynamic Intensity-Modulated Radiation Therapy (d-IMRT).

Material and Methods

In this experimental study, Computerized Imaging Reference System (CIRS) phantom was used with an inhomogeneous Racemosa wood cylinder for two types of tumors, namely, Left Lung Central Tumor (LCT) and Left Lung Peripheral Tumor (LPT) in the CIRS left lung cavity. The computed tomography (CT) datasets were employed with the generation of VMAT, d-IMRT and ss-IMRT plans for the LCT and LPT irradiated with 6 MV photon beams. In this study, the accuracy and efficacy of two algorithms: Monte Carlo (MC) and the Pencil Beam (PB), from the Monaco treatment planning system (TPS), were tested by using Gafchromic EBT3 films and CIRS thorax phantom.

Results

Regardless of treatment techniques, both algorithms exhibited higher divergence in LPT than LCT. In both LCT and LPT, the highest deviation was near the tumor-lung junction. However, the deviation was higher in the PB algorithm than MC algorithm, with a minimally acceptable variation of -0.8%.

Conclusion

The MC algorithm shows more consistency for EBT3 measured dose in lung equivalent heterogeneous medium. However, accurate dose predictions are complicated due to electronic disequilibrium within and at the interface of inhomogeneity. These constraints may cause variations from the anticipated outcomes of the treatments.

Introducing new plan evaluation indices for prostate dose painting IMRT plans based on apparent diffusion coefficient images

BACKGROUND

Dose painting planning would be more complicated due to different levels of prescribed doses and more complex evaluation with conventional plan quality indices considering uniform dose prescription. Therefore, we tried to introduce new indices for evaluating the dose distribution conformity and homogeneity of treatment volumes based on the tumoral cell density and relative volumes of each lesion in prostate IMRT.

METHODS

CT and MRI scans of 20 male patients having local prostate cancer were used for IMRT DP planning. Apparent diffusion coefficient (ADC) images were imported to a MATLAB program to identify lesion regions based on ADC values automatically. Regions with ADC values lower than 750 mm²/s and regions with ADC values higher than 750 and less than 1500 mm²/s were considered CTV_70Gy (clinical tumor volume with 70 Gy prescribed dose), and CTV_60Gy, respectively. Other regions of the prostate were considered as CTV_53Gy. New plan evaluation indices based on evaluating the homogeneity (IOE(H)), and conformity (IOE(C)) were introduced, considering the relative volume of each lesion and cellular density obtained from ADC images. These indices were compared with conventional homogeneity and conformity indices and IOEs without considering cellular density. Furthermore, tumor control probability (TCP) was calculated for each patient, and the relationship of the assessed indices were evaluated with TCP values.

RESULTS

IOE (H) and IOE (C) with considering cellular density had significantly lower values compared to conventional indices and IOEs without considering cellular density. (P < 0.05). TCP values had a stronger relationship with IOE(H) considering cell density (R² = -0.415), and IOE(C) without considering cell density (R² = 0.624).

CONCLUSION

IOE plan evaluation indices proposed in this study can be used for evaluating prostate IMRT dose painting plans. We suggested to consider cell densities in the IOE(H) calculation formula and it's appropriate to calculate IOE(C) without considering cell density values.

Dosimetric Evaluation of the Treatment Plan on Indigenous Heterogeneous Phantoms using Analytical Anisotropic Algorithm and Acuros-XB Algorithm for Different Photon Energies

BACKGROUND

Modern radiotherapy techniques are using advanced algorithms; however, phantoms used for quality assurance have homogeneous density; accordingly, the development of heterogeneous phantom mimicking human body sites is imperative to examine variation between planned and delivered doses.

OBJECTIVE

This study aimed to analyze the accuracy of planned dose by different algorithms using indigenously developed heterogeneous thoracic phantom (HT).

MATERIAL AND METHODS

In this experimental study, computed tomography (CT) of HT was done, and the density of different parts was measured. The plan was generated on CT images of HCP with 6 and 15 Megavoltage (MV) photon beams using different treatment techniques, including three-dimensional conformal radiotherapy (3D-CRT), intensity-modulated radiation therapy (IMRT), and volumetric modulated arc therapy (VMAT). Plans were delivered by the linear accelerator, and the dose was measured using the ion chamber (IC) placed in HT; planned and measured doses were compared.

RESULTS

Density patterns for different parts of the fabricated phantom, including rib, spine, scapula, lung, chest wall, and heart were 1.849, 1.976, 1.983, 0.173, 0.855, and 0.833 g/cc, respectively. Variation between planned and IC estimated doses with the tolerance (±5%) for all photon energies using different techniques. Acuros-XB (AXB) showed a slightly higher variation between computed and IC estimated doses using HCP compared to the analytical anisotropic algorithm (AAA).

CONCLUSION

The indigenous heterogeneous phantom can accurately simulate the dosimetric scenario for different algorithms (AXB or AAA) and be also utilized for routine patient-specific QA.

Dose calculation accuracy for photon small fields in treatment planning systems with comparison by Monte Carlo simulations

Purpose: Advanced radiation therapy techniques use small fields in treatment planning and delivery. Small fields have the advantage of more accurate dose delivery, but with the cost of some complications in dosimetry. Different dose calculation algorithms imported in various treatment planning systems (TPSs) which each of them has different accuracy. Monte Carlo (MC) simulation has been reported as one of the accurate methods for calculating dose distribution in radiation therapy. The aim of this study was the evaluation of TPS dose calculation algorithms in small fields against 2 MC codes.

Methods: A linac head was simulated in 2 MC codes, MCNPX, and GATE. Then three small fields (0.5×0.5, 1×1 and 1.5×1.5 cm2) were simulated with 2 MC codes, and also these fields were planned with different dose calculation algorithms in Isogray and Monaco TPS. PDDs and lateral dose profiles were extracted and compared between MC simulations and dose calculation algorithms.

Results: For 0.5×0.5 cm2 field mean differences in PDDs with MCNPX were 2.28, 4.6, 5.3, and 7.4% and with GATE were -0.29, 2.3, 3 and 5% for CCC, superposition, FFT and Clarkson algorithms respectively. For 1×1 cm2 field mean differences in PDDs with MCNPX were 1.58, 0.6, 1.1 and 1.4% and with GATE were 0.77, 0.1, 0.6 and 0.9% for CCC, superposition, FFT and Clarkson algorithms respectively. For 1.5×1.5 cm2 field mean differences in PDDs with MCNPX were 0.82, 0.4, 0.6 and -0.4% and with GATE were 2.38, 2.5, 2.7 and 1.7% for CCC, superposition, FFT and Clarkson algorithms respectively.

Conclusions: Different dose calculation algorithms were evaluated and compared with MC simulation in small fields. Mean differences with MC simulation decreased with the increase of field sizes for all algorithms.

Dose calculation validation of a convolution algorithm in a solid water phantom

PURPOSE

The dose calculated using a convolution algorithm should be validated in a simple homogeneous water-equivalent phantom before clinical use. The dose calculation accuracy within a solid water phantom was investigated.

METHODS

The specific Gamma knife design requires a dose rate calibration within a spherical solid water phantom. The TMR10 algorithm, which approximates the phantom material as liquid water, correctly computes the absolute dose in water. The convolution algorithm, which considers electron density miscalculates the dose in water as the phantom Hounsfield units were converted into higher electron density when the original CT calibration curve was used. To address this issue, the electron density of liquid water was affected by modifying the CT calibration curve. The absolute dose calculated using the convolution algorithm was compared with that computed by the TMR10. The measured depth dose profiles were also compared to those computed by the convolution and TMR10 algorithms. A patient treatment was recalculated in the solid-water phantom and the delivery quality assurance was checked.

RESULTS

The convolution algorithm and the TMR10 calculate an absolute dose within 1% when using the modified CT calibration curve. The dose depth profile calculated using the convolution algorithms was superimposed on the TMR10 and measured dose profiles when the modified CT calibration curve was applied. The Gamma index was better than 93%.

CONCLUSIONS

Dose calculation algorithms, which consider electron density, require a CT calibration curve adapted to the phantom material to correctly compute the dose in water.

Radiotherapy for Primary Tracheal Carcinoma: Experience at a Single Institution

Background:

There is limited understanding of tracheal carcinoma (TC) because of its rarity. We examined the efficacy of radiotherapy (RT) for patients with primary TC.

Methods:

We analyzed the records of 32 patients with primary TC who received RT at our center between November 1996 and December 2016.

Results:

Thirteen patients received adjuvant RT and 18 received definitive RT. Eight patients achieved complete remission (CR) after definitive RT. Among all patients, the 5-year overall survival (OS) rate was 46.9% and the locoregional progression free survival (LRPFS) rate was 68.1%. Univariate analysis indicated the 5-year OS was better in those with adenoid cystic adenocarcinoma than squamous cell carcinoma (P = 0.001); the 5-year LRPFS was better in patients who received surgical resection than those who did not (92.9% vs 46.4%, P = 0.013) and in patients who received postoperative RT than in those who received definitive RT (91.7% vs 50.1%, P = 0.038). A sub-group univariate analysis indicated the 5-year PFS was better for those who received at least 68 Gy of radiation (44.4% vs 13.0%, P = 0.044). Patients who achieved CR had a better 5-year PFS than those who did not (57.1% vs 10%, P = 0.006). No patients had a toxicity of grade 3 or more.

Conclusions:

Adjuvant and definitive RT are safe and effective treatments for TC. Patients who received dosages of 68 Gy or more and who had complete tumor regression following definitive RT seemed to have better long-term survival.

Impact of acuros XB algorithm in deep-inspiration breath-hold (DIBH) respiratory techniques used for the treatment of left breast cancer

Aim

To investigate the impact of Acuros XB (AXB) algorithm in the deep-inspiration breath-hold (DIBH) technique used for treatment of left sided breast cancer.

Background

AXB may estimate better lung toxicities and treatment outcome in DIBH.

Materials and Methods

Treatment plans were computed using the field-in-field technique for a 6 MV beam in two respiratory phases - free breathing (FB) and DIBH. The AXB-calculations were performed under identical beam setup and the same numbers of monitor units as used for AAA-calculation.

Results

Mean Hounsfield units (HU), mass density (g/cc) and relative electron density were -782.1 ± 24.8 and -883.5 ± 24.9; 0.196 ± 0.025 and 0.083 ± 0.032; 0.218 ± 0.025 and 0.117 ± 0.025 for the lung in the FB and DIBH respiratory phase, respectively. For a similar target coverage (p > 0.05) in the DIBH respiratory phase between the AXB and AAA algorithm, there was a slight increase in organ at risk (OAR) dose for AXB in comparison to AAA, except for mean dose to the ipsilateral lung. AAA predicts higher mean dose to the ipsilateral lung and lesser V_20Gy for the ipsilateral and common lung in comparison to AXB. The differences in mean dose to the ipsilateral lung were 0.87 ± 2.66 % (p > 0.05) in FB, and 1.01 ± 1.07% (p < 0.05) in DIBH, in V_20Gy the differences were 1.76 ± 0.83% and 1.71 ± 0.82% in FB (p < 0.05), 3.34 ± 1.15 % and 3.24 ± 1.17 % in DIBH (p < 0.05), for the ipsilateral and common lung, respectively.

Conclusion

For a similar target volume coverage, there were important differences between the AXB and AAA algorithm for low-density inhomogeneity medium present in the DIBH respiratory phase for left sided breast cancer patients. DIBH treatment in conjunction with AXB may result in better estimation of lung toxicities and treatment outcome.

Dosimetric comparison of different algorithms in stereotactic body radiation therapy (SBRT) plan for non-small cell lung cancer (NSCLC)

Purposes

The main aim of the study was to investigate the dosimetric difference between acuros XB algorithm (AXB), anisotropic analytic algorithm (AAA), and pencil beam convolution (PBC) algorithm in stereotactic body radiation therapy (SBRT) plan for non-small cell lung cancer (NSCLC).

Patients and Methods

Thirty-eight NSCLC patients were included. GTV, PTV, and organs at risk were delineated by the radiation oncologists. Three optimized SBRT plans for each patients were gained using three algorithms of AXB, AAA, and PBC with the identical plan parameters. Dosimetric endpoints were collected and compared among the three plans, including dosimetric criteria: V100%, V90%, PTV D_min, D_max, D_mean, homogeneity index (HI), and Paddick conformity index (CI).

Results

AXB plan resulted in decreased V100% with a mean difference 6.14% compared with PBC plan (For V100%, AXB vs AAA vs PBC=93.44% vs 95.54% vs 99.58%, P<0.05). Three plans showed no significant difference as to the parameter V90%. AXB plan leaded to reduced D_min of PTV compared with other two algorithms (For D_min of PTV, AXB vs AAA vs PBC=4048cGy vs 4365Gy vs 4873Gy, P<0.05). PBC induced the enhanced trend of D_max of PTV compared with other two algorithms (D_max among three algorithms, P>0.05); and increased the D_mean of PTV in three algorithms with significant difference (For D_mean of PTV, AXB vs AAA vs PBC=5332cGy vs 5330Gy vs 5785Gy, P<0.05). AXB algorithm achieved a similar plan conformity with other two algorithms (For CI, AXB vs AAA vs PBC=0.80 vs 0.85 vs 0.71, P>0.05).

Conclusion

For SBRT plan of NSCLC, AAA and PBC algorithms overestimate target coverage, AXB algorithm is recommended for the SBRT plan of NSCLC.

Comparison of five dose calculation algorithms in a heterogeneous media using design of experiment

PURPOSE

Design of experiments (DoE) provides a methodology to reveal the influence of input values on the measured output with a limited number of trials. The purpose of this study was to describe how DoE can be used to evaluate the performances of several dose calculation systems in heterogeneous media, including algorithms like Pencil Beam (PB), Anisotropic Analytical Algorithm (AAA), Acuros XB (AXB), Monte Carlo (MC) and Collapsed Cone Volume (CCV).

METHOD

This study was carried out using a CIRS Model 002LFC IMRT Thorax Phantom customized with a water-equivalent heterogeneity inside the lung. The calculated dose distributions were compared to Gafchromic® EBT3 film measurements. The beam configurations were selected using DoE to study the influence of five parameters simultaneously (energy, collimator angulation, gantry angulation, X and Y jaws) and to optimize the number of experiments. An analysis of variance was performed over the entire irradiation field and over various regions of interest (tumour, shadow of tumour and lungs).

RESULTS

DoE enabled to quantify and determine the statistically significant factors, leading to an evaluation of the dose calculation systems in the lung case. The resulting scoring could be as follow (from best to worst): AXB_D_m, CCV, AXB_D_w, XVMC_D_m, XVMC_D_w, AAA and last PB. Differences between the algorithms were specially observed in the tumour and the shadow regions.

CONCLUSION

DoE is a robust statistical method to compare several dose calculation systems. The various analyses lead to the conclusion that AXB handled more accurately most of the situations investigated in heterogeneous media.

Evaluation of AAA and XVMC Algorithms for Dose Calculation in Lung Equivalent Heterogeneity in Photon Fields: A Comparison of Calculated Results with Measurements

AIMS

The aims of the present work are (1) to evaluate dose calculation accuracy of two commonly used algorithms for 15 MV small photon fields in a medium encompassing heterogeneity and (2) to compare them with measured results obtained from gafchromic film EBT2.

MATERIALS AND METHODS

Authors employed kailwood (Pinus Wallichiana) to mimic lung. Briefly, seven Kailwood plates, each measuring 25x25 cm² of varying thicknesses totaling 13 cm equivalent to the mean thickness of an adult human lung, were sandwiched between 5 cm tissue equivalent material from top and 10 cm below. Physical measurements were performed using Radiochromic film EBT2. The field sizes of 1x1, 2x2, 5x5 and 10x10 cm² were selected at 100 cm SSD. Simulations were performed using EGSnrc/DOSRZnrc Monte Carlo code. The dose variation inside the inhomogeneity and near the interface was calculated using AAA & XVMC algorithm.

RESULTS

Preliminary results show that there is large variation of dose inside inhomogeneity. The maximum variation of dose inside the inhomogeneity for 1x1 cm² was found 40% by AAA and 4.5% by XVMC compared to measured/simulated results. For the field size of 2x2 cm², these figures were 27% by AAA & 3.5% by XVMC. For 5x5 cm² field size, the variation is small which becomes insignificant for larger fields.

CONCLUSION

The results presented in this work indicate that for smaller fields, XVMC algorithm gives more realistic prediction, while there is the need for caution on using AAA algorithm for dose calculations involving small area irradiation encompassing heterogeneities and low-density media.

Comparative study between Acuros XB algorithm and Anisotropic Analytical Algorithm in the case of heterogeneity for the treatment of lung cancer

The aim of this study was to investigate the impact of heterogeneity on the dose calculation for two algorithms implemented in the TPS “Analytical Anisotropic Algorithm (AAA) and Acuros XB” and validated the use of Acuros XB algorithm in clinical routine. First, we compare the dose calculated by these algorithms and the dose measured at the given point P, which is found after heterogeneity insert. Second, we extend our work on clinical cases that present a complex heterogeneity. By evaluating the impact of the choice of the algorithm on the dose coverage of the tumor, and the dose received by the organs at risk for 20 patients affected by lung cancer.

The result of our phantom study showed a good agreement with several studies that showed the superiority of the Acuros XB over the AAA in predicting dose when it concerns heterogeneous media. The treatment plans for 20 lung cancers were calculated by two algorithms AAA and Acuros XB, the results show a statistical significant difference between algorithms for Homogeneity Index and the maximum dose of planning target volume (HI: 0.11±0.01 vs 0.05±0.01 p = 0.04; Dmax: 69.30±3.12 vs 68.51±2.64 p = 0.02). Instead, no statistically significant difference was observed for conformity index CI and mean dose (CI: 0.98±0.18 vs 0.99±0.14 p = 0.33; Dmean: 66.3±0.65 vs 66.10 ±0.61 p = 0.54). For organs at risk, the maximum dose for spinal cord, mean dose and D37 % of lung minus GTV (dose receiving 37% of lung volume) were found to be lower for AAA plans than Acuros XB and the differences were statistically significant (p<0.05). For the heart D33% and D67% were found to be higher for AAA plans than Acuros XB and the differences were statistically significant (p<0.05), but No difference was observed for D100% of the heart.

The use of the AXB algorithm is suitable in the case of presence of heterogeneity, because it allows to have a better accuracy close to the Monte Carlo calculation.

Verification of Acuros XB dose algorithm using 3D printed low-density phantoms for clinical photon beams

The transport-based dose calculation algorithm Acuros XB (AXB) has been shown to accurately account for heterogeneities primarily through comparisons with Monte Carlo simulations. This study aims to provide additional experimental verification of AXB for clinically relevant flattened and unflattened beam energies in low density phantoms of the same material. Polystyrene slabs were created using a bench-top 3D printer. Six slabs were printed at varying densities from 0.23 to 0.68 g/cm3 , corresponding to different density humanoid tissues. The slabs were used to form different single and multilayer geometries. Dose was calculated with Eclipse™ AXB 11.0.31 for 6MV, 15MV flattened and 6FFF (flattening filter free) energies for field sizes of 2 × 2 and 5 × 5 cm2 . EBT3 film was inserted into the phantoms, which were irradiated. Absolute dose profiles and 2D Gamma analyses were performed for 96 dose planes. For all single slab configurations and energies, absolute dose differences between the AXB calculation and film measurements remained <3% for both fields in the high-dose region, however, larger disagreement was seen within the penumbra. For the multilayered phantom, percentage depth dose with AXB was within 5% of discrete film measurements. The Gamma index at 2%/2 mm averaged 98% in all combinations of fields, phantoms and photon energies. The transport-based dose algorithm AXB is in good agreement with the experimental measurements for small field sizes using 6MV, 6FFF and 15MV beams adjacent to various low-density heterogeneous media. This work provides preliminary experimental grounds to support the use of AXB for heterogeneous dose calculation purposes.

A Dosimetric Study on Slab-pinewood-slab Phantom for Developing the Heterogeneous Chest Phantom Mimicking Actual Human Chest

The aim is to study the density, isodose depths, and doses at different points in slab-pinewood-slab (SPS) phantom, solid phantom SP34 (made up of polystyrene), and chest level of actual patient for developing heterogeneous chest phantom mimicking thoracic region of human body. A 6 MV photon beam of field size of 10 cm × 10 cm was directed perpendicular to the surface of computed tomography (CT) images of chest level of patient, SPS phantom, and SP34 phantom. Dose was calculated using anisotropic analytical algorithm. Hounsfield units were used to calculate the density of each medium. Isodose depths in all the three sets of CT images were measured. Variations between planned doses on treatment planning system (TPS) and measured on linear accelerator (LA) were calculated for three points, namely, near slab–pinewood interfaces (6 and 18 cm depths) and 10 cm depth in SPS phantom and at the same depths in SP34 phantom. Density of pinewood, SP34 slabs, chest wall, lung, and soft tissue behind lung was measured as 0.329 ± 0.08, 0.999 ± 0.02, 0.898 ± 0.02, 0.291 ± 0.12, and 1.002 ± 0.03 g/cc, respectively. Depths of 100% and 90% isodose curves in all the three sets of CT images were found to be similar. Depths of 80%, 70%, 60%, 50%, and 40% isodose lines in SPS phantom images were found to be equivalent to that in chest images, while it was least in SP34 phantom images. Variations in doses calculated at 6, 10, and 18 cm depths on TPS and measured on LA were found to be 0.36%, 1.65%, and 2.23%, respectively, in case of SPS phantom, while 0.24%, 0.90%, and 0.93%, respectively, in case of SP34 slab phantom. SPS phantom seemed equivalent to the chest level of human body. Dosimetric results of this study indicate that patient-specific quality assurance can be done using chest phantom mimicking thoracic region of human body, which has been fabricated using polystyrene and pinewood.

Dosimetric influence of photon beam energy and number of arcs on volumetric modulated arc therapy in carcinoma cervix: A planning study

AIM

Aim of the present study was to compare the dosimetric impact of different photon beam energies and number of arcs in the treatment of carcinoma cervix.

BACKGROUND

Carcinoma cervix is a common cancer in women worldwide with a high morbidity rate. Radiotherapy is used to treat such tumours. Volumetric Modulated Arc Therapy (VMAT) is considered superior to other techniques with multiple arcs and energies.

MATERIALS AND METHODS

Twenty patients with carcinoma cervix underwent radiotherapy in a prospective observation study conducted at our institute. Volumetric modulated arc plans with 6 MV, 10 MV and 15 MV photon energies using single arc (SA) and dual arc (DA) were generated. Several physical indices for planning target volume (PTV) like V95%, V100%, V110%, D98%, D50%, D2% and total number of MUs were compared. Normal Tissue Integral Dose (NTID) and dose to a shell structure PHY2.5 and PHY5.0 were analyzed.

RESULTS

Comparable dose coverage to PTV was observed for all the energies and arcs. CI for DA6MV (1.095) was better than SA6MV (1.127), SA10MV (1.116) and SA15MV (1.116). Evaluated parameters showed significant reduction in OAR doses. Mean bladder dose for DA6MV (41.90 Gy) was better than SA6MV (42.48 Gy), SA10MV (42.08 Gy) and SA15MV (41.93 Gy). Similarly, p-value for the mean rectal dose calculated was 0.001 (SA6 vs 15), 0.013 (DA6 vs 10) and 0.003 (DA6 vs 15) and subsequently favoured DA6MV. Difference in NTID was very small.

CONCLUSIONS

The study showed no greater advantage of higher energy, and DA VMAT plan with 6 MV photon energy was a good choice of treatment for carcinoma cervix as it delivered a highly homogeneous and conformal plan with superior target coverage and better OAR sparing.

Quantitative comparison of dose distribution in radiotherapy plans using 2D gamma maps and X-ray computed tomography

BACKGROUND

The advanced dose calculation algorithms implemented in treatment planning system (TPS) have remarkably improved the accuracy of dose calculation especially the modeling of electrons transport in the low density medium. The purpose of this study is to evaluate the use of 2D gamma (γ) index to quantify and evaluate the impact of the calculation of electrons transport on dose distribution for lung radiotherapy.

METHODS

X-ray computed tomography images were used to calculate the dose for twelve radiotherapy treatment plans. The doses were originally calculated with Modified Batho (MB) 1D density correction method, and recalculated with anisotropic analytical algorithm (AAA), using the same prescribed dose. Dose parameters derived from dose volume histograms (DVH) and target coverage indices were compared. To compare dose distribution, 2D γ-index was applied, ranging from 1%/1 mm to 6%/6 mm. The results were displayed using γ-maps in 2D. Correlation between DVH metrics and γ passing rates was tested using Spearman's rank test and Wilcoxon paired test to calculate P values.

RESULTS

the plans generated with AAA predicted more heterogeneous dose distribution inside the target, with P<0.05. However, MB overestimated the dose predicting more coverage of the target by the prescribed dose. The γ analysis showed that the difference between MB and AAA could reach up to ±10%. The 2D γ-maps illustrated that AAA predicted more dose to organs at risks, as well as lower dose to the target compared to MB.

CONCLUSIONS

Taking into account of the electrons transport on radiotherapy plans showed a significant impact on delivered dose and dose distribution. When considering the AAA represent the true cumulative dose, a readjusting of the prescribed dose and an optimization to protect the organs at risks should be taken in consideration in order to obtain the better clinical outcome.

Lung dose analysis in loco-regional hypofractionated radiotherapy of breast cancer

OBJECTIVES

To report the ipsilateral lung dosimetry data of breast cancer (BC) patients treated with loco-regional hypofractionated radiotherapy (HFRT). 

METHODS

Treatment plans of 150 patients treated in the Radiotherapy Unit, King Abdulaziz University Hospital, Jeddah, Kingdom of Saudi Arabia between January 2012 and March 2015 by HFRT for BC were retrospectively reviewed. All patients received 42.4 Gy in 16 fractions by tangential and supra-clavicular fields with 6 MV, 18 MV, or mixed energies. Ipsilateral lung dosimetric data V20Gy and mean lung dose (MLD) were recorded. Correlations between lung dose, patient characteristics, and treatment delivery parameters were assessed by a logistic regression test.

RESULTS

The mean ipsilateral lung V20Gy was 24.6% and mean MLD was 11.9 Gy. A weak, but statistically significant correlation was found between lung dose and lung volume (p=0.043). The lung dose was significantly decreasing with patient separation and depth of axillary lymph node (ALN) and supra-claviculary lymph nodes (SCLN) (p less than 0.0001), and increasing with ALN (p=0.001) and SCLN (p=0.003) dose coverage. Lung dose significantly decreased with beam energy (p less than 0.0001): mean V20Gy was 27.8%, 25.4% for 6 MV, mixed energy, and 21.2% for 18 MV. The use of a low breast-board angle correlates with low lung dose.

CONCLUSION

Our data suggest that the use of high energy photon beams and low breast-board angulation can reduce the lung dose.

Comparative evaluation of modern dosimetry techniques near low- and high-density heterogeneities

The purpose of this study is to compare performance of several dosimetric methods in heterogeneous phantoms irradiated by 6 and 18 MV beams. Monte Carlo (MC) calculations were used, along with two versions of Acuros XB, anisotropic analytical algorithm (AAA), EBT2 film, and MOSkin dosimeters. Percent depth doses (PDD) were calculated and measured in three heterogeneous phantoms. The first two phantoms were a 30×30×30 cm3 solid‐water slab that had an air‐gap of 20×2.5×2.35 cm3. The third phantom consisted of 30×30×5 cm3 solid water slabs, two 30×30×5 cm3 slabs of lung, and one 30×30×1 cm3 solid water slab. Acuros XB, AAA, and MC calculations were within 1% in the regions with particle equilibrium. At media interfaces and buildup regions, differences between Acuros XB and MC were in the range of +4.4% to −12.8%. MOSkin and EBT2 measurements agreed to MC calculations within ∼2.5%, except for the first centimeter of buildup where differences of 4.5% were observed. AAA did not predict the backscatter dose from the high‐density heterogeneity. For the third, multilayer lung phantom, 6 MV beam PDDs calculated by all TPS algorithms were within 2% of MC. 18 MV PDDs calculated by two versions of Acuros XB and AAA differed from MC by up to 2.8%, 3.2%, and 6.8%, respectively. MOSkin and EBT2 each differed from MC by up to 2.9% and 2.5% for the 6 MV, and by −3.1% and ∼2% for the 18 MV beams. All dosimetric techniques, except AAA, agreed within 3% in the regions with particle equilibrium. Differences between the dosimetric techniques were larger for the 18 MV than the 6 MV beam. MOSkin and EBT2 measurements were in a better agreement with MC than Acuros XB calculations at the interfaces, and they were in a better agreement to each other than to MC. The latter is due to their thinner detection layers compared to MC voxel sizes.

PACS numbers: 87.55.K‐, 87.55.kd, 87.55.km, 87.53.Bn, 87.55.k

Commissioning and comprehensive evaluation of the ArcCHECK cylindrical diode array for VMAT pretreatment delivery QA

We present commissioning and comprehensive evaluation for ArcCHECK as a QA equipment for volumetric-modulated arc therapy (VMAT), using the 6 MV photon beam with and without the flattening filter, and the SNC patient software (version 6.2). In addition to commissioning involving absolute dose calibration, array calibration, and PMMA density verification, ArcCHECK was evaluated for its response dependency on linac dose rate, instantaneous dose rate, radiation field size, beam angle, and couch insertion. Scatter dose characterization, consistency and symmetry of response, and dosimetry accuracy evaluation for fixed aperture arcs and clinical VMAT patient plans were also investigated. All the evaluation tests were performed with the central plug inserted and the homogeneous PMMA density value. Results of gamma analysis demonstrated an overall agreement between ArcCHECK-measured and TPS-calculated reference doses. The diode based field size dependency was found to be within 0.5% of the reference. The dose rate-based dependency was well within 1% of the TPS reference, and the angular dependency was found to be ± 3% of the reference, as tested for BEV angles, for both beams. Dosimetry of fixed arcs, using both narrow and wide field widths, resulted in clinically acceptable global gamma passing rates on the 3%/3mm level and 10% threshold. Dosimetry of narrow arcs showed an improvement over published literature. The clinical VMAT cases demonstrated high level of dosimetry accuracy in gamma passing rates.

Clinical impact of using the deterministic patient dose calculation algorithm Acuros XB for lung stereotactic body radiation therapy

PURPOSE

To evaluate the clinical impact of using the deterministic dose calculation algorithm, Acuros XB, for early stage lung cancer patients undergoing stereotactic body radiotherapy (SBRT).

MATERIAL AND METHODS

Seventy-seven stage I non-small cell lung cancer patients who underwent lung SBRT from 2008 to 2012 at our center were included in this study. All treatment plans originally calculated by the anisotropic analytical algorithm (AAA) were recalculated using the AAA and Acuros XB algorithms with identical monitor units and beam arrangements. The dose, dose distribution, conformality number (CN) and heterogeneity index (HI) of the target were determined for each plan. A paired matched t-test was used to evaluate the difference between the mean dose, the dose distribution, and the CN and HI for the target. The importance of tumor (volume, location), patient (pulmonary functional, body mass index) and treatment (number of SBRT beams) on the dose distributions obtained from the two algorithms was statistically determined using linear regression analyses.

RESULTS

The mean target dose was same for both algorithms. Compared to AAA, a small and significant difference in dose distribution in the target was found for the Acuros XB algorithm, resulting in lower conformity (-2.1%, p < 0.0001) and higher heterogeneity (p < 0.0001) of dose. Single logistic regression identified pulmonary function, number of beams and target location as being correlated with the difference of CN between the two calculations. Multivariate analysis indicated that the patient's pulmonary function (p = 0.0296) was the only predictor for the difference in conformality between the two dose calculation algorithms.

CONCLUSIONS

In lung SBRT, the patient's pulmonary function is responsible for the difference in target dose distribution between the Acuros XB and AAA algorithms. The Acuros XB algorithm could be used to advantage in patients with compromised pulmonary function based on its accurate modeling of lung tissue in comparison to AAA.

Optimal set of grid size and angular increment for practical dose calculation using the dynamic conformal arc technique: a systematic evaluation of the dosimetric effects in lung stereotactic body radiation therapy

PURPOSE

To recommend the optimal plan parameter set of grid size and angular increment for dose calculations in treatment planning for lung stereotactic body radiation therapy (SBRT) using dynamic conformal arc therapy (DCAT) considering both accuracy and computational efficiency.

MATERIALS AND METHODS

Dose variations with varying grid sizes (2, 3, and 4 mm) and angular increments (2°, 4°, 6°, and 10°) were analyzed in a thorax phantom for 3 spherical target volumes and in 9 patient cases. A 2-mm grid size and 2° angular increment are assumed sufficient to serve as reference values. The dosimetric effect was evaluated using dose-volume histograms, monitor units (MUs), and dose to organs at risk (OARs) for a definite volume corresponding to the dose-volume constraint in lung SBRT. The times required for dose calculations using each parameter set were compared for clinical practicality.

RESULTS

Larger grid sizes caused a dose increase to the structures and required higher MUs to achieve the target coverage. The discrete beam arrangements at each angular increment led to over- and under-estimated OARs doses due to the undulating dose distribution. When a 2° angular increment was used in both studies, a 4-mm grid size changed the dose variation by up to 3-4% (50 cGy) for the heart and the spinal cord, while a 3-mm grid size produced a dose difference of <1% (12 cGy) in all tested OARs. When a 3-mm grid size was employed, angular increments of 6° and 10° caused maximum dose variations of 3% (23 cGy) and 10% (61 cGy) in the spinal cord, respectively, while a 4° increment resulted in a dose difference of <1% (8 cGy) in all cases except for that of one patient. The 3-mm grid size and 4° angular increment enabled a 78% savings in computation time without making any critical sacrifices to dose accuracy.

CONCLUSIONS

A parameter set with a 3-mm grid size and a 4° angular increment is found to be appropriate for predicting patient dose distributions with a dose difference below 1% while reducing the computation time by more than half for lung SBRT using DCAT.

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.

On the quantification of the dosimetric accuracy of collapsed cone convolution superposition (CCCS) algorithm for small lung volumes using IMRT

Specialized techniques that make use of small field dosimetry are common practice in today's clinics. These new techniques represent a big challenge to the treatment planning systems due to the lack of lateral electronic equilibrium. Because of this, the necessity of planning systems to overcome such difficulties and provide an accurate representation of the true value is of significant importance. Pinnacle3 is one such planning system. During the IMRT optimization process, Pinnacle3 treatment planning system allows the user to specify a minimum segment size which results in multiple beams composed of several subsets of different widths. In this study, the accuracy of the engine dose calculation, collapsed cone convolution superposition algorithm (CCCS) used by Pinnacle3, was quantified by Monte Carlo simulations, ionization chamber, and Kodak extended dose range film (EDR2) measurements for 11 SBRT lung patients. Lesions were < 3.0 cm in maximal diameter and <27.0cm3 in volume. The Monte Carlo EGSnrc\BEAMnrc and EGS4\MCSIM were used in the comparison. The minimum segment size allowable during optimization had a direct impact on the number of monitor units calculated for each beam. Plans with the smallest minimum segment size (0.1 cm2 to 2.0 cm2) had the largest number of MUs. Although PTV coverage remained unaffected, the segment size did have an effect on the dose to the organs at risk. Pinnacle3-calculated PTV mean doses were in agreement with Monte Carlo-calculated mean doses to within 5.6% for all plans. On average, the mean dose difference between Monte Carlo and Pinnacle3 for all 88 plans was 1.38%. The largest discrepancy in maximum dose was 5.8%, and was noted for one of the plans using a minimum segment size of 1.0 cm2. For minimum dose to the PTV, a maximum discrepancy between Monte Carlo and Pinnacle3 was noted of 12.5% for a plan using a 6.0 cm2 minimum segment size. Agreement between point dose measurements and Pinnacle3-calculated doses were on average within 0.7% in both phantoms. The profiles show a good agreement between Pinnacle3, Monte Carlo, and EDR2 film. The gamma index and the isodose lines support the result.

Impact of the calculation resolution of AAA for small fields and RapidArc treatment plans

PURPOSE

To investigate the impact of the calculation resolution of the anisotropic analytical algorithms (AAA) for a variety of small fields in homogeneous and heterogeneous media and for RapidArc plans.

METHODS

Dose distributions calculated using AAA version 8.6.15 (AAA8) and 10.0.25 (AAA10) were compared to measurements performed with GafChromic EBT film, using phantoms made of polystyrene or a combination of polystyrene and cork. The accuracy of the algorithms calculated using grid resolutions of 2.5 and 1.0 mm was investigated for different field sizes, and for a limited selection of RapidArc plans (head and neck, small meningioma, and lung). Additional plans were optimized to create excessive multileaf collimator modulation and measured on a homogenous phantom. Gamma evaluation criterion of 3% dose difference and 2- or 1-mm distance to agreement (DTA) were applied to evaluate the accuracy of the algorithms.

RESULTS

For fields < or = 3 x 3 cm2, both versions of AAA predicted lower peak doses and broader penumbra widths than the measurements. However, AAA10 and a finer calculation grid improved the agreement. For RapidArc plans with many small multileaf collimator (MLC) segments and relatively high number of monitor units (MU), AAA8 failed to identify small dose peaks within the target. Both versions performed better in polystyrene than in cork. In homogeneous cork layers, AAA8 underestimated the average target dose for a clinical lung plan. This was improved with AAA10 calculated using a 1 mm grid.

CONCLUSIONS

AAA10 improves the accuracy of dose calculations, and calculation grid of 1.0 mm is superior to using 2.5 mm, although calculation times increased by factor of 5. A suitable upper MU constraint should be assigned during optimization to avoid plans with high modulation. For plans with a relative high number of monitor units, calculations using 1 mm grid resolution are recommended. For planning target volume (PTV) which contains relatively large area of low density tissue, users should be aware of possible dose underestimation in the low density region and recalculation with AAA10 grid 1.0 mm is recommended.

Dependences of mucosal dose on photon beams in head-and-neck intensity-modulated radiation therapy: a Monte Carlo study

Dependences of mucosal dose in the oral or nasal cavity on the beam energy, beam angle, multibeam configuration, and mucosal thickness were studied for small photon fields using Monte Carlo simulations (EGSnrc-based code), which were validated by measurements. Cylindrical mucosa phantoms (mucosal thickness = 1, 2, and 3 mm) with and without the bone and air inhomogeneities were irradiated by the 6- and 18-MV photon beams (field size = 1 × 1 cm(2)) with gantry angles equal to 0°, 90°, and 180°, and multibeam configurations using 2, 4, and 8 photon beams in different orientations around the phantom. Doses along the central beam axis in the mucosal tissue were calculated. The mucosal surface doses were found to decrease slightly (1% for the 6-MV photon beam and 3% for the 18-MV beam) with an increase of mucosal thickness from 1-3 mm, when the beam angle is 0°. The variation of mucosal surface dose with its thickness became insignificant when the beam angle was changed to 180°, but the dose at the bone-mucosa interface was found to increase (28% for the 6-MV photon beam and 20% for the 18-MV beam) with the mucosal thickness. For different multibeam configurations, the dependence of mucosal dose on its thickness became insignificant when the number of photon beams around the mucosal tissue was increased. The mucosal dose with bone was varied with the beam energy, beam angle, multibeam configuration and mucosal thickness for a small segmental photon field. These dosimetric variations are important to consider improving the treatment strategy, so the mucosal complications in head-and-neck intensity-modulated radiation therapy can be minimized.

Dosimetric validation of Acuros XB with Monte Carlo methods for photon dose calculations

PURPOSE

The dosimetric accuracy of the recently released Acuros XB advanced dose calculation algorithm (Varian Medical Systems, Palo Alto, CA) is investigated for single radiation fields incident on homogeneous and heterogeneous geometries, and a comparison is made to the analytical anisotropic algorithm (AAA).

METHODS

Ion chamber measurements for the 6 and 18 MV beams within a range of field sizes (from 4.0 x 4.0 to 30.0 x 30.0 cm2) are used to validate Acuros XB dose calculations within a unit density phantom. The dosimetric accuracy of Acuros XB in the presence of lung, low-density lung, air, and bone is determined using BEAMnrc/DOSXYZnrc calculations as a benchmark. Calculations using the AAA are included for reference to a current superposition/convolution standard.

RESULTS

Basic open field tests in a homogeneous phantom reveal an Acuros XB agreement with measurement to within +/- 1.9% in the inner field region for all field sizes and energies. Calculations on a heterogeneous interface phantom were found to agree with Monte Carlo calculations to within +/- 2.0% (sigmaMC = 0.8%) in lung (p = 0.24 g cm(-3)) and within +/- 2.9% (sigmaMC = 0.8%) in low-density lung (p = 0.1 g cm(-3)). In comparison, differences of up to 10.2% and 17.5% in lung and low-density lung were observed in the equivalent AAA calculations. Acuros XB dose calculations performed on a phantom containing an air cavity (p = 0.001 g cm(-3)) were found to be within the range of +/- 1.5% to +/- 4.5% of the BEAMnrc/DOSXYZnrc calculated benchmark (sigmaMC = 0.8%) in the tissue above and below the air cavity. A comparison of Acuros XB dose calculations performed on a lung CT dataset with a BEAMnrc/DOSXYZnrc benchmark shows agreement within +/- 2%/2mm and indicates that the remaining differences are primarily a result of differences in physical material assignments within a CT dataset.

CONCLUSIONS

By considering the fundamental particle interactions in matter based on theoretical interaction cross sections, the Acuros XB algorithm is capable of modeling radiotherapy dose deposition with accuracy only previously achievable with Monte Carlo techniques.

Monte Carlo study on mucosal dose in oral and naval cavity using photon beams with small field

We study how mucosal dose in the oral or nasal cavity depends on the irradiated small segmental photon fields varying with beam energy, beam angle and mucosa thickness. Dose ratio (mucosal dose with bone underneath to dose at the same point without bone) reflecting the dose enhancement due to the bone backscatter was determined by Monte Carlo simulation (EGSnrc-based code), validated by measurements. Phase space files based on the 6 and 18 MV photon beams with small field size of 1 × 1 cm2, produced by a Varian 21 EX linear accelerator, were generated using the BEAMnrc Monte Carlo code. Mucosa phantoms (mucosa thickness = 1, 2 and 3 mm) with and without a bone under the mucosa were irradiated by photon beams with gantry angles varying from 0 to 30°. Doses along the central beam axis in the mucosa and the dose ratio were calculated with different mucosa thicknesses. For the 6 MV photon beams, the dose at the mucosa-bone interface increased by 44.9–41.7%, when the mucosa thickness increased from 1 to 3 mm for the beam angle ranging from 0 to 30°. These values were lower than those (58.8–53.6%) for the 18 MV photon beams with the same beam angle range. For both the 6 and 18 MV photon beams, depth doses in the mucosa were found to increase with an increase of the beam angle. Moreover, the dose gradient in the mucosa was greater for the 18 MV photon beams compared to the 6 MV. For the dose ratio, it was found that the dose enhancement due to the bone backscatter increased with a decrease of mucosa thickness, and was more significant at both the air-mucosa and mucosa-bone interface. Mucosal dose with bone was investigated by Monte Carlo simulations with different experimental configurations, and was found vary with the beam energy, beam angle and mucosa thickness for a small segmental photon field. The dosimetric information in this study should be considered when searching for an optimized treatment strategy to minimize the mucosal complications in the head-and-neck intensity-modulated radiation therapy.

The impact of dose calculation algorithms on partial and whole breast radiation treatment plans

Background

This paper compares the calculated dose to target and normal tissues when using pencil beam (PBC), superposition/convolution (AAA) and Monte Carlo (MC) algorithms for whole breast (WBI) and accelerated partial breast irradiation (APBI) treatment plans.

Methods

Plans for 10 patients who met all dosimetry constraints on a prospective APBI protocol when using PBC calculations were recomputed with AAA and MC, keeping the monitor units and beam angles fixed. Similar calculations were performed for WBI plans on the same patients. Doses to target and normal tissue volumes were tested for significance using the paired Student's t-test.

Results

For WBI plans the average dose to target volumes when using PBC calculations was not significantly different than AAA calculations, the average PBC dose to the ipsilateral breast was 10.5% higher than the AAA calculations and the average MC dose to the ipsilateral breast was 11.8% lower than the PBC calculations. For ABPI plans there were no differences in dose to the planning target volume, ipsilateral breast, heart, ipsilateral lung, or contra-lateral lung. Although not significant, the maximum PBC dose to the contra-lateral breast was 1.9% higher than AAA and the PBC dose to the clinical target volume was 2.1% higher than AAA. When WBI technique is switched to APBI, there was significant reduction in dose to the ipsilateral breast when using PBC, a significant reduction in dose to the ipsilateral lung when using AAA, and a significant reduction in dose to the ipsilateral breast and lung and contra-lateral lung when using MC.

Conclusions

There is very good agreement between PBC, AAA and MC for all target and most normal tissues when treating with APBI and WBI and most of the differences in doses to target and normal tissues are not clinically significant. However, a commonly used dosimetry constraint, as recommended by the ASTRO consensus document for APBI, that no point in the contra-lateral breast volume should receive >3% of the prescribed dose needs to be relaxed to >5%.

Verification of IMRT dose calculations using AAA and PBC algorithms in dose buildup regions

The purpose of this comparative study was to test the accuracy of anisotropic analytical algorithm (AAA) and pencil beam convolution (PBC) algorithms of Eclipse treatment planning system (TPS) for dose calculations in the low- and high-dose buildup regions. AAA and PBC algorithms were used to create two intensity-modulated radiotherapy (IMRT) plans of the same optimal fluence generated from a clinically simulated oropharynx case in an in-house fabricated head and neck phantom. The TPS computed buildup doses were compared with the corresponding measured doses in the phantom using thermoluminescence dosimeters (TLD 100). Analysis of dose distribution calculated using PBC and AAA shows an increase in gamma value in the dose buildup region indicating large dose deviation. For the surface areas of 1, 50 and 100 cm2, PBC overestimates doses as compared to AAA calculated value in the range of 1.34%-3.62% at 0.6 cm depth, 1.74%-2.96% at 0.4 cm depth, and 1.96%-4.06% at 0.2 cm depth, respectively. In high-dose buildup region, AAA calculated doses were lower by an average of -7.56% (SD = 4.73%), while PBC was overestimated by 3.75% (SD = 5.70%) as compared to TLD measured doses at 0.2 cm depth. However, at 0.4 and 0.6 cm depth, PBC overestimated TLD measured doses by 5.84% (SD = 4.38%) and 2.40% (SD = 4.63%), respectively, while AAA underestimated the TLD measured doses by -0.82% (SD = 4.24%) and -1.10% (SD = 4.14%) at the same respective depth. In low-dose buildup region, both AAA and PBC overestimated the TLD measured doses at all depths except -2.05% (SD = 10.21%) by AAA at 0.2 cm depth. The differences between AAA and PBC at all depths were statistically significant (p < 0.05) in high-dose buildup region, whereas it is not statistically significant in low-dose buildup region. In conclusion, AAA calculated the dose more accurately than PBC in clinically important high-dose buildup region at 0.4 cm and 0.6 cm depths. The use of an orfit cast increases the dose buildup effect, and this buildup effect decreases with depth.

Monte Carlo evaluation of RapidArc oropharynx treatment planning strategies for sparing of midline structures

The aim of the study was to perform the Monte Carlo (MC) evaluation of RapidArc (Varian Medical Systems, Palo Alto, CA) dose calculations for four oropharynx midline sparing planning strategies. Six patients with squamous cell cancer of the oropharynx were each planned with four RapidArc head and neck treatment strategies consisting of single and double photon arcs. In each case, RTOG0522 protocol objectives were used during planning optimization. Dose calculations performed with the analytical anisotropic algorithm (AAA) are compared against BEAMnrc/DOSXYZnrc dose calculations for the 24-plan dataset. Mean dose and dose-to-98%-of-structure-volume (D(98%)) were used as metrics in the evaluation of dose to planning target volumes (PTVs). Mean dose and dose-to-2%-of-structure-volume (D(2%)) were used to evaluate dose differences within organs at risk (OAR). Differences in the conformity index (CI) and the homogeneity index (HI) as well as 3D dose distributions were also observed. AAA calculated PTV mean dose, D(98%), and HIs showed very good agreement with MC dose calculations within the 0.8% MC (statistical) calculation uncertainty. Regional node volume (PTV-80%) mean dose and D(98%) were found to be overestimated (1.3%, sigma = 0.8% and 2.3%, sigma = 0.8%, respectively) by the AAA with respect to MC calculations. Mean dose and D(2%) to OAR were also observed to be consistently overestimated by the AAA. Increasing dose calculation differences were found in planning strategies exhibiting a higher overall fluence modulation. From the plan dataset, the largest local dose differences were observed in heavily shielded regions and within the esophageal and sinus cavities. AAA dose calculations as implemented in RapidArc demonstrate excellent agreement with MC calculations in unshielded regions containing moderate inhomogeneities. Acceptable agreement is achieved in regions of increased MLC shielding. Differences in dose are attributed to inaccuracies in the AAA-modulated fluence modeling, modeling of material inhomogeneities and dose deposition within low-density materials. The use of MC dose calculations leads to the same general conclusion as using AAA that a two arc delivery with limited collimator opening can provide the greatest amount of midline sparing compared to the other techniques investigated.

Validation of the Eclipse AAA algorithm at extended SSD

The accuracy of dose calculations at extended SSD is of significant importance in the dosimetric planning of total body irradiation (TBI). In a first step toward the implementation of electronic, multi-leaf collimator compensation for dose inhomogeneities and surface contour in TBI, we have evaluated the ability of the Eclipse AAA to accurately predict dose distributions in water at extended SSD. For this purpose, we use the Eclipse AAA algorithm, commissioned with machine-specific beam data for a 6 MV photon beam, at standard SSD (100 cm). The model was then used for dose distribution calculations at extended SSD (179.5 cm). Two sets of measurements were acquired for a 6 MV beam (from a Varian linear accelerator) in a water tank at extended SSD: i) open beam for 5 x 5, 10 x 10, 20 x 20 and 40 x 40 cm2 field sizes (defined at 179.5 cm SSD), and ii) identical field sizes but with a 1.3 cm thick acrylic spoiler placed 10 cm above the water surface. Dose profiles were acquired at 5 cm, 10 cm and 20 cm depths. Dose distributions for the two setups were calculated using the AAA algorithm in Eclipse. Confidence limits for comparisons between measured and calculated absolute depth dose curves and normalized dose profiles were determined as suggested by Venselaar et al. The confidence limits were within 2% and 2 mm for both setups. Extended SSD calculations were also performed using Eclipse AAA, commissioned with Varian Golden beam data at standard SSD. No significant difference between the custom commissioned and Golden Eclipse AAA was observed. In conclusion, Eclipse AAA commissioned at standard SSD can be used to accurately predict dose distributions in water at extended SSD for 6 MV open beams.

Variations of lung density and geometry on inhomogeneity correction algorithms: a Monte Carlo dosimetric evaluation

This work contributed the following new information to the study of inhomogeneity correction algorithm: (1) Evaluation of lung dose calculation methods as a function of lung relative electron density (rhoe,lung) and treatment geometry and (2) comparison of doses calculated using the collapsed cone convolution (CCC) and adaptive convolution (AC) in lung using the Monte Carlo (MC) simulation with the EGSnrc-based code. The variations of rhoe,lung and geometry such as the position and dimension of the lung were studied with different photon beam energies and field sizes. Three groups of inhomogeneous lung phantoms, namely, "slab," "column," and "cube," with different positions, volumes, and shapes of lung in water as well as clinical computed tomography lung images were used. The rhoe,lung in each group of phantoms vary from 0.05 to 0.7. 6 and 18 MV photon beams with small (4 x 4 cm2) and medium (10 x 10 cm2) field sizes produced by a Varian 21 EX linear accelerator were used. This study reveals that doses in the inhomogeneous lung calculated by the CCC match well with those by AC within +/- 1%, indicating that the AC, with an advantage of shorter computing times (three to four times shorter than CCC), is a good substitute for CCC. Comparing the CCC and AC to MC in general, significant dose deviations are found when the rhoe,lung is < or =0.3. The degree of deviation depends on the photon beam energy and field size and is relatively large when high-energy photon beams with small fields are used. For penumbra widths (20%-80%), the CCC and AC agree well with MC for the slab and cube phantoms with the lung volumes at the central beam axis (CAX). However, deviations (>2 mm) occur in the column phantoms, with two lung volumes separated by a unit density column along the CAX in the middle using the 18 MV beam with 4 x 4 cm2 field for rhoe,lung < or =0.1. This study provides new dosimetric data to evaluate the impact of the variations of rhoe,lung and geometry on dose calculations in inhomogeneous media using CCC and AC.