Clinical knowledge-based inverse treatment planning

Clinical IMRT treatment plans are currently made using dose-based optimization algorithms, which do not consider the nonlinear dose-volume effects for tumours and normal structures. The choice of structure specific importance factors represents an additional degree of freedom of the system and makes rigorous optimization intractable. The purpose of this work is to circumvent the two problems by developing a biologically more sensible yet clinically practical inverse planning framework. To implement this, the dose-volume status of a structure was characterized by using the effective volume in the voxel domain. A new objective function was constructed with the incorporation of the volumetric information of the system so that the figure of merit of a given IMRT plan depends not only on the dose deviation from the desired distribution but also the dose-volume status of the involved organs. The conventional importance factor of an organ was written into a product of two components: (i) a generic importance that parametrizes the relative importance of the organs in the ideal situation when the goals for all the organs are met; (ii) a dose-dependent factor that quantifies our level of clinical/dosimetric satisfaction for a given plan. The generic importance can be determined a priori, and in most circumstances, does not need adjustment, whereas the second one, which is responsible for the intractable behaviour of the trade-off seen in conventional inverse planning, was determined automatically. An inverse planning module based on the proposed formalism was implemented and applied to a prostate case and a head-neck case. A comparison with the conventional inverse planning technique indicated that, for the same target dose coverage, the critical structure sparing was substantially improved for both cases. The incorporation of clinical knowledge allows us to obtain better IMRT plans and makes it possible to auto-select the importance factors, greatly facilitating the inverse planning process. The new formalism proposed also reveals the relationship between different inverse planning schemes and gives important insight into the problem of therapeutic plan optimization. In particular, we show that the EUD-based optimization is a special case of the general inverse planning formalism described in this paper.

A method for determination of the absorption and scattering properties interstitially in turbid media

We have developed a method to quickly determine tissue optical properties (absorption coefficient mu(a) and transport scattering coefficient mu'(s)) by measuring the ratio of light fluence rate to source power along a linear channel at a fixed distance (5 mm) from an isotropic point source. Diffuse light is collected by an isotropic detector whose position is determined by a computer-controlled step motor, with a positioning accuracy of better than 0.1 mm. The system automatically records and plots the light fluence rate per unit source power as a function of position. The result is fitted with a diffusion equation to determine mu(a) and mu'(s). We use an integrating sphere to calibrate each source-detector pair, thus reducing uncertainty of individual calibrations. To test the ability of this algorithm to accurately recover the optical properties of the tissue, we made measurements in tissue simulating phantoms consisting of Liposyn at concentrations of 0.23, 0.53 and 1.14% (mu'(s) = 1.7-9.1 cm(-1)) in the presence of Higgins black India ink at concentrations of 0.002, 0.012 and 0.023% (mu(a) = 0.1-1 cm(-1)). For comparison, the optical properties of each phantom are determined independently using broad-beam illumination. We find that mu(a) and mu'(s) can be determined by this method with a standard (maximum) deviation of 8% (15%) and 18% (32%) for mu(a) and mu'(s), respectively. The current method is effective for samples whose optical properties satisfy the requirement of the diffusion approximation. The error caused by the air cavity introduced by the catheter is small, except when mu(a) is large (mu(a) > 1 cm(-1)). We presented in vivo data measured in human prostate using this method.

Dosimetric evaluation of MRI-based treatment planning for prostate cancer

The purpose of this study is to evaluate the dosimetric accuracy of MRI-based treatment planning for prostate cancer using a commercial radiotherapy treatment planning system. Three-dimensional conformal plans for 15 prostate patients were generated using the AcQPlan system. For each patient, dose distributions were calculated using patient CT data with and without heterogeneity correction, and using patient MRI data without heterogeneity correction. MR images were post-processed using the gradient distortion correction (GDC) software. The distortion corrected MR images were fused to the corresponding CT for each patient for target and structure delineation. The femoral heads were delineated based on CT. Other anatomic structures relevant to the treatment (i.e., prostate, seminal vesicles, lymph notes, rectum and bladder) were delineated based on MRI. The external contours were drawn separately on CT and MRI. The same internal contours were used in the dose calculation using CT- and MRI-based geometries by directly transferring them between MRI and CT as needed. Treatment plans were evaluated based on maximum dose, isodose distributions and dose-volume histograms. The results confirm previous investigations that there is no clinically significant dose difference between CT-based prostate plans with and without heterogeneity correction. The difference in the target dose between CT- and MRI-based plans using homogeneous geometry was within 2.5%. Our results suggest that MRI-based treatment planning is suitable for radiotherapy of prostate cancer.

Experimental characterization and physical modelling of the dose distribution of scanned proton pencil beams

In this paper we present the pencil beam dose model used for treatment planning at the PSI proton gantry, the only system presently applying proton therapy with a beam scanning technique. The scope of the paper is to give a general overview on the various components of the dose model, on the related measurements and on the practical parametrization of the results. The physical model estimates from first physical principles absolute dose normalized to the number of incident protons. The proton beam flux is measured in practice by plane-parallel ionization chambers (ICs) normalized to protons via Faraday-cup measurements. It is therefore possible to predict and deliver absolute dose directly from this model without other means. The dose predicted in this way agrees very well with the results obtained with ICs calibrated in a cobalt beam. Emphasis is given in this paper to the characterization of nuclear interaction effects, which play a significant role in the model and are the major source of uncertainty in the direct estimation of the absolute dose. Nuclear interactions attenuate the primary proton flux, they modify the shape of the depth-dose curve and produce a faint beam halo of secondary dose around the primary proton pencil beam in water. A very simple beam halo model has been developed and used at PSI to eliminate the systematic dependences of the dose observed as a function of the size of the target volume. We show typical results for the relative (using a CCD system) and absolute (using calibrated ICs) dosimetry, routinely applied for the verification of patient plans. With the dose model including the nuclear beam halo we can predict quite precisely the dose directly from treatment planning without renormalization measurements, independently of the dose, shape and size of the dose fields. This applies also to the complex non-homogeneous dose distributions required for the delivery of range-intensity-modulated proton therapy, a novel therapy technique developed at PSI.

Investigation of dose homogeneity for loose helical tomotherapy delivery in the context of breath-hold radiation therapy

Loose helical delivery is a potential solution to account for respiration-driven tumour motion in helical tomotherapy (HT). In this approach, a treatment is divided into a set of interlaced 'loose' helices commencing at different gantry angles. Each loose helix covers the entire target length in one gantry rotation during a single breath-hold. The dosimetric characteristics of loose helical delivery were investigated by delivering a 6 MV photon beam in a HT-like manner. Multiple scenarios of conventional 'tight' HT and loose helical deliveries were modelled in treatment planning software, and carried out experimentally with Kodak EDR2 film. The advantage of loose helical delivery lies in its ability to produce a more homogeneous dose distribution by eliminating the 'thread' effect-an inherent characteristic of HT, which results in dose modulations away from the axis of gantry rotation. However, loose helical delivery was also subjected to undesirable dose modulations in the direction of couch motion (termed 'beating' effect), when the ratio between the number of beam projections per gantry rotation (n) and pitch factor (p) was a non-integer. The magnitude of dose modulations decreased with an increasing n/p ratio. The results suggest that for the current HT unit (n = 51), dose modulations could be kept under 5% by selecting a pitch factor smaller than 7. A pitch factor of this magnitude should be able to treat a target up to 30 cm in length. Loose helical delivery should increase the total session time only by a factor of 2, while the planning time should stay the same since the total number of beam projections remains unchanged. Considering its dosimetric advantage and clinical practicality, loose helical delivery is a promising solution for the future HT treatments of respiration-driven targets.

Spectrum reconstruction from dose measurements as a linear inverse problem

There are three ways to determine the spectrum of a clinical photon beam: direct measurement, modelling the source and reconstruction from ion-chamber measurements. We focus on reconstruction because the necessary equipment is readily available and it provides independent confirmation of source models for a given machine. Reconstruction methods involve measuring the dose in an ion chamber after the beam passes through an attenuator. We gain information about the spectrum from measurements using attenuators of differing compositions and thicknesses since materials have energy dependent attenuation. Unlike the procedures used in other papers, we do not discretize or parametrize the spectrum. With either of these two approximations, reconstruction is a least squares problem. The forward problem of going from a spectrum to a series of dose measurements is a linear operator, with the composition and thickness of the attenuators as parameters. Hence the singular value decomposition (SVD) characterizes this operator. The right singular vectors form a basis for the spectrum, and, at first approximation, only those corresponding to singular values above a threshold are measurable. A more rigorous error analysis shows with what confidence different components of the spectrum can be measured. We illustrate this theory with simulations and an example utilizing six sets of dose measurements with water and lead as attenuators.

Accurate dosimetry in 131I radionuclide therapy using patient-specific, 3-dimensional methods for SPECT reconstruction and absorbed dose calculation

(131)I radionuclide therapy studies have not shown a strong relationship between tumor absorbed dose and response, possibly due to inaccuracies in activity quantification and dose estimation. The goal of this work was to establish the accuracy of (131)I activity quantification and absorbed dose estimation when patient-specific, 3-dimensional (3D) methods are used for SPECT reconstruction and for absorbed dose calculation.

METHODS

Clinically realistic voxel-phantom simulations were used in the evaluation of activity quantification and dosimetry. SPECT reconstruction was performed using an ordered-subsets expectation maximization (OSEM) algorithm with compensation for scatter, attenuation, and 3D detector response. Based on the SPECT image and a patient-specific density map derived from CT, 3D dosimetry was performed using a newly implemented Monte Carlo code. Dosimetry was evaluated by comparing mean absorbed dose estimates calculated directly from the defined phantom activity map with those calculated from the SPECT image of the phantom. Finally, the 3D methods were applied to a radioimmunotherapy patient, and the mean tumor absorbed dose from the new calculation was compared with that from conventional dosimetry obtained from conjugate-view imaging.

RESULTS

Overall, the accuracy of the SPECT-based absorbed dose estimates in the phantom was >12% for targets down to 16 mL and up to 35% for the smallest 7-mL tumor. To improve accuracy in the smallest tumor, more OSEM iterations may be needed. The relative SD from multiple realizations was <3% for all targets except for the smallest tumor. For the patient, the mean tumor absorbed dose estimate from the new Monte Carlo calculation was 7% higher than that from conventional dosimetry.

CONCLUSION

For target sizes down to 16 mL, highly accurate and precise dosimetry can be obtained with 3D methods for SPECT reconstruction and absorbed dose estimation. In the future, these methods can be applied to patients to potentially establish correlations between tumor regression and the absorbed dose statistics from 3D dosimetry.

Synthesis, in vitro binding and biodistribution in B16 melanoma-bearing mice of new iodine-125 spermidine benzamide derivatives

In the course of our investigations aimed at improving the biological characteristics of iodobenzamides for melanoma therapeutic applications, four new derivatives containing a spermidine chain have been prepared and radiolabeled with (125)I. In vitro studies showed that all compounds displayed high affinity for melanin superior to the reference compound BZA, thus validating our experimental approach. In vivo biodistribution was investigated in B16 melanoma-bearing mice. All four compounds, particularly benzamide 3, showed accumulation in the tumor, but lower, however, than that of BZA. Moreover, high concentrations of radioactivity in other organs, namely, the liver and lung, demonstrated nonspecific tumoral uptake. In view of these results, compounds 1 2 3 4 do not appear to be suitable radiopharmaceuticals for melanoma radionuclide therapy.

Progress in medical ultrasound exposimetry

Biomedical applications of ultrasound have experienced tremendous growth over the past 50 years. Early work in thermal therapy and surgery soon was followed by diagnostic imaging and Doppler. Because patient safety was an important issue from the beginning, the study of methods for measuring exposure levels, and their relationship to possible biological effects, paralleled the growth of the various therapeutic and diagnostic techniques. The diverse conditions of use have presented a range of exposure measurement challenges, and the sensors and techniques used to evaluate ultrasound fields have had to evolve as new or expanded clinical applications have emerged. In this paper some of the more notable of these developments are presented and discussed. Topics covered include devices and techniques, methods of calibration, progress in standardization, and current problem areas, including the effects of nonlinear propagation. Some early methods are described, but emphasis is given to more recent work applicable to present and future uses of ultrasound in medicine and biology.

5-[123I/125I]iodo-2'-deoxyuridine in metastatic lung cancer: radiopharmaceutical formulation affects targeting

This study assesses targeting of lung metastases in mice with the radioiodinated thymidine analog 5-[(123)I/(125)I]iodo-2'-deoxyuridine ((123)I-IUdR/(125)I-IUdR), formulated with varying amounts of tributyltin precursor and injected intravenously.

METHODS

Six- to 8-wk-old C57BL/6 mice were injected intravenously with B16F10 melanoma cells. Two weeks later, when lung tumors were established, the animals were injected intravenously with (125)I-IUdR synthesized using 1, 35, 100, 150, 200, or 250 microg 5-tributylstannyl-2'-deoxyuridine (SnUdR) in the presence of an oxidant. Nontumor-bearing mice were also injected with these formulations and served as control animals. Twenty-four hours later, the animals were killed, and the radioactivity associated with the lungs and other tissues was measured in a gamma-counter. The percentage injected dose per gram tissue (%ID/g) and tumor-to-nontumor ratios (T/NT ratios) were calculated. Phosphor imaging was done on lungs from tumor-bearing and nontumor-bearing mice injected with (125)I-IUdR formulated with each tin precursor concentration. Scintigraphy was also performed 3 and 24 h after intravenous injection of (123)I-IUdR.

RESULTS

The %ID/g (125)I-IUdR was higher in lungs of tumor-bearing animals than in lungs of control animals. Although the increase in SnUdR present led to a small but statistically significant decrease in the radioactive content of normal lungs, a 3-fold increase was observed in the lungs of tumor-bearing animals with radiopharmaceutical formulated with 100 microg SnUdR (5 microg per mouse). This enhancement in radioactive uptake by the lungs led to approximately 14-fold increases in T/NT ratios. Phosphor imaging ((125)I-IUdR) of lungs as well as scintigraphy ((123)I-IUdR) of whole animals substantiated these findings.

CONCLUSION

The formulation for the synthesis of radio-IUdR that leads to the highest %ID/g in tumor and the best T/NT ratio has been identified. Further studies are required to determine the factors responsible for specific enhancement in IUdR tumor uptake.

Radiation exposure rate from 131I-treated hyperthyroid patients--a dynamic study, with data for up to 42 d post therapy

Hyperthyroid patients treated with radioactive 131I are a potential source of external and internal exposure to family members and others in close contact with these patients. Information on the exposure rate from the patient on any day post administration of the dosage may be helpful when implementing an effective radiation safety or ALARA strategy for the family or members of the general public. Exposure rate measurements were completed on 78 out of 128 hyperthyroid patients participating in the study. Measurements were taken at 1 m, 0.6 m, and 0.3 m from the patient for eight different dose regimens and for up to 42 d post dose administration. The measured exposure rate was plotted against days post dose administration to demonstrate how quickly the exposure rate reduced with time. As anticipated, significant positive correlation was found between exposure rate at 1 m, 0.6 m, and 0.3 m for all radioactive dose regimens. No significant correlation was found between the external exposure rate reduction post-therapy and the 131I uptake at 2 or 24 h, prior to therapy. This work is a dynamic study that provides comprehensive external radiation exposure rate measurements in hyperthyroid patients post therapy dose administration and may serve as a database for radiation safety related decision-making.

Knoop hardness of ten resin composites irradiated with high-power LED and quartz-tungsten-halogen lights

This study compared a high-power light-emitting-diode (LED) curing light (FreeLight 2, 3M ESPE) with a quartz-tungsten-halogen (QTH) light (TriLight, 3M ESPE) to determine which was the better at photo-polymerising 10 resin composites. Class I preparations were prepared 4-mm deep into human teeth and filled with 10 different composites. The composites were irradiated for 50% or 100% of their recommended times using the LED light, and for 100% of their recommended times with the QTH light on either the high or medium power setting. Fifteen minutes later, the Knoop hardness of the composites was measured to a depth of 3.5 mm from the surface. When irradiated by the LED light for their recommended curing times, the Knoop hardness of all 10 composites stayed above 80% of the maximum hardness of the composite to a depth of at least 1.5 mm; three composites maintained a Knoop hardness that was more than 80% of their maximum hardness to a depth of 3.5 mm. Repeated measurements analysis of variance indicated that all the two-way and three-way interactions between the curing light, depth, and composite were significant (p < 0.01). To eliminate the choice of composite as a factor, an overall comparison of the lights was performed using the Kruskal-Wallis test and distribution free multiple comparisons of the ranked hardness values. The LED light, used for the composite manufacturer's recommended time, was ranked the best at curing the composites to a depth of 3mm (p < 0.01). The LED light used for 50% of the recommended time was not significantly different from the QTH light used for 100% of the recommended time on the high power setting.

Rôle de la personne compétente dans la sensibilisation au principe ALARA à travers l’application de la directive européenne 97-43

The purpose of this article is to define the role of the radiation safety officer in raising the awareness of the radiology staff to the ALARA (As low as reasonable achievable) principle specified in European directive 97-43. The actions taken and the techniques used in our hospital, as well as the potential improvements that could be achieved with extra funding, will be presented. The didactic value of flow charts recording technical factors and fluoroscopy times for quality improvement will be demonstrated. In the future, a dosimeter incorporated on the new equipment could allow direct recording of the dose. The different items presented in this paper should allow routine implementation of the required elements described in the law 2003-270, i.e the French translation of European Directive 97-43.

Measurements of neutron effective doses and attenuation lengths for shielding materials at the heavy-ion medical accelerator in Chiba

The effective doses and attenuation lengths for concrete and iron were measured for the design of heavy ion facilities. Neutrons were produced through the reaction of copper, carbon, and lead bombarded by carbon ions at 230 and 400 MeV.A, neon ions at 400 and 600 MeV.A, and silicon ions at 600 and 800 MeV.A. The detectors used were a Linus and a Andersson-Braun-type rem counter and a detector based on the activation of a plastic scintillator. Representative effective dose rates (in units of 10(-8) microSv h(-1) pps(-1) at 1 m from the incident target surface, where pps means particles per second) and the attenuation lengths (in units of m) were 9.4 x 10(4), 0.46 for carbon ions at 230 MeV.A; 8.9 x 10(5), 0.48 for carbon ions at 400 MeV.A; 9.3 x 10(5), 0.48 for neon ions at 400 MeV.A; 3.8 x 10(6), 0.50 for neon ions at 600 MeV.A; 3.9 x 10(6), 0.50 for silicon ions at 600 MeV.A; and 1.1 x 10(7), 0.51 for silicon ions at 800 MeV.A. The attenuation provided by an iron plate approximately 20 cm thick (nearly equal to the attenuation length) corresponded to that of a 50-cm block of concrete in the present energy range. Miscellaneous results, such as the angular distributions of the neutron effective dose, narrow beam attenuation experiments, decay of gamma-ray doses after the bombardment of targets, doses around an irradiation room, order effects in the multi-layer (concrete and iron) shielding, the doses from different targets, the doses measured with a scintillator activation detector, the gamma-ray doses out of walls and the ratio of the response between the Andersson-Braun-type and the Linus rem counters are also reported.

[A rapid searching calculation of radiation dose distribution based on the region growing algorithm in 3D for CT-robot gamma knife]

This paper presents a rapid searching algorithm for dose calculation based on the region growing algorithm. Using this algorithm, we can automatically and rapidly search out the dose computational region for the gamma knife, so as to reduce the computational time, and space complexity.

Test of radiation detectors used in homeland security applications

This work was performed as part of the National Institute of Standards and Technology (NIST) program to support the development of the new American National Standards Institute (ANSI) standards N42.32-2003 and N42.33-2003 for hand-held detectors, and personal electronic dosimeters, as well as to support the Office of Law Enforcement Standards (OLES) and the Department of Homeland Security (DHS) in testing these types of detectors for their use by first responders. These instruments are required to operate over a photon energy range of 60 keV to 1.33 MeV and over a wide range of air-kerma rates. The performance and response of various radiation detectors, purchased by the NIST, was recorded when placed in 60Co, 137Cs, and x-ray beams at different air-kerma rates. The measurements described in this report were performed at the NIST x-ray and gamma-ray radiation calibration facilities. The instruments' response (exposure or dose rate readings) shows strong energy dependence but almost no dependence to different air-kerma rates. The data here reported provide a benchmark in support of current protocols that are being developed for radiation detection instrumentation used in homeland security applications. A future plan is to test these devices, plus other commercially available detectors, against ANSI standards N42.32-2003 and N42.33-2003.

[Radioprotection and environmental pollution by the use of the radionuclides 89Sr, 186Re, and 153Sm for pain palliation in metastatic bone diseases. Related calculations]

Due to the fact that the existing commercial analgesic drugs are not able to reduce effectively the pain caused by the metastatic bone disease, the use of radiopharmaceuticals with avidity to selectively localize in the metastatic skeletal sites, such as strondium-89 chloride (89Sr-Cl2), rhenium-186-hydroxy ethylene diphosphonate (186Re-HEDP), and samarium-153-ethylene diamine tetramethylene (153Sm-EDTMP), is widely accepted. However this medical application may be dangerous for the occupied personnel and more for general public, if radioactive waste is not properly disposed. In the following article we try to estimate the degree and the significance of that risk. For that reason we discuss the physical properties of these radionuclides and their distribution in the body of the patient. We conclude that 89Sr is not harmful for the physician, the attending personnel or those who live with the patient, because it radiates beta-radiation, while its gamma-radiation is negligeable. The radionuclides 186Re and 153Sm besides beta-radiation, also emit a perceptible amount of gamma-radiation. It has been shown that the exposure to gamma-radiation from these radionuclides of the physician, the attending personnel or those who live with the patient is very low as compared to the internationally accepted radioprotection limits. However the environmental contamination per treatment by either of these three radionuclides is not negligeable in comparison to the national and international accepted limits. Patients that are not in good clinical condition may pose an additional contamination danger to those attending them. For limiting radiocontamination, the annual number of treatments by the above three previous radionuclides, should be considered according to the ALARA principle in relation with the correct handling of these patients, and also considering the fundamentals of radioprotection.

Light transport in two-layer tissues

We study theoretically light backscattered by tissues using the radiative transport equation. In particular we consider a two-layered medium in which a finite slab is situated on top of a half space. We solve the one-dimensional problem in which a plane wave is incident normally on the top layer and is the only source of light. The solution to this problem is obtained formally by imposing continuity between the solutions for the upper and lower layers. However, we are interested solely in probing the top layer. Assuming that the optical properties in the lower layer are known, we remove it from the problem yielding a finite slab problem by prescribing an alternate boundary condition. This boundary condition is derived using the theory of Green's functions and is exact. Hence, one needs only to solve the transport equation in a finite slab using this alternate boundary condition. We derive an asymptotic solution for the case when the slab is optically thin. We extend these results to the three-dimensional problem using Fourier transforms. These results are validated by comparisons with numerical solutions for the entire two-layered problem.

The helical tomotherapy thread effect

Inherent to helical tomotherapy is a dose variation pattern that manifests as a "ripple" (peak-to-trough relative to the average). This ripple is the result of helical beam junctioning, completely unique to helical tomotherapy. Pitch is defined as in helical CT, the couch travel distance for a complete gantry rotation relative to the axial beam width at the axis of rotation. Without scattering or beam divergence, an analytical posing of the problem as a simple integral predicts minima near a pitch of 1/n where n is an integer. A convolution-superposition dose calculator (TomoTherapy, Inc.) included all the physics needed to explore the ripple magnitude versus pitch and beam width. The results of the dose calculator and some benchmark measurements demonstrate that the ripple has sharp minima near p=0.86(1/n). The 0.86 factor is empirical and caused by a beam junctioning of the off-axis dose profiles which differ from the axial profiles as well as a long scatter tail of the profiles at depth. For very strong intensity modulation, the 0.86 factor may vary. The authors propose choosing particular minima pitches or using a second delivery that starts 180 deg off-phase from the first to reduce these ripples: "Double threading." For current typical pitches and beam widths, however, this effect is small and not clinically important for most situations. Certain extremely large field or high pitch cases, however, may benefit from mitigation of this effect.

Impact of multileaf collimator leaf positioning accuracy on intensity modulation radiation therapy quality assurance ion chamber measurements

Quality assurance (QA) procedures for intensity modulation radiation therapy (IMRT) usually involve an ion chamber measurement in a phantom using the beam configuration of the actual treatment plan. In our QA procedures it was observed that the degree of agreement between the measurement and the calculation could vary from plan to plan, from linac to linac, as well as over time, with a discrepancy up to 8%. In this paper we examine one aspect of the process which can contribute to such poor reproducibility, namely, the leaf end position accuracy. A series of measurements was designed to irradiate an ion chamber using small beam segments where one multileaf collimator (MLC) edge covers half of the chamber. It was shown that the reproducibility varied up to 13%, which provides a possible explanation for the observed discrepancies above. A useful tool was also developed to measure ionization signals from individual segments of an IMRT sequence. In addition, an understanding of the leaf end position variations offers some insight into the overall quality of an IMRT dose distribution.