An optimisation algorithm for determination of treatment margins around moving and deformable targets

PURPOSE

Determining treatment margins for inter-fractional motion of moving and deformable clinical target volumes (CTVs) remains a major challenge. This paper describes and applies an optimisation algorithm designed to derive such margins.

MATERIAL AND METHODS

The algorithm works by expanding the CTV, as determined from a pre-treatment or planning scan, to enclose the CTV positions observed during treatment. CTV positions during treatment may be obtained using, for example, repeat CT scanning and/or repeat electronic portal imaging (EPI). The algorithm can be applied to both individual patients and to a set of patients. The margins derived will minimise the excess volume outside the envelope that encloses all observed CTV positions (the CTV envelope). Initially, margins are set such that the envelope is more than adequately covered when the planning CTV is expanded. The algorithm uses an iterative method where the margins are sampled randomly and are then either increased or decreased randomly. The algorithm is tested on a set of 19 bladder cancer patients that underwent weekly repeat CT scanning and EPI throughout their treatment course.

RESULTS

From repeated runs on individual patients, the algorithm produces margins within a range of +/-2 mm that lie among the best results found with an exhaustive search approach, and that agree within 3mm with margins determined by a manual approach on the same data. The algorithm could be used to determine margins to cover any specified geometrical uncertainty, and allows for the determination of reduced margins by relaxing the coverage criteria, for example disregarding extreme CTV positions, or an arbitrarily selected volume fraction of the CTV envelope, and/or patients with extreme geometrical uncertainties.

CONCLUSION

An optimisation approach to margin determination is found to give reproducible results within the accuracy required. The major advantage with this algorithm is that it is completely empirical, and it is therefore particularly useful for CTVs where the geometrical uncertainties are difficult to model, such as the bladder.

Distortion of Magnetic Resonance Images Used in Gamma Knife Radiosurgery Treatment Planning: Implications for Acoustic Neuroma Outcomes

OBJECTIVE

To quantify the image distortion of our series of acoustic neuromas treated with gamma knife radiosurgery.

STUDY DESIGN

Retrospective chart and digital radiographic file review with quantitative assessment of gamma knife treatment plans.

SETTING

Tertiary referral center.

PATIENTS

Patients undergoing gamma knife radiosurgery for the treatment of acoustic neuromas.

INTERVENTION

Gamma knife radiosurgery.

MAIN OUTCOME MEASURES

Gamma knife treatment plans containing magnetic resonance images were reviewed at each axial, sagittal, and coronal slice. The length of the greatest displacement of the treatment plan was measured and the volume of the treatment plan that fell outside of the internal auditory canal calculated. Known clinical measurements of audiometric, vestibular, facial, and trigeminal nerve functions were then compared with current measurements of tumor size.

RESULTS

Twenty-two of the 23 patients had measurable image shifts on the axial images. The range of the image shift was 0 to 5.8 mm, with a mean shift of 1.92 +/- 1.29 mm (+/- standard deviation). Tumor volumes of the treatment plan that fell outside of the internal auditory canal ranged from 0 to 414 mm, with a mean of 90.5 mm. The mean percentage that fell outside of the internal auditory canal was 16.7% of total tumor volume (range, 2.4-77.6%). We could not draw any consistent correlations between degree of image shift and continued tumor growth or objective examination values.

CONCLUSION

We have demonstrated a small but potentially significant shift in the treatment plan of gamma knife radiosurgery when based on magnetic resonance images. Although the image shift does not seem to affect the growth of the acoustic neuromas or auditory or facial nerve function, longer term follow-up is required to fully appreciate the true impact of this image shift.

Quality assurance: fundamental reproducibility tests for 3-D treatment-planning systems

The use of image-based 3D treatment planning has significantly increased the complexity of commercially available treatment-planning systems (TPSs). Medical physicists have traditionally focused their efforts on understanding the calculation algorithm; this is no longer possible. A quality assurance (QA) program for our 3D treatment-planning system (ADAC Pinnacle3) is presented. The program is consistent with the American Association of Physicists in Medicine Task Group 53 guidelines and balances the cost-versus-benefit equation confronted by the clinical physicist in a community cancer center environment. Fundamental reproducibility tests are presented as required for a community cancer center environment using conventional and 3D treatment planning. A series of nondosimetric tests, including digitizer accuracy, image acquisition and display, and hardcopy output, is presented. Dosimetric tests include verification of monitor units (MUs), standard isodoses, and clinical cases. The tests are outlined for the Pinnacle3 TPS but can be generalized to any TPS currently in use. The program tested accuracy and constancy through several hardware and software upgrades to our TPS. This paper gives valuable guidance and insight to other physicists attempting to approach TPS QA at fundamental and practical levels.

Technical note: Monte Carlo derivation of TG-43 dosimetric parameters for radiation therapy resources and 3M Cs-137 sources

In clinical brachytherapy dosimetry, a detailed dose rate distribution of the radioactive source in water is needed in order to plan for quality treatment. Two Cs-137 sources are considered in this study; the Radiation Therapy Resources 67-800 source (Radiation Therapy Resources Inc., Valencia, CA) and the 3M model 6500/6D6C source. A complete dosimetric dataset for both sources has been obtained by means of the Monte Carlo GEANT4 code. Dose rate distributions are presented in two different ways; following the TG43 formalism and in a 2D rectangular dose rate table. This 2D dose rate table is helpful for the TPS quality control and is fully consistent with the TG43 dose calculation formalism. In this work, several improvements to the previously published data for these sources have been included: the source asymmetries were taken explicitly into account in the MC calculations, TG43 data were derived directly from MC calculations, the data radial range was increased, the angular grid in the anisotropy function was increased, and TG43 data is now consistent with the along and away dose rate table as recommended by the TG43 update.

The sliding slit test for dynamic IMRT: a useful tool for adjustment of MLC related parameters

For treatments with dynamic intensity modulated radiotherapy (IMRT), the adjustment of multileaf collimator (MLC) parameters affecting both the optimization algorithm and dose distributions is crucial. The main parameters characterizing the MLC are the transmission (T) and the dosimetric leaf separation (DLS). The aim of this study is twofold: a methodology based on the 'sliding slit' test is proposed to determine (T, DLS) combinations inducing the best conformity between calculations and measurements. Secondly, the effects of the MLC adjustment on measured dose and on optimization are presented for different configurations as the chair test and for the patient dosimetric quality control (DQC). Tests were performed with a Varian 23EX linac operated at 20 MV and equipped with a 120 leaf Millenium dynamic collimator. The treatment planning system was CadPlan/Helios (version 6.3.6). Results demonstrated that the sliding width (SW) strongly depends on the (T, DLS) combinations, and the measured dose is a linear function of the SW. Different (T, DLS) combinations induced a good agreement between calculations and measurements. The influence of the MLC calibration was found to be particularly important on the 'sliding slit' test (11.8% for a gap change of 0.8 mm) but not so much on the chair test and on the DQC. To detect small variations in leaf adjustment and to ensure consistency between calculation and actual dose delivered to patients, a daily check called IMRT MU check is proposed.

Quality assurance procedures for the neutron beam monitors at the FiR 1 BNCT facility

In order to assure the stability of the beam, the reliability of the beam monitoring system and the quality of the patient dose delivered, several procedures are followed at the FiR 1 epithermal beam in Finland. Routine procedures include in-phantom activation measurements before each patient treatment and a long-term follow-up of the results. The sensitivity of the beam monitors to external objects in the beam and to variations in the control rod positions in the reactor has been checked and found insignificant. The linearity of the beam monitor channels has been checked with activation measurements. It was found that due to saturation effects a correction of 11% has to be applied when extrapolating results from experiments at low power to full power using the reference monitor channel. The correction is even larger for other channels with higher count rates.

A Monte Carlo derived TG-51 equivalent calibration for helical tomotherapy

Helical tomotherapy (HT) requires a method of accurately determining the absorbed dose under reference conditions. In the AAPM's TG-51 external beam dosimetry protocol, the quality conversion factor, kQ, is presented as a function of the photon component of the percentage depth-dose at 10 cm depth, %dd(10)x, measured under the reference conditions of a 10 x 10 cm2 field size and a source-to-surface distance (SSD) of 100 cm. The value of %dd(10)x from HT cannot be used for the determination of kQ because the design of the HT does not meet the following TG-51 reference conditions: (i) the field size and the practical SSD required by TG-51 are not obtainable and (ii) the absence of the flattening filter changes the beam quality thus affecting some components of kQ. The stopping power ratio is not affected because of its direct relationship to %dd(10)x. We derive a relationship for the Exradin A1SL ion chamber converting the %dd(10)x measured under HT "reference conditions" of SSD=85 cm and a 5 x 10 cm2 field-size [%dd(10)x[HT Ref]], to the dosimetric equivalent value under for TG-51 reference conditions [%dd(10)x[HT TG-51]] for HT. This allows the determination of kQ under the HT reference conditions. The conversion results in changes of 0.1% in the value of kQ for our particular unit. The conversion relationship should also apply to other ion chambers with possible errors on the order of 0.1%.

Interactively exploring optimized treatment plans

PURPOSE

A new paradigm for treatment planning is proposed that embodies the concept of interactively exploring the space of optimized plans. In this approach, treatment planning ignores the details of individual plans and instead presents the physician with clinical summaries of sets of solutions to well-defined clinical goals in which every solution has been optimized in advance by computer algorithms.

METHODS AND MATERIALS

Before interactive planning, sets of optimized plans are created for a variety of treatment delivery options and critical structure dose-volume constraints. Then, the dose-volume parameters of the optimized plans are fit to linear functions. These linear functions are used to show in real time how the target dose-volume histogram (DVH) changes as the DVHs of the critical structures are changed interactively. A bitmap of the space of optimized plans is used to restrict the feasible solutions. The physician selects the critical structure dose-volume constraints that give the desired dose to the planning target volume (PTV) and then those constraints are used to create the corresponding optimized plan.

RESULTS

The method is demonstrated using prototype software, Treatment Plan Explorer (TPEx), and a clinical example of a patient with a tumor in the right lung. For this example, the delivery options included 4 open beams, 12 open beams, 4 wedged beams, and 12 wedged beams. Beam directions and relative weights were optimized for a range of critical structure dose-volume constraints for the lungs and esophagus. Cord dose was restricted to 45 Gy. Using the interactive interface, the physician explored how the tumor dose changed as critical structure dose-volume constraints were tightened or relaxed and selected the best compromise for each delivery option. The corresponding treatment plans were calculated and compared with the linear parameterization presented to the physician in TPEx. The linear fits were best for the maximum PTV dose and worst for the minimum PTV dose. Based on the root-mean-square error between the fit values and their corresponding data values, the linear fit appears to be adequate, although higher order polynomials could give better results. Some of the variance in fit is due to the stochastic nature of the simulated annealing optimization algorithm, which does not reproduce the exact same results in repetitions of the same calculation. Using a directed search algorithm for plan optimization should produce better parameter fits and, therefore, better predictions of plan characteristics by TPEx.

CONCLUSIONS

Using TPEx, the physician can easily select the optimum plan for a patient, with no imposed arbitrary definition of the "best" plan. More importantly, the physician can readily see what can be achieved for the patient with a given delivery technique. There is no more uncertainty about whether or not a better plan exists. By comparing the "best" plans for different delivery options (e.g., three-dimensional conformal radiotherapy versus intensity-modulated radiation therapy), the physician can gauge the clinical benefits of greater technical complexity. However, before the TPEx process can be clinical useful, faster computers and/or algorithms are needed and more studies are needed to better model the spaces of optimized solutions.

Quality assurance evaluation of delivery of respiratory-gated treatments

We describe a method for evaluating the quality of respiratory-gated radiation delivery using a commercially available device. During irradiation, gating traces for one field for each treatment were extracted from the system for each of 14 patients. The data were then transferred to a spreadsheet. Software was developed to evaluate the following parameters: duty cycle, amplitude of fiducial motion, fraction of amplitude of motion during gated delivery, and respiratory cycle time. Criteria were established for acceptability of gating traces. In our sample, over 85% of the traces indicated acceptability. An example of results for one patient extracted from analyzed gating traces is as follows: mean duty cycle, 57%, average amplitude of motion, 0.89 cm, average fraction of motion during gated delivery, 0.45; mean respiratory cycle time, 4.5 s. This technique can be used to evaluate delivery of respiratory-gated radiation therapy for quality assurance purposes and to assess various techniques for improving delivery of gated therapy. A hardcopy of the gating traces can be used to document gated treatment delivery for potential billing of the gated delivery process.

An algorithm for independent verification of Gamma Knife treatment plans

A formalism for independent treatment verification has been developed for Gamma Knife radiosurgery in analogy to the second checks being performed routinely in the field of external beam radiotherapy. A verification algorithm is presented, and evaluated based on its agreement with treatment planning calculations for the first 40 Canadian Gamma Knife patients. The algorithm is used to calculate the irradiation time for each shot, and the value of the dose at the maximum dose point in each calculation matrix. Data entry consists of information included on the plan printout, and can be streamlined by using an optional plan import feature. Calculated shot times differed from those generated by the treatment planning software by an average of 0.3%, with a standard deviation of 1.4%. The agreement of dose maxima was comparable with an average of -0.2% and a standard deviation of 1.3%. Consistently accurate comparisons were observed for centrally located lesions treated with a small number of shots. Large discrepancies were almost all associated with dose plans utilizing a large number of collimator plugs, for which the simplifying approximations used by the program are known to break down.

Can Intensity-Modulated Radiation Therapy of the Paraaortic Region Overcome the Problems of Critical Organ Tolerance?

BACKGROUND AND PURPOSE

The recent RTOG guidelines for future clinical developments in gynecologic malignancies included the investigation of dose escalation in the paraaortic (PO) region which is, however, very difficult to target due to the presence of critical organs such as kidneys, liver, spinal cord, and digestive structures. The aim of this study was to investigate intensity-modulated radiotherapy's (IMRT) possibilites of either increasing, in a safe way, the dose to 50-60 Gy in case of macroscopic disease or decreasing the dose to organs at risk (OR) when treatment is given in an adjuvant setting.

MATERIAL AND METHODS

The dosimetric charts of 14 patients irradiated to the PO region at the Department of Radiation Oncology, University Hospital of Liege, Belgium, in 2000 were analyzed in order to compare six-field conformal external-beam radiotherapy (CEBR) and five-beam IMRT approaches. Both CEBR and IMRT investigations were planned to theoretically deliver 60 Gy to the PO region in the safest way possible. Dose-volume histograms (DVHs) were calculated for clinical target volume (CTV), planning target volume (PTV), and OR. Student's t-test was used to compare the paired DVH data issued from CEBR and IMRT planning.

RESULTS

The IMRT approach allowed to cover the PTV at a higher level as compared to CEBR. Using IMRT, the maximal dose to the spinal cord was reduced from 42.5 Gy to 26.2 Gy in comparison with CEBR (p < 0.00001). Doses to the kidneys were significantly reduced, with < 20% receiving >or= 20 Gy in the IMRT approach (p < 0.00001). Irradiation of digestive structures was not different, with < 25% receiving 35 Gy. Doses to the liver remained low regardless of the method used.

CONCLUSION

At 60 Gy, IMRT is largely sparing the spinal cord and kidneys as compared to CEBR and represents an interesting approach not only for dose escalation up to 50-60 Gy (probably facilitating the radiochemotherapy approaches) but also in an adjuvant setting at lower doses. The dosimetric data of this study are in the same range as those published recently with a dynamic arc conformal approach.

Enhanced dynamic wedge and independent monitor unit verification

Some serious radiation accidents have occurred around the world during the delivery of radiotherapy treatment. The regrettable incident in Panama clearly indicated the need for independent monitor unit (MU) verification. Indeed the International Atomic Energy Agency (IAEA), after investigating the incident, made specific recommendations for radiotherapy centres which included an independent monitor unit check for all treatments. Independent monitor unit verification is practiced in many radiotherapy centres in developed countries around the world. It is mandatory in USA but not yet in Australia. This paper describes development of an independent MU program, concentrating on the implementation of the Enhanced Dynamic Wedge (EDW) component. The difficult case of non centre of field (COF) calculation points under the EDW was studied in some detail. Results of a survey of Australasian centres regarding the use of independent MU check systems is also presented. The system was developed with reference to MU calculations made by Pinnacle 3D Radiotherapy Treatment Planning (RTP) system (ADAC - Philips) for 4MV, 6MV and 18MV X-ray beams used at the Newcastle Mater Misericordiae Hospital (NMMH) in the clinical environment. A small systematic error was detected in the equation used for the EDW calculations. Results indicate that COF equations may be used in the non COF situation with similar accuracy to that achieved with profile corrected methods. Further collaborative work with other centres is planned to extend these findings.

Dosimetric evaluation of a commercial 3D treatment planning system using the AAPM Task Group 23 test package

The accuracy of the dose calculation algorithm is one of the most critical steps in assessing the radiotherapy treatment to achieve the 5% accuracy in dose delivery, which represents the suggested limit to increase the complication-free local control of tumor. We have used the AAPM Task Group 23 (TG-23) test package for clinical photon external beam therapy to evaluate the accuracy of the new version of the PLATO TPS algorithm. The comparison between tabulated values and calculated ones has been performed for 266 and 297 dose values for the 4 and 18 MV photon beams, respectively. Dose deviations less than 2% were found in the 98.5%- and 90.6% analyzed dose points for the two considered energies, respectively. Larger deviations were obtained for both energies, in large dose gradients, such as the build-up region or near the field edges and blocks. As far as the radiological field width is concerned, 64 points were analyzed for both the energies: 53 points (83%) and 64 points (100%) were within +/-2 millimeters for the 4 and 18 MV photon beams, respectively. The results show the good accuracy of the algorithm either in simple geometry beam conditions or in complex ones, in homogeneous medium, and in the presence of inhomogeneities, for low and high energy beams. Our results fit well the data reported by several authors related to the calculation accuracy of different treatment planning systems (TPSs) (within a mean value of 0.7% and 1.2% for 4 and 18 MV respectively). The TG-23 test package can be considered a powerful instrument to evaluate dose calculation accuracy, and as such may play an important role in a quality assurance program related to the commissioning of a new TPS.

Development of a 30-week-pregnant female tomographic model from computed tomography (CT) images for Monte Carlo organ dose calculations

Assessment of radiation dose and risk to a pregnant woman and her fetus is an important task in radiation protection. Although tomographic models for male and female patients of different ages have been developed using medical images, such models for pregnant women had not been developed to date. This paper reports the construction of a partial-body model of a pregnant woman from a set of computed tomography (CT) images. The patient was 30 weeks into pregnancy, and the CT scan covered the portion of the body from above liver to below pubic symphysis in 70 slices. The thickness for each slice is 7 mm, and the image resolution is 512x512 pixels in a 48 cm x 48 cm field; thus, the voxel size is 6.15 mm3. The images were segmented to identify 34 major internal organs and tissues considered sensitive to radiation. Even though the masses are noticeably different from other models, the three-dimensional visualization verified the segmentation and its suitability for Monte Carlo calculations. The model has been implemented into a Monte Carlo code, EGS4-VLSI (very large segmented images), for the calculations of radiation dose to a pregnant woman. The specific absorbed fraction (SAF) results for internal photons were compared with those from a stylized model. Small and large differences were found, and the differences can be explained by mass differences and by the relative geometry differences between the source and the target organs. The research provides the radiation dosimetry community with the first voxelized tomographic model of a pregnant woman, opening the door to future dosimetry studies.

Dose calibration of nonconventional treatment systems applied to helical tomotherapy

Current dosimetric protocols based on the absorbed dose (AAPM TG-51 and IAEA TRS-398 protocols) require calibration measurements under reference conditions. For some radiotherapy systems, this requirement cannot be met, and calibration has to be performed under nonreference experimental conditions. In order to solve this problem, both protocols can be extended by inclusion of the measured-to-reference conversion factor, k(mr). In order to determine this factor, basic dosimetric quantities, like stopping power ratios, mass attenuation coefficients and chamber correction factors have to be calculated. If measurements are not feasible, accurate Monte Carlo modeling is required. The extension of the protocols is illustrated using the case of the helical tomotherapy radiation unit, where the typical calibration measurement conditions are the 10 x 5 cm2 field size and the 85 cm surface source distance, limited by the system design. It was calculated that the k(mr) factor for this conditions is close to unity (0.997+/-0.001). In addition, the deviation of the measurement conditions from the reference conditions results in the change of the quality conversion factor (approximately 0.995-0.998, depending on the ionization chamber used). This change is the same regardless of the used calibration protocol. For smaller field sizes the corrections become more significant, resulting in the total correction factor compared to the reference conditions of up to 1.5% for the smallest considered field size of 2 x 2 cm2.

An extensive log-file analysis of step-and-shoot intensity modulated radiation therapy segment delivery errors

We present a study to evaluate the monitor unit (MU), dosimetric, and leaf-motion errors found in the delivery of 91 step-and-shoot IMRT treatment plans performed at three nominal dose rates using a dual modality high energy Linac (Varian 2100 C/D, Varian Medical Systems Inc., Palo Alto, CA) equipped with a 120-leaf multileaf collimator (MLC). The analysis was performed by studying log files generated by the MLC controller system. Recent studies by our group have validated that the automatically generated MLC log files accurately record the actual system delivery. A total of 635 beams were delivered at three nominal dose rates: 100, 300, and 600 MU/min. The log files were manually retrieved and analysis software was developed to extract the recorded MU delivery and leaf positions for each segment. Our analysis revealed that the magnitude of segment MU errors were independent of the planned segment MUs. Segment MU errors were found to increase with dose rate having maximum errors per segment of +/-1.8 MU at 600 MU/min, +/-0.8 MU at 300 MU/min, and +/-0.5 MU at 100 MU/min. The total absolute MU error in each plan was observed to increase with the number of plan segments, with the trend increasing more rapidly for higher dose rates. Three dimensional dose distributions were recomputed based on the observed segment MU errors for three plans with large cumulative absolute MU errors. Comparison with the original treatment plans indicated no clinically significant consequences due to these errors. In addition, approximately 80% of the total segment deliveries reported at least one collimator leaf moving at least 1 mm (projected at isocenter) during segment delivery. Such errors occur near the end of segment delivery and have been previously observed by our group using a fast video-based electronic portal imaging device. At 600 MU/min, between 5% and 23% of the plan MUs were delivered during leaf motion that had exceeded a 1 mm position tolerance. These leaf motion errors were not included in the treatment plan recalculations performed in this study.

Therapeutic step and shoot proton beam spot-scanning with a multi-leaf collimator: a Monte Carlo study

In step and shoot spot-scanning, a small-diameter proton beam is magnetically swept and varied in energy in order to cover the tumour. Initial estimates of the beam size indicate that additional collimating hardware will be needed for lower energy proton beams in order to achieve a clinically acceptable lateral dose falloff at the edge of the proton beam. In this report, we present dosimetric data from Monte Carlo simulations with a model of a simple multileaf collimator which indicate that such a device may be used to improve the lateral dose falloff. The dosimetric quantities relevant to the clinical usefulness of the device are studied, including lateral penumbra, leaf transmission and scalloping effect. Multileaf collimation is compared with a differential spot-weighting technique of sharpening the lateral dose falloff.

Virtual commissioning of a treatment planning system for proton therapy of ocular cancers

The virtual commissioning of a treatment planning system (TPS) for ocular proton beam therapy was performed using Monte Carlo (MC) simulations and a model of a double-scattering ocular treatment nozzle. The simulations produced both the input data required by the TPS and the dose distributions to validate the analytical predictions from the TPS. An MC simulation of a typical ocular melanoma treatment was compared with the TPS predictions, revealing generally good agreement in the absorbed dose distribution. However, in the depth-dose profiles, differences >5% existed in the proximal region of all validation cases considered. Comparison of the radiation coverage at or above the 90% dose level, showed that MC calculated coverage was 82% and 68% of the coverage calculated by the TPS in two planes intersecting the tumour.

Über das Auflösungsvermögen und die Empfindlichkeit eines zweidimensionalen Ionisationskammer-Arrays (PTW: Typ 10024)

The two-dimensional verification of intensity-modulated radiation plans is one of the major requirements for the safe application of this technique. The present study examines the resolution and sensitivity of a two-dimensional ionisation-chamber array (PTW2D-Array, type 10024), which can be used for plan verification instead of films. According to the Shannon-Nyquist theorem, the resolution of the 2D-Array is sufficient for dose distributions with a minimal field size of 2 cm x 2 cm. The minimal field size can be reduced to 1 cm x 1 cm by shifting the array 5 mm in the direction of the MLC movement and by repeating the measurements. The high sensitivity against a monitor decalibration for a single field of a sequence is demonstrated on the basis of an individual case. The minimal threshold for MLC misalignment detected by a chamber of the array is less than 1 mm. Therefore, the resolution capabilities of the 2D-Array are sufficient for most intensity-modulated radiation therapy (IMRT)fields.

Teatment planning figures of merit in thermal and epithermal boron neutron capture therapy of brain tumours

The boron neutron capture therapy (BNCT) figures of merit of advantage depth, therapeutic depth, modified advantage depth and maximum therapeutic depth have been studied as functions of 10B tumour to blood ratios and absolute levels. These relationships were examined using the Monte Carlo neutron photon transport code, MCNP, with an ideal 18.4 cm diameter neutron beam incident laterally upon all ellipsoidal neutron photon brain-equivalent model. Mono-energetic beams of 0.025 eV (thermal) and 35 eV (epithermal) were simulated. Increasing the tumour to blood 10B ratio predictably increases all figures of merit. concentration was also shown to have a strong bearing on the figures of merit when low levels were present in the system. This is the result of a non-10B dependent background dose. At higher levels however, the concentration of 10B has a diminishing influence. For boron sulphydryl (BSH), little advantage is gained by extending the blood 10B level beyond 30 ppm, whilst for D,L,-p-boronophenylalanine (BPA) this limit is 10 ppm. To achieve a therapeutic depth of 6 cm (brain mid-line from brain surface) using the thermal beam, a tumour to blood ratio of 25 with 10 ppm 10B in the blood is required for BPA. Similarly, a tumour to blood ratio of 8.5 with 30 ppm blood 10B is required for the maximum therapeutic depth of BSH to reach the brain mid-line. These requirements are five times above current values for these compounds in humans. Applying the epithermal beam under identical conditions, the therapeutic depth reaches the brain mid-line with a tumour to blood 10B ratio of only 5.7 for BPA. For BSH, the maximum therapeutic depth reaches the brain mid-line with a tumour to blood ratio of only 1.9 with 30 ppm in the blood. Human data for these compounds are very close to these requirements.

Determination of the relative linear collision stopping power and linear scattering power of electron bolus material

The linear collision stopping power and linear scattering power for machineable wax relative to water have been determined for electron energies between 2 and 20 MeV. Knowledge of these quantities is necessary for the use of this wax as bolus in electron pencil-beam dose algorithms. The atomic composition of the wax (rho = 0.920 +/- 0.001 g cm(-3)) was obtained by having the wax assayed. The formalisms expressed in the ICRU Report 35 were used to calculate the relative linear collision stopping and linear scattering powers of the wax. The calculated relative linear collision stopping powers of 2 to 20 MeV electrons in the wax ranged from 0.949 +/- 0.005 to 0.952 +/- 0.005, and the calculated relative linear scattering powers ranged from 0.734 +/- 0.004 to 0.729 +/- 0.004. As a check of the calculation method, the relative linear collision stopping power was measured by determining the shift in electron central-axis depth-ionization curves when varying thicknesses of water were replaced by wax. These measurements, made using 10, 12, 15 and 18 MeV electron beams with wax thicknesses from 1.0 - 4.0 cm, resulted in a mean value of 0.931 +/- 0.008. Determination of the relative linear stopping power and the linear scattering power by using the measured CT number to extract values from patient data tables resulted in values of 0.933 +/- 0.009 and 0.746 +/- 0.016, respectively, indicating that it should be acceptable to use the Hounsfield values obtained with CT scans for treatment planning dose calculations.

Monte Carlo and experimental derivation of TG43 dosimetric parameters for CSM-type Cs-137 sources

In this study, complete dosimetric datasets for the CSM2 and CSM3 Cs-137 sources were obtained using the Monte Carlo GEANT4 code. The application of this calculation method was experimentally validated with thermoluminescent dosimetry (TLD). Functions and parameters following the TG43 formalism are presented: the dose rate constant, the radial dose functional, and the anisotropy function. In addition, to aid the quality control process on treatment planning systems, a two-dimensional (2D) rectangular dose rate table (the traditional along-away table), coherent with the TG43 dose calculation formalism, is given. The data given in this study complement existing information for both sources on the following aspects: (i) the source asymmetries were considered explicitly in the Monte Carlo calculations, (ii) TG43 data were derived directly from Monte Carlo calculations, (iii) the radial range of the different tables was increased as well as the angular resolution in the anisotropy function, including angles close to the longitudinal source axis. The CSM2 source TG-43 data of Liu et al. [Med. Phys. 31, 477-483 (2004)] are not consistent with the Williamson 2D along-away data [Int. J. Radiat. Oncol., Biol., Phys. 15, 227-237 (1988)] at distances closer than approximately 2 cm from the source. The data presented here for this source are consistent with this 2D along-away table, and are suitable for use in clinical practice.

Improved radial dose function estimation using current version MCNP Monte-Carlo simulation: Model 6711 and ISC3500 125I brachytherapy sources

Improved cross-sections in a new version of the Monte-Carlo N-particle (MCNP) code may eliminate discrepancies between radial dose functions (as defined by American Association of Physicists in Medicine Task Group 43) derived from Monte-Carlo simulations of low-energy photon-emitting brachytherapy sources and those from measurements on the same sources with thermoluminescent dosimeters. This is demonstrated for two 125I brachytherapy seed models, the Implant Sciences Model ISC3500 (I-Plant) and the Amersham Health Model 6711, by simulating their radial dose functions with two versions of MCNP, 4c2 and 5.

Significance of different conformity indices for evaluation of radiosurgery treatment plans for vestibular schwannomas

OBJECT

There are various kinds of conformity parameters currently in use, although several of them are limited and reflect only target volume coverage or normal tissue overdosage. Indices are reviewed with the goal of determining those that are most significant for the evaluation of radiosurgery treatment plans for patients with vestibular schwannoma, based on the authors' experience at the Novalis Shaped Beam Surgery Center.

METHODS

Fifty-five radiosurgery plans for patients with vestibular schwannomas (VSs) have been evaluated. In this paper the conformation number (CN) and dose-related CN (dCN) are evaluated, and a penalty for underdosed target volumes and overdosed normal tissue is incorporated. A strategy is discussed to apply these indices (CN and dCN) to define the optimal prescription isodose (PI). For a given radiosurgery treatment plan, permitting partial target underdosage may offer an improvement of the CN. Variations of different conformation indices have been calculated for varying prescription levels--for example, an isodose plan. The resulting graph for the CN is discussed in detail to illustrate its use in defining the optimal PI level. For the 55 cases of VSs reported on, the median CNmax result was 0.78.

CONCLUSIONS

It is possible to achieve highly conformal dose distributions with Novalis radiosurgical system. The CN is the parameter of choice when evaluating radiosurgery treatment plans and scoring possible treatment plans. It takes into account both target underdosage and normal tissue overdosage and offers a valuable scoring parameter while avoiding false-perfect scores.

Geometrical accuracy of the Novalis stereotactic radiosurgery system for trigeminal neuralgia

OBJECT

Stringent geometrical accuracy and precision are required in the stereotactic radiosurgical treatment of patients. Accurate targeting is especially important when treating a patient in a single fraction of a very high radiation dose (90 Gy) to a small target such as that used in the treatment of trigeminal neuralgia (3 to 4-mm diameter). The purpose of this study was to determine the inaccuracies in each step of the procedure including imaging, fusion, treatment planning, and finally the treatment. The authors implemented a detailed quality-assurance program.

METHODS

Overall geometrical accuracy of the Novalis stereotactic system was evaluated using a Radionics Geometric Phantom Chamber. The phantom has several magnetic resonance (MR) and computerized tomography (CT) imaging-friendly objects of various shapes and sizes. Axial 1-mm-thick MR and CT images of the phantom were acquired using a T1-weighted three-dimensional spoiled gradient recalled pulse sequence and the CT scanning protocols used clinically in patients. The absolute errors due to MR image distortion, CT scan resolution, and the image fusion inaccuracies were measured knowing the exact physical dimensions of the objects in the phantom. The isocentric accuracy of the Novalis gantry and the patient support system was measured using the Winston-Lutz test. Because inaccuracies are cumulative, to calculate the system's overall spatial accuracy, the root mean square (RMS) of all the errors was calculated. To validate the accuracy of the technique, a 1.5-mm-diameter spherical marker taped on top of a radiochromic film was fixed parallel to the x-z plane of the stereotactic coordinate system inside the phantom. The marker was defined as a target on the CT images, and seven noncoplanar circular arcs were used to treat the target on the film. The calculated system RMS value was then correlated with the position of the target and the highest density on the radiochromic film. The mean spatial errors due to image fusion and MR imaging were 0.41+/-0.3 and 0.22+/-0.1 mm, respectively. Gantry and couch isocentricities were 0.3+/-0.1 and 0.6+/-0.15 mm, respectively. The system overall RMS values were 0.9 and 0.6 mm with and without the couch errors included, respectively (isocenter variations due to couch rotation are microadjusted between couch positions). The positional verification of the marker was within 0.7+/-0.1 mm of the highest optical density on the radiochromic film, correlating well with the system's overall RMS value. The overall mean system deviation was 0.32+/-0.42 mm.

CONCLUSIONS

The highest spatial errors were caused by image fusion and gantry rotation. A comprehensive quality-assurance program was developed for the authors' stereotactic radiosurgery program that includes medical imaging, linear accelerator mechanical isocentricity, and treatment delivery. For a successful treatment of trigeminal neuralgia with a 4-mm cone, the overall RMS value of equal to or less than 1 mm must be guaranteed.