Dosimetric properties of megavoltage grid therapy

Grid/lattice therapy: consideration of small field dosimetry

Small-field dosimetry used in special procedures such as gamma knife, Cyberknife, Tomotherapy, IMRT, and VMAT has been in evolution after several radiation incidences with very significant (70%) errors due to poor understanding of the dosimetry. IAEA-TRS-483 and AAPM-TG-155 have provided comprehensive information on small-fields dosimetry in terms of code of practice and relative dosimetry. Data for various detectors and conditions have been elaborated. It turns out that with a suitable detectors dose measurement accuracy can be reasonably (±3%) achieved for 6 MV beams for fields >1×1 cm2. For grid therapy, even though the treatment is performed with small fields created by either customized blocks, multileaf collimator (MLC), or specialized devices, it is multiple small fields that creates combined treatment. Hence understanding the dosimetry in collection of holes of small field is a separate challenge that needs to be addressed. It is more critical to understand the scattering conditions from multiple holes that form the treatment grid fields. Scattering changes the beam energy (softer) and hence dosimetry protocol needs to be properly examined for having suitable dosimetric parameters. In lieu of beam parameter unavailability in physical grid devices, MLC-based forward and inverse planning is an alternative path for bulky tumours. Selection of detectors in small field measurement is critical and it is more critical in mixed beams created by scattering condition. Ramification of small field concept used in grid therapy along with major consideration of scattering condition is explored. Even though this review article is focussed mainly for dosimetry for low-energy megavoltage photon beam (6 MV) but similar procedures could be adopted for high energy beams. To eliminate small field issues, lattice therapy with the help of MLC is a preferrable choice.

Beam quality and the mystery behind the lower percentage depth dose in grid radiation therapy

Grid therapy recently has been picking momentum due to favorable outcomes in bulky tumors. This is being termed as Spatially Fractionated Radiation Therapy (SFRT) and lattice therapy. SFRT can be performed with specially designed blocks made with brass or cerrobend with repeated holes or using multi-leaf collimators where dosimetry is uncertain. The dosimetric challenge in grid therapy is the mystery behind the lower percentage depth dose (PDD) in grid fields. The knowledge about the beam quality, indexed by TPR20/10 (Tissue Phantom Ratio), is also necessary for absolute dosimetry of grid fields. Since the grid may change the quality of the primary photons, a new [Formula: see text] should be evaluated for absolute dosimetry of grid fields. A Monte Carlo (MC) approach is provided to resolving the dosimetric issues. Using 6 MV beam from a linear accelerator, MC simulation was performed using MCNPX code. Additionally, a commercial grid therapy device was used to simulate the grid fields. Beam parameters were validated with MC model for output factor, depth of maximum dose, PDDs, dose profiles, and TPR20/10. The electron and photon spectra were also compared between open and grid fields. The dmax is the same for open and grid fields. The PDD with grid is lower (~ 10%) than the open field. The difference in TPR20/10 of open and grid fields is observable (~ 5%). Accordingly, TPR20/10 is still a good index for the beam quality in grid fields and consequently choose the correct [Formula: see text] in measurements. The output factors for grid fields are 0.2 lower compared to open fields. The lower depth dose with grid therapy is due to lower depth fluence with scatter radiation but it does not impact the dosimetry as the calibration parameters are insensitive to the effective beam energies. Thus, standard dosimetry in open beam based on international protocol could be used.

Lattice position optimization for LATTICE therapy

BACKGROUND

LATTICE radiation therapy delivers 3D heterogenous dose of high peak-to-valley dose ratio (PVDR) to the tumor target, with peak dose at lattice vertices inside the target and valley dose for the rest of the target. Although the lattice vertex positions can impact PVDR inside the target and sparing of organs-at-risk (OAR), they are fixed as constants and not optimized during treatment planning in current clinical practice.

PURPOSE

This work proposes a new LATTICE plan optimization method that can optimize lattice vertex positions during LATTICE treatment planning, which is the first lattice position optimization study to the best of our knowledge.

METHODS

The new LATTICE treatment planning method optimizes lattice vertex positions as well as other plan variables (e.g., photon fluences or proton spot weights), with optimization objectives for target PVDR and OAR sparing. To satisfy mathematical differentiability, the lattice vertices are approximated in sigmoid functions. For geometric feasibility, proper geometry constraints are enforced onto lattice vertex positions. The lattice position optimization problem is solved by iterative convex relaxation (ICR) method and alternating direction method of multipliers (ADMM), and lattice vertex positions and photon/proton plan variables are jointly updated via the Quasi-Newton method.

RESULTS

Both photon and proton LATTICE RT were considered, and the optimal lattice vertex positions in terms of plan objectives were found by solving all possible combinations on given discrete positions via exhaustive searching based on standard IMRT/IMPT, which served as the ground truth for validating the new LATTICE method. The results show that the new method indeed provided the optimal lattice vertex positions with the smallest optimization objective, the largest target PVDR, and the best OAR sparing.

CONCLUSIONS

A new LATTICE treatment planning method is proposed and validated that can optimize lattice vertex positions as well as other photon or proton plan variables for improving target PVDR and OAR sparing.

Dosimetric Performance Evaluation of MLC-based and Cone-based 3D Spatially Fractionated LATTICE Radiotherapy

This study aims to dosimetrically compare multi-leaf collimator (MLC)-based and cone-based 3D LATTICE radiotherapy (LRT) plans. Valley-peak ratios were evaluated using seven different 3D LATTICE designs. Target volumes of 8 cm and 12 cm were defined on the RANDO phantom. Valley-peak dose patterns were obtained by creating high-dose vertices in the target volumes. By changing the vertex diameter, vertices separation, and volume ratio, seven different LATTICE designs were generated. Treatment plans were implemented using CyberKnife and Varian RapidArc. Thermoluminescent dosimeter (TLD), EBT3 films, and electronic portal-imaging device (EPID) were employed for dosimetric treatment verification, and measured doses were compared to calculated doses. By changing the vertex diameter and vertices separation, the valley-peak ratio was exhibited little difference between the two systems. By changing the vertex diameter and volume ratio, the valley-peak ratio was observed nearly the same for the two systems. The film, TLD, and EPID dosimetry showed good agreement between the calculated and measured doses. Based on the results, we concluded that although smaller valley-peak ratios were obtained with cone-based plans, the dose-volume histograms were comparable in both systems. Also, when we evaluated the treatment duration, the MLC-based plans were more appropriate to apply the treatment in a single fraction.

Radiobiological and Treatment-Related Aspects of Spatially Fractionated Radiotherapy

The continuously evolving field of radiotherapy aims to devise and implement techniques that allow for greater tumour control and better sparing of critical organs. Investigations into the complexity of tumour radiobiology confirmed the high heterogeneity of tumours as being responsible for the often poor treatment outcome. Hypoxic subvolumes, a subpopulation of cancer stem cells, as well as the inherent or acquired radioresistance define tumour aggressiveness and metastatic potential, which remain a therapeutic challenge. Non-conventional irradiation techniques, such as spatially fractionated radiotherapy, have been developed to tackle some of these challenges and to offer a high therapeutic index when treating radioresistant tumours. The goal of this article was to highlight the current knowledge on the molecular and radiobiological mechanisms behind spatially fractionated radiotherapy and to present the up-to-date preclinical and clinical evidence towards the therapeutic potential of this technique involving both photon and proton beams.

An investigation of kV mini-GRID spatially fractionated radiation therapy: dosimetry and preclinical trial

Objective. To develop and characterize novel methods of extreme spatially fractionated kV radiation therapy (including mini-GRID therapy) and to evaluate efficacy in the context of a pre-clinical mouse study.Approach. Spatially fractionated GRIDs were precision-milled from 3 mm thick lead sheets compatible with mounting on a 225 kVp small animal irradiator (X-Rad). Three pencil-beam GRIDs created arrays of 1 mm diameter beams, and three 'bar' GRIDs created 1 × 20 mm rectangular fields. GRIDs projected 20 × 20 mm2fields at isocenter, and beamlets were spaced at 1, 1.25, and 1.5 mm, respectively. Peak-to-valley ratios and dose distributions were evaluated with Gafchromic film. Syngeneic transplant tumors were induced by intramuscular injection of a soft tissue sarcoma cell line into the gastrocnemius muscle of C57BL/6 mice. Tumor-bearing mice were randomized to four groups: unirradiated control, conventional irradiation of entire tumor, GRID therapy, and hemi-irradiation (half-beam block, 50% tumor volume treated). All irradiated mice received a single fraction of 15 Gy.Results. High peak-to-valley ratios were achieved (bar GRIDs: 11.9 ± 0.9, 13.6 ± 0.4, 13.8 ± 0.5; pencil-beam GRIDs: 18.7 ± 0.6, 26.3 ± 1.5, 31.0 ± 3.3). Pencil-beam GRIDs could theoretically spare more intra-tumor immune cells than bar GRIDs, but they treat less tumor tissue (3%-4% versus 19%-23% area receiving 90% prescription, respectively). Bar GRID and hemi-irradiation treatments significantly delayed tumor growth (P < 0.05), but not as much as a conventional treatment (P < 0.001). No significant difference was found in tumor growth delay between GRID and hemi-irradiation.Significance. High peak-to-valley ratios were achieved with kV grids: two-to-five times higher than values reported in literature for MV grids. GRID irradiation and hemi-irradiation delayed tumor growth, but neither was as effective as conventional whole tumor uniform dose treatment. Single fraction GRID therapy could not initiate an anti-cancer immune response strong enough to match conventional RT outcomes, but follow-up studies will evaluate the combination of mini-GRID with immune checkpoint blockade.

A Dosimetric Parameter Reference Look-Up Table for GRID Collimator-Based Spatially Fractionated Radiation Therapy

Simple Summary

Dose prescription for the inhomogeneous dosing in spatially fractionated radiation therapy (SFRT) is challenging, and further hampered by the inability of several planning systems to incorporate complex SFRT dose patterns. We developed dosing reference tables for an inventory of tumour scenarios and tested their accuracy with water phantom measurements of GRID therapy, delivered by a standard commercial GRID collimator. We find that dose heterogeneity parameters and EUD modeling are consistent across tumour sizes, configurations, and treatment depths. These results suggest that the developed reference tables can be used as a practical clinical resource for clinical decision-making on GRID therapy and to facilitate heterogeneity dose estimates in clinical patients when this commercially available GRID device is used.

Abstract

Computations of heterogeneity dose parameters in GRID therapy remain challenging in many treatment planning systems (TPS). To address this difficulty, we developed reference dose tables for a standard GRID collimator and validate their accuracy. The .decimal Inc. GRID collimator was implemented within the Eclipse TPS. The accuracy of the dose calculation was confirmed in the commissioning process. Representative sets of simulated ellipsoidal tumours ranging from 6–20 cm in diameter at a 3-cm depth; 16-cm ellipsoidal tumours at 3, 6, and 10 cm in depth were studied. All were treated with 6MV photons to a 20 Gy prescription dose at the tumour center. From these, the GRID therapy dosimetric parameters (previously recommended by the Radiosurgery Society white paper) were derived. Differences in D5 through D95 and EUD between different tumour sizes at the same depth were within 5% of the prescription dose. PVDR from profile measurements at the tumour center differed from D10/D90, but D10/D90 variations for the same tumour depths were within 11%. Three approximation equations were developed for calculating EUDs of different prescription doses for three radiosensitivity levels for 3-cm deep tumours. Dosimetric parameters were consistent and predictable across tumour sizes and depths. Our study results support the use of the developed tables as a reference tool for GRID therapy.

The role of the spatially fractionated radiation therapy in the management of advanced bulky tumors

Spatially fractionated radiation therapy (SFRT) refers to the delivery of a single large dose of radiation within the target volume in a heterogeneous pattern using either a custom GRID block, multileaf collimators, and virtual methods such as helical tomotherapy or synchrotron-based microbeams. The potential impact of this technique on the regression of bulky deep-seated tumors that do not respond well to conventional radiotherapy has been remarkable. To date, a large number of patients have been treated using the SFRT techniques. However, there are yet many technical and medical challenges that have limited their routine use to a handful of clinics, most commonly for palliative intent. There is also a poor understanding of the biological mechanisms underlying the clinical efficacy of this approach. In this article, the methods of SFRT delivery together with its potential biological mechanisms are presented. Furthermore, technical challenges and clinical achievements along with the radiobiological models used to evaluate the efficacy and safety of SFRT are highlighted.

Spatially Fractionated Radiotherapy (GRID) Prior to Standard Neoadjuvant Conventionally Fractionated Radiotherapy for Bulky, High-Risk Soft Tissue and Osteosarcomas: Feasibility, Safety, and Promising Pathologic Response Rates

Spatially fractionated radiotherapy (GRID) has been utilized primarily in the palliative and definitive treatment of bulky tumors. Delivered in the modern era primarily with megavoltage photon therapy, this technique offers the promise of safe dose escalation with potential immunogenic, bystander and microvasculature effects that can augment a conventionally fractionated course of radiotherapy. At the University of Maryland, an institutional standard has arisen to incorporate a single fraction of GRID radiation in large (>8 cm), high-risk soft tissue and osteosarcomas prior to a standard fractionated course. Herein, we report on the excellent pathologic responses and apparent safety of this regimen in 26 consecutive patients.

Photon GRID Radiation Therapy: A Physics and Dosimetry White Paper from the Radiosurgery Society (RSS) GRID/LATTICE, Microbeam and FLASH Radiotherapy Working Group

The limits of radiation tolerance, which often deter the use of large doses, have been a major challenge to the treatment of bulky primary and metastatic cancers. A novel technique using spatial modulation of megavoltage therapy beams, commonly referred to as spatially fractionated radiation therapy (SFRT) (e.g., GRID radiation therapy), which purposefully maintains a high degree of dose heterogeneity across the treated tumor volume, has shown promise in clinical studies as a method to improve treatment response of advanced, bulky tumors. Compared to conventional uniform-dose radiotherapy, the complexities of megavoltage GRID therapy include its highly heterogeneous dose distribution, very high prescription doses, and the overall lack of experience among physicists and clinicians. Since only a few centers have used GRID radiation therapy in the clinic, wide and effective use of this technique has been hindered. To date, the mechanisms underlying the observed high tumor response and low toxicity are still not well understood. To advance SFRT technology and planning, the Physics Working Group of the Radiosurgery Society (RSS) GRID/Lattice, Microbeam and Flash Radiotherapy Working Groups, was established after an RSS-NCI Workshop. One of the goals of the Physics Working Group was to develop consensus recommendations to standardize dose prescription, treatment planning approach, response modeling and dose reporting in GRID therapy. The objective of this report is to present the results of the Physics Working Group's consensus that includes recommendations on GRID therapy as an SFRT technology, field dosimetric properties, techniques for generating GRID fields, the GRID therapy planning methods, documentation metrics and clinical practice recommendations. Such understanding is essential for clinical patient care, effective comparisons of outcome results, and for the design of rigorous clinical trials in the area of SFRT. The results of well-conducted GRID radiation therapy studies have the potential to advance the clinical management of bulky and advanced tumors by providing improved treatment response, and to further develop our current radiobiology models and parameters of radiation therapy design.

Biological and Mechanical Synergies to Deal With Proton Therapy Pitfalls: Minibeams, FLASH, Arcs, and Gantryless Rooms

Proton therapy has advantages and pitfalls comparing with photon therapy in radiation therapy. Among the limitations of protons in clinical practice we can selectively mention: uncertainties in range, lateral penumbra, deposition of higher LET outside the target, entrance dose, dose in the beam path, dose constraints in critical organs close to the target volume, organ movements and cost. In this review, we combine proposals under study to mitigate those pitfalls by using individually or in combination: (a) biological approaches of beam management in time (very high dose rate “FLASH” irradiations in the order of 100 Gy/s) and (b) modulation in space (a combination of mini-beams of millimetric extent), together with mechanical approaches such as (c) rotational techniques (optimized in partial arcs) and, in an effort to reduce cost, (d) gantry-less delivery systems. In some cases, these proposals are synergic (e.g., FLASH and minibeams), in others they are hardly compatible (mini-beam and rotation). Fixed lines have been used in pioneer centers, or for specific indications (ophthalmic, radiosurgery,…), they logically evolved to isocentric gantries. The present proposals to produce fixed lines are somewhat controversial. Rotational techniques, minibeams and FLASH in proton therapy are making their way, with an increasing degree of complexity in these three approaches, but with a high interest in the basic science and clinical communities. All of them must be proven in clinical applications.

A simple dosimetric approach to spatially fractionated GRID radiation therapy using the multileaf collimator for treatment of breast cancers in the prone position

The purpose of this study was to explore the treatment planning methods of spatially fractionated radiation therapy (SFRT), commonly referred to as GRID therapy, in the treatment of breast cancer patients using multileaf collimator (MLC) in the prone position. A total of 12 patients with either left or right breast cancer were retrospectively chosen. The computed tomography (CT) images taken for the whole breast external beam radiation therapy (WB‐EBRT) were used for GRID therapy planning. Each GRID plan was made by using two portals and each portal had two fields with 1‐cm aperture size. The dose prescription point was placed at the center of the target volume, and a dose of 20 Gy with 6‐MV beams was prescribed. Dose‐volume histogram (DVH) curves were generated to evaluate dosimetric properties. A modified linear‐quadratic (MLQ) radiobiological response model was used to assess the equivalent uniform doses (EUD) and therapeutic ratios (TRs) of all GRID plans. The DVH curves indicated that these MLC‐based GRID therapy plans can deliver heterogeneous dose distribution in the target volume as seen with the conventional cerrobend GRID block. The plans generated by the MLC technique also demonstrated the advantage for accommodating different target shapes, sparing normal structures, and reporting dose metrics to the targets and the organs at risks. All GRID plans showed to have similar dosimetric parameters, implying the plans can be made in a consistent quality regardless of the shape of the target and the size of volume. The mean dose of lung and heart were respectively below 0.6 and 0.7 Gy. When the size of aperture is increased from 1 to 2 cm, the EUD and TR became smaller, but the peak/valley dose ratio (PVDR) became greater. The dosimetric approach of this study was proven to be simple, practical and easy to be implemented in clinic.

Enhanced response of radioresistant carcinoma cell line to heterogeneous dose distribution of grid; the role of high-dose bystander effect

PURPOSE

The classical dogma that restricted the radiation effect to the directly irradiated cells has been challenged by the bystander effect. This off-target phenomenon which was manifested in adjacent cells via signaling of fully exposed cells might be involved in high-dose Grid therapy as well. Here, an in-vitro study was performed to examine the possible extent of carcinoma cells response to the inhomogeneous dose distribution of Grid irradiation in the context of the bystander effect.

MATERIALS AND METHODS

Bystander effect was investigated in human carcinoma cell lines of HeLa and HN5 adjacent to those received high-dose Grid irradiation using 'medium transfer' and 'cell-to-cell contact' strategies. Based on the Grid peak-to-valley dose profile, medium transfer was exerted from 10 Gy uniformly exposed donors to 1.5 Gy uniformly irradiated recipients. Cell-contact bystander was evaluated after nonuniform dose distribution of 10 Gy Grid irradiation using cloning cylinders. GammaH2AX foci, micronucleus and clonogenic assays besides gene expression analysis were performed.

RESULTS

Various parameters (ɑ/β, D37, D50) extracted from survival curve which fitted to the Linear Quadratic model, verified more radioresistance of HN5. Survival fraction at 2 Gy (SF2) indicated as 0.42 ± 0.06 in HeLa and 0.5 ± 0.03 in HN5. The level of survival decrease, DNA damages and micronucleus of cells located in the Grid shielded areas (1.5 Gy cell-to-cell contact bystander cells) were significantly more than the values obtained from cells which were irradiated by merely uniform dose of 1.5 Gy. The gH2AX foci and micronuclei frequencies were enhanced in cell-contact bystander approximately more than 1.8 times. Relative expression of DNA damage repair pathway genes (Xrcc6 and H2afx) in bystander cells increased significantly. The most cell survival reduction (11.6 times) was revealed in the Grid bystander cells of radioresistant cell line (HN5). No statistically significant difference between 10 Gy uniform beam and Grid non-uniform beam was observed.

CONCLUSIONS

Various endpoints confirmed an augmented response of cells in the valley dose region of the Grid block significantly (compared with the cells irradiated by identical dose of uniform beam), suggesting the role of high-dose bystander effect which was more pronounced in resistant carcinoma cell lines. These findings could provide a partial explanation for the Grid beneficial response seen in a number of pre-clinical and clinical studies.

Photon and photon–neutron experimental dosimetry in Grid therapy with 18 MV photon beams

Propose:

Spatially fractionated Grid radiation therapy (SFGRT) in an effective technique for bulky and radio-sensitive tumours. SFGRT using a constructed block has been used to evaluate the photon and photo-neutron (PN) dose measurement in 18-MV photon beam energy.

Methods and materials:

A mounted Grid block on to a Varian Clinac 2100c linear accelerator was used to perform photon dosimetry. The percentage depth dose, in-plane and cross-plane beam profile and output factor was measured by ionization chamber in water. The PN contamination was measured after photon dosimetry using the combination of thermoluminescence dosimetry types 600 and 700, and Polycarbonate Film dosimeters on the surface and in the maximum depth dose (dmax) of solid water™ slabs.

Results:

The valley-to-peak ration for 6 and 18 MV photon beams obtained from the beam profiles was ~35 and 72%, respectively. Fast and thermal PN equivalent dose decreased in the Grid field compared to an open field (without Grid).

Conclusion:

The Grid therapy dosimetry compared to the conventional radiotherapy (without the grid) the production of fast and thermal neutrons were reduced. Using of a Grid block in high-energy photon beams for a long period of the treatment continuously might be a new source of contamination due to the interaction of photon beam resulting the activation of the Grid block

FLASH and minibeams in radiation therapy: the effect of microstructures on time and space and their potential application to protontherapy

After years of lethargy, studies on two non-conventional microstructures in time and space of the beams used in radiation therapy are enjoying a huge revival. The first effect called “FLASH” is based on very high dose-rate irradiation (pulse amplitude ≥10⁶ Gy/s), short beam-on times (≤100 ms) and large single doses (≥10 Gy) as experimental parameters established so far to give biological and potential clinical effects. The second effect relies on the use of arrays of minibeams (e.g., 0.5–1 mm, spaced 1–3.5 mm). Both approaches have been shown to protect healthy tissues as an endpoint that must be clearly specified and could be combined with each other (e.g., minibeams under FLASH conditions). FLASH depends on the presence of oxygen and could proceed from the chemistry of peroxyradicals and a reduced incidence on DNA and membrane damage. Minibeams action could be based on abscopal effects, cell signalling and/or migration of cells between “valleys and hills” present in the non-uniform irradiation field as well as faster repair of vascular damage. Both effects are expected to maintain intact the tumour control probability and might even preserve antitumoural immunological reactions. FLASH in vivo experiments involving Zebrafish, mice, pig and cats have been done with electron beams, while minibeams are an intermediate approach between X-GRID and synchrotron X-ray microbeams radiation. Both have an excellent rationale to converge and be applied with proton beams, combining focusing properties and high dose rates in the beam path of pencil beams, and the inherent advantage of a controlled limited range. A first treatment with electron FLASH (cutaneous lymphoma) has recently been achieved, but clinical trials have neither been presented for FLASH with protons, nor under the minibeam conditions. Better understanding of physical, chemical and biological mechanisms of both effects is essential to optimize the technical developments and devise clinical trials.

A Current Review of Spatial Fractionation: Back to the Future?

Spatially fractionated radiation therapy represents a significant departure from canonical thinking in radiation oncology despite having origins in the early 1900s. The original and most common implementation of spatially fractionated radiation therapy uses commercially available blocks or multileaf collimators to deliver a nonconfluent, sieve-like pattern of radiation to the target volume in a nonuniform dose distribution. Dosimetrically, this is parameterized by the ratio of the valley dose in cold spots to the peak dose in hot spots, or the valley-to-peak dose ratio. The radiobiologic mechanisms are postulated to involve radiation-induced bystander effects, microvascular alterations, and/or immunomodulation. Current indications include bulky or locally advanced disease that would not be amenable to conventional radiation or that has proved refractory to chemoradiation. Early-phase clinical trials have shown remarkable success, with some response rates >90% and minimal toxicity. This has promoted technological developments in 3-dimensional formats (LATTICE), micron-size beams (microbeam), and proton arrays. Nevertheless, more clinical and biological data are needed to specify ideal dosimetry parameters and to formulate robust clinical indications and guidelines for optimal standardized care.

Spatially fractionated proton minibeams

Extraordinary normal tissue response to highly spatially fractionated X-ray beams has been explored for over 25 years. More recently, alternative radiation sources have been developed and utilized with the aim to evoke comparable effects. These include protons, which lend themselves well for this endeavour due to their physical depth dose characteristics as well as corresponding variable biological effectiveness. This paper addresses the motivation for using protons to generate spatially fractionated beams and reviews the technological implementations and experimental results to date. This includes simulation and feasibility studies, collimation and beam characteristics, dosimetry and biological considerations as well as the results of in vivo and in vitro studies. Experimental results are emerging indicating an extraordinary normal tissue sparing effect analogous to what has been observed for synchrotron generated X-ray microbeams. The potential for translational research and feasibility of spatially modulated proton beams in clinical settings is discussed.

Dose evaluation of Grid Therapy using a 6 MV flattening filter-free (FFF) photon beam: A Monte Carlo study

PURPOSE

Spatially fractionated radiotherapy is a strategy to overcome the main limitation of radiotherapy, i.e., the restrained normal tissue tolerances. A well-known example is Grid Therapy, which is currently performed at some hospitals using megavoltage photon beams delivered by Linacs. Grid Therapy has been successfully used in the management of bulky abdominal tumors with low toxicity. The aim of this work was to evaluate whether an improvement in therapeutic index in Grid Therapy can be obtained by implementing it in a flattening filter-free (FFF) Linac. The rationale behind is that the removal of the flattening filter shifts the beam energy spectrum towards lower energies and increase the photon fluence. Lower energies result in a reduction of lateral scattering and thus, to higher peak-to-valley dose ratios (PVDR) in normal tissues. In addition, the gain in fluence might allow using smaller beams leading a more efficient exploitation of dose-volume effects, and consequently, a better normal tissue sparing.

METHODS

Monte Carlo simulations were used to evaluate realistic dose distributions considering a 6 MV FFF photon beam from a standard medical Linac and a cerrobend mechanical collimator in different configurations: grid sizes of 0.3 × 0.3 cm² , 0.5 × 0.5 cm² , and 1 × 1 cm² and a corresponding center-to-center (ctc) distance of 0.6, 1, and 2 cm, respectively (total field size of 10 × 10 cm² ). As figure of merit, peak doses in depth, PVDR, output factors (OF), and penumbra values were assessed.

RESULTS

Dose at the entrance is slightly higher than in conventional Grid Therapy. However, it is compensated by the large PVDR obtained at the entrance, reaching a maximum of 35 for a grid size of 1 × 1 cm² . Indeed, this grid size leads to very high PVDR values at all depths (≥ 10), which are much higher than in standard Grid Therapy. This may be beneficial for normal tissues but detrimental for tumor control, where a lower PVDR might be requested. In that case, higher valley doses in the tumor could be achieved by using an interlaced approach and/or adapting the ctc distance. The smallest grid size (0.3 × 0.3 cm² ) leads to low PVDR at all depths, comparable to standard Grid Therapy. However, the use of very thin beams might increase the normal tissue tolerances with respect to the grid size commonly used (1 × 1 cm² ). The gain in fluence provided by FFF implies that the important OF reduction (0.6) will not increase treatment time. Finally, the intermediate configuration (0.5 × 0.5 cm² ) provides high PVDR in the first 5 cm, and comparable PVDR to previous Grid Therapy works at depth. Therefore, this configuration might allow increasing the normal tissue tolerances with respect to Grid Therapy thanks to the higher PVDR and thinner beams, while a similar tumor control could be expected.

CONCLUSIONS

The implementation of Grid Therapy in an FFF photon beam from medical Linac might lead to an improvement of the therapeutic index. Among the cases evaluated, a grid size of 0.5 × 0.5 cm² (1-cm-ctc) is the most advantageous configuration from the physics point of view. Radiobiological experiments are needed to fully explore this new avenue and to confirm our results.

Grid Block Design Based on Monte Carlo Simulated Dosimetry, the Linear Quadratic and Hug-Kellerer Radiobiological Models

Purpose

The clinical efficacy of Grid therapy has been examined by several investigators. In this project, the hole diameter and hole spacing in Grid blocks were examined to determine the optimum parameters that give a therapeutic advantage.

Methods

The evaluations were performed using Monte Carlo (MC) simulation and commonly used radiobiological models. The Geant4 MC code was used to simulate the dose distributions for 25 different Grid blocks with different hole diameters and center-to-center spacing. The therapeutic parameters of these blocks, namely, the therapeutic ratio (TR) and geometrical sparing factor (GSF) were calculated using two different radiobiological models, including the linear quadratic and Hug-Kellerer models. In addition, the ratio of the open to blocked area (ROTBA) is also used as a geometrical parameter for each block design. Comparisons of the TR, GSF, and ROTBA for all of the blocks were used to derive the parameters for an optimum Grid block with the maximum TR, minimum GSF, and optimal ROTBA. A sample of the optimum Grid block was fabricated at our institution. Dosimetric characteristics of this Grid block were measured using an ionization chamber in water phantom, Gafchromic film, and thermoluminescent dosimeters in Solid Water™ phantom materials.

Results

The results of these investigations indicated that Grid blocks with hole diameters between 1.00 and 1.25 cm and spacing of 1.7 or 1.8 cm have optimal therapeutic parameters (TR > 1.3 and GSF~0.90). The measured dosimetric characteristics of the optimum Grid blocks including dose profiles, percentage depth dose, dose output factor (cGy/MU), and valley-to-peak ratio were in good agreement (±5%) with the simulated data.

Conclusion

In summary, using MC-based dosimetry, two radiobiological models, and previously published clinical data, we have introduced a method to design a Grid block with optimum therapeutic response. The simulated data were reproduced by experimental data.

Spatially Fractionated GRID Radiation Treatment of Advanced Neck Disease Associated with Head and Neck Cancer

Advanced nodal disease associated with head and neck cancer warrants aggressive, often multi-modality therapy to maximize local-regional control. The expansion of a novel treatment paradigm developed by our institution includes the addition of a single-fraction of high dose spatially-fractionated radiation (GRID) to a conventional course of treatment.

Between 1995 and 2002 a series of 27 patients (median age 65) with bulky N2-3 disease were treated. Median nodal tumor size was 7 cm. Two groups of patients were evaluated. Group 1 (N=14) patients received a median neck dose 69 Gy (range 54–79 Gy) plus GRID treatment. Group 2 (N=13) patients received a median neck dose of 59 Gy (range 54–72 Gy) plus GRID treatment followed by planned neck dissection. Patients were evaluated for local-regional control, pathological response, survival, and morbidity.

Median time to follow-up for Group 1 was 10 months (range 3–44 months). Neck control was 93%. Disease specific survival was 50%. Morbidity was limited to soft-tissue related damage and was mild. Median time to follow-up for Group 2 was 38 months (range 5–116 months). Pathologic complete response rate was 85%. Overall neck control rate was 92%. Disease specific survival was 85%. Surgical morbidity was limited to three wound healing complications.

GRID treatment may be safely added to conventional treatment management of locally advanced neck disease related to cancer with acceptable morbidity. It may improve pathologic complete response rates in those patients who undergo planned neck dissection, possibly leading to improved survival. In patients with inoperable bulky disease, addition of GRID enhances local-regional control.

Is grid therapy useful for all tumors and every grid block design?

Grid therapy is a treatment technique that has been introduced for patients with advanced bulky tumors. The purpose of this study is to investigate the effect of the radiation sensitivity of the tumors and the design of the grid blocks on the clinical response of grid therapy. The Monte Carlo simulation technique is used to determine the dose distribution through a grid block that was used for a Varian 2100C linear accelerator. From the simulated dose profiles, the therapeutic ratio (TR) and the equivalent uniform dose (EUD) for different types of tumors with respect to their radiation sensitivities were calculated. These calculations were performed using the linear quadratic (LQ) and the Hug-Kellerer (H-K) models. The results of these calculations have been validated by comparison with the clinical responses of 232 patients from different publications, who were treated with grid therapy. These published results for different tumor types were used to examine the correlation between tumor radiosensitivity and the clinical response of grid therapy. Moreover, the influence of grid design on their clinical responses was investigated by using Monte Carlo simulations of grid blocks with different hole diameters and different center-to-center spacing. The results of the theoretical models and clinical data indicated higher clinical responses for the grid therapy on the patients with more radioresistant tumors. The differences between TR values for radioresistant cells and radiosensitive cells at 20 Gy and 10 Gy doses were up to 50% and 30%, respectively. Interestingly, the differences between the TR values with LQ model and H-K model were less than 4%. Moreover, the results from the Monte Carlo studies showed that grid blocks with a hole diameters of 1.0 cm and 1.25 cm may lead to about 19% higher TR relative to the grids with hole diameters smaller than 1.0 cm or larger than 1.25 cm (with 95% confidence interval). In sum-mary, the results of this study indicate that grid therapy is more effective for tumors with radioresistant characteristics than radiosensitive tumors.

Spatially fractionated radiotherapy (GRID) using helical tomotherapy

Spatially fractionated radiotherapy (GRID) was designed to treat large tumors while sparing skin, and it is usually delivered with a linear accelerator using a commercially available block or multileaf collimator (LINAC-GRID). For deep-seated (skin to tumor distance (> 8 cm)) tumors, it is always a challenge to achieve adequate tumor dose coverage. A novel method to perform GRID treatment using helical tomotherapy (HT-GRID) was developed at our institution. Our approach allows treating patients by generating a patient-specific virtual GRID block (software-generated) and using IMRT technique to optimize the treatment plan. Here, we report our initial clinical experience using HT-GRID, and dosimetric comparison results between HT-GRID and LINAC-GRID. This study evaluates 10 previously treated patients who had deep-seated bulky tumors with complex geometries. Five of these patients were treated with HT-GRID and replanned with LINAC-GRID for comparison. Similarly, five other patients were treated with LINAC-GRID and replanned with HT-GRID for comparison. The prescription was set such that the maximum dose to the GTV is 20 Gy in a single fraction. Dosimetric parameters compared included: mean GTV dose (DGTV mean), GTV dose inhomogeneity (valley-to-peak dose ratio (VPR)), normal tissue doses (DNmean), and other organs-at-risk (OARs) doses. In addition, equivalent uniform doses (EUD) for both GTV and normal tissue were evaluated. In summary, HT-GRID technique is patient-specific, and allows adjustment of the GRID pattern to match different tumor sizes and shapes when they are deep-seated and cannot be adequately treated with LINAC-GRID. HT-GRID delivers a higher DGTV mean, EUD, and VPR compared to LINAC-GRID. HT-GRID delivers a higher DNmean and lower EUD for normal tissue compared to LINAC-GRID. HT-GRID plans also have more options for tumors with complex anatomical relationships between the GTV and the avoidance OARs (abutment or close proximity).

Exploiting sensitization windows of opportunity in hyper and hypo-fractionated radiation therapy

In contrast to the conventional radiotherapy/chemoradiotherapy paradigms used in the treatment of majority of cancer types, this review will describe two areas of radiobiology, hyperfractionated and hypofractionated radiation therapy, for cancer treatment focusing on application of novel concepts underlying these treatment modalities. The initial part of the review discusses the phenomenon of hyper-radiation sensitivity (HRS) at lower doses (0.1 to 0.6 Gy), describing the underlying mechanisms and how this could enhance the effects of chemotherapy, particularly, in hyperfractionated settings. The second part examines the radiobiological/physiological mechanisms underlying the effects of high-dose hypofractionated radiation therapy that can be exploited for tumor cure. These include abscopal/bystander effects, activation of immune system, endothelial cell death and effect of hypoxia with re-oxygenation. These biological properties along with targeted dose delivery and distribution to reduce normal tissue toxicity may make high-dose hypofractionation more effective than conventional radiation therapy for treatment of advanced cancers. The novel radiation physics based methods that take into consideration the tumor volume to be irradiated and normal tissue avoidance/tolerance can further improve treatment outcome and post-treatment quality of life. In conclusion, there is enough evidence to further explore novel avenues to exploit biological mechanisms from hyper-fractionation by enhancing the efficacy of chemotherapy and hypo-fractionated radiation therapy that could enhance tumor control and use imaging and technological advances to reduce toxicity.

Feasibility of a simple method of hybrid collimation for megavoltage grid therapy

PURPOSE

Megavoltage grid therapy is currently delivered with step-and-shoot multisegment techniques or using a high attenuation block with divergent holes. However, the commercial availability of grid blocks is limited, their construction is difficult, and step-and-shoot techniques require longer treatment times and are not practical with some multileaf collimators. This work studies the feasibility of a hybrid collimation system for grid therapy that does not require multiple segments and can be easily implemented with widely available technical means.

METHODS

The authors have developed a system to generate a grid of beamlets by the simultaneous use of two perpendicular sets of equally spaced leaves that project stripe patterns in orthogonal directions. One of them is generated with the multileaf collimator integrated in the accelerator and the other with an in-house made collimator constructed with a low melting point alloy commonly available at radiation oncology departments. The characteristics of the grid fields for 6 and 18 MV have been studied with a shielded diode, an unshielded diode, and radiochromic film.

RESULTS

The grid obtained with the hybrid collimation is similar to some of the grids used clinically with respect to the beamlet size (about 1 cm) and the percentage of open beam (1/4 of the total field). The grid fields are less penetrating than the open fields of the same energy. Depending on the depth and the direction of the profiles (diagonal or along the principal axes), the measured valley-to-peak dose ratios range from 5% to 16% for 6 MV and from 9% to 20% for 18 MV. All the detectors yield similar results in the measurement of profiles and percent depth dose, but the shielded diode seems to overestimate the output factors.

CONCLUSIONS

The combination of two stripe pattern collimators in orthogonal directions is a feasible method to obtain two-dimensional arrays of beamlets and has potential usefulness as an efficient way to deliver grid therapy. The implementation of this method is technically simpler than the construction of a conventional grid block.

Monte Carlo simulation of stereotactic microbeam radiation therapy: evaluation of the usage of a linear accelerator as the x-ray source

The usage of linear accelerator-generated x-rays for the stereotactic microbeam radiation therapy technique was evaluated in this study. Dose distributions were calculated with the Monte Carlo code MCNPX. Unidirectional single beams and beam arrays were simulated in a cylindrical water phantom to observe the effects of x-ray energies and irradiation geometry on dose distributions. Beam arrays were formed with square pencil beams. Two orthogonally interlaced beam arrays were simulated in a detailed head phantom and dose distributions were compared with ones which had been calculated for a bidirectional interlaced microbeam therapy (BIMRT) technique that uses synchrotron-generated x-rays. A parallel pattern of the beams was preserved through the phantom; however an unsegmented dose region could not be formed at the target. Five orthogonally interlaced beam array pairs (ten beam arrays) were simulated in a mathematical head phantom and the unsegmented dose region was formed. However, the dose fall-off distance is longer than the one that had been calculated for the BIMRT technique. Besides, the peak-to-dose ratios between the phantom's outer surface and the target region are lower. Therefore, the advantages of the MRT technique may not be preserved with the usage of a linac as the x-ray source.

General properties of different models used to predict normal tissue complications due to radiation

In the current study the author analyzes general properties of three different models used to predict normal tissue complications due to radiation: (1) Surviving fraction of normal cells in the framework of the linear quadratic (LQ) equation for cell kill, (2) the Lyman-Kutcher-Burman (LKB) model for normal tissue complication probability (NTCP), and (3) generalized equivalent uniform dose (gEUD). For all considered cases the author assumes fixed average dose to an organ of interest. The author's goal is to establish whether maximizing dose uniformity in the irradiated normal tissues is radiobiologically beneficial. Assuming that NTCP increases with increasing overall cell kill, it is shown that NTCP in the LQ model is maximized for uniform dose. Conversely, NTCP in the LKB and gEUD models is always smaller for a uniform dose to a normal organ than that for a spatially varying dose if parameter n in these models is small (i.e., n <1). The derived conflicting properties of the considered models indicate the need for more studies before these models can be utilized clinically for plan evaluation and/or optimization of dose distributions. It is suggested that partial-volume irradiation can be used to establish the validity of the considered models.

Role of tumor necrosis factor-alpha and TRAIL in high-dose radiation-induced bystander signaling in lung adenocarcinoma

In the present study, ionizing radiation (IR)-induced bystander effects were investigated in two lung cancer cell lines. A549 cells were found to be more resistant to radiation-conditioned medium (RCM) obtained from A549 cells when compared with the H460 exposed to RCM procured from H460 cells. Significant release of tumor necrosis factor-alpha (TNF-alpha) was observed in A549 cells after IR/RCM exposure, and the survival was reversed with neutralizing antibody against TNF-alpha. In H460 cells, significant release of TNF-related apoptosis-inducing ligand (TRAIL), but not TNF-alpha, was observed in response to IR, RCM exposure, or RCM + 2Gy, and neutralizing antibody against TRAIL diminished clonogenic inhibition. Mechanistically, TNF-alpha present in RCM of A549 was found to mediate nuclear factor-kappaB (NF-kappaB) translocation to nucleus, whereas the soluble TRAIL present in RCM of H460 cells mobilized the nuclear translocation of PAR-4 (a proapoptotic protein). Analysis of IR-inducible early growth response-1 (EGR-1) function showed that EGR-1 was functional in A549 cells but not in H460 cells. A significant decrease in RCM-mediated apoptosis was observed in both A549 cells stably expressing small interfering RNA EGR-1 and EGR-1(-/-) mouse embryonic fibroblast cells. Thus, the high-dose IR-induced bystander responses in A549 may be dependent on the EGR-1 function and its target gene TNF-alpha. These findings show that the reduced bystander response in A549 cells is due to activation of NF-kappaB signaling by TNF-alpha, whereas enhanced response to IR-induced bystander signaling in H460 cells was due to release of TRAIL associated with nuclear translocation of PAR-4.

Cellular response to modulated radiation fields

Cell survival following exposure to spatially modulated beams, as created by intensity-modulated radiotherapy (IMRT), is investigated. In vitro experiments were performed using malignant melanoma cells (MM576) exposed to a therapeutic megavoltage photon beam. We compared cell survival in modulated fields with cell survival in uniform control fields. Three different spatial modulations of the field were used: a control 'uniform' field in which all cells in a flask were uniformly exposed; a 'quarter' field in which 25% of cells at one end of the flask were exposed and a 'striped' field in which 25% of cells were exposed in three parallel stripes. The cell survival in both the shielded and unshielded regions of the modulated fields, as determined by a clonogenic assay, were compared to the cell survival in the uniform field. We have distinguished three ways in which cell survival is influenced by the fate of neighbouring cells. The first of these (type I effect) is the previously reported classical Bystander effect, where cell survival is reduced when communicating with irradiated cells. We find two new types of Bystander effect. The type II effect is an observed increase in cell survival when nearby cells receive a lethal dose. The type III effect is an increase in the survival of cells receiving a high dose of radiation, when nearby cells receive a low dose. These observations of the Bystander effects emphasize the need for improved radiobiological models, which include communicated effects and account for the effects of modulated dose distribution.

Dosimetric evaluation of parallel opposed spatially fractionated radiation therapy of deep-seated bulky tumors

Application of a single fraction of parallel opposed GRID beams as a means of increasing the efficiency of radiation delivery to deep-seated tumors has been investigated. This evaluation was performed by measurement of dosimetric characteristics of the GRID radiation field in parallel opposed and single beam geometry. The limitations of the parallel opposed technique in terms of field size and tumor thickness have been evaluated for the conditions of acceptable spatial modulation. The results of this investigation have demonstrated an increase in therapeutic advantage for the parallel opposed technique over the single beam method when treating a deep seated tumor.

Dosimetric validation of the MCNPX Monte Carlo simulation for radiobiologic studies of megavoltage grid radiotherapy

PURPOSE

To validate the MCNPX Monte Carlo simulation for radiobiologic studies of megavoltage grid radiotherapy.

METHODS AND MATERIALS

EDR2 films, a scanning water phantom with microionization chamber and MCNPX Monte Carlo code, were used to study the dosimetric characteristics of a commercially available megavoltage grid therapy collimator. The measured dose profiles, ratios between maximum and minimum doses at 1.5 cm depth, and percentage depth dose curve were compared with those obtained in the simulations. The simulated two-dimensional dose profile and the linear-quadratic formalism of cell survival were used to calculate survival statistics of tumor and normal cells for the treatment of melanoma with a list of doses of the fractionated grid therapy.

RESULTS

A good agreement between the simulated and measured dose data was found. The therapeutic ratio based on normal cell survival has been defined and calculated for treating both the acute and late responding melanoma tumors. The grid therapy in this study was found to be advantageous for treating the acutely responding tumors, but not for late responding tumors.

CONCLUSIONS

Monte Carlo technique was demonstrated to be able to provide the dosimetric characteristics for grid therapy. The therapeutic ratio was dependent not only on the single alpha/beta value, but also on the individual alpha and beta values. Acutely responding tumors and radiosensitive normal tissues are more suitable for using the grid therapy.

Dosimetric characteristics of a newly designed grid block for megavoltage photon radiation and its therapeutic advantage using a linear quadratic model

Grid radiation therapy with megavoltage x-ray beam has been proven to be an effective technique for management of large, bulky malignant tumors. The clinical advantage of GRID therapy, combined with conventional radiation therapy, has been demonstrated using a prototype GRID block [Mohiuddin, Curtis, Grizos, and Komarnicky, Cancer 66, 114-118 (1990)]. Recently, a new GRID block design with improved dosimetric properties has become commercially available from Radiation Product Design, Inc. (Albertive, MN). This GRID collimator consists of an array of focused apertures in a cerrobend block arranged in a hexagonal pattern having a circular cross-section with a diameter and center-to-center spacing of 14.3 and 21.1 mm, respectively, in the plane of isocenter. In this project, dosimetric characteristics of the newly redesigned GRID block have been investigated for a Varian 21EX linear accelerator (Varian Associates, Palo Alto, CA). These determinations were performed using radiographic films, thermoluminescent dosimeters in Solid Water phantom materials, and an ionization chamber in water. The output factor, percentage depth dose, beam profiles, and isodose distributions of the GRID radiation as a function of field size and beam energy have been measured using both 6 and 18 MV x-ray beams. In addition, the therapeutic advantage obtained from this treatment modality with the new GRID block design for a high, single fraction of dose has been calculated using the linear quadratic model with alpha/beta ratios for typical tumor and normal cells. These biological characteristics of the new GRID block design will also be presented.

IMRT using simultaneously integrated boost (SIB) in head and neck cancer patients

Background

Preliminary very encouraging clinical results of intensity modulated radiation therapy (IMRT) in Head Neck Cancer (HNC) are available from several large centers. Tumor control rates seem to be kept at least at the level of conventional three-dimensional radiation therapy; the benefit of normal tissue preservation with IMRT is proven for salivary function. There is still only limited experience with IMRT using simultaneously integrated boost (SIB-IMRT) in the head and neck region in terms of normal tissue response.

The aim of this work was (1) to establish tumor response in HNC patients treated with SIB-IMRT, and (2) to assess tissue tolerance following different SIB-IMRT schedules.

Results

Between 1/2002 and 12/2004, 115 HNC patients have been curatively treated with IMRT. 70% received definitive IMRT (dIMRT), 30% were postoperatively irradiated. In 78% concomitant chemotherapy was given.

SIB radiation schedules with 5–6 × 2 Gy/week to 60–70 Gy, 5 × 2.2 Gy/week to 66–68.2 Gy (according to the RTOG protocol H-0022), or 5 × 2.11 Gy/week to 69.6 Gy were used.

After mean 18 months (10–44), 77% of patients were alive with no disease. Actuarial 2-year local, nodal, and distant disease free survival was 77%, 87%, and 78%, respectively. 10% were alive with disease, 10% died of disease. 20/21 locoregional failures occurred inside the high dose area. Mean tumor volume was significantly larger in locally failed (63 cc) vs controlled tumors (32 cc, p <0.01), and in definitive (43 cc) vs postoperative IMRT (25 cc, p <0.05); the locoregional failure rate was twofold higher in definitively irradiated patients.

Acute reactions were mild to moderate and limited to the boost area, the persisting grade 3/4 late toxicity rate was low with 6%. The two grade 4 reactions (dysphagia, laryngeal fibrosis) were observed following the SIB schedule with 2.2 Gy per session.

Conclusion

SIB-IMRT in HNC using 2.0, 2.11 or 2.2 Gy per session is highly effective and safe with respect to tumor response and tolerance. SIB with 2.2 Gy is not recommended for large tumors involving laryngeal structures.

Feasibility of delivering grid therapy using a multileaf collimator

The feasibility of using a multileaf collimator (MLC) for grid therapy is demonstrated in this study. Grids with the projected field openings of 10 mm x 10 mm and 5 mm x 5 mm were created using multiple MLC-shaped fields. The deposited doses were measured with films at different depths in a solid water phantom and compared to those of Cerrobend grid collimators of similar hole sizes and hole separations. At the depth of maximum dose (dmax), the valley-to-peak dose ratios of the MLC grids were found to be about 11% and 19% for the respective 10 mm x 10 mm and 5 mm X 5 mm grid openings, and those of the corresponding grid blocks were about 15% and 20%. To quantify the dose contributed by transmission in the blocked areas due to the limited leaf thickness, Monte Carlo simulations (based on convolution/superposition method) were performed to calculate the doses in the solid water phantom using an ideal MLC with no leakage and perfect divergence in both the leaf end and side. About 7% reduction in the valley-to-peak dose ratio was found for both grid sizes at dmax. The results clearly showed that MLCs can be used to provide grid treatments with at least as good dosimetric properties as those of the Cerrobend grid blocks, though the former would in general require a longer delivery time.

Concomitant GRID boost for Gamma Knife radiosurgery

We developed an integrated GRID boost technique for Gamma Knife radiosurgery. The technique generates an array of high dose spots within the target volume via a grid of 4-mm shots. These high dose areas were placed over a conventional Gamma Knife plan where a peripheral dose covers the full target volume. The beam weights of the 4-mm shots were optimized iteratively to maximize the integral dose inside the target volume. To investigate the target volume coverage and the dose to the adjacent normal brain tissue for the technique, we compared the GRID boosted treatment plans with conventional Gamma Knife treatment plans using physical and biological indices such as dose-volume histogram (DVH), DVH-derived indices, equivalent uniform dose (EUD), tumor control probabilities (TCP), and normal tissue complication probabilities (NTCP). We found significant increase in the target volume indices such as mean dose (5%-34%; average 14%), TCP (4%-45%; average 21%), and EUD (2%-22%; average 11%) for the GRID boost technique. No significant change in the peripheral dose coverage for the target volume was found per RTOG protocol. In addition, the EUD and the NTCP for the normal brain adjacent to the target (i.e., the near region) were decreased for the GRID boost technique. In conclusion, we demonstrated a new technique for Gamma Knife radiosurgery that can escalate the dose to the target while sparing the adjacent normal brain tissue.

Measurement of the three-dimensional distribution of radiation dose in grid therapy

A single large dose of megavoltage x-rays delivered through a grid is currently being utilized by some centres for palliative radiotherapy treatments of large tumours. In this note, we investigate the dosimetry of grid therapy using two-dimensional film dosimetry and three-dimensional gel dosimetry. It is shown that the radiation dose is attenuated more rapidly with depth in a grid field than an open field, and that even shielded regions receive approximately 25% of the dose to the unshielded areas.

Therapeutic advantage of grid irradiation for large single fractions

PURPOSE

In the present work, we used model calculations of cell survival to compare the effects of single fraction high-dose grid therapy with those of uniform dose delivery on tumor and normal tissues.

METHODS AND MATERIALS

The grid consisted of a hexagonal pattern of divergent holes in a Cerrobend block. A linear-quadratic model was used to find the surviving fraction of tumor and normal tissue cells after high-dose irradiation. Equivalent uniform doses were determined according to the tumor cell kill. The ratio of the normal tissue surviving fraction under grid irradiation to that obtained under equivalent uniform dose irradiation was taken as a measure of therapeutic gain.

RESULTS

The therapeutic ratio varied from 0.80 to 13.22 for the range of cell sensitivities investigated, with single fraction doses of 10.0-20.0 Gy. Optimization studies showed no significant dependence of therapeutic gain on hole spacing.

CONCLUSION

With high, single-fraction doses, grid irradiation revealed a therapeutic advantage over uniform dose irradiation whenever the tumor and surrounding normal tissues cells were equally radiosensitive, or, particularly, if the tumor cells were more radioresistant than the normal cells. The therapeutic gain did not appear to be a strong function of grid design.