Some limitations in the practical delivery of intensity modulated radiation therapy

An Analytical-empirical Calculation of Linear Attenuation Coefficient of Megavoltage Photon Beams

BACKGROUND

In this study, a method for linear attenuation coefficient calculation was introduced.

METHODS

Linear attenuation coefficient was calculated with a new method that base on the physics of interaction of photon with matter, mathematical calculation and x-ray spectrum consideration. The calculation was done for Cerrobend as a common radiotherapy modifier and Mercury.

RESULTS

The values of calculated linear attenuation coefficient with this new method are in acceptable range. Also, the linear attenuation coefficient decreases slightly as the thickness of attenuating filter (Cerrobend or mercury) increased, so the procedure of linear attenuation coefficient variation is in agreement with other documents. The results showed that the attenuation ability of mercury was about 1.44 times more than Cerrobend.

CONCLUSION

The method that was introduced in this study for linear attenuation coefficient calculation is general enough to treat beam modifiers with any shape or material by using the same formalism; however, calculating was made only for mercury and Cerrobend attenuator. On the other hand, it seems that this method is suitable for high energy shields or protector designing.

Influence of compensator thickness, field size, and off-axis distance on the effective attenuation coefficient of a cerrobend compensator for intensity-modulated radiation therapy

Intensity-modulated radiation therapy (IMRT) can be performed by using compensators. To make a compensator for an IMRT practice, it is required to calculate the effective attenuation coefficient (μ(eff)) of its material, which is affected by various factors. We studied the effect of the variation of the most important factors on the calculation of the μ(eff) of the cerrobend compensator for 6-MV photon beams, including the field size, compensator thickness, and off-axis distance. Experimental measurements were carried out at 100 cm source-to-surface distance and 10 cm depth for the 6-MV photon beams of an Elekta linac using various field size, compensator thickness, and off-axis settings. The field sizes investigated ranged from 4 × 4 to 25 × 25 cm² and the cerrobend compensator thicknesses from 0.5-6 cm. For a fixed compensator thickness, variation of the μ(eff) with the field size ranged from 3.7-6.8%, with the highest value attributed to the largest compensator thickness. At the reference field size of 10 × 10 cm², the μ(eff) varied by 16.5% when the compensator thickness was increased from 0.5-6 cm. However, the variation of the μ(eff) with the off-axis distance was only 0.99% at this field size, whereas for the largest field size, it was more significant. Our results indicated that the compensator thickness and field size have the most significant effect on the calculation of the compensator μ(eff) for the 6-MV photon beam. Therefore, it is recommended to consider these parameters when calculating the compensator thickness for an IMRT practice designed for these beams. The off-axis distance had a significant effect on the calculation of the μ(eff) only for the largest field size. Hence, it is recommended to consider the effect of this parameter only for field sizes larger than 25 × 25 cm².

Beam rate influence on dose distribution and fluence map in IMRT dynamic technique

AIM

To examine the impact of beam rate on dose distribution in IMRT plans and then to evaluate agreement of calculated and measured dose distributions for various beam rate values.

BACKGROUND

Accelerators used in radiotherapy utilize some beam rate modes which can shorten irradiation time and thus reduce ability of patient movement during a treatment session. This aspect should be considered in high conformal dynamic techniques.

MATERIALS AND METHODS

Dose calculation was done for two different beam rates (100 MU/min and 600 MU/min) in an IMRT plan. For both, a comparison of Radiation Planning Index (RPI) and MU was conducted. Secondly, the comparison of optimal fluence maps and corresponding actual fluence maps was done. Next, actual fluence maps were measured and compared with the calculated ones. Gamma index was used for that assessment. Additionally, positions of each leaf of the MLC were controlled by home made software.

RESULTS

Dose distribution obtained for lower beam rates was slightly better than for higher beam rates in terms of target coverage and risk structure protection. Lower numbers of MUs were achieved in 100 MU/min plans than in 600 MU/min plans. Actual fluence maps converted from optimal ones demonstrated more similarity in 100 MU/min plans. Better conformity of the measured maps to the calculated ones was obtained when a lower beam rate was applied. However, these differences were small. No correlation was found between quality of fluence map conversion and leaf motion accuracy.

CONCLUSION

Execution of dynamic techniques is dependent on beam rate. However, these differences are minor. Analysis shows a slight superiority of a lower beam rate. It does not significantly affect treatment accuracy.

The inter- and intrafraction reproducibilities of three common IMRT delivery techniques

PURPOSE

Intensity modulated radiation therapy (IMRT) treatment delivery requires higher precision than conventional 3D treatment delivery because of the sensitivity of the resulting dose to small geometric misalignment of the modulated beamlets. The chosen treatment delivery technique will affect the treatment precision in different ways, based on the characteristics of the delivery method. Delivery using a multileaf collimator (MLC) can reduce treatment time and therapist workload, but typically requires a greater number of monitor units and the fields are prone to both systematic and random leaf positioning errors. An alternative to MLC-based fields, patient specific brass compensators, do not suffer from these leaf positioning errors. In our study, we set out to investigate which delivery method will provide the highest levels of dosimetric reproducibility and the minimum amount of interfraction variability.

METHODS

In our study, a seven field IMRT plan for a head and neck treatment was created using the Pinnacle3 treatment planning system and the intensity maps for each field were obtained. The intensity maps of the fields were delivered with a Varian 2100C/D linear accelerator, using solid compensators and sliding window (SW) and step-and-shoot (SS) MLC segments. Three fields were selected from the seven-beam IMRT plan for comparison. Analysis was carried out using the MatriXX ion chamber array, radiochromic film, and Varian dynalog files.

RESULTS

Our results show that the error in MLC leaf positioning has no gantry angle dependence. The compensator and SW deliveries showed excellent agreement, even when stricter than usual gamma criteria were applied. However, we noted that under these strict conditions, the SS field had at least ten times more pixels out of range than did the compensators. When using step-and-shoot MLC fields, it was observed that the increase in dose rate or the increase of MU/segment degrades the quality of the plan. Analysis of the dynalog files showed that while each individual field had its own propensity for error, all fields showed the same trend: a greater percentage of time the leaves are out of position as dose rate increases, MUs decrease, or both.

CONCLUSIONS

The compensator-based field and both types of MLC-based fields have MatriXX results that are within the clinically acceptable tolerance of 3% dose difference and 2 mm DTA. However, when the criteria are tightened, it becomes evident that the compensators have a definite advantage over their comparable MLC-based competitors in terms of interfraction reproducibility. Fewer monitor units are required to deliver each portal, potentially improving patient outcomes and reducing unwanted side effects to both patients and therapists. In centers without MLC, compensators represent a simple and cost effective way to offer patients state of the art treatment. Based on the results of this study, compensator-based IMRT is a reliable, viable option for use in clinics both with and without MLC-equipped linacs.

Commissioning of modulator-based IMRT with XiO treatment planning system

This article describes the procedures for correction of the modulator thickness and commissioning of the XiO treatment planning system (TPS) for modulator-based intensity modulated radiation therapy (M-IMRT). This modulator manufacturing system adopts a method in which the modulator is milled using a floor-type computer-aided numerical control milling machine (CNC-mill) with modulator data calculated by XiO TPS. XiO TPS uses only effective attenuation coefficients (EAC) for modulator thickness calculation. This article describes a modified method for assessing modulator thickness. A two-dimensional linear attenuation array was used to correct the modulator thickness calculated by XiO. Narrow-beam geometry was used for measuring the linear attenuation coefficient (LAC) at off-axis positions (OAP) for varying brass thicknesses. An equation for the two-dimensional LAC ratio (2D-LACR) can be used to calculate the corrected modulator thickness. It is assumed that the broad beam EAC of a small field varies with the brass thickness and the OAP distance in the same way as that of LACR, so the two-dimensional EAC (2D-EAC) is equal to the EAC corrected using the LACR. The dose distribution was evaluated for three geometric patterns and one clinical case on low energy x ray (4 MV) with a large field size (20 x 20 cm2). The results using the proposed correction method of modulator thickness showed a good agreement between the measured dose distributions and the dose distributions calculated by TPS with the correction. Hence, the method is effective to improve the accuracy of M-IMRT in XiO TPS. An important problem for the brass modulator is the milling condition, such as the drill diameter and the cutting pitch size. It is necessary to improve the accuracy of M-IMRT for the "softening" and "hardening" effects of the beam to be considered in dose calculation in patients and the modulator profile design.

Dosimetric characteristics of a cubic-block-piled compensator for intensity-modulated radiation therapy in the Pinnacle radiotherapy treatment planning system

We examined the dose distributions generated by Pinnacle3 (Philips Radiation Oncology Systems, Milpitas, CA) for intensity‐modulated radiotherapy (IMRT) plans using a cubic‐block‐piled compensator as the intensity modulator for 4‐MV and 10‐MV photon beams. The Pinnacle treatment planning system (TPS) uses an algorithm in which only the physical density of the absorber is required for calculating the characteristics of the modulator. The intensity modulator consists of cubic blocks (attenuator) of a tungsten alloy, plus cubic blocks of polyethylene resin foam that fill the spaces between the attenuator blocks and polymethyl methacrylate (PMMA) boards that act as the platform for the modulator. By measuring the transmission for various thicknesses of attenuator and by deriving values for the total physical density of the modulator, we determined the optimal effective density by comparing the curves fitted for the actual transmission data with the transmission calculated by the TPS. Using these effective densities, we examined the accuracy of Pinnacle3 for dose profiles of specific geometric patterns. The levels of consistency between the measurements and the calculations were within a tolerance of 3% of the dose difference and had a 3‐mm distance to agreement for the ladder‐, stairstep‐, and pyramid‐shaped test patterns, except in the high dose gradient region. In this modulator assembly, leakage occurred from the slits between the cubic blocks. This leakage was about 1.6% at maximum, and its influence on dose distribution was not crucial. In the TPS, in which physical density was the only user‐controllable parameter, we used the effective density of the absorber deduced from the effective mass attenuation coefficient. We conclude that the intensity modulation compensator system, together with a piled cubic attenuator, is clinically applicable, with an acceptable tolerance level. For the intensity map of the IMRT plan, measurements in treatment fields met 3% and 3‐mm criteria, excluding some regions of high gradient, which had a discrepancy of less than 5% and 4 mm.

PACS numbers: 87.53.Mr, 87.53.Tf

Compensators: an alternative IMRT delivery technique

Seven years of experience in compensator intensity-modulated radiotherapy (IMRT) clinical implementation are presented. An inverse planning dose optimization algorithm was used to generate intensity modulation maps, which were delivered via either the compensator or segmental multileaf collimator (MLC) IMRT techniques. The in-house developed compensator-IMRT technique is presented with the focus on several design issues. The dosimetry of the delivery techniques was analyzed for several clinical cases. The treatment time for both delivery techniques on Siemens accelerators was retrospectively analyzed based on the electronic treatment record in LANTIS for 95 patients. We found that the compensator technique consistently took noticeably less time for treatment of equal numbers of fields compared to the segmental technique. The typical time needed to fabricate a compensator was 13 min, 3 min of which was manual processing. More than 80% of the approximately 700 compensators evaluated had a maximum deviation of less than 5% from the calculation in intensity profile. Seventy-two percent of the patient treatment dosimetry measurements for 340 patients have an error of no more than 5%. The pros and cons of different IMRT compensator materials are also discussed. Our experience shows that the compensator-IMRT technique offers robustness, excellent intensity modulation resolution, high treatment delivery efficiency, simple fabrication and quality assurance (QA) procedures, and the flexibility to be used in any teletherapy unit.

The delivery of IMRT with a single physical modulator for multiple fields: a feasibility study for paranasal sinus cancer

PURPOSE

This study describes a new intensity-modulated radiation therapy (IMRT) delivery method that utilizes a single modulator to deliver multiple fields ("multifield modulator"). This technique reduces the treatment time and manufacturing costs typically associated with modulator-IMRT. Technical feasibility was evaluated for treating paranasal sinus cancers.

METHODS AND MATERIALS

Technical feasibility was measured by three criteria: The dose distributions of the multifield modulator-IMRT plans should offer improvements over those produced by 3D conformal plans and be equivalent to those of step-and-shoot multileaf collimator (MLC) IMRT plans, the manufactured modulators should meet quality assurance specifications, and the effort required to use this technology should not substantially exceed the effort required for current IMRT practice. Seven paranasal cancer cases were examined. The Wilcoxon signed rank test was used for statistical analysis.

RESULTS

Multifield modulator-IMRT plans can improve target coverage while reducing critical structure doses compared to 3D conformal plans. Multifield modulator-IMRT plans are at least equivalent to the corresponding step-and-shoot MLC-IMRT plans. Multifield modulators can be constructed to meet design specifications in quality assurance tests. The time required for manufacturing, quality assurance, and treatment delivery using multifield modulators was measured and found to be only slightly greater than that for current IMRT treatment methods.

CONCLUSIONS

IMRT treatments using multifield modulators for paranasal sinus tumors are feasible. Clinics may find it worthwhile to commit the minimal extra time for quality assurance and treatment to benefit from the improved dose distribution and lack of interplay between MLC leaf motion and internal target motion.

IMRT: delivery techniques and quality assurance

Intensity modulated radiotherapy (IMRT) is a major development in the delivery of radiation therapy that has the potential to improve patient outcome by reducing morbidity or increasing local tumour control. Delivery techniques include those based on purpose built devices and treatment machines together with those utilizing the capabilities of computer controlled multileaf collimators which are more widely available. The complexity of IMRT techniques demands a high level of quality control both in the operation of the equipment and in the delivery of treatment to individual patients. The purpose of this paper is therefore to review the techniques available, concentrating on the use of multileaf collimators, and to consider the necessary quality control requirements for clinical application. It demonstrates that the technology is mature and sufficiently well understood so that IMRT can be safely implemented in the general clinical environment rather than being limited to application in the research environment.

Guidance document on delivery, treatment planning, and clinical implementation of IMRT: report of the IMRT Subcommittee of the AAPM Radiation Therapy Committee

Intensity-modulated radiation therapy (IMRT) represents one of the most significant technical advances in radiation therapy since the advent of the medical linear accelerator. It allows the clinical implementation of highly conformal nonconvex dose distributions. This complex but promising treatment modality is rapidly proliferating in both academic and community practice settings. However, these advances do not come without a risk. IMRT is not just an add-on to the current radiation therapy process; it represents a new paradigm that requires the knowledge of multimodality imaging, setup uncertainties and internal organ motion, tumor control probabilities, normal tissue complication probabilities, three-dimensional (3-D) dose calculation and optimization, and dynamic beam delivery of nonuniform beam intensities. Therefore, the purpose of this report is to guide and assist the clinical medical physicist in developing and implementing a viable and safe IMRT program. The scope of the IMRT program is quite broad, encompassing multileaf-collimator-based IMRT delivery systems, goal-based inverse treatment planning, and clinical implementation of IMRT with patient-specific quality assurance. This report, while not prescribing specific procedures, provides the framework and guidance to allow clinical radiation oncology physicists to make judicious decisions in implementing a safe and efficient IMRT program in their clinics.

Spatial accuracy of fractionated IMRT delivery studies in canine paraspinal irradiation

Intensity modulated radiation therapy (IMRT) theoretically allows detailed tailoring of the dose distribution in tissue. The goal of this study was to determine if a method of dynamic IMRT could be used to deliver a high dose of radiation to a concave shaped target around the cervical spinal cord. Fifteen young adult dogs from our laboratory population were randomly divided into two groups. A radiation dose of 84 Gy in 4 Gy fractions was delivered with a conventional 4 field technique for Group A dogs, and with dynamic IMRT for Group B dogs to a "C-shaped" target close to the cervical spinal cord. Neurologic status, magnetic resonance imaging results and histopathologic changes were compared among dogs in the two groups. Group A dogs developed myelomalacia with a latency period of 65 +/- 9 days. Group B dogs did not have any histologic changes to the cervical spinal cord when euthanasia was performed 12 months after irradiation. The results demonstrate that this IMRT technique can be safely and precisely delivered to a patient in a clinical situation.

Reshapable physical modulator for intensity modulated radiation therapy

A new method of generating beam intensity modulation filters for intensity modulated radiation therapy (IMRT) is presented. The modulator was based on a reshapable material, which is not compressible but can be deformed under pressure. A two-dimensional (2D) piston array was used to repeatedly shape the attenuating material. The material is a mixture of tungsten powder and a silicon-based binder. The linear attenuation coefficient of the material was measured to be 0.409 cm(-1) for a 6 MV x-ray beam. The maximum thickness of the physical modulator is 10.2 cm, allowing a transmission of 1.5%. A 16 x 16 square piston array was used to generate a depth pattern in the deformable attenuating material. Each piston has a cross section of 6.37 x 6.37 mm2. The modulator was placed 65 cm from the radiation source of the linear accelerator in the position of the shielding tray. At this position, each piston projects to a 1.0 x 1.0 cm2 area at the isocenter, giving a treatment field of 16 x 16 cm2. The percent depth dose curve and output factor measurement show a slight beam hardening and a 1%-4% increase in scatter fraction when 2.2-4.4 cm uniform thickness filters are in the beam. The surface dose was decreased with the filter in the beam. Ion chamber and verification films were used to verify the entrance dose. The measured absolute and relative doses were compared with the calculated dose. The agreement of measurements and calculations is within 3%. In order to verify the spatial modulation of dose, 1-D dose profiles were obtained using dose calculations. Calculated and measured profiles were compared. The 20%-80% penumbra of the modulator was measured to be 5.5-10 mm. The results show that a physical modulator formed using a 16 x 16 piston array and a deformable attenuation material can provide intensity modulation for IMRT comparable with those provided by currently available commercial MLC techniques.

[Intensity modulated radiotherapy (IMRT) with compensators]

The irradiation with intensity-modulated fields is possible with static as well as dynamic methods. In our university hospital, the intensity-modulated radiotherapy (IMRT) with compensators was prepared and used for the first time for patient irradiation in July 2001. The compensators consist of a mixture of tin granulate and wax, which is filled in a milled negative mould. The treatment planning is performed with Helax-TMS (MDS Nordion). An additional software is used for editing the modulation matrix ("Modifix"). Before irradiation of the first patient, extensive measurements have been carried out in terms of quality assurance of treatment planning and production of compensators. The results of the verification measurements have shown that IMRT with compensators possesses high spatial and dosimetric exactness. The calculated dose distributions are applied correctly. The accuracy of the calculated monitor units is normally better than 3%; in small volumes, further dosimetric inaccuracies between calculated and measured dose distributions are mostly less than 3%. Therefore, the compensators contribute to the achievement of high-level IMRT even when apparatuses without MLC are used. This paper describes the use of the IMRT with compensators, presents the limits of this technology, and discusses the first practical experiences.