A fast GPU-accelerated Monte Carlo engine for calculation of MLC-collimated electron fields

BACKGROUND

Although intensity-modulated radiation therapy and volumetric arc therapy have revolutionized photon external beam therapies, the technological advances associated with electron beam therapy have fallen behind. Modern linear accelerators contain technologies that would allow for more advanced forms of electron treatments, such as beam collimation, using the conventional photon multi-leaf collimator (MLC); however, no commercial solutions exist that calculate dose from such beam delivery modes. Additionally, for clinical adoption to occur, dose calculation times would need to be on par with that of modern dose calculation algorithms.

PURPOSE

This work developed a graphics processing unit (GPU)-accelerated Monte Carlo (MC) engine incorporating the Varian TrueBeam linac head geometry for a rapid calculation of electron beams collimated using the conventional photon MLC.

METHODS

A compute unified device architecture framework was created for the following: (1) transport of electrons and photons through the linac head geometry, considering multiple scattering, Bremsstrahlung, Møller, Compton, and pair production interactions; (2) electron and photon propagation through the CT geometry, considering all interactions plus the photoelectric effect; and (3) secondary particle cascades through the linac head and within the CT geometry. The linac head collimating geometry was modeled according to the specifications provided by the vendor, who also provided phase-space files. The MC was benchmarked against EGSnrc/DOSXYZnrc/GEANT by simulating individual interactions with simple geometries, pencil, and square beam dose calculations in various phantoms. MC-calculated dose distributions for MLC and jaw-collimated electron fields were compared to measurements in a water phantom and with radiochromic film.

RESULTS

Pencil and square beam dose distributions are in good agreement with DOSXYZnrc. Angular and spatial distributions for multiple scattering and secondary particle production in thin slab geometries are in good agreement with EGSnrc and GEANT. Dose profiles for MLC and jaw-collimated 6-20-MeV electron beams showed an average absolute difference of 1.1 and 1.9 mm for the FWHM and 80%-20% penumbra from measured profiles. Percent depth doses showed differences of <5% for as compared to measurement. The computation time on an NVIDIA Tesla V100 card was 2.5 min to achieve a dose uncertainty of <1%, which is ∼300 times faster than published results in a similar geometry using a single-CPU core.

CONCLUSIONS

The GPU-based MC can quickly calculate dose for electron fields collimated using the conventional photon MLC. The fast calculation times will allow for a rapid calculation of electron fields for mixed photon and electron particle therapy.

Automated testing platform for radiotherapy treatment planning scripts

Realizing the potential of user-developed automation software interacting with a treatment planning system (TPS) requires rigorous testing to ensure patient safety and data integrity. We developed an automated test platform to allow comparison of the treatment planning database before and after the execution of a write-enabled script interacting with a commercial TPS (Eclipse, Varian Medical Systems, Palo Alto, CA) using the vendor-provided Eclipse Scripting Application Programming Interface (ESAPI). The C#-application known as Write-Enable Script Testing Engine (WESTE) serializes the treatment planning objects (Patient, Structure Set, PlanSetup) accessible through ESAPI, and then compares the serialization acquired before and after the execution of the script being tested, documenting identified differences to highlight the changes made to the treatment planning data. The first two uses of WESTE demonstrated that the testing platform could acquire and analyze the data quickly (<4 s per test case) and facilitate the clinical implementation of write-enabled scripts.

The Dark Side of the MedPhys Match

This article is related content to the article by Hendrickson et al: https://doi.org/10.1002/acm2.12135

Treatment planning for metals using an extended CT number scale

Metal implants which saturate the CT number scale may require dosimetrist and physicist involvement to manually contour and assign an appropriate value to the metal for accurate dose calculation. This study investigated dose calculation based directly on extended CT scale images for different metals and geometries. The aim was to evaluate extended CT accuracy as a suitable alternative to standard CT methods in the presence of high‐Z materials and artifacts, despite the reduced HU resolution of extended CT. Gafchromic film measurements were made for comparison to calculated doses. The method of direct dose calculation on extended CT scale was compared to our institution's standard method of manually contouring and assigning metal values on saturated CT images for each of the metal samples. Clinical patient plans with metal implants were investigated and DVHs were compared between standard CT and extended CT dose calculations. Dose calculations showed agreement within 2% between the two methods of metal characterization and the film measurement in the case of the strongest metal attenuator, cobalt‐chromium. In the clinical treatment plans, the greatest dose discrepancy between the two methods was 1.2%. This study suggests that direct dose calculation on an extended scale CT image in the presence of metal implants can produce accurate clinically viable treatment plans, thereby improving efficiency of clinical workflow and eliminating a potential source of human error by manual CT number assignment.

PACS number(s): 87.55.dk

Evaluation of the Eclipse eMC algorithm for bolus electron conformal therapy using a standard verification dataset

The purpose of this study was to evaluate the accuracy and calculation speed of electron dose distributions calculated by the Eclipse electron Monte Carlo (eMC) algorithm for use with bolus electron conformal therapy (ECT). The recent commercial availability of bolus ECT technology requires further validation of the eMC dose calculation algorithm. eMC‐calculated electron dose distributions for bolus ECT have been compared to previously measured TLD‐dose points throughout patient‐based cylindrical phantoms (retromolar trigone and nose), whose axial cross sections were based on the mid‐PTV (planning treatment volume) CT anatomy. The phantoms consisted of SR4 muscle substitute, SR4 bone substitute, and air. The treatment plans were imported into the Eclipse treatment planning system, and electron dose distributions calculated using 1% and <0.2% statistical uncertainties. The accuracy of the dose calculations using moderate smoothing and no smoothing were evaluated. Dose differences (eMC‐calculated less measured dose) were evaluated in terms of absolute dose difference, where 100% equals the given dose, as well as distance to agreement (DTA). Dose calculations were also evaluated for calculation speed. Results from the eMC for the retromolar trigone phantom using 1% statistical uncertainty without smoothing showed calculated dose at 89% (41/46) of the measured TLD‐dose points was within 3% dose difference or 3 mm DTA of the measured value. The average dose difference was −0.21%, and the net standard deviation was 2.32%. Differences as large as 3.7% occurred immediately distal to the mandible bone. Results for the nose phantom, using 1% statistical uncertainty without smoothing, showed calculated dose at 93% (53/57) of the measured TLD‐dose points within 3% dose difference or 3 mm DTA. The average dose difference was 1.08%, and the net standard deviation was 3.17%. Differences as large as 10% occurred lateral to the nasal air cavities. Including smoothing had insignificant effects on the accuracy of the retromolar trigone phantom calculations, but reduced the accuracy of the nose phantom calculations in the high‐gradient dose areas. Dose calculation times with 1% statistical uncertainty for the retromolar trigone and nose treatment plans were 30 s and 24 s, respectively, using 16 processors (Intel Xeon E5‐2690, 2.9 GHz) on a framework agent server (FAS). In comparison, the eMC was significantly more accurate than the pencil beam algorithm (PBA). The eMC has comparable accuracy to the pencil beam redefinition algorithm (PBRA) used for bolus ECT planning and has acceptably low dose calculation times. The eMC accuracy decreased when smoothing was used in high‐gradient dose regions. The eMC accuracy was consistent with that previously reported for accuracy of the eMC electron dose algorithm and shows that the algorithm is suitable for clinical implementation of bolus ECT.

PACS number(s): 87.55.kd

Monitor unit calculations for external photon and electron beams: Report of the AAPM Therapy Physics Committee Task Group No. 71

A protocol is presented for the calculation of monitor units (MU) for photon and electron beams, delivered with and without beam modifiers, for constant source-surface distance (SSD) and source-axis distance (SAD) setups. This protocol was written by Task Group 71 of the Therapy Physics Committee of the American Association of Physicists in Medicine (AAPM) and has been formally approved by the AAPM for clinical use. The protocol defines the nomenclature for the dosimetric quantities used in these calculations, along with instructions for their determination and measurement. Calculations are made using the dose per MU under normalization conditions, D'0, that is determined for each user's photon and electron beams. For electron beams, the depth of normalization is taken to be the depth of maximum dose along the central axis for the same field incident on a water phantom at the same SSD, where D'0 = 1 cGy/MU. For photon beams, this task group recommends that a normalization depth of 10 cm be selected, where an energy-dependent D'0 ≤ 1 cGy/MU is required. This recommendation differs from the more common approach of a normalization depth of dm, with D'0 = 1 cGy/MU, although both systems are acceptable within the current protocol. For photon beams, the formalism includes the use of blocked fields, physical or dynamic wedges, and (static) multileaf collimation. No formalism is provided for intensity modulated radiation therapy calculations, although some general considerations and a review of current calculation techniques are included. For electron beams, the formalism provides for calculations at the standard and extended SSDs using either an effective SSD or an air-gap correction factor. Example tables and problems are included to illustrate the basic concepts within the presented formalism.

Total skin electron therapy in the lying-on-the-floor position using a customized flattening filter to eliminate field junctions

A total skin electron (TSE) floor technique is presented for treating patients who are unable to safely stand for extended durations. A customized flattening filter is used to eliminate the need for field junctioning, improve field uniformity, and reduce setup time. The flattening filter is constructed from copper and polycarbonate, fits into the linac's accessory slot, and is optimized to extend the useful height and width of the beam such that no field junctions are needed during treatment. A TSE floor with flattening filter (TSE FF) treatment course consisted of six patient positions: three supine and three prone. For all treatment fields, electron beam energy was 6 MeV; collimator settings were an x of 30 cm, y of 40 cm, and θcoll of 0°; and a 0.4 cm thick polycarbonate spoiler was positioned in front of the patient. Percent depth dose (PDD) and photon contamination for the TSE FF technique were compared with our standard technique, which is similar to the Stanford technique. Beam profiles were measured using radiochromic film, and dose uniformity was verified using an anthropomorphic radiological phantom. The TSE FF technique met field uniformity requirements specified by the American Association of Physicists in Medicine Task Group 30. TSE FF R80 ranges from 4 to 4.8 mm. TSE FF photon contamination was ~ 3%. Anthropomorphic radiological phantom verification demonstrated that dose to the entire skin surface was expected to be within about ±15% of the prescription dose, except for the perineum, scalp vertex, top of shoulder, and soles of the feet. The TSE floor technique presented herein eliminates field junctioning, is suitable for patients who cannot safely stand during treatment, and provides comparable quality and uniformity to the Stanford technique.

Recommendations for clinical electron beam dosimetry: supplement to the recommendations of Task Group 25

The goal of Task Group 25 (TG-25) of the Radiation Therapy Committee of the American Association of.Physicists in Medicine (AAPM) was to provide a methodology and set of procedures for a medical physicist performing clinical electron beam dosimetry in the nominal energy range of 5-25 MeV. Specifically, the task group recommended procedures for acquiring basic information required for acceptance testing and treatment planning of new accelerators with therapeutic electron beams. Since the publication of the TG-25 report, significant advances have taken place in the field of electron beam dosimetry, the most significant being that primary standards laboratories around the world have shifted from calibration standards based on exposure or air kerma to standards based on absorbed dose to water. The AAPM has published a new calibration protocol, TG-51, for the calibration of high-energy photon and electron beams. The formalism and dosimetry procedures recommended in this protocol are based on the absorbed dose to water calibration coefficient of an ionization chamber at 60Co energy, N60Co(D,w), together with the theoretical beam quality conversion coefficient k(Q) for the determination of absorbed dose to water in high-energy photon and electron beams. Task Group 70 was charged to reassess and update the recommendations in TG-25 to bring them into alignment with report TG-51 and to recommend new methodologies and procedures that would allow the practicing medical physicist to initiate and continue a high quality program in clinical electron beam dosimetry. This TG-70 report is a supplement to the TG-25 report and enhances the TG-25 report by including new topics and topics that were not covered in depth in the TG-25 report. These topics include procedures for obtaining data to commission a treatment planning computer, determining dose in irregularly shaped electron fields, and commissioning of sophisticated special procedures using high-energy electron beams. The use of radiochromic film for electrons is addressed, and radiographic film that is no longer available has been replaced by film that is available. Realistic stopping-power data are incorporated when appropriate along with enhanced tables of electron fluence data. A larger list of clinical applications of electron beams is included in the full TG-70 report available at http://www.aapm.org/pubs/reports. Descriptions of the techniques in the clinical sections are not exhaustive but do describe key elements of the procedures and how to initiate these programs in the clinic. There have been no major changes since the TG-25 report relating to flatness and symmetry, surface dose, use of thermoluminescent dosimeters or diodes, virtual source position designation, air gap corrections, oblique incidence, or corrections for inhomogeneities. Thus these topics are not addressed in the TG-70 report.

Influence of source parameters on large-field electron beam profiles calculated using Monte Carlo methods

The purpose of this paper was to study the source model for a Monte Carlo simulation of electron beams from a medical linear accelerator. In a prior study, a non-divergent Gaussian source with a full-width at half-maximum (FWHM) of 0.15 cm was successful in predicting relative dose distributions for electron beams with applicators. However, for large fields with the applicator removed, discrepancies were found between measured and calculated profiles, particularly in the shoulder region. In this work, the source was changed to a divergent Gaussian spatial distribution and the FWHM parameter was varied to produce better agreement with measured data. The influence of the FWHM source parameter on profiles was observed at multiple locations in the simulation geometry including in-air fluence profiles at a 95 cm source-to-surface distance (SSD), percent depth dose profiles and off-axis profiles (OARs) in a water phantom for two SSDs, 80 and 100 cm. For a 6 MeV 40 x 40 cm(2) OAR profile, discrepancies in the shoulder region were reduced from 15% to 4% using a FWHM value of 0.45 cm. The optimal FWHM values for the other energies were 0.45 cm for 9 MeV, 0.22 for 12 MeV, 0.25 for 16 MeV and 0.2 cm for 20 MeV. Although this range of values was larger than measured focal spot sizes reported by other researchers, using the increased FWHM values improved the fit at most locations in the simulation geometry, giving confidence that the model could be used with a variety of SSDs and field sizes.

The impact of temporal inaccuracies on 4DCT image quality

Accurate delineation of target volumes is one of the critical components contributing to the success of image-guided radiotherapy treatments and several imaging modalities are employed to increase the accuracy in target identification. Four-dimensional (4D) techniques are incorporated into existing radiation imaging techniques like computed tomography (CT) to account for the mobility of the target volumes. However, these methods in some cases introduce further inaccuracies in the target delineation when further quality assurance measures are not implemented. A source of commonly observed inaccuracy is the misidentification of the respiration cycles and resulting respiration phase assignments used in the construction of the 4D patient model. The aim of this work is to emphasize the importance of optimal respiration phase assignment during the 4DCT image acquisition process and to perform a quantitative assessment of the effect of inaccurate phase assignments on the overall image quality. The accuracy of the phase assignment was assessed by comparison with an independent calculation of the respiration phases. Misplaced phase assignments manifest themselves as deformations and artifacts in reconstructed images. These effects are quantified as volumetric discrepancies in the localization of target objects represented by spherical phantoms. Measurements are performed using a fully programmable motion phantom designed and built at Mayo Clinic (Rochester, MN). Implementation of a case based independent check and correction procedure is also demonstrated with emphasis on the use of this procedure in the clinical environment. Review of clinical 4D scans performed in this institution showed discrepancies in the phase assignments in about 40% of the cases when compared to our independent calculations. It is concluded that for improved image reconstruction, an independent check of the sorting procedure should be performed for each clinical 4DCT case.

Evaluation of the accuracy of fetal dose estimates using TG-36 data

The American Association of Physicists in Medicine Radiation Therapy Committee Task Group 36 report (TG-36) provides guidelines for managing radiation therapy of pregnant patients. Included in the report are data that can be used to estimate the dose to the fetus. The purpose of this study is to evaluate the accuracy of these fetal dose estimates as compared to clinically measured values. TG-36 calculations were performed and compared with measurements of the fetal dose made in vivo or in appropriately-designed phantoms. Calculation and measurement data was collected for eight pregnant patients who underwent radiation therapy at the MD Anderson Cancer Center as well as for several fetal dose studies in the literature. The maximum measured unshielded fetal dose was 47 cGy, which was 1.5% of the prescription dose. For all cases, TG-36 calculations and measured fetal doses differed by up to a factor of 3--the ratio of the calculated to measured dose ranged from 0.34 to 2.93. On average, TG-36 calculations underestimated the measured dose by 31%. No significant trends in the relationship between the calculated and measured fetal doses were found based on the distance from, or the size of, the treatment field.

Calculating percent depth dose with the electron pencil-beam redefinition algorithm

In the present work, we investigated the accuracy of the electron pencil‐beam redefinition algorithm (PBRA) in calculating central‐axis percent depth dose in water for rectangular fields. The PBRA energy correction factor C(E) was determined so that PBRA‐calculated percent depth dose best matched the percent depth dose measured in water. The hypothesis tested was that a method can be implemented into the PBRA that will enable the algorithm to calculate central‐axis percent depth dose in water at a 100‐cm source‐to‐surface distance (SSD) with an accuracy of 2% or 1‐mm distance to agreement for rectangular field sizes ≥2×2 cm. Preliminary investigations showed that C(E), determined using a single percent depth dose for a large field (that is, having side‐scatter equilibrium), was insufficient for the PBRA to accurately calculate percent depth dose for all square fields ≥2×2 cm. Therefore, two alternative methods for determining C(E) were investigated. In Method 1, C(E), modeled as a polynomial in energy, was determined by fitting the PBRA calculations to individual rectangular‐field percent depth doses. In Method 2, C(E) for square fields, described by a polynomial in both energy and side of square W [that is, C=C(E,W)], was determined by fitting the PBRA calculations to measured percent depth dose for a small number of square fields. Using the function C(E, W), C(E) for other square fields was determined, and C(E) for rectangular field sizes was determined using the geometric mean of C(E) for the two measured square fields of the dimension of the rectangle (square root method). Using both methods, PBRA calculations were evaluated by comparison with measured square‐field and derived rectangular‐field percent depth doses at 100‐cm SSD for the Siemens Primus radiotherapy accelerator equipped with a 25×25‐cm applicator at 10 MeV and 15 MeV. To improve the fit of C(E) and C(E, W) to the electron component of percent depth dose, it was necessary to modify the PBRA's photon depth dose model to include dose buildup. Results showed that, using both methods, the PBRA was able to predict percent depth dose within criteria for all square and rectangular fields. Results showed that second‐ or third‐order polynomials in energy (Methods 1 and 2) and in field size (Method 2) were typically required. Although the time for dose calculation using Method 1 is approximately twice that using Method 2, we recommend that Method 1 be used for clinical implementation of the PBRA because it is more accurate (most measured depth doses predicted within approximately 1%) and simpler to implement.

PACS number: 87.53.Fs

Application of the electron pencil beam redefinition algorithm to electron arc therapy

This project investigated the potential of summing fixed-beam dose distributions calculated using the pencil-beam redefinition algorithm (PBRA) at small angular steps (1 degree) to model an electron arc therapy beam. The PRBA, previously modified to model skin collimation, was modified further by incorporating two correction factors. One correction factor that is energy, SSD (source-to-surface distance), and field-width dependent constrained the calculated dose output to be the same as the measured dose output for fixed-beam geometries within the range of field widths and SSDs encountered in arc therapy. Another correction factor (single field-width correction factor for each energy) compensated for large-angle scattering not being modeled, allowing a more accurate calculation of dose output at mid arc. The PBRA was commissioned to accurately calculate dose in a water phantom for fixed-beam geometries typical of electron arc therapy. Calculated central-axis depth doses agreed with measured doses to within 2% in the low-dose gradient regions and within 1-mm in the high-dose gradient regions. Off-axis doses agreed to within 2 mm in the high-dose gradient regions and within 3% in the low-dose gradient regions. Arced-beam calculations of dose output and depth dose at mid arc were evaluated by comparing to data measured using two cylindrical water phantoms with radii of 12 and 15 cm at 10 and 15 MeV. Dose output was measured for all combinations of phantom radii of curvature, collimator widths (4, 5, and 6 cm), and arc angles (0 degrees, 20 degrees, 40 degrees, 60 degrees, 80 degrees, and 90 degrees) for both beam energies. Results showed the calculated mid-arc dose output to agree within 2% of measurement for all combinations. For a 90 degree arc angle and 5 x 20 cm2 field size, the calculated mid-arc depth dose in the low-dose gradient region agreed to within 2% of measurement for all depths at 10 MeV and for depths greater than depth of dose maximum R100 at 15 MeV. For depths in the buildup region at 15 MeV the calculations overestimated the measured dose by as much as 3.4%. Mid-arc depth dose in the high-dose gradient region agreed to within 2.2 mm of measured dose. Calculated two-dimensional relative dose distributions in the plane of rotation were compared to dose measurements using film in a cylindrical polystyrene phantom for a 90 degree arc angle and field widths of 4, 5, and 6 cm at 10 and 15 MeV. Results showed that off-axis dose at the ends of arc (without skin collimation) agreed to within 2% in the low-dose gradient region and to within 1.2 mm in the high-dose gradient region. This work showed that the accuracy of the PBRA arced-beam dose model met the criteria specified by Van Dyk et al. [Int. J. Radiat. Oncol. Biol. Phys. 26, 261-273 (1993)] with the exception of the buildup region of the 15 MeV beam. Based on the present results, results of a previous study showing acceptable accuracy in the presence of skin collimation, and results of a previous study showing acceptable accuracy in the presence of internal heterogeneities, it is concluded that the PBRA arced-beam dose model should be adequate for planning electron arc therapy.

Comprehensive evaluation of a commercial macro Monte Carlo electron dose calculation implementation using a standard verification data set

A commercial electron dose calculation software implementation based on the macro Monte Carlo algorithm has recently been introduced. We have evaluated the performance of the system using a standard verification data set comprised of two-dimensional (2D) dose distributions in the transverse plane of a 15 X 15 cm2 field. The standard data set was comprised of measurements performed for combinations of 9-MeV and 20-MeV beam energies and five phantom geometries. The phantom geometries included bone and air heterogeneities, and irregular surface contours. The standard verification data included a subset of the data needed to commission the dose calculation. Additional required data were obtained from a dosimetrically equivalent machine. In addition, we performed 2D dose measurements in a water phantom for the standard field sizes, a 4 cm X 4 cm field, a 3 cm diameter circle, and a 5 cm X 13 cm triangle for the 6-, 9-, 12-, 15-, and 18-MeV energies of a Clinac 21EX. Output factors were also measured. Synthetic CT images and structure contours duplicating the measurement configurations were generated and transferred to the treatment planning system. Calculations for the standard verification data set were performed over the range of each of the algorithm parameters: statistical precision, grid-spacing, and smoothing. Dose difference and distance-to-agreement were computed for the calculation points. We found that the best results were obtained for the highest statistical precision, for the smallest grid spacing, and for smoothed dose distributions. Calculations for the 21EX data were performed using parameters that the evaluation of the standard verification data suggested would produce clinically acceptable results. The dose difference and distance-to-agreement were similar to that observed for the standard verification data set except for the portion of the triangle field narrower than 3 cm for the 6- and 9-MeV electron beams. The output agreed with measurements to within 2%, with the exception of the 3-cm diameter circle and the triangle for 6 MeV, which were within 5%. We conclude that clinically acceptable results may be obtained using a grid spacing that is no larger than approximately one-tenth of the distal falloff distance of the electron depth dose curve (depth from 80% to 20% of the maximum dose) and small relative to the size of heterogeneities. For judicious choices of parameters, dose calculations agree with measurements to better than 3% dose difference and 3-mm distance-to-agreement for fields with dimensions no less than about 3 cm.

Displacement-based binning of time-dependent computed tomography image data sets

Respiration can cause tumors in the thorax or abdomen to move by as much as 3 cm; this movement can adversely affect the planning and delivery of radiation treatment. Several techniques have been used to compensate for respiratory motion, but all have shortcomings. Manufacturers of computed tomography (CT) equipment have recently used a technique developed for cardiac CT imaging to track respiratory-induced anatomical motion and to sort images according to the phase of the respiratory cycle they represent. Here we propose a method of generating CT images that accounts for respiratory-induced anatomical motion on the basis of displacement, i.e., displacement-binned CT image sets. This technique has shown great promise, however, it is not fully supported by currently used CT image reconstruction software. As an interim solution, we have developed a method for extracting displacement-binned CT image data sets from data sets assembled on the basis of a prospectively determined breathing phase acquired on a multislice helical CT scanner. First, the projection data set acquired from the CT scanner was binned at small phase intervals before reconstruction. The manufacturer's software then generated image sets identified as belonging to particular phases of the respiratory cycle. All images were then individually correlated to the displacement of an external fiducial marker. Next, CT image data sets were resorted on the basis of the displacement and assigned an appropriate phase. Finally, displacement-binned image data sets were transferred to a treatment-planning system for analysis. Although the technique is currently limited by the phase intervals allowed by the CT software, some improvement in image reconstruction was seen, indicating that this technique is useful at least as an interim measure.

Modeling skin collimation using the electron pencil beam redefinition algorithm

Skin collimation is an important tool for electron beam therapy that is used to minimize the penumbra when treating near critical structures, at extended treatment distances, with bolus, or using arc therapy. It is usually made of lead or lead alloy material that conforms to and is placed on patient surface. Presently, commercially available treatment-planning systems lack the ability to model skin collimation and to accurately calculate dose in its presence. The purpose of the present work was to evaluate the use of the pencil beam redefinition algorithm (PBRA) in calculating dose in the presence of skin collimation. Skin collimation was incorporated into the PBRA by terminating the transport of electrons once they enter the skin collimator. Both fixed- and arced-beam dose calculations for arced-beam geometries were evaluated by comparing them with measured dose distributions for 10- and 15-MeV beams. Fixed-beam dose distributions were measured in water at 88-cm source-to-surface distance with an air gap of 32 cm. The 6 x 20-cm2 field (dimensions projected to isocenter) had a 10-mm thick lead collimator placed on the surface of the water with its edge 5 cm inside the field's edge located at +10 cm. Arced-beam dose distributions were measured in a 13.5-cm radius polystyrene circular phantom. The beam was arced 90 degrees (-45 degrees to +45 degrees), and 10-mm thick lead collimation was placed at +/- 30 degrees. For the fixed beam at 10 MeV, the PBRA- calculated dose agreed with measured dose to within 2.0-mm distance to agreement (DTA) in the regions of high-dose gradient and 2.0% in regions of low dose gradient. At 15 MeV, the PBRA agreed to within a 2.0-mm DTA in the regions of high-dose gradient; however, the PBRA underestimated the dose by as much as 5.3% over small regions at depths less than 2 cm because it did not model electrons scattered from the edge of the skin collimation. For arced beams at 10 MeV, the agreement was 1-mm DTA in the high-dose gradient regions, and 2% in the low-dose gradient regions. For arced beams at 15 MeV, the agreement was 1 mm in the high-dose gradient regions, and in the low-dose gradient region at depth less than 2 cm, as much as 5% dose difference was observed. This study demonstrated the ease with which skin collimation can be incorporated into the PBRA. The good agreement of PBRA calculated with measured dose shows that the PBRA is likely sufficiently accurate for clinical use in the presence of skin collimation for electron arc therapy. To further improve the accuracy of the PBRA in regions having significant electrons scattered from the edge of the skin collimation would require transporting the electrons through the lead skin collimation near its edges.

Dual scattering foil design for poly-energetic electron beams

The laser wakefield acceleration (LWFA) mechanism can accelerate electrons to energies within the 6-20 MeV range desired for therapy application. However, the energy spectrum of LWFA-generated electrons is broad, on the order of tens of MeV. Using existing laser technology, the therapeutic beam might require a significant energy spread to achieve clinically acceptable dose rates. The purpose of this work was to test the assumption that a scattering foil system designed for a mono-energetic beam would be suitable for a poly-energetic beam with a significant energy spread. Dual scattering foil systems were designed for mono-energetic beams using an existing analytical formalism based on Gaussian multiple-Coulomb scattering theory. The design criterion was to create a flat beam that would be suitable for fields up to 25 x 25 cm2 at 100 cm from the primary scattering foil. Radial planar fluence profiles for poly-energetic beams with energy spreads ranging from 0.5 MeV to 6.5 MeV were calculated using two methods: (a) analytically by summing beam profiles for a range of mono-energetic beams through the scattering foil system, and (b) by Monte Carlo using the EGS/BEAM code. The analytic calculations facilitated fine adjustments to the foil design, and the Monte Carlo calculations enabled us to verify the results of the analytic calculation and to determine the phase-space characteristics of the broadened beam. Results showed that the flatness of the scattered beam is fairly insensitive to the width of the input energy spectrum. Also, results showed that dose calculated by the analytical and Monte Carlo methods agreed very well in the central portion of the beam. Outside the useable field area, the differences between the analytical and Monte Carlo results were small but significant, possibly due to the small angle approximation. However, these did not affect the conclusion that a scattering foil system designed for a mono-energetic beam will be suitable for a poly-energetic beam with the same central energy. Further studies of the dosimetric properties of LWFA-generated electron beams will be done using Monte Carlo methods.

A novel platform simulating irregular motion to enhance assessment of respiration-correlated radiation therapy procedures

Respiratory motion continues to present challenges in the delivery of radiation therapy to tumors in the thorax and abdomen by causing movement of structures within those areas. Several approaches to account for this movement in the planning and delivery of treatment have been developed over the past several years. To assist in the development and assessment of various techniques for respiration‐correlated radiation therapy, a platform capable of programmable irregular longitudinal motion has been designed and fabricated to simulate intrafractional respiratory motion. A sliding platform and the base on which it was mounted were constructed from polycarbonate plastic, and a stepper motor provided platform motion. Respiratory motion data, either artificially generated on a spreadsheet or extracted from respiratory monitoring files, were converted to a format appropriate for driving the stepper motor. Various phantoms were placed on top of the platform and used in studies related to respiration‐correlated radiation therapy. Several applications of the platform were demonstrated, such as improving the quality of acquisition of time‐dependent computed tomography image datasets, comparing various methods of acquiring such datasets, and implementing feedback‐guided breath hold treatment delivery procedures. This study showed that a platform capable of programmable irregular motion is a useful tool for the development and assessment of procedures related to the effects of respiratory motion in radiation therapy.

PACS number: 87.66.Xa

Dose properties of x-ray beams produced by laser-wakefield-accelerated electrons

Given that laser wakefield acceleration (LWFA) has been demonstrated experimentally to accelerate electron beams to energies beyond 25 MeV, it is reasonable to assess the ability of existing LWFA technology to compete with conventional radiofrequency linear accelerators in producing electron and x-ray beams for external-beam radiotherapy. We present calculations of the dose distributions (off-axis dose profiles and central-axis depth dose) and dose rates of x-ray beams that can be produced from electron beams that are generated using state-of-the-art LWFA. Subsets of an LWFA electron energy distribution were propagated through the treatment head elements (presuming an existing design for an x-ray production target and flattening filter) implemented within the EGSnrc Monte Carlo code. Three x-ray energy configurations (6 MV, 10 MV and 18 MV) were studied, and the energy width deltaE of the electron-beam subsets varied from 0.5 MeV to 12.5 MeV. As deltaE increased from 0.5 MeV to 4.5 MeV, we found that the off-axis and central-axis dose profiles for x-rays were minimally affected (to within about 3%), a result slightly different from prior calculations of electron beams broadened by scattering foils. For deltaE of the order of 12 MeV, the effect on the off-axis profile was of the order of 10%, but the central-axis depth dose was affected by less than 2% for depths in excess of about 5 cm beyond d(max). Although increasing deltaE beyond 6.5 MeV increased the dose rate at d(max) by more than 10 times, the absolute dose rates were about 3 orders of magnitude below those observed for LWFA-based electron beams at comparable energies. For a practical LWFA-based x-ray device, the beam current must be increased by about 4-5 orders of magnitude.

Respiration-correlated treatment delivery using feedback-guided breath hold: A technical study

Respiratory motion causes movement of internal structures in the thorax and abdomen, making accurate delivery of radiation therapy to tumors in those areas a challenge. To reduce the uncertainties caused by this motion, we have developed feedback-guided breath hold (FGBH), a novel delivery technique in which radiation is delivered only during a voluntary breath hold that is sustained for as long as the patient feels comfortable. Here we present the technical aspects of FGBH, which involve (1) fabricating the hardware so the respiratory trace can be displayed to the patient, (2) assembling a delay box to be used as a breath-hold detector, and (3) performing quality control tests to ensure that FGBH can be delivered accurately and safely. A commercial respiratory tracking system that uses an external fiducial to monitor abdominal wall motion generates and displays the breathing trace and specific positions in the breathing cycle where a breath hold needs to occur. Hardware was developed to present this display to the patient in the treatment position. Patients view the presentation either on a liquid crystal display or through a pair of virtual reality goggles. Using the respiratory trace as a visual aid, the patient performs a breath hold so that the position representing the location of a fiducial is held within a specified gating window. A delay box was fabricated to differentiate between gating signals received during free breathing and those received during breath hold, allowing radiation delivery only when the fiducial was within the breath-hold gating window. A quality control analysis of the gating delay box and the integrated system was performed to ensure that all of the hardware and components were ready for clinical use.

Dosimetry of a prototype retractable eMLC for fixed-beam electron therapy

An electron multileaf collimator (eMLC) has been designed that is unique in that it retracts to 37 cm from the isocenter [63-cm source-to-collimator distance (SCD)] and can be deployed to distances of 20 and 10 cm from the isocenter (80 and 90 cm SCD, respectively). It is expected to be capable of arc therapy at 63 cm SCD; isocentric, fixed-beam therapy at 80 cm SCD; and source-to-surface distance (SSD), fixed-beam therapy at 90 cm SCD. In all positions, its leaves could be used for unmodulated or intensity-modulated therapy. Our goal in the present work is to describe the general characteristics of the eMLC and to demonstrate that its leakage characteristics and dosimetry are adequate for SSD, fixed-beam therapy as an alternative to Cerrobend cutouts with applicators once the prototype's leaves are motorized. Our eMLC data showed interleaf electron leakage at 15 MeV to be less than 0.1% based on a 0.0025 cm manufacturing tolerance, and lateral electron leakage at 5 and 15 MeV to be less than 2%. X-ray leakage through the leaves was 1.6% at 15 MeV. Our data showed that beam penumbra was independent of direction and leaf position. The dosimetric properties of square fields formed by the eMLC were very consistent with those formed by Cerrobend inserts in the 20 x 20 cm2 applicator. Output factors exhibited similar field-size dependence. Airgap factors exhibited almost identical field-size dependence at two SSDs (105 and 110 cm), consistent with the common assumption that airgap factors are applicator independent. Percent depth-dose curves were similar, but showed variations up to 3% in the buildup region. The pencil-beam algorithm (PBA) fit measured data from the eMLC and applicator-cutout systems equally well, and the resulting two-dimensional (2-D) dose distributions, as predicted by the PBA, agreed well at common airgap distance. Simulating patient setups for breast and head and neck treatments showed that almost all fields could be treated using similar SSDs as when using applicators, although head and neck treatments require placing the patient's head on a head-holder treatment table extension. The results of this work confirmed our design goals and support the potential use of the eMLC design in the clinical setting. The eMLC should allow the same treatments as are typically delivered with the electron applicator-cutout system currently used for fixed-beam therapy.

Dose properties of a laser accelerated electron beam and prospects for clinical application

Laser wakefield acceleration (LWFA) technology has evolved to where it should be evaluated for its potential as a future competitor to existing technology that produces electron and x-ray beams. The purpose of the present work is to investigate the dosimetric properties of an electron beam that should be achievable using existing LWFA technology, and to document the necessary improvements to make radiotherapy application for LWFA viable. This paper first qualitatively reviews the fundamental principles of LWFA and describes a potential design for a 30 cm accelerator chamber containing a gas target. Electron beam energy spectra, upon which our dose calculations are based, were obtained from a uniform energy distribution and from two-dimensional particle-in-cell (2D PIC) simulations. The 2D PIC simulation parameters are consistent with those reported by a previous LWFA experiment. According to the 2D PIC simulations, only approximately 0.3% of the LWFA electrons are emitted with an energy greater than 1 MeV. We studied only the high-energy electrons to determine their potential for clinical electron beams of central energy from 9 to 21 MeV. Each electron beam was broadened and flattened by designing a dual scattering foil system to produce a uniform beam (103%>off-axis ratio>95%) over a 25 x 25 cm2 field. An energy window (deltaE) ranging from 0.5 to 6.5 MeV was selected to study central-axis depth dose, beam flatness, and dose rate. Dose was calculated in water at a 100 cm source-to-surface distance using the EGS/BEAM Monte Carlo algorithm. Calculations showed that the beam flatness was fairly insensitive to deltaE. However, since the falloff of the depth-dose curve (R10-R90) and the dose rate both increase with deltaE, a tradeoff between minimizing (R10-R90) and maximizing dose rate is implied. If deltaE is constrained so that R10-R90 is within 0.5 cm of its value for a monoenergetic beam, the maximum practical dose rate based on 2D PIC is approximately 0.1 Gy min(-1) for a 9 MeV beam and 0.03 Gy min(-1) for a 15 MeV beam. It was concluded that current LWFA technology should allow a table-top terawatt (T3) laser to produce therapeutic electron beams that have acceptable flatness, penetration, and falloff of depth dose; however, the dose rate is still 1%-3% of that which would be acceptable, especially for higher-energy electron beams. Further progress in laser technology, e.g., increasing the pulse repetition rate or number of high energy electrons generated per pulse, is necessary to give dose rates acceptable for electron beams. Future measurements confirming dosimetric calculations are required to substantiate our results. In addition to achieving adequate dose rate, significant engineering developments are needed for this technology to compete with current electron acceleration technology. Also, the functional benefits of LWFA electron beams require further study and evaluation.

Utilization of custom electron bolus in head and neck radiotherapy

Conventional methods of treating superficial head and neck tumors, such as the wedge pair technique or the use of multiple electron fields of varying energies, can result in excellent tumor control. However, in some cases, these techniques irradiate healthy tissue unnecessarily and/or create hot and cold spots in junction regions, particularly in patients with complex surface contour modification or varying planning target volume (PTV) thickness. The objective of this work is to demonstrate how bolus electron conformal therapy can be used for these patients. Two patients treated using this technique are presented. The first patient was diagnosed with malignant fibrous histiocytoma involving the right ear concha and was treated with 12-MeV electrons. The second patient was diagnosed with acinic cell carcinoma of the left parotid gland and was treated with 20-MeV electrons after having undergone a complete parotidectomy. Each patient's bolus was designed using bolus design tools implemented in an in-house treatment-planning system (TPS). The bolus was fabricated using a computer-controlled milling machine. As part of the quality assurance process to ensure proper fabrication and placement of the bolus, the patients underwent a second computed tomography (CT) scan with the bolus in place. Using that data, the final dose distribution was computed using the Philips Pinnacle(3) TPS (Philips Medical Systems, Andover, MA). Results showed that the 90% isodose surface conformed well to the PTV and that the dose to critical structures such as cord, brain, and lung was well below tolerance limits. Both patients showed no evidence of disease six months post-radiotherapy. In conclusion, electron bolus conformal therapy is a viable option for treating head and neck tumors, particularly patients having a variable thickness PTV or surface anatomy with surgical defects.

Phase I study of concomitant gemcitabine and IMRT for patients with unresectable adenocarcinoma of the pancreatic head

PURPOSE

We hypothesized that dynamic intensity-modulated radiotherapy (IMRT) would protect normal tissues enough to allow the escalation of either the gemcitabine or radiotherapy dose in unresectable pancreatic cancer patients.

METHODS AND MATERIALS

The trial was designed to build on a previous phase I trial that determined the maximum tolerated dose (MTD) of gemcitabine (350 mg/m2) with concurrent radiotherapy (30 Gy/10 fractions). Only patients with unresectable disease based on established criteria were eligible. The plan was to alternate escalating the radiation dose by 3 Gy and the gemcitabine dose by 50 mg/m2. The starting dose of gemcitabine was 350 mg/m2 and 33 Gy/11 fractions of IMRT to the regional lymphatics and primary disease. The NCI Common Toxicity Criteria were used for dose-limiting toxicity (DLT).

RESULTS

All three patients in the first cohort treated suffered DLT. Therefore, a second cohort of patients received a lower gemcitabine dose (250 mg/m2). Both patients treated at this dose level experienced DLT. The DLTs were all due to myelosuppression and upper gastrointestinal toxicity. All patients required a gemcitabine dose reduction. Also, four patients required hospital admission for supportive care, while the fifth died of an unrelated cause shortly after completing therapy. The trial was then closed due to excessive toxicity.

CONCLUSION

Hypofractionated dynamic IMRT to the primary site and regional lymphatics did not permit escalation of either the radiation or gemcitabine dose. Dynamic IMRT requires further investigation before it can be applied to toxic combinations of chemotherapy and radiation in the upper abdomen.

Prostate biopsy status and PSA nadir level as early surrogates for treatment failure: analysis of a prostate cancer randomized radiation dose escalation trial

PURPOSE

A positive biopsy after external beam radiotherapy in patients free of any evidence of treatment failure is not synonymous with eventual recurrence. Although biopsy positivity is a predictor of outcome, the utility of biopsy status as a surrogate end point, the effect of radiation dose on biopsy status, and the interrelationships of these associations to prostate-specific antigen (PSA) nadir level are not well-defined. These issues were investigated in a cohort of men with Stage T1-T3 prostate cancer who were randomized to receive between 70 Gy and 78 Gy and were prospectively biopsied at about 2 years after the completion of radiotherapy (RT).

METHODS AND MATERIALS

Of the 301 assessable patients in the trial, 168 underwent planned sextant or greater prostate post-RT biopsies in the absence of biochemical or clinical failure; this group constituted the study cohort. Of the 168 patients, 87 were in the 70-Gy arm and 81 in the 78-Gy arm. Biopsies were classified into four groups: negative (no tumor), atypical/suspicious cells (not diagnostic of carcinoma), carcinoma with treatment effect (CaTxEffect), and carcinoma without treatment effect (CaNoTxEffect). Any diagnosis of carcinoma in the specimen was classified as biopsy positive. Freedom from failure (FFF) included biochemical failure and/or clinical failure. Kaplan-Meier curves were calculated from the completion of RT. For those alive in the study cohort, the median follow-up was 65 months.

RESULTS

The rate of biopsy without tumor was 42%; with atypical cells, it was 28%, with CaTxEffect 21%, and with CaNoTxEffect 9%. The overall biopsy positivity rate (CaTxEffect + CaNoTxEffect) was 30%; 28% in the 70-Gy group and 32% in the 78-Gy group (p = 0.52). The distribution of PSA nadir levels was 73% <or=0.5, 20% >0.5-1.0, 5% >1.0-2.0, and 1% >2.0 ng/mL. Significantly more patients randomized to 78 Gy had a PSA nadir of <or=0.5 ng/mL (80% vs. 67%; p = 0.02). No relationship was found between PSA nadir level and prostate biopsy status. The 5-year FFF rate for those classified as biopsy negative was 84% and for those biopsy positive was 60% (p = 0.0002). Radiation dose did not significantly alter FFF rates by prostate biopsy status. Nadir PSA level correlated with FFF, although this was dependent on the inclusion of the 2 patients with a PSA nadir >2.0 ng/mL.

CONCLUSION

For patients free of treatment failure at the time of prostate biopsy 2 years after RT, the prognosis of no tumor cells was the same as that of atypical/suspicious cells and CaTxEffect was the same as CaNoTxEffect. The biopsy positivity rate was not altered by dose, suggesting that most of the outcome differences between the 70-Gy and 78-Gy groups were due to events occurring before prostate biopsy at 2 years and/or were not entirely dependent on biopsy status. Biopsy status is a strong prognostic factor, but, as an early end point, it may be misleading. PSA nadir appears to have little clinical value in patients treated to doses of >/=70 Gy who are failure free 2 years after RT.

The use of an extra-focal electron source to model collimator-scattered electrons using the pencil-beam redefinition algorithm

Currently, the pencil-beam redefinition algorithm (PBRA) utilizes a single electron source to model clinical electron beams. In the single-source model, the electrons appear to originate from a virtual source located near the scattering foils. Although this approach may be acceptable for most treatment machines, previous studies have shown dose differences as high as 8% relative to the given dose for small fields for some machines such as the Varian Clinac 1800. In such machines collimation-scattered electrons originating from the photon jaws and the applicator give rise to extra-focal electron sources. In this study, we examined the impact of modeling an additional electron source to better account for the collimator-scattered electrons. The desired dose calculation accuracy in water throughout the dose distribution is 3% or better relative to the given dose. We present here a methodology for determining the electron-source parameters for the dual-source model using a minimal set of data, that is, two central-axis depth-dose curves and two off-axis profiles. A Varian Clinac 1800 accelerator was modeled for beam energies of 20 and 9 MeV and applicator sizes of 15 x 15 and 6 x 6 cm2. The improvement in the accuracy of PBRA-calculated dose, evaluated using measured two-dimensional dose distributions in water, was characterized using the figure of merit, FA3%, which represents the fractional area containing dose differences greater than 3%. For the 15 x 15 cm2 field the evaluation was restricted to the penumbral region, and for the 6 x 6 cm2 field the central region of the beam was included as it was impacted by the penumbra. The greatest improvement in dose accuracy was for the 6 x 6 cm2 applicator. At 9 MeV, FA3% decreased from 15% to 0% at 100 cm SSD and from 34% to 4% at 110 cm SSD. At 20 MeV, FA3% decreased from 17% to 2% at 100 cm SSD and from 41% to 10% at 110 cm SSD. In the penumbra of the 15 x 15 cm2 applicator, the improvement was less, but still significant. At 9 MeV, FA3% changed from 11% to 1% at 100 cm SSD and from 10% to 12% at 110 cm SSD. At 20 MeV, FA3% decreased from 12% to 8% at 100 cm SSD and from 14% to 5% at 110 cm SSD. Results demonstrate that use of a dual-source beam model can provide significantly improved accuracy in the PBRA-calculated dose distribution that was not achievable with a single-source beam model when modeling the Varian Clinac 1800 electron beams. Time of PBRA dose calculation was approximately doubled; however, dual-source beam modeling of newer accelerators (e.g., the Varian Clinac 2100) may not be necessary because of less impact of collimator-scattered electrons on dosimetry.

Prostate cancer radiation dose response: results of the M. D. Anderson phase III randomized trial

PURPOSE

A randomized radiotherapy dose escalation trial was undertaken between 1993 and 1998 to compare the efficacy of 70 vs. 78 Gy in controlling prostate cancer.

METHODS AND MATERIALS

A total of 305 Stage T1-T3 patients were entered into the trial and, of these, 301 with a median follow-up of 60 months, were assessable. Of the 301 patients, 150 were in the 70 Gy arm and 151 were in the 78 Gy arm. The primary end point was freedom from failure (FFF), including biochemical failure, which was defined as 3 rises in the prostate-specific antigen (PSA) level. Kaplan-Meier survival analyses were calculated from the completion of radiotherapy. The log-rank test was used to compare the groups. Cox proportional hazard regression analysis was used to examine the independence of study randomization in multivariate analysis.

RESULTS

There was an even distribution of patients by randomization arm and stage, Gleason score, and pretreatment PSA level. The FFF rates for the 70- and 78 Gy arms at 6 years were 64% and 70%, respectively (p = 0.03). Dose escalation to 78 Gy preferentially benefited those with a pretreatment PSA >10 ng/mL; the FFF rate was 62% for the 78 Gy arm vs. 43% for those who received 70 Gy (p = 0.01). For patients with a pretreatment PSA <or=10 ng/mL, no significant dose response was found, with an average 6-year FFF rate of about 75%. Although no difference occurred in overall survival, the freedom from distant metastasis rate was higher for those with PSA levels >10 ng/mL who were treated to 78 Gy (98% vs. 88% at 6 years, p = 0.056). Rectal side effects were also significantly greater in the 78 Gy group. Grade 2 or higher toxicity rates at 6 years were 12% and 26% for the 70 Gy and 78 Gy arms, respectively (p = 0.001). Grade 2 or higher bladder complications were similar at 10%. For patients in the 78 Gy arm, Grade 2 or higher rectal toxicity correlated highly with the proportion of the rectum treated to >70 Gy.

CONCLUSION

An increase of 8 Gy resulted in a highly significant improvement in FFF for patients at intermediate-to-high risk, although the rectal reactions were also increased. Dose escalation techniques that limit the rectal volume that receives >or=70 Gy to <25% should be used.

Electron conformal radiotherapy using bolus and intensity modulation

PURPOSE

Conformal electron beam therapy can be delivered using shaped bolus, which varies the penetration of the electrons across the incident beam so that the 90% isodose surface conforms to the distal surface of the planning target volume (PTV). Previous use of this modality has shown that the irregular proximal surface of the bolus causes the dose heterogeneity in the PTV to increase from 10%, the typical dose spread of a flat-water surface to approximately 20%. The present work evaluates the ability to restore dose homogeneity by varying the incident electron intensity.

METHODS AND MATERIALS

Three patients, one each with chest wall, thorax, and head-and-neck cancer, were planned using electron conformal therapy with bolus, with and without intensity modulation. Resulting dose distributions and dose-volume histograms were compared with non-intensity-modulated bolus plans.

RESULTS

In all cases, the DeltaD(90%-10%) for the PTV was reduced; for example, for the head-and-neck case, the DeltaD(90%-10%) for the PTV was reduced from 14.9% to 9.2%. This reduction in dose spread is a direct result of intensity modulation.

CONCLUSIONS

The results showed that intensity-modulated electron beams could significantly improve the dose homogeneity in the PTV for patients treated with electron conformal therapy using shaped bolus.

PTV margin determination in conformal SRT of intracranial lesions

The planning target volume (PTV) includes the clinical target volume (CTV) to be irradiated and a margin to account for uncertainties in the treatment process. Uncertainties in miniature multileaf collimator (mMLC) leaf positioning, CT scanner spatial localization, CT-MRI image fusion spatial localization, and Gill-Thomas-Cosman (GTC) relocatable head frame repositioning were quantified for the purpose of determining a minimum PTV margin that still delivers a satisfactory CTV dose. The measured uncertainties were then incorporated into a simple Monte Carlo calculation for evaluation of various margin and fraction combinations. Satisfactory CTV dosimetric criteria were selected to be a minimum CTV dose of 95% of the PTV dose and at least 95% of the CTV receiving 100% of the PTV dose. The measured uncertainties were assumed to be Gaussian distributions. Systematic errors were added linearly and random errors were added in quadrature assuming no correlation to arrive at the total combined error. The Monte Carlo simulation written for this work examined the distribution of cumulative dose volume histograms for a large patient population using various margin and fraction combinations to determine the smallest margin required to meet the established criteria. The program examined 5 and 30 fraction treatments, since those are the only fractionation schemes currently used at our institution. The fractionation schemes were evaluated using no margin, a margin of just the systematic component of the total uncertainty, and a margin of the systematic component plus one standard deviation of the total uncertainty. It was concluded that (i) a margin of the systematic error plus one standard deviation of the total uncertainty is the smallest PTV margin necessary to achieve the established CTV dose criteria, and (ii) it is necessary to determine the uncertainties introduced by the specific equipment and procedures used at each institution since the uncertainties may vary among locations.

Using Monte Carlo methods to commission electron beams: a feasibility study

The purpose of this study was to investigate the feasibility of using Monte Carlo methods to assist in the commissioning of electron beams for a medical linear accelerator. The EGS4/BEAM code system was used to model an installed linear accelerator at this institution. Following an initial tuning of the input parameters, dosimetry data normally measured during the machine commissioning was calculated using the Monte Carlo code. All commissioning data was calculated for 6- and 12-MeV electron beams, and a subset of the commissioning data was calculated for the 20-MeV electron beams. On central axis, calculated percentage depth dose, cross-beam profiles, cone-insert ratios, and air-gap factors were generally within 2% of Dmax or 1 mm of the measured commissioning data; however, calculated open-cone ratios were not within 2%, in most cases. Calculated off-axis dose profiles for small fields were generally within the 2% (1-mm) criteria; however, calculated dose profiles for larger (open cone) fields frequently failed the 2% (1-mm) criteria. The remaining discrepancies between Monte Carlo calculations and measurement could be due to flaws in the Monte Carlo code, inaccuracies in the simulation geometry, the approximation of the initial source configuration, or a combination of the above. Although agreement between Monte Carlo calculated and measured doses was impressive and similar to previously published comparisons, our results did not prove our hypothesis that Monte Carlo calculations can generate electron commissioning data that is accurate within 2% of Dmax or 0.1 cm over the entire range of clinical treatment parameters. Although we believe that this hypothesis can be proved, it remains a challenge for the medical physics community. We intend to pursue this further by developing systematic methods for isolating causes of these differences.

The effect of scattering foil parameters on electron-beam Monte Carlo calculations

The sensitivity of electron-beam Monte Carlo dose calculations to scattering foil geometrical parameters is described. A method for resolving discrepancies between Monte Carlo calculation and measured data in a systematic manner is also described. As part of a project to investigate the utility of Monte Carlo methods for calculating data required for commissioning electron beams, a large discrepancy between measured and calculated 20 MeV cross-beam profiles for the largest field size was found. It was hypothesized that the discrepancy was due to incorrect input data and that better agreement between calculation and measurement could be achieved with small changes in the scattering foil system geometry. Four parameters describing the foil system were varied individually until better agreement between calculation and measurement was achieved, and the percentage change in the parameter was tabulated as an indication of the sensitivity of the model to that parameter. The accelerator model for the 20 MeV electron beam was most sensitive to the distance between the scattering foils and to a slightly lesser extent, to the width of the shaped secondary scattering foil. Changes to the primary or secondary foil thickness also significantly modified the falloff and bremsstrahlung component of depth dose, which was unacceptable for the present case. Therefore, the distance between the two scattering foils was changed in our calculations, which the manufacturer later confirmed was indeed the case. For 6 and 12 MeV electron beams, the change was not nearly as significant. It was concluded that Monte Carlo calculations for higher-energy beams and larger field sizes are most sensitive to the geometric configuration of the scattering foil system and should therefore be calculated first to help verify the accuracy of the geometric information.

Correlation between lung fibrosis and radiation therapy dose after concurrent radiation therapy and chemotherapy for limited small cell lung cancer

PURPOSE

To evaluate the relationship between physician-identified radiographic fibrosis, lung tissue physical density change, and radiation dose after concurrent radiation therapy and chemotherapy for limited small cell lung cancer.

MATERIALS AND METHODS

Fibrosis volumes of different severity levels were delineated on computed tomography (CT) images obtained at 1-year follow-up of 21 patients with complete response to concurrent radiation therapy and chemotherapy for limited small cell lung carcinoma. Delivered treatments were reconstructed with a three-dimensional treatment planning system and geometrically registered to the follow-up CT images. Tissue physical density change and radiation dose were computed for each voxel within each fibrosis volume and within normal lung. Patient responses were grouped per radiation and chemotherapy protocol.

RESULTS

A significant correlation was noted between fibrosis grade and tissue physical density change and fibrosis grade. For doses less than 30 Gy, the probability of observing fibrosis was less than 2% with conventional fractionation and less than 4% with accelerated fractionation. Physical lung density change also showed a threshold of 30-35 Gy. For doses of 30-55 Gy and cisplatin and etoposide (PE) chemotherapy, fibrosis probability was 2.0 times greater for accelerated fractionation compared with conventional fractionation (P < .005) and was correlated to increasing dose for both fractionation schedules.

CONCLUSION

Lung tissue physical density changes correlated well with fibrosis incidence, and both increased with increasing dose greater than a threshold of 30-35 Gy. With concurrent PE chemotherapy, fibrosis probability was twice as great with accelerated fractionation as with once-daily fractionation.

A custom three-dimensional electron bolus technique for optimization of postmastectomy irradiation

PURPOSE

Postmastectomy irradiation (PMI) is a technically complex treatment requiring consideration of the primary tumor location, possible risk of internal mammary node involvement, varying chest wall thicknesses secondary to surgical defects or body habitus, and risk of damaging normal underlying structures. In this report, we describe the application of a customized three-dimensional (3D) electron bolus technique for delivering PMI.

METHODS AND MATERIALS

A customized electron bolus was designed using a 3D planning system. Computed tomography (CT) images of each patient were obtained in treatment position and the volume to be treated was identified. The distal surface of the wax bolus matched the skin surface, and the proximal surface was designed to conform to the 90% isodose surface to the distal surface of the planning target volume (PTV). Dose was calculated with a pencil-beam algorithm correcting for patient heterogeneity. The bolus was then fabricated from modeling wax using a computer-controlled milling device. To aid in quality assurance, CT images with the bolus in place were generated and the dose distribution was computed using these images.

RESULTS

This technique optimized the dose distribution while minimizing irradiation of normal tissues. The use of a single anterior field eliminated field junction sites. Two patients who benefited from this option are described: one with altered chest wall geometry (congenital pectus excavatum), and one with recurrent disease in the medial chest wall and internal mammary chain (IMC) area.

CONCLUSION

The use of custom 3D electron bolus for PMI is an effective method for optimizing dose delivery. The radiation dose distribution is highly conformal, dose heterogeneity is reduced compared to standard techniques in certain suboptimal settings, and excellent immediate outcome is obtained.

Calculation of the 3-D dose distribution surrounding a 103Pd stent

PURPOSE

This study was designed to assess the suitability of a 103Pd-implanted stent for use in intravascular brachytherapy.

MATERIALS AND METHODS

A stent was modeled as a superposition of 201 identical struts and the EGS4/DOSRZ Monte Carlo code was used to calculate the dose distribution for each strut. To verify the simulation parameters, doses along the transverse axis of a Model 200 103Pd interstitial seed were calculated and compared to those calculated by the TG43 method.

RESULTS

Dose profiles within 1 mm of the stent's outer surface were heterogeneous and reflected the stent's structure. For a 2-mm outer-diameter 103Pd-implanted stent, approximately 2.68 x 10(7) Bq were required to deliver 31.5 Gy in 28 days at a distance of 0.5 mm along the perpendicular bisector from the stent's outer surface. The Monte Carlo simulation of the 103Pd seed showed relative doses within 7% of the values calculated by the TG43 method.

CONCLUSION

The dosimetry about a 103Pd-implanted stent suggests that the stent is suitable for use in intravascular brachytherapy.

A measured data set for evaluating electron-beam dose algorithms

The purpose of this work was to develop an electron-beam dose algorithm verification data set of high precision and accuracy. Phantom geometries and treatment-beam configurations used in this study were similar to those in a subset of the verification data set produced by the Electron Collaborative Working Group (ECWG). Measurement techniques and quality-control measures were utilized in developing the data set to minimize systematic errors inherent in the ECWG data set. All measurements were made in water with p-type diode detectors and using a Wellhöfer dosimetry system. The 9 and 20 MeV, 15 x 15 cm2 beams from a single linear accelerator composed the treatment beams. Measurements were made in water at 100 and 110 cm source-to-surface distances. Irregular surface measurements included a "stepped surface" and a "nose-shaped surface." Internal heterogeneity measurements were made for bone and air cavities in differing orientations. Confidence in the accuracy of the measured data set was reinforced by a comparison with Monte Carlo (MC)-calculated dose distributions. The MC-calculated dose distributions were generated using the OMEGA/BEAM code to explicitly model the accelerator and phantom geometries of the measured data set. The precision of the measured data, estimated from multiple measurements, was better than 0.5% in regions of low-dose gradients. In general, the agreement between the measured data and the MC-calculated data was within 2%. The quality of the data set was superior to that of the ECWG data set, and should allow for a more accurate evaluation of an electron beam dose algorithm. The data set will be made publicly available from the Department of Radiation Physics at The University of Texas M. D. Anderson Cancer Center.

Preliminary results of a randomized radiotherapy dose-escalation study comparing 70 Gy with 78 Gy for prostate cancer

PURPOSE

To determine the effect of radiotherapy dose on prostate cancer patient outcome and biopsy positivity in a phase III trial.

PATIENTS AND METHODS

A total of 305 stage T1 through T3 patients were randomized to receive 70 Gy or 78 Gy of external-beam radiotherapy between 1993 and 1998. Of these, 301 were assessable; stratification was based on pretreatment prostate-specific antigen level (PSA). Dose was prescribed to the isocenter at 2 Gy per fraction. All patients underwent planning pelvic computed tomography scan to confirm prostate position. Treatment failure was defined as an increasing PSA on three consecutive follow-up visits or the initiation of salvage treatment. Median follow-up was 40 months.

RESULTS

One hundred fifty patients were randomized to the 70-Gy arm and 151 to the 78-Gy arm. The difference in freedom from biochemical and/or disease failure (FFF) rates of 69% and 79% for the 70-Gy and 78-Gy groups, respectively, at 5 years was marginally significant (log-rank P: =.058). Multiple-covariate Cox proportional hazards regression showed that the study randomization was an independent correlate of FFF, along with pretreatment PSA, Gleason score, and stage. The patients who benefited most from the 8-Gy dose escalation were those with a pretreatment PSA of more than 10 ng/mL; 5-year FFF rates were 48% and 75% (P: =.011) for the 70-Gy and 78-Gy arms, respectively. There was no difference between the arms ( approximately 80% 5-year FFF) when the pretreatment PSA was < or = 10 ng/mL.

CONCLUSION

A modest dose increase of 8 Gy using conformal radiotherapy resulted in a substantial improvement in prostate cancer FFF rates for patients with a pretreatment PSA of more than 10 ng/mL. These findings document that local persistence of prostate cancer in intermediate- to high-risk patients is a major problem when doses of 70 Gy or less are used.

Three-dimensional treatment planning for central lymphatic irradiation

The purpose of this study was to investigate the applicability of 3-dimensional (3D) treatment planning for central lymphatic irradiation (CLI). CLI requires more than 1 course of treatment with large, highly blocked, overlapping beams, and careful planning is required to ensure that such treatments are delivered safely and effectively. Three patients were selected for this study. Each patient completed at least 1 course of radiation therapy for CLI and was scheduled to receive irradiation to an adjacent area with overlapping beams. Two treatment plans were generated for each patient: a standard, 2-dimensional (2D) treatment plan and a 3D treatment plan designed to mimic the standard plan, taking advantage of unique 3D features. The time required to complete the treatment plans and differences in the treatment planning processes were noted. The time required to generate a 3D treatment plan was approximately the same as the time required to generate a standard 2D treatment plan; however, the 3D planning process required less redundancy of data entry than the 2D process. The 3D treatment plan was qualitatively similar to the standard 2D treatment plan; however, differences in beam penumbra and beam junctions were noted, and are most likely due to differences in the dose-calculation models used in these 2 treatment planning systems. Dose-volume histograms (DVHs) were calculated for the spinal cord and were found to be useful to the physicians for quickly and accurately evaluating the presence or absence of hot spots in the junction region. 3D treatment-planning has some advantages over 2D treatment planning for CLI; the main advantage of the 3D treatment plan is that it provides a single plan for each patient with multiple views of the data, including different planar cross-sections and DVHs. For the 2D system, a separate plan was generated for each view, requiring redundant data entry. The quality of the output of the 3D treatment plans is superior to that of 2D treatment plans, but the clinical utility is about the same. Currently, the time required for 2D and 3D treatment plans is similar. However, as dosimetrists become more familiar with 3D treatment planning systems, we expect this familiarity and regularity of use to translate into a significant time advantage.

Planning target volumes for radiotherapy: how much margin is needed?

PURPOSE

The radiotherapy planning target volume (PTV) encloses the clinical target volume (CTV) with anisotropic margins to account for possible uncertainties in beam alignment, patient positioning, organ motion, and organ deformation. Ideally, the CTV-PTV margin should be determined solely by the magnitudes of the uncertainties involved. In practice, the clinician usually also considers doses to abutting healthy tissues when deciding on the size of the CTV-PTV margin. This study calculates the ideal size of the CTV-PTV margin when only physical position uncertainties are considered.

METHODS AND MATERIALS

The position of the CTV for any treatment is assumed to be described by independent Gaussian distributions in each of the three Cartesian directions. Three strategies for choosing a CTV-PTV margin are analyzed. The CTV-PTV margin can be based on: 1. the probability that the CTV is completely enclosed by the PTV; 2. the probability that the projection of the CTV in the beam's eye view (BEV) is completely enclosed by the projection of the PTV in the BEV; and 3. the probability that a point on the edge of the CTV is within the PTV. Cumulative probability distributions are derived for each of the above strategies.

RESULTS

Expansion of the CTV by 1 standard deviation (SD) in each direction results in the CTV being entirely enclosed within the PTV 24% of the time; the BEV projection of the CTV is enclosed within the BEV projection of the PTV 39% of the time; and a point on the edge of the CTV is within the PTV 84% of the time. To have the CTV enclosed entirely within the PTV 95% of the time requires a margin of 2.8 SD. For the BEV projection of the CTV to be within the BEV projection of the PTV 95% of the time requires a margin of 2.45 SD. To have any point on the surface of the CTV be within the PTV 95% of the time requires a margin of 1.65 SD.

CONCLUSION

In the first two strategies for selecting a margin, the probability of finding the CTV within the PTV is unrelated to dose variations in the CTV. In the third strategy, the specified confidence limit is correlated with the minimum target dose. We recommend that the PTV be calculated from the CTV using a margin of 1.65 SD in each direction. This gives a minimum CTV dose that is greater than 95% of the minimum PTV dose. Additional sparing of adjoining healthy structures should be accomplished by modifying beam portals, rather than adjusting the PTV. Then, the dose distributions more accurately reflect the clinical compromise between treating the tumor and sparing the patient.

Fetal dose estimates for electron-beam treatment to the chest wall of a pregnant patient

The purpose of this report is to discuss dosimetry and shielding for electron-beam radiotherapy of pregnant patients. Specifically, we have determined fetal dose for a pregnant patient considering electron radiotherapy for a chest wall recurrence of breast cancer. The treatment was simulated using an anthropomorphic phantom, and the measured dose to the unshielded fetus for this plan was 5.3 cGy, a level at which risk to the fetus is uncertain. Therefore abdominal shielding, consisting of 6.6 cm of lead, was used to reduce the dose to the fetus to less than 1.5 cGy, a level considered to be of little risk. We further found that using the lower (instead of upper) variable trimmer bars to define the field edge closest to the fetus resulted in approximately 30% lower dose to the fetus. These results show that it is possible to reduce fetal dose to acceptable limits in electron-beam radiotherapy of the chest wall using the general principles recommended for photon-beam radiotherapy.

Prostate target volume variations during a course of radiotherapy

PURPOSE

The purpose of this study was to measure the mobility of the clinical target volume (CTV) in prostate radiotherapy with respect to the pelvic anatomy during a course of therapy. These data are needed to properly design the planning target volume (PTV).

METHODS AND MATERIALS

Seventeen patients were studied. Each patient underwent computed tomography (CT) scanning for treatment planning purposes. Subsequently, three CT scans were obtained at approximately 2-week intervals during treatment. The prostate, seminal vesicles, bladder, and rectum were outlined on each CT study. The second through the fourth CT studies were aligned with the first study using a rigid body transformation based on the bony anatomy. The transformation was used to compute the center of mass position and bounding box of each organ in the subsequent studies relative to the first study. Differences in the bounding box limits and center of mass positions between the first and subsequent studies were tabulated and correlated with bladder and rectal volume and positional parameters.

RESULTS

The mobility of the CTV was characterized by standard deviations of 0.09 cm (left-right), 0.36 cm (cranial-caudal), and 0.41cm (anterior-posterior). Prostate mobility was not significantly correlated with bladder volume. However, the mobility of both the prostate and seminal vesicles was very significantly correlated with rectal volume. Bladder and rectal volumes decreased between the pretreatment CT scan and the first on-treatment CT scan, but were constant for all on-treatment CT scans.

CONCLUSION

Margins between the CTV and PTV based on the simple geometric requirement that a point on the edge of the CTV is enclosed by the PTV 95% of the time are 0.7 cm in the lateral and cranial-caudal directions, and 1.1 cm in the anterior-posterior direction. However, minimum dose to the CTV and avoidance of organs at risk are more important considerations when drawing beam apertures. More consistent methods for reproducing prostate position (e.g., empty rectum) and more sophisticated beam aperture optimization are needed to guarantee consistent coverage of the CTV while avoiding organs at risk.