Initial beam size study for passive scatter proton therapy. I. Monte Carlo verification

The purpose of this work was to provide an initial validation of a Monte Carlo (MC) model of the passive scattering treatment nozzle at the University of Texas M. D. Anderson Cancer Center Proton Therapy Center. The MC model included a detailed definition of each beam-modifying element in the nozzle, and calculations accounted for interactions of the beam with the rotating modulator wheel used to create the spread out Bragg peak. In this work we show comparisons of calculated dose and fluence profiles with measured data from the nozzle for the 250 and 180 MeV beam energies used for patient treatments. Agreement to within 1.5 mm of measured data was observed for all MC calculations. The high level of agreement between the measurements and the MC model for the two beam energies studied provides validation for use of the model in a study of the dosimetric effects of the proton beam size and shape at the nozzle entrance.     

Initial beam size study for passive scatter proton therapy. II. Changes in delivered depth dose profiles

In passively scattered proton radiotherapy, a clinically useful treatment beam is produced by spreading a small proton "pencil beam" extracted from the accelerator to create both a uniform dose profile laterally and a uniform spread-out Bragg peak (SOBP) in depth. Lateral spreading and range modulation of the beam are accomplished using specially designed components within the treatment delivery nozzle. The purpose of this study was to determine how changes in the size of the initial proton pencil beam affect the delivery of dose with a passive scatter treatment nozzle. Monte Carlo calculations were used to study changes of the beam's in-air energy distribution at the exit of the nozzle and the central axis depth dose profiles in water resulting from changes in the incident beam size. Our results indicate that the width of the delivered SOBP decreases as the size of the initial beam increases.     

Feasibility of MRI guided proton therapy: magnetic field dose effects

Many methods exist to improve treatment outcome in radiotherapy. Two of these are image-guided radiotherapy (IGRT) and proton therapy. IGRT aims at a more precise delivery of the radiation, while proton therapy is able to achieve more conformal dose distributions. In order to maximally exploit the sharp dose gradients from proton therapy it has to be combined with soft-tissue based IGRT. MRI-guided photon therapy (currently under development) offers unequalled soft-tissue contrast and real-time image guidance. A hybrid MRI proton therapy system would combine these advantages with the advantageous dose steering capacity of proton therapy. This paper addresses a first technical feasibility issue of this concept, namely the impact of a 0.5 T magnetic field on the dose distribution from a 90 MeV proton beam. In contrast to photon therapy, for MR-guided proton therapy the impact of the magnetic field on the dose distribution is very small. At tissue-air interfaces no effect of the magnetic field on the dose distribution can be detected. This is due to the low-energy of the secondary electrons released by the heavy protons.     

Monte Carlo study of neutron dose equivalent during passive scattering proton therapy

Stray radiation exposures are of concern for patients receiving proton radiotherapy and vary strongly with several treatment factors. The purposes of this study were to conservatively estimate neutron exposures for a contemporary passive scattering proton therapy system and to understand how they vary with treatment factors. We studied the neutron dose equivalent per therapeutic absorbed dose (H/D) as a function of treatment factors including proton energy, location in the treatment room, treatment field size, spread-out Bragg peak (SOBP) width and snout position using both Monte Carlo simulations and analytical modeling. The H/D value at the isocenter for a 250 MeV medium field size option was estimated to be 20 mSv Gy(-1). H/D values generally increased with the energy or penetration range, fell off sharply with distance from the treatment unit, decreased modestly with the aperture size, increased with the SOBP width and decreased with the snout distance from the isocenter. The H/D values from Monte Carlo simulations agreed well with experimental results from the literature. The analytical model predicted H/D values within 28% of those obtained in simulations; this value is within typical neutron measurement uncertainties.     

Prompt gamma imaging with a slit camera for real-time range control in proton therapy

Treatments delivered by proton therapy are affected by uncertainties on the range of the beam within the patient, requiring medical physicists to add safety margins on the penetration depth of the beam. To reduce these margins and deliver safer treatments, different projects are currently investigating real-time range control by imaging prompt gammas emitted along the proton tracks in the patient. This study reports on the feasibility, development and test of a new concept of prompt gamma camera using a slit collimator to obtain a one-dimensional projection of the beam path on a scintillation detector. This concept was optimized, using the Monte Carlo code MCNPX version 2.5.0, to select high energy photons correlated with the beam range and detect them with both high statistics and sufficient spatial resolution. To validate the Monte Carlo model, spectrometry measurements of secondary particles emitted by a PMMA target during proton irradiation at 160 MeV were realized. An excellent agreement with the simulations was observed when using subtraction methods to isolate the gammas in direct incidence. A first prototype slit camera using the HiCam gamma detector was consequently prepared and tested successfully at 100 and 160 MeV beam energies. Results confirmed the potential of this concept for real-time range monitoring with millimetre accuracy in pencil beam scanning mode for typical clinical conditions. If we neglect electronic dead times and rejection of detected events, the current solution with its collimator at 15 cm from the beam axis can achieve a 1-2 mm standard deviation on range estimation in a homogeneous PMMA target for numbers of protons that correspond to doses in water at the Bragg peak as low as 15 cGy at 100 MeV and 25 cGy at 160 MeV assuming pencil beams with a Gaussian profile of 5 mm sigma at target entrance.     

The basic study of a bi-material range compensator for improving dose uniformity for proton therapy

A range compensator (abbreviated as a RC hereafter) is used to form a conformal dose distribution for heavy-charged-particle therapy. However, it induces distortion of the dose distribution. The induced inhomogeneity may result in a calibration error of a monitor unit (MU) assigned to a transmission ionization chamber. By using a bi-material RC made from a low-Z material and a high-Z material instead of the regular RC, the dose inhomogeneity has been obviously reduced by equalizing the lateral dose distributions formed by pencil beams traversing elements of the RC with different base thicknesses at the same water-equivalent depth. We designed and manufactured a 4 x 4 matrix-shaped single-material RC and a bi-material RC with the same range losses at corresponding elements of the RCs. The bi-material RC is made from chemical wood (the main chemical component is an ABS resin) as a low-Z material and from brass as a high-Z material. Sixteen segments of the RC are designed so that the range-loss differences of the adjacent segments of the RC range from 0 to 50 mm in steps of 5 mm. We measured dose distributions in water formed by a 160 MeV proton beam traversing the single-material RC or the bi-material RC, using the HIMAC biology beam port. Large dips and bumps were observed in the dose distribution formed by the use of the single-material RC; the dose uniformity has been significantly improved in the target region by the use of the bi-material RC. The improvement has been obtained at the expense of blurring lateral penumbra. For clinical application of this method to a patient with large density inhomogeneity, a simple modification method of the original calculation model has been given.     

Leakage and scatter radiation from a double scattering based proton beamline

Proton beams offer several advantages over conventional radiation techniques for treating cancer and other diseases. These advantages might be negated if the leakage and scatter radiation from the beamline and patient are too large. Although the leakage and scatter radiation for the double scattering proton beamlines at the Loma Linda University Proton Treatment Facility were measured during the acceptance testing that occurred in the early 1990s, recent discussions in the radiotherapy community have prompted a reinvestigation of this contribution to the dose equivalent a patient receives. The dose and dose equivalent delivered to a large phantom patient outside a primary proton field were determined using five methods: simulations using Monte Carlo calculations, measurements with silver halide film, measurements with ionization chambers, measurements with rem meters, and measurements with CR-39 plastic nuclear track detectors. The Monte Carlo dose distribution was calculated in a coronal plane through the simulated patient that coincided with the central axis of the beam. Measurements with the ionization chambers, rem meters, and plastic nuclear track detectors were made at multiple locations within the same coronal plane. Measurements with the film were done in a plane perpendicular to the central axis of the beam and coincident with the surface of the phantom patient. In general, agreement between the five methods was good, but there were some differences. Measurements and simulations also tended to be in agreement with the original acceptance testing measurements and results from similar facilities published in the literature. Simulations illustrated that most of the neutrons entering the patient are produced in the final patient-specific aperture and precollimator just upstream of the aperture, not in the scattering system. These new results confirm that the dose equivalents received by patients outside the primary proton field from primary particles that leak through the nozzle are below the accepted standards for x-ray and electron beams. The total dose equivalent outside of the field is similar to that received by patients undergoing treatments with intensity modulated x-ray therapy. At the center of a patient for a whole course of treatment, the dose equivalent is comparable to that delivered by a single whole-body XCT scan.     

Parametrization and application of scatter kernels for modelling scanned proton beam collimator scatter dose

Collimators are routinely used in proton radiotherapy to laterally confine the field and improve the penumbra. Collimator scatter contributes up to 15% of the local dose and is therefore important to include in treatment planning dose calculation. We present a method for reconstruction of the collimator scatter phase space based on the parametrization of pre-calculated scatter kernels. Collimator scatter distributions, generated by the Monte Carlo (MC) package GEANT4.8.2, were scored differential in direction and energy. The distributions were then parametrized so as to enable a fast reconstruction by sampling. MC calculated dose distributions in water based on the parametrized phase space were compared to full MC simulations that included the collimator in the simulation geometry, as well as to experimental data. The experiments were performed at the scanned proton beam line at the The Svedberg Laboratory (TSL) in Uppsala, Sweden. Dose calculations using the parametrization of this work and the full MC for isolated typical cases of collimator scatter were compared by means of the gamma index. The result showed that in total 96.7% (99.3%) of the voxels fulfilled the gamma 2.0%/2.0 mm (3.0%/3.0 mm) criterion. The dose distribution for a collimated field was calculated based on the phase space created by the collimator scatter model incorporated into the generation of the phase space of a scanned proton beam. Comparing these dose distributions to full MC simulations, including particle transport in the MLC, yielded that in total for 18 different collimated fields, 99.1% of the voxels satisfied the gamma 1.0%/1.0 mm criterion and no voxel exceeded the gamma 2.6%/2.6 mm criterion. The dose contribution of collimator scatter along the central axis as predicted by the model showed good agreement with experimental data.     

Development of an easy-to-handle range measurement tool using a plastic scintillator for proton beam therapy

Proton beam therapy can concentrate the dose on a tumour. In order to offer high-precision proton beam therapy to the patient, it is important to confirm the range every day. At the National Cancer Center Hospital East (NCC), the range measurement tool consists of a water phantom and an ionization chamber. These large and heavy tools take a long time to set up. Therefore, we developed a simple and easy-to-handle range measurement tool for proton beam therapy. This tool consists of a plastic scintillator block and a CCD camera. We recorded visible scintillation light generated by proton irradiation on the scintillator, and could measure the range from the shape of light distribution by using a computer with automatic analysis software installed. We carried out proton irradiation experiments with this tool to examine its performance as a tool of daily range measurements. The precision of the range measurement is within 0.3 mm (sd). The tool can measure possible short-term range variation with 1 s sampling time during the time interval of a typical treatment in a few minutes. We conclude that this tool can measure the range with sufficient resolution in a short time, and is useful for range control in a clinical setting.     

Accounting for range uncertainties in the optimization of intensity modulated proton therapy

Treatment plans optimized for intensity modulated proton therapy (IMPT) may be sensitive to range variations. The dose distribution may deteriorate substantially when the actual range of a pencil beam does not match the assumed range. We present two treatment planning concepts for IMPT which incorporate range uncertainties into the optimization. The first method is a probabilistic approach. The range of a pencil beam is assumed to be a random variable, which makes the delivered dose and the value of the objective function a random variable too. We then propose to optimize the expectation value of the objective function. The second approach is a robust formulation that applies methods developed in the field of robust linear programming. This approach optimizes the worst case dose distribution that may occur, assuming that the ranges of the pencil beams may vary within some interval. Both methods yield treatment plans that are considerably less sensitive to range variations compared to conventional treatment plans optimized without accounting for range uncertainties. In addition, both approaches--although conceptually different--yield very similar results on a qualitative level.     

Accurate Monte Carlo simulations for nozzle design, commissioning and quality assurance for a proton radiation therapy facility

Monte Carlo dosimetry calculations are essential methods in radiation therapy. To take full advantage of this tool, the beam delivery system has to be simulated in detail and the initial beam parameters have to be known accurately. The modeling of the beam delivery system itself opens various areas where Monte Carlo calculations prove extremely helpful, such as for design and commissioning of a therapy facility as well as for quality assurance verification. The gantry treatment nozzles at the Northeast Proton Therapy Center (NPTC) at Massachusetts General Hospital (MGH) were modeled in detail using the GEANT4.5.2 Monte Carlo code. For this purpose, various novel solutions for simulating irregular shaped objects in the beam path, like contoured scatterers, patient apertures or patient compensators, were found. The four-dimensional, in time and space, simulation of moving parts, such as the modulator wheel, was implemented. Further, the appropriate physics models and cross sections for proton therapy applications were defined. We present comparisons between measured data and simulations. These show that by modeling the treatment nozzle with millimeter accuracy, it is possible to reproduce measured dose distributions with an accuracy in range and modulation width, in the case of a spread-out Bragg peak (SOBP), of better than 1 mm. The excellent agreement demonstrates that the simulations can even be used to generate beam data for commissioning treatment planning systems. The Monte Carlo nozzle model was used to study mechanical optimization in terms of scattered radiation and secondary radiation in the design of the nozzles. We present simulations on the neutron background. Further, the Monte Carlo calculations supported commissioning efforts in understanding the sensitivity of beam characteristics and how these influence the dose delivered. We present the sensitivity of dose distributions in water with respect to various beam parameters and geometrical misalignments. This allows the definition of tolerances for quality assurance and the design of quality assurance procedures.     

A point dose method for in vivo range verification in proton therapy

Range uncertainty in proton therapy is a recognized concern. For certain treatment sites, less optimal beam directions are used to avoid the potential risk, but also with reduced benefit. In vivo dosimetry, with implanted or intra-cavity dosimeters, has been widely used for treatment verification in photon/electron therapy. The method cannot, however, verify the beam range for proton treatment, unless we deliver the treatment in a different manner. Specifically, we split the spread-out Bragg peaks in a proton field into two separate fields, each delivering a 'sloped' depth-dose distribution, rather than the usual plateau in a typical proton field. The two fields are 'sloped' in opposite directions so that the total depth-dose distribution retains the constant dose plateau covering the target volume. By measuring the doses received from both fields and calculating the ratio, the water-equivalent path length to the location of the implanted dosimeter can be verified, thus limiting range uncertainty to only the remaining part of the beam path. Production of such subfields has been experimented with a passive scattering beam delivery system. Phantom measurements have been performed to illustrate the application for in vivo beam range verification.     

Effect of tissue heterogeneity on an in vivo range verification technique for proton therapy

It was proposed recently that time-resolved dose measurements during proton therapy treatment by passively scattered beams may be used for in vivo range verification. The method was shown to work accurately in a water tank. In this paper, we further evaluated the potential of the method for more clinically relevant situations where proton beams must pass through regions with significant tissue heterogeneities. Specifically, we considered prostate treatment where the use of anterior or anterior- oblique fields was recently proposed in order to reduce rectal dose by taking advantage of the sharp distal fall-off of the Bragg peak. These beam portals pass through various parts of pubic bone and potential air cavities in the bladder and bowels. Using blocks of materials with densities equivalent to bone, air, etc, arranged in the water tank in relevant configurations, we tested the robustness of the method against range shifting and range mixing. In the former, the beam range is changed uniformly by changes in tissue density in the beam path, while in the latter, variations in tissue heterogeneities across the beam cross section causes the mixing of beam energies downstream, as often occurs when the beam travels along the interface of materials with significantly different densities. We demonstrated that in the region of interest, the method can measure water-equivalent path length with accuracy better than ±0.5?mm for pure range shifting and still reasonable accuracy for range mixing between close beam energies. In situations with range mixing between significantly different beam energies, the dose rate profiles may be simulated for verifying the beam range. We also found that the above performances can be obtained with very small amount of dose (<0.5 cGy), if silicon diodes are used as detectors. This makes the method suitable for in vivo range verification prior to each treatment delivery.     

Uncertainties and correction methods when modeling passive scattering proton therapy treatment heads with Monte Carlo

Nowadays, Monte Carlo models of proton therapy treatment heads are being used to improve beam delivery systems and to calculate the radiation field for patient dose calculations. The achievable accuracy of the model depends on the exact knowledge of the treatment head geometry and time structure, the material characteristics, and the underlying physics. This work aimed at studying the uncertainties in treatment head simulations for passive scattering proton therapy. The sensitivities of spread-out Bragg peak (SOBP) dose distributions on material densities, mean ionization potentials, initial proton beam energy spread and spot size were investigated. An improved understanding of the nature of these parameters may help to improve agreement between calculated and measured SOBP dose distributions and to ensure that the range, modulation width, and uniformity are within clinical tolerance levels. Furthermore, we present a method to make small corrections to the uniformity of spread-out Bragg peaks by utilizing the time structure of the beam delivery. In addition, we re-commissioned the models of the two proton treatment heads located at our facility using the aforementioned correction methods presented in this paper.