Experimental verification of a portal dose prediction model

Electronic portal imaging devices (EPIDs) can be used to measure a two-dimensional (2D) dose distribution behind a patient, thus allowing dosimetric treatment verification. For this purpose we experimentally assessed the accuracy of a 2D portal dose prediction model based on pencil beam scatter kernels. A straightforward derivation of these pencil beam scatter kernels for portal dose prediction models is presented based on phantom measurements. The model is able to predict the 2D portal dose image (PDI) behind a patient, based on a PDI without the patient in the beam in combination with the radiological thickness of the patient, which requires in addition a PDI with the patient in the beam. To assess the accuracy of portal dose and radiological thickness values obtained with our model, various types of homogeneous as well as inhomogeneous phantoms were irradiated with a 6 MV photon beam. With our model we are able to predict a PDI with an accuracy better than 2% (mean difference) if the radiological thickness of the object in the beam is symmetrically situated around the isocenter. For other situations deviations up to 3% are observed for a homogeneous phantom with a radiological thickness of 17 cm and a 9 cm shift of the midplane-to-detector distance. The model can extract the radiological thickness within 7 mm (maximum difference) of the actual radiological thickness if the object is symmetrically distributed around the isocenter plane. This difference in radiological thickness is related to a primary portal dose difference of 3%. It can be concluded that our model can be used as an easy and accurate tool for the 2D verification of patient treatments by comparing predicted and measured PDIs. The model is also able to extract the primary portal dose with a high accuracy, which can be used as the input for a 3D dose reconstruction method based on back-projection.     

A 4 MV flattening filter-free beam: commissioning and application to conformal therapy and volumetric modulated arc therapy

Recent studies have indicated that radiotherapy treatments undertaken on a flattening filter-free (FFF) linear accelerator have a number of advantages over treatments undertaken on a conventional linear accelerator. In addition, 4 MV photon beams may give improved isodose coverage for some treatment volumes at air/tissue interfaces, compared to when utilizing the clinical standard of 6 MV photons. In order to investigate these benefits, FFF beams were established on an Elekta Beam Modulator linear accelerator for 4 MV photons. Commissioning beam data were obtained for open and wedged fields. The measured data were then imported into a treatment planning system and a beam model was commissioned. The beam model was optimized to improve dose calculations at shallow, clinically relevant depths. Following verification, the beam model was utilized in a treatment planning study, including volumetric modulated arc therapy, for a selection of lung, breast/chest wall and larynx patients. Increased dose rates of around 800 MU min(-1) were recorded for open fields (relative to 320 MU min(-1) for filtered open fields) and reduced head scatter was inferred from output factor measurements. Good agreement between planned and delivered dose was observed in verification of treatment plans. The planning study indicated that with a FFF beam, equivalent (and in some cases improved) isodose profiles could be achieved for small lung and larynx treatment volumes relative to 4 MV filtered treatments. Furthermore, FFF treatments with wedges could be replicated using open fields together with an 'effective wedge' technique and isocentre shift. Clinical feasibility of a FFF beam was therefore demonstrated, with beam modelling, treatment planning and verification being successfully accomplished.     

Monitor unit calculations for wedged asymmetric photon beams

Algorithms for calculating monitor units (MUs) in wedged asymmetric high-energy photon beams as implemented in treatment planning systems have their limitations. Therefore an independent method for MU calculation is necessary. The aim of this study was to develop an empirical method to determine MUs for points at the centre of wedged fields, asymmetric in two directions. The method is based on the determination of an off-axis factor (OAF) that corrects for the difference in dose between wedged asymmetric and wedged symmetric beams with the same field size. Measurements were performed in a water phantom irradiated with 6 and 18 MV photon beams produced by Elekta accelerators, which are fitted with an internal motorized wedge that has a complex shape. The OAF perpendicular to the wedge direction changed significantly with depth for the 18 MV beam. Dose values measured for a set of 18 test cases were compared with those calculated with our method. The maximum difference found was 6.5% and in 15 cases this figure was smaller than 2.0%. The analytical method of Khan and the empirical method of Georg were also tested and showed errors up to 12.8%. It can be concluded that our simple formalism is able to calculate MUs in wedged asymmetric fields with an acceptable accuracy in most clinical situations.     

Characteristics of photon beams from Philips SL25 linear accelerators

The Philips SL25 accelerator is a multimodality machine offering asymmetric collimator jaws and a new type of beam bending and transport system. It produces photon beams, nominally at 6 and 25 MV, and a scattered electron beam with nine selectable energies between 4 and 22 MeV. Dosimetric characteristics for the 6- and 25-MV photon beams are presented with respect to field flatness, surface and depth dose characteristics, isodose distribution, field size factors for both open and wedged fields, and narrow beam transmission data in different materials.     

Testing of the analytical anisotropic algorithm for photon dose calculation

The analytical anisotropic algorithm (AAA) was implemented in the Eclipse (Varian Medical Systems) treatment planning system to replace the single pencil beam (SPB) algorithm for the calculation of dose distributions for photon beams. AAA was developed to improve the dose calculation accuracy, especially in heterogeneous media. The total dose deposition is calculated as the superposition of the dose deposited by two photon sources (primary and secondary) and by an electron contamination source. The photon dose is calculated as a three-dimensional convolution of Monte-Carlo precalculated scatter kernels, scaled according to the electron density matrix. For the configuration of AAA, an optimization algorithm determines the parameters characterizing the multiple source model by optimizing the agreement between the calculated and measured depth dose curves and profiles for the basic beam data. We have combined the acceptance tests obtained in three different departments for 6, 15, and 18 MV photon beams. The accuracy of AAA was tested for different field sizes (symmetric and asymmetric) for open fields, wedged fields, and static and dynamic multileaf collimation fields. Depth dose behavior at different source-to-phantom distances was investigated. Measurements were performed on homogeneous, water equivalent phantoms, on simple phantoms containing cork inhomogeneities, and on the thorax of an anthropomorphic phantom. Comparisons were made among measurements, AAA, and SPB calculations. The optimization procedure for the configuration of the algorithm was successful in reproducing the basic beam data with an overall accuracy of 3%, 1 mm in the build-up region, and 1%, 1 mm elsewhere. Testing of the algorithm in more clinical setups showed comparable results for depth dose curves, profiles, and monitor units of symmetric open and wedged beams below dmax. The electron contamination model was found to be suboptimal to model the dose around dmax, especially for physical wedges at smaller source to phantom distances. For the asymmetric field verification, absolute dose difference of up to 4% were observed for the most extreme asymmetries. Compared to the SPB, the penumbra modeling is considerably improved (1%, 1 mm). At the interface between solid water and cork, profiles show a better agreement with AAA. Depth dose curves in the cork are substantially better with AAA than with SPB. Improvements are more pronounced for 18 MV than for 6 MV. Point dose measurements in the thoracic phantom are mostly within 5%. In general, we can conclude that, compared to SPB, AAA improves the accuracy of dose calculations. Particular progress was made with respect to the penumbra and low dose regions. In heterogeneous materials, improvements are substantial and more pronounced for high (18 MV) than for low (6 MV) energies.     

A practical method to calculate head scatter factors in wedged rectangular and irregular MLC shaped beams for external and internal wedges

Factor based methods for absorbed dose or monitor unit calculations are often based on separate data sets for open and wedged beams. The determination of basic beam parameters can be rather time consuming, unless equivalent square methods are applied. When considering irregular wedged beams shaped with a multileaf collimator, parametrization methods for dosimetric quantities, e.g. output ratios or wedge factors as a function of field size and shape, become even more important. A practical method is presented to derive wedged output ratios in air (S(c,w)) for any rectangular field and for any irregular MLC shaped beam. This method was based on open field output ratios in air (S(c)) for a field with the same collimator setting, and a relation f(w) between S(c,w) and S(c). The relation f(w) can be determined from measured output ratios in air for a few open and wedged fields including the maximum wedged field size. The function f(w) and its parametrization were dependent on wedge angle and treatment head design, i.e. they were different for internal and external wedges. The proposed method was tested for rectangular wedged fields on three accelerators with internal wedges (GE, Elekta, BBC) and two accelerators with external wedges (Varian). For symmetric regular beams the average deviation between calculated and measured S(c,w) / S(c) ratios was 0.3% for external wedges and about 0.6% for internal wedges. Maximum deviations of 1.8% were obtained for elongated rectangular fields on the GE and ELEKTA linacs with an internal wedge. The same accuracy was achieved for irregular MLC shaped wedged beams on the accelerators with MLC and internal wedges (GE and Elekta), with an average deviation < 1% for the fields tested. The proposed method to determine output ratios in air for wedged beams from output ratios of open beams, combined with equivalent square approaches, can be easily integrated in empirical or semi-empirical methods for monitor unit calculations.     

Monte Carlo simulation and dosimetric verification of radiotherapy beam modifiers.

Monte Carlo simulation of beam modifiers such as physical wedges and compensating filters has been performed with a rectilinear voxel geometry module. A modified version of the EGS4/DOSXYZ code has been developed for this purpose. The new implementations have been validated against the BEAM Monte Carlo code using its standard component modules (CMs) in several geometrical conditions. No significant disagreements were found within the statistical errors of 0.5% for photons and 2% for electrons. The clinical applicability and flexibility of the new version of the code has been assessed through an extensive verification versus dosimetric data. Both Varian multi-leaf collimator (MLC) wedges and standard wedges have been simulated and compared against experiments for 6MV photon beams and different field sizes. Good agreement was found between calculated and measured depth doses and lateral dose profiles along both wedged and unwedged directions for different depths and focus-to-surface distances. Furthermore, Monte Carlo-generated output factors for both open and wedged fields agreed with linac commissioning beam data within statistical uncertainties of the calculations (<3% at largest depths). Compensating filters of both low-density and high-density materials have also been successfully simulated. As a demonstration, a wax compensating filter with a complex three-dimensional concave and convex geometry has been modelled through a CT scan import. Calculated depth doses and lateral dose profiles for different field sizes agreed well with experiments. The code was used to investigate the performance of a commercial treatment planning system in designing compensators. Dose distributions in a heterogeneous water phantom emulating the head and neck region were calculated with the convolution-superposition method (pencil beam and collapsed cone implementations) and compared against those from the MC code developed herein. The new technique presented in this work is versatile, DICOM-RT compliant and accurate in the simulation of beam modulators. This paper addresses the need to reduce the sources of error in the modelling of beam modifiers since they remain a viable alternative to the MLC technique in the delivery of IMRT beams.     

The impact of MLC transmitted radiation on EPID dosimetry for dynamic MLC beams

The purpose of this study was to experimentally quantify the change in response of an amorphous silicon (a-Si) electronic portal imaging device (EPID) to dynamic multileaf collimator (dMLC) beams with varying MLC-transmitted dose components and incorporate the response into a commercial treatment planning system (TPS) EPID prediction model. A combination of uniform intensity dMLC beams and static beams were designed to quantify the effect of MLC transmission on EPID response at the central axis of 10 x 10 cm2 beams, at off-axis positions using wide dMLC beam profiles, and at different field sizes. The EPID response to MLC transmitted radiation was 0.79 +/- 0.02 of the response to open beam radiation at the central axis of a 10 x 10 cm2 field. The EPID response to MLC transmitted radiation was further reduced relative to the open beam response with off-axis distance. The EPID response was more sensitive to field size changes for MLC transmitted radiation compared to open beam radiation by a factor of up to 1.17 at large field sizes. The results were used to create EPID response correction factors as a function of the fraction of MLC transmitted radiation, off-axis distance, and field size. Software was developed to apply the correction factors to each pixel in the TPS predicted EPID image. The corrected images agreed more closely with the measured EPID images in areas of intensity modulated fields with a large fraction of MLC transmission and, as a result the accuracy of portal dosimetry with a-Si EPIDs can be improved. Further investigation into the detector response function and the radiation source model are required to achieve improvements in accuracy for the general case.     

Optimization of combined electron and photon beams for breast cancer

Recently, intensity-modulated radiation therapy and modulated electron radiotherapy have gathered a growing interest for the treatment of breast and head and neck tumours. In this work, we carried out a study to combine electron and photon beams to achieve differential dose distributions for multiple target volumes simultaneously. A Monte Carlo based treatment planning system was investigated, which consists of a set of software tools to perform accurate dose calculation, treatment optimization, leaf sequencing and plan analysis. We compared breast treatment plans generated using this home-grown optimization and dose calculation software for different treatment techniques. Five different planning techniques have been developed for this study based on a standard photon beam whole breast treatment and an electron beam tumour bed cone down. Technique 1 includes two 6 MV tangential wedged photon beams followed by an anterior boost electron field. Technique 2 includes two 6 MV tangential intensity-modulated photon beams and the same boost electron field. Technique 3 optimizes two intensity-modulated photon beams based on a boost electron field. Technique 4 optimizes two intensity-modulated photon beams and the weight of the boost electron field. Technique 5 combines two intensity-modulated photon beams with an intensity-modulated electron field. Our results show that technique 2 can reduce hot spots both in the breast and the tumour bed compared to technique 1 (dose inhomogeneity is reduced from 34% to 28% for the target). Techniques 3, 4 and 5 can deliver a more homogeneous dose distribution to the target (with dose inhomogeneities for the target of 22%, 20% and 9%, respectively). In many cases techniques 3, 4 and 5 can reduce the dose to the lung and heart. It is concluded that combined photon and electron beam therapy may be advantageous for treating breast cancer compared to conventional treatment techniques using tangential wedged photon beams followed by a boost electron field.     

Beam modeling and verification of a photon beam multisource model

Dose calculations for treatment planning of photon beam radiotherapy require a model of the beam to drive the dose calculation models. The beam shaping process involves scattering and filtering that yield radiation components which vary with collimator settings. The necessity to model these components has motivated the development of multisource beam models. We describe and evaluate clinical photon beam modeling based on multisource models, including lateral beam quality variations. The evaluation is based on user data for a pencil kernel algorithm and a point kernel algorithm (collapsed cone) used in the clinical treatment planning systems Helax-TMS and Nucletron-Oncentra. The pencil kernel implementations treat the beam spectrum as lateral invariant while the collapsed cone involves off axis softening of the spectrum. Both algorithms include modeling of head scatter components. The parameters of the beam model are derived from measured beam data in a semiautomatic process called RDH (radiation data handling) that, in sequential steps, minimizes the deviations in calculated dose versus the measured data. The RDH procedure is reviewed and the results of processing data from a large number of treatment units are analyzed for the two dose calculation algorithms. The results for both algorithms are similar, with slightly better results for the collapsed cone implementations. For open beams, 87% of the machines have maximum errors less than 2.5%. For wedged beams the errors were found to increase with increasing wedge angle. Internal, motorized wedges did yield slightly larger errors than external wedges. These results reflect the increased complexity, both experimentally and computationally, when wedges are used compared to open beams.     

Partially wedged radiation beams

To increase dose homogeneity within certain radiotherapy targets, we defined a partially wedged radiation beam as a beam with wedge modification in one part of the field only. Partially wedged beams may be beneficial in cases with curved surfaces inside parts of the beam only, where they may compensate for missing tissue and/or for variations in depth to the target region. Possible sites suitable for partially wedged beams include urinary bladder and tangential breast irradiation. Customized partially wedged beams were delivered applying dynamic collimation techniques. Two different linear detector arrays, a semiconductor diode array and an ionization chamber array, were used independently in the same standard water tank to verify that the partially wedged beams were delivered according to the definition. Dose calculations of partial wedge fields were implemented in our treatment planning system and compared with the measured dose distributions. We re-planned a representative treatment plan for both advanced urinary bladder cancer and tangential breast irradiation using partially wedged beams. For both patients the target dose homogeneity was improved, and the doses to surrounding critical normal tissues were reduced.     

Verification of segmented beam delivery using a commercial electronic portal imaging device.

In modern radiotherapy, three-dimensional conformal dose distributions are achieved through the delivery of beam ports having precalculated planar distributions of photon beam intensity. Although sophisticated means to calculate and deliver these spatially modulated beams have been developed, means to verify their actual delivery are relatively cumbersome, making equipment and treatment quality assurance difficult to enforce. An electronic portal imaging device of the scanning liquid ionization chamber type yields images which, once calibrated from a previously determined calibration curve, provide highly precise planar maps of the incident dose rate. For verification of an intensity-modulated beam delivered in the segmented approach with a multileaf collimator, a portal image is acquired for each subfield of the leaf sequence. Subsequent to their calibration, the images are multiplied by their respective associated monitor unit settings, and summed to produce a planar dose distribution at the measurement depth in phantom. The excellent agreement of our portal imager measurements with calculations of our treatment planning system and measurements with a one-dimensional beam profiler attests to the usefulness of this method for the planar verification of intensity-modulated fields produced in the segmented approach on a computerized linear accelerator equipped with a multileaf collimator.     

A comparative dosimetric study on tangential photon beams,intensity-modulated radiation therapy (IMRT) and modulated electron radiotherapy (MERT) for breast cancer treatment

Recently, energy- and intensity-modulated electron radiotherapy (MERT) has garnered a growing interest for the treatment of superficial targets. In this work. we carried out a comparative dosimetry study to evaluate MERT, photon beam intensity-modulated radiation therapy (IMRT) and conventional tangential photon beams for the treatment of breast cancer. A Monte Carlo based treatment planning system has been investigated, which consists of a set of software tools to perform accurate dose calculation, treatment optimization, leaf sequencing and plan analysis. We have compared breast treatment plans generated using this home-grown treatment optimization and dose calculation software forthese treatment techniques. The MERT plans were planned with up to two gantry angles and four nominal energies (6, 9, 12 and 16 MeV). The tangential photon treatment plans were planned with 6 MV wedged photon beams. The IMRT plans were planned using both multiple-gantry 6 MV photon beams or two 6 MV tangential beams. Our results show that tangential IMRT can reduce the dose to the lung, heart and contralateral breast compared to conventional tangential wedged beams (up to 50% reduction in high dose volume or 5 Gy in the maximum dose). MERT can reduce the maximum dose to the lung by up to 20 Gy and to the heart by up to 35 Gy compared to conventional tangential wedged beams. Multiple beam angle IMRT can significantly reduce the maximum dose to the lung and heart (up to 20 Gy) but it induces low and medium doses to a large volume of normal tissues including lung, heart and contralateral breast. It is concluded that MERT has superior capabilities to achieve dose conformity both laterally and in the depth direction, which will be well suited for treating superficial targets such as breast cancer.     

Optimized dynamic rotation with wedges.

Dynamic rotation is a computer-controlled therapy technique utilizing an automated multileaf collimator in which the radiation beam shape changes dynamically as the treatment machine rotates about the patient so that at each instant the beam shape matches the projected shape of the target volume. In simple dynamic rotation, the dose rate remains constant during rotation. For optimized dynamic rotation, the dose rate is varied as a function of gantry angle. Optimum dose rate at each gantry angle is computed by linear programming. Wedges can be included in the optimized dynamic rotation therapy by using additional rotations. Simple and optimized dynamic rotation treatment plans, with and without wedges, for a pancreatic tumor have been compared using optimization cost function values, normal tissue complication probabilities, and positive difference statistic values. For planning purposes, a continuous rotation is approximated by static beams at a number of gantry angles equally spaced about the patient. In theory, the quality of optimized treatment planning solutions should improve as the number of static beams increases. The addition of wedges should further improve dose distributions. For the case studied, no significant improvements were seen for more than 36 beam angles. Open and wedged optimized dynamic rotations were better than simple dynamic rotation, but wedged optimized dynamic rotation showed no definitive improvement over open beam optimized dynamic rotation.     

Monte Carlo modelling of a virtual wedge

Compared with a set of physical photon wedges, a non physical wedge (virtual or dynamic wedge), realized by a moving collimator jaw, offers an alternative that allows creation of a wedged field with any arbitrary wedge angle instead of the traditional four physical wedges (15 degrees, 30 degrees, 45 degrees and 60 degrees). It is commonly assumed that non-physical wedges do not alter the photon spectrum compared with physical wedges that introduce beam hardening and loss of dose uniformity in the unwedged direction. In this study, we investigated the influence of a virtual wedge on the photon spectra of a 6-10 MV Siemens MD2 accelerator with the Monte Carlo code EGS4/BEAM. Good agreement was obtained between calculated and measured lateral dose profiles at the depth of maximum dose and at 10 cm depth for 20 x 20 cm2 fields for 6 and 10 MV photon beams. By comparing Monte Carlo models of a physical wedge and the virtual wedge that was studied in this work, it is confirmed that the latter has an insignificant effect on the beam quality, whereas the former can introduce significant beam hardening.     

Mixing intensity modulated electron and photon beams: combining a steep dose fall-off at depth with sharp and depth-independent penumbras and flat beam profiles.

For application in radiotherapy, intensity modulated high-energy electron and photon beams were mixed to create dose distributions that feature: (a) a steep dose fall-off at larger depths, similar to pure electron beams, (b) flat beam profiles and sharp and depth-independent beam penumbras, as in photon beams, and (c) a selectable skin dose that is lower than for pure electron beams. To determine the required electron and photon beam fluence profiles, an inverse treatment planning algorithm was used. Mixed beams were realized at a MM50 racetrack microtron (Scanditronix Medical AB, Sweden), and evaluated by the dose distributions measured in a water phantom. The multileaf collimator of the MM50 was used in a static mode to shape overlapping electron beam segments, and the dynamic multileaf collimation mode was used to realize the intensity modulated photon beam profiles. Examples of mixed beams were generated at electron energies of up to 40 MeV. The intensity modulated electron beam component consists of two overlapping concentric fields with optimized field sizes, yielding broad, fairly depth-independent overall beam penumbras. The matched intensity modulated photon beam component has high fluence peaks at the field edges to sharpen this penumbra. The combination of the electron and the photon beams yields dose distributions with the characteristics (a)-(c) mentioned above.     

The dosimetric verification of a pencil beam based treatment planning system

A new three-dimensional treatment planning system (TPS) based on convolution/superposition algorithms (TMS-Radix from HELAX AB, Uppsala, Sweden) was recently installed at the University Hospital in Lund. The purpose of the present study was to design a quality assurance and acceptance testing programme to meet the specific characteristics of this convolution model. The model is based on parametrization of a non-measurable quantity-the polyenergetic pencil beam. However, the verification of the treatment planning model is still dependent on numerous comparisons of measured depth-doses and dose profiles. The test programme was divided in two basic parts: (i) model implementation and beam data consistency and (ii) model performance and limitations in special situations. The first part was scheduled for all photon beam qualities available before they could be used for clinical treatment planning. The second part was performed for selected energies only. The results indicate clearly that the model is well suited for clinical three-dimensional dose planning and that the TPS handles data as expected. For example, calculated depth-doses for open and wedge beams at depths larger than the depth of dose maximum and profiles for open beams shows a very good agreement with measurements. However, depth-dose deviations at shallow depths, especially for high energies, were found. Monitor units calculated by the system were accurate for most fields except for very large fields, where deviations of several per cent were found.     

Verification of treatment parameter transfer by means of electronic portal dosimetry

Electronic portal imaging devices (EPIDs) are mainly used for patient setup verification during treatment but other geometric properties like block shape and leaf positions are also determined. Electronic portal dosimetry allows dosimetric treatment verification. By combining geometric and dosimetric information, the data transfer between treatment planning system (TPS) and linear accelerator can be verified which in particular is important when this transfer is not carried out electronically. We have developed a pretreatment verification procedure of geometric and dosimetric treatment parameters of a 10 MV photon beam using an EPID. Measurements were performed with a CCD camera-based iView EPID, calibrated to convert a greyscale EPID image into a two-dimensional absolute dose distribution. Central field dose calculations, independent of the TPS, are made to predict dose values at a focus-EPID distance of 157.5 cm. In the same EPID image, the presence of a wedge, its direction, and the field size defined by the collimating jaws were determined. The accuracy of the procedure was determined for open and wedged fields for various field sizes. Ionization chamber measurements were performed to determine the accuracy of the dose values measured with the EPID and calculated by the central field dose calculation. The mean difference between ionization chamber and EPID dose at the center of the fields was 0.8 +/- 1.2% (1 s.d.). Deviations larger than 2.5% were found for half fields and fields with a jaw in overtravel. The mean difference between ionization chamber results and the independent dose calculation was -0.21 +/- 0.6% (1 s.d.). For all wedged fields, the presence of the wedge was detected and the mean difference in actual and measured wedge direction was 0 +/- 3 degrees (1 s.d.). The mean field size differences in X and Y directions were 0.1 +/- 0.1 cm and 0.0 +/- 0.1 cm (1 s.d.), respectively. Pretreatment monitor unit verification is possible with high accuracy and also geometric parameters can be verified using the same EPID image.