Electron radiotherapy: a study on dosimetric uncertainty using small cutouts

This note investigated the dosimetric uncertainties due to the positional error when centring a small cutout to the machine central beam axis (CAX) in electron radiotherapy. A group of six circular cutouts with 4 cm diameter were made with their centres shifting 0, 2, 4, 6, 8 and 10 mm from the machine CAX for the 6 x 6 cm(2) applicator. The per cent depth doses, beam profiles and output factors were measured using the 4, 9 and 16 MeV clinical electron beams produced by a Varian 21 EX linear accelerator. The 2D isodose distributions in the z-x (or cross-line) and z-y (or in-line) plane were calculated by Monte Carlo simulation using the EGSnrc system. When the cutout centre was shifted away from the machine CAX for the 4 MeV beam, the d(m), R(80) and R(90) at the machine CAX had no significant change (<0.1 mm). For higher energies of 9 and 16 MeV beams, the d(m) was reduced by 0.45 and 1.63 mm per mm, between the cutout centre and the machine CAX with off-axis shift <6 mm respectively. R(80) and R(90) were reduced by more than 0.3 mm per mm off-axis shift for both energies. The isodose coverage of the in-line axis beam profile was reduced when the cutout centre was shifted away from machine CAX. It is important for oncology staff to note such dosimetric changes in the clinical electron radiotherapy, particularly when a high energy electron beam is used for small cutout. Such positional uncertainty is unavoidable in fabricating an electron cutout in the mould room.     

Peripheral dose outside applicators in electron beams

The peripheral dose outside the applicators in electron beams was studied using a Varian 21 EX linear accelerator. To measure the peripheral dose profiles and point doses for the applicator, a solid water phantom was used with calibrated Kodak TL films. Peak dose spot was observed in the 4 MeV beam outside the applicator. The peripheral dose peak was very small in the 6 MeV beam and was ignorable at higher energies. Using the 10 x 10 cm(2) cutout and applicator, the dose peak for the 4 MeV beam was about 12 cm away from the field central beam axis (CAX) and the peripheral dose profiles did not change with depths measured at 0.2, 0.5 and 1 cm. The peripheral doses and profiles were further measured by varying the angle of obliquity, cutout and applicator size for the 4 MeV beam. The local peak dose was increased with about 3% per degree angle of obliquity, and was about 1% of the prescribed dose (angle of obliquity equals zero) at 1 cm depth in the phantom using the 10 x 10 cm(2) cutout and applicator. The peak dose position was also shifted 7 mm towards the CAX when the angle of obliquity was increased from 0 to 15 degrees.     

Small-field electron dosimetry for the Philips SL25 linear accelerator

Electron-beam characteristics of a Philips SL25 linear accelerator have been studied. Central-axis percentage depth doses, cross-beam profiles and beam output factors of 6-, 10-, and 20-MeV beams, selected from the available energy range of 4 to 22 MeV, are reported in this paper. The main thrust of this work is to determine the systematic variation of beam characteristics, especially the output factor, with standard cone sizes and cerrobend beam-shaping cutouts down to a field size of 2 X 2 cm Output factors for the standard cones (open field) are energy dependent in a complex manner, increasing with the cone size for the 6-MeV beam whereas decreasing for 10- and 20-MeV beams. The output factor falls below unity at lower energies (6 and 10 MeV) for fields with at least one side smaller than 6 cm, and stays nearly constant for the 20-MeV beam. Measured output factors of small fields are least squares fitted by a second-order polynomial function. Output factors for small rectangular fields have been derived from the one-dimensional and square-root formulas, and the equivalent-square method. Only the one-dimensional formula predicts the measured output factors of highly elongated fields to within +/- 1% experimental uncertainties. Different cones with the same size electron cutout show a varied dose response, primarily due to variation in scattered electron contamination from the cones.     

Manual multi-leaf collimator for electron beam shaping--a feasibility study

In electron beam therapy, lead or low melting point alloy (LMA) sheet cutouts of sufficient thickness are commonly used to shape the beam. In order to avoid making cutouts for each patient, an attempt has been made to develop a manual multi-leaf collimator for electron beams (eMLC). The eMLC has been developed using LMA for a 15 x 15 cm2 applicator. Electron beam characteristics such as depth dose, beam profiles, surface dose, output factors and virtual source position with the eMLC have been studied and compared with those of an applicator electron beam. The interleaf leakage radiation has also been measured with film dosimetry. Depth dose values obtained using the eMLC were found to be identical to those with the applicator for depths larger than Dmax. However, a decrease in the size of the beam penumbra with the eMLC and increase in the values of surface dose, output factors and virtual source position with eMLC were observed. The leakage between the leaves was less than 5% and the leakage between the opposing leaves was 15%, which could be minimized further by careful positioning of the leaves. It is observed that it is feasible to use such a manual eMLC for patients and eliminate the fabrication of cutouts for each patient.     

A two-source model for electron beams: calculation of relative output factors

A two-source model for the calculation of relative output factors (ROF) for clinical applications of electron beams has been developed. The model consists of (1) an effective extended source above the final field-defining aperture (cutout) plane and (2) a source due to scattering from the aperture. Calculations are based on Fermi-Eyges theory and a pencil beam algorithm with parameters determined independently for each major scattering component. The model predicts a modified inverse square law for determining the dose rate for the electron beams. It also generalizes the "square-root method" and "one-dimensional method" that are often used clinically for ROF calculations. A computer program based on the model has been developed to calculate ROF for irregular fields. The predictions of ROF values have been compared with measurements on a Varian CLINAC 2100C/D accelerator for different cutout size, energies, applicators, and SSDs for square fields, rectangular fields, circular fields, and irregular fields. The agreement between prediction and measurement of the ROF for these wide range of conditions is generally within 1% for energies from 6 to 20 MeV. This two-source model can be used for clinical applications and it requires a minimal set of measured input data.     

Depth dose characteristics of elongated fields for electron beams from a 20-MeV accelerator

In a Therac-20 linear accelerator, 6-20 MeV electron beams are normally produced by shaping a scanned electron beam through primary x-ray collimators and secondary electron trimmers. The collimator settings range continuously from 2 to 30 cm. Depth dose and field flatness parameters were measured for small elongated fields of the various electron energies. Depth dose of narrow fields defined either by the machine's collimator or lead cutouts agreed with data predicted from small square fields using the "square-root" method.     

Leakage radiation from electron applicators on a medical accelerator

The leakage characteristics of electron applicators on our Clinac 2500 linear accelerator have been measured. The leakage radiation in the patient plane and at the surface of the electron applicators has been measured for applicator sizes from 6 cm X 6 cm to 25 cm X 25 cm and beam energies from 6 to 22 MeV. For certain applicator/energy combinations the leakage radiation was significant. The leakage radiation, relative to the central axis dose, was found to be up to 7% in the patient plane and up to 39% at the applicator surface. Reducing the collimator setting or adding lead at select locations on the applicator surface was effective in reducing the magnitude of the radiation leakage.     

Calculation of lateral buildup ratio using Monte Carlo simulation for electron radiotherapy

Monte Carlo simulation was used to calculate the lateral buildup ratio (LBR) used in estimating the percentage depth dose (PDD) and dose per monitor unit for an irregular shaped cutout field in electron radiotherapy. Monte Carlo code BEAMnrc/EGSnrc was used to build a simulation model for a Varian 21 EX linear accelerator producing clinical electron beams with energies of 4, 6, 9, 12, and 16 MeV. The model is optimized by adjusting the incident electron energy within the Monte Carlo simulation so that the calculated PDD curves agree with the measurement within +/-2%. The LBR is calculated from the PDD curves for different diameters of circular cutouts. Although Monte Carlo simulation requires a longer time to create a LBR database compared to measurement using scanning water tank and dosimeter, the simulation models for different electron energies, applicators, and cutouts are very similar. As the calculations can be carried out in a batch mode automatically run by a computer, human efforts in carrying out measurements in the treatment room and fabricating the circular cutouts in the mold room are greatly saved. Moreover, the simulation avoids human error in the experimental setup and can better handle the electron scattering affecting accuracy in the measurement. Using Monte Carlo simulation to calculate the LBR is proved to be useful in the commissioning of the electron beams for electron radiotherapy.     

Experimental verification and clinical implementation of a commercial Monte Carlo electron beam dose calculation algorithm

This study describes the modeling and the experimental verification and clinical implementation of the alpha release of Pinnacle3 Monte Carlo (MC) electron beam dose calculation algorithm for patient-specific treatment planning. The MC electron beam modeling was performed for beam energies ranging from 6 to 18 MeV from a Siemens (Primus) linear accelerator using standard-shaped electron applicators and 100 cm source-to-surface distance (SSD). The agreement between MC calculations and measurements was, on average, within 2% and 2 mm for all applicator sizes. However, differences of the order of 3%-4% were noted in the off-axis dose profiles for the largest applicator modeled and for all energies. Output factors were calculated for standard electron cones and square cutouts inserted in the 10 x 10 cm2 applicator for different SSDs and were found to be within 4% of measured data. Experimental verification of the MC electron beam model was carried out using an ionization chamber and film in solid-water slab and anthropomorphic phantoms containing bone and lung materials. Agreement between calculated and measured dose distributions was within +/-3%. Clinical comparison was performed in four patient treatment plans with lesions in highly irregular anatomies, such as the ear, face, and breast, where custom-designed bolus and field shaping blocks were used in the patient treatments. For comparison purposes, treatment planning was also performed using the conventional pencil beam (PB) algorithm with the Pinnacle3 treatment planning system. Differences between MC and PB dose calculations for the patient treatment plans were significant, particularly in anatomies where the target was in close proximity to low density tissues, such as lung and air cavities. Concerning monitor unit calculations, the largest differences obtained between MC and PB algorithms were between 4.0% and 5.0% for two patients treated with oblique beams and involving highly irregular surfaces, i.e., breast and cheek. Clinical results are reported for overall uncertainty values (averaged over voxels with doses >50% dosemax) ranging from 2% to 0.3% and calculations were performed using cubic voxels with side 0.3 cm. Timing values ranged from 2 min to 24.5 h, depending on the field size, beam energy, number, and thickness of computed tomography slices used to define the patient's anatomy for the overall uncertainty values mentioned above.     

Characterization of an extendable multi-leaf collimator for clinical electron beams

An extendable x-ray multi-leaf collimator (eMLC) is investigated for collimation of electron beams on a linear accelerator. The conventional method of collimation using an electron applicator is impractical for conformal, modulated and mixed beam therapy techniques. An eMLC would allow faster, more complex treatments with potential for reduction in dose to organs-at-risk and critical structures. The add-on eMLC was modelled using the EGSnrc Monte Carlo code and validated against dose measurements at 6-21 MeV with the eMLC mounted on a Siemens Oncor linear accelerator at 71.6 and 81.6 cm source-to-collimator distances. Measurements and simulations at 8.4-18.4 cm airgaps showed agreement of 2%/2 mm. The eMLC dose profiles and percentage depth dose curves were compared with standard electron applicator parameters. The primary differences were a wider penumbra and up to 4.2% reduction in the build-up dose at 0.5 cm depth, with dose normalized on the central axis. At 90 cm source-to-surface distance (SSD)--relevant to isocentric delivery--the applicator and eMLC penumbrae agreed to 0.3 cm. The eMLC leaves, which were 7 cm thick, contributed up to 6.3% scattered electron dose at the depth of maximum dose for a 10 × 10 cm2 field, with the thick leaves effectively eliminating bremsstrahlung leakage. A Monte Carlo calculated wedge shaped dose distribution generated with all six beam energies matched across the maximum available eMLC field width demonstrated a therapeutic (80% of maximum dose) depth range of 2.1-6.8 cm. Field matching was particularly challenging at lower beam energies (6-12 MeV) due to the wider penumbrae and angular distribution of electron scattering. An eMLC isocentric electron breast boost was planned and compared with the conventional applicator fixed SSD plan, showing similar target coverage and dose to critical structures. The mean dose to the target differed by less than 2%. The low bremsstrahlung dose from the 7 cm thick MLC leaves had the added advantage of reducing the mean dose to the whole heart. Isocentric delivery using an extendable eMLC means that treatment room re-entry and repositioning the patient for SSD set-up is unnecessary. Monte Carlo simulation can accurately calculate the fluence below the eMLC and subsequent patient dose distributions. The eMLC generates similar dose distributions to the standard electron applicator but provides a practical method for more complex electron beam delivery.     

Electron beam therapy at extended SSDs: an analysis of output correction factors for a Mitsubishi linear accelerator

The effects of extended source-to-surface distance (SSD) on the electron beam dose profiles were evaluated for various electron beam energies--6, 9, 12, 15 and 20 MeV-and the accuracy of various output correction methods was analysed on a Mitsubishi linear accelerator using a radiation field analyser (RFA). The dose fall-off region of the central axis depth-dose curves was nearly independent for SSDs up to 120 cm where as in the build-up region, a marginal reduction of surface dose was observed, particularly for lower energies and for smaller field sizes. Effective SSDs and virtual source distances were evaluated for field sizes ranging from 5 x 5 to 15 x 15 cm2 for various energies. Curve fitting was done with the measured outputs with various equations and coefficients were evaluated. The accuracy of the derived output correction factors by effective SSD, virtual source distance and curve-fit methods was assessed by evaluating correlation coefficients between the calculated and the measured values. The correlation coefficient was best with the linear-quadratic equation followed by the effective SSD method and the virtual source method. The output correction based on the linear-quadratic equation showed the best estimate of electron beam output at extended SSDs with an accuracy well within +/- 1%. The rapid reduction of dose due to the applicator-scattered component at d(max) point with an extended SSD was significant for the 5 x 5 cm2 applicator and lower energies.     

Determination of electron beam output factors for a 20-MeV linear accelerator

The demands of a busy clinic require that basic machine calculations be performed as accurately, rapidly, and simply as possible. For the electron beam of the Therac 20 Saturne linear accelerator, a method suitable for a programmable calculator is described to predict the dose output from the measurement of selected fields. One-dimensional output factors were measured; these are defined as output factors of rectangular fields where one side is always equal to the side of the square reference field. The output of an arbitrary rectangular field X, Y is given by the product of the output factors OF(X,Y) = OF(X,10) X OF(10,Y), where 10 is the side of the square reference field. The measured data indicate that the output of very large rectangular and square fields is underestimated using this method for the lower energies. A correction factor of the form CF = C X [(X - 10)(Y - 10)/(X - 10)(Y - 10) 1/2] results in agreement with measured data to within 1.5% for all energies.     

Levels of leakage radiation from electron collimators of a linear accelerator

The leakage radiation from electron applicators used with our linear accelerator has been measured. For the applicators 6 X 6 to 25 X 25 cm size, the leakage was measured in the plane of the patient and on the sides of the applicators with the available electron energies of 6, 9, 12, 15 and 18 MeV. The levels were significant. The highest leakage on the side was for the combination of 6 X 6-cm applicator and 9-MeV electrons (32%) and in the plane of the patient for 25 X 25-cm applicator with 18 MeV (10%) relative to the peak dose. Adding lead 1-2 mm, at appropriate locations inside the applicators has reduced the leakages to acceptable levels without affecting the beam parameters.     

高能电子线放射治疗的剂量学参数测量与分析

目的：对高能电子线总输出因子、百分深度剂量、深度剂量分布的剂量学参数进行测量并分析讨论。方法：在Varian23EX直线加速器上,利用9606剂量测量仪和0．6cc指型电离室测量不同能量、不同限光筒及不同射野下的输出剂量并作归一,得到我们所要的剂量学参数,然后分析数据。结果：总输出因子在不同能量下与正方形射野边长的关系可满足等式：y=a·e^bx＋c·e^dx。水模体百分剂量分布中,6MeV电子线各限光筒的90％、85％等剂量深度基本不变,9MeV-15MeV下90％、85％等剂量深度随着限光筒尺寸增大而变深。对于水模体的深度剂量分布情况,6MeV和12MeV能量的10cmx10cm、15cmxl5cm限光筒均整区内对称点的最大相对剂量差分别都为0．04％、O．03％。结论：通过测量掌握实际照射中的剂量学特点．对于电子线剂量的准确计算以及临床计划制定具有很大的参考价值。     

Using Monte Carlo simulations to commission photon beam output factors--a feasibility study

This study investigates the feasibility of using Monte Carlo methods to assist the commissioning of photon beam output factors from a medical accelerator. The Monte Carlo code, BEAMnrc, was used to model 6 MV and 18 MV photon beams from a Varian linear accelerator. When excellent agreements were obtained between the Monte Carlo simulated and measured dose distributions in a water phantom, the entire geometry including the accelerator head and the water phantom was simulated to calculate the relative output factors. Simulated output factors were compared with measured data, which consist of a typical commission dataset for the output factors. The measurements were done using an ionization chamber in a water phantom at a depth of 10 cm with a source-detector distance of 100 cm. Square fields and rectangular fields with widths and lengths ranging from 4 cm to 40 cm were studied. The result shows a very good agreement (< 1.5%) between the Monte Carlo calculated and the measured relative output factors for a typical commissioning dataset. The Monte Carlo calculated backscatter factors to the beam monitor chamber agree well with measured data in the literature. Monte Carlo simulations have also been shown to be able to accurately predict the collimator exchange effect and its component for rectangular fields. The information obtained is also useful to develop an algorithm for accurate beam modelling. This investigation indicates that Monte Carlo methods can be used to assist commissioning of output factors for photon beams.     

The dosimetric properties of an applicator system for intraoperative electron-beam therapy utilizing a Clinac-18 accelerator

A prototype electron applicator system providing circular and rectangular fields for use in intraoperative electron beam therapy with a Varian Clinac 18 linear accelerator has been fabricated. The dosimetric properties of this system for a variety of electron-beam energies, applicator sizes, and x-ray collimator settings was documented. Significant findings include: (a) surface dose values are in excess of 90% for electron energies of 12 MeV and above; (b) for the 18-MeV beam, the deepest depth where the central axis dose in 90% of its maximum value is in excess of 50 mm for circular applicators whose diameters are in excess of 5 cm; and (c) the treatment time to deliver 1000 rads "given dose" (at given dose rate of 300 MU/min) is on the order of 3-4 min. Cross-field behavior is acceptable for the intended application and x-ray contamination is less than 4% for any applicator/electron energy combination. A system for irregular field blocking and TLD verification dosimetry has been developed.     

Electron contamination from the lead cutout used in kilovoltage radiotherapy

In kilovoltage radiotherapy, low-energy electrons are generated on the lead cutout plate frequently used to shape the x-ray field. They can cause surface dose enhancement and affect the percentage depth dose (PDD) and cutout factor when these parameters are measured with a parallel plate chamber. Although many previous studies concerning a similar surface dose enhancement have suggested using a thin electron filter to eliminate the effect of these low-energy electrons, no details have been given regarding the adequacy of the filter. This paper describes the procedures required to test an electron filter for our Darpec 2000 superficial x-ray machine. A piece of plain paper was found to be an adequate electron filter, which could block all the low-energy electrons without affecting the PDD and cutout factor measurement. The surface dose enhancement caused by the presence of the cutout plate was studied with such a filter. The enhancement was found to increase with x-ray energy and decrease with cutout size as well as applicator size. At the highest x-ray energy in this study (120 kV, HVL 8.6 mmAl), the enhancement ranges from less than 1% for a 8 cm diameter cutout to a maximum of 14% for a 2 cm diameter cutout with a 10 cm applicator. For a 5 cm diameter applicator it ranges from about 1% to about 11%. The difference between the measured and predicted cutout factor displays similar characteristics. Since the low-energy electrons do not generate any useful treatment dose but their presence can lead to potential dosimetry problems, we suggest that a filter tested with the procedure described in this paper should be used when percentage depth dose and cutout factor for kilovoltage x-ray are measured with a parallel-plate chamber.     

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.     

The dosimetric properties of an intraoperative radiation therapy applicator system for a Mevatron-80

An applicator system for intraoperative radiation therapy has been fabricated which does not require physical docking with the accelerator. A dosimetric study has been completed which documents the properties of this system for a variety of electron beam energies, applicator sizes, collimator settings, both primary and secondary, and source-surface distance (SSD) settings. Sensitivity of the system to common misalignment errors was also determined. Results indicate (a) applicator leakage of less than 5%, (b) beam flatness to within plus or minus 5% at the dMAX with a single primary collimator setting, (c) smooth changes in output with cone size, beam energy and SSD, and (d) negligible changes in dose distributions within alignment errors permitted by the system.     

Monte Carlo simulation of large electron fields

Two Monte Carlo systems, EGSnrc and Geant4, the latter with two different 'physics lists,' were used to calculate dose distributions in large electron fields used in radiotherapy. Source and geometry parameters were adjusted to match calculated results to measurement. Both codes were capable of accurately reproducing the measured dose distributions of the six electron beams available on the accelerator. Depth penetration matched the average measured with a diode and parallel-plate chamber to 0.04 cm or better. Calculated depth dose curves agreed to 2% with diode measurements in the build-up region, although for the lower beam energies there was a discrepancy of up to 5% in this region when calculated results are compared to parallel-plate measurements. Dose profiles at the depth of maximum dose matched to 2-3% in the central 25 cm of the field, corresponding to the field size of the largest applicator. A 4% match was obtained outside the central region. The discrepancy observed in the bremsstrahlung tail in published results that used EGS4 is no longer evident. Simulations with the different codes and physics lists used different source energies, incident beam angles, thicknesses of the primary foils, and distance between the primary and secondary foil. The true source and geometry parameters were not known with sufficient accuracy to determine which parameter set, including the energy of the source, was closest to the truth. These results underscore the requirement for experimental benchmarks of depth penetration and electron scatter for beam energies and foils relevant to radiotherapy.