Optimized treatment planning for prostate cancer comparing IMPT,VHEET and 15 MV IMXT

The merits of intensity-modulated very-high energy electron therapy (VHEET) and intensity-modulated proton therapy (IMPT) in relation to intensity-modulated x-ray therapy (IMXT) with respect to the treatment of the prostate have been quantified. Optimized dose distributions were designed for 5-11 beams of 250 MeV VHEET and 15 MV IMXT as well as 1-9 beam ports of IMPT. In the case of the comparison between 250 MeV VHEET and 15 MV IMXT, it was found that the quality of target coverage achievable with VHEET was comparable to or sometimes better than that provided by IMXT. However, VHEET provided an improvement over IMXT in the dose sparing of the sensitive structures and normal tissues. Compared to IMXT, VHEET decreased the mean rectal dose and bladder dose by up to 10% of the prescribed target dose, while reducing by up to 12% of the prescribed target dose the integral dose to normal tissues. In quantifying the merits of IMPT relative to IMXT, it was found that using intensity-modulated proton beams for inverse planning instead of intensity-modulated photon beams improved target dose homogeneity by up to 1.3% of the prescribed target dose, while reducing the mean rectal dose, bladder dose, and normal tissue integral dose by up to 27%, 30% and 28% of the prescribed target dose respectively. The comparison of optimized planning for IMPT and VHEET showed that the quality of target coverage achievable with IMPT is comparable to or better (by up to 1.3% of the prescribed target dose) than that provided by VHEET. Compared to VHEET, IMPT delivered a mean rectal dose and a bladder dose that was lower by up to 17% and 23% of prescribed target dose respectively, and also reduced the integral dose to normal tissues by up to 17% of the prescribed target dose. These results indicate that of the three modalities the greatest dose escalation will be possible with IMPT, then VHEET, and then IMXT. It follows that IMPT will result in the highest probability of complication-free tumour control, while IMXT will provide the lowest probability.     

Intensity and energy modulated radiotherapy with proton beams: variables affecting optimal prostate plan

Inverse planning for intensity- and energy-modulated radiotherapy (IEMRT) with proton beams involves the selection of (i) the relative importance factors to control the relative importance of the target and sensitive structures, (ii) an appropriate energy resolution to achieve an acceptable depth modulation, (iii) an appropriate beamlet width to modulate the beam laterally, and (iv) a sufficient number of beams and their orientations. In this article we investigate the influence of these variables on the optimized dose distribution of a simulated prostate cancer IEMRT treatment. Good dose conformation for this prostate case was achieved using a constellation of I factors for the target, rectum, bladder, and normal tissues of 500, 50, 15, and 1, respectively. It was found that for an active beam delivery system, the energy resolution should be selected on the basis of the incident beams' energy spread (sigmaE) and the appropriate energy resolution varied from 1 MeV at sigmaE = 0.0 to 5 MeV at sigmaE= 2.0 MeV. For a passive beam delivery system the value of the appropriate depth resolution for inverse planning may not be critical as long as the value chosen is at least equal to one-half the FWHM of the primary beam Bragg peak. Results indicate that the dose grid element dimension should be equal to or no less than 70% of the beamlet width. For this prostate case, we found that a maximum of three to four beam ports is required since there was no significant advantage to using a larger number of beams. However for a small number (< or = 4) of beams the selection of beam orientations, while having only a minor effect on target coverage, strongly influenced the sensitive structure sparing and normal tissue integral dose.     

Comparative analysis of 60Co intensity-modulated radiation therapy

In this study, we perform a scientific comparative analysis of using (60)Co beams in intensity-modulated radiation therapy (IMRT). In particular, we evaluate the treatment plan quality obtained with (i) 6 MV, 18 MV and (60)Co IMRT; (ii) different numbers of static multileaf collimator (MLC) delivered (60)Co beams and (iii) a helical tomotherapy (60)Co beam geometry. We employ a convex fluence map optimization (FMO) model, which allows for the comparison of plan quality between different beam energies and configurations for a given case. A total of 25 clinical patient cases that each contain volumetric CT studies, primary and secondary delineated targets, and contoured structures were studied: 5 head-and-neck (H&N), 5 prostate, 5 central nervous system (CNS), 5 breast and 5 lung cases. The DICOM plan data were anonymized and exported to the University of Florida optimized radiation therapy (UFORT) treatment planning system. The FMO problem was solved for each case for 5-71 equidistant beams as well as a helical geometry for H&N, prostate, CNS and lung cases, and for 3-7 equidistant beams in the upper hemisphere for breast cases, all with 6 MV, 18 MV and (60)Co dose models. In all cases, 95% of the target volumes received at least the prescribed dose with clinical sparing criteria for critical organs being met for all structures that were not wholly or partially contained within the target volume. Improvements in critical organ sparing were found with an increasing number of equidistant (60)Co beams, yet were marginal above 9 beams for H&N, prostate, CNS and lung. Breast cases produced similar plans for 3-7 beams. A helical (60)Co beam geometry achieved similar plan quality as static plans with 11 equidistant (60)Co beams. Furthermore, 18 MV plans were initially found not to provide the same target coverage as 6 MV and (60)Co plans; however, adjusting the trade-offs in the optimization model allowed equivalent target coverage for 18 MV. For plans with comparable target coverage, critical structure sparing was best achieved with 6 MV beams followed closely by (60)Co beams, with 18 MV beams requiring significantly increased dose to critical structures. In this paper, we report in detail on a representative set of results from these experiments. The results of the investigation demonstrate the potential for IMRT radiotherapy employing commercially available (60)Co sources and a double-focused MLC. Increasing the number of equidistant beams beyond 9 was not observed to significantly improve target coverage or critical organ sparing and static plans were found to produce comparable plans to those obtained using a helical tomotherapy treatment delivery when optimized using the same well-tuned convex FMO model. While previous studies have shown that 18 MV plans are equivalent to 6 MV for prostate IMRT, we found that the 18 MV beams actually required more fluence to provide similar quality target coverage.     

Intensity modulated radiation therapy using laser-accelerated protons: a Monte Carlo dosimetric study

In this paper we present Monte Carlo studies of intensity modulated radiation therapy using laser-accelerated proton beams. Laser-accelerated protons coming out of a solid high-density target have broad energy and angular spectra leading to dose distributions that cannot be directly used for therapeutic applications. Through the introduction of a spectrometer-like particle selection system that delivers small pencil beams of protons with desired energy spectra it is feasible to use laser-accelerated protons for intensity modulated radiotherapy. The method presented in this paper is a three-dimensional modulation in which the proton energy spectrum and intensity of each individual beamlet are modulated to yield a homogeneous dose in both the longitudinal and lateral directions. As an evaluation of the efficacy of this method, it has been applied to two prostate cases using a variety of beam arrangements. We have performed a comparison study between intensity modulated photon plans and those for laser-accelerated protons. For identical beam arrangements and the same optimization parameters, proton plans exhibit superior coverage of the target and sparing of neighbouring critical structures. Dose-volume histogram analysis of the resulting dose distributions shows up to 50% reduction of dose to the critical structures. As the number of fields is decreased, the proton modality exhibits a better preservation of the optimization requirements on the target and critical structures. It is shown that for a two-beam arrangement (parallel-opposed) it is possible to achieve both superior target coverage with 5% dose inhomogeneity within the target and excellent sparing of surrounding tissue.     

Feasibility study of beam orientation class-solutions for prostate IMRT

IMRT is being increasingly used for treatment of prostate cancer. In practice, however, the beam orientations used for the treatments are still selected empirically, without any guideline. The purpose of this work was to investigate interpatient variation of the optimal beam configuration and to facilitate intensity modulated radiation therapy (IMRT) prostate treatment planning by proposing a set of beam orientation class-solutions for a range of numbers of incident beams. We used fifteen prostate cases to generate the beam orientation class-solutions. For each patient and a given number of incident beams, a multiobjective optimization engine was employed to provide optimal beam directions. For the fifteen cases considered, the gantry angle of any of the optimized plans were all distributed within a certain range The angular distributions of the optimal beams were analyzed and the most selected directions are identified as optimal directions. The optimal directions for all patients are averaged to obtain the class-solution. The class-solution gantry angles for prostate IMRT were found to be: three beams (0 degrees, 120 degrees, 240 degrees), five beams (35 degrees, 110 degrees, 180 degrees, 250 degrees, 325 degrees), six beams (0 degrees, 60 degrees, 120 degrees, 180 degrees, 240 degrees, 300 degrees), seven beams (25 degrees, 75 degrees, 130 degrees, 180 degrees, 230 degrees, 285 degrees, 335 degrees), eight beams (20 degrees, 70 degrees, 110 degrees, 150 degrees, 200 degrees, 250 degrees, 290 degrees, 340 degrees), and nine beams (20 degrees, 60 degrees, 100 degrees, 140 degrees, 180 degrees, 220 degrees, 260 degrees, 300 degrees, 340 degrees). The level of validity of the class-solutions was tested using an additional clinical prostate case by comparing with the individually optimized beam configurations. The difference between the plans obtained with class-solutions and patient-specific optimizations was found to be clinically insignificant.     

Determining optimal two-beam axial orientations for heart sparing in left-sided breast cancer patients

BACKGROUND AND PURPOSE: The optimal intensity fluence profile of a beam depends on the profiles of other beams but most optimizations assume fixed beam orientations, a priori. Breast cancer radiotherapy attempts to cover the target and to spare critical structures such as the heart and lungs. The study aims are (1) to determine and document the optimal two-beam orientation that best spares the heart for left-sided breast cancer patients and (2) to investigate the influence of the treatment technique (i.e., conformal versus intensity modulation) on the optimal objective cost function. MATERIAL AND METHODS: Ten left-sided breast cancer patients were planned using a conformal (3DCRT) and a simplified intensity modulated (sIMRT) technique using predefined segments and different two-beam orientations. Optimal segment weights were determined exhaustively for all axial two-beam combinations, in 5 degree increments, by minimizing a quadratic objective cost function. The resulting objective cost function was analyzed with respect to target geometry and treatment technique. RESULTS: The sIMRT plans are generally less sensitive to beam orientation compared to 3DCRT plans. Optimal two-beam orientations for 3DCRT and sIMRT plans exist and they correspond to a hinge angle of approximately 188 degrees and 160 degrees or 210 degrees (the latter is bimodal), respectively. CONCLUSIONS: The optimization software is a useful tool that can test many different beam combinations and estimate their associated objective cost values. Afterwards, the most promising beam orientations could be re-optimized under the TPS to fine-tune and verify the dose distributions. Optimal uniform two-beam orientations for the breast consist of opposing tangential medial and lateral beams. Optimal nonuniform two-beam orientations for left-sided breast cancers are bimodal, containing hinge angles around 160 degrees and 210 degrees. Nonuniform beam techniques are less sensitive to beam orientation compared to uniform beam techniques and result in significantly improved heart sparing but at a cost of slightly compromised planning target volume coverage.     

Computer-assisted selection of coplanar beam orientations in intensity-modulated radiation therapy

In intensity-modulated radiation therapy (IMRT), the incident beam orientations are often determined by a trial and error search. The conventional beam's-eye view (BEV) tool becomes less helpful in IMRT because it is frequently required that beams go through organs at risk (OARs) in order to achieve a compromise between the dosimetric objectives of the planning target volume (PTV) and the OARs. In this paper, we report a beam's-eye view dosimetrics (BEVD) technique to assist in the selection of beam orientations in IMRT. In our method, each beam portal is divided into a grid of beamlets. A score function is introduced to measure the 'goodness' of each beamlet at a given gantry angle. The score is determined by the maximum PTV dose deliverable by the beamlet without exceeding the tolerance doses of the OARs and normal tissue located in the path of the beamlet. The overall score of the gantry angle is given by a sum of the scores of all beamlets. For a given patient. the score function is evaluated for each possible beam orientation. The directions with the highest scores are then selected as the candidates for beam placement. This procedure is similar to the BEV approach used in conventional radiation therapy, except that the evaluation by a human is replaced by a score function to take into account the intensity modulation. This technique allows one to select beam orientations without the excessive computing overhead of computer optimization of beam orientation. It also provides useful insight into the problem of selection of beam orientation and is especially valuable for complicated cases where the PTV is surrounded by several sensitive structures and where it is difficult to select a set of 'good' beam orientations. Several two-dimensional (2D) model cases were used to test the proposed technique. The plans obtained using the BEVD-selected beam orientations were compared with the plans obtained using equiangular spaced beams. For all the model cases investigated, the use of BEVD-selected beam orientations improved the dose distributions significantly. These examples indicate that the technique has considerable potential for simplifying the IMRT treatment planning process and allows for better utilization of the technical capacity of IMRT.     

Dose calculation validation of Vmc++ for photon beams

The radiation therapy specific Voxel Monte Carlo (VMC+ +) dose calculation algorithm achieves a dramatic improvement in MC dose calculation efficiency for radiation therapy treatment planning dose evaluation compared with other MC algorithms. This work aims to validate VMC+ + for radiation therapy photon beam planning. VMC++ was validated with respect to the well-benchmarked EGS-based DOSXYZnrc by comparing depth dose and lateral profiles for field sizes ranging from 1 X 1 to 40 x 40 cm(2) for 6 and 18 MV beams in a homogeneous water phantom and in a simulated bone-lung-bone phantom. Patient treatment plan dose distributions were compared for five prostate plans and five head-and-neck (H/N) plans, all using intensity-modulated radiotherapy beams. For all tests, the same incident particles were used in both codes to isolate differences due to modeling of the radiation source. Voxel-by-voxel observed differences were analyzed to distinguish between systematic and purely statistical differences. Dose-volume-histogram-derived dose indices were compared for the patient plans. For the homogeneous water phantom and the bone-lung-bone phantom, the depth dose curve predicted by VMC+ + agreed with that predicted by DOSXYZnrc within expected statistical uncertainty in all voxels except the surface voxel of the water phantom, where VMC+ + predicted a lower dose. When the electron cutoff parameter was decreased for both codes, the surface voxel agreed within expected statistical uncertainty. For prostate plans, the most severe difference between the codes resulted in 55% of the voxels showing a systematic difference of 0.32% of maximum dose. For H/N plans, the largest difference observed resulted in 2% of the voxels showing a systematic difference of 0.98% of maximum dose. For the prostate plans, the most severe difference in the planning target volume D95 was 0.4%, the rectum D35 was 0.2%, the rectum DI7 was 0.2%, the bladder D50 was 0.3% and the bladder D25 was 0.3%. For the H/N plans, the most severe difference in the gross tumor volume D98 was 0.4%, the clinical target volume D90 was 0.2%, the nodes D90 was 0.2%, the parotids D95 was 0.8%, and the cord D2 was 0.8%. All of these differences are clinically insignificant. VMC++ showed an average efficiency gain over DOSXYZnrc of at least an order of magnitude without introducing significant systematic bias. VMC + + can be used for photon beam MC patient dose computations without a clinically significant loss in accuracy.     

Characteristics of the high-energy photon beam of a 25-MeV accelerator

The CGR Saturne 25 is an isocentrically mounted standing wave medical linear accelerator that produces dual-energy photon beams and a scanned electron beam with six selectable energies between 4 and 25 MeV. The highest energy photon beam is nominally referred to as 23 MV. For this beam the mean energy of the accelerated electron beam on the 1.3 radiation length (4 mm) tungsten x-ray target is found to be approximately 21 MeV, with the energy acceptance stated to be +/- 5%. The electron beam traverses a 270 degrees bending magnet upstream of the x-ray production target. The resulting bremsstrahlung beam passes through a combination steel and lead flattening filter, 4-cm maximum thickness. Dosimetric data for the 23-MV beam are presented with respect to rectangular field output factor, depth of maximum dose as a function of field size, surface and buildup dose, central axis percent depth dose, tissue-phantom ratios, beam profile, applicability of inverse square, and block transmission. Some data are also presented on the effect of different flattening filter designs on apparent beam energy.     

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.     

Dosimetric characteristics of acrylic and stainless steel cones for electron beam therapy.

Dosimetric characteristics of acrylic and stainless steel cones for electron beam therapy were investigated. Acrylic and stainless steel cylindrical cones of 6, 7, and 8 cm in diameter and electron beams of energies 6, 9, 12, 15, 18, and 21 MeV were used for the measurements. Both acrylic and stainless steel cones showed high dose areas along the rim. The dose along the rim grew with increasing electron beam energy. The highest dose along the rim was 115% of the maximum dose on a central axis when a 6-cm-diameter acrylic cone and 21-MeV electrons were combined.     

Constrained customization of non-coplanar beam orientations in radiotherapy of brain tumours

A methodology for the constrained customization of non-coplanar beam orientations in radiotherapy treatment planning has been developed and tested on a cohort of five patients with tumours of the brain. The methodology employed a combination of single and multibeam cost functions to produce customized beam orientations. The single-beam cost function was used to reduce the search space for the multibeam cost function, which was minimized using a fast simulated annealing algorithm. The scheme aims to produce well-spaced, customized beam orientations for each patient that produce low dose to organs at risk (OARs). The customized plans were compared with standard plans containing the number and orientation of beams chosen by a human planner. The beam orientation constraint-customized plans employed the same number of treatment beams as the standard plan but with beam orientations chosen by the constrained-customization scheme. Improvements from beam orientation constraint-customization were studied in isolation by customizing the beam weights of both plans using a dose-based downhill simplex algorithm. The results show that beam orientation constraint-customization reduced the maximum dose to the orbits by an average of 18.8 (+/-3.8, ISD)% and to the optic nerves by 11.4 (+/-4.8, ISD)% with no degradation of the planning target volume (PTV) dose distribution. The mean doses, averaged over the patient cohort, were reduced by 4.2 (+/-1.1, ISD)% and 12.4 (+/-3.1, ISD)% for the orbits and optic nerves respectively. In conclusion, the beam orientation constraint-customization can reduce the dose to OARs, for few-beam treatment plans, when compared with standard treatment plans developed by a human planner.     

Higher energy: is it necessary, is it worth the cost for radiation oncology?

The physical characteristics of the interactions of megavoltage photons and electrons with matter provide distinct advantages, relative to low-energy (orthovoltage) x rays, that lead to better radiation dose distributions in patients. Use of these high-energy radiations has resulted in better patient care, which has been reflected in improved radiation treatment outcome in recent years. But, as the desire for higher energy radiation beams increases, it becomes important to determine whether the physical characteristics that make megavoltage beams beneficial continue to provide a net advantage. It is demonstrated that, in fact, there is an energy range from 4 to 15 MV for photons and 4 to 20 MeV for electrons that is optimally suited for the treatment of cancer in humans. Radiation beams that exceed these maximum energies were found to add no advantage. This is because the costs (price of unit, installation, maintenance, shielding for neutron and photons) are not justified by either improved physical characteristics of the radiation (penetration, skin sparing, dose distribution) or treatment outcome. In fact, for photon beams some physical characteristics result in less desirable dose distributions, less accurate dosimetry, and increased safety problems as the energy increases for example, increasingly diffuse beam edges, loss of electron equilibrium, uncertainty in dose perturbations at interfaces, increased neutron contamination, and potential for higher personnel dose. The special features that make electron beams useful at lower energies, for example, skin sparing and small penetration, are lost at high energies. These physical factors are analyzed together with the economic factors related to radiation therapy patient care using megavoltage beams.     

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.     

Selecting beam weight and wedge filter on the basis of dose gradient analysis

This study proposes an algorithm for selecting beam weight, wedge angle, and wedge orientation for three-dimensional radiation therapy treatment planning. According to dose gradient analysis, the necessary and sufficient condition for achieving a homogeneous dose over the target volume is that the total vector sum of the dose gradients of all beams be zero everywhere in the target volume. This study presents equations for calculating the beam weight, wedge angle, and collimator angle (because the collimator angle determines wedge orientation when beam direction is known) for treatment plans using two angled beams or three coplanar or noncoplanar beams. It also provides suggestions for calculations of treatment plans using more than three beams, for which many feasible solutions will be available. When tested using two clinical cases, this algorithm achieved homogeneous dose distributions over target volumes. With this algorithm, repeated manual adjustments are reduced, and the quality and efficiency of treatment planning are improved.     

Improvement of a p(65)+Be neutron beam for therapy at Cyclone, Louvain-la-Neuve

The variable energy cyclotron of the Catholic University of Louvain is used to produce intense neutron beams for neutron therapy purposes. As a first step, neutrons were produced by bombarding a Be target with 50 MeV deuterons; at present they are produced by 65 MeV protons. This paper describes the improvements to the target system. A new (17 mm) Be target together with the old (10 mm) Be target are inserted in a movable support which allows the production of neutrons either by 65 MeV protons or by 50 MeV deuterons. Both targets can be removed for proton beam therapy. The dosimetric characteristics of the p(65)+Be and d(50)+Be neutron beams are compared: dose rate, gamma-contribution, depth dose and room activation.