Investigation of the relative surface dose from Lipowitz-metal tissue compensators for 24- and 6-MV photon beams

Our radiation therapy department has acquired a tissue compensator system for construction of patient-specific Lipowitz-metal tissue compensators. Since the arrival of this apparatus its use has been limited due to the observance of marked skin reactions located directly beneath the area of the compensator. Although there has been extensive literature on the dose distribution of these metal compensators, there is little data on the effects to the skin for energies greater than 10 MV. Determination of the relative surface dose from Lipowitz-metal tissue compensators is herein investigated for 24- and 6-MV x-ray beams. Effects of field size, source-to-skin distance and thickness of compensator are evaluated as well as the effect of the Lexan tray which supports the compensator during treatment.     

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.     

Compensators for dose and scatter management in cone-beam computed tomography

The ability of compensators (e.g., bow-tie filters) designed for kV cone-beam computed tomography (CT) to reduce both scatter reaching the detector and dose to the patient is investigated. Scattered x rays reaching the detector are widely recognized as one of the most significant challenges to cone-beam CT imaging performance. With cone-beam CT gaining popularity as a method of guiding treatments in radiation therapy, any methods that have the potential to reduce the dose to patients and/or improve image quality should be investigated. Simple compensators with a design that could realistically be implemented on a cone-beam CT imaging system have been constructed to determine the magnitude of reduction of scatter and/or dose for various cone-beam CT imaging conditions. Depending on the situation, the compensators were shown to reduce x-ray scatter at the detector and dose to the patient by more than a factor of 2. Further optimization of the compensators is a possibility to achieve greater reductions in both scatter and dose.     

The value of EDR2 film dosimetry in compensator-based intensity modulated radiation therapy

Radiographic or silver halide film is a well-established 2D dosimeter with an unquestioned spatial resolution. But its higher sensitivity to low-energy photons has to be taken into consideration. Metal compensators or physical modulators to deliver intensity modulated radiation therapy (IMRT) are known to change the beam energy spectrum and to produce scattered photons and contaminating electrons. Therefore the reliability of film dosimetry in compensator-based IMRT might be questioned. Conflicting data have been reported in the literature. This uncertainty about the validity of film dosimetry in compensator-based IMRT triggered us to conduct this study. First, the effect of MCP-96 compensators of varying thickness on the depth dose characteristics was investigated using a diamond detector which has a uniform energy response. A beam hardening effect was observed at 6 MV that resulted in a depth dose increase that remained below 2% at 20 cm depth. At 25 MV, in contrast, beam softening produced a dose decrease of up to 5% at the same depth. Second, dose was measured at depth using EDR2 film in perpendicular orientation to both 6 MV and 25 MV beams for different compensator thicknesses. A film dose underresponse of 1.1% was found for a 30 mm thick block in a 25 MV beam, which realized a transmission factor of 0.243. The effect induced by the compensators is higher than the experimental error but still within the accepted overall uncertainty of film dosimetry in clinical IMRT QA. With radiographic film as an affordable QA tool, the physical compensator remains a low threshold technique to deliver IMRT.     

Intensity modulated irradiation of a thorax phantom: comparisons between measurements, Monte Carlo calculations and pencil beam calculations.

The present study investigates the application of compensators for the intensity modulated irradiation of a thorax phantom. Measurements are compared with Monte Carlo and standard pencil beam algorithm dose calculations. Compensators were manufactured to produce the intensity profiles that were generated from the scientific version of the KonRad IMRT treatment-planning system for a given treatment plan. The comparison of dose distributions calculated with a pencil beam algorithm, with the Monte Carlo code EGS4 and with measurements is presented. By measurements in a water phantom it is demonstrated that the method used to manufacture the compensators reproduces the intensity profiles in a suitable manner. Monte Carlo simulations in a water phantom show that the accelerator head model used for simulations is sufficient. No significant overestimations of dose values inside the target volume by the pencil beam algorithm are found in the thorax phantom. An overestimation of dose values in lung by the pencil beam algorithm is also not found. Expected dose calculation errors of the pencil beam algorithm are suppressed, because the dose to the low density region lung is reduced by the use of a non-coplanar beam arrangement and by intensity modulation.     

Accuracy of dose calculation methods for retracted tissue compensators

Uncertainties arise in dose calculations involving retracted tissue compensators due to the effects of the compensator upon the scatter component of the dose. Many commercial treatment-planning systems cannot allow directly for the presence of a compensator in isodose calculation or else use simple 2D methods. We present data to test calculation accuracy for a wax compensation system by comparing retraction factors measured along central-axis and off-axis raylines for a variety of compensator shapes, with those derived using effective attenuation coefficient and 3D analytical calculations. The accuracy of using measured uniform-thickness retraction factors for non-uniform shapes and the dose uniformity achievable using a simple compensation system are also discussed. We conclude that the accuracy of simple calculation methods is shape dependent and that calculation errors and dose variations can exceed +/-5% where missing-tissue thickness variations are large. The analytical method is shown to give good agreement with experiment and indicates that it should be possible to adapt algorithms that calculate scatter from the patient for use with compensators.     

A packed building-block compensator (TETRIS-RT) and feasibility for IMRT delivery

A packed building-block compensator (TETRIS-RT) for IMRT (Intensity Modulated Radiation Therapy) delivery has been proposed. The compensator contains two kinds of cubic blocks: x-ray absorbing blocks for intensity modulation and x-ray transparent blocks for packing. The packed blocks are placed inside a rectangular enclosure, and the resulting compensators can be attached to a linac gantry head through a rotatable mount for efficient multiportal IMRT. A fabrication device and a sorting device were also developed. The fabrication device can automatically stack two different types of blocks to produce a compensator while the sorting device can separate each type of the blocks for subsequent fabrication. Preliminary film experiments have shown that an additional leakage dose through the rounded edges of the ten-layered x-ray absorbing blocks was 0.9% of the delivered dose with a total shielded dose ratio of 10% including the peak leakage. It was observed that the proposed compensator may provide a highly modulated dose distribution. This suggests its feasibility for IMRT delivery with a limit of 1 cm x 1 cm spatial resolution at isocenter in the plane perpendicular to the beam, and larger discrete intensity steps of approximately 10% compared to conventional compensators. Advantages of the proposed compensator include that the compensator blocks are reusable and can be utilized to automatically and quickly fabricate a compensator, thereby minimizing human labor.     

The impact of inter-fraction dose variations on biological equivalent dose (BED): the concept of equivalent constant dose

Inter-fraction dose fluctuations, which appear as a result of setup errors, organ motion and treatment machine output variations, may influence the radiobiological effect of the treatment even when the total delivered physical dose remains constant. The effect of these inter-fraction dose fluctuations on the biological effective dose (BED) has been investigated. Analytical expressions for the BED accounting for the dose fluctuations have been derived. The concept of biological effective constant dose (BECD) has been introduced. The equivalent constant dose (ECD), representing the constant physical dose that provides the same cell survival fraction as the fluctuating dose, has also been introduced. The dose fluctuations with Gaussian as well as exponential probability density functions were investigated. The values of BECD and ECD calculated analytically were compared with those derived from Monte Carlo modelling. The agreement between Monte Carlo modelled and analytical values was excellent (within 1%) for a range of dose standard deviations (0-100% of the dose) and the number of fractions (2 to 37) used in the comparison. The ECDs have also been calculated for conventional radiotherapy fields. The analytical expression for the BECD shows that BECD increases linearly with the variance of the dose. The effect is relatively small, and in the flat regions of the field it results in less than 1% increase of ECD. In the penumbra region of the 6 MV single radiotherapy beam the ECD exceeded the physical dose by up to 35%, when the standard deviation of combined patient setup/organ motion uncertainty was 5 mm. Equivalently, the ECD field was approximately 2 mm wider than the physical dose field. The difference between ECD and the physical dose is greater for normal tissues than for tumours.     

调强放射治疗射野和剂量的验证

目的：为确保调强放射治疗的精确,利用自制和专用设备对每个射野的位置、形状和野内剂量分布进行验证。方法：用自制的位置验证标记球,贴在病人体表的某个固定位置,和病人一起进行CT扫描,设计计划时将此标记球设为位置验证靶区进行射野位置验证。利用加速器自带的射野影像系统（EPID）和治疗计划系统（TPS）的DRR图比对进行射野形状验证。利用Matrixx二维电离室矩阵和OnmiPro软件进行每个射野的剂量验证。结果：射野位置验证在统一调整系统后,误差结果满意。射野形状验证以3mm为标准,调整前的吻合率约为75％。剂量验证通过率大于等于95％的射野占77％。结论：通过81例鼻咽癌调强放疗的实验证明,利用上述三种方法对调强计划进行验证,可以及时纠正误差,确保计划准确执行。     

A study of effective attenuation coefficient for calculating tissue compensator thickness

Dose uniformity throughout the treatment volume is essential to precision radiation therapy. Tissue compensators are often used as a means to eliminate dose nonuniformity resulting from surface contour irregularities. This paper evaluates the accuracy of using an effective attenuation coefficient for calculating the thickness of missing tissue. This coefficient is found to vary strongly with thickness of missing tissue when the initial depth is situated in the buildup region. The use of a single attenuation coefficient produces errors as high as 54% in the calculated compensator thickness when 10-MV x rays are used. At depths greater than the depth of maximum dose, the attenuation coefficient remains a function of field size, not the initial depth.     

Skin dose near compensating filters in radiotherapy

In radiotherapy treatments with MV beams, the use of tissue compensators affects the dose to the skin. Methods of calculating the relative skin dose (RSD) are described and a formula is derived to predict the contribution of a tissue compensator to the RSD. Measurements of RSD for various field sizes and distances from the compensator are presented.     

Compensator thickness verification using an a-Si EPID

Electronic portal imaging devices (EPIDs) are being increasingly employed to make therapy verification and dose measurements in the clinic. In this work, we investigate the use of an amorphous silicon (a-Si) EPID to verify the accuracy of compensator fabrication and mounting. Compensator thickness estimates on a two-dimensional grid were calculated from the primary component of transmission obtained by subtracting a modeled scatter component from the total transmission measured with the EPID. The primary component was related to the thickness via an exponential relation that includes beam hardening. Implementation of the method involved determination of: (i) a calibration curve relating EPID pixel values to energy fluence for open and attenuated fields, which was found to be linear for open fields but to have a small quadratic component for attenuated beams; (ii) EPID scatter factors to account for field size effects, which exhibited a small dependence on compensator thickness and field size; (iii) the attenuation coefficient of the steel shot compensator material, which varied slightly with off-axis distance and field size, and (iv) an analytical model to predict scatter from the compensator, which was calculated to be <4% at the standard EPID imaging distance of 140 cm. Thickness distributions were then measured for several types of attenuators including flat, test, and clinical compensators. Although uncertainties associated with compensator manufacturing were non-negligible and made assessment of thickness measurement uncertainty difficult, we estimate the latter to be approximately 0.5 mm for steel shot compensators of thickness <4 cm.     

Effects of intra-fraction motion on IMRT dose delivery: statistical analysis and simulation

There has been some concern that organ motion, especially intra-fraction organ motion due to breathing, can negate the potential merit of intensity-modulated radiotherapy (IMRT). We wanted to find out whether this concern is justified. Specifically, we wanted to investigate whether IMRT delivery techniques with moving parts, e.g., with a multileaf collimator (MLC), are particularly sensitive to organ motion due to the interplay between organ motion and leaf motion. We also wanted to know if, and by how much, fractionation of the treatment can reduce the effects. We performed a statistical analysis and calculated the expected dose values and dose variances for volume elements of organs that move during the delivery of the IMRT. We looked at the overall influence of organ motion during the course of a fractionated treatment. A linear-quadratic model was used to consider fractionation effects. Furthermore, we developed software to simulate motion effects for IMRT delivery with an MLC, with compensators, and with a scanning beam. For the simulation we assumed a sinusoidal motion in an isocentric plane. We found that the expected dose value is independent of the treatment technique. It is just a weighted average over the path of motion of the dose distribution without motion. If the treatment is delivered in several fractions, the distribution of the dose around the expected value is close to a Gaussian. For a typical treatment with 30 fractions, the standard deviation is generally within 1% of the expected value for MLC delivery if one assumes a typical motion amplitude of 5 mm (1 cm peak to peak). The standard deviation is generally even smaller for the compensator but bigger for scanning beam delivery. For the latter it can be reduced through multiple deliveries ('paintings') of the same field. In conclusion, the main effect of organ motion in IMRT is an averaging of the dose distribution without motion over the path of the motion. This is the same as for treatments with conventional beams. Additional effects that are specific to the IMRT delivery technique appear to be relatively small, except for the scanning beam.     

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

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

An Active Matrix Flat Panel Dosimeter (AMFPD) for in-phantom dosimetric measurements

An a-Si Active Matrix Flat Panel Imager (AMFPI) prototype developed in-house has been modified to function as an in-phantom dosimetry system providing high resolution two-dimensional (2-D) data. This Active Matrix Flat Panel Dosimeter (AMFPD) system can be used as a replacement device for standard in-phantom dosimeters, such as scanning ion chambers in water, or film in solid water. The initial characterization of the device demonstrates a wide dynamic range (up to 160 cGy), a stable calibration curve (less than 1.5% variation over 1 year), dose rate independence (less than 1%), and excellent agreement of output factors with ion chamber measurements for a range of field sizes (less than 2%). The device also compares well to film for 2-D planar dose distributions. It is expected that the AMFPD system will be useful for beam commissioning, algorithm verification test data, and routine IMRT quality assurance dosimetry.     

In vivo diode dosimetry for routine quality assurance in IMRT

Due to the complexity of IMRT dosimetry, dose delivery evaluation is generally done using a treatment plan in which the optimized fluence distribution has been transferred to a test phantom for accessibility and simplicity of measurement. The actual patient doses may be reconstructed in vivo through the use of electronic portal imaging devices or films, but the assessment of absolute dose from these measurements is time-consuming and complicated. In our clinic we have instituted the use of routine diode dosimetry for IMRT patients following the same procedure used for standard radiation therapy patients in which each new treatment field is checked at the start of treatment. For standard cases the dose at dmax is calculated as part of the monitor unit calculation. For the IMRT cases, the dose contribution to the dmax depth for each field is taken from the treatment plan. We found that about 90% of the diode measurements agreed to within +/- 10% of the planned doses (45/51 fields) and 63% (32/51 fields) achieved +/- 5% agreement. By using this direct in vivo method to verify the clinical doses delivered, we have been able to make a uniform startup procedure for all patients while simplifying our IMRT QA process.     

Reference dosimetry condition and beam quality correction factor for CyberKnife beam

This article is intended to improve the certainty of the absorbed dose determination for reference dosimetry in CyberKnife beams. The CyberKnife beams do not satisfy some conditions of the standard reference dosimetry protocols because of its unique treatment head structure and beam collimating system. Under the present state of affairs, the reference dosimetry has not been performed under uniform conditions and the beam quality correction factor kQ for an ordinary 6 MV linear accelerator has been temporally substituted for the kQ of the CyberKnife in many sites. Therefore, the reference conditions and kQ as a function of the beam quality index in a new way are required. The dose flatness and the error of dosimeter reading caused by radiation fields and detector size were analyzed to determine the reference conditions. Owing to the absence of beam flattening filter, the dose flatness of the CyberKnife beam was inferior to that of an ordinary 6 MV linear accelerator. And if the absorbed dose is measured with an ionization chamber which has cavity length of 2.4, 1.0 and 0.7 cm in reference dosimetry, the dose at the beam axis for a field of 6.0 cm collimator was underestimated 1.5%, 0.4%, and 0.2% on a calculation. Therefore, the maximum field shaped with a 6.0 cm collimator and ionization chamber which has a cavity length of 1.0 cm or shorter were recommended as the conditions of reference dosimetry. Furthermore, to determine the kQ for the CyberKnife, the realistic energy spectrum of photons and electrons in water was simulated with the BEAMnrc. The absence of beam flattening filter also caused softer photon energy spectrum than that of an ordinary 6 MV linear accelerator. Consequently, the kQ for ionization chambers of a suitable size were determined and tabulated as a function of measurable beam quality indexes in the CyberKnife beam.     

Spot scanning system for proton radiotherapy

In order to provide a uniform and desirable dose distribution over a large radiation field, spot beam scanning is one of the most useful methods. A new spot beam scanning system was constructed for a 70 MeV proton beam. The lateral dose distribution was uniform with +/- 2.5% for an 18 cm square field. It was possible to control the dose at each point in the radiation field by this spot scanning method. This system has been confirmed to be satisfactory for delivering a proton beam in the desired field shape and dose level.