Examination of geometric and dosimetric accuracies of gated step-and-shoot intensity modulated radiation therapy

Due to the complicated technical nature of gated radiation therapy, electronic and mechanical limitations may affect the precision of delivery. The purpose of this study is to investigate the geometric and dosimetric accuracies of gated step-and-shoot intensity modulated radiation treatments (SS-IMRT). Unique segmental MLC plans are designed, which allow quantitative testing of the gating process. Both ungated and gated deliveries are investigated for different dose sizes, dose rates, and gating window times using a commercial treatment system (Varian Trilogy) together with a respiratory gating system [Varian Real-Time Position Management system]. Radiographic film measurements are used to study the geometric accuracy, where it is found that with both ungated and gated SS-IMRT deliveries the MLC leaf divergence away from planned is less than or equal to the MLC specified leaf tolerance value for all leafs (leaf tolerance being settable from 0.5-5 mm). Nevertheless, due to the MLC controller design, failure to define a specific leaf tolerance value suitable to the SS-IMRT plan can lead to undesired geometric effects, such as leaf motion of up to the maximum 5 mm leaf tolerance value occurring after the beam is turned on. In this case, gating may be advantageous over the ungated case, as it allows more time for the MLC to reach the intended leaf configuration. The dosimetric precision of gated SS-IMRT is investigated using ionization chamber methods. Compared with the ungated case, it is found that gating generally leads to increased dosimetric errors due to the interruption of the "overshoot phenomena." With gating the average timing deviation for intermediate segments is found to be 27 ms, compared to 18 ms for the ungated case. For a plan delivered at 600 MU/min this would correspond to an average segment dose error of approximately 0.27 MU and approximately 0.18 MU for gated and ungated deliveries, respectively. The maximum dosimetric errors for individual intermediate segments are found to deviate by up to approximately 0.64 MU from their planned value when delivered at 600 MU/min using gating, this compares to only approximately 0.32 MU for the ungated case.     

A dosimetric leaf-setting strategy for shaping radiation fields using a multileaf collimator

A dosimetric leaf-setting strategy of using multileaf collimators (MLC) for shaping radiation fields has been developed. Existing MLC leaf-setting strategies are all based upon geometric criteria. This new approach, however, matches a prescribed field contour with a MLC using clinically consistent dosimetric criteria. The leaf positions are determined using an iterative optimization algorithm. An empirical dose model was developed to compare the dosimetric-based leaf-setting strategy with the geometric-based leaf-setting strategies. Differences up to half a centimeter in the leaf positions and isodose lines were found between setting the MLC geometrically and setting the MLC dosimetrically. The dosimetric leaf-setting strategy provides the ability to achieve better dose conformation for a clinically desired isodose line. Since the desired isodose line that covers a treatment volume is typically higher than 50% of the maximum dose, the scalloping effects due to the finite leaf width at the leaf edge or 50% isodose lines are much reduced. Another benefit of the dosimetric leaf-setting is that it separates the leaf-setting process from the treatment planning process, and this frees the treatment planning vendors from developing detailed dose models for various existing types and future upgrades of MLC systems.     

Enhancement of IMRT delivery through MLC rotation

Multileaf collimator (MLC) based intensity modulated radiation therapy (IMRT) techniques are well established but suffer several physical limitations. Dosimetric spatial resolution is limited by the MLC leaf width; interleaf leakage and tongue-and-groove effects degrade dosimetric accuracy and the range of leaf motion limits the maximum deliverable field size. Collimator rotation is used in standard radiation therapy to improve the conformity of the MLC shape to the target volume. Except for opposed orthogonal fields, collimator rotation has not been exploited in IMRT due to the complexity of deriving the MLC leaf configurations for rotated sub-fields. Here we report on a new way that MLC-based IMRT is delivered which incorporates collimator rotation, providing an extra degree of freedom in deriving leaf sequences for a desired fluence map. Specifically, we have developed a series of unique algorithms that are capable of determining rotated MLC segments. These IMRT fields may be delivered statically (with the collimator rotating to a new position in between sub-fields) or dynamically (with the collimator rotating and leaves moving simultaneously during irradiation). This introductory study provides an analysis of the rotating leaf motion calculation algorithms with focus on radiation efficiency, the range of collimator rotation and number of segments. We then evaluate the technique by characterizing the ability of the algorithms to generate rotating leaf sequences for desired fluence maps. Comparisons are also made between our method and conventional sliding window and step-and-shoot techniques. Results show improvements in spatial resolution, reduced interleaf effects and maximum deliverable field size over conventional techniques. Clinical application of these enhancements can be realized immediately with static rotational delivery although improved dosimetric modelling of the MLC will be required for dynamic delivery.     

Impact of MLC leaf position errors on simple and complex IMRT plans for head and neck cancer

The dosimetric impact of random and systematic multi-leaf collimator (MLC) leaf position errors is relatively unknown for head and neck intensity-modulated radiotherapy (IMRT) patients. In this report we studied 17 head and neck IMRT patients, including 12 treated with simple plans (<50 segments) and 5 treated with complex plans (>100 segments). Random errors (-2 to +2 mm) and systematic errors (+/-0.5 mm and +/-1 mm) in MLC leaf positions were introduced into the clinical plans and the resultant dose distributions were analyzed based on defined endpoint doses. The dosimetric effect was insignificant for random MLC leaf position errors up to 2 mm for both simple and complex plans. However, for systematic MLC leaf position errors, we found significant dosimetric differences between the simple and complex IMRT plans. For 1 mm systematic error, the average changes in D(95%) were 4% in simple plans versus 8% in complex plans. The average changes in D(0.1 cc) of the spinal cord and brain stem were 4% in simple plans versus 12% in complex plans. The average changes in parotid glands were 9% in simple plans versus 13% for the complex plans. Overall, simple IMRT plans are less sensitive to leaf position errors than complex IMRT plans.     

Incorporation of realistic delivery limitations into dynamic MLC treatment delivery

The clinical implementation of IMRT involves the use of a number of complex software-based systems, typically including an inverse planning system, a leaf sequencer, and a computer-controlled treatment delivery system. The inverse planning system determines the desired fluence patterns, the leaf sequencer translates those fluence maps into leaf trajectories, and the control system delivers those trajectories. While verification of intensity-modulated treatment fields has focused primarily on the dosimetric aspects of delivery, accurate delivery of the intended fluence distribution is dependent upon both the leaf sequencer and delivery control systems. Leaf sequencing algorithms typically do not incorporate many control system limitations, and this can lead to discrepancies between planned and delivered sequences. In this work, simple and complex fields were sequenced for the dynamic sliding window technique using different leaf speeds and tolerance settings to identify various limitations of the accelerator control system. This work was conducted on a Varian 2100 EX equipped with a Millennium 120 leaf MLC. The identified limitations were then incorporated into the sequencing algorithm using a limiting leaf velocity (less than the maximum leaf velocity), the leaf position tolerance, and the communications delay in the control system. Collision avoidance in leaf pairs was found to depend on a control system-enforced minimum gap between leaves and led to acceleration effects. By incorporating these effects into the leaf sequencing algorithm, dynamic sliding-window leaf sequences were produced which did not require beam interruptions or dose rate modulations for the parameter values used in calculating the sequence (dose rate, tolerance, leaf speed, and total monitor units). Incorporation of control system limitations into the leaf sequencing algorithm results in IMRT fields that are delivered with the prescribed constant dose rate, require less time to deliver, and have well-defined, calculable transmission dose characteristics.     

Leaf position error during conformal dynamic arc and intensity modulated arc treatments

Conformal dynamic arc (CD-ARC) and intensity modulated arc treatments (IMAT) are both treatment modalities where the multileaf collimator (MLC) can change leaf position dynamically during gantry rotation. These treatment techniques can be used to generate complex isodose distributions, similar to those used in fix-gantry intensity modulation. However, a beam-hold delay cannot be used during CD-ARC or IMAT treatments to reduce spatial error. Consequently, a certain amount of leaf position error will have to be accepted in order to make the treatment deliverable. Measurements of leaf position accuracy were taken with leaf velocities ranging from 0.3 to 3.0 cm/s. The average and maximum leaf position errors were measured, and a least-squares linear regression analysis was performed on the measured data to determine the MLC velocity error coefficient. The average position errors range from 0.03 to 0.21 cm, with the largest deviations occurring at the maximum achievable leaf velocity (3.0 cm/s). The measured MLC velocity error coefficient was 0.0674 s for a collimator rotation of 0 degrees and 0.0681 s for a collimator rotation of 90 degrees. The distribution in leaf position error between the 0 degrees and 90 degrees collimator rotations was within statistical uncertainty. A simple formula was developed based on these results for estimating the velocity-dependent dosimetric error. Using this technique, a dosimetric error index for plan evaluation can be calculated from the treatment time and the dynamic MLC leaf controller file.     

Hardware-sensitive optimization for intensity modulated radiotherapy

The multileaf collimator (MLC) hardware constraints are usually neglected in the process of intensity-modulated beam optimization. Consequently, it is not always possible to deliver planned beam modulation using dynamic MLC. Beam optimization is significantly diminished if the results must be approximated due to limitations imposed by the delivery device. To overcome this problem, an inverse beam optimization method which incorporates the hardware constraints has been developed. The hardware constraints, including the leaf velocity, the dose rate and the minimum required gap between opposing and adjacent leaves, were considered. An iterative search for feasible modulation was conducted alternately in the dosimetric space and the MLC position-time space. The optimization algorithm was designed for a unidirectional leaf trajectory and a constant dose rate. A scheme to reduce tongue-and-groove underdosage during optimization was also implemented. Comparisons were made between the solutions produced by this method and conventional optimization disregarding the hardware restrictions. The beam profiles generated by the conventional method were modified to satisfy the hardware specifications. The results indicate that inclusion of MLC constraints during optimization can improve the degree of conformity that is deliverable.     

Management of three-dimensional intrafraction motion through real-time DMLC tracking

Tumor tracking using a dynamic multileaf collimator (DMLC) represents a promising approach for intrafraction motion management in thoracic and abdominal cancer radiotherapy. In this work, we develop, empirically demonstrate, and characterize a novel 3D tracking algorithm for real-time, conformal, intensity modulated radiotherapy (IMRT) and volumetric modulated arc therapy (VMAT)-based radiation delivery to targets moving in three dimensions. The algorithm obtains real-time information of target location from an independent position monitoring system and dynamically calculates MLC leaf positions to account for changes in target position. Initial studies were performed to evaluate the geometric accuracy of DMLC tracking of 3D target motion. In addition, dosimetric studies were performed on a clinical linac to evaluate the impact of real-time DMLC tracking for conformal, step-and-shoot (S-IMRT), dynamic (D-IMRT), and VMAT deliveries to a moving target. The efficiency of conformal and IMRT delivery in the presence of tracking was determined. Results show that submillimeter geometric accuracy in all three dimensions is achievable with DMLC tracking. Significant dosimetric improvements were observed in the presence of tracking for conformal and IMRT deliveries to moving targets. A gamma index evaluation with a 3%-3 mm criterion showed that deliveries without DMLC tracking exhibit between 1.7 (S-IMRT) and 4.8 (D-IMRT) times more dose points that fail the evaluation compared to corresponding deliveries with tracking. The efficiency of IMRT delivery, as measured in the lab, was observed to be significantly lower in case of tracking target motion perpendicular to MLC leaf travel compared to motion parallel to leaf travel. Nevertheless, these early results indicate that accurate, real-time DMLC tracking of 3D tumor motion is feasible and can potentially result in significant geometric and dosimetric advantages leading to more effective management of intrafraction motion.     

Dosimetric considerations for validation of a sequential IMRT process with a commercial treatment planning system

Commercial multileaf collimator (MLC) systems can employ leaves with rounded ends. Treatment planning beam modelling should consider the effects of transmission through rounded leaf ends to provide accurate dosimetry for IMRT treatments delivered with segmented MLC. We determined that an MLC leaf gap reduction of 1.4 mm is required to obtain an agreement between calculated and measured profile 50% dose points. A head and neck dosimetry phantom, supplied by the Radiological Physics Center (RPC), was planned and irradiated as a necessary credentialing requirement for the RTOG H-0022 protocol. The agreement between the RPC TLD measurements and treatment planning calculations was within experimental error for the primary and secondary planning target volumes (PTVs); however, the calculated mean dose for the critical structure was approximately 9% lower than the RPC TLD measurements. RPC radiochromic film profile measurements also indicated significant discrepancies (>5%) with calculated values especially in the high dose gradient region in the vicinity of the critical structure. These results substantiate our own in-house phantom measurements, performed with the same IMRT fields as for the RPC phantom experiment, using Kodak EDR2 film to measure absolute dose. Our results indicate a maximum underestimate of calculated dose of 12% with no leaf gap reduction. The discrepancy between measured and calculated phantom values is reduced to +/- 5% when a leaf gap reduction of 1.4 mm is used. A further improvement in the accuracy of dose calculation is not possible without a more accurate modelling of the leaf end transmission by the planning system. In the absence of published dosimetric criteria for IMRT our results stress the need for stringent in-house dosimetric QA and validation for IMRT treatments. We found the dosimetric validation service provided by the RPC to be a valuable component of our IMRT validation efforts.     

An improved MLC segmentation algorithm and software for step-and-shoot IMRT delivery without tongue-and-groove error

We present an improved multileaf collimator (MLC) segmentation algorithm, denoted by SLS(NOTG) (static leaf sequencing with no tongue-and-groove error), for step-and-shoot intensity-modulated radiation therapy (IMRT) delivery. SLS(NOTG) is an improvement over the MLC segmentation algorithm called SLS that was developed by Luan et al. [Med. Phys. 31(4), 695-707 (2004)], which did not consider tongue-and-groove error corrections. The aims of SLS(NOTG) are (1) shortening the treatment times of IMRT plans by minimizing their numbers of segments and (2) minimizing the tongue-and-groove errors of the computed IMRT plans. The input to SLS(NOTG) is intensity maps (IMs) produced by current planning systems, and its output is (modified) optimized leaf sequences without tongue-and-groove error. Like the previous SLS algorithm [Luan et al., Med. Phys. 31(4), 695-707 (2004)], SLS(NOTG) is also based on graph algorithmic techniques in computer science. It models the MLC segmentation problem as a weighted minimum-cost path problem, where the weight of the path is the number of segments and the cost of the path is the amount of tongue-and-groove error. Our comparisons of SLS(NOTG) with CORVUS indicated that for the same intensity maps, the numbers of segments computed by SLS(NOTG) are up to 50% less than those by CORVUS 5.0 on the Elekta LINAC system. Our clinical verifications have shown that the dose distributions of the SLS(NOTG) plans do not have tongue-and-groove error and match those of the corresponding CORVUS plans, thus confirming the correctness of SLS(NOTG). Comparing with existing segmentation methods, SLS(NOTG) also has two additional advantages: (1) SLS(NOTG) can compute leaf sequences whose tongue-and-groove error is minimized subject to a constraint on the maximum allowed number of segments, which may be desirable in clinical situations where a treatment with the complete correction of tongue-and-groove error takes too much time, and (2) SLS(NOTG) can be used to minimize a more general type of error called the tongue-or-groove error.     

The sliding slit test for dynamic IMRT: a useful tool for adjustment of MLC related parameters

For treatments with dynamic intensity modulated radiotherapy (IMRT), the adjustment of multileaf collimator (MLC) parameters affecting both the optimization algorithm and dose distributions is crucial. The main parameters characterizing the MLC are the transmission (T) and the dosimetric leaf separation (DLS). The aim of this study is twofold: a methodology based on the 'sliding slit' test is proposed to determine (T, DLS) combinations inducing the best conformity between calculations and measurements. Secondly, the effects of the MLC adjustment on measured dose and on optimization are presented for different configurations as the chair test and for the patient dosimetric quality control (DQC). Tests were performed with a Varian 23EX linac operated at 20 MV and equipped with a 120 leaf Millenium dynamic collimator. The treatment planning system was CadPlan/Helios (version 6.3.6). Results demonstrated that the sliding width (SW) strongly depends on the (T, DLS) combinations, and the measured dose is a linear function of the SW. Different (T, DLS) combinations induced a good agreement between calculations and measurements. The influence of the MLC calibration was found to be particularly important on the 'sliding slit' test (11.8% for a gap change of 0.8 mm) but not so much on the chair test and on the DQC. To detect small variations in leaf adjustment and to ensure consistency between calculation and actual dose delivered to patients, a daily check called IMRT MU check is proposed.     

Improving IMRT quality control efficiency using an amorphous silicon electronic portal imager

An amorphous silicon electronic portal imaging device (EPID) has been investigated to determine its usefulness and efficiency for performing linear accelerator quality control checks specific to step and shoot intensity modulated radiation therapy (IMRT). Several dosimetric parameters were measured using the EPID: dose linearity and segment to segment reproducibility of low dose segments, and delivery accuracy of fractions of monitor units. Results were compared to ion chamber measurements. Low dose beam flatness and symmetry were tested by overlaying low dose beam profiles onto the profile from a stable high-dose exposure and visually checking for differences. Beam flatness and symmetry were also calculated and plotted against dose. Start-up reproducibility was tested by overlaying profiles from twenty successive two monitor unit segments. A method for checking the MLC leaf calibration was also tested, designed to be used on a daily or weekly basis, which consisted of summing the images from a series of matched fields. Daily images were coregistered with, then subtracted from, a reference image. A threshold image showing dose differences corresponding to > 0.5 mm positional errors was generated and the number of pixels with such dose differences used as numerical parameter to which a tolerance can be applied. The EPID was found to be a sensitive relative dosemeter, able to resolve dose differences of 0.01 cGy. However, at low absolute doses a reproducible dosimetric nonlinearity of up to 7% due to image lag/ghosting effects was measured. It was concluded that although the EPID is suitable to measure segment to segment reproducibility and fractional monitor unit delivery accuracy, it is still less useful than an ion chamber as a tool for dosimetric checks. The symmetry/flatness test proved to be an efficient method of checking low dose profiles, much faster than any of the alternative methods. The MLC test was found to be extremely sensitive to sudden changes in MLC calibration but works best with a composite reference image consisting of an average of five successive days' images. When used in this way it proved an effective and efficient daily check of MLC calibration. Overall, the amorphous silicon EPID was found to be a suitable device for IMRT QC although it is not recommended for dosimetric tests. Automatic procedures for low monitor unit profile analysis and MLC leaf positioning yield considerable time-savings over traditional film techniques.     

Management of the interplay effect when using dynamic MLC sequences to treat moving targets

Interplay between organ motion and leaf motion has been shown to generally have a small dosimetric impact for most clinical intensity-modulated radiation therapy treatments. However, it has also been shown that for some MLC sequences there can be large daily variations in the delivered dose, depending on details of patient motion or the number of fractions. This study investigates guidelines for dynamic MLC sequences that will keep daily dose variations due to the interplay between organ motion and leaf motion within 10%. Dose distributions for a range of MLC separations (0.2-5.0 cm) and displacements between adjacent MLCs (0-1.5 cm) were exported from ECLIPSE to purpose-written software, which simulated the dose distribution delivered to a moving target. Target motion parallel and perpendicular to the MLC motion was investigated for a range of amplitudes (0.5-4.0 cm), periods (1.5-10 s), and MLC speeds (0.1-3.0 cm/s) with target motions modeled as sin. Results were confirmed experimentally by measuring the dose delivered to an ion chamber array in a moving phantom for different MLC sequences. The simulation results were used to identify MLC sequences that kept dose variations within 10% compared to the dose delivered with no motion. The maximum allowable MLC speed, when target motion is parallel to the MLC motion, was found to be a simple function of target period and MLC separation. When the target motion is perpendicular to MLC motion, the maximum allowable MLC speed can be described as a function of MLC separation and the displacement of adjacent MLCs. These guidelines were successfully applied to two-dimensional motion, and a simple program was written to import MLC sequence files and evaluate whether the maximum daily dose discrepancy caused by the interplay effect will be larger than 10%. This software was experimentally evaluated, and found to conservatively predict whether a given MLC sequence could give large daily dose discrepancies.     

Optimization of intensity modulated radiotherapy under constraints for static and dynamic MLC delivery.

Multi-leaf collimators (MLCs) are emerging as the prevalent modality to apply intensity modulated radiotherapy (IMRT). Both the principle and the particular design of MLCs stipulate complex constraints on the practically applicable intensity modulated radiation fields. Most consequentially, the distribution of exposure times across the maximum field outline is either a piecewise constant function in the static mode or a piecewise linear function in the dynamic mode of driving an MLC. In view of clinical utility, the total leaf movement should be minimized, which requires that MLC-related constraints be considered in the dose optimization process. A method is proposed to achieve this for both static MLC fields and dynamic leaf close-in application. The method is an amendment to a generic gradient-based IMRT dose optimization algorithm and solves numerical problems related to the non-convexity of the MLC constraints, which can cause erratic behaviour of a gradient-based algorithm. It employs bistable penalty functions to select preferrable leaf configurations from the configuration space of the MLC, which is limited by specific design features. Together with an 'annealing' escape mechanism from local minima, the algorithm is capable of finding the optimum of an IMRT problem as leaf sequences with minimized leaf travel. In particular, the efficiency of static IMRT can be raised to the levels of unmodulated fields with very few field segments, thereby increasing the utility of IMRT in clinical practice.     

两种准直器宽度对鼻咽癌放疗中的剂量学差异影响

目的:研究两种规格（等中心处投影0.5和1.0 cm）多叶准直器（MLC）在鼻咽癌调强放射治疗（IMRT）计划中的区别,从剂量学方面探究MLC的宽度对患者靶区和危及器官的影响。方法:随机选取已完成治疗的31例鼻咽癌患者计划,在放疗处方和物理优化参数不变的情况下分别使用两种规格MLC的加速器射野模型进行重新优化计算,统计靶区及主要危及器官的体积剂量、平均剂量（Dmean）、适形度指数（CI）、均匀性指数（HI）等参数,分析其差异性。结果:全样本分析显示,所有靶区HI和部分靶区（PGTVnx、PCTV2）CI差异有统计学意义（P<0.05）,0.5 cm MLC优于1.0 cm MLC;危及器官中,右侧视神经和视交叉最大剂量（Dmax）、左侧颞叶和右侧颞颌关节Dmean、左右腮腺V30、气管和脊髓Dmean差异有统计学意义（P<0.05）,0.5 cm MLC优于1.0 cm MLC,其他危及器官无统计学差异（P>0.05）;在Pinnacle3和Monaco计划系统中得到了相似结果,两种MLC在靶区适形度和均匀性方面及部分危及器官受量差异有统计学意义（P<0.05）。结论:0.5 cm MLC在鼻咽癌调强计划中能有效提高靶区适形度和均匀性,也能有效降低部分危及器官受量,可以更好地保护与靶区邻近或有重叠的一些危及器官,推荐有条件的医院使用。     

Leaf sequencing algorithms for segmented multileaf collimation

The delivery of intensity-modulated radiation therapy (IMRT) with a multileaf collimator (MLC) requires the conversion of a radiation fluence map into a leaf sequence file that controls the movement of the MLC during radiation delivery. It is imperative that the fluence map delivered using the leaf sequence file is as close as possible to the fluence map generated by the dose optimization algorithm, while satisfying hardware constraints of the delivery system. Optimization of the leaf sequencing algorithm has been the subject of several recent investigations. In this work, we present a systematic study of the optimization of leaf sequencing algorithms for segmental multileaf collimator beam delivery and provide rigorous mathematical proofs of optimized leaf sequence settings in terms of monitor unit (MU) efficiency under most common leaf movement constraints that include minimum leaf separation constraint and leaf interdigitation constraint. Our analytical analysis shows that leaf sequencing based on unidirectional movement of the MLC leaves is as MU efficient as bidirectional movement of the MLC leaves.     

IMAT-SIM: a new method for the clinical dosimetry of intensity-modulated arc therapy (IMAT)

Dynamic-gantry multi-leaf collimator (MLC)-based, intensity-modulated radiotherapy (IMAT) has been proposed as an alternative to tomotherapy. In contrast to fixed-gantry, MLC-based intensity-modulated radiotherapy (IMRT), where commercial treatment planning systems (TPS) or dosimetric analysis software currently provide many automatic tools enabling two-dimensional (2D) detectors (matrix or electronic portal imaging devices) to be used as measurement systems, for the planning and delivery of IMAT these tools are generally not available. A new dosimetric method is proposed to overcome some of these limitations. By converting the MLC files of IMAT beams from arc to fixed gantry-angle modality, while keeping the leaf trajectories equal, IMAT plans can be both simulated in the TPS and executed as fixed-gantry, sliding-window DMLC treatments. In support of this idea, measurements of six IMAT plans, in their double form of original arcs and converted fixed-gantry DMLC beams (IMAT-SIM), have been compared among themselves and with their corresponding IMAT-SIM TPS calculations. Radiographic films and a 2D matrix ionization chamber detector rigidly attached to the accelerator gantry and set into a cubic plastic phantom have been used for these measurements. Finally, the TPS calculation-algorithm implementations of both conformal dynamic MLC arc (CD-ARC) modalities, used for clinical IMAT calculations, and DMLC modalities (IMAT-SIM), proposed as references for validating IMAT plan dose-distributions, have been compared. The comparisons between IMAT and IMAT-SIM delivered beams have shown very good agreement with similar shapes of the measured dose profiles which can achieve a mean deviation (+/-2sigma) of (0.35+/-0.16) mm and (0.37+/-0.14)%, with maximum deviations of 1.5 mm and 3%. Matching the IMAT measurements with their corresponding IMAT-SIM data calculated by the TPS, these deviations remain in the range of (1.01+/-0.28) mm and (-1.76+/-0.42)%, with maximums of 3 mm and 5%, limits generally accepted for IMRT plan dose validation. Differences in the algorithm implementations have been found, but by correcting CD-ARC calculations for the leaf-end transmission offset (LTO) effect the IMAT and IMAT-SIM simulations agree well in terms of final dose distributions. The differences found between IMAT and the IMAT-SIM beam measurements are due to the different controls of leaf motion (via electron gun delay in the latter) that cannot be used in the former to correct possible speed variations in the rotation of the gantry. As the IMAT delivered beams are identical to what the patient will receive during the treatment, and the IMAT-SIM beam calculations made by the TPS reproduce exactly the treatment plans of that patient, the accuracy of this new dosimetric method is comparable to that which is currently used for static IMRT. This new approach of 2D-detector dosimetry, together with the commissioning, quality-assurance, and preclinical dosimetric procedures currently used for IMRT techniques, can be applied and extended to any kind of dynamic-gantry MLC-based treatment modality either CD-ARC or IMAT.     

Optimal leaf sequencing with elimination of tongue-and-groove underdosage

The individual leaves of a multileaf collimator (MLC) have a tongue-and-groove or stepped-edge design to minimize leakage radiation between adjacent leaves. This design element has a drawback in that it creates areas of underdosages in intensity-modulated photon beams unless a leaf trajectory is specifically designed such that for any two adjacent leaf pairs, the direct exposure under the tongue-and-groove is equal to the lower of the direct exposures of the leaf pairs. In this work, we present a systematic study of the optimization of a leaf sequencing algorithm for segmental multileaf collimator beam delivery that completely eliminates areas of underdosages due to tongue-and-groove or stepped-edge design of the MLC. Simultaneous elimination of tongue-and-groove effect and leaf interdigitation is also studied. This is an extension of our previous work (Kamath et al 2003a Phys. Med. Biol. 48 307) in which we described a leaf sequencing algorithm that is optimal for monitor unit (MU) efficiency under most common leaf movement constraints that include minimum leaf separation. Compared to our previously published algorithm (without constraints), the new algorithms increase the number of sub-fields by approximately 21% and 25%, respectively, but are optimal in MU efficiency for unidirectional schedules.     

The dosimetric impact of leaf interdigitation and leaf width on VMAT treatment planning in Pinnacle: comparing Pareto fronts

To evaluate in an objective way the effect of leaf interdigitation and leaf width on volumetric modulated arc therapy plans in Pinnacle. Three multileaf collimators (MLCs) were modeled: two 10?mm leaf width MLCs, with and without interdigitating leafs, and a 5?mm leaf width MLC with interdigitating leafs. Three rectum patients and three prostate patients were used for the planning study. In order to compare treatment techniques in an objective way, a Pareto front comparison was carried out. 200 plans were generated in an automated way, per patient per MLC model, resulting in a total of 3600 plans. From these plans, Pareto-optimal plans were selected which were evaluated for various dosimetric variables. The capability of leaf interdigitation showed little dosimetric impact on the treatment plans, when comparing the 10?mm leaf width MLC with and without leaf interdigitation. When comparing the 10?mm leaf width MLC with the 5?mm leaf width MLC, both with interdigitating leafs, improvement in plan quality was observed. For both patient groups, the integral dose was reduced by 0.6 J for the thin MLC. For the prostate patients, the mean dose to the anal sphincter was reduced by 1.8 Gy and the conformity of the V(95%)?was reduced by 0.02 using the thin MLC. The V(65%)?of the rectum was reduced by 0.1% and the dose homogeneity with 1.5%. For rectum patients, the mean dose to the bowel was reduced by 1.4 Gy and the mean dose to the bladder with 0.8 Gy for the thin MLC. The conformity of the V(95%)?was equivalent for the 10 and 5?mm leaf width MLCs for the rectum patients. We have objectively compared three types of MLCs in a planning study for prostate and rectum patients by analyzing Pareto-optimal plans which were generated in an automated way. Interdigitation of MLC leafs does not generate better plans using the SmartArc algorithm in Pinnacle. Changing the MLC leaf width from 10 to 5?mm generates better treatment plans although the clinical relevance remains to be proven.