Technical Note: Fabricating Cerrobend grids with 3D printing for spatially modulated radiation therapy: A feasibility study.

PURPOSE: Grid therapy has promising applications in the radiation treatment of large tumors. However, research and applications of grid therapy are limited by the accessibility of the specialized blocks that produce the grid of pencil-like radiation beams. In this study, a Cerrobend grid block was fabricated using the 3D printing technique. METHODS: A grid block mold was designed with flared tubes which follow the divergence of the beam. The mold was 3D printed using a resin with the working temperature below 230 °C. The melted Cerrobend liquid at 120 °C was cast into the resin mold to yield a block with a thickness of 7.4 cm. At the isocenter plane, the grid had a hexagonal pattern, with each pencil beam diameter of 1.4 cm; the distance between the beam centers was 2.1 cm. RESULTS: The dosimetric properties of the grid block were studied using small field dosimeters: a pinpoint ionization chamber and a stereotactic diode. For a 6 MV photon beam, its valley-to-peak ratio was 20% at dmax and 30% at 10 cm depth; the output factor was 84.9% at dmax and 65.1% at 10 cm depth. CONCLUSIONS: This study demonstrates that it is feasible to implement 3D printing technique in applying grid therapy in clinic.

Direct aperture optimization using an inverse form of back-projection.

Direct aperture optimization (DAO) has been used to produce high dosimetric quality intensity-modulated radiotherapy (IMRT) treatment plans with fast treatment delivery by directly modeling the multileaf collimator segment shapes and weights. To improve plan quality and reduce treatment time for our in-house treatment planning system, we implemented a new DAO approach without using a global objective function (GFO). An index concept is introduced as an inverse form of back-projection used in the CT multiplicative algebraic reconstruction technique (MART). The index, introduced for IMRT optimization in this work, is analogous to the multiplicand in MART. The index is defined as the ratio of the optima over the current. It is assigned to each voxel and beamlet to optimize the fluence map. The indices for beamlets and segments are used to optimize multileaf collimator (MLC) segment shapes and segment weights, respectively. Preliminary data show that without sacrificing dosimetric quality, the implementation of the DAO reduced average IMRT treatment time from 13 min to 8 min for the prostate, and from 15 min to 9 min for the head and neck using our in-house treatment planning system PlanUNC. The DAO approach has also shown promise in optimizing rotational IMRT with burst mode in a head and neck test case.

Comparison of User-Directed and Automatic Mapping of the Planned Isocenter to Treatment Space for Prostate IGRT.

Image-guided radiotherapy (IGRT), adaptive radiotherapy (ART), and online reoptimization rely on accurate mapping of the radiation beam isocenter(s) from planning to treatment space. This mapping involves rigid and/or nonrigid registration of planning (pCT) and intratreatment (tCT) CT images. The purpose of this study was to retrospectively compare a fully automatic approach, including a non-rigid step, against a user-directed rigid method implemented in a clinical IGRT protocol for prostate cancer. Isocenters resulting from automatic and clinical mappings were compared to reference isocenters carefully determined in each tCT. Comparison was based on displacements from the reference isocenters and prostate dose-volume histograms (DVHs). Ten patients with a total of 243 tCTs were investigated. Fully automatic registration was found to be as accurate as the clinical protocol but more precise for all patients. The average of the unsigned x, y, and z offsets and the standard deviations ( σ ) of the signed offsets computed over all images were (avg. ± σ (mm)): 1.1 ± 1.4, 1.8 ± 2.3, 2.5 ± 3.5 for the clinical protocol and 0.6 ± 0.8, 1.1 ± 1.5 and 1.1 ± 1.4 for the automatic method. No failures or outliers from automatic mapping were observed, while 8 outliers occurred for the clinical protocol.

Improving quality of patient care by improving daily practice in radiation oncology.

Radiation oncology is an ever-advancing, complex, technologically based specialty that has been thrust into the public spotlight because of recent reports of serious treatment delivery errors that have impacted the quality of patient care. Although quality assurance (QA) initiatives are already common place in radiation oncology, the continued complex technology and automation-based advances in radiotherapy have created new safety challenges. The ongoing evolution of safety challenges in radiation oncology requires corresponding evolution in workflow and QA programs to ensure the quality of patient care. We believe that the incorporation of QA themes into our daily practice will help to create safer patient environments. Practical QA approaches that can be readily incorporated and applied in the daily practice of radiation oncology include process engineering and human factors engineering, medical peer review, "safety rounds," and software QA tools. Most importantly, we need to develop a culture of safety in which all team members work together to maximize the quality of our patient care.

Compensators: an alternative IMRT delivery technique.

Seven years of experience in compensator intensity-modulated radiotherapy (IMRT) clinical implementation are presented. An inverse planning dose optimization algorithm was used to generate intensity modulation maps, which were delivered via either the compensator or segmental multileaf collimator (MLC) IMRT techniques. The in-house developed compensator-IMRT technique is presented with the focus on several design issues. The dosimetry of the delivery techniques was analyzed for several clinical cases. The treatment time for both delivery techniques on Siemens accelerators was retrospectively analyzed based on the electronic treatment record in LANTIS for 95 patients. We found that the compensator technique consistently took noticeably less time for treatment of equal numbers of fields compared to the segmental technique. The typical time needed to fabricate a compensator was 13 min, 3 min of which was manual processing. More than 80% of the approximately 700 compensators evaluated had a maximum deviation of less than 5% from the calculation in intensity profile. Seventy-two percent of the patient treatment dosimetry measurements for 340 patients have an error of no more than 5%. The pros and cons of different IMRT compensator materials are also discussed. Our experience shows that the compensator-IMRT technique offers robustness, excellent intensity modulation resolution, high treatment delivery efficiency, simple fabrication and quality assurance (QA) procedures, and the flexibility to be used in any teletherapy unit.

Beam orientation selection for intensity-modulated radiation therapy based on target equivalent uniform dose maximization.

PURPOSE: To develop an automated beam-orientation selection procedure for intensity-modulated radiotherapy (IMRT), and to determine if a small number of beams picked by this automated procedure can yield results comparable to a large number of manually placed orientations. METHODS AND MATERIALS: The automated beam selection procedure maximizes an unconstrained objective function composed of target equivalent uniform dose (EUD) and critical structure dose-volume histogram (DVH) constraints. Beam orientations are selected from a large feasible set of directions through a series of alternating fluence optimization and orientation alteration steps, until convergence to a stable orientation set. The fluence optimization step adjusts fluences to maximize the objective function. The orientation alteration step substitutes beams in the orientation set currently under consideration with beams of the parent set in the immediate angular vicinity; the altered orientation set is deemed current if it produces a higher objective function value in the fluence optimization step. RESULTS AND CONCLUSIONS: It is demonstrated, for prostate IMRT planning, that a modest number of appropriately selected beam orientations (3 or 5) can provide dose distributions as satisfactory as those produced by a large number of unselected equispaced orientations. Such selected beam orientations can reduce overall treatment time, thus making IMRT more clinically practical.

Dose optimization via index-dose gradient minimization.

This paper presents an iterative optimization algorithm based on gradient minimization of index dose, defined as the product of physical dose and a numerical index. Acting as a template the index distribution is designed to represent the dosimetry that meets the dose volume histogram-based optimization objectives. The treatment dosimetry is optimized when the uniformity of the index-dose distribution is maximized. Prior to optimization the user can select all or only some of the beams to be intensity modulated. The remaining unmodulated beams can be either open or wedged photon beams, electron beams, or beams of previous treatments. The optimization result and treatment delivery efficiency can often be enhanced by including not only the IM photon beams but also all suitable fixed-beams available on the linac in the treatment plan. In addition, the doses from previous treatments can also be considered in the optimization of current treatment. Five clinical examples with different complexities in optimization objective are presented. The effects of two nonoptimization variables, beam setup and initial beam weights, on the quality of the dose optimization are also presented. The results are analyzed in terms of isodose distribution, dose volume histograms, and a dose optimization quality factor. The optimization algorithm, implemented in our in-house TPS PLanUNC, has been used in clinical application since 1996. The primary advantages of our optimization algorithm include computational efficiency, intensity modulation selection choice, and performance reliability for a wide range of clinical beam setups and optimization objectives.

A quality and efficiency analysis of the IMFAST segmentation algorithm in head and neck "step & shoot" IMRT treatments.

The performance of segmentation algorithms used in IMFAST for "step & shoot" IMRT treatment delivery is evaluated for three head and neck clinical treatments of different optimization objectives. The segmentation uses the intensity maps generated by the in-house TPS PLANUNC using the index-dose minimization algorithm. The dose optimization objectives include PTV dose uniformity and dose volume histogram-specified critical structure sparing. The optimized continuous intensity maps were truncated into five and ten intensity levels and exported to IMFAST for MLC segments optimization. The MLC segments were imported back to PLUNC for dose optimization quality calculation. The five basic segmentation algorithms included in IMFAST were evaluated alone and in combination with either tongue and groove/match line correction or fluence correction or both. Two criteria were used in the evaluation: treatment efficiency represented by the total number of MLC segments and optimization quality represented by a clinically relevant optimization quality factor. We found that the treatment efficiency depends first on the number of intensity levels used in the intensity map and second the segmentation technique used. The standard optimal segmentation with fluence correction is a consistent good performer for all treatment plans studied. All segmentation techniques evaluated produced treatments with similar dose optimization quality values, especially when ten-level intensity maps are used.