Sci-Thur PM: YIS - 04: Forcing lateral electron disequilibrium to spare lung tissue: A novel technique for SBRT of small lung tumours.

Stereotactic body radiation therapy(SBRT), a technique that uses tightly conformed Megavoltage(MV) x-ray fields, improves local control of lung cancer. However, small MV x-ray fields can cause lateral electron disequilibrium(LED), which reduces the dose within lung. These effects are difficult to predict and are presently a cause of alarm for the radiotherapy community. Previously, we developed The Relative Depth Dose Factor(RDDF), which is an indicator of the extent of LED (RDDF < 1). We propose a positive application of LED for lung sparing in SBRT: LED can be exploited to irradiate a small tumor while greatly reducing the dose in surrounding lung tissue. The Monte Carlo code, DOSXYZnrc, was employed to calculate dose within a cylindrical lung phantom. The phantom's diameter and height were set to 25 cm, and consisted of water and lung (density = 0.25g/cm3 ) shells surrounding a small water tumor (volume = 0.8 cm3 ). Two 180° 6MV arcs were focused onto the tumor with field sizes of 1×1cm2 (RDDF∼0.5) and 3×3cm2 (RDDF∼1). Analyzing dose results, the 1×1cm2 arc reduced dose within lung and water tissues by 70% and 80% compared to the 3×3cm2 arc. Although, central tumor dose was also reduced by 15% using the 1×1cm2 arc, these reductions can be offset by escalating the prescription dose appropriately. Using the RDDF as a guideline, it's possible to design a SBRT treatment plan that reduces lung dose while maintaining relatively high tumor dose levels. Clinical application requires an accurate dose algorithm and may lower SBRT dose-induced toxicity levels in patients.

Sci-Fri PM: Delivery - 11: Accuracy considerations in modern radiation oncology: An update.

The most recent reviews of accuracy requirements in radiation oncology were published in the 1990s, primarily in an era that was transitioning from 2-D to 3-D conformal radiation therapy (CRT). Since then, the technology associated with radiation oncology has changed dramatically. The combination of various forms of imaging for radiation therapy planning, treatment planning software, dose delivery technology including 4-D considerations as well as in-room daily image guidance has resulted in new perspectives on accuracy considerations. The underlying hypothesis for the use of these advanced technologies is that loco-regional control of cancer remains a significant barrier to cancer cure for many common cancers and that better dose distributions will translate into better outcomes. However, further clinical gain using these new technologies may be limited by single or compounded uncertainties associated with the entire treatment process. Thus, it is important to understand what factors should be considered in determining accuracy requirements as well as the realistic expectations of uncertainties that exist within the total treatment process. The need for accuracy is based on clinical requirements such as the steepness of dose-response curves, inherent heterogeneity in patient response to treatment, and the level of accuracy that is practically achievable. Statements on accuracy are dependent on the technology used and the reality of what is practically achievable and necessary. This review highlights some of the major differences between accuracy requirements as determined in the 2-D RT and 3-D CRT era versus the modern era of intensity modulated, image-guided, 4-D radiation therapy.

Evaluation of inter-fraction prostate motion using kilovoltage cone beam computed tomography during radiotherapy.

AIMS: The success of delivering the prescribed radiation dose to the prostate while sparing adjacent sensitive tissues is largely dependent on the ability to accurately target the prostate during treatment. Kilovoltage cone beam computed tomography (CBCT) imaging can be used to monitor and compensate for inter-fraction prostate motion, but this procedure increases treatment session time and adds incidental radiation dose to the patient. We carried out a retrospective study of CBCT data to evaluate the systematic and random correction shifts of the prostate with respect to bones and external marks. MATERIALS AND METHODS: A total of 449 daily CBCT studies from 17 patients undergoing intensity-modulated radiotherapy (IMRT) for localised prostate cancer were analysed. The difference between patient set-up correction shifts applied by radiation therapists (via matching prostate position in CBCT and planning computed tomography) and shifts obtained by matching bony anatomy in the same studies was used as a measure of the daily inter-fraction internal prostate motion. RESULTS: The average systematic and random shifts in prostate positions, calculated over all fractions versus only 10 fractions, were not found to be significantly different. DISCUSSION: The measured prostate shifts with respect to bony anatomy and external marks after the first 10 imaging sessions were shown to provide adequate predictive power for defining patient-specific margins in future fractions without a need for ongoing computed tomography imaging. Different options for CBCT imaging schedule are proposed that will reduce the treatment session time and imaging dose to radiotherapy patients while ensuring appropriate prostate cover and normal tissue sparing.

Effect of lateral target motion on image registration accuracy in CT-guided helical tomotherapy: a phantom study.

Optimisation of imaging modes for kilovoltage CT (kVCT) used for treatment planning and megavoltage CT (MVCT) image guidance used in ungated helical tomotherapy was investigated for laterally moving targets. Computed tomography images of the QUASAR Respiratory Motion Phantom were acquired without target motion and for lateral motion of the target, with 2-cm peak-to-peak amplitude and a period of 4 s. Reference kVCT images were obtained using a 16-slice CT scanner in standard fast helical CT mode, untagged average CT mode and various post-processed 4D-CT modes (0% phase, average and maximum intensity projection). Three sets of MVCT images with different inter-slice spacings of were obtained on a Hi-Art tomotherapy system with the phantom displaced by a known offset position. Eight radiation therapists performed co-registration of MVCT obtained with 2-, 4- and 6-mm slice spacing and kVCT studies independently for all 15 CT imaging combinations. In the investigated case, the untagged average kVCT and 4-mm slice spacing for the MVCT yielded more accurate registration in the transverse plane. The average residual uncertainty of this combination of imaging procedures was 0.61 +/- 0.16 mm in the longitudinal direction, 0.45 +/- 0.14 mm in the anterior-posterior direction and insignificant in the lateral direction. Manual registration of MVCT-kVCT study pairs is necessary to account for a target in significant lateral motion with respect to bony structures.

Fundamental x-ray interaction limits in diagnostic imaging detectors: spatial resolution.

The practice of diagnostic x-ray imaging has been transformed with the emergence of digital detector technology. Although digital systems offer many practical advantages over conventional film-based systems, their spatial resolution performance can be a limitation. The authors present a Monte Carlo study to determine fundamental resolution limits caused by x-ray interactions in four converter materials: Amorphous silicon (a-Si), amorphous selenium, cesium iodide, and lead iodide. The "x-ray interaction" modulation transfer function (MTF) was determined for each material and compared in terms of the 50% MTF spatial frequency and Wagner's effective aperture for incident photon energies between 10 and 150 keV and various converter thicknesses. Several conclusions can be drawn from their Monte Carlo study. (i) In low-Z (a-Si) converters, reabsorption of Compton scatter x rays limits spatial resolution with a sharp MTF drop at very low spatial frequencies (< 0.3 cycles/mm), especially above 60 keV; while in high-Z materials, reabsorption of characteristic x rays plays a dominant role, resulting in a mid-frequency (1-5 cycles/mm) MTF drop. (ii) Coherent scatter plays a minor role in the x-ray interaction MTF. (iii) The spread of energy due to secondary electron (e.g., photoelectrons) transport is significant only at very high spatial frequencies. (iv) Unlike the spread of optical light in phosphors, the spread of absorbed energy from x-ray interactions does not significantly degrade spatial resolution as converter thickness is increased. (v) The effective aperture results reported here represent fundamental spatial resolution limits of the materials tested and serve as target benchmarks for the design and development of future digital x-ray detectors.

Fundamental x-ray interaction limits in diagnostic imaging detectors: frequency-dependent Swank noise.

A frequency-dependent x-ray Swank factor based on the "x-ray interaction" modulation transfer function and normalized noise power spectrum is determined from a Monte Carlo analysis. This factor was calculated in four converter materials: amorphous silicon (a-Si), amorphous selenium (a-Se), cesium iodide (CsI), and lead iodide (PbI2) for incident photon energies between 10 and 150 keV and various converter thicknesses. When scaled by the quantum efficiency, the x-ray Swank factor describes the best possible detective quantum efficiency (DQE) a detector can have. As such, this x-ray interaction DQE provides a target performance benchmark. It is expressed as a function of (Fourier-based) spatial frequency and takes into consideration signal and noise correlations introduced by reabsorption of Compton scatter and photoelectric characteristic emissions. It is shown that the x-ray Swank factor is largely insensitive to converter thickness for quantum efficiency values greater than 0.5. Thus, while most of the tabulated values correspond to thick converters with a quantum efficiency of 0.99, they are appropriate to use for many detectors in current use. A simple expression for the x-ray interaction DQE of digital detectors (including noise aliasing) is derived in terms of the quantum efficiency, x-ray Swank factor, detector element size, and fill factor. Good agreement is shown with DQE curves published by other investigators for each converter material, and the conditions required to achieve this ideal performance are discussed. For high-resolution imaging applications, the x-ray Swank factor indicates: (i) a-Si should only be used at low-energy (e.g., mammography); (ii) a-Se has the most promise for any application below 100 keV; and (iii) while quantum efficiency may be increased at energies just above the K edge in CsI and PbI2, this benefit is offset by a substantial drop in the x-ray Swank factor, particularly at high spatial frequencies.

[Optimization of MVCT imaging schedule in prostate cancer treatment using helical tomotherapy]. / Optimisation du processus d'imagerie de haute énergie (MVCT) pour la tomothérapie hélicoïdale des cancers de la prostate.

PURPOSE: Megavoltage CT (MVCT) study on helical tomotherapy permits to verify and correct the patient setup by coregistration with the planning kVCT. This process is time-consuming and our objective is to investigate a possibility of using a smaller number of imaging studies in the case of patients with prostate cancer. PATIENTS AND METHODS: The interfraction shifts of 20 patients (about 700 MVCT studies) treated in our institution have been recorded and analyzed. A new reference position has been calculated as an average of shifts observed during different initial number of fractions imaged. RESULTS: The analysis of the reference position obtained for the set of 20 patients as a function of the number of imaging sessions has shown that MVCT studies during first four fractions are sufficient for the majority of patients. CONCLUSION: Imaging during the first four fractions can be used to determine a reference position for patients with prostate cancer treated on helical tomotherapy. A study on Planned Adaptive (TomoTherapy Inc., Madison, WI, USA) software to evaluate the clinical significance of this scenario is currently in process in our institution.

Poster - Thurs Eve-18: Performance evaluation of MV CT imaging on the HI ART II tomotherapy unit.

The HI-ART II unit (TomoTherapy Inc., Madison WI) is a modality used by the London Regional Cancer Program (LRCP) for radiation therapy. This machine uses the same source of Megavoltage energy radiation to image (3.5 MV) and to treat (6MV) patients, combining the functionality of a traditional linear accelerator and CT simulator into one unit. Thus, it is possible to assess patient positioning and adjust for anatomy changes just prior to radiation therapy. Unfortunately, at MV energy levels, the physics of radiation interaction limits image quality, and gives rise to an inherent dose limitation concern that enhances noise levels. Therefore, we propose to quantify the image quality produced by the HI-ART II unit using techniques established for kVCT scanner technology. Our study involved the use of three standard phantoms to test image resolution, noise, uniformity, and linearity for a 512 × 512 reconstruction matrix and three scan pitch settings (0.8, 1.6, and 2.4). Results follow: linearity between MV CT number versus relative electron density was observed, noise calculations ranged from 2.15-2.51%, and a distinct central artifact was revealed during uniformity testing. The linearity between MV CT number versus relative electron density implies that MV CT images are highly suitable for dose calculations. MV CT image quality of uniform phantoms were acceptable and demonstrated noise levels higher than those produced by kVCT simulators. Further study is necessary to correct for the central artifact in MV CT images.

3D thoracoscopic ultrasound volume measurement validation in an ex vivo and in vivo porcine model of lung tumours.

The purpose of this study was to validate the accuracy and reliability of volume measurements obtained using three-dimensional (3D) thoracoscopic ultrasound (US) imaging. Artificial "tumours" were created by injecting a liquid agar mixture into spherical moulds of known volume. Once solidified, the "tumours" were implanted into the lung tissue in both a porcine lung sample ex vivo and a surgical porcine model in vivo. 3D US images were created by mechanically rotating the thoracoscopic ultrasound probe about its long axis while the transducer was maintained in close contact with the tissue. Volume measurements were made by one observer using the ultrasound images and a manual-radial segmentation technique and these were compared with the known volumes of the agar. In vitro measurements had average accuracy and precision of 4.76% and 1.77%, respectively; in vivo measurements had average accuracy and precision of 8.18% and 1.75%, respectively. The 3D thoracoscopic ultrasound can be used to accurately and reproducibly measure "tumour" volumes both in vivo and ex vivo.

Signal and noise transfer properties of photoelectric interactions in diagnostic x-ray imaging detectors.

Image quality in diagnostic x-ray imaging is ultimately limited by the statistical properties governing how, and where, x-ray energy is deposited in a detector. This in turn depends on the physics of the underlying x-ray interactions. In the diagnostic energy range (10-100 keV), most of the energy deposited in a detector is through photoelectric interactions. We present a theoretical model of the photoelectric effect that specifically addresses the statistical nature of energy absorption by photoelectrons, K and L characteristic x rays, and Auger electrons. A cascaded-systems approach is used that employs a complex structure of parallel cascades to describe signal and noise transfer through the photoelectric effect in terms of the modulation transfer function, Wiener noise power spectrum, and detective quantum efficiency (DQE). The model was evaluated by comparing results with Monte Carlo calculations for x-ray converters based on amorphous selenium (a-Se) and lead (Pb), representing both low and high-Z materials. When electron transport considerations can be neglected, excellent agreement (within 3%) is obtained for each metric over the entire diagnostic energy range in both a-Se and Pb detectors up to 30 cycles/mm, the highest frequency tested. The cascaded model overstates the DQE when the electron range cannot be ignored. This occurs at approximately two cycles/mm in a-Se at an incident photon energy of 80 keV, whereas in Pb, excellent agreement is obtained for the DQE over the entire diagnostic energy range. However, within the context of mammography (20 keV) and micro-computed tomography (40 keV), the effects of electron transport on the DQE are negligible compared to fluorescence reabsorption, which can lead to decreases of up to 30% and 20% in a-Se and Pb, respectively, at 20 keV; and 10% and 5%, respectively, at 40 keV. It is shown that when Swank noise is identified in a Fourier model, the Swank factor must be frequency dependent. This factor decreases quickly with frequency, and in the case of a-Se and Pb, decreases by up to a factor of 3 at five cycles/mm immediately above the K edge. The frequency-dependent Swank factor is also equivalent to what we call the "photoelectric DQE," which describes signal and noise transfer through photoelectric interactions.

Feasibility of a fast inverse dose optimization algorithm for IMRT via matrix inversion without negative beamlet intensities.

A fast optimization algorithm is very important for inverse planning of intensity modulated radiation therapy (IMRT), and for adaptive radiotherapy of the future. Conventional numerical search algorithms such as the conjugate gradient search, with positive beam weight constraints, generally require numerous iterations and may produce suboptimal dose results due to trapping in local minima. A direct solution of the inverse problem using conventional quadratic objective functions without positive beam constraints is more efficient but will result in unrealistic negative beam weights. We present here a direct solution of the inverse problem that does not yield unphysical negative beam weights. The objective function for the optimization of a large number of beamlets is reformulated such that the optimization problem is reduced to a linear set of equations. The optimal set of intensities is found through a matrix inversion, and negative beamlet intensities are avoided without the need for externally imposed ad-hoc constraints. The method has been demonstrated with a test phantom and a few clinical radiotherapy cases, using primary dose calculations. We achieve highly conformal primary dose distributions with very rapid optimization times. Typical optimization times for a single anatomical slice (two dimensional) (head and neck) using a LAPACK matrix inversion routine in a single processor desktop computer, are: 0.03 s for 500 beamlets; 0.28 s for 1000 beamlets; 3.1 s for 2000 beamlets; and 12 s for 3000 beamlets. Clinical implementation will require the additional time of a one-time precomputation of scattered radiation for all beamlets, but will not impact the optimization speed. In conclusion, the new method provides a fast and robust technique to find a global minimum that yields excellent results for the inverse planning of IMRT.

Dosimetric impact of image-guided 3D conformal radiation therapy of prostate cancer.

The goal of this work is to quantify the impact of image-guided conformal radiation therapy (CRT) on the dose distribution by correcting patient setup uncertainty and inter-fraction tumour motion. This was a retrospective analysis that used five randomly selected prostate cancer patients that underwent approximately 15 computed tomography (CT) scans during their radiation treatment course. The beam arrangement from the treatment plan was imported into each repeat CT study and the dose distribution was recalculated for the new beam setups. Various setup scenarios were then compared to assess the impact of image guidance on radiation treatment precision. These included (1) daily alignment to skin markers, thus representing a conventional beam setup without image guidance, (2) alignment to bony anatomy for correction of daily patient setup error, thus representing on-line portal image guidance, and (3) alignment to the 'CTV of the day' for correction of inter-fraction tumour motion, thus representing on-line CT or ultrasound image guidance. Treatment scenarios (1) and (3) were repeated with a reduced CTV to PTV margin, where the former represents a treatment using small margins without daily image guidance. Daily realignment of the treatment beams to the prostate showed an average increase in minimum tumour dose of 1.5 Gy, in all cases where tumour 'geographic miss' without image guidance was apparent. However, normal tissue sparing did not improve unless the PTV margin was reduced. Daily realignment to the tumour combined with reducing the margin size by a factor of 2 resulted in an average escalation in tumour dose of 9.0 Gy for all five static plans. However, the prescription dose could be escalated by 13.8 Gy when accounting for changes in anatomy by accumulating daily doses using nonlinear image registration techniques. These results provide quantitative information on the effectiveness of image-guided radiation treatment of prostate cancer and demonstrate that the dosimetric impact is patient dependent.

Validation of contour-driven thin-plate splines for tracking fraction-to-fraction changes in anatomy and radiation therapy dose mapping.

The goal of this study is to validate a deformable model using contour-driven thin-plate splines for application to radiation therapy dose mapping. Our testing includes a virtual spherical phantom as well as real computed tomography (CT) data from ten prostate cancer patients with radio-opaque markers surgically implanted into the prostate and seminal vesicles. In the spherical mathematical phantom, homologous control points generated automatically given input contour data in CT slice geometry were compared to homologous control point placement using analytical geometry as the ground truth. The dose delivered to specific voxels driven by both sets of homologous control points were compared to determine the accuracy of dose tracking via the deformable model. A 3D analytical spherically symmetric dose distribution with a dose gradient of approximately 10% per mm was used for this phantom. This test showed that the uncertainty in calculating the delivered dose to a tissue element depends on slice thickness and the variation in defining homologous landmarks, where dose agreement of 3-4% in high dose gradient regions was achieved. In the patient data, radio-opaque marker positions driven by the thin-plate spline algorithm were compared to the actual marker positions as identified in the CT scans. It is demonstrated that the deformable model is accurate (approximately 2.5 mm) to within the intra-observer contouring variability. This work shows that the algorithm is appropriate for describing changes in pelvic anatomy and for the dose mapping application with dose gradients characteristic of conformal and intensity modulated radiation therapy.

Tracking the dose distribution in radiation therapy by accounting for variable anatomy.

The goal of this research is to calculate the daily and cumulative dose distribution received by the radiotherapy patient while accounting for variable anatomy, by tracking the dose distribution delivered to tissue elements (voxels) that move within the patient. Non-linear image registration techniques (i.e., thin-plate splines) are used along with a conventional treatment planning system to combine the dose distributions computed for each 3D computed tomography (CT) study taken during treatment. For a clinical prostate case, we demonstrate that there are significant localized dose differences due to systematic voxel motion in a single fraction as well as in 15 cumulative fractions. The largest positive dose differences in rectum, bladder and seminal vesicles were 29%, 2% and 24%, respectively, after the first fraction of radiation treatment compared to the planned dose. After 15 cumulative fractions, the largest positive dose differences in rectum, bladder and seminal vesicles were 23%, 32% and 18%, respectively, compared to the planned dose. A sensitivity analysis of control point placement is also presented. This method provides an important understanding of actual delivered doses and has the potential to provide quantitative information to use as a guide for adaptive radiation treatments.

The influence of brachytherapy dose heterogeneity on estimates of alpha/beta for prostate cancer.

The sensitivity of estimates of alpha/beta for prostate tumours to dose heterogeneity in 125I brachytherapy implants, as well as to variation in selected radiobiological parameters, is analysed. The tumour control probabilities of brachytherapy and external beam radiotherapy are equated for ranges of alpha, Tpot, RBE and external beam dose. For each combination of parameters, the equality is used to derive the value of alpha/beta. Different clinical (non-uniform) brachytherapy dose distributions, and three uniform brachytherapy dose distributions (120, 144 and 160 Gy) are used. For 'nominal' input parameter values of Tpot = 45 days, alpha = 0.2 Gy(-1), RBE = 1.4, and an external beam dose of 70 Gy, the values obtained for alpha/beta ranged between 2.1 and 12.3 Gy for all of the clinical DVHs, between 2.1 and 3.8 Gy for the better quality clinical implants and between 1.0 and 1.8 Gy for the uniform brachytherapy doses. When only 2% of the volume receiving the lowest dose is omitted from the clinical DVHs, the estimated alpha/beta values ranged between 1.4 and 2.1 Gy. When ranges of input parameters were also considered, the overall range of alpha/beta values for the clinical brachytherapy dose distributions lay between 1.1 and 12.3 Gy for the three best clinical implants, and between 0.7 and 6.3 Gy for uniform doses. We conclude that estimation of alpha/beta without taking into account dose heterogeneity and inter-patient variation may underestimate the actual value alpha/beta.

Monte Carlo simulations of DNA damage from incorporated cold iodine following photoelectrically induced Auger electron cascades.

Radiation-induced damage in nucleosomal DNA from Auger electron cascades due to incorporated cold IUdR has been modelled through Monte Carlo simulations. Probabilities of DNA double strand break (DSB) production following a vacancy in the K, L, M and N shells of iodine are estimated. DSB complexity from the base damage accompanying a break was also estimated. Multiple DSB events were analysed for correlated breaks due to nucleosome periodicity. The probability of an Auger cascade causing at least one DSB strongly depended on the shell in which the initial vacancy was produced. This probability was approximately 0.35 for K and L shells and fell to 0.02 for the N shell. As expected, DSBs were predominantly induced in a nucleosome containing incorporated iodine and were accompanied with extensive base damage. Analysis of multiple DSB events showed that approximately 14% of the DSBs produced following a vacancy in the L1 orbital can be interpreted as correlated with base pair separation attributable to the nucleosome periodicity. The data generated in this work provide a basis for the development of photon-activation therapy using kilovoltage X rays incident upon IUdR sensitised tumours.

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

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

Operational characteristics of a prototype x-ray needle device.

A prototype x-ray needle, which emits 62.5 kVp x-rays at the tip of a 20 cm long, 4 mm diameter steel needle, has been developed by Titan Pulse Sciences Incorporated (PSI) (Albuquerque, NM) and was tested for its suitability in brachytherapy applications in comparison with a similar device by the Photoelectron Corporation. The depth dose profiles were also compared with those of two common brachytherapy sources (125I and 192Ir). The depth dose characteristics of the radiation were comparable with the two brachytherapy sources with a slightly reduced attenuation gradient. The dose rate from the x-ray needle tip was relatively isotropic at the needle tip and was continuously adjustable over the range of 0 cGy min(-1) to upwards of 62 cGy min(-1) at a reference distance of 1 cm in air. We detected a significant proportion of x-rays generated along the needle shaft, and not at the needle tip, as intended. The energy spectrum emitted from this device had a peak intensity at 21 keV and an average energy of 28 keV. The beam was attenuated in both aluminium (the first half-value layer being less than 0.1 mm) and in water (50% dose at approximately 2 mm). These studies confirm that although there is potential for a system similar to this one for clinical applications, the simplistic electron guidance used in this particular prototype device limits it to research applications. Further optimization is required in focusing and steering the electron beam to the target, improving x-ray production efficiency and using x-ray target cooling to achieve higher dose rates.