Evaluating the effectiveness of a longitudinal magnetic field in reducing underdosing of the regions around upper respiratory cavities irradiated with photon beams--a Monte Carlo study.

The problem of underdosing lesions adjacent to upper respiratory cavities and a proposal to correct it are presented in this work. The EGS4 Monte Carlo code was used to simulate a 6 MV x-ray beam passing through a block of tissues with air cavities 2, 4, and 6 cm wide. The geometry used approximates the tracheal geometry used by previous researchers who investigated the underdosing phenomenon. A uniform longitudinal magnetic field of 0.5 T strength is used to reduce secondary electron outscatter caused by the presence of an air gap, and thus improving the dose at the distal surface of air cavities. We introduce the term "percent dose reduction" (PDR), which is defined as the difference between the dose after the air cavity and the dose at the same depth in soft-tissue phantom normalized to the dose in the tissue phantom, to quantify the reduction in dose after an air gap. We also introduce the term dose improvement ratio (DIR), which is defined as the dose ratio with magnetic field to the dose, at the same point, without magnetic field, to quantify the improvement in dose when the magnetic field is applied. For 2 x 2 x 20 cm3 and 4 x 4 x 20 cm3 air cavities irradiated by 2 x 2 cm2 beams, we found PDRs of 38% and 52%, respectively. This means that for these cavities, there is a 38% and a 52% reduction in dose at the cavity edge compared to the same dose in tissue at the same depth for each cavity. The dose improved by 30% (DIR= 1.3) and 87% (DIR= 1.87), respectively, when applying the magnetic field. The worst effect on dose at the distal side came from larger cavities irradiated with small fields. In these situations, the improvement in dose due to the presence of magnetic field was the largest. This article deals with "ideal" head and neck geometries with a uniform magnetic field. In a paper to follow we will use a CT-based phantom to study the effect in realistic geometries with the presence of a magnetic field from a Helmholtz coil pair.

Roles of glucitol in the GutR-mediated transcription activation process in Bacillus subtilis: glucitol induces GutR to change its conformation and to bind ATP.

GutR is a 95-kDa glucitol-dependent transcription activator that mediates the expression of the Bacillus subtilis glucitol operon. Glucitol allows GutR to bind tightly to its binding site located upstream of the gut promoter. In this study, a second functional role of glucitol is identified. Glucitol induces GutR to change its conformation and triggers GutR to bind ATP efficiently. After sequential binding of glucitol and ATP to GutR, GutR adopts a new conformation by forming a compact structure that is resistant to trypsin digestion. Under this condition, the ATP.glucitiol.GutR complex can dissociate slowly from the gutR-binding site (t(12) = 274 min). Interestingly, if ATP in the ATP.glucitiol.GutR complex is replaced by ADP, GutR adopts another conformation and can dissociate from the gutR-binding site even faster (t(12) = 82 min). In all these GutR-DNA binding studies in the presence of different ligands (glucitol, ATP, or ADP), only the off-rate is affected. The vital role of ATP in the GutR-mediated transcription activation process is reflected by the poor transcription from the gut promoter with GutR(D285A) which has a mutation in the motif B of the putative ATP-binding site. A working model for this transcription activation process is presented.

Dynamic wedge versus physical wedge: a Monte Carlo study.

The purpose of this study is to analyze the characteristics of dynamic wedges (DW) and to compare DW to physical wedges (PW) in terms of their differences in affecting beam spectra, energy fluence, angular distribution, contaminated electrons, and dose distributions. The EGS4/BEAM Monte Carlo codes were used to simulate the exact geometry of a 6 MV beam and to calculate 3-D dose distributions in phantom. The DW was simulated in accordance with the segmented treatment tables (STT). The percentage depth dose curves and beam profiles for PW, DW, and open fields were measured and used to verify the Monte Carlo simulations. The Monte Carlo results were found to agree within 2% with the measurements performed using film and ionizing chambers in a water phantom. The present EGS4 calculation reveals that the effects of a DW on beam spectral and angular distributions, as well as electron contamination, are much less significant than those for a PW. For the 6 MV photon beam, a 45 degrees PW can result in a 30% increase in mean photon energy due to the effect of beam hardening. It can also introduce a 5% dose reduction in the build-up region due to the reduction of contaminated electrons by the PW. Neither this mean-energy increase nor such dose reduction is found for a DW. Compared to a DW, a PW alters the photon-beam spectrum significantly. The dosimetric differences between a DW and a PW are significant and clearly affect the clinical use of these beams. The data presented may be useful for DW commissioning.

Reducing loss in lateral charged-particle equilibrium due to air cavities present in x-ray irradiated media by using longitudinal magnetic fields.

The underdosing of lesions distal to air cavities, such as those found in upper respiratory passages, occurs due to the loss in lateral charged-particle equilibrium (CPE). The degree of underdosing worsens for smaller field sizes, resulting in more frequent recurrence of the cancer treated. Higher photon energies further aggravate the outcome by producing longer second build-up regions beyond the cavity. Besides underdosing, the larger lateral spread of secondary electron fluence in the air cavity produces diffuse dose distributions at the tissue-air interface for shaped or intensity modulated fields. These disequilibrium effects create undesirable deviations from the intended treatment. The clinical concern is further intensified by the failure of traditional treatment planning systems to even account for such defects. In this work, the use of longitudinal magnetic fields on the order of 0.5 T is proposed for alleviating lateral electronic disequilibrium due to the presence of air cavities in the irradiated volume. The magnetic field enforces lateral CPE by restricting the lateral range of electrons in the air cavity. The problem is studied in a simple water-air-water slab geometry using EGS4 Monte Carlo simulations for 6 MV photons. Electronic disequilibrium is evaluated for beams of various sizes, shapes and intensity distributions constructed by linear superposition of the dose distributions for 0.5 x 0.5 cm2 beamlets. Comparison is also made with 60Co irradiation. The results indicate that the lateral confinement of secondary electrons in the air cavity by sub-MRI strength longitudinal fields is effective in reducing deterioration of dose distributions near tissue-air interfaces. This can potentially reduce recurrence rates of cancers such as the larynx carcinoma.

Modulation of radiotherapy photon beam intensity using magnetic field.

The purpose of this study was to explore the potential advantages of using strong magnetic fields to increase tumor dose and to decrease normal tissue dose in radiation therapy. Strong magnetic fields are capable of altering the trajectories of charged particles. A magnetic field applied perpendicularly to the X-ray beam forces the secondary electrons and positrons to spiral and produces a dose peak. The same magnetic field also prevents the electrons and positrons from traveling downstream and produces a lower dose region distal to the dose peak. The locations of these high- and low-dose regions are potentially adjustable to enhance the dose to the target volume and decrease the dose to normal tissues. We studied this effect using the Monte Carlo simulation technique. The EGS4 code was used to simulate the effect produced by a coil magnet currently under construction. The coil magnet is designed to support up to 350 A operating current and 15 T peak field on windings. Dose calculations in a water phantom show that the transverse magnetic field produces significant dose effects along the beam direction of radiation therapy X-rays. Depending on the beam orientation, the radiation dose at different depths along the beam can be increased or reduced. This dose effect varies with photon energy, field size, magnetic field strength, and relative magnet/beam geometry. The off-axis beam profiles also show considerable skewness under the influence of the magnetic field. The magnetic field-induced dose shift may result in high dose regions outside the geometrical boundary of the initial radiation beam. We have demonstrated that current or near-term magnet technology is capable of producing significant dose enhancement and reduction in radiation therapy photon beams. This technology should be further developed to improve our ability to deliver higher doses to the tumor and lower doses to normal tissues in radiation therapy.

Applications of simulator computed tomography number for photon dose calculations during radiotherapy treatment planning.

PURPOSE: To study the variation of computed tomography (CT) number from a simulator-based scanner and the effect of this variation on photon-dose calculations. METHOD AND MATERIALS: CT images of a cylindrical phantom with multiple inserts were obtained using a commercially-available simulator-CT (Ximatron: Varian, Palo Alto, CA). The linear correlation coefficient and Chi-square methods were used to determine the X-ray effective energy in a phantom. CT numbers in Hounsfield units (HU) were measured as a function of phantom size, orientation, field of view (FOV), distance from the center, and time for various inserts. The change of dose calculations due to the CT number variations was then determined using the equivalent path-length (EPL) and collapsed cone convolution methods. RESULTS AND DISCUSSION: A significant beam-hardening effect was observed for the simulator-CT. Consequently, the CT number from the sim-CT was more sensitive to the size of the phantom than those from a conventional CT. The sim-CT number is not sensitive to the locations within the phantom and is stable over a 6-week period. It is important to use the proper FOV for sim-CT studies; scanning a small polystyrene phantom using a large FOV may result in an increase of l20 HU in CT number at the center of the field. However, the dose-calculation variations, due to the CT number uncertainty, do not exceed 2-3% for 6-18 MV photon beams. CONCLUSION: The simulator CT images were acquired with patients in the treatment position, and these CT numbers are useful for CT-based dose calculations.

Dosimetric perturbations of linear array of beta-emitter seeds and metallic stent in intravascular brachytherapy.

The radiation treatment with catheter-based beta-emitter sources is under clinical trials to prevent restenosis following interventional coronary procedures. There are still large uncertainties in the dose calculation due to the complicated treatment geometry. We present the Monte Carlo simulations to account for the dosimetric perturbations due to neighboring trained seeds, proximal/distal gold markers, and a stainless steel stent. A catheter-based beta-emitter system is modeled using the Monte Carlo code, MCNP4B. Dose distributions and dose rates are calculated in voxels (0.64x0.64x0.5 mm3) around the long cylindrical trains of 90Sr/Y source with and without the stent (at 1.92 mm from the source axis). For the total activity of 70 mCi (2.59x10(9) Bq), the dose around most of the source length (except for edge seeds and gold markers) varies from 40 to 0.23 cGy/s as the radial distance from the source axis (r) increases from 0.64 to 6.4 mm. At the prescription range of r = 1.5-4.0 mm, the dose gradient is very steep and the contribution of neighboring seeds to the dose is significant. The dose enhancement due to neighboring seeds (the so-called "train effect") varies from 9% to 64% as r increases from 0.64 to 5.2 mm. The doses at r = 2 mm from the last edge seed and the gold marker are about 80% and 40% of that of the nonedge seed (8.7 cGy/s), respectively. The dose enhancement due to the secondary electrons and the primary electrons scattered with the stent is shown to be about 9.3% in the voxel including the stent. However, as r increases beyond the stent (r = 2.0-6.4 mm), the dose is slightly reduced by 4%-12%, compared to that without the stent.

Dose enhancement by a thin foil of high-Z material: a Monte Carlo study.

The purpose of this work is to study the dose enhancement by a thin foil (thickness of 0.2-4 mm) of high-Z material in a water phantom, irradiated by high-energy photon beams. EGS4 Monte Carlo technique was used. Perturbations on the beam spectra due to the presence of the foils, and dose enhancement dependence of photon-beam quality, beam incident angle, atomic number (Z), the thickness and size of the foil, and the depth of the foil situated in the phantom were studied. Analysis of photon and secondary-electron spectra indicates that the dose enhancement near an inhomogeneity interface is primarily due to secondary electrons. A calculation for 1-mm-thick planar lead foil in a water phantom shows that the dose enhancements at 0.25, 1, 2 and 3 mm away from the foil in the backward region were 58%, 37%, 24% and 17%, respectively, for a 15 MV beam. Calculations for a variety of planar foils and photon beams show that dose enhancement: (a) increases with Z; (b) decreases with decreasing foil thickness when the foils are thinner than a certain value (1 mm for lead foil for 15 MV); (c) decreases with decreasing incident photon-beam energies; (d) changes slightly for beam incident angles less than 45 degrees and more prominently for larger angles; (e) increases with size of foil; and (f) is almost independent of the depth at which the foil is situated when the foil is placed beyond the range of secondary electrons. The dose enhancement calculation is also performed for a cylindrically shaped lead foil irradiated by a four-field-box. The dose enhancement of 34%/13% was obtained at 0.25/2 mm away from the cylindrical outer interface for a 15 MV four-field-box.

Calculation of head scatter factors at isocenter or at center of field for any arbitrary jaw setting.

The purpose of this work is to calculate the head scatter factors for any arbitrary jaw setting by using two different semi-empirical methods. The head scatter factor at the center of field (COF) for any arbitrary jaw setting can be defined as H(COF)(X1,X2,Y1,Y2,r)=DairCOF(XI1,X2,Y1,Y2,r)/ [Dair(5,5,5,5,0)*OAR(r)], where X1, X2, Y1, and Y2 are the jaw positions; r is the distance between COF and isocenter (IC); OAR(r) is the Off-Axis-Ratio; DairCOF(X1,X2,Y1,Y2,r) is the dose in air measured at COF; Dair(5,5,5,5,0) is the dose in air measured at IC for the 10 x 10 cm2 field. In certain clinical situations, doses are prescribed at IC instead of COF for asymmetric fields. In these cases, head scatter factors should be determined at IC. It is found that the head scatter factors at IC for asymmetric fields [H(IC)(X1,X2,Y1,Y2)] are lower than H(COF)(X1,X2,Y1,Y2,r) for the same jaw setting by up to 4%. The values of H(IC)(X1,X2,Y1,Y2) and H(COF)(X1,X2,Y1,Y2,r) for a variety of jaw settings were measured using a miniphantom of 3-cm diameter for a 6- and a 18-MV photon beams. An equivalent square formula, derived presently at the source plane for any jaw setting, was used to calculate H(COF)(X1,X2,Y1,Y2,r). The calculation and the measurement agree within +/-1% (+/-0.5% for most clinical situations). To calculate H(IC)(X1,X2,Y1,Y2), we have generalized the Day's "quarter-field" method, i.e., H(IC)(X1,X2,Y1,Y2) = [H(X1,X1,Y1,Y1) + H(X1,X1,Y2,Y2) + H(X2,X2,Y1,Y1) + H(X2,X2,Y2,Y2)]/4. We found that the calculation and the measurement agree within +/-0.8% for the beams studied.

CT and PET lung image registration and fusion in radiotherapy treatment planning using the chamfer-matching method.

PURPOSE: We present a validation study of CT and PET lung image registration and fusion based on the chamfer-matching method. METHODS AND MATERIALS: The contours of the lung surfaces from CT and PET transmission images were automatically segmented by the thresholding technique. The chamfer-matching technique was then used to register the extracted lung surfaces. Arithmetic means of distance between the two data sets of the pleural surfaces were used as the cost function. Matching was then achieved by iteratively minimizing the cost function through three-dimensional (3D) translation and rotation with an optimization method. RESULTS: Both anatomic thoracic phantom images and clinical patient images were used to evaluate the performance of our registration system. Quantitative analysis from five patients indicates that the registration error in translation was 2-3 mm in the transverse plane, 3-4 mm in the longitudinal direction, and about 1.5 degree in rotation. Typical computing time for chamfer matching is about 1 min. The total time required to register a set of CT and PET lung images, including contour extraction, was generally less than 30 min. CONCLUSION: We have implemented and validated the chamfer-matching method for CT and PET lung image registration and fusion. Our preliminary results show that the chamfer-matching method for CT and PET images in the lung area is feasible. The described registration system has been used to facilitate target definition and treatment planning in radiotherapy.

A simple algorithm for planar image registration in radiation therapy.

A simple algorithm is presented for planar image registration and the method is applied to the simulator and portal image registration for patient setup verification in radiation therapy. Basically, the algorithm follows the concept proposed by Balter et al. [Med. Phys. 19, 329-334 (1992)], which converts the problem of open curve registration into matching a series of points along the curves. Balter's algorithm consists of three steps: (1) to determine a common starting point for each curve pair, (2) acquire two corresponding point sets along each curve, and (3) obtain a global transform matrix by matching two point sets. We integrate all three steps into one simple procedure which fits the sampled points along the intended curve pair by taking the relative path length shift as an independent fitting parameter. After being modified, the algorithm is able to take the different magnification factors of images into account, and it avoids curvature calculations. Numerical simulation as well as clinical and phantom images have been utilized to test the accuracy of the algorithm. The typical errors are less than 1 mm in translation and 1 degree in rotation. We also made a comparison study with the chamfer method. The results of the two methods agree to within 0.5 mm in translation and 0.5 degree in rotation.

A method for more efficient source localization of interstitial implants with biplane radiographs.

The conventional method for source localization in an interstitial ribbon implant by means of biplane radiographs can be difficult, especially when a large number of seeds are involved. We present a new algorithm for more efficient source localization with the same conventional biplane radiographs. The method does not require a one-to-one source correspondence between two radiographs. The user needs only to digitize several points, following the shape of each ribbon from both films. The points that are digitized do not need to be the location of the seeds, and they do not have to correspond to the same points on both films. The algorithm uses the multidimensional minimization method to reconstruct the three-dimensional locus of the ribbon. The location of each seed is then determined by its pathlength relative to the corresponding starting point. We have used phantom experiments and clinical cases to test the reliability of the algorithm. The results show that the errors in the determination of seed locations are less than 2 mm, and the efficiency in source digitization for data entry can be increased by a factor up to 5.

Dose to contralateral breast: a comparison of four primary breast irradiation techniques.

PURPOSE: Contralateral breast dose from primary breast irradiation has been implicated in the risk of second breast malignancies. It has been previously shown that the use of half-beam blocking can increase the opposite breast dose by a factor of five. This study evaluates four different breast treatment techniques to compare the radiation dose to the contralateral breast. METHODS AND MATERIALS: Dose measurements were made using thermoluminescent dosimeters (TLD) capsules, which were placed in the Rando phantom in the following locations in the contralateral breast: seven along the central axis plane, on at 5 cm superior to, and one 5 cm inferior to the central axis plane. One TLD capsule was placed in the midcenter of the treated breast. The following radiation techniques were used: (a) half-beam with a custom block (HB+CB), (b) half-beam using asymmetric collimator jaw (HB/AJ), (c) half-beam using asymmetric collimator jaw with custom block (H/AJ+CB), and (d) isocentric technique with nondivergent posterior borders [Joint Center for Radiation Therapy (JCRT) techique]. For each technique, isodose distributions for the Rando phantom were optimized using (a) 15 degree medial and lateral compensating wedges, and (b) a single 30 degree lateral compensating wedge. The phantom was treated with 6 MV photons. Each technique was repeated six times, and the TLD readings were averaged. RESULTS: The custom cerrobend half-beam block technique gives the highest contralateral breast dose, regardless of wedge. The remaining techniques give results in a similar range, with the asymmetric jaw with no medial wedge technique giving the lowest total dose (p = not significant). The use of a medial wedge increases the opposite breast dose for all techniques. The asymmetric half-beam technique gives significantly less dose than the cerrobend half-beam technique, due to decreased transmission through the asymmetric collimators. The asymmetric jaw vs JCRT technique results in similar contralateral breast dose. CONCLUSIONS: As expected, dose to the contralateral breast increases with the use of a medial wedge. Cerrobend half-beam blocking gives the highest opposite breast dose. The lowest contralateral breast dose is with the asymmetric jaw with no medial wedge and no block. The asymmetric jaw technique with block yields equivalent contralateral breast doses to the JCRT technique.

Using simulation data to predict lung geometry for inhomogeneity corrections in breast cancer treatments.

PURPOSE: To develop a statistical model based only on simulation measurement data, to predict the lung geometry in the central slice of the tangential radiation treatment fields for breast cancer. METHODS AND MATERIALS: A linear regression analysis was performed on 22 patients to determine the shape of lung in the central axis plane of the tangential radiation fields. Data collected include the greatest perpendicular distance (GPD) measured from the chest wall to the field border on computed tomography (CT) images, the central lung distance (CLD) measured from the posterior field border to the chest wall on the simulation portal images, and the lung contours digitized at 1 cm intervals. The lung contours of these patients were fitted to a parabolic curve through a polynomial regression model. A lung template based on the regression model is used to construct a "generic lung" contour on patients' external body contours for treatment planning. The accuracy of this technique was tested on another group of 15 patients for its ability to predict the shape of lung on the central axis plane and the accuracy of dose to the prescription point. RESULTS: The polynomial regression indicates that all the patients' lung contours in the tangential fields follow a parabolic curve: Y = -0.0808 X2 + 0.0096 X + 0.0326. The maximum lung involvement (GPD) can be determined from the value of CLD measured on the simulation film by the linear regression model with a determination coefficient of 0.712. The 15-patient test results indicate that our model predicts the lung separation on the central axis with an average deviation of 1.35 cm, and the average absolute dose deviation to the dose prescription point is 1.46%. CONCLUSION: The model presented in this article provides an efficient method to estimate the lung geometry for breast cancer treatment planning without the requirement of CT data. The lung contour predicted by our model is useful for calculating dose distributions with inhomogeneity correction and may potentially benefit patients at higher risk of pulmonary toxicity.

Calculation of monitor units for a linear accelerator with asymmetric jaws.

A simple approach was developed that calculates the output factors and tissue maximum ratio of an asymmetric field at any point within the open field, and specifically both at the central axis (when the jaws do not shadow it) and at the effective center of the open field, using the existing tables for symmetric fields and the multidepth profile information for the largest available field size (either open or with a wedge present). Day's method was adapted to calculate the effective values of the usual field-size-dependent parameters. This approach makes these parameters also dependent on the location of the calculation point relative to the field edges in an asymmetric field. This algorithm was tested by comparing its predictions with measurements of asymmetric and half blocked fields, with and without wedges, in a water phantom at different depths and off-axis distances. The agreement between calculated and measured dose rate is within 1%-3% even in highly asymmetric fields for both 6- and 18-MV photons.

A single isocenter three-field breast irradiation technique using an empiric simulation and asymmetric collimator.

The treatment of abutting fields presents multiple difficulties, including problems of field overlaps or gaps, complexity of simulation, and the difficulties of daily setup and variation. Multiple techniques have been described for the treatment of the breast/chest wall and supraclavicular nodes using tangents and a matched supraclavicular field. The techniques described have used collimator angles, couch angles, and/or corner blocks in an attempt to match these fields with no overlap or gap. Some of these techniques required complex calculations or treatment devices to achieve a geometric match between fields. We describe a technique for treatment of breast and supraclavicular nodes that uses a single isocenter and requires asymmetric collimator jaws to give half-blocked fields. The simulation and setup are done empirically, with no complex calculations required. The daily setup and treatment can be done rapidly and reliably, with no extra equipment required. Custom blocks may be used to conform to the chest wall contour and decrease the amount of lung in the treatment fields.

Streptolysin O-permeabilized cell system for studying trans-acting activities of exogenous nuclear proteins.

Efficient transfer of exogenous proteins into culture animal cells can be achieved by Streptolysin O (SLO) permeabilization of plasma membranes. We used this method to establish an in vitro transcription system for early response genes. The promoters of many early response genes contain an essential DNA motif known as the Serum Response Element (SRE). Recent data has shown that this DNA sequence is recognized by Serum Response Factor (SRF) and its associated proteins. Our initial experiments showed that HeLa nuclear extracts induced the transcription of the c-fos gene in serum-starved murine fibroblasts which were permeabilized by either physical method (glass beads) or cytolytic pore-forming protein (SLO). Plasma membrane permeabilization presumably permits passive diffusion of macromolecules into target cells and we showed that a truncated SRF expressed in bacteria was translocated into the nucleus within 30 minutes after SLO permeabilization. HeLa crude extracts were fractionated in order to identify the active nuclear factors. SRF was purified by binding to Wheat Germ Agglutinin (WGA)-agarose but the active factors remained in the WGA-unbound fractions. Our results demonstrate that this permeabilized cell in vitro transcription system is simple, efficient and can be used to test crude nuclear fractions as well as purified proteins expressed in bacteria; it will be an useful tool for the reproduction of transcriptional regulation on chromatin templates in vitro as well as the investigation of the biochemical functions of specific transcription factors or signal transduction effectors.

Use of computerized hot wire block cutter in radiation therapy.

The ability to define the target volume more accurately and to deliver the radiation therapy with better precision in modern radiation oncology has resulted in radiation treatments with tighter margins in order to spare additional normal tissues. This type of treatment requires that the radiation shielding blocks be produced with high accuracy. The computer-driven block cutter has the advantage of being able to accept block contours designed from digital simulation and portal images as well as beam's-eye-view patterns produced during treatment planning. A computerized hot wire block cutter installed in our department has shown the capability to produce accurate blocks and has reduced the number of blocks requiring modifications by about one-third. The use of templates plotted on the transparencies facilitates the accurate mounting of the blocks has resulted in further reduction of the number of block modifications.

Three-dimensional dosimetric comparison of radiation therapy treatment planning of the pancreas.

Radiation therapy for carcinoma of the pancreas requires high doses for local control. Three-dimensional dose distributions are calculated for four patients with pancreatic cancer using two conventional (4-field box and 3-field techniques) and two noncoplanar (4 and 6 oblique fields) treatment field arrangements. Uniform dose distributions are obtained for all beam arrangements. The 4-field oblique beams show a potential advantage for lower dose to the kidneys when compared with 4-field box technique, and to the small bowel, when compared with 3-field beams. The data suggest that the noncoplanar beams may be useful alternative techniques for treating this disease with certain case presentations and should be considered during the treatment planning process.