Characterisation of flattening filter free (FFF) beam properties for initial beam set-up and routine QA, independent of flattened beams.

Flattening filter free (FFF) beams have reached widespread use for clinical treatment deliveries. The usual methods for FFF beam characterisation for their quality assurance (QA) require the use of associated conventional flattened beams (cFF). Methods for QA of FFF without the need to use associated cFF beams are presented and evaluated against current methods for both FFF and cFF beams. Inflection point normalisation is evaluated against conventional methods for the determination of field size and penumbra for field sizes from 3 cm × 3 cm to 40 cm × 40cm at depths from dmax to 20 cm in water for matched and unmatched FFF beams and for cFF beams. A method for measuring symmetry in the cross plane direction is suggested and evaluated as FFF beams are insensitive to symmetry changes in this direction. Methods for characterising beam energy are evaluated and the impact of beam energy on profile shape compared to that of cFF beams. In-plane symmetry can be measured, as can cFF beams, using observed changes in profile, whereas cross-plane symmetry can be measured by acquiring profiles at collimator angles 0 and 180. Beam energy and 'unflatness' can be measured as with cFF beams from observed shifts in profile with changing beam energy. Normalising the inflection points of FFF beams to 55% results in an equivalent penumbra and field size measurement within 0.5 mm of conventional methods with the exception of 40 cm × 40 cm fields at a depth of 20 cm. New proposed methods are presented that make it possible to independently carry out set up and QA measurements on beam energy, flatness, symmetry and field size of an FFF beam without the need to reference to an equivalent flattened beam of the same energy. The methods proposed can also be used to carry out this QA for flattened beams, resulting in universal definitions and methods for MV beams. This is presented for beams produced by an Elekta linear accelerator, but is anticipated to also apply to other manufacturers' beams.

Benchmarking of a treatment planning system for spot scanning proton therapy: comparison and analysis of robustness to setup errors of photon IMRT and proton SFUD treatment plans of base of skull meningioma.

PURPOSE: Base of skull meningioma can be treated with both intensity modulated radiation therapy (IMRT) and spot scanned proton therapy (PT). One of the main benefits of PT is better sparing of organs at risk, but due to the physical and dosimetric characteristics of protons, spot scanned PT can be more sensitive to the uncertainties encountered in the treatment process compared with photon treatment. Therefore, robustness analysis should be part of a comprehensive comparison between these two treatment methods in order to quantify and understand the sensitivity of the treatment techniques to uncertainties. The aim of this work was to benchmark a spot scanning treatment planning system for planning of base of skull meningioma and to compare the created plans and analyze their robustness to setup errors against the IMRT technique. METHODS: Plans were produced for three base of skull meningioma cases: IMRT planned with a commercial TPS [Monaco (Elekta AB, Sweden)]; single field uniform dose (SFUD) spot scanning PT produced with an in-house TPS (PSI-plan); and SFUD spot scanning PT plan created with a commercial TPS [XiO (Elekta AB, Sweden)]. A tool for evaluating robustness to random setup errors was created and, for each plan, both a dosimetric evaluation and a robustness analysis to setup errors were performed. RESULTS: It was possible to create clinically acceptable treatment plans for spot scanning proton therapy of meningioma with a commercially available TPS. However, since each treatment planning system uses different methods, this comparison showed different dosimetric results as well as different sensitivities to setup uncertainties. The results confirmed the necessity of an analysis tool for assessing plan robustness to provide a fair comparison of photon and proton plans. CONCLUSIONS: Robustness analysis is a critical part of plan evaluation when comparing IMRT plans with spot scanned proton therapy plans.

Beam characteristics of energy-matched flattening filter free beams.

PURPOSE: Flattening filter free (FFF) linear accelerators can increase treatment efficiency and plan quality. There are multiple methods of defining a FFF beam. The Elekta control system supports tuning of the delivered FFF beam energy to enable matching of the percentage depth-dose (PDD) of the flattened beam at 10 cm depth. This is compared to FFF beams where the linac control parameters are identical to those for the flattened beam. All beams were delivered on an Elekta Synergy accelerator with an Agility multi-leaf collimator installed and compared to the standard, flattened beam. The aim of this study is to compare "matched" FFF beams to both "unmatched" FFF beams and flattened beams to determine the benefits of matching beams. METHODS: For the three modes of operation 6 MV flattened, 6 MV matched FFF, 6 MV unmatched FFF, 10 MV flattened, 10 MV matched FFF, and 10 MV unmatched FFF beam profiles were obtained using a plotting tank and were measured in steps of 0.1 mm in the penumbral region. Beam penumbra was defined as the distance between the 80% and 20% of the normalized dose when the inflection points of the unflattened and flattened profiles were normalized with the central axis dose of the flattened field set as 100%. PDD data was obtained at field sizes ranging from 3 cm × 3 cm to 40 cm × 40 cm. Radiation protection measurements were additionally performed to determine the head leakage and environmental monitoring through the maze and primary barriers. RESULTS: No significant change is made to the beam penumbra for FFF beams with and without PDD matching, the maximum change in penumbra for a 10 cm × 10 cm field was within the experimental error of the study. The changes in the profile shape with increasing field size are most significant for the matched FFF beam, and both FFF beams showed less profile shape variation with increasing depth when compared to flattened beams, due to consistency in beam energy spectra across the radiation field. The PDDs of the FFF beams showed less variation with field size, the d(max) value was deeper for the matched FFF beam than the FFF beam and deeper than the flattened beam for field sizes greater than 5 cm × 5 cm. The head leakage when using the machine in FFF mode is less than half that for a flattened beam, but comparable for both FFF modes. The radiation protection dose-rate measurements show an increase of instantaneous dose-rates when operating the machines in FFF mode but that increase is less than the ratio of MU/min produced by the machine. CONCLUSIONS: The matching of a FFF beam to a flattened beam at a depth of 10 cm in water by increasing the FFF beam energy does not reduce any of the reported benefits of FFF beams. Conversely, there are a number of potential benefits resulting from matching the FFF beam; the depth of maximum dose is deeper, the out of field dose is potentially reduced, and the beam quality and penetration more closely resembles the flattened beams currently used in clinical practice, making dose distributions in water more alike. Highlighted in this work is the fact that some conventional specifications and methods for measurement of beam parameters such as penumbra are not relevant and further work is required to address this situation with respect to "matched" FFF beams and to determine methods of measurement that are not reliant on an associated flattened beam.

A dosimetric characterization of a novel linear accelerator collimator.

PURPOSE: The aim of this work is to characterize a new linear accelerator collimator which contains a single pair of sculpted diaphragms mounted orthogonally to a 160 leaf multileaf collimator (MLC). The diaphragms have "thick" regions providing full attenuation and "thin" regions where attenuation is provided by both the leaves and the diaphragm. The leaves are mounted on a dynamic leaf guide allowing rapid leaf motion and leaf travel over 350 mm. METHODS: Dosimetric characterization, including assessment of leaf transmission, leaf tip transmission, penumbral width, was performed in a plotting tank. Head scatter factor was measured using a mini-phantom and the effect of leaf guide position on output was assessed using a water phantom. The tongue and groove effect was assessed using multiple exposures on radiochromic film. Leaf reproducibility was assessed from portal images of multiple abutting fields. RESULTS: The maximum transmission through the multileaf collimator is 0.44% at 6 MV and 0.52% at 10 MV. This reduced to 0.22% and 0.27%, respectively, when the beam passes through the dynamic leaf guide in addition to the MLC. The maximum transmission through the thick part of the diaphragm is 0.32% and 0.36% at 6 and 10 MV. The combination of leaf and diaphragm transmission ranges from 0.08% to 0.010% at 6 MV and 0.10% to 0.14% depending on whether the shielding is through the thick or thin part of the diaphragm. The off-axis intertip transmission for a zero leaf gap is 2.2% at 6 and 10 MV. The leaf tip penumbra for a 100 × 100 mm field ranges from 5.4 to 4.3 mm at 6 and 10 MV across the full range of leaf motion when measured in the AB direction, which reduces to 4.0-3.4 mm at 6 MV and 4.5-3.8 mm at 10 MV when measured in the GT direction. For a 50 × 50 mm field, the diaphragm penumbra ranges from 4.3 to 3.7 mm at 6 MV and 4.5 to 4.1 mm at 10 MV in the AB direction and 3.7 to 3.2 mm at 6 MV and 4.2 to 3.7 mm when measured in the GT direction. The tongue and groove effect observed from exposure of a radiochromic film to two abutting fields is an underdose of 25%. The head scatter factor at both 6 and 10 MV is similar to that from the MLCi2 collimator to within 0.8%. The uncertainty in the leaf position reproducibility is 0.05 mm (2σ). CONCLUSIONS: The Agility collimator is a low leakage, high definition collimator where both the MLC and the sculpted diaphragm have been optimized for dynamic treatments.

Measuring linac photon beam energy through EPID image analysis of physically wedged fields.

PURPOSE: Electronic portal imaging devices (EPIDs) have proven to be useful tools for measuring several parameters of interest in linac quality assurance (QA). However, a method for measuring linac photon beam energy using EPIDs has not previously been reported. In this report, such a method is devised and tested, based on fitting a second order polynomial to the profiles of physically wedged beams, where the metric of interest is the second order coefficient α. The relationship between α and the beam quality index [percentage depth dose at 10 cm depth (PDD10)] is examined to produce a suitable calibration curve between these two parameters. METHODS: Measurements were taken in a water-tank for beams with a range of energies representative of the local QA tolerances about the nominal value 6 MV. In each case, the beam quality was found in terms of PDD10 for 100 × 100 mm(2) square fields. EPID images of 200 × 200 mm(2) wedged fields were then taken for each beam and the wedge profile was fitted in MATLAB 2010b (The MathWorks, Inc., Natick, MA). α was then plotted against PDD10 and fitted with a linear relation to produce the calibration curve. The uncertainty in α was evaluated by taking five repeat EPID images of the wedged field for a beam of 6 MV nominal energy. The consistency of measuring α was found by taking repeat measurements on a single linac over a three month period. The method was also tested at 10 MV by repeating the water-tank crosscalibration for a range of energies centered approximately about a 10 MV nominal value. Finally, the calibration curve from the test linac and that from a separate clinical machine were compared to test consistency of the method across machines in a matched fleet. RESULTS: The relationship between α and PDD10 was found to be strongly linear (R(2) = 0.979) while the uncertainty in α was found to be negligible compared to that associated with measuring PDD10 in the water-tank (± 0.3%). The repeat measurements over a three month period showed the method to be reasonably consistent (i.e., well within the limits defined by local QA tolerances). The measurements were repeated on a matched machine and the same linear relationship between α and PDD10 was observed. The results for both machines were found to be indistinguishable across the energy range of interest (i.e., across and close to the thresholds defined by local QA tolerances), hence a single relation could be established across a matched fleet. Finally, the experiment was repeated on both linacs at 10 MV, where the linear relationship between α and PDD10 was again observed. CONCLUSIONS: The authors conclude that EPID image analysis of physically wedged beam profiles can be used to measure linac photon beam energy. The uncertainty in such a measurement is dominated by that associated with measuring PDD10 in the water-tank; hence, the accuracies of these two methods are directly comparable. This method provides a useful technique for quickly performing energy constancy measurements while saving significant clinical downtime for QA.

The matching of wedge transmission factors across six multi-energy linear accelerators.

Elekta Precise linear accelerators create a wedged isodose distribution using a single, fixed, motorized wedge with a nominal wedge angle of 60 degrees. Wedge angles of less than 60 degrees can be produced by varying the proportion of open and wedge monitor units for a given exposure. The fixed wedge can be replaced with a mobile wedge, the position of which can be moved in order to adjust the wedge transmission factor (WTF). Using the original fixed wedges installed in our fleet of six Elekta accelerators, we found a range of 4% in measured wedge transmission factor for 6 MV beams. Results are presented which demonstrate that by using the mobile wedge it is possible to match the wedge transmission factors to within 1% for the six linear accelerators over three energies.

An investigation of the safety of oral calcium formate in dairy cows using clinical, biochemical and histopathological parameters.

AIM: To investigate the safety of orally administered calcium formate in dairy cows fed adequate amounts of good quality pasture. METHODS: Twelve mixed-age pasture-fed lactating dairy cows were randomly allocated to three groups (n=4 cows/ group). Group 1 served as untreated controls. Group 2 was treated orally with 400 ml of 13.4% (w/w) calcium as calcium chloride gel, four times at approximately 12-h intervals. Group 3 was treated orally with 350 ml of 11.4 % (w/w) calcium as a 48.6% aqueous suspension of calcium formate, four times at approximately 12-h intervals. Cows grazed good quality autumn ryegrass and white clover pasture throughout the trial. All cows were examined clinically each evening and a blood sample collected. Cows were slaughtered 75 h after the last treatment and viscera examined visually for lesions. Samples from the mid-fundic area of the abomasum of each cow were collected for histopathological examination. Blood samples collected pre and 90-h post-first treatment were analysed for serum haptoglobin and pepsinogen concentrations. RESULTS: No evidence of abnormality was detected by observation or clinical examination in any of the trial cows. Serum haptoglobin concentrations were basal for all groups pre-treatment and remained basal for Groups 1 and 3 post-treatment, but were elevated post-treatment for Group 2 (p=0.016). No differences in serum pepsinogen concentrations were detected between sampling times or treatment groups. One cow from Group 2 had several small (5 mm) abomasal ulcers present at necropsy. Another cow from the same group had histopathology suggestive of thrombosis and re-endothelialisation. CONCLUSIONS: Oral administration of calcium formate (350 ml of 48.6% aqueous suspension) administered on four occasions at 12-h intervals had no adverse effects on the four cows examined, and as such is considered a safe form of calcium supplementation in adult dairy cows.

Combined MR imaging and CFD simulation of flow in the human descending aorta.

A combined MR and computational fluid dynamics (CFD) study is made of flow in the upper descending thoracic aorta. The aim was to investigate further the potential of CFD simulations linked to in vivo MRI scans. The three-dimensional (3D) geometrical images of the aorta and the 3D time-resolved velocity images at the entry to the domain studied were used as boundary conditions for the CFD simulations of the flow. Despite some measurement uncertainties, comparisons between simulated and measured flow structures at the exit from the domain demonstrated encouraging levels of agreement. Moreover, the CFD simulation allowed the flow structure throughout the domain to be examined in more detail, in particular the flow separation region in the distal aortic arch and its influence on the downstream flow during late systole. Additional information such as relative pressure and wall shear stress, which could not be measured via MRI, were also extracted from the simulation. The results have encouraged further applications of the methods described. J. Magn. Reson. Imaging 2001;13:699-713.

Isocentric treatment of inclined volumes planned using coronal sections.

The treatment parameters necessary for the isocentric treatment of an inclined volume have to be determined either analytically or through simulation. The derivation of the treatment parameters for the treatment of a transverse plane has been described previously. This work describes the derivation of the treatment parameters necessary for the isocentric treatment of an inclined volume that has been planned from an angled coronal section. Ways of implementing the system in the clinic are described.

Combined MRI and CFD analysis of fully developed steady and pulsatile laminar flow through a bend.

A combined MR and computational fluid dynamics (CFD) study is made of flow in a simple phantom laboratory flow rig consisting of a 180 degree bend with straight entry and exit sections. The aim was to investigate the potential of the use of MRI-linked CFD simulations for in vivo use. To this end, the experiment was set up for both steady and pulsatile laminar flow conditions, with Reynolds and Dean numbers and Womersley pulsatility parameter representative of resting flow in the human aorta. The geometrical images of the pipe and the velocity images at entry to the bend were used as boundary conditions for CFD simulations of the flow. The CFD results for both steady and pulsatile cases compared favorably with velocity images obtained at exit from the bend. Additional information such as pressure and wall shear stress, which either could not be measured adequately via MRI, or could not be measured at all, was also extracted from the simulation. Overall, the results were sufficiently promising to justify pursuing subsequent in vivo studies.

Implementation of the Varian EDW into a commercial RTP system.

An enhanced dynamic wedge system (EDW) has been installed onto our Clinac 600C (6 MV) linear accelerator. This paper addresses and describes the measurements taken and subsequent analysis required to enable the planning of EDW using our commercial radiotherapy treatment planning (RTP) system. This implementation into a 'closed' commercial system is performed without the use of specialized measurement equipment or the necessity of introducing new calculation algorithms and is therefore independent of the RTP manufacturer. We consider that, for incorporation of techniques such as EDW into routine clinical use, a simple verifiable method of inclusion into the RTP system must be achieved. This paper also presents a methodology for quality control of dynamic fields chosen for clinical use which is quick and easy to use by virtue of its use of film dosimetry. We present the method of film calibration used in this work.