Monte Carlo computed machine-specific correction factors for reference dosimetry of TomoTherapy static beam for several ion chambers.

PURPOSE: To determine k(Q(msr),Q(o) ) (f(msr),f(o) ) correction factors for machine-specific reference (msr) conditions by Monte Carlo (MC) simulations for reference dosimetry of TomoTherapy static beams for ion chambers Exradin A1SL, A12; PTW 30006, 31010 Semiflex, 31014 PinPoint, 31018 microLion; NE 2571. METHODS: For the calibration of TomoTherapy units, reference conditions specified in current codes of practice like IAEA∕TRS-398 and AAPM∕TG-51 cannot be realized. To cope with this issue, Alfonso et al. [Med. Phys. 35, 5179-5186 (2008)] described a new formalism introducing msr factors k(Q(msr),Q(o) ) (f(msr),f(o) ) for reference dosimetry, applicable to static TomoTherapy beams. In this study, those factors were computed directly using MC simulations for Q(0) corresponding to a simplified (60)Co beam in TRS-398 reference conditions (at 10 cm depth). The msr conditions were a 10 × 5 cm(2) TomoTherapy beam, source-surface distance of 85 cm and 10 cm depth. The chambers were modeled according to technical drawings using the egs++ package and the MC simulations were run with the egs_chamber user code. Phase-space files used as the source input were produced using PENELOPE after simulation of a simplified (60)Co beam and the TomoTherapy treatment head modeled according to technical drawings. Correlated sampling, intermediate phase-space storage, and photon cross-section enhancement variance reduction techniques were used. The simulations were stopped when the combined standard uncertainty was below 0.2%. RESULTS: Computed k(Q(msr),Q(o) ) (f(msr),f(o) ) values were all close to one, in a range from 0.991 for the PinPoint chamber to 1.000 for the Exradin A12 with a statistical uncertainty below 0.2%. Considering a beam quality Q defined as the TPR(20,10) for a 6 MV Elekta photon beam (0.661), the additional correction k(Q(msr,)Q) (f(msr,)f(ref) ) to k(Q,Q(o) ) defined in Alfonso et al. [Med. Phys. 35, 5179-5186 (2008)] formalism was in a range from 0.997 to 1.004. CONCLUSION: The MC computed factors in this study are in agreement with measured factors for chamber types already studied in literature. This work provides msr correction factors for additional chambers used in reference dosimetry. All of them were close to one (within 1%).

On the relationships between electron spot size, focal spot size, and virtual source position in Monte Carlo simulations.

PURPOSE: Every year, new radiotherapy techniques including stereotactic radiosurgery using linear accelerators give rise to new applications of Monte Carlo (MC) modeling. Accurate modeling requires knowing the size of the electron spot, one of the few parameters to tune in MC models. The resolution of integrated megavoltage imaging systems, such as the tomotherapy system, strongly depends on the photon spot size which is closely related to the electron spot. The aim of this article is to clarify the relationship between the electron spot size and the photon spot size (i.e., the focal spot size) for typical incident electron beam energies and target thicknesses. METHODS: Three electron energies (3, 5.5, and 18 MeV), four electron spot sizes (FWHM = 0, 0.5, 1, and 1.5 mm), and two tungsten target thicknesses (0.15 and 1 cm) were considered. The formation of the photon beam within the target was analyzed through electron energy deposition with depth, as well as photon production at several phase-space planes placed perpendicular to the beam axis, where only photons recorded for the first time were accounted for. Photon production was considered for "newborn" photons intersecting a 45 x 45 cm2 plane at the isocenter (85 cm from source). Finally, virtual source position and "effective" focal spot size were computed by back-projecting all the photons from the bottom of the target intersecting a 45 x 45 cm2 plane. The virtual source position and focal spot size were estimated at the plane position where the latter is minimal. RESULTS: In the relevant case of considering only photons intersecting the 45 x 45 cm2 plane, the results unambiguously showed that the effective photon spot is created within the first 0.25 mm of the target and that electron and focal spots may be assumed to be equal within 3-4%. CONCLUSIONS: In a good approximation photon spot size equals electron spot size for high energy X-ray treatments delivered by linear accelerators.

Monte Carlo-based simulation of dynamic jaws tomotherapy.

PURPOSE: Original TomoTherapy systems may involve a trade-off between conformity and treatment speed, the user being limited to three slice widths (1.0, 2.5, and 5.0 cm). This could be overcome by allowing the jaws to define arbitrary fields, including very small slice widths (<1 cm), which are challenging for a beam model. The aim of this work was to incorporate the dynamic jaws feature into a Monte Carlo (MC) model called TomoPen, based on the MC code PENELOPE, previously validated for the original TomoTherapy system. METHODS: To keep the general structure of TomoPen and its efficiency, the simulation strategy introduces several techniques: (1) weight modifiers to account for any jaw settings using only the 5 cm phase-space file; (2) a simplified MC based model called FastStatic to compute the modifiers faster than pure MC; (3) actual simulation of dynamic jaws. Weight modifiers computed with both FastStatic and pure MC were compared. Dynamic jaws simulations were compared with the convolution∕superposition (C∕S) of TomoTherapy in the "cheese" phantom for a plan with two targets longitudinally separated by a gap of 3 cm. Optimization was performed in two modes: asymmetric jaws-constant couch speed ("running start stop," RSS) and symmetric jaws-variable couch speed ("symmetric running start stop," SRSS). Measurements with EDR2 films were also performed for RSS for the formal validation of TomoPen with dynamic jaws. RESULTS: Weight modifiers computed with FastStatic were equivalent to pure MC within statistical uncertainties (0.5% for three standard deviations). Excellent agreement was achieved between TomoPen and C∕S for both asymmetric jaw opening∕constant couch speed and symmetric jaw opening∕variable couch speed, with deviations well within 2%∕2 mm. For RSS procedure, agreement between C∕S and measurements was within 2%∕2 mm for 95% of the points and 3%∕3 mm for 98% of the points, where dose is greater than 30% of the prescription dose (gamma analysis). Dose profiles acquired in transverse and longitudinal directions through the center of the phantom were also compared with excellent agreement (2%∕2 mm) between all modalities. CONCLUSIONS: The combination of weights modifiers and interpolation allowed implementing efficiently dynamic jaws and dynamic couch features into TomoPen at a minimal cost in terms of efficiency (simulation around 8 h on a single CPU).

Maximum proton kinetic energy and patient-generated neutron fluence considerations in proton beam arc delivery radiation therapy.

Several compact proton accelerator systems for use in proton therapy have recently been proposed. Of paramount importance to the development of such an accelerator system is the maximum kinetic energy of protons, immediately prior to entry into the patient, that must be reached by the treatment system. The commonly used value for the maximum kinetic energy required for a medical proton accelerator is 250 MeV, but it has not been demonstrated that this energy is indeed necessary to treat all or most patients eligible for proton therapy. This article quantifies the maximum kinetic energy of protons, immediately prior to entry into the patient, necessary to treat a given percentage of patients with rotational proton therapy, and examines the impact of this energy threshold on the cost and feasibility of a compact, gantry-mounted proton accelerator treatment system. One hundred randomized treatment plans from patients treated with IMRT were analyzed. The maximum radiological pathlength from the surface of the patient to the distal edge of the treatment volume was obtained for 180 degrees continuous arc proton therapy and for 180 degrees split arc proton therapy (two 90 degrees arcs) using CT# profiles from the Pinnacle (Philips Medical Systems, Madison, WI) treatment planning system. In each case, the maximum kinetic energy of protons, immediately prior to entry into the patient, that would be necessary to treat the patient was calculated using proton range tables for various media. In addition, Monte Carlo simulations were performed to quantify neutron production in a water phantom representing a patient as a function of the maximum proton kinetic energy achievable by a proton treatment system. Protons with a kinetic energy of 240 MeV, immediately prior to entry into the patient, were needed to treat 100% of patients in this study. However, it was shown that 90% of patients could be treated at 198 MeV, and 95% of patients could be treated at 207 MeV. Decreasing the proton kinetic energy from 250 to 200 MeV decreases the total neutron energy fluence produced by stopping a monoenergetic pencil beam in a water phantom by a factor of 2.3. It is possible to significantly lower the requirements on the maximum kinetic energy of a compact proton accelerator if the ability to treat a small percentage of patients with rotational therapy is sacrificed. This decrease in maximum kinetic energy, along with the corresponding decrease in neutron production, could lower the cost and ease the engineering constraints on a compact proton accelerator treatment facility.

A new formalism for reference dosimetry of small and nonstandard fields.

The use of small fields in radiotherapy techniques has increased substantially, in particular in stereotactic treatments and large uniform or nonuniform fields that are composed of small fields such as for intensity modulated radiation therapy (IMRT). This has been facilitated by the increased availability of standard and add-on multileaf collimators and a variety of new treatment units. For these fields, dosimetric errors have become considerably larger than in conventional beams mostly due to two reasons; (i) the reference conditions recommended by conventional Codes of Practice (CoPs) cannot be established in some machines and (ii) the measurement of absorbed dose to water in composite fields is not standardized. In order to develop standardized recommendations for dosimetry procedures and detectors, an international working group on reference dosimetry of small and nonstandard fields has been established by the International Atomic Energy Agency (IAEA) in cooperation with the American Association of Physicists in Medicine (AAPM) Therapy Physics Committee. This paper outlines a new formalism for the dosimetry of small and composite fields with the intention to extend recommendations given in conventional CoPs for clinical reference dosimetry based on absorbed dose to water. This formalism introduces the concept of two new intermediate calibration fields: (i) a static machine-specific reference field for those modalities that cannot establish conventional reference conditions and (ii) a plan-class specific reference field closer to the patient-specific clinical fields thereby facilitating standardization of composite field dosimetry. Prior to progressing with developing a CoP or other form of recommendation, the members of this IAEA working group welcome comments from the international medical physics community on the formalism presented here.

The impact of linac output variations on dose distributions in helical tomotherapy.

It has been suggested for quality assurance purposes that linac output variations for helical tomotherapy (HT) be within +/-2% of the long-term average. Due to cancellation of systematic uncertainty and averaging of random uncertainty over multiple beam directions, relative uncertainties in the dose distribution can be significantly lower than those in linac output. The sensitivity of four HT cases with respect to linac output uncertainties was assessed by scaling both modeled and measured systematic and random linac output uncertainties until a dose uncertainty acceptance criterion failed. The dose uncertainty acceptance criterion required the delivered dose to have at least a 95% chance of being within 2% of the planned dose in all of the voxels in the treatment volume. For a random linac output uncertainty of 5% of the long-term mean, the maximum acceptable amplitude of the modeled, sinusoidal, systematic component of the linac output uncertainty for the four cases was 1.8%. Although the measured linac output variations represented values that were outside of the +/-2% tolerance, the acceptance criterion did not fail for any of the four cases until the measured linac output variations were scaled by a factor of almost three. Thus, the +/-2% tolerance in linac output variations for HT is a more conservative tolerance than necessary.

A compact linac for intensity modulated proton therapy based on a dielectric wall accelerator.

A novel compact CT-guided intensity modulated proton radiotherapy (IMPT) system is described. The system is being designed to deliver fast IMPT so that larger target volumes and motion management can be accomplished. The system will be ideal for large and complex target volumes in young patients. The basis of the design is the dielectric wall accelerator (DWA) system being developed at the Lawrence Livermore National Laboratory (LLNL). The DWA uses fast switched high voltage transmission lines to generate pulsed electric fields on the inside of a high gradient insulating (HGI) acceleration tube. High electric field gradients are achieved by the use of alternating insulators and conductors and short pulse times. The system will produce individual pulses that can be varied in intensity, energy and spot width. The IMPT planning system will optimize delivery characteristics. The system will be capable of being sited in a conventional linac vault and provide intensity modulated rotational therapy. Feasibility tests of an optimization system for selecting the position, energy, intensity and spot size for a collection of spots comprising the treatment are underway. A prototype is being designed and concept designs of the envelope and environmental needs of the unit are beginning. The status of the developmental new technologies that make the compact system possible will be reviewed. These include, high gradient vacuum insulators, solid dielectric materials, SiC photoconductive switches and compact proton sources.

Comparison of intensity modulated x-ray therapy and intensity modulated proton therapy for selective subvolume boosting: a phantom study.

Selective subvolume boosting can theoretically improve tumour control probability while maintaining normal tissue complication probabilities similar to those of uniform dose distributions. In this work the abilities of intensity-modulated x-ray therapy (IMXT) and intensity-modulated proton therapy (IMPT) to deliver boosts to multiple subvolumes of varying size and proximities are compared in a thorough phantom study. IMXT plans were created using the step-and-shoot (IMXT-SAS) and helical tomotherapy (IMXT-HT) methods. IMPT plans were created with the spot scanning (IMPT-SS) and distal gradient tracking (IMPT-DGT) methods. IMPT-DGT is a generalization of the distal edge tracking method designed to reduce the number of proton beam spots required to deliver non-uniform dose distributions relative to IMPT-SS. The IMPT methods were delivered over both 180 degrees and 360 degrees arcs. The IMXT-SAS and IMPT-SS methods optimally satisfied the non-uniform dose prescriptions the least and the most, respectively. The IMPT delivery methods reduced the normal tissue integral dose by a factor of about 2 relative to the IMXT delivery methods, regardless of the delivery arc. The IMPT-DGT method reduced the number of proton beam spots by a factor of about 3 relative to the IMPT-SS method.

History of tomotherapy.

Tomotherapy is the delivery of intensity modulated radiation therapy using rotational delivery of a fan beam in the manner of a CT scanner. In helical tomotherapy the couch and gantry are in continuous motion akin to a helical CT scanner. Helical tomotherapy is inherently capable of acquiring CT images of the patient in treatment position and using this information for image guidance. This review documents technological advancements of the field concentrating on the conceptual beginnings through to its first clinical implementation. The history of helical tomotherapy is also a story of technology migration from academic research to a university-industrial partnership, and finally to commercialization and widespread clinical use.

The helical tomotherapy thread effect.

Inherent to helical tomotherapy is a dose variation pattern that manifests as a "ripple" (peak-to-trough relative to the average). This ripple is the result of helical beam junctioning, completely unique to helical tomotherapy. Pitch is defined as in helical CT, the couch travel distance for a complete gantry rotation relative to the axial beam width at the axis of rotation. Without scattering or beam divergence, an analytical posing of the problem as a simple integral predicts minima near a pitch of 1/n where n is an integer. A convolution-superposition dose calculator (TomoTherapy, Inc.) included all the physics needed to explore the ripple magnitude versus pitch and beam width. The results of the dose calculator and some benchmark measurements demonstrate that the ripple has sharp minima near p=0.86(1/n). The 0.86 factor is empirical and caused by a beam junctioning of the off-axis dose profiles which differ from the axial profiles as well as a long scatter tail of the profiles at depth. For very strong intensity modulation, the 0.86 factor may vary. The authors propose choosing particular minima pitches or using a second delivery that starts 180 deg off-phase from the first to reduce these ripples: "Double threading." For current typical pitches and beam widths, however, this effect is small and not clinically important for most situations. Certain extremely large field or high pitch cases, however, may benefit from mitigation of this effect.

Feasibility study of helical tomotherapy for total body or total marrow irradiation.

Total body radiation (TBI) has been used for many years as a preconditioning agent before bone marrow transplantation. Many side effects still plague its use. We investigated the planning and delivery of total body irradiation (TBI) and selective total marrow irradiation (TMI) and a reduced radiation dose to sensitive structures using image-guided helical tomotherapy. To assess the feasibility of using helical tomotherapy, (A) we studied variations in pitch, field width, and modulation factor on total body and total marrow helical tomotherapy treatments. We varied these parameters to provide a uniform dose along with a treatment times similar to conventional TBI (15-30 min). (B) We also investigated limited (head, chest, and pelvis) megavoltage CT (MVCT) scanning for the dimensional pretreatment setup verification rather than total body MVCT scanning to shorten the overall treatment time per treatment fraction. (C) We placed thermoluminescent detectors (TLDs) inside a Rando phantom to measure the dose at seven anatomical sites, including the lungs. A simulated TBI treatment showed homogeneous dose coverage (+/-10%) to the whole body. Doses to the sensitive organs were reduced by 35%-70% of the target dose. TLD measurements on Rando showed an accurate dose delivery (+/-7%) to the target and critical organs. In the TMI study, the dose was delivered conformally to the bone marrow only. The TBI and TMI treatment delivery time was reduced (by 50%) by increasing the field width from 2.5 to 5.0 cm in the inferior-superior direction. A limited MVCT reduced the target localization time 60% compared to whole body MVCT. MVCT image-guided helical tomotherapy offers a novel method to deliver a precise, homogeneous radiation dose to the whole body target while reducing the dose significantly to all critical organs. A judicious selection of pitch, modulation factor, and field size is required to produce a homogeneous dose distribution along with an acceptable treatment time. In addition, conformal radiation to the bone marrow appears feasible in an external radiation treatment using image-guided helical tomotherapy.

Verification dosimetry during treatment for helical tomotherapy using radiographic film.

Helical tomotherapy (HT) is a novel radiotherapy treatment modality that allows the delivery of intensity modulated radiation in a rotational fashion. Due to the complexity of the treatment approach, it is desirable to have a simple tool for treatment delivery verification. Radiographic film placed under the patient is exposed to dose from most of the possible beam projections and therefore constitutes a useful in vivo dosimetry record of the whole treatment. Measurements were performed during the initial clinical implementation of HT at the London Regional Cancer Centre on all patients during the first treatment fraction. It was possible to predict the optical density of the film using a dose calculation on a phantom of similar size to the patient. The comparison of expected and delivered dose allows the verification of dose delivery patterns which was found to be particularly useful in the case of treatment interruptions. The absolute dose measured with film differed in general by less than 10% from the expected one despite the fact that no build-up was used on the film. The agreement improved with proximity of the primary target to the location of the film on the treatment couch. Due to the rotational delivery mode, radiographic film was shown to be a useful, cheap and convenient method to verify dose delivery in helical tomotherapy.

Tomotherapy.

Tomotherapy is delivery of intensity-modulated, rotational radiation therapy using a fan-beam delivery. The NOMOS (Sewickley, PA) Peacock system is an example of sequential (or serial) tomotherapy that uses a fast-moving, actuator-driven multileaf collimator attached to a conventional C-arm gantry to modulate the beam intensity. In helical tomotherapy, the patient is continuously translated through a ring gantry as the fan beam rotates. The beam delivery geometry is similar to that of helical computed tomography (CT) and requires the use of slip rings to transmit power and data. A ring gantry provides a stable and accurate platform to perform tomographic verification using an unmodulated megavoltage beam. Moreover, megavoltage tomograms have adequate tissue contrast and resolution to provide setup verification. Assuming only translational and rotational offset errors, it is also possible to determine the offsets directly from tomographic projections, avoiding the time-consuming image reconstruction operation. The offsets can be used to modify the leaf delivery pattern to match the beam to the patient's anatomy on each day of a course of treatment. If tomographic representations of the patient are generated, this information can also be used to perform dose reconstruction. In this way, the actual dose distribution delivered can be superimposed onto the tomographic representation of the patient obtained at the time of treatment. The results can be compared with the planned isodose on the planning CT. This comparison may be used as an accurate basis for adaptive radiotherapy whereby the optimized delivery is modified before subsequent fractions. The verification afforded tomotherapy allows more precise conformal therapy. It also enables conformal avoidance radiotherapy, the complement to conformal therapy, for cases in which the tumor volume is ill-defined, but the locations of sensitive structures are adequately determined. A clinical tomotherapy unit is under construction at the University of Wisconsin.

An iterative filtered backprojection inverse treatment planning algorithm for tomotherapy.

PURPOSE: An inverse treatment planning algorithm for tomotherapy is described. METHODS AND MATERIALS: The algorithm iteratively computes a set of nonnegative beam intensity profiles that minimizes the least-square residual dose defined in the target and selected normal tissue regions of interest. At each iteration the residual dose distribution is transformed into a set of residual beam profiles using an inversion method derived from filtered backprojection image reconstruction theory. These "residual" profiles are used to correct the current beam profile estimates resulting in new profile estimates. Adaptive filtering is incorporated into the inversion model so that the gross structure of the dose distribution is optimized during initial iterations of the algorithm, and the fine structure corresponding to edges is obtained at later iterations. A three dimensional, kernel based, convolutions/superposition dose model is used to compute dose during each iteration. RESULTS: Two clinically relevant treatment planning examples are presented illustrating the use of the algorithm for planning conformal radiotherapy of the breast and the prostate. Solutions are generally achieved in 10-20 iterations requiring about 20 h of CPU time using a midrange workstation. The majority of the calculation time is spent on the three-dimensional dose calculation. CONCLUSIONS: The inverse treatment planning algorithm is a useful research tool for exploring the potential of tomotherapy for conformal radiotherapy. Further work is needed to (a) achieve clinically acceptable computation times; (b) verify the algorithm using multileaf collimator technology; and (c) extend the method to biological objectives.

A unified approach to the optimization of brachytherapy and external beam dosimetry.

Semi-automated optimization of dose distributions is possible using techniques borrowed from imaging science. The ideal distribution of dose is first deconvolved by a convolution kernel yielding an ideal weighting distribution in the patient. The weighting distribution describes the total energy released per unit mass of the irradiated medium. For internal and external radiation sources, this is directly related to the amount and distribution of radioactivity and energy fluence in the medium, respectively. For external sources, the exponential Radon transform is used to obtain ideal fluence projections incident on the patient. In both instances negative values are produced, which when set to zero result in perturbed dose distributions. This may necessitate iterative techniques to reduce the 'residual dose' produced by the zeroing process. Application of the approach is presented for the optimization of 2-dimensional dose distributions in external beam therapy, radioimmunotherapy, and brachytherapy sources.

A three-dimensional volume visualization package applied to stereotactic radiosurgery treatment planning.

A comprehensive software package has been developed for visualization and analysis of 3-dimensional data sets. The system offers a variety of 2- and 3-dimensional display facilities including highly realistic volume rendered images generated directly from the data set. The package has been specifically modified and successfully used for stereotactic radiosurgery treatment planning. The stereotactic coordinate transformation is determined by finding the localization frame automatically in the CT volume. Treatment arcs are specified interactively and displayed as paths on 3-dimensional anatomical surfaces. The resulting dose distribution is displayed using traditional 2-dimensional displays or as an isodose surface composited with underlying anatomy and the target volume. Dose volume histogram analysis is an integral part of the system. This paper gives an overview of volume rendering methods and describes the application of these tools to stereotactic radiosurgery treatment planning.

A solid water pelvic and prostate phantom for imaging, volume rendering, treatment planning, and dosimetry for an RTOG multi-institutional, 3-D dose escalation study. Radiation Therapy Oncology Group.

PURPOSE: With increased interest in 3-D conformal radiation therapy and dose escalation, it is necessary to provide advanced techniques to assure quality in treatment delivery. Multi-institutional trials for these newer treatment techniques require methods of verifying the consistency of treatments between the participating institutions. For this reason, a phantom was designed to address the quality and consistency of Radiation Therapy Oncology Group (RTOG) 3-D prostate treatment protocol. METHODS AND MATERIALS: A solid water pelvic and prostate phantom for imaging, volume rendering, treatment planning, and dosimetry applications for performing comprehensive quality assurance has been designed and fabricated. Its configuration was based upon CT slices obtained from a patient study. Individual slices were machined with corresponding contours of the prostate, bladder, rectum, and the left and right femurs. Most of the phantom is made of solid water (Gammex/RMI, Middleton, WI), while the femurs are made of bone-equivalent material. The CT numbers from patient images were used to adjust the solid water composition within the organ volumes, providing image contrast from the remainder of the phantom. Cylindrical insertion grooves are machined in the phantom to allow placement of ionization chambers and thermal luminal dosimeters (TLDs) for dosimetry applications. During imaging, the cavities are filled with rods fabricated from solid water material. RESULTS: The phantom is being used to evaluate the consistency of a range of processes in radiation therapy simulation, planning, and delivery of 3-D-based treatments for prostate cancer. CONCLUSION: The ultimate study objective is to use the phantom to evaluate the accuracy and consistency of treatments delivered by institutions participating in national collaborative clinical trials involving 3-D conformal dose escalation.

Monte Carlo and convolution dosimetry for stereotactic radiosurgery.

The dosimetry of small photon beams used for stereotactic radiosurgery was investigated using Monte Carlo simulation, convolution calculations, and measurements. A Monte Carlo code was used to simulate radiation transport through a linear accelerator to produce and score energy spectrum and angular distribution of 6 MV bremsstrahlung photons exiting from the accelerator treatment head. These photons were then transported through a stereotactic collimator system and into a water phantom placed at isocenter. The energy spectrum was also used as input for the convolution method of photon dose calculation. Monte Carlo and convolution results were compared with the measured data obtained using an ionization chamber, a diode, and film.

Defining the role of radiosurgery in the management of brain metastases.

The role of stereotactic radiosurgery in the management of recurrent and newly diagnosed brain metastases was evaluated prospectively. From December 1988 to March 1991, 58 lesions in 40 patients were treated with accelerator-based stereotactic radiosurgery. All patients were followed for a minimum of 6 months or to death. The primary purpose was to determine the impact of radiosurgery on local control and its subsequent effects on quality of life. An overall tumor control rate of 82% with a complete response rate of 43% were achieved. As anticipated, the response rate for smaller tumors was substantially better than that for larger tumors (78% for lesions < 2 cm3; 50% for lesions > or = 10 cm3). Although the overall in-field progression rate was 18.5%, only 1/23 (4%) complete responders subsequently recurred. The in-field failure rate is highly comparable with recently published surgical data. Progression outside the brain was noted in two-thirds of patients. One quarter of the deaths were neurologic. The median survival for this minimally selected patient population was 6.5 months. Stereotactic radiosurgery was also associated with improved quality of life as measured by Karnofsky score, neurologic function, and steroid dependence. Long-term steroid dependence was encountered in only four patients. We conclude that stereotactic radiosurgery can be used effectively in patients with brain metastases. In this series, a high tumor response rate was achieved which was associated with improved quality of life.

Fine tuning of linear accelerator accessories for stereotactic radiotherapy.

PURPOSE: Experience with the University of Wisconsin's stereotactic radiotherapy (SRT) accessory system was applied to build a new system, facilitate alignment of linac photon beams with a Brown-Roberts-Wells (BRW) stereotaxy, and increase the versatility and stability of the stereotaxy. METHODS AND MATERIALS: High tensile strength stainless steel was used in the floor stand to increase the range of gantry rotation relative to ranges allowed by truss-mounted stands. The collimator assembly and floor stand were each fitted with two-axis gimbal and translation adjustments in addition to the floor stand's three-axis adjustments. The head ring positioning assembly was fitted with two braces to prevent the head ring from deforming with patient motion. Six MV linac photon beam characteristics were measured with a computer-controlled scanning system and a diode in water, at source to surface distances (SSD) of 80 and 100 cm, and for 13 divergent collimators ranging in diameter from 1-4 cm at 100 cm SSD. Quality assurance software was applied to screen data for questionable consistency or symmetry. Integrity of the stereotaxy was evaluated with target simulation films and repeated measurements which were part of the quality assurance of clinical treatments. A method was developed using a glass etched contact reticle to obtain average simulated target to beam center distances (delta av) from target simulation films. RESULTS AND CONCLUSION: New aspects of the current system have improved the ability to fine tune and analyze stereotactic alignment. Beam characteristics met stringent output criteria and penumbral widths were the same or narrower than penumbral widths reported elsewhere. The precision of measuring delta av was 0.1 mm, and delta av averaged over 50 target simulation films was 0.7 +/- 0.1 mm. Results suggest that it may be useful to determine delta av from target simulation films with the method described here.