Optimization of image quality and dose for Varian aS500 electronic portal imaging devices (EPIDs).

This study was carried out to investigate whether the electronic portal imaging (EPI) acquisition process could be optimized, and as a result tolerance and action levels be set for the PIPSPro QC-3V phantom image quality assessment. The aim of the optimization process was to reduce the dose delivered to the patient while maintaining a clinically acceptable image quality. This is of interest when images are acquired in addition to the planned patient treatment, rather than images being acquired using the treatment field during a patient's treatment. A series of phantoms were used to assess image quality for different acquisition settings relative to the baseline values obtained following acceptance testing. Eight Varian aS500 EPID systems on four matched Varian 600C/D linacs and four matched Varian 2100C/D linacs were compared for consistency of performance and images were acquired at the four main orthogonal gantry angles. Images were acquired using a 6 MV beam operating at 100 MU min(-1) and the low-dose acquisition mode. Doses used in the comparison were measured using a Farmer ionization chamber placed at d(max) in solid water. The results demonstrated that the number of reset frames did not have any influence on the image contrast, but the number of frame averages did. The expected increase in noise with corresponding decrease in contrast was also observed when reducing the number of frame averages. The optimal settings for the low-dose acquisition mode with respect to image quality and dose were found to be one reset frame and three frame averages. All patients at the Northern Ireland Cancer Centre are now imaged using one reset frame and three frame averages in the 6 MV 100 MU min(-1) low-dose acquisition mode. Routine EPID QC contrast tolerance (+/-10) and action (+/-20) levels using the PIPSPro phantom based around expected values of 190 (Varian 600C/D) and 225 (Varian 2100C/D) have been introduced. The dose at dmax from electronic portal imaging has been reduced by approximately 28%, and while the image quality has been reduced, the images produced are still clinically acceptable.

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.

Reduction of small and large bowel irradiation using an optimized intensity-modulated pelvic radiotherapy technique in patients with prostate cancer.

PURPOSE: To investigate the role of intensity-modulated radiation therapy (IMRT) to irradiate the prostate gland and pelvic lymph nodes while sparing critical pelvic organs, and to optimize the number of beams required. METHODS AND MATERIALS: Target, small bowel, colon, rectum, and bladder were outlined on CT planning scans of 10 men with prostate cancer. Optimized conventional (RT) and 3-dimensional conformal radiotherapy (3D-CRT) plans were created and compared to inverse-planned IMRT dose distributions using dose-volume histograms. Optimization of beam number was undertaken for the IMRT plans. RESULTS: With RT the mean percentage volume of small bowel and colon receiving >45 Gy was 21.4 +/- 5.4%. For 3D-CRT it was 18.3 +/- 7.7% (p = 0.0043) and for 9-field IMRT it was 5.3 +/- 1.8% (p < 0.001 compared to 3D-CRT). For 7, 5, and 3 IMRT fields, it was 6.4 +/- 2.9%, 7.2 +/- 2.8%, and 8.4 +/- 3.8% (all p < 0.001 compared to 3D-CRT). The rectal volume irradiated >45 Gy was reduced from 50.5 +/- 16.3% (3D-CRT) to 5.8 +/- 2.1% by 9-field IMRT (p < 0. 001) and bladder from 52.2 +/- 12.8% to 7 +/- 2.8% (p < 0.001). Similar benefits were maintained for 7, 5, and 3 IMRT fields. CONCLUSIONS: The reduction in critical pelvic organ irradiation seen with IMRT may reduce side effects in patients, and allow modest dose escalation within acceptable complication rates. These reductions were maintained with 3-5 IMRT field plans which potentially allow less complex delivery techniques and shorter delivery times.

Potential role of intensity-modulated radiotherapy in the treatment of tumors of the maxillary sinus.

PURPOSE: To assess 3-dimensional conformal radiotherapy (3D-CRT) and intensity-modulated radiotherapy (IMRT) techniques to see whether doses to critical structures could be reduced while maintaining planning target volume (PTV) coverage in patients receiving conventional radiotherapy (RT) for carcinoma of the maxillary sinus because of the risk of radiation-induced complications, particularly visual loss. METHODS AND MATERIALS: Six patients who had recently received conventional RT for carcinoma of the maxillary sinus were studied. Conventional RT, 3D-CRT, and step-and-shoot IMRT plans were prepared using the same 2-field arrangement. The effect of reducing the number of segments in the IMRT beams was investigated. RESULTS: 3D-CRT and IMRT reduced the brain and ipsilateral parotid gland doses compared with the conventional plans. IMRT reduced doses to both optic nerves; for the contralateral optic nerve, 15-segment IMRT plans delivered an average maximal dose of 56.4 Gy (range 53.9-59.3) compared with 65.7 Gy (range 65.3-65.9) and 64.2 Gy (range 61.4-65.6) for conventional RT and 3D-CRT, respectively. IMRT also gave improved PTV homogeneity and improved coverage, with an average of 8.5% (range 7.0-11.7%) of the volume receiving <95% of the prescription dose (64 Gy) compared with 14.7% (range 14.1-15.9%) and 15.1% (range 14.4-16.1%) with conventional RT and 3D-CRT, respectively. Little difference was found between the 15 and 7-segment plans, but 5 segments resulted in a reduced minimal PTV dose. CONCLUSIONS: IMRT offers significant advantages over conventional RT and 3D-CRT techniques for treatment of maxillary sinus tumors. Good results can be obtained from 7 segments per beam without compromising the PTV coverage. This number of segments is practical for implementation in a busy RT department.

Hypofractionated stereotactic radiotherapy in the management of recurrent glioma.

PURPOSE: This study aimed to assess the efficacy and toxicity of hypofractionated stereotactic radiotherapy (SRT) in the management of patients with recurrent glioma. METHODS AND MATERIALS: From January 1989 to July 1994, 36 patients with glioma were treated at the time of recurrence. Twenty-nine had recurrent high-grade astrocytoma, 3 high-grade oligodendroglioma, 1 high-grade ependymoma, and 3 pilocytic astrocytoma. Hypofractionated stereotactic radiotherapy was given using either three noncoplanar arcs or four to six noncoplanar fixed beams at 5 Gy/fraction, to doses ranging from 20 to 50 Gy initially on a dose escalation program. Two patients received 20 Gy, 8 received 30 Gy, 10 received 35 Gy, 10 received 40 Gy, 5 received 45 Gy, and 1 received 50 Gy, treating 5 days/week. RESULTS: The median survival of 29 patients with recurrent high-grade astrocytoma was 11 months from the time of SRT. This compared to a median survival of 7 months for a cohort matched for age, performance status, and initial histologic grade who received nitrosourea-based chemotherapy at recurrence (p < 0.05). Initial low-grade astrocytoma histology was the only favorable prognostic factor for survival on univariate analysis. Three patients with recurrent oligodendroglioma remain alive 11, 23, and 34 months after SRT. Three children treated for recurrent pilocytic astrocytoma remain alive 14, 41, and 55 months following SRT. Presumed radiation damage, defined as reversible steroid-dependent toxicity, was observed in 13 patients (36%) and required reoperation in 2 (6%). A total dose of >40 Gy was a major predictor of radiation damage (p < 0.005). CONCLUSION: Hypofractionated SRT is a noninvasive, well-tolerated, outpatient-based method of delivering palliative, high-dose, focal irradiation.

Optimization of stereotactically-guided conformal treatment planning of sellar and parasellar tumors, based on normal brain dose volume histograms.

PURPOSE: To investigate the optimal treatment plan for stereotactically-guided conformal radiotherapy (SCRT) of sellar and parasellar lesions, with respect to sparing normal brain tissue, in the context of routine treatment delivery, based on dose volume histogram analysis. METHODS AND MATERIALS: Computed tomography (CT) data sets for 8 patients with sellar- and parasellar-based tumors (6 pituitary adenomas and 2 meningiomas) have been used in this study. Treatment plans were prepared for 3-coplanar and 3-, 4-, 6-, and 30-noncoplanar-field arrangements to obtain 95% isodose coverage of the planning target volume (PTV) for each plan. Conformal shaping was achieved by customized blocks generated with the beams eye view (BEV) facility. Dose volume histograms (DVH) were calculated for the normal brain (excluding the PTV), and comparisons made for normal tissue sparing for all treatment plans at > or =80%, > or =60%, and > or =40% of the prescribed dose. RESULTS: The mean volume of normal brain receiving > or =80% and > or =60% of the prescribed dose decreased by 22.3% (range 14.8-35.1%, standard deviation sigma = 7.5%) and 47.6% (range 25.8-69.1%, sigma = 13.2%), respectively, with a 4-field noncoplanar technique when compared with a conventional 3-field coplanar technique. Adding 2 further fields, from 4-noncoplanar to 6-noncoplanar fields reduced the mean normal brain volume receiving > or =80% of the prescribed dose by a further 4.1% (range -6.5-11.8%, sigma = 6.4%), and the volume receiving > or =60% by 3.3% (range -5.5-12.2%, sigma = 5.4%), neither of which were statistically significant. Each case must be considered individually however, as a wide range is seen in the volume spared when increasing the number of fields from 4 to 6. Comparing the 4- and 6-field noncoplanar techniques to a 30-field conformal field approach (simulating a dynamic arc plan) revealed near-equivalent normal tissue sparing. CONCLUSION: Four to six widely spaced, fixed-conformal fields provide the optimum class solution for the treatment of sellar and parasellar lesions, both in terms of normal brain tissue sparing and providing a relatively straightforward patient setup. Increasing the number of fields did not result in further significant sparing, with no clear benefit from techniques approaching dynamic conformal radiotherapy in the cases examined.

Commissioning of a micro multi-leaf collimator and planning system for stereotactic radiosurgery.

PURPOSE: A computer controlled micro multi-leaf collimator, m3 mMLC, has been commissioned for conformal, fixed-field radiosurgery applications. Measurements were made to characterise the basic dosimetric properties of the m3, such as leaf transmission, leakage and beam penumbra. In addition, the geometric and dosimetric accuracy of the m3 was verified when used in conjunction with a BrainSCAN v3.5 stereotactic planning system. MATERIALS AND METHODS: The m3 was detachably mounted to a Varian Clinac 2100C accelerator delivering 6 MV X-rays. Leaf transmission, leakage, penumbra and multiple, conformal fixed field dose distributions were measured using calibrated film in solid water. Beam data were collected using a diamond detector in a scanning water tank and planned dose distributions were verified using LiF TLDs and film. A small, shaped phantom was also constructed to confirm field shaping accuracy using portal images. RESULTS: Mean transmission through the closed multi-leaves was 1.9 +/- 0.1% and leakage between leaves was 2.8 +/- 0.15%. Between opposing leaves abutting along the central beam-axis transmission was approximately 15 +/- 3%, but was reduced to a mean of 4.5 +/- 0.6% by moving the abutmen position 4.5 cm off-axis. Beam penumbrae were effectively constant as a function of increasing square field size and asymmetric fields and was seen to vary non-linearly when shaped to diagonal, straight edges. TMR, OAR and relative output beam data measurements of circular m3 fields were comparable to conventional, circular stereotactic collimators. Multiple, conformal field dose distributions were calculated with good spatial and dosimetric accuracy, with the planned 90% isodose curves agreeing with measurements to within 1-2 mm and to +/- 3% at isocentre. Portal films agreed with planned beams eye-view field shaping to within 1 mm. CONCLUSIONS: The m3 micro multi-leaf collimator is a stable, high precision field-shaping device suitable for small-field, radiosurgery applications. Dose distributions can be accurately calculated by a planning system using only a few beam data parameters.

A comparison of conformal and intensity-modulated techniques for oesophageal radiotherapy.

BACKGROUND AND PURPOSE: To investigate the potential of intensity-modulated radiotherapy (IMRT) to reduce lung irradiation in the treatment of oesophageal carcinoma with radical radiotherapy. MATERIALS AND METHODS: A treatment planning study was performed to compare two-phase conformal radiotherapy (CFRT) with IMRT in five patients. The CFRT plans consisted of anterior, posterior and bilateral posterior oblique fields, while the IMRT plans consisted of either nine equispaced fields (9F), or four fields (4F) with orientations equal to the CFRT plans. IMRT plans with seven, five or three equispaced fields were also investigated in one patient. Treatment plans were compared using dose-volume histograms and normal tissue complication probabilities. RESULTS: The 9F IMRT plan was unable to improve on the homogeneity of dose to the planning target volume (PTV), compared with the CFRT plan (dose range, 16.9+/-4.5 (1 SD) vs. 12.4+/-3.9%; P=0.06). Similarly, the 9F IMRT plan was unable to reduce the mean lung dose (11.7+/-3.2 vs. 11.0+/-2.9 Gy; P=0.2). Similar results were obtained for seven, five and three equispaced fields in the single patient studied. The 4F IMRT plan provided comparable PTV dose homogeneity with the CFRT plan (11.8+/-3.3 vs. 12.4+/-3.9%; P=0.6), with reduced mean lung dose (9.5+/-2.3 vs 11.0+/-2.9 Gy; P=0.001). CONCLUSIONS: IMRT using nine equispaced fields provided no improvement over CFRT. This was because the larger number of fields in the IMRT plan distributed a low dose over the entire lung. In contrast, IMRT using four fields equal to the CFRT fields offered an improvement in lung sparing. Thus, IMRT with a few carefully chosen field directions may lead to a modest reduction in pneumonitis, or allow tumour dose escalation within the currently accepted lung toxicity.

Optimisation of radiotherapy for carcinoma of the parotid gland: a comparison of conventional, three-dimensional conformal, and intensity-modulated techniques.

BACKGROUND AND PURPOSE: To compare external beam radiotherapy techniques for parotid gland tumours using conventional radiotherapy (RT), three-dimensional conformal radiotherapy (3DCRT), and intensity-modulated radiotherapy (IMRT). To optimise the IMRT techniques, and to produce an IMRT class solution. MATERIALS AND METHODS: The planning target volume (PTV), contra-lateral parotid gland, oral cavity, brain-stem, brain and cochlea were outlined on CT planning scans of six patients with parotid gland tumours. Optimised conventional RT and 3DCRT plans were created and compared with inverse-planned IMRT dose distributions using dose-volume histograms. The aim was to reduce the radiation dose to organs at risk and improve the PTV dose distribution. A beam-direction optimisation algorithm was used to improve the dose distribution of the IMRT plans, and a class solution for parotid gland IMRT was investigated. RESULTS: 3DCRT plans produced an equivalent PTV irradiation and reduced the dose to the cochlea, oral cavity, brain, and other normal tissues compared with conventional RT. IMRT further reduced the radiation dose to the cochlea and oral cavity compared with 3DCRT. For nine- and seven-field IMRT techniques, there was an increase in low-dose radiation to non-target tissue and the contra-lateral parotid gland. IMRT plans produced using three to five optimised intensity-modulated beam directions maintained the advantages of the more complex IMRT plans, and reduced the contra-lateral parotid gland dose to acceptable levels. Three- and four-field non-coplanar beam arrangements increased the volume of brain irradiated, and increased PTV dose inhomogeneity. A four-field class solution consisting of paired ipsilateral coplanar anterior and posterior oblique beams (15, 45, 145 and 170 degrees from the anterior plane) was developed which maintained the benefits without the complexity of individual patient optimisation. CONCLUSIONS: For patients with parotid gland tumours, reduction in the radiation dose to critical normal tissues was demonstrated with 3DCRT compared with conventional RT. IMRT produced a further reduction in the dose to the cochlea and oral cavity. With nine and seven fields, the dose to the contra-lateral parotid gland was increased, but this was avoided by optimisation of the beam directions. The benefits of IMRT were maintained with three or four fields when the beam angles were optimised, but were also achieved using a four-field class solution. Clinical trials are required to confirm the clinical benefits of these improved dose distributions.

Improvements in target coverage and reduced spinal cord irradiation using intensity-modulated radiotherapy (IMRT) in patients with carcinoma of the thyroid gland.

BACKGROUND AND PURPOSE: External beam radiotherapy for thyroid carcinoma poses a significant technical challenge as the target volume lies close to or surrounds the spinal cord. The potential of intensity-modulated radiotherapy (IMRT) to improve the dose distributions was investigated. MATERIALS AND METHODS: A planning study was performed on patients with thyroid carcinoma. Plans were generated to irradiate the thyroid bed alone or to treat the thyroid bed and the loco-regional lymph nodes in two phases. Conventional plans with minimal beam shaping were compared to three-dimensional conformal radiotherapy (3DCRT) and inverse-planned IMRT plans to assess target coverage and normal tissue sparing. IMRT techniques were optimized to find the minimum number of equispaced beams required to achieve the clinical benefit and a concomitant boost technique was explored. RESULTS: For the thyroid bed alone and the thyroid bed plus loco-regional lymph nodes, conventional and conformal techniques produced low minimum doses to the planning target volume (PTV) if spinal cord tolerance was respected. 3DCRT reduced the irradiated volume of normal tissue (P=0.01). IMRT plans achieved the goal dose to the PTV (P<0.01) and also reduced the spinal cord maximum dose (P<0.01). IMRT, using a concomitant boost technique, produced better target coverage than a two-phase technique. For both the two-phase and concomitant boost techniques, IMRT plans with seven and five equispaced fields produced similar dose distributions to nine fields, but three fields were significantly worse. CONCLUSIONS: 3DCRT reduced normal tissue irradiation compared to conventional techniques, but did not improve PTV or spinal cord doses. IMRT improved the PTV coverage and reduced the spinal cord dose. A simultaneous integrated boost technique with five equispaced fields produced the best dose distribution. IMRT should reduce the risk of myelopathy or may allow dose escalation in patients with thyroid cancer.

Comparison of a multi-leaf collimator with conformal blocks for the delivery of stereotactically guided conformal radiotherapy.

Stereotactically-guided conformal radiotherapy is a practical technique for irradiating irregular lesions in the brain. The shaping of the conformal fields may be achieved using lead alloy blocks, a conventional multi-leaf collimator (MLC) or a mini/micro-MLC. Although the former gives more precise shaping, it is labour intensive. The latter methods are more practical as both mould room and treatment room times are reduced, but the shaping is limited by the finite leaf-width. This study compares treatment plans, in terms of normal tissue doses and tumour coverage, for fields shaped using conformal blocks and a conventional MLC in two series of geometrical shapes and nine patient tumours. For the range of tumour sizes considered (volumes 14-264 cm3, minimum dimension 30 mm, maximum 102 mm), the MLC treats, on average, 14% (range 3-34%) and 17% (range 0-36%) more normal brain tissue than conformal blocks to >50% and >80% of the prescription dose, respectively. The large variability is due to strong dependence on tumour shape and the presence of partial leaf-widths in the MLC fit. It is therefore important to consider both of these effects when deciding whether the MLC is appropriate for a particular target volume.

A modified polymer gel for radiotherapy dosimetry: assessment by MRI and MRS.

The characteristics of a new formulation of polymer gel are assessed for MRI-based radiotherapy dosimetry. The gel, based on the first BANG gel formulation, replaces acrylamide with the less toxic monomer sodium methacrylate. The relationship between MR T2 relaxation time and radiation dose for the gel formulation was studied using spin-echo imaging. Proton magnetic resonance spectroscopy was also used to assess the gel composition as a function of dose. The effect of gel pH on the dose-response and baseline R2 was then investigated. A calibration performed on gel without pH modulation (pH = 6.6) revealed a dose-response of 0.14 s(-1) Gy(-1) within the range 0-8 Gy. The baseline R2 increases with pH above neutrality, rising from 1.2 s(-1) at pH = 5.1 to 5.0 s(-1) at pH = 10.1. The dose-response is also pH dependent, having a minimum value of 0.09 s(-1) Gy(-1) at pH = 10.1 and peaking at 0.21 s(-1) Gy(-1) at pH = 7.7. Undertaking proton spectroscopy on the gels enabled resonances associated with the monomer and co-monomer to be studied. By integrating the peaks from the respective monomers and normalizing to the signal at 0 Gy it was shown that only 50% of the methacrylate monomer was used at 10 Gy, whereas 80% of the co-monomer was used at this dose. The data indicate that this gel has a reduced toxicity and a comparable dose response to the previously reported BANG gel. In addition, the performance of the gel can be optimized by controlling the pH. MR spectroscopy revealed that the crosslinking co-monomer is consumed more readily than the monomer, which is in agreement with previous compositional studies.

Proton spectroscopic imaging of polyacrylamide gel dosimeters for absolute radiation dosimetry.

Proton spectroscopy has been evaluated as a method for quantifying radiation induced changes in polyacrylamide gel dosimeters. A calibration was first performed using BANG-type gel samples receiving uniform doses of 6 MV photons from 0 to 9 Gy in 1 Gy intervals. The peak integral of the acrylic protons belonging to acrylamide and methylenebisacrylamide normalized to the water signal was plotted against absorbed dose. Response was approximately linear within the range 0-7 Gy. A large gel phantom irradiated with three, coplanar 3 x 3 cm square fields to 5.74 Gy at isocentre was then imaged with an echo filter technique to map the distribution of monomers directly. The image, normalized to the water signal, was converted into an absolute dose map. At the isocentre the measured dose was 5.69 Gy (SD = 0.09) which was in good agreement with the planned dose. The measured dose distribution elsewhere in the sample shows greater errors. A T2 derived dose map demonstrated a better relative distribution but gave an overestimate of the dose at isocentre of 18%. The data indicate that MR measurements of monomer concentration can complement T2-based measurements and can be used to verify absolute dose. Compared with the more usual T2 measurements for assessing gel polymerization, monomer concentration analysis is less sensitive to parameters such as gel pH and temperature, which can cause ambiguous relaxation time measurements and erroneous absolute dose calculations.

The reproducibility of polyacrylamide gel dosimetry applied to stereotactic conformal radiotherapy.

The reproducibility of polyacrylamide gel (PAG) dosimetry has been evaluated when used to verify two radiotherapy treatment plans of increasing complexity. The plans investigated were a three-field coplanar arrangement, using the linac jaws for field shaping, and a four-field, conformal, non-coplanar plan using precision-cast lead alloy shielding blocks. Each treatment was performed three times using phantoms and calibration gels manufactured in-house. Two phantoms were specially designed for this work to aid accurate positioning of the gels for irradiation and imaging. All gels were imaged post-irradiation using a Siemens Vision 1.5T MR scanner. T2 relaxation images were calibrated to absorbed dose distributions using a number of smaller calibration vessels to produce distribution maps of relative dose. The relative dose distributions were found to be reproducible, with the standard deviation on the mean areas enclosed by the > or = 50% isodose lines measured in three orthogonal planes being 6.4% and 4.1% for the coplanar and non-coplanar plans respectively. The measured distributions were also consistent with those planned, with isodose lines generally agreeing to within a few millimetres. However, the measured absolute doses were on average 23.5% higher than those planned. Although the polyacrylamide gel dosimetry technique has some limitations, particularly when calibrating distributions to absolute dose, the ability to resolve sharp dose gradients in three dimensions with millimetre precision is invaluable when verifying complex conformal treatment plans, where avoidance of proximal, critical structures is a treatment criterion.

Experimental 3D dosimetry around a high-dose-rate clinical 192Ir source using a polyacrylamide gel (PAG) dosimeter.

It is well known that the experimental dosimetry of brachytherapy sources presents a challenge. Depending on the particular-dosimeter used, measurements can suffer from poor spatial resolution (ion chambers), lack of 3D information (film) or errors due to the presence of the dosimeter itself distorting the radiation flux. To avoid these problems, we have investigated the dosimetry of a clinical 192Ir source using a polyacrylamide gel (PAG) dosimeter. Experimental measurements of dose versus radial distance from the centre of the source (cross-line plots) were compared with calculations produced with a Nucletron NPS planning system. Good agreement was found between the planning system and gel measurements in planes selected for analysis. Gel dosimeter measurements in a coronal plane through the phantom showed a mean difference between measured absorbed dose and calculated dose of 0.17 Gy with SD = 0.13 Gy. Spatially, the errors at the reference point remain within one image pixel (1.0 mm). The use of polymer gel dosimetry shows promise for brachytherapy applications, offering complete, three-dimensional dose information, good spatial resolution and small measurement errors. Measurements close to the source, however, are difficult, due to some of the limiting properties of the polyacrylamide gel.

Radiation dosimetry using polymer gels: methods and applications.

New, complex radiotherapy delivery techniques require dosimeters that are able to measure complex three-dimensional dose distributions accurately and with good spatial resolution. Polymer gel is an emerging new dosimeter being applied to these challenges. The aim of this review is to present a practical overview of polymer gel dosimetry, including gel manufacture, imaging, calibration and application to radiotherapy verification. The dosimeters consist of a gel matrix within which is suspended a solution of acrylic molecules. These molecules polymerize upon exposure to radiation, with the degree of polymerization being proportional to absorbed dose. The polymer distribution can be measured in two or three dimensions using MRI or optical tomography and, after calibration, the images can be converted into radiation dose distributions. Manufacture of the gel is reported to be reproducible, and measured dose in the range 0-10 Gy is accurate to within 3-5%. In-plane image resolution of 1 mm x 1 mm, with image slice thicknesses of between 2-5 mm, is typically achievable using clinical 1.5 T MR scanners and standard T2 weighted imaging sequences. The gels have been used to verify a number of conventional and novel radiotherapy modalities, including brachytherapy, intensity modulated radiotherapy and stereotactic radiosurgery. All the studies have confirmed the value and versatility of the dosimetry technique.

Potential improvements in the therapeutic ratio of prostate cancer irradiation: dose escalation of pathologically identified tumour nodules using intensity modulated radiotherapy.

The potential of intensity modulated radiotherapy (IMRT) to improve the therapeutic ratio in prostate cancer by dose escalation of intraprostatic tumour nodules (IPTNs) was investigated using a simultaneous integrated boost technique. The prostate and organs-at-risk were outlined on CT images from six prostate cancer patients. Positions of IPTNs were transferred onto the CT images from prostate maps derived from sequential large block sections of whole prostatectomy specimens. Inverse planned IMRT dose distributions were created to irradiate the prostate to 70 Gy and all the IPTNs to 90 Gy. A second plan was produced to escalate only the dominant IPTN (DIPTN) to 90 Gy, mimicking current imaging techniques. These plans were compared with homogeneous prostate irradiation to 70 Gy using dose-volume histograms, tumour control probability (TCP) and normal tissue complication probability (NTCP) for the rectum. The mean dose to IPTNs was increased from 69.8 Gy to 89.1 Gy if all the IPTNs were dose escalated (p=0.0003). This corresponded to a mean increase in TCP of 8.7-31.2% depending on the alpha/beta ratio of prostate cancer (p<0.001), and a mean increase in rectal NTCP of 3.0% (p<0.001). If only the DIPTN was dose escalated, the TCP was increased by 6.4-27.5% (p<0.003) and the rectal NTCP was increased by 1.8% (p<0.01). In the dose escalated DIPTN IMRT plans, the highest rectal NTCP was seen in patients with IPTNs in the posterior peripheral zone close to the anterior rectal wall, and the lowest NTCP was seen with IPTNs in the lateral peripheral zone. The ratio of increased TCP to NTCP may represent an improvement in the therapeutic ratio, but was dependent on the position of the IPTN relative to the anterior rectal wall. Improvements in prostate imaging and prostate immobilization are required before clinical implementation would be possible. Clinical trials are required to confirm the clinical benefits of these improved dose distributions.

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.

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.