Performance of a commercial Macro Monte Carlo dose calculation algorithm for determining output factors of clinical electron fields.

We compare measured output factors of clinical electron fields to those calculated by a commercial treatment planning system based on an electron Monte Carlo algorithm. The measured data is comprised of 195 fields with energies 6 to 18 MeV, applicator sizes 6 x 6 cm(2) to 25 x 25 cm(2), and source to surface distances (SSDs) of 97 to 107 cm. Due to a scarcity of clinical fields for the highest energies and the largest applicator sizes, additional measurements were made at arbitrarily chosen large field sizes at previously not used energies, for a total of 223 output factors. The difference between calculation and measurement ranged from -2.9% to 3.9%, with a mean difference of -0.2%. Half of the field shapes had a difference with magnitude less than 0.8%. Only 7 (3%) of the field shapes were outliers, having differences greater than 2%. All outliers had field widths at the normalization point < 3.5 cm, were applied at SSDs > 100 cm, were inserts for the 25 _ 25 cm(2) applicator, or had more than one of these characteristics. For narrow and elongated fields the TPS slightly overestimated output factors, whereas for field shapes with aspect ratio close to 1 the TPS slightly underestimated the output factors. No strong dependence of the difference on energy was observed.

Comprehensive evaluation of a commercial macro Monte Carlo electron dose calculation implementation using a standard verification data set.

A commercial electron dose calculation software implementation based on the macro Monte Carlo algorithm has recently been introduced. We have evaluated the performance of the system using a standard verification data set comprised of two-dimensional (2D) dose distributions in the transverse plane of a 15 X 15 cm2 field. The standard data set was comprised of measurements performed for combinations of 9-MeV and 20-MeV beam energies and five phantom geometries. The phantom geometries included bone and air heterogeneities, and irregular surface contours. The standard verification data included a subset of the data needed to commission the dose calculation. Additional required data were obtained from a dosimetrically equivalent machine. In addition, we performed 2D dose measurements in a water phantom for the standard field sizes, a 4 cm X 4 cm field, a 3 cm diameter circle, and a 5 cm X 13 cm triangle for the 6-, 9-, 12-, 15-, and 18-MeV energies of a Clinac 21EX. Output factors were also measured. Synthetic CT images and structure contours duplicating the measurement configurations were generated and transferred to the treatment planning system. Calculations for the standard verification data set were performed over the range of each of the algorithm parameters: statistical precision, grid-spacing, and smoothing. Dose difference and distance-to-agreement were computed for the calculation points. We found that the best results were obtained for the highest statistical precision, for the smallest grid spacing, and for smoothed dose distributions. Calculations for the 21EX data were performed using parameters that the evaluation of the standard verification data suggested would produce clinically acceptable results. The dose difference and distance-to-agreement were similar to that observed for the standard verification data set except for the portion of the triangle field narrower than 3 cm for the 6- and 9-MeV electron beams. The output agreed with measurements to within 2%, with the exception of the 3-cm diameter circle and the triangle for 6 MeV, which were within 5%. We conclude that clinically acceptable results may be obtained using a grid spacing that is no larger than approximately one-tenth of the distal falloff distance of the electron depth dose curve (depth from 80% to 20% of the maximum dose) and small relative to the size of heterogeneities. For judicious choices of parameters, dose calculations agree with measurements to better than 3% dose difference and 3-mm distance-to-agreement for fields with dimensions no less than about 3 cm.

Monte Carlo techniques for scattering foil design and dosimetry in total skin electron irradiations.

Total skin electron irradiation (TSEI) with single fields requires large electron beams having good dose uniformity, dmax at the skin surface, and low bremsstrahlung contamination. To satisfy these requirements, energy degraders and scattering foils have to be specially designed for the given accelerator and treatment room. We used Monte Carlo (MC) techniques based on EGS4 user codes (BEAM, DOSXYZ, and DOSRZ) as a guide in the beam modifier design of our TSEI system. The dosimetric characteristics at the treatment distance of 382 cm source-to-surface distance (SSD) were verified experimentally using a linear array of 47 ion chambers, a parallel plate chamber, and radiochromic film. By matching MC simulations to standard beam measurements at 100 cm SSD, the parameters of the electron beam incident on the vacuum window were determined. Best match was achieved assuming that electrons were monoenergetic at 6.72 MeV, parallel, and distributed in a circular pattern having a Gaussian radial distribution with full width at half maximum = 0.13 cm. These parameters were then used to simulate our TSEI unit with various scattering foils. Two of the foils were fabricated and experimentally evaluated by measuring off-axis dose uniformity and depth doses. A scattering foil, consisting of a 12 x 12 cm2 aluminum plate of 0.6 cm thickness and placed at isocenter perpendicular to the beam direction, was considered optimal. It produced a beam that was flat within +/-3% up to 60 cm off-axis distance, dropped by not more than 8% at a distance of 90 cm, and had an x-ray contamination of <3%. For stationary beams, MC-computed dmax, Rp, and R50 agreed with measurements within 0.5 mm. The MC-predicted surface dose of the rotating phantom was 41% of the dose rate at dmax of the stationary phantom, whereas our calculations based on a semiempirical formula in the literature yielded a drop to 42%. The MC simulations provided the guideline of beam modifier design for TSEI and estimated the dosimetric performance for stationary and rotational irradiations.

Determination of field size-dependent wedge factors from a few selected measurements.

Some modern treatment-planning systems (TPSs) provide for input of wedge factor (WF) tables covering the entire range of square and elongated fields available on the LINAC. Depending on the field size increment chosen and the number of available wedge orientations, one may have to take more than 100 measurements per wedge and photon energy to commission the TPS. To expedite TPS commissioning while maintaining high accuracy, we demonstrate a simple method that requires only a few measurements per wedge, from which the remaining wedge factors can be found through linear interpolation based on field area. For the externally mounted wedges of two common LINACs, we have shown that WFs are proportional to field area and are nearly independent of field elongation and wedge orientation. Wedge factors computed from five to seven measurements comprised of square fields and a single, large rectangular field agreed with direct measurements throughout the entire range of achievable field dimensions within 0.6% at 6 MV and within 1% at 15 MV. Making the same set of measurements and using the equivalent square method to find WFs at other field sizes leads to errors up to 2%. Measuring the WF for a 10 x 10 cm2 field and applying the same value to all field sizes can lead to errors of up to 10% at both 6 MV and 15 MV.

Assaying 192Ir line sources using a standard length well chamber.

The strength of intravascular 192Ir sources is typically measured by the manufacturer before shipment, and treatment planning is based on that assay. However, in-house verification of source strength is required at some institutions by state law or internal policy, is recommended by the AAPM TG 60 report on intravascular brachytherapy, and is considered a necessity by many medical physicists. To accommodate the long sources used in intravascular therapy, special well chambers with extended regions of constant response have been designed. To allow assays using a widely available standard well chamber, we have measured its position dependent sensitivity and derived from it a table of correction factors that account for the extended length of intravascular sources. An experimental verification shows that application of these correction factors yields assays with sufficient accuracy for routine quality assurance tests.

Dosimetric effect of respiration-gated beam on IMRT delivery.

Intensity modulated radiation therapy (IMRT) with a dynamic multileaf collimator (DMLC) requires synchronization of DMLC leaf motion with dose delivery. A delay in DMLC communication is known to cause leaf lag and lead to dosimetric errors. The errors may be exacerbated by gated operation. The purpose of this study was to investigate the effect of leaf lag on the accuracy of doses delivered in gated IMRT. We first determined the effective leaf delay time by measuring the dose in a stationary phantom delivered by wedge-shaped fields. The wedge fields were generated by a DMLC at various dose rates. The so determined delay varied from 88.3 to 90.5 ms. The dosimetric effect of this delay on gated IMRT was studied by delivering wedge-shaped and clinical IMRT fields to moving and stationary phantoms at dose rates ranging from 100 to 600 MU/min, with and without gating. Respiratory motion was simulated by a linear sinusoidal motion of the phantom. An ionization chamber and films were employed for absolute dose and 2-D dose distribution measurements. Discrepancies between gated and nongated delivery to the stationary phantom were observed in both absolute dose and 2-D dose distribution measurements. These discrepancies increased monotonically with dose rate and frequency of beam interruptions, and could reach 3.7% of the total dose delivered to a 0.6 cm3 ion chamber. Isodose lines could be shifted by as much as 3 mm. The results are consistent with the explanation that beam hold-offs in gated delivery allowed the lagging leaves to catch up with the delivered monitor units each time that the beam was interrupted. Low dose rates, slow leaf speeds and low frequencies of beam interruptions reduce the effect of this delay-and-catch-up cycle. For gated IMRT it is therefore important to find a good balance between the conflicting requirements of rapid dose delivery and delivery accuracy.

Attenuation of intracavitary applicators in 192Ir-HDR brachytherapy.

Unlike the penetrating monoenergetic 662 keV gamma rays emitted by 137Cs LDR sources, the spectrum of 192Ir used in HDR brachytherapy contains low-energy components. Since these are selectively absorbed by the high-atomic number materials of which intracavitary applicators are made, the traditional neglect of applicator attenuation can lead to appreciable dose errors. We investigated the attenuation effects of a uterine applicator, and of a set of commonly used vaginal cylinders. The uterine applicator consists of a stainless steel source guide tube with a wall thickness of 0.5 mm and a density of 8.02 g/cm3, whereas the vaginal cylinders consist of the same stainless steel tube plus concentric polysulfone cylinders with a radius of 1 or 2 cm and a density of 1.40 g/cm3. Monte Carlo simulations were performed to compute dose distributions for a bare 192Ir-HDR source, and for the same source located within the applicators. Relative measurements of applicator attenuation using ion-chambers (0.125 cm3) confirmed the Monte Carlo results within 0.5%. We found that the neglect of the applicator attenuation overestimates the dose along the transverse plane by up to 3.5%. At oblique angles, the longer photon path within applicators worsens the error. We defined attenuation-corrected radial dose and anisotropy functions, and applied them to a treatment having multiple dwell positions inside a vaginal cylinder.

Validation of target volume and position in respiratory gated CT planning and treatment.

The capability of a commercial respiratory gating system based on video tracking of reflective markers to reduce motion-induced CT planning and treatment errors was evaluated. Spherical plastic shells (2.8-82 cm3), simulating the gross target volume (GTV), were placed in a water-filled body phantom that was moved sinusoidally along the longitudinal axis of the CT scanner and the accelerator for +/- 1 cm at 15-30 cycle/min. During gated CT imaging, the x-ray exposure was initiated by the gating system shortly before the end of expiration (so that the imaging time would be centered at the end of expiration); it was terminated by the scanner after completion of each slice. In nongated CT images, the target appeared distorted and often broken up. GTVs volume errors ranged 16%-110% in axial scans, and 7%-36% in spiral scans. In gated CT images, the spheres appeared 3 and 5 mm longer than their actual diameters (volume errors 2%-16%), at the respective respiration rates of 15 and 20 cycles/min. At 30 cycles/min the target appeared 1 cm longer, and volume error ranged 25%-53%. During treatment, gating kept the beam on for a duration equal to the CT acquisition time of 1 s/slice. The difference in positional errors between gated CT and portal films was 1 mm, regardless the size of residual motion errors. Because of the potential of suboptimal placement of the gating window between CT imaging and treatment, an extra 1.5-2.5 mm safety margin can be added regardless of the size of residual motion error. For respiratory rates > or = 30 cycles/min, the effectiveness of gating is limited by large residual motion in the 1 s CT acquisition time.

Model prediction of treatment planning for dose-fractionated radioimmunotherapy.

BACKGROUND: Clinical trials of radioimmunotherapy (RIT) often use dose fractionation to reduce marrow toxicity. The dosing scheme can be optimized if marrow and tumor cell kinetics following radiation exposure are known. METHODS: A mathematic model of tumor clonogenic cell kinetics was combined with a previously reported marrow cell kinetics model that included marrow stromal cells, progenitor cells, megakaryocytes, and platelets. Reported values for murine tumor and marrow cellular turnover rates and radiosensitivity were used in the model calculation. RESULTS: Given a tolerated level of thrombocytopenia, there is a fractionation scheme in which total radioactive dose administration can be maximized. Isoeffect doses that had different numbers of fractions and total radioactivity, but induced identical platelet nadirs of 20%, were determined. Assuming identical tumor uptake for all dose fractions, six tumor types were examined: early-responding tumors, late-responding tumors, and tumors that lacked a late-responding effect, with either constant or accelerated doubling time. For most tumor types, better tumor control (tumor growth delay and nadir of survival fraction) was predicted for a dosing scheme in which total radioactive dose was maximized. For late-responding tumors with accelerated doubling time, tumor growth delay increased, but the nadir of survival fraction became shallower as the number of fractions increased. CONCLUSIONS: A mathematic model has been developed that allows prediction of the nadir and duration of thrombocytopenia as well as tumor clonogenic cell response to various RIT doses and fractionation schemes. Given a maximum tolerated level of thrombocytopenia, the model can be used to determine a dosing scheme for optimal tumor response.