Impact of collimator leaf width on stereotactic radiosurgery and 3D conformal radiotherapy treatment plans.

PURPOSE: The authors undertook a study to analyze the impact of collimator leaf width on stereotactic radiosurgery and 3D conformal radiotherapy treatment plans. METHODS AND MATERIALS: Twelve cases involving primary brain tumors, metastases, or arteriovenous malformations that had been planned with BrainLAB's conventional circular collimator-based radiosurgery system were re-planned using a beta-version of BrainLAB's treatment planning software that is compatible with MRC Systems' and BrainLAB's micro-multileaf collimators. These collimators have a minimum leaf width of 1.7 mm and 3.0 mm, respectively, at isocenter. The clinical target volumes ranged from 2.7-26.1 cc and the number of static fields ranged from 3-5. In addition, for 4 prostate cancer cases, 2 separate clinical target volumes were planned using MRC Systems' and BrainLAB's micro-multileaf collimators and Varian's multileaf collimator: the smaller clinical target volume consisted of the prostate gland and the larger clinical target volume consisted of the prostate and seminal vesicles. For the prostate cancer cases, treatment plans were generated using either 6 or 7 static fields. A "PITV ratio," which the Radiation Therapy Oncology Group defines as the volume encompassed by the prescription isodose surface divided by the clinical target volume, was used as a measure of the quality of treatment plans (a PITV ratio of 1.0-2.0 is desirable). Bladder and rectal volumes encompassed by the prescription isodose surface, isodose distributions and dose volume histograms were also analyzed for the prostate cancer patients. RESULTS: In 75% of the cases treated with radiosurgery, a PITV ratio between 1.0-2.0 could be achieved using a micro-multileaf collimator with a leaf width of 1.7-3.0 mm at isocenter and 3-5 static fields. When the clinical target volume consisted of the prostate gland, the micro-multileaf collimator with a minimum leaf width of 3.0 mm allowed one to decrease the median volume of bladder and rectum within the prescription isodose surface by 26% and 17%, respectively, compared to the multileaf collimator with a leaf width of 10 mm. Use of the 1.7 mm leaf width micro-multileaf collimator allowed one to decrease the median volume of bladder and rectum within the prescription isodose surface by 48% and 39%, respectively, compared to the multileaf collimator with a leaf width of 10 mm. CONCLUSIONS: For most lesions treated with radiosurgery, the use of a micro-multileaf collimator with a leaf width of 1.7-3.0 mm at isocenter and 3-5 static fields allows one to meet the Radiation Therapy Oncology Group guidelines for treatment planning. Both planning and treatment are relatively straightforward with a micro-multileaf collimator, allowing for efficient treatment of non-spherical targets with either stereotactic radiosurgery or fractionated stereotactic radiotherapy. When the clinical target volume consists of the prostate gland, micro-multileaf collimators with a minimum leaf width of 1.7-3.0 mm allow one to spare more bladder and rectum than one can with a multileaf collimator that has a 10-mm leaf width based on an analysis of PITV ratios, isodose distributions, and dose volume histograms.

An equation to QA check the total treatment time for single-catheter HDR brachytherapy.

PURPOSE: To develop a simple equation that can be used to quickly QA check the total treatment time needed for straight or moderately bending, single-catheter implants from the treatment length and dose-prescription depth. A method to quickly check the total treatment time is useful for high dose rate (HDR) treatments, but may be most useful for intravascular patients that are catheterized while planning the treatment. METHODS AND MATERIALS: Nucletron-Oldelft treatment planning software was used to plan treatments with treatment lengths from 50 to 200 mm, and dose-prescription depths from 2 to 14 mm. For each plan, dose points were defined at a fixed depth away from the catheter. Doses were calculated, normalized, and optimized using the dose points. From these plans, a single equation was developed for the total treatment time as a function of treatment length and dose-prescription depth. RESULTS: Total treatment time increases linearly with treatment length and supra-linearly with dose-prescription depth. A difference of 3% or more between the treatment time determined by the QA check equation and by the treatment planning software will alert the clinician and physicist to check for potential errors in dose prescription, prescription depth, source activity, treatment length, or inadvertent modifications to physics parameters used in the treatment planning software. CONCLUSION: The simple equation that is developed can be used to quickly and accurately QA check the total treatment time needed for straight or moderately bending, single-catheter implants.

Mandibular reconstruction using a titanium plate: the impact of radiation therapy on plate preservation.

PURPOSE: To evaluate the soft tissue and bone tolerance of radiation therapy (RT) in patients undergoing radical composite resection and mandibular reconstruction using a bridging titanium plate with myocutaneous flap closure. METHODS AND MATERIALS: From 1990 to 1994, 47 patients with primary or recurrent oral cavity or oropharyngeal carcinomas were treated with radical composite resection and mandibular reconstruction using a bridging titanium plate with myocutaneous flap closure. Eleven patients received no RT (no RT), 10 patients received RT greater than 10 months from the time of surgery (remote RT), and 26 patients received RT within 12 weeks of surgery (perioperative RT). The radiation dose to the reconstructed mandible ranged from 45 to 75 Gy (median 63 Gy). The effect of the titanium plate on the radiation dose was measured using film dosimetry and soft tissue and bone-equivalent materials. The median follow-up was 17 months (range: 3-50 months). RESULTS: Late complications included four patients with osteomyelitis or necrosis, two plate exposures requiring flap revision, one chronic infection, two cases of chronic pain, two fistulae, and one case of trismus and malocclusion. The crude incidence of late complications by treatment was: (a) no RT: 3 of 11 patients (27%); (b) remote RT: 2 of 10 patients (20%); and (c) perioperative RT: 9 of 26 patients (35%). One patient in the no-RT group lost the plate due to chronic pain. Five patients in the perioperative RT group also had plate loss, four due to osteomyelitis and/or necrosis, and one due to pain related to a recurrent tumor. No patients in the remote RT group had plate loss. The actuarial prosthesis preservation rate at 2 years was 88% for the no RT, 100% for the remote RT, and 57% for the perioperative RT groups (p = 0.05). Phantom dose measurements showed that for parallel opposed 6 MV photon beams, there was no significant increase in the dose proximal or distal to the plate in either a soft tissue- or bone-equivalent phantom. CONCLUSIONS: The impact of radiation therapy on plate preservation after mandibular reconstructive surgery using a titanium plate may be dependent on the timing of RT relative to surgery. Significantly more mandibular reconstruction plates were lost when the involved mandible received RT in the perioperative period than when RT was delivered beyond 10 months from surgery or when no RT was given. The use of alloplastic implants such as titanium plates in conjunction with myocutaneous flap coverage for mandibular reconstruction is attractive because it allows immediate reconstruction of the defect and promotes a good functional and cosmetic result; however, administration of perioperative RT may result in a higher plate failure rate.

Report of the ad hoc committee of the AAPM radiation therapy committee on 125I sealed source dosimetry.

PURPOSE: Two developments in 125I-sealed source dosimetry have necessitated swift and accurate implementation of TG43 dosimetry in clinic: (a) the dosimetry constants of 125I endorsed by the AAPM Task Group 43 Report result in calculated dose rate that deviates by as much as 15% from currently accepted dose-rate distributions, and (b) The National Institute of Standards and Technology (NIST) has proposed modifying the 125I air-kerma strength standard by approximately 10%. METHODS AND MATERIALS: The ad hoc committee of AAPM Radiation Therapy Committee describes specific procedures to implement these two developments without causing confusion and mistakes. CONCLUSIONS: Confusion and mistakes may be avoided when the following two general steps are taken: 1) STEP I, TG-43 implementation, and 2) STEP II, new air-kerma strength standard implementation when available from NIST.

Acute toxicity of three-dimensional conformal radiotherapy in prostate cancer patients eligible for implant monotherapy.

PURPOSE: To assess the acute toxicity of three-dimensional conformal radiotherapy (3D-CRT) in prostate cancer patients eligible for implant monotherapy. METHODS AND MATERIALS: Between December 1991 and June 1998, 198 prostate cancer patients were treated with 3D-CRT at the University of California Davis Medical Center. Fifty-two of these patients had a prostate-specific antigen (PSA) level /= Grade 3, e.g., hourly nocturia, gross hematuria, diarrhea requiring parenteral support, narcotics for pain control, or catheterization for acute urinary retention, was observed. CONCLUSION: Although relatively high doses of radiation are delivered to prostate cancers with 3D-CRT compared with conventional radiotherapy, 3D-CRT is surprisingly well-tolerated. No patients in the cohort eligible for implant monotherapy experienced acute toxicity >/= Grade 3.

A comparison of arc-based and static mini-multileaf collimator-based radiosurgery treatment plans.

BACKGROUND: The purpose of this study is to compare arc-based and mini-multileaf collimator (mMLC)-based radiosurgery treatment plans using isodose distributions and dose-volume histograms. METHODS: Of 11 patients who underwent conventional arc-based radiosurgery for intracranial malignancies, four were treated with one isocenter, four were treated with two isocenters and three were treated with three isocenters. The same cases were re-planned using a test version of mMLC-based radiosurgery software for multiple static non-coplanar fields. RESULTS AND CONCLUSION: For non-spherical targets, treatment planning is relatively intuitive with mMLC-based radiosurgery, reducing the amount of time required for planning. Moreover, a lower dose of radiation is delivered to normal tissue with mMLC-based radiosurgery than with arc-based radiosurgery, which theoretically should lead to a reduced risk of complications.

Compatibility of Varian 2100C gated operations with enhanced dynamic wedge and IMRT dose delivery.

An enhanced dynamic wedge (EDW) is one of the latest technical innovations frequently used in the radiotherapy department. Its usage is enthusiastically supported by radiation therapists. Intensity modulated radiotherapy (IMRT) is the other, which has become popular within the past several years. Its usage is not as straightforward as the EDW. However, its ability to further increase dose conformity to the target and to spare the surrounding normal tissues has been evidenced. Both of these treatment modalities demand sophisticated software, which controls precision motion and speed of jaws or multileaf collimators as well as dose rate. This paper deals with the question of how accurately the EDW profiles and IMRT dose distributions be maintained when the additional constraint of linear accelerator gating is invoked. For this, square pulses mimicking breathing were used in gated and nongated modes for film dosimetry and ion chamber measurements using the Varian 2100C linear accelerator. The results show no observable difference between gated and nongated EDW profiles and IMRT dose distribution regardless of the machine repetition rate. Also studied in this paper are the "fuzzy" dose distributions caused by realistic finite gate window settings.

Considerations for superficial photon dosimetry.

Dose measurements at superficial energies required special considerations. First, care must be taken in selecting appropriate phantom materials. Materials that are adequate tissue substitutes at megavoltage energies might not be adequate at superficial energies. The suitability of a material can be judged by comparing its mass attenuation and mass energy absorption coefficients at superficial energies to those of the tissue of interest. Second, very low energy x-ray and electron contaminants must be removed from the superficial beam before they reach the detector. For detectors with a very thin window, this can be achieved by placing thin film on top of the detector. Failure to properly eliminate contaminants can result in a large increase in dose measured directly at the surface.

Breathing-synchronized radiotherapy program at the University of California Davis Cancer Center.

In this paper we present a complete description of the breathing synchronized radiotherapy (BSRT) system, which has been jointly developed between the University of California Davis Cancer Center and Varian Associates. BSRT is a description of an emerging radiation oncology procedure, where simulation, CT scan, treatment planning, and radiation treatment are synchronized with voluntary breath-hold, forced breath-hold, or breathing gating. The BSRT system consists of a breathing monitoring system (BMOS) and a linear accelerator gating hardware and software package. Two methods, a video camera-based method and the use of wraparound inductive plethysmography (RespiTrace), generate the BMOS signals. The BMOS signals and the synchronized fluoroscopic images are simultaneously recorded in the simulation room and are later analyzed to define the ideal treatment point (ITP) where organ motion is stationary. The BMOS signals at ITP can be used to gate a CT scanner or a linear accelerator to maintain the same organ configuration as in the simulation. The BSRT system allows breath-hold or gating. This dual role allows the system to be applicable for a variety of patients, i.e., the breath-hold method for those patients who can maintain and reproduce the ITP, and the forced breath-hold or gating method for those who are not ideal for voluntary breath-hold.

Potential and role of a prototype amorphous silicon array electronic portal imaging device in breathing synchronized radiotherapy.

Current electronic portal imaging devices (EPID) are limited in their ability to provide direct and quick verification and monitoring of patients during both setup and treatment of breathing synchronized radiotherapy (BSRT, including breathing gated, voluntary and forced breath-hold radiotherapy treatment.) These limitations are largely due to their slow image capture rate and poor image quality. An amorphous silicon array flat panel electronic portal imaging device (si-EPID) is emerging to meet the challenge. The purpose of this study is threefold: (1) to characterize the performance of a prototype si-EPID; (2) to compare image quality against that of digitized films; and (3) to evaluate the device in terms of verification of patient setup and monitoring during BSRT. In this study a Varian prototype si-EPID detector array and Clinic accelerator at the University of California Davis Cancer Center were used for imaging. Three quality assurance phantoms: a Lutz PVC phantom, a modified "Las Vegas" phantom, and a RMI model 1151 phantom, were used to characterize the imaging system. A Rando head phantom was used for anthropomorphic imaging tests. Images were obtained with the si-EPID and a Fuji RX film in a Kodak X-Omatic cassette. To investigate the clinical application, two sets of si-EPID images were collected from a lung cancer patient during a 22 s breath-hold and normal breathing. The quality of images obtained with the fast mode was found to be comparable to that obtained with the digitized films. The images with the standard mode were found to be better than the digitized film images. With this prototype si-EPID, it is possible to collect the images at the beginning, middle, and end of each breath-hold for those patients who can hold their breath for longer than 15 s. The si-EPID images can provide a quick verification of the initial patient setup and subsequent treatment position throughout the daily fractionation.

Accuracy of a photogrammetry-based patient positioning and monitoring system for radiation therapy.

A photogrammetry system designed to reduce simulator-to-treatment and treatment-to-treatment patient positioning errors has been developed. Two complete systems have been installed in our department: one in the simulator room and one in a treatment room. Each system consists of three charge-coupled device (CCD) cameras; a ring of infrared LEDs around the lens of each camera; and several small, circular, retroreflective markers that are applied to the patient. The markers reflect infrared light directly back to the cameras, producing a binary image of oval hot spots when the image is thresholded. The three-dimensional position of each marker is calculated by conventional photogrammetry methods. At simulation, marker positions are measured, then transferred to the treatment room system. The system may be used to actively position patients, and to passively monitor a patient's position and motion during treatment. Studies have focused on measuring the system's temporal stability, precision, and accuracy; on optimal positioning of markers and cameras; and on assessing the system's capability to reduce the positioning error. The repeatability of measuring a marker's position is <0.1 mm in each orthogonal direction. The accuracy is approximately 0.5 mm over a 40 X 40 X 40 cm3 field of view. The system drift over four hours is approximately +/-0.2 mm. The photogrammetry system has been used to actively position a lead BB, embedded within a head phantom, at the isocenter; repeatability was +/-0.3 mm, as determined radiographically. The system has also been used to passively monitor the positioning of several head and neck patients that were set up by a therapist; setup errors of up to 10 mm in each orthogonal direction were measured, as well as the motion of the patient during treatment.

High dose-rate brachytherapy treatment delivery: report of the AAPM Radiation Therapy Committee Task Group No. 59.

The goals of this task group are to examine the current high dose-rate (HDR) treatment delivery practices and to prepare a document to assure safe delivery of HDR treatments. The document consists of detailed HDR procedures for design of an HDR brachytherapy program, staffing and training, treatment specific quality assurance, and emergency procedures. The document provides an extensive quality assurance (QA) check list. It reviews all aspects of HDR treatment delivery safety, including prescription, treatment plan, treatment delivery, and radiation safety.

Respiration gated radiotherapy treatment: a technical study.

In order to optimize external-beam conformal radiotherapy, patient movement during treatment must be minimized. For treatment on the upper torso, the target organs are known to move substantially due to patient respiration. This paper deals with the technical aspects of gating the radiotherapy beam synchronously with respiration: the optimal respiration monitoring system, measurements of organ displacement and linear accelerator gating. Several respiration sensors including a thermistor, a thermocouple, a strain gauge and a pneumotachograph were examined to find the optimal sensor. The magnitude of breast, chest wall and lung motion were determined using playback of fluoroscopic x-ray images recorded on a VCR during routine radiotherapy simulation. Total dose, beam symmetry and beam uniformity were examined to determine any effects on the Varian 2100C linear accelerator due to gating.

[Measurements of Gamma-Knife helmet output factors using a radiophotoluminescent glass rod dosimeter and a diode detector].

A radiophotoluminescent (RPL) glass rod dosimeter (GRD) and a small active volume p-type silicon diode detector (stereotactic field detector, SFD) were used for the measurement of Gamma-Knife output factors. All measurements were done using a 16 cm diameter spherical polystyrene phantom with the detector at the focal spot of Gamma-Knife. The GRD system consists of small rod-shaped glass chip detectors and an automatic readout device. The output factors measured with GRD of the 14, 8 and 4 mm helmets relative to the 18 mm helmet are 0.981, 0.942 and 0.877, respectively. Similarly, the corresponding output factors measured with SFD are 0.980, 0.949 and 0.867, respectively. These output factors are comparable with the values given in a recent publication and the values recommended by Elekta, the manufacture. The angular dependence of these detectors is also measured using a linear accelerator-based stereotactic radiosurgery system. For the Gamma-Knife angle ranging from 6 to 36 degrees from the vertical axis, the measured angular dependence of the GRD is approximately 1.0% at a 4 MV x-ray beam. The response of SFD indicates approximately 3-4% directional dependence for the same angle range for a 6 MV x-ray beam. The Gamma-Knife helmet output factors measured with SFD are corrected for angular dependence. In summary, GRD can be a good candidate in measuring small field output factor. Due to an angular dependence the small p-type diode detector needs care when calculating the Gamma-Knife dose.