Beam characteristics and clinical possibilities of a new compact treatment unit design combining narrow pencil beam scanning and segmental multileaf collimation

Not until the last decade has flexible intensity modulated three-dimensional dose delivery techniques with photon beams become a clinical reality, first in the form of heavy metal transmission blocks and other beam compensators, then in dynamic and segmented multileaf collimation, and most recently by scanning high-energy narrow electron and photon beams. The merits of various treatment unit and bremsstrahlung target designs for high-energy photon therapy are investigated theoretically for two clinically relevant target sites, a cervix and a larynx cancer both in late stages. With an optimized bremsstrahlung target it is possible to generate photon beams with a half-width of about 3 cm at a source to axis distance (SAD) of 100 cm and an initial electron energy of 50 MeV. By making a more compact treatment head and shortening the SAD, it is possible to reduce the half-width even further to about 2 cm at a SAD of 70 cm and still have sufficient clearance between the collimator head and the patient. One advantage of a reduced SAD is that the divergence of the beam for a given field size on the patient is increased, and thus the exit dose is lowered by as much as 1%/cm of the patient cross section. A second advantage of a reduced SAD is that the electron beam on the patient surface will be only about 8 mm wide and very suitable for precision spot beam scanning. It may also be possible to reduce the beamwidth further by increasing the electron energy up to about 60 MeV to get a photon beam of around 15 mm half-width and an electron beam as narrow as 5 mm. The compact machine will be more efficient and easy to work with, due to the small gantry and the reduced isocentric height. For a given target volume and optimally selected static multileaf collimator, it is no surprise that the narrowest possible scanned elementary bremsstrahlung beam generates the best possible treatment outcome. In fact, by delivering a few static field segments with individually optimized scan patterns, it is possible to combine the advantage of being able to fine tune the fluence distribution by the scanning system with the steeper dose gradients that can be delivered by a few static multileaf collimator segments. It is demonstrated that in most cases a few collimator segments are sufficient and often a single segment per beam portal may suffice when narrow scanned photon beams are employed, and they can be delivered sequentially with a negligible time delay. A further advantage is the increase of therapeutically useful photons and improved patient protection, since the pencil beam is only scanned where the leaf collimator is open. Consequently, some of the problems associated with dynamic multileaf collimation such as the tongue and groove and edge leakage effects are significantly reduced. Fast scanning beam techniques combined with good treatment verification systems allow interesting future possibilities to counteract patient and internal organ motions in real time.     

Negative regulation of the anti-human immunodeficiency virus and chemotactic activity of human stromal cell-derived factor 1alpha by CD26/dipeptidyl peptidase IV

A method to characterize the energy distribution in the whole photon field is valuable when designing an accelerator for choosing target and flattening filter or scan pattern. Another field of application is beam characterization for treatment planning systems or other dosimetric purposes. This work is focused on the energy distribution in different 50 MV bremsstrahlung beams with different scanning of electrons on three different targets. Fluence differential in energy and angle at the exit of each target has been determined by Monte Carlo calculations for a narrow beam. Data for broad beams were obtained by convolution of the narrow beams with different scan patterns. Photon energy fluence differential in energy at SSD 100 were thus found to be rather different for the targets studied. The results are presented as mean energy profiles and narrow beam half-value layer (HVL) in water. Two different experimental setups were used to measure HVL at the central axis and at off-axis positions. The two methods gave results which differ by 5%-6% and the calculated data where within these experimental results. In conclusion, the presented method for characterization of the photon field energy distribution is well within the experimental results and can thus be used to improve accelerator design or dosimetric calculations, e.g., for treatment planning.     

Electron contamination in clinical high energy photon beams

The electron contamination in photon beams has been investigated by means of contaminating lepton depth doses and dose profiles in different geometries with two 20 MV beams. Different components of this contamination have been investigated separately by systematically adding contamination to a "clean" reference field. At 20 MV, the air generated electrons were found to be almost negligible compared to the electrons originating from the accelerator head when measurements were performed in standard fields at SSDs between 80 and 120 cm. The total electron part of the depth dose curve was then almost the same, i.e., independent of SSD, when the collimator opening was held fixed. However, when different accessories such as a shaping block and different attenuating plates were located in the beam path below the collimators, a large SSD dependence of the electron contamination was noticed. A comparison was also made between two machines, one equipped with a multileaf collimator, with similar beam qualities at 20 MV. These measurements indicate that the interior view of the treatment head seen by the detector (mainly the flattening filter, monitor chamber, or other electron generating material) influences the magnitude of the electron contamination. When the collimator opening is decreased the electron contamination will also decrease as parts of the electron source will be shielded by the collimator blocks.     

Quantification of mean energy and photon contamination for accurate dosimetry of high-energy electron beams

The scientific background of the standard procedure for determination of the mean electron energy at the phantom surface (E0) from the half-value depth (R50) has been studied. The influence of energy, angular spread and range straggling on the shape of the depth dose distribution and the R50 and Rp ranges is described using the simple Gaussian range straggling model. The relation between the R50 and Rp ranges is derived in terms of the variance of the range straggling distribution. By describing the mean energy imparted by the electrons both as a surface integral over the incident energy fluence and as a volume integral over the associated absorbed dose distribution, the relation between E0 and different range concepts, such as R50 and the maximum dose and the surface dose related mean energy deposition ranges, Rm and R0, is analysed. In particular the influence of multiple electron scatter and phantom generated bremsstrahlung on R50 is derived. A simple analytical expression is derived for the ratio of the incident electron energy to the half-value depth. Also, an analytical expression is derived for the maximum energy deposition in monoenergetic plane-parallel electron beams in water for energies between 2 and 50 MeV. Simple linear relations describing the relative absorbed dose and mass ionization at the depth of the practical range deposited by the bremsstrahlung photons generated in the phantom are derived as a function of the incident electron energy. With these relations and a measurement of the extrapolated photon background at Rp, the treatment head generated bremsstrahlung distribution can be determined. The identification of this photon contamination allows an accurate calculation of the absorbed dose in electron beams with a high bremsstrahlung contamination by accounting for the difference in stopping power ratios between a clean electron beam and the photon contamination. The absorbed dose determined using ionization chambers in heavily photon contaminated (10%) electron beams may be too low--by as much as 1.5%--without correction.     

Measurement of photon beam backscatter from collimators to the beam monitor chamber using target-current-pulse-counting and telescope techniques

Backscattered radiation (BSR) arising from field-defining collimators and entering the beam monitor chamber (BMC) may contribute to observed variations in medical linear accelerator photon beam output with collimator setting. Measuring the magnitude of such contributions for particular accelerators under specified operating conditions is therefore important when attempting to understand and model accelerator head scatter. The present work was conducted to confirm some backscatter measurements for collimating jaws reported previously and to extend these to include other accelerators and a multileaf collimator (MLC). BSR reaching the BMC from the jaws of Clinac 600C, 2100C and 2300CD accelerators and from an MLC on the 2300CD was investigated using both target-current-pulse-counting and telescope methods. Our measurements show that for the Clinac 600C BSR-dependent output variations are negligible. However, for the 2100C and 2300CD BSR-dependent relative output increased in an almost linear fashion, by up to 2.4% for 15 and 18 MV beams, and by up to 1.7% for 6 MV beams, as the field size varied from 5 x 5 cm2 to 40 x 40 cm2. The magnitude of BSR dependent upon collimator location in the head, as expected, thereby contributing to the collimator exchange effect. An earlier study at our centre using the telescope method had reported higher BSR levels. This discrepancy was resolved when corrections for telescope block and room scatter, previously assumed negligible, were made.     

A thin target approach for portal imaging in medical accelerators

A new thin-target method (patent pending) is described for portal imaging with low-energy (tens of keV) photons from a medical linear accelerator operating in a special mode. Low-energy photons are usually produced in the accelerator target, but are absorbed by the target and flattening filter, both made of medium- or high-Z materials such as Cu or W. Since the main contributor to absorption of the low-energy photons is self-absorption by the thick target through the photoelectric effect, it is proposed to lower the thickness of the portal imaging target to the minimum required to get the maximum low-energy photon fluence on the exit side of the target, and to lower the atomic number of the target so that predominantly photoelectric absorption is reduced. To determine the minimum thickness of the target, EGS4 Monte Carlo calculations were performed. As a result of these calculations, it was concluded that the maximum photon fluence for a 4 MeV electron beam is obtained with a 1.5 mm Cu target. This value is approximately five times less than the thickness of the Cu target routinely used for bremsstrahlung production in radiotherapeutic practice. Two sets of experiments were performed: the first with a 1.5 mm Cu target and the second with a 5 mm Al target (Cu mass equivalent) installed in the linear accelerator. Portal films were taken with a Rando anthropomorphic phantom. To emphasize the low-energy response of the new thin target we used a Kodak Min-R mammographic film and cassette combination, with a strong low-energy response. Because of its high sensitivity, only 1 cGy is required. The new portal images show a remarkable improvement in sharpness and contrast in anatomical detail compared with existing ones. It is also shown that further lowering of the target's atomic number (for example to C or Be) produces no significant improvement.     

Megavoltage imaging with low Z targets: implementation and characterization of an investigational system

The poor quality of stereotactic radiotherapy portal images is a limiting factor in precise image registration. To alleviate this problem, a low atomic number (Z) target was implemented on our Siemens MXE linear accelerator. This investigational system was used to assess the performance of various target materials by filming an aluminum contrast object. Beryllium, carbon and conventional target materials were studied. The bremsstrahlung spectra of these materials were simulated using Monte Carlo techniques. These spectra were used to calculate the dependence of narrow beam contrast on phantom thickness for verification of the data measured from film. A Monte Carlo simulation of the beryllium spectrum in a wide beam geometry was used to evaluate the effect of phantom-to-film distance on contrast. Although the same degree of contrast improvement with distance was not realized in practice, the improvement in image quality rivaled that achieved using a scatter reduction grid. A comparison of conventional localization images of the head and neck of an anthropomorphic phantom with images produced with a beryllium or carbon target and a mammography film and screen system supports earlier suggestions that the technique is clinically useful.     

Intensity modulation with electrons: calculations, measurements and clinical applications

Intensity modulation of electron beams is one step towards truly conformal therapy. This can be realized with the MM50 racetrack microtron that utilizes a scanning beam technique. By adjusting the scan pattern it is possible to obtain arbitrary fluence distributions. Since the monitor chambers in the treatment head are segmented in both x- and y-directions it is possible to verify the fluence distribution to the patient at any time during the treatment. Intensity modulated electron beams have been measured with film and a plane parallel chamber and compared with calculations. The calculations were based on a pencil beam method. An intensity distribution at the multileaf collimator (MLC) level was calculated by superposition of measured pencil beams over scan patterns. By convolving this distribution with a Gaussian pencil beam, which has propagated from the MLC to the isocentre, a fluence distribution at isocentre level was obtained. The agreement between calculations and measurements was within 2% in dose or 1 mm in distance in the penumbra zones. A standard set of intensity modulated electron beams has been developed. These beams have been implemented in a treatment planning system and are used for manual optimization. A clinical example (prostate) of such an application is presented and compared with a standard irradiation technique.     

The secretory intestinal transport of some beta-lactam antibiotics and anionic compounds: a mechanism contributing to poor oral absorption

PURPOSE: To measure the effect of silicon diode detectors used for in vivo dosimetry on beam characteristics and determine whether this effect is clinically significant. METHODS AND MATERIALS: Commercially available photon and electron diodes were placed on the central axis of photon and electron beams. The beam characteristics were measured for 6- and 10-MV photon and 6-20-MeV electron energies from a Varian Clinac 1800 medical linear accelerator. Water was used for the medium, and measurements were made for various clinically common field sizes and depths. RESULTS: Beam attenuations along the central axis were 10 and 7.5% for 6- and 10-MV photons, respectively. Electron beam dose reductions were between 13 and 25% for 20-6-MeV electrons. Photon beam flatness varied up to 7% at different depths, but the symmetry was not affected much. Electron beam flatness and symmetry were significantly changed to as much as 18 and 6%, respectively. CONCLUSION: Use of diode detectors on central axis of photon and electron beams for in vivo dosimetry causes significant attenuation and alteration of the beam characteristics. The percentage of the volume affected is significant (e.g., 23% of the volume in a 4 x 4 field gets 10% less dose for a 6-MV photon beam), especially if these diodes are used for in vivo dosimetry on the central axis every day for every treatment, as is done in some clinics. Other beam parameters such as penumbra and skin dose are also affected. It is therefore recommended that the diodes be used only as needed.     

The simple excision

A method for the fully computerized determination and optimization of positions of target points and collimator sizes in convergent beam irradiation is presented. In conventional interactive trial and error methods, which are very time consuming, the treatment parameters are chosen according to the operator's experience and improved successively. This time is reduced significantly by the use of a computerized procedure. After the definition of target volume and organs at risk in the CT or MR scans, an initial configuration is created automatically. In the next step the target point positions and collimator diameters are optimized by the program. The aim of the optimization is to find a configuration for which a prescribed dose at the target surface is approximated as close as possible. At the same time dose peaks inside the target volume are minimized and organs at risk and tissue surrounding the target are spared. To enhance the speed of the optimization a fast method for approximate dose calculation in convergent beam irradiation is used. A possible application of the method for calculating the leaf positions when irradiating with a micromultileaf collimator is briefly discussed. The success of the procedure has been demonstrated for several clinical cases with up to six target points.     

A method for implementing dynamic photon beam intensity modulation using independent jaws and a multileaf collimator

A mathematical model is derived for digitally controlled linear accelerators to deliver a desired photon intensity distribution by combining collimator motion and machine dose rate variations. It shows that, at any instant, the quotient of the machine dose rate and the speed of collimator motion is proportional to the gradient of the desired in-air photon fluence distribution. The model is applicable for both independently controlled collimator jaws and multileaf collimators and can be implemented by controlling different parameters to accommodate linear accelerators from different manufactures. For independent jaws, each pair of jaws creates photon fluence variations along the direction of the jaw movement. For multileaf collimators, where each leaf is independently controlled, any two-dimensional (2D) photon fluence distribution can be delivered. The model has been implemented for wedged isodose distributions using independent jaws, and 2D intensity modulation using a multileaf collimator. One-dimensional (1D) wedged isodose distributions are created by moving an independent jaw at constant speed while varying machine dose rate. 2D intensity modulation has been implemented using a 'dynamic stepping' scheme, which controls the leaf progression during irradiation at constant machine dose rate. With this automated delivery scheme, the beam delivery time for dynamic intensity modulation, which depends on the complexity of the desired intensity distribution, approaches that of conventional beam modifiers. This paper shows the derivation of the model, its application, and our delivery scheme. Examples of 1D dynamic wedges and 2D intensity modulations will be given to illustrate the versatility of the model, the simplicity of its application, and the efficiency of beam delivery. These features make this approach practical for delivering conformal therapy treatments.     

A dual source photon beam model used in convolution/superposition dose calculations for clinical megavoltage x-ray beams

A realistic photon beam model based on Monte Carlo simulation of clinical linear accelerators was implemented in a convolution/superposition dose calculation algorithm. A primary and an extra-focal sources were used in this beam model to represent the direct photons from the target and the scattered photons from other head structures, respectively. The effect of the finite size of the extra-focal source was modeled by a convolution of the source fluence distribution with the collimator aperture function. Relative photon output in air (Sc) and in phantom (Scp) were computed using the convolution method with this new photon beam model. Our results showed that in a 10 MV photon beam, the Sc, Sp (phantom scatter factor), and Scp factors increased by 11%, 10%, and 22%, respectively, as the field size changed from 3 x 3 cm2 to 40 x 40 cm2. The variation of the Sc factor was contributed mostly by an increase of the extra-focal radiation with field size. The radiation backscattered into the monitor chamber inside the accelerator head affected the Sc by about 2% in the same field range. The output factors in elongated fields, asymmetric fields, and blocked fields were also investigated in this study. Our results showed that if the effect of the backscattered radiation was taken into account, output factors in these treatment fields can be predicted accurately by our convolution algorithm using the dual source photon beam model.     

Improved estimation of the detector response function for converging beam collimators

Converging beam collimator geometries offer improved tradeoffs between resolution and noise for single photon emission computed tomography (SPECT). The major factor limiting the resolution in SPECT is the collimator-detector response blurring. In order to compensate for this blurring it is useful to be able to calculate the collimator response function. A previous formulation presented a method for calculating the response for parallel and converging beam collimators that assumed that the shape of the holes did not change over the face of the collimator. However, cast collimators are fabricated using pins with a constant cross-section (shape perpendicular to the pin axis). As a result, due to the angulation of the pins, the holes made by these pins have shapes on the front and back faces of the collimator that change with position. This change in hole shape is especially pronounced when the angle between the collimator hole and the collimator normal is large, as is the case for half-fan-beam or short-focal-length collimators. This paper presents a derivation of a modification to the original method that accounts for the change in shape of the collimator holes. The method has been verified by comparing predicted line spread functions to experimentally measured ones for a collimator with a maximum hole angle of 35 degrees with respect to the normal. This formulation is useful for predicting the response of fan-beam collimators in the design process and for use in detector response compensation algorithms.     

On absorbed dose in narrow 60Co gamma-ray beams and dosimetry of the gamma knife

Using separate analytical functions describing primary dose, P0(dm,r), collimator scatter, Sc(r), and phantom scatter, TAR(d,r), an expression for absorbed dose in narrow 60Co gamma-ray beams is developed and each function is quantified: D(d,r) = P0(dm,r) Sc(r) TAR(d,r). The absorbed dose is calculated in beams as narrow as 0.2 cm in radius. Analytical and experimental results are compared using measured dose data for the Gamma Knife. Close agreement with experimental data is observed.     

Blocked field effects on collimator scatter factors

In routine dosimetry we assume separability of the collimator (Sc) and phantom (Sp) scatter components that together comprise the total scatter factor (Sc,p). In practice, the addition of blocking also affects the photon fluence attributable to the treatment head and flattening filter in a complicated way. The reduced aperture blocks out some of the head scatter contribution, while the block and tray add back secondary scatter. In the following we present techniques for directly measuring the aperture effect on Sc in air or in a full-scatter phantom. The change in Sc is found to be a scaleable quantity that can be modelled as a simple linear fit to the ratio of projected open-to-blocked equivalent square fields. Measurements have been made for 6, 18 and 24 MV photon beams on one Varian 2500 and two Varian 2100c accelerators. Results indicate a progressive loss of collimator scatter contribution with increased field blocking that is amplified with increasing energy. Block and tray scatter only contribute significantly to Sc for large fields and treatment distances of 80 cm or less. Application of these corrections in monitor unit calculations is presented.     

Two replica blotting methods for fast immunological analysis of common proteins in two-dimensional electrophoresis

Knowledge of the photon spectrum of a radiotherapy beam is often needed for three-dimensional (3-D) dose calculations using Monte Carlo methods and/or algorithms employing energy deposition kernels. Direct measurement of the x-ray energy fluence spectrum is not feasible for the high-energy photon beams used clinically. In this paper, the spectrum is extracted from basic beam data that are readily obtained for a clinical beam. We describe the photon spectrum using just two parameters. One parameter, which determines the high-energy part of the spectrum, is obtained using the measured dose in the buildup region for a small field, where electron contamination of the beam can be neglected. The other parameter is extracted from the photon beam attenuation in water. The results compare favorably to spectra generated from Monte Carlo simulations.     

Conversion of ionization measurements to radiation absorbed dose in non-water density material

The radiation absorbed dose to non-water equivalent materials of interest in radiotherapy is the dose to lung and the dose to bone. The measurement and calculation of dose to the lung has been of great interest and much effort has gone into the development of accurate lung dose calculation methods. The radiation absorbed dose to the bone is usually not calculated and most absorbed dose calculations have been done without correcting for the presence of bone. For the lower megavoltage photon beams this may be appropriate, however, as the energy of the photon beam increases, the region of electronic disequilibrium becomes larger and pair production which depends on the atomic number of the material becomes significant. Therefore the bone will produce greater perturbations of the dose distribution. The dose to lung-equivalent material is uniquely obtained from ionization measurements. However, in bone-equivalent materials two different calculations of absorbed dose are possible: the absorbed dose to soft tissue plastic (polystyrene) within bone-equivalent material and the dose to the bone-equivalent material itself. Both can be calculated from ionization measurements in phantoms. These two calculations result in significantly different doses in a heterogeneous phantom composed of polystyrene and aluminium (a bone substitute). The dose to a thin slab of polystyrene in aluminium is much higher than the dose to the aluminium itself at the same depth in the aluminium. Monte Carlo calculations confirm that the calculation of dose to polystyrene in aluminium can be accurately carried out using existing dosimetry protocols. However, the conversion of ionization measurements to absorbed dose to high atomic number materials cannot be accurately carried out with existing protocols and appropriate conversion factors need to be determined.     

Field study on the distribution of Entamoeba histolytica and Entamoeba dispar in the northern Philippines as detected by the polymerase chain reaction

The influence of the electron contamination at in vivo dosimetry with diodes on the patient surface has been investigated by introducing different accessories in the beam path and by changing the field size and SSD. The results show a clear correlation between the electron contamination at an effective measuring depth of the diode and the signal from the patient diode. When the electron contamination is taken into account the agreement between the diode values and the absorbed dose is greatly improved. More accurate in vivo dosimetry with less error margins is therefore possible if better predictions of the electron contamination in high-energy photon beams can be performed.     

Use of CEA TVS film for measuring high energy photon beam dose distributions

CEA TVS film is a therapy verification film that has been recently introduced in the North American market. This film features linear characteristic curves for photon energies from 137Cs to 18 MV as reported by Cheng and Das [Med. Phys. 23, 1225 (1996)]. In Saskatoon, TVS film was investigated for its application in the measurement of dose distributions with 4 and 18 MV linacs and a 60Co unit. The TVS film jacket has a layer of conductive material that has a minimal effect on the film's response. Film sensitivity generally increases for exposures normal to the incident beam as compared with parallel exposures, but was highly dependent on beam energy and depth of measurement. Fractional depth doses obtained in the parallel orientation agreed well with ion chamber measurements for the linac beams at depths beyond Dmax; ion chamber measurements differed by a maximum of 1.6% and 2.6% for the 4 and 18 MV beams, respectively. In the buildup region, an increase in film response was found when compared to the ion chamber measurements for both linac beams. With the 60Co beam, the TVS film showed an increase in sensitivity with depth as the proportion of scattered soft x rays increases; the maximum difference between ion chamber and film fractional depth doses was 7.8%. The TVS film demonstrates a substantial improvement over Kodak X-Omat V film for measuring depth doses in the parallel orientation, for all beams considered. Generally, the results confirm TVS film as an accurate and practical dosimeter for the measurement of dose distributions in high energy photon beams.     

Field margin reduction using intensity-modulated x-ray beams formed with a multileaf collimator

PURPOSE: In axial, coplanar treatments with multiple fields, the superior and inferior ends of a planning target volume (PTV) are at risk to get underdosed due to the overlapping penumbras of all treatment fields. We have investigated a technique using intensity modulated x-ray beams that allows the use of small margins for definition of the superior and inferior field borders while still reaching a minimum PTV-dose of 95% of the isocenter dose. METHODS AND MATERIALS: The applied intensity modulated beams, generated with a multileaf collimator, include narrow (1.1-1.6 cm) boost fields to increase the dose in the superior and inferior ends of the PTV. The benefits of this technique have been assessed using 3D treatment plans for 10 prostate cancer patients. Treatment planning was performed with the Cadplan 3D planning system (Varian-Dosetek). Dose calculations for the narrow boost fields have been compared with measurements. The application of the boost fields has been tested on the MM50 Racetrack Microtron (Scanditronix Medical AB), which allows fully computer-controlled setup of all involved treatment fields. RESULTS: Compared to our standard technique, the superior-inferior field length can be reduced by 1.6 cm, generally yielding smaller volumes of rectum and bladder in the high dose region. For the narrow boost fields, calculated relative dose distributions agree within 2% or 0.2 cm with measured dose distributions. For accurate monitor unit calculations, the phantom scatter table used in the Cadplan system had to be modified using measured data for square fields smaller than 4 x 4 cm2. The extra time needed at the MM50 for the setup and delivery of the boost fields is usually about 1 min. CONCLUSION: The proposed use of intensity modulated beams yields improved conformal dose distributions for treatment of prostate cancer patients with a superior-inferior field size reduction of 1.6 cm. Treatments of other tumor sites can also benefit from the application of the boost fields.