Comparative study of old and new versions of treatment planning system using dose volume histogram indices of clinical plans.

Recently, Eclipse treatment planning system (TPS) version 8.8 was upgraded to the latest version 13.6. It is customary that the vendor gives training on how to upgrade the existing software to the new version. However, the customer is provided less inner details about changes in the new software version. According to manufacturer, accuracy of point dose calculations and irregular treatment planning is better in the new version (13.6) compared to the old version (8.8). Furthermore, the new version uses voxel-based calculations while the earlier version used point dose calculations. Major difference in intensity-modulated radiation therapy (IMRT) plans was observed between the two versions after re-optimization and re-calculations. However, minor difference was observed for IMRT cases after performing only re-calculations. It is recommended TPS quality assurance to be performed after any major upgrade of software. This can be done by performing dose calculation comparisons in TPS. To assess the difference between the versions, 25 clinical cases from the old version were compared keeping all the patient data intact including the monitor units and comparing the differences in dose calculations using dose volume histogram (DVH) analysis. Along with DVH analysis, uniformity index, conformity index, homogeneity index, and dose spillage index were also compared for both versions. The results of comparative study are presented in this paper.

Adaptation of telecobalt unit for stereotactic irradiation.

We investigated the feasibility of using an isocentric telecobalt unit for advanced treatment techniques, such as stereotactic radiotherapy. To adapt the telecobalt unit (Th780 C) for stereotactic irradiation, collimator inserts of various sizes, collimator mount, and a couch mount suitable for the telecobalt unit were developed, and the characteristics of the narrow beams of Cobalt-60 (60Co) were studied. Comparative study was carried out between the stereotactic radiotherapy plans of 6 MV and 60Co beams using a 3-dimensional (3D) treatment planning system. The beam penumbra of 60Co beams was found to be larger than those of 6 MV beams. The dose-volume histograms (DVH) obtained from the 60Co beam plan were comparable to those obtained from the 6 MV plan. The DVH of nontarget tissue obtained from the plans of the 2 beams were found to be in good agreement to each other. The difference in equivalent fall-off distance (EFOD) for all 3 cases was found insignificant; hence, it can be concluded that the fall-off dose in the dose distribution of the 60Co stereotactic plan is as good as that of the 6 MV stereotactic plan. In all 3 cases for which the treatment plans were compared between 60Co and 6 MV beams, it was observed that the fall-off doses outside the target were similar; therefore, considering 60Co with 5-mm margin is a cost effective alternative for the linac-based stereotactic radiotherapy.

Design and development of motorized multileaf collimator for telecobalt unit.

A manual multileaf collimator developed for telecobalt unit was motorized to accomplish the easy movement of the leaves. The required field shaping using MLC could be achieved by either using template or display. The beam characteristics were investigated and then compared with those of customized blocks. The maximum interleaf leakage and the percentage of transmission measured at the depth of maximum ionization (0.5cm) were found to be 2.7% and 2.4%, respectively. The field shaping performed by the MLC was verified using film dosimetry. The comparative study of treatment plans of 3DCRT and IMRT between (60)Co beam and 6 MV beams was carried out. This MLC could be used as a substitute for conventional blocks in static fields, there by eliminating the effort and cost of fabricating customized blocks, the need for storage space for blocks and other practical difficulties during the process of the block making. It is also demonstrated that if a provision for IMRT delivery with MLC for (60)Co is made, could be a cost effective alternative to IMRT with 6 MV beam.

Dose volume histogram comparison between ADAC Pinnacle and Nomos Corvus systems for IMRT.

This paper compares dose volume histograms (DVHs) generated by the ADAC Pinnacle and the Nomos Corvus planning systems. Seven prostate cases and seven head and neck cases were selected for review. Plans computed on both systems possessed exactly the same anatomical contours and IMRT segments. The Pinnacle system used the collapsed cone convolution superposition, while Corvus employed a finite size pencil beam (FSPB) convolution. Prostate DVH results demonstrated similar DVH curves from both systems. For each structure, the ratio of Pinnacle dose value divided by Corvus value was calculated. The high dose structures (which might contain tumour) had ratios close to unity, while the low dose structures (the critical organs) had ratios farther away from unity. Almost all ratios were less than unity, indicating a systematic difference that Pinnacle calculated doses were lower than Corvus ones. Head and neck data provided similar findings. A possible cause for this discrepancy could be the beam modelling. The difference in DVH parameters that we discovered between the two systems was about the same order of magnitude as the measurement-computation difference. When low dose is critical, such difference may affect the clinical planning decision.

Study on dosimetric parameters for stereotactic radiosurgery and intensity-modulated radiotherapy.

This study is an attempt to compare the dosimetric parameters of intensity-modulated radiation therapy (IMRT) and stereotactic radiosurgery (SRS) using patient data. Radiosurgery was delivered through circular tertiary collimators attached to a linear accelerator. Six patients who were treated with SRS were replanned and evaluated with the IMRT planning system. Contouring of all structures, including target volume, was done on the IMRT system to closely match the SRS system. Treatment plans were generated after specifying the goals in the prescription module. The NOMOS BEAK collimator attached to the NOMOS MIMiC delivery device was chosen for treatment delivery. Various parameters such as conformity index, homogeneity index, target volume coverage, nontarget tissue, and brainstem doses were calculated and compared between the IMRT and SRS systems. Patient data were divided into 2 groups based on the complexity of the lesion and the number of isocenters used for radiosurgery. Analysis was done for each group and for the cumulative data. Superior conformality and homogeneous dose distribution in IMRT for multiple isocenter cases were observed. In addition, critical structure volumes for 50%, 70%, and 90% of the prescribed dose were lower in IMRT compared to SRS treatment. However, nontarget tissue received significantly higher doses with IMRT plans. Results show that IMRT treatment modality produces similar results as radiosurgery for small, spherical lesions, whereas it is found to be superior to SRS for irregular lesions in terms of critical structure sparing and better dose homogeneity.

Commissioning and quality assurance for MLC-based IMRT.

The commissioning and quality assurance (QA) associated with the implementation of linear accelerator multileaf collimator (MLC)-based intensity-modulated radiation therapy (IMRT) at the University of Nebraska Medical Center are described. Our MLC-based IMRT is implemented using the PRIMUS linear accelerator interface through the IMPAC record and verification system to the CORVUS treatment planning system. The "step-and-shoot" technique is used for this MLC-based IMRT. Commissioning process requires the verification of predefined parameters available on the CORVUS and the collection of some machine data. The machine data required are output factor in air and output factor in phantom, and percent depth dose for a number of field sizes. In addition, inplane and crossplane dose profiles of 4 x 4 cm and 20 x 20 cm field sizes and diagonal dose profiles of a large field size have to be measured. Validation of connectivity and dose model includes the use of uniform intensity bar strips, triangular-shaped nonuniform intensity bar strip, and N-shaped target. QA procedure follows the recommendation of the AAPM Task Group No. 40 report. In addition, the leaf position accuracy and reproducibility of the MLC should be checked at regular intervals. The dose validation is implemented through the hybrid plan where the patient beam parameters are applied to a flat phantom. Independent dose calculation method is used to confirm the dose delivery plan and data input to the CORVUS.

Independent dose calculations for the corvus MLC IMRT.

Two independent dose calculation methods have been explored to validate MLC-based IMRT plans from the NOMOS CORVUS system. After the plan is generated on the CORVUS planning system, the beam parameters are imported into an independent workstation. The beam parameters consist of intensity maps at each gantry angle. In addition, CT scans of the patient are imported into the independent workstation to obtain the external contour of the patient. The coordinate system is defined relative to the alignment point chosen in the CORVUS plan. The 2 independent calculation methods are based on a pencil beam kernel convolution and a Clarkson-type differential scatter summation, respectively. The pencil beam data for a 1 x 1-cm beam, as formed by the multileaf collimator, were measured for the 6-MV photon beam from a Siemens PRIMUS linear accelerator using film dosimetry. In the pencil beam method, the dose at a point is calculated using the depth and off-axis distance from a given pencil beam, corrected for beam intensity. The scatter summation method used the conversion of measured depth dose data into scatter maximum ratios. In this method, the differential scatter from each pencil beam is corrected for the beam intensity. Isodose distributions were generated using the independent dose calculations and compared to the CORVUS plans. Although isodose distributions from both methods show good agreement with the CORVUS plan, our implementation of the differential scatter summation approach seems more favorable. The 2 independent dose calculation algorithms are described in this paper.

Leaf sequencing techniques for MLC-based IMRT.

The nonuniform fields required by intensity-modulation radiation therapy (IMRT) can be delivered using conventional multileaf collimators (MLC) as beam modulators. In MLC-based IMRT, the nonuniform field is initially converted into an intensity map represented as a matrix of beam intensities. The intensity map is then decomposed into a series of subfields or segments of uniform intensities. Although there are many ways of segmenting the beam intensity matrix, a resulting subfield is only deliverable if it satisfies the constraints imposed by the MLC. These constraints exist as a result of the design of the MLC. The simplest constraint of the MLC is that its pairs of leaves can only move in and out in one dimension. Additional constraints include collision of opposing leaves and the need to match the tongue-and-groove to reduce interleaf leakage. The practical aspect of MLC-based IMRT requires that an optimized algorithm decomposes the nonuniform field into the least number of segments and therefore reduces the delivery time. This paper examines the static use and the dynamic use of MLCs to perform MLC-based IMRT.

Independent dose calculations for the PEACOCK System.

An independent dose calculation method has been developed to validate intensity-modulated radiation therapy (IMRT) plans from the NOMOS PEACOCK System. After the plan is generated on the CORVUS planning system, the beam parameters are imported into an independent workstation. The beam parameters consist of intensity maps at each gantry angle and each arc position. In addition, CT scans of the patient are imported into the independent workstation to obtain the external contour of the patient. The coordinate system is defined relative to the alignment point chosen in the CORVUS plan. The independent calculation uses the pencil beam data viz tissue maximum ratio (TMR) and beam profiles for a single 1 x 0.8-cm beamlet formed by the NOMOS multileaf intensity-modulating collimator (MIMiC) leaf. The pencil beam data were measured for the 6-MV photon beam from Siemens PRIMUS linear accelerator using film dosimetry. The dose at a point is calculated using the depth and off-axis distance from a given pencil beam, corrected for its beam intensity. Isodose distributions are generated using the independent dose calculations and compared to the CORVUS plans. Isodose distributions show good agreement with the CORVUS plans for a number of clinical cases. The independent dose calculation algorithm is described in this paper.

Comparative study between IMRT with NOMOS BEAK and linac-based radiosurgery in the treatment of intracranial lesions.

A comparative study was undertaken to examine intracranial irradiation using intensity-modulation radiation therapy (IMRT) and linear accelerator-based radiosurgery. The IMRT was examined using the Peacock system with a BEAK attachment. A clinical case involving a metastatic brain lesion, treated with 3 radiosurgery isocenters, was planned for IMRT. The radiosurgery was planned using the Leibinger planning system. The IMRT was planned using the CORVUS planning system. The CORVUS planning system uses an inverse planning algorithm, a recent development in radiotherapy. Isodose distributions and dose volume histograms were generated and compared. Analysis of the dosimetry shows that the dose conformity and homogeneity within the target using the RTOG guidelines are superior for IMRT. The advantages of IMRT using inverse planning system include the ease of planning and execution of treatment, especially for cases that involve concave targets that require multiple isocenters using radiosurgery.

Commissioning of Peacock System for intensity-modulated radiation therapy.

The Peacock System was introduced to perform tomographic intensity-modulated radiation therapy (IMRT). Commissioning of the Peacock System included the alignment of the multileaf intensity-modulating collimator (MIMiC) to the beam axis, the alignment of the RTA device for immobilization, and checking the integrity of the CRANE for indexing the treatment couch. In addition, the secondary jaw settings, couch step size, and transmission through the leaves were determined. The dosimetric data required for the CORVUS planning system were divided into linear accelerator-specific and MIMiC-specific. The linear accelerator-specific dosimetric data were relative output in air, relative output in phantom, percent depth dose for a range of field sizes, and diagonal dose profiles for a large field size. The MIMiC-specific dosimetric data were the in-plane and cross-plane dose profiles of a small and a large field size to derive the penumbra fit. For each treatment unit, the Beam Utility software requires the data be entered into the CORVUS planning system in modular forms. These modules were treatment unit information, angle definition, configuration, gantry and couch angles range, dosimetry, results, and verification plans. After the appropriate machine data were entered, CORVUS created a dose model. The dose model was used to create known simple dose distribution for evaluation using the verification tools of the CORVUS. The planned doses for phantoms were confirmed using an ion chamber for point dose measurement and film for relative dose measurement. The planning system calibration factor was initially set at 1.0 and will be changed after data on clinical cases are acquired. The treatment unit was released for clinical use after the approval icon was checked in the verification plans module.

Immobilization devices for intensity-modulated radiation therapy (IMRT).

Three-dimensional conformal radiation therapy (3DCRT) and intensity-modulated radiation therapy (IMRT) plans show radiation dose distribution that is highly conformal to the target volume. The successful clinical implementation of these radiotherapy modalities requires precise positioning of the target to avoid a geographical miss. Effective reduction in target positional inaccuracies can be achieved with the proper use of immobilization devices. This paper reviews some of the immobilization devices that have been used and/or have the potential of being used for IMRT. The immobilization devices being reviewed include stereotactic frame, Talon system, thermoplastic molds, Alpha Cradles, and Vac-Lok system. The implementation of these devices at various anatomical sites is discussed.

Quality assurance procedures for the Peacock system.

The Peacock system is the product of technological innovations that are changing the practice of radiotherapy. It uses dynamic beam modulation technique and inverse planning algorithm, both of which are new methodologies, to perform intensity-modulation radiation therapy (IMRT). The quality assurance (QA) procedure established by Task Group No. 40 did not adequately consider these emerging modalities. A review of literature indicates that published articles on QA procedures concentrate primarily on the verification of dose delivered to phantom during commissioning of the system and dose delivered to phantom before treating patients. Absolute dose measurements using ion chambers and relative dose measurements using film dosimetry have been used to verify delivered doses. QA on equipment performance and equipment safety is limited. This paper will discuss QA on equipment performance, equipment safety, and patient setup reproducibility.

Review of dosimetric functions for meterset calculations.

Mathematical expressions used to calculate doses in a patient, based on data measured in a phantom, have to be simple, understandable, and reliable to minimize possible calculational error. In light of this concern, this paper reviews the dosimetric functions used in meterset calculations to determine the treatment times or monitor units for a prescribed dose. The dosimetric functions are the percent depth dose, the tissue-air ratio, the tissue-phantom ratio, and the inverse square law. This review examined the definition of the dosimetric functions, the inter-relationships among the dosimetric functions, and the mathematical expressions used in meterset calculations for nonstandard source-to-surface distances in a phantom.

IORT apparatus design improvement through the evaluation of electron spectral distributions using Monte Carlo methods.

Clinically used IORT electron beam characteristics may vary with respect to typical external beams due to the decrease of lateral scatter equilibrium and the addition of the IORT apparatus itself. Additionally, chamber size effects may lead to inaccurate measurements of the changes in electron beam characteristics. The causal components of these beam characteristics are often difficult or impossible to measure using experimental techniques. For this reason, and for potential design improvement, the electron beams were modeled using the OMEGA/BEAM Monte Carlo software for radiation transport. The IORT electron beam characteristics of the Varian Clinac 1800 were studied for 6, 12, and 20 MeV electrons and 1-4 in. diameter flat-end applicators. The characteristics studied include electron energy spectra, percentage depth dose, and cross-plane profiles. It was found that by increasing the thickness of the aluminum base plate of the main attachment, the dose at d(max) outside the primary field could be reduced from approximately 9% to 1% of maximum.

Accuracy of magnetic resonance imaging stereotactic coordinates with the cosman-roberts-wells frame.

Quality assessment on the accuracy of a Cosman-Roberts-Wells (CRW) magnetic resonance imaging (MRI) stereotactic ring which had nonferrous stainless steel screws and positioning posts and a localizer with petroleum jelly in the fiducials, purchased in 1994, revealed errors of greater than 4 mm with targets in phantoms. Image fusion of objects within the phantom indicated the central area was accurately depicted by CT or MRI. We then tested a newer CRW- MRI ring (MRIA-IHR with titanium screws and posts) and localizer (MRIA-2-LF with fiducials filled with copper sulfate) and found that the MRI stereotactically calculated target coordinates matched both the known position of these targets in the phantom as well as the CT stereotactically calculated coordinates within approximately 1 mm. We also describe excellent superimposition of CT and MRI stereotactically determined surfaces in a recent clinical case using the new hardware. This shows that recent modifications to the CRW-MRI stereotactic system can make it accurate for small targets, but we emphasize that all systems need to undergo ongoing local quality assessment to ensure acceptable accuracy in practice.

Dose perturbation caused by high-density inhomogeneities in small beams in stereotactic radiosurgery.

The influence of high-density tissue heterogeneities in small-diameter beams used in stereotactic radiosurgery has been investigated. Dose perturbation immediately behind aluminium sheets, used to simulate a high-density tissue inhomogeneity such as bone, was studied in a solid water phantom. Dose reduction factors (DRFs), which are the ratios of the dose in the presence of the inhomogeneity to dose in a uniform density solid water phantom, were measured with a diamond detector for three thicknesses of aluminium. DRFs exhibit dependence on both the inhomogeneity thickness and the beam diameter. The DRF decreases with inhomogeneity thickness. The DRF initially decreases with increase in the beam diameter from 12.5 to 25 mm. For fields greater than 25 mm, the DRFs are nearly constant. The commonly used algorithms such as the TAR ratio method underestimate the magnitude of the measured effect. A good agreement between these measurements and Monte Carlo calculations is obtained. The influence of the high-density inhomogeneity on the tissue maximum ratio (TMR) was also measured with the inhomogeneity at a fixed depth dmax from the entrance surface. The TMR is reduced for all detector-inhomogeneity distances investigated. The dose build-up phenomenon observed in the presence of low-density air inhomogeneity is absent in the presence of a high-density inhomogeneity. The beam width (defined by 50% dose points) immediately beyond the inhomogeneity is unaffected by the high-density inhomogeneity. However, the 90%-10% and 80%-20% dose penumbra widths and the dose outside the beam edge (beyond the 50% dose point) are reduced. This reduction in dose outside the beam edge is caused by the reduced range of the secondary radiation (photons and electrons) in the high-density medium.

Do we need Monte Carlo treatment planning for linac based radiosurgery? A case study.

The accuracy of conventional empirical and semi-empirical dose calculation algorithms for radiation therapy treatment planning is limited. The main problem is that these algorithms fail to adequately consider the lateral transport of radiation. Most conventional algorithms use measured dose distribution data as input. These data induce an added inaccuracy to stereotactic radiosurgery dose calculations due to the difficulty of acquiring accurate dosimetric data for very small beams; however, since multiple arcs of large solid angles are usually used in stereotactic radiosurgery, the errors introduced by conventional dose algorithms are quite likely to be diluted. The use of Monte Carlo treatment planning for stereotactic radiosurgery has been investigated and described in the present paper. The OMEGA Monte Carlo code system is used as the dose engine in an in-house developed radiosurgery treatment planning system. The Monte Carlo treatment plans are done for two typical clinical cases. In one case, the collimator of 20 mm diameter is used and the lesion is located in the peripheral part of the brain. In the other case, the collimator diameter is 30 mm and the lesion is in the central part of the brain. The resultant dose distributions are compared with those calculated with a conventional dose algorithm which is based on the standard Tissue Maximum Ratio (TMR)/Off Axis Ratio (OAR) formalism. Without the inhomogeneity correction, the conventional algorithm yields accurate relative dose distributions for both cases compared with the Monte Carlo calculations. The absolute dose at the isocenter may be overestimated by the conventional algorithm by 1.5% for the first case and 2.6% for the second case; however, using the method of ratio of TMRs for inhomogeneity correction, the overestimation can be greatly reduced for both cases. The inclusion of the inhomogeneity correction into the conventional dose algorithm does not alter the relative dose distributions. Based on the clinical cases studied, it may be concluded that the conventional dose algorithm is sufficient for radiosurgery treatment planning and the Monte Carlo based radiosurgery treatment planning is unwarranted.