Preliminary report of toxicity following 3D radiation therapy for prostate cancer on 3DOG/RTOG 9406.

PURPOSE: A prospective Phase I dose escalation study was conducted to determine the maximally-tolerated radiation dose in men treated with three-dimensional conformal radiation therapy (3D CRT) for localized prostate cancer. This is a preliminary report of toxicity encountered on the 3DOG/RTOG 9406 study. METHODS AND MATERIALS: Each participating institution was required to implement data exchange with the RTOG 3D quality assurance (QA) center at Washington University in St. Louis. 3D CRT capabilities were strictly defined within the study protocol. Patients were registered according to three stratification groups: Group 1 patients had clinically organ-confined disease (T1,2) with a calculated risk of seminal vesicle invasion of < 15%. Group 2 patients had clinical T1,2 disease with risk of SV invasion > or = 15%. Group 3 (G3) patients had clinical local extension of tumor beyond the prostate capsule (T3). All patients were treated with 3D techniques with minimum doses prescribed to the planning target volume (PTV). The PTV margins were 5-10 mm around the prostate for patients in Group 1 and 5-10 mm around the prostate and SV for Group 2. After 55.8 Gy, the PTV was reduced in Group 2 patients to 5-10 mm around the prostate only. Minimum prescription dose began at 68.4 Gy (level I) and was escalated to 73.8 Gy (level II) and subsequently to 79.2 Gy (level III). This report describes the acute and late toxicity encountered in Group 1 and 2 patients treated to the first two study dose levels. Data from RTOG 7506 and 7706 allowed calculation of the expected probability of observing a > or = grade 3 late effect more than 120 days after the start of treatment. RTOG toxicity scores were used. RESULTS: Between August 23, 1994 and July 2, 1997, 304 Group 1 and 2 cases were registered; 288 cases were analyzable for toxicity. Acute toxicity was low, with 53-54% of Group 1 patients having either no or grade 1 toxicity at dose levels I and II, respectively. Sixty-two percent of Group 2 patients had either none or grade 1 toxicity at either dose level. Few patients (0-3%) experienced a grade 3 acute bowel or bladder toxicity, and there were no grade 4 or 5 toxicities. Late toxicity was very low in all patient groups. The majority (81-85%) had either no or mild grade 1 late toxicity at dose level I and II, respectively. A single late grade 3 bladder toxicity in a Group 2 patient treated to dose level II was recorded. There were no grade 4 or 5 late effects in any patient. Compared to historical RTOG controls (studies 7506, 7706) at dose level I, no grade 3 or greater late effects were observed in Group 1 and Group 2 patients when 9.1 and 4.8 events were expected (p = 0.003 and p = 0.028), respectively. At dose level II, there were no grade 3 or greater toxicities in Group 1 patients and a single grade 3 toxicity in a Group 2 patient when 12.1 and 13.0 were expected (p = 0.0005 and p = 0.0003), respectively. Multivariate analysis demonstrated that the relative risk of developing acute bladder toxicity was 2.13 if the percentage of the bladder receiving > or = 65 Gy was more than 30% (p = 0.013) and 2.01 if patients received neoadjuvant hormonal therapy (p = 0.018). The relative risk of developing late bladder complications also increased as the percentage of the bladder receiving > or = 65 Gy increased (p = 0.026). Unexpectedly, there was a lower risk of late bladder complications as the mean dose to the bladder and prescription dose level increased. This probably reflects improvement in conformal techniques as the study matured. There was a 2.1 relative risk of developing a late bowel complication if the total rectal volume on the planning CT scan exceeded 100 cc (p = 0.019). CONCLUSION: Tolerance to high-dose 3D CRT has been better than expected in this dose escalation trial for Stage T1,2 prostate cancer compared to low-dose RTOG historical experience. With strict quality assurance standards and review, 3D CRT can be safely studied in a co

A software tool for the quantitative evaluation of 3D dose calculation algorithms.

Current methods for evaluating modern radiation therapy treatment planning (RTP) systems include the manual superposition of calculated and measured isodose curves and the comparison of a limited number of calculated and measured point doses. Both techniques have significant limitations in providing quantitative evaluations of the large number of dose data generated by modern RTP systems. More sophisticated comparison techniques have been presented in the literature, including dose-difference and distance-to-agreement (DTA) analyses. A software tool has been developed that uses superimposed isodose plots, dose-difference, and DTA distributions to quantify errors in computed dose distributions. Dose-difference and DTA analyses are overly sensitive in regions of high- and low-dose gradient, respectively. The logical union of locations that fail both dose-difference and DTA acceptance criteria, termed the composite evaluation, is calculated and displayed. The composite evaluation provides a method for the physicist to efficiently identify regions that fail both the dose-difference and DTA acceptance criteria. The tool provides a computer platform for the quantitative comparison of calculated and measured dose distributions.

Quality assurance for 3D conformal radiation therapy.

Three-dimensional conformal radiation therapy (3D CRT) can be considered as an integrated process of treatment planning, delivery, and verification that attempts to conform the prescription dose closely to the target volume while limiting dose to critical normal structures. Requiring the prescription dose to conform as closely as possible to the target volume raises the level of the precision and accuracy requirements generally found in conventional radiation therapy. 3D CRT treatment planning requires robust patient immobilization/repositioning systems and volumetric image data (CT and/or MR) acquired in the treatment position. 3D treatment planning more explicitly details the particulars of a patient's treatment than was ever possible with 2D treatment planning. In 1992, we implemented a formal 3D treatment planning service in our clinic and at that same time instituted a formal quality assurance (QA) program addressing the individual procedures that make up the 3D CRT process. Our 3D QA program includes systematic testing of the hardware and software used in the 3D treatment planning process, careful review of each patient's treatment plan, careful review of the physical implementation of the treatment plan, a peer review 3D QA Case Conference, and a formal continuing education program in 3D CRT for our radiation therapy staff. This broad 3D QA program requires the involvement of physicians, physicists, dosimetrists, and the treating radiation therapists that complete the team responsible for 3D CRT. 3D CRT capabilities change the kinds of radiation therapy treatments that are possible and that changes the process with which treatment planning and treatment delivery are performed. There is no question that 3D CRT shows significant potential for improving the quality of radiation therapy and improving the efficiency with which it can be delivered. However, its implementation and wide spread use is still in its initial stages. The techniques used for 3D treatment planning and the associated QA procedures and tests should still be considered developmental and changes are likely to continue to occur over the next several years.

Initial experience with quality assurance of multi-institutional 3D radiotherapy clinical trials. A brief report.

In 1992, a 3D Quality Assurance (3D QA) Center was established at the Mallinckrodt Institute of Radiology under the auspices of the Radiation Therapy Oncology Group (RTOG). The role of the 3D QA Center is to provide quality assurance reviews of external beam treatment planning and verification (TPV) information for patients enrolled in multi-institutional 3D radiotherapy treatment protocols. Computer hardware and software components have been implemented which allow participating institutions to submit (via either the Internet or magnetic tape) common format 3D TPV data for QA review including: volumetric CT image data, normal structure, tumor and target volume contours, digitally reconstructed radiographs or simulator (prescription) and portal radiographs, beam geometry, dose distributions, fractionation information, and dose-volume histograms. Prior to enrolling patients on a 3D radiotherapy treatment protocol, each participating institution is required to complete a 3D Facility Questionnaire documenting their 3D treatment planning capability. In addition, the successful completion of a protocol "dry run" test is required to demonstrate the participating institution's ability to submit a protocol complaint digital data set to the 3D QA Center prior to placing patients on the 3D CRT study. Two site specific (prostate and lung) phase I/II 3D dose escalation trials are currently accruing patients. The QA center reviews at a minimum the first 5 cases from each participating institution and spot checks subsequent submissions. For each case review the following parameters are evaluated: 1. data exchange compliance, 2. CT data quality, 3. target volume contours, 4. normal structure contours, 5. field placement, 6. field shape, 7. dose prescription, 8. dose uniformity, and 9. dose conformity. By April 1997, over 300 protocol patient TPV data sets have been submitted and reviewed by the 3D QA Center.

A technique for the quantitative evaluation of dose distributions.

The commissioning of a three-dimensional treatment planning system requires comparisons of measured and calculated dose distributions. Techniques have been developed to facilitate quantitative comparisons, including superimposed isodoses, dose-difference, and distance-to-agreement (DTA) distributions. The criterion for acceptable calculation performance is generally defined as a tolerance of the dose and DTA in regions of low and high dose gradients, respectively. The dose difference and DTA distributions complement each other in their useful regions. A composite distribution has recently been developed that presents the dose difference in regions that fail both dose-difference and DTA comparison criteria. Although the composite distribution identifies locations where the calculation fails the preselected criteria, no numerical quality measure is provided for display or analysis. A technique is developed to unify dose distribution comparisons using the acceptance criteria. The measure of acceptability is the multidimensional distance between the measurement and calculation points in both the dose and the physical distance, scaled as a fraction of the acceptance criteria. In a space composed of dose and spatial coordinates, the acceptance criteria form an ellipsoid surface, the major axis scales of which are determined by individual acceptance criteria and the center of which is located at the measurement point in question. When the calculated dose distribution surface passes through the ellipsoid, the calculation passes the acceptance test for the measurement point. The minimum radial distance between the measurement point and the calculation points (expressed as a surface in the dose-distance space) is termed the gamma index. Regions where gamma > 1 correspond to locations where the calculation does not meet the acceptance criteria. The determination of gamma throughout the measured dose distribution provides a presentation that quantitatively indicates the calculation accuracy. Examples of a 6 MV beam penumbra are used to illustrate the gamma index.

Real-time 3D dose calculation and display: a tool for plan optimization.

PURPOSE: Both human and computer optimization of treatment plans have advantages; humans are much better at global pattern recognition, and computers are much better at detailed calculations. A major impediment to human optimization of treatment plans by manipulation of beam parameters is the long time required for feedback to the operator on the effectiveness of a change in beam parameters. Our goal was to create a real-time dose calculation and display system that provides the planner with immediate (fraction of a second) feedback with displays of three-dimensional (3D) isodose surfaces, digitally reconstructed radiographs (DRRs), dose-volume histograms, and/or a figure of merit (FOM) (i.e., a single value plan score function). This will allow the experienced treatment planner to optimize a plan by adjusting beam parameters based on a direct indication of plan effectiveness, the FOM value, and to use 3D display of target, critical organs, DRRs, and isodose contours to guide changes aimed at improving the FOM value. METHODS AND MATERIALS: We use computer platforms that contain easily utilized parallel processors and very tight coupling between calculation and display. We ported code running on a network of two workstations and an array of transputers to a single multiprocessor workstation. Our current high-performance graphics workstation contains four 150-MHz processors that can be readily used in a shared-memory multithreaded calculation. RESULTS: When a 10 x 10-cm beam is moved, using an 8-mm dose grid, the full 3D dose matrix is recalculated using a Bentley-Milan-type dose calculation algorithm, and the 3D dose surface display is then updated, all in < 0.1s. A 64 x 64-pixel DRR calculation can be performed in < 0.1 s. Other features, such as automated aperture calculation, are still required to make real-time feedback practical for clinical use. CONCLUSION: We demonstrate that real-time plan optimization using general purpose multiprocessor workstations is a practical goal. Parallel processing technology provides this capability for 3D planning systems, and when combined with objective plan ranking algorithms should prove effective for optimizing 3D conformal radiation therapy. Compared to our earlier transputer work, multiprocessor workstations are more easily programmed, making software development costs more reasonable compared with uniprocessor development costs. How the dose calculation is partitioned into parallel tasks on a multiprocessor work station can make a significant difference in performance. Shared-memory multiprocessor workstations are our first choice for future work, because they require minimum programming effort and continue to be driven to higher performance by competition in the workstation arena.

Systematic verification of a three-dimensional electron beam dose calculation algorithm.

A three-dimensional electron beam dose calculation algorithm implemented on a commercial radiotherapy treatment planning system is described. The calculation is based on the M. D. Anderson Hospital (M.D.A.H.) pencil beam model, which uses the Fermi-Eyges theory of thick-target multiple Coulomb scattering. To establish the calculation algorithm's accuracy as well as its limitations, it was systematically and extensively tested and evaluated against a set of benchmark measurements. Various levels of dose and spatial tolerances were used to validate the calculation quantitatively. Results are presented in terms of the percentage of data points meeting a specific tolerance level. The algorithm's ability to accurately simulate commonly used clinical setup geometries, including standard or extended SSDs, blocked fields, irregular surfaces, and heterogeneities, is demonstrated. Regions of disagreement between calculations and measurements are also shown. The clinical implication of such disagreements is addressed, and the algorithmic assumptions involved are discussed.

Clinical implementation of a commercial multileaf collimator: dosimetry, networking, simulation, and quality assurance.

PURPOSE: Clinical implementation of multileaf collimation (MLC) includes commissioning (including leaf calibration), dosimetric measurements (penumbra, transmission, calculation parameters), shaping methods, networking for file transfer, verification simulation, and development of a quality assurance (QA) program. Differences of MLC and alloy shaping in terms of penumbra and stair-step effects must be analyzed. METHODS AND MATERIALS: Leaf positions are calibrated to light field. The resultant decrement line, penumbras, leaf transmission data, and isodoses in various planes were measured with film. Penumbra was measured for straight edges and corners, in various media. Ion chambers were used to measure effects of MLC on output, scatter, and depth dose. We maintain midleaf intersection criteria. MLC fields are set 7 mm beyond planning target volumes. After shaping by vendor software or by our three-dimensional planning system, files are transferred to the MLC workstation by means of sharing software, interface cards, and cabling. A MLC emulator was constructed for simulation. Our QA program includes file checks, monthly checks (leaf position accuracy and interlock tests), and annual review. RESULTS: We found the MLC leaf position (light field) corresponds to decrement lines ranging from 50 to 59%. Transmission through MLC (1.5-2.5%) is less than alloy (3.5%). Multileaf penumbra is slightly wider than for alloy. Relative penumbra did not increase in the lung, and composite field dosimetry exhibited negligible differences compared with alloy. Verification simulations provide diagnostic image quality hard copies of the MLC fields. Monitor unit parameters used for alloy held for MLC. DISCUSSION: Clinical implementation for MLC as a block replacement was conducted on a site-by-site basis. Time studies indicate significant (25%) in-room time reductions. Through imaging and dosimetric analysis, the accuracy of field delivery has increased with MLC. The most significant impact of MLC is the ability to increase the number of daily treatment fields, thereby reducing normal tissue dosing, which is vital for dose escalation.

Three dimensional conformal radiation therapy in pediatric parameningeal rhabdomyosarcomas.

PURPOSE: We evaluated the utility of three dimensional (3D) treatment planning in the management of children with parameningeal head and neck rhabdomyosarcomas. METHODS AND MATERIALS: Five children with parameningeal rhabdomyosarcoma were referred for treatment at our radiation oncology center from May 1990 through January 1993. Each patient was evaluated, staged, and treated according to the Intergroup Rhabdomyosarcoma Study. Patients were immobilized and underwent a computed tomography scan with contrast in the treatment position. Tumor and normal tissues were identified with assistance from a diagnostic radiologist and defined in each slice. The patients were then planned and treated with the assistance of a 3D treatment planning system. A second plan was then devised by another physician without the benefit of the 3D volumetric display. The target volumes designed with the 3D system and the two-dimensional (2D) method were then compared. The dosimetric coverage to tumor, tumor plus margin, and normal tissues was also compared with the two methods of treatment planning. RESULTS: The apparent size of the gross tumor volume was underestimated with the conventional 2D planning method relative to the 3D method. When margin was added around the gross tumor to account for microscopic extension of disease in the 2D method, the expected area of coverage improved relative to the 3D method. In each circumstance, the minimum dose that covered the gross tumor was substantially less with the 2D method than with the 3D method. The inadequate dosimetric coverage was especially pronounced when the necessary margin to account for subclinical disease was added. In each case, the 2D plans would have delivered substantial dose to adjacent normal tissues and organs, resulting in a higher incidence of significant complications. CONCLUSIONS: 3D conformal radiation therapy has a demonstrated advantage in the treatment of sarcomas of the head and neck. The improved dosimetric coverage of the tumor and its margin for subclinical extensions may result in improvement in local control of these tumors. In addition, lowering of radiation dose to adjacent critical structures may help lower the incidence of adverse late effects in children.

Preliminary results of a prospective trial using three dimensional radiotherapy for lung cancer.

PURPOSE: To evaluate the preliminary results of a prospective trial using three-dimensional (3D) treatment for lung cancer. METHODS AND MATERIALS: Seventy patients with inoperable Stage I through IIIB lung cancer were treated with three-dimensional thoracic irradiation with or without chemotherapy (35% received chemotherapy). Total prescribed dose to the tumor ranged from 60-74 Gy (uncorrected for lung density). All patients were evaluated for local control, survival, and development of pneumonitis. These parameters were evaluated in respect to and compared with three-dimensional parameters used in their treatment planning. RESULTS: With a minimum follow-up of 6 to 30 months, the 2-year cause-specific survival rate for Stages I and II was 90% and 53% for Stage III (no difference between Stages IIIA and IIIB). Patients with local tumor control had a better 2-year overall survival rate (47%) than those with local failure (31%). Volumetrically heterogeneously calculated doses were important to the accurate delineation of dose-volume coverage as there was a wide range of discrepancies between a homogeneously prescribed point dose calculation and the heterogeneously calculated volume coverage of that prescription. High-grade pneumonitis was correlated with the location of the tumor with lower lobe tumors having a much higher risk than those with upper lobe tumors. A critical volume effect and threshold dose were apparent in the development of high-grade pneumonitis. CONCLUSIONS: Three-dimensional therapy for lung cancer has been practically implemented at the Mallinckrodt Institute of Radiology and shows promising results in our preliminary analysis. The incidence of high-grade pneumonitis, however, warrants careful selection of patients for future dose escalation. Future dose escalation trials in lung cancer should be directed to volumes that limit the amount of elective nodal irradiation. However, the volume of necessary elective nodal irradiation remains unknown and should be studied prospectively. Dose escalation trials are indicated and may be facilitated by smaller target volumes.

Measurement of a photon penumbra-generating kernel for a convolution-adapted ratio-TAR algorithm for 3D treatment planning.

A method has been developed to measure a photon penumbra-generating kernel using dosimetry equipment available in most radiation therapy departments. The kernel is used in a convolution-adapted ratio-TAR algorithm in our three-dimensional treatment planning system. The kernel is assumed to be invariant with respect to off-axis position, axially symmetric, and is divided into short- and long-range components, with a different measurement technique for each. The data required to obtain the short-range component are measured by scanning across a split-field geometry incident on a water phantom. The derivative of the measured profile is proportional to one-dimensional projections across the kernel. Because the kernel is axially symmetric, only one profile measurement is required for each depth. A CT reconstruction technique is used to extract the radial dependence of the kernel from the strip integrals. Electronic noise in the acquisition system yields significant uncertainties in the kernel shape for distances beyond 3 cm. The long-range portion of the kernel is obtained by examining tissue-air ratios (TARs). The derivative of the TAR at the center of a circular field is proportional to the kernel value at the distance corresponding to the radius of the field. The kernel measurement method was tested by comparing measured and calculated square-field profiles at a variety of depths. Agreement was within 1% within the field boundary and 3% outside the field boundary for all depths.

A convolution-adapted ratio-TAR algorithm for 3D photon beam treatment planning.

A convolution-adapted ratio of tissue-air ratios (CARTAR) method of dose calculation has been developed at the Mallinckrodt Institute of Radiology. This photon pencil-beam algorithm has been developed and implemented specifically for three-dimensional treatment planning. In a standard ratio of tissue-air ratios (RTAR) algorithm, doses to points in irregular field geometries are not adequately modeled. This is inconsistent with the advent of conformal therapy, the goal of which is to conform the dose distribution to the target volume while sparing neighboring sensitive normal critical structures. This motivated us to develop an algorithm that can model the beam penumbra near irregular field edges, while retaining much of the speed for the original RTAR algorithm. The dose calculation algorithm uses two-dimensional (2D) convolutions, computed by 2D fast Fourier transform, of pencil-beam kernels with a beam transmission array to calculate 2D off-axis profiles at a series of depths. These profiles are used to replace the product of the transmission function and measured square-field boundary factors used in the standard RTAR calculation. The 2D pencil-beam kernels were derived from measured data for each modality using commonly available dosimetry equipment. The CARTAR algorithm is capable of modeling the penumbra near block edges as well as the loss of primary and scattered beam in partially blocked regions. This paper describes the dose calculation algorithm, implementation, and verification.

The Electronic View Box: a software tool for radiation therapy treatment verification.

PURPOSE: We have developed a software tool for interactively verifying treatment plan implementation. The Electronic View Box (EVB) tool copies the paradigm of current practice but does so electronically. A portal image (online portal image or digitized port film) is displayed side by side with a prescription image (digitized simulator film or digitally reconstructed radiograph). The user can measure distances between features in prescription and portal images and "write" on the display, either to approve the image or to indicate required corrective actions. The EVB tool also provides several features not available in conventional verification practice using a light box. METHODS AND MATERIALS: The EVB tool has been written in ANSI C using the X window system. The tool makes use of the Virtual Machine Platform and Foundation Library specifications of the NCI-sponsored Radiation Therapy Planning Tools Collaborative Working Group for portability into an arbitrary treatment planning system that conforms to these specifications. The present EVB tool is based on an earlier Verification Image Review tool, but with a substantial redesign of the user interface. A graphical user interface prototyping system was used in iteratively refining the tool layout to allow rapid modifications of the interface in response to user comments. RESULTS: Features of the EVB tool include 1) hierarchical selection of digital portal images based on physician name, patient name, and field identifier; 2) side-by-side presentation of prescription and portal images at equal magnification and orientation, and with independent grayscale controls; 3) "trace" facility for outlining anatomical structures; 4) "ruler" facility for measuring distances; 5) zoomed display of corresponding regions in both images; 6) image contrast enhancement; and 7) communication of portal image evaluation results (approval, block modification, repeat image acquisition, etc.). CONCLUSION: The EVB tool facilitates the rapid comparison of prescription and portal images and permits electronic communication of corrections in port shape and positioning.

Integrated software tools for the evaluation of radiotherapy treatment plans.

PURPOSE: This article announces the availability of a convenient and useful software environment for the evaluation of three-dimensional (3D) radiotherapy treatment plans. MATERIALS AND METHODS: Using standards such as American National Standards for Information Systems C and the X Window System allowed us to bring the computation and display of dose-volume histograms, dose statistics, tumor control probabilities, normal tissue complication probabilities, and a figure of merit together under one user interface. These plan evaluation tools are not stand alone, but must interact with a 3D radiation therapy planning system to obtain the required dose matrices and patient anatomical contours. Installation of the software involves a programmer who writes a software bridge between the radiation therapy planning system and the tools, thereby providing access to local data files. This design strategy confines portability issues to one area of the software. RESULTS: Access to the other tools is through the Graphical Plan Evaluation Tool (GPET). GPET coordinates the use of each of the tools and provides graphical facilities for display of their results. Importantly, GPET assures that the displayed results of each tool have been computed with the same input specifications for all treatment plans being compared. For added convenience, the user can rearrange the resultant data to be reviewed in various ways on the video screen. The software design also allows incorporation of customized algorithms and input data for computing tumor control probability and normal tissue complication probabilities, since those currently available are controversial. CONCLUSION: The Graphical Plan Evaluation Tool unifies the simultaneous computation for several analytical tools and graphical display of their results. Within the constraints of the X Window System environment, this assemblage of software tools provides a portable, flexible, and convenient method for the quantitative evaluation of several radiotherapy treatment plans.

Three-dimensional radiation treatment planning study for patients with carcinoma of the lung.

PURPOSE: Several reports in the literature suggest that local-regional control and possibly survival could be improved for inoperable nonsmall cell lung cancer if the radiation dose to the target volume could be increased. Higher doses, however, bring with them the potential for increased side effects and complications of normal tissues. Three-dimensional treatment planning has shown significant potential for improving radiation treatment planning in several sites, both for tumor coverage and for sparing of normal tissue from high doses of radiation and, thus, has the potential of developing radiation therapy techniques that result in uncomplicated local-regional control of lung cancer. We have studied the feasibility of large-scale implementation of true three-dimensional technologies in the treatment of patients with cancers of the thorax. METHODS AND MATERIALS: CT scans were performed on 10 patients with inoperable nonsmall cell lung cancer to obtain full volumetric image data, and therapy was planned on our three-dimensional radiotherapy treatment planning system. Target volumes were determined using the new ICRU nomenclature--Gross Tumor Volume, Clinical Target Volume, and Planning Target Volume. Plans were performed according to our standard treatment policies based on traditional two-dimensional radiotherapy treatment planning methodologies and replanned using noncoplanar three-dimensional beam techniques. The results were quantitatively compared using dose-volume histograms, dose-surface displays, and dose statistics. RESULTS: Target volume delineation remains a difficult problem for lung cancer. Defining Gross Tumor Volume and Clinical Target Volume may depend on window and level settings of the three-dimensional radiotherapy treatment planning system, suggesting that target volume delineation on hard copy film is inadequate. Our study shows that better tumor coverage is possible with three-dimensional plans. Dose to critical structures (e.g., the heart) could often be reduced (or at least remain acceptable) using noncoplanar beams even with dose escalation to 75 to 80 Gy for the planning volume surrounding the Gross Target Volume. CONCLUSION: Commonly used beam arrangements for treatment of lung cancer appear to be inadequate to safely deliver tumor doses of higher than 70 Gy. Although conventional treatment techniques may be adequate for tumor coverage, they are inadequate for sparing of normal tissues when the prescription dose is escalated. The ability to use noncoplanar fields for such patients is a major advantage of three-dimensional planning. This capability led to better tumor coverage and reduced dose to critical normal tissues. However, this advantage was achieved at the expense of a greater time commitment by the treatment planning staff (particularly the radiation oncologist) and a greater complexity of treatment delivery. In summary, three-dimensional radiotherapy treatment planning appears to provide the radiation oncologist with the necessary tools to increase tumor dose, which may lead to increased local-regional control in patients with lung cancer while maintaining normal tissue doses at acceptable tolerance levels.

Advances in 3-dimensional radiation treatment planning systems: room-view display with real time interactivity.

PURPOSE: We describe our 3-dimensional (3-D) radiation treatment planning system for external photon and electron beam 3-D treatment planning which provides high performance computational speed and a real-time display which we have named "room-view" in which the simulated target volumes, critical structures, skin surfaces, radiation beams and/or dose surfaces can be viewed on the display monitor from any arbitrary viewing position. METHODS AND MATERIALS: We have implemented the 3-D planning system on a graphics superworkstation with parallel processing. Patient's anatomical features are extracted from contiguous computed tomography scan images and are displayed as wireloops or solid surfaces. Radiation beams are displayed as a set of diverging rays plus the polygons formed by the intersection of these rays with planes perpendicular to the beam axis. Controls are provided for each treatment machine motion function. Photon dose calculations are performed using an effective pathlength algorithm modified to accommodate 3-D off-center ratios. Electron dose calculations are performed using a 3-D pencil beam model. RESULTS: Dose distribution information can be displayed as 3-D dose surfaces, dose-volume histograms, or as isodoses superimposed on 2-D gray scale images of the patient's anatomy. Tumor-control-probabilities, normal-tissue-complication probabilities and a figure-of-merit score function are generated to aid in plan evaluation. A split-screen display provides a beam's-eye-view for beam positioning and design of patient shielding block apertures and a concurrent "room-view" display of the patient and beam icon for viewing multiple beam set-ups, beam positioning, and plan evaluation. Both views are simultaneously interactive. CONCLUSION: The development of an interactive 3-D radiation treatment planning system with a real-time room-view display has been accomplished. The concurrent real-time beam's-eye-view and room-view display significantly improves the efficacy of the 3-D planning process.

Independent collimator dosimetry for a dual photon energy linear accelerator.

PURPOSE: The independent collimator feature in medical linear accelerators can define radiation fields that are asymmetric with respect to the flattening filter and oblique to the incident surface. Prior to clinical implementation, it is necessary to evaluate the dosimetry of this non-standard treatment delivery technique. An investigation of the independent collimator dosimetry for 6 MV and 18 MV x-ray beams has been undertaken. METHODS AND MATERIALS: Dose to tissue in free space, percent depth dose and dose distribution were measured and compared to that for symmetric field collimation. RESULTS: The dosimetry results were consistent for both photon modes. Dose in free space with asymmetric collimation can be calculated from the corresponding symmetric field dose in free space to within 1.2 +/- 0.7% by applying an appropriate off-axis factor. Asymmetric field percent depth dose differs from symmetric field percent depth dose on average by 1.1 +/- 0.7% for 6 MV and by 0.7 +/- 0.5% for 18 MV for field sizes ranging from 5 x 5 to 20 x 20, centered 3 cm and 10 cm off-axis. The measured isodose curves demonstrate divergence effects and reduced doses (less than 3%) adjacent to the field edge closest to the flattening filter center. This dose asymmetry result is identical to that from secondary collimation. CONCLUSION: The methodology for clinical implementation of the independent collimator feature is straightforward. However, accurate representation of the isodose distributions by commercial radiotherapy treatment planning systems requires special dose calculation algorithms.