Dosimetric validation of intensity-modulated bolus electron conformal therapy planning and delivery using an anthropomorphic cylindrical head phantom.

PURPOSE: This work investigated the dosimetric accuracy of the intensity-modulated bolus electron conformal therapy (IM-BECT) planning and delivery process using the decimal ElectronRT (eRT) treatment planning system. METHODS: An IM-BECT treatment plan was designed using eRT for a cylindrical, anthropomorphic retromolar trigone phantom. Treatment planning involved specification of beam parameters and design of a variable thickness wax bolus and Passive Radiotherapy Intensity Modulator for Electrons (PRIME) device, which was comprised of 33 tungsten island blocks of discrete diameters from 0.158 to 0.223 cm (Intensity Reduction Factors from 0.937 to 0.875, respectively) inside a 10.1 × 6.7 cm2 copper cutout. For comparison of calculation accuracy, a BECT plan was generated by copying the IM-BECT plan and removing the intensity modulation. For both plans, a 16 MeV electron beam was used with 104.7 cm source-to-surface distance to bolus. In-phantom TLD-100 measurements (N = 47) were compared with both eRT planned dose distributions, which used the pencil beam redefinition algorithm with modifications for passive electron intensity modulation (IM-PBRA). Dose difference and distance to agreement (DTA) metrics were computed for each measurement point. RESULTS: Comparison of measured dose distributions with planned dose distributions yielded dose differences (calculated minus measured) characterized by a mean and standard deviation of -0.36% ± 1.64% for the IM-BECT plan, which was similar to -0.36% ± 1.90% for the BECT plan. All dose measurements were within 5% of the planned dose distribution, with both the BECT and IM-BECT measurement sets having 46/47 (97.8%) points within 3% or within 3 mm of the respective treatment plans. CONCLUSIONS: It was found that the IM-BECT treatment plan generated using eRT was sufficiently accurate for clinical use when compared to TLD measurements in a cylindrical, anthropomorphic phantom, and was similarly accurate to the BECT treatment plan in the same phantom.

Factory quality assurance of passive radiotherapy intensity modulators for electrons using kilovoltage x-ray imaging.

PURPOSE: This work developed an x-ray-based method for performing factory quality assurance (QA) of Passive Radiotherapy Intensity Modulators for Electrons (PRIME) device fabrication. This method measures errors in position, diameter, and orientation of cylindrical island blocks on a hexagonal grid that comprises PRIME devices and the impact of such errors on the underlying intensity distribution. METHODS: X-ray images were acquired of six PRIME devices, which modeled three error cases (small random, large random, and systematic errors) for two island block diameters (0.158 and 0.352 cm). Island blocks in each device, 0.6 cm long tungsten cylinders of constant diameter, were spaced 0.6 cm on a hexagonal grid over approximately 8 cm square. Using a 50 kVp x-ray image, each island block projected a racetrack, whose perimeter was fit to a function that allowed determination of its position, diameter, and angular orientation (θ, ϕ). These measured parameters were input into a pencil beam algorithm (PBA) dose calculation performed in water (16 MeV, SSD = 103 cm) for each device. PBA calculated intensity distributions using measured and planned (exact) island block parameters were compared. RESULTS: Θ distributions for the 0.158 and 0.352 cm devices were nearly identical for each error case, with θ values for most island blocks being within 3.2°, 8.5°, and 7.5° for the small random, large random, and systematic error PRIME devices, respectively. Corresponding intensity differences between using measured and planned island block parameters were within 1.0% and 2.8% (small random), 2.2% and 4.8% (large random), and 3.2% and 6.7% (systematic) for the 0.158 and 0.352 cm devices, respectively. CONCLUSION: This approach provides a viable and economical method for factory QA of fabricated PRIME devices by determining errors in their planned intensity distribution from which their quality can be assessed prior to releasing to the customer.

Modeling scatter through sides of island blocks used for intensity-modulated bolus electron conformal therapy.

PURPOSE: Passive Radiotherapy Intensity Modulators for Electrons (PRIME) devices are comprised of cylindrical tungsten island blocks imbedded in a machinable foam slab within the patient's cutout. Intensity-modulated bolus electron conformal therapy (IM-BECT) uses PRIME devices to reduce dose heterogeneity caused by the irregular bolus surface. Heretofore, IM-BECT dose calculations used the pencil beam redefinition algorithm (PBRA) assuming perfect collimation. This study investigates modeling electron scatter into and out the sides of island blocks. METHODS: Dose distributions were measured in a water phantom at 7, 13, and 20 MeV for devices having nominal intensity reduction factors of 1.000 (foam only), 0.937, 0.812, and 0.688, corresponding to nominal island block diameters (dnom ) of 0.158, 0.273, and 0.352 cm, respectively. Pencil beam theory derived an effective diameter (dIS ) to account for in-scattered electrons as a function of dnom and beam energy (Ep,0 ). However, for out-scattered electrons, an effective diameter (dmod ) was estimated by best fitting measured data. RESULTS: In the modulated region (under island blocks, depth < R90 ), modified PBRA-calculated dose distributions showed 2%/2 mm passing rates for dnom  = 0.158, 0.273, and 0.352 cm of (100%, 100%, 100%) at 7 MeV, (100%, 100%, 93.5%) at 13 MeV, and (99.8%, 85.4%, and 71.5%) at 20 MeV. The largest dose differences (≤ 6%) occurred at the highest energy (20 MeV), largest dnom , shallowest depths (≤ 2 cm), and on central axis. CONCLUSIONS: An equation for modeling island block scatter, dmod (dnom , Ep,0 ), has been developed for use in the PBRA, insignificantly impacting calculation time. Although inaccuracy sometimes exceeded our 2%/2 mm criteria, it could be clinically acceptable, as superficial dose differences often fall inside the bolus. Also, patient PRIME devices are expected to have fewer large diameter island blocks than did test devices. Inaccuracies are attributed to out-scattered electrons having energy spectra different than the primary beams.

Planning and delivery of intensity modulated bolus electron conformal therapy.

PURPOSE: Bolus electron conformal therapy (BECT) is a clinically useful, well-documented, and available technology. The addition of intensity modulation (IM) to BECT reduces volumes of high dose and dose spread in the planning target volume (PTV). This paper demonstrates new techniques for a process that should be suitable for planning and delivering IM-BECT using passive radiotherapy intensity modulation for electrons (PRIME) devices. METHODS: The IM-BECT planning and delivery process is an addition to the BECT process that includes intensity modulator design, fabrication, and quality assurance. The intensity modulator (PRIME device) is a hexagonal matrix of small island blocks (tungsten pins of varying diameter) placed inside the patient beam-defining collimator (cutout). Its design process determines a desirable intensity-modulated electron beam during the planning process, then determines the island block configuration to deliver that intensity distribution (segmentation). The intensity modulator is fabricated and quality assurance performed at the factory (.decimal, LLC, Sanford, FL). Clinical quality assurance consists of measuring a fluence distribution in a plane perpendicular to the beam in a water or water-equivalent phantom. This IM-BECT process is described and demonstrated for two sites, postmastectomy chest wall and temple. Dose plans, intensity distributions, fabricated intensity modulators, and quality assurance results are presented. RESULTS: IM-BECT plans showed improved D90-10 over BECT plans, 6.4% versus 7.3% and 8.4% versus 11.0% for the postmastectomy chest wall and temple, respectively. Their intensity modulators utilized 61 (single diameter) and 246 (five diameters) tungsten pins, respectively. Dose comparisons for clinical quality assurance showed that for doses greater than 10%, measured agreed with calculated dose within 3% or 0.3 cm distance-to-agreement (DTA) for 99.9% and 100% of points, respectively. CONCLUSION: These results demonstrated the feasibility of translating IM-BECT to the clinic using the techniques presented for treatment planning, intensity modulator design and fabrication, and quality assurance processes.