Cheng B Saw

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.

DOSIMETRIC EVALUATION OF ABUTTED FIELDS USING ASYMMETRIC COLLIMATORS FOR TREATMENT OF HEAD AND NECK

PURPOSE The objective of this study was to reevaluate the dose nonuniformity of abutted fields defined using asymmetric collimators and one isocenter for treatment of the head and neck region. METHODS AND MATERIALS Bilateral parallel-opposed fields abutted to the anterior field at one isocenter were implemented in the treatment of head and neck. The effect of digital display tolerance can produce dose nonuniformity at the junction of the abutted fields. The amount of dose nonuniformity was quantified using both mathematical summation of dose profiles and by direct measurement of doses at the junction of the two abutted fields. The dose nonuniformity was obtained by irradiating the superior part of a film using bilateral parallel-opposed fields and the inferior part by an anterior field with a gap or an overlap. Dose profiles were taken at the depth of maximum dose for the anterior field across the abutted fields. The dose nonuniformity was determined for the case where the asymmetric jaw was set at -2 mm, -1 mm, 0, +1 mm, and +2 mm from the beam central axis. RESULTS The dose at the junction increases systematically as the abutment of the fields changes from a gap to an overlap. The dose nonuniformity with 1-mm gap and 1-mm overlap is about 15% underdose and overdose, respectively. CONCLUSION Imperfect abutment of split fields due to digital display tolerance (+/-1 mm) of asymmetric collimator can cause an underdose or overdose of 15% of the delivered dose.

Clinical implementation of intensity-modulated radiation therapy

The clinical implementation of intensity-modulated radiation therapy (IMRT) is a complex process because of the introduction of new treatment planning algorithms and beam delivery systems compared to conventional 3-dimensional conformal radiation therapy (3D-CRT) and the lack of established national performance protocols. IMRT uses an inverse-planning algorithm to create nonuniform fields that are only deliverable through a newly designed beam-modulating delivery system. The intent of this paper is to describe our experience and to elucidate the new clinical procedures that must be executed to have a successful IMRT program. Patients who undergo IMRT at our institution are immobilized and simulated before proceeding to computed tomography scan for patient data acquisition. Treatment planning involves the use of different prescription dose formats and different planning techniques compared to 3D-CRT. The desired dose goals for the target and sensitive structures must be specified before initiating the planning process, which is computer intensive. After the plan is completed, the delivery instructions are transferred to the delivery system via either a floppy disk for MIMiC-based IMRT or through the network for MLC-based IMRT. Target localizations are carried out using orthogonal radiographs. Ultrasound imaging system (BAT) is used to localize the prostate. Dose validation is performed using films, ion chambers or dose-calculation-based techniques.

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.

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.

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.

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.

Independent calculations to validate monitor units from ADAC treatment planning system

Current standards of practice are based on the use of an independent calculation to validate the monitor units (MUs) derived from a treatment planning system. The ADAC PINNACLE treatment planning system has shown discrepancies of 10% or more compared to simple independent calculations for highly contoured areas such as tangential breast and chest wall irradiation. The ADAC treatment planning system generally requires more MUs to deliver the same prescribed dose. Independent MU calculation methods are based on full phantom conditions. On the other hand, the MUs from the ADAC treatment planning system are derived using realistic phantom scatter. As such, differences exist in TMR factors, off-axis wedge factors, and the phantom scatter factor. To systematically study the discrepancies due to phantom conditions, experimental measurements were performed with various percentages of tissue missing. The agreement between the experimental measurements and ADAC calculations was found to be within 2%. Using breast field geometry, a relationship between missing tissue and the dosimetric parameters used by ADAC was developed. This relationship, when applied, yielded independent MU calculations whose values closely matched those from the ADAC treatment planning system.

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.

Dosimetric assessment of nonperfectly abutted fields using asymmetric collimators.

The abutment of adjacent fields has been facilitated through the use of asymmetric collimators. Conceptually, the abutment yields a perfectly uniform dose distribution across the junction, provided the asymmetric jaw is set precisely at the beam central axis. However, the asymmetric jaw has an associated tolerance, which can cause the abutment to be misaligned. This study examined the dose distribution at the junction of nonperfectly abutted fields. The abutment of fields was carried out using an asymmetric collimation of 5 x 10 cm, with an asymmetric jaw positioned at the beam central axis. A film was initially exposed using this field with the collimator set at 90 degrees. The collimator was then rotated 180 degrees and the same film was exposed for the second time to create the field abutment. Positioning the asymmetric jaw with respect to the beam central axis set the amount of gap and overlap between the abutted fields. The dose distribution was measured for asymmetric jaw positioning of -2, -1, 0, + 1, and +2 mm from the beam central axis. In addition, the dose distribution was also computed mathematically by summing the 2 dose profiles with defined gap or overlap. A field mismatch of +/-1 mm would result in a dose nonuniformity of 17%, and a +/-2 mm mismatch would produce a 35% dose nonuniformity.