Dale W. Litzenberg

Daily prostate targeting using implanted radiopaque markers

PURPOSE A system has been implemented for daily localization of the prostate through radiographic localization of implanted markers. This report summarizes an initial trial to establish the accuracy of patient setup via this system. METHODS AND MATERIALS Before radiotherapy, three radiopaque markers are implanted in the prostate periphery. Reference positions are established from CT data. Before treatment, orthogonal radiographs are acquired. Projected marker positions are extracted semiautomatically from the radiographs and aligned to the reference positions. Computer-controlled couch adjustment is performed, followed by acquisition of a second pair of radiographs to verify prostate position. Ten patients (6 prone, 4 supine) participated in a trial of daily positioning. RESULTS Three hundred seventy-four fractions were treated using this system. Treatment times were on the order of 30 minutes. Initial prostate position errors (sigma) ranged from 3.1 to 5.8 mm left-right, 4.0 to 10.1 mm anterior-posterior, and 2.6 to 9.0 mm inferior-superior in prone patients. Initial position was more reproducible in supine patients, with errors of 2.8 to 5.0 mm left-right, 1.9 to 3.0 mm anterior-posterior, and 2.6 to 5.3 mm inferior-superior. After prostate localization and adjustment, the position errors were reduced to 1.3 to 3.5 mm left-right, 1.7 to 4.2 mm anterior-posterior, and 1.6 to 4.0 mm inferior-superior in prone patients, and 1.2 to 1.8 mm left-right, 0.9 to 1.8 mm anterior-posterior, and 0.8 to 1.5 mm inferior-superior in supine patients. CONCLUSIONS Daily targeting of the prostate has been shown to be technically feasible. The implemented system provides the ability to significantly reduce treatment margins for most patients with cancer confined to the prostate. The differences in final position accuracy between prone and supine patients suggest variations in intratreatment prostate movement related to mechanisms of patient positioning.

Daily targeting of intrahepatic tumors for radiotherapy

INTRODUCTION A system has been developed for daily targeting of intrahepatic tumors using a combination of ventilatory immobilization, in-room diagnostic imaging, and on-line setup adjustment. By reducing geometric position uncertainty, as well as organ movement, this system permits reduction of margins and thus potentially higher treatment doses. This paper reports our initial experience treating 8 patients with focal liver tumors using this system. METHODS AND MATERIALS The system includes diagnostic X-ray tubes mounted on the wall and ceiling of a treatment room, an active matrix flat panel imager, in-room control for image acquisition and setup adjustment, and a ventilatory immobilization system via active breathing control (ABC). Eight patients participated in the study, two using an early prototype ABC unit, and the remaining six with a commercial ABC system and improved setup measurement tools. Treatment margins were reduced, and dose consequently increased because of increased confidence in target position under this protocol. After daily setup via skin marks, orthogonal radiographs were acquired at suspended ventilation. The images were aligned to the CT model using the diaphragm for inferior-superior (IS) alignment, and the skeleton for left-right (LR) and anterior-posterior (AP) alignment. Adjustments were made for positioning errors greater than a threshold (3 or 5 mm). After treatment, retrospective analysis determined the final setup accuracy, as well as the error in initial setup measurement performed before setup adjustment. RESULTS Two hundred sixty-two treatment fractions were delivered on eight patients, with 171 treatments requiring repositioning. Typical treatment times were 25-30 min. Patients were able to tolerate ABC throughout the course of treatment. Breath holds up to 35 s long were used for treatment. The use of on-line imaging and setup adjustment reduced setup errors (sigma) from 4.0 mm (LR), 6.7 mm (IS), and 3.8 mm (AP) to 2.1 mm (LR), 3.5 mm (IS), and 2.3 mm (AP). Prescribed doses were increased using this system by an average of 5 Gy. CONCLUSIONS Daily targeting of intrahepatic targets has been demonstrated to be feasible. The potential for reduction in treatment margin and consequential safe dose escalation has been demonstrated, while maintaining reasonable treatment delivery times.

A comparison of ventilatory prostate movement in four treatment positions

PURPOSE To ensure target coverage during radiotherapy, all sources of geometric uncertainty in target position must be considered. Movement of the prostate due to breathing has not traditionally been considered in prostate radiotherapy. The purpose of this study is to report the influence of patient orientation and immobilization on prostate movement due to breathing. METHODS AND MATERIALS Four patients had radiopaque markers implanted in the prostate. Fluoroscopy was performed in four different positions: prone in alpha cradle, prone with an aquaplast mold, supine on a flat table, and supine with a false table under the buttocks. Fluoroscopic movies were videotaped and digitized. Frames were analyzed using 2D-alignment software to determine the extent of movement of the prostate markers and the skeleton for each position during normal and deep breathing. RESULTS During normal breathing, maximal movement of the prostate markers was seen in the prone position (cranial-caudal [CC] range: 0.9-5.1 mm; anterior-posterior [AP] range: up to 3.5 mm). In the supine position, prostate movement during normal breathing was less than 1 mm in all directions. Deep breathing resulted in CC movements of 3.8-10.5 mm in the prone position (with and without an aquaplast mold). This range was reduced to 2.0-7.3 mm in the supine position and 0.5-2.1 mm with the use of the false table top. Deep breathing resulted in AP skeletal movements of 2.7-13.1 mm in the prone position, whereas AP skeletal movements in the supine position were negligible. CONCLUSION Ventilatory movement of the prostate is substantial in the prone position and is reduced in the supine position. The potential for breathing to influence prostate movement, and thus the dose delivered to the prostate and normal tissues, should be considered when positioning and planning patients for conformal irradiation.

Verification of dynamic and segmental IMRT delivery by dynamic log file analysis.

A program has been developed to evaluate the delivered fluence of step‐and‐shoot segmental and sliding window dynamic multileaf collimator (MLC) fields. To automate these checks, a number of tools have been developed using data available from the dynamic log files that can be created each time a dynamic delivery occurs. Experiments were performed with a Varian 2100EX with a 120 leaf MLC equipped with dynamic capabilities. A dynamic leaf sequence is delivered and measured with film or an amorphous silicon imager. After delivery, the dynamic log file is written by the accelerator control system. The file reports the expected and actual position for each leaf and the dose fraction every 0.055 seconds. Leaf trajectories are calculated from this data and expected and actual fluence images are created from the difference of opposing leaf trajectories. These images can be compared with the expected delivery, measurements, and calculations of fluence. Tools have been developed to investigate other aspects of the delivery, such as specific leaf errors, beam hold‐off flags sent by the control system to the MLC, and gap widths. This program is part of a semi‐automated quality assurance (QA) system for pretreatment fluence verification and daily treatment verification of dynamic multileaf collimation (DMLC) delivery. PACS number(s): 87.53.–j, 87.52.–g

On‐line monitoring of radiotherapy beams: Experimental results with proton beams

Proton radiotherapy is a powerful tool in the local control of cancer. The advantages of proton radiotherapy over gamma-ray therapy arise from the phenomenon known as the Bragg peak. This phenomenon enables large doses to be delivered to well-defined volumes while sparing surrounding healthy tissue. To fully realize the potential of this technique the location of the high-dose volume must be controlled very accurately. An imaging system was designed and tested to monitor the positron-emitting activity created by the beam as a means of verifying the beams range, monitoring dose, and determining tissue composition. The prototype imaging system consists of 12 pairs of cylindrical BGO detectors shielded in lead. Each crystal was 1.9 cm in diameter, 5.0 cm long, and separated by 0.5 cm from other detectors in the row. These are arranged in two rows, 60 cm apart, with the proton beam and tissue phantoms half-way between and parallel to the detector rows. Experiments were conducted with 150 MeV continuous and macro-pulsed proton beams which had beam currents ranging from 0.14 nA to 1.75 nA. The production and decay of short-lived isotopes, 15O and 14O, was studied using 1 min irradiations with a continuous beam. These isotopes provide a significant signal on short time scales, making on-line imaging possible. Macro-pulsed beams, having a period of 10 s, were used to study on-line imaging and the production and decay of long-lived isotopes, 13N, 11C, and 18F. Decay data were acquired and on-line images were obtained between beam pulses and indicate that range verification is possible, for a 150 MeV beam, after one beam pulse, to within the 1.2 cm resolution limit of the imaging system. The dose delivered to the patient may also be monitored by observing the increase in the number of coincidence events detected between successive beam pulses. Over 80% of the initial positron-emitting activity is from 15O while the remainder is primarily 11C, 13N, 14O with traces of 18F, and 10C. Radioisotopic imaging may also be performed along the beam path by fitting decay data collected after the treatment is complete. Using this technique, it is shown that variations in elemental composition in inhomogenous treatment volumes may be identified and used to locate anatomic landmarks. Radioisotopic imaging also reveals that 14O is created well beyond the Bragg peak, apparently by secondary neutrons.

Accelerating protons to therapeutic energies with ultraintense, ultraclean, and ultrashort laser pulses

Proton acceleration by high-intensity laser pulses from ultrathin foils for hadron therapy is discussed. With the improvement of the laser intensity contrast ratio to 10(-1) achieved on the Hercules laser at the University of Michigan, it became possible to attain laser-solid interactions at intensities up to 10(22) W/cm2 that allows an efficient regime of laser-driven ion acceleration from submicron foils. Particle-in-cell (PIC) computer simulations of proton acceleration in the directed Coulomb explosion regime from ultrathin double-layer (heavy ions/light ions) foils of different thicknesses were performed under the anticipated experimental conditions for the Hercules laser with pulse energies from 3 to 15 J, pulse duration of 30 fs at full width half maximum (FWHM), focused to a spot size of 0.8 microm (FWHM). In this regime heavy ions expand predominantly in the direction of laser pulse propagation enhancing the longitudinal charge separation electric field that accelerates light ions. The dependence of the maximum proton energy on the foil thickness has been found and the laser pulse characteristics have been matched with the thickness of the target to ensure the most efficient acceleration. Moreover, the proton spectrum demonstrates a peaked structure at high energies, which is required for radiation therapy. Two-dimensional PIC simulations show that a 150-500 TW laser pulse is able to accelerate protons up to 100-220 MeV energies.

Incorporation of realistic delivery limitations into dynamic MLC treatment delivery

The clinical implementation of IMRT involves the use of a number of complex software-based systems, typically including an inverse planning system, a leaf sequencer, and a computer-controlled treatment delivery system. The inverse planning system determines the desired fluence patterns, the leaf sequencer translates those fluence maps into leaf trajectories, and the control system delivers those trajectories. While verification of intensity-modulated treatment fields has focused primarily on the dosimetric aspects of delivery, accurate delivery of the intended fluence distribution is dependent upon both the leaf sequencer and delivery control systems. Leaf sequencing algorithms typically do not incorporate many control system limitations, and this can lead to discrepancies between planned and delivered sequences. In this work, simple and complex fields were sequenced for the dynamic sliding window technique using different leaf speeds and tolerance settings to identify various limitations of the accelerator control system. This work was conducted on a Varian 2100 EX equipped with a Millennium 120 leaf MLC. The identified limitations were then incorporated into the sequencing algorithm using a limiting leaf velocity (less than the maximum leaf velocity), the leaf position tolerance, and the communications delay in the control system. Collision avoidance in leaf pairs was found to depend on a control system-enforced minimum gap between leaves and led to acceleration effects. By incorporating these effects into the leaf sequencing algorithm, dynamic sliding-window leaf sequences were produced which did not require beam interruptions or dose rate modulations for the parameter values used in calculating the sequence (dose rate, tolerance, leaf speed, and total monitor units). Incorporation of control system limitations into the leaf sequencing algorithm results in IMRT fields that are delivered with the prescribed constant dose rate, require less time to deliver, and have well-defined, calculable transmission dose characteristics.

Generation of GeV protons from 1 PW laser interaction with near critical density targets.

The propagation of ultraintense laser pulses through matter is connected with the generation of strong moving magnetic fields in the propagation channel as well as the formation of a thin ion filament along the axis of the channel. Upon exiting the plasma the magnetic field displaces the electrons at the back of the target, generating a quasistatic electric field that accelerates and collimates ions from the filament. Two dimensional particle-in-cell simulations show that a 1 PW laser pulse tightly focused on a near-critical density target is able to accelerate protons up to an energy of 1.3 GeV. Scaling laws and optimal conditions for proton acceleration are established considering the energy depletion of the laser pulse.

Technical note: A deformable phantom for dynamic modeling in radiation therapy

A deformable phantom was developed to aid in quality assurance for dynamic imaging and targeting techniques in radiation therapy. Made of simple materials combined with standard components for imaging and motion experiments, this phantom can be relatively easily constructed and used for both diagnostic imaging and dosimetry. Repeat imaging studies indicate that the phantom meets criteria of relative attenuation, deformation, and reproducibility of configuration, necessary for quality assurance of radiographic and tomographic targeting.

An apparatus for applying strong longitudinal magnetic fields to clinical photon and electron beams

Monte Carlo studies have recently renewed interest in the use of the effect of strong transverse and longitudinal magnetic fields to manipulate the dose characteristics of clinical photon and electron beams. A 3.5 T superconducting solenoidal magnet was used to evaluate the effect of a longitudinal field on both photon and electron beams. This note describes the apparatus and demonstrates some of the effects on the beam trajectory and dose distributions for measurements in a homogeneous phantom. The effects were studied using film in air and in phantoms which fit in the magnet bore. The magnetic field focused and collimated the electron beams. The converging, non-uniform field confined the beam and caused it to converge with increasing depth in the phantom. Due to the fields collecting and focusing effect, the beam flux density increased, leading to increased dose deposition near the magnetic axis, especially near the surface of the phantom. This study illustrates some benefits and challenges associated with the use of non-uniform longitudinal magnetic fields in conjunction with clinical electron and photon beams.