Franca T. Kuchnir

Comparison of static conformal field with multiple noncoplanar arc techniques for stereotactic radiosurgery or stereotactic radiotherapy

PURPOSE Compare the use of static conformal fields with the use of multiple noncoplanar arcs for stereotactic radiosurgery or stereotactic radiotherapy treatment of intracranial lesions. Evaluate the efficacy of these treatment techniques to deliver dose distributions comparable to those considered acceptable in current radiotherapy practice. METHODS AND MATERIALS A previously treated radiosurgery case of a patient presenting with an irregularly shaped intracranial lesion was selected. Using a three-dimensional (3D) treatment-planning system, treatment plans using a single isocenter multiple noncoplanar arc technique and multiple noncoplanar conformal static fields were generated. Isodose distributions and dose volume histograms (DVHs) were computed for each treatment plan. We required that the 80% (of maximum dose) isodose surface enclose the target volume for all treatment plans. The prescription isodose was set equal to the minimum target isodose. The DVHs were analyzed to evaluate and compare the different treatment plans. RESULTS The dose distribution in the target volume becomes more uniform as the number of conformal fields increases. The volume of normal tissue receiving low doses (> 10% of prescription isodose) increases as the number of static fields increases. The single isocenter multiple arc plan treats the greatest volume of normal tissue to low doses, approximately 1.6 times more volume than that treated by four static fields. The volume of normal tissue receiving high (> 90% of prescription isodose) and intermediate (> 50% of prescription isodose) doses decreases by 29 and 22%, respectively, as the number of static fields is increased from four to eight. Increasing the number of static fields to 12 only further reduces the high and intermediate dose volumes by 10 and 6%, respectively. The volume receiving the prescription dose is more than 3.5 times larger than the target volume for all treatment plans. CONCLUSIONS Use of a multiple noncoplanar conformal static field treatment technique can significantly reduce the volume of normal tissue receiving high and intermediate doses compared with a single isocenter multiple arc treatment technique, while providing a more uniform dose in the target volume. Close conformation of the prescription isodose to the target volume is not possible using static uniform conformal fields for target shapes lacking an axis of rotational symmetry or plane of mirror symmetry.

Radiotherapy of the resected mandible following stainless steel plate fixation

There is general concern among otolaryngologists that irradiation of a stainless steel prosthesis used in mandibular reconstruction may cause irradiation overdosage to adjacent tissues.

Repositioning accuracy of a noninvasive head fixation system for stereotactic radiotherapy

We report on the repositioning accuracy of patient setup achieved with a noninvasive head fixation device for stereotactic radiotherapy. A custom head mask which attaches to our stereotactic radiosurgery head ring assembly is fabricated for each patient. The position and orientation of a patient in the stereotatic space at the time of treatment are determined from analyzing portal films containing images of radio-opaque spheres embedded in a custom mouthpiece. From analysis of 104 setups of 12 patients, we find that the average distance between the treated isocenter and its mean position is 1.8 mm, and that the standard deviations of the position of the treated isocenter in stereotactic coordinate space about its mean position are less than 1.4 mm in translation in any direction and less than 1 degree of rotation about any axis.

Determination of the source position for the electron beams from a high-energy linear accelerator

We have investigated the energy and field-size dependence of the source position of the electron beams from a Varian Clinac-2,500 accelerator. Three independent experimental methods were used: (1) multipinhole camera (MPC), (2) back projection of the full width at half maximum (FWHM), and (3) the inverse square law (ISL). The positions of the virtual and effective sources were calculated using the multiple Coulomb scattering (MCS) formalism. The results obtained from the MPC agree, within the experimental uncertainties, with the calculated values for the virtual source position. Similarly, the results from the FWHM method agree with the calculations with the exception of those for small field sizes at the lower energies. This is consistent with the fact that both kinds of measurements are not very sensitive to scattering in the photon and electron collimators. In contrast, the source position determined by the ISL method shows strong dependence on field size and energy, and does not agree with the values predicted by the MCS formalism. This is due to contamination from electrons scattered in the x ray and electron collimation system. The techniques and results reported here should be generally applicable to other scatter foil linear accelerators.

Photon neutron mixed-beam radiotherapy of locally advanced prostate cancer

PURPOSE In this article we present the results of mixed-beam, photon/neutron radiation therapy in 45 patients with locally advanced, bulky, or postoperative recurrent prostate cancer treated at the University of Chicago between 1978 and 1991. Survival, disease-free survival, local control, and long-term complications are analyzed in detail. METHODS AND MATERIALS Between 1978 and 1991, 45 patients with locally advanced (> 5 cm State B2, Stage C, or Stage D1) prostate cancer underwent mixed-beam (photon/neutron) radiation therapy. Forty percent of the treatment was delivered with neutron irradiation at either the University of Chicago or Fermilab. Sixty percent of treatment was delivered with photons at the University of Chicago. Initially, the whole pelvis was irradiated to 50 photon Gy equivalent. This was followed by a boost to the prostate for an additional 20 photon Gy equivalent. RESULTS The median follow-up for patients in this series is 72 months. The overall 5-year actuarial survival was 72%, and the 5-year disease-free survival was 45%. Thus far, 18 patients have died. Eleven patients have died from prostate cancer and 7 from other medical illness. Twenty-seven patients are alive, and 12 of these patients have recurrent and or metastatic disease. The local control rate was 89% (40 out of 45). Histologic material was available on 18 patients following treatment (i.e., prostate biopsy in 16 patients and autopsy in 2 patients) and was negative for carcinoma in 13 (72%). Significant Grade 3-5 complications occurred in 36% (16 out of 45) of the patients treated with mixed-beam radiation therapy and were related to dose and beam quality. Factors related to survival, disease-free survival, local control, and complications are analyzed. CONCLUSIONS The survival and local control results of mixed-beam radiation therapy at the University of Chicago appear to be superior to those series using photon radiation in patients with locally advanced prostate carcinoma. Mixed-beam radiation therapy should remain an alternative to studies using dose escalation or implant techniques as a method to increase local control and survival at institutions with this capability. However, appropriate plans with high-energy neutrons are necessary to minimize complications.

Verification of the omni wedge technique.

The optimal field shape achieved using a multileaf collimator (MLC) often requires collimator rotation to minimize the adverse effects of the scalloped dose distribution the leaf steps produce. However, treatment machines are designed to deliver wedged fields parallel or perpendicular to the direction of the leaves. An analysis of cases from our clinic showed that for 25% of the wedged fields used to treat brain and lung tumors, the wedge direction and optimal MLC orientation differed by 20 degrees or more. The recently published omni wedge technique provides the capability of producing a wedged field with orientation independent of the orientation of the collimator. This paper presents a comparison of the three-dimensional (3D) dose distributions of the omni wedged field with distributions of wedged fields produced using both the universal and dynamic wedge techniques. All measurements were performed using film dosimetry techniques. The omni wedge generated fields closely matched the conventional wedged fields. Throughout 95% of the irradiated volume (excluding the penubra), the dose distribution of the omni wedged field ranged from +5.5 to -3.5 +/- 1.5% of that of the conventionally wedged fields. Calculation of the omni wedged field is as accurate as conventional wedged field calculation when using a 3D treatment planning systems. For two-dimensional treatment planning systems, where one must assume that the omni wedged field is identical to a conventional field, the calculated field and the delivered field differs by a small amount.

Optimization of relative weights and wedge angles in treatment planning

An efficient technique to optimize beam weights and wedge angles in radiotherapy treatment planning has been developed. Based on the fact that a wedged field can be regarded as a superposition of an open field and a nominal wedged field, this approach reduces the problem of finding J beam weights and the corresponding wedge angles to optimizing a linear system with 2J unknowns (weights of J open beams and J nominal wedged beams), where J is the total number of incident beam directions. Two iterative algorithms similar to the iterative-least-square technique in image reconstruction are used to optimize the system. Application of the algorithms to two specific examples shows that this technique can reduce treatment planning time and effort, and promises to create a better solution for an arbitrarily complex treatment plan.

Dosimetry of Sr-90 ophthalmic applicators.

Sr-90 ophthalmic applicators are commonly used for the treatment of superficial eye disorders. Although a variety of dosimetric devices such as film, thermoluminescent dosimeters (TLDs), ion chambers, and radiochromic foils have been used to measure the peak dose at the applicator surface, there is no internationally agreed upon calibration procedure. Recently, large discrepancies among calibrations of the same applicator at three institutions have been reported. Here we describe a technique to obtain the peak dose rate at the applicator surface using LiF TLDs. The technique can be used for the calibration of flat as well as curved surface applicators. Results for two flat and three concave applicators are presented. Our measurement of the surface dose rate for one of the flat applicators is compared with those obtained by four other institutions, each using different dosimetric devices.

Measurement of the replacement correction factor for parallel-plate chambers in electron fields.

When parallel-plate chambers are used for dosimetry in electron fields, the AAPM dosimetry protocol recommends a value of 1.0 for the replacement correction factor, P(repl),pp,E, until further data become available. Here, P(repl),pp,E for five commercially available parallel-plate chambers was measured as a function of electron energy from a nominal value of 5.5 to 22 MeV by comparison with a cylindrical chamber whose P(repl),cyl,E was obtained from data in the protocol. Since this method is based on the concept of a constant value for Ngas,pp, the energy and modality dependence of Ngap,pp is also investigated for these chambers for Co-60, 4-, 6-, 24-MV photons and for 22-MeV electrons. It is found that for three of the chambers P(repl),pp,E is independent of energy, consistent with unity within one or two standard deviations (s.d.). For the fourth chamber P(repl),pp,E is similarly consistent with one above 10 MeV, but decreases at lower energies, while for the fifth one it shows a systematic drop with decreasing energy.

Measured overall perturbation factors at depths greater than dmax for ionization chambers in electron beams.

In electron beam dosimetry the perturbation effect in the medium by the ionization chamber cavity is accounted for by introducing a replacement correction factor, P(repl). Another perturbation correction factor, denoted as P(wall), is due to the materials of the walls of the parallel-plate chamber differing from the phantom material. Because of the difficulties in separating these two components, we measure the overall perturbation factor, p(q) = P(repl)P(wall). A distinct advantage of parallel-plate ionization chambers over cylindrical chambers is that p(q) has been shown to be close to unity at the standard calibration depth, d(max). However, for many dosimetry applications it is necessary to know the overall perturbation factor at depths greater than d(max). We measured the overall perturbation factor at depths greater than d(max) (approximating the 95%, 90% and 50% depth dose) for a Farmer-type cylindrical ionization chamber and three parallel-plate ionization chambers. We assumed that p(q) for the NACP chamber is unity at these measurement depths. The depth dependence for the other chambers was then measured relative to the NACP chamber. The mean energy at depth, E(d), and percentage depth dose gradient ranges studied were 1.9-18.5 MeV and 0 to 4.5%/mm, respectively. For the other two parallel-plate chambers, we find p(q) to be unity at depths where the percent depth dose is greater than 90%, but it deviates from unity at deeper depths, where the dose gradients exceed about 2.5%/mm. For the cylindrical chamber, p(q) values at depths greater than d(max) were found to be in good agreement with those in TG 21, where the energy at depth, E(d), is used to evaluate p(q).