Joseph Leong

ACCURACY OF RADIATION FIELD ALIGNMENT IN CLINICAL PRACTICE

We present an analysis of simulator and portal films of 71 patients. Twenty-five were analyzed retrospectively, 39 prospectively, but without changing routine filming practice, and 7 had daily portal films taken. Treatment-to-treatment variations in anatomy with respect to the field were determined by comparing sequential portal films. The standard deviation of the variations was approximately normally distributed with an average value of 3 mm independent of site and field shaping technique. Discrepancies between the portal and simulator films were greater and depended on the site of treatment. The mean worst-case discrepancy averaged over all sites was 7.7 mm; the lowest value was 3.5 mm in the head and neck region; the highest value was 9.2 mm in the thorax.

LARGE SCALE OPTIMIZATION OF BEAM WEIGHTS UNDER DOSE-VOLUME RESTRICTIONS

The problem of choosing weights for beams in a multifield plan which maximizes tumor dose under conditions that recognize the volume dependence of organ tolerance to radiation is considered, and its solution described. Structures are modelled as collections of discrete points, and the weighting problem described as a combinatorial linear program (LP). The combinatorial LP is solved as a mixed 0/1 integer program with appropriate restrictions on normal tissue dose. The method is illustrated through the assignment of weights to a set of 10 beams incident on a pelvic target. Dose-volume restrictions are placed on surrounding bowel, bladder, and rectum, and a limit placed on tumor dose inhomogeneity. Different tolerance restrictions are examined, so that the sensitivity of the target dose to changes in the normal tissue constraints may be explored. It is shown that the distributions obtained satisfy the posed constraints. The technique permits formal solution of the optimization problem, in a time short enough to meet the needs of treatment planners.

Optimization of beam weights under dose-volume restrictions.

A basic problem in treatment planning is the selection of weights for a set of beams which will yield the largest tumor dose under constraints limiting the doses received in specified fractions of different normal tissue structures. This report describes a method for formulating and solving this optimization problem as a combinatorial linear program. An illustration is provided by a problem in planning treatment of a thoracic tumor, in which no more than 1/2 or 2/3 of the lung is permitted to receive greater than 20 Gy and no part of the spinal cord allowed to receive greater than 45 Gy. The optimization technique was applied to this example to determine how the maximum tumor dose is affected by changes in the normal tissue constraints and the addition of a tumor dose homogeneity restriction. The linear programming technique yielded a rigorous and efficient determination of the beam weights for the thoracic plan considered. An exhaustive specification of all the underlying linear programs allows problems of moderate dimensions to be solved, while developments in mathematical programming and computer processing suggest approaches to problems of greater complexity.

Potential for improvement in radiation therapy

A successful strategy for improving the efficacy of radiation therapy has been to improve dose distribution, that is, reduce treatment volume toward target volume. This is so as the smaller treatment volume has permitted a higher dose to the target (hence a high tumor control probability) and a lesser volume of non-target tissues being irradiated (consequently a reduced frequency and severity of treatment related morbidity). There are in place several important means for further improvements in dose distributions. These include: (a) 3D graphic reconstruction of the affected part with definition of the position of the tumor vis-a-vis the adjacent normal structures; (b) explicit inclusion in the treatment plan of the uncertainty band around each isodose contour; (c) on-line contrast enhanced visual monitoring of the target tissue during the individual treatment session; (d) gating of treatment so as to reduce the impact of patient motion on the needed treatment volume; (e) use of computer control systems to execute the treatment; and (f) use of treatment methods which achieve a reduced treatment volume. In an examination for sites for which treatment volumes might be decreased by a substantial factor we have compared treatment volumes for radical surgical and radiation therapy. Results are presented for carcinomas of the cervix (Stage IB), breast (Stage II), floor of mouth (Stage II). We describe a system developed here for on-line visual monitoring of the tissues covered by the treatment field. Brief descriptions are given of results of low LET charged particle radiation therapy and of intraoperative electron beam therapy. Also, the program developed here to use computer graphic techniques to display tumor and normal structures and isodose countours with uncertainty bands around each contour is mentioned.

Visualization of internal motion within a treatment portal duringa radiation therapy treatment

We offer a method for visualization of treatment portals continually during a radiation therapy treatment. Using digital image processing in conjunction with a fluorescent screen, portal images are obtained almost instantly. Images of quality that are clinically useful can be visualized every second. Digital enhancement further improves the quality of the images. The availability of instant portal images before each treatment can be most helpful in verifying that the patient is correctly and precisely set up prior to the onset of radiation. The ability to visualize treatment portals continuously during a treatment can help to ensure that radiation is restricted to the prescribed field and is not altered significantly by patient motion. In this report, we show and discuss a sequence of instant portal images obtained during a single treatment in which motion and absence of motion of internal anatomy is clearly demonstrated.

A method for consistent precision radiation therapy

Using a meticulous setup procedure in which repeated portal films were taken before each treatment until satisfactory portal verifications were obtained, a high degree of precision in patient positioning was achieved. A fluctuation from treatment to treatment, over 11 treatments, of less than +/- 0.10 cm (S.D.) for anatomical points inside the treatment field was obtained. This, however, only applies to specific anatomical points selected for this positioning procedure and does not apply to all points within the portal. We have generalized this procedure and have suggested a means by which any target volume can be consistently positioned which may approach this degree of precision.

Stage IA to IIB mediastinal Hodgkin's disease: three-dimensional volumetric assessment of response to treatment.

From 1979 to 1986, the response to treatment of 53 patients with stage IA to IIB mediastinal Hodgkins disease was evaluated by three-dimensional volumetric analysis using thoracic computed tomographic (CT) scans. The mean initial volume of mediastinal disease in 34 patients treated with mantle and para-aortic irradiation was 166 mL, whereas for 19 patients treated with two to six cycles of multiagent chemotherapy and mantle and para-aortic irradiation the mean initial volume was 446 mL. Preliminary data suggested that patients with mediastinal volumes of less than 200 mL had a lower mediastinal relapse rate (13%) than patients with volumes greater than 200 mL (32%). For 12 patients receiving six cycles of nitrogen mustard, vincristine, procarbazine, and prednisone (MOPP), those with a greater than 85% reduction in volume 1 to 2 months after chemotherapy had a lower incidence of mediastinal relapse (zero of six, 0%) compared with patients having 85% or less reduction in volume (four of six, 67%). The primary value of this technique is that it provides a sensitive assessment of response to treatment and may aid in monitoring the effectiveness of a given treatment.

Three-dimensional volumetric assessment of response to treatment: Stage I and II diffuse large cell lymphoma of the mediastinum

From 1981 to 1986, 12 patients with Stage I and II diffuse large cell lymphoma of the mediastinum were treated with 4 or more cycles of multiagent chemotherapy and for nine patients this was followed by mediastinal irradiation. The response to treatment was assessed by three-dimensional volumetric analysis utilizing thoracic CT scans. The initial mean tumor volume of the five patients relapsing was 540 ml in contrast to an initial mean tumor volume of 360 ml for the seven patients remaining in remission. Of the eight patients in whom mediastinal lymphoma volumes could be assessed 1-2 months after chemotherapy prior to mediastinal irradiation, the three patients who have relapsed had volumes of 292, 92, and 50 ml (mean volume 145 ml) in contrast to five patients who have remained in remission with residual volume abnormalities of 4-87 ml (mean volume 32 ml). Four patients in prolonged remission with CT scans taken one year after treatment have been noted to have mediastinal tumor volumes of 0-28 ml with a mean value of 10 ml. This volumetric technique to assess the extent of mediastinal large cell lymphoma from thoracic CT scans appears to be a useful method to quantitate the amount of disease at presentation as well as objectively monitor response to treatment.

A one-dimensionally position-sensitive scintillation detector

Abstract A NaI(Tl) detector has been designed to measure the position, along its midline, of a scintillation caused by the absorption of a 137 Cs γ photon. The 1.3 cm thick, 40 cm long scintillator is viewed by twenty-seven photomultipliers, placed closely together on a zig-zag line along the detector. This geometry is shown to be superior to a side-by side linear photomultiplier configuration. The detector utilizes a delay-line readout technique for position assignment, in combination with pulse-height discrimination. The spatial resolution is characterized by 5.8 mm full width at half maximum. The influence of photomultiplier characteristics and geometry, including light guide thickness, has been studied experimentally and by calculations.

VARIATION IN THE LUNG INHOMOGENEITY CORRECTION FACTOR WITH BEAM ENERGY Clinical implications

In order to determine the magnitude of the dosimetry error introduced by failing to correct for increased transmission through lung tissue in treating thoracic malignancies, measurements in a phantom were taken using different field sizes, inhomogeneity thicknesses and photon qualities. The results indicate that the error introduced by neglecting the inhomogeneity correction is greatest at lower photon energies, smaller field sizes and greater thickness of inhomogeneity. Correction factors to account for the lung inhomogeneity were obtained from phantom measurements and were compared with those calculated using the tissue-air ratio and Batho-Young algorithms; correlation coefficients describing the relationship between measured and calculated values exceeded 0.995. The calculated values tended to overestimate the correction factor and differed most from the measured correction factors at lower energies, smaller field sizes, and greater inhomogeneity thicknesses. The importance of these results in clinical radiation therapy is discussed.