K Vergote

Whole abdominopelvic radiotherapy (WAPRT) using intensity-modulated arc therapy (IMAT): First clinical experience

PURPOSE Whole abdominopelvic radiation therapy (WAPRT) is a treatment option in the palliation of patients with relapsed ovarian cancer. With conventional techniques, kidneys and liver are the dose- and homogeneity-limiting organs. We developed a planning strategy for intensity-modulated arc therapy (IMAT) and report on the treatment plans of the first 5 treated patients. METHODS AND MATERIALS Five consecutive patients with histologically proven relapsed ovarian cancer were sent to our department for WAPRT. The target volumes and organs at risk (OAR) were delineated on 0.5-cm-thick CT slices. The clinical target volume (CTV) was defined as the total peritoneal cavity. CTV and kidneys were expanded with 0.5 cm. In a preset range of 8 degrees interspaced gantry angles, machine states were generated with an anatomy-based segmentation tool. Machine states of the same class were stratified in arcs. The optimization of IMAT was done in several steps, using a biophysical objective function. These steps included weight optimization of machine states, leaf position optimization adapted to meet the maximal leaf speed constraint, and planner-interactive optimization of the start and stop angles. The final control points (machine states plus associated cumulative monitor unit counts) were calculated using a collapsed cone convolution/superposition algorithm. For comparison, two conventional plans (CONV) were made, one with two fields (CONV2), and one with four fields (CONV4). In these CONV plans, dose to the kidneys was limited by cerrobend blocks. The IMAT and the CONV plans were normalized to a median dose of 33 Gy to the planning target volume (PTV). Monomer/polymer gel dosimetry was used to assess the dosimetric accuracy of the IMAT planning and delivery method. RESULTS The median volume of the PTV was 8306 cc. The mean treatment delivery time over 4 patients was 13.8 min. A mean of 444 monitor units was needed for a fraction dose of 150 cGy. The fraction of the PTV volume receiving more than 90% of the prescribed dose (V(90)) was 9% higher for the IMAT plan than for the CONV4 plan (89.9% vs. 82.5%). Outside a build-up region of 0.8 cm and 1 cm away from both kidneys, the inhomogeneity in the PTV was 15.1% for the IMAT plans and 24.9% for the CONV4 plans (for CONV2 plans, this was 34.9%). The median dose to the kidneys in the IMAT plans was lower for all patients. The 95th percentile dose for the kidneys was significantly higher for the IMAT plans than for the CONV4 and CONV2 plans (28.2 Gy vs. 22.2 Gy and 22.6 Gy for left kidney, respectively). No relevant differences were found for liver. The gel-measured dose was within clinical planning constraints. CONCLUSION IMAT was shown to be deliverable in an acceptable time slot and to produce dose distributions that are more homogeneous than those obtained with a CONV plan, with at least equal sparing of the OARs.

Validation and application of polymer gel dosimetry for the dose verification of an intensity-modulated arc therapy (IMAT) treatment

Polymer gel dosimetry was used to assess an intensity-modulated arc therapy (IMAT) treatment for whole abdominopelvic radiotherapy. Prior to the actual dosimetry experiment, a uniformity study on an unirradiated anthropomorphic phantom was carried out. A correction was performed to minimize deviations in the R2 maps due to radiofrequency non-uniformities. In addition, compensation strategies were implemented to limit R2 deviations caused by temperature drift during scanning. Inter- and intra-slice R2 deviations in the phantom were thereby significantly reduced. This was verified in an investigative study where the same phantom was irradiated with two rectangular superimposed beams: structural deviations between gel measurements and computational results remained below 3% outside high dose gradient regions; the spatial shift in those regions was within 2.5 mm. When comparing gel measurements with computational results for the IMAT treatment, dose deviations were noted in the liver and right kidney, but the dose-volume constraints were met. Root-mean-square differences between both dose distributions were within 5% with spatial deviations not more than 2.5 mm. Dose fluctuations due to gantry angle discretization in the dose computation algorithm were particularly noticeable in the low-dose region.

On the relation between the spatial dose integrity and the temporal instability of polymer gel dosimeters

When irradiating a polymer gel dosimeter to relatively high doses, edge enhancing effects (overshoots) may be noticed near dose gradients, resulting in a loss of spatial dose integrity. These overshoots are believed to be a consequence of monomers diffusing into the high-dose region, where they react with long-living macroradicals. Macroradicals may also be responsible for the temporal chemical instability of post-irradiation polymerization that occurs in the polymer gel dosimeter. In this study, a mathematical model is proposed that simulates the edge enhancing effect. The model is based on the hypothesis that the macroradicals are responsible for both the temporal instability and loss of spatial dose integrity. All input parameters for the model are obtained from independent experiments. The edge enhancing effect is studied both experimentally and theoretically for polymer gel dosimeters with various gelatin concentrations. The change in the edge enhancement is also investigated over post-irradiation time. Comparisons between polymer gel measurements and simulations confirm the hypothesis that there is a strong relation between the spatial and temporal instabilities.

Application of monomer/polymer gel dosimetry to study the effects of tissue inhomogeneities on intensity-modulated radiation therapy (IMRT) dose distributions

BACKGROUND AND PURPOSE When planning an intensity-modulated radiation therapy (IMRT) treatment in a heterogeneous region (e.g. the thorax), the dose computation algorithm of a treatment planning system may need to account for these inhomogeneities in order to obtain a reliable prediction of the dose distribution. An accurate dose verification technique such as monomer/polymer gel dosimetry is suggested to verify the outcome of the planning system. MATERIALS AND METHODS The effects of low-density structures: (a) on narrow high-energy (18 MV) photon beams; and (b) on a class-solution IMRT treatment delivered to a thorax phantom have been examined using gel dosimetry. The used phantom contained air cavities that could be filled with water to simulate a homogeneous or heterogeneous configuration. The IMRT treatment for centrally located lung tumors was delivered on both cases, and gel derived dose maps were compared with computations by both the GRATIS and Helax-TMS planning system. RESULTS Dose rebuildup due to electronic disequilibrium in a narrow photon beam is demonstrated. The gel measurements showed good agreement with diamond detector measurements. Agreement between measured IMRT dose maps and dose computations was demonstrated by several quantitative techniques. An underdosage of the planning target volume (PTV) was revealed. The homogeneity of the phantom had only a minor influence on the dose distribution in the PTV. An expansion of low-level isodoses in the lung volume was predicted by collapsed cone computations in the heterogeneous case. CONCLUSIONS For the class-solution described, the dose in centrally located mediastinal tumors can be computed with sufficient accuracy, even when neglecting the lower lung density. Polymer gel dosimetry proved to be a valuable technique to verify dose calculation algorithms for IMRT in 3D in heterogeneous configurations.

Three dimensional radiation dosimetry in lung-equivalent regions by use of a radiation sensitive gel foam: proof of principle.

A polymer hydrogel foam is proposed as a potential three dimensional experimental dosimeter for radiation treatment verification in low-density tissue such as the lung. A gel foam is created by beating a radiation sensitive polymer gel mixture in an anoxic atmosphere. The mass density of the gel foam is in the order of 0.25-0.35 kg/dm3. Both nuclear magnetic resonance (NMR) spin-spin relaxation rate (R2) and magnetization transfer ratio (MTR) have been used to map the dose distribution from the gel dosimeter. It is found that MTR has significant advantages compared to R2 for mapping the dose distribution in the polymer gel foam dosimeters. The magnetization transfer ratio is found to be less dependent on the density and microstructure of the gel foam dosimeter while spin-spin relaxation dispersion has been observed making the spin-spin relaxation rate dependent on the interecho time interval. Optical microscopy reveals a microstructure that shows great similarity with human lung tissue. It is also shown how NMR hydrogen proton density measurements can be used to map the density distributions in gel dosimeters.

The use of static light scattering for the structure analysis of radiosensitive polymer gels: a literature survey

Static light scattering (SLS) could be a worthy technique to perform a structure analysis of the polymer structures inside radiation sensitive gels. The information obtained with SLS is a static characterization of the particle structures inside the gel. SLS will be combined with NMR relaxometry and NMR diffusion measurements, which deliver a hydrodynamic characterization of the microstructure of the gels.

Alternative gelling agents for normoxic gels: a stability study

In this paper the influence of the use of alternative gelling agents on the dose response curve of normoxic gels is investigated. Part of the experiment is still in progress.

Clinical validation of intensity modulated arc therapy (IMAT) by means of polymer gel dosimetry

Polymer gel dosimetry was used to verify the clinical use of IMAT. There was a satisfactory correlation between calculated and measured dose, thus validating the planning procedure, the calculation algorithm and the delivery. Although still elaborate and costly, polymer gel dosimetry has some unique features (3D absolute dosimetry) for verification of complex irradiation techniques.