Marina Pla

Dynamic stereotactic radiosurgery

Two radiosurgical procedures using a stereotactic frame and a linear accelerator X ray beam with a circular field diameter between 0.5 and 3 cm are presented. One technique is based on a single plane rotation (single plane radiosurgery) whereas the other uses simultaneous and continuous motions of both the gantry (approximately 360 degrees) and couch (approximately 180 degrees) during the radiosurgical procedure (dynamic radiosurgery). The dose, typically a few thousand cGy, is prescribed to the 90% isodose line which just covers the target volume. The dose fall-off outside the spherical target volume is considerably sharper for the dynamic rotation than for the single plane rotation, and is comparable to the dose fall-off obtained with the two presently known dedicated radiosurgical techniques: one based on focused cobalt beams and the other on proton beams. The dose fall-off in the dynamic radiosurgery discussed here is also comparable to that of previously described linear accelerator based multiple converging are techniques, making the dynamic radiosurgery an attractive alternative to presently known radiosurgical procedures. The radiation beam parameters are discussed and the stereotactic frame described. The dose distributions for both radiosurgical techniques are calculated in a single plane and then corrected for the attenuation effects in the stereotactic frame (approximately 2%) and for the effects of the dynamic rotation (approximately 2%). The skin doses are 0.7% and 2%, and the lens doses, if the beam passes through the eyes, are 2.5% and 3.5% for the dynamic rotation and single plane rotation, respectively. The scatter and leakage dose for the radiosurgical procedures is typically 0.2% to the patients thyroid, 0.06% to the breast, and 0.02% to the gonads.

Radiosurgery with high energy photon beams: A comparison among techniques

The presently known radiosurgical techniques with high energy photon beams are based either on the commercially available Gamma unit utilizing 201 stationary cobalt beams or on isocentric linear accelerators. The techniques using linear accelerators are divided into the single plane rotation, the multiple non-coplanar arcs, and the dynamic rotation. A brief description of these techniques is given, and their physical characteristics, such as precision of dose delivery, dose fall-off outside the target volume, and isodose distributions are discussed. It is shown that the multiple non-coplanar arcs technique and the dynamic rotation give dose distributions similar to those of the Gamma unit, which makes these two linear accelerator based techniques attractive alternatives to radiosurgery with the Gamma unit.

Fractionated stereotactic radiation therapy for intracranial tumors.

In stereotactic radio surgery, a single, large dose of radiation is delivered to a small, well‐defined, stereotactically localized intracranial lesion. In contrast to conventional radiation therapy, in radio surgery no attempt is made to spare normal cells within the target volume by fractionating the tumor dose. In 1987, the authors began a program of fractionated stereotactic radiation therapy for selected tumors involving sensitive brain structures. Their objective was to improve the therapeutic index and study the feasibility of the fractionated technique. Fifteen patients were treated with a multifraction regimen typically consisting of six fractions of 700 cGy each, given on alternate days for 2 weeks (total tumor dose, 4200 cGy). All patients were treated with the dynamic stereotactic radio surgical technique. A head ring (“halo frame”) was used for immobilization and setup during radiation treatments. At a median follow‐up time of 27 months, the symptoms of the majority of the patients improved clinically; this improvement usually occurred within a few weeks after completion of the treatment. The radiologic response was much slower. Currently, only two patients have had complete radiologic disappearance of their lesions; the majority of the patients have only had a decrease in tumor size. The treatments were well tolerated by the patients and no acute complications were observed. One patient who had a vasogenic edema 11 months after treatment fully recovered after steroid therapy. Fractionated stereotactic radiation therapy is a feasible treatment technique and may prove to be useful for selected patients with intracranial tumors. Although the preliminary data are encouraging, this technique should still be considered experimental. A larger number of patients and a longer follow‐up time are necessary to determine whether the results of this technique are actually better than those of conventional radiation therapy. Cancer 68:2101–2108.

Radiosurgery of cerebral arteriovenous malformations with the dynamic stereotactic irradiation

From December 1986 through December 1988, 33 patients with inoperable arteriovenous malformation (AVM) were treated in our center with the dynamic stereotactic radiosurgery, which uses a standard 10 MV isocentric linear accelerator. There were 18 females and 15 males with a median age of 26 years (range: 9-69) and a median follow-up time of 16 months (range: 7-32). The arteriovenous malformation volumes treated ranged from 0.2 to 42 cm3. The prescribed doses at the isocenter varied from 50 to 55 Gy and were given as a single fraction in the majority of the patients (31/33). Late complications consisting of intracranial bleeding and/or hemiparesis were observed in three patients. To date, 21 patients underwent repeat angiographic studies at 1 year post-treatment. A complete obliteration of the lesion was achieved in 38% of these patients. For the patients whose arteriovenous malformation nidus was covered by a minimum dose of 25 Gy, the total obliteration rate was 61.5% (8/13), whereas none of the patients who had received less than 25 Gy at the edge of the nidus obtained a total obliteration. Our preliminary analysis at 1 year post-radiosurgery reveals results comparable to those previously reported for other radiosurgical techniques for the same follow-up period.

Physical aspects of a rotational total skin electron irradiation

A technique for rotational total skin electron irradiation is presented in which the patient stands on a slowly rotating platform (SSD = 285 cm) in a large uniform linear accelerator electron field (Eo = 3.5 MeV). The beam is scattered by the transmission ionization chamber and by a special lead/aluminum scattering filter, and then degraded by a sheet of Lucite. A Farmer chamber is used as a patient dose monitor and a method for absolute dose calibration is presented. The field is uniform to within +/- 5% for dimensions of 180 X 40 cm2. The surface dose for rotational therapy is equal to 45% of the maximum dose in a stationary beam. The rotating beam exhibits a dose maximum on the surface, falls to 80% at 0.5 cm and has an x-ray contamination of approximately 4%. The surface dose rate is about 25 cGy/min for the rotating beam. The rotational beam percentage depth dose distributions, calculated using stationary beam information, agree well with measured data. The stationary beam exhibits a dose maximum at 4 mm in tissue, a surface dose of 93%, 80% dose at a depth of 1 cm, a practical range of 1.75 cm, and an x-ray contamination of 2.5%. The rotational total skin electron irradiation significantly reduces the patient treatment and setup time and solves the problem of beam matching, when compared to standard multiple-beam techniques.

Physical aspects of dynamic stereotactic radiosurgery.

Dynamic stereotactic radiosurgery is a radiosurgical technique based on a medium-energy isocentric linear accelerator and a stereotactic frame. The technique uses concurrent and continuous rotations of both the gantry (300 degrees, from 30 to 330 degrees) and the couch (150 degrees, from 75 to -75 degrees). It gives a uniform dose (+/- 5%) within the target volume and dose fall-offs outside the target volume comparable to those obtained from presently known radiosurgical techniques.

Total body irradiation with a sweeping beam.

A technique for total body irradiation, in which the patient lies in the prone or supine position in the beam of a conventional column mounted 4 MV linear accelerator, is described. A sufficiently large radiation field is obtained by rotating the beam in a vertical plane about the source (i.e., sweeping beam) at a source-to-skin distance of 190 cm on the vertical axis. The variation of the midplane dose is less than +/- 5% in parallel-opposed beams, when attenuators are placed over the region containing the lungs and bolus is employed around the head and legs. The percentage depth dose for the sweeping beam is identical to that of a stationary beam for the same collimator setting and source-to-skin distance. A method for monitoring the dose to the patient by means of a thimble ionization chamber located on the vertical beam axis is outlined. The average dose rates used are between 5 and 10 cGy/min. The design and placement of lung attenuators is simple. The treatment technique with the sweeping beam requires minimal modification of a treatment unit and can be applied on any unit which has a head swivel option.

Radiosurgery with photon beams: physical aspects and adequacy of linear accelerators

The question of the adequacy of isocentric linear accelerators (linacs) for use in radiosurgery is addressed. The general physical requirements for radiosurgery, mainly a high spatial and numerical accuracy of dose delivery, reasonable treatment time, and low skin and leakage dose as well as cost considerations are examined. Various linac-based procedures are analyzed in view of their ability to meet these requirements and are contrasted with the clinically proven system of the Gamma unit. It is shown that the linac-based multiple converging arcs techniques and the dynamic rotation meet the stringent physical requirements on dose delivery and are thus viable alternatives to radiosurgery with the commercially available and dedicated Gamma unit.

The influence of phantom size on output, peak scatter factor, and percentage depth dose in large‐field photon irradiation

Machine outputs, peak scatter factors, and central axis percentage depth dose distributions were measured for various phantom sizes in large radiation fields produced at extended distances by cobalt, 6-MV, and 10-MV photon beams. The results can be applied to practical total body irradiation procedures which usually involve treatment volumes smaller than the actual field sizes in order to provide a uniform total body exposure to radiation. Our study addresses the question of the appropriate phantom dimension to be used in the calibration of photon beams employed in total body irradiations. The measurements show that the machine outputs are only slightly dependent on phantom size; the percentage depth dose distributions, however, are strongly dependent on the phantom size, suggesting that machine data for total body irradiations should be measured in phantoms whose dimensions approximate the patient during the total body irradiation. Peak scatter factors measured in large-field/small-phantom configurations link up well with the published small-field/large-phantom data. The finite patient thickness lowers the dose to points close to the beam exit surface by a few percent, when compared to dose measured at the same depths in infinitely thick phantoms. The surface doses in large radiation fields are essentially independent of phantom cross sections and range from 40% for the 10-MV beam, to 65% for the 6-MV beam and 80% for the cobalt beam.

Evaluation of lung dose correction methods for photon irradiations of thorax phantoms

Radiation absorbed dose in lung is measured and calculated using several algorithms available on commercial treatment planning systems. Phantoms resembling the human thorax are used and irradiated with small and large photon beams of 60Co, 4, 6, and 10 MV X ray energies. The applicability and usefulness of the different calculation methods in clinical situations is discussed.