Simeon Nill

Proton versus photon radiotherapy for common pediatric brain tumors: comparison of models of dose characteristics and their relationship to cognitive function.

To determine whether proton radiotherapy has clinical advantages over photon radiotherapy, we modeled the dose characteristics of both to critical normal tissue volumes using data from patients with four types of childhood brain tumors.

Evaluation of salivary gland function after treatment of head-and-neck tumors with intensity-modulated radiotherapy by quantitative pertechnetate scintigraphy

PURPOSE To evaluate salivary gland function after inversely planned stereotactic intensity-modulated radiotherapy (IMRT) for tumors of the head-and-neck region using quantitative pertechnetate scintigraphy. METHODS AND MATERIALS Since January 2000, 18 patients undergoing IMRT for cancer of the head and neck underwent pre- and posttherapeutic scintigraphy to examine salivary gland function. The mean dose to the primary planning target volume was 61.5 Gy (range 50.4-73.2), and the median follow-up was 23 months. In all cases, the parotid glands were directly adjacent to the planning target volume. The treatment planning goal was for at least one parotid gland to receive a mean dose of <26 Gy. Two quantitative parameters (change in maximal uptake and change in the relative excretion rate before and after IMRT) characterizing the change in salivary gland function after radiotherapy were determined. These parameters were compared with respect to the dose thresholds of 26 and 30 Gy for the mean dose. In addition, dose-response curves were calculated. RESULTS Using IMRT, it was possible in 16 patients to reduce the dose for at least one parotid gland to < or =26 Gy. In 7 patients, protection of both parotid glands was possible. No recurrent disease adjacent to the protected parotid glands was observed. Using the Radiation Therapy Oncology Group/European Organization for the Research and Treatment of Cancer scoring system, only 3 patients had Grade 2 xerostomia. No greater toxicity was seen for the salivary glands. The change in the relative excretion rate was significantly greater, if the parotid glands received a mean dose of > or =26 Gy or > or =30 Gy. For the change in maximal uptake, a statistically significant difference was seen only for the parotid glands and a dose threshold of 30 Gy. For the end point of a reduction in the parotid excretion rate of >50% and 75%, the dose-response curves yielded a dose at 50% complication probability of 34.8 +/- 3.6 and 40.8 +/- 5.3 Gy, respectively. CONCLUSION Using IMRT, it is possible to protect the parotid glands and reduce the incidence and severity of xerostomia in patients. Doses <26-30 Gy significantly preserve salivary gland function. The results support the hypothesis that application of IMRT does not lead to increased local failure rates.

Linac-integrated 4D cone beam CT: first experimental results

A new online imaging approach, linac-integrated cone beam CT (CBCT), has been developed over the past few years. It has the advantage that a patient can be examined in their treatment position directly before or during a radiotherapy treatment. Unfortunately, respiratory organ motion, one of the largest intrafractional organ motions, often leads to artefacts in the reconstructed 3D images. One way to take this into account is to register the breathing phase during image acquisition for a phase-correlated image reconstruction. Therefore, the main focus of this work is to present a system which has the potential to investigate the correlation between internal (movement of the diaphragm) and external (data of a respiratory gating system) information about breathing phase and amplitude using an inline CBCT scanner. This also includes a feasibility study about using the acquired information for a respiratory-correlated 4D CBCT reconstruction. First, a moving lung phantom was used to develop and to specify the required methods which are based on an image reconstruction using only projections belonging to a certain moving phase. For that purpose, the corresponding phase has to be detected for each projection. In the case of the phantom, an electrical signal allows one to track the movement in real time. The number of projections available for the image reconstruction depends on the breathing phase and the size of the position range from which projections should be used for the reconstruction. The narrower this range is, the better the inner structures can be located, but also the noise of the images increases due to the limited number of projections. This correlation has also been analysed. In a second step, the methods were clinically applied using data sets of patients with lung tumours. In this case, the breathing phase was detected by an external gating system (AZ-733V, Anzai Medical Co.) based on a pressure sensor attached to the patients abdominal region with a fixation belt. The comparison of the reconstructed 4D CBCT images and the corresponding 4D CT images used for the treatment planning provides the required information for the calculation of possible setup errors. So, a repositioning of the patient is feasible even though the patient moves due to respiration. In addition to the external signal, the position of the diaphragm in the cranial-caudal direction could be extracted from each projection. Both independent sources of information show a very good agreement of the phase and even the amplitude of the movement and the external signal respectively. This suggests the usability of such a system for a gated dose delivery approach. However, more studies involving patients with different incidences have to be carried out to confirm these first results.

What is the optimum leaf width of a multileaf collimator

UNLABELLED The following question is investigated: How narrow do the leaves of a multileaf collimator have to be such that further reduction of the leaf width does not lead to physical improvements of the dose distribution. Because of the physical principles of interaction between radiation and matter, dose distributions in radiotherapy are generally relatively smooth. According to the theory of sampling, the dose distribution can therefore be represented by a set of evenly spaced samples. The distance between the samples is identified with the distance between the leaf centers of a multileaf collimator. The optimum sampling distance is derived from the 20% to 80% field edge penumbra through the concept of the dose deposition kernel, which is approximated by a Gaussian. The leaf width of the multileaf collimator is considered to be independent from the sampling distance. Two cases are studied in detail: (i) the leaf width equals the sampling distance, which is the regular case, and (ii) the leaf width is twice the sampling distance. The practical delivery of the latter treatment geometry requires a couch movement or a collimator rotation. The optimum sampling distance equals the 20%-80% penumbra divided by 1.7 and is on the order of 1.5-2 mm for a typical 6 MV beam in soft tissue. The optimum leaf width equals this sampling distance in the regular case. A relatively small deterioration results if the leaf width is doubled, while the sampling distance remains the same. The deterioration can be corrected for by deconvolving the fluence profile with an inverse filter. CONCLUSIONS With the help of the sampling theory and, more generally, the theory of linear systems, one can find a general answer to the question about the optimum leaf width of a multileaf collimator from a physical point of view. It is important to distinguish between the sampling distance and the leaf width. The sampling distance is more critical than the leaf width. The leaf width can be up to twice as large as the sampling width. Furthermore, the derived sampling distance can be used to select the optimum resolution of both the fluence and the dose grid in dose calculation and inverse planning algorithms.

Correction of patient positioning errors based on in-line cone beam CTs: clinical implementation and first experiences

BackgroundThe purpose of the study was the clinical implementation of a kV cone beam CT (CBCT) for setup correction in radiotherapy.Patients and methodsFor evaluation of the setup correction workflow, six tumor patients (lung cancer, sacral chordoma, head-and-neck and paraspinal tumor, and two prostate cancer patients) were selected. All patients were treated with fractionated stereotactic radiotherapy, five of them with intensity modulated radiotherapy (IMRT). For patient fixation, a scotch cast body frame or a vacuum pillow, each in combination with a scotch cast head mask, were used. The imaging equipment, consisting of an x-ray tube and a flat panel imager (FPI), was attached to a Siemens linear accelerator according to the in-line approach, i.e. with the imaging beam mounted opposite to the treatment beam sharing the same isocenter. For dose delivery, the treatment beam has to traverse the FPI which is mounted in the accessory tray below the multi-leaf collimator. For each patient, a predefined number of imaging projections over a range of at least 200 degrees were acquired. The fast reconstruction of the 3D-CBCT dataset was done with an implementation of the Feldkamp-David-Kress (FDK) algorithm. For the registration of the treatment planning CT with the acquired CBCT, an automatic mutual information matcher and manual matching was used.Results and discussionBony landmarks were easily detected and the table shifts for correction of setup deviations could be automatically calculated in all cases. The image quality was sufficient for a visual comparison of the desired target point with the isocenter visible on the CBCT. Soft tissue contrast was problematic for the prostate of an obese patient, but good in the lung tumor case. The detected maximum setup deviation was 3 mm for patients fixated with the body frame, and 6 mm for patients positioned in the vacuum pillow. Using an action level of 2 mm translational error, a target point correction was carried out in 4 cases. The additional workload of the described workflow compared to a normal treatment fraction led to an extra time of about 10–12 minutes, which can be further reduced by streamlining the different steps.ConclusionThe cone beam CT attached to a LINAC allows the acquisition of a CT scan of the patient in treatment position directly before treatment. Its image quality is sufficient for determining target point correction vectors. With the presented workflow, a target point correction within a clinically reasonable time frame is possible. This increases the treatment precision, and potentially the complex patient fixation techniques will become dispensable.

From physical dose constraints to equivalent uniform dose constraints in inverse radiotherapy planning.

Optimization algorithms in inverse radiotherapy planning need information about the desired dose distribution. Usually the planner defines physical dose constraints for each structure of the treatment plan, either in form of minimum and maximum doses or as dose-volume constraints. The concept of equivalent uniform dose (EUD) was designed to describe dose distributions with a higher clinical relevance. In this paper, we present a method to consider the EUD as an optimization constraint by using the method of projections onto convex sets (POCS). In each iteration of the optimization loop, for the actual dose distribution of an organ that violates an EUD constraint a new dose distribution is calculated that satisfies the EUD constraint, leading to voxel-based physical dose constraints. The new dose distribution is found by projecting the current one onto the convex set of all dose distributions fulfilling the EUD constraint. The algorithm is easy to integrate into existing inverse planning systems, and it allows the planner to choose between physical and EUD constraints separately for each structure. A clinical case of a head and neck tumor is optimized using three different sets of constraints: physical constraints for all structures, physical constraints for the target and EUD constraints for the organs at risk, and EUD constraints for all structures. The results show that the POCS method converges stable and given EUD constraints are reached closely.

Does electron and proton therapy reduce the risk of radiation induced cancer after spinal irradiation for childhood medulloblastoma? A comparative treatment planning study

Aim The aim of this treatment planning comparison study was to explore different spinal irradiation techniques with respect to the risk of late side-effects, particularly radiation-induced cancer. The radiotherapy techniques compared were conventional photon therapy, intensity modulated x-ray therapy (IMXT), conventional electron therapy, intensity/energy modulated electron therapy (IMET) and proton therapy (IMPT). Material and methods CT images for radiotherapy use from five children, median age 8 and diagnosed with medulloblastoma, were selected for this study. Target volumes and organs at risk were defined in 3-D. Treatment plans using conventional photon therapy, IMXT, conventional electron therapy, IMET and IMPT were set up. The probability of normal tissue complication (NTCP) and the risk of cancer induction were calculated using models with parameters-sets taken from published data for the general population; dose data were taken from dose volume histograms (DVH). Results Similar dose distributions in the targets were achieved with all techniques but the absorbed doses in the organs-at-risk varied significantly between the different techniques. The NTCP models based on available data predicted very low probabilities for side-effects in all cases. However, the effective mean doses outside the target volumes, and thus the predicted risk of cancer induction, varied significantly between the techniques. The highest lifetime risk of secondary cancers was estimated for IMXT (30%). The lowest risk was found with IMPT (4%). The risks associated with conventional photon therapy, electron therapy and IMET were 20%, 21% and 15%, respectively. Conclusion This model study shows that spinal irradiation of young children with photon and electron techniques results in a substantial risk of radiation-induced secondary cancers. Multiple beam IMXT seems to be associated with a particularly high risk of secondary cancer induction. To minimise this risk, IMPT should be the treatment of choice. If proton therapy is not available, advanced electron therapy may provide a better alternative.

Development of an optimization concept for arc-modulated cone beam therapy

In this paper, we propose an optimization concept for a rotation therapy technique which is referred to as arc-modulated cone beam therapy (AMCBT). The aim is a reduction of the treatment time while achieving a treatment plan quality equal to or better than that of IMRT. Therefore, the complete dose is delivered in one single gantry rotation and the beam is modulated by a multileaf collimator. The degrees of freedom are the field shapes and weights for a predefined number of beam directions. In the new optimization loop, the beam weights are determined by a gradient algorithm and the field shapes by a tabu search algorithm. We present treatment plans for AMCBT for two clinical cases. In comparison to step-and-shoot IMRT treatment plans, it was possible by AMCBT to achieve dose distributions with a better dose conformity to the target and a lower mean dose for the most relevant organ at risk. Furthermore, the number of applied monitor units was reduced for AMCBT in comparison to IMRT treatment plans.

Real-time tumor tracking: automatic compensation of target motion using the Siemens 160 MLC.

PURPOSE Advanced high quality radiation therapy techniques such as IMRT require an accurate delivery of precisely modulated radiation fields to the target volume. Interfractional and intrafractional motion of the patients anatomy, however, may considerably deteriorate the accuracy of the delivered dose to the planned dose distributions. In order to compensate for these potential errors, a dynamic real-time capable MLC control system was designed. METHODS The newly developed adaptive MLC control system contains specialized algorithms which are capable of continuous optimization and correction of the aperture of the MLC according to the motion of the target volume during the dose delivery. The algorithms calculate the new leaf positions based on target information provided online to the system. The algorithms were implemented in a dynamic target tracking control system designed for a Siemens 160 MLC. To assess the quality of the new target tracking system in terms of dosimetric accuracy, experiments with various types of motion patterns using different phantom setups were performed. The phantoms were equipped with radiochromic films placed between solid water slabs. Dosimetric results of exemplary deliveries to moving targets with and without dynamic MLC tracking applied were compared in terms of the gamma criterion to the reference dose delivered to a static phantom. RESULTS Our measurements indicated that dose errors for clinically relevant two-dimensional target motion can be compensated by the new control system during the dose delivery of open fields. For a clinical IMRT dose distribution, the gamma success rate was increased from 19% to 77% using the new tracking system. Similar improvements were achieved for the delivery of a complete IMRT treatment fraction to a moving lung phantom. However, dosimetric accuracy was limited by the systems latency of 400 ms and the finite leaf width of 5 mm in the isocenter plane. CONCLUSIONS Different experimental setups representing different target tracking scenarios proved that the tracking concept, the new algorithms and the dynamic control system make it possible to effectively compensate for dose errors due to target motion in real-time. These early results indicate that the method is suited to increasing the accuracy and the quality of the treatment delivery for the irradiation of moving tumors.

Intensity-modulated radiotherapy of nasopharyngeal carcinoma: a comparative treatment planning study of photons and protons

BackgroundThe aim of this treatment planning study was to investigate the potential advantages of intensity-modulated (IM) proton therapy (IMPT) compared with IM photon therapy (IMRT) in nasopharyngeal carcinoma (NPC).MethodsEight NPC patients were chosen. The dose prescriptions in cobalt Gray equivalent (GyE) for gross tumor volumes of the primary tumor (GTV-T), planning target volumes of GTV-T and metastatic (PTV-TN) and elective (PTV-N) lymph node stations were 72.6 GyE, 66 GyE, and 52.8 GyE, respectively. For each patient, nine coplanar fields IMRT with step-and-shoot technique and 3D spot-scanned three coplanar fields IMPT plans were prepared. Both modalities were planned in 33 fractions to be delivered with a simultaneous integrated boost technique. All plans were prepared and optimized by using the research version of the inverse treatment planning system KonRad (DKFZ, Heidelberg).ResultsBoth treatment techniques were equal in terms of averaged mean dose to target volumes. IMPT plans significantly improved the tumor coverage and conformation (P < 0.05) and they reduced the averaged mean dose to several organs at risk (OARs) by a factor of 2–3. The low-to-medium dose volumes (0.33–13.2 GyE) were more than doubled by IMRT plans.ConclusionIn radiotherapy of NPC patients, three-field IMPT has greater potential than nine-field IMRT with respect to tumor coverage and reduction of the integral dose to OARs and non-specific normal tissues. The practicality of IMPT in NPC deserves further exploration when this technique becomes available on wider clinical scale.