Juergen Meyer

Abstract: X-ray detectors based on single crystal diamond film made via chemical vapor deposition were investigated to evaluate their performance under clinically relevant conditions for radiotherapy dosimetry. Studies focused on repeatability, dose rate dependence, tissue phantom ratios, output factors and beam profiling. Repeatability experiments revealed a temporary loss in sensitivity due to charge detrapping effects following irradiation, which was modeled to make corrections that improved short-term precision. Dose rate dependence was observed (Fowler fitting parameter Δ = 0.96 ± 0.2) using dose rates up to ∼2 Gy min^-1. The detector statistically distinguished (n = 5, P < 0.05) between dose values separated by 7.7 × 10^-3 Gy (1 MU). Depth dose measurements from 1 to 15 cm and output factors using 3 × 3 to 10 × 10 cm^2 field sizes compared well with a Farmer ion chamber (<1.3% difference). Output factor measurements indicate encouraging results for fields sizes <4 × 4 cm^2. Off-axis measurements showed that perturbation of the beam could be reduced when the detector is used in the edge-on orientation due to its thin-film sandwich configuration and ∼200 nm thick Ag contacts. This relatively inexpensive detector has potential to be used for routine dosimetry using conventional radiotherapy instrumentation.

Abstract: The performance of a synthetic diamond X-ray detector during typical clinical beam characterisation procedures was compared to the performance of standard clinical detectors; this diamond detector used a single crystal diamond film synthesised using chemical vapour deposition as its sensitive element. Measurements were performed using 6?MV photons from a Varian 600C linear accelerator. The procedures measured the dose profile with depth along the central axis in a phantom (tissue maximum ratio) for a 10?× 10?cm2 field, variation in dose at the isocentre with field size (output factor), and dose profile across and beyond the X-ray beam (off-axis ratio) for 10?× 10?cm2 and 1?× 1?cm2 fields. Tissue maximum ratio values were within 0.8% of the values from a standard ion chamber, over a depth range of 1-15?cm. Output factors were measured for field sizes from 0.6?× 0.6?cm2 to 15?× 15?cm2 and agreed well (<1.3% difference) with available ion chamber data for field sizes down to 3?× 3?cm2. Off-axis measurements showed reduced penumbral width when the lateral size of the detector was reduced by holding the diamond detector in an edge-on orientation; values were comparable to those obtained using a diode detector. Overall, these results demonstrate the potential of synthetic diamond detectors for clinical beam characterisation, particularly for small beam sizes.

Abstract: Spectral x-ray imaging using novel photon counting x-ray detectors (PCDs) with energy resolving abilities is capable of providing energy-selective images. PCDs have energy thresholds, enabling the classification of photons into multiple energy bins. The extra energy information provided may allow materials such as iodine and calcium, or water and fat to be distinguishable. The information content of spectral x-ray images, however, depends on how the photons are grouped together. In this work, we present a model to optimize energy windows for maximum material discrimination. Multivariate statistics allows the confidence region of the correlated uncertainties to be mapped in the thickness space. Minimization of the uncertainties enables optimization of energy windows. Applications related to small animal imaging and breast imaging are considered.

Abstract: Background: 2-step intensity modulated arc therapy (IMAT) is a simplified IMAT technique which delivers the treatment over typically two continuous gantry rotations. The aim of this work was to implement the technique into a computerized treatment planning system and to develop an approach to optimize the segment weights and widths. Methods: 2-step IMAT was implemented into the Prism treatment planning system. A graphical user interface was developed to generate the plan segments automatically based on the anatomy in the beam's-eye-view. The segment weights and widths of 2-step IMAT plans were subsequently determined in Matlab using a dose-volume based optimization process. The implementation was tested on a geometric phantom with a horseshoe shaped target volume and then applied to a clinical paraspinal tumour case. Results: The phantom study verified the correctness of the implementation and showed a considerable improvement over a non-modulated arc. Further improvements in the target dose uniformity after the optimization of 2-step IMAT plans were observed for both the phantom and clinical cases. For the clinical case, optimizing the segment weights and widths reduced the maximum dose from 114% of the prescribed dose to 107% and increased the minimum dose from 87% to 97%. This resulted in an improvement in the homogeneity index of the target dose for the clinical case from 1.31 to 1.11. Additionally, the high dose volume V105 was reduced from 57% to 7% while the maximum dose in the organ-at-risk was decreased by 2%. Conclusions: The intuitive and automatic planning process implemented in this study increases the prospect of the practical use of 2-step IMAT. This work has shown that 2-step IMAT is a viable technique able to achieve highly conformal plans for concave target volumes with the optimization of the segment weights and widths. Future work will include planning comparisons of the 2-step IMAT implementation with fixed gantry intensity modulated radiotherapy (IMRT) and commercial IMAT implementations.

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Abstract: A 3D system of springs and dashpots is presented to model the motion of a lung tumour during respiration. The main guiding factor in configuring the system is the spatial relationship between abdominal and lung tumour motion. A coupled, non-dimensional triple of ordinary differential equations models the tumour motion when driven by a 3D breathing signal. Asymptotic analysis is used to reduce the system to a single equation driven by a 3D signal, in the limit of small lateral and transverse tumour motions. A numerical scheme is introduced to solve this equation, and tested over wide parameter ranges. Real clinical data is used as input to the model, and the tumour motion output is in excellent agreement with that obtained by a prototype tumour tracking system, with model parameters obtained by optimization. The fully 3D model has the potential to accurately model the motion of any lung tumour given an abdominal signal as input, with model parameters obtained from an internal optimization routine.

Abstract: A prototype clinical radiation detector based on commercially available single crystal diamond film made via chemical vapor deposition was investigated to determine optimal operating parameters for clinical dosimetry. This study examined how changes in applied electric field affected dosimetric performance, and determined a preferred operating voltage within the limits of clinical dosimetry equipment. Dosimetric analysis included leakage current, response dynamics such as rise and fall times, sensitivity, polarity and dependence on dose and dose rate. The results of this study indicate a preference for using a setting of 62.5 V due to its minimal rise time of 2 s, including a faster time to equilibrium, yet sufficient sensitivity of 37 nC Gy^-1, which was nearly independent of polarity. At this voltage, a wider range of dose may therefore be recorded with charge collecting instruments than at higher voltages. Additionally, no clear trend was found over the range of voltages tested when evaluating dose dependence (R²=1 for 0.78-7.8 Gy) and dose rate dependence using Fowler fitting parameter Δ (0.95≤Δ≤1.01). Leakage currents were negligible (&lt;2.5 pA). The highest voltage setting of 248.0 V resulted in the highest sensitivity of 235 nC Gy^-1, but corresponding rise times of ≥7 s may limit the use of this detector. Following the optimization of operating parameters, clinical studies are ongoing to evaluate the use of this detector for small field and IMRT applications. © 2009 Elsevier B.V. All rights reserved.

Abstract: Diamond detectors are particularly well suited for dosimetry applications in radiotherapy for reasons including near-tissue equivalence and high-spatial resolution resulting from small sensitive volumes. However, these detectors have not become commonplace due to high cost and poor availability arising from the need for high-quality diamond. We have fabricated relatively cheap detectors from commercially-available synthetic diamond fabricated using chemical vapour deposition. Here, we present a comparison of one of these detectors with the only commercially-available diamond-based detector (which uses a natural diamond crystal). Parameters such as the energy dependence and linearity of charge with dose were investigated at orthovoltage energies (50-250 kV), and dose-rate dependence of charge at linear accelerator energy (6 MV). The energy dependence of a synthetic diamond detector was similar to that of the natural diamond detector, albeit with slightly less variation across the energy range. Both detectors displayed a linear response with dose (at 100 kV) over the limited dose range used. The sensitivity of the synthetic diamond detector was 302 nC/Gy, compared to 294 nC/Gy measured for the natural diamond detector; however, this was obtained with a bias of 246.50 V compared to a bias of 61.75 V used for the natural diamond detector. The natural diamond detector exhibited a greater dependency on dose-rate than the synthetic diamond detector. Overall, the synthetic diamond detector performed well in comparison to the natural diamond detector.

Abstract: Since the clinical implementation of novel rotational forms of intensity-modulated radiotherapy, a variety of planning studies have been published that reinforce the major selling points of the technique. Namely, comparable or even improved dose distributions with a reduction in both monitor units and treatment times, when compared with static gantry intensity-modulated radiotherapy. Although the data are promising, a rigorous approach to produce these plans has yet to be established. As a result, this study outlines a robust and streamlined planning strategy with a concentration on RapidArc class solutions for prostate with a simultaneous integrated boost. This planning strategy outlines the field setup, recommended starting objectives, required user interactions to be made throughout optimization and post-optimization adjustments. A comparative planning study, with static gantry IMRT, is then presented as justification for the planning strategy itself. A variety of parameters are evaluated relating to both the planning itself (optimization and calculation time) and the plans that result. Results of this comparative study are in line with previously published data, and the planning process is streamlined to a point where the RapidArc optimization time takes 15 ± 1.3 minutes. Application of this planning strategy reduces the dependence of the produced plan on the experience of the planner, and has the potential to streamline the planning process within radiotherapy departments.

Abstract: Sandwich-type x-ray detectors were fabricated on commercially-available chemical vapour deposition diamond sourced from three manufacturers: Diamond Materials GmbH, Diamonex, and Element Six. These devices were investigated using Raman spectroscopy and 6 megavolt photons from a clinical linear accelerator. Parameters such as the level of the dark (leakage) and photo- currents, necessary priming dose, linearity of photocurrent with dose rate, and device sensitivity were considered. Device characteristics vary considerably. Devices fabricated using Diamonex material required high priming doses, and displayed high dark currents, low photocurrents (and hence low x-ray sensitivity), and a sub-linear dose-rate response. In contrast, devices fabricated from Diamond Materials and Element Six material required lower priming doses, and displayed 'zero' dark currents (beyond the detection limit), higher photocurrents and linear dose-rate responses. In addition, the Element Six devices exhibited less variation in response when irradiated at different angles of incidence.

Abstract: Objective: The prognosis of cancer patients treated with intensity-modulated radiation therapy (IMRT) is inherently uncertain, depends on many decision variables, and requires that a physician balance competing objectives: maximum tumor control with minimal treatment complications. Methods: In order to better deal with the complex and multiple objective nature of the problem we have combined a prognostic probabilistic model with multi-attribute decision theory which incorporates patient preferences for outcomes. Results: The response to IMRT for prostate cancer was modeled. A Bayesian network was used for prognosis for each treatment plan. Prognoses included predicting local tumor control, regional spread, distant metastases, and normal tissue complications resulting from treatment. A Markov model was constructed and used to calculate a quality-adjusted life-expectancy which aids in the multi-attribute decision process. Conclusions: Our method makes explicit the tradeoffs patients face between quality and quantity of life. This approach has advantages over current approaches because with our approach risks of health outcomes and patient preferences determine treatment decisions.

Abstract: Introduction: Treatment of large target volumes with intensity modulated radiotherapy (IMRT) can be restricted by the maximum field size of the multileaf collimator (MLC). In this work, a straightforward technique for MLC based IMRT is presented, which is generally applicable and does not depend on the capabilities of the linear accelerator’s IMRT delivery system. Methods: A dual isocentre technique was developed which maximizes beams overlap. The beams at the first isocentre are arranged such that they interlace with the beams at the second isocentre. All beams contribute to the overlap region, whereas only some contribute to the superior and some to the inferior part of the target. The interlaced technique (9 beams) was compared with an alternative more complex approach (14 beams) for a head-and-neck case with simultaneous integrated boost and three different dose levels. The plans were compared in terms of complexity, dosimetry and the effect of inaccurate translation between the isocentres. Results: The interlaced and the more complex IMRT technique resulted in nearly identical dose distributions without clinically relevant differences. The total number of monitor units (MU) was comparable with more MUs per segment for the interlaced technique. For the interlaced technique the number of segments ≤ 5 MU was reduced by 43%. Simulation of isocentre set-up errors of ±1, ±2 and ±3 mm revealed maximum dose point errors of 1.8 %, 3.8 % and 5.4 % in the target volume for the interlaced technique. Conclusion: The interlaced IMRT technique resulted in an equivalent plan to the more complex technique without compromising the dose distribution. The technique is less complex and is robust against inaccurate isocentre translations of up to ±1 mm. Due to the versatility of the technique it can easily be applied to other anatomical regions and is well suited for clinical routine usage.

Abstract: Gafchromic® XR-RV2 is a revised version of the obsolete Gafchromic® XR-R-type radiochromic film. This article investigates the dose response, energy response, postexposure growth, and polarizing effects of this film after exposure to ionizing radiation in the diagnostic energy range. The effect of bit depth on scanning was also investigated. Films were scanned using an Epson Expression 10000XL document scanner or an X-Rite model 301 spot densitometer. Color channel analysis was performed. The film showed usable response in the air kerma range of 1–1000 cGy, although by 1500 cGy the film appeared saturated when using the red color channel on a document scanner. The film response varied by 11% between 60 and 96 kVp and 3.5% between 96 and 125 kVp for doses above 1 Gy. Postexposure growth was found to be approximately logarithmic and fairly stable after 24 h. Films stored under office lighting exhibited around twice the density growth compared with film stored in a dark environment. The film showed strong orientation dependence when scanned using a polarized light source. A 48 bit scan provided no increase in sensitivity over 24 bits. Gafchromic XR-RV2 film is a radiochromic film ideally suited for measurement of wide dose ranges at diagnostic energies. The energy dependence of this film limits its accuracy for dosimetry of unknown energy beams. For the document scanners used in this study a 24 bit scan was more than sufficient compared to a 48 bit scan. This is likely to be the case for most document scanners where electrical noise prevents higher bit depths from increasing the sensitivity of measurements.

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Abstract: BACKGROUND: The ability of a geometry-based method to expeditiously adapt a "2-Step" step and shoot IMRT plan was explored. Both changes of the geometry of target and organ at risk have to be balanced. A retrospective prostate planning study was performed to investigate the relative benefits of beam segment adaptation to the changes in target and organ at risk coverage. METHODS: Four patients with six planning cases with extraordinarily large deformations of rectum and prostate were chosen for the study. A 9-field IMRT plan (A) using 2-Step IMRT segments was planned on an initial CT study. The plan had to fulfil all the requirements of a conventional high-quality step and shoot IMRT plan. To adapt to changes of the anatomy in a further CT data set, three approaches were considered: the original plan with optimized isocentre position (B), a newly optimized plan (C) and the original plan, adapted using the 2-Step IMRT optimization rules (D). DVH parameters were utilized for quantification of plan quality: D(99) for the CTV and the central planning target volume (PTV), D(95) for an outer PTV, V(95), V(80) and V(50) for rectum and bladder. RESULTS: The adapted plan (D) achieved almost the same target coverage as the newly optimized plan (C). Target coverage for plan B was poor and for the organs at risk, the rectum V(80) was slightly increased. The volume with more than 95% of the target dose (V(95)) was 1.5+/-1.5 cm(3) for the newly optimized plan (C), compared to 2.2+/-1.3 cm(3) for the original plan (A) and 7.2+/-4.8 cm(3) (B) on the first and the second CT, respectively. The adapted plan resulted in 4.3+/-2.1 cm(3) (D), an intermediate dose load to the rectum. All other parameters were comparable for the newly optimized and the adapted plan. CONCLUSIONS: The first results for adaptation of interfractional changes using the 2-Step IMRT algorithm are encouraging. The plans were superior to plans with optimized isocentre position and only marginally inferior to a newly optimized plan.

Abstract: Steep dose gradients between two planning target volumes (PTVs) as may be required for simultaneous integrated boosts (SIB) should be an option provided by IMRT algorithms. The aim was to analyse the geometry of the SIB problem and to implement the results in an algorithm for IMRT segment generation denoted two-step intensity modulated radiotherapy (2-Step IMRT). It was hypothesized that a gap between segments directed to the inner and the outer PTV would steepen the dose gradient. The mathematical relationships were derived from the individual dose levels and the geometry (diameters) of the PTVs. The results generated by means of 2-Step IMRT segments were equivalent or better than the segment generation using a commercial IMRT planning system. The dose to both the inner and the outer PTV was clearly more homogeneous and the composite objective value was the lowest. The segment numbers were lower or equal--with better sparing of the surrounding tissue. In summary, it was demonstrated that 2-Step IMRT was able to achieve steep dose gradients for SIB constellations.

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Abstract: A framework for a tutorial for treatment planning in radiation oncology physics was developed, based on the University of Washington treatment planning system Prism. The tutorial is aimed at students in Medical Physics to accompany the lectures on treatment planning to enhance their theoretical knowledge. A web-based layout was chosen to allow independent work of the students. The tutorial guides the students through three different learning modules, designed mainly to enhance their understanding of the processes involved in treatment planning but also to learn the specific features of a modern treatment planning system. Each of the modules contains four units, with the aim to introduce the relevant Prism features, practice skills in different tasks and finally check the learning outcomes with a challenge and a self-scoring quiz. A survey for students' feedback completes the tutorial. Various tools and learning methods help to create an interactive, appealing learning environment, in which the emphasis is shifted from teacher-centred to student-centred learning paradigms. In summary, Prism lends itself well for educational purposes. The tutorial covers all main aspects of treatment planning. In its current form the tutorial is self-contained but still adjustable and expandable. The tutorial can be made available upon request to the authors.

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Abstract: The aim of this study is to review the clinical potential of spectroscopic X-ray detectors and to undertake a feasibility study using a novel detector in a clinical hospital setting. Detectors currently in development, such as Medipix-3, will have multiple energy thresholds allowing for routine use of spectroscopic bio-medical imaging. We have coined the term MARS (Medipix All Resolution System) for bio-medical images that provide spatial, temporal, and energy information. The full clinical significance of spectroscopic X-ray imaging is difficult to predict but insights can be gained by examining both image reconstruction artifacts and the current uses of dual-energy techniques. This paper reviews the known uses of energy information in vascular imaging and mammography, clinically important fields. It then presents initial results from using Medipix-2, to image human tissues within a clinical radiology department. Detectors currently in development, such as Medipix-3, will have multiple energy thresholds allowing for routine use of spectroscopic bio-medical imaging in the future.

Abstract: A novel system for real-time tumor tracking and motion compensation with a robotic HexaPOD treatment couch is described. The approach is based on continuous tracking of the tumor motion in portal images without implanted fiducial markers, using the therapeutic megavoltage beam, and tracking of abdominal breathing motion with optical markers. Based on the two independently acquired data sets the table movements for motion compensation are calculated. The principle of operation of the entire prototype system is detailed first. In the second part the performance of the HexaPOD couch was investigated with a robotic four-dimensional-phantom capable of simulating real patient tumor trajectories in three-dimensional space. The performance and limitations of the HexaPOD table and the control system were characterized in terms of its dynamic behavior. The maximum speed and acceleration of the HexaPOD were 8 mm/s and 34.5 mm/s2 in the lateral direction, and 9.5 mm/s and 29.5 mm/s2 in longitudinal and anterior-posterior direction, respectively. Base line drifts of the mean tumor position of realistic lung tumor trajectories could be fully compensated. For continuous tumor tracking and motion compensation a reduction of tumor motion up to 68% of the original amplitude was achieved. In conclusion, this study demonstrated that it is technically feasible to compensate breathing induced tumor motion in the lung with the adaptive tumor tracking system.

Abstract: BACKGROUND: Modern intensity modulated radiotherapy (IMRT) mostly uses iterative optimisation methods. The integration of machine parameters into the optimisation process of step and shoot leaf positions has been shown to be successful. For IMRT segmentation algorithms based on the analysis of the geometrical structure of the planning target volumes (PTV) and the organs at risk (OAR), the potential of such procedures has not yet been fully explored. In this work, 2-Step IMRT was combined with subsequent direct machine parameter optimisation (DMPO-Raysearch Laboratories, Sweden) to investigate this potential. METHODS: In a planning study DMPO on a commercial planning system was compared with manual primary 2-Step IMRT segment generation followed by DMPO optimisation. 15 clinical cases and the ESTRO Quasimodo phantom were employed. Both the same number of optimisation steps and the same set of objective values were used. The plans were compared with a clinical DMPO reference plan and a traditional IMRT plan based on fluence optimisation and consequent segmentation. The composite objective value (the weighted sum of quadratic deviations of the objective values and the related points in the dose volume histogram) was used as a measure for the plan quality. Additionally, a more extended set of parameters was used for the breast cases to compare the plans. RESULTS: The plans with segments pre-defined with 2-Step IMRT were slightly superior to DMPO alone in the majority of cases. The composite objective value tended to be even lower for a smaller number of segments. The total number of monitor units was slightly higher than for the DMPO-plans. Traditional IMRT fluence optimisation with subsequent segmentation could not compete. CONCLUSION: 2-Step IMRT segmentation is suitable as starting point for further DMPO optimisation and, in general, results in less complex plans which are equal or superior to plans generated by DMPO alone.

Abstract: Background Breathing motion should be considered for stereotactic body radiotherapy (SBRT) of lung tumors. Four-dimensional computer tomography (4D-CT) offers detailed information of tumor motion. The aim of this work is to evaluate the influence of inhomogeneous dose distributions in the presence of breathing induced target motion and to calculate margins for motion compensation. Methods Based on 4D-CT examinations, the probability density function of pulmonary tumors was generated for ten patients. The time-accumulated dose to the tumor was calculated using one-dimensional (1D) convolution simulations of a 'static' dose distribution and target probability density function (PDF). In analogy to stereotactic body radiotherapy (SBRT), different degrees of dose inhomogeneity were allowed in the target volume: minimum doses of 100 % were prescribed to the edge of the target and maximum doses varied between 102 % (P102) and 150 % (P150). The dose loss due to breathing motion was quantified and margins were added until this loss was completely compensated. Results With the time-weighted mean tumor position as the isocentre, a close correlation with a quadratic relationship between the standard deviation of the PDF and the margin size was observed. Increased dose inhomogeneity in the target volume required smaller margins for motion compensation: margins of 2.5 mm, 2.4 mm and 1.3 mm were sufficient for compensation of 11.5 mm motion range and standard deviation of 3.9 mm in P105, P125 and P150, respectively. This effect of smaller margins for increased dose inhomogeneity was observed for all patients. Optimal sparing of the organ-at-risk surrounding the target was achieved for dose prescriptions P105 to P118. The internal target volume concept over-compensated breathing motion with higher than planned doses to the target and increased doses to the surrounding normal tissue. Conclusions Treatment planning with inhomogeneous dose distributions in the target volume required smaller margins for compensation of breathing induced target motion with the consequence of lower doses to the surrounding organs-at-risk.

Abstract: PURPOSE: To investigate the influence of tumor motion on the calculation of four-dimensional (4D) dose distributions of the gross tumor volume (GTV) in pulmonary stereotactic body radiotherapy. METHODS AND MATERIALS: For 7 patients with eight pulmonary tumors, a respiratory-correlated 4D-computed tomography study was acquired. The internal target volume was the sum of all tumor positions in the planning 4D-computed tomography study, and a 5-mm margin was used for generation of the planning target volume. Three-dimensional (3D) treatment plans were generated with a dose prescription of 3 x 12.5 Gy to the planning target volume enclosing the 65% and 80% isodose. After model-based nonrigid image registration, the 4D dose distributions were calculated. RESULTS: No significant difference was found in the dose to the GTV with the tumor in the end-exhalation, end-inhalation, or mid-ventilation phase of the breathing cycle. The high-dose region was confined to the solid tumor, and lower doses were delivered to the surrounding pulmonary tissue of lower density. This nonstatic, variant dose distribution increased the 4D dose to the GTV by 6.2%, on average, compared with calculations using on a static dose distribution during the breathing cycle. The 4D accumulation resulted in a biologic effective dose (BED) of 143 +/- 8 Gy and 106 +/- 4 Gy to the GTV in the plan-65% and plan-80%, respectively. The dose to the ipsilateral lung was not different between the 3D and 4D dose calculations or between plan-65% and plan-80%. CONCLUSIONS: In this study, the dose to the GTV was not decreased or blurred in the 4D plan compared with the 3D plan. The 3D doses to the GTV, internal target volume, and dose at the isocenter were good approximations of the 4D dose calculations. The 3D dose at the planning target volume margin underestimated the 4D dose significantly.

Abstract: PURPOSE: Intra-fractional variability of tumor position and breathing motion was evaluated in cone-beam CT (CB-CT) based image-guided radiotherapy (IGRT) of pulmonary tumors. MATERIALS AND METHODS: Twenty-four patients (27 lesions: prim. NSCLC n=6; metastases n=21) were treated with stereotactic body radiotherapy (SBRT) (one to eight fractions). Prior to every treatment fraction (n=66) and immediately after treatment a CB-CT was acquired. Patient motion, absolute drift and drift of the tumor relative to the bony anatomy were measured. Tumor motion was investigated based on the density distribution in the CB-CT. RESULTS: Absolute intra-fractional drift (3D vector) of the tumor position was 2.8 mm+/-1.6 mm (mean +/- SD), maximum 7.2 mm. Poor correlation between patient motion and absolute tumor drift was observed. Changes of the tumor position due to patient motion and due to drifts independently from the bony anatomy were of similar magnitude with 2.1 mm +/- 1.4 mm and 2.3 mm +/- 1.6 mm, respectively. No systematic increase or decrease of breathing motion was seen. The intra-fractional change of breathing motion was more than 2 mm and 3 mm in 39% and 16%, respectively. CONCLUSION: Intra-fractional tumor position and breathing motion were stable. In IGRT of pulmonary tumors we suggest an ITV-to-PTV margin of 5 mm to compensate intra-fractional changes.

Abstract: PURPOSE: Respiratory correlated computed tomography has been shown to be effective for evaluation of breathing-induced motion of pulmonary tumors. This study investigated whether a single four-dimensional CT study (4D-CT) is representative and sufficient for treatment planning in stereotactic body radiotherapy (SBRT). METHODS AND MATERIALS: Four repeated helical 4D-CT studies were acquired every 10 min for 10 patients with 14 pulmonary metastases. Patients remained immobilized in a stereotactic body frame (SBF) for 30 min; abdominal compression was applied to seven patients. Using amplitude based sorting, eight phases equally distributed over the breathing cycle were reconstructed for each 4D-CT study. Tumor position was defined in a total of 406 CT series and variability of breathing motion and mean tumor position were evaluated. RESULTS: Peak-to-peak tumor motion was 9.9 mm +/- 6.8 mm (mean +/- standard deviation) and 9.0 mm +/- 7.4 mm at time point 0 min (t(0)) and t(30), respectively. In one patient with poor pulmonary function, continuous increase of breathing motion from 17.4 mm at t(0) to 28.3 mm at t(30) was seen. In five and two lesions, respectively, a drift of the mean tumor position greater than 3 mm and 5 mm was observed. A borderline significance was calculated for larger tumor position variability in midventilation phases compared with peak-ventilation phases of the breathing cycle (p = 0.08). CONCLUSION: Treatment planning based on a single 4D-CT study is reliable for the majority of patients. Increased intrafractional uncertainties were seen for patients with poor pulmonary function and with tumors located in the lower lobe.

Abstract: PURPOSE: To scrutinize the positioning accuracy and reproducibility of a commercial hexapod robot treatment table (HRTT) in combination with a commercial cone-beam computed tomography system for image-guided radiotherapy (IGRT). METHODS AND MATERIALS: The mechanical stability of the X-ray volume imaging (XVI) system was tested in terms of reproducibility and with a focus on the moveable parts, i.e., the influence of kV panel and the source arm on the reproducibility and accuracy of both bone and gray value registration using a head-and-neck phantom. In consecutive measurements the accuracy of the HRTT for translational, rotational, and a combination of translational and rotational corrections was investigated. The operational range of the HRTT was also determined and analyzed. RESULTS: The system performance of the XVI system alone was very stable with mean translational and rotational errors of below 0.2 mm and below 0.2 degrees , respectively. The mean positioning accuracy of the HRTT in combination with the XVI system summarized over all measurements was below 0.3 mm and below 0.3 degrees for translational and rotational corrections, respectively. The gray value match was more accurate than the bone match. CONCLUSION: The XVI image acquisition and registration procedure were highly reproducible. Both translational and rotational positioning errors can be corrected very precisely with the HRTT. The HRTT is therefore well suited to complement cone-beam computed tomography to take full advantage of position correction in six degrees of freedom for IGRT. The combination of XVI and the HRTT has the potential to improve the accuracy of high-precision treatments.

Abstract: BACKGROUND AND PURPOSE: 2-Step intensity modulated radiation therapy (2-Step IMRT) is an IMRT segmentation procedure based on analytical approximations [Bratengeier K. 2-Step IMAT and 2-Step IMRT: a geometrical approach. Med Phys 2005;32:777-785; Bratengeier K. 2-Step IMAT and 2-Step IMRT in three dimensions. Med Phys 2005;32:3849-3861]. The aim was to benchmark it with other IMRT algorithms and to establish it as planning tool for fast IMRT application with a reduced number of segments. MATERIALS AND METHODS: 2-Step IMRT plans were compared with IMRT-solutions obtained with methods from a commercial planning system (Pinnacletrade mark TPS). The four clinical cases chosen were: paraspinal tumour, carcinoma of the prostate, head and neck carcinoma and breast carcinoma. In addition the "Quasimodo" phantom study was used to compare the quality of the 2-Step IMRT method with respect to other planning procedures in the ESTRO study. RESULTS: The number of segments (and - to a minor degree - the monitor units per dose) of the majority of 2-Step IMRT plans was lower than for the commercial algorithms. The quality of the 2-Step IMRT-plan was comparable. In the Quasimodo comparison 2-Step IMRT plans with nine beams would place in the mid-range of all participants, whereas the 15-beam arrangements could compete with the best results. CONCLUSIONS: 2-Step IMRT is a valuable IMRT segmentation method, especially if the number of segments is to be limited (e.g. for reasons of precision, speed and leakage radiation).

Abstract: PURPOSE: To evaluate the precision of image-guided radiotherapy (IGRT) using cone-beam computed tomography (CB-CT) for volume imaging and a robotic couch for correcting setup errors in six degrees of freedom. PATIENTS AND METHODS: 47 consecutive patients with 372 fractions were classified according to whether a patient fixation device was used (pat(fix): n = 28) or not (pat(non-fix): n = 19). Prior to treatment a CB-CT was acquired and translational and rotational setup errors were corrected online without an action level using a robotic couch (HexaPOD). A second CB-CT was acquired after the correction process and after treatment in 134 and 238 fractions, respectively. RESULTS: In 17 fractions (4.6%) rotational errors > 3 degrees exceeded the motion range of the HexaPOD. Errors (3D vector) after the correction process were significantly smaller for pat(fix) compared to pat(non-fix) (p < 0.001): 0.9 mm +/- 0.5 mm and 1.6 mm +/- 0.8 mm, respectively. For pat(non-fix) the correction of rotational errors resulted in displacements of the patients on the angled couch of 0.6 mm/1 degree. Intrafractional motion further decreased precision in pat(non-fix) but not in pat(fix). CONCLUSION: Very high precision in cranial and extracranial treatment of immobilized patients was demonstrated. Without application of adequate immobilization the correction of rotational errors and intrafractional patient motion significantly decreased the accuracy of the online correction protocol.

Abstract: INTRODUCTION: To evaluate the precision required in dose-escalated IMRT treatment of spinal metastases and paraspinal tumors. METHODS: In IMRT treatment plans of nine patients with spinal metastases (n=7) and paraspinal tumors (n=2) translational patient positioning errors (0-10mm) and rotational errors (0-7.5 degrees ) were simulated. The dose to the spinal cord (D5(spine)) resulting from these simulations was evaluated and NTCP for spinal cord necrosis was calculated. All patient set-up errors observed during treatment were simulated and the influence on D5(spine) was investigated. RESULTS: To keep the dose distribution to the spinal cord within +/-5% (+/-10%) of the prescribed dose, maximum tolerable errors of 1mm (2mm) in the transversal plane, 4mm (7mm) in superior-inferior direction and maximum rotations of 3.5 degrees (5 degrees ) were calculated on average. The translational and rotational component of clinically observed set-up errors increased D5(spine) by 23+/-14% and 3+/-2% on average, respectively. CONCLUSION: Steep dose gradients of IMRT planning require very high precision. In selected patients correction of both translational and rotational errors may be beneficial.

Abstract: Four different algorithms were investigated with the aim to determine their suitability to track an object in conventional megavoltage portal images. The algorithms considered were the mean of the sum of squared differences (MSSD), mutual information (MI), the correlation ratio (CR), and the correlation coefficient (CC). Simulation studies were carried out with various image series containing a rigid object of interest that was moved along a predefined trajectory. For each of the series the signal-to-noise ratio (SNR) was varied to compare the performance of the algorithms under noisy conditions. For a poor SNR of -6 dB the mean tracking error was 2.4, 6.5, 39.0, and 17.2 pixels for MSSD, CC, CR and MI, respectively, with a standard deviation of 1.9, 12.9, 19.5, and 7.5 pixels, respectively. The size of a pixel was 0.5 mm. These results improved to 1.1, 1.3, 1.3, and 2.0 pixels, respectively, with a standard deviation of 0.6, 0.8, 0.8, and 2.1 pixels, respectively, when a mean filter was applied to the images prior to tracking. The implementation of MSSD into existing in-house software demonstrated that, depending on the search range, it was possible to process between 2 and 15 images/s, making this approach capable of real-time applications. In conclusion, the best geometric tracking accuracy overall was obtained with MSSD, followed by CC, CR, and MI. The simplest and best algorithm, both in terms of geometric accuracy as well as computational cost, was the MSSD algorithm and was therefore the method of choice.

Abstract: BACKGROUND: The dose distribution to the rectum, delineated as solid organ, rectal wall and rectal surface, in 3D conformal (3D-CRT) and intensity-modulated radiotherapy treatment (IMRT) planning for localized prostate cancer was evaluated. MATERIALS AND METHODS: In a retrospective planning study 3-field, 4-field and IMRT treatment plans were analyzed for ten patients with localized prostate cancer. The dose to the rectum was evaluated based on dose-volume histograms of 1) the entire rectal volume (DVH) 2) manually delineated rectal wall (DWH) 3) rectal wall with 3 mm wall thickness (DWH3) 4) and the rectal surface (DSH). The influence of the rectal filling and of the seminal vesicles' anatomy on these dose parameters was investigated. A literature review of the dose-volume relationship for late rectal toxicity was conducted. RESULTS: In 3D-CRT (3-field and 4-field) the dose parameters differed most in the mid-dose region: the DWH showed significantly lower doses to the rectum (8.7% +/- 4.2%) compared to the DWH3 and the DSH. In IMRT the differences between dose parameters were larger in comparison with 3D-CRT. Differences were statistically significant between DVH and all other dose parameters and between DWH and DSH. Mean doses were increased by 23.6% +/- 8.7% in the DSH compared to the DVH in the mid-dose region. Furthermore, both the rectal filling and the anatomy of the seminal vesicles influenced the relationship between the dose parameters: a significant correlation of the difference between DVH and DWH and the rectal volume was seen in IMRT treatment. DISCUSSION: The method of delineating the rectum significantly influenced the dose representation in the dose-volume histogram. This effect was pronounced in IMRT treatment planning compared to 3D-CRT. For integration of dose-volume parameters from the literature into clinical practice these results have to be considered.

Abstract: PURPOSE: To establish volume imaging using an on-board cone-beam CT (CB-CT) scanner for evaluation of three-dimensional patient setup errors. METHODS AND MATERIALS: The data from 24 patients were included in this study, and the setup errors using 209 CB-CT studies and 148 electronic portal images were analyzed and compared. The effect of rotational errors alone, translational errors alone, and combined rotational and translational errors on target coverage and sparing of organs at risk was investigated. RESULTS: Translational setup errors using the CB-CT scanner and an electronic portal imaging device differed <1 mm in 70.7% and <2 mm in 93.2% of the measurements. Rotational errors >2 degrees were recorded in 3.7% of pelvic tumors, 26.4% of thoracic tumors, and 12.4% of head-and-neck tumors; the corresponding maximal rotational errors were 5 degrees , 8 degrees , and 6 degrees . No correlation between the magnitude of translational and rotational setup errors was observed. For patients with elongated target volumes and sharp dose gradients to adjacent organs at risk, both translational and rotational errors resulted in considerably decreased target coverage and highly increased doses to the organs at risk compared with the initial treatment plan. CONCLUSIONS: The CB-CT scanner has been successfully established for the evaluation of patient setup errors, and its feasibility in day-to-day clinical practice has been demonstrated. Our results have indicated that rotational errors are of clinical significance for selected patients receiving high-precision radiotherapy.

Abstract: PURPOSE: To evaluate the delineation of either the rectal volume (RV) or the rectal wall (RW) in intensity-modulated radiotherapy (IMRT) for prostate cancer: influence on dose distribution to the targets and organs at risk (OARs) was investigated. MATERIAL AND METHODS: For ten patients with localized prostate cancer IMRT treatment plans were generated with the RV, wall including the filling, and the RW without the lumen as OAR (plan-RV and plan-RW), respectively. Two different IMRT treatment- planning systems (TPS) were utilized. The influence on target coverage and sparing of OARs was investigated. RESULTS: No influence was seen on target coverage and sparing of the bladder and femoral heads. Doses to the RV were significantly reduced in plan-RV for all evaluated dose levels: maximum 26% and 17%, respectively, in both TPS. The dose distribution to the RW was not significantly different between plan-RV and plan-RW. CONCLUSION: The different delineation of the OAR rectum significantly affected the inverse IMRT treatment-planning process. The use of the RV as OAR resulted in improved dose distributions to the RV. Therefore, it is suggested using the RV as OAR in IMRT treatment planning of the prostate.

Abstract: The aim of this research was to investigate whether a spatial correlation could be found between an external 3-D respiratory signal and the tumour trajectory. The respiratory signal was obtained by tracking the abdominal movement and the tumour trajectory was obtained by automatically determining the tumour position in a series of portal images. Three different models, based on Systems Identification, are presented to model the correlation using a 1-D respiratory signal, a 3-D respiratory signal and a 3-D respiratory signal together with previously determined tumour positions. Adequate correlation was found for all models in the direction of the tumour movement with standard deviations of 0.89 mm, 0.72 mm and 0.75 mm, respectively, and model fit of Rt2 = 0.19, 0.63 and 0.82, respectively. Increasing the frame rate for the acquisition of portal images from 3 to 15 frames per second improved the standard deviation and model fit. In summary, it is possible to spatially correlate a 3-D respiratory signal with the tumour trajectory using this approach. The models presented provide a framework that can be extended to include more information if required. A 3-D respiratory signal is preferable to a 1-D signal in modelling the tumour motion that is not along the main axis of tumour movement.

Abstract: Cone-beam CT (CB-CT) based image-guidance was evaluated for extracranial stereotactic radiotherapy of intrapulmonary tumors. A total of 21 patients (25 lesions: prim. NSCLC n = 6; pulmonary metastases n = 19) were treated with stereotactic radiotherapy (1 to 8 fractions). Prior to every fraction a CB-CT was acquired in treatment position, errors between planned and actual tumor position were measured and corrected. Intra- and inter-observer variability of manual evaluation of tumor position error was investigated and this manual method was compared with automatic image registration. Based on CB-CTs from 66 fractions the discrepancy (3-D vector) between planned and actual tumor position was 7.7 mm +/-1.3 mm. Tumor position error relative to the bony anatomy was 5.3 mm +/-1.2 mm, the correlation between bony anatomy and tumor position was poor. Intra-observer and inter-observer variability of manual evaluation of tumor position error was 0.9 mm +/-0.8 mm and 2.3 mm +/-1.1 mm, respectively. Automatic image registration showed highly reproducible results (<1 mm). However, compared with manual registration a systematic error was found in direction of predominant tumor breathing motion (2.5 mm vs 1.4 mm). Image-guidance using CB-CT was validated for high precision radiotherapy of intrapulmonary tumors. It was shown that both the planning reference and the verification image study have to consider tumor breathing motion.

Abstract: BACKGROUND AND PURPOSE: The retrospective planning study for intensity-modulated radiotherapy (IMRT) of prostate cancer evaluated whether proximal rectum and supra-anal rectum/anal canal should be delineated as separated organs-at-risk (OARs) to achieve optimal dose distributions to the anorectal region. PATIENTS AND METHODS: For 10 patients with localized prostate cancer IMRT plans were generated with the rectum and anal canal as separated OARs (Rec-sep) and as one single OAR (Rec-tot). Two different treatment planning systems (TPS) were utilized. Influence on dose distributions to target and OARs was analyzed. RESULTS: Results from both TPS showed significantly increased doses to the distal rectum/anal canal for plans Rec-tot compared with Rec-sep in case of a distended rectum in the planning CT study: doses were increased by up to mean 31% (P = 0.02) and 18% (P = 0.03), respectively, in both TPS. For the patient with the largest rectum, the maximum dose increase was 61%. No significant differences in doses to target, bladder, femoral head and proximal rectum were seen. CONCLUSIONS: For patients with a distended rectum in the planning CT, delineation of separated OARs for proximal rectum and distal rectum/anal canal resulted in superior dose distributions to the anorectal region and therefore, we recommend this as standard procedure for IMRT planning of prostate cancer.

Abstract: The present paper describes the fast acquisition and processing of portal images directly from a TV camera-based portal imaging device (Siemens Beamview Plus). This approach employs not only hard- and software included in the standard package installed by the manufacturer (in particular the frame grabber card and the Matrox Intellicam interpreter software), but also a software tool developed in-house for further processing and analysis of the images. The technical details are presented, including the source code for the Matrox interpreter script that enables the image capturing process. With this method it is possible to obtain raw images directly from the frame grabber card at an acquisition rate of 15 images per second. The original configuration by the manufacturer allows the acquisition of only a few images over the course of a treatment session. The approach has a wide range of applications, such as quality assurance (QA) of the radiation beam, real-time imaging, real-time verification of intensity-modulated radiation therapy (IMRT) fields, and generation of movies of the radiation field (fluoroscopy mode).

Abstract: BACKGROUND: 2-deoxy-2[(18)F]fluoro-D-glucose-positron emission tomography (FDG-PET) imaging can be registered with CT images and can potentially improve neck staging sensitivity and specificity in patients with head and neck squamous cell cancer. The intent of this study was to examine the use of registered FDG-PET/CT imaging to guide head and neck intensity modulated radiotherapy (IMRT) planning. METHODS: Twenty patients with squamous cell carcinoma of the oral cavity, oropharynx, larynx, or hypopharynx underwent FDG-PET and contrast-enhanced CT imaging of the head and neck before neck dissection surgery. Combined FDG-PET/CT images were created by use of a nonrigid image registration algorithm. All IMRT plans were theoretical and were not used for treatment. We prescribed 66 Gy in 30 fractions to FDG-avid CT abnormalities and nodal zones directly involved with disease, without prophylactic coverage of uninvolved neck levels. Matched CT-guided IMRT plans designed according to the specifications of Radiation Therapy Oncology Group (RTOG) H-0022 were available for comparison. We investigated the feasibility of FDG-PET/CT-directed IMRT dose escalation in five patients with FDG-avid disease located away from critical normal structures. After 66 Gy, FDG-avid disease with 0.5-cm margins was boosted in 220 cGy increments until dose-limiting criteria were reached. RESULTS: Elimination of prophylactic coverage to FDG-PET/CT-negative neck levels markedly reduced mean dose (Dmean) to the contralateral parotid gland (p < .001) and Dmean to the laryngeal cartilage (p = .001). No FDG-PET/CT-directed plan missed pathologically verified nodal disease. During the dose escalation exercise, we successfully increased the dose to 95% of the planning target volume (PTV95%) to a mean of 7490 cGy (range, 7153-8098 cGy). CONCLUSIONS: We demonstrate early proof of the principle that FDG-PET/CT-guided IMRT planning can selectively target and intensify treatment of head and neck disease while reducing critical normal tissue doses. Routine clinical use of such planning should not be engaged until the accuracy of FDG-PET/CT is fully validated. Future directions, including refinement of treatment to gross disease and radiologically uninvolved neck nodal levels, are discussed.

Abstract: PURPOSE: Image localization of head-and-neck squamous cell carcinoma lags behind current techniques to deliver a precise radiation dose with intensity-modulated radiotherapy. This pilot study prospectively examined the use of registered 18-F-fluorodeoxyglucose (FDG)-positron emission tomography (PET)/CT for preradiotherapy staging of the neck. METHODS AND MATERIALS: Sixty-three patients with squamous cell carcinoma of the oral cavity, oropharynx, larynx, or hypopharynx were enrolled into an institutional FDG-PET imaging protocol between September 2000 and June 2003. Of these patients, 20 went on to immediate neck dissection surgery and were studied further. Of these 20, 17 (85%) had American Joint Committee on Cancer Stage III or IV disease. All patients underwent preoperative FDG-PET and contrast-enhanced CT of the head and neck. FDG-PET/CT images were created using a nonrigid image registration algorithm developed at the University of Washington. Alternate primary and nodal gross tumor volumes were contoured with radiotherapy treatment planning software, blinded to each other and to the pathology results. One set of volumes was designed with CT guidance alone and the other with the corresponding FDG-PET/CT images. Neck dissection specimens were subdivided into surgical nodal levels intraoperatively, and the histopathologic findings were correlated with the CT and FDG-PET/CT nodal level findings. RESULTS: FDG-PET/CT detected 17 of 17 heminecks and 26 of 27 nodal zones histologically positive by dissection (100% and 96% sensitivity, respectively). The nodal level staging sensitivity and specificity for FDG-PET/CT was 96% (26 of 27) and 98.5% (68 of 69), respectively. FDG-PET/CT correctly detected nodal disease in 2 patients considered to have node-negative disease by CT alone. Agreement between the imaging results and pathology findings was stronger for FDG-PET/CT (kappa 0.95, 95% confidence interval 0.82-0.99) than for CT alone (kappa 0.81, 95% confidence interval 0.63-0.91; p = 0.06 by two-sided McNemar's testing). CONCLUSION: These early findings suggest that FDG-PET/CT is superior to CT alone for geographic localization of diseased neck node levels. Confirmatory trials to substantiate the accuracy of FDG-PET/CT neck staging should be prioritized.

Abstract: An algorithm is described, based on ray-tracing and the beam's-eye-view, that exhaustively searches all permitted beam directions. The evaluation of the search is based on a general cost function that can be adapted to the clinical objectives by means of parameters and weighting factors. The approach takes into account the constraints of the linear accelerator by discarding beam directions that are not permitted. A sensitivity analysis was carried out to determine appropriate parameters for different sized organs, and a prostate case was used to benchmark the approach. The algorithm was also applied to two clinical cases (brain and sinus) to test the benefits of the approach compared with manual angle selection. The time to perform a beam direction search was approximately 2 min for the coplanar and 12 min for the non-coplanar beam space. The angles obtained for the prostate case compared well with reports in the literature. For the brain case, the mean dose to the right and left optic nerves was reduced by 12% and 50%, respectively, whilst the target dose uniformity was improved. For the sinus case, the mean doses to the right and left parotid glands were reduced by 54% and 46%, respectively, to the right and left optic nerves by 37% and 62%, respectively, and to the optic chiasm by 39%, whilst the target dose uniformity was also improved. For the clinical cases the plans based on optimized beam directions were simpler and resulted in better sparing of critical structures compared with plans based on manual angle selection. The approach provides a practical alternative to elaborate and time consuming beam angle optimization schemes and is suitable for routine clinical usage.

Abstract: The purpose is to incorporate clinically relevant factors such as patient-specific and dosimetric information as well as data from clinical trials in the decision-making process for the selection of prostate intensity-modulated radiation therapy (IMRT) plans. The approach is to incorporate the decision theoretic concept of an influence diagram into the solution of the multiobjective optimization inverse planning problem. A set of candidate IMRT plans was obtained by varying the importance factors for the planning target volume (PTV) and the organ-at-risk (OAR) in combination with simulated annealing to explore a large part of the solution space. The Pareto set for the PTV and OAR was analysed to demonstrate how the selection of the weighting factors influenced which part of the solution space was explored. An influence diagram based on a Bayesian network with 18 nodes was designed to model the decision process for plan selection. The model possessed nodes for clinical laboratory results, tumour grading, staging information, patient-specific information, dosimetric information, complications and survival statistics from clinical studies. A utility node was utilized for the decision-making process. The influence diagram successfully ranked the plans based on the available information. Sensitivity analyses were used to judge the reasonableness of the diagram and the results. In conclusion, influence diagrams lend themselves well to modelling the decision processes for IMRT plan selection. They provide an excellent means to incorporate the probabilistic nature of data and beliefs into one model. They also provide a means for introducing evidence-based medicine, in the form of results of clinical trials, into the decision-making process.

Abstract: A spatial modelling technique is presented to model inversely the attenuation behaviour of poly-energetic high-energy photon beams within a metal compensator for intensity-modulated radiotherapy. The algorithm aims to predict modulators (compensators), which produce an intended intensity-modulated beam after the beam has passed through the metal. The proposed method considers two spatial dimensions and is based on a least-squares approach. The nonlinear system is modelled by means of an initial 2-D spatial model, which is linear in the parameters, and which takes into account primary and scattered radiation. This model is then refined and simplified resulting in a rotational-symmetrical 2-D spatial representation, which reduces the calculation time and makes the model more generally applicable. Compared with other techniques, it is not necessary to know the linear absorption coefficient of the compensator material.

Abstract: The thesis deals with the practical implementation of intensity modulated radiation therapy (IMRT) generated by means of patient specific metal compensators. An elaborate comparison between several compensator-machining techniques, with respect to their suitability for production within a hospital workshop, is presented. The limitations associated with the selected compensator manufacturing technique are identified and implemented as constraints in an existing inverse treatment-planning algorithm. In order to obtain the profile of a compensator, which produces a desired intensity distribution, inverse modeling of the radiation attenuation within the compensator is required. Two novel and independent approaches, based on deconvolution and system identification, are proposed to accomplish this. To compare the approach with the "rival" state of the art beam modulation technique, a theoretical and experimental examination of the modulated fields generated by manufactured compensators and multileaf collimators is presented. This comparison focused on the achievable resolution of the intensity modulated beams in lateral and longitudinal directions. To take into account the characteristics of a clinical environment the suitability of the most common commercially available treatment couch systems for IMRT treatments is studied. An original rule based advisory system is developed to alert the operator of any potential collision of the beam with the movable supporting structures of the treatment couch. The system is capable of finding alternative positions for the supporting frames and, if necessary, can suggest alternative beam directions. Finally, a head and neck phantom is designed for gel dosimetry to assess IMRT treatment delivery techniques. The phantom is based on a simplistic but realistic design and contains the main anatomical features. ©2002 American Association of Physicists in Medicine.

Abstract: PURPOSE: Three treatment couches, henceforth referred to as the standard, the variable standard and the C-arm couch, each based on a different supporting frame system, were investigated for their suitability for the delivery of a high number of coplanar beams (> or =5) as may be required for intensity-modulated radiation therapy treatments. MATERIALS AND METHODS: A number of equispaced beam arrangements (five to nine) were examined in combination with two circular target sizes (Phi6 and Phi10 cm) at different locations within an elliptical body on the investigated couches, resulting in 70 different plans per couch. A rule based advisory system determined possible intersections of the beam paths with the supporting frames of the respective treatment couch and suggested a suitable constellation for the supporting frames. In cases of intersection, a beam-couch collision was eliminated by minimal rotation of the beams from the initial equispaced beam arrangement. To investigate the effect of a rotation of the posterior-oblique beams for five, seven and nine initially equispaced beams by an angle of 10 degrees, a prostate plan was generated and compared with equispaced beam arrangement. RESULTS: Initial beam paths intersected with the standard couch in 63% of the plans, necessitating a rotation of one or two beams. It was necessary to modify the beam angles in 34% of the cases on the variable standard couch to avoid an intersection of the beams with the couch. All the plans would have been delivered satisfactorily on the C-arm couch without a rotation of beams. Simulation studies showed that the dose distribution for a prostate treatment could be affected significantly, but not detrimentally, by the rotation of the two posterior-oblique beam orientations by an angle of 10 degrees.

Abstract: The resolution characteristics of intensity modulated beam (IMB) profiles produced by milled compensators and by multileaf collimators (MLCs) are independently investigated with respect to the primary fluence. It is shown that both methods have different characteristics in the longitudinal and lateral direction and, as a consequence, the resolutions of the longitudinal and lateral delivered IMB profiles differ. For both methods, the restrictions are identified. For compensators, the maximum slopes in the machining process, which should not be exceeded, are quantified. For MLCs, emphasis is given to the direction perpendicular to leaf movement. A number of test modulations were created and the effect of different size MLCs on the intensity profile revealed that unacceptable errors can be introduced if the profiles are heavily modulated. The production of intensity modulated radiation therapy (IMRT) beams by both machined compensators or by MLCs is limited by physical constraints. Having identified these constraints, some steps should now be taken to accommodate them either in the objective function for the calculation of the beam profiles or in the delivery system.

Abstract: The field uniformity of a superficial X-ray machine operating at 90 kV, 10 mA and filtered with a 1.1 mm aluminium beam hardening filter was investigated at a depth of 1 cm below the surface. Uniformity measurements were carried out using films and a densitometer to detect the relative absorbed dose across the field. Film dosimetry was assessed by comparison with ionization chamber dosimetry in a water tank. The original flat hardening aluminium filter was replaced by a combined, profiled filter to improve the uniformity across field sizes 20 cm, 5 cm and 2 cm diameter as well as hardening the beam. Flatness of the beam profile was improved for the 20 cm field size from +/-7.5% to +/-1.3% across the anode/cathode direction and from +/-7.9% to +/-4.7% in the anode/cathode direction. For the 5 cm field size the improvement was from +/-4% to +/-3% and from +/-5.3% to +/-3.6% and for 2 cm field size from +/-3.4% to +/-2.8% and from 10.5% to +/-9.7% in the same directions, respectively. Beam quality measurements were made and the original half-value-layer was reduced from 2.21 +/- 0.09 mm to 2.07 +/- 0.09 mm. The project demonstrated that it was possible to build a filter capable of flattening the beam profile for different sized applicators without significantly changing the penetrating ability of the beam.

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Abstract: Radiotherapy (RT) is an important weapon in the arsenal of treatment modalities to fight cancer. It has been applied for curative and palliative management of cancer for more than a century. Intensity-modulated radiation therapy (IMRT) is a specialised RT treatment technique, which is on the verge of being routinely implemented in clinical environments within the National Health Service. In contrast to the uniform beams used for traditional RT, the aim of IMRT is to modulate the intensity of a set of high-energy photon beams in such a way that the dose can be tailored to the shape of the designated region to be treated, whilst at the same time sparing surrounding healthy tissues and critical organs. Because of normal tissue avoidance and the ability to escalate dose, acute radiation toxicity in IMRT is reduced. This Thesis deals with the practical implementation of IMRT generated by means of patient specific metal compensators. Intensity modulation is achieved by placing a profiled compensator in the beam path in order to attenuate the beam differentially. A comprehensive comparison between several compensator-machining techniques, with respect to their suitability for production within a hospital workshop, is presented. The limitations associated with the selected compensator manufacturing techniques are identified and implemented as constraints in an existing inverse treatment-planning algorithm. In order to obtain the profile of a compensator, which produces a desired intensity distribution, inverse modelling of the radiation attenuation within the compensator is required. Two novel and independent approaches, based on deconvolution and system identification, respectively, are proposed to accomplish this. To compare the approach with the ‘rival’ state of the art beam modulation technique, a theoretical and experimental examination of the modulated fields generated by manufactured compensators and multileaf collimators is presented. This comparison focused on the achievable resolution of the intensity modulated beams in lateral and longitudinal directions. To take into account the characteristics of a clinical environment, a comprehensive study has been carried out to investigate the suitability of the most common commercially available treatment couch systems for their suitability for IMRT treatments. In this context, an original rule based advisory system has been developed to alert the operator of any potential collision of the beam with the moveable supporting structures of the treatment couch. The system is capable of finding alternative positions for the supporting frames and, if necessary, can suggest alternative beam directions. Finally, a head & neck phantom has been designed for gel dosimetry to assess IMRT treatment delivery techniques. The phantom is based on a simplistic but realistic design and contains the main anatomical features.