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Purpose: It is generally believed that “hot” spots should be avoided in radiotherapy because they lead to complications. Dose homogeneity within the target volume is much more difficult to achieve during brachytherapy than during external beam irradiation, and implants are rarely geometrically perfect. To not underdose some parts of the target volume, therefore, it may be necessary to accept hot spots in other parts of the target volumes, but it is not at all clear from the literature how much dose heterogeneity should be considered excessive. We undertook this study in an effort to determine just how high a dose to a hot spot is associated with clinically significant complications. Methods and Materials: We studied 40 patients treated by high-dose rate brachytherapy with or without external irradiation. For each patient, we calculated the minimum dose to the “hottest” 1 cubic centimeter (cc) volume (Dmax1) and, for 18 patients, the minimum dose to the hottest 10 cc volume (Dmax10) as well. Results: Considerable dose heterogeneity existed within the target volume. The Dmax1 ranged from 150–2000% (median 320%) of the minimum target dose (MTD). The median MTD/fraction was 2.50 Gy (range 1.50–25.00), and the median Dmax1/fraction was 10.00 Gy (range 3.75–150.00). The median Dmax1 from the entire course of brachytherapy was 75.00 Gy (range 25.00–550.00). Adding the doses from planned external irradiation, plus any prior irradiation to the same area, the median total Dmax1 was 112.50 Gy (range 30.00–580.00), yet the incidence of complications, even among those in the highest quartile of this dose range, was not greater than the lowest quartile. The total median Dmax10 was 85.00 Gy (range 32.00–130.00), but the incidence of complications was, again, similar whether the dose was in the lower or the upper half of this range (32.00–85.00 Gy, or 86.00–130.00 Gy, respectively). Conclusions: We had expected to find that the patients with the highest Dmax1 and/or Dmax10 would be the ones most likely to suffer complications, but the results did not support this hypothesis. Thus, dose heterogeneity, within the scope of our study, turned out to be rather unimportant with regard to complications. This finding contradicts the conventional wisdom and suggests that concerns about hot spots need not preclude optimization to ensure adequate dosage to all parts of the target volume.

Purpose: Microscopically positive or close margins after surgical resection results in an approximately 21-26% local failure rate despite excellent postoperative external radiation therapy. We sought to demonstrate improved local control in head and neck cancer patients who had a resection with curative intent, and had unexpected, microscopically positive or close surgical margins. Methods and Materials: Twenty-nine patients with microscopically close or positive margins after curative surgery were given definitive, adjuvant external radiation therapy and 125 I brachytherapy. All 29 patients had squamous cell cancer and tonsil was the most common subsite within the head and neck region. After external radiation therapy and thorough discussions with the attending surgeon and pathologists, the slides, gross specimens, and appropriate radiographs were reviewed and a target volume was determined. The target volume was the region of the margin in question and varied in size based on the surgery and pathologic results. Once the target volume was identified the patient was taken back to the operating room for insertion of 125 I seeds. Activity implanted (range 2.9-21.5 millicuries) was designed to administer a cumulative lifetime dose of 120-160 Gy. Results: Twenty-nine patients were followed for a median of 26 months (range 5-86 months). Two-year actuarial local control was 92%. Conclusion: 125 I, after external radiation therapy, is an excellent method to improve local control in the subset of patients with unexpectedly unsatisfactory margins.

Purpose : To analyze the effect that immobilization devices used in conjunction with beam modifiers may have on the dose to the skin and build-up region. Methods and Materials : Central axis depth dose measurements were made in a polystyrene phantom in the build-up regions using the 6 and 15 MV photon beams, at two different source-to-phantom distances, and various field sizes. The effects of acrylic blocking trays, lead wedges, and cerrobend blocks were assessed in conjunction with the enhancement of dose in the build-up region due to immobilizing devices using plaster and thermoplastic casting materials of different thicknesses. Results : For the 6 MV photons, solid (3 mm) thermoplastic casting material was found to have the greatest effect on surface dose: for a 12 × 12 cm field we measured 79% of maximum dose when treating through the material versus 22% of maximum dose when no beam modifiers or immobilization devices are used. Measurements were also made to evaluate the effect of the immobilization of patients receiving three-dimensional conformal treatments using a 15 MV photon beam. Conclusions : The relevance of these results to treatments in the pelvis, breast, and head and neck regions is discussed. For 6 MV beams, special consideration should be given if the need arises to treat through the immobilization device, as unacceptable skin reactions may result.

Purpose : The specific aim of 3-dimensional conformal radiation therapy is to improve the target dose distribution while concomitantly reducing normal tissue dose. Such an approach should permit dose escalation until the limits of acceptable normal tissue toxicity are reached. To evaluate the feasibility of tumor dose escalation for nine patients with lung cancer, we determined the dose distribution to the target and normal tissues with 3-dimensional conformal radiation therapy and conventional planning. Methods and Materials : Plans were compared to assess adequacy of dose delivery to target volumes, dose-volume histograms for normal tissue, and normal tissue complication probabilities (NTCP) for nine patients with lung tumors. Results : The mean percentage of gross disease which received ≤ 70.2 Gy with 3-dimensional conformal radiation therapy (31)CRT) was 40% of the mean percentage of gross disease which received ≤ 70.2 Gy with conventional treatment planning (CTP). The mean NTCP for lung parenchyma with 3DCRT was 36% of the mean NTCP with CTP. The mean esophageal NTCP with 3DCRT was 88% of the mean NTCP with CTP. Conclusion : This preliminary analysis suggests that three dimensional conformal radiation therapy may provide superior delivery of high dose radiation with reduced risk to normal tissue, suggesting that this approach may have the potential to improve the therapeutic ratio of high dose radiation therapy for lung cancer.

Purpose: Electron beam radiotherapy is frequently administered based on clinical setups without formal treatment planning. We felt, therefore, that it was important to monitor electron beam treatments by in vivo dosimetry to prevent errors in treatment delivery. In this study, we present our clinical experience with patient dose verification using electron diodes and quantitatively assess the dose perturbations caused by the diodes during electron beam radiotherapy. Methods and Materials: A commercial diode dosimeter was used for the in vivo dose measurements. During patient dosimetry, the patients were set up as usual by the therapists. Before treatment, a diode was placed on the patient's skin surface and secured with hypoallergenic tape. The patient was then treated and the diode response registered and stored in the patient radiotherapy system database via our in-house software. A customized patient in vivo dosimetry report showing patient details, expected and measured dose, and percent difference was then generated and printed for analysis and record keeping. We studied the perturbation of electron beams by diodes using film dosimetry. Beam profiles at the 90% prescription isodose depths were obtained with and without the diode on the beam central axis, for 6–20 MeV electron beams and applicator/insert sizes ranging from a 3-cm diameter circular field to a 25 × 25 cm open field. Results: In vivo dose measurements on 360 patients resulted in the following ranges of deviations from the expected dose at the various anatomic sites: Breast (222 patients) −20.3 to +23.5% (median deviation 0%); Head and Neck (63 patients) −21.5 to +14.8% (median −0.7%); Other sites (75 patients) −17.6 to +18.8% (median +0.5%). Routine diode dosimetry during the first treatment on 360 patients (460 treatment sites) resulted in 11.5% of the measurements outside our acceptable ±6% dose deviation window. Only 3.7% of the total measurements were outside ±10% dose deviation. Detailed investigations revealed that the dose discrepancies, overwhelmingly, were due to inaccurate diode orientation and positioning, especially in the regions with rapidly changing contours and/or sloping surfaces. The presence of a diode in the treatment field was found, in some cases, to cause significant dose reduction, most noticeable with smaller fields and lower energy beams. The reduction in dose ranged from 16% (for a 6 MeV beam and a 3 cm diameter circular field) to 4% (for a 12 MeV beam and a 10× 10 cm field). Conclusions: Diode dosimetry was found to be convenient and valuable for verifying in real time the dose delivery accuracy of electron beam treatments, but with some caveats. When treating a small field by low energy electrons, frequent use of diodes is undesirable, because it might result in appreciable reduction of dose to the target volume.

To compare different treatment techniques for unilateral treatment of parotid gland tumors.The CT-scans of a representative parotid patient were used. The field size was 9 x 11 cm, the separation was 15.5 cm, and the prescription depth was 4.5 cm. Using 3D dose distributions, tissue inhomogeneity corrections, scatter integration (for photons) and pencil beam (for electrons) algorithms and dose-volume histogram (DVH), nine treatment techniques were compared. [1] unilateral 6 MV photons [2] unilateral 12 MeV electrons [3] unilateral 16 MeV electrons [4] an ipsilateral wedge pair technique using 6 MV photons [5] a 3-field AP (wedged), PA (wedged) and lateral portal technique using 6 MV photons [6] a mixed beam technique using 6 MV photons and 12 MeV electrons (1:4 weighting) [7] a mixed beam technique using 6 MV photons and 16 MeV electrons (1:4 weighting) [8] a mixed beam technique using 18 MV photons and 20 MeV electrons (2:3 weighting) [9] a mixed beam technique using 18 MV photons and 20 MeV electrons (1:1 weighting).Using dose-volume histograms to evaluate the dose to the contralateral parotid gland, the percentage of contralateral parotid volume receivingor = 30% of the prescribed dose was 100% for techniques [1], [8] and [9], and5% for techniques [2] through [7]. Evaluating the "hottest" 5 cc of the ipsilateral mandible and temporal lobes, the hot spots were: 152% and 150% for technique [2], 132% and 130% for technique [6]. Comparing the exit doses, techniques [1], [8] and [9] contributed toor = 50% of the prescribed dose to the contralateral mandible and the temporal lobes. Only techniques [2] and [6] kept the highest point doses to both the brain stem and the spinal cord below 50% of the prescribed dose.The single photon lateral field [1] and the mixed electron-photon beams [8] and [9] are not recommended treatment techniques for unilateral parotid irradiation because of high doses delivered to the contralateral parotid gland and high exit doses which are associated with Xerostomia. The en face electron beam technique [2] and the mixed electron-photon beam technique [6] are unacceptable due to the excessive dose heterogeneity to the contiguous normal structures. In spite of optimal dose fall-off achieved using the en face technique [3], most patients cannot tolerate the resulting high skin doses. We conclude that the ipsilateral wedge pair [4], the 3-field [5], and the mixed electron-photon beam [7] techniques are optimal techniques in providing relatively homogeneous dose distributions within the target area and for minimizing dose to the relevant normal structures.

Purpose : To study the attenuation and scattering effects of ocular implants, made from different materials, on the dose distributions of a 6 MV photon beam, and 6, 9, and 12 MeV electron beams used in orbital radiotherapy. Methods and Materials : Central axis depth-dose measurements were performed in a polystyrene phantom with embedded spherical ocular implants using film dosimetry of a 6 MV photon beam and electron beams of 6, 9, and 12 MeV energy. The isodose distributions were also calculated by a computerized treatment planning system using computerized tomography (CT) scans of a polystyrene phantom that had silicone, acrylic, and hydroxyapatite ocular implants placed into it. Results : Electron beam dose distributions display distortions both on the measured and calculated data. This effect is most accentuated for the hydroxyapatite implants, for which the transmissions through ocular implants are on the order of 93% for the 6 MV photon beam, and range from 60% for 6 MeV electrons to 90% for 12 MeV electrons. Conclusion : We studied the effect of ocular implants of various materials, embedded in a polystyrene phantom, on the dose distributions of a 6 MV photon beam, and 6, 9, and 12 MeV electron beams. Our investigations show that while 6 MV photons experience only a few percent attenuation, lower energy electron beam with 60% transmission is not a suitable choice of treating tumors behind the ocular implants.

It is difficult to make an accurate calculation of dose distribution incorporating blocks using a ray model. One approach is to simulate the blocking in a treatment planning distribution by using negatively weighted beams. A second is to employ an external contour. The parameters of the negative beam or contour can be adjusted using empirical dosimetric data. This paper discusses the calculation of the dose distributions using negatively weighted beams and external contours, compares them with measurements in and around blocked areas for a range of field sizes, block sizes, and depths of interest in treatment planning applications, for 60Co, 6 MV, and 10 MV beams, and assesses their applicability.