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The helical tomotherapy is a technologically advanced radiation dose delivery system designed to perform intensity-modulated radiation therapy (IMRT). It is mechanistically unique, based on a small 6-MV linear accelerator mounted on a ring gantry that rotates around the patient while the patient moves through a bore, ultimately yielding a helical path of radiation dose delivery. The helical pattern of dose delivery differentiated tomotherapy from other contemporary radiation therapy systems at the time of its inception. The accompanying 3-dimensional (3D) treatment planning system has been developed to solely support this specific type of dose delivery system. The treatment planning system has 2 modules identified as TomoHelical and TomoDirect to perform IMRT and conformal radiation therapy, respectively. The focus of this work within the scope of this special issue on 3D treatment planning systems is to assess the use of planning tools to generate treatment plans for helical tomotherapy. Clinical examples are used throughout to demonstrate the quality and differences of various clinical scenarios planned with tomotherapy.

This article gives a tutorial on basic therapeutic medical physics. Medical health physics dealing with the issue of radiation protection for personnel and the public in the radiation environment is explained first. Next, we introduce the concept of absorbed dose related to energy deposition in tissues and then dosimetry instrumentation. Three-dimensional treatment planning systems that are now an integral component of modern radiation therapy are described. External beam radiation therapy, particle beam radiation therapy, and brachytherapy are briefly described. The change in quality assurance for contemporary radiation therapy program is highlighted.

Eclipse is a 3-dimensional (3D) treatment planning system for radiation therapy offered by Varian Medical Systems, Inc. The system has the network connectivity for the electronic transfer of image datasets and digital data communication among different equipment. The scope of this project for this special issue of Medical Dosimetry on 3D treatment planning systems is the assessment of planning tools in the external beam planning module of Eclipse to generate optimized treatment plans for patients undergoing external beam radiation therapy. This treatment planning system is relatively mature to be able to generate (1) simple treatment plans, (2) conformal radiation therapy plans, (3) static intensity-modulated radiation therapy (IMRT) plans, (4) volumetric-modulated arc therapy (VMAT) plans, and (5) treatment plans for electron beam therapy. The treatment planning tools are relatively plentiful to assist in the radiation therapy treatment planning. Some new features have been incorporated in the latest version and are helpful for making high-quality treatment plans. However, the location of the tools is not intuitive, and hence, familiarity with the user interface is essential to the efficient use of the treatment planning system. In addition, there are a number of dose algorithms available for the computation of dose distributions. The understanding of each dose computation algorithm is essential for the optimal use of this treatment planning system.

CyberKnife is an image-guided stereotactical dose delivery system designed for both focal irradiation and radiation therapy (SRT). Focal irradiation refers the use of many small beams to deliver highly focus dose to a small target region in a few fractions. The system consists of a 6-MV linac mounted to a robotic arm, coupled with a digital x-ray imaging system. The radiation dose is delivered using many beams oriented at a number of defined or nodal positions around the patients. The CyberKnife can be used for both intracranial and extracranial treaments unlike the Gamma Knife which is limited to intracranial cases. Multiplan (Accuray Inc., Sunnyvale, CA) is the treatment planning system developed to cooperate with this accurate and versatile SRS and SRT system, and exploit the full function of Cyberknife in high-precision radiosurgery and therapy. Optimized inverse treatment plan can be achieved by fine-tuning contours and planning parameters. Precision is the newest version of Cyberknife treatment planning system (TPS) and an upgrade to Multiplan. It offers several new features such as Monte Carlo for multileaf collimator (MLC) and retreatment for other modalities that added more support for the Cyberknife system. The Cybeknife TPS is an easy-to-use and versatile inverse planning platform, suitable for stereotactic radiosurgery and radiation therapy. The knowledge and experience of the planner in this TPS is essential to improve the quality of patient care.

Dose or treatment planning management is necessary for the re-irradiation of intracranial relapses after focal irradiation, radiosurgery, or stereotactic radiotherapy. The current clinical guidelines for metastatic brain tumors are the use of focal irradiation if the patient presents with 4 lesions or less. Salvage treatments with the use of whole brain radiation therapy (WBRT) can then be used to limit disease progression if there is an intracranial relapse. However, salvage WBRT poses a number of challenges in dose planning to limit disease progression and preserve neurocognitive function. This work presents the dose planning management that addresses a method of delineating previously treated volumes, dose level matching, and the dose delivery techniques for WBRT.

Studies of organs in the thorax and abdomen have shown that these organs can move as much as 40 mm due to respiratory motion. Without compensation for this motion during the course of external beam radiation therapy, the dose coverage to target may be compromised. On the other hand, if compensation of this motion is by expansion of the margin around the target, a significant volume of normal tissue may be unnecessarily irradiated. In hypofractionated regimens, the issue of respiratory compensation becomes an important factor and is critical in single-fraction extracranial radiosurgery applications. CyberKnife is an image-guided radiosurgery system that consists of a 6-MV LINAC mounted to a robotic arm coupled through a control loop to a digital diagnostic x-ray imaging system. The robotic arm can point the beam anywhere in space with 6 degrees of freedom, without being constrained to a conventional isocenter. The CyberKnife has been recently upgraded with a real-time respiratory tracking and compensation system called Synchrony. Using external markers in conjunction with diagnostic x-ray images, Synchrony helps guide the robotic arm to move the radiation beam in real time such that the beam always remains aligned with the target. With the aid of Synchrony, the tumor motion can be tracked in three-dimensional space, and the motion-induced dosimetric change to target can be minimized with a limited margin. The working principles, advantages, limitations, and our clinical experience with this new technology will be discussed.

A medical linear accelerator equipped with optical position tracking, ultrasound imaging, portal imaging, and radiographic imaging systems was installed at University of Pittsburgh Cancer Institute for the purpose of performing image-guided radiation therapy (IGRT) and image-guided radiosurgery (IGRS) in October 2005. We report the performance characteristics and quality assurance aspects of the kilovoltage cone-beam computed tomography (kV-CBCT) technique. This radiographic imaging system consists of a kilovoltage source and a large-area flat panel amorphous silicon detector mounted on the gantry of the medical linear accelerator via controlled arms. The performance characteristics and quality assurance aspects of this kV-CBCT technique involves alignment of the kilovoltage imaging system to the isocenter of the medical linear accelerator and assessment of (a) image contrast, (b) spatial accuracy of the images, (c) image uniformity, and (d) computed tomography (CT)-to-electron density conversion relationship were investigated. Using the image-guided tools, the alignment of the radiographic imaging system was assessed to be within a millimeter. The low-contrast resolution was found to be a 6-mm diameter hole at 1% contrast level and high-contrast resolution at 9 line pairs per centimeter. The spatial accuracy (50 mm +/- 1%), slice thickness (2.5 mm and 5.0 mm +/- 5%), and image uniformity (+/- 20 HU) were found to be within the manufacturer's specifications. The CT-to-electron density relationship was also determined. By using well-designed procedures and phantom, the number of parameter checks for quality assurance of the IGRT system can be carried out in a relatively short time.

Therapeutic radiological physics is the branch of physics as applied to radiation therapy. Therapeutic radiological physics involves the understanding of the radiation sources, types, and characteristics of radiation, interaction of radiation with matter, and thereafter the deposition of energy in matter. In clinical practice, therapeutic radiological physics deals with the technical tasks of preparing a patient to undergo radiation therapy. These tasks include simulation, patient data acquisition, individualized planning, verification, and dose delivery. The role of a therapeutic radiological physicist is to manage the technical aspects of patient care: providing technical expertise to the development of the institution, recommending and introducing new treatment techniques, and ensuring that all patients undergoing radiation therapy receive the best standard of care.

Dosimetry verification is an important step during intensity modulated radiotherapy treatment (IMRT). The verification is usually conducted with measurements and independent dose calculations. However, currently available independent dose calculation methods were developed for step-and-shoot beam delivery methods, and their uses for dynamic multi-leaf collimator (MLC) delivery methods are not efficient. In this study, a dose calculation method was developed to perform independent dose verifications for a dynamic MLC-based IMRT technique for Varian linear accelerators. This method extracts the machine delivery parameters from the dynamic MLC (DMLC) files generated by the IMRT treatment planning system. Based on the parameters a monitor unit (MU) matrix was separately calculated as two terms: direct exposure from the open MLC field and leakage contributions, where the leaf-end leakage contribution becomes more important in higher dose gradient regions. The MU matrix was used to compute the primary dose and the scattered dose with a modified Clarkson technique. The doses computed using the method were compared with both measurement and treatment planning for 14 and 25 plans respectively. An average of less than 2% agreement was observed and the standard deviation was about 1.9%.

The implementation of tissue inhomogeneity correction in image-based treatment planning will improve the accuracy of radiation dose calculations for patients undergoing external-beam radiotherapy. Before the tissue inhomogeneity correction can be applied, the relationship between the computed tomography (CT) value and density must be established. This tissue characterization relationship allows the conversion of CT value in each voxel of the CT images into density for use in the dose calculations. This paper describes the proper procedure of establishing the CT value to density conversion relationship. A tissue characterization phantom with 17 inserts made of different materials was scanned using a GE Lightspeed Plus CT scanner (120 kVp). These images were then downloaded into the Eclipse and Pinnacle treatment planning systems. At the treatment planning workstation, the axial images were retrieved to determine the CT value of the inserts. A region of interest was drawn on the central portion of the insert and the mean CT value and its standard deviation were determined. The mean CT value was plotted against the density of the tissue inserts and fitted with bilinear equations. A new set of CT values vs. densities was generated from the bilinear equations and then entered into the treatment planning systems. The need to obtain CT values through the treatment planning system is very clear. The 2 treatment planning systems use different CT value ranges, one from −1024 to 3071 and the other from 0 to 4096. If the range is correct, it would result in inappropriate use of the conversion curve. In addition to the difference in the range of CT values, one treatment planning system uses physical density, while the other uses relative electron density.

An independent dose calculation method has been developed to validate intensity-modulated radiation therapy (IMRT) plans from the NOMOS PEACOCK System. After the plan is generated on the CORVUS planning system, the beam parameters are imported into an independent workstation. The beam parameters consist of intensity maps at each gantry angle and each arc position. In addition, CT scans of the patient are imported into the independent workstation to obtain the external contour of the patient. The coordinate system is defined relative to the alignment point chosen in the CORVUS plan. The independent calculation uses the pencil beam data viz tissue maximum ratio (TMR) and beam profiles for a single 1 x 0.8-cm beamlet formed by the NOMOS multileaf intensity-modulating collimator (MIMiC) leaf. The pencil beam data were measured for the 6-MV photon beam from Siemens PRIMUS linear accelerator using film dosimetry. The dose at a point is calculated using the depth and off-axis distance from a given pencil beam, corrected for its beam intensity. Isodose distributions are generated using the independent dose calculations and compared to the CORVUS plans. Isodose distributions show good agreement with the CORVUS plans for a number of clinical cases. The independent dose calculation algorithm is described in this paper.

Three-dimensional conformal radiation therapy (3DCRT) and intensity-modulated radiation therapy (IMRT) plans show radiation dose distribution that is highly conformal to the target volume. The successful clinical implementation of these radiotherapy modalities requires precise positioning of the target to avoid a geographical miss. Effective reduction in target positional inaccuracies can be achieved with the proper use of immobilization devices. This paper reviews some of the immobilization devices that have been used and/or have the potential of being used for IMRT. The immobilization devices being reviewed include stereotactic frame, Talon system, thermoplastic molds, Alpha Cradles, and Vac-Lok system. The implementation of these devices at various anatomical sites is discussed.

The Peacock System was introduced to perform tomographic intensity-modulated radiation therapy (IMRT). Commissioning of the Peacock System included the alignment of the multileaf intensity-modulating collimator (MIMiC) to the beam axis, the alignment of the RTA device for immobilization, and checking the integrity of the CRANE for indexing the treatment couch. In addition, the secondary jaw settings, couch step size, and transmission through the leaves were determined. The dosimetric data required for the CORVUS planning system were divided into linear accelerator-specific and MIMiC-specific. The linear accelerator-specific dosimetric data were relative output in air, relative output in phantom, percent depth dose for a range of field sizes, and diagonal dose profiles for a large field size. The MIMiC-specific dosimetric data were the in-plane and cross-plane dose profiles of a small and a large field size to derive the penumbra fit. For each treatment unit, the Beam Utility software requires the data be entered into the CORVUS planning system in modular forms. These modules were treatment unit information, angle definition, configuration, gantry and couch angles range, dosimetry, results, and verification plans. After the appropriate machine data were entered, CORVUS created a dose model. The dose model was used to create known simple dose distribution for evaluation using the verification tools of the CORVUS. The planned doses for phantoms were confirmed using an ion chamber for point dose measurement and film for relative dose measurement. The planning system calibration factor was initially set at 1.0 and will be changed after data on clinical cases are acquired. The treatment unit was released for clinical use after the approval icon was checked in the verification plans module.

To quantify the difference between the area of brain irradiated using the posterior fossa boost (PFB) and tumor bed boost (TBB) in medulloblastoma, we studied 15 simulation radiographs of patients treated in our institution from 1990 and 1999. The PFB was compared with the TBB, which was defined as the tumor bed plus 2-cm margin as demonstrated by postoperative magnetic resonance imaging. The PFB field treated a mean area of 9.43 cm2 more brain than the TBB. In 3 patients (20%), the area of the brain in the TBB was larger than the PFB. In 11 patients (73.3%), the PFB field had more than 10% more brain than the TBB. The cochlea was in the PFB and TBB field in all patients. In more than two thirds of patients, the area of brain irradiated with the PFB was at least 10% greater than the TBB. Future studies are needed to determine whether the TBB can replace the PFB in patients with medulloblastoma.

Purpose: The objective of this study was to reevaluate the dose nonuniformity of abutted fields defined using asymmetric collimators and one isocenter for treatment of the head and neck region. Methods and Materials: Bilateral parallel-opposed fields abutted to the anterior field at one isocenter were implemented in the treatment of head and neck. The effect of digital display tolerance can produce dose nonuniformity at the junction of the abutted fields. The amount of dose nonuniformity was quantified using both mathematical summation of dose profiles and by direct measurement of doses at the junction of the two abutted fields. The dose nonuniformity was obtained by irradiating the superior part of a film using bilateral parallel-opposed fields and the inferior part by an anterior field with a gap or an overlap. Dose profiles were taken at the depth of maximum dose for the anterior field across the abutted fields. The dose nonuniformity was determined for the case where the asymmetric jaw was set at −2 mm, −1 mm, 0, +1 mm, and +2 mm from the beam central axis. Results: The dose at the junction increases systematically as the abutment of the fields changes from a gap to an overlap. The dose nonuniformity with 1-mm gap and 1-mm overlap is about 15% underdose and overdose, respectively. Conclusion: Imperfect abutment of split fields due to digital display tolerance (±1 mm) of asymmetric collimator can cause an underdose or overdose of 15% of the delivered dose.

Mathematical expressions used to calculate doses in a patient, based on data measured in a phantom, have to be simple, understandable, and reliable to minimize possible calculational error. In light of this concern, this paper reviews the dosimetric functions used in meterset calculations to determine the treatment times or monitor units for a prescribed dose. The dosimetric functions are the percent depth dose, the tissue-air ratio, the tissue-phantom ratio, and the inverse square law. This review examined the definition of the dosimetric functions, the inter-relationships among the dosimetric functions, and the mathematical expressions used in meterset calculations for nonstandard source-to-surface distances in a phantom.

Purpose: An independent technique for verfying high-dose rate (HDR) brachytherpy treatment plans has been formulated and validated clinically. Methods and Materials: In HDR brachytherapy, dwell times at respective dwell positions are computed, using an optimization algorithm in a HDR treatment-planning systems to deliver a specified dose to many target points simultaneously. Because of the variability of dwell times, concerns have been expressed regarding the ability of the algorithm to compute the correct dose. To address this concern, a commercially available low-dose rate (LDR) algorithm was used to compute the doses at defined distances, based on the dwell times obtained from the HDR treatment plans. The percent deviation between doses computed using the HDR and LDR algorithms were reviewed for HDR procedures performed over the last year. Results: In this retrospective study, the differene between computed doses using the HDR and LDR algorithms was found to be within 5% for about 80% of the HDR procedures. All of the reviewed procedures have dose difference of less than 10%. Conclusion: An independent technique for verifying HDR brachytherapy treatment plans has been validated based on clinical data. Provided both systems are available, this technique is universal in its applications and not limited to either a particular implant applicator, implant site, or implant type.

Purpose : Evaluating the validity of the universal wedge equation over the range of 60Cobalt (60CO) to 25 MV photon beam energies. Methods and Materials : The universal wedge equation relates the beam weight of the wedged field to the effective wedge angle produced by combining the wedged field to the nonwedged field and is expressed as tan (θ) = B tan (θw), where B is the normalized weight imposed on the wedged field, θw is the maximum wedge angle of the wedge filter, and θ is the effective wedge angle. The isodose distributions from 60Co to 25 MV photon beam energies were used. For each photon energy, the isodose distributions of wedged and nonwedged fields were combined in different proportions. The effective wedge angle was determined from each resultant isodose distribution. Results : The relationship between the weight of wedged field and the effective wedge angle was found to be nonlinear for wedge filters with maximum wedge angle greater than 30°. The universal wedge equation predicts the effective wedge angle to within 2° compared to the measured value.

The substitution of Ir-192 seed ribbons for wires in the Paris system of interstitial implants was re-evaluated using the dose nonuniformity ratio. The dose nonuniformity ratio, which is based on volumetric data, measures the dose nonuniformity of the implant quantitatively. The lower the dose nonuniformity ratio value, the smaller the dose nonuniformity, and the better is the dose homogeneity for the implant. Implants configured in a single-plane and double-planes in the form of squares or triangles using Ir-192 wires or seed ribbons were considered. The difference between the particular reference dose rate that yielded a minimum in the dose nonuniformity ratio curve for wire implants and seed implants is about 4 cGy/hr. The difference between the minimum dose nonuniformity ratio value representing the optimal dose homogeneity of the implants is about 5%. The dose homogeneity may be considered better for implants configured using seed ribbons.

Standardized radioactive plaques have been used in the irradiation of intraocular tumors. These plaques have defined slots to accommodate 125I seeds and hence produce predictable isodose distributions. The seed strength has to be adjusted to deliver 100 Gy to the prescription point, which varies with the tumor size. The purpose of this work is to develop lookup tables that relate the seed strength to different prescription distances. Dose rates were determined for a set of standardized eye plaques. Using these dose rates and the source strength decaying expression, the seed strengths were determined as a function of distance along a line through the plaque. Two seed-strength tables were created based on four-day and five-day treatment times delivering a 100 Gy to the prescription distance.

The isodose distributions are related to the source configurations in the Paris system of interstitial implants. In this system, the basal dose rates are determined at those points identified relative to the implant. Once these points have been located, the basal dose rates are merely the summation of the dose rate contributions from all the sources. By applying the symmetry properties of the implant, the number of basal dose rate computations and the number of dose rate summations are reduced. The reduction in both the number of computations and the number of summations has facilitated the determination of the average basal dose rate. After the average basal dose rate has been determined, the reference dose rate that is used clinically is calculated. Examples of determining the basal dose rates for a few interstitial implants are presented.

Various wedge isodose angles or simply wedge angles smaller than the nominal wedge angle were created by combining the isodose distributions generated from a single physical wedge with the isodose distributions of the open field for the 8-MV photon beam. The particular wedge angle generated depends on the weights imposed on these isodose distributions. The relationship between these weights and the wedge angle were examined and found to be nonlinear. The difference between the wedge angles defined at 10 cm depth and those defined using the 50% isodose curve is less 6 degrees. The present data was fitted using two proposed empirical equations.

Objective Minority patients with cancer have higher recurrence rates than the general population and are more likely to be treated at community centers where the standard of care has been reported to be inferior to that at academic centers. These issues are being explored by Radiation Oncology Community Outreach Group (ROCOG), a consortium of 5 Community Radiation Oncology centers participating in a National Cancer Institute-funded Disparities Grant. As a quality assurance/quality improvement initiative, this study was undertaken to ensure that treatment was at a "best practice" level. Methods With the use of the American College of Radiology (ACR) accreditation criteria, an initial self-evaluation was done on 10 randomly selected cases at each of 5 radiation oncology clinics for patients treated between July 2002 and December 2003. The results were analyzed and presented to the centers with recommendations for improvements in April 2004. As part of an application to the ACR for accreditation, a second self-evaluation was performed on randomly selected cases treated between July and December 2004. ACR surveyors conducted the last randomly selected case evaluation. Results All centers had acceptable standards at baseline. The ROCOG average compliance rate at first evaluation was 88% vs 92% for ACR-accredited facilities. At reevaluation, the ROCOG average compliance rate was 95% vs 92% (ACR-accredited facilities). At the final evaluation, the ROCOG average compliance rate was 92% vs 90% (ACR-accredited facilities). All 5 sites received ACR accreditation. Conclusion Despite a small sample, patients served by these institutions, regardless of minority status, received radiation oncology care at or above the accepted standards. A quality assessment/quality improvement initiative using ACR accreditation to ensure that "best practice" levels led to improved standards. Accreditation is one method that could be used to support a "pay-for-performance" program.

In breast cancer treatment, intensity-modulated radiation therapy (IMRT) can be utilized to deliver more homogeneous dose to target tissues to minimize the cosmetic impact. We have investigated the effect of the respiratory cycle and radiation beam-on timing on the dose distribution in free-breathing dynamic breast IMRT treatment. Six patients with early stage cancer of the left breast were included in this study. A helical computed tomography (CT) scan was acquired for treatment planning. A four-dimensional computed tomography (4D CT) scan was obtained right after the helical CT scan with little or no setup uncertainty to simulate patient respiratory motion. After optimizing based on the helical CT scan, the sliding-window dynamic multileaf collimator (DMLC) leaf sequence was segmented into multiple sections that corresponded to various respiratory phases per respiratory cycle and radiation beam-on timing. The segmented DMLC leaf sections were grouped according to respiratory phases and superimposed over the radiation fields of corresponding 4D CT image set. Dose calculation was then performed for each phase of the 4D CT scan. The total dose distribution was computed by accumulating the contribution of dose from each phase to every voxel in the region of interest. This was tracked by a deformable registration program throughout all of the respiratory phases of the 4D CT scan. A dose heterogeneity index, defined as the ratio between (D20-D80) and the prescription dose, was introduced to numerically illustrate the impact of respiratory motion on the dose distribution of treatment volume. A respiratory cycle range of 4-8 s and randomly distributed beam-on timing were assigned to simulate the patient respiratory motion during the free-breathing treatment. The results showed that the respiratory cycle period and radiation beam-on timing presented limited impact on the target dose coverage and slightly increased the target dose heterogeneity. This motion impact tended to increase the variation of target dose coverage and heterogeneity between treatment fractions with different radiation beam-on timing. The target dose coverage and heterogeneity were more susceptible to the radiation beam-on timing for patients with long respiratory cycle (longer than 6 s) and large breast motion amplitudes (larger than 0.7 cm). The same results could be found for respiratory cycle up to 8 s and respiratory motion amplitude up to 1 cm. The heart dose distribution did not change significantly regardless of respiratory cycle and radiation beam-on timing.

Skin doses from brachytherapy using MammoSite® HDR, Intensity Modulated Radiation Therapy (IMRT), and conventional tangential fields techniques were compared. For each treatment technique, skin doses were measured using paired thermoluminescent dosimeters placed on the patient's skin: (i) directly above the balloon catheter during MammoSite® HDR brachytherapy treatments and (ii) 4 cm inside the treatment borders during the IMRT and conventional breast treatments. The mean dose measured was about 58% of the prescription dose for the patients treated using the MammoSite® technique. On the other hand, for patients treated with IMRT and tangential fields, the mean dose was found to be about 69% and 71% of the corresponding prescription dose. This study suggests that in breast cancer radiation treatments the MammoSite® HDR technique reduces skin doses compared to IMRT and tangential field techniques. PACS numbers: 87.53.Jw, 87.53.Xd, 87.66.Sq

Current standards of practice are based on the use of an independent calculation to validate the monitor units (MUs) derived from a treatment planning system. The ADAC PINNACLE treatment planning system has shown discrepancies of 10% or more compared to simple independent calculations for highly contoured areas such as tangential breast and chest wall irradiation. The ADAC treatment planning system generally requires more MUs to deliver the same prescribed dose. Independent MU calculation methods are based on full phantom conditions. On the other hand, the MUs from the ADAC treatment planning system are derived using realistic phantom scatter. As such, differences exist in TMR factors, off-axis wedge factors, and the phantom scatter factor. To systematically study the discrepancies due to phantom conditions, experimental measurements were performed with various percentages of tissue missing. The agreement between the experimental measurements and ADAC calculations was found to be within 2%. Using breast field geometry, a relationship between missing tissue and the dosimetric parameters used by ADAC was developed. This relationship, when applied, yielded independent MU calculations whose values closely matched those from the ADAC treatment planning system.

Two commercially fabricated esophageal applicators for low dose rate intraluminal brachytherapy were compared using the dose non-uniformity ratio (DNR). One of the applicators has a single afterloading catheter while the other applicator has six afterloading catheters to accommodate low dose rate 192 Ir ribbon or wire sources. Five sets of source configurations, each with a different ribbon length in the range of 5–17 cm were analysed using the DNR. The DNR shows the delivery of relatively higher total doses at higher dose rates to tissues closer to the applicators. The difference in the inhomogeneity of dose rates and the treatment volume exposed to higher dose rates than the prescribed dose rate between the two applicators are minimal. The dose homogeneity is better for the single-source applicator while the worst dose homogeneity for the six-source applicator is caused by the placement of each source closer to the surface of the applicator. The implications of higher dose rates were discussed using the αβ model.

The clinical implementation of intensity-modulated radiation therapy (IMRT) is a complex process because of the introduction of new treatment planning algorithms and beam delivery systems compared to conventional 3-dimensional conformal radiation therapy (3D-CRT) and the lack of established national perfor- mance protocols. IMRT uses an inverse-planning algorithm to create nonuniform fields that are only deliverable through a newly designed beam-modulating delivery system. The intent of this paper is to describe our experience and to elucidate the new clinical procedures that must be executed to have a successful IMRT program. Patients who undergo IMRT at our institution are immobilized and simulated before proceeding to computed tomogra- phy scan for patient data acquisition. Treatment planning involves the use of different prescription dose formats and different planning techniques compared to 3D-CRT. The desired dose goals for the target and sensitive structures must be specified before initiating the planning process, which is computer intensive. After the plan is completed, the delivery instructions are transferred to the delivery system via either a floppy disk for MIMiC-based IMRT or through the network for MLC-based IMRT. Target localizations are carried out using orthogonal radiographs. Ultrasound imaging system (BAT) is used to localize the prostate. Dose validation is performed using films, ion chambers or dose-calculation-based techniques. © 2002 American Association of Medical Dosimetrists.

The Peacock system is the product of technological innovations that are changing the practice of radiotherapy. It uses dynamic beam modulation technique and inverse planning algorithm, both of which are new methodologies, to perform intensity-modulation radiation therapy (IMRT). The quality assurance (QA) procedure established by Task Group No. 40 did not adequately consider these emerging modalities. A review of literature indicates that published articles on QA procedures concentrate primarily on the verification of dose delivered to phantom during commissioning of the system and dose delivered to phantom before treating patients. Absolute dose measurements using ion chambers and relative dose measurements using film dosimetry have been used to verify delivered doses. QA on equipment performance and equipment safety is limited. This paper will discuss QA on equipment performance, equipment safety, and patient setup reproducibility.

A comparative study was undertaken to examine intracranial irradiation using intensity-modulation radiation therapy (IMRT) and linear accelerator-based radiosurgery. The IMRT was examined using the Peacock system with a BEAK® attachment. A clinical case involving a metastatic brain lesion, treated with 3 radiosurgery isocenters, was planned for IMRT. The radiosurgery was planned using the Leibinger planning system. The IMRT was planned using the CORVUS planning system. The CORVUS planning system uses an inverse planning algorithm, a recent development in radiotherapy. Isodose distributions and dose volume histograms were generated and compared. Analysis of the dosimetry shows that the dose conformity and homogeneity within the target using the RTOG guidelines are superior for IMRT. The advantages of IMRT using inverse planning system include the ease of planning and execution of treatment, especially for cases that involve concave targets that require multiple isocenters using radiosurgery.

The authors evaluated a flexible vaginal localizer contrast tampon for radiation therapy simulation. In 51 patients, the degree of cervical or vaginal cuff displacement secondary to the contrast tampon was evaluated by comparing simulation radiographs (with tampon) and initial portal radiographs (without tampon). The same comparisons were made on the radiographs obtained in 25 control subjects who underwent simulation without a tampon. Mean displacement in the group who underwent simulation with a tampon was minimal (or = 5 mm in each direction) and similar to that in the control group. This technique provides reliable cervical and vaginal cuff localization.

The dosimetry of high-energy photon beams in the treatment of superficial lesions occurring in extremities was examined. Large parallel-opposed fields with different photon beam energies were used. The extremity was immersed in water contained in a commercially available plastic wastebasket. The water bolus serves to even out the surface irregularities of the extremities and to remove the skin sparing effect. A polystyrene block was placed at the floor of the wastebasket to ensure that the extremity was encompassed in the radiation fields. The photon beam energies considered were 4 MV, 6 MV, 10 MV, and 24 MV. The results show that the dose distributions are more homogeneous with higher photon beam energies. The isodose lines are more constricted at mid-plane for low energy photon beams. Higher energy photon beams, 10 MV and up would be preferable for the treatment of superficial lesions of the extremities immersed in water bolus contained in a typical wastebasket size.

Any newly introduced radiation dosimeters must be evaluated for clinical use. This paper reports an evaluation of the energy response of a newly fabricated solid state diode for low-energy photon beam dosimetry. The diode, which has minimal buildup, is one of five models designed for in vivo patient dosimetry. Measurements were made using this diode for x-ray beams with kilovoltage potential from 20 to 100 kVp from a superficial x-ray treatment unit. In addition, measurements were also made using calibrated ion chamber designed for low-energy x-ray beams. A cone size of 20 x 20 cm was used and measurements were taken with diode and ion chamber placed at 35 cm from the source. The energy response was determined by taking the ratio of the diode measurement to the ion chamber measurement. The results show that the response of this new diode increases as the quality of the x-ray beam increases at low energy range; however, the percent difference of the detector response between the 70 kVp and 100 kVp x-ray beam is less than 1%, suggesting that this detector can be used as a dosimetry tool for the typical superficial x-ray treatments.

As part of the quality assurance protocol for linear accelerators at West Virginia University Hospitals, the local temperature and pressure are recorded on a daily basis by the radiation therapists. These temperature and pressure values are not used for temperature and pressure correction unless the ionometric measurements of radiation beam outputs from linear accelerators are outside the established tolerance levels. This paper presents a study on the variation of temperature and pressure over the past two years. Analysis of the data showed that the variation of pressure is within +/- 1.5% of the average value. Likewise, the variation of temperature is within +/- 1.5% of the average value. the worst possible effects of temperature and pressure on ionometric measurements would be within +/- 3%, which is at the tolerance levels recommended by the American Association of Physicists in Medicine (AAPM) Task Group No. 13. By maintaining machine output fluctuation to within +/- 2%, the maximum deviation of uncorrected ionometric measurements would be within +/- 5%. This study collaborates with the tolerance levels suggested by the AAPM Task Group No. 40.

The supraclavicular-axillary region is often irradiated if multiple lymph nodes are found to be positive in the staging of breast cancer. The doses delivered to supraclavicular-axillary region are typically computed using IRREG program. As such, the dose distributions through these regions are rarely examined. The intent of this study is to examine dose distributions through the supraclavicular-axillary region. The results of this study indicate that the anterior region of the axilla receives about 20% more dose than the supraclavicular region or the mid-axillary point. This excess dose results from the posterior axillary field used to supplement the dose from the supraclavicular-axillary field.

Purpose : Evaluation of the 3-dimensional dose distributions of interstitial implants using the dose nonuniformity ratio. Methods and Materials : Single source, two sources, three and four sources arranged both linearly and in the form of a triangle or a square, ribbons with different seed spacings, a single-plane and double-plane implants were evaluated. The evaluations involved the use of differential dose volume histograms and the dose nonuniformity ratio defined as the ratio of the high dose volume to the reference volume. Results : For a single source, the dose nonuniformity is the same regardless which dose rate is selected as the treatment dose rate. For any multi-source implant, the dose nonuniformity is altered depending on the selection of the reference dose rate. In addition, the dose nonuniformity curve exhibited three characteristics zones. Conclusion : The dose nonuniformity ratio can be a useful tool in assessing and optimizing interstitial implants.

The percent depth dose of 8 MV and 18 MV photon beams were measured for various field sizes. The percent depth dose curves exhibited crossed over at selective depth in phantom. Hence, the percent depth dose increases at shallower depth, is independent at crossed over depth, and decreases at deeper depth with decreasing field size. This peculiar phenomenon, which cannot be explained using the primary and scattered radiation concept, should be noted.

Quantitative assessment of interstitial implants is proposed using volume versus dose curves and four well-defined dosimetric parameters. The volume versus dose curves, both differential and cumulative, provide quantitative data on the volumes of tissues irradiated to different doses. They also offer a qualitative assessment of the variations in dose delivery. The dose nonuniformity ratio (DNR) quantitatively determines the degree of dose nonuniformity specific to the implant configuration. The dose rate at which the DNR shows a minimum value, if selected as the treatment dose rate, gives an optimized dose distribution. The three volumetric irradiation indices are formulated with respect to a well-defined target volume. They offer quantitative data on the extent to which the implant delivers the prescribed dose to the target volume. These dosimetric parameters determine the degree of coverage of the target volume, dose homogeneity within the target volume, and irradiation of tissues outside the target volume. The method of quantitative assessment is demonstrated using, as examples, an ideal Ir-192 double-plane implant and an actual clinical Ir-192 double-plane breast implant.

A low sensitivity medium energy collimator (LSMEC) designed with thick septa and long bore (theoretical leakage less than 3% 364 keV), was evaluated using 131I for a SPECT system operated in both planar and tomographic imaging modes. The collimator was designed to minimize the influence of photon penetration on spatial resolution, in particular the resolution index FWTM. Overall spatial resolution for the planar imaging mode at 10 cm from the collimator face was found to be 11.6 mm FWHM and 21.6 mm FWHM. The corresponding transverse plane and slice thickness resolution was of the order of 17 mm FWHM and 31 mm FWTM, for a radius of rotation of 16 cm. A SPECT resolution phantom was imaged. Two quadrants of cold rods were well resolved, with rod dimensions of 16 and 12.7 mm respectively, the resolution being comparable to that obtained using 99Tcm (140 keV) and a low-energy high-resolution collimator. NEMA sensitivity obtained was 75 cpm/microCi 131I. The resolution measurements obtained suggest that this collimator should be useful for SPECT imaging with 131I in either radioimmunoimaging or radioimmunotherapy.

Dose distributions of stereotactic brain implants performed by four institutions were analyzed. In these implants 192Ir or 125I sources were used. The analyses involved an evaluation of the isodose distributions in two orthogonal planes, the dose gradient outside, and the dose homogeneity within the target volume. Quantitative evaluation of the dose homogeneity was performed using three volumetric irradiation indices. The dose homogeneity was observed to improve as the number of catheters increased. However, the number of catheters used is influenced by neurosurgical considerations. Thus, it is necessary to make a compromise between dose homogeneity and the maximum number of catheters to be used. The dose gradient, a centimeter outside the target volume, was found to depend on the geometry of the implant and at distances beyond, it was found to depend on the type of radioisotopes used.