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Purpose: This paper introduces a new external beam radiotherapy device named GammaPod that is dedicated for stereotactic radiotherapy of breast cancer., Methods: The design goal of the GammaPod as a dedicated system for treating breast cancer is the ability to deliver ablative doses with sharp gradients under stereotactic image guidance. Stereotactic localization of the breast is achieved by a vacuum-assisted breast immobilization cup with built-in stereotactic frame. Highly focused radiation is achieved at the isocenter due to the cross-firing from 36 radiation arcs generated by rotating 36 individual Cobalt-60 beams. The dedicated treatment planning system optimizes an optimal path of the focal spot using an optimization algorithm borrowed from computational geometry such that the target can be covered by 90%-95% of the prescription dose and the doses to surrounding tissues are minimized. The treatment plan is intended to be delivered with continuous motion of the treatment couch. In this paper the authors described in detail the gamma radiation unit, stereotactic localization of the breast, and the treatment planning system of the GammaPod system., Results: A prototype GammaPod system was installed at University of Maryland Medical Center and has gone through a thorough functional, geometric, and dosimetric testing. The mechanical and functional performances of the system all meet the functional specifications., Conclusions: An image-guided breast stereotactic radiotherapy device, named GammaPod, has been developed to deliver highly focused and localized doses to a target in the breast under stereotactic image guidance. It is envisioned that the GammaPod technology has the potential to significantly shorten radiation treatments and even eliminate surgery by ablating the tumor and sterilizing the tumor bed simultaneously.

Purpose: A dedicated stereotactic gamma irradiation device, the GammaPod™ from Xcision Medical Systems, was developed specifically to treat small breast cancers. This study presents the first evaluation of dosimetric and geometric characteristics from the initial prototype installed at University of Maryland Radiation Oncology Department., Methods: The GammaPod™ stereotactic radiotherapy device is an assembly of a hemi-spherical source carrier containing 36 (60)Co sources, a tungsten collimator, a dynamically controlled patient support table, and the breast immobilization system which also functions as a stereotactic frame. The source carrier contains the sources in six columns spaced longitudinally at 60° intervals and it rotates together with the variable-size collimator to form 36 noncoplanar, concentric arcs focused at the isocenter. The patient support table enables motion in three dimensions to position the patient tumor at the focal point of the irradiation. The table moves continuously in three cardinal dimensions during treatment to provide dynamic shaping of the dose distribution. The breast is immobilized using a breast cup applying a small negative pressure, where the immobilization cup is embedded with fiducials also functioning as the stereotactic frame for the breast. Geometric and dosimetric evaluations of the system as well as a protocol for absorbed dose calibration are provided. Dosimetric verifications of dynamically delivered patient plans are performed for seven patients using radiochromic films in hypothetical preop, postop, and target-in-target treatment scenarios., Results: Loaded with 36 (60)Co sources with cumulative activity of 4320 Ci, the prototype GammaPod™ unit delivers 5.31 Gy/min at the isocenter using the largest 2.5 cm diameter collimator. Due to the noncoplanar beam arrangement and dynamic dose shaping features, the GammaPod™ device is found to deliver uniform doses to targets with good conformity. The spatial accuracy of the device to locate the radiation isocenter is determined to be less than 1 mm. Single shot profiles with 2.5 cm collimator are measured with radiochromic film and found to be in good agreement with respect to the Monte Carlo based calculations (congruence of FWHM less than 1 mm). Dosimetric verifications corresponding to all hypothetical treatment plans corresponding to three target scenarios for each of the seven patients demonstrated good agreement with gamma index pass rates of better than 97% (99.0% ± 0.7%)., Conclusions: Dosimetric evaluation of the first GammaPod™ stereotactic breast radiotherapy unit was performed and the dosimetric and spatial accuracy of this novel technology is found to be feasible with respect to clinical radiotherapy standards. The observed level of agreement between the treatment planning system calculations and dosimetric measurements has confirmed that the system can deliver highly complex treatment plans with remarkable geometric and dosimetric accuracy.

Purpose: Rotational IMRT has been adopted by many clinics for its promise to deliver treatments in a shorter amount of time than other conventional IMRT techniques. In this paper, the authors investigate whether RapidArc is more susceptible to delivery uncertainties than dynamic IMRT using fixed fields., Methods: Dosimetric effects of delivery uncertainties in dose rate, gantry angle, and MLC leaf positions were evaluated by incorporating these uncertainties into RapidArc and sliding window IMRT (SW IMRT) treatment plans for five head-and-neck and five prostate cases. Dose distributions and dose-volume histograms of original and modified plans were recalculated and compared using Gamma analysis and dose indices of planned treatment volumes (PTV) and organs at risk (OAR). Results of Gamma analyses using passing criteria ranging from 1%-1 mm up to 5%-3 mm were reported., Results: Systematic shifts in MLC leaf bank positions of SW-IMRT cases resulted in 2-4 times higher average percent differences than RapidArc cases. Uniformly distributed random variations of 2 mm for active MLC leaves had a negligible effect on all dose distributions. Sliding window cases were much more sensitive to systematic shifts in gantry angle. Dose rate variations during RapidArc must be much larger than typical machine tolerances to affect dose distributions significantly; dynamic IMRT is inherently not susceptible to such variations., Conclusions: RapidArc deliveries were found to be more tolerant to variations in gantry position and MLC leaf position than SW IMRT. This may be attributed to the fact that the average segmental field size or MLC leaf opening is much larger for RapidArc. Clinically acceptable treatments may be delivered successfully using RapidArc despite large fluctuations in dose rate and gantry position.

Purpose: Dose-rate-regulated tracking (DRRT) is a tumor tracking strategy that programs the MLC to track the tumor under regular breathing and adapts to breathing irregularities during delivery using dose rate regulation. Constant-dose-rate tracking (CDRT) is a strategy that dynamically repositions the beam to account for intrafractional 3D target motion according to real-time information of target location obtained from an independent position monitoring system. The purpose of this study is to illustrate the differences in the effectiveness and delivery accuracy between these two tracking methods in the presence of breathing irregularities., Methods: Step-and-shoot IMRT plans optimized at a reference phase were extended to remaining phases to generate 10-phased 4D-IMRT plans using segment aperture morphing (SAM) algorithm, where both tumor displacement and deformation were considered. A SAM-based 4D plan has been demonstrated to provide better plan quality than plans not considering target deformation. However, delivering such a plan requires preprogramming of the MLC aperture sequence. Deliveries of the 4D plans using DRRT and CDRT tracking approaches were simulated assuming the breathing period is either shorter or longer than the planning day, for 4 IMRT cases: two lung and two pancreatic cases with maximum GTV centroid motion greater than 1 cm were selected. In DRRT, dose rate was regulated to speed up or slow down delivery as needed such that each planned segment is delivered at the planned breathing phase. In CDRT, MLC is separately controlled to follow the tumor motion, but dose rate was kept constant. In addition to breathing period change, effect of breathing amplitude variation on target and critical tissue dose distribution is also evaluated., Results: Delivery of preprogrammed 4D plans by the CDRT method resulted in an average of 5% increase in target dose and noticeable increase in organs at risk (OAR) dose when patient breathing is either 10% faster or slower than the planning day. In contrast, DRRT method showed less than 1% reduction in target dose and no noticeable change in OAR dose under the same breathing period irregularities. When ±20% variation of target motion amplitude was present as breathing irregularity, the two delivery methods show compatible plan quality if the dose distribution of CDRT delivery is renormalized., Conclusions: Delivery of 4D-IMRT treatment plans, stemmed from 3D step-and-shoot IMRT and preprogrammed using SAM algorithm, is simulated for two dynamic MLC-based real-time tumor tracking strategies: with and without dose-rate regulation. Comparison of cumulative dose distribution indicates that the preprogrammed 4D plan is more accurately and efficiently conformed using the DRRT strategy, as it compensates the interplay between patient breathing irregularity and tracking delivery without compromising the segment-weight modulation.

Purpose: In intensity-modulated radiation therapy (IMRT) planning, reducing the pencil-beam size may lead to a significant improvement in dose conformity, but also increase the time needed for the dose calculation and plan optimization. The authors develop and evaluate a postoptimization refinement (POpR) method, which makes fine adjustments to the multileaf collimator (MLC) leaf positions after plan optimization, enhancing the spatial precision and improving the plan quality without a significant impact on the computational burden., Methods: The authors' POpR method is implemented using a commercial treatment planning system based on direct aperture optimization. After an IMRT plan is optimized using pencil beams with regular pencil-beam step size, a greedy search is conducted by looping through all of the involved MLC leaves to see if moving the MLC leaf in or out by half of a pencil-beam step size will improve the objective function value. The half-sized pencil beams, which are used for updating dose distribution in the greedy search, are derived from the existing full-sized pencil beams without need for further pencil-beam dose calculations. A benchmark phantom case and a head-and-neck (HN) case are studied for testing the authors' POpR method., Results: Using a benchmark phantom and a HN case, the authors have verified that their POpR method can be an efficient technique in the IMRT planning process. Effectiveness of POpR is confirmed by noting significant improvements in objective function values. Dosimetric benefits of POpR are comparable to those of using a finer pencil-beam size from the optimization start, but with far less computation and time., Conclusions: The POpR is a feasible and practical method to significantly improve IMRT-plan quality without compromising the planning efficiency.

Purpose: Dose calculation is a key component in radiation treatment planning systems. Its performance and accuracy are crucial to the quality of treatment plans as emerging advanced radiation therapy technologies are exerting ever tighter constraints on dose calculation. A common practice is to choose either a deterministic method such as the convolution/superposition (CS) method for speed or a Monte Carlo (MC) method for accuracy. The goal of this work is to boost the performance of a hybrid Monte Carlo convolution/superposition (MCCS) method by devising a graphics processing unit (GPU) implementation so as to make the method practical for day-to-day usage., Methods: Although the MCCS algorithm combines the merits of MC fluence generation and CS fluence transport, it is still not fast enough to be used as a day-to-day planning tool. To alleviate the speed issue of MC algorithms, the authors adopted MCCS as their target method and implemented a GPU-based version. In order to fully utilize the GPU computing power, the MCCS algorithm is modified to match the GPU hardware architecture. The performance of the authors' GPU-based implementation on an Nvidia GTX260 card is compared to a multithreaded software implementation on a quad-core system., Results: A speedup in the range of 6.7-11.4x is observed for the clinical cases used. The less than 2% statistical fluctuation also indicates that the accuracy of the authors' GPU-based implementation is in good agreement with the results from the quad-core CPU implementation., Conclusions: This work shows that GPU is a feasible and cost-efficient solution compared to other alternatives such as using cluster machines or field-programmable gate arrays for satisfying the increasing demands on computation speed and accuracy of dose calculation. But there are also inherent limitations of using GPU for accelerating MC-type applications, which are also analyzed in detail in this article.

Intensity modulated radiation therapy (IMRT) is an advanced form of external beam radiation therapy. IMRT offers an additional dimension of freedom as compared with field shaping in three-dimensional conformal radiation therapy because the radiation intensities within a radiation field can be varied according to the preferences of locations within a given beam direction from which the radiation is directed to the tumor. This added freedom allows the treatment planning system to better shape the radiation doses to conform to the target volume while sparing surrounding normal structures. The resulting dosimetric advantage has shown to translate into clinical advantages of improving local and regional tumor control. It also offers a valuable mechanism for dose escalation to tumors while simultaneously reducing radiation toxicities to the surrounding normal tissue and sensitive structures. In less than a decade, IMRT has become common practice in radiation oncology. Looking forward, the authors wonder if IMRT has matured to such a point that the room for further improvement has diminished and so it is pertinent to ask what the future will hold for IMRT. This article attempts to look from the perspective of the current state of the technology to predict the immediate trends and the future directions. This article will (1) review the clinical experience of IMRT; (2) review what we learned in IMRT planning; (3) review different treatment delivery techniques; and finally, (4) predict the areas of advancements in the years to come.

Intensity-modulated arc therapy (IMAT) is a rotational IMRT technique. It uses a set of overlapping or nonoverlapping arcs to create a prescribed dose distribution. Despite its numerous advantages, IMAT has not gained widespread clinical applications. This is mainly due to the lack of an effective IMAT leaf-sequencing algorithm that can convert the optimized intensity patterns for all beam directions into IMAT treatment arcs. To address this problem, we have developed an IMAT leaf-sequencing algorithm and software using graph algorithms in computer science. The input to our leaf-sequencing software includes (1) a set of (continuous) intensity patterns optimized by a treatment planning system at a sequence of equally spaced beam angles (typically 10 degrees apart), (2) a maximum leaf motion constraint, and (3) the number of desired arcs, k. The output is a set of treatment arcs that best approximates the set of optimized intensity patterns at all beam angles with guaranteed smooth delivery without violating the maximum leaf motion constraint. The new algorithm consists of the following key steps. First, the optimized intensity patterns are segmented into intensity profiles that are aligned with individual MLC leaf pairs. Then each intensity profile is segmented into k MLC leaf openings using a k-link shortest path algorithm. The leaf openings for all beam angles are subsequently connected together to form 1D IMAT arcs under the maximum leaf motion constraint using a shortest path algorithm. Finally, the 1D IMAT arcs are combined to form IMAT treatment arcs of MLC apertures. The performance of the implemented leaf-sequencing software has been tested for four treatment sites (prostate, breast, head and neck, and lung). In all cases, our leaf-sequencing algorithm produces efficient and highly conformal IMAT plans that rival their counterpart, the tomotherapy plans, and significantly improve the IMRT plans. Algorithm execution times ranging from a few seconds to 2 min are observed on a laptop computer equipped with a 2.0 GHz Pentium M processor.

Using direct aperture optimization, we have developed an inverse planning approach that is capable of producing efficient intensity modulated radiotherapy (IMRT) treatment plans that can be delivered without a multileaf collimator. This "jaws-only" approach to IMRT uses a series of rectangular field shapes to achieve a high degree of intensity modulation from each beam direction. Direct aperture optimization is used to directly optimize the jaw positions and the relative weights assigned to each aperture. Because the constraints imposed by the jaws are incorporated into the optimization, the need for leaf sequencing is eliminated. Results are shown for five patient cases covering three treatment sites: pancreas, breast, and prostate. For these cases, between 15 and 20 jaws-only apertures were required per beam direction in order to obtain conformal IMRT treatment plans. Each plan was delivered to a phantom, and absolute and relative dose measurements were recorded. The typical treatment time to deliver these plans was 18 min. The jaws-only approach provides an additional IMRT delivery option for clinics without a multileaf collimator.

We present an improved multileaf collimator (MLC) segmentation algorithm, denoted by SLS(NOTG) (static leaf sequencing with no tongue-and-groove error), for step-and-shoot intensity-modulated radiation therapy (IMRT) delivery. SLS(NOTG) is an improvement over the MLC segmentation algorithm called SLS that was developed by Luan et al. [Med. Phys. 31(4), 695-707 (2004)], which did not consider tongue-and-groove error corrections. The aims of SLS(NOTG) are (1) shortening the treatment times of IMRT plans by minimizing their numbers of segments and (2) minimizing the tongue-and-groove errors of the computed IMRT plans. The input to SLS(NOTG) is intensity maps (IMs) produced by current planning systems, and its output is (modified) optimized leaf sequences without tongue-and-groove error. Like the previous SLS algorithm [Luan et al., Med. Phys. 31(4), 695-707 (2004)], SLS(NOTG) is also based on graph algorithmic techniques in computer science. It models the MLC segmentation problem as a weighted minimum-cost path problem, where the weight of the path is the number of segments and the cost of the path is the amount of tongue-and-groove error. Our comparisons of SLS(NOTG) with CORVUS indicated that for the same intensity maps, the numbers of segments computed by SLS(NOTG) are up to 50% less than those by CORVUS 5.0 on the Elekta LINAC system. Our clinical verifications have shown that the dose distributions of the SLS(NOTG) plans do not have tongue-and-groove error and match those of the corresponding CORVUS plans, thus confirming the correctness of SLS(NOTG). Comparing with existing segmentation methods, SLS(NOTG) also has two additional advantages: (1) SLS(NOTG) can compute leaf sequences whose tongue-and-groove error is minimized subject to a constraint on the maximum allowed number of segments, which may be desirable in clinical situations where a treatment with the complete correction of tongue-and-groove error takes too much time, and (2) SLS(NOTG) can be used to minimize a more general type of error called the tongue-or-groove error.

The feasibility of using a multileaf collimator (MLC) for grid therapy is demonstrated in this study. Grids with the projected field openings of 10 mm x 10 mm and 5 mm x 5 mm were created using multiple MLC-shaped fields. The deposited doses were measured with films at different depths in a solid water phantom and compared to those of Cerrobend grid collimators of similar hole sizes and hole separations. At the depth of maximum dose (dmax), the valley-to-peak dose ratios of the MLC grids were found to be about 11% and 19% for the respective 10 mm x 10 mm and 5 mm X 5 mm grid openings, and those of the corresponding grid blocks were about 15% and 20%. To quantify the dose contributed by transmission in the blocked areas due to the limited leaf thickness, Monte Carlo simulations (based on convolution/superposition method) were performed to calculate the doses in the solid water phantom using an ideal MLC with no leakage and perfect divergence in both the leaf end and side. About 7% reduction in the valley-to-peak dose ratio was found for both grid sizes at dmax. The results clearly showed that MLCs can be used to provide grid treatments with at least as good dosimetric properties as those of the Cerrobend grid blocks, though the former would in general require a longer delivery time.

Respiration-induced tumor motion is known to cause artifacts on free-breathing spiral CT images used in treatment planning. This leads to inaccurate delineation of target volumes on planning CT images. Flow-volume spirometry has been used previously for breath-holds during CT scans and radiation treatments using the active breathing control (ABC) system. We have developed a prototype by extending the flow-volume spirometer device to obtain gated CT scans using a PQ 5000 single-slice CT scanner. To test our prototype, we designed motion phantoms to compare image quality obtained with and without gated CT scan acquisition. Spiral and axial (nongated and gated) CT scans were obtained of phantoms with motion periods of 3-5 s and amplitudes of 0.5-2 cm. Errors observed in the volume estimate of these structures were as much as 30% with moving phantoms during CT simulation. Application of motion-gated CT with active breathing control reduced these errors to within 5%. Motion-gated CT was then implemented in patients and the results are presented for two clinical cases: lung and abdomen. In each case, gated scans were acquired at end-inhalation, end-exhalation in addition to a conventional free-breathing (nongated) scan. The gated CT scans revealed reduced artifacts compared with the conventional free-breathing scan. Differences of up to 20% in the volume of the structures were observed between gated and free-breathing scans. A comparison of the overlap of structures between the gated and free-breathing scans revealed misalignment of the structures. These results demonstrate the ability of flow-volume spirometry to reduce errors in target volumes via gating during CT imaging.

We have implemented a three-dimensional dose calculation technique accounting for dose inhomogeneity within the liver and tumor of a patient treated with 90Y microspheres. Single-photon emission computed tomography (SPECT) images were used to derive the activity distribution within liver. A Monte Carlo calculation was performed to create a voxel dose kernel for the 90Y source. The activity distribution was convolved with the voxel dose kernel to obtain the three-dimensional (3D) radiation absorbed dose distribution. An automated technique was developed to accurately register the computed tomography (CT) and SPECT scans in order to display the 3D dose distribution on the CT scans. In addition, dose-volume histograms were generated to fully analyze the tumor and liver doses. The calculated dose-volume histogram indicated that although the patient was treated to the nominal whole liver dose of 110 Gy, only 16% of the liver and 83% of the tumor received a dose higher than 110 Gy. The mean tumor and liver doses were 163 and 58 Gy, respectively.

We present a new MLC segmentation algorithm/software for step-and-shoot IMRT delivery. Our aim in this work is to shorten the treatment time by minimizing the number of segments. Our new segmentation algorithm, called SLS (an abbreviation for static leaf sequencing), is based on graph algorithmic techniques in computer science. It takes advantage of the geometry of intensity maps. In our SLS approach, intensity maps are viewed as three-dimensional (3-D) "mountains" made of unit-sized "cubes." Such a 3-D "mountain" is first partitioned into special-structured submountains using a new mixed partitioning scheme. Then the optimal leaf sequences for each submountain are computed by either a shortest-path algorithm or a maximum-flow algorithm based on graph models. The computations of SLS take only a few minutes. Our comparison studies of SLS with CORVUS (both the 4.0 and 5.0 versions) and with the Xia and Verhey segmentation methods on Elekta Linac systems showed substantial improvements. For instance, for a pancreatic case, SLS used only one-fifth of the number of segments required by CORVUS 4.0 to create the same intensity maps, and the SLS sequences took only 25 min to deliver on an Elekta SL 20 Linac system in contrast to the 72 min for the CORVUS 4.0 sequences (a three-fold improvement). To verify the accuracy of our new leaf sequences, we conducted film and ion-chamber measurements on phantom. The results showed that both the intensity distributions as well as dose distributions of the SLS delivery match well with those of CORVUS delivery. SLS can also be extended to other types of Linac systems.

Treatment verification has been a weak link in external beam radiation therapy. As new and more complicated treatment techniques, such as intensity-modulated radiation therapy (IMRT), are implemented into clinical practice, verifying the accuracy of treatment delivery becomes increasingly important. Existing methods for treatment verification are highly labor intensive. We have developed a method for verifying the delivery of external beam radiotherapy and implemented the methodology into a system consisting of both hardware and software components. The system uses grayscale images acquired on the treatment machine from the planned treatment beams. From these images, the photon fluence distribution of each beam is derived. These measured photon fluence maps are then used as input to a separate dose calculation engine to compute the delivered absolute dose and the dose distribution in the same patient, assuming that the patient is set up as required by the treatment plan. The dose distribution generated from the measured fluence maps can then be compared to that of the treatment plan. Software tools, such as overlaying isodose curves generated with this method on those imported from the plan, dose difference maps, dose difference volume histograms, and three-dimensional perspective views of the dose differences, have also been developed. The system thus provides a means to verify the dose, the dose prescription, and the monitor units applied. The potential exists with a suitable electronic portal imaging system to reduce the quality assurance efforts, especially for IMRT.

Intensity-modulated radiation therapy (IMRT) represents one of the most significant technical advances in radiation therapy since the advent of the medical linear accelerator. It allows the clinical implementation of highly conformal nonconvex dose distributions. This complex but promising treatment modality is rapidly proliferating in both academic and community practice settings. However, these advances do not come without a risk. IMRT is not just an add-on to the current radiation therapy process; it represents a new paradigm that requires the knowledge of multimodality imaging, setup uncertainties and internal organ motion, tumor control probabilities, normal tissue complication probabilities, three-dimensional (3-D) dose calculation and optimization, and dynamic beam delivery of nonuniform beam intensities. Therefore, the purpose of this report is to guide and assist the clinical medical physicist in developing and implementing a viable and safe IMRT program. The scope of the IMRT program is quite broad, encompassing multileaf-collimator-based IMRT delivery systems, goal-based inverse treatment planning, and clinical implementation of IMRT with patient-specific quality assurance. This report, while not prescribing specific procedures, provides the framework and guidance to allow clinical radiation oncology physicists to make judicious decisions in implementing a safe and efficient IMRT program in their clinics.

A quality assurance method is developed for measuring, verifying and analyzing intensity modulated radiation fields. It is applicable for rotational and fixed-beam intensity modulated radiation therapy (IMRT) treatments. A gantry-mount device was constructed to measure the transmission dose of an IMRT field using radiographic films. A double-exposure technique with optimal kernel estimate method was developed to minimize the errors from measurements. A chi2 confidence level test method was developed to detect the discrepancies between measured and prescribed IMRT fluence distributions. Our method was tested for rotational and fixed-beam IMRT treatment verifications. The method was found insensitive to the hardware-related parameters for rotational and fixed-beam IMRT deliveries. The chi2 confidence level test was found to be more sensitive than linear correlation method in detecting relative small errors for cases with a few segments or narrow regions of interest. In conclusion, we demonstrated a quantitative method for verifying and analyzing IMRT treatment deliveries.

Administration of yttrium-90 microspheres via the hepatic artery is an attractive approach to selectively deliver therapeutic doses of radiation to liver malignancies. This procedure allows delivering radiation absorbed doses in excess of 100 Gy to the tumors without significant liver toxicity. The microsphere therapy involves different specialties including medical oncology, radiation oncology, nuclear medicine, interventional radiology, medical physics, and radiation safety. We have treated 80 patients with nonresectable hepatic tumors with yttrium-90 microspheres during the past two years on an institutional study protocol. The nominal radiation absorbed dose to the tumor in this study was 150 Gy. Required activity was calculated based on the nominal radiation absorbed dose and patient's liver volume obtained from the CT scan, assuming a uniform distribution of the microspheres within the liver. Microspheres were administered via a catheter placed into the hepatic artery. The actual radiation absorbed doses to tumors and normal liver tissue were calculated retrospectively based on the patient's 99mTc-MAA study and CT scans. As expected, the activity uptake within the liver was found to be highly nonuniform and multifold tumor to nontumor uptake was observed. A partition model was used to calculate the radiation absorbed dose within each region. For a typical patient the calculated radiation absorbed doses to the tumor and liver were 402 and 118 Gy, respectively. The radiation safety procedure involves confinement of the source and proper disposal of the contaminated materials. The average exposure rates at 1 m from the patients and on contact just anterior to the liver were 6 and 135 uSv/h, respectively. The special physics and dosimetry protocol developed for this procedure is presented.

The optimal field shape achieved using a multileaf collimator (MLC) often requires collimator rotation to minimize the adverse effects of the scalloped dose distribution the leaf steps produce. However, treatment machines are designed to deliver wedged fields parallel or perpendicular to the direction of the leaves. An analysis of cases from our clinic showed that for 25% of the wedged fields used to treat brain and lung tumors, the wedge direction and optimal MLC orientation differed by 20 degrees or more. The recently published omni wedge technique provides the capability of producing a wedged field with orientation independent of the orientation of the collimator. This paper presents a comparison of the three-dimensional (3D) dose distributions of the omni wedged field with distributions of wedged fields produced using both the universal and dynamic wedge techniques. All measurements were performed using film dosimetry techniques. The omni wedge generated fields closely matched the conventional wedged fields. Throughout 95% of the irradiated volume (excluding the penubra), the dose distribution of the omni wedged field ranged from +5.5 to -3.5 +/- 1.5% of that of the conventionally wedged fields. Calculation of the omni wedged field is as accurate as conventional wedged field calculation when using a 3D treatment planning systems. For two-dimensional treatment planning systems, where one must assume that the omni wedged field is identical to a conventional field, the calculated field and the delivered field differs by a small amount.

Significant advances have been made in recent years to improve photon dose calculation. However, accurate prediction of dose perturbation effects near the interfaces of different media, where charged particle equilibrium is not established, remain unsolved. Furthermore, changes in atomic number, which affect the multiple Coulomb scattering of the secondary electrons, are not accounted for by current photon dose calculation algorithms. As local interface effects are mainly due to the perturbation of secondary electrons, a photon-electron cascade model is proposed which incorporates explicit electron transport in the calculation of the primary photon dose component in heterogeneous media. The primary photon beam is treated as the source of many electron pencil beams. The latter are transported using the Fermi-Eyges theory. The scattered photon dose contribution is calculated with the dose spread array [T.R. Mackie, J.W. Scrimger, and J.J. Battista, Med. Phys. 12, 188-196 (1985)] approach. Comparisons of the calculation with Monte Carlo simulation and TLD measurements show good agreement for positions near the polystyrene-aluminum interfaces.

The equivalent tissue-air-ratio (ETAR) method employs three-dimensional (3D) CT pixel information to approximate scatter dose contribution for inhomogeneity correction. In general, the calculation provides better agreement with measurements than the one-dimensional (1D) methods typically used in commercial treatment planning systems. In its original implementation, the 3D formulation of the ETAR method is modified empirically as a 2D calculation in order to reduce computation time. The modification compromises the use of the method in several treatment geometries. An examination of the ETAR formulation shows that the calculation can be expressed as a convolution and thus can be performed in 3D using fast Fourier transform (FFT) techniques. The algorithm has been implemented as a 3D FFT convolution. Making use of the symmetric properties of the FFT, the new approach shows significant savings in computation time without excessive memory requirement. Despite its fundamental limitations when applied to regions of electronic disequilibrium, the ETAR method offers a practical solution to improving current dose calculation in 3D treatment planning, particularly when the more advanced scatter ray-tracing dose calculation algorithms remain impractical for clinical use. Recent work to extend the method to approximate electron transport is also encouraging.

An apparatus capable of measuring small fractional changes in ionization current has been used to study the effect of small inhomogeneities on photon dose in water. Small ring-shaped inhomogeneities were introduced into a water phantom and measurements have been made for 4-, 6-, and 18-MV x-rays. The results show beyond the range of secondary electrons, the dose perturbation is basically a photon transport phenomenon which becomes less important as the beam energy increases; within the range of secondary electrons, dose perturbation also involves electron transport, which has a strong dependence on atomic number and could result in a substantially large effect on dose deposition.

Based on the Fermi-Eyges theory, a set of recursion relations was derived for calculating electron distributions in the layered geometry. The electron distribution at a specific depth was obtained by convolving the upstream electron distribution with a kernel determined by the scattering parameters of the layer. Modifications were made to overcome some inherent limitations of the Fermi-Eyges theory. For each point in the medium, the most probable, or mean, path traversed by the electrons in reaching the point was derived. The skewness of the mean paths and the related energy degradation were included in a multiray model for pencil beam calculations. The resultant electron planar fluence distributions are no longer Gaussian as predicted by the original theory. The effects of edges or localized inhomogeneities are also included. Comparisons between our calculations and Monte Carlo simulations show good agreement.