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Hearing aid impression material composed of vinylpolysiloxane is an ideal bolus material which may be used to aid in delivery of adjuvant radiation to complex surgical defects of the head and neck. It is affordable, easily accessed, and efficient.

In this study, we evaluated the performance of an Elekta linac in the delivery of gated radiotherapy. Delivery accuracy was examined with an emphasis on the impact of using short gating windows (low monitor unit beam‐on segments) or long beam hold times. The performance was assessed using a 20cm by 20cm open field with the radiation delivered using a range of beam‐on and beam‐off time periods. Gated delivery measurements were also performed for two SBRT plans delivered using volumetric modulated arc therapy (VMAT). Tests included both free‐breathing based gating (covering a variety of gating windows) and simulated breath‐hold based gating. An IBA MatriXX 2D ion chamber array was used for data collection, and the gating accuracy at low MU was evaluated using gamma passing rates. For the 20 cm by 20 cm open field, the measurements generally showed close agreement between the gated and non‐gated beam deliveries. Discrepancies, however, began to appear with a 5‐to‐1 ratio of the beam‐off to beam‐on times. The discrepancies observed for these tight gating windows can be attributed to the small number of monitor units delivered during each beam‐on segment. Dose distribution analysis from the delivery of the two SBRT plans showed gamma passing rates (± 1%, 2%/1 mm) in the range of 95% to 100% for gating windows of 25%, 38%, 50%, 63%, 75%, and 83%. Using a simulated sinusoidal breathing signal with a 4 second period, the gamma passing rate of free‐breathing gating and breath‐hold gating deliveries were measured in the range of 95.7% to 100%. In conclusion, the results demonstrate that Elekta linacs can accurately deliver respiratory gated treatments for both free‐breathing and breath‐hold patients. Some caution should be exercised with the use of very tight gating windows.

Purpose The objective of this study was to investigate the influence of tumor motion on dose delivery in stereotactic body radiotherapy (SBRT) for lung cancer, using fixed field intensity- modulated radiotherapy (IMRT) and volumetric modulated arc therapy (VMAT). Methods and Materials For each of 10 patients with stage I/II non-small-cell pulmonary tumors, a respiration-correlated four-dimensional computed tomography (4DCT) study was carried out. The internal target volume was delineated on the maximum intensity projection CT, which was reconstructed from the 4DCT dataset. A 5-mm margin was used for generation of the planning target volume. VMAT and five-field IMRT plans were generated using Pinnacle 3 SmartArc and direct machine parameter optimization, respectively. All plans were generated for an Elekta Synergy linear accelerator using 6-MV photons. Simulation was performed to study the interplay between multileaf collimator (MLC) sequences and target movement during the delivery of VMAT and IMRT. For each plan, 4D dose was calculated using deformable image registration of the 4DCT images. Target volume coverage and doses to critical structures calculated using 4D methodology were compared with those calculated using 3D methodology. Results For all patients included in this study, the interplay effect was found to present limited impact (less than 1% of prescription) on the target dose distribution, especially for SBRT, in which fewer fractions (three fractions) are delivered. Dose to the gross tumor volume (GTV) was, on average, slightly decreased (1% of prescription) in the 4D calculation compared with the 3D calculation. The motion impact on target dose homogeneity was patient-dependent and relatively small. Conclusions Both VMAT and IMRT plans experienced negligible interplay effects between MLC sequence and tumor motion. For the most part, the 3D doses to the GTV and critical structures provided good approximations of the 4D dose calculations.

Purpose: Intensity modulated arc therapy (IMAT) is a radiation therapy delivery technique that combines the efficiency of arc based delivery with the dose painting capabilities of intensity modulated radiation therapy (IMRT). A key challenge in developing robust inverse planning solutions for IMAT is the need to account for the connectivity of the beam shapes as the gantry rotates from one beam angle to the next. To overcome this challenge, inverse planning solutions typically impose a leaf motion constraint that defines the maximum distance a multileaf collimator (MLC) leaf can travel between adjacent control points. The leaf motion constraint ensures the deliverability of the optimized plan, but it also impacts the plan quality, the delivery accuracy, and the delivery efficiency. In this work, the authors have studied leaf motion constraints in detail and have developed recommendations for optimizing the balance between plan quality and delivery efficiency. Methods: Two steps were used to generate optimized IMAT treatment plans. The first was the direct machine parameter optimization (DMPO) inverse planning module in the Pinnacle{sup 3} planning system. Then, a home-grown arc sequencer was applied to convert the optimized intensity maps into deliverable IMAT arcs. IMAT leaf motion constraints were imposed using limits ofmore » between 1 and 30 mm/deg. Dose distributions were calculated using the convolution/superposition algorithm in the Pinnacle{sup 3} planning system. The IMAT plan dose calculation accuracy was examined using a finer sampling calculation and the quality assurance verification. All plans were delivered on an Elekta Synergy with an 80-leaf MLC and were verified using an IBA MatriXX 2D ion chamber array inserted in a MultiCube solid water phantom. Results: The use of a more restrictive leaf motion constraint (less than 1-2 mm/deg) results in inferior plan quality. A less restrictive leaf motion constraint (greater than 5 mm/deg) results in improved plan quality but can lead to less accurate dose distribution as evidenced by increasing discrepancies between the planned and the delivered doses. For example, the results from our patient-specific quality assurance measurements demonstrated that the average gamma analysis passing rate decreased from 98% to 80% when the allowable leaf motion increased from 3 to 20 mm/deg. Larger leaf motion constraints also led to longer treatment delivery times (2 to 4 folds) due to the additional MLC leaf motion. Conclusions: Leaf motion constraints significantly impact IMAT plans in terms of plan quality, delivery accuracy, and delivery efficiency with the impact magnified for more complex cases. Our studies indicate that a leaf motion constraint of 2 to 3 mm/deg of gantry rotation can provide an optimal balance between plan quality, delivery accuracy, and efficiency.« less

Volumetric modulated arc therapy (VMAT) has the potential to reduce treatment times while producing comparable or improved dose distributions relative to fixed-field intensity-modulated radiation therapy. In order to take full advantage of the VMAT delivery technique, one must select a robust inverse planning tool. The purpose of this study was to evaluate the effectiveness and efficiency of VMAT planning techniques of three categories: anatomy-based, fluence-based and aperture-based inverse planning. We have compared these techniques in terms of the plan quality, planning efficiency and delivery efficiency. Fourteen patients were selected for this study including six head-and-neck (HN) cases, and two cases each of prostate, pancreas, lung and partial brain. For each case, three VMAT plans were created. The first VMAT plan was generated based on the anatomical geometry. In the Elekta ERGO++ treatment planning system (TPS), segments were generated based on the beam's eye view (BEV) of the target and the organs at risk. The segment shapes were then exported to Pinnacle TPS followed by segment weight optimization and final dose calculation. The second VMAT plan was generated by converting optimized fluence maps (calculated by the Pinnacle TPS) into deliverable arcs using an in-house arc sequencer. The third VMAT plan was generated using the Pinnacle SmartArc IMRT module which is an aperture-based optimization method. All VMAT plans were delivered using an Elekta Synergy linear accelerator and the plan comparisons were made in terms of plan quality and delivery efficiency. The results show that for cases of little or modest complexity such as prostate, pancreas, lung and brain, the anatomy-based approach provides similar target coverage and critical structure sparing, but less conformal dose distributions as compared to the other two approaches. For more complex HN cases, the anatomy-based approach is not able to provide clinically acceptable VMAT plans while highly conformal dose distributions were obtained using both aperture-based and fluence-based inverse planning techniques. The aperture-based approach provides improved dose conformity than the fluence-based technique in complex cases.

Purpose: Helical tomotherapy (HT) and volumetric modulated arc therapy (VMAT) are arc-based approaches to IMRT delivery. The objective of this study is to compare VMAT to both HT and fixed field IMRT in terms of plan quality, delivery efficiency, and accuracy. Methods: Eighteen cases including six prostate, six head-and-neck, and six lung cases were selected for this study. IMRT plans were developed using direct machine parameter optimization in the Pinnacle{sup 3} treatment planning system. HT plans were developed using a Hi-Art II planning station. VMAT plans were generated using both the Pinnacle{sup 3} SmartArc IMRT module and a home-grown arc sequencing algorithm. VMAT and HT plans were delivered using Elekta's PreciseBeam VMAT linac control system (Elekta AB, Stockholm, Sweden) and a TomoTherapy Hi-Art II system (TomoTherapy Inc., Madison, WI), respectively. Treatment plan quality assurance (QA) for VMAT was performed using the IBA MatriXX system while an ion chamber and films were used for HT plan QA. Results: The results demonstrate that both VMAT and HT are capable of providing more uniform target doses and improved normal tissue sparing as compared with fixed field IMRT. In terms of delivery efficiency, VMAT plan deliveries on average took 2.2 min for prostate andmore » lung cases and 4.6 min for head-and-neck cases. These values increased to 4.7 and 7.0 min for HT plans. Conclusions: Both VMAT and HT plans can be delivered accurately based on their own QA standards. Overall, VMAT was able to provide approximately a 40% reduction in treatment time while maintaining comparable plan quality to that of HT.« less

The recent development in linear accelerator control systems, named volumetric-modulated arc therapy (VMAT), has generated significant interest in arc-based intensity-modulated radiation therapy (IMRT). The VMAT delivery technique features simultaneous changes in dose rate, gantry angle and gantry rotation speed as well as multi-leaf collimator (MLC) leaf positions while radiation is on. In this paper, we describe a generalized VMAT planning tool that is designed to take full advantage of the capabilities of the new linac control systems. The algorithm incorporates all of the MLC delivery constraints such as restrictions on MLC leaf interdigitation and the MLC leaf velocity constraints. A key feature of the algorithm is that it is able to plan for both single- and multiple-arc deliveries. Compared to conventional step-and-shoot IMRT plans, our VMAT plans created using this tool can achieve similar or better plan quality with less MU and better delivery efficiency. The accuracy of the obtained VMAT plans is also demonstrated through plan verifications performed on an Elekta Synergy linear accelerator equipped with a conventional MLC of 1 cm leaf width using a PreciseBeam? VMAT linac control system.

Dose calculations for radiation arc therapy are traditionally performed by approximating continuous delivery arcs with multiple static beams. For 3D conformal arc treatments, the shape and weight variation per degree is usually small enough to allow arcs to be approximated by static beams separated by 5 degrees -10 degrees . But with intensity-modulated arc therapy (IMAT), the variation in shape and dose per degree can be large enough to require a finer angular spacing. With the increase in the number of beams, a deterministic dose calculation method, such as collapsed-cone convolution/superposition, will require proportionally longer computational times, which may not be practical clinically. We propose to use a homegrown Monte Carlo kernel-superposition technique (MCKS) to compute doses for rotational delivery. The IMAT plans were generated with 36 static beams, which were subsequently interpolated into finer angular intervals for dose calculation to mimic the continuous arc delivery. Since MCKS uses random sampling of photons, the dose computation time only increased insignificantly for the interpolated-static-beam plans that may involve up to 720 beams. Ten past IMRT cases were selected for this study. Each case took approximately 15-30 min to compute on a single CPU running Mac OS X using the MCKS method. The need for a finer beam spacing is dictated by how fast the beam weights and aperture shapes change between the adjacent static planning beam angles. MCKS, however, obviates the concern by allowing hundreds of beams to be calculated in practically the same time as for a few beams. For more than 43 beams, MCKS usually takes less CPU time than the collapsed-cone algorithm used by the Pinnacle(3) planning system.

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 deg. 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 amore » 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.« less

Intensity modulated arc therapy (IMAT) is an intensity modulated radiation therapy delivery technique originally proposed as an alternative to tomotherapy. IMAT uses a series of overlapping arcs to deliver optimized intensity patterns from each beam direction. The full potential of IMAT has gone largely unrealized due in part to a lack of robust and commercially available inverse planning tools. To address this, we have implemented an IMAT arc-sequencing algorithm that translates optimized intensity maps into deliverable IMAT plans. The sequencing algorithm uses simulated annealing to simultaneously optimize the aperture shapes and weights throughout each arc. The sequencer enforces the delivery constraints while minimizing the discrepancies between the optimized and sequenced intensity maps. The performance of the algorithm has been tested for ten patient cases (3 prostate, 3 brain, 2 head-and-neck, 1 lung, and 1 pancreas). Seven coplanar IMAT plans were created using an average of 4.6 arcs and 685 monitor units. Additionally, three noncoplanar plans were created using an average of 16 arcs and 498 monitor units. The results demonstrate that the arc sequencer can provide efficient and highly conformal IMAT plans. An average sequencing time of approximately 20 min was observed.

As intensity modulated radiation therapy (IMRT) becomes routine clinical practice, its advantages and limitations are better understood. With these new understandings, some new developments have emerged in an effort to alleviate the limitations of the current IMRT practice. This article describes a few of these efforts made at the University of Maryland, including: i) improving IMRT efficiency with direct aperture optimization; ii) broadening the scope of optimization to include the mode of delivery and beam angles; and iii) new planning methods for intensity modulated arc therapy (IMAT).

A new leaf-sequencing approach has been developed that is designed to reduce the number of required beam segments for step-and-shoot intensity modulated radiation therapy (IMRT). This approach to leaf sequencing is called continuous-intensity-map-optimization (CIMO). Using a simulated annealing algorithm, CIMO seeks to minimize differences between the optimized and sequenced intensity maps. Two distinguishing features of the CIMO algorithm are (1) CIMO does not require that each optimized intensity map be clustered into discrete levels and (2) CIMO is not rule-based but rather simultaneously optimizes both the aperture shapes and weights. To test the CIMO algorithm, ten IMRT patient cases were selected (four head-and-neck, two pancreas, two prostate, one brain, and one pelvis). For each case, the optimized intensity maps were extracted from the Pinnacle{sup 3} treatment planning system. The CIMO algorithm was applied, and the optimized aperture shapes and weights were loaded back into Pinnacle. A final dose calculation was performed using Pinnacle's convolution/superposition based dose calculation. On average, the CIMO algorithm provided a 54% reduction in the number of beam segments as compared with Pinnacle's leaf sequencer. The plans sequenced using the CIMO algorithm also provided improved target dose uniformity and a reduced discrepancy between the optimized and sequencedmore » intensity maps. For ten clinical intensity maps, comparisons were performed between the CIMO algorithm and the power-of-two reduction algorithm of Xia and Verhey [Med. Phys. 25(8), 1424-1434 (1998)]. When the constraints of a Varian Millennium multileaf collimator were applied, the CIMO algorithm resulted in a 26% reduction in the number of segments. For an Elekta multileaf collimator, the CIMO algorithm resulted in a 67% reduction in the number of segments. An average leaf sequencing time of less than one minute per beam was observed.« less

Purpose: Surface guided radiation therapy (SGRT) uses stereoscopic video images in combination with patterns projected onto the patient's surface to dynamically capture and reconstruct a 3D surface map. In this work, we used a C-RAD Catalyst HD system (C-RAD) to evaluate intrafraction motion in the delivery of lung SBRT. Methods: The surface acquired from the 4DCT images from our preliminary cohort of eight lung cancer patients treated with SBRT were matched to the surface images acquired prior to each treatment. Additionally, a CBCT image set was acquired. A linear regression model was established between the external and internal motion of tumor during pretreatment and used to predict the CBCT deviation during treatment. The shifts determined from CBCT and the shifts from surface map imaging were compared and assessed using Bland-Altman method. For intrafraction motion, we assessed the percentage of mean errors that fell outside of the threshold of 2 mm, 3 mm, and 5 mm along the translational directions. The required PTV margin was quantified over the course of treatment. The correlation between intrafraction treatment time and mean error of 3D displacement was evaluated using the Pearson coefficient, r Results: A total of 7971 data points were analyzed. Deviations of 2mm, 3mm, and 5mm were observed less than 7%, 2 %, and 0 % of the time along the translational direction. CBCT and Catalyst showed close agreement during patient positioning. Furthermore, the calculated PTV margins were less than our clinical tolerance of 5 mm. Using the Pearson coefficient r,the mean error of 3D displacement showed significant correlation with treatment time (r=0.69, p= 0.000002). Conclusion: SGRT can be used to ensure accurate patient positioning during treatment without an additional delivery of dose to the patient. This study shows that importance of treatment time as a consideration during the treatment planning process.

Mn2+-doped ZnSe nanoparticles were synthesized from molecular cluster precursors. Four ZnSe nanoparticle samples, one with low Mn2+ concentration (A), one with an intermediate Mn2+ concentration (B), one with a high Mn2+ concentration (C), and one with no Mn2+, were prepared and characterized using UV−vis, luminescence, electron spin resonance (ESR), and X-ray absorption fine structure (XAFS) techniques. The sample with no Mn2+ had a sharp ZnSe band edge emission peak and a quantum yield of ∼2%. The samples with Mn2+ had a significant decrease in band edge emission. Sample A had no Mn2+ 4T1 → 6A1 emission but showed some ZnSe band edge emission and trap state emission. Sample B had Mn2+ 4T1 → 6A1 emission and a further reduction in ZnSe band edge emission and trap state emission. Sample C showed an increase in the Mn2+ 4T1 → 6A1 emission, a dramatic increase in trap state emission, and essentially no ZnSe band edge emission. The overall emission from all four samples was quenched with time. To better unde...

Purpose: The diode detectors for photon beam In-Vivo dose (IVD) measurement are usually manufactured with intrinsic buildup, which may cause the IVD respond differently from the predicted dose when the source-to-surface distance (SSD) and/or the beam incident angle changes, such as that in breast or chest wall irradiations. This work is to evaluate this systematic discrepancy. Methods: In-Vivo dose was measured on a solid water phantom as a function of varying SSD and beam oblique incidence. The cylindrical IVD detectors were calibrated to 100cGy at nominal gantry angle, 100MU, 10×10cm field, 100 SAD with isocenter at dmax. To study SSD dependence, beams were delivered from nominal gantry angle at SSDs from 105 to 75cm. Doses calculated at the dmax were used as the predicted values. To study the oblique incidence responses, measurements were performed at fixed 100 SSD with gantry angles ranging from the nominal angle (0 degree) to horizontal (90 degree). Two calculation points were used for comparison, one at dmax from nominal angle, a second one at dmax along the oblique beam ray. For both setup, IVD was positioned at the beam CAX on the phantom surface. Results: Dose discrepancy increases with decreasing SSD and is more pronounced with high photon energy. This discrepancy is as high as 4.6% for an 18MV beam at 75SSD. For oblique measurements, both calculated values decrease as the oblique angle increases; however, the measured IVD doses exhibited little changes, which introduce significant systematic errors (∼20% at 80 degree) for incident angles larger than 60 degrees. Conclusion: Significant systematic dose discrepancies are observed between IVD measurements and the predicted values for short SSD and oblique incident angles. Cautions must be taken in evaluating IVD results at short SSD and at oblique incidence angles larger than 60 degrees.

Purpose: Recent evidence is emerging that long term swallowing function may be improved after radiotherapy for head-&-neck cancer if doses are limited to certain swallowing structures. Immobilization of patients with head-&-neck cancer is typically done with a mask. This mask, however, doesn’t limit patient swallowing. Patient voluntary or involuntary swallowing may introduce significant tumor motion, which can lead to suboptimal delivery. In this study, we have examined the feasibility of using surface mapping technology to detect patient swallowing during treatment and evaluated its magnitude. Methods: The C-RAD Catalyst system was used to detect the patient surface map. A volunteer lying on the couch was used to simulate the patient under treatment. A virtual marker was placed near the throat and was used to monitor the swallowing action. The target motion calculated by the Catalyst system through deformable registration was also collected. Two treatment isocenters, one placed close to the throat and the other placed posterior to the base-of-tongue, were used to check the sensitivity of surface mapping technique. Results: When the patient’s throat is not in the shadow of the patient’s chest, the Catalyst system can clearly identify the swallowing motion. In our tests, the vertical motion of the skinmore » can reach to about 5mm. The calculated target motion can reach up to 1 cm. The magnitude of this calculated target motion is more dramatic when the plan isocenter is closer to the skin surface, which suggests that the Catalyst motion tracking technique is more sensitive to the swallowing motion with a shallower isocenter. Conclusion: Surface mapping can clearly identify patient swallowing during radiation treatment. This information can be used to evaluate the dosimetric impact of the involuntary swallowing. It may also be used to potentially gate head-&-neck radiation treatments. A prospective IRB approved study is currently enrolling patients in our institution. Research was funded through an Elekta grant.« less

Validating the Use of Surfacing Mapping Tools for Monitoring Motion and Irregular Breathing Patterns for Lung SBRT Patients Purpose: In this study, we have examined the utility of surface mapping in the treatment of lung SBRT patients. We examined the extent to which intra-fraction patient motion and irregular breathing patterns impact the accuracy of treatment deliveries. Materials and Methods: The C-RAD Catalyst, an optical surface mapping system was used to track the intra-fractional isocenter motion of five lung SBRT patients treated with VMAT. A respiratory tracking tool was used to track the breathing pattern of these patients and to correlate the breathing pattern to the isocenter motion. Results: For 2 of the 5 patients the isocenter displacement exceeding the 5mm planning margin for a portion of the treatment delivery with the time outside of tolerance at 2.2%, and 2.5%. Conclusions: 1) Breathing patterns may change between different fractions for the same patient; 2)Breathing patterns can change from the beginning to the end of the same fraction; 3) Not only amplitude, but also the baseline of breathing may change during an individual fraction; 4) We cannot predict which patients will have a stable isocenter in treatment even after the simulation study; and5)Real-time motion monitoring with surface-mapping tools and respiratory gating (free breathing or breath-hold) may provide clinically valuable solution in motion management for lung SBRT patients. The research is supported by funding from Elekta.

Purpose: In this study, we evaluated the performance of an Elekta linac in the delivery of gated radiotherapy. We examined whether the use of either a short gating window or a long beam hold impacts the accuracy of the delivery Methods: The performance of an Elekta linac in the delivery of gated radiotherapy was assessed using a 20cmX 20cm open field with the radiation delivered using a range of beam-on and beam-off time periods. Two SBRT plans were used to examine the accuracy of gated beam delivery for clinical treatment plans. For the SBRT cases, tests were performed for both free-breathing based gating and for gated delivery with a simulated breath-hold. A MatriXX 2D ion chamber array was used for data collection, and the gating accuracy was evaluated using gamma score. Results: For the 20cmX20cm open field, the gated beam delivery agreed closely with the non-gated delivery results. Discrepancies in the agreement, however, began to appear with a 5-to-1 ratio of the beam-off to beam-on. For these tight gating windows, each beam-on segment delivered a small number of monitor units. This finding was confirmed with dose distribution analysis from the delivery of the two VMAT plans where the gamma score(±1%,2%/1mm) showed passing rates in the range of 95% to 100% for gating windows of 25%, 38%, 50%, 63%, 75%, and 83%. Using a simulated sinusoidal breathing signal with a 4 second period, the gamma score of freebreathing gating and breath-hold gating deliveries were measured in the range of 95.7% to 100%. Conclusion: The results demonstrate that Elekta linacs can be used to accurately deliver respiratory gated treatments for both free-breathing and breath-hold patients. The accuracy of beams delivered in a gated delivery mode at low small MU proved higher than similar deliveries performed in a non-gated (manually interrupted) fashion.

Purpose: Clinical implementation of gated lung SBRT requires tools to verify the accuracy of the target positioning on a daily basis. This is a particular challenge on Elekta linacs where the XVI imaging system does not interface directly to any commercial gating solution. In this study, we used the Elekta's intra-fractional imaging functionality to perform the pretreatment CBCT verifications and evaluated both the image quality and gating accuracy. Methods: To use intrafraction imaging tools for pretreatment verifications, we planned a 360-degree arc with 1mmx5mm MLC opening. This beam was designed to drive the gantry during the gated CBCT data collection. A Catphan phantom was used to evaluate the image quality for the intra-fractional CBCT. A CIRS lung phantom with a 3cm sphereinsert and a moving chest plate were programmed with a simulated breathhold breathing pattern was used to check the gating accuracy. A C-Rad CatalystHD surface mapping system was used to provide the gating signal. Results: The total delivery time of the arc was 90 seconds. The uniformity and low contrast resolution for the intra-fractional CBCT was 1.5% and 3.6%, respectively. The values for the regular CBCT were 1.7% and 2.5%, respectively. The spatial resolution was 7 line-pairs/cm and the 3D spatial integrity was less than 1mm for the intra-fractional CBCT. The gated CBCT clearly demonstrated the accuracy of the gating image acquisition. Conclusion: The intra-fraction CBCT capabilities on an Elekta linac can be used to acquire pre-treatment gated images to verify the accuracy patient positioning. This imaging capability should provide for accurate patient alignments for the delivery of lung SBRT. This research was partially supported by Elekta

Intensity modulated arc therapy (IMAT) is a radiation therapy delivery technique that combines the efficiency of arc based delivery with the dose painting capabilities of intensity modulated radiation therapy (IMRT). A key challenge in developing robust inverse planning solutions for IMAT is the need to account for the connectivity of the beam shapes as the gantry rotates from one beam angle to the next. To overcome this challenge, inverse planning solutions typically impose a leaf motion constraint that defines the maximum distance a multileaf collimator (MLC) leaf can travel between adjacent control points. The leaf motion constraint ensures the deliverability of the optimized plan, but it also impacts the plan quality, the delivery accuracy, and the delivery efficiency. In this work, the authors have studied leaf motion constraints in detail and have developed recommendations for optimizing the balance between plan quality and delivery efficiency.Two steps were used to generate optimized IMAT treatment plans. The first was the direct machine parameter optimization (DMPO) inverse planning module in the Pinnacle(3) planning system. Then, a home-grown arc sequencer was applied to convert the optimized intensity maps into deliverable IMAT arcs. IMAT leaf motion constraints were imposed using limits of between 1 and 30 mm∕deg. Dose distributions were calculated using the convolution∕superposition algorithm in the Pinnacle(3) planning system. The IMAT plan dose calculation accuracy was examined using a finer sampling calculation and the quality assurance verification. All plans were delivered on an Elekta Synergy with an 80-leaf MLC and were verified using an IBA MatriXX 2D ion chamber array inserted in a MultiCube solid water phantom.The use of a more restrictive leaf motion constraint (less than 1-2 mm∕deg) results in inferior plan quality. A less restrictive leaf motion constraint (greater than 5 mm∕deg) results in improved plan quality but can lead to less accurate dose distribution as evidenced by increasing discrepancies between the planned and the delivered doses. For example, the results from our patient-specific quality assurance measurements demonstrated that the average gamma analysis passing rate decreased from 98% to 80% when the allowable leaf motion increased from 3 to 20 mm∕deg. Larger leaf motion constraints also led to longer treatment delivery times (2 to 4 folds) due to the additional MLC leaf motion.Leaf motion constraints significantly impact IMAT plans in terms of plan quality, delivery accuracy, and delivery efficiency with the impact magnified for more complex cases. Our studies indicate that a leaf motion constraint of 2 to 3 mm∕deg of gantry rotation can provide an optimal balance between plan quality, delivery accuracy, and efficiency.

Intensity-modulated arc therapy (IMAT) is a rotational approach to radiation therapy delivered on a conventional linear accelerator using a conventional multileaf collimator. There are 2 key advantages of IMAT. First, the rotational nature of the delivery provides great flexibility in shaping each dose distribution. As a result, IMAT can provide dosimetric advantages relative to fixed-field intensity-modulated radiation therapy (IMRT). The second advantage is the highly efficient nature of the delivery. For centers with an active IMRT program, the clinical implementation of IMAT should be relatively straightforward. For clinical implementation of IMAT, it is important to fully characterize the accuracy of the dose model used, and the performance of the quality assurance equipment.

The objective of this study was to investigate the influence of tumor motion on dose delivery in stereotactic body radiotherapy (SBRT) for lung cancer, using fixed field intensity- modulated radiotherapy (IMRT) and volumetric modulated arc therapy (VMAT).For each of 10 patients with stage I/II non-small-cell pulmonary tumors, a respiration-correlated four-dimensional computed tomography (4DCT) study was carried out. The internal target volume was delineated on the maximum intensity projection CT, which was reconstructed from the 4DCT dataset. A 5-mm margin was used for generation of the planning target volume. VMAT and five-field IMRT plans were generated using Pinnacle(3) SmartArc and direct machine parameter optimization, respectively. All plans were generated for an Elekta Synergy linear accelerator using 6-MV photons. Simulation was performed to study the interplay between multileaf collimator (MLC) sequences and target movement during the delivery of VMAT and IMRT. For each plan, 4D dose was calculated using deformable image registration of the 4DCT images. Target volume coverage and doses to critical structures calculated using 4D methodology were compared with those calculated using 3D methodology.For all patients included in this study, the interplay effect was found to present limited impact (less than 1% of prescription) on the target dose distribution, especially for SBRT, in which fewer fractions (three fractions) are delivered. Dose to the gross tumor volume (GTV) was, on average, slightly decreased (1% of prescription) in the 4D calculation compared with the 3D calculation. The motion impact on target dose homogeneity was patient-dependent and relatively small.Both VMAT and IMRT plans experienced negligible interplay effects between MLC sequence and tumor motion. For the most part, the 3D doses to the GTV and critical structures provided good approximations of the 4D dose calculations.

Helical tomotherapy (HT) and volumetric modulated arc therapy (VMAT) are arc-based approaches to IMRT delivery. The objective of this study is to compare VMAT to both HT and fixed field IMRT in terms of plan quality, delivery efficiency, and accuracy.Eighteen cases including six prostate, six head-and-neck, and six lung cases were selected for this study. IMRT plans were developed using direct machine parameter optimization in the Pinnacle3 treatment planning system. HT plans were developed using a Hi-Art II planning station. VMAT plans were generated using both the Pinnacle3 SmartArc IMRT module and a home-grown arc sequencing algorithm. VMAT and HT plans were delivered using Elekta's PreciseBeam VMAT linac control system (Elekta AB, Stockholm, Sweden) and a TomoTherapy Hi-Art II system (TomoTherapy Inc., Madison, WI), respectively. Treatment plan quality assurance (QA) for VMAT was performed using the IBA MatriXX system while an ion chamber and films were used for HT plan QA.The results demonstrate that both VMAT and HT are capable of providing more uniform target doses and improved normal tissue sparing as compared with fixed field IMRT. In terms of delivery efficiency, VMAT plan deliveries on average took 2.2 min for prostate and lung cases and 4.6 min for head-and-neck cases. These values increased to 4.7 and 7.0 min for HT plans.Both VMAT and HT plans can be delivered accurately based on their own QA standards. Overall, VMAT was able to provide approximately a 40% reduction in treatment time while maintaining comparable plan quality to that of HT.

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.

Purpose Intensity-modulated arc therapy (IMAT) is an arc-based approach to intensity-modulated radiotherapy (IMRT) that can be delivered on a conventional linear accelerator using a conventional multileaf collimator. In a previous work, we demonstrated that our arc-sequencing algorithm can produce highly conformal IMAT plans. Through plan comparisons, we explored the ability of IMAT to serve as an alternative to helical tomotherapy. Methods and Materials The IMAT plans were created for 10 patients previously treated with helical tomotherapy. Treatment plan comparisons, according to the target dose coverage and critical structure sparing, were performed to determine whether similar plan quality could be achieved using IMAT. Results In 8 of 10 patient cases, IMAT was able to provide plan quality comparable to that of helical tomotherapy. In 2 of these 8 cases, the use of non-axial coplanar or non-coplanar arcs in IMAT planning led to significant improvements in normal tissue sparing. The remaining 2 cases posed particular dosimetric challenges. In 1 case, the target was immediately adjacent to a spinal cord that had received previous irradiation. The second case involved multiple target volumes and multiple prescription levels. Both IMAT and tomotherapy were able to produce clinically acceptable plans. Tomotherapy, however, provided a more uniform target dose and improved critical structure sparing. Conclusions For most cases, IMAT can provide plan qualities comparable to that of helical tomotherapy. For some intracranial tumors, IMAT's ability to deliver non-coplanar arcs led to significant dosimetric improvements. Helical tomotherapy, however, can provide improved dosimetric results in the most complex cases.

A new leaf-sequencing approach has been developed that is designed to reduce the number of required beam segments for step-and-shoot intensity modulated radiation therapy (IMRT). This approach to leaf sequencing is called continuous-intensity-map-optimization (CIMO). Using a simulated annealing algorithm, CIMO seeks to minimize differences between the optimized and sequenced intensity maps. Two distinguishing features of the CIMO algorithm are (1) CIMO does not require that each optimized intensity map be clustered into discrete levels and (2) CIMO is not rule-based but rather simultaneously optimizes both the aperture shapes and weights. To test the CIMO algorithm, ten IMRT patient cases were selected (four head-and-neck, two pancreas, two prostate, one brain, and one pelvis). For each case, the optimized intensity maps were extracted from the Pinnacle3 treatment planning system. The CIMO algorithm was applied, and the optimized aperture shapes and weights were loaded back into Pinnacle. A final dose calculation was performed using Pinnacle's convolution/superposition based dose calculation. On average, the CIMO algorithm provided a 54% reduction in the number of beam segments as compared with Pinnacle's leaf sequencer. The plans sequenced using the CIMO algorithm also provided improved target dose uniformity and a reduced discrepancy between the optimized and sequenced intensity maps. For ten clinical intensity maps, comparisons were performed between the CIMO algorithm and the power-of-two reduction algorithm of Xia and Verhey [Med. Phys. 25(8), 1424-1434 (1998)]. When the constraints of a Varian Millennium multileaf collimator were applied, the CIMO algorithm resulted in a 26% reduction in the number of segments. For an Elekta multileaf collimator, the CIMO algorithm resulted in a 67% reduction in the number of segments. An average leaf sequencing time of less than one minute per beam was observed.

Purpose: In this work, we have tested the performance of new respiratory gating solutions for Elekta linacs. These solutions include the Response gating and the C-RAD Catalyst surface mapping system.Verification measurements have been performed for a series of clinical cases. We also examined the beam on latency of the system and its impact on delivery efficiency. Methods: To verify the benefits of tighter gating windows, a Quasar Respiratory Motion Platform was used. Its vertical-motion plate acted as a respiration surrogate and was tracked by the Catalyst system to generate gating signals. A MatriXX ion-chamber array was mounted on its longitudinal-moving platform. Clinical plans are delivered to a stationary and moving Matrix array at 100%, 50% and 30% gating windows and gamma scores were calculated comparing moving delivery results to the stationary result. It is important to note that as one moves to tighter gating windows, the delivery efficiency will be impacted by the linac's beam-on latency. Using a specialized software package, we generated beam-on signals of lengths of 1000ms, 600ms, 450ms, 400ms, 350ms and 300ms. As the gating windows get tighter, one can expect to reach a point where the dose rate will fall to nearly zero, indicating that themore » gating window is close to beam-on latency. A clinically useful gating window needs to be significantly longer than the latency for the linac. Results: As expected, the use of tighter gating windows improved delivery accuracy. However, a lower limit of the gating window, largely defined by linac beam-on latency, exists at around 300ms. Conclusion: The Response gating kit, combined with the C-RAD Catalyst, provides an effective solution for respiratorygated treatment delivery. Careful patient selection, gating window design, even visual/audio coaching may be necessary to ensure both delivery quality and efficiency. This research project is funded by Elekta.« less

Purpose: Recently, there has been a renewed interest in the delivery of arcbased IMRT using conventional linear accelerators. Elekta and Varian have developed linear acceleratorcontrol systems that are capable of delivering rotational IMRT by combining gantry rotation, dynamic MLC leaf motion, and a variable dose rate. Elekta's new Precise Beam Infinity™ control system has been installed in our clinic and acceptance testing and plan verifications have been performed. In this study, we will report on our initial experiences with volumetric modulated arc therapy (VMAT) delivered using an Elekta Precise linear accelerator.Method and Materials: VMAT is a radiotherapydelivery technique that combines the dosimetric advantages of rotational delivery with the dose painting capabilities of IMRT. We have developed an arc sequencing algorithm that translates optimized fluence maps into deliverable VMAT treatment plans. In this investigation, one head‐and‐neck and five prostate plans have been delivered in an effort to quantify the efficiency and accuracy of the VMAT delivery system. Results: A complex head‐and‐neck plan involving two targets and a simultaneous boost was delivered in 5 minutes 29 seconds. For this three‐arc head‐and‐neck plan, the point dose agreed within 1.9%. Additional measurements for 5 prostate cases demonstrated an average delivery time of 3 minutes 28 seconds with all ion chamber measurements agreeing within 3%. Film measurements demonstrated close agreement between the predicted and measured isodose curves. Measurements have also been performed to quantify efficiency of single‐arc versus multi‐arc VMAT deliveries.Conclusion: Elekta's Precise Beam Infinity control system can safely and efficiently delivery highly complex VMAT treatment plans. In our initial investigation, all plans delivered in less than 5.5 minutes. Numerous additional plan verifications will be performed as we move towards an anticipated clinical implementation of VMAT in May 2008. Research sponsored in part through a grant from Elekta.

Purpose: KV cone‐beam CTimaging(CBCT) was used to analyze setup errors when treating patients with non‐small cell lungcancer(NSCLC). For patients where an off‐line correction strategy was adopted, CBCT was also used to determine the patient specific planning target volume (PTV). Method and Materials: Eighteen patients with NSCLC were treated with CBCTimage‐guidedradiotherapy using an Elekta Synergy linac. 4D‐CT imaging was used for treatment planning. Patients were scanned in the supine position during normal relaxed free‐breathing and were immobilized with a wing‐board. The internal target volume (ITV) was determined using the maximum‐intensity‐projection (MiP) CT data to account for organ motion. A 5‐mm PTV margin was used to account for setup error. On‐line setup correction was based on the daily CBCTimaging prior to treatment. The systematic and random errors were analyzed retrospectively. The results were then fit to our CBCT off‐line correction strategy where a setup correction was made at the fifth treatment fraction to correct for the systematic error. The patient specific PTV margin was also analyzed.Results: The systematic and random errors were 5.7 ± 3.2 mm, 4.2 ± 2.6 mm and 4.8 ± 3.1 mm for anterior‐posterior (AP), medial‐lateral (ML) and superior‐inferior (SI) directions respectively. The 3D displacement vectors were 4.1 mm ± 3.1 mm (systematic ± random). If the patients were treated with the off‐line correction strategy, a patient specific PTV margin ranging from 7.0 to 17.4 mm would be needed. Conclusions: The use of a 5 mm PTV margin on the ITV determined by MiP dataset combined with daily CBCT on‐line correction is adequate to avoid geometric miss of the tumor for NSCLC patients. A larger patient specific PTV margin, ranging from 7.0 to 17.4 mm, would be needed if an off‐line correction is used.

Purpose: To develop an image‐guidedradiotherapy technique for compensating intra‐fraction organ motions by taking full advantage of 4‐D CT and motion tracking. Methods and Material: We have developed a new image‐guidedradiotherapy technique called patient breathing motion‐synchronized intensity‐modulated arc therapy (IMAT) based on the following observations. (1) If the LINAC gantry rotates x degrees in one breathing cycle during an IMAT arc delivery, then the beam source “sees” the same breathing phase at beam angles spaced x degrees apart. (2) If each breathing cycle is divided into k breathing phases, then we can partition all discrete beam angles used for planning an IMAT treatment into k groups, with each group “seeing” a particular breathing phase. If one can first calculate an intensity map for each group of beam angles using their corresponding snapshot in the 4D CTimage set as a gantry‐fixed IMRT plan, then the resulting k groups of intensity maps can be combined and converted into a final set of IMAT treatment arcs. As long as the patient can reproduce his/her own pre‐recorded breathing patterns, the IMAT plan can be delivered and is optimal in 4‐D. (3) To ensure that the patient's breathing is always at the correct breathing phase at the start of the irradiation of each IMAT arc, the beam is not turned on after pressing the “Beam‐On” button until the breathing pattern reaches the predetermined phase through motion tracking. Results: We applied the motion‐synchronized IMAT technique to the dynamic phantom from CIRS Inc., which can simulate patient breathing motions. Our experimental study indicated that this technique can deliver optimal treatments under motions. Conclusion: We have developed a new image‐guidedradiotherapy technique called patient breathing motion‐synchronized IMAT. Our prototype study has demonstrated the feasibility and advantage of this novel method that warrants further investigation.

Purpose: We have tested the capabilities of an innovative surface‐mapping system that utilizes deformable image registration tools (C‐RAD Catalyst). Its 3D positioning stability has been verified as well as its respiratory capabilities. Methods: The Catalyst daily QA phantom was used to test the stability of the system. A MatriXX ion‐chamber array in a solid water phantom was mounted on a motion platform which can provide longitudinal 1D motion.The vertical‐motion plate (respiratory plate) of the platform was used to mimic the chest movement in respiratory cycles. The respiratory plate was tracked by the Catalyst surface‐mapping system. A static 10×10 field was first delivered to establish the baseline. Gated deliveries using different gating windows (from 10% to 90% duty cycle) were also performed and the results were recorded. A comparison between the Catalyst surface tracking signal and ABC data was performed for a breast cancer patient on‐treatment. Results: Analysis of the experiment data indicates that the Catalyst is stable and reliable in detecting surface position and movement. With 50 numbers of phantom setups, the mean deviation of the shifts and rotations along all three directions was 0.6mm and 0.02 degrees, respectively. The gating capacity study suggested that respiratory gating using Catalyst system on an Elekta linac can be delivered safely and accurately. In fact, in gated beam delivery with the Catalyst system, dose distribution, dose profiles, gamma passing rates all show improvements as the gating window gets smaller. Gamma passing rates increase from 84.7% at non‐gating to 95.6% at 10% gating window. The Catalyst system also correctly recognizes the respiratory pattern of a patient under our ABC gated treatment delivery. Conclusion: Based on a phantom study and clinical observations, we have found that Catalyst system is robust in surface tracking and positioning. It also can serve as a respiratory gating solution. Funded by Elekta

Purpose: In this study, we evaluated the accuracy and clinical effectiveness of a novel surface mapping system utilizing deformable image registration. Comparisons were made between the shifts determined using conebeam CT (CBCT) and those calculated using the surface mapping tool, the C‐RAD Catalyst. Materials and Methods: For the CBCT and surface mapping comparisons, a turkey was used as a patient surrogate. A reference CT scan was first taken when the turkey was frozen (non‐deformable). Initial setups were made using the Catalyst system for each of two locations (spine and left breast). A CBCT scan was performed immediately after each Catalyst setup. The three dimensional shifts and rotations along three axes were recorded for comparison purposes. Setups were made using both the frozen (non‐deformable) and unfrozen (deformable) turkey. Results: When the turkey was frozen, surface mapping and CBCT setups agreed within 2mm. A 2‐degree rotation along longitudinal axis detected by the Catalyst system was confirmed with CBCT based alignment. For tests performed after the turkey was defrosted, differences of up to 10mm were observed in the vertical positioning when comparing setups performed using surface mapping and CBCT. The left breast site setup using Catalyst agreed closely with the CBCT data even when significant body deformation was introduced. The rotations obtained from Catalyst and CBCT data agreed within 2 degrees for both treatment sites with body deformation. Conclusions: As a surface mapping technology, the C‐RAD Catalyst system can provide accurate and efficient patient setup when there is no significant body deformation. Caution must be exercised, however, in using this tool in cases where significant deformation may occur particularly when the isocenter is significantly displaced from the detected patient surface. Research was partially funded by Elekta

Purpose: The objective of this study is to investigate the impact of the interplay effect between multi‐leaf collimator(MLC) sequences and tumor motion in the delivery of lungradiotherapy using both volumetric modulated arc therapy (VMAT) and fixed‐field intensity‐modulated radiotherapy(IMRT).Methods and Materials: For 10 patients with Stage I/II non‐small‐cell pulmonary tumors, a respiratory‐correlated four dimensional computed tomography (4DCT) study was acquired. The internal target volume was determined based on the maximum intensity projection 4DCT dataset, and a 3 to 5 mm margin was used for generation of the planning target volume. VMAT and 5‐field IMRT (step‐and‐shoot) plans were generated using Pinnacle3 SmartArc and direct machine parameter optimization (DMPO), respectively. All plans were generated for an Elekta Synergy linear accelerator using 6‐MV photons. A model was developed to simulate the interplay between MLC sequences and target movement during the delivery of VMAT and IMRT, respectively. The 4D dose distributions were calculated using a non‐rigid deformable image registration algorithm. Target volume coverage and doses to critical structures calculated using 4D methodology were compared with those calculated using 3D methodology. Results: For all patients included in this study, the interplay effect was found to present limited impact (less than 0.5%) on the target dose distribution, especially for stereotactic body radiation therapy, in which fewer fractions (3∼5) are delivered. The dose to the GTV was slightly decreased on average (1% of prescription) in the 4D calculation compared with the 3D calculation. The motion impact on target dose homogeneity was patient dependent and relatively small. Negligible effects were observed on the doses to critical structures. Conclusions: Both VMAT and IMRT plans experienced negligible interplay effects between MLC sequence and tumor motion. For the most part, the 3D doses to the GTV and critical structures provided good approximations of the 4D dose calculations.

Purpose: In this work, we report on our initial testing, commissioning, and clinical implementation of the Elekta's VMAT planning solution in the Monaco treatment planning system. Monaco VMAT was released clinically in February 2010. Method and Materials: Monaco is an IMRT‐only treatment planning system that was recently updated to include an inverse planning module for VMAT. VMAT plans are produced using a two‐step process. First, optimized fluence maps are determined from each beam direction. Next, the optimized maps are translated into a deliverable VMAT sequence. VMAT plans are delivered using a sweeping window technique where the leaves move unidirectionally across the field in alternating directions over the course of each arc. We have tested the Monaco VMAT system for a variety of treatment sites including intracranial, prostate, and head‐and‐neck. Initially five cases have been planned and verified. For each case, comparisons were made with both fixed field IMRT and VMAT plans produced using the Philips SmartArc planning module. Plan verifications were performed using phantom irradiations with the IBA MatriXX 2D ion chamber array embedded in a MULTIcube phantom. Results: On average, single arc Monaco VMAT plans delivered in 4 minutes 24 seconds. Plans verified with an average of 99.6% of the points passing a gamma analysis using a 3%/3mm distance to agreement criteria. For complex head and neck cases, Monaco produced VMAT plans delivered using a hybrid technique combining rotational and fixed field delivery. The hybrid delivery technique provided greater flexibility in shaping the dose distributions but significantly lengthened the deliver times. Conclusion: Elekta's Monaco VMAT planning tools provides a full inverse planning solution for VMAT. All of our plans have delivered accurately and the commissioning process has been completed. We anticipate commencing Monaco VMAT treatments in March 2010. Research sponsored in part through a grant from Elekta.