Flattening Filter Free Beams Research Articles

Monte Carlo computation of photon energy spectra in central axis of flattened and unflattened beams and doses in critical organs in a water phantom model of prostate radiotherapy

A thorough understanding of the energy spectra for clinical linear accelerators is essential in modern cancer treatment planning. We aimed to determine the radiation spectra and out-of-field doses in a water phantom under the conditions of prostate radiotherapy in beams with a flattening filter (FF) and without (FFF). Monte Carlo simulations were performed to determine the energy spectra and doses outside the irradiated volume. Doses were registered in locations corresponding to critical organs (kidneys, lungs, and thyroid) and the spectra was determined in the central axis (prostate gland). Simulations were conducted for 6 MV and 10 MV for FF and FFF beams. The out-of-field doses were calculated at selected points from the field edge for 6 MV photon beams (FF and FFF), and for 10 and 15 MV beams (FFF only). Compared to FF beams, we found that the mean energy for the photon spectra of FFF beams was lower. For 6 MV FF beams, the relative doses for the critical organs (kidneys, lungs and thyroid) were 0.7%, 1.2%, 0.6% versus 1.6%, 1.2%, 1.3% for the unflattened beams. For 10 MV FF beams, the out-of-field doses to the organs were 0.1%, 0.4% and 0.4% versus 0.4%, 0.2% and 0.3% with the FFF beam. FFF beams had a higher photon fluence, indicating less scattered radiation. Removal of the filter leads to lower doses in the areas surrounding the irradiated volumes, especially at large distances from the treatment field. These findings are consistent with previous reports, indicating that flattening filter free beams are likely to improve clinical outcomes. The reduction in scattered radiation lowers the probability of inducing second cancers.

Retrospective study of random and systematic errors in Head and Neck cancer Patients with Image guided Helical Intensity Modulated Radiation Therapy

The Precision of radiotherapy is checked based on the matching of pre-treatment 2D portal imaging/CBCT to the reference image. The objective of this study is to find inter-fractional systematic and random setup errors (mm) for head and Neck cancer patients and also find setup margin for Planning Target Volume (PTV) at Mohan Dai Oswal Cancer Hospital Ludhiana Punjab. Inter-fractional motion errors were quantified for 10 Head and neck cancer patients who underwent image guided helical intensity modulated radiation therapy with Radixact X9 machine. One hundred fan beam computed tomography scans of 2mm slice thickness, 3.5 MV average energy and flattening filter free beam has been used to collect the data for the calculation of systematic and random errors. After patient immobilization, patient accuracy is checked with registration of pre-treatment image with reference planning image with the help of Accuray Precision image guidance protocol. For every patient 10 fan beam computed tomography images has been taken. Translational errors have been calculated in X, Y and Z direction to find systematic error (∑) and random error (σ). The final PTV margin is calculated by van Herk’s equation (2.5∑ + 0.7σ). The results of this study shows that mean translational errors varies from -2.3 mm to 3.3 mm in lateral direction (X), -3.6 mm to 1.7 mm in longitudinal direction (Y), -2.7 mm to 1.5 mm in vertical direction (Z). The mean and standard deviation (SD) for systematic errors are 1.467, 0.8, 0.923 and random error 0.0595, 0.02266, 0.03824 in X, Y and Z direction has been calculated. The Total Margin for CTV to PTV which include setup margin (mm) in X, Y and Z direction are 3.7 mm, 2.02 mm and 2.33 mm. In addition to that, a PTV margin of 5.00 mm is the appropriate margin for Mohan Dai Oswal Cancer Hospital’s patients. This work conclude that CTV to PTV margin of 5.00 mm is suitable for image guided helical intensity modulated radiation therapy for Head and neck patients to ensure the minimum 95% coverage of dose to target

3D star shot analysis using MAGAT gel dosimeter for integrated imaging and radiation isocenter verification of MR-Linac system.

PurposeThis study aims to investigate a star shot analysis using a three‐dimensional (3D) gel dosimeter for the imaging and radiation isocenter verification of a magnetic resonance linear accelerator (MR‐Linac).MethodsA mixture of methacrylic acid, gelatin, and tetrakis (hydroxymethyl) phosphonium chloride, called MAGAT gel, was fabricated. One MAGAT gel for each Linac and MR‐Linac was irradiated under six gantry angles. A 6 MV photon beam of Linac and a 6 MV flattening filter free beam of MR‐Linac were delivered to two MAGAT gels and EBT3 films. MR images were acquired by MR‐Linac with a clinical sequence (i.e., TrueFISP). The 3D star shot analysis for seven consecutive slices of the MR images with TrueFISP was performed. The 2D star shot analysis for the central plane of the gel was compared to the results from the EBT3 films. The radius of isocircle (ICr) and the distance between the center of the circle and the center marked on the image (ICd) were evaluated.ResultsFor MR‐Linac with MAGAT gel measurements, ICd at the central plane was 0.46 mm for TrueFISP. Compared to EBT3 film measurements, the differences in ICd and ICr for both Linac and MR‐Linac were within 0.11 and 0.13 mm, respectively. For the 3D analysis, seven consecutive slices of TrueFISP images were analyzed and the maximum radii of isocircles (ICr_max) were 0.18 mm for Linac and 0.73 mm for MR‐Linac. The tilting angles of radiation axis were 0.31° for Linac and 0.10° for MR‐Linac.ConclusionThe accuracy of 3D star shot analysis using MAGAT gel was comparable to that of EBT3 film, having a capability for integrated analysis for imaging isocenter and radiation isocenter. 3D star shot analysis using MAGAT gel can provide 3D information of radiation isocenter, suggesting a quantitative extent of gantry‐tilting.

Small static radiosurgery field dosimetry with small volume ionization chambers

PurposeTo evaluate the response of the four smallest active volume thimble type ionization chambers commercially available (IBA-dosimetry RAZOR Nano Chamber, Standard Imaging Exradin A16, IBA-dosimetry CC01 and PTW T31022) when measuring SRS cone collimated Flattening Filter Free (FFF) fields. MethodsWe employed Monte Carlo simulation for calculating correction factors as defined in IAEA TRS-483. Monte Carlo simulation beam model and ion chamber geometry definitions were supported by an extensive set of measurements. Type A and B uncertainty components were evaluated. ResultsCommissioning of Monte Carlo 6 MV and 10 MV FFF beam models yielded relative differences between measured and simulated dose distributions lower than 1.5%. Monte Carlo simulated output factors for 5 mm SRS field agree with experimental values within 1% local relative difference for all chambers. Smallest active volume ion chamber (IBA-dosimetry RAZOR Nano Chamber) exhibits smallest correction, being compatible with unity. Correction factor combined uncertainties range between 0.7% and 0.9%. Smallest uncertainties were recorded for smallest and largest active volume ion chambers, although the latter exhibited largest correction factor. Highest contribution to combined uncertainty was type B component associated with beam model initial electron spatial Full Width Half Maximum (FWHM) uncertainty. ConclusionsAmong the investigated chambers, the IBA RAZOR Nano Chamber was found to be an excellent choice for narrow beam output factor measurement since it requires minimum correction (in line with IAEA TRS-483 recommendations). This is caused by its tiny size and tissue equivalence materials which produce minimum volume averaging and fluence perturbation.

Dosimetric comparison of normal breathing and deep inspiration breath hold technique for synchronous bilateral breast cancer using 6MV flattened beam and flattening filter free beam.

BackgroundThe present study was to investigate the usefulness of deep inspiration breath hold (DIBH) in bilateral breast patients using 6MV flattened beam (FB) and flattening filter free beam (FFFB).Materials and methodsTwenty bilateral breast cancer patients were simulated, using left breast patients treated with DIBH technique. CT scans were performed in the normal breathing (NB) and DIBH method. Three-dimensional conformal radiotherapy (3DCRT) and volumetric arc therapy (VMAT) plans were generated.ResultsIn our study the best organ at risk (OAR) sparing is achieved in the 3DCRT DIBH plan with adequate PTV coverage (V95 ≥ 47.5 Gy) as compared to 6MV FB and FFFB VMAT DIBH plans. The DIBH scan plan reduces the heart mean dose significantly at the rate of 49% in 3DCRT (p = 0.00) and 22% in VMAT (p = 0.010). Similarly, the DIBH scan plan produces lesser common lung mean dose of 18% in 3DCRT (p = 0.011) and 8% in VMAT (0.007) as compared to the NB scan. The conformity index is much better in VMAT FB (1.04 ± 0.04 vs. 1.04 ± 0.05), p =1.00 and VMAT FFFB (1.04 ± 0.05 vs. 1 ± 0.24, p = 0.345) plans as compared to 3DCRT (1.63 ± 0.2 vs. 1.47 ± 0.28, p = 0.002). The homogeneity index of all the plans is less than 0.15. The global dmax is more in VMAT FFFB DIBH plan (113.7%). The maximum MU noted in the NB scan plan (478 vs. 477MU, 1366 vs. 1299 MU and 1853 vs. 1788 MU for 3DCRT, VMAT FB and VMAT FFFB technique as compared to DIBH scan.ConclusionWe recommend that the use of DIBH techniques for bilateral breast cancer patients significantly reduces the radiation doses to OARs in both 3DCRT and VMAT plans.

Local dose rate effects in implantable cardioverter–defibrillators with flattening filter free and flattened photon radiation

PurposeIn the beam penumbra of stereotactic body radiotherapy volumes, dose rate effects in implantable cardioverter–defibrillators (ICDs) may be the predominant cause for failures in the absence of neutron-generating photon energies. We investigate such dose rate effects in ICDs and provide evidence for safe use of lung tumor stereotactic radioablation with flattening filter free (FFF) and flattened 6 Megavolt (MV) beams in ICD-bearing patients.MethodsSixty-two ICDs were subjected to scatter radiation in 1.0, 2.5, and 7.0 cm distance to 100 Gy within a 5 × 5 cm2 radiation field. Radiation was applied with 6 MV FFF beams (constant dose rate of 1400 cGy/min) and flattened (FLAT) 6 MV beams (430 cGy/min). Local dose rates (LDR) at the position of all ICDs were measured. All ICDs were monitored continuously.ResultsWith 6 MV FFF beams, ICD errors occurred at distances of 1.0 cm (LDR 46.8 cGy/min; maximum ICD dose 3.4 Gy) and 2.5 cm (LDR 15.6 cGy/min; 1.1 Gy). With 6 MV FLAT beams, ICD errors occurred only at 1 cm distance (LDR 16.8 cGy/min; 3.9 Gy). No errors occurred at an LDR below 7 cGy/min, translating to a safe distance of 2.5 cm (1.5 Gy) in flattened and 7 cm (0.4 Gy) in 6 MV FFF beams.ConclusionA LDR in ICDs larger than 7 cGy/min may cause ICD malfunction. At identical LDR, differences between 6 MV FFF and 6 MV FLAT beams do not yield different rates of malfunction. The dominant reason for ICD failures could be the LDR and not the total dose to the ICD. For most stereotactic treatments, it is recommended to generate a planning risk volume around the ICD in which LDR larger than 7 cGy/min are avoided.

Medical linac photon skyshine: Monte Carlo calculations and a methodology for estimates.

It has been shown that a widely quoted formula for estimating medical linac photon skyshine equivalent doses is erroneous. Monte Carlo calculations have been performed to develop an easy method for quickly and accurately estimating skyshine radiation levels and to gain improved physical insight into the skyshine phenomenon. Calculations of linac photon skyshine have been performed for 4, 6, 10, 15, and 18 MV beams for 10 × 10 cm2 and 40 × 40 cm2 fields and for a range of room dimensions and roof thicknesses. The effect of flattening filter free beams has been considered. Air kerma rates (AKRs) can be accurately fitted to a simple algebraic formula that is a function of the horizontal distance from the isocenter with a single energy dependent fitting parameter. The AKR, at a height of 1.3 m above level ground, reaches a local maximum at a distance d max = 1.5dw + 1.1h, where dw is the horizontal distance from the isocenter to the outside of the side wall, and h is the vertical distance from the isocenter to the top of the roof. For thin roofs, low energy beams lead to significantly more skyshine than high energy beams because low energy photons are more easily scattered through large angles. In the absence of a roof, the maximum skyshine dose rate is on the order of 8 × 10−7 times the dose rate at isocenter. The average energy of the skyshine photons is about 0.15 MeV, and it is remarkably independent of almost all parameters. A simple methodology is outlined for the evaluation of photon skyshine.

Flattening Filter-Free Volumetric-Modulated Arc Radiotherapy for Left-Sided Whole-Breast, Partial-Breast, and Postmastectomy Irradiations.

Purpose:Unflattened photon beams exhibit many benefits over traditional flattened beams for radiotherapy (RT), but comprehensive evaluations of dosimetric results and beam-on time using flattening filter-free (FFF) beams for all types of breast irradiations are still lacking. The purpose of this study was to investigate if FFF RT can maintain equal or better dose coverage than standard flattened-beam RT while reducing doses to organs at risk (OARs) and beam-on time for various types of breast cancer irradiations.Methods and Materials:FFF volumetric-modulated arc therapy (FFF-VMAT) and standard VMAT (STD-VMAT) treatment plans were created for 15 whole-breast irradiation (WBI) patients with 50 Gy/25 fractions, 13 partial-breast irradiation (PBI) patients with 38.5 Gy/10 fractions, and 9 postmastectomy irradiation (PMI) patients with 50 Gy/25 fractions. Planning target volume (PTV) coverage and dose to OARs were evaluated.Results:Both techniques produced clinically acceptable plans for all three types of irradiations. For WBI, FFF-VMAT plans exhibited similar PTV and OARs evaluation metrics as STD-VMAT. For PBI, FFF-VMAT plans showed significantly lower mean and maximum doses for ipsilateral and contralateral lungs, contralateral breast, and heart. For PMI, FFF-VMAT plans showed significantly lower mean dose and V5 for contralateral breast but significantly higher Dmean, Dmax, and V20 for ipsilateral lung and significantly higher Dmean, V22.5, and V30 for heart. FFF-VMAT techniques significantly reduced beam-on time than STD-VMAT for all cases.Conclusion:This work has shown that FFF beams are most beneficial for small-field irradiation such as PBI, and breast cancer patients could potentially benefit from the shortened beam-on time.

OD37 - Comparison of detectors performances in small field dosimetry of Versa HD flattened and flattening filter free beams

OD37 - Comparison of detectors performances in small field dosimetry of Versa HD flattened and flattening filter free beams

Evaluation of parameters affecting gamma passing rate in patient-specific QAs for multiple brain lesions IMRS treatments using ray-station treatment planning system.

PurposeUsing intensity‐modulated radiosurgery (IMRS) with single isocenter for the treatment of multiple brain lesions has gained acceptance in recent years. One of the challenges of this technique is conducting a patient‐specific quality assurance (QA), involving accurate gamma passing rate (GPR) calculations for small and wide spread‐out targets. We evaluated effects of parameters such as dose grid and energy on GPR using our clinical IMRS plans.MethodsTen patients with total of 40 volumetric modulated arc therapy (VMAT) plans were created in Raystation (V.8A) treatment planning system (TPS) for the Varian Edge Linac using 6 and 10 flattening filter‐free (FFF) beams and planned dose grids of 1 mm and 2 mm resulting in four plans with 6–10 targets per patient. All parameters and objectives except dose grid and energy were kept the same in all plans. Next, patient‐specific QAs were measured evaluating GPR with 10% threshold, 3%/3 mm objective, and an acceptance criterion of 95%. Modulation factors (MF) and confidence intervals were calculated. Two modes of measurements, standard density (SD) and high density (HD), were used.ResultsGenerally, plans computed with 1 mm dose grid have higher GPRs than those with 2 mm dose grid for both energies used. The GPRs of 6 FFF plans were higher than those of 10 FFF plans. GPR showed no noticeable difference between HD and SD measurements. Negative correlation between MF and GPR was observed. The HD pass rates fall within the confidence interval of SD.ConclusionCalculated dose grid should be less than or equal to one‐third of distance to agreement, thus 1 mm planned dose grid is recommended to reduce artifacts in gamma calculation. GPR of SD and HD measurement modes is almost the same, which indicates that SD mode is clinically preferable for performing patient‐specific QAs. According to our results, using 6 FFF beams with 1 mm planned dose grid is more accurate and reliable for dose calculation of IMRS plans.

Efficiency of modulated and dose rate altered flattening filter free beams in high dose per fraction radiotherapy applications on the survival of prostate cancer cell lines

Efficiency of modulated and dose rate altered flattening filter free beams in high dose per fraction radiotherapy applications on the survival of prostate cancer cell lines

Feasibility of operating a millimeter-scale graphite calorimeter for absolute dosimetry of small-field photon beams in the clinic.

To characterize and build a cylindrically layered graphite calorimeter the size of a thimble ionization chamber for absolute dosimetry of small fields. This detector has been designed in a familiar probe format to facilitate integration into the clinical workflow. The feasibility of operating this absorbed dose calorimeter in quasi-adiabatic mode is assessed for high-energy accelerator-based photon beams. This detector, herein referred to as Aerrow MK7, is a miniaturized version of a previously validated aerogel-insulated graphite calorimeter known as Aerrow. The new model was designed and developed using numerical methods. Medium conversion factors from graphite to water, small-field output correction factors, and layer perturbation factors for this dosimeter were calculated using the EGSnrc Monte Carlo code system. A range of commercially available aerogel densities were studied for the insulating layers, and an optimal density was selected by minimizing the small-field output correction factors. Heat exchange within the detector was simulated using a five-body compartmental heat transfer model. In quasi-adiabatic mode, the sensitive volume (a 3mm diameter cylindrical graphite core) experiences a temperature rise during irradiation on the order of 1.3mK·Gy-1 . The absorbed dose is obtained by calculating the product of this temperature rise with the specific heat capacity of the graphite. The detector was irradiated with 6MV ( =63.5%) and 10MV ( =71.1%) flattening filter-free (FFF) photon beams for two field sizes, characterized by dimensions of 2.16 and 11.0cm. The dose readings were compared against a calibrated Exradin A1SL ionization chamber. All dose values are reported at in water. The field output correction factors for this dosimeter design were computed for field sizes ranging from =0.54 to 11.0cm. For all aerogel densities studied, these correction factors did not exceed 1.5%. The relative dose difference between the two dosimeters ranged between 0.3% and 0.7% for all beams and field sizes. The smallest field size experimentally investigated, =2.16cm, which was irradiated with the 10MV FFF beam, produced readings of 84.4cGy (±1.3%) in the calorimeter and 84.5cGy (±1.3%) in the ionization chamber. The median relative difference in absorbed dose values between a calibrated A1SL ionization chamber and the proposed novel graphite calorimeter was 0.6%. This preliminary experimental validation demonstrates that Aerrow MK7 is capable of accurate and reproducible absorbed dose measurements in quasi-adiabatic mode.

Efficiency of modulated and dose rate altered flattening filter free beams in high dose per fraction radiotherapy applications on the survival of prostate cancer cell lines

Efficiency of modulated and dose rate altered flattening filter free beams in high dose per fraction radiotherapy applications on the survival of prostate cancer cell lines

Comparison of calculation algorithms to predict the IQM detector response for various modulation degrees of VMAT treatment plans on linear accelerator equipped with the HD120 MLC.

The calculation model for the integral quality monitor (IQM) system does not take into account the characteristics of the HD120 multileaf collimator (MLC), which some Varian accelerators are equipped with. Some treatment plans prepared with this collimator are characterized by a high level of modulation. The aim of the work was to prepare a model for that collimator and to determine the influence of modulation on results of the verification carried out with the use of IQM system. The short and long stabilities of the IQM detector response were verified by measuring the signal for a 6MV flattening filter-free (FFF) beam with the static field of 10×10cm2 size. The obtained results were compared with the measurements performed with the PTW Farmer chamber. Next, the signals for 35 static square fields 4×4cm2 , covering the whole field 38×20cm2 , were measured with the IQM. Based on the results of these measurements, the original calculation model has been changed in order to achieve the smallest differences between calculations and measurements. While tuning the model, the characteristics of the HD120 MLC were included. Measurements were performed for 30 clinical plans (86 arcs) prepared with 6MV FFF beams. Among those 30 plans, there were were multitarget plans with single isocenter. For each plan, the modulation complexity score (MCS) was calculated. The measurement results were compared with the calculation results performed with the original and authors' calculation model. Very good stability of the short and long stabilities of the IQM detector response was obtained. Measurements performed for 35 static fields revealed that for the manufacturer's and for the authors' models, the deviation exceeded 3% for 12 and five of the 35 static fields, respectively. The differences for the manufacturer's and authors' algorithms were in the range of ±2% for the 15 and 26 of the fields, respectively. For original and the authors' models, the differences between measured and calculated signals (starting with the segment number 40) were within the range of ±3.5% for 87.6% and 96.7% of all arcs for the respective models. For both models, the dependence of the compliance of measurements and calculations on the MCS was observed. For most of the very modulated arcs, the measured signal was at least 3% lower than the calculated one. The largest differences between measurements and calculations were obtained for single-isocenter multitarget plans. The signal predicted by an algorithm taking into account the real geometry of the collimating system of the Edge accelerator (equipped with the HD120 MLC) made it possible to obtain greater consistency between the measurements and calculations. We characterized the dependence between the MCS of each arc and the compliance of the measurements and calculations. Much worse results were obtained for single-isocenter multitarget plans.

Verification of Surface Dose for Flattening Filter and Flattening Filter Free Beams in Beam-Matched Medical Linear Accelerators.

Background:The purpose of this study was to evaluate the surface dose (SD) of 6 and 10 MV flattening filter beam (FF) and flattening filter free (FFF) beam for different square field sizes in three Beam-matched medical linear accelerators using a parallel-plate ionization chamber. Materials and Methods:The experiment was carried out in a phantom composed of 40×40 cm2 solid Water slabs of varying thickness. Further sheets of solid water phantom were added to take readings in the build-up region for both SSD and SAD technique. Surface doses are measured with a PPC-05 chamber and DOSE 1 electrometer, at measurement depth of 1 mm interval and all results are plotted relative to the dose measured at Dmax for various field sizes. Surface dose readings are therefore reported as relative surface dose. Results:Surface dose increased linearly with field size for both FF and FFF photon beams in all three beam-matched linear accelerators in both SSD and SAD setup. The surface dose of FFF was higher than FF beams in all field sizes. For the given energy the surface dose difference (relative to 10x10 cm2 field size of 6FF) between FF and FFF beam was larger for large field size. For 6FF and 6FFF beam the surface dose difference for 5x5 cm2 is -5.27%, and for 30x30 cm2 it is 12.91%. The measured surface dose differences between linear accelerators are not statically significant (P>0.989). Similarly, the surface dose difference between SSD and SAD setup was also analysed and had no statistical significance (P>0.849). Conclusion:Study showed that the surface dose difference between beam-matched linear accelerators are insignificant. The surface dose difference between SSD and SAD setup were also found negligible. Most importantly, changing patients between beam-matched linear accelerators will not have any significant changes in surface dose in clinical setup.

Comparison between flattening filter-free (FFF) and flattened photon beam VMAT plans for the whole brain radiotherapy (WBRT) with hippocampus sparing.

PurposeTo evaluate and investigate the feasibility of flattening filter‐free (FFF) beam for the whole‐brain radiotherapy (WBRT) with hippocampus sparing.MethodsEighteen patients with volumetric‐modulated arc therapy (VMAT) plans in FFF and conventional beam modes were included in this study. The prescribed dose was 30 Gy in 10 fractions. The conformity index (CI), heterogeneity index reported by TPS (HI‐M), and homogeneity index (HI) for planning target volume (PTV) were evaluated. Subsequently, the following parameters for PTV were calculated and compared: D 2%, D 98%; the mean dose, maximum dose, and minimal dose for OARs. Plan modulation index, total MUs, and the gamma index were used to evaluate the plan quality.ResultsHI‐M results were similar for the two techniques (1.239 vs. 1.247, respectively, p = 0.048); FFF beam plans yielded lower D2% compared to FF beam plans (3,416.3 cGy vs. 3,437.2 cGy, p = 0.22), mean dose (3,177.5 cGy vs. 3,195.2 cGy, p = 0.009), and CI (0.884 vs. 0.876, p = 0.001) for PTV. Significant differences were observed between the two beam modes (FF model vs. FFF model) for the maximum dose (1,612.9 cGy vs. 1,470.2 cGy, respectively, p < 0.001), minimum dose (987.6 cGy vs. 898.8 cGy, respectively, p < 0.001), and the mean dose (1144.4 cGy vs. 1047.3 cGy, respectively, p < 0.001) to the hippocampus, and the maximum dose to the eyes (2,792.6 cGy vs. 2,751.3 cGy, respectively, p < 0.001). The average total MUs for FFF‐VMAT plans was significantly greater than FF‐VMAT plans. However, differences for the plan modulation index and the gamma index were negligible.ConclusionIn comparison with FF beam, the FFF beam mode offers a clear benefit with respect to WBRT with hippocampal sparing.

Progress and prospects of flattening filter free beam technology in radiosurgery and stereotactic body radiotherapy.

The aim of this work is to summarize and evaluate the current status of knowledge on flattening filter free (FFF) beams and their applications in stereotactic radiosurgery (SRS) and stereotactic body radiotherapy (SBRT). A PubMed search was undertaken in order to identify relevant publications using FFF and stereotactic radiotherapy as keywords. On a clinical aspect, lung tumors treated with FFF SBRT show promising results in terms of local control and overall survival with acute toxicities consistent with those that occur with standard radiotherapy. Beside lung, SBRT is suitable for different anatomical sites such as liver, prostate, cervix, etc. offering similar results: reduced treatment time, good tumor control and mild acute toxicities. Regarding brain tumors, the employment of SRS with FFF beams significantly reduces treatment time and provides notable normal tissue sparing due to the sharp dose fall-off outside the tumor.

A regression-based approach to compute the pixels sensitivity map of linear accelerator portal imaging devices.

To determine the pixel sensitivity map (PSM) for amorphous silicon electronic portal imaging devices (EPIDs) using a single flood field signal. A raw EPID signal results from the incident particle energy fluence, the inherent pixels response, and the background signal. In large open fields, particle energy fluence is a slow-varying signal that is locally considered spatially constant. Pixels response is a fast and abrupt varying behavior. The background signal is due to the EPID panel electronics, which is determined during radiation absence. To determine the PSM, after correcting for the background signal, we apply a model that captures the underlying smooth particle energy fluence-induced signal. This fluence signal-fitted model is then used to determine the PSM. Here, we use a polynomial-based regression surface model in both x and y dimensions. To validate the generated PSM, we measure beams and compute PSMs for multiple beam energies with and without flattening filters and for multiple source-to-imager distances. Since the PSM is a detector characteristic, it should be independent of those variables. We also intercompare measurements of fixed slit fields with the EPID being shifted between measurements. The fluence signal of the flattening filter-free (FFF) beams was optimally modeled as a 12th degree polynomial surfaces, which had 0.1% residuals near the central axis. The 6 and 10MV FFF PSMs were within ˜0.1%, and independent of the EPID SID, suggesting that the PSM is energy independent. The 6, 10, and 15MV flattened-beam PSMs were well modeled as 12th degree polynomial surfaces, which were equivalent within ˜0.24% but differed from the FFF PSM by up to 0.5% near the beam central axis. Applying the FFF PSMs to the flattened-beam measurements reduced the central-axis deviation between the raw and corrected signal to 0.1%, confirming the PSM energy independence hypothesis. When the FFF PSM is utilized, output verification with shifted slit deliveries agreed within ˜0.5% for all beam energies, which is within the radiation delivery uncertainty of ˜0.57%. PSM for MV EPIDs can be determined by separating out the slowly varying, well-behaved fluence signal from the pixel-to-pixel sensitivity variations. The quality of the PSM is found to be dependent on the quality of the surface fit, which is best for the 6MV FFF beam measured at SID equal to 180cm. Within fitting errors, the PSM is independent of beam energy for 6, 10, and 15MV beams with and without flattening filters. The PSM generation does not require shifting the EPID panel nor multiple EPID panel irradiations and should be usable for linacs with fixed geometry EPIDs.

Comparison of 2 dynamic conformal arc plans based on high-dose rate flattening filter free beams for peripheral lung cancer.

To compare 2 dynamic conformal arc plans based on the high dose rate flattening filter free (FFF) beams, and to evaluate the dosimetric differences. A total of 20 patients with early peripheral non-small cell lung cancer were selected, and 2 dynamic conformal arc plans were designed in the Eclipse 10.0 treatment planning system (TPS). One of them was based on tumor-center (T-DCA), and the other was based on iso-center (Iso-DCA). Both plans were created by using the Truebeam linear accelerator, based on 6 MV FFF photons with a dose rate at 1 400 monitor unit (MU)/min. All patients received the prescribed dose of 4 800 cGy in 4 fractions (1 200 cGy/fraction). Target coverage and organ at risk limits were planned and designed according to the Radiation Therapy Oncology Group (RTOG) Criteria, and were compared between the T-DCA and the Iso-DCA plans. There was no significant difference in the target coverage between the T-DCA and Iso-DCA plans (P>0.05). Conformal index and homogeneity index had no significant differences (both P>0.05), but the percentage of the maximum dose in any direction 2 cm away from the planned target area (D2 cm) and the ratio of the volume wrapped by the isodose line of 50% prescription dose to the volume of the planned target area (R50%) showed significant differences (both P<0.05). The MU of the Iso-DCA plan was increased by 21% compared with that of the T-DCA plan. Except the maximum dose of spinal cord and esophagus, there was no significant difference in the other dosimetric parameters of the organs at risk between the T-DCA and the Iso-DCA plans (all P>0.05). The dose fall-off of Iso-DCA plan is better than T-DCA plan, but the T-DCA plan is consistently superior in sparing dose to spinal cord and esophagus, and the T-DCA plan has fewer MU.

Out-of-field dose in stereotactic radiotherapy for paediatric patients.

Stereotactic radiotherapy combines image guidance and high precision delivery with small fields to deliver high doses per fraction in short treatment courses. In preparation for extension of these treatment techniques to paediatric patients we characterised and compared doses out-of-field in a paediatric anthropomorphic phantom for small flattened and flattening filter free (FFF) photon beams. Dose measurements were taken in several organs and structures outside the primary field in an anthropomorphic phantom of a 5year old child (CIRS) using thermoluminescence dosimetry (LiF:Mg,Cu,P). Out-of-field doses from a medical linear accelerator were assessed for 6MV flattened and FFF beams of field sizes between 2×2 and 10×10cm2. FFF beams resulted in reduced out-of-field doses for all field sizes when compared to flattened beams. Doses for FFF and flattened beams converged for all field sizes at larger distances (>40cm) from the central axis as leakage becomes the primary source of out-of-field dose. Rotating the collimator to place the MLC bank in the longitudinal axis of the patient was shown to reduce the peripheral doses measured by up to 50% in Varian linear accelerators. Minimising out-of-field doses by using FFF beams and aligning the couch and collimator to provide tertiary shielding demonstrated advantages of small field, FFF treatments in a paediatric setting.