MV Flattening Filter Free Research Articles

A Monte Carlo investigation of low‐Z target image quality generated in a linear accelerator using Varianˈs VirtuaLinaca)

The focus of this work was the demonstration and validation of VirtuaLinac with clinical photon beams and to investigate the implementation of low-Z targets in a TrueBeam linear accelerator (Linac) using Monte Carlo modeling. VirtuaLinac, a cloud based web application utilizing Geant4 Monte Carlo code, was used to model the Linac treatment head components. Particles were propagated through the lower portion of the treatment head using BEAMnrc. Dose distributions and spectral distributions were calculated using DOSXYZnrc and BEAMdp, respectively. For validation, 6 MV flattened and flattening filter free (FFF) photon beams were generated and compared to measurement for square fields, 10 and 40 cm wide and at dmax for diagonal profiles. Two low-Z targets were investigated: a 2.35 MeV carbon target and the proposed 2.50 MeV commercial imaging target for the TrueBeam platform. A 2.35 MeV carbon target was also simulated in a 2100EX Clinac using BEAMnrc. Contrast simulations were made by scoring the dose in the phosphor layer of an IDU20 aSi detector after propagating through a 4 or 20 cm thick phantom composed of water and ICRP bone. Measured and modeled depth dose curves for 6 MV flattened and FFF beams agree within 1% for 98.3% of points at depths greater than 0.85 cm. Ninety three percent or greater of points analyzed for the diagonal profiles had a gamma value less than one for the criteria of 1.5 mm and 1.5%. The two low-Z target photon spectra produced in TrueBeam are harder than that from the carbon target in the Clinac. Percent dose at depth 10 cm is greater by 3.6% and 8.9%; the fraction of photons in the diagnostic energy range (25-150 keV) is lower by 10% and 28%; and contrasts are lower by factors of 1.1 and 1.4 (4 cm thick phantom) and 1.03 and 1.4 (20 cm thick phantom), for the TrueBeam 2.35 MV/carbon and commercial imaging beams, respectively. VirtuaLinac is a promising new tool for Monte Carlo modeling of novel target designs. A significant spectral difference is observed between the low-Z target beam on the Clinac platform and the proposed imaging beam line on TrueBeam, with the former providing greater diagnostic energy content.

Practical approach for pretreatment verification of IMRT with flattening filter free(FFF) beams using Varian Portal Dosimetry.

Patient‐specific pretreatment verification of intensity‐modulated radiation therapy (IMRT) or volumetric‐modulated arc therapy (VMAT) is strongly recommended for all patients in order to detect any potential errors in treatment planning process and machine deliverability, and is thus performed routinely in many clinics. Portal dosimetry is an effective method for this purpose because of its prompt setup, easy data acquisition, and high spatial resolution. However, portal dosimetry cannot be applied to IMRT or VMAT with flattening filter‐free (FFF) beams because of the high dose‐rate saturation effect of the electronic portal imaging device (EPID). In our current report, we suggest a practical QA method of expanding the conventional portal dosimetry to FFF beams with a QA plan generated by the following three steps: 1) replace the FFF beams with flattening filtered (FF) beams of the same nominal energy; 2) reduce the dose rate to avoid the saturation effect of the EPID detector; and 3) adjust the total MU to match the gantry and MLC leaf motions. Two RapidArc plans with 6 and 10 MV FFF beams were selected, and QA plans were created by the aforementioned steps and delivered. The trajectory log files of TrueBeam obtained during the treatment and during the delivery of QA plan were analyzed and compared. The maximum discrepancies in the expected trajectories between the treatment and QA plans were within 0.002 MU for the MU, 0.06° for the motion of gantry rotation, and 0.006 mm for the positions of the MLC leaves, indicating much higher levels of accuracy compared to the mechanical specifications of the machine. For further validation of the method, direct comparisons of the delivered QA FF beam to the treatment FFF beam were performed using film dosimetry and show that gamma passing rates under 2%/2 mm criteria are 99.0%–100% for the all four arc beams. This method can be used on RapidArc plans with FFF beams without any additional procedure or modifications on the conventional portal dosimetry of IMRT and is, therefore, a practical option for routine clinical use.PACS numbers: 87.53.Kn, 87.55.T‐, 87.56.bd, 87.59.‐e

Effects of flattening filter‐free and volumetric‐modulated arc therapy delivery on treatment efficiency

Flattening filter‐free (FFF) beams are available on an increasing number of commercial linear accelerators. FFF beams have higher dose rates than flattened beams of equivalent energy which can lead to increased efficiency of treatment delivery, especially in conjunction with increased FFF beam energy and arc‐based delivery configurations. The purpose of this study is to quantify and assess the implications of improved treatment efficiency for several FFF delivery options on common types of linac applicable radiotherapy. Eleven characteristic cases representative of a variety of clinical treatment sites and prescription doses were selected from our patient population. Treatment plans were generated for a Varian TrueBeam linear accelerator. For each case, a reference plan was created using DMLC IMRT with 6 MV flat beams. From the same initial objectives, plans were generated using DMLC IMRT and volumetric‐modulated arc therapy (VMAT) with 6 MV FFF and 10 MV FFF beams (max. dose rates of 1400 and 2400 MU/min, respectively). The plans were delivered to a phantom; beam‐on time, total treatment delivery time, monitor units (MUs), and integral dose were recorded. For plans with low dose fractionations (1.8–2.0 & 3.85 Gy/fraction), mean beam‐on time difference between reference plan and most efficient FFF plan was 0.56 min (41.09% decrease); mean treatment delivery time difference between the reference plan and most efficient FFF plan was 1.54 min (range: 0.31–3.56 min), a relative improvement of 46.1% (range: 29.2%‐59.2%). For plans with high dose fractionations (16–20 Gy/fraction), mean beam‐on time difference was 6.79 min (74.9% decrease); mean treatment delivery time difference was 8.99 min (range: 5.40–13.05 min), a relative improvement of 71.1% (range: 53.4%‐82.4%). 10 MV FFF VMAT beams generated the most efficient plan, except in the spine SBRT case. The distribution of monitor unit counts did not vary by plan type. In cases where respiratory motion management would be applicable, 10 MV FFF DMLC IMRT reduced beam‐on time/field to less than 12 sec. FFF beams significantly reduced treatment delivery time. For radiosurgical doses, the efficiency improvement for FFF beams was clinically significant. For conventional fractionation, a large improvement in relative treatment delivery time was observed, but the absolute time savings were not likely to be of clinical value. In cases that benefit from respiratory motion management, beamon/field was reduced to a time for which most patients can comfortably maintain deep inspiratory breath hold.PACS numbers: 87.55.D‐, 87.55.de, 87.56.bd, 87.56.N‐

Characteristics of flattening filter free beams at low monitor unit settings

Newer linear accelerators (linacs) have been equipped to deliver flattening filter free (FFF) beams. When FFF beams are used for step-and-shoot intensity-modulated radiotherapy (IMRT), the stability of delivery of small numbers of monitor units (MU) is important. The authors developed automatic measurement techniques to evaluate the stability of the dose profile, dose linearity, and consistency. Here, the authors report the performance of the Artiste™ accelerator (Siemens, Erlangen, Germany) in delivering low-MU FFF beams. A 6 MV flattened beam (6X) with 300 MU/min dose rate and FFF beams of 7 (7XU) and 11 MV (11XU), each with a 500 MU/min dose rate, were measured at 1, 2, 3, 5, 8, 10, and 20 MU settings. For the 2000 MU/min dose rate, the 7 (7XUH) and 11 MV (11XUH) beams were set at 10, 15, 20, 25, and 30 MU because of the limits of the minimum MU settings. Beams with 20 × 20 and 10 × 10 cm(2) field sizes were alternately measured ten times in intensity modulated (IM) mode, with which Siemens linacs regulate beam delivery for step-and-shoot IMRT. The in- and crossplane beam profiles were measured using a Profiler™ Model 1170 (Sun Nuclear Corporation, Melbourne, FL) in multiframe mode. The frames of 20 × 20 cm(2) beams were identified at the off-axis profile. The 6X beam profile was normalized at the central axis. The 7 and 11 MV FFF beam profiles were rescaled to set the dose at the central axis at 145% and 170%, respectively. Point doses were also measured using a Farmer-type ionization chamber and water-equivalent solid phantom to evaluate the linearity and consistency of low-MU beam delivery. The values displayed on the electrometer were recognized with a USB-type camera and read with open-source optical character recognition software. The symmetry measurements of the 6X, 7XU, and 11XU beam profiles were better than 2% for beams ≥ 2 MU and improved with increasing MU. The variations in flatness of FFF beams ≥ 2 MU were ± 5%. The standard deviation of the symmetry and flatness also decreased with increasing MU. The linearity of the 6X beam was ± 1% and ± 2% for the beams of ≥ 5 and ≥ 3 MU, respectively. The 7XU and 11XU beams of ≥ 2 MU showed linearity with ± 2% except the 7XU beam of 8 MU (+2.9%). The profiles of the FFF beams with 2000 and 500 MU/min dose rate were similar. The characteristics of low-MU beams delivered in IM mode were evaluated using an automatic measurement system developed in this study. The authors demonstrated that the profiles of FFF beams of the Artiste™ linac were highly stable, even at low MU. The linearity of dose output was also stable for beams ≥ 2 MU.

Octavius 4D characterization for flattened and flattening filter free rotational deliveries

In this study the Octavius detector 729 ionization chamber (IC) array with the Octavius 4D phantom was characterized for flattening filter (FF) and flattening filter free (FFF) static and rotational beams. The device was assessed for verification with FF and FFF RapidArc treatment plans. The response of the detectors to field size, dose linearity, and dose rate were assessed for 6 MV FF beams and also 6 and 10 MV FFF beams. Dosimetric and mechanical accuracy of the detector array within the Octavius 4D rotational phantom was evaluated against measurements made using semiflex and pinpoint ionization chambers, and radiochromic film. Verification FF and FFF RapidArc plans were assessed using a gamma function with 3%∕3 mm tolerances and 2%∕2 mm tolerances and further analysis of these plans was undertaken using film and a second detector array with higher spatial resolution. A warm-up dose of >6 Gy was required for detector stability. Dose-rate measurements were stable across a range from 0.26 to 15 Gy∕min and dose response was linear, although the device overestimated small doses compared with pinpoint ionization chamber measurements. Output factors agreed with ionization chamber measurements to within 0.6% for square fields of side between 3 and 25 cm and within 1.2% for 2 × 2 cm(2) fields. The Octavius 4D phantom was found to be consistent with measurements made with radiochromic film, where the gantry angle was found to be within 0.4° of that expected during rotational deliveries. RapidArc FF and FFF beams were found to have an accuracy of >97.9% and >90% of pixels passing 3%∕3 mm and 2%∕2 mm, respectively. Detector spatial resolution was observed to be a factor in determining the accurate delivery of each plan, particularly at steep dose gradients. This was confirmed using data from a second detector array with higher spatial resolution and with radiochromic film. The Octavius 4D phantom with associated Octavius detector 729 ionization chamber array is a dosimetrically and mechanically stable device for pretreatment verification of FF and FFF RapidArc treatments. Further improvements may be possible through use of a detector array with higher spatial resolution (detector size and∕or detector spacing).

Linac based SBRT for prostate cancer in 5 fractions with VMAT and flattening filter free beams: preliminary report of a phase II study

BackgroundTo evaluate the feasibility and early side effects of a short course hypo-fractionated SBRT programme with Volumetric Modulated Arc Therapy (VMAT) and Flattening Filter Free (FFF) beams.MethodsA prospective phase I-II study, started on February 2012. Inclusion criteria were: age ≤ 80 years, WHO-PS ≤ 2, PSA ≤ 20 ng/ml, histologically proven prostate adenocarcinoma, T1-T2 stage, no distant metastases, no previous surgery other than TURP, no malignant tumours in the previous 5 years, IPSS 0–7. The schedule was 35 Gy in 5 alternative days. SBRT was delivered with RapidArc VMAT, with 10MV FFF photons. Toxicity assessment was performed according to CTCAE v4.0 scale. EPIC questionnaires assessed Quality-of-Life. Neo-adjuvant/concomitant hormonal-therapy was prescribed according to risk classification. SpaceOAR™ gel was optionally implanted to increase the separation space between the prostate and the rectal wall.ResultsMedian follow-up was 11 months (range: 5–16); 40 patients were recruited in the protocol and treated. According to NCCN criteria, 26/40 patients were low-risk and 14/40 were intermediate risk. Median age was 70 years (56–80), median initial PSA was 6.25 ng/ml (0.50-13.43 ng/ml). Median Gleason score was 6 (6–7). All patients completed the treatment as programmed (median 11.8 days (9–22). Acute Toxicities were as follow: Rectum G0: 30/40 cases (75%); G1: 6/40 (15%); G2: 4/40 (10%). Genito-urinary: G0: 16/40 (40%); G1: 8/40 (20%); G2: 16/34 (40%). In two G2 urinary retention cases, intermittent catheter was needed. No acute G3 or greater toxicity was found. Median treatment time was 126 sec (120–136). SpaceOAR™ was implanted in 8 patients. PSA reduction from the pre-treatment value of the marker was documented in all patients.ConclusionsEarly findings suggest that SBRT with RapidArc and FFF beams for prostate cancer in 5 fractions is feasible and tolerated in acute setting. Longer follow-up is needed for assessment of late toxicity and outcome.

Dosimetric Impact of the Interplay Effect During Stereotactic Lung Radiation Therapy Delivery Using Flattening Filter-Free Beams and Volumetric Modulated Arc Therapy

We investigated the dosimetric impact of the interplay effect during RapidArc stereotactic body radiation therapy for lung tumors using flattening filter-free (FFF) beams with different dose rates. Seven tumors with motion ≤20 mm, treated with 10-MV FFF RapidArc, were analyzed. A programmable phantom with sinusoidal longitudinal motion (30-mm diameter "tumor" insert; period = 5 s; individualized amplitude from planning 4-dimensional computed tomography) was used for dynamic dose measurements. Measurements were made with GafChromic EBT III films. Plans delivered the prescribed dose to 95% of the planning target volume, created by a 5-mm expansion of the internal target volume. They comprised 2 arcs and maximum dose rates of 400 and 2400 MU/min. For 2400 MU/min plans, measurements were repeated at 3 different initial breathing phases to model interplay over 2 to 3 fractions. For 3 cases, 2 extra plans were created using 1 full rotational arc (with contralateral lung avoidance sector) and 1 partial arc of 224° to 244°. Dynamic and convolved static measurements were compared by use of gamma analysis of 3% dose difference and 1 mm distance-to-agreement. For 2-arc 2400 MU/min plans, maximum dose deviation of 9.4% was found in a single arc; 7.4% for 2 arcs (single fraction) and <5% and 3% when measurements made at 2 and 3 different initial breathing phases were combined, simulating 2 or 3 fractions. For all 7 cases, >99% of the area within the region of interest passed the gamma criteria when all 3 measurements with different initial phases were combined. Single-fraction single-arc plans showed higher dose deviations, which diminished when dose distributions were summed over 2 fractions. All 400 MU/min plans showed good agreement in a single fraction measurement. Under phantom conditions, single-arc and single-fraction 2400 MU/min FFF RapidArc lung stereotactic body radiation therapy is susceptible to interplay. Two arcs and ≥2 fractions reduced the effect to a level that appeared unlikely to be clinically significant.

Evaluation of inhomogeneity correction factors for 6 MV flattening filter‐free beams with brass compensators

The 6 MV flattening filter‐free (FFF) beam has been commissioned for use with compensators at our institution. This novel combination promises advantages in mitigating tumor motion due to the reduced treatment time made possible by the greatly increased dose rate of the FFF beam. Given the different energy spectrum of the FFF beam and the beam hardening effect of the compensator, the accuracy of the treatment planning system (TPS) model in the presence of low‐density heterogeneities cannot be assumed. Therefore, inhomogeneity correction factors (ICF) for an FFF beam attenuated by brass slabs were measured and compared to the TPS calculations in this work. The ICF is the ratio of the point dose in the presence of inhomogeneity to the dose in the same point in a homogeneous medium. The ICFs were measured with an ion chamber at a number of points in a flat water‐equivalent slab phantom containing a 7.5 cm deep heterogeneity (air or 0.27 g/cm3 wood). Comparisons for the FFF beam were carried out for the field sizes from 5×5 to 20×20 cm2 with the brass slabs ranging from 0 to 5 cm in thickness. For a low‐density wood heterogeneity in a slab phantom, with the exception of the point 1 cm beyond the proximal buildup interface, the TPS handles the inhomogeneity correction with the brass‐filtered 6 MV FFF beam at the requisite 2% error level. The combinations of field sizes and compensator thicknesses when the error exceeds 2% (2.6% maximum) are not likely to be experienced in clinical practice. In terms of heterogeneity corrections, the beam model is adequate for clinical use.PACS number: 87.56.ng

Dosimetric Impact of Intrafraction Motion During RapidArc Stereotactic Vertebral Radiation Therapy Using Flattened and Flattening Filter-Free Beams

To study the dosimetric impact of relatively short-duration intrafraction shifts during a single fraction of RapidArc delivery for vertebral stereotactic body radiation therapy (SBRT) using flattened (FF) and flattening filter-free (FFF) beams. The RapidArc plans, each with 2 to 3 arcs, were generated for 9 patients using 6-MV FF and 10-MV FFF beams with maximum dose rates of 1000 and 2400 MU/min, respectively. A total of 1272 plans were created to estimate the dosimetric consequences in target and spinal cord volumes caused by intrafraction shifts during one of the arcs. Shifts of 1, 2, and 3 mm for periods of 5, 10, and 30 seconds, and 5 mm for 5 and 10 seconds, were modelled during a part of the arc associated with high doses and steep dose gradients. For FFF plans, shifts of 2 mm over 10 seconds and 30 seconds could increase spinal cord Dmax by up to 6.5% and 13%, respectively. Dosimetric deviations in FFF plans were approximately 2-fold greater than in FF plans. Reduction in target coverage was <1% for 83% and 96% of the FFF and FF plans, respectively. Even short-duration intrafraction shifts can cause significant dosimetric deviations during vertebral SBRT delivery, especially when using very high dose rate FFF beams and when the shift occurs in that part of the arc delivering high doses and steep gradients. The impact is greatest on the spinal cord and its planning-at-risk volume. Accurate and stable patient positioning is therefore required for vertebral SBRT.

Clinical application of flattening filter free beams for extracranial stereotactic radiotherapy

PurposeTo investigate the clinical application of flattening filter free (FFF) beams at maximum dose rate for stereotactic body radiotherapy (SBRT). Methods and materialsPatients with tumors in the lung or abdomen were subjected to SBRT using 6MV FFF or 10MV FFF beams. For each patient, three plans were calculated using 6MV flattened, 6MV FFF, and 10MV FFF beams. Treatment times were recorded and analyzed, and tumor displacements were assessed by pre- and post-treatment cone beam computed tomography (CBCT). ResultsAltogether, 26 patients (16 lung, 10 abdominal tumors) were treated. The average dose rate per patient ranged from 442 to 1860MU/min. Beam-on time was on average 1.6min (1SD=0.6min), with the total treatment times recorded at 18.5min (1SD=3.5min). The time advantage of using FFF beams was dose-dependent and started at 4Gy for 6MV FFF and at 10Gy for 10MV FFF beams. The average of the tumor displacements during treatment was 2.0mm (1SD=1.0mm). ConclusionsSBRT using FFF beams is time efficient and associated with excellent patient stability. According to Van Herk’s formula, ITV–PTV margins of 6mm are sufficient in our patient cohort. Further studies are necessary to assess clinical outcome and toxicity.

A Monte Carlo approach to validation of FFF VMAT treatment plans for the TrueBeam linac

To commission and benchmark a vendor-supplied (Varian Medical Systems) Monte Carlo phase-space data for the 6 MV flattening filter free (FFF) energy mode on a TrueBeam linear accelerator for the purpose of quality assurance of clinical volumetric modulated arc therapy (VMAT) treatment plans. A method for rendering the phase-space data compatible with BEAMnrc/DOSXYZnrc simulation software package is presented. Monte Carlo (MC) simulations were performed to benchmark the TrueBeam 6 MV FFF phase space data that have been released by the Varian MC Research team. The simulations to benchmark the phase space data were done in three steps. First, the original phase space which was created on a cylindrical surface was converted into a format that was compatible with BEAMnrc. Second, BEAMnrc was used to create field size specific phase spaces located underneath the jaws. Third, doses were calculated with DOSXYZnrc in a water phantom for fields ranging from 1 × 1 to 40 × 40 cm(2). Calculated percent depth doses (PDD), transverse profiles, and output factors were compared with measurements for all the fields simulated. After completing the benchmarking study, three stereotactic body radiotherapy (SBRT) VMAT plans created with the Eclipse treatment planning system (TPS) were calculated with Monte Carlo. Ion chamber and film measurements were also performed on these plans. 3D gamma analysis was used to compare Monte Carlo calculation with TPS calculations and with film measurement. For the benchmarking study, MC calculated and measured values agreed within 1% and 1.5% for PDDs and in-field transverse profiles, respectively, for field sizes >1 × 1 cm(2). Agreements in the 80%-20% penumbra widths were better than 2 mm for all the fields that were compared. With the exception of the 1 × 1 cm(2) field, the agreement between measured and calculated output factors was within 1%. It is of note that excellent agreement in output factors for all field sizes including highly asymmetric fields was achieved without accounting for backscatter into the beam monitor chamber. For the SBRT VMAT plans, the agreement between Monte Carlo and ion chamber point dose measurements was within 1%. Excellent agreement between Monte Carlo, treatment planning system and Gafchromic film dose distribution was observed with over 99% of the points in the high dose volume passing the 3%, 3 mm gamma test. The authors have presented a method for making the Varian IAEA compliant 6 MV FFF phase space file of the TrueBeam linac compatible with BEAMnrc/DOSXYZnrc. After benchmarking the modified phase space against measurement, they have demonstrated its potential for use in MC based quality assurance of complex delivery techniques.

Evaluation of Flattening Filter-free Lung/Tissue Heterogeneity Dose Calculations for 2 Commercial Planning Systems

To evaluate the accuracy of two commercial treatment planning systems (TPS) to calculate dose distributions produced by a flattening filter free (FFF) beam incident on a heterogeneous lung/tissue phantom. Two TPS were evaluated using phantom geometries constructed from Solid Water and lung equivalent material (0.28g/cm3). The phantom consisted of 3cm Solid Water, 11cm lung equivalent material, and 4 cm of Solid Water, with a 2cm x 2cm cylinder of Solid Water located at 10cm depth along the central axis to represent a lung tumor. Planar dose measurements with film for a 10MV FFF beam were taken at four lung/tissue interfaces (3cm, 9cm, 11cm, and 14cm depth) and at mid-tumor (10cm depth) for two field sizes (MLC shaped 2x2cm2, and a jaw collimated 4x4cm2). A CT scan of the phantom was transferred to the TPSs for dose calculations. Planar dose distributions corresponding to the measurement planes were exported from the TPSs and compared to measurements in RIT113 software. Ionization chamber point dose measurements at mid-tumor depth along the central axis confirmed the film measurements. Penumbra width (90%-10%) and gamma analysis (3%, 3mm) were used to evaluate the accuracy of the calculated dose distributions which were normalized relative to the central axis for each depth. The effect of the dose grid was evaluated by calculating both TPSs at 3mm, 2mm, and 1mm resolution. The largest discrepancies existed in the 50%-10% penumbra region at mid-tumor depth and at the tissue/lung interface distal to the tumor, for the 2x2cm2 field, with the calculated dose for both planning systems exceeding the measured dose by more than the gamma criteria (Table). Other calculated planes had less than 3% of pixels exceeding the gamma criteria, with the TPS1 calculated dose marginally more accurate than TPS2 dose calculations. One notable exception was the Eclipse calculated dose exceeding measured dose by 7% along the central axis for the 2x2cm2 field at the plane distal to the lung tissue. The 1mm resolution was used for comparison to film measurements for best accuracy. Current clinical TPSs over-estimate the penumbral width for small FFF fields incident on tissue equivalent material located within lung, resulting in incorrect dose calculations to the neighboring healthy lung tissue.Poster Viewing Abstract 3741; TablePenumbra size and percent of pixels failing gamma criteria for mid and distal tumor planesMeasurement 2x2cm2 Field SizeTPS1 2x2cm2 Field SizeTPS2 2x2cm2 Field SizeLocationPenumbra 90%-10% (cm)Penumbra 90%-10% (cm)Gamma(% Fail)Penumbra 90%-10%(cm)Gamma(% Fail)Mid tumor0.811.124.881.24.37Distal to tumor0.881.1715.221.227.12 Open table in a new tab

Verification of dosimetric accuracy on the TrueBeam STx: Rounded leaf effect of the high definition MLC

The dosimetric leaf gap (DLG) in the Varian Eclipse treatment planning system is determined during commissioning and is used to model the effect of the rounded leaf-end of the multileaf collimator (MLC). This parameter attempts to model the physical difference between the radiation and light field and account for inherent leakage between leaf tips. With the increased use of single fraction high dose treatments requiring larger monitor units comes an enhanced concern in the accuracy of leakage calculations, as it accounts for much of the patient dose. This study serves to verify the dosimetric accuracy of the algorithm used to model the rounded leaf effect for the TrueBeam STx, and describes a methodology for determining best-practice parameter values, given the novel capabilities of the linear accelerator such as flattening filter free (FFF) treatments and a high definition MLC (HDMLC). During commissioning, the nominal MLC position was verified and the DLG parameter was determined using MLC-defined field sizes and moving gap tests, as is common in clinical testing. Treatment plans were created, and the DLG was optimized to achieve less than 1% difference between measured and calculated dose. The DLG value found was tested on treatment plans for all energies (6 MV, 10 MV, 15 MV, 6 MV FFF, 10 MV FFF) and modalities (3D conventional, IMRT, conformal arc, VMAT) available on the TrueBeam STx. The DLG parameter found during the initial MLC testing did not match the leaf gap modeling parameter that provided the most accurate dose delivery in clinical treatment plans. Using the physical leaf gap size as the DLG for the HDMLC can lead to 5% differences in measured and calculated doses. Separate optimization of the DLG parameter using end-to-end tests must be performed to ensure dosimetric accuracy in the modeling of the rounded leaf ends for the Eclipse treatment planning system. The difference in leaf gap modeling versus physical leaf gap dimensions is more pronounced in the more recent versions of Eclipse for both the HDMLC and the Millennium MLC. Once properly commissioned and tested using a methodology based on treatment plan verification, Eclipse is able to accurately model radiation dose delivered for SBRT treatments using the TrueBeam STx.

Sci-Thur AM: Planning - 05: Lung SBRT: Dosimetric accuracy of the Analytical Anisotropic Algorithm (AAA) for 6MV FFF RapidArc planning.

Stereotactic Body Radiation Therapy (SBRT) requires the delivery of a high biologically effective dose in only a few fractions. These large doses per fraction can necessitate long treatment times. The Varian Truebeam is capable of RapidArc delivery and also has the optional Flattening Filter Free (FFF) modes which greatly increase the dose rate. We have commissioned the 6MV FFF beam (1400 MU/min) for RapidArc lung SBRT, and verified heterogeneous dose calculations with Monte Carlo (MC). The standard commissioning data was acquired for Varian's Analytical Anisotropic Algorithm (AAA) beam model. Measurements were acquired with the IBA Blue Phantom, using the CC13 and CC01 ion chambers and PTW diode. MLC-defined fields were also acquired for model verification. The Dosimetric Leaf Gap (DLG) was measured and then optimized using RapidArc lung SBRT plans, matching Eclipse with ion chamber measurements. Heterogeneous dose calculations were independently verified using MC. There were some discrepancies regarding leaf transmission and penumbra, but the AAA model was generally well within 2% and 2 mm. A nominal DLG value of 1.6 mm was chosen. A representative lung SBRT case utilizing FFF RapidArc was calculated with MC. For the high dose region, 99% matched Eclipse within 3% and 3 mm. The mean dose difference of the PTV was 0.7%. Although we have observed some minor infield discrepancies between the AAA and Monte Carlo calculations in heterogeneous media, the Eclipse AAA is reasonably accurate for complex FFF, RapidArc, SBRT lung planning.

SU-E-T-74: Assessing Effects of Ion Collection Efficiency in Flattening Filter-Free (FFF) Beams on Three TrueBeam Machines

IntroductionA TrueBeam linear accelerator (TB-LINAC) is a new generation digital linear accelerator designed to deliver both standard flattened and flattening filter-free (FFF) beams. It has been reported that incomplete ion collection efficiency of an ion chamber occurs in FFF beams; however, recent works reported considerable differences in variation of ion collection efficiency. To ensure accurate dosimetry, we further investigated the ion collection efficiency under FFF conditions on three TB-LINAC units.MethodsEach TB-LINAC is capable of delivering photon beams from 4MV to 15MV, electron beams from 6MeV to 22MeV, and 6MV-FFF and 10MV-FFF photon beams. Ion collection efficiency of an ionization chamber for various dose rates at various locations under 6MV, 10MV, 6MV FFF and 10MV FFF conditions was measured, quantified as Pion. The standard Boag's two-voltage technique was used to calculate Pion.All these measurements were conducted in a standard Wellhofer water tankwith a compact ion-chamber (CC13, IBA dosimetry, Germany). ResultsVariations of ion collection efficiency of the chamber CC13 are less than 0.3% in standard 6MV and 10MV from 5cm depth to the 35cm depth under 40×40cm2 under the dose rates ranging from 100MU/min to 600MU/min. Variations of Pion of the chamber CC13 are 1.2% (from 1.015±0.002 to 1.002±0.001) under 6MV FFF and 2.0% (from 1.023±0.006to 1.002±0.001) from dmax to the 18cm-off-axis point at 35cm depth under 40×40cm2. Variations of ion collection efficiency are less than 0.1% across dose rates from 400MU/min to 1400MU/min in 6MV FFF and less than 0.2% across dose rates from 400MU/min to 2400MU/min in 10MV FFF at various locations.ConclusionVariations of Pion in FFF beams are much greater than those in the corresponding flatten beams. Given the approximate 2% variation in 10MV FFF, proper correction may be considered for the incomplete ion collection efficiency in 10MV FFF.

SU-E-T-447: Evaluation of the Anisotropic Analytical Algorithm (AAA) Heterogeneity Correction Dose Calculation in Flattened and Flattening- Filter-Free (FFF) Beams for High Energy X-Ray Beams Using the Radiological Physics Center (RPC) Lung Phantom.

Compare the accuracy of AAA heterogeneity corrected dose calculation algorithm for high energy x-ray beams (>10 MV) for flattened and FFF beams using RPC anthropomorphic thorax phantom. Six static beam SBRT treatment plans were created using the Varian Eclipse treatment planning system (TPS) AAA v.8.9.08 heterogeneity correction algorithm. Two flattened beam plans (6 MV and 18 MV) and four other plans (6 MV, 6 MV FFF, 10 MV FFF and 15 MV) were delivered using a Clinac 21EX and TrueBeam STx, respectively. Prescription dose/coverage, 6 Gy to 95% PTV, and constraints were the same for all plans. The phantom contained radiochromic films in the 3 major planes and TLDs in the heart, spine, and tumor. Point doses and 2D dose distributions were exported from the Eclipse TPS and compared with the measured doses. The gamma index analysis evaluation criteria of ±5% dose to agreement and 3 mm distance to agreement was used. TLD to TPS tumor point dose ratios were 0.971±0.006(6MV) and 0.957±0.002(6MV), 0.995±0.005(15MV), 1.114±0.006(18MV), and 0.957±0.003(6MV FFF), 0.974±0.011(10MV FFF) for the six plans. Using ±5%/3mm gamma analysis criteria, the average passing rates for all three films were 96.3% and 95.5%, 97.4%, 66.1%, 93.7%, and 96.3% for the 6 MV, 6 MV, 15 MV, 18 MV, 6 MV FFF, and 10 MV FFF plans, respectively. Dose profiles were also evaluated. The current RPC credentialing criteria are: RPC/Inst. tumor dose ratio of 0.97±0.05 and 85% of the pixels in each film plane must pass a ±5%/5mm gamma index analysis. These data demonstrate that the AAA heterogeneity correction dose calculation algorithm is accurate for photon energies in 6-15 MV range for flattened and FFF beams. Heterogeneity corrected dose calculations for photon energies >15 MV were not accurate. Work supported by grants CA10953 and CA81647 (NCI, DHHS).

SU-E-T-536: Is BJR Supplement #25 Recommendation for Megavoltage Energy Independent Scatter Factor Still Valid for Flattening Filter Free Photon Beams?

In the process of measuring and validating fundamental dosimetry data prior to the clinical use of a treatment unit, it is prudent to compare measurements with previously published equivalent data. During the commissioning of an accelerator with flattening filter free (FFF) photon beams (Varian True Beam 6 MV FFF and 10 MV FFF) we compared measured Phantom Scatter Factors (Sp) with the Normalized Peak Scatter Factors (NPSFs) from the British Journal of Radiology Supplement 25 (BJR #25). The purpose of this work was to determine whether the energy independent NPSFs BJR#25 are valid for comparison with FFF photon beams. All measurements were performed using a Varian TrueBeam linear accelerator with photon energies of 6-MV, 6-MV FFF and 10-MV FFF modes. For all measurements, a Scanditronix CC04 ionization chamber was used. Both water and in-air measurements were made to obtain NPSFs normalized to the 10 × 10 cm2 field size. For measurements in water, the chamber was positioned at 100 cm source-to-axis distance at the depth of dose maximum. For in-air measurements, the chamber was positioned at 100 cm source-to-axis distance with appropriate build-up cap. From BJR #25, NPSFs were obtained for comparison with the measurements. The NPSF agreement between the 6-MV and 6-MV FFF with the BJR#25 were all within ±0.5%. The agreement ranged from 0.996 to 1.004 and 0.995 to 1.002 for 6-MV and 6-MV FFF, respectively. We also found that 10-MV FFF showed very similar trend. The scatter factors reported in BJR #25 are valid for comparison for 6-MV, 6-MV FFF, and 10-MV. Additional investigation is needed to further understand the dosimetric characteristics of FFF mode.

SU-E-T-499: Validation of the Varian Generic Phase Space Files for Monte Carlo Calculations of Dose Distributions for the TrueBeam Linac Head.

To validate the generic phase space files for Varian TrueBeam linac head simulations. The generic phase space files include the simulation results of 6MV, 10MV, 6MV FFF, and 10MV FFF (flattening-filter free) operating modes of TrueBeam for patient-independent linac head components. Using the generic phase space files as the radiation sources, the BEAMnrc Monte Carlo codes are used to simulate the patient-dependent parts of the TrueBeam linac and the resulting phase space files are generated at a plane just before entering a water phantom for 4 different field sizes (5×5, 10×10, 20×20, and 40×40 cm2 ). Dose distributions are calculated by DOSXYZnrc in the water phantom of size 50×50×40 cm3 . The percentage-depth-dose (PDD) curves and lateral dose profiles at three different depths (dmax, 10cm, 20cm) are obtained. Comprehensive comparisons have been made for a total of 64 dose profiles (including PDDs) between the Monte Carlo calculations and the measured data. The gamma index analysis is performed for all the comparisons. The matching of the calculated dose distributions to the measured ones is analyzed by the gamma index method with a criterion of 2% dose tolerance and 2 mm distance-to-agreement. Of the 64 comparisons, the minimum gamma index passing rate is at least 92%, after taking into account the statistical nature of the Monte Carlo calculated dose values. Despite the existence of latent variance of phase space files, the phantom dose calculation uncertainty can be less than 1% for field sizes as small as 5×5 cm2 . The computing time saved by using phase space files could be a factor of 5-10. The Varian generic phase space files are accurate and efficient radiation sources for Monte Carlo calculations of radiation dose distributions for TrueBeam linac head. This work was supported in part by Varian Medical Systems and the NIH (1R01 CA104205 and 1R21 CA153587).

SU-E-T-509: Photon Spectrum Modeling of Flattening Filter Free (FFF) Beam and the Optimization of Model Parameters.

To determine the distribution of photon spectrum on flattening filter free (FFF) beams, novel and fast optimization methods that were applicable on a convolution/superposition dose calculation algorithm were implemented. Two-step optimization method was designed to model the virtual photon spectrums for FFF beams. At first, simple functional form of photon spectrums proposed by E. S. M. Ali was modified and used to make rough shapes of photon spectrum. The distributions of photon spectrums were defined at various field sizes (FSs) to consider the changes of the contribution for scattered photons. Percent depth doses (PDDs) at various FSs were used, and collapsed cone convolution (CCC) algorithm was used to calculate PDDs by considering cone-shaped photon fluence in fields. At next, an arbitrary functional form of photon spectrums where the values of photon intensity itself were free parameters was designed. Line search method was used for optimization and gradient terms at each free parameter were derived from CCC algorithm to enhance the speed of iterations. The mean energies of the optimized spectrums were decreased from 1.40 to 1.21 MeV for 6 MV FFF beams and from 2.45 to 1.27 MeV for 10MV FFF beams as FSs were increased from 3×3 to 40×40 cm2 because of the contributions of scattered photons. The shape of the spectrums were not greatly changed with field sizes, but root mean squared differences (RMSDs) between the measured PDDs and the calculated PDDs using optimized spectrums were increased upto 0.87% as the FSs were decreased to 3×3 cm2 . Developed method for spectrum modeling showed good agreements when the PDDs were calculated with the optimized results. Suggested method is proper to the radiation treatment planning systems because it only requires measured PDDs, and based on the analytic dose calculation algorithm. This work was supported by the National Research Foundation of Korea(NRFK)⌉ grant funded by the Korean government (MEST)⌉ (Grant No. K20901000001-09E0100-00110⌉), Varian Medical Systems, NCI Grant No.1R01 CA98523⌉, and NSF Grant No. 0854492⌉.

SU-E-T-01: Applications of 6MV FFF Photon Beams in Optimizing Radiobiological Response for Respiratory-Gated Liver SBRT.

To establish a radiobiological basis for gated stereotactic body radiotherapy of primary and metastatic liver cancers using volumetric arc radiotherapy in a flattening filter free (FFF) mode. Human cervical carcinoma, SiHa, non-small cell lung carcinoma, H460, and Chinese hamster V79 cells were irradiated in a water bath with 6MV photons from a Varian TrueBeam linear accelerator. To establish dose-response and its sensitivity to dose rate following acute irradiation, doses of 2, 4, 6, 8 and 10 Gy were delivered in FFF mode at 400 and 1200 MU/min. To investigate whether removal of the flattening filter affects cell response, doses of 5 and 10 Gy were delivered to SiHa and H460 cells in FFF and filtered modes at 400 MU/min. Finally, to assess the effect of protracting dose delivery by gating, a dose of 10 Gy was delivered to SiHa and H460 cells acutely and also over 15, 30 and 60 min. Dose-response over doses examined was independent of dose rate in FFF mode. Differences in cell survival following irradiation in FFF and filtered modes were not significant. However a significant increase in survival for both H460 and SiHa cells was observed for 15 min split-dose irradiation compared to acute irradiation but further increase in irradiation time to 60 min did not affect cell survival. Dose rate and presence of a flattening filter showed no effect on cell survival, however, survival was significantly affected when dose delivery time was protracted to that typical of conformal field therapy. Volumetric arc based gated SBRT may be beneficial for tumor cell kill, though the gating window and duty cycle have to be balanced against the effect of dose delivery protraction. Research Support (Varian Medical Systems).