Publications

The aim of this article was to test a simple approach of using pixel density values from fluoroscopy images to enable gated radiotherapy.

The Normal Tissue Complication Probability (NTCP) for rectum is usually defined for late rectal bleeding. This study calculates NTCP parameter values for additional rectal toxicity endpoints observed in clinical practise.

The effectiveness of intensity-modulated radiation therapy (IMRT) is compromised by involuntary motion (e.g. respiration, cardiac activity). The feasibility of processing ultrasound echo data to automatically estimate 3D liver motion for real-time IMRT guidance was previously demonstrated, but performance was limited by an acquisition speed of 2 volumes per second due to hardware restrictions of a mechanical linear array probe. Utilizing a 2D matrix array probe with parallel receive beamforming offered increased acquisition speeds and an opportunity to investigate the benefits of higher volume rates. In vivo livers of three volunteers were scanned with and without respiratory motion at volume rates of 24 and 48 Hz, respectively. Respiration was suspended via voluntary breath hold. Correlation-based, phase-sensitive 3D speckle tracking was applied to consecutively acquired volumes of echo data. Volumes were omitted at fixed intervals and 3D speckle tracking was re-applied to study the effect of lower scan rates. Results revealed periodic motion that corresponded with the heart rate or breathing cycle in the absence or presence of respiration, respectively. For cardiac-induced motion, volume rates for adequate tracking ranged from 8 to 12 Hz and was limited by frequency discrepancies between tracking estimates from higher and lower frequency scan rates. Thus, the scan rate of volume data acquired without respiration was limited by the need to sample the frequency induced by the beating heart. In respiratory-dominated motion, volume rate limits ranged from 4 to 12 Hz, interpretable from the root-mean-squared deviation (RMSD) from tracking estimates at 24 Hz. While higher volume rates yielded RMSD values less than 1 mm in most cases, lower volume rates yielded RMSD values of 2-6 mm.

In this paper, the effect on image quality of significantly reducing the primary electron energy of a radiotherapy accelerator is investigated using a novel waveguide test piece. The waveguide contains a novel variable coupling device (rotovane), allowing for a wide continuously variable energy range of between 1.4 and 9 MeV suitable for both imaging and therapy.

Artifacts in treatment-room cone-beam reconstructions have been observed at the authors' center when cone-beam acquisition is simultaneous with radio frequency (RF) transponder tracking using the Calypso 4D system (Calypso Medical, Seattle, WA). These artifacts manifest as CT-number modulations and increased CT-noise. The authors present a method for the suppression of the artifacts.

To assess feasibility and reproducibility of an Active Breathing Coordinator (ABC) used throughout radical radiotherapy for non-small-cell lung cancer, and compare lung dosimetric parameters between free-breathing and ABC plans.

Scatter in a detector and its housing can result in image degradation. Typically, such scatter leads to a low-spatial frequency 'glare' superimposed on the primary signal. We infer the glare-spread function (GSF) of an amorphous-silicon flat-panel detector via an edge-spread technique. We demonstrate that this spread (referred to as 'scatter-glare' herein) causes a low-spatial frequency drop in the associated modulation-transfer function. This results in a compression of the range of reconstructed CT (computed tomography) numbers and is an impediment to accurate CT-number calibration. We show that it can also lead to visual artefacts. This explains previously unresolved CT-number discrepancies in an earlier work (Poludniowski et al 2009 Phys. Med. Biol. 54 3847). We demonstrate that after deconvolving the GSF from the projection images, in conjunction with a correction for phantom-scatter, the CT-number discrepancies disappear. We show results for an in-house-built phantom with inserts of tissue-equivalent materials and for a patient scan. We conclude that where scatter-glare has not been accounted for, the calibration of cone-beam CT numbers to material density will be compromised. The scatter-glare measurement method we propose is simple and requires no special equipment. The deconvolution process is also straightforward and relatively quick (60 ms per projection on a desktop PC).

Computed tomography images have been acquired using an experimental (low atomic number (Z) insert) megavoltage cone-beam imaging system. These images have been compared with standard megavoltage and kilovoltage imaging systems. The experimental system requires a simple modification to the 4 MeV electron beam from an Elekta Precise linac. Low-energy photons are produced in the standard medium-Z electron window and a low-Z carbon electron absorber located after the window. The carbon electron absorber produces photons as well as ensuring that all remaining electrons from the source are removed. A detector sensitive to diagnostic x-ray energies is also employed. Quantitative assessment of cone-beam computed tomography (CBCT) contrast shows that the low-Z imaging system is an order of magnitude or more superior to a standard 6 MV imaging system. CBCT data with the same contrast-to-noise ratio as a kilovoltage imaging system (0.15 cGy) can be obtained in doses of 11 and 244 cGy for the experimental and standard 6 MV systems, respectively. Whilst these doses are high for everyday imaging, qualitative images indicate that kilovoltage like images suitable for patient positioning can be acquired in radiation doses of 1–8 cGy with the experimental low-Z system.

To test a prone position against the international-standard supine position in women undergoing whole-breast-radiotherapy (WBRT) after wide-local-excision (WLE) of early breast cancer (BC) in terms of feasibility, set-up errors, and respiratory motion.

We describe a feasibility study testing the use of gold seeds for the identification of post-operative tumour bed after breast conservation surgery (BCS).

The data from eight patients who had undergone stereotactic body radiotherapy were selected due to their 4D-CT planning scans showing that their tumours had respiratory induced motion trajectories of large amplitude (greater than 9 mm in cranio-caudal direction). Radiotherapy plans with personalized motion-assessed margins were generated for these eight patients. The margins were generated by inverse 4D planning on an eight-bin phase-sorted 4D-CT scan. The planning was done on an in-house software system with a non-rigid registration stage being completed using freely available software. The resultant plans were then recalculated on a 4D-CT scan taken later during the course of treatment. Simulated image-guided patient set-up was used to align the geometric centres of the tumour region and minimize any misalignment between the two reconstructions. In general, the variation in the patient breathing patterns was found to be very small. Consequently, the degradation of the mean dose to the tumour region was found to be around a few percent (<3%) and hence was not a large effect.

The purpose of this work was to investigate the use of an experimental complementary metal-oxide-semiconductor (CMOS) active pixel sensor (APS) for tracking of moving fiducial markers during radiotherapy.

Three-dimensional (3D) soft tissue tracking using 3D ultrasound is of interest for monitoring organ motion during therapy. Previously we demonstrated feature tracking of respiration-induced liver motion in vivo using a 3D swept-volume ultrasound probe. The aim of this study was to investigate how object speed affects the accuracy of tracking ultrasonic speckle in the absence of any structural information, which mimics the situation in homogenous tissue for motion in the azimuthal and elevational directions. For object motion prograde and retrograde to the sweep direction of the transducer, the spatial sampling frequency increases or decreases with object speed, respectively. We examined the effect object motion direction of the transducer on tracking accuracy. We imaged a homogenous ultrasound speckle phantom whilst moving the probe with linear motion at a speed of 0-35 mm s⁻¹. Tracking accuracy and precision were investigated as a function of speed, depth and direction of motion for fixed displacements of 2 and 4 mm. For the azimuthal direction, accuracy was better than 0.1 and 0.15 mm for displacements of 2 and 4 mm, respectively. For a 2 mm displacement in the elevational direction, accuracy was better than 0.5 mm for most speeds. For 4 mm elevational displacement with retrograde motion, accuracy and precision reduced with speed and tracking failure was observed at speeds of greater than 14 mm s⁻¹. Tracking failure was attributed to speckle de-correlation as a result of decreasing spatial sampling frequency with increasing speed of retrograde motion. For prograde motion, tracking failure was not observed. For inter-volume displacements greater than 2 mm, only prograde motion should be tracked which will decrease temporal resolution by a factor of 2. Tracking errors of the order of 0.5 mm for prograde motion in the elevational direction indicates that using the swept probe technology speckle tracking accuracy is currently too poor to track homogenous tissue over a series of volume images as these errors will accumulate. Improvements could be made through increased spatial sampling in the elevational direction.

There is significant current interest in the use of biological image guidance in radiotherapy planning. In lung-cancer treatment, tumor motion due to respiration is known to be a limitation. This is particularly true in PET, where image data are collected over a number of minutes. An in-house-developed 4D PET acquisition mode is described and an analysis of the effects of acquisition parameters on the reconstructed image quality is presented. The potential impact of the resulting biological image quality on radiotherapy planning is then quantified in terms of tumor control probability (TCP).

The characteristics of an Elekta Precise treatment machine with a gating interface were investigated. Three detectors were used: a Farmer ionization chamber, a MatriXX ionization chamber array and an in-house, single pulse-measurement ionization chamber (IVC). Measurements were made of dosimetric accuracy, flatness and symmetry characteristics and duty cycle for a range of beam-on times and gating periods. Results were compared with a standard ungated delivery as a reference. For all beam-on times, down to 0.5 s, dosimetric differences were below +/-1% and flatness and symmetry parameter variations were below +/-1.5%. For the shorter beam-on times the in-house detector deviated from the other two detectors, suggesting that this device should be used in conjunction with other detectors for absolute dosimetry purposes. However, it was found to be useful for studying gated beam characteristics pulse by pulse.

We have evaluated a 4D ultrasound-based motion tracking system developed for tracking of abdominal organs during therapy. Tracking accuracy and precision were determined using a tissue-mimicking phantom, by comparing tracked motion with known 3D sinusoidal motion. The feasibility of tracking 3D liver motion in vivo was evaluated by acquiring 4D ultrasound data from four healthy volunteers. For two of these volunteers, data were also acquired whilst simultaneously measuring breath flow using a spirometer. Hepatic blood vessels, tracked off-line using manual tracking, were used as a reference to assess, in vivo, two types of automated tracking algorithm: incremental (from one volume to the next) and non-incremental (from the first volume to each subsequent volume). For phantom-based experiments, accuracy and precision (RMS error and SD) were found to be 0.78 mm and 0.54 mm, respectively. For in vivo measurements, mean absolute distance and standard deviation of the difference between automatically and manually tracked displacements were less than 1.7 mm and 1 mm respectively in all directions (left-right, anterior-posterior and superior-inferior). In vivo non-incremental tracking gave the best agreement. In both phantom and in vivo experiments, tracking performance was poorest for the elevational component of 3D motion. Good agreement between automatically and manually tracked displacements indicates that 4D ultrasound-based motion tracking has potential for image guidance applications in therapy.

Radical radiotherapy for prostate cancer is effective but dose limited because of the proximity of normal tissues. Comprehensive dose-volume analysis of the incidence of clinically relevant late rectal toxicities could indicate how the dose to the rectum should be constrained. Previous emphasis has been on constraining the mid-to-high dose range (>/=50 Gy). Evidence is emerging that lower doses could also be important.

To compare partial-breast clinical target volumes generated using a standard 15 mm margin (CTV(standard)) with those generated using three-dimensional surgical excision margins (CTV(tailored 30)) in women who have undergone wide local excision (WLE) for breast cancer.

Volumetric-modulated arc therapy (VMAT), a form of intensity-modulated arc therapy (IMAT), has become a topic of research and clinical activity in recent years. As a form of arc therapy, portal images acquired during the treatment fraction form a (partial) Radon transform of the patient. We show that these portal images, when used in a modified global cone-beam filtered backprojection (FBP) algorithm, allow a surprisingly recognizable CT-volume to be reconstructed. The possibility of distinguishing anatomy in such VMAT-CT reconstructions suggests that this could prove to be a valuable treatment position-verification tool. Further, some potential for local-tomography techniques to improve image quality is shown.

To compare non-target tissue (including left-anterior-descending coronary-artery (LAD)) dosimetry of prone versus supine whole (WBI) and partial-breast irradiation (PBI).

Stitched, large area, complementary metal-oxide-semiconductor (CMOS), active pixel sensors (APS) show promises for X-ray imaging applications. In this paper we present an investigation of the effects of stitching on uniformity of sensor response for an experimental APS. The sensor, known as LAS (large area sensor), was made by reticular stitching onto a single silicon wafer of a 5 x 5 array of regions consisting of 270 x 270 pixels with 40 mu m pixel pitch, to yield 1350 x 1350 pixels and an imaging area of 54 x 54 mm. Data acquired from two different sensors of the same type were filtered to remove spiking pixels and electromagnetic interference (EMI). The non-linear compensation (NLC) technique for CMOS sensor analysis was used to determine the variation in gain, read noise, full well capacity and dynamic range between stitched regions. Variations across stitched regions were analysed using profiles, analysis of pixel variations at stitch boundaries and using a measurement of non-uniformity within a stitched region. The results showed that non-uniformity variations were present, which increased with signal (1.5-3.5% at dark signal, rising to 3-8%). However, these were found to be smaller than variations caused by differences in readout electronics, particularly at low signal levels. The results suggest these variations should be correctable using standard calibration methods. (C) 2010 Elsevier B.V. All rights reserved.

This work evaluates a three-dimensional (3D) freehand ultrasound-based localisation system with new probe pressure correction for use in partial breast irradiation. Accuracy and precision of absolute position measurement was measured as a function of imaging depth (ID), object depth, scanning direction and time using a water phantom containing crossed wires. To quantify the improvement in accuracy due to pressure correction, 3D scans of a breast phantom containing ball bearings were obtained with and without pressure. Ball bearing displacements were then measured with and without pressure correction. Using a single scan direction (for all imaging depths), the mean error was <1.3 mm, with the exception of the wires at 68.5 mm imaged with an ID of 85 mm, which gave a mean error of -2.3 mm. Precision was greater than 1 mm for any single scan direction. For multiple scan directions, precision was within 1.7 mm. Probe pressure corrections of between 0 mm and 2.2 mm have been observed for pressure displacements of 1.1 mm to 4.2 mm. Overall, anteroposterior position measurement accuracy increased from 2.2 mm to 1.6 mm and to 1.4 mm for the two opposing scanning directions. Precision is comparable to that reported for other commercially available ultrasound localisation systems, provided that 3D image acquisition is performed in the same scan direction. The existing temporal calibration is imperfect and a "per installation" calibration would further improve the accuracy and precision. Probe pressure correction was shown to improve the accuracy and will be useful for the localisation of the excision cavity in partial breast radiotherapy.

A new method is proposed for scatter-correction of cone-beam CT images. A coarse reconstruction is used in initial iteration steps. Modelling of the x-ray tube spectra and detector response are included in the algorithm. Photon diffusion inside the imaging subject is calculated using the Monte Carlo method. Photon scoring at the detector is calculated using forced detection to a fixed set of node points. The scatter profiles are then obtained by linear interpolation. The algorithm is referred to as the coarse reconstruction and fixed detection (CRFD) technique. Scatter predictions are quantitatively validated against a widely used general-purpose Monte Carlo code: BEAMnrc/EGSnrc (NRCC, Canada). Agreement is excellent. The CRFD algorithm was applied to projection data acquired with a Synergy XVI CBCT unit (Elekta Limited, Crawley, UK), using RANDO and Catphan phantoms (The Phantom Laboratory, Salem NY, USA). The algorithm was shown to be effective in removing scatter-induced artefacts from CBCT images, and took as little as 2 min on a desktop PC. Image uniformity was greatly improved as was CT-number accuracy in reconstructions. This latter improvement was less marked where the expected CT-number of a material was very different to the background material in which it was embedded.

A software program, SpekCalc, is presented for the calculation of x-ray spectra from tungsten anode x-ray tubes. SpekCalc was designed primarily for use in a medical physics context, for both research and education purposes, but may also be of interest to those working with x-ray tubes in industry. Noteworthy is the particularly wide range of tube potentials (40-300 kVp) and anode angles (recommended: 6-30 degrees) that can be modelled: the program is therefore potentially of use to those working in superficial/orthovoltage radiotherapy, as well as diagnostic radiology. The utility is free to download and is based on a deterministic model of x-ray spectrum generation (Poludniowski 2007 Med. Phys. 34 2175). Filtration can be applied for seven materials (air, water, Be, Al, Cu, Sn and W). In this note SpekCalc is described and illustrative examples are shown. Predictions are compared to those of a state-of-the-art Monte Carlo code (BEAMnrc) and, where possible, to an alternative, widely-used, spectrum calculation program (IPEM78).

One method to overcome the problem of lung tumour movement in patients treated with radiotherapy is to restrict tumour motion with an active breathing control (ABC) device. This study evaluated the feasibility of using ABC in patients receiving radical radiotherapy for non-small cell lung cancer.

Monte Carlo simulation is the gold standard method for modelling scattering processes in medical x-ray imaging. General-purpose Monte Carlo codes, however, typically use the independent atom approximation (IAA). This is known to be inaccurate for Rayleigh scattering, for many materials, in the forward direction. This work addresses whether the IAA is sufficient for the typical modelling tasks in medical kilovoltage x-ray imaging. As a means of comparison, we incorporate a more realistic 'interference function' model into a custom-written Monte Carlo code. First, we conduct simulations of scatter from isolated voxels of soft tissue, adipose, cortical bone and spongiosa. Then, we simulate scatter profiles from a cylinder of water and from phantoms of a patient's head, thorax and pelvis, constructed from diagnostic-quality CT data sets. Lastly, we reconstruct CT numbers from simulated sets of projection images and investigate the quantitative effects of the approximation. We show that the IAA can produce errors of several per cent of the total scatter, across a projection image, for typical x-ray beams and patients. The errors in reconstructed CT number, however, for the phantoms simulated, were small (typically < 10 HU). The IAA can therefore be considered sufficient for the modelling of scatter correction in CT imaging. Where accurate quantitative estimates of scatter in individual projection images are required, however, the appropriate interference functions should be included.

To determine target volume changes by using volume and shape analysis for patients receiving radiotherapy after breast conservation surgery and to compare different methods of automatically identifying changes in target volume, position, size, and shape during radiotherapy for use in adaptive radiotherapy.

A target-tracking, intensity-modulated delivery on an Elekta MLCi system was assessed by film measurement with a simulated target-motion trajectory. A toroidally shaped idealized target surrounding an organ at risk necessitating multiple field segments to irradiate the target and spare the organ at risk was defined in a solid-water phantom. The phantom was programmed to move following a reproducible 2D elliptical trajectory in the beam's-eye view with a period of 10 s. Static and target-tracking treatments were planned for delivery on a standard Elekta Precise series linac with integrated MLCi system. Dose was delivered in three ways: (i) a static treatment to a static phantom, (ii) a static treatment to a moving phantom and (iii) a target-tracking treatment to a moving phantom. The dose delivered was assessed by film measurement on the central plane through the target and organ at risk. The target dose blurring was quantified by the standard deviation of the dose to the target which was evaluated as 2.8% for the static treatment to the static phantom, 7.2% for the static treatment to the moving phantom and 2.6% for the tracking treatment to the moving phantom. The mean organ-at-risk dose was 38.2%, 54.0% and 38.2% of the prescription dose for each delivery case. We have therefore shown that the linac is capable of delivering target-tracking fields with MLCs for the target trajectories tested.

An amorphous silicon EPID has been investigated to determine whether it is capable of quality control constancy measurements for linear accelerator electron beams. The EPID grayscale response was found to be extremely linear with dose over a wide dose range and, more specifically, for exposures of 95-100 MU. Small discrepancies of up to 0.8% in linearity were found at 6 MeV (8-15 MeV showed better agreement). The shape of the beam profile was found to be significantly altered by scatter in air over the approximately 60 cm gap between the end of the applicator and the EPID. Nevertheless, relative changes in EPID-measured profile flatness and symmetry were linearly related to changes in these parameters at 95 cm focus to surface distance (FSD) measured using a 2D diode array. Similar results were obtained at 90 degrees and 270 degrees gantry angles. Six months of daily images were acquired and analyzed to determine whether the device is suitable as a constancy checker. EPID output measurements agreed well with daily ion chamber measurements, with a 0.8% standard deviation in the difference between the two measurement sets. When compared to weekly parallel plate chamber measurements, this figure dropped to 0.5%. A Monte Carlo (MC) model of the EPID was created and demonstrated excellent agreement between MC-calculated profiles in water and the EPID at 95 and 157 cm FSD. Good agreement was also found with measured EPID profiles, demonstrating that the EPID provides an accurate measurement of electron profiles. The EPID was thus shown to be an effective method for performing electron beam daily constancy checks.

A technique is presented to allow a breathing pattern to be obtained from any multi-slice CT, cone-beam or other series of sequential chest x-ray image sets. The technique requires no extra signals to be recorded and does not need specific external or internal oscillating structures to be visible in the field of view. The breathing pattern is instead acquired from analysing the variation in pixel values between projection images. For cone-beam image sets, slowly varying changes, due to an angular attenuation dependence, must be corrected before the breathing trace analysis can begin. All the results of the new technique were checked visually and were in good agreement. If the studied image set could be analysed using the existing 'Amsterdam shroud' technique, then the results it provided were also used for comparison. In cases that allowed comparison by both techniques, the results were in agreement. The new technique was also shown to provide a usable signal when applied to cardiac motion.

To compare tumor bed (TB) volumes delineated using magnetic resonance imaging plus computed tomography and clips (MRCT) with those delineated using CT and clips (CT/clips) alone in postlumpectomy breast cancer patients positioned prone and to determine the value of MRCT for planning partial breast irradiation (PBI).

The technical feasibility and potential benefits of voxel-based nonuniform dose prescriptions for biologically heterogeneous tumors have been widely demonstrated. In some cases, an "ideal" dose prescription has been generated by individualizing the dose to every voxel within the target, but often this voxel-based prescription has been discretized into a small number of compartments. The number of dose levels utilized and the methods used for prescribing doses and assigning tumor voxels to different dose compartments have varied significantly. The authors present an investigation into the relationship between the complexity of the dose prescription and the tumor control probability (TCP) for a number of these methods. The linear quadratic model of cell killing was used in conjunction with a number of modeled tumors heterogeneous in clonogen density, oxygenation, or proliferation. Models based on simple mathematical functions, published biological data, and biological image data were investigated. Target voxels were assigned to dose compartments using (i) simple rules based on the initial biological distribution,(ii) iterative methods designed to maximize the achievable TCP, or (iii) methods based on an ideal dose prescription. The relative performance of the simple rules was found to depend on the form of heterogeneity of the tumor, while the iterative and ideal dose methods performed comparably for all models investigated. In all cases the maximum achievable TCP was approached within the first few (typically two to five) compartments. Results suggest that irrespective of the pattern of heterogeneity, the optimal dose prescription can be well approximated using only a few dose levels but only if both the compartment boundaries and prescribed dose levels are well chosen. (C) 2009 American Association of Physicists in Medicine. [DOI: 10.1118/1.3213519]

The Large Area Sensor (LAS) is a 1350 x 1350 array of active pixels on a 40im pitch fabricated in a 0.35im CMOS process. Stitching technology is employed to achieve an area of 5.4 cm x 5.4 cm. The sensor includes 'regions of reset', whereby three different integration times can lie set on the array to achieve a large imaging range for static scenes. Characterization of the noise performance included temporal and fixed pattern sources. LAS was found to have a read noise of 62 e(-), a full well capacity of 61 x 10(3) e(-) and a conversion gain of 5 e(-) per digital number (DN). The fixed pattern noise (FPN) was evaluated at half saturation; within a single stitched section of the array, column-to-column FPN was found to be 0.6%, while the pixel-to-pixel FPN was 3%. Both FPN sources were found to be gain related and could be corrected via flat fielding. Based on the results of characterization, LAS was coupled to a structured CsI:TI scintillator and included in an X-ray diffraction system developed for the analysis of breast biopsy samples. Data acquired with plastic test objects agrees with that acquired by a previous prototype sensor. It is demonstrated that an imaging output range of 140 dB can be achieved using integration times of 0.1 ms to record the transmitted X-ray beam and 2.3 s to record the lower intensity scattered radiation.

Three CMOS active pixel sensors have been investigated for their application to Nuclear Medicine imaging. Startracker with 525 x 525 25 mu m square pixels has been coupled via a fibre optic stud to a 2 mm thick segmented CsI(Tl) crystal. Imaging tests were performed using Tc-99m sources, which emit 140keV gamma rays. The system was interfaced to a PC via FPGA-based DAQ and optical link enabling imaging rates of 10 f/s. System noise was measured to be > 100e and it was shown that the majority of this noise was fixed pattern in nature. The intrinsic spatial resolution was measured to be similar to 80 mu m and the system spatial resolution measured witha slit was similar to 450 mu m. The second sensor, On Pixel Intelligent CMOS(OPIC), had 64 x 7240 mu m pixels and was used to evaluate noise characteristics and to develop a method of differentiation between fixed pattern and statistical noise. The third sensor, Vanilla, had 520 x 52025 mu m pixels and a measured system noise of similar to 25e. This sensor was coupled directly to the segmented phosphor. Imaging results show that even at this lower level of noise the signal from 140 keV gamma rays is small as the light from the phosphor is spread over a large number of pixels. Suggestions for the 'ideal' sensor are made.

MI-3 is a consortium of 11 universities and research laboratories whose mission is to develop complementary metal-oxide semiconductor (CMOS) active pixel sensors (APS) and to apply these sensors to a range of imaging challenges. A range of sensors has been developed: On-Pixel Intelligent CMOS (OPIC)-designed for in-pixel intelligence; FPN-designed to develop novel techniques for reducing fixed pattern noise; HDR-designed to develop novel techniques for increasing dynamic range; Vanilla/PEAPS-with digital and analogue modes and regions of interest, which has also been back-thinned; Large Area Sensor (LAS)-a novel, stitched LAS; and eLeNA-which develops a range of low noise pixels. Applications being developed include autoradiography, a gamma camera system, radiotherapy verification, tissue diffraction imaging, X-ray phase-contrast imaging, DNA sequencing and electron microscopy.

To evaluate the utility of intraprostatic markers in the treatment verification of prostate cancer radiotherapy. Specific aims were: to compare the effectiveness of offline correction protocols, either using gold markers or bony anatomy; to estimate the potential benefit of online correction protocol's using gold markers; to determine the presence and effect of intrafraction motion.

The goal of radiation therapy is to achieve maximal therapeutic benefit expressed in terms of a high probability of local control of disease with minimal side effects. Physically this often equates to the delivery of a high dose of radiation to the tumour or target region whilst maintaining an acceptably low dose to other tissues, particularly those adjacent to the target. Techniques such as intensity modulated radiotherapy (IMRT), stereotactic radiosurgery and computer planned brachytherapy provide the means to calculate the radiation dose delivery to achieve the desired dose distribution. Imaging is an essential tool in all state of the art planning and delivery techniques: (i) to enable planning of the desired treatment, (ii) to verify the treatment is delivered as planned and (iii) to follow-up treatment outcome to monitor that the treatment has had the desired effect. Clinical imaging techniques can be loosely classified into anatomic methods which measure the basic physical characteristics of tissue such as their density and biological imaging techniques which measure functional characteristics such as metabolism. In this review we consider anatomical imaging techniques. Biological imaging is considered in another article. Anatomical imaging is generally used for goals (i) and (ii) above. Computed tomography (CT) has been the mainstay of anatomical treatment planning for many years, enabling some delineation of soft tissue as well as radiation attenuation estimation for dose prediction. Magnetic resonance imaging is fast becoming widespread alongside CT, enabling superior soft-tissue visualization. Traditionally scanning for treatment planning has relied on the use of a single snapshot scan. Recent years have seen the development of techniques such as 4D CT and adaptive radiotherapy (ART). In 4D CT raw data are encoded with phase information and reconstructed to yield a set of scans detailing motion through the breathing, or cardiac, cycle. In ART a set of scans is taken on different days. Both allow planning to account for variability intrinsic to the patient. Treatment verification has been carried out using a variety of technologies including: MV portal imaging, kV portal/fluoroscopy, MVCT, conebeam kVCT, ultrasound and optical surface imaging. The various methods have their pros and cons. The four x-ray methods involve an extra radiation dose to normal tissue. The portal methods may not generally be used to visualize soft tissue, consequently they are often used in conjunction with implanted fiducial markers. The two CT-based methods allow measurement of inter-fraction variation only. Ultrasound allows soft-tissue measurement with zero dose but requires skilled interpretation, and there is evidence of systematic differences between ultrasound and other data sources, perhaps due to the effects of the probe pressure. Optical imaging also involves zero dose but requires good correlation between the target and the external measurement and thus is often used in conjunction with an x-ray method. The use of anatomical imaging in radiotherapy allows treatment uncertainties to be determined. These include errors between the mean position at treatment and that at planning (the systematic error) and the day-to-day variation in treatment set-up (the random error). Positional variations may also be categorized in terms of inter- and intra-fraction errors. Various empirical treatment margin formulae and intervention approaches exist to determine the optimum strategies for treatment in the presence of these known errors. Other methods exist to try to minimize error margins drastically including the currently available breath-hold techniques and the tracking methods which are largely in development. This paper will review anatomical imaging techniques in radiotherapy and how they are used to boost the therapeutic benefit of the treatment.

In order to reduce the sensitivity of radiotherapy treatments to organ motion, compensation methods are being investigated such as gating of treatment delivery, tracking of tumour position, 4D scanning and planning of the treatment, etc. An outstanding problem that would occur with all these methods is the assumption that breathing motion is reproducible throughout the planning and delivery process of treatment. This is obviously not a realistic assumption and is one that will introduce errors. A dynamic internal margin model (DIM) is presented that is designed to follow the tumour trajectory and account for the variability in respiratory motion. The model statistically describes the variation of the breathing cycle over time, i.e. the uncertainty in motion amplitude and phase reproducibility, in a polar coordinate system from which margins can be derived. This allows accounting for an additional gating window parameter for gated treatment delivery as well as minimizing the area of normal tissue irradiated. The model was illustrated with abdominal motion for a patient with liver cancer and tested with internal 3D lung tumour trajectories. The results confirm that the respiratory phases around exhale are most reproducible and have the smallest variation in motion amplitude and phase (approximately 2 mm). More importantly, the margin area covering normal tissue is significantly reduced by using trajectory-specific margins (as opposed to conventional margins) as the angular component is by far the largest contributor to the margin area. The statistical approach to margin calculation, in addition, offers the possibility for advanced online verification and updating of breathing variation as more data become available.

This work is a feasibility study to use a four-dimensional computed tomography (4D CT) dataset generated by a continuous motion model for treatment planning in lung radiotherapy. The model-based 4D CT data were derived from multiple breathing cycles. Four patients were included in this retrospective study. Treatment plans were optimized at end-exhale for each patient and the effect of respiratory motion on the dose delivery investigated. The accuracy of the delivered dose as determined by the number of intermediate respiratory phases used for the calculation was considered. The time-averaged geometry of the anatomy representing the mid-ventilation phase of the breathing cycle was generated using the motion model and a treatment plan was optimized for this phase for one patient. With respiratory motion included, the mid-ventilation plan achieved better target coverage than the plan optimized at end-exhale when standard margins were used to expand the clinical target volume (CTV) to planning target volume (PTV). Using a margin to account for set-up uncertainty only, resulted in poorer target coverage and healthy tissue sparing. For this patient cohort, the results suggest that conventional three-dimensional treatment planning was sufficient to maintain target coverage despite respiratory motion. The motion model has proved a useful tool in 4D treatment planning.

Experimental and Monte Carlo simulations were conducted for an Elekta Ltd Precise Treatment System linac fitted with a low Z insert of sufficient thickness to remove all primary electrons. A variety of amorphous silicon based panels employing different scintillators were modelled to determine their response to a variety of x-ray spectra and produce an optimized portal imaging system. This study has shown that in a low Z configuration the vast majority of x-rays are produced in the nickel electron window, and with a combination of a carbon insert and caesium iodide based XVI-panel, significant improvement in the object contrast was achieved. For thin, head and neck-type geometries, contrast is 4.62 times greater for 1.6 cm bone in 5.8 cm water than the standard 6 MV/iViewGT system. For thicker, pelvis-type geometries contrast increases by a factor of 1.3 for 1.6 cm of bone in 25.8 cm water. To obtain images with the same signal-to-noise ratio as the 6 MV/iViewGT system, dose reductions of a factor of 15 and 4.2 are possible for 5.8 cm and 25.8 cm phantoms respectively. This design has the advantage of being easily implemented on a standard linac and provides a portal image directly from the therapy beam aperture.

The purpose of this study was to investigate methods used to modulate dose distributions in radiotherapy planning, to determine the fundamental features of these and to establish the attainable dose uniformity. Published modulation methods were categorized, and a simple physical model devised to predict the weight of the wedged beam and the relative dose distribution for each category. Each technique was applied to patient data with planning target volume sizes ranging from below 500 cm(3) to 2200 cm(3). The spatial distribution of high-dose regions in the breast, and maximum dose for the heart and lung, were determined for each plan. The dose uniformity was analysed by evaluating the volume of the breast (V(I)) receiving <95% and <105% of the prescribed dose. The difference between V(105%) and V(95%) for each method for each patient data set was also calculated. The simple model predicted the trend in percentage weight of the wedge beam and the form of the dose distribution in the transverse plane with the modulation method. Improvements in the dose uniformity were seen for the majority of modulation methods. The magnitude of the change was between 5.6% and 11.1% (p<0.05) of the breast volume for breast sizes above 500 cm(3). Some modulation methods introduced high dose at the chest wall. In conclusion, the majority of the methods improved dose uniformity for breast sizes of 500 cm(3) or greater. No method showed a clear advantage over the others. The use of modulation methods should be governed by consideration of its effects relative to a simple wedge plan.

The increased intelligence, read-out speed, radiation hardness and potential large size of CMOS active pixel sensors (APS) gives them a potential advantage over systems currently used for verification of complex treatments such as IMRT and the tracking of moving tumours. The aim of this work is to investigate the feasibility of using an APS-based system to image the megavoltage treatment beam produced by a linear accelerator (Linac), and to demonstrate the logic which may ultimately be incorporated into future sensor and FPGA design to evaluate treatment and track motion. A CMOS APS was developed by the MI3 consortium and incorporated into a megavoltage imaging system using the standard lens and mirror configuration employed in camera-based EPIDs. The ability to resolve anatomical structure was evaluated using an Alderson RANDO head phantom, resolution evaluated using a quality control (QC3) phantom and contrast using an in-house developed phantom. A complex intensity-modulated radiotherapy (IMRT) treatment was imaged and two algorithms were used to determine the field-area and delivered dose, and the position of multi-leaf collimator (MLC) leaves off-line. Results were compared with prediction from the prescription and found to agree within a single image frame time for dose delivery and 0.02-0.03 cm for the position of collimator leaves. Such a system therefore shows potential as the basis for an on-line verification system capable of treatment verification and monitoring patient motion.

The effectiveness of ABC has been traditionally measured as the reduction in internal margin (IM) within the planning target volume (PTV). Not to overestimate the benefit of ABC, the effect of patient movement during treatment also needs to be taken into account. We determined the IM and set-up error with ABC and the effect on physical lung parameters compared to standard margins used with free breathing. We also assessed interfraction oesophageal movement to determine a planning organ at risk volume (PRV).

We present a formalism for using functional imaging both to derive patient-specific radiobiological properties and consequently to prescribe optimal nonuniform radiotherapy dose distributions. The ability to quantitatively assess the response to an initial course of radiotherapy would allow the derivation of radiobiological parameters for individual patients. Both an iterative optimization and an analytical approach to this problem were investigated and illustrated by application to the linear-quadratic model of cell killing using simulated parametric data for a modeled tumor. Potential gains in local control were assessed by comparing uniform dose distributions with optimized dose distributions of equal integral dose. The effect on local prescribed dose of variations in effective radiosensitivity, tumor burden, and proliferation rate was investigated, with results suggesting that dose variations would be significant but clinically achievable. The sensitivity of derived parameters to image noise and the effect of varying the initial fractionation and imaging schedule were assessed. The analytical approach proved remarkably robust, with 10% image noise resulting in dose errors of approximately 1% for a clinically relevant set of parameters. Potential benefits were demonstrated by using this formalism to prescribe nonuniform dose distributions for model tumors using a range of literature-derived parameters. The redistribution of dose improved tumor control probability by factors between 1.03 and 4.27 for a range of model tumors. (C) 2008 American Association of Physicists in Medicine.

The benefits of using Synchrony (TM) Respiratory Tracking System (RTS) in conjunction with the CyberKnife robotic treatment device to treat a "breathing tumor" in an anthropomorphic, tissue-equivalent, thoracic phantom have been investigated. The following have been studied: (a) Synchrony's ability to allow the CyberKnife to deliver accurately a planned dose distribution to the free-breathing phantom and (b) the dosimetric implications when irregularities in the breathing cycle and phase differences between internal (tumor) and external (chest) motion exist in the course of one treatment fraction. The breathing phantom PULMONE (phantom used in lung motion experiments) has been used, which can imitate regular or irregular breathing patterns. The breathing traces from two patients with lung cancer have been selected as input. Both traces were irregular in amplitude, frequency, and base line. Patient B demonstrated a phase difference between internal and external motion, whereas patient A did not. The experiment was divided into three stages: In stage I-static, the treatment was delivered to the static phantom. In stage II-motion, the phantom was set to breathe, following the breathing trace of each of the two patients. Synchrony (TM) was switched off, so no motion compensation was made. In stage III-compensation, the phantom was set to breathe and Synchrony (TM) was switched on. A linear correspondence model was chosen to allow for phase differences between internal and external motion. Gafchromic EBT film was inserted in the phantom tumor to measure dose. To eradicate small errors in film alignment during readout, a gamma comparison with pass criteria of 3%/3 mm was selected. For a more quantitative approach, the percentage of pixels in each gamma map that exceeded the value of 1 (P-1) was also used. For both breathing signals, the dose blurring caused by the respiratory motion of the tumor in stage II was degraded considerably compared with stage I (P-1=15% for patient A and 8% for patient B). The motion compensation via the linear correspondence model was sufficient to provide a dose distribution that satisfied the set gamma criteria (P-1=3% for patient A and 2% for patient B). Synchrony (TM) RTS has been found satisfactory in recovering the initial detail in dose distribution, for realistic breathing signals, even in the case where a phase delay between internal tumor motion and external chest displacement exists. For the signals applied here, a linear correspondence model provided an acceptable degree of motion compensation.

The penetration characteristics of electron beams into x-ray targets are investigated for incident electron kinetic energies in the range 50-150 keV. The frequency densities of electrons penetrating to a depth x in a target, with a fraction of initial kinetic energy, u, are calculated using Monte Carlo methods for beam energies of 50, 80, 100, 120 and 150 keV in a tungsten target. The frequency densities for 100 keV electrons in Al, Mo and Re targets are also calculated. A mixture of simple modeling with equations and interpolation from data is used to generalize the calculations in tungsten. Where possible, parameters derived from the Monte Carlo data are compared to experimental measurements. Previous electron transport approximations in the semiempirical models of other authors are discussed and related to this work. In particular, the crudity of the use of the Thomson-Whiddington law to describe electron penetration and energy loss is highlighted. The results presented here may be used towards calculating the target self-attenuation correction for bremsstrahlung photons emitted within a tungsten target.

Three-dimensional (3D) soft tissue tracking is of interest for monitoring organ motion during therapy. Our goal is to assess the tracking performance of a curvilinear 3D ultrasound probe in terms of the accuracy and precision of measured displacements. The first aim was to examine the depth dependence of the tracking performance. This is of interest because the spatial resolution varies with distance from the elevational focus and because the curvilinear geometry of the transducer causes the spatial sampling frequency to decrease with depth. Our second aim was to assess tracking performance as a function of the spatial sampling setting (low, medium or high sampling). These settings are incorporated onto 3D ultrasound machines to allow the user to control the trade-off between spatial sampling and temporal resolution. Volume images of a speckle-producing phantom were acquired before and after the probe had been moved by a known displacement (1, 2 or 8 mm). This allowed us to assess the optimum performance of the tracking algorithm, in the absence of motion. 3D speckle tracking was performed using 3D cross-correlation and sub-voxel displacements were estimated. The tracking performance was found to be best for axial displacements and poorest for elevational displacements. In general, the performance decreased with depth, although the nature of the depth dependence was complex. Under certain conditions, the tracking performance was sufficient to be useful for monitoring organ motion. For example, at the highest sampling setting, for a 2 mm displacement, good accuracy and precision (an error and standard deviation of <0.4 mm) were observed at all depths and for all directions of displacement. The trade-off between spatial sampling, temporal resolution and size of the field of view (FOV) is discussed.

For EPID dosimetry, the calibration should ensure that all pixels have a similar response to a given irradiation. A calibration method (MC), using an analytical fit of a Monte Carlo simulated flood field EPID image to correct for the flood field image pixel intensity shape, was proposed. It was compared with the standard flood field calibration (FF), with the use of a water slab placed in the beam to flatten the flood field (WS) and with a multiple field calibration where the EPID was irradiated with a fixed 10 x 10 field for 16 different positions (MF). The EPID was used in its normal configuration (clinical setup) and with an additional 3 mm copper slab (modified setup). Beam asymmetry measured with a diode array was taken into account in MC and WS methods. For both setups, the MC method provided pixel sensitivity values within 3% of those obtained with the MF and WS methods (mean difference < 1%, standard deviation < 2%). The difference of pixel sensitivity between MC and FF methods was up to 12.2% (clinical setup) and 11.8% (modified setup). MC calibration provided images of open fields (5 x 5 to 20 x 20 cm(2)) and IMRT fields to within 3% of that obtained with WS and MF calibrations while differences with images calibrated with the FF method for fields larger than 10 x 10 cm2 were up to 8%. MC, WS and MF methods all provided a major improvement on the FF method. Advantages and drawbacks of each method were reviewed.

Radiation dose distributions created by two dimensional (2D) treatment planning are responsible for partial volumes receiving >107% of the prescribed dose in a proportion of patients prescribed whole breast radiotherapy after tumour excision of early breast cancer. These may contribute to clinically significant late radiation adverse effects.

The potential for systematic errors in radiotherapy of a breathing patient is considered using the statistical model of Bortfeld et al (2002 Phys. Med. Biol. 47 2203-20). It is shown that although averaging over 30 fractions does result in a narrow Gaussian distribution of errors, as predicted by the central limit theorem, the fact that one or a few samples of the breathing patient's motion distribution are used for treatment planning (in contrast to the many treatment fractions that are likely to be delivered) may result in a much larger error with a systematic component. The error distribution may be particularly large if a scan at breath-hold is used for planning.

This study focuses on understanding the impact of intensity-modulated radiotherapy (IMRT) delivery effects when applied to plans generated by commercial treatment-planning systems such as Pinnacle (ADAC Laboratories Inc.) and CadPlan/Helios (Varian Medical Systems). These commercial planning systems have had several version upgrades (with improvements in the optimization algorithm), but the IMRT delivery effects have not been incorporated into the optimization process. IMRT delivery effects include head-scatter fluence from IMRT fields, transmission through leaves and the effect of the rounded shape of the leaf ends. They are usually accounted for after optimization when leaf sequencing the "optimal" fluence profiles, to derive the delivered fluence profile. The study was divided into two main parts: (a) analysing the dose distribution within the planning-target volume (PTV), produced by each of the commercial treatment-planning systems, after the delivered fluence had been renormalized to deliver the correct dose to the PTV; and (b) studying the impact of the IMRT delivery technique on the surrounding critical organs such as the spinal cord, lungs, rectum, bladder etc. The study was performed for tumours of (i) the oesophagus and (ii) the prostate and pelvic nodes. An oesophagus case was planned with the Pinnacle planning system for IMRT delivery, via multiple-static fields (MSF) and compensators, using the Elekta SL25 with a multileaf collimator (MLC) component. A prostate and pelvic nodes IMRT plan was performed with the Cadplan/Helios system for a dynamic delivery (DMLC) using the Varian 120-leaf Millennium MLC. In these commercial planning systems, since IMRT delivery effects are not included into the optimization process, fluence renormalization is required such that the median delivered PTV dose equals the initial prescribed PTV dose. In preparing the optimum fluence profile for delivery, the PTV dose has been "smeared" by the IMRT delivery techniques. In the case of the oesophagus, the critical organ, spinal cord, received a greater dose than initially planned, due to the delivery effects. The increase in the spinal cord dose is of the order of 2-3 Gy. In the case of the prostate and pelvic nodes, the IMRT delivery effects led to an increase of approximately 2 Gy in the dose delivered to the secondary PTV, the pelvic nodes. In addition to this, the small bowel, rectum and bladder received an increased dose of the order of 2-3 Gy to 50% of their total volume. IMRT delivery techniques strongly influence the delivered dose distributions for the oesophagus and prostate/pelvic nodes tumour sites and these effects are not yet accounted for in the Pinnacle and the CadPlan/Helios planning systems. Currently, they must be taken into account during the optimization stage by altering the dose limits accepted during optimization so that the final (sequenced) dose is within the constraints.

A new model of the light output from single-crystal scintillators in megavoltage energy x-ray beams has been developed, based on the concept of a Lambertian light guide model (LLG). This was evaluated in comparison with a Monte Carlo (MC) model of optical photon transport, previously developed and reported in the literature, which was used as a gold standard. The LLG model was developed to enable optimization of scintillator detector design. In both models the dose deposition and light propagation were decoupled, the scintillators were cuboids, split into a series of cells as a function of depth, with Lambertian side and entrance faces, and a specular exit face. The signal in a sensor placed 1 and 1000 mm beyond the exit face was calculated. Cesium iodide (CSI) crystals of 1.5 and 3 mm square cross section and 1, 5, and 10 mm depth were modeled. Both models were also used to determine detector signal and optical gain factor as a function of CsI scintillator thickness, from 2 to 10 mm. Results showed a variation in light output with position of dose deposition of a factor of up to approximately 5, for long, thin scintillators (such as 10 X 1.5 x 1.5 mm3). For short, fat scintillators (such as 1 X 3 X 3 mm3) the light output was more uniform with depth. MC and LLG generally agreed to within 5%. Results for a sensor distance of 1 mm showed an increase in light output the closer the light originates to the exit face, while a distance of 1000 mm showed a decrease in light output the closer the light originates to the exit face. For a sensor distance of 1 mm, the ratio of signal for a 10 mm scintillator to that for a 2 mm scintillator was 1.98, whereas for the 1000 mm distance the ratio was 3.00. The ratio of quantum efficiency (QE) between 10 and 2 mm thicknesses was 4.62. We conclude that these models may be used for detector optimization, with the light guide model suitable for parametric study.

This study investigated the sensitivity of static planning of intensity-modulated beams (IMBs) to intrafraction deformable organ motion and assessed whether smoothing of the IMBs at the treatment-planning stage can reduce this sensitivity. The study was performed with a 4D computed tomography (CT) data set for an IMRT treatment of a patient with liver cancer. Fluence profiles obtained from inverse-planning calculations on a standard reference CT scan were redelivered on a CT scan from the 4D data set at a different part of the breathing cycle. The use of a nonrigid registration model on the 4D data set additionally enabled detailed analysis of the overall intrafraction motion effects on the IMRT delivery during free breathing. Smoothing filters were then applied to the beam profiles within the optimization process to investigate whether this could reduce the sensitivity of IMBs to intrafraction organ motion. In addition, optimal fluence profiles from calculations on each individual phase of the breathing cycle were averaged to mimic the convolution of a static dose distribution with a motion probability kernel and assess its usefulness. Results from nonrigid registrations of the CT scan data showed a maximum liver motion of 7 mm in superior-inferior direction for this patient. Dose-volume histogram (DVH) comparison indicated a systematic shift when planning treatment on a motion-frozen, standard CT scan but delivering over a full breathing cycle. The ratio of the dose to 50% of the normal liver to 50% of the planning target volume (PTV) changed up to 28% between different phases. Smoothing beam profiles with a median-window filter did not overcome the substantial shift in dose due to a difference in breathing phase between planning and delivery of treatment. Averaging of optimal beam profiles at different phases of the breathing cycle mainly resulted in an increase in dose to the organs at risk (OAR) and did not seem beneficial to compensate for organ motion compared with using a large margin. Additionally, the results emphasized the need for 4D CT scans when aiming to reduce the internal margin (IM). Using only a single planning scan introduces a systematic shift in the dose distribution during delivery. Smoothing beam profiles either based on a single scan or over the different breathing phases was not beneficial for reducing this shift.

The purpose of this work was to determine the accuracy and precision of a real-time motion-tracking system (Osiris+) for the monitoring of external markers used on patients receiving radiotherapy treatments. Random and systematic errors in the system were evaluated for linear (1D), circular (2D) and elliptical (3D) continuous motions, and for a set of static positions offset from an origin. A Wellhofer beam data measurement system and a computer controlled platform (which could be programmed to give motion in 3D) were used to move a hemi-spherical test object. The test object had four markers of the type used on patients. Three markers were aligned in the central plane and a fourth was positioned out of plane. Errors were expressed as deviations from the planned positions at the sampled time points. The marked points on the test object were tracked for the linear motion case with a variation from the true position of less than +/-1 mm, except for two extreme situations. The variation was within +/-2 mm when the lights were dimmed and when the amplitude of the movement was +/-5.0 cm. The 2D circular motion was tracked with a standard deviation of 1 mm or less over four cycles. The sampling rates of the system were found to be 0.3-0.4 s when it was monitoring actively and 1.5-1.6 s otherwise. The recorded Osiris+ measurements of known static positions were within +/-1 mm of the value from the computer controlled platform moving the test object. The elliptical motions in 3D were tracked to +/-1 mm in two directions (Y,Z), and generally to within +/-2 mm for the third direction (X); however, specific marked points could display an error of up to 5 mm at certain positions in X. The overall displacement error for the 3D motion was +/-1 mm with a standard deviation of 2.5 mm. The system performance is satisfactory for use in tracking external marker motion during radiotherapy treatments.

To investigate the feasibility of fully automated detection of fiducial markers implanted into the prostate using portal images acquired with an electronic portal imaging device.

Photon dose calculation algorithms (such as the pencil beam and collapsed cone, CC) model the attenuation of a primary photon beam in media other than water, by using pathlength scaling based on the relative mass density of the media to water. In this study, we assess if differences in the electron density between the water and media, with different atomic composition, can influence the accuracy of conventional photon dose calculations algorithms. A comparison is performed between an electron-density scaling method and the standard mass-density scaling method for (i) tissues present in the human body (such as bone, muscle, etc.), and for (ii) water-equivalent plastics, used in radiotherapy dosimetry and quality assurance. We demonstrate that the important material property that should be taken into account by photon dose algorithms is the electron density, and not the mass density. The mass-density scaling method is shown to overestimate, relative to electron-density predictions, the primary photon fluence for tissues in the human body and water-equivalent plastics, where 6%-7% and 10% differences were observed respectively for bone and air. However, in the case of patients, differences are expected to be smaller due to the large complexity of a treatment plan and of the patient anatomy and atomic composition and of the smaller thickness of bone/air that incident photon beams of a treatment plan may have to traverse. Differences have also been observed for conventional dose algorithms, such as CC, where an overestimate of the lung dose occurs, when irradiating lung tumors. The incorrect lung dose can be attributed to the incorrect modeling of the photon beam attenuation through the rib cage (thickness of 2-3 cm in bone upstream of the lung tumor) and through the lung and the oversimplified modeling of electron transport in convolution algorithms. In the present study, the overestimation of the primary photon fluence, using the mass-density scaling method, was shown to be a consequence of the differences in the hydrogen content between the various media studied and water. On the other hand, the electron-density scaling method was shown to predict primary photon fluence in media other than water to within 1%-2% for all the materials studied and for energies up to 5 MeV. For energies above 5 MeV, the accuracy of the electron-density scaling method was shown to depend on the photon energy, where for materials with a high content of calcium (such as bone, cortical bone) or for primary photon energies above 10 MeV, the pair-production process could no longer be neglected. The electron-density scaling method was extended to account for pair-production attenuation of the primary photons. Therefore the scaling of the dose distributions in media other than water became dependent on the photon energy. The extended electron-scaling method was shown to estimate the photon range to within 1% for all materials studied and for energies from 100 keV to 20 MeV, allowing it to be used to scale dose distributions to media other than water and generated by clinical radiotherapy photon beams with accelerator energies from 4 to 20 MV. (c) 2006 American Association of Physicists in Medicine.

In intensity modulated radiation treatments (IMRT), the position of the field edges and the modulation within the beam are often achieved with a multileaf collimator (MLC). During the MLC calibration process, due to the finite accuracy of leaf position measurements, a systematic error may be introduced to leaf positions. Thereafter leaf positions of the MLC depend on the systematic error introduced on each leaf during MLC calibration and on the accuracy of the leaf position control system (random errors). This study presents and evaluates two methods to predict the systematic errors on the leaf positions introduced during the MLC calibration. The two presented methods are based on a series of electronic portal imaging device (EPID) measurements. A comparison with film measurements showed that the EPID could be used to measure leaf positions without introducing any bias. The first method, referred to as the "central leaf method," is based on the method currently used at this center for MLC leaf calibration. It mimics the manner in which leaf calibration parameters are specified in the MLC control system and consequently is also used by other centers. The second method, a new method proposed by the authors and referred to as the "individual leaf method," involves the measurement of two positions for each leaf (-5 and +15 cm) and the interpolation and extrapolation from these two points to any other given position. The central leaf method and the individual leaf method predicted leaf positions at prescribed positions of -11, 0, 5, and 10 cm within 2.3 and 1.0 mm, respectively, with a standard deviation (SD) of 0.3 and 0.2 mm, respectively. The individual leaf method provided a better prediction of the leaf positions than the central leaf method. Reproducibility tests for leaf positions of -5 and +15 cm were performed. The reproducibility was within 0.4 mm on the same day and 0.4 mm six weeks later (I SD). Measurements at gantry angles of 0 degrees, 90 degrees, and 270 degrees for leaf positions of -5 and +15 cm showed no significant effect of gravity. The individual leaf method could be used in various applications to improve the accuracy of radiotherapy treatment from planning to delivery. Three cases are discussed: IMRT beam verification, MLC calibration and dose calculation. (c) 2006 American Association of Physicists in Medicine.

This study focused on predicting the electronic portal imaging device (EPID) image of intensity modulated radiation treatment (IMRT) fields in the absence of attenuation material in the beam with Monte Carlo methods. As IMRT treatments consist of a series of segments of various sizes that are not always delivered on the central axis, large spectral variations may be observed between the segments. The effect of these spectral variations on the EPID response was studied with fields of various sizes and off-axis positions. A detailed description of the EPID was implemented in a Monte Carlo model. The EPID model was validated by comparing the EPID output factors for field sizes between 1 X 1 and 26 X 26 cm 2 at the isocenter. The Monte Carlo simulations agreed with the measurements to within 1.5%. The Monte Carlo model succeeded in predicting the EPID response at the center of the fields of various sizes and offsets to within 1 % of the measurements. Large variations (up to 29%) of the EPID response were observed between the various offsets. The EPID response increased with field size and with field offset for most cases. The Monte Carlo model was then used to predict the image of a simple test IMRT field delivered on the beam axis and with all offset. A variation of EPID response up to 28% was found between the on- and off-axis delivery. Finally, two clinical IMRT fields were simulated and compared to the measurements. For all IMRT fields, simulations and measurements agreed within 3%-0.2 cm for 98% of the pixels. The spectral variations were quantified by extracting from the spectra at the center of the fields the total photon yield (Y-total), the photon yield below 1 MeV (Y-low), and the percentage of photons below 1 MeV (P-low). For the studied cases, a correlation was shown between the EPID response variation and Y-total, Y-low, and P-low. (c) 2006 American Association of Physicists in Medicine.

This study was designed to examine the feasibility of utilizing transabdominal ultrasound for real-time monitoring of target motion during a radiotherapy fraction. A clinical Acuson 128/XP ultrasound scanner was used to image various stationary and moving phantoms while an Elekta SL25 linear accelerator radiotherapy treatment machine was operating. The ultrasound transducer was positioned to image from the outer edge of the treatment field at all times. Images were acquired to videotape and analyzed using in-house motion tracking algorithms to determine the effect of the SL25 on the quality of the displacement measurements. To determine the effect on the dosimetry of the presence of the transducer, dose distributions were examined using thermoluminescent dosimeters loaded into an Alderson Rando phantom and exposed to a 10 x 10 cm2 treatment field with and without the ultrasound transducer mounted 2.5 cm outside the field edge. The ultrasound images acquired a periodic noise that was shown to occur at the pulsing frequency of the treatment machine. Images of moving tissue were analyzed and the standard deviation on the displacement estimates within the tissue was identical with the SL25 on and off. This implies that the periodic noise did not significantly degrade the precision of the tracking algorithm (which was better than 0.01 mm). The presence of the transducer at the surface of the phantom presented only a 2.6% change to the dose distribution to the volume of the phantom. The feasibility of ultrasonic motion tracking during radiotherapy treatment is demonstrated. This presents the possibility of developing a noninvasive, real-time and low-cost method of tracking target motion during a treatment fraction.

A combined modality radiotherapy (CMRT) incorporates both external beam radiotherapy (EBT) and targeted radionuclide therapy (TRT) components. The spatial aspects of this combination were explored by utilising intensity modulated radiotherapy (IMRT) to provide a non-uniform EBT dose distribution.

A Monte Carlo based computer model has been developed for electron beam computed tomography (EBCT) to calculate organ and effective doses in a humanoid hermaphrodite phantom. The program has been validated by comparison with experimental measurements of the CT dose index in standard head and body CT dose phantoms; agreement to better than 8% has been found. The robustness of the model has been established by varying the input parameters. The amount of energy deposited at the 12:00 position of the standard body CT dose phantom is most susceptible to rotation angle, whereas that in the central region is strongly influenced by the beam quality. The program has been used to investigate the changes in organ absorbed doses arising from partial and full rotation about supine and prone subjects. Superficial organs experience the largest changes in absorbed dose with a change in subject orientation and for partial rotation. Effective doses for typical clinical scan protocols have been calculated and compared with values obtained using existing dosimetry techniques based on full rotation. Calculations which make use of Monte Carlo conversion factors for the scanner that best matches the EBCT dosimetric characteristics consistently overestimate the effective dose in supine subjects by typically 20%, and underestimate the effective dose in prone subjects by typically 13%. These factors can therefore be used to correct values obtained in this way. Empirical dosimetric techniques based on the dose-length product yield errors as great as 77%. This is due to the sensitivity of the dose length product to individual scan lengths. The magnitude of these errors is reduced if empirical dosimetric techniques based on the average absorbed dose in the irradiated volume (CTDIvol) are used. Therefore conversion factors specific to EBCT have been calculated to convert the CTDIvol to an effective dose. (c) 2005 American Association of Physicists in Medicine.

Background and purpose: To investigate the feasibility and the advantages of a portal-imaging mode on a medical accelerator, consisting of a thin low-Z bremsstrahlung target and a thin Gd2O2S/film detector, for patient imaging.Patients and methods: The international code of practice for high-energy photon dosimetry was used to calibrate dosimetry instruments for the imaging beam produced by 4.75 MeV electrons hitting a 6 mm thick aluminium target. Images of the head and neck of a humanoid phantom were taken with a mammography film system and the dose in the phantom was measured with TLDs calibrated for this beam. The first head and neck patient images are compared with conventional images (taken with the treatment beam on a film radiotherapy verification detector). Visibility of structures for six patients was evaluated.Results: Images of the head and neck of a humanoid phantom, taken with both imaging systems showed that the contrast increased dramatically for the new system while the dose required to form an image was less than 10(-2) Gy. The patient images taken with the new and the conventional systems showed that air-tissue interfaces were better defined in the new system image. Anatomical structures, visible on both films, are clearer with the new system. Additionally, bony structures, such as vertebrae, were clearly visible only with the new system. The system under evaluation was significantly better for all features in lateral images and most features in anterior images.Conclusions: This pilot study of the new portal imaging system showed the image quality is significantly improved. (C) 2005 Elsevier Ireland Ltd. All rights reserved.

The use of geometrical phantoms for computed tomography (CT) dosimetry can incur errors in the calculation of effective dose due to the anatomically incorrect organ shapes and distributions, and unrepresentative body dimensions. A Monte Carlo program that makes use of an anatomically correct voxel phantom has been developed to calculate effective doses in CT and to compare with conventional dosimetric techniques. The code was validated against the latter by matching the phantom dimensions and simulating whole-body irradiation; agreement to within 6% was found. Effective doses were calculated for brain, lung, abdomen and pelvis CT scans for voxel phantom sizes corresponding to those of standard-sized adult, a teenager and 10% greater than those of standard-sized adult. Errors incurred by using the conventional techniques are minimised if the scan range is set by matching the fractions of radiosensitive organs that are irradiated directly. Under these circumstances, the conventional techniques will underestimate the dose to a 15 y old by up to 22% while the dose to a large subject is overestimated by up to 11%.

Methods of performing dosimetry for a combined modality radiotherapy (CMRT) consisting of a targeted radionuclide therapy (TRT) and separately delivered external beam therapy (EBT) have been established using the biologically effective dose (BED). However, a concurrent delivery of the two therapies may influence the radiobiologic effect of the treatment resulting from interaction between the therapies, and this situation has been modeled to assess the likely consequences of this regime.

Dose resolution, DdeltaP, is becoming a common method for characterizing the performance of a gel dosimeter. In this note we examine how the goodness of fit of the calibration function affects DdeltaP and show that its inclusion in the calculation of DdeltaP is essential to avoid overestimating the performance of the gel.

Inverse planning techniques are known to produce intensity-modulated beams (IMBs) that are highly modulated. They are characterized by the fact that they contain high-frequency modulations that are absent in the profiles that are easier to deliver. For the purpose of this study these clinically unwanted fluctuations are being defined as 'noise'. Although these highly modulated solutions are also optimal solutions, as soon as the profiles are being delivered, they become unfavourable with respect to delivery efficiency and the analysis and verification of treatment. The aim of this work was therefore to understand the origins of the structure and complexity of IMBs. Ultimately, if one can characterize the essential features in optimum beam profiles, it might be possible to control the frequency distribution of IMBs and simplify the IMRT planning and delivery process. The study was based on two common optimization techniques: simulated annealing (SA) and gradient-descent (GD). The assumptions made at the start of this work were that the stochastic noise caused by the SA optimization technique is dominant over other sources of noise and that it could be separated out from the essential modulation after convergence of the cost function by averaging minimum-cost fluence profiles. The results indicate that there are three possible sources of stochastic noise in IMBs, i.e. the optimization technique, the cost function and the definition of convergence of that cost function. In terms of the optimization technique itself, it was confirmed that the gradient-descent technique does not introduce stochastic noise in the IMBs. The SA technique does introduce stochastic noise but averaging of minimum-cost fluence profiles does not result in smoother beam profiles. This originates from the fact that this type of noise is not the dominant factor in the optimization, but rather the curvature of the cost function close to the global minimum. It is shown that the choice of initial temperature in the SA optimization technique is crucial for the convergence of the cost function and the frequency distribution of the fluence profiles. If the initial temperature is too small the stochastic noise will get frozen into the fluence profiles and become the dominant component of noise, resulting in very random-looking and difficult to deliver patterns.

The purpose of the work presented in this paper was to determine whether patient positioning and delivery errors could be detected using electronic portal images of intensity modulated radiotherapy (IMRT).

It is not uncommon for a patient to receive both external beam and targeted radionuclide therapy during the course of a cancer treatment. The total dose received by the tumor and by normal tissues will therefore be subject to the contributions of both treatment modalities. However, the two treatments are generally applied independently of one another, with little attention paid to the combined effect. With the availability of patient-specific three-dimensional dosimetry for radionuclide therapies, it is pertinent now to consider the combined effect of the two treatments, and to investigate how dosimetry for this situation may be carried out. Methodology has been developed to allow a combination of dose information from the two types of therapy. The biologically effective dose (BED) has been employed to address the issue of inequivalence of biological effect of the two therapies. Dose distributions have been represented as distributions of BED, and the net effect resulting from the combination of these two therapies demonstrated through a combination of BED maps. Examples are presented of cases in which this analysis of a combined therapy provides a more favorable treatment than either therapy alone. For one patient the ratio of the mean spinal cord dose to the mean CTV dose was calculated for both an external beam therapy alone and for a combined therapy and was found to be 0.40 and 0.16, respectively.

Intensity-modulated (IM) beam profiles computed by inverse-planning systems tend to be complex and may have multiple spatial minima and maxima. In addition to the structure originating from the treatment objectives, beam profiles might contain stochastic structure or noise and numerical artefacts, which present certain practical difficulties. The combinational use of conformal and intensity-modulated beams could be a different method of making the total fluence distribution less noisy and deliverable without compromising the advantages of IMRT. The investigation of this possibility provided the basis for this paper. A treatment-planning study was performed to compare plans combining modulated and unmodulated beams with a 5-field, equally spaced, full IMRT plan for treating the prostate and seminal vesicles in three patients. Beam angles for this study were 0 degrees, 72 degrees, 144 degrees, 216 degrees and 288 degrees. Additionally, a study was performed on a patient with a different beam arrangement (36 degrees, 108 degrees, 180 degrees, 252 degrees, 324 degrees) from the first study to test the obtained results. This study has demonstrated that it is possible to substitute up to two conformal beams in the originally full IMRT plan when carefully selecting the conformal beam angles. Making the anterior beam (0 degrees) and an anterior oblique beam (between 0 degrees and 90 degrees) conformal leads to a reduction in the total number of monitor units and segments of about 15% and 39%, respectively. Additionally, these two open fields can be used for simpler treatment verification.

Polymer gel dosimetry has been used to measure the radiotherapy dose homogeneity in a breast phantom for two different treatment methods. The first 'standard' method uses two tangential wedged fields while the second method has three static fields shaped by multileaf collimators (MLCs) in addition to the standard wedged fields to create intensity modulated fields. Gel dose distributions from the multileaf modulation treatment show an improved dose uniformity in comparison to the standard treatment with a decreased volume receiving doses over 105%.

An intensity-modulated beam optimization algorithm is presented which incorporates the delivery constraints into the optimization cycle. The optimization algorithm is based on the quasi-Newton method of iteratively solving minimization problems. The developed algorithm iteratively corrects the incident, pencil-beam-like, fluence to incorporate the delivery constraints. In the present study, the goal of the optimization algorithm is to achieve the best deliverable radiotherapy plan, subject to the constraints of the delivery technique described by a leaf-sequencing algorithm being applied concurrently. In general, if they are applied after, rather than during, the optimization cycle, the delivery constraints associated with the IMRT technique can produce local variations up to 6% in the 'optimized' dose (i.e., distribution without applied constraints) and reduce the degree of conformity, of the dose, to the PTV region. The optimization method has been applied to three IMRT delivery techniques: dynamic multileaf (DMLC), multiple-static-field (MSF) and slice-by-slice tomotherapy (NOMOS MIMiC). The beam profiles were generated for a prostate tumour with organs at risk being the rectum, bladder and femoral heads. The optimization method described was shown to generate optimum and deliverable IMRT plans for these three delivery techniques. In the case of the DMLC and MSF the optimization converged within 3-5 iterations to a mean PTV dose of 69.60 +/- 1.34 Gy and 69.71 +/- 1.34 Gy, respectively, while for NOMOS MIMiC approximately 10 iterations were needed to obtain 69.68 +/- 1.55 Gy. In addition to this, the IMRT optimization also yielded optimum fluence profiles when clustering was performed concurrently with the leaf-sequencer. An optimum between 8 and 15 clusters of equal fluence 'intensity' was shown to establish the best compromise between the number of fluence levels and the PTV dose coverage.

The precise shape of the three-dimensional dose distributions created by intensity-modulated radiotherapy means that the verification of patient position and setup is crucial to the outcome of the treatment. In this paper, we investigate and compare the use of two different image calibration procedures that allow extraction of patient anatomy from measured electronic portal images of intensity-modulated treatment beams.

The aim of this work was to evaluate the positional distribution of dose in a concise manner and to analyse dose-histogram results in tangential breast radiotherapy in 300 patients, randomized to standard wedged or intensity modulated radiotherapy (IMRT), for future correlation with clinical outcome data. A simple method for analysing the dose-position relationship in the treatment volume was used to compare the spatial distribution of dose in patients. The breast was divided into equal thirds (upper, middle and lower) and dose was assessed using three dose bands; 95-105%, >105-110% and >110% of the prescription dose. The effect of using IMRT on the dosimetry was assessed from dose-volume histogram data using the following parameters: percentage of the target volume receiving a dose less than 95%, greater than 105%, either less than 95% or greater than 105% of that prescribed; the mean dose; and the maximum dose. Doses greater than 105% were predominantly in the upper and lower regions of the breast in the standard wedged treatment. 96% of these patients received doses greater than 105% in the upper region of the breast and 70% received doses greater than 105% in the lower breast. Only 4% of patients allocated IMRT received doses greater than 105% in either region. Analysis of dose-volume histogram data showed that IMRT reduced the volume receiving a dose greater than 105% by a mean of 10.7% (p= or <0.001); the mean change in the volume receiving a dose less than 95% was 0.2% (p=0.63). Average mean plan dose was 101.6% for standard treatment and 99.6% for IMRT (p<0.001 for each compared with 100.0% ideal). The mean value of maximum dose was reduced from 111% to 106% in the group of patients randomized to IMRT. A simple method for describing the relationship between dose and position in the breast, which is helpful for the effective correlation of dosimetry and clinical effects, is reported. Further, application of IMRT to the tangential field irradiation of the breast has been demonstrated to reduce high dose regions in both volume and dose level without compromising either minimum dose coverage or mean dose delivered to the breast.

Megavoltage portal images suffer from poor quality compared to those produced with kilovoltage x-rays. Several authors have shown that the image quality can be improved by modifying the linear accelerator to generate more low-energy photons. This work addresses the problem of using Monte Carlo simulation and experiment to optimize the beam and detector combination to maximize image quality for a given patient thickness. A simple model of the whole imaging chain was developed for investigation of the effect of the target parameters on the quality of the image. The optimum targets (6 mm thick aluminium and 1.6 mm copper) were installed in an Elekta SL25 accelerator. The first beam will be referred to as A16 and the second as Cu1.6. A tissue-equivalent contrast phantom was imaged with the 6 MV standard photon beam and the experimental beams with standard radiotherapy and mammography film/screen systems. The arrangement with a thin Al target/mammography system improved the contrast from 1.4 cm bone in 5 cm water to 19% compared with 2% for the standard arrangement of a thick, high-Z target/radiotherapy verification system. The linac/phantom/detector system was simulated with the BEAM/EGS4 Monte Carlo code. Contrast calculated from the predicted images was in good agreement with the experiment (to within 2.5%). The use of MC techniques to predict images accurately, taking into account the whole imaging system, is a powerful new method for portal imaging system design optimization.

A model has been developed to describe the sampling process that occurs when intensity modulated radiotherapy treatments (delivered with a multileaf collimator) are imaged with an electronic portal imaging device that acquires a set of frames with a finite dead-time between them. The effects of the imaging duty cycle and frame rate on the accuracy of dosimetric verification have been studied. A frame interval of 1 s with 25%, 50% and 75% duty cycle, and a 50% duty cycle with frame intervals of 1, 2, 4, 8, and 16 s have been studied for a smoothly varying hemispherical intensity profile, and a 50% duty cycle with frame intervals of 1, 2, 4, and 8 s for a pixellated distribution. In addition an intensity modulated beam for breast radiotherapy has been modeled and imaged for 0.33 s frame time and 1, 2, and 3 s frame separation. The results show that under sparse temporal sampling conditions, errors of the order of 10% may ensue and occur with an oscillatory pattern. For the beams studied, imaging with a 1 or 2 s frame interval resulted in small errors at the 1%-2% level, for all duty cycles shown.

A comparison between three classes of intensity-modulated delivery techniques was undertaken to examine the dosimetric consequences of using a multileaf collimator (MLC) reshaped on each imaged fraction as opposed to compensators designed on the first day of treatment potentially giving a treatment technique whose accuracy is thus degraded by movement.

The effect of interfractional patient movement on dosimetry has been investigated for breast radiotherapy. Errors in patient set-up and changes in breast volume were simulated individually to determine how each contributes to the total dosimetric error. Two treatment techniques were investigated: a conventional treatment and an intensity-modulated treatment delivered using compensators. Six patients were investigated and anterior-posterior (AP) and superior-inferior (SI) displacements were simulated by displacing the isocentre in both directions by 2, 5 and 10 mm. A model of the breast was developed from the six patients to simulate changes in breast volume. In this model, the breast was described as a set of semi-ellipses. The volume of the breast was changed by varying the magnitude of the semi-major and semi-minor axes. Anisotropic changes in breast volume were also investigated. The dosimetric error was evaluated for each dose plan by calculating the volume outside the 95-105% dose range resulting from the simulations. A number of parameters describing the size and shape of the breast were also investigated to determine whether a susceptibility of outline sets to interfractional patient movement could be predicted. A parameter describing the increase in the breast volume outside the 95-105% dose range was calculated for AP a

The process of delivering an IMRT treatment may involve various beam-modifying techniques such as multileaf collimators (MLCs), the NOMOS MIMiC, blocks, wedges, etc. In the case of the MLC, the spatial/temporal variation of the position of the leaves and diaphragms in the beam allows the delivery of modulated beam profiles either by the multiple-static-field (MSF) method or by the dynamic multileaf collimator (DMLC) method. The constraints associated with the IMRT delivery technique are usually neglected in the process of obtaining the 'optimal' inverse treatment plan. Consequently, dose optimization may be significantly reduced when the 'optimal' beam profiles are converted to leaf/diaphragm positions via a leaf-sequencing interpreter. The paper presented here assesses the effects on the optimum treatment plan of the following leaf-sequencing algorithms: MSF, DMLC and NOMOS MIMiC. The results obtained suggest that the delivery of an 'optimum' plan produces an overdosage of the PTV region due to various factors such as leaf/diaphragm transmission effects, head-scatter and phantom-scatter contributions. The overdosage observed for a cohort of ten patients was 2.5, 3.7 and 5.7%, respectively, for the DMLC, MSF and NOMOS MIMiC, after normalizing the delivered fluence to account for IMRT effects (using the method of Convery et al (Convery D J, Cogrove V P and Webb S 2000 Proc. 13th Int. Conf. on Computers in Radiotherapy (Heidelberg, 2000)) such as to obtain 70 Gy at the isocentre. The IMRT techniques DMLC, MIMiC and MSF were compared for the organs at risk: rectum, bladder, and left and right femoral heads.

Intensity-modulated radiotherapy beams can be delivered using a multileaf collimator by one of two methods: either by superposition of a series of multiple-static fields, or by moving the collimators while the beam is on to produce 'dynamically' modulated beams. The leaf trajectories in this dynamic mode are given by a series of linear steps between control points defining each collimator position at known intervals throughout an exposure, The complexity of the resulting modulation is limited in the first case by the number of fields superposed and in the second case by the number of control points defined.Results are presented for an experimental study that investigates the effect of changing both the number of fields for the multiple-static technique, and the number of control points for a dynamic 'close-in' technique. All deliveries studied are clinical intensity-modulated breast fields. The effect of using a universal wedge in conjunction with the multileaf collimator is also studied, together with a comparison of the relative efficiency, time taken and the absolute dosimetric accuracy of the various delivery options.It is shown that all delivery techniques produce equivalent dose distributions when using 15 control points. with 10 control points being sufficient to produce an adequate breast compensator distribution. Except for the case of a four-control-point dynamic delivery, the universal wedge makes no significant difference to the dose distribution. However, it makes the delivery less efficient. The close-in interpreter consistently produces deliveries that are more efficient than the more conventional sliding-window technique and faster than the multiple-static-field technique. Finally the close-in technique is compared to the more 'standard' leaf-sweep technique and shown to be equivalent.

A method that uses electronic portal imaging to design intensity-modulated beams for compensation in breast radiotherapy was implemented using multiple static fields in a planning study. We present the results of the study to verify the algorithm, and to assess improvements to the dosimetry.

A method has been developed to enable a comparison to be made between the effects of movement on conventional tangential breast treatments and intensity-modulated treatments delivered using compensators.

In this paper we present a novel method of reducing the dosimetric effects of the finite leaf width of a multileaf collimator (MLC) in conformal and intensity modulated radiotherapy (IMRT). This is achieved by decomposing the required high-resolution fluence distribution into two orthogonal components, which are delivered with two leaf sweeps with head-twists differing by 90 degrees. Before the decomposition stage, a filter is applied to the required beam to force it to have a constant gradient in the two delivery directions. The component deliveries were found to be very spiky in nature, resulting in very inefficient delivery with the scanning leaves of our MLC. This method was evaluated using film dosimetry of four idealized beams: a 45 degree edge, a circle, a hemispherical intensity modulated beam (IMB) and a sine-like IMB. The measurements showed that this method had significantly reduced the effects of the 1 cm leaf width of our MLC at the 50% isodose level, but there was significant overdosage at the edge of the field and immediately inside the held edge. This method shows promise but further work is required before it may find clinical utility.

To develop a method of using a multileaf collimator (MLC) to deliver intensity modulated radiotherapy (IMRT) for tangential breast fields, using an MLC to deliver a set of multiple static fields (MSFs).

In this study a direct measurement of scatter in portal imaging for various air Saps and scatterer thicknesses at a beam energy of 6 MV is presented. The experimental data are compared with results from a Monte Carlo (MC) scatter model. In the regime where the air gap is larger than 9.3 cm the MC and the experiment agree. Based on this MC model an analytical model is developed, which takes all important interaction processes into account. It comprises a rigorous treatment of first order scattering and an estimation of photons scattered more than once within the phantom. This estimation is based on the assumption that higher order scattering can be considered as isotropically distributed around a certain scatter origin located in the midplane of the phantom. It is found that relative deviations between the MC model and the analytical model are of 2% to 3% in regions where scattering is very large. (C) 2000 American Association of Physicists in Medicine. [S0094-2405(00)01203-7].

The use of a dynamic multileaf collimator (MLC) to deliver intensity-modulated beams presents a problem for conventional verification techniques. The use of electronic portal imaging to track MLC leaves during beam delivery has been shown to provide a solution to this problem. An experimental comparison of three different verification systems, each using a different electronic portal imaging technology, is presented. Two of the systems presented are commercially available imagers with in-house modifications, with the third system being an in-house built experimental system. The random and systematic errors present in each of the verifications systems an measured and presented, together with the study of the effects of varying dose rate and leaf speed on verification system performance. The performance of the three systems is demonstrated to be very similar, with an overall accuracy in comparing measured and prescribed collimator trajectories of approximately +/-1.0 mm. Systematic errors in the percentage delivered dose signal provided by the accelerator are significant and must be corrected for good performance of the current systems. It is demonstrated that, with suitable modifications, commercially available portal imaging systems can be used to verify dynamic MLC beam delivery. (C) 2000 American Association of Physicists in Medicine. [S0094-2405 (00)00607-6].

An evaluation of the capabilities of a commercially available camera-based electronic portal imaging system for intensity-modulated radiotherapy verification is presented. Two modifications to the system are demonstrated which use a novel method to tag each image acquired with the delivered dose measured by the linac monitor chamber and reduce optical cross-talk in the imager. A detailed performance assessment is presented, including measurements of the optical decay characteristics of the system. The overall geometric accuracy of the system is determined to be +/-2.0 mm, with a dosimetric accuracy of +/-1.25 MU. Finally a clinical breast IMRT treatment, delivered by dynamic multileaf collimation, is successfully verified both by tracking the position of each leaf during beam delivery and recording the integrated intensity observed over the entire beam.

We present a method of calibrating the Portal Vision electronic portal imaging device to obtain radiological thickness maps for compensator design. In this method, coefficients are derived to describe the relationship between intensity and thickness for a set of water-equivalent blocks. The effects of four parameters were studied: (a) The dose response of the system was measured and found to be describable by a square-root function. (b) The calibration data and images were taken with a wedge in situ. The effects of using different wedges and different wedge orientations were investigated. The intrinsic accuracy of the accelerator/imager system was found to be 1.9 mm, for both 15 degrees and 30 degrees wedges. Changing the wedge orientation between calibration and imaging and rotating the calibration coefficients accordingly led to an error of 3.5 mm. (c) The variation in detector response with gantry angle was measured and corrected. The residual error in this process was 2.4 mm. (d) The use of a model to correct the effects of imaging with different field sizes was investigated and found to yield a residual error of 2.9 mm. The overall error in image calibrations was approximately 4 mm or 2% in dose. This is considered to be sufficiently small for the intended use of designing compensators for tangential breast irradiation.

Methods of removing the effects of linear accelerator (linac) output fluctuation from electronic portal images are described and compared. The output of the linac is measured using a specially constructed large-area ionization chamber during imaging and recorded with the image. The use of a dose-rate signal directly from the linac monitor chamber is discussed. Various versions of a quadratic thickness calibration scheme are tested, incorporating linac output data measured by the ionization chamber. Experimental results are presented showing that the incorporation of data from the ionization chamber gives improved absolute calibration accuracy and flatness. Immediately after calibration, the mean systematic thickness error in calibration of a uniform 136.8 mm water-equivalent slab was shown to be no more than 0.6 mm with a thickness variation within each image also of no more than +/-0.8 mm. This was true even when imaging with an unstable linac beam giving mean thickness errors between images of 8.8 mm and variations within each image of +/-4.9 mm without the ionization chamber correction. Up to one month after calibration, use of the ionization chamber to remove short-term linac fluctuations is shown to still keep mean thickness errors to less than 1.6 mm with variations within each image of no more than +/-1.4 mm.

An investigation of scintillation light scattering within camera-based electronic portal imaging devices is presented. A simple analytical scatter model is adapted for the precise geometries of two different camera-based imaging systems and the results of modelling and experimental measurements are compared. The results of the study strongly suggest that the main source of optical scattering is multiple reflection between the scintillation screen and 45 degrees mirror in both systems. The scattered light has a highly non-uniform distribution, which is strongly dependent upon field size. For large radiation fields the scatter contribution can be over 20% of the primary signal scintillation light intensity in the centre of the field. A purely optical method of removing the scattered light signal using a louvre grid on the surface of the scintillation screen is then presented and experimentally demonstrated to be effective.

A method of using electronic portal imaging to design compensators for tangential breast irradiation has been developed. We describe how this has been implemented.

The use of intensity modulation with multiple static fields has been suggested by many authors as a way to achieve highly conformal fields in radiotherapy. However, quality assurance of linear accelerators is generally done only for beam segments of 100 MU or higher, and by measuring beam profiles once the beam has stabilized. We propose a set of measurements to check the stability of dose delivery in small segments, and present measured data from three radiotherapy centres. The dose delivered per monitor unit, MU, was measured for various numbers of MU segments. The field flatness and symmetry were measured using either photographic films that are subsequently scanned by a densitometer, or by using a diode array. We performed the set of measurements at the three radiotherapy centres on a set of five different Philips SL accelerators with energies of 6 MV, 8 MV, 10 MV and 18 MV. The dose per monitor unit over the range of 1 to 100 MU was found to be accurate to within +/-5% of the nominal dose per monitor unit as defined for the delivery of 100 MU for all the energies. For four out of the five accelerators the dose per monitor unit over the same range was even found to be accurate to within +/-2%. The flatness and symmetry were in some cases found to be larger for small segments by a maximum of 9% of the flatness/symmetry for large segments. The result of this study provides the dosimetric evidence that the delivery of small segment doses as top-up fields for beam intensity modulation is feasible. However, it should be stressed that linear accelerators have different characteristics for the delivery of small segments, hence this type of measurement should be performed for each machine before the delivery of small dose segments is approved. In some cases it may be advisable to use a low pulse repetition frequency (PRF) to obtain more accurate dose delivery of small segments.

A detailed validation of a physical model for scattered radiation in portal images at 10 MV is presented. The ratio of the signal due to scattered radiation to the signal due to primary radiation (SPR) in an electronic portal image is defined. A simple physical model for SPR on the central axis (SPR*) was presented by Swindell and Evans for 6 MV and validated for field sizes up to 320 cm2. In this paper, the model is extended to 10 MV and validated for field sizes up to 625 cm2. The model is first compared with Monte Carlo modelled data for field areas A from 40 to 320 cm2, scatterer thicknesses d of 5 to 35 cm water and scatterer to detector distances L2 of 40 to 100 cm. The physical model has one free parameter, which is fitted empirically using these data. Second, experimental measurements are performed with A from 40 to 625 cm2, d from 4.6 to 27.4 cm and L2 fixed at 100 cm. The root mean square (rms) difference between the physical model and the Monte Carlo calculations was less than 0.001 for all L2 greater than 60 cm. Agreement between experimentally measured and physically modelled data amounts to a radiological thickness error of at best 0.7 mm in 273.6 mm and at worst 0.4 in 45.6 mm. The model performs equally well at all field sizes tested. This study shows that the Swindell and Evans SPR* model is accurate at 10 MV for L2 greater than 60 cm for all A up to 625 cm2.

Highly conformal dose distributions can be generated by intensity-modulated radiotherapy. Intensity-modulated beams (IMBs) are generally determined by inverse-planning techniques designed to maximize conformality. Usually such techniques apply no constraints on the form of the IMBs which may then develop fine-scale modulation. In this paper we present a technique for generating smoother IMBs, which yields a dose distribution almost identical to that without the constraint on the form of the IMBs. The method applies various filters successively at intervals throughout the iterative inverse planning. It is shown that the IMBs so determined using a simple median window filter have desirable properties in terms of increasing the efficiency of delivery by the dynamic multileaf collimator method and may be 'more like conventional beams' than unconstrained, highly modulated IMBs.

The design, construction, and performance evaluation of an electronic portal imaging device (EPID) are described. The EPID has the same imaging geometry as the current mirror-based systems except for the x-ray detection stage, where a two-dimensional (2D) array of 1 cm thick CsI(Tl) detector elements are utilized. The approximately 18% x-ray quantum efficiency of the scintillation detector and its 30 x 40 cm2 field-of-view at the isocenter are greater than other area-imaging EPIDs. The imaging issues addressed are theoretical and measured signal-to-noise ratio, linearity of the imaging chain, influence of frame-summing on image quality and image calibration. Portal images of test objects and a humanoid phantom are used to measure the performance of the system. An image quality similar to the current devices is achieved but with a lower dose. With approximately 1 cGy dose delivered by a 6 MV beam, a 2 mm diam structure of 1.3% contrast and an 18 mm diam object of 0.125% contrast can be resolved without using image-enhancement methods. A spatial resolution of about 2 mm at the isocenter is demonstrated. The capability of the system to perform fast sequential imaging, synchronized with the radiation pulses, makes it suitable for patient motion studies and verification of intensity-modulated beams as well as its application in cone-beam megavoltage computed tomography.

A prototype scanner for large-volume megavoltage computed tomography (MVCT) in a clinical set-up is described. The ultimate aim is to improve treatment accuracy in conformal radiotherapy through patient set-up error reduction and transit dosimetry.

An experimental study of radiation output intensity fluctuations of a Philips SL25 Linear accelerator is presented. Measurements are obtained using an electronic portal imaging device, and the consequences of the measured fluctuations for various different applications of megavoltage imaging including portal imaging, transit dosimetry and megavoltage computed tomography (MVCT) are discussed with examples. Fluctuations in output of +/- 0.7% (1 SD) are seen on every radiation pulse after photon noise and uncertainties caused by the detection system have been accounted for. Large fluctuations are also seen during the initial beam stabilization period (15%), during normal accelerator operation after the beam has been on for more than 1 min (4.5%) and during are therapy as a repeatable function of gantry angle (9%). Such output intensity fluctuations are shown to produce image artifacts in portal imaging devices with scanned detector readout and can also produce systematic errors in detector calibration that would lead to uncertainty in transit dose calculations. The propagation of these intensity fluctuations through MVCT image reconstruction is shown to produce ring artifacts in the reconstructed image. Sample portal and MVCT images are presented. All observed fluctuations in accelerator output are well within the manufacturer's specifications and do not affect the total dose delivered during normal treatment. Finally, megavoltage imaging is shown to be a powerful tool for accelerator quality assurance and treatment verification. (C) 1998 American Association of Physicists in Medicine.

The use of intensity-modulated radiation fields in radiotherapy treatment has been shown to have the potential to deliver highly conformal dose distributions. One technique for delivering these intensity-modulated beams is a computerized dynamic multileaf collimator (MLC). A major current impediment to the development of dynamic MLC therapy is verification of these highly complex treatments. Electronic portal imaging is shown here to be a solution to this verification problem. Experimental results are presented showing that leaf penumbra measured with a portal imager can be used to accurately define the positions of moving leaves. The random error in these leaf positions is compared with mean leaf positions along each leaf bank and specified leaf positions at prescription control points to check mechanical performance. Individual leaves are also checked for systematic motion errors. All leaf positions are found to be well within the manufacturer's specifications at all times. Finally, integral intensity images are presented that can be related to the dose distribution delivered. Portal imaging is shown to have the potential to become a valuable tool for the verification of dynamic MLC irradiation. (C) 1998 American Association of Physicists in Medicine. [S0094-2405(98)01310-8].

A parametric study is described leading to the optimization of a custom-made scintillation detector with a relatively high quantum efficiency (QE) for megavoltage photons and light output toward a remote lens. This detector allows low-dose portal imaging and continuous cone-beam megavoltage CT acquisition. The EGS4 Monte Carlo code was used to simulate the x-ray and electron transport in the detector. A Monte Carlo model of optical photon transport in a detector element was devised and used as well as various irradiation experiments on scintillators. Different detector materials and configurations were compared in terms of the optical photon irradiance on the lens from on- and off-axis detector elements and the practical constraints regarding detector construction and weight. Effects of scintillator material, detector element size, crystal coating type, and reflectivity, combinations of different coatings on detector faces, scintillator doping level, and crystal transparency were studied. With scintillator thickness adjusted to give an 18% x-ray QE at 6 MV, the Light output of CsI(Tl) was at least eight times higher than ZnWO4, EGO and NE118 plastic. Further, CsI(Tl) showed the smallest decrease in QE going from 6 to 24 MV. The off-axis reduction in emittance from the periphery of the detector was relatively small with a slight dependence on the type and reflectivity of the coating and the crystal thickness for a fixed detector element cross section. Light output was more strongly dependent on the reflectivity of lambertian coatings than specular ones. For a fixed detector element cross section, optimum coating type depended on crystal thickness. Typical CsI(Tl) crystals showed a relatively small variation in light output with changes in optical attenuation length. The optimum detector element was found to be CsI(Tl) coated on five faces with TiO2-loaded epoxy resin offering about a ten-fold improvement in light output per incident photon compared to typical metal/phosphor screens. (C) 1998 American Association of Physicists in Medicine. [S0094-2405(98)01410-2].

Electronic portal images may be used to design the compensation required to maximise dose uniformity in the breast from opposed tangential beams.

A method of determining the optimum beam intensities for compensation using multiple static multileaf collimator fields is presented. In this method a histogram of the number of beam pixels against beam intensity is generated for the intensity-modulated beam (IMB). The intensity of each beam to be used is chosen to minimize the mean square deviation between each bin in the histogram and the closest beam intensity. This method has been applied to sample IMBs possessing one maximum and two maxima. For both cases, the use of uniform beam intensity increments is shown to be close to optimal. In the case with two maxima, the efficacy of irradiating both peaks simultaneously, rather than separately, has been studied and shown to be of potential benefit. The optimum intensities for an IMB for breast radiotherapy are also presented.

The effectiveness of conformal radiotherapy can ultimately only be assessed by the use of clinical trials. As large multicentre clinical trials become more widespread, methods of transferring patient and plan data between radiotherapy treatment planning systems become increasingly important. In this paper, the general strategy for the transfer of data is discussed, and also illustrated with reference to two specific systems: TARGET 2 (GE Medical Systems) and VOXELPLAN (DKFZ-Heidelberg). The transfer method involves using a computer program to translate the data formats used by each of the two systems for CT scans, patient outlines, plan information and block descriptions. This paper does not address the question of transferring beam data between systems: beam data must first be entered separately into both machines. The physical concepts encountered when transferring plans are described, with specific reference to the two planning systems used. Differences in the strategies used by the two planning systems for definition of irregular field shapes are compared. The dose calculations used by the two systems are also briefly evaluated. Isodoses produced by VOXELPLAN around a circular target volume are found to be up to 3 mm different in location to those produced by TARGET 2, owing to the use of a smooth field shape contour as opposed to a stepped field shape which closely models the leaves of a multileaf collimator. In general, dose distributions generated by both systems are comparable, but some differences are found in the presence of large tissue inhomogeneities. It is concluded that the transfer of patient and plan data between two different treatment planning systems is feasible, provided that any differences in field shape definition methods or dose calculation methods between the two systems are understood.

A model is presented in which the scatter signal in images obtained obtained by electronic portal imaging devices (EPIDs) is removed by a forward convolution method. The convolution kernel, kt(r) is a cylindrically symmetric kernel, generated by Monte Carlo, representing the scattered signal of a pencil beam at the image plane after the photons have gone through an object of thickness, t. A set of the kernels is presented and used to extract the primary signal. The signal from primary photons in the image, P(r), is extracted by an iterative method in which the essential assumption is that the scatter signal S(r) can be described by a superposition of the signal that would be obtained with the object removed from the beam, O(r), and the kernel kt(r). The thickness, t, that is used to choose the kernel, is directly related to P(r) by a simple exponential relationship; hence the thickness, t, of the object and the primary signal, P(r), are both iterated to better estimates through this procedure. The model is tested on Monte Carlo simulated data, where the extracted primary signal is compared with the "true" primary signal. Results are presented for a set of phantoms of uniform thicknesses up to 35 cm, and for field areas up to 320 cm(2), and for an inhomogeneous phantom containing a sphere of different density. The primary signal can be extracted to better than 1.5%, even when the original Scatter-to-Primary Ratio (SPR) is more than 25%. Finally, we have tested the model on EPID images, a nonuniform (breast) phantom is presented here. The breast phantom both have a curved external contour and contains a structure of a different density (lung). The radiological thickness of this breast phantom, as extracted using the above convolution model, was found to be within 2.8 mm (1 sd) of the true radiological thickness.

An electronic portal imaging device has been designed and constructed. It consists of an array of 128 CsI scintillation crystals coupled to photodiodes which is scanned across the field in 4 seconds. The linac is operated at a dose rate of 400 cGy min-1 and the dose delivered for image acquisition is approximately 27 cGy. The data acquisition controller is a stand-alone STE computer located within the scan arm. Sample images are presented showing contrast and spatial resolution of the system together with a humanoid phantom image and a clinical image of a breast cancer patient. The phantom images show the detector has a contrast resolution of 0.3% (at 15 mm diameter) and a spatial resolution of 2.5-3.2 mm. Images of uniform Perspex blocks have also been calibrated for thickness, indicating the system can measure radiological thickness to an accuracy of 2-3 mm of water. These results indicate the detector may be used for transit dosimetry applications including compensator design.

The scattered radiation in 6 MV radiotherapy portal images is analyzed. First, a quantity SPR* is studied, by means of Monte Carlo (MC) modeling. SPR* is defined as the ratio, on the central axis, of the signal due to scattered radiation to that due to the primary radiation. The detector model mimics a high-energy photon detector in the context of transit dosimetry. Second, a physical model of SPR* has been developed from first principles. For a cylindrical phantom, placed symmetrically about the isocenter, it predicts that SPR* depends on the area A at the isocenter of the circular field and the phantom thickness d as follows. SPR* = k0Ad(1 + k1d)(1 + k2A), where k0 = 0.0266(L1 + L2)2/(L1L2)2, k2 = - [L1(-2) + L2(-2) + (L1(-1) + L2(-1))2((2/3) + (3 kappa/2))]/2pi, L1 is the source-to-isocenter distance, L2 is the isocenter-to-detector distance, and kappa is the mean energy of the radiation beam (MeV/0.511). Constant k1, for which there is no simple expression, depends on L2. Comparison to the MC data shows that for 60 <or= L2 <or= 100 cm the dependence is weak and k1 approximately equal to 2 x 10(-3) cm-1. The root mean square (rms) agreement between the MC-derived values of SPR* and the physical model is better than 0.001 over a wide range of A and d values likely to be encountered in clinical practice for L2 >or= 50 cm. Third, experimental measurements of the scatter-to-primary ratio were obtained using our custom built imaging system mounted on a Philips SL25 linear accelerator. In the first experiment, A was varied from 40 to 400 cm2 with L1 = L2 = 100 cm with d = 20 cm. In the second experiment water depth d was varied from 0 to 28 cm with L1 = L2 = 100 cm and A = 200 cm2. The rms agreements between the MC data and the experiments were 0.0015 and 0.0045, respectively.

A method of using electronic portal imaging (EPI) for transit dosimetry is described. In this method, a portal image of the treatment field is first aligned with a digitally reconstructed radiograph (DRR) to geometrically relate the computed tomography (CT) scan, used to generate the DRR, with the EPI. Then the EPI is corrected for scatter within the patient to yield a map of primary fluence striking the detector. This is backprojected through the planning CT data set to yield a distribution of primary fluence within the patient. This distribution is then convolved with dose deposition kemels to yield a map of dose delivery within the patient. Such a distribution may be compared with the dose distribution resulting from the original treatment plan in order to evaluate the adequacy of the treatment. This method has been evaluated using a humanoid phantom. We find the transit dosimetry relative dose distribution when compared with film and thermoluminescent dosimeter (TLD) measurements and compared with our planning system to agree within 2% in the pelvic region of a humanoid phantom.

A portal imaging system has been used, in conjunction with a movie measurement technique to measure set-up errors for 15 patients treated with radiotherapy of the pelvis and for 12 patients treated with radiotherapy of the brain. The pelvic patients were treated without fixation devices and the brain patients were treated with individually-moulded plastic shells. As would be expected the brain treatments were found to be more accurate than the pelvic treatments. Results are presented in terms of five error types: random error from treatment to treatment, error between mean treatment position and simulation position, random simulation error, systematic simulator-to-treatment errors and total treatment error. For the brain patients the simulation-to-treatment error predominates and random treatment errors were small (95% < or = 3 mm, 77% < or = 1.5 mm). Vector components of the systematic simulation-to-treatment errors were 1-2 mm with maximal random simulation error of +/- 5 mm (2 S.D.). There is much interest in the number of verification films necessary to evaluate treatment accuracy. These results indicate that one check film performed at the first treatment is likely to be sufficient for set-up evaluation. For the pelvis the random treatment error is larger (95% < or = 4.5 mm, 87% < or = 3 mm). The systematic simulation-to-treatment error is up to 3 mm and the maximal random simulation error is +/- 6 mm (2 S.D.). Thus corrections made solely on the basis of a first day check film may not be sufficient for adequate set-up evaluation.

A novel method of designing intensity modulated beams (IMBs) to achieve compensation in external beam radiotherapy of the breast, without the need for CT scans, is presented. The design method comprises three parts: (1) an electronic portal image is used to generate a map of radiological thickness; (2) this map is then used to obtain an estimate of the breast and lung outline; (3) a TMR-based dose calculation algorithm is then used to determine the optimum beam profile to achieve the best dose distribution. The dose distributions calculated for IMBs were compared with those calculated for the use of simple wedges. The results for two patients studied indicate that the dose inhomogeneity for IMBs is +/- 5%, compared with a value of +/- 10% for a wedged plan. The uncertainty in radiological thickness measurement corresponds to a dosimetric error of +/- 2%. Other errors associated with outline estimation are typically less than 2%, with a largest value of +5% for one of the patients who had a large and highly asymmetrical breast. The results for the two patients studied suggest that the uncertainties in the method are significantly smaller than the improvement in dose uniformity produced.

Effectiveness of radiotherapy is dependent on the accuracy of beam alignment. Recent developments in megavoltage imaging allow real-time monitoring of beam placement. Maximum gains from this new technology can only be made if the information is utilised to correct patient positioning prospectively before the majority of a treatment fraction is delivered. We have developed and utilised an integrated megavoltage imaging system to perform a randomised trial demonstrating significant improvements in accuracy using treatment intervention techniques for pelvic radiotherapy. The mean field-placement accuracy improved from 4.3 mm to 2 mm and the proportion of treatments given with a field-placement error of > or = 5 mm decreased from 69% to 7%. This improvement in accuracy may enable smaller margins around the target volume to be chosen whilst ensuring complete target coverage at each treatment fraction.

In this note it is shown that for a fixed integral dose to the planning target volume, the highest tumour control probability arises when the dose is spatially uniform. This 'uniform dose theorem' is proved both for (i) a specific TCP model based on Poisson/independent voxel statistics and (ii) any model for voxel control probability having a specific shape with respect to increasing dose.

A Monte Carlo model has been devised for a study of the effects of various scintillation crystal parameters on light irradiance upon a remote lens. The purpose of these simulations is to optimise the design of the scintillation crystal array for our 3-D megavoltage CT scanner. The scanner will be attached to the gantry of a linear accelerator and will be implemented to measure and reduce errors in patient positioning during a course of cancer treatment with radiotherapy. The scintillator studied here is CsI(Tl) irridiated with 6 MV X-rays. The angular distributions of light emerging from crystals coated with specular and lambertian reflectors are compared. The effect of crystal size on the light output of crystals coated with the above reflectors is shown. The relative dependence of light output (to a remote lens) on crystal optical attenuation length and coating reflectivity is demonstrated. Comparison with some experimental data is also included.

A scanning megavoltage imaging detector, with associated image storage and analysis facilities has been developed. This produces images of the treatment portals in under 10 seconds, in a digital format, facilitating rapid, quantitative image analysis. Image quality is comparable to, and at some sites improves upon, that available from film. Clinical problems in the use of megavoltage imaging include limited field of view, loss of information at the field edge due to penumbra effects, degradation of the image by bowel gas, and difficulties in the detection of soft tissue-air interfaces. Possible solutions to these problems are discussed. The imaging system has been used to assess the random errors occurring during routine para-aortic nodal irradiation. The errors detected are small, with over 95% of set-ups lying within +/- 4.5 mm of the mean daily position. No differences were detected in the magnitude of random errors between anterior and posterior treatment fields.

We have further developed a system for generating megavoltage CT images immediately prior to the administration of external beam radiotherapy. The detector is based on the scanner of Simpson (Simpson et al 1982)--the major differences being a significant reduction in dose required for image formation, faster image formation and greater convenience of use in the clinical setting. Attention has been paid to the problem of ring artefacts in the images. Specifically, a Fourier-space filter has been applied to the sinogram data. After suitable detector calibration, it has been shown that the device operates close to its theoretical specification of 3 mm spatial resolution and a few percent contrast resolution. Ring artefacts continue to be a major source of image degradation. A number of clinical images have been presented. The next stage of this work is to use the system to make clinical measurements of patient set-up inaccuracies building on our work making such measurements from digital portal images (Evans et al 1992).

In this paper we describe software facilities for enabling patient positioning studies using the megavoltage imaging system developed at the Royal Marsden Hospital and Institute of Cancer Research. The study focuses on the use of the system for three purposes: patient position verification (by comparing images taken at treatment simulation with megavoltage images taken at treatment time); reproducibility studies (by analysing a set of megavoltage images); and set-up correction (by adjusting the set-up until the megavoltage image obtained at treatment registers with the simulation image). The need is discussed for suitably presented simulator images, a method of determining field boundaries and the possibility of delineating soft-tissue interfaces. Several algorithms of different types, developed specifically for the purpose of intercomparison of planar projection images, are presented. The techniques employed and their usefulness, in both the qualitative and the quantitative sense, are discussed. The results are presented of a phantom and clinical study, to evaluate the rigour and reproducibility of the algorithms. These results indicate that measurements can be made to an accuracy of about 1-2 mm, with a similar value for interobserver reproducibility for the best image comparison techniques available.

An imaging device has been developed to acquire images during external photon-beam radiotherapy treatments. It consists of a linear array of 128 zinc tungstate (ZnWO4) scintillation crystals each of which is individually optically coupled to a photodiode and associated electronics. The image is formed by scanning the linear array across the radiation field using a stepping motor under the control of a microcomputer. Image archive, display, and analysis are performed using a microVAX II computer. Results from a general theoretical analysis are presented before a detailed description of the particular detector construction. The mechanical design of the detector is such that the detector is automatically positioned to within a millimeter relative to the treatment source. This simplifies procedures for analyzing setup variations when comparing a treatment image to any other treatment, or planning, images. Image acquisition takes under 4 s with a contrast resolution of better than 1% at a spatial resolution of 2.5 mm in the object plane. The primary dose used to form these images is 0.55 cGy although the dose received by the patient will be closer to 25 cGy due to the linear scanning geometry and 3.8-s scan time that is used.

This study investigates factors associated with the imaging of a patient using a high-energy radiotherapy treatment beam. Both single-stage (e.g., solid-state detector) and two-stage (e.g., scintillation screen plus TV) systems are considered. First an expression is derived that relates dose at the buildup depth in the object to the structure of the object, the scatter-to-primary signal-variance ratio and the differential-signal-to-noise ratio in the image. Second the number of bits required to digitize the image is derived. Third the effect of scattered radiation is investigated for photon counting, photopeak, and Compton detector types. Fourth the effect of noise in the detection process is considered. Finally, the relationship between x-ray source size, detector aperture, and image magnification is derived. The optimum magnification for given source size and detector aperture is discussed in terms of the system transfer function. The study indicates that at a primary beam energy of 2 MeV, a dose of 10(-3) cGy is required to detect reliably the presence of a bone section of area 10 x 10 mm and thickness 4 mm in 250 mm of soft tissue. For this example, it is also estimated that a digitization accuracy of 10 bits is required. The calculations indicate that for a Compton detector, the scatter-to-primary signal-variance ratio drops from a value of around 30% at the exit surface of the object to 5% at a distance of 80 cm from the object with a consequent small reduction in the dose required to form the image.

Mass, energy, charge and angular distributions from fully damped reactions of the Ca-40 + Ca-40 systems have been measured at 197 and 231 MeV, in both singles and coincidence. The data display features of compound nucleus fission. Comparison with similar, but asymmetric systems, however, shows an entrance-channel dependence which invalidates a fusion-fission description. A discussion in terms of fission barriers calculated using the finite-range liquid drop model suggests a fast-fission mechanism. Re-analyses of systems studied in the literature are presented in terms of the finite-range liquid drop model, indicating fast fission-a process previously assumed only to be relevant for heavier systems-to be significant in most cases. Furthermore, using the finite-range liquid drop model, we find that the systematic behaviour of the mass distributions from systems where complete fusion-fission is expected to be dominant is well described in terms of the revised locus of the Businaro-Gallone transition from symmetric to asymmetric fission.