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Radiotherapy

Treatment Planning 4
FRCR
Matt Clarke
May 2013
Radiotherapy
Treatment Planning
Lecture 1
– Concepts of ICRU reports 50 & 62
Lecture 2
– Changing the variables
(i.e. the treatment parameters)
– Assessment tools
(e.g. DVH)
Lecture 3
– Fundamental Planning Principles
Lecture 4
– Important Treatment Techniques
Important Treatment Techniques
Arc & Rotation Therapy
• Dose distribution
• Uses
Irregular field shapes and Blocking
• Methods
• Calculations
Field Matching
• Principles
• Examples: Medullo, 2 phase neck
• Breast plan divergence & matching
Total Body Irradiation (TBI)
• Principles
• Techniques
Arc & Rotation Therapy
• Beam moves continuously around patient
• or, patient rotated while beam is fixed
• Isodoses are roughly circular
• Isodoses are modified by patient shape
• No unwanted areas of high dose in irradiated volume
Arc & Rotation Therapy
4 field 8MV
Arc & Rotation Therapy
100 degree arc
Arc & Rotation Therapy
180 degree arc
Arc & Rotation Therapy
358 degree arc
Arc & Rotation Therapy
Full Rotation: coronal view
Arc & Rotation Therapy
Full Rotation with MLC
Arc & Rotation Therapy
Uses of Rotation Treatment
• Best for small, deep-seated tumours
•Has been used for:
• Oesophagus
• Bladder
• Prostate
• Cervix
• Brain
• Little advantage over 3 or 4 field technique – just
individual preference
Arc & Rotation Therapy
Points to Consider
• Patient positioning
• Body Shape – a cylinder would be ideal
• Blocking – not too complex
• Size of PTV – not too big
• Position of PTV – fairly central
Arc & Rotation Therapy
Recent Developments: VMAT/IMAT/RapidArc
• Jaws and MLC leaves move as the gantry rotates
• Main advantage: machine efficiency
Irregular Field Shapes & Blocking
• Beam data is measured for square and
rectangular fields
• Not all treatments used regular shaped fields
• So how do you calculate dose?
• e.g. for independent MU check
• Does the dose depend on the shape or just
the area?
Irregular Field Shapes & Blocking
When blocking is introduced into a rectangular
field
• Dose from primary radiation is unaffected
• Dose from secondary radiation is reduced

i.e. dose depends


on shape, as well
as area
Irregular Field Shapes & Blocking
Primary contributions can be…
• …derived from measurements in air
• …computed from a model of the linac head geometry
Scatter contribution is calculated…
• …using a table of differential scatter air ratios (SARs)
for fields of different radii
• …summing (i.e. integrating) over every sector of the
beam
Irregular Field Shapes & Blocking
Corner Blocking
• Use equivalent square area (ESA) to calculate
dose
• ESA = 2 x area / perimeter
Large irregular shape
• e.g. lymphoma treatment or complex MLC shape
• For the calculation, use sector integration or
Clarkson integral to find the ESA
Irregular Field Shapes & Blocking
• Sector Integration
• Scatter contribution for the segment shown is
proportional to:

S (d , r ) x
2

• S(d, r) = SAR for depth, d,


and radius, r
• θ = angular width of sector
Field Matching

• Treatments requiring field matching:


• Medulloblastoma: spine fields matched at the depth
of the spine & collimator twist of head fields matches
parallel pair to the superior border of the spine field.
• Anterior neck fields matched to parallel pair
• 3-field breast treatments: use asymmetric jaws
Field Matching
Two abutting fields: how does the radiation combine?

• 2 Beams with central axes parallel:


• Match the 50% dose at a chosen depth
• Leads to a slight underdose at shallower depths and
overdose at greater depth
Field Matching
Two abutting fields: how does the radiation combine?

• 2 Beams with central axes tilted:


• The 50% dose lines are parallel
• Dose is match at all depths
Field Matching
Two abutting fields: how does the radiation combine?

• 2 Beams with asymmetric jaws:


• Dose is match at all depths
Field Matching
e.g. medullo
Field Matching
e.g. 2 phase parallel pair to the neck
Field Matching
e.g. 2 phase parallel pair to the neck with
matching anterior neck field

overlap Couch & gantry rotation


Field Matching
Breast: non-divergent fields

Directly opposed tangent pair Tangent pair with non-divergent


back edge
Field Matching
Breast: non-divergent fields
Field Matching
Breast: non-divergent fields

Tipped fields Half-blocked fields


Field Matching
Breast: non-divergent fields

Source Beam
axis

Collimators

No divergence along central axis!


Field Matching
2-field Breast: non-divergent fields

Tipped fields Assymetric fields


Provides straight back-edge
Field Matching
3-field Breast: non-divergent fields

Also provides straight sup edge


to match peripheral field
Total Body Irradiation
• Requires large field sizes
• Long FSD used
• FSD limited by the size of the treatment room
(usually ~4m)
• No standard technique
Total Body Irradiation
From AAPM
Report 17

“THE
PHYSICAL
ASPECTS
OF
TOTAL
AND HALF
BODY
PHOTON
IRRADIA-
TION”
Total Body Irradiation
Total Body Irradiation
Patient in the standing TBI position
with the head turned sideways for
shielding of the brain. A 5-HVL
cerrobend block is mounted on an
acrylic plate attached to the TBI
stand.

From Levitt SH, Khan FM, Potish RA et al


Total Body Irradiation

Common factors in TBI techniques:


• Dose is limited by late-responding tissues (e.g. lungs,
kidneys, liver).
• The main toxicity seen is mucositis
• Common UK dose for paediatrics is 1440 cGy in 8
fractions twice daily
• Common UK dose for adults is 1200 cGy in 6
fractions, twice daily
• These are often prescribed to a maximum lung dose
Total Body Irradiation

Common factors in TBI techniques:


• Compensators or bolus are used to improve dose
homogeneity
• Accept an inhomogeneity of dose ±10%
• Skin sparing is minimised
• Bolus can be used
• A beam spoiler (1 or 2cm thick acrylic screen) can be
positioned close to the patient, producing additional scatter
Total Body Irradiation
3 main methods in UK, though centres vary:
1. Simple set-up
• Accept dose inhomogeneities
2. CT Planned
• Use CT data to generate a dose distribution throughout
the body
• Use MLC leaves to shield high dose areas for part of the
treatment
3. Test Doses, then full treatment
• Measure dose at different positions on the body at first
fraction
• Add bolus and adjust patient position for subsequent
fractions
Total Body Irradiation
The Christie Technique:
• Preferred energy 4-6 MV to minimise internal build-
up at lung tissue interface
• FSD 4m to perspex beam spoiler (12mm thick)
• Spoiler placed near to patient skin to reduce build-up
effect
• Collimator set to max field size & rotated 45°.
• Perspex compensator mounted on lead tray
• Compensator reduces high dose off-axis due to beam
flattening filter
• No compensation for patient shape
• Arms positioned to shield lungs for half of the
treatment
Total Body Irradiation

Linac Head 270 deg, Collimator 45 deg.


Total Body Irradiation
The Christie Technique:
• Jaws 38cm x 38cm, which equate to 152cm x
152cm at 4m; 214 cm along diagonal
• Patient lies perpendicular to the beam axis
• 4 fields – Ant, post, right, left
• The linac head remains still, the patient moves
Ant. Post. Rt. Lat Lt. Lat

#1,3,5 Lie on Rt. Lie on Rt. Supine Supine


AAC 100% AAC 50% AAC 50%
#2,4,6 Lie on Lt. Lie on Lt. Supine Supine
AAC 100% AAC 50% AAC 50%
Total Body Irradiation
The Christie Technique:
• 2/3 of dose from AP parallel pair
• 1/3 of dose from lateral parallel pair
• MU tabulated for different patient dimensions
• Measured dose homogeneity in children
• ± 5% throughout most of body
• + 11 % for neck

Vollans SE, Perrin B, Wilkinson JM, Gatamaneni H Rao, Deakin DP


Investigation of dose homogeneity in paediatric anthropomorphic phantoms for
a simple total body irradiation technique
BJR 72 (2000), 317-321

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