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
