A method for implementing dynamic photon beam intensity modulation using independent jaws and a multileaf collimator

A mathematical model is derived for digitally controlled linear accelerators to deliver a desired photon intensity distribution by combining collimator motion and machine dose rate variations. It shows that, at any instant, the quotient of the machine dose rate and the speed of collimator motion is proportional to the gradient of the desired in-air photon fluence distribution. The model is applicable for both independently controlled collimator jaws and multileaf collimators and can be implemented by controlling different parameters to accommodate linear accelerators from different manufactures. For independent jaws, each pair of jaws creates photon fluence variations along the direction of the jaw movement. For multileaf collimators, where each leaf is independently controlled, any two-dimensional (2D) photon fluence distribution can be delivered. The model has been implemented for wedged isodose distributions using independent jaws, and 2D intensity modulation using a multileaf collimator. One-dimensional (1D) wedged isodose distributions are created by moving an independent jaw at constant speed while varying machine dose rate. 2D intensity modulation has been implemented using a 'dynamic stepping' scheme, which controls the leaf progression during irradiation at constant machine dose rate. With this automated delivery scheme, the beam delivery time for dynamic intensity modulation, which depends on the complexity of the desired intensity distribution, approaches that of conventional beam modifiers. This paper shows the derivation of the model, its application, and our delivery scheme. Examples of 1D dynamic wedges and 2D intensity modulations will be given to illustrate the versatility of the model, the simplicity of its application, and the efficiency of beam delivery. These features make this approach practical for delivering conformal therapy treatments.     

Beam characteristics and clinical possibilities of a new compact treatment unit design combining narrow pencil beam scanning and segmental multileaf collimation

Not until the last decade has flexible intensity modulated three-dimensional dose delivery techniques with photon beams become a clinical reality, first in the form of heavy metal transmission blocks and other beam compensators, then in dynamic and segmented multileaf collimation, and most recently by scanning high-energy narrow electron and photon beams. The merits of various treatment unit and bremsstrahlung target designs for high-energy photon therapy are investigated theoretically for two clinically relevant target sites, a cervix and a larynx cancer both in late stages. With an optimized bremsstrahlung target it is possible to generate photon beams with a half-width of about 3 cm at a source to axis distance (SAD) of 100 cm and an initial electron energy of 50 MeV. By making a more compact treatment head and shortening the SAD, it is possible to reduce the half-width even further to about 2 cm at a SAD of 70 cm and still have sufficient clearance between the collimator head and the patient. One advantage of a reduced SAD is that the divergence of the beam for a given field size on the patient is increased, and thus the exit dose is lowered by as much as 1%/cm of the patient cross section. A second advantage of a reduced SAD is that the electron beam on the patient surface will be only about 8 mm wide and very suitable for precision spot beam scanning. It may also be possible to reduce the beamwidth further by increasing the electron energy up to about 60 MeV to get a photon beam of around 15 mm half-width and an electron beam as narrow as 5 mm. The compact machine will be more efficient and easy to work with, due to the small gantry and the reduced isocentric height. For a given target volume and optimally selected static multileaf collimator, it is no surprise that the narrowest possible scanned elementary bremsstrahlung beam generates the best possible treatment outcome. In fact, by delivering a few static field segments with individually optimized scan patterns, it is possible to combine the advantage of being able to fine tune the fluence distribution by the scanning system with the steeper dose gradients that can be delivered by a few static multileaf collimator segments. It is demonstrated that in most cases a few collimator segments are sufficient and often a single segment per beam portal may suffice when narrow scanned photon beams are employed, and they can be delivered sequentially with a negligible time delay. A further advantage is the increase of therapeutically useful photons and improved patient protection, since the pencil beam is only scanned where the leaf collimator is open. Consequently, some of the problems associated with dynamic multileaf collimation such as the tongue and groove and edge leakage effects are significantly reduced. Fast scanning beam techniques combined with good treatment verification systems allow interesting future possibilities to counteract patient and internal organ motions in real time.     

An experimental investigation of the tongue and groove effect for the Philips multileaf collimator

The tongue and groove effect is an underdosing effect which can occur in certain applications of multileaf collimators. It results from the need to overlap adjacent leaves of a multileaf collimator in order to limit leakage between leaves. The applications in which the effect can occur are the abutment of fields where the beam edges are defined by the leaf edge and the production of intensity-modulated fields by dynamic collimation. The effect has been measured for the 'worst case' when just two MLC fields are matched along leaf edges which have overlapping steps. Measurements of the dose have been made at d(max) and also at a more clinically relevant depth of 87 mm in Perspex for beam energies of 6 MV, 8 MV and 20 MV on two Philips SL series accelerators. Dose distributions were recorded on radiographic film which was subsequently digitized for analysis. The dose reduction of the tongue and groove effect was found to be 15-28% and spread over a width of 3.8 to 4.2 mm. This is somewhat shallower and wider than would be expected from a simple, idealized model of the effect which would predict a dose reduction of 80% over a width of 1 mm.     

Verification of the omni wedge technique

The optimal field shape achieved using a multileaf collimator (MLC) often requires collimator rotation to minimize the adverse effects of the scalloped dose distribution the leaf steps produce. However, treatment machines are designed to deliver wedged fields parallel or perpendicular to the direction of the leaves. An analysis of cases from our clinic showed that for 25% of the wedged fields used to treat brain and lung tumors, the wedge direction and optimal MLC orientation differed by 20 degrees or more. The recently published omni wedge technique provides the capability of producing a wedged field with orientation independent of the orientation of the collimator. This paper presents a comparison of the three-dimensional (3D) dose distributions of the omni wedged field with distributions of wedged fields produced using both the universal and dynamic wedge techniques. All measurements were performed using film dosimetry techniques. The omni wedge generated fields closely matched the conventional wedged fields. Throughout 95% of the irradiated volume (excluding the penubra), the dose distribution of the omni wedged field ranged from +5.5 to -3.5 +/- 1.5% of that of the conventionally wedged fields. Calculation of the omni wedged field is as accurate as conventional wedged field calculation when using a 3D treatment planning systems. For two-dimensional treatment planning systems, where one must assume that the omni wedged field is identical to a conventional field, the calculated field and the delivered field differs by a small amount.     

Clinical use of a simulation-multileaf collimator

BACKGROUND: At the University of Lübeck, radiotherapy is delivered by a 6/18-MV linear accelerator. Using the integrated multileaf collimator, irradiation of individually shaped treatment fields is possible in place of alloy blocks. Due to unsatisfactory pretherapeutic review of the radiation-field-specific multileaf collimator (MLC) configuration, we developed a simulation-multileaf collimator (SMLC) and assessed its feasibility at different tumor sites. MATERIAL AND METHODS: The SMLC is made of a perspex carrier with 52 horizontal sliding leaves. The position of each leaf is calculated by a 3D treatment-planning computer. The technician manually adjusts the leaves according to the beams-eye-view plot of the planning computer. Consequently, the SMLC is mounted on the therapy simulator at a distance of 64.8 cm from the focus. The treatment fields and the position of the leaves are documented by X-ray films. RESULTS: Using the SMLC, radiation oncologists are able to review exactly the leaf configuration of each MLC-shaped radiation field and to correlate the MLC-shaped radiation field with the treated volume, the organs at risk and the port films acquired by the Portal Vision system. CONCLUSION: The SMLC is a new tool to review radiation planning that uses an MLC in daily routine. The use of the SMLC improves the documentation and the quality assurance. It accelerates the treatment field review at the linear accelerator by comparing the SMLC simulator films with the portal images.     

Dynamic multileaf collimation without 'tongue-and-groove' underdosage effects

In all commercially available multileaf collimators, a 'tongue-and-groove'--or similar--construction is used for reduction of leakage radiation between adjacent leaves. These constructions can cause serious underdosages in intensity-modulated photon beams. A method for leaf trajectory calculation for dynamic multileaf collimation, which fully avoids these underdosage effects, is presented. The method is based on pairwise synchronizations of trajectories of adjacent leaf pairs, such that the delivered beam intensity in each 'tongue-and-groove' region is always equal to the smallest of the two prescribed intensities for the two corresponding leaf pairs. The effectiveness of the method has been proven for a large number of intensity-modulated fields, using the dynamic multileaf collimation mode of our MM50 Racetrack Microtron. Compared to dynamic multileaf collimation without synchronization, beam-on times are always equal or longer. For the cases that we studied, the beam-on time was typically increased by 5 to 15%.     

Rectangular edge synchronization for intensity modulated radiation therapy with dynamic multileaf collimation

The implementation of intensity modulated radiotherapy by dynamic multileaf collimator control involves the use of interpreter software which creates leaf trajectory plans for each leaf pair. Interpreter software for use with an Elekta SL15 linear accelerator and dedicated multileaf collimator has been written and tested. In practice the ideal trajectory plans often predict contact between leaves from opposing leaf banks, but this is prohibited by control software on the Elekta system as it could lead to mechanical damage. If the modulation within the geometric limits of a shaped field is not to be compromised then strategies to avoid leaf contact result in additional unwanted doses outside the geometric edge. The magnitude of any such additional dose can be reduced to acceptable levels by a technique which we have called rectangular edge synchronization. The performance of interpreter software which incorporates rectangular edge synchronization has been compared with that of potentially more efficient software which does not. The option containing the rectangular edge synchronization algorithm was shown to work consistently well at high monitor unit rates, and without incurring leaf contacts, under a wide range of test conditions. It therefore provides a sound basis for using intensity modulation to replace mechanical wedges, to simulate customized patient shape compensators, or to implement the results of inverse treatment planning processes that require superimposed intensity modulated beams.     

Intensity-modulated arc therapy with dynamic multileaf collimation: an alternative to tomotherapy

The desire to improve local tumour control and cure more cancer patients, coupled with advances in computer technology and linear accelerator design, has spurred the developments of three-dimensional conformal radiotherapy techniques. Optimized treatment plans, aiming to deliver high dose to the target while minimizing dose to the surrounding tissues, can be delivered with multiple fields each with spatially modulated beam intensities or with multiple-slice treatments. This paper introduces a new method, intensity-modulated arc therapy (IMAT), for delivering optimized treatment plans to improve the therapeutic ratio. It utilizes continuous gantry motion as in conventional arc therapy. Unlike conventional arc therapy, the field shape, which is conformed with the multileaf collimator, changes during gantry rotation. Arbitrary two-dimensional beam intensify distributions at different beam angles are delivered with multiple superimposing arcs. A system capable of delivering the IMAT has been implemented. An example is given that illustrates the feasibility of this new method. Advantages of this new technique over tomotherapy and other slice-based delivery schemes are also discussed.     

Head scatter modelling for irregular field shaping and beam intensity modulation

Scattered radiation from within the treatment head can contribute significant dose to all parts of a radiotherapy treatment field. A multileaf collimator may be used to create an arbitrarily shaped field, and may also be used, under dynamic control, to modulate the beam intensity over the field. This method of intensity modulation is effectively a superposition of a large number of fields which have the same beam direction, but different shapes, and some of these shapes may have unusually small dimensions, particularly in the direction of the leaf movement. Two models for predicting the head scatter under these conditions have been investigated. These are a first-order Compton scatter approximation from the flattening filter, and an empirical fit to measured data using an exponential function. The first model only considers scatter from the flattening filter and has been applied to field sizes between 2 cm by 2 cm and 10 cm by 10 cm, where agreements are all within 1%. However it is not satisfactory at larger field sizes where small scatter contributions, from scattering sources other than the flattening filter, are integrated over large areas. The second model uses measured data between 4 cm by 4 cm and 30 cm by 30 cm to optimize the exponential function and is used to calculate the head scatter contribution for all field sizes. In this case good agreement is achieved over the full field size range, and hence this is a more generally applicable model. Results are presented for static irregularly shaped fields and intensity modulated beams created using a Philips multileaf collimator.     

Quality assurance of serial tomotherapy for head and neck patient treatments

PURPOSE: A commercial serial tomotherapy intensity-modulated radiation therapy (IMRT) treatment planning (Peacock, NOMOS Corp., Sewickley, PA) and delivery system is in clinical use. The dose distributions are highly conformal, with large dose gradients often surrounding critical structures, and require accurate localization and dose delivery. Accelerator and patient-specific quality assurance (QA) procedures have been developed that address the localization, normalization, and delivery of the IMRT dose distributions. METHODS AND MATERIALS: The dose distribution delivered by serial tomotherapy is highly sensitive to the accuracy of the longitudinal couch motion. There is also an unknown sensitivity of the dose distribution on the dynamic mutlileaf collimator alignment. QA procedures were implemented that assess these geometric parameters. Evaluations of patient positioning accuracy and stability were conducted by exposing portal films before (single exposure) and after (single or double exposure) treatments. The films were acquired with sequential exposures using the largest available fixed multileaf portal (3.36 x 20 cm2). Comparison was made against digitally reconstructed radiographs generated using independent software and appropriate beam geometries. The delivered dose was verified using homogeneous cubic phantoms. Radiographic film was used to determine the localization accuracy of the delivered isodose distributions, and ionization chambers and thermoluminescent dosimetry (TLD) chips were used to verify absolute dose at selected points. Ionization chamber measurements were confined to the target dose regions and TLD measurements were obtained throughout the irradiated volumes. Because many more TLD measurements were made, a statistical evaluation of the measured-to-calculated dose ratio was possible. RESULTS: The accelerator QA techniques provided adequate monitoring of the geometric patient movement and dynamic multileaf collimator alignment and positional stability. The absolute delivered dose as measured with the ionization chamber varied from 0.94 to 0.98. Based on these measurements, the delivered monitor units for both subsequent QA measurements and patient treatments were adjusted by the ratio of measured to calculated dose. TLD measurements showed agreement, on average, with the ionization chamber measurements. The distribution of TLD measurements in the high-dose regions indicated that measured doses agreed within 4.2% standard deviation of the calculated doses. In the low-dose regions, the measured doses were on average 5% greater than the calculated doses, due to a lack of leakage dose in the dose calculation algorithm. CONCLUSIONS: The QA system provided adequate determination of the geometric and dosimetric quantities involved in the use of IMRT for the head and neck. Ionization chamber and TLD measurements provided accurate determination of the absolute delivered dose throughout target volumes and critical structures, and radiographic film yielded precise dose distribution localization verification. Portal film acquisition and subsequent portal film analysis using 3.36 x 20 cm2 portals proved useful in the evaluation of patient immobilization quality. Adequate bony landmarks were imaged when carefully selected portals were used.     

Advances in treatment with intensity-modulated conformal radiotherapy

One-dimensional (1D) intensity-modulated beams (IMBs) can be generated by multiple static fields (MSFs) created by a multileaf collimator (MLC) with the radiation switched off between field re-settings (Bortfeld-Boyer method). Each component irradiation is of equal fluence. This paper presents and analyses the formulae for the number of physically allowed combinations of leaf settings which generate any given IMB. The formulae are general to an IMB with any number of local minima and extend from the well-known N! formula for a single-peaked IMB with N left-leaf (L-leaf) and N right-leaf (R-leaf) positions. A 'combination' is a set of N L-leaf and R-leaf pairings. A 'physically allowed combination' is one in which no L-leaf is paired with an R-leaf to its left. The physically allowed combinations are grouped by specific properties into classes in which the well-known techniques of 'leaf-sweep' and 'close-in' are just two members. Consideration of these properties leads to a new suggestion of the 'forced-baseline' configuration in which the first intensity increment is delivered for the full field width and there remain choices concerning the delivery of the rest of the IMB within which two different possibilities are 'one-out-of-sync leaf-sweep' and 'minimum leaf travel'. The extension to 2D is briefly introduced.     

Electron contamination in clinical high energy photon beams

The electron contamination in photon beams has been investigated by means of contaminating lepton depth doses and dose profiles in different geometries with two 20 MV beams. Different components of this contamination have been investigated separately by systematically adding contamination to a "clean" reference field. At 20 MV, the air generated electrons were found to be almost negligible compared to the electrons originating from the accelerator head when measurements were performed in standard fields at SSDs between 80 and 120 cm. The total electron part of the depth dose curve was then almost the same, i.e., independent of SSD, when the collimator opening was held fixed. However, when different accessories such as a shaping block and different attenuating plates were located in the beam path below the collimators, a large SSD dependence of the electron contamination was noticed. A comparison was also made between two machines, one equipped with a multileaf collimator, with similar beam qualities at 20 MV. These measurements indicate that the interior view of the treatment head seen by the detector (mainly the flattening filter, monitor chamber, or other electron generating material) influences the magnitude of the electron contamination. When the collimator opening is decreased the electron contamination will also decrease as parts of the electron source will be shielded by the collimator blocks.     

Inverse planning with constraints to generate smoothed intensity-modulated beams

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 language of quality

Several methods for dose deposition of a given isodose distribution were developed by implementation of different techniques of accelerator use. Common to all of these methods is the time-dependent change of certain accelerator parameters during radiation treatment. The accelerators for which these methods can be used are equipped with independent collimator jaws, however, not with any kind of multileaf collimation. This method was designed to deposit a certain group of dose distributions that are restricted by a small number of constraints. The developed methods were implemented into a digitally controlled medical linear accelerator and the dosimetric results of such treatments were evaluated. Dose distributions with spatial dependencies in one and in two dimensions were deposited by movement of one X-ray jaw pair. Furthermore, a method for generation of a two-dimensional rotationally symmetric dose distribution was developed.     

Generation of discrete beam-intensity modulation by dynamic multileaf collimation under minimum leaf separation constraints

An algorithm to generate discrete beam-intensity modulation by dynamic multileaf collimation is presented which incorporates constraints on minimum allowed leaf separations. MLC positioning information is derived simultaneously for all leaf pairs and back-up diaphragms as they progress across the field. A feedback mechanism allows corrections to be applied to eliminate potential violations of minimum separation conditions and any underexposure in the interleaf tongue-and-groove region as they are encountered. The resulting motion correctly delivers the intended modulation and is physically realizable. Implementation of the algorithm is described. Results of the algorithm can also alternatively be interpreted as defining a series of static fields to deliver the same modulation.     

Field margin reduction using intensity-modulated x-ray beams formed with a multileaf collimator

PURPOSE: In axial, coplanar treatments with multiple fields, the superior and inferior ends of a planning target volume (PTV) are at risk to get underdosed due to the overlapping penumbras of all treatment fields. We have investigated a technique using intensity modulated x-ray beams that allows the use of small margins for definition of the superior and inferior field borders while still reaching a minimum PTV-dose of 95% of the isocenter dose. METHODS AND MATERIALS: The applied intensity modulated beams, generated with a multileaf collimator, include narrow (1.1-1.6 cm) boost fields to increase the dose in the superior and inferior ends of the PTV. The benefits of this technique have been assessed using 3D treatment plans for 10 prostate cancer patients. Treatment planning was performed with the Cadplan 3D planning system (Varian-Dosetek). Dose calculations for the narrow boost fields have been compared with measurements. The application of the boost fields has been tested on the MM50 Racetrack Microtron (Scanditronix Medical AB), which allows fully computer-controlled setup of all involved treatment fields. RESULTS: Compared to our standard technique, the superior-inferior field length can be reduced by 1.6 cm, generally yielding smaller volumes of rectum and bladder in the high dose region. For the narrow boost fields, calculated relative dose distributions agree within 2% or 0.2 cm with measured dose distributions. For accurate monitor unit calculations, the phantom scatter table used in the Cadplan system had to be modified using measured data for square fields smaller than 4 x 4 cm2. The extra time needed at the MM50 for the setup and delivery of the boost fields is usually about 1 min. CONCLUSION: The proposed use of intensity modulated beams yields improved conformal dose distributions for treatment of prostate cancer patients with a superior-inferior field size reduction of 1.6 cm. Treatments of other tumor sites can also benefit from the application of the boost fields.     

The potential for increased sparing of normal tissue in parallel opposed techniques with a multileaf collimator

A multileaf collimator (MLC) can be used in parallel opposed techniques as a direct replacement for standard-shaped beam blocks. However, improved shielding is possible if the MLC field is designed to fit a target rather than to mimic a straight-edged block. This study has compared the treatment areas produced by the MLC and by conventionally blocked fields with the target area for 43 parallel opposed treatments. It was found in every case that the MLC treated less than 10% excess tissue, and, in over 70% of patients, the excess was less than 5%. The conventional fields, however, treated more than 10% excess tissue in 70% of patients. The effect of MLC orientation and the benefits of using an MLC are discussed.     

Initial clinical experience with computer-controlled conformal radiotherapy of the prostate using a 50-MeV medical microtron

PURPOSE: We have described previously a model for delivering computer-controlled radiation treatments. We report here on the implementation and first year's clinical experience with such treatments using a 50 MeV medical microtron. METHODS AND MATERIALS: The microtron is equipped with a multileaf collimator and is capable of setting up and treating a sequence of fixed fields called segments, under computer control. An external computer derives machine parameters for the segments from a three-dimensional treatment planning system, transfers them to the microtron control computer, checks the machine settings before allowing dose delivery to begin, and records the treatment. We describe the patient treatment methodology, portal film acquisition, electronic portal imaging, and quality assurance. RESULTS: Patient treatments began in July 1992, comprising six-segment conformal treatments of the prostate. Using the recorded treatment data, the system performance has been examined and compared to other treatment machines. The average treatment time is 10 min, of which 4 min is for computer-controlled setup and irradiation; the remaining time is for patient positioning and checking of clearances. Long-term reproducibility of computer-controlled setup of the gantry and multileaf position is better than 0.5 degrees and 1 mm, respectively. Termination due to a machine fault has occurred in 5.5% of treatments, improving to 2.5% in recent months. CONCLUSION: Our initial experience indicates that computer-controlled segmental therapy can be performed reliably on a routine basis. Treatment times with the microtron are significantly shorter than with conventional linacs, and setup accuracy is consistent with that needed for conformal therapy. We believe that treatment times can be further improved through software upgrades and integration of electronic portal imaging.     

Population dynamics of the Wolbachia infection causing cytoplasmic incompatibility in Drosophila melanogaster

PURPOSE: The use of escalated radiation doses to improve local control in conformal radiotherapy of prostatic cancer is becoming the focus of many centers. There are, however, increased side effects associated with increased radiotherapy doses that are believed to be dependent on the volume of normal tissue irradiated. For this reason, accurate patient positioning, CT planning with 3D reconstruction of volumes of interest, clear definition of treatment margins and verification of treatment fields are necessary components of the quality control for these procedures. In this study electronic portal images are used to (a) evaluate the magnitude and effect of the setup errors encountered in patient positioning techniques, and (b) verify the multileaf collimator (MLC) field patterns for each of the treatment fields. METHODS AND MATERIALS: The Phase I volume, with a planning target volume (PTV) composed of the gross tumour volume (GTV) plus a 1.5 cm margin is treated conformally with a three-field plan (usually an anterior field and two lateral or oblique fields). A Phase II, with no margin around the GTV, is treated using two lateral and four oblique fields. Portal images are acquired and compared to digitally reconstructed radiographs (DRR) and/or simulator films during Phase I to assess the systematic (CT planning or simulator to treatment error) and the daily random errors. The match results from these images are used to correct for the systematic errors, if necessary, and to monitor the time trends and effectiveness of patient imobilization systems used during the Phase I treatment course. For the Phase II, portal images of an anterior and lateral field (larger than the treatment fields) matched to DRRs (or simulator images) are used to verify the isocenter position 1 week before start of Phase II. The Portal images are acquired for all the treatment fields on the first day to verify the MLC field patterns and archived for records. The final distribution of the setup errors was used to calculate modified dose-volume histograms (DVHs). This procedure was carried out on 36 prostate cancer patients, 12 with vacuum-molded (VacFix) bags for immobilization and 24 with no immobilization. RESULTS: The systematic errors can be visualized and corrected for before the doses are increased above the conventional levels. The requirement for correction of these errors (e.g., 2.5 mm AP shift) was demonstrated, using DVHs, in the observed 10% increase in rectal volume receiving at least 60 Gy. The random (daily) errors observed showed the need for patient fixation devices when treating with reduced margins. The percentage of fields with displacements of < or = 5.0 mm increased from 82 to 96% with the use of VacFix bags. The rotation of the pelvis is also minimized when the bags are used, with over 95% of the fields with rotations of < or = 2.0 degrees compared to 85% without. Currently, a combination of VacFix and thermoplastic casts is being investigated. CONCLUSION: The systematic errors can easily be identified and corrected for in the early stages of the Phase I treatment course. The time trends observed during the course of Phase I in conjunction with the isocenter verification at the start of Phase II give good prediction of the accuracy of the setup during Phase II, where visibility of identifiable structures is reduced in the small fields. The acquisition and inspection of the portal images for the small Phase I fields has been found to be an effective way of keeping a record of the MLC field patterns used. Incorporation of the distribution of the setup errors into the planning system also gives a clearer picture of how the prescribed dose was delivered. This information can be useful in dose-escalation studies in determining the relationship between the local control or morbidity rates and prescribed dose.     

Multileaf collimator leaf sequencing algorithm for intensity modulated beams with multiple static segments

The "stop and shoot" method of producing intensity modulation using combinations of static multileaf collimator (MLC) segments has a number of advantages including precise dose delivery, easy verification, and general availability. However, due to the potential limitation of prolonged treatment time, it is essential to keep the number of required segments to a reasonable number. We propose an algorithm to minimize the number of segments for an intensity modulated field. In this algorithm, the sequence of delivery intensity is proposed to be a series of powers of 2, depending on the maximum intensity level in the matrix. The MLC leaf position sequence is designed directly on the two-dimensional intensity matrix to irradiate the largest possible area in each segment. The algorithm can be applied directly to MLC systems with different motion constraints. This algorithm has been evaluated by generating 1000 random 15 x 15 cm intensity matrices, each having from 3 to 16 intensity levels. Five clinical intensity modulated fields generated from the NOMOS CORVUS planning system for a complex clinical head and neck case were also tested with this and two other algorithms. The results of both the statistical and clinical studies showed that for all the intensity matrices tested, the proposed algorithm results in the smallest number of segments with a moderately increased monitor units. Thus it is well-suited for use in static MLC intensity modulation beam delivery. For MLC systems with interleaf motion constraint, we prove mathematically that this constraint reduces the tongue and groove effect at the expense of an increase of 25% in the number of segments.