Faculty Publications

It is shown that the energy of protons accelerated in laser matter inter-action experiments may be significantly increased through the process of splitting the incoming laser pulse into multiple interaction stages of equal intensity. From a thermodynamic point of view, the splitting procedure can be viewed as an effective way of increasing the efficiency of energy transfer from the laser light to protons, which peaks for processes having the least amount of entropy gain. It is predicted that it should be possible to achieve at least a 100% increase in the energy efficiency in a six-stage laser proton accelerator compared with a single laser target interaction scheme.

Accurate dosimetry of the narrow beam tends to be difficult to perform due to the absence of lateral electronic equilibrium and the steep dose gradient, as well as the finite size of detectors. Thus, although the high dose rate 6 MV beam on the VARIAN Trilogy accelerator is increasingly utilized for stereotactic radiosurgery (SRS) treatment, there is no general agreement in the SRS beam output factor values among the Trilogy user community. Trilogy SRS beams are confined by cone collimators and the available collimator sizes range from 5 and 10 to 30 mm, in every 2 mm increment. A range of the relative output factors are in clinic use. This variation may impair observations of dose response and optimizations of the prescribed dose. It is necessary to investigate an accurate, easily performable, and detector independent method for the narrow beam output factor measurement. In this study, a scanning beam/scanning chamber method was proposed to overcome the limitation/ difficulty of using a relatively large detector in narrow beam output factor measurement. Specifically, for the scanning beam method, multiple narrow beams are used for the dose measurement using a finite size chamber. These multiple scanning beams form an equivalent large uniform field which provides lateral electron equilibrium condition. After the measurement, the contributions from neighboring beams are deconvolved and the value is used for output factor determinations. For a Linac that cannot move a beam laterally, the scanning chamber method can be used to achieve the same result. The output factors determined in such a method were compared to chambers (a 0.015 cc PTW PinPoint ion chamber and a 0.125 cc PTW ion chamber) and film measurement, as well as with Monte Carlo simulation. Film and Monte Carlo results are found to be in excellent agreement with the measurement using the scan beam method. However, the VARIAN recommended output factors measured directly by Wellhofer CC01 chamber and Scanditronix photon field diode are consistently higher for all the cones. Especially for the 5 mm cone, the difference is more than 10%. Overall, the results suggested that the new method can help overcoming the detector volume averaging effect and the positioning uncertainties, which constitute the major challenge in small radiosurgical beam output factor measurement, and provide reliable output factors. (C) 2009 American Association of Physicists in Medicine. [DOI: 10.1118/1.3232217]

PURPOSE: To study the time spent with radiation-induced dermatitis during a course of radiation therapy for breast cancer in women treated with conventional or intensity-modulated radiation therapy (IMRT). METHODS AND MATERIALS: The study population consisted of 804 consecutive women with early-stage breast cancer treated with breast-conserving surgery and radiation from 2001 to 2006. All patients were treated with whole-breast radiation followed by a boost to the tumor bed. Whole-breast radiation consisted of conventional wedged photon tangents (n = 405) earlier in the study period and mostly of photon IMRT (n = 399) in later years. All patients had acute dermatitis graded each week of treatment. RESULTS: The breakdown of the cases of maximum acute dermatitis by grade was as follows: 3%, Grade 0; 34%, Grade 1; 61%, Grade 2; and 2%, Grade 3. The breakdown of cases of maximum toxicity by technique was as follows: 48%, Grade 0/1, and 52%, Grade 2/3, for IMRT; and 25%, Grade 0/1, and 75%, Grade 2/3, for conventional radiation therapy (p < 0.0001). The IMRT patients spent 82% of weeks during treatment with Grade 0/1 dermatitis and 18% with Grade 2/3 dermatitis, compared with 29% and 71% of patients, respectively, treated with conventional radiation (p < 0.0001). Furthermore, the time spent with Grade 2/3 toxicity was decreased in IMRT patients with small (p = 0.0015), medium (p < 0.0001), and large (p < 0.0001) breasts. CONCLUSIONS: Breast IMRT is associated with a significant decrease both in the time spent during treatment with Grade 2/3 dermatitis and in the maximum severity of dermatitis compared with that associated with conventional radiation, regardless of breast size.

PURPOSE: To investigate the dosimetric impact of using 4D CT and multiphase (helical) CT images for treatment planning target definition and the daily target coverage in hypofractionated stereotactic body radiotherapy (SBRT) of lung cancer. MATERIALS AND METHODS: For 10 consecutive patients treated with SBRT, a set of 4D CT images and three sets of multiphase helical CT scans, taken during free-breathing, end-inspiration and end-expiration breath-hold, were obtained. Three separate planning target volumes (PTVs) were created from these image sets. A PTV(4D) was created from the maximum intensity projection (MIP) reconstructed 4D images by adding a 3mm margin to the internal target volume (ITV). A PTV(3CT) was created by generating ITV from gross target volumes (GTVs) contoured from the three multiphase images. Finally, a third conventional PTV (denoted PTV(conv)) was created by adding 5mm in the axial direction and 10mm in the longitudinal direction to the GTV (in this work, GTV=CTV=clinical target volume) generated from free-breathing helical CT scans. Treatment planning was performed based on PTV(4D) (denoted as Plan-1), and the plan was adopted for PTV(3CT) and PTV(conv) to form Plan-2 and Plan-3, respectively, by superimposing "Plan-1" onto the helical free-breathing CT data set using modified beam apertures that conformed to either PTV(3CT) or PTV(conv). We first studied the impact of PTV design on treatment planning by evaluating the dosimetry of the three PTVs under the three plans, respectively. Then we examined the effect of the PTV designs on the daily target coverage by utilizing pre-treatment localization CT (CT-on-rails) images for daily GTV contouring and dose recalculation. The changes in the dose parameters of D(95) and D(99) (the dose received by 95% and 99% of the target volume, respectively), and the V(p) (the volume receiving the prescription dose) of the daily GTVs were compared under the three plans before and after setup error correction. RESULTS: For all 10 patients, we found that the PTV(4D) consistently resulted in the smallest volumes compared with the other PTV's (p=0.005). In general, the plans generated based PTV(3CT) could provide reasonably good coverage for PTV(4D), while the reverse can only achieve 90% of the planned values for PTV(3CT). The coverage of both PTV(4D) and PTV(3CT) in Plan-3 generally reserves the original planned values in terms of D(95), D(99), and V(p,) with the average ratios of 0.996, 0.977, and 0.977, respectively, for PTV(3CT), and 1.025, 1.025, and 1.0, respectively, for PTV(4D). However, it increased the dose significantly to normal lung tissue. Additionally, the plans generated using the PTV(4D) presented an equivalent daily target coverage compared to the plans generated using the PTV(3CT) (p=0.953) and PTV(conv) (p=0.773) after setup error correction. Consequently, this minimized the dose to the surrounding normal lung. CONCLUSION: Compared to the conventional approach using helical images for target definition, 4D CT and multiphase 3D CT have the advantage to provide patient-specific tumor motion information, based on which such designed PTVs could ensure daily target coverage. 4D CT-based treatment planning further reduces the amount of normal lung being irradiated while still providing a good target coverage when image guidance is used.

As a clinical application of an exciting scientific breakthrough, a compact and cost-efficient proton therapy unit using high-power laser acceleration is being developed at Fox Chase Cancer Center. The significance of this application depends on whether or not it can yield dosimetric superiority over intensity-modulated radiation therapy (IMRT). The goal of this study is to show how laser-accelerated proton beams with broad energy spreads can be optimally used for proton therapy including intensity-modulated proton therapy (IMPT) and achieve dosimetric superiority over IMRT for prostate cancer. Desired energies and spreads with a varying delta E/E were selected with the particle selection device and used to generate spread-out Bragg peaks (SOBPs). Proton plans were generated on an in-house Monte Carlo-based inverse-planning system. Fifteen prostate IMRT plans previously used for patient treatment have been included for comparison. Identical dose prescriptions, beam arrangement and consistent dose constrains were used for IMRT and IMPT plans to show the dosimetric differences that were caused only by the different physical characteristics of proton and photon beams. Different optimization constrains and beam arrangements were also used to find optimal IMPT. The results show that conventional proton therapy (CPT) plans without intensity modulation were not superior to IMRT, but IMPT can generate better proton plans if appropriate beam setup and optimization are used. Compared to IMRT, IMPT can reduce the target dose heterogeneity ((D-5-D-95)/D-95) by up to 56%. The volume receiving 65 Gy and higher (V-65) for the bladder and the rectum can be reduced by up to 45% and 88%, respectively, while the volume receiving 40 Gy and higher (V-40) for the bladder and the rectum can be reduced by up to 49% and 68%, respectively. IMPT can also reduce the whole body non-target tissue dose by up to 61% or a factor 2.5. This study has shown that the laser accelerator under development has a potential to generate high-quality proton beams for cancer treatment. Significant improvement in target dose uniformity and normal tissue sparing as well as in reduction of whole body dose can be achieved by IMPT with appropriate optimization and beam setup.

Increasing the dose rate offers time saving for IMRT delivery but the dosimetric accuracy is a concern, especially in the case of treating a moving target. The objective of this work is to determine the effect of dose rate associated with organ motion and gated treatment using step-and-shoot IMRT delivery. Both measurements and analytical simulation on clinical plans are performed to study the dosimetric differences between high dose rate and low dose rate gated IMRT step-and-shoot delivery. Various sites of IMRT plans for liver, lung, pancreas, and breast cancers were delivered to a custom-made motorized phantom, which simulated sinusoidal movement. Repeated measurements were taken for gated and nongated delivery with different gating settings and three dose rates, 100, 500, and 1000 MU/min using ion chambers and extended dose range films. For the study of the residual motion effect for individual segment dose and composite dose of IMRT plans, our measurements with 30%-60% phase gating and without gating for various dose rates were compared. A small but clinically acceptable difference in delivered dose was observed between 1000, 500, and 100 MU/min at 30%-60% phase gating. A simulation is presented, which can be used for predicting dose profiles for patient cases in the presence of motion and gating to confirm that IMRT step-and-shoot delivery with gating for 1000 MU/min are not much different from 500 MU/min. Based on the authors sample plan analyses, our preliminary results suggest that using 1000 MU/Min dose rate is dosimetrically accurate and efficient for IMRT treatment delivery with gating. Nonetheless, for the concern of patient care and safety, a patient specific QA should be performed as usual for IMRT plans for high dose rate deliveries.

Increasing the dose rate offers time saving for IMRT delivery but the dosimetric accuracy is a concern, especially in the case of treating a moving target. The objective of this work is to determine the effect of dose rate associated with organ motion and gated treatment using step-and-shoot IMRT delivery. Both measurements and analytical simulation on clinical plans are performed to study the dosimetric differences between high dose rate and low dose rate gated IMRT step-and-shoot delivery. Various sites of IMRT plans for liver, lung, pancreas, and breast cancers were delivered to a custom-made motorized phantom, which simulated sinusoidal movement. Repeated measurements were taken for gated and nongated delivery with different gating settings and three dose rates, 100, 500, and 1000 MU/min using ion chambers and extended dose range films. For the study of the residual motion effect for individual segment dose and composite dose of IMRT plans, our measurements with 30%-60% phase gating and without gating for various dose rates were compared. A small but clinically acceptable difference in delivered dose was observed between 1000, 500, and 100 MU/min at 30%-60% phase gating. A simulation is presented, which can be used for predicting dose profiles for patient cases in the presence of motion and gating to confirm that IMRT step-and-shoot delivery with gating for 1000 MU/min are not much different from 500 MU/min. Based on the authors sample plan analyses, our preliminary results suggest that using 1000 MU/Min dose rate is dosimetrically accurate and efficient for IMRT treatment delivery with gating. Nonetheless, for the concern of patient care and safety, a patient specific QA should be performed as usual for IMRT plans for high dose rate deliveries. (C) 2008 American Association of Physicists in Medicine. [DOI: 10.1118/1.2996176]

The Monte Carlo (MC) method has been shown through many research studies to calculate accurate dose distributions for clinical radiotherapy, particularly in heterogeneous patient tissues where the effects of electron transport cannot be accurately handled with conventional, deterministic dose algorithms. Despite its proven accuracy and the potential for improved dose distributions to influence treatment outcomes, the long calculation times previously associated with MC simulation rendered this method impractical for routine clinical treatment planning. However, the development of faster codes optimized for radiotherapy calculations and improvements in computer processor technology have substantially reduced calculation times to, in some instances, within minutes on a single processor. These advances have motivated several major treatment planning system vendors to embark upon the path of MC techniques. Several commercial vendors have already released or are currently in t!

In the present paper, we describe the results of a prospective trial that compared isocenter shifts produced by BAT Ultrasound (Nomos, Sewicky, PA) to those produced by a computed tomography (CT) unit in the treatment room to aid in positioning during image-guided radiation therapy. The trial included 15 consecutive patients with localized prostate cancer. All patients underwent CT and MR simulation immobilized supine in an Alpha Cradle and were treated with intensity-modulated radiation therapy. BAT Ultrasound was used daily to correct for interfraction motion by obtaining shift in the x, y, and z directions. Two days per week during therapy, CT scans blinded to the ultrasound shifts were obtained and recorded. We analyzed 218 alignments from the 15 patients and observed a high level of correlation between the CT and ultrasound isocenter shifts (correlation coefficients: 0.877 anterior-posterior, 0.842 lateral, and 0.831 superior-inferior). The systematic differences were less than 1 mm, and the random differences were approximately 2 mm. The average absolute differences, including both systemic and random differences, were less than 2 mm in all directions. The isocenter shifts generated by using a CT unit in the treatment room correlate highly with shifts produced by the BAT Ultrasound system.