Ch-12-A Advanced RT Georg Part 1 - IMRT U. SRT - V2017!01!10

Advanced Treatment Techniques Part 1
IMRT/IGRT and S(B)RT
Dietmar Georg
Division Medical Radiation Physics
Department of Radiooncology / Medical University Vienna & AKH Wien
Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology
2016 ULG Chapter 12 - Georg 1
Introduction
In addition to routine RT techniques used in standard

radiotherapy departments, several techniques are used for
special and/or high-precision procedures and treatments.
These techniques deal with specific problems that usually
require equipment modifications, special quality assurance
procedures, and heavy involvement and support from clinical
physicists.
increased complexity and the relatively low number of patients
usually available only in larger, regional centers.
1
Categories of specialized & precision techniques
1. Total Body Irradiation (TBI)

2. Total Skin Electron Irradiation (TSEI)
3. Endorectal irradiation
4. Intraoperative radiotherapy (IORT)
5. Stereotactic irradiation
6. Intensity Modulated Radiotherapy (IMRT)
7. Particle Beam therapy
8. Image Guided and Adaptive RT (IGART)
New developments: BioART, .
Conformal Radiotherapy (CRT)
Basic premise CRT: in comparison with simple dose delivery

techniques, tumor control can be improved by using special
techniques that allow the delivery of a higher tumor dose while
maintaining an acceptable level of normal tissue complications.
Conforms or shapes the prescription dose volume to the planning
target volume (PTV) while at the same time keeping the dose to
specified organs at risk at doses below their tolerance dose.
larger number of beams to reduce the high dose region
3D target localization, 3-D treatment planning, and 3-D dose delivery
techniques
2
Basic aspects Conformal Radiotherapy
100 %
90%
80%
70%
60%
50%
40%
30%
Conventional RT 3D CRT
Conformal Radiotherapy
Target localization - anatomical and functional imaging:
computed tomography (CT)
magnetic resonance imaging (MRI)
single photon emission computed tomography (SPECT)
positron-emission computed tomography (PET)
ultrasound (US)
3
Treatment planning : standard forward planning techniques, which design
uniform intensity beams shaped to the geometrical projection of the target,
or, for more advanced conformal radiotherapy techniques, with inverse
planning which, in addition to beam shaping, uses intensity-modulated
beams to improve target dose homogeneity and spare organs at risk
Collimator
Treated Target Target

Volume Volume Treated
Volume
Volume
OAR
OAR
Dose delivery techniques range from the use of standard regular and
uniform coplanar beams to intensity-modulated non-coplanar beams
produced with multileaf collimators (MLCs) or individual irregular
blocks in the simplest form of CRT
4
Inter- & intra-observer variations in RO
Hurkmans et al IJROPB (2001)
Steenbakkers et al R&O (2005)
4 radiation oncologists, each 3 times following
11 radiation oncologists (5
a protocol 1 patient
institutions) delineated 22 lung
targets Same institution
Rasch et al RO (2010)
10 radiation oncologists
delineated 10 pts
IGART requires auto-segmentation . . .

Intensity modulation ( = fluence modulation)
In addition to field shaping in conformal radiotherapy, an MLC may also be

used to achieve beam intensity modulation (IMRT) for use in 3D conformal
radiotherapy.
Primary fluence incident on the patient varies across the field, it may even vary
across the tumor for a certain beam.
1.5 0.2 1.2 2.2 3.4 3.3
1.5 1.3 2.4 4.4 2.9 3.5 1.5
0.2 0.2 2.5 3.8 4.6 4.7 1.5
2.3 2.3 4.9 4.8
3.5 2.4
3.3
5
What is fluence?
Definition: the energy fluence is the quotient dR by dA, where

dR is the radiant energy incident on a sphere of cross-sectional
area dA:
dR

dA
Unit of energy fluence: J m2.
P dA
Intensity Modulated RadioTherapy ( I M R T )
From an obscure, highly specialized radiotherapy technique practiced

in only a few specialized centers around the world, intensity
modulated radiotherapy (IMRT) is developing into a mainstream
technique available in most major radiotherapy centers.
The IMRT technique is currently the most advanced form of
conformal radiotherapy and holds great promise for improving
radiotherapy both through increased tumor control and decreased
treatment morbidity.
Complexity of equipment used for dose delivery and planning
QA issues related with dose distribution calculation and dose delivery,
which makes QA in IMRT very labor intensive.
6
History of I M R T
< 1960 primitive IMRT with blocks, wedges, compensators
1960 gravity orientated devices
1982 mathematical solution for wedged and blocked 1 D IM
1988 general concept of inverse planning for IM
1989 simulated annealing proposed for optim.
1991 principle of segmented field delivery
1992 principle dynamic MLC delivery
1992 serial tomotherapy delivery for IMRT
1993 conceptual design of spiral tomotherapy
1994 clinical application of segmented field delivery
History of I M R T
...
1994 dynamic field delivery in clinical application
1992-7 wide availability of MLCs (purchase reason: intending to go towards IMRT?
1994 refinement of techniques & explosion of commercial interest (e.g T & G effect)
1995 concept of Intensity modulated arc therapy
1999 evaluation of impact of functional imaging on IMRT
1999 IM proton therapy
2000 robotic linac for IMRT
> 2000 publications on clinical experience and outcome of IMRT
> 2000 commercial turn-key solutions for IMRT
2001 IMAT in clinical application
> 2010 VMAT becomes new delivery standard
7
Remark on history of I M R T
IMRT is not a concept of the 21st century, it was mainly developed

during the last decade of the 20st century, although the roots of
IMRT go back to the early 1960ies.
Rudimentary IMRT treatments with wedges and compensators
Modern IMRT became possible in the late 1990s due to a synergistic
effect among areas that only then became well established:
(1) 3-D medical imaging by CT, MRI, SPECT, and PET,
(2) computer-controlled dose delivery - multileaf collimators;
(3) inverse treatment planning,
(4) quality assurance techniques for verification of dose delivery.
IMRT Treatment Delivery
Various approaches to IMRT - ranging from simple standard physical

compensators to scanned pencil beams.
Most commonly applied techniques: cone beam & slit beam techniques.
Other approaches: robotic linac, arc therapy.
Cone beam techniques: multiple static MLC-shaped fields (segmental
MLC technique or step-and-shoot technique), dynamic MLC dose
delivery, or VMAT / IMAT.
standard MLC is sufficient
Slit beam delivery: tomotherapy : serial and helical tomotherapy.
8
FIGURE: IMRT cone beam techniques with fixed gantry angles.
IMRT based on Cone Beams
apply conventional divergent beams

(cone beams)
accelerator requirements
standard linac
standard MLC
delivery techniques
Segmental MLC IMRT
dynamic MLC IMRT
VMAT
Rotational therapy & intensity modulation
Dynamic arcs: subarcs with leafs adapting to

target, constant collimator angle, constant
doserate
IMAT: Rotational IMRT delivered on a
conventional Linac with a conventional MLC
RapidArc: Varian`s IMAT solution that focuses
on single arc delivery
Phys. Med. Biol. 40 (1995)
VMAT: Elekta`s IMAT delivery solution
Cone Beam Therapy: Siemens work in
progress
Smart Arc: Planning solution in Pinnacle
Hybrid Arc: Planning solution in iPlan
.
9
Serial Tomotherapy
Standard linac + dedicated
multi-vane collimator
binary shutters create 1-D
intensity profile
treating one slice of the patient
at a time
arcing gantry
2001: most IMRT patients
treated so far with this device
couch translation via CRANE device
Helical Tomotherapy
Idea formulated late 1980s

University Wisconsin patent
CT gantry + X band linac (6 MV)
originally kV unit + detector
multivane collimator
64 vanes
10 cm height
fan beams 0.5 - 5 cm in
longitudinal direction
40 cm in axial direction
10
Tomotherapy today..
Helical Tomotherapy
Smaller integral doses and more

homogeneous doses to the target as
compared to step & shoot IMRT.
Can improve on conformal
avoidance of organs at risk.
IGRT for target localization
and set-up accuracy. Elekta without diaphragms 25 MV
Varian 20 MV
Siemens 15 MV
Some additional physics and clinical TomoTherapy 6 MV

Leakage ( % )
improvements over conventional

and MLC-based IMRT
0.5%
0.3%
Position (cm)
11
Rotational IMRT
BrainLAB Vero System
Linac
X-ray 1 X-ray 2
MLC
Imager 2 EPID Imager 1
Beam-stopper
CBCT options
Linac and MLC on
gimbals
Vero system configuration
Accelerator type Standing wave

C-Band accelerator
Dose rate fluctuation 1%
Dose flatness 3%
Dose stability (long term) 1%
Ring rotation accuracy 1
Gantry rotation accuracy 1
Gantry rotational 0.1 mm
isocenter fluctuation
12
Symbiotic relation IMRT - IGRT
Collimator

Volume Volume Treated Volume
Volume
OAR
OAR
Inversely planned IMRT needs IGRT for safe delivery of steep

dose gradients
Biologically motivated IGRT needs inverse planning for
inhomogeneous dose delivery
Rotational IMRT and IGRT verification
Variation of dose rate (intensity) and field size + shape during

gantry rotation
Faster delivery minimizes intra-fraction motion
Future (WIP): Plan of the day
13
Technology evolution in Radiation Oncology
Linac Ion Beam
..
Anatomic Conformity
Cyberknife Therapy
Tomotherapy MR
Volumetric Modulated RT
Image Guided RT
Intensity
Modulated RT
~ 2005
Stereotactic
Radiotherapy ~ 2000
Main focus behind developments:

3D
dose conformation to anatomic
2D ~ 1990 target in 3D / 4D and OAR sparing
Sophistication
Continuous improvement in beam delivery & dose conformity
Radiation Oncology & Imaging

Linac Ion Beam
..
Anatomic Conformity
Cyberknife Therapy
Tomotherapy MR
Volumetric Modulated RT
Image Guided RT
Intensity mp-MR / PET
Modulated RT PET-CT
Stereotactic Linac + kV imaging
Radiotherapy
MRI & CT-MR fusion
3D
2D kV volumetric (CT)
kV planar
Sophistication
Advancements in imaging & its use in Radiation Oncology
14
Biologically adaptive radiotherapy
High-precision beam delivery BioART
Biological and Anatomic Conformity
Image Guided RT
Intensity mp-MR / PET
Modulated RT PET-CT
Stereotactic Linac + kV imaging
Radiotherapy Main focus of
MRI & CT-MR fusion developments:
3D dose conformation
to sub targets &
2D kV volumetric (CT)
OAR sparing
kV planar
Sophistication
Dimensions in Radiotherapy moved from 3D via 4D to 5D+
Dose rate & flattening filter free treatment units

Kawachi et al MP 35 (2008)
Target
exchanger Beam
scanning
magnets
Purging
magnet Cyberknife
Filter revolver
Wedge
filter Video camera
Ion Multileaf
Chamber collimator
(MLC)
Helium
atmosphere
Scanditronix MM50 racetrack microtron (1987)

Tomotherapy
Head design of conventional

C-arm based linacs is revisited Jeraj et al MP 31 (2004)
Thanks for your attention!
15
Inverse treatment planning
Today IMRT (VMAT; IMPT, ..) is intuitively linked with inverse

treatment planning (ITP)
IMRT is understood as being based on ITP for the determination of
fluence maps
As a precision RT technique IMRT planning is based on 3-D multi-
modality medical imaging to avoid geographical tumor misses.
Forward treatment planning is obsolete in todays IMRT, VMAT, IMPT,
Optimization remains an iterative trial and error process based on
human intelligence.
Automated treatment planning is entering the clinic
Inverse planning in IMRT
Collimator

Volume Volume Treated
Volume
Volume
OAR
OAR
Intensity modulation enables dose sculpting to better spare

organs at risk
Improved sparing implies/assumes reduced toxicity
16
IMRT workflow
Volume definitions
Defining objectives and constraints
Fluence optimization
Dose calculation (certain approximations used)
Objective function (and its gradient) calculated
New fluence setting
Segmentation - Leaf pattern determination #
#not in all systems
Continued optimization of segment settings and weights #
Final dose calculation to remedy approximations during fluence optimization #
Plan evaluation,
QA Delivery
Fluence/opening density optimization
Courtesy A Ahnesj
17
Inverse Treatment Planning - ITP
Optimization algorithm drives the optimization process.

minimizes or maximizes a specific objective function, which is based on
treatment goals.
physical doses to the PTV or OAR, biological parameters and EUD, ...
It is still up to the user to specify the treatment geometry
table, collimator, gantry.
ITP changes the thought process
Optimization is impossible if the treatment prescription is unrealistic.
Results of optimizations are often non-intuitive and the effect of
prescription changes is difficult to predict.
General thoughts - IMRT optimization
Typical Treatment Goals:

Sufficient target dose
Dont exceed acceptable OAR dose
Target dose should be
conformal spare normal tissue
No large or excessive hot spots in the target
Goal need to be communicated to the TPS

Concise, comprehensive, transparent, based on numerical values
Is there and advantage of biological formalism compared to

physical cost functions?
18
j-th pencil
beam
Dose to i-th point:
D i a1 d 1 i .......... . a N d N i i-th point
(voxel)
Di a d i
PTV
N pencil beams
OAR
Dose deposited to the i-th point (voxel) in the body from the j-th ray is
linearly related to the intensity aj of that ray.
Objective functions and IPT
Based on weighting factors (penalties) for dose constraints (target and

OAR), such as maximum dose, minimum dose, or DVH constraints.
Weighting factors have no clinical meaning but the dose constraints are
easy to use. Unfortunately they do not reflect non-linear response of
tumors or normal structures.
2016 ULG Chapter 12 - Georg
19
Todays inverse planning cockpit . . .
Objective functions and ITP
Objective function: mathematical formulation of desired treatment goal,

taking into account all (clinical) endpoints mathematically optimized plan
can be clinically in-acceptable (garbage in garbage out).
The objective functions of commercial systems depend largely on the vendor.
Example: QUADRATIC DIFFERENCE between desired & actual dose - most
frequently used objective function:
K
v v
F ( a ) FT ( a ) F ( av )
k
dose at voxel i in PTV
k 1
( )
N
v v
FT ( a ) w T D i ( a ) - D idesired
T
2 Positivity operator
i 1
penalty u for u 0
( ) C {u}
N
v v
Fk ( a ) w k C {D k , j ( a ) - D max
k
2
}
0 otherwise
k
j 1
dose at voxel j in OAR k tolerance dose
20
Advantages over the standard forward planning approaches:

improved dose homogeneity inside the target volume and the
potential for limited irradiation of surrounding sensitive structures,
increased speed and lesser complexity of the proposed solution
a quantitative introduction of cost functions often incorporating

dose-volume constraints and biological functions
adjusting the optimal treatment planning to the actual dose
delivery technique and accounting for all practical hardware
limitations.
Structure segmentation and objectives
PTV subtracted
from Bladder
Volume
No hot spots are allowed

in the Rectum part of the
PTV
21
Biological Objectives are also possible
Dose-based IMRT Plan Biological IMRT Plan
brain stem
Courtesy of Philips Medical Systems
Biological cost functions and EUD
EUD-based formalism:
EUD is equivalent (in terms of the same level of the probability of
a local control or complication) to a given non-uniform dose
distribution.
EUD-based cost functions allow to explore a larger solution space
than dose based objective functions.
Based on Poisson Dose Response

Model (Munro,Guilbert 1961) / TCP
model (Tome, Bentzen 2005)
22
Equivalent Uniform Dose - EUD
Optimization tries to modify the intensities in order to maximize the

EUD for the target and minimizes the EUD for OAR.
Advantages: basis on the mechanistic formulation of linear quadratic
cell survival model and the small number of input parameter.
Disadvantage is that dose inhomogeneity needs to be separately
limited (EUD is insensitive to hot spots).
We in the RO community - are not thinking in terms of EUDs.
Optimization Parameters
Physical Parameter: Biological Parameter:

DVH, D01% , D99% , Dmin , Dmax gEUD, Target EUD, EUDmin ,
Dmean , EUDmax ,
Volume
Volume
Dose Dose
23
Biological vs. physical cost function
..
Radiobiological consideration.
Dose volume histogram and information

extracted can be misleading..
What is delineated and where
is the radiation effect happening
Bladder vs bladder wall
DVH data used to extract NTCP....

BUT many organs have subunits
Use of DVH + dose distribution
24
Sequencer / Interpreter
To convert the intensity pattern derived during the optimization

process into deliverable MLC settings.
...
4,00
3,00
2,00
R9
R8
1,00
R7
R6
R5
R4
R3
0,00
R2
R1
1 2 3 4 5 6 7 8 9 10 11
Reminder on MLC and impact on IMRT

[cm] [cm]
0 0
primary collimator primary
10 collimator 10
flattening filter monitor chamber
monitor chamber flattening filter
20 20
internal wedge
upper collimator 30
30
lower leaves
40
collimator 40
backup collimator
collimator 50
lower collimator 50
housing
leaves [cm]
0
primary
collimator
10
FIGURE : MLC designsflattening filter internal
wedge
monitor chamber
in commercially available 20
linear accelerators. upper collimator 30
leaves 40
50
25
Reminder on MLC and impact on IMRT
Important that an elaborate acceptance testing protocol is performed

MLC has big impact an IMRT delivery accuracy !
Mechanical: motion of leaves and their maximum travel; abutting of
leaves on and off the central field axis; alignment of MLC axes with
axes of the linac secondary collimators; positional reproducibility of
leaves; interlocks for leaf and jaw positional tolerances.
Radiation: transmission of leaves, leakage between leaves; leakage in
junction of two abutting leaves both on- and off field axis; leaf
penumbra both along the leaf and perpendicularly to it.
Software: linkage between treatment planning system and the MLC;
accuracy of field shaping and functioning of the controller.
QA for MLC
To ensure a reliable and safe operation of software and all

mechanical components.
positional accuracy, leaf motion reliability, leakage, interlocks,
networking and data transfer
regular: weekly, monthly, etc.
Example: picket fence test
26
Picket fence test
Machine specific QA - Picket fence
EPID Image:
Slit 1
Analysis of slit width
Slit 2
Mean
Slit 3 Max
Min
Slit 4
Slit 5
27
Leaf leakage and transmission
0,9
0,8
0,7
LEAKAGE [%]
0,6
0,5
0,4
0,3
0,2
0,1
0
0 50 100 150 200 250 300 350 400
DISTANCE [mm]
Principle: Interpreter for segmental MLC IMRT

I-3
Example: 1-D intensity profile with
I-2 3 intensity levels
I -1
N = 3 P = N ! 6 delivery schemes
Close in
Leaf sweep
28
Mechanical restrictions of MLCs
Collision non-contiguous
0 0 0 1 0 0 0 1 0 1 0 0
0 1 0 0 0 0 0 1 0 1 0 0
NO - collision contiguous
0 0 0 1 0 0 0 1 1 1 0 0
0 0 1 0 0 0 0 1 1 1 0 0
Varian Siemens Elekta
Principle of an interpreter for dynamic MLC IMRT

T (s) or MU
T (s) or MU
1 2 3 4
+ - + -
x x
T (s) or MU T (s) or MU Leaf A
Leaf B
x x
29
Choice of Beam Directions
9, 7 and 5 beams have been used in coplanar plans
Plans do not have to be coplanar
Experience in 3D treatment planning important for IMRT planning
Appropriate choice of beam direction can be very effective
Some systems now allow beam angle optimisation
Increasingly arc therapy with dynamic jaw movements is being used
Choice of Beam Directions & arc length
Increasingly arc therapy with dynamic MLC movements is being used

and there optimisation is w.r.t number of arcs and arc length
30
Rotational therapy & intensity modulation
Dynamic arcs: subarcs with leafs adapting to

target, constant collimator angle, constant
doserate
IMAT: Rotational IMRT delivered on a
conventional Linac with a conventional MLC.
RapidArc: Varian`s IMAT solution that focuses on
single arc delivery.
VMAT: Elekta`s IMAT delivery solution.
Cone Beam Therapy: Siemens work in progress.
Smart Arc: Planning solution in Pinnacle.
Hybrid Arc: Planning solution in iPlan.
.
What Makes an Optimum Plan?
Maximised dose to the tumour

Minimised dose to normal tissue
Additional considerations
Dose uniformity
May become less important in the future
Ease of delivery
Accuracy required of equipment
Interventions by staff
31
Summary - Inverse Treatment Planning
IMRT is linked to an iterative optimization process

Weight factors might be assigned to structures and specific
properties do not necessarily reflect radiobiology
Coverage, volume fraction of OAR and function, non-linear dose
response,
Changes the thought process
Optimization impossible if the treatment prescription is
unrealistic.
Mathematical description of treatment goal
Results of optimizations are often non-intuitive and the effect of

prescription changes is difficult to predict.
Fluence/opening density optimization
Courtesy A Ahnesj
32
Parotid gland sparing IMRT
Parotid glands
Impact of IMRT/IGRT for prostate treatments
IGRT
Local control
Local control
2007
Conventional RT
2000
1994
f.u. months
AKH : 66 Gy Wachter et al. Strahlenther.Onkol. 1999 ; IJORBP 2002

AKH : 70 74 Gy Goldner et al. IJORBP 2007 ; Radioth.Oncol
AKH : 78 80 Gy mit IGRT / IMRT
33
Most important IMRT indications
Head and Neck Cancer
CNS
Para-nasal Sinus tumours
NPC and other ENT tumours
Pelvis
Prostate / Integrated boost
Bowel sparing
Gastric cancer
Breast Cancer
Lung Cancer
Para-spinal metastases
IMRT / VMAT in clinical practice
34
IMRT / VMAT in clinical practice
FIGURE : Typical Gamma-knife treatment (small metastasis)
Highly irregular concave targets can be nicely covered

Optimization of planning in reasonable time frame
Symbiotic relation IMRT - IGRT
Collimator

Volume Volume Treated Volume
Volume
OAR
OAR
Inversely planned IMRT needs IGRT for safe delivery of steep

dose gradients
Biologically motivated IGRT needs inverse planning for
inhomogeneous dose delivery
35
Rotational IMRT and IGRT verification
Variation of dose rate (intensity) and field size + shape during

gantry rotation
Faster delivery minimizes intra-fraction motion
Future (WIP): Plan of the day
4D effects: Inter- and Intra-fraction motion
36
Today's IGRT Technology
Beam quality
MV (3 6 MV)
kV (80 130 kV)
Beam collimation
CBCT
FBCT
Dimensions
2D
3D
Rail-track-,
Korreman et al, Radiother Oncol 2010
ceiling/floor-, gantry-mounted systems Yin et al, AAPM Rpt Nr. 104
HYBRID system: MRI-linac
Limited soft tissue contrast with

current IGRT solutions
Experience from MRI guided
Brachytherapy
Different concepts for
combination of a linac
and a MRI
Thanks for your attention!

Courtesy J. Lagendijk
37
State of the art
Precision RT based on
Snapshot CT
Verellen
Conpcet of margins
Time as
4-th dimension
Van Herk
ICRU concepts
Development of internationally acceptable recommendations
In external beam therapy dose band width - concepts of maximium and
minimum target dose
Different and successful clinical practice and experience: brachytherapy

and hypofractionated stereotactic radiotherapy
Why not giving as much dose as possible?
38
Trend towards BioART
ICRU 83: GTV concept based on imaging modality and

depending on applied dose
Prior RT
After 20 Gy
Clinical practice versus ICRU

Research centers .
Smaller center .
Multi-modality imaging
Move towards BioART

Development of Image registration & handling tools
automated, efficient and user independent decisions
modified after Brock K, 2007
Insert picture of Brock
simplifying inter- and intra-

fraction imaging
39
Image Guided Adaptive Radiotherapy
When and how often to adapt ?

How to minimize workload (planning, QA, clinical validation, )?
fraction 1 fraction 2 fraction i
. .
S S S
I T I T I T
Time
survey survey
New plan Is it worth the effort?
Regular IMRT QA
A comprehensive quality assurance (QA) program must be developed to
ensure accurate IMRT treatment planning and dose delivery.
All steps involved need to be subject to a comprehensive QA program.
PLANNING CHAIN
IMAGE STRUCTURE
IMMOBILIZATION PLANNING
ACQUISITION SEGMENTATION
DELIVERY CHAIN
NETWORK FILE PLAN POSITION

DELIVERY
MANAGEMENT VERIFICATION VERIFICATION
40
Regular IMRT QA
Program needs to include standard verification of accelerator

radiation output and testing of MLC positioning and movement.
DOSE VERIFICATION for IMRT treatment plans as regular
patient specific QA
Traditional methods for dose and MU verification are based on
data measured in flat homogenous phantom.
Manual calculations or simple software are used which can handle
3D CRT including MLCs or blocks.
Regular IMRT QA
Perform an independent verification of all IMRT treatment plans

in similar way as for 3D-CRT.
point checks are not considered sufficient
Experimental methods are more frequently used than

verification calculations (at least at present).
transferring each IMRT plan to a representative phantom for dose
calculation which can be also loaded dosimeters.
2D comparison measured vs. delivered dose: dedicated software and
hardware can greatly simplify the evaluation of IMRT dose delivery
In-vivo dosimetry
41
Stereotactic irradiation
From an obscure irradiation technique practiced in the 1960s

and 1970s in only a few specialized centers, stereotactic
irradiation has during the past ten years developed into a
mainstream radiotherapeutic technique practiced in most
major radiotherapy centers
Stereotactic irradiation: term used to describe focal irradiation
techniques that deliver a prescribed dose of ionizing radiation to
preselected and stereotactically localized lesions
primarily in the brain, however, attempts have been made to
extend the technique to other parts of the body.
Aim of stereotactic irradiation: treat small volume lesions

considered inoperable or carrying excessive risk from
conventional surgery with a high geometric precision and high
dose gradient.
Stereotactic treatments are equivalent to a surgery
Total doses: in the order of 10 to 50 Gy and the planning targets

are small, with typical volumes between 1 and 35 cm.
Requirements for positional and numerical accuracy in dose
delivery are 1 mm and 5%, respectively.
42
Dose in stereotactic irradiation may be delivered through

stereotactic implantation of radioactive sources (stereotactic
brachytherapy) or, more commonly, with one or several external
radiation sources (stereotactic external beam irradiation)
Essentially any radiation beam that was found useful for external
beam radiotherapy has also found use in radiosurgery
cobalt gamma rays, megavoltage photon beams, proton and heavy
charged particle beams, and even neutron beams...
FIGURE : SRS(T) and RT
External beam stereotactic irradiation
is divided into two categories RADIOTHERAPY
Stereotactic radiosurgery SRS: total

dose is delivered in a single session.
The term SRS was introduced by
Leksell (1951). Is applicable to a single-
fraction.
Stereotactic radiotherapy SRT - like
standard radiotherapy, delivers the
dose
total dose in multiple fractions

Technical point of view: no difference
!
RADIOSURGERY
43
Equipment for SRT - considerations
Imaging equipment (CT, MR, DSA)

Target localization software: used in conjunction with the
stereotactic frame system and imaging equipment to determine
the coordinates of the target in the stereotactic frame reference
system.
3D Treatment planning system for radiosurgical treatment: dose
is calculated and superimposed on the patient's anatomical
information
Appropriate radiation source and radiosurgical treatment
technique
History of Stereotactic Radiotherapy I
1908: Sir Victory Horsley and Robert H. Clarke
Stereotactic technique based on the reproducibility of the

relationships between landmarks on the skull (external auditory
canals, midline) and anatomical structures within the brain.
44
History of Stereotactic Radiotherapy
Problem: relationship between bony landmarks and cerebral structures are unsure
Targeting of sub-cortical structures only e.g. gasserian ganglion with foramen ovale as
landmark
Imaging e.g.v entriculography stereotactic atlas
History of stereotactic Radiotherapy
Combined use of stereotaxy and irradiation in treatment of disease

was introduced in the early 1950s by the Swedish neurosurgeon
Leksell who also coined the term radiosurgery
used initially 200 kVp x rays to deliver - in a single session - a high
radiation dose (~ 100 Gy) to an intracranial target.
several directions to focus the dose on the target within the brain and
spare the surrounding vital structures.
discontinued in the late 1950s with kV beams
Idea of focal brain irradiation was carried over to first to protons from
cyclotrons, then to focussed cobalt-60 gamma rays, and more recently
to megavoltage X-rays from linear accelerators (linacs)
45
History of stereotactic Radiotherapy
1951, using the Uppsala Univ. cyxclotron, Lars Leksell

and the physicist and radiobiologist Borje Larsson,
developed the concept of radiosurgery
first employed proton beams ! (several directions)
experiments in animals and in the first treatments of
human patients.
called this technique "strlkniven" (ray knives).
New non-invasive method of destroying discrete
anatomical regions within the brain while minimizing
the effect on the surrounding tissues.
intended for use in functional brain surgery for the
section of deep fiber tracts (treatment of intractable pain
and movement disorders).
History of Stereotactic Radiotherapy
1968: Gamma Knife Radiosurgery

using Co-60 for treatment or
functional disorders
First surgery performed at
Karolinska on an Acoustic
schwannoma in 1969: Pituitary
tumors (1969), AVM (1970),
Craniopharyngiomas,
Meningiomas (in 1976),
Metastases and skull base
tumors (in 1986))
46
GAMMA KNIFE based SRS
Incorporates 201 cobalt-60 sources

sources produce 201 collimated beams directed to a single focal point at a
source-focus distance of ~ 40 cm.
Final definition of the circular beam field size is provided by one of

four helmets delivering circular fields with nominal diameters between
4 and 18 mm at the machine focal point
HELMETS: 6 cm thick cast iron

shield with an inner radius of 16.5
cm and an outer radius of 22.5
cm.
201 channels are drilled in each
helmet and 6 cm thick removable
collimators are placed.
The COLLIMATORS have circular
apertures (4, 8, 14, 18 mm
diameter at the focus).
The helmet is fixated to the left
and the right of the frame.
47
Gamma knife treatment planning
Gamma Knife dose prescription rather different from ICRU concepts

50% isodose line commonly used
48
Optimizing Dose Gradient with Plugged Collimators
Features of a gamma-knife
Radiation Unit ~ 17 t
201 60Co sources - focused to a single point at the center of the
radiation unit (focal distance = 40.3 cm)
mechanical precision of focus is 0.3 mm
Patient treatment table
Hydraulic system
Control panel
FIGURE: Schematic
sketch of a
Gamma-Knife
unit
49
Physical and clinical requirements in S(B)RT
Accurate determination of target volume and its location

multimodality imaging techniques
Image fusion
Calculation of 3-D dose distributions inside and outside the target

Dose-volume histograms (DVHs) for the target and OARs
Dose distributions which conform to target shapes and give a sharp
dose fall-off outside the target volume.
Superposition of dose distributions on diagnostic images, showing the
anatomical location of the target and surrounding structures.
Imaging for treatment planning
Depends on the diseases

treated with SRT
Functional disorders.
Vascular lesions.
Primary benign and

malignant tumors.
Metastatic tumors
MR has become standard

CT for density effects
50
Physical and clinical requirements in S(B)RT
Accurate knowledge of the total dose and fractionation scheme.

Accurate positional (within 1 mm) delivery of dose to the target
Accurate numerical (within 5%) delivery of dose to the target
Dose delivery accomplished in a reasonable amount of time
Low skin dose (to avoid epilation) and low eye lens dose (to avoid
cataracts) and low or negligible scatter and leakage dose to
radiosensitive organs (to avoid subsequent somatic and genetic effects
of radiation)
TECHNICAL PREQUISITES for stereotactic irradiation techniques !
Wording / Defintions
Frame-based vs. Frame-less

A stereotactic system of external coordinates is used for
localisation and positioning vs positioning in a mask system
with real time imaging control before each treatment
Invasive vs. Non-invasive

The patient is rigidly fixed to the stereotactic system using
invasive techniques, ideal for single fraction vs a mask type
System re-locatable used for > 1 fraction
51
Frame based SRT
immobilization (invasive,
non-invasive)
y
Stereotactic
x coordinate system
z
Precise target localization in the stereotactic

coordinate system
Relates imaging & treatment position
Immobilization non-invasive
Stereotactic frame: defines a fixed coordinate system for an

accurate localization and irradiation of the planning target
volume.
also used for patient setup on the treatment machine and for
patient immobilization during the actual treatment procedure
52
LINAC based SRT/SRS
Supplementary collimation either in the form of a set of

collimators to define the small diameter circular radiosurgical
beams or a micro-multileaf collimator (micro-MLC)
Remotely controlled motorized couch or treatment chair
rotation; couch brackets or a floor stand for immobilizing the
stereotactic frame during treatment
Inter-locked readouts for angular and height position of the
couch; and special brakes to immobilize the vertical,
longitudinal, and lateral couch motions during treatment.
LINAC based SRT/SRS
Treatment techniques currently fall into three categories:

multiple non-coplanar converging arcs
dynamic stereotactic radiosurgery
multiple conformal fields
IMRT/VMAT based delivery
Each technique is characterized by a particular set of individual

rotational motions of the linac gantry and the patient support
assembly (couch) from given start to stop angles
53
Treatment technique features
Comparison of four
arc conformal
linac based SRT
techniques applied
to ocular tumors
In all examples the
dose is prescribed to
dyn-arc IMRS
the 80% isodose
Linac based arc therapy
Circular Collimators in several :

(10,13,16,20,24,28,32,36,40,45mm @
isocenter)
Treatment planning time consuming
Typical treatments: 1-3 isocenters with
4 - 7 arcs per isocenter.
54
Linac based arc therapy
Typical isodose
distribution of linac
based SRS of a brain
metastasis .
single isocenter
6 arcs
single dose of
18 Gy is prescribed
to the 80% isodose.
Linac based arc therapy multiple isocenters

For each isocenters 5 arcs are applied,
2 x 10 Gy are prescribed to the 80% isodose beams.
ALTERNATIVE technique: static mMLC shaped fields - single isocenter
CORONAL SAGITTAL
1 12
2
55
VMAT based SRT in clinical practice
LINAC based SRT/SRS
Miniature linac on a robotic arm (Cyberknife): rather new

approach to linac-based radiosurgery, both in target localization
and in beam delivery
image-guided target localization
miniature 6 MV linac, operated

in the X-band at 104 MHz and
mounted on an industrial
robotic manipulator
56
Dynamic arc based SRT
Features of dynamic arc therapy:

Usually steps 5 10
VERY (!!) fast planning
Good conformity with 1-3 arcs
Table and gantry angle optimization
less critical, therefore the experience
of planner is less critical
micro MLC based SRT
mMLC features
weight appr. 31 kg
max. field size 10x10 cm2
interleave leakage &transmission
26 leaf pairs, 3 - 5.5 mm leaf
width @ isocenter
Typical treatments encompass

1 isocenter with 8 - 12 static beams
Treatment planning process is fast (!)
57
Gamma Knife vs. Linac based SRS/SRT
Different philosophies for stereotactic irradiations

Move of linac based SRS/SRT into radiation oncology departments has
also caused some differences of opinions between neurosurgeons
Inventors, principal users versus professionals trained and licensed in
treatment of disease with ionizing radiations
General consensus among radiation oncologists and medical physicists
is that linac-based radiosurgical treatments
with regard to treatment outcomes are equivalent to those provided by
Gamma units
are considerably more complicated but have a much greater potential for
new and exciting developments, for example image guided treatments.
Stereotactic Body Radiotherapy (SBRT)
SBRT is a stereotactic irradiation of lesions outside the cranium (head)

Head & neck lesions are strictly speaking extra-cranial too.
SBRT outside the cranium limited to linac

Compared to cranial SRT, SBRT is compromised in geometric precision
by several facts:
Organs in the body are not
rigidly located as is case in the head
Breathing influences the
position of targets and organs at risk.
To account for these uncertainties.
58
Origin of SBRT Bodyframe
Bodyframe
Laser
Reference system
(fixed scales)
Laser
Arm-rest Laser
Tattoos Laser
Tools needed
for patient immobilization
SBRT immobilization
Underpressure
between foil and
vacuum cushion
for mechanical
stability and
localizer for image
acquisition
59
SBRT treatment planning aspects
Hypo-fractionation with a small number of fractions;

e.g. 7 12 Gy prescribed to the 65% isodose level applied in 3 fr.
Practice: (large) volume variations of patients receiving SBRT

impact on fractionation scheme
SBRT labor intensive .

SBRT immobilization devices can be used in conventional RT for
patient positioning as well
SBRT is largely influenced by new advances in image guided
radiotherapy!
CBCT, stereoscopic fluoroscopy,
SRT - dose prescription and fractionation
Prescribed dose and fractionation depend on the disease

treated as well as on the volume and location of the target
Benign diseases are typically treated with a single session, while
malignant tumors are treated with fractionated regimens
Dose per fraction is larger than that in standard treatment
Complexity of SRT & SBRT
Typical dose/fractionation regimens are: 6x7 Gy (total dose: 42 Gy)

with treatment given every second day, or 10x4 Gy (total dose: 40
Gy) with treatment given daily..
60
SRT - dose prescription and fractionation
SRS (single session treatment): treatment of functional

disorders, vascular malformations, some benign tumors, and
metastatic lesions.
Occasionally used as a boost in conjunction with standard
treatment of malignant intracranial lesions
Prescribed doses: 12 - 25 Gy; the larger the lesion, the lower the
dose.
For stereotactic applications biological doses need to be

considered especially for organs at risk!
SRT Uncertainties in dose delivery
Minimum uncertainty in target localization achievable with

modern imaging equipment - combined with a frame-based
stereotactic technique - is on the order of 1 mm
Possible target motion.
61
Measured uncertainty in radiosurgical dose delivery for a linac in

an excellent mechanical condition is about 0.5 mm, while for
a Gamma unit it is somewhat smaller, i.e. 0.3 mm.
Both the Gamma unit and linac provide very similar overall accuracies in
dose delivery
Achieving and maintaining the optimal accuracy with an linac in
comparison to a Gamma unit requires a much larger effort as well as a
very stringent and disciplined QA program
Radiosurgery with isocentric linacs has a much greater potential
for new developments than does the Gamma unit
E.g. computer-controlled mMLC are commercially available, allowing
single isocenter treatments with rotational IMRT
Multiple isocenters need to be used for irregular target when circular

collimators and arc therapy are the treatment option.
Dose distributions are not especially conformal and an inhomogeneous
dose distribution must be accepted
In comparison with multiple-isocenter treatments, the micro-MLC
treatments are simpler, use a single isocenter, and result in dose
distributions which are more homogeneous inside the target, conform
better to the target shape, and contribute a much lower scatter and
leakage dose to radiation sensitive organs.
62
QA Aspects of S(B)RT
Basic principles involved in commissioning are very similar for all

radiosurgical devices:
Properties of radiation beams must be measured to ensure radiation
safety of the patient and accurate treatment planning.
Special small volume detectors must be used for accurate dosimetric
measurements!
Mechanical integrity of the radiosurgical device must be within
acceptable tolerances to provide reliable and accurate delivery
All steps involved in the therapeutic procedure from target localization,
through planning to dose delivery must be verified experimentally
Reliable and accurate performance of the hardware and software
Dosimetric aspects of S(B)RT

FIGURE : Effect of
detector size on beam
profile measurements
in stereotactic irradiations.
McKarracher et al
63
QA Aspects of S(B)RT
S(B)RT is a very complex treatment technique requiring a close

collaboration among the members of the team members,
Team ideally consists of neuro-surgeon, radiation oncologist,
medical physicist, and radiotherapy technologist
QA protocols for radiosurgery fall into three categories:
1. Basic QA protocols: performance of TPS and dose delivery.
2. Treatment QA protocols: calibration and preparation of
equipment immediately preceding the treatment of a patient.
3. Treatment QA: during the radiosurgical procedure on a patient.
Example of SBRT treatment plan
65 %
Patient with two metastasis using a 65 % 65 %

single isocenter and 7 coplanar
conformal beams.
12 Gy prescribed to 65% isodose
64
Example of SBRT treatment result
30%
SBRT of a lung metastasis and PTV
CTV
follow-up CT scans after 4 50%
weeks and 4 months 90% 65%
4 weeks 4 months after SBRT
Precision Immobilization versus S(B)RT .
PTV : 828 cm
Fractionation:
6 x 5 Gy to 90%
isodose
Pre-irradiation
in 1988: 48 Gy
Myelon
65
Summary
IMRT/IGRT/S(BRT) are advanced treatment

techniques with a strong technology RADIATION
ONCOLOG
component Y
BioART
Refinement of conformal RT
IMRT has initiated the beginning of the end

of the concept of physical conformality
Image guided radiotherapy (IGRT) and
functional imaging have launched the
beginning of a new area of anatomical and
biological conformality
High precision and high-tech RO is teamwork
Some final remarks on advanced RT techniques
Potential for dose escalation must always be weighted against

the higher risks for the patient.
What is the clinical therapeutic benefit?
Steep dose gradients: geometrical precision (immobilization,

equipment performance) is of outmost importance for the
success of IMRT.
Workload (treatment planning including delineation, QA
procedures for 3D verification) is much larger than for 3D
conformal radiotherapy.
Treatment planning based on a computerized optimization
procedure is missing biological information.
66

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Advanced Treatment Techniques Part 1

IMRT/IGRT and S(B)RT

2016 ULG Chapter 12 - Georg 1

In addition to routine RT techniques used in standard

usually available only in larger, regional centers.

2016 ULG Chapter 12 - Georg 2

1. Total Body Irradiation (TBI)

2016 ULG Chapter 12 - Georg 3

Conformal Radiotherapy (CRT)

Basic premise CRT: in comparison with simple dose delivery

2016 ULG Chapter 12 - Georg 4

2016 ULG Chapter 12 - Georg 5

magnetic resonance imaging (MRI)

single photon emission computed tomography (SPECT)

positron-emission computed tomography (PET)

2016 ULG Chapter 12 - Georg 6

Treated Target Target

2016 ULG Chapter 12 - Georg 7

2016 ULG Chapter 12 - Georg 8

IGART requires auto-segmentation . . .

Intensity modulation ( = fluence modulation)

In addition to field shaping in conformal radiotherapy, an MLC may also be

1.5 0.2 1.2 2.2 3.4 3.3

1.5 1.3 2.4 4.4 2.9 3.5 1.5

0.2 0.2 2.5 3.8 4.6 4.7 1.5

2.3 2.3 4.9 4.8

2016 ULG Chapter 12 - Georg 10

Definition: the energy fluence is the quotient dR by dA, where

Unit of energy fluence: J m2.

2016 ULG Chapter 12 - Georg 11

Intensity Modulated RadioTherapy ( I M R T )

From an obscure, highly specialized radiotherapy technique practiced

2016 ULG Chapter 12 - Georg 12

1994 clinical application of segmented field delivery

2016 ULG Chapter 12 - Georg 13

IMRT is not a concept of the 21st century, it was mainly developed

2016 ULG Chapter 12 - Georg 15

IMRT Treatment Delivery

Various approaches to IMRT - ranging from simple standard physical

2016 ULG Chapter 12 - Georg 16

apply conventional divergent beams

2016 ULG Chapter 12 - Georg 17

Rotational therapy & intensity modulation

Dynamic arcs: subarcs with leafs adapting to

2016 ULG Chapter 12 - Georg 18

couch translation via CRANE device

2016 ULG Chapter 12 - Georg 19

Idea formulated late 1980s

2016 ULG Chapter 12 - Georg 20

2016 ULG Chapter 12 - Georg 21

Smaller integral doses and more

Some additional physics and clinical TomoTherapy 6 MV

improvements over conventional

2016 ULG Chapter 12 - Georg 22

BrainLAB Vero System

Imager 2 EPID Imager 1

2016 ULG Chapter 12 - Georg 23

Vero system configuration

Accelerator type Standing wave

2016 ULG Chapter 12 - Georg 24

Treated Target Target

Inversely planned IMRT needs IGRT for safe delivery of steep

2016 ULG Chapter 12 - Georg 25