RADIATION

THERAPY
P C S 4 0 7 RY E R S O N U N I V E R S I T Y, W I N T E R 2 0 2 1
D R . J A M E S G R Ä F E , P H D, M C C P M
WEEK 9 PART 3

• IMRT/VMAT
SPECIAL TECHNIQUES

 Intensity Modulated Radiation Therapy (IMRT)

 Volumetric Modulated Arc Therapy (VMAT)

Other topics:
 Patient Specific Quality Assurance
INTENSITY MODULATED RADIATION THERAPY (IMRT)
 CAN I HANDLE IT?

3 D conformal RT IMRT
Prostate: Prostate:
- 6 gantry angles - 7 gantry angles
- 1 penumbra margin - 9 apertures
- 30 leaves

6 parameters 1890 parameters

No, you
can not!
Slide adapted from Dr. Janos Juhasz
 Radiation Oncology20149:44
DOI: 10.1186/1748-717X-9-44
© Sveistrup et al.; licensee BioMed
Central Ltd. 2014
WHAT IS IMRT?

Beamlet
Smallest element to be Beamlet
modified Field Width

IMRT

Field Length
Ability to deliver many
beamlets of varying
radiation intensity within
one treatment field
THE INVERSE TREATMENT PLANNING
PROCESS

What do you need?

 Patient data set: CT images and structure sets
 Structure set: contours of tumor and critical
(OAR) volumes and any other optimization
volumes
 Inverse planning algorithm
 Objectives and Constraints
OPTIMIZER: INVERSE PLANNING
ALGORITHM
 Patient Selection
↓
Simulation
↓
Target and Tissue Delineation
↓
Treatment Planning/Optimization
↓
Plan Evaluation
↓
Quality Assurance
↓
Treatment Delivery
↓
Follow up

Is it any different than the standard

treatment process?
 Patient Selection
↓
Simulation (immobilization)
↓
Target and Tissue Delineation (contours)
↓
The Treatment Planning/Optimization
Physics (Inverse Planning/Objectives)
↓
Plan Evaluation
↓
Quality Assurance (Day 0)
↓
Technical Treatment Delivery (image guidance)
aspects ↓
Follow up

Is it any different than the standard

treatment process?
 SIMULATION
Patient immobilization is disease site specific
Masks
Chest board
Vacuum cushions
Breath Hold/Gating
Others…
TREATMENT PLANNING: DOSE
COMPUTATION
• Number of beams and
placement of beams
• Specify dose
• Objectives …Press
and GO
• Standard beam arrangements usually used
• Usually 5-9 fields sufficient
• Some planning systems capable of Beam Angle
Optimization prior to Fluence map optimization

4 5 6
3 4 5

3 7 2 6

1 7
2 8

1 9
STEP AND SHOOT IMRT

https://www.youtube.com/watch?v=5CzXYnDsAEs
VARIAN IMRT (SLIDING WINDOW)

• https://www.youtube.com/watch?v=eZS6DVGBx0k
VOLUMETRIC MODULATED ARC
THERAPY (VMAT)
 Dose is delivered in a ARC (can be 360° or shorter down to
minimum length)
 Increase conformity by having a high number of beam
directions, rotational approach to IMRT
 Vary leaf speed and position
 Vary Gantry speed
 Vary dose rate
www.varian.com
VMAT

• https://www.youtube.com/watch?v=GYqNcuXN-hQ
Localization on the treatment unit

Using treatment beams: Cone-beam

MV imaging CT
kV imaging
PATIENT SPECIFIC QA
DOSE DELIVERY VERIFICATION TOOLS
 2D diode array (MapCHECK, Sun Nuclear Corp.)
 Electronic portal imaging deviced (EPID)
 Gafchromic EBT3 films (Ashland Advanced
Materials)
ion chamber measurements
TOOLS: THE ADVANTAGES AND THE
DISADVANTAGES
ION CHAMBERS
Ion Chambers:
oMost accurate-A
oSubject to volume averaging, must be used in low gradient regions-
D
oPoint measurement-D
FILM
Film:
oHigh resolution (72-150 dpi -> 0.35-0.17 mm)-A
o2D dose plane verification-A
oDifficult to acquire accurate, reproducible, results-D
oScanner artifacts and film uniformity need to be taken into
account-D
oEBT3-Poor low dose accuracy-D
 ELECTRONIC PORTAL IMAGING
DEVICE
EPID:
oExcellent resolution (0.39
mm (aSi 1000), 0.78 mm aSi
500)-A
oEasy and Fast results-A
oCalculation of prediction
dose to EPID is difficult-D
o2D dose plane verification-A
DIODE ARRAYS
2D diode array:
o poor resolution (7 mm,
10x10, 14 mm outside)-D
o Easy to use and well
known behavior-A
o 2D dose plane
verification-A
RADIOCHROMIC FILM
EBT3 FILM
• Self-developing, water resistant, low sensitivity to
light. Polyester, 100 μm
Active layer, 30 μm
• Symmetric coatings Polyester, 100 μm

• Near tissue equivalence (for keV region??), Active

layer Zeff = 6.84, ρ = 1.2 g/cm3.
• Can be used with multi-channel dosimetry (Red
color channel is typically used).
CALIBRATION
N0 = initial Pixel Value (pre-irradiation), N = final pixel value (post-irradiation).

50 cGy 100 cGy 200 cGy 400 cGy 800 cGy

Post-

Pre-
RADIOCHROMIC FILM
Advantages: Disadvantages:

• Self developing • Energy dependent (keV region)*

• Water resistant • Time dependent

• Near tissue equivalent* • Resource intensive: Scanner

corrections required, calibration
• High resolution
curves (batch dependent)
• Instant results
• Less sensitive than radiographic
film (not good for out of field
measurements)
VMAT QA
ArcCHECK

https://www.sunnuclear.com/documents/datashee
ts/arccheck3dvh.pdf
VMAT QA

https://www.sunnuclear.com/documents/datashee
ts/arccheck3dvh.pdf
REFERENCES AND FURTHER
READINGS
 Khan Faiz M. and Gibbons John P. The Physics of Radiation Therapy. (Lippincott Williams
& Wilkins, 2014)
 P Mayles, A Nahum, J.C Rosenwald. Handbook of Radiotherapy Physics: Theory and
Practice. ISBN 9780750308601 - CAT# IP345. Taylor and Francis Group, LLC, 2007.
 S Webb, Intensity Modulated Radiation Therapy, 2001, CRC Press.