Advanced Techniques - IMRT

ADVANCED TECHNIQUES - IMRT
CONCEPT & PRINCIPLES

PLANNING IN ECLIPSE
VARIAN Lena Wittgren November 2015

ONCOLOGY
SYSTEMS
1 | VARIAN ONCOLOGY SYSTEMS
EC13.6-PPT-04-A
Inverse treatment planning
Basic idea
conventional IMRT
THIS DOCUMENT AND ITS CONTENTS ARE VARIAN’S CONFIDENTIAL AND PROPRIETARY INFORMATION AND ARE DISCLOSED SOLELY FOR THE INFORMATION OF IMMEDIATE RECIPIENT ONLY. DO NOT DISSEMINATE. EC13.6-PPT-04-A
• Intensity Modulated Radiation Therapy – IMRT

• Ability to modulate radiation intensity within one
treatment field
• Concave shaped dose

• Steep gradients
• Low dose bath
• IMRT
• Definition of fixed Beam Angles
• Optimization of fluence distributions
• Treatment planning process

• Clinical goals translated into physical constraints that
are specified mathematically
• Planning system able to change beam parameters
leading to the desired dose distribution
• Voxel Model inside the Optimizer

• Image is converted into a voxel matrix with fixed
resolution
• All structures share the same voxel space
• Dose information is available everywhere
Image
slice
• Each structure’s volumetric

contribution per voxel is
calculated
• Inverse Plan Optimization

• Each field divided into beamlets (2.5 x 2.5 mm)
• Beamlets are grouped to match leaf width
• Target masking
OAR 1
OAR 2
PTV 2 PTV 1
Fluence 0
Fluence 1
Optimization – Objective Function

• Measure of “goodness” of a solution
• Objective function Fobj for a selected set of
fluence matrices (at the end of iteration j) is:
Nt
Fobj ( j )   (d i  p) 2
i 1
• Optimal solution is reached, when the value of

objective function reaches its minimum
• Minimizing objective function is equivalent to
setting its derivative to zero
Fobj ( j )  MIN
Fobj ( j )  0
• Objective function Fobj combines all objectives

into a single function
Fobj  F
allPTVs
PTV   FCritical  FNTO 
allCS
F
Fields
SmoothXY
Intensity Modulated Radiation Therapy - IMRT
Beamlet
• Result of Optimization –
Non-uniform fluence Map
Varian MLC Design
• Carriage (bank)
• Part of MLC which
carries leaves
• Leaf
• Part of MLC used
as final beam
limiting device
Varian MLC Design
• Rounded Leaf Edge & Interlocking Leaf Design

• Interlocking Mechanism
Varian MLC Design
• Tongue and Groove Effect
Varian MLC Design
• Leaf Interdigitation
• Ability of MLC to position two opposing neighbor
leaves next to each other
Carriage A Carriage B
Varian MLC Design
• MLC Transmission
• Amount of radiation transmitted through leaves fully
blocking a beam
• Consist of
• Inter-leaf transmission
• Intra-leaf transmission
Arnfield, Med.Phys. 27 (10), 2000
Varian MLC Design
• Dosimetric Leaf Gap

• Accounts for extra transmission through the rounded
leaf edge
• Modeled as an apparent gap between two closed straight
edge leaves
Varian MLC Design
• Minimum Dose/Arc Dynamic Leaf Gap

• Minimal tip to tip distance which needs to be
maintained for any moving leaf pair during dynamic
mode of MLC
Varian MLC Design
• MLC Leaf Speed

• Speed of the leaf at the level of isocenter.
• Maximum limit for Varian MLC is 3 cm/s.
• Model 2.5 cm/s in LMC.
• Allows for adjustment of any leaf during treatment
Varian MLC Design
• Dose/Arc Dynamic Leaf Tolerance – C-Series

• Maximum allowed difference between the planned and
actual leaf positions
Planned leaf
position
Actual leaf
position
Beam On Beam On
 Dynamic Leaf Tolerance
Varian MLC Design
• Jaw Over Travel

• The maximum distance
the collimator jaw can 10cm Y
extend over the central
axis
2cm x
Varian MLC Design
• Leaf Over-travel
• The maximum distance over the beam CAX to which
an MLC leaf can travel
CAX
Varian MLC Design
• MLC Leaf Span

• Maximum distance from tip of the most retracted leaf to
the tip of the most extended leaf
Large Field IMRT
• Delivery of large
IMRT fields
• Treatment field
divided into
subfields with a
width smaller than
the leaf span
• Beam put on hold
while the carriages
move
Multiple Carriage Delivery
• Used for large

modulated fields
• Carriages cannot
move while the
beam is on
• Treatment field split
into subfields with a
width smaller than
the leaf span
Intensity Modulated Radiation Therapy - IMRT
• Delivery Methods
• Multiple Static Segments
• Dynamic mode of MLC (dMLC)

• Multi-leaf collimator is capable of changing the shape while the
machine is in “beam on” state
Multiple Static Segment (MSS) Delivery
• An IMRT delivery method

in which the modulated
beam is delivered in a
sequence of static MLC
positions
• “Step and Shoot”
• This delivery method is
known also as “Stop and
Shoot”, “Step and Shoot” or
“Segmental MLC”
Sliding Window Delivery
• An IMRT delivery method in which the shape of MLC

is changed during the beam is on
• This delivery method is known also as “Sweeping
gap”, “Moving Window”
Optimal Fluence
• Result of the mathematical optimization

• Independent of the delivery method
Leaf Motion Calculator (LMC)
• Software module that converts the optimal

fluence into Actual Fluence
• Leaf Sequencing File (STT file) deliverable on
treatment unit by MLC device
• Takes into account DMLC characteristics
• Supports Sliding Window and MSS for Varian
• Supports MSS for third party linac
• Calculates MU (internally only)
Actual Fluence
• Derived from the optimal fluence by Leaf Motion

Calculator
• Depends on the delivery technique
• Accounts for physical, mechanical and dosimetric
characteristics of MLC
actual fluence - sliding window actual fluence – step&shoot
Process
Step Fluence
IMRT Planning • Constraints Optimal fluence

• Fluence Optimization
Converter “Sequencer” – LMC Actual fluence

• Leaf Motion-Calculation
• Machine parameters
Dose Calculation Algorithms Calculated fluence

• AAA
• Acuros XB
Pre-Treatment QA
Delivery “Sliding window” Real Fluence
Contouring
• Review and post-process all structures

• Voxels delineated outside intended target volumes
may cause hotspots
• Smooth contours preferred
• High density objects (ex skin-markers from CT)
• Artefacts
• BODY
• Superficial PTV:s
Contouring – artefacts
Contouring
• To better control the dose, additional structures

might be utilized for optimization
• Overlapping structures might need separation
• Simultaneous boost => delta PTV
• Consider margins between structures used for
optimization
• Consider use of “Dummy structures” ex “Optimization
PTV”
Contouring – overlapping structures
Contouring – overlapping structures
• Target coverage is most important

OAR NEW = OAR – Target
• Critical structure sparing is most important

PTV NEW = PTV – OAR
• Always keep original structures
Contouring – simultaneous boost
• When optimizing several target volumes to

different dose levels – create delta-volumes to
avoid ambiguity in dose constraints
Contouring – Organ motion
• Inter and Intra-fraction motion

• Addressed by margins for conventional treatment
• Important for IMRT as there may be interplay between
anatomy and MLC motion
Dose
Planned
Delivered
dose
Contouring – Organ motion
Interplay Between Anatomy and MLC Leaves

Moving target leads to differences between planned
and delivered dose distribution
Dose
Planned dose
Delivered dose
Position
IMRT Field setup
• Manual Setup of Fields / Template
IMRT Field setup
Energy
• Photons, 6 MV (predominantly used)
Dose rate
• Often 400 MU/min (“output vs leaf speed)
Beam directions (Gantry)

• Check BEV for Target and OAR
• Avoid opposing fields
IMRT Field setup
Number of fields
• Often odd number, 5-9 fields
Beam directions (Collimator)

• Check BEV for OAR
Use Jaws (not MLC) for
critical OAR:S
IMRT Field setup
• Consider field size in “leaf moving”-direction (X)

to avoid splitting fields into multiple carriage
groups (~15 cm)
Terminology
• Clinical objectives (Dose limits) are defined by the

Radiation Oncologist:
• Acceptable target coverage
• Acceptable max/mean doses to critical structures/ normal tissue
• Physical constraints entered into optimization are

generally different
• The objectives and priorities is a tool to get an appropriate dose
distribution and DVH
IMRT Optimization
Relative weight in
V (%)
cost function
Initial
condition
Target
D-V constraints in
cost function
Organ at risk
D (Gy)
Acknowledgement A Fogliata Humanitas, Milano
IMRT Optimization in Eclipse
• Check that correct algorithms are selected

• Start IMRT fluence Optimizer
IMRT optimization
User selection in Calculation Model defines which UI is

opened.
Optimization from Objectives
 How do we tell the system what we want?

• Contoured Structures
• Upper objectives
• Max doses to structures,
based upon the volume
• Lower objectives
• Min doses to targets
• Priorities
• Importance
 Objectives control
 Dose distribution
 Fluence
Dose Volume Objectives
• Upper objective
• Maximum allowed dose
• Penalty issued if the delivered dose is higher than an
objective
• Lower objective
• Minimum dose request
• Structure(s) with a lower objective
are considered target structure
• Penalty issued if delivered
dose is lower than objective
• Mean objective
• Used as “upper objective” (OAR)
• Penalty issued if the delivered dose is higher than an
objective
Normal Tissue Objective (NTO)
• Controls dose outside the target

structures
• Used to control hot spots
• Obtain sharp gradient around PTV
• Defined in the form of dose fall-off
as a function of distance from PTV
• Manual
• Automatic – penalty issued for points
having higher dose than average at a
given distance
X Smoothing and Y Smoothing
• Smooth X
• Direction of leaf movement for Varian MLC
• Has higher impact on number of MU
• Smooth Y
• Does not have very high impact on number of MU
• Helps to minimize tongue and groove effect
EC13.6-PPT-04-A
IMRT optimization
IMRT optimization
IMRT optimization
Intermediate Dose Calculation
• Automatic intermediate dose allows Optimizer to perform a 3D dose

calculation when Overall Objective Function becomes static
• IMRT optimization continues when Intermediate Dose is completed
using calculated dose as reference
• Manual Intermediate Dose Calculation is also available
IMRT Post-processing
• Edit fluence
Absorbed Dose calculation
Dose Prescription:
- Dose / fraction
- Amount of fractions
- Total Dose
Define algorithm for dose calculation:

- Photons: AAA, AcurosXB
Rerun LMC after Renormalizing
• Leaf sequence based

on MU
• Rerun after
normalization or
changes to dose
prescription
• Always rerun for non-
Varian treatment
machines

- Photons: AAA
Anisotropic Analytical Algorithm
3D pencil beam convolution / superposition IPS

algorithm using separate Monte Carlo
derived modeling for primary photons,
scattered extra-focal photons and electrons
scattered from the beam limiting devices.
MPS
Increasing tissue heterogeneity modeling and
accuracy of the scattered dose calculation.

- Photons: AcurosXB
Accuracy comparable to Monte Carlo
calculations.
Very efficient for

- Large attenuation areas
- High number of fields and arc calculations.
Calculation based on cross sections. Conversion

of HU-units not just to electron density but to a
specific material.
Assignment of biological material to existing HU

is performed automatically based on CT
calibration and Acuros material library.
Thank you !
EC13.6-PPT-04-A
Disclaimer
Notice
• This information is an educational aid only and is intended solely as a supplemental
document. This provides information concerning the use of the Eclipse Treatment
Planning System. For complete information concerning components, safety
instructions, installation, maintenance, troubleshooting, etc., refer to the applicable
Varian product Operator’s Manual. This information does not replace the Varian
Operator’s Manual.
• Carefully read all instructions prior to use. Observe all contraindications, warnings and
precautions noted in these instructions. Failure to do so may result in patient and/or
user complications.
• This information is subject to change without notice and does not represent a
commitment on the part of Varian. Varian is not liable for errors contained in this
information or for incidental or consequential damages in connection with furnishing or
use of this material. This contains proprietary information protected by copyright. No
part of this may be reproduced, translated, or transmitted without the express written
permission of Varian Medical Systems, Inc.
EC13.6-PPT-04-A

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ADVANCED TECHNIQUES - IMRT

CONCEPT & PRINCIPLES

VARIAN Lena Wittgren November 2015

2 | VARIAN ONCOLOGY SYSTEMS

• Intensity Modulated Radiation Therapy – IMRT

• Concave shaped dose

3 | VARIAN ONCOLOGY SYSTEMS

4 | VARIAN ONCOLOGY SYSTEMS

• Treatment planning process

5 | VARIAN ONCOLOGY SYSTEMS

• Voxel Model inside the Optimizer

• Each structure’s volumetric

6 | VARIAN ONCOLOGY SYSTEMS

• Inverse Plan Optimization

7 | VARIAN ONCOLOGY SYSTEMS

8 | VARIAN ONCOLOGY SYSTEMS

Optimization – Objective Function

9 | VARIAN ONCOLOGY SYSTEMS

• Optimal solution is reached, when the value of

10 | VARIAN ONCOLOGY SYSTEMS

• Objective function Fobj combines all objectives

11 | VARIAN ONCOLOGY SYSTEMS

12 | VARIAN ONCOLOGY SYSTEMS

13 | VARIAN ONCOLOGY SYSTEMS

• Rounded Leaf Edge & Interlocking Leaf Design

14 | VARIAN ONCOLOGY SYSTEMS

• Tongue and Groove Effect

15 | VARIAN ONCOLOGY SYSTEMS

16 | VARIAN ONCOLOGY SYSTEMS

Arnfield, Med.Phys. 27 (10), 2000

17 | VARIAN ONCOLOGY SYSTEMS

• Dosimetric Leaf Gap

18 | VARIAN ONCOLOGY SYSTEMS

• Minimum Dose/Arc Dynamic Leaf Gap

19 | VARIAN ONCOLOGY SYSTEMS

• MLC Leaf Speed

20 | VARIAN ONCOLOGY SYSTEMS

• Dose/Arc Dynamic Leaf Tolerance – C-Series

 Dynamic Leaf Tolerance

21 | VARIAN ONCOLOGY SYSTEMS

• Jaw Over Travel

22 | VARIAN ONCOLOGY SYSTEMS

23 | VARIAN ONCOLOGY SYSTEMS

• MLC Leaf Span

24 | VARIAN ONCOLOGY SYSTEMS

25 | VARIAN ONCOLOGY SYSTEMS

• Used for large

26 | VARIAN ONCOLOGY SYSTEMS

• Multiple Static Segments

• Dynamic mode of MLC (dMLC)

27 | VARIAN ONCOLOGY SYSTEMS

• An IMRT delivery method

28 | VARIAN ONCOLOGY SYSTEMS

• An IMRT delivery method in which the shape of MLC

29 | VARIAN ONCOLOGY SYSTEMS

• Result of the mathematical optimization

30 | VARIAN ONCOLOGY SYSTEMS

• Software module that converts the optimal

• Calculates MU (internally only)

31 | VARIAN ONCOLOGY SYSTEMS

• Derived from the optimal fluence by Leaf Motion

actual fluence - sliding window actual fluence – step&shoot

32 | VARIAN ONCOLOGY SYSTEMS