Radiotherapy

Glioblastoma multiforme (GBM) is an aggressive and highly resistant brain tumour, necessitating advanced treatment approaches to improve patient outcomes. This thesis provides a comprehensive review of recent advancements in GBM treatment, including innovations in treatment planning, radiation therapy, and their impacts on patient survival. The study also involves a detailed analysis of five GBM patients, examining critical dosimetric and radiobiological parameters, including Dose Volume Histogram, CT and MRI Images, T1, T2, T3 and T4 images. These parameters are analyzed using key radiobiological models, such as the linear-quadratic model, and factors like α/β, dose per fraction, and survival fractions. Through this data analysis, the study aims to evaluate the effectiveness of the treatment protocols and their impact on tumour control probability (TCP) and normal tissue complication probability (NTCP). The results will contribute to the understanding of GBM radiotherapy outcomes and provide insights for optimizing future treatment strategies.

An algorithm to determine IMRT optimization parameters within the Elekta Monaco® treatment planning system that increases dose homogeneity and dose conformity in the planning target volume was developed. This algorithm determines IMRT optimization parameters by calculating the difference between two pairs of dose points along the target volume’s dose volume histogram: Dmax – Dmin, and D2 – D98. The algorithm was tested on the Elekta Monaco® Treatment Planning System at GenesisCare of Coconut Creek, Florida using CT data from 10 anonymized patients with non-small cell lung cancer of various tumor sizes and locations. Nine iterations of parameters were tested on each patient. Once the ideal parameters were found, the results were evaluated using the ICRU report 83 homogeneity index as well as the Paddick conformity index. As an outcome of this research, it is recommended that at least three iterations of IMRT optimization parameters should be calculated to find the ideal parameters.

The Monaco treatment planning system offers three different dose calculation algorithms for use in calculating 3D treatment plans. These include Monte Carlo (MC), Collapsed Cone (CC) and the pencil beam algorithms. The aim of this study is an in-depth analysis of Monte Carlo and Collapsed Cone dose calculation methods to find the optimal parameters for clinical use for both algorithms.
An end-to-end phantom with inhomogeneities was scanned and the DICOM images were imported into Monaco for contouring and planning. Treatment plans were then created in Monaco for both MC and CC using different permutations of variables for approximately 400 plans. These variables include CT Slice thickness, grid size, statistical uncertainty, and beam energy. Following planning the end-to-end phantom was then irradiated on an Elekta Linac and plans for each beam energy were created. Clinical beam data was then compared to the computed plans for each dose calculation method.

In proton therapy systems with pencil-beam scanning, output of Halo effect is not necessarily included in Treatment Planning System (TPS). Halo effect (low-intensity tail) can significantly affect a patient’s dose distribution. The output of this dose depends on the field size being irradiated. Although much research has been made to investigate such relation to the field size, the number of reports on dose calculations including the halo effect is small. In this work we have investigated the Halo effect, including field size factor, target depth factor, and air gaps with a range shifter for a Varian ProBeam.
Dose calculations created on the Eclipse Treatment Planning System (vs15.6 TPS) are compared with plane-parallel ionization chambers (PTW Octavius 1500) measurements using PCS and AcurosPT MC model in different isocenters: 5cm, 10cm, and 20cm. We find that in AcurosPT algorithm deviations range between -7.53% (for 2cm field in 25cm air gap with range shifter) up to +7.40% (for 20cm field in 15cm air gap with range shifter). Whereas, in PCS algorithm the deviations are -2.07% (for 20x20cm field in open conditions) to -6.29% (for 20x20cm field in 25cm air gap with range shifter).

Skin collimation in electron therapy ensures sharper penumbra and maximal protection to adjacent critical structures. It also provides a better clinical dose to the target and avoids recurrences at the periphery. The thickness of the electron skin collimation must be adequate for shielding purposes, not too thick to cause discomfort to the patient and be conformal to the skin. This study assessed the clinical potential of machined brass skin collimation with variable thickness. Brass transmission factors for 6, 9, and 12 MeV electron beams were measured and used to determine the skin collimation clinically acceptable thickness. Dosimetric performance of the variable thickness skin collimation was evaluated for 9 MeV electrons within a rectilinear water-equivalent phantom and a water-filled head phantom. Results showed the variable thickness skin collimation is dosimetrically equivalent to the uniform thickness collimation. Favorable dosimetric advantages for brass skin collimation for small electron fields were achieved.

Physical cones equipped on GammaKnife, Cyberknife, and C-arm linacs have been the standard practice in Stereotactic Ablative Radiotherapy (SART) for small intracranial lesions, such as treating trigeminal or glossopharyngeal neuralgia targets. The advancement of high-definition multi-leaf collimators (HDMLC), treatment planning systems, and small field dosimetry now allows for treatment without the need for an auxiliary mounted physical cone. This treatment type uses the “virtual cone”, a permanent high-definition MLC, arrangement to deliver “very small fields” with comparable spherical dose distributions to physical cones. The virtual cone therapy, on a Varian Edge™ linac using multiple non-coplanar arcs with static HDMLCs, is a comparable technique that can be used to treat small intracranial neuralgia or other small lesions.
In this investigation, two flattening filter free (FFF) photon beams, 6MV FFF and 10MV FFF, were tested for optimal delivery and safety conditions for treating intracranial lesions. The virtual cone method on a Varian Edge™ Linear accelerator using rapid arc stereotactic radiosurgery was used to treat cranial neuralgia for chronic pain for six patients. Absolute dose, relative dose measurements, and monitor units were the main characteristics that were examined to decide which energy was the best for treatment. Source-to-axis distances (SAD) of 100cm measurements were taken at depths of 10cm and 5cm, respectively.

The Thesis explores additional applications of LAP's Aquarius external laser alignment verification Phantom by examining geometric accuracy of magnetic resonance images commonly used for planning intracranial stereotactic radiation surgery (ICSRS) cases. The scans were performed with MRI protocols used for ICSRS, and head and neck diagnosis, and their images fused to computerized tomographic (CT) images. The geometric distortions (GDs) were measured against the CT in all axial, sagittal, and coronal directions at different levels. Using the Aquarius Phantom, one is able to detect GD in ICSRS planning MRI acquisitions, and align the external LAP patient alignment lasers, by following the LAP QA protocol. GDs up to about 2 mm are observed at the distal regions of the longitudinal axis in the SRS treatment planning MR images. Based on the results, one may recommend the use of the Aquarius Phantom to determine if margins should be included for SRS treatment planning.

A simple method to verify the total treatment time generated by the treatment planning system (TPS) when the CONTURA MLB or the SAVI applicator are used for APBI treatments has been developed. The method compares the time generated by the TPS to a predicted time, calculated by inserting parameters obtained from the TPS in equations generated in this Thesis. The equations were generated by linearly fitting data from clinical cases that had been treated using the Contura MLB or the SAVI applicator at the Lynn Cancer Institute of the Boca Raton Regional Hospital. The parameters used were the PTV coverage, Air Kerma Strength, Balloon Volume (Contura data fit) and Evaluation PTV (SAVI data fit). As an outcome of this research, it is recommended that the plan should be reevaluated when the percent difference between the generated and the predicted times exceeds 5% for the Contura MLB, or 10% for the SAVI.