Combination of beams. Chapter 12 Treatment Planning Combination of Beams. Opposing pairs of beams. Opposing pairs of beams. Opposing pairs of beams

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1 Chapter 12 Treatment Planning Cmbinatin f Beams Radiatin Dsimetry I Text: H.E Jhns and J.R. Cunningham, The physics f radilgy, 4 th ed. Cmbinatin f beams Achieve high dse cnfrmity t the target Spare healthy surrunding tissues Several general appraches: and their cmbinatin Angled fields and wedge pairs Rtatin therapy Isdse lines in (a) and (b) are nrmalized differently Unequal dse t the ppsing fields The simplest cmbinatin f tw fields is achieved by directing them alng the same axis frm ppsite sides The variatin in dse alng the axis f ppsing pair f beams depends n the field separatin and beam energy It can be made very small, yielding an almst unifrm dsage frm ne beam entrance t the ther Single beam An arrangement ften used fr treatment f a tumr situated apprximately midway between tw parallel surfaces High energy beams must be used t avid the dip in the middle Fr small separatins (<10 cm) lw MV energy beams are well suited: extended regin f unifrm dse with relatively flat plateau between the maxima Fr larger separatins (>15cm) high energy beam are required t avid ht spts in the regins f bth maxima Many anatmical sites can adequately be treated with parallel-ppsed beams (lung, brain, head and neck lesins) 1

2 A unifrm bx cverage is achieved in planes perpendicular t the axis f ppsing fields In practice the isdse distributin is altered by curved surfaces and has t be prperly adjusted (blcks, etc.) Cmbinatin f ppsing pairs Cmbinatin f ppsing pairs Allws fr higher dse in the beam intersectin regin Fur-field bx (tw ppsing pairs at 90 angle) used mst ften fr treatment f pelvis with centrally lcated lesins (prstate, bladder, uterus) Three-field bx (tw wedged ppsing beams and 3 rd beam at 90 ) fr lesins clser t the surface (rectum) 4-field 3-field Using setup at different angles, equal r unequal width, and beam intensities, can achieve cnfrmity t the tumr shape/depth Split fields Single beam Oppsing pair Angled fields and wedge pairs P Can be used t prtect sensitive critical structures in the middle f the field Often used fr irradiatin f a small tumr thrugh the same skin surface Althugh the fields are directed twards the pint P, the high dse regin ccurs much nearer the surface, therefre the beams shuld be aimed cnsiderably belw P ("past pinting") 2

3 Angled fields and wedge pairs Parameters f the wedge beams: θ is wedge angle, Φ is hinge angle, and S is separatin Isdse curves fr each wedge field are parallel t the bisectr An ptimum relatinship between the wedge angle θ and the hinge angle Φ that prvides the mst unifrm distributin f radiatin dse in the plateau: 90 / 2 Three field technique Prvides better dse hmgeneity within the tumr Hmgeneity can be further imprved with tissue cmpensatrs Example 1 Which ne f the fllwing plans has the wedges in the crrect rientatin? Example 2 The wedge angle that wuld give the mst hmgeneus distributin in the "wedged pair" in the diagram belw is degrees. (Field axes are at 90 ). A. 10 B. 20 C. 30 D. 45 E / Example 3 Which f the fllwing isdse patterns is cnsistent with the field cnfiguratins and wedges shwn? Rtatin therapy Prvides maximum dse unifrmity within the tumr and the mst f healthy tissue sparing: a) patient in a rtating chair; b) surce is mved arund a statinary patient; c) surce mves in a circular path and simultaneusly transverse hrizntally t cver the surface f a cylinder; d) x-ray head mves abut a spiral with the beam always directed t ne pint belw the surface; e) patient lies n a cuch that rtates abut a vertical axis; f) beam is ffset frm the axis f rtatin t cver an annular ring abut the center f rtatin (chest wall irradiatin) 3

4 Rtatin therapy: isdse distributins Rtatin therapy: effect f energy Calculatins are generally based n the superpsitin f single beam isdse charts, with isdes lines nrmalized t 100% at the axis f rtatin The ttal dse at a pint in a patient is btained by adding tgether the cntributins frm a series f fixed fields spaced at equal angular intervals Penetratin depth and skin sparing gvern the chice f the beam energy Rtatin therapy: effect f arc length Rtatin therapy: effect f field size field width field length As the degree f rtatin becmes less than 360, the isdse curves are defrmed in such a way that the side ppsite the beam entrance surface becme flatter with the decrease in the arc angle When the arc angle is 180 r less, the isdse curves tend t be pinched in at the sides and the lwer prtin again mves further frm the axis The length f the field has a little effect, while the width has a prfund effect n the isdse distributin Rtatinal therapy is nt recmmended if wide fields must be used, due t high dse delivered utside f the target Cmparisn f fixed field and rtatin therapy Figure f merit A treatment plan shuld deliver a high and unifrm dse ver a target vlume, but minimum dse t all utside structures Figure f merit: Energy imparted tthetarget vlume f Ttalenergy imparted tpatient In rtatin therapy the skin dse is less than with fixed field therapy (~15 vs. 40%) because rtatin therapy is equivalent t using 8 t 12 fields The isdse curves fr rtatin therapy are smther arund the tumr regin; with fixed fields "hrns" between adjacent fields are present Hwever, with fixed fields sme areas can be cmpletely spared f = 0.14 f =

5 Example 4 Example 5 A patient is planned fr equally weighted, parallelppsed 6 MV phtn fields treating the mediastinum, AP thickness 22 cm. If the beam energy is changed t 18 MV phtns, all f the fllwing wuld decrease except: A. MU B. Skin dse C. Depth f maximum tissue dse D. Percent variatin in dse acrss the treated vlume In a 3-field plan t treat the rectum using pen PA and wedged lateral fields, a hmgeneus distributin can be btained in the PTV with either 45 r 60 wedges. With 60 wedges, the relative dse at the iscenter fr the PA field wuld be that in the 45 wedged plan. A. Greater than B. Less than C. The same as Lateral wedges cmpensate fr depth-dse fall-ff f the PA field. The greater is the cntributin frm PA field, the larger is the wedge angle required 5

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