Veronica Laird

Treatment planning
4/25/17
Class solutions as related to IMRT treatments
With advancement in technology, there is now a variety of ways to deliver radiation to
patients. The process by which external beams of radiation are designed and used to selectively
and exclusively irradiate tumor bearing sites is called three dimensional conformal radiation
therapy (3D CRT).1 With conventional 3D CRT, the beam intensity is nearly uniform for each
treatment field. An advanced form of 3D CRT is intensity modulated radiation therapy (IMRT).
IMRT allows a more conformal dose to the tumor volume by changing the beam intensity of
each of the fields through a computer controlled delivery system. The goal with IMRT is to
produce a homogeneous radiation beam throughout the patient. This allows for the same dose
throughout a defined volume.
Because patients are composed of different tissue densities and thicknesses, there must be
compensation of the beam to adjust for these inhomogeneities. The use of multileaf collimation
(MLC) allows for the beam shaping for the IMRT fields.1 The MLC is used for field shaping
without the need for custom made cast blocks.2 The MLC consists of a series of motorized
tungsten leaves which move under computer control. Depending on the treatment machine
manufacturer, the MLC can replace one set of jaws or can be used as a tertiary field shaping
device. Tertiary MLC means that the field is blocked by the primary collimator, movable second
jaws, and MLC. The issue with tertiary MLC is it reduces the available clearance between the
head of the machine and the isocenter. Varian utilizes tertiary MLC, Elekta uses the MLC to
replace the upper jaw, and Siemens MLC replaces the lower jaws.
A type of IMRT technique that is used is segmental MLC IMRT (SMLC).3 This method is
also called step-and-shoot or stop-and-shoot IMRT. The patient is treated by multiple fields
and each fields is divided into segments. A segment refers to the shape of the MLC during part of
the total dose delivered.2 An example of segments is shown in figure 1 below. In this example,
there are 6 segments where the MLC change for this particular beam. After each segment the
radiation will turn off and then the MLC will move into the next position and the radiation beam
will turn back on for the calculated monitor units (MU) for that segment.
Figure 1. This shows the different MLC segments that are used to make an IMRT plan.

Advantages of step-and-shoot technique is the ease of implementation from engineering and

safety points of view.3 A disadvantage is the inability for some accelerators to reset the leaves
when the beam is off and then back on within a fraction of a second. This method can also be
more time consuming than other IMRT methods.
Another technique that can be used with certain linear accelerators is the use of a
dynamic step-and-shoot technique.3 With this method, the radiation is on even when the leaves
are moving from one static position to the next. The advantage with this method is it blurring the
incremental steps in the delivery of static subfields, which can decrease overall treatment time.
Another technique that is used is utilizing a dynamic MLC delivery. This technique is
also known as the sliding window technique.3 The leaves sweep simultaneously and uni-
directionally, with different velocity as a function of time. The accelerator beam is on while the
leaves are moving. This allows for delivery of variable intensity to different points in the field.
The MLCs are motor driven and can move at a speed greater than 2 cm/sec. The computer
accurately monitors the leaf positions. There is a concern when linear accelerators do not offer
jaw tracking technique (JTT). JTT traces the MLC aperture with jaws to minimize leakage and
transmission of the MLC leaves, which helps to reduce organ at risk doses adjacent to the target.
MLC transmission through the jaw and MLC are smaller than 0.1%.4 Dynamic MLC delivery
also improves dose fall-off towards the critical structures. Please click on the link below to see
dynamic MLC delivery in action.

Sliding Window technique video

The next type of IMRT treatment is Intensity-Modulated Arc-Therapy (IMAT). This

technique is similar to step and shoot technique in that each field is subdivided into subfields of
uniform intensity.3 The difference is that the MLC dynamically shape each subfield while the
gantry is rotating and the beam is on the whole time. There are multiple overlapping arcs with
the leaves moving to new positions at a regular angular interval. Each arc delivers one subfield
of each gantry angle, and the dose rate remains constant. It typically takes three to five arcs. This
method has not been widely utilized because it does not offer much improvement over other
forms of IMRT. Because of the insufficiencies in IMAT, in the late 2000s, Varian and Elekta both
introduced variable dose rate rotational delivery options.3 This technique is known as volumetric-
modulated arc therapy (VMAT). With VMAT the gantry moves continuously, with the MLC
leaves and dose rate varying throughout. Varians system is called RapidArc. VMAT is referred
to any arc therapy that uses dose rate variations. The biggest advantage to VMAT is its delivery
efficiency. Please view the video below to see an example of a VMAT treatment.

Example of a VMAT treatment

Lastly, some facilities use a Tomotherapy machines for treatment. Tomotherapy is an

IMRT technique where the patient is treated slice by slice in a manner analogous to CT imaging.3
These treatment machines use a MIMiC collimator device that consists of a long transverse slit
aperture with two banks of 20 leaves each. A problem with MIMiC- based iMRT is the
possibility of mismatch between adjacent slice pairs to treat a long target volume. There is also
helical Tomotherapy. The linac head and gantry rotate while the patient goes through the scanner.
This form of Tomotherapy minimizes the interslice match lines because of the continuous helical
motion around the longitudinal axis. Below is a video that shows how helical Tomotherapy
works

Example of Helical Tomotherapy treatment

There are many IMRT techniques that are available in radiation therapy. Availability of
the technology and knowing when to use different techniques is critical in the treatment planning
process. IMRT helps to maximize dose to the tumor volume and minimize dose to the critical
structures. As a dosimetrist, it is vital to know these techniques and be able to properly utilize
them.
References:
1. Washington charles M, Leaver DT. Principles and practice of radiation therapy. St.
Louis, MO: Mosby; 2010.
2. McDermott PN, Orton CG. The physics & technology of radiation therapy. Madison:
Medical Physics Publishing; 2010.
3. Khan FM, Gibbons JP. Khan's the physics of radiation therapy. Philadelphia: Wolters
Kluwer Health; 2014.
4. Feng Z, Wu H, Zhang Y, Zhang Y, Cheng J, Su X. Dosimetric comparison between jaw
tracking and static jaw techniques in intensity-modulated radiotherapy. Radiation
Oncology. 2015;10(1):28. https://doi:10.1186/s13014-015-0329-4.