Treatment planning tools that use biologically related models for plan optimization and/or evaluation are being introduced for clinical use. A variety of dose-response models and quantities along with a series of organ-specific model parameters are included in these tools. However, due to various limitations, such as the limitations of models and available model parameters, the incomplete understanding of dose responses, and the inadequate clinical data, the use of biologically based treatment planning system (BBTPS) represents a paradigm shift and can be potentially dangerous. There will be a steep learning curve for most planners. The purpose of this task group is to address some of these relevant issues before the use of BBTPS becomes widely spread. In this report, the authors (1) discuss strategies, limitations, conditions, and cautions for using biologically based models and parameters in clinical treatment planning; (2) demonstrate the practical use of the three most commonly used commercially available BBTPS and potential dosimetric differences between biologically model based and dose-volume based treatment plan optimization and evaluation; (3) identify the desirable features and future directions in developing BBTPS; and (4) provide general guidelines and methodology for the acceptance testing, commissioning, and routine quality assurance (QA) of BBTPS.

A theoretical investigation of factors limiting the detective quantum efficiency (DQE) of active matrix flat-panel imagers (AMFPIs), and of methods to overcome these limitations, is reported. At the higher exposure levels associated with radiography, the present generation of AMFPIs is capable of exhibiting DQE performance equivalent, or superior, to that of existing film-screen and computed radiography systems. However, at exposure levels commonly encountered in fluoroscopy, AMFPIs exhibit significantly reduced DQE and this problem is accentuated at higher spatial frequencies. The problem applies both to AMFPIs that rely on indirect detection as well as direct detection of the incident radiation. This reduced performance derives from the relatively large magnitude of the square of the total additive noise compared to the system gain for existing AMFPIs. In order to circumvent these restrictions, a variety of strategies to decrease additive noise and enhance system gain are proposed. Additive noise could be reduced through improved preamplifier, pixel and array design, including the incorporation of compensation lines to sample external line noise. System gain could be enhanced through the use of continuous photodiodes, pixel amplifiers, or higher gain x-ray converters such as lead iodide. The feasibility of these and other strategies is discussed and potential improvements to DQE performance are quantified through a theoretical investigation of a variety of hypothetical 200 microm pitch designs. At low exposures, such improvements could greatly increase the magnitude of the low spatial frequency component of the DQE, rendering it practically independent of exposure while simultaneously reducing the falloff in DQE at higher spatial frequencies. Furthermore, such noise reduction and gain enhancement could lead to the development of AMFPIs with high DQE performance which are capable of providing both high resolution radiographic images, at approximately 100 microm pixel resolution, as well as variable resolution fluoroscopic images at 30 fps.

After years of aggressive development, active matrix flat-panel imagers (AMFPIs) have recently become commercially available for radiotherapy imaging. In this paper we report on a comprehensive evaluation of the signal and noise performance of a large-area prototype AMFPI specifically developed for this application. The imager is based on an array of 512 x 512 pixels incorporating amorphous silicon photodiodes and thin-film transistors offering a 26 x 26 cm2 active area at a pixel pitch of 508 microm. This indirect detection array was coupled to various x-ray converters consisting of a commercial phosphor screen (Lanex Fast B, Lanex Regular, or Lanex Fine) and a 1 mm thick copper plate. Performance of the imager in terms of measured sensitivity, modulation transfer function (MTF), noise power spectra (NPS), and detective quantum efficiency (DQE) is reported at beam energies of 6 and 15 MV and at doses of 1 and 2 monitor units (MU). In addition, calculations of system performance (NPS, DQE) based on cascaded-system formalism were reported and compared to empirical results. In these calculations, the Swank factor and spatial energy distributions of secondary electrons within the converter were modeled by means of EGS4 Monte Carlo simulations. Measured MTFs of the system show a weak dependence on screen type (i.e., thickness), which is partially due to the spreading of secondary radiation. Measured DQE was found to be independent of dose for the Fast B screen, implying that the imager is input-quantum-limited at 1 MU, even at an extended source-to-detector distance of 200 cm. The maximum DQE obtained is around 1%--a limit imposed by the low detection efficiency of the converter. For thinner phosphor screens, the DQE is lower due to their lower detection efficiencies. Finally, for the Fast B screen, good agreement between calculated and measured DQE was observed.

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Optimization problems in IMRT inverse planning are inherently multicriterial since they involve multiple planning goals for targets and their neighbouring critical tissue structures. Clinical decisions are generally required, based on tradeoffs among these goals. Since the tradeoffs cannot be quantitatively determined prior to optimization, the decision-making process is usually indirect and iterative, requiring many repetitive optimizations. This situation becomes even more challenging for cases with a large number of planning goals. To address this challenge, a multicriteria optimization strategy called lexicographic ordering (LO) has been implemented and evaluated for IMRT planning. The LO approach is a hierarchical method in which the planning goals are categorized into different priority levels and a sequence of sub-optimization problems is solved in order of priority. This prioritization concept is demonstrated using two clinical cases (a simple prostate case and a relatively complex head and neck case). In addition, a unique feature of LO in a decision support role is discussed. We demonstrate that a comprehensive list of planning goals (e.g., approximately 23 for the head and neck case) can be optimized using only a few priority levels. Tradeoffs between different levels have been successfully prohibited using the LO method, making the large size problem representations simpler and more manageable. Optimization time needed for each level was practical, ranging from approximately 26 s to approximately 217 s. Using prioritization, the LO approach mimics the mental process often used by physicians as they make decisions handling the various conflicting planning goals. This method produces encouraging results for difficult IMRT planning cases in a highly intuitive manner.

The first examination of the use of active matrix flat-panel arrays for dosimetry in radiotherapy is reported. Such arrays are under widespread development for diagnostic and radiotherapy imaging. In the current study, an array consisting of 512 x 512 pixels with a pixel pitch of 508 microm giving an area of 26 x 26 cm2 has been used. Each pixel consists of a light sensitive amorphous silicon (a-Si:H) photodiode coupled to an a-Si:H thin-film transistor. Data was obtained from the array using a dedicated electronics system allowing real-time data acquisition. In order to examine the potential of such arrays as quality assurance devices for radiotherapy beams, field profile data at photon energies of 6 and 15 MV were obtained as a function of field size and thickness of overlying absorbing material (solid water). Two detection configurations using the array were considered: a configuration (similar to the imaging configuration) in which an overlying phosphor screen is used to convert incident radiation to visible light photons which are detected by the photodiodes; and a configuration without the screen where radiation is directly sensed by the photodiodes. Compared to relative dosimetry data obtained with an ion chamber, data taken using the former configuration exhibited significant differences whereas data obtained using the latter configuration was generally found to be in close agreement. Basic signal properties, which are pertinent to dosimetry, have been investigated through measurements of individual pixel response for fluoroscopic and radiographic array operation. For signal levels acquired within the first 25% of pixel charge capacity, the degree of linear response with dose was found to be better than 99%. The independence of signal on dose rate was demonstrated by means of stability of pixel response over the range of dose rates allowed by the radiation source (80-400 MU/min). Finally, excellent long-term stability in pixel response, extending over a 2 month period, was observed.

The present work uses experimental measurements in a realistic clinical environment to show potential benefits of DECT for proton therapy treatment planning. Our results show clear improvements over SECT in tissue-equivalent plastic materials and animal tissues. Further work towards using Monte Carlo simulations for treatment planning with DECT data and a more detailed investigation of the uncertainties on I-value and limitations on the Bragg additivity rule could potentially further enhance the benefits of this imaging technology for proton therapy.

The results of an empirical and theoretical investigation of the performance of a high-resolution, active matrix flat-panel imager performed under mammographic conditions are reported. The imager is based upon a prototype, indirect detection active matrix array incorporating a discrete photodiode in each pixel and a pixel-to-pixel pitch of 97 microm. The investigation involved three imager configurations corresponding to the use of three different x-ray converters with the array. The converters were a conventional Gd2O2S-based mammographic phosphor screen (Min-R) and two structured CsI:Tl scintillators: one optimized for high spatial resolution (FOS-HR) and the other for high light output (FOS-HL). Detective quantum efficiency for mammographic exposures ranging from approximately 2 to approximately 40 mR at 26 kVp were determined for each imager configuration through measurements of x-ray sensitivity, modulation transfer function (MTF), and noise power spectrum (NPS). All configurations were found to provide significant presampling MTF at frequencies beyond the Nyquist frequency of the array, approximately 5.2 mm(-1) , consistent with the high spatial resolution of the converters. In addition, the effect of additive electronic noise on the NPS was found to be significantly larger for the configuration with lower system gain (FOS-HR) than for the configurations with higher gain (Min-R, FOS-HL). The maximum DQE values obtained with the CsI:Tl scintillators were considerably greater than those obtained with the Min-R screen due to the significantly lower Swank noise of the scintillators. Moreover, DQE performance was found to degrade with decreasing exposure, although this exposure-dependence was considerably reduced for the higher gain configurations. Theoretical calculations based on the cascaded systems model were found to be in generally good agreement with these empirically determined NPS and DQE values. In this study, we provide an example of how cascaded systems modeling can be used to identify factors limiting system performance and to examine trade-offs between factors toward the goal of maximizing performance.