Purpose: Leaf positions for dynamic multileaf collimator (DMLC) intensity modulated radiation therapy must be closely synchronized with MU delivery. For the Varian C3 series MLC controller, if the planned trajectory (leaf position vs. MU) requires velocities exceeding the capability of the MLC, the leaves fall behind the planned positions, causing the controller to momentarily hold the beam and thereby introduce dosimetric errors. We investigated the merits of a new commercial linear accelerator, TrueBeam™, that integrates MLC control with prospective dose rate modulation. If treatment is delivered at dose rates so high that leaves would fall behind, the controller reduces the dose rate such that harmony between MU and leaf position is preserved.
Methods: For three sets of DMLC leaf trajectories, point doses and two-dimensional dose distributions were measured in phantom using an ionization chamber and film, respectively. The first set, delivered using both a TrueBeam™ and a conventional C3 controller, comprised a single leaf bank closing at planned velocities of 2.4, 7.1, and 14 cm/s. The maximum achievable leaf velocity for both systems was 3 cm/s. The remaining two sets were derived from clinical fluence maps using a commercial treatment planning system for a range of planned dose rates and were delivered using TrueBeam™ set to the maximum dose rate, 600 MU/min. Generating trajectories using a planned dose rate that is lower than the delivery dose rate effectively increased the leaf velocity constraint used by the planning system for trajectory calculation. The second set of leaf trajectories was derived from two fluence maps containing regions of zero fluence obtained from representative beams of two different patient treatment plans. The third set was obtained from all nine fields of a head and neck treatment plan. For the head and neck plan, dose-volume histograms of the spinal cord and target for each planned dose rate were obtained.
Results: For the single closing leaf bank trajectories, the TrueBeam™ control system reduced the dose rate such that the leaf velocity was less than the maximum. Dose deviations relative to the 2.4 cm/s trajectory were less than 3%. For the conventional controller, the leaves repeatedly fell behind the planned positions until the beam hold threshold was reached, resulting in deviations of up to 19% relative to the 2.4 cm/s trajectory. For the two clinical fluence maps, reducing the planned dose rate reduced the dose in the zero fluence regions by 15% and 24% and increased the delivery time by 5 s and 14 s. No significant differences were noted in the high and intermediate dose regions measured using film. The DVHs for the head and neck plan showed a 10% reduction in cord dose for 20 MU/min relative to 600 MU/min sequencing dose rate, which was confirmed by measurement. No difference in target DVHs were observed. The reduction in cord dose increased total treatment time by 1.8 min.
Conclusions: Leaf sequencing algorithms for integrated control systems should be modified to reflect the reduced importance of maximum leaf velocity for accurate dose delivery.