Acta Oncologica

ISSN: 0284-186X (Print) 1651-226X (Online) Journal homepage: http://www.tandfonline.com/loi/ionc20

Aspects on the Optimal Photon Beam Energy for

Radiation Therapy

Svante Söderström, Anders Eklöf, Anders Brahme

To cite this article: Svante Söderström, Anders Eklöf, Anders Brahme (1999) Aspects on the
Optimal Photon Beam Energy for Radiation Therapy, Acta Oncologica, 38:2, 179-187, DOI:
10.1080/028418699431591

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Published online: 08 Jul 2009.

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 ORIGINAL ARTICLE

Aspects on the Optimal Photon Beam Energy for

Radiation Therapy
Svante Söderström, Anders Eklöf and Anders Brahme
From the Department of Medical Radiation Physics, Karolinska Institutet and Stockholm University

Correspondence to: Dr Svante Söderström, Department of Medical Radiation Physics, Karolinska Institutet
and Stockholm University, P.O. Box 260, S-171 76 Stockholm, Sweden. Tel: +46 8 51 70 00 00.
Fax: +46 8 34 35 25. E-mail: svante@radfys.ks.se

Acta Oncologica Vol. 38, No. 2, pp. 179–187, 1999

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The selection of optimal photon beam energy is investigated both for realistic clinical bremsstrahlung beams and for monoenergetic
photon beams. The photon energies covered in this investigation range from 60Co to bremsstrahlung and monoenergetic beams with
maximum energies up to 50 MeV. One head and neck tumor and an advanced cervix tumor are investigated and the influence of beam
direction is considered. It is shown that the use of optimized intensity modulated photon beams significantly reduces the need of beam
energy selection. The most suitable single accelerator potential will generally be in the range 6 – 15 MV for both superficially located and
deep-seated targets, provided intensity-modulated dose delivery is employed. It is also shown that a narrow penumbra region of a photon
beam ideally should contain low-energy photons ( 54 MV), whereas the gross tumor volume, particularly when deep-seated targets are
concerned, should be irradiated by high-energy photons. The regions where low photon energies are most beneficial are where organs at
risk are laterally close to the target volume. The situation is completely changed when uniform or wedged beams are used. The selection
of optimal beam energy then becomes a very important task in line with the experience from traditional treatment techniques. However,
even with a large number of uniform beam portals, the treatment outcome is substantially lower than with a few optimized
intensity-modulated beams.
Recei6ed 24 April 1998
Accepted 1 October 1998

During the past 30 years, optimization of external beam
radiation therapy has been focused mainly on different
methods to improve the dose delivery by using multiple
uniform or wedge-shaped beams. The goal of the opti-
mization process has often been to deliver a dose to the
target volume as close as possible to the prescribed one
or, to achieve as small a deviation as possible from the
dose constraints for the tumor and the organs at risk.
For this purpose a large number of techniques and al-
gorithms have been developed that optimize the beam
weights and/or the wedge angle with respect to a number
of dose constraints or an objective function (1–3). More
recently, arbitrary fluence profile optimizations have been
studied by several authors (4–8). Another recent develop-
ment can be seen in stationary and dynamic multi-leaf
collimation (9–13) where the goal is to deliver truly 3-D
conformal irradiation by modulation of the photon
fluence and/or electron fluence profiles. Dose optimiza-
tion with scanned photon and electron beams is a poten-
tially flexible and practical technique (12, 14).
Furthermore, different methods for fan beam intensity
modulation during arc therapy have recently been pro-
posed by Mackie and co-workers (15).
The selection and optimization of the photon beam
energy for external beam radiation therapy have been
somewhat neglected during this period. However, during
recent years some attention has been devoted to the inter-
esting and important subject of finding the ideal energy for
radiation therapy (16 – 18). Most of these investigations
used the fairly unimportant integral dose concept, or in
modern terminology the mean energy imparted, as a
quantifier of the merits of treatment plans.
In our study we use a more clinically relevant endpoint,
namely the probability to control the tumor growth with-
out inducing severe damage in irradiated normal tissues.
This probability was calculated based on clinically estab-
lished dose-response relations for tumors and normal tis-
sues (19 – 21). Today the beam energy is generally selected
using more or less standardized protocols for each tumor
site. Sometimes the standard energy selection is modified
on a trial and error basis to increase the dose level and
uniformity in the target volume or to reduce the dose to
organs at risk. This can be useful when uniform or wedged
beams are used but the role of beam energy in intensity-
modulated dose delivery has not yet been carefully investi-
gated. In light of the new developments in the field of

© Scandinavian University Press 1999. ISSN 0284-186X Acta Oncologica

 180 S. Söderström et al. Acta Oncologica 38 (1999)

external beam radiation therapy optimization and consid-
ering the new possibilities to modulate the incoming beam
profiles, the best selection of beam energy and energy
distribution should also be carefully investigated.
One of the on-going developments of radiation therapy
equipment to better treat deep-seated tumors is that to-
wards higher photon beam energies. The highest accelera-
tor energy available today, the Racetrack microtron,
covers the whole range from 2 MeV up to 50 MV (22). A
higher photon beam energy reduces the dose to shallow
organs but increases the exit dose and moves the maxi-
mum dose deep into the patient (almost 7 cm at 50 MV)
due to the increasing energy of the secondary electrons. At
the same time a reduced difference in energy deposition in
bone and soft tissue is seen at medium energies (4–25 MV)
due to the domination of the Compton process. At higher
energies the pair production process slowly raises the
energy deposition again. The value of using high-energy
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side of Fig. 1. In this case the normal tissue stroma and the
spinal cord are the principal organs at risk. The gross
tumor and the local lymphatic spread are regarded as
separate biological structures and are associated with dif-
ferent biological responses (20). The gross tumor volume is
assumed to consist of normal tissue infiltrated to 50% by
clonogenic tumor cells and the region of presumed
lymphatic spread is assumed to contain a uniform clono-
genic tumor cell burden of 10%. When uniform, as well as
intensity-modulated, photon beams are used, this target is
treated with a three-field technique using one frontal field
and two oblique lateral fields.
An advanced cervix cancer including locally involved
lymph nodes was taken as an example of a deep-seated
tumor. The geometry of the cervix target is shown on the
left-hand side of Fig. 1. In this case the organs at risk are
the bladder, the rectum, the hip joints, the small bowel,
and the surrounding normal tissue stroma. The gross

therapeutic photon beams has been questioned on rather

subjective and economic grounds by Das & Kase (18) and
on the risks associated with neutron production in high-
energy electron accelerators (23, 24) but also on the risk of
patient activation (25). However, no severe risk or negative
effect for the patient, associated with the use of high-en-
ergy x-ray beams should really be expected. Today it is
well established that the peak neutron production per unit
photon dose occurs at around 20–25 MV (26). Particularly
when scanned photon beams are used, and consequently
no flattening filter is needed, the neutron production per
unit photon dose in the patient is quite low at the highest
photon energies (27). The present study was carried out
using a recently developed radiobiological model (19, 21)
and a generalized pencil beam optimization algorithm (12,
28). The objective function used during the optimization
procedure was the probability of achieving tumor control
without causing severe complications in normal tissues,
P + . The P-values obtained also served as a figure of merit
when comparing optimized dose plans and dose distribu-
tional parameters such as the mean dose and its variance
in the target volume and organs at risk.
Radiotherapy optimization with a small number of
beam portals is very sensitively dependent on the angle of
incidence, at least when the treatment outcome is
quantified in terms of complication-free control (29, 30).
For this reason we also consider the problem of finding the
optimal beam entry directions as a function of photon
beam energy.

MATERIAL AND METHODS

Treatment geometries
A head and neck target including the locally involved
lymph nodes of a larynx cancer in addition to the gross
tumor was used as the first test configuration. The geome-
try of the head and neck target is shown on the right-hand
Fig. 1. The cervix target geometry (left-hand side) and the head
and neck target geometry (right-hand side). Bony structures are
shown in light grey, the presumed spread in middle grey, and the
gross tumor in dark grey. From top to bottom, for each of the
target geometries, an AP-view, a lateral view, and three transver-
sal slices through the target volume.
 Acta Oncologica 38 (1999) Optimal photon beam energy 181

Table 1 ergetic bremsstrahlung pencil beam kernels. Polyenergetic

The radiobiological data set used in the calculations. The normal- pencil beams are calculated as the sum of the different
ized gradient of the dose response relation, g, the 50% response monoenergetic pencil beam kernels according to the
dose, D50, and the relati6e seriality, s approximation
Organ type g D50 [Gy] s
p(CE, r) : %pEi (r)
& CEi
Ei + 1
dE= %pEi (r)
Ci
[2]
i Ei C i C
Head and neck geometry
Normal tissue stroma 2.76 65.0 1.00 where CE is the energy fluence differential in energy and
Spinal cord 1.78 60.0 1.00 Ci is the energy fluence covered by energy bin i.
Lymph nodes 3.00 32.0 –
Tumor 3.00 52.0 –
The final energy deposition kernels are stored in a
Cartesian matrix of the size 64 ×64× 64 voxels. Each
Cervix geometry
voxel in the matrix has a side length corresponding to 5
Small bowel 2.00 60.0 1.00
Bladder 3.00 80.0 0.30 mm, i.e. a total volume of 32 × 32×32 cm3. Examples of
Rectum 2.50 75.0 0.70 the radial profile of bremsstrahlung and monoenergetic
Lymph nodes 3.00 55.0 – pencil beam kernels have previously been published by
Tumor 4.00 80.0 – Eklöf et al. (32). It is seen that at low energies the central
electron part of the kernel is very narrow with a large
tumor and the involved local lymph nodes are regarded as background of scattered photons, whereas at high energies
separate biological structures. The gross tumor is assumed
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the situation is reversed, with a wider electron contribution

to be infiltrated to 50% by clonogenic tumor cells and the
local nodes are assumed to have a 10% clonogenic tumor
cell infiltration. Independently of beam energy and level of
beam modulation, this target volume is also irradiated by
a three-field technique with one anterior beam and two
oblique lateral beams separated by 120° to distribute all
three beams equidistantly around the patient.
The radiobiological parameters are presented in Table 1
for both of the target geometries used in this study. The
data set is based on published data and reasonable esti-
mates where no solid patient data were available (20). The
target geometries are both defined in a 32 × 32× 12 cm3
volume sampled in square voxels of a 0.5 cm side length.
Photon pencil beam kernels
Both monoenergetic and polyenergetic, 3D photon pencil
beam kernels based on realistic bremsstrahlung spectra
have been used in the present study. The monoenergetic
kernels have energies ranging from 0.5 MeV up to 50
MeV. Polyenergetic kernels are calculated for accelerator
potentials between 5 MV and 50 MV. Also included is a
kernel for 60Co g-ray beams.
All monoenergetic photon pencil beam kernels, pE i(r),
have been calculated from point energy deposition kernels
by the convolution method using
and low background due to photon scatter. Because the
dominating central electron part of the kernels is very
similar independent of energy, it is sufficient with the
present fairly course sampling, since most of the energy
dependence influences the shape at large radius.
Based on the pencil beam kernels, standard beam char-
acteristics for the used photon beams have been calculated
from the central axis depth dose for a 10 × 10 cm2 field at
a 100 cm SSD. To simplify quantification, a fairly general
analytical expression for the description of the broad beam
depth dose curve has been used (34), as given by:
D(z) = Dc (e − mp z − 6e − me z) [3]
In this approximation the longitudinal energy deposition
kernel is reduced to a sum of a Dirac d-function and an
exponential function describing the energy deposition by
secondary electrons and scattered photons as specified by 6
and me. It is straight forward to show that this corresponds
to a direct convolution of the photon energy fluence or
more exactly the TERMA proportional to e − mp z with an
electron and scattered photon kernel according to (35).
r
D(z) =Dc e − m0z œ ((1− 6)d(z)+ 6(me − m0)e − me z
m̄
+(m0 − mp )e − mp z) [4]

&
pEi (r)= hEi (r, z− z%)mEie − mEi z% dz%
where the vector r =(r, z) and hEi (r, z−z%) is a monoen-
ergetic Monte Carlo calculated point energy deposition
kernel with the energy Ei (31) and mEie − mEi z%is the depth
dependence of the TERMA of a monoenergetic and
monodirectional photon beam of energy Ei (32). The
bremsstrahlung spectra for different accelerator potentials
have previously been calculated by semi-empirical methods
(33). These spectra have been used to generate polyen-
[1]
A summary of the photon beam characteristics for the
presently used photon pencil beams is given in Table 2. It
is clear from previously published data (32) and Table 2
that the build-up properties and the electron and photon
scatter are the main properties influencing the properties of
the photon beams.
Optimization algorithm
The principal problem of forward radiation therapy plan-
ning can be formulated in the form of an integral equation
that expresses the resultant dose distribution in the patient
 182 S. Söderström et al. Acta Oncologica 38 (1999)

for given incoming radiation beam fluence profiles. The

unknown quantity to be determined in the optimization of
the treatment is the incident energy fluence profiles that
maximize the probability P + to cure the patient without
inducing normal tissue damage. Gustafsson et al. (12, 28)
have developed an iterative algorithm suitable for opti-
mization of the incident fluences.
With a suitable biological objective functional, the opti-
mization can automatically be directed at the best compro-
mise between the probability that the tumor is totally
eradicated and that there are severe complications in the
normal tissues. One such biological objective function is
the probability of achieving tumor control without causing
severe complications, P + . It would also be possible to
maximize the probability of cure under given constraints
on the probability of inducing severe normal tissue dam- Fig. 2. The probability of achieving complication-free tumor con-
age. The use of the probability of complication-free tumor trol, P + , for treatment of cervical cancer with three uniform
control, as an objective function and especially as a rea- photon beams (lower curves) and optimized intensity-modulated
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photon beams (upper curves) as a function of energy. The acceler-

sonable figure of merit when comparing different treat-
ation potential (lower scale and solid lines) and the monoenergetic
ment plans, is also justified by the close relationship found photon beam energy (upper scale and dashed lines) is indicated
between the probability of achieving complication-free tu- for comparison. The accelerator potential can be approximated by
mor control and the relative standard deviation of the dose a monoenergetic beam with the photon energy equal to one-third
distribution in the target volume (36). This biological of the accelerator potential (E/MeV: (U/3)/MV).
objective function has been extensively described in several
publications (20, 37) and will therefore not be discussed in iteratively maximizing the biological objective function
further detail here. The presently used optimization al- P + (28).
gorithm is based on a steepest descent scheme capable of
RESULTS AND DISCUSSION
Table 2
Deep-seated tumors
Characteristics of plane parallel photon beams. The effecti6e atten-
uation coefficient, mp, the ratio of the absorbed dose at 20 and 10 When treating deep-seated pelvic tumors, such as the
cm depth, D20 /D10, the absorption coefficient for the secondary cervix tumor used here as a test case, it might be expected
electrons, me, the fitting parameter, 6, and the depth of the dose that the extended build-up region at high photon energies
maximum, R100 would result in a better treatment outcome than lower
photon energies. This can be seen in Fig. 2, where the
mp (m−1) D20/D10 me (cm−1) 6 R100 (cm)
variation of P + value with uniform monoenergetic pho-
Bremsstrahlung beams ton beams increases steadily with increasing photon en-
60
Co 6.83 0.51 2.40 – – ergy. In Table 3 the corresponding PB and PI are
5 MV 5.84 0.56 1.85 0.86 1.84 presented. This increase is primarily explained by the
6 MV 5.62 0.57 1.68 0.87 2.01
increased depth of the build-up region in high-energy
10 MV 4.99 0.61 1.27 0.89 2.56
15 MV 4.71 0.62 1.03 0.91 3.04 photon beams (lower me values) and thus a better possibil-
20 MV 4.53 0.64 0.90 0.92 3.40 ity to deliver high doses to the tumor without causing
25 MV 4.42 0.64 0.82 0.94 3.68 injury to shallow normal tissues. However, when the pho-
35 MV 4.29 0.65 0.74 0.95 4.01 ton energy reaches approximately 3 MeV or 10 MV a
50 MV 4.16 0.66 0.68 0.96 4.31
gradual saturation sets in, with a small increase in the
Monoenergetic beams P + level at higher energies. To be precise a small decrease
0.5 MeV 8.91 0.41 2.76 0.89 1.24
in the P + level may be observed beyond 30 MeV for
1 MeV 7.07 0.49 2.49 0.87 1.41
2 MeV 5.52 0.57 1.97 0.80 1.75 monoenergetic beams, whereas in uniform bremsstrahlung
5 MeV 4.31 0.65 0.96 0.83 3.18 beams P + increases steadily all the way up to 50 MV and
10 MeV 4.04 0.68 0.49 0.87 5.24 beyond. The small decrease in the P + level at the highest
15 MeV 4.30 0.70 0.32 0.90 6.87 monoenergetic photon beam energies is due to the larger
20 MeV 4.94 0.72 0.22 0.93 8.33
lateral electron range and thus the larger electron penum-
25 MeV 6.54 0.74 0.14 0.97 9.79
30 MeV 8.93 0.82 0.09 1.00 11.15 bra width. For very large tumor masses, the optimal
40 MeV 7.76 0.95 0.08 1.00 12.69 energy will go on increasing since, owing to scattered
50 MeV 6.80 1.06 0.07 1.00 14.49 photons, the dose outside the field edge decreases with
 Acta Oncologica 38 (1999) Optimal photon beam energy 183

energy as does the importance of the penumbra width (the

circumference to volume ratio decreases with tumor ra-
dius, cf. section headed Target 6olume dependence, to
follow).
With optimized, intensity-modulated dose delivery a sig-
nificantly higher P + level is obtained at all energy levels.
This is in line with the findings of previous investigations
(30, 38). It is also interesting to note that the variation in
the P + level with energy is much smaller, and almost
negligible, for all beam energies except the very lowest. A
slightly lower P + level is also seen for clinical photon
beams throughout the energy range studied. This may be
expected since the clinical bremsstrahlung beams have
generally a larger electron and scattered photon penumbra Fig. 3. Optimized energy fluence spectra for each portal of the
compared to the monoenergetic photon beams, with corre- cervix target, 0° beam portal (solid line), 120° (dotted line) and
240° (dashed line). Two energy fluence spectra from clinical beams
sponding attenuation properties. This is due to the pres-
are also shown for comparison. A 50 MV beam from a 1 mm
ence of higher secondary electron energies generated by the tungsten target (solid histogram) and 50 MV beam from a 3 mm
high-energy part of the bremsstrahlung spectrum, which Be-target (dashed histogram) are included for comparison.
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extends to about three times the monoenergetic energy,

and to more low-energy scattered photons both contribut- field. Owing to the extremely slow asymptotic convergence
ing to the lateral tails of the pencil beam. The cross-over at of this type of optimization, no significant improvement in
4 MeV ( :12 MV) for uniform beams is explained by the P + can be observed compared to the optimizations with
increased dose build-up at higher energies, since this effect 50 MV spectra. However, a clear trend can be observed in
is more important for uniform beams and large target the resulting energy spectra. As can be seen in Fig. 3, the
volumes. resultant optimal energy spectra for all three beams essen-
For the deep-seated cervix target, an optimization of the tially consists of two parts, one low-energy part with a
entire energy fluence spectrum has also been attempted. maximum at 2 MeV and one high-energy part with a
Different spectra are allowed for each of the three con- maximum fluence above 25 MeV. This shape of the opti-
stituent beams but with the same spectra throughout each mal energy fluence spectrum can be explained by the need
to sharpen the dose fall-off in the penumbra region at the
Table 3 same time as the dose build-up extends as deeply as
The probabilities of tumor control, PB, and normal tissue injury, PI, possible. The increase in the dose gradient at the borders
for the results in Figs. 2 and 4 of the tumor will enable a higher dose in the target volume
while the dose causing normal tissue injury remains con-
Cervix Head & Neck stant or even reduced. One way to increase the high energy
content of the spectrum is to use a thin low Z target
PB nodes PI rectum PB nodes PI cord
yielding a spectrum such as that obtained by a 3 mm Be
Uniform beams target shown in Fig. 3 (39). This type of target will yield a
60
Co 0.92 0.09 0.78 0.10 spectrum that more closely resembles the optimal spectra
5 MV 0.92 0.09 0.77 0.13 than the spectrum generated by a thick target. It is thus
6 MV 0.92 0.09 0.75 0.11
also of some importance to optimize or select a suitable
10 MV 0.92 0.06 0.73 0.13
15 MV 0.93 0.07 0.67 0.12 bremsstrahlung target for different treatment geometries.
20 MV 0.93 0.07 0.59 0.09
25 MV 0.93 0.07 0.50 0.05 Shallow tumors
35 MV 0.93 0.07 n.a. n.a.
50 MV 0.93 0.07 n.a. n.a. For the head and neck tumor in Fig. 4, it is obvious that
low photon energies are most advantageous (see also Table
Intensity modulated beams
60
Co 0.95 0.003 0.98 B0.001
3). This is especially the case when the treatment is per-
5 MV 0.96 0.004 0.98 B0.001 formed with strictly uniform dose delivery. Non-uniform
6 MV 0.96 0.004 0.98 B0.001 dose delivery improves the expected treatment outcome
10 MV 0.96 0.004 0.98 B0.001 significantly, just as was the case for the deep-seated cervix
15 MV 0.96 0.004 0.98 B0.001 target. However, both monoenergetic and clinical
20 MV 0.96 0.005 0.98 B0.001
25 MV 0.96 0.005 0.98 B0.001
bremsstrahlung beams give a clear reduction of the
35 MV 0.96 0.005 0.98 B0.001 P + level with increasing beam energy. In fact, the next to
50 MV 0.96 0.003 0.98 B0.001 lowest beam energy tested, namely 1.0 MeV, was the most
 184 S. Söderström et al.
favorable one with optimal intensity modulated dose deliv-
ery. The P + level for monoenergetic beams drops dramat-
ically for energies above 10 MeV. This is not the case for
the clinical bremsstrahlung beams because of the large
amount of low-energy photons present in such beams and
the associated more superficial dose maximum (reverse
situation compared with Fig. 2).
Optimization of the energy fluence spectra demonstrates
the need for very low photon beam energies for the
treatment of superficial tumors. The optimum energy
fluence spectra for the two oblique lateral beams are shown
in Fig. 5. During the optimization procedure the energy
fluence spectrum of the third anterior beam was reduced to
a single beam energy, the lowest energy available (0.5 MeV).
The optimal spectrum of the 110° lateral beam closely
resembles the spectrum obtained at an acceleration poten-
tial of 20 MV and a 1 mm tungsten target, as shown in Fig.
5. The optimal spectrum of the 250° lateral beam displays
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a slightly higher maximum energy and would therefore
correspond approximately to a spectrum obtained at an
acceleration potential of 30 MV. None of the optimal
spectra contains higher energy contributions as a result of
the deep build-up depth of such beams. Owing to the slow
asymptotic convergence of this type of optimization, no
significant improvement in P + can be observed compared
to the optimizations with 50 MV and 20 MV spectra.
Optimal beam entry directions
The angular dependence of P + for different beam energies
was investigated by the calculation of P + for one beam
direction at a time. This calculation will thus only serve as
a comparison of the angular dependence between different
beam energies. It will not give information suitable for
selection of optimal beam entry directions for multiple
Fig. 4. The probability of achieving complication-free tumor con-
trol, P + , for treatment of a larynx cancer with uniform photon
beams (lower curves) and intensity modulated photon beams
(upper curves) as a function of energy (cf. Fig. 2).
Acta Oncologica 38 (1999)
Fig. 5. Optimized energy fluence spectra for each portal of the
head and neck target, 90° (solid line) and 270° (dotted line). Two
energy fluence spectra from clinical beams are also shown for
comparison. A 20 MV beam from a 1 mm tungsten target (solid
histogram) and a 50 MV beam from a 3 mm Be-target (dashed
histogram) are also included. The optimal anterior field is in this
case 0.5 MeV monochromatic (not shown).
beam treatments (40). It will, however, reveal interesting
properties of the treatment geometry from a radiobiological
perspective. For the cervix target there are only small
variations in the angular dependence of P + when varying
the beam energy for deep-seated targets (see Fig. 6a). For
the cervix tumor, there is an almost monotonic increase in
P + with energy independent of angle of incidence. This
indicates that, to a first approximation, the variation in the
optimal beam entry directions with varying beam energy is
small for deep-seated tumors in large patients.
For shallow target volumes, the optimal angle of inci-
dence varies considerably with energy, as seen in Fig. 6b.
For the lower energies ( B10 MV) frontal beams appear to
be more favorable, with high P + values for directions
between 270° and 90°. At these low energies the dose
maximum is so superficially located that the build-up region
will not reach the target volume, even with frontal beams.
Posterior directions will, for the same reason, result in a too
high dose at shallow depths in normal tissue, causing the
observed decrease in P + . For higher energies ( \10 MV)
two distinct directions, 120° and 240°, are the most promis-
ing. The frontal directions cannot be used with these
energies since the build-up region would enter the target
volume. Not even with the highest energies will the poste-
rior directions become favorable.
Target 6olume dependence
A third target geometry was used to investigate the depen-
dence of optimal photon beam energy on the size of the
target volume. This treatment geometry could be thought
of as a simplified pelvic tumor consisting of a cubical target
volume of side length d at the center of a cubical patient of
thickness 25 cm. The radiobiological parameters
 Acta Oncologica 38 (1999)
selected for this target geometry were taken from the
cervix case. The normal tissue stroma data is used for the
normal tissues and the cervix tumor data is used for the
target volume. The amount of clonogenic cell infiltration
inside the target volume is assumed to be 50%. This target
volume was irradiated with two parallel-opposed fields of
normal incidence on the target volume.
As can be seen in Fig. 7, the optimal photon beam
energy for small deep-seated target volumes is as low as 3
MeV. The optimal energy increases as the volume of the
target increases to values above 40 MeV for target volumes
larger than 5× 5× 5 cm3. The explanation for the low
optimal energy for small deep-seated targets is that the
ratio of the target circumference area to the target volume
is inversely proportional to the mean cord length, C( , of the
target volume (A/V=4/C( ) and thus decreases with tumor
area to the target volume. Really small target volumes thus
have a larger amount of tumor-normal tissue interface
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relative to the target volume and are thus in need of
photon beams with a narrower penumbra. This is particu-
larly true for targets treated with conformal therapy but it
is also to some extent valid for few field treatment tech-
Fig. 6. The one-dimensional phase space of complication-free
1
tumor control, P + (V), for five different photon beam energies:
60
Co, 6 MV, 10 MV, 25 MV and 50 MV. (a) The phase space for
the cervix target geometry. (b) The phase space for the head and
neck target geometry.
Optimal photon beam energy 185
Fig. 7. The optimal monoenergetic photon beam energy and the
obtained probability of complication-free tumor control, P + , as a
function of the side length, d, of a cubical target located at the
center of a 25 × 25 ×25 cm3 volume of tissue irradiated with two
parallel-opposed fields. Owing to the larger volume of normal
tissue involved with larger targets, the optimal energy rapidly
increases beyond 2 – 2.5 cm sized tumors.
niques. When a small number of fields are used, only a
small portion of the circumference of a spherical target is
irradiated tangentially, where a narrow penumbra is re-
quired. If the target, on the other hand, is more cube-like,
as much as four-sixths of the circumference may be irradi-
ated by one single field. The importance of a narrow
penumbra is thus exaggerated by the present somewhat
unclinical cubical target volume. In a more realistic clinical
situation a larger number of beam portals would reason-
ably be required to obtain a narrow penumbra at the
complete tumor – normal tissue interface. However, as the
number of beams increases, the need for a deep dose
maximum is relaxed and the relative importance of a
sharper penumbra increases if further improvements in the
dose distribution are required. This is a well-known princi-
ple utilized in, for instance, stereotactic radiosurgery with
the Gamma Knife® by Elekta.
A narrow penumbra enables a high dose delivery to the
target volume without causing severe injury to the sur-
rounding normal tissues. In addition, the treatment of
small tumors produces less normal tissue damage because
of the small beam portals and normal tissue volumes
irradiated. As the volume of the target increases, the ratio
of tumor to the normal tissue interface volume decreases
and the need to deliver large doses to bulky tumors
increases. To be able to deliver high doses to large vol-
umes, the dose maximum of the photon beam should
preferably be reached inside the target volume. Since only
one photon beam energy level is allowed during the
present optimization process, the probability of achieving
complication-free tumor control will decrease with increas-
ing target volume. The main reason for this is the increas-
ing risk of normal tissue damage and thus an inability to
 186 S. Söderström et al.
reach a high enough dose in the target volume with a
single parallel-opposed pair of photon beams. However, if
two beam energies were allowed from each direction, a
high photon beam energy (]50 MV) could be selected to
deliver the bulk dose and a significantly lower energy
could be selected to make the total dose uniform, particu-
larly in the more superficial parts of the target volume. At
the same time the sharpened penumbra at the target – nor-
mal tissue interface would be more advantageous.
CONCLUSIONS
Independent of beam energy, a substantial improvement in
the treatment outcome has been demonstrated when using
intensity-modulated dose delivery. It has also been shown
that the traditional standpoint, that higher photon energies
are required to improve the treatment outcome for deep-
seated target volumes, is true primarily for large targets
with classical uniform dose delivery. If optimal intensity-
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modulated photon beams of a single fixed energy spectrum
are used, accelerator potentials higher than 25 MV are not
generally required for treatment optimization. The mar-
ginally decreasing probability of achieving a complication-
free cure above that energy is due to the larger lateral
spread of the intrinsic electron penumbra of the photon
pencil beams. However, high photon energies are more
desirable in the central part of deep-seated target volumes
to improve the sparing of superficial tissues. Therefore, in
a strict optimization the beam should contain a central
high-energy component with a low-energy component at
the periphery in order to sharpen the penumbra.
When also considering the method of intensity-modu-
lated dose delivery using scanned photon beams, it may be
desirable to use a very high photon energy with a thin
target so that the bremsstrahlung lobe becomes as narrow
as possible (38). This interesting option for future dose
delivery optimization has been left largely untested in this
study.
Single-field techniques may require completely different
beam energy selections due to the absence of cooperating
beams in the target volume. In the periphery of deep-
seated targets, lower photon energies are preferred in order
to gain the steepest possible lateral dose fall-off to spare
normal tissues close to the target volume. For superficial
targets, very low photon energies are the most advanta-
geous, if intensity modulation is not available, suggesting
that electron beams, possibly combined with photon
beams, might be preferred in many configurations. How-
ever, the need to combine electron and photon beams
could be avoided if the optimization and delivery of inten-
sity modulated beams are at hand.
ACKNOWLEDGEMENTS
The guidance given by Anders Gustafsson in the handling of the
generalized pencil beam algorithm is gratefully acknowledged.
Acta Oncologica 38 (1999)
REFERENCES
1. Hope CS, Laurie J, Orr JS. The optimization of treatment
plans. Computer calculation of dose distributions in radio-
therapy. In: Cohen M, Stovall M, Welsh CN, eds. Technical
reports series. Vienna, Austria: IAEA, 1966: 118 – 28.
2. Cooper REM. A gradient method of optimizing external-
beam radiotherapy treatment plans. Radiology 1978; 128:
235 – 43.
3. Redpath AT, Vickery B, Wright DH. A new technique for
radiation therapy planning using quadratic programming.
Phys Med Biol 1976; 21: 781 – 91.
4. Webb S. Optimisation of conformal radiotherapy dose distri-
butions by simulated annealing. Phys Med Biol 1989; 34:
1349 – 70.
5. Bortfeld T, Burkelbach J, Boesecke R, Schlegel W. Methods
of image reconstruction from projections applied to confor-
mation radiotherapy. Phys Med Biol 1990; 35: 1423 – 34.
6. Lind BK. Properties of an algorithm for solving the inverse
problem in radiation therapy. Inv Prob 1990; 6: 415 – 26.
7. Rosen II, Lane RG, Morrill SM, Belli JA. Treatment plan
optimization using linear programming. Med Phys 1991; 18:
141 – 52.
8. Niemierko A. A random search algorithm (RONSC) for
optimization of radiation therapy with both physical and
biological end points and constraints. Int J Radiat Oncol Biol
Phys 1992; 23: 89 – 98.
9. Källman P, Lind BK, Eklöf A, Brahme A. Shaping of arbi-
trary dose distributions by dynamic multileaf collimation.
Phys Med Biol 1988; 33: 1291 – 300.
10. Convery DJ, Rosenbloom ME. The generation of intensity-
modulated fields for conformal radiotherapy by dynamic col-
limation. Phys Med Biol 1992; 37: 1359 – 74.
11. Bortfeld T, Kahler DL, Waldron TJ, Boyer AL. X-ray field
compensation with multileaf collimators. Int J Radiat Oncol
Biol Phys 1994; 28: 723 – 30.
12. Gustafsson A, Lind BK, Svensson R, Brahme A. Simulta-
neous optimization of dynamic multileaf collimation and
scanning patterns or compensation filters using a general
pencil beam algorithm. Med Phys 1995; 22: 1141 – 56.
13. Svensson R, Källman P, Brahme A. An analytical solution
for the dynamic control of multileaf collimators. Phys Med
Biol 1994; 39: 37 – 61.
14. Lind BK, Brahme A. Optimization of radiation therapy dose
distributions with scanned photon beams. Proc of the 9th
ICCR, The Use of Computers in Radiation Therapy. 1987;
235 – 9.
15. Mackie TR, Holmes TW, Swerdloff S, et al. Tomotherapy: A
new concept for the delivery of conformal radiotherapy. Med
Phys 1993; 20: 1709 – 19.
16. Hanks GE, Diamond JJ, Kramer S. The need for complex
technology in radiation oncology, correlations of facility char-
acteristics and structure with outcome. Cancer 1985; 55:
2198 – 201.
17. Laughlin JS, Mohan R, Kutcher GJ. Choice of optimum
megavoltage for accelerators for photon beam treatment. Int
J Radiat Oncol Biol Phys 1986; 12: 1551 – 7.
18. Das IJ, Kase KR. Higher energy: is it necessary, is it worth
the cost for radiation oncology? Med Phys 1992; 19: 917 –25.
19. Ågren-Cronqvist A-K, Källman P, Brahme A. Determination
of the relative seriality of a tissue from its response to
non-uniform dose delivery. In: Baier K, Baltas D, eds. Mod-
elling in clinical radiobiology. Freiburg, Germany: Albert-
Lundwigs-University, 1997: 127 – 41.
20. Ågren A-K, Brahme A, Turesson I. Optimization of uncom-
plicated control for head and neck tumors. Int J Radiat Oncol
Biol Phys 1990; 19: 1077 – 85.
 Acta Oncologica 38 (1999)
21. Källman P, Lind BK, Brahme A. An algorithm for maximiz-
ing the probability of complication free tumor control in
radiation therapy. Phys Med Biol 1992; 37: 871–90.
22. Brahme A. Design principles and clinical possibilities with a
new generation of radiation therapy equipment. Acta Oncol
1987; 26: 403 – 12.
23. Swanson WP. Estimate of the risk in radiation therapy due to
unwanted neutrons. Med Phys 1980; 7: 141–4.
24. Nath R, Epp ER, Laughlin JS, Swanson WP, Bond VP.
Neutrons from high-energy x-ray medical accelerators: An
estimate of risk to the radiotherapy patient. Med Phys 1984;
11: 231 – 41.
25. Dunscombe PB, McLellan J, Huda W, Gillies J. Patient
activation with a 25 M therapeutic x-ray beam. Br J Radiol
1988; 61: 843 – 6.
26. Followill D, Geis P, Boyer A. Estimates of whole-body dose
equivalent produced by beam intensity modulated conformal
therapy. Int J Radiat Oncol Biol Phys 1997; 38: 667– 72.
27. Gudowska I, Brahme A. Neutron radiation from high-energy
x-ray medical accelerators. Nukleonika 1996; 41: 105– 18.
28. Gustafsson A, Lind BK, Brahme A. A generalized pencil
beam algorithm for optimization of radiation therapy. Med
Downloaded by [47.29.227.33] at 00:50 28 November 2017
Phys 1994; 21: 343–56.
29. Söderström S, Brahme A. Selection of suitable beam orienta-
tions in radiation therapy using entropy and Fourier trans-
form measures. Phys Med Biol 1992; 37: 911–24.
30. Söderström S, Brahme A. Which is the most suitable number
of beam portals in coplanar radiation therapy? Int J Radiat
Oncol Biol Phys 1995; 32: 151–9.
Optimal photon beam energy 187
31. Ahnesjö A, Andreo P, Brahme A. Calculation and application
of point spread functions for treatment planning with high
energy photon beams. Acta Oncol 1987; 26: 49 – 56.
32. Eklöf A, Ahnesjö A, Brahme A. Photon beam energy deposi-
tion kernels for inverse radiotherapy planning. Acta Oncol
1990; 29: 447 – 54.
33. Andreo P, Brahme A. Stopping power data for high-energy
photon beams. Phys Med Biol 1986; 31: 839 – 58.
34. Brahme A, Svensson H. Radiation beam characteristics of a
22 MeV microtron. Acta Radiol Oncol 1979; 18: 244 – 72.
35. Sorcini BB, Hyödynmaa S, Brahme A. Quantification of
mean energy and photon contamination for accurate dosime-
try of high-energy electron beams. Phys Med Biol 1997; 42:
1849 – 74.
36. Brahme A. Optimisation of radiation therapy for cancer
patients. Forum 1994; 4: 569 – 84.
37. Källman P, Ågren A, Brahme A. Tumor and normal tissue
response to fractionated non-uniform dose delivery. Int J
Radiat Biol 1992; 62: 249 – 62.
38. Söderström S, Gustafsson A, Brahme A. Few field radiation
therapy optimization in the phase space of complication free
tumor control. Int J Imag Syst Technol 1995; 6: 91 – 103.
39. Svensson R, Brahme A. Effective source size, yield and beam
profile from multi-layered bremsstrahlung targets. Phys Med
Biol 1996; 41: 1353 – 79.
40. Söderström S, Brahme A. Optimization of the dose delivery in
a few field techniques using radiobiological objective func-
tions. Med Phys 1993; 20: 1201 – 10.