Calculation algorithms in radiation

therapy treatment planning systems

Colleen DesRosiers, Ph.D.

AAMD Region III annual meeting, Indianapolis, Indiana
April 12, 2013
Learning Objectives
1. The learner will be able to describe the different
types of algorithms used in treatment planning
systems
2. The learner will be able to identify strengths
and weakness of algorithms used in treatment
planning systems
3. The learner will be able to identify reasons for
disagreement between monitor unit calculations
generated by treatment planning systems and
by monitor unit check programs.

Image from: http://oeaeuprrp.blogspot.com/2011/09/workshop-how-to-write-and-assess.html

http://toons.beck-cartoons.info/?section=tooned
I am not the expert …

1. Khan, FM Gerbi, BJ Treatment Planning in Radiation Oncology, 3rd

edition, 2012
2. Khan, The Physics of Radiation Therapy, 4th edition, 2010
3. Murlidhar, KR, Murthy, NP, Raju, AK, Sresty, NVNM. Comparative study
of convolution, superposition, and fast superposition algorithms in
conventional radiotherapy, three-dimensional conformal radiotherapy,
and intensity modulated radiotherapy techniques for various sites, done
on CMS XIO planning system J Med Phys [serial online] 2009
[cited 2013 Apr 1];34:12-22.
4. Ahnesjö , Anders, Basic modeling concepts in treatment planning dose
dose calculations, fluence, raytracing, kernels, etc- Uppsala University,
Sweden, 2013
5. Ahnesjö , Anders Patient dose calculation models in TPS.
More references…
6. Wiesmeyer MD, Miften MM. A multigrid approach for accelerating three-
dimensional photon dose calculation Med Phys 1999; 26 :1149 (Abstract)
7. Mackie TR, Bielajew AF, Rogers DWO, Battista JJ. Generation of photon energy
deposition kernels using the EGS Monte Carlo code. Phys Med Biol 1988;33:1-20.
8. Sharpe MB, Battista JJ. Dose calculations using convolution and superposition
principles: The orientation of dose spread kernels in divergent X-ray beams. Med
Phys 1993;20:1685-94.
9. Mackie TR, Scrimger JW, Battista JJ. A convolution method of calculating dose for
15 MV X-rays. Med Phys 1985;12:188-96
10. Gagné, I, Zavgorodni, S. Evaluation of the analytical anisotropic algorithm in an
extreme water–lung interface phantom using Monte Carlo dose calculations.
Journal of Applied Clinical Medical Physics, vol. 8, (1), Winter 2007
11. Das, I, Cheng, C.W., Srivastava, S, et al. Variability of Low-Z Inhomogeneity
Correction in IMRT/SBRT: A Multi-Institutional Collaborative Study AAPM annual
meeting 2008
Acknowledgments

Vadim Moskvin, Ph.D

Indra Das, Ph.D.
al·go·rithm \ˈal-gə-ˌri-thəm\

1. a procedure for solving a

mathematical problem in a finite
number of steps that frequently
involves repetition of an operation;
2. a step-by-step procedure for solving
a problem or accomplishing some
end especially by a computer

From: http://www.merriam-webster.com/dictionary/
 Where, in the planning system, do we
find algorithms?

• MU calculations
• Isodose distributions
• DVH generation
• IMRT optimization
• DRR generation
• Brachytherapy calculations
• Any process that occurs when the user does not
dictate each step (e.g. generating a 3D image from a
series of slices, placing a margin around a structure,
etc.)
 In the beginning …
• Calculations were performed
strictly based on empirical
(directly measured) data in
tabular format.

• Isodose curves were generated

based on PDD and profile data

• Corrections based on patient

were very simplistic, depth
corrections only (attenuation)
Most advanced …
Monte Carlo method

Histories of millions of photons and

secondary electrons are traced to calculate
dose deposition based on physics
interactions in matter

Monte Carlo method is the most accurate

method for dose calculation but requires the
greatest processing time. Most calculation
algorithms use pre-calculated MC kernels.
4. Ahnesjö , Anders
Monte Carlo terms
• Random number generator (RNG)– the random
number generator selects a number between 0 and 1
to determine the path of the particle (photon)

• History – the tracking of a single particle (how is the

photon losing energy as it passes through the medium)

• Phase space – characterizes position in 6D

• Events – PE, CE, PP, electron interactions

More Monte Carlo terms…
• Sampling – the draw of the parameters of events from
the probability distributions using RNG
• Scoring – acquiring the value of the parameter of
interest during the simulation
• Estimator – mathematical and algorithmical description
of the scoring method
• Kernel – Pencil or point; a Monte Carlo simulation that
has been “scored” of a small “pencil” beam which
incorporates the events in that path, or that occur at a
“point”
 Photon interactions…
or events in Monte Carlo terms

1. Photoelectric effect – photon transfers all energy to

electron, ejected, increases with Z3 and decreases with E3
2. Compton effect – dominant at therapy energies, results in
scattered photons and secondary electrons, decreases slowly with
E and is independent of Z
3. Pair Production – results in the creation of electron/positron
pair, annihilation, dependent on Z2 and E2.
Which lead to Electron interactions – ionization, excitation,
bremsstrahlung, ultimately dose deposition
(There are other effects that contribute to dose, such as neutron
production, which may or may not be modeled)
Monte Carlo method
• MC method uses known probabilities and probability
distributions in sampling to predict results of interactions
(events) (e.g. Compton: Klein-Nishina coefficients)
• MC utilizes the Law of Large Numbers (LLN)
Theorem: The average of the results obtained from a large number of trials should
be close to the expected value, and will tend to become closer as more trials are
performed.

• The convergence of the Monte Carlo method follows the

Central Limit Theorem (CLT)
Example: 2 Gy dose in 3x3x3 mm voxel could be delivered by 1011 photons
crossed this voxel. However, simulation of 1011 photons multiplied on field size will
take infinite amount of time. According to LLN, we can simulate 107 photons for
whole field and get results according to CLT with 1% accuracy.
Monte Carlo method
• Direct Monte Carlo method
o Particle trajectory is simulated in details on the even-
by-even basis with the maximum accuracy in details.
o Binary estimator is used.
Example: General-purpose code algorithms, PENELOPE, EGSnrc, FLUKA

• Specialized Monte Carlo method

o Variance reduction based simulation or certain
simplifications in the transport description
o Weighted estimator is used.
Example: FLUKA and MCNPX neutron transport module, MMC used in TPS,
DPM electron-photon code.
Monte Carlo code uses programming
subroutines and interaction
probabilities to calculate dose
Why does MC method work?
• As the number of photons required for dose delivery
decreases, dose delivery uncertainty increases
• Example: a quarter landed on “heads” or “tails”
Probability = 50%
If the quarter is flipped 10 times
If the quarter is flipped 100 times
If the quarter is flipped 1011 times
• If only a few photons were needed to deliver dose, the
MC method would not be accurate
So, if MC is the most accurate method for
calculation, why develop other algorithms?
1. Time! Processing time makes
MC calculations impractical for
clinic as the TPS engine, but
may serve well for treatment
plan verification.
2. Since the cost associated with
higher performance computing
has decreased over the years,
more sophisticated algorithms
employing MC calculations are
Khan, 2010 (1) clinically available.
On the light side …

Two atoms are sitting in a field of ionizing radiation.

One atom says, "I think I lost an electron."
The other says, "Are you sure?"
The first atom says, "I'm positive!"
Phase Space
• Phase space is a 6 dimensional
characterization of the particles

r  ( x, y , z )
6 D  ( x, y , z ,  ,  , E )
Monte Carlo accuracy - Modeling
• Highly dependent on
the modeling of the
components of the
accelerator head

• Where can secondary

electrons be
produced? Where can
scatter occur? Where
does the calculation
start?

http://health-7.com/imgs/20/7507.jpg
 • Finite photon source size
Monte Carlo input  Open fluence distribution
 Fluence modulation
 Head scatter sources
 flattening filter
 collimators
 wedges
 Monitor back scatter
 Collimator leakage, including
 MLC interleaf leakage
 shape of MLC leaf ends
• Beam spectra
• Spectral changes
• Electron contamination
Monte Carlo Codes
• EGS4
• EGSnrc
• GEANT
• PENELOPE
• MCNP
• MCNPx
• FLUKA
Different types of calculation
algorithms
• Semi-empirically based
• Model based
• Direct Monte Carlo
• Hybrid
Give me 30 minutes and I can confuse
anyone. I don’t need to prepare.

Lech Papiez, Ph.D.

Indiana University

Dr. Papiez’ response to a request to give a talk on

algorithms to medical residents on the same
day of the request.
Why do we need calculation algorithms?

Measurements are performed under specific conditions:

- Fixed square fields
- Fixed depths
- Homogenous medium (water)
- Flat surface

Monte Carlo based algorithms and the simplest of

empirically based algorithms reasonably agree in
homogeneous media
Physical Density
Material Density Relative to Impact
(g/cm3) water
Air 0.0012 1/800 Attenuation and
scattering
Lung 0.2-0.3 1/5 Attenuation and
scattering
Water(soft 1.000 1.000
tissue)
Bone 1.600 1.6X (Attenuation
and scattering)
Titanium 4.5 4.5X Attenuation

Steel 7.5 7.5X Attenuation

Semi Empirical (also called Correction
or Factor based)
• Based on measured data
PDD
Profile
• TAR
• ETAR
• Batho
• Power Law
• Clarkson
 Photon dose calculation methods
“Dose engines”
Method Remarks
characteristics
Monte Carlo Explicit particle transport Standard research tool,
simulation clinical use under
+ Accurate development
Model - Noisy distributions
Based Point kernel methods Implicit particle transport Current workhorse for
Convolution/superposition , + Accurate accurate calculations in
Collapsed Cone - Minor systematic errors lung.

Pencil Kernel Methods Heterogeneity impact The workhorse for many

through corrections applications
Factor Scatter dose estimations ”Semi” pencil kernel Often used for factor
Based metods based calculation
schemes

1D heterogeneity corrections Models what happen Can be used to correct

along the incident beam dose calculated with any
direction only method for heterogeneities

Ahnesjö, 2013 (4)

Calculation algorithms for TPS (photons)
Elekta XiO
• Clarkson
• FFT Convolution
• Multigrid Convolution
• Superposition
• Fast Superposition
Phillips Pinnacle
• Collapsed Cone Convolution
• Pencil Beam
Varian ECLIPSE
• AAA Collapsed Cone Convolution
• Pencil Beam
Model based algorithms
• Empirically based algorithms rely on measurement,
corrections performed based on patient
characteristics
• Model based algorithms rely less on measured data,
more on predictions of dose distribution (equations,
probabilities)
• No clear distinction!
Empirical based algorithms use models for
corrections and model based algorithms use some
measured data.
Pencil Beam algorithm (Convolution)
• Monte Carlo “kernels”
• Spatially invariant (non-divergent)
• Scatter not modeled well
- Lateral scatter not considered
- Heterogeneity correction largely attenuation
correction only (generally convolved with Batho or
other correction)
- Generally a “hybrid” algorithm (modeled with semi-
empirical correction)
Monte Carlo kernel Summation of
kernels

In the pencil beam algorithm, kernels are spatially

invariant, i.e., parallel to surface, non-divergent,
source of some inaccuracy
 Homogeneous media Inhomogeneous media

High density
heterogeneity

Pencil beam algorithm predictions

Changes in side scatter not modeled
Low density
Attenuation correction only heterogeneity
High density Low density
Inhomogeneous heterogeneity
heterogeneity
media

Increased areas of Decreased areas of

scatter not modeled scatter not modeled

Will result in higher

MUs than is needed Will result in lower MUs
Convolution känvəˈlo͞ oSHən
• A coil or twist, esp. one of many
• A thing that is complex and difficult to follow
• a mathematical operation on two functions f
and g, producing a third function that is typically
viewed as a modified version of one of the
original functions.
• It is based on theory of Laplace transformation
of functions.
http://en.wikipedia.org/wiki/Convolution
Convolution-Superposition method
(Collapsed Cone, Superposition)

• Most commonly used and widely accepted

algorithm class in radiotherapy planning
systems.

• Primary photons are treated separately from

scattered photons and electrons set in motion
Convolution-Superposition algorithms
• Point kernels (finer resolution than pencil kernels)
• Consideration of divergence
• Consideration of lateral scatter
• Consideration of energy spectrum
• Consideration of primary/secondary interactions with
inhomogeneous media
• Effects of collimator, flattening filter
• Less averaging than pencil beam
 Equations
     
Dr     r Ar  r 'd 3 r '

Convolution    
 T p (r ) Ar  r 'd 3 r '
Equation 
T p r   TERMA, total energy released in the mass
 
Ar  r '  accounts simplistically for scatter

     
Dr     r Ar  r 'd 3 r '

Convolution-    
 Tp (  r  r ) A r  r '  r  r 'd 3 r '
Superposition  
where  r  r '  r  r 'is the radiologic distance from the dose
Equation 
deposition site to the primary photon site and  r  r is the radiologic
distance from the source to the photon site
Data and Clinical Examples
Treatment Planning and
Measurements

Experimental geometry for the treatment planning and measurement.

The phantom consists of 14.4 cm of lung equivalent material (Cork, 
=0.25g/cm3) sandwiched between slabs of solid water. Measurements
were made at various depth with micro-chamber
Das et al., 2008 (11)
 Charged particle equilibrium (CPE)

Pencil beam algorithm does medium

not accurately account for
secondary electron
production, calculations at
the tissue/lung interface are
not accurate.

Region of non-
equilibrium

From Khan, 2010 (2)

 Pencil Beam Superposition Monte Carlo

CMS-XiO, 6 MV CMS-XiO, 6 MV Monte Carlo, 6 MV

1.8
1.8 1.8
Pencil Beam Superposition PENELOPE, MC
1.6 1.6
1.6
Convolution

C o rre c tio n F a c to r (D i/D h )

C o rre c tio n F a c to r (D i/D h )

1.4 1.4

C orrection F actor (D i/D h)

1.4
1x1
1.2 2x2 1.2 1.2
3x3 1x1 1x1
1.0 4x4 1.0 2x2 1.0
2x2
3x3
5x5 3x3
0.8 4x4 0.8
6x6 0.8
5x5 4x4
8x8 6x6 3x3
0.6 0.6
10x10 0.6 8x8
6x6
0.4 10x10
0.4
0.4
0 2 4 6 8 10 12 14 16 18 20 0 2 4 6 8 10 12 14 16 18 20
0 2 4 6 8 10 12 14 16 18 20
Depth (cm) Depth (cm) Depth (cm)

Plot = Di/Dh
Das et al., 2008 (11)
Lung Case

1. SBRT case –
10 fields
2. 1 cm volume
3. 6 MV
4. AAA and Pencil
beam
5. Heterogeneity
corrections
“on”
AAA
100% White
95%
90%
80%

Calculation verification
program predicts 11.3%
higher dose than AAA with
same MUs
Pencil Beam
100% White
95%
90%
80%

Calculation verification
program agrees well with
Pencil beam (.01%)
Comparison of isodose curves
AAA Pencil Beam

Max dose = 100.8% Max dose = 102.2%

80% volume = 42.4 cc 80% volume = 57.7 cc
The 80% volume generated in PBC is 36% greater than AAA
Spine Case – High Z
APPA spine
6 MV beams
High density implanted
devices, 3000+ HU
Bone measured density
values = 900-1500 HU
AAA and Pencil Beam
Heterogeneity
corrections on
 AAA MU
sum = 206

Pencil Beam
MU
sum = 208
AAA – edge of heterogeneity PBC– edge of heterogeneity

PBC results in 10% higher dose at edge of high Z

heterogeneity
AAA – inside heterogeneity PBC – inside heterogeneity

PBC results in 10% higher dose inside the high Z

heterogeneity
 Spine case
No implant
APPA
16 MV photons
200 cGy anterior
to vertebral body
No difference in
MUs between
AAA and PBC
Heterogeneity
corrections on
 AAA PBC
Less than 1% difference in dose calculated to cord
 AAA PBC

Less than 1% difference in calculated dose in bone

Summary
• Algorithms are step by step processes which are used
in planning systems (and otherwise) to complete
specific tasks.
• The simplest of algorithms perform as accurately as the
most sophisticated algorithms for ideal conditions.
• Time is a critical factor in the development of treatment
planning algorithms.
• Heterogeneities pose the greatest challenge to
predicting accurate dose distributions in patients
Summary (cont.)
• The Monte Carlo method is the most accurate method
for calculating dose in heterogeneities. The most
accurate currently available algorithms incorporate
Monte Carlo kernels.
• Discrepancies in calculations more likely to arise from
low density media than from high density media
• Safer to rely on your “convolution-superposition”
algorithm than your verification calculation, since your
verification calculation uses a simpler, less accurate
algorithm
The academic portion of
the lecture is now
complete.

www.pythian.com
An Irish blessing for the Medical
Dosimetrist …
May your first optimization meet your dose constraint
If not, may you meet with a little dose paint
May your calc’d and your plan MUs always agree
May you need not replan for a re-drawn GTV
May your MD not change his mind post approval
And your user rights never suffer removal
May your IMRT QA turn out right
And you get to go home while there is still light
 Questions?

http://crippledcollie.com/wordpress/wp-content/uploads/2012/08/deer-in-headlights.jpg