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Vadim Moskvin, Colleen DesRosiers, Lech
To cite this article: Vadim Moskvin et al 2004 Phys. Med. Biol. 49 4879 Papiez et al.

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INSTITUTE OF PHYSICS PUBLISHING PHYSICS IN MEDICINE AND BIOLOGY
Phys. Med. Biol. 49 (2004) 4879–4895 PII: S0031-9155(04)79112-5

Monte Carlo simulation of the Leksell Gamma

Knife

R
: II. Effects of heterogeneous versus
homogeneous media for stereotactic radiosurgery

Vadim Moskvin, Robert Timmerman, Colleen DesRosiers,

Marcus Randall, Paul DesRosiers, Phil Dittmer and Lech Papiez
Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis,
535 Barnhill Dr, RT041, IN 46202-5289, USA

E-mail: vmoskvin@iupui.edu

Received 12 April 2004, in final form 2 September 2004

Published 8 October 2004
Online at stacks.iop.org/PMB/49/4879
doi:10.1088/0031-9155/49/21/003

Abstract
The absence of electronic equilibrium in the vicinity of bone-tissue or air-
tissue heterogeneity in the head can misrepresent deposited dose with treatment
planning algorithms that assume all treatment volume as homogeneous media.
In this paper, Monte Carlo simulation (PENELOPE) and measurements with
a specially designed heterogeneous phantom were applied to investigate the
effect of air-tissue and bone-tissue heterogeneity on dose perturbation with
the Leksell Gamma Knife
R
. The dose fall-off near the air-tissue interface
caused by secondary electron disequilibrium leads to overestimation of dose
by the vendor supplied treatment planning software (GammaPlan
R
) at up to
4 mm from an interface. The dose delivered to the target area away from an
air-tissue interface may be underestimated by up to 7% by GammaPlan
R
due
to overestimation of attenuation of photon beams passing through air cavities.
While the underdosing near the air-tissue interface cannot be eliminated with
any plug pattern, the overdosage due to under-attenuation of the photon beams
in air cavities can be eliminated by plugging the sources whose beams intersect
the air cavity. Little perturbation was observed next to bone-tissue interfaces.
Monte Carlo results were confirmed by measurements. This study shows that
the employed Monte Carlo treatment planning is more accurate for precise
dosimetry of stereotactic radiosurgery with the Leksell Gamma Knife
R
for
targets in the vicinity of air-filled cavities.
(Some figures in this article are in colour only in the electronic version)

0031-9155/04/214879+17$30.00 © 2004 IOP Publishing Ltd Printed in the UK 4879

4880 V Moskvin et al

1. Introduction

Radiosurgery has emerged as a favourable treatment modality for cranial base tumours in
patients with lesions in eloquent locations or those deemed medically unsuitable for surgery
(Chen et al 2001, Iwai et al 2003, Kim et al 2002, Nakamura et al 2002, Nicolato et al 2002b,
Ottaviani et al 2002). Until the advent of radiosurgery, almost all radiation therapy to
intracranial targets was fractionated. ‘Stereotactic radiosurgery (SRS) is a technique for
treating lesions, typically intracranial, most often with a single high dose of ionizing radiation
which is enabled by use of a stereotactic device(s) for accurate target location and patient
immobilization’ (Regine 2003)1 . SRS requires that a single high dose of radiation will be
delivered with the intention of altering tissue in the high dose volume in a clinically favourable
manner. Because of radiation intolerance of surrounding brain, SRS requires a more rapid
dose fall-off at the boundary of the target and a much lower dose to the surrounding structures
than in conventional external beam radiation therapy. The Leksell Gamma Knife
R
provides
an advanced stereotactic approach to the treatment of tumours, vascular malformations and
pain disorders within the head.
Gamma Knife
R
SRS significantly decreases frequencies of permanent side effects and
mortality rates in the cases of cavernous sinus meningiomas compared to microsurgery and
conventional radiotherapy (Nicolato et al 2002a, 2002b, Shin et al 2001, Nakamura et al
2001, Kim et al 2002). Cavernous sinus meningiomas often compress the optic apparatus
(Nicolato et al 2002a, 2002b). Tolerance to radiation by optic apparatus is limited, and results
in a reduced dose for tumours, which has been reported to correlate with lower tumour growth
control rate. For example, control of tumour growth was achieved in 100% of patients in
whom full coverage of the tumour with 14 Gy was achieved. However, tumour regrowth
occurred in 20% of patients who received 10–12 Gy to the tumour margin (Shin et al 2001).
Low dose radiosurgery has been applied to avoid surgical resection (Iwai et al 2003). A
mean marginal dose of 11 Gy (from 8 to 15 Gy) demonstrated a decrease in recurrence and
progression in patients treated for tumours near the optic pathways. Most recurrences and
regrowth of cavernous sinus meningiomas occurred outside or peripheral to the treatment
site implying a possible underdosing at the target’s margin. Similar results were seen after
treatment of cavernous haemangiomas in the cavernous sinus (Nakamura et al 2002). Patients
with cerebral hemispheric meningiomas of convexity or parasagittal region have a higher
incidence of peritumourous imaging changes after Gamma Knife
R
radiosurgery than those
with skull base meningiomas (Chang et al 2003). Thus, the clinical data indicate the cases of
lesions close to the area of air-filled cavities in the head are still a challenge for radiosurgery
with the Leksell Gamma Knife
R
.
Numerous studies have been done to investigate the importance of the ‘inhomogeneity’
corrections for head and neck fractionated treatments with megavoltage beams. When tumours
are either in contact with air cavities or surround air cavities, the overall dose distribution is
influenced by the competing effects of increased transmission, decreased photon scatter and the
loss of electronic equilibrium in an air cavity. The effect of dose perturbation for megavoltage
beams of 3 × 3 cm2 and larger depends strongly upon cavity volume, field size and beam
energy (Kan et al 1998). The effect becomes less significant for field sizes above 4 × 4 cm2.
Narrow megavoltage beams having a diameter of 1–3 cm have been investigated in
radiosurgical applications to the head and neck (Solberg et al 1995). Underdosage of targets
across the air cavity is significant for these beams. Critical normal tissue structures lying
1 An issue of Technology in Cancer Research and Treatment 2, (2003) is dedicated to stereotactic radiosurgery

providing a comprehensive review of the intracranial lesions treatment technique and its extension to stereotactic
body radiation therapy for extracranial targets.
Monte Carlo simulation of Leksell Gamma Knife (II) 4881

adjacent to air cavities may receive additional dosage in comparison with a treatment plan
that assumes homogeneity due to under-attenuation of the photon beams (Solberg et al 1998),
while portions of targets next to these same cavities may be underdosed. While it seems that
importance of the inhomogeneity corrections for megavoltage beams is recognized, there are
no results published on the investigation of the impact of air-tissue interface on treatment
with the Leksell Gamma Knife
R
.
Gamma Knife radiosurgery dose computations are carried out by the GammaPlan


R R

R
treatment planning system (Elekta 1996). GammaPlan employs a simple, empirical dose
calculation method (Wu et al 1990, Wu 1992). The dose profile of each beam is measured
for final beam sizes of 4, 8, 14 and 18 mm. A standard set of beam data is included with
the planning system. The dose distribution in the patient is calculated by adding the dose
distributions for all 201 beams. It is a common opinion that inhomogeneity correction is not
important for intracranial SRS (Yu and Shepard 2003). At least it is not commonly practiced.
Since the GammaPlan
R
algorithm is based on the assumption that the target material is
composed entirely of unit density substance, any perturbations due to tissue heterogeneity
are neglected (Yu and Shepard 2003). The thesis of this paper is that assuming purely
homogeneous media may produce undesirable consequences when applied to certain cases
such as when treating targets near bone-tissue or air-tissue interfaces.
Inability to account for dose perturbation in GammaPlan
R
requires the application of
alternative methods of dose calculation. This paper is the second of a series of discussions
of Monte Carlo application to Leksell Gamma Knife
R
treatment planning. Our previous
paper (Moskvin et al 2002a) presented the method and details of the simulation of the Leksell
Gamma Knife
R
with Monte Carlo code, utilizing a general purpose package PENELOPE
(Salvat et al 2001). Our model was verified independently by Al-Dweri et al (Al-Dweri et al
2004, Al-Dweri and Lallena 2004) and confirmed to be acceptable for simulation of the
treatment with the Leksell Gamma Knife
R
. This computational model of the Leksell Gamma

R
Knife was applied for the present investigation. The goal of this paper is to investigate
the importance of air-tissue heterogeneity in stereotactic radiosurgery with the Leksell
Gamma Knife
R
.

2. Methodology

2.1. Inhomogeneous phantom

In order to investigate the effect of heterogeneity on dose perturbation with the Leksell
Gamma Knife
R
, a combined strategy that includes phantom measurements, GammaPlan
R

dosimetry and Monte Carlo simulation has been utilized. Benchmarking of the Monte
Carlo simulation, or independent verification of results with measurements, requires a special
approach to heterogeneous dosimetry for Leksell Gamma Knife
R
. This approach demands, in
particular, the design of the heterogeneous phantom that will adequately represent air-tissue
inhomogeneities in the human head, and will be simple enough to be represented with the
PENGEOM geometrical module of PENELOPE code.
The idea and design of the heterogeneous phantom was proposed recently (Moskvin et al
2002b). The phantom prototype was used for the preliminary study of the inhomogeneity
effect on dose perturbation (Moskvin et al 2003). The updated phantom was designed as a
modification of the phantom LUCYTM (Sandstrom Trade & Technology). Figure 1 illustrates
the design of the phantom, together with images of phantom elements and its set-up for
measurements.
4882 V Moskvin et al

Figure 1. The heterogeneous phantom concept, design and treatment set-up. Areas 1 and 2 were
selected as the targeting areas. The dots illustrate the positions of the isocentre. Outlines of
objects (a) and (c) represent air-filled cavities associated with the maxillary and frontal sinuses;
(c) represents the eye and (d) represents skull. The images illustrate the heterogeneous phantom
module and its assembly with the standard LUCY phantom for the treatment set-up.

LUCYTM is a spherical acrylic phantom, designed for quality assurance measurements

in radiosurgery (Ramani et al 1995). LUCY consists of two semi-spheres of radius 70 mm,
with several modular components, such as imaging cylinder markers, a dosimetry chamber,
a volume chamber, an optical pointer, a radiation pointer, etc. An interface is available such
that the LUCY phantom can be mounted onto the Leksell stereotactic head frame, thereby
allowing the fiducial box to be attached and the phantom to be fixed in position for the
experiment, in the same manner as patients are fixed in position. The skull scaling instrument
(Elekta) that is used to define surface contours for the Leksell Gamma Knife
R
patient is also
used for the LUCY phantom. The total positioning error, based on the surface contouring
accuracy, MRI fiducial correspondence and overall positioning accuracy of the Gamma Knife
is ±2 mm, similar to the error expected for patient treatment.
An acrylic inhomogeneous module which modifies LUCYTM was designed, as illustrated
in figure 2. Air cavities were drilled in the acrylic slab, having a thickness of 30 mm, to
simulate frontal and maxillary sinuses. The aluminium slab on the opposite end of this slab
simulates occipital bone. For some measurements, the aluminium slab can be replaced with
an acrylic insert of equivalent size. The module is assembled with two LUCYTM semi-spheres
in one unit clamped firmly together. The module has slots which are used to maintain the films
for measurements. Air cavities between the film and acrylic were filled with thinner sheets
of acrylic. Positions of the shots of the phantom are marked as ‘targets’ in figure 2. Figure 2
illustrates the orientation of the phantom relative to the Leksell Gamma Knife
R
helmet and
main planes, which will be referred to during discussion of the results.
Monte Carlo simulation of Leksell Gamma Knife (II) 4883

Sagittal View Transverse View

15.1 15.1
B Target
Air Air

19
Air

33
27

22

45.6
27

28.9
A
Acrylic Acrylic Acrylic
Acrylic
56.3

D
20 Bone
Bone
7

140 70 30

Helmet

Coronal Plane Air cavities

Transverse Plane

Lucy phantom semi-spheres Al slab (Bone substitution)

Sagittal Plane

Figure 2. Detail rendering of the inhomogeneous phantom. Points A, B and D show the areas of
isocentre positions. The dimensions on the draft are given in mm.

Irradiation for measurements was planned using a computerized tomography (CT) image
set of the phantom and input into GammaPlan
R
. The dose of 50 Gy was prescribed to the
50% isodose. The dosimetry media film, GafChromic MD-55-2 film (manufactured by ISP
Technologies, Inc.), was mounted in marked positions.
Calibration of the film was achieved using the unmodified LUCYTM for 201 sources,
unplugged, with a collimator size of 18 mm. The MD-55-2 film was calibrated for doses 0,
20, 40, 50, 60, 80, 100 and 140 Gy with the 18 mm collimator on the Gamma Knife. All
films, calibration and experiment, were read with the VIDAR film scanner, VXR16DP, at
178 µm resolution driven by RIT113 version 4 radiation therapy dosimetry software. All
films, calibration and experiment, were scanned between 26 and 28 h post-irradiation. The
error in the optical density due to the non-uniformity of the film has been reported to be ±3%
for the dose range used in this experiment (Lewis 2004, Butson et al 2003 Niroomand-Rad
et al 1998).
4884 V Moskvin et al

2.2. Monte Carlo simulation

The choice of Monte Carlo code for this investigation was determined by two criteria, i.e.
accuracy of simulation at the presence of inhomogeneity and flexibility of the code. Few
general purpose Monte Carlo codes, EGS4 (Nelson et al 1985), EGSnrc (Kawrakow 2000),
MCNP4 (Briesmeister 2000) and PENELOPE (for version of 2001, see Salvat et al (2001))
are, at present, commonly used in radiation therapy applications (Verhaegen and Seuntjens
2003). There are some results in the literature on inter-comparison between codes and
comparison with measurements that may justify the selection of the code for one or another
problem. The results of simulation with MCNP are closer to measurements than results
of EGS4 (Das et al 2001, Jeraj et al 1999). MCNP code implements physics of electron
transport that is claimed to be the same as in ITS 3.0 (Halbleib et al 1992). However, it is
difficult to reproduce electron dose distributions with the latter code (MCNP4C) (Schaart et al
2002). The results of simulation with MCNP depend sufficiently on the code customization
parameters (Schaart et al 2002, Chibani and Li 2002, Reynaert et al 2002). Moreover, MCNP
requires improvement of the interface crossing algorithm that is limited by the physical
model used in this code (Schaart et al 2002). The difference between MCNP, EGS4 and
EGS4nrc can reach 20% in the area of interest or near the interface between materials due
to differences in the electron transport algorithms, physics models and interface crossing
algorithms (Das et al 1999, Wang and Li 2001). Wang and Li state that EGSnrc produces
more reliable results (within 5% difference with MCNP) than EGS4. A similar conclusion
was reached by Verhaegen for calculations of the dose in the presence of high Z interface
(Verhaegen 2002). It was clearly shown by Kawrakow (2000) and Verhaegen (2002) that
the EGS4 model has limitations at low energies due to the boundary crossing algorithm and
condensed history method limitations implemented in the code. Simulation with EGSnrc for
electron and photon beams shows that reasonable accuracy can be reached when spin effects
are included in simulation (Verhaegen 2002, 2003). Comparing MCNP and EGSnrc with
measurements for planar geometry shows that EGSnrc output is closer to measurements than
MCNP (Chibani and Li 2002). This discrepancy worsens in the area close to the interface.
Comparison of an early version of PENELOPE (1996/1998 version), EGS4 and MCNP with
measurements has shown that the results of simulation with these three codes are consistent for
areas far from the interface in heterogeneous media (Das et al 2001, 2002). This conclusion
is supported by independent analysis of the results for transport of electrons of energies above
100 keV (Ye et al 2004) However, PENELOPE results are closer to experimental data on
interface dose than MCNP and EGS4 results both for high and low-Z interfaces (Das et al 2001,
2002). PENELOPE incorporates the latest cross section data and random-hinge algorithm
(Salvat et al 2001) providing a more detailed description of low energy electron transport
compared to the latest updated version of EGS4nrc. Discrepancies of about 8% were reported
recently between PENELOPE and EGSnrc code for low energy photons (103Pd and 125I) in
the presence of inhomogeneity (Fragoso et al 2003). Experimental benchmarking of
PENELOPE code demonstrates consistency in the description of electron transport processes
in an energy range from a few keV up to about 1 GeV (Sempau et al 2003). The code is stable
to variation of its customizing parameters over a wide range (Salvat et al 2001, Sempau et al
2003). Overall, PENELOPE allows adequate simulation of the low-energy secondary electron
field in the vicinity of low atomic number interfaces and facilitates the study of the dose
perturbation in this area. PENELOPE code is attractive for application to radiation therapy
since it allows simulation of treatment down to radiobiological effects (Stewart et al 2002).
The second criterion determining our choice was the flexibility of the code. PENELOPE
code is written in a standard FORTRAN-77 language that makes it independent of
Monte Carlo simulation of Leksell Gamma Knife (II) 4885

computational platform. We compiled and ran code under Windows (98, 2000, XP), Linux
(RedHat 7–9) and AIX operation systems. Although the code was originally written to be user
friendly (assuming relatively minimal user programming) (Salvat et al 2001, Sempau et al
2003), its structure is clear and flexible for sophisticated usage with additional design of
sampling schemes under complex initial conditions, tracing in mixed geometries (both with
the usage of PENGEOM and voxel structures in the same program) (Moskvin et al 2004) and
use of different custom designed units implementing variance reduction techniques (Moskvin
et al 2001, Moskvin and Papiez 2002). Such flexibility of PENELOPE makes it more attractive
for creative usage than EGSnrc. Thus, Monte Carlo simulation with general-purpose code
PENELOPE (version of 2001) (Salvat et al 2001) was applied to this investigation.
For the purpose of further development of this project into the treatment plan verification
system, PENELOPE code was modified for parallel processing to reach higher performance
in computation (Cruise et al 2003). The code was parallelized on the Indiana University IBM
Teraflop SP Aries Complex, under the AIX 5.1.0 operation system. The Aries Complex
includes eight frames of 4-cpu Power3+ Thin nodes, providing a homogeneous parallel
processing environment, with a total of 508 processors2 . A parallelized PENELOPE code
has been compiled and linked with the IBM XL Fortran 90 compiler, version 7.1.1. This
parallelized version of the PENELOPE code is available from RSICC under title PENELOPE-
MPI (RSICC 2002). PENELOPE-MPI was thoroughly tested and results from use of this
code were found to be identical to data produced with serial version of the PENELOPE code
for the application presented in this paper. To keep original code name unaltered, the parallel
version of the code used in this paper will be called PENELOPE.
We compared the results from computation of the same irradiation set-ups that will be
discussed below in the next section with three versions of PENELOPE code (v. 2000, v. 2001
and v. 2002). No differences were found between results of simulation with these three versions
of the code in the limits of statistical uncertainty. This supports the conclusion reached recently
by Al-Dweri et al (Al-Dweri et al 2004, Al-Dweri and Lallena 2004) regarding difference
between PENELOPE versions of 2000 and 2001 in Gamma Knife application. This paper
presents data computed with the use of PENELOPE (v. 2001) only.
The user designed code used in this investigation utilizes results of our previous work on
Gamma Knife source modelling (Moskvin et al 2002a). The model presented in that paper
was verified independently by Al-Dweri et al (Al-Dweri et al 2004, Al-Dweri and Lallena
2004). It was confirmed that the model’s accuracy is acceptable for Gamma Knife simulation.
The numerical model of the source (see Moskvin et al (2002a)) was used to sample initial
parameters of radiation in simulation. A voxel of 0.5 × 0.5 × 0.5 mm was selected for
dose calculations. The cut-off energy of secondary electron transport and the threshold of
secondary electron generation were selected at 10 keV. The residual electron range for that
energy is considerably less than the characteristic size of the spatial scoring bin (voxel).
Table 1 contains summary of the PENELOPE tracking parameters used in simulation. All 201
sources were assumed to be unplugged in all simulations, except in those whose plug pattern
is given below. Single shots were used in this study.
The heterogeneous phantom presented in the previous section (see figure 2) was described
by quadrics, and coded at the geometry file for the PENGEOM unit of PENELOPE code.
Materials used for computations were taken from PENELOPE material database.
Corresponding database indexes of the materials are given in table 1. An aluminium insert
simulates bone. This insert was replaced by a piece of acrylic for measurements referred
in sections 3.2–3.4 of this paper. Results presented in section 3.5 were computed for two

2 Details on Indiana University Teraflop SP are available through dedicated Web-page http://sp-www.iu.edu/.
4886 V Moskvin et al

Table 1. PENELOPE tracking parameters used in simulation for each material of the phantom
design.

Acrylic Aluminium
Materials (PMMA) Air (Bone substitution)
PENELOPE material 224 104 13
database index
Eabs (γ ) (keV) 10.0 10.0 10.0
Eabs (e−/e+) (keV) 10.0 10.0 10.0
C1 0.1 0.1 0.1
C2 0.1 0.1 0.1
Wcc (keV) 10.0 10.0 10.0
Wcr (keV) 10.0 10.0 10.0
Smax(cm) 10 1 10

numerical phantoms. One is the original described above with an aluminium slab insert.
A second phantom was designed as an additional numerical phantom, with the aluminium
coating of the entire phantom excluding air cavities (see figure 9 which contains a slice of the
phantom). The acrylic layer over bone has the thickness of 6.7 mm. The external contour of
the modified phantom remains the same as for the original one.
Homogeneous media are assumed while planning dose delivery to the target with
GammaPlan
R
. To represent GammaPlan
R
plan calculations, the homogeneous representation
of the phantom was also coded. The homogeneous version of the phantom has exactly the
same external shape as the original heterogeneous phantom.
Data on dose calculations for the homogeneous phantom were used to renormalize
Monte Carlo dose data into absolute values of Gy for the heterogeneous phantom. The
procedure of renormalization consists of the following.
in hom
(i) Calculation of the dose DMC at the isocentrein inhomogeneous phantom for a given
in hom
set-up. Value DMC is determined by interpolation through eight neighbourhood voxels
surrounding the isocentre.
hom
(ii) Calculation of the dose in homogeneous phantom DMC for the same irradiation set-up.
(iii) Determining the expected value of dose in Gy at the isocentre from GammaPlan
R

calculation DGP.
(iv) The set of Monte Carlo calculated data for inhomogeneous phantom is renormalized as
in hom
DMC
DMC = hom
DGP . (1)
DMC

An amount of initial photon trajectories of 300 million was used to ensure statistical
uncertainty of 2%, at 5% dose level in simulation.

3. Results and discussion

3.1. Dose distribution from GammaPlan

R
versus Monte Carlo simulation for
homogeneous phantom representation
Results of simulation with Monte Carlo code for homogeneous representation of the phantom
were compared to those produced by GammaPlan
R
. The dose distribution from GammaPlan
R

is nearly identical to that produced by Monte Carlo simulation for a homogeneous phantom
representation. Figure 3 illustrates the case of the 8 mm collimator, with the isocentre position
Monte Carlo simulation of Leksell Gamma Knife (II) 4887

2
cm
1.5 Air

0.5

-0.5

-1

-1.5
Acrylic D = 1 mm
-2
-2 -1.5 -1 -0.5 0 0.5 1 1.5 2
cm

Figure 3. Monte Carlo calculated isodoses for homogeneous phantom representation (dashed
lines) versus GammaPlan output (solid lines). Isodose lines are given on the background of a
CT image in the transverse plane of the heterogeneous phantom for illustration of the isocentre
position relative to the air-acrylic interface. The 8 mm collimator and the isocentre position of
1 mm from the air-tissue (acrylic) interface were implemented in this case. The labels ‘acrylic’
and ‘air’ are given as indications to background image. D indicates the distance from isocentre to
the interface.

1 mm from the air-tissue interface. The targeted area has been marked as ‘A’ in figure 2. The
observed small discrepancies are likely due to the error in determining the surface contour
required for GammaPlan
R
and the differences in calculation methods.
The non-ideal geometrical model of the source may also contribute to error, as well as
statistical fluctuations. The model of the beam from a single source was constructed on the
basis of information on the source, collimator system, source positions etc, extracted from
multiple sources (Moskvin et al 2002a). The lack of complete disclosure of information on
the design of the Gamma Knife by its manufacturer can lead to possible model error. Based
on the comparison of multiple calculations for homogeneous phantom, measurements and
GammaPlan
R
output, we estimate that this error is in the limits of or close to the statistical
uncertainty of 2% at the 5% isodose level and uncertainty of the position of the isocentre that
is less than 2 mm. This estimation is supported by comparison with results of an independent
test of our model (Al-Dweri et al 2004, Al-Dweri and Lallena 2004). Overall, it may be
concluded that homogeneous calculations with our model yield results that match well with
those produced by GammaPlan
R
.

3.2. Measurements versus Monte Carlo simulation for a heterogeneous phantom

Several measurements using film were done for positions indicated by the dots in figures 1
and 2. Figure 4 illustrates the comparison of measured data (dashed lines) with Monte Carlo
results (solid lines) in the case of an 8 mm collimator. The targeted area corresponds to that
marked as ‘A’ in figure 2. Positions of the isocentre were selected at 1 mm and 4 mm from
the air cavity interface. Figure 4(c) shows the difference in dose values between Monte Carlo
calculated DMC and measured DF. The difference is given along the line across isocentre
and perpendicular to the cavity at figures 4(a), (b). The value of the difference is about 4%.
4888 V Moskvin et al

cm 2 cm 2
(a) Air 8 mm Air
(b) 8 mm
1.5 1.5

1 1

0.5 0.5

0 0
30 10090 30 100 90
80
-0.5 20 50 80
-0.5 20 50
10 10
-1 5 Gy -1 5 Gy

-1.5 -1.5 Acrylic

Acrylic D = 1 mm D = 4 mm
-2 -2
-2 -1.5 -1 -0.5 0 0.5 1 1.5 2 -2 -1.5 -1 -0.5 0 0.5 1 1.5 2
cm cm
Dose difference DMC-DF, Gy

8 (c)
D = 1 mm
4 D = 4 mm

-4

-8

-1.6 -1.2 -0.8 -0.4 0 0.4

Distance, cm

Figure 4. Comparison of the measured data (dashed lines) with Monte Carlo results (solid lines)
in the case of an 8 mm collimator in the transverse plane. The targeted area corresponds to that
marked as (A) in figure 2. Film was positioned in the transverse plane. Positions of the isocentre
were selected at 1 mm (a) and 4 mm (b) from the air cavity interface. D indicates the distance from
isocentre to the interface. The difference in dose values between Monte Carlo calculated DMC and
measured DF is given along the line crossed isocentre and perpendicular to the cavity (c).

The factors that were discussed above, i.e. error in determining the external contour, film
non-uniformity, possible model error contribute to this difference.
Similar comparisons as shown in figure 4 were made at other locations within the phantom
and agreement was similar. It can be concluded that comparison of Monte Carlo results and
measurements for the heterogeneous phantom show agreement between two sets of the data
within the limits of 4%. This is in the limits of three standard deviations of the Monte Carlo
results and close to the error of the measurements estimated in the previous section of the
paper. As seen above, the current Monte Carlo model of irradiation of inhomogeneous media
with Leksell Gamma Knife
R
is acceptable for dose evaluation next to tissue heterogeneities.

3.3. Dose distribution near an air-tissue inhomogeneity

The area near the posterior wall of the air cavity (sinuses) will be referred to as area 1 (see
figure 1). The area corresponding to the target positions is marked as ‘A’ in figure 2. An area
near the superior wall of the cavity (target position B) will be identified as area 2. Some results
of the Monte Carlo simulation of the dose distribution in the presence of inhomogeneity
(solid lines) in comparison with homogeneous phantom representation (dashed lines) are
Monte Carlo simulation of Leksell Gamma Knife (II) 4889

cm 2 cm 2 cm 2
(a) Air 8 mm (b) Air 8 mm (c) Air 8 mm
1.5 Area 2 1.5 Area 2 1.5 Area 2
1 1 1

0.5 0.5 0.5

0 0 0

-0.5 -0.5 -0.5

-1 -1 -1

-1.5 -1.5 -1.5

Acrylic D = 1 mm Acrylic D = 3 mm Acrylic D = 5 mm
-2 -2 -2
-2 -1.5 -1 -0.5 0 0.5 1 1.5 2 -2 -1.5 -1 -0.5 0 0.5 1 1.5 2 -2 -1.5 -1 -0.5 0 0.5 1 1.5 2
cm cm cm

cm 1 cm 3 cm 4
(d) Air 4 mm (e) Air 14 mm (f) Area 1
18 mm
Area 1 3
2 Area 1
0.5 2
1 Air
1

0 0 0
100
-1
-1
-0.5 -2
-2
-3
Acrylic D = 2 mm Acrylic D = 2 mm Acrylic D = 2 mm
-1 -3 -4
-1 -0.5 0 0.5 1 -3 -2 -1 0 1 2 3 -4 -3 -2 -1 0 1 2 3 4
cm cm cm

Figure 5. Monte Carlo simulation of dose distribution in the presence of air-tissue (acrylic)
heterogeneity (solid lines) versus dose in the homogeneous representation of the phantom (dashed
lines) for various positions of the isocentre for areas 1 and 2, as outlined in figure 1. Isolines
for area 2 ((a)–(c)) are given in the coronal plane and in the transverse plane for area 1 ((d)–(f)).
D indicates the distance from the isocentre to the interface.

shown in figure 5. The results of calculation for area 1, figures 5(d)–(f), are presented in the
transverse plane, and the results for area 2, figures 5(a)–(c), are given in the coronal plane.
The secondary electron disequilibrium in the presence of air-tissue (or air-acrylic, in the
modelled case) inhomogeneity will cause diminished energy deposition near the wall of the
cavity in comparison with the homogeneous media. Thus, results of Monte Carlo simulation
for heterogeneous phantom and for measurements (for example, those given in figure 4)
when compared to the data for homogeneous media show that dose distribution has rapid
fall-off near the air-acrylic interface. Figure 5 illustrates that the fall of the dose is more
dramatic when the distance between an isocentre and an interface decreases. As the treatment
isocentre approaches the interface, additional levels of isodose curves will be affected by dose
perturbation.

3.4. Dose value in the isocentre in the presence of air-tissue inhomogeneity

When targeting the lesion near the sinus cavity for area 1, we observe not only the phenomenon
of dose inadequacy near the interface but also nearby regions of dose excess. The photon
beams experience under-attenuation when passing the air-filled cavity. Their contribution to
the dose at the isocentre may be higher than expected from the calculations for the
homogeneous media. Figures 6(a), (b) show that the dose far from the interface has a 6–7%
enhancement, in comparison to the expected dose value from the homogeneous calculation.
The area of overdosage is small in comparison to the targeted area when the isocentre is close
to the interface (see figure 6(a)). However, the enhanced dose may cover most of the targeted
4890 V Moskvin et al

(a) (b)

Figure 6. Dose profiles in the direction perpendicular to the air-tissue interface for homogeneous
(dashed lines) and heterogeneous (solid lines) phantoms. A collimator of 8 mm is used for
computations. The positions of the isocentre were selected at 1 mm (a) and 4 mm (b) from the
interface. In the case of area 2 (see figure 1), the isocentre is marked as ‘A’ in figure 2. D indicates
the distance from isocentre to the interface.

(a) (b)

Figure 7. The ratio of dose at the isocentre for the heterogeneous phantom to dose at the isocentre
for its homogeneous representation. The dependence of the dose ratio on distance to the interface
for targets in areas 1 and 2 for 4 mm (a) and 8 mm (b) collimators is shown.

area when the isocentre is far from the interface (see figure 6(b)). This overdosing effect is
less significant for profiles in area 2 since fewer individual beams are passing through the
air cavity.
The value of the dose at isocentre depends upon the distance to the interface. The ratio
of the dose at the isocentre for the heterogeneous phantom to the dose at the isocentre for
its homogeneous representation characterizes the dose perturbation due to inhomogeneity.
Figures 7(a), (b) show the dependence of this dose ratio on the distance to the interface for
targets in areas 1 and 2 (see figure 1). While the absolute values of the ratio may be different
for various collimators due to some variances in target area position relative to the cavity,
geometry of the cavity and phantom surface, output beam size, etc, the general trend shown in
figure 7 remains unaltered by these factors. If the distance from the isocentre to the interface
Monte Carlo simulation of Leksell Gamma Knife (II) 4891

(a) (b)

(c) (d)

Figure 8. Dose distribution while plugging the sources whose beams pass through the air cavity
en route to the isocentre. The position of the isocentre corresponds to point (A) in figure 2, and is
1 mm from the air-tissue (acrylic) interface. (a) Plug pattern used in simulation. (b) Comparison
of GammaPlan output (dashed lines) and Monte Carlo results for homogeneous phantom (solid
lines). (c) Sagittal plane view is given for this comparison of the Monte Carlo calculated dose
in heterogeneous phantom (solid lines) with the dose in its homogeneous representation (dashed
lines). (d) Dose profile for the heterogeneous (solid line) and homogeneous phantom (dashed line).
Comparison with figure 6(a) where profiles for all 201 open sources are given shows elimination
of the overdosing effect (seen without plugging). D indicates the distance from the isocentre to
the interface.

is less than 1.5 mm, the dose at the isocentre in heterogeneous media is below the dose
at the isocentre in homogeneous media under conditions of the equivalent geometry of the
phantom external surfaces. The isocentre positions from 1.5 to 3 mm to the interface are
characterized by the dose enhancement that reaches saturation at larger distances. The dose at
larger distances (distances greater than 4 mm) is higher than the dose in homogeneous media
by 5–6%, due to the under-attenuation of beams passing through air cavities.

3.5. Dose perturbation for different plug patterns

The results of calculations and measurements presented above were acquired for all 201
Cobalt-60 sources. We hypothesized that it may be possible to reduce the effects described
above by plugging beams that pass through the air cavity en route to the isocentre. Evaluating
the beam intersection with air cavity for the target position A (see figure 2) at a 1 mm distance
from the isocentre to the interface, a plug pattern was designed (see figure 8). Figure 8(b) shows
4892 V Moskvin et al

(a)
1.5
cm Transverse View
Acrylic Air
1
Acrylic

0.5 Isocentre Bone

0 Sagittal View

Bone (Aluminium insert)

-0.5
Acrylic
-1 Isocentre Bone

-1.5
-1.5 -1 -0.5 0 0.5 1 1.5 Transverse View
cm
(b) 1.5
cm Transverse View
Tissue Air
1
Acrylic
0.5 Isocentre Bone

0 Sagittal View

-0.5 Bone (Aluminium insert)

Acrylic
-1
Isocentre Bone

-1.5
-1.5 -1 -0.5 0 0.5 1 1.5 Transverse View
cm

Figure 9. Dose distribution in the presence of bone-tissue (acrylic-aluminium) heterogeneity.

Results are presented in a transverse plane view. Monte Carlo simulation is shown by solid lines,
and (a) measurements are given by dashed lines, (b) calculations for homogeneous phantom are
given by dash-dot line. Sagittal and transverse slices of the phantom with the position of the
isocentre are shown for corresponding phantoms. D indicates the distance from the isocentre to
the interface.

that it is not significantly different between GammaPlan
R

output and Monte Carlo results for
a homogeneous phantom. The results of the measurements and the Monte Carlo calculations
for an inhomogeneous phantom do not differ significantly. While the overdosage effects are
reduced, both sets of data clearly show the underdosage near the air-acrylic interface presented
in figure 8(c). The underdosage near the air-tissue interface cannot be eliminated with any
plug pattern, since the effect is determined by the disequilibrium in the secondary electron
field that is created in the targeting area. However, the overdosage due to under-attenuation
of the photon beams in air cavities can be eliminated by plugging the sources whose beams
intersect the air cavity (see figure 8(d) in comparison with figures 6(a), (b) for unplugged 201
sources).

3.6. Dose in the presence of bone-tissue heterogeneity

The case of targeting an area close to the skull is presented in figure 9. It is seen from
figure 9(a) that the dose distribution measured (dashed lines) matches the results of the Monte
Carlo simulation (solid lines). Figure 9(b) illustrates the simulation for the modified numerical
Monte Carlo simulation of Leksell Gamma Knife (II) 4893

phantom discussed in section 2.2. Results for an inhomogeneous phantom (solid lines) are
presented together with the data for a homogeneous phantom (dot-dashed lines). Simulations
for both versions of the phantom (figures 9(a) and (b)) show that there is no significant dose
perturbation in the targeted area. Dose perturbation may occur close to the external surface
(skin area) due to forward scattering of the secondary electrons from bone (Das et al 2001,
2002).
Figure 9 indicates that corrections for the bone-tissue heterogeneity are not as important
for stereotactic radiosurgery as are corrections for air cavities. Algorithms that are currently
implemented in treatment planning systems for Gamma Knife that utilize a homogeneous
media approach may be applicable for skull-based lesion treatment planning. However,
further investigation of dose changes in the presence of the bone-tissue interface may be
necessary for typical clinical set-ups to determine limitations of these algorithms.
There is some indication of higher clinical efficacy in the treatment of skull-based
lesions than lesions near air-filled cavities (Chang et al 2003). Observed differences in the
roles of these two types of heterogeneities for dose perturbation and observed differences
between dose data for homogeneous and heterogeneous media, as well as some clinical data
(Chang et al 2003), suggest that the current treatment planning system GammaPlan
R
used for
Gamma Knife needs improvement for proper inclusion of air-tissue inhomogeneity corrections
in its algorithm.

4. Conclusions

The findings of this study indicate that variations in attenuation and the absence of electronic
equilibrium adjacent to air-tissue heterogeneity can cause errors in dose calculations when
using algorithms that ignore cavities and assume homogeneous media geometry. The study
shows that air-tissue inhomogeneity leads to rapid dose fall-off near the interface due to lack
of electron equilibrium. As a result, algorithms assuming homogeneous media geometry
overestimate values at distances up to 4 mm from the interface. The dose delivered to the
targeting area is underestimated by these algorithms by up to 7% in the presence of the
interface. A beam passing through an air cavity is under-attenuated, which increases dose
away from the interface. Moreover, the plugging of beams passing through the air cavity
does not decrease the underdosage due to the inhomogeneity. In addition, the dose to
critical structures may be underestimated, even when these critical structures are far from the
targeting area but close to the air-filled cavity. The use of algorithms utilizing the assumption
of homogeneous media (without proper inhomogeneity corrections) may lead to incorrect
characterization of dose in these circumstances.

Acknowledgments

The computational resources of the Research SP (Indiana University IBM Teraflop SP) used
to acquire the data for this work have been funded in part by the Indiana Genomics Initiative
and Shared University Research grants from International Business Machines, Inc. The
Indiana Genomics Initiative of Indiana University is supported in part by Lilly Endowment,
Inc.

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