ObjectiveTo measure the setup errors with infrared marker-based positioning system (IM-BPS) and electronic portal imaging device (EPID) for patients with esophageal carcinoma and lung cancer and investigate the accuracy and practicality of IM-BPS. MethodsFrom January 2007 to January 2008, 40 patients with esophageal carcinoma and 27 patients with lung cancer received three-dimensional conformal radiotherapy or intensity-modulated radiotherapy, setup errors during the treatment were measured with IM-BPS and EPID, and the data of setup errors were compared with paired t-test and agreement with x2-test. ResultsIt takes 10 - 12 mins to complete the validating for each patient by EPID) system, while IMBPS system only needs 2 -5 mins. The mean setup errors along x, y and z-axis for patients with esophageal carcinoma measured by IM-BPS and EPID were 3.49 mm, 3. 19 mm, 3.31 mm and 4. 03 mm, 3.41 mm, 3.43 mm, respectively. For the patients with lung cancer, the setup errors were 4. 23 mm, 3.51 mm, 3. 39mm and 4. 85 mm, 3. 53 mm, 3.74 mm, respectively. The difference of setup errors meanured by the two systems was within 1 mm for 65％ esophageal carcinoma patients ( x2 =51.09, P =0. 000), and 55％ lung cancer patients ( x2 =53. 35, P =0. 000).Conclusions The measurement results of setup errors for patients with esophageal carcinoma and lung cancer show that IM-BPS is mostly better than EPID. Though validating for patients can be measured accurately and be well quality controlled, IM-BPS is used easily because of macroscopic, homely,spare time and real-time monitoring.

Objective With the Monte Carlo method to recaleulate the IMRT dose distributions from four TPS to provide a platform for independent comparison and evaluation of the plan quality.These results wiU help make a clinical decision as which TPS will be used for prostate IMRT planning.Methods Eleven prostate cancer cases were planned with the Corvus,Xio,Pinnacle and Eclipse TPS.The plans were recalculated bv Monte Cado using leaf sequences and MUs for individual plans.Dose-volume-histograms and isodose distributions were compared.Other quantities such as Dmin(the minimum dose received by 99% of CTV/PTV),Dmax(the maximum dose received by 1%of CTV/PTV),V110%,V105%,V95%(the volume of CTV/PTV receiving 110%,105%.95% of the prescription dose),the volume of rectum and bladder receiving>65 Gy and>40 Gy,and the volume of femur receiving>50 Gy were evaluated.Total segments and MUs were also compared.Results The Monte Carlo results agreed with the dose distributions from the TPS to within 3%/3 mm.The Xio,Pinnacle and Eclipse plans show less target dose heterogeneity and lower V65 and V40 for the rectum and bladder compared to the Corvus plans.The PTV Dmin is about 2 Gy lower for Xio plans than others while the Corvus plans have slightly lower female head V50(0.03%and 0.58%)than others.The Corvus plans require significantly most segments(187.8)and MUs(1264.7)to deliver and the Pinnacle plans require fewest segments(82.4)and MUs(703.6).Conclusions We have tested an independent Monte Carlo dose catculation system for dose reconstruction and plan evaluation.This system provides a platform for the fair comparison and evaluation of treatment plans to facilitate clinical decision making in selecting a TPS and beam delivery system for particular treatment sites.

Objective To study the relationship between parameter settings in the intensity-modulated radiation therapy (IMRT) planning in order to explore the effect of parameters on absolute dose verification.Methods Forty-three esophageal carcinoma cases were optimized with Pinnacle 7.6c by experienced physicist using appropriate optimization parameters and dose constraints with a number of iterations to meet the clinical acceptance criteria.The plans were copied to water-phantem,0.13 cc ion Farmer chamber and DOSE1 dosimeter was used to measure the absolute dose.The statistical data of the parameters of beams for the 43 cases were collected,and the relationships among them were analyzed.The statistical data of the dosimetry error were collected,and comparative analysis was made for the relation between the parameters of beams and ion chamber absolute dose verification results.Results The parameters of beams were correlated among each other.Obvious affiliation existed between the dose accuracy and parameter settings.When the beam segment number of IMRT plan was more than 80,the dose deviation would be greater than 3％ ; however,if the beam segment number was less than 80,the dose deviation was smaller than 3％.When the beam segment number was more than 100,part of the dose deviation of this plan was greater than 4％.On the contrary,if the beam segment number was less than 100,the dose deviation was smaller than 4％ definitely.Conclusions In order to decrease the absolute dose verification error,less beam angles and less beam segments are needed and the beam segment number should be controlled within the range of 80.

Objective To measure the setup errors and organ movements of patients with esophagus carcinoma during radiotherapy and find a reasonable margin from the clinic target volume (CTV) to the planning target volume (PTV). Methods (1) Set-up veri cation: Forty-two cases of untreated esophageal cancer were enrolled into this study. The physicist firstly made the planning according to the doctor requests and ensured the best distribution at the target. Thereafter, the 0° and 90° digitally reconstructed radiograph (DRR) was transmitted to the iView GT workshop. Meanwhile, two copies of cross-cut electronic portal image (EPI) were required before radiotherapy. Two doctors confirmed the variance of the osteal mark from the EPI and DRR,and output a 3D direction (left to right, superior to inferior, anterior to posterior) of the setup errors through the iView GT software. (2)Breathing motion:Ten cases of untreated esophageal cancer were enrolled into this study.Three distinct breathing levels were deflned: FB (free breathing), EBH (expiration with breath-held) and IBH (inspiration with breath-held). We gave the treatment planning in FB, then by moving the isocenter to EBH and IBH, we recalculated the dose distribution without changing the field angle, shape and weighing (Mus). Displacements were analyzed at four points (anterior, posterior, right lateral and left lateral) and five levels of target (upper, quarter, isocenter, three-quarter and lower). Results (1) The systematic setup errors were -0.23 cm, -0.02 cm and -0.06 cm, and the random errors were 0.44 cm, 0.45 cm and 0.44 cm at the direction of left to right(LR), superior to inferior (SI), anterior to posterior(AP), respectively. (2) The organ movements were 0.3 cm, 0.6cm and 0.3cm at the LR, SI, AP, respectively. Conclusions As an alternative, the root-sum-of-squares of set-up error and organ motion are suggested by σtot=√ (σITV2+σSM2). The CTV to PTV margins are 0.8cm left to right, 0.78cm superior to inferior, 0.5cm anterior to posterior.

Objective To figure out the optimal parameters of a volumetric modulated arc therapy ( VMAT) plan for cervical and upper esophageal cancer by quality evaluation of VMAT plans with different parameters, and to provide a reference for the design of clinical VMAT treatment plan. Methods Ten patients with cervical esophageal cancer and ten patients with upper esophageal cancer were enrolled as subjects. The Nucletron Oncentra 4. 3 treatment planning system was used to generate plans for Elekta Synergy VMAT accelerator. Six VMAT plans were made with variation in the gantry angle ( 2°, 3°, and 4°), the maximum delivery time (80 s, 110 s, and 150 s), and the collimator angle (0° and 45°). The doses to the planning target volume and organs at risk were analyzed by paired t test. Results For cervical and upper esophageal cancer, the quality of VMAT plans with a collimator angle of 45° was better than those with a collimator angle of 0°(P=0. 003?0. 007). For cervical esophageal cancer, there was no significant difference in quality between VMAT plans with a maximum delivery time of 110 s or 150 s and those with a maximum delivery time of 80 s ( P>0. 05 );for upper esophageal cancer, there was also no significant difference in quality between VMAT plans with three different maximum delivery times ( P>0. 05 ) . For cervical esophageal cancer, the VMAT plans with a gantry angle of 3° had a better quality than those with a gantry angle of 2° or 4°(P=0. 010?0. 048). For upper esophageal cancer, the VMAT plans with a gantry angle of 3° had a better quality than those with a gantry angle of 4° ( P=0. 010?0. 048) . Compared with those with a gantry angle of 2° , the VMAT plans with a gantry angle of 3° had a slightly better dose distribution in the target volume ( P=0. 046 ) , but a slightly higher dose to lung tissue ( V25 and V30 , P=0. 007 and 0. 026) . Conclusions The optimal initial parameters of a VMAT plan for cervical and upper esophageal cancer are a collimator angle of 45°, a maximum delivery time of 80 s, and a gantry angle of 3°.

Objective To investigate the optimization of therapeutic regimen through the adjustment of the minimum sub-field area in intensity-modulated radiotherapy (IMRT) for cervical cancer,under the premise of no influence on the dose to target volume or organs at risk.Methods A total of 12 patients with pathologically confirmed cervical cancer were enrolled,and the prescribed dose to the planning target volume (PTV) was 50 Gy in 25 fractions.The Pinnacle 8.0m treatment planning system was used for all patients,and 16 IMRT plans were developed for each patient,with the application of 9 evenly distributed fixed incidence directions (0°,40°,80°,120°,160°,200°,240°,280°,and 320°),a minimum sub-field number of 80,and a minimum sub-field hop count (MU) of 5 MU.The range of sub-field area was 2-81 cm2.Direct machine parameter optimization was used for inverse-planned optimization calculation,and all the plans met the requirements of the clinical prescribed dose.The dose-volume histogram was used to evaluate the dose distribution in target volume and organs at risk.Results With the sub-field area increasing from 2 cm2 to 81cm2,the total hop count of IMRT plan was reduced from (1405±170) MU to (490±47) MU (P=0.000),and when the sub-field area increased above 6 cm×6 cm,the total hop count was reduced significantly (P=0.000).In the IMRT plan with a minimum sub-field area of 2-49 cm2,there was no significant difference in dose between the target volume and the organs at risk (P＞0.05).The dose to the rectum,the bladder,and both femoral heads showed no significant differences across the IMRT plans with different minimum sub-field areas (P＞0.05).Conclusions When the Pinnacle 8.0m treatment planning system is used to develop IMRT plans for cervical cancer,the requirements for clinical dose can still be met with a minimum sub-field area reaching 7 cm×7 cm,and there are significant reductions in sub-field hop count and total hop count.

Objective To compare the results of three dose verification solutions of esophageal carcinoma IMRT plans. Methods Seven esophageal carcinoma cases were planned with Pinnacle 8.0 h.The MATRIXX and Delta4 were chosen as the two-dimensional dosimetry and three-dimensional dosimetry.IMRT plans and Delta4 phantom plans were also recalculated by Monte Carlo. Gamma values were evaluated for MATRIXX and Delta4 with 3 mm/3% gamma criteria. For the comparison of Pinnacle, Delta4 and Monte gamma maps, the dose distribution in central plane, dose profiles and dose-volume histograms were used to evaluate the agreement. Results The gamma maps comparison show that with 3 mm/3% gamma criteria an over 98% pass ratio was obtained by MATRIXX measurement. A 94. 4% gamma pass ratio whicl.contains 4 fields gamma pass ratio lower than 90%, was obtained by Delta4 measurement. A 97.6% and 99. 8% gamma pass ratio was obtained between the Delta4 measurement and Monte Carlo simulation with 2 mm/2% and 3 mm/3% gamma criteria. The dose distribution in central plane and dose profiles from Pinnacle calculation were almost in agreement with both the Monte Carlo simulation and Delta4 measurement. The DVH plot have slightly differences between Pinnacle and Delta4 measurement as well as Pinnacle and Monte Carlo simulation, but have excellent agreement between Delta4 measurement and Monte Carlo simulation. Conclusions It was shown that all the three methods can be used very efficiently to verify esophageal carcinoma IMRT delivery, Delta4 and Monte Carlo simulation no data missed. The primary advantage of Delta4 is the fact it can measure true 3D dosimetry while Monte Carlo can simulate in patients CT images but not in phantom.

Objective To evaluate the variance and the concordance between the tumor length measured by CT scans and that measured by surgical specimens in esophageal carcinoma. Methods Fiftytwo surgical specimens of the esophageal carcinoma were made into pathological giant section.The shrinkage ratio of tumor was calculated by comparing the length of the specimen fixed by formalin for 24 h and that measured during the operation.One hundred and thirty-seven patients with esophageal carcinoma underwent spiral CT scan before the surgery,and the length of the gross tumor volume was obtained.After the tumor length of the fixed specimen had been measured,the real tumor length in situ was calculated using the shrinkage ratio.Then the variance and the concordance between the tumor length in CT scans and that in situ were compared.Results The mean shrinkage ratio was 90%±10%.The mean tumor length in CT scans was longer than that in situ(5.8 am±2.4 cm vs 4.1 cm±1.8 cm,P=9.68,P=0.000).The concordance of the length measured by the two methods was 40.9%(56/137). Conclusions A certain variance existed between the tumor length in CT images and that computed from surgical specimen in esophageal carcinoma.The results of esophagography and endoscopy should also be referred to delineate the gross tumor volume of esophageal carcinoma.

ObjectiveTo evaluate correlation factors of cervical lymph nodes metastasis in thoracic esophageal carcinoma.MethodsLocal-regional metastasis of lymph node for 126 cases with esophageal squamous cell cancer after surgery from 2004 to 2009 were reviewed.Risk factors of cervical lymph nodes metastasis were examined by multiple Logistic regression analysis.ResultsIn 126 cases,supraclavicular lymph node metastasis rate was 43.7％ (55/126).By logistic regression,none of the primary site,T stage,N stage,histological grade,lymph node metastasis rate,lymph node metastasis degree and number of lymph nodes metastatic field was not the high risk of cervical lymph nodes metastasis.In addition,multivariate analysis found that lymph node metastasis in mediastinum region 1 was high risk factor for lymph node metastasis of region 1 ( x2 =12.14,9.27,P =0.000,0.002),lymph node metastasis in region Ⅲ and region 2 were high risk factors for lymph node metastasis of region Ⅱa ( x2 =14.56,8.27,8.02,3.93,P =0.000,0.004,0.005,0.047 ).ConclusionMediastinal para-recurrent nerve lymph node metastasis is a significant predictor for cervical lymph nodes metastasis.

Objective To investigate the application of the Monte Carlo dose calculation of output factors for electron beams in radiotherapy.Methods The code EGS4/MCTP was used to simulate the head of a medical linear accelerator (Varian 23EX) to calculate the output factors for 6 MeV,9 MeV and 18 MeV electron beams.The source-to-surface distance used was 100 cm.The field sizes ranged from 2 cm × 2 cm to 25 cm × 25 cm.The calculated output factors agreed with the corresponding measured factors which were measured by the IBA Phantom system to within 2％.Then,the output factors of direct articles and indirect articles which were under different energy and various cone-insert combinations were calculated by the code EGS4/MCTP.Results The calculated output factors agreement with the measurements is found to be mostly under the 1％ level.The variation of output factors depends on the characteristics of the beams and the modifications that the various cone-insert combinations introduce to these characteristics.Conclusions Monte Carlo dose calculations for electron beams in homogeneous water phantoms have been demonstrated to be accurate under the 1％ level in comparison with measurements.The output factors were influenced by energy and cone-insert combinations in complex ways.