Choice of optimum megavoltage for accelerators for photon beam treatment

Over three decades ago, the development of megavoltage accelerators revolutionized radiation oncology and provided the therapist with photons and electrons of any desired energy. The initial advantages cited for high energy photon therapy, listed below, have proved valid and accelerators have almost totally replaced orthovoltage units. Initially, it appeared that most of these cited advantages should continue to improve with increasing energy, and there has been an impetus for the production of ever higher megavoltage accelerators. Some of these advantages are reviewed in this paper. Also, recent investigations have indicated increasing diffuseness of the photon beam boundary with increasing energy because of lateral transport of electrons. The impact on treatment planning as a function of energy of the increase in volume dose due to the diffuseness of beam boundaries, "build-down" and "rebuild-up" effects in tissues at cavity and inhomogeneity interfaces, bone absorption, and photoneutron production are discussed. Consideration of the behavior of these parameters indicates that optimum photon energies have been achieved and that the impetus for higher megavoltages is unwarranted for most treatment. For many therapeutic applications, there are major advantages of 4 MV to 8 MV photon beams relative to 60Co gamma rays. For large lesions in the abdomen or pelvis there is an advantage to energies above those provided by 15 MV units. The various considerations above are discussed and summarized as a function of lesion site and megavoltage.