Which is the most suitable number of photon beam portals in coplanar radiation therapy?

Computer-controlled milling machines for compensator manufacture, dynamic multileaf collimators, and narrow scanned electron or bremsstrahlung photon beams have opened up new possibilities to shape nonuniform fluence profiles and have thus, paved the road for truly three dimensional (3D) dose delivery. The present paper investigates the number of beam portals required to optimize coplanar radiation therapy using uniform and nonuniform dose delivery.

A recently developed algorithm has been used for optimization of the dose delivery in such a way that the probability of achieving tumor control without causing severe reactions in healthy normal tissues becomes as high as possible. This method has been used to optimize the delivered dose distribution for an increasing number of beam portals to determine how many coplanar beam portals are desirable to safely achieve a good treatment outcome. Target volumes in the head and neck, thorax, and abdomen have been investigated.

Nonuniform dose delivery allows a considerable improvement in the treatment outcome compared to uniform dose delivery. This is evident both from the probability of achieving complication-free tumor control and the value of relevant properties of the dose distribution, such as the mean value and the standard deviation of the mean dose to target volume and organs at risk. The results also show a close relationship between the dose distribution parameters and the probability of achieving complication-free tumor control. The level of complication-free tumor control first increases rapidly when the number of beam portals is increased, but already reaches a level of saturation after three to five beam portals. When the saturation level has been reached, the standard deviation of the mean dose to the target volume is around 3%.

To achieve optimal expectation value of the treatment outcome, within an accuracy of a few percent as measured by the probability of achieving complication-free tumor control, it is generally sufficient to use three nonuniform beam portals. A very large number of coplanar beams may only raise the probability of achieving complication-free tumor control by 1 to 2%. However, good treatment outcome with three beam portals requires that the directions of incidence of the coplanar nonuniform beams are optimally selected. If, on the other hand, the treatment is performed using uniform beams, it is not possible, even with an infinite number of fields, to obtain as high a level of complication-free tumor control as with a few nonuniform beams. From an optimization point of view, it is sufficient to reach a relative standard deviation of the mean dose to the target volume of around 3%. Improved dose homogeneity beyond this level will, in general, not significantly improve the complication-free tumor control.