Original

Investigation of Collapsed-cone MSc, Medical Physics

1

Department, Students
Algorithm Accuracy in Small Fields and Research Committee,
Kermanshah University
Heterogeneous Environments of Medical Sciences,
Kermanshah, Iran
2
MD, Radiation oncolo-
gist, Faculty of Medicine,
Hamedan University
Razieh Zaghian1 , Abdolazim SedighiPashaki2, Abbas Hagh- of Medical Sciences,
parast3* , Mohammad Hadi Gholami4, Mahdi Mohammadi1 Hamedan, Iran
3
PhD, Department of
Medical Physics, Faculty
of Medicine, Kerman-
ABSTRACT shah University of Medi-
cal Sciences, Kerman-
Background: The use of small fields has increased by the emergence of advanced shah, Iran
radiotherapy. Dose calculations of these fields are complex and challenging for many 4
PhD, Medical Physicist
reasons such as lack of electrical equilibrium even in homogeneous environments, of Radiotherapy, Mah-
and this complexity will increase in presence of heterogeneity. According to the dieh Radiotherapy and
importance of delivery the accurate prescription dose to the target volume in the pa- Brachytherapy Charity
tient’s body, the dose calculation accuracy of used commercial algorithms in clinical Center, Hamedan, Iran
treatment planning systems (TPS) should be evaluated.
Objective: The present study aims to evaluate the accuracy of Collapsed-cone
dose measurement algorithm in Isogray treatment planning system.
Material and Methods: In this analytical study, the measurements were
made in tissue equivalent solid water phantom with lung and bone heterogeneities
by Pinpoint dosimeter (0.015 cm3 sensitive volume) in several radiation fields (1×1
to 5×5 cm2). The phantoms were irradiated with 6, 10 and 18 MV photon beams and
finally, the results of experimental calculations were compared with treatment plan-
ning outputs.
Results: In all setups, the maximum deviation occurred in the field of 1×1 cm2.
Then, the maximum deviation was observed for 2×2 cm2 field size; however, it was
up to 5% for homogeneous water phantom and lung heterogeneity. In 3×3 cm2 and
larger fields, there was a good agreement between the results of the TPS and experi-
mental dosimetry. The maximum deviation was observed in water-bone heterogene-
ity.
Conclusion: This algorithm was able to pass the standard audit criteria, but it is
better to be used more cautiously in bone heterogeneity, especially in low energies.
Citation: Zaghian R, SedighiPashaki A, Haghparast A, Gholami MH, Mohammadi M. Investigation of Collapsed-cone Algorithm Accuracy in
Small Fields and Heterogeneous Environments. J Biomed Phys Eng. 2021;11(2):143-150. doi: 10.31661/jbpe.v0i0.1121.

Keywords
Radiotherapy; Dosimetry; Small Field; Algorithms; Phantoms, Imaging; Ab-
*Corresponding author:
sorbed Dose
Abbas Haghparast
Department of Medi-
cal Physics, Faculty of

R
Introduction Medicine, Kermanshah
University of Medical
adiotherapy with ionizing radiation is one of the most frequent Sciences, Kermanshah,
techniques for treating cancers [1, 2]. Radiotherapy can lead to Iran
the DNA damage of cancer cells and stop cell dividing or growth, E-mail: abbas.haghpar-
[email protected]
or prevent them from returning. Irradiation can also damage healthy
Received: 22 January 2019
cells, but the normal cells are more radiation-resistant. However, the Accepted: 16 February 2019

J Biomed Phys Eng 2021; 11(2) 143

Razieh Zaghian, et al
main goal of radiotherapy is to obtain an opti- complicated and magnitude of the error in-
mal balance between delivering the maximum creases [1, 4]. Thus, prediction of the received
dose to target volume and the minimum dose dose in each part of the body is very important
to normal tissue tumor [3]. To this end, the use before initiating the radiotherapy [9, 10].
of modern radiotherapy techniques such as Calculations of absorbed dose are applied
intensity modulated radiotherapy (IMRT), ste- by TPSs. Basic of a TPS is algorithms of dose
reotactic radiosurgery (SRS/SRT), and stereo- calculations [11, 12]. The use of low accuracy
tactic body radiotherapy (SBRT) and as a re- algorithms can lead to prediction errors of the
sult the use of small fields have increased [4]. absorbed dose and inappropriate treatment
The treatment targets in small fields (≤4×4 since the accuracy of dose calculation in both
cm2) are smaller than the size of the field in small fields and heterogeneous environments
conventional radiotherapy. Therefore, target leads to more errors in calculations; thus, TPS
volume receives high radiation dose; on the algorithms should be evaluated [4, 13].
other hand, smaller volume of healthy sur- The aim of present study was to evaluate
rounding tissues has been exposed to radia- the dose calculation accuracy of Collapsed-
tion. Therefore, one of the most fundamental cone algorithm (a model-based algorithm) of
goals of radiation therapy is achieved; on the Isogray TPS in both homogeneous and nonho-
other hand, small-field dosimetry is a chal- mogeneous media, for 6, 10 and 18 MV pho-
lenging issue for a variety of reasons that one ton beam energies in square small fields. The
of these reasons is lack of electron equilibrium results of TPS calculation was compared with
intensifying the heterogeneity and accuracy experimental results as a gold standard.
of determination absorbed dose that becomes
more complicated [5]. Electrical disequilib- Material and Methods
rium occurs when the range of secondary elec- This analytical study aims to determine the
trons is larger than field size, thus it can cause accuracy of Collapsed-cone dose calculation
significant inaccuracies in absorbed doses in algorithm of Isogray TPS. For this purpose, cu-
heterogeneous environments [6, 7]. bic phantoms, which consisted of plates with
Delivering the accurate dose to treatment dimensions of 30×30cm2 and 1cm thickness,
targets is an essential requirement in radio- including soft tissue, bone, and lung equiva-
therapy, as the criterion success rate of radia- lent materials (the setups is shown in Figure
tion therapy depends on the measurement of 1), were used. Electron density specifications
accurate absorbed dose in tumor and compli- and density of various types of used tissues in
ance with the amount of the prescribed dose. If the present study are listed in Table 1.
the absorbed dose is less than prescribed dose, Experimental measuring of absorbed doses
it can lead to the resistance of cancer cells to at the interesting point in phantoms was stud-
radiation or tumor recurrence. Conversely, if ied by Pinpoint 31014 and Dose One electrom-
the absorbed dose be more than the prescribed eter (manufactured by PTW Germany and IBA
dose, it can lead to death or serious damage to respectively). This dosimeter is one of the type
healthy surrounding tissues [7, 8]. According ionization chambers with 0.015 cm3 sensitive
to international commission on radiation units volume (0.1 and 0.5 cm of radius and length)
and measurement (ICRU) reports, the accu- and measuring the dose of high energy pho-
racy of absorbed dose calculation required to tons at high spatial resolution. This dosimeter
control a tumor with less of complications is is most effective in the following conditions:
about ±5% [8]. However, in the vicinity of the the range of gamma energy, cobalt -60 to 50
heterogeneous tissues, and especially in small MV photons, temperatures of 10 to 40 °C,
fields, the dose distribution becomes more and 2×2 to 30×30 cm2 fields. This waterproof

144 J Biomed Phys Eng 2021; 11(2)

 Algorithm Accuracy in Small Filed

Figure 1: Solid water phantom with a) lung and b) bone heterogeneity. The placement of dosim-
eter is shown as a small black circle.

Table 1: Specifications of different materials used in chest heterogeneous phantom.

The electron density per Electron density relative to

Density (g/cm³)
cm3× 1023 water
Soft-tissue 1.06 3.48 1.042
SP34 1.045 3.539 1.003
lung 0.21 0.69 0.207
Cork 0.23 0.57 0.301
Bone 2.00 5.03 1.506
PTFE 2.2 6.243 1.868

dosimeter can be used in air, water, and solid lent material (solid water slabs) from top and
phantom with a polarity effect less than 2%. 5 cm below (Figure 1a). To evaluate the inho-
The thickness of the sensitive pinpoint wall mogeneity of soft tissue-bone, 5 cm solid wa-
is 0.57 mm of PMMA with a density of 1.19 ter slabs were used in addition to 3 cm PTFE
g/cm3 and 0.90 mm graphite and a density of equivalent to bone and again 5 cm of solid wa-
1.85 g/cm3. The central electrode is made of ter (Figure 1b). After heterogeneity, the Pin-
aluminum with a diameter of 0.3 mm. point dosimeter was placed at 0.5 cm in solid
water slab (i.e.at 8.5 depth for the bone and
Radiation to the heterogeneous 10.5 cm for the lung). The location of dosim-
soft tissue-lung and soft tissue- eter is shown in Figure 2.
bone phantoms Then the phantoms were irradiated with an
In order to investigate the effect of soft tis- Elekta linear accelerator (Synergy) with three
sue-lung heterogeneity, 5cm Cork equivalent photon beams energies of 6, 10 and 18 MV
was sandwiched between 5 cm tissue equiva- and measurements made in radiation fields

J Biomed Phys Eng 2021; 11(2) 145

Razieh Zaghian, et al
from 1 × 1 to 5 × 5 cm2. are shown in Figures 1 and 3 were scanned
In all setups, the source to surface distance using computed tomography (CT) scanner
(SSD) was 100 cm and the gantry angle was (16 slices) for treatment planning. After the
0° so that the beam was perpendicular to the CT simulation, transferring the sets of CT im-
surface of the phantom and dosimeter. ages to the TPS was performed. Then, 3D-CT
The all of above steps were carried out for datasets were reconstructed and the intended
homogeneous solid water phantom and the ab- points were determined for dosimetry.
sorbed dose was measured at depth of 5.5 cm After calculating the absorbed dose by TPS,
(Figure 3). the results were compared with the results of
the experimental dosimetry and the relative er-
Dose calculation in TPS ror percentage of CC algorithm was calculated
The slab phantoms with the same setups that according to the following formula.

Figure 2: The location of pinpoint is shown as a black line at the solid water slab’s groove and
in the center of it.

Figure 3: Solid water phantom (soft tissue equivalent).

146 J Biomed Phys Eng 2021; 11(2)

 Algorithm Accuracy in Small Filed

=%E
( DM − DT ) ×100 gies studied, a significant decrease of deviation
DM was observed with increasing field size to 3×3
cm2, but no significant change was observed
In which DM is calculated dose empirically for larger field sizes. Deviation increased with
and DT is the result of TPS calculations. incremental energy in 1×1 cm2. Equal to more
than 2×2 cm2 fields, there was no significant
Results difference between the relative errors in differ-
Figure 4 illustrates the relationship between ent energies but founded the increasing mag-
TPS relative error percentage and field size for nitude of error from 10-18 MV for 2×2 cm2
three studied energies in all setups. field size. In the homogeneous water environ-
ment, at minimum and maximum deviations
Homogeneous water environment were 0.2% and 14% for energy 18 MV and
In this environment, for each of the 3 ener- in 3×3 and 1×1 cm2 field sizes, respectively.
In the mentioned environment, deviation was
negligible and up to 2% with the exception of
1×1 and 2×2 cm2.

Water/Lung heterogeneity
The results obtained from this environment
were similar to the homogeneous water media;
thus, the deviation decreased with the increase
of field size. But it increased in 18 MV with
increasing the field size from 3×3 to 4×4 cm2.
This increasing was still with an acceptable
level of error. From another view, the energy
dependence of the heterogeneity was similar
to the homogeneous water phantom. In this
environment, the minimum error occurred in
4×4 and 5×5 cm2 field size with 6 MV photon
energy, and the maximum error occurred in
1×1 cm2 field size with 18 MV photon energy
and their values were 0.03% and 22.2%, re-
spectively. In this environment, deviation was
up to 2% with the exception of 1×1 and 2×2
cm2.

Water/bone heterogeneity
In this heterogeneity, which was compared
to the previous two environments, there was
a greater difference between the calculations
Figure 4: Curves of relative error percent- of TPS and experimental measurements. The
age of calculated Collapsed-cone algorithm lowest and the highest deviation occurred in
for every field size in three studied media a) 3×3 cm2 and 1×1 cm2 fields for energy 18 MV
solid water phantom with lung heterogene- similar to the homogeneous water environ-
ity b) solid water phantom with bone hetero- ment and deviations were 1.7% and 17.5%,
geneity and c) homogenous water phantom. respectively. Although there was no signifi-

J Biomed Phys Eng 2021; 11(2) 147

Razieh Zaghian, et al

cant difference in this energy for the magni- measuring the absolute dose. The signal quan-
tude of error in 3×3 cm2 and larger fields, the tum noise of the dosimeters depends on the
minimum deviation occurred in the energy of detector`s material, in addition to the sensitive
6 MV (2.6%) in 1×1 cm2 field size. Regard- volume of the detector. This noise is very low
less of this data, deviation was reduced with in pinpoint dosimeter, even rather than diode
increasing the field size, but there was no dif- type E with a sensitive volume of 0.03 mm3.
ference between 4×4 cm2 and 5×5 cm2 field As a result, the precision and speed of the Pin-
sizes for 6 MV photons. For energy of 10 and point dosimeters are very high in dose mea-
18 MV, it decreased by increasing the size to surement [17]. Furthermore, in a similar study
3×3 cm2, and a slight increase was observed in carried out by Alagar [4], a scintillator plastic
larger field sizes than 3×3 cm2. In all fields, a dosimeter was used, which has a high level
deviation reduction occurred with increasing of noise compared to chambers; the highest
energy. quantum noise can be expected from these de-
tectors and dosimetry measurement is a time-
Discussion consuming performance.
In this study, the accuracy of Collapsed-cone This study was carried out in 1×1 to 5×5 cm2
algorithm dose calculating from Isogray TPS field sizes. For all setups, the greatest devia-
was compared with the experimental results tion was observed in the 1×1 cm2 field size,
obtained using the pinpoint dosimeter in the except for bone heterogeneity at 6 MV ener-
homogeneous water phantom, heterogeneous gy, which was consonant with the results of
water-lung and water-bone phantoms exposed Alagar’s study [4]. The maximum deviations
to photon beam radiation with 6, 10 and 18 of the 1×1 cm2 field size for water-lung and
MV in 1×1 to 5×5 cm2 field sizes. In most sim- water-bone heterogeneity were 22% and 17%,
ilar studies, the Monte Carlo simulation has respectively, and for the homogeneous water
been used to verify the accuracy of dose cal- environment was 14%. The most important
culation for clinical measurement algorithms reason for this significant error could be in-
[5, 14, 15], although the Monte Carlo simula- appropriateness of the pinpoint dosimeter in
tion can’t be considered as a golden standard field sizes smaller than 2×2 cm2. The effect of
without experimental confirmation [16]. charged particle disequilibrium in this small
Due to the absence of a single protocol for field should not be ignored.
absolute dose measurement in small fields, the Although the magnitude of error decreased
complexity of direct measurement and com- significantly in 2×2 cm2 field size, the final
paring with calculations of the TPS, most of value was still significant. This behavior can
the studies have investigated the accuracy of be described based on the electrical disequi-
algorithms with measuring the percentage of librium effect. Deviation in this field for 6 and
depth doses. The use of absolute dosimetry 10 MV of photon energy in the lung and water
instead of the relative dosimetry for compar- heterogeneity was relatively lower and about
ing the TPS results and also Pinpoint ionizing 3.5%. While for 18 MV energy, it was 9.1%
chamber (an ideal chamber for small field do- and 5.9% in the lungs and water, respectively.
simetry) led into difference between this study Due to the enhancement of the photon energy,
from other studies. the range of the secondary scatter electron has
Due to the challenges of small-field dosime- increased and the effect of electrical disequi-
try, selecting a suitable detector for dose mea- librium, which is usually not considered in the
surement in these fields is very necessary. Ac- treatment planning algorithms, leads to more
cording to study carried out by J. U. Wuerfel,et deviation.
al., ionizing chambers are the best choice for Generally, for field sizes larger than 2×2

148 J Biomed Phys Eng 2021; 11(2)

 Algorithm Accuracy in Small Filed
cm2, a significant reduction in deviation was sity such as bone. On the other hand, due to
observed with increasing field size in all set- the major difference between water and bone
ups; thus, there was a good agreement between density and the considerable effect of hetero-
experimental results and TPS calculations for geneity in low energies, the heterogeneous
3×3 cm2 and larger field sizes in all energies. correction seems to be inadequate in a Col-
(Deviation less than 2% in water and lung and lapsed-cone algorithm.
less than 5% in bone). Although the deviation
is expected to be low in all fields for homo- Conclusion
geneous water environment but it should be Based on comparison between results of ex-
noted that the electrical disequilibrium effect perimental measurement and calculation of
exists in small fields and high energies, even absorbed dose by Collapsed-cone algorithm
in homogeneous environments. Thus, it seems in a homogeneous water environment and also
this effect causes a relatively significant devia- after inhomogeneous environments of lung
tion in 1×1 and 2×2 cm2 field sizes especially and bone, the greatest deviation was occurred
in18 MV. On the other hand, it was expected for the 1×1 cm2 field size, except for the bone
that the deviation in heterogeneous lung en- heterogeneity at 6 MV. According to this, the
vironment is higher than homogeneous water; Pinpoint dosimeter is not ideal for the absorbed
however, this difference was not observed ex- dose measurement in 1×1 cm2 field size; thus,
cept in the 1×1 cm2 field size and in 18 MV we cannot definitely comment on the accuracy
energy for a 2×2 cm2 field size, which could or inaccuracy of the Collapsed-cone algorithm
be one of the defects of the studied algorithm. in this field size and this relatively large mag-
Jones et al. [5] showed that in low-density nitude of deviation cannot be attributed sepa-
medium such as a lung for a photon 6 MV rately to one of the two mentioned items.
photon in 3×3 cm2 and larger field sizes, the In all setups, the magnitude of error de-
charged particle equilibrium can be recovered creased by increasing the field size, but there
and the algorithms can fairly predict the dose was no specific relationship between devia-
in and out of the inhomogeneity. In the present tion and energy of the photons. In most of the
study, it was also observed that there is an ap- obtained data, the Collapsed-cone algorithm
propriate correlation between the calculations has overestimation rather than experimental
of the TPS and experimental measurements measurements. In the case of high dose cal-
for this region and 6 MV energy; thus, the culation, overestimation values could lead to
magnitude of error was up to 1%. defective tumor treatment or recurrence. Al-
In the presence of high-density heterogene- though in this study, regardless of the 1×1 cm2
ity, such as bone, deviation was dropped by field size, there was an appropriate accordance
increasing the energy values, similar to the re- between the results of the experimental mea-
sults of Alagar’s study [4]. In this heterogene- surements and TPS calculations; however, the
ity, the greatest deviation was observed in 6 observed deviation in water-bone heterogene-
MV for all fields except for 1×1 cm2. ity compared to the water-lung heterogeneity
The dose calculation deviation of bone het- and the homogeneous water environment was
erogeneity in each field size and energy was significant especially in low energies due to
higher than other environments in contrast to the weakness of the Collapsed-cone algorithm
the observation of Alagar. This phenomenon in heterogeneous correction, or the inconsider-
could be due to differences in type of dosim- ation of the backscattering electrons effect in
eter and algorithm; in addition, TPS could not the presence of high-density materials. Nev-
calculate backscattering electrons effect on ertheless, it is better to use this algorithm with
dose distribution in materials with high den- more caution in presence of inhomogeneity

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Razieh Zaghian, et al
with high density (such as bone), and espe- Phys. 1984;10 Suppl 1:23-9.doi: 10.1016/0360-
cially in low energies. 3016(84)90441-3. PubMed PMID: 6735791.
8. Wambersie A. The role of the ICRU in quality as-
Acknowledgment surance in radiation therapy. Int J Radiat Oncol Biol
Authors gratefully acknowledge the Re- Phys. 1984;10 Suppl 1:81-6. doi: 10.1016/0360-
3016(84)90454-1. PubMed PMID: 6429103.
search committee of Kermanshah University
9. Fippel M. Fast Monte Carlo dose calculation for
of Medical Sciences for the financial support. photon beams based on the VMC electron al-
Also, the authors declare their gratitude to staff gorithm. Med Phys. 1999;26:1466-75. doi:
of Radiotherapy Department of Imam Reza 10.1118/1.598676. PubMed PMID: 10501045.
Hospital, Kermanshah, Iran and Mahdieh Ra- 10. Jabbari K, Bagher Tavakoli M, Mojtaba Hosseini S.
diotherapy and Brachytherapy Charity Center, Development and Implementation of the Convolu-
Hamedan, Iran. tion Method for Photon Dose Calculation in Radia-
tion Therapy. Journal of Isfahan Medical School.
2012;30(198):11.
Conflict of Interest 11. Fogliata A, Nicolini G, Clivio A, Vanetti E, Cozzi L.
None Accuracy of Acuros XB and AAA dose calculation
for small fields with reference to RapidArc® ste-
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