%0 Generic
%A Bortfeld, Thomas
%C Heidelberg
%D 2023
%F heidok:33027
%K Intensity Modulated Radiation Therapy (IMRT); Intensity Modulated Proton Therapy (IMPT); Intensity Modulated Arc Therapy
%R 10.11588/heidok.00033027
%T Dose Conformation in Tumor Therapy with External Ionizing Radiation: Physical Possibilities and Limitations
%U https://archiv.ub.uni-heidelberg.de/volltextserver/33027/
%X The central problem in tumor irradiation is to deposit a high and spatially uniform dose in the tumor target volume while sparing the surrounding normal tissue as much as possible. The present work investigates how such an adaptation ("conformation") of the spatial dose distribution to arbitrarily shaped target volumes can be achieved, and where the physical limits lie. In particular, the specific possibilities of irradiation with different types of radiation are determined under these aspects, whereby a rough distinction is made between irradiation with charged and uncharged particles. Due to the different mechanisms of radiation-tissue interaction, a conformal dose distribution can be achieved with only one radiation field in the case of heavy charged particles; in the case of uncharged particles, several radiation fields from different directions are required.    First, the possibilities and limits of dose conformation are evaluated theoretically. Analytical approximations for modeling dose distributions with uncharged and charged particles are developed. Within the framework of these approximations, the theory of the exponential Radon transform is used to determine the optimal parameters for obtaining a desired dose distribution. It is shown that for an infinite number of radiation fields in the plane, it is possible to adapt the high-dose region to arbitrarily shaped target volumes for both uncharged and charged particles. The dose in a small radiation-sensitive organ at risk in the immediate vicinity of the target volume can be reduced to small scatter contributions. In the case of charged particles, this is also possible for multiple organs at risk. Furthermore, the non-conformal "dose background" is always smaller for charged particles than for uncharged particles.    In a more application-oriented chapter, an algorithm is developed for the optimization of dose distributions under practical boundary conditions, i.e. in three dimensions, with finitely many radiation fields and for finite resolutions of the beam shaping devices. To achieve optimal dose distributions, the use of fluence- and (in the case of charged particles) energy-modulated radiation fields is necessary. Especially in the case of uncharged particles, the technical prerequisites for this are not yet available in clinical practice. Therefore, newly developed approaches to fluence modulation for uncharged particles using a dynamically or quasi-dynamically driven "multileaf collimator" are presented.     Furthermore, the first phantom experiment is described in which these generalized methods for achieving the best possible conformal dose distribution were realized with high-energy photons (15-MV bremsstrahlung spectrum). The high degree of practically achievable dose conformation is thus verified. Finally, a comparison of the optimized dose distributions achievable with photons and protons is performed for challenging clinical cases where conventional radiotherapy reaches its limits.    The most important result is that irradiation with uncharged particles, and in particular with high-energy X-rays, can be optimized in such a way that, in all clinically relevant cases, tumor-conformal dose distributions can be achieved with relatively few (less than ten) radiation fields. The exposure of healthy tissue is naturally higher than for heavy charged particles. However, the tolerance dose values are not exceeded. Exceptions are the rare cases in which the target volume is surrounded on almost all sides by particularly radiation-sensitive risk organs. Only in these cases can a much better result be achieved with the technically more demanding heavy charged particle therapy.
%Z English translation of the Habilitation thesis that was originally published in German: https://doi.org/10.11588/heidok.00032663