AN OVERVIEW OF MONTE CARLO TREATMENT

PLANNING FOR RADIOTHERAPY

Emiliano Spezi* and Geraint Lewis
Department of Medical Physics, Velindre Cancer Centre, Velindre Road, Whitchurch,
Cardiff CF14 2TL, Wales, UK
The implementation of Monte Carlo dose calculation algorithms in clinical radiotherapy treatment planning systems has been
anticipated for many years. Despite a continuous increase of interest in Monte Carlo Treatment Planning (MCTP), its intro-
duction into clinical practice has been delayed by the extent of calculation time required. The development of newer and faster
MC codes is behind the commercialisation of the rst MC-based treatment planning systems. The intended scope of this
article is to provide the reader with a compact primer on different approaches to MCTP with particular attention to the
latest developments in the eld.
INTRODUCTION
Recent statistics have shown that radiotherapy con-
tributes to cure of 40% of cancer patients in the
UK
(1)
. However, radiotherapy represents only 5% of
the total National Health Service expenditure in
cancer care
(2)
. Radiotherapy can therefore be con-
sidered to be a clinically important and cost-effective
form of cancer treatment. It has been shown that
dose differences up to 7% can be clinically detectable
and that deviations from the prescribed dose of 5%
or more can compromise tumour response and
tissue morbidity
(3,4)
. The introduction into clinical
practice of more accurate algorithms for patient
dose calculation is therefore of paramount import-
ance. Dose calculation algorithms based on the
Monte Carlo (MC) method are widely regarded as
the most accurate tool available in radiotherapy
(5)
.
A number of general-purpose MC codes are publicly
available (e.g. FLUKA
(6)
, MCNP
(7)
, EGSnrc
(8)
,
Penelope
(9)
, GEANT
(10)
) and have been intensively
used for research and development in medical appli-
cations over the past decades. Recently, Rogers
(11)
reviewed techniques for electronphoton transport
simulations with special emphasis on the
EGS4/EGSnrc code system. Ma and Jiang
(12)
reviewed MC modelling techniques of clinical elec-
tron beams, whereas Verhaegen and Seuntjens
(13)
focused their review on the modelling of external
radiotherapy photon beams. Figure 1 summarises
the number of publications between 1985 and 2007
for general-purpose MC codes of major interest in
medical physics (http://www.isiknowledge.com).
Entries are grouped per scientic area. It is evident
that the MCNP code is used extensively in different
scientic elds. This is because of the exibility and
usability provided by the combinatorial geometry
package and because of the possibility to transport
all particles (i.e. neutrons, protons and heavy ions as
well as photons and electrons). However, in medi-
cally related elds the EGS4/EGSnrc code system is
very popular, representing a de facto standard
for photonelectron transport in the energy range
(110 MeV) of radiotherapy interest.
In particular, the number of publications reporting
the use of MC in radiotherapy treatment planning
(MCTP) has increased exponentially in the last
25 years. This is clearly shown in Figure 2, where
the number of MCTP scientic articles between
1985 and 2007 is sorted per year of publication.
Despite a continuous increase of interest in MCTP,
the introduction of MC algorithms in clinical prac-
tice has been delayed by the excessive calculation
times involved. The development of newer and faster
MC codes is behind the rst wave of commercially
available MC-based treatment planning systems.
Reynaert et al.
(14)
have recently discussed existing
MC dose calculation engines and reported on
specic issues regarding the commissioning of
MCTP systems. Similarly Chetty et al.
(5)
have
reviewed major MC codes being used in clinical
applications and provided useful recommendations
for the clinical implementation of MCTP.
The intended scope of this article is to provide the
reader with a compact primer on the different
approaches to MCTP rather than an exhaustive
review of the available MC codes and techniques,
which have been already covered elsewhere.
A BRIEF HISTORY OF MCTP
Several MC codes have been developed and used in
medical radiation physics in the past few decades.
Figure 3 summarises the major release of popular
MC codes used in radiotherapy physics, radiation
*Corresponding author: emiliano.spezi@velindre-tr.wales.
nhs.uk, espezi@cardiff.ac.uk
# The Author 2008. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
Radiation Protection Dosimetry (2008), pp. 17 doi:10.1093/rpd/ncn277
Radiation Protection Dosimetry Advance Access published October 16, 2008
Figure 1. Number of publications between 1985 and 2007 for main MC codes of interest in radiation therapy.
Publications are sorted by application eld (source: ISI Web of knowledge).
Figure 2. Number of publications on MCTP between 1985 and 2007 (source: ISI Web of knowledge). The exponential
growth is highlighted by the solid trend line.
E. SPEZI AND G. LEWIS
Page 2 of 7
protection and treatment planning in the last
25 years: related codes are linked together along
family lines.
The release of the BEAM code system in 1995
(15)
undoubtedly represents a milestone in the use of the
MC technique in the simulation of radiotherapy
linear accelerators (linacs). BEAM provided the user
with an extensive set of predened component
modules that could be used for the simulation of
individual elements of the linac, without the need to
rewrite the routines for the transport of the particles
each time they were required. BEAM also provided
some innovative features such as the possibility to
generate phase space ( phsp) les by saving location,
energy, direction and type of particle crossing a
specic plane in space. phsp les can be reused for
subsequent simulation of downstream elements of
the linac, such as beam modiers, for the simulation
of the irradiation of a patient, or for the characteris-
ation of the radiation source and the generation of
virtual source models. A recent review of the current
status of MCTP in Europe
(16)
has shown that 66%
of responding centres use the BEAM code for
research and development in radiotherapy physics.
The introduction of variance reduction tech-
niques leads to increased efciency of MC simu-
lations, and the development of new MC codes
optimised for radiotherapy dose calculation, such as
XVMC
(17)
, VMC
(18)
and DPM
(19)
, has reduced
patient calculation time signicantly. This has been
demonstrated rst for electrons and then for photons
(in some cases, with speed increasing by a factor of
50 or more). However, current radiotherapy treat-
ments involving heavy beam modulation, such as
intensity modulated radiation therapy (IMRT),
demands the continuous generation of patient-
specic uence maps leaving scope for distributing
MC simulations on multiple processors.
USE OF MC IN TREATMENT PLANNING
Accurate clinical dose calculation can be computed,
provided that the radiation source and the patient
anatomy are modelled correctly. Although it is fore-
seeable that newer MC codes will allow one to simu-
late both radiation transport through the linac and
dose delivered to the patient in one fast simulation,
until now a common approach has been to split cal-
culations into two parts: source and patient
simulation.
Source simulation
The simulation of the radiation source can be
accomplished in several ways. One option is to
model particle interaction in the treatment head and
to save a phsp le above the beam collimators. In
this case, the upper part of the linac (containing
xed components) is simulated only once (Figure 4).
Treatment-specic beam collimation (involving
moving components) can then be simulated by
saving a second phsp le which will be used to feed
patient dose calculation. Alternatively, the patient
volume can be integrated into the transport geo-
metry, and both beam collimation and patient simu-
lation can be carried out at the same time.
A second option is to use a virtual source
model
(5)
to feed the treatment-specic beam colli-
mation. Virtual source models are parameterisations
of the linac head and can be built from phsp les or
Figure 3. Timeline of the release of major versions of MC codes used in medical radiation physics from the 1980s to the
present.
OVERVIEW OF MCTP FOR RADIOTHERAPY
Page 3 of 7
from measurements. Source models have three
advantages over phsp les: (1) they do not require
large disk space for storage, (2) they can be opti-
mised automatically for different linacs and (3) they
are not susceptible to noise which can affect phsp
les when a relatively low number of particles are
recorded.
Patient simulation
Patient data can be processed in two ways. A
common approach is to convert CT numbers in
materials and densities using a predened CT con-
version function. This is shown in Figure 5 where
the original diagnostic scan in DICOM (Digital
Imaging and Communication in Medicine Standard:
http://www.nema.org/stds) format (Figure 5a) is
converted (for demonstration purposes) to a text le
(Figure 5b) where material number and density are
stored for each voxel of the calculation grid using
the conversion function in Figure 5c. During MC
simulation, the appropriate cross-section data for
each material are sourced from the database when
the particles enter a specic voxel. A second
approach, which has been implemented in the
XVMC/VMC codes, is based on the consider-
ation that the variation of mass and radiation stop-
ping powers with density can be expressed by a
simple relationship for biological tissues at energies
of therapeutic interest
(17)
. In this method, CT
numbers are converted to mass densities which are
then used to sample interaction probabilities using
stopping power ratio to water. This technique has
the advantage of providing a continuous conversion
mechanism between CT numbers and interaction
probabilities. Recently, Vanderstraeten et al.
(20)
developed a CT conversion method though a stoi-
chiometric CT calibration carried in a European
multicentre study. This study has shown the feasi-
bility of using dosimetrically equivalent tissue
subsets for clinical photon beams and highlighted
Figure 5. Patient modelling: conversion of Hounseld
numbers (a) into materials and densities (b) using a
predened CT conversion function (c).
Figure 4. Invariant and patient-specic parts of a
radiotherapy linac. Patient data and electronic portal
imaging devices used for imaging and in vivo dosimetry
purposes are also shown.
E. SPEZI AND G. LEWIS
Page 4 of 7
the need for multiple bone bins when MC calcu-
lations of patient dose distributions are computed
and compared to dose from conventional treatment
planning systems.
RECENT APPROACHES TO MCTP
A number of MC-based treatment planning systems
(TPS) are commercially available today. Although
photon MCTP is reportedly due to be commercia-
lised later this year by several vendors, electrons are
the prevalent treatment modality in MCTP. As
recently pointed out
(16)
, new releases of MC-based
TPS will continue to use MC technology only for
the nal dose calculation and not in the plan optim-
isation phase. This is because full inverse MC treat-
ment planning is not yet a practical option due to
calculation time and to the number of times the
simulations need to be repeated within an iterative
optimisation loop. However, it is common to refer to
Monte Carlo as an embarrassingly parallel problem,
that is, a problem which can easily be parallelised or
distributed in supercomputer clusters. Several papers
have been published about MC-based radiotherapy
planning environments using supercomputer facilities
to support intensive calculation requirements. This
section will review some recent approaches.
MCRTV
An integrated system for MC routine radiotherapy
plan verication (MCRTV)
(21)
has been developed at
the Osaka University Graduate School of Medicine.
The system is built on the EGS4 MC code and
divides the patient simulation into three steps:
(1) simulation of the invariant part of the linacs
head, (2) simulation of the patient-specic beam
modulation and (3) simulation of the patient
irradiation. During routine radiotherapy dose veri-
cation, only patient-specic beam modulation and
patient dose calculation are performed: the invariant
part of the linacs head is not simulated but rep-
resented by a phsp le. MCRTV has been integrated
with the Eclipse TPS (Varian Medical Systems, Palo
Alto, CA). Linac and patient information are
sourced from DICOM-RT les, whereas the multi
leaf collimator (MLC) elds are read from Varians
proprietary le format. The three MC codes used in
the above steps have been parallelised using Message
Passing Interface (MPI; http://www-unix.mcs.anl.
gov/mpi) and MC simulations are sent to a dedi-
cated computer cluster. MCRTV is not yet publicly
available.
MMCTP
The McGill radiotherapy research environment for
MC treatment planning (MMCTP), developed at
McGill University
(22)
, is a multi-platform (Windows,
Linux, Macintosh) software system that implements
the BEAMnrc and XVMC codes for patient-specic
treatment planning. The two MC codes are used in
sequence to calculate the nal dose to the patient.
BEAMnrc is used for treatment head simulation,
whereas XVMC is used for patient dose calculation.
The system runs on a single workstation, supports
input in DICOM-RT, RTOG (Radiation Therapy
Oncology Group format: http://itc.wustl.edu/
exchange_les/tapeexch400.htm) and Varian CART
format, although the internal data format is an
enhancement of the RTOG format called McGill
RT. Simulations are run on a remote cluster,
through the MMCTP graphical user interface
(GUI), using standard protocols such as secure shell
(SSH). A set of daemons running on the back-
ground checks the status of the simulations, adding
phsp les or downloading dose distribution les
when calculations are complete. Patient data are
anonymised. MMCTP also provides contouring
software and data analysis tools such as DVHs. The
system is not yet publicly available for download.
SMCP
The Swiss Monte Carlo Plan (SMCP) developed at
the University Hospital of Berne has been interfaced
with the Eclipse TPS
(23)
. The authors of the code
have developed a exible environment in which MC
simulations can be initiated from within the Eclipse
TPS through a dedicated GUI where the user can
adjust several simulation parameters. Simulations
are sent to a remote cluster and monitored. When
simulations are completed, the results are collected
and transferred back for analysis using all the fea-
tures of the TPS. This software implements
EGSnrc
(8)
, VMC
(18)
, analytical anisotropic
algorithm (AAA)
(24)
and PIN, an in-house MC code
for the simulation of photon interactions. Since par-
ticle transport and geometry are decoupled, the user
can mix and match the codes used for the simulation
of a radiotherapy treatment. The source above beam
modiers, such as dynamic wedges or MLCs, can be
simulated using phsp les, source models, the AAA
beam model or full head simulation using
VMC. Patient-specic beam modiers can be
simulated using EGSnrc, VMC or PIN. Patient
dose calculation can be carried out using EGSnrc or
VMC. No public release of the code has been
mentioned.
RTGRID
The RTGrid distributed simulation environment
for conformal radiotherapy
(25)
was developed at
Cardiff University and Velindre Cancer Centre.
In the RTGrid environment, MC simulations of
OVERVIEW OF MCTP FOR RADIOTHERAPY
Page 5 of 7
radiotherapy treatment plans can be submitted to a
computational resource via a web portal (http://
www.wesc.ac.uk/projectsite/rtgrid). The user can
upload the MC input and data les in the portal
and start the experiment. A DICOM server is also
available to receive computation requests from the
TPS and automatically start the experiment, as an
alternative submission method. Remote simulations
are monitored and results are available for download
from the RTGrid web portal when the calculation is
nished, or available in DICOM format in the
RTGrid server. Currently congured resources are
(1) the Cardiff University condor pool, (2) Velindre
Cancer Centre condor pool and (3) the UK
National Grid Service. The software implements the
BEAMnrc code system that is used for the concur-
rent transport of particles through both linac and
the patient. The RTgrid database contains XML
experiment proles which are parametrised with an
extension mechanism to allow the easy conguration
for a particular simulation case. User authentication
is established through a username/password combi-
nation or through the use of a grid certicate.
RTGrid is one of the rst examples of grid-enabled
computing in radiotherapy physics.
CURRENT STATUS AND FUTURE
PERSPECTIVE
At the time this article is written, only three com-
mercial MC systems are available in the market and
only one supports photons. However, the number of
systems for MC-based retrospective verication of
radiotherapy plans and prospective planning is in
continuous growth. In addition to this, the number
of commercial MC-based TPS is expected to double
in 2008 with more than 30 centres, in Europe alone,
currently evaluating commercial MCTP technology.
It is foreseen that only one vendor out of six will
provide a full MC-based IMRT optimisation solu-
tion
(16)
. Therefore, it is reasonable to think that
MCTP will remain a forward planning tool for the
time being. Nonetheless, since MC is a very general
and exible method, it becomes advantageous as the
complexity of the problem increases
(27)
. In fact, in
analogy with the simulation of dynamic wedges or
dynamic MLCs, the MC method is very well suited
for the simulation of radiotherapy treatments
accounting for respiratory motion
(2629)
. This is
because the voxel dataset representing the patient
can be moved mathematically during the MC dose
computation to simulate patient motion, with no
additional computational overhead.
Another eld of application of MCTP is nuclear
medicine
(30)
. With the advance of imaging modalities
such as positron emitted tomography in identifying
and monitoring patients response to cancer treat-
ment and molecular targeted radiotherapy, it is very
likely that MC will play a very important role in the
assessment of the dose delivered to the patient by
internal emitters
(31)
. Recent investigations have
shown the effectiveness of using MC modelling of
the dose delivered to skeletal metastases by bone-
seeking radiopharmaceuticals
(32)
.
Another challenging area of investigation and pro-
ductive application for MCTP is represented by the
simulation of exit dosimetry. Using MCTP techno-
logy, it is indeed possible to predict accurately the
exit dose recorded in electronic portal imagers (cf.
Figure 4), overcoming the limitations of convention-
al calculation methods in modelling all different
scattering conditions
(33)
. MCTP can then be used to
validate radiotherapy treatments by comparing them
with in vivo dosimetry. Furthermore, patient dose
can be reconstructed using MC-based scatter-
corrected exit dose maps and back-projection algor-
ithms for daily patient-specic dosimetry and
verication of patient movement
(34)
.
FUNDING
The nancial support of Cancer Research Wales and
Yr Ysgol Uwchradd Tregaron is greatly appreciated.
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