BJR © 2015 The Authors.

Published by the British Institute of Radiology

Received: Revised: Accepted: doi: 10.1259/bjr.20140363

20 May 2014 29 October 2014 6 November 2014

Cite this article as:

Nobah A, Mohiuddin M, Devic S, Moftah B. Effective spatially fractionated GRID radiation treatment planning for a passive grid block. Br J
Radiol 2015;88:20140363.

FULL PAPER
Effective spatially fractionated GRID radiation treatment
planning for a passive grid block
1
A NOBAH, MSc, DABR, 2M MOHIUDDIN, MD, 3S DEVIC, PhD, FCCPM and 1,3
B MOFTAH, PhD, FCCPM
1
Biomedical Physics Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
2
Oncology Centre, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
3
Medical Physics Unit, McGill University, Montreal, Quebec, Canada

Address correspondence to: Mr Ahmad Nobah

E-mail: [email protected]

Objective: To commission a grid block for spatially Film sheets were used to measure dose profiles at zmax
fractionated grid radiation therapy (SFGRT) treat- and 10-cm depth.
ments and describe its clinical implementation and Results: The largest observed percentage difference be-
verification through the record and verify (R&V) tween output factors for the grid block technique calculated
system. by the TPS and measured with the PinPoint ion chamber
Methods: SFGRT was developed as a treatment mo- was 3.6% for the 5 3 5-cm2 field size. Relatively significant
dality for bulky tumours that cannot be easily controlled discrepancies between measured and calculated PDD
with conventionally fractionated radiation. Treatment is values appear only in the build-up region, which was found
delivered in the form of open–closed areas. Currently, to amount to ,4%, while a good agreement (differences
SFGRT is performed by either using a commercially ,2%) at depths beyond zmax was observed. Dose verifica-
available grid block or a multileaf collimator (MLC) of tion comparisons performed between calculated and mea-
a linear accelerator. In this work, 6-MV photon beam was sured dose distributions were in clinically acceptable
used to study dosimetric characteristics of the grid block. agreements. When comparing the MLC-based with the
We inserted the grid block into a commercially available grid block technique, the advantage of treating large
treatment planning system (TPS), and the feasibility of tumours with a single field reduces treatment time by
delivering such treatment plans on a linear accelerator at least 3–5 times, having significant impact on patient
using a R&V system was verified. Dose measurements throughput.
were performed using a miniature PinPointTM ion cham- Conclusion: The proposed method supports and helps to
ber (PTW, Freiburg, Germany) in a water phantom and standardize the clinical implementation of the grid block
radiochromic film within solid water slabs. PinPoint ion in a safer and more accurate way.
chamber was used to measure the output factors, Advances in knowledge: This work describes the method
percentage depth dose (PDD) curves and beam profiles to implement treatment planning for the grid block
at two depths, depth of maximum dose (zmax) and 10 cm. technique in radiotherapy departments.

The treatments of large size tumours represent a challenge in a grid field, which represents a group of non-uniform
radiation therapy. The increase in tumour size will raise the pencil beams giving high radiation dose (usually, 15–18 Gy)
extent of the surrounding normal tissue damage, which will in in a single fraction, prescribed at depth of maximum
turn limit the eventual dose escalation strategies. Based on the dose (zmax) for a given beam size. This treatment is fol-
fact that small volumes of tissues can tolerate high radiation lowed by a uniform 2 Gy per fraction dose coverage to the
doses, it was postulated that the local control for the bulky whole planning target volume using standard radiotherapy
tumour can be achieved by a combination of open–closed approaches (three-dimensional conformal or intensity-
radiation areas. In the 1950s, this technique was used with modulated radiotherapy/volumetric arc therapy). The beam
orthovoltage units in order to minimize skin toxicity while delivered by the grid technique has a beam’s eye view (BEV)
delivering high doses to deeply seated tumours.1,2 pattern shown in Figure 1.

Spatially fractionated grid radiation therapy (SFGRT) Clinical experience in a large cohort of patients treated to
was established in late 1980s, as a palliative treatment different body sites (abdomen, lung) surrounded by sen-
modality for bulky tumours.3 The SFGRT starts with sitive tissues indicates that this approach is well tolerated
 BJR A Nobah et al

Figure 1. Dose distribution calculated using the Eclipse treatment planning system (Varian Medical Systems, Palo Alto, CA) for
passive grid block technique. A, anterior; BEV, beam’s eye view; F, feet; GTV, gross tumour volume; H, head; L, left; LPO, left posterior
oblique; max, maximum; min, minimum; P, posterior; R, right; RT, radiation therapy; SAD, source axis distance.

both in terms of acute effects, and that it produces no significant pattern of high-dose brachytherapy and allows safe delivery of
long-term complication.4 Clinical experience with open field doses similar to stereotactic body radiation therapy (15–20 Gy,
radiation indicates that doses .15 Gy would produce not only Figure 1). The technique itself has been used extensively with
significant acute morbidity but also substantial late toxicity. By orthovoltage radiation until the 1970s but was not utilized with
contrast, SFGRT doses of .15 Gy have been utilized in con- the advent of megavoltage linear accelerators. However, the
junction with definitive doses of conventionally fractionated challenge of treating large tumours still persists. Clinical expe-
radiation without adding to the morbidity or detracting from the rience using megavoltage SFGRT indicates that dramatic tumour
tolerance of normal tissues. responses can be produced even in tumours with intrinsic re-
sistance to radiation, such as large sarcomas and melanomas.
While the existing clinical studies1,5 suggest improved tumour Recent experience in pre-operative treatment of soft-tissue sar-
control especially for resistant tumours to conventional radia- coma for tumours ranging in size from 8 to 22 cm (median,
tion, such as melanomas and soft tissue sarcomas, the radio- 11.5 cm) utilizing a combination of SFGRT (18 Gy) and con-
biological mechanisms of grid therapy are not fully explored. ventional radiation (50 Gy, study recently presented at American
Many studies have been undertaken in order to understand the Society of Clinical Oncology 201411) shows that the treatment
radiobiological effects of the grid treatment on tumour cells.6–8 was safe with low operative morbidity (,5%) and resulted in
It has been shown in tumour models that a key component of .90% tumour necrosis in 65% of patients and 15% with
treatment efficacy is the induction of endothelial apoptosis;9 this a complete pathological response. SFGRT has been used to treat
requires doses of .12 Gy. Similarly, the cytokine release associated large intra-abdominal, thoracic, and head and neck cancers with
with bystander effects and autosensitization to subsequent con- similar success.3 There is an increasing interest in incorporating
ventional doses of radiation require minimum doses of .10 Gy.10 this technique into treatment strategies at several major centres
with new information that shows that SFGRT may have not just
Tumour volume, hypoxia and intrinsic cellular resistance remain a local effect on treated tumours but could potentially induce
key factors in the inability to eradicate larger tumours with positive immune modulatory systemic effects and release of
conventional radiation dose/time fractionation. Much of the cytokines such as tumour necrosis factor-a, transforming growth
recent improvements in treatment delivery systems have also factor-b and ceramide, the latter especially responsible for
focused on better targeting of tumour and normal tissue vol- enhanced vascular apoptosis within tumour volumes that can
umes, improving dose homogeneity and reduction of dose to accelerate the response and regression of treated tumours and
critical surrounding organs. In some cases, this has enabled dose also produce apscopal effects that can be harnessed with systemic
escalation strategies for better local control, and in small therapies. Historically the dose profile with SFGRT had been an
tumours, this has enabled the use of effective high-dose ste- extrapolation from single-field prescriptions at depth of dose
reotactic treatment approaches. However, with larger tumours, maximum, but with the incorporation into a robust clinical
especially those adjacent to critical organs, both our ability to treatment planning system (TPS) and the ability to extend dose
target them and the dose that can be safely delivered could delivery to a multifield approach this technique has promising
be severely compromised. The experience with megavoltage applications for a wide variety of cancers that have been especially
SFGRT1,4,5 shows that the treatment mimics the dose rate frustrating for oncologists with traditional approaches of treatment.

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Figure 2. Grid block design. (a) Actual design; (b) treatment planning system design; (c) geometrical parameters; and (d)
experimental set-up used to determine size and distribution of openings at the isocentre level, with a source-to-surface distance
(SSD) of 100 cm and source-to-grid distance (SGD) of 64.5 cm.

Currently, SFGRT is performed by either using a commercially calculated by the TPS with dose measurements performed using
available grid block or a multileaf collimator (MLC) of a linear both edge detector (miniature diode) within a water phantom
accelerator. More recently, a spatially fractionated radiation and radiochromic films within solid water phantom.
treatment on TomoTherapy® unit (Accuray Inc., Sunnyvale, CA)
using a TOMOGRID template was described.12 The MLC-based METHODS AND MATERIALS
grid approach is widely used, and its feasibility was demon- A dual-energy Varian linear accelerator (23EX linac) was used in
strated by many authors.13,14 The MLC-based grid technique has this study together with the ARIA v. 10 record and verify (R&V)
many advantages: (a) the ease of creating the MLC grid shape; system (Varian Medical Systems, Palo Alto, CA). The TPS used
(b) carrying and mounting of the heavy grid block is not needed; was Eclipse (v. 10) with analytic anisotropic algorithm (AAA v.
(c) using the MLC-based grid approach allows for dose calcu- 10.0.28; Varian Medical Systems) as dose calculation algorithm.
lation within TPS and hence radiation oncologists can examine In our calculations, we have set the dose calculation grid size to
dose distribution on CT images prior to treatment. be 2.5 3 2.5 3 2.5 mm3. A 6-MV photon beam was commis-
sioned for the grid treatments.
On the other hand, owing to the X1 and X2 jaws over travel
distance limitation, the maximum field size for the MLC-based grid Grid treatment planning system commissioning
technique on Varian linear accelerators will be 3 cm wide. This in Figure 2 depicts the grid block (Radiation Products Design Inc.,
turn means that for a 9-cm diameter tumour, three segments will Albertville, MN), which is a 7.5-cm thick cerrobend block (lead
be required to cover the target fully. In addition, the MLC-based alloy) specifically designed for Varian linacs, mounted in such a way
grid technique uses 1 3 1 cm2 square openings, arranged in a chess that the bottom edge of the grid block is at 64.5 cm from the source
pattern and separated by 1 cm. In the case where tumour size is and is considered a block accessory. It is fixed onto a metallic frame
wider than 9 cm, more than a single isocentre will be required, that is mounted on the linac’s accessory mount. The maximum
which includes the isocentre shift during the course of treatment. field size that the grid block can treat at 100 cm source-to-surface
distance (SSD) is 25 3 25 cm2.
This article studies the grid block delivery technique that has not
only better maximum to minimum dose distribution compared The grid block has diverging cylindrical holes arranged in
with MLC but also that the technique is much faster than the a hexagonal pattern as shown in Figure 2. Grid holes have
more convenient MLC-based approach. However, one disad- a diameter of 1.4 and 2.1 cm centre-to-centre spacing when
vantage of SFGRT using a grid block has been the inability of the projected at an orthogonal to the beam plane 100 cm from the
commercially available treatment planning software to tailor the source. The actual grid block design was based on the previous
dose to the target. In this work, the grid block was incorporated work of Meigooni et al15 and Stathakis et al.16 To measure the
into a commercially available TPS, and the feasibility of de- size of the holes and their spacing, we irradiated a piece of EBT3
livering such treatment plan on a linear accelerator using a re- model GAFCHROMICTM film (Ashland, Wayne, NJ) positioned
cord and verify (R&V) system was also demonstrated. As a part at the isocentre (Figure 2d). The beam centre was first marked
of the commissioning process, we compared dose distributions on the film piece prior to insertion of the grid block using the

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beam cross hair. The film piece was scanned 24 h after irradia- measurements were performed with MP1 water phantom and
tion and the transmission signal from the red colour channel UNIDOS E electrometer (PTW). The ion chamber was placed at
was converted into relative dose using radiochromic film depth of dose maximum at the centre of the central hole of the
dose–response linearization method.17 The size of the hole was grid block. Output factors were calculated as the ratio of readings
measured at 50% of the maximum dose. for different field sizes divided by the reading for 10 3 10-cm open
field. The PDD along the central axis was also measured using the
To incorporate the grid block into the Eclipse TPS, the option PPIC for 10 3 10 and 20 3 20 cm2 field sizes.
called “fit to structure” was used. This grid structure was com-
posed of 149 spheres distributed within the grid block projected at In-line and cross-line dose profiles were measured using two
plane at 100 cm from the source. The finalarrangement and size methods: (a) PPIC within a water phantom as described above and
adjustment of these holes were achieved using the film mea- (b) EBT3 model GAFCHROMIC film sheets sandwiched in solid
surement described above. Finally, the block was attached to the water phantom at depths of zmax (1.5 cm) and 10 cm. The radio-
field that was fitted to the grid structure using the “fit to struc- chromic film reference dosimetry system was calibrated using the
ture” option in the Eclipse. This way, the holes of the grid block protocol described by Devic et al.18 An Epson® Expression®
could be inserted in the TPS and mimic the actual block design. 10000XL document scanner (Epson America, Long Beach, CA)
was used to scan both calibration film pieces and measuring film
As a measure of safety, a metallic bar was added to the grid block sheets to obtain dose profiles along both transverse and longitu-
so that the linac would recognize the grid block as both block dinal directions. A red colour channel from scanned tiff images
and User-X accessory. The User-X accessory option is provided was used with a scanning resolution of 0.2 mm per pixel.
by Varian on clinical linear accelerators to add a user-defined
accessory other than the default ones. The linear accelerator can In order to determine the transmission factor of the grid
recognize any accessory by distribution of the drilled holes in the block (ratio of the charge measured in air under blocked
accessory attached, which can be made by the user as well. region with the block inserted to that measured without the
A coded metallic bar was customized in our hospital workshop block for the same number of monitor units), a Brilliance CT
so that the grid block can be recognized as a User-X accessory. Big Bore (Philips Healthcare, Cleveland, OH) was used to
With this, the maximum field size for the Grid block treatments acquire an image set of the solid water phantom. Dose dis-
can be limited and not exceed 25 3 25 cm2. tribution was subsequently calculated using the AAA algo-
rithm in order to obtain the TPS-generated dose profiles.
Dose measurements Because of the difficulty related to measurements of the grid
In order to validate the grid block design inserted into the block transmission factor, the factor was found by setting
TPS, dose measurements using PTW PinPoint™ ion chamber a range of different values within TPS and then by comparing
(PPIC; PTW, Freiburg, Germany) in the water phantom and it with the film measurements. The transmission factor for
EBT3 model GAFCHROMIC film within solid water slabs the 6-MV beam was found to be 7.5%. For comparison, the
were performed. The PPIC was used to measure output fac- transmission factor of the solid cerrobend block of the same
tors, percentage depth dose (PDD) curves and beam profiles thickness for the 6-MV photon beam is 3.5%.
at two depths, at zmax and at a depth of 10 cm. Radiochromic
film sheets were also used to measure dose profiles at the RESULTS
same two depths. All measurements were performed in a 100- Table 1 summarizes the comparison between the output factors
cm SSD set-up. Both the results of ion chamber and film for the grid block technique calculated by the Eclipse TPS and
measurements were resampled to the size of the calculation measured by using an ion chamber. The maximum observed
grid of 2.5 mm used by the TPS prior to comparison. percentage difference was 3.6% for the 5 3 5 -cm2 field size, and
within 2% for the rest of the field sizes.
PTW PinPoint ion chamber with 0.015 cm3 volume (model:
31014) was used to measure output factors for different field PDD measurements were performed by using the ionization
sizes: 5 3 5, 10 3 10, 15 3 15, 20 3 20 and 25 3 25 cm2. These chamber for 10 3 10 and 20 3 20 cm2 and compared with the

Table 1. Comparison between treatment planning system (TPS)-calculated and ion chamber-measured output factors for the 6-MV
beam

Field size (cm2)

Output factor
535 10 3 10 15 3 15 20 3 20 25 3 25
TM
PinPoint IC (measured) 87.0 88.9 91.2 93.0 94.6
TPS (Calc.) 83.9 88.8 92.0 94.6 95.8
% Diff. 3.6 0.1 20.9 21.7 21.3
Calc., calculated; Diff., difference; Ic, ion chamber.
Pinpoint, PTW, Freiburg, Germany.

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Figure 3. Percentage depth dose for 10 3 10 cm2 (left) and 20 3 20 cm2 (right) field size: treatment planning system (TPS) (solid line)
vs ion chamber measurements (dots). Insets show differences in percentage depth dose (PDD) values between TPS and measured
values. PPIC, PinPointTM ion chamber (PTW, Freiburg, Germany).

PDD data calculated with the TPS. Figure 3 shows that a signifi- low signal created within a relatively small ion chamber volume,
cant discrepancy between measured and calculated PDD appears and the percentage difference between the measured and cal-
in the build-up region. Such discrepancies are readily observed and culated dose profiles were all within 5%. In the high-dose
attributed to inaccuracies of model calculations close to the surface regions, discrepancies between the measured and calculated dose
of phantoms/patients. On the other hand, a good agreement values were within 2%, in accordance to the increased precision
(percentage difference ,2%) at depths beyond zmax for both field of the radiochromic film dosimetry system at higher doses.15
sizes was observed, all the way down to 20-cm depth. The
agreement between measured and calculated PDD data indicates Results presented in Table 1 and Figures 3 and 5 indicate that the
that the beam quality calculated by Eclipse matches the actual commissioning process for the grid block incorporation into the
beam quality generated by the attenuation of the radiation beam Eclipse TPS described in this work results in acceptable dosi-
with small field-sized holes within the grid block. metric accuracy. In addition, the incorporation of the grid block
into the R&V system provides a safe way of treatment and
Transverse dose profiles were measured at a depth of zmax and prevents an adverse dose delivery that could be implicated by an
depth of 10 cm using the ion chamber and sheets of EBT3 model attempt to deliver a plan with a field size larger than 25 3 25 cm
GAFCHROMIC film. Figure 4 shows the irradiated piece of at the isocentre plane.
EBT3 model GAFCHROMIC film with indication of directions
along which the dose profiles were obtained and subsequently DISCUSSION
compared with the corresponding dose profiles calculated by the The treatment of advanced, bulky malignant tumours continues
TPS. Figure 5 shows a comparison between measured (PPIC and to be a major challenge for the oncologist. Therapeutic options
EBT3 films) and the calculated dose profiles along the in-line of fractionated radiation are often hampered by the bulk or the
and cross-line dose profiles, respectively. Discrepancies were volume of disease and limited by normal tissue tolerance.
observed for PPIC in low-dose regions owing to the relatively SFGRT is an innovative concept in radiation therapy that has
utilized spatially fractionated radiation delivery as a means of
Figure 4. Exposed sheet of radiochromic film at zmax with overcoming limitations of acute and late normal tissue tolerance.
20 3 20 cm2 collimator setting. G, gantry direction. The MLC-based approach for treatment delivery of SFGRT
appears to be attractive since the MLC is already incorporated
into the linac head, and the dose calculation is readily available
within the TPSs. However, from our clinical experience, we have
found that the main drawback of the MLC-based approach is the
relatively long delivery time when compared with that of the
grid block approach. In addition to the actual prescription dose,
delivery time with MLC-based approach is 2–3 times longer for
smaller tumours (up to 9 cm in diameter), 3–6 times longer for
medium size tumours (9–18 cm in diameter, using 2 isocentres)
and 6–9 times longer for large tumours (18–27 cm in diameter,
using 3 isocentres). The use of multiple isocentres do not only
imply longer beam on time, they also require realignment of
patients and, depending on the actual clinical protocol, the eventual
reimaging of the patient in the new position. Additionally, the grid
block approach provides better shielding-to-open beam ratio than

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Figure 5. In-line profiles at depths of (a) depth of maximum dose (zmax) and (b) 10 cm, and the cross-line profiles at depths of (c)
zmax and (d) 10 cm. PPIC, PinpointTM ion chamber (PTW, Freiburg, Germany); TPS, treatment planning system.

the MLC-generated spatially fractionated dose distributions. To CONCLUSION

date, however, the use of the grid block for SFGRT is limited in Results presented in this work allow for implementing the grid
ability to perform treatment planning and patient-specific dose block technique into the radiation therapy process in a safer
assessment on a case-by-case basis. In addition, tabulated output and more accurate manner. Since the spatially fractionated
factors for monitor units calculation (following more or less the grid therapy is not considered as a standard of care, all
same approach, as it was used for electron beam treatments in the commercially available linear accelerators, as well as their
past) were readily available only in cases whereby fixed collimator accompanying TPSs are not customized to recognize the grid
jaw settings were applicable. In such cases, the physicist would have block as an accessory. Dose verification comparisons that we
to measure the corresponding output factors for almost every pa- performed between the calculated and measured point doses as
tient. The ability to calculate dose distribution for SFGRT within well as dose profiles were in clinically acceptable agreements.
the TPS does not only provide a fast and accurate method for When comparing the MLC-based technique with the grid
monitor unit calculation but it also allows the physician to visualize block technique, we should take into account the advantage of
the actual dose distribution to the target and to the surrounding treating large tumours with a single field that would reduce
critical structures and prescribe a clinically relevant dose as well. treatment time by at least 3–5 times, which may have a sig-
nificant impact on the patient throughput.
Commissioning method described in this work was applied to
one commercially available clinical linear accelerator and its FUNDING
accompanying TPS. However, it can be easily extended to any This work was supported in part by the Natural Sciences and
other commercially available treatment modality. Engineering Research Council of Canada, contracts number

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386009. SD is a research scientist supported by the Fonds de ACKNOWLEDGMENTS

Recherche en Santé du Québec (FRSQ) 26856. We thank Dr Rana Mahmood for useful discussions.

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