Special Issue-(2nd ICTSA-2022) International Journal of Innovative Science and Research Technology

ISSN No:-24562165

Comparison of Different Number of Beams in

Intensity Modulated Radiotherapy in Head and
Neck Cancer
Radiotherapy Techniques

Khaled Saeed Sallam Sohir Mahmoud El Kholy

Faculty of Medicine and Health Sciences, Taiz University Medical Biophysics Department, Medical Research Institute,
National Cancer Control Foundation, Taiz, Yemen Alexandria University, Alexandria, Egypt

Mostafa Aly El Naggar Fatma Ismael Nasr

Cancer Management and Research Department, Medical Research Medical Biophysics Department, Medical Research Institute,
Institute, Alexandria University, Alexandria, Egypt Alexandria University, Alexandria, Egypt

Walla Taman
Radiotherapy Department, Ayadi Al Mostakbal Oncology Center, Alexandria, Egypt.

Abstract:-  Results
The total results showed that, there was significant
 Purpose difference between 5, 7 and 9 beams IMRT in term of
The aim of the work was to determine the best mean values for PTV95% coverage were 96.76, 97.51
beams number and segments in order to improve the and 98.22 respectively with p = 0.005. The conformation
plans conformity and homogeneity that generate low mean values were1.60, 1.49 and 1.34 with p = 0.007. HI
monitor units (MUs) and faster irradiated time for values for the PTV were 0.14 ± 0.05, 0.13 ± 0.05 and 0.12
different types of head and neck cancer (HNC). ± 0.04 with p = 0.001. Right parotid were 21.96, 20.72
and 20.43 with p = 0.003. Left parotid were22.14, 21.04
 Methods and 20.70 with p = 0.100. Spinal cord 45.34, 44.51 and
This study includes 30 patients with different HNC. 43.23 with p = 0.003. Brain stem were 49.52, 49.77 and
Intensity modulated radiotherapy (IMRT) treatment 48.74 with p = 0.058. Number of segments were 79.85,
planning techniques were done with step and shoot 106.55 and 131.80 with p = 0.001. MUs were 23879.8,
delivery technique, 5, 7 and 9 beams IMRT were carried 24252.6and 22501.8with p = 0.003and the total irradiated
out for each patient. The treatment plans for all patients time were 79.60, 80.84 and 75.0 respectively with p =
were calculated and optimized using fast superposition 0.003. In fact that, the plan quality improved with an
algorithm. All plans were generated using equal spaced increasing the number of intensity modulated beams.
odd beam number around the target. 6 MV were used in
all beams. Multiple segments were created for each  Conclusions
beam. Typically maximum iteration was carried out to From this study we can conclude that, the 9 beams
achieve optimized plans. The beam weight optimized to IMRT is superior to techniques using less number of
generate the plan, then the segment weight optimized for beams (5 and 7) where, the 9 beams IMRT significantly
all plans by using sliding window methods. The final improved the PTV coverage, dose distribution,
optimization maps were converted into a way of step and conformity, homogeneity to the PTV with better sparing
shoot sequence map which delivered by linear OARs and reduce the dose to surrounding normal
accelerator using multi leaf collimator (MLC). IMRT tissues. Moreover, the 9 beams significantly reduced the
plans were compared based on several criteria: Isodose mean MUs and pure irradiated time compared with 5
distributions, the mean and standard deviation with p- and 7 beams IMRT.
values for planning target volume (PTV) 95%,
conformity index (CI), homogeneity index (HI), organs Keyword:- IMRT, Radiotherapy Techniques, Beam Number,
at risk (OARs), number of segments, MUs and total Treatment Planning.
irradiated time were presented and compared in all
patients. Statically analyses were compared for all
patients used ANOVA testes.

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I. INTRODUCTION the OARs. The main disadvantage is increase the treatment
delivery times and MUs (18). This lead to patient discomfort,
The goal of radiotherapy is to deliver a homogenous reduce the machine output and increase the dose to the
dose of radiation to tumor, while delivering a dose as low as surrounding healthy tissues around the PTV which arise
possible to healthy surrounding tissues (1). Conventional from the MLC transmission and scatter radiation from the
three-dimensional conformal radiotherapy (3DCRT) linear accelerator, these doses proportional to the number of
delivers a homogenous dose to tumor volume with MUs. These scatter radiation can increase the risk of
acceptable low dose to normal structures(2) . However, in secondary malignances (19, 20). Reduction of irradiated time
some tumor sites with concave shape such as in HNC, limits can be achieved by using different numbers of beams or
the ability of conventional radiotherapy to shape the dose to segments or by using high modern delivery techniques such
the target volumes and to spare the OARs (3). as VMAT (8).

Significant advances in imaging technology resulted in The treatment planning optimization system helps to
more precise localization of the tumor and critical organs in determine the distribution of the beam intensity which
three-dimensional (3D).These developments have been across the treatment volumes(21). The optimization explores
mainly driven by the need to reduce the dose to normal these possibilities to find the optimum intensity maps that
tissues. To that end, newer IMRT have been developed (4, 5). are matches the dose and volumes constraints with
IMRT is an advanced form of high precision of 3DCRT, objectives for PTV and OARs using system priorities (3).
which use linear accelerator to deliver precise radiation dose The different plans can be evaluated and compared to select
to tumor (6, 7). IMRT allows to deliver radiation dose to the optimum intensity modulation. The optimum pattern
conform more precisely to 3D concave shape tumor by then converted to a complex sequences of beams segment
(16)
modulating the intensity of radiation beam in multiple .
segments which minimizes the dose to surrounding healthy
tissues (5, 8). Typically, combination radiation beams II. PATIENTS AND METHODS
intensity modulated fields coming from different beam
directions produce precise shape of radiation dose (9). IMRT Thirty HNC patients were enrolled in this study.
techniques for treatment of HNC replaced conventional Seventy percent nasopharynx, 10 % hypopharnx, 6 % neck
3DCRT, which resulted in much better dose conformity, lymph nodes, 10 % tongue and 4 % check cancer. The
sparing of OARs and less radiation toxicity (10). patients included 13 males and 17 females with a mean age
of 39 years (range 16 - 76 years). The patients were at
IMRT includes forward and inverse planning. In the different stages I, II and III with exclusion metastatic IV
forward planning, the planner selects the planning stage. Patients were recruited from Ayadi Al-Mostakbal
parameters, the computer then calculates the dose Oncology Center, Alexandria, Egypt.
distribution and the plans are optimized by the manual
iteration. The inverse planning begins by defining the  Immobilization and Computed Tomography
prescription dose to the targets volumes with clinical Simulation
objectives then the planning system algorithm determine the Computed tomography (CT) simulator images were
beams parameters which results dose distribution for the obtained in the supine position with a head and neck
targets and the system undergo thousands of iterations to support. Patients were immobilized using thermoplastic
find the best solution for the treatment plans (11, 12). Inverse mask. CT images were done for all patients with thickness 2
IMRT for HNC is complex due to the large number of mm, using SomAtom Emotion Duo Computed tomography,
OARs locates near to the PTV (13) , so the correct selection of Siemens.
the beam number and direction in HNC IMRT improve the
planning target volume (PTV) coverage as well as sparing  IMRT Target Volumes and OARs Delineation
the OARs (14). In the contouring, the CT slices of selected patients
were transferred to focal pro computer system by DICOM
The IMRT can delivered by three delivery techniques: network, where outlining of the target volumes and OARs
step and shoot IMRT, dynamic IMRT and intensity were done according to the RTOG guidelines.
modulated arc therapy (IMAT) with tomotherapy or
volumetric arc therapy (VMAT) (3, 9, 15). The step and shoot  Planning Objectives
is most commonly available in cancer treatment centers. In For all HNC patients, the treatment goal was to
this delivery techniques, the beams divided into different delivers the prescribed dose to achieve minimum dose more
segments and the radiation is turn off between the segments. than 95% of the prescribed dose and maximum lower than
The MLC shape the first segments then the radiation turn on 107% for the primary target volumes PTV. In all IMRT
to delivers into the segment, the radiation then turn off to plans, the objectives were applied to achieve minimum
allow the MLC move to create the next segment. In the doses to OARs without compromising the PTV coverage.
dynamic the radiation delivered as the leaves are moving (3). The mean dose to the right and left parotid was aimed to be
below 26 Gy, maximum dose allowed for spinal cord was 45
The IMRT process consist of multiple steps for Gy and for brain stem 54 Gy.
treatment planning until delivery of radiation (17). IMRT is
more conformity for irregular targets and reduce the dose to

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 IMRT Planning Techniques assess the conformation of the dose to the PTV. The ideal
IMRT treatment planning techniques were done on conformation is 1 so, the greater conformity than 1 indicates
Xio computerized treatment planning system. Inverse IMRT greater healthy tissues irradiated around the PTV and the CI
planning were used with step and shoot IMRT delivery defined as CI = VTV/VPTV (25, 26). OARs sparing were
technique using ARTISTE Linear Accelerator, Siemens, compared in term of maximum and mean received doses for
with modulator MLC include 160 leafs with 0.5 cm all plans. Dose volume histograms (DVHs) were used to
thickness to deliver the treatment. The IMRT planning assess and compare the different coverage of the PTV and
parameters were defined and selected manually. For each the doses received to OARs. The number of segments was
patient 5, 7 and 9 beams IMRT plans were carried out. compared to assess the plan efficiency for all IMRT
plans. The MUs and pure irradiation time were calculated
The treatment plans for all patients were calculated and compared as important parameters for all patients. The
and optimized using fast superposition algorithm to generate pure irradiated time defined as MU/D where MU is the
beam modulation as a specific objectives and constraints. monitor units and the D is the dose rate (Mu/min) (27).
All IMRT plans were generated using equal spaced odd Statically analyses were compared for all patients used
beam number around the target to avoided opposing beams. ANOVA testes.
In all IMRT beams 6 MV were used. The gantry angle
started from 180 in all cases as the following: The gantry III. RESULTS
angles in 5 beams were 40, 110, 180, 250, 320, in 7 beams
were 30, 80,130, 180, 230, 280, 320 and in 9 beams were The total results including the mean and standard
20, 60, 100, 140, 180, 220, 260, 300, 340 for all IMRT HNC deviation with p-values for PTV95%, CI, HI, right and left
techniques. All plans were normalized to the PTV to achieve parotids, spinal cord , brain stem, DVHs, number of
coverage of the PTV by at least 95 % of the prescribed dose. segments, MUs and total irradiated time were presented and
Objectives were generated priority as the following: PTV, compared in all HNC patients.
right and left parotids, spinal cord and brain stem. The
IMRT dose prescription and constraints for each PTV and  PTV95%:
OARs were adjusted to achieve results as the planning Most IMRT plans for HNC were considered
goals. acceptable in term of PTV95% coverage of the prescribed
dose in this study except some plans when using 5 beams
With delivery method step and shoot inverse IMRT IMRT. In general, the plans were acceptable if the 95% of
treatments planning each optimization were started with the isodose surface covers the 100% of the PTV. In fact, the
generation the flunce map. Multiple segments were created larger number of intensity modulated beams, the better PTV
for each beam. Typically maximum iteration was carried out coverage by 95% of the prescribed dose. As present in
to achieve optimized plans. The segmentation parameters Table (1) and Fig. (1) the means and standard deviations
were specified using sliding window methods with discrete comparison between 5, 7 and 9 beams IMRT according
intensity levels10, minimum segment size 2 cm to reduce to PTV95% coverage were 96.76 ± 2.17, 97.51 ± 2.15 and
the number of segments, in the segment weight optimization 98.22 ± 1.61 respectively. Statically, there were significantly
gird spacing 0.3 cm with minimum segment MU 5 were difference between 5, 7 and 9 beams in mean PTV95%
used. The beam weight optimized to generate the plan, then coverage by the prescribed dose p < 0.05. Results show that,
the segment weight optimized for all IMRT HNC plans by the 9 beams for HNC was superior in PTV95% coverage of
using sliding window methods. In the optimization process, the prescribed dose compared with 5 and 7beam IMRT.
the optimal maps were calculated according to priorities,
constraints and objectives. The final optimization maps were Table 1 Comparison between 5, 7 and 9 Beams IMRT
converted into a way of step and shoot sequence map which According to PTV
delivered by linear accelerator using MLC. The plans were PTV95%
5 Beams 7 Beams 9 Beams p
transferred to the LANTIS system for verification and (%)
approval by medical physicist and radiation oncologist and Min. – 91.80 – 91.60 – 95.15 –
were clinically considered acceptable. Max. 99.93 99.88 99.99
Mean ± 96.76 ± 97.51 ± 98.22 ±
 IMRT Plans Comparison 0.005*
SD. 2.17 2.15 1.61
For each patents 5, 7 and 9 beams IMRT plans were Median 96.74 97.75 98.57
carried out and compared. IMRT plans were compared *: Statistically significant at p ≤ 0.05
based on several criteria:
Table 2 Comparison between 5, 7 and 9 Beams IMRT
Isodose distributions were compared visually on According to CI
different images slices with respect the degree of conformity CI (No) 5 Beams 7 Beams 9 Beams p
of the prescribed dose to the PTV. The PTV volumes Min. – 1.18 – 1.17 – 0.84 –
(PTV95%) receiving 95% of the prescribed dose were Max. 2.93 2.89 1.79
compared. The HI was used to assess the dose uniformity Mean ± 1.60 ± 1.49 ± 1.34 ±
with the PTV. The ideal values of HI is 0 so, greater value 0.007*
SD. 0.43 0.38 0.24
indicate heterogeneity inside the PTV (24) and is defined as Median 1.39 1.34 1.36
HI = D2% -D98% / D50%(25). The CI also calculated to

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 DVH:
The DVHs were calculated for all PTV and OARs in
all IMRT HNC patients. Fig. (3) shows the DVHs
comparison between 5, 7 and 9 beams IMRT according to
PTV coverage and OARs received doses include right and
left parotid, spinal cord and brain stem as example HNC
case. The DVHs were not sufficient to evaluate the dose
distribution for PTV, so the conformity and homogeneity
were considered. DVHs showed higher doses received by
the right and left parotids in 5 beams compared with 7 and 9
beams. The 9 beams were superior in PTV coverage of
prescribed dose and OARs sparring compared with 5 and 7
beams IMRT.

Fig 1 Shows the means and standard deviations comparison

between 5, 7 and 9 IMRT beams according to
PTV95% for all HNC Patients.

 Isodose Distributions:
Clinically, the dose distribution in most IMRT plans
for HNC was acceptable except few cases in 5 beams. The
dose distribution comparison between 5, 7 and 9 beams
IMRT as shows in Fig. (2), a typical isodose distribution
was superior in 9 beams compared with 5 and 7 beams. The
isodose lines were showed comparable between the different
beams. Some areas received high doses outside the PTV and
more normal tissues irradiated in 5 beams were observed.
The dose is more conformed to the PTV as well as the dose
reduced to the surrounded healthy tissues in 9 beams
compared with 5 and 7 beams IMRT. In fact, the increasing
in number of beams lead to reduce the doses received to the
normal tissues and the dose were more conformed with
more homogenous doses to the PTV.

Fig 3 Shows DVHs comparison between 5, 7 and 9 beams

IMRT for patient No 4. The PTV coverage by 95% of the
prescribed dose is better in 9 beams compared with 5 and 7
Fig 2 Shows comparison of dose distribution between 5, 7 beams. The doses received by right and left parotids were
and 9 beams for patient No 4 in axial images. The PTV low in 9 beams. Spinal cord received lower maximum dose
coverage by 95% of the prescribed dose is similar in 5 and 7 in 7 beams. The dose was reduced to brain stem in 5 beams
beams compared with 9 beams IMRT. compared with 7 and 9 beams IMRT.

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 CI of PTV: Table 3 Comparison between 5, 7 and 9 Beams IMRT
The means and standard deviations comparison According to HI
between 5, 7 and 9 beams IMRT according to CI of the PTV HI (No) 5 Beams 7 Beams 9 Beams p
were showed in Table (2) and Fig. (4). The conformation Min. – 0.06 – 0.07 – 0.06 –
values were1.60 ± 0.43, 1.49 ± 0.38 and 1.34 ± 0.24 Max 0.24 0.26 0.20
respectively. The 5 beams was the worst conformation Mean ± 0.14 ± 0.13 ± 0.12 ±
compared with 7 and 9 beams, in fact that, due to the beam 0.001*
SD. 0.05 0.05 0.04
number not sufficient to conform the radiation dose exactly Median 0.15 0.13 0.13
to the PTV. The conformation improve was observed when
the number of the beams increased from 7 to 9 beams
IMRT. There were significant differences between 7 and 9
beams when compared according to conformity degree, with
p < 0.05. The 9 beams were superior in conformation the
dose to the PTV with reduced the radiation received to the
healthy surrounding tissues for HNC IMRT treatment.

Fig 5 Shows the means and standard deviations comparison

between 5, 7 and 9 IMRT beams according to HI of PTV for
all HNC patients.

 Right Parotid:
The comparison values between 5, 7 and 9 beams
IMRT for right parotid in all HNC patients were listed in
Table (4) and Fig. (6). The means and standard deviations
for mean dose to the right parotid were 21.96 ± 2.30, 20.72
± 3.41and 20.43 ± 2.19 respectively. The mean dose to the
Fig 4 Shows the means and standard deviations comparison right parotid was aimed to be below the 26 Gy to preserve
between 5, 7 and 9 IMRT beams according to CI of PTV for the parotid function and reduce the xerostomia. Most
all HNC patients. techniques were meet the requirements criteria except the 5
beams, due to hot areas were found surrounding the PTV, in
 HI of PTV: fact that related to the number of beams not conform the
The dose uniformity inside the PTV was evaluated by dose exactly to the PTV and the radiation received to the
the HI. The means and standard deviations values normal surrounding tissues. There were significant
comparison between 5, 7 and 9 beams IMRT for all HNC differences between 5, 7 and 9 beams were observed. The
patients were presented in Table (3) and Fig. (5). The HI significant lower mean doses to the right parotid were
values for the PTV were 0.14 ± 0.05, 0.13 ± 0.05 and 0.12 ± achieved by using 9 beams compared with 5 and 7 beams
0.04 respectively. There were significant differences in the IMRT with the p < 0.05.
dose homogeneity inside the PTV when compared the
different beams with p < 0.05. The HI was indicated that,  Left Parotid:
the dose homogeneity was inferior in 5 beams. The results The effect of beams number also evaluated by
showed that when increased the beam number from 7 to 9 comparison the doses received by the left parotid. The
beams, the dose uniformity within the PTV were improved means and standard deviations comparison between 5, 7 and
compared with 5 beams. The typical dose uniformity inside 9 beams for mean dose to the left parotid were 22.14 ± 2.72,
the PTV was achieved by the 9 beams IMRT. 21.04 ± 3.89 and 20.70 ± 2.77 respectively. As mentioned
before when compared the means and standard deviations of
mean dose received by the right parotid, when compared
different beams IMRT, the results were close to it in term of
sparing. The left parotid sparing was improved when the
number of beams increased. The results showed that, there
were significant differences with p < 0.05 as presented in
Table (4) and Fig. (6).

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Table 4 Comparison between 5, 7 and 9 Beams IMRT Table 5 Comparison between 5, 7 and 9 Beams IMRT
According to Right and Left Parotids According to Spinal Cord
Parotids Spinal
5 Beams 7 Beams 9 Beams p Cord 5 Beams 7 Beams 9 Beams p
(Gy)
Right (Gy)
Min. – 17.93 – 12.54 – 16.85 – Min. – 38.62 – 38.65 – 36.34 –
Max. 25.32 26.40 25.04 Max. 49.57 50.18 46.22
Mean ± 21.96 ± 20.72 ± 20.43 ± Mean ± 45.34 ± 44.51 ± 43.23 ±
0.003* 0.003*
SD. 2.30 3.41 2.19 SD. 3.15 3.31 2.37
Median 21.67 20.68 20.30 Median 45.46 44.44 43.73
Left
Min. – 16.05 – 10.16 – 12.93 –
Max. 25.76 26.23 25.41
Mean ± 22.14 ± 21.04 ± 20.70 ±
0.100
SD. 2.72 3.89 2.77
Median 22.58 21.62 21.24

Fig 7 Shows the means and standard deviations comparison

between 5, 7 and 9 IMRT beams according to spinal cord
for all HNC patients.

 Brain Stem:
In brain stem, the maximum dose was aimed to be
below 54 Gy to protect it from radiation. The means and
Fig 6 Shows the means and standard deviations comparison
standard deviations comparison between 5, 7 and 9 beams
between 5, 7 and 9 IMRT beams according to right and left
IMRT were showed in Table (6) and Fig. (8) for all
parotids for all HNC patients.
patients. The values of means and standard deviations were
49.52 ± 7.27, 49.77 ± 5.78 and 48.74 ± 6.41 respectively.
 Spinal Cord:
The results showed significant difference with p < 0.05. The
The relationship between the mean maximum dose to
dose reduced to the brain stem in 9 beams compared with 5
spinal cord and the number of the beams for all patients
and 7 beams for all HNC treated by IMRT.
were showed in Table (5) and Fig. (7). The means and
standard deviations comparison between 5, 7 and 9 beams
Table 6 Comparison between 5, 7 and 9 Beams IMRT
IMRT were 45.34 ± 3.15, 44.51 ± 3.31 and 43.23 ± 2.37
According to Brain Stem
respectively. In this study, the maximum dose allowed for
Brain
spinal cord was below 45 Gy. In all patients, most plans 5 Beams 7 Beams 9 Beams p
Stem (Gy)
were meet the constraints criteria except some cases with 5
beams. The means maximum dose to spinal cord was Min. – 30.67 – 38.96 – 31.39 –
showed a significant difference between different IMRT Max. 57.93 57.12 55.48
plans with p < 0.05. In this study, the number of the beams Mean ± 49.52 ± 49.77 ± 48.74 ±
0.058
have significant effect on the maximum dose to the spinal SD. 7.27 5.78 6.41
cord, so when increased the number of the beams, the Median 51.70 52.56 51.46
maximum dose to spinal cord reduced. The spinal cord
received low doses in 9 beams compared with 5 and 7
beams IMRT.

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 MUs:
The means and standard deviations comparison
between 5, 7 and 9 beams IMRT according to total MUs for
all HNC patients were showed in Table (8) and Fig. (10).
The values of means and the standard deviations were
23879.8±4308.1, 24252.6±4891.9 and 22501.8±3566.97
respectively. In this study, the MUs in all plans were not
restricted by the constraints. In few cases with 5 beams, the
MUs were lowest with fewest numbers of segments but the
PTV coverage was worst and the surrounding normal tissues
received high dose. On the other hand, the longest MUs
were observed with 7 beams IMRT in all cases. Statically,
there were significant differences between the different
Fig 8 Shows the means and standard deviations comparison IMRT beams with p < 0.05. The lowest MUs were achieved
between 5, 7 and 9 IMRT beams according to brain with 9 beams as well as the number of segments were
Stem for all HNC patients. highest with better PTV coverage and the dose received by
the normal surrounding tissues were reduced in most cases
 Number of Segments: compared with 5 and 7 beams IMRT.
All IMRT beams with different segments were
compared for all HNC patients. The means and standard Table 8 Comparison between 5, 7 and 9 Beams IMRT
deviations comparison between 5, 7 and 9 beams IMRT According to MUs
showed in Table (7) and Fig. (9). The values of means and
standard deviations were 79.85 ± 13.74, 106.55 ± 16.72 and MUs 5 Beams 7 Beams 9 Beams p
131.80 ± 24.62 respectively. In this study, the quality of the Min.
14759.3– 15972.3– 15209.6–
plans was associated with the number of segments and –
30017.1 32650.1 27365.4
irradiated times. When the number of segments decreases, Max.
the quality of the plans was worse in PTV coverage and the Mean 23879.8±43 24252.6±48 22501.8±356 0.00
doses received by the surrounding normal tissues were high. ± SD. 08.1 91.9 6.97 3*
In most patients the results related to number of segments Medi
24225.36 25270.35 23553.32
were acceptable except some plans with 5 beams. The an
results showed that, there were significant difference
between 5, 7 and 9 beams with p < 0.05. Moreover, when
the number of beams increased the number of segment
increased as well as the dose was improved to the PTV and
the irradiated time was reduced.

Table 7 Comparison between 5, 7 and 9 Beams IMRT

No of
5 Beams 7 Beams 9 Beams p
Segments
Min. – 60.0 – 78.0 – 99.0 –
Max. 105.0 139.0 185.0
Mean ± 79.85 ± 106.55 ± 131.80 ±
<0.001*
SD. 13.74 16.72 24.62
Median 77.50 105.0 125.0
According to Number of Segments Fig 10 Shows the means and standard deviations
comparison between 5, 7 and 9 IMRT beams according to
MUs for all HNC patients

 Total Irradiated Time:

The total pure irradiated time were calculated and
compared for all HNC patients. The means and standard
deviations comparison between 5, 7 and 9 beams IMRT
showed in Table (9) and Fig. (11). The values of means and
standard deviations were 79.60 ± 14.36, 80.84 ± 16.31and
75.0 ± 11.89 respectively. The results showed that,
increased the number of MUs lead to increase the irradiated
time in all IMRT cases. On the other hand, when the number
of segments increased due to increase in number of IMRT
beams, that lead to reduced in MUs as well as the irradiated
Fig 9 Shows the means and standard deviations comparison
time were reduced, in fact, Few cases with 5 beams, the
between 5, 7 and 9 IMRT beams according to number of
irradiated time were shortest but the PTV coverage were
Segments for all HNC patients

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worst and the surrounding normal tissues were received high sparing of OARs. Before optimization process, it is
dose. The longest irradiated time with 7 beams were important to placement the appropriate number of beams to
observed in most IMRT cases. There were significantly obtain acceptable IMRT plans (32). For HNC patients
difference between the 5, 7 and 9 beams with p < 0.05. The treatment usually requires 5 to 9 beams IMRT (26, 33-36). In
shortest pure irradiated time were achieved with 9 beams this study, the aim was to determine the best beams number
with better in PTV coverage, homogeneity, conformity and and segments in order to improve the plans conformity and
the surrounding normal tissues received low dose compared homogeneity that generate low MUs and faster treatment
with 5 and 7 beams IMRT for treatment HNC patients. time for different types of HNC. Moreover, attention to
reach the desired dose distribution as well as sparing the
Table 9 Comparison between 5, 7 and 9 Beams IMRT surrounding normal tissues.
Total
Irradiated 9 In this feasibility study, we compared 5, 7 and 9 beams
5 Beams 7 Beams p step and shoot IMRT for HNC in term of PTV coverage,
Time Beams
(Minute) dose distributions in the target, conformity and homogeneity
50.69 the dose to the PTV, OARs sparing which include right and
49.19 – 53.24 –
Min. – Max. – left parotids, spinal cord and brain stem, also number of
100.06 108.83 segments, the total number of MUs and total pure irradiated
91.22
79.60 ± 80.84 ± 75.0 ± time for 30 patients HNC. In this comparative planning
Mean ± SD. 0.003* study, we depended on the defined of IMRT objectives and
14.36 16.31 11.89
Median 80.85 84.24 78.51 planning constraints for any individualized HNC patients
According to the Total Irradiated Time. before optimization process.

To our knowledge, none evidence previous studies

compared between 5, 7 and 9 beams static IMRT for
treatment HNC. Narayanan VS, etal and Derbyshire SJ,
etal clear that, when increase the number of beams in IMRT
provide greater dose distribution to the PTV and more
sparing of OARs (37, 38). Obtaining better of dose
distributions with lower number of MUs basically require
suitable selections of beams and their angles (37).

In IMRT, the PTV coverage was acceptable if 95% of

the volume were covered by 95% of the prescribed dose (39).
The results indicated that, the 5, 7 and 9 beams IMRT were
show comparable in PTV coverage. The 9 beams IMRT
Fig 11 Shows the means and standard deviations were able to provide acceptable target coverage with better
comparison between 5, 7 and 9 IMRT beams according to sparing of OARs, it was more difficult to meet all criteria of
total irradiated time for all HNC patients. IMRT when using 5 beams IMRT in this study. It is evident
from the shape of DVH and isodose distribution when
IV. DISCUSSION increase the number of beams improved the dose
distribution and reduced the radiation doses to the OARs
IMRT is an advanced form of radiotherapy that and surrounding normal tissues.
delivers higher radiation dose to the target with strict
constraints for the OARs (28). High dose of IMRT can be In the current study, the conformity of the dose to the
achieved better dose distribution in the PTV with better PTV was better in 9 beams IMRT compared with 5 and 7
sparing of OARs and surrounding normal tissues compared beams with statically significant difference p < 0.05. The
with 3DCRT (29, 30). HNC is one of the most technically mean of CI in 9 beams IMRT indicate better values when
treatments in radiotherapy, due to the number of concave compared with 5 and 7 beams IMRT. The homogeneity of
complex targets with different dose prescription. IMRT is the dose inside the PTV was better in 9 beams compared
one option treatment planning for HNC (31). The beam with 5 and 7 beams IMRT with statically significant
number selection affects the optimized dose distribution difference p < 0.05. The dose received by the right and left
particularly for concave HNC targets, so the increase of parotids, spinal cord and brain stem was reduction with 9
beams in HNC treatment more than 5 beams is optimal beams IMRT compared with 5 and 7 beams IMRT with
option (29). significant difference p< 0.05.

Currently, the beam number selection in IMRT is In general, when increase the number of the beams in
depended on the experience of treatment planners, many static step and shoot IMRT the MUs were decreased (37, 38, 40)
researchers have attempted to automate the beam selection . The reduced in number of MUs should lead to less leakage
in IMRT. Moreover, such as in complex concave situations, of radiation from the collimator head. This reductions lead
it is difficult to decide a suitable number of beams without to less peripheral doses (41, 42). The dose to the healthy
trails, errors and compromise in dose distribution and tissues around the PTV arise from the collimator

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Special Issue-(2nd ICTSA-2022) International Journal of Innovative Science and Research Technology
ISSN No:-24562165
transmission and scatter radiation from the linear  Studying the different between beam numbers using
accelerator, this dose is proportional to the number of MUs. different IMRT delivery techniques include dynamic or
This scatter radiation can increase the risk of secondary sliding window and arc therapy.
malignances (19, 41, 43). It is important to know that, the
number of MUs is one factor which influences in the ACKNOWLEDGMENT
peripheral doses with others factors like linear accelerator
head shielding and collimator system such as materials, I would like to thanks and it is a great pleasure to
shapes and MLC thickness (2). Sabatino M, etal suggested express my deepest gratitude to Prof. Dr. Fatma Ismael
that, the low number of MUs is the main reasons for the Nasr, Professor in Medical Biophysics Department, Medical
shortest treatment times, the reasons of this time saving are Research Institute, Alexandria University, for supported me
the creation of fluence modulation. For the low dose until this moment. I would like to thank Prof. Dr. Sohir
exposure, two reasons could be responsible: chosen of Mahmoud El-Kholy, Professor in Medical Biophysics
gantry angles and the dose calculation algorithms. More Department, Medical Research Institute, Alexandria
number of IMRT beams lead to reduce the number of MUs University, for guided and encouraged me during study my
as well as lead to reduce the irradiated time using step and PhD courses and thesis, I would like to express my deep
shoot IMRT(41). It is to be noted that, in the step and shoot appreciation for her continuous encouragement and advices.
IMRT, the algorithms used for beam intensity optimization
and segmentation can also influence on the final beam Strongly appreciation and thankful to Dr. Mostafa Aly
numbers obtained results (37). In this study, the MUs were El Naggar, Fellow, Department of Cancer Management and
significantly reduced in 9 beams compared with 5 and 7 Research, Medical Research Institute, Alexandria
beams IMRT with p< 0.05, this associated with above University, for continues advised and supported me during
previous studies. practical research in Ayadi Al-Mostakbal Oncology Center,
Alexandria, Egypt.
Our finding that, the fast pure treatment time when
compared the 5, 7 and 9 beams IMRT, 9 beams IMRT is I would specially like to thanks Medical Physicists
sufficient to produce a better dose distribution, PTV Wala Tammam for helping and assisted me during practical
conformity, homogeneity and OARs sparing with faster part. Additionally I would like to thanks all medical
comparable pure irradiated time in 75.0 minutes while 5 physicists in Ayadi Al-Mostakbal Oncology Center. All
beams may require79.60 minutes and 7 beams require 80.84 acknowledgment to whom helping and supported me and
minutes as a mean total pure irradiated time. Chang SX, etal deserve more than word of thanks. Finally, strongly
and Qi P, etal mentioned that, used more segments improved appreciations to my family, whom stay patience and
the conformity and play an important role in MUs reduction supported me until graduation.
as well as the treatment time decreased (40, 44). It is important
to note that, the pure irradiated time were shortest in 9 REFERENCES
beams step and shoot IMRT using Xio software treatment
planning system and artist linear accelerator for treatment [1] Elith C, Dempsey SE, Findlay N, Warren-Forward
HNC patients. HM. An introduction to the intensity-modulated
radiation therapy (IMRT) techniques, tomotherapy,
V. CONCLUSION and VMAT. J Med Imaging Radiat Sci.
2011;42(1):37-43.
From this study we can conclude that, the 9 beams [2] Wiezorek T, Brachwitz T, Georg D, Blank E, Fotina
IMRT is superior to techniques using less number of beams I, Habl G, et al. Rotational IMRT techniques
(5 and 7) where, the 9 beams IMRT significantly improved compared to fixed gantry IMRT and tomotherapy:
the PTV coverage, dose distribution, conformity, multi-institutional planning study for head-and-neck
homogeneity to the PTV with better sparing OARs and cases. Radiat Oncol 2011:doi: 10.1186/748-717X-6-
reduce the dose to surrounding normal tissues. Moreover, 20.
the 9 beams significantly reduced the mean MUs and pure [3] Gomez-Millan J, Fernández JR, Carmona JAM.
irradiated time compared with 5 and 7 beams IMRT. Current status of IMRT in head and neck cancer. Rep
Pract Oncol Radiother. 2013;18(6):371-75.
RECOMMENDATIONS [4] Mundt AJ, Roeske JC. Image-guided radiation
therapy: a clinical perspective: PMPH-USA; 2010.
 In view of the results of this study and significant of [5] Teoh M, Clark C, Wood K, Whitaker S, Nisbet A.
superiority of 9 beams plans compared to the 5 and 7 Volumetric modulated arc therapy: a review of
beams in IMRT of HNC, we recommend using more current literature and clinical use in practice. Br J
number of beams in treatment planning preferably 9 Radiol. 2014;84(1007):967-96.
beams. [6] Bakiu E, Telhaj E, Kozma E, Ruçi F, Malkaj P.
 More studies comparing different beams number is Comparison of 3D CRT and IMRT tratment plans.
encourage to consolidate our results. Acta Inform Med. 2013;21(3):211-12.
 Conducting similar studies on different tumor sites.
 We recommend study the integral dose using the same
methods.

IJISRT22DEC1494 www.ijisrt.com 102

Special Issue-(2nd ICTSA-2022) International Journal of Innovative Science and Research Technology
ISSN No:-24562165
[7] Ratko TA, Douglas G, De Souza JA, Belinson SE, [20] Elith CA, Dempsey SE, Warren‐Forward HM. A
Aronson N. Radiotherapy treatments for head and retrospective planning analysis comparing intensity
neck cancer update. Agency for Healthcare Research modulated radiation therapy (IMRT) to volumetric
and Quality (AHRQ), USA 2014. modulated arc therapy (VMAT) using two
[8] Dzierma Y, Nuesken FG, Fleckenstein J, Melchior P, optimization algorithms for the treatment of early‐
Licht NP, Rübe C. Comparative planning of stage prostate cancer. J Med Radiat Sci.
flattening-filter-free and flat beam IMRT for 2013;60(3):84-92.
hypopharynx cancer as a function of beam and [21] Bucci MK, Bevan A, Roach M. Advances in
segment number. PloS one. 2014:doi: radiation therapy: conventional to 3D, to IMRT, to
10.1371.0094371. 4D, and beyond. CA Cancer J Clin. 2005;55(2):117-
[9] Fraass BA, Steers JM, Matuszak MM, McShan DL. 34.
Inverse-optimized 3D conformal planning: [22] Iqbal K, Isa M, Buzdar SA, Gifford KA, Afzal M.
Minimizing complexity while achieving equivalence Treatment planning evaluation of sliding window and
with beamlet IMRT in multiple clinical sites. Med multiple static segments technique in intensity
Phys. 2012;39(6):3361-74. modulated radiotherapy. Rep Pract Oncol Radiother.
[10] Holt A, Van Gestel D, Arends MP, Korevaar EW, 2013;18(2):101-06.
Schuring D, Kunze-Busch MC, et al. Multi- [23] Otto K. Volumetric modulated arc therapy: IMRT in
institutional comparison of volumetric modulated arc a single gantry arc. Med Phys. 2008;35(1):310-17.
therapy vs. intensity-modulated radiation therapy for [24] Dunlop A, Welsh L, McQuaid D, Dean J, Gulliford S,
head-and-neck cancer: a planning study. Radiat Hansen V, et al. Brain-sparing methods for IMRT of
Oncol 2013:doi: 10.1186/748-717X-8-26. head and neck cancer. PloS one. 2015:doi:
[11] Nasr A, Habash A. Dosimetric analytic comparison 10.1371.0120141.
of inverse and forward planned IMRT techniques in [25] Amin AE, Kelaney M, Elshamndy SK, Guirguis OW.
the treatment of head and neck cancer. J Egypt Natl Impact of different IMRT techniques to improve
Canc Inst. 2014;26(3):119-25. conformity and normal tissue sparing in upper
[12] Lee NY, Le Q-T, editors. New developments in esophageal cancer. Int J Cancer Ther Oncol.
radiation therapy for head and neck cancer: intensity- 2015:doi:10.14319/0301.13.
modulated radiation therapy and hypoxia targeting. [26] Dybwad A. Comparison of Dose Distributions
Semin Oncol; 2008. resulting from IMRT and VMAT, and Assessment of
[13] Peszynska-Piorun M, Malicki J, Golusinski W. Doses MLC Leaf Positioning Errors. NTNU 2013.
in organs at risk during head and neck radiotherapy [27] Bratengeier K, Gainey MB, Flentje M. Fast IMRT by
using IMRT and 3D-CRT. Radiother Oncol. increasing the beam number and reducing the number
2012;46(4):328-36. of segments. Radiat Oncol. 2011: doi: 10.1186/748-
[14] Takamiya R, Missett B, Weinberg V, Akazawa C, 717X-6-170.
Akazawa P, Zytkovicz A, et al. Simplifying IMRT [28] Kouloulias V, Antypas C, Liakouli Z, Armpilia C,
plans with fewer beam angles for the treatment of Zygogianni A, Floros I, et al. Τhe first
oropharyngeal carcinoma. J Appl Clin Med Phys. implementation of IMRT technique for head & neck
2007;8(2):26-36. and prostate cancer patients in public sector in
[15] Van Gestel D, Verellen D, Van De Voorde L, de Ost Greece: feasibility, treatment planning and dose
B, De Kerf G, Vanderveken O, et al. The potential of delivery verification using the delta4PT Pre-
helical tomotherapy in the treatment of head and neck Treatment volumetric quality assurance system. J
cancer. Oncologist. 2013;18(6):697-706. BUON.6:196-205.
[16] Ballivy O, Santamaría RG, Borbalas AL, Edo FG. [29] Zayat DMA, Attalla EM, Abouelenein H, Fadel S,
Clinical application of intensity-modulated Khalil W. Dosimetric comparison of intensity-
radiotherapy for head and neck cancer. Clin Transl modulated radiotherapy versus 3D conformal
Oncol. 2008;10(7):407-14. radiotherapy in patients with head-and-neck cancer.
[17] Hartford AC, Galvin JM, Beyer DC, Eichler TJ, JMEST. 2015;2(4):3159-0040.
Ibbott GS, Kavanagh B, et al. American College of [30] Yuan J, Lei M, Yang Z, Fu J, Huo L, Hong J.
Radiology (ACR) and American Society for Dosimetric comparison between intensity-modulated
Radiation Oncology (ASTRO) practice guideline for radiotherapy and RapidArc with single arc and dual
intensity-modulated radiation therapy (IMRT). Am J arc for malignant glioma involving the parietal lobe.
Clin Oncol. 2012;35(6):612-17. Mol Clin Oncol. 2016;5(1):181-88.
[18] Kumar SS, Vivekanandan N, Sriram P. A study on [31] Shang Q, Shen ZL, Ward MC, Joshi NP, Koyfman
conventional IMRT and RapidArc treatment planning SA, Xia P. Evolution of treatment planning
techniques for head and neck cancers. Rep Pract techniques in external-beam radiation therapy for
Oncol Radiother. 2012;17(3):168-75. head and neck cancer. applied radiation
[19] DAOUD MA, ALIDRISI MA, HABASH AS, oncology.25:1-8.
ABDELKHALEK SE. A Comparative Study of
Volumetric Intensity Modulated Arc Therapy Versus
Conventional IMRT in Head and Neck Cancer
Patients. Med J Cairo Univ. 2014;82(2):9-15.

IJISRT22DEC1494 www.ijisrt.com 103

Special Issue-(2nd ICTSA-2022) International Journal of Innovative Science and Research Technology
ISSN No:-24562165
[32] Ranganathan V, Das KM. Determination of optimal
number of beams in direct machine parameter
optimization-based intensity modulated radiotherapy
for head and neck cases. J Med Phys.
2016;41(2):129-34.
[33] Yirmibesoglu E, Fried DV, Kostich M, Rosenman J,
Shockley W, Weissler M, et al. Dosimetric evaluation
of an ipsilateral intensity modulated radiotherapy
beam arrangement for parotid malignancies. Radiol
Oncol. 2013;47(4):411-18.
[34] Zhu XR, Schultz CJ, Gillin MT. Planning quality and
delivery efficiency of sMLC delivered IMRT
treatment of oropharyngeal cancers evaluated by
RTOG H-0022 dosimetric criteria. J Appl Clin Med
Phys. 2004;5(4):80-95.
[35] Cozzi L, Fogliata A. IMRT in the treatment of head
and neck cancer: is the present already the future?
Expert Rev Anticancer Ther. 2002;2(3):297-308.
[36] Schmidt MC. Knowledge-Based IMRT Treatment
Planning for Bilateral Head and Neck Cancer: Duke
University; 2013.
[37] Narayanan VS, Vaitheeswaran R, Bhangle JR, Basu
S, Maiya V, Zade B. An experimental investigation
on the effect of beam angle optimization on the
reduction of beam numbers in IMRT of head and
neck tumors. J Appl Clin Med Phys. 2012:doi:
10.1120/jacmp.v13i4.3912.
[38] Derbyshire SJ, Morgan AM, Thompson RC, Henry
AM, Thwaites DI. Optimal planning parameters for
simultaneous boost IMRT treatment of prostate
cancer using a Beam Modulator™. Rep Pract Oncol
Radiother. 2009;14(6):205-13.
[39] Al Zayat DM, Attalla EM, Abouelenein HS, Elkem
YM, Khalil W. Dosimetric Comparison of Intensity-
Modulated Radiotherapy versus Three-Dimensional
Conformal Radiotherapy for Patients with Brain
Tumors. OJRad. 2014;4:85-96.
[40] Chang SX, Cullip TJ, Deschesne KM. Intensity
modulation delivery techniques:“Step & shoot” MLC
auto-sequence versus the use of a modulator. Med
Phys. 2000;27(5):948-59.
[41] Sabatino M, Kretschmer M, Zink K, Würschmidt F.
The impact of direct aperture optimization on plan
quality and efficiency in complex head and neck
IMRT. Radiat Oncol. 2012:doi: 10.1186/748-717X-7-
7.
[42] Caraman A. A Comparison Between 3D-CRT,
Intensity modulated Radiotherapy, and Volumetric
modulated Arc Therapy Techniques for head and
neck cancer. Journal of Advanced Research in
Physics. 2016;6(1).
[43] Lu J-Y, Zheng J, Zhang W-Z, Huang B-T. Flattening
Filter-Free Beams in Intensity-Modulated
Radiotherapy and Volumetric Modulated Arc
Therapy for Sinonasal Cancer. PloS one. 2016:doi:
10.1371/0146604.
[44] Qi P, Xia P. Relationship of segment area and
monitor unit efficiency in aperture-based IMRT
optimization. J Appl Clin Med Phys. 2013;14(3):40-
56.

IJISRT22DEC1494 www.ijisrt.com 104