Implications of tissue heterogeneity for radiosurgery in head and neck tumors

Purpose: This study was undertaken to investigate the perturbation of small radiation beams by low density heterogeneities and to evaluate the ability of a Monte Carlo code to accout for such perturbation. Performance of an inexpensive film scanning system was also evaluated. Methods and Materials: Film and diode measurements were made in an acrylic phantom in which the size and position of an air gap were varied. Monte Carlo analysis was used to obtain additional verification of the measurements, to provide insight into photon and electron transport phenomena not directly measurable, and as a benchmark for the code. Results: With 10 MV photons and a 1 cm circular field, a small 3-mm air cavity placed 2.6 cm deep in acrylic (full buildup) results in a reduction in central axis dose of 21% immediately following the cavity. Equilibrium is then reestablished over the next centimeter, after which the dose exceeds that of the homogeneous case by 3-4%. The loss in central axis equilibrium is highly field-size dependent, with some loss occurring even for the largest (32 mm) collimator. In addition, the presence of the air cavity produces a significant increase in dose up to 2 cm lateral and outside the primary field. Conclusions: Tissue heterogeneities are not presently accounted for in radiosurgery calculations, yet have the ability to perturb dose significantly. Targets may potentially be underdosed, and adjacent critical structures overdosed. Inability to account for tissue heterogeneities may limit the use of the radiosurgery approach in some areas. A Monte Carlo approach may be the method of choice for small field dose calculation when tissue heterogeneities are encountered.