title: Revision of orthovoltage chest wall treatment using Monte Carlo simulations.
abstract: OBJECTIVE
  Given the high local control rates observed in breast cancer patients undergoing chest wall irradiation by kilovoltage x-rays, we aimed to revisit this treatment modality by accurate calculation of dose distributions using Monte Carlo simulation.
  
  
  METHODS
  The machine components were simulated using the MCNPX code. This model was used to assess the dose distribution of chest wall kilovoltage treatment in different chest wall thicknesses and larger contour or fat patients in standard and mid sternum treatment plans. Assessments were performed at 50 and 100 cm focus surface distance (FSD) and different irradiation angles. In order to evaluate different plans, indices like homogeneity index, conformity index, the average dose of heart, lung, left anterior descending artery (LAD) and percentage target coverage (PTC) were used. Finally, the results were compared with the indices provided by electron therapy which is a more routine treatment of chest wall.
  
  
  RESULTS
  These indices in a medium chest wall thickness in standard treatment plan at 50 cm FSD and 15 degrees tube angle was as follows: homogeneity index 2.57, conformity index 7.31, average target dose 27.43 Gy, average dose of heart, lung and LAD, 1.03, 2.08 and 1.60 Gy respectively and PTC 11.19%. Assessments revealed that dose homogeneity in planning target volume (PTV) and conformity between the high dose region and PTV was poor. To improve the treatment indices, the reference point was transferred from the chest wall skin surface to the center of PTV. The indices changed as follows: conformity index 7.31, average target dose 60.19 Gy, the average dose of heart, lung and LAD, 3.57, 6.38 and 5.05 Gy respectively and PTC 55.24%. Coverage index of electron therapy was 89% while it was 22.74% in the old orthovoltage method and also the average dose of the target was about 50 Gy but in the given method it was almost 30 Gy.
  
  
  CONCLUSIONS
  The results of the treatment study show that the optimized standard and mid sternum treatment for different chest wall thicknesses is with 50 cm FSD and zero (vertical) tube angle, while in large contour patients, it is with 100 cm FSD and zero tube angle. Finally, chest wall kilovoltage and electron therapies were compared, which revealed that electron therapy produces a better dose distribution than kilovoltage therapy.
authors.affiliation: Medical Radiation Department, School of Mechanical Engineering, Shiraz University, Shiraz, Iran.|Medical Imaging Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
authors.forename: B
authors.initials: B
authors.lastname: Zeinali-Rafsanjani
authors.affiliation: Medical Radiation Department, School of Mechanical Engineering, Shiraz University, Shiraz, Iran.|Radiation Research Center, School of Mechanical Engineering, Shiraz University, Shiraz, Iran.
authors.forename: R
authors.initials: R
authors.lastname: Faghihi
authors.affiliation: Medical Imaging Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.|Radiotherapy and Oncology Department, Shiraz University of Medical Sciences, Shiraz, Iran.
authors.forename: M A
authors.initials: MA
authors.lastname: Mosleh-Shirazi
authors.affiliation: Radiotherapy and Oncology Department, Shiraz University of Medical Sciences, Shiraz, Iran.
authors.forename: A
authors.initials: A
authors.lastname: Mosalaei
authors.affiliation: Medical Radiation Department, School of Mechanical Engineering, Shiraz University, Shiraz, Iran.
authors.forename: K
authors.initials: K
authors.lastname: Hadad
mesh_terms: D001943:Breast Neoplasms / Q000532:radiotherapy; D004307:Dose-Response Relationship, Radiation; D005260:Female; D006321:Heart / Q000528:radiation effects; D006801:Humans; D008168:Lung / Q000528:radiation effects; D009010:Monte Carlo Method; D011829:Radiation Dosage; D035441:Thoracic Wall / Q000033:anatomy & histology / Q000528:radiation effects*
keywords: Chest wall irradiation; Monte Carlo simulation; orthovoltage therapy; treatment planning