Mantle fields in the era of dynamic multileaf collimation: Field shaping and electronic tissue compensation

Mantle field radiotherapy for Hodgkin's disease is complicated by significant dose gradient (up to 10-20%) across the large fields required. Many different strategies of tissue compensation have been investigated, including custom physical compensators to provide better dose distributions. We present a method using dynamic multileaf collimator (dMLC) fluence modulation to simultaneously shape the treatment field and give homogeneous dose at depth throughout the classic mantle field. Five patients were treated for early-stage Hodgkin's disease with a conventional anterior-posterior-posterior-anterior (AP-PA) mantle field. The patients were planned using the Varian Eclipse treatment planning system, version 6.1.3, and treated on a Varian 2300CD. An AP-PA dynamic MLC beam-shaped and dose-compensated plan was created for each, and compared with the conventional blocked plan. Nine dose points were calculated at midplane in each plan. Chamber measurements were taken to confirm accurate dMLC delivery of the planned doses. The mean dose per fraction, relative to a central axis dose of 1.8 Gy, was increased in the conventional plans compared with the dMLC plans in the right (R) neck, left (L) neck, R supraclavicular, L supraclavicular, and L axillary points. The mediastinum tended to be underdosed relative to central axis, with the mid-mediastinal and lower mediastinal points showing improved coverage with the dMLC plans. Measurements showed excellent agreement between planned doses and delivered doses, with less than 2% in-field variation. Dynamic MLC fluence modulation was used to effectively deliver a mantle field that is both shape- and electronically-dose-compensated with sliding window MLC. Homogeneity was significantly improved throughout the treatment field, and measurements confirmed accurate dose delivery using this technique.