A Comparison Between Halcyon™ and Truebeam® Treatment Delivery Systems
A Comparison Between Halcyon™ and Truebeam® Treatment Delivery Systems
A Comparison Between Halcyon™ and Truebeam® Treatment Delivery Systems
Abstract
Purpose
A new dual-layer multi-leaf collimator (MLC) system with several improved characteristics was
introduced with the Varian Halcyon™ treatment platform. This study evaluated this new MLC’s
impact on head and neck plan quality and delivery efficiency.
Methods
Nine patients were retrospectively studied with Institutional Review Board (IRB) approval. To
compare plan quality between the Halcyon dual-layer MLC and Truebeam® MLC, all patients
were replanned with the same prescription and target coverage following the institutional
clinical protocol for both platforms and using both intensity modulated radiation therapy
(IMRT) or volumetrically modulated arc therapy (VMAT) techniques. Organs-at-risk (OAR)
dose-volume histogram (DVH) statistics were compared along with total plan monitor units
(MU). To evaluate delivery efficiency, actual beam-on time for five patients’ plans were
recorded and compared. To evaluate the impact of MLC performance parameters on plan
quality, virtual MLC models were generated by matching Truebeam MLC’s parameters to those
of the Halcyon dual-layer MLC both individually and combined. OAR doses were then compared
between these virtual MLCs, the Truebeam MLC, and the actual Halcyon MLC.
Received 11/13/2018
Review began 11/17/2018
Results
Review ended 11/23/2018
Overall the Halcyon dual-layer MLC provided similar plan quality compared to Truebeam MLC
Published 11/28/2018
for VMAT plans, and improved sparing for majority of the OARs when using IMRT. Paired
© Copyright 2018 comparison showed median dose differences in mean doses to the parotids, cochlea, esophagus,
Li et al. This is an open access article
and larynx ranged from -0.83 Gy to 0.37 Gy for VMAT, and from -4.79 Gy to -0.04 Gy for IMRT,
distributed under the terms of the
Creative Commons Attribution License
with negative values indicating improved performance by Halcyon. Despite a slight increase in
CC-BY 3.0., which permits plan MU, the Halcyon reduced the total beam-on time by 42.8 ± 8.5%. Virtual MLC simulations
unrestricted use, distribution, and demonstrated that matching MLC transmission accounted for nearly half of the total dose
reproduction in any medium, provided difference between Halcyon and Truebeam IMRT plans.
the original author and source are
credited.
Conclusion
Introduction
Radiation therapy plays a key role in managing head and neck cancer. Due to the complexity of
the shape and configuration of tumor and lymph nodes in the target region, and close
proximity of organs-at-risk (OARs), intensity-modulated radiation therapy (IMRT) or
volumetrically modulated arc therapy (VMAT) has been widely used in treatment planning for
head neck patients.
The delivery of IMRT/VMAT treatment plans relies heavily on the multi-leaf collimator (MLC).
Therefore, it is expected that MLC parameters such as inter-leaf leakage, leaf transmission,
dosimetric leaf gap (DLG), leaf width, leaf over-travel limits, and leaf speed, play important
roles in impacting the quality of the treatment plan. Previous studies have heavily investigated
the impact of MLC leaf width on the quality of IMRT plans. Burmeister et al. [1] and Wu et al. [2]
investigated the difference in plan quality between 1 cm, 0.5 cm, and 0.25 cm leaf widths for
head and neck and central nervous system (CNS) malignancies, and concluded that leaf width
has limited impact on plan quality for large volume targets. This conclusion was also supported
by several other studies [3-8]. Topolnjak et al. investigated the impact of MLC characteristics on
plan quality for seven head and neck cancer patients using a hypothetical linac model, and
concluded that leaf transmission has a major impact on the normal tissue mean dose [9]. In
their work the increase of leaf transmission from 0.75% to 1.5% resulted in an increase in
parotids mean dose by 1.8 Gy. The impact of other MLC parameters such as DLG and leaf speed
has not been extensively tested or reported for head and neck applications.
Recently a new straight-through jawless treatment delivery system was introduced by Varian
Medical Systems (Palo Alto, CA) trademarked Halcyon™. In this system, a new dual-layer MLC
design was introduced to fulfill jawless configuration while simultaneously providing sufficient
beam attenuation and shape modulation. The new MLC design, referred to here as “dual-layer
MLC,” features a dual-layer of stacked and staggered MLC leaves with 1 cm leaf width in each
layer when projected to the isocenter plane, which is at 100 cm source-to-axis distance (SAD).
This MLC system also features faster speed than Varian’s current mainstream MLC system used
in the Truebeam® accelerator product lines, the Millennium 120, referred to here as TB MLC,
providing 5.0 cm/s movement at the isocenter plane compared to 2.5 cm/s for the Millennium
120. The Halcyon dual-layer MLC can also achieve full-field modulation with 100% leave over-
travel and interdigitation. The Halcyon linac system offers only the six megavoltage (6 MV)
flattening-filter-free (6FFF) mode for treatment delivery. The omission of flattening filter
increases the beam output and has a lower average energy than 6 MV beams produced with the
same maximal energy but flattened with a filter (6X). This lower average energy, combined with
the improvement in the MLC design, provided a significant improvement in the leakage and
transmission properties of the dual-layer MLC compared to Millennium 120 MLC: 0.7% per
layer leaf transmission for the dual-layer MLC compared to around 1.5% leaf transmission for
Millennium 120 used in the Truebeam linac. Dosimetric leaf gap for this dual-layer MLC was
changed to 0.1 mm in the Halcyon beam model. At the time of this study, the dual-layer MLC is
only able to provide modulation using the distal layer of MLC, i.e., the layer away from the
radiation source and closer to the patient, while the proximal MLC layer follows the opening of
Since the dual-layer MLC has improved transmission, speed, over-travel, and DLG, but twice as
large leaf width, it is important to understand the impact to plan quality and delivery efficiency
when compared to the regular Truebeam Millennium 120 MLC design. In the first part of this
study, we compared the dosimetric and delivery parameters for plans generated with both types
of delivery systems to determine if there were any significant differences between plans
generated with the two MLC designs. In the second part of the study, we focused on the cases
with significant difference, and studied how these MLC parameters contributed to those
differences.
Key dosimetric parameters of clinical interest were compared among different planning
techniques and delivery systems: global maximal dose, maximum cord dose, and mean dose to
the parotids, cochleae, esophagus, and larynx (non-target). Total monitor units required to
delivery treatment were also compared. The paired treatment plans, i.e. plans created with
different delivery system for the same patient, were compared statistically with the Wilcoxon
signed-rank test. This comparison was done separately for IMRT and VMAT. Statistical
significances (p-values) from this test were reported.
Results
Another comparison shown in Figure 1 is the total number of MUs required to deliver the
treatment plans. In general, the dual-layer MLC delivery system requires higher total MU, which
is expected because the Halcyon uses 6FFF energy compared to the 6 MV flattened beam for
head and neck plans on the Truebeam platform. The inherently lower effective energy of the
6FFF beam, as well as the non-flat beam profiles, would require more MUs to deliver the same
dose to a given depth.
OAR doses were compared for key dose-volume histogram (DVH) parameters and is visualized
in Figure 2. It is evident that for the majority of the DVH parameters, TB and dual-layer MLC
plans have a large overlap of boxes, indicating the similarity in range of the underlying
distribution of data. This is especially true for VMAT plans.
The paired differences between TB MLC and the dual-layer MLC plans are highlighted in Figure
3. Comparing IMRT and VMAT techniques, the differences in OAR dosimetric parameters for
VMAT were mostly centered around zero except for the maximum cord dose, indicating similar
performances between TB MLC and the dual-layer MLC for VMAT plans. For cord Dmax, all
plans had Dmax < 48 Gy per RTOG 0522. The median difference between dual-layer and TB
MLC on cord Dmax is 1.48 Gy. For IMRT plans, the difference between dual-layer MLC and TB
MLC plans was mostly distributed in the negative region, which indicates that the dual-layer
MLC in general achieved better OAR sparing when compared to TB MLC for IMRT plans.
Wilcoxon signed-rank tests were performed between TB and dual-layer MLC plan pairs to
determine the statistical significance of the observed differences, and the resulting p-values
were included in Figure 3. Overall no statistical significance was observed for VMAT plans,
except for the maximum cord dose: a lower maximum cord dose was observed for VMAT plans
using TB MLC. However, from Figure 2 it is evident that all plans had cord Dmax < 45 Gy, which
is our clinical limit. For IMRT plans, reductions in OAR dose were statistically significant (p <
0.05) for mean doses for esophagus, larynx, and marginal (p = 0.06) for left and right cochlea.
Lower mean dose was observed for both parotid glands based on distribution of points but was
not significant statistically. These results agreed with the general observation from Figure 2.
FIGURE 4: Plot of total beam-on time for plan delivery vs. plan
total monitor units (MU) for the two techniques and two
delivery platforms. Blue corresponds to intensity-modulated
radiation therapy (IMRT) plans, and red to volumetrically
modulated arc therapy (VMAT) plans. Halcyon™ and
Truebeam® plans are represented by circle and cross markers,
respectively. A trend line was also fitted for the two platforms
(Halcyon™ and Truebeam) using combined data points from
both IMRT and VMAT plans.
Another observation that can be made from Figure 4 is that for VMAT plans in the low MU
range, the Truebeam platform had nearly the same delivery time regardless of MU while
Halcyon still maintains a relatively linear relationship between beam-on time and total MU.
This is mainly because at this MU range the Truebeam delivery is mainly limited by the gantry
angle rotation speed (six degree per sec or one revolution per min) therefore lowering the total
MU will not translate into saving time during delivery. For Halcyon, however, since the gantry
rotation can be four times faster, delivery efficiency is no longer limited by the gantry rotation
speed, and allows the user to reduce delivery time by limiting total MU if desired. Therefore
generally speaking, the delivery speed of the current Halcyon design is limited by mainly the
maximal dose rate (800 MU/min).
Discussion
In this study we first compared Halcyon’s dual layer MLC’s performance in IMRT and VMAT
treatment for head and neck cancer to that of Truebeam’s Millennium 120 MLC in terms of plan
quality and delivery speed, and later identified which MLC parameter contributed the most to
observed plan quality differences. Our finding on VMAT plan quality and delivery time
comparison between Halcyon and Truebeam agrees with Michiels et al., who evaluated head
and neck patients and concluded that Halcyon maintains plan quality for VMAT technique [10].
The main contribution and added value from our study to the current knowledge of Halcyon
delivery system are the differences in IMRT plan quality and delivery time, and investigations
When comparing dual-layer MLC with TB MLC on OAR doses for IMRT plans, one could
question whether Figure 3 and Figure 5 showed meaningful differences: only some OAR doses
were significantly improved but all OAR doses were consistently improved using dual-layer
MLC, which is shown in Figure 5. This inconsistency is likely due to the difference in study aims
and designs, as well as sample differences. In the planning study, the planners were instructed
to approach each case as if it were a new clinical case, i.e., to freely adjust planning objectives
until they think that it is the best achievable plan in a clinically relevant timeframe. This study
design was based on the hypothesis that Halcyon plans using 6FFF beams are comparable to
Truebeam plans using 6 MV beams, which is our clinical standard. However, for the MLC
parameters study, focus was on isolating OAR dose difference as a result of changes in MLC
parameters by keeping the same beam energy, beam arrangement, and planning objectives
across all treatment plans. In addition, Figure 3 included two unilateral cases that were not
included in Figure 5, which might also have contributed to the differences in observed OAR
dose reduction. Therefore, the results from Figure 3 and Figure 5 should not be directly
compared due to the differences in study design and sampling.
It was observed that the OAR dose reduction is more pronounced for IMRT plans than for VMAT
plans. This is mainly due to higher MU used in IMRT to deliver same target dose compared to
VMAT. Since target dose is the same, for a given MLC transmission factor higher MU results in
more leakage radiation through the MLC reaching the OARs. Also because leakage radiation
through the MLC is proportional to both the transmission factor and total MU, for a given
transmission factor reduction, e.g. from TB to Halcyon MLC, more MU would result in more
pronounced difference in the transmitted radiation beyond MLC, which directly contributes to
OAR dose. This explains why the difference in OAR dose due to MLC transmission change is
more pronounced for IMRT than for VMAT.
It is evident from Figure 5 that even with all three parameters, transmission, leaf speed, and
DLG, matched to the Halcyon dual-layer MLC, there are still residual differences when
compared to the actual dual-layer MLC. This residual difference is likely to be a result of two
competing factors that cannot be easily modeled by changing the TB MLC's parameters. Firstly,
the dual-layer MLC has 1 cm width, whereas TB MLC has 0.5 cm width. Even though statistical
differences were not observed in most of the dosimetric parameters from the planning study
presented in the first part of this paper, the effect of MLC width may still have an impact on
normal tissue dose, particularly for small structures like the cochlea. In some cases, limited
sparing power due to wider leaves might overshadow the gain from other improvements,
resulting in inferior DVH parameters for some structures.
On the other hand, because Halcyon MLCs are dual-layer stacked, the area under two layers of
MLCs effectively experiences even less leaf leakage. The leakage with two layers blocking the
beam can be approximated to be 0.0072 = 0.000049, or ~0.005%. This further reduces leakage
and transmission dose to blocked areas, making the actual dual-layer MLC perform better than
a single layer TB MLC with 0.007 transmission factor. There are other factors that were not
simulated, such as the full range modulation and interdigitation, which are limited in TB MLC
model. The ability of unrestricted leaf movement allows for additional capability to modulate
beam intensity. This could explain why in some cases, the dual-layer MLC has lower mean
normal tissue dose compared to simulated TB MLC, even with wider leaves. For Truebeam
linacs with jaw-tracking capabilities, the dynamic jaws conforming to MLC openings may help
reduce the MLC leakage to blocked regions albeit to a limited level since the jaws can only
conform to the least extended (i.e., most open) leaf position for any given aperture.
It should be noted that Halcyon MLC transmission factor used in this study was based on pre-
Conclusions
When compared to Truebeam's Millennium 120 MLC, the Halcyon treatment delivery system's
newly designed dual-layer MLC is capable of generating head and neck IMRT/VMAT plans of
similar quality despite having thicker MLC leaves. For some OARs, the IMRT plan using the
dual-layer MLC provided better sparing in terms of mean dose. Detailed analysis showed that
this improvement was largely due to a combination of lowered leaf transmission, faster leaf
speed, and smaller DLG. Among these three MLC parameters, lower leaf transmission had the
largest contribution for the improved OAR sparing. Thicker MLC leaves provided stronger
mechanical construction, which resulted faster MLC movement speed. The delivery speed of
head and neck treatment plans using Halcyon platform were nearly twice as fast than the TB
MLC for both fixed gantry beam arrangement (IMRT mode) and VMAT mode.
Additional Information
Disclosures
Human subjects: Consent was obtained by all participants in this study. University of
Pennsylvania IRB issued approval 830201. This research was based on an IRB-approved
retrospective study. Animal subjects: All authors have confirmed that this study did not
involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform
disclosure form, all authors declare the following: Payment/services info: Research was
partially supported by Varian Medical Systems. Financial relationships: Lei Dong declare(s) a
grant from Varian Medical Systems. Christopher Kennedy, Ryan Scheuermann, Michelle Alonso-
Basanta, James M Metz declare(s) personal fees from Varian Medical Systems. Other
relationships: All authors have declared that there are no other relationships or activities that
could appear to have influenced the submitted work.
Acknowledgements
This work is partially supported by Varian Medical Systems.
References
1. Burmeister J, McDermott PN, Bossenberger T, Ben‐Josef E, Levin K, Forman JD: Effect of MLC
leaf width on the planning and delivery of SMLC IMRT using the CORVUS inverse treatment
planning system. Med Phys. 2004, 31:3187-3193. 10.1118/1.1812607
2. Wu QJ, Wang Z, Kirkpatrick JP, et al.: Impact of collimator leaf width and treatment technique
on stereotactic radiosurgery and radiotherapy plans for intra- and extracranial lesions. Radiat
Oncol. 2009, 4:3. 10.1186/1748-717X-4-3
3. Fiveash JB, Murshed H, Duan J, Hyatt M, Caranto J, Bonner JA, Popple RA: Effect of multileaf
collimator leaf width on physical dose distributions in the treatment of CNS and head and
neck neoplasms with intensity modulated radiation therapy. Med Phys. 2002, 29:1116-1119.
10.1118/1.1481515
4. Leal A, Sánchez-Doblado F, Arráns R, Capote R, Lagares JI, Pavón EC, Roselló J: MLC leaf
width impact on the clinical dose distribution: a Monte Carlo approach. Int J Radiat Oncol Biol
Phys. 2004, 59:1548-1559. 10.1016/j.ijrobp.2004.03.014
5. Nill S, Tücking T, Münter MW, Oelfke U: Intensity modulated radiation therapy with multileaf
collimators of different leaf widths: a comparison of achievable dose distributions. Radiother
Oncol. 2005, 75:106-111. 10.1016/j.radonc.2005.02.007
6. Wang L, Hoban P, Paskalev K, et al.: Dosimetric advantage and clinical implication of a micro-