Open Access Original

Article DOI: 10.7759/cureus.3648

Impact of Multi-leaf Collimator Parameters

on Head and Neck Plan Quality and
Delivery: A Comparison between Halcyon™
and Truebeam® Treatment Delivery
Systems
Taoran Li 1 , Ryan Scheuermann 1 , Alexander Lin 1 , Boon-Keng Kevin Teo 1 , Wei Zou 1 , Samuel
Swisher-McClure 1 , Michelle Alonso-Basanta 1 , John N. Lukens 1 , Alireza Fotouhi Ghiam 1 ,
Chris Kennedy 1 , Michele M. Kim 1 , Dimitris Mihailidis 1 , James M. Metz 1 , Lei Dong 1

1. Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania,

Philadelphia, USA

 Corresponding author: Taoran Li, [email protected]

Disclosures can be found in Additional Information at the end of the article

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

How to cite this article

Li T, Scheuermann R, Lin A, et al. (November 28, 2018) Impact of Multi-leaf Collimator Parameters on
Head and Neck Plan Quality and Delivery: A Comparison between Halcyon™ and Truebeam® Treatment
Delivery Systems. Cureus 10(11): e3648. DOI 10.7759/cureus.3648
 When compared to the Truebeam, the Halcyon’s dual-layer MLC achieved similar plan quality
using VMAT, and improved OAR sparing using IMRT, while providing nearly twice as fast
treatment delivery. Reduction in MLC transmission is the dominating factor contributing to
dosimetric differences in OAR sparing.

Categories: Medical Physics, Radiation Oncology

Keywords: halcyon, multi-leaf collimator, head and neck, radiation therapy, fff, vmat, imrt

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

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 distal layer MLC, providing additional shielding essentially similar to backup jaws but for each
individual interleaf region. Therefore, in this study the effective leaf width for all Halcyon plans
is 1.0 cm, compared to 0.5 cm for the regular Truebeam Millennium 120 MLC design. In the
recently released Halcyon 2.0 both layers of MLC participate in active fluence modulation, for
which results were still being generated and not included in this study.

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.

Materials And Methods

Nine head and neck cancer patients previously treated at our institution were included in this
study under an Institutional Review Board (IRB)-approved retrospective study protocol.

Overall plan quality evaluation

All nine cases were planned in parallel using combinations of the Truebeam with Millennium
120 (TB MLC) and the Halcyon system with the dual-layer MLC system as well as two planning
techniques: IMRT and VMAT. For the beam arrangements, all cases used nine equally spaced
beams for IMRT and two full or half arcs for VMAT. Half arcs were only used for two unilateral
post-operative cases to reduce dose spread to the contralateral neck, which is our standard
institutional approach in such patients. The same isocenter was used across all different
planning techniques and platforms. Plans were generated by experienced physicists and
dosimetrists and subsequently reviewed by a single attending physician to ensure the quality of
the plans meet clinical requirements. To simulate how a clinical plan would be generated, 6X
was used for Truebeam and 6FFF for Halcyon, which is our standard beam energy choice in our
clinical planning procedure. The planners were instructed to approach each plan as a separate
clinical case and to achieve overall the best plan without comparing between platforms. All
plans were performed with the Eclipse™ treatment planning systems using Photon
Optimizer™ and a pre-clinical Anisotropic Analytical Algorithm (AAA) v15.1 dose calculation
algorithm with the same dose calculation grid size (2.5 mm). All plans for the same patients
were normalized so that the same dose coverage (100% Rx dose covering 95% of PTV volume)
was achieved for the highest prescribed target.

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.

Plan delivery time comparison

One of the advantages of the Halcyon platform is that the gantry rotation speed is four times
that of the Truebeam linac. This potentially enables plans to be delivered in a much shorter
time and therefore increases efficiency and patient throughput. In this study the treatment
delivery efficiency was evaluated by comparing the actual total beam-on time between the

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 Truebeam and Halcyon platforms and between IMRT and VMAT plans. Five patients’ plans
were included in this part of the study, each with four plans delivered: Truebeam-IMRT,
Truebeam-VMAT, Halcyon-IMRT, Halcyon-VMAT. All plans were delivered with automation
enabled, i.e. the machine automatically delivered all treatment fields without operator
intervention, to mimic actual clinical usage.

Impact of MLC parameters on plan quality

An additional study was completed to identify the MLC parameters that contributed most to the
observed differences in the plan quality. Because the Halcyon platform does not allow end users
to modify the beam data within the treatment planning system, the TB MLC’s transmission, leaf
speed, and DLG parameters were altered in the TB beam model configuration to (virtually)
match with those of the Halcyon dual-layer MLC, as shown in (Table 1). It should be noted that
these values are based on pre-clinical system, and might be different from the clinical system.
In order to isolate only the effect from selected MLC parameters on plan quality, the
optimization objective settings were extracted from clinical plans and were kept the same for all
plans for the same patient case. All plans using different simulated TB MLC and actual dual-
layer MLC were optimized anew using the same objectives from the plan done with original TB
MLC parameters, 200 iterations, and automatic intermediate dose calculation. All re-optimized
plans were normalized to 95% PTV covered by 100% prescription dose. The re-optimized plans,
now with different hypothetical MLC systems, were then compared to the Halcyon dual-layer
MLC plans in terms of dosimetric difference. In this way, the change or combination of changes
to the TB MLC parameters that yielded the closest dosimetric parameters to the dual-layer MLC
plan represents the parameters that contributed the most to the difference in plan quality
between two different delivery systems. The comparison baselines were set to plans generated
using Truebeam 6FFF photons and Millennium 120 MLC since Halcyon only has 6FFF energy.
Because of the extensive amount of planning needed to be done for all hypothetical MLC types,
this study was only performed for three patients’ IMRT plans that exhibited relatively large
differences in the previous planning comparison between TB and dual-layer MLCs.

Leaf Width DLG Leaf Speed Transmission

TB MLC DLG Matched 0.5 cm (0.01 mm) 2.5 cm/s 1.5%

TB MLC Leaf Speed Matched 0.5 cm 0.13 mm (5.0 cm/s) 1.5%

TB MLC Transmission Matched 0.5 cm 0.13 mm 2.5 cm/s (0.7%)

TB MLC All 3 Matched 0.5 cm (0.01 mm) (5.0 cm/s) (0.7%)

Halcyon Dual-Layer MLC 1.0 cm 0.01 mm 5.0 cm/s 0.7%

TABLE 1: Simulated Truebeam® multi-leaf collimator (TB MLC) with different

parameters from the Halcyon™ dual-layer MLC. The parameters inside the bracket
are simulated hypothetical MLC parameters, including leaf width, dosimetric leaf gap
(DLG), leaf speed, and transmission. Values used here were based on pre-clinical
system and might be different from clinical system.

Results

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 Plan comparisons
It is meaningful to compare global maximal dose (Dmax) under the same target coverage since
all plans were normalized to have the same target coverage by the Rx dose. The left pane in
Figure 1 compares global Dmax across IMRT/VMAT and dual-layer/TB MLCs. The horizontal
line inside each box represents the median value. Each box plot represents the range between
the 25th and 75th quartile within the data; the cap on each end represents data within 1.5
inter-quartile ranges. Any data outside this range is visualized by individual dots. For both
IMRT and VMAT, the majority of the cases had a similar range of Dmax between the dual-layer
and TB MLC plans with one outlier. The dual-layer MLC in general has a slightly smaller range
of Dmax distribution. When comparing across planning techniques, generally VMAT saw higher
Dmax than IMRT for both the dual-layer and TB MLC plans.

FIGURE 1: Box plots and individual data point comparison of

global maximal dose in % (left) and total number of monitor
units (MU) (right) across two multi-leaf collimator (MLC) types
and two planning techniques.
IMRT: Intensity-modulated radiation therapy; VMAT: Volumetrically modulated arc therapy;
MU: Monitor unit.

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.

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 FIGURE 2: Box plots comparing key dose-volume histogram
(DVH) parameters of organs-at-risk (OARs) for two delivery
systems and intensity-modulated radiation therapy (IMRT) or
volumetrically modulated arc therapy (VMAT) techniques. Red
represents Truebeam® plans using TB multi-leaf collimator
(MLC), and blue represents Halcyon™ plans using the
Halcyon™ dual-layer MLC.

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.

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 FIGURE 3: Box plots, distributions, and Wilcoxon signed-rank
test p-values of the paired differences in organs-at-risk (OARs)
dose-volume histogram (DVH) parameters between paired
plans (Truebeam® multi-leaf collimator (TB MLC) and
Halcyon™ dual-layer MLC) for the same patients. A negative
number in the vertical axis means that Halcyon™ has lower
OAR dose than Truebeam, i.e. better performance.

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.

Plan delivery time comparison

Plan delivery time was evaluated and shown in Figure 4. Overall the Halcyon platform was able
to deliver treatment for the same case with substantially reduced time: on average a 42.8 ± 8.5%
reduction from the corresponding Truebeam plans was observed despite the higher total MU as
shown in Figure 1. Average reduction in beam-on time brought on by the Halcyon platform was
3.4 ± 1.2 min for the IMRT technique and 0.8 ± 0.1 min for the VMAT technique. This suggests
that the Halcyon platform can offer nearly double the delivery efficiency when compared to the

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 Truebeam platform in the real-world scenario.

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).

MLC parameters impact on OAR doses

In this section, four types of hypothetical TB MLCs were simulated with DLG, leaf speed, and
transmission, and all three of the above matched to the specifications of the Halcyon dual-layer
MLC. Treatment plans were then re-optimized using these simulated MLC systems that
resemble one or three parameters of the dual-layer MLC features.

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 OAR dose reduction from simulated MLCs and the actual dual-layer MLC was extracted from re-
optimized plans and visualized in Figure 5. At a glance, all simulated MLCs improved OAR
doses for the cases analyzed. This is expected since the dual-layer MLC features improved DLG,
leaf speed, and transmission when compared to TB MLC, and therefore would translate into
improved dosimetric performance. When comparing plans with only one MLC parameter
matched to the dual-layer MLC, it is evident that matching MLC transmission produced the
closest OAR dose reduction compared to the reduction achieved with the actual dual-layer MLC.
This means that MLC leakage is the dominating factor that improved the quality of the plan.
This is consistent with the finding from Topolnjak et al. [9].

FIGURE 5: Organs-at-risk (OARs) dose reduction observed in

plans using different simulated Truebeam® multi-leaf
collimator (TB MLC) with key parameters matched to those of
the Halcyon™ dual-layer MLC. Reference OAR doses, i.e. zero
reduction, were set to plans done with actual TB MLC. Error
bars indicate the full range of all test cases for a particular
dose-volume histogram (DVH) parameter.

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

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 on MLC parameter’s impact on observed plan quality differences for IMRT plans.

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-

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 clinical system that we had access to at the time of data acquisition. In the clinical release of
Eclipse™ treatment planning system the transmission factor was changed to 0.047%. This will
likely enhance the normal tissue sparing effect that was observed due to transmission factor
being smaller than TB MLC.

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.

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