For classical and intensity modulated radiation therapy of deep-seated tumors, high-energy photons
are the optimal radiation modality from an integral dose point of view. By using narrow scanned
beams the treatment outcome can be improved substantially by delivering biologically optimized
intensity modulated distributions often with sharp dose gradients. This requires using photons
with energies well above 15 MV enabling verification of the treatment delivery in vivo by PET/
CT imaging in a manner not previously possible. This new technique is based on the production
of positron emitting radionuclides when the incoming high-energy photons interact through
photonuclear reactions with the body tissues. The produced radionuclides, commonly 11C, 15O and
13N can then be monitored by PET and the distribution of activated nuclei show exactly where the
radiation has penetrated the patient. In the subcutaneous fat, present in all humans, a high induced
activity produces a perfect visualization of the location and even the intensity modulation of the
incident beams. The reason for this is the high carbon content in combination with a low biological
perfusion in fat tissues. Errors in the patient positioning such as setup errors or misplacement of the
beams will thus show up in the PET images as a deviation from the actual radiation treatment plan.
Interestingly, the imaged activity distribution from the subcutaneous fat also visualizes how the
dose delivery can be deformed when the patient is erroneously positioned on the treatment couch
as seen on the cover figure. Furthermore, the different half-lives of the produced radionuclides
(20 min, 2 min, and 10 min, for 11C, 15O and 13N, respectively) allows for analysis of the dynamic
behavior of tissue activity with the possibility of retrieving information such as tissue composition,
biological and physical half-lives. The present thesis shows that considerable clinical information
regarding the treatment delivery with high-energy photon beams can be obtained using PET/CT
imaging. Although the study is based on the use of 50 MV photons the method may apply for
beams with energies > 20 MV at higher doses.