Abstract
Simple SummaryStereotactic radiosurgery (SRS) and hypofractionated stereotactic radiotherapy (SRT) are promising treatment options for patients with multiple brain metastases in the current era of personalized medicine. Recent international guidelines propose SRS also in patients with more than three brain metastases with low-volume disease. Optimal treatment quality with sparing of healthy brain tissue is essential to avoid SRS/SRT complications such as brain necrosis. The aim of this study was to compare linac (linear accelerator)-based SRS/SRT plan quality of automated planning, intensity modulated radiotherapy (IMRT), volumetric modulated arc radiotherapy (VMAT) and manually planned dynamic conformal arc (DCA) plans as well as single- and multiple-isocenter techniques. We found that automated planning with DCA or IMRT can make linac-based SRS/SRT plan quality with single isocenter comparable with a manually planned DCA plan with a separate isocenter for each metastasis.The purpose was to compare linac-based stereotactic radiosurgery and hypofractionated radiotherapy plan quality of automated planning, intensity modulated radiotherapy (IMRT) and manual dynamic conformal arc (DCA) plans as well as single- and multiple-isocenter techniques for multiple brain metastases (BM). For twelve patients with four to ten BM, seven non-coplanar linac-based plans were created: a manually planned DCA plan with a separate isocenter for each metastasis, a single-isocenter dynamic IMRT plan, an automatically generated single-isocenter volumetric modulated arc radiotherapy (VMAT) plan, four automatically generated single-isocenter DCA plans with three or five couch angles, with high or low sparing of normal tissue. Paddick conformity index, gradient index (GI), mean dose, total V12Gy and V5Gy of uninvolved brain, number of monitor units (MUs), irradiation time and pass rate were compared. The GI was significantly higher for VMAT than for separate-isocenter, IMRT, and all automatically generated plans. The number of MUs was lowest for VMAT, followed by automatically generated DCA and IMRT plans and highest for manual DCA plans. Irradiation time was the shortest for automatically planned DCA plans. Automatically generated linac-based single-isocenter plans for multiple BM reduce the number of MUs and irradiation time with at least comparable GI and V5Gy relative to the reference separate-isocenter DCA plans.
Highlights
Whole brain radiotherapy (WBRT) has been the standard treatment of multiple brain metastases (BM) for many years
The purpose of this study was to investigate whether linac-based Stereotactic radiosurgery (SRS)/stereotactic radiotherapy (SRT) plan quality of single-isocenter plans, either automatically generated (DCA and volumetric modulated arc radiotherapy (VMAT)) or using dynamic intensity modulated radiotherapy (IMRT), could be comparable or even superior to the plan quality of manually planned dynamic conformal arc (DCA) plans with separate isocenters for each metastasis as a reference
We found that automated planning with DCA or IMRT can make linac-based SRS/SRT plan quality with single isocenter comparable with a manually planned DCA plan with a separate isocenter for each metastasis
Summary
Whole brain radiotherapy (WBRT) has been the standard treatment of multiple brain metastases (BM) for many years. According to the guidelines of the American Society for Radiation Oncology, SRS alone, WBRT and SRS, or WBRT alone should be considered for selected patients with multiple BM. These guidelines only support SRS without concurrent WBRT for patients with up to four BM [2]. In 2014, Yamamoto et al [3] published a multi-institutional prospective observational trial (JLGK0901) of patients with one to ten newly diagnosed brain metastases (largest tumor
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