Conformal Plans Research Articles

Optimizing focused very-high-energy electron beams for radiation therapy based on Monte Carlo simulation.

A TOPAS-based optimization program has been developed to precisely concentrate the dose of focused very-high-energy electron (VHEE) beams on deep-seated targets. This is accomplished by optimizing the magnetic gradients, positions, and number of quadrupole magnets within TOPAS. Using only three quadrupole magnets, the program focuses 250MeV VHEE beams to achieve a maximum dose position deeper than 17cm, while maintaining entrance and exit doses within 25% and limiting the lateral dimensions to ≤ 1cm at the maximum dose location. The linear relationship between the magnetic gradient of the last quadrupole magnet and the maximum dose position enables dose location adjustments through gradient variation. Multiple positions were validated in TOPAS with errors within 1%. The spread-out electron peak (SOEP) is achieved by combining two VHEE beams with different maximum dose positions using the differential evolution method, covering a target depth of 12-17cm and attaining a dose flatness better than 99%. This pioneering program imposes constraints on entrance dose, exit dose, maximum dose position, and the lateral dimensions of dose deposition at the maximum dose position within phantom. This program may be a promising tool in the applications of focused VHEE in highly conformal treatment plans based on TOPAS.

Intensity-modulated radiotherapy (IMRT) versus three-dimensional conformal radiotherapy (3DCRT) as treatment plans for head and neck tumours.

To compare intensity-modulated radiation therapy with three-dimensional conformal radiation therapy 3DCRTwith respect to dose coverage for target volume. The cross-sectional study was conducted at Al-Amal National Hospital, Baghdad, Iraq, from November 2020 to March 2021 and comprised patients with head and neck cancerous tumours. The patients underwent computed tomography scans, and were subsequently subjected to three-dimensional conformal radiotherapy and intensity-modulated radiotherapy treatment planning techniques on the basis of Monaco 5.1. The oncologist selected the better plan depending on evaluation parameters for each patient who was then irradiated with X-ray treatment. Data was analysed using SPSS 24. There were 30 patients, 17 (57%) females and 13 (43%) males with the age range of 19-45 years. Of the total, 28 received chemotherapy and 6 patients underwent brain surgery. The intensity-modulated radiation therapy resulted in significant coverage of the tumour than the three-dimensional conformal radiation therapy in phase 1 (p<0.00001) and phase II (p=0.0023). The intensity-modulated radiation therapy technique achieved a lower homogeneity value (p=0.0004) and higher conformity value (p<0.00001) than three-dimensional conformal radiation therapy. In phase II, no significant homogeneity index was found between the two therapies (p=0.072). The intensity-modulated radiation therapy showed significantly better conformity compared to three-dimensional conformal radiation therapy (p<0.00001). The intensity-modulated radiation therapy significantly improved coverage, plan conformity, and humongous dose distribution for head and neck tumours compared to the three-dimensional conformal radiation therapy 3DCRT.

Assessment of prostate cancer radiotherapy using three-dimensional treatment planning technique.

To assess the available commercial treatment planning system using three-dimensional conformal radiation therapy with respect to treatment for prostate cancer patients. This is a cross-sectional study was conducted from June 2021 to February 2022 at the Baghdad Centre for Radiation Therapy and Nuclear Medicine, Baghdad, Iraq, and comprised patients with prostate cancer who were treated with 6MV or 10MV energy using three-dimensional conformal radiation therapy technique, and irradiated using a linear accelerator. The patents were divided into three treatment phases. The prescribed dose in Phase I was 5000 centigrade, in Phase II it was 1800 centigrade, and in Phase III it was 600 centigrade. The number of beams used was 5 and 7. Data was analysed using SPSS 24. Out of 35 patients, 10 (28.6%) in phase I, 15 (42.8%) in phase II, and 10 (28.6%) in phase III. The PTV dose of 5 and 7 beams 6MV energy at the centre was higher than at 1mm, 2mm, and 3mm p values = (0.351, 0.013*, 0.076, 0.295), respectively. Dose to the rectum comparing 6MV and 10MV for beams 5, and 7. The dose to the rectum on phase one at 6MV and 10MV was similar for 5 beams (p=0.611) and 7 beams (p=0.778). A significant difference was seen for 7 beams (p-value=0.008). Phase three showed significant variations in rectum dose at 6 MV and 10MV for 5 beams (p=0.0004). For bladder, a significant difference observed between the energies for 5 beams on phase one and three (p-value=<0.00001*, 0.002*), while at 7 beams only phase 3 were significant (p-value=0.041*). The three-dimensional conformal radiation therapy plan with 10MV energy and a higher number of beams gave a higher coverage of dose for prostate tumours and was found to be a safe dose for the rectum and bladder.

Multi-segments conformal plan optimization for head and neck cancer.

To evaluate better dose distribution with three-dimensional radiation therapy, and to compare it with multi-segmented treatment planning techniques in patients with head and neck cancer. The prospective study was conducted at the Baghdad Centre for Radiation Therapy and Nuclear Medicine, Baghdad, Iraq, and comprised data of 50 patients with head and neck cancerous tumours from June 2021 to February 2022. There were 35 (70%) females and 15(30%) males. The mean age was 47.31 ± 3.95 years (range 19 - 69 years The patients had undergone computed tomography simulation. The images were exported to Monaco 5.1 for contouring by the radiation oncologist. The data was then imported to XiO planning system. Each plan was repeated twice; once with three-dimensional conformal radiation therapy and the other with field-in-field technique. Data was analysed using SPSS 24. There were 50 patients whose data was analysed. The results showed significant differences between three-dimensional conformal radiation therapy and field-in-field techniques for dose coverage at 90% and 95% volumes (p<0.05). There was a significant difference between the two techniques for 2Gy dose (p<0.05), but the difference was not significant for 5Gy dose (p>0.05). The field-in-field treatment planning technique was found to be more effective than the threedimensional conformal radiation therapy technique.

The Effect of Contrast Material in Three Dimensional Conformal and Helical Treatment Plans in Rectal Radiotherapy

The Effect of Contrast Material in Three Dimensional Conformal and Helical Treatment Plans in Rectal Radiotherapy

Characterizing devices for validation of dose, dose rate, and LET in ultra high dose rate proton irradiations.

Ultra high dose rate (UHDR) radiotherapy using ridge filter is a new treatment modality known as conformal FLASH that, when optimized for dose, dose rate (DR), and linear energy transfer (LET), has the potential to reduce damage to healthy tissue without sacrificing tumor killing efficacy via the FLASH effect. Clinical implementation of conformal FLASH proton therapy has been limited by quality assurance (QA) challenges, which include direct measurement of UHDR and LET. Voxel DR distributions and LET spectra at planning target margins are paramount to the DR/LET-related sparing of organs at risk. We hereby present a methodology to achieve experimental validation of these parameters. Dose, DR, and LET were measured for a conformal FLASH treatment plan involving a 250-MeV proton beam and a 3D-printed ridge filter designed to uniformly irradiate a spherical target. We measured dose and DR simultaneously using a 4D multi-layer strip ionization chamber (MLSIC) under UHDR conditions. Additionally, we developed an "under-sample and recover (USRe)" technique for a high-resolution pixelated semiconductor detector, Timepix3, to avoid event pile-up and to correct measured LET at high-proton-flux locations without undesirable beam modifications. Confirmation of these measurements was done using a MatriXX PT detector and by Monte Carlo (MC) simulations. MC conformal FLASH computed doses had gamma passing rates of>95% (3mm/3% criteria) when compared to MatriXX PT and MLSIC data. At the lateral margin, DR showed average agreement values within 0.3% of simulation at 100Gy/s and fluctuations ∼10% at 15Gy/s. LET spectra in the proximal, lateral, and distal margins had Bhattacharyya distances of<1.3%. Our measurements with the MLSIC and Timepix3 detectors shown that the DR distributions for UHDR scenarios and LET spectra using USRe are in agreement with simulations. These results demonstrate that the methodology presented here can be used effectively for the experimental validation and QA of FLASH treatment plans.

In vivo bioluminescence tomography-guided system for pancreatic cancer radiotherapy research.

Recent development of radiotherapy (RT) has heightened the use of radiation in managing pancreatic cancer. Thus, there is a need to investigate pancreatic cancer in a pre-clinical setting to advance our understanding of the role of RT. Widely-used cone-beam CT (CBCT) imaging cannot provide sufficient soft tissue contrast to guide irradiation. The pancreas is also prone to motion. Large collimation is unavoidably used for irradiation, costing normal tissue toxicity. We innovated a bioluminescence tomography (BLT)-guided system to address these needs. We established an orthotopic pancreatic ductal adenocarcinoma (PDAC) mouse model to access BLT. Mice underwent multi-projection and multi-spectral bioluminescence imaging (BLI), followed by CBCT imaging in an animal irradiator for BLT reconstruction and radiation planning. With optimized absorption coefficients, BLT localized PDAC at 1.25 ± 0.19 mm accuracy. To account for BLT localization uncertainties, we expanded the BLT-reconstructed volume with margin to form planning target volume(PTVBLT) for radiation planning, covering 98.7 ± 2.2% of PDAC. The BLT-guided conformal plan can cover 100% of tumors with limited normal tissue involvement across both inter-animal and inter-fraction cases, superior to the 2D BLI-guided conventional plan. BLT offers unique opportunities to localize PDAC for conformal irradiation, minimize normal tissue involvement, and support reproducibility in RT studies.

Inter-fraction motion robustness in a prospective phase II trial on dose-escalated proton reirradiation for locally recurrent rectal cancer

Background and purposeIntensity modulated proton therapy (IMPT) enables generation of conformal dose plans with organ at risk (OAR) sparing potential. However, pelvic IMPT robustness is challenged by inter-fraction motion caused by constant anatomical variations. In this study, the dosimetric impact of inter-fraction motion on target coverage and dose to OAR was quantified in the prospective phase II study ReRad-II on dose-escalated proton reirradiation for locally recurrent rectal cancer (LRRC). Materials and methodsThe inter-fraction motion robustness was assessed for the initial twelve patients enrolled in the ReRad-II study. Patients with resectable LRRC were assessed for neoadjuvant IMPT (55 Gy(RBE)/44Fx) and unresectable recurrences for definitive IMPT (57.5–65 Gy(RBE)/ 46-52Fx). Target coverage and dose to OAR were assessed for robustly optimised three-field IMPT, on 12 plan computerized tomography (CT) scans (pCT) − and 47 repetitive control CT scans (cCTs) during the treatment. The target coverage and doses to OAR were re-calculated on each cCT and the mean dose ratio (pCT/cCT-ratio) and target coverage (V95%) was evaluated. ResultsThe target coverage was robust with a mean dose pCT/cCT-ratio of 1.00 (+/-1%). The V95% target coverage for every cCT were above the accepted worst-case scenario in the robust evaluation. Considerable variation in bladder-, bowel bag-, and bowel loop volume was observed. The OAR with the largest variation in ratio was the bladder (pCT/cCT-ratio: 1.3 (range: 0.5–4.7). ConclusionsIMPT for dose-escalated reirradiation of LRRC provided anatomically robust target coverage despite OAR changes. Inter-fraction motion resulted in OAR doses varying within clinically acceptable range.

Dosimetric Impact of Prescription Point Placement in Heterogeneous Medium for Conformal Radiotherapy Dose Calculation with Various Algorithms.

The aim of the study is to compare the accuracy of dose calculation for different dose calculation algorithms with different prescription points (air, tissue, air-tissue interface in carcinoma lung patients and bone, tissue, and bone-tissue interface in carcinoma buccal Mucosa tumors). Forty-one patients with carcinoma lung and buccal mucosa were retrospectively selected for this study. A three-dimensional conformal radiotherapy reference plan was created using the prescription point in the tissue with Monte Carlo (MC) algorithms for both the groups of patients. The reference plan was modified by changing the prescription point and algorithms in the tissue, air, air-tissue interface for lung patients and tissue, bone, and bone-tissue interface for buccal mucosa patients. The dose received by the target volume and other organs at risk (OAR) structures was compared. To find out the statistical difference between different prescription points and algorithms, the statistical tests were performed with repeated measures ANOVA. The target volume receiving 95% dose coverage in lung patients decreased to -3.08%, -5.75%, and -1.87% in the dose prescription point at the air-tissue interface with the dose calculation algorithms like MC, collapsed cone (CC), and pencil beam (PB), respectively, compared to that of the MC tissue. Spinal cord dose was increased in the CC and PB algorithms in all prescription points in patients with lung and buccal mucosa. OAR dose calculated by PB in all prescription points showed a significant deviation compared to MC tissue prescription point. This study will help demonstrate the accuracy of dose calculation for the different dose prescription points with the different treatment algorithms in radiotherapy treatment planning.

Comparative analysis of plan quality and delivery efficiency: ZAP-X vs. CyberKnife for brain metastases treatment

Purpose/ObjectivesZAP-X, a novel and dedicated radiosurgery (SRS) system, has recently emerged, while CyberKnife has solidified its position as a versatile solution for SRS and stereotactic body radiation therapy over the past two decades. This study aims to compare the dosimetric performance and delivery efficiency of ZAP-X and CyberKnife in treating brain metastases of varying target sizes, employing circular collimation.Methods and materialsTwenty-three patients, encompassing a total of 47 brain metastases, were included in the creation of comparative plans of ZAP-X and CyberKnife for analysis. The comparative plans were generated to achieve identical prescription doses for the targets, while adhering to the same dose constraints for organs at risk (OAR). The prescription isodose percentage was optimized within the range of 97–100% for each plan to ensure effective target-volume coverage. To assess plan quality, indices such as conformity, homogeneity, and gradient (CI, HI, and GI) were computed, along with the reporting of total brain volumes receiving 12Gy and 10Gy. Estimated treatment time and monitor units (MUs) were compared between the two modalities in evaluating delivery efficiency.ResultsOverall, CyberKnife achieved better CI and HI, while ZAP-X exhibited better GI and a smaller irradiated volume for the normal brain. The superiority of CyberKnife’s plan conformity was more pronounced for target size less than 1 cc and greater than 10 cc. Conversely, the advantage of ZAP-X’s plan dose gradient was more notable for target sizes under 10 cc. The homogeneity of ZAP-X plans, employing multiple isocenters, displayed a strong correlation with the target’s shape and the planner’s experience in placing isocenters. Generally, the estimated treatment time was similar between the two modalities, and the delivery efficiency was significantly impacted by the chosen collimation sizes for both modalities.ConclusionThis study demonstrates that, within the range of target sizes within the patient cohort, plans generated by ZAP-X and CyberKnife exhibit comparable plan quality and delivery efficiency. At present, with the current platform of the two modalities, CyberKnife outperforms ZAP-X in terms of conformity and homogeneity, while ZAP-X tends to produce plans with a more rapid dose falloff.

Conformity of the Work Plan with the Budget Implementation Document at the Marine and Fisheries Service of Central Lombok Regency

The writing of this article is aimed at finding out the suitability of the work plan with the Budget Implementation Document at the Marine and Fisheries Service of Central Lombok Regency by using descriptive qualitative. The results and discussion can be seen from the Details of the DPA Expenditure Activities of the Central Lombok Marine and Fisheries Service has reflected the conformity with the performance of the service which can be seen in the Central Lombok Regent Regulation No. 83 of 2016 concerning the Position, Organizational Structure, Main Tasks and Functions of the Central Lombok Regency Marine and Fisheries Service. As for activities and expenditures that are samples are Expenditure on Fishing Management activities in Rivers, Lakes, Reservoirs, Swamps, and Other Reservoirs that can be Pursued in 1 (one) Regency/City Region with official travel expenses, Small Fishermen Empowerment Activities in the Regency/City Region with competition prize spending, and Small Fish Cultivation Empowerment Activities with fish health and environmental management training expenses.

Optimising craniospinal irradiation for medulloblastoma: a dosimetric comparison of two VMAT planning methods.

Craniospinal irradiation (CSI) poses a challenging planning process because of the complex target volume. Traditional 3D conformal CSI does not spare any critical organs, resulting in toxicity in patients. Here the dosimetric advantages of volumetric-modulated arc therapy (VMAT) using partial arc and avoidance sectors are compared with each other in planning in adult patients undergoing CSI to develop a clinically feasible technique that is both effective and efficient. Eight adult patients treated with CSI were retrospectively identified. In total 16 plans were made. We generated two plans for each patient: 1. VMAT plan using partial arc, namely VMAT_pa. 2. VMAT plan using avoidance sectors, namely VMAT_as. The dose prescribed was 36 Gy in 20 fractions. The dose-volume histogram for planning target volume (PTV) and organs at risk (OAR) (lens, eye, heart, thyroid, lungs, liver, gonads and kidneys) were analysed and compared. Dose parameters of mean dose, V95%, and V107% for the PTV were evaluated. The median length of PTV is 65.58 cm (45.8-79.5). The volume of PTV receiving 95% of the dose (V95%) in both the plans are 97.51% (VMAT_as) and 97.99% (VMAT_pa) (p = 0.121) while V107% are 0.733 and 0.742 for VMAT_as and VMAT_pa, respectively (p = 0.969). The doses of OARs such as lens, eye, liver and gonads were comparable. The mean heart dose was 10.4 and 9.0 Gy in VMAT_as and VMAT_pa plans, respectively (p = 0.005). Significant lower doses to the thyroid, kidneys and lungs were seen in VMAT plans using avoidance sectors. This study provides a practically useful VMAT planning method for the treatment of CSI and illustrates the ability of VMAT using avoidance sectors to generate highly conformal and homogeneous treatment plans for CSI, while limiting the dose to the relevant OARs.

Abstract PO5-22-02: Evaluation of a surface-guided and tattoo-less approach to setup for whole breast radiotherapy

Abstract Background: In preparation for adjuvant breast radiation therapy (RT), several small but permanent skin tattoo marks are often placed to assist with surface alignment for treatment setup and delivery. With advancements in surface-guided technologies, it may be possible to achieve setup accuracy with a “tattoo-less” approach, which can improve cosmetic and quality of life outcomes. This study evaluates the feasibility, accuracy, and potential dosimetric implications of a tattoo-less setup technique. Method: A retrospective analysis of 10 patients diagnosed with right-sided breast cancer who received adjuvant whole breast RT using a tattoo-less approach were included in this study. All patients received an initial whole breast dose of 42.56 Gray (Gy) in 16 daily fractions using a tangential three-dimensional conformal planning technique. This was followed by a 10Gy boost to the lumpectomy site delivered in 4 daily fractions. Daily setup for whole breast treatment was performed by aligning each patient to their individual reference breast surface generated from the planning computed tomography (CT) images via the Vision RT system. Bony landmarks were then verified via daily kV imaging, and translational shifts were recorded for each fraction. The kV imaging was performed to confirm the treatment positioning since the tattoo-less approach was new to the department. For 5 patients, dosimetric differences between initial surface alignment and shifts performed based on bony landmarks were evaluated by recalculating the original clinical plan with a new isocenter position using kV image shifts for each of their 16 treatment fractions. A plan sum of the 16 recalculated plans for each patient was used in further dosimetric analysis. Boost fractions were not included in this study, as setup was verified using surgical clips instead of bony anatomy. Results: Translational shifts for 158 fractions were reviewed as no kV imaging was performed for the other 2 fractions. The mean absolute kV imaging shift was 0.29 cm (CI (95%): 0.25, 0.32; range: 0 to 1.25) in the vertical axis, 0.28 cm (0.23, 0.32; 0 to 1.27) in the longitudinal axis, and 0.24 cm (0.20, 0.28; 0 to 1.98) in the lateral axis. Clinical plans for 5 patients were evaluated with a mean absolute kV shift of 0.27 cm (range: 0.15 to 0.39) in the vertical, 0.32 cm (0.13 to 0.77) in the longitudinal, and 0.29 cm (0.18 to 0.38) in the lateral directions. Dosimetric analysis revealed a slight increase in mean heart dose from the original clinical plan, with an average difference of 4.12 cGy (range: 0.7 to 10.5 cGy). The maximum increase in V20Gy of the ipsilateral lung was 2.7%. Less than 1% of change was observed in the maximum plan dose, as well as in the V95% coverage, expect for one patient, whose V95% was decreased from 99.6% to 94.6%. This difference was caused by a large longitudinal shift which could be attributed to possible patient movement. Conclusions: These findings demonstrate the feasibility and accuracy of a tattoo-less treatment approach in a small cohort of breast cancer patients receiving whole breast RT. Further investigation with larger cohorts is warranted. Citation Format: Xinxin Zhang, Swati Mamidanna, Yin Zhang, Xiao Wang, Ning Yue, Shicha Kumar, Lindsay Potdevin, Maria Kowzun, Mridula George, Lara Hathout, Bruce Haffty, Nisha Ohri. Evaluation of a surface-guided and tattoo-less approach to setup for whole breast radiotherapy [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-22-02.

1533: New cyclotron-based proton therapy facility development to achieve conformal FLASH treatment plans

1533: New cyclotron-based proton therapy facility development to achieve conformal FLASH treatment plans

Treatment planning and delivery practice of lung SBRT: Results of the 2022 ESTRO physics survey

Background and purposeThe use of Stereotactic Body Radiation Therapy (SBRT) in lung cancer is increasing. However, there is no consensus on the most appropriate treatment planning and delivery practice for lung SBRT. To gauge the range of practice, quantify its variability and identify where consensus might be achieved, ESTRO surveyed the medical physics community. Materials and methodsAn online survey was distributed to ESTRO’s physicist membership in 2022, covering experience, dose and fractionation, target delineation, dose calculation and planning practice, imaging protocols, and quality assurance. ResultsTwo-hundred and forty-four unique answers were collected after data cleaning. Most respondents were from Europe the majority of which had more than 5 years’ experience in SBRT. The large majority of respondents deliver lung SBRT with the VMAT technique on C-arm Linear Accelerators (Linacs) employing daily pre-treatment CBCT imaging. A broad spectrum of fractionation schemes were reported, alongside an equally wide range of dose prescription protocols. A clear preference was noted for prescribing to 95% or greater of the PTV. Several issues emerged regarding the dose calculation algorithm: 22% did not state it while 24% neglected to specify the conditions under which the dose was calculated. Contouring was usually performed on Maximum or Average Intensity Projection images while dose was mainly computed on the latter. No clear indications emerged for plan homogeneity, complexity, and conformity assessment. Approximately 40% of the responders participated in inter-centre credentialing of SBRT in the last five years. Substantial differences emerged between high and low experience centres, with the latter employing less accurate algorithms and older equipment. ConclusionThe survey revealed an evident heterogeneity in numerous aspects of the clinical implementation of lung SBRT treatments. International guidelines and codes of practice might promote harmonisation.

Balancing robustness and adaptation rate for proton therapy of lung cancer patients

IntroductionAn increase in plan robustness leads to a higher dose to organs-at-risk (OARs), and an increased chance of post-treatment toxicities. In contrast, more conformal plans lead to sparing of healthy surrounding tissue at the expense of a higher sensitivity to anatomical changes, requiring costly adaptations. In this study, we assess the trade-off and impact of treatment plan robustness on the adaptation rate. MethodTreatment planning was performed for 40 lung cancer patients, each having a planning 4DCT and up to eight weekly repeated 4DCTs (reCTs). For each patient, plans were made with three different levels of robustness based on setup uncertainty of 3, 6 and 9 mm. These plans were robustly re-evaluated on all reCTs to assess whether the clinical constraints were met. ResultsFor the 3, 6 and 9 mm robustness levels, adaptation rates of 87.5 %, 70.0 % and 57.5 %, respectively, were observed. A mean absolute normal tissue complication probability (NTCP) gain of 2.9 percentage points (pp) was calculated for pneumonitis grade ≥ 2 when transitioning from 9 mm plans to 3 mm plans, 7.6 pp for esophagitis grade ≥ 2, and 2.5 pp for mortality risk 2 years post-treatment. ConclusionThe lowered risk of post treatment toxicities at lower robustness levels is clinically relevant but comes at the expense of more treatment adaptations, particularly in cases where meeting our clinical goals is not compromised by having a dose that is more conformal to the target. The trade-off between workload and reduced NTCP needs to be individually assessed.

Knowledge-based planning for Gamma Knife.

Current methods for Gamma Knife (GK) treatment planning utilizes either manual forward planning, where planners manually place shots in a tumor to achieve a desired dose distribution, or inverse planning, whereby the dose delivered to a tumor is optimized for multiple objectives based on established metrics. For other treatment modalities like IMRT and VMAT, there has been a recent push to develop knowledge-based planning (KBP) pipelines to address the limitations presented by forward and inverse planning. However, no complete KBP pipeline has been created forGK. To develop a novel (KBP) pipeline, using inverse optimization (IO) with 3D dose predictions for GK. Data were obtained for 349 patients from Sunnybrook Health Sciences Centre. A 3D dose prediction model was trained using 322 patients, based on a previously published deep learning methodology, and dose predictions were generated for the remaining 27 out-of-sample patients. A generalized IO model was developed to learn objective function weights from dose predictions. These weights were then used in an inverse planning model to generate deliverable treatment plans. A dose mimicking (DM) model was also implemented for comparison. The quality of the resulting plans was compared to their clinical counterparts using standard GK quality metrics. The performance of the models was also characterized with respect to the dosepredictions. Across all quality metrics, plans generated using the IO pipeline performed at least as well as or better than the respective clinical plans. The average conformity and gradient indices of IO plans was 0.737 0.158 and 3.356 1.030 respectively, compared to 0.713 0.124 and 3.452 1.123 for the clinical plans. IO plans also performed better than DM plans for five of the six quality metrics. Plans generated using IO also have average treatment times comparable to that of clinical plans. With regards to the dose predictions, predictions with higher conformity tend to result in higher quality KBP plans. Plans resulting from an IO KBP pipeline are, on average, of equal or superior quality compared to those obtained through manual planning. The results demonstrate the potential for the use of KBP to generate GK treatment with minimal humanintervention.

Treatment planning with high-resolution 3D dose maps in preclinical and translational synchrotron microbeam radiation therapy

Background and PurposeMicrobeam Radiation Therapy (MRT) aims to deliver higher doses to the target while minimizing radiation damage to healthy tissues using synchrotron x-ray microbeams. Translational MRT research has now started, driven by promising results from preclinical studies. This study aimed to propose a first dose-outcome model by analyzing micrometric dose distributions obtained with high-resolution 3D dose calculations, accounting for the inherent physical dose distribution complexity in MRT. The feasibility of integrating penMRT, our full Monte Carlo multiscale dose calculation algorithm based on PENELOPE into translational research on veterinary patients was also investigated. Material and MethodsMicrometric dose distributions were calculated in tumor-bearing rats and for a veterinary patient with penMRT, for conformal multi-directional MRT treatment plans. Absorbed dose maps were obtained with 0.005 × 0.005 × 1 mm3 voxel sizes. High-resolution dose-volume histograms were extracted and analyzed against radiobiology studies. ResultsThe complexity of the MRT dose distribution was properly rendered at a micrometer scale on 3D dose maps, with well separated dose regions observed on the differential dose-volume histograms. The median survival time of glioma-bearing rats varied linearly with the volume fraction of the planning target volume that received doses higher than 50 Gy (R2 = 0.98). The feasibility of using penMRT for treatment planning in large volumes has been shown on a veterinary patient. ConclusionsThis study demonstrated the significant added value of penMRT for planning and prescribing MRT treatments. It also shed light on the correlation between the high-resolution 3D dose distributions and the treatment outcome.

Stereotactic radiotherapy of intracranial tumor beds on a ring-mounted Halcyon LINAC.

This study sought to evaluate the feasibility and efficacy of the Halcyon Ring Delivery System (RDS) for delivering stereotactic radiotherapy (SRT) treatments for intracranial tumors beds. Ten previously treated brain SRT patients for 30Gy in five fractions with non-coplanar HyperArc plans on TrueBeam (6MV-FFF) were replanned on Halcyon (6MV-FFF) using the same number of arcs and Eclipse's AcurosXB dose engine. Plan quality evaluation metrics per SRT protocol included: PTV coverage, GTV dose (minimum and mean), target conformity indices (CI), heterogeneity index (HI), gradient index (GI), maximum dose 2cm away from the PTV (D2cm), and doses to organs-at-risk (OAR). Additionally, patient-specific quality assurance (QA) results and beam-on-time (BOT) were analyzed. The Halcyon RDS provided highly conformal SRT plans for intracranial tumor beds with similar dose to target. When benchmarked against clinically delivered HyperArc plans, target coverage, CI(s) and HI were statistically similar. The Halcyon plans saw no statistical difference in maximum OAR doses to the brainstem, spinal cord, and cochlea. Due to the machine's coplanar geometry, the Halcyon plans showed a decrease in optic pathway dose (0.75Gy vs. 2.08Gy, p=0.029). Overall, Halcyon's coplanar geometry resulted in a larger GI (3.33vs. 2.72, p=0.008) and a larger D2cm (39.59%vs. 29.07%, p<0.001). In this cohort, multiple cases had the PTV and the optic pathway in the same axial plane. In one such instance, the PTV was<2cm away from the optic pathway but even at this close proximity OAR, Halcyon still adequately spared the optic pathway. Additionally, the Halcyon's geometry provided slightly larger amount of normal brain dose receiving 24.4Gy (8.99 cc vs. 7.36 cc) and 28.8Gy (2.9 cc vs. 2.5 cc), although statistically insignificant. The Halcyon plans achieved similar delivery accuracy, quantified by patient-specific QA results evaluated with a 2%/2mm gamma criteria (99.42%vs. 99.70%). For both plans, independent Monte Carlo second checks calculation agreed within 1%. Average Halcyon BOT was slightly higher by 0.35min (p=0.045), however, due to the one-step patient set-up and verification overall estimated treatment times on Halcyon were lower compared to HyperArc treatments (7.61min vs. 10.26min, p<0.001). When benchmarked against clinically delivered HyperArc treatments, the Halcyon brain SRT plans provided similar plan quality and delivery accuracy but achieved faster overall treatment times. We have started treating select brain SRT patients on the Halcyon RDS for patients having tumor beds greater than 1cm in diameter with the closest OAR distance of greater than 2cm away from the target. We recommend other clinics to consider commissioning SRT treatments on their Halcyon systems-allowing including remote Halcyon-only clinics to provide exceptionally high-quality therapeutic brain SRT treatments to an otherwise underserved patient cohort.

Generation of tissues outside the field of view (FOV) of radiation therapy simulation imaging based on machine learning and patient body outline (PBO)

BackgroundIt is not unusual to see some parts of tissues are excluded in the field of view of CT simulation images. A typical mitigation is to avoid beams entering the missing body parts at the cost of sub-optimal planning.MethodsThis study is to solve the problem by developing 3 methods, (1) deep learning (DL) mechanism for missing tissue generation, (2) using patient body outline (PBO) based on surface imaging, and (3) hybrid method combining DL and PBO. The DL model was built upon a Globally and Locally Consistent Image Completion to learn features by Convolutional Neural Networks-based inpainting, based on Generative Adversarial Network. The database used comprised 10,005 CT training slices of 322 lung cancer patients and 166 CT evaluation test slices of 15 patients. CT images were from the publicly available database of the Cancer Imaging Archive. Since existing data were used PBOs were acquired from the CT images. For evaluation, Structural Similarity Index Metric (SSIM), Root Mean Square Error (RMSE) and Peak signal-to-noise ratio (PSNR) were evaluated. For dosimetric validation, dynamic conformal arc plans were made with the ground truth images and images generated by the proposed method. Gamma analysis was conducted at relatively strict criteria of 1%/1 mm (dose difference/distance to agreement) and 2%/2 mm under three dose thresholds of 1%, 10% and 50% of the maximum dose in the plans made on the ground truth image sets.ResultsThe average SSIM in generation part only was 0.06 at epoch 100 but reached 0.86 at epoch 1500. Accordingly, the average SSIM in the whole image also improved from 0.86 to 0.97. At epoch 1500, the average values of RMSE and PSNR in the whole image were 7.4 and 30.9, respectively. Gamma analysis showed excellent agreement with the hybrid method (equal to or higher than 96.6% of the mean of pass rates for all scenarios).ConclusionsIt was first demonstrated that missing tissues in simulation imaging could be generated with high similarity, and dosimetric limitation could be overcome. The benefit of this study can be significantly enlarged when MR-only simulation is considered.