Intensity-modulated Radiotherapy Arc Research Articles

A Randomised Phase II Trial to Evaluate the Feasibility of Radiotherapy Dose Escalation, Facilitated by Intensity-Modulated Arc Radiotherapy Techniques, in High-Risk Neuroblastoma

BACKGROUND AND PURPOSEFor high-risk neuroblastoma, planning target volume coverage is often compromised to respect adjacent kidney tolerance. This trial investigated whether intensity-modulated arc radiotherapy techniques (IMAT) could facilitate dose escalation better than conventional techniques. MATERIALS AND METHODSChildren with high-risk abdominal neuroblastoma referred for radiotherapy to the primary tumour site and involved regional lymph nodes were randomised to receive either standard dose (21 Gy in 14 fractions) or escalated dose (36 Gy in 24 fractions) radiotherapy. Dual planning with both a conventional anterior-posterior parallel opposed pair radiotherapy technique and an IMAT technique was performed. The quality of target volume and organ-at-risk delineation, and dosimetric plans, were externally reviewed. Dosimetric parameters were used to judge the superior technique for treatment. This feasibility trial was not powered to detect improvement in outcome with dose escalation. RESULTSBetween 2017 and 2020, 50 patients were randomised and dual-planned. The IMAT technique was judged more favourable in 48 patients. In all patients randomised to receive 36 Gy, IMAT would have permitted delivery of the full dose (median D50% 36.0 Gy, inter-quartile range 36.0–36.1 Gy) to the target volume, whereas dose compromise would have been required with conventional planning (median D50% 35.6 Gy, inter-quartile range 28.7–35.9 Gy). CONCLUSIONIMAT facilitates safe dose escalation to 36 Gy in patients receiving radiotherapy for neuroblastoma. The value of dose escalation is now being evaluated in a current prospective phase III randomised trial.

Intensity-modulated ventricular irradiation for intracranial germ-cell tumors: Survival analysis and impact of salvage re-irradiation.

Background and purposeThe roles of surgery, chemotherapy, and parameters of radiation therapy for treating very rare central nervous system germ cell tumors (CNS-GCT) are still under discussion. We aimed to evaluate the survival and recurrence patterns of patients with CNS-GCT treated with chemotherapy followed by whole ventricle irradiation with intensity-modulated radiation therapy.Materials and methodsWe reviewed the clinical outcomes of 20 consecutive patients with CNS-GCT treated with chemotherapy and intensity-modulated radiation therapy from 2004 to 2014 in two partner institutions.ResultsTwenty children with a median age of 12 years were included (16 males). Sixteen tumors were pure germinomas, and 4 were non-germinomatous germ cell tumors (NGGCT). All patients were treated with intensity-modulated radiation therapy guided by daily images, and 70% with volumetric intensity-modulated arc radiotherapy additionally. The median dose for the whole-ventricle was 25.2 Gy (range: 18–30.6 Gy) and 36 Gy (range: 30–54 Gy) for the tumor bed boost. The median post-radiation therapy follow-up was 57.5 months. There were 3 recurrences (2 NGGCT and 1 germinoma that recurred as a NGGCT), with 1 death from the disease and the other 2 cases each successfully rescued with chemotherapy and craniospinal irradiation. The overall survival at 5 years was 95% and disease-free survival was 85%.ConclusionsThe results of this study suggest that the combined use of chemotherapy followed by whole ventricle irradiation with intensity-modulated radiation therapy is effective for CNS-GCTs, especially pure germinomas. Even being rescued with craniospinal irradiation, the NGGCT cases have markedly worse prognoses and should be more rigorously selected for localized treatment.

The Utility of Penile Bulb Contouring to Localise the Prostate Apex as Compared to Urethrography

PurposeHigh-precision radiotherapy relies on accurate anatomic localisation. Urethrography is often used to localise the prostatic apex. However, urethrography is an invasive localisation procedure and may introduce a systemic error. The penile bulb (PB) is contoured to minimise the risk of erectile dysfunction. The purpose of this study is to assess the value of using the PB, as an alternative to urethrography, to localise the prostate. Methods and MaterialsThe PB was localised on 10 patients treated with simplified intensity-modulated arc radiotherapy at computed tomography simulation during treatment weeks 1 and 7. All patients underwent placement of fiducial markers. Urethrography was used only at simulation. Distances from the superior PB contour to the inferior prostate contour, the apex fiducial marker, and to the inferior prostate contour were obtained as well. The PB was contoured by two observers independently. Agreement coefficients and analysis of variance were used to assess reliability between rates and consistency of measurements over time. ResultsThe PB-apex distance was greater than or equal to the urethrogram-apex distance in 24/30 (80%) measurements, and the median difference was 3 mm and was consistent between raters. The greatest variation in PB-IM distance between weeks was 6 mm, the median was 3 mm, and the agreements of measurements between weeks for raters 1 and 2 were 0.79 and 0.69, respectively. These differences were not statistically different and were consistent with the computed tomography slice thickness. ConclusionsThe PB can be used to identify the prostate apex and can be reliably contoured between observers. Measurements are consistent between patients and through the duration of treatment. The PB distance measurements support studies indicating that urethrography causes a shift of the prostate superiorly. The distance from the PB to prostate apex remains stable during treatment for individual patients but varies between patients.

[The need for a paradigm shift in radiotherapy].

The status and indications of radiotherapy have significantly changed in the past decade because novel techniques, radiobiological research and major advances in informatics have made better local control possible. Using supplemented marking of the target volume with computer tomography based other image-making methods adapted made it possible to define the tumor and intact surrounding tissues more precisely. With novel radiotherapy techniques the dosage of the homogenity and the covering in the target volume can be raised optimally, especially with intensity modulated arc radiotherapy (volumetric modulated arc therapy) without causing radiation injury or damage to intact surrounding tissues. Furthermore, with novel techniques and target volume marking, new indications have appeared in clinical practice and besides stereotactic radiotherapy for intracranial metastases, the extracranial so-called oligometastic conditions can be maintained close to a curative state (or in remission) for many years. Among these, perhaps the most striking is the stereotactic radiotherapy treatment of liver, lung and spinal cord metastases in one or more fractions, for which the indispensable condition is the image or respiratory guided technique.

Dosimetric study of volumetric arc modulation with RapidArc and intensity-modulated radiotherapy in patients with cervical cancer and comparison with 3-dimensional conformal technique for definitive radiotherapy in patients with cervical cancer

IntroductionFor patients with cervical cancer, intensity-modulated radiation therapy (IMRT) improves target coverage and allows dose escalation while reducing the radiation dose to organs at risk (OARs). In this study, we compared dosimetric parameters among 3-dimensional conformal radiotherapy (3D-CRT), “step-and-shoot” IMRT, and volumetric intensity-modulated arc radiotherapy (VMAT) in a series of patients with cervical cancer receiving definitive radiotherapy. Computed tomography (CT) scans of 10 patients with histologically proven cervical cancer treated with definitive radiation therapy (RT) from December 2008 to March 2010 at our department were selected for this study. The gross tumor volume (GTV) and clinical target volume (CTV) were delineated following the guidelines of the Gyn IMRT consortium that included cervix, uterus, parametrial tissues, and the pelvic nodes including presacral. The median age was 57 years (range: 30 to 85 years). All 10 patients had squamous cell carcinoma with Federation of Gynecology and Obstetrics (FIGO) stage IB-IIIB. All patients were treated by VMAT. OAR doses were significantly reduced for plans with intensity-modulated technique compared with 3D-CRT except for the dose to the vagina. Between the 2 intensity-modulated techniques, significant difference was observed for the mean dose to the small intestine, to the benefit of VMAT (p < 0.001). There was no improvement in terms of OARs sparing for VMAT although there was a tendency for a slightly decreased average dose to the rectum: − 0.65Gy but not significant (p = 0.07). The intensity modulation techniques have many advantages in terms of quality indexes, and particularly OAR sparing, compared with 3D-CRT. Following the ongoing technologic developments in modern radiotherapy, it is essential to evaluate the intensity-modulated techniques on prospective studies of a larger scale.

Dosimetric study of two intensity-modulated arc radiotherapy in esophageal cancer

Objective Comparing the dosimetric characteristics of volumetric modulated arc therapy (VMAT) and constant dose rate intensity modulated arc therapy (IMAT) in esophagus cancer to evaluate the performance of the two different arc therapy delivery techniques.Methods 22 cases of esophageal cancer patients were selected for the planning comparison study.All plans were done for IMAT and VMAT treatment plans on Oncentra 4.1 treatment planning system,prescription dose of 2 Gy in total 30 fractions.Planning objectives for PTV were at least 95％ reached the prescription dose and V110 no more than 10％.The maximum dose of spinalcord below 45 Gy and double lung dose V20 ≤ 28％,V30 ≤ 18％ were constrained.Plans were evaluated based on the ability to meet the dose volume histogram.The dose homogeneity index (HI),radiation conformity index (CI),radiation delivery time,monitor units and γ pass rate were also compared.SPSS 19.0 software paired ttest analysis was carried out on the two sets of data.Results The results showed that the IMAT plans in terms of the PTV's CI (t =3.35,P=0.003),D2(t =-2.27,P=0.034) lung's V30(t =-2.46,P=0.023) were better than that of VMAT group.But the VMAT plans spinal's V40 (t =2.37,P =0.027),lung's V5 (t =2.43,P =0.024) were superior to that of IMAT plans.There were no significant differences between IMAT and VMAT plans in the average dose of PTV,CTV,GTV,heart,spinal cord,double lung and the γpass rate.Conclusion IMAT presents a slight improvement in the OAR sparing in high dose with shorter treatment time when compared to VMAT.While in terms of delivered MU and tissue of low dose irradiated area is higher than that of in VMAT.These two treatment methods all can meet the clinical demand,which should be selected according to the actual situation of the patient. Key words: Esophageal neoplasms ;  Radiotherapy ;  Radiotherapy dosage

Epithelioid hemangioendothelioma of the spine treated with RapidArc volumetric-modulated radiotherapy

Radiotherapy for epithelioid hemangioendothelioma (EHE) using volumetric intensity-modulated arc radiotherapy (VMAT). A 48-year-old woman was referred for curative irradiation of a vertebral EHE after failure of surgery. A comparison between VMAT and conventional conformal tridimensional (3D) dosimetry was performed and potential advantage of VMAT for sparing critical organs from irradiation׳s side effects was discussed. The total delivered dose on the planning target volume was 54Gy in 27 fractions. The patient was finally treated with VMAT. The tolerance was excellent. There was no acute toxicity, including no increase in pain. With a follow-up of 18 months, no delayed toxicity was reported. The clinical response consisted of a decrease in the dorsal pain. The Dmax for the spinal cord was reduced from 55Gy (3D-radiotherapy [RT]) (which would be an unacceptable dose to the spine because of the risk of myelopathy) to 42.8Gy (VMAT), which remains below the recommended dose threshold (45Gy). The dose delivered to 20% of organ volume (D20) was reduced from 47Gy (3D-RT) to 3Gy (VMAT) for the spinal cord. The study shows that VMAT allows the delivery of curative treatment for vertebral EHEs because of critical organ sparing.

Hypofractionated intensity-modulated arc therapy for lymph node metastasized prostate cancer: Early late toxicity and 3-year clinical outcome

Background and purposeFor patients with N1 prostate cancer (PCa) aggressive local therapies can be advocated. We evaluated clinical outcome, gastro-intestinal (GI) and genito-urinary (GU) toxicity after intensity modulated arc radiotherapy (IMAT)+androgen deprivation (AD) for N1 PCa. Material and methodsEighty patients with T1-4N1M0 PCa were treated with IMAT and 2–3years of AD. A median dose of 69.3Gy (normalized isoeffective dose at 2Gy per fraction: 80Gy [α/β=3]) was prescribed in 25 fractions to the prostate. The pelvic lymph nodes received a minimal dose of 45Gy. A simultaneous integrated boost to 72Gy and 65Gy was delivered to the intraprostatic lesion and/or pathologically enlarged lymph nodes, respectively.GI and GU toxicity was scored using the RTOG/RILIT and RTOG-SOMA/LENT-CTC toxicity scoring system respectively. Three-year actuarial risk of grade 2 and 3/4 GI–GU toxicity and biochemical and clinical relapse free survival (bRFS and cRFS) were calculated with Kaplan–Meier statistics. ResultsMedian follow-up was 36months. Three-year actuarial risk for late grade 3 and 2 GI toxicity is 8% and 20%, respectively. Three-year actuarial risk for late grade 3–4 and 2 GU toxicity was 6% and 34%, respectively. Actuarial 3-year bRFS and cRFS was 81% and 89%, respectively. Actuarial 3-year bRFS and cRFS was, respectively 26% and 32% lower for patients with cN1 disease when compared to patients with cN0 disease. ConclusionIMAT for N1 PCa offers good clinical outcome with moderate toxicity. Patients with cN1 disease have poorer outcome.

Comparison of two different IMRT planning techniques in the treatment of nasopharyngeal carcinoma

To compare the effect of two different intensity-modulated radiation therapy (IMRT) planning techniques on parotid gland doses in patients with nasopharyngeal carcinoma (NPC). Radiotherapy for 10 NPC patients referred to the University of Istanbul Cerrahpasa Medical School was planned with arc- and static seven-field IMRT. The simultaneous integrated boost (SIB) technique was used to deliver 70 Gy (2.12 Gy per fraction) to the primary tumor and involved nodes; 60 Gy (1.81 Gy per fraction) to the entire nasopharynx and 54 Gy (1.63 Gy per fraction) to elective lymph nodes in 33 fractions. Plans also aimed to keep the mean parotid dose below 26 Gy and limit the maximum doses to the spinal cord and brain stem to 45 and 54 Gy, respectively. Mean parotid gland doses for the two planning techniques were compared using a paired t-test. Target coverage and dose inhomogeneity were evaluated by calculating conformity- (CI) and homogeneity index (HI) values. Target coverage and dose homogeneity were identical and good for both planning techniques: CI = 1.05 ± 0.08 and 1.05 ± 0.08; HI = 1.08 ± 0.02 and 1.07 ± 0.01 for arc- and static field IMRT, respectively. Mean doses to contralateral parotid glands were 25.73 ± 4.27 and 27.73 ± 3.5 Gy(p = 0.008) for arc- and static field IMRT plans, respectively, whereas mean ipsilateral parotid doses were 30.65 ± 6.25 and 32.55 ± 5.93 Gy (non-significant p-value), respectively. Mean monitor units (MU) per fraction for the 10 patients were considerably lower for arc- than for static field treatments-540.5 ± 130.39 versus 1288.4 ± 197.28 (p < 0.001). Normal tissues--particularly the parotid glands--are better spared with the arc technique in patients with NPC. MU and treatment times are considerably reduced in arc IMRT plans.

SU-E-J-118: Quantifying Intrafractional Prostate Rotation From Cone-Beam Computed Tomography with Radiopaque Markers

Purpose: Rotation greater than one degree can severely compromise the accuracy of radiotherapy treatments. Prostate intrafractional rotation is not negligible because peristaltic motion has a time scale that is shorter than the delivery time of a single fraction. The objectives of this study were (a) to investigate a clinically feasible method to calculate tumor rotation with radiopaque markers; (b) to evaluate the accuracy of the method and (c) to quantify prostate intrafractional rotation in intensity‐modulated arc radiotherapy (IMAT). Methods: 2D kilovoltage (kV) cone‐beam computed tomography (CBCT) images were acquired for prostate cancer patients with three implanted gold fiducial markers as surrogates for the tumor position during fractionated IMAT. Post‐treatment, 3D marker trajectories were determined from the 2D projection images by maximum likelihood estimation of a 3D probability density function. Rotations about each axis (roll (right/left), pitch (superior/inferior) and yaw (anterior/posterior)) were then calculated based on the iterative closest point algorithm (ICP) method, with the origin set at the centroid of the three markers. Results: Intrafractional rotation was studied for10 patients, 268 fractions. Average roll, pitch and yaw were calculated as 0.85±1.16, 0.41±0.51 and 0.37±0.4 degrees, respectively. Roll was the predominant rotation among the three axes which is consistent with literature. Rotations showed a similar pattern among different fractions for the same patient. The pattern acquired at the first few fractions could be used as a prediction for the rest of the fractions. Conclusion: This study demonstrated a novel method to quantify intrafractional tumor rotation from 2D kV projections with radiopaque markers. Intrafractional rotation is small but significant for certain cases. Real‐time radiopaque marker‐based adaptive radiotherapy with rotation correction could make a positive impact on reducing treatment margins. This project is supported by an NHMRC Australia Fellowship and NHMRC project grant 1034060.

SU‐E‐T‐366: Time‐Resolved EPID Dosimetry for Validating ArcIMRT

Purpose: The purpose of this study is to demonstrate time‐resolved dosimetry for verifying arc intensity modulated radiation therapy (arcIMRT) delivery, utilizing the continuous image acquisition of an electronic portal imaging device (EPID). Methods: An arcIMRT field was made of sliding, multi‐leaf collimator (MLC) motion of X1 leaves traveling from −5 cm to +5 cm and back, while Y opening was kept at 10 cm. For this field, this travel was repeated three times during the gantry rotation of 180°. The images were continuously acquired while the EPID was irradiated with 240 MU at a constant dose rate of 300 MU/min. By summing 10 frames, and thus reducing the temporal resolution to 1 second, a longitudinal non‐uniformity in the images was reduced to less than 3%. Dose images in EPID were also calculated by the XVMC code for MLC positions at 1 mm interval using the EPID model developed in our previous study. The calculated images at 1 sec resolution were then correlated to and compared with the images, validating the time‐resolved dosimetry. Results: Over the period of 48 seconds, 481 EPID images were acquired. The MLCs traveled at 1.25 cm/sec. Thus, 10 images were assigned to 1.25 cm of MLC travel for the correlation and for dose evaluation. For all gantry angles, the agreement of the gamma tests was above 90%, given 3 mm distance to agreement and 3% dose difference, when MLCs moved forwardly to the X2 side. However, when they travel back, the pass rates were below 90% due to MLC lagging which was detected in time‐resolved EPID dose imaging. Conclusion: Time‐resolved, four‐dimensional dose validation of arcIMRT was demonstrated, showing the temporal information of dynamic radiation delivery. This can be used for the validation of 4D treatment delivery techniques.

Definitive image guided (IGRT) intensity-modulated arc radiotherapy (arctherapy) for locally advanced squamous cell carcinoma of the vulva.

e16540 Background: To determine early clinical outcome of PET-CT image guided intensity modulated arc radiotherapy with concomitant weekly cisplatin as definitive treatment of locally advanced or loco-regional unresectable relapsed vulvar cancer. Methods: Primary or relapsed (after surgery) patients (pts) with locally or loco-regionally advanced vulvar cancer not amenable to surgery were treated with radiation (RT) plus weekly cisplatin. All pts were planed by PET-CT scan. The decision to irradiate vulva and/or unilateral/bilateral nodes was made independently. Vulva was irradiated if macroscopic tumor was present (64Gy) or free-margins were less than 8mm (50Gy). Radiotherapy was applied to the unilateral or bilateral nodal regions according to nodal involvement/sentinal node/central or lateral vulvar tumor statuses. Principal of one-plus nodal region was applied. Target volumes were delineated together with onc-radiologist. Arctherapy was used. Results: 24 consecutive pts (median age 68 years) were treated during 01.09.2008-30.09.2012. In the initial period IMRT was used (9 pts). Vulva was treated in 20 pts; unilateral nodal RT in 7 pts and bilateral nodal RT in 17 pts. Grade ≥2 skin toxicity was registered in 20 pts, diarrhea in 3 pts., bladder related toxicity in 4 pts. Median follow-up is 15.7 months. 18 pts had complete clinical &amp; radiological remission. 6 pts had treatment failure (residual tumor at 3 months follow-up) and another 6 pts relapsed. Conclusions: Image guided arctherapy is well tolerated and is effective in unresectable locally advanced vulvar cancer pts. Further experience and long-term data with this technique is to be attained.

Adjuvant image guided (IGRT) intensity-modulated Arc radiotherapy for vulvar cancer.

e16541 Background: A retrospective analysis to determine the efficacy and toxicity of PET-CT image guided intensity modulated arc radiotherapy (arctherapy) with concomitant weekly cisplatin as adjuvant treatment of vulvar cancer patients (pts) with high-risk of relapse after primary surgery. Methods: Pts were identified as high-risk of relapse after primary surgery (free-margins of vulvar tumor &lt;8mm; positive sentinel node/nodes). Pts were treated with radiation (RT) plus weekly cisplatin. All pts were planed by PET-CT scan. Target volumes were delineated together with onc-radiologist. The decision to irradiate vulva and/or unilateral/bilateral nodes was made independently. Principal of one-plus nodal region was applied. 46-50,7Gys were delivered in 23-27 daily fractions by arctherapy. Results: 25 consecutive pts (median age 64 years) were treated during 01.09.2008-30.09.2012. In the initial period IMRT was used (4 pts). Vulva was treated in all pts; unilateral nodal RT in 8 pts and bilateral nodal RT in 17 pts. No grade ≥2 toxicities were recorded. 24 pts are relapse-free with a median follow-up of 14.8 months. 1 pt had early relapse with later fatal outcome. Conclusions: Image guided arctherapy is highly effective and well tolerated. Further experience and long-term data with this technique is to be attained.

Volumetric modulated arc radiotherapy for limited osteosclerotic myeloma

To assess the feasibility of volumetric intensity-modulated arc radiotherapy (VMAT) in patients with limited polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes syndrome. A 70-year-old male with histologically confirmed osteosclerotic myeloma was treated in our department in July 2010 with VMAT. Fourty-six Gray in 23 fractions were given on three bone lesions. Doses delivered to target volume and critical organs were compared with a tridimensional conformal radiotherapy (3D-RT) plan. Treatment was well tolerated without any side effects. VMAT improved dose homogeneity within the target volume, as compared to 3D-RT (standard deviations: 2.9 Gy and 1.6 Gy for 3D and VMAT, respectively). VMAT resulted in a better sparing of critical organs. Dose delivered to 20% of organ volume (D20) was reduced from 22 Gy (3D-RT) to 15 Gy (VMAT) for small bowel, from 24 Gy (3D-RT) to 17 Gy (VMAT) for bladder and from 47 Gy (3D-RT) to 3 Gy (VMAT) for spinal cord. Volumes of critical organs that received at least 20 Gy (V20) were decreased by the use of VMAT, as compared to 3D-RT (V20 bladder: 10% vs 99%; V20 small bowel: 6% vs 21%). One year after treatment completion, no tumor progression has been reported. VMAT improved dose distribution as compared to 3D-RT for limited osteosclerotic myeloma, with better saving of critical organs.

Dosimetric benefit of DMLC tracking for conventional and sub-volume boosted prostate intensity-modulated arc radiotherapy

This study investigated the dosimetric impact of uncompensated motion and motion compensation with dynamic multileaf collimator (DMLC) tracking for prostate intensity modulated arc therapy. Two treatment approaches were investigated; a conventional approach with a uniform radiation dose to the target volume and an intraprostatic lesion (IPL) boosted approach with an increased dose to a subvolume of the prostate. The impact on plan quality of optimizations with a leaf position constraint, which limited the distance between neighbouring adjacent MLC leaves, was also investigated. Deliveries were done with and without DMLC tracking on a linear acceleration with a high-resolution MLC. A cylindrical phantom containing two orthogonal diode arrays was used for dosimetry. A motion platform reproduced six patient-derived prostate motion traces, with the average displacement ranging from 1.0 to 8.9 mm during the first 75 s. A research DMLC tracking system was used for real-time motion compensation with optical monitoring for position input. The gamma index was used for evaluation, with measurements with a static phantom or the planned dose as reference, using 2% and 2 mm gamma criteria. The average pass rate with DMLC tracking was 99.9% (range 98.7–100%, measurement as reference), whereas the pass rate for untracked deliveries decreased distinctly as the average displacement increased, with an average pass rate of 61.3% (range 32.7–99.3%). Dose–volume histograms showed that DMLC tracking maintained the planned dose distributions in the presence of motion whereas traces with >3 mm average displacement caused clear plan degradation for untracked deliveries. The dose to the rectum and bladder had an evident dependence on the motion direction and amplitude for untracked deliveries, and the dose to the rectum was slightly increased for IPL boosted plans compared to conventional plans for anterior motion with large amplitude. In conclusion, optimization using a leaf position constraint had minimal dosimetric effect, DMLC tracking improved the target and normal tissue dose distributions compared to no tracking for target motion >3 mm, with the DMLC tracking distributions showing generally good agreement between the planned and delivered doses.

191 High-dose intensity-modulated arc radiotherapy for lymph node metastasized prostate cancer: Toxicity and early clinical outcome

191 High-dose intensity-modulated arc radiotherapy for lymph node metastasized prostate cancer: Toxicity and early clinical outcome

Radiation Therapy for Nasopharyngeal Carcinoma Using Simultaneously Integrated Boost (SIB) Protocol: A Comparison Planning Study between Intensity Modulated Arc Radiotherapy vs. Intensity Modulated Radiotherapy

The aim of this paper is to compare the dosimetric difference between intensity-modulated arc therapy (IMAT) and conventional intensity-modulated radiation therapy (IMRT) for radiotherapy of nasopharyngeal carcinoma (NPC) using simultaneously integrated boost (SIB) protocol. Ten patients with nasopharyngeal carcinoma underwent SIB protocol were retrospectively studied. The plan target volume (PTV) of NPC contained nasopharynx gross target volume and the positive neck lymph nodes, PTV1 contained the high-risk sites of microscopic extension and the whole nasopharynx and PTV2 contained the low-risk sites. The prescription dose of PTV was 66 Gy/30 fractions, and for PTV1 60 Gy/30 fractions and for PTV2 54 Gy/30 fractions. IMAT (two 358° arcs) and IMRT (7 fields) plans were designed for each patients using SIB strategies. The monitor unit (MU), treatment time (T) and dosimetric difference between IMRT and IMAT were compared. IMAT can achieve better conformal index (CI) than IMRT (P < 0.05) for all PTVs, while no significant difference were found in homogeneity index (HI) (P > 0.05). There's no significant difference found in radiation dose of brain stem, lenses and parotids, while the maximum dose of spinal cord of IMAT was higher than IMRT (P < 0.05). The monitor unit of IMRT (1308 ± 213) was more than IMAT (606 ± 96) (P < 0.05), while the treatment time of IMRT (540 ± 160S) was more than IMAT (160 ± 10S). This study shows that IMAT using SIB strategies for NPC radiotherapy can achieve similar target coverage with better conformity with less MU and delivery time comparing to IMRT.

Dosimetric comparison of intensity-modulated arc radiotherapy and fixed beam dynamic intensity-modulated radiation therapy in nasopharyngeal carcinoma

To compare the dosimetric differences of dosiology between intensity-modulated arc radiotherapy (IMAT) and dynamic intensity-modulated radiation therapy (dIMRT) in nasopharyngeal carcinoma. CT data from 25 patients treated in our radiotherapy center were selected randomly for this study. For each patient, the IMAT technique and the fixed beam dIMRT technique were accomplished by the simultaneously integrated boost. Dose volume histogram (DVH) data, isodose distribution, monitor units (MUs) and treatment time were compared in the two techniques. There was no significant difference between the IMAT and the dIMRT in dose received by 95% of target volumes (D(95)) (P>0.05). Overall, the mean dose (D(mean)), maximal dose (D(max)) and volume percentage receiving at least of 107% of the prescribed dose (V(107%)) of planning target volume (PTV) for the IMAT were increased slightly ,compared with the dlMRT (P<0.05). There were no significant differences in dosimetric indices of organs at risk (OARs) including spinal cord,optical nerves,lens and temporomandibular joints in the two techniques (P>0.05). Compared with the dlMRI, the D(max) of brain stem for the IMAT was increased slightly (P<0.05). Similar trends was observed for the D(mean) and dose received by 50% of volume (D(50)) of the left and right parotid glands (P<0.05). Healthy tissue (defined as the volume of the body minus PTV,B-P) irradiated from 800 cGy in the IMAT was higher, and that from 1200-4500 cGy was lower compared with the dlMRI (P<0.05).The average number of MUs was reduced by 62.7% per fraction, and the treatment time was on average reduced by 60.1% per fraction in the IMAT compared with the dlMRI. There is a slight difference in dosiology between the two radiotherapy techniques investigated, but they both meet the clinical requirement. Compared with the dIMRT, the IMAT delivers less irradiation to healthy tissue, uses fewer MUs and takes less time during radiotherapy for nasopharyngeal carcinoma.

Dosimetric research on intensity-modulated arc radiotherapy planning for left breast cancer after breast-preservation surgery

Intensity-modulated radiotherapy (IMRT) has played an important role in breast cancer radiotherapy after breast-preservation surgery. Our aim was to study the dosimetric and implementation features/feasibility between IMRT and intensity-modulated arc radiotherapy (Varian RapidArc, Varian, Palo Alto, CA). The forward IMRT plan (f-IMRT), the inverse IMRT, and the RapidArc plan (RA) were generated for 10 patients. Afterward, we compared the target dose distribution of the 3 plans, radiation dose on organs at risk, monitor units, and treatment time. All 3 plans met clinical requirements, with RA performing best in target conformity. In target homogeneity, there was no statistical significance between RA and IMRT, but both of homogeneity were less than f-IMRT's. With regard to the V5 and V10 of the left lung, those in RA were higher than in f-IMRT but were lower than in IMRT; for V20 and V30, the lowest was observed in RA; and in the V5 and V10 of the right lung, as well as the mean dose in normal-side breast and right lung, there was no statistically significance difference between RA and IMRT, and the lowest value was observed in f-IMRT. As for the maximum dose in the normal-side breast, the lowest value was observed in RA. Regarding monitor units (MUs), those in RA were higher than in f-IMRT but were lower than in IMRT. Treatment time of RA was 84.6% and 88.23% shorter than f-IMRT and IMRT, respectively, on average. Compared with f-IMRT and IMRT, RA performed better in target conformity and can reduce high-dose volume in the heart and left lung—which are related to complications—significantly shortening treatment time as well. Compared with IMRT, RA can also significantly reduce low-dose volume and MUs of the afflicted lung.

Impact of Gantry Rotation Time on Plan Quality and Dosimetric Verification – Volumetric Modulated Arc Therapy (VMAT) vs. Intensity Modulated Radiotherapy (IMRT)

To compare plan quality criteria and dosimetric accuracy of step-and-shoot intensity-modulated radiotherapy (ss-IMRT) and volumetric modulated arc radiotherapy (VMAT) using two different gantry rotation times. This retrospective planning study based on 20 patients was comprised of 10 prostate cancer (PC) and 10 head and neck (HN) cancer cases. Each plan contained two target volumes: a primary planning target volume (PTV) and a boost volume. For each patient, one ss-IMRT plan and two VMAT plans at 90 s (VMAT90) and 120 s (VMAT120) per arc were generated with the Pinnacle© planning system. Two arcs were provided for the PTV plans and a single arc for boost volumes. Dosimetric verification of the plans was performed using a 2D ionization chamber array placed in a full scatter phantom. VMAT reduced delivery time and monitor units for both treatment sites compared to IMRT. VMAT120 vs. VMAT90 increased delivery time and monitor units in PC plans without improving plan quality. For HN cases, VMAT120 provided comparable organs at risk sparing and better target coverage and conformity than VMAT90. In the VMAT plan verification, an average of 97.1% of the detector points passed the 3 mm, 3% γ criterion, while in IMRT verification it was 98.8%. VMAT90, VMAT120, and IMRT achieved comparable treatment plans. Slower gantry movement in VMAT120 plans only improves dosimetric quality for highly complex targets.