Reduction In Monitor Units Research Articles

Modulated Arc Therapy for hippocampal-avoidance whole brain radiation therapy: planning comparison with intensity modulated Radiation Therapy.

This study aimed to evaluate the modulated arc therapy (mARC) technique as a planning and treatment option for hippocampal sparing whole brain radiotherapy (HS-WBRT) following the Radiation Therapy Oncology Group (RTOG) 0933 dosimetric criteria. Computed tomography (CT) and magnetic resonance imaging (MRI) were selected retrospectively for 15 patients. Two types of plans were created for each patient, namely an intensity-modulated radiation therapy (IMRT) and a mARC plan. IMRT and mARC plans were compared in terms of plan quality indices, absorbed dose to organs at risk (OARs), number of monitor units (MUs), and treatment time. All plans in both techniques were considered clinically acceptable for treatment. However, IMRT plans presented a higher conformity (p = 0.01) as well as a higher homogeneity as compared to mARC plans, but this difference was not statistically significant (p > 0.05). In terms of the preservation of the hippocampus, it was observed that the IMRT plans achieved significantly lower doses for both 100% of its volume and for its maximum dose (p < 0.001). The evaluation of the remaining OARs showed that the IMRT technique resulted in lower doses, and significant differences were observed for the following organs: left cochlea (p < 0.001), left eye (p < 0.001), right eye (p = 0.03), both lenses of the eye (p < 0.001), and right optic nerve (p = 0.02). Despite these differences, the absolute differences in all dosimetric parameters were low enough to bear any clinical relevance. A drastic (close to 65%) and significant (p < 0.001) decrease was observed in the number of MUs for the mARC plans. This resulted in a substantial decrease in treatment time (60.45%, p < 0.001). It is concluded that the mARC technique is a feasible planning and treatment solution for HS-WBRT that meets the RTOG 0933 criteria. The main advantage of using mARC over IMRT for HS-WBRT is the considerable reduction in MUs and treatment time.

Progressive resolution optimizer (PRO) predominates over photon optimizer (PO) in sparing of spinal cord for spine SABR VMAT plans

Backgroundwe assessed the performance of the optimization algorithms by comparing volumetric modulated arc therapy generated by a progressive resolution optimized (VMATPRO) and photon optimizer (VMATPO) in terms of plan quality, MU reduction, sparing of the spinal cord (or cauda equina), and plan complexity.MethodsFifty-seven patients who received spine stereotactic ablative radiotherapy (SABR) with tumors located in the cervical, thoracic, and lumbar spine were retrospectively selected. For each patient, VMATPRO and VMATPO with two full arcs were generated with using the PRO and PO algorithms. For dosimetric evaluation, the dose-volumetric (DV) parameters of the planning target volume (PTV), organs at risk (OARs), the corresponding planning organs at risk (PRV), and 1.5-cm ring structure surrounding the PTV (Ring1.5 cm) were calculated for all VMAT plans. The total number of monitor units (MUs) and the modulation complexity score for the VMAT (MCSv) were compared. To investigate the correlations of OAR sparing to plan complexity, Pearson’s and Spearman’s correlation tests were conducted between the two algorithms (PO – PRO, denoted as Δ) in the DV parameters for normal tissues, total MUs, and MCSv.ResultsFor the PTVs, Target conformity and dose homogeneity in the PTVs of VMATPRO were better than those of VMATPO with statistical significance. For the spinal cords (or cauda equine) and the corresponding PRVs, all of the DV parameters for VMATPRO were markedly lower than those for VMATPO, with statistical significance (all p < 0.0001). Among them, the difference in the maximum dose to the spinal cord between VMATPRO and VMATPO was remarkable (9.04 Gy vs. 11.08 Gy with p < 0.0001). For Ring1.5 cm, no significant difference in V115% for VMATPRO and VMATPO was observed.ConclusionsThe use of VMATPRO resulted in improved coverage and uniformity of dose to the PTV, as well as OARs sparing, compared with that of VMATPO for cervical, thoracic, and lumbar spine SABR. Better dosimetric plan quality generated by the PRO algorithm was observed to result in higher total MUs and plan complexity. Therefore, careful evaluation of its deliverability should be performed with caution during the routine use of the PRO algorithm.

A Dosimetric Study on the Impact of Collimator Angles in Nasopharynx Carcinoma using VMAT Planning

Objective: This study aims to rule out the best collimator angle using Monte- Carlo algorithm in Nasopharynx Carcinoma (NPC) with adequate tumour coverage and less OAR. Methods: Twenty-nine NPC patients were selected retrospectively. VMAT with dual arc were made with same constraints but with different collimator angles for each patient. Total often plans were created for each patient with a collimator angles of 0;5;10;15;20;25;30;35;40;45 in Monaco Treatment Planning System(TPS) using Monte-Carlo algorithm. Plans were evaluated based on Dosimetric parameters such as target coverage, organ at risk (OAR), conformity index(CI) and homogeneity index(HI). Mean dose (Dmean), and Maximum dose (Dmax) of OARs were also analysed. Data were further evaluated by using SPSS software. Findings: The VMAT plans with collimator angles 15◦-30◦ demonstrated better target coverage with a range of (92-94) %0.7195 for the high-dose PTV and significant reduction in monitor units (MU) by an average of 75 with a CI (0.95-0.96)0.0068. Moreover, significant reduction in Dmax of Brainstem and Right optic nerve were obtained with increasing angles. Also,5◦-10◦ showed least PTV coverage and 45◦ got highest MUs compared to 0◦. Novelty : This study shows that collimator angles 15◦-30◦ is superior compared with other angles in Ca Nasopharynx VMAT planning by Elekta-HD Versa Linac using Monte-Carlo algorithm. Keywords: Ca Nasopharynx; Collimator angle; Montecarlo algorithm; Elekta HD Versa Linac; VMAT

Built-in wavelet-induced smoothness to reduce plan complexity in intensity modulated radiation therapy (IMRT)

Objective. Reducing plan complexity in intensity modulated radiation therapy (IMRT) to ensure dosimetric accuracy and delivery efficiency of the radiation treatment plans. We propose a novel approach by representing the beamlet intensities using an incomplete wavelet basis that explicitly excludes fluctuating intensity maps from the decision space (explicit hard constraint). This technique provides a built-in wavelet-induced smoothness that improves both dosimetric plan quality and delivery efficiency. Approach. The beamlet intensity maps need to be especially smooth in the leaf travel direction (referred to as the X-direction). We treat the intensity map of each beam as a 2D image and represent it using the wavelets corresponding to low-frequency changes in the X-direction (i.e. approximation and horizontal). The absence of wavelets corresponding to high-frequency changes (i.e. vertical and diagonal) induces built-in smoothness. We still utilize a regularization term in the objective function to promote smoothness in the Y-direction (perpendicular to the X-direction) and further possible smoothness in the X-direction. This technique has been tested on three patient cases of different disease sites (paraspinal, lung, prostate) and all final evaluations and comparisons have been performed on an FDA-approved commercial treatment planning system (Varian EclipseTM). Main results. Wavelet-induced smoothness reduced monitor units by about 10%, 45%, and 14% for paraspinal, lung, and prostate cases, respectively. It also improved organ at risk sparing, especially on the complex paraspinal case where it resulted in about 7%, 13%, and 14% less mean dose to esophagus, lung, and cord, respectively. Moreover, built-in wavelet-induced smoothness desensitizes the results to changing the weight associated to the regularization term, and thereby mitigates the weight fine-tuning difficulty. Significance. Fluence smoothness is often achieved by smoothing the beamlet intensity maps using a proper regularization term in the objective function aiming at disincentivizing fluctuation in the beamlet intensities (implicit soft constraint). This work reports a novel application of wavelets in imposing an explicit smoothness hard constraint in the search space using an incomplete wavelet basis. This idea has been successfully applied to exclude complex and clinically irrelevant radiation plans from the search space. The code and pertained models along with a sample dataset are released on our LowDimRT GitHub (https://github.com/PortPy-Project/LowDimRT).

A measurement validation of improved plan deliverability with monitor unit objective tool for spine stereotactic ablative radiotherapy.

Spine stereotactic body radiation therapy (SBRT) uses high dose per fraction for palliative pain control. The treatment plans are often heavily modulated due to close proximity to spinal cord and this can lead to poor plan quality which are susceptible to dose delivery discrepancy. Therefore, we aim to assess the effectiveness of the monitor unit (MU) objective tool in Eclipse treatment planning systems in modulating the plan complexity to improve the plan quality in spine SBRT. Seven retrospective spine SBRT plans are re-optimized using the MU objective tool in Eclipse TPS v13.6 and were compared with the original plans. The dose metrics of the tumor PTV were compared using D1cc. D99%, D95%, D0.03cc, D0.1cc, D0.35cc and D1cc, and that of cord PRV were compared using D0.03cc, D0.1cc, D0.35cc. Four different plan complexities were also calculated for the original and re-optimized plans to quantify the impact of the tool on the modulation. Patient specific quality assurance measurements were performed with Stereophan and SRS MapCheck, and analyzed using the 1%/1-mm and 2%/2-mm criteria with gamma analysis. The dose metrics of the PTV and cord PRV of the re-optimized and original plans are similar and still meet the planning dose constraints. In particular, the PTV dose coverage has a small percentage difference of (0.15 ± 1.33)% and (0.01 ± 1.04)% for D99% and D95%, respectively. The 4 calculated plan complexity metrics consistently show that the re-optimized plans are quantitatively less complex than the original plan. The gamma passing rate of the re-optimized plans improved from (92.2 ± 2.0)% to (94.2 ± 1.6)% with the 1%/1-mm criterion, and (98.7 ± 1.0)% to (99.5 ± 0.3)% with the 2%/2-mm criterion. Overall, the re-optimized plans achieve at least a 10% MU reduction (11.7% to 24.6%). Our study shows that optimization with the MU objective tool can reduce plan complexity and improves dose delivery accuracy, while not compromising the dose distribution.

Influence of Specific Treatment Parameters on Nontarget and Out-of-Field Doses in a Phantom Model of Prostate SBRT with CyberKnife and TrueBeam.

The aim of the study was to determine the influence of a key treatment plan and beam parameters on overall dose distribution and on doses in organs laying in further distance from the target during prostate SBRT. Multiple representative treatment plans (n = 12) for TrueBeam and CyberKnife were prepared and evaluated. Nontarget doses were measured with anionization chamber, in a quasi-humanoid phantom at four sites corresponding to the intestines, right lung, thyroid, and head. The following parameters were modified: radiotherapy technique, presence or not of a flattening filter, degree of modulation, and use or not of jaw tracking function for TrueBeam and beam orientation set-up, optimization techniques, and number of MUs for CyberKnife. After usual optimization doses in intestines (near the target) were 0.73% and 0.76%, in head (farthest from target) 0.05% and 0.19% for TrueBeam and CyberKnife, respectively. For TrueBeam the highest peripheral (head, thyroid, lung) doses occurred for the VMAT with the flattening filter while the lowest for 3DCRT. For CyberKnife the highest doses were for gantry with caudal direction beams blocked (gantry close to OARs) while the lowest was the low modulated VOLO optimization technique. The easiest method to reduce peripheral doses was to combine FFF with jaw tracking and reducing monitor units at TrueBeam and to avoid gantry position close to OARs together with reduction of monitor units at CyberKnife, respectively. The presented strategies allowed to significantly reduce out-of-field and nontarget doses during prostate radiotherapy delivered with TrueBeam and CyberKnife. A different approach was required to reduce peripheral doses because of the difference in dose delivery techniques: non-coplanar using CyberKnife and coplanar using TrueBeam, respectively.

Evaluation of target autocrop function in nasopharyngeal carcinoma SIB IMRT plan.

A new target autocrop function was introduced in the Varian Eclipse™ treatment planning software (version 15.5 above) (Lohynská in Klin Onkol 33(4):288-294, 2020). The study aimed to evaluate this new target autocrop impact on nasopharyngeal carcinoma (NPC) plan quality and delivery efficiency. Randomly 66 approved NPC simultaneous integrated boost (SIB) intensity-modulated radiation therapy (IMRT) treatment plans were retrospectively studied. The manual cropping-based plans served as reference and were designed using sliding-window IMRT. Reference plans were re-optimized with identical plan parameters following the institutional clinical protocol, except for the redundant optimization objective of the manual cropping targets deleted. Additionally, each target within 5mm of another had one minimum objective at 100% volume and one maximum objective at 0% volume for the autocrop plans. Plan quality was assessed based on selected parameters, including TCP (tumor control probability), NTCP (normal tissue complication probability), conformality index (CI), homogeneity index (HI), and dose-volume characteristics. Additionally, the delivery efficiency, the total plan treatment time defined as a sum of monitor units (MUs) for each treated field, and delivery accuracy, γ passing rate of treatment plan quality assurance (QA) also were compared. Both the manual cropping plans and the autocrop plans could be approved by an experienced oncologist. Overall, the autocrop plans could provide approximately a 13% reduction in linac MU while maintaining comparable plan quality, radiobiological ranking, and accuracy to the manual cropping plans. The new target autocrop tip facilitated the SIB IMRT plans for nasopharyngeal cancer patients. The autocrop could guarantee the quality and delivery accuracy of the radiotherapy plan and improved the planning efficiency, treatment efficiency, and reduced machine wear and tear. It was a promising tool for optimal plan selection for NPC SIB IMRT.

Dosimetric justification for the use of volumetric modulated arc therapy in head and neck cancer-A systematic review of the literature.

IntroductionRadiotherapy for head and neck cancer (HNC) has evolved rapidly in the past decades from conformal three‐dimensional technique (3D‐CRT) to intensity‐modulated radiotherapy (IMRT) and volumetric‐modulated arc therapy (VMAT). This paper presents a dosimetric comparative study between VMAT and IMRT delivery based on current literature, while also presenting the potential challenges encountered with volumetric arc therapy.MethodsA systematic search of the scientific literature was conducted within Medline/Pubmed databases. A number of 13 papers fulfilled the search criteria which was based on the main objective to evaluate dosimetric characteristics of comparative treatment delivery with VMAT vs IMRT in HNC.ResultsOverall, from a dosimetric perspective, dose delivery via VMAT and IMRT present comparable results. Beside the delivery technique, target volume coverage also depends on the planner's expertise as well as the employed planning algorithm. At times, the superiority of VMAT emerges from the improved sparing of normal tissue, reduction of monitor units (MU) and of treatment delivery time. Similar to IMRT, one of the most important challenges of VMAT is the risk of developing secondary cancer due to the higher number of MUs compared to 3D‐CRT.ConclusionsBased on the comparative results with the more established IMRT, VMAT in HNC can be safely delivered either as a single treatment or combined with other techniques.

A Dosimetric Comparison of Volumetric-Modulated Arc Therapy to Intensity-Modulated Radiation Therapy in the Treatment of Locally Advanced Rectal Carcinoma

Introduction: The study was conducted to compare volumetric-modulated arc therapy (VMAT) with intensity-modulated radiation therapy (IMRT) in patients with locally advanced rectal cancer (LARC). Material and Methods: Ten computed tomography (CT) scans were selected and for each CT scan, two plans were calculated (IMRT and VMAT). The average cumulative dose-volume histograms of VMAT plans for the planning target volumes (PTVs), organs at risk (OARs), and normal tissues were calculated and compared with those reported for the corresponding IMRT technique. Results: Target coverage was equivalent for both techniques. For primary PTV, the average homogeneity index (HI) of IMRT was significantly lower than the VMAT plans (0.10±0.04 vs. 0.11±0.03; p <0.0001). The average conformity index (CI) values for IMRT and VMAT were 1.21 and 1.12, respectively, with a nonsignificant trend for better results with VMAT (p =0.1). For the PTV boost, there was a nonsignificant trend for better results with VMAT in average HI and CI. The VMAT was superior to IMRT in OAR sparing. For monitor units (MUs), VMAT plans required 70% less MUs than IMRT. Conclusion: For LARC patients, VMAT was able to deliver treatment plans dosimetrically equivalent to IMRT in terms of PTV coverage. The VMAT provided better OAR sparing and significant reduction of MUs in comparison to IMRT.

Evaluation of three VMAT-TMI planning methods to find an appropriate balance between plan complexity and the resulting dose distribution

PurposeEvaluation of different planning methods of treatment plan preparation for volumetric modulated arc therapy during total marrow irradiation (VMAT-TMI). MethodThree different planning methods were evaluated to establish the most appropriate VMAT-TMI technique, based on organ at risk (OAR) dose reduction, conformity and plan simplicity. The methods were: (M1) the sub-plan method, (M2) use of eight arcs optimised simultaneously and (M3) M2 with monitor unit reduction. Friedman ANOVA comparison, with Nemenyi's procedures, was used in the statistical analysis of the results. ResultsThe dosimetric results obtained for the planning target volume and for most OARs do not differ statistically between methods. The M3 method was characterized by the lowest numbers of monitor units (3259 MU vs. 4450 MU for M1 and 4216 MU for M2) and, in general, the lowest complexity. The variability of the monitor units from control points was almost half for M3 than M1 and M2 (i.e. 0.33 MU vs. 0.61 MU for M1 and 0.58 for M2). Analysing the relationship between the dose distributions obtained for the plans and their complexity, the best result was observed for the M3 method. ConclusionThe use of eight simultaneously optimised arcs with MU reduction allows to obtain VMAT-TMI plans that are characterized by the lowest complexity, with dose distributions comparable to the plans generated by other methods.

Clinical impact of the VOLO optimizer on treatment plan quality and clinical treatment efficiency for CyberKnife.

With the recent CyberKnife treatment planning system (TPS) upgrade from Precision 1.0 to Precision 2.0, the new VOLO optimizer was released for plan optimization. The VOLO optimizer sought to overcome some of the limitations seen with the Sequential optimizer from previous TPS versions. The purpose of this study was to investigate the clinical impact of the VOLO optimizer on treatment plan quality and clinical treatment efficiency as compared to the Sequential optimizer. Treatment plan quality was evaluated in four categories of patients: Brain Simple (BS), Brain Complex (BC), Spine Complex (SC), and Prostate (PC). A total of 60 treatment plans were compared using both the Sequential and VOLO optimizers with Iris and MLC collimation with the same clinical constraints. Metrics evaluated included estimated treatment time, monitor units (MUs) delivered, conformity index (CI), and gradient index (GI). Furthermore, the clinical impact of the VOLO optimizer was evaluated through statistical analysis of the patient population treated during the 4 months before (n = 297) and 4 months after (n = 285) VOLO introduction. Significant MU and time reductions were observed for all four categories planned. MU reduction ranged from −14% (BS Iris) to −52% (BC MLC), and time reduction ranged from −11% (BS Iris) to −22% (BC MLC). The statistical analysis of patient population before and after VOLO introduction for patients using 6D Skull tracking with fixed cone, 6D Skull tracking with Iris, and Xsight Spine tracking with Iris were −4.6%, −22.2%, and −17.8% for treatment time reduction, −1.1%, −22.0%, and −28.4% for beam reduction and −3.2%, −21.8%, and −28.1% for MU reduction, respectively. The VOLO optimizer maintains or improves the plan quality while decreases the plan complexity and improves treatment efficiency. We anticipate an increase in patient throughput with the introduction of the VOLO optimizer.

Dosimetric Study of Tissue Heterogeneity Correction for Breast Conformal Radiotherapy

Introduction: Heterogeneity correction is an important parameter in dose calculation for cancer patients where it may be cause inaccuracy in dose calculation as a result of different densities of patients. This study studied the impact of dose calculation of breast cancer patients with and without heterogeneity correction. Material and Methods: Twenty breast cancer patients were treated with Three-Dimensional Conformal Radiotherapy(3DCRT). Dose calculations were performed using two modes: Fast Photon mode for homogeneity and Fast Photon Effective Path length for heterogeneity with two photon energies. Monitor Units(MU), Modulation Factor, Dose Volume Histograms(DVH) and quality indices were used to evaluate the effect of heterogeneity correction on dose calculation and investigate the mechanism of this effect in the low and high energies. Results: Heterogeneity correction compared to without it showed significant reduction in MU and modulation factor at 6MVand 10MV (p <0.05). Dosimetric parameters derived from DVH were significantly lower for Planning Target Volume (PTV) with homogeneity versus heterogeneity (p <0.05) as D95% (95.1%vs93.7%) and V95%(95.3%vs89%) for 6MV while max Dose and D2 increased. Also the dose for organs at risk exhibited an increase with heterogeneity correction. Quality indices were be worst with heterogeneity correction with a significant difference (p <0.05). The differences between the dose with heterogeneity correction and without it in 6MV and 10MV were as follows: ΔD95% (4.4%vs3.4%;P=0.001) and ΔV95%(4.76%vs4.5%;P=0.001). Conclusion: non-use of the heterogeneity correction can be cause to deliver under or overdose dose to the target volume. Tissue heterogeneity correction had an impact on dose calculation for breast cancer patients and this impact was more effective for the low energy.

Optimal collimator rotation based on the outline of multiple brain targets in VMAT

BackgroundThe aim of this study was to investigate the dosimetric quality in volumetric modulated arc therapy (VMAT) plans with optimal collimator angles that can represent the outline of multiple brain targets.MethodsTwenty patients with multiple target volumes in the brain cases were selected retrospectively. To better represent the outline of the multiple brain targets, four conformal arc plans were generated for each patient using one full arc with four collimator settings. The optimal collimator angles calculated from the integrated multi-leaf collimator (MLC) aperture that had the smallest aperture size for certain collimator settings of the conformal arc plan were selected. VMAT plans with the optimal collimator angles with angular sections of 40° and 60° (Colli-VMAT (40°), Colli-VMAT (60°)) were generated, followed by evaluation of field sizes, dose-volumetric parameters and total monitor units (MUs).ResultsPatient-averaged values of field sizes for Colli-VMAT (40°) (111.5 cm2) were lowest and 1.3 times smaller than those for Std-VMAT (143.6 cm2). Colli-VMAT plans improved sparing of most normal organs but for brain stem and left parotid gland. For the total MUs, the averaged values obtained with the Colli-VMAT (40°) (390 ± 148 MU) were smaller than those obtained with the Std-VMAT (472 ± 235 MU).ConclusionsThe Colli-VMAT plans with smaller angular sections could be suitable in the clinic for multiple brain targets as well as for irregularly shaped targets. Determination of the optimal collimator rotation generally showed good normal tissue sparing and MU reduction for multiple brain targets.

Assessment of the Monitor Unit Objective tool for VMAT in the Eclipse treatment planning system.

This work aims to achieve the highest possible monitor units (MU) reduction using the MU Objective tool included in the Eclipse treatment planning system, while preserving the plan quality. The treatment planning system Eclipse (Varian Medical Systems, Palo Alto, CA) includes a control mechanism for the number of monitor units of volumetric modulated arc therapy (VMAT) plans, named the MU Objective tool. Forty prostate plans, 20 gynecological plans and 20 head and neck plans designed with VMAT were retrospectively studied. Each plan (base plan) was optimized without using the MU Objective tool, and it was re-optimized with different values of the Maximum MU (MaxMU) parameter of the MU Objective tool. MU differences were analyzed with a paired samples t-test and changes in plan quality were assessed with a set of parameters for OARs and PTVs. The average relative MU difference [Formula: see text] considering all treatment sites, was the highest when MaxMU=400 (-4.2%, p<0.001). For prostate plans, the lowest [Formula: see text] was obtained (-3.7%, p<0.001). For head and neck plans [Formula: see text] was -7.3% (p<0.001) and for gynecological plans [Formula: see text] was 7.0% (p=0.002). Although similar MU reductions were observed for both sites, for some gynecological plans maximum differences were greater than 10%. All the assessed parameters for PTVs and OARs sparing showed average differences below 2%. For the three studied clinical sites, establishing MaxMU=400 led to the optimum MU reduction, maintaining the original dose distribution and dosimetric parameters practically unaltered.

Dynamic collimator trajectory algorithm for multiple metastases dynamic conformal arc treatment planning

To develop an algorithm for dynamic collimator positioning to optimize beam's eye view (BEV) fitting of targets in dynamic conformal arc (DCA)-based radiotherapy procedures, of particular use in multiple metastases stereotactic radiosurgery procedures. A trajectory algorithm was developed to dynamically modify the angle of the collimator as a function of arc-based control point to provide optimized collimation of target volume(s). Central to this algorithm is a concept denoted herein as "whitespace" defined as any nontarget area in the BEV that is not covered by any collimation system and is open to exposure from the radiation beam. Calculating whitespace at all collimator angles and every control point, a two-dimensional topographical map depicting the tightness-of-fit of the MLC was generated. A bidirectional gradient trajectory algorithm identified a number of candidate trajectories of continuous collimator motion. Minimization of integrated whitespace was used to identify an optimal solution for the navigation of the parameter space. Plans with dynamic collimator trajectories were designed for multiple metastases targets and were compared with fixed collimator angle dynamic conformal arc (DCA) plans and standard VMAT plans. Algorithm validation was performed on simple test cases with known solutions. The whitespace metric showed a strong correlation (R2 = 0.90) with mean dose to proximal normal tissue. Seventeen cases were studied using our algorithm to generate dynamic conformal arc (DCA) plans with optimized collimator trajectories for three and four target SRS patients and comparing them to DCA plans generated with optimized fixed collimator angles per arc and standard VMAT plans generated via template. Optimized collimator trajectories were found to produce a reduction in monitor units of up to 49.7 ± 5.1% when compared to VMAT across 17 patients, and all organ-at-risk and normal brain metrics were found to be superior or comparable. Dynamic collimator trajectories have the potential to improve DCA deliveries through increased efficiency, especially in the treatment of multiple cranial metastases. Implementation of this technology should not be hindered by mechanical safety considerations as collimator motions do not modify or introduce any new risks of collisions with patients.

Safety and Efficacy of Treatment of Malignant Pleural Mesothelioma with Imprint Radiation Therapy Using VMAT Following Pleurectomy/Decortication

In the treatment of malignant pleural mesothelioma (MPM), there is evidence to support the use of pleurectomy/decortication (P/D) for surgical resection. This presents a unique challenge to the radiation oncologist to treat the pleura and chest wall while minimizing radiation dose to the underlying lung. Treatment with Intensity-Modulated Pleural Radiation Therapy (IMPRINT) has previously been shown to be efficacious and safe (Rimner et al. J Clin Oncol 2016). It has been shown that Volumetric Modulated Arc Therapy (VMAT) provides superior sparing of critical organs with reduced monitor units (MU) and delivery time when compared to IMRT, while adequately covering the planning target volume (PTV) (Dumane et al. Applied Rad Onc 2016). In this study we evaluated the safety and efficacy of treating this population with IMPRINT using VMAT at our institution. We identified 40 patients at our institution who underwent P/D followed by adjuvant radiation therapy (RT) from 2010-2016. VMAT typically included a minimum of 2 complementary co-planar arcs to cover the PTV. Electronic Medical Records were reviewed for toxicity, recurrence and survival data. Statistical analysis was performed using the Life Table method. The cohort included 26 men and 14 women. 73% had epithelial histology, 3% - sarcomatoid, 23% - mixed and 3% - pleomorphic/anaplastic. The median follow up time was 14.5 months (range 3-42 months). The median radiation dose delivered was 45 Gy (range, 30 – 54 Gy). Chemotherapy (pemetrexed/platinum doublet) consisted of: none (33%), induction (20%), adjuvant (23%). 15% of patients received chemotherapy following surgery but prior to the initiation of RT. The majority of patients (60%) began RT within one month following surgical resection. 70% of patients had an R1 resection and 30% had an R2 resection prior to radiation treatment. The most common adverse effect was fatigue: 80%, 12.5% and 7.5% of patients reported grade 1, 2 or 3 fatigue respectively. 62.5%, 35% and 2.5% of patients reported grade 1, 2 or 3 nausea respectively. Six patients (15%) developed grade 2 or 3 pneumonitis and 1 patient (3%) had grade 5 pneumonitis. 2 patients (5%) developed grade 2 or 3 pericarditis. The 1- and 2-year actuarial rates of overall survival were 62.5% and 17.5%, respectively. The 1- and 2- year actuarial rates of recurrence-free survival were 52.5% and 12.5%, respectively. This is the largest analysis to date of treatment outcomes with adjuvant radiation therapy with IMPRINT using VMAT following pleurectomy/decortication. VMAT provides a reduction in treatment time and improves sparing of critical structures. Our data demonstrate that treatment with this technique is well tolerated and survival is comparable with previous reports.

A Comparison of IMRT and VMAT Treatment Planning for Head and Neck Cancer With NTCP/TCP Analysis

Intensity-modulated radiation therapy (IMRT) and volumetric intensity-modulated arc therapy (VMAT) for HN cancers have been used with comparable coverage of planning target volumes (PTV). However, there is controversy over superiority of these techniques in management of HN cancers due to proximity to organs at risk (OAR), beam time, monitor units (MU) and integral dose. Using conventional dosimetric parameters conformity and homogeneity index (CI, HI), and biological indices NTCP/TCP, we evaluated VMAT and IMRT in their ability to provide superior coverage of PTV while sparing OAR. Fourteen consecutive HN cancer patients treated to the bilateral neck were planned with both IMRT and VMAT techniques in a commercial treatment planning system with 100% coverage to 95% PTV volume to a dose of 7000cGy. If OAR dose constraints were met for both VMAT and IMRT plans, a VMAT plan was preferred for treatment. The CI, HI, MU, gradient, as well as NTCP/TCP values were calculated. OAR studied include spinal cord, brachial plexus, bilateral parotids, constrictors, and larynx. Maximum doses for serial organs and mean doses for parallel organs were calculated for each OAR. NTCP model parameters were taken from QUANTEC and calculated for larynx, parotid, and spinal cord. TCP was modeled with published parameters based on a Poisson model with repopulation and sublethal damage. Statistical comparisons between VMAT and IMRT parameters were made using the paired t-test. The TCP values ranged 70-85% and were not significantly different (P>0.05) in IMRT compared to VMAT. NTCPs for the larynx and left/right parotid did not differ significantly between IMRT and VMAT plans. The PTV HI and CI were not significantly different between plans. Based on OAR coverage, six plans were treated with IMRT instead of VMAT. The OARs that were better spared in these six IMRT plans were constrictors (N=3), oral cavity (N=1), parotid (N=1) and brachial plexus (N=1). Significantly more MUs were used in IMRT plans than VMAT plans (average difference 733 MU, p<0.001). Maximum doses in VMAT plans were significantly greater than IMRT plans (mean max-dose difference 98cGy, p = 0.001). VMAT plans had an average maximum cord dose 1800cGy lower than IMRT plans (p < 0.001). IMRT delivered significantly lower mean dose to the oral cavity (mean dose difference 288cGy, p = 0.003) and middle/inferior constrictors (mean dose difference 121cGy, p = 0.02; 220cGy, p = 0.03, respectively). There was no significant difference between techniques in mean dose delivered to larynx or parotids or maximum dose delivered to the brachial plexus. IMRT and VMAT techniques generated comparable coverage of PTV and resulted in similar TCP. VMAT showed a significant reduction of MU and maximum dose delivered to spinal cord. Selection of techniques should be based on a more nuanced clinical decision rather than purely physical parameters.

Dosimetric comparison of single-beam multi-arc and 2-beam multi-arc VMAT optimization in the Monaco treatment planning system

The purpose of this study was to evaluate the dosimetric and practical effects of the Monaco treatment planning system “max arcs-per-beam” optimization parameter in pelvic radiotherapy treatments. We selected for this study a total of 17 previously treated patients with a range of pelvic disease sites including prostate (9), bladder (1), uterus (3), rectum (3), and cervix (1). For each patient, 2 plans were generated, one using an arc-per-beam setting of “1” and another with an arc-per-beam setting of “2” using the volumes and constraints established from the initial clinical treatments. All constraints and dose coverage objects were kept the same between plans, and all plans were normalized to 99.7% to ensure 100% of the planning target volume (PTV) received 95% of the prescription dose. Plans were evaluated for PTV conformity, homogeneity, number of monitor units, number of control points, and overall plan acceptability. Treatment delivery time, patient-specific quality assurance procedures, and the impact on clinical workflow were also assessed. We found that for complex-shaped target volumes (small central volumes with extending arms to cover nodal regions), the use of 2 arc-per-beam (2APB) parameter setting achieved significantly lower average dose-volume histogram values for the rectum V20 (p = 0.0012) and bladder V30 (p = 0.0036) while meeting the high dose target constraints. For simple PTV shapes, we found reduced monitor units (13.47%, p = 0.0009) and control points (8.77%, p = 0.0004) using 2APB planning. In addition, we found a beam delivery time reduction of approximately 25%. In summary, the dosimetric benefit, although moderate, was improved over a 1APB setting for complex PTV, and equivalent in other cases. The overall reduced delivery time suggests that the use of mulitple arcs per beam could lead to reduced patient-on-table time, increased clinical throughput, and reduced medical physics quality assurance effort.

40. Evaluation of the Incise2™ multileaf collimator for stereotactic radiotherapy on Cyberknife®

Introduction The CyberKnife® (Accuray) is a stereotactic robotic system using historically circular collimators to define the beam apertures. A new multileaf collimator (MLC) is now available on the Cyberknife® M6 version. The purpose of this study was to evaluate the quality of treatment plans using MLC compared to treatment plans using a variable circular aperture collimator IRIS™ for radiosurgery (SRS) and stereotactic body radiotherapy (SBRT). Methods The study was performed on a Cyberknife® M6™ v10.6. A total of 17 cases including cranial, liver, spinal and prostatic cases were investigated. For each case, two treatment plans were generated with Multiplan® v5.3 treatment planning system: one plan using the Incise2™ MLC associated with the Finite Size Pencil Beam (FSPB) dose calculation algorithm and one using the IRIS™ collimator associated with Ray Tracing or Monte Carlo dose calculation algorithm. The dose was prescribed near the 80% isodose level relative to max dose. Plans were normalized to have the same target coverage at ±0.5%. The quality of the MLC and IRIS™ treatment plans was assessed using two criteria: - Dose distribution by reporting the conformal index (COIN), Homogeneity Index (HI) and dose gradient index (GI). - Efficiency by reporting the number of delivered monitor units (MUs) and the treatment time. To evaluate the accuracy of dose calculation algorithm within heterogeneity, a typical lung treatment plan for each collimator was created on a QUASAR™ Respiratory phantom (Modus Medical Inc) with a lung target insert. Calculated planar dose was compared with measurements by radiochromic EBT3 films (Ashland). The analysis was done using gamma analysis 3% (local) / 2 mm (threshold: 30% of the max dose) Results Results are summarized in Table 1. Dose conformality and homogeneity were equivalent for both collimator systems (mean differences less than 3%) except for targets with volumes smaller than 2 cm3 for which dose conformality was better of 14% on average with the IRIS collimator. The dose gradient index was improved by 10.5% on average with the MLC and up to 26% on average for volume larger than 100 cm3. The number of MUs decreased by 25% on average (up to 70%) and the treatment times were systematically reduced with a mean reduction of 28% (max 54%) with the MLC. The comparison between calculated and measured dose in lung phantom showed a gamma passing rate of 51.6 %, 45.5 % and 98.7% for FSPB, Ray Tracing and Monte Carlo respectively. Conclusion The MLC Incise2™ on Cyberknife® allows a significant reduction of MUs and treatment time compared to circular collimators while maintaining a high degree of conformality and a steep dose gradient. For treatment of target volumes smaller than 2 cm3, circular collimators should be still used. The use of MLC for SBRT of lung targets should not be recommended currently due to the absence of type B dose calculation algorithm.

SU-F-T-591: SBRT Treatment of Multiple Extracranial Oligometastases Using a Single-Isocenter with Distinct Optimizations (SIDO)

Purpose: A new development in linac-based intracranial radiosurgery is treatment of multiple targets using single isocenter VMAT, which dramatically reduces treatment time while maintaining high conformality and dose gradient. Our purpose is to translate this technique to extracranial SBRT of oligometastases and address additional challenges such as interplay from motion and setup uncertainties. Methods: We propose SIDO (Single Isocenter with Distinct Optimizations) planning in which all VMAT arcs share an isocenter but each arc treats only one target. Setup uncertainties from rotations and deformations are mitigated by applying a couch translation between VMAT arcs, while interplay is minimized by using dynamic conformal arcs (DCAs) as the starting point for VMAT optimization. We compared SIDO to single (VMAT) and dual (VMAT & DCA) isocenter plans for phantom and patient (N=2) cases. Dose statistics included conformity index (CI), gradient index (GI), and modulation factor (MLC opening & total MU). Finally, we determined likelihood of needing a translational shift between SIDO arcs to correct rotational uncertainties using CBCTs from eleven previous SBRT cases. Results: For phantoms with target separations of 5–15cm, CI was 0.87±0.02, 0.89±0.05, and 0.91±0.02, for SIDO, single, and dual-isocenter VMAT respectively. GI was 6.83±1.0, 7.45±1.0 and 5.94±0.7 respectively. SIDO conformity did not trend with increasing distance between PTVs, while gradient decreased for all planning techniques. Using DCAs as the starting point of VMAT optimization decreased modulation, with a 39.4% reduction in monitor units. SIDO had 4.9% and 39% less MU than single and dual-isocenter VMAT respectively. A translational shift between SIDO arcs would be required in 10–28% of cases due to rotational uncertainties to stay within a 5mm margin, for targets separated by ≥10cm. Conclusion: SIDO for extracranial oligometastases has comparable dosimetry to traditional VMAT with low modulation similar to DCAs. Future work will quantify decrease in dosimetric interplay.