Non-coplanar Beams Research Articles

Margin derivation from intrafraction patient motion of multi-target, single isocentre, brain stereotactic radiosurgery treatments.

Brain metastases are the most common intracranial malignancy and remain a substantial source of morbidity and mortality in cancer patients. Linear accelerator based stereotactic radiosurgery (SRS) is widely used and is frequently delivered by hypo-fractionnated volumetric modulated arc therapy using non-coplanar beams, where geometric accuracy and planning margins are a majorconcern. To give a practical analysis of intrafraction patient motion for multi-target, single isocentre, brain SRS treatments and to derive adapted GTV-to-PTV margins. Data of 154 lesions, spread over 85 fractions from 56 patients treated in our institution with the Varian HyperArc SRS solution was processed. Intrafraction patient motion were recorded using an Optical Surface Monitoring System during irradiation. The present study focuses on small tumor volumes, roughly equal or inferior to 1.5 , and frameless mask-based immobilization. For each treatment session, a tumor displacement vector matrix was calculated from the patient drifts as a function of time. Data were combined together into a representative treatment scenario and the dosimetric impact of GTV displacement was calculated. Recommended margins due to patient motion range between 0.3 and 1mm, depending on the distance tumor-isocentre, and the desired GTV edge dose coverage. Those values should be added quadratically with other sources of uncertainty, such as mechanical isocentre and kV-MVmisalignment. Thorough analysis of intrafraction patient motion was performed, the dosimetric impact was calculated for different scenarios, and adequate GTV-to-PTV margins were derived. These values vary according to the distance isocentre-to-GTV, as well as the desired dose coverage, and should be chosenadequately.

EP.08C.02 Impact of Non-Coplanar Radiation Beam Geometry on Effective Dose to Immune Cells (EDIC) In Stage III NSCLC

EP.08C.02 Impact of Non-Coplanar Radiation Beam Geometry on Effective Dose to Immune Cells (EDIC) In Stage III NSCLC

New findings on clinical experience on surface-guided radiotherapy for frameless non-coplanar stereotactic radiosurgery treatments.

The aim of this study was to assess the accuracy of a surface-guided radiotherapy (SGRT) system for setup and intra-fraction motion control in frameless non-coplanar stereotactic radiosurgery (fSRS) using actual patient data immobilized with two different types of open-faced masks and employing a novel SGRT systems settings. Forty-four SRS patients were immobilized with two types of open-faced masks. Sixty lesions were treated, involving the analysis of 68 cone-beam scans (CBCT), 157 megavoltage (MV) images, and 521 SGRT monitoring sessions. The average SGRT translations/rotations and 3D vectors (MAG-Trasl and MAG-Rot) were compared with CBCT or antero-posterior MV images for 0° table or non-coplanar beams, respectively. The intrafraction control was evaluated based on the average shifts obtained from each monitoring session. To assess the association between the SGRT system and the CBCT, the two types of masks and the 3D vectors, a generalized estimating equations (GEE) regression analysis was performed. The Wilcoxon singed-rank test for paired samples was performed to detect differences in couch rotation with longitudinal (LNG) and lateral (LAT) translations and/or yaw. The average SGRT corrections were smaller than those detected by CBCT (≤0.5mm and 0.1°), with largest differences in LNG and yaw. The GEE analysis indicated that the average MAG-Trasl, obtained by the SGRT system, was not statistically different (p=0.09) for both mask types, while, the MAG-Rot was different (p=0.01). For non-coplanar beams, the Wilcoxon singed-rank test demonstrated no significantly differences for the corrections (LNG, LAT, and yaw) for any table rotation except for LNG corrections at 65° (p=0.04) and 75° (p=0.03) table angle position; LAT shifts at 65° (p=0.03) and 270° (p<0.001) table angle position, and yaw rotation at 30° (p=0.02) table angle position. The average intrafraction motion was<0.1mm and 0.1° for any table angle. The SGRT system used, along with the novel workflow performed, can achieve the setup and intra-fraction motion control accuracy required to perform non-coplanar fSRS treatments. Both masks ensure the accuracy required for fSRS while providing a suitable surface for monitoring.

Reducing treatment time for robotic radiosurgery by considering path efficiency during node selection.

Robotic radiosurgery treatments allow for precise non-coplanar beam delivery by utilizing a robot equipped with a linac that traverses through a set of predetermined nodes. High quality treatment plans can be produced but treatment times can grow large, with one substantial component being the robot traversal time. The aim of this study is to reduce the treatment time for robotic radiosurgery treatments by introducing algorithms for reducing the robot traversal time. The algorithms are integrated into a commercial treatment planning system. First, an optimization framework for robotic radiosurgery planning is detailed, including a heuristic optimization method for node selection. Second, two methods aimed at reducing the traversal time are introduced. One utilizes a centrality measure focusing on the structure of the node network, while the other is based on the direct computation of traversal times during optimization. A comparison between plans with and without the time-reducing algorithms is made for three brain cases and one liver case with basis in treatment time, plan quality, monitor units, and network structure of the selectednodes. Large decreases in traversal times are obtained by the traversal time reducing algorithms, with reductions of up to 49 % in the brain cases and 31 % in the liver case. The resulting reductions in treatment times are up to 30 % and 13 %, respectively. Small differences in plan quality are observed, with similar dose-volume histograms, dose distributions, and conformity/gradientindices. The total treatment time of the robotic radiosurgery treatments can be reduced by selecting nodes with more efficient robot traversal paths, while maintaining planquality.

Treatment plan quality for stereotactic treatment of multiple cranial metastases: Comparison of C-arm and O-ring treatment platforms

C-arm linacs have been used widely to treat multiple cranial metastases using stereotactic radiosurgery (SRS). A new generation of O-ring linacs offer several workflow advantages when compared to C-arm platforms. However, O-ring linacs are not able to employ couch rotations for noncoplanar beams used in SRS treatments. This study was conducted in order to simulate further possible developments of O-ring treatment units by assessing their geometrical efficiency. In this work we compare the plan quality for C-arm versus an O-ring platform including metrics that are relevant to SRS for multiple metastases. The comparison is conducted by incorporating tilted arcs on the O-ring platform therefore introducing noncoplanarity.Total 40 patients previously treated for SRS with 20 Gy single fraction were replanned for C-arm with a standard noncoplanar 5-arc arrangement and O-ring with both coplanar and noncoplanar beams. For the O-ring plans, we considered a default 3-arc coplanar arrangement, as well as 3- and 5-arc arrangements with arcs tipped up to 10 degrees from the axial plane. Target coverage, organ-at-risk (OAR) doses, monitor unit (MU) efficiency, conformity and gradient indices were assessed for all plans.For most metrics the O-ring geometries, even the coplanar arrangement, produced statistically comparable results to the C-arm. Small but significant differences were found for the 3 arc O-ring for PTV: D90%, D2% and MU/Gy and for the 5 arc O-ring at D2% when both were compared to the C-arm. Cumulative dose volume histograms (DVHs) for normal brain showed a cross-over between the C-arm and coplanar O-ring geometry at a low dose (2.3 ± 1.8 Gy), with O-ring associated with higher volumes above this cross-over dose. However, no statistical difference was seen in the brainstem, optic pathway and volumes of normal brain receiving 12 Gy or 20 Gy.This study has found that O-ring geometry linacs can produce SRS plans of comparable quality to those from a C-arm for multiple cranial metastases.

Non-coplanar Arc-Involved Beam Arrangement With Sufficient Arc Rotations Is Suitable for Volumetric-Modulated Arc-Based Radiosurgery for Single Brain Metastasis

Non-coplanar Arc-Involved Beam Arrangement With Sufficient Arc Rotations Is Suitable for Volumetric-Modulated Arc-Based Radiosurgery for Single Brain Metastasis

Quantification of Dosimetry Improvement With or Without Patient Surface Guidance

PurposeNon-coplanar beams and arcs are routinely used to improve dosimetry for intracranial cases but their application for extra-cranial cases has been hampered by the risk of collision. This has led to conservative beam selection whose impact on plan dosimetry has not been previously studied. Methods and materialA full-body 3D patient surface was acquired using optical cameras for a single lung patient at the time of CT simulation. Eight SBRT plans were created for the patient, with varying degrees of non-coplanarity and deliverability. The plans included VMAT and IMRT plans ranging from simple, coplanar arcs to multiple non-coplanar arcs and IMRT beams. There was a total of 70 fields created across the 8 plans, of which 21 fields were undeliverable with a 5cm buffer. OAR metrics including R50, Dmax 2 cm from the PTV, lung V20 and chest wall V30 were evaluated. Five expert SBRT dosimetrists from five institutions evaluated field deliverability, with or without the guidance of the clearance map. ResultsIn the dosimetry evaluation, a clear trend in increasing dosimetric compactness and OAR sparing is observed with increasing plan non-coplanarity. R50, Dmax 2cm, lung V20, and chest wall V30 decreased 41%, 39%, 43%, 57%, respectively, from plan 1 (two coplanar partial arcs) to plan 8 (19 non-coplanar IMRT beams). In the observer tests, the expert dosimetrists’ ability to accurately discern beam deliverability due to collision significantly increases with the clearance map. The errors in predicting colliding fields were eliminated using the whole-body surface and clearance map, and the user was able to select fields based on plan quality and patient comfort instead of being overly conservative. ConclusionThe study shows that incorporating a personalized, whole-body clearance map in the treatment planning workflow can facilitate the adoption of non-coplanar beams or arcs that benefit the SBRT plan dosimetry.

Technical Notes: Robustness of three-dimensional treatment and imaging isocenter testing using a new gel dosimeter and kilovoltage CBCT.

Coincidence of the treatment and imaging isocenter coordinates is required to safely perform small-margin treatments, such as stereotactic radiosurgery of multiple brain metastases. A comprehensive and direct methodology for verifying concordance of kilovoltage cone-beam computed tomography (kV-CBCT) and treatment coordinates using an x-ray CT-based polymer gel dosimeter (dGEL) and onboard kV-CBCT was previously reported. Using this methodology, we tested the ability of a new commercially available x-ray CT-based polymer dGEL with a rapid response to provide efficient quality assurance (QA). The aim of this study was to evaluate the robustness of the three-dimensional geometric QA methodology using dGEL. The dGEL were commercially manufactured. The prescribed dose for each field was determined by visually identifying the 5, 10, and 20Gy isodose lines. A linear accelerator was used to irradiate the gels with seven non-coplanar beams. An in-house analysis program was used to identify the beam axes and treatment isocenter in kV-CBCT coordinates by processing the pre- and post-irradiation CBCT images. The impact of the radiation dose on the test reproducibility was examined, and the detectability of an intentional geometric error was assessed. The treatment isocenter was within 0.4mm of the imaging isocenter for all radiation doses. The residual error of the test with the intentional error was within 0.2mm. The analysis and image quality variations for a single dGEL introduced displacement errors less than 0.3mm. The test assessed the coincidence of treatment and kV-CBCT isocenter coordinates and detected errors with high robustness. Even for a 10Gy dose, the test yielded results comparable with those obtained using higher radiation doses owing to the rapid response of the dGEL dosimeter.

Comparison between Volumetric Modulated arc Therapy based Coplanar and Noncoplanar Planning for Stereotactic Body Radiation Therapy of Liver

The study aims to investigate potential dosimetric benefits between non-coplanar and coplanar beam arrangements of Volumetric-Modulated Arc Therapy (VMAT) plans for liver stereotactic body radiotherapy (SBRT). Thirteen patients who had undergone liver SBRT treatment in our department were chosen retrospectively for the study. Two sets of SBRT-VMAT plans namely, non-coplanar (NC-VMAT) and Coplanar (C-VMAT) were generated in Monaco(v5.11) planning system for Elekta Versa HD Linac using unflatten 6MV photon. The NC-VMAT plans were created by two/three non-coplanar partial arcs with couch rotation of ±150 and had an arc span of 1300 to 1600 whereas the C-VMAT plans consisted of a full arc. Both plans were compared by statistically analyzing various dosimetric and technical parameters. There is no statistically significant difference observed between the C-VMAT and NC-VMAT plans for planning target volume (PTV) coverage. However, the spine dose (D1cc) was much less in the NC-VMAT plan compared to the C-VMAT plan, with mean values of 6.127 ± 3.08Gy and 9.058 ± 4.76Gy, respectively (p-value=0.002). The low dose spillage to the healthy tissue was compared by the volume receiving 5Gy (V5Gy) and 10Gy (V10Gy). V5Gy of the NC-VMAT plan was 2399.23±1870.76cc while that of C-VMAT plans was 2835.36±1930.20cc with the p-value <0.001. Moreover, the monitor units(MU) were less with NC-VMAT than with C-VMAT SBRT plans (p=0.015). The plan quality of NC-VMAT plans was favorable compared to C-VMAT plans for liver SBRT especially in reducing spine dose, low dose spillage to healthy tissue, and MU.

Dosimetric comparison of glioblastoma radiotherapy treatment plans on a low-field MRI-guided linear accelerator compared to conventional C-arm linear accelerator

Magnetic resonance imaging (MRI)-guided radiation therapy has proven to provide many benefits such as real-time tracking, dose escalation, and the ability to perform online adaptive therapy. The objective of this study is to compare curative treatment plans for glioblastoma tumors on a low-field MR-guided linac vs a C-arm linac and evaluate if they are comparable in terms of coverage, organ at risk sparing, delivery time, and deliverability. This is a retrospective study that consisted of 15 previously treated patients who received radiation therapy for glioblastoma on a C-arm linac. The CT simulation data used for the original clinical plans was imported into the MR-linac treatment planning system (TPS) and utilized for MR-linac plan generation. The plans were evaluated utilizing the dose volumetric histogram (DVH) and isodose lines, then compared in terms of plan quality consisting of PTV coverage, dose distributions, and OAR constraints. Statistical analysis was performed to compare differences between the two planning techniques. QA was performed on a subset of the plans to verify deliverability. Plans generated on the MR-linac were more heterogenous compared to C-arm linac plans. A statistically significant difference was found in the homogeneity index (HI) and the PTV V105% volume (cc) values. The volume of the normal brain receiving 30 Gy also showed a statistically significant (p = 0.0479) difference, where on average an additional 41.5 cc's of the normal brain tissue received 30 Gy in the MR-linac plans. The maximum dose to the normal brain structure also increased in the MR-linac plans on average by 2.6 Gy (p = 0.0002). Similarly, the average maximum dose to the scalp 4 mm structure was 6.5 Gy higher in the MR-linac plans compared to C-arm linac plans (p = 0.0103). The total MU's were higher in the MR-linac plans compared to the C-arm linac plans (p = 0.0015). Both MR-linac and C-arm linac plans met constraints for PTV coverage and OAR sparing, were deliverable, and resulted to be clinically acceptable. However, our study showed that MR-linac plans were not as conformal or as homogenous as C-arm linac plans utilizing noncoplanar beams.

Functional lung avoidance in radiotherapy using optimisation of biologically effective dose with non-coplanar beam orientations

Background and purposeIn external beam radiotherapy for non-small cell lung cancer, dose to functioning lung should be minimised to reduce lung morbidity. This study aimed to develop a method for avoiding beam delivery through functional lung and to quantify the possible benefit to the patients. Materials and methodsTwelve patients that were treated as part of a clinical trial of single photon emission computed tomography (SPECT) functional lung avoidance were retrospectively studied. During treatment planning, the dose in the lung was weighted by the relative intensity of the functional image. A single conformal beam was scanned systematically around the planning target volume to find optimum orientations and the resulting map of functional dose variation with gantry and couch angle was used to select five non-coplanar intensity-modulated beams, taking into account directions prohibited due to collision risk. Expected reduction in pneumonitis risk was calculated using a logistic model. ResultsThe volume of lung irradiated to a functionally weighted dose of 5 Gy was 11.8 % (range 3.5 %–22.0 %) for functional plans, versus 20.9 % (range 4.9 %–33.3 %) for conventional plans (p = 0.002). Mean functionally weighted dose was 4.1 Gy (range 1.3 Gy-7.2 Gy) for functional plans, versus 4.5 Gy (range 1.5 Gy-8.3 Gy) for conventional plans (p = 0.002). Predicted pneumonitis risk was reduced by 4.3 % (range 0.4 %-15.6 %) (p = 0.002). ConclusionsBy seeking the optimum non-coplanar beam orientations, it is possible to reduce dose/volume lung parameters by 10% or more, consistently in all patients, regardless of the pattern of lung perfusion. A prediction model indicates that this will improve radiation-associated lung injury.

Five-Fraction Proton Therapy for Chordomas and Chondrosarcomas of the Skull Base: Preliminary Results of a Prospective Series

To describe the first series of patients with clival chordomas and chondrosarcomas treated with extremely hypofractionated proton therapy in a single institution with focus on acute tolerance and dosimetric parameters. A total of 11 consecutive patients with biopsy proven chordomas and chondrosarcomas were prospectively included in a five-fraction proton therapy protocol between June 2022 and January 2023. The inclusion criteria for this protocol were: Age > 18 yo., Karnofsky Performance Status (KPS) ≥ 70%, absence of metastases, no previous radiation courses, clinical target volume (CTV) up to 50 cc and CTV location relative to organs at risk that allowed compliance with the necessary dose restrictions for hypofractionated treatments in 5 fractions, according to the international guidelines. Treatment was delivered with a Proteus®ONE cyclotron using Pencil Beam Scanning (PBS) Intensity-Modulated Proton Therapy (IMPT). Patient setup was performed with CBCT imaging at isocenter and X-Ray obliques, allowing a robust planning with 1 mm setup uncertainty and 3.5% range uncertainty. IMPT plans were obtained with RayStation employing 4 to 6 non-coplanar beams. In 7 patients' apertures were used in 2 of the beams, to reduce lateral penumbra and to optimize dose gradient. A total of 11 patients (7 males and 5 females) with an age range between 29 and 79 yo, were included. 6 patients with classic chordomas and 5 patients with grade I-II chondrosarcomas were treated with a total dose of 37.5 GyRBE and 35 GyRBE, respectively, in 5 daily fractions. All the patients had received previous surgery with complete resection in 2 patients, subtotal resection in 7 patients and partial resection in 2 patients. Most common symptoms at diagnosis were diplopia and headache and baseline median KPS after surgery was 90% (70 - 100%). Median CTV was 30.62 cc (10.56 - 47.47 cc). Median CTV coverage was V95% = D95.5%. Median maximal dose for the brainstem was 26.5 GyRBE (30 - 24.7 GyRBE) and for the optic pathway was 20.7 GyRBE (8.9 - 23.6 GyRBE). Median follow-up was 3 months (8 - 1 months). Acute toxicity during follow-up was mild, with grade I - II headache (64%), grade I asthenia (45%), grade I nausea (27%), grade I dysphagia (18%) and reversible alopecia (45%). Only one patient showed nystagmus and mild loss of strength in left lower limb related with an ischemic brainstem lesion, in a low dose region, not clearly radiation related. 8 patients had a 3-month follow-up MRI with no signs of progression. Five-fraction proton therapy for the treatment of clival chordomas and chondrosarcomas is dosimetrically feasible and well tolerated for selected patients. Proton therapy remains a limited resource, consequently, reducing treatment time can have significant financial and psychosocial implications. Longer follow up is needed to validate these results.

In-vivo quality assurance of dynamic tumor tracking (DTT) for liver SABR using EPID images.

To assess dynamic tumor tracking (DTT) target localization uncertainty for in-vivo marker-based stereotactic ablative radiotherapy (SABR) treatments of the liver using electronic-portal-imaging-device (EPID) images. The Planning Target Volume (PTV) margin contribution for DTT is estimated. Phantom and patient EPID images were acquired during non-coplanar 3DCRT-DTT delivered on a Vero4DRT linac. A chain-code algorithm was applied to detect Multileaf Collimator (MLC)-defined radiation field edges. Gold-seed markers were detected using a connected neighbor algorithm. For each EPID image, the absolute differences between the measured center-of-mass (COM) of the markers relative to the aperture-center (Tracking Error, (ET )) was reported in pan, tilt, and 2D-vector directions at the isocenter-plane. An acrylic cube phantom implanted with gold-seed markers was irradiated with non-coplanar 3DCRT-DTT beams and EPID images collected. Patient Study: Eight liver SABR patients were treated with non-coplanar 3DCRT-DTT beams. All patients had three to four implanted gold-markers. In-vivo EPID images were analyzed. Phantom Study: On the 125 EPID images collected, 100% of the markers were identified. The average±SD of ET were 0.24±0.21, 0.47±0.38, and 0.58±0.37mm in pan, tilt and 2D directions, respectively. Patient Study: Of the 1430 EPID patient images acquired, 78% had detectable markers. Over all patients, the average±SD of ET was 0.33±0.41mm in pan, 0.63±0.75mm in tilt and 0.77±0.80mm in 2D directions The random 2D-error, σ, for all patients was 0.79mm and the systematic 2D-error, Σ, was 0.20mm. Using the Van Herk margin formula 1.1mm planning target margin can represent the marker based DTT uncertainty. Marker-based DTT uncertainty can be evaluated in-vivo on a field-by-field basis using EPID images. This information can contribute to PTV margin calculations for DTT.

Clinical Feasibility of Using Single-isocentre Non-coplanar Volumetric Modulated Arc Therapy Combined with Non-coplanar Cone Beam Computed Tomography in Hypofractionated Stereotactic Radiotherapy for Five or Fewer Multiple Intracranial Metastases

AimsTo evaluate the clinical feasibility of single-isocentre non-coplanar volumetric modulated arc therapy (NC-VMAT) with non-coplanar cone beam computed tomography (NC-CBCT) in hypofractionated stereotactic radiotherapy (HSRT) for five or fewer multiple brain metastases. Materials and methodsTen patients with multiple brain metastases who underwent single-isocentre NC-VMAT HSRT with limited couch rotations (within ±45°) and NC-CBCT with a limited scanning range (150–200°) were included in the current analysis. Conventional single-isocentre coplanar VMAT (C-VMAT) plans were generated and compared with NC-VMAT plans. The intracranial response and toxicities of single-isocentre NC-VMAT HSRT were also evaluated. ResultsCompared with C-VMAT, NC-VMAT generated better target conformity (P < 0.05), a lower gradient index (P < 0.05) and better normal brain tissue sparing, especially for volume ≥12 Gy, with a median reduction of 12.65 cm3. For 45° couch rotation, NC-CBCT produced sufficient image quality to differentiate bony anatomy, even with a 150° scanning range, which could be successfully used for patient set-up correction. After NC-CBCT, 57.1% of the measured non-coplanar set-up errors exceeded the threshold value. The median gamma passing rate of NC-VMAT was higher than that of C-VMAT plans (P < 0.05). The non-coplanar beam of NC-VMAT with NC-CBCT corrections exhibited superior gamma passing rate to that without NC-CBCT corrections. The intracranial objective response rate and disease control rate for all patients were 80% (8/10) and 100% (10/10), respectively, and the most common toxicities were headache (20%) and dizziness (20%). ConclusionNC-VMAT with limited couch rotation (within ±45°) combined with NC-CBCT with a limited scanning range (150–200°) markedly improves the plan quality and set-up accuracy in single-isocentre multiple-target HSRT.

Operations research contribution to totally automated radiotherapy treatment planning: A noncoplanar beam angle and fluence map optimization engine based on optimization models and algorithms

The planning of radiotherapy treatments is based on the use of mathematical optimization models and algorithms. A treatment plan will correspond to an admissible solution to a problem that is defined by the medical prescription. The medical prescription defines the constraints that have to be satisfied, and that are patient dependent. To find a treatment plan complying with all the defined constraints, an objective function is built, having a set of parameters that can be tuned. In the clinical practice, the objective function parameters are tuned through a trial-and-error procedure. One common way of defining this objective function is to consider as parameters weights that are related with the importance of the corresponding structures of interest (volumes to treat and organs to spare), as well as upper and lower bounds that are related with the constraints defined by the medical prescription. Some treatment options, like the set of irradiation directions (beam angles), are usually defined beforehand by the planner, considering previous experiences with similar cases. This trial-and-error process is lengthy, since it can take up to several hours to calculate an admissible treatment plan for a single patient. There have been some research efforts to automate the treatment planning procedure, releasing the planner for other important tasks in the radiotherapy treatment workflow and guaranteeing the consistent calculation of high-quality plans. In this work derivative-free optimization algorithms are integrated with fuzzy inference systems that automatically tune the objective function parameters so that an admissible solution is found. This fully automated approach was tested and assessed considering six head-and-neck cancer cases already treated at the Portuguese Institute of Oncology at Coimbra (IPOC). For the clinical cases tested, comparisons between different treatment plans clearly favor the proposed approach. For a similar tumor coverage, it was possible to improve the sparing of the spinal cord, brainstem and parotids. Automating radiotherapy treatment planning can contribute to improved treatment plans in a consistent way.

Effect of angular dependence for small-field dosimetry using seven different detectors.

Small-field dosimetry is challenging for radiotherapy dosimetry because of the loss of lateral charged equilibrium, partial occlusion of the primary photon source by the collimating devices, perturbation effects caused by the detector materials and their design, and the detector size relative to the radiation field size, which leads to a volume averaging effect. Therefore, a suitable tool for small-field dosimetry requires high spatial resolution, tissue equivalence, angular independence, and energy and dose rate independence to achieve sufficient accuracy. Recently, with the increasing use of combinations of coplanar and non-coplanar beams for small-field dosimetry, there is a need to clarify angular dependence for dosimetry where the detector is oriented at various angles to the incident beam. However, the effect of angular dependence on small-field dosimetry with coplanar and non-coplanar beams has not been fully clarified. This study clarified the effect of angular dependence on small-field dosimetry with coplanar and non-coplanar beams using various detectors. Seven different detectors were used: CC01, RAZOR, RAZOR Nano, Pinpoint 3D, stereotactic field diode (SFD), microSilicon, and microDiamond. All measurements were taken using a TrueBeam STx with 6MV and 10MV flattening filter-free (FFF) energies using a water-equivalent spherical phantom with a source-to-axis distance of 100cm. The detector was inserted in a perpendicular orientation, and the gantry was rotated at 15° increments from the incidence beam angle. A multi-leaf collimator (MLC) with four field sizes of 0.5 × 0.5, 1 × 1, 2 × 2, and 3 × 3cm2 , and four couch angles from 0°, 30°, 60°, and 90° (coplanar and non-coplanar) were adopted. The angular dependence response (AR) was defined as the ratio of the detector response at a given irradiation gantry angle normalized to the detector response at 0°. The maximum AR differences were calculated between the maximum and minimum AR values for each detector, field size, energy, and couch angle. The maximum AR difference for the coplanar beam was within 3.3% for all conditions, excluding the maximum AR differences in 0.5 × 0.5cm2 field for CC01 and RAZOR. The maximum AR difference for non-coplanar beams was within 2.5% for fields larger than 1 × 1cm2 , excluding the maximum AR differences for RAZOR Nano, SFD, and microSilicon. The Pinpoint 3D demonstrated stable AR tendencies compared to other detectors. The maximum difference was within 2.0%, except for the 0.5 × 0.5cm2 field and couch angle at 90°. The tendencies of AR values for each detector were similar when using different energies. This study clarified the inherent angular dependence of seven detectors that were suitable for small-field dosimetry. The Pinpoint 3D chamber had the smallest angular dependence of all detectors for the coplanar and non-coplanar beams. The findings of this study can contribute to the calculation of the AR correction factor, and it may be possible to adapt detectors with a large angular dependence on coplanar and non-coplanar beams. However, note that the gantry sag and detector-specific uncertainties increase as the field size decreases.

Dosimetric Comparision of Coplanar versus Noncoplanar Volumetric Modulated Arc Therapy for Treatment of Bilateral Breast Cancers.

The purpose of this study was to compare the dosimetric parameters of volumetric modulated arc therapy (VMAT) treatment plans using coplanar and noncoplanar beams in patients with bilateral breast cancer/s (BBCs) in terms of organ at risk sparing and target volume coverage. The hypothesis was to test whether VMAT with noncoplanar beams can result in lesser dose delivery to critical organs such as heart and lung, which will result in lesser overall toxicity. Data of nine BBC cases treated at our hospital were retrieved. Computed tomography simulation data of these cases was used to generate noncoplanar VMAT plans and the parameters were compared with standard VMAT coplanar plans. Contouring was done using radiation therapy oncology group guidelines. Forty-five Gray in 25 fractions was planned followed by 10 Gy in five fractions boost in breast conservation cases. No significant difference in planning target volume (PTV) coverage was found for the right breast/chestwall (P = 0.940), left breast/chestwall (P = 0.872), and in the total PTV (P = 0.929). Noncoplanar beams resulted in better cardiac sparing in terms of Dmean heart. The difference in mean dose was >1 Gy (8.80 ± 0.28 - 7.28 ± 0.33, P < 0.001). The Dmean, V20 and V30 values for total lung slightly favor noncoplanar beams, although there was no statistically significant difference. The average monitor units (MUs) were similar for coplanar plans (1515 MU) and noncoplanar plans (1455 MU), but the overall treatment time was higher in noncoplanar plans due to more complex setup and beam arrangement. For noncoplanar VMAT plans, the mean conformity index was slightly better although the homogeneity indices were similar. VMAT plans with noncoplanar beam arrangements had significant dosimetric advantages in terms of sparing of critical organs, that is Dmean of heart doses with almost equivalent lung doses and equally good target coverage. Larger studies with clinical implications need to be considered to validate this data.

Applying mixed-integer linear programming to the non-coplanar beam angle optimization of intensity-modulated radiotherapy for liver cancer.

Currently, intensity-modulated radiation therapy (IMRT) is commonly used in radiotherapy clinics. However, designing a treatment plan with multiple beam angles depends on the experience of human planners, and is mostly achieved using a trial-and-error approach. It is preferrable but challenging to solve this issue automatically and mathematically using an optimization approach. The goal of this study is to develop a mixed-integer linear programming (MILP) approach for the beam angle optimization (BAO) of non-coplanar IMRT for liver cancer. MILP models for the BAO of both coplanar and non-coplanar IMRT treatment plans were developed. The beam angles of the IMRT plans were first selected by the MILP model built using mathematical optimization software. Next, the IMRT plans with the selected beam angles was created in a commercial treatment planning system. Finally, the fluence map and dose distribution of the IMRT plans were generated under pre-defined dose-volume constraints. The IMRT plans of 10 liver cancer patients previously treated at our institute were used to assessed the proposed MILP models. For each patient, both coplanar and non-coplanar IMRT plans with beam angles optimized by the MILP models were compared with the IMRT plan clinically approved by physicians. The MILP model-guided IMRT plans showed reduced doses for most of the organs at risk (OARs). Compared with the IMRT plans clinically approved by physicians, the doses for the spinal cord (28.5 vs. 36.1, P=0.001<0.05) and liver (27.6 vs. 29.1, P=0.005<0.05) decreased significantly in the IMRT plans with non-coplanar beams selected by the MILP models. The MILP model is an effective tool for the BAO in coplanar and non-coplanar IMRT treatment planning. It facilitates the automation of IMRT treatment planning for current high-precision radiotherapy.

Noncoplanar Volumetric Modulated Arc Therapy for Hepatocellular Carcinoma Based on a Cage-Like Radiotherapy System: A Simulation Study.

The incorporation of noncoplanar beam arrangements has been proposed in liver radiotherapy modalities, which can reduce the dose in normal tissues compared to coplanar techniques. Noncoplanar radiotherapy techniques for hepatocellular carcinoma treatment based on the Linac design have a limited effective arc angle to avoid collisions. To propose a novel noncoplanar volumetric modulated arc therapy technique based on a cage-like radiotherapy system and investigate its performance in hepatocellular carcinoma patients. The computed tomography was deflected 90° to meet the structure of a cage-like radiotherapy system and design the noncoplanar volumetric modulated arc therapy technique based on a cage-like radiotherapy system plan in the Pinnacle3 planning system. An noncoplanar volumetric modulated arc therapy technique based on a cage-like radiotherapy system plan was customized for each of 10 included hepatocellular carcinoma patients, with 6 dual arcs ranging from -30° to 30°. Six couch angles were set with an interval of 36° and distributed along with the longest diameter of planning target volume. The dosimetric parameters of noncoplanar volumetric modulated arc therapy technique based on a cage-like radiotherapy system plan were compared with the noncoplanar volumetric modulated arc therapy and volumetric modulated arc therapy plan. The 3 radiotherapy techniques regarding planning target volume were statistically different for D98%, D2%, conformity index, and homogeneity index with χ2 = 9.692, 14.600, 8.600, and 12.600, and P = .008, .001, .014, and .002, respectively. Further multiple comparisons revealed that noncoplanar volumetric modulated arc therapy technique based on a cage-like radiotherapy system significantly reduced the mean dose (P = .005) and V5 (P = .005) of the normal liver, the mean dose (P = .005) of the stomach, and V30 (P = .028) of the lung compared to noncoplanar volumetric modulated arc therapy. Noncoplanar volumetric modulated arc therapy technique based on a cage-like radiotherapy system significantly reduced the mean dose (P = .005) and V5 (P = .005) of the normal liver, the mean dose (P = .017) of the spinal cord, V50 (P = .043) of the duodenum, the maximum dose (P = .007) of the esophagus, and V30 (P = .047) of the whole lung compared to volumetric modulated arc therapy. The results indicate that noncoplanar volumetric modulated arc therapy technique based on a cage-like radiotherapy system protects the normal liver, stomach, and lung better than noncoplanar volumetric modulated arc therapy and protects the normal liver, spinal cord, duodenum, esophagus, and lung better than volumetric modulated arc therapy. The noncoplanar volumetric modulated arc therapy technique based on a cage-like radiotherapy system technique with the arrangement of noncoplanar arcs provided optimal dosimetric gains compared with noncoplanar volumetric modulated arc therapy and volumetric modulated arc therapy, except for the heart. Noncoplanar volumetric modulated arc therapy technique based on a cage-like radiotherapy system should be considered in more clinically challenging cases.

Feasibility study of deep learning-based markerless real-time lung tumor tracking with orthogonal X-ray projection images.

The feasibility of a deep learning-based markerless real-time tumor tracking (RTTT) method was retrospectively studied with orthogonal kV X-ray images and clinical tracking records acquired during lung cancer treatment. Ten patients with lung cancer treated with marker-implanted RTTT were included. The prescription dose was 50Gy in four fractions, using seven- to nine-port non-coplanar static beams. This corresponds to 14-18 X-ray tube angles for an orthogonal X-ray imaging system rotating with the gantry. All patients underwent 10 respiratory phases four-dimensional computed tomography. After a data augmentation approach, for each X-ray tube angle of a patient, 2250 digitally reconstructed radiograph (DRR) images with gross tumor volume (GTV) contour labeled were obtained. These images were adopted to train the patient and X-ray tube angle-specific GTV contour prediction model. During the testing, the model trained with DRR images predicted GTV contour on X-ray projection images acquired during treatment. The predicted three-dimensional (3D) positions of the GTV were calculated based on the centroids of the contours in the orthogonal images. The 3D positions of GTV determined by the marker-implanted RTTT during the treatment were considered as the ground truth. The 3D deviations between the prediction and the ground truth were calculated to evaluate the performance of the model. The median GTV volume and motion range were 7.42 (range, 1.18-25.74) cm3 and 22 (range, 11-28) mm, respectively. In total, 8993 3D position comparisons were included. The mean calculation time was 85ms per image. The overall median value of the 3D deviation was 2.27 (interquartile range: 1.66-2.95) mm. The probability of the 3D deviation smaller than 5mm was 93.6%. The evaluation results and calculation efficiency show the proposed deep learning-based markerless RTTT method may be feasible for patients with lung cancer.