Paddick Gradient Index Research Articles

Patient-specific geometrical distortion corrections of MRI images improve dosimetric planning accuracy of vestibular schwannoma treated with gamma knife stereotactic radiosurgery.

To investigate the impact of MRI patient-specific geometrical distortion (PSD) on the quality of Gamma Knife stereotactic radiosurgery (GK-SRS) plans of the vestibular schwannoma (VS) tumors. Three open access datasets including the MPI-Leipzig Mind-Brain-Body (318 patients), the slow event-related fMRI designs dataset (62 patients), and the VS dataset (242 patients) were used. We used first two datasets to train a 3D convolution network to predict the distortion map of third dataset that were then used to calculate and correct the PSD. GK-SRS plans of VS dataset were used to evaluate dose distribution of PSD-corrected MRI images. GK-SRS prescription dose of VS cases was 12Gy. Geometric and dosimetric discrepancies were assessed between the dose distributions and contours before and after the PSD corrections. Geometry indices were center of the contours, Dice coefficient (DC), Hausdorff distance (HD), and dosimetric indices were , , , and doses, target coverage (TC), Paddick's conformity index (PCI), Paddick's gradient index (GI), and homogeneity index (HI). Geometric distortions of about 1.2mm were observed at the air-tissue interfaces at the air canal and nasal cavity borders. Average center of the targets was significantly distorted along the frequency encoding direction after the PSD-correction. Average DC and HD metrics were 0.90 and 2.13mm. Average , and in Gy significantly increased after PSD correction from 16.85 to 17.25, 12.30 to 12.77, and from 8.98 to 9.92. did not significantly change after the correction. Average TC and PCI significantly increased from 0.97 to 0.98, and 0.94 to 0.96. Average GI decreased significantly from 2.24 to 2.15 after PSD correction. However, HI did not significantly change after the correction. The proposed method could predict and correct the PSD that indicates the importance of PSD correction before GK-SRS plans of the VS patients.

Evaluation of Dosimetry Metrics in Single Isocenter Multiple Targets and Single Isocenter Single Target in the Treatment of Brain Metastases

Purpose: This study compares two LINAC-based techniques for treating multiple brain lesions using quantitative evaluation of plan dosimetric indices. Material and Methods: Twenty-one patients with a total of 168 targets were selected. All plans were designed with five non-coplanar arcs in the RayStation treatment planning system (TPS). The composite dose of Multiple Isocenter Multiple Targets (MIMT) was compared to that of single isocenter multiple targets (SIMT) by evaluating conformity indices, Paddick gradient-index (PGI), V8, V12, and Delivery Time (DT).

Dosimetric Effects of Dynamic Jaw Tracking and Collimator Angle Optimization in Non-Coplanar Cranial Arc Radiotherapy.

The stereotactic treatment of single cranial targets using noncoplanar volumetric modulated arc therapy (VMAT) allows for effective dose delivery to the target, while sparing normal brain tissue. In this study, the dosimetric effect of adding dynamic jaw tracking and automatic collimator angle selection in the optimization of single target cranial VMAT plans was investigated. Twenty-two cranial targets, previously treated with VMAT without dynamic jaw tracking and automatic collimator angle optimization (CAO) were chosen for replanning. Target volumes ranged from 0.441cc to 25.863cc with doses between 18Gy and 30Gy delivered in 1 to 5 fractions. Original plans were reoptimized with automatic CAO, keeping all other objectives the same (CAO plans). Next, original plans were reoptimized with both dynamic jaw tracking and CAO (DJT plans). Original, CAO, and DJT target doses were compared using the Paddick gradient index (GI) and the Paddick inverse conformity index (ICI), while normal tissue dose was compared using the volume of the normal brain receiving 5Gy, 10Gy, and 12Gy. The normal tissue volume was normalized to target size to allow cross comparison between plans. A one-sided t-test was performed to determine whether the changes in the plan metrics were statistically significant. CAO plans had improved GIs compared to the originals (p = 0.03) with insignificant changes in other plan metrics (p > 0.20). The addition of dynamic jaw tracking in DJT plans greatly improved ICIs and normal brain metrics (p < 0.01) compared to the CAO plans with minor improvement in ICIs (p = 0.07). The combined effect of adding dynamic jaw tracking and collimator optimization led to improvements in all metrics of the DJT plans when compared to the original (p < 0.02). The addition of dynamic jaw tracking and CAO led to improvements in both target and normal tissue dose metrics for single-target noncoplanar cranial VMAT plans.

Impact of Plan Quality and Complexity Metrics on Gamma Passing Rate SIMT SRS Technique

<h3>Purpose/Objective(s)</h3> Multiple studies have reported different outcomes regarding the effect of plan complexity and quality metrics on gamma passing rate. However, there is very little information in literature regarding a single isocenter multitarget (SIMT) SRS technique. This study aims to evaluate the effect of different plan complexity metrics and quality metrics on gamma passing rate (GPR). Moreover, we aim to analyze the impact of distance to isocenter (DIS) & target size on plan quality metrics for the SIMT SRS technique. <h3>Materials/Methods</h3> 40 previously treated patient scans with 4–11 targets, an average volume of 1.2 cc and DIS range of 1.45 to 8.75 cm were used to create SIMT SRS in a treatment planning system (TPS) for a Linac using 6MV-FFF beam energy. In-house programs were developed to compute complexity metrics such as Plan averaged beam Area (PA), Plan averaged beam Irregularity (PI), Total MU, Leaf Travel (LT), mean Dose Rate variation (DR), mean Gantry Speed (GS) variation. Also, target volume, DIS, Paddick Conformity (PCI), and RTOG Conformity (RTOG_CI) indices were calculated per target & per plan. Paddick Gradient index (PGI) only was computed per plan. Patient QAs were then performed on a 4-D detector phantom using SNC software for comparison between measurements and calculated dose with objectives of 3%2mm & 10% threshold as per AAPM TG-218 recommendation. Spearman correlation was used for correlation and T-test for determining whether there are any statistically significant differences between the means of calculation per target vs per plan for PCI and RTOG_CI. <h3>Results</h3> The following results were observed: no correlation between GPR and PGI/RTOG_CI/number of targets/ target size, a positive but weak correlation between PCI & GPR (0.322, p-value = 0.023) and a negative weak correlation between DIS & GPR (-0.38, p-value = 0.01). However, a strong correlation was observed between target size & PCI/RTOG_CI/PGI (0.793, 0.719 & 0.636 respectively (p-value<0.001)), but no correlation between plan quality metrics and DIS. There was a positive weak correlation between GPR & DR/PA and a negative weak correlation between PI & GPR (0.35, 0.302 & -0.33 respectively). A moderate correlation was observed between GS & GPR (0.46, p-value= 0.0025), while no correlation was found between GPR & LT/total MU. Moreover, there was significant difference in mean PCI, RTOG_CI between per target and per plan. <h3>Conclusion</h3> GPR of SRS/SRT using single-isocenter VMAT for multiple targets is not associated with DIS, LT, total MU, and plan quality metrics. Also, DIS does not have any impact on plan quality metrics. Instead, there is a strong correlation between tumor volume & plan quality metrics, indicating volume is an important predictor for plan quality metrics. Moreover, DIS has a moderate impact on GPR, showing that a larger distance between target location and isocenter can result in lower GPR. For plan quality evaluation, calculation of PCI & RTOG_CI should be done per tumor.

The Optimal Choice of Technique for Stereotactic Radiosurgery—A LINAC-Based Dosimetric Study between DCA, DCA-SSO, DCA-SSO-VDR, and VMAT

Abstract Introduction Advanced radiation therapy delivery techniques require greater understanding of various planning sequences and methods. The aim of this study is to determine a class solution that finds the best possible technique to deliver for stereotactic radiosurgery between dynamic conformal arc (DCA) techniques using various options such as DCA, DCA + SSO (segment shape optimization), and DCA + SSO + VDR (variable dose rate) using noncoplanar beam arrangement and volumetric modulated arc therapy (VMAT) using coplanar beams. Materials and Methods In this dosimetric study, 11 brain cases were retrospectively planned for various techniques and analyzed for the Paddick conformity index (CI), Radiation Therapy Oncology Group homogeneity index (HI), Paddick gradient index (GI), treatment time in terms of monitor units (MU) and normal brain dose (V12Gy). The paired t-test was performed to know the statistical significance between the techniques. Results In terms of CI, GI, and control of the normal brain dose, the VMAT plan was superior to other techniques. But, HI was found to be better with DCA. Above all, VMAT delivered higher MU than any other technique. The p-values between DCA + SSO and DCA, DCA + SSO + VDR and DCA + SSO, and VMAT and DCA + SSO + VDR are as follows: CI: 0.0004, 0.015, and 0.03; GI: 0.03, 0.33, and 0.29; HI: 0.008, 0.04, and 0.06; V12 Gy of normal brain: 0.1, 0.01, 0.38. VMAT requires approximately 41 ± 17% more MU than DCA + SSO + VDR. Conclusion VMAT using coplanar beams is preferable among all the techniques, considering the dosimetric parameters studied. If VMAT is not available in the facility, DCA + SSO + VDR technique using non coplanar beams can be used to deliver SRS treatment.

Analysis of R50% location dependence on LINAC-based VMAT cranial stereotactic treatments.

Stereotactic radiosurgery (SRS) and stereotactic radiation therapy (SRT) techniques are used to deliver high doses per fraction to various types of intra-cranial targets. LINAC-based solutions are growing in prevalence due to recent advances in technologies such as high-definition multi-leaf collimators and volumetric arc therapy radiation delivery. A wide variety of clinical pathologies including intracranial metastases, meningioma, glioblastoma, arteriovenous malformation, acoustic neuroma, and trigeminal neuralgia have been successfully treated using SRS/SRT techniques. These lesions can be in virtually at any location within the cranium. Several publications have shown a wide dispersion of intermediate dose conformality (intermediate dose spill) indices such as the Paddick Gradient Index or R50% for lesions of a specific volume. A complete explanation of this dispersion is lacking but location has been suggested as a contributing factor. While prior studies of PTV location in SRS/SRT are retrospective in nature, we have conducted a prospective study to ascertain the potential effects of location within the cranium on plan intermediate dose conformality as measured by R50% while controlling for lesion volume, lesion shape, prescription (Rx) dose, and Rx isodose surface. Lesion volumes utilized in this study are consistent with metastatic disease presentation. Results indicate only a weak relationship between intermediate dose conformality as measured by R50% and the lesion location when considering nine different, strategically placed lesions. Close proximity to critical structures can reduce the degree of conformality, but the effect appears to be minimal. Single isocenter multiple target cases were studied in addition to single target plans. All critical structure doses observed in this study were found to be within the recommendations of AAPM Task Group report 101. Lesion location does not appear to be a significant contributing factor to the observed variation of dose conformality seen in several SRS/SRT publications.

Combined effect of dose gradient and rotational error on prescribed dose coverage for single isocenter multiple brain metastases in frameless stereotactic radiotherapy

BackgroundTo evaluate the combined effect of rotational error and dose gradient on target dose coverage in frameless stereotactic radiotherapy.MethodsThree spherical targets of different diameters (1, 1.5, and 2 cm) were drawn and placed equidistantly on the same axial brain computed tomography (CT) images. To test the different isocenter-target distances, 2.5- and 5-cm configurations were prepared. Volumetric modulated arc therapy plans were created for different dose gradients from the target, in which the dose gradients were modified using the maximum dose inside the target. To simulate the rotational error, CT images and targets were rotated in two ways by 0.5°, 1°, and 2°, in which one rotation was in the axial plane and the other was in three dimensions. The initial optimized plan parameters were copied to the rotated CT sets, and the doses were recalculated. The coverage degradation after rotation was analyzed according to the target dislocation and 12-Gy volume.ResultsA shallower dose gradient reduced the loss of target coverage under target dislocation, and the effect was clearer for small targets. For example, the coverage of the 1-cm target under 1-mm dislocation increased from 93 to 95% by increasing the Paddick gradient index from 5.0 to 7.9. At the same time, the widely accepted necrosis indicator, the 12-Gy volume, increased from 1.2 to 3.5 cm3, which remained in the tolerable range. From the differential dose volume histogram (DVH) analysis, the shallower dose gradient ensured that the dose-deficient under-covered target volume received a higher dose similar to that in the prescription.ConclusionsFor frameless stereotactic brain radiotherapy, the gradient, alongside the margin addition, can be adjusted as an ancillary parameter for small targets to increase target coverage or at least limit coverage reduction in conditions with probable positioning error.

Transition From Manual to Automated Planning and Delivery of Volumetric Modulated Arc Therapy Stereotactic Radiosurgery: Clinical, Dosimetric, and Quality Assurance Results

PurposeProperly planned single isocenter volumetric modulated arc therapy (VMAT) radiosurgery plans exhibit high quality and efficiency. We report here the largest clinical experience to date, to our knowledge, comparing manual planning with a new automated platform designed to standardize and simplify radiosurgery planning and delivery processes. MethodsWe treated 693 patients with single isocenter VMAT radiosurgical plans generated by either our conventional manual (mVMAT) or a recently implemented automated (HyperArcTM) technique. All plans targeted the gross tumor volume without margin. Radiochromic film was used for patient-specific quality assurance (PSQA). We evaluated local control and toxicity data for a subgroup of 107 patients having 377 metastatic tumors that were treated with HyperArc. ResultsThe median Radiation Therapy Oncology Group (RTOG) conformity index was 1.14 and was not different between the 2 techniques. The median Paddick gradient index was 5.42 for HyperArc versus 7.09 for mVMAT (P < .001). The median mean brain doses were 4.6% and 5.1% for HyperArc and mVMAT, respectively (P = .04). The PSQA for both techniques met clinical criteria, but 97% of the HyperArc plans satisfied the gamma tolerance limit recommended by the American Association of Physicists in Medicine Task Group No. 218, compared with 94% of the mVMAT plans (P = .02). The median treatment-planning times were not significantly different. The median treatment times were 10.5 and 11.4 minutes for HyperArc and mVMAT, respectively (P < .001). The Kaplan-Meier estimate of local control was 90.1% at 1 year. ConclusionsHyperArc produces high-quality radiosurgical plans that are at least as good as mVMAT plans created by an expert manual planner with easier planning and more efficient delivery workflow. A less experienced planner can produce very high-quality radiosurgical plans even for patients with more than 10 targets. The use of a single-isocenter technique for multiple targets with no PTV margin did not compromise clinical outcomes, and 1-year local control for treated targets remained congruent with historical series.

Accuracy of dose-volume metric calculation for small-volume radiosurgery targets.

PurposeFor stereotactic radiosurgery (SRS), accurate evaluation of dose‐volume metrics for small structures is necessary. The purpose of this study was to compare the DVH metric capabilities of five commercially available SRS DVH analysis tools (Eclipse, Elements, Raystation, MIM, and Velocity).MethodsDICOM RTdose and RTstructure set files created using MATLAB were imported and evaluated in each of the tools. Each structure set consisted of 50 randomly placed spherical targets. The dose distributions were created on a 1‐mm grid using an analytic model such that the dose‐volume metrics of the spheres were known. Structure sets were created for 3, 5, 7, 10, 15, and 20 mm diameter spheres. The reported structure volume, V100% [cc], and V50% [cc], and the RTOG conformity index and Paddick Gradient Index, were compared with the analytical values.ResultsThe average difference and range across all evaluated target sizes for the reported structure volume was − 4.73%[−33.2,0.2], 0.11%[−10.9, 9.5], −0.39%[−12.1, 7.0], −2.24%[−21.0, 1.3], and 1.15%[−15.1,0.8], for TPS‐A through TPS‐E, respectively. The average difference and range for the V100%[cc] (V20Gy[cc]) was − 0.4[−24.5,9.8], −2.73[−23.6, 1.1], −3.01[−23.6, 0.6], −3.79[−27.3, 1.3], and 0.26[−6.1,2.6] for TPS‐A through TPS‐E, respectively. For V50%[cc](V10Gy[cc]) in TPS‐A through TPS‐E the average and ranger were − 0.05[−0.8,0.4], −0.18[−1.2, 0.5], −0.44[−1.4, 0.3], −0.26[−1.8, 2.6], and 0.09[−1.4,2.7].ConclusionThis study expanded on the previously published literature to quantitatively compare the DVH analysis capabilities of software commonly used for SRS plan evaluation and provides freely available and downloadable analytically derived set of ground truth DICOM dose and structure files for the use of radiotherapy clinics. The differences between systems highlight the need for standardization and/or transparency between systems, especially when evaluating plan quality for multi‐institutional clinical trials.

Implementation and validation of an in-house geometry optimization software for SRS VMAT planning of multiple cranial metastases.

PurposeThe implementation and evaluation of an in‐house developed geometry optimization (GO) software are described. The GO script provides optimal lesion clustering, isocenter placement, and collimator angle of each arc for cranial multi‐lesion stereotactic radiosurgery (SRS) volumetric modulated arc therapy (VMAT) planning.Materials and methodsAn Eclipse‐plugin program was developed to facilitate automatic plan geometry generation for multiple metastases SRS VMAT plans. A mixed, semi‐supervised exhaustive and k‐means clustering method is used to group lesions and place isocenters. The sum of squared euclidean distance (SSED) and the boundaries of lesions’ projection from beams’ eye view are used as supervised parameters to determine the optimal isocenter numbers. The collimator angle is optimized by minimizing the sum of the MLC opening area from all gantry angles for each arc. In all, 10 clinical cases treated during 2016–2017 were compared to plan quality of GO script generated plans. Paddick gradient index (GI), conformity index (CI), and local brain volume receiving 12 Gy (local V12 Gy) around each lesion were compared.ResultFor four cases, the number of isocenters was reduced in the GO plans. For four other cases, the GO plans had the same number of isocenters as their corresponding clinical plans but with different lesion grouping. The GO plans had significantly lower GI (4.1 ± 1.0 vs 4.4 ± 0.9, P < 0.0001) and local V12 Gy (5.1 ± 4.2 vs 5.5 ± 4.3 in cm3, P < 0.0001), but not significantly different mean normal brain dose or CI. The volume of normal brain receiving ≥6 Gy was significantly lower in the GO plans. The total time to run the GO script for each case was <2 min.ConclusionThe GO software automates lesion grouping, isocenter placement, and the collimator angles for SRS VMAT planning. When tested on 10 cases, the GO script resulted in improved plan quality and shorter planning time when compared to the clinical SRS VMAT plans.

Automated Planning to Improve Linac-Based Stereotactic Radiosurgery Plan Quality in Patients with 4 up to 10 Brain Metastases

Stereotactic radiosurgery (SRS) is a promising treatment option for patients with multiple brain metastases (BM). We studied whether automated planning can improve LINAC-based SRS plan quality for multiple BM. Additionally, the use of one isocenter instead of separate isocentres for each metastasis was studied. For 12 patients with 4 up to 10 brain metastases, five non-coplanar LINAC-based SRS plans were created for 6MV photons: a manually planed dynamic conformal arc (DCA) plan with a separate isocenter for each metastasis, a dynamic IMRT plan with one isocenter, a VMAT plan with one isocenter, two DCA plans with one isocenter for 3 and 5 couch rotations. The last three plans were automatically generated. The maximum allowed gross tumor volume to planning target volume (PTV) margin was 1 mm. The prescription dose was 21 Gy or 18 Gy in a single fraction or 8.5 Gy in 3 fractions depending on the PTV volume. All plans were calculated with Monte Carlo, except the VMAT which was calculated with Collapsed Cone algorithm. The PTV coverage should be at least 98%. To assess SRS plan quality, the Paddick conformity index (CI), the Paddick gradient index (GI), the total V12Gy and V5Gy were studied and reported as MEAN±1SD. The number of monitor units (MU) and irradiation time were also compared. The mean total CI was the highest for dynamic IMRT (see table). The lowest GI was for DCA plans with the separate-isocenter approach (3.7±0.6) and automatically generated DCA plans with one isocenter, whereas the highest GI was for VMAT plans (7.0±3.0). Moreover, the GI was 4.4±0.6 and 4.2±0.6 for automatically generated DCA plans with 3 couch and 5 couch rotations, respectively. The total V12Gy of automatically generated DCA plans with one isocenter (4.7±5.6% and 4.1±4.3% for 3 and 5 couch rotations, respectively) and dynamic IMRT plans (4.4±4.5%) were comparable with the manual DCA plans (3.6±3.7%). For the total V5Gy, quite the same behaviour as for the GI was found. The number of MU was the smallest for VMAT plans, followed by automatically generated DCA and IMRT plans and much lower than the manual DCA plans. The irradiation time was the smallest for automatically planned DCA plans followed by VMAT and IMRT plans. Automatically generated LINAC-based SRS plans for multiple BM in one isocenter can make the number of MU and irradiation time smaller with a comparable plan quality to manual DCA plans with the separate-isocenter approach. Based on all compared parameters, dynamic IMRT and DCA plans with one isocenter were the best and comparable with manual DCA plans with separate isocentres for each metastasis. Moreover, we can conclude that automated DCA plans with 5 couch and 3 couch rotations were comparable.Abstract 3798; Table 1Conf IGIV12Gy [%]V5Gy [%]MUIrradiation time [s]Separate-isocenter DCA0.713.73.619146641832IMRT 1 isoc0.724.84.42675171235VMAT 1 isoc0.707.05.7374123976Multimets DCA 1 isoc 3 table rotations0.694.44.7206130820Multimets DCA 1 isoc 5 table rotations0.714.24.1185403724 Open table in a new tab

Feasibility of 5-mm vs 2.5-mm width multileaf collimator in noncoplanar volumetric modulated arc stereotactic radiotherapy for multiple brain metastases

The aim of this study was to examine the feasibility of noncoplanar volumetric modulated arc stereotactic radiotherapy (VMAT-SRT) using a 5-mm multileaf collimator (MLC) for multiple brain metastases. We identified 34 multiple-target cases (3 to 19 targets in each case) with a total of 257 of targets and constructed noncoplanar VMAT-SRT plans using 5-mm and 2.5-mm MLCs with 4-arc. The prescribed dose was 36 Gy/6 fr. Plans were evaluated using the Paddick conformity indices (PCI), Paddick gradient index (PGI), and normal brain dose (NBD, equal to the mean brain dose minus gross tumor volume). There were no significant differences in PCI (median [range]: 5 mm, 0.88 [0.78 to 0.94]; 2.5 mm, 0.89 [0.78 to 0.94]; p= 0.691), PGI (median [range]: 5 mm, 3.96 [2.21 to 6.63]; 2.5 mm, 3.96 [2.24 to 6.45]; p= 0.358), or NBD (median [range]: 5 mm, 7.5 Gy [2.5 to 12.4]; 2.5 mm, 7.5 Gy [2.5 to 12.5]; p= 0.675). The performance of the 5-mm MLC was not inferior to the 2.5-mm MLC in applications of noncoplanar VMAT-SRT for multiple brain metastases with regards to dose conformity, gradient, and NBD. This study provides the necessary background for generalizing noncoplanar VMAT-SRT approaches in treating multiple brain lesions.

Dosimetric Comparison of 6 MV Flattening Filter Free and 6 MV Stereotactic Radiosurgery Beam Using 4 mm Conical Collimator for Trigeminal Neuralgia Radiosurgery

Background: The purpose of our study was to compare the dosimetric advantages of Flattening filter free (FFF) beams for trigeminal neuralgia patients using 4 mm conical collimators over previously treated patients with 6 MV SRS beam. Materials and Methods: A retrospective study was conducted for 5 TN patients who had been previously treated at our institution using frame-based, LINAC-based stereotactic radiosurgery (SRS) on Novalis Tx using 6 MV SRS beam were replanned on 6X FFF beams on Edge Linear accelerator with same beam angles and dose constraints using 4 mm conical collimator. The total number of monitor units along with the beam on time was compared for both Edge and Novalis Tx by redelivering the plans in QA mode of LINAC to compare the delivery efficiency. Plan quality was evaluated by homogeneity index (HI) and Paddick gradient index (GI) for each plan. We also analyzed the doses to brainstem and organ at risks (OARs). Results and Discussion: A 28% beam-on time reduction was achieved using 6X FFF when compared with 6X SRS beam of Novalis Tx. A sharp dose fall off with gradient index value of 3.4 ± 0.27 for 4 mm Varian conical collimator while 4.17 ± 0.20 with BrainLab cone. Among the 5 patients treated with a 4 mm cone, average maximum brainstem dose was 10.24 Gy for Edge using 6X FFF and 14.28 Gy for Novalis Tx using 6X SRS beam. Conclusion: The use of FFF beams improves delivery efficiency and conical collimator reduces dose to OAR’s for TN radiosurgery. Further investigation is warranted with larger sample patient data.

Stereotactic radiotherapy for choroidal melanomas by means of HybridArc™ : Physics and technique of linac-based photon beam therapy.

Stereotactic radiotherapy (SRT) is suitable to treat ocular tumours. The optimal beam geometry for SRT, however, has not been defined. Here we evaluate acombination technique with dynamic conformal arcs (DCAs) and intensity-modulated static fields (IMRT), known as HybridArc™ (HA). For the first consecutive 25cases with choroidal melanomas with volumes of 0.02 to 1.18 cm3 treated with 50 Gy in five fractions, the results with respect to dose conformity, homogeneity, and dose distributions were summarised. To describe the dose distribution at the planning target volume (PTV) boundary, we defined aspatially averaged dose gradient (SADG) and compared it with Paddick's gradient index (GI). We made dosimetric comparisons between HA and other irradiation techniques. The PTVs ranged from 0.42 to 3.37 cm3. The conformity index (CI) was 1.25 ± 0.15, and the homogeneity index (HI) 0.08 ± 0.02. The SADG was (-3.5 ± 0.5) Gy/mm or (-7.0 ± 1.0) %/mm between the isodose levels 95 and 20%; local minima reached -11.5 Gy/mm or -22.9%/mm. The coefficient of determination for anonlinear regression of GI on SADG was 0.072. After amedian follow-up time of 19.6months, local tumour control was 100% without any case of post-therapeutic enucleation. Two patients (8%) developed liver metastases. SRT of ocular tumours by HA is highly appropriate, and HA is superior to intensity-modulated arc therapy (IMAT) concerning dose reduction in organs at risk (OARs). The novel gradient measure SADG is more informative than Paddick's GI.

Plan quality comparison between 4-arc and 6-arc noncoplanar volumetric modulated arc stereotactic radiotherapy for the treatment of multiple brain metastases

To compare the plans of 4-arc and 6-arc noncoplanar volumetric modulated arc stereotactic radiotherapy (VMA-SRT) for multiple brain metastases and to investigate the cutoff value for the tumor number and volume for 6-arc rather than 4-arc VMA-SRT. We identified 24 consecutive multiple-target cases (3 to 19 targets in each case) with 189 total targets. We constructed plans using both 4- and 6-arc noncoplanar VMA-SRT. The prescribed dose was 36 Gy/6 fr, and it was delivered to 95% of the planning target volume (PTV). The plans were evaluated for the dose conformity using the Radiation Therapy Oncology Group and Paddick conformity indices (RCI and PCI), fall-off (Paddick gradient index [PGI]), and the normal brain dose. The median (range) RCI, PCI, and PGI was 0.94 (0.92 to 0.99), 0.89 (0.77 to 0.94), and 3.75 (2.24 to 6.54) for the 4-arc plan and 0.94 (0.91 to 0.98), 0.89 (0.76 to 0.94), and 3.65 (2.24 to 6.5) for the 6-arc plan, respectively. The median (range) of the normal brain dose was 910.3 cGy (381.4 to 1268.9) for the 4-arc plan and 898.8 cGy (377 to 1252.9) for the 6-arc plan. The PGI of the 6-arc plan was significantly superior to that of the 4-arc plan (p = 0.0076), and the optimal cutoff values for the tumor number and volume indicative of 6-arc (and not 4-arc) VMA-SRT were cases with ≥ 5 metastases and a PTV of ≥ 12.9 mL, respectively. The PCI values, however, showed no significant difference between the 2 plans. We believe these results will help in considering the use of 6-arc VMA-SRT for multiple brain metastases.

Evaluation of Plan Quality Metrics in Stereotactic Radiosurgery/Radiotherapy in the Treatment Plans of Arteriovenous Malformations.

Aim:Several plan quality metrics are available for the evaluation of stereotactic radiosurgery/radiotherapy plans. This is a retrospective analysis of 60 clinical treatment plans of arteriovenous malformation (AVM) patients to study clinical usefulness of selected plan quality metrics.Materials and Methods:The treatment coverage parameters Radiation Therapy Oncology Group (RTOG) Conformity Index (CIRTOG), RTOG Quality of Coverage (QRTOG), RTOG Homogeneity Index (HIRTOG), Lomax Conformity Index (CILomax), Paddick's Conformity Index (CIPaddick), and dose gradient parameters Paddick's Gradient Index (GIPaddick) and Equivalent Fall-off Distance (EFOD) were calculated for the cohort of patients. Before analyzing patient plans, the influence of calculation grid size on selected plan quality metrics was studied on spherical targets.Results:It was found that the plan quality metrics are independent of calculation grid size ≤2 mm. EFOD was found to increase linearly with increase in target volume, and a linear fit equation was obtained.Conclusions:The analysis shows that RTOG indices and EFOD would suffice for routine clinical radiosurgical treatment plan evaluation if a dose distribution is available for visual inspection.

A technique to reduce low dose region for craniospinal irradiation (CSI) with RapidArc and its dosimetric comparison with 3D conformal technique (3DCRT).

We proposed a method to reduce the volume of normal tissues irradiated by low doses in patients receiving CSI with RapidArc (RA) using Avoidance-Sector technique (RA+AS) and to compare its dosimetric implications with RA using full-arc (RA+FA) and 3D conformal technique (3DCRT). Four patients of CSI were retrospectively planned with 3DCRT, RA+FA, and RA+AS. Conformity-Index (CI), Homogeneity-Index (HI), and Paddick Gradient-Index (GI) were calculated. Quantitative evaluation was done using DVH analysis for PTVs and OARs. When compared with 3DCRT, GI, CI, and HI were favorable to RA based techniques. In comparison with 3DCRT the doses to OARs were lower with RA+AS with the difference being statistically significant in most instances. RA+AS significantly decreases the dose to OARs and their volumes receiving low doses in comparison with RA+FA and 3DCRT.

Comparison study of intensity modulated arc therapy using single or multiple arcs to intensity modulated radiation therapy for high-risk prostate cancer

PurposeIntensity modulated arc therapy (IMAT) is a form of intensity modulated radiation therapy (IMRT) that delivers dose in single or multiple arcs. We compared IMRT plans versus single-arc field (1ARC) and multi-arc fields (3ARC) IMAT plans in high-risk prostate cancer.Materials and MethodsSixteen patients were studied. Prostate (PTVP), right pelvic (PTVRtLN) and left pelvic lymph nodes (PTVLtLN), and organs at risk were contoured. PTVP, PTVRtLN, and PTVLtLN received 50.40 Gy followed by a boost to PTVB of 28.80 Gy. Three plans were per patient generated: IMRT, 1ARC, and 3ARC. We recorded the dose to the PTV, the mean dose (DMEAN) to the organs at risk, and volume covered by the 50% isodose. Efficiency was evaluated by monitor units (MU) and beam on time (BOT). Conformity index (CI), Paddick gradient index, and homogeneity index (HI) were also calculated.ResultsAverage Radiation Therapy Oncology Group CI was 1.17, 1.20, and 1.15 for IMRT, 1ARC, and 3ARC, respectively. The plans' HI were within 1% of each other. The DMEAN of bladder was within 2% of each other. The rectum DMEAN in IMRT plans was 10% lower dose than the arc plans (p < 0.0001). The GI of the 3ARC was superior to IMRT by 27.4% (p = 0.006). The average MU was highest in the IMRT plans (1686) versus 1ARC (575) versus 3ARC (1079). The average BOT was 6 minutes for IMRT compared to 1.3 and 2.9 for 1ARC and 3ARC IMAT (p < 0.05).ConclusionFor high-risk prostate cancer, IMAT may offer a favorable dose gradient profile, conformity, MU and BOT compared to IMRT.

Consideration of optimal isodose surface selection for target coverage in micro-multileaf collimator-based stereotactic radiotherapy for large cystic brain metastases: comparison of 90%, 80% and 70% isodose surface-based planning

This study aims to compare dynamic conformal arc (DCA) plans based on different-percentage isodose surfaces (IDSs), normalised to 100% at the isocentre, for target coverage (TC; dose prescription) in stereotactic radiotherapy for large cystic brain metastases. The DCA plans were generated for 15 targets (5 spherical models and 10 metastatic brain lesions) based on 90%, 80% and 70% IDSs for dose prescription to attain ≥99% TC values using the Novalis Tx platform. These plans were optimised mainly by leaf margin and/or collimator angle adjustment, while similar arc arrangements were used. TC values were equivalent among the three plans. Conformity index values were similar between the 80% and 70% plans, while they were worse in the 90% plans. Mean doses (D(mean)) of the interior 3 mm rind structure were highest in the 70% plans, followed by the 80% plans and lowest in the 90% plans. D(mean) of the exterior 3 mm rind structure and the ratio of 50%/100% isodose volumes (Paddick's gradient index values) were highest in the 90% plans, followed by 80% and lowest in the 70% plans. These results suggest that the 70% IDS plans might be beneficial for both tumour control and reducing toxicity to surrounding normal tissue if appropriate dose conformity and precise treatment set-up are ensured. The 90% IDS plans are unfavourable in view of inferior dose gradient outside the target and should be limited to cases in which the target dose homogeneity is given the highest priority.

Plan quality and treatment planning technique for single isocenter cranial radiosurgery with volumetric modulated arc therapy

PurposeTo demonstrate plan quality and provide a practical, systematic approach to the treatment planning technique for single isocenter cranial radiosurgery with volumetric modulated arc therapy (VMAT; RapidArc, Varian Medical systems, Palo Alto, CA). Methods and materialsFifteen patients with 1 or more brain metastases underwent single isocenter VMAT radiosurgery. All plans were normalized to deliver 100% of the prescription dose to 99%-100% of the target volume. All targets per plan were treated to the same dose. Plans were created with dose control tuning structures surrounding targets to maximize conformity and dose gradient. Plan quality was evaluated by calculation of conformity index (CI = 100% isodose volume/target volume) and homogeneity index (HI = maximum dose/prescription dose) scores for each target and a Paddick gradient index (GI = 50% isodose volume/100% isodose volume) score for each plan. ResultsThe median number of targets per patient was 2 (range, 1-5). The median number of non-coplanar arcs utilized per plan was 2 (range, 1- 4). Single target plans were created with 1 or 2 non-coplanar arcs while multitarget plans utilized 2 to 4 non-coplanar arcs. Prescription doses ranged from 5-16 Gy in 1-5 fractions. The mean conformity index was 1.12 (± SD, 0.13) and the mean HI was 1.44 (± SD, 0.11) for all targets. The mean GI per plan was 3.34 (± SD, 0.42). ConclusionsWe have outlined a practical approach to cranial radiosurgery treatment planning using the single isocenter VMAT platform. One or 2 arc single isocenter plans are often adequate for treatment of single targets, while 2-4 arcs may be more advantageous for multiple targets. Given the high plan quality and extreme clinical efficiency, this single isocenter VMAT approach will continue to become more prevalent for linac-based radiosurgical treatment of 1 or more intracranial targets and will likely replace multiple isocenter techniques.