Prostate Intensity-modulated Radiotherapy Plans Research Articles

Performance assessment of variant UNet-based deep-learning dose engines for MR-Linac-based prostate IMRT plans

Objective. UNet-based deep-learning (DL) architectures are promising dose engines for traditional linear accelerator (Linac) models. Current UNet-based engines, however, were designed differently with various strategies, making it challenging to fairly compare the results from different studies. The objective of this study is to thoroughly evaluate the performance of UNet-based models on magnetic-resonance (MR)-Linac-based intensity-modulated radiation therapy (IMRT) dose calculations. Approach. The UNet-based models, including the standard-UNet, cascaded-UNet, dense-dilated-UNet, residual-UNet, HD-UNet, and attention-aware-UNet, were implemented. The model input is patient CT and IMRT field dose in water, and the output is patient dose calculated by DL model. The reference dose was calculated by the Monaco Monte Carlo module. Twenty training and ten test cases of prostate patients were included. The accuracy of the DL-calculated doses was measured using gamma analysis, and the calculation efficiency was evaluated by inference time. Results. All the studied models effectively corrected low-accuracy doses in water to high-accuracy patient doses in a magnetic field. The gamma passing rates between reference and DL-calculated doses were over 86% (1%/1 mm), 98% (2%/2 mm), and 99% (3%/3 mm) for all the models. The inference times ranged from 0.03 (graphics processing unit) to 7.5 (central processing unit) seconds. Each model demonstrated different strengths in calculation accuracy and efficiency; Res-UNet achieved the highest accuracy, HD-UNet offered high accuracy with the fewest parameters but the longest inference, dense-dilated-UNet was consistently accurate regardless of model levels, standard-UNet had the shortest inference but relatively lower accuracy, and the others showed average performance. Therefore, the best-performing model would depend on the specific clinical needs and available computational resources. Significance. The feasibility of using common UNet-based models for MR-Linac-based dose calculations has been explored in this study. By using the same model input type, patient training data, and computing environment, a fair assessment of the models’ performance was present.

A comprehensive evaluation of the quality and complexity of prostate IMRT and VMAT plans generated by an automated inverse planning tool

AbstractIntroduction:The Pinnacle3 Auto-Planning (AP) package is an automated inverse planning tool employing a multi-sequence optimisation algorithm. The nature of the optimisation aims to improve the overall quality of radiotherapy plans but at the same time may produce higher modulation, increasing plan complexity and challenging linear accelerator delivery capability.Methods and materials:Thirty patients previously treated with intensity-modulated radiotherapy (IMRT) to the prostate with or without pelvic lymph node irradiation were replanned with locally developed AP techniques for step-and-shoot IMRT (AP-IMRT) and volumetric-modulated arc therapy (AP-VMAT). Each case was also planned with VMAT using conventional inverse planning. The patient cohort was separated into two groups, those with a single primary target volume (PTV) and those with dual PTVs of differing prescription dose levels. Plan complexity was assessed using the modulation complexity score.Results:Plans produced with AP provided equivalent or better dose coverage to target volumes whilst effectively reducing organ at risk (OAR) doses. For IMRT plans, the use of AP resulted in a mean reduction in bladder V50Gy by 4·2 and 4·7 % (p ≤ 0·01) and V40Gy by 4·8 and 11·3 % (p < 0·01) in the single and dual dose level cohorts, respectively. For the rectum, V70Gy, V60Gy and V40Gy were all reduced in the dual dose level AP-VMAT plans by an average of 2·0, 2·7 and 7·3 % (p < 0·01), respectively. A small increase in plan complexity was observed only in dual dose level AP plans.Findings:The automated nature of AP led to high quality treatment plans with improvement in OAR sparing and minimised the variation in achievable dose planning metrics when compared to the conventional inverse planning approach.

Automatic IMRT planning via static field fluence prediction (AIP-SFFP): a deep learning algorithm for real-time prostate treatment planning

The purpose of this work was to develop a deep learning (DL) based algorithm, Automatic intensity-modulated radiotherapy (IMRT) Planning via Static Field Fluence Prediction (AIP-SFFP), for automated prostate IMRT planning with real-time planning efficiency. The following method was adopted: AIP-SFFP generates a prostate IMRT plan through predictions of fluence maps using patient anatomy. No inverse planning is required. AIP-SFFP is centered on a custom-built deep learning (DL) neural network for fluence map prediction. Predictions are imported to a commercial treatment-planning system for dose calculation and plan generation. AIP-SFFP was demonstrated for prostate IMRT simultaneously-integrated-boost planning (58.8 Gy/70 Gy to PTV58.8 Gy/PTV70 Gy in 28 fx, PTV = Planning Target Volume). Training data was generated from 106 patients using a knowledge-based planning (KBP) plan generator. Two types of 2D projection images were designed to represent structures’ sizes and locations, and a total of eight projections were utilized to describe targets and organs-at-risk. Projections at nine template beam angles were stacked as inputs for artificial intelligence (AI) training. 14 patients were used as independent tests. The generated test plans were compared with the plans from the KBP training plan generator and clinic practice. The following results were obtained: After normalization (PTV70 Gy V70 Gy = 95%), all 14 AI plans met institutional criteria. The coverage of PTV58.8 Gy in the AI plans was comparable to KBP and clinic plans without statistical significance. The whole body (BODY) D1cc and rectum D0.1cc of AI plans were slightly higher (<1 Gy) compared to KBP and clinic plans; in contrast, the bladder D1cc and other rectum and bladder low doses in the AI plans were slightly improved without clinical relevance. The overall isodose distribution in the AI plans was comparable with KBP plans and clinical plans. AIP-SFFP generated each test plan within 20s including the prediction and the dose calculation. In conclusion, AIP-SFFP was successfully developed for prostate IMRT planning. AIP-SFFP demonstrated good overall plan quality and real-time efficiency. Showing great promise, AIP-SFFP will be investigated for immediate clinical application.

Technical Note: A feasibility study on deep learning-based radiotherapy dose calculation.

Various dose calculation algorithms are available for radiation therapy for cancer patients. However, these algorithms are faced with the tradeoff between efficiency and accuracy. The fast algorithms are generally less accurate, while the accurate dose engines are often time consuming. In this work, we try to resolve this dilemma by exploring deep learning (DL) for dose calculation. We developed a new radiotherapy dose calculation engine based on a modified Hierarchically Densely Connected U-net (HD U-net) model and tested its feasibility with prostate intensity-modulated radiation therapy (IMRT) cases. Mapping from an IMRT fluence map domain to a three-dimensional (3D) dose domain requires a deep neural network of complicated architecture and a huge training dataset. To solve this problem, we first project the fluence maps to the dose domain using a broad beam ray-tracing (RT) algorithm, and then we use the HD U-net to map the RT dose distribution into an accurate dose distribution calculated using a collapsed cone convolution/superposition (CS) algorithm. The model is trained on 70 patients with fivefold cross validation, and tested on a separate 8 patients. It takes about 1s to compute a 3D dose distribution for a typical 7-field prostate IMRT plan, which can be further reduced to achieve real-time dose calculation by optimizing the network. The average Gamma passing rate between DL and CS dose distributions for the 8 test patients are 98.5% (±1.6%) at 1mm/1% and 99.9% (±0.1%) at 2mm/2%. For comparison of various clinical evaluation criteria (dose-volume points) for IMRT plans between two dose distributions, the average difference for dose criteria is less than 0.25Gy while for volume criteria is <0.16%, showing that the DL dose distributions are clinically identical to the CS dose distributions. We have shown the feasibility of using DL for calculating radiotherapy dose distribution with high accuracy and efficiency.

Fluence-map generation for prostate intensity-modulated radiotherapy planning using a deep-neural-network

A deep-neural-network (DNN) was successfully used to predict clinically-acceptable dose distributions from organ contours for intensity-modulated radiotherapy (IMRT). To provide the next step in the DNN-based plan automation, we propose a DNN that directly generates beam fluence maps from the organ contours and volumetric dose distributions, without inverse planning. We collected 240 prostate IMRT plans and used to train a DNN using organ contours and dose distributions. After training was done, we made 45 synthetic plans (SPs) using the generated fluence-maps and compared them with clinical plans (CP) using various plan quality metrics including homogeneity and conformity indices for the target and dose constraints for organs at risk, including rectum, bladder, and bowel. The network was able to generate fluence maps with small errors. The qualities of the SPs were comparable to the corresponding CPs. The homogeneity index of the target was slightly worse in the SPs, but there was no difference in conformity index of the target, V60Gy of rectum, the V60Gy of bladder and the V45Gy of bowel. The time taken for generating fluence maps and qualities of SPs demonstrated the proposed method will improve efficiency of the treatment planning and help maintain the quality of plans.

A Novel 2D Probability Density Function Integrating the Rectal Motion and Wall Thickness in Prostate IMRT

Background and purposeThis study investigated the variations of rectal motion and wall thickness in prostate intensity-modulated radiotherapy using a novel 2D probability density function. To evaluate the impact of the position, thickness, and deformation of the rectum on the dose distribution in prostate intensity-modulated radiotherapy plans, probability density functions (pdf) of the deformation of rectal cross-section (DW), rectal dose distribution (RM), and changes in rectal wall thickness (TW) were used in the planning optimization. Materials and MethodsThe problem of approximating the product of a number of Gaussian mixture distributions arises in the number of parameters describing the specific mean value, standard deviation, and weight in every Gaussian. In this work, a pdf model has been developed which specifies the variability of the average rectal wall thickness. The model is based on the histogram of 587 randomly selected patients with prostate cancer. ResultsThe average wall thicknesses were determined based on the rectal structure contours drawn on the planning CT image set of the patient. The pdf describing the variability of the rectal wall thickness (pdfTW) is represented as a three-mode Gaussian mixture of specific (μF,σF); (μPF,σPF) and (μE,σE) and individual weights (wF, wPF, and wE) representing full, partially full, and empty rectal states, respectively. ConclusionA 2D Gaussian pdf of rectal motion and rectal thickness (2D pdfM&TW) function, as a product-mixture model of the pdf of the rectal motion (pdfM) and the pdfTW, was developed using published and experimental data, respectively, and presented mathematically. Using correlation values between the functions pdfM and pdfTW, the sensitivity of profiles and projections to the 2D pdfM&TW is numerically demonstrated.

134. DynaLog file-based Procedure for a daily monitoring of IMRT dose delivery

PurposeThanks to the intensity modulated radiation therapy (IMRT) it is possible to achieve highly conformal dose distribution with an important shield to the adjacent organs at risk. Nevertheless, the complex nature of such treatments requires a comprehensive Quality Assurance (QA). The last decade witnessed a proliferation of QA method based on machine log files (DynaLogs Files) since their several advantages [1,2]. In this study we propose a DynaLog file-based method to ensure a daily monitoring of the correct dose delivery. MethodsThe delivery of one prostate IMRT treatment has been daily monitored thanks to the DynaLogs Files. These files are generated for each field delivery and record many useful information [1,2]. Herein the DynaLogs information about planned and actual cumulative dose fraction is taken into account. The prostate IMRT plan consists of 5 fixed field arrangements using a dynamic delivery technique (sliding window). It was calculated using the Varian Eclipse TPS (version 13.6; Varian, Palo Alto) with the analytical anisotropic algorithm (AAA) and it was delivered on a Varian Clinac2100CD. Target dose prescription is 80 Gy in 40 fractions. ResultsThe deviation between planned and actual dose fraction was calculated, for each field, as a function of both fraction numbers and delivery time. The mean and maximum dose deviations were 0.1 and 0.3 Monitor Units, respectively. ConclusionsUsually the IMRT QA is performed before the treatment beginning and it is assumed that no further variations will occur. The proposed method allows to daily assess the correct dose delivery thanks to DynaLogs Files in a no time-consuming way.

Modeling and Prediction of SIB Prostate IMRT Plans

To use retrospective data from simultaneously integrated boost (SIB) prostate intensity modulated radiation therapy (IMRT) plans to model and optimize dose plan outcomes. Modeled outcomes could provide plan guidance for new cases and could also be used as a plan comparison tool. A nonlinear regression based model was developed to map distance to target histograms (DTH) for organs at risk (OARs) to their dose volume histograms (DVH). Contours of patients' planning target volumes (PTVs) and OARs were overlaid on CT image data to compute organ volumes and DTHs. For the training cohort, DVHs were extracted from the SIB PTV (58.8 - 70 Gy) and the OARs. Principle component analysis (PCA) was used to elicit the key feature correlations between the DTH and DVH curves. The initial model cohort consisted of 23 retrospective prostate SIB plans. A leave-one-out training scheme was followed to generate a predicted DVH for each plan. For 85% of the cases, the expert planned OAR DVHs either fell within the 68% confidence interval of the predicted DVH, or the model predicted that a lower dose could be delivered to the OARs. A regression based model was used to map patient anatomical features to OAR DVHs. Cases where the trained model differed significantly from the planned DVH can be further examined to evaluate plan integrity. The results are promising considering the small training set, and model robustness should improve with a larger training cohort. Future work will focus on comparing models trained locally to national planning data. Lung cases, along with head and neck cases will also be considered.

Software-based evaluation of a class solution for prostate IMRT planning.

To use plan analysis software to evaluate a class solution for prostate intensity modulated radiotherapy (IMRT) planning. Class solutions for radiotherapy planning are increasingly being considered for streamlining planning. Plan analysis software provides an objective approach to evaluating radiotherapy plans. Three iterations of a class solution for prostate IMRT planning (T1, T2 and Tfinal) were compared to the clinical plan of 74 prostate patients using radiotherapy plan analysis software (Plan IQ™, Sun Nuclear Corporation). A set of institution-specific plan quality metrics (scores) were established, based on best practice guidelines. For CTV coverage, Tfinal was not significantly different to the clinical plan. With the exception of 95% PTV coverage, Tfinal metrics were significantly better than the clinical plan for PTV coverage. In the scoring analysis, mean dose, 95% and 107% isodose coverage scores were similar for all the templates and clinical plan. 100% coverage of the CTV clinical plan was similar to Tfinal but scored higher than T1 and T2. There were no significant differences between Tfinal and the clinical plan for the metrics and scores associated with organs at risk. The total plan score was similar for Tfinal and the clinical plan, although the scores for volume receiving total dose outside the PTV were higher for Tfinal than for the clinical plan (P<0.0001). The radiotherapy plan analysis software was useful for evaluating a class solution for prostate IMRT planning and provided evidence that the class solution produced clinically acceptable plans for these patients.

The impact of intensity-modulated radiation therapy plan normalization in the postprostatectomy setting—does it matter?

The International Commission on Radiation Units & Measurements -83 recommends prescribing intensity-modulated radiation therapy (IMRT) in a dose-volume manner. Despite this, clinical variation still exists in how prostate IMRT plans are prescribed. This study aims to investigate the impact of different plan normalization methods for postprostatectomy IMRT.IMRT treatment plans were created retrospectively for 20 postprostatectomy patients. These were normalized such that the dose received by 98% (D98) of the planning target volume (PTV) was equal to 100% of the prescribed dose. All plans were individually optimized to achieve target coverage and organ at risk (OAR) dose constraints. Each patient's plan was then copied and normalized such that the mean dose (Dmean) received by the PTV was equal to 100% of the prescribed dose. The International Commission on Radiation Units & Measurements -83 recommended dosimetric end points were extracted for targets and Quantitative Analyses of Normal Tissue Effects in the Clinic or Radiation Therapy Oncology Group 0534 end points extracted for OARs. Statistical analysis using the Wilcoxon signed-rank test to measure the difference between data from plans normalized to D98 and Dmean was conducted.Extracted dosimetric end points of the targets and OARs were significantly higher in plans normalized to D98 than Dmean (p < 0.05) with the exceptions of D2 of the rectum and right femoral head.Normalization impacts on dosimetric end points of a plan. Hence, reporting the normalization method used is necessary to allow for meaningful interpretation of IMRT dosimetric studies.

Dose-volume consistency and radiobiological characterization between prostate IMRT and VMAT plans

Purpose: Dose-volume consistency of the planning target volume (PTV) and rectum for the prostate intensity modulated radiotherapy (IMRT) and volumetric modulated arc therapy (VMAT) plans were evaluated and compared. Dependences of radiobiological parameters of the prostate and rectum on the PTV and rectal volume were also investigated. Methods: From 40 prostate IMRT and 50 VMAT patients treated with the same prescription (78 Gy per 39 fractions) and dose-volume criteria in the inverse planning, the prostate tumour control probability (TCP), rectal equivalent uniform dose (EUD) and rectal normal tissue complication probability (NTCP) were calculated. The dose-volume consistency of the PTV and rectum, demonstrating the variability of dose-volume histogram (DVH) among patients, was defined and calculated as per the deviation between the corresponding and mean DVH. Results: For the IMRT plans, the prostate TCP was found increasing with the PTV with a rate equal to 1.05 × 10 -3 % cm -3 , which was lower than 1.11 × 10 -3 % cm -3 for the VMAT plans. Both the rectal EUD and rectal NTCP were found decreasing with the rectal volume. The decrease rates for the IMRT plans (EUD = 0.47 × 10 -3 Gy cm -3 and NTCP = 3.94 × 10 -2 % cm -3 ) were higher than those for the VMAT (EUD = 0.28 × 10 -3 Gy cm -3 and NTCP = 2.61 × 10 -2 % cm -3 ). Conclusion: For the dose-volume consistency, small prostate TCP variation could be achieved by decreasing the dose-volume variability among the IMRT and VMAT plans. However, dependences of the rectal EUD and rectal NTCP on the dose-volume variability were not significant. It is concluded that maintaining a good dose-volume consistency in prostate plans can decrease the prostate TCP variation among the IMRT and VMAT patients. However, dose-volume variability is not affected by variations of the rectal EUD and rectal NTCP.

The benefit of using bladder sub-volume equivalent uniform dose constraints in prostate intensity-modulated radiotherapy planning.

BackgroundTo assess the benefits of bladder wall sub-volume equivalent uniform dose (EUD) constraints in prostate cancer intensity-modulated radiotherapy (IMRT) planning.MethodsTwo IMRT plans, with and without EUD constraints on the bladder wall, were generated using beams that deliver 80 Gy to the prostate and 46 Gy to the seminal vesicles and were compared in 53 prostate cancer patients. The bladder wall was defined as the volume between the external manually delineated wall and a contraction of 7 mm apart from it. The bladder wall was then separated into two parts: the internal-bladder wall (bla-in) represented by the portion of the bladder wall that intersected with the planning target volume (PTV) plus 5 mm extension; the external-bladder wall (bla-ex) represented by the remaining part of the bladder wall. In the IMRT plan with EUD constraints, the values of “a” parameter for the EUD models were 10.0 for bla-in and 2.3 for bla-ex. The plans with and without EUD constraints were compared in terms of dose–volume histograms, 5-year bladder and rectum normal tissue complication probability values, as well as tumor control probability (TCP) values.ResultsThe use of bladder sub-volume EUD constraints decreased both the doses to the bladder wall (V70: 22.76% vs 19.65%, Dmean: 39.82 Gy vs 35.45 Gy) and the 5-year bladder complication probabilities (≥LENT/SOMA Grade 2: 20.35% vs 17.96%; bladder bleeding: 10.63% vs 8.64%). The doses to the rectum wall and the rectum complication probabilities were also slightly decreased by the EUD constraints compared to physical constraints only. The minimal dose and the V76Gy of PTVprostate were, however, slightly decreased by EUD optimization, nevertheless without significant difference in TCP values between the two plans, and the PTV parameters finally respected the Groupe d’Etude des Tumeurs Uro-Génitales recommendations.ConclusionSeparating the bladder wall into two parts with appropriate EUD optimization may reduce bladder toxicity in prostate IMRT. Combining biological constraints with physical constraints in the organs at risk at the inverse planning step of IMRT may improve the dose distribution.

Prostate intensity-modulated radiotherapy planning in seven mouse clicks: Development of a class solution for cancer

AimThe aim of the retrospective study was to develop a planning class solution for prostate intensity-modulated radiotherapy (IMRT) that achieved target and organs-at-risk (OAR) doses within acceptable departmental protocol criteria using the Monaco treatment planning system (Elekta-CMS Software, MO, USA). BackgroundAdvances in radiation therapy technology have led to a re-evaluation of work practices. Class solutions have the potential to produce highly conformal plans in a time-efficient manner. Materials and MethodsUsing data from intermediate and high risk prostate cancer patients, a stepwise quality improvement model was employed. Stage 1 involved the development of a broadly based treatment template developed across 10 patients. Stage 2 involved template refinement and clinical audit (n=20); Stage 3, template review (n=50) and Stage 4 an assessment of a revised template against the actual treatment plan involving 72 patients. ResultsThe computer algorithm that comprised the Stage 4 template met clinical treatment criteria for 82% of patients. Minor template changes were required for a further 13% of patients. Major changes were required in 4%; one patient could not be assessed. The average calculation time was 13min and involved seven mouse clicks by the planner. Thus, the new template met treatment criteria or required only minor changes in 95% of prostate patients; this is an encouraging result suggesting improvements in planning efficiency and consistency. ConclusionIt is feasible to develop a class solution for prostate IMRT using a stepwise quality improvement model which delivers clinically acceptable plans in the great majority of prostate cases.

SU-F-T-378: Evaluation of Dose-Volume Variability and Parameters Between Prostate IMRT and VMAT Plans

Purpose: This study compared the rectal dose-volume consistency, equivalent uniform dose (EUD) and normal tissue complication probability (NTCP) in prostate intensity modulated radiotherapy (IMRT) and volumetric modulated arc therapy (VMAT). Methods: For forty prostate IMRT and fifty VMAT patients treated using the same dose prescription (78 Gy/39 fraction) and dose-volume criteria in inverse planning optimization, the rectal EUD and NTCP were calculated for each patient. The rectal dose-volume consistency, showing the variability of dose-volume histogram (DVH) among patients, was defined and calculated based on the deviation between the mean and corresponding rectal DVH. Results: From both the prostate IMRT and VMAT plans, the rectal EUD and NTCP were found decreasing with the rectal volume. The decrease rates for the IMRT plans (EUD = 0.47 × 10−3 Gy cm−3 and NTCP = 3.94 × 10−2 % cm−3) were higher than those for the VMAT (EUD = 0.28 × 10−3 Gy cm−3 and NTCP = 2.61 × 10−2 % cm−3). In addition, the dependences of the rectal EUD and NTCP on the dose-volume consistency were found very similar between the prostate IMRT and VMAT plans. This shows that both delivery techniques have similar variations of the rectal EUD and NTCP on the dose-volume consistency. Conclusion: Dependences of the dose-volume consistency on the rectal EUD and NTCP were compared between the prostate IMRT and VMAT plans. It is concluded that both rectal EUD and NTCP decreased with an increase of the rectal volume. The variation rates of the rectal EUD and NTCP on the rectal volume were higher for the IMRT plans than VMAT. However, variations of the rectal dose-volume consistency on the rectal EUD and NTCP were found not significant for both delivery techniques.

Dosimetric comparison between the prostate intensity-modulated radiotherapy (IMRT) and volumetric-modulated arc therapy (VMAT) plans using the planning target volume (PTV) dose–volume factor

AbstractBackgroundWe demonstrated that our proposed planning target volume (PTV) dose–volume factor (PDVF) can be used to evaluate the PTV dose coverage between the intensity-modulated radiotherapy (IMRT) and volumetric-modulated arc therapy (VMAT) plans based on 90 prostate patients.PurposePDVF were determined from the prostate IMRT and VMAT plans to compare their variation of PTV dose coverage. Comparisons of the PDVF with other plan evaluation parameters such as D5%, D95%, D99%, Dmean, conformity index (CI), homogeneity index (HI), gradient index (GI) and prostate tumour control probability (TCP) were carried out.Methods and materialsProstate IMRT and VMAT plans using the 6 MV photon beams were created from 40 and 50 patients, respectively. Dosimetric indices (CI, HI and GI), dose–volume points (D5%, D95%, D99% and Dmean) and prostate TCP were calculated according to the PTV dose–volume histograms (DVHs) of the plans. All PTV DVH curves were fitted using the Gaussian error function (GEF) model. The PDVF were calculated based on the GEF parameters.ResultsFrom the PTV DVHs of the prostate IMRT and VMAT plans, the average D99% of the PTV for IMRT and VMAT were 74·1 and 74·5 Gy, respectively. The average prostate TCP were 0·956 and 0·958 for the IMRT and VMAT plans, respectively. The average PDVF of the IMRT and VMAT plans were 0·970 and 0·983, respectively. Although both the IMRT and VMAT plans showed very similar prostate TCP, the dosimetric and radiobiological results of the VMAT technique were slightly better than IMRT.ConclusionThe calculated PDVF for the prostate IMRT and VMAT plans agreed well with other dosimetric and radiobiological parameters in this study. PDVF was verified as an alternative of evaluation parameter in the quality assurance of prostate treatment planning.

MRI-based IMRT planning for MR-linac: comparison between CT- and MRI-based plans for pancreatic and prostate cancers**This work was present in part at the 2014 ASTRO annual meeting.

The treatment planning in radiation therapy (RT) can be arranged to combine benefits of computed tomography (CT) and magnetic resonance imaging (MRI) together to maintain dose calculation accuracy and improved target delineation. Our aim is study the dosimetric impact of uniform relative electron density assignment on IMRT treatment planning with additional consideration given to the effect of a 1.5 T transverse magnetic field (TMF) in MR-Linac.A series of intensity modulated RT (IMRT) plans were generated for two representative tumor sites, pancreas and prostate, using CT and MRI datasets. Representative CT-based IMRT plans were generated to assess the impact of different electron density (ED) assignment on plan quality using CT without the presence of a 1.5 T TMF. The relative ED (rED) values used were taken from the ICRU report 46. Four types of rED assignment in the organs at risk (OARs), the planning target volumes (PTV) and in the non-specified tissue (NST) were considered. Dose was recalculated (no optimization) using a Monaco 5.09.07a research planning system employing Monte Carlo calculations with an option to include TMF. To investigate the dosimetric effect of different rED assignment, the dose-volume parameters (DVPs) obtained from these specific rED plans were compared to those obtained from the original plans based on CT.Overall, we found that uniform rED assignment results in differences in DVPs within 3% for the PTV and 5% for OAR. The presence of 1.5 T TMF on IMRT DVPs resulted in differences that were generally within 3% of the Gold St for both the pancreas and prostate. The combination of uniform rED assignment and TMF produced differences in DVPs that were within 4–5% of the Gold St. Larger differences in DVPs were observed for OARs on T2-based plans.The effects of using different rED assignments and the presence of 1.5 T TMF for pancreas and prostate IMRT plans are generally within 3% and 5% of PTV and OAR Gold St values. There are noticeable dosimetric differences between the CT- and MRI-based IMRT plans caused by a combination of anatomical changes between the two image acquisition times, uniform rED assignment and 1.5 T TMF.

Evaluating the influence of 6 MV and 15 MV photon beams on prostate intensity-modulated radiation therapy plans

Abstract Objective We aimed to determine the effects of low- and high-energy intensity-modulated radiation therapy (IMRT) photon beams on the target volume planning and on the critical organs in the case of prostate cancer. Methods Thirty plans were generated by using either 6 MV or 15 MV beams separately, and a combination of both 6 and 15 MV beams. All plans were generated by using suitable planning objectives and dose constraints, which were identical across the plans, except the beam energy. The plans were analyzed in terms of their target coverage, conformity, and homogeneity, regardless of the beam energy. Results The mean percentage values of V70 Gy for the rectal wall for the plans with 6 MV, 15 MV, and mixedenergy beams were 16.9%, 17.8%, and 16.4%, respectively, while the mean percentage values of V40 Gy were 53.6%, 52.3%, and 50.4%. The mean dose values to the femoral heads for the 6 MV, 15 MV, and mixed-energy plans were 30.1 Gy, 25.5 Gy, and 25.4 Gy, respectively. The mean integral dose for the 6 MV plans was 10% larger than those for the 15 MV and mixed-energy plans. Conclusion These preliminary results suggest that mixed-energy IMRT plans may be advantageous with respect to the dosimetric characteristics of low- and high-energy beams. Although the reduction of dose to the organs at risk may not be clinically relevant, in this study, IMRT plans using mixed-energy beams exhibited better OAR sparing and overall higher plan quality for deep-seated tumors.

Leakage-Penumbra effect in intensity modulated radiation therapy step-and-shoot dose delivery.

To study the leakage-penumbra (LP) effect with a proposed correction method for the step-and-shoot intensity modulated radiation therapy (IMRT). Leakage-penumbra dose profiles from 10 randomly selected prostate IMRT plans were studied. The IMRT plans were delivered by a Varian 21 EX linear accelerator equipped with a 120-leaf multileaf collimator (MLC). For each treatment plan created by the Pinnacle(3) treatment planning system, a 3-dimensional LP dose distribution generated by 5 coplanar photon beams, starting from 0(o) with equal separation of 72(o), was investigated. For each photon beam used in the step-and-shoot IMRT plans, the first beam segment was set to have the largest area in the MLC leaf-sequencing, and was equal to the planning target volume (PTV). The overshoot effect (OSE) and the segment positional errors were measured using a solid water phantom with Kodak (TL and X-OMAT V) radiographic films. Film dosimetric analysis and calibration were carried out using a film scanner (Vidar VXR-16). The LP dose profiles were determined by eliminating the OSE and segment positional errors with specific individual irradiations. A non-uniformly distributed leaf LP dose ranging from 3% to 5% of the beam dose was measured in clinical IMRT beams. An overdose at the gap between neighboring segments, represented as dose peaks of up to 10% of the total BP, was measured. The LP effect increased the dose to the PTV and surrounding critical tissues. In addition, the effect depends on the number of beams and segments for each beam. Segment positional error was less than the maximum tolerance of 1 mm under a dose rate of 600 monitor units per minute in the treatment plans. The OSE varying with the dose rate was observed in all photon beams, and the effect increased from 1 to 1.3 Gy per treatment of the rectal intersection. As the dosimetric impacts from the LP effect and OSE may increase the rectal post-radiation effects, a correction of LP was proposed and demonstrated for the central beam profile for one of the planned beams. We concluded that the measured dosimetric impact of the LP dose inaccuracy from photon beam segment in step-and-shoot IMRT can be corrected.

Assessment of a 2D electronic portal imaging devices-based dosimetry algorithm for pretreatment and in-vivo midplane dose verification.

Background:The use of electronic portal imaging devices (EPIDs) is a method for the dosimetric verification of radiotherapy plans, both pretreatment and in vivo. The aim of this study is to test a 2D EPID-based dosimetry algorithm for dose verification of some plans inside a homogenous and anthropomorphic phantom and in vivo as well.Materials and Methods:Dose distributions were reconstructed from EPID images using a 2D EPID dosimetry algorithm inside a homogenous slab phantom for a simple 10 × 10 cm2 box technique, 3D conformal (prostate, head-and-neck, and lung), and intensity-modulated radiation therapy (IMRT) prostate plans inside an anthropomorphic (Alderson) phantom and in the patients (one fraction in vivo) for 3D conformal plans (prostate, head-and-neck and lung).Results:The planned and EPID dose difference at the isocenter, on an average, was 1.7% for pretreatment verification and less than 3% for all in vivo plans, except for head-and-neck, which was 3.6%. The mean γ values for a seven-field prostate IMRT plan delivered to the Alderson phantom varied from 0.28 to 0.65. For 3D conformal plans applied for the Alderson phantom, all γ1% values were within the tolerance level for all plans and in both anteroposterior and posteroanterior (AP-PA) beams.Conclusion:The 2D EPID-based dosimetry algorithm provides an accurate method to verify the dose of a simple 10 × 10 cm2 field, in two dimensions, inside a homogenous slab phantom and an IMRT prostate plan, as well as in 3D conformal plans (prostate, head-and-neck, and lung plans) applied using an anthropomorphic phantom and in vivo. However, further investigation to improve the 2D EPID dosimetry algorithm for a head-and-neck case, is necessary.

SU‐E‐T‐441: Gamma Passing Rates for IMRT QA and VMAT QA

Purpose:This study compares gamma passing rates for a cohort of similar intensity modulated radiotherapy (IMRT) and volumetric modulated arc therapy (VMAT) quality assurance (QA) plans to determine the equivalence of the patient specific QA plan delivery. The passing criterion is 90% gamma index with 3% dose difference (DD), 3mm distance‐to‐agreement (DTA) and a dose threshold of 10%.Methods:Gamma passing results of previously treated IMRT QA plans, delivered to Sun Nuclear MapCheck phantom, and VMAT QA plans, delivered to ScandiDos Delta4 phantom, are organized by anatomical site and treatment machine. Both Varian and Elekta machines are included. Pairs of IMRT and VMAT plans are matched based on site, machine, and PTV volume to ensure similar plan cohorts. A two‐tailed t‐test analysis of the data with an alpha of 0.05 determines if there exists a statistically significant difference. Power was calculated to detect a difference of 4%; all data sets were strong with above a 0.8 power.Results:The first data set consisting of 20 matched pairs of prostate plans was statistically insignificant (p‐value=0.90, Power=0.99). The 14 matched pairs set of head and neck plans has a statistically significant Result (p‐value=0.028, Power=0.88). The head and neck IMRT gamma indexes have a mean of 93.1% and range of 82%‐100% while the VMAT gamma indexes have a mean of 96.7% and range of 92%‐100%. The two combined data sets of matched plans had a statistically insignificant Result (p‐value=0.073, Power=0.99).Conclusion:Overall, IMRT and VMAT have equivalent passing rates when comparing the gamma analysis using a passing criterion of 3% DD and 3mm DTA. When separated by site, prostate IMRT and VMAT plans have equivalent passing rates while head and neck plans have a statistically significant variation of passing rates. The passing rates for the two modalities are independent of delivery machine for matched PTV target volumes.