Stereotactic Body Radiotherapy Plans Research Articles

Dosimetric benefits of hemigland stereotactic body radiotherapy for prostate cancer: implications for focal therapy.

Compared with standard, whole-gland (WG) therapies for prostate cancer, focal approaches may provide equivalent oncologic outcomes with fewer adverse effects. The purpose of this study was to compare organ-at-risk (OAR) dosimetry between hemigland (HG) and WG stereotactic body radiotherapy (SBRT) plans. Volumetric-modulated arc radiotherapy-based SBRT plans were designed to treat the left HG, right HG and WG in eight patients, using five fractions of 8 Gy. OARs of interest included the contralateral HG, rectum, urinary bladder, urethra, penile bulb and contralateral neurovascular bundle. Rectal V80% (the percentage of a normal structure receiving a dose of 80%) and V90% were significantly lower with HG plans than with WG plans (median values of 4.4 vs 2.5 cm(3) and 2.1 vs 1.1 cm(3), respectively, p < 0.05 by Student's t-test). Bladder V50% was also reduced significantly in HG plans (32.3 vs 17.4 cm(3), p < 0.05), with a trend towards reduction of V100% (3.4 vs 1.3 cm(3), p = 0.09). Urethral maximum dose and mean doses to the penile bulb and contralateral neurovascular bundle were also reduced significantly (42.0 vs 39.7 Gy, p < 0.00001; 13.3 vs 9.2 Gy, p < 0.05; and 40.2 vs 19.3 Gy, p < 0.00001, respectively). Targeting an HG volume rather than a WG volume when delivering SBRT can offer statistically significant reductions for all OARs. Given the large magnitude of the reduction in dose to these OARs, it is anticipated that HG SBRT could offer a superior toxicity profile when compared with WG SBRT. This is likely to be most relevant in the context of salvaging a local failure after radiation therapy. The dosimetric feasibility of HG SBRT is demonstrated. When compared with WG SBRT plans, the HG plans demonstrate statistically significant and large magnitude reduction in doses to the rectum, bladder, urethra, penile bulb and contralateral neurovascular bundle, suggesting the possibility of improved toxicity outcomes with HG SBRT. This is likely to be most relevant in the context of salvaging a local failure after radiation therapy.

Investigating the clinical advantages of a robotic linac equipped with a multileaf collimator in the treatment of brain and prostate cancer patients

The purpose of this study was to evaluate the performance of a commercially available CyberKnife system with a multileaf collimator (CK‐MLC) for stereotactic body radiotherapy (SBRT) and standard fractionated intensity‐modulated radiotherapy (IMRT) applications. Ten prostate and ten intracranial cases were planned for the CK‐MLC. Half of these cases were compared with clinically approved SBRT plans generated for the CyberKnife with circular collimators, and the other half were compared with clinically approved standard fractionated IMRT plans generated for conventional linacs. The plans were compared on target coverage, conformity, homogeneity, dose to organs at risk (OAR), low dose to the surrounding tissue, total monitor units (MU), and treatment time. CK‐MLC plans generated for the SBRT cases achieved more homogeneous dose to the target than the CK plans with the circular collimators, for equivalent coverage, conformity, and dose to OARs. Total monitor units were reduced by 40% to 70% and treatment time was reduced by half. The CK‐MLC plans generated for the standard fractionated cases achieved prescription isodose lines between 86% and 93%, which was 2%–3% below the plans generated for conventional linacs. Compared to standard IMRT plans, the total MU were up to three times greater for the prostate (whole pelvis) plans and up to 1.4 times greater for the intracranial plans. Average treatment time was 25 min for the whole pelvis plans and 19 min for the intracranial cases. The CK‐MLC system provides significant improvements in treatment time and target homogeneity compared to the CK system with circular collimators, while maintaining high conformity and dose sparing to critical organs. Standard fractionated plans for large target volumes (>100 cm3) were generated that achieved high prescription isodose levels. The CK‐MLC system provides more efficient SRS and SBRT treatments and, in select clinical cases, might be a potential alternative for standard fractionated treatments.PACS numbers: 87.56.nk, 87.56.bd

A multi-institutional study to assess adherence to lung stereotactic body radiotherapy planning goals.

A multi-institutional planning study was performed to evaluate the frequency that current guidelines established by Radiation Therapy Oncology Group (RTOG) protocols and other literature for lung stereotactic body radiotherapy (SBRT) treatments are followed. A total of 300 patients receiving lung SBRT treatments in four different institutions were retrospectively reviewed. The treatments were delivered using Linac based SBRT (160 patients) or image guided robotic radiosurgery (140). Most tumors were located peripherally (250/300). Median fractional doses and ranges were 18 Gy (8-20 Gy), 12 Gy (6-15 Gy), and 10 Gy (5-12 Gy) for three, four, and five fraction treatments, respectively. The following planning criteria derived from RTOG trials and the literature were used to evaluate the treatment plans: planning target volumes, PTVV 100 ≥ 95% and PTVV 95 ≥ 99%; conformality indices, CI100% < 1.2 and CI50% range of 2.9-5.9 dependent on PTV; total lung-ITV: V20Gy < 10%, V12.5Gy < 15%, and V5Gy < 37%; contralateral lung V5Gy < 26%; and maximum doses for spinal cord, esophagus, trachea/bronchus, and heart and great vessels. Populations were grouped by number of fractions, and dosimetric criteria satisfaction rates (CSRs) were reported. Five fraction regimens were the most common lung SBRT fractionation (46%). The median PTV was 27.2 cm(3) (range: 3.8-419.5 cm(3)). For all plans: mean PTVV 100 was 94.5% (±5.6%, planning CSR: 69.8%), mean PTVV 95 was 98.1% (±4.1%, CSR: 69.5%), mean CI100% was 1.14 (±0.21, CSR: 79.1%, and 16.5% within minor deviation), and mean CI50% was 5.63 (±2.8, CSR: 33.0%, and 28.0% within minor deviation). When comparing plans based on location, peripherally located tumors displayed higher PTVV 100 and PTVV 95 CSR (71.5% and 71.9%, respectively) than centrally located tumors (61.2% and 57.1%, respectively). Overall, the planning criteria were met for all the critical structure such as lung, heart, spinal cord, esophagus, and trachea/bronchus for at least 85% of the patients. Among the various parameters that were used to evaluate the SBRT plans, the CI100% and CI50% were the most challenging criteria to meet. Although the CSRs of organs at risk were higher among all cases, their proximity to the PTV was a significant factor.

SU‐F‐BRB‐04: Comparison of Coplanar VMAT, Non‐Coplanar VMAT, and 4π Treatment Plans

Purpose:The 4π non‐coplanar radiotherapy delivery technique has demonstrated significantly better normal tissue sparing and dose conformality than the clinically used volumetric modulated arc therapy (VMAT). It is unclear whether this is a fundamental limitation of VMAT delivery or the coplanar nature of its typical clinical plans. The non‐coplanar basis of 4π is incorporated into VMAT treatment planning to compare its effect on plan quality.Methods:Clinical stereotactic body radiation therapy plans for 9 liver patients treated with 30–60 Gy using coplanar VMAT (cVMAT) were re‐planned using non‐coplanar VMAT (nVMAT) with 3 arcs and 4 π with 20 intensity‐modulated non‐coplanar fields. All plans were optimized to deliver 100% of the prescribed dose to 95% of the planning target volume (PTV), and nVMAT and 4π plans were tailored to match the maximum and mean PTV dose from the clinical plan. The conformality index (CI), 50% dose spillage volume (R50), normal liver volume receiving &gt;15 Gy (VL&gt;15), and doses to organs at risk (OARs) were compared for all three treatment plans.Results:Compared to cVMAT, the nVMAT and 4π plans reduced VL&gt;15 by an average of 30.6 cm3 and 96.3 cm3, respectively. The average CI was also reduced from 1.22 (cVMAT) to 1.17 (nVMAT) and 1.14 (4π), indicating higher conformality in the same order. Similarly, R50 was reduced from 3.87 (cVMAT) to 3.58 (nVMAT) and 2.74 (4π). With the exception of the mean right kidney dose, which increased by an average of only 0.6 Gy for nVMAT, the dose differences to OARs were not statistically significant between the two VMAT plans. 4π plans either significantly decreased or maintained OAR doses.Conclusion:While the manual selection of intuitive non‐coplanar arcs does show some improvement over coplanar VMAT, the automated beam selection for 4π still results in superior plan quality.This project is supported in part by Varian Medical Systems and NIH R43 CA183390.

SU-D-BRB-07: Lipiodol Impact On Dose Distribution in Liver SBRT After TACE

Purpose: Stereotactic body radiotherapy (SBRT) combining transarterial chemoembolization (TACE) with Lipiodol is expected to improve local control. This study aims to evaluate the impact of Lipiodol on dose distribution by comparing the dosimetric performance of the Acuros XB (AXB) algorithm, anisotropic analytical algorithm (AAA), and Monte Carlo (MC) method using a virtual heterogeneous phantom and a treatment plan for liver SBRT after TACE. Methods: The dose distributions calculated using AAA and AXB algorithm, both in Eclipse (ver. 11; Varian Medical Systems, Palo Alto, CA), and EGSnrc-MC were compared. First, the inhomogeneity correction accuracy of the AXB algorithm and AAA was evaluated by comparing the percent depth dose (PDD) obtained from the algorithms with that from the MC calculations using a virtual inhomogeneity phantom, which included water and Lipiodol. Second, the dose distribution of a liver SBRT patient treatment plan was compared between the calculation algorithms. Results In the virtual phantom, compared with the MC calculations, AAA underestimated the doses just before and in the Lipiodol region by 5.1% and 9.5%, respectively, and overestimated the doses behind the region by 6.0%. Furthermore, compared with the MC calculations, the AXB algorithm underestimated the doses just before and in the Lipiodol region by 4.5% and 10.5%, respectively, and overestimated the doses behind the region by 4.2%. In the SBRT plan, the AAA and AXB algorithm underestimated the maximum doses in the Lipiodol region by 9.0% in comparison with the MC calculations. In clinical cases, the dose enhancement in the Lipiodol region can approximately 10% increases in tumor dose without increase of dose to normal tissue. Conclusion: The MC method demonstrated a larger increase in the dose in the Lipiodol region than the AAA and AXB algorithm. Notably, dose enhancement were observed in the tumor area; this may lead to a clinical benefit.

SU‐E‐T‐115: Analysis of Patient Specific QA for VMAT by Disease Site and Planning‐Delivery System Using the ScandiDos Delta4 Phantom

Purpose:To evaluate patient specific quality assurance (PSQA) for the delivery of volumetric modulated arc therapy (VMAT) by disease site. To compare planning‐delivery system (PDS) PSQA pass rates in a dual vendor institution.Methods:PSQA is performed for VMAT plans using a ScandiDos Delta4 phantom. Verification plans are calculated using Varian Eclipse and Elekta Monaco treatment planning systems (TPS) for patients treated using Varian Truebeam and Elekta linear accelerators respectively. Individual arcs are delivered to the Delta4 phantoms and assessed using the gamma index pass criterion(3% Dose Deviation(DD%), 3mm Distance to Agreement(DTA),10% dose threshold and 90% gamma index).Results:A total of 287 VMAT plans and 680 arcs were analyzed. The passing rates for VMAT QA plans were 95% and 98% for head/neck and pelvis/prostate plans respectively, and 100% for chest/abdomen, spine, lung Stereotactic Body Radiotherapy (SBRT) and Stereotactic Radiosurgery(SRS) plans. Average gamma indices were: (99 ± 2) % for pelvis/prostate, chest/abdomen and lung SBRT plans, (97 ± 4) % for head and neck plans and (98 ± 3) % for spine plans. The average DD% and DTA pass rates ranged from 82% to 90% and 98% to 99% respectively for plans in different disease sites. Paired t‐test analysis (two tails) indicated no significant differences in the gamma indices between plans delivered using different PDS; the P values were: 0.08, 0.45, and 0.94 for lung SBRT, head/neck and pelvis/prostate plans respectively. The statistical power for comparing PDS in different disease sites with an alpha of 0.05 is 1.Conclusion:The Gamma indices based on 3% DD%, 3 mm DTA and 10% dose threshold for the VMAT QA plans in all disease sites were well above 90%, suggesting the possibility of using a more stringent PSQA criterion. No significant differences were observed in the QA of VMAT plans delivered using different PDS.

SU‐E‐T‐323: Dosimetric Evaluation of Small Fields for SBRT Treatment

Purpose:Stereotactic body radiation therapy (SBRT) is commonly employed to treat small targets for effective tumor control with radiation beams of small field sizes. The goal of this work was to evaluate dosimetrically a treatment planning system (TPS) by comparing the calculated dose for SBRT treatment with ion‐chamber measurements.Methods:3D images of a solid‐water phantom with a pinpoint ion‐chamber (0.015cm3) inside were acquired with a CT scanner. Active volume of the ion‐chamber was delineated on CT images. Targets with a diameter of 1.5cm, 2cm, 3cm, 4cm and 5cm were drawn around the chamber. 3DCRT plans were generated for each target size with centrally opened 6MV beams and off‐axis beams by changing the isocenter location, respectively, using a TPS with the Analytical Anisotropic Algorithm. A 21iX linear accelerator was employed for plan delivery. The measured and calculated doses were compared. To evaluate the dose calculations in heterogeneity for small fields SBRT treatment, similar plans were also generated and delivered on a heterogeneous thoracic phantom for 5 different size targets in the lung.Results:Dose comparisons between measurements and calculations showed 5.2%, 1.88%, 1.34%, 1.01% and 0.85% difference for SBRT plans with small central axis beams and 0.96%, 0.15%, 0.58%, 0.22% and 0.77% difference for plans with off‐axis beams for five different size targets. For the thoracic phantom, the differences on dose between measurements and calculations are bigger, which are 8%, 5.9%, 4.5%, 3.9% and 4.5%, respectively.Conclusion:Dose verification for small fields used in the SBRT treatment has been performed based on ion‐chamber measurements in both homogenous and heterogeneous phantoms. More than a 5% difference has been observed in the heterogeneous phantom, especially for very small fields. To meet the ICRU recommendation on a dose difference of no more than 5%, some corrections on the commissioning parameters of the TPS are needed.

MO‐F‐CAMPUS‐T‐04: Development and Evaluation of a Knowledge‐Based Model for Treatment Planning of Lung Cancer Patients Using Stereotactic Body Radiotherapy (SBRT)

Purpose:To describe the development of a knowledge‐based treatment planning model for lung cancer patients treated with SBRT, and to evaluate the model performance and applicability to different planning techniques and tumor locations.Methods:105 lung SBRT plans previously treated at our institution were included in the development of the model using Varian's RapidPlan DVH estimation algorithm. The model was trained with a combination of IMRT, VMAT, and 3D–CRT techniques. Tumor locations encompassed lesions located centrally vs peripherally (43:62), upper vs lower (62:43), and anterior vs posterior lobes (60:45). The model performance was validated with 25 cases independent of the training set, for both IMRT and VMAT. Model generated plans were created with only one optimization and no planner intervention. The original, general model was also divided into four separate models according to tumor location. The model was also applied using different beam templates to further improve workflow. Dose differences to targets and organs‐at‐risk were evaluated.Results:IMRT and VMAT RapidPlan generated plans were comparable to clinical plans with respect to target coverage and several OARs. Spinal cord dose was lowered in the model‐based plans by 1Gy compared to the clinical plans, p=0.008. Splitting the model according to tumor location resulted in insignificant differences in DVH estimation. The peripheral model decreased esophagus dose to the central lesions by 0.5Gy compared to the original model, p=0.025, and the posterior model increased dose to the spinal cord by 1Gy compared to the anterior model, p=0.001. All template beam plans met OAR criteria, with 1Gy increases noted in maximum heart dose for the 9‐field plans, p=0.04.Conclusion:A RapidPlan knowledge‐based model for lung SBRT produces comparable results to clinical plans, with increased consistency and greater efficiency. The model encompasses both IMRT and VMAT techniques, differing tumor locations, and beam arrangements.Research supported in part by a grant from Varian Medical Systems, Palo Alto CA.

Validating FMEA output against incident learning data: A study in stereotactic body radiation therapy.

Though failure mode and effects analysis (FMEA) is becoming more widely adopted for risk assessment in radiation therapy, to our knowledge, its output has never been validated against data on errors that actually occur. The objective of this study was to perform FMEA of a stereotactic body radiation therapy (SBRT) treatment planning process and validate the results against data recorded within an incident learning system. FMEA on the SBRT treatment planning process was carried out by a multidisciplinary group including radiation oncologists, medical physicists, dosimetrists, and IT technologists. Potential failure modes were identified through a systematic review of the process map. Failure modes were rated for severity, occurrence, and detectability on a scale of one to ten and risk priority number (RPN) was computed. Failure modes were then compared with historical reports identified as relevant to SBRT planning within a departmental incident learning system that has been active for two and a half years. Differences between FMEA anticipated failure modes and existing incidents were identified. FMEA identified 63 failure modes. RPN values for the top 25% of failure modes ranged from 60 to 336. Analysis of the incident learning database identified 33 reported near-miss events related to SBRT planning. Combining both methods yielded a total of 76 possible process failures, of which 13 (17%) were missed by FMEA while 43 (57%) identified by FMEA only. When scored for RPN, the 13 events missed by FMEA ranked within the lower half of all failure modes and exhibited significantly lower severity relative to those identified by FMEA (p = 0.02). FMEA, though valuable, is subject to certain limitations. In this study, FMEA failed to identify 17% of actual failure modes, though these were of lower risk. Similarly, an incident learning system alone fails to identify a large number of potentially high-severity process errors. Using FMEA in combination with incident learning may render an improved overview of risks within a process.

Dosimetric verification of stereotactic body radiation therapy for lung cancer treatment plans using flattening filter-free beams.

This study aimed to analyze the dose distribution using different dosimetric tools in conducting pretreatment quality assurance for lung cancer stereotactic body radiation therapy (SBRT) plans with flattening filter free (FFF) beams. Nine patients with lung cancer treated via SBRT were randomly selected, and their treatment plans were generated using the Eclipse treatment planning system (TPS) with FFF beams. For each patient, the same plan was applied to the Delta4 phantom and MatriXX by the TPS, which calculated the dose distribution. The Delta4 and MatriXX phantoms were then used to measure the actual dose distribution at the linear accelerator, and these measured doses were compared to with the calculated doses. Gamma analysis was employed in verifying the correspondence between the dose distributions. The absolute point doses were measured by a 0.016 mL Microchamber with the RW3 phantom and Thorax phantom. The absolute point doses measured by the 0.016 mL Microchamber were within ±3% of the calculated results for the central point of the RW3 and Thorax phantoms. The Delta4 and MatriXX dose distributions agreed well with the measured and calculated doses, over 98%, based on the 3% maximum dose and 3 mm gamma criteria. Both measured and calculated doses for the Delta4 and MatriXX phantoms agreed well for each patient with lung cancer. The absolute point dose measurements using the 0.016 mL Microchamber exhibited excellent agreement with the TPS calculated between the RW3 and Thorax phantoms.

Feasibility of magnetic resonance imaging–guided liver stereotactic body radiation therapy: A comparison between modulated tri-cobalt-60 teletherapy and linear accelerator–based intensity modulated radiation therapy

PurposeThe purpose of this study was to investigate the dosimetric feasibility of liver stereotactic body radiation therapy (SBRT) using a teletherapy system equipped with 3 rotating 60Co sources (tri-60Co system) and a built-in magnetic resonance imager (MRI). We hypothesized tumor size and location would be predictive of favorable dosimetry with tri-60Co SBRT. Methods and materialsThe primary study population consisted of 11 patients treated with SBRT for malignant hepatic lesions whose linear accelerator (LINAC)–based SBRT plans met all mandatory Radiation Therapy Oncology Group (RTOG) 1112 organ-at-risk (OAR) constraints. The secondary study population included 5 additional patients whose plans did not meet the mandatory constraints. Patients received 36 to 60 Gy in 3 to 5 fractions. Tri-60Co system SBRT plans were planned with ViewRay system software. ResultsAll patients in the primary study population had tri-60Co SBRT plans that passed all RTOG constraints, with similar planning target volume coverage and OAR doses to LINAC plans. Mean liver doses and V10Gy to the liver, although easily meeting RTOG 1112 guidelines, were significantly higher with tri-60Co plans. When the 5 additional patients were included in a univariate analysis, the tri-60Co SBRT plans were still equally able to pass RTOG constraints, although they did have inferior ability to pass more stringent liver and kidney constraints (P < .05). A multivariate analysis found the ability of a tri-60Co SBRT plan to meet these constraints depended on lesion location and size. Patients with smaller or more peripheral lesions (as defined by distance from the aorta, chest wall, liver dome, and relative lesion volume) were significantly more likely to have tri-60Co plans that spared the liver and kidney as well as LINAC plans did (P < .05). ConclusionsIt is dosimetrically feasible to perform liver SBRT with a tri-60Co system with a built-in MRI. Patients with smaller or more peripheral lesions are more likely to have optimal liver and kidney sparing, with the added benefit of MRI guidance, when receiving tri-60Co–based SBRT.

A dosimetric retrospective planning study comparing volumetric arc therapy (VMAT) and stereotactic body radiotherapy (SBRT) treatment plans for non-small cell lung cancer (NSCLC)

Purpose A retrospective planning study comparing volumetric arc therapy (VMAT) and stereotactic body radiotherapy (SBRT) treatment plans for non-small cell lung cancer (NSCLC). Methods and materials Five randomly selected early stage lung cancer patients were included in the study. For each patient, four plans were created: the SBRT plan and three VMAT plans using different optimisation methodologies. A total of 20 different plans were evaluated. The dose parameters of dose conformity results and the target dose constraints results were compared for these plans. Results The mean planning target volume (PTV) for all the plans (SBRT and VMAT) was 18·3 cm3, with a range from 15·6 to 20·1 cm3. The maximum dose tolerance to 1 cc of all the plans was within 140% (84 Gy) of the prescribed dose, and 95% of the PTV of all the plans received 100% of the prescribed dose (60 Gy). In all the plans, 99% of the PTV received a dose >90% of the prescribed dose, and the mean dose in all the plans ranged from 67 to 72 Gy. The planning target dose conformity for the SBRT and the VMAT (0°, 15° collimator single arc plans and dual arc) plans showed the tightness of the prescription isodose conformity to the target. Conclusions SBRT and VMAT are radiotherapy approaches that increase doses to small tumour targets without increasing doses to the organs at risk. Although VMAT offers an alternative to SBRT for NSCLC and the potential advantage of VMAT is the reduced treatment times over SBRT, the statistical results show that there was no significant difference between the SBRT and VMAT optimised plans in terms of dose conformity and organ-at-risk sparing.

Dosimetric effects on small-field beam-modeling for stereotactic body radiation therapy

The treatment planning of stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT) requires high accuracy of dosimetric data for small radiation fields. The dosimetric effects on the beam-modeling process of a treatment planning system (TPS) were investigated using different measured small-field data sets. We performed small-field dosimetry with three detectors: a CC13 ion chamber, a CC01 ion chamber, and an edge detector. Percentage depth doses (PDDs) and dose profiles for field sizes given by 3 × 3 cm2, 2 × 2 cm2, and 1 × 1 cm2 were obtained for 6 MV and 15 MV photon beams. Each measured data set was used as data input for a TPS, in which a beam-modeling process was implemented using the collapsed cone convolution (CCC) algorithm for dose calculation. The measured data were used to generate six beam-models based on each combination of detector type and photon energy, which were then used to calculate the corresponding PDDs and dose profiles for various depths and field sizes. Root mean square differences (RMSDs) between the calculated and the measured doses were evaluated for the PDDs and the dose profiles. The RMSDs of PDDs beyond the maximum dose depth were within an accuracy of 0.2–0.6%, being clinically acceptable. The RMSDs of the dose profiles corresponding to the CC13, the CC01, and the edge detector were 2.80%, 1.49%, and 1.46% for a beam energy of 6 MV and 2.34%, 1.15%, and 1.44% for a beam energy of 15 MV, respectively. The calculated results for the CC13 ion chamber showed the most discrepancy compared to the measured data, due to the relatively large sensitive volume of this detector. However, the calculated dose profiles for the detectors were not significantly different from another. The physical algorithm used in the beam-modeling process did not seem to be sensitive to blurred data measured with detectors with large sensitive volumes. Each beam-model was used to clinically evaluate lung and lymphatic node SBRT plans, yielding almost equal dose distributions for the treatment targets, while the mean doses related to the organs at risk (OARs) deviated by approximately 0.7–1.2%. The use of the measured data sets from different detectors for the beam-modeling process still provided acceptable dose distributions with accuracies within 2%.

Dosimetric comparison of volumetric modulated arc therapy with robotic stereotactic radiation therapy in hepatocellular carcinoma.

PurposeTo compare volumetric modulated arc therapy of RapidArc with robotic stereotactic body radiation therapy (SBRT) of CyberKnife in the planning and delivery of SBRT for hepatocellular carcinoma (HCC) treatment by analyzing dosimetric parameters.Materials and MethodsTwo radiation treatment plans were generated for 29 HCC patients, one using Eclipse for the RapidArc plan and the other using Multiplan for the CyberKnife plan. The prescription dose was 60 Gy in 3 fractions. The dosimetric parameters of planning target volume (PTV) coverage and normal tissue sparing in the RapidArc and the CyberKnife plans were analyzed.ResultsThe conformity index was 1.05 ± 0.02 for the CyberKnife plan, and 1.13 ± 0.10 for the RapidArc plan. The homogeneity index was 1.23 ± 0.01 for the CyberKnife plan, and 1.10 ± 0.03 for the RapidArc plan. For the normal liver, there were significant differences between the two plans in the low-dose regions of V1 and V3. The normalized volumes of V60 for the normal liver in the RapidArc plan were drastically increased when the mean dose of the PTVs in RapidArc plan is equivalent to the mean dose of the PTVs in the CyberKnife plan.ConclusionCyberKnife plans show greater dose conformity, especially in small-sized tumors, while RapidArc plans show good dosimetric distribution of low dose sparing in the normal liver and body.

Spine stereotactic body radiation therapy plans: Achieving dose coverage, conformity, and dose falloff

We report our experience of establishing planning objectives to achieve dose coverage, conformity, and dose falloff for spine stereotactic body radiation therapy (SBRT) plans. Patients with spine lesions were treated using SBRT in our institution since September 2009. Since September 2011, we established the following planning objectives for our SBRT spine plans in addition to the cord dose constraints: (1) dose coverage—prescription dose (PD) to cover at least 95% planning target volume (PTV) and 90% PD to cover at least 99% PTV; (2) conformity index (CI)—ratio of prescription isodose volume (PIV) to the PTV < 1.2; (3) dose falloff—ratio of 50% PIV to the PTV (R50%); (4) and maximum dose in percentage of PD at 2cm from PTV in any direction (D2cm) to follow Radiation Therapy Oncology Group (RTOG) 0915. We have retrospectively reviewed 66 separate spine lesions treated between September 2009 and December 2012 (31 treated before September 2011 [group 1] and 35 treated after [group 2]). The χ2 test was used to examine the difference in parameters between groups. The PTV V100% PD ≥ 95% objective was met in 29.0% of group 1 vs 91.4% of group 2 (p < 0.01) plans. The PTV V90% PD ≥ 99% objective was met in 38.7% of group 1 vs 88.6% of group 2 (p < 0.01) plans. Overall, 4 plans in group 1 had CI > 1.2 vs none in group 2 (p = 0.04). For D2cm, 48.3% plans yielded a minor violation of the objectives and 16.1% a major violation for group 1, whereas 17.1% exhibited a minor violation and 2.9% a major violation for group 2 (p < 0.01). Spine SBRT plans can be improved on dose coverage, conformity, and dose falloff employing a combination of RTOG spine and lung SBRT protocol planning objectives.

4π Noncoplanar Stereotactic Body Radiation Therapy for Head-and-Neck Cancer: Potential to Improve Tumor Control and Late Toxicity

To evaluate the potential benefit of 4π radiation therapy in recurrent, locally advanced, or metastatic head-and-neck cancer treated with stereotactic body radiation therapy (SBRT). Twenty-seven patients with 29 tumors who were treated using SBRT were included. In recurrent disease (n=26), SBRT was delivered with a median 44 Gy (range, 35-44 Gy) in 5 fractions. Three patients with sinonasal mucosal melanoma, metastatic breast cancer, and primary undifferentiated carcinoma received 35 Gy, 22.5 Gy, and 40 Gy in 5 fractions, respectively. Novel 4π treatment plans were created for each patient to meet the objective that 95% of the planning target volume was covered by 100% of the prescription dose. Doses to organs at risk (OARs) and 50% dose spillage volumes were compared against the delivered clinical SBRT plans. Local control (LC), late toxicity, tumor control probability (TCP), and normal tissue complication probability were determined. Using 4π plans, mean/maximum doses to all OARs were reduced by 22% to 89%/10% to 86%. With 4π plans, the 50% dose spillage volume was decreased by 33%. Planning target volume prescription dose escalation by 10 Gy and 20 Gy were achieved while keeping doses to OARs significantly improved or unchanged from clinical plans, except for the carotid artery maximum dose at 20-Gy escalation. At a median follow-up of 10 months (range, 1-41 months), crude LC was 52%. The 2-year LC of 39.2% approximated the predicted mean TCP of 42.2%, which increased to 45.9% with 4π plans. For 10-Gy and 20-Gy dose escalation, 4π plans increased TCP from 80.1% and 88.1% to 85.5% and 91.4%, respectively. The 7.4% rate of grade ≥3 late toxicity was comparable to the predicted 5.6% mean normal tissue complication probability for OARs, which was significantly reduced by 4π planning at the prescribed and escalated doses. 4π plans may allow dose escalation with significant and consistent improvements in critical organ sparing, tumor control, and coverage.

Evaluation of dosimetric misrepresentations from 3D conventional planning of liver SBRT using 4D deformable dose integration.

The purpose of this study is to evaluate dosimetric errors in 3D conventional planning of stereotactic body radiotherapy (SBRT) by using a 4D deformable image registration (DIR)‐based dose‐warping and integration technique. Respiratory‐correlated 4D CT image sets with 10 phases were acquired for four consecutive patients with five liver tumors. Average intensity projection (AIP) images were used to generate 3D conventional plans of SBRT. Quasi‐4D path‐integrated dose accumulation was performed over all 10 phases using dose‐warping techniques based on DIR. This result was compared to the conventional plan in order to evaluate the appropriateness of 3D (static) dose calculations. In addition, we consider whether organ dose metrics derived from contours defined on the average intensity projection (AIP), or on a reference phase, provide the better approximation of the 4D values. The impact of using fewer (<10) phases was also explored. The AIP‐based 3D planning approach overestimated doses to targets by 1.4% to 8.7% (mean 4.2%) and underestimated dose to normal liver by up to 8% (mean −5.5%; range −2.3% to −8.0%), compared to the 4D methodology. The homogeneity of the dose distribution was overestimated when using conventional 3D calculations by up to 24%. OAR doses estimated by 3D planning were, on average, within 10% of the 4D calculations; however, differences of up to 100% were observed. Four‐dimensional dose calculation using 3 phases gave a reasonable approximation of that calculated from the full 10 phases for all patients, which is potentially useful from a workload perspective. 4D evaluation showed that conventional 3D planning on an AIP can significantly overestimate target dose (ITV and GTV+5mm), underestimate normal liver dose, and overestimate dose homogeneity. Implementing nonadaptive quasi‐4D dose calculation can highlight the potential limitation of 3D conventional SBRT planning and the resultant misrepresentations of dose in some regions affected by motion and deformation. Where the 4D approach is unavailable, contouring on the full expiration phase may yield more accurate dose calculations, most relevant in the case of the healthy liver, but the absolute dose differences are in general small for the other healthy organs. The technique has the potential to quantify under‐ and over‐dosage and improve treatment plan evaluation, retrospective plan analysis, and clinical outcome correlation.PACS numbers: 87.55.‐x, 87.55.D‐, 87.55.de, 87.55.dk, 87.55.Qr, 87.57.nj

A dosimetric comparison of ultra-hypofractionated passively scattered proton radiotherapy and stereotactic body radiotherapy (SBRT) in the definitive treatment of localized prostate cancer

Background. We compared target and normal tissue dosimetric indices between ultra-hypofractionated passively scattered proton radiotherapy and stereotactic body radiotherapy (SBRT) in the definitive treatment of localized prostate cancer.Material and methods. Ten patients were treated definitively for localized prostate cancer with SBRT to a dose of 36.25 Gy in 5 fractions prescribed to a volume encompassing the prostate only. Dose-volume constraints were applied to the rectum, bladder, penile bulb, femoral heads, and prostatic and membranous urethra. Three-field passively scattered proton plans were retrospectively generated using target volumes from the same patients. Dosimetric indices were compared between the SBRT and proton plans using the Wilcoxon signed rank test.Results. All dose constraints were achieved using both ultra-hypofractionated passively scattered proton and SBRT planning. Proton plans demonstrated significant improvement over SBRT in mean dose delivered to the penile bulb (5.2 CGE vs. 11.4 Gy; p = 0.002), rectum (6.7 CGE vs. 10.6 Gy; p = 0.002), and membranous urethra (32.2 CGE vs. 34.4 Gy; p = 0.006) with improved target homogeneity resulting in a significant reduction in hot spots and volumes of tissue exposed to low doses of radiation. Compared to proton planning, SBRT planning resulted in significant improvement in target conformality with a mean index of 1.17 versus 1.72 (p = 0.002), resulting in a dose reduction to the volume of bladder receiving more than 90% of the PD (V32.6, 7.5% vs. 15.9%; p = 0.01) and mean dose to the left (7.1 Gy vs. 10.4 CGE; p = 0.004) and right (4.0 Gy vs. 10.9 CGE; p = 0.01) femoral heads.Conclusion. Target and normal tissue dose constraints for ultra-hypofractionated definitive radiotherapy of localized prostate cancer are readily achieved using both CK SBRT and passively scattered proton-based therapy suggesting feasibility of either modality.

Treatment planning for SBRT using automated field delivery: A case study

Stereotactic body radiation therapy (SBRT) treatment planning and delivery can be accomplished using a variety of techniques that achieve highly conformal dose distributions. Herein, we describe a template-based automated treatment field approach that enables rapid delivery of more than 20 coplanar fields. A case study is presented to demonstrate how modest adaptations to traditional SBRT planning can be implemented to take clinical advantage of this technology. Treatment was planned for a left-sided lung lesion adjacent to the chest wall using 25 coplanar treatment fields spaced at 11° intervals. The plan spares the contralateral lung and is in compliance with the conformality standards set forth in Radiation Therapy and Oncology Group protocol 0915, and the dose tolerances found in the report of the American Association of Physicists in Medicine Task Group 101. Using a standard template, treatment planning was accomplished in less than 20 minutes, and each 10Gy fraction was delivered in approximately 5.4 minutes. For those centers equipped with linear accelerators capable of automated treatment field delivery, the use of more than 20 coplanar fields is a viable SBRT planning approach and yields excellent conformality and quality combined with rapid planning and treatment delivery. Although the case study discusses a laterally located lung lesion, this technique can be applied to centrally located tumors with similar results.

Monte Carlo–Based Treatment Planning May Increase Chest Wall Pain and Rib Fractures in Lung Stereotactic Body Radiation Therapy (SBRT) Patients Treated According to RTOG 0915 Protocol

Evaluate the impact of Monte Carlo (MC) based planning for lung SBRT on risk of chest wall pain and rib fracture and correlate dosimetric parameters with development of toxicity. Twenty consecutive lung SBRT patients treated from 2010 to 2012 with heterogeneity corrected Pencil Beam (PB) plans were selected. Treatment plans were normalized to deliver 50-60 Gy PTV dose in 4-5 fractions using 7-12 non-coplanar, conformal, 6 MV fields. Using MC dose algorithm, each plan was optimized for > 95% PTV dose coverage as per RTOG 0915 protocol. Chest wall (CW) was contoured as a 3 cm expansion of the ipsilateral lung and ribs were contoured via auto-segmentation in a bone window. Patients were classified based on PTV location: island tumors (8), adjacent to CW (9), or mixed (3), and PTV size (cc) : small (< 25), medium (25-60), or large (> 60). Treatment plans were evaluated for toxicity risk based on four dosimetric thresholds (CW: Dmax < 50 Gy, V30 < 30 cc, V40 < 5 cc and Ribs: Dmax <50 Gy) and outcomes were assessed via review of patient charts and follow-up CT scans. With MC-based planning, tumor size and location were strong predictors of risk of toxicity to CW and ribs. 0% (0/6) of small, 62.5% (5/8) of medium, and 100% (6/6) of large tumors exceeded all four CW and ribs toxicity thresholds. 78% (7/9) of tumors located adjacent to CW surpassed every CW / ribs threshold vs 67% (2/3) of mixed and 25% (2/8) of island tumors. Mean Dmax for ribs was significantly higher for tumors adjacent to CW than for island tumors (61.6±11.7 Gy vs 45.0±11.7 Gy, p = .007). Transitioning from PB to MC planning resulted in a higher overall risk of toxicity. Mean relative dose increases from PB to MC plans for small, medium, and large tumors were 32.4±12.7%, 24.8±10.4%, and 20.3±6.4%, and for island, mixed, and adjacent tumors, 32.5±11.6%, 26.6%±8.8%, and 19.5±7.2%, respectively. 30% (6/20) of patients developed chest wall pain or rib fracture (mean follow-up: 23.6 months). All patients experiencing toxicity were female. The majority (5/6) exceeded ≥ 2 of the four risk thresholds and had a medium/large PTV adjacent to chest wall. These patients would have received even higher Dmax to chest wall and ribs (average increase of 22.6%) if treated with an MC-optimized plan. MC-based lung SBRT plans that satisfy RTOG 0915 criteria for PTV dose coverage result in an increased risk of chest wall and rib toxicity. Large tumor size and proximity to CW predict highest absolute dose to CW and ribs. However, low-risk small island tumors experience the greatest relative increase in CW / ribs dose when planned with the MC algorithm. Our clinical and dosimetric data support development of techniques aimed at lowering doses to CW and ribs in Monte Carlo-based lung SBRT.