Varian Eclipse Research Articles

A Method to Correct Cone Beam CT (CBCT) Images Using Planning CT for Derivation of Plan of the Day in STEREOTACTIC Body Radiotherapy (SBRT)

A robust method for voxel by voxel enhancement of Cone-beam CT (CBCT) images using a priori knowledge from the planning Computed Tomography (pCT) scan has been developed and used to evaluate the dosimetric accuracy of pCT based CBCT correction method for SBRT dose verification in lung metastasis. This is a retrospective study under which SBRT is carried out in 10 patients presented with lung metastasis. pCT images of patients were acquired and treatment planning was carried out on Varian Eclipse (V11) for 30 Gy in 5 fractions. Daily imaging using CBCT has been done for each patient with an On-Board Imaging system. CBCT is corrected using Matlab function considering CT as fixed and CBCT as moving, the images are registered. Planning target volume (PTV), lung, heart and spine were recontoured on uncorrected CBCT and corrected CBCT separately and the calculated plan on CT is recalculated on both the CBCTs. The dose distribution between the pCT and both the CBCT images were compared. A paired sample test was performed to test the variations. The distribution of pixel intensity of corrected CBCT is closer to the pCT than the uncorrected CBCT. The maximum percentage difference between the corrected CBCT and pCT is 1% in PTV evaluation, which is 3.5% between uncorrected CBCT and pCT. The method increases the accuracy of CBCT density values and enabling the use of CBCT images for dose calculation in radiotherapy.

Multi-institutional Analysis of MLC Parameters for Commissioning of IMRT

Multi-leaf collimator (MLC) parameters, which are registered with radiation treatment planning systems, are very important for intensity modulated radiation therapy (IMRT). In this study, we investigated MLC parameters of respective institutions for efficient commissioning of IMRT. Data of linac models, MLC types, nominal energy, irradiation technique, calculation algorithm, dosimetric leaf gap (DLG) values, and MLC transmission values were collected from each institution in which Varian linac and Eclipse were owned, and analyzed. The numbers of responses from institutions to questionnaire were 15, and the total number of linac was 22. In most institutions, volumetric modulated arc therapy (VMAT) technique was used, and the most used nominal energy was 10 MV. The higher nominal energy was, the higher values of MLC parameters (DLG and MLC transmission) were. In addition, values of MLC parameters of flattening filter free (FFF) beams were smaller than those of flattening filter (FF) beams, even when nominal energy was same. Values of DLG of VMAT tended to be greater than those of multi-field IMRT. These results are expected to be useful for institutions, in which IMRT is implemented.

Dosimetric and planning efficiency comparison for lung SBRT: CyberKnife vs VMAT vs knowledge-based VMAT

This is the first study that compared treatment plan quality and planning efficiency for lung stereotactic body radiation therapy (SBRT) using CyberKnife (CK) Multiplan vs Varian Eclipse treatment planning systems, including volumetric modulated arc therapy (VMAT) and knowledge-based VMAT (KBP-VMAT). Thirteen lung SBRT patients treated with 50 to 55 Gy in 3 or 5 fractions were retrospectively included in this study. CK plans created with Multiplan V. 4.6.1 using 2 fixed circular cones were previously approved used for treatment. For the comparison, the computed tomography (CT) data sets and contours from the CK plans were used to generate VMAT and KBP-VMAT plans (University of California San Diego publicly-shared RapidPlan model) using Eclipse V. 13.7. Metrics used for the comparison of CK, VMAT, and KBP-VMAT plans included monitor units (MUs), conformity indices, dose heterogeneity, high-dose spillage, low-dose spillage, adjacent organs at risk (OAR) doses, and treatment planning time. One-way analysis of variance with post-hoc Tukey tests and paired t-tests were used to analyze the difference of these metrics corresponding to the different planning techniques. All of the 3 planning techniques achieved our clinical goals. With similar planning target volume (PTV) coverage, CK plans yielded the most MU (p< 0.001), the least dose homogeneity (p < 0.002), and the least D2cm dose (p < 0.001), while KBP-VMAT plans resulted in the most OAR sparing. No significant difference was found among other dosimetric metrics such as high-dose spillage, lung V20 and volume receiving 50% of the prescription dose. Compared to VMAT, KBP-VMAT improved OAR sparing (p < 0.05), but required significantly more MU (p < 0.001). KBP-VMAT was associated with the shortest planning time. Eclipse-based VMAT can achieve comparable plan quality for lung SBRT as CK, in a more efficient manner. RapidPlan can facilitate the planning process of KBP-VMAT, with potentially better OAR sparing but higher MU requirements. Further improvement for KBP-VMAT is likely achievable by developing site-specific patient models.

Evaluation of a new GPU-enabled VMAT multi-criteria optimisation plan generation algorithm

To evaluate the new Varian, graphical processing unit (GPU)-enabled, volumetric-modulated arc therapy (VMAT) multi-criteria optimisation (MCO) tool for both its dosimetric accuracy and calculation time. This is a new capability within V16.0 and greater of the Varian Eclipse treatment planning system that allows VMAT optimisation and dose calculation using the GPU (termed GPU-VMAT). In versions prior to V16.0 VMAT multi-criteria optimisation calculations were only possible using central processing unit (CPU) (termed CPU-VMAT) and Hybrid-VMAT (H-VMAT). The H-VMAT method breaks down the VMAT plan into IMRT fields which utilised GPU calculations. The study consisted of a cohort of 50 patients representing a range of anatomical treatment sites; bladder (5), brain (5), gynae (5), head & neck (5), lung (7), mediastinum (7) prostate (4), oesophagus (7) and rectum (5). Each case was planned to that of a clinical standard (Base) which was compared to a CPU-VMAT, GPU-VMAT and H-VMAT approaches. The study analysed dose to organ at risk (OAR) and target coverage, plan calculation time data and plan complexity through monitor unit (MU) for each approach. Negligible dosimetric differences were found between the CPU-VMAT, GPU-VMAT and H-VMAT approaches for the cohort of patients evaluated. The largest dosimetric change were observed in the lacrimal gland for a head and neck case, where the GPU-VMAT and H-VMAT achieved a max dose of +2.8 ± 0.0 Gy and −4.6 ± 0.0 Gy, respectively, when compared to CPU-VMAT. The majority of organ at risk’s (OAR) provided indistinguishable dosimetric outcomes, namely: heart, kidneys, femur, lens, oral cavity and oesophagus. Large time savings were found using the GPU-VMAT technique compared to CPU-VMAT, a mean decrease in calculation time across all sites of 60.2% ± 15.6%. Negligible dosimetric change between the 2 techniques and large time saving were observed with the GPU-VMAT and H-VMAT approaches when compared to the CPU-VMAT. We have shown that the GPU-VMAT technique has been safely implemented with minimal differences from CPU-VMAT, but with significant optimisation and calculation times savings.

A novel approach to Verify air gap and SSD for proton radiotherapy using surface imaging

PurposeTo develop a novel approach to accurately verify patient set up in proton radiotherapy, especially for the verification of the nozzle – body surface air gap and source-to-skin distance (SSD), the consistency and accuracy of which is extremely important in proton treatment.MethodsPatient body surfaces can be captured and monitored with the optical surface imaging system during radiation treatment for improved intrafraction accuracy. An in-house software package was developed to reconstruct the patient body surface in the treatment position from the optical surface imaging reference capture and to calculate the corresponding nozzle – body surface air gap and SSD. To validate this method, a mannequin was scanned on a CT simulator and proton plans were generated for a Mevion S250 Proton machine with 20 gantry/couch angle combinations, as well as two different snout sizes, in the Varian Eclipse Treatment Planning Systems (TPS). The surface generated in the TPS from the CT scan was imported into the optical imaging system as an RT Structure for the purpose of validating and establishing a benchmark for ground truth comparison. The optical imaging surface reference capture was acquired at the treatment setup position after orthogonal kV imaging to confirm the positioning. The air gaps and SSDs calculated with the developed method from the surface captured at the treatment setup position (VRT surface) and the CT based surface imported from the TPS were compared to those calculated in TPS. The same approach was also applied to 14 clinical treatment fields for 10 patients to further validate the methodology.ResultsThe air gaps and SSDs calculated from our program agreed well with the corresponding values derived from the TPS. For the phantom results, using the CT surface, the absolute differences in the air gap were 0.45 mm ± 0.33 mm for the small snout, and 0.51 mm ± 0.49 mm for the large snout, and the absolute differences in SSD were 0.68 mm ± 0.42 mm regardless of snout size. Using the VRT surface, the absolute differences in air gap were 1.17 mm ± 1.17 mm and 2.1 mm ± 3.09 mm for the small and large snouts, respectively, and the absolute differences in SSD were 0.81 mm ± 0.45 mm. Similarly, for patient data, using the CT surface, the absolute differences in air gap were 0.42 mm ± 0.49 mm, and the absolute differences in SSD were 1.92 mm ± 1.4 mm. Using the VRT surface, the absolute differences in the air gap were 2.35 mm ± 2.3 mm, and the absolute differences in SSD were 2.7 mm ± 2.17 mm.ConclusionThese results showed the feasibility and robustness of using an optical surface imaging approach to conveniently determine the air gap and SSD in proton treatment, providing an accurate and efficient way to confirm the target depth at treatment.

Using the iterative kV CBCT reconstruction on the Varian Halcyon linear accelerator for radiation therapy planning for pelvis patients

PurposeThe ability to utilise a linear accelerators kV cone beam CT, for treatment planning and dosimetry calculation, has a number of potential uses including adaptive planning and daily dose analysis. This work validates the use of the iterative reconstruction of the Varian Halcyon cone beam CT (iCBCT) as datasets for radiation therapy planning of pelvis patients. MethodsA CT to electron density (ED) curve was created in the Varian Eclipse treatment planning system (TPS) using scans of a CIRS ED phantom under a variety of scattering conditions. A pelvis phantom was imaged using a diagnostic CT scanner and Halcyon iCBCT. Ten pelvis patient plans were copied onto each dataset and compared using a global 3D gamma analysis. Each patient being treated on Halcyon has a daily iCBCT, and each plan was also recalculated on their respective day 1 iCBCT dataset. Results3D Gamma analysis results for the patients planned on the pelvis phantom were analysed using a 1%/1mm and 2%/2mm, 10% low dose threshold criteria. The average pass rate was 99.4% ± 0.2%. The same metrics were used to analyse the patient plans recalculated on day 1 iCBCTs. The average result for the 1%/1mm gamma analysis was 94.4% ± 6.1%, and 98.6% ± 2.0% for 2%/2mm. A comparison of typical patient volumes showed average mean dose volume differences of 0.0% ± 1.4%, 0.0% ± 0.9% and 1.0% ± 4.0% for the PTV, Bladder and Rectum volumes respectively. ConclusionsHalcyon iCBCT datasets can be used for dose calculation in radiation therapy treatment planning for pelvis patients.

The dosimetric comparison between tomotherapy and RapidArc in normal tissue sparing for nasopharyngeal carcinoma

AbstractPurpose:To compare the dosimetric results regarding the sparing effect on normal tissue between RapidArc (RA) and helical tomotherapy (HT) plans for nasopharyngeal carcinoma (NPC) patients in cases of the equal target dose controls utilising two techniques.Materials and Methods:Thirteen NPC patients treated with HT were replanned using the Varian Eclipse treatment planning system (TPS) for the RA plan. The target dose of the RA plan was optimised equally to the HT plan in terms of target coverage, dose conformity (CI) and dose homogeneity (HI) for assessing the normal tissue sparing between two techniques. All dose–volume parameters monitor units (MUs) and delivery time were also investigated.Results:All dosimetric parameter comparisons of organs-at-risk (OARs) between the RA and HT plans were not significantly different for brain stem, spinal cord and cochlea. However, the RA plan showed a significantly lower dose to the left parotid gland. The mean and median dose were significantly lower in the RA plan versus the HT plan by p-value 0·005 and 0·039, respectively. The MUs and delivery time were also significantly lower in the RA plan with a p-value of 0·00.Conclusions:With the same planning target volume coverage, homogeneity and conformity, almost all of RA and HT treatment planning met the planning goal for normal tissue sparing. There were no significant differences between the two techniques except in the left parotid gland. The RA plans were superior to HT plans by effectively reducing the MUs and treatment time.

Radical accelerated radiotherapy for non-small cell lung cancer (NSCLC): A 5-year retrospective review of two dose fractionation schedules

Background and purposeNumerous fractionation regimes are used for inoperable NSCLC patients not suitable for stereotactic ablative radiotherapy. Continuous hyperfractionated accelerated radiotherapy (CHART, 54 Gy, 36 fractions over 12 days) and hypofractionated accelerated radiotherapy (55 Gy, 20 fractions over 4 weeks) are recommended UK schedules. In this single-centre retrospective analysis, we compare both fractionation schemes for patients treated at our institution from 2010 to 15. Materials and methodsClinical demographic, tumour and survival data were collected alongside radiotherapy dosimetric data from the Varian Eclipse Scripting application programming interface. Differences were assessed using independent samples t-tests. Multivariate survival analysis was performed using Cox regression. ResultsWe identified 563 eligible patients; 43% received CHART and 57% hypofractionated radiotherapy. Median age was 71 years, 56% were male, 95% PET staged with 53% WHO performance status 0–1. 30%, 14%, 50% and 6% were stage I, II, III and IV, respectively. 38% of patients underwent induction chemotherapy. 99% completed their prescribed radiotherapy treatment. Overall response rate was 50% with a 6.5% 90-day mortality rate. Median disease-free survival was 19 months, 50% recurred locally. Median overall survival was 22.5 months with 48% alive at 2 years. Multivariate analysis identified histology, stage, performance status, chemotherapy and radiotherapy response as independent predictors of survival; no significant differences between radiotherapy regimes were observed. ConclusionIn our centre, CHART and hypofractionated accelerated radiotherapy produce similar outcomes. Dose escalation studies are in progress to develop these schedules to match outcomes reported in concurrent chemo-radiation studies.

Application of OSL dosimetry and 3D printed phantom for comparison of calculation algorithms for VMAT treatment planning

The application of new commercial and industrial technologies in the fields of dosimetry and medical physics is of great interest to the scientific community, both to validate existing protocols and to develop new methodologies. The popularization of 3D printing techniques has been analyzed as a great advantage in quality control in complex treatment techniques, such as radiotherapy and the development of patient simulators. Portable dosimetry systems such as Landauer MicroStar OSL system are versatile and their use in quality control is of great importance. The aim of this paper is to compare two of the most used dose calculation algorithms used in Varian Eclipse TPS – AAA and Acuros XB – for treatment planning of multiple brain metastases using a 3D printed anthropomorphic phantom and the OSL InLight system for experimental dosimetry validation. A 3D printed anthropomorphic skull phantom was submitted to a CT scan and planed five target volumes. In order of comparison, two dose calculations were performed in the Varian Eclipse 13.6 TPS with "Alabama technique", using the Varian’s AAA and AXB algorithms, and treatment delivered with 6 MV photon beam of a Varian TrueBeam linear accelerator. Landauer nanoDot dosimeters were positioned inside each of the five target volumes planned and the experimental dosimetric results were compared with the algorithms’ calculated doses. The findings of this work indicate that ACUROS XB calculates more accurate doses compared with AAA, with all the experimental agreements better than 96.0 %, probably because of the heterogeneity corrections. The uncertainty analysis of the InLight system device is enough to sustain the dosimetric uncertainties below 3.0 %, validating the results.&#x0D;

Optimizing Efficiency and Safety in External Beam Radiotherapy Using Automated Plan Check (APC) Tool and Six Sigma Methodology

PURPOSE To develop and implement an automated plan check (APC) tool using a Six Sigma methodology with the aim of improving safety and efficiency in external beam radiotherapy. METHODS The Six Sigma define-measure-analyze-improve-control (DMAIC) framework was used by measuring defects stemming from treatment planning that were reported to the departmental incidence learning system (ILS). The common error pathways observed in the reported data were combined with our departmental physics plan check list, and AAPM TG-275 identified items. Prioritized by risk priority number (RPN) and severity values, the check items were added to the APC tool developed using Varian Eclipse Scripting Application Programming Interface (ESAPI). At 9 months post-APC implementation, the tool encompassed 89 check items, and its effectiveness was evaluated by comparing RPN values and rates of reported errors. To test the efficiency gains, physics plan check time and reported error rate were prospectively compared for 20 treatment plans. RESULTS The APC tool was successfully implemented for external beam plan checking. FMEA RPN ranking re-evaluation at 9 months post-APC demonstrated a statistically significant average decrease in RPN values from 129.2 to 83.7 (P < .05). After the introduction of APC, the average frequency of reported treatment-planning errors was reduced from 16.1% to 4.1%. For high-severity errors, the reduction was 82.7% for prescription/plan mismatches and 84.4% for incorrect shift note. The process shifted from 4σ to 5σ quality for isocenter-shift errors. The efficiency study showed a statistically significant decrease in plan check time (10.1 ± 7.3 min, P = .005) and decrease in errors propagating to physics plan check (80%). CONCLUSIONS Incorporation of APC tool has significantly reduced the error rate. The DMAIC framework can provide an iterative and robust workflow to improve the efficiency and quality of treatment planning procedure enabling a safer radiotherapy process.

Modeling Elekta VersaHD using the Varian Eclipse treatment planning system for photon beams: A single‐institution experience

The aim of this study was to report a single‐institution experience and commissioning data for Elekta VersaHD linear accelerators (LINACs) for photon beams in the Eclipse treatment planning system (TPS). Two VersaHD LINACs equipped with 160‐leaf collimators were commissioned. For each energy, the percent‐depth‐dose (PDD) curves, beam profiles, output factors, leaf transmission factors and dosimetric leaf gaps (DLGs) were acquired in accordance with the AAPM task group reports No. 45 and No. 106 and the vendor‐supplied documents. The measured data were imported into Eclipse TPS to build a VersaHD beam model. The model was validated by creating treatment plans spanning over the full‐spectrum of treatment sites and techniques used in our clinic. The quality assurance measurements were performed using MatriXX, ionization chamber, and radiochromic film. The DLG values were iteratively adjusted to optimize the agreement between planned and measured doses. Mobius, an independent LINAC logfile‐based quality assurance tool, was also commissioned both for routine intensity‐modulated radiation therapy (IMRT) QA and as a secondary check for the Eclipse VersaHD model. The Eclipse‐generated VersaHD model was in excellent agreement with the measured PDD curves and beam profiles. The measured leaf transmission factors were less than 0.5% for all energies. The model validation study yielded absolute point dose agreement between ionization chamber measurements and Eclipse within ±4% for all cases. The comparison between Mobius and Eclipse, and between Mobius and ionization chamber measurements lead to absolute point dose agreement within ±5%. The corresponding 3D dose distributions evaluated with 3%global/2mm gamma criteria resulted in larger than 90% passing rates for all plans. The Eclipse TPS can model VersaHD LINACs with clinically acceptable accuracy. The model validation study and comparisons with Mobius demonstrated that the modeling of VersaHD in Eclipse necessitates further improvement to provide dosimetric accuracy on par with Varian LINACs.

Optimizing efficiency and safety in external beam radiotherapy using automated plan check (APC) tool and six sigma methodology.

PurposeTo develop and implement an automated plan check (APC) tool using a Six Sigma methodology with the aim of improving safety and efficiency in external beam radiotherapy.MethodsThe Six Sigma define‐measure‐analyze‐improve‐control (DMAIC) framework was used by measuring defects stemming from treatment planning that were reported to the departmental incidence learning system (ILS). The common error pathways observed in the reported data were combined with our departmental physics plan check list, and AAPM TG‐275 identified items. Prioritized by risk priority number (RPN) and severity values, the check items were added to the APC tool developed using Varian Eclipse Scripting Application Programming Interface (ESAPI). At 9 months post‐APC implementation, the tool encompassed 89 check items, and its effectiveness was evaluated by comparing RPN values and rates of reported errors. To test the efficiency gains, physics plan check time and reported error rate were prospectively compared for 20 treatment plans.ResultsThe APC tool was successfully implemented for external beam plan checking. FMEA RPN ranking re‐evaluation at 9 months post‐APC demonstrated a statistically significant average decrease in RPN values from 129.2 to 83.7 (P < .05). After the introduction of APC, the average frequency of reported treatment‐planning errors was reduced from 16.1% to 4.1%. For high‐severity errors, the reduction was 82.7% for prescription/plan mismatches and 84.4% for incorrect shift note. The process shifted from 4σ to 5σ quality for isocenter‐shift errors. The efficiency study showed a statistically significant decrease in plan check time (10.1 ± 7.3 min, P = .005) and decrease in errors propagating to physics plan check (80%).ConclusionsIncorporation of APC tool has significantly reduced the error rate. The DMAIC framework can provide an iterative and robust workflow to improve the efficiency and quality of treatment planning procedure enabling a safer radiotherapy process.

Evaluation of a new hybrid VMAT-IMRT multi-criteria optimization plan generation algorithm

To evaluate the Varian ‘Fast hybrid multi-criteria optimization (MCO) volumetric modulated arc therapy (VMAT)’ (H-VMAT) tool for both its dosimetric accuracy and calculation time. This is a new function within V15.6 of the Varian Eclipse treatment planning system that allows VMAT optimization and dose calculation using the graphical processing unit (GPU). In versions prior to V15.6 VMAT MCO calculations were only possible using central processing unit (CPU) not GPU. We termed this approach as native VMAT (N-VMAT). The study consisted of a cohort of 53 patients representing a range of anatomical treatment sites; bladder (5), brain (6), gynaecological (5), head & neck (5), lung (7), mediastinum (7) prostate (6), oesophagus (7), and rectum (5). Each case was planned to that of a clinical standard (Base) which was compared to a H-VMAT and N-VMAT approach. The study analyzed plan calculation time data, dose to organ at risk (OAR) and target coverage for each approach. Negligible dosimetric differences were found between the H-VMAT and N-VMAT approach for the cohort of patients evaluated. The largest dosimetric changes where observed in the optic chiasm and lacrimal gland where the H-VMAT achieved a max dose of 50.9 ± 7.7 Gy and 8.0 ± 0.5 Gy in comparison to the N-VMAT 53.1 ± 6.3 Gy and 10.2 ± 2.9 Gy, respectively. Several OAR's provided indistinguishable dose outcomes, namely; brainstem, heart, kidney's, lens, parotid, and spinal cord. Large time savings were found using the H-VMAT technique when compared to N-VMAT, being 5 to 40 times faster or up to 75 minutes time saving (average of 25 minutes). Negligible dosimetric change between the 2 techniques and large time savings were observed with the GPU enabled H-VMAT approach. We have shown that the H-VMAT technique has been safely implemented and is ready for clinical use.

Tomotherapy as a neoadjuvant treatment for locally advanced esophageal cancer might increase bone marrow toxicity in comparison with intensity-modulated radiotherapy and volumetric-modulated arc therapy

This study compares dosimetric parameters in these following 3 neoadjuvant chemoradiotherapy (NCRT) methods in treating locally advanced esophagus cancer: helical tomotherapy (TOMO), volumetric modulated arc therapy (VMAT), and intensity-modulated radiotherapy (IMRT). It is aimed to ascertain the efficient technique that kept high target coverage and availed the dose sparing of bone marrow (BM). This research collected data on 11 patients from October 2014 to June 2017 who received NCRT for pathologically confirmed esophageal cancer. The prescription doses to the planning target volume (PTV) were all given as 60 Gy (2 Gy per fraction, 5 days a week). Three physicists via Varian Eclipse Treatment Planning System and Accuray planning stations redesigned 5 radiotherapy plans (fixed 5-field IMRT, fixed 7-field IMRT, 2-arc VMAT, 3-arc VMAT, and TOMO) for each of the patients. At the end of the planning, we then appraised the dosimetric quality based on the PTV parameters and the doses to organs at risk (OARs). In the study VMAT reached the highest conformity index (CI; 2 arcs VMAT: 0.74 ± 0.10; 3 arcs VMAT: 0.78 ± 0.07; p< 0.05), and IMRT the lowest homogeneity index (HI; fivefields IMRT: 0.12 ± 0.03; sevenfields IMRT: 0.10 ± 0.02; p< 0.05). Besides, 7 fields IMRT (0.10 ± 0.02) achieved superior HI to that of 5 fields IMRT (0.12 ± 0.03, p< 0.01). TOMO (p< 0.05) and VMAT (p< 0.05) were both significantly superior to IMRT in terms of the dose to lung (V5, V10, V15, V20, and V30). These 5 radiation techniques were similar regarding the dose to heart (V5, V20, and V30), but IMRT (5 fields IMRT: 19.27 ± 5.33; 7 fields IMRT: 20.05 ± 4.19) significantly raised the dose to the V50 of the heart when compared to VMAT (2 arcs VMAT: 16.6 ± 5.68; 3 arcs VMAT: 15.04 ± 5.75; p< 0.05) and TOMO (15.05 ± 4.7, p< 0.05). VMAT reduced the dose to BM (V5, V10, V20, and V30) as compared to TOMO (p< 0.05) and IMRT (p< 0.05). The CI of VMAT was the supreme one in those of the techniques in this study, so was the HI of IMRT. VMAT also provided another advantage that it reduced the dose to the BM. TOMO ameliorated the dose sparing of the lung, but the dose that the BM absorbed from TOMO was of some concern about BM toxicity.

A GATE/Geant4 Monte Carlo toolkit for surface dose calculation in VMAT breast cancer radiotherapy

The accuracy of superficial dose calculations for breast cancer treatments with Volumetric Modulated Arc Therapy (VMAT) is of major importance. For target volumes close to the surface, the inverse dosimetric planning can lead to very high fluences in the build-up region to properly cover the volume to be treated. Various radiotherapy modalities are currently used in parallel with additional protocols to enable a better control on the dose delivery (bolus, target volume margins). One of the difficulties currently facing medical physicists is the lack of available tools to test the impact of these different solutions on the superficial dose distribution. We present a new open source toolkit to assist medical physicists in evaluating the 3D distributions of superficial dose in VMAT breast cancer treatments. This tool is based on the GATE Monte Carlo software, a Geant4 application dedicated to medical physics. A set of macros has been developed to simulate in an easy way a full VMAT plan from the information available in the DICOM-RT files (image, plan, structure and dose). The toolkit has been tested on a 6 MV Varian NovalisTx™ accelerator. The paper presents a precise comparison of 3D surface dose distributions from experimental measurements (EBT3 films), TPS (Varian Eclipse) and Monte Carlo simulation (GATE). The comparison made it possible to highlight both the TPS biases for the surface dose calculation and the good performances of the developed toolkit. The simulation of surface dose distributions on a real patient has also been performed to illustrate the potential clinical applications.

Investigation of AAA dose calculation algorithm accuracy in surface and buildup region for 6MV photon beam using markus parallel-plate ion chamber.

In radiotherapy, dose distributions are obtained by using dose calculation algorithms that are implanted in treatment planning systems (TPS). This study aims to compare the surface doses of separate field sizes calculated by different version of The Analytical Anisotropic Algorithm (AAA) and measured by the parallel-plate ion chamber that is admitted as the most reliable dosimetry system for the surface region dose measurements. In order to measure the near surface dose, water equivalent solid phantom was used and measurements were made for 6MV photon beam at 100 cm source-detector distance for 5×5, 10×10, and 20×20 cm2 field sizes. AAA 8.9 and AAA 15.1 versions of the Varian Eclipse TPS were used for surface dose calculations by generating beams with separate field sizes. The doses were read by considering the effective buildup thickness of Markus parallel-plate ion chamber. The surface doses using 6 MV photon beams for 10×10 cm2 field size at 0.07 mm were found to be 11.04%, 26.25%, and 19.69% for AAA v8.9, AAA v15.1 and Markus chamber, respectively. It was seen that for both of the AAA versions and Markus parallel-plate ion chamber, increasing field sizes also increase surface dose. For all field sizes, surface dose was lowest by using AAA v8.9 at 0.07 mm. The different versions of the same TPS algorithms may calculate the surface doses distinctively. After upgrading of TPS algorithms, surface doses should be calculated and compared by measurements with different dosimetry systems to better understand their calculation behaviors in the near surface region.

Automated Closed- and Open-Loop Validation of Knowledge-Based Planning Routines Across Multiple Disease Sites

PurposeKnowledge-based planning (KBP) clinical implementation necessitates significant upfront effort, even within a single disease site. The purpose of this study was to demonstrate an efficient method for clinicians to assess the noninferiority of KBP across multiple disease sites and estimate any systematic dosimetric differences after implementation. We sought to establish these endpoints in a plurality of previously treated patients (validation set) with both closed-loop (training set overlapping validation set) and open-loop (independent training set) KBP routines. Methods and MaterialsWe identified 53 prostate, 24 prostatic fossa, 54 hypofractionated lung, and 52 head and neck patients treated with volumetric modulated arc therapy in the year directly preceding our clinic's broad adoption of RapidPlan (Varian Medical Systems, Palo Alto, CA). Using the Varian Eclipse Scripting API, our program takes as input a list of patients, then performs semiautomated structure matching, fully automated RapidPlan-driven optimization, and plan comparison. All plans were normalized to the planning target volume (PTV) D95% = 100%. Dose metric differences (ΔDx = Dx,clinical − Dx,KBP) were computed for standard PTV and organ-at-risk (OAR) dose-volume histogram parameters across disease sites. A 2-tailed paired t test quantified statistical significance (P < .001). ResultsStatistically significant organ dose-volume histogram improvements were observed in the KBP cohort: the rectum, bladder, and penile bulb in prostate/prostatic fossa; and the larynx, esophagus, cricopharyngeus, parotid glands, and cochlea in head and neck. No OAR dose metric was statistically worse in any KBP sample. PTV ΔD1% increases in prostatic fossa were deemed acceptable given organ-sparing gains. PTV ΔD1% and internal target volume ΔD99% increase for the lung was by design owing to the prescription normalization variance in the pre-KBP lung sample. ConclusionsOur automated method showed multiple disease sites' KBP routines to be noninferior to manual planning, with statistically significant superiority in some aspects of OAR sparing. This method is applicable to any institution implementing either closed-loop or open-loop KBP autoplanning routines.

A Model-Based Method for Assessment of Salivary Gland and Planning Target Volume Dosimetry in Volumetric-Modulated Arc Therapy Planning on Head-and-Neck Cancer.

This study examined the relationship of achievable mean dose and percent volumetric overlap of salivary gland with the planning target volume (PTV) in volumetric-modulated arc therapy (VMAT) plan in radiotherapy for a patient with head-and-neck cancer. The aim was to develop a model to predict the viability of planning objectives for both PTV coverage and organs-at-risk (OAR) sparing based on overlap volumes between PTVs and OARs, before the planning process. Forty patients with head-and-neck cancer were selected for this retrospective plan analysis. The patients were treated using 6 MV photons with 2-arc VMAT plan in prescriptions with simultaneous integrated boost in dose of 70 Gy, 63 Gy, and 58.1 Gy to primary tumor sites, high-risk nodal regions, and low-risk nodal regions, respectively, over 35 fractions. A VMAT plan was generated using Varian Eclipse (V13.6), in optimization with biological-based generalized equivalent uniform dose (gEUD) objective for OARs and targets. Target dose coverage (D95, Dmax, conformity index) and salivary gland dose (Dmean and Dmax) were evaluated in those plans. With a range of volume overlaps between salivary glands and PTVs and dose constraints applied, results showed that dose D95 for each PTV was adequate to satisfy D95 >95% of the prescription. Mean dose to parotid <26 Gy could be achieved with <20% volumetric overlap with PTV58 (parotid-PTV58). On an average, the Dmean was seen at 15.6 Gy, 21.1 Gy, and 24.2 Gy for the parotid-PTV58 volume at <5%, <10%, and <20%, respectively. For submandibular glands (SMGs), an average Dmean of 27.6 Gy was achieved in patients having <10% overlap with PTV58, and 36.1 Gy when <20% overlap. Mean doses on parotid and SMG were linearly correlated with overlap volume (regression R2 = 0.95 and 0.98, respectively), which were statistically significant (P < 0.0001). This linear relationship suggests that the assessment of the structural overlap might provide prospective for achievable planning objectives in the head-and-neck plan.

Biological Dose Comparison between a Fixed RBE and a Variable RBE in SFO and MFO IMPT with Various Multi-Beams for Brain Cancer

IMPT plans with various multi-angle beams were planned by the Varian Eclipse treatment planning system for one case of brain cancer. Dose distributions for each plan, along with the associated linear energy transfer distributions, were recomputed using an in-house fast Monte Carlo dose calculator with a FRBE of 1.1 or with a previously published VRBE model. We then compared dosimetric parameters obtained by the VRBE with those obtained by the FRBE. Biological doses obtained by the VRBE for the clinical target volume in all plans were 1% - 2% larger than those obtained by the FRBE. The minimum dose obtained by the VRBE for the right optic nerve in the MFO IMPT with 4 fields was 70% larger than that obtained by the FRBE, but the difference was only 18.1 cGy (RBE). The difference in maximum dose for the right optic nerve in the MFO IMPT with 5 fields was less than 10.4%, but the difference was 131.8 cGy (RBE). The mean difference in maximum dose was less than 2% for all other organs at risk. We found that biological dose with the FRBE had any dose errors in IMPT with various multi-angle beams.

Dosimetric Evaluation of TF-3DCRT, FIF-Forward IMRT and FF Inversely Optimized IMRT for Breast Conserving Treatment

Objective: To compare the dosimetric characteristic of tangential field 3D conformal (TF-3DCRT, TF), field-in-field intensity-modulated (FIF-IMRT, FIF) and fixed-field inversely optimized intensity-modulated Radiotherapy (FFIO-IMRT, FFIO) for breast conserving treatment, and explore the benefit and efficiency for the three techniques. Materials and Methods: TF-3DCRT, FIF-IMRT and FFIO-IMRT treatment plans were analyzed for 16 breast patients (8 right-sided and 8 left-sided) after breast-conserving surgery. The target and organs at risk (OARs) were contoured by the same physician in the CT images. The prescription dose was 50Gy/25f. TF-3DCRT and FIF-IMRT were designed using Varian Eclipse Ver10.0 planning system, and FFIO-IMRT in the planning system of Pinnacle Ver9.6. Treatment plans were compared according to dose volume histogram (DVH) analysis in terms of PTV homogeneity and conformity indices (HI and CI) as well as OARs dose and volume parameters, and the efficiency was also evaluated. Results: In all cases, the treatment plans showed statistically significant difference between TF-3DCRT, FIF and FFIO-IMRT. The MUs were 244.9±8.3MU vs 285.9±20.3MU vs 534.0±56.2MU (p<0.001), the CIs of dose distribution and the target were 0.40±0.12 vs 0.48±0.12 vs 0.57±0.12 (p<0.01), and the HIs were 0.20±0.02 vs 0.13±0.02 vs 0.17±0.02 (p<0.01). Compared with TF and FFIO, FIF-IMRT showed smaller in the dose of D2 and volume of V107 and V110 in the target. FFIO-IMRT generally increased the D mean, V10 and V20 of ipsilateral lung, the D1 of contralateral breast and the mean dose of contralateral lung, heart, esophagus, and spinal cord relative to TF and FIF techniques. Conclusion: In breast-conserving RT, FIF-IMRT improved the overall quality of dose distribution and delivery efficiency, and the patients are most likely to benefit from FIF-IMRT.