Evaluation of robustness of optimization methods in breast intensity-modulated radiation therapy using TomoTherapy.

Intensity-modulated radiation therapy (IMRT) has become a popular choice for breast cancer treatment. We aimed to evaluate and compare the robustness of each optimization method used for breast IMRT using TomoTherapy. A retrospective analysis was performed on 10 patients with left breast cancer. For each optimization method (clipping, virtual bolus, and skin flash), a corresponding 50 Gy/25 fr plan was created in the helical and direct TomoTherapy modes. The dose-volume histogram parameters were compared after shifting the patients anteriorly and posteriorly. In the helical mode, when the patient was not shifted, the median D1cc (minimum dose delivered to 1 cc of the organ volume) of the breast skin for the clipping and virtual bolus plans was 52.2 (interquartile range: 51.9-52.6) and 50.4 (50.1-50.8) Gy, respectively. After an anterior shift, D1cc of the breast skin for the clipping and virtual bolus plans was 56.0 (55.6-56.8) and 50.9 (50.5-51.3) Gy, respectively. When the direct mode was used without shifting the patient, D1cc of the breast skin for the clipping, virtual bolus, and skin flash plans was 52.6 (51.9-53.1), 53.4 (52.6-53.9), and 52.3 (51.7-53.0) Gy, respectively. After shifting anteriorly, D1cc of the breast skin for the clipping, virtual bolus, and skin flash plans was 55.6 (54.1-56.4), 52.4 (52.0-53.0), and 53.6 (52.6-54.6) Gy, respectively. The clipping method is not sufficient for breast IMRT. The virtual bolus and skin flash methods were more robust optimization methods according to our analyses.

Respiratory motion tracking of spine stereotactic radiotherapy in prone position.

PURPOSE: The CyberKnife system is a specialized device for non-coplanar irradiation; however, it possesses the geometric restriction that the beam cannot be irradiated from under the treatment couch. Prone positioning is expected to reduce the dose to normal lung tissue in spinal stereotactic body radiotherapy (SBRT) owing to the efficiency of beam arrangement; however, respiratory motion occurs. Therefore, the Xsight spine prone tracking (XSPT) system is used to reduce the effects of respiratory motion. The purpose of this study was to evaluate the motion-tracking error of the spine in the prone position. MATERIALS AND METHODS: Data from all 25 patients who underwent spinal SBRT at our institution between April 2020 and February 2022 using CyberKnife (VSI, version 11.1.0) with the XSPT tracking system were retrospectively analyzed using log files. The tumor motion, correlation, and prediction errors for each patient were examined. Furthermore, to assess the potential relationships between the parameters, the relationships between the tumor-motion amplitudes and correlation or prediction errors were investigated using linear regression. RESULTS: The tumor-motion amplitudes in each direction were as follows: superior-inferior (SI), 0.51 ± 0.39 mm; left-right (LR), 0.37 ± 0.29 mm; and anterior-posterior (AP), 3.43 ± 1.63 mm. The overall mean correlation and prediction errors were 0.66 ± 0.48 mm and 0.06 ± 0.07 mm, respectively. The prediction errors were strongly correlated with the tumor-motion amplitudes, whereas the correlation errors were not. CONCLUSIONS: This study demonstrated that the correlation error of spinal SBRT in the prone position is sufficiently small to be independent of the tumor-motion amplitude. Furthermore, the prediction error is small, contributing only slightly to the tracking error. These findings will improve the understanding of how to compensate for respiratory-motion uncertainty in the prone position.

Fiducial marker position affects target volume in stereotactic lung irradiation.

PURPOSE: Real-time tracking systems of moving respiratory targets such as CyberKnife, Radixact, or Vero4DRT are an advanced robotic radiotherapy device used to deliver stereotactic body radiotherapy (SBRT). The internal target volume (ITV) of lung tumors is assessed through a fiducial marker fusion using four-dimensional computed tomography (CT). It is important to minimize the ITV to protect normal lung tissue from exposure to radiation and the associated side effects post SBRT. However, the ITV may alter if there is a change in the position of the fiducial marker with respect to the tumor. This study investigated the relationship between fiducial marker position and the ITV in order to prevent radiation exposure of normal lung tissue, and correct target coverage. MATERIALS AND METHODS: This study retrospectively reviewed 230 lung cancer patients who received a fiducial marker for SBRT between April 2015 and September 2021. The distance of the fiducial marker to the gross tumor volume (GTV) in the expiratory (dex ) and inspiratory (din ) CT, and the ratio of the ITV/V(GTVex ), were investigated. RESULTS: Upon comparing each lobe, although there was no significant difference in the ddiff and the ITV/V(GTVex ) between all lobes for dex  < 10 mm, there was significant difference in the ddiff and the ITV/V(GTVex ) between the lower and upper lobes for dex ≥ 10 mm (p < 0.05). Moreover, there was significant difference in the ddiff and the ITV/V(GTVex ) between dex ≥10 mm and dex  < 10 mm in all lung regions (p < 0.05). CONCLUSION: The ITV that had no margin from GTVs increased when dex was ≥10 mm for all lung regions (p < 0.05). Furthermore, the increase in ITV tended to be greater in the lower lung lobe. These findings can help decrease the possibility of adverse events post SBRT, and correct target coverage.

Plan comparison of prostate stereotactic radiotherapy in spacer implant patients.

In prostate stereotactic body radiation therapy (SBRT), hydrogel spacers are increasingly used. This study aimed to perform a dosimetry comparison of treatment plans using CyberKnife (CK), commonly used for prostate SBRT, Helical TomoTherapy (HT), and TrueBeam (TB) in patients with hydrogel spacer implantations. The data of 20 patients who received hydrogel spacer implantation for prostate SBRT were retrospectively analyzed. The prescription dose was 36.25 Gy in five fractions to 95% of the planning target volume (PTV; D95). The conformity index (CI), gradient index (GI), homogeneity index (HI), and dose-volume histogram (DVH) were analyzed for the three modalities, using the same PTV margins. The monitor unit (MU) and the beam-on-time (BOT) values were subsequently compared. The CI of TB (0.93 ± 0.02) was significantly superior to those of CK (0.82 ± 0.03, p < 0.01) and HT (0.86 ± 0.03, p < 0.01). Similarly, the GI value of TB (3.59 ± 0.12) was significantly better than those of CK (4.31 ± 0.43, p < 0.01) and HT (4.52 ± 0.24, p < 0.01). The median doses to the bladder did not differ between the CK and TB (V18.1 Gy: 16.5% ± 4.5% vs. 15.8% ± 4.4%, p = 1.00), but were significantly higher for HT (V18.1 Gy: 33.2% ± 7.3%, p < 0.01 vs. CK, p < 0.01 vs. TB). The median rectal dose was significantly lower for TB (V18.1 Gy: 5.6% ± 4.5%) than for CK (V18.1 Gy: 11.2% ± 6.7%, p < 0.01) and HT (20.2% ± 8.3%, p < 0.01). TB had the shortest BOT (2.6 min; CK: 17.4 min, HT: 6.9 min). TB could create treatment plans dosimetrically comparable to those of CK when using the same margins, in patients with hydrogel spacers.

Determination of appropriate conversion factors for calculating size-specific dose estimates based on X-ray CT scout images after miscentering correction.

In this study, we proposed and evaluated the validity of an optimized size-specific dose estimate, a widely used index of radiation dose in X-ray computed tomography (CT) examinations. Based on miscentering correction of scout images, we determined the appropriate conversion factors (CF) by using a phantom. Scans were conducted using a multi-detector CT system (Aquilion ONE, Canon Medical Systems). Four cylindrical phantoms were taken in the anteroposterior (AP) and axial directions to determine the relationship between pixel value and water-equivalent length (Lw). In the AP scout image, the pixel values at the selected slice positions were converted to Lw to calculate the water-equivalent diameter (Dw). The CF was derived from Dw and CF values before and after miscentering correction was calculated. Finally, the CF values were compared to those calculated from the axial image using the conventional methodology of the American Association of Physicists in Medicine. Before miscentering correction, the maximum difference between the CF values of the axial and scout images was 7.26%. However, after miscentering correction, the maximum difference was 1.34%. Validation using a whole-body phantom generally revealed low maximum differences between the CF from the axial image and the values from the miscentering-corrected scout images. These were 2.41% in the chest, 6.30% in the upper abdomen, 1.43% in the abdomen, and 2.45% in the pelvic region. Consequently, we concluded that our miscentering correction method for deriving the appropriate CF values based on scout images is advantageous.

Optimization of the Timing of the Portal Venous Phase in Preoperative 3DCT for Malignant Liver Tumors.

Preoperative three-dimensional computed tomography (3DCT) of the liver is the most important examination in performing preoperative simulation. Detailed visualization of the portal vein using the workstation is critical to enable accurate liver segmentation. However, the timing of imaging in the portal venous phase has mostly been reported equivalent to that of the liver screening examinations commonly performed. The purpose of this study was to examine the optimal timing of image capture to create the best portal vein visualization in preoperative 3DCT of the liver. Seventy-nine patients who underwent hepatectomy for malignant liver tumors were enrolled in this study. All patients were preoperatively examined using protocol A (imaging method separated into a portal venous phase and a hepatic venous phase) and then examined 1 week after surgery using protocol B (normal liver screening protocol). We first established the regions of interest in the portal vein and the hepatic vein and then compared CT values for these regions under protocol A and protocol B. The average CT value of the portal vein in protocol A and B was 239.8±28.1 HU and 202.2±18.5 HU, respectively. The average CT value of the portal vein in protocol A was significantly higher compared with protocol B (p<0.01). By introducing separate timing for portal venous phase imaging before preoperative 3DCT (protocol A), it is possible to satisfactorily depict the portal vein.

Evaluation of Size Correction Factor for Size-specific Dose Estimates (SSDE) Calculation.

American Association of Physicists in Medicine (AAPM) Report No.204 recommends the size-specific dose estimates (SSDE), wherein SSDE=computed tomography dose index-volume (CTDIvol )×size correction factor (SCF), as an index of the CT dose to consider patient thickness. However, the study on SSDE has not been made yet for area detector CT (ADCT) device such as a 320-row CT scanner. The purpose of this study was to evaluate the SCF values for ADCT by means of a simulation technique to look into the differences in SCF values due to beam width. In the simulation, to construct the geometry of the Aquilion ONE X-ray CT system (120 kV), the dose ratio and the effective energies were measured in the cone angle and fan angle directions, and these were incorporated into the simulation code, Electron Gamma Shower Ver.5 (EGS5). By changing the thickness of a PMMA phantom from 8 cm to 40 cm, CTDIvol and SCF were determined. The SCF values for the beam widths in conventional and volume scans were calculated. The differences among the SCF values of conventional, volume scans, and AAPM were up to 23.0%. However, when SCF values were normalized in a phantom of 16 cm diameter, the error tended to decrease for the cases of thin body thickness, such as those of children. It was concluded that even if beam width and device are different, the SCF values recommended by AAPM are useful in clinical situations.