Impact of MLC properties and IMRT technique in meningioma and head-and-neck treatments.

PURPOSE: The impact of multileaf collimator (MLC) design and IMRT technique on plan quality and delivery improvements for head-and-neck and meningioma patients is compared in a planning study. MATERIAL AND METHODS: Ten previously treated patients (5 head-and-neck, 5 meningioma) were re-planned for step-and-shoot IMRT (ssIMRT), sliding window IMRT (dMLC) and VMAT using the MLCi2 without (-) and with (+) interdigitation and the Agility-MLC attached to an Elekta 6MV linac. This results in nine plans per patient. Consistent patient individual optimization parameters are used. Plans are generated using the research tool Hyperion V2.4 (equivalent to Elekta Monaco 3.2) with hard constraints for critical structures and objectives for target structures. For VMAT plans, the improved segment shape optimization is used. Critical structures are evaluated based on QUANTEC criteria. PTV coverage is compared by EUD, Dmean, homogeneity and conformity. Additionally, MU/plan, treatment times and number of segments are evaluated. RESULTS: As constrained optimization is used, all plans fulfill the hard constraints. Doses to critical structures do not differ more than 1 Gy between the nine generated plans for each patient. Only larynx, parotids and eyes differ up to 1.5 Gy (Dmean or Dmax) or 7% (volume-constraint) due to (1) increased scatter, (2) not avoiding structures when using the full range of gantry rotation and (3) improved leaf sequencing with advanced segment shape optimization for VMAT plans. EUD, Dmean, homogeneity and conformity are improved using the Agility-MLC. However, PTV coverage is more affected by technique. MU increase with the use of dMLC and VMAT, while the MU are reduced by using the Agility-MLC. Fastest treatments are always achieved using Agility-MLC, especially in combination with VMAT. CONCLUSION: Fastest treatments with the best PTV coverage are found for VMAT plans with Agility-MLC, achieving the same sparing of healthy tissue compared to the other combinations of ssIMRT, dMLC and VMAT with either MLCi2(-/+) or Agility.

Stereotactic radiotherapy of intrapulmonary lesions: comparison of different dose calculation algorithms for Oncentra MasterPlan®.

BACKGROUND: The use of high accuracy dose calculation algorithms, such as Monte Carlo (MC) and Collapsed Cone (CC) determine dose in inhomogeneous tissue more accurately than pencil beam (PB) algorithms. However, prescription protocols based on clinical experience with PB are often used for treatment plans calculated with CC. This may lead to treatment plans with changes in field size (FS) and changes in dose to organs at risk (OAR), especially for small tumor volumes in lung tissue treated with SABR. METHODS: We re-evaluated 17 3D-conformal treatment plans for small intrapulmonary lesions with a prescription of 60 Gy in fractions of 7.5 Gy to the 80% isodose. All treatment plans were initially calculated in Oncentra MasterPlan® using a PB algorithm and recalculated with CC (CCre-calc). Furthermore, a CC-based plan with coverage similar to the PB plan (CCcov) and a CC plan with relaxed coverage criteria (CCclin), were created. The plans were analyzed in terms of Dmean, Dmin, Dmax and coverage for GTV, PTV and ITV. Changes in mean lung dose (MLD), V10Gy and V20Gy were evaluated for the lungs. The re-planned CC plans were compared to the original PB plans regarding changes in total monitor units (MU) and average FS. RESULTS: When PB plans were recalculated with CC, the average V60Gy of GTV, ITV and PTV decreased by 13.2%, 19.9% and 41.4%, respectively. Average Dmean decreased by 9% (GTV), 11.6% (ITV) and 14.2% (PTV). Dmin decreased by 18.5% (GTV), 21.3% (ITV) and 17.5% (PTV). Dmax declined by 7.5%. PTV coverage correlated with PTV volume (p < 0.001). MLD, V10Gy, and V20Gy were significantly reduced in the CC plans. Both, CCcov and CCclin had significantly increased MUs and FS compared to PB. CONCLUSIONS: Recalculation of PB plans for small lung lesions with CC showed a strong decline in dose and coverage in GTV, ITV and PTV, and declined dose in the lung. Thus, switching from a PB algorithm to CC, while aiming to obtain similar target coverage, can be associated with application of more MU and extension of radiotherapy fields, causing greater OAR exposition.

Comparison and limitations of DVH-based NTCP models derived from 3D-CRT and IMRT data for prediction of gastrointestinal toxicities in prostate cancer patients by using propensity score matched pair analysis.

PURPOSE: This study compared normal tissue complication probability (NTCP) modeling of chronic gastrointestinal toxicities following prostate cancer treatment for 2 treatment modalities. Possible factors causing discrepancies in optimal NTCP model parameters between 3-dimensional conformal radiation therapy (3D-CRT) and intensity modulated RT (IMRT) were analyzed and discussed, including the impact of patient characteristics, image guidance, toxicity scoring bias, and NTCP model limitations. METHODS AND MATERIALS: Rectal wall dose-volume histograms of 1115 patients treated for prostate cancer under an adaptive radiation therapy protocol were used to model gastrointestinal toxicity grade ≥2 (according to Common Terminology Criteria for Adverse Events). A total of 457 patients were treated with 3D-CRT and 658 with IMRT. 3D-CRT patients were matched to IMRT patients based on various patient characteristics, using a propensity score-based algorithm. Parameters of the Lyman equivalent uniform dose and cut-off dose logistic regression NTCP models were estimated for the 2 matched treatment modalities and the combined group. RESULTS: After they were matched, the 3D-CRT and IMRT groups contained 275 and 550 patients with a large discrepancy of 28.7% versus 7.8% toxicities, respectively (P<.001). For both NTCP models, optimal parameters found for the 3D-CRT groups did not fit the IMRT patients well and vice versa. Models developed for the combined data overestimated NTCP for the IMRT patients and underestimated NTCP for the 3D-CRT group. CONCLUSIONS: Our analysis did not reveal a single definitive cause for discrepancies of model parameters between 3D-CRT and IMRT. Patient characteristics and bias in toxicity scoring, as well as image guidance alone, are unlikely causes of the large discrepancy of toxicities. Whether the cause was inherent to the specific NTCP models used in this study needs to be verified by future investigations. Because IMRT is increasingly used clinically, it is important that appropriate NTCP model parameters are determined for this treatment modality.