Reporting and analyzing dose distributions: a concept of equivalent uniform dose

Is it beneficial to selectively boost high-risk tumor subvolumes? A comparison of selectively boosting high-risk tumor subvolumes versus homogeneous dose escalation of the entire tumor based on equivalent EUD plans

PURPOSE

To quantify and compare expected local tumor control and expected normal tissue toxicities between selective boosting IMRT and homogeneous dose escalation IMRT for the case of prostate cancer.

METHODS

Four different selective boosting scenarios and three different high-risk tumor subvolume geometries were designed to compare selective boosting and homogeneous dose escalation IMRT plans delivering the same equivalent uniform dose (EUD) to the entire PTV. For each scenario, differences in tumor control probability between both boosting strategies were calculated for the high-risk tumor subvolume and remaining low-risk PTV, and were visualized using voxel based iso-TCP maps. Differences in expected rectal and bladder complications were quantified using radiobiological indices (generalized EUD (gEUD) and normal tissue complication probability (NTCP)) as well as %-volumes.

RESULTS

For all investigated scenarios and high-risk tumor subvolume geometries, selective boosting IMRT improves expected TCP compared to homogeneous dose escalation IMRT, especially when lack of control of the high-risk tumor subvolume could be the cause for tumor recurrence. Employing, selective boosting IMRT significant increases in expected TCP can be achieved for the high-risk tumor subvolumes. The three conventional selective boosting IMRT strategies, employing physical dose objectives, did not show significant improvement in rectal and bladder sparing as compared to their counterpart homogeneous dose escalation plans. However, risk-adaptive optimization, utilizing radiobiological objective functions, resulted in reduction in NTCP for the rectum when compared to its corresponding homogeneous dose escalation plan.

CONCLUSIONS

Selective boosting is a more effective method than homogeneous dose escalation for achieving optimal treatment outcomes. Furthermore, risk-adaptive optimization increases the therapeutic ratio as compared to conventional selective boosting IMRT.

Characteristics of movement-induced dose reduction in target volume: a comparison between photon and proton beam treatment

We compared the main characteristics of movement-induced dose reduction during photon and proton beam treatment, based on an analysis of dose-volume histograms. To simulate target movement, a target contour was delineated in a scanned phantom and displaced by 3 to 20 mm. Although the dose reductions to the target in the 2 treatment systems were similar for transverse (perpendicular to beam direction) target motion, they were completely different for longitudinal (parallel to beam direction) target motion. While both modalities showed a relationship between the degree of target shift and the reduction in dose coverage, dose reduction showed a strong directional dependence in proton beam treatment. Clinical simulation of target movement for a prostate cancer patient showed that, although coverage and conformity indices for a 6-mm lateral movement of the prostate were reduced by 9% and 16%, respectively, for proton beam treatment, they were reduced by only 1% and 7%, respectively, for photon treatment. This difference was greater for a 15-mm target movement in the lateral direction, which lowered the coverage and conformity indices by 34% and 54%, respectively, for proton beam treatment, but changed little during photon treatment. In addition, we found that the equivalent uniform dose (EUD) and homogeneity index show similar characteristics during target movement. These results suggest that movement-induced dose reduction differs significantly between photon and proton beam treatment. Attention should be paid to the target margin in proton beam treatment due to the distinct characteristics of heavy ion beams.

Analyzing adjuvant radiotherapy suggests a non monotonic radio-sensitivity over tumor volumes

BACKGROUND

Adjuvant Radiotherapy (RT) after surgical removal of tumors proved beneficial in long-term tumor control and treatment planning. For many years, it has been well concluded that radio-sensitivities of tumors upon radiotherapy decrease according to the sizes of tumors and RT models based on Poisson statistics have been used extensively to validate clinical data.

RESULTS

We found that Poisson statistics on RT is actually derived from bacterial cells despite of many validations from clinical data. However cancerous cells do have abnormal cellular communications and use chemical messengers to signal both surrounding normal and cancerous cells to develop new blood vessels and to invade, to metastasis and to overcome intercellular spatial confinements in general. We therefore investigated the cell killing effects on adjuvant RT and found that radio-sensitivity is actually not a monotonic function of volume as it was believed before. We present detailed analysis and explanation to justify above statement. Based on EUD, we present an equivalent radio-sensitivity model.

CONCLUSION

We conclude that radio sensitivity is a sophisticated function over tumor volumes, since tumor responses upon radio therapy also depend on cellular communications.

Observation of a dose-control relationship for lung and liver tumors after stereotactic body radiation therapy

PURPOSE

To determine prognostic factors for local control of primary or metastatic tumors within the lung or liver treated with stereotactic body radiation therapy (SBRT) within a single institution.

METHODS AND MATERIALS

The records of 141 consecutive patients with 246 lesions treated with three-fraction SBRT from Oct 1999 through Aug 2005 were reviewed. Local control was assessed radiographically. Univariate and multivariate analyses were performed to evaluate the influence of the following factors on local control: total dose, expressed as either nominal prescription dose or equivalent uniform dose (EUD); gross tumor volume; primary site; treatment site (lung vs. other); histologic characteristics (adenocarcinoma vs. other); gender; age; and primary vs. metastatic tumor.

RESULTS

On univariate analysis, increased dose (either nominal or EUD) and smaller gross tumor volume were significant predictors of higher local control. Lesions treated to a nominal dose of 54 Gy or greater had a 3-year actuarial local control rate of 89.3% compared with 59.0% and 8.1% for those treated to 36-53.9 Gy and less than 36 Gy. On multivariate analysis, only increased nominal dose and EUD retained statistical significance. Treatment was well tolerated; 5.7% of patients experienced Grade 3 or higher toxicity.

CONCLUSIONS

This large single-institution series suggests a dose-control relationship within the range of SBRT doses applied. Excellent local control rates are achieved with a nominal dose of 54 Gy or greater, corresponding to an EUD greater than 65.3 Gy. These results support the use of aggressive SBRT regimens when durable tumor control is the primary objective.

Intensity modulation with photons for benign intracranial tumours: a planning comparison of volumetric single arc, helical arc and fixed gantry techniques

BACKGROUND AND PURPOSE

The potential benefits and limitations of the new RapidArc treatment concept compared to Helical Tomotherapy and fixed gantry intensity modulation techniques have been assessed at treatment planning level on 12 patients presenting with 'benign' brain tumours.

MATERIALS AND METHODS

Plans for five acoustic neurinomas, five meningiomas and two pituitary adenomas were computed for an Helical Tomotherapy (HT) unit, for RapidArc delivery (RA) on a linac equipped with two types of MLC (RA_HD120 with the new High Definition MLC with 2.5mm leaf width at isocentre and RA_M120 with the standard Millennium with 5mm resolution) and for fixed beam IMRT with the High Definition MLC. Analysis was mostly performed on physical quantities derived from Dose-Volume Histograms (DVHs).

RESULTS

Target coverage resulted basically equivalent among techniques. V(95%) (in %) was higher than 99% for all techniques, minimum significant dose (D(99%)) was 95.5+/-1.4 for IMRT, 96.2+/-1.4 and 97.0+/-1.2 for the RA_HD120 and RA_M120 approaches and 96.8+/-1.7 for HT, maximum significant dose (D(1%), in %) was 102.2+/-0.8, 102.7+/-0.5, 102.4+/-0.5 and 103.0+/-1.1, respectively, standard deviation (in %) was 1.4+/-0.4, 1.3+/-0.3, 1.1+/-0.2 and 0.8+/-0.3, respectively. Conformity Index (CI(95%)) was 0.47+/-0.12, 0.46+/-0.12, 0.43+/-0.11 and 0.38+/-0.11, respectively. For organs at risk all techniques respected planning objectives. Concerning the healthy tissue: V(10 Gy) (in %) was 9.4+/-5.5, 9.9+/-6.1, 9.2+/-6.1 and 12.1+/-8.8, respectively. Integral dose measured on the healthy tissue was 7.5+/-3.3, 9.7+/-3.4, 8.7+/-3.4, 10.4+/-4.2 10(3) Gy cm(3), respectively.

CONCLUSIONS

For the class of tumours investigated in this report, HT and RA and IMRT proved to be adequate to properly treat patients. Further studies on more complex cases need to be investigated in order to assess the effectiveness of this new technique in a broader clinical perspective.

Lung 4D-IMRT treatment planning: an evaluation of three methods applied to four-dimensional data sets

PURPOSE

To compare 4D-dose distributions for IMRT planning on three data sets: a single 4D-CT phase, a 4D-CT phase with a density override to the tumor motion envelope (TME) volume, and the average intensity projection (AIP).

METHODS

Eight planning cases were considered. IMRT inverse planning optimization was performed on each of the three data set types, for each case considered. The plans were then applied to all ten phases of the associated 4D-CT data set. The dose to the GTV in each breathing phase was compared to the TME dose from the optimized dose distribution, as well as the GTV dose determined from a model-based deformable registration algorithm.

RESULTS

IMRT optimization on a single 3D data set resulted in a greater equivalent uniform dose (EUD) to the GTV when applied to a 4D-CT data set than the EUD for the TME in the optimized plan. The difference was up to 5.5Gy in one case. For all cases and planning techniques considered, a maximum difference of 0.3Gy in the NTDmean to the healthy lung throughout the breathing cycle was found.

CONCLUSIONS

For tumors located in the periphery of the lung, optimization on the AIP image resulted in a more uniform GTV dose throughout the breathing cycle. Averages in GTV EUD and healthy lung NTDmean taken over all the breathing phases were found to be in agreement with the dose effect parameters obtained from model-based deformable registration algorithms. All planning methods yielded GTV EUD values that were larger than the prescribed dose when the full 4D data set was considered.

Volumetric modulated arc therapy for delivery of prostate radiotherapy: comparison with intensity-modulated radiotherapy and three-dimensional conformal radiotherapy

PURPOSE

Volumetric modulated arc therapy (VMAT) is a novel form of intensity-modulated radiotherapy (IMRT) optimization that allows the radiation dose to be delivered in a single gantry rotation of up to 360 degrees , using either a constant dose rate (cdr-VMAT) or variable dose rate (vdr-VMAT) during rotation. The goal of this study was to compare VMAT prostate RT plans with three-dimensional conformal RT (3D-CRT) and IMRT plans.

PATIENTS AND METHODS

The 3D-CRT, five-field IMRT, cdr-VMAT, and vdr-VMAT RT plans were created for 10 computed tomography data sets from patients undergoing RT for prostate cancer. The parameters evaluated included the doses to organs at risk, equivalent uniform doses, dose homogeneity and conformality, and monitor units required for delivery of a 2-Gy fraction.

RESULTS

The IMRT and both VMAT techniques resulted in lower doses to normal critical structures than 3D-CRT plans for nearly all dosimetric endpoints analyzed. The lowest doses to organs at risk and most favorable equivalent uniform doses were achieved with vdr-VMAT, which was significantly better than IMRT for the rectal and femoral head dosimetric endpoints (p < 0.05) and significantly better than cdr-VMAT for most bladder and rectal endpoints (p < 0.05). The vdr-VMAT and cdr-VMAT plans required fewer monitor units than did the IMRT plans (relative reduction of 42% and 38%, respectively; p = 0.005) but more than for the 3D-CRT plans (p = 0.005).

CONCLUSION

The IMRT and VMAT techniques achieved highly conformal treatment plans. The vdr-VMAT technique resulted in more favorable dose distributions than the IMRT or cdr-VMAT techniques, and reduced the monitor units required compared with IMRT.

Evaluating target cold spots by the use of tail EUDs

PURPOSE

To propose a new measure of target underdose that can be used in the evaluation and optimization of radiotherapy dose distributions.

METHODS AND MATERIALS

We compare various formulations of the equivalent uniform dose (EUD) and introduce a modification of existing EUD definitions, which we call tail EUD. Tail EUD is a measure of "cold spots" below the prescription dose in the target dose distribution, using units of gray (Gy). We investigate the mathematical properties of various target EUD concepts, including tail EUD. We apply the tail EUD measure retrospectively to intensity modulated radiation therapy (IMRT) treatment plans from our plan database. We also use tail EUD as an optimization objective in the optimization of prostate, pancreas, and head-and-neck plans.

RESULTS

Tail EUD has desirable mathematical properties. In particular, it is convex and it leads to convex level sets (i.e., no local minima) if the EUD from which it is derived is concave. The tail EUD value is correlated with the subjective degree of target coverage. Constraining tail EUDs to a certain level in plan optimization leads to comparable target coverage in different plans and treatment sites.

CONCLUSIONS

The newly introduced concept of tail EUD appears to be useful for both plan evaluation and optimization. In addition it can potentially be applied in the design of new clinical protocols.

Dose-volume and biological-model based comparison between helical tomotherapy and (inverse-planned) IMAT for prostate tumours

BACKGROUND AND PURPOSE

Helical tomotherapy (HT) and intensity-modulated arc therapy (IMAT) are two arc-based approaches to the delivery of intensity-modulated radiotherapy (IMRT). Through plan comparisons we have investigated the potential of IMAT, both with constant (conventional or IMAT-C) and variable (non-conventional or IMAT-NC, a theoretical exercise) dose-rate, to serve as an alternative to helical tomotherapy.

MATERIALS AND METHODS

Six patients with prostate tumours treated by HT with a moderately hypo-fractionated protocol, involving a simultaneous integrated boost, were re-planned as IMAT treatments. A method for IMAT inverse-planning using a commercial module for static IMRT combined with a multi-leaf collimator (MLC) arc-sequencing was developed. IMAT plans were compared to HT plans in terms of dose statistics and radiobiological indices.

RESULTS

Concerning the planning target volume (PTV), the mean doses for all PTVs were similar for HT and IMAT-C plans with minimum dose, target coverage, equivalent uniform dose (EUD) and tumour control probability (TCP) values being generally higher for HT; maximum dose and degree of heterogeneity were instead higher for IMAT-C. In relation to organs at risk, mean doses and normal tissue complication probability (NTCP) values were similar between the two modalities, except for the penile bulb where IMAT was significantly better. Re-normalizing all plans to the same rectal toxicity (NTCP=5%), the HT modality yielded higher TCP than IMAT-C but there was no significant difference between HT and IMAT-NC. The integral dose with HT was higher than that for IMAT.

CONCLUSIONS

with regards to the plan analysis, the HT is superior to IMAT-C in terms of target coverage and dose homogeneity within the PTV. Introducing dose-rate variation during arc-rotation, not deliverable with current linac technology, the simulations result in comparable plan indices between (IMAT-NC) and HT.

The influence of changes in tumor hypoxia on dose-painting treatment plans based on 18F-FMISO positron emission tomography

PURPOSE

To evaluate how changes in tumor hypoxia, according to serial fluorine-18-labeled fluoro-misonidazole (18F-FMISO) positron emission tomography (PET) imaging, affect the efficacy of intensity-modulated radiotherapy (IMRT) dose painting.

METHODS AND MATERIALS

Seven patients with head and neck cancers were imaged twice with FMISO PET, separated by 3 days, before radiotherapy. Intensity-modulated radiotherapy plans were designed, on the basis of the first FMISO scan, to deliver a boost dose of 14 Gy to the hypoxic volume, in addition to the 70-Gy prescription dose. The same plans were then applied to hypoxic volumes from the second FMISO scan, and the efficacy of dose painting evaluated by assessing coverage of the hypoxic volumes using Dmax, Dmin, Dmean, D95, and equivalent uniform dose (EUD).

RESULTS

Similar hypoxic volumes were observed in the serial scans for 3 patients but dissimilar ones for the other 4. There was reduced coverage of hypoxic volumes of the second FMISO scan relative to that of the first scan (e.g., the average EUD decreased from 87 Gy to 80 Gy). The decrease was dependent on the similarity of the hypoxic volumes of the two scans (e.g., the average EUD decrease was approximately 4 Gy for patients with similar hypoxic volumes and approximately 12 Gy for patients with dissimilar ones).

CONCLUSIONS

The changes in spatial distribution of tumor hypoxia, as detected in serial FMISO PET imaging, compromised the coverage of hypoxic tumor volumes achievable by dose-painting IMRT. However, dose painting always increased the EUD of the hypoxic volumes.

Simultaneous tumour dose escalation and liver sparing in Stereotactic Body Radiation Therapy (SBRT) for liver tumours due to CTV-to-PTV margin reduction

PURPOSE

To quantify potential benefits of CTV-to-PTV margin reduction for SBRT of liver tumours, as allowed by enhanced treatment precision.

MATERIALS AND METHODS

For 14 patients plans were generated for the clinical margin and for 3 tighter margins. An in-house developed algorithm was used to optimise beam directions, shapes, and weights for generation of the plan with the highest isocenter dose (D(iso)), while keeping the minimum PTV dose at least 65%xD(iso) and strictly adhering to all imposed hard OAR constraints. Each plan contains 10 optimal beam directions, automatically selected from up to 252 coplanar and non-coplanar input directions.

RESULTS

Apart from the expected tumour dose escalation (D(iso), EUD(PTV), gEUD(PTV)) with decreasing margin, a simultaneous improved sparing of the normal liver (D33%, D50%, D(mean)) was also observed. The smaller the margin was, the bigger both effects were. For renormalized plans with D(iso) equal to the clinical value (3x19.2Gy), and a margin reduction of 50% (2.5mm laterally, 5mm longitudinally), normal liver D33% and D50% reduced on average by 22% (maximum 38%), and 26% (maximum 47%), respectively.

CONCLUSIONS

Using an algorithm for beam direction, shape and weight optimisation, large increases in the therapeutic ratio of liver plans could be obtained for reduced margins.

Inter- and intrafractional movement-induced dose reduction of prostate target volume in proton beam treatment

PURPOSE

To quantify proton radiotherapy dose reduction in the prostate target volume because of the three-dimensional movement of the prostate based on an analysis of dose-volume histograms (DVHs).

METHODS AND MATERIALS

Twelve prostate cancer patients underwent scanning in supine position, and a target contour was delineated for each using a proton treatment planning system. To simulate target movement, the contour was displaced from 3 to 15 mm in 3-mm intervals in the superior-to-inferior (SI), inferior-to-superior (IS), anterior-to-posterior (AP), posterior-to-anterior (PA), and left-to-right (LR) directions.

RESULTS

For both intra- and interfractional movements, the average coverage index and conformity index of the target were reduced in all directions. For interfractional movements, the magnitude of dose reduction was greater in the LR direction than in the AP, PA, SI. and IS directions. Although the reduction of target dose was proportional to the magnitude of intrafractional movement in all directions, a proportionality between dose reduction and the magnitude of interfractional target movement was clear only in the LR direction. Like the coverage index and conformity index, the equivalent uniform dose and homogeneity index showed similar reductions for both types of target movements.

CONCLUSIONS

Small target movements can significantly reduce target proton radiotherapy dose during treatment of prostate cancer patients. Attention should be given to interfractional target movement along the longitudinal direction, as image-guided radiotherapy may be ineffective if margins are not sufficient.

Is daily CT image guidance necessary for nasal cavity and nasopharyngeal radiotherapy: an investigation based on helical tomotherapy

To analyze the magnitude of setup errors corrected by helical tomotherapy megavoltage computed tomography (MVCT) on a daily or weekly basis and the impact of those corrections on the delivered dose to the tumor and organs at risk (OARs), we retrospectively analyzed the setup errors for 6 nasal cavity and 4 nasopharyngeal cancer patients treated with helical tomotherapy for 25 – 33 fractions. Each patient had MVCT‐guided repositioning for all fractions of treatment. The new dose–volume histograms (DVHs) and equivalent uniform doses (EUDs) for the planning target volume (PTV) and OARs were calculated for hypothetical situations in which no imaging guidance (IG) or once‐weekly imaging guidance (WIG) took place. The mean total setup error for treatment without daily IG was 3.6±1.0 mm, which could be reduced to 1.7±0.6 mm if WIG were to be performed. The geometric uncertainties from the absence of IG resulted in a reduction of mean PTV EUD by 2.1%±1.0%, which could be reduced to 1.4%±1.0% with WIG. The EUDs of the OARs increased to 1.8±2.0 Gy or 0.8±1.3 Gy without and with WIG respectively. Without daily IG, the mean uncertainty in patient position has a relatively small effect on the mean dosimetry for PTV and OARs, and the use of WIG can further reduce those effects by approximately half. On the other hand, because of the large variance, with low probability, substantial deviation from the original planned dosimetry may occur without IG. Therefore, daily MVCT is preferred as an important safety measure in the delivery of intensity‐modulated radiation therapy.

PACS number: 87.53.Dq

Advances in radiation therapy for brain tumors

Radiation therapy is used postoperatively as adjunctive therapy to decrease local failure; to delay tumor progression and prolong survival; as a curative treatment; as a therapy that halts further tumor growth; to alter function; and for palliation. Registration of MRI scan data sets with the treatment-planning CT scan is essential for accurate definition of the tumor and surrounding organs at risk. Integrating additional imaging studies that reflect the biologic characteristics of central nervous system tumors is an area of active research. Conformal treatment delivery is used to spare adjacent normal tissue from receiving unnecessary dose. In the dose range used when treating these tumors, the probability of causing serious late toxicity is relatively low and secondary malignancies are rare.

Parotid gland dose in intensity-modulated radiotherapy for head and neck cancer: is what you plan what you get?

PURPOSE

To quantify the differences between planned and delivered parotid gland and target doses, and to assess the benefits of daily bone alignment for head and neck cancer patients treated with intensity-modulated radiotherapy (IMRT).

METHODS AND MATERIALS

Eleven head and neck cancer patients received two CT scans per week with an in-room CT scanner over the course of their radiotherapy. The clinical IMRT plans, designed with 3-mm to 4-mm planning margins, were recalculated on the repeat CT images. The plans were aligned using the actual treatment isocenter marked with radiopaque markers (BB) and bone alignment to the cervical vertebrae to simulate image-guided setup. In-house deformable image registration software was used to map daily dose distributions to the original treatment plan and to calculate a cumulative delivered dose distribution for each patient.

RESULTS

Using conventional BB alignment led to increases in the parotid gland mean dose above the planned dose by 5 to 7 Gy in 45% of the patients (median, 3.0 Gy ipsilateral, p = 0.026; median, 1.0 Gy contralateral, p = 0.016). Use of bone alignment led to reductions relative to BB alignment in 91% of patients (median, 2 Gy; range, 0.3-8.3 Gy; 15 of 22 parotids improved). However, the parotid dose from bone alignment was still greater than planned (median, 1.0 Gy, p = 0.007). Neither approach affected tumor dose coverage.

CONCLUSIONS

With conventional BB alignment, the parotid gland mean dose was significantly increased above the planned mean dose. Using daily bone alignment reduced the parotid dose compared with BB alignment in almost all patients. A 3- to 4-mm planning margin was adequate for tumor dose coverage.

A new formula for normal tissue complication probability (NTCP) as a function of equivalent uniform dose (EUD)

To facilitate the use of biological outcome modeling for treatment planning, an exponential function is introduced as a simpler equivalent to the Lyman formula for calculating normal tissue complication probability (NTCP). The single parameter of the exponential function is chosen to reproduce the Lyman calculation to within approximately 0.3%, and thus enable easy conversion of data contained in empirical fits of Lyman parameters for organs at risk (OARs). Organ parameters for the new formula are given in terms of Lyman model m and TD(50), and conversely m and TD(50) are expressed in terms of the parameters of the new equation. The role of the Lyman volume-effect parameter n is unchanged from its role in the Lyman model. For a non-homogeneously irradiated OAR, an equation relates d(ref), n, v(eff) and the Niemierko equivalent uniform dose (EUD), where d(ref) and v(eff) are the reference dose and effective fractional volume of the Kutcher-Burman reduction algorithm (i.e. the LKB model). It follows in the LKB model that uniform EUD irradiation of an OAR results in the same NTCP as the original non-homogeneous distribution. The NTCP equation is therefore represented as a function of EUD. The inverse equation expresses EUD as a function of NTCP and is used to generate a table of EUD versus normal tissue complication probability for the Emami-Burman parameter fits as well as for OAR parameter sets from more recent data.

BGRT: biologically guided radiation therapy-the future is fast approaching!

Rapid advances in functional and biological imaging, predictive assays, and our understanding of the molecular and cellular responses underpinning treatment outcomes herald the coming of the long-sought goal of implementing patient-specific biologically guided radiation therapy (BGRT) in the clinic. Biological imaging and predictive assays have the potential to provide patient-specific, three-dimensional information to characterize the radiation response characteristics of tumor and normal structures. Within the next decade, it will be possible to combine such information with advanced delivery technologies to design and deliver biologically conformed, individualized therapies in the clinic. The full implementation of BGRT in the clinic will require new technologies and additional research. However, even the partial implementation of BGRT treatment planning may have the potential to substantially impact clinical outcomes.

On the making of sharp longitudinal dose profiles with helical tomotherapy

Since the beam width on the helical tomotherapy machine produced by TomoTherapy Inc., is typically a few centimeters in the longitudinal direction (into the bore), the optimizer must choose to have a relatively high intensity local to the inside edge of a tumor or planning treatment volume (PTV) when avoiding an immediately adjacent organ at risk (OAR), either superior or inferior. By using a standalone version of the TomoTherapy dose calculator, a realistic beam is applied to idealized deconvolution schemes including the MATLAB Optimizer Toolbox for a simple one-dimensional PTV with adjacent OARs. The results are compared to a clinical example on the TomoTherapy planning station. It is learned that a Gibbs phenomenon type of oscillation in the dose within the tumor under these special circumstances is not unique to TomoTherapy, but is related to the attempt to form a sharp dose gradient-sharper than the beam profile with typical optimization constraints set to achieve a uniform dose as close as possible to the prescription. The clinical implication is that the Gibbs-induced cold spots force the dose to increase in the PTV if a typical PTV dose-volume constraint is used. It is recommended that the dose prescription be smoothed prior to optimization or the dosimetric goals for an OAR adjacent to the PTV are such that a sharp dose falloff is not demanded, especially if the user reduces the requirements that such an OAR be of both high importance and immediately adjacent to the PTV edge.

Quantification of incidental dose to potential clinical target volume (CTV) under different stereotactic body radiation therapy (SBRT) techniques for non-small cell lung cancer – Tumor motion and using internal target volume (ITV) could improve dose distribution in CTV

PURPOSE

Clinical target volume (CTV), although present, is usually not considered during stereotactic body radiation therapy (SBRT) for non-small cell lung cancer. This study aimed to quantify the incidental dose to the potential CTV under different SBRT techniques.

MATERIALS AND METHODS

Ten patients with various tumor motions were included in the study. Gated-4DCT was performed for all patients. Three treatment plans were generated. Plan A was based on free breathing gross tumor volume (GTV) from a regular CT. Plan B was based on internal target volume (ITV) from gated 4DCT. Plan C was a perfect gated treatment at the exhale phase. The hypothetical CTV was represented by three CTV shells (5, 10, and 15 mm). Time-averaged dose for different respiratory phases was calculated for 18 representative points in each shell.

RESULTS

The minimum doses for plans A, B, and C were 84+/-20%, 94+/-3%, and 80+/-17% of the isocenter dose to the 5mm shell, 72+/-27%, 64+/-7%, and 20+/-11% to the 10mm shell, and 38+/-27%, 27+/-17%, and 6+/-7% to the 15 mm shell, respectively. The caudal and cranial ends of each shell usually had lower dose compared to the other points on the shell. Plan B had the most uniform and reasonable doses to the CTV shells, and patients with large respiratory motion had significantly higher minimum dose than patients with less motion.

CONCLUSION

The potential CTV may incidentally receive adequate and relatively homogeneous doses when ITV is used and the patients have large respiratory motion. However, it could be underdosed for gated treatment or for patients with little motion.

On the parameter describing the generalised equivalent uniform dose (gEUD) for tumours

The purpose of the present work was to estimate the parameter 'a' describing the generalised equivalent uniform dose (gEUD) for tumours and its dependence on radiobiological parameters. The consequences of uncertainties in a on the gEUD were also studied. An estimate of a was found by requiring that, for a given target dose distribution, the mechanistic EUD (based on radiobiological linear quadratic modelling) equals gEUD. The estimate of a was found to depend on the dose distribution, and decreased with factors that increase the slope of the cell survival curve (i.e. decreasing alpha/beta values and increasing alpha values). Furthermore, the parameter a was estimated for 35 prostate cancer IMRT plans of varying dose distributions, for two sets of previously published radiobiological parameters: (1) alpha=0.15 Gy(-1) and alpha/beta=3 Gy, and (2) alpha=0.26 Gy(-1) and alpha/beta=10 Gy. The estimated values of a ranged from -25.6 to -22.4 for all combinations of dose distributions and parameter sets. Uncertainties in a were found to give only small uncertainties in gEUD. Although the current work shows limitations of the gEUD model for tumours, gEUD may still be preferable for biological treatment plan optimization, evaluation and reporting.

Correction of conebeam CT values using a planning CT for derivation of the "dose of the day"

BACKGROUND AND PURPOSE

Verification of the actually delivered 3D dose distribution during each treatment fraction ("dose of the day") is the most complete and clinical relevant "in-vivo" check of an IMRT treatment. To do this, during patient treatment portal dose images are routinely acquired with our electronic portal imaging device to derive the delivered fluence map for each treatment field. In addition, a conebeam CT scan is acquired just prior to treatment to derive the patient geometry at the time of treatment. However, the use of conebeam CT scans for dose calculation is hampered by inaccuracies in the conversion of CT values to electron densities due to an enlarged scatter contribution.

MATERIALS AND METHODS

In this work, a method is described for mapping of Hounsfield Units of the planning CT to the conebeam CT scan, while accounting for non-rigidity in the anatomy, e.g. related to weight loss, in an approximate way. The method was validated for head and neck cancer patients by comparing dose distributions calculated using adjusted Hounsfield Units with a golden standard.

RESULTS AND CONCLUSIONS

The observed dose differences were less than 1% in the majority of points, and in at least 96% of the points a 3D gamma analysis resulted in gamma values of less than 1 when applying a 2%/2mm criterion, showing that this straightforward approach allows for an accurate dose calculation based on conebeam CT scans.

Multicentre quality assurance of intensity-modulated radiation therapy plans: A precursor to clinical trials

A multicentre planning study comparing intensity-modulated radiation therapy (IMRT) plans for the treatment of a head and neck cancer has been carried out. Three Australian radiotherapy centres, each with a different planning system, were supplied a fully contoured CT dataset and requested to generate an IMRT plan in accordance with the requirements of an IMRT-based radiation therapy oncology group clinical trial. Plan analysis was carried out using software developed specifically for reviewing multicentre clinical trial data. Two out of the three plans failed to meet the prescription requirements with one misinterpreting the prescription and the third failed to meet one of the constraints. Only one plan achieved all of the dose objectives for the critical structures and normal tissues. Although each centre used very similar planning parameters and beam arrangements the resulting plans were quite different. The subjective interpretation and application of the prescription and planning objectives emphasize one of the many difficulties in carrying out multicentre IMRT planning studies. The treatment prescription protocol in a clinical trial must be both lucid and unequivocally stated to avoid misinterpretation. Australian radiotherapy centres must show that they can produce a quality IMRT plan and that they can adhere to protocols for IMRT planning before using it in a clinical trial.

Optimization of equivalent uniform dose using the L-curve criterion

Optimization of equivalent uniform dose (EUD) in inverse planning for intensity-modulated radiation therapy (IMRT) prevents variation in radiobiological effect between different radiotherapy treatment plans, which is due to variation in the pattern of dose nonuniformity. For instance, the survival fraction of clonogens would be consistent with the prescription when the optimized EUD is equal to the prescribed EUD. One of the problems in the practical implementation of this approach is that the spatial dose distribution in EUD-based inverse planning would be underdetermined because an unlimited number of nonuniform dose distributions can be computed for a prescribed value of EUD. Together with ill-posedness of the underlying integral equation, this may significantly increase the dose nonuniformity. To optimize EUD and keep dose nonuniformity within reasonable limits, we implemented into an EUD-based objective function an additional criterion which ensures the smoothness of beam intensity functions. This approach is similar to the variational regularization technique which was previously studied for the dose-based least-squares optimization. We show that the variational regularization together with the L-curve criterion for the regularization parameter can significantly reduce dose nonuniformity in EUD-based inverse planning.

Towards an objective evaluation of tolerances for beam modeling in a treatment planning system

The performance of a convolution/superposition based treatment planning system depends on the ability of the dose calculation algorithm to accurately account for physical interactions taking place in the tissue, key components of the linac head and on the accuracy of the photon beam model. Generally the user has little or no control over the performance of the dose calculation algorithm but is responsible for the accuracy of the beam model within the constraints imposed by the system. This study explores the dosimetric impact of limitations in photon beam modeling accuracy on complex 3D clinical treatment plans. A total of 70 photon beam models was created in the Pinnacle treatment planning system. Two of the models served as references for 6 MV and 15 MV beams, while the rest were created by perturbing the reference models in order to produce specific deviations in specific regions of the calculated dose profiles (central axis and transverse). The beam models were then used to generate 3D plans on seven CT data sets each for four different treatment sites (breast and conformal prostate, lung and brain). The equivalent uniform doses (EUD) of the targets and the principal organs at risk (OARs) of all plans ( approximately 1000) were calculated and compared to the EUDs delivered by the reference beam models. In general, accurate dosimetry of the target is most greatly compromised by poor modeling of the central axis depth dose and the horns, while the EUDs of the OARs exhibited the greatest sensitivity to beam width accuracy. Based on the results of this analysis we suggest a set of tolerances to be met during commissioning of the beam models in a treatment planning system that are consistent in terms of clinical outcomes as predicted by the EUD.

Possible fractionated regimens for image-guided intensity-modulated radiation therapy of large arteriovenous malformations

The aim of this study was to estimate a plausible alpha/beta ratio for arteriovenous malformations (AVMs) based on reported clinical data, and to design possible fractionation regimens suitable for image-guided intensity-modulated radiation therapy (IG-IMRT) for large AVMs based on the newly obtained alpha/beta ratio. The commonly used obliteration rate (OR) for AVMs with a three year angiographic follow-up from many institutes was fitted to linear-quadratic (LQ) formalism and the Poisson OR model. The determined parameters were then used to calculate possible fractionation regimens for IG-IMRT based on the concept of a biologically effective dose (BED) and an equivalent uniform dose (EUD). The radiobiological analysis yields a alpha/beta ratio of 2.2 +/- 1.6 Gy for AVMs. Three sets of possible fractionated schemes were designed to achieve equal or better biological effectiveness than the single-fraction treatments while maintaining the same probability of normal brain complications. A plausible alpha/beta ratio was derived for AVMs and possible fractionation regimens that may be suitable for IG-IMRT for large AVM treatment are proposed. The sensitivity of parameters on the calculation was also studied. The information may be useful to design new clinical trials that use IG-IMRT for the treatment of large AVMs.

Principal Component Analysis-Based Pattern Analysis of Dose–Volume Histograms and Influence on Rectal Toxicity

PURPOSE

The variability of dose-volume histogram (DVH) shapes in a patient population can be quantified using principal component analysis (PCA). We applied this to rectal DVHs of prostate cancer patients and investigated the correlation of the PCA parameters with late bleeding.

METHODS AND MATERIALS

PCA was applied to the rectal wall DVHs of 262 patients, who had been treated with a four-field box, conformal adaptive radiotherapy technique. The correlated changes in the DVH pattern were revealed as "eigenmodes," which were ordered by their importance to represent data set variability. Each DVH is uniquely characterized by its principal components (PCs). The correlation of the first three PCs and chronic rectal bleeding of Grade 2 or greater was investigated with uni- and multivariate logistic regression analyses.

RESULTS

Rectal wall DVHs in four-field conformal RT can primarily be represented by the first two or three PCs, which describe approximately 94% or 96% of the DVH shape variability, respectively. The first eigenmode models the total irradiated rectal volume; thus, PC1 correlates to the mean dose. Mode 2 describes the interpatient differences of the relative rectal volume in the two- or four-field overlap region. Mode 3 reveals correlations of volumes with intermediate doses ( approximately 40-45 Gy) and volumes with doses >70 Gy; thus, PC3 is associated with the maximal dose. According to univariate logistic regression analysis, only PC2 correlated significantly with toxicity. However, multivariate logistic regression analysis with the first two or three PCs revealed an increased probability of bleeding for DVHs with more than one large PC.

CONCLUSIONS

PCA can reveal the correlation structure of DVHs for a patient population as imposed by the treatment technique and provide information about its relationship to toxicity. It proves useful for augmenting normal tissue complication probability modeling approaches.

High-dose Radiotherapy in the Management of Chordoma and Chondrosarcoma of the Skull Base and Cervical Spine: Part 1 — Clinical Outcomes

AIMS

Patients with chordoma and chondrosarcoma in the skull base present a complex multidisciplinary problem. These tumours are rare and occur in difficult anatomical regions. We reviewed the local control and survival of patients treated in our centre.

MATERIALS AND METHODS

Between 1996 and 2005, 12 adult cases of chordoma (nine) and chondrosarcoma (three) in the skull base or cervical spine were treated in our centre. The median follow-up is currently 38 months. One patient was treated with palliative intent. In 10 cases the prescription dose was 65 Gy in 39 fractions. The target volumes were measured, and the target maximum and minimum doses and the equivalent uniform dose (EUD) for the phase I plans were recorded.

RESULTS

Local control was achieved in 11 of 12 cases. One chordoma patient failed locally, and one other died of metastatic disease despite local control. The 3- and 5-year cause-specific survival for the series was 88 and 75%, respectively. The mean phase I planning target volume (PTV) was 120.4 cm(3). The median minimum dose in the phase I PTV was 81.0%. The median EUD (expressed as a percentage of the prescribed dose) for the phase I PTV, calculated using a value for the exponent a of -15, was 98.3%. The phase I EUD was below 80% in two of the 12 cases.

CONCLUSIONS

Our results confirm a need for aggressive local surgery and high-dose radiotherapy, and endorse multidisciplinary working. Although charged particle therapy is accepted as providing optimal treatment plans, in eight of our patients travel abroad would not have been feasible. This series provides encouraging results for carefully planned photon conformal radiotherapy, carried out in close collaboration with a specialist surgical team.

Comparison of three accelerated partial breast irradiation techniques: Treatment effectiveness based upon biological models

BACKGROUND AND PURPOSE

Accelerated partial breast irradiation (APBI) is being studied in a phase III randomized trial as an alternative to whole breast irradiation (WBI) for early stage breast cancer patients. There are three methods for APBI: multi-catheter brachytherapy (MCT), MammoSite brachytherapy (MST), or 3D conformal (3DCRT). There is a paucity of data comparing among methods. Using a linear-quadratic (LQ) model, we evaluated the anticipated efficacy among the APBI methods for equivalent uniform dose (EUD), Tumor Control Probability (TCP), and Normal Tissue Complication Probability (NTCP).

MATERIALS AND METHODS

Treatment plans from five patients treated by each APBI modality were retrospectively selected. Dose-volume-histograms (DVH) for planning target volume (PTV), breast, and lung were generated. The LQ parameters alpha=0.3Gy(-1) and alpha/beta=10Gy were used for calculations. The values of EUD, TCP, and NTCP were calculated based on DVHs.

RESULTS

The average EUD (normalized to 3.4Gy BID) for the MCT, MST, and 3DCRT APBI was 35, 37.2, and 37.6Gy. When normalized to 2Gy fractionation these become, 42.2, 46.4, and 46.9Gy. Average TCP for MCT, MST, and 3DCRT PBI was 94.8%, 99.1%, and 99.2%. The NTCP values for breast and lung were low for all three methods.

CONCLUSIONS

The EUD for PTV and TCP were most similar in MST and 3DCRT APBI and were lower in MCT APBI. This questions the equivalence of the three APBI modalities that are currently being evaluated in the NSABP-B39/RTOG 0413 protocol.

The use of BED and EUD concepts in heterogeneous radioactivity distributions on a multicellular scale for targeted radionuclide therapy

There is evidence that nonuniform activity distributions within tumors might cause targeted radionuclide therapy (TRT) to fail. The aim of this study was to investigate the effects of the temporal and spatial behavior of the radioactivity in TRT, focusing on heterogeneous radiopharmaceutical distributions at a multicellular scale. Various activity distributions at the multicellular level from three radionuclides ((32)P, (90)Y, and (131)I) were simulated in cubic matrices (1- and 3-mm side). The in-house software package DOVE was used to calculate dose-rate maps, and survival fractions were calculated taking into account an up-take and a clearance phase. The effect from nonuniform activity distributions was analyzed in terms of dose volume histograms (DVHs), biologically effective dose (BED), and the effective uniform dose (EUD). The fraction of the absorbed dose that is "wasted," without producing a biological effect to the treatment, reaches 60% in the highly nonuniform distributions. For (32)P and (90)Y, the loss of therapeutic effectiveness was shown to be less than for (131)I. However, (90)Y, owing to its shorter physical half-life, presented lower mean BED values in almost every geometry, compared to (32)P and (131)I, and thus was less effective. (131)I, among all geometries, appeared to be more effective in more homogeneous activity distributions and in the 1-mm volume of interest, whereas it was the least effective radionuclide in the more heterogeneous activity distributions. (32)P presented the highest values of EUD, compared to (90)Y and (131)I. The EUD is a unique value that facilitates comparisons between different activity distributions in terms of treatment outcome. This study showed that as the degree of the heterogeneity in the dose distributions increases, the therapy effectiveness worsens. Nonuniform absorbed dose distributions can create a situation in which a fraction of cells are underirradiated, while another fraction of cells is "over-killed."

Self-consistent tumor control probability and normal tissue complication probability models based on generalized EUDa)

Traditional methods to compute the tumor control probability (TCP) or normal tissue complication probability (NTCP) typically require a heterogeneous radiation dose distribution to be converted into a simple uniform dose distribution with an equivalent biological effect. Several power-law type dose-volume-histogram reduction schemes, particularly Niemierko's generalized equivalent uniform dose model [Med. Phys. 26, 1000 (1999)], have been proposed to achieve this goal. In this study, we carefully examine the mathematical outcome of these schemes. We demonstrate that (1) for tumors, with each tumor cell independently responding to local radiation dose, a closed-form analytical solution for tumor survival fraction and TCP can be obtained; (2) for serial structured normal tissues, an exponential power-law form relating survival to functional sub-unit (FSU) radiation is required, and a closed-form analytical solution for the related NTCP is provided; (3) in the case of a parallel structured normal tissue, when NTCP is determined solely by the number of the surviving FSUs, a mathematical solution is available only when there is a non-zero threshold dose and/or a finite critical dose defining the radiotherapy response. Some discussion is offered for the partial irradiation effect on normal tissues in this category; (4) for normal tissues with alternative architectures, where the radiation response of FSU is inhomogeneous, there is no exact global mathematical solution for SF or NTCP within the available schemes. Finally, numerical fits of our models to some experimental data are also presented.

Treatment plan comparison between helical tomotherapy and MLC-based IMRT using radiobiological measures

The rapid implementation of advanced treatment planning and delivery technologies for radiation therapy has brought new challenges in evaluating the most effective treatment modality. Intensity-modulated radiotherapy (IMRT) using multi-leaf collimators (MLC) and helical tomotherapy (HT) are becoming popular modes of treatment delivery and their application and effectiveness continues to be investigated. Presently, there are several treatment planning systems (TPS) that can generate and optimize IMRT plans based on user-defined objective functions for the internal target volume (ITV) and organs at risk (OAR). However, the radiobiological parameters of the different tumours and normal tissues are typically not taken into account during dose prescription and optimization of a treatment plan or during plan evaluation. The suitability of a treatment plan is typically decided based on dosimetric criteria such as dose-volume histograms (DVH), maximum, minimum, mean and standard deviation of the dose distribution. For a more comprehensive treatment plan evaluation, the biologically effective uniform dose (D) is applied together with the complication-free tumour control probability (P(+)). Its utilization is demonstrated using three clinical cases that were planned with two different forms of IMRT. In this study, three different cancer types at different anatomical sites were investigated: head and neck, lung and prostate cancers. For each cancer type, a linac MLC-based step-and-shoot IMRT plan and a HT plan were developed. The MLC-based IMRT treatment plans were developed on the Philips treatment-planning platform, using the Pinnacle 7.6 software release. For the tomotherapy HiArt plans, the dedicated tomotherapy treatment planning station was used, running version 2.1.2. By using D as the common prescription point of the treatment plans and plotting the tissue response probabilities versus D for a range of prescription doses, a number of plan trials can be compared based on radiobiological measures. The applied plan evaluation method shows that in the head and neck cancer case the HT treatment gives better results than MLC-based IMRT in terms of expected clinical outcome P(+) of 62.2% and 46.0%, D to the ITV of 72.3 Gy and 70.7 Gy, respectively). In the lung cancer and prostate cancer cases, the MLC-based IMRT plans are better over the clinically useful dose prescription range. For the lung cancer case, the HT and MLC-based IMRT plans give a P(+) of 66.9% and 72.9%, D to the ITV of 64.0 Gy and 66.9 Gy, respectively. Similarly, for the prostate cancer case, the two radiation modalities give a P(+) of 68.7% and 72.2%, D to the ITV of 86.0 Gy and 85.9 Gy, respectively. If a higher risk of complications (higher than 5%) could be allowed, the complication-free tumour control could increase by over 40%, 2% and 30% compared to the initial dose prescription for the three cancer cases, respectively. Both MLC-based IMRT and HT can encompass the often-large ITV required while they minimize the volume of the organs at risk receiving high doses. Radiobiological evaluation of treatment plans may provide an improved correlation of the delivered treatment with the clinical outcome by taking into account the dose-response characteristics of the irradiated targets and normal tissues. There may exist clinical cases, which may look dosimetrically similar but in radiobiological terms may be quite different. In such situations, traditional dose-based evaluation tools can be complemented by the use of P(+)--D diagrams to effectively evaluate and compare treatment plans.

Radiotherapy treatment of early-stage prostate cancer with IMRT and protons: a treatment planning comparison

PURPOSE

To compare intensity-modulated photon radiotherapy (IMRT) with three-dimensional conformal proton therapy (3D-CPT) for early-stage prostate cancer, and explore the potential utility of intensity-modulated proton therapy (IMPT).

METHODS AND MATERIALS

Ten patients were planned with both 3D-CPT (two parallel-opposed lateral fields) and IMRT (seven equally spaced coplanar fields). Prescribed dose was 79.2 Gy (or cobalt Gray-equivalent, [CGE] for protons) to the prostate gland. Dose-volume histograms, dose conformity, and equivalent uniform dose (EUD) were compared. Additionally, plans were optimized for 3D-CPT with nonstandard beam configuration, and for IMPT assuming delivery with beam scanning.

RESULTS

At least 98% of the planning target volume received the prescription dose. IMRT plans yielded better dose conformity to the target, whereas proton plans achieved higher dose homogeneity and better sparing of rectum and bladder in the range below 30 Gy/CGE. Bladder volumes receiving more than 70 Gy/CGE (V70) were reduced, on average, by 34% with IMRT vs. 3D-CPT, whereas rectal V70 were equivalent. EUD from 3D-CPT and IMRT plans were indistinguishable within uncertainties for both bladder and rectum. With the use of small-angle lateral-oblique fields in 3D-CPT and IMPT, the rectal V70 was reduced by up to 35% compared with the standard lateral configuration, whereas the bladder V70 increased by less than 10%.

CONCLUSIONS

In the range higher than 60 Gy/CGE, IMRT achieved significantly better sparing of the bladder, whereas rectal sparing was similar with 3D-CPT and IMRT. Dose to healthy tissues in the range lower than 50% of the target prescription was substantially lower with proton therapy.