Minimizing normal tissue low dose bath for left breast Volumetric Modulated Arc Therapy (VMAT) using jaw offset.

PURPOSE: With proper beam setup and optimization constraints in the treatment planning system, volumetric modulated arc therapy (VMAT) can improve target dose coverage and conformity while reducing doses to adjacent structures for whole breast radiation therapy. However, the low-dose bath effect on critical structures, especially the heart and the ipsilateral lung, remains a concern. In this study, we present a VMAT technique with the jaw offset VMAT (JO-VMAT) to reduce the leakage and scatter doses to critical structures for whole breast radiation therapy. MATERIALS AND METHODS: The data of 10 left breast cancer patients were retrospectively used for this study. CT images were acquired on a CT scanner (GE, Discovery) with the deep-inspiration breath hold (DIBH) technique. The planning target volumes (PTVs) and the normal structures (the lungs, the heart, and the contralateral breast) were contoured on the DIBH scan. A 3D field-in-field plan (3D-FiF), a tangential VMAT (tVMAT) plan, and a JO-VMAT plan were created with the Eclipse treatment planning system. An arc treatment field with the x-jaw closed across the central axis creates a donut-shaped high-dose distribution and a cylinder-shaped low-dose volume along the central axis of gantry rotation. Applying this setup with proper multi-leaf collimator (MLC) modulation, the optimized plan potentially can provide sufficient target coverage and reduce unnecessary irradiation to critical structures. The JO-VMAT plans involve 5-6 tangential arcs (3 clockwise arcs and 2-3 counterclockwise arcs) with jaw offsets. The plans were optimized with objective functions specified to achieve PTV dose coverage and homogeneity; For organs at risk (OARs), objective functions were specified individually for each patient to accomplish the best achievable treatment plan. For tVMAT plans, optimization constraints were kept the same except that the jaw offset was removed from the initial beam setup. The dose volume histogram (DVH) parameters were generated for dosimetric evaluation of PTV and OARs. RESULTS: The D95% to the PTV was greater than the prescription dose of 42.56 Gy for all the plans. With both VMAT techniques, the PTV conformity index (CI) was statistically improved from 0.62 (3D-FiF) to 0.83 for tVMAT and 0.84 for JO-VMAT plans. The difference in the homogeneity index (HI) was not significant. The Dmax to the heart was reduced from 12.15 Gy for 3D-FiF to 8.26 Gy for tVMAT and 7.20 Gy for JO-VMAT plans. However, a low-dose bath effect was observed with tVMAT plans to all the critical structures including the lungs, the heart, and the contralateral breast. With JO-VMAT, the V5Gy and V2Gy of the heart were reduced by 32.7% and 15.4% compared to 3D-FiF plans. Significantly, the ipsilateral lung showed a reduction in mean dose (4.65-3.44 Gy) and low dose parameters (23.4% reduction for V5Gy and 10.7% reduction for V2Gy) for JO-VMAT plans compared to the 3D-FiF plans. The V2Gy dose to the contralateral lung and breast was minimal with JO-VMAT techniques. CONCLUSION: A JO-VMAT technique was evaluated in this study and compared with 3D-FiF and tVMAT techniques. Our results showed that the JO-VMAT technique can achieve clinically comparable coverage and homogeneity and significantly improve dose conformity within PTV. Additionally, JO-VMAT eliminated the low-dose bath effect at all OARs evaluation metrics including the ipsilateral/contralateral lung, the heart, and the contralateral breast compared to 3D-FiF and tVMAT. This technique is feasible for the whole breast radiation therapy of left breast cancers.

Dosimetric evaluations of the interplay effect in respiratory-gated intensity-modulated radiation therapy.

The interplay between a mobile target and a dynamic multileaf collimator can compromise the accuracy of intensity-modulated radiation therapy (IMRT). Our goal in this study is to investigate the dosimetric effects caused by the respiratory motion during IMRT. A moving phantom was built to simulate the typical breathing motion. Different sizes of the gating windows were selected for gated deliveries. The residual motions during the beam-on period ranged from 0.5 to 3 cm. An IMRT plan with five treatment fields from different gantry angles were delivered to the moving phantom for three irradiation conditions: Stationary condition, moving with the use of gating system, and moving without the use of gating system. When the residual motion was 3 cm, the results showed significant differences in dose distributions between the stationary condition and the moving phantom without gating beam control. The overdosed or underdosed areas enclosed about 33% of the treatment area. In contrast, the dose distribution on the moving phantom with gating window set to 0.5 cm showed no significant differences from the stationary phantom. With the appropriate setting of the gating window, the deviation of dose from the respiratory motion can be minimized. It appeals that limiting the residual motion to less than 0.5 cm is critical for the treatments of mobile structures.

Four-dimensional computed tomography-based interfractional reproducibility study of lung tumor intrafractional motion.

PURPOSE: To evaluate the interfractional reproducibility of respiration-induced lung tumors motion, defined by their centroids and the intrafractional target motion range. METHODS AND MATERIALS: Twentythree pairs of four-dimensional/computed tomography scans were acquired for 22 patients. Gross tumor volumes were contoured, Clinical target volumes (CTVs) were generated. Geometric data for CTVs and lung volumes were extracted. The motion tracks of CTV centroids, and CTV edges along the cranio-caudal, anterior-posterior, and lateral directions were evaluated. The Pearson correlation coefficient for motion tracks along the cranio-caudal direction was determined for the entire respiratory cycle and for five phases about the end of expiration. RESULTS: The largest motion extent was along the cranio-caudal direction. The intrafractional motion extent for five CTVs was <0.5 cm, the largest motion range was 3.59 cm. Three CTVs with respiration-induced displacement >0.5 cm did not exhibit the similarity of motion, and for 16 CTVs with motion >0.5 cm the correlation coefficient was >0.8. The lung volumes in corresponding phases for cases that demonstrated CTVs motion similarity were reproducible. No correlation between tumor size and mobility was found. CONCLUSION: Target motion reproducibility seems to be present in 87% of cases in our dataset. Three cases with dissimilar motion indicate that it is advisable to verify target motion during treatment. The adaptive adjustment to compensate the possible interfractional shifts in a target position should be incorporated as a routine policy for lung cancer radiotherapy.

A 3D correction method for predicting the readings of a PinPoint chamber on the CyberKnife® M6™ machine.

The use of small fields in radiation therapy techniques has increased substantially in particular in stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT). However, as field size reduces further still, the response of the detector changes more rapidly with field size, and the effects of measurement uncertainties become increasingly significant due to the lack of lateral charged particle equilibrium, spectral changes as a function of field size, detector choice, and subsequent perturbations of the charged particle fluence. This work presents a novel 3D dose volume-to-point correction method to predict the readings of a 0.015 cc PinPoint chamber (PTW 31014) for both small static-fields and composite-field dosimetry formed by fixed cones on the CyberKnife® M6™ machine. A 3D correction matrix is introduced to link the 3D dose distribution to the response of the PinPoint chamber in water. The parameters of the correction matrix are determined by modeling its 3D dose response in circular fields created using the 12 fixed cones (5 mm-60 mm) on a CyberKnife® M6™ machine. A penalized least-square optimization problem is defined by fitting the calculated detector reading to the experimental measurement data to generate the optimal correction matrix; the simulated annealing algorithm is used to solve the inverse optimization problem. All the experimental measurements are acquired for every 2 mm chamber shift in the horizontal planes for each field size. The 3D dose distributions for the measurements are calculated using the Monte Carlo calculation with the MultiPlan® treatment planning system (Accuray Inc., Sunnyvale, CA, USA). The performance evaluation of the 3D conversion matrix is carried out by comparing the predictions of the output factors (OFs), off-axis ratios (OARs) and percentage depth dose (PDD) data to the experimental measurement data. The discrepancy of the measurement and the prediction data for composite fields is also performed for clinical SRS plans. The optimization algorithm used for generating the optimal correction factors is stable, and the resulting correction factors were smooth in the spatial domain. The measurement and prediction of OFs agree closely with percentage differences of less than 1.9% for all the 12 cones. The discrepancies between the prediction and the measurement PDD readings at 50 mm and 80 mm depth are 1.7% and 1.9%, respectively. The percentage differences of OARs between measurement and prediction data are less than 2% in the low dose gradient region, and 2%/1 mm discrepancies are observed within the high dose gradient regions. The differences between the measurement and prediction data for all the CyberKnife based SRS plans are less than 1%. These results demonstrate the existence and efficiency of the novel 3D correction method for small field dosimetry. The 3D correction matrix links the 3D dose distribution and the reading of the PinPoint chamber. The comparison between the predicted reading and the measurement data for static small fields (OFs, OARs and PDDs) yield discrepancies within 2% for low dose gradient regions and 2%/1 mm for high dose gradient regions; the discrepancies between the predicted and the measurement data are less than 1% for all the SRS plans. The 3D correction method provides an access to evaluate the clinical measurement data and can be applied to non-standard composite fields intensity modulated radiation therapy point dose verification.

Breast skin doses from brachytherapy using MammoSite HDR, intensity modulated radiation therapy, and tangential fields techniques.

Skin doses from brachytherapy using MammoSite HDR, Intensity Modulated Radiation Therapy (IMRT), and conventional tangential fields techniques were compared. For each treatment technique, skin doses were measured using paired thermoluminescent dosimeters placed on the patient's skin: (i) directly above the balloon catheter during MammoSite HDR brachytherapy treatments and (ii) 4 cm inside the treatment borders during the IMRT and conventional breast treatments. The mean dose measured was about 58% of the prescription dose for the patients treated using the MammoSite technique. On the other hand, for patients treated with IMRT and tangential fields, the mean dose was found to be about 69% and 71% of the corresponding prescription dose. This study suggests that in breast cancer radiation treatments the MammoSite HDR technique reduces skin doses compared to IMRT and tangential field techniques.

Motion management strategies and technical issues associated with stereotactic body radiotherapy of thoracic and upper abdominal tumors: A review from NRG oncology.

The efficacy of stereotactic body radiotherapy (SBRT) has been well demonstrated. However, it presents unique challenges for accurate planning and delivery especially in the lungs and upper abdomen where respiratory motion can be significantly confounding accurate targeting and avoidance of normal tissues. In this paper, we review the current literature on SBRT for lung and upper abdominal tumors with particular emphasis on addressing respiratory motion and its affects. We provide recommendations on strategies to manage motion for different, patient-specific situations. Some of the recommendations will potentially be adopted to guide clinical trial protocols.

Abdominal organ motion measured using 4D CT.

PURPOSE: To measure respiration-induced abdominal organ motion using four-dimensional computed tomography (4D CT) scanning and to examine the organ paths. METHODS AND MATERIALS: During 4D CT scanning, consecutive CT images are acquired of the patient at each couch position. Simultaneously, the patient's respiratory pattern is recorded using an external marker block taped to the patient's abdomen. This pattern is used to retrospectively organize the CT images into multiple three-dimensional images, each representing one breathing phase. These images are analyzed to measure organ motion between each phase. The displacement from end expiration is compared to a displacement limit that represents acceptable dosimetric results (5 mm). RESULTS: The organs measured in 13 patients were the liver, spleen, and left and right kidneys. Their average superior to inferior absolute displacements were 1.3 cm for the liver, 1.3 cm for the spleen, 1.1 cm for the left kidney, and 1.3 cm for the right kidney. Although the organ paths varied among patients, 5 mm of superior to inferior displacement from end expiration resulted in less than 5 mm of displacement in the other directions for 41 of 43 organs measured. CONCLUSIONS: Four-dimensional CT scanning can accurately measure abdominal organ motion throughout respiration. This information may result in greater organ sparing and planning target volume coverage.

Localizing moving targets and organs using motion-managed CTs.

Respiration-induced target and organ motion impacts the radiotherapy strategies of some cancers. Various methods and techniques have been used to investigate motion-related radiotherapy issues, including retrospective 4-dimensional (4D) computed tomography (CT), prospective gated CT, and breath-hold CT scans. This paper reviews these methods and, particularly, the method using retrospective 4D CT scans, which has been developed at our institution. Some motion studies based on retrospective 4D CT images of patients are also examined. These studies have led to reduced planning target volume (PTV) margins for a number of patients, because the respiratory motion was observed to be minimal or gated radiotherapy was used. Respiratory motion managed CTs and, particularly, retrospective 4D CTs are proving to be useful for measuring soft tissue motion, identifying patients who could benefit from gated radiotherapy, and evaluating the effects of respiratory motion during radiotherapy.

Does breast size affect the scatter dose to the ipsilateral lung, heart, or contralateral breast in primary breast irradiation using intensity-modulated radiation therapy (IMRT)?

PURPOSE: To evaluate the relationship between the primary breast volume and dose received by the ipsilateral lung, heart (for left-breast cancers), and contralateral breast during primary breast irradiation using intensity-modulated radiation therapy (IMRT). METHODS AND MATERIALS: Sixty-five patients with breast carcinoma were treated using 6-MV photons with IMRT technique using the Eclipse Planning System following breast conserving surgery. All patients had a treatment planning CT scan. The primary breast, ipsilateral lung, and heart were contoured on the axial CT slices. The primary breast volume was calculated using the Eclipse Planning System. The mean ipsilateral lung and heart doses were obtained from the dose-volume histogram. The contralateral breast dose was measured using paired thermoluminescent dosimeters (TLDs) placed on the patient's contralateral breast, 4 cm from the center of the medial border of the primary breast irradiation field. RESULTS: The mean dose delivered with photons to the primary breast for all patients was 49.97 Gy. The mean volume of the primary irradiated breast was 1167.9 cc. As a percentage, the mean ipsilateral lung, heart, and contralateral breast doses were 11.2%, 6.1%, and 7.2%, respectively. The primary breast volume positively correlated with the contralateral breast dose (P < 0.0005). There was no significant correlation between the breast volume and the ipsilateral lung or heart dose (P = 0.463 and 0.943, respectively). CONCLUSION: This study suggests that the primary breast size significantly affects the scatter dose to the contralateral breast but not the ipsilateral lung or heart dose when using IMRT for breast irradiation.

Intensity modulated radiation therapy (IMRT) reduces the dose to the contralateral breast when compared to conventional tangential fields for primary breast irradiation.

PURPOSE: To determine the dose received by the contralateral breast during primary breast irradiation using IMRT compared to conventional tangential field techniques. METHODS AND MATERIALS: Between March 2003 and March 2004, 83 patients with breast carcinoma were treated using 6, 10, or mixed 6/18 MV photons (65 with tangential IMRT technique and 18 with 3-dimensional technique using tangential fields with wedges) for primary breast irradiation following breast-conserving surgery. Paired thermoluminescent dosimeters (TLDs) were placed on each patient's contralateral breast, 4 and 8 cm from the center of the medial border of the tangential field. The TLDs were left on the patient during a single fraction and then measured 24 h afterwards. RESULTS: The mean dose delivered with photons to the primary breast for all patients was 4999 cGy (SD = 52) with a mean single fraction dose of 199 cGy (SD = 8). The mean percent of the prescribed dose to the contralateral breast measured at the 4- and 8-cm positions were 7.19% (SD = 2.28) and 4.63% (SD = 2.12), respectively, for patients treated with IMRT compared to 11.22% (SD = 2.73) and 10.70% (SD = 3.44), respectively, for the patients treated with conventional tangential field techniques. This represented a 36% and 57% reduction at the 4 and 8-cm contralateral positions, respectively, in the mean dose to the contralateral breast using IMRT compared to 3-D technique which was statistically significant (p < 0.0005, <0.0005, respectively). CONCLUSION: Primary breast irradiation with tangential IMRT technique significantly reduces the dose to the contralateral breast compared to conventional tangential field techniques.

Intensity-modulated radiation therapy (IMRT) reduces the dose to the contralateral breast when compared to conventional tangential fields for primary breast irradiation: initial report.

PURPOSE: This study was designed to compare the dose received by the contralateral breast during primary breast irradiation using intensity-modulated radiotherapy with the dose received via conventional tangential field techniques. METHODS/MATERIALS: Between March 2003 and March 2004, 44 patients with breast carcinoma were treated using 6-, 10-, or mixed 6/18-MV photons(36 with tangential intensity-modulated radiotherapy technique and eight with three-dimensional technique using tangential fields with wedges) for primary breast irradiation after breast-conserving surgery. Paired thermoluminescent dosimeters were placed on each patient's contralateral breast, 4 cm from the center of the medial border of the tangential field. The thermoluminescent dosimeters were left on the patient during a single fraction and then measured 24 hours later. RESULTS: The mean dose delivered with photons to the primary breast for all patients was 4998 cGy [SD = 52], and the mean single fraction dose was 200 cGy [SD = 9]. The mean percent of the prescribed dose to the contralateral breast was 7.74% (SD = 2.35) for patients treated with intensity-modulated radiotherapy, compared with 9.74% [SD = 2.04] for the patients treated with conventional tangential field techniques. This represented a 20% reduction in the mean dose to the contralateral breast with the use of intensity-modulated radiotherapy when compared with the dose received via the three-dimensional technique, a result that was statistically significant. CONCLUSION: Primary breast irradiation with tangential intensity-modulated radiotherapy technique significantly reduces the dose to the contralateral breast when compared with conventional tangential techniques.