Noncoplanar Volumetric Modulated Arc Therapy for Hepatocellular Carcinoma Based on a Cage-Like Radiotherapy System: A Simulation Study.

BACKGROUND: The incorporation of noncoplanar beam arrangements has been proposed in liver radiotherapy modalities, which can reduce the dose in normal tissues compared to coplanar techniques. Noncoplanar radiotherapy techniques for hepatocellular carcinoma treatment based on the Linac design have a limited effective arc angle to avoid collisions. PURPOSE: To propose a novel noncoplanar volumetric modulated arc therapy technique based on a cage-like radiotherapy system and investigate its performance in hepatocellular carcinoma patients. METHODS: The computed tomography was deflected 90° to meet the structure of a cage-like radiotherapy system and design the noncoplanar volumetric modulated arc therapy technique based on a cage-like radiotherapy system plan in the Pinnacle3 planning system. An noncoplanar volumetric modulated arc therapy technique based on a cage-like radiotherapy system plan was customized for each of 10 included hepatocellular carcinoma patients, with 6 dual arcs ranging from -30° to 30°. Six couch angles were set with an interval of 36° and distributed along with the longest diameter of planning target volume. The dosimetric parameters of noncoplanar volumetric modulated arc therapy technique based on a cage-like radiotherapy system plan were compared with the noncoplanar volumetric modulated arc therapy and volumetric modulated arc therapy plan. RESULTS: The 3 radiotherapy techniques regarding planning target volume were statistically different for D98%, D2%, conformity index, and homogeneity index with χ2 = 9.692, 14.600, 8.600, and 12.600, and P = .008, .001, .014, and .002, respectively. Further multiple comparisons revealed that noncoplanar volumetric modulated arc therapy technique based on a cage-like radiotherapy system significantly reduced the mean dose (P = .005) and V5 (P = .005) of the normal liver, the mean dose (P = .005) of the stomach, and V30 (P = .028) of the lung compared to noncoplanar volumetric modulated arc therapy. Noncoplanar volumetric modulated arc therapy technique based on a cage-like radiotherapy system significantly reduced the mean dose (P = .005) and V5 (P = .005) of the normal liver, the mean dose (P = .017) of the spinal cord, V50 (P = .043) of the duodenum, the maximum dose (P = .007) of the esophagus, and V30 (P = .047) of the whole lung compared to volumetric modulated arc therapy. The results indicate that noncoplanar volumetric modulated arc therapy technique based on a cage-like radiotherapy system protects the normal liver, stomach, and lung better than noncoplanar volumetric modulated arc therapy and protects the normal liver, spinal cord, duodenum, esophagus, and lung better than volumetric modulated arc therapy. CONCLUSIONS: The noncoplanar volumetric modulated arc therapy technique based on a cage-like radiotherapy system technique with the arrangement of noncoplanar arcs provided optimal dosimetric gains compared with noncoplanar volumetric modulated arc therapy and volumetric modulated arc therapy, except for the heart. Noncoplanar volumetric modulated arc therapy technique based on a cage-like radiotherapy system should be considered in more clinically challenging cases.

Delivery of intensity-modulated electron therapy by mechanical scanning: An algorithm study.

Purpose: In principle, intensity-modulated electron therapy (IMET) can be delivered through mechanical scanning, with a robotic arm mounting a linac. Materials and methods: Here is a scanning algorithm to identify the back-and-forth, top-to-bottom (zigzag) pattern scan sequence. The algorithm includes generating beam positions with a uniform resolution according to the applicator size; adopting discrete energies to achieve the depth of 90% dose by compositing energies; selecting energy by locating the target's distal edge; and employing the energy-by-energy scan strategy for step-and-shoot discrete scanning. After a zigzag scan sequence is obtained, the delivery order of the scan spots is optimized by fast simulated annealing (FSA) to minimize the path length. For algorithm evaluation, scan sequences were generated using the computed tomography data of 10 patients with pancreatic cancer undergoing intraoperative radiotherapy, and the results were compared between the zigzag path and an optimized path. A simple calculation of the treatment delivery time, which comprises the irradiation time, the total robotic arm moving time, the time for energy switch, and the time to stop and restart the beam, was also made. Results: In these clinical cases, FSA optimization shortened the path lengths by 12%-43%. Assuming the prescribed dose was 15 Gy, machine dose rate was 15 Gy/s, energy switch time was 2 s, stop and restart beam time was 20 ms, and robotic arm move speed was 50 mm/s, the average delivery time was 124±38 s. The largest reduction in path length yielded an approximately 10% reduction in the delivery time, which can be further reduced by increasing the machine dose rate and the robotic arm speed, decreasing the time for energy switch, and/or developing more efficient algorithms. Conclusion: Mechanically scanning IMET is potentially feasible and worthy of further exploration.

Dosimetric comparison of coplanar and noncoplanar beam arrangements for radiotherapy of patients with lung cancer: A meta-analysis.

PURPOSE: Radiotherapy plays an important role in the treatment of lung cancer, and both coplanar beam arrangements (CBA) and noncoplanar beam arrangements (NCBA) are adopted in clinic practice. The aim of this study is to answer the question whether NCBA are dosimetrically superior to CBA. METHODS: Search of publications were performed in PubMed, Web of Science, and the Cochran Library till March 2020. The searching terms were as following: ((noncoplanar) or ("non coplanar") or ("4pi") or ("4π")) AND (("lung cancer") or ("lung tumor") or ("lung carcinoma")) AND ((radiotherapy) or ("radiation therapy")). The included studies and extracted data were manually screened. All forest and funnel plots were carried out with RevMan software, and the Egger's regression asymmetry tests were conducted with STATA software. RESULTS: Nine studies were included and evaluated in the meta-analysis and treatment plans were designed with both CBA and NCBA. For the planning target volumes (PTV), D98%, D2%, the conformity index (CI), and the gradient index (GI) had no statistically significant difference. For organs-at-risk (OAR), V20 of the whole lung and the maximum dose of the spinal cord were significantly reduced in NCBA plans compared with CBA ones. But V10, V5, and mean dose of the whole lung, the maximum dose of the heart, and the maximum dose of the esophagus exhibited no significant difference when the two types of beam arrangements were compared. CONCLUSION: After combining multicenter results, NCBA plans have significant advantages in reducing V20 of the whole lung and max dose of spinal cord.

Ultrasound-guided intraoperative electron beam radiation therapy: A phantom study.

PURPOSE: To develop the method for ultrasound (US)-guided intra-operative electron beam radiation therapy (IOERT). METHODS: We first established the simulation, planning, and delivery methods for US-guided IOERT and constructed appropriate hardware (the multi-function applicator, accessories, and US phantom). We tested our US-guided IOERT method using this hardware and the Monte Carlo simulation IOERT treatment planning system (TPS). The IOERT TPS used a compensator to build the conformal dose distribution. Then, we used the TPS to evaluate the effect of setup uncertainty on target coverage by introducing phantom setup error ranging from 0 mm to 10 mm to the plans with and without the compensator. RESULTS: The simulation, planning, and delivery methods for US-guided IOERT were introduced and validated on a phantom. A complete technique for US-guided IOERT was established. Target coverage decreased by about 12% and 29% as the phantom setup error increased to 5 mm and 10 mm for the plans with compensator, respectively. Without compensator, the corresponding target coverage decreases were 2% and 13%, respectively. CONCLUSION: In our study, we developed the multi-function applicator, US Phantom, and TPS for IOERT. The procedures included not only dose distribution planning, but also intraoperative US imaging, which provided the information necessary during surgery to improve IOERT quality assurance. Target coverage was more sensitive to setup errors with compensator compared to no compensator. Further studies are needed to validate the clinical efficacy of this US-guided IOERT method.

A practical method for predicting patient-specific collision in radiotherapy.

PURPOSE: To develop a practical method for predicting patient-specific collision during the treatment planning process. MATERIALS AND METHOD: Based on geometry information of the accelerator gantry and the location of plan isocenter, the collision-free space region could be determined. In this study, collision-free space region was simplified as a cylinder. Radius of cylinder was equal to the distance from isocenter to the collimator cover. The collision-free space was converted and imported into treatment planning system (TPS) in the form of region of interest (ROI) which was named as ROISS. Collision was viewed and evaluated on the fusion images of patient's CT and ROIs in TPS. If any points of patient's body or couch fell beyond the safety space, collision would occur. This method was implemented in the Pinnacle TPS. The impact of safety margin on accuracy was also discussed. Sixty-five plans of clinical patients were chosen for the clinical validation. RESULTS: When the angle of couch is zero, the ROISS displays as a series of circles on the cross section of the patient's CT. When the couch angle is not zero, ROISS is a series of ellipses in the transverse view of patient's CT. The ROISS can be generated quickly within five seconds after a single mouse click in TPS. Adding safety margin is an effective measure in preventing collisions from being undetected. Safety margin could increase negative predictive value (NPV) of test cases. Accuracy obtained was 96.3% with the 3 cm safety margin with 100% true positive collision detection. CONCLUSION: This study provides a reliable, accurate, and fast collision prediction during the treatment planning process. Potential collisions can be discovered and prevented early before delivering. This method can integrate with the current clinical workflow without any additional required resources, and contribute to improvement in the safety and efficiency of the clinic.

Selecting noncoplanar beam directions in a patient coordinate system for radiotherapy planning.

To introduce a beam angle selection method based on the patient coordinate system for treatment planning of noncoplanar intensity-modulated radiation therapy (IMRT). Traditionally, in radiotherapy planning, beam directions are selected in the machine coordinate system. A noncoplanar beam direction is established through a treatment table rotation followed by a gantry rotation. However, visualizing the beam direction relative to the patient is difficult. The suggestion here is to describe the beam direction in the patient coordinate system. First, a coplanar beam direction is selected in the transverse plane of the patient coordinate system. The noncoplanar beam direction is then obtained by adjusting the coplanar beam toward the foot or head in the patient coordinate system. Finally, the noncoplanar beam direction is expressed in terms of gantry and table angles in the machine coordinate system via formulae developed in this study. A 3D computer-aided design model of the linear accelerator (linac) is established with Solidworks and used to validate the feasibility of the proposed method. A clinical case was chosen to demonstrate the effectiveness of this method. Treatment plans with the conventional coplanar and noncoplanar beam settings were made. Compared with the conventional coplanar IMRT plan, improved normal tissue sparing of the organs at risk using the noncoplanar IMRT plan is evident. The proposed method for noncoplanar treatment planning makes beam direction selection simpler and straightforward.

Dosimetric impact of hysteresis on lung cancer tomotherapy: A moving phantom study.

PURPOSE: To investigate the dosimetric impact of hysteresis on lung cancer tomotherapy. METHODS: Measurements were acquired using MapCheck with an XY4D motion simulation table. Six hysteresis states (0, π/32, π/16, π/8, 3π/16, and π/4) were considered with sinusoidal motions in the superior-inferior and left-right orientations. The measured data were analyzed both globally (from all detectors) and structure-by-structure in the measurement plane. The dose difference (DD) analysis method with local normalization in the absolute dose mode with a DD threshold of 6 cGy was adopted to analyze each hysteresis vs. static state (H(∗)S) and nonzero vs. zero hysteresis (H(∗)0). The threshold was 10% for all analyses. Wilcoxon signed rank tests with significance level p = 0.05 were used for statistical analysis. RESULTS: The DD analysis of each H(∗)S mostly indicated that the passing rate differed between structures but was similar between hysteresis states. The DD analysis of H(∗)0 showed that the passing rate decreased with increasing hysteresis. The differences between larger hysteresis (≥3π/16) and other states were significant for comparisons between global, left lung, chest wall, and target. Both analyses showed that the DD distribution changed with hysteresis. CONCLUSIONS: Hysteresis difference causes the DD distribution to change. Structural difference had more impact than hysteresis state difference on hysteresis motion vs. static comparisons. Remarkable effects on nonzero vs. zero hysteresis comparisons were only seen for structures closely related to the target at large hysteresis. Small organs at risk that are close to the target need to be considered further.