Dosimetric comparison of proton therapy and CyberKnife in stereotactic body radiation therapy for liver cancers.

Stereotactic body radiation therapy (SBRT) has been increasingly used for the ablation of liver tumours. CyberKnife and proton beam therapy (PBT) are two advanced treatment technologies suitable to deliver SBRT with high dose conformity and steep dose gradients. However, there is very limited data comparing the dosimetric characteristics of CyberKnife to PBT for liver SBRT. PBT and CyberKnife plans were retrospectively generated using 4DCT datasets of ten patients who were previously treated for hepatocellular carcinoma (HCC, N = 5) and liver metastasis (N = 5). Dose volume histogram data was assessed and compared against selected criteria; given a dose prescription of 54 Gy in 3 fractions for liver metastases and 45 Gy in 3 fractions for HCC, with previously published consensus-based normal tissue dose constraints. Comparison of evaluation parameters showed a statistically significant difference for target volume coverage and liver, lungs and spinal cord (p < 0.05) dose, while chest wall and skin did not indicate a significant difference between the two modalities. A number of optimal normal tissue constraints was violated by both the CyberKnife and proton plans for the same patients due to proximity of tumour to chest wall. PBT resulted in greater organ sparing, the extent of which was mainly dependent on tumour location. Tumours located on the liver periphery experienced the largest increase in organ sparing. Organ sparing for CyberKnife was comparable with PBT for small target volumes.

Assessment of HDR brachytherapy-replicating prostate radiotherapy planning for tomotherapy, cyberknife and VMAT.

A dosimetric study was undertaken to assess the ability of Cyberknife (CK), Volumetric Modulated Arc Therapy (VMAT), and TomoTherapy (Tomo) to generate treatment plans that mimic the dosimetry of high dose-rate brachytherapy (HDR BT) for prostate cancer. The project aimed to assess the potential of using stereotactic body radiotherapy (SBRT) for boost treatment of high-risk prostate cancer patients where HDR BT in combination with conformal external beam radiotherapy (EBRT) is the standard of care. The datasets of 6 prostate patients previously treated with HDR BT were collated. VMAT, CK, and TomoTherapy treatment plans were generated for each dataset using the target and organ-at-risk structures as defined by the Radiation Oncologist during the HDR BT treatment process. The HDR BT plan isodoses were also converted into planning structures to assist the other modalities to achieve a HDR BT-like dose distribution. CK plans were created using both the iris collimator (IC) and a multileaf collimator (MLC). Comparison of the techniques was made based on dose-volume indices. Each plan was created at centres experienced using the respective treatment planning systems (TPS). Planning target volume (PTV V100%), i.e., the volume of the planning target volume (PTV) receiving 100% of the relative dose, in VMAT and TomoTherapy SBRT plans was higher than HDR BT plans. PTV V150% and V200%, i.e., volume of the PTV receiving 150% and 200% of the relative dose, were approached on all the CK MLC and TomoTherapy SBRT plans. However, it is not presently achievable for "virtual brachytherapy" SBRT to replicate the same high intraprostatic doses as HDR BT while meeting the constraints on the organs-at-risk (OARs). Half of the CK IC plans achieved PTV V150% but this was at the expense of high rectal dose. TomoTherapy and CK MLC plans achieved PTV V150% and V200% but the bladder dose was higher compared to CK IC plans. VMAT exhibited excellent PTV coverage based on V100 and OAR sparing, but without any ability to achieve the high intra-prostatic doses of HDR (V150% and V200%). SBRT techniques can be used to deliver hypofractionated radiotherapy to the PTV V100%. Based on the comparison of "physical" dose distributions, SBRT cannot presently achieve the same high intraprostatic doses as HDR BT while respecting the OAR constraints. SBRT still remains an attractive treatment option for delivering hypofractionated treatments for prostate cancer compared to HDR BT, in particular as it is less invasive and less resource intensive. Long-term outcomes of clinical trials comparing HDR BT and SBRT "prostate boosts" may show whether the high intraprostatic doses are clinically significant and correlate with outcomes.

CyberKnife reference dosimetry: An assessment of the impact of evolving recommendations on correction factors and measured dose.

PURPOSE: Specialized treatment machines such as the CyberKnife, TomoTherapy, or the GammaKnife, utilize flattening filter free (FFF) photon beams and may not be able to generate a 10 cm x 10 cm reference field. A new Code of Practice has recently been published (IAEA TRS483) to give recommendations for these machines. Additionally, some standard laboratories provide measured beam quality correction factors for the user's reference chamber, which can be used instead of the published tabulated beam quality correction factors. The purpose of this study was first to assess how different recommendations, as outlined below, affect the reference dosimetry at the CyberKnife, and second, to assess the impact of using measured rather than tabulated beam quality correction factors on measured dose. METHODS: Following recommendations in TRS398, three field chambers (IBA CC04, Exradin A19, and Exradin A12S) were cross-calibrated with a user's reference chamber (IBA FC65-G), which was calibrated in a Cobalt-60 (Co-60) beam by a primary standards laboratory. The chamber response was corrected for influence quantities such as temperature, pressure, ion recombination, polarity, and beam quality. Additionally, correction factors for volume averaging and differences due the FFF beam spectrum were determined for the CyberKnife beam. Three different methods were utilized - TRS398; Intermediate (i.e. TRS398 with additional published recommendations); and TRS483. The measurements were undertaken in a 10 cm × 10 cm field defined by jaws for a uniform flattened (WFF) 6 MV photon beam of a Varian TrueBeam linear accelerator (linac) with a source to detector distance (SDD) of 100 cm, and in a 60 mm diameter circular field for a 6 MV flattening filter free (FFF) Accuray CyberKnife beam with SDD of 80 cm. All measurement was performed at 10 cm deep in a full scatter phantom as defined in TRS398. RESULTS: Differences between the three methods in volume averaging correction factors ranged from 0.01% to 0.45% depending on the chamber assessed. As expected, an increased chamber length leads to a larger correction factor. The differences in beam spectrum correction factors range from 0.09% to 0.3%. Negligible differences in beam quality correction factors were observed; however, differences up to 1% were found between measured and tabulated values. Differences in cross-calibrated chamber calibration coefficients range from 0.05% to 0.51% depending on the chamber assessed. Differences in measured dose are up to 0.87% between Method TRS398 and Intermediate, again chamber dependent, and 0.28% between Method Intermediate and TRS483. CONCLUSION: Using chambers cross-calibrated in the linac beam can lead to differences in measured dose per Monitor Unit (MU) in the CyberKnife beam of approximately 0.5% between chambers. Using Method Intermediate vs using recommendations given in TRS483 led to a difference of 0.28% in measured dose per MU, which is due to differences in volume averaging and beam spectrum correction factors. Using TRS483 is recommended as the cross-calibration is done in the CyberKnife beam and accounts for its specific reference conditions. It will also ensure consistency between different centers. The measured beam quality correction factors agree within the uncertainties with the tabulated values.