Influence of the Planning Parameters of a New Algorithm on the Dosimetric Quality, Beam-On Time and Delivery Accuracy of Tomotherapy Plans.

BACKGROUND: This work aimed to determine the optimum VOLOTM Ultra algorithm parameters for tomotherapy treatments. METHODS: 1056 treatment plans were generated with VOLOTM Ultra for 36 patients and six anatomical locations. The impact of varying four parameters was studied: the accelerated treatment (AT), leaf open/close time (LOT) cutoff, normal tissue objective (NTO) weight, and number of iterations. The beam-on time and dosimetric metrics were quantified for the target volumes and organs at risk (OARs). Delivery quality assurance measurements were obtained for 36 plans to assess the delivery accuracy. RESULTS: The mean beam-on time for the helical tomotherapy and TomoDirect (TD) plans decreased by 26.6 ± 2.8% and 17.4 ± 4.3%, respectively, when the accelerated treatment parameter was increased from 0 to 10, at the expense of the planning target volume (PTV) coverage (2% lower D98%) and OAR dose (up to 15% increase). For TD plans, it seems preferable to systematically use an AT value of 10. Increasing the number of iterations beyond six seems unnecessary. In this study, an NTO weight of approximately 10 appears to be ideal and eliminates the need to use rings in the treatment plan. Finally, no correlation was found between the leaf open/close time cutoff and the delivery accuracy, while a leaf open/close cutoff of 60 ms seemed to degrade dosimetry quality. CONCLUSION: Optimal values for the AT, LOT cutoff, NTO weight, and number of optimization rounds were identified and should help improve the management of patients whose tomotherapy treatments are planned with VOLOTM Ultra.

Image Processing Pitfalls in Vendor Adaptive Radiotherapy Software with Tomotherapy-like Systems: Feedback from Clinical Case Reports.

BACKGROUND: Adaptive radiotherapy (ART) has the potential to reduce the toxicities of radiotherapy and improve overall survival by considering variations in the patient's anatomy during the course of treatment. ART's first commercial solutions are now implemented in clinical radiotherapy departments. However, before they can be used safely with real patients, these solutions must be rigorously evaluated to precisely determine the limits of their use. METHODS: In this paper, we evaluated an offline ART vendor system in 50 patients treated on tomotherapy- like systems for six months. Illustrated by numerous examples of head and neck, thoracic and abdominopelvic localizations, two limitations of image processing used in the ART workflow have been highlighted: deformable image registration (DIR) accuracy and the way the limited field of view (FOV) is compensated. This feedback from clinical experience makes it possible to identify topics of image processing research with strong clinical interest. RESULTS: Current DIR method accuracy may be too weak for some clinical ART applications, and their improvement remains highly important, especially for multimodality registration. Improvements in contour propagation methods also remain crucial today. We showed that there is a need for the development of automatic DIR accuracy quantification methods to help streamline the ART process. Finally, the limited FOV of the onboard images may induce dose calculation errors, highlighting the need to develop new FOV extension methods. CONCLUSION: We have evaluated a vendor ART system, but some image processing pitfalls, such as DIR accuracy and the limited FOV of the onboard images, make its implementation into clinical practice difficult for the moment.

Megavoltage 2D topographic imaging: An attractive alternative to megavoltage CT for the localization of breast cancer patients treated with TomoDirect.

PURPOSE: To show the usefulness of topographic 2D megavoltage images (MV2D) for the localization of breast cancer patients treated with TomoDirect (TD), a radiotherapy treatment technique with fixed-angle beams performed on a TomoTherapy system. METHODS: A method was developed to quickly localize breast cancer patients treated with TD by registering the MV2D images produced before a TD treatment with reference images reconstructed from a kilovoltage CT simulation scanner and by using the projection of the beam-eye-view TD treatment field. Dose and image quality measurements were performed to determine the optimal parameters for acquiring MV2D images. A TD treatment was simulated on a chest phantom equipped with a breast attachment. MVCT and MV2D images were performed for 7 different shifted positions of the phantom and registered by 10 different operators with the simulation kilovoltage CT images. RESULTS: Compared to MVCT, MV2D imaging reduces the dose by a factor of up to 45 and the acquisition time by a factor of up to 49. Comparing the registration shift values obtained for the phantom images obtained with MVCT in the coarse mode to those obtained with MV2D, the mean difference is 1.0±1.1mm, -1.1mm±1.1, and -0.1±2.2mm, respectively, in the lateral, longitudinal, and vertical directions. CONCLUSIONS: With dual advantages (very fast imaging and a potentially reduced dose to the heart and contralateral organs), MV2D topographic images may be an attractive alternative to MVCT for the localization of breast cancer patients treated with TomoDirect.

Is the lack of respiratory gating prejudicial for left breast TomoDirect treatments?

BACKGROUND AND PURPOSE: TomoDirect (TD) can only operate in free-breathing. The purpose of this study is to compare TD with breath-hold 3D conformal radiotherapy (3DCRT) and intensity modulated radiotherapy (IMRT) techniques for left breast treatments, and to determine if the lack of respiratory gating is a handicap for cardiac sparing. MATERIALS AND METHODS: 15 patients treated for left breast had two computed tomography simulation, in free breathing (FB) and in deep-inspiration breath-hold (DIBH). Four treatments were planned: TD-FB, 3DCRT-FB, 3DCRT-DIBH and IMRT-DIBH. Dose to PTV, heart, lungs, right breast and patient were compared. RESULTS: A slightly lower cardiac mean dose is found for 3DCRT-DIBH than for TD-FB group (1.99Gy Vs 2.89Gy, p=0.0462), while no statistical difference is found for heart V20. TD-FB plans show the best PTV dose homogeneity (0.053, p<0.001) and the lowest left lung mean dose (5.16Gy, p<0.001). No major differences are found for the other organs. CONCLUSIONS: TomoDirect and breath-hold 3DCRT are complementary techniques for left breast treatments: for a minority of patients, respiratory gating is mandatory to lower cardiac dose; for the remaining majority of patients, TomoDirect achieves better PTV homogeneity and reduced left lung dose, with cardiac dose equivalent to 3DCRT-DIBH.

The optimal tomotherapy treatment planning parameters for extremity soft tissue sarcomas.

BACKGROUND AND PURPOSE: To determine the optimum combination of treatment parameters between pitch, field width (FW) and modulation factor (MF) for extremity sarcomas in tomotherapy. MATERIALS AND METHODS: Six patients previously treated for extremity sarcomas (3 arms and 3 legs) with tomotherapy were included in this study. 288 treatment plans were recalculated, corresponding to all combinations between 2 FW (2.5 and 5 cm), 4 MF (1.5, 2, 2.5 and 3) and 6 pitches (0.215, 0.287, 0.43 and 3 off-axis pitches). The treatment parameters (MF, FW or pitch) are modified between each plan, and the calculation is relaunched for 400 iterations, without modifying the optimisation constraints of the plan under which the patient has been treated. RESULTS: We suggest eliminating the 0.43 pitch and never combining a 0.215 pitch with an MF ≤ 2. We also do not recommend using an MF = 1.5 unless treatment time is an absolute priority over plan quality. We did not see any advantage in using Chen off-axis pitches, except for targets far from the axis (>15 cm) treated with a high pitch. A combination of MF = 2/FW = 5 cm/pitch = 0.287 gives plans of acceptable quality, combined with reduced treatment times. These conclusions are true only for extremity sarcomas treated in 2 Gy/fraction. CONCLUSIONS: We have shown that the choice of pitch/MF/FW combination is crucial for the treatment of extremity sarcomas in tomotherapy: some produce good dosimetric quality with a reduced irradiation time, while others may increase the time without improving the quality.

Contribution of three-dimensional conformal intensity-modulated radiation therapy for women affected by bulky stage II supradiaphragmatic Hodgkin disease.

PURPOSE: To analyze the outcome and dose distribution of intensity-modulated radiation therapy (IMRT) by helical tomotherapy in women treated for large supradiaphragmatic Hodgkin's disease. MATERIAL AND METHODS: A total of 13 patients received adjuvant radiation at a dose of 30 Gy to the initially involved sites with a boost of 6 Gy to those areas suspected of harboring residual disease on the simulation CT scan. RESULTS: With a median follow-up of 23 months, the two-year progression-free survival was 91.6%, and the 2- and 3-year overall survivals were 100%. We did not report any heart or lung acute side effects. The conformity index of PTV (Planning Target Volume) was better for IMRT than for 3D-CRT (p=0.001). For the breasts, lungs, heart, thyroid and esophagus, the volume distributions favored the IMRT plans. For the breasts, the V(20Gy), V(25Gy) and V(30Gy) were 1.5, 2.5 and 3.5 times lower, respectively, for IMRT than for 3D-CRT. For the lung tissues, the V(20Gy) and V(30Gy) were 2 times and 4.5 times lower, respectively, for IMRT than for 3D-CRT. For the heart, the V(20Gy) and V(30Gy) were 1.4 and 2 times lower, respectively, for IMRT than for 3D-CRT. For the esophagus, the V(35Gy) was 1.7 lower for IMRT than for 3D-CRT, and for the thyroid, the V(30Gy) was 1.2 times lower for IMRT. CONCLUSION: IMRT by helical tomotherapy improved the PTV coverage and dramatically decreased the dose in organs at risk. The treatment was well tolerated, but a longer follow-up is necessary to prove a translation of these dosimetric improvements in the outcome of the patients.

Comparison of the dosimetries of 3-dimensions Radiotherapy (3D-RT) with linear accelerator and intensity modulated radiotherapy (IMRT) with helical tomotherapy in children irradiated for neuroblastoma.

BACKGROUND: Intensity modulated radiotherapy is an efficient radiotherapy technique to increase dose in target volumes and decrease irradiation dose in organs at risk. This last objective is mainly relevant in children. However, previous results suggested that IMRT could increase low dose, factor of risk for secondary radiation induced cancer. This study was performed to compare dose distributions with 3D-radiotherapy (3D-RT) and IMRT with tomotherapy (HT) in children with neuroblastoma. Seven children with neuroblastoma were irradiated. Treatment plans were calculated for 3D-RT, and for HT. For the volume of interest, the PTV-V95% and conformity index were calculated. Dose constraints of all the organs at risk and integral dose were compared. RESULTS: The conformity index was statistically better for HT than for 3D-RT. PTV-V95% constraint was reached in 6 cases with HT compared to 2 cases with 3D-RT. For the ipsilateral kidney of the tumor, the V12 Gy constraint was reached for 3 patients with both methods. The values were lower with HT than with 3D-RT in two cases and higher in one case. The threshold was not reached for one patient with either technique, but the value was lower with HT than with 3D-RT. For the contralateral kidney of the tumors, the V12 Gy constraint was reached for all patients with both methods. The values were lower with HT than with 3D-RT in 5 of 7 children, equal in one patient and higher in one patient. The organ-at-risk volumes receiving low doses were significantly lower with 3D-RT but larger for the highest doses, compared to those irradiated with HT. The integral doses were not different. CONCLUSIONS: IMRT with HT allows a better conformity treatment, a more frequently acceptable PTV-V95% than 3D-RT and, concomitantly, a better shielding of the kidneys. The integral doses are comparable between both techniques but consideration of differences in dose distribution between the two techniques, for the organs at risk, has to be taken in account when validating treatment.