Simultaneous integrated boost (SIB) to dominant intra-prostatic lesions during extreme hypofractionation for prostate cancer: the impact of rectal spacers.

PURPOSE: Boosting dominant intra-prostatic lesions (DILs) has the potential to increase the therapeutic ratio in prostate cancer radiotherapy. In this study, employing 5-fraction stereotactic ablative radiotherapy (SABR) volumetric modulated arc therapy (VMAT) to deliver 40 Gy to the prostate clinical target volume (CTV) while boosting the DIL up to 50 Gy was evaluated for patients before and after rectal spacer insertion. MATERIALS AND METHODS: 24 Computed Tomography (CT) scans of 12 prostate cancer patients with unfavourable intermediate or high risk prostate cancer were employed in this study. At least two treatment plans were generated for each patient to compare pre- and post-spacer insertion plans. Plans were evaluated for target coverage, organs-at-risk doses, and the achievable boost dose level. RESULTS: The CTV coverage was significantly better in plans with a spacer, V40Gy 98.4% versus 97.0% (p = 0.012). Using spacers significantly reduced rectal dose in all 12 patients in this study. It was possible to boost DIL to 50 Gy to without violating dose constraints in 6 of 12 patients and to 47.5 Gy in 3 patients post-spacer insertion. For 3 patients (25%) it was not possible to boost DIL above 45 Gy even with a spacer in situ. Without a spacer, for 6 patient (50%) clinically acceptable plan were only achieved when the DIL dose was lowered to 45 Gy. In five of these 6 patients the dose limiting structure was the urethra (urethra planning risk volume V45Gy [cc] ≤ 0.1 cc constraint). CONCLUSIONS: Clinically acceptable plans for 5 fraction SABR, 40 Gy to the prostate CTV, with a SIB to DIL (45-50 Gy) were achieved. The boost dose achieved was DIL location dependent and primarily affected by DIL's proximity to the urethra. Compared to plans before spacer insertion, higher DIL dose were achieved with spacer in situ for 25% of the patients. Moreover, significant reduction in rectal dose and better target coverage were also achieved for all patients with spacers in situ.

Towards real-time PGS range monitoring in proton therapy of prostate cancer.

Proton therapy of prostate cancer (PCPT) was linked with increased levels of gastrointestinal toxicity in its early use compared to intensity-modulated radiation therapy (IMRT). The higher radiation dose to the rectum by proton beams is mainly due to anatomical variations. Here, we demonstrate an approach to monitor rectal radiation exposure in PCPT based on prompt gamma spectroscopy (PGS). Endorectal balloons (ERBs) are used to stabilize prostate movement during radiotherapy. These ERBs are usually filled with water. However, other water solutions containing elements with higher atomic numbers, such as silicon, may enable the use of PGS to monitor the radiation exposure of the rectum. Protons hitting silicon atoms emit prompt gamma rays with a specific energy of 1.78 MeV, which can be used to monitor whether the ERB is being hit. In a binary approach, we search the silicon energy peaks for every irradiated prostate region. We demonstrate this technique for both single-spot irradiation and real treatment plans. Real-time feedback based on the ERB being hit column-wise is feasible and would allow clinicians to decide whether to adapt or continue treatment. This technique may be extended to other cancer types and organs at risk, such as the oesophagus.

Rectal wall sparing effect of a rectal retractor in prostate intensity-modulated radiotherapy.

PURPOSE: The objective of the study was to evaluate the effectiveness of a rectal retractor (RR) designed to protect rectal tissue in intensity-modulated radiotherapy (IMRT) by pushing rectal wall (RW) away from the prostate. MATERIALS AND METHODS: Twelve patients with localized prostate cancer were enrolled into this study. Patients underwent two computed tomography (CT) scans without and with RR. A prescription of 80 Gy in 40 fractions was planned on CT scans with and without RR. This study evaluates the ability of the RR in RW dose reduction, in particular reduction of the RW V70Gy≥ 25% in comparison with the plan without RR dose-volume histograms were generated with and without RR. The patient's tolerance was assessed by patient-reported outcomes. RESULTS: The planning target volume coverage was equal for both without and with RR (P = 0.155). The mean dose to the RW was statistically significantly lower for the plan with RR than that for the plan without RR, a mean reduction of 5.8 Gy (P = 0.003). Significant relative reductions in rectal dose-volume parameters whether in absolute volume (cc) or as a percentage of contoured RW were detected. A relative reduction more than 25% in RW V70Gy(%) in 100% of patients was achieved. The rectal retraction resulted in a significant increase in the prostate to the rectum space at the prostate midgland level, an absolute increase of 2.7 mm. The retraction of the rectum induced a mean (±standard deviation) pain score of 2.7 (±1.3) according to the visual analog score. CONCLUSION: The application of a RR showed a remarkable rectal sparing effect during prostate IMRT. This may lead to reduced acute and late rectal toxicities in prostate IMRT.

Dosimetric comparison of volumetric modulated arc therapy (VMAT) and high-dose-rate brachytherapy (HDR-BT) for superficial skin irradiation with significant curvature in one or more planes.

PURPOSE: This study compares the plan quality of high-dose-rate brachytherapy (HDR-BT) and volumetric modulated arc therapy (VMAT) for superficial irradiation of large areas of skin with significant curvature in one or more planes. METHODS: A total of 14 patients from two centres previously treated with either HDR-BT or VMAT were retrospectively replanned using the alternative technique. Sites included scalp and lower limbs. Identical computed tomography (CT) scans, clinical target volume (CTV) and organs at risk (OARs) and prescription were used for both techniques. Conformity, skin surface dose and OAR doses were compared. RESULTS: Conformity index was consistently better with VMAT than HDR-BT (p < 0.01). Maximum skin surface dose (D0.1cc) had a higher mean of 49.6 Gy with HDR-BT compared to 31.4 Gy for VMAT (p < 0.01). Significantly smaller volumes of healthy tissue were irradiated with VMAT than with HDR-BT. This can be seen in brain volumes receiving 10, 20 and 30 Gy EQD2 and in extremities receiving 5 and 10 Gy. When close to the volume, the lens received significantly lower doses with VMAT (p < 0.01). CONCLUSION: In this small sample, VMAT gives equal coverage with lower OAR and skin surface doses than HDR-BT for both scalp and extremities. VMAT is a useful technique for treating large, superficial volumes with significant curvature in one or more planes.

Beam complexity and monitor unit efficiency comparison in two different volumetric modulated arc therapy delivery systems using automated planning.

BACKGROUND: To investigate the beam complexity and monitor unit (MU) efficiency issues for two different volumetric modulated arc therapy (VMAT) delivery technologies for patients with left-sided breast cancer (BC) and nasopharyngeal carcinoma (NPC). METHODS: Twelve left-sided BC and seven NPC cases were enrolled in this study. Each delivered treatment plan was optimized in the Pinnacle3 treatment planning system with the Auto-Planning module for the Trilogy and Synergy systems. Similar planning dose objectives and beam configurations were used for each site in the two different delivery systems to produce clinically acceptable plans. The beam complexity was evaluated in terms of the segment area (SA), segment width (SW), leaf sequence variability (LSV), aperture area variability (AAV), and modulation complexity score (MCS) based on the multileaf collimator sequence and MU. Plan delivery and a gamma evaluation were performed using a helical diode array. RESULTS: With similar plan quality, the average SAs for the Trilogy plans were smaller than those for the Synergy plans: 55.5 ± 21.3 cm2 vs. 66.3 ± 17.9 cm2 (p < 0.05) for the NPC cases and 100.7 ± 49.2 cm2 vs. 108.5 ± 42.7 cm2 (p < 0.05) for the BC cases, respectively. The SW was statistically significant for the two delivery systems (NPC: 6.87 ± 1.95 cm vs. 6.72 ± 2.71 cm, p < 0.05; BC: 8.84 ± 2.56 cm vs. 8.09 ± 2.63 cm, p < 0.05). The LSV was significantly smaller for Trilogy (NPC: 0.84 ± 0.033 vs. 0.86 ± 0.033, p < 0.05; BC: 0.89 ± 0.026 vs. 0.90 ± 0.26, p < 0.05). The mean AAV was significantly larger for Trilogy than for Synergy (NPC: 0.18 ± 0.064 vs. 0.14 ± 0.037, p < 0.05; BC: 0.46 ± 0.15 vs. 0.33 ± 0.13, p < 0.05). The MCS values for Trilogy were higher than those for Synergy: 0.14 ± 0.016 vs. 0.12 ± 0.017 (p < 0.05) for the NPC cases and 0.42 ± 0.106 vs. 0.30 ± 0.087 (p < 0.05) for the BC cases. Compared with the Synergy plans, the average MUs for the Trilogy plans were larger: 828.6 ± 74.1 MU and 782.9 ± 85.2 MU (p > 0.05) for the NPC cases and 444.8 ± 61.3 MU and 393.8 ± 75.3 MU (p > 0.05) for the BC cases. The gamma index agreement scores were never below 91% using 3 mm/3% (global) distance to agreement and dose difference criteria and a 10% lower dose exclusion threshold. CONCLUSIONS: The Pinnacle3 Auto-Planning system can optimize BC and NPC plans to achieve the same plan quality using both the Trilogy and Synergy systems. We found that these two systems resulted in different SAs, SWs, LSVs, AAVs and MCSs. As a result, we suggested that the beam complexity should be considered in the development of further methodologies while optimizing VMAT autoplanning.

Treatment planning comparison of volumetric modulated arc therapy with the trilogy and the Halcyon for bilateral breast cancer.

BACKGROUND: The Halcyon is a new machine from the Varian company. The purpose of this study was to evaluate the dosimetry of the Halcyon in treatment of bilateral breast cancer with volumetric modulated arc therapy. METHODS: On CT images of 10 patients with bilateral breast cancer, four Halcyon plans with different setup fields were generated, and dosimetric comparisons using Bonferroni's multiple comparisons test were conducted among the four plans. Whole and partial arc plans on the Trilogy and the Halcyon, referred to as T-4arc, T-8arc, H-4arc and H-8arc, were designed. The prescription dose was 50 Gy in 2-Gy fractions. All plans were designed with the Eclipse version 15.5 treatment planning system. The dosimetric differences between whole and partial arc plans in the same accelerator were compared using the Mann-Whitney U test. The better Halcyon plan was selected for the further dosimetric comparison of the plan quality and delivery efficiency between the Trilogy and the Halcyon. RESULTS: Halcyon plans with high-quality megavoltage cone beam CT setup fields increased the Dmean, D2 and V107 of the planning target volume (PTV) and the V5 and Dmean of the heart, left ventricle (LV) and lungs compared with other Halcyon setup plans. The mean dose and low dose volume of the heart, lungs and liver were significantly decreased in T-8arc plans compared to T-4arc plans. In terms of the V5, V20, V30, V40 and Dmean of the heart, the V20, V30, V40 and Dmean of the LV, the V30, V40, Dmax and Dmean of the left anterior descending artery (LAD), and the V5 and V40 of lungs, H-8arc was significantly higher than H-4arc (p < 0.05). Compared with the Trilogy's plans, the Halcyon's plans reduced the high-dose volume of the heart and LV but increased the mean dose of the heart. For the dose of the LAD and the V20 and V30 of lungs, there was no significant difference between the two accelerators. Compared with the Trilogy, plans on the Halcyon significantly increased the skin dose but also significantly reduced the delivery time. CONCLUSION: For the Halcyon, the whole-arc plans have more dosimetric advantages than partial-arc plans in bilateral breast cancer radiotherapy. Although the mean dose of the heart and the skin dose are increased, the doses of the cardiac substructure and other OARs are comparable to the Trilogy, and the delivery time is significantly reduced.

Proof-of-concept delivery of intensity modulated arc therapy on the Elekta Unity 1.5 T MR-linac.

In this work we present the first delivery of intensity modulated arc therapy on the Elekta Unity 1.5 T MR-linac. The machine's current intensity modulated radiation therapy based control system was modified suitably to enable dynamic delivery of radiation, for the purpose of exploring MRI-guided radiation therapy adaptation modes in a research setting. The proof-of-concept feasibility was demonstrated by planning and delivering two types of plans, each investigating the performance of different parts of a dynamic treatment. A series of fixed-speed arc plans was used to show the high-speed capabilities of the gantry during radiation, while several fully modulated prostate plans-optimised following the volumetric modulated arc therapy approach-were delivered in order to establish the performance of its multi-leaf collimator and diaphragms. These plans were delivered to Delta4 Phantom+ MR and film phantoms passing the clinical quality assurance criteria used in our clinic. In addition, we also performed some initial MR imaging experiments during dynamic therapy, demonstrating that the impact of radiation and moving gantry/collimator components on the image quality is negligible. These results show that arc therapy is feasible on the Elekta Unity system. The machine's high performance components enable dynamic delivery during fast gantry rotation and can be controlled in a stable fashion to deliver fully modulated plans.

ROAD: ROtational direct Aperture optimization with a Decoupled ring-collimator for FLASH radiotherapy.

Ultra-high dose rate in radiotherapy (FLASH) has been shown to increase the therapeutic index with markedly reduced normal tissue toxicity and the same or better tumor cell killing. The challenge to achieve FLASH using x-rays, besides developing a high output linac, is to intensity-modulate the high-dose-rate x-rays so that the biological gain is not offset by the lack of physical dose conformity. In this study, we develop the ROtational direct Aperture optimization with a Decoupled ring-collimator (ROAD) to achieve simultaneous ultrafast delivery and complex dose modulation. The ROAD design includes a fast-rotating slip-ring linac and a decoupled collimator-ring with 75 pre-shaped multi-leaf-collimator (MLC) modules. The ring-source rotates at 1 rotation per second (rps) clockwise while the ring-collimator is either static or rotating at 1 rps counterclockwise, achieving 75 (ROAD-75) or 150 (ROAD-150) equal-angular beams for one full arc. The Direct Aperture Optimization (DAO) for ROAD was formulated to include a least-square dose fidelity, an anisotropic total variation term, and a single segment term. The FLASH dose (FD) and FLASH biological equivalent dose (FBED) were computed voxelwise, with the latter using a spatiotemporal model accounting for radiolytic oxygen depletion. ROAD was compared with clinical volumetric modulated arc therapy (VMAT) on a brain, a lung, a prostate, and a head and neck cancer patient. The mean dose rate of ROAD-75 and ROAD-150 are 76.2 Gy s-1 and 112 Gy s-1 respectively to deliver 25 Gy single-fraction dose in 1 s. With improved PTV homogeneity, ROAD-150 reduced (max, mean) OAR physical dose by (4.8 Gy, 6.3 Gy). The average R50 and integral dose of (VMAT, ROAD-75, ROAD-150) are (4.8, 3.2, 3.2) and (89, 57, 56) Gy×Liter, respectively. The FD and FBED showed model dependent FLASH effects. The novel ROAD design achieves ultrafast dose delivery and improves physical dosimetry compared with clinical VMAT, providing a potentially viable engineering solution for x-ray FLASH radiotherapy.

Small Animal IMRT Using 3D-Printed Compensators.

PURPOSE: Preclinical radiation replicating clinical intensity modulated radiation therapy (IMRT) techniques can provide data translatable to clinical practice. For this work, treatment plans were created for oxygen-guided dose-painting in small animals using inverse-planned IMRT. Spatially varying beam intensities were achieved using 3-dimensional (3D)-printed compensators. METHODS AND MATERIALS: Optimized beam fluence from arbitrary gantry angles was determined using a verified model of the XRAD225Cx treatment beam. Compensators were 3D-printed with varied thickness to provide desired attenuation using copper/polylactic-acid. Spatial resolution capabilities were investigated using printed test-patterns. Following American Association of Physicists in Medicine TG119, a 5-beam IMRT plan was created for a miniaturized (∼1/8th scale) C-shape target. Electron paramagnetic resonance imaging of murine tumor oxygenation guided simultaneous integrated boost (SIB) plans conformally treating tumor to a base dose (Rx1) with boost (Rx2) based on tumor oxygenation. The 3D-printed compensator intensity modulation accuracy and precision was evaluated by individually delivering each field to a phantom containing radiochromic film and subsequent per-field gamma analysis. The methodology was validated end-to-end with composite delivery (incorporating 3D-printed tungsten/polylactic-acid beam trimmers to reduce out-of-field leakage) of the oxygen-guided SIB plan to a phantom containing film and subsequent gamma analysis. RESULTS: Resolution test-patterns demonstrate practical printer resolution of ∼0.7 mm, corresponding to 1.0 mm bixels at the isocenter. The miniaturized C-shape plan provides planning target volume coverage (V95% = 95%) with organ sparing (organs at risk Dmax < 50%). The SIB plan to hypoxic tumor demonstrates the utility of this approach (hypoxic tumor V95%,Rx2 = 91.6%, normoxic tumor V95%,Rx1 = 95.7%, normal tissue V100%,Rx1 = 7.1%). The more challenging SIB plan to boost the normoxic tumor rim achieved normoxic tumor V95%,Rx2 = 90.9%, hypoxic tumor V95%,Rx1 = 62.7%, and normal tissue V100%,Rx2 = 5.3%. Average per-field gamma passing rates using 3%/1.0 mm, 3%/0.7 mm, and 3%/0.5 mm criteria were 98.8% ± 2.8%, 96.6% ± 4.1%, and 90.6% ± 5.9%, respectively. Composite delivery of the hypoxia boost plan and gamma analysis (3%/1 mm) gave passing results of 95.3% and 98.1% for the 2 measured orthogonal dose planes. CONCLUSIONS: This simple and cost-effective approach using 3D-printed compensators for small-animal IMRT provides a methodology enabling preclinical studies that can be readily translated into the clinic. The presented oxygen-guided dose-painting demonstrates that this methodology will facilitate studies driving much needed biologic personalization of radiation therapy for improvements in patient outcomes.

A technique for quantifying the sensitivity of dosimetric tool gamma with 2D detector array in pretreatment IMRT plans by segment deletion method.

OBJECTIVES: Motivation of this study is to check the sensitivity of dosimetric tool gamma with 2D detector array combination when unexpected errors occur while transferring intensity-modulated radiation therapy treatment plans from planning system to treatment unit. METHODS: This study consists of 17 head and neck cancer patient's treatment plans. Nine types of verification plans are created for all 17 clinically approved treatment plans by consecutively deleting different segments (up to eight) one by one from each field of the plan. Decrement factor (χ) is introduced in our study which illustrated the degree of decay of gamma passing rate when intentional errors are introduced. We analyzed the data by two different methods-one without selecting the region of interest (ROI) in dose distributions and the other by selecting the region of interest. RESULTS: By linear regression, the absolute value of slopes is 0.025, 0.024 and 0.015 without ROI and 0.030, 0.027 and 0.015 with ROI for 2%/2 mm, 3%/3 mm and 5%/5 mm criteria, respectively. The higher absolute value of the fitted slope indicates the higher sensitivity of this method to identify erroneous plan in treatment unit. The threshold value for 2%/2 mm equivalent to 95% passing criteria in 3%/3 mm used in clinical practice is obtained as 83.44%. CONCLUSIONS: The 2D detector array with dosimetric tool gamma is less sensitive in detecting errors when unprecedented errors of segment deletion occur within the treatment plans.

Toward an effective use of laser-driven very high energy electrons for radiotherapy: Feasibility assessment of multi-field and intensity modulation irradiation schemes.

Radiotherapy with very high energy electrons has been investigated for a couple of decades as an effective approach to improve dose distribution compared to conventional photon-based radiotherapy, with the recent intriguing potential of high dose-rate irradiation. Its practical application to treatment has been hindered by the lack of hospital-scale accelerators. High-gradient laser-plasma accelerators (LPA) have been proposed as a possible platform, but no experiments so far have explored the feasibility of a clinical use of this concept. We show the results of an experimental study aimed at assessing dose deposition for deep seated tumours using advanced irradiation schemes with an existing LPA source. Measurements show control of localized dose deposition and modulation, suitable to target a volume at depths in the range from 5 to 10 cm with mm resolution. The dose delivered to the target was up to 1.6 Gy, delivered with few hundreds of shots, limited by secondary components of the LPA accelerator. Measurements suggest that therapeutic doses within localized volumes can already be obtained with existing LPA technology, calling for dedicated pre-clinical studies.

Patient-based low dose cone beam CT acquisition settings for prostate image-guided radiotherapy treatments on a Varian TrueBeam linear accelerator.

OBJECTIVE: To evaluate the performance of low dose cone beam CT (CBCT) acquisition protocols for image-guided radiotherapy of prostate cancer. METHODS: CBCT images of patients undergoing prostate cancer radiotherapy were acquired with the settings currently used in our department and two low dose settings at 50% and 63% lower exposure. Four experienced radiation oncologists and two radiation therapy technologists graded the images on five image quality characteristics. The scores were analysed through Visual Grading Regression, using the acquisition settings and the patient size as covariates. RESULTS: The low dose acquisition settings have no impact on the image quality for patients with body profile length at hip level below 100 cm. CONCLUSIONS: A reduction of about 60% of the dose is feasible for patients with size below 100 cm. The visibility of low contrast features can be compromised if using the low dose acquisition settings for patients with hip size above 100 cm. ADVANCES IN KNOWLEDGE: Low dose CBCT acquisition protocols for the pelvis, based on subjective evaluation of patient images.

On the three-objective static unconstrained leaf sequencing in IMRT.

Algorithms are an essential part of radiation therapy planning, which includes three optimizations problems: beam angle configuration, fluence map, and realization. This study addresses the third one, also called the leaf sequencing problem, which arises for each chosen irradiation angle, given the optimized fluence map. It consists in defining a sequence of configurations of a device (called multileaf collimator) that correctly delivers radiation to the patient. A usual model for this problem is the decomposition of a matrix into a weighted sum of (0,1)-matrices, called segments, in which the ones in each row appear consecutively. Each (0,1)-matrix corresponds to a configuration of the device. The realization problem has three objectives. The first one is to minimize the sum of weights assigned to the (0,1)-matrices. The second is to minimize the number of segments. Finally, the third one is to find the best order to apply those configurations. This study presents a greedy and randomized algorithm to this problem and compares it with other algorithms presented previously in the literature. Statistical tests show that our algorithm outperformed the previous ones regarding the quality indicators investigated. Graphical Abstract a Illustrates how the IMRT realization is modelled to a mathematical problem. b Shows a decomposition example of the IMRT realization. c The scheme of the algorithm that is proposed on this work, called GRA-SRA.

Plan optimization with L0-norm and group sparsity constraints for a new rotational, intensity-modulated brachytherapy for cervical cancer.

The aim of this work is to build a framework that comprehends inverse planning procedure and plan optimization algorithm tailored to a novel directional beam intensity-modulated brachytherapy (IMBT) of cervical cancer using a rotatable, single-channel radiation shield. Inverse planning is required for finding optimal beam emitting direction, source dwell position and dwell time, which begin with creating a kernel matrix for each structure based on Monte-Carlo simulated dose distribution in the rotatable shield. For efficient beam delivery and less transit dose, the number of source dwell positions and angles needs to be minimized. It can be solved by L0-norm regularization for fewest possible dwell points, and by group sparsity constraint in L2,p-norm (0≤p<1) besides L0-norm for fewest active applicator rotating angles. The dose distributions from our proposed algorithms were compared to those of conventional tandem-based intracavitary brachytherapy (ICR) plans for six cervical cancer patients. The algorithmic performance was evaluated in delivery efficiency and plan quality relative to the unconstrained algorithm. The proposed framework yielded substantially enhanced plan quality over the conventional ICR plans. The L0-norm and (group sparsity+L0-norm) constrained algorithms reduced the number of source dwell points by 60 and 70% and saved 5 and 8 rotational angles on average (7 and 11 angles for highly modulated cases), relative to the unconstrained algorithm, respectively. Though both algorithms reduced the optimal source dwell positions and angles, the group sparsity constrained optimization with L0-norm was more effective than the L0-norm constraint only, mainly because of considering physical constraints of the new IMBT applicator. With much fewer dwell points compared to the unconstrained, the proposed algorithms led to statistically similar plan quality in dose volume histograms and iso-dose lines. It also demonstrated that the plan optimized by rotating the applicator resulted in much better plan quality than that of conventional applicator-based plans.

Quality assurance of IMRT treatment plans for a 1.5 T MR-linac using a 2D ionization chamber array and a static solid phantom.

MR-guided radiotherapy requires novel quality assurance (QA) methods for intensity-modulated radiotherapy treatment plans (TPs). Here, an optimized method for TPs for a 1.5 T MR-linac was developed and implemented clinically. A static solid phantom and an MR-compatible 2D ionization chamber array were used. The array's response with respect to the incident beam gantry angles was characterized for four different orientations of the array relative to the beam. A lookup table was created identifying the optimum orientation for each gantry angle. For the QA of clinical MR-linac TPs, beams were grouped according to their gantry angles and measured with up to four setups. The method was applied to n = 106 clinical TPs of 54 patients for different tumour entities. Reference plans and plans created in the online adaptive workflow were analysed, using a local 3%/3 mm gamma criterion for dose values larger than 30% of the maximum. Pass rates were averaged over all beam groups. The array's response strongly depends on the beam incidence angle. Optimum angles typically range from -10° to 80° around the phantom setup angle. Consequently, plan verification required up to four setups. For clinical MR-linac TPs, the overall median pass rate was 98.5% (range 88.6%-100%). Pass rates depended on the tumour entity. Median pass rates were for liver metastases stereotactic body radiotherapy 99.2%, prostate cancer 99%, pancreatic cancer 98.9%, lymph node metastases 98.7%, partial breast irradiation (PBI) 98%, head-and-neck cancer 97.7%, rectal cancer 94% and others 96.6%. 85% of plans were accepted straightaway, with pass rates above 95%. A single plan with a pass rate below 90% was subsequently verified with a modified method. Off-axis target volumes, e.g. PBI, were verified successfully using a lateral shift of the phantom. The method is suitable to verify reference and online adapted TPs for a 1.5 T MR-linac, including plans for off-axis target volumes.

Intensity modulated Ir-192 brachytherapy using high-Z 3D printed applicators.

Gynecologic cancers are often asymmetric, yet current Ir-192 brachytherapy techniques provide only limited radial modulation of the dose. The shielded solutions investigated here solve this by providing the ability to modulate between highly asymmetric and radially symmetric dose distributions at a given location. To find applicator designs that can modulate between full dose and less than 50% dose, at the dimensions of the urethra, a 2D calculation algorithm was developed to narrow down the search space. Two shielding design types were then further investigated using Monte Carlo and Boltzmann-solver dose calculation algorithms. 3D printing techniques using ISO 10993 certified biocompatible plastics and 3D printable tungsten-loaded plastics were tested. It was also found that shadowing effects set by the shape of the shielding cannot be easily modulated out, hence careful design is required. The shielded applicator designs investigated here, allow for reduction of the dose by over 50% at 5 mm from the applicator surface in desired regions, while also allowing radially symmetric dose with isodose line deviations less than 0.5 mm from circular. The shielding designs were also chosen with treatment delivery time in mind. Treatment times for these shielded designs were found to be less than 1.4 times longer than a 6-channel unshielded cylinder for the equivalent fully symmetric dose distribution. The 2D calculation methods developed here provide a simple way to rapidly evaluate shielding designs, while the 3D printing techniques also allow for devices with novel shapes to be rapidly prototyped. Both TOPAS Monte Carlo and Acuros BV calculations show that significant dose shaping and organ at risk sparing can be achieved without significantly compromising the plan in regions that require the full dose.

Standardized flattening filter free volumetric modulated arc therapy plans based on anteroposterior width for total body irradiation.

In this work, the feasibility of using flattening filter free (FFF) beams in volumetric modulated arc therapy (VMAT) total body irradiation (TBI) treatment planning to decrease protracted beam-on times for these treatments was investigated. In addition, a methodology was developed to generate standardized VMAT TBI treatment plans based on patient physical dimensions to eliminate plan optimization time. A planning study cohort of 47 TBI patients previously treated with optimized VMAT ARC 6 MV beams was retrospectively examined. These patients were sorted into six categories depending on height and anteroposterior (AP) width at the umbilicus. Using Varian Eclipse, clinical 40 cm × 10 cm open field arcs were substituted with 6 MV FFF. Mid-plane lateral dose profiles in conjunction with relative arc output factors (RAOF) yielded how far a given multileaf collimator (MLC) leaf must move in order to achieve a mid-plane 100% isodose for a specific control point. Linear interpolation gave the dynamic MLC aperture for the entire arc for each patient AP width category, which was subsequently applied through Python scripting. All FFF VMAT TBI plans were then evaluated by two radiation oncologists and deemed clinically acceptable. The FFF and clinical VMAT TBI plans had similar Body-5 mm D98% distributions, but overall the FFF plans had statistically significantly increased or broader Body-5 mm D2% and mean lung dose distributions. These differences are not considered clinically significant. Median beam-on times for the FFF and clinical VMAT TBI plans were 11.07 and 18.06 min, respectively, and planning time for the FFF VMAT TBI plans was reduced by 34.1 min. In conclusion, use of FFF beams in VMAT TBI treatment planning resulted in dose homogeneity similar to our current VMAT TBI technique. Clinical dosimetric criteria were achieved for a majority of patients while planning and calculated beam-on times were reduced, offering the possibility of improved patient experience.

Flattening filter free VMAT for a stereotactic, single-dose of 30 Gy to lung lesion in a 15-min treatment slot.

Cone-beam CT-guided single dose of lung stereotactic body radiotherapy (SBRT) treatment with a flattening filter free (FFF) beam and volumetric modulated arc therapy (VMAT) is a safe and highly effective treatment modality for selective small lung lesions. Four-dimensional (4D) CT-based treatment plans were generated using advanced AcurosXB algorithm for heterogeneity corrections. 6X-FFF beam produced highly conformal radiosurgical dose distribution to the target and reduced lung SBRT fraction duration to less than 10 min for a single dose of 30 Gy, significantly improving patient comfort and clinic workflow. Early follow-up CT imaging results (mean, 8 months) show high local control rates (100%) with no acute lung or rib toxicity. Longer clinical follow-up in a larger patient cohort managed in this fashion is underway to further validate this treatment approach.