Volumetric modulated arc therapy versus intensity-modulated proton therapy in the irradiation of infra diaphragmatic Hodgkin Lymphoma in female patients.

PURPOSE: To investigate the role of infra diaphragmatic intensity-modulated proton therapy (IMPT) compared to volumetric modulated arc therapy (VMAT) for female Hodgkin Lymphoma (HL) patients and to estimate the risk of secondary cancer and ovarian failure. METHODS: A comparative treatment planning study was performed on 14 patients, and the results were compared according to conventional dose-volume metrics. In addition, estimates of the excess absolute risk (EAR) of secondary cancer induction were determined for the bowel, the bladder and the rectum. For the ovaries, the risk of ovarian failure was estimated. RESULTS: The dosimetric findings demonstrate the equivalence between VMAT and IMPT in terms of target coverage. A statistically significant reduction of the mean and near-to-maximum doses was proven for the organs at risk. The EAR ratio estimated for IMPT to VMAT was 0.51 ± 0.32, 0.32 ± 0.35 and 0.05 ± 0.11 for the bowel, bladder and rectum, respectively. Concerning the risk of ovarian failure for the chronologic age ranging from 18 to 46 years, the expected net loss in fertility years ranged from 4.8 to 3.0 years for protons and 12.0 to 5.7 years for photons. CONCLUSION: This in-silico study confirmed the beneficial role of IMPT from a dosimetric point of view. Mathematical models suggested that the use of protons might be further advantageous due to the expected reduction of the risk of secondary cancer induction and its milder impact on the reduction of fertility.

Dosimetric comparison between VMAT with different dose calculation algorithms and protons for soft-tissue sarcoma radiotherapy.

BACKGROUND: To appraise the potential of volumetric modulated arc therapy (VMAT, RapidArc) and proton beams to simultaneously achieve target coverage and enhanced sparing of bone tissue in the treatment of soft-tissue sarcoma with adequate target coverage. MATERIAL AND METHODS: Ten patients presenting with soft-tissue sarcoma of the leg were collected for the study. Dose was prescribed to 66.5 Gy in 25 fractions to the planning target volume (PTV) while significant maximum dose to the bone was constrained to 50 Gy. Plans were optimised according to the RapidArc technique with 6 MV photon beams or for intensity modulated protons. RapidArc photon plans were computed with: 1) AAA; 2) Acuros XB as dose to medium; and 3) Acuros XB as dose to water. RESULTS: All plans acceptably met the criteria of target coverage (V95% >90-95%) and bone sparing (D(1 cm3) <50 Gy). Significantly higher PTV dose homogeneity was found for proton plans. Near-to-maximum dose to bone was similar for RapidArc and protons, while volume receiving medium/low dose levels was minimised with protons. Similar results were obtained for the remaining normal tissue. Dose distributions calculated with the dose to water option resulted ~5% higher than corresponding ones computed as dose to medium. CONCLUSION: High plan quality was demonstrated for both VMAT and proton techniques when applied to soft-tissue sarcoma.

On the impact of dose rate variation upon RapidArc implementation of volumetric modulated are therapy.

PURPOSE: A study was carried out to evaluate the robustness and mutual interplay of two variables concurring to generate modulation patterns of the RapidArc (RapidArc) implementation of volumetric modulated are therapy. Dose rate (DR) and gantry speed (GS) are free parameters optimized alongside field aperture shape by the RapidArc engine; however, they are limited by machine constraints and mutually compensate in order to deliver the proper MU/deg during the gantry rotation. METHODS: Four test cases (one geometrical and three clinical) were selected and RapidArc plans were optimized using maximum allowed dose rates from 100 to 600 MU/min. The maximum gantry speed was fixed at 4.8 deg/s. Qualitative analysis of DR and GS patterns from these cases was summarized together with quantitative assessment of delivery parameters. Pretreatment quality assurance measurements and scoring of plan quality aimed to determine whether preferable initial conditions might be identified or the optimization engine might be invariant to those variables and capable of providing adequate plans independently from the limits applied. RESULTS: The results of the study were: (i) High dynamic range in MU/deg is achievable across all dose rates by means of gantry speed modulation; (ii) there is a robust compensation mechanism between the two variables; (iii) from a machine delivery point-of-view, slightly improved accuracy is achieved when lower DRs are applied; however, this does not have practical consequences since measurements and plan evaluation showed a lack of clinically relevant deviation; and (iv) reduced total treatment time is a major advantage of high DR. CONCLUSIONS: A trend toward improved plan quality for clinical cases was observed with high DR but cannot be generalized, due to the limited amount of cases investigated and the consequent limited significance of the observed differences. As a minimum benefit, the reduced total treatment time should be considered as well.

Accuracy of Acuros XB and AAA dose calculation for small fields with reference to RapidArc(®) stereotactic treatments.

PURPOSE: To assess the accuracy against measurements of two photon dose calculation algorithms (Acuros XB and the Anisotropic Analytical algorithm AAA) for small fields usable in stereotactic treatments with particular focus on RapidArc(®). METHODS: Acuros XB and AAA were configured for stereotactic use. Baseline accuracy was assessed on small jaw-collimated open fields for different values for the spot sizes parameter in the beam data: 0.0, 0.5, 1, and 2 mm. Data were calculated with a grid of 1 × 1 mm(2). Investigated fields were: 3 × 3, 2 × 2, 1 × 1, and 0.8 × 0.8 cm(2) with a 6 MV photon beam generated from a Clinac2100iX (Varian, Palo Alto, CA). Profiles, PDD, and output factors were measured in water with a PTW diamond detector (detector size: 4 mm(2), thickness 0.4 mm) and compared to calculations. Four RapidArc test plans were optimized, calculated and delivered with jaw settings J3 × 3, J2 × 2, and J1 × 1 cm(2), the last was optimized twice to generate high (H) and low (L) modulation patterns. Each plan consisted of one partial arc (gantry 110° to 250°), and collimator 45°. Dose to isocenter was measured in a PTW Octavius phantom and compared to calculations. 2D measurements were performed by means of portal dosimetry with the GLAaS method developed at authors' institute. Analysis was performed with gamma pass-fail test with 3% dose difference and 2 mm distance to agreement thresholds. RESULTS: Open square fields: penumbrae from open field profiles were in good agreement with diamond measurements for 1 mm spot size setting for Acuros XB, and between 0.5 and 1 mm for AAA. Maximum MU difference between calculations and measurements was 1.7% for Acuros XB (0.2% for fields greater than 1 × 1 cm(2)) with 0.5 or 1 mm spot size. Agreement for AAA was within 0.7% (2.8%) for 0.5 (1 mm) spot size. RapidArc plans: doses were evaluated in a 4 mm diameter structure at isocenter and computed values differed from measurements by 0.0, -0.2, 5.5, and -3.4% for Acuros XB calculations (1 mm spot size), and of -0.1, 0.3, 6.7, and -1.2% for AAA, respectively for J3 × 3, J2 × 2, J1 × 1H, J1 × 1L RapidArc plans. Gamma Agreement Index from 2D dose analysis was higher than 95% for J3 × 3 and J2 × 2 plans, being around 80% for J1 × 1 maps. Sensitivity with respect to the dosimetric leaf gap and transmission factor MLC parameters was evaluated in the four RapidArc plans, showing the need to properly set the dosimetric leaf gap for accurate calculations. CONCLUSIONS: Acuros XB and AAA showed acceptable characteristics for stereotactic small fields if adequate tuning of configuration parameters is performed. Dose calculated for RapidArc stereotactic plans showed an acceptable agreement against point and 2D measurements. Both algorithms can therefore be considered safely applicable to stereotactic treatments.

On the role of the optimization algorithm of RapidArc(®) volumetric modulated arc therapy on plan quality and efficiency.

PURPOSE: The RapidArc volumetric modulated arc therapy (VMAT) planning process is based on a core engine, the so-called progressive resolution optimizer (PRO). This is the optimization algorithm used to determine the combination of field shapes, segment weights (with dose rate and gantry speed variations), which best approximate the desired dose distribution in the inverse planning problem. A study was performed to assess the behavior of two versions of PRO. These two versions mostly differ in the way continuous variables describing the modulated arc are sampled into discrete control points, in the planning efficiency and in the presence of some new features. The analysis aimed to assess (i) plan quality, (ii) technical delivery aspects, (iii) agreement between delivery and calculations, and (iv) planning efficiency of the two versions. METHODS: RapidArc plans were generated for four groups of patients (five patients each): anal canal, advanced lung, head and neck, and multiple brain metastases and were designed to test different levels of planning complexity and anatomical features. Plans from optimization with PRO2 (first generation of RapidArc optimizer) were compared against PRO3 (second generation of the algorithm). Additional plans were optimized with PRO3 using new features: the jaw tracking, the intermediate dose and the air cavity correction options. RESULTS: Results showed that (i) plan quality was generally improved with PRO3 and, although not for all parameters, some of the scored indices showed a macroscopic improvement with PRO3. (ii) PRO3 optimization leads to simpler patterns of the dynamic parameters particularly for dose rate. (iii) No differences were observed between the two algorithms in terms of pretreatment quality assurance measurements and (iv) PRO3 optimization was generally faster, with a time reduction of a factor approximately 3.5 with respect to PRO2. CONCLUSIONS: These results indicate that PRO3 is either clinically beneficial or neutral in terms of dosimetric quality while it showed significant advantages in speed and technical aspects.

Volumetric modulated arc therapy versus intensity-modulated proton therapy in neoadjuvant irradiation of locally advanced oesophageal cancer.

BACKGROUND: To investigate the role of intensity-modulated proton therapy (IMPT) compared to volumetric modulated arc therapy (VMAT), realised with RapidArc and RapidPlan methods (RA_RP) for neoadjuvant radiotherapy in locally advanced oesophagal cancer. METHODS: Twenty patients were retrospectively planned for IMPT (with two fields, (IMPT_2F) or with three fields (IMPT_3F)) and RA_RP and the results were compared according to dose-volume metrics. Estimates of the excess absolute risk (EAR) of secondary cancer induction were determined for the lungs. For the cardiac structures, the relative risk (RR) of coronary artery disease (CAD) and chronic heart failure (CHF) were estimated. RESULTS: Both the RA_RP and IMPT approached allowed to achieve the required coverage for the gross tumour volume, (GTV) and the clinical and the planning target volumes, CTV and PTV (V98% > 98 for CTV and GTV and V95% > 95 for the PTV)). The conformity index resulted in 0.88 ± 0.01, 0.89 ± 0.02 and 0.89 ± 0.02 for RA_RP, IMPT_2F and IMPT_3F respectively. With the same order, the homogeneity index for the PTV resulted in 5.6 ± 0.6%, 4.4 ± 0.9% and 4.5 ± 0.8%. Concerning the organs at risk, the IMPT plans showed a systematic and statistically significant incremental sparing when compared to RA_RP, especially for the heart. The mean dose to the combined lungs was 8.6 ± 2.9 Gy for RA_RP, 3.2 ± 1.5 Gy and 2.9 ± 1.2 Gy for IMPT_2F and IMPT_3F. The mean dose to the whole heart resulted to 9.9 ± 1.9 Gy for RA_RP compared to 3.7 ± 1.3 Gy or 4.0 ± 1.4 Gy for IMPT_2F or IMPT_3F; the mean dose to the left ventricle resulted to 6.5 ± 1.6 Gy, 1.9 ± 1.5 Gy, 1.9 ± 1.6 Gy respectively. Similar sparing effects were observed for the liver, the kidneys, the stomach, the spleen and the bowels. The EAR per 10,000 patients-years of secondary cancer induction resulted in 19.2 ± 5.7 for RA_RP and 6.1 ± 2.7 for IMPT_2F or 5.7 ± 2.4 for IMPT_3F. The RR for the left ventricle resulted in 1.5 ± 0.1 for RA_RP and 1.1 ± 0.1 for both IMPT sets. For the coronaries, the RR resulted in 1.6 ± 0.4 for RA_RP and 1.2 ± 0.3 for protons. CONCLUSION: With regard to cancer of the oesophagogastric junction type I and II, the use of intensity-modulated proton therapy seems to have a clear advantage over VMAT. In particular, the reduction of the heart and abdominal structures dose could result in an optimised side effect profile. Furthermore, reduced risk of secondary neoplasia in the lung can be expected in long-term survivors and would be a great gain for cured patients.

Volumetric modulated arc therapy versus intensity-modulated proton therapy in the postoperative irradiation of thymoma.

BACKGROUND: To investigate the role of intensity-modulated proton therapy (IMPT) compared to volumetric modulated arc therapy (VMAT) for the radiation treatment of thymoma cancer. METHODS: Twenty patients were retrospectively planned for IMPT [with (IMPT_R1 or IMPT_R2 according to the approach adopted) and without robust optimization] and VMAT. The results were compared according to dose-volume metrics on the clinical and planning target volumes (CTV and PTV) and the main organs at risk (heart, breasts, lungs, spinal cord and oesophagus). Estimates of the excess absolute risk (EAR) of secondary cancer induction were determined for the oesophagus, the breasts and the composite lungs. For the heart, the relative risk (RR) of chronic heart failure (CHF) was assessed. RESULTS: IMPT and VMAT plans resulted equivalent in terms of target coverage for both the CTV and the PTV. The CTV homogeneity index resulted in 0.03 ± 0.01 and 0.04 ± 0.01 for VMAT and all IMPT plans, respectively. The conformality index resulted in 1.1 ± 0.1 and 1.2 ± 0.1 for VMAT and all IMPT plans. The mean dose to the breasts resulted in 10.5 ± 5.0, 4.5 ± 3.4, 4.7 ± 3.5 and 4.6 ± 3.4 Gy for VMAT, IMPT, IMPT_R1 and IMPT_R2. For the lungs, the mean dose was 9.6 ± 2.3, 3.5 ± 1.5, 3.6 ± 1.6 and 3.8 ± 1.4 Gy; for the heart: 8.7 ± 4.4, 4.3 ± 1.9, 4.5 ± 2.0 and 4.4 ± 2.4 Gy and for the oesophagus 8.2 ± 3.5, 2.2 ± 3.4, 2.4 ± 3.6 and 2.5 ± 3.5 Gy. The RR for CHF was 1.6 ± 0.3 for VMAT and 1.3 ± 0.2 for IMPT (R1 or R2). The EAR was 3.6 ± 0.v vs 1.0 ± 0.6 or 1.2 ± 0.6 (excess cases/10,000 patients year) for the oesophagus; 17.4 ± 6.5 vs 5.7 ± 3.2 or 6.1 ± 3.8 for the breasts and 24.8 ± 4.3 vs 8.1 ± 2.7 or 8.7 ± 2.3 for the composite lungs for VMAT and IMPT_R, respectively. CONCLUSION: The data from this in-silico study suggest that intensity-modulated proton therapy could be significantly advantageous in the treatment of thymoma patients with particular emphasis to a substantial reduction of the risk of cardiac failure and secondary cancer induction. Robust planning is a technical pre-requisite for the safety of the delivery.

The impact of treatment couch modelling on RapidArc.

A planning and dosimetric study was carried out on a cohort of six CT datasets from patients treated for prostate cancer to assess the impact of couch modelling on the accuracy of dose calculation for the volumetric modulated arc technique RapidArc. For each patient, RapidArc plans were optimized using the couch while final dose calculation was performed with different conditions (thin, medium, thick and no couch). Analysis was performed in terms of dose volume histograms, dose difference histograms and 3D-gamma tests. Pre-treatment verification measurements were performed using the PTW-729 array in conjunction with the Octavius phantom (PTW, Freiburg); similarly, HU characterization of couch was performed with the same phantom and ion chamber measurements comparing calculations and experimental data. A set of Hounsfield Units (HU) valid for low and high energy and the entire couch length was found as internal structure HU = -960, surface shell HU = -700. Analysis of dose plans showed that differences larger than 1.5 Gy for a 70 Gy prescription might be observed on significant fractions of PTVs. Smaller differences are visible in the medium low-dose regions. Pre-treatment verification on composite delivery confirmed these observations and, at the same time, showed good accuracy of dose calculations in the presence of couch modelling compared to delivery in the same conditions (GAI ranging from 95% to 100%). Results confirmed the reliability of the geometrical model build in the planning system Eclipse, and (i) there is no measurable effect if the wrong segment of the couch is used in the calculations; (ii) there are significant discrepancies of potential clinical impact at the level of the target volumes if calculations are performed without couch and delivery is performed with couch, and (iii) the effect is particularly relevant at low energy (6 MV in this case) that is the configuration clinically used by most of the centres adopting technologies based on intensity-modulated arcs.

Intensity modulation with photons for benign intracranial tumours: a planning comparison of volumetric single arc, helical arc and fixed gantry techniques.

BACKGROUND AND PURPOSE: The potential benefits and limitations of the new RapidArc treatment concept compared to Helical Tomotherapy and fixed gantry intensity modulation techniques have been assessed at treatment planning level on 12 patients presenting with 'benign' brain tumours. MATERIALS AND METHODS: Plans for five acoustic neurinomas, five meningiomas and two pituitary adenomas were computed for an Helical Tomotherapy (HT) unit, for RapidArc delivery (RA) on a linac equipped with two types of MLC (RA_HD120 with the new High Definition MLC with 2.5mm leaf width at isocentre and RA_M120 with the standard Millennium with 5mm resolution) and for fixed beam IMRT with the High Definition MLC. Analysis was mostly performed on physical quantities derived from Dose-Volume Histograms (DVHs). RESULTS: Target coverage resulted basically equivalent among techniques. V(95%) (in %) was higher than 99% for all techniques, minimum significant dose (D(99%)) was 95.5+/-1.4 for IMRT, 96.2+/-1.4 and 97.0+/-1.2 for the RA_HD120 and RA_M120 approaches and 96.8+/-1.7 for HT, maximum significant dose (D(1%), in %) was 102.2+/-0.8, 102.7+/-0.5, 102.4+/-0.5 and 103.0+/-1.1, respectively, standard deviation (in %) was 1.4+/-0.4, 1.3+/-0.3, 1.1+/-0.2 and 0.8+/-0.3, respectively. Conformity Index (CI(95%)) was 0.47+/-0.12, 0.46+/-0.12, 0.43+/-0.11 and 0.38+/-0.11, respectively. For organs at risk all techniques respected planning objectives. Concerning the healthy tissue: V(10 Gy) (in %) was 9.4+/-5.5, 9.9+/-6.1, 9.2+/-6.1 and 12.1+/-8.8, respectively. Integral dose measured on the healthy tissue was 7.5+/-3.3, 9.7+/-3.4, 8.7+/-3.4, 10.4+/-4.2 10(3) Gy cm(3), respectively. CONCLUSIONS: For the class of tumours investigated in this report, HT and RA and IMRT proved to be adequate to properly treat patients. Further studies on more complex cases need to be investigated in order to assess the effectiveness of this new technique in a broader clinical perspective.

A treatment planning study comparing volumetric arc modulation with RapidArc and fixed field IMRT for cervix uteri radiotherapy.

PURPOSE: A treatment planning study was performed to evaluate the performance of the novel volumetric modulated single arc radiotherapy on cervix uteri cancer patients. Conventional fixed field IMRT was used as benchmark. METHODS AND MATERIALS: CT datasets of eight patients were included in the study. Plans were optimised with the aim to assess organs at risk and healthy tissue sparing while enforcing highly conformal target coverage. Planning objectives for PTV were: maximum significant dose lower than 52.5 Gy and minimum significant dose higher than 47.5 Gy. For organs at risk, the median and maximum doses were constrained to be lower than 30 (rectum), 35 (bladder) and 25 Gy (small bowel) and 47.5 Gy; additional objectives were set on various volume thresholds. Plans were evaluated on parameters derived from dose volume histograms and on NTCP estimates. Peripheral doses at 5, 10 and 15 cm from the PTV surface were recorded to assess the low-level dose bath. The MU and delivery time were scored to measure expected treatment efficiency. RESULTS: Both RapidArc and IMRT resulted in equivalent target coverage but RapidArc had an improved homogeneity (D(5%)-D(95%) = 3.5 +/- 0.6 Gy for RapidArc and 4.3 +/- 0.8 Gy for IMRT) and conformity index (CI(90%) = 1.30 +/- 0.06 for RapidArc and 1.41 +/- 0.15 for IMRT). On rectum the mean dose was reduced by about 6 Gy (10 Gy for the rectum fraction not included in the PTV). Similar trends were observed for the various dose levels with reductions ranging from approximately 3 to 14.4 Gy. For the bladder, RapidArc allowed a reduction of mean dose ranging from approximately 4 to 6Gy and a reduction from approximately 3 to 9 Gy w.r.t. IMRT. Similar trends but with smaller absolute differences were observed for the small bowel and left and right femur. NTCP calculations on bladder and rectum confirmed the DVH data with a potential relative reduction ranging from 30 to 70% from IMRT to RapidArc. The healthy tissue was significantly less irradiated in the medium to high dose regions (from 20 to 30 Gy) and the integral dose reduction with RapidArc was about 12% compared to IMRT. Concerning peripheral dose, the relative difference between IMRT and RapidArc was of 9 +/- 2%, 43 +/- 11% and 36 +/- 5% at 5, 10 and 15 cm from the PTV surface, respectively. The MU/Gy from RapidArc was 245 +/- 17 corresponding to an expected average beam on time of 73 +/- 10 s per fractions of 2 Gy. IMRT plans presented higher values with an average of MU/Gy = 479 +/- 63. CONCLUSION: RapidArc was investigated for cervix uteri cancer showing significant improvements in organs at risk and healthy tissue sparing with uncompromised target coverage leading to better conformal avoidance of treatments w.r.t. conventional IMRT. This, in combination with the confirmed short delivery time, can lead to clinically significant advances in the management of this highly aggressive cancer type. Clinical protocols are now advised to evaluate prospectively the potential benefit observed at the planning level.

Testing the GlaaS algorithm for dose measurements on low- and high-energy photon beams using an amorphous silicon portal imager.

The GLAaS algorithm for pretreatment intensity modulation radiation therapy absolute dose verification based on the use of amorphous silicon detectors, as described in Nicolini et al. [G. Nicolini, A. Fogliata, E. Vanetti, A. Clivio, and L. Cozzi, Med. Phys. 33, 2839-2851 (2006)], was tested under a variety of experimental conditions to investigate its robustness, the possibility of using it in different clinics and its performance. GLAaS was therefore tested on a low-energy Varian Clinac (6 MV) equipped with an amorphous silicon Portal Vision PV-aS500 with electronic readout IAS2 and on a high-energy Clinac (6 and 15 MV) equipped with a PV-aS1000 and IAS3 electronics. Tests were performed for three calibration conditions: A: adding buildup on the top of the cassette such that SDD-SSD = d(max) and comparing measurements with corresponding doses computed at d(max), B: without adding any buildup on the top of the cassette and considering only the intrinsic water-equivalent thickness of the electronic portal imaging devices device (0.8 cm), and C: without adding any buildup on the top of the cassette but comparing measurements against doses computed at d(max). This procedure is similar to that usually applied when in vivo dosimetry is performed with solid state diodes without sufficient buildup material. Quantitatively, the gamma index (gamma), as described by Low et al. [D. A. Low, W. B. Harms, S. Mutic, and J. A. Purdy, Med. Phys. 25, 656-660 (1998)], was assessed. The gamma index was computed for a distance to agreement (DTA) of 3 mm. The dose difference deltaD was considered as 2%, 3%, and 4%. As a measure of the quality of results, the fraction of field area with gamma larger than 1 (%FA) was scored. Results over a set of 50 test samples (including fields from head and neck, breast, prostate, anal canal, and brain cases) and from the long-term routine usage, demonstrated the robustness and stability of GLAaS. In general, the mean values of %FA remain below 3% for deltaD equal or larger than 3%, while they are slightly larger for deltaD = 2% with %FA in the range from 3% to 8%. Since its introduction in routine practice, 1453 fields have been verified with GLAaS at the authors' institute (6 MV beam). Using a DTA of 3 mm and a deltaD of 4% the authors obtained %FA = 0.9 +/- 1.1 for the entire data set while, stratifying according to the dose calculation algorithm, they observed: %FA = 0.7 +/- 0.9 for fields computed with the analytical anisotropic algorithm and %FA = 2.4 +/- 1.3 for pencil-beam based fields with a statistically significant difference between the two groups. If data are stratified according to field splitting, they observed %FA = 0.8 +/- 1.0 for split fields and 1.0 +/- 1.2 for nonsplit fields without any significant difference.

The impact of photon dose calculation algorithms on expected dose distributions in lungs under different respiratory phases.

A planning study was carried out on a cohort of CT datasets from breast patients scanned during different respiratory phases. The aim of the study was to investigate the influence of different air filling in lungs on the calculation accuracy of photon dose algorithms and to identify potential patterns of failure with clinical implications. Selected respiratory phases were free breathing (FB), representative of typical end expiration, and deep inspiration breath hold (DIBH), a typical condition for clinical treatment with respiratory gating. Algorithms investigated were the pencil beam (PBC), the anisotropic analytical algorithm (AAA) and the collapsed cone (CC) from the Varian Eclipse or Philips Pinnacle planning system. Reference benchmark calculations were performed with the Voxel Monte Carlo (VMC++). An analysis was performed in terms of physical quantities inspecting either dose-volume or dose-mass histograms and in terms of an extension to three dimensions of the gamma index of Low. Results were stratified according to a breathing phase and algorithm. Collectives acquired in FB or DIBH showed well-separated average lung density distributions with mean densities of 0.27 +/- 0.04 and 0.16 +/- 0.02 g cm(-3), respectively, and average peak densities of 0.17 +/- 0.03 and 0.09 +/- 0.02 g cm(-3). Analysis of volume-dose or mass-dose histograms proved the expected deviations on PBC results due to the missing lateral transport of electrons with underestimations in the low dose region and overestimations in the high dose region. From the gamma analysis, it resulted that PBC is systematically defective compared to VMC++ over the entire range of lung densities and dose levels with severe violations in both respiratory phases. The fraction of lung voxels with gamma > 1 for PBC reached 25% in DIBH and about 15% in FB. CC and AAA performed, in contrast, similarly and with fractions of lung voxels with gamma > 1 in average inferior to 2% in FB and 4-5% (AAA) or 6-8% (CC) in DIBH. In summary, PBC proved to be severely defective in calculations involving lungs and particularly for cases where specific respiratory phases (e.g. DIBH) are assumed for treatment. In contrast, CC and AAA manifested a high degree of consistency against the Monte Carlo method and provided stable results over the entire range of clinically relevant densities.

Basic dosimetric verification in water of the anisotropic analytical algorithm for Varian, Elekta and Siemens linacs.

Since early 2007 a new version of the Anisotropic Analytical Algorithm (AAA) for photon dose calculations was released by Varian Medical Systems for clinical usage on Elekta linacs and also, with some restrictions, for Siemens linacs. Basic validation studies were performed and reported for three beams. 4,6 and 15 MV for an Elekta Synergy, 6 and 15 MV for a Siemens Primus and, as a reference, for 6 and 15 MV from a Varian Clinac 2100C/D. Generally AAA calculations reproduced well measured data and small deviations were observed for open and wedged fields. PDD curves showed in average differences between calculation and measurement smaller than 1% or 1.2 mm for Elekta beams, 1% or 1.8 mm for Siemens beams and 1% or 1 mm for Varian beams. Profiles in the flattened region matched measurements with deviations smaller than 1% for Elekta and Varian beams, 2% for Siemens. Percentage differences in Output Factors were observed as small as 1% in average.

A treatment planning study using non-coplanar static fields and coplanar arcs for whole breast radiotherapy of patients with concave geometry.

PURPOSE: A treatment planning study was performed to evaluate the performance of new radiotherapy techniques based on non-coplanar multiple fields or on dynamic conformal arcs for early stage breast treatments. METHODS AND MATERIALS: CT datasets of 7 different patients that were deemed unsuitable for tangential beam treatment due to a large volume of lung in the treatment fields were used as input for the study. Standard tangential field plans and inversely modulated IMRT plans were used as benchmark to evaluate performances of conformal plans with 3 non-coplanar fields (3F-NC), with 2 short dynamic conformal arcs (2-Arc) or hybrid plans with one static conformal field and one dynamic conformal arc (P-Arc). All plans were designed to achieve the higher target coverage and minimum ipsilateral lung involvement depending on the planning technique with a key objective to avoid involvement of the contralateral breast. The following planning objectives were selected. For PTV: D(1%) (maximum significant dose) lower than 110% and D(99%) (minimum significant dose) higher than 90%. For the ipsilateral lung a mean dose lower than 15 Gy and/or a volume receiving more than 20 Gy lower than 22%. For contralateral breast, all techniques but IMRT were set to have no beam impinging this organ at risk, while for IMRT plans were further designed to keep the mean dose lower than 5 Gy and to minimise the volume receiving a dose higher than 70% of the prescribed dose. RESULTS: P-Arc resulted to be on average a better technique, as it provides a PTV dose distribution highly conformal (Conformity index 1.45), homogeneous (D(5%)-D(95%)=15.6%), with adequate coverage (V(90%)=96.4%) and a limited involvement of the ipsilateral lung (MLD approximately 9 Gy, V(5 Gy) approximately 36%, NTCP<2%) when compared to four other treatment techniques. 3F-NC presented similar but slightly worse performances on target: Conformity index 1.57, D(5%)-D(95%)=18.1%, V(90%)=95.7%). 3F-NC on ipsilateral lung resulted as the P-Arc. The tangential approach, the 2-Arc or the IMRT techniques, resulted to be inferior to the previous in either conformality (tangentials), ipsilateral lung sparing (tangentials, 2-Arc and IMRT) and in contralateral or healthy tissue involvement (IMRT). CONCLUSION: For early stage breast cancer when high sparing of lung tissues is required and no involvement of contralateral breast is allowed, the P-Arc or the 3F-NC techniques might be recommended in terms of dosimetric expectations.

On the dosimetric behaviour of photon dose calculation algorithms in the presence of simple geometric heterogeneities: comparison with Monte Carlo calculations.

A comparative study was performed to reveal differences and relative figures of merit of seven different calculation algorithms for photon beams when applied to inhomogeneous media. The following algorithms were investigated: Varian Eclipse: the anisotropic analytical algorithm, and the pencil beam with modified Batho correction; Nucletron Helax-TMS: the collapsed cone and the pencil beam with equivalent path length correction; CMS XiO: the multigrid superposition and the fast Fourier transform convolution; Philips Pinnacle: the collapsed cone. Monte Carlo simulations (MC) performed with the EGSnrc codes BEAMnrc and DOSxyznrc from NRCC in Ottawa were used as a benchmark. The study was carried out in simple geometrical water phantoms (rho = 1.00 g cm(-3)) with inserts of different densities simulating light lung tissue (rho = 0.035 g cm(-3)), normal lung (rho = 0.20 g cm(-3)) and cortical bone tissue (rho = 1.80 g cm(-3)). Experiments were performed for low- and high-energy photon beams (6 and 15 MV) and for square (13 x 13 cm2) and elongated rectangular (2.8 x 13 cm2) fields. Analysis was carried out on the basis of depth dose curves and transverse profiles at several depths. Assuming the MC data as reference, gamma index analysis was carried out distinguishing between regions inside the non-water inserts or inside the uniform water. For this study, a distance to agreement was set to 3 mm while the dose difference varied from 2% to 10%. In general all algorithms based on pencil-beam convolutions showed a systematic deficiency in managing the presence of heterogeneous media. In contrast, complicated patterns were observed for the advanced algorithms with significant discrepancies observed between algorithms in the lighter materials (rho = 0.035 g cm(-3)), enhanced for the most energetic beam. For denser, and more clinical, densities a better agreement among the sophisticated algorithms with respect to MC was observed.

GLAaS: an absolute dose calibration algorithm for an amorphous silicon portal imager. Applications to IMRT verifications.

A new calibration algorithm (GLAaS) to derive absolute dose maps from images acquired with the Varian PV-aS500 electronic portal imager (based on amorphous silicon detectors) has been developed incorporating the dependence of detector response on primary and transmitted radiation and on field size. Detector calibration and algorithm validation were performed at different depths (10.0, 3.8, 1.5, and 0.8 cm) in solid water to investigate various application possibilities. Calibration data were obtained against ion chamber measurements. Validation experiments were performed on intensity-modulated fields and comparison was carried out against calculated dose maps as well as against film measurements. Split fields were acquired independently and PV-aS500 images were summed offline with the new algorithm allowing complex fields to be verified in conditions most closely resembling clinical conditions. Excellent results were obtained for the 3.8, 1.5, and 0.8 depths on a set of 34 modulated fields including both split and nonsplit fields. Applying the gamma index analysis (with distance to agreement and dose thresholds set to 3 mm and 4%, respectively), only 2.3% of the field area showed gamma > 1 at 1.5 cm depth (8.1%, 3.1%, 2.7% at 10.0, 3.8, and 0.8 and 2.5% with films at 10 cm depth). Tests were also performed to verify GLAaS at gantry angles different from 0 degrees. No statistical differences were obtained for the comparison between split and nonsplit fields and between different gantry angles. Highly significant statistical differences were obtained when comparing independent samples of 240 fields verified either with GLAaS or with film. Fields verified with GLAaS presented a mean area with gamma > 1 of 2.1 +/-1.3% while for film this value was 3.9 +/- 3.4% (p<0.001). Absolute dosimetry proved to be reliable with the PV-aS500 detector with the GLAaS algorithm. The minimal settings at depths of 1.5 or 3.8 cm would allow the use of the detector at any gantry angle without the need for any special fixation tool.

Dosimetric validation of the anisotropic analytical algorithm for photon dose calculation: fundamental characterization in water.

In July 2005 a new algorithm was released by Varian Medical Systems for the Eclipse planning system and installed in our institute. It is the anisotropic analytical algorithm (AAA) for photon dose calculations, a convolution/superposition model for the first time implemented in a Varian planning system. It was therefore necessary to perform validation studies at different levels with a wide investigation approach. To validate the basic performances of the AAA, a detailed analysis of data computed by the AAA configuration algorithm was carried out and data were compared against measurements. To better appraise the performance of AAA and the capability of its configuration to tailor machine-specific characteristics, data obtained from the pencil beam convolution (PBC) algorithm implemented in Eclipse were also added in the comparison. Since the purpose of the paper is to address the basic performances of the AAA and of its configuration procedures, only data relative to measurements in water will be reported. Validation was carried out for three beams: 6 MV and 15 MV from a Clinac 2100C/D and 6 MV from a Clinac 6EX. Generally AAA calculations reproduced very well measured data, and small deviations were observed, on average, for all the quantities investigated for open and wedged fields. In particular, percentage depth-dose curves showed on average differences between calculation and measurement smaller than 1% or 1 mm, and computed profiles in the flattened region matched measurements with deviations smaller than 1% for all beams, field sizes, depths and wedges. Percentage differences in output factors were observed as small as 1% on average (with a range smaller than +/-2%) for all conditions. Additional tests were carried out for enhanced dynamic wedges with results comparable to previous results. The basic dosimetric validation of the AAA was therefore considered satisfactory.

A broad scope knowledge based model for optimization of VMAT in esophageal cancer: validation and assessment of plan quality among different treatment centers.

BACKGROUND: To evaluate the performance of a broad scope model-based optimisation process for volumetric modulated arc therapy applied to esophageal cancer. METHODS AND MATERIALS: A set of 70 previously treated patients in two different institutions, were selected to train a model for the prediction of dose-volume constraints. The model was built with a broad-scope purpose, aiming to be effective for different dose prescriptions and tumour localisations. It was validated on three groups of patients from the same institution and from another clinic not providing patients for the training phase. Comparison of the automated plans was done against reference cases given by the clinically accepted plans. RESULTS: Quantitative improvements (statistically significant for the majority of the analysed dose-volume parameters) were observed between the benchmark and the test plans. Of 624 dose-volume objectives assessed for plan evaluation, in 21 cases (3.3 %) the reference plans failed to respect the constraints while the model-based plans succeeded. Only in 3 cases (<0.5 %) the reference plans passed the criteria while the model-based failed. In 5.3 % of the cases both groups of plans failed and in the remaining cases both passed the tests. CONCLUSIONS: Plans were optimised using a broad scope knowledge-based model to determine the dose-volume constraints. The results showed dosimetric improvements when compared to the benchmark data. Particularly the plans optimised for patients from the third centre, not participating to the training, resulted in superior quality. The data suggests that the new engine is reliable and could encourage its application to clinical practice.

Performance of a Knowledge-Based Model for Optimization of Volumetric Modulated Arc Therapy Plans for Single and Bilateral Breast Irradiation.

PURPOSE: To evaluate the performance of a model-based optimisation process for volumetric modulated arc therapy, VMAT, applied to whole breast irradiation. METHODS AND MATERIALS: A set of 150 VMAT dose plans with simultaneous integrated boost were selected to train a model for the prediction of dose-volume constraints. The dosimetric validation was done on different groups of patients from three institutes for single (50 cases) and bilateral breast (20 cases). RESULTS: Quantitative improvements were observed between the model-based and the reference plans, particularly for heart dose. Of 460 analysed dose-volume objectives, 13% of the clinical plans failed to meet the constraints while the respective model-based plans succeeded. Only in 5 cases did the reference plans pass while the respective model-based failed the criteria. For the bilateral breast analysis, the model-based plans resulted in superior or equivalent dose distributions to the reference plans in 96% of the cases. CONCLUSIONS: Plans optimised using a knowledge-based model to determine the dose-volume constraints showed dosimetric improvements when compared to earlier approved clinical plans. The model was applicable to patients from different centres for both single and bilateral breast irradiation. The data suggests that the dose-volume constraint optimisation can be effectively automated with the new engine and could encourage its application to clinical practice.

Evaluation of the Machine Performance Check application for TrueBeam Linac.

BACKGROUND: Machine Performance Check (MPC) is an application to verify geometry and beam performances of TrueBeam Linacs, through automated checks based on their kV-MV imaging systems. In this study, preliminary tests with MPC were analyzed using all photon beam energies of our TrueBeam, comparing whenever possible with external independent checks. METHODS: Data acquisition comprises a series of 39 images (12 with kV and 27 with MV detector) acquired at predefined positions without and with the IsoCal phantom in the beam, and with particular MLC pattern settings. MPC performs geometric and dosimetric checks. The geometric checks intend to test the treatment isocenter size and its coincidence with imaging devices, the positioning accuracy of the imaging systems, the collimator, the gantry, the jaws, the MLC leaves and the couch position. The dosimetric checks: refer to a reference MV image and give the beam output, uniformity and center change relative to the reference. MPC data were acquired during 10 repetitions on different consecutive days. Alternative independent checks were performed. Geometric: routine mechanical tests, Winston-Lutz test for treatment isocenter radius. Dosimetric: the 2D array StarCheck (PTW) was used just after the MPC data acquisition. RESULTS: Results were analyzed for 6, 10, 15 MV flattened, and 6, 10 MV FFF beams. Geometric checks: treatment isocenter was between 0.31 ± 0.01 mm and 0.42 ± 0.02 mm with MPC, compared to 0.27 ± 0.01 mm averaged on all energies with the Winston-Lutz test. Coincidence of kV and MV imaging isocenters was within 0.36 ± 0.0 and 0.43 ± 0.06 mm, respectively (0.4 ± 0.1 mm with external tests). Positioning accuracy of MLC was within 0.5 mm; accuracy of jaws was 0.04 ± 0.02, 0.10 ± 0.05, -1.01 ± 0.03, 0.92 ± 0.04 mm for X1, X2, Y1, Y2 jaws, respectively, with MPC. Dosimetric tests: the output stability relative to the baseline was in average 0.15 ± 0.07% for MPC to compare with 0.3 ± 0.2% with the independent measurement. CONCLUSIONS: MPC proved to be a reliable, fast and easy to use method for checking the machine performances on both geometric and dosimetric aspects.