Novel hybrid treatment planning approach for irradiation a pediatric craniospinal axis.

This study presents a new treatment planning approach merging 3D-CRT and VMAT fields into a hybrid treatment plan (HybTP), in order to achieve an optimum dose coverage of the planning target volume (PTV) and protection of OAR. Craniospinal axis irradiation (CSI) treated with 3D conformal radiotherapy (3D-CRT) is associated with high doses to the heart and eye lenses but provides better sparing of lungs and kidneys compared to volumetric modulated arc therapy (VMAT). VMAT treatment spares eye lenses and the heart, but lungs and kidneys are not as effective as 3D-CRT. Thus, a combination of both techniques (HybTP) may be optimal in sparing all these organs at risk (OAR). The results of HybTP are compared with helical tomotherapy (HT), intensity modulated radio therapy (IMRT), VMAT, and 3D-CRT plans. Hybrid, HT, VMAT, IMRT, and 3D-CRT treatment plans for a male child (age 6 years) with medulloblastoma were created and compared. A total dose of 35.2 Gy (PTV) with a dose per fraction of 1.6 Gy was prescribed. The following dose acceptance criteria were defined: The plans were compared regarding dose homogeneity index (HI) and conformity index (CI), PTV coverage, (particularly at cribriform plate) and doses at OARs. Best conformity was achieved with HT (CI = 0.98) followed by VMAT (CI = 0.96), IMRT (CI = 0.91), HybTP (CI = 0.86), and 3D-CRT (CI = 0.83). The homogeneity index varied marginally. For both HT and IMRT the HI was 0.07, and for 3D-CRT, VMAT and HybTP the HI was between 0.13 and 0.15. The cribriform plate was sufficiently covered by HybTP, VMAT, and 3D-CRT. The dose acceptance criteria for OARs were met by HT and HybTP. VMAT did not meet the criteria for lung (Dmean = right 10.4 Gy/left 10.2 Gy), 3D-CRT did not meet the criteria for eye lenses (Dmax = right 32.3 Gy/left 33.1), and heart (V25≈44%) and IMRT did not meet the criteria for lung (Dmean = right 11.1 Gy/left 11.2 Gy) and eye lenses (Dmax = right 12.2 Gy/left 13.1). HybTP meets all defined acceptance criteria and has proved to be a reasonable alternative for CSI. With HybTP that combines VMAT at the brain and heart with 3D-CRT posterior spinal fields (to spare lungs and kidneys), both appropriate coverage of the PTV and sparing of OAR can be achieved.

Dosimetric comparisons of craniospinal axis irradiation using helical tomotherapy, volume-modulated arc therapy and intensity-modulated radiotherapy for medulloblastoma.

BACKGROUND: To evaluate the potential dosimetric gains of helical tomotherapy (HT) versus intensity-modulated radiotherapy (IMRT) and volume-modulated arc therapy (VMAT) for craniospinal axis irradiation (CSI) of medulloblastoma. METHODS: A total of 36 treatment plans were calculated retrospectively for 12 patients with medulloblastoma receiving CSI using HT with TomoTherapy Hi-Art Software (Version 2.0.7) (Accuray, Madison, WI, USA). For each case, the other two different delivery techniques were re-planned with IMRT/VMAT optimized with Eclipse treatment planning system (TPS) (Version 11.0.31). Homogeneity index (HI) and conformity index (CI) of the planning target volume (PTV) and organs at risk (OARs) sparing were analyzed. Differences in plans were evaluated using paired-samples t-test for various dosimetric parameters. RESULTS: HT yielded the highest CI in all PTV coverage including PTV of gross tumor volume (PGTV) (HT: 0.7163; VMAT: 0.6688; IMRT: 0.6096), PTVbrain (HT: 0.8490; VMAT: 0.8384; IMRT: 0.7815) and PTVspine (HT: 0.5904; VMAT: 0.5862; IMRT: 0.5797). Meanwhile, HT yielded better HI in PGTV (HT: 0.0543; VMAT: 0.0759; IMRT: 0.0736), PTVbrain (HT: 0.5525; VMAT: 0.5619; IMRT: 0.5554) and PTVspine (HT: 0.0700; VMAT: 0.0782; IMRT: 0.0877). As for OARs, HT demonstrated marked superiority in critical organs including maximal/mean doses of brainstem PRV, optical chiasm and optic nerves. CONCLUSIONS: For CSI of medulloblastoma, HT offers superior outcomes in terms of PTV conformity, PTV homogeneity and critical OAR sparing as compared with IMRT/VMAT.

Evaluation of localization errors for craniospinal axis irradiation delivery using volume modulated arc therapy and proposal of a technique to minimize such errors.

PURPOSE: To dosimetrically evaluate the effects of improper patient positioning in the junction area of a VMAT cranio-spinal axis irradiation technique consisting of one superior and one inferior arc and propose a solution to minimize these patient setup errors. METHODS: Five (n=5) cranio-spinal axis irradiation patients were planned with 2 arcs: one superior and one inferior. In order to mimic patient setup errors, the plans were recalculated with the inferior isocenter shifted by: 1, 2, 5, and 10mm superiorly, and 1, 2, 5, and 10mm inferiorly. The plans were then compared with the corresponding original, non-shifted arc plans on the grounds of target metrics such as conformity number and homogeneity index, as well as several normal tissue dose descriptors. "Gradient-optimized" plans were then created for each patient in an effort to reduce dose discrepancies due to setup errors. RESULTS: Percent differences were calculated in order to compare each of the eight shifted plans with the original non-shifted arc plan, which corresponds to the ideal patient setup. The conformity number was on average lower by 0.9%, 2.7%, 5.8%, and 9.1% for the 1, 2, 5, and 10mm inferiorly-shifted plans and 0.4%, 0.8%, 2.8%, and 6.0% for the respective superiorly-shifted plans. The homogeneity indices were, averaged among the five patients and they indicated less homogeneous dose distributions by 0.03%, 0.3%, 1.0%, and 2.8% for the inferior shifts and 0.2%, 1.2%, 6.3%, and 15.3% for the superior shifts. Overall, the mean doses to the organs at risk deviate by less than 2% for the 1, 2, and 5mm shifted plans. The 10mm shifted plans, however, showed average percent differences, over all studied organs, from the original plan of up to 5.6%. Using "gradient-optimized" plans, the average dose differences were reduced by 0.2%, 0.5%, 1.2%, and 2.1% for 1, 2, 5, and 10mm shifts, respectively compared to the originally optimized plans, and the maximum dose differences were reduced by 11.7%, 8.5%, 12.4%, and 13.9% on average for the 1, 2, 5, and 10mm shifted plans. CONCLUSIONS: Setup errors related to isocenter shifting should be minimized in order to provide the patient with the most dosimetrically accurate treatment possible. Errors of 1-2mm can negatively affect the quality of the delivered treatment, most notably in the arc junction area, but the deterioration of the treatment plan accuracy is not as problematic as in the cases of larger errors such as 5-10mm. By employing a new planning technique, the dose differences due to setup errors can be greatly reduced.