[show abstract][hide abstract] ABSTRACT: Purpose
To investigate the dosimetric impact of intrafraction prostate motion and the effect of robot correction strategies for hypofractionated CyberKnife treatments with a simultaneously integrated boost.
Methods and Materials
A total of 548 real-time prostate motion tracks from 17 patients were available for dosimetric simulations of CyberKnife treatments, in which various correction strategies were included. Fixed time intervals between imaging/correction (15, 60, 180, and 360 seconds) were simulated, as well as adaptive timing (ie, the time interval reduced from 60 to 15 seconds in case prostate motion exceeded 3 mm or 2° in consecutive images). The simulated extent of robot corrections was also varied: no corrections, translational corrections only, and translational corrections combined with rotational corrections up to 5°, 10°, and perfect rotational correction. The correction strategies were evaluated for treatment plans with a 0-mm or 3-mm margin around the clinical target volume (CTV). We recorded CTV coverage (V100%) and dose-volume parameters of the peripheral zone (boost), rectum, bladder, and urethra.
Planned dose parameters were increasingly preserved with larger extents of robot corrections. A time interval between corrections of 60 to 180 seconds provided optimal preservation of CTV coverage. To achieve 98% CTV coverage in 98% of the treatments, translational and rotational corrections up to 10° were required for the 0-mm margin plans, whereas translational and rotational corrections up to 5° were required for the 3-mm margin plans. Rectum and bladder were spared considerably better in the 0-mm margin plans. Adaptive timing did not improve delivered dose.
Intrafraction prostate motion substantially affected the delivered dose but was compensated for effectively by robot corrections using a time interval of 60 to 180 seconds. A 0-mm margin required larger extents of additional rotational corrections than a 3-mm margin but resulted in lower doses to rectum and bladder.
International journal of radiation oncology, biology, physics 01/2014; 88(5):1154–1160. · 4.59 Impact Factor
[show abstract][hide abstract] ABSTRACT: Purpose
To develop and evaluate fully automated volumetric modulated arc therapy (VMAT) treatment planning for prostate cancer patients, avoiding manual trial-and-error tweaking of plan parameters by dosimetrists.
Methods and Materials
A system was developed for fully automated generation of VMAT plans with our commercial clinical treatment planning system (TPS), linked to the in-house developed Erasmus-iCycle multicriterial optimizer for preoptimization. For 30 randomly selected patients, automatically generated VMAT plans (VMATauto) were compared with VMAT plans generated manually by 1 expert dosimetrist in the absence of time pressure (VMATman). For all treatment plans, planning target volume (PTV) coverage and sparing of organs-at-risk were quantified.
All generated plans were clinically acceptable and had similar PTV coverage (V95% > 99%). For VMATauto and VMATman plans, the organ-at-risk sparing was similar as well, although only the former plans were generated without any planning workload.
Fully automated generation of high-quality VMAT plans for prostate cancer patients is feasible and has recently been implemented in our clinic.
International journal of radiation oncology, biology, physics 01/2014; · 4.59 Impact Factor
[show abstract][hide abstract] ABSTRACT: Radiotherapy dose delivery in the tumor and surrounding healthy tissues is affected by movements and deformations of the corresponding organs between fractions. The random variations may be characterized by non-rigid, anisotropic principal component analysis (PCA) modes. In this article new dynamic dose deposition matrices, based on established PCA modes, are introduced as a tool to evaluate the mean and the variance of the dose at each target point resulting from any given set of fluence profiles. The method is tested for a simple cubic geometry and for a prostate case. The movements spread out the distributions of the mean dose and cause the variance of the dose to be highest near the edges of the beams. The non-rigidity and anisotropy of the movements are reflected in both quantities. The dynamic dose deposition matrices facilitate the inclusion of the mean and the variance of the dose in the existing fluence-profile optimizer for radiotherapy planning, to ensure robust plans with respect to the movements.
Physics in Medicine and Biology 12/2013; 59(2):289-310. · 2.70 Impact Factor
[show abstract][hide abstract] ABSTRACT: Deformation and correlated target motion remain challenges for margin recipes in radiotherapy (RT). This study presents a statistical deformable motion model for multiple targets and applies it to margin evaluations for locally advanced prostate cancer i.e. RT of the prostate (CTV-p), seminal vesicles (CTV-sv) and pelvic lymph nodes (CTV-ln).
The 19 patients included in this study, all had 7-10 repeat CT-scans available that were rigidly aligned with the planning CT-scan using intra-prostatic implanted markers, followed by deformable registrations. The displacement vectors from the deformable registrations were used to create patient-specific statistical motion models. The models were applied in treatment simulations to determine probabilities for adequate target coverage, e.g. by establishing distributions of the accumulated dose to 99% of the target volumes (D99) for various CTV-PTV expansions in the planning-CTs.
The method allowed for estimation of the expected accumulated dose and its variance of different DVH parameters for each patient. Simulations of inter-fractional motion resulted in 7, 10, and 18 patients with an average D99 >95% of the prescribed dose for CTV-p expansions of 3mm, 4mm and 5mm, respectively. For CTV-sv and CTV-ln, expansions of 3mm, 5mm and 7mm resulted in 1, 11 and 15 vs. 8, 18 and 18 patients respectively with an average D99 >95% of the prescription.
Treatment simulations of target motion revealed large individual differences in accumulated dose mainly for CTV-sv, demanding the largest margins whereas those required for CTV-p and CTV-ln were comparable.
Radiotherapy and Oncology 10/2013; · 4.52 Impact Factor
[show abstract][hide abstract] ABSTRACT: To investigate interfraction setup variations of the primary tumor, elective nodes, and vertebrae in laryngeal cancer patients and to validate protocols for cone beam computed tomography (CBCT)-guided correction.
For 30 patients, CBCT-measured displacements in fractionated treatments were used to investigate population setup errors and to simulate residual setup errors for the no action level (NAL) offline protocol, the extended NAL (eNAL) protocol, and daily CBCT acquisition with online analysis and repositioning.
Without corrections, 12 of 26 patients treated with radical radiation therapy would have experienced a gradual change (time trend) in primary tumor setup ≥4 mm in the craniocaudal (CC) direction during the fractionated treatment (11/12 in caudal direction, maximum 11 mm). Due to these trends, correction of primary tumor displacements with NAL resulted in large residual CC errors (required margin 6.7 mm). With the weekly correction vector adjustments in eNAL, the trends could be largely compensated (CC margin 3.5 mm). Correlation between movements of the primary and nodal clinical target volumes (CTVs) in the CC direction was poor (r(2)=0.15). Therefore, even with online setup corrections of the primary CTV, the required CC margin for the nodal CTV was as large as 6.8 mm. Also for the vertebrae, large time trends were observed for some patients. Because of poor CC correlation (r(2)=0.19) between displacements of the primary CTV and the vertebrae, even with daily online repositioning of the vertebrae, the required CC margin around the primary CTV was 6.9 mm.
Laryngeal cancer patients showed substantial interfraction setup variations, including large time trends, and poor CC correlation between primary tumor displacements and motion of the nodes and vertebrae (internal tumor motion). These trends and nonrigid anatomy variations have to be considered in the choice of setup verification protocol and planning target volume margins. eNAL could largely compensate time trends with minor prolongation of fraction time.
International journal of radiation oncology, biology, physics 10/2013; 87(2):401-6. · 4.59 Impact Factor
[show abstract][hide abstract] ABSTRACT: To investigate how dose distributions for liver stereotactic body radiation therapy (SBRT) can be improved by using automated, daily plan reoptimization to account for anatomy deformations, compared with setup corrections only.
For 12 tumors, 3 strategies for dose delivery were simulated. In the first strategy, computed tomography scans made before each treatment fraction were used only for patient repositioning before dose delivery for correction of detected tumor setup errors. In adaptive second and third strategies, in addition to the isocenter shift, intensity modulated radiation therapy beam profiles were reoptimized or both intensity profiles and beam orientations were reoptimized, respectively. All optimizations were performed with a recently published algorithm for automated, multicriteria optimization of both beam profiles and beam angles.
In 6 of 12 cases, violations of organs at risk (ie, heart, stomach, kidney) constraints of 1 to 6 Gy in single fractions occurred in cases of tumor repositioning only. By using the adaptive strategies, these could be avoided (<1 Gy). For 1 case, this needed adaptation by slightly underdosing the planning target volume. For 2 cases with restricted tumor dose in the planning phase to avoid organ-at-risk constraint violations, fraction doses could be increased by 1 and 2 Gy because of more favorable anatomy. Daily reoptimization of both beam profiles and beam angles (third strategy) performed slightly better than reoptimization of profiles only, but the latter required only a few minutes of computation time, whereas full reoptimization took several hours.
This simulation study demonstrated that replanning based on daily acquired computed tomography scans can improve liver stereotactic body radiation therapy dose delivery.
International journal of radiation oncology, biology, physics 09/2013; · 4.59 Impact Factor
[show abstract][hide abstract] ABSTRACT: This study investigates whether 'pencil beam resampling', i.e. iterative selection and weight optimization of randomly placed pencil beams (PBs), reduces optimization time and improves plan quality for multi-criteria optimization in intensity-modulated proton therapy, compared with traditional modes in which PBs are distributed over a regular grid. Resampling consisted of repeatedly performing: (1) random selection of candidate PBs from a very fine grid, (2) inverse multi-criteria optimization, and (3) exclusion of low-weight PBs. The newly selected candidate PBs were added to the PBs in the existing solution, causing the solution to improve with each iteration. Resampling and traditional regular grid planning were implemented into our in-house developed multi-criteria treatment planning system 'Erasmus iCycle'. The system optimizes objectives successively according to their priorities as defined in the so-called 'wish-list'. For five head-and-neck cancer patients and two PB widths (3 and 6 mm sigma at 230 MeV), treatment plans were generated using: (1) resampling, (2) anisotropic regular grids and (3) isotropic regular grids, while using varying sample sizes (resampling) or grid spacings (regular grid). We assessed differences in optimization time (for comparable plan quality) and in plan quality parameters (for comparable optimization time). Resampling reduced optimization time by a factor of 2.8 and 5.6 on average (7.8 and 17.0 at maximum) compared with the use of anisotropic and isotropic grids, respectively. Doses to organs-at-risk were generally reduced when using resampling, with median dose reductions ranging from 0.0 to 3.0 Gy (maximum: 14.3 Gy, relative: 0%-42%) compared with anisotropic grids and from -0.3 to 2.6 Gy (maximum: 11.4 Gy, relative: -4%-19%) compared with isotropic grids. Resampling was especially effective when using thin PBs (3 mm sigma). Resampling plans contained on average fewer PBs, energy layers and protons than anisotropic grid plans and more energy layers and protons than isotropic grid plans. In conclusion, resampling resulted in improved plan quality and in considerable optimization time reduction compared with traditional regular grid planning.
Physics in Medicine and Biology 09/2013; 58(19):6969-6983. · 2.70 Impact Factor
[show abstract][hide abstract] ABSTRACT: Daily treatment plan selection from a plan library is a major adaptive radiotherapy strategy to account for individual internal anatomy variations. This strategy depends on the initial input images being representative for the variations observed later in the treatment course. Focusing on locally advanced prostate cancer, our aim was to evaluate if residual motion of the prostate (CTV-p) and the elective targets (CTV-sv, CTV-ln) can be prospectively accounted for with a statistical deformable model based on images acquired in the initial part of treatment. Methods. Thirteen patients with locally advanced prostate cancer, each with 9-10 repeat CT scans, were included. Displacement vectors fields (DVF) obtained from contour-based deformable registration of delineations in the repeat- and planning CT scans were used to create patient-specific statistical motion models using principal component analysis (PCA). For each patient and CTV, four PCA-models were created: one with all 9-10 DVF as input in addition to models with only four, five or six DVFs as input. Simulations of target shapes from each PCA-model were used to calculate iso-coverage levels, which were converted to contours. The levels were analyzed for sensitivity and precision. Results. A union of the simulated shapes was able to cover at least 97%, 97% and 95% of the volumes of the evaluated CTV shapes for PCA-models using six, five and four DVFs as input, respectively. There was a decrease in sensitivity with higher iso-coverage levels, with a sharper decline for greater target movements. Apart from having the steepest decline in sensitivity, CTV-sv also displayed the greatest influence on the number of geometries used in the PCA-model. Conclusions. PCA-based simulations of residual motion derived from four to six DVFs as input could account for the majority of the target shapes present during the latter part of the treatment. CTV-sv displayed the greatest range in both sensitivity and precision.
[show abstract][hide abstract] ABSTRACT: Purpose. To dosimetrically evaluate a margin-of-the-day (MoD) online adaptive intensity-modulated radiotherapy (IMRT) strategy for cervical cancer patients. The strategy is based on a single planning computed tomography (CT) scan and a pretreatment constructed IMRT plan library with incremental clinical target volumes (CTV)-to-planning target volumes (PTV) margins. Material and methods. For 14 patients, 9-10 variable bladder filling CT scans acquired at pretreatment and after 40 Gy were available. Bladder volume variability during the treatment course was recorded by twice-weekly US bladder-volume measurements. A MoD strategy that selects the best IMRT plan of the day from a library of plans with incremental margins in steps of 5 mm was compared with a clinically recommended population-based margin (15 mm). To compare the strategies, for each fraction that had a recorded US bladder-volume measurement, the CT scan with the nearest bladder volume was selected from the pretreatment CT series and from the CT series acquired after 40 Gy. A frequency-weighted average of the dose-volume histograms (DVH) parameters calculated for the two selected CT scans was used to estimate the DVH parameters of the fraction of interest. Results. The 15-mm recommended margin resulted in cervix-uterus underdosage in six of 14 patients. Compared with the 15-mm margin, the MoD strategy resulted in significantly better cervix-uterus coverage (p = 0.008) without a significant difference in the sparing of rectum, bladder, and small bowel. For each patient, 3-8 (median 5) plans were needed in the library of plans for the MoD strategy. The required range of the MoD was 5-45 mm (median 15 mm). Twenty-five percent of all fractions could be treated with a MoD of 5 mm and 81% of all fractions could be treated with a MoD up to 25 mm. Conclusions. Compared with a clinically recommended margin, a simple online adaptive strategy resulted in better cervix-uterus coverage without compromising organs at risk sparing.
[show abstract][hide abstract] ABSTRACT: Purpose. To investigate the robustness of single vocal cord intensity modulated radiation therapy (IMRT) treatment plans for set-up errors, respiration, and deformation. Material and methods. Four-dimensional computed tomography (4D-CT) scans of 10 early glottic carcinoma patients, previously treated with conventional techniques, were used in this simulation study. For each patient a pre-treatment 4D-CT was used for IMRT planning, generating a reference dose distribution. Prescribed PTV dose was 66 Gy. The impact of systematic set-up errors was simulated by applying shifts of ± 2 mm to the planning CT scans, followed by dose re-calculation with original beam segments, MUs, etc. Effects of respiration and deformation were determined utilizing extreme inhale and exhale CT scans, and repeat scans acquired after 22 Gy, 44 Gy, and 66 Gy, respectively. All doses were calculated using Monte Carlo dose simulations. Results. Considering all investigated geometrical perturbations, reductions in the clinical target volume (CTV) V95%, D98%, D2%, and generalized equivalent uniform dose (gEUD) were limited to 1.2 ± 2.2%, 2.4 ± 2.9%, 0.2 ± 1.8%, and 0.6 ± 1.1 Gy, respectively. The near minimum dose, D98%, was always higher than 89%, and gEUD always remained higher than 66 Gy. Planned contra-lateral (CL) vocal cord DMean, gEUD, and V40 Gy were 38.2 ± 6.0 Gy, 43.4 ± 5.6 Gy, and 42.7 ± 14.9%. With perturbations these values changed by -0.1 ± 4.3 Gy, 0.1 ± 4.0 Gy, and -1.0 ± 9.6%, respectively. Conclusions. On average, CTV dose reductions due to geometrical perturbations were very low, and sparing of the CL vocal cord was maintained. In a few observations (6 of 103 simulated situations), the near-minimum CTV-dose was around 90%, requiring attention in deciding on a future clinical protocol.
[show abstract][hide abstract] ABSTRACT: For online adaptive radiotherapy of cervical cancer, fast and accurate image segmentation is required to facilitate daily treatment adaptation. Our aim was twofold: (1) to test and compare three intra-patient automated segmentation methods for the cervix-uterus structure in CT-images and (2) to improve the segmentation accuracy by including prior knowledge on the daily bladder volume or on the daily coordinates of implanted fiducial markers. The tested methods were: shape deformation (SD) and atlas-based segmentation (ABAS) using two non-rigid registration methods: demons and a hierarchical algorithm. Tests on 102 CT-scans of 13 patients demonstrated that the segmentation accuracy significantly increased by including the bladder volume predicted with a simple 1D model based on a manually defined bladder top. Moreover, manually identified implanted fiducial markers significantly improved the accuracy of the SD method. For patients with large cervix-uterus volume regression, the use of CT-data acquired toward the end of the treatment was required to improve segmentation accuracy. Including prior knowledge, the segmentation results of SD (Dice similarity coefficient 85 ± 6%, error margin 2.2 ± 2.3 mm, average time around 1 min) and of ABAS using hierarchical non-rigid registration (Dice 82 ± 10%, error margin 3.1 ± 2.3 mm, average time around 30 s) support their use for image guided online adaptive radiotherapy of cervical cancer.
Physics in Medicine and Biology 07/2013; 58(15):5317-5332. · 2.70 Impact Factor
[show abstract][hide abstract] ABSTRACT: To predict the lowest achievable rectum D35 for quality assurance of IMRT plans of prostate cancer patients.
For each of 24 patients from a database of 47 previously treated patients, the anatomy was compared to the anatomies of the other 46 to predict the minimal achievable rectum D35. The 24 patients were then replanned to obtain maximally reduced rectum D35. Next, the newly derived plans were added to the database to replace the original clinical plans, and new predictions of the lowest achievable rectum D35 were made.
After replanning, the rectum D35 reduced by 9.3Gy±6.1 (average±1 SD; p<0.001) compared to the original plan. The first predictions of the rectum D35 were 4.8Gy±4.2 (average±1 SD; p<0.001) too high when evaluated with the new plans. After updating the database, the replanned and newly predicted rectum D35 agreed within 0.1Gy±2.8 (average±1 SD; p=0.89). The doses to the bladder, anus and femoral heads did not increase compared to the original plans.
For individual prostate patients, the lowest achievable rectum D35 in IMRT planning can be accurately predicted from dose distributions of previously treated patients by quantitative comparison of patient anatomies. These predictions can be used to quantitatively assess the quality of IMRT plans.
Radiotherapy and Oncology 07/2013; · 4.52 Impact Factor
[show abstract][hide abstract] ABSTRACT: Purpose: To compare IMRT planning strategies for prostate cancer patients with metal hip prostheses.Methods: All plans were generated fully automatically (i.e., no human trial-and-error interactions) using iCycle, the authors' in-house developed algorithm for multicriterial selection of beam angles and optimization of fluence profiles, allowing objective comparison of planning strategies. For 18 prostate cancer patients (eight with bilateral hip prostheses, ten with a right-sided unilateral prosthesis), two planning strategies were evaluated: (i) full exclusion of beams containing beamlets that would deliver dose to the target after passing a prosthesis (IMRTremove) and (ii) exclusion of those beamlets only (IMRTcut). Plans with optimized coplanar and noncoplanar beam arrangements were generated. Differences in PTV coverage and sparing of organs at risk (OARs) were quantified. The impact of beam number on plan quality was evaluated.Results: Especially for patients with bilateral hip prostheses, IMRTcut significantly improved rectum and bladder sparing compared to IMRTremove. For 9-beam coplanar plans, rectum V60Gy reduced by 17.5% ± 15.0% (maximum 37.4%, p = 0.036) and rectum Dmean by 9.4% ± 7.8% (maximum 19.8%, p = 0.036). Further improvements in OAR sparing were achievable by using noncoplanar beam setups, reducing rectum V60Gy by another 4.6% ± 4.9% (p = 0.012) for noncoplanar 9-beam IMRTcut plans. Large reductions in rectum dose delivery were also observed when increasing the number of beam directions in the plans. For bilateral implants, the rectum V60Gy was 37.3% ± 12.1% for coplanar 7-beam plans and reduced on average by 13.5% (maximum 30.1%, p = 0.012) for 15 directions.Conclusions: iCycle was able to automatically generate high quality plans for prostate cancer patients with prostheses. Excluding only beamlets that passed through the prostheses (IMRTcut strategy) significantly improved OAR sparing. Noncoplanar beam arrangements and, to a larger extent, increasing the number of treatment beams further improved plan quality.
Medical Physics 07/2013; 40(7):071704. · 2.91 Impact Factor
[show abstract][hide abstract] ABSTRACT: In a recent paper, we have published a new algorithm, designated 'iCycle', for fully automated multi-criterial optimization of beam angles and intensity profiles. In this study, we have used this algorithm to investigate the relationship between plan quality and the extent of the beam direction search space, i.e. the set of candidate beam directions that may be selected for generating an optimal plan. For a group of ten prostate cancer patients, optimal IMRT plans were made for stereotactic body radiation therapy (SBRT), mimicking high dose rate brachytherapy dosimetry. Plans were generated for five different beam direction input sets: a coplanar (CP) set and four non-coplanar (NCP) sets. For CP treatments, the search space consisted of 72 orientations (5° separations). The NCP CyberKnife (CK) space contained all directions available in the robotic CK treatment unit. The fully non-coplanar (F-NCP) set facilitated the highest possible degree of freedom in selecting optimal directions. CK(+) and CK(++) were subsets of F-NCP to investigate some aspects of the CK space. For each input set, plans were generated with up to 30 selected beam directions. Generated plans were clinically acceptable, according to an assessment of our clinicians. Convergence in plan quality occurred only after around 20 included beams. For individual patients, variations in PTV dose delivery between the five generated plans were minimal, as aimed for (average spread in V(95): 0.4%). This allowed plan comparisons based on organ at risk (OAR) doses, with the rectum considered most important. Plans generated with the NCP search spaces had improved OAR sparing compared to the CP search space, especially for the rectum. OAR sparing was best with the F-NCP, with reductions in rectum D(Mean), V(40Gy), V(60Gy) and D(2%) compared to CP of 25%, 35%, 37% and 8%, respectively. Reduced rectum sparing with the CK search space compared to F-NCP could be largely compensated by expanding CK with beams with relatively large direction components along the superior-inferior axis (CK(++)). Addition of posterior beams (CK(++) → F-NCP) did not lead to further improvements in OAR sparing. Plans with 25 beams clearly performed better than 11-beam plans. For CP plans, an increase from 11 to 25 involved beams resulted in reductions in rectum D(Mean), V(40Gy), V(60Gy) and D(2%) of 39%, 57%, 64% and 13%, respectively.
Physics in Medicine and Biology 08/2012; 57(17):5441-58. · 2.70 Impact Factor
[show abstract][hide abstract] ABSTRACT: To quantify improved salivary gland sparing for head and neck cancer patients using intensity-modulated radiotherapy (IMRT) plans based on integrated computerized optimization of beam orientations and intensity profiles. To assess if optimized nonzero couch angles also improve VMAT plans.
Our in-house developed algorithm iCycle was used for automated generation of multicriterial optimized plans with optimized beam orientations and intensity profiles, and plans with optimized profiles for preselected beam arrangements. For 20 patients, five IMRT plans, based on one "wish-list," were compared: (i) and (ii) seven- and nine-beam equiangular coplanar plans (iCycle(7equi), iCycle(9equi)), (iii) and (iv) nine-beam plans with optimized coplanar and noncoplanar beam orientations (iCycle(copl), iCycle(noncopl)), and (v) a nine-beam coplanar plan with optimized gantry angles and one optimized couch rotation (iCycle(couch)). VMAT plans without and with this optimized couch rotation were evaluated.
iCycle(noncopl) resulted in the best salivary gland sparing, while iCycle(couch) yielded similar results for 18 patients. For iCycle(7equi), submandibular gland NTCP values were on average 5% higher. iCycle(9equi) performed better than iCycle(7equi). iCycle(copl) showed further improvement. Application of the optimized couch angle from iCycle(couch) also improved NTCP values in VMAT plans.
iCycle allows objective comparison of competing planning strategies. Integrated optimization of beam profiles and angles can significantly improve normal tissue sparing, yielding optimal results for iCycle(noncopl).
Medical Physics 08/2012; 39(8):4858-65. · 2.91 Impact Factor
[show abstract][hide abstract] ABSTRACT: Purpose: Setup, range and anatomical uncertainties influence the dose delivered with proton pencil-beams, but a quantification of these errors for intensity-modulated proton therapy (IMPT) for oropharyngeal cancer is lacking. The purpose of this work is to quantify these effects. We also investigate whether treatment plans are more robust against errors when more beam directions are applied. Methods: We used an in-house developed inverse treatment planning system for proton pencil-beam scanning, which performs multi-criteria optimization. First, treatment plans for 3, 5, and 7 beam directions were created for 5 oropharyngeal cancer patients. A simultaneous-integrated boost technique was used, prescribing 66Gy and 54Gy to high and low dose regions, respectively, delivered in 30 fractions. Second, 300 treatment simulations were performed, recalculating the dose while including uncertainties. Anatomical uncertainties were taken into account by using two CT scans per patient. For setup errors an online setup-protocol was simulated. DVH parameters were used for dose evaluation. Results: The treatment plans were of high quality, with good target coverage and excellent OAR sparing. However, setup, range and anatomical uncertainties can lead to large differences between the planned and delivered dose. For the 3-beam plans, the expected V95% of the high- dose CTV reduced from 100% (planned) to on average 92%(range:82-98%), and the expected V107% increased from 1.3% (planned) to on average 4.2%(range:0.1%-6.7%). The expected V95% of the low-dose CTV reduced from 100% (planned) to on average 94% (range:86-99%). The dose to the OARs generally increased. The plans with more beam directions were not more robust against errors (p>0.05). Conclusions: Setup, range and anatomical uncertainties in IMPT for oropharyngeal cancer patients can lead to considerable underdosage of the target volume, which should be accounted for by replanning and/or robust optimization techniques. Robustness is not achieved by increasing the number of beam directions included in the treatment plan.
Medical Physics 06/2012; 39(6):3983-3984. · 2.91 Impact Factor
[show abstract][hide abstract] ABSTRACT: Purpose: To prospectively compare plans generated with iCycle, an in-house developed algorithm for fully automated multi-criterial IMRT beam profile and beam orientation optimization (Breedveld, Med. Phys. 2012), and plans manually generated by dosimetrists with the clinical treatment planning system. Methods: For 20 randomly selected head-and-neck cancer patients with various tumour locations (of whom 13 received sequential boost treatments) we offered the treating physician the choice between an automatically generated iCycle plan and a manually optimized plan following standard clinical procedures. While iCycle used a fixed'wish-list' with hard constraints and prioritised objectives, the dosimetrists manually selected the beam configuration and fine-tuned the constraints and objectives for each IMRT plan. Dosimetrists and treating physicians were not informed in advance whether a competing iCycle plan was made or not. The two plans were simultaneously presented to the physician who then selected the plan to be used for treatment. For the patient group, we quantified differences in PTV coverage and sparing of critical tissues. Results: In 32/33 plan comparisons the physician selected the iCycle plan for treatment. This highly consistent preference for automatically generated plans was mainly caused by improved sparing for the large majority of critical structures. With iCycle, the NTCPs for parotid and submandibular glands were reduced by 2.4% ± 4.9% (maximum: 18.5%, p=0.001) and 6.5% ± 8.3% (maximum: 27%, p=0.005), respectively. The reduction in mean oral cavity dose was 2.8 Gy ± 2.8 Gy (maximum: 8.1 Gy, p=0.005). For swallowing muscles, esophagus and larynx, the mean dose reduction was 3.3 Gy ± 1.1Gy (maximum: 9.2 Gy, p<0.001). Moreover, for 15 patients, the target coverage was improved as well. Conclusions: In 97% of cases, the automatically generated plan was selected for treatment because of superior quality. Apart from improved plan quality, automatic plan generation is economically attractive because of reduced workload.
Medical Physics 06/2012; 39(6):3848. · 2.91 Impact Factor
[show abstract][hide abstract] ABSTRACT: Purpose: To investigate the relationship between plan quality and the extent of the beam direction search space in computerized beam angle selection for generating optimal (non-coplanar) IMRT plans for prostate SBRT with dose distributions simulating HDR brachytherapy. Methods: iCycle (1) was used to investigate the relationship between plan quality and the extent of the set of beam directions available for plan generation. For a group of 10 prostate patients, optimal plans were generated for 5 direction search spaces. For coplanar treatments (CP set), 72 orientations were available for selection (separation 5°). The fully non-coplanar set (F-NCP) included the CP directions plus 430 directions spread over the sphere. The CK set contained the directions available at the robotic Cyberknife unit. CK+ and CK++ were extensions of CK to investigate some of its characteristics. Generated plans were in accordance with our clinical SBRT protocol for Cyberknife treatment, delivering 4 fractions of 9.5 Gy. Adequate PTV coverage had the highest priority. Reduction of rectum dose was the highest OAR priority. Results: The mean PTV coverage (V95) of all SBRT plans was 99% ï,± 0.9% (1 SD). F-NCP plans had most favorable OAR dose parameters, while for coplanar plans OAR doses were highest. Compared to coplanar treatment, rectum Dmean/V60 were 25% / 37% and 19% / 21% lower in F-NCP and CK plans. Higher rectum dose for the Cyberknife set compared to F-NCP was not caused by a lack of posterior beams for Cyberknife. For all search spaces, reduction in OAR dose only leveled off with > 20 beams in the plans (for CP, rectum V60 in 25 beam plans was reduced by 64% compared to 11 beams). In the non-coplanar set-ups, there was a preference for beams with a (large) lateral component. Conclusions: Plan quality clearly improved with the extent of the beam direction search space (coplanar worst), and the number of beam directions in the plan (25 clearly better than 11).(1) Breedveld S, Storchi P, Voet P, Heijmen B, Med Phys 2012; DOI: 10.1118/1.3676689.
Medical Physics 06/2012; 39(6):3855. · 2.91 Impact Factor