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At least 991 records · Page 55
All sourcesNASA NTRSDOE OSTI
DOE OSTI2015

SU-E-T-561: Monte Carlo-Based Organ Dose Reconstruction Using Pre-Contoured Human Model for Hodgkins Lymphoma Patients Treated by Cobalt-60 External Beam Therapy

Purpose: Organ doses for the Hodgkin’s lymphoma patients treated with cobalt-60 radiation were estimated using an anthropomorphic model and Monte Carlo modeling. Methods: A cobalt-60 treatment unit modeled in the BEAMnrc Monte Carlo code was used to produce phase space data. The Monte Carlo simulation was verified with percent depth dose measurement in water at various field sizes. Radiation transport through the lung blocks were modeled by adjusting the weights of phase space data. We imported a precontoured adult female hybrid model and generated a treatment plan. The adjusted phase space data and the human model were imported to the XVMC Monte Carlo code for dose calculation. The organ mean doses were estimated and dose volume histograms were plotted. Results: The percent depth dose agreement between measurement and calculation in water phantom was within 2% for all field sizes. The mean organ doses of heart, left breast, right breast, and spleen for the selected case were 44.3, 24.1, 14.6 and 3.4 Gy, respectively with the midline prescription dose of 40.0 Gy. Conclusion: Organ doses were estimated for the patient group whose threedimensional images are not available. This development may open the door to more accurate dose reconstruction and estimates of uncertainties in secondary cancer risk for Hodgkin’s lymphoma patients. This work was partially supported by the intramural research program of the National Institutes of Health, National Cancer Institute, Division of Cancer Epidemiology and Genetics.

61 RADIATION PROTECTION AND DOSIMETRY↗
DOE OSTI2015

SU-E-T-574: Novel Chance-Constrained Optimization in Intensity-Modulated Proton Therapy Planning to Account for Range and Patient Setup Uncertainties

Purpose: We propose to apply a probabilistic framework, namely chanceconstrained optimization, in the intensity-modulated proton therapy (IMPT) planning subject to range and patient setup uncertainties. The purpose is to hedge against the influence of uncertainties and improve robustness of treatment plans. Methods: IMPT plans were generated for a typical prostate patient. Nine dose distributions are computed — the nominal one and one each for ±5mm setup uncertainties along three cardinal axes and for ±3.5% range uncertainty. These nine dose distributions are supplied to the solver CPLEX as chance constraints to explicitly control plan robustness under these representative uncertainty scenarios with certain probability. This probability is determined by the tolerance level. We make the chance-constrained model tractable by converting it to a mixed integer optimization problem. The quality of plans derived from this method is evaluated using dose-volume histogram (DVH) indices such as tumor dose homogeneity (D5% – D95%) and coverage (D95%) and normal tissue sparing like V70 of rectum, V65, and V40 of bladder. We also compare the results from this novel method with the conventional PTV-based method to further demonstrate its effectiveness Results: Our model can yield clinically acceptable plans within 50 seconds. The chance-constrained optimization produces IMPT plans with comparable target coverage, better target dose homogeneity, and better normal tissue sparing compared to the PTV-based optimization [D95% CTV: 67.9 vs 68.7 (Gy), D5% – D95% CTV: 11.9 vs 18 (Gy), V70 rectum: 0.0 % vs 0.33%, V65 bladder: 2.17% vs 9.33%, V40 bladder: 8.83% vs 21.83%]. It also simultaneously makes the plan more robust [Width of DVH band at D50%: 2.0 vs 10.0 (Gy)]. The tolerance level may be varied to control the tradeoff between plan robustness and quality. Conclusion: The chance-constrained optimization generates superior IMPT plan compared to the PTV-based optimization with explicit control of plan robustness. NIH/NCI K25CA168984, Eagles Cancer Research Career Development, The Lawrence W. and Marilyn W. Matteson Fund for Cancer Research, Mayo ASU Seed Grant, and The Kemper Marley Foundation.

62 RADIOLOGY AND NUCLEAR MEDICINE↗
DOE OSTI2015

SU-E-T-578: On Definition of Minimum and Maximum Dose for Target Volume

Purpose: This study aims to investigate the impact of different minimum and maximum dose definitions in radiotherapy treatment plan quality evaluation criteria by using tumor control probability (TCP) models. Methods: Dosimetric criteria used in RTOG 1308 protocol are used in the investigation. RTOG 1308 is a phase III randomized trial comparing overall survival after photon versus proton chemoradiotherapy for inoperable stage II-IIIB NSCLC. The prescription dose for planning target volume (PTV) is 70Gy. Maximum dose (Dmax) should not exceed 84Gy and minimum dose (Dmin) should not go below 59.5Gy in order for the plan to be “per protocol” (satisfactory).A mathematical model that simulates the characteristics of PTV dose volume histogram (DVH) curve with normalized volume is built. The Dmax and Dmin are noted as percentage volumes Dη% and D(100-δ)%, with η and d ranging from 0 to 3.5. The model includes three straight line sections and goes through four points: D95%= 70Gy, Dη%= 84Gy, D(100-δ)%= 59.5 Gy, and D100%= 0Gy. For each set of η and δ, the TCP value is calculated using the inhomogeneously irradiated tumor logistic model with D50= 74.5Gy and γ50=3.52. Results: TCP varies within 0.9% with η; and δ values between 0 and 1. With η and η varies between 0 and 2, TCP change was up to 2.4%. With η and δ variations from 0 to 3.5, maximum of 8.3% TCP difference is seen. Conclusion: When defined maximum and minimum volume varied more than 2%, significant TCP variations were seen. It is recommended less than 2% volume used in definition of Dmax or Dmin for target dosimetric evaluation criteria. This project was supported by NIH grants U10CA180868, U10CA180822, U24CA180803, U24CA12014 and PA CURE Grant.

61 RADIATION PROTECTION AND DOSIMETRY↗
DOE OSTI2015

SU-E-T-580: On the Significance of Model Based Dosimetry for Breast and Head and Neck 192Ir HDR Brachytherapy

Purpose: To assess the dosimetric and radiobiological differences between TG43-based and model-based dosimetry in the treatment planning of {sup 192}Ir HDR brachytherapy for breast and head and neck cancer. Methods: Two cohorts of 57 Accelerated Partial Breast Irradiation (APBI) and 22 head and neck (H&N) patients with oral cavity carcinoma were studied. Dosimetry for the treatment plans was performed using the TG43 algorithm of the Oncentra Brachy v4.4 treatment planning system (TPS). Corresponding Monte Carlo (MC) simulations were performed using MCNP6 with input files automatically prepared by the BrachyGuide software tool from DICOM RT plan data. TG43 and MC data were compared in terms of % dose differences, Dose Volume Histograms (DVHs) and related indices of clinical interest for the Planning Target Volume (PTV) and the Organs-At-Risk (OARs). A radiobiological analysis was also performed using the Equivalent Uniform Dose (EUD), mean survival fraction (S) and Tumor Control Probability (TCP) for the PTV, and the Normal Tissue Control Probability (N TCP) and the generalized EUD (gEUD) for the OARs. Significance testing of the observed differences performed using the Wilcoxon paired sample test. Results: Differences between TG43 and MC DVH indices, associated with the increased corresponding local % dose differences observed, were statistically significant. This is mainly attributed to their consistency however, since TG43 agrees closely with MC for the majority of DVH and radiobiological parameters in both patient cohorts. Differences varied considerably among patients only for the ipsilateral lung and ribs in the APBI cohort, with a strong correlation to target location. Conclusion: While the consistency and magnitude of differences in the majority of clinically relevant DVH indices imply that no change is needed in the treatment planning practice, individualized dosimetry improves accuracy and addresses instances of inter-patient variability observed. Research co-financed by the ESF and Greek funds through the Operational Program Education and Lifelong Learning Investing in Knowledge Society of the NSRF. Research Funding Program Aristeia. Nucletron, an Elekta company (Veenendaal, The Netherlands) is gratefully acknowledged for providing Oncentra Brachy v4.4 for research purposes.

61 RADIATION PROTECTION AND DOSIMETRY↗
DOE OSTI2015

SU-E-T-621: Planning Methodologies for Cancer of the Anal Canal: Comparing IMRT, Rapid Arc, and Pencil Beam Scanning Proton Beam

Purpose: To evaluate planning methods for anal canal cancer and compare the results of 9-field Intensity Modulated Radiotherapy (IMRT), Volumetric Modulated Arc Therapy (Varian, RapidArc), and Proton Pencil Beam Scanning (PBS). Methods: We generated plans with IMRT, RapidArc (RA) and PBS for twenty patients for both initial phase including nodes and cone down phase of treatment using Eclipe (Varian). We evaluated the advantage of each technique for each phase. RA plans used 2 to 4 arcs and various collimator orientations. PBS used two posterior oblique fields. We evaluated the plans comparing dose volume histogram (DVH), locations of hot spots, and PTV dose conformity. Results: Due to complex shape of target, for RA plans, multiple arcs (>2) are required to achieve optimal PTV conformity. When the PTV exceeds 15 cm in the superior-inferior direction, limitations of deliverability start to dominate. The PTV should be divided into a superior and an inferior structure. The optimization is performed with fixed jaws for each structure and collimator set to 90 degrees for the inferior PTV. Proton PBS plans show little advantage in small bowel sparing when treating the nodes. However, PBS plan reduces volumetric dose to the bladder at the cost of higher doses to the perineal skin. IMRT plans provide good target conformity, but they generate hot spots outside of the target volume. Conclusion: When using one planning technique for entire course of treatment, Multiple arc (>2) RA plans are better as compared to IMRT and PBS plans. When combining techniques, RA for the initial phase in combination with PBS for the cone down phase results in the most optimal plans.

62 RADIOLOGY AND NUCLEAR MEDICINE↗
DOE OSTI2015

SU-E-T-625: Potential for Reduced Radiation Induced Toxicity for the Treatment of Inoperable Non-Small-Cell Lung Cancer Using RapidArc Planning

Purpose: To investigate the feasibility of using RapidArc (RA) treatment planning to reduce irradiation volume of normal lung and other organs at risk (OARs) in the treatment of inoperable non-small-cell lung cancer (NSCLC) patients. Methods: A retrospective treatment planning and delivery study was performed to compare target coverage and the volumes of the normal lung, spinal cord, heart and esophagus on 4D-CT scan above their dose tolerances delivered by RA vs. IMRT for ten inoperable NSCLC patients (Stage I-IIIB). RA plans consisted of either one-full or two-partial co-planar arcs used to treat 95% of the planning target volume (PTV) with 6MV beam to a prescription of 66Gy in 33 fractions. IMRT plans were generated using 5–7 co-planar fields with 6MV beam. PTV coverage, dose-volume histograms, homogeneity/conformity indices (CI), total number of monitor units(MUs), beam-on time and delivery accuracy were compared between the two treatment plans. Results: Similar target coverage was obtained between the two techniques. RA (CI=1.02) provided more conformal plans without loss of homogeneity compared to IMRT plans (CI=1.12). Compared to IMRT, RA achieved a significant median dose reduction in V10 (3%), V20 (8%), and mean lung dose (3%) on average, respectively. On average, V5 was comparable between the two treatment plans. RA reduced mean esophagus (6%), mean heart (18%), and maximum spinal cord dose (7%), on average, respectively. Total number of MUs and beam-on time were each reduced almost by a factor of 2 when compared to IMRT-patient comfort, reduced intra-fraction-motion and leakage dose. The average IMRT and RA QA pass rate was about 98% for both types of plans for 3%/3mm criterion. Conclusion: Compared to IMRT plans, RA provided not only comparable target coverage, but also improved conformity, treatment time, and significant reduction in irradiation of OARs. This may potentially allow for target dose escalation without increase in normal tissue toxicity.

61 RADIATION PROTECTION AND DOSIMETRY↗
DOE OSTI2015

SU-E-T-632: Preliminary Study On Treating Nose Skin Using Energy and Intensity Modulated Electron Beams with Monte Carlo Based Dose Calculations

Purpose: Uneven nose surfaces and air cavities underneath and the use of bolus present complexity and dose uncertainty when using a single electron energy beam to plan treatments of nose skin with a pencil beam-based planning system. This work demonstrates more accurate dose calculation and more optimal planning using energy and intensity modulated electron radiotherapy (MERT) delivered with a pMLC. Methods: An in-house developed Monte Carlo (MC)-based dose calculation/optimization planning system was employed for treatment planning. Phase space data (6, 9, 12 and 15 MeV) were used as an input source for MC dose calculations for the linac. To reduce the scatter-caused penumbra, a short SSD (61 cm) was used. Our previous work demonstrates good agreement in percentage depth dose and off-axis dose between calculations and film measurement for various field sizes. A MERT plan was generated for treating the nose skin using a patient geometry and a dose volume histogram (DVH) was obtained. The work also shows the comparison of 2D dose distributions between a clinically used conventional single electron energy plan and the MERT plan. Results: The MERT plan resulted in improved target dose coverage as compared to the conventional plan, which demonstrated a target dose deficit at the field edge. The conventional plan showed higher dose normal tissue irradiation underneath the nose skin while the MERT plan resulted in improved conformity and thus reduces normal tissue dose. Conclusion: This preliminary work illustrates that MC-based MERT planning is a promising technique in treating nose skin, not only providing more accurate dose calculation, but also offering an improved target dose coverage and conformity. In addition, this technique may eliminate the necessity of bolus, which often produces dose delivery uncertainty due to the air gaps that may exist between the bolus and skin.

62 RADIOLOGY AND NUCLEAR MEDICINE↗
DOE OSTI2015

SU-E-T-642: PTV Is the Voxel-Wise Worst-Case of CTV in Prostate Photon Therapy

Purpose: To examine the adequacy of the planning target volume (PTV) dose distribution as the worst-case representation of clinical target volume (CTV) dose distribution in prostate volumetric-modulated arc therapy (VMAT) plans. Methods: Ten intact prostate cancer cases treated by VMAT at our institution were randomly selected. Isocenter was shifted in the three cardinal directions by a displacement equal to the PTV expansion on the CTV (±3 mm) for a total of six shifted plans per original plan. Rotationally-perturbed plans were generated with a couch rotation of ±1° to simulate patient yaw. The eight perturbed dose distributions were recalculated in the treatment planning system using the same, fixed fluence map as the original plan. The voxel-wise worst-case CTV dose distribution was constructed from the minimum value per voxel from the eight perturbed doses. The resulting dose volume histograms (DVH) were evaluated for statistical correlation between the worst-case CTV and nominal PTV dose distributions based on D95% by Wilcoxon signed-rank test with significance level p ≤ 0.05. Results: Inspection demonstrates the PTV DVH in the nominal dose distribution is bounded by the CTV DVH in the worst-case dose distribution. Comparison of D95% for the two dose distributions by Wilcoxon signed-rank test gives p = 0.131. Therefore the null hypothesis cannot be rejected since the difference in median values is not statistically significant. Conclusion: The assumption that the nominal dose distribution for PTV represents the worst-case dose distribution for CTV appears valid for the ten plans under examination. Although the worst-case dose distribution is unphysical since the dose per voxel is chosen independently, it serves as a lower bound for the possible CTV coverage. Furthermore, this is consistent with the unphysical nature of the PTV. Minor discrepancies between the two dose distributions are expected since the dose cloud is not strictly static. Funding Support: NIH/NCI K25CA168984, Eagles Cancer Research Career Development, The Lawrence W. and Marilyn W. Matteson Fund for Cancer Research, Mayo ASU Seed Grant, and The Kemper Marley Foundation.

62 RADIOLOGY AND NUCLEAR MEDICINE↗
DOE OSTI2015

SU-E-T-746: The Use of Radiochromic Film Analyzed with Three Channel Dosimetry as a Secondary Patient-Specific QA Tool for Small SBRT Fields

Introduction: As diagnostic techniques become more sensitive and targeting methods grow in accuracy, target volumes continue to shrink and SBRT becomes more prevalent. Due to this fact, patient-specific QA must also enhance resolution and accuracy in order to verify dose delivery in these volumes. It has been suggested that when measuring small fields at least two separate detectors be used to verify delivered dose. Therefore, we have instituted a secondary patient QA verification for small (<3cm) SBRT fields using Gafchromic EBT2 film. Methods: Films were cross-calibrated using a Farmer chamber in plastic water at reference conditions as defined by TG-51. Films were scanned, and an RGB calibration curve was created according to best practices published by Ashland, Inc. Four SBRT cases were evaluated both with the Scandidos Delta4 and with EBT2 films sandwiched in plastic water. Raw values obtained from the film were converted to dose using an in-house algorithm employing all three color channels to increase accuracy and dosimetric range. Gamma and dose profile comparisons to Eclipse dose calculations were obtained using RIT and compared to values obtained with the Delta4. Results: Film gamma pass rates at 2% and 2mm were similar to those obtained with the Delta4. However, dose difference histograms showed better absolute dose agreement, with the average mean film dose agreeing with calculation to 0.3% and the Delta4 only agreeing to 3.1% across the cases. Additionally, films provided more resolution than the Delta4 and thus their dose profiles better succeeded in diagnosing dose calculation inaccuracies. Conclusion: We believe that the implementation of secondary patient QA using EBT2 film analyzed with all three color channels is an invaluable tool for evaluation of small SBRT fields. Furthermore, we have shown that this method can sometimes provide a more detailed and faithful reproduction of plan dose than the Delta4.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2015

SU-E-T-764: Track Repeating Algorithm for Proton Therapy Applied to Intensity Modulated Proton Therapy for Head-And-Neck Patients

Purpose: To determine the suitability of fast Monte Carlo techniques for dose calculation in particle therapy based on track-repeating algorithm for Intensity Modulated Proton Therapy, IMPT. The application of this technique will make possible detailed retrospective studies of large cohort of patients, which may lead to a better determination of Relative Biological Effects from the analysis of patient data. Methods: A cohort of six head-and-neck patients treated at the University of Texas MD Anderson Cancer Center with IMPT were utilized. The dose distributions were calculated with the standard Treatment Plan System, TPS, MCNPX, GEANT4 and FDC, a fast track-repeating algorithm for proton therapy for the verification and the patient plans. FDC is based on a GEANT4 database of trajectories of protons in a water. The obtained dose distributions were compared to each other utilizing the g-index criteria for 3mm-3% and 2mm-2%, for the maximum spatial and dose differences. The γ-index was calculated for voxels with a dose at least 10% of the maximum delivered dose. Dose Volume Histograms are also calculated for the various dose distributions. Results: Good agreement between GEANT4 and FDC is found with less than 1% of the voxels with a γ-index larger than 1 for 2 mm-2%. The agreement between MCNPX with FDC is within the requirements of clinical standards, even though it is slightly worse than the comparison with GEANT4.The comparison with TPS yielded larger differences, what is also to be expected because pencil beam algorithm do not always performed well in highly inhomogeneous areas like head-and-neck. Conclusion: The good agreement between a track-repeating algorithm and a full Monte Carlo for a large cohort of patients and a challenging, site like head-and-neck, opens the path to systematic and detailed studies of large cohorts, which may yield better understanding of biological effects.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2015

SU-E-T-766: Treatment Planning Comparison Study On Two Different Multileaf Collimators Delivered with Volumetric Modulated Arc Therapy

Purpose: To compare and evaluate the performance of two different multileaf collimators(MLCi2 and Agility) delivery with volumetric modulated arc therapy techniques. Methods: Treatment plans were graded four (Low, Moderate, Moderate-High and High complexity) accorrding to the complexity. This includes 1 Low complexity(brain metastasis), 2 Moderate complexity(Lung and Liver), 1 Moderate-High complexity(prostate) and 1 High complexity ( head and neck) cases. Total dose of 60 Gy was given for all the plans. All cases were desigined two VMAT plans, one with MLCi2(group A) and the other with Agility(group B). All plans were done on Elekta VMAT with Monaco treatment planning system. All plans were generated with 6 MV X-rays for both Plan A and Plan B. Plans were evaluated based on the ability to meet the dose volume histogram, radiation conformity index, estimated radiation delivery time, dose homogeneity index(HI) and monitor units(MU) needed to deliver the prescribed dose. Results: Plans of group B achieved the best HI (HI = 1.05 Vs. 1.06) at the Low complexity cases while plans of group A were slightly better at the high complexity cases (HI = 1.12 Vs. 1.14). Faster VMAT plan delivery with Agility than with MLCi2 as plan complexity increased (Low complexity:52s Vs.52s, Moderate complexity:58s Vs. 55s, Moderate-High complexity: 171s Vs.152s, High complexity : 326s Vs. 202s ), especially for the most complex paradigms delivered time can be decresed 38%. No Significant changes were observed between the group B and group A plans in terms of the healthy tissue mean dose and MU. Both plans respected the planning objective for all organs at risk. Conclusion: The study concludes that VMAT plans with the novel Agility MLC can significant decrease the delivering time at the high complexity cases, while a slight compromise in the dose homogeneity index should be noted. This work was supported by The Medical Science Foundation of The health department of Hebei Province (No. 20130253)

60 APPLIED LIFE SCIENCES↗
DOE OSTI2015

SU-E-T-775: Use of Electronic Portal Imaging Device (EPID) for Quality Assurance (QA) of Electron Beams On Varian Truebeam System

Purpose: In a previous study we have demonstrated the feasibility of using EPID to QA electron beam parameters on a single Varian TrueBeam LINAC. This study aims to provide further investigation on (1) reproducibility of using EPID to detect electron beam energy changes on multiple machines and (2) evaluation of appropriate calibration methods to compare results from different EPIDs. Methods: Ad-hoc mode electron beam images were acquired in developer mode with XML code. Electron beam data were collected on a total of six machines from four institutions. A custom-designed double-wedge phantom was placed on the EPID detector. Two calibration methods - Pixel Sensitivity Map (PSM) and Large Source-to-Imager Distance Flood Field (LSID-FF) - were used. To test the sensitivity of EPID in detecting energy drifts, Bending Magnet Current (BMC) was detuned to invoke energy changes corresponding to ∼±1.5 mm change in R50% of PDD on two machines from two institutions. Percent depth ionization (PDI) curves were then analyzed and compared with the respective baseline images using LSID-FF calibration. For reproducibility testing, open field EPID images and images with a standard testing phantom were collected on multiple machines. Images with and without PSM correction for same energies on different machines were overlaid and compared. Results: Two pixel shifts were observed in PDI curve when energy changes exceeded the TG142 tolerance. PSM showed the potential to correct the differences in pixel response of different imagers. With PSM correction, the histogram of images differences obtained from different machines showed narrower distributions than those images without PSM correction. Conclusion: EPID is sensitive for electron energy changes and the results are reproducible on different machines. When overlaying images from different machines, PSM showed the ability to partially eliminate the intrinsic variation of various imagers. Research Funding from Varian Medical Systems Inc.Dr. Sasa Mutic receives compensation for providing patient safety training services from Varian Medical Systems, the sponsor of this study.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2015

SU-E-T-807: VMAT Vs. DIMRT Vs. SsIMRT Assessing the Dosimetric Parameters of Cervical Carcinoma Treatment with a 20-Patient Sample

Purpose: The purpose of this study is to assess the dosimetric parameters of cervical carcinoma treatment using 3 different radiation therapy delivery Methods: volumetric-modulated arc therapy (VMAT), the static-field dynamic multileaf collimator intensity-modulated radiation therapy (dIMRT) and the static-field step-and-shoot intensity-modulated radiotherapy (ssIMRT). Methods: Twenty patients with cervical carcinoma were selected to be planned with dual arc VMAT, dIMRT and ssIMRT using Monaco 3.3 TPS on the Axesse™ linear accelerator in this investigation. The total dose of the planning target volume (PTV) is 60Gy. The homogeneity index (HI), conformity index (CI), dose volume histograms (DVHs), delivery efficiency, dose of organs at risks (bladder, rectum, and femoral heads), were all measured. Results: Dose distribution in 3 different radiation therapy delivery methods satisfied clinical requirements. Mean HI of PTV with VMAT, dIMRT and ssIMRT is 1.08, 1.10, and 1.09 (p>0.05). Mean CI of PTV with VMAT, dIMRT and ssIMRT is 0.82, 0.8 and 0.8 (p>0.05). For the DVH of V10, V20 and V30 in bladder, there was a significant difference: VMAT>dIMRT=ssIMRT (p <0.05). For the DVH of V40 and V50, there was a significant difference: VMAT dIMRT >ssIMRT (p <0.05). Conclusion: The results show that VMAT has a great advantage in delivery efficiency than dIMRT and ssIMRT, without compromise to the PTV coverage, HI and CI. The delivery methods should be considered under the actual cervical carcinoma radiotherapy situation.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2015

SU-E-T-811: Volumetric Modulated Arc Therapy Vs. C-IMRT for the Treatment of Upper Thoracic Esophageal Cancer

Purpose: To compare plans using volumetric-modulated arc therapy (VMAT) with conventional sliding window intensity-modulated radiation therapy (c-IMRT) to treat upper thoracic esophageal cancer (EC). Methods: CT datasets of 11 patients with upper thoracic EC were identified. Four plans were generated for each patient: c-IMRT with 5 fields (5F) and VMAT with a single arc (1A), two arcs (2A), or three arcs (3A). The prescribed doses were 64 Gy/32 F for the primary tumor (planning target volume 64, PTV64). The dose-volume histogram data, the number of monitoring units (MUs) and the treatment time (TT) for the different plans were compared. Results: All of the plans generated similar dose distributions for PTVs and organs at risk (OARs), except that the 2A- and 3A-VMAT plans yielded a significantly higher conformity index (CI) than the c-IMRT plan. The CI of the PTV64 was improved by increasing the number of arcs in the VMAT plans. The maximum spinal cord dose and the planning risk volume of the spinal cord dose for the two techniques were similar. The 2A- and 3A-VMAT plans yielded lower mean lung doses and heart V50 than the c-IMRT. The V20 and V30 for the lungs in all of the VMAT plans were lower than those in the c-IMRT plan, at the expense of increasing V5, V10 and V13. The VMAT plan resulted in significant reductions in MUs and TT. Conclusion: The 2A-VMAT plan appeared to spare the lungs from moderate-dose irradiation most effectively of all plans, at the expense of increasing the low-dose irradiation volume, and also significantly reduced the number of required MUs and the TT. The CI of the PTVs and the OARs was improved by increasing the arc-number from 1 to 2. however, no significant improvement was observed using the 3A-VMAT, except for an increase in the TT. This work was sponsored by Shantou University Medical College Clinical Research Enhancement Initiative(NO.201424)

60 APPLIED LIFE SCIENCES↗
DOE OSTI2015

SU-F-BRD-01: A Novel 4D Robust Optimization Mitigates Interplay Effect in Intensity-Modulated Proton Therapy for Lung Cancer

Purpose: To compare the impact of interplay effect on 3D and 4D robustly optimized intensity-modulated proton therapy (IMPT) plans to treat lung cancer. Methods: Two IMPT plans were created for 11 non-small-cell-lung-cancer cases with 6–14 mm spots. 3D robust optimization generated plans on average CTs with the internal gross tumor volume density overridden to deliver 66 CGyE in 33 fractions to the internal target volume (ITV). 4D robust optimization generated plans on 4D CTs with the delivery of prescribed dose to the clinical target volume (CTV). In 4D optimization, the CTV of individual 4D CT phases received non-uniform doses to achieve a uniform cumulative dose. Dose evaluation software was developed to model time-dependent spot delivery to incorporate interplay effect with randomized starting phases of each field per fraction. Patient anatomy voxels were mapped from phase to phase via deformable image registration to score doses. Indices from dose-volume histograms were used to compare target coverage, dose homogeneity, and normal-tissue sparing. DVH indices were compared using Wilcoxon test. Results: Given the presence of interplay effect, 4D robust optimization produced IMPT plans with better target coverage and homogeneity, but slightly worse normal tissue sparing compared to 3D robust optimization (unit: Gy) [D95% ITV: 63.5 vs 62.0 (p=0.014), D5% - D95% ITV: 6.2 vs 7.3 (p=0.37), D1% spinal cord: 29.0 vs 29.5 (p=0.52), Dmean total lung: 14.8 vs 14.5 (p=0.12), D33% esophagus: 33.6 vs 33.1 (p=0.28)]. The improvement of target coverage (D95%,4D – D95%,3D) was related to the ratio RMA3/(TVx10−4), with RMA and TV being respiratory motion amplitude (RMA) and tumor volume (TV), respectively. Peak benefit was observed at ratios between 2 and 10. This corresponds to 125 – 625 cm3 TV with 0.5-cm RMA. Conclusion: 4D optimization produced more interplay-effect-resistant plans compared to 3D optimization. It is most effective when respiratory motion is modest compared to TV. NIH/NCI K25CA168984; Eagles Cancer Research Career Development; The Lawrence W. and Marilyn W. Matteson Fund for Cancer Research; Mayo ASU Seed Grant; The Kemper Marley Foundation.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2015

SU-F-BRB-07: A Plan Comparison Tool to Ensure Robustness and Deliverability in Online-Adaptive Radiotherapy

Purpose: To develop a plan comparison tool that will ensure robustness and deliverability through analysis of baseline and online-adaptive radiotherapy plans using similarity metrics. Methods: The ViewRay MRIdian treatment planning system allows export of a plan file that contains plan and delivery information. A software tool was developed to read and compare two plans, providing information and metrics to assess their similarity. In addition to performing direct comparisons (e.g. demographics, ROI volumes, number of segments, total beam-on time), the tool computes and presents histograms of derived metrics (e.g. step-and-shoot segment field sizes, segment average leaf gaps). Such metrics were investigated for their ability to predict that an online-adapted plan reasonably similar to a baseline plan where deliverability has already been established. Results: In the realm of online-adaptive planning, comparing ROI volumes offers a sanity check to verify observations found during contouring. Beyond ROI analysis, it has been found that simply editing contours and re-optimizing to adapt treatment can produce a delivery that is substantially different than the baseline plan (e.g. number of segments increased by 31%), with no changes in optimization parameters and only minor changes in anatomy. Currently the tool can quickly identify large omissions or deviations from baseline expectations. As our online-adaptive patient population increases, we will continue to develop and refine quantitative acceptance criteria for adapted plans and relate them historical delivery QA measurements. Conclusion: The plan comparison tool is in clinical use and reports a wide range of comparison metrics, illustrating key differences between two plans. This independent check is accomplished in seconds and can be performed in parallel to other tasks in the online-adaptive workflow. Current use prevents large planning or delivery errors from occurring, and ongoing refinements will lead to increased assurance of plan quality.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2015

SU-F-BRB-10: A Statistical Voxel Based Normal Organ Dose Prediction Model for Coplanar and Non-Coplanar Prostate Radiotherapy

Purpose: Knowledge learned from previous plans can be used to guide future treatment planning. Existing knowledge-based treatment planning methods study the correlation between organ geometry and dose volume histogram (DVH), which is a lossy representation of the complete dose distribution. A statistical voxel dose learning (SVDL) model was developed that includes the complete dose volume information. Its accuracy of predicting volumetric-modulated arc therapy (VMAT) and non-coplanar 4π radiotherapy was quantified. SVDL provided more isotropic dose gradients and may improve knowledge-based planning. Methods: 12 prostate SBRT patients originally treated using two full-arc VMAT techniques were re-planned with 4π using 20 intensity-modulated non-coplanar fields to a prescription dose of 40 Gy. The bladder and rectum voxels were binned based on their distances to the PTV. The dose distribution in each bin was resampled by convolving to a Gaussian kernel, resulting in 1000 data points in each bin that predicted the statistical dose information of a voxel with unknown dose in a new patient without triaging information that may be collectively important to a particular patient. We used this method to predict the DVHs, mean and max doses in a leave-one-out cross validation (LOOCV) test and compared its performance against lossy estimators including mean, median, mode, Poisson and Rayleigh of the voxelized dose distributions. Results: SVDL predicted the bladder and rectum doses more accurately than other estimators, giving mean percentile errors ranging from 13.35–19.46%, 4.81–19.47%, 22.49–28.69%, 23.35–30.5%, 21.05–53.93% for predicting mean, max dose, V20, V35, and V40 respectively, to OARs in both planning techniques. The prediction errors were generally lower for 4π than VMAT. Conclusion: By employing all dose volume information in the SVDL model, the OAR doses were more accurately predicted. 4π plans are better suited for knowledge-based planning than the VMAT plans that are strongly biased in its dose gradient orientation. This project is supported by Varian Medical Systems.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2015

SU-F-303-12: Implementation of MR-Only Simulation for Brain Cancer: A Virtual Clinical Trial

Purpose: To perform a retrospective virtual clinical trial using an MR-only workflow for a variety of brain cancer cases by incorporating novel imaging sequences, tissue segmentation using phase images, and an innovative synthetic CT (synCT) solution. Methods: Ten patients (16 lesions) were evaluated using a 1.0T MR-SIM including UTE-DIXON imaging (TE = 0.144/3.4/6.9ms). Bone-enhanced images were generated from DIXON-water/fat and inverted UTE. Automated air segmentation was performed using unwrapped UTE phase maps. Segmentation accuracy was assessed by calculating intersection and Dice similarity coefficients (DSC) using CT-SIM as ground truth. SynCTs were generated using voxel-based weighted summation incorporating T2, FLAIR, UTE1, and bone-enhanced images. Mean absolute error (MAE) characterized HU differences between synCT and CT-SIM. Dose was recalculated on synCTs; differences were quantified using planar gamma analysis (2%/2 mm dose difference/distance to agreement) at isocenter. Digitally reconstructed radiographs (DRRs) were compared. Results: On average, air maps intersected 80.8 ±5.5% (range: 71.8–88.8%) between MR-SIM and CT-SIM yielding DSCs of 0.78 ± 0.04 (range: 0.70–0.83). Whole-brain MAE between synCT and CT-SIM was 160.7±8.8 HU, with the largest uncertainty arising from bone (MAE = 423.3±33.2 HU). Gamma analysis revealed pass rates of 99.4 ± 0.04% between synCT and CT-SIM for the cohort. Dose volume histogram analysis revealed that synCT tended to yield slightly higher doses. Organs at risk such as the chiasm and optic nerves were most sensitive due to their proximities to air/bone interfaces. DRRs generated via synCT and CT-SIM were within clinical tolerances. Conclusion: Our approach for MR-only simulation for brain cancer treatment planning yielded clinically acceptable results relative to the CT-based benchmark. While slight dose differences were observed, reoptimization of treatment plans and improved image registration can address this limitation. Future work will incorporate automated registration between setup images (cone-beam CT and kilovoltage images) for synCT and CT-SIM. Submitting institution holds research agreements with Philips HealthCare, Best, Netherlands and Varian Medical Systems, Palo Alto, CA. Research partially sponsored via an Internal Mentored Research Grant.

60 APPLIED LIFE SCIENCES↗