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Purpose: To develop and validate an intensity modulated radiation therapy (IMRT) treatment plan quantitative score using QUANTEC dose/volume parameters to assess plan quality., Methods: 132 IMRT and volumetric modulated Arc therapy (VMAT) patient plans of various treatment sites were evaluated. The optimized plan's dose volume histogram (DVH) was exported to Velocity for evaluation. The proposed scoring was based on calculating the shortest distance from the QUANTEC objective to the DVH line of each organ. Each plan was normalized against the ideal plan where the organs at risk (OARs) received no dose and hence the distance between the QUANTEC objective and the DVH line was maximized. These normalized scores enabled the comparison of the quality of plans across treatment sites and dosimetrists. The scores were plotted and statistically analyzed to serve as a basis for future research., Results: The score for each treatment site was evaluated and the average percentage scores±SD were found to be 43.5 ± 21.0, 33.3 ± 31.7, 42.6 ± 23.3, 40.2 ± 24.4, 33.5 ± 23.5 for the sites of abdomen, brain, chest, head/neck, and pelvis respectively. Differences in scores between the treatment sites were largely attributed to OAR segmentation and proximity of the OAR to the planning target volume (PTV). Small score differences between dosimetrists were attributed to the number of plans they have completed., Conclusion: This approach allows comparison of patient treatments which will help improve patient care and treatment outcomes. A larger sample of treatment plans is being evaluated to investigate the effect of dosimetrist's experience on plan quality.

There has been growing interest in the use of stereotactic body radiotherapy (SBRT) technique for the treatment of cervical cancer. The purpose of this study was to characterize dose distributions as well as model the target dose fall-off for intensity-modulated radiation therapy (IMRT) and volumetric-modulated arc therapy (VMAT) delivery techniques using 6 and 10 MV photon beam energies. Fifteen (n = 15) patients with non-bulky cervical tumors were planned in Pinnacle 3 with a Varian Novalis Tx (HD120 MLC) using 6 and 10 MV photons with the following techniques: (1) IMRT with 10 non-coplanar beams (2) dual, coplanar 358° VMAT arcs (4° spacing), and (3) triple, non-coplanar VMAT arcs. Treatment volumes and dose prescriptions were segmented according to University of Texas Southwestern (UTSW) Phase II study. All plans were normalized such that 98% of the planning target volume (PTV) received 28 Gy (4 fractions). For the PTV, the following metrics were evaluated: homogeneity index, conformity index, D 2cc , D mean , D max , and dose fall-off parameters. For the organs at risk (OARs), D 2cc , D 15cc , D 0.01cc , V 20 , V 40 , V 50 , V 60 , and V 80 were evaluated for the bladder, bowel, femoral heads, rectum, and sigmoid. Statistical differences were evaluated using a Friedman test with a significance level of 0.05. To model dose fall-off, expanding 2-mm-thick concentric rings were created around the PTV, and doses were recorded. Statistically significant differences (p < 0.05) were noted in the dose fall-off when using 10 MV and VMAT 3-arc , as compared with IMRT. VMAT 3-arc improved the bladder V 40 , V 50 , and V 60 , and the bowel V 20 and V 50 . All fitted regressions had an R 2  ≥ 0.98. For cervical SBRT plans, a VMAT 3-arc approach offers a steeper dose fall-off outside of the target volume. Faster dose fall-off was observed in smaller targets as opposed to medium and large targets, denoting that OAR sparing is dependent on target size. These improvements are further pronounced with the use of 10-MV photons., (Published by Elsevier Inc.)

Immobilization devices serve several purposes in radiation oncology including improved positional reproducibility and decreased patient movement. If immobilization device beam attenuation is unaccounted for in the treatment planning process, planning target volume (PTV) coverage can be compromised. A retrospective case study was performed to evaluate beam attenuation from head and neck (HN) immobilization devices in volumetric-modulated arc therapy using the Eclipse treatment planning system and the Anisotropic Analytical Algorithm. Three facilities retrospectively evaluated 15 patients with various HN carcinomas. A test plan was created from each patient's existing plan in Eclipse to include immobilization devices in the dose calculation. Plan comparisons were performed using dose-volume histograms, which assessed the maximum dose, percentage of the PTV that received 95% of the prescription dose (V 95 ), and dose covering 100% of the PTV (D 100 ). The test plan normalization values were then adjusted to match the original PTV coverage. The maximum dose difference calculated ranged from 0.3% to 4.1%. The absolute difference in V 95 coverage between the HN and the test plans ranged from 0.4% to 2.3%. The difference in the D 100 was more statistically significant, reporting a range of 1.2% to 71.4%. Finally, to achieve the same PTV coverage as observed in the HN plan, an adjustment to the normalization value was needed, which required a change ranging from 0.1 to 7.7. Attenuation from immobilization devices, when unaccounted for, can cause a misrepresentation of the dose delivered to the PTV. It is not a standardized practice among institutions to include immobilization devices within the body contour for dose calculations. However, with the increasing use of volumetric-modulated arc therapy for treatment of the HN region, precision is of the utmost importance, and inclusion of immobilization devices should be standardized., (Copyright © 2017 American Association of Medical Dosimetrists. Published by Elsevier Inc. All rights reserved.)

Introduction: With the advent of complex treatment techniques like volumetric modulated arc therapy, there has been increasing interest in treatment planning technologies aimed at reducing planning time. One of these such technologies is auto-planning, which is an automated planning module within Pinnacle 3 . This study seeks to retrospectively evaluate the dosimetric quality of auto-planning-derived treatment plans as they compare to manual plans for intact prostate, prostate and lymph nodes, and brain treatment sites., Materials and Methods: Previous clinical plans were used to generate site-specific auto-planning templates. These templates were used to compare the 3 evaluated treatment sites. Plans were replanned using auto-planning and compared to the clinically delivered plans. For the planning target volume, the following metrics were evaluated: homogeneity index, conformity index, D 2cc , D mean , D 2% , D 98%, and multiple dose fall-off parameters. For the organs at risk, D 2cc , D mean , and organ-specific clinical metrics were evaluated. Statistical differences were evaluated using a Wilcoxon paired signed-rank test with a significance level of 0.05. Statistically significant ( P < 0.05) differences were noted in organs at risk sparing., Results: For the prostate, there was as much as 6.8% reduction in bladder D mean and 23.5% reduction in penile bulb D mean . For the prostate + lymph nodes, decreases in D mean values ranging from 4.1% in the small bowel to 22.3% in the right femoral head were observed. For brain, significant improvements were observed in D max and D mean to most organs at risk., Conclusion: Our study showed improved organs at risk sparing in most organs while maintaining planning target volume coverage. Overall, auto-planning can generate plans that delivered the same target coverage as the clinical plans but offered significant reductions in mean dose to organs at risk.

Purpose: The purpose of this study was to dosimetrically compare 6- and 10-MV photon beam energies in high-risk prostate cancer patients of various body habitus using a volumetric modulated arc therapy (VMAT) radiation delivery technique. The objectives of the study were to evaluate whether dosimetric differences exist and to investigate whether differences are dependent on patient body habitus., Methods and Materials: Forty patients with various body habitus who had previously received treatment to the prostate and pelvic lymph nodes with VMAT techniques were chosen. Patients were planned in the Pinnacle(3) treatment planning system with double or triple SmartArc plans with 6- and 10-MV photon energies. All patients were optimized with the same planning objectives and normalized such that 95% of the planning target volume (PTV) received the prescription dose. Patients were evaluated for PTV and organ at risk (OAR) parameters for the bladder, rectum, small bowel, penile bulb, and sigmoid colon. Metrics used for comparison were D2%, D98%, homogeneity, conformity, and dose falloff for the PTV and D(2%), D(mean), V(80%), V(60%), and V(40%) for OARs. Statistical differences were evaluated with a paired-sample Wilcoxon signed rank test with a significance level of .05., Results: For the PTV, there were no statistically significant differences in D(mean), D(2cc), conformation number, and homogeneity index values, but the dose falloff parameters, R50 and R25, showed a median improvement of 6.7% (P<.01) and 6.2% (P<.01), respectively, with 10 MV. A correlation between patient anterior-posterior distance (d(AP)) and percentage reduction in R50 of 0.436% per centimeter (P<.01) was determined. For OARs, statistically significant reductions in dose metrics were found in the small bowel and bladder, but increases in the D(2cc) of 3.5% in the penile bulb (P<.01) and 0.2% in the rectum (P=.02) were shown with 10 MV. The use of 10 MV also demonstrated a statistically significant reduction in the total number of monitor units of 15.9% (P<.01) compared with 6 MV., Conclusions: The study showed that 10 MV provides a faster dose falloff than 6 MV for patients whose prostate and pelvic lymph nodes are treated using a VMAT technique irrespective of body habitus; however, the improvement in dose falloff is dependent on body habitus and increases as the patient body habitus increases., (Copyright © 2015 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.)

A Monte Carlo model of the Novalis Tx linear accelerator equipped with high-definition multileaf collimator (HD-120 HD-MLC) was commissioned using ionization chamber measurements in water. All measurements in water were performed using a liquid filled ionization chamber. Film measurements were made using EDR2 film in solid water. Open rectangular fields defined by the jaws or the HD-MLC were used for comparison against measurements. Furthermore, inter- and intraleaf leakage calculated by the Monte Carlo model was compared against film measurements. The statistical uncertainty of the Monte Carlo calculations was less than 1% for all simulations. Results for all regular field sizes show an excellent agreement with commissioning data (percent depth-dose curves and profiles), well within 1% of difference in the relative dose and 1 mm distance to agreement. The computed leakage through HD-MLCs shows good agreement with film measurements. The Monte Carlo model developed in this study accurately represents the new Novalis Tx Varian linac with HD-MLC and can be used for reliable patient dose calculations.

Purpose: The feasibility of intensity modulated brachytherapy (IMBT) to improve dose conformity for irregularly shaped targets has been previously investigated by researchers by means of using partially shielded sources. However, partial shielding does not fully explore the potential of IMBT. The goal of this study is to introduce the concept of three dimensional (3D) intensity modulated brachytherapy and solve two fundamental issues regarding the application of 3D IMBT treatment planning: The dose calculation algorithm and the inverse treatment planning method., Methods: A 3D IMBT treatment planning system prototype was developed using the MATLAB platform. This system consists of three major components: (1) A comprehensive IMBT source calibration method with dosimetric inputs from Monte Carlo (EGSnrc) simulations; (2) a "modified TG-43" (mTG-43) dose calculation formalism for IMBT dosimetry; and (3) a physical constraint based inverse IMBT treatment planning platform utilizing a simulated annealing optimization algorithm. The model S700 Axxent electronic brachytherapy source developed by Xoft, Inc. (Fremont, CA), was simulated in this application. Ten intracavitary accelerated partial breast irradiation (APBI) cases were studied. For each case, an "isotropic plan" with only optimized source dwell time and a fully optimized IMBT plan were generated and compared to the original plan in various dosimetric aspects, such as the plan quality, planning, and delivery time. The issue of the mechanical complexity of the IMBT applicator is not addressed in this study., Results: IMBT approaches showed superior plan quality compared to the original plans and tht isotropic plans to different extents in all studied cases. An extremely difficult case with a small breast and a small distance to the ribs and skin, the IMBT plan minimized the high dose volume V200 by 16.1% and 4.8%, respectively, compared to the original and the isotropic plans. The conformity index for the target was increased by 0.13 and 0.04, respectively. The maximum dose to the skin was reduced by 56 and 28 cGy, respectively, per fraction. Also, the maximum dose to the ribs was reduced by 104 and 96 cGy, respectively, per fraction. The mean dose to the ipsilateral and contralateral breasts and lungs were also slightly reduced by the IMBT plan. The limitations of IMBT are the longer planning and delivery time. The IMBT plan took around 2 h to optimize, while the isotropic plan optimization could reach the global minimum within 5 min. The delivery time for the IMBT plan is typically four to six times longer than the corresponding isotropic plan., Conclusions: In this study, a dosimetry method for IMBT sources was proposed and an inverse treatment planning system prototype for IMBT was developed. The improvement of plan quality by 3D IMBT was demonstrated using ten APBI case studies. Faster computers and higher output of the source can further reduce plan optimization and delivery time, respectively.