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Aims: This study evaluated the influence of high dose (HD) vertex numbers and its placement on equivalent uniform dose (EUD) and peak-to-valley dose ratio (PVDR) in lattice radiotherapy (LRT). Settings and Design: One hundred and eighty-eight RapidArc (RA) plans were created for a cohort of 15 patients. Materials and Methods: RA plans were created with zero to eight HD vertices to analyze their relationship with EUD. Eight lattices were systematically and optimally placed (by avoiding proximity to organs at risks [OARs]) to study the impact of vertex placement. Variations in PVDR were assessed using PVDR1 (mean dose to HD vertices by the difference of mean doses to planning target volume [PTV] and HD vertices) and PVDR2 (D10/D90 of PTV in composite plans) across 38 RA plans with HD vertex doses of 9 Gy, 12 Gy, 15 Gy, and 18 Gy. PVDR3 (product of PVDR1 and PVDR2) was evaluated for its variation with peak dose. Statistical Analysis Used: Hypothesis testing between vertex placements was performed using a two-tailed Student’s t-test. Results: EUD values ranged from 32.88 Gy to 40.63 Gy. In addition, statistical analysis revealed significant associations (P = 0.0074) between the placement patterns of HD vertices, both in systematic and optimized arrangements. The PVDR and D10/D90 product values were 1.6, 1.8, 2.1, and 2.3 for peak doses of 9 Gy, 12 Gy, 15 Gy, and 18 Gy, respectively. Conclusions: The addition of one HD vertex increased EUD, emphasizing the impact of individual vertex increments on outcomes. Systematic and optimized vertex placements enhance EUD, with optimized placement yielding better doses to PTV and OARs. PVDR3 offers superior dose reporting for LRT compared to PVDR1 and PVDR2.

Purpose: To evaluate the dosimetric, radiobiological, and toxicity differences between different cylinder diameters (d) in high-dose-rate three-dimensional computed-tomography-guided vaginal brachytherapy (VBT) for early-stage endometrial cancer (EC). Methods: From January 2019 to January 2024, postoperative EC patients treated with exclusive VBT using cylinders were classified by the cylinder diameter (d ≤ 2.6 cm: small-size; d ≥ 3.0 cm: large-size) and matched according to 1:2 propensity score matching. Vaginal clinical target volume (CTV) was a 3-mm expansion around the cylinder surface. Dosimetric parameters in equivalent dose in 2 Gy (EQD2) (α/β = 3 Gy) and equivalent uniform dose (EUD) of vaginal_CTV and organs at risk (OARs) were evaluated. Urinary, gastrointestinal, and vaginal toxicities were assessed using CTCAE v5.0. Results: After matching, 132 patients (small-size: 44; large-size: 88) were analyzed. For vaginal_CTV, the small-size group had higher doses to 2%, 5%, 0.1 cc, 1 cc, and 2 cc of the volume (D2, D5, D0.1 cc, D1cc, and D2cc) than the large-size group while lower doses to the 95%, 98%, and 100% volume (D95, D98, and D100). The D2cc and D5cc of bladder and all dosimetric parameters of rectum were smaller in the small-size group. The EUD of vaginal_CTV, bladder, and rectum showed no significant differences. No significant differences in toxicities were found within the median follow-up of 26.8 months. Conclusion: Cylinders with smaller diameters produced more nonuniform dose distributions in the target and delivered lower doses to bladder and rectum than large-size cylinders. However, the dosimetric differences did not translate into significant differences of radiobiological parameters or outcomes. [ABSTRACT FROM AUTHOR]

Aims: This study evaluated the influence of high dose (HD) vertex numbers and its placement on equivalent uniform dose (EUD) and peak-to-valley dose ratio (PVDR) in lattice radiotherapy (LRT). Settings and Design: One hundred and eighty-eight RapidArc (RA) plans were created for a cohort of 15 patients. Materials and Methods: RA plans were created with zero to eight HD vertices to analyze their relationship with EUD. Eight lattices were systematically and optimally placed (by avoiding proximity to organs at risks [OARs]) to study the impact of vertex placement. Variations in PVDR were assessed using PVDR1 (mean dose to HD vertices by the difference of mean doses to planning target volume [PTV] and HD vertices) and PVDR2 (D10/D90 of PTV in composite plans) across 38 RA plans with HD vertex doses of 9 Gy, 12 Gy, 15 Gy, and 18 Gy. PVDR3 (product of PVDR1 and PVDR2) was evaluated for its variation with peak dose. Statistical Analysis Used: Hypothesis testing between vertex placements was performed using a two-tailed Student's t -test. Results: EUD values ranged from 32.88 Gy to 40.63 Gy. In addition, statistical analysis revealed significant associations (P = 0.0074) between the placement patterns of HD vertices, both in systematic and optimized arrangements. The PVDR and D10/D90 product values were 1.6, 1.8, 2.1, and 2.3 for peak doses of 9 Gy, 12 Gy, 15 Gy, and 18 Gy, respectively. Conclusions: The addition of one HD vertex increased EUD, emphasizing the impact of individual vertex increments on outcomes. Systematic and optimized vertex placements enhance EUD, with optimized placement yielding better doses to PTV and OARs. PVDR3 offers superior dose reporting for LRT compared to PVDR1 and PVDR2. [ABSTRACT FROM AUTHOR]

ObjectiveTo investigate the application of equivalent uniform dose (EUD) in intensity-modulated rotational radiotherapy and to explore optimization methods for improving the quality of modulated treatment plans. MethodsThe impact of the parameter a in the EUD formula on the characteristics of the EUD curve was analyzed using Python. Thirty cases of head and neck tumors, thoracic tumors, and pelvic tumors were randomly selected for treatment planning. Dose optimization for the target area and organs at risk were performed using a physics-based optimization approach or an optimization approach that combines physical constraints with the EUD function. The dose distribution and compliance with constraints of the two groups of plans were compared, while also observing the effect of different values of a on the planning outcomes. ResultsThe impact of the value of a on the changes in EUD curve characteristics was consistent with its impact on the results of EUD plan optimization. When −15≤a≤−5, the dose distribution in the target area was more uniform; when 1≤a≤7, the effect on the uniform dose and low-dose regions in organs at risk was more noticeable; when 10≤a≤30, the effect of constraining the high-dose regions in organs at risk was more pronounced, with the EUD for the target area and organs at risk exhibiting different expressions under different a values. The study also found that the target dose distribution and the protection of organs at risk in the EUD optimization group were better than those in the physical optimization group only. ConclusionThe a-value has a significant impact on the, the dose distribution in the target area and the organ at risk, providing a reference for the setting of a-value while using EUD to optimize the intensity modulation plan. The using of EUD optimization method can not only achieve excellent dose distribution in the target area, but also significantly reduce the normal tissue dose and the probability of complications, which has certain clinical application value.

Abstract Purpose To facilitate the use of quantitative modeling of biological effects in treatment planning by introducing a simpler function equivalent to the Lyman formula for calculating normal tissue complication probability (NTCP). Methods We first provide an approximation of the Lyman‐Kutcher‐Burman (LKB) formula using three parameters (n, m, TD50) as a function of equivalent uniform dose (EUD). The parameters for the new formula are defined in terms of the Lyman model's m and TD50. Conversely, m and TD50 are expressed in terms of the parameters of the new equation. The role of the Lyman volume‐effect parameter n remains unchanged from its role in the Lyman model. Results The new formula, which exhibits a sigmoidal shape, demonstrates symmetry about TD50, akin to the LKB model. The difference in NTCP between the two formulas is less than 0.1%. The parameters (n, m, TD50) are preserved through rigorous mathematical deduction and have been recalibrated to the tolerance data of Emani et al. using the proposed formula. This new model provides a better fit to these data than the model by Burman et al., which was fitted “by eye” rather than using statistical methods. Conclusion We have developed a formula that represents NTCP as a function of EUD, which proves to be potentially useful. The parameters derived in this study are mathematically robust and offer a superior fit to the data compared to previous efforts. Additionally, the new model fits brain data as well as, if not better than, the LKB model.

Purpose: To facilitate the use of quantitative modeling of biological effects in treatment planning by introducing a simpler function equivalent to the Lyman formula for calculating normal tissue complication probability (NTCP). Methods: We first provide an approximation of the Lyman‐Kutcher‐Burman (LKB) formula using three parameters (n, m, TD50) as a function of equivalent uniform dose (EUD). The parameters for the new formula are defined in terms of the Lyman model's m and TD50. Conversely, m and TD50 are expressed in terms of the parameters of the new equation. The role of the Lyman volume‐effect parameter n remains unchanged from its role in the Lyman model. Results: The new formula, which exhibits a sigmoidal shape, demonstrates symmetry about TD50, akin to the LKB model. The difference in NTCP between the two formulas is less than 0.1%. The parameters (n, m, TD50) are preserved through rigorous mathematical deduction and have been recalibrated to the tolerance data of Emani et al. using the proposed formula. This new model provides a better fit to these data than the model by Burman et al., which was fitted "by eye" rather than using statistical methods. Conclusion: We have developed a formula that represents NTCP as a function of EUD, which proves to be potentially useful. The parameters derived in this study are mathematically robust and offer a superior fit to the data compared to previous efforts. Additionally, the new model fits brain data as well as, if not better than, the LKB model. [ABSTRACT FROM AUTHOR]

Background: This study aimed to evaluate the dosimetric and radiobiological differences between 6MV flattened filter (FF) and flattening filter free (FFF) using volumetric modulated arc (VMAT) technique for head and neck (H&N) cancer patients. Materials and methods: Fifteen patients with H&N carcinoma were selected and treated with VMAT with FF (VMATFF) treatment plan. Retrospectively, additional VMAT treatment plans were developed using FFF beams (VMATFFF). Radiobiological parameters, such as equivalent uniform dose (EUD), tumor cure probability (TCP), and normal tissue complication probability (NTCP), were calculated using Niemierko's model for both VMATFF and VMATFFF. Correlation between dosimetric and radiobiological data were analyzed and compared. Results: The conformity index (CI) was 0.975 ± 0.014 (VMATFF) and 0.964 ± 0. 019 (VMATFFF) with p > 0.05. Statistically, there was an insignificant difference in the planning target volume (PTV) results for TCP (%) values, with values of 81.20 ± 0.88% (VMATFF) and 81.01 ± 0.92 (%) (VMATFF). Similarly, there was an insignificant difference in the EUD (Gy) values, which were 71.53 ± 0.33 Gy (VMATFF) and 71.46 ± 0.34 Gy (VMATFFF). The NTCP values for the spinal cord, left parotid, and right parotid were 6.54 X 10-07%, 8.04%, and 7.69%, respectively, in the case of VMATFF. For VMATFFF, the corresponding NTCP values for the spinal cord, parotids left, and parotid right were 3.09 x 10-07%, 6.57%, and 6.73%, respectively. Conclusion: The EUD and Mean Dose to PTV were strongly correlated for VMATFFF. An increased mean dose to the PTV and greater TCP were reported for the VMATFF, which can enhance the delivery of the therapeutic dose to the target. [ABSTRACT FROM AUTHOR]

Simple Summary: Online adaptive radiotherapy (ART) allows adaptation of the dose distribution to the anatomy captured with pre-adaptation imaging. Since ART is time-consuming, intra-fraction deformations can occur, antagonizing the advantages of ART. In this study from a prospective registry, the effects of intra-fraction deformations of the clinical target volume (CTV) on the equivalent uniform dose (EUDCTV) of focal radiotherapy of invasive bladder cancer were evaluated. Using margins of 5–10 mm around CTV, intra-fraction CTV-deformations reduced the effect of ART, lowering the 10th percentile of EUDCTV values per fraction from 101.1% to 63.2% of the prescribed dose. A strong fractionation effect was demonstrated, making the EUDCTV for a series of dose fractions insensitive to EUDCTV-declines per fractions. Two dose accumulation methods showed that EUDCTV values were >92.5% for all series of dose fractions, which could be explained by the small size and the spatial variations of cold spots. Our data showed that ART for each dose fraction is unnecessary. Online adaptive radiotherapy (ART) allows adaptation of the dose distribution to the anatomy captured by with pre-adaptation imaging. ART is time-consuming, and thus intra-fractional deformations can occur. This prospective registry study analyzed the effects of intra-fraction deformations of clinical target volume (CTV) on the equivalent uniform dose (EUDCTV) of focal bladder cancer radiotherapy. Using margins of 5–10 mm around CTV on pre-adaptation imaging, intra-fraction CTV-deformations found in a second imaging study reduced the 10th percentile of EUDCTV values per fraction from 101.1% to 63.2% of the prescribed dose. Dose accumulation across fractions of a series was determined with deformable-image registration and worst-case dose accumulation that maximizes the correlation of cold spots. A strong fractionation effect was demonstrated—the EUDCTV was above 95% and 92.5% as determined by the two abovementioned accumulation methods, respectively, for all series of dose fractions. A comparison of both methods showed that the fractionation effect caused the EUDCTV of a series to be insensitive to EUDCTV-declines per dose fraction, and this could be explained by the small size and spatial variations of cold spots. Therefore, ART for each dose fraction is unnecessary, and selective ART for fractions with large inter-fractional deformations alone is sufficient for maintaining a high EUDCTV for a radiotherapy series. [ABSTRACT FROM AUTHOR]

Grid radiotherapy is one of the treatment techniques applied to treat patients with advanced bulky tumors. Purpose: This study aims to estimate the difference in biological and dosimetric parameters of the grid radiotherapy technique for the treatment of bulky head and neck (H and N) tumors and compare it with conventional conformal radiotherapy. Subjects and Methods: Three-dimensional conformal and grid radiotherapy were designed by the Monaco treatment planning system (TPS). Eight bulky tumors of (H and N) cases were selected, using a single fraction 15–20 Gy. Dose-volume histogram of the tumors and organs at risk (OARs) used to calculate the equivalent uniform dose (EUD) (Gy) by Matlab program. Furthermore, dosimetric parameters of the tumors from the TPS were compared for two techniques (grid radiotherapy and the conventional conformal radiotherapy). Results: Grid attained a lower EUD (Gy) in tumors and OARs as compared to conformal therapy, as Grid principle protects about half of the tumor area from the radiation leads to less coverage of the tumor. Also, where OARs in closed with tumors and the shielding by multi-leaf (1 cm) were more effective than other techniques, lead to a decrease of radiobiological values according to its definition by Niemierko. Radiobiological results showed significant differences between the two methods, and dosimetric data obtained by the TPS for tumours for two plans were P < 0.05. Conclusions: The grid plan achieves lower values of EUDs than the conformal technique for OARs. Hence, it achieves more sparing and fewer complications for these organs.

Abstract Objective The aim of this study was to investigate the normal tissue complication probability (NTCP) for parotid gland of ca tongue patients from two different radiobiological models and to establish a dosimetric validity. Methods Lyman–Kutcher–Burman (LKB) model and linear quadratic (LQ) model were considered for determination of NTCP and tolerance dose (TD5/5 and TD50/5) for the parotid gland of 67 number of ca tongue patients who were treated with the volumetric arc therapy (VMAT) technique. An in‐house developed software on Excel (VBA) was used for this study. Results The equivalent uniform dose (EUD) was linearly proportional to the effective volume (veff) for parotid glands and there was a strong correlation between EUD and veff. At EUD = 46 to 47 Gy, the NTCP of parotid was 0.5 for both the models. The tolerance doses, TD5/5 (veff) and TD50/5 (veff) were exponentially reduced with increase of veff for LKB model; whereas these parameters were volume‐independent in the LQ model. TD5/5 (veff) and TD50/5 (veff) were 31.98 Gy and 45.98 Gy respectively for all 67 patients in the LQ model. Below TD50/5, NTCP of LKB model was less than the NTCP , calculated from LQ model. Conclusion One may consider radiobiological LQ model for estimation of clinical tolerance dose for OARs. Due to lack of clinical data, there are inaccuracy in determination of NTCP from LQ model. If sufficient number of tolerance data for partial volumes are available, the prediction of NTCP would be more confident.

The normal brain is an important dose-limiting organ for brain cancer patients undergoing radiotherapy. This study aims to develop a model to calculate photon isoeffective doses (D I s o E) to normal brain that can explain the incidence of grade 2 or higher somnolence syndrome (SS ⩾ 2) after Boron Neutron Capture Therapy (BNCT). A D I s o E model was constructed to find the reference photon dose that equals the Normal Tissue Complication Probability (NTCP) of the absorbed dose from BNCT. Limb paralysis rates from the rat spinal cord model exposed to conventional or BNCT irradiation were used to determine model parameters. NTCP expressions for both irradiations were constructed based on Lyman's model accordingly. D I s o E values were calculated for BNCT treatments performed in Finland and USA. An equivalent uniform dose (EUD) based on peak and average whole-brain doses and treatment fields was also introduced. Combining D I s o E and EUD models, a dose–response curve for SS ⩾ 2 in BNCT patients was constructed and compared to conventional radiotherapy outcomes. The D I s o E model reveals higher than expected photon-equivalent doses in the brain, indicating the need to modify standard dose calculation methods. Neither peak dose nor average whole-brain dose alone predicts SS ⩾ 2 development. However, the dose–response curve derived from combining D I s o E and EUD models effectively explains the incidence of SS ⩾ 2 after BNCT. The introduced D I s o E and EUD models predict the incidence of somnolence syndrome after BNCT. The first dose–response relationship for SS ⩾ 2 derived entirely from brain tumour patients treated with BNCT, consistent with photon radiotherapy responses, is presented. • Novel model to calculate photon isoeffective doses (DIsoE) in BNCT for normal brain. • Evidence of normal brain dose underestimation in BNCT clinical practice. • An EUD model based on peak and average whole-brain doses and treatment fields. • Suitability of DIsoE and EUD models to explain the incidence of SS ⩾ 2 after BNCT. • First dose–response relationship for SS ⩾ 2 from BNCT-treated brain tumour patients. [ABSTRACT FROM AUTHOR]

Introduction: The number of beams used in a Radiotherapy (RT) plan effects the overall quality of the plan and hence the treatment. The inclusion of radiobiological concepts in finding the optimum number of beams for a particular planning technique has the potential to provide a step ahead of the routine clinical practice where clinical decisions are more dependent on the physical dose parameters. Aim: To optimise the number of beams for Intensity Modulated Radiotherapy (IMRT) plan based on Tumour Control Probability (TCP) and Normal Tissue Complication Probability (NTCP) biological parameters. Materials and Methods: This retrospective study was done on 30 patients with pituitary macro-adenoma who underwent radiotherapy with a prescribed dose of 50.4 Gy in 28 fractions in Delhi State Cancer Institutes, Delhi, India from December 2012 to August 2018. The study data was collected and analysed between June 2018 and April 2020. These patients were treated with step and shoot IMRT technique on ONCORTM Expression linear accelerator (Siemens Healthineers, USA). But, the number of beams used to deliver IMRT plans were different as decided by the medical physicist and hence planner dependent rather than the disease. Being a centrally located disease, a symmetric beam arrangement was adopted for IMRT planning. For dosimetric comparison, three IMRT plans with five, seven, and nine equispaced beams were generated in Monaco treatment planning system for each patient and thus, a total of 90 IMRT plans were created and evaluated. For fair comparison, same IMRT planning parameters were utilized in all three plans of each patient. Monte Carlo (MC) dose calculation algorithm was used for all the plans. Resulting Cumulative Dose Volume Histograms (CDVHs) were exported to MATLAB, where these cDVHs were processed as per Niemierko's radiobiological model to calculate the values of TCP and NTCP based on the Equivalent Uniform Dose (EUD). After this, the analysis of variance, ANOVA test was conducted over the resulting values of EUD, TCP, and NTCP to assess the difference of quality among plans having different beam arrangements at 0.05 level of significance. Results: The mean tumour control probability (TCP) for IMRT plans with seven and nine beams were found to be 89.0±0.8% and 89.1±0.9% respectively for planning target volume (PTV). These values were not significantly different from each other. However, the mean TCP value for IMRT plans with five beams was found to be 88.4±1.1% for PTV. Further, this TCP value was proved to be significantly lower as compared to IMRT plans with seven and nine beams with a p-value of 0.008 and 0.004 respectively. On the other hand, the mean Normal Tissue Complication Probability (NTCP) was assessed to be less than 1% for all critical organs irrespective of the beam arrangement, indicating almost no probability of radiation induced toxicity in any of the organ. Conclusion: This study concludes that the plan efficiency can be improved by using optimum number of beams for IMRT planning of pituitary adenoma. [ABSTRACT FROM AUTHOR]

Grid radiotherapy is one of the treatment techniques applied to treat patients with advanced bulky tumors. Purpose: This study aims to estimate the difference in biological and dosimetric parameters of the grid radiotherapy technique for the treatment of bulky head and neck (H and N) tumors and compare it with conventional conformal radiotherapy. Subjects and Methods: Three-dimensional conformal and grid radiotherapy were designed by the Monaco treatment planning system (TPS). Eight bulky tumors of (H and N) cases were selected, using a single fraction 15-20 Gy. Dose-volume histogram of the tumors and organs at risk (OARs) used to calculate the equivalent uniform dose (EUD) (Gy) by Matlab program. Furthermore, dosimetric parameters of the tumors from the TPS were compared for two techniques (grid radiotherapy and the conventional conformal radiotherapy). Results: Grid attained a lower EUD (Gy) in tumors and OARs as compared to conformal therapy, as Grid principle protects about half of the tumor area from the radiation leads to less coverage of the tumor. Also, where OARs in closed with tumors and the shielding by multi-leaf (1 cm) were more effective than other techniques, lead to a decrease of radiobiological values according to its definition by Niemierko. Radiobiological results showed significant differences between the two methods, and dosimetric data obtained by the TPS for tumours for two plans were P < 0.05. Conclusions: The grid plan achieves lower values of EUDs than the conformal technique for OARs. Hence, it achieves more sparing and fewer complications for these organs. [ABSTRACT FROM AUTHOR]

Background and purpose: Microbeam radiotherapy (MRT) is a preclinical concept in radiation oncology with arrays of alternating micrometer-wide high-dose peaks and low-dose valleys. Experiments demonstrated a superior normal tissue sparing at similar tumor control rates with MRT compared to conventional radiotherapy. Possible clinical applications are currently limited to large third-generation synchrotrons. Here, we investigated the line-focus X-ray tube as an alternative microbeam source. Materials and methods: We developed a concept for a high-voltage supply and an electron source. In Monte Carlo simulations, we assessed the influence of X-ray spectrum, focal spot size, electron incidence angle, and photon emission angle on the microbeam dose distribution. We further assessed the dose distribution of microbeam arc therapy and suggested to interpret this complex dose distribution by equivalent uniform dose. Results: An adapted modular multi-level converter can supply high-voltage powers in the megawatt range for a few seconds. The electron source with a thermionic cathode and a quadrupole can generate an eccentric, high-power electron beam of several 100 keV energy. Highest dose rates and peak-to-valley dose ratios (PVDRs) were achieved for an electron beam impinging perpendicular onto the target surface and a focal spot smaller than the microbeam cross-section. The line-focus X-ray tube simulations demonstrated PVDRs above 20. Conclusion: The line-focus X-ray tube is a suitable compact source for clinical MRT. We demonstrated its technical feasibility based on state-of-the-art high-voltage and electron-beam technology. Microbeam arc therapy is an effective concept to increase the target-to-entrance dose ratio of orthovoltage microbeams.

To study dosimetric effects of leaf positioning errors (LPEs) of the Halcyon(2.0) dual-layer MLC on the long-course chemoradiotherapy (LCCRT) with 45∼50.4 Gy in 25∼28 fractions for rectal cancer. Nine Halcyon(2.0)-based LCCRT plans of rectal cancer were retrospectively involved. Four types of LPEs were introduced: (1) Uniformly distributed dual-layer random LPEs (Dual-R); (2) Proximal-layer systemic LPEs (P-S); (3) Distal-layer systemic LPEs (D-S); (4) Dual-layer systemic LPEs (Dual-S). The sensitivities of D 98% , D 2% and the Equivalent Uniform Dose (EUD) of PTV to various LPEs were investigated as well as varying ranges of EUDs of OARs. The sensitivities of D 98% and EUD of PTV to Dual-R was -0.65%/mm and -0.38%/mm; the sensitivities of both indices to the P-S and D-S were similar to each other, ranging from 1.92%/mm to 2.87%/mm; both indices were more sensitive to the Dual-S and values were 4.97%/mm and 3.84%/mm respectively. The EUD changes of the bladder, and left and right femoral heads were from -13.23% to 14.82%. Single-side systemic LPEs lower than 0.7 mm are acceptable for Halcyon(2.0)-based LCCRT, while dual-layer systemic LPEs lower than 0.4 mm are acceptable, considering relative changes of 2% for D 98% of PTV as threshold., Competing Interests: Conflicts of Interest The author declares no conflicts of interest., (Copyright © 2024 American Association of Medical Dosimetrists. Published by Elsevier Inc. All rights reserved.)

PurposeTo study the impact of dose distribution on volume-effect parameter and predictive ability of equivalent uniform dose (EUD) model, and to explore the improvements.Methods and MaterialsThe brains of 103 nasopharyngeal carcinoma patients treated with IMRT were segmented according to dose distribution (brain and left/right half-brain for similar distributions but different sizes; VD with different D for different distributions). Predictive ability of EUDVD (EUD of VD) for radiation-induced brain injury was assessed by receiver operating characteristics curve (ROC) and area under the curve (AUC). The optimal volume-effect parameter a of EUD was selected when AUC was maximal (mAUC). Correlations between mAUC, a and D were analyzed by Pearson correlation analysis. Both mAUC and a in brain and half-brain were compared by using paired samples t-tests. The optimal DV and VD points were selected for a simple comparison.ResultsThe mAUC of brain/half-brain EUD was 0.819/0.821 and the optimal a value was 21.5/22. When D increased, mAUC of EUDVD increased, while a decreased. The mAUC reached the maximum value when D was 50–55 Gy, and a was always 1 when D ≥55 Gy. The difference of mAUC/a between brain and half-brain was not significant. If a was in range of 1 to 22, AUC of brain/half-brain EUDV55 Gy (0.857–0.830/0.845–0.830) was always larger than that of brain/half-brain EUD (0.681–0.819/0.691–0.821). The AUCs of optimal dose/volume points were 0.801 (brain D2.5 cc), 0.823 (brain V70 Gy), 0.818 (half-brain D1 cc), and 0.827 (half-brain V69 Gy), respectively. Mean dose (equal to EUDVD with a = 1) of high-dose volume (V50 Gy–V60 Gy) was superior to traditional EUD and dose/volume points.ConclusionVolume-effect parameter of EUD is variable and related to dose distribution. EUD with large low-dose volume may not be better than simple dose/volume points. Critical-dose-volume EUD could improve the predictive ability and has an invariant volume-effect parameter. Mean dose may be the case in which critical-dose-volume EUD has the best predictive ability.

Purpose: To study the impact of dose distribution on volume-effect parameter and predictive ability of equivalent uniform dose (EUD) model, and to explore the improvements. Methods and Materials: The brains of 103 nasopharyngeal carcinoma patients treated with IMRT were segmented according to dose distribution (brain and left/right half-brain for similar distributions but different sizes; V D with different D for different distributions). Predictive ability of EUDVD (EUD of V D) for radiation-induced brain injury was assessed by receiver operating characteristics curve (ROC) and area under the curve (AUC). The optimal volume-effect parameter a of EUD was selected when AUC was maximal (mAUC). Correlations between mAUC, a and D were analyzed by Pearson correlation analysis. Both mAUC and a in brain and half-brain were compared by using paired samples t -tests. The optimal D V and V D points were selected for a simple comparison. Results: The mAUC of brain/half-brain EUD was 0.819/0.821 and the optimal a value was 21.5/22. When D increased, mAUC of EUDVD increased, while a decreased. The mAUC reached the maximum value when D was 50–55 Gy, and a was always 1 when D ≥55 Gy. The difference of mAUC/ a between brain and half-brain was not significant. If a was in range of 1 to 22, AUC of brain/half-brain EUDV55 Gy (0.857–0.830/0.845–0.830) was always larger than that of brain/half-brain EUD (0.681–0.819/0.691–0.821). The AUCs of optimal dose/volume points were 0.801 (brain D2.5 cc), 0.823 (brain V70 Gy), 0.818 (half-brain D1 cc), and 0.827 (half-brain V69 Gy), respectively. Mean dose (equal to EUDVD with a = 1) of high-dose volume (V50 Gy–V60 Gy) was superior to traditional EUD and dose/volume points. Conclusion: Volume-effect parameter of EUD is variable and related to dose distribution. EUD with large low-dose volume may not be better than simple dose/volume points. Critical-dose-volume EUD could improve the predictive ability and has an invariant volume-effect parameter. Mean dose may be the case in which critical-dose-volume EUD has the best predictive ability. [ABSTRACT FROM AUTHOR]

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Objective: The aim of this study was to investigate the normal tissue complication probability (NTCP) for parotid gland of ca tongue patients from two different radiobiological models and to establish a dosimetric validity. Methods: Lyman–Kutcher–Burman (LKB) model and linear quadratic (LQ) model were considered for determination of NTCP and tolerance dose (TD5/5 and TD50/5) for the parotid gland of 67 number of ca tongue patients who were treated with the volumetric arc therapy (VMAT) technique. An in‐house developed software on Excel (VBA) was used for this study. Results: The equivalent uniform dose (EUD) was linearly proportional to the effective volume (veff) for parotid glands and there was a strong correlation between EUD and veff. At EUD = 46 to 47 Gy, the NTCP of parotid was 0.5 for both the models. The tolerance doses, TD5/5 (veff) and TD50/5 (veff) were exponentially reduced with increase of veff for LKB model; whereas these parameters were volume‐independent in the LQ model. TD5/5 (veff) and TD50/5 (veff) were 31.98 Gy and 45.98 Gy respectively for all 67 patients in the LQ model. Below TD50/5, NTCP of LKB model was less than the NTCP , calculated from LQ model. Conclusion: One may consider radiobiological LQ model for estimation of clinical tolerance dose for OARs. Due to lack of clinical data, there are inaccuracy in determination of NTCP from LQ model. If sufficient number of tolerance data for partial volumes are available, the prediction of NTCP would be more confident. [ABSTRACT FROM AUTHOR]

Purpose: To examine the equivalent uniform dose (EUD) formalism using the universal survival curve (USC) applicable to high-dose stereotactic body radiotherapy (SBRT).Materials and Methods: For nine non-small-cell carcinoma cell (NSCLC) lines, the linear-quadratic (LQ) and USC models were used to calculate the EUD of a set of hypothetical two-compartment tumor dose-volume histogram (DVH) models. The dose was varied by ±5%, ±10%, and ±20% about the prescription dose (60 Gy/3 fractions) to the first compartment, with fraction volume varying from 1% and 5% to 30%. Clinical DVHs of 21 SBRT treatments of NSCLC prescribed to the 70-83% isodose lines were also considered. The EUD of non-standard SBRT dose fractionation (EUDSBRT) was further converted to standard fractionation of 2 Gy (EUDCFRT) using the LQ and USC models to facilitate comparisons between different SBRT dose fractionations. Tumor control probability (TCP) was then estimated from the LQ- and USC-EUDCFRT.Results: For non-standard SBRT fractionation, the deviation of the USC- from the LQ-EUDSBRT is largely limited to 5% in the presence of dose variation up to ±20% to fractional tumor volume up to 30% in all NSCLC cell lines. Linear regression with zero constant yielded USC-EUDSBRT = 0.96 × LQ-EUDSBRT (r2 = 0.99) for the clinical DVHs. Converting EUDSBRT into standard 2‑Gy fractions by the LQ formalism produced significantly larger EUDCFRT than the USC formalism, particularly for low [Formula: see text] ratios and large fraction dose. Simplified two-compartment DVH models illustrated that both the LQ- and USC-EUDCFRT values were sensitive to cold spot below the prescription dose with little volume dependence. Their deviations were almost constant for up to 30% dose increase above the prescription. Linear regression with zero constant yielded USC-EUDCFRT = 1.56 × LQ-EUDCFRT (r2 = 0.99) for the clinical DVHs. The clinical LQ-EUDCFRT resulted in median TCP of almost 100% vs. 93.8% with USC-EUDCFRT.Conclusion: A uniform formalism of EUD should be defined among the SBRT community in order to apply it as a single metric for dose reporting and dose-response modeling in high-dose-gradient SBRT because its value depends on the underlying cell survival model and the model parameters. Further investigations of the optimal formalism to derive the EUD through clinical correlations are warranted. [ABSTRACT FROM AUTHOR]

Introduction Proximity of organs at risk (OAR) hinders radiation dose escalation for the treatment of pancreatic cancer. To address this limitation, there is interest in protracted-fractionation (PF: 15 to 25 fractions) courses employing moderate hypofractionation (MHF: 3-4 Gy/fraction). However, there persists underdosing where tumor interfaces with OAR. The significance of compromised tumor coverage and dose heterogeneity on tumor control remains unknown. Here, we report our initial planning experience with PF-MHF in pancreatic cancer. Methods We retrospectively reviewed radiation courses for locally advanced or recurrent pancreatic cancer with a PF-MHF approach: 45 Gy in 25 fractions (1.8 Gy/fraction) to PTV with 75 Gy (3 Gy/fraction) as an integrated boost to the GTV. We reviewed dosimetric parameters for the GTV: percentage overlap with planning OAR volume (PRV-GTV overlap), D99.9%, D0.1cc, Dmean, V75Gy, and V60Gy. We also calculated the GTV's generalized equivalent uniform dose (gEUD) value using two different  a  values (-5 and -15). Lastly, we reoptimized two plans with two approaches: increasing gEUD or relaxing the maximum dose constraint. Results A total of 26 plans were included in our analysis: 14 locally advanced and 12 locally recurrent pancreatic cancer cases. While the D0.1cc median value was 81.7 Gy, target volume coverage was relatively low (V75Gy median 71%). Median gEUD were 71 Gy ( a = -5) and 62.8 Gy ( a = -15) and inversely correlated with PRV-GTV overlap. On reoptimized plans, both approaches yielded similar results, but an increase in target coverage and gEUD were seen only when there was limited PRV-GTV overlap. Conclusion Although radiation dose can be escalated within the GTV, there continues to be low coverage by the prescription dose, especially with high PRV-GTV overlap. Relaxing the maximum dose constraint in planning allows for meaningful improvement in tumor coverage in limited PRV overlap scenarios. Continued refinement of the PF-MHF approach is needed., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Johns Hopkins Institutional Review Board issued approval IRB00314418. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: Amol K. Narang declare(s) a grant from Nanocan. Payment to institution for research support. Amol K. Narang declare(s) a grant from Flavocure. Payment to institution for research support. Jeffrey Meyer declare(s) royalties from Springer. Jeffrey Meyer declare(s) royalties from UpToDate. Jeffrey Meyer declare(s) a grant from Boston Scientific. Payment to institution for research support. William T. Hrinivich declare(s) a grant from Varian Medical Systems. Research Grant to institution, 07/2023-06/2024 Payment to institution for research support. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Liu et al.)

With the improvement of mobile device performance, the requirement of equivalent dose description in intensity-modulated radiation therapy is increasing in mobile multimedia for healthcare. The emergence of mobile cloud computing will provide cloud servers and storage for intensity-modulated radiotherapy (IMRT) mobile applications, thus realizing visualized radiotherapy in a real sense. Equivalent uniform dose (EUD) is a biomedical indicator based on the dose measure. In this paper, the dose volume histogram is used to describe the dose distribution of different tissues in target and nontarget regions. The traditional definition of EUD, such as the exponential form and the linear form, has only a few parameters in the model for fast calculation. However, there is no close relationship between this traditional definition and the dose volume histogram. In order to establish the consistency between the EUD and the dose volume histogram, this paper proposes a novel definition of EUD based on the volume dose curve, called VD-EUD. By using a unique organic volume weight curve, it is easy to calculate VD-EUD for different dose distributions. In definition, different weight curves are used to represent the biological effects of different organs. For the target area, we should be more careful about those voxels with a low dose (cold point); thus, the weight curve is monotonically decreasing. While for the nontarget area, the curve is monotonically increasing. Furthermore, we present the curves for parallel, serial, and mixed organs of nontarget areas separately, and we define the weight curve form with only two parameters. Medical doctors can adjust the curve interactively according to different patients and organs. We also propose a fluence map optimization model with the VD-EUD constraint, which means that the proposed EUD constraint will lead to a large feasible solution space. We compare the generalized EUD (gEUD) and the proposed VD-EUD by experiments, which show that the VD-EUD has a closer relationship with the dose volume histogram. If the biological survival probability is equivalent to the VD-EUD, the feasible solution space would be large, and the target areas can be covered. By establishing a personalized organic weight curve, medical doctors can have a unique VD-EUD for each patient. By using the flexible and adjustable EUD definition, we can establish the VD-EUD-based fluence map optimization model, which will lead to a larger solution space than the traditional dose volume constraint-based model. The VD-EUD is a new definition; thus, we need more clinical testing and verification.

In current knowledge-based treatment planning for intensity-modulated radiation therapy (IMRT), 3-dimensional dosimetric goals are predicted to provide abundant and appropriate starting points for planning optimization, but considering there're uncertainties with those dose distribution predictions, how to tailor the objective function and constraints accordingly is quite a concern. Here, we represent a novel automatic treatment optimization method that is capable of making the most of dose distribution prediction meanwhile achieving its optimum as much as possible. On the foundation of an in-house organs-at-risk (OARs) dose distribution prediction model, we reformulate a traditional fluence map optimization (FMO) model by a predicted dose distribution-based objective, an equivalent uniform dose sparing for OARs and hard dose constraints for planning target volume (PTV). Feasibility and performance of the method is evaluated with 10 gynecology (GYN) cancer IMRT cases by comparing the plan quality of the generated to the original clinical ones, in the term of dose-volume-histogram (DVH) curves, dose distribution and detailed dosimetric endpoints. Results show plan quality improvement by our proposed method, with comparable PTV dose coverage but further dose sparing for OARs. Among 6 investigated OAR dosimetric endpoints, 4 of them are observed with significant improvement (P

Abstract Background For a given prescribed dose of radiotherapy, with the successive generations of dose calculation algorithms, more monitor units (MUs) are generally needed. This is due to the implementation of successive improvements in dose calculation: better heterogeneity correction and more accurate estimation of secondary electron transport contribution. More recently, there is the possibility to report the dose-to-medium, physically more accurate compared to the dose-to-water as the reference one. This last point is a recent concern and the main focus of this study. Methods In this paper, we propose steps for a general analysis procedure to estimate the dosimetric alterations, and the potential clinical changes, between a reference algorithm and a new one. This includes dosimetric parameters, gamma index, radiobiology indices based on equivalent uniform dose concept and statistics with bootstrap simulation. Finally, we provide a general recommendation on the clinical use of new algorithms regarding the dose prescription or dose limits to the organs at risks. Results The dosimetrical and radiobiological data showed a significant effect, which might exceed 5–10%, of the calculation method on the dose the distribution and clinical outcomes for lung cancer patients. Wilcoxon signed rank paired comparisons indicated that the delivered dose in MUs was significantly increased (> 2%) using more advanced dose calculation methods as compared to the reference one. Conclusion This paper illustrates and explains the use of dosimetrical, radiobiologcal and statistical tests for dosimetric comparisons in radiotherapy. The change of dose calculation algorithm may induce a dosimetric shift, which has to be evaluated by the physicists and the oncologists. This includes the impact on tumor control and on the risk of toxicity based on normal tissue dose constraints. In fact, the alteration in dose distribution makes it hard to keep exactly the same tumor control probability along with the same normal tissue complication probability.

The aim of this study is to investigate the robustness of our institutionally applied clinical target volume (CTV)-to-planning target volume (PTV) margins in cervical cancer patients in terms of an equivalent uniform dose (EUD) based on tumor control probability (TCP). We simulated target motion using 25 IMRT cervical cancer plans to demonstrate the effect of geometrical uncertainties on the EUD and TCP. The different components of the total geometrical uncertainties budget were estimated. The biological effects were compared by calculating the EUDs from the trial DVHs. The impact of geometric uncertainties was calculated as a percentage of the difference between 〖EUD〗_static and 〖EUD〗_motion, where the 〖EUD〗_static is the EUD calculated from the target DVHs and 〖EUD〗_motion is averaged, over a 1000 calculated EUDs for each of the analyzed IMRT treatment plans. The multivariate nonlinear regression was used to find the predicted difference between the static and motion EUD. The estimate of the systematic and random motion errors were Σ_(total(SI,LR,AP)) (mm)=(2.6; 2.5; 1.8) and σ_(total(SI,LR,AP)) (mm)=(3.4; 1.4; 3.4). For average 〈EUD〉_motion=44.3 Gy (over 25 patients) we have found a TCP decrease of about 1%, %(ΔTCP)≈1% for predefined PTV margin. According to the calculated EUD motion-distributions, for particular patients, the CTV does receive the prescribed EUD of 45 Gy. The predicted difference in EUD showed that our isotropic margin of 10 mm is large enough to absorb geometric uncertainties and ensure dose coverage of the moving CTV in the cervical cancer patients. [ABSTRACT FROM AUTHOR]

Purpose: To examine general dose–volume characteristics in Gamma Knife (GK) plans which may be associated with higher tumor control probability (TCP) and equivalent uniform dose (EUD) using characteristic curve sets. Methods: Two sets of dose–volume histograms (DVHs) were exported alongside an analytical purpose‐generated DVH: (a) single‐shot large collimator (8 or 16 mm) emulated with multiple shots of 4 mm collimator. (b) shot‐within‐shot (SWS) technique with isodose lines (IDLs) of 40–75%. TCP, average dose, EUD in single‐fraction (EUDT) and 2 Gy fractionated regimens (EUDR) were examined for trends with cumulative DVH (cDVH) shape as calculated using a linear‐quadratic cell survival model (α/β = 10.0 Gy, N0 = 1 × 106) with both α = 0.20 Gy−1 and α = 0.23 Gy−1. Results: Using α = 0.20 Gy−1 (α = 0.23 Gy−1), plans in the analytical set with higher shoulder regions had TCP, EUDT, EUDR increased by 180%, 5.9%, 10.7% (11.2%, 6.3%, 10.0%), respectively. With α = 0.20 Gy−1 (α = 0.23 Gy−1), plans with higher heels had TCP, EUDT, EUDR increased by 4.0%, <1%, <1% (0.6%, <1%, <1%), respectively. In emulating a 16 (8) mm collimator, 64 (12) shots of the small collimators were used. Plans based on small collimators had higher shoulder regions and, with α = 0.20 Gy−1 (α = 0.23 Gy−1), TCP, EUDT, EUDR was increased up to 351.4%, 5.0%, 8.8% (270.4%, 5.0%, 6.8%) compared with the single‐shot large collimator. Delivery times ranged from 10.2 to 130.3 min. The SWS technique used 16:8 mm collimator weightings ranging from 1:2 to 9.2:1 for 40–75% IDL. With α = 0.20 Gy−1 (α = 0.23 Gy−1), the 40% IDL plan had the highest shoulder with increased TCP, EUDT, EUDR by 130.7%, 9.6%, 17.1% (12.9%, 9.1%, 16.4%) over the 75% IDL plan. Delivery times ranged 6.9–13.8 min. Conclusions: The magnitude of the shoulder region characteristic to GK cDVHs may be used to rapidly identify superior plan among candidates. Practical issues such as delivery time may require further consideration. [ABSTRACT FROM AUTHOR]

Purpose: Targeted marrow irradiation (TMI) is an alternative conditioning regimen to total body irradiation (TBI) before bone marrow transplantation in hematologic malignancies. Intensity‐modulation methods of external beam radiation therapy are intended to permit significant organ sparing while maintaining adequate target coverage, improving the therapeutic ratio. This study directly compares the dose distributions to targets and organs at risk from TMI and TBI, both modalities conducted by general‐use medical linacs at our institution. Methods: TMI treatments were planned for 10 patients using multi‐isocentric feathered volumetric arc therapy (VMAT) plans, delivered by 6 MV photon beams of Elekta Synergy linacs. The computed tomography (CT) datasets used to obtain these plans were also used to generate dose distributions of TBI treatments given in the AP/PA extended‐field method. We compared dose distributions normalized to the same prescription for both plan types. The generalized equivalent uniform dose (gEUD) of Niemierko for organs and target volumes was used to quantify effective whole structure dose and dose savings. Results: For the clinical target volume (CTV), no significant differences were found in mean dose or gEUD, although the radical dose homogeneity index (minimum dose divided by maximum dose) was 31.7% lower (P = 0.002) and the standard deviation of dose was 28.0% greater (P = 0.027) in the TMI plans than in the TBI plans. For the TMI plans, gEUD to the lungs, brain, kidneys, and liver was significantly lower (P < 0.001) by 47.8%, 33.3%, 55.4%, and 51.0%, respectively. Conclusion: TMI is capable of maintaining CTV coverage as compared to that achieved in TBI, while significantly sparing organs at risk. Improvement on sparing organs at risk permits a higher prescribed dose to the target or the maximum number of times marrow conditioning may be delivered to a patient while maintaining similar typical tissue complication rates. [ABSTRACT FROM AUTHOR]

Copyright of Chinese Medical Equipment Journal is the property of Chinese Medical Equipment Journal Editorial Office and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

In this study, we intend to estimate the effects of normal tissue sparing between intensity modulated radiotherapy (IMRT) treatment plans generated with and without a dose volume (DV)-based physical cost function using equivalent uniform dose (EUD). Twenty prostate cancer patients were retrospectively selected for this study. For each patient, two IMRT plans were generated (i) EUD-based optimization with a DV-based physical cost function to control inhomogeneity (EUDWith DV) and (ii) EUD-based optimization without a DV-based physical cost function to allow inhomogeneity (EUDWithout DV). The generated plans were prescribed a dose of 72 Gy in 36 fractions to planning target volume (PTV). Mean dose, D30%, and D5%were evaluated for all organ at risk (OAR). Normal tissue complication probability was also calculated for all OARs using BioSuite software. The average volume of PTV for all patients was 103.02 ± 27 cm3. The PTV mean dose for EUDWith DVplans was 73.67 ± 1.7 Gy, whereas for EUDWithout DVplans was 80.42 ± 2.7 Gy. It was found that PTV volume receiving dose more than 115% of prescription dose was negligible in EUDWith DV plans, whereas it was 28% in EUDWithout DV plans. In almost all dosimetric parameters evaluated, dose to OARs in EUDWith DVplans was higher than in EUDWithout DVplans. Allowing inhomogeneous dose (EUDWithout DV) inside the target would achieve better normal tissue sparing compared to homogenous dose distribution (EUDWith DV). Hence, this inhomogeneous dose could be intentionally dumped on the high-risk volume to achieve high local control. Therefore, it was concluded that EUD optimized plans offer added advantage of less OAR dose as well as selectively boosting dose to gross tumor volume.

Purpose: Nowadays, most of the radiotherapy (RT) treatment planning systems (TPSs) uses dose or dose-volume (DV)-based cost functions for Intensity modulated radiation therapy (IMRT) fluence optimization. Recently, some of the TPSs incorporated biological-based cost function for IMRT optimization. Most of the previous studies compared IMRT plans optimized using biological-based and DV-based cost functions in two different TPSs. Hence, the purpose of the study is to compare equivalent uniform dose (EUD)-based and DV-based IMRT plans generated using the same TPS. Materials and Methods: Twenty patients with prostate cancer were retrospectively selected for this study. For each patient, two IMRT plans were generated using EUD-based cost function (EUD_TP) and DV-based cost (DV_Treatment Plan (TP)), respectively. The generated IMRT plans were evaluated using both physical and biological dose evaluation indices. Results: Biological-based plans ended up with a highly inhomogeneous target dose when compared to DV-based plans. For serial organs, Dnear-max or D2% (Gy) of EUD-based plans showed significant difference with DV-based plans (P = 0.003). For both rectum and bladder, there was a significant difference in mean dose and D30% (Gy) dose between EUD-based plans and DV-based plans. Conclusion: In this study, we decoupled the influence of optimization parameters from the potential use of EUD-based cost functions on plan quality by generating both plans in the same TPS. [ABSTRACT FROM AUTHOR]

In the forward intensity-modulated radiotherapy (FIMRT) technique of treatment planning, the isocenter cannot fulfill the requirements of the International Commission on Radiation Units and Measurements (ICRU) reference point. This study aimed to propose dose prescription points to be used in breast and head/neck cancer patients treated using the FIMRT technique. Two-hundred patients with head/neck (n = 100) and breast (n = 100) cancers were selected. Treatment plans involved using the FIMRT technique. The suggested reference points (SRPs) for dose prescription were placed at selected locations in the lateral neck site and the tangential site in breast and head/neck cancer patients, respectively. Next, doses at the SRPs (DSRPs) were compared to the planning treatment volume (PTV)-equivalent uniform dose (EUD) and mean dose in the PTV (Dmean) extracted from dose-volume histograms. The differences between DSRPs and Dmean for the PTVs were less than 2% in 78 cases and less than 1% in 28 cases. The DSRPs were comparable with the EUD in both types of PTVs; moreover, paired t test analyses indicated that the SRP doses and PTV EUD were statistically similar (p > 0.05). In 116 cases, the discrepancy between DSRP and EUD was less than 2% and less than 1% in 74 cases. The SRPs satisfy the ICRU requirement that the reference point dose should be clinically relevant and representative of the dose throughout the PTV. A consensus on the definition of the reference point is expected to lead to accurate inter-comparison between results from different treatment centers, facilitating the optimization of treatment procedures. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study is to evaluate the impact of normal tissue complication probability (NTCP)-based radiobiological models on the estimated risk for late radiation lung damages. The second goal is to propose a medical decision-making approach to select the eligible patient for particle therapy. Materials and methods: Fourteen pediatric patients undergoing cranio-spinal irradiation were evaluated. For each patient, two treatment plans were generated using photon and proton therapy with the same dose prescriptions. Late radiation damage to lung was estimated using three NTCP concepts: the Lyman-Kutcher-Burman, the equivalent uniform dose (EUD) and the mean lung dose according to the quantitative analysis of normal tissue effects in the clinic QUANTEC review. Wilcoxon paired test was used to calculate p-value. Results: Proton therapy achieved lower lung EUD (Gy). The average NTCP values were significantly lower with proton plans, p < .05, using the three NTCP concepts. However, applying the same TD50/5 using radiobiological models to compare NTCP from proton and photon therapy, the ΔNTCP was not a convincing method to measure the potential benefit of proton therapy. Late radiation pneumonitis estimated from the mean lung dose model correlated with QUANTEC data better. Conclusions: Treatment effectiveness assessed on NTCP reduction depends on radiobiological predictions and parameters used as inputs for in silico evaluation. Because estimates of absolute NTCP values from LKB and GN models are imprecise due to EUD ≪ TD50/5, a reduction of the EUD value with proton plans would better predict a reduction of dose/toxicity. The EUD concept appears as a robust radiobiological surrogate of the dose distribution to select the optimal patient’s plan. [ABSTRACT FROM AUTHOR]

Aim: To evaluate the impact of couch translational shifts on dose–volume histogram (DVH) and radiobiological parameters [tumour control probability (TCP), equivalent uniform dose (EUD) and normal tissue complication probability (NTCP)] of volumetric modulated arc therapy (VMAT) plans and to develop a simple and swift method to predict the same online, on a daily basis. Methods: In total, ten prostate patients treated with VMAT technology were selected for this study. The plans were generated using Eclipse TPS and delivered using Clinac ix LINAC equipped with a Millennium 120 multileaf collimator. In order to find the effect of systematic translational couch shifts on the DVH and radiobiological parameters, errors were introduced in the clinically accepted base plan with an increment of 1 mm and up to 5 mm from the iso-centre in both positive and negative directions of each of the three axis, x [right–left (R-L)], y [superior–inferior (S-I)] and z [anterior–posterior (A-P)]. The percentages of difference in these parameters (∆D, ∆TCP, ∆EUD and ∆NTCP) were analyzed between the base plan and the error introduced plans. DVHs of the base plan and the error plans were imported into the MATLAB software (R2013a) and an in-house MATLAB code was generated to find the best curve fitted polynomial functions for each point on the DVH, there by generating predicted DVH for planning target volume (PTV), clinical target volume (CTV) and organs at risks (OARs). Functions f(x, vj), f(y, vj) and f(z, vj) were found to represent the variation in the dose when there are couch translation shifts in R-L, S-I and A-P directions, respectively. The validation of this method was done by introducing daily couch shifts and comparing the treatment planning system (TPS) generated DVHs and radiobiological parameters with MATLAB code predicted parameters. Results: It was noted that the variations in the dose to the CTV, due to both systematic and random shifts, were very small. For CTV and PTV, the maximum variations in both DVH and radiobiological parameters were observed in the S-I direction than in the A-P or R-L directions. ∆V70 Gy and ∆V60 Gy of the bladder varied more due to S-I shift whereas, ∆V40 Gy, ∆EUD and ∆NTCP varied due to A-P shifts. All the parameters in rectum were most affected by the A-P shifts than the shifts in other two directions. The maximum percentage of deviation between the TPS calculated and MATLAB predicted DVHs of plans were calculated for targets and OARs and were found to be less than 0·5%. Conclusion: The variations in the parameters depend upon the direction and magnitude of the shift. The DVH curves generated by the TPS and predicted by the MATLAB showed good correlation. [ABSTRACT FROM AUTHOR]

Purpose To characterize the dosimetric impact of using different sizes of spherical applicators in Intrabeam™ Intraoperative Radiation Therapy (IB-IORT) to treat unicentric cancer lesions after breast-conserving lumpectomy. Methods Using the commissioned depth dose rates, the three-dimensional dosages of the 3.5, 4.0, 4.5, and 5.0 cm spherical applicators of the IB-IORT PRS400 machine were established. Five different cancer cell infiltration depths of unicentric breast lesions were formulated by a linearly declining cancer cell density distribution from the surgical surface. The equivalent uniform dose (EUD), which is the dosage of a homogeneous dose treatment for killing the same amount of cancer cells as IB-IORT in the same target volume, was then calculated using the modified linear quadratic model (MLQ). The radiobiological response of two types of cancer cell lines and three types of normal tissues in the TARGIT-A clinical trial of 20 Gy dose was estimated. The study was carried out for an acutely responding breast cancer cell line with an α/β ratio of 10 and a slow responding breast cancer cell line with an α/β ratio of 3.85, respectively. The cancer cell density at the surgical excision surface was assumed to be 0.01%, 0.1%, 1%, and 10%, respectively. The three types of normal tissue are radiosensitive, moderate radiosensitive, and radioresistant, respectively. The therapeutic ratio (TR), which was defined by a ratio between the survival fractions of normal tissue cells respectively in IB-IORT and in homogeneous dose treatments, was calculated. Results The EUDs are moderately dependent on the applicator size (increasing from 1 to 10% depending on the cancer infiltrating depth when increasing diameter by 0.5 cm), not on the cancer cell radiosensitivity (differing by less than 1.30% between two cancer cell lines), and not dependent on the cancer cell population density at the surgical excision surface (differing by 0% among the tested surface densities). The EUDs decrease with the cancer cell maximum infiltrating depth. EUD of a 10 mm spherical shell target volume is about 50% of EUD of a 1 mm spherical shell. TRs are dependent on the applicator size, cancer cell infiltrating depth, and the radiosensitivities of cancer cells and normal tissue. A smaller size of applicator was found to produce a greater TR for a shallowly seated lesion (<5 mm), while a large size of applicator is better to treating a deeply seated lesion (>5 mm). Conclusions The applicator size has a moderate impact on the EUDs, a greater size of applicator will deliver a greater EUD at the same cancer cell infiltrating depth, but a smaller size of applicator is seen to produce a greater TR for the shallow lesions (depth <5 mm). In addition, a greater size of applicator is preferred for treating a deeply seated lesion (depth >5 mm) because it produces a greater TR and EUD than a smaller size of applicator. IB-IORT is a preferable alternative to uniform dose treatment when treating unicentric breast cancer at smaller infiltration depths. [ABSTRACT FROM AUTHOR]

Background: To assess the benefits of bladder wall sub-volume equivalent uniform dose (EUD) constraints in prostate cancer intensity-modulated radiotherapy (IMRT) planning. Methods: Two IMRT plans, with and without EUD constraints on the bladder wall, were generated using beams that deliver 80 Gy to the prostate and 46 Gy to the seminal vesicles and were compared in 53 prostate cancer patients. The bladder wall was defined as the volume between the external manually delineated wall and a contraction of 7 mm apart from it. The bladder wall was then separated into two parts: the internal-bladder wall (bla-in) represented by the portion of the bladder wall that intersected with the planning target volume (PTV) plus 5 mm extension; the external-bladder wall (bla-ex) represented by the remaining part of the bladder wall. In the IMRT plan with EUD constraints, the values of "a" parameter for the EUD models were 10.0 for bla-in and 2.3 for bla-ex. The plans with and without EUD constraints were compared in terms of dose-volume histograms, 5-year bladder and rectum normal tissue complication probability values, as well as tumor control probability (TCP) values. Results: The use of bladder sub-volume EUD constraints decreased both the doses to the bladder wall (V70: 22.76% vs 19.65%, Dmean: 39.82 Gy vs 35.45 Gy) and the 5-year bladder complication probabilities ($LENT/SOMA Grade 2: 20.35% vs 17.96%; bladder bleeding: 10.63% vs 8.64%). The doses to the rectum wall and the rectum complication probabilities were also slightly decreased by the EUD constraints compared to physical constraints only. The minimal dose and the V76Gy of PTVprostate were, however, slightly decreased by EUD optimization, nevertheless without significant difference in TCP values between the two plans, and the PTV parameters finally respected the Groupe d'Etude des Tumeurs Uro-Génitales recommendations. Conclusion: Separating the bladder wall into two parts with appropriate EUD optimization may reduce bladder toxicity in prostate IMRT. Combining biological constraints with physical constraints in the organs at risk at the inverse planning step of IMRT may improve the dose distribution. [ABSTRACT FROM AUTHOR]