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Introduction: HyperArc (HA) auto‐planning offers simplicity for the end user and consistently high‐quality SRS plans. The "Ask For It" (AFI) optimization strategy offers a manual planning technique that, when coupled with R50%Analytic, can be guided to deliver a plan with an intermediate dose spill "as low as reasonably achievable" and high target dose conformity. A direct comparison of SRS plan quality obtained using the manual planning AFI strategy and HA has been performed. Methods: Using a CT data set available from the Radiosurgery Society, 54 PTVs were created and used to generate 19 individual SRS/SRT cases. Case complexity ranged from single PTV plans to multiple PTV plans with a single isocenter. PTV locations ranged from relative isolation from critical structures to lesions within 1.5 mm of the optic apparatus and abutting the brainstem. All cases were planned using both the AFI and HA optimization strategies as implemented in the Varian Medical Systems Eclipse Treatment Planning System. A range of treatment plan quality metrics were obtained including Intermediate Dose Spill (R50%), Conformity Indices CIRTOG and CIPaddick, PTV Dose Coverage (Dn%), PTV Mean Dose, and Modulation Factor. The Wilcoxon Signed Rank Sum non‐parametric statistical method was utilized to compare the obtained plan quality metrics. Results: Statistically significant improvements were found for the AFI strategy for metrics R50%, CIRTOG, CIPaddick, and PTV Mean Dose (p < 0.001). HA achieved superior coverage for Dn% (p = 0.018), while the Modulation Factors were not significantly different for AFI compared to HA optimization (p = 0.13). Conclusion: This study provides evidence that the AFI manual planning strategy can produce high‐quality planning metrics similar to the HA auto‐planning method. [ABSTRACT FROM AUTHOR]

Background: This research aims to evaluate the usability of the HyperArc (HA) technique in stereotactic radiosurgery for cervical spine metastasis by comparing the dosimetry of the target and organs at risk, specifically the spinal cord, between HA and VMAT and conventional volumetric modulated arc therapy (VMAT). Methods: A RANDO® phantom and QFix EncompassTM and support system were used to simulate three target types (A, B, and C) based on RTOG0631 guidelines. Treatment plans included one VMAT and two HyperArc techniques with different SRS NTO values (100 and 250). Dosimetric parameters such as conformity index (CI), homogeneity index (HI), R50, and spinal cord sparing were analyzed. Gamma analysis was performed using portal dosimetry to validate the dose delivery accuracy. Results: HyperArc plans demonstrated higher conformity, sharper dose fall-off, and improved quality assurance (QA) results compared to VMAT plans. HA with SRS NTO 250 showed even better results in terms of conformity, dose fall-off, and spinal cord dose reduction (V10 and Dmax) compared to HA with SRS NTO 100. Although the mean gamma passing rates were slightly lower, all plans achieved rates above 95%. Conclusion: The findings suggest that HA provides superior dosimetric benefits over VMAT and could be effectively utilized for cervical spine radiation therapy. [ABSTRACT FROM AUTHOR]

Background: As radiotherapy techniques advance, so do planning methods for multi‐target intracranial SRS cases. Multi‐target‐single‐isocenter (MTSI) planning offers high‐precision beam delivery with shortened duration. However, accommodating all targets in a single Patient‐Specific‐Quality‐Assurance (PSQA) with QA devices like SRS MapCHECK (SRS MC) is generally impractical. Purpose: Consequently, we conducted PSQA, using a custom script, by relocating each Target or Neighboring‐Target‐Group (T‐NTG) relative to the beam isocenter on the PSQA device, ensuring each target's dose coverage at high precision. Methods: SRS treatment plans use 6MV–FFF beams, consisting of four Volumetric Modulated ARC Therapy (VMAT) arcs, including one full‐arc and three half arcs with couch‐kicks. A custom script calculated T‐NTG coordinates relative to the beam isocenter. QA verification plans were created for each T‐NTG, redefining the beam isocenter for precise alignment with the center of the SRS MC. CBCT images were acquired during PSQA for SRS MC alignment, and gamma‐index analysis (GIA) was performed. A single‐tail paired t‐test assessed the passing rate (PR) for 75 QA verification plans. Results: GIA with l.0 mm/2.0% criteria for each QA plan yielded a PR > 95.5%, with an average of 98.9%. Plans achieving PR > 99.0% and > 97.0% constituted 63% and 92% of studied plans, respectively. Statistical significance was observed in a t‐test with an ideal PR value of 100%, while insignificance was found with a PR value of 99%, suggesting that PSQA for individual targets consistently approaches 99% PR. In MTSI cases using 6MV‐FFF beams, targets within the lateral dose‐fall‐off region require careful verification for acceptability. Our clinical study on individual T‐NTG relocation demonstrates that the presented PSQA methods are generally acceptable, supported by a statistically insignificant PR against a 99% PR value. Conclusions: Presented statistical analysis results indicate that the proposed PSQA approach can serve as a reliable tool in clinical settings. [ABSTRACT FROM AUTHOR]

This study provides a concise and structured overview of a dosimetric comparison study conducted to assess the feasibility and effectiveness of 4 advanced radiotherapy techniques in treating brain metastases with hippocampus sparing and simultaneous integrated boost (HS-WBRT+SIB). Eleven patients with brain metastases previously treated with radiotherapy were included in the study. Planning CT scans with 2 mm slice thickness and MR imaging were used for contouring and dose prescription. The bilateral hippocampus and other organs at risk (OARs) were automatically contoured, and hippocampal avoidance regions (HAR) were defined as a 7 mm 3D expansion around the hippocampus. Gross tumor volume for each metastasis (GTV met) and planning target volume for metastases (PTV met) were delineated. The whole-brain CTV (CTV WB) and planning target volume for whole brain (PTV WB) were defined accordingly. Treatment planning and optimization were conducted using state-of-the-art radiotherapy techniques: Ethos, HyperArc, VMAT, and Tomotherapy. Tomotherapy achieved the highest D98% for PTV met , indicating the best metastasis coverage. HyperArc plans showed the highest D98% for PTV WB , suggesting superior whole-brain coverage. Tomotherapy demonstrated significantly lower D98%, D2%, and D mean values for the hippocampus, indicating its superiority in sparing the hippocampus. VMAT resulted in the lowest D2% values for the eyes, optic nerves, brainstem, and hypophysis, showing the best sparing of these critical structures. Tomotherapy consistently achieved lower D mean values for parotids, oral cavity, and lips compared to the other techniques. The dosimetric comparison revealed distinct strengths and weaknesses for each radiotherapy technique. Tomotherapy excelled in sparing the hippocampus, while VMAT showed promise in sparing OARs. HyperArc plans demonstrated the best overall whole-brain coverage. These findings should guide clinicians in selecting the most suitable technique based on patient characteristics and institutional resources. [ABSTRACT FROM AUTHOR]

Purpose: The study aimed to investigate the optimal isodose line (IDL) in linear accelerator‐based stereotactic radiotherapy for single brain metastasis, using HyperArc. We compared the dosimetric parameters for target and normal brain tissue among six plans with different IDLs. Methods: This study included 30 patients with single brain metastasis. We retrospectively generated six plans for each tumor with different IDLs (80%, 70%, 60%, 50%, 40%, and 33%) using HyperArc. All treatment plans were normalized to the prescription dose of 35 Gy in five fractions which was covered by 95% of the planning target volume (PTV), defined by adding a 1.0 mm margin to the gross tumor volume (GTV). The dosimetric parameters were compared among the six plans. Results: For GTV > 0.1 cm3, the ratio of brain–GTV volumes receiving 25 Gy to PTV (V25Gy/PTV) was significantly lower at IDL 40%–70% than at IDL 80% and 33% (p < 0.01, retrospectively). For GTV < 0.1 cm3, V25Gy/PTV decreased continuously as IDL decreased. The values of D99% and D80% for GTV increased with decreasing IDL. An IDL of 50% or less was required to achieve D99% of greater than 43 Gy and D80% of greater than 50 Gy. The mean values of D99% and D80% for IDL 50% were 44.3 and 51.9 Gy. Conclusion: The optimal IDL is 40%–50% for GTV > 0.1 cm3. These lower IDLs could increase D99% and D80% of GTV while lowering V25Gy of normal brain tissue, which may help reduce the risk of radiation necrosis and improve local control. [ABSTRACT FROM AUTHOR]

Objective: To assess the performance and advantages of HyperArc for radiotherapy of multiple brain metastases with dosimetric parameters with respect to coplanar volumetric modulated arc radiotherapy (c-VMAT), and characterize implicit correlations between tumor features and dosimetric parameters. Methods: This retrospective study involved 40 patients with multiple brain metastases (4–16 tumors, 12.8–240.8 cm3) who received simultaneous radiotherapy at the Department of Radiation Oncology, Shenzhen People's Hospital from January 2019 to December 2022. Both HyperArc and c-VMAT plans were designed by the same and qualified physicist using the Eclipse system with Truebeam. A single isocenter and a 6 ​MV flattening filter-free (6FFF) photon beam were used for radiotherapy of multiple brain metastases in each plan. Dosimetric parameters of tumors and organs at risk (OARs) were compared between HyperArc and c-VMAT plans. Correlations between tumor features (number and volume) and dosimetric parameters were revealed and analyzed. Furthermore, monitor units (MUs) of both plan types were recorded to assess rays utilization and delivery efficiency. Results: Compared to c-VMAT plans, HyperArc plans achieved higher maximum dose (Dmax) (5.23%, t ​= ​7.87, P ​ ​0.05). Conclusions: This study demonstrates the promising performance of HyperArc for radiotherapy of multiple brain metastases, including better dose conformity for the tumors, more rapid dose drop and less dose spillage outside the tumors area, effective reduction of dose bridges among close tumors, and sparing OARs. It also reveals the correlations between the number or volume of tumors and dose parameters, which can help optimize the use of HyperArc and predict clinical benefits.

Background and purpose: This study aimed to compare the dosimetric attributes of two multi‐leaf collimator based techniques, HyperArc and Incise CyberKnife, in the treatment of brain metastases. Material and methods: 17 cases of brain metastases were selected including 6 patients of single lesion and 11 patients of multiple lesions. Treatment plans of HyperArc and CyberKnife were designed in Eclipse 15.5 and Precision 1.0, respectively, and transferred to Velocity 3.2 for comparison. Results: HyperArc plans provided superior Conformity Index (0.91 ± 0.06 vs. 0.77 ± 0.07, p < 0.01) with reduced dose distribution in organs at risk (Dmax, p < 0.05) and lower normal tissue exposure (V4Gy–V20Gy, p < 0.05) in contrast to CyberKnife plans, although the Gradient Indexes were similar. CyberKnife plans showed higher Homogeneity Index (1.54 ± 0.17 vs. 1.39 ± 0.09, p < 0.05) and increased D2% and D50% in the target (p < 0.05). Additionally, HyperArc plans had significantly fewer Monitor Units (MUs) and beam‐on time (p < 0.01). Conclusion: HyperArc plans demonstrated superior performance compared with MLC‐based CyberKnife plans in terms of conformity and the sparing of critical organs and normal tissues, although no significant difference in GI outcomes was noted. Conversely, CyberKnife plans achieved a higher target dose and HI. The study suggests that HyperArc is more efficient and particularly suitable for treating larger lesions in brain metastases. [ABSTRACT FROM AUTHOR]

To determine the feasibility and utility of conebeam CT-guided stereotactic radiotherapy for locally recurrent, previously irradiated head and neck cancer (HNC) patients on the Halcyon, a ring delivery system (RDS). This research aims to quantify plan quality, treatment delivery accuracy, and overall efficacy by comparing against novel clinical TrueBeam HyperArc method. Ten recurrent HNC patients who were treated at our institution on TrueBeam (6MV-FFF) for 30 to 40 Gy in 3 to 5 fractions with noncoplanar HyperArc plans were re-planned on Halcyon (6MV-FFF). These plans were re-planned with the same Acuros-based dose engine. Additionally, we used site-specific full/partial coplanar VMAT arcs. PTV coverage, mean dose to GTV, maximum dose to organs-at-risk (OAR), beam-on time (BOT), and quality assurance (QA) results were investigated and compared. Halcyon provided highly conformal HNC SRT plans with slightly superior mean PTVD99 coverage (96.7% vs 95.5%, p = 0.071), and slightly lower mean GTV dose (37.8 Gy vs 38.2 Gy, p = 0.241) when compared to the HyperArc plans. Differences in plan conformality and maximum dose to OARs were statistically insignificant. Due to Halcyon's coplanar geometry, D2cm was significantly higher (p = 0.001) but Halcyon did result in a reduced normal brain dose by 1 Gy on average and up to 5.2 Gy in some cases. Halcyon provided similar patient-specific QA pass rates with a 2%/2mm gamma criteria (98.2% vs 98.5%) and independent in-house Monte Carlo second check results (97.7% vs 98.2%), suggesting identical treatment delivery accuracy. Halcyon plans resulted in slightly longer beam-on time (3.16 vs 2.30 minutes, p = 0.010), however door-to-door patient time is expected to be <10 minutes. Compared to clinical TrueBeam HyperArc, Halcyon SRT plans provided similar plan quality and treatment delivery accuracy with a potentially faster overall treatment using fully automated patient setup and verification. Rapid delivery of recurrent HNC SRT may reduce intrafraction motion errors while also improving patient compliance and comfort. To provide high-quality of HNC SRT similar to HyperArc, we recommend Halcyon users consider commissioning this novel method. This method will be useful for remote and underserved patient cohorts including Halcyon-only clinics as well. [ABSTRACT FROM AUTHOR]

The HyperArc technique is known for generating high-quality radiosurgical treatment plans for intracranial lesions or hippocampal-sparing whole-brain radiotherapy (WBRT). However, there is no reported feasibility of using the HyperArc technique in hippocampal-sparing WBRT with a simultaneous integrated boost (SIB). This study aimed to compare dosimetric parameters of 2 commercially-available volumetric-modulated arc radiotherapy techniques, HyperArc and RapidArc, when using hippocampal-sparing WBRT with a SIB to treat brain metastases. Treatment plans using HyperArc and RapidArc techniques were generated retrospectively for 19 previously treated patients (1 to 3 brain metastases). The planning target volumes for the whole brain (excluding the hippocampal avoidance region; PTV WB) and metastases (PTV met) were prescribed 25 and 45 Gy, respectively, in 10 fractions. Each plan included homogeneous and inhomogeneous delivery to the PTV met. Dosimetric parameters for the target (conformity index [CI], homogeneity index [HI], target coverage [D 95% ]), and nontarget organs at risk were compared for the HyperArc and RapidArc plans. For homogeneous delivery, dosimetric parameters, including mean CI, HI, and target coverage in PTV WB and PTV met , were superior for HyperArc than RapidArc plans (all p < 0.01). The PTV WB and PTV met target coverage for HyperArc plans was significantly greater than for RapidArc plans (96.17% vs 93.38%, p < 0.01; 94.02% vs 92.21%, p < 0.01, respectively). HyperArc plans had significantly lower mean hippocampal D max and D min values than RapidArc plans (D max : 15.53 Gy vs , 16.71 Gy, p < 0.01; D min : 8.33 Gy vs 8.93 Gy, p < 0.01, respectively). Similarly, inhomogeneous delivery of hyperArc produced a superior target and lower hippocampal dosimetric parameters than RapidArc, except for the HI of PTV met (all p < 0.01). HyperArc generated superior conformity and target coverage with lower hippocampal doses than RapidArc. HyperArc could be an attractive technique for hippocampal-sparing WBRT with an SIB. [ABSTRACT FROM AUTHOR]

Aims: Evaluate effectiveness and safety of multiple HyperArc courses and patterns of progression in patients affected by BMs with intracranial progression. Methods: 56 patients were treated for 702 BMs with 197 (range 2–8) HyperArc courses in case of exclusive intracranial progression. Primary end-point was the overall survival (OS), secondary end-points were intracranial progression-free survival (iPFS), toxicity, local control (LC), neurological death (ND), and whole-brain RT (WBRT)-free survival. Site of progression was evaluated against isodoses levels (0, 1, 2, 3, 5, 7, 8, 10, 13, 15, 20, and 24 Gy.). Results: The 1-year OS was 70 %, and the median was 20.8 months (17–36). At the univariate analysis (UVA) biological equivalent dose (BED) > 51.3 Gy and non-melanoma histology significantly correlated with OS. The median time to iPFS was 4.9 months, and the 1-year iPFS was 15 %. Globally, 538 new BMs occurred after the first HA cycle in patients with extracranial disease controlled. 96.4 % of them occurred within the isodoses range 0–7 Gy as follows: 26.6 % (0 Gy), 16.5 % (1 Gy), 16.5 % (2 Gy), 20.1 % (3 Gy), 13.1 % (5 Gy), 3.4 % (7 Gy) (p = 0.00). Radionecrosis occurred in 2 metastases (0.28 %). No clinical toxicity of grade 3 or higher occurred during follow-up. One- and 2-year LC was 90 % and 79 %, respectively. At the UVA BED > 70 Gy and non-melanoma histology were significant predictors of higher LC. The 2-year WBRT-free survival was 70 %. After a median follow-up of 17.4 months, 12 patients deceased by ND. Conclusion: Intracranical relapses can be safely and effectively treated with repeated HyperArc, with the aim to postpone or avoid WBRT. Diffuse dose by volumetric RT might reduce microscopic disease also at relatively low levels, potentially acting as a virtual CTV. Neurological death is not the most common cause of death in this population, which highlights the impact of extracranial disease on overall survival.

Abstract Background To compare the dosimetric quality of three widely used techniques for LINAC-based single-isocenter multi-target multi-fraction stereotactic radiosurgery (fSRS) with more than 20 targets: dynamic conformal arc (DCA) in BrainLAB Multiple Metastases Elements (MME) module and volumetric modulated arc therapy (VMAT) using RapidArc (RA) and HyperArc (HA) in Varian Eclipse. Methods Ten patients who received single-isocenter fSRS with 20–37 targets were retrospectively replanned using MME, RA, and HA. Various dosimetric parameters, such as conformity index (CI), Paddick CI, gradient index (GI), normal brain dose exposures, maximum organ-at-risk (OAR) doses, and beam-on times were extracted and compared among the three techniques. Wilcoxon signed-rank test was used for statistical analysis. Results All plans achieved the prescribed dose coverage goal of at least 95% of the planning target volume (PTV). HA plans showed superior conformity compared to RA and MME plans. MME plans showed superior GI compared to RA and HA plans. RA plans resulted in significantly higher low and intermediate dose exposure to normal brain compared to HA and MME plans, especially for lower doses of ≥ 8Gy and ≥ 5Gy. No significant differences were observed in the maximum dose to OARs among the three techniques. The beam-on time of MME plans was about two times longer than RA and HA plans. Conclusions HA plans achieved the best conformity, while MME plans achieved the best dose fall-off for LINAC-based single-isocenter multi-target multi-fraction SRS with more than 20 targets. The choice of the optimal technique should consider the trade-offs between dosimetric quality, beam-on time, and planning effort.

Background: To compare the dosimetric quality of three widely used techniques for LINAC-based single-isocenter multi-target multi-fraction stereotactic radiosurgery (fSRS) with more than 20 targets: dynamic conformal arc (DCA) in BrainLAB Multiple Metastases Elements (MME) module and volumetric modulated arc therapy (VMAT) using RapidArc (RA) and HyperArc (HA) in Varian Eclipse. Methods: Ten patients who received single-isocenter fSRS with 20–37 targets were retrospectively replanned using MME, RA, and HA. Various dosimetric parameters, such as conformity index (CI), Paddick CI, gradient index (GI), normal brain dose exposures, maximum organ-at-risk (OAR) doses, and beam-on times were extracted and compared among the three techniques. Wilcoxon signed-rank test was used for statistical analysis. Results: All plans achieved the prescribed dose coverage goal of at least 95% of the planning target volume (PTV). HA plans showed superior conformity compared to RA and MME plans. MME plans showed superior GI compared to RA and HA plans. RA plans resulted in significantly higher low and intermediate dose exposure to normal brain compared to HA and MME plans, especially for lower doses of ≥ 8Gy and ≥ 5Gy. No significant differences were observed in the maximum dose to OARs among the three techniques. The beam-on time of MME plans was about two times longer than RA and HA plans. Conclusions: HA plans achieved the best conformity, while MME plans achieved the best dose fall-off for LINAC-based single-isocenter multi-target multi-fraction SRS with more than 20 targets. The choice of the optimal technique should consider the trade-offs between dosimetric quality, beam-on time, and planning effort. [ABSTRACT FROM AUTHOR]

Purpose: The Mobius3D system was validated as a modern secondary check dosimetry system. In particular, our objective has been to assess the suitability of the M3D as pre‐treatment patient‐specific Quality Assurance (QA) tool for Stereotactic Radiosurgery (SRS) HyperArc (HA) treatments. We aimed to determine whether Mobius3D could safely replace the measurements‐based patient‐specific QA for this type of treatment. Methods: 30 SRS HA treatment plans for brain were selected. The dose distributions, calculated by Mobius and our routinely used algorithm (AcurosXB v.15.6), were compared using gamma analysis index and DVH parameters based on the patient's CT dataset. All 30 plans were then delivered across the ionization chamber in a homogeneous phantom and the measured dose was compared with both M3D and TPS calculated one. The plans were delivered and verified in terms of PSQA using the electronic portal imaging device (EPID) with Portal Dosimetry (PD) and myQA SRS (IBA Dosimetry) detector. Plans that achieved a global gamma passing rate (GPR) ≥ 97% based on 2%/2 mm criteria, with both Mobius3D and the conventional methods were evaluated acceptable. Finally, we assessed the capability of the M3D system to detect errors related to the position of the Multi‐Leaf Collimator (MLC) in comparison to the analyzed measurement‐based systems. Results: No relevant differences were observed in the comparison between the dose calculated on the CT‐dataset by M3D and the TPS. Observed discrepancies are imputable to different used algorithms, but no discrepancies related to goodness of plans have been found. Average differences between calculated (M3D and TPS) vs measured dose with ionization chamber were 2.5% (from 0.41% to 3.2%) and 1.81% (from 0.66% to 2.65%), for M3D and TPS, respectively. All plans passed with a gamma passing rate > 97% using conventional PSQA methods with a gamma criterion of 2% dose difference and 2 mm distance‐to‐agreement. The average gamma passing rate for the M3D system was determined to be 99.4% (from 97.3% to 100%). Results from this study also demonstrated Mobius has better error detectability than conventional measurement‐based systems. Conclusion: Our study shows Mobius3D could be a suitable alternative to conventional measured based QA methods for SRS HyperArc treatments. [ABSTRACT FROM AUTHOR]

Purpose/objectives: (A) To examine the alignment accuracy of CBCT guidance for brain metastases with off centered isocenters, (B) to test dose delivery and targeting accuracy for single isocenter treatments with multiple brain metastases. We report the results of the end‐to‐end test for Truebeam stereotactic radiosurgery (SRS). Materials/methods: An anthropomorphic CT head phantom was drilled with five MOSFET inserts and two PTW Pinpoint chamber inserts. The phantom was simulated, planned, and delivered. For the purpose of comparing the accuracy of alignment, CBCTs were acquired with the isocenter centered and offset superiorly 8 cm, inferiorly 8 cm, anteriorly 7 cm, posteriorly 7 cm, and right 5 cm. There were six degrees of freedom corrections applied to the plans, as well as intentional rotational and translational errors for dose comparisons. Dose accuracy checks were performed with MOSFET and PTW Pinpoint chamber, and targeting accuracy was assessed with GafChromic films. Result: (A) Compared to centered CBCT, off‐centered CBCT scan showed some alignment errors, with a maximum difference of 0.6‐degree pitch and 0.9 mm translation when the phantom was placed 8 cm inferior off center. (B) For the single isocenter plan, measured doses of the five MOSFET were 95%–100% of the planned dose, whereas the multiple isocenter plans were 96%–100%. With intentional setup errors of 1‐degree pitch, doses were 97.1%–100.4% compared to the perfect setup. The same was found for the two pinpoint chamber readings with 1‐degree rotation and 1 mm translation. (C) Targeting accuracy for targets at the isocenter is 0.67 mm, within the machine specification of 0.75 mm. Targeting accuracy for isocenters 6–12 cm away from the target is in the range 0.67–1.18 mm. Conclusion: (A) Single isocenter HyperArc treatments for multiple brain metastases are feasible and targeting accuracy is clinically acceptable. (B) The vertex in a cranial scan is very important for proper alignment. [ABSTRACT FROM AUTHOR]

We modeled the Qfix Encompass™ immobilization system and further verified the calculated dose distribution of the AcurosXB (AXB) dose calculation algorithm using SRS MapCHECKⓇ (SRSMC) in the HyperArc™ (HA) clinical plan. An Encompass system with a StereoPHAN™ QA phantom was scanned by SOMATOM go.Sim and imported to an Eclipse™ treatment planning system to create a treatment plan for Encompass modeling. The Encompass modeling was performed in the StereoPHAN with a pinpoint ion chamber for 6 MV and 6 MV flattening filter free (6 MV FFF), and 2 × 2 cm2, 4 × 4 cm2, and 6 × 6 cm2 irradiation field sizes. The dose calculation algorithm used was AXB ver. 15.5 with a 1.0 mm calculation grid size. The Hounsfield unit (HU) values of the Encompass modeling were set to 400, −100, −200, and −300 for Encompass, and −400, −600, −700, and −800 for the Encompass base. We evaluated the dose distribution after Encompass modeling by SRSMC using gamma analysis in 12 patients. We adopted HU values of −200 for Encompass, −800 for Encompass base for 6 MV, and −200 for Encompass and −700 for Encompass. Base for 6 MV FFF was adopted as the HU values for the Encompass modeling based on the measurement results. The proposed Encompass modeling resulted in a mean pass rate evaluation >98% for both 6 MV and 6 MV FFF when the 1%/1 mm criterion was used, demonstrating that the proposed HU value can be adopted to calculate more accurate dose distributions. [ABSTRACT FROM AUTHOR]

This study reports the initial results for the first 15 patients on a prospective phase II clinical trial exploring the safety, feasibility, and efficacy of the HyperArc technique for recurrent head and neck cancer treatment. Eligible patients were simulated and planned with both conventional VMAT and HyperArc techniques and the plan with superior dosimetry was selected for treatment. Dosimetry, delivery feasibility and safety, treatment-related toxicity, and patient-reported quality of life (QOL) were all evaluated. HyperArc was chosen over conventional VMAT for all 15 patients and enabled statistically significant increases in dose conformity (R50% reduced by 1.2 ± 2.1, p < 0.05) and mean PTV and GTV doses (by 15.7 ± 4.9 Gy, p < 0.01 and 17.1 ± 6.0 Gy, p < 0.01, respectively). The average HyperArc delivery was 2.8 min longer than conventional VMAT (p < 0.01), and the mean intrafraction motion was ≤ 0.5 ± 0.4 mm and ≤0.3 ± 0.1°. With a median follow-up of 12 months, treatment-related toxicity was minimal (only one grade 3 acute toxicity above baseline) and patient-reported QOL metrics were favorable. HyperArc enabled superior dosimetry and significant target dose escalation compared to conventional VMAT planning, and treatment delivery was feasible, safe, and well-tolerated by patients.

Purpose: This study aims to evaluate different methods for calibrating EBT-XD films to develop a precise pre-treatment verification method for stereotactic radiotherapy (SRT) patients using the HyperArc (HA, Varian Medical System) technique. Methods: Gafchromic EBT-XD films were calibrated using three different approaches: manual calibration, EDW calibration, and PDD calibration. Films were digitalized with an Epson V850 Pro scanner applying the local scanning protocol. Three clinical treatment plans were selected for evaluation. Patient-specific QA films were irradiated in the Mobius MVP phantom and the STEEV phantom. Scanned film images were converted into dose images using the calibration curves. Gamma analysis was performed to compare film dose and TPS calculated dose with various criteria. Results: The scan-to-scan variation was evaluated to be ≤ 0.2%. The accuracy of the calibration curves was verified and the deviation from the converted dose deviates ≤ 3% from the known delivered dose. The gamma passing rate for all calibration methods was found to be over 94% with clinically relevant criteria. EDW calibration demonstrated higher average gamma passing rates compared to the manual method for single target plans, which is 99% ± 1.2% and 98.8% ± 1.5%, respectively. PDD method demonstrated improved agreement for multiple targets with the result of 99.3% ± 0.8%. Conclusions: The three calibration methods were validated, and they produced accurate calibration curves for EBT-XD films to enable pre-treatment patient-specific QA for stereotactic radiotherapy. [ABSTRACT FROM AUTHOR]

This study aimed to compare dosimetric parameters for targets and organs at risk (OARs) between volumetric modulated arc therapy (VMAT) and automated VMAT (HyperArc, HA) plans in stereotactic radiotherapy for patients with cervical metastatic spine tumors. VMAT plans were generated for 11 metastases using the simultaneous integrated boost technique to deliver 35 to 40 and 20 to 25 Gy for high dose and elective dose planning target volume (PTVHD and PTVED), respectively. The HA plans were retrospectively generated using 1 coplanar and 2 noncoplanar arcs. Subsequently, the doses to the targets and OARs were compared. The HA plans provided significantly higher (p < 0.05) D min (77.4 ± 13.1%), D 99% (89.3 ± 8.9%), and D 98% (92.5 ± 7.7%) for gross tumor volume (GTV) than those of the VMAT plans (73.4 ± 12.2%, 84.2 ± 9.6 and 87.3 ± 8.8% for D min , D 99% and D 98% , respectively). In addition, D 99% and D 98% for PTVHD were significantly higher in the HA plans, whereas dosimetric parameters were comparable between the HA and VMAT plans for PTVED. The D max values for the brachial plexus, esophagus, and spinal cord were comparable, and no significant difference was observed in the D mean for the larynx, pharyngeal constrictor, thyroid, parotid grand (left and right), and Submandibular gland (left and right). The HA plans provided significantly higher target coverage of GTV and PTVHD, with a comparable dose for OARs with VMAT plans. The results of this study may contribute to the improvement of local control in clinical practice. [ABSTRACT FROM AUTHOR]

This study evaluates the potential for tumor dose escalation in recurrent head and neck cancer (rHNC) patients with automated non-coplanar volumetric modulated arc therapy (VMAT) stereotactic body radiation therapy (SBRT) planning (HyperArc). Twenty rHNC patients are planned with conventional VMAT SBRT to 40 Gy while minimizing organ-at-risk (OAR) doses. They are then re-planned with the HyperArc technique to match these minimal OAR doses while escalating the target dose as high as possible. Then, we compare the dosimetry, tumor control probability (TCP), and normal tissue complication probability (NTCP) for the two plan types. Our results show that the HyperArc technique significantly increases the mean planning target volume (PTV) and gross tumor volume (GTV) doses by 10.8 ± 4.4 Gy (25%) and 11.5 ± 5.1 Gy (26%) on average, respectively. There are no clinically significant differences in OAR doses, with maximum dose differences of

To compare dosimetric parameters for the hippocampus, organs at risk (OARs), and targets of volumetric modulated arc therapy (VMAT), noncoplanar VMAT (NC-VMAT), and HyperArc (HA) plans in patients undergoing postoperative radiotherapy for primary brain tumors. For 20 patients, HA plans were generated to deliver 40.05 to 60 Gy for the planning target volume (PTV). In addition, doses for the hippocampus and OARs were minimized. The VMAT and NC-VMAT plans were retrospectively generated using the same optimization parameters as those in the HA plans. For the hippocampus, the equivalent dose to be administered in 2 Gy fractions (EQD 2) was calculated assuming α/β = 2. Dosimetric parameters for the PTV, hippocampus, and OARs in the VMAT, NC-VMAT, and HA plans were compared. For PTV, the HA plans provided significantly lower D max and D 1% than the VMAT and NC-VMAT plans (p < 0.05), whereas the D 99% and D min were significantly higher (p < 0.05). For the contralateral hippocampus, the dosimetric parameters in the HA plans (8.1 ± 9.6, 6.5 ± 7.2, 5.6 ± 5.8, and 4.8 ± 4.7 Gy for D 20% , D 40% , D 60% and D 80% , respectively) were significantly smaller (p < 0.05) than those in the VMAT and NC-VMAT plans. Except for the optic chiasm, the D max in the HA plans (brainstem, lens, optic nerves, and retinas) was the smallest (p < 0.05). In addition, the doses in the HA plans for the brain and skin were the smallest (p < 0.05) among the 3 plans. HA planning, instead of coplanar and noncoplanar VMAT, significantly reduces the dosage to which the contralateral hippocampus as well as other OARs are exposed without compromising on target coverage. [ABSTRACT FROM AUTHOR]

To compare the dosimetric parameters of automated noncoplanar volumetric modulated arc therapy plans using single-isocentric (SIC) and multi-isocentric (MIC) techniques for patients with two brain metastases (BMs) in stereotactic irradiation and to evaluate the robustness of rotational errors. The SIC and MIC plans were retrospectively generated (35 Gy/five fractions) for 58 patients. Subsequently, a receiver operating characteristic curve analysis between the tumor surface distance (TSD) and V25Gy was performed to determine the thresholds for the brain tissue. The SIC and MIC plans were recalculated based on the rotational images to evaluate the dosimetric impact of rotational error. The MIC plans showed better brain tissue sparing for TSD > 6.6 cm. The SIC plans provided a significantly better conformity index for TSD ≤ 6.6 cm, while significantly lower gradient index was obtained (3.22 ± 0.56vs. 3.30 ± 0.57, p < 0.05) in the MIC plans with TSD > 6.6 cm. For organs at risk (OARs) (brainstem, chiasm, lens, optic nerves, and retinas), D0.1 cc was significantly lower (p < 0.05) in the MIC plans than in the SIC plans. The prescription dose could be delivered (D99%) to the gross tumor volume (GTV) for patients with TSD ≤ 6.6 cm when the rotational error was < 1°, whereas 31% of the D99% of GTV fell below the prescription dose with TSD > 6.6 cm. MIC plans can be an optimal approach for reducing doses to OARs and providing robustness against rotational errors in BMs with TSD > 6.6 cm. [ABSTRACT FROM AUTHOR]

Abstract Background Stereotactic radiotherapy (SRT) and hypo-fractionated radiotherapy are feasible treatment options for single glioblastoma multiforme when combined with conventional radiotherapy or delivered alone. HyperArc (HA), a novel linac-based method with 4 noncoplanar arcs, has been introduced into stereotactic radiosurgery (SRS) for single and multiple metastases. In this study, we compared the dosimetric quality of HyperArc with the well-established CyberKnife (CK) and conventional VMAT methods of SRT for a single, large target. Methods Sixteen patients treated in our center with their clinical CK plans were enrolled, and the linac-based plans were designed in silico. From the aspect of normal tissue protection and treatment efficacy, we compared the conformity index (CI), gradient index (GI), homogeneity index (HI), dose distribution in planning target volume, dose in the normal brain tissue, and mean dose of several organs at risk (OARs). All of the data were evaluated with nonparametric Kruskal‒Wallis tests. We further investigated the relationship of the dose distribution with the tumor volume and its location. Results The results showed that with a higher CI (0.94 ± 0.03) and lower GI (2.57 ± 0.53), the HA plans generated a lower dose to the OARs and the normal tissue. Meanwhile, the CK plans achieved a higher HI (0.35 ± 0.10) and generated a higher dose inside the tumor. Although manual VMAT showed slight improvement in dose quality and less monitoring units (2083 ± 225), HA can save half of the delivery time of CK (37 minutes) on average. Conclusion HA plans have higher conformity and spare OARs with lower normal tissue irradiation, while CK plans achieve a higher mean dose in tumors. HA with 4 arcs is sufficient in dosimetric quality for a single tumor with great convenience in planning and treatment processes compared with conventional VMAT. The tumor size and location are factors to be considered when selecting treatment equipment.

Objective: Dosimetric potential of knowledge‐based RapidPlan planning model trained with HyperArc plans (Model‐HA) for brain metastases has not been reported. We developed a Model‐HA and compared its performance with that of clinical volumetric modulated arc therapy (VMAT) plans. Methods: From 67 clinical stereotactic radiosurgery (SRS) HyperArc plans for brain metastases, 47 plans were used to build and train a Model‐HA. The other 20 clinical HyperArc plans were recalculated in RapidPlan system with Model‐HA. The model performance was validated with the 20 plans by comparing dosimetric parameters for normal brain tissue between clinical plans and model‐generated plans. The 20 clinical conventional VMAT‐based SRS or stereotactic radiotherapy plans (CL‐VMAT) were reoptimized with Model‐HA (RP) and HyperArc system (HA), respectively. The dosimetric parameters were compared among three plans (CL‐VMAT vs. RP vs. HA) in terms of planning target volume (PTV), normal brain excluding PTVs (Brain − PTV), brainstem, chiasm, and both optic nerves. Results: In model validation, the optimization performance of Model‐HA was comparable to that of HyperArc system. In comparison to CL‐VMAT, there were no significant differences among three plans with respect to PTV coverage (p > 0.17) and maximum dose for brainstem, chiasm, and optic nerves (p > 0.40). RP provided significantly lower V20 Gy, V12 Gy, and V4 Gy for Brain − PTV than CL‐VMAT (p < 0.01). Conclusion: The Model‐HA has the potential to significantly reduce the normal brain dose of the original VMAT plans for brain metastases. [ABSTRACT FROM AUTHOR]

Background: Stereotactic radiotherapy (SRT) and hypo-fractionated radiotherapy are feasible treatment options for single glioblastoma multiforme when combined with conventional radiotherapy or delivered alone. HyperArc (HA), a novel linac-based method with 4 noncoplanar arcs, has been introduced into stereotactic radiosurgery (SRS) for single and multiple metastases. In this study, we compared the dosimetric quality of HyperArc with the well-established CyberKnife (CK) and conventional VMAT methods of SRT for a single, large target. Methods: Sixteen patients treated in our center with their clinical CK plans were enrolled, and the linac-based plans were designed in silico. From the aspect of normal tissue protection and treatment efficacy, we compared the conformity index (CI), gradient index (GI), homogeneity index (HI), dose distribution in planning target volume, dose in the normal brain tissue, and mean dose of several organs at risk (OARs). All of the data were evaluated with nonparametric Kruskal‒Wallis tests. We further investigated the relationship of the dose distribution with the tumor volume and its location. Results: The results showed that with a higher CI (0.94 ± 0.03) and lower GI (2.57 ± 0.53), the HA plans generated a lower dose to the OARs and the normal tissue. Meanwhile, the CK plans achieved a higher HI (0.35 ± 0.10) and generated a higher dose inside the tumor. Although manual VMAT showed slight improvement in dose quality and less monitoring units (2083 ± 225), HA can save half of the delivery time of CK (37 minutes) on average. Conclusion: HA plans have higher conformity and spare OARs with lower normal tissue irradiation, while CK plans achieve a higher mean dose in tumors. HA with 4 arcs is sufficient in dosimetric quality for a single tumor with great convenience in planning and treatment processes compared with conventional VMAT. The tumor size and location are factors to be considered when selecting treatment equipment. [ABSTRACT FROM AUTHOR]

Purpose: In the implementation of the use of EncompassTM partially open immobilization mask to perform SRS of multiple brain metastasis, the evaluation of patient's intrafraction motion (IM) is deemed convenient to verify that the margins applied to the GTV are able to ensure adequate dose coverage to each lesion. Methods: IM was determined by comparing the pre- and post-treatment CBCT images with respect to the simulation CT for a total of 23 fractions. The dosimetric impact on GTV coverage due to translational errors in patient positioning and rotational uncertainties of LINAC's performance was also evaluated. Results: The absolute magnitude of IM was less than 1 mm in all cases. The dosimetric difference on GTV coverage due to patient's IM was inferior to 5%. There was not found any significant correlation between the dosimetric impact of rotational uncertainties with the distance to the isocenter. Conclusions: The margins applied to the GTV are adequate when using EncompassTM immobilization device. [ABSTRACT FROM AUTHOR]

• This study describes the first application of Monte Carlo software for pre‐treatment verification of HyperArc SRS plans. • The freely available Monte Carlo software called PRIMO is used. • PRIMO software was used in conjunction with the space phase files freely distributed by Varian for a TrueBeam linac. To investigate the feasibility of using the free PRIMO Monte Carlo software for independent dose check of cranial SRS plans designed with the Varian HyperArc (HA) technique. In this study, the PRIMO Monte Carlo software v. 0.3.64.1800 was used with the phase-space files (v. 2, Feb. 27, 2013) provided by Varian for 6 MV flattening-filter-free (FFF) photon beams from a Varian TrueBeam linear accelerator (linac), equipped with a Millennium 120 multileaf collimator (MLC). This configuration was validated by comparing the percentage depth doses (PDDs), lateral profiles and relative output factors (OFs) simulated in a water phantom against measurements for field sizes from 1 × 1 to 40 × 40 cm2. The agreement between simulated and experimental relative dose curves was evaluated using a global (G) gamma index analysis. In addition, the accuracy of PRIMO to model the MLC was investigated (dosimetric leaf gap, tongue and groove, leaf transmission and interleaf leakage). Thirty-five HA SRS plans computed in the Eclipse treatment planning system (TPS) were simulated in PRIMO. The Acuros XB algorithm v. 16.10 (dose to medium) was used in Eclipse. Sixty targets with diameters ranging from 6 to 33 mm were included. Agreement between the dose distributions given by Eclipse and PRIMO was evaluated in terms of 3D global gamma passing rates (GPRs) for the 2 %/2 mm criteria. Average GPR greater than 95 % with the 2 %(G)/1 mm criteria were obtained over the PDD and profiles of each field size. Differences between PRIMO calculated and measured OFs were within 0.5 % in all fields, except for the 1 × 1 cm2 with a discrepancy of 1.5 %. Regarding the MLC modeling in PRIMO, an agreement within 3 % was achieved between calculated and experimental doses. Excellent agreement between PRIMO and Eclipse was found for the 35 HA plans. The 3D global GPRs (2 %/2 mm) for the targets and external patient contour were 99.6 % ± 1.1 % and 99.8 % ± 0.5 %, respectively. According to the results described in this study, the PRIMO Monte Carlo software, in conjunction with the 6X FFF Varian phase-space files, can be used as secondary dose calculation software to check stereotactic radiosurgery plans from Eclipse using the HyperArc technique. [ABSTRACT FROM AUTHOR]

Multiple brain metastases single-isocenter stereotactic radiosurgery (SRS) treatment is increasingly employed in radiotherapy department. Before its use in clinical routine, it is recommended to perform end-to-end tests. In this work, we report the results of five HyperArcTM treatment plans obtained by both ionization chamber (IC) and polymer gel. The end-to-end tests were performed using a water equivalent Mobius Verification PhantomTM (MVP) and a 3D-printed anthropomorphic head phantom PseudoPatient® (PP) (RTsafe P.C., Athens, Greece); 2D and 3D dose distributions were evaluated on the PP phantom using polymer gel (RTsafe). Gels were read by 1.5T magnetic resonance imaging (MRI). Comparison between calculated and measured distributions was performed using gamma index passing rate evaluation by different criteria (5% 2 mm, 3% 2 mm, 5% 1 mm). Mean point dose differences of 1.01% [min −0.77%–max 2.89%] and 0.23% [min 0.01%–max 2.81%] were found in MVP and PP phantoms, respectively. For each target volume, the obtained results in terms of gamma index passing rate show an agreement >95% with 5% 2 mm and 3% 2 mm criteria for both 2D and 3D distributions. The obtained results confirmed that the use of a single isocenter for multiple lesions reduces the treatment time without compromising accuracy, even in the case of target volumes that are quite distant from the isocenter. [ABSTRACT FROM AUTHOR]

The aim of this study was to present our experience on clinical implementation of HyperArc including dosimetric comparison between VMAT and HyperArc plans and dosimetric verification of HyperArc. In this study, eleven previously treated cases of brain metastasis were selected from our brain stereotactic radiotherapy program. The cases were retrospectively planned using HyperArc technique and the plan quality was evaluated. In addition, dosimetric effects of HyperArc plan with different energies and using jaw tracking technique were evaluated. Furthermore, dosimetric verification of HyperArc plans was performed using ion chamber and radiochromic film. Our results of dosimetric comparison shows that HyperArc technique improved both conformity index and gradient index compared to VMAT plans. We also found that using 6MV flattening filter free (6MV-FFF) beam improves gradient index in HyperArc plans compared to using 6MV flattening filter beam. Furthermore, our results show that jaw tracking technique reduces the size of low dose volume while maintaining similar target coverage, conformity index, and gradient index. In our dosimetric verification study, results of ion chamber and film measurement indicate no significant difference between VMAT and HyperArc plans. In conclusion, HyperArc simplifies planning of stereotactic treatment for brain and improves the dosimetry in treatment plans. Additionally, HyperArc provides for a safe and efficient treatment delivery system for stereotactic treatments to brain. [ABSTRACT FROM AUTHOR]

The goal of this study is to fully automate the treatment planning and delivery process of hippocampal-sparing whole brain irradiation (HS-WBRT) by combining a RapidPlan (RP) knowledge-based planning model and HyperArc (HA) technology. Additionally, this study compares the dosimetric performance of RapidPlan-HyperArc (RP-HA) treatment plans with RP plans and volumetric modulated arc therapy (VMAT) plans. Ten patients previously treated with HS-WBRT using conventional VMAT were re-planned using RP-HA technique and RP model for HS-WBRT. Treatment plans were generated for 30Gy in 3Gy fractions using 6MV photon beam on a TrueBeam linear accelerator (Varian Medical Systems, Palo Alto, CA) equipped with high definition multileaf collimator (HDMLC). Target coverage, homogeneity index (HI), Paddick Conformity index (CI), dose to organs-at-risk (OARs) provided by the 3 planning modalities were compared, and a paired t-test was performed. Total number of monitor units (MU), effective planning time and beam-on-time time were reported and evaluated for each plan. RP-HA plans achieved on average a 4% increase in D 98% of PTV, a 26% improvement in HI, a 2.3% increase in CI, when compared to RP plans. Furthermore, RP-HA plans provided on average 11% decrease in D 100% of hippocampi when compared to VMAT plans. All RP-HA plans were generated in less than 30 minutes while RP plans took 40 minutes and VMAT plans required on average 9 hours to complete. Regarding beam-on-time time, it was estimated that RP-HA plans take on average 5 minutes to deliver while RP and VMAT plans require 6.5 and 10 minutes, respectively. RP-HA method provides fully automated planning and delivery for HS-WBRT. The auto-generated plans together with automated treatment delivery allow standardization of plan quality, increased efficiency and ultimately improved patient care. [ABSTRACT FROM AUTHOR]

Abstract Background Total scalp irradiation presents technical and dosimetric challenges. While reports suggest that HyperArc, a new stereotactic radiosurgery planning technique applied to non-coplanar volumetric-modulated arc therapy (VMAT) technique, is associated with high conformity and rapid dose fall-off, the performance of HyperArc for total scalp irradiation has not been explored. The current study aimed to compare the dosimetric performance of HyperArc plans with those of non-coplanar VMAT plans in angiosarcoma of the scalp. Methods Ten patients with angiosarcoma of the scalp were included in this study. The performance of three different plans administered using TrueBeam Edge were compared: non-coplanar VMAT using flattening filter (FF) beams (VMAT-FF), HyperArc using FF beams (HyperArc-FF), and HyperArc using flattening filter free (FFF) beams (HyperArc-FFF). The dose distribution, dosimetric parameters, and dosimetric accuracy for each of these plans were evaluated. Results The three plans showed no statistically significant differences in target volume coverage, conformity, and homogeneity. The HyperArc-FF and HyperArc-FFF plans provided significantly lower mean brain doses (12.63 ± 3.31 Gy and 12.71 ± 3.40 Gy) than did the VMAT-FF plans (17.11 ± 5.25 Gy). There were almost no differences in sparing the organs at risk between the HyperArc-FF and HyperArc-FFF plans. The HyperArc-FF and HyperArc-FFF plans provided a shorter beam-on time than did the VMAT-FF plan. The 3%/2 mm gamma test pass rates were above 95% for all three plans. Conclusions Our results suggest that the HyperArc plan can be potentially used for radiation therapy of target regions with large and complicated shapes, such as the scalp, and that there are no advantages of using FFF beams.

Abstract Background To evaluate dosimetric differences of salvage irradiations using two commercially available volumetric modulated arc therapy (VMAT) stereotactic body radiation therapy (SBRT) techniques: RapidArc (RA) and HyperArc (HA), for recurrent nasopharyngeal carcinoma (NPC) after initial radiation therapy. Methods Ten patients with recurrent NPC status previously treated with radiation therapy were considered suitable candidates for salvage SBRT using VMAT approach. Two separate treatment plans were created with HA and RA techniques for each case, with dosimetric outcomes compared with respect to tumor target coverage and organs-at-risk (OARs) sparing. Furthermore, the cumulative radiobiological effects to the relevant OARs from the original radiotherapy to the respective salvage SBRT plans were analyzed in terms of biologically effective dose (BED). Results Treatment with HA exhibited similar target dose coverage as with RA, while delivering a higher mean dose to the targets. Using RA technique, the mean maximal doses to optic apparatus and the mean brain dose were reduced by 1 to 1.5 Gy, comparing to HA technique. The conformity index, gradient radius, and intermediate dose spillage in HA plans were significantly better than those in RA. With HA technique, the volume of brain receiving 12 Gy or more was reduced by 44%, comparing to RA technique. The cumulative BEDs to spinal cord and optic apparatus with RA technique were 1 to 2 Gy3 less than those with HA. HA technique significantly reduced the volume within body that received more than 100 Gy. Conclusions With better dose distribution than RA while maintaining sufficient target dose coverage, HA represents an attractive salvage SBRT technique for recurrent NPC.

Background: Radiotherapy (RT) plays an integral role in the management of low-grade gliomas (LGG). Late toxicity from RT can cause progressive neurocognitive dysfunction. Radiation-induced damage to the hippocampus (HCP) plays a considerable role in memory decline. Advancements in photon planning software have resulted in the development of multi-criteria optimization (MCO) and HyperArc technologies which may improve HCP sparing while maintaining planning target volume (PTV) target coverage., Methods: Three planning methods for hippocampal sparing (HS) were compared, volumetric modulated arc therapy (VMAT) without HS (VMAT&#95;noHS), VMAT with HS (VMAT&#95;HS), MCO with HS (MCO&#95;HS), and HyperArc with HS (HyperArc&#95;HS)., Results: Twenty-five patients were identified. The contralateral HCP was spared in 16 patients and bilateral HCP in 9 patients with superiorly located tumors. All 3 HS planning techniques showed significant reductions in dose to the spared HCP in contralateral cases but only VMAT&#95;HS and MCO&#95;HS achieved this in bilateral cases ( P  < .008). Only MCO&#95;HS was superior to VMAT&#95;HS in lowering the dose to both contralateral HCP and bilateral HCP in all measured metrics ( P  < .008). PTV and OAR (organ at risk) dose constraints were achieved for all plans., Conclusions: This retrospective dosimetric study demonstrated the feasibility of HS for low-grade glioma. All 3 HS planning techniques achieved significant dose reductions to the spared contralateral hippocampus, but only MCO&#95;HS and VMAT&#95;HS achieved this in bilateral cases. MCO was superior to other planning techniques for sparing both bilateral and contralateral hippocampi., Competing Interests: The authors have no relevant disclosures., (© The Author(s) 2024. Published by Oxford University Press, the Society for Neuro-Oncology and the European Association of Neuro-Oncology.)

Aims: Evaluate effectiveness and safety of multiple HyperArc courses and patterns of progression in patients affected by BMs with intracranial progression., Methods: 56 patients were treated for 702 BMs with 197 (range 2-8) HyperArc courses in case of exclusive intracranial progression. Primary end-point was the overall survival (OS), secondary end-points were intracranial progression-free survival (iPFS), toxicity, local control (LC), neurological death (ND), and whole-brain RT (WBRT)-free survival. Site of progression was evaluated against isodoses levels (0, 1, 2, 3, 5, 7, 8, 10, 13, 15, 20, and 24 Gy.)., Results: The 1-year OS was 70 %, and the median was 20.8 months (17-36). At the univariate analysis (UVA) biological equivalent dose (BED) > 51.3 Gy and non-melanoma histology significantly correlated with OS. The median time to iPFS was 4.9 months, and the 1-year iPFS was 15 %. Globally, 538 new BMs occurred after the first HA cycle in patients with extracranial disease controlled. 96.4 % of them occurred within the isodoses range 0-7 Gy as follows: 26.6 % (0 Gy), 16.5 % (1 Gy), 16.5 % (2 Gy), 20.1 % (3 Gy), 13.1 % (5 Gy), 3.4 % (7 Gy) (p = 0.00). Radionecrosis occurred in 2 metastases (0.28 %). No clinical toxicity of grade 3 or higher occurred during follow-up. One- and 2-year LC was 90 % and 79 %, respectively. At the UVA BED > 70 Gy and non-melanoma histology were significant predictors of higher LC. The 2-year WBRT-free survival was 70 %. After a median follow-up of 17.4 months, 12 patients deceased by ND., Conclusion: Intracranical relapses can be safely and effectively treated with repeated HyperArc, with the aim to postpone or avoid WBRT. Diffuse dose by volumetric RT might reduce microscopic disease also at relatively low levels, potentially acting as a virtual CTV . Neurological death is not the most common cause of death in this population, which highlights the impact of extracranial disease on overall survival., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Author(s).)

The purpose of this work was to evaluate using Varian HyperArc as a planning and treatment solution for whole brain radiotherapy (WBRT) with hippocampal sparing following Radiation Therapy Oncology Group (RTOG) 0933 dosimetric criteria. Ten patients previously treated for intracranial lesions were retrospectively planned for WBRT with hippocampal sparing using HyperArc and a 2-arc coplanar VMAT technique. The whole brain and hippocampus were delineated on fused MRI and CT datasets. The planning target volume (PTV), defined as the whole brain excluding the hippocampal avoidance region, was prescribed 30 Gy in 10 fractions. Plans were evaluated using dosimetric parameters which included the volume of 105% of the prescription dose (V105%) and the maximum dose to the PTV, and the minimum dose to the hippocampus. The planning time, delivery time, and delivery quality assurance (QA) results were also evaluated. Statistical significance was performed between the HyperArc and coplanar VMAT metrics using the Wilcoxon signed-rank test with a significance level of 0.05. All plans met RTOG 0933 dosimetric criteria. HyperArc plans demonstrated significant improvements in PTV dosimetric quality which included a reduced V105% of 6 ± 7% and decreased maximum dose of 1.3 ± 0.3 Gy, compared to coplanar VMAT. Significant OAR sparing was also found for HyperArc plans that included a decreased minimum dose to the hippocampus of 0.3 ± 0.3 Gy. Coplanar VMAT plans resulted in significantly shorter planning and delivery times, compared to HyperArc, by 2.4 minutes and 1.5 minutes, respectively. No significant difference was found between the delivery QA results. This study demonstrated using Varian HyperArc as a planning and treatment solution for WBRT with hippocampal sparing following RTOG 0933 dosimetric criteria. The primary advantages of WBRT with hippocampal sparing using HyperArc, compared to coplanar VMAT, are the gains in OAR sparing and reduced high dose volumes to the PTV. [ABSTRACT FROM AUTHOR]

Purpose: Radiosurgery (SRS) is an effective treatment option for brain metastases (BMs). Long-term results of the first worldwide experience with a mono-isocentric, non-coplanar, linac-based stereotactic technique in the treatment of multiple BMs are reported. Methods: patients with multiple BMs, life expectancy > 3 months, and good performance status (≤ 2) were treated with simultaneous SRS with volumetric modulated arc technique. Data were retrospectively evaluated. Results: 172 patients accounting for 1079 BMs were treated at our institution from 2017 to 2020. The median number of treated metastases was 4 (range 2–22). Primary tumor histology was: lung (44.8%), breast (32%), and melanoma (9.4%). The 2-year LPFS was 71.6%, respectively. A biological effective dose (BED) ≥ 51.3 Gy10 correlated with higher local control. Uncontrolled systemic disease and melanoma histology were independent prognostic factors correlated with decreased iPFS. Patients with > 10 BMs had a trend towards shorter iPFS (p = 0.055). 31 patients received multiple SRS courses (2–7) in case of intracranial progression. The median iOS was 22.4 months. Brainstem metastases and total PTV > 7.1 cc correlated with shorter iOS. The 1- and 2-year WBRT-free survival was 83.2% and 61.1%, respectively. Conclusion: Long-term results in a large patient population treated with a mono-isocentric, dedicated technique demonstrated its effectiveness and safety also in the case of multiple courses. The shortened treatment time and the possibility to safely spare healthy brain tissue allows the safe treatment of patients with a large number of metastases and to deliver multiple courses of SRS. In selected cases, the administration of WBRT can be delayed. [ABSTRACT FROM AUTHOR]

The purpose of this study was to evaluate the feasibility and efficacy of HyperArc (HA) for recurrent nasopharyngeal cancer (NPC) by comparing it with the CyberKnife system (CK). Fifteen patients with recurrent nasopharyngeal cancer who were treated using the noncoplanar cone-based robotic CK system were enrolled. CK was delivered with a median dose of 37.5 Gy in 5 fractions. The delivered CK treatment plans were the sources for the corresponding homogeneous HA (HA-H) and inhomogeneous HA (HA-IH) plans. The HA-H plans were generated to meet the corresponding treatment plan criteria for the CK plans. The HA-IH plans were designed to emulate the corresponding inhomogeneous CK isodose distributions. These three SBRT treatment plans were compared with target coverage, sparing of organs at risk (OARs), and dose distribution metrics. The HA-H and HA-IH plans consistently exhibited CTV and PTV coverage levels similar or better to those of the CK plans but significantly reduced the dose to OARs. Using the HA techniques (both HA-H and HA-IH plans), the mean maximal doses to the spinal cord, brainstem, optic nerves, and optic chiasm were reduced by approximately 60%, compared to the CK plans. The high dose spillage, conformity, and homogeneity indices of the HA-H plans were significantly better than those of the CK plans. The HA-IH plans showed faster dose falloff and similar conformity of the HA-H plans and dose heterogeneity of the CK plans. Here we demonstrated the HA treatment plan system for recurrent NPC is feasible, either homogeneous or inhomogeneous delivery. Excellent sparing of OARs and dosimetric distribution and very efficient delivery make HA an attractive SBRT technique for recurrent NPC treatment. [ABSTRACT FROM AUTHOR]

Multiple brain metastases single-isocenter stereotactic radiosurgery (SRS) treatment is increasingly employed in radiotherapy department. Before its use in clinical routine, it is recommended to perform end-to-end tests. In this work, we report the results of five HyperArcTM treatment plans obtained by both ionization chamber (IC) and polymer gel. The end-to-end tests were performed using a water equivalent Mobius Verification PhantomTM (MVP) and a 3D-printed anthropomorphic head phantom PseudoPatient® (PP) (RTsafe P.C., Athens, Greece); 2D and 3D dose distributions were evaluated on the PP phantom using polymer gel (RTsafe). Gels were read by 1.5T magnetic resonance imaging (MRI). Comparison between calculated and measured distributions was performed using gamma index passing rate evaluation by different criteria (5% 2 mm, 3% 2 mm, 5% 1 mm). Mean point dose differences of 1.01% [min −0.77%–max 2.89%] and 0.23% [min 0.01%–max 2.81%] were found in MVP and PP phantoms, respectively. For each target volume, the obtained results in terms of gamma index passing rate show an agreement >95% with 5% 2 mm and 3% 2 mm criteria for both 2D and 3D distributions. The obtained results confirmed that the use of a single isocenter for multiple lesions reduces the treatment time without compromising accuracy, even in the case of target volumes that are quite distant from the isocenter.

Purpose: This study investigated the intra‐fractional motion (IM) of patients immobilized using the QFix Encompass Immobilization System during HyperArc (HA) treatment. Method: HA treatment was performed on 89 patients immobilized using the Encompass. The IM during treatment (including megavoltage (MV) registration) was analyzed for six degrees of freedom including three axes of translation (anterior‐posterior, superior‐inferior (SI) and left‐right (LR)) and three axes of rotation (pitch, roll, and yaw). Then, the no corrected IM (IMNC) was retrospectively simulated (excluding MV registration) in three directions (SI, LR, and yaw). Finally, the correlation between the treatment time and the IM of the 3D vector was assessed. Results: The average IM in terms of the absolute displacement were 0.3 mm (SI), 0.3 mm (LR) and 0.2° (yaw) for Stereotactic radiosurgery (SRS), and 0.3 mm (SI), 0.2 mm (LR), and 0.2° (yaw) for stereotactic radiotherapy (SRT). The absolute maximum values of IM were <1 mm along the SI and LR axes and <1° along the yaw axis. The absolute maximum displacements for IMNC were >1 mm along the SI and LR axes and >1° along the yaw axis. In the correlation between the treatment time and the IM, the r‐values were −0.025 and 0.027 for SRS and SRT respectively, along the axes of translation. For the axes of rotation, the r‐values were 0.012 and 0.206 for SRS and SRT, respectively. Conclusion: Encompass provided patient immobilization with adequate accuracy during HA treatment. The absolute maximum displacement IM was less than IMNC along the translational/rotational axes, and no statistically significant relationship between the treatment time and the IM was observed. [ABSTRACT FROM AUTHOR]

For many patients, stereotactic radiosurgery (SRS) offers a minimally invasive, curative option when surgical techniques are not possible. To date, the literature supporting the efficacy and safety of SRS treatment techniques uses photon beams. However, with the number of proton therapy facilities exponentially growing and the favorable physical properties of proton beam radiation therapy, there is an opportunity to develop proton therapy techniques for SRS. The goal of this paper is to determine the ability of clinical proton treatment planning systems to model small field dosimetry accurately and to compare various planning metrics used to evaluate photon SRS to determine the optimum beam configurations and settings for proton SRS (PSRS) treatment plans. Once established, these plan settings were used to perform a planning comparison on a variety of different SRS cases and compare SRS metrics between the PSRS plans and HyperArc™ (VMAT) SRS plans. [ABSTRACT FROM AUTHOR]

Abstract Background To appraise the dosimetric features and the quality of the treatment plan for radiosurgery of multiple brain metastases optimized with a novel automated engine and to compare with plans optimized for robotic-based delivery. Methods A set of 15 patients with multiple brain metastases was selected for this in silico study. The technique under investigation is the recently introduced HyperArc. For all patients, three treatment plans were computed and compared: i: a HyperArc; ii: a standard VMAT; iii) a CyberKnife. Dosimetric features were computed for the clinical target volumes as well as for the healthy brain tissue and the organs at risk. Results The data showed that the best dose homogeneity was achieved with the VMAT technique. HyperArc allowed to minimize the volume of brain receiving 4Gy (as well as for the mean dose and the volume receiving 12Gy, although not statistically significant). The smallest dose on 1 cm3 volume for all organs at risk is for CK techniques, and the biggest for VMAT (p

Abstract Background Linac-based stereotactic radiosurgery or fractionated stereotactic radiotherapy (SRS/FSRT) of multiple brain lesions using volumetric modulated arc therapy (VMAT) is typically performed by a multiple-isocenter approach, i.e. one isocenter per lesion, which is time-demanding for the need of independent setup verifications of each isocenter. Here, we present our initial experience with a new dedicated mono-isocenter technique with multiple non-coplanar arcs (HyperArc™, Varian Inc.) in terms of a plan comparison with a multiple-isocenter VMAT approach. Methods From August 2017 to October 2017, 20 patients with multiple brain metastases (mean 5, range 2–10) have been treated by HyperArc in 1–3 fractions. The prescribed doses (Dp) were 18–25 Gy in single-fraction, and 21–27 Gy in three-fractions. Planning Target Volume (PTV), defined by a 2 mm isotropic margin from each lesion, had mean dimension of 9.6 cm3 (range 0.5–27.9 cm3). Mono-isocenter HyperArc VMAT plans (HA) with 5 non-coplanar 180°-arcs (couch at 0°, ±45°, ±90°) were generated and compared to multiple-isocenter VMAT plans (RA) with 2 coplanar 360°-arcs per isocenter. A dose normalization of 100%Dp at 98%PTV was adopted, while D2%(PTV)

Abstract Purpose The HyperArc VMAT (HA-VMAT) planning approach was newly developed to fulfill the demands of dose delivery for brain metastases stereotactic radiosurgery. We compared the dosimetric parameters of the HA-VMAT plan with those of the conventional VMAT (C-VMAT). Material and methods For 23 patients (1–4 brain metastases), C-VMAT and HA-VMAT plans with a prescription dose of 20–24 Gy were retrospectively generated, and dosimetric parameters for PTV (homogeneity index, HI; conformity index, CI; gradient index, GI) and brain tissue (V2Gy-V16Gy) were evaluated. Subsequently, the physical characteristics (modulation complexity score for VMAT, MCSV; Monitor unit, MU) of both treatment approaches were compared. Results HA-VMAT provided higher HI (1.41 ± 0.07 vs. 1.24 ± 0.07, p

Background: Total scalp irradiation presents technical and dosimetric challenges. While reports suggest that HyperArc, a new stereotactic radiosurgery planning technique applied to non-coplanar volumetric-modulated arc therapy (VMAT) technique, is associated with high conformity and rapid dose fall-off, the performance of HyperArc for total scalp irradiation has not been explored. The current study aimed to compare the dosimetric performance of HyperArc plans with those of non-coplanar VMAT plans in angiosarcoma of the scalp.Methods: Ten patients with angiosarcoma of the scalp were included in this study. The performance of three different plans administered using TrueBeam Edge were compared: non-coplanar VMAT using flattening filter (FF) beams (VMAT-FF), HyperArc using FF beams (HyperArc-FF), and HyperArc using flattening filter free (FFF) beams (HyperArc-FFF). The dose distribution, dosimetric parameters, and dosimetric accuracy for each of these plans were evaluated.Results: The three plans showed no statistically significant differences in target volume coverage, conformity, and homogeneity. The HyperArc-FF and HyperArc-FFF plans provided significantly lower mean brain doses (12.63 ± 3.31 Gy and 12.71 ± 3.40 Gy) than did the VMAT-FF plans (17.11 ± 5.25 Gy). There were almost no differences in sparing the organs at risk between the HyperArc-FF and HyperArc-FFF plans. The HyperArc-FF and HyperArc-FFF plans provided a shorter beam-on time than did the VMAT-FF plan. The 3%/2 mm gamma test pass rates were above 95% for all three plans.Conclusions: Our results suggest that the HyperArc plan can be potentially used for radiation therapy of target regions with large and complicated shapes, such as the scalp, and that there are no advantages of using FFF beams. [ABSTRACT FROM AUTHOR]

Background: To evaluate dosimetric differences of salvage irradiations using two commercially available volumetric modulated arc therapy (VMAT) stereotactic body radiation therapy (SBRT) techniques: RapidArc (RA) and HyperArc (HA), for recurrent nasopharyngeal carcinoma (NPC) after initial radiation therapy.Methods: Ten patients with recurrent NPC status previously treated with radiation therapy were considered suitable candidates for salvage SBRT using VMAT approach. Two separate treatment plans were created with HA and RA techniques for each case, with dosimetric outcomes compared with respect to tumor target coverage and organs-at-risk (OARs) sparing. Furthermore, the cumulative radiobiological effects to the relevant OARs from the original radiotherapy to the respective salvage SBRT plans were analyzed in terms of biologically effective dose (BED).Results: Treatment with HA exhibited similar target dose coverage as with RA, while delivering a higher mean dose to the targets. Using RA technique, the mean maximal doses to optic apparatus and the mean brain dose were reduced by 1 to 1.5 Gy, comparing to HA technique. The conformity index, gradient radius, and intermediate dose spillage in HA plans were significantly better than those in RA. With HA technique, the volume of brain receiving 12 Gy or more was reduced by 44%, comparing to RA technique. The cumulative BEDs to spinal cord and optic apparatus with RA technique were 1 to 2 Gy3 less than those with HA. HA technique significantly reduced the volume within body that received more than 100 Gy.Conclusions: With better dose distribution than RA while maintaining sufficient target dose coverage, HA represents an attractive salvage SBRT technique for recurrent NPC. [ABSTRACT FROM AUTHOR]

We assessed the effect of collimator angle on the dosimetric parameters for targets and organs at risk (OARs) for collimator-optimized HA (CO-HA) and non-CO-HA (nCO-HA) plans. The nCO-HA and CO-HA plans were retrospectively generated for 26 patients (1 to 8 brain metastases). The dosimetric parameters for planning target volume (homogeneity index [HI]; conformity index [CI]; gradient index [GI]) and for OARs were compared. The modulation complexity score for volumetric modulated arc therapy (MCSV) and monitor units (MUs) were calculated. Doses were measured using the electronic portal imaging device and compared with the expected doses. Dosimetric parameters of the HI, CI, and GI for single (n = 12) and multiple (n = 14) metastases cases were comparable (p > 0.05). For multiple metastases cases, the CO-HA plan provided lower V 4Gy , V 12Gy , V 14Gy , V 16Gy for brain tissue compared to the nCO-HA plan (p < 0.05). Doses for OARs (D 0.1cc) (brainstem, chiasm, Hippocampus, lens, optic nerves, and retinas) were comparable (p > 0.05). For multiple metastases cases, the CO-HA plan resulted in less complex multileaf collimator (MLC) patterns (MCSV = 0.19 ± 0.04, p < 0.01), lower MUs (8596 ± 1390 MUs, p < 0.01), and shorter beam-on time (6.2 ± 1.0 min, p < 0.01) compared to the nCO-HA plan (0.16 ± 0.04, 9365 ± 1630, and 6.7 ± 1.2 for MCSV, MUs, and beam-on time, respectively). For both treatment approach, the equivalent gamma passing rate was obtained with the 3%/3 mm and 2%/2 mm criteria (p > 0.05). The collimator optimization in the HA planning reduced doses to brain tissues and improved the treatment efficacy. [ABSTRACT FROM AUTHOR]