Treatment planning comparison of volumetric modulated arc therapy employing a dual-layer stacked multi-leaf collimator and helical tomotherapy for cervix uteri

Development and validation of an automated Tomotherapy planning method for cervical cancer

PURPOSE

This study aimed to develop an automated Tomotherapy (TOMO) planning method for cervical cancer treatment, and to validate its feasibility and effectiveness.

MATERIALS AND METHODS

The study enrolled 30 cervical cancer patients treated with TOMO at our center. Utilizing scripting and Python environment within the RayStation (RaySearch Labs, Sweden) treatment planning system (TPS), we developed automated planning methods for TOMO and volumetric modulated arc therapy (VMAT) techniques. The clinical manual TOMO (M-TOMO) plans for the 30 patients were re-optimized using automated planning scripts for both TOMO and VMAT, creating automated TOMO (A-TOMO) and automated VMAT (A-VMAT) plans. We compared A-TOMO with M-TOMO and A-VMAT plans. The primary evaluated relevant dosimetric parameters and treatment plan efficiency were assessed using the two-sided Wilcoxon signed-rank test for statistical analysis, with a P-value < 0.05 indicating statistical significance.

RESULTS

A-TOMO plans maintained similar target dose uniformity compared to M-TOMO plans, with improvements in target conformity and faster dose drop-off outside the target, and demonstrated significant statistical differences (P+ < 0.01). A-TOMO plans also significantly outperformed M-TOMO plans in reducing V50Gy, V40Gy and Dmean for the bladder and rectum, as well as Dmean for the bowel bag, femoral heads, and kidneys (all P+ < 0.05). Additionally, A-TOMO plans demonstrated better consistency in plan quality. Furthermore, the quality of A-TOMO plans was comparable to or superior than A-VMAT plans. In terms of efficiency, A-TOMO significantly reduced the time required for treatment planning to approximately 20 min.

CONCLUSION

We have successfully developed an A-TOMO planning method for cervical cancer. Compared to M-TOMO plans, A-TOMO plans improved target conformity and reduced radiation dose to OARs. Additionally, the quality of A-TOMO plans was on par with or surpasses that of A-VMAT plans. The A-TOMO planning method significantly improved the efficiency of treatment planning.

Evaluation of the Treatment Planning and Delivery for Hip Implant Cases on Tomotherapy

Purpose

The metal present in the implant creates artifacts during the treatment simulation, which impacts the treatment planning and delivery of the prescribed dose to the target and sparing normal tissues. This retrospective study evaluated the uncertainties in the planning and delivery of doses for prosthesis cases with dedicated phantom.

Materials and Methods

In this retrospective study, 11 patients with a hip prosthesis having cervix carcinoma were selected. Two treatment plans were generated on treatment planning system (TPS) for each case. Plan_No_Res was without any beam restriction, and Plan_exit_only was the plan with restricted beam entry through the metallic implant. An indigenous phantom was utilized to verify the accuracy of the treatment. In the phantom, some groves were present, which could be filled by implants that mimic the patient's geometries, like left, right and bilateral femur implants. The delivered doses were recorded using optically stimulated luminescence dosimeters (OSLDs), which were placed at different positions in the phantom. The plans were further calculated using megavoltage computed tomography (MVCT) scans acquired during treatment.

Results

The patient data showed no significant dose changes between the two planning methods. The treatment time increases from 412.18 ± 86.65 to 427.36 ± 104.80 with P = 0.03 for Plan_No_Res and Plan_exit_only, respectively. The difference between planned and delivered doses of various points across phantom geometries was within ± 9.5% in each case as left, right, and bilateral implant. The variations between OSLDs and MVCT calculated doses were also within ± 10.8%.

Conclusion

The study showed the competency of tomotherapy planning for hip prosthesis cases. The phantom measurements demonstrate the errors in dosimetry near the implant material, suggesting the need for precise methods to deal with artifact-related issues.

Dosimetric comparison between VMAT plans using the fast-rotating O-ring linac with dual-layer stacked MLC and helical tomotherapy for nasopharyngeal carcinoma

BACKGROUND

To compare the dosimetric profiles of volumetric modulated arc therapy (VMAT) plans using the fast-rotating O-ring linac (the Halcyon system) based on a dual-layer stacked multi-leaf collimator and helical tomotherapy (HT) for nasopharyngeal cancer (NPCa).

METHODS

For 30 NPCa patients, three sets of RT plans were generated, under the same policy of contouring and dose constraints: HT plan; Halcyon VMAT plan with two arcs (HL_2arc); and Halcyon VMAT plan with four arcs (HL_4arc), respectively. The intended dose schedule was to deliver 67.2 Gy to the planning gross target volume (P-GTV) and 56.0 Gy to the planning clinical target volume (P-CTV) in 28 fractions using the simultaneously integrated boost concept. Target volumes and organ at risks dose metrics were evaluated for all plans. Normal tissue complication probabilities (NTCP) for esophagus, parotid glands, spinal cord, and brain stem were compared.

RESULTS

The HT plan achieved the best dose homogeneity index for both P_GTV and P_CTV, followed by the HL_4arc and L_2arc plans. No significant difference in the dose conformity index (CI) for P_GTV was observed between the HT plan (0.80) and either the HL_2arc plan (0.79) or the HL_4arc plan (0.83). The HL_4arc plan showed the best CI for P_CTV (0.88), followed by the HL_2arc plan (0.83) and the HT plan (0.80). The HL_4arc plan (median, interquartile rage (Q1, Q3): 25.36 (22.22, 26.89) Gy) showed the lowest D_mean in the parotid glands, followed by the HT (25.88 (23.87, 27.87) Gy) and HL_2arc plans (28.00 (23.24, 33.99) Gy). In the oral cavity (OC) dose comparison, the HT (22.03 (19.79, 24.85) Gy) plan showed the lowest D_mean compared to the HL_2arc (23.96 (20.84, 28.02) Gy) and HL_4arc (24.14 (20.17, 27.53) Gy) plans. Intermediate and low dose regions (40-65% of the prescribed dose) were well fit to the target volume in HL_4arc, compared to the HT and HL_2arc plans. All plans met the dose constraints for the other OARs with sufficient dose margins. The between-group differences in the median NTCP values for the parotid glands and OC were < 3.47% and < 1.7% points, respectively.

CONCLUSIONS

The dosimetric profiles of Halcyon VMAT plans were comparable to that of HT, and HL_4arc showed better dosimetric profiles than HL_2arc for NPCa.

Investigation of Halcyon multi-leaf collimator model in Eclipse treatment planning system: A focus on the VMAT dose calculation with the Acuros XB algorithm

Purpose

The dual‐layer multi‐leaf collimator (MLC) in Halcyon involves further complexities in the dose calculation process, because the leaf‐tip transmission varies according to the leaf trailing pattern. For the volumetric modulated arc therapy (VMAT) treatment, the prescribed dose for the target volume can be sensitive to the leaf‐tip transmission change. This report evaluates the dosimetric consequence due to the uncertainty of the dual‐layer MLC model in Eclipse through the dose verifications for clinical VMAT. Additionally, the Halcyon leaf‐tip model is empirically adjusted for the VMAT dose calculation with the Acuros XB.

Materials and methods

For this evaluation, an in‐house program that analyzes the leaf position in each layer was developed. Thirty‐two clinical VMAT plans were edited into three leaf sequences: dual layer (original), proximal single layer, or distal single layer. All leaf sequences were verified using Delta4 according to the dose difference (DD) and the global gamma index (GI). To improve the VMAT dose calculation accuracy, the dosimetric leaf gap (DLG) was adjusted to minimize the DD in single‐layer leaf sequences.

Results

The mean of DD were −1.35%, −1.20%, and −1.34% in the dual‐layer, proximal single‐layer, and distal single‐layer leaf sequences, respectively. The changes in the mean of DD between leaf sequences were within 0.2%. However, the calculated doses differed from the measured doses by approximately 1% in all leaf sequences. The tuned DLG was increased by 0.8 mm from the original DLG in Eclipse. When the tuned DLG was used in the dose calculation, the mean of DD neared 0% and GI with a criterion of 2%/2 mm yielded a pass rate of more than 98%.

Conclusion

No significant change was confirmed in the dose calculation accuracy between the leaf sequences. Therefore, it is suggested that the dosimetric consequence due to the leaf trailing was negligibly small in clinical VMAT plans. The DLG tuning for Halcyon can be useful for reducing the dose calculation uncertainties in Eclipse VMAT and required in the commissioning for Acuros XB.

Plan Quality Comparison Between Hippocampus-Sparing Whole-Brain Radiotherapy Treated With Halcyon and Tomotherapy Intensity-Modulated Radiotherapy

Objective: Hippocampus-sparing whole-brain radiotherapy using Halcyon, an instrument dedicated to volumetric modulated arc therapy, has not been studied till date; hence, we aimed to examine whether it can meet the RTOG0933 criteria. Based on this, we compared Halcyon to Tomotherapy, which also uses an O-ring-type linear accelerator. Methods: This exploratory, experimental, and retrospective study used 5 sets of computed tomography images in the head area to investigate the planning target volume, hippocampal doses, and irradiation time. Calculations were performed from 1 to 4 arcs to determine the optimal number of arcs in the Halcyon plan, which were compared to those of Tomotherapy. Results: The Radiation Therapy Oncology Group 0933 criteria could not be satisfied in Halcyon with 1 arc. With 2 arcs, the condition D_max<16 Gy was not satisfied for 1 case in the hippocampus. Since there were no significant differences between 3 and 4 arcs, including the irradiation time, 3 arcs were considered the best. We compared Halcyon at 3 arcs with tomotherapy and found that tomotherapy was inferior to Halcyon at D_98%; however, it was superior to Halcyon in other dose parameters. In contrast, the irradiation time in Halcyon was overwhelmingly superior, with the irradiation time for Halcyon being 1/ninth the time for Tomotherapy. Conclusion: Halcyon was effective in handling hippocampus-sparing whole-brain radiotherapy. We believe that 3-arc radiation is best suited for this procedure. Although Halcyon was inferior to Tomotherapy in terms of dose distribution excluding D_98%, it was overwhelmingly superior in terms of irradiation time.

Dosimetric comparison of VitalBeam® and HalcyonTM 2.0 for hypofractionated VMAT with simultaneous integrated boost treatment of early-stage left-sided breast cancer

Purpose

This study compared the quality of treatment plans for early‐stage, left‐sided breast cancer, as planned for and delivered by the Halcyon^TM and VitalBeam^®.

Materials and methods

Fifteen patients diagnosed with early‐stage left‐sided breast cancer, who had received VMAT with hypofractionated SIB, were recruited. All cases were planned using Halcyon^TM comprising a dual‐layer MLC (DL‐MLC) and VitalBeam^® with a Millennium 120 MLC (VB‐MLC). For the PTVs, the quality of coverage (QC), conformity index (CI), and homogeneity index (HI) were calculated for each plan. The dosimetric differences between the two treatment plans were statistically compared using the Wilcoxon signed‐rank test (p < 0.05). To evaluate delivery efficiency, the average delivery time for each patient's treatment plan was recorded and compared.

Results

For the PTVs, the two plans (DL‐MLC and VB‐MLC) were comparable in terms of the QC, CI, and HI. However, V_30Gy and D_mean for the heart in the DL‐MLC plan were significantly reduced by 0.49% and 14.6%, respectively, compared with those in the VB‐MLC plan (p < 0.05). The D_mean value for the ipsilateral lung in the DL‐MLC plan significantly decreased by 5.5%, compared with that in the VB‐MLC plan (p < 0.05). In addition, the delivery times for the DL‐MLC and VB‐MLC plans were 79 ± 10 and 101 ± 11 s, respectively.

Conclusions

DL‐MLC plans were found to improve OAR sparing. In particular, when treating left‐sided breast cancer via DL‐MLC plans, the risk of heart toxicity is expected to be reduced.

Contribution of Tata Memorial Centre, India, to cervical cancer care: Journey of two decades

Cervical cancer continues to be a major public health concern in India and other low- and middle-income countries. Tata Memorial Centre, India, has been at the forefront in providing treatment, developing best practice guidelines for low-cost efficacious interventions, conducting practice-changing randomized trials and engaging in regional and international collaborations for education and research in cervical cancer. This review summarizes how cervical cancer research and clinical care has evolved over the past two decades at the Tata Memorial Centre, right from testing low-cost public health screening of cervical cancers to the incorporation of the latest technological advancements and providing high-quality evidence for therapeutic management of cervical cancer. The various ongoing strategies for improving survival, toxicity reduction, translational research studies, educational activities and teaching programmes initiated by the Tata Memorial Centre at both national and international levels are discussed.

A novel external beam radiotherapy method for cervical cancer patients using virtual straight or bending boost areas; an in-silico feasibility study

Aim

To investigate the potential role of a novel spatially fractionated radiation therapy (SFRT) method where heterogeneous dose patterns are created in target areas with virtual rods, straight or curving, of variable position, diameter, separation and alignment personalised to a patient’s anatomy. The images chosen for this study were CT scans acquired for the external beam part of radiotherapy.

Methods

Ten patients with locally advanced cervical cancer were retrospectively investigated with SFRT. The dose prescription was 30 Gy in 5 fractions to 90% target volume coverage. Peak-and-valley (SFRT_1) and peak-only (SFRT_2) strategies were applied to generate the heterogeneous dose distributions. The planning objectives for the target (CTV) were D_90% ≥ 30 Gy, V_45Gy ≥ 50–55% and V_60Gy ≥ 30%. The planning objectives for the organs at risk (OAR) were: D_2cm3 ≤ 23.75 Gy, 17.0 Gy, 19.5 Gy, 17.0 Gy for the bladder, rectum, sigmoid and bowel, respectively. The plan comparison was performed employing the quantitative analysis of the dose-volume histograms.

Results

The D_2cm3 was 22.4 ± 2.0 (22.6 ± 2.1) and 13.9 ± 2.9 (13.2 ± 3.0) for the bladder and the rectum for SFRT_1 (SFRT_2). The results for the sigmoid and the bowel were 2.6 ± 3.1 (2.8 ± 3.0) and 9.1 ± 5.9 (9.7 ± 7.3), respectively. The hotspots in the target volume were V_45Gy = 43.1 ± 7.5% (56.6 ± 5.6%) and V_60Gy = 15.4 ± 5.6% (26.8 ± 6.6%) for SFRT_1 (SFRT_2). To account for potential uncertainties in the positioning, the dose prescription could be escalated to D_90% = 33–35 Gy to the CTV without compromising any constraints to the OARs

Conclusion

In this dosimetric study, the proposed novel planning technique for boosting the cervix uteri was associated with high-quality plans, respecting constraints for the organs at risk and approaching the level of dose heterogeneity achieved with routine brachytherapy. Based on a sample of 10 patients, the results are promising and might lead to a phase I clinical trial.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13014-021-01838-x.

Brachytherapy or external beam radiotherapy as a boost in locally advanced cervical cancer: a Gynaecology Study Group in the Italian Association of Radiation and Clinical Oncology (AIRO) review

This review analyzes the experience and trends in external beam radiotherapy for delivering a boost in locally advanced cervical cancer, identifying whether radiation therapy modalities impact clinical outcomes with the ultimate aim of evaluating alternatives to brachytherapy. Three independent Italian radiation oncologists conducted a literature search on different external beam radiotherapy boost modalities in locally advanced cervical cancer. The search yielded 30 studies. Eight dosimetric studies, evaluating target coverage and dose to organs at risk, and nine clinical investigations, reporting clinical outcomes, were analyzed. Dosimetric studies comparing external beam radiotherapy boost with brachytherapy produced divergent results, while clinical studies were limited by their retrospective nature, heterogeneous doses, radiation schedules, volumes and techniques, diverse follow-up times, and small cohorts of patients. Evidence emerged that high-tech external beam radiotherapy seemed no better than image-guided brachytherapy for delivering a boost in locally advanced cervical cancer. Prospective clinical studies comparing high-tech external beam radiotherapy and image-guided brachytherapy should be encouraged.