Capstone Research Paper Outline

Group7_2019

I. ABSTRACT
II. Introduction
A. Stereotactic body radiation therapy (SBRT) in the treatment of liver cancer or
liver metastases has been shown to be safe and provide excellent outcomes.1,2
1. Stereotactic body radiation therapy treatment planning goals are to
deliver the prescribed therapeutic radiation dose to the planning target
volume (PTV) and ensure rapid dose fall-off from the PTV to provide
needed organs at risk (OAR) sparing.
2. Dosimetric coverage of PTV is of paramount importance to achieve
goals of both local control (LC) and overall survival (OS).
3. Studies have shown superior outcomes in both LC and OS in patients
treated with liver SBRT when a biologically effective dose (BED10Gy) of
100Gy or more is delivered.3,4
4. Inherent risks of increased doses to organs at risk (OAR) are associated
with SBRT and special considerations must be made during treatment
planning.5
5. Challenges in gaining adequate dosimetric coverage to PTV can arise
when surrounded by, include, or abut tissues of low density such as lung
parenchyma.
B. Differing dose calculation algorithms can result in disparate calculated doses of
both OAR and PTVs that neighbor or include tissues of low densities and can
have the potential to make a clinical impact.6
1. Although the Analytical Anisotropic Algorithm (AAA) is more widely
used in clinical routine, Acuros XB algorithm (AXB) has been shown to
more accurately model dose distributions, especially in tissue with high
heterogeneity.7
 2. Furthermore, AAA has the tendency to overestimate the median and
mean dose to the PTV and gross tumor volume (GTV) respectively,
which in turn has the potential to directly affect clinical outcomes.7
3. Cakir8 studied dosimetric plan results with 10MV flattening filter free
(FFF) beams using AAA and AXB calculation algorithms in the
treatment of liver lesions and the effect of calculation grid size.
4. This study is limited in that it is not specific to liver PTVs located near
the liver dome which interface with lung tissue.
5. As treatment facilities replace older generation linear accelerators with
modern ones, a greater number of patients will receive stereotactic
radiation therapy treatments with state-of-the-art equipment with
enhanced features such as FFF beams.
C. The utilization of FFF beams, when available to clinicians, has become the
standard for both stereotactic radiosurgery (SRS) and SBRT.
1. The dramatic increased dose rate of FFF beams in comparison to
flattening filter (FF) beams enables a decrease in treatment delivery
times with reduction in OAR and PTV intra-fraction motion.
2. Additionally, patient comfort is enhanced with less time spent on the
treatment table.
3. Flattening filter free beams have several advantages over FF beams
including an increased dose rate factor of 2-4, decreased production of
head scatter, and less lateral transport due to a softer beam spectra.9
4. Flattening filter free beams and the effects of OAR sparing and PTV
coverage have been studied.10
5. Yan et al10 found although PTV coverage was similar between 10MV
FFF and FF beams, differences in OAR sparing with FFF beam was
significant for some treatment sites.
D. In the SBRT treatment of liver lesions, an optimal 10 MV FFF beam MLC margin
surrounding PTV was investigated.11
 1. A study performed by Ogata et al11 identified the suitable multi-leaf
collimator (MLC) margins in patients treated with liver SBRT and
10MV FFF beams.
2. This study was limited in that an advanced calculation such as AXB 7
was not employed, and the liver PTV’s studied were not explicitly
reported to be at the dome of the liver. Planning target volume
coverage challenges arise in SBRT planning when PTVs are associated
with tissues of low densities.
3. Dosimetric coverage of PTV’s in liver SBRT is critical to achieve
positive LC and OS results.
4. Acuros XB algorithm has been shown to be superior in comparison to
convolution-superposition algorithms such as AAA in modeling doses
in regions of high tissue inhomogeneities.
5. The use of FFF beams in SBRT is advantageous over FF beams in terms
of considerable reduction in treatment delivery times and less head
scatter production.
6. This study intends to find optimal 10MV FFF beam MLC margins in
SBRT of liver PTVs at the dome of liver utilizing an algorithm with
superior dose modeling capabilities.
III. Methods and Materials
Patients
A. Ten patients who were previously treated in our department for primary liver
cancer or liver metastases located at the dome of liver were selected for the study.
1. Planning target volumes ranged between 7.8cc and 59.4cc.
B. Computed Tomography scans were obtained with the patient in supine orientation
with head towards gantry and both arms above head.
1. Treatment planning computed tomography (TPCT) images were
acquired with 2.5mm slice thickness during end expiratory breath-hold
phase for simulation and subsequent treatment.
a. Varian RPM system was utilized during simulation to track
patient breathing cycle and allow gated TPCT acquisition.
 2. Immobilization devices used include headrest, Vac-Loc bag under
patient head through hips, wingboard, and triangle sponge under knees
with feet banded.
Contouring

A. Gross tumor volume was delineated on TPCT by the attending physician in

Eclipse treatment planning system (TPS).
1. Planning target volume was then generated by GTV expansion of 1cm in
the superior and inferior directions and 0.5cm radially.
2. Organs at Risk volumes including the liver, spinal cord, heart, lungs, and
esophagus were outlined by the planning medical dosimetrist.
3. Liver volume was specified as normal liver minus GTV.

Treatment Planning

A. All ten patients selected for this study were planned for 50Gy to be delivered to
PTV at 10Gy per fraction for 5 fractions.
1. Treatment plans were created in Eclipse TPS utilizing a dynamic
conformal arc (DCA) technique consisting of 6 non-coplanar arcs with
each arc travel range between 35 to 60 degrees.
2. Flattening filter free 10MV photon beams with dose rate of 2400
monitor units (MU) per minute were used in planning for treatment on a
Varian TrueBeam linear accelerator with 120 MLC system.
3. Plans were normalized such that 95% of the PTV was encompassed by
the prescription dose of 50Gy (D95 = 50Gy).
B. Optimized DCA plans were developed using both AAA and AXB algorithms
followed by plans then calculated with AXB algorithm with preset MU from
AAA plans.
1. Dynamic conformal arc treatment plans were generated using AAA
algorithm with various MLC margins surrounding PTV.
a. Multi leaf collimator margins ranged between -3mm to 5mm in
1mm increments.
 b. Plan normalization was set such that 95% of PTV received
prescription dose of 50Gy.
2. Treatment plans with DCA technique were then developed using AXB
algorithm with various MLC margins surrounding PTV.
a. Multi leaf collimator margins ranged between -3mm to 5mm in
1mm increments.
b. Plan normalization was set such that 95% of PTV received
prescription dose of 50Gy
3. Optimized AAA plans were then recalculated with AXB algorithm using
preset MU from AAA plans.
a. No plan normalization was assigned.
Plan Comparisons

A. Plan result comparisons were made between the optimized AAA and AXB
treatment plans to evaluate differences between them using various quality
indices.
1. Metrics used in analysis were dose received by 99% of PTV volume
(D99), dose received by 95% of PTV volume (D95), mean PTV dose,
homogeneity index (HI) defined as dose received by 5% of volume (D5%)
divided by dose received by 95% of volume (D95%), RTOG conformity
index (CIRTOG) defined as prescription isodose volume (PIV) divided by
target volume (TV), gradient index (GI) defined as half prescription
isodose volume (PIVhalf) divided by prescription isodose volume (PIV),
mean liver dose, and volume of liver receiving 20Gy or more (V20Gy).
B. PTV doses were correlated between the optimized AAA plans and AXB plans
recalculated with preset MU from AAA plans.
1. Dose received by 99% of PTV volume (D99), D95, and mean PTV dose
were compared between plans.
C. Optimized AXB plans were then analyzed to identify the optimal MLC margins
using plan quality metrics including PTV D99, mean PTV dose, HI, CI, GI, liver
mean dose and liver V20Gy.
 References
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