Evaluation of Plan Dosimetry using Scoring Index for Prostate Intensity Modulated Radiation Therapy (IMRT)

Ghufran Ali, Shoukat Ali, Abdul Qadir Jangda

Radiation Oncology, Aga Khan University Hospital Karachi

Background
For the radiation therapy of prostate cancer, IMRT has been established in modern clinic to improve dose distribution with possible fewer side effects. The no. of fields and field orientation is the most important and basic parameter to establish IMRT in achieving the optimum target coverage while sparing organs at risk. This study focuses on the dosimetric comparison on the basis of Scoring Index with respect to lateral separation of patients in prostate IMRT.

IMRT Beam Orientation

Dose Volume histogram

Five Fields Plan

Seven Fields Plan

Nine Fields Plan

Comparison of different plans

Table1. Composite Score for Target Coverage

No. Of Separation 30-34cm Separation 40-44cm Fields Parameters CS Avg. CS Criteria Parameters CS Avg. CS MUs 4 MUs 4 CI 3 CI 2 5 3.25 G 2.5 GM 3 GM 1 Hot Spot 3 Hot Spot 3 MUs 2 MUs 3 CI 3 CI 2 7 2.5 A 3 GM 3 GM 3 Hot Spot 2 Hot Spot 4 MUs 2 MUs 2 CI 2 CI 3 9 2.25 A 2.5 GM 3 GM 2 Hot Spot 2 Hot Spot 3 Criteria

Results
The study shows that 5 fields provides a good dose homogeneity and less dose to OAR for the lateral separation ranging from 30 to 34 cm. However, it is noted that Seven field plan is good compare to five and nine field if patients separation in between 40 to 44cm.Table 1,2 and 3 show details of evaluation of treatment plans on the basis of composite score. However if we use nine field for greater separation than there is no dosimetric advantages. It may increase number of monitor units (MUs) and treatment time.

Objectives
Intensity Modulated Radiation Therapy (IMRT) has been most employed for the successful treatment of prostate cancer by dose escalation to the target while sparing organs at risk. The present study is designed to investigate the dosimetric effects of number of fields and field orientation on the basis of lateral separation through composite scoring in prostate IMRT.

Table2. Composite Score for OAR

Separation 30-34cm Separation 40-44cm No. Of CS CS Fields Parameters Avg. CS Criteria Parameters Avg. CS 5 Rectum Bladder F.H Rectum Bladder F.H Rectum Bladder F.H 3 3 3 2 2 1 2 1 1 3 G Rectum Bladder F.H Rectum Bladder F.H Rectum Bladder F.H 2 2 1 3 3 3 2 2 2 1.66 Criteria P

Methods and Materials

Six patients of prostate cancer were chosen for the study in which three patients were of less separation (30-34cm) and three of larger separation (40-44 cm). Each patient planned in three phases. First phase was planned with three dimensional conformal radiotherapy 3DCRT up to 45Gy in 25 fractions with four field box technique to whole pelvis. Then patients replanned with IMRT to 66Gy to cover planning target volume (PTV) and seminal vesicle. Third phase were also planned with IMRT up to 77.40Gy to cover only Gross tumor volume(GTV).All planning were performed in Eclipse treatment planning system and evaluated on the basis of scoring index which is our assumed value based on doses of Organ at risk (OAR) and all necessary parameters which describe in Table 1 and 2.on the behalf of this scoring index we classified treatment plan as Excellent (E), good (G), average (A) and poor (P) and assigned the composite score (CS) 4,3,2 and 1 respectively.

Conclusion
3 G

1.66

1.33

Table3. Cumulative CS
Cumulative CS No. Of Fields Separation 30-34cm Criteria Cumulative CS Separation 40-44cm Criteria

5 7 9

3.13 2.08 1.83

G A P

2.08 3 2.25

A G A

Cumulative CS = (Avg. CS of target coverage + Avg. CS of OAR)/2 CI= Conformity index, GM= Gradient measure, FH= Femoral head CS =4 E, 3CS<4 G, 2CS<3 A, CS<2 P

The composite score is a good tool for the dosimetric evaluation of different plans. The scoring method is an excellent mean to assess different plans quantitatively and to choose the best in terms of target coverage and doses to OAR. The study shows that 5 fields with gantry angles of -0o, 65o, 135o, 225o and 295o is the best optimum arrangement in terms of dose homogeneity in target and doses to OAR in the patients with the lateral separation ranging from 30 to 34 cm. Further increase in the no. of fields does not improve the dosimetric benefits. However, for the lateral separation of more than 35 cm requires 7 fields as the best optimum with gantry orientations of 30o, 65o, 130o, 180o, 230o, 295o and 330o.