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PURPOSE: To perform a comparative study of heterogeneities and finite patient dimension effects in 60Co and 192Ir high-dose-rate (HDR) brachytherapy. MATERIAL AND METHODS: Clinically equivalent plans were prepared for 19 cases (8 breast, 5 esophagus, 6 gynecologic) using the Ir2.A85-2 and the Co0.A86 HDR sources, with a TG-43 based treatment planning system (TPS). Phase space files were obtained for the two source designs using MCNP6, and validated through comparison to a single source dosimetry results in the literature. Dose to water, taking into account the patient specific anatomy and materials (Dw,m), was calculated for all plans using MCNP6, with input files prepared using the BrachyGuide software tool to analyze information from DICOM RT plan exports. RESULTS: A general TG-43 dose overestimation was observed, except for the lungs, with a greater magnitude for 192Ir. The distribution of percentage differences between TG-43 and Monte Carlo (MC) in dose volume histogram (DVH) indices for the planning target volume (PTV) presented small median values (about 2%) for both 60Co and 192Ir, with a greater dispersion for 192Ir. Regarding the organs at risk (OARs), median percentage differences for breast V50% were 3% (5%) for 60Co (192Ir). Differences in median skin D2cc were found comparable, with a larger dispersion for 192Ir, and the same applied to the lung D10cc and the aorta D2cc. TG-43 overestimates D2cc for the rectum and the sigmoid, with median differences from MC within 2% and a greater dispersion for 192Ir. For the bladder, the median of the difference is greater for 60Co (~2%) than for 192Ir (~0.75%), demonstrating however a greater dispersion again for 192Ir. CONCLUSIONS: The magnitude of differences observed between TG-43 based and MC dosimetry and their smaller dispersion relative to 192Ir, suggest that 60Co HDR sources are more amenable to the TG-43 assumptions in clinical treatment planning dosimetry.

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PURPOSE: To define, in the setting of cervical cancer, to what extent information from additional pretreatment magnetic resonance imaging (MRI) without the brachytherapy applicator improves conformity of CT-based high-risk clinical target volume (CTVHR) contours, compared with the MRI for various tumor stages (International Federation of Gynecology and Obstetrics [FIGO] stages I-IVA). METHODS AND MATERIALS: The CTVHR was contoured in 39 patients with cervical cancer (FIGO stages I-IVA) (1) on CT images based on clinical information (CTVHR-CTClinical) alone; and (2) using an additional MRI before brachytherapy, without the applicator (CTVHR-CTpre-BT MRI). The CT contours were compared with reference contours on MRI with the applicator in place (CTVHR-MRIref). Width, height, thickness, volumes, and topography were analyzed. RESULTS: The CT-MRIref differences hardly varied in stage I tumors (n=8). In limited-volume stage IIB and IIIB tumors (n=19), CTVHR-CTpre-BT MRI-MRIref volume differences (2.6 cm(3) [IIB], 7.3 cm(3) [IIIB]) were superior to CTVHR-CTClinical-MRIref (11.8 cm(3) [IIB], 22.9 cm(3) [IIIB]), owing to significant improvement of height and width (P<.05). In advanced disease (n=12), improved agreement with MR volume, width, and height was achieved for CTVHR-CTpre-BT MRI. In 5 of 12 cases, MRIref contours were partly missed on CT. CONCLUSIONS: Pre-BT MRI helps to define CTVHR before BT implantation appropriately, if only CT images with the applicator in place are available for BT planning. Significant improvement is achievable in limited-volume stage IIB and IIIB tumors. In more advanced disease (extensive IIB to IVA), improvement of conformity is possible but may be associated with geographic misses. Limited impact on precision of CTVHR-CT is expected in stage IB tumors.

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The aim of this work was to compare different approaches to VMAT optimization (biological vs. physical DVH-based) in two commercial treatment planning systems (TPS) for head and neck and prostate cases, using Pareto fronts. VMAT vs. IMRT Pareto front comparison was additionally performed in order to benchmark the optimizer efficiency and VMAT plan quality for each TPS. Three prostate and three head and neck cancer patients were selected for nine-beam IMRT and single-arc VMAT planning in Monaco 3.00 and Oncentra MasterPlan (OMP) 3.3 planning systems. Pareto fronts for prostate cases were constructed based on PTV coverage by 95% isodose and volume of rectum receiving 60 Gy or more. For head and neck cases, PTV coverage by the same isodose and mean dose to parotid gland were used for the construction of Pareto fronts. DVH analysis was performed together with evaluation of planning and delivery efficiency for all the plans. In the intersystem comparison for prostate plans, Monaco generated very similar IMRT and VMAT solutions. Quality of Monaco VMAT plans was superior compared to Oncentra in terms of conformity, homogeneity, and lower median dose to bladder due to biological formalism of optimization cost functions. For the head and neck cases, IMRT and VMAT plans were similar in both systems, except the case where a very strong modulation was required. In this situation single-arc VMAT plan generated with OMP was inferior compared to IMRT. VMAT OMP solutions were similar to Monaco or slightly better for two less-modulated head and neck cases. However, this advantage was achieved on the cost of lower conformity and homogeneity of the Oncentra VMAT plans. IMRT and VMAT solutions generated by Monaco were very similar for both prostate and head and neck cases. Oncentra system shows a bigger difference, and use of the dual-arc VMAT would be recommended to achieve the same plan quality as nine-field IMRT. Biological optimization seems beneficial in terms of plan conformity and homogeneity and allowed achieving lower OAR doses for prostate cases. In complex anatomical situations represented by head and neck cases, sequencing algorithm in Monaco imposed limitations on VMAT plan quality in the intersystem comparison.

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BACKGROUND AND PURPOSE: The aim of this work was to compare the accuracy of different HU adjustments for CBCT-based dose calculation. METHODS AND MATERIALS: Dose calculation was performed on CBCT images of 30 patients. In the first two approaches phantom-based (Pha-CC) and population-based (Pop-CC) conversion curves were used. The third method (WAB) represents override of the structures with standard densities for water, air and bone. In ROI mapping approach all structures were overridden with average HUs from planning CT. All techniques were benchmarked to the Pop-CC and CT-based plans by DVH comparison and γ-index analysis. RESULTS: For prostate plans, WAB and ROI mapping compared to Pop-CC showed differences in PTV D(median) below 2%. The WAB and Pha-CC methods underestimated the bladder dose in IMRT plans. In lung cases PTV coverage was underestimated by Pha-CC method by 2.3% and slightly overestimated by the WAB and ROI techniques. The use of the Pha-CC method for head-neck IMRT plans resulted in difference in PTV coverage up to 5%. Dose calculation with WAB and ROI techniques showed better agreement with pCT than conversion curve-based approaches. CONCLUSIONS: Density override techniques provide an accurate alternative to the conversion curve-based methods for dose calculation on CBCT images.

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PURPOSE: It is generally agreed that the safe implementation of stereotactic body radiotherapy requires image guidance. The aim of this work was to assess interobserver variability in the delineation of lung lesions on cone-beam CT (CBCT) images compared with CT-based contouring for adaptive stereotactic body radiotherapy. The influence of target size was also evaluated. METHODS AND MATERIALS: Eight radiation oncologists delineated gross tumor volumes in 12 patient cases (non-small cell lung cancer I-II or solitary metastasis) on planning CTs and on CBCTs. Cases were divided into two groups with tumor diameters of less than (Group A) or more than 2 cm (Group B). Comparison of mean volumes delineated by all observers and range and coefficient of variation were reported for each case and image modality. Interobserver variability was assessed by means of standard error of measurement, conformity index (CI), and its generalized observer-independent approach. The variance between single observers on CT and CBCT images was measured via interobserver reliability coefficient. RESULTS: Interobserver variability on CT images was 17% with 0.79 reliability, compared with 21% variability on CBCT and 0.76 reliability. On both image modalities, values of the intraobserver reliability coefficient (0.99 for CT and 0.97 for CBCT) indicated high reproducibility of results. In general, lower interobserver agreement was observed for small lesions (CI(genA) = 0.62 ± 0.06 vs. CI(genB) = 0.70 ± 0.03, p < 0.05). The analysis of single patient cases revealed that presence of spicules, diffuse infiltrations, proximity of the tumors to the vessels and thoracic wall, and respiration motion artifacts presented the main sources of the variability. CONCLUSION: Interobserver variability for Stage I-II non-small cell lung cancer and lung metastasis was slightly higher on CBCT compared with CT. Absence of significant differences in interobserver variability suggests that CBCT imaging provides an effective tool for tumor localization, and image data could be also used for target volume delineation purposes.

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PURPOSE: Comparison of the dosimetric accuracy of the enhanced collapsed cone (eCC) algorithm with the commercially available Monte Carlo (MC) dose calculation for complex treatment techniques. MATERIAL AND METHODS: A total of 8 intensity-modulated radiotherapy (IMRT) and 2 stereotactic body radiotherapy (SBRT) lung cases were calculated with eCC and MC algorithms with the treatment planning systems (TPS) Oncentra MasterPlan 3.2 (Nucletron) and Monaco 2.01 (Elekta/CMS). Fluence optimization as well as sequencing of IMRT plans was primarily performed using Monaco. Dose prediction errors were calculated using MC as reference. The dose-volume histrogram (DVH) analysis was complemented with 2D and 3D gamma evaluation. Both algorithms were compared to measurements using the Delta4 system (Scandidos). RESULTS: Recalculated with eCC IMRT plans resulted in lower planned target volume (PTV) coverage, as well as in lower organs-at-risk (OAR) doses up to 8%. Small deviations between MC and eCC in PTV dose (1-2%) were detected for IMRT cases, while larger deviations were observed for SBRT (up to 5%). Conformity indices of both calculations were similar; however, the homogeneity of the eCC calculated plans was slightly better. Delta4 measurements confirmed high dosimetric accuracy of both TPS. CONCLUSION: Mean dose prediction errors < 3% for PTV suggest that both algorithms enable highly accurate dose calculations under clinical conditions. However, users should be aware of slightly underestimated OAR doses using the eCC algorithm.

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BACKGROUND: Recent developments enable to deliver rotational IMRT with standard C-arm gantry based linear accelerators. This upcoming treatment technique was benchmarked in a multi-center treatment planning study against static gantry IMRT and rotational IMRT based on a ring gantry for a complex parotid gland sparing head-and-neck technique. METHODS: Treatment plans were created for 10 patients with head-and-neck tumours (oropharynx, hypopharynx, larynx) using the following treatment planning systems (TPS) for rotational IMRT: Monaco (ELEKTA VMAT solution), Eclipse (Varian RapidArc solution) and HiArt for the helical tomotherapy (Tomotherapy). Planning of static gantry IMRT was performed with KonRad, Pinnacle and Panther DAO based on step&shoot IMRT delivery and Eclipse for sliding window IMRT. The prescribed doses for the high dose PTVs were 65.1Gy or 60.9Gy and for the low dose PTVs 55.8Gy or 52.5Gy dependend on resection status. Plan evaluation was based on target coverage, conformity and homogeneity, DVHs of OARs and the volume of normal tissue receiving more than 5Gy (V5Gy). Additionally, the cumulative monitor units (MUs) and treatment times of the different technologies were compared. All evaluation parameters were averaged over all 10 patients for each technique and planning modality. RESULTS: Depending on IMRT technique and TPS, the mean CI values of all patients ranged from 1.17 to 2.82; and mean HI values varied from 0.05 to 0.10. The mean values of the median doses of the spared parotid were 26.5Gy for RapidArc and 23Gy for VMAT, 14.1Gy for Tomo. For fixed gantry techniques 21Gy was achieved for step&shoot+KonRad, 17.0Gy for step&shoot+Panther DAO, 23.3Gy for step&shoot+Pinnacle and 18.6Gy for sliding window.V5Gy values were lowest for the sliding window IMRT technique (3499 ccm) and largest for RapidArc (5480 ccm). The lowest mean MU value of 408 was achieved by Panther DAO, compared to 1140 for sliding window IMRT. CONCLUSIONS: All IMRT delivery technologies with their associated TPS provide plans with satisfying target coverage while at the same time respecting the defined OAR criteria. Sliding window IMRT, RapidArc and Tomo techniques resulted in better target dose homogeneity compared to VMAT and step&shoot IMRT. Rotational IMRT based on C-arm linacs and Tomotherapy seem to be advantageous with respect to OAR sparing and treatment delivery efficiency, at the cost of higher dose delivered to normal tissues. The overall treatment plan quality using Tomo seems to be better than the other TPS technology combinations.

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BACKGROUND AND PURPOSE: In-room cone-beam CT (CBCT) imaging and adaptive treatment strategies are promising methods to decrease target volumes and to spare organs at risk. The aim of this work was to analyze the inter-observer contouring uncertainties of target volumes and organs at risks (oars) in localized prostate cancer radiotherapy using CBCT images. Furthermore, CBCT contouring was benchmarked against other image modalities (CT, MR) and the influence of subjective image quality perception on inter-observer variability was assessed. METHODS AND MATERIALS: Eight prostate cancer patients were selected. Seven radiation oncologists contoured target volumes and oars on CT, MRI and CBCT. Volumes, coefficient of variation (COV), conformity index (cigen), and coordinates of center-of-mass (COM) were calculated for each patient and image modality. Reliability analysis was performed for the support of the reported findings. Subjective perception of image quality was assessed via a ten-scored visual analog scale (VAS). RESULTS: The median volume for prostate was larger on CT compared to MRI and CBCT images. The inter-observer variation for prostate was larger on CBCT (CIgen=0.57±0.09, 0.61 reliability) compared to CT (CIgen=0.72±0.07, 0.83 reliability) and MRI (CIgen=0.66±0.12, 0.87 reliability). On all image modalities values of the intra-observer reliability coefficient (0.97 for CT, 0.99 for MR and 0.94 for CBCT) indicated high reproducibility of results. For all patients the root mean square (RMS) of the inter-observer standard deviation (σ) of the COM was largest on CBCT with σ(x)=0.4 mm, σ(y)=1.1 mm, and σ(z)=1.7 mm. The concordance in delineating OARs was much stronger than for target volumes, with average CIgen>0.70 for rectum and CIgen>0.80 for bladder. Positive correlations between CIgen and VAS score of the image quality were observed for the prostate, seminal vesicles and rectum. CONCLUSIONS: Inter-observer variability for target volume delineation in prostate cancer is larger for CBCT-based contouring compared to CT and MRI. This factor of influence needs to be considered when defining safety margins for CBCT-based Adaptive Radiotherapy (ART).

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PURPOSE: The aim of this study was to compare the dose calculation accuracy of advanced kernel-based methods and Monte Carlo algorithms in commercially available treatment planning systems. MATERIALS AND METHODS: Following dose calculation algorithms and treatment planning (TPS) systems were compared: the collapsed cone (CC) convolution algorithm available in Oncentra Masterplan, the XVMC Monte Carlo algorithm implemented in iPlan and Monaco, and the analytical anisotropic algorithm (AAA) implemented in Eclipse. Measurements were performed with a calibrated ionization chamber and radiochromic EBT type films in a homogenous polystyrene phantom and in heterogeneous lung phantoms. Single beam tests, conformal treatment plans and IMRT plans were validated. Dosimetric evaluations included absolute dose measurements, 1D gamma-evaluation of depth-dose curves and profiles using 2mm and 2% dose difference criteria for single beam tests, and gamma-evaluation of axial planes for composite treatment plans applying 3mm and 3% dose difference criteria. RESULTS: Absolute dosimetry revealed no large differences between MC and advanced kernel dose calculations. 1D gamma-evaluation showed significant discrepancies between depth-dose curves in different phantom geometries. For the CC algorithm gamma(mean) values were 0.90+/-0.74 vs. 0.43+/-0.41 in heterogeneous vs. homogeneous conditions and for the AAA gamma(mean) values were 1.13+/-0.91 vs. 0.41+/-0.28, respectively. In general, 1D gamma results obtained with both MC TPS were similar in both phantoms and on average equal to 0.5 both for profiles and depth-dose curves. The results obtained with the CC algorithm in heterogeneous phantoms were slightly better in comparison to the AAA algorithm. The 2D gamma-evaluation results of IMRT plans and four-field plans showed smaller mean gamma-values for MC dose calculations compared to the advanced kernel algorithms (gamma(mean) for four-field plan and IMRT obtained with Monaco MC were 0.28 and 0.5, respectively, vs. 0.40 and 0.54 for the AAA). CONCLUSION: All TPS investigated in this study demonstrated accurate dose calculation in homogenous and heterogeneous phantoms. Commercially available TPS with Monte Carlo option performed best in heterogeneous phantoms. However, the difference between the CC and the MC algorithms was found to be small.

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The dosimetric performance of a Monte Carlo algorithm as implemented in a commercial treatment planning system (iPlan, BrainLAB) was investigated. After commissioning and basic beam data tests in homogenous phantoms, a variety of single regular beams and clinical field arrangements were tested in heterogeneous conditions (conformal therapy, arc therapy and intensity-modulated radiotherapy including simultaneous integrated boosts). More specifically, a cork phantom containing a concave-shaped target was designed to challenge the Monte Carlo algorithm in more complex treatment cases. All test irradiations were performed on an Elekta linac providing 6, 10 and 18 MV photon beams. Absolute and relative dose measurements were performed with ion chambers and near tissue equivalent radiochromic films which were placed within a transverse plane of the cork phantom. For simple fields, a 1D gamma (gamma) procedure with a 2% dose difference and a 2 mm distance to agreement (DTA) was applied to depth dose curves, as well as to inplane and crossplane profiles. The average gamma value was 0.21 for all energies of simple test cases. For depth dose curves in asymmetric beams similar gamma results as for symmetric beams were obtained. Simple regular fields showed excellent absolute dosimetric agreement to measurement values with a dose difference of 0.1% +/- 0.9% (1 standard deviation) at the dose prescription point. A more detailed analysis at tissue interfaces revealed dose discrepancies of 2.9% for an 18 MV energy 10 x 10 cm(2) field at the first density interface from tissue to lung equivalent material. Small fields (2 x 2 cm(2)) have their largest discrepancy in the re-build-up at the second interface (from lung to tissue equivalent material), with a local dose difference of about 9% and a DTA of 1.1 mm for 18 MV. Conformal field arrangements, arc therapy, as well as IMRT beams and simultaneous integrated boosts were in good agreement with absolute dose measurements in the heterogeneous phantom. For the clinical test cases, the average dose discrepancy was 0.5% +/- 1.1%. Relative dose investigations of the transverse plane for clinical beam arrangements were performed with a 2D gamma-evaluation procedure. For 3% dose difference and 3 mm DTA criteria, the average value for gamma(>1) was 4.7% +/- 3.7%, the average gamma(1%) value was 1.19 +/- 0.16 and the mean 2D gamma-value was 0.44 +/- 0.07 in the heterogeneous phantom. The iPlan MC algorithm leads to accurate dosimetric results under clinical test conditions.

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