Cochlea-sparing acoustic neuroma treatment with 4π radiation therapy.

PurposeThis study investigates whether 4π noncoplanar radiation therapy can spare the cochleae and consequently potentially improve hearing preservation in patients with acoustic neuroma who are treated with radiation therapy.Methods and materialsClinical radiation therapy plans for 30 patients with acoustic neuroma were included (14 stereotactic radiation surgery [SRS], 6 stereotactic radiation therapy [SRT], and 10 intensity modulated radiation therapy [IMRT]). The 4π plans were created for each patient with 20 optimal beams selected using a greedy column generation method and subsequently recalculated in Eclipse for comparison. Organ-at-risk (OAR) doses, homogeneity index, conformity, and tumor control probability (TCP) were compared. Normal tissue complication probability (NTCP) was calculated for sensorineural hearing loss (SNHL) at 3 and 5 years posttreatment. The dose for each plan was then escalated to achieve 99.5% TCP.Results4π significantly reduced the mean dose to both cochleae by 2.0 Gy (32%) for SRS, 3.2 Gy (29%) for SRT, and 10.0 Gy (32%) for IMRT. The maximum dose to both cochleae was also reduced with 4π by 1.6 Gy (20%), 2.2 Gy (15%), and 7.1 Gy (18%) for SRS, SRT, and IMRT plans, respectively. The reductions in mean/maximum brainstem dose with 4π were also statistically significant. Mean doses to other OARs were reduced by 19% to 56% on average. 4π plans had a similar CN and TCP, with a significantly higher average homogeneity index (0.93 vs 0.92) and significantly lower average NTCP for SNHL at both 3 years (30.8% vs 40.8%) and 5 years (43.3% vs 61.7%). An average dose escalation of approximately 116% of the prescription dose achieved 99.5% TCP, which resulted in 32.6% and 43.4% NTCP for SNHL at 3 years and 46.4% and 64.7% at 5 years for 4π and clinical plans, respectively.ConclusionsCompared with clinical planning methods, optimized 4π radiation therapy enables statistically significant sparing of the cochleae in acoustic neuroma treatment as well as lowering of other OAR doses, potentially reducing the risk of hearing loss

Dynamic photon painting

Photon-based radiosurgery is widely used for treating local and regional tumors. The key to improving the quality of radiosurgery is to increase the dose falloff rate from high dose regions inside the tumor to low dose regions of nearby healthy tissues and structures. Currently, most radiosurgeries rely on focusing a number of external radiation beams to create a sharp dose falloff. As the number of focused beams increases, the contributions from each beam will inevitably decrease, and hence an improved dose falloff will be obtained. However, with most radiosurgeries being delivered in a step-and-shoot manner, the number of external beams is limited to a few hundred. For example, Gamma Knife radiosurgery, which has long been a gold standard for radiosurgery, uses about two hundred beams. In this research, we investigated the use of Dynamic Photon Painting (DPP) to further increase dose falloff rate. The key idea of DPP is to treat a target by moving a beam source along a dynamic trajectory, where the speed, directions and even dose rate of the beam source change constantly during irradiation. A number of studies regarding DPP were carried out in this research. We found that DPP can create a dose gradient that rivals proton Bragg Peak and outperforms Gamma Knife radiosurgery. These promising results indicate that DPP has the potential to significantly improve current photon-based radiosurgery

Optimization of Treatment Geometry to Reduce Normal Brain Dose in Radiosurgery of Multiple Brain Metastases with Single-Isocenter Volumetric Modulated Arc Therapy

Treatment of patients with multiple brain metastases using a single-isocenter volumetric modulated arc therapy (VMAT) has been shown to decrease treatment time with the tradeoff of larger low dose to the normal brain tissue. We have developed an efficient Projection Summing Optimization Algorithm to optimize the treatment geometry in order to reduce dose to normal brain tissue for radiosurgery of multiple metastases with single-isocenter VMAT. The algorithm: (a) measures coordinates of outer boundary points of each lesion to be treated using the Eclipse Scripting Application Programming Interface, (b) determines the rotations of couch, collimator, and gantry using three matrices about the cardinal axes, (c) projects the outer boundary points of the lesion on to Beam Eye View projection plane, (d) optimizes couch and collimator angles by selecting the least total unblocked area for each specific treatment arc, and (e) generates a treatment plan with the optimized angles. The results showed significant reduction in the mean dose and low dose volume to normal brain, while maintaining the similar treatment plan qualities on the thirteen patients treated previously. The algorithm has the flexibility with regard to the beam arrangements and can be integrated in the treatment planning system for clinical application directly

The Relationship Between the Number of Shots and the Quality of Gamma Knife Radiosurgeries

Radiosurgery is a non-invasive alternative to brain surgery that uses a single focused application of high radiation to destroy intracerebral target tissues. A Gamma Knife delivers such treatments by using 201 cylindrically collimated cobalt-60 sources that are arranged in a hemispherical pattern and aimed to a common focal point. The accumulation of radiation at the focal point, called a \shot due to the spherical nature of the dose distribution, is used to ablate (or destroy) target tissue in the brain. If the target is small and spherical, it is easily treated by choosing one of four available collimators (4, 8, 14, or 18 mm). For large, irregular targets, multiple shots are typically required to treat the entire lesion, and the process of determining the optimal arrangement and number of shots is complex. In this research, fast simulated annealing and a novel objective function are used to investigate the relationship between the number of shots and the quality of the resulting treatment. Sets of 5, 10, 25, 50, and an unrestricted number of shots are studied for an arteriovenous malformation (AVM). As the shot limit increases the following improvements in plan quality are observed: the conformity of the prescription isodose line increases, the lesion dose becomes more homogeneous, and an increase use of smaller collimators to deposit dose. Large improvements in plan quality are realized by increasing the number of shots from 5 to 50, and to achieve a similar magnitude of improvement past 50 requires an increase over 1500 shots for the complex lesion investigated. This observation suggests that it is clinically valuable to improve the Gamma Knife\u27s delivery capabilities so that 50 shot treatments are possible

Plan Quality and Treatment Efficiency for Radiosurgery to Multiple Brain Metastases: Non-Coplanar RapidArc vs. Gamma Knife.

OBJECTIVES: This study compares the dosimetry and efficiency of two modern radiosurgery [stereotactic radiosurgery (SRS)] modalities for multiple brain metastases [Gamma Knife (GK) and LINAC-based RapidArc/volumetric modulated arc therapy], with a special focus on the comparison of low-dose spread. METHODS: Six patients with three or four small brain metastases were used in this study. The size of targets varied from 0.1 to 10.5 cc. SRS doses were prescribed according to the size of lesions. SRS plans were made using both Gamma Knife(®) Perfexion and a single-isocenter, multiple non-coplanar RapidArc(®). Dosimetric parameters analyzed included RTOG conformity index (CI), gradient index (GI), 12 Gy isodose volume (V 12Gy) for each target, and the dose spread (Dspread) for each plan. Dspread reflects SRS plan\u27s capability of confining radiation to within the local vicinity of the lesion and to not spread out to the surrounding normal brain tissues. Each plan has a dose (Dspread), such that once dose decreases below Dspread (on total tissue dose-volume histogram), isodose volume starts increasing dramatically. Dspread is defined as that dose when volume increase first exceeds 20 cc/0.1 Gy dose decrease. RESULTS: RapidArc SRS has smaller CI (1.19 ± 0.14 vs. 1.50 ± 0.16, p \u3c 0.001) and larger GI (4.77 ± 1.49 vs. 3.65 ± 0.98, p \u3c 0.01). V 12Gy results were comparable (2.73 ± 1.38 vs. 3.06 ± 2.20 cc, p = 0.58). Moderate to lower dose spread, V6, V4.5, and V3, were also equivalent. GK plans achieved better very low-dose spread (≤3 Gy) and also had slightly smaller Dspread, 1.9 vs. 2.5 Gy. Total treatment time for GK is estimated between 60 and 100 min. GK treatments are between 3 and 5 times longer compared to RapidArc treatment techniques. CONCLUSION: Dosimetric parameters reflecting prescription dose conformality (CI), dose fall off (GI), radiation necrosis indicator (V 12Gy), and dose spread (Dspread) were compared between GK SRS and RapidArc SRS for multi-mets. RapidArc plans have smaller CI but larger GI. V 12Gy are comparable. GK appears better at reducing only very low-dose spread (\u3c3 \u3eGy). The treatment time of RapidArc SRS is significantly reduced compared to GK SRS