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 (BED 10Gy) of
100 Gy 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 it is surrounded by, includes, or abuts 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
 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 (CGS),
which showed no significant differences between PTV doses calculated
with AXB 1 mm CGS and AXB with 2.5 mm CGS.
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. 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.
 to be at the dome of the liver. Planning target volume coverage
challenges arise in SBRT planning when PTV is associated with tissues
of low densities.12
3. Dosimetric PTV coverage in liver SBRT is critical to achieve positive
LC and OS results.
4. This study intends to find optimal 10 MV 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. For this single institution retrospective study, 10 patients who treated for primary
liver cancer or liver metastases located at the dome of liver were selected for the
study.
1. Planning target volumes ranged between 7.8 cc and 59.4 cc.
B. Computed Tomography scans were obtained with the patient in supine orientation
with head towards gantry and both arms above head.
1. Computed tomography scans for treatment planning were acquired on a
General Electric LightSpeed 16 slice CT scanner with 2.5 mm slice
thickness during end expiratory breath-hold phase for simulation and
subsequent treatment.
a. RPM (Varian Medical Systems, Palo Alto, CA) system was
utilized during simulation to track patient breathing cycle and
allow gated TPCT acquisition.
2. Immobilization devices used include headrest, Vac-Lok (Civco,
Coralville, IA) bag under patient head through hips, wingboard (Civco,
Coralville, IA), and triangle sponge under knees with feet banded as
seen in Figure 1.
 1. Due to patient simulation and treatment in end expiratory breath-hold
phase, Internal Target Volume (ITV) was not utilized.
2. Planning target volume was then generated by GTV expansion of 1cm in
the superior and inferior directions and 0.5 cm radially.
3. Organs at Risk volumes including the liver, spinal cord, heart, lungs, and
esophagus were outlined by the planning medical dosimetrist.
4. Liver volume was specified as normal liver minus GTV.

Treatment Planning

A. All ten patients selected for this study were planned for 50 Gy to be delivered to
PTV at 10 Gy per fraction for 5 fractions.
1. Treatment plans were created in Eclipse version 13.6 (Varian Medical
Systems, Palo Alto, CA) treatment planning system utilizing a dynamic
conformal arc (DCA) technique consisting of 6 non-coplanar arcs with
each arc travel range between 35 to 60 degrees.
a. Goals were to create a conformal dose distribution surrounding
PTV and to meet OAR dose constraints such as normal liver dose
levels recommended by Pollom et al13 for patients receiving
abdominal SBRT.
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
TrueBeam (Varian Medical Systems, Palo Alto, CA) linear accelerator
with 120 MLC system.
3. Plans were normalized such that 95% of the PTV was encompassed by
the prescription dose of 50 Gy (D95% = 50Gy).
B. Optimized DCA treatment plans using AAA and AXB algorithms were generated
to allow comparison between them in terms of PTV and normal liver metrics.
 1. Dynamic conformal arc treatment plans were generated using AAA
algorithm with various MLC margins surrounding PTV.
a. Multi leaf collimator margins ranged between -3 mm to 5 mm in
1 mm increments.
b. Plan normalization was set such that 95% of PTV received
prescription dose of 50 Gy.
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 50 Gy.
3. Optimized AAA plans were then recalculated with AXB algorithm using
preset MU from AAA plans with no plan normalization 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. Planning target volume doses were correlated between the optimized AAA 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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