Volume 84  Number 3S  Supplement 2012
Materials/Methods: IMRT plans of 10 sequential and 12 SIB cases were
studied retrospectively. For both methods 9 beam angles were used. A
cumulative dose of 73.5 Gy was prescribed sequentially, and a range of 60
to 70 Gy for SIB method. The homogeneity (HI: Dmax/prescription dose
(PD)) and radiation conformality indices (RCI: PTVPD/PTV0.95PD) were
calculated from dose-volume histograms (DVHs). DVH statistics for the
critical spots (normalized volume > normal tissue tolerance dose TD50,5
(>2/3 organ)) and hot spots (normalized volume > PD) were utilized to
estimate the radiobiological outcomes of TCP and NTCP using the Poisson
statistics and JT Lyman models in the HART. TD50,5 and other corre-
sponding radiobiological parameters such as volume parameter (n) and
slope parameter (m) were selected from Luxton et al. and Emami et al.
TD50,5 used were 46, 80, and 47 Gy for bilateral parotids, larynx, and
esophagus, respectively.
Results: The HI and RCI were 1.100.1 and 0.980.01 in the sequential
method, and 1.100.02 and 0.960.02 in SIB method, respectively.
Critical spots for parotids, larynx, and esophagus were 0.750.03,
0.060.02, and 0.340.02 in the sequential method, and 0.290.07,
<0.01, and 0.220.06 in SIB method, respectively. Hot spots for parotids,
larynx, and esophagus were 0.340.03, 0.540.02, and <0.01, respec-
tively in the sequential method whereas 0.100.05, <0.01, and 0.050.03
in SIB method, respectively. The estimated values of the TCP and NTCP
correlated well with patient outcome in a 2-year follow up study with
sequential boost; and the follow up study for SIB treatments is in process.
NTCP estimates for parotids, larynx, and esophagus were 0.450.14,
0.030.01, and 0.170.09 in the sequential method, and 0.090.04,
<0.01, and 0.180.04 in SIB method, respectively (95% confidence
interval).
Conclusion: Mean HIs were comparable for both techniques while mean
RCI was relatively better with the sequential than SIB method (not
statistically significant). The critical spots and hot spots were reduced in
SIB method which may partially be related to smaller prescription doses.
Both sequential and SIB methods yielded similar NTCP for larynx and
esophagus. These findings are not in direct comparison due to the differ-
ences in tumors and stages; however, better parotid sparing with the SIB
method than sequentially was observed. This novel methodology of
radiobiological outcome-related analysis can be utilized to evaluate
different treatment plan techniques.
Author Disclosure: S. Jang: None. A.P. Pyakuryal: None. O. Cahlon: None.
L. Mao: None. D. Powell: None. A.S. Greenberg: None. H.K. Tsai: None.
T.T. Sio: None. B.B. Mittal: None. J. Hanley: None.
3580
Skin Flash in IMRT Plans
J.K. Ha and A. Rashtian; LAC+USC, Los Angeles, CA
Purpose/Objective(s): It is common practice to reduce PTV margin to
about 3mm below the skin, if no subclinical disease is suspected to be in
the skin. In these cases, bolus is generally not used to minimize skin dose.
However, this compromises the patient setup margin, even for patients with
head and neck cancer treated with thermoplastic masks that typically have
a margin of uncertainty of a few millimeters. The objective of this dosi-
metric study is to include the appropriate PTV margin extended outside the
patient body without having the plan dose algorithm depositing a lot of
monitor units in the space distal to the skin and creating hot spots at and
below the skin surface.
Materials/Methods: Using planning software, GTV, CTV, and critical
structures are contoured by the radiation oncologist. The two PTVs —
PTV-skin and PTV-ext — are drawn from the CTV. The PTV-skin is an
expansion from the CTV but with its distal surface being trimmed to 3 mm
below the skin surface. The PTV-ext keeps the appropriate CTV expansion,
even if it extends beyond the skin. The IMRT optimization and dose
calculations are done in two steps: First, a one cm tissue-equivalent bolus
is used for IMRT optimization. The dose is calculated using the generated
leaf sequence but without bolus to simulate the actual dose delivery to the
patient. At this first step, the calculated dose to the PTV-skin is expected to
be underdosed because of the missing bolus. In the second step, this
Poster Viewing Abstracts S813
deficiency in dose coverage in the PTV-skin near the skin surface is cor-
rected by creating an artificial PTV-cor structure which is used in the
optimization to add more MUs to the underdose region. The dose is then
recalculated with the new generated leaf sequence, again without bolus to
simulate the actual dose delivery. The second step can be repeated by
redesigning the PTV-cor or changing the dose constraint parameter until
the desired dose coverage to the PTV-skin is achieved. The proposed
method has been evaluated on treatment plans of patients with meningioma
and cancers of the H&N.
Results: Our study shows that if patient setup is off by 3mm in the radial
direction perpendicular to the skin surface from that of the plan, PTV-skin
coverage can drop from 95% of the prescribed dose, as planned, to only
90%. Clearly, depending on the volume of CTV and how close it is to the
skin surface, dose to PTV-skin can drop even more significantly. By
including the flash as proposed above, our study shows the PTV coverage
can be made rather insensitive to the setup error.
Conclusions: The proposed method is a good way to introduce flash in
IMRT plans. The current practice by reducing PTV margin below the skin
or adding a bolus is far from being ideal in treating disease regions near
patient body surface. A future clinical study can confirm the importance of
including flash in IMRT plans.
Author Disclosure: J.K. Ha: None. A. Rashtian: None.
3581
Correlation of Delivery Reproducibility With Anatomical
Modifications and Intrafraction Motion During Treatments Using
Helical Tomotherapy (HT)-Integrated Detectors
E. Cagni, A. Botti, E. Mezzenga, V. D’errico, P. Ciammella, and M. Iori; S.
Maria Nuova Hospital, Reggio Emilia, Italy
Purpose/Objective(s): To investigate the correlation of the dose repro-
ducibility acquired during treatment delivered, using integrated HT MVCT
detectors, with the patient anatomy modifications that can occur during
fractionated treatments. To assess the dosimetric effect of intra-fraction
motion on the signal acquired by MVCT detectors during the HT treatment
delivery (sinogram).
Materials/Methods: First, the MVCT detector data variations related only
to the delivery component were quantified. Ten HT plans, with increased
level of complexity, were ranked using an extension of the Webb’s
Modulation Index (MI) for helical delivery. These plans were delivered
several times with a phantom positioned between the radiation source and
the detectors. Then, five H&N plans, acquired by MVCT detectors during
clinical treatments delivery, were studied and correlated with patient
anatomic variations evaluated by daily MVCT imaging. As a last step, an
anthropomorphic phantom placed on a respiratory gating platform was
used to simulate breathing movement during treatments. Setting different
ranges of motion and respiratory amplitudes, a clinical HT plan was
delivered several time and acquired with MVCT detectors. Two indices
were introduced: the “Reproducibility Index” (RI) based on the definition
of M.S. Padro (the RIDELIV was used to evaluate data acquired with the
phantom while the RITREAT for patient data) and the SIN_DEV index, that
quantify the differences on the acquired sinograms respect to the reference
one. This indexes were related to the treatment complexity, the patient’s
anatomy variation and the intra-fraction motions.
Results: A dependence of the RIDELIV with the MI factor was observed
(R2 Z 0.6367), pointing out higher RIDELIV values for the most complex
plan. Our analysis confirm the existence of a correlation between the
RITREAT and the patient anatomy reductions in the neck diameter (R2 Z
0.687) and parotids shrinkage (R2 Z 0.521). The analysis of SIN_DEV
index related to the anatomical modifications was assessed by means of
Spearman correlation (SC), indicate higher SIN_DEV indexes at the end of
the treatment that correspond to a larger parotids shrinkage (SC Z -0.78,
p<0.0001) and neck diameter reduction (SC Z -0.75, p<0.0001). The
preliminary results concerning the sinogram variations related to the
respiratory amplitude and frequency, have showed SIN_DEV indexes up to
5% respect to no movement MVCT data, with a 5,4% of the sinogram area
over 5% of difference.