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A Study of IMRT Planning Parameters On Planning Efficiency, Delivery
A Study of IMRT Planning Parameters On Planning Efficiency, Delivery
A Study of IMRT Planning Parameters On Planning Efficiency, Delivery
061704-1 Med. Phys. 40 (6), June 2013 0094-2405/2013/40(6)/061704/13/$30.00 © 2013 Am. Assoc. Phys. Med. 061704-1
061704-2 Mittauer et al.: Parametric analysis of IMRT planning 061704-2
Less “complex”4 IMRT plans allow for improved deliv- treatment delivery time can be improved. To assess delivery
ery accuracy and reduced delivery time.4 Several measures time, we have proposed a delivery time model. Similar efforts
on how to reduce the plan complexity have been proposed.4–15 include Li and Xing’s delivery time model for a Varian (Var-
These efforts focused on limiting the intensity fluctuations by ian Oncology System, Palo Alto, CA) linear accelerator.20
setting maximum intensity limits8, 9 or applying a smoothing However, no such model has been proposed at this time for
filter.4–7, 9, 10 Filtration or maximum intensity limits are ap- an Elekta (Elekta Oncology Systems, Norcross, GA) linear
plied either inside the optimization loop (i.e., concurrently accelerator. Finally, we evaluate the impact of the calculation
or postiteratively) or outside the optimization loop (i.e., prior parameters of both dose grid and fluence grid resolution on
to leaf sequencing). By limiting the intensity spikes, the plan plan quality and calculation time. We seek alternative options
complexity is reduced through the impact on the number of for both dose grid and fluence grid resolution based on plan-
MUs delivered per segment, the total number of segments, ning time considerations. The parameters found in this study
and/or the segment width. will provide a class solution that can reduce planning time.
However, there are inverse planning parameters that im-
pact the segmentation directly during IMRT optimization:
(1) the minimum segment area parameter (MSAP) limits the II. MATERIALS AND METHODS
MLC area to greater than a minimum size for each seg- II.A. Overview
ment, (2) the minimum MU parameter (MMUP) influences
the plan’s segments by limiting an individual segment’s mini- Eleven head and neck patients were chosen for this
mum MU, and (3) the maximum number of segments controls study. Plans were recomputed for each patient with varying
the total segment number for the plan. Since these parame- dose grid resolution (4 variations), minimum segment area
ters are incorporated directly into the optimization loop, plan (12 variations), minimum MU (9 variations), and the mini-
quality is not degraded with postprocessing methods, such as mum segment area and minimum MU were varied together
filtration or smoothing.9, 16 Although strategies15 on limiting (20 variations), while all other variables were held constant.
the maximum number of segments have been studied using The patients and plan variations are described in more detail
the Pinnacle treatment planning system (TPS) (Philips Radi- in Secs. II.B–II.D. An overview of this study can be seen in
ation Oncology Systems, Andover, MA), to our knowledge Table I. Plan quality, calculation time, and delivery time
initial settings for MSAP and MMUP in light of delivery effi- served as the study’s endpoints.
ciency have not been discussed.
Niemierko and Goitein first reported that a smaller grid
II.B. Patients
resolution provides superior dosimetric accuracy due to a
smaller interpolation of dose between calculation points.17 Eleven head and neck patients previously treated with
Investigators17–19 through both empirical methods18, 19 and IMRT were selected for this retrospective study. Head and
analytical models17, 18 reached a common consensus that a neck cases were chosen because of the planning complex-
dose grid resolution of 2 mm is sufficient to minimize dose ity associated with this site. As displayed in Fig. 1, all ex-
errors from a finite grid resolution. Chung et al. reported the isting treatment plans were prescribed 70 Gy to the high risk
impact on plan quality for various dose grid resolutions us- planning target volume (PTV 70) and 56 Gy to the standard
ing the Pinnacle TPS.19 However, this study did not report risk PTV (PTV 56) in 35 fractions. Since this fractionation
the cost of planning time nor did it report plan quality dif- treated both PTVs concurrently, both PTVs were optimized
ferences for critical structures. Although dose grid resolution simultaneously under the same fractionation. A summary of
has been well studied, the impact of fluence grid resolution the eleven initial treatment plans is given in Table II to show
has not been investigated at this time. Note the Pinnacle TPS that a variety of cases were selected.
allows for the user to specify these grid resolutions separately As shown in Table II, existing patient plans utilized six
for dose and fluence. or seven coplanar IMRT beams with varying gantry angles.
The purpose of this study is to recommend a set of in- Based on investigations of the appropriate number of beams
verse planning parameters for head and neck IMRT planning to use for head and neck IMRT,21 6–7 beams was considered a
that provides a relatively low planning effort without com- reasonable choice. Beam angles were chosen to best minimize
promising plan quality. Towards this goal, this study evalu- doses to planning at risk volumes (PRVs) while maximizing
ates a range of fundamental inverse planning parameters and PTV coverage. Beam energy was 6 MV for all cases.
their effect on plan quality, dose calculation time, and deliv- Patients selected included eight whole neck IMRT cases
ery time. Such a study is useful for setting an initial set of and three partial neck IMRT cases. Whole neck IMRT, illus-
parameters that allow for fast planning and efficient treatment trated in Fig. 1, was used when the gross disease extended
delivery, while allowing the user to be confident that planning into the lower neck region. For these eight patient plans, the
calculations are being performed accurately. planning isocenter was placed inside of PTV 70. For the three
In this study parameters of the MSAP and the MMUP are partial neck IMRT cases, an AP lower anterior neck (LAN)
studied both independently (i.e., varied one at a time) and de- field was added separately to treat the nodal region to 56 Gy.
pendently (i.e., varied simultaneously) in light of plan qual- A technique described by Li et al. was used in which the
ity and delivery time differences. By relaxing the MSAP and LAN field was feathered by shifting the match line 1 cm per
the MMUP, the plan complexity can be reduced; hence, the segment for a total of four segments (Fig. 2).22 On the last
1 2 2 5 3 3 17 4 2 26 4 3
2 3 3 6 4 3 18 4 3 27 4 5
3 4 4 7 5 3 19 4 4 28 4 7
4 4 2 8 6 3 20 4 5 29 4 10
9 7 3 21 4 6 30 6 3
10 8 3 22 4 7 31 6 5
11 9 3 23 4 10 32 6 7
12 10 3 24 4 20 33 6 10
13 16 3 25 4 35 34 8 3
14 25 3 35 8 5
15 36 3 36 8 7
16 49 3 37 8 10
38 10 3
39 10 5
40 10 7
41 10 10
42 16 3
43 16 5
44 16 7
45 16 10
Note: MSAP, min segment area parameter; MMUP, min monitor unit parameter; MMUSAP, min monitor unit and segment area parameters. (1) There are some trial
redundancies between parameters.
TABLE II. Summary of diagnosis and plan information for the 11 head and neck cases in this study.
Volume (cm3 )
Case no. Disease site No. of IMRT beams MU for 2 mm grid resolution plan PTV 70 PTV 56
Note: PTV, planning target volume; LAN, lower anterior neck; PTV 70, high risk PTV; PTV 56, standard risk PTV. (1) PTV 70 volume is excluded from PTV 56 volume.
F IG . 1. Whole neck IMRT with isodose distribution for case no. 2 with display of high risk PTV 70 and standard risk PTV 56.
F IG . 2. AP LAN field of case no. 8 treated to 56 Gy using match line feathering in 1 cm intervals with four IMRT segments. The rightmost digitally reconstructed
radiograph (DRR) is the last segment in which the cord is blocked.
segment of the LAN field, the cord was blocked to reduce its data and experiences. Optimization objectives for organs at
dose to less than 50 Gy. The planning isocenter was placed at risk (OARs) were previously determined by organ classifica-
the junction of the LAN field with the head and neck fields, at tion, serial or parallel. Objectives for serial structures were
a depth greater than 1 cm. specified as maximum dose and volumetric maximum DVH.
Parallel structure objectives were defined as volumetric max-
imum DVH. PTV objectives were minimum dose, uniform
II.C. Treatment planning dose, and volumetric minimum DVH. Note that the objective
functions during the initial planning were customized for each
New treatment plans were generated from each of the
patient based upon the tumor size and the anatomy, which can
eleven cases by varying parameters of dose and fluence grid,
be slightly different from patient to patient. All optimization
minimum MU, and minimum segment area. Forty-five trials
objectives and contours were kept the same as the original
per patient, 495 trials in total, were reoptimized and/or re-
treatment plan when generating the 495 trials.
computed on the Pinnacle TPS (version 9.0) using direct ma-
All contour volumes were previously delineated by clin-
chine parameter optimization (DMPO) and adaptive super-
icians and were used on the initial patient treatment plan.
position/convolution for the dose calculation. The maximum
The gross tumor volume (GTV) and positive nodes were ex-
number of optimization iterations was set to 25, with intensity
panded, excluding OARs, to delineate the high risk clinical
optimization occurring within the first five iterations. Twenty-
target volume (CTV), CTV 70. A 3 mm contour expansion
five iterations was selected based on UF planning experiences
was applied to OARs and CTVs to delineate PRVs and PTVs
with DMPO as well as the Pinnacle’s historical recommen-
(Table III).
dations of using a TPS default preset of 25 iterations. After
calculation, all plans were scaled such that the dose to 95%
of PTV 70, D95%, received at least 70 Gy. Differential dose
II.D. Parameter variations
volume histograms (DVHs) were exported for plan quality re-
sults. The dose grid resolution, minimum MU, and minimum
All initial eleven cases were planned according to the pro- segment area were varied while keeping the all other param-
cess and dose objectives found in Table III. The generic dose eters constant. Note that planning parameters are TPS depen-
objectives are derived from quantitative analysis of normal dent and apply to the Pinnacle TPS. Dose grid resolution was
tissue effect in the clinic (QUANTEC) data,23 Radiation Ther- selected to evaluate the tradeoff between dose uncertainties
apy Oncology Group (RTOG) protocols, and UF historical caused by grid resolution variation and the cost of planning
TABLE III. ROIs (regions of interest) with expansions and dose goals for all cases.
CTV (95% Vol > Rx) 3 95% Vol > 70 Gy (PTV70), 56 Gy (PTV56)
CTV (99% Vol > 93% Rx) 3 99% Vol > 65.1 Gy (PTV70), 46.5 Gy (PTV56)
CTV (20% Vol < 110% Rx) 3 20% Vol < 77 Gy (PTV70)
Brainstem 3 0.1 cc ≤ 55 Gy
Cochlea 3 0.1 cc ≤ 45 Gy
Cord 3 0.1 cc ≤ 50 Gy
Larynx 3 Mean ≤ 36 Gy
Parotid 3 Mean ≤ 26 Gy
Note: Contour expansion was performed after physician’s initial contour delineation.
time. Minimum segment area and minimum MU were se- positional error for a 1 cm2 segment would result in a 10% dif-
lected to study the effect of modulation (i.e., intensity) on plan ference in the segment area. Furthermore, the dosimetric out-
quality and treatment delivery time. put (i.e., dose/MU) for an Elekta linear accelerator (LINAC)
Default parameters were the values the parameters take fluctuates due to head scatter and loss of electronic equilib-
when not intentionally varied. Table I specifies these default rium for field sizes below 3 cm2 .27
parameters as boxed values, representing the reference plan
used for dose comparison in Sec. III. Default parameters were
2 mm (dose and fluence grid resolution), 4 cm2 (minimum II.D.3. MMUP
segment area), and 3 MU (minimum MU). We infer from pre- The MMUP influences the plan’s segments by limiting an
vious work,17–19 a 2 mm dose and fluence grid resolution as individual segment’s MU. Here, a segment cannot contribute
the established standard to measure dose accuracy. Default less than a specified MU. The MMUP was chosen to range
parameters of 4 cm2 and 3 MU were chosen empirically to from 2 to 35 MU in nine trials (Table I). Similar to Sec. II.D.2,
decrease the likeliness of mechanical inaccuracies and output the minimum limit was taken at one value below the default
fluctuations, which can arise for small MU and/or small field value of 3 MU. The maximum limit was selected when the
size deliveries.24–27 A more detailed discussion of the impact number of segments per beam approached one.
of these parameters on mechanical and dosimetric accuracy is The default MMUP was selected based on considerations
presented below. of an Elekta LINAC. Dosimetric accuracy can become com-
promised when delivering only a few MUs per segment, due
II.D.1. Dose grid and fluence grid parameter to the LINAC’s servo requiring a few MUs to stabilize the
beam. Sharpe et al. reported dosimetric output fluctuations of
From this point forward, grid resolution variation will refer the order of 2% for 1–3 MU deliveries on an Elekta LINAC.27
to the resolution variation of both dose grid and fluence grid
resolution. If dose grid resolution and fluence grid resolution
are not equal, then the dose grid resolution and the fluence II.D.4. Minimum MU and segment area
grid resolution will be noted separately. parameters (MMUSAP)
Four trials with final calculation grid resolutions of 2, Since both minimum MU and minimum segment area af-
3, and 4 mm, in addition to a 4 mm dose grid with a 2 fect the plan’s segments and modulation by different means,
mm fluence grid resolution, were computed for each patient the effect of these two parameters changing together was also
(Table I). These four trials were chosen based on the TPS re- examined. A set of 20 trials for MMUSAP (i.e., MMUP +
quirement that the dose grid resolution be a multiple of the flu- MSAP), varying the minimum MU parameter from 3 to 10
ence grid resolution. While a grid resolution of greater than 2 MU and the segment area parameter from 4 to 16 cm2 , were
mm is considered adequate for IMRT planning,17–19 any uni- computed for each patient (Table I).
form grid resolution of greater than 4 mm is considered inac- The MMUSAP parameter was included in this study to
curate in terms of dose calculation quality.18 validate that the MMUP and MSAP trends would be main-
Optimization grid resolution was kept constant as 4 mm tained when simultaneously changing both parameters. Thus,
among the four trials. Calculation times for each trial were MMUSAP trials were examined for their trend, and were not
recorded for determining planning efficiency. As previously taken to the maximum limits of 49 cm2 and 35 MU as in
noted in Sec. II.C, after the final dose calculation all plans Secs. II.D.2 and II.D.3.
were scaled by the appropriate number of monitor units to
meet D95% of the PTV 70.
II.E. Treatment delivery time model
II.D.2. MSAP II.E.1. Model derivation
The MSAP controls the plan’s modulation by limiting the Delivery time for step and shoot IMRT has been previously
MLC area to greater than a minimum size for each segment. described by Li and Xing, and serves as the basis of our de-
Twelve trials per patient of varying minimum segment area livery time model.20 Li and Xing20 previously reported an av-
from 3 to 49 cm2 were computed (Table I). To have a greater erage deviation of 2.1% with a maximum difference of 3.9%
evaluation of the parametric trend, we took the minimum pa- (16 s) between calculated and measured times on a Varian
rameter limit to one unit below our default value of 4 cm2 . TrueBeam. The Li and Xing20 model provides a valid for-
The maximum limit for MSAP was selected in consideration malism for LINACs with gridded guns and delivery methods
of the mean high risk treatment volume (Table I). The mean without a gantry position verification control point. However,
PTV 70 volume 241 cm3 (planar area 39 cm2 ) would be sat- a more detailed model is needed to account for machine-
isfied as far as coverage by a maximum segmental area of derived metrics. Also expanding the model to include fac-
49 cm2 . tors for delivery with nongridded guns, unequally spaced
The default value for MSAP was selected based on the beam geometry, and MOSAIQ Radiation Oncology Informa-
mechanical limitations and dosimetric effects of an Elekta tion System (Elekta Oncology Systems, Norcross, GA) auto-
MLC.24–26 The positional accuracy of the Elekta MLC has field-sequence (AFS) mode would allow for a more universal
been reported to be within 0.4 mm.25, 26 For example, a 1 mm model.
TABLE IV. Inputs, parameters, and outputs for treatment delivery time model.
dt G
Gantry degree spacing xG Gantry speed dx Time Ttotal
No. of beams NB Gantry lag toG
dt MLC
MLC travel distance (cm) xMLC MLC speed dx
No. of segments NSeg MLC lag + intersegmental beam-on delay toMLC
MU per fraction xMU AFS-gantry delay TCPG
dt MU
Dose rate dx
Interbeam beam-on delay toMU
Notes: AFS, auto-field-sequence mode. (1) Inputs are treatment plan dependent and correspond to Eq. (4). (2) Parameters
are machine dependent and correspond to Eqs. (1)–(4). (3) Output is the total treatment time for any step and shoot IMRT
plan.
For the success of such a model, parameters unique to the results of Eqs. (1)–(3), with the exception of the following
treatment machine must first be defined. Second, inputs from terms, because they are plan dependent: xG (the gantry degree
the patient-specific treatment plan would need to be deter- spacing between first and last beam), xMLC (the sum of the
mined. Such model (Table IV) would then use corresponding maximum leaf travel distance of each segment), and xMU (the
plan-based inputs and machine-based parameters to output the MU per fraction).
total treatment delivery time. This model relies on the following assumptions: TCPG ap-
Three independent equations can be formulated to model plies only to MOSAIQ users with AFS mode on an Elekta
the machine-based parameters from the linear relationship of LINAC, and was determined to be 4.9 s. AFS mode uses an in-
parametric incremental change and time: terbeam control point to verify the gantry position once a new
dt G G gantry angle has been reached. The MLC is able to update
TG = x + toG , (1) as the gantry rotates to the next beam, thus the first segment
dx
for each beam is excluded from the MLC speed and interseg-
mental beam-on delay; instead, the first segment of each beam
dt MLC MLC uses interbeam beam-on delay.
T MLC = x + toMLC , (2)
dx
the amount of change, x, versus time, T, and a linear fit was trials, like the other redundant trials listed in Table I, have the
performed. The three tests are as follows: same plan quality results. Evaluated dose was taken from the
DVH, using the dose criteria in Table III: mean dose (larynx,
(1) Gantry speed was measured in service mode by man-
parotid), 0.1 cc dose (spinal cord, cochleae, and brainstem),
ually rotating the gantry through various incremen-
D20% and D99% (PTV 56, PTV 70), and D95% (PTV 56).
tal angles, e.g., 10o , 20o , 70o , 90o , 180o , 200o , 340o ,
PTV 70 D95% was excluded since all plans were scaled to be
and 360o while measuring the time. No difference was
equal at D95%. Percentage differences for PRVs and PTVs
found between counterclockwise and clockwise rota-
were calculated between the evaluated DVH dose of each trial
tion, but this could be an issue with an unbalanced
and the DVH dose from its respective reference plan. These
gantry.
percentage differences will be referred to as dose differences,
(2) MLC speed was determined by delivering an IMRT
which are the dose calculation differences in DVH results that
plan designed with symmetric leaf sequences and sin-
result from changing the specified parameter.
gle direction leaf sequences. The sequences were rep-
Note for MSAP, MMUP, and MMUSAP plans, statistical
etitions of transitions from small fields to large fields,
results were eliminated for PRVs where dose was negligi-
and vice versa. Thus, both MLC extension and retrac-
ble; specifically, if the dose was less than 50% of either the
tion was accounted for. Time was calculated from the
0.1 cc or mean dose objective from Table III. These PRVs
LINAC “beam-off” indicator at the completion of one
are not statistically relevant because of the ease of achieving
segment to the delivery of the first MU on the next seg-
optimization objectives.
ment. Primary jaws and backup jaws were also tested,
and for an Elekta LINAC their speed was negligible
(i.e., faster) compared to the MLC speed.
III.A. Dose and fluence grid parameter
Note for nongridded guns there is a beam-on delay due
to the dose rate and gun ramp-up period. This beam- Dose differences among the grid resolutions of 2, 4, and
on lag time is inherently included in the above testing the 4 mm dose grid with 2 mm fluence grid resolution are
condition. However, this beam-on lag is representative displayed on the cumulative DVH (Fig. 3) for case no. 9. The
of the IMRT intersegmental beam-on delay and not the results for case no. 9 were representative of the results for all
interbeam beam-on delay. The subtle difference is that cases. The 3 mm grid resolution was eliminated from Fig. 3 to
in the former intersegmental beam-on delay the gun re- better display the maximum and minimum DVH differences
mains in active mode and in the latter interbeam beam- for grid resolution.
on delay the gun current must ramp-up from standby For PTVs and PRVs, the 4 mm dose grid with 2 mm flu-
mode to active mode. The latter contributes to a greater ence grid resolution was found to be most comparable in
time delay and is measured in the following test. Note terms of DVH to the 2 mm grid resolution in Fig. 3. The
that this test does not decouple MLC lag from acceler- 4 mm grid resolution varied the most from the 2 mm grid
ation/deceleration and intersegmental beam-on delay. resolution (Fig. 3). Specifically, Fig. 3 shows PTV 70 for the
From our observations, MLC lag is much less of a con- 4 mm grid resolution lacking a steep gradient; this represents
tribution to time compared with the beam-on delay. a breakdown of dose coverage and loss of dose homogeneity.
(3) Dose rate and interbeam beam-on delay were deter- Note that the DVH results for the 3 mm grid resolution fell
mined by delivering static fields of varying MU from
1 to 20 MU. Static fields were used to measure the
delay at the first segment of each new beam as the
gun warmed up out of standby mode, thus character-
istic of interbeam beam-on delay. Time was measured
between the “beam-on” and the “beam-off” indicator.
For gridded gun machines instantaneous dose rate is
possible because the gun remains in active mode, thus
the interbeam beam-on delay would be negligible.
TABLE V. PRV and PTV dose differences for grid resolution parameter.
Notes: flu., fluence; Dmax , max dose difference; Dmax , mean max dose difference; D, mean dose difference. (1) 3
and 4 mm denote matching dose/fluence grid. (2) 4, 2 flu. denotes 4 mm dose grid with 2 mm fluence grid. (3) Reference
taken at 2 mm dose/fluence grid. (4) Dmax was the cochlea and PTV 70 D99% among all cases.
between the DVH for the 4 mm dose grid with 2 mm fluence higher dose differences for serial than for parallel PRVs. Since
grid resolution and the DVH for the 4 mm grid resolution. the serial structures were defined by 0.1 cc dose objectives and
Table V lists the maximum dose difference (Dmax ), the parallel structures were typically defined by mean dose ob-
mean dose difference (D), and the mean maximum dose jectives, the same conclusion as above applies here that small
difference (Dmax ), for PRVs and PTVs. All dose differences volumetric objectives have greater dose variability due to grid
in Table V were measured as absolute percentage differences resolution.
from the 2 mm grid resolution reference plan. To best de- The greatest dose deviation for the PTV maximum dose
termine the dose variability of the grid resolution, sign con- difference in Table V was 8.2% or 5.5 Gy, for PTV 70 D99%,
vention was not used because we sought to measure the ab- 4 mm grid resolution. Thus, overall, the dose variability due
solute change of dose due to grid resolution. Note that each to grid resolution was found to be as high as 8.2% for PTVs
dose objective for PTV 56 and PTV 70 was considered sepa- and 13.3% for PRVs.
rately when averaging in the last two columns as five criteria: One anomaly in Table V was that the 3 mm grid resolu-
PTV 56 (D99%, D20%, D95%) and PTV 70 (D99%, D20%). tion PTV maximum dose difference and PTV mean maximum
The PRV maximum dose difference, being the greatest dose difference were more comparable to the 2 mm grid res-
PRV percentage difference for all cases of that grid resolu- olution than the 4 mm dose grid with 2 mm fluence grid res-
tion, was the cochlea at 13.3% or 2.1 Gy (3 mm grid reso- olution. This result was only seen for PTV 70. The anomaly
lution); 7.9% or 1.8 Gy (4 mm grid resolution); and 5.5% or is attributed to the plans being scaled to PTV 70 D95% using
1.2 Gy (4 mm dose grid with 2 mm fluence grid resolution) the nearest whole MU. Thus, whole number approximation
(Table V). This result was due to the cochlea having a 0.1 cc led to some plans being scaled higher than exactly D95%, re-
volumetric objective where dose is determined by the tail-end sulting in D99% and D20% being somewhat inconsistent for
of the DVH. As expected, small volumes with small volumet- PTV 70.
ric objectives were more susceptible to dose inaccuracies due The PRV and PTV mean dose differences remained under
to grid resolution. 1.2% for all trials (Table V), meaning the effect of grid res-
For PRVs, the mean maximum dose difference of Table V olution averaged over all structures was less than 1.2%. Note
is the mean across each maximum PRV percentage difference. there was no difference between dose objectives passing or
PRV mean maximum dose difference was calculated by deter- failing among the four grid resolutions for all cases.
mining the greatest deviation for each PRV, and then averag- The effect of grid resolution on calculation time and plan
ing the results among serial and parallel PRVs. Table V shows MU is presented in Table VI. The mean plan MU (Table VI)
TABLE VI. Planning calculation time and total plan MU for grid resolution parameter.
Note: flu., fluence grid; 2 mm, 2 mm dose/fluence grid; 3 mm, 3 mm dose/fluence grid; 4 mm, 4 mm dose/fluence grid; 4, 2 flu., 4 mm dose grid with 2 mm fluence grid.
increased by 0.8% (3 mm grid resolution), 1.8% (4 mm grid III.B. Minimum segment area parameter
resolution), and 0.4% (4 mm dose grid with 2 mm fluence
grid resolution). The planning time (Table VI) was reduced by Figures 4(a)–4(d) illustrate the effects on dose for PTVs
69.8% (3 mm grid resolution), 84.4% (4 mm grid resolution), and PRVs with varying MSAP and MMUP. The PTV and
and 62.7% (4 mm dose grid with 2 mm fluence grid resolu- PRV dose differences are noted separately as mean [Figs. 4(a)
tion), compared to the mean calculation time for the reference and 4(b)] and maximum dose differences [Figs. 4(c) and 4(d)]
plan of 3 min. with respect to the reference plan (Table I). Note that Fig. 4
The 4 mm dose grid with 2 mm fluence grid resolution adheres to sign convention. A positive dose difference denotes
saved considerable calculation time, about 2/3 the calculation plan quality degradation for all PRVs and for PTV D20% (i.e.,
time of the 2 mm grid resolution (Table VI). As previously PTV hotspot). On the other hand, a negative dose difference
noted, the 4 mm dose grid with 2 mm fluence grid resolu- denotes a loss of plan quality for PTV D95% and D99% (i.e.,
tion was most comparable to the 2 mm grid resolution for PTV coverage).
plan quality results (Fig. 3 and Table V). This indicates that a For MSAP there was a marked increase in the maximum
4 mm dose grid with 2 mm fluence grid resolution is a viable dose difference in Fig. 4(c) from 4% (MSAP of 5 cm2 ) to
alternative to a 2 mm grid resolution setting with considera- 11% (MSAP of 6 cm2 ). Then, dose differences remained be-
tion of dose accuracy and calculation time. low 12% for plans with MSAP < 25 cm2 . Note the anomaly
Technically, all segments are the same among plans, since at a MSAP of 3 cm2 [Fig. 4(c)]. Here, the cochlea had a large
plans were optimized as the one before the grid resolution maximum dose difference at 6%, but remained under its dose
was changed; thus, there is no effect from optimization. Dose objective.
differences are, therefore, a direct measure of the uncertain- Another measure of how MSAP changes plan quality is
ties of the dose calculation after the plan has been scaled by the threshold of MSAP that dose objectives fail. The dose
the appropriate MUs to achieve the prescription (i.e., PTV 70 to PRVs remained within the objectives for all plans with a
D95%). Since it is known that interpolation of a larger grid MSAP of <6 cm2 . For the PTV objectives, PTV 56 D95%
resolution leads to these dose differences,17–19 interpolation and D99% failed at greater than 8 and 5 cm2 , respectively.
was the cause of the dose volume index uncertainty. PTV 70 D20% and D99% objectives also failed at 25 and
F IG . 4. Mean (a) and (b) and maximum (c) and (d) percentage dose differences for all PRVs and PTVs with varying MSAP (a) and (c) and MMUP (b) and (d)
for all cases. Notes: (1) The max is the max magnitude of plan quality degradation being a negative sign for D20% and D99% and a positive sign for all other
structures. (2) Reference taken at 3 MU, 4 cm2 .
TABLE VII. Delivery time model parameters of an Elekta LINAC compared to vendor specifications.
Notes: (1) Measured results from characterization testing [Eqs. (1)–(3)] of an Elekta Synergy. (2) Numerical equivalent are measured results converted into the same units
as the vendor specifications.
a
Dose rate is unique to each Elekta LINAC.
F IG . 7. Percentage difference in treatment delivery time, number of segments, and plan MU for the 3 MU, 4 cm2 reference plan versus plans of varying sizes
of MSAP (a) and MMUP (b) for all cases.
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