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Research Proposal
Working Title

Dosimetric Comparison of ECHO Planning versus IMRT for Paraspinal Retreatment

Problem Statement

The problem with retreatment using conventional IMRT planning is the compromise on
achieving an effective therapeutic dose to the retreated area while sparing the surrounding OAR.

Purpose statement

The purpose of this study was to determine whether the Expedited Constrained Hierarchical
Optimization (ECHO) planning system offers superior dosimetric effectiveness compared to
conventionally fractionated IMRT for paraspinal retreatment.

Hypotheses Statements or Research Questions

H1A: The first research hypothesis (H1) is that using ECHO planning system for spinal body
retreatment will decrease the maximum dose to the spinal cord by ≥ 5% compared to
conventional IMRT.

H10: The first null hypothesis (H10) is that using ECHO planning system for spinal body
retreatment will not result in reduced maximum dose of ≥ 5% to the spinal cord compared to
conventional IMRT.

H2A: The second research hypothesis (H2) is that using ECHO planning system will achieve CI
of 0.9 to 1.0 and at least PTV V95 of 95% (normalized to PTV) to the target volume while
maintaining or improving spinal cord sparing compared to conventional IMRT in spinal body
retreatment.
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H20: The second null hypothesis (H40) is that using Echo planning system will not achieve CI of
0.9 to 1.0 and at least PTV V95 of 95% to the target volume while maintaining or improving
spinal cord sparing compared to conventional IMRT in spinal body retreatment.

Summary

Researchers found that 50% of patients that are diagnosed with cancer will develop bone

metastases.1 Bone metastasis leads to the local invasion of the bone and surrounding nerves,

heightening inflammation and directly exacerbating the pain experienced by patients.1 To combat

the pain and improve quality of life and mobility, radiation treatments, such as palliative spinal

radiation, IMRT and SBRT, have been found to rapidly alleviate the pain patients experience1.

Researchers found that up to 84%-90% of patients will have continued pain relief for up to a

year, while 50% will have complete relief in just 6 months1. However, the pain management has

been closely attributed to the dose and fractional regimen employed2. Doses ranging from 24Gy

in 1-2fx, 30Gy in 10fx, and 8Gy in 1fx have been studied. Overall pain relief can be achieved as

early as three months when using higher dose per fraction2.

Expedited constrained hierarchical optimization (ECHO) was introduced as a fully

automated approach to treatment planning. The optimization algorithm was developed as two

types of planning goals. In the first step, the plan algorithm must meet strict constraints such as

the maximum doses to spinal cord3,4. The second goal is called desirable goals, which is

introduced to solve optimization problems such as improving planning target volume coverage,

reducing doses to OARs, and creating a smoother deliverable plan by implementing optimal
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fluence mapping into the treatment planning system 4. The optimal fluence map created by ECHO

is imported into the treatment planning system (TPS) to ensure the accuracy of the leaf

sequencing and full dose calculation. A dose correction loop technique using Lagrange

multipliers is used to find any dose‐discrepancy between the ECHO and the TPS' dose

calculation that eventually gets incorporated into the final treatment plan 3,4. In a retrospective

study conducted by Zarepisheh et al4 seventy-five SBRT paraspinal plans were created by ECHO

and compared to clinically treated VMAT plans that were generated by planners. They found

ECHO plans to be dosimetrically superior when evaluating tumor coverage, plan conformity, and

OAR sparing4.

ECHO has already been implemented for paraspinal irradiation and has been shown to be

dramatically superior compared to conventionally fractionated VMAT paraspinal plans.

Zarepisheh et al4 compared the DVHs of ECHO created plans with manually generated plans

(plan created by treatment planners) for uniformity and OAR sparing. The DVH plot comparison

showed that the ECHO plan delivered less dose to the esophagus and created a more uniform

dose to the tumor which was closer to the prescription than the manually generated plan4.

Although literature shows conventional IMRT plans have been successful in paraspinal

reirradiation, the case for maintaining effective therapeutic target coverage while still sparing

normal tissue remains a problem. The purpose of this study is to determine whether the ECHO

planning system offers superior dosimetric effectiveness compared to conventional IMRT for

paraspinal retreatment. We will be focusing specifically on the evaluation of plan conformity to

the target and OAR sparing. The research hypotheses test that using ECHO planning for spinal
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reirradiation will reduce the maximum dose to the spinal cord by £5% (H1A), achieve

Conformity Index (CI) of 0.9 to 1.0 and at least PTV V95 of 95% (normalization to the PTV) to

the target volume (H2A) across all plans evaluated.

Reference

1. Sierko E, Hempel D, Zuzda K, Wojtukiewicz M. Personalized Radiation Therapy in

Cancer Pain Management. Cancers. 2019;11(3):390.
doi:https://doi.org/10.3390/cancers11030390
2. Thibault I, Campbell M, Tseng CL, et al. Salvage Stereotactic Body Radiotherapy
(SBRT) Following In-Field Failure of Initial SBRT for Spinal Metastases.
2015;93(2):353-360. doi:https://doi.org/10.1016/j.ijrobp.2015.03.029 Masoud
3. Zarepisheh, Hong L, Zhou Y, et al. Automated intensity modulated treatment planning:
The expedited constrained hierarchical optimization (ECHO) system. 2019;46(7):2944-
2954. doi:https://doi.org/10.1002/mp.13572
4. Zarepisheh M, Hong L, Zhou Y, et al. Automated and Clinically Optimal Treatment
Planning for Cancer Radiotherapy. INFORMS Journal on Applied Analytics.
2022;52(1):69-89. doi:https://doi.org/10.1287/inte.2021.1095