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Group 3
Clinical Practicum III
Craniospinal Irradiation Project
November 9, 2016
feathering and take advantage of inverse planning, IMRT, volumetric modulated arc
radiotherapy (VMAT), and IMPT have been used for CSI. Usually, several small regions are
contoured at the junction area and different dose levels were set for inverse optimization to
simulate a gradient region at the junction. The concept of robust optimization has recently been
implemented in commercial treatment planning software, like RayStation, to take the worst case
scenario into consideration during optimization. Generally CTV is used as the target for
optimization and a robust optimization is performed to account all the uncertainties caused by
proton range, setup, and anatomical motion.2, 7 The idea of this project is to use robust
optimization to optimize the dose in the junction area without creating any extra contours. In a
CSI proton plan, 4 to 5 fields are used. When robust optimization is used for independent beams,
as shown in Figure 1, the total number of scenarios is too much for the optimizer to compute. So
in this IMPT planning, only the superiorinferior direction robust optimization was used to
compensate the over and under dose of the matching fields.7 To compensate the setup errors and
anatomical motions in the other directions, a pencil beam scattering target volume (PBSTV) was
generated by adding a 3 mm margin to the anterior and posterior directions of the brain CTV,
and the left and right directions of spinal CTV, and a 1 mm margin to the left and right directions
of the brain CTV and the anterior and posterior directions of the spinal CTV, which were also the
beam directions. Since robust optimization was used for the superior and inferior directions to
compensate the field misalignment uncertainties at the field junctions, no margin was added in
these two directions. All organs at risk (OR) shown in Table 2 were contoured. The PBSTV and
OR are shown in Figure 2 and 3.
Figure 1. Robust optimization settings for CSI IMPT planning. A 0.3 cm uncertainty in Sup-Inf
direction was used. Independent beams were checked to account all possible combinations of
patient ISO shift uncertainties.
PBSTV
Optic
nerves
PBSTV
CTV
A dose of 36 Gy at 1.8 Gy per day was prescribed to the target volume. A 3mm setup
uncertainty in the superior-inferior direction and 3.5% range uncertainty for the PBSTV were
used for robust optimization (Figure 1). IMPT is delivered by scanning the target volume layerby-layer. By switching energies the proton beams penetrate the target volume at different depths
so that the Bragg peaks stop at different layers. A 1 cm wall with 1 mm gap outside the PBSTV
was generated to keep the dose more conformal. The plan optimization objectives are shown in
Figure 5.
Desired Objective
Achieved objective
3888 cGy
D99:
3359 cGy
V100:
> 95%
95.1%
V95:
98.9%
Desired
Achieved
Constraints
Objective(s)
Objective(s)
Met/Exceeded
Heart
6 cGy
Met
Stomach
V22.5 < 10 cc
0 cc
Met
Lung rt
80 cGy
Met
Lung lt
107 cGy
Met
Liver
4 cGy
Met
Kidney rt
6 cGy
Met
Kidney lt
7 cGy
Met
Bowel
V24 < 20 cc
0 cc
Met
Rectum
V27.5 < 20 cc
0 cc
Met
Bladder
V16.8 < 15 cc
0 cc
Met
Femur rt
V24 < 10 cc
0 cc
Met
Femur lt
V24 < 10 cc
0 cc
Met
Mandible
800 cGy
Met
Parotids
274 cGy
Met
Submandibular Glands
57 cGy
Met
Glottis
24 cGy
Met
Thyroid
0.0
Met
Lens
105 cGy
Met
This technique takes into consideration of the field misalignment uncertainties and
optimizes to generate a decreasing dose gradient in the overlapped junction area of one field, and
an increasing dose gradient in the same area of the adjacent field. Figure 9 shows the dose
gradient in the cranial fields and the mid-spinal field when the superior spinal field is removed.
By adding a line dose profile in that area as shown in Figure 10, the dose gradient, as displayed
10
in Figure 11, can be measured. Thus, the proton CSI plan is able to achieve field junction
homogeneity and substantially reduce dose to healthy tissues.
Dose gradient
Dose gradient
11
Figure 10. The line dose profile added to measure the dose gradient (orange)
12
Figure 11. The dose gradient of the overlapped area for the two adjacent fields
13
The hot spots locate at the superior part of the cranial PTV, due to the reduced thickness
of anatomy. The cold spots are at the junction area between fields, which are caused by robust
optimization to prevent hot spots when adjacent fields overlap more than predefined.
For both conventional and IMPT techniques, the higher sensitivity to organ motion was
thought to be the biggest disadvantage to proton therapy, as the beams are not synchronized with
organ motion during beam delivery.8 The newly developed robust optimization method of IMPT
has been demonstrated to account for the range and patient setup uncertainties including tumor
shrinkage, patient weight gain/loss, field misalignment, intrafractional organ motion, etc.2 In
recent published research, the plan robustness was evaluated for robust optimized and
conventional non-robust IMPT plans by shifting the isocenter 3 mm per field.3 Results showed
the deviation for the simulated mismatching error was significantly smaller than that in the
conventional plan, which proved the robust optimization is able to compensate the setup errors
for multi-isocenter fields. This robust optimization method of IMPT allows multi-field
optimization for large targets without field junction shifting, which is an advantage for CSI
planning.
Proton therapy, especially PBS therapy, has been proven to be effective and superior
when treating the craniospinal axis compared to standard photon therapy. The aforementioned
benefits surrounding PBS proton therapy supports the superiority of proton therapy. However,
proton therapy presents with disadvantages of which includes monetary constraints on facilities
to support such equipment and patients to receive treatments of that caliber. Proton therapy
equipment also requires a large operating space within the facility or another spare building. For
the robust optimization, too many scenarios will significantly increase the optimization time. As
a result, more experience is still needed in balancing the number of scenarios and plans adequate
robustness. Lastly, since proton therapy is a newer technique, quality assurance programs are
limited and facilities must implement their own programs until national protocols become
available.8
14
Conclusion
The IMPT using robust optimization is able to account iso shift uncertainties in CSI
treatments. The planning process is much simpler and more robust than other methods. The
doses to the OR and normal tissues are considerably less than photon treatments, which is critical
for young patients.
15
References
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http://dx.doi.org/10.5732/cjc.010.10529
2. Liu W, Zhang X, Li Y, Mohan R. Robust optimization of intensity modulated proton therapy.
Med Phys. 2012;39(2):1079-1091. http://dx.doi.org/10.1118/1.3679340
3. Liao L, Lim GJ, Li Y, et al. Robust optimization for intensity modulated proton therapy
plans with multi-Isocenter large fields. Int J Part Ther. September 2016.
http://dx.doi.org/10.14338/IJPT-16-00012.1
4. South, M. Using Composite Planning and Delivery with Feathered Junctions in
Craniospinal, Brain-Spine and Spine-Spine Abutted Fields. [PowerPoint]. Methodist Cancer
Center; 2015.
5. Lin H, Ding X, Kirk M, et al. Supine craniospinal irradiation using a proton pencil beam
scanning technique without match line changes for field junctions. Int J Radiat Oncol Biol
Phys. 2014;90(1):71-78. http://dx.doi.org/10.1016/j.ijrobp.2014.05.029
6. Paulino AC. Radiotherapeutic management of medulloblastoma. Oncology (Williston Park).
1997;11(6):813-823, 827-828, 831.
7. Liu W, Frank SJ, Li X, et al. PTV-based IMPT optimization incorporating planning risk
volumes vs robust optimization. Med Phys. 2013;40(2):021709-1-8.
http://dx.doi.org/10.1118/1.4774363
8. Khan FM, Gibbons JP. The Physics of Radiation Therapy. 5th ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2014.