The dosimetric impact of random and systematic multi-leaf collimator (MLC) leaf position errors is relatively unknown for head and neck intensity-modulated radiotherapy (IMRT) patients. In this report we studied 17 head and neck IMRT patients, including 12 treated with simple plans (<50 segments) and 5 treated with complex plans (>100 segments). Random errors (-2 to +2 mm) and systematic errors (+/-0.5 mm and +/-1 mm) in MLC leaf positions were introduced into the clinical plans and the resultant dose distributions were analyzed based on defined endpoint doses. The dosimetric effect was insignificant for random MLC leaf position errors up to 2 mm for both simple and complex plans. However, for systematic MLC leaf position errors, we found significant dosimetric differences between the simple and complex IMRT plans. For 1 mm systematic error, the average changes in D(95%) were 4% in simple plans versus 8% in complex plans. The average changes in D(0.1 cc) of the spinal cord and brain stem were 4% in simple plans versus 12% in complex plans. The average changes in parotid glands were 9% in simple plans versus 13% for the complex plans. Overall, simple IMRT plans are less sensitive to leaf position errors than complex IMRT plans.

Hypofractionated stereotactic body radiotherapy (SBRT) has been tested for prostate cancer radiotherapy. This study aims to investigate the dosimetric effects of intrafraction prostate motion on the target and the normal structures for SBRT. For prostate cancer patients treated with an image-tracking CyberKnife system, the intrafraction prostate movements were recorded during 50-70 min treatment time. Based on the recorded intrafraction prostate movements, treatment plans were created for these cases using intensity modulated beams while scaling the average time patterns from the CyberKnife treatment to simulate hypofractionated intensity modulated radiotherapy (IMRT) delivery. The effect of delivery time on the intrafraction organ motion was investigated. For a nominal single fraction delivery of 9.5 Gy with IMRT, we found that the dosimetric effect of the intrafraction prostate movement is case dependent. For most cases, the dose volume histograms exhibited very small changes from the treatment plans that assumed no intrafractional prostate motion when the maximum intrafraction movements were within +/-5 mm. However, when sporadic prostate movements greater than 5 mm were present in any one direction, significant changes were found. For example, the V100, for the prostate could be reduced by more than 10% to less than 85% of the prostate volume coverage. If these large movements could be excluded by some active correction strategies, then the average V100% for the simulated plan could be restored to within approximately 2% of the ideal treatment plans. On average, the sporadic intrafraction motion has less dosimetric impact on the prolonged treatment delivery versus fast treatment delivery. For example, the average V100% for the clinical target volume was reduced from the original 95.1% to 92.1 +/- 3.7% for prolonged treatment, and to 91.3 +/- 5.4% when the treatment time was shortened by 50%. Due to the observed large sporadic prostate motions, we conclude that an on-line target motion monitoring and correction strategy is necessary to implement hypofractionated SBRT with intensity modulated beams for prostate cancer treatments.

Concurrent treatment of the prostate and the pelvic lymph nodes encounters the problem of the prostate gland moving independently from the pelvic lymph nodes on a daily basis. The purpose of this study is to develop a leaf-tracking algorithm for adjustment of IMRT portals without requirement of online dose calculation to account for daily prostate position during concurrent treatment with pelvic lymph nodes. A leaf-shifting algorithm was developed and programmed to adjust the positions of selected MLC leaf pairs according to prostate movement in the plane perpendicular to each beam angle. IMRT plans from five patients with concurrent treatment of the prostate and pelvic lymph nodes were selected to test the feasibility of this algorithm by comparison with isocenter-shifted plans, using defined dose endpoints. When the prostate moved 0.5, 1.0, and 1.5 cm along the anterior/posterior direction, the average doses to 95% of the prostate (D95%) for the iso-shift plans were similar to the MLC-shift plans, (54.7, 54.4, and 54.1 Gy versus 54.5, 54.3, and 53.9 Gy, respectively). The corresponding D95% averages to the pelvic lymph nodes were reduced from the prescription dose of 45 Gy to 42.7, 38.3, and 34.0 Gy for iso-shift plans (p = 0.04 for each comparison), while the D95% averages for the MLC-shift plans did not significantly differ from the prescription dose, at 45.0, 44.8, and 44.5 Gy. Compensation for prostate movement along the superior/inferior direction was more complicated due to a limiting MLC leaf width of 1.0 cm. In order to concurrently treat the prostate and pelvic lymph nodes with the prostate moving independently, shifting selected MLC leaf pairs may be a more practical adaptive solution than shifting the patient.

The aim of this study is to investigate the feasibility of prostate stereotactic body radiation therapy treatment with a newly developed Varian Halcyon TM 2.0 machine by comparing radiotherapy plans with previously delivered CyberKnife G4 plans created with the previous version of CyberKnife Treatment Planning System Multiplan 4.6.1. Methods Fifteen previously treated prostate stereotactic body radiation therapy treatment CyberKnife plans were replanned retrospectively according to the Radiation Therapy Oncology Group 0938 protocol on a Halcyon TM 2.0 machine with a prescription of 3625 cGy in five fractions. Results All re-plans on a Halcyon TM 2.0 were able to meet the Radiation Therapy Oncology Group 0938 protocol goals and constraints. The re-plans decreased the maximum dose to skin and urethra, mean doses to the bladder and rectum, and also improve the conformity index and the Planning Target Volume coverage. However, D1cc to the rectum, D1cc and D10% to the bladder increased with no statistically significant differences (p > 0.05) with the re-plans. Conclusion The Halcyon TM 2.0 can generate stereotactic body radiation therapy treatment prostate plans created based on the Radiation Therapy Oncology Group 0938 protocol by delivering adequate coverage to the target while sparing healthy tissues.

Previous studies have demonstrated that simple intensity-modulated radiotherapy (IMRT) plans can be produced with a series of rectangular segments formed by conventional jaws. This study investigates whether complex IMRT plans for head and neck cancer can be delivered with the conventional jaws efficiently. Six nasopharyngeal cancer patients, previously treated with multi-leaf collimator (MLC)-IMRT plans, were re-planned using conventional jaw delivery options. All IMRT plans were subject to the plan acceptance criteria of the RTOG-0225 protocol. For a selected patient, the maximum number of segments varied from five to nine per beam, and was tested for both jaws-only IMRT (JO-IMRT) plans and MLC-IMRT plans. Subsequently, JO-IMRT plans and MLC-IMRT on the same treatment planning system were attempted for all patients with identical beams. The dose distribution, dose volume histograms (DVH), the conformal index (COIN), the uniformity index and delivery efficiency were compared between the MLC-IMRT and JO-IMRT plans. All JO-IMRT plans met the RTOG-0225 criteria for tumor coverage and sensitive structures sparing. The corresponding MLC-IMRT and JO-IMRT plans show comparable conformality and uniformity, with average COINs of the planning gross tumor volume(pGTV) 37.7% +/- 18.7% versus 37.9% +/- 18.1%, and the average uniformity index 82.8% +/- 2.5% versus 83.6% +/- 3.1%, respectively. The average monitor unit for JO-IMRT plans was about twice that of MLC-IMRT plans. In conclusion, conventional jaws can be used solely to deliver complex IMRT plans for patients with nasopharyngeal cancer yet still within a practical delivery time.