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Purpose: Two-dimensional GRID therapy, traditionally planned and delivered using a dedicated GRID block or MLC modulation, has shown clinical efficacy in treating bulky tumors. However, the large dose to normal tissues outside target can be limiting. We hypothesize that modulation in the third dimension will improve dose sparing of normal tissues, maximize the bystander effect within the target, and ultimately improve the therapy effectiveness. This study aims to investigate the feasibility of a three-dimensional GRID technique using conventional LINACs to achieve a 3D lattice of high dose volumes within a target. Methods: Datasets of patient’s having large tumor sizes were used to investigate the planning and delivering of 3D GRID using a Varian TrueBeam linac. Original patient contours of PTV are exported from a TPS to DICOManTX where 3D GRID targets are generated in programmable configurations. A structure of avoidance (SOA), i.e., PTV minus GRID targets, is also generated to facilitate inverse planning to achieve the desired pattern. The artificial structures were sent back to the TPS where an IMRT or VMAT plan is designed to deliver a desired high dose to GRID targets while minimizing the dose to the SOA as much as possible. Results: The programmable GRID target generator enables us to modify the target geometry to maximize the peak-to-valley ratio. Preliminary results show that plans based on spherical GRID targets achieve a higher peak-to-valley dose ratio compared with cylindrical targets. High dose spillage outside the target was eliminated. IMRT planning requires the number of beams to be larger than 16, while for VMAT the number of arcs should be at least 4 in order to achieve dosimetric goals. Conclusion: Planning and delivering 3D GRID therapy using conventional LINACs was shown to be feasible. More research and development are required before this new modality can be implemented clinically.

Purpose: To compare the radiobiological effect on large tumors and surrounding normal tissues from single fraction SRS, multi-fractionated SRT, and multi-staged SRS treatment. Methods: An anthropomorphic head phantom with a centrally located large volume target (18.2 cm3) was scanned using a 16 slice large bore CT simulator. Scans were imported to the Multiplan treatment planning system where a total prescription dose of 20Gy was used for a single, three staged and three fractionated treatment. Cyber Knife treatment plans were inversely optimized for the target volume to achieve at least 95% coverage of the prescription dose. For the multistage plan, the target was segmented into three subtargets having similar volume and shape. Staged plans for individual subtargets were generated based on a planning technique where the beam MUs of the original plan on the total target volume are changed by weighting the MUs based on projected beam lengths within each subtarget. Dose matrices for each plan were export in DICOM format and used to calculate equivalent dose distributions in 2Gy fractions using an alpha beta ratio of 10 for the target and 3 for normal tissue. Results: Singe fraction SRS, multi-stage plan and multi-fractionated SRT plans had an average 2Gy dose equivalent to the target of 62.89Gy, 37.91Gy and 33.68Gy, respectively. The normal tissue within 12Gy physical dose region had an average 2Gy dose equivalent of 29.55Gy, 16.08Gy and 13.93Gy, respectively. Conclusion: The single fraction SRS plan had the largest predicted biological effect for the target and the surrounding normal tissue. The multi-stage treatment provided for a more potent biologically effect on target compared to the multi-fraction SRT treatments with less biological normal tissue than single-fraction SRS treatment.

Purpose: Abdominal compression (AC) has been widely used to reduce pancreas motion due to respiration for pancreatic cancer patients undergoing stereotactic body radiotherapy (SBRT). However, the inter-fractional and intra-fractional patient motions may degrade the treatment. The purpose of this work is to study daily CBCT projections and 4DCT to evaluate the inter-fractional and intra-fractional pancreatic motions. Methods: As a standard of care at our institution, 4D CT scan was performed for treatment planning. At least two CBCT scans were performed for daily treatment. Retrospective studies were performed on patients with implanted internal fiducial markers or surgical clips. The initial motion pattern was obtained by extracting marker positions on every phase of 4D CT images. Daily motions were presented by marker positions on CBCT scan projection images. An adaptive threshold segmentation algorithm was used to extract maker positions. Both marker average positions and motion ranges were compared among three sets of scans, 4D CT, positioning CBCT, and conformal CBCT, for inter-fractional and intra-fractional motion variations. Results: Data from four pancreatic cancer patients were analyzed. These patients had three fiducial markers implanted. All patients were treated by an Elekta Synergy with single fraction SBRT. CBCT projections were acquired by XVI. Markers weremore » successfully detected on most of the projection images. The inter-fractional changes were determined by 4D CT and the first CBCT while the intra-fractional changes were determined by multiple CBCT scans. It is found that the average motion range variations are within 2 mm, however, the average marker positions may drift by 6.5 mm. Conclusion: The patients respiratory motion variation for pancreas SBRT with AC was evaluated by detecting markers from CBCT projections and 4DCT, both the inter-fraction and intra-fraction motion range change is small but the drift of marker positions may be comparable to motion ranges.« less

Purpose: To compare treatment isocenter placement based on OBI 2D kV imaging and OBI 3D‐CBCT imaging for patients undergoing SBRT, and compare the CBCT based isocenter shifts among liver,lung and spine lesions. Material and Methods: 119 SBRT fractions were delivered to 40 lesions of 32 patients. The patients were initially localized with 2D orthogonal on‐board kV images. 3D on‐board CBCTimages were then acquired to localize the isocenter for treatment. The shifts from 2D to 3D localization were recorded. Histograms, mean values and standard deviation of the isocenter shifts were calculated. Results: The isocenter shifts based on the 3D CBCT for all 119 SBRT fractions were 0.27 ± 0.25 cm, 0.19 ± 0.23 cm, and 0.23 ± 0.27 cm in the A‐P, C‐C, and M‐L direction, respectively. The mean values and standard deviations of the magnitudes of the shifts along AP, CC and ML directions were 0.30 ± 0.26 cm, 0.21 ± 0.20 cm, and 0.31 ± 0.35 cm for liver patients, 0.31 ± 0.29 cm, 0.30 ± 0.31 cm, and 0.28 ± 0.33 cm for lung patients, and 0.22 ± 0.21 cm, 0.13 ± 0.16 cm, and 0.18 ± 0.18 cm for spine patients. Conclusion:CBCT guidance enhances the setup accuracy of SBRTtreatment by using 3D anatomical information. Partly supported by Varian Research Grant.

Purpose: To develop and assess a technique using cone‐beam CT(CBCT) to localize treatment targets for stereotactic body radiation therapy(SBRT).Material and Methods: Patients selected for SBRT had 3‐D or 4‐D CT simulation with immobilization. GTV, CTV, ITV, and PTV were identified for treatment planning. Intensity‐modulated radiation beams, multiple 3‐D conformal beams, or dynamic conformal shaped arcs were designed (physician preference) and delivered using a Varian 21EX with 120‐leaf MLC. Pre‐treatment CBCTimages (acquired over sixty seconds) were registered to the planning CT based on target soft tissue and bony structures. After the physician confirmed the potential deviations of the treatment target, the couch was automatically shifted for positioning correction. Radiographicimages (kV, MV or CBCT) were taken before and after beam delivery to assess for potential intra‐fraction motion. Results: Five patients with lung, liver, and spine lesions received 18 fractions (all 3 fractions except one 6 fractions) using this technique. Pre‐treatment CBCTimages were successfully obtained for 17 fractions. Compared to traditional 2D matching using bony structures (tumor are usually not visible), use of CBCT, which is essentially imaging ITV, is able to correct target deviation from 1 mm to 15 mm with an average of 5 mm. The comparison on pre‐treatment and post‐treatment radiographicimages demonstrated an average 2 mm deviation (ranging from 0–4 mm), suggesting that better immobilization might further improve the positioning accuracy. Typical total “in‐room” times for the patients are about 1 hour. Conclusion: CBCT‐guided SBRT is reasonable and allows for alignment based on 3‐D anatomical information prior to treatment. Partially supported by a Varian research grant.