Practical Tips and Timesavers for IMRT and IGRT Planning

Lori Bizzle, R.T. (r), (t), CMD West Texas Cancer Center Odessa

Results
Figures 4 and 5 show total dose displays of a 9 angle, 10 field IMRT pelvis plan and a 9 angle, 18 field IMRT plan. Target coverage and critical structure doses are shown with the DVH illustrations. Coverage and avoidance are similar and the 9 angle 10 field plan saves approximately 8 minutes on the treatment machine. Figure 6 and 7 shows total dose displays of a 9 angle 10 field IMRT head and neck plan and an 18 field IMRT plan. The use of minimizing conflicting objectives when optimizing IMRT plans delivers better conformity and control and the use of a stepby-step approach helps minimize human error. In the case of high dose head and neck patients the use of pre-defined objectives for optimization helps preserve salivary function. See figures 6, 8 and 9. Optimizing gantry movement and arranging treatment fields in a logical order improves treatment efficiency for the patient and the therapist. Having a visual aid such as the figure included with the objectives helps to achieve this.

Introduction
Intensity Modulated Radiation Therapy (IMRT) and Image Guided Radiation Therapy (IGRT) are welcome advances to our profession and offer better treatments and outcomes for the patients we serve. Along with these advances come greater challenges and complexity with more time required for treatment planning. The following tips can be helpful timesavers for dosimetric planning by minimizing IMRT objective conflicts created by overlapping structures (OLs) and using a pre-determined parotid sparing technique to help preserve salivary gland function in high dose head and neck patients. In addition time at the treatment machine can be saved by limiting the number of fields needed to deliver IMRT treatment and by maximizing treatment field arrangement to optimize gantry movement.

Operational Definitions:
Controlled fields refer to the dosimetrist determining the number and size of the fields used when planning an IMRT patient instead of the TPS automatically defining the fields. When the TPS automatically defines the fields, the TPS might make a 9 angle, 10 field controlled plan into a 9 angle, 18 field plan. The dosimetrist can attribute and visualize the PTV as being either a right-sided target or a left-sided target based on the angles being used for treatment and can manually set the field size maintaining good target coverage without MLC abutment issues. See figures 2 and 3. Right-sided target refers to a PTV on the patients right side, assuming your patient is head first and supine. Left-sided target refers to the PTV on the patients left side.
Figure 4 shows comparative total dose coverage between 10 fields and 18 fields. Figure 5 shows comparative DVH of a 10 field pelvis and an 18 field pelvis.

OBJECTIVES
1. The Medical Dosimetrist will learn to create and use visual tools to optimize treatment field arrangement when preparing daily Kilo Voltage (KV), Image Guided Radiation Therapy (IGRT). A. The Medical Dosimetrist will recognize which orthogonal digitally reconstructed radiographs (DRRs) are optimal for specific setups. B. The Medical Dosimetrist will learn to control gantry movement direction by the use of .decimal angles. See following figure.

Figure 6 showing comparative total dose coverage of a 10 field IMRT and an 18 field IMRT plan. Figure 2 shows 9 of 10 controlled field DRRs used for planning IMRT pelvis patient.

Figure 7 displays comparative DVH for a 10 field and an 18 field IMRT head and neck plan.

2.

The Medical Dosimetrist will learn techniques to shorten treatment delivery times of Intensity Modulated Radiation Therapy (IMRT) by controlling the number of fields used when planning by defining right-sided and left-sided treatment fields.
Figure 3 showing the 9 controlled fields with 1 split field for IMRT pelvis patient.

Figure 8 shows total dose coverage and sparing of parotid glands.

Figure 9 shows total dose coverage and sparing of parotid glands.

3. The Medical Dosimetrist will be able to improve dose conformity in IMRT plans by minimizing objective conflicts with the use of a step-by-step methodology to define the regions of dosing overlaps (OL). The objectives include; organs at risk (OAR), planning target volumes (PTV), clinical target volumes (CTV), gross target volumes (GTV) and overlapping (OL) regions of interest (ROI). 4. The Medical Dosimetrist will be able to help preserve salivary gland function in high dose head and neck IMRT treatments by using predefined scripting. In the book, Handbook of Evidencebased Radiation Oncology, Editors Eric K. Hansen and Mark Roach III, specify V24, <50% as dose limiting for parotids when treating Nasopharyngeal cancer, 2.12/70 Gy.

Creating IMRT Head and Neck Multi-dose Overlapping Objectives Separation It is important to help minimize conflicting structures/doses when planning multi-dose, multi-target IMRT treatments. By following the step-by-step instructions below you can help conform and shape your coverage doses. These instructions are for our treatment planning system which is Philips Pinnacle3, Version 9.0 and 9.2. The following example includes 4 target objectives: GTV 70Gy, CTV1 60Gy, CTV2 54 Gy, and CTV3 50 Gy. Each contoured target is expanded by a 4 mm margin resulting in several overlapping areas with varying dose areas. The following procedure is suggested to create overlapping structures for planning purposes, using the ROI Expansion/Contraction routine. See figure 10 below.

Discussion
The information presented here is limited by the equipment used in our department, but the concepts presented are applicable to any radiation therapy department. The amount of time saved is significant for both the comfort of your patient and the workflow of your staff.

Conflicting Objectives refers to the differing dose objectives created when expanding target volumes. A good example would be a high dose head and neck patient with multiple defined targets of varying doses and many critical structures of avoidance. A typical prescription might be 70 Gy to the GTV, 60 Gy to CTV 1, 54 Gy to CTV2, and 50 Gy to CTV3. When expanding the target volumes by 4 mm the resulting volumes have conflicting areas. Scripting refers to following a written step-by-step approach to help minimize conflicts created when expanding GTV and CTVs by grouping structures together based on overlapping areas and prescribed doses. Scripting also refers to using a predefined critical structure objective in the DVH data set for optimizing parotid gland function.
PAROTID GLAND MAX DVH OBJECTIVES
First it is a good idea to separate any overlapping areas and create your parotid contours without any ol to use as IMRT planning objectives. The ol area can also be used to help achieve desired dose outcome. Parotid Rt no ol Max DVH 2000 cGy 30% volume Repeat for Lt Parotid Parotid Rt no ol Max DVH 1500 cGy 50% volume Parotid Rt no ol Max DVH 2500 cGy 15% volume Any parotid areas overlapping with PTV targets can be set around 0-5% above target dose to 95% volume. Example: Parotid Rt ol Max DVH 7000/7350cGy 95% volume

Conclusions
PTV 70 PTV 60 CTV1 70 ol CTV 60 no ol PTV 54 CTV2 70 ol CTV2 60 ol CTV 54 no ol PTV 50 CTV3 70 ol CTV3 60 ol CTV3 54 ol CTV 50 no ol GTV + 4mm, Avoid Exterior Body Contour CTV1 + 4mm, Avoid Interior PTV 70, Avoid Ext. Body Contour Create 70 ol -> CTV 1 -> Avoid Exterior PTV 70

Create no ol -> CTV 1 -> Avoid Interior PTV 70

CTV 2 + .4, Avoid Int, PTV 70, PTV 60, Avoid Ext. Body Create 70 ol -> CTV 2 -> Avoid Exterior PTV 70 Create 60 ol -> CTV 2 -> Avoid Ext PTV 60 Create no ol -> CTV2 -> Avoid Int. PTV 70, PTV 60 CTV 3 + .4, Avoid Int. PTV70, PTV60, PTV54, Avoid Ext Body Create 70 o l-> CTV 3 -> Avoid Ext PTV 70 Create 60 ol -> CTV 3 -> Avoid Ext PTV 60 Create 54 ol -> CTV 3 -> Avoid Ext PTV 54 Create no ol -> CTV3 -> Avoid Int. PTV 70, PTV 60, PTV 54

Methods and Materials

All references, drawings and graphics presented are based on the following equipment: Philips Pinnacle3 treatment planning system (TPS), version 9.2 and 9.0; Elektas Impac Medical Systems MOSAIQ 1.6y information management system (IMS) and Varian 21ix Linear Accelerator with On Board Imaging (OBI) and 120 multi-leaf collimation (MLC) for treatment delivery. The ideas and concepts presented, especially regarding controlling beam field size (f.s.) setups could easily be translated to other planning and delivery systems.

In the book, IMRT * IGRT * SBRT, Advances in the Treatment Planning and Delivery of Radiotherapy, Editor, John L. Meyer, chapter I, talks about the difficulties encountered when planning IMRT treatments. On page 45, (3) Hard-to-Control Tradeoffs and the Lack of Clear Priorities states: Again, the planner wants the target to receive a high uniform dose, but nearby normal structures should be avoided...There is no perfect compromise between conflicting goals, and it is almost always impossible for the planner to determine if the right compromise has been achieved.

Using visual aids increases the efficiency of the treatment planning process and limits the frustration of the Medical Dosimetrist to recall the field arrangements with each new plan. Time is saved on the treatment machine by arranging the field order for treatments and determining use of which KV fields are needed for daily IGRT QA. As indicated in the accompanying figures, treating 10 fields instead of 18 fields saves treatment time without sacrificing quality. The approximate delivery time per field is 1 minute, saving 8 minutes for a 10 field plan compared to the 18 field plan. Planning with fewer conflicts helps control and conform dose while meeting OAR objectives. The use of pre-determined DVH parameters helps meet objectives, such as RTOG 0619 and works well for most complicated IMRT head and neck treatment plans.

Figure 10 demonstrates a 70 Gy ol created during target expansion.