Capstone Research Paper Outline

Group7_2019

I. ABSTRACT
II. Introduction
A. Stereotactic body radiation therapy (SBRT) in the treatment of liver cancer or
liver metastases has been shown to be safe and provide excellent outcomes. 1,2
1. Stereotactic body radiation therapy treatment planning goals are to
deliver the prescribed therapeutic radiation dose to the planning target
volume (PTV) and ensure rapid dose fall-off from the PTV to provide
needed organs at risk (OAR) sparing.
2. Inherent risks of increased doses to organs at risk (OAR) are associated
with SBRT and special considerations must be made during treatment
planning.3
3. Dosimetric coverage of PTV is of paramount importance to achieve
goals of both local control (LC) and overall survival (OS).
4. Studies have shown superior outcomes in both LC and OS in patients
treated with liver SBRT when a biologically effective dose (BED 10Gy) of
100Gy or more is delivered.4,5
5. Challenges in gaining adequate dosimetric coverage to PTV can arise
when surrounded by, include, or abut tissues of low density such as lung
parenchyma.
B. Differing dose calculation algorithms can result in disparate calculated doses of
both OAR and PTV that neighbor or include tissues of low densities and can
have the potential to make a clinical impact. 6
1. Although the Analytical Anisotropic Algorithm (AAA) is more widely
 2. Furthermore, AAA has the tendency to overestimate the median and
mean dose to the PTV and gross tumor volume (GTV) respectively,
which in turn has the potential to directly affect clinical outcomes.7
3. Cakir8 studied dosimetric plan results with 10MV flattening filter free
(FFF) beams using AAA and AXB calculation algorithms in the
treatment of liver lesions and the effect of calculation grid size.
4. This study is limited in that it is not specific to liver PTV s located near
the liver dome which interface with lung tissue.
5. As treatment facilities replace older generation linear accelerators with
modern ones, a greater number of patients will receive stereotactic
radiation therapy treatments with state-of-the-art equipment with
enhanced features such as FFF beams.
C. The utilization of FFF beams, when available to clinicians, has become the
standard for both stereotactic radiosurgery (SRS) and SBRT.
1. The dramatic increased dose rate of FFF beams in comparison to FF
beams enables a decrease in treatment delivery times with reduction in
OAR and PTV intra-fraction motion.
2. Additionally, patient comfort is enhanced with less time spent on the
treatment table.
3. Flattening filter free beams have several advantages over flattening
filter (FF) beams including an increased dose rate factor of 2-4,
decreased production of head scatter, and less lateral transport due to a
softer beam spectra.9
4. FFF beams and the effects of OAR sparing and PTV coverage have
been studied.10
5. Yan et al10 found although PTV coverage was similar between 10MV
 7. A study performed by Ogata et al11 identified the suitable multi-leaf
collimator (MLC) margins in patients treated with liver SBRT and
10MV FFF beams.
D. This study was limited in that an advanced calculation such as AXB 7 was not
rted to be at the
dome of the liver with lung involvement. Planning target volume coverage

densities.
1. Dosimetric coverage of PTV is critical to achieve
positive LC and OS results.
2. Acuros XB algorithm has been shown to be superior in comparison to
convolution-superposition algorithms such as AAA in modeling doses
in regions of high tissue inhomogeneities.
3. The use of FFF beams in SBRT is advantageous over FF beams in terms
of considerable reduction in treatment delivery times and less head
scatter production.
4. This study intends to find optimal 10MV FFF beam MLC margins in
ung utilizing an algorithm with
superior dose modeling capabilities.
III. Methods and Materials
Patients
A. Ten patients who were previously treated for primary liver cancer or liver
metastases were selected for the study.
1. Planning target volumes ranged between 7.8cc and 59.4cc.
B. Computed Tomography scans were obtained with patient in supine orientation
with head towards gantry and both arms above head.
 b. ExacTrac (BrainLab) infrared system with body markers was
used for treatment delivery image guidance and motion
management.
2. Immobilization devices used include headrest, Vac-Loc bag under
patient head through hips, wingboard, and triangle sponge under knees
with feet banded.

Contouring

A. Gross tumor volume was delineated by the attending physician in Eclipse

treatment planning system (TPS).
B. Planning target volume was then generated by GTV expansion of 1cm in the
superior and inferior directions and 0.5cm radially.
C. Organs at Risk volumes including the liver, spinal cord, heart, lungs, and
esophagus were outlined by the planning medical dosimetrist.
1. Liver volume was specified as normal liver minus GTV.
 References
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