Research Proposal

Title: SBRT of superior liver lesions using Acuros XB calculation algorithm and 10MV FFF
beams: a search of optimal multi-leaf collimator (MLC) margins.

Problem Statement: Stereotactic body radiation therapy (SBRT) in the treatment of liver cancer
or metastases has been shown to be safe and provide excellent outcomes.1 With inherent risk of
increased dose to organs at risk (OAR’s) with SBRT, a rapid dose falloff from the planning
target volume (PTV) is necessary to minimize dose to normal tissue. Differing algorithms can
result in differing dose calculation results of both OAR’s and PTV; which have the potential to
make a clinical impact.2 Challenges in gaining adequate dosimetric coverage to PTV’s can arise
when they are surrounded by or abut tissues of low density such as lung parenchyma. Cakir3
studied dosimetric plan results with 10MV FFF beams using Anisotropic Analytical Algorithm
(AAA) and Acuros XB (Varian; Palo Alto, CA) calculation algorithm in the treatment of liver
lesions and the effect of calculation grid size; however, the study was not specific to liver PTV’s
located near the dome which interface with lung tissue. This study is designed to identify the
most suitable multi-leaf collimator (MLC) margin in the treatment of superior liver lesions using
DCA SBRT technique with 10MV FFF beams.

Literature Review: Previous studies have identified suitable FFF MLC margins in SBRT
treatment planning. A limitation of such studies is advanced dose calculation algorithms such as
Acuros XB were not employed.4.5 Although AAA is more widely used in clinical routine,
Acuros XB has been shown to more accurately model dose distributions, especially in tissue with
high heterogeneity.6 Furthermore, AAA has the tendency to overestimate the median and mean
dose to the PTV and GTV respectively, which in turn has the potential to directly affect clinical
outcomes.6 A dosimetric study using a robust algorithm such as Acuros XB will further quantify
the clinical differences between FFF and FF beams. Yan et al7 found although PTV coverage
was similar between 10MV FFF and FF beams, differences in OAR sparing with FFF beam was
significant for some treatment sites. FFF beams have several advantages over FF beams
including; increased dose rate by a factor of 2-4, decreased production of head scatter, and less
lateral transport due to a softer beam spectra.8 This study intends to quantify the outcomes of
these advantages when paired with varying MLC margins while implementing an algorithm with
superior dose modeling capabilities.
Hypothesis: Optimal FFF MLC margins using the Acuros XB algorithm in the treatment
planning of SBRT for superior liver lesions located near the dome will be found. This data will
identify a benchmark for optimal MLC margins to obtain optimal PTV coverage and OAR
sparing.

Materials and Methods: Treatment plans from 10 patients with liver cancer or metastases
located at the dome of the liver will be planned retrospectively. Each PTV will be planned using
AAA algorithm with a three-dimensional dynamic conformal arc (DCA) technique and MLC
margins ranging from -3 to 5mm. 10 MV FFF beams will be used. Each plan will then be
recalculated with Acuros XB to see the differences between algorithms. Additional plans will be
executed utilizing Acuros XB to find appropriate MLC margins in order to obtain adequate PTV
coverage. For the scope of this study, target volume will be defined between approximately 7
and 93cm3. These target parameters were chosen to parallel the study parameters defined by
Ogata et al in order to avoid forward planning challenges due to unilateral heterogeneous effects
found in targets of increasing size.4,9 Dose distributions will be compared. Dosimetric
parameters that will be evaluated include D90, homogeneity index (HI), conformity index (CI),
gradient index (GI), liver volume receiving 20Gy or more (V20), and mean normal liver dose.
 References

1. Lee P, Sioshani S. Outcomes of SBRT for HCC in Patients with Child-Pugh B and C
Cirrhosis. Int J Radiat Oncol Biol Phys. 2018;102(3):S136.
https://doi.org/10.1016/j.ijrobp.2018.06.334
2. Yan C, Combine AG, Bednarz G, et al. Clinical implementation and evaluation of the
Acuros dose calculation algorithm. J Appl Clin Med Phys. 2017;18(5):195-209.
http://dx.doi.org/10.1002/acm2.12149
3. Cakir A. Dosimetric comparison of anisotropic analytical algorithm and Acuros XB in
stereotactic body radiotherapy and effect of calculation grid size. Turk J Oncol.
2017:32(3):100-105. http://dx.doi.org/10.5505/tjo.2017.1619
4. Ogata T, Nishimura H, Mayahara H, Uehara K, Okayama T. Identification of the
suitable leaf margin for liver stereotactic body radiotherapy with flattening filter-free
beams. Med Dosim. 2017;42(4):268-272.
http://dx.doi.org/10.1016/j.meddos.2017.06.002
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body radiotherapy using a flattening filter-free beam. Med. Phys. 2015;42(5):2125-
2131. http://dx.doi.org/10.1118/1.4916683
6. Padmanaban S, Warren S, Walsh A, Partridge M, Hawkins MA. Comparisons of Acuros
(AXB) and Anisotropic Analytical Algorithm (AAA) for dose calculation in treatment of
esophageal cancer: effects on modelling tumour control probability. Radiat Oncol.
2014;9:286. http://dx.doi.org/10.1186/s13014-014-0286-3
7. Yan Y, Yadav P, Bassetti M, et al. Dosimetric differences in flattened and flattening
filter-free beam treatment plans. J Med Phys. 2016;41(2):92-99.
http://dx.doi.org/10.4103/0971-6203.181636
8. Sharma SD. Unflattened photon beams from the standard flattening filter free
accelerators for radiotherapy: Advantages, limitations and challenges. J Med Phys.
2011;36(3):123-125. http://dx.doi.org/10.4103/0971-6203.83464
9. Vieillevigne L, Bessieres S, Ouali M, Lanaspeze, C. Dosimetric comparison of flattened
and unflattened beams for stereotactic body radiation therapy: Impact of the size of the
PTV on dynamic conformal arc and volumetric modulated arc therapy. Physica Medica.
2016;32(11):1405-1414. http://dx.doi.org/10.1016/j.ejmp.2016.10.007T