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Results of a multicenter intensity modulated radiation therapy treatment planning comparison study for a sample prostate cancer case

Ergebnisse einer multizentrischen Planvergleichsstudie mit fluenzmodulierten Photonenfeldern für einen exemplarischen Prostatakarzinom-Fall

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Abstract

Purpose

To determine the influence of different medical physicists, photon energies, treatment planning systems and treatment machines on the resulting external beam radiotherapy dose distribution for a sample prostate cancer case.

Methods

A pre-contoured computed tomography (CT) dataset containing planning target volume 1 (PTV1) prostate and seminal vesicles (single dose [SD] 1.8 Gy, total dose [TD] 59.4 Gy), PTV2 prostate (simultaneously integrated boost [SIB], SD 2.0 Gy, TD 66 Gy), PTV3 prostate and seminal vesicles approach (SD 1.8 Gy, TD 73.8 Gy/80.4 Gy SIB) as well as organs at risk (OAR: rectum, bladder, femoral heads, bowel, anus) was offered to the members of the task group IMRT (intensity-modulated radiation therapy) of the German Society for Medical Physics. The purpose was to calculate one combined treatment plan (TP) for PTV1 and PTV2, as well as a separate one for PTV3. Dose volume histograms (DVH), different dose values, conformity index (CI), homogeneity index (HI), gradient index (GI) and a new “better than average score” were used to analyse the dose distributions.

Results

Altogether 44 institutions took part in this study and submitted acceptable dose distributions for the PTVs. However, there were statistically significant differences, especially for the doses administered to the OAR, such as rectum, bladder and femoral heads. Differences between the treatment plans were not easily detectable by visual inspection of the isodose distribution. Dose maxima may occur outside the PTV. Even though scoring indices are already published, the new “better than average score” was needed to identify a plan that minimises dose to all OAR simultaneously.

Conclusion

Different medical physicists or dosimetrists, photon energies, treatment planning systems, and treatment machines have an impact on the resulting dose distribution. However, the differences only become apparent when comparing DVH, analysing dose values, comparing CI, HI, GI, as well as reviewing the dose distribution in every single plane. A new score was introduced to identify treatment plans that simultaneously deliver a low dose to all OAR. Such inter- and intra-institutional comparison studies are needed to explore different treatment planning strategies; however, there is still no automatic solution for an “optimal” treatment plan.

Zusammenfassung

Zielsetzung

Es sollten die Einflüsse unterschiedlicher Planer, der Photonenenergie sowie der Bestrahlungsplanungssysteme und Therapiegeräte auf die resultierende Dosisverteilung für einen exemplarischen Prostata-Bestrahlungsfall untersucht werden.

Methoden

Ein vorkonturierter Computertomographiedatensatz mit den Planungszielvolumina 1 (PTV1) Prostata und Samenblasen (Einzeldosis [SD] 1,8 Gy, Gesamtdosis [TD] 59,4 Gy), PTV2 Prostata (simultan integrierter Boost [SIB], SD 2,0 Gy, TD 66 Gy) und PTV3 Prostata und Samenblasenansatz (SD 1,8 Gy, TD 73,8 Gy/80,4 Gy im SIB) sowie den Risikoorganen Rektum, Blase, Anus, Darm und Femurköpfe wurde über den Arbeitskreis IMRT (intensitätsmodulierte Radiotherapie) der Deutschen Gesellschaft für Medizinische Physik allen interessierten strahlentherapeutischen Einrichtungen im deutschsprachigen Raum angeboten. Es war die Aufgabe, einen gemeinsamen Plan für PTV1 und PTV2 als auch einen weiteren für PTV3 zu berechnen. Es wurden Dosis-Volumen-Histogramme (DVH), unterschiedliche Dosiswerte, der Konformitätsindex (CI), Homogenitätsindex (HI) und Gradientenindex (GI) sowie ein neuer „Besser-als-der-Durchschnitt-Score“ miteinander verglichen sowie die Dosisverteilungen in jeder Schicht analysiert.

Ergebnisse

Insgesamt 44 strahlentherapeutische Einrichtungen nahmen an der Studie teil und sandten akzeptable Bestrahlungspläne für die PTV ein. Es fanden sich statistisch signifikante Unterschiede in den Therapieplänen, insbesondere in den Risikoorgandosen, etwa für Rektum, Blase und Hüftköpfe. Diese Unterschiede lassen sich allein anhand des Isodosenverlaufs nur schwer erkennen. Es können Dosismaxima außerhalb des PTV auftreten. Obwohl bereits mehrere Scores zur Bewertung von Therapieplänen publiziert wurden, wurde ein weiterer Score benötigt, um einen Plan mit gleichzeitig geringer Dosisbelastung für alle Risikoorgane zu identifizieren.

Schlussfolgerung

Unterschiedliche Planer, Photonenenergien, eingesetzte Bestrahlungsplanungssysteme und Therapiegeräte haben einen Einfluss auf die resultierende Dosisverteilung. Die Unterschiede werden aber erst durch einen Vergleich der DVH, eine numerische Analyse der Dosiswerte, die Kontrolle von CI, HI und GI sowie eine Begutachtung der Dosisverteilungen in jeder Schicht deutlich. Es wurde ein neuer Score eingeführt, um Bestrahlungspläne zu finden, die die Dosisbelastung aller Risikoorgane gleichzeitig minimieren. Solche inter- und intrainstitutionellen Planvergleichsstudien sind nötig, um unterschiedliche Bestrahlungstechniken zu bewerten. Aber weiterhin gibt es keine automatische Lösung für einen „optimalen“ Bestrahlungsplan.

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Acknowledgements

The authors thank all participants of this treatment planning comparison study who sent in two treatment plans: Thomas Barthel (Würzburg), Dr. Klaus Bratengeier (Würzburg), David Büch (Nürnberg), Benjamin Bujak (Goslar), Stephan Dröge (Hemer), Dr. Jörg Eckardt (Bochum), Anke Engbert (Lüneburg), Christiane Feyrer (Heilbronn), Karsten Gerull (Lübeck), Julia Göpner (Berlin), Sascha Großmann (Mainz), Benjamin Gülden (Berlin), Laura Günther (Wuppertal), Dietmar Hahm (Bielefeld), Thomas Hauschild (Bamberg), Simon Howitz (Jena), Dr. Daniel Hummel (Stuttgart), Petra Hüttenrauch (Göttingen), Severin Kampfer (München), Jürgen Karg (Roth), Wolfgang Lechner (Wien, Österreich), Kathleen Lorenz (Chemnitz), Imke Lütjens (Hamburg), Steffen Lutz (Stuttgart), Manfred Mayr (Kaufbeuren), Tristan Mensing (Berlin), Dr. Knut Merla (Dresden), Dr. Christos Moustakis (Münster), Marcel Renz (Braunschweig), Dr. Thomas Rothe (Freiburg), Dr. Henrik Schachner (Weilheim), Dr. Nanda Schmidt-Petersen (Stade), Frank Szafinski (Düsseldorf), Michael Tartz (Hannover), Maik Teicher (Neubrandenburg), Kathleen Trombalski (Berlin), Prof. Dr. Ulrich Wolf (Leipzig), as well as five colleagues who wanted to take part anonymously.

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Authors and Affiliations

  1. Outpatient Center of the UKE GmbH, Department for Radiation Oncology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany

    Thorsten Frenzel &  Andreas Krüll

  2. Department of Radiotherapy and Radiation Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

    Dirk Albers, Maximilian Grohmann &  Andreas Krüll

Authors
  1. Thorsten Frenzel
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  2. Dirk Albers
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  3. Maximilian Grohmann
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  4. Andreas Krüll
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Contributions

The authors of the article did the following specific work: Thorsten Frenzel: Study design, technical implementation (server, communication), evaluation of the data, presentation of the data at each community meeting (AK IMRT), drafting of the manuscript, literature search, proofreading. Dirk Albers: Technical implementation (anonymization of the CT data; import of the treatment plans), data processing, editing of the manuscript, proofreading. Maximilian Grohmann: Technical support, e.g., with Varian’s script language for the evaluation of the treatment plans, editing of the manuscript, proofreading. Andreas Krüll: Evaluation of the treatment plans, editing of the manuscript, literature search, proofreading

Corresponding author

Correspondence to Thorsten Frenzel.

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Conflict of interest

T. Frenzel, D. Albers, M. Grohmann, and A. Krüll declare that they have no competing interests.

Ethical standards

This article is about the comparison of multiple treatment plans that were created by medical physicists in Germany and Austria. All participants gave their consent for blinded publication when sending in their treatment plan. Some participants wanted to stay anonymous in the final paper. All study participants were informed about the preliminary results and ongoing work during AK IMRT and AK Tomotherapie meetings.

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Frenzel, T., Albers, D., Grohmann, M. et al. Results of a multicenter intensity modulated radiation therapy treatment planning comparison study for a sample prostate cancer case. Strahlenther Onkol 195, 913–922 (2019). https://doi.org/10.1007/s00066-019-01496-9

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  • DOI: https://doi.org/10.1007/s00066-019-01496-9

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