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Reirradiation of Spinal Column Metastases

Comparison of Several Treatment Techniques and Dosimetric Validation for the Use of VMAT

Rebestrahlung von paraspinalen Metastasen: Vergleich verschiedener Bestrahlungstechniken und dosimetrische Validierung von VMAT

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Background:

For reirradiation of spinal column metastases, intensity-modulated radiation therapy (IMRT) reduces the dose to the spinal cord, while allowing longer treatment times. We analyzed the potential of volumetric modulated arc therapy (VMAT) to reduce treatment time and number of monitor units (MU).

Patients and Methods:

In CT datasets of 9 patients with spinal column metastases, the planned target volume (PTV) encompassed the macroscopic tumor including the spinal cord or medullary cone, respectively. The prescribed dose for the target was 40 Gy, but median spinal cord dose was intended to be < 26 Gy. We compared a posterior (3D-PA) static field technique, a two-field wedge technique (3D-wedge) and 5-/7-beam IMRT with VMAT. Conformity index (CI), homogeneity index (HI40), dose volume histogram (DVH) parameters, treatments delivery time (T), and MU were analyzed. Dosimetry was validated with EDR2-film/ionization chambers.

Results:

PTV coverage was insufficient for 3D-conformal radiotherapy (3D-CRT) when spinal cord tolerance was respected. The IMRT approach provided excellent results but has the longest treatment time. VMAT produced dose distributions similar to IMRT with shorter treatment times (VMAT: mean 4:49 min; IMRT: mean 6:50 min) and fewer MU (VMAT: 785; IMRT: 860). Reduced conformity and increased homogeneity for VMAT when compared to IMRT were observed. An absolute deviation between measured and calculated dose of +0.70 ± 3.69% was recorded. γ-Index analysis showed an agreement of 91.33 ± 3.53% for the 5%/5 mm criteria.

Conclusion:

For this paradigm, VMAT produces high quality treatment plans with homogeneity/conformity similar to static IMRT, shorter treatment times, and fewer MU. Verification measurements showed good agreement between calculation and delivered dose, leading to clinical implementation.

Ziel:

Die Intensitätsmodulierte Radiotherapie (IMRT) ermöglicht bei der Rebestrahlung von Wirbelsäulenmetastasen eine Reduktion der Dosis im Spinalkanal bei gleichzeitig längerer Bestrahlungszeit im Vergleich zur konventionellen 3D-Technik. Wir analysierten das Potential der volumetrisch modulierten Rotationstherapie (VMAT), um die Bestrahlungszeit und die Anzahl der Monitor-Einheiten (MU) zu reduzieren.

Patienten und Methoden:

9 CT-Datensätze von Patienten mit Wirbelsäulenmetastasen wurden untersucht, bei denen das Zielvolumen (ZV) den makroskopischen Tumor inklusive Spinalkanal umfasste. Verschreibungsdosis für das ZV waren 40 Gy unter Berücksichtigung der medianen Spinalkanaldosis von < 26 Gy. Wir verglichen eine posteriore 3D-Technik (3D-PA), eine 2-Felder-Technik mit Keilen (3D-Wedge) und 5/7-Felder-IMRT mit VMAT. Konformitätsindex (CI), Homogenitätsindex (HI40), Dosis-Volumen-Histogramme (DVH), Bestrahlungszeit (T) und MU wurden verglichen. Die Dosimetrie wurde mit EDR2 Filmen und Ionistationskammer überprüft.

Ergebnisse:

Die ZV-Abdeckung für die 3D-Techniken war insuffizient, wenn die Toleranzdosis des Spinalmarks berücksichtigt wurde. Der IMRT-Ansatz ergab exzellente Resultate, allerdings mit der längsten Bestrahlungszeit. Mit VMAT ließen sich ähnliche Dosisverteilungen wie mit IMRT mit kürzeren Bestrahlungszeiten (VMAT Mittel 4:49 Min., IMRT Mittel 6:50 Min.) und weniger MU (VMAT:785, IMRT:860) realisieren. Eine geringere Konformität und höhere Homogenität von VMAT wurde im Vergleich zu IMRT beobachtet. Die absolute Abweichung zwischen gemessener und berechneter Dosis betrug +0.70±3.69%. Die γ-Analyse zeigte eine Übereinstimmung von 91.33 ± 3.53% für 5%/5 mm.

Schlussfolgerung:

Für dieses Paradigma erzeugt VMAT qualitativ hochwertige Bestrahlungspläne mit zu IMRT vergleichbarer Homogenität/Konformität, kürzeren Bestrahlungszeiten und weniger MU. Verifikationsmessungen zeigten gute Übereinstimmungen zwischen errechneten und gemessenen Dosen und erlaubten die klinische Implementierung.

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Authors and Affiliations

  1. Department of Radiation Oncology, University Medical Center Mannheim, University Heidelberg, Heidelberg, Germany

    Dirk Wolff, Linda Bauer, Hans-Jörg Wertz, Frederik Wenz & Frank Lohr

  2. Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Mannheim, Medizinische Fakultät Mannheim, Theodor-Kutzer-Ufer 1–3, 68167, Mannheim, Germany

    Florian Stieler MSc

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  1. Florian Stieler MSc
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  2. Dirk Wolff
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Correspondence to Florian Stieler MSc.

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Stieler, F., Wolff, D., Bauer, L. et al. Reirradiation of Spinal Column Metastases. Strahlenther Onkol 187, 406–415 (2011). https://doi.org/10.1007/s00066-011-2198-6

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  • DOI: https://doi.org/10.1007/s00066-011-2198-6

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