Treatment planning for spinal radiosurgery

Christos Moustakis, Mark K. H. Chan, Jinkoo Kim, Joakim Nilsson, Alanah Bergman, Tewfik J. Bichay, Isabel Palazon Cano, Savino Cilla, Francesco Deodato, Raffaela Doro, Jürgen Dunst, Hans Theodor Eich, Pierre Fau, Ming Fong, Uwe Haverkamp, Simon Heinze, Guido Hildebrandt, Detlef Imhoff, Erik de Klerck, Janett Köhn, Ulrike Lambrecht, Britta Loutfi-Krauss, Fatemeh Ebrahimi, Laura Masi, Alan H. Mayville, Ante Mestrovic, Maaike Milder, Alessio G. Morganti, Dirk Rades, Ulla Ramm, Claus Rödel, Frank-Andre Siebert, Wilhelm den Toom, Lei Wang, Stefan Wurster, Achim Schweikard, Scott G. Soltys, Samuel Ryu, Oliver Blanck

To investigate the quality of treatment plans of spinal radiosurgery derived from different planning and delivery systems. The comparisons include robotic delivery and intensity modulated arc therapy (IMAT) approaches. Multiple centers with equal systems were used to reduce a bias based on individual's planning abilities. The study used a series of three complex spine lesions to maximize the difference in plan quality among the various approaches. Internationally recognized experts in the field of treatment planning and spinal radiosurgery from 12 centers with various treatment planning systems participated. For a complex spinal lesion, the results were compared against a previously published benchmark plan derived for CyberKnife radiosurgery (CKRS) using circular cones only. For two additional cases, one with multiple small lesions infiltrating three vertebrae and a single vertebra lesion treated with integrated boost, the results were compared against a benchmark plan generated using a best practice guideline for CKRS. All plans were rated based on a previously established ranking system. All 12 centers could reach equality (n = 4) or outperform (n = 8) the benchmark plan. For the multiple lesions and the single vertebra lesion plan only 5 and 3 of the 12 centers, respectively, reached equality or outperformed the best practice benchmark plan. However, the absolute differences in target and critical structure dosimetry were small and strongly planner-dependent rather than system-dependent. Overall, gantry-based IMAT with simple planning techniques (two coplanar arcs) produced faster treatments and significantly outperformed static gantry intensity modulated radiation therapy (IMRT) and multileaf collimator (MLC) or non-MLC CKRS treatment plan quality regardless of the system (mean rank out of 4 was 1.2 vs. 3.1, p = 0.002). High plan quality for complex spinal radiosurgery was achieved among all systems and all participating centers in this planning challenge. This study concludes that simple IMAT techniques can generate significantly better plan quality compared to previous established CKRS benchmarks.