title: Comparison between manual and automatic segment generation in step-and-shoot IMRT of prostate cancer.
abstract: OBJECTIVE
  To compare two methods to generate treatment plans for intensity-modulated radiotherapy (IMRT) of prostate cancer, delivered in a step-and-shoot mode. The first method uses fluence optimization (inverse planning) followed by conversion of the fluence weight map into a limited number of segments. In the second method, segments are manually assigned using a class solution (forward planning), followed by computer optimization of the segment weights.
  
  
  METHODS
  Treatment plans for IMRT, utilizing a simultaneous integrated boost, were created. Plans comprise a five-field technique to deliver 78 Gy to the prostate plus seminal vesicles. Five patients were evaluated. Optimization objectives of both planning approaches concerned dose coverage of the target volumes and the dose distribution in the rectal wall. The two methods were evaluated by comparing dose distributions, the complexity of the resulting plan and the time expenditure to generate and to deliver the plan.
  
  
  RESULTS
  For both planning approaches 99% of the target volumes received 95% of the prescribed dose, which complies with our planning objectives. Inverse planning resulted in more conformal dose distributions than forward planning (conformity index: 1.37 versus 1.51). Inverse planning reduced the dose to the rectal wall compared to a manually designed plan, albeit to a small extent. The theoretical probability of severe rectal proctitis and/or stenosis was reduced on average by 1.9% with inverse planning. Maximal sparing of the rectal wall was achieved with inverse planning for a patient whose target volume was partly wrapped around the rectum. The number of segments generated with inverse planning ranged between 33 and 52, and between 9 and 13 segments for manually created segments.
  
  
  CONCLUSIONS
  Dose coverage of the planning target volumes is adequate for both approaches of planning. Inverse planning results in slightly better dose distributions with respect to the rectal wall compared to manual planning, at the cost of an increase of the number of segments by a factor of 3.
authors.affiliation: Radiotherapy Department, The Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands.
authors.forename: Luc J
authors.initials: LJ
authors.lastname: Bos
authors.forename: Marco
authors.initials: M
authors.lastname: Schwarz
authors.forename: Werner
authors.initials: W
authors.lastname: Bär
authors.forename: Markus
authors.initials: M
authors.lastname: Alber
authors.forename: Ben J
authors.initials: BJ
authors.lastname: Mijnheer
authors.forename: Joos V
authors.initials: JV
authors.lastname: Lebesque
authors.forename: Eugène M F
authors.initials: EM
authors.lastname: Damen
mesh_terms: D006801:Humans; D008297:Male; D011467:Prostate / Q000528:radiation effects*; D011471:Prostatic Neoplasms / Q000532:radiotherapy*; D011835:Radiation Protection / Q000379:methods; D011879:Radiotherapy Dosage; D020266:Radiotherapy, Conformal; D012007:Rectum / Q000528:radiation effects*; D012669:Seminal Vesicles / Q000528:radiation effects*