title: Treatment planning for MRI assisted brachytherapy of gynecologic malignancies based on total dose constraints.
abstract: OBJECTIVE
  To develop a method for treatment planning and optimization of magnetic resonance imaging (MRI)-assisted gynecologic brachytherapy that includes biologically weighted total dose constraints.
  
  
  METHODS
  The applied algorithm is based on the linear-quadratic model and includes dose, dose rate, and fractionation of the whole radiotherapy setting, consisting of external beam therapy plus high-dose-rate (HDR), low-dose-rate (LDR) or pulsed-dose rate (PDR) brachytherapy. Biologically effective doses (BED) are converted to more familiar isoeffective (equivalent) doses in 2-Gy fractions. For individual treatment planning of each brachytherapy fraction, the algorithm calculates the physical dose per brachytherapy fraction that corresponds to a predefined isoeffective total dose constraint. Achieved target dose and sparing of organs at risk of already delivered brachytherapy fractions are incorporated.
  
  
  RESULTS
  Since implementation for use in clinical routine in 2001, MRI assisted treatment plans of 216 gynecologic patients (161 HDR, 55 PDR brachytherapy) were prospectively optimized taking into account isoeffective dose-volume histogram-based total dose constraints for high-risk clinical target volume (HR CTV) and organs at risk (bladder, rectum, sigmoid). The algorithm is implemented in a spreadsheet and the procedure is fast and efficient. An uncertainty analysis of the isoeffective total doses based on variations of tissue parameters shows that confidence intervals are larger for PDR compared with HDR brachytherapy. For common treatment schedules, overall uncertainties of high-risk clinical target volume and organs at risk are within 8 Gy, except for the bladder when using the PDR technique.
  
  
  CONCLUSIONS
  The presented method to respect total dose constraints is reliable and efficient and an essential tool when aiming to increase local control and minimize side effects.
authors.affiliation: Department of Radiotherapy, Medical University of Vienna, Vienna, Austria. stefan.lang@akhwien.at
authors.forename: Stefan
authors.initials: S
authors.lastname: Lang
authors.forename: Christian
authors.initials: C
authors.lastname: Kirisits
authors.forename: Johannes
authors.initials: J
authors.lastname: Dimopoulos
authors.forename: Dietmar
authors.initials: D
authors.lastname: Georg
authors.forename: Richard
authors.initials: R
authors.lastname: Pötter
mesh_terms: D000465:Algorithms; D001918:Brachytherapy / Q000379:methods*; D012809:Colon, Sigmoid / Q000528:radiation effects; D016001:Confidence Intervals; D019583:Dose Fractionation, Radiation; D005260:Female; D005833:Genital Neoplasms, Female / Q000532:radiotherapy*; D006801:Humans; D016014:Linear Models; D053783:Magnetic Resonance Imaging, Interventional / Q000379:methods*; D011832:Radiation Injuries / Q000517:prevention & control; D011880:Radiotherapy Planning, Computer-Assisted / Q000379:methods*; D012007:Rectum / Q000528:radiation effects; D012062:Relative Biological Effectiveness; D013679:Technology, Radiologic; D001743:Urinary Bladder / Q000528:radiation effects