title: Transition from a simple to a more advanced dose calculation algorithm for radiotherapy of non-small cell lung cancer (NSCLC): implications for clinical implementation in an individualized dose-escalation protocol.
abstract: OBJECTIVE
  To investigate the clinical consequences of the transition from a simple convolution algorithm (CA) to a more advanced superposition dose calculation algorithm (SA) in an individualized isotoxic dose-escalation protocol for NSCLC patients.
  
  
  METHODS
  First, treatment plans designed according to ICRU50-criteria using the CA were recalculated using the SA, for 16 patients. Next, two additional plans were designed for each patient using only the SA: one with 95%-isodose coverage (ICRU50-criteria), the other allowing PTV coverage with 90%-isodose at the lung side. PTV dose was escalated to a maximum dose of 79.2Gy or lower when limited by either a mean lung dose (MLD) of 19Gy or a maximum spinal cord dose of 54Gy. Equivalent uniform doses (EUD) in the PTV were compared.
  
  
  RESULTS
  Recalculation of the CA plans using the SA, showed PTV underdosage in the CA plans: the median PTV EUD was 61.3Gy (range 44.9-80.4Gy) and 55.5Gy (43.9-76.8Gy), for CA and SA, respectively (p<0.001). Redesigning plans using the SA resulted in an almost identical PTV EUD of 55.1Gy (43.7-79.2Gy). For the subgroup (N=9) with MLD as dose-limiting factor a gain in PTV EUD of 2.7+/-1.8Gy (p=0.008) was achieved using the 90%-isodose coverage plan.
  
  
  CONCLUSIONS
  Plans calculated using the CA caused large PTV underdosage. Plans designed using the SA often lead to lower maximum achievable tumour doses due to higher MLD values. Allowing somewhat relaxed PTV coverage criteria increased the PTV dose again for MLD restricted cases. Consequently, in clinics where isotoxic individual dose-escalation is applied, implementation of an SA should be accompanied by accepting limited PTV underdosage in patients with MLD as the dose-limiting factor.
authors.affiliation: Department of Radiation Oncology (MAASTRO), GROW, University Hospital Maastricht, Maastricht, The Netherlands. wouter.vanelmpt@maastro.nl
authors.forename: Wouter van
authors.initials: Wv
authors.lastname: Elmpt
authors.forename: Michel
authors.initials: M
authors.lastname: Ollers
authors.forename: Marije
authors.initials: M
authors.lastname: Velders
authors.forename: Kim
authors.initials: K
authors.lastname: Poels
authors.forename: Ben
authors.initials: B
authors.lastname: Mijnheer
authors.forename: Dirk De
authors.initials: DD
authors.lastname: Ruysscher
authors.forename: André
authors.initials: A
authors.lastname: Dekker
authors.forename: Philippe
authors.initials: P
authors.lastname: Lambin
authors.forename: Liesbeth
authors.initials: L
authors.lastname: Boersma
mesh_terms: D000465:Algorithms; D002289:Carcinoma, Non-Small-Cell Lung / Q000000981:diagnostic imaging / Q000473:pathology / Q000532:radiotherapy*; D004307:Dose-Response Relationship, Radiation; D006801:Humans; D008175:Lung Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology / Q000532:radiotherapy*; D009010:Monte Carlo Method; D009367:Neoplasm Staging; D011879:Radiotherapy Dosage; D011880:Radiotherapy Planning, Computer-Assisted; D018709:Statistics, Nonparametric; D014055:Tomography, Emission-Computed; D014057:Tomography, X-Ray Computed