title: Whole-brain radiotherapy with simultaneous integrated boost to multiple brain metastases using volumetric modulated arc therapy.
abstract: OBJECTIVE
  Volumetric modulated arc therapy (RapidArc [RA]; Varian Medical Systems, Palo Alto, CA) allows for the generation of intensity-modulated dose distributions by use of a single gantry rotation. We used RA to plan and deliver whole-brain radiotherapy (WBRT) with a simultaneous integrated boost in patients with multiple brain metastases.
  
  
  METHODS
  Composite RA plans were generated for 8 patients, consisting of WBRT (20 Gy in 5 fractions) with an integrated boost, also 20 Gy in 5 fractions, to the brain metastases, and clinically delivered in 3 patients. Summated gross tumor volumes were 1.0 to 37.5 cm(3). RA plans were measured in a solid water phantom by use of Gafchromic films (International Specialty Products, Wayne, NJ).
  
  
  RESULTS
  Composite RA plans could be generated within 1 hour. Two arcs were needed to deliver the mean of 1,600 monitor units with a mean "beam-on" time of 180 seconds. RA plans showed excellent coverage of planning target volume for WBRT and planning target volume for the boost, with mean volumes receiving at least 95% of the prescribed dose of 100% and 99.8%, respectively. The mean conformity index was 1.36. Composite plans showed much steeper dose gradients outside the brain metastases than plans with a conventional summation of WBRT and radiosurgery. Comparison of calculated and measured doses showed a mean gamma for double-arc plans of 0.30, and the area with a gamma larger than 1 was 2%. In-room times for clinical RA sessions were approximately 20 minutes for each patient.
  
  
  CONCLUSIONS
  RA treatment planning and delivery of integrated plans of WBRT and boosts to multiple brain metastases is a rapid and accurate technique that has a higher conformity index than conventional summation of WBRT and radiosurgery boost.
authors: Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands. fj.lagerwaard@vumc.nl
authors: Frank J
authors: FJ
authors: Lagerwaard
authors: Elles A P
authors: EA
authors: van der Hoorn
authors: Wilko F A R
authors: WF
authors: Verbakel
authors: Cornelis J A
authors: CJ
authors: Haasbeek
authors: Ben J
authors: BJ
authors: Slotman
authors: Suresh
authors: S
authors: Senan
mesh_terms: D001932:Brain Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology / Q000532:radiotherapy* / Q000556:secondary / Q000601:surgery*; D003131:Combined Modality Therapy / Q000379:methods; D016371:Cranial Irradiation / Q000379:methods*; D019583:Dose Fractionation, Radiation; D005240:Feasibility Studies; D006801:Humans; D019047:Phantoms, Imaging; D011859:Radiography; D016634:Radiosurgery / Q000379:methods*; D011880:Radiotherapy Planning, Computer-Assisted / Q000379:methods*; D050397:Radiotherapy, Intensity-Modulated / Q000379:methods*; D047368:Tumor Burden