title: Shortening treatment time in robotic radiosurgery using a novel node reduction technique.
abstract: OBJECTIVE
  The fraction duration of robotic radiosurgery treatments can be reduced by generating more time-efficient treatment plans with a reduced number of node positions, beams, and monitor units (MUs). Node positions are preprogramed locations where the robot can position the focal spot of the x-ray beam. As the time needed for the robot to travel between node positions takes up a large part of the treatment time, the aim of this study was to develop and evaluate a node reduction technique in order to reduce the treatment time per fraction for robotic radiosurgery.
  
  
  METHODS
  Node reduction was integrated into the inverse planning algorithm, developed in-house for the robotic radiosurgery modality. It involved repeated inverse optimization, each iteration excluding low-contribution node positions from the planning and resampling new candidate beams from the remaining node positions. Node reduction was performed until the exclusion of a single node position caused a constraint violation, after which the shortest treatment plan was selected retrospectively. Treatment plans were generated with and without node reduction for two lung cases of different complexity, one oropharyngeal case and one prostate case. Plan quality was assessed using the number of node positions, beams and MUs, and the estimated treatment time per fraction. All treatment plans had to fulfill all clinical dose constraints. Extra constraints were added to maintain the low-dose conformality and restrict skin doses during node reduction.
  
  
  RESULTS
  Node reduction resulted in 12 residual node positions, on average (reduction by 77%), at the cost of an increase in the number of beams and total MUs of 28% and 9%, respectively. Overall fraction durations (excluding patient setup) were shortened by 25% (range of 18%-40%), on average. Dose distributions changed only little and dose in low-dose regions was effectively restricted by the additional constraints.
  
  
  CONCLUSIONS
  The fraction duration of robotic radiosurgery treatments can be reduced considerably by node reduction with minimal changes in dosimetrical plan quality. Additional constraints are required to guarantee low-dose conformality and to avoid unacceptable skin dose.
authors.affiliation: Department of Radiation Oncology, Erasmus MC-Daniel den Hoed Cancer Center, Groene Hilledijk 301, 3075 EA Rotterdam, The Netherlands. s.vandewater@erasmusmc.nl
authors.forename: Steven
authors.initials: S
authors.lastname: van de Water
authors.forename: Mischa S
authors.initials: MS
authors.lastname: Hoogeman
authors.forename: Sebastiaan
authors.initials: S
authors.lastname: Breedveld
authors.forename: Ben J M
authors.initials: BJ
authors.lastname: Heijmen
mesh_terms: D000465:Algorithms; D006801:Humans; D008297:Male; D009369:Neoplasms / Q000532:radiotherapy; D016634:Radiosurgery / Q000379:methods*; D011879:Radiotherapy Dosage; D011880:Radiotherapy Planning, Computer-Assisted; D012371:Robotics; D013997:Time Factors