title: Quantifying and improving the efficiency of Gamma Knife treatment plans for brain metastases: results of a 1-year audit.
abstract: OBJECTIVE
  A method for quantifying the efficiency of Gamma Knife treatment plans for metastases was previously implemented by the authors to retrospectively identify the least efficient plans and has provided insights into improved planning strategies. The aim of the current work was to ascertain whether those insights led to improved treatment plans.
  
  
  METHODS
  Following completion of the initial study, a 1-year audit of metastasis plans created at St. James's Institute of Oncology was carried out. Audited recent plans were compared with the earlier plans of the initial study, in terms of their efficiency and dosimetric quality. The statistical significance of any differences between relevant plan parameters was quantified by Mann-Whitney U-tests. Comparisons were made between all plans and repeated for a reduced set of plans from which the smallest lesions treated with a single 4-mm shot were excluded. The plan parameters compared were a plan efficiency index (PEI), the number of shots, Paddick conformity index (PCI), gradient index (GI), and percent coverage (of the lesion by the prescription isodose).
  
  
  RESULTS
  A total of 157 metastatic lesions were included in the audit and were compared with 241 in the initial study. In a comparison of all cases, the audited plans achieved a higher median PEI score than did the earlier plans from the initial study (1.08 vs 1.02), indicating improved efficiency of the audited plans. When the smallest lesions (for which there was little scope for varying plan strategy) were discounted, the improvement in median PEI score was greater (1.23 vs 1.03, p < 0.001). This improvement in efficiency corresponds to an estimated mean (maximum) time saving of 15% (66%) per lesion (11 minutes [64 minutes] on the day of treatment). The modified planning strategy yielding these efficiency improvements did not rely on the use of significantly fewer shots (median 11 vs 11 shots, p = 0.924), nor did it result in significant detriment to dosimetric quality (median coverage 99% vs 99%, median PCI 0.84 vs 0.83, p = 0.449, and median GI 2.72 vs 2.67, p = 0.701, audited plans vs initial plans, respectively).
  
  
  CONCLUSIONS
  Choice of planning strategy can substantially affect plan efficiency and thus strongly influence treatment time. Through increased emphasis on efficiency, resulting from the introduction of PEI combined with a modified planning strategy informed by previous work, it has been possible to reduce times for metastatic plans without compromising their dosimetric quality. Although the average time savings achieved per lesion are moderate, the potential benefits per patient are greater for those with multiple metastases. Reducing treatment times has clear benefits with regard to patient comfort and throughput. In addition, optimization of plan efficiency may potentially affect the biologically effective dose from Gamma Knife treatments and offers opportunity for further work.
authors.affiliation: St. James's Institute of Oncology, St. James's University Hospital, Leeds, United Kingdom.
authors.forename: Gavin
authors.initials: G
authors.lastname: Wright
authors.forename: Paul
authors.initials: P
authors.lastname: Hatfield
authors.forename: Carmel
authors.initials: C
authors.lastname: Loughrey
authors.forename: Beatrice
authors.initials: B
authors.lastname: Reiner
authors.forename: Peter
authors.initials: P
authors.lastname: Bownes
mesh_terms: D001932:Brain Neoplasms / Q000401:mortality / Q000556:secondary / Q000601:surgery; D016208:Databases, Factual; D006801:Humans; D008485:Medical Audit; D010347:Patient Care Planning; D058996:Quality Improvement; D011829:Radiation Dosage; D016634:Radiosurgery / Q000379:methods* / Q000401:mortality / Q000592:standards; D012189:Retrospective Studies; D012720:Severity of Illness Index
keywords: GI = gradient index; Gamma Knife; PCI = Paddick conformity index; PEI = plan efficiency index; dose rate product; efficiency; metastases; nTRPcorr = attenuation-corrected, normalized treatment time; radiosurgery; stereotactic radiosurgery; treatment planning; treatment time