title: Treatment planning for radiotherapy with very high-energy electron beams and comparison of VHEE and VMAT plans.
abstract: OBJECTIVE
  The aim of this work was to develop a treatment planning workflow for rapid radiotherapy delivered with very high-energy electron (VHEE) scanning pencil beams of 60-120 MeV and to study VHEE plans as a function of VHEE treatment parameters. Additionally, VHEE plans were compared to clinical state-of-the-art volumetric modulated arc therapy (VMAT) photon plans for three cases.
  
  
  METHODS
  VHEE radiotherapy treatment planning was performed by linking EGSnrc Monte Carlo (MC) dose calculations with inverse treatment planning in a research version of RayStation. In order to study the effect of VHEE treatment parameters on VHEE dose distributions, a matlab graphical user interface (GUI) for calculation of VHEE MC pencil beam doses was developed. Through the GUI, pediatric case MC simulations were run for a number of beam energies (60, 80, 100, and 120 MeV), number of beams (13, 17, and 36), pencil beam spot (0.1, 1.0, and 3.0 mm) and grid (2.0, 2.5, and 3.5 mm) sizes, and source-to-axis distance, SAD (40 and 50 cm). VHEE plans for the pediatric case calculated with the different treatment parameters were optimized and compared. Furthermore, 100 MeV VHEE plans for the pediatric case, a lung, and a prostate case were calculated and compared to the clinically delivered VMAT plans. All plans were normalized such that the 100% isodose line covered 95% of the target volume.
  
  
  RESULTS
  VHEE beam energy had the largest effect on the quality of dose distributions of the pediatric case. For the same target dose, the mean doses to organs at risk (OARs) decreased by 5%-16% when planned with 100 MeV compared to 60 MeV, but there was no further improvement in the 120 MeV plan. VHEE plans calculated with 36 beams outperformed plans calculated with 13 and 17 beams, but to a more modest degree (<8%). While pencil beam spacing and SAD had a small effect on VHEE dose distributions, 0.1-3 mm pencil beam sizes resulted in identical dose distributions. For the 100 MeV VHEE pediatric plan, OAR doses were up to 70% lower and the integral dose was 33% lower for VHEE compared to 6 MV VMAT. Additionally, VHEE conformity indices (CI100 = 1.09 and CI50 = 4.07) were better than VMAT conformity indices (CI100 = 1.30 and CI50 = 6.81). The 100 MeV VHEE lung plan resulted in mean dose decrease to all OARs by up to 27% for the same target coverage compared to the clinical 6 MV flattening filter-free (FFF) VMAT plan. The 100 MeV prostate plan resulted in 3% mean dose increase to the penile bulb and the urethra, but all other OAR mean doses were lower compared to the 15 MV VMAT plan. The lung case CI100 and CI50 conformity indices were 3% and 8% lower, respectively, in the VHEE plan compared to the VMAT plan. The prostate case CI100 and CI50 conformity indices were 1% higher and 8% lower, respectively, in the VHEE plan compared to the VMAT plan.
  
  
  CONCLUSIONS
  The authors have developed a treatment planning workflow for MC dose calculation of pencil beams and optimization for treatment planning of VHEE radiotherapy. The authors have demonstrated that VHEE plans resulted in similar or superior dose distributions for pediatric, lung, and prostate cases compared to clinical VMAT plans.
authors.affiliation: Department of Radiation Oncology, Stanford University, Stanford, California 94305.
authors.forename: Magdalena
authors.initials: M
authors.lastname: Bazalova-Carter
authors.affiliation: Department of Radiation Oncology, Stanford University, Stanford, California 94305.
authors.forename: Bradley
authors.initials: B
authors.lastname: Qu
authors.affiliation: Department of Radiation Oncology, Stanford University, Stanford, California 94305.
authors.forename: Bianey
authors.initials: B
authors.lastname: Palma
authors.affiliation: RaySearch Laboratories AB, Stockholm SE-103 65, Sweden.
authors.forename: Björn
authors.initials: B
authors.lastname: Hårdemark
authors.affiliation: RaySearch Laboratories AB, Stockholm SE-103 65, Sweden.
authors.forename: Elin
authors.initials: E
authors.lastname: Hynning
authors.affiliation: Department of Radiation Oncology, Stanford University, Stanford, California 94305.
authors.forename: Christopher
authors.initials: C
authors.lastname: Jensen
authors.affiliation: Department of Radiation Oncology, Stanford University, Stanford, California 94305.
authors.forename: Peter G
authors.initials: PG
authors.lastname: Maxim
authors.affiliation: Department of Radiation Oncology, Stanford University, Stanford, California 94305.
authors.forename: Billy W
authors.initials: BW
authors.lastname: Loo
mesh_terms: D001932:Brain Neoplasms / Q000532:radiotherapy; D002648:Child; D003198:Computer Simulation; D004583:Electrons / Q000627:therapeutic use*; D006801:Humans; D008175:Lung Neoplasms / Q000532:radiotherapy; D008297:Male; D009010:Monte Carlo Method; D011471:Prostatic Neoplasms / Q000532:radiotherapy; D011879:Radiotherapy Dosage; D011880:Radiotherapy Planning, Computer-Assisted / Q000379:methods*; D050397:Radiotherapy, Intensity-Modulated / Q000379:methods*; D014584:User-Computer Interface