title: Do technological advances in linear accelerators improve dosimetric outcomes in stereotaxy? A head-on comparison of seven linear accelerators using volumetric modulated arc therapy-based stereotactic planning.
abstract: BACKGROUND
  Linear accelerator (Linac) based stereotactic radiosurgery (SRS) and stereotactic radiotherapy (SRT) using volumetric modulated arc therapy (VMAT) has been used for treating small intracranial lesions. Recent development in the Linacs such as inbuilt micro multileaf collimator (MLC) and flattening filter free (FFF) beam are intended to provide a better dose conformity and faster delivery when using VMAT technique. This study was aimed to compare the dosimetric outcomes and monitor units (MUs) of the stereotactic treatment plans for different commercially available MLC models and beam profiles.
  
  
  METHODS
  Ten patients having 12 planning target volume (PTV)/gross target volume's (GTVs) who received the SRS/SRT treatment in our clinic using Axesse Linac (considered reference arm gold standard) were considered for this study. The test arms comprised of plans using Elekta Agility with FFF, Elekta Agility with the plane beam, Elekta APEX, Varian Millennium 120, Varian Millennium 120HD, and Elekta Synergy in Monaco treatment planning system. Planning constraints and calculation grid spacing were not altered in the test plans. To objectively evaluate the efficacy of MLC-beam model, the resultant dosimetric outcomes were subtracted from the reference arm parameters.
  
  
  RESULTS
  V95%, V100%, V105%, D1%, maximum dose, and mean dose of PTV/GTV showed a maximum inter MLC - beam model variation of 1.5% and 2% for PTV and GTV, respectively. Average PTV conformity index and heterogeneity index shows a variation in the range 0.56-0.63 and 1.08-1.11, respectively. Mean dose difference (excluding Axesse) for all organs varied between 1.1 cGy and 74.8 cGy (mean dose = 6.1 cGy standard deviation [SD] = 26.9 cGy) and 1.7 cGy-194.5 cGy (mean dose 16.1 cGy SD = 57.2 cGy) for single and multiple fraction, respectively.
  
  
  CONCLUSIONS
  The dosimetry of VMAT-based SRS/SRT treatment plan had minimal dependence on MLC and beam model variations. All tested MLC and beam model could fulfil the desired PTV coverage and organs at risk dose constraints. The only notable difference was the halving of the MU for FFF beam as compared to the plane beam. This has the potential to reduce the total patient on couch time by 15% (approximately 2 min).
authors.affiliation: Department of Radiation Oncology, Fortis Memorial Research Institute, Gurgaon, Haryana; Department of Physics, GLA University, Mathura, Uttar Pradesh, India.
authors.forename: B
authors.initials: B
authors.lastname: Sarkar
authors.forename: A
authors.initials: A
authors.lastname: Pradhan
authors.forename: A
authors.initials: A
authors.lastname: Munshi
mesh_terms: D006801:Humans; D009369:Neoplasms / Q000532:radiotherapy*; D010315:Particle Accelerators / Q000295:instrumentation*; D011874:Radiometry / Q000295:instrumentation* / Q000379:methods; D016634:Radiosurgery / Q000295:instrumentation* / Q000379:methods; D011879:Radiotherapy Dosage; D011880:Radiotherapy Planning, Computer-Assisted / Q000295:instrumentation* / Q000379:methods; D050397:Radiotherapy, Intensity-Modulated / Q000295:instrumentation* / Q000379:methods