title: An online replanning method using warm start optimization and aperture morphing for flattening-filter-free beams.
abstract: OBJECTIVE
  In a situation where a couch shift for patient positioning is not preferred or prohibited (e.g., MR-linac), segment aperture morphing (SAM) can address target dislocation and deformation. For IMRT/VMAT with flattening-filter-free (FFF) beams, however, SAM method would lead to an adverse translational dose effect due to the beam unflattening. Here the authors propose a new two-step process to address both the translational effect of FFF beams and the target deformation.
  
  
  METHODS
  The replanning method consists of an offline and an online step. The offline step is to create a series of preshifted-plans (PSPs) obtained by a so-called "warm start" optimization (starting optimization from the original plan, rather than from scratch) at a series of isocenter shifts. The PSPs all have the same number of segments with very similar shapes, since the warm start optimization only adjusts the MLC positions instead of regenerating them. In the online step, a new plan is obtained by picking the closest PSP or linearly interpolating the MLC positions and the monitor units of the closest PSPs for the shift determined from the image of the day. This two-step process is completely automated and almost instantaneous (no optimization or dose calculation needed). The previously developed SAM algorithm is then applied for daily deformation. The authors tested the method on sample prostate and pancreas cases.
  
  
  RESULTS
  The two-step interpolation method can account for the adverse dose effects from FFF beams, while SAM corrects for the target deformation. Plan interpolation method is effective in diminishing the unflat beam effect and may allow reducing the required number of PSPs. The whole process takes the same time as the previously reported SAM process (5-10 min).
  
  
  CONCLUSIONS
  The new two-step method plus SAM can address both the translation effects of FFF beams and target deformation, and can be executed in full automation except the delineation of target contour required by the SAM process.
authors.affiliation: Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin 53226.
authors.forename: Ergun E
authors.initials: EE
authors.lastname: Ahunbay
authors.affiliation: Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin 53226.
authors.forename: O
authors.initials: O
authors.lastname: Ates
authors.affiliation: Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin 53226.
authors.forename: X A
authors.initials: XA
authors.lastname: Li
mesh_terms: D000465:Algorithms; D001331:Automation; D006801:Humans; D008297:Male; D058958:Organs at Risk; D010190:Pancreatic Neoplasms / Q000532:radiotherapy; D011471:Prostatic Neoplasms / Q000532:radiotherapy; D011879:Radiotherapy Dosage; D011880:Radiotherapy Planning, Computer-Assisted / Q000379:methods*; D050397:Radiotherapy, Intensity-Modulated / Q000379:methods*