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ARTICLE IN PRESS <a href=Medical Dosimetry ■■ (2018) ■■ ■■ Medical Dosimetry journal homepage: www.meddos.org Medical Physics Contribution: 3D treatment planning system—Pinnacle system Ping Xia, PhD, and Eric Murray , CMD Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH 44195, USA ARTICLE INFO Article history: Received 9 February 2018 Accepted 15 February 2018 Keywords: External beam radiotherapy Treatment planning system Three-dimensional conformal Intensity modulated radiotherapy Volumetric modulated arc radiotherapy ABSTRACT The treatment planning system is key for the success of external beam radiotherapy, direct- ly impacting the quality of treatment plans and accuracy of dose calculation in the plans. In this article, we provided an overview of the Pinnacle treatment planning system for ex- ternal beam planning, including 3-dimensional (3D) conformal plans, step-shoot intensity modulated radiotherapy (IMRT) plans, and volumetric modulated arc therapy (VMAT) plans. We discussed dose calculation algorithm and other utilities, including image fusion, plan documentation, and adaptive planning. Based on our many years of clinical experience with the system, the aim of this article is to provide readers with a summary of this particular planning system. © 2018 American Association of Medical Dosimetrists. Introduction The Pinnacle treatment planning system was initially called the “Analytical Development Associates Corporation” planning system. Its early version focused on conventional 3-dimensional (3D) plans for photon beams and electron beams with and without computed tomography (CT) images. Before CT simulators are equipped for every center, a simple module (named as “irregular calculation”) can define blocked fields and calculate monitor units (MUs) for these fields without CT images. The MU calculation in this simple module is based on the following key param- eters entered by users: field sizes, treatment depths, and source-to-distance or source-to-axis-distance treatment tech- nique. In the advent of intensity modulated radiotherapy (IMRT), the IMRT module was introduced in version 6.0. In this version, the fluence maps of IMRT fields were opti- mized and then converted by a leaf sequencer to deliverable Reprint requests to Ping Xia, PhD, Department of Radiation Oncology, Cleveland Clinic, 9500 Euclid Avenue CA-50, Cleveland, OH 44195, USA. E-mail: xiap@ccf.org multileaf collimator (MLC) shapes or segments. During this conversion, the quality of the IMRT plan degraded, depending on the IMRT delivery modes, the maximum number of intensity levels, and the leaf sequencing algo- rithms along with other delivery parameters. In version 7.4, direct machine parameter optimization was intro- duced for step-shoot IMRT delivery such that the resultant IMRT plans are deliverable without further conversion and thus plan quality degradation. In version 9.0, volumetric modulated arc therapy (VMAT) module (named as SmartArc) was added. In version 9.10, the automatic planning (AP) module was added, allowing a progressive IMRT planning through 6 loops of optimization. The newest version of the Pinnacle system is P16, which has a new user interface, al- though most functionalities remain the same as in version 9.10. In this review article, we will discuss the major function- ality of the Pinnacle treatment system, primarily based on our clinical experience in version 9.10. As version P16 does not have any major function changes, except for user interface and enabling deformable image registration, we believe the materials presented in this article are still up-to-date. https://doi.org/10.1016/j.meddos.2018.02.004 0958-3947/Copyright © 2018 American Association of Medical Dosimetrists " id="pdf-obj-0-14" src="pdf-obj-0-14.jpg">

Medical Dosimetry

journal homepage: www.meddos.org

ARTICLE IN PRESS <a href=Medical Dosimetry ■■ (2018) ■■ ■■ Medical Dosimetry journal homepage: www.meddos.org Medical Physics Contribution: 3D treatment planning system—Pinnacle system Ping Xia, PhD, and Eric Murray , CMD Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH 44195, USA ARTICLE INFO Article history: Received 9 February 2018 Accepted 15 February 2018 Keywords: External beam radiotherapy Treatment planning system Three-dimensional conformal Intensity modulated radiotherapy Volumetric modulated arc radiotherapy ABSTRACT The treatment planning system is key for the success of external beam radiotherapy, direct- ly impacting the quality of treatment plans and accuracy of dose calculation in the plans. In this article, we provided an overview of the Pinnacle treatment planning system for ex- ternal beam planning, including 3-dimensional (3D) conformal plans, step-shoot intensity modulated radiotherapy (IMRT) plans, and volumetric modulated arc therapy (VMAT) plans. We discussed dose calculation algorithm and other utilities, including image fusion, plan documentation, and adaptive planning. Based on our many years of clinical experience with the system, the aim of this article is to provide readers with a summary of this particular planning system. © 2018 American Association of Medical Dosimetrists. Introduction The Pinnacle treatment planning system was initially called the “Analytical Development Associates Corporation” planning system. Its early version focused on conventional 3-dimensional (3D) plans for photon beams and electron beams with and without computed tomography (CT) images. Before CT simulators are equipped for every center, a simple module (named as “irregular calculation”) can define blocked fields and calculate monitor units (MUs) for these fields without CT images. The MU calculation in this simple module is based on the following key param- eters entered by users: field sizes, treatment depths, and source-to-distance or source-to-axis-distance treatment tech- nique. In the advent of intensity modulated radiotherapy (IMRT), the IMRT module was introduced in version 6.0. In this version, the fluence maps of IMRT fields were opti- mized and then converted by a leaf sequencer to deliverable Reprint requests to Ping Xia, PhD, Department of Radiation Oncology, Cleveland Clinic, 9500 Euclid Avenue CA-50, Cleveland, OH 44195, USA. E-mail: xiap@ccf.org multileaf collimator (MLC) shapes or segments. During this conversion, the quality of the IMRT plan degraded, depending on the IMRT delivery modes, the maximum number of intensity levels, and the leaf sequencing algo- rithms along with other delivery parameters. In version 7.4, direct machine parameter optimization was intro- duced for step-shoot IMRT delivery such that the resultant IMRT plans are deliverable without further conversion and thus plan quality degradation. In version 9.0, volumetric modulated arc therapy (VMAT) module (named as SmartArc) was added. In version 9.10, the automatic planning (AP) module was added, allowing a progressive IMRT planning through 6 loops of optimization. The newest version of the Pinnacle system is P16, which has a new user interface, al- though most functionalities remain the same as in version 9.10. In this review article, we will discuss the major function- ality of the Pinnacle treatment system, primarily based on our clinical experience in version 9.10. As version P16 does not have any major function changes, except for user interface and enabling deformable image registration, we believe the materials presented in this article are still up-to-date. https://doi.org/10.1016/j.meddos.2018.02.004 0958-3947/Copyright © 2018 American Association of Medical Dosimetrists " id="pdf-obj-0-22" src="pdf-obj-0-22.jpg">

Medical Physics Contribution:

3D treatment planning system—Pinnacle system

Ping Xia, PhD, and Eric Murray, CMD

Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH 44195, USA

ARTICLE INFO

Article history:

Received 9 February 2018 Accepted 15 February 2018

Keywords:

External beam radiotherapy

Treatment planning system Three-dimensional conformal Intensity modulated radiotherapy Volumetric modulated arc radiotherapy

ABSTRACT

The treatment planning system is key for the success of external beam radiotherapy, direct- ly impacting the quality of treatment plans and accuracy of dose calculation in the plans. In this article, we provided an overview of the Pinnacle treatment planning system for ex-

ternal beam planning, including 3-dimensional (3D) conformal plans, step-shoot intensity modulated radiotherapy (IMRT) plans, and volumetric modulated arc therapy (VMAT) plans. We discussed dose calculation algorithm and other utilities, including image fusion, plan documentation, and adaptive planning. Based on our many years of clinical experience with the system, the aim of this article is to provide readers with a summary of this particular planning system.

© 2018 American Association of Medical Dosimetrists.

Introduction

The Pinnacle treatment planning system was initially called the “Analytical Development Associates Corporation” planning system. Its early version focused on conventional 3-dimensional (3D) plans for photon beams and electron beams with and without computed tomography (CT) images. Before CT simulators are equipped for every center, a simple module (named as “irregular calculation”) can define blocked fields and calculate monitor units (MUs) for these fields without CT images. The MU calculation in this simple module is based on the following key param- eters entered by users: field sizes, treatment depths, and source-to-distance or source-to-axis-distance treatment tech- nique. In the advent of intensity modulated radiotherapy (IMRT), the IMRT module was introduced in version 6.0. In this version, the fluence maps of IMRT fields were opti- mized and then converted by a leaf sequencer to deliverable

Reprint requests to Ping Xia, PhD, Department of Radiation Oncology, Cleveland Clinic, 9500 Euclid Avenue CA-50, Cleveland, OH 44195, USA. E-mail: xiap@ccf.org

multileaf collimator (MLC) shapes or segments. During this conversion, the quality of the IMRT plan degraded, depending on the IMRT delivery modes, the maximum number of intensity levels, and the leaf sequencing algo- rithms along with other delivery parameters. In version 7.4, direct machine parameter optimization was intro- duced for step-shoot IMRT delivery such that the resultant IMRT plans are deliverable without further conversion and thus plan quality degradation. In version 9.0, volumetric modulated arc therapy (VMAT) module (named as SmartArc) was added. In version 9.10, the automatic planning (AP) module was added, allowing a progressive IMRT planning through 6 loops of optimization. The newest version of the

Pinnacle system is P16, which has a new user interface, al- though most functionalities remain the same as in version

9.10.

In this review article, we will discuss the major function- ality of the Pinnacle treatment system, primarily based on our clinical experience in version 9.10. As version P16 does not have any major function changes, except for user interface and enabling deformable image registration, we believe the materials presented in this article are still up-to-date.

https://doi.org/10.1016/j.meddos.2018.02.004

0958-3947/Copyright © 2018 American Association of Medical Dosimetrists

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Methods and Materials

General description of the system

The Pinnacle system can create external beam treat- ment plans for C-arm linear accelerators manufactured by Varian, Elekta, and Siemens, supporting both photon (in- cluding flattening filter free beams) and electron beams. The major modules for external beam planning are listed in Fig. 1. The image fusion module allows users to co- register the planning CT images with other image sets, including CT images acquired at a different date and images from other modalities such as MRI and positron emission tomography/CT. Four-dimensional CT images are also sup- ported. The other special modules for proton beam and brachytherapy are not widely used, and thus are not in- cluded in this review article. The basic 3D/electron, IMRT/ SmartArc, and AP modules will be discussed in detail later. The dynamic planning module is to facilitate adaptive planning, allowing user to transfer all contours from one planning CT to another planning CT (or cone beam CT) through either deformable (only available in P16 version) or rigid image registration and to apply previous treat- ment beams (including IMRT/VMAT beams) to the new dataset such that the users can recalculate the resultant dose to the new dataset. Upon comparison of the initial plan and the plan with the current patient anatomy (re- flected in the new CT), physicians can determine whether an adaptive plan is necessary. If so, based on the new CT and modified contours, the planner can use the same beam angles and the same planning objectives to generate a new adaptive plan.

Dose calculation algorithm

The dose calculation algorithm in Pinnacle includes a col- lapsed cone convolution (CCC) calculation and an adaptive CCC calculation. 1-3 The adaptive CCC is an approximation method of the CCC, calculating every fourth point in the total energy released per unit mass (TERMA) array while

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Fig. 1. A list of major modules in the Pinnacle system.

performing a gradient search on the TERMA array. If the TERMA has a low gradient, doses in between the calcula- tion points are interpolated. If the TERMA has a high gradient, convolution calculation is performed in every point in this region. The calculation dose grid resolution can be set by users, typically at 4 mm but can be reduced to 1 mm for very small tumors. The calculation speed decreases as the dose grid resolution increases. Most external photon beam plans are created with CT images with heterogeneity correction. The isocenter coor- dinates can be directly input from CT simulation, or placed manually at the center of 3 radiopaque markers on an axial image. If desirable, the users can use the point of interest automatic placement function to place the point in the center of the specified region of interest volume with an option of a box, sphere, or centroid of the volume. Upon input of the CT images, the system will prompt the user to select a proper CT density table if multiple CT density tables exist in the system. If not, a default CT density table is applied for heterogeneity correction in the dose calculation. For special clinical scenario, one can choose to use nonheterogeneity dose calculation for each beam, or to override the density of the body external contour while keeping the dose calculation with heteroge- neity correction.

Contouring tools and dose prescription

The system supports various contouring tools, includ- ing manual drawing, model-based segmentation (in a separated module), threshold contour, and atlas-based contour (in a module called Spice). A plan can be normal- ized to a user-defined point, or the maximum dose point, or the mean dose of a user-selected volume. For 3D plans, a user-defined point (e.g., isocenter, midline point, etc.) is typically used for the plan normalization. For IMRT plans, either the plan maximum point or the mean dose of a plan- ning treatment volume (PTV) is typically used for plan normalization. For a 3D plan, the user can add many pre- scriptions, each normalized to a different point. For an IMRT plan, all IMRT fields under the optimization must be asso- ciated with the same prescription. Users must manually define the dose calculation grid size, drawing directly in the axial, coronal, and sagittal images. Whereas the tissue outside of the grid size is ac- counted during the dose calculation, the dose-volume histogram (DVH) and the dose statistics for each structure do not take into account the issue outside of the dose grid. For example, if the entire lung is not included in the dose grid, the DVHs for the whole lung could be inaccurate. On the statistics page, the percentage of each structure volume outside of the dose grid is listed. Users need to pay atten- tion to this information.

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Fig. 2. An example of a 4-panel display window, including an axial image, a 3D skin render view, and 2 DRR views. DRR, digital reconstructed ra- diograph. (Color version of figure is available online.)

3D planning

The Pinnacle system supports multiple-image view window settings. In 3D planning, an experienced user typ- ically utilizes a window that contains a panel to display an axial CT slice, a panel for a 3D skin rendering, and 2 panels for 2 beam’s eye views for 3D planning, as shown in Fig. 2. One or multiple selected organs at risk (OARs) can be pro- jected in the beam’s eye view to aid in both blocks drawing

and beam angle selections. Blocks can be drawn manually or can be generated using the option of auto-surround on the tumor target with a defined block margin. By viewing the projections of both the tumor target and the critical struc- tures in the beam’s eye view, the planners can choose the optimal beam angles with the following 3 rules of thumb:

(1) the shortest distance to the tumor target; (2) the largest spatial separation between the target and the critical struc- tures; and (3) the orthogonal beams or sufficient separations between beams. With the control point feature, the users can manually create a forward-planned simple IMRT plan with 3 to 5 control points (i.e., manually defined segments). By adding 2 to 4 control points per beam, a standard breast case treated with tangents can be completed without the use of wedges. Figure 3A shows the dose distribution of a tangent plan with the field-within-field technique. Figure 3B shows 3 segments for one of the tangential beams in a breast plan. Control points are also used to eliminate hot spots or cold spots. Figure 4A shows an extra segment for a lateral beam of the whole brain irradiation. With 1 added segment on each lateral beam, the hot spot of 110% of the prescription dose was visibly minimized, as shown in Fig. 4B. In the Pinnacle system, bolus can be added and modi- fied in several ways. The most commonly used method is to define the 2 bolus edges on the axial image plus the su- perior and inferior extent along with the bolus thickness. The second method is to create a custom bolus directly from a 3D skin rendering view of a beam’s eye view, as shown in Fig. 5, such as a bolus near the ear. With another method, users can extend the patient external contour with a defined

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Fig. 3. (A) Dose distributions of tangent-only plan using a field-within-field technique. The solid red is the contour of the tumor bed. (B) The first segment is the open field from one of the tangent fields, 2 segments (outlined in red) for 1 tangent field, and 1 segment (outlined in green) for the other tangent field. This plan used a total of 5 segments, including 2 open fields. (Color version of figure is available online.)

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Fig. 4. (A) Two segments for one of the lateral fields for whole brain irradiation. The first segment is a typical open field that carries 48% of beam weight and the other segment carries only 2% of the beam weight. (B) The prescription dose for this whole brain irradiation is 20 Gy in 5 fractions. The left panel is the dose distributions of 22 Gy, and 20 Gy for opposed lateral fields with an extra segment for each field shown in (A). Without the extra segment, the panel on the right displays the dose distributions of 22 Gy and 20 Gy without the extra segment. Notice the hot spot of 22 Gy reduces in the left panel. (Color version of figure is available online.)

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Fig. 5. An example of a bolus (in blue) manually drawn on the 3D skin rendering view. (Color version of figure is available online.)

thickness and override the extended region to a density of 1 g/cm 3 .

IMRT planning

Under the IMRT module, each beam can have 1 of 4 op- timization types such as none, beam weight, segment weight, intensity modulation, and direct machine parameter opti- mization (DMPO). The “none” option allows the user to create a composite plan from previously treated fields with current IMRT fields. These previously treated fields, however, must be associated with a different prescription that is not asso- ciated with current IMRT fields. The beam weight optimization option allows the user to mix 3D fields with current IMRT fields. The segment weight optimization option allows the user to delete small segments or segments as- sociated with low MUs and then continue with segment

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Table 1

Types of planning objectives, definitions, and applications

5

Objective function

Definition

How to apply

Min/max dose

Maximum or minimum dose to any point

Apply to PTVs and serial OARs

Min DVH

Dose to % volume > defined dose

Apply to PTVs

Max DVH

Dose to % volume < defined dose

Apply to parallel OARS and PTVs

Max EUD

Controls the distribution of the entire ROI. Equal to mean dose with a = 1

Apply to parallel OARs (a = 1)

Uniform dose

Dose to the entire volume is uniform

Apply to PTVs

EUD, equivalent uniform dose; ROI, region of interest.

weight optimization to redistribute MUs. This option is not used often. The “intensity modulation” option is for early 2-step optimization: fluence optimization and then convert to deliverable MLC segments. Some users use this option to create an ideal plan while gathering information about the maximum number of segments required for a specific IMRT plan using DMPO. Under DMPO, the user can define the maximum permissible number of segments to control the delivery speed during step-shoot IMRT delivery. DMPO is a popular option for step-shoot IMRT planning and delivery with the users controlling the number of segments, the minimum area of segments, and the minimum MUs asso- ciated with each segment. Table 1 lists the types of planning objectives and their typical application. Again, we focus on the DMPO optimi- zation here. Before running DMPO optimization, a few optimization parameters should be set by the user, includ- ing the number of iterations (typically 30 to 40) and at which iteration (n = 15 to 20, halfway through the optimization), a CCC calculation is performed. During first n iterations, the optimizer searches for ideal fluence without considering de- livery. After the nth iteration, an interim CCC calculation is performed, and a leaf sequencing algorithm is carried out while considering machine parameters and the user-defined delivery parameters. Because of the CCC calculation, the nth iteration takes longer than other iterations. Because of the conversion from fluence to MLC segments, the cost func- tion value increases at nth iteration. After nth iteration, the optimizer continues to reduce the cost while adjusting the weights of each segment and shape but keeping the same number of segments.

VMAT planning

With VMAT planning, each beam must be set to a beam type as the dynamic arc with an arc range and rotation di- rection (counterclockwise/clockwise). Under the SmartArc parameter setting, the users can choose whether to have the optimizer create a mirror arc or not, the final gantry spacing (4-degree spacing is a default), and the maximum delivery time (default is 90 seconds). The planning objectives for VMAT are similar to IMRT, except the “constraint” for any planning objective cannot be selected. One segment is

allowed for every angle. Therefore, 90 segments are created for a full arc of 360 degrees at a 4-degree spacing.

Staged planning

Similar to most commercially available treatment plan- ning systems, the Pinnacle system uses a gradient-based search in optimization. To take into account the volume effect, a dose–volume-based cost function is used such as the max DVH and min DVH as defined in Table 1. With the gradient search algorithm, the dose–volume-based cost function can have multiple minima, and thus the final solution may not have the lowest cost (the best solution), particularly for a complex case (e.g., head and neck) with numerous sensi- tive structures. To circumvent being trapped in a local minimum, multiple manual iterative runs of optimization are needed, particularly for complex plans with many crit- ical structures near the tumor volume. Without resetting the intensity modulated beams from a previous run of optimi- zation (so called warm start), warm start allows the user to continue the optimization while adding and adjusting the planning objectives. We refer to this multiple iterative process as the staged planning. In the first stage (the first round optimization), an expe- rienced planner typically starts with the planning objectives for the PTVs, 1 or 2 critical structures, and a dose ring structure. The dose ring is the external body excluding 1-cm expansion of all combined PTVs. The dose ring struc- ture is used to control the dose spillage to the unspecified normal tissue. On the second round optimization, without resetting IMRT beams (warm start), the planners add more planning objectives for additional OARs. This process is repeated multiple times to improve plan uniformity and conformity while further reducing the dose to all OARs. This manual iterative process is time-consuming for complex cases with many OARs. Additional tuning structures may be needed to further guide the optimizer to remove the hot or cold spots.

Automatic planning (AP)

The AP module is introduced in version 9.10, in which a multiple iterative planning process (staged planning

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Fig. 6. (A) An example of planning goals entered for a spine SBRT case. (B) An example of advanced parameter setting for this spine SBRT case. (C) An example of how AP translates the planning goals from panel A into the planning objectives. EUD, equivalent uniform dose; ROI, region of in- terest; SBRT, stereotactic body radiotherapy. (Color version of figure is available online.)

mentioned earlier) is made to automation. AP is a progres- sive optimization process where the users enter the planning goals for the treatment targets and OARs as shown in Fig. 6A. Note that the planning goals are not exactly the same as the planning objectives in the IMRT or VMAT optimization. The AP module translates the planning goals into the planning objectives, progressively adding new planning objectives after each iteration, mimicking the manual process of the staged planning. The AP-created planning objectives are shown in Fig. 6C for the planning goals in Fig. 6A. The AP can also create dose tuning structures such as cold/hot spots and dose ring structures. AP can be applied to both step-shoot and VMAT plans. On the advanced settings (shown in Fig. 6B), the users can set the steepness of dose gradient and desired dose uni- formity. For a conventional IMRT plan, the dose gradient is

set to 2 cm and the dose uniformity is set to 107%. For ste- reotactic body radiotherapy plans, the dose gradient is set to 1 cm (the lowest number) and the dose uniformity is set to 170%. The highest dose uniformity index is 250% for a single-fractioned brain lesion. Further, the planner can create a disease-specific tech- nique, including a set of beam angles and planning goals. After AP, the users can continue optimization to further improve the plan quality. Along with the AP planning, one can create treatment protocol-specific technique libraries with predefined beam angles or number of arcs and arc range, collimator angles, photon energy, couch angles, op- timization parameters, and planning goals. A pull-down panel allows the user to match the OARs names from the library to the OARs in the current plan.

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Fig. 7. An example of scorecard for an HN case, treated with 40 Gy in 5 fractions. HN, head and neck; ROI, region of interest. (Color version of figure is available online.)

Scorecard utility

Users can establish treatment protocol-specific score- cards. At our institution, the use of a scorecard for 3D conformal and IMRT plans is mandatory. During the weekly chart rounds, we review the scorecard for each new patient who received a definitive radiotherapy. The scorecard in- cludes primary goals and a second goal, as shown in Fig. 7. In our institution, we allow users to supplement a second goal if the plan does not meet the primary goal, based on the discretion of attending physician.

Results

A field-within-field breast plan

The detailed field-within-field planning technique has been published. The control point feature of the Pinnacle system allows these manually constructed segments embedded in 2 tangent beams, not displayed as an individ- ual beam, simplifying displays in the plan document and in the treatment console. Alternatively, one can use a hybrid approach of combining open tangent fields with

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Fig. 8. (A) A typical open segment for one of the lateral fields. (B) Four segments (light blue outlines) for 1 lateral field and 3 segments (red out- lines) for the other lateral field, created with inverse planning. DAO, direct aperture optimization. (Color version of figure is available online.)

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Fig. 9. Comparing the DVHs for Stage 1 and Stage 2 planning for PTV_7000, PTV_5600, spinal cord, parotid R and parotid L. (Color version of figure is available online.)

inverse-planned tangent beams, as described in Descovich et al. 4 Figure 8 shows the open field from 1 tangent field and 4 segments from 1 tangent beam and 3 segments from the other tangent beams. Compared with manually created seg- ments shown in Fig. 3B , the segments created from the inverse planning are more irregular. Depending on the ex- perience of the planners and the specific geometry of the breast, the field-in-field technique is used more frequently than the hybrid technique.

Manual staged planning for a head and neck (HN) case

As discussed in the Methods and Materials section, we use a palate case to describe a manual staged planning. This case has 2 PTVs: high dose PTV and low dose PTV, pre- scribed to 70 Gy and 56 Gy in 35 fractions. In the first stage of planning, we include all PTVs and the ring structure. In the second stage of planning, we add the critical struc- tures such as the spinal cord, brain stem, and parotid glands to continue the optimization after the first stage optimiza- tion without resetting the result of the first stage of optimization. The resulting DVHs from Stage 2 compared with the DVHs from Stage 1 are shown in Fig. 9. In the third stage of planning, we add other normal structures, includ- ing submandibular glands, oral cavity, mandible, larynx, and esophagus. In the third stage of planning, we found that the planning dose constraints of mean dose of 35 Gy to both sub- mandibular glands were too strict, resulting in an underdose of the PTV_5600. In the fourth stage of planning, we in- creased the planning dose constraints to the submandibular glands from the mean dose of 35 Gy to 39 Gy. The PTV_5600

dose coverage was improved in the Stage 4 planning. In Stage 5, we increased the weight factor of the PTV_5600 from 50 Gy to 70 Gy, and further increased the planning dose con- straints to the submandibular glands from 39 Gy to 45 Gy. After 5 manual iterations, the plan is clinically acceptable. Figure 10 shows the planning dose constraints progressive- ly added during the 5-stage planning. Figure 11A and B shows the final dose distributions and DVHs with 9-field step-shoot and 2-arc VMAT plans. Before VMAT, 9 equally spaced fixed IMRT beams with step and shoot delivery were a standard IMRT technique for head and neck plans, with a total number of segments of 60 to 90, de- pending on the anatomic relationship among the tumor and nearby sensitive structures. The 2 full-arc VMAT tech- nique, with a total number of segments of 180, has overperformed more than the 9-field fixed beam IMRT, not only in plan quality but also in delivery.

Comparison of clinical IMRT and AP plans

For a postoperative base of tongue case, Fig. 12A to C shows the dose distributions and DVHs of the clinical, au- tomatic planning-step and shoot (AP-SS), and AP-VMAT plans. The patient was treated with the clinical plan using the equally spaced 9-field IMRT technique. The AP-SS plan used the same 9 fields while the AP-VMAT plan used 2 full arcs. This patient received 64 Gy to the tumor bed (PTV_64), 60 Gy to the high-risk region (PTV_60), and 54 Gy to the low-risk region (PTV_54). Three plans were normalized to have > 95% of all PTVs that received the corresponding pre- scription doses. As shown in Fig. 12A, the isodose lines are

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Fig. 10. An example of planning objectives for Stage 1, Stage 2, Stage 3, Stage 4, and Stage 5 for an HN case. HN, head and neck. (Color version of figure is available online.)

more conformal to the tumor volumes in the AP plans compared with the clinical step-shoot plan. The AP-SS plan is hotter than the clinical 9-field plan and AP-VMAT plan. As shown in Fig. 12B and C, the AP plans reduced the mean dose to the larynx and oral cavity. The maximum dose to the spinal cord was 41 Gy in the clinical plans and AP-SS, below the tolerance dose of 45 Gy. The AP-VMAT reduced the maximum dose to the spinal cord to 34 Gy, which will ease the retreatment if the tumor recurs. AP plans can serve as a good starting point or as a benchmark for all manual plans.

Discussion

The Pinnacle treatment planning system is a mature system with a long development history. In particular, it allows physicists to augment in-house tools with scripting languages. The scripts can also be created through a “re- cording” function, recording a serial of routine actions. More advance scripts are developed through the scripting lan- guages. These tools can be implemented clinically for the local institutions to improve the planning process and to

develop standardized documentations. In our institution, we developed many utilities through scripting. For example, we developed standard organ names for 8 common treat- ment sites; these standard organ names can facilitate the use of the scorecard function (introduced in version 9.10), which allows the users to evaluate plan quality objectively. Although AP module improved the plan quality and plan- ning efficiency, the AP process can be slow, depending on the capability of the system hardware and optimization volumes. Once a treatment plan is completed, the treatment plan documentation process can be tedious. The plan docu- ment generated from the system includes a summary sheet of all beam information, dose prescription, isocenter location and shift information, if any, density override information, and specific information for each individual beam. For the IMRT plan, the planning objectives and statistics of each critical organ are included in the report. The isodose distributions in the axial, coronal, and sagittal images, however, must be captured through a screen capture, which can be tedious, similar to the DVHs. In our institu- tion, we developed a script to make this process streamlined

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Fig. 11. (A) Comparison dose distributions for a 9-field step-shoot and a 2-arc VMAT plans. (B) Comparison of the dose-volume histograms of an HN case in panel A. HN, head and neck. (Color version of figure is available online.)

and standardized. Digital imaging and communications in medicine (DICOM) export for the treatment fields, OARs, and planning CT are supported. One area to improve is to allow the users to export selected OARs. The Pinnacle system is not a Window-based treatment planning system, which prevents many potential “virus” threats. The system management requires the special knowl- edge in the Unix system. IMRT quality assurance plans are typically created by copying a patient plan to a phantom and recalculating the dose, based on the geometry of the phantom. When using the ionization chamber array system (Matrixx, IBA, Bartlett, TN), our IMRT quality assurance passing cri- terion is 5% difference in a selected point dose between the measured and calculated, and a Gamma index of 90% with 4 mm/4% with the lowest 10% dose excluded (10% thresh- old). Using a third-party portal dosimetry software (PerFraction, Sun Nuclear, Melbourne, FL), the IMRT passing criterion can be set to Gamma index of 95% with 3 mm/3%.

Conclusions

At our institution, we have a total of 10 centers; 9 of them located in northeastern Ohio and 1 located in Florida. The Pinnacle system allows us to use a centralized server for these 10 centers, enabling us to integrate our practice while the hardware and software maintenance is provided (IT support) from 1 location. Although the initial learning curve may be steep because the Pinnacle system is not a Window-based system, experienced users can navigate the system easily, and the plan quality, in general, is satisfied.

Acknowledgment

Dr. Ping Xia received research grant from Philips Medical Solution although this article is not relevant to the specific research project.

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Fig. 12. (A) For a selected HN case, dose distributions displayed in 4 axial images for the clinical plans, AP step-shoot plan, and AP-VMAT plan. The solid green is PTV 64; the solid pink is PTV 60; and solid blue is PTV 54. (B) and (C) DVHs for the HN case in (A). HN, head and neck. (Color version of figure is available online.)

References