A primer on treatment planning aspects for temporally modulated pulsed radiation therapy

TL;DR

This paper reviews treatment planning techniques for temporally modulated pulsed radiotherapy (TMPRT), focusing on VMAT and 3D-CRT methods, plan evaluation, and delivery accuracy at low dose rates, highlighting their clinical feasibility and technical considerations.

Contribution

It provides a comprehensive overview of planning strategies and technical assessments for TMPRT, including the development of guidelines and evaluation of plan deliverability.

Findings

Single arc VMAT plans are acceptable for TMPRT.

Delivery accuracy at low dose rates is high on modern LINACs.

3D-CRT increases TMPRT accessibility across clinics.

Abstract

Temporally modulated pulsed radiotherapy (TMPRT) delivers conventional fraction doses of radiation using temporally separated pulses of low doses (<30 cGy) yielding fraction-effective dose rates of around 6.7 cGy/min with the goal to exploit tumor radiation hypersensitivity, which was observed in both, preclinical models and in human clinical trials. To facilitate TMPRT, volumetric modulated arc therapy (VMAT) and 3D-CRT planning techniques were developed following the guidelines of the proposed NRG CC-017 trial. Plans were evaluated with respect to homogeneity, conformality, and adherence to dose constraints. Deliverability of plans was assessed using in-phantom measurements for absorbed dose accuracy at low dose rates and using EPID for isodose verification. For VMAT only single arc plans were found to be acceptable due to otherwise unacceptably heterogeneous field doses, while for dynamic conformal arcs machine limtations on the number of monitor units per degree require the use of partial arcs for each pulse. Delivery of plans at low dose rates (< 100 MU/min) was accurate with high Gamma pass rates on modern LINACs and moderate pass rates on legacy LINACs, in line with their general performance. Generally, VMAT is preferred to achieve optimal homogeneity, conformality, and organ-at-risk sparing, while the use of 3D-CRT can increase the availability of TMPRT for more patients and clinics.