A comparison of three stereotactic radiotherapy techniques; arcs vs. noncoplanar fixed fields vs. intensity modulation

Purpose: Linae arc based stereotactic radiotherapy is being used with increasing frequency to treat brain tumors. This approach can be used for single or fractionated treatments, and is typically carried out with circular collimators which are optimal for small, spherical targets. Treatment planning using fixed noncoplanar beams or intensity-modulated beams may enhance the ability to conform to irregularly shaped and/or large tumors, especially when combined with stereotactic localization. We compare the dose conformity and normal brain dose characteristics of three stereotactic techniques for various nonspherical target shapes. Methods and Materials: Three intracranial test targets were constructed using a 3D treatment planning system after a patient underwent CT simulation. The targets included an ellipsoid with major axis dimensions of 4.0, 2.0, and 2.0 cm, a hemisphere with a diameter of 4.0 cm, and an irregularly shaped patient tumor with a maximum dimension of 5.3 cm. The following stereotactic techniques were compared for each target: a) 5 arcs as used in traditional linae radiosurgery/radiotherapy (noncoplanar arcs [ARCS]), b) 6 fixed noncoplanar custom blocked fields (3D), c) intensity modulation using 6 noncoplanar beams and a mini-multileaf collimator (intensity-modulated radiation therapy [IMRT]). Dose volume histograms were performed for each target/technique combination. Results: For the ellipsoid, dose conformity is similar for all three techniques and normal brain isodose distributions are more favorable with the ARCS plan. For the hemisphere and irregular tumor targets, dose conformity and high/low isodose normal brain volumes are more favorable with the IMRT technique. Conclusions: For the targets described above, the intensity-modulated technique results in improved dose conformity and decreased dose to nontarget brain in high and low isodose regions as compared to the standard noncoplanar are technique or noncoplanar fixed fields for the hemisphere and tumor targets. Intensity-modulated treatment delivery may allow for an increase in the therapeutic ratio for treating stereotactically defined large and/or irregularly shaped intracranial targets.