Improvement of tomographic intensity modulated radiotherapy dose distributions using periodic shifting of arc abutment regions

Based on the study of treatment arc positioning versus target length, a method that allowed periodic shift of arc abutment regions through the course of intensity modulated radiotherapy (IMRT) was developed. In this method, two treatment plans were developed for the same tumor. The first plan contained the original target (Planning Target Volume as defined by radiation oncologist) and the second one contained a modified target. The modification of the original target consisted of simply increasing its length, adding a small extension to it, or creating a distant pseudo target. These modifications cause arc abutment regions in the second plan to be shifted relative to their positions in the first plan. Different methods of target modification were investigated because in some cases (for instance, when a critical structure might overlap with the target extension) a simple extension of the target would cause an unacceptable irradiation of the sensitive structures. The dose prescribed to the modified portion of the target varied from 10% to 100% of the original target dose. It was found that a clinically significant shift (> or =5 mm) in abutment region locations occurred when the dose prescribed to the extended portion of the target was > or =95% of the original target dose. On the other hand, the pseudo target required only approximately 10% to 20% of the original target dose to produce the same shift in arc positions. Results of the film dosimetry showed that when a single plan was used for the treatment delivery, the dose nonuniformity was 17% and 25% of the prescribed dose with 0.5 and 1 mm errors in couch indexing, respectively. The dose nonuniformity was reduced by at least half when two plans were used for IMRT delivery.