Comparisons of treatment optimization directly incorporating random patient setup uncertainty with a margin‐based approach
Authors: Moore Joseph A. , Gordon John J. , Anscher Mitchell S. , Siebers Jeffrey V. 
Published: August 2009

The purpose of this study is to incorporate the dosimetric effect of random patient positioning uncertainties directly into a commercial treatment planning system's IMRT plan optimization algorithm through probabilistic treatment planning (PTP) and compare coverage of this method with margin‐based planning. In this work, PTP eliminates explicit margins and optimizes directly on the estimated integral treatment dose to determine optimal patient dose in the presence of setup uncertainties. Twenty‐eight prostate patient plans adhering to the RTOG‐0126 criteria are optimized using both margin‐based and PTP methods. Only random errors are considered. For margin‐based plans, the planning target volume is created by expanding the clinical target volume (CTV) by 2.1 mm to accommodate the simulated 3 mm random setup uncertainty. Random setup uncertainties are incorporated into IMRT dose evaluation by convolving each beam's incident fluence with a Gaussian prior to dose calculation. PTP optimization uses the convolved fluence to estimate dose to ensure CTV coverage during plan optimization. PTP‐based plans are compared to margin‐based plans with equal CTV coverage in the presence of setup errors based on dose‐volume metrics. The sensitivity of the optimized plans to patient‐specific setup uncertainty variations is assessed by evaluating dose metrics for dose distributions corresponding to halving and doubling of the random setup uncertainty used in the optimization. Margin‐based and PTP‐based plans show similar target coverage. A physician review shows that PTP is preferred for 21 patients, margin‐based plans are preferred in 2 patients, no preference is expressed for 1 patient, and both autogenerated plans are rejected for 4 patients. For the PTP‐based plans, the average CTV receiving the prescription dose decreases by 0.5%, while the mean dose to the CTV increases by 0.7%. The CTV tumor control probability (TCP) is the same for both methods with the exception of one case in which PTP gave a slightly higher TCP. For critical structures that do not meet the optimization criteria, PTP shows a decrease in the volume receiving the maximum specified dose. PTP reduces local normal tissue volumes receiving the maximum dose on average by 48%. PTP results in lower mean dose to all critical structures for all plans. PTP results in a 2.5% increase in the probability of uncomplicated control , along with a 1.9% reduction in rectum normal tissue complication probability (NTCP), and a 0.7% reduction in bladder NTCP. PTP‐based plans show improved conformality as compared with margin‐based plans with an average PTP‐based dosimetric margin at 7100 cGy of 0.65 cm compared with the margin‐based 0.90 cm and a PTP‐based dosimetric margin at 3960 cGy of 1.60 cm compared with the margin‐based 1.90 cm. PTP‐based plans show similar sensitivity to variations of the uncertainty during treatment from the uncertainty used in planning as compared to margin‐based plans. For equal target coverage, when compared to margin‐based plans, PTP results in equal or lower doses to normal structures. PTP results in more conformal plans than margin‐based plans and shows similar sensitivity to variations in uncertainty.