Dose delivery uncertainties assessment in the field junction region of craniospinal irradiation with Volumetric Modulated Arc Therapy using a robustness index and experimental dose verification.

Abstract

Due to its inherent technical challenges, craniospinal irradiation (CSI) entails crucial considerations regarding plan complexity and robustness. The scope of this work was to establish and validate methods suitable for the evaluation of robustness, as well as for dose verification in CSI with VMAT. Five patients previously treated with CSI were retrospectively selected. For each patient, two technically different treatment plans were generated, based on the conventional (static overlap) and staggered (dynamic overlap) configuration. These techniques served as a benchmark to evaluate the potential of a metric proposed in this work, aimed at quantifying robustness, the Overlap Robustness Index (ORI). Furthermore, they were utilized to assess the suitability of two experimental methods relying on film dosimetry, as well as on Delta4 phantom for identifying sources of uncertainties in CSI applications. In accordance with the positional error simulation performed, the staggered approach yielded a statistically significant superior ORI value compared to the conventional one. Additionally, the strong correlation observed between the positional shift induced dose distribution changes and ORI results (Spearman's r = -0.941, p-value < 0.001) demonstrated the sensitivity of ORI in detecting areas of steep dose gradients within the overlapping regions that could potentially compromise the quality of treatment. Concerning dose verification, analysis in terms of dose profiles revealed a superior dosimetric accuracy for the staggered technique relative to conventional for both film and Delta4 measurements. Film-based gamma index results showed that staggered technique outperformed the conventional for the majority of passing criteria considered, with differences in passing rates up to 8.1%. The two treatment techniques however, exhibited equivalent dose delivery accuracy for the clinically relevant passing criteria when Delta4 was employed, with passing rate differences less than 0.6%. Findings of this study revealed that ORI is suitable for quantifying robustness in CSI with VMAT, while radiochromic films appeared to be the best candidate for CSI dose verification in this work.