Despite the recent advanced developments in radiation therapy planning, treatment planning for head-neck and pelvic cancers remains challenging due to large concave target volumes, multiple dose prescriptions and numerous organs at risk close to targets. Inter-institutional studies highlighted that plan quality strongly depends on planner experience and skills. Automated optimization of planning procedure may improve plan quality and best practice. We performed a comprehensive dosimetric and clinical evaluation of the Pinnacle³ AutoPlanning engine, comparing automatically generated plans (AP) with the historically clinically accepted manually-generated ones (MP). Thirty-six patients (12 for each of the following anatomical sites: head-neck, high-risk prostate and endometrial cancer) were re-planned with the AutoPlanning engine. Planning and optimization workflow was developed to automatically generate “dual-arc” VMAT plans with simultaneously integrated boost. Various dose and dose-volume parameters were used to build three metrics able to supply a global Plan Quality Index evaluation in terms of dose conformity indexes, targets coverage and sparing of critical organs. All plans were scored in a blinded clinical evaluation by two senior radiation oncologists. Dose accuracy was validated using the PTW Octavius-4D phantom together with the 1500 2D-array. Autoplanning was able to produce high-quality clinically acceptable plans in all cases. The main benefit of Autoplanning strategy was the improvement of overall treatment quality due to significant increased dose conformity and reduction of integral dose by 6–10%, keeping similar targets coverage. Overall planning time was reduced to 60–80 minutes, about a third of time needed for manual planning. In 94% of clinical evaluations, the AP plans scored equal or better to MP plans. Despite the increased fluence modulation, dose measurements reported an optimal agreement with dose calculations with a γ-pass-rate greater than 95% for 3%(global)-2 mm criteria. Autoplanning engine is an effective device enabling the generation of VMAT high quality treatment plans according to institutional specific planning protocols.

Background: Radiotherapy (RT) is widely used in the treatment of pancreatic cancer. Currently, recommendation has been given for the delineation of the clinical target volume (CTV) in adjuvant RT. Based on recently reviewed pathologic data, the aim of this study is to propose criteria for the CTV definition and delineation including elective nodal irradiation (ENI) in the preoperative and definitive treatment of pancreatic cancer. Methods: The anatomical structures of interest, as well as the abdominal vasculature were identified on intravenous contrast-enhanced CT scans of two different patients with pancreatic cancer of the head and the body. To delineate the lymph node area, a margin of 10 mm was added to the arteries. Results: We proposed a set of guidelines for elective treatment of high-risk nodal areas and CTV delineation. Reference CT images were provided. Conclusions: The proposed guidelines could be used for preoperative or definitive RT for carcinoma of the head and body of the pancreas. Further clinical investigations are needed to validate the defined CTVs.

Scarce data are available on the use of extracranial stereotactic radiotherapy in recurrent gynecological tumors. The aim of this report was to analyze the results of our preliminary experience with extracranial stereotactic radiotherapy in locally or distantly recurrent gynecological tumors. Extracranial stereotactic radiotherapy was planned by the Precise-Plan treatment planning system. Patients were immobilized using the Stereotactic Body-Frame. Five consecutive daily fractions were delivered; dose/fraction and total dose were defined based on an institutional dose-escalation protocol. A class solution with 4 non-coplanar fixed beams based on the tetrad configuration was used in all patients. Eleven patients (12 lesions), were included in the analysis. Stereotactic radiotherapy was delivered as first radiotherapy treatment (5 patients), or as retreatment (6 patients). Complete clinical response was achieved in 8/12 lesions (66.6%), while partial response was documented in 2/12 lesions (16.6%). With a median follow-up of 19 months (range, 2-37 months), 7 patients (63%) experienced local and/or distant progression of disease. The 2-year local progression-free survival was 81.8%, while the 2-year metastases-free survival was 54.4%. The 2-year overall survival was 63.6%. Acute and late toxicities were grade 2 or less. There was no difference in quality of life scores between the data collected before extracranial stereotactic radiotherapy and at first follow-up evaluation. Fractionated extracranial stereotactic radiotherapy administered up to a dose of 30 Gy in five fractions is well tolerated. Further studies of extracranial stereotactic radiotherapy and novel radiotherapy techniques are warranted in the challenging setting of recurrent gynecological tumors.