Combined MV + kV inverse treatment planning for optimal kV dose incorporation in IGRT

Despite the existence of real-time kV intra-fractional tumor tracking strategies for many years, clinical adoption has been held back by concern over the excess kV imaging dose cost to the patient when imaging in continuous fluoroscopic mode. This work aims to solve this problem by investigating, for the first time, the use of convex optimization tools to optimally integrate this excess kV imaging dose into the MV therapeutic dose in order to make real-time kV tracking clinically feasible. Phase space files modeling both a 6 MV treatment beam and a kV on-board-imaging beam of a commercial LINAC were generated with BEAMnrc, and used to generate dose influence matrices in DOSXYZnrc for ten previously treated lung cancer patients. The dose optimization problem for IMRT, formulated as a quadratic problem, was modified to include additional constraints as required for real-time kV intra-fractional tracking. An interior point optimizer was used to solve the modified optimization problem. It was found that when using large kV imaging apertures during fluoroscopic tracking, combined MV + kV optimization lead to a 0.5%-5.17% reduction in the total number of monitor units assigned to the MV beam due to inclusion of the kV dose over the ten patients. This was accompanied by a reduction of up to 42% of the excess kV dose compared to standard MV IMRT with kV tracking. For all kV field sizes considered, combined MV + kV optimization provided prescription dose to the treatment volume coverage equal to the no-imaging case, yet superior to standard MV IMRT with non-optimized kV fluoroscopic tracking. With combined MV + kV optimization, it is possible to quantify in a patient specific way the dosimetric effect of real-time imaging on the patient. Such information is necessary when substantial kV imaging is performed.