Clinical Evaluation of Shot-Within-Shot Optimization for Gamma Knife Radiosurgery Planning and Delivery

Shot-within-shot (SWS) optimization is a new planning technique that relies on various combinations of shot weighting and prescription isodose line (IDL) to reduce beam-on time. The method differs from other planning techniques that incorporate mixed collimation, multiple stereotactic coordinates, and traditionally low prescription IDLs (<60%). In this work, we evaluate the percentage of brain metastasis for which the method can be applied, the magnitude of the resultant time savings, and the possible tradeoffs in plan quality.

A retrospective analysis was performed on 75 patients treated for 241 metastatic lesions in the brain. For each lesion, the original planning metrics related to target coverage, conformity, gradient, and beam-on time were recorded. A subset of lesions were selected for replanning using the SWS technique based on size, shape, and proximity to critical structures. Two replans were done, a reference plan was prescribed at the 50% IDL, and an optimized plan was prescribed at an IDL typically >50%. Planning metrics were then compared among the original plan and the 2 replans.

More than a third (39%) of the brain metastases were eligible for the SWS technique. For these lesions, the differences between the original plan and reference SWS plan were as follows: ΔV_12Gy < 0.5 cc in 93% of cases, ΔV_12Gy < 0.5 cc in 100% of cases, Δselectivity < 0.1 in 79% of cases. Negligible differences were seen between the 2 replans in terms of Δselectivity and ΔV_12Gy; ΔGI < 5% in 99% of cases. After optimization, beam-on time was reduced by 25%-30% in approximately 40%-50% of eligible lesions when compared with the reference SWS plan (ΔT_max = 42%). In comparison with the original plan, beam-on time was reduced even further, ΔT > 50% in 20% of cases (ΔT_max = 70%).

This work demonstrates clinically that optimization using the shot-within-shot technique can reduce beam-on time without degrading treatment plan quality.