Influence of dwell time homogeneity error weight parameter on treatment plan quality in inverse optimized high-dose-rate cervix brachytherapy using SagiPlan

PURPOSE: Restricting the gradients of dwell times between adjacent dwell positions can potentially be beneficial in reducing the probability of unwanted hot/cold spots occurring, if the planned applicators/anatomy relative positions change before or during treatment. This constraint, however, may degrade plan quality. This study, for the first time, aims to quantify the impact of modulation restriction on plan quality indices in inverse optimization for cervix high-dose-rate (HDR) brachytherapy using the BEBIG SagiPlan treatment planning system. MATERIAL AND METHODS: Ten cervical cancer patient plans were optimized for treatment with a BEBIG SagiNova (60)Co HDR afterloader using the min/max inverse planning method, with dwell time homogeneity error weight (DTHEW) parameter values of 0 to 10. Dwell time homogeneity and gradients as well as various plan quality indices were analyzed. RESULTS: For DTHEW = 0, min/max-based optimization yielded higher HR-CTV D(90) values than the variance-based option (p < 0.001) and was therefore selected for this study. Averaging over all patients, selecting non-zero DTHEWs resulted in a general increase in dwell time homogeneity and decrease in mean and maximum adjacent dwell time gradients, especially between DTHEWs of 0 and 1. For DTHEW > 1, an increase of this parameter did not always result in more homogeneous dwell times or reduced gradients in individual patients. There was a negative correlation between DTHEW and both HR-CTV D(90) and V(100) (p < 0.001, r = –0.91). Increasing DTHEW also negatively affected conformity index (p < 0.001, r = –0.99). Changes in rectum and sigmoid colon D(2cc) were insignificant. There was a strong positive relationship between bladder D(2cc) and DTHEW (p < 0.001, r = 0.99). CONCLUSIONS: Assuming a static geometry, statistically significant degradation of plan quality can result from restricting the dwell time homogeneity in min/max-based optimization of cervix HDR brachytherapy plans using SagiPlan. Therefore, setting DTHEW to zero is indicated for the type of patient plans considered in this study.