A new metric for assessing IMRT modulation complexity and plan deliverability.

Purpose: To evaluate the utility of a new complexity metric, the modulation complexity score (MCS), in the treatment planning and quality assurance processes and to evaluate the relationship of the metric with deliverability.

Methods: A multisite (breast, rectum, prostate, prostate bed, lung, and head and neck) and site-specific (lung) dosimetric evaluation has been completed. The MCS was calculated for each beam and the overall treatment plan. A 2D diode array (MapCHECK, Sun Nuclear, Melbourne, FL) was used to acquire measurements for each beam. The measured and planned dose (PINNACLE3, Phillips, Madison, WI) was evaluated using different percent differences and distance to agreement (DTA) criteria (3%/ 3 mm and 2%/ 1 mm) and the relationship between the dosimetric results and complexity (as measured by the MCS or simple beam parameters) assessed.

Results: For the multisite analysis (243 plans total), the mean MCS scores for each treatment site were breast (0.92), rectum (0.858), prostate (0.837), prostate bed (0.652), lung (0.631), and head and neck (0.356). The MCS allowed for compilation of treatment site-specific statistics, which is useful for comparing different techniques, as well as for comparison of individual treatment plans with the typical complexity levels. For the six plans selected for dosimetry, the average diode percent pass rate was 98.7% (minimum of 96%) for 3%/3 mm evaluation criteria. The average difference in absolute dose measurement between the planned and measured dose was 1.7 cGy. The detailed lung analysis also showed excellent agreement between the measured and planned dose, as all beams had a diode percentage pass rate for 3%/3 mm criteria of greater than 95.9%, with an average pass rate of 99.0%. The average absolute maximum dose difference for the lung plans was 0.7 cGy. There was no direct correlation between the MCS and simple beam parameters which could be used as a surrogate for complexity level (i.e., number of segments or MU). An evaluation criterion of 2%/ 1 mm reliably allowed for the identification of beams that are dosimetrically robust. In this study we defined a robust beam or plan as one that maintained a diode percentage pass rate greater than 90% at 2%/ 1 mm, indicating delivery that was deemed accurate when compared to the planned dose, even under stricter evaluation criterion. MCS and MU threshold criteria were determined by defining a required specificity of 1.0. A MCS threshold of 0.8 allowed for identification of robust deliverability with a sensitivity of 0.36. In contrast, MU had a lower sensitivity of 0.23 for a threshold of 50 MU.

Conclusions: The MCS allows for a quantitative assessment of plan complexity, on a fixed scale, that can be applied to all treatment sites and can provide more information related to dose delivery than simple beam parameters. This could prove useful throughout the entire treatment planning and QA process.