Comparative dosimetric evaluation of the simultaneous integrated boost with photon intensity modulation in head and neck cancer patients

Background and purpose: The objective of this study is to evaluate, at planning and dosimetric level, the potential benefits of the simultaneous integrated boost (SIB) concept with intensity-modulated radiation therapy (IMRT), using a comparative analysis on physical dose distributions corrected for radiobiological models. The concept of SIB at the end of the treatment has been analysed as an alternative acceleration scheme. Patients and methods: Physical dose distributions were computed on a commercial planning system (Varian Cadplan-Helios) for five patients presenting with advanced head and neck carcinomas. Treatment plans were designed using five IMRT beams. Three fractionation strategies were compared in the study: the standard sequential irradiation SEQ of elective and boost volumes, the pure SIB, and a modified SIB (SEQ/SIB), where the actual SIB follows a first phase of conventional fractionation to the elective volume. All physical dose distributions were corrected using a linear quadratic biological model, taking into account also repopulation and time at repopulation onset. Objective quantities, derived from biological dose volume histograms, were used for the analysis. Results: Physical doses equivalent to 50 and 80 Gy (in fractions of 2 Gy) to elective volume and boost were calculated for the SIB and SEQ/SIB regimes. With SIB 54 and 72 Gy dose levels have to be delivered in 30 fractions, while in the SEQ/SIB scheme 36 Gy are delivered in 20 sessions to the elective volume, and further 18 and 35.5 Gy during the last 10 fractions are delivered to elective volume and boost, respectively (for a total physical dose of 71.5 Gy). The comparison showed: (1) the boost target homogeneity resulted in generally acceptable and comparable among sequential and modified SIB schemes, while it was statistically worse for the pure SIB approach; (2) the fraction of elective target volume not included in the boost volume was characterised by a higher level of dose heterogeneity; (3) the spinal cord never reached tolerance levels and maximum point dose was on average below 38 Gy (biologically corrected to 2 Gy/fraction); and (4) sparing of parotid glands strongly depends on their eventual inclusion in the target volumes: for glands not included or only partially included, it was possible on average to keep the dose to 2/3 of the volume below 29 Gy for all regimes (32 Gy as physical dose). Conclusions: Feasibility of SIB techniques and in particular of the modified SIB appears to be dosimetrically proven and the results reported here justify the activation of a phase I protocol to verify clinically their impact using INIRT photon-based techniques. (C) 2003 Elsevier Ireland Ltd. All rights reserved.