Evaluation of multiple factors affecting normal brain dose in single-isocenter multiple target radiosurgery

We investigated the effects of multiple planning factors on normal brain dose for single-isocenter VMAT stereotactic radiosurgery (SRS). Ten patients were retrospectively planned using a standardized objective function and all 16 combinations of 2 versus 4 arcs, collimator angle 45 degrees versus selected per beam to minimize area of normal brain exposed in the beams-eye-view, fixed jaw versus following the trailing MLC leaf, and a 2 Gy mean dose objective for healthy brain versus no low dose objective. Limiting the normal brain mean dose in the optimization objective function significantly reduced the low dose spill into the normal brain without changing target coverage. Jaw tracking and appropriate selection of collimator also reduced the low dose volume, but to a lesser extent. To reduce low dose spill into normal brain for single isocenter VMAT radiosurgery of multiple targets, it is important to incorporate a limit on low dose spill into the objective function. This study has implications beyond single-isocenter VMAT radiosurgery. When comparing different inverse-planned treatment techniques, metrics that are important for evaluation of plan quality must be included the objective function.