What is an acceptably smoothed fluence? Dosimetric and delivery considerations for dynamic sliding window IMRT Nicolini Giorgia1, Fogliata Antonella1, Vanetti Eugenio1,2, Clivio Alessandro1,2, Ammazzalorso Filippo4 and Cozzi Luca*1,3

Background: The study summarised in this report aimed to investigate the interplay between fluence complexity, dose calculation algorithms, dose calculation spatial resolution and delivery characteristics (monitor units, effective field width and dose delivery against dose prediction agreement) was investigated. A sample set of complex planning cases was selected and tested using a commercial treatment planning system capable of inverse optimisation and equipped with tools to tune fluence smoothness. Methods: A set of increasingly smoothed fluence patterns was correlated to a generalised expression of the Modulation Index (MI) concept, in nature independent from the specific planning system used that could therefore be recommended as a predictor to score fluence "quality" at a very early stage of the IMRT QA process. Fluence complexity was also correlated to delivery accuracy and characteristics in terms of number of MU, dynamic window width and agreement between calculation and measurement (expressed as percentage of field area with a γ > 1 (%FA)) when comparing calculated vs. delivered modulated dose maps. Different resolutions of the calculation grid and different photon dose algorithms (pencil beam and anisotropic analytical algorithm) were used for the investigations. Results and Conclusion: i) MI can be used as a reliable parameter to test different approaches/ algorithms to smooth fluences implemented in a TPS, and to identify the preferable default values for the smoothing parameters if appropriate tools are implemented; ii) a MI threshold set at MI < 19 could ensure that the planned beams are safely and accurately delivered within stringent quality criteria; iii) a reduction in fluence complexity is strictly correlated to a corresponding reduction in MUs, as well as to a decrease of the average sliding window width (for dynamic IMRT delivery); iv) a smoother fluence results in a reduction of dose in the healthy tissue with a potentially relevant clinical benefit; v) increasing the smoothing parameter s, MI decreases with %FA: fluence complexity has a significant impact on the accuracy of delivery and the agreement between calculation and measurements improves with the advanced algorithms. Published: 23 November 2007 Radiation Oncology 2007, 2:42 doi:10.1186/1748-717X-2-42 Received: 5 September 2007 Accepted: 23 November 2007 This article is available from: http://www.ro-journal.com/content/2/1/42 © 2007 Giorgia et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.