Background: Throughout the last years, carbon-fibre-reinforced PEEK (CFP) pedicle screw systems were introduced to replace standard titanium alloy (Ti) implants for spinal instrumentation, promising improved radiotherapy (RT) treatment planning accuracy. We compared the dosimetric impact of both implants for intensity modulated proton (IMPT) and volumetric arc photon therapy (VMAT), with the focus on uncertainties in Hounsfield unit assignment of titanium alloy.
Methods: Retrospective planning was performed on CT data of five patients with Ti and five with CFP implants. Carbon-fibre-reinforced PEEK systems comprised radiolucent pedicle screws with thin titanium-coated regions and titanium tulips. For each patient, one IMPT and one VMAT plan were generated with a nominal relative stopping power (SP) (IMPT) and electron density (ρ) (VMAT) and recalculated onto the identical CT with increased and decreased SP or ρ by ±6% for the titanium components.
Results: Recalculated VMAT dose distributions hardly deviated from the nominal plans for both screw types. IMPT plans resulted in more heterogeneous target coverage, measured by the standard deviation σ inside the target, which increased on average by 7.6 ± 2.3% (Ti) vs 3.4 ± 1.2% (CFP). Larger SPs lead to lower target minimum doses, lower SPs to higher dose maxima, with a more pronounced effect for Ti screws.
Conclusions: While VMAT plans showed no relevant difference in dosimetric quality between both screw types, IMPT plans demonstrated the benefit of CFP screws through a smaller dosimetric impact of CT-value uncertainties compared to Ti. Reducing metal components in implants will therefore improve dose calculation accuracy and lower the risk for tumor underdosage.
Keywords: IMPT; carbon-fibre-reinforced PEEK; radiation therapy; radiolucent spinal implants; spinal instrumentation; treatment planning.
© 2020 The Authors. Journal of Applied Clinical Medical Physics published by Wiley Periodicals, Inc. on behalf of American Association of Physicists in Medicine.