Background: Vestibular schwannoma (VS) stereotactic radiosurgery (SRS) requires high target conformality and rapid dose falloff to spare adjacent organs at risk (OARs), particularly the brainstem. HyperArc (HA) is an automated noncoplanar volumetric-modulated arc therapy (VMAT) approach designed to standardize and streamline cranial SRS planning and delivery. We compared CyberKnife (CK) with HA for single-fraction VS SRS and evaluated the impact of multileaf collimator (MLC) leaf width. Methods: Fifteen VS cases previously treated with single-fraction CK SRS (12.5 Gy) were retrospectively replanned using HA. HA plans used four preconfigured noncoplanar partial arcs and were created with either a standard 5.0 mm MLC (HA-SMLC) or a 2.5 mm high-definition MLC (HA-HDMLC). HA plans were normalized to match the prescription dose target coverage of the corresponding CK plan for each of the patients. Endpoints included planning target volume (PTV) dosimetric statistics (Dmean, Dmin, Dmax, D98%), Paddick conformity index (PCI), Paddick gradient index (GI), ICRU Report 83 homogeneity index (HI), brain V12Gy, and brainstem Dmax. Because plans were generated for the same patients, paired comparisons were performed using two-sided Wilcoxon signed-rank tests (p < 0.05). Results: Both HA techniques achieved a higher near-minimum target dose than CK, with significantly higher PTV D98% (CK 12.35 ± 0.52 Gy; HA-SMLC 12.54 ± 0.28 Gy; HA-HDMLC 12.57 ± 0.35 Gy; p < 0.05). HA reduced target hotspots, with lower PTV Dmax than CK (CK 15.25 ± 0.32 Gy; HA-SMLC 14.70 ± 0.39 Gy; HA-HDMLC 14.73 ± 0.32 Gy; p < 0.05), and improved homogeneity and dose falloff as reflected by HI and GI (p < 0.05). CK achieved the highest conformity by PCI (p < 0.05), while HA-HDMLC improved PCI compared with HA-SMLC (p < 0.05). Brain V12Gy and brainstem Dmax were low and did not differ significantly among techniques. Conclusions: HA provides dosimetric performance comparable to CK for single-fraction VS SRS, with improved near-minimum PTV dose, reduced hotspots, and steeper dose gradients. Although CK showed the highest PCI overall, conformity improved with HA when a high-definition MLC was used. Overall, these findings support HA, particularly HA-HDMLC, as an efficient and clinically practical option for VS SRS treatment planning.
Xiong et al. (Fri,) studied this question.