Clinical Evaluation of Shot-Within-Shot Optimization for Gamma Knife Radiosurgery Planning and Delivery

Perry B. Johnson, Maria I. Monterroso, Fei Yang, Elizabeth Bossart, Amir Keyvanloo, Eric A. Mellon

Research output: Contribution to journalArticlepeer-review

3 Scopus citations


Objective: Shot-within-shot (SWS) optimization is a new planning technique that relies on various combinations of shot weighting and prescription isodose line (IDL) to reduce beam-on time. The method differs from other planning techniques that incorporate mixed collimation, multiple stereotactic coordinates, and traditionally low prescription IDLs (<60%). In this work, we evaluate the percentage of brain metastasis for which the method can be applied, the magnitude of the resultant time savings, and the possible tradeoffs in plan quality. Methods: A retrospective analysis was performed on 75 patients treated for 241 metastatic lesions in the brain. For each lesion, the original planning metrics related to target coverage, conformity, gradient, and beam-on time were recorded. A subset of lesions were selected for replanning using the SWS technique based on size, shape, and proximity to critical structures. Two replans were done, a reference plan was prescribed at the 50% IDL, and an optimized plan was prescribed at an IDL typically >50%. Planning metrics were then compared among the original plan and the 2 replans. Results: More than a third (39%) of the brain metastases were eligible for the SWS technique. For these lesions, the differences between the original plan and reference SWS plan were as follows: ΔV 12Gy < 0.5 cc in 93% of cases, ΔV 12Gy < 0.5 cc in 100% of cases, Δselectivity < 0.1 in 79% of cases. Negligible differences were seen between the 2 replans in terms of Δselectivity and ΔV 12Gy ; ΔGI < 5% in 99% of cases. After optimization, beam-on time was reduced by 25%–30% in approximately 40%–50% of eligible lesions when compared with the reference SWS plan (ΔT max = 42%). In comparison with the original plan, beam-on time was reduced even further, ΔT > 50% in 20% of cases (ΔT max = 70%). Conclusions: This work demonstrates clinically that optimization using the shot-within-shot technique can reduce beam-on time without degrading treatment plan quality.

Original languageEnglish (US)
Pages (from-to)e218-e227
JournalWorld neurosurgery
StatePublished - Mar 2019


  • Gamma Knife
  • Gradient index
  • Metastases
  • Optimization
  • Radiosurgery
  • Shot-within-shot technique

ASJC Scopus subject areas

  • Surgery
  • Clinical Neurology


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