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Due to the complexity and cumbersomeness of Gamma Knife (GK) manual forwardplanning, the quality of the resulting treatment plans heavily depends on theplanners skill, experience and the amount of effort devoted to plandevelopment. Hence, GK plan quality may vary significantly among institutionsand planners, and even for a same planner at different cases. This isparticularly a concern for challenging cases with complicated geometry, such asvestibular schwannoma cases. The purpose of this retrospective study is toinvestigate the plan quality and variation in the manually forward planned,clinically acceptable GK treatment plans of 22 previous vestibular schwannomacases. Considering the impacts of different patient geometry and differenttrade-offs among the planning objectives in GK planning, it is difficult toobjectively assess the plan quality across different cases. To reduce theseconfounding factors on plan quality assessment, we employed our recentlydeveloped multiresolution-level inverse planning algorithm to generate a goldenplan for each case, which is expected to be on or close to the pareto surfacewith a similar trade-off as used in the manual plan. The plan quality of themanual plan is then quantified in terms of its deviation from the golden plan.A scoring criterion between 0-100 was designed to calculate a final score foreach manual plan to simplify our analysis. Large quality variation was observedin these 22 cases, with two cases having a score lower than 75, three casesscoring between 80 and 85, two cases between 85 and 90, eight cases between 90and 95, and seven cases higher than 95. Inter- and intra- planner variabilitywas also observed in our study. This large variation in GK manual planningdeserves high attention, and merits further investigation on how to reduce thevariation in GK treatment plan quality.

An institutional study on plan quality and variation of manual forward planning for Gamma Knife radiosurgery for vestibular schwannoma