The use of conformity indices to optimize Gamma Knife planning is common, but does not address important tradeoffs between dose to tumor and normal tissue. Pareto analysis has been used for this purpose in other applications, but not for Gamma Knife (GK) planning. The goal of this work is to use computer models to show that Pareto analysis may be feasible for GK planning to identify dosimetric tradeoffs. We define a GK plan A to be Pareto dominant to B if the prescription isodose volume of A covers more tumor but not more normal tissue than B, or if A covers less normal tissue but not less tumor than B. A plan is Pareto optimal if it is not dominated by any other plan. Two different Pareto optimal plans represent different tradeoffs between dose to tumor and normal tissue, because neither plan dominates the other. ‘GK simulator’ software calculated dose distributions for GK plans, and was called repetitively by a genetic algorithm to calculate Pareto dominant plans. Three irregular tumor shapes were tested in 17 trials using various combinations of shots. The mean number of Pareto dominant plans/trial was 59 ± 17 (sd). Different planning strategies were identified by large differences in shot positions, and 70 of the 153 coordinate plots (46%) showed differences of 5mm or more. The Pareto dominant plans dominated other nearby plans. Pareto dominant plans represent different dosimetric tradeoffs and can be systematically calculated using genetic algorithms. Automatic identification of non-intuitive planning strategies may be feasible with these methods.
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