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Cinira Johnson
Final Clinical Project
October 30, 2014

Single lesion SBRT VMAT versus 3D static beams

History of Illness: Patient MB has a medical history of: heart attack, kidney failure, dialysis
care, hypertension and coronary artery disease. MB had a kidney transplant in early 2013.
Oncology history: Squamous cell carcinoma of the base of tongue treated in 2013 with definitive
concurrent carboplatin and intensity-modulated radiation therapy (IMRT), image-guided,
external beam radiotherapy to 6510 cGy in 31 fractions to his primary tumor and bilateral neck
nodes completed in April 2012. In July 2013, a positron emission tomography/ computed
tomography (PET/CT) scans showed a suspicious lesion for metastatic disease at the right upper
lobe (RUL) of right lung. A repeat PET/SCAN done a moth later demonstrated an interval
increase in size/activity of pulmonary nodule. A biopsy was performed in September 2014,
revealing poorly differentiated carcinoma suggesting of metastatic squamous cell carcinoma
from the base of tongue.
The plan: The radiation oncologist recommendation was to treat the lesion with stereotactic
body radiation therapy (SBRT) over 3 fractions to provide good local control of the lesion.1 The
prescription dose was 60 Gy to the planning target volume (PTV) in 3 fractions. The technique
actually used for this treatment was volumetric-modulated arc therapy (VMAT). For comparison
purposes, a second three-dimension (3D) static fields plan was created.
Patient Setup/Immobilization: Patient was setup supine with an alphacradle over a blue arm
pillow, arms up, large knee sponge, a head holder C and a compression belt was used over the
abdomen. Please see figure 1 for patient setup details. Patient was scanned from mandible to
liver. A gated scan was also acquired and sent to MIM version 6.3.7 (software that helps with
image fusions). At University of Colorado Hospital (UCH), the respiratory management used is
free breathing with compression belt/plate. Respiratory tumor motion can cause severe geometric
distortions in a free breathing non-gated CT scan.2 A gated scan can reduce interplay effect.
Interplay effect happens when the MLC leaves travel across the field while the dose is delivere
and the lesion is moving, there is a potential that some of the lesion will not be treated properly.

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The gated scan or 4 dimension-CT (4D/CT) data set sent to MIM creates a second set of data
image based on the gated scan. This second data image created is called MIP (maximum
intensity project) and it shows the maximum amount of tumor movement during the respiratory
cycle. This is very important while contouring the ITV (internal tumor volume) so the amount of
tumor movement during respiration can be accounted for when the radiation oncologist draws
the ITV. This is particularly important for SBRT treatment because of the use of negative
margins in the plan.
Anatomical Contouring: After the radiation oncologist drew his volumes in MIM the structure
set and the scans were sent to Varian Eclipse radiation treatment planning system (TPS). The
structure set included the Internal Tumor Volume (ITV) RUL, the Planning treatment volume
(PTV) RUL and the right chest wall volume. The medical dosimetrist student contoured: right
and left lungs, spinal cord, heart liver, esophagus and carina. The purpose of contouring the
carina is for imaging purposes. The carina is easily identifiable on daily scans and it is a great
tool to help the therapists to properly align the patient for treatment. The constraints are: right
chest wall V30 (volume of right chest wall receiving 30 Gy) to be less than 40 cc, ipsilateral lung
minus ITV mean dose to be less than 9 Gy. The radiation oncologist used Timmermans dose
constraints recommendation and request that at least 95% of PTV RUL receives prescription
dose.
Treatment Planning: SBRT planning is a technique that generally has a much higher maximal
dose compared to other plans. It uses a hot central dose to achieve a sharp dose gradient and
helps with dose fall off from the tumor.3 It mimics an SRS (stereotactic radio surgery) brain
treatment because a negative margin and it is prescribed to lower isodose line. It is not
uncommon to see 60 to 80% normalization in 3D static plans. At UCH the goal is to get a
maximum dose of 140% of the prescription dose inside the ITV inner, safely according with
Timmermans constraints. The central dose structure was created by cropping an inner structure
that is 3 mm within the ITV volume. It is named ITV inner, please see figure 2. The isocenter
was placed at the center of the PTV RUL. The VMAT plan have 2 partial arcs that started from
48.8 to 180 degrees and another 2 partial arcs starting from 180 to 48.8 degrees. All 4 partial arcs
rotate around the right lung, avoiding irradiation to the contralateral lung. Please see table 1 for
more detail information per individual arc. The VMAT plan was not normalized. The normal
tissue objectives set in the VMAT optimization window was set to reflect a tight margin and fall-

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off. The 3D static plan has a total of 16 static beams and none of them entered the contralateral
lung, please see table 2 for all 3D plan beam details. The 3D static plan was normalized to 74%
in order to get 95% of PTV RUL volume receiving 100% of prescribed dose. A block margin of
-1 mm (negative margin) inside the PTV RUL was used to shape the field for each beam. Both
plans were calculated using Acuros XB 11030.

Treatment Plans Analysis: The isodose distribution as seen on Figure 3 demonstrates obvious
differences due to the nature of dose delivery of a static plan compared to a dynamic VMAT
plan. According to the plan comparison DVH in figure 4, the VMAT plan has a point max dose
of 141% located in the center of the inner ITV. The volume of PTV RUL receiving prescription
dose is 97.42%, the chest wall V30 is 29% and the ipsilateral lung minus ITV mean dose is 8 Gy.
The 3D Static plan has a max point dose of 140.7%, also located at the center of the inner ITV.
Only 95% of PTV RUL receives prescription, the chest wall V30 is 35.9% and the ipsilateral
lung minus ITV mean dose is 8 Gy also. For more details regarding dose constrains please see
table 3.

Reflection: Overall the VMAT plan is a better option when compared to the 3D static plan. It
provides a more conformal and better coverage than the 3D static plan. Due to the sharp dose
gradient the dose to the chest wall is much smaller in the VMAT plan. The VMAT plan was
much easier to create than the static plan. It was very educational to create a 3D SBRT plan
because even a very small change can produce radical changes in the isodose distribution
because of the small field size (usually SBRT lesions are small). It is important to point out that
many facilities do not like to treat SBRT with very small fields using dynamic leaves because
some physicists believe that the Quality Assurance (QA) of such plans are not realistic so 3D
static SBRT are widely used still even in facilities that have VMAT as a treatment option.3

References

1. Videtic GM, Stephans K, Reddy C, et al. Intensity-modulated radiotherapy-based

stereotactic body radiotherapy for medically inoperable early-stage lung cancer:
excellent local control. Int J Radiation Oncology Biol Phys. 2010;77(2):344-349.
Doi: 10.1016/j.ijrobp.2009.05.004
2. Wolthaus JW, Sonke JJ, Herk MV, et al. Comparison of different strategies to use
four-dimensional computed tomography in treatment planning for lung cancer
patients. Int. J. Radiation Oncology Biol. Phys. 2008:70(4):1229-1238. Doi:
10.1016/j.ijrobp.2007.11.042
3. Song DY, Kavanagh BD, Beneditc SH, et al. Stereotatic body radiation therapy.
Rationale, techniques, applications and optimization. Radiat Oncol.
2004:18(11):1419-30; discussion 1430, 1432, 1435-6. PMID: 15609470. Accessed
November 1, 2014.
4. Zhang GG, Ku L, Dilling TJ, et al. Volumetric modulated arc planning for lung
stereotactic body radiotherapy using conventional and unflattened photon beams: a
Dosimetric comparison with 3D technique. Radiat Oncol. 2011:6(1):152. Doi:
10.1186/1748-717X-6-15

Figures

Figure 1: Patient setup at simulation.

PTV RUL

ITV

ITV INNER

Figure 2: PTV RUL, ITV RUL and ITV inner.

Figure 3: Dose distribution for static plan (left) and VMAT plan (right).

PTV VMAT

PTV 3D

Chest wall VMAT

Chest wall 3D

Ipsilateral lung
VMAT
Ipsilateral lung
3D

Figure 4: DVH comparison of 3D static plan and VMAT plan.

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Tables

Field

Energy

Gantry

Collimator

Couch
Rotation

Field
Weighting

Arc 1

6 MV

From 180 CW
48.8

30

0.632

Arc 2

6 MV

From 180 CW
48.8

330

0.634

Arc 3

6 MV

From 48.8
CCW to 180

30

0.669

Arc 4

6 MV

From 48.8
CCW to 180

330

0.669

Table 1: VMAT plan arcs details.

Fields

Energy

Gant
ry

Collimator

Cough Rotation

Field Weighting

6 MV

40

0..094

6 MV

12.5

0.013

6 MV

355

0.016

6 MV

337.5

0.033

6 MV

320

0.043

6 MV

302.5

0.015

6 MV

285

0.044

6 MV

267.5

0.0.95

6 MV

250

0.147

10

6 MV

232.5

0.037

11

6 MV

215

0.047

12

6 MV

197.5

0.037

13

6 MV

180

0.168

14

6 MV

197.5

0.027

15

6 MV

302.5

0.31

16

6 MV

250

.154

Table 2: 3D plan beams details.

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3D Static Plan

60 Gy PTV RUL Coverage

VMAT Plan

95 %

97.42%

140.7%

141%

Ipsilateral Lung ITV Mean

Dose

8 Gy

8 Gy

Right Chest wall ITV V30

35.9 cc

29 cc

3.38 Gy

Maximum Point Dose

5 cc of Esophagus

Table 3: Dose constrains.