LUNG CA: VMAT VS 3D

Jackson Baumgartner
 PRESENTATION
• March 2017 – Patient presents with chest congestion
• Prompted a Chest X-ray (4/28/17)
• Revealed a 7.9 x 7.2 x 6.6 cm LUL mass abutting the mediastinum and invading
the left suprahilar region, encasing the pulmonary vasculature
• 5/5/17 – LUL biopsy showed NSCLC (poorly differentiated, necrotic,
adenocarcinoma)
• 5/8/17 – MRI Brain scan reveals 1.1 x 1.3 cm left occipital lesion
 IMMOBILIZATION
• Patient in the supine position
• Wingboard with Upper Vacbag – patient’s arms overhead to keep them out
of the beam
• Dosemax Board – note the board number, helps with repositioning
• Legs in knee sponge
 TISSUE TOLERANCES (TD 5/5)
• Heart
• 4000 cGy (3/3)
• 4500 cGy (2/3)
• 6000 cGy (1/3)
• Lung
• 1750 cGy (3/3)
• 3000 cGy (2/3)
• 4500 cGy (1/3)
• Spinal Cord
• 4700 cGy (Across 20cm)
• 5000 cGy (Across 10cm)
• 5000 cGy (Across 5cm)
• Esophagus
• 5500 cGy (3/3)
• 5800 cGy (2/3)
• 6000 cGy (1/3)
• Brachial Plexus
• 6000 cGy (3/3)
• 6100 cGy (2/3)
• 6200 cGy (1/3)
 VMAT
• 6000 cGy: 200 cGy over 30 fractions
• standard conventional dose
• Tx Energy: 6X
• Higher energies not as effective at accurately delivering dose
• Due to the air within the lung – will alter the buildup of the beam
• Once the beam hits tissue, it begins to build up  hits air within lung  starts
building up all over again once it hits lung tissue on the other side
• This can cause an under-dose to the PTV
 VMAT
• Physician will order 4D simulation for many plans
• Due to the motion of the tumor during each phase of the breathing cycle
• Physician draws (smallest to largest):
• GTV (using free breathing scan)
• ITV (GTV + Range of Tumor motion)
• CTV (accounts for microscopic disease)
• PTV (accounts for setup errors)
 VMAT
• Pros
• More effective at controlling higher doses
• Achieves tighter Isodose lines (more conformed and uniform dose distribution)
• Can dramatically reduce cord dose
• Cons
• The whole body within the range of the arc will receive some dose. While small,
the total dose can add up
• Will cause a larger amount of low exit dose
 VMAT
• How many arcs?
• 2 for this plan – why?
• Number of arcs depends on the complexity of the case
• More modulation can help when delivering higher doses or there are many critical
structures
• This patient in particular has a tumor that is very large and relatively round
• The patient’s ability to tolerate lying on the table for long durations of time may also
impact the number of arcs – less arcs for patients with lower tolerances
• How long is the arc?
• Half arc – this is because the tumor is only on one side
 3D CONFORMAL
• No modulation - fields are usually completely open
• Utilizes any number of coplanar and non-coplanar beam angles
• 3D plans can be complicated or simple, depending on how many beams
are planned
• Pros and cons to small and large number of beams
• Large number of beams – achieves a more uniform and conformed dose
distribution at the expense of larger entrance and exit doses
• Small number of beams – achieves minimal entrance and exit doses at the
expense of dose conformality
 3D CONFORMAL
• Due to the fact that there is no modulation, the dose will never be
conformed as well as a VMAT plan
• The 100% Isodose line will be slightly larger than the PTV, thus tissue outside of the
PTV will receive a higher dose
• Sometimes the hotspots will be outside of the PTV
• Can be hotter than a VMAT plan
• There are ways to address this issue
• Inserting a Wedge can push the hotspot into the PTV, improving coverage
• Adding a Reduced Field can block the hotspot outside of the PTV and help cool
down the plan
 3D CONFORMAL
• Benefits?
• Lung patients are required to keep their arms overhead
• Not all patients can do this
• If this is the case, we can plan a Statc IMRT treatment – this way we can choose
which angles will miss the patient’s arms and we can spare them
• Downside – longer treatment times and even less dose conformity due to the fact
that we cannot use as many beams
• Able to have better tumor coverage during tumor motion
• Tumors move within the body
• Since the fields are completely open for a 3D plan, the movement of the tumor has
littler effect on the plans ability to deliver dose to it
• VMAT plans are at a disadvantage here since they are so dependent on MLC
positions
TX GOALS
TX GOALS
 TX GOALS
• Optimization:
• Can enter upper and lower objectives
• Upper objectives are used to tell the computer what is more important to spare
• Critical Structures
• Lower objectives are used to tell the computer what is less important to spare
• Treatment volumes
• Enter each goal outlined by the physician in the optimizer with an upper or a lower
objective – can enter multiple objectives for the same structure
• Computer needs to be told every detail in order for optimization to be the best
• For this VMAT plan
• Upper Objectives (highest to lowest): Spinal Cord & Brachial Plexus; Lung, Heart, and
esophagus
• Lower objectives: PTV
• Once objectives are entered, optimization proceeds through 4 levels
• Each level seeks to refine the plan more and more
• Most optimization occurs in levels 1 and 2
DVH COMPARISON

Squares = VMAT
Triangles = 3D

Purple = Lung
Magenta = Spinal Cord
Peach = Heart
 CONCLUSION
• VMAT
• Superior when it comes to making the dose conformal to the PTV
• Can create very tight and even Isodose lines, sparing much of the normal tissues
from higher doses
• Treatment times are much faster – beneficial for both the patient and the
department
• Biggest downside: Much higher entrance and exit dose since the arc delivers dose
along it’s entire path
• 3D
• Inferior to VMAT’s ability to create tight isodose lines
• No modulation – hotter than VMAT plans
• Longer treatment times
• Benefit: can accommodate patients if unable to hold arms over their heads and
able to and are not as dependent on MLC positions (can cover tumor during
breathing cycle)