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RapidArc (RA) - Planning Techniques,

Tips and Tricks


Its More Than Just Creating Contours

Ontida Apinorasethkul, BS, CMD


Lisa Wojtowicz, MS, CMD

AAMD, Orlando, FL - June 25, 2015

Disclaimer
This presentation is not sponsored by any vendor nor is it
endorsing one VMAT system over other systems. The material
presented is based on our planning experience. The intention
of this talk is meant for educational purposes. Each technique
discussed should be evaluated on a case by case basis.

Outline

General use for RapidArc (RA)


Normal Tissue Objective (NTO)
Use of different collimator angles
Limiting X-jaw
Intermediate dose
Jaw tracking
Avoidance sector versus separate arcs

General Use of RapidArc

Why RapidArc?
What is RapidArc?

Volumetric modulated arc therapy

What does RapidArc do?


Automatically changes aperture shape, delivery dose rate, and gantry
speed as the gantry rotates
Multiple beam angles of IMRT

Why use RapidArc?


Shorter treatment time compared to IMRT
Less intra-fraction movement
To treat Head and Neck, Lung SBRT, Abdomen, Whole Pelvis, etc.

Why Not RapidArc?


When is RapidArc not ideal?
Need to limit low dose spread
V5 of lung
Max dose to pacemaker
Dose limit to previously treated organs
Breast skin flash

IMRT!!

IMRT

RA

Planning a RA plan
Contours
Targets
Organs at risk
Avoidance structures

Fields
Choose favorable arc
angles

Optimize
Planning objective
templates

Contours Dose Painting H&N

(D) PTV_5400

(D) PTV 6000

Contours Dose Painting H&N

Anterior Cooler

Posterior Cooler

Dose Spills

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Dose Spills

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Contours Male Whole Pelvis

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Contours Male Whole Pelvis


Show bowel overlap structure

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Contours Male Whole Pelvis

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Dose Spills

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Fields
Maximum number of 10
arcs
Each arc needs at least 30
degrees
More arcs = more control
points = more potential for
dose modulation
Maximum dose rate
should be used for the
given energy mode
Increase the dynamic range
of modulation

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Fields
Center isocenter
Choose optimal arc angles

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Fields
Isocenter
Clearance issues

Choose optimal arc angles

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Fields
Arc angle clearance
Clearance issues Arc1:136131 Arc2: 220225
Collides

Clears

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Multiple Arcs?
What is the optimal number of arcs?
More # of arcs, more modulation, expect to increase plan optimality
Example with unilateral H&N
1 partial arc vs 2 partial arcs (Total MUs: 392 vs 406)
Treatment volumes receive similar coverage. Normal tissue organs
are generally better with 2 arc plan. Lower global max with 2 arc plan.

Esophagus

One partial arc


Two partial arcs

Brachial
Plexus
Oral Cavity
Larynx_glottic

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Multiple Arcs?
What is the optimal number of arcs?
2 partial arcs vs 3 partial arcs (Total MUs: 406 vs 434)
Differences are not significant or not at all.

Need to balance among the time for patient on the table, more MUs,
and benefits of increasing the number of arcs.

Esophagus

Three partial arcs


Two partial arcs

Brachial
Plexus
Oral Cavity
Larynx_glottic

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Fields
Set up collimator angles
Tongue and groove effect

Set up field size


Optimizer modulates
fluence with leaf position,
dose rate and gantry
speed.
Gantry needs to slow down
to deliver high MU per
degree segments

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Optimization
Optimization templates
Save time by inserting objectives
Upper
Lower
Mean dose
Set NTO objectives

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Optimization
Resolution Levels/Steps
Iterative optimization process multiple resolution levels
Hold allows user to make changes to objectives before next resolution
level
As resolution levels increase, the penalty function decreases
Beam parameters and beam segments change as penalty function
changes
Algorithm corrects for the change in parameters
Leaf motions are created during optimization (IMRT is after)

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Optimization
Resolution Levels/Steps
Levels 1-2: majority of optimization, most flexible to make changes in
optimization
Levels 3-4: focus on making the fluence treatable within the set arc(s)

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Optimization
Line chart

Objective function similar to IMRT


Lines in the chart represent structure specific curves.
Line chart displays the optimization quality and progress
Displays structures visualized in optimization.

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Optimization
Bar chart
Shows which structures contribute most to the overall objective
function
Structures that are not doing well will be at or near top of chart
Length of bar indicates that structures contribution to overall objective
function relative to other structures.

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Normal Tissue Optimization (NTO)

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NTO
What is NTO?
Normal Tissue Objective
Prevents hotspots in normal tissue
Produces a sharp dose gradient around target volumes
to take into account the decrease in dose level as the distance
from targets is increased

How is NTO defined?

Distance from target border


Start Dose
End Dose
Fall-off
Priority

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NTO

30

NTO
Without NTO
Higher global max dose
Hot spot on axial slice is outside PTV volume.
Use coolers
No significant save on OAR doses on one or the other.

NTO

No NTO

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Collimator Angles

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Collimator Angles Unilateral H&N


2 partial arcs complimentary angles
10 / 350
30 / 330
45 / 315

10 / 350

30 / 330

45 / 315

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Collimator Angles Unilateral H&N


2 partial arcs

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Collimator Angles Unilateral H&N

10/350
Total MUs: 406

30/330
Total MUs: 418

45/315
Total MUs: 412

No significant difference
10 and 30 collimator angles are similar.
45 collimator angle gives higher normal structure doses.

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Collimator Angles Bilateral H&N


2 full arcs complimentary angles
10 / 350
30 / 330
45 / 315

10 / 350

30 / 330

45 / 315

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Collimator Angle 10/350

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Collimator Angle 30/330

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Collimator Angle 45/315

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Collimator Angle 10/350

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Collimator Angle 30/330

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Collimator Angle 45/315

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Collimator Angle 10/350

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Collimator Angle 30/330

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Collimator Angle 45/315

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Collimator Angles Bilateral H&N

10/350
Total MUs: 446

30/330
Total MUs: 563

45/315
Total MUs: 521

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Collimator Angles Male Whole Pelvis


2 full arcs complimentary angles
10 / 350
30 / 330
45 / 315

10 / 350

30 / 330

45 / 315

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Collimator Angle 10/350

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Collimator Angle 30/330

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Collimator Angle 45/315

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Collimator Angle 10/350

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Collimator Angle 30/330

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Collimator Angle 45/315

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Collimator Angle 10/350

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Collimator Angle 30/330

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Collimator Angle 45/315

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Collimator Angles Male Whole Pelvis

10/350
Total MUs: 416

30/330
Total MUs: 480

45/315
Total MUs: 516

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Limiting X-Jaws

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H&N Open Jaws

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H&N Limit X-Jaw

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Whole Pelvis Open Jaw

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Whole Pelvis Limit X-Jaw

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Field Size Limitations


Limit X-jaw to 15cm-20cm
Field size could be larger, BUT the MLC only have a leaf span out to
15cm.
Leaves will not move completely across the field when the size is
>15cm in the x-direction.
Leaf overtravel distance

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Field Size Limitations


The field doesnt have to cover whole target as long as parts
of it are covered in an arc.

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Field Size Limitations Bilateral H&N


2 full arcs complimentary angles
10 / 350
30 / 330
45 / 315

Limit all x-jaw to 15cm

10 / 350

30 / 330

45 / 315

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Collimator Angle 10/350 + X-Jaw limitation

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Collimator Angle 30/330 + X-Jaw limitation

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Collimator Angle 45/315 + X-Jaw limitation

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Collimator Angle 10/350 + X-Jaw limitation

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Collimator Angle 30/330 + X-Jaw limitation

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Collimator Angle 45/315 + X-Jaw limitation

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Collimator Angle 10/350 + X-Jaw limitation

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Collimator Angle 30/330 + X-Jaw limitation

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Collimator Angle 45/315 + X-Jaw limitation

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Collimator Angle + X-Jaw limitation

10/350 + 15 X-jaw
Total MUs: 886

30/330 + 15 X-jaw
Total MUs: 677

45/315 + 15 X-jaw
Total MUs: 647

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Summary - Collimator Angle + X-Jaw limitation


10/350
Total MUs: 446

30/330
Total MUs: 563

45/315
Total MUs: 521

10/350 + 15 X-jaw
Total MUs: 886

30/330 + 15 X-jaw
Total MUs: 677

45/315 + 15 X-jaw
Total MUs: 647
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Field Size Limitations Whole Male Pelvis


2 full arcs complimentary angles
10 / 350
30 / 330
45 / 315

Limit all x-jaw to 15cm

10 / 350

30 / 330

45 / 315

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Collimator Angle 10/350 + X-Jaw limitation

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Collimator Angle 30/330 + X-Jaw limitation

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Collimator Angle 45/315 + X-Jaw limitation

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Collimator Angle 10/350 + X-Jaw limitation

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Collimator Angle 30/330 + X-Jaw limitation

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Collimator Angle 45/315 + X-Jaw limitation

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Collimator Angle 10/350 + X-Jaw limitation

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Collimator Angle 30/330 + X-Jaw limitation

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Collimator Angle 45/315 + X-Jaw limitation

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Collimator Angle + X-Jaw limitation

10/350 + 15 X-jaw
Total MUs: 499

30/330 + 15 X-jaw
Total MUs: 497

45/315 + 15 X-jaw
Total MUs: 527

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Summary -Collimator Angle + X-Jaw limitation


10/350
Total MUs: 416

10/350 + 15 X-jaw
Total MUs: 499

30/330
Total MUs: 480

30/330 + 15 X-jaw
Total MUs: 497

45/315
Total MUs: 516

45/315 + 15 X-jaw
Total MUs: 527
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Intermediate Dose

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Intermediate Dose Calculation


This feature corrects for differences between DVH in the
optimization from the final dose calculation.
More differences are seen with:
Volumes close to surfaces
Large amount of heterogeneity
Ex: nasal cavity, lung, etc.

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Intermediate Dose Calculation


Nasal Cavity Bilateral Plan
Optimization WITHOUT intermediate dose calculation
Optimization time: 10m 10s
Calculation time: 2m 51s
Total MU: 499

Optimization WITH intermediate dose calculation


Optimization time: 15m 53s
Calculation time: 2m 46s
Total MU: 520

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Intermediate Dose Calculation

PTV 5600
PTV 5950
PTV 7000

No intermediate dose
With intermediate dose

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Intermediate Dose Calculation


Intermediate dose

No intermediate dose

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Intermediate Dose Calculation

Brainstem
52Gy max intermediate dose
54Gy max no intermediate dose

Right Ear
Right parotid

Left Ear

No intermediate dose
With intermediate dose

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Jaw Tracking

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Jaw Tracking
Enable jaw tracking in Truebeam
Keeps the collimator jaws as close to the MLC aperture as
possible
Minimize leakage between MLC leaves

Maximum jaw positions = initial jaw setting

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Jaw Tracking

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Jaw Tracking
Jaw Tracking plan
at 17

No Jaw Tracking plan


at 17

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Jaw Tracking
Jaw Tracking

20% dose: 2132cc


50% dose: 1056cc
80% dose: 605cc

No Jaw Tracking

20% dose: 2114cc


50% dose: 1081cc
80% dose: 600cc
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Jaw Tracking
SBRT
Small volumes
Measurements needed for small field size
May not be suitable for jaw tracking on very small volume.

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Avoidance Sector

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Avoidance Sector vs. Separate Arcs


Setting 4 separate arcs

CCW 315 ->180.1


CCW 179.9 -> 50
CW 50 -> 179.9
CW 180.1 -> 315

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Avoidance Sector vs. Separate Arcs


Using avoidance sector
Set the arc angles as 2 full arcs

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Avoidance Sector vs. Separate Arcs


In VMAT optimization window
Set avoidance sectors

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Avoidance Sector vs. Separate Arcs


Beam is off when gantry rotates through the specified
avoidance sectors

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Separate Arcs

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Avoidance Sector

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Separate Arcs

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Avoidance Sector

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Avoidance Sector vs. Separate Arcs

Left optic nerve

Right optic nerve


Optic chiasm

Avoidance sector plan


4 separate arc plan

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Avoidance Sector vs. Separate Arcs

Left optic nerve


Left Cochlea
Pituitary
Right optic nerve
Optic chiasm
Hypothalamus
Avoidance sector plan
4 separate arc plan

Right Cochlea

Avoidance sector plan


4 separate arc plan

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Summary

RA produces highly conformal plans


NTO reduces hot spots outside of target volumes
Collimator angles, limiting x-jaw
Intermediate dose
Jaw tracking
Avoidance sector

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Questions

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Acknowledgements

Ryan Scheuermann, M.S.


Josh Scheuermann, M.S.
Chuan Zeng, Ph.D.
Dosimetry and physics teams

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