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Capstone Outline: Evaluation of mixed energy volumetric modulated arc therapy for anal
cancers with lymph node involvement
Mikayla Eskens, Helen Nguyen, and Will Deere
University of Wisconsin – La Crosse

I. Abstract
A. This will be left blank until the end of the semester.
II. Introduction
A. While creating a radiation therapy treatment plan, medical dosimetrists are able to
utilize photons of varying energies depending on the depth of the planning target
volume (PTV).
1. Deep-seeded tumors require higher energy photons because of their ability
to penetrate through matter. Tumors that are more superficial require low
energy photons. This is also the case when skin irradiation is desirable.
2. Considering the typical patient habitus observed in many clinics today,
additional focus is placed on the dosimetric benefits in using higher
treatment energies.
3. A study comparing photon energies in prostate volumetric modulated arc
therapy (VMAT) treatments demonstrated lower relative integral dose,
monitor units, depth of maximum dose (dmax), and bladder volume
receiving 30 Gy (V30) for the 10 MV plans versus the 6 MV plans.1
4. Though higher energies can be beneficial in reaching deep seated tumors,
photon energies higher than 10 MV are not recommended for VMAT
treatments due to the additional dose contributed from photo-neutron
contamination.2
5. Additionally, 6 MV and 10 MV VMAT treatments were found to be more
beneficial than using 15 MV photons in a study by Yadav et al.3
6. Some cancers, such as those found in the pelvis region, range drastically in
depth from the skin surface; these can be difficult to treat and may
necessitate the use of multiple photon energies.
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7. One such treatment, historically treated using multiple photon energies, is

anal cancers with lymph node involvement (AC-LNI).
B. Multiple treatment plan methods have been implemented in treating AC-LNI in
attempt to produce adequate PTV coverage while preventing organs at risk (OAR)
from receiving excess dose.
1. Before VMAT and dynamic intensity modulated radiation therapy
(IMRT) technology was available, AC-LNI was conventionally treated
with mixed energy three-dimensional conformal radiation therapy (3D-
CRT).
2. These mixed energy 3D-CRT treatment plans consisted of deep-
penetrating static beams (15 MV or 18 MV photons) and superficially
penetrating static beams (6 MV photons or various energies of electrons)
in order to treat both the deep seated anal tumor and superficial nodes
respectively.4,5
3. With the introduction of VMAT and IMRT, 3D-CRT became unsuitable
for treating AC-LNI.
4. Multiple studies, including those by Vieillot et al,6 Clivio et al,7 and
Franco et al8 support the current convention of VMAT as the optimal form
of treatment for AC-LNI.
5. Research in combining traditional methods, such as mixed energy
treatments, with the more advantageous VMAT therapy for pelvic cancers
other than AC-LNI has shown interesting results in recent years.
C. Investigation into using mixed energy VMAT planning for prostate cancer has
shown benefits in terms of dose conformity and sparing dose to OAR.
1. In one study, Park et al9 evaluated mixed energy treatments for prostate
patients undergoing IMRT, and concluded that using mixed energies for
IMRT prostate plans can enhance the overall quality of the plan by
reducing dose delivered to organs at risk (OAR).
2. Another study by Momin et al10 showed that mixed-energy VMAT plans
could be used to improve dose conformity to the PTV, and further limit
dose delivered to OAR.
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3. Shyam Pokharel11 also studied the dosimetric impact of mixed‐energy

VMAT plans, and concluded that mixed-energy VMAT could reduce
integral dose and minimize the dose to the rectum in bladder when used
for high-risk prostate cancer cases.
4. Lastly, Mcgeachy et al used an external optimizer to provide beam energy
as a degree of freedom in IMRT optimization processes and found that
plans could be dosimetrically improved through sparing dose delivered to
OAR.12
5. Through the results of the above studies, a need was presented for further
research into the viability of mixed energy VMAT planning for applicable
pelvic sites with a large range in treatment depth, such as AC-LNI.
D. A mixed energy VMAT treatment may present dosimetric advantages for treating
AC-LNI.
1. Using different photon energies during radiotherapy is a method medical
dosimetrists implement in order to treat target volumes at various depths.
2. The large range in treatment depth from the skin in AC-LNI has
historically been treated using mixed energy 3D-CRT.
3. Treating AC-LNI using mixed energy 3D-CRT is no longer clinically
conventional because VMAT has been established as the optimal form of
treatment.
4. Research in combining 3D-CRT mixed energy methods with VMAT
treatment has shown some benefits for simple pelvic cancers, but has not
been investigated for cancers with a large range in treatment depth, such
as AC-LNI.
5. The purpose of this study is to investigate the clinical applicability of
using mixed energy VMAT plans to treat AC-LNI in comparison to
conventional single energy VMAT plans.
III. Methods and Materials
Patients
A. Patients with AC-LNI were considered for this study.
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1. The patient demographic was collected from two clinical sites, and
consisted of 20 patients with AC-LNI.
2. The lymph node systems involved for the patients considered in this study
included the external iliac system, internal iliac system, and inferior
mesenteric system.
3. No patients with metastatic disease were included in this research.
4. All cases included in this research were evaluated retrospectively using the
patient’s CT image collected during the simulation process of their
treatment.
B. Computed Tomography scans from each patient’s simulation procedure were
collected.
1. All patients were simulated, planned, and treated in the supine position.
2. The CT images were taken head-first with the scanning field of view
(FOV) including the pelvic region, at 3 mm slice thickness.
3. Patients included from site 1 were simulated on a Siemens Somatom
Sensation Open CT machine, and were immobilized with a Civco Hipfix
Thermoplastic positioning tool.
4. Patients taken from site 2 were simulated on a Philips Big Bore CT
machine, and were immobilized using a Civco Vac-Lok cushions and a Q-
Fix indexing tool.
5. Contours were added to each patient’s CT image for the purpose of this
study.
Contouring
A. Treatment volumes including gross tumor volume (GTV), clinical target volume
(CTV) and planning target volume (PTV) were contoured by the radiation
oncologist who had treated the patient during their radiation therapy.
1. For the purpose of this study, all CTV volumes include a primary tumor
(GTV) with associated lymph nodes.
2. For the PTV, a 1 cm margin was added to the CTV.
B. Normal structures were contoured by a single medical dosimetrist responsible for
carrying out the planning in this study.
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1. The structures included the skin, bladder, bowel bag, external genitalia or
vagina, left femur, and right femur.
2. In cases where the patient’s CT included contrast in the bowel, the
contrast was also contoured to allow for Hounsfield Unit (HU)
corrections.
3. A Truebeam Couch structure was also added to all CT images for
consistency during the planning process.
Treatment Planning
A. All patients in this study were prescribed a dose of 1.8 Gy over 25 fractions for a
total of 45 Gy.
1. This prescription was used for curative intent.
2. All parameters used for creating the treatment plans in this study remained
consistent between patients.
3. All plans were created for treatments to take place using a Varian
TrueBeam 1032 with a multileaf collimator (MLC) leaf thickness of 0.5 to
1 cm.
4. The algorithm used to perform all optimizations was the Varian Eclipse
Analytical Anisotropic Algorithm (AAA) and the calculation resolution
was 2.
B. Three treatment plans were created for each patient on the Varian Eclipse
treatment planning system, version 15.
1. These plans included one plan using 6 MV photons, one using 10 MV
photons, and one plan that used both 6 MV and 10 MV photons.
i. Each of these plans was created using three whole arcs covering
359° around the patient in the axial plane.
ii. All plans included an arc with a 10° collimator rotation, an arc
with a 0° collimator rotation, and an arc with a 350° collimator
rotation.
2. The two single energy plans were created with the same setup
configurations.
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i. Each plan was made with two counterclockwise (CCW) arcs and
one clockwise (CW) arc.
ii. The first CCW arc had a collimator rotation of 10°, with the Y-axis
and X1 jaws encompassing the PTV given a 1 cm margin, and the
X2 jaw opened 2 cm.
iii. The CW arc had a collimator rotation of 0°, with the Y-axis jaws
encompassing the PTV given a 1 cm margin, and the X-axis jaws
opened 7.5 cm each.
iv. The second CCW arc had a collimator rotation of 350°, with the Y-
axis and X2 jaws encompassing the PTV given a 1 cm margin, and
the X1 jaw opened 2 cm.
3. The mixed energy 6 MV and 10 MV plan was created by splitting the dose
delivered in each fraction between two separate plans that were then
summed together.
i. The 10 MV partial plan was used as a base dose plan when
creating the 6 MV partial plan. This was done so that the previous
dose delivered from the 10 MV partial plan could be taken into
account by the optimizer when creating the 6 MV plan.
ii. After the creation of the two partial plans, they were summed
together to create a mixed energy VMAT plan that delivered a total
of 45 Gy over 25 fractions.
4. The 10 MV partial plan was created with a prescription of 1.2 Gy over 25
fractions using two CCW arcs.
i. The first CCW arc had a collimator rotation of 10°, with the Y-axis
and X1 jaws encompassing the PTV given a 1 cm margin, and the
X2 jaw opened 2 cm.
ii. The second CCW arc had a collimator rotation of 350°, with the Y-
axis and X2 jaws encompassing the PTV given a 1 cm margin, and
the X1 jaw opened 2 cm.
5. The 6 MV partial plan was created with a prescription of .6 Gy over 25
fractions and optimized using the 10 MVpartial plan as a base dose plan.
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i. This plan using a single CCW arc had a collimator rotation of 0°.
ii. The Y-axis jaws encompassed the PTV given a 1 cm margin, and
the X-axis jaws were both opened to 7.5 cm.
C. Optimization structures were contoured by the medical dosimetrist responsible for
carrying out the planning in this study.
1. The same optimization structures were used for each plan.
2. Two optimization structures were added to all patient CTs and used during
optimization of the treatment plan.
1. One structure was created by cropping the bowel bag normal structure
from going into the PTV, with a 0.1 cm margin; this structure was named
Opti Bowel Bag.
2. Similarly, the second structure was created by cropping the bladder
normal structure from going into the PTV, with a 0.1 cm margin; this
structure was named Opti Bladder.
D. All treatment plans were optimized to the set prescription dose and referenced
specific OAR constraints.
1. All plans had Normal Tissue Objectives (NTO) set manually.
i. The priority was set to 150%, the distance from target border was
0.22 cm, the start dose was 104%, the end does was 60%, and fall-
off was set to 0.3 cm.
2. Automatic intermediate dose was used for each plan.
3. All plans were normalized to the PTV target volume so that 95% of the
PTV received 100% of the prescription dose.
4. Single energy plans were optimized to the full prescription dose, while the
two partial plans used to create the mixed energy plan sum were optimized
to their respective partial prescription doses.
5. Plans were optimized to meet OAR constraints as proposed by the
Radiation Therapy Oncology Group (RTOG).13

Plan Comparisons
A. The three treatment plan types created for each patient were compared.
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1. The three plan types included the 6 MV photon plan with full prescription
dose, the 10 MV photon plan with full prescription dose, and the mixed
energy plan sum created from the 6 MV and 10 MV plans with partial
prescription doses.
2. The comparisons were in terms of OAR sparing, monitor unit (MU) usage,
and PTV coverage
B. The OAR considered in comparing the 6 MV and 10 MV single energy plans with
the mixed energy plans were chosen based on RTOG standards.
1. The OAR included the bladder, bowel, and femoral heads.
2. Specific comparison points were included from RTOG 0529 normal tissue
tolerances.14
i) Include as Table 1 in first draft.
C. The MUs were compared between plan types.
1. The total MUs for each arc of each plan type were totaled and averaged
between patients.
D. The PTV was also compared between plan types in terms of uniformity and
coverage.
1. The PTV coverage was determined using the conformity index (CI).
2. The PTV uniformity was determined using the homogeneity index (HI).
IV. Results
A. The preliminary results show that OAR sparing did not benefit from a mixed
energy plan.
1. The 6 MV single plan produced the best sparing to the bladder.
2. The 10 MV single plan produced the best sparing to the bowel.
3. Both femurs were spared best by the 10 MV single plan.
B. The preliminary results show that the MUs were affected by the mixed energy
VMAT plan.
1. The number of MUs needed was lowest on average for the 10 MV plans,
but only by a small margin.
2. The mixed energy plans on average used significantly less MUs than the
single energy 6 MV plans.
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C. The preliminary results show mixed results when analyzing the PTV coverage.
1. The percentage of the PTV receiving 100% of the prescription dose was
larger for the mixed energy plan than the single energy plans.
2. The HI demonstrates limited variation between the three plans.
3. The CI was lower on average for the mixed energy plans than the single
energy plans, which were very similar.
V. Discussion
A. The results of this study were not consistent with the research conclusions
provided by Momin et al10 and Shyam Pokharel11.
1. This study on AC-LNI treatment using mixed energy VMAT planning did
not show that OAR sparing was increased by a mixed energy plan.
2. Unlike the two aforementioned studies, this research showed that PTV
coverage could improve by implementing a mixed energy VMAT plan.
3. This suggests that the benefits provided in using mixed energy VMAT
plans may depend on the range in depth of the PTV site being treated.
B. This study additionally investigated the number of MUs used for mixed energy
VMAT plans in comparison to single energy VMAT plans.
VI. Conclusion
A. Mixed energy plans in VMAT treatment of AC-LNI can affect PTV coverage and
OAR sparing.
1. PTV coverage is greater for mixed energy VMAT plans than for single
energy VMAT plans.
2. Conversely, the OAR sparing decreased for mixed energy VMAT plans
when compared to single energy VMAT plans.
3. This conclusion, which conflicts with studies produced by Momin et al10
and Shyam Pokharel11, may be a result of the method for normalizing the
10 MV and 6 MV partial plans before the two partial plans were summed.
B. This study was limited by the number of patients available for retrospective
treatment planning.
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1. Only twenty patients were able to be included in this study due to a lack
of patients previously treated with AC-LNI from the sites providing
patient CT images.
C. Further research into this topic could be done to advance the clinical
understanding of mixed energy VMAT treatments for AC-LNI.
1. This study focused on the primary treatment of a AC-LNI radiation
therapy prescription, which would typically include an additional boost
treatment.15
2. More research is needed to assess the effects of implementing mixed
energy VMAT planning with both the primary and boost treatments in
AC-LNI treatment.
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References

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