University of Experimental Technological Research YACHAY TECH

Jonathan Patricio Recalde Moreno

Biomedical devices

A treatment planning comparison between modulated tri-cobalt-60 teletherapy and

linear accelerator–based stereotactic body radiotherapy for central early-stage non-small
cell lung cancer
Introduction
High-dose stereotactic body radiation therapy (SBRT) is increasingly used as an
effective local alternative therapy to surgery in the treatment of early-stage non-small cell
lung cancer (NSCLC). The size of the gross tumor volume (GTV) can range from 0.2% to
22.3% and move a Hausdorff distance (a measure of distance between 2 subsets of space,
here used to represent maximum tumor displacement) from 3.9 to 17.6 mm during the
breathing. This significant variability is further complicated by irregular breathing rates,
heart movement, and elliptical movement patterns.
The GTV expands to a planning target volume (PTV), resulting in a larger treatment
volume, it was concluded that the size of the GTV was a significant predictor of high-grade
toxicity, with tumors > 10 ml in volume with an eightfold increased risk of high-grade
toxicity compared to smaller tumors.
The ViewRay cobalt-60 (60Co) system presents the opportunity for continuous real-
time MRI guidance during radiotherapy delivery. Improved soft tissue resolution of MRI
can improve treatment target coverage while optimizing managing respiratory movement
and reducing normal tissue doses. The use of 60Co sources instead of a linear accelerator
(LINAC) avoids radio frequency interference with a magnetic field. The ViewRay system
employs 3 60Co sources arranged at 1201 on a single rotating gantry to maximize treatment
efficiency through simultaneous radiation at multiple beam angles while minimizing
parallel beam interference.
Methods and materials
Patient characteristics
Among the patients, 12 were men and eight women, with a mean age of 69 years
(range: 45 to 90 years). The average PTV was 48.3 cc (range: 12.1 to 139.4 cc). We define
large tumors as those with a maximum tumor extension > 3 cm, and centrally located lung
NSCLC as those within 2 cm of the superior bronchial tree or that touch central critical
structures, including major vessels and organs, including the heart, esophagus, upper
bronchus, tree, pulmonary artery, aorta, and superior vena cava. The locations of the tumors
in this patient population were posterior right upper lobe (n = 2), anterior right middle lobe
(n = 2), anterior right lower lobe (n = 2), anterior left upper lobe (n = 2), posterior left
superior lobe, lobe (n = 6) and posterior left inferior lobe (n = 6). Various adjoining tumors
≥ 1 critical structure [ie esophagus (n = 1), bronchi (n = 8), pulmonary artery (n = 2),
proximal bronchi (n = 5), heart (n = 4), aorta (n = 6), and superior vena cava (n = 1)].
Treatment planning
Clinical treatment plans were designed using the iPlan TPS using a single isocenter
and intensity modulated non-coplanar multiple field radiotherapy treatment fields or
coplanar dynamic conformal arch treatments. Unlike conventional LINACs that have a
single source, the ViewRay system defines the group portal angle as the angle that source 1
forms to the ViewRay coordinate system.
Blind physician plan reviews
The individual comparisons between the dosimetric parameters were made
accordingly with a p < 0.05 as the threshold of statistical significance.
Results
A representative case of LINAC and tri-60Co SBRT treatment plans is shown in
Fig. A. A PTV V100 ranging from 90% to 99% was achieved for clinical plans with a
balance between target coverage and preservation of normal tissue. The ViewRay plan was
standardized to provide the same PTV coverage as the corresponding clinical plan.
There were no statistically significant differences between the tri-60Co SBRT plans
and the LINAC plans in V35 and V40 (volume receiving 35 or 40 Gy) for the bronchus,
major vessels, and heart, V20 for normal lung, and V15 for medulla. spinal. The conformity
index of the target dose was similar between both planning systems. The mean Dmin and
Dmax (minimum and maximum dose) for the PTV were, respectively, 36.7 ± 10.6 Gy and
62.1 ± 2.6 Gy for the LINAC plans vs. 43.8 ± 2.8 Gy (p = 0.0073) and 63.1 ± 4.6 Gy (p =
0.43) for tri-60Co SBRT plans.
On average, an average of 97.4% of the dosimetric parameters per patient were
within the MD Anderson restrictions, compared to an average of 98.8% for the LINAC
plans (p = 0.056). For the LINAC plans, 1 patient had V40 and V35 for the main vessels,
respectively, of 18.9 and 26.7 cc, 1 patient had V40 for the main vessels of 1.4 cc, and 1
patient had a V35 for the main vessel. 4.4 cc esophagus. In a blinded review by 4 radiation
oncologists, an average of 90% of SBRT tri-60Co plans were considered clinically
acceptable compared to 100% of corresponding LINAC-based SBRT plans (p = 0.17).
Discussion
In a cohort of patients with central lung tumors previously treated with LINAC-
based SBRT, we demonstrated that an average of 97.4% of the dosimetric constraints met
the MD Anderson constraints for plans generated with the tri-60Co system, compared to the
98.8% for the LINAC-based plans The compliance of the PTV prescription dose measured
by R100 and the hot spots (Dmax) were similar between both systems. Radiation
oncologists also blindly reviewed the plans and assessed the feasibility of clinical delivery
to find that 90% of SBRT tri-60Co plans were adequate for treatment compared to 100% of
LINAC-based SBRT plans.
Due to concern about severe toxicity, the optimal SBRT dose regimen for central
lung tumors remains under investigation. We have adopted the MD Anderson 50 Gy
regimen in 4 fractions, while others have reported a variety of dosage regimens with
different clinical outcomes. Our results showed that, in most cases, the tri-60Co ViewRay
system provided clinically acceptable treatment plans.
Conclusions
SBRT planning using the tri-60Co system with embedded MRI is feasible and
achieves clinically acceptable plans for the majority of tested cases, with an adequate
compliance target dose and dosimetry of organs at risk compared to LINAC-based SBRT
planning. The added benefit of real-time MRI-guided therapy can further optimize tumor
targeting while improving the preservation of normal tissue, ensuring further investigation
in a potential clinical feasibility trial.