1

Limiting Dose to Normal Lung Tissue for Volumetric Modulated Arc Therapy Medial
Lung Radiotherapy Treatments by Using a Partial Sagittal Arc: A Case Study

Authors: Tenzin Yiga, R.T.(T), Tiffany G. Lin, M.S., Brandon Williamson, R.T.(T), Nishele
Lenards, Ph.D., CMD, R.T.(R)(T), FAAMD, Matt Tobler, CMD, R.T.(T), Sabrina Zeiler, M.S.,
CMD, R.T.(T), Ashley Coffey, M.S., CMD, R.T.(T), Ashley Hunzeker, M.S., CMD

Medical Dosimetry Program at the University of Wisconsin - La Crosse

Introduction
Developing a radiation treatment plan requires finding a balance to ensure a tumor
volume receives adequate dose while nearby normal tissues are within safe dose limits. While
the primary goal is to treat the tumor, patients may develop side effects after completing a course
of treatment. For any thoracic radiotherapy treatment, radiation pneumonitis (RP) is a possible
acute dose-limiting toxicity. Radiation pneumonitis is an inflammation of healthy lung tissue due
to radiation treatment commonly observed 1-6 months after the completion of thoracic
radiation.1 To reduce the risk of patients developing RP, the normal bilateral lung volume
receiving dose should be limited when developing a treatment plan. The lung V20, V10, and V5
represent the percentages of bilateral lung volume which receive more than 20 Gy, 10 Gy, and 5
Gy, respectively. The mean lung dose (MLD) is the average absorbed dose in the bilateral lung
volume. Luna et al2 demonstrated that V20, V10, V5, and MLD are significant predictors for RP.
Therefore, treatment plans for thoracic radiation must be designed with an optimal planning
technique that minimizes lung V20, V10, V5, and MLD values to prevent possible injury to the
patient.
The most common planning techniques utilized in radiation therapy include 3D
conformal radiation therapy (3D-CRT), intensity-modulated radiation therapy (IMRT), and
volumetric modulated arc therapy (VMAT). With the advancement in technology for radiation
treatments, VMAT allows for the dose to be delivered continuously to the patient from angles
along the gantry arc path and offers increased isodose line conformity when compared to static
IMRT. In turn, IMRT offers improved conformality over the traditional conventional 3D-CRT.
When comparing IMRT and 3D-CRT techniques on locally advanced lung cancer, Boyle et al3
showed a statistically significant decrease in the V20 and MLD when using IMRT. However, the
increased conformality from the treatment techniques can also increase the volume of tissue that
 2

receives low dose radiation and affect the V5 value. Li et al4 compared the clinical effects of
IMRT, single full arc, single partial arc, or two partial arcs on the V5, V10, and V20 for centrally
located lung lesions that did not encompass the mediastinal lymphatic region. The researchers
revealed that the VMAT plans resulted in lower V5, V10, and V20 values compared to IMRT
plans for most cases.4 While planning goals can sometimes be met using 2 arcs, a third arc is
necessary to adequately meet dose requirements for the tumor volume and the nearby organs at
risk (OAR).
Lung tumors are typically treated with coplanar beams, but there are cases where
conformality could be improved with an added couch angle. Introducing different couch angles
in the treatment plan generates non-coplanar beams and creates more beam entry points to reach
the target volume that are not accessible for plans generated at a constant couch position.
Fitzgerald et al5 compared 3 different VMAT techniques for lung stereotactic ablative radiation
therapy, which included the use of a full arc, a partial arc, or 3 non-coplanar arcs. The non-
coplanar technique resulted in a better conformity index (CI) of the prescription dose, while the
planning target volume (PTV) coverage across all techniques was similar.5 Although Fitzgerald
et al5 demonstrated the benefits of non-coplanar arcs, there is a paucity of literature investigating
the effects of a partial sagittal arc on lower doses to normal lung tissue.
An investigation into the effects of including a sagittal arc technique was therefore
needed to evaluate the bilateral lung volume dose that can potentially reduce the risk of patients
developing RP. The problem is limiting dose to normal lung tissue and maintaining protocol
dose criteria when a third coplanar VMAT arc does not provide optimal medial lung tumor
coverage. The purpose of this research was to compare the effects on the bilateral lung V20, V10,
V5, and MLD values when medial lung tumors are treated with 3 partial coplanar arcs versus 2
partial coplanar arcs with a partial sagittal arc. The researchers hypothesized that the 2 partial
coplanar arcs and partial sagittal arc plan would lower the V20, V10, V5, and MLD (H1, H2, H3,
and H4, respectively) when compared to the 3 partial coplanar arc plan.
Case Description
Patient Selection
Patients in this study were selected in a retrospective manner. Each patient was diagnosed
with lung cancer without nodal involvement. Selected patients had bulky medial lesions of
approximately 300 cm3 or greater that were not suitable for stereotactic ablative treatment.
 3

Patients were simulated supine on a wing board with arms raised out of the treatment
field holding pegs. Each patient was given a head holder and knee roll for comfort. Three
permanent marks were given on the patient’s surface for setup and triangulation, 1 anterior and 2
on the sides. Radiopaque markers were placed on these marks for visualization during the scan.
Patients were scanned head first on a GE BrightSpeed Elite CT scanner. As per the clinic’s
protocol, a 3-phase breathing scan was performed for each patient to track tumor movement,
resulting in 3 separate scans for normal free-breathing, inhalation, and exhalation. All 3 scans
were obtained with a 2.5 mm slice thickness.
Target Delineation
Following the simulation scan, all target delineation and treatment planning was
performed using Eclipse version 13.6 treatment planning software. From registered images of the
3-phase breathing CT scans, the physician determined the gross tumor volume (GTV) and added
a 7 mm or 1 cm circular margin to establish the PTV, at the physician’s discretion. The OAR
were contoured by the medical dosimetrist and consisted of the bilateral lung, heart, esophagus,
and spinal cord (Figure 1).
Treatment Planning
To maintain consistency among patient plans, the same arc geometry, collimator rotation,
and couch rotations were used for each case. The coplanar arc plan contained 3 partial coplanar
arcs with the couch rotation set at 0°. The non-coplanar plan began with the same 2 partial
coplanar arcs with a partial sagittal arc as the third arc, as fully described in Table 1. In both
plans, the first arc started with the gantry in the posterior position at 181° and traveled clockwise
around the patient’s right side to a left anterior oblique (LAO) gantry position of 30°, with a
collimator angle set to 30° rotation. The second arc returned the gantry to the posterior position
at 181° in a counter-clockwise direction, with a complementary collimator rotation of 330°. For
the coplanar plan, the last arc followed the same path as the first arc, but with a 0° collimator
angle. In the non-coplanar plan, the third arc was set up as a partial sagittal arc, with a 90° couch
rotation and 0° collimator angle. The gantry traveled above the patient from 330° to 30°, passing
over the anterior side of the patient superiorly in a clockwise direction.
The treatment planning goals specified by the physician included minimizing doses to the
heart, esophagus, and normal lung tissue. All plans were normalized such that 100% of the
prescription dose covers 95% of the PTV volume. The desired dose to critical structures was not
 4

to exceed the guidelines from Radiation Therapy Oncology Group (RTOG) protocol 0623, given
a prescription dose of 60 Gy in 30 fractions. From the RTOG protocol, the spinal cord maximum
dose cannot exceed 45 Gy, and the esophagus mean dose cannot exceed 34 Gy. The dose to the
heart must be less than 60 Gy to one-third of the heart’s volume (D33 < 60 Gy), less than 45 Gy
to two-thirds of the heart’s volume (D67 < 45 Gy), and less than 40 Gy to the whole heart (D100 <
40 Gy). The RTOG protocol also sets limits on normal bilateral lung tissue (defined as total lung
volume minus the GTV) for MLD less than 20 Gy. The physician specified a lung V5 planning
constraint of less than 70% of the bilateral lung volume. The physician also requested a V20 with
a value less than 35% of the bilateral lung volume, which is consistent with the RTOG protocol
limit of 37%. No specific requirement for lung V10 was provided by the physician or from
RTOG, but this metric was included in the study as a significant predictor for RP.2 All plans
were optimized to the same criteria to meet the planning constraints. The summary of the dose-
volume constraints can be found in Table 2.
Plan Analysis and Evaluation
The final study consisted of 5 test patients who had medially located lesions in the right
lung. From the sample population, the mean PTV volume was 403.50 cm3, and the mean normal
lung volume was 3064.94 cm3. The V20, V10, and V5 metrics were measured in relative volumes,
since normal lung volumes differed between patients. All plans were prescribed to 60Gy,
therefore MLD was measured in absolute dose in centigray (cGy). Two plans were created for
each patient, a coplanar and a non-coplanar plan, using the previously described arc geometry.
All plans met the OAR constraints, as defined by RTOG 0623 and the physician. A comparison
dose volume histogram (DVH) for patient 1 is shown in Figure 2. A two-tailed t-test was used to
compare the V20, V10, V5, and MLD for the coplanar and non-coplanar plans. A level of
significance of P < 0.05 was used to determine if each null hypothesis could be rejected.
For the first hypothesis (H1), the V20 lung metric showed little or no change for all 5 test
cases between the coplanar and non-coplanar plans. As shown in Table 3, patient 1 had a V20
value of 22.00% for both plans. Patients 2 and 5 had lower V20 values from the coplanar plan,
while the non-coplanar plans for patients 3 and 4 had produced lower V20 values. With a P value
of 0.76 for the V20 lung metric, thus, the null hypothesis H10 failed to be rejected.
When comparing the differences for the V10 lung metric for the second hypothesis (H2),
the non-coplanar arc geometry showed lower values for 4 of the 5 test cases. From Table 3,
 5

patient 1 showed the most substantial difference in V10 values at 6% change, while patient 2
showed a 1.2% difference when using the non-coplanar plan. Patient 4 was the only case that had
a slightly higher V10 value of 35.47% for the coplanar plan when compared to 35.51% for the
non-coplanar plan. However, the P value for the V10 lung metric was 0.06; thus, the null
hypothesis H20 failed to be rejected.
The V5 lung metric, tested for the third hypothesis (H3), was comparable to the coplanar
plan in 4 of the 5 test cases. All values were within 1% of the other for these 4 cases (Table 3).
Patient 1 had a V5 value of 60.90% for both coplanar and non-coplanar plans. Patient 5 was the
only exception with a V5 value of 64.60% for the coplanar plan and 62.74% for the non-coplanar
plan. Patients 4 and 5 showed lower V5 values from the non-coplanar plan. Despite this result,
the P value for the V5 lung metric was 0.29; thus, the null hypothesis H30 failed to be rejected.
In comparing the MLD values for testing hypothesis H4, the non-coplanar plans
generated similar results for all test cases when compared to the coplanar plans. As shown in
Table 3, non-coplanar plans resulted in lower MLD values for 4 of the 5 patients. Although
patient 2 had a slightly lower MLD for the coplanar plan, measuring 1257.6 cGy (20.96%),
compared to the non-coplanar plan MLD of 1267.3 cGy (21.12%). The P value for the MLD
lung metric was 0.13; thus, the null hypothesis H40 failed to be rejected.
Despite lacking statistical significance, the results of this study demonstrated that the use
of a partial sagittal arc could be used to decrease the dose to normal lung tissue, depending on
the metric (V20, V10, V5, and MLD) evaluated. Although the V10 showed the most considerable
decrease when using the non-coplanar arc geometry, the P value of 0.06 was again not
statistically significant. The null hypothesis (H10, H20, H30, H40) failed to be rejected for the V20,
V10, V5, and MLD when using the two-tailed t-test.
Conclusion
Reducing all radiation dose to healthy lung tissue is an important goal in attempting to
prevent possible injury to the patient. Although this is not always avoidable, many methods can
be implemented in this pursuit. For this study, the researchers introduced non-coplanar beam
arrangements in VMAT plans by altering the couch angle to evaluate the V20, V10, V5, and MLD
of normal lung volumes for the treatment of large medially located lung tumors. Comparison
plans were created for each of the 5 patients selected for this study, a coplanar plan with 3 partial
 6

coplanar arc plan versus a non-coplanar plan with 2 partial coplanar arcs and a partial sagittal
arc.
Researchers in this study revealed that the use of a partial sagittal arc decreased V20, V10,
V5, and MLD values in some cases. However, the results of the study were not shown to be
statistically significant. Therefore, the researchers failed to reject the null hypotheses, revealing
that non-coplanar beam arrangements had little impact on the dose to normal lung tissue when
analyzing V20, V10, V5, and MLD. Final plan approvals are at the discretion of the physician, and
the additional use of couch rotations can result in minor changes in these metrics, but the dose
differences may not be worth the increased time the patient is on the table that would be
necessary to rotate the couch.
There were many limitations in this study as a result of the small sample population. All
5 patients from this study had tumors located in the right lung. Two patients with left lung
tumors were excluded from the study due to incomplete CT datasets that prevented the use of a
partial sagittal arc for targeting tumors in the superior aspect of the lung. Also, data was collected
from only one clinic, and the same radiation oncologist drew all tumor contours for this study,
which reduces the diversity of the sample group. In future studies, a larger patient population
across different clinics and physicians could possibly produce statistically significant results.
 7

References

1. Simone CB. Thoracic radiation normal tissue injury. Semin Radiat Oncol. 2017;27(4):370-
377. http://doi.org/10.1016/j.semradonc.2017.04.009
2. Luna JM, Chao H-H, Diffenderfer ES, et al. Predicting radiation pneumonitis in locally
advanced stage II–III non-small cell lung cancer using machine learning. Radiother Oncol.
2019;133:106-112. http://doi.org/10.1016/j.radonc.2019.01.003
3. Boyle J, Ackerson B, Gu L, Kelsey CR. Dosimetric advantages of intensity modulated
radiation therapy in locally advanced lung cancer. Adv Radiat Oncol. 2017;2(1):6–11.
http://doi.org/10.1016/j.adro.2016.12.006
4. Li Y, Wang J, Tan L, et al. Dosimetric comparison between IMRT and VMAT in irradiation
for peripheral and central lung cancer. Oncol Lett. 2018;15(3):3735-3745.
http://doi.org/10.3892/ol.2018.7732
5. Fitzgerald R, Owen R, Hargrave C, et al. A comparison of three different VMAT techniques
for the delivery of lung stereotactic ablative radiation therapy. J Med Radiat Sci.
2016;63(1):23-30. http://doi.org/10.1002/jmrs.156
 8

Figures

Figure 1. Frontal view of patient

atient 1 shows the location of the PTV (magenta) in relation to the
esophagus (cyan), heart (pink), and bil
bilateral normal lung tissue (yellow).

Figure 2. Dose volume histogram (DVH) comparison for the PTV (magenta), spinal cord (dark
green), esophagus (cyan), heart (pink), and bilateral normal lung tissue (yellow) are shown for
patient 1 for the coplanar plan (triangle markers) and non
non-coplanar
coplanar plan (square markers).
 9

Tables
Table 1. This table describes the arc geometry for the coplanar and non-coplanar plans.
Arc Number Gantry Angles Collimator Couch Rotation
Angles
Coplanar 1 181.0 CW 30.0 30° 0°
2 30.0 CCW 181.0 330° 0°
3 181.0 CW 30.0 0° 0°
Non-Coplanar 1 181.0 CW 30.0 30° 0°
2 30.0 CCW 181.0 330° 0°
3 330.0 CW 30.0 0° 90°
*Clockwise (CW); counter-clockwise (CCW)

Table 2. This table summarizes the constraints for OAR.

Structures Constraints
Spinal Cord Max Dose < 45 Gy
Esophagus Mean Dose < 34 Gy
Heart D100 < 40 Gy, D67 < 45 Gy, D33 < 60 Gy
Lung (Total Lung – GTV) V20 < 35%, V5 < 70%, Mean Dose < 20 Gy
*Organs at risk (OAR); gross tumor volume (GTV); all constraints were from RTOG 0623, except the V20 and V5 per physician specification

Table 3. This table displays the results for the coplanar and non-coplanar plans.
Patient Coplanar vs. PTV Size Total Lung- Lung Lung Lung Mean
Non-Coplanar (cm3) GTV Volume V20 V10 V5 Lung
(cm3) (%) (%) (%) Dose
(MLD)
(cGy)
1 Coplanar 510.39 2445.40 22.00 37.20 60.90 1402.30
1 Non-Coplanar 510.39 2445.40 22.00 31.60 60.90 1355.00
2 Coplanar 388.02 3215.00 21.20 31.20 47.10 1257.60
2 Non-Coplanar 388.02 3215.00 21.40 30.00 47.11 1267.30
3 Coplanar 401.25 2608.10 18.00 35.17 49.79 1112.00
3 Non-Coplanar 401.25 2608.10 17.86 31.48 50.04 1065.40
4 Coplanar 290.82 3558.50 24.60 35.47 61.45 1283.70
4 Non-Coplanar 290.82 3558.50 23.70 35.51 60.69 1275.80
5 Coplanar 426.90 3497.70 15.93 31.20 64.60 1091.10
5 Non-Coplanar 426.90 3497.70 16.40 28.63 62.74 1077.90
mean Coplanar 403.48 3064.94 20.35 34.05 56.77 1229.34
mean Non-Coplanar 403.48 3064.94 20.27 31.44 56.30 1208.28