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Physical ring versus NTO dose fall-off structures in VMAT prostate plans: a comparison of
integral dose while maintaining OAR constraints and PTV coverage
I. Abstract
II. Introduction
A. PI: Inverse planning (IMRT, VMAT): advantages, but concerns with integral
dose, particularly in prostate (Reference: Teoh et al,1 Buwenge et al,2 Piotrowski
et al,3 Joseph et al4)
B. PII: Introduce concept and purpose of dose gradient; state that integral dose
affected by dose fall-off; introduce physical ring and NTO as dose fall-off
techniques; provide description of physical ring and NTO dose fall-off techniques
; state that is unknown if dose fall-off technique leads to a superior plan (lower
integral dose though maintain dose to OAR and PTV coverage) (Reference: Xia et
al,5 Narayanasamy et al,6 Bell et al7)
C. PIII: Findings and conclusions of other researchers who compared various dose
fall-off structures; state that not evaluated comparing NTO and ring with VMAT
plans in prostate cancer (Reference: Bell et al,7 Ehlert Tvile8)
D. PIV: Dose fall-off evaluation in the prostate PTV: state commonality of prostate
cancer, state that PTV well-located for dose fall-off evaluation, provide physical
ring characteristics from a previous VMAT prostate cancer study (Reference:
Tran et al,9 Daoud et al10)
E. PV: Summarize introduction points
1. Problem: The problem is the integral pelvis radiation dose when treating
low risk prostate patients to curative doses with VMAT.
2. Purpose: The purpose of this study is to compare the effects of 2 common
dose fall-off approaches in low risk curative prostate VMAT plans, a
physical ring structure or the automatic NTO feature (Eclipse), to determine
which technique lowers integral dose while maintaining dose constraints to
OAR and PTV coverage.
3. Hypotheses: The first research hypothesis (H1A) is that the NTO dose fall-
off approach will lower mean normal tissue integral dose as compared to the
physical ring while maintaining OAR constraints and PTV coverage. The
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first null hypothesis (H10) is that use of the NTO dose fall-off approach will
not lower mean normal tissue integral dose as compared to the physical ring
while maintaining dose constraints to OAR and PTV coverage.
The second research hypothesis (H2A) is that the NTO dose fall-off approach
will lower maximum normal tissue integral dose as compared to the physical
ring while maintaining OAR constraints and PTV coverage. The second null
hypothesis (H20) is that use of the NTO dose fall-off approach will not lower
the maximum normal tissue integral dose as compared to the physical ring
while maintaining dose constraints to OAR and PTV coverage.
III. Materials and Methods
A. Patient selection and setup
1. PI: Patient population
a. 15 patients
b. Inclusion criteria (low risk classification per National Comprehensive
Cancer Network guidelines, 79.2 Gy in 44 fractions)
c. Exclusion criteria (no lymph nodes, no boosts)
2. PII: Simulation procedures
B. Contours
1. PI: Targets (CTV, PTV)
2. PII: (Body – (PTV+ring)), OAR (bladder, rectum, left femoral head, right
femoral head) (Reference: Male RTOG Normal Pelvis Atlas 11)
C. Treatment Planning
1. PI: Planning details
a. Eclipse v. 15.6, AAA algorithm, TrueBeam accelerator
b. 6 MV, VMAT, two full arcs, collimator rotations of 15˚ and 345˚
2. PII: Planning procedures
a. Physical ring (Figure 1) (Reference: Daoud et al10)
b. Automatic NTO (Eclipse v. 15.6)
3. PIII: Optimization
a. Dose objectives (identical across plans)
b. Dose priorities (identical across plans)
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c. Plan normalization (all plans - 100% of dose covers 95% of PTV)

D. Plan Comparison
1. PI: Evaluated metrics
a. Mean and maximum dose for each: (Body – (PTV+ring)), bladder,
rectum, left femoral head, right femoral head
b. Maximum dose PTV
E. PI: Statistical Analysis
1. Benjamini and Hochberg adjustment (Reference: Benjamini et al12) for false
discovery rate, Shapiro-Wilk normality test (deemed differences to be
acceptable for use of paired t-tests)
2. Paired t-tests were performed to compare the population mean dose for the
NTO and physical ring planning techniques
3. P < 0.05: considered statistically significant
4. All statistical analyses performed using R (Reference: R Core Team13)
IV. Results
A. PI: Ring vs. NTO and mean integral dose (H1)
1. Paired t-test results for mean integral dose. NTO less than Ring
2. Difference P < 0.0005 (Statistically significant) (Table 2, Figure 2)
3. Mean and maximum rectum dose, mean and maximum bladder dose, mean
and maximum left femoral head dose, mean and maximum right femoral
head dose, and maximum PTV dose were similar between the 2 plans
4. PTV dose normalized: 100% of PTV received 95% of dose
5. Mean integral dose while maintaining OAR constraints and PTV coverage =
reject null hypothesis
B. PII: Ring vs. NTO and maximum integral dose (H2)
1. Paired t-test results for maximum integral dose
2. Difference P < 0.618 (Statistically insignificant) (Table 2, Figure 2)
3. Mean and maximum rectum dose, mean and maximum bladder dose, mean
and maximum left femoral head dose, mean and maximum right femoral
head dose, and maximum PTV dose were similar between the 2 plans
4. PTV dose normalized: 100% of PTV received 95% of dose
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5. Maximum integral dose while maintaining OAR constraints and PTV

coverage = fail to reject null hypothesis
V. Discussion
A. PI: Summarize mean integral dose results comparing ring to NTO
1. Reference Table 2
B. PII: Summarize maximum integral dose results comparing ring to NTO
1. Reference Table 2
C. PIII: Summarize all results in study (Reference: Piotrowski et al,3 Joseph et al4)
VI. Conclusion
A. PI: Summarize the study
1. Problem: The problem is the integral pelvis radiation dose when treating
low risk prostate patients to curative doses with VMAT.
2. Purpose: The purpose of this study is to compare the effects of 2 common
dose fall-off approaches in low risk curative prostate VMAT plans, a
physical ring structure or the automatic NTO feature (Eclipse), to determine
which technique lowers integral dose while maintaining dose constraints to
OAR and PTV coverage.
B. PII: Limitations/future research
1. Limitations: only 15 patients studied, all patients from 1 site, only Eclipse
version 15.6 and 1 algorithm used
2. Future research: combine ring and automatic NTO, different ring
characteristics, use different TPS and algorithms, apply study to patients
with nodal involvement or different anatomical locations
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