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Volumetric modulated arc therapy for large non-spherical anorectal disease: the
implications to organs-at-risk with static jaw (SJ) versus jaw tracking (JT) planning
techniques in Eclipse

I. Abstract
II. Introduction
A. PI: Toxicities to OAR during anorectal irradiation (Reference: Nicholas et al,1
Kachnic et al,2 Pawlowski et al,3)
B. PII: MLC interleaf transmission using static jaw IMRT (Reference: Mohan et al,4)
C. PIII: Research indicating benefits of jaw tracking (Reference: Wu et al,5 Yao et
al,6 Feng et al,7)
D. PIV: Summarize introduction points
1. Problem: Interleaf transmission from SJ techniques could deliver
unnecessary dose to OAR when anorectal patients are treated with VMAT.
2. Purpose: The purpose of this study was to determine whether the use of
JT would improve OAR sparing in large non-spherical anorectal VMAT
plans.
3. Hypotheses: Researchers tested the hypotheses that using JT for anorectal
VMAT plans will reduce the mean dose to the bladder (H1), iliac crests
(H2), and bowel (H3), in addition to reducing the maximum dose to the
bowel (H4). Researchers tested the null hypotheses that using JT for
anorectal VMAT plans will not reduce mean dose to the bladder (H10),
iliac crests (H20), and bowel (H30), and will not reduce the maximum dose
to the bowel (H40).
III. Materials and Methods
A. Patient selection and setup
1. PI: Patient population
a. 10 anorectal patients with nodal risk (7 anal and 3 rectal)
b. Inclusion criteria (pelvic lymph nodes with or without inguinal
nodes, 45 Gy in 30 fractions with SIB to 54 Gy)
c. Exclusion criteria (non-anorectal disease, no lymph node risk)
2. PII: CT simulation and patient immobilization
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B. Contouring
1. PI: Target delineation in MIM software with use of PET or MRI (GTV,
CTV, PTV) (Reference: Myerson et al,8)
2. PII: OAR delineation in MIM software (bladder, iliac crests, small bowel,
large bowel, femoral heads, external genitalia) (Reference: Kachnic et al,2)
C. Treatment Planning
1. PI: General planning details
a. Eclipse treatment planning system with AAA algorithm
b. Varian TrueBeam linear accelerator with 10 MV photons
c. 4 full arcs, collimator rotations, various field sizes
2. PII: Static jaw and jaw tracking planning procedures
a. Jaw tracking plan optimization according to RTOG 0529
constraints (Reference: Kachnic et al,2)
b. Static jaw plan copied from JT plan and re-optimized (References:
Park et al,9 Mani et al,10)
c. Normalization of 54 Gy to 95% of PTV5400
D. PI: Plan Comparison
1. Evaluated coverage of PTV4500 at 45 Gy and PTV5400 at 54 Gy
2. Evaluated OAR metrics (bladder mean dose, iliac crest mean dose, bowel
mean dose, bowel maximum dose)
E. PI: Statistical Analysis
1. One-sided Wilcoxon signed rank test for plan comparison
2. Benjamini-Hochberg adjustment applied to control type 1 errors
(Reference: Benjamini and Hochberg11)
3. R statistical analysis due to small sample and 1 outlier
4. P < 0.05 is statistically significant
IV. Results
A. PI: Jaw tracking and target coverage
1. SJ coverage of PTV4500 and PTV5400
2. JT coverage of PTV4500 and PTV5400
B. PII: Jaw tracking and bladder mean dose (H1A)
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1. Population results for bladder mean dose (Table 1)

2. WSR difference in bladder mean dose Padj = 0.056 (P < .05 statistically
significant) (Figure 1; Table 2)
3. Do notFail to reject null hypothesis (H10)
C. PIII: Jaw tracking and iliac crest mean dose (H2A)
1. Population results for iliac crest mean dose (Table 1)
2. WSR difference in iliac crest mean dose Padj = 0.004 (P < .05 statistically
significant) (Figure 1; Table 2)
3. Reject null hypothesis (H20)
D. PIV: Jaw tracking and bowel mean dose (H3A)
1. Population results for iliac crest mean dose (Table 1)
2. WSR difference in bowel mean dose Padj = 0.004 (P < .05 statistically
significant) (Figure 1; Table 2)
3. Reject null hypothesis (H30)
E. PV: Jaw tracking and bowel maximum dose (H4A)
1. Population results for bowel maximum dose (Table 1)
2. WSR difference in bowel maximum dose Padj = 0.278 (P < .05 statistically
significant) (Figure 1; Table 2)
3. Do notFail to reject null hypothesis (H40)
V. Discussion
A. PII: Summarize bladder mean dose between SJ and JT (Reference: Feng et al,7)
1. Effect of the one outlier on approaching statistical significance
2. Outlier target volume was smaller and more spherical (References: Wu et
al,5 Yao et al,6 Feng et al,7)
B. PIII: Summarize iliac crest mean dose between SJ and JT (Reference: Wu et al,5)
C. PIV: Summarize bowel mean dose and bowel maximum dose between SJ and JT
(References: Wu et al,5 Feng et al,7)
D. PV: Summarize all results
VI. Conclusion
A. PI: Summarize the study
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1. Problem: Interleaf transmission from SJ techniques could deliver

unnecessary dose to OAR when anorectal patients are treated with VMAT.
2. Purpose: The purpose of this study was to determine whether the use of
JT would improve OAR sparing in large non-spherical anorectal VMAT
plans.
B. PII: Limitations and future research
1. Limitations: Limited sample size (n=10) at single institution, patients with
and without inguinal nodal volumes
2. Future research: Multiple institutions and larger sample size, other TPS,
evaluate dose to genitalia for anorectal patients
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References

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