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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
A. PI: Overview of study
1. Integral pelvic radiation dose, which is affected by dose fall-off, is a concern
when treating low risk prostate patients to curative doses with VMAT
2. Purpose of study
3. Fifteen low-risk prostate patients were selected for this retrospective study
and were planned using VMAT with a physical ring and then the automatic
NTO
4. Plans were compared by evaluating integral dose, mean and maximum dose
to OAR, and maximum dose to PTV
5. Paired t-tests were used for statistical evaluation
6. Summarize findings: NTO showed statistically significant lower mean
integral dose (P < 0.0005), and no statistically significant difference in
maximum integral dose (P < 0.618). Maximum PTV dose, and the mean and
maximum doses to the OAR, were similar between the 2 planning
techniques. PTV coverage was normalized identically for all plans.
7. Conclusion of study
B. Keywords: integral dose, dose fall-off, normal tissue objective (NTO), physical
ring, volumetric modulated arc therapy (VMAT), prostate
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)
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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
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
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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)
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
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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
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
1. Current research indicated that for low risk curative prostate VMAT plans,
the automatic NTO planning technique was superior to the physical ring
technique in reducing mean integral dose
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2. NTO plans were superior to non-NTO plans in plan outcome in a lung

stereotactic body radiation therapy study, but study did not compare NTO to
a physical ring structure or evaluate integral dose (Reference: Bell et al7)
3. Ring vs. NTO gave mixed results in SRS, and authors recommended that
manual optimization technique with or without the ring structure is best, but
authors’ recommendation was specific to SRS and study did not evaluate
integral dose (Reference: Ehlert Tvile8)
4. Previous studies comparing fall-off structures did not have enough similar
features to the current research to allow insightful comparison
5. High integral dose has been demonstrated to selectively cause cellular
mutation, a potential mechanism for secondary malignancies in prostate
cancer patients; state that higher whole pelvic integral dose in this patient
population is associated with worse functional outcomes (Reference:
Piotrowski et al,3 Joseph et al4)
6. State that current research indicated that the automatic NTO technique could
be used instead of a physical ring to lower mean integral dose in low risk
prostate patients treated with curative doses using VMAT
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
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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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