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Group 2 Outline

Tiffany Lin, Tenzin Yiga, Brandon Williamson

A Case Study Evaluating Bilateral Lung Dose for VMAT Treatment Planning Using a
Partial Sagittal Arc

I. Abstract
II. Introduction
A. PI: Details thoracic cancer including radiation pneumonitis and total lung volume
analyzation factors such as V20, V10, V5, and mean lung dose (MLD) (Reference:
Simone,1 Luna et al2)
B. PII: Introduce radiation therapy techniques such as three-dimensional conformal
radiation therapy (3D-CRT), intensity-modulated radiation therapy (IMRT), and
volumetric modulated arc therapy (VMAT) on lowering total lung volume factors
and dose to organs at risk (OAR) (Reference: Boyle et al,3 Li et al4)
C. PIII: Introduce the use of non-coplanar beams to increase target coverage while
reducing irradiated volume (Reference: Fitzgerald et al,5 Fitzgerald et al6)
D. PIV: Summarize introduction
1. Problem: 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.
2. Purpose: The purpose of this research is to compare the effects on 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.
3. Hypothesis: The hypothesis is that the 2 partial coplanar arcs and partial
sagittal arc plan will lower the V20, V10, V5, and MLD (H1, H2, H3, and
H4, respectively) when compared to the 3 partial coplanar arc plan. The
corresponding null hypothesis is that the 2 partial arc and partial sagittal
arc plan will have no effect on the V20, V10, V5, and MLD (H10, H20, H30,
and H40, respectively) when compared to the 3 partial coplanar arc plan.
III. Case Description
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a. Patient Selection
i. PI: Inclusion Criteria
1. Retrospective
2. External beam treating lung cancer without nodes
3. Medially located
4. Large tumor volume around 300 cm3
ii. PII-PIII: Simulation procedures
b. Target Delineation
i. PI: Targets (PTV) and OAR (Lung, Heart, Spine, Esophagus)
c. Treatment Planning
i. PI: Planning Details (Table 1)
1. Field arrangement and arc geometry
ii. PII: OAR Constraints from RTOG 0623 (Table 2)
1. Spinal Cord <45Gy
2. Total Lung-GTV V20<37%, mean <20Gy
3. Esophagus mean <34Gy
4. Heart D100 < 40Gy, D67< 45Gy, D33 <60Gy
d. Plan Analysis and Evaluation
i. PI: Lung Analysis Metrics (V20, V10, V5, and MLD)
1. 5 patients (test cases)
2. Mean PTV volume of 403.5 cm3
3. Figures 1 and 2
a. Example of tumor location and DVH for patient 1
4. Statistics: Two-tailed t-test
a. P<0.05 for null hypothesis to be rejected
ii. PII: V20 Results (Table 3)
1. Comparable between the coplanar and non-coplanar plans
a. P=0.76
i. Null hypothesis H10 failed to be rejected
iii. PIII: V10 Results (Table 3)
1. Lower values for 4 of the 5 test cases in the non-coplanar plans
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a. P = 0.06
i. Null hypothesis H20 failed to be rejected
iv. PIV: V5 Results (Table 3)
1. Comparable in 4 of the 5 test cases between the coplanar and non-
coplanar plans
a. P = 0.29
i. Null hypothesis H30 failed to be rejected
v. PV: MLD Results (Table 3)
1. Comparable in all test cases between the coplanar and non-
coplanar plans
a. P = 0.13
i. Null hypothesis H40 failed to be rejected
vi. PVI: Summary of Results
1. All metrics were not statistically significant
2. V10 most considerable decrease
a. P = 0.06
IV. Conclusion
a. PI: Summarize purpose of study
b. PII: Summarize results
c. PIII: Limitations/future research
i. Small sample size due to incomplete CT datasets
ii. All test patients were from the same clinic and same physician contours
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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
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Figures

Figure 1. Frontal view of patient 1 shows the location of the PTV (magenta) in relation to the
esophagus (cyan), heart (pink), and 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).
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Tables
Table 1. Arc geometry for the coplanar and non-coplanar plans shows the path of the gantry, the
collimator rotation, and couch rotation.
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. Dose limits serve as planning constraints for the organs at risk (OAR) in plan
evaluation.
Structures Constraints
Spinal Cord Maximum 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); Dose to 100% of heart volume (D100); Dose to 67% of heart volume (D67); Dose to 33% of
heart volume (D33); Volume of lung receiving 20 Gy (V20); Volume of lung receiving 5 Gy (V5); all constraints were from RTOG 0623, except
the V20 and V5 per physician specification
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Table 3. Measured lung metrics show a slight decrease to lung dose when using a non-coplanar
plan compared to the coplanar plan.
Patient Coplanar PTV Size Total Lung V20 Lung V10 Lung V5 Mean
vs. Non- (cm3) Lung- (%) (%) (%) Lung
Coplanar GTV Dose
Volume (MLD)
(cm3) (cGy)
1 Coplanar 510.39 2445.40 22.00 37.20 60.90 1402.30
1 Non- 510.39 2445.40 22.00 31.60 60.90 1355.00
Coplanar
2 Coplanar 388.02 3215.00 21.20 31.20 47.10 1257.60
2 Non- 388.02 3215.00 21.40 30.00 47.11 1267.30
Coplanar
3 Coplanar 401.25 2608.10 18.00 35.17 49.79 1112.00
3 Non- 401.25 2608.10 17.86 31.48 50.04 1065.40
Coplanar
4 Coplanar 290.82 3558.50 24.60 35.47 61.45 1283.70
4 Non- 290.82 3558.50 23.70 35.51 60.69 1275.80
Coplanar
5 Coplanar 426.90 3497.70 15.93 31.20 64.60 1091.10
5 Non- 426.90 3497.70 16.40 28.63 62.74 1077.90
Coplanar
mean Coplanar 403.48 3064.94 20.35 34.05 56.77 1229.34
mean Non- 403.48 3064.94 20.27 31.44 56.30 1208.28
Coplanar
* Volume of lung receiving 20 Gy (V20); Volume of lung receiving 10 Gy (V10); Volume of lung receiving 5 Gy (V5); Centigray (cGy)