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A dosimetric comparison of 3D DCAT vs. VMAT for palliative and early-stage liver lesions
Authors: Jina Lee, R.T.(T), Caitlyn Huelskamp, R.T.(T), Collin Nappi, R.T.(T), Nishele Lenards,
Ph.D., CMD, R.T.(R)(T), FAAMD, Ashley Hunzeker, M.S., CMD, Ashley Cetnar Ph.D., DABR
Medical Dosimetry Program at the University of Wisconsin – La Crosse

I. Abstract
Volumetric modulated arc therapy (VMAT) and 3D dynamic conformal arc therapy
(DCAT) are 2 methods proven useful for the clinical implementation of stereotactic body
radiation therapy (SBRT) for lung lesions however, similar comparisons of SBRT liver lesions
are lacking. The purpose of this study was to determine if the conformity of dose, irradiated
volume, and dose to organs at risk (OAR) are equivalent or improved with the use of DCAT as
an alternative treatment method when compared to standard VMAT for SBRT delivery of
palliative and early-stage liver lesions. Twenty patients with liver lesions sized 2.0-5.0 cm were
selected for this study. Plans were created with both DCAT and VMAT techniques for each
patient. Metrics evaluated included the mean heart, kidney, large bowel, small bowel, esophagus,
and stomach doses, the lung volume receiving 20 Gy (V20), the volume of the normal liver
receiving 15 Gy (V15), conformity index (CI), heterogeneity index (HI), and the irradiated
volume or volume receiving 25 Gy (V25). The P-values for the mean dose to kidneys, small
bowel, esophagus and the lung V20 were greater than 0.05, and no statistical difference could be
determined between DCAT and VMAT. The P-values for the mean heart, large bowel, stomach,
and liver V15 were less than 0.05, indicating statistical significance and superiority of VMAT for
minimizing dose to these organs, especially V15 of the liver. The DCAT technique produced CI
greater than 1.0 for all patients proving superior coverage, while standard VMAT produced
significantly improved V25 with P-values less than 0.0001, and consequently higher HI.

Keywords: VMAT, DCAT, liver cancer, SBRT, palliative care, metastatic disease

II. Introduction
a. PI: Prominence of liver cancer incidence statistics globally, VMAT is readily
chosen over 3D methods, especially for SBRT. There is a paucity in literature
regarding DCAT for liver SBRT. (Siegel et al1, Han et al2)
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b. PII: Research/Lit review on the pros (modulation and conformity) and cons
(interplay effect during breathing cycles, low dose spread) of VMAT (Afrin et al3,
Bae et al4, Tsai et al5, Lu et al6, Edvardsson et al7)
c. PIII: Advantages of DCAT highlighted by previous studies done comparing
VMAT and DCAT on lung, new research done comparing VMAT and DCAT for
liver SBRT, implications on insurance (Pokhrel et al8, Bokrantz et al9, Verma et
al10, Roach et al11)
d. PIV: Recent research done on DCAT vs VMAT on the liver: Benefits, outcomes,
and unexplored metrics including mean dose to nearby OAR, specifically V15 of
normal liver (Moon et al12, Thaper et al13)
e. PV: Summarize key points, mention rising cost of IMRT and how DCAT of the
liver is not extensively researched like for the lung (Piana et al14)
i. Problem: The problem is that there is a paucity of literature comparing
3D DCAT to VMAT for early-staged or small metastatic liver lesions
ii. Purpose: The purpose of this study is to determine if the conformity of
dose, irradiated volume, and dose to OAR are equivalent or improved with
the use of 3D DCAT as an alternative method of treatment when
compared to standard VMAT for SBRT treatment of liver lesions.
iii. Hypothesis: Researchers tested the hypotheses that 3D dynamic
conformal arc therapy for liver lesions will achieve a (H1A) mean heart,
(H2A) kidney, (H3A) large bowel, (H4A) small bowel, and (H5A) stomach,
(H6A) esophagus, ≤ to those created with VMAT; (H7A) V20 for the lungs
≤ to those created by VMAT; (H8A) V15 < 700 cc to the normal liver;
(H9A) conformity index ≥ 1; (H10A) Homogeneity index ≤ 2; and (H11A)
volume irradiated by 50% of the dose ≤ to that of VMAT.
III. Materials and Methods
a. Patient selection and setup
i. PI: Patient population
1. 20 early-stage or metastatic liver patients
2. Inclusion criteria (liver lesion >2 cm and <5 cm, adults aged 45-
85)
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3. Exclusion criteria (patients not initially planned with VMAT, liver

lesions)
ii. PII: Patient Setup
1. Civco board, Q-fix knee sponge, arm shuttle, full body vacuum
bag, compression belt
b. Contouring
i. PI: Planning objectives, target volumes, and critical structures partly
adopted from RTOG 1112 protocol (Dawson15)
c. Treatment Planning
i. PI: General planning details
1. Eclipse treatment planning system with AcurosXB 13.7
2. Varian TrueBeam linear accelerator with 10 MV FFF photons
3. VMAT plan utilizing 2-3 partial arcs, slight collimator rotations,
variable field sizes
4. DCAT plan utilizing 3 partial arcs (one 40-degree arc, 5-degree
gap, one 135-degree partial arc, 5-degree gap, another 40-degree
partial arc), slight collimator rotations, variable field sizes
a. Larger arc is weighted more heavily than the other two
smaller arcs
5. Normalized to 100% of prescription dose (50 Gy) covering 95% of
the treatment volume
6. SBRT parameters used for both techniques
d. PI: Plan Comparison
i. Compared coverage between VMAT and DCAT plans
ii. Compared OAR dose metrics between VMAT and DCAT plans (heart
mean dose, kidney mean dose, stomach mean dose, esophagus mean dose,
small bowel mean dose, large bowel mean dose, V20 of lungs, and V15 of
liver)
iii. Compared conformity index, homogeneity index, and V25 of the treatment
volume
e. Statistical Analysis (UW-La Crosse Stats Center)
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i. Wilcoxon Test
1. Mean Heart, Kidney, Large Bowel, Small bowel doses, V20 of
lungs
2. Significance level: P < 0.05 is statistically significant or different
ii. Paired t-test
1. V15 of the liver, mean dose to esophagus and stomach, CI, HI, V25
2. Significance level: P < 0.05 is statistically significant or different
IV. Results
a. PI: Mean dose to OAR: Evaluate mean dose difference of heart, kidneys, large
bowel, small bowel, stomach, esophagus (H1A-H6A); Refer to the average
difference and standard deviation of the mean dose to OAR produced by VMAT
vs DCAT (Table 1)
i. Evaluate mean dose of heart (H1A)
1. P value = 0.0046, Mean: -26.30
2. Fail to reject H10 that DCAT will not be able to produce a mean
heart dose ≤ to that of VMAT
3. Mean dose to heart statistically lower with VMAT
ii. Evaluate mean dose of kidneys (H2A)
1. P value = 0.0696, mean: -1.01
2. Reject null hypothesis H20 that DCAT will not be able to produce
a mean kidney dose ≤ to that of VMAT
3. DCAT is statistically effective in producing mean kidney dose ≤ to
that of VMAT
iii. Evaluate mean dose of large bowel (H3A)
1. P value = 0.0023, mean: -32.88
2. Fail to reject null hypothesis H30 that DCAT will not be able to
produce a mean bowel dose ≤ to that of VMAT
3. Mean large bowel dose statistically lower with VMAT
iv. Evaluate mean dose of small bowel (H4A)
1. P value = 0.3223, mean: -2.82
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2. Reject null H40 that DCAT will not be able to produce a mean
small bowel dose ≤ to that of VMAT
3. DCAT is statistically effective in producing mean small bowel
dose ≤ to that of VMAT
v. Evaluate mean dose of stomach (H5A)
1. P value = 0.0353, mean: -37.50
2. Fail to reject null H50 that DCAT will not be able to produce a
mean stomach dose ≤ to that of VMAT
3. Mean dose of stomach statistically lower with VMAT
vi. Evaluate mean dose of esophagus (H6A)
1. P value = 0.792, mean: -4.81
2. Reject null hypothesis H60 that DCAT will not be able to produce
a mean esophagus dose ≤ that that of VMAT
3. DCAT is statistically effective in producing mean kidney dose ≤ to
that of VMAT
b. PII: Evaluate critical metrics for liver SBRT plans that will determine safety of
the overall plan, and deliverability. (Table 2)
i. Evaluate V20 of the lungs (H7A)
1. P value = 0.2622, mean: -.06
2. Reject H70 that DCAT will not be able to produce V20 of lungs ≤ to
that of VMAT
3. DCAT is statistically effective in producing V20 of lungs ≤ to those
created by VMAT
ii. Compare V15 of the liver (H8A)
1. Indicate if V15 of liver is < 700 ccs for both plans
2. P value < 0.0001, mean: -61.73
3. Fail to reject null hypothesis H80 that DCAT will not be able to
produce V15 of liver ≤ to that of VAMT
4. VMAT produces significantly less V15 (cc’s) of the liver
iii. CI
1. P value <0.0001
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2. CI range:
a. VMAT: 0.95-1.11
b. DCAT: 1.09-1.28
3. CI for VMAT is statistically lower than that of DCA; DCAT
superior in achieving CI>1.
iv. HI
1. P value = 0.0479
2. HI range:
a. VMAT: 1.162-1.682
b. DCAT: 1.213-1.361
3. P value still < 0.05; HI for VMAT is statistically lower than that of
DCA
v. V25
1. P value <0.0001
2. Fail to reject H110 that DCAT will not achieve a volume irradiated
by the 50% isodose line ≤ to the volume achieved by VMAT
3. V25 statistically lower with VMAT than with DCA
V. Discussion
a. PI: Discuss average doses to OAR (H1A-H6A)
i. Indicate severity of difference (if statistically significant)
1. mean doses to heart, large bowel, stomach shown to be statistically
significant but maybe not clinically significant
ii. Indicate potential clinical side effects and recommended tolerances, and
clinical acceptability (Quantec16, Mobius Medical Systems17)
b. PII: Discuss critical metrics (V15 of liver, V20 of lung)
i. VMAT produced statistically lower values for V15 of the liver (Figure 1)
1. V15 < 700 for all patients but 2 when planned VMAT and DCAT.
2. One additional patient V15 > 700 for DCAT
3. Indicate potential side effects if over 700 cc (Koay et al18)
4. V20 of lung was not statistically different when produced by
VMAT vs DCAT
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c. PIII: Discuss CI, HI, and V25

i. DCAT better achieved CI >1
1. Ideal value = 1; better overall coverage of PTV with DCAT
2. Possible VMAT’s increased modulation of MLC leading to
tightening of 100% IDL
3. Implication of geometric miss, increased QA/immobilization
requirement for VMAT due to requiring more accurate delivery
ii. HI
1. Both plans were able to achieve HI <2
2. HI measures overall safety of SBRT plan, although ideal range can
vary depending on desire coverage
a. SBRT by nature will be less homogeneous due to hotter
center (Macià et al19)
b. However, HI<2 ensures that plan is not excessively hot
iii. V25
1. V50%/PTV volume important component to measure deviation of
conformality of Rx dose (RTOG 081320) based on PTV, expresses
intermediate dose spillage
2. Reference back to Pokhrel at al8 for lung and Moon et al12 for liver
and compare results for CI, HI, V25
3. Tighter 50% line may correspond with higher HI due to integral
low doses being condensed for VMAT plans (Figure 2&3)
VI. Conclusion
a. PI: Summarize the study, summarized hypothesis
i. Problem: The problem is that there is a paucity of literature comparing
3D DCAT to VMAT for early-staged or small metastatic liver lesions.
ii. Purpose: The purpose of this study is to determine if the conformity of
dose, irradiated volume, and dose to OAR are equivalent or improved with
the use of 3D DCAT as an alternative method of treatment when
compared to standard VMAT for SBRT treatment of liver lesions.
b. PII: Limitations and future research
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i. Limitations: single institution, small sample size (n=20), patients with

either early-stage or metastatic liver lesions
ii. Future research: Multiple institutions, increased sample size, various
tumor sizes/locations, other TPS algorithms besides Eclipse
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Figures

Figure 1. Dose volume histogram comparison for the V15 liver metric for VMAT and DCAT
plan for patient 16.

Figure 2. Isodose distribution showing the conformality around the PTV at isocenter for patient
19. Figure (A) shows the DCAT plan and Figure (B) shows the VMAT plan.
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Figure 3. Homogeneity index and maximum dose for Figure A showing the DCAT plan and
Figure B showing the VMAT plan.
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Tables
Table 1. Average mean difference of all VMAT and DCAT plans, standard deviation, and P-
value for heart, kidneys, large bowel, small bowel, stomach, esophagus, lungs, and liver.
Mean Difference Standard
OAR P-Value
(cGy) Deviation
Heart -26.30 48.24 0.0046*
Kidneys -1.01 7.50 0.0696
Large Bowel -32.88 59.15 0.0023*
Small Bowel -2.82 17.29 0.3223
Stomach -37.5 74.01 0.0353*
Esophagus -4.81 80.41 0.792
* = P-value of mean difference is statistically significant, VMAT < DCAT
VMAT = Volumetric modulated arc therapy; DCAT = Dynamic conformal arc therapy; OAR = Organs at Risk; cGy
= centigray.

Table 2. Average mean difference of all patient VMAT and DCAT plans, standard deviation,
and P-value for CI, HI, and V25 of the treatment volume.
Critical Metrics Mean Standard P-Value
Difference Deviation
V20 of Lungs -0.06 % 0.41 0.2622
V15 of Liver -61.73 cc 42.66 < 0.0001*
CI -0.18 0.06 < 0.0001*
HI 0.06 0.13 0.0479*
V25 of treatment volume -46.30 cc 31.09 < 0.0001*
* = P-value is statistically significant
VMAT = Volumetric modulated arc therapy; DCAT = Dynamic conformal arc therapy; V20 = volume receiving 20
Gray; V15 = volume receiving 15 Gray; CI = conformity index; HI = homogeneity index; V25 = total volume
receiving 25 Gray; cc = cubic centimeters.