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A comparison of volumetric modulated arc radiotherapy techniques to evaluate left

anterior descending artery dose sparing in left non-small cell lung tumor patients
Bryn Dahms, BS; Jessalyn Mitchem, BS, RT(T); Nishele Lenards, PhD, CMD, RT(R)(T),
FAAMD; Ashley Hunzeker, MS, CMD; Ashley Cetnar, MS, CMD
Medical Dosimetry Program at the University of Wisconsin – La Crosse
I. Abstract
II. Introduction
A. PI: Influence of increased screening and treatment techniques on survival in
patients diagnosed with NSCLC (References: Siegel et al, 1 Ganti et al,2
Howlander et al3)
B. PII: Introduction to volumetric modulated arc therapy
C. PIII: Effects of radiation exposure to the left anterior descending artery
(Reference: Atkins et al,4 McKenzie et al,5 Reshko et al,6 Atkins et al,7 Yegya-
Raman et al,8 Atkins et al9)
D. PIV: Summarize introduction points (References: Howlander et al, 3 Yegya-Raman
et al8)
1. Problem: The problem is that there is an increased risk for major
adverse cardiac events and coronary heart disease for medial, left-
sided upper lobe lung VMAT patients when the volume of the LAD
receiving 15 Gy exceeds 10%.
2. Purpose: The purpose of this study was to compare dose to the LAD
in VMAT plans optimized with and without an LAD planning organ at
risk volume (PRV) in medial, left-sided, upper lobe non-small cell
lung cancer patients to evaluate dose sparing of the LAD while
maintaining 95% coverage of the PTV with prescribed dose.
3. Hypothesis: Researchers tested the hypothesis that VMAT plans
optimized with an LAD PRV will reduce the LAD V15 Gy dose while
maintaining 95% coverage of the PTV with prescribed dose (H10).
III. Materials and Methods
A. Patient Selection and Setup
1. PI: Patient Population
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a. 20 patients
b. Inclusion criteria: left lung, upper lobe, medially located tumors,
initially treated with VMAT, previously received dose to the
LAD
2. PII: Simulation (4D)
B. Contours
1. PI: Target volumes (GTV, ITV, PTV)
2. PII: OAR (heart and LAD)
C. Treatment Planning
1. PI: Equipment used (Eclipse TPS Version 15 and Varian TrueBeam
Linear Accelerators)
2. PII: Treatment Planning Technical Factors
a. Beam energy
b. Number of arcs
c. Collimator rotation
D. Plan Comparison
1. PI: Evaluation of planning metrics (Davey et al 10)
a. Volume of the LAD receiving greater than or equal 15 Gy
b. Volume of the PTV receiving greater than or equal to 60 Gy
c. OAR Constraints (Table 1)
E. Statistical Analysis
1. PI: Shapiro-Wilk test for normality
a. p ≤ 0.05 is significant
b. Data are not normally distributed, we will use a Wilcoxon Signed
Rank test (p ≤ 0.05)
2. Wilcoxon Signed-Rank Test with continuity correction
a. Conducted for LAD metric
b. p ≤ 0.05 is significant
IV. Results
A. PI: PTV Dose
1. Plan normalization consistency between treated and research plans
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2. Differences in PTV coverage between treated and research plans

B. PII: LAD Dose
1. Difference = (Treatment Plan LAD V15 Gy metric) – (Research Plan
LAD V15 Gy metric)
2. V15 coverage of the LAD
a. Range of V15 Gy dose to the LAD in treated plans
b. Range of V15 Gy dose to the LAD in research plans
c. Range of observed change in the LAD V15 Gy metric between
treated and research plans
d. Reject H0: There is statistically significant evidence to suggests
that there is a difference in V15 Gy for the LAD between initial
and research plans
i. 𝛼 = 0.05 > 𝑝 = 0.000143
ii. 𝐶𝐼: (3.541, 11.184)
C. OAR Dose
1. PI: Failure to meet the 300 cGy difference threshold in for dose-type
constraints.
2. PII: Failure to meet the 5% difference threshold for volume-type dose
constraints.
V. Discussion
A. PI: Summarize PTV Dose (References: Davey et al10)
1. Adequate PTV dose was generally prioritized over sparing of OAR
2. Inadequate dose to the PTV may increase the risk of disease recurrence
B. PII: Summarize LAD Results (References: Atkins et al,4 McKenzie et al,5 Yegya-
Raman et al,8 Atkins et al9)
1. Dose to the LAD was significantly lower in plans that were optimized
with LAD constraints in mind
2. Not all plans that demonstrated a reduction in LAD dose met the V 15 Gy
< 10% constraint metric
C. PIII: Summarize OAR dose constraint variations between treated and research
plans
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1. Dose to OAR was monitored but not statistically evaluated

2. 4/7 OAR dose variations that failed to meet the difference threshold
occurred in Patient A
3. Most commonly failed metric was the V5 Gy < 60-65% for the Total
Lung minus ITV metric
D. PIV: Summarize all results
VI. Conclusion
A. PI: Summary of the Study
1. Problem: The problem is that there is an increased risk for major
adverse cardiac events and coronary heart disease for medial, left-sided
upper lobe lung VMAT patients when the volume of the LAD receiving
15 Gy exceeds 10%.
2. Purpose: The purpose of this study was to compare dose to the LAD in
VMAT plans optimized with and without an LAD planning organ at risk
volume (PRV) in medial, left-sided, upper lobe non-small cell lung
cancer patients to evaluate dose sparing of the LAD while maintaining
95% coverage of the PTV with prescribed dose.
3. Hypothesis: Researchers tested the hypothesis that VMAT plans
optimized with an LAD PRV will reduce the LAD V15 Gy dose while
maintaining 95% coverage of the PTV with prescribed dose (H10).
B. PII: Study Limitations and Future Research
1. Limitations:
a. Single institution study, limited population size
b. Dose to the LAD, and the ability to spare such was greatly
influenced by the location of the tumor
2. Future Research
a. Analysis of the variations in dose to OAR in plans optimized with
and without LAD constraints
b. Variations between LAD dose in plans that are initially optimized
with LAD constraints versus those that are optimized retroactively
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(ie adjusting LAD dose constraints and priorities in MR4 or

intermediate dose)
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References
1. Siegel RL, Miller KD, Wagle NS, Jemal A. Cancer statistics, 2023. CA Cancer J Clin.
2023;73(1):17-48. https://doi.org/10.3322/caac.21763
2. Ganti AK, Klein AB, Cotarla I, Seal B, Chou E. Update of incidence, prevalence, survival,
and initial treatment in patients with non–small cell lung cancer in the US. JAMA Oncol.
2021;7(12):1824-1832. https://doi.org10.1001/jamaoncol.2021.4932
3. Howlader N, Forjaz G, Mooradian MJ, et al. The effect of advances in lung-cancer treatment
on population mortality. N Engl J Med. 2020;383(7):640-649.
https://doi.org/10.1056/NEJMoa1916623
4. Atkins KM, Chaunzwa TL, Lamba N, et al. Association of left anterior descending coronary
artery radiation dose with major adverse cardiac events and mortality in patients with non–
small cell lung cancer. JAMA Oncol. 2021;7(2):206-219.
https://doi.org/10.1001/jamaoncol.2020.6332
5. McKenzie E, Zhang S, Zakariaee R, et al. Left anterior descending coronary artery radiation
dose association with all-cause mortality in NRG oncology trial RTOG 0617. Int J Radiat
Oncol Biol Phys. 2023;115(5):1138-1143. https://doi.org/10.1016/j.ijrobp.2022.11.033
6. Reshko LB, Kalman NS, Hugo GD, Weiss E. Cardiac radiation dose distribution, cardiac
events and mortality in early-stage lung cancer treated with stereotactic body radiation
therapy (SBRT). J Thorac Dis. 2018;10(4):2346-2356. https://doi.org/10.21037/jtd.201
7. Atkins KM, Bhupendra R, Tafadzwa CL, et al. Cardiac radiation dose, cardiac disease, and
mortality in patients with lung cancer. J Am Coll Cardiol. 2019;73(23):2976-2978.
https://doi.org/10.1016/j.jacc.2019.03.500
8. Yegya-Raman N, Wang, K, Kin S, et al. Dosimetric Predictors of symptomatic cardiac events
after conventional-dose chemoradiation therapy for inoperable NSCLC. J Thorac Oncol.
2018;13(10):1508-1518. https://doi.org/10.1016/j.jtho.2018.05.028
9. Atkins KM, Bitterman DS, Chaunzwa TL, et al. Mean heart dose is an inadequate surrogate
for left anterior descending coronary artery dose and the risk of major adverse cardiac events
in lung cancer radiation therapy. Int J Radiat Oncol Biol Phys. 2021;110(5):1473-1479.
https://doi.org/10.1016/j.ijrobp.2021.03.005
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10. Davey A, Thor M, van Herk M, et al. Predicting cancer relapse following lung stereotactic
radiotherapy: an external validation study using real-world evidence. Front Oncol.
2023;13:1156389. https://doi.org/10.3389/fonc.2023.1156389
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Tables
Table 1. Dose constraints for organs at risk for NSCLC patients with tumors located medially in
the upper lobe of the left lung.
Organ Constraint
Body Max < 115%
LAD V15 Gy < 10%
Spinal Canal Max < 50 Gy
Spinal Canal D0.03cc < 45 Gy
Total Lung minus ITV V5 Gy < 60-65%
Total Lung minus ITV V20 Gy < 35%
Total Lung minus ITV Mean < 20 Gy
Esophagus Mean < 34 Gy
Esophagus V35 Gy < 50%
Esophagus V60 Gy < 17%
Heart Max < 70 Gy
Heart Mean < 20 Gy
Heart V45 Gy < 35%
Heart V30 Gy < 50%