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Reducing Mean Heart Dose with Partial Arcs for Left-Sided Lung Tumors Treated with
Stereotactic Body Radiation Therapy

Alex Mckennell BS R.T.(T); Martina Stewart BS R.T.(T); Melissa Piercey BS R.T.(T); Nishele
Lenards, PhD, CMD, RT(R)(T), FAAMD; Ashley Hunzeker, MS, CMD; Matt Tobler, R.T.(T),
CMD, FAAMD
Medical Dosimetry Program at the University of Wisconsin-La Crosse, WI

Abstract
Stereotactic body radiation therapy (SBRT) of left sided lung tumors increases the mean heart
dose to > 10.4 Gy; thus, increasing the potential for cardiac toxicity. Treatment planning
techniques such as volumetric modulated arc therapy (VMAT), may be utilized to assist in
minimizing mean heart dose. The problem is when treating left lung tumors stereotactically, the
heart can receive mean doses > 10.4 Gy; therefore, increasing the potential for cardiac toxicity.
The purpose of this retrospective study was to evaluate partial arc VMAT configurations for left
sided lung tumors near the heart to determine a technique that will deliver a mean heart dose of ≤
10.4 Gy while maintaining ≥ 95% planning target volume (PTV) dose. Twenty patients were
selected for this study and treatment plans utilizing various gantry rotational configurations, with
and without heart avoidance, were created. Researchers compared these treatment plans by
evaluating mean heart dose, target volume coverage and dose to organs at risk (OAR). Statistical
analyses were performed using MATLAB Statistics and Machine Learning Toolbox. Researchers
in this study demonstrated that using partial arc VMAT configurations is an efficient strategy for
minimizing the mean heart dose and should be considered for patients with left lung tumors near
the heart.

Keywords: Lung Cancer, Cardiac Toxicity, Mean Heart Dose, Heart avoidance, VMAT, Left
Lung

Introduction
Individuals with lung cancer often possess risk factors for cardiovascular disease or pre-
existing cardiac conditions. The American Cancer Society identifies lung cancer as the most
common and fatal cancer worldwide.1 An estimated 238,340 new cases of lung cancer will be
diagnosed and approximately 127,070 deaths will occur from lung cancer in 2023.1 Researchers
have concluded that the risk of a major adverse cardiac event (MACE) is elevated in non-small
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cell lung cancer (NSCLC) patients in the 2 years following radiation therapy and that MACE can
be independently predicted by cardiac radiation dose exposure.3,4 Therefore, cardiac dose
reduction during radiation treatment planning is of significance and future trials should be
investigated.3,4
Radiation induced damage to the heart and substructures is linked to severe cardiac
events and death.3 A trial conducted by the Radiation Therapy Oncology Group (RTOG 0617)
compared the average survival of patients receiving concurrent chemotherapy given high-dose
radiation therapy as opposed to standard dose radiation therapy.4 An incidental result of this trial
was the revelation that higher doses to the heart resulted in an increased risk of
mortality.3According Herr et al,5 mean heart dose should be ≤ 10.4 Gy when treating patients
with NSCLC. Using advanced treatment planning techniques such as volumetric-modulated arc
therapy (VMAT), radiation doses to the heart and substructures can be minimized; therefore,
reducing cardiac toxicity.
Volumetric-modulated arc therapy, which was first introduced in 2007, can be described
as an innovative planning and delivery technique where the multi-leaf collimator (MLC) and
dose rate fluctuate while the linear accelerator gantry moves in a continuous arc around the
patient.6 When compared to fixed field intensity-modulated radiation therapy (IMRT) and three-
dimensional conformal radiation therapy (3D-CRT), VMAT is the preferred method for treating
lung cancer.6-8 Volumetric-modulated arc therapy enables enhanced precision in radiation
delivery, resulting in improved conformal dose distributions and escalation of radiation dose to
the tumor while protecting critical structures like the heart. 6-8 In an effort to spare critical
structures such as the heart, the degree of gantry arc angle and treatment planning objectives can
be manipulated to avoid entering or exiting the critical structure.9-11
Previous researchers have demonstrated the potential for cardiac toxicity during lung
radiotherapy.3-6 The problem is when treating tumors left lung tumors stereotactically, the heart
can receive mean doses > 10.4 Gy; therefore, increasing the potential for cardiac toxicity.
Treatment planning techniques, such as VMAT, can be used to assist in minimizing mean heart
dose. The purpose of this retrospective study was to evaluate partial arc configurations for left
sided lung tumors treated stereotactically, to determine a technique that will deliver a mean heart
dose ≤ 10.4 Gy while maintaining ≥ 95% planning target volume (PTV) dose coverage.
Researchers tested the hypothesis (H1A) using 2 partial arcs versus 2 full 360° VMAT arcs for
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left-sided lung tumors would effectively reduce the mean heart dose to ≤ 10.4 Gy while
maintaining ≥ 95% PTV dose.
Methods and Materials
Patient Selection & Setup
Twenty patients were chosen for this retrospective study. Seventeen patients were treated
with a motion management device and 3 patients were treated while free breathing. The inclusion
criteria were patients with left-sided lung tumors at the level with the heart, treated using VMAT.
Patients with right lung tumors, mediastinal tumors, boost volumes and lymph node involvement
were excluded from this study. Daily patient set up and immobilization devices established in CT
simulation included: thorax board, blue pad, arms above head in cup holders, knee-fix wedge,
and a carbon fiber head rest. Patients were oriented in the headfirst supine position for the CT
scan. The slice thickness of the CT scans was 3.0 mm with imaging parameters that included the
apex of the lung extending through the diaphragm.
Contours
All patient contours were drawn using version 16.1 of the Eclipse treatment planning
system (TPS). The organs at risk (OAR) contours utilized for each plan included: heart, great
vessels, left lung, right lung, main bronchus, chest wall, spinal cord, and esophagus. The target
volume for this study was the PTV, and delineation was dependent upon motion management.
For the patients utilizing a motion management device, the physician defined the gross tumor
volume (GTV) on the breath hold CT scan, and a certified medical dosimetrist added an
automatic expansion of 0.5 cm to 0.8 cm as directed by the physician based on their evaluation
of the GTV to form the PTV. Alternatively, for patients who were treated with free breathing, the
physician defined the GTV on each phase of the 4DCT scan. A physicist then created the internal
gross tumor volume (IGTV) based on the 4D average, and a certified medical dosimetrist added
an automatic expansion of 0.5 cm to 0.8 cm as directed by the physician based on their
evaluation of motion uncertainty to then establish the PTV.
Treatment Planning
In this study, treatment planners utilized Eclipse version 16.1, with the Anisotropic
Analytical Algorithm. All patients were planned on a Varian Truebeam linear accelerator, which
utilized MLCs with a width of 0.5 cm. The isocenter was placed in the center of the PTV
volume. The prescription followed a stereotactic body radiation therapy regime of 10 Gy per
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fraction for 5 fractions to a total dose of 50 Gy. A beam energy of 6 MV flattening filter free
(FFF) was used with a dose rate of 1400 monitor unit per minute (MU/min). Two plans were
created for each patient. In the first plan, researchers used 2 full 360° arcs ensuring there would
be no collision of the gantry with the patient or treatment table. One clockwise arc rotating from
181° to 179°, with a 30° collimator rotation and a counterclockwise arc rotating from 179° to
181° with a 330° collimator rotation. This arc configuration did not avoid the radiation beam
from entering through the heart and therefore was denoted as without avoidance. For the second
plan, researchers used 2 partial arcs that avoided entry of the radiation beam through the heart,
denoted as with avoidance. The first arc rotated clockwise from 10° left anterior oblique (LAO)
position to 170° left posterior oblique (LPO) position with a 30° collimator rotation and the
second arc rotated counterclockwise from 170° to 10° with a collimator rotation of 330°. During
optimization, objectives were adjusted on OAR to keep dose to them as low as reasonably
achievable as well as on the PTV to ensure coverage was met. Upon completion of the
optimization process, the dose volume histogram (DVH) was assessed.
Plan Comparison
Planned target volume dose coverage and mean heart dose were the primary metrics
evaluated for this study. Left lung, esophagus and spinal cord doses were evaluated to ensure no
dose limits were exceeded. For each plan, the mean heart dose was required to be ≤ 10.4 Gy
while maintaining ≥ 95% PTV dose. Through this evaluation, researchers identified arc
arrangements that best achieved the lowest mean heart dose, with no significant changes to left
lung dose, esophagus dose, or spinal cord dose while preserving necessary dose coverage of the
PTV.
Statistical Analysis
For this study, patient plans were examined individually for data collection. A one-tailed
t-test was used to determine if the average mean heart dose was lower for the partial arc
treatment plans. To consider the data as statistically significant, a P value of < 0.05 was required.
Results
Target Coverage
To maintain consistency between with avoidance and without avoidance treatment plans,
all plans were optimized to ensure that ≥ 95% of the PTV was covered by 100% of the
prescribed dose. For the partial arc with avoidance treatment plans, the dose to 95% of the PTV
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ranged from 50 Gy to 51.1 Gy. For full arc without avoidance treatment plans, the dose to 95%
of the PTV ranged from 49.8 Gy to 50.9 Gy.
Mean Heart Dose
The mean heart dose for plans with avoidance ranged from 0.156 Gy to 8.248 Gy and
0.149 Gy to 8.656 Gy for plans without avoidance (Table 1). Mean heart doses were lower in 19
of 20 patients (Table 1). The most significant difference was observed for patient 2, where mean
heart dose was lowered by 1.03 Gy due to the use of partial arcs to assist in avoiding the heart.
For one patient, the mean heart dose was 0.007 Gy higher in the treatment plan with avoidance.
Statistical analysis of the data utilized a one-tailed t-test which revealed a P value of < 0.001
when evaluating mean heart dose with partial arcs, confirming this study as statistically
significant. Therefore, the null hypothesis (H10) was rejected.
Discussion
Cardiac toxicity remains a concern for patients with lung cancer that are receiving
radiation therapy.3,4 Atkins et al3 highlighted the importance of avoiding high cardiac doses
during radiation therapy treatments through modifications in the treatment planning process.
The results from the current study suggest that partial arc VMAT configurations may play a
significant role in reducing mean dose to the heart when treating tumors in the left lung near the
heart (Table 1).
This retrospective study provides evidence that modifying gantry arc configurations
during treatment planning can reduce mean heart dose. The most significant difference in
lowering mean heart dose with heart avoidance configurations was observed in patient 2 where
mean heart dose was lowered by 1.03 Gy (Table 1). However, there was an increase in mean
heart dose in the plans with avoidance configurations seen in patient 4 (Table 1). This difference
was due to increased PTV proximity to the heart as PTV coverage was maintained with the heart
avoidance gantry configurations.
It is essential to maintain acceptable dose coverage to target volumes when modifying
treatment planning techniques to limit OAR radiation therapy dose. Researchers in this study
revealed that it is possible to attain comparable target volume dose coverage while concurrently
reducing radiation dose to critical OAR, notably the heart, left lung, esophagus, and spinal cord
by utilizing VMAT during radiation treatment planning. These findings highlight the
significance of optimizing treatment planning methodologies to provide effective tumor
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irradiation while reducing the potential adverse effects on surrounding healthy tissues, thereby
enhancing the overall outcome for patients.
Conclusion
Previous researchers showed that when treating left sided lung tumors, mean heart doses
> 10.4 Gy increased the potential for cardiac toxicity.3 Treatment planning techniques such as
VMAT, may be utilized to assist in minimizing mean heart dose. The problem is when treating
left lung tumors stereotactically, the heart can receive mean doses > 10.4 Gy; therefore,
increasing the potential for cardiac toxicity. The purpose of this retrospective study was to
determine VMAT configurations for left sided lung tumors near the heart that would deliver a
mean heart dose of ≤ 10.4 Gy while maintaining ≥ 95% PTV dose. Researchers in the current
study showed a benefit in using partial arc configurations that avoided the heart, leading to a
lower mean heart dose while maintaining OAR metrics and PTV dose coverage.
A limitation of this study was that data were collected from one institution using a limited
population size (n=20). Further research should include a larger population size across multiple
clinical facilities. Furthermore, it would be useful to replicate this study using non-centrally
located lung tumors as well as evaluation of additional OAR.
Acknowledgements
The authors would like to thank Dr. Douglas Baumann of the Statistical Consulting
Center at the University of Wisconsin – La Crosse for assistance with analysis and interpretation
of statistical data; however, any errors of fact or interpretation remain the sole responsibility of
the authors.
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Tables
Table 1. Mean heart dose with and without heart avoidance for the 20 patients in the study.
With Without Difference
Patient Avoidance (Gy) Avoidance (Gy) in Dose (Gy)
1 1.253 1.398 0.145
2 3.558 4.588 1.03
3 4.643 4.771 0.128
4 1.687 2.158 0.471
5 1.494 1.641 0.147
6 0.242 0.244 0.002
7 1.894 2.335 0.441
8 8.248 8.656 0.408
9 2.627 3.003 0.376
10 1.836 2.028 0.192
11 3.431 3.825 0.394
12 2.332 2.76 0.428
13 1.834 2.099 0.265
14 0.156 0.149 -0.007
15 5.598 5.642 0.044
16 3.913 4.455 0.542
17 1.769 2.006 0.237
18 3.606 3.773 0.167
19 1.28 1.554 0.274
20 4.963 5.329 0.366
Gy = Gray