A Case Study Comparing 3D Conformal Hybrid Arc to VMAT technique for Mediastinal

Lung Cancer

Authors: Nicole Peckham R.T.(T), Stacey Song R.T.(T), Carlos Torres Teran R.T.(R), Nishele
Lenards, PhD, CMD, R.T.(R)(T), FAAMD, Ashley Hunzeker, MS, CMD, Ashley Cetnar, PhD,
DABR

Medical Dosimetry Program at the University of Wisconsin – La Crosse

I. Abstract
II. Introduction
A. PI: Overview of the medical dosimetry profession
B. PII: Explanation, benefits, and drawbacks of three-dimensional conformal
radiation therapy (3D-CRT), Intensity-modulated radiotherapy (IMRT),
volumetric modulated arc radiotherapy (VMAT) and conformal dynamic arc
(CDA) (References: Liu et al,1 Makhtar et al,2 Pokhrel et al,3 Basaran et al4)
C. PIII: Dosimetric comparison of 3D-CRT, dynamic IMRT and a combination of
hybrid-dynamic conformal IMRT (H-DCIMRT) for thoracic treatment
(Reference: Basaran et al4)
D. PIV: Dosimetric comparison of 3D-dynamic conformal arc (h-DCA) technique
using flattening filter free (FFF) beams and VMAT for treatment to mobile lung
lesions (Reference: Pokhrel et al3)
E. PV:
1. Problem: The problem is that there is a paucity of literature supporting 3D
Conformal Hybrid Arc for radiotherapy treatment of mediastinal lung
cancer.
2. Purpose: The purpose of this study is to compare 3D Conformal Hybrid
Arc to VMAT planning to achieve prescribed PTV coverage while
maintaining OAR dose constraints for mediastinal lung cancer patients.
3. Goals: Therefore, researchers created a 3D Conformal Hybrid Arc plan with
the objective of reducing maximum dose to the spinal canal to less than 45
Gy, achieve mean doses of ≤ 20 Gy to the lungs and heart, a mean dose of ≤
 34 Gy to the esophagus and maintain coverage of ≥95% of the PTV by
100% of the prescribed dose.
III. Case Description
A. Patient selection and setup
1. PI: Patient population
a. Inclusion criteria (mediastinal patients diagnosed with
primary lung cancer, tumor size, 60 Gy in 30 fx, planned
with VMAT technique)
b. 6 patients
c. Exclusion criteria (fx other than 60 Gy in 30 fx, multiple
dose levels, conformal arcs, patient separation outside
normal calculated range
2. PII: Simulation procedures
a. Philips Big Bore CT scanner
b. Patient position
c. Immobilization devices, no motion management
d. Tattoo setup and markers
e. Planning CT with IV contrast and 4DCT with 3.0 mm slice
thickness
B. Contours
1. PI: Targets and OAR
a. PTV
b. Spinal canal, bilateral lungs, heart and esophagus
C. Treatment Planning
1. PI-PIV: Planning details
a. Plan setup (treatment planning system, beam selection,
fields, energy, prescribed dose, technique, weighting,
treatment margin, collimator angle, gantry angle,
optimization, normalization)
D. Plan Analysis and Evaluation
1. PI: Overview of metrics
 a. PTV coverage, spinal canal, heart, lung, and esophagus
dose
2. PII: Summary of patient results (Table 1.0)
3. PIII: Analysis of results Patient 1
a. PTV, mean dose to heart and esophagus
b. VMAT comparison: comparable
4. PIII: Analysis of results Patient 2
a. PTV coverage, mean lung dose
b. VMAT comparison: not comparable
5. PIV: Analysis of results Patient 3
a. PTV Coverage, mean heart dose
b. VMAT comparison: comparable
6. PV: Analysis of results Patient 4
a. Mean dose to the lung, heart, esophagus, and spinal canal
b. VMAT comparison: comparable
7. PVI: Analysis of results Patient 5
a. Mean dose to the heart and esophagus
b. VMAT comparison: comparable
8. PVII: Analysis of results Patient 6
a. Mean dose to the heart and esophagus
b. VMAT comparison: comparable
9. PVIII: Summary of results
a. Significance of plan metrics
IV. Conclusion
A. PI: Case study purpose
1. Problem: The problem is that there is a paucity of literature supporting 3D
Conformal Hybrid Arc for radiotherapy treatment of mediastinal lung
cancer.
2. Purpose: The purpose of this study is to compare 3D Conformal Hybrid
Arc to VMAT planning to achieve prescribed PTV coverage while
maintaining OAR dose constraints for mediastinal lung cancer patients.
B. PII: Summary of results
1. VMAT and 3D Hybrid Arc comparability
C. PIII: Case study limitations and need for further research
 References
1. Liu YC, Chang HM, Lin HH, Lu CC, Lai LH. Dosimetric comparison of intensity-modulated
radiotherapy, volumetric modulated arc therapy and hybrid three-dimensional conformal
radiotherapy/intensity-modulated radiotherapy techniques for right breast cancer. J Clin Med.
2020;9(12):3884. https://doi.org/10.3390/jcm9123884
2. Makhtar I, Ghassaly ME, Abdouh E, El-Shahat K. Comparison study for IMRT, VMAT and
3D conformal in the treatment of gastric cancer patients. Oncol and Radiother. 2022;16
(3):001-004.
3. Pokhrel D, Halfman M, Sanford L. A simple, yet novel hybrid-dynamic conformal arc
therapy planning via flattening filter-free beam for lung stereotactic body radiotherapy. J
Appl Clin Med Phys. 2020;21(6):83-92. https://doi.org/10.1002/acm2.12868
4. Basaran H, Inan G, Gul OV, Duzova M. Dosimetric comparison of three-dimensional
conformal radiotherapy, dynamic intensity modulated radiation therapy, and hybrid
planning for treatment of locally advanced lung cancer. Middle East J Cancer.
2022;13(3):523-530. https://doi.org/10.30476/mejc.2021.90142.156
 Tables

Table 1. Patient data for 3D Conformal Hybrid arc and VMAT plans.

Heart Lungs PTV

Spinal Canal Esophagus
Mean Mean Coverage of
Patient # / Plan Type Point Mean Dose
Dose Dose 100% Rx
Dose(cGy) (cGy)
(cGy) (cGy) (%)

Patient 1
3D Conformal Hybrid 3,707 70 915 1,453 96.04
VMAT 2,728 104 850 1,463 95.03
Patient 2
3D Conformal Hybrid 6,312 3,517 1,578 3,177 99.02
VMAT 3,633 1,971 1,596 2,842 94.36
Patient 3
3D Conformal Hybrid 2,785 83 776 2,310 98
VMAT 1,938 86 752 1,602 95.11
Patient 4
3D Conformal Hybrid 1,964 73 744 1,159 96.18
VMAT 2,713 79 754 1,181 98.7
Patient 5
3D Conformal Hybrid 2,942 492 636 1,594 96.11
VMAT 2,355 585 584 1,695 98.35
Patient 6
3D Conformal Hybrid 3,878 746 1,459 1,272 95.25
VMAT 3,710 768 1,370 1,487 97.84

Tables

Table 1. Measured results from 3D Conformal Hybrid arc and VMAT plans.

Patient # / Plan Type Spinal Heart Lungs Esophagus PTV

Canal Point Mean Mean Mean Dose Coverage of
Dose(cGy) Dose Dose (cGy) 100% Rx
(cGy) (cGy) (%)
 Patient 1
3D Conformal Hybrid 3,707 70 915 1,453 96.04
VMAT 2,728 104 850 1,463 95.03
Patient 2
3D Conformal Hybrid 6,312 3,517 1,578 3,177 99.02
VMAT 3,633 1,971 1,596 2,842 94.36
Patient 3
3D Conformal Hybrid 2,785 83 776 2,310 98
VMAT 1,938 86 752 1,602 95.11
Patient 4
3D Conformal Hybrid 1,964 73 744 1,159 96.18
VMAT 2,713 79 754 1,181 98.7
Patient 5
3D Conformal Hybrid 2,942 492 636 1,594 96.11
VMAT 2,355 585 584 1,695 98.35
Patient 6
3D Conformal Hybrid 3,878 746 1,459 1,272 95.25
VMAT 3,710 768 1,370 1,487 97.84
p-Value* 0.1027 .1025 .4142 .4142 1.0000

* Significance Level p<0.05