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Comparison of coplanar vs. non-coplanar VMAT stereotatic body radiation therapy

techniques for non-small cell lung cancer based on dosimetric evaluation
Authors: Doris Chen, B.S., Wael Makhael, B.S., R.T.(T), Nishele Lenards, M.S., CMD, R.T.(R)
(T), FAAMD
Abstract:
Introduction: This study compares two volumetric modulated arc therapy (VMAT) techniques,
coplanar arcs versus non-coplanar arcs, for early stage non-small cell lung cancer (NSCLC). The
goal of the study is to determine which of technique best optimizes dosimetric parameters as well
as ease of delivery.
Case Description: The department routinely uses coplanar arcs to plan SBRT lung cases. Each
plan had a full arc and 1 or 2 partial arcs that varied between 100-140 with the intention of
sparing as much of the contralateral lung as possible without compromising coverage. All plans
were normalized to 100% of the prescribed dose covering 95% of the target volume.
Conclusion: Each plan was scored based on ease of treatment delivery, dose volume histogram
(DVH), conformity index (CI), heterogeneity index (HI), and total monitor units. The DVH was
used to evaluate the delineated organs at risk (OR), which included sum lungs, spinal cord,
esophagus, heart, chest wall, skin, and brachial plexus.
Keywords: SBRT, VMAT, NSCLC

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Introduction
Lung cancer is the leading cause of mortality, and the second most common cancer in
males and females.1 Patients with Stage I (T1 or T2, N0, M0) lung cancer normally have to
option of surgery, radiation, chemotherapy or a combination of treatment modalities. However,
one may refuse surgery or may not be a suitable candidate for surgical intervention due
complications in wound healing. When a lesion is inoperable, radiation therapy is the one of the
non-surgical modality to provide curative care or palliative relief.
If lesions have diameters less than 5cm, stereotactic body radiation therapy (SBRT) is a
hypofractionation treatment procedure that delivers high dose radiation of 10-30Gy per fraction.2
This procedure incorporates four-dimensional computed tomography (4D CT) and image
guidance which all take into account a patients respiratory motion. Traditionally, SBRT lung
plans were created with three-dimensional conformal radiation therapy (3D CRT), which uses
10-15 static fields to achieve a distribution comparable to an arc field. Disadvantages of 3D CRT
plans are: long treatment time, high toxicity to OR,
When SBRT lung is delivered with VMAT technique, the arcs use gantry rotation and
multi-leaf collimator speed to modulate fluence and dose rate. As a result, VMAT plans are able
to localize high dose to a specific region and at the meantime, reduce high dose spillage to
uninvolved neighboring tissues or organs, shorten treatment time, and decrease monitor units.
Although coplanar VMAT plans yield adequate planning target volume (PTV) coverage,
the hotspot is generally higher than desired. Since the planes of non-coplanar plans only intersect
at the isocenter, it is predicted that this property would decrease the global hot spot and improve
conformity. However, since non-coplanar plans have different plane entrances and the planes are
spatial spread apart, integral dose and low dose spillage might be negatively impacted. This can
lead to higher integral dose and an increase risk of second malignancies.
The purpose of this research is to determine whether non-coplanar plans could improve
the quality of VMAT SBRT Lung treatments based on dosimetric comparisons.

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Methods and Materials
A. Patients
Three stage I (1A and 1B) NSCLC patients were chosen for this study. The lesions were located
centrally on the left lobe with diameters less than 5cm. All 3 patients had a past history of
smoking, and vascular diseases such as hypertension. The mean patient age was 74 years old
with a range of 62-89. Among the 3 patients, 2 were females and 1 was male.
B. Simulation and Setup
Prior to treatment, patients underwent computed tomography simulation (CT-sim) for the
purpose of localizing the tumor and neighboring organs. Simulations and the placement of
positional tattoos were performed under meticulous attention and extreme precision since SBRT
involves treating a small volume to with high doses. Patients were positioned supine on a
wingboard with a headrest to support the patients head. Then, the patients arms were extended
above their head and held onto an indexed handle bar; this configuration would allow plans to
use multiple gantry angles without treating through the arms. For added comfort and
reproducibility, the arms were relaxed against the wingboard. A Vac-Lok bag was placed
underneath the patient, which would conform to the patients natural curvature for
immobilization. Respiratory gating or 4D CT was used to account for target motion in which
gating recorded the spectrum of the breathing cycle to determine the range of tumor movement.
The addition of a positron emission tomography (PET) scan helped to further identify the target
volume based on functional processes of the body.

C. Contouring
Target volumes and contours of OR were done in accordance with the RTOG 0813 guidelines.
The radiation oncologist defined the clinical target volumes (CTV) that included possible
microscopic diseases. The CTVs were expanded 2.5 mm panoramically to create the PTVs.
Figure 3 illustrates CTV and PTV delineations. The OR delineated included: the left and right
lungs, esophagus, spinal cord, chest wall, heart, skin, and brachial plexus.

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D. Treatment Planning
The total prescribed dose was 50Gy to be delivered over 5 fractions at 10Gy/fac. All plans were
created with 6 MV beams for Varian iX linear accelerator. The coplanar VMAT plans have either
2 to 3 arcs with 1 full arc and the remaining being partial arcs varied between 100-140. Noncoplanar plans were generated with 15 couch kicks in the opposite directions to minimize plane
overlapping. For example, if the couch of the full arc was rotated 10 then couch of the partial
arc would be rotated 345. Figure 1 and Figure 2 show the orientations of conplanar and
noncoplanar arcs respectively.
Results
Each one of the plans was evaluated with respect to the dose distribution and dosevolume histograms.3-5 The comparisons of the treatment plans were based on doses delivered to
the PTV and organs at risk. Figure 4 shows the dose-volume histogram (DVH) comparison of
coplanar and noncoplanar plans. The maximum dose, mean dose, and minimum dose of the PTV
were evaluated. The CI and HI were computed using the Paddick formula to evaluate the plan
quality with respect to the dose delivered to the tumor. In comparison the coplanar plans, the
noncoplanar plan reflected a slight improvement in PTV coverage, and slightly lower volumes of
lung irradiated to V5 and V20. Each received 5000 cGy, 5 fractions, and 1000 cGy per fraction.
Comparing the average number of MU per fraction, the number of MU of the coplanar plan was
higher than the non-coplanar and in addition, the beam on time of coplanar plan was significantly
higher than that of non-coplanar plan, the non-coplanar treatment plans yielded on average of 8%
reduction in dose to the heart and also noticed increase in conformity compared with the
coplanar plan. The amount of normal tissue receiving 105% of the prescription dose decreased
when using non-coplanar. The overall dosimetrically best case was reducing the dose to the heart
from 832 cGy in the coplanar plan to 765 cGy in the non-coplanar plan. Comparing the average
dose to spinal cord, the coplanar plan was higher than the non-coplanar, The spinal cord dose
decreased from 1370 cGy in the coplanar plan to 1120 cGy in the non-coplanar plan, Although it
was not desired that the mean lung dose increased from average 338 cGy in the coplanar plan to
450 cGy in the non-coplanar plan, but it was still within the acceptance criteria. Using partial
arcs made us able to reduce the dose to the contralateral lung, non-coplanar arcs did not affect
V(20) but reduced V(12) and V(5) by 8% and 6% respectively.6 The range of the arcs was limited

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due to mechanical collision limitations, although these limitation exist but our study was still
able to produce an increase in dose conformity to the target volumes and decrease dose to the
contralateral lung. Using non-coplanar plan reduces the dose to the heart in treating of lower lung
tumors.3

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References:
1. Onishi H, Shirato H, Nagata Y, et al. Stereotactic body radiotherapy (SBRT) or operable
state I non-small-cell lung cancer: can SBRT be comparable to surgery? Int J Rad Oncol
Biol Phy. 2011;81(5):1352-1358. http://dx.doi.org/10.1016/j.ijrobp.2009.07.1751
2. Merrow CE, Wang IZ, Podgorsak MB. A dosimetric evaluation of VMAT for the
treatment of non-small cell lung cancer. J Appl Clin Med Phys. 2013;14(1):228-238.
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Li Y, Liu B, Zhai F, et al. Dosimetric study of coplanar and non-conplanar intensitymodulated radiation therapy planning for esophageal cancer. Int J Med Phy.
2013;2(4):133-138. http://dx.doi.org/10.4236/ijmpcero.2013.24018

4. Oliver CT, Mustapha K, Patrice J, et al. Potential benefits of using non-coplanar field and
intensity modulated radiation therapy to preserve the heart in irradiation of lung tumors in
the middle and lower lobes. Radiother Oncol. 2006;80(3):333-340.
http://dx.doi.org/10.1016/j.radonc.2006.07.009
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pneumonitis in non-small cell lung cancer patients treated with stereotactic body
radiation therapy. Int J Radiat Oncol Biol Phys. 2012;82(1):457-462.
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Oncol Biol Phys. 1999;45(2):323-329. http://dx.doi.org/10.1016/S0360-3016(99)00183-2

Figure 1: Coplanar arcs.

Figure 2: Noncoplanar arcs with 15 and 345 couch kicks.

Figure 3: A transversal slice taken from the isocenter cut. The orange structure
denotes CTV, and the PTV, represented in blue is a 2.5mm expansion of the CTV.

Figure 4: DVH comparison of coplanar vs nocoplanar plans.