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A Comparison of Rapid Arc IMRT & Freiburg Flap Brachytherapy for Treatment of
Angiosarcoma of the Scalp
Authors: Heather Tlougan R.T., B.S., Nishele Lenards M.S., CMD, R.T.(R)(T), FAAMD
Medical Dosimetry Program at the University of Wisconsin La Crosse, WI
Abstract
Introduction: The purpose of this case study is to evaluate the advantages and disadvantages of
using Rapid Arc Intensity Modulated Radiation Therapy (IMRT) versus the Freiburg Flap
brachytherapy application with regard to planning target volume (PTV) coverage, doses to
critical structures, and daily setup.
Case Description: This case study compares the treatment of an angiosarcoma of the scalp with
Rapid Arc IMRT versus the Freiburg Flap brachytherapy technique. A 72 year-old male patient
presented with a 4 cm lesion on the apex of the skull. When excised, the tumor was diagnosed as
an angiosarcoma staged at T2N0M0. Angiosarcomas are very aggressive tumors that
classically spread through the skin, recurring locally and metastasizing early to lung, liver, lymph
nodes and skin. Many different treatment approaches have been tried with little success. To
improve overall survival, using multimodality treatments approaches including surgery and
radiotherapy have proven most effective.1
Conclusion: Rapid Arc IMRT and Freiburg Flap Brachytherapy treatment techniques were
evaluated by the radiation oncologist comparing dose coverage to the PTV and dose to the
organs at risk (OR). The treatment plan using Rapid Arc IMRT was superior to the Freiburg flap
brachytherapy method. The rapid arc plan provided better coverage to the PTV and decreased
doses to the OR.
Key Words: Angiosarcoma, Rapid Arc IMRT, Freiburg Flap brachytherapy

Introduction
Angiosarcomas are very rare malignant vascular tumors. They account for approximately 2%
of all soft tissue sarcomas.1 Cutaneous angiosarcomas frequently arise on the face or scalp,
although they can be located anywhere on the body.2 Angiosarcomas are highly aggressive
tumors predominantly occurring in the elderly; affecting men more frequently than women.3
Angiosarcomas are characterized to spread through the skin recurring locally and metastasizing
early to lung, liver, lymph nodes and skin. Due to their extremely poor prognosis, with a 5-year
survival less than 15%, researchers feel angiosarcomas should be in their own subgroup.1 Ward

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et al4 emphasized that tumor location was the only predictor of local control and absolute
survival at 5 years. The prognosis is very discouraging when the primary tumor is located on the
scalp compared to those in other anatomic locations with the predominant pattern of failure being
local recurrence.4 According to Ward et al,4 the patients disease needs to be treated aggressively
to include surgical resection and pre-operative or post-operative radiation therapy. Previously,
surgery was the mainstay of treatment but the high frequency of local recurrence was
discouraging.1 Radiation therapy treatments were generally performed in cases of wide spread
unresectable tumors frequently metastasizing to the lung, but the outcomes were also
unsatisfactory.1 Today, the primary treatment is wide local excision followed by adjuvant
chemotherapy and radiotherapy for positive margins and lymph node metastases.5 To improve
overall survival, using multimodality treatments including surgery and radiotherapy has proven
most effective.1 Wide regions of dermis can be treated with radiation sparing the underlying
normal tissues making radiation a logical treatment modality for this disease.6 Research
performed recently for combined chemotherapy and immunotherapy demonstrated prolonged
survival.7,8 However, it is unclear what the best regimen is for these tumors.
This case study aims to evaluate the advantages and disadvantages of using Rapid Arc IMRT
versus the Freiburg Flap brachytherapy application with regard to PTV coverage, doses to
critical structures, and daily setup.
Case Description
Patient Description and Setup
A 72 year-old male patient with angiosarcoma of the scalp, status post wide excision with
close margins, presented to a primary care doctor with a rapidly growing purplish-colored lesion
on the scalp. The patient promptly underwent a wide excision of the scalp lesion. The lesion
measured > 4 cm. A 2 cm margin of normal tissue was excised around the visible tumor. The
patient underwent sentinel node biopsies on both left and right cervical lymph node chains.
Pathology showed both sentinel nodes were negative. The tumor was staged at T2N0M0. The
patients past medical history included pleural plaques from asbestos exposure. The patient
retired as a cement mason.
The radiation oncologist recommended post-operative radiation therapy to the resection with
wide margins. The patient had negative radial margins, but close deep margins < 1 mm. The
radiation oncologist requested a plan comparison of Rapid Arc IMRT versus the Freiburg Flap
brachytherapy technique to evaluate the best dose distribution to the PTV with the least amount

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of dose to the normal brain tissue. The prescription, including dose and fractions were the same
for both plans. The radiation oncologist prescribed a PTV dose of 200 cGy per fraction for 32
fractions to a total dose of 6400 cGy. The radiation oncologist did not prescribe an increased
dose per fraction for the brachytherapy technique because the PTV area was too large for a
higher fractionation scheme.
The patient underwent two different Computed Tomography (CT) simulations. The first was
a standard CT simulation with the patient lying supine with the head and neck on a headrest.
Before construction of an aquaplast mask, the radiation oncologist marked the gross tumor
volume (GTV) with a radiopaque wire. The patient was positioned with preliminary marks
drawn on the mask with radiopaque markers to define the reference point for treatment planning.
The radiation oncologist requested the head to be scanned at 1.5 mm slices. For the second CT
simulation, the Freiburg Flap was constructed (Figure 1). The Freiburg Flap, used with high
dose rate (HDR) brachytherapy, is a flexible mesh style surface mold for skin brachytherapy
treatments. The flexible applicator can be easily shaped to fit curved surfaces and is ideally
suited for large or surface lesions that are difficult to encompass, such as the skull or face.9 An
advantage of using the Freiburg Flap ensures a constant distance of 5 mm from the treatment
catheter to the surface of the skin.9,10 For the second CT simulation, the patient was lying supine
with the head and neck on a headrest. The physician outlined the GTV and PTV with a sharpie
marker on the skin, an aquaplast mask was made, and the physician marked the mask where the
underlying volumes were located on the patients scalp. The mask was cut out where the
Freiburg Flap needed to be constructed. Once the flap was constructed, it was sewn on the mask
ensuring a very tight fit with no gaps. The catheters used for planning were put into the
channels to be seen on the CT scan. The CT simulation was performed to include the entire head
scanned with 1.5 mm slices. Both CT simulation scans were exported to the Advantage
workstation for isocenter placement before being imported into the Varian Eclipse 10.0
Treatment Planning System.
Target Delineation
Using the Varian Eclipse 10.0 Treatment Planning System, the medical dosimetrist delineated
the OR including the brain, brain stem, eyes, lenses, and skull. The radiation oncologist
delineated the GTV and added a 1cm margin for the PTV. The contours were exported to
Oncentra, the brachytherapy planning system. The radiation oncologist provided the medical
dosimetrist with dose constraints to the critical structures near the PTV.

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Treatment Planning
The radiation oncologist prescribed a PTV dose of 200 cGy per fraction for 32 fractions to a
total dose of 6400 cGy. The radiation oncologist discussed the critical structure dose tolerances
with the medical dosimetrist. The normal tissue dose objectives included a maximum dose to the
lens < 700 cGy and mean dose to the eyes < 3500 cGy. The objectives also included achieving
the best coverage to the PTV and to spare as much normal brain tissue as possible. The medical
dosimetrist designed and provided two plans to the physician for comparison including a Rapid
Arc IMRT plan and a Freiburg Flap brachytherapy technique. With the tumor being located at
the apex of the skull, two full rotational arcs utilizing 6-megavoltage (MV) was utilized. The
arcs utilized a 15-degree and 345 degree collimator angle to decrease leaf leakage and allow the
optimal movement of the multi leaf collimator (MLC) leaves. After designing the rotational
arcs, the medical dosimetrist input the dose constraints into the optimizer along with the
weighting priority. The medical dosimetrist re-optimized increasing the priority on the coverage
of the PTV. After two iterations, the medical dosimetrist was satisfied with the overall Rapid
Arc IMRT plan.
The brachytherapy technique used a High Dose Rate (HDR) remote after-loading machine
loaded with a radioactive isotope, Iridium 192. The brachytherapy treatment planning process
began by verifying the normal structure contours and the PTV. The physicist verified the decay
of the isotope and the prescription. The dwell positions were determined based on the size and
shape of the PTV. Using the prescription, the computer calculated how long the seed would stay
in each dwell position. Coverage to the PTV was evaluated to see if any adjustments in dwell
position and time were needed. The physicist presented the plan to the physician for approval.
Plan Analysis & Evaluation
When planning the Rapid Arc IMRT or brachytherapy, the dose was quite conformal
delivering less dose to critical structures (Table 1). When compared, the dose volume histogram
showed the minimum dose, maximum dose and mean dose were superior in the Rapid Arc IMRT
plan for the critical structures. The critical structures were well below the tolerance doses. The
dose coverage to the PTV was also superior. The 100 % isodose line in the Rapid Arc plan
covered 86.6 % of the volume compared to the brachytherapy plan covered by 79% (Figures 2 &
3). In the Rapid Arc IMRT plan, the 95% isodose line covered 99.7% of the PTV compared to
the 95% isodose line covering only 90% of the PTV in the brachytherapy plan. Another
comparison was made to evaluate how much normal brain tissue was being treated and the dose

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received in each plan. In the Rapid Arc IMRT plan, the 50% isodose line was converted to a
structure showing that the volume of normal brain treated to 3200 cGy was 487cm3 compared to
290 cm3 for brachytherapy (Figure 4). The 20 % isodose line was converted to a structure
showing Rapid Arc IMRT treated a volume of 1016 cm3 of normal brain tissue compared to
brachytherapy at 838cm3. Normal brain tissue was measured to be 1442.8 cm3.
Conclusion
There are advantages and disadvantages that were evaluated in this case study. Advantages of
the Rapid Arc IMRT treatment involved a less complex setup in simulation and the treatment
machine. Although the dose to the critical structures was less in the Rapid Arc IMRT plan, the
overall total dose to the normal brain tissue was higher. For brachytherapy, an advantage was
less normal brain tissue being treated. However, disadvantages included the need for the
physician and physics staff being present daily for the treatment setup, more complex treatment
setup, and a great deal of machine time.
The radiation oncologist requested two different treatment techniques to evaluate which plan
was best for the patient. In this case, the Rapid Arc IMRT plan had many advantages, including
the best coverage to the PTV, less complex setup, and less time for treatment delivery. The
radiation oncologist accepted a higher dose to the normal brain tissue and chose the Rapid Arc
IMRT plan for treatment.
Angiosarcoma tumors of the scalp are very rare making this a limiting factor for this case
study. More research needs to be completed to determine the optimal treatment regimen.
Oncologists who are treating an angiosarcoma of the scalp should encourage the patient to
participate in a study so more can be learned about this aggressive tumor with a very dismal
long-term survival.

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References
1. Ogawa K, Takahaski K, Asato Y, et al. Treatment and prognosis of angiosarcoma of the
scalp and face: a retrospective analysis of 48 patients. Br J of Radiol. 2012;85(1019):11271133. http://dx.doi.org/10.1259/bjr/31655219
2. Hodgkinson DJ, Soule EH, Woods JE. Cutaneous angiosarcoma of the head and neck.
Cancer. 1979;44(3):1106-1113. http://dx.doi.org/10.1002/10970142(197909)44:3%3C1106::AID-CNCR2820440345%3E3.0.CO;2-C
3. Holden CA, Spittle MF, Jones EW. Angiosarcoma of the face and scalp, prognosis and
treatment. Cancer. 1987;59(5):10461057. http://dx.doi.org/10.1002/10970142(19870301)59:5%3C1046::AID-CNCR2820590533%3E3.0.CO;2-6
4. Ward JR, Feigenberg SJ, Mendenhall NP, Marcus RB Jr, Mendenhall WM. Radiation
therapy for angiosarcoma. Head Neck. 2003;25(10):873878.
http://dx.doi.org/10.1002/hed.10276
5. Dhanasekar P, Karthikeyan VS, Rajkumar N, et al. Cutaneous angiosarcoma of the scalp
masquerading as a squamous cell carcinoma: case report and literature review. J Cutan Med
Surg. 2012;16(3):187-190.
6. Morrison WH, Byers RM, Garden AS, Evans HL, Ang KK, Peters LJ. Cutaneous
angiosarcoma of the head and neck. A therapeutic dilemma. Cancer. 1995;76(2):319-327.
http://dx.doi.org/10.1002/10970142(19950715)76:2<319::AIDCNCR2820760224>3.0.CO;28
7. Ohguri T, Imada H, Nomoto S, et al. Angiosarcoma of the scalp treated with curative
radiotherapy plus recombinant interkeukin-2 immunotherapy. Int J Radiat Oncol Biol Phys.
2005;61(5):14461453. http://dx.doi.org/10.1016/j.ijrobp.2004.08.008
8. Sasaki R, Soejima T, Kishi K, et al. Angiosarcoma treated with radiotherapy: impact of
tumor type and size on outcome. Int J Radiat Oncol Biol Phys. 2002;52(4):1032-1040.
http://dx.doi.org/10.1016/S0360-3016(01)02753-5
9. Freiburg Flap/Elekta. Elekta AB Website. http://www.elekta.com/healthcareprofessionals/products/elekta-brachytherapy/applicators/skin-surface/Freiburg-flap.html.
Published 2014. Accessed July 20, 2014.
10. Stewart A. Radiotherapy of complex superficial targets: modality choices. Nowotwory J of
Onc. 2008;58(2):58-61.

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Figures

Figure 1. Construction of the Freiburg Flap brachytherapy procedure.

Figure 2. Dose Volume Histogram for Rapid Arc IMRT Plan.

Figure 3. Dose Volume Histogram for Freiburg Flap Brachytherapy plan.

Figure 4. Rapid Arc Transverse plane showing dose coverage. The 50% isodose (3000 cGy)
line in hot pink was converted to a structure to measure the amount of normal brain tissue being
treated.

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Tables
Table 1. Dose comparison of critical structures in each treatment plan.
Rapid Arc IMRT
Freiburg Flap Brachytherapy
Volume
Min
Max
Mean
Min
Max
Mean
Organ
3
(cm )
Dose
Dose
Dose
Dose
Dose
Dose
(cGy)
(cGy)
(cGy)
(cGy)
(cGy)
(cGy)
Left Lens
0.1
7.2
8.6
8.0
49.0
58.0
53.0
Right Lens
0.1
11.8
13.4
12.6
56.0
66.0
61.0
Right Eye
7.7
11.0
20.8
14.4
47.0
90.0
63.0
Lt Eye
8.1
6.4
16.2
9.6
39.0
76.0
54.0
Brainstem
10.5
9.6
21.0
15.2
11.0
24.0
17.0
Brain
1442.8
2.8
206.0
43.0
9.0
210.0
48.0
Skull
551.3
1.6
213.0
63.6
8.0
268.0
35.0