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Derek Smith
Clinical project
November 6, 2014
UAB SRS Technique Vs. Dual Isocenter Rapidarc SRS Technique
A secondary malignancy to the brain can be a very traumatic diagnosis for a patient
dealing with cancer. The primary radiotherapy purpose is for symptom palliation. In some
instances long-term survival is a possibility. In these cases, stereotactic radiosurgery (SRS) is a
preferable treatment option due to the treatments precision and long track record. However,
there has been some controversy because SRS as a primary treatment to the brain instead of
whole brain radiotherapy (WBRT) could lead to failure in brain regions that are left untreated.1
For the purpose of this clinical project I focused solely on the SRS technique to treat two brain
metastases with two different planning techniques: a dual isocenter RapidArc SRS technique,
and a University of Alabama-Birmingham (UAB) SRS method slightly modified to meet better
constraints.
History of Illness
Patient EK is a 58 year old female who originally presented with a primary complaint of
a left breast mass. She then had a left breast biopsy that identified a grade 2 infiltrating ductal
carcinoma. Following the biopsy EK received a PET scan that found uptake in the left breast
mass and in level II and level III of the axilla lymphadenopathy where there was also asymmetric
uptake in the left cerebellum. Following her PET scan, EK was imaged with a MRI of the brain
that found a left cerebellar extra-axial mass. EK was then taken for a craniotomy for resection of
the left cerebellar mass. EK was subsequently taken to the operating room for a left modified
radical mastectomy with a prophylactic right total mastectomy. Following this procedure, EK
was given adjuvant WBRT to a total dose of 35 Gy in 14 fractions. Per EKs surveillance of her
cancer she had a PET scan performed. The PET scan found no evidence of metastatic disease in
the chest, abdomen or pelvis; however, abnormalities within the brain were identified. An MRI
following the PET scan found greater than 20 lesions in the brain with the largest measuring 2.1
cm in the right frontal lobe and 1.8 cm in the right parietal occipital lobe (Figure 1).

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Radiation Oncology recommendations/prescription
The radiation oncologist recommended stereotactic radiosurgery to the two dominant
lesions found from the MRI scan that appeared to be the source of edema. The options reviewed
with EK were palliative in nature and could possibly slow down the progression of disease. EK
was interested in receiving the limited stereotactic radiosurgery. The radiation oncologist
recommended and proceeded with a SRS treatment of 15 Gy to the tumor in the right frontal lobe
and 18 Gy to the tumor in the right parietal lobe.
Patient Setup
EK was simulated for stereotactic treatment to the brain. She was placed on the
simulation table in the supine position on the head and neck board, B headrest, and an
aquaplast mask was placed over the patients face and shoulders. EKs arms were placed at her
side with a wedge under her knees and feet banded. The radiation oncologist was present during
the simulation to review the CT images and place two separate isocenters on the aquaplast mask.
UAB Method Planning
The UAB method utilizes a smart geometry technique that sets the Varian Eclipse VMAT
optimization up for success. This method is a useful tool when faced with numerous brain
metastases that need SRS or SBRT treatment. With a specific contouring and optimization
process, only a single isocenter is needed for up to 15 separate brain metastases.2
Contouring
The UAB methods key to conformity is the concentric shell based control structure
arrangement. The control structure contouring is essential to maintaining the dose within the
control structures. A typical concentric shell based control structure arrangement is the target
structures plus a 0.5 cm inner margin, 1.0 cm middle margin, and a 3.0 cm outer margin these
concentric shells are useful as long as a similar ratio is used.2 To create these structures, the first
step is to make a structure that encompasses all clinical prescribed target volumes delineated by
the radiation oncologist. I named this structure PTV-total. To create the PTV-total structure
you simply use the boolean contouring tool and use the equation (PTV1 or PTV2) to combine the
separate PTVs. The second step is to generate the concentric shell structures. To create the inner

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shell create an outer margin from the PTV-total structure. From the inner shell structure create
a 1.0 cm, or ratio equivalent, outer margin that will comprise of the middle shell. For the third
shell create a 1.5 cm, or ratio equivalent margin from the middle shell structure (Figure 2). The
Final step to making the concentric shells is use the Boolean operator tool to hollow out the
structures that were created and make them true concentric shells. The order of Boolean
operators to apply is important as follows:
1. outer shell equation: =outer sub middle
2.middle shell equation: = middle sub inner
3.inner shell equation: = inner sub PTV total
The last structure to create is the healthy tissue structure for optimization and evaluation
purposes. The healthy tissue structure is made by using a simple Boolean operator as follows
(skull sub PTV-total). It is also important to contour the following organs at risk to reduce
dose to healthy tissue: Brain, brainstem, cochlea, eye, lens, optic nerve, optic chiasm, pituitary
gland, retina, and spinal cord.
Beam arrangement
The Varian Eclipse V.11 planning software was used for the contouring, optimization,
and treatment planning in this clinical project. This plan was comprised of only two different
arcs because the UAB method suggests 2 arcs for any metastases below 3 cm. The first Arc was
a full clockwise arc with start angle at 181.0 and stop angle at 179.0 collimator set to 45 and
table set to 0. The second arc was a counter-clockwise half arc with a start angle at 1.0,stop
angle of 181, collimator set at 45, and couch set at 315. The isocenter was placed at the
geometric center of PTV-total (Figure 3).2
Optimization
The optimization process is where the concentric shell contouring becomes key to the
UAB method. The optimization objectives following the UAB formula are as follows:

PTV_total: lower =99.9% of the target to receive 107% of prescription , no upper

constraint.

Inner control max dose=98% of prescription dose.

Middle control max dose= 50% of prescription

Outer control max dose= 40% of prescription.

Priority weighting was given highest to the inner control ~ 150 on a scale of 150 and ~ 50 for
the middle and outer while the individual GTVs were given ~150 weighting as well.2 For the
purpose of this Clinical project I followed all of the UAB method guidelines except adding
an upper constraint to the PTV-total set at 0.1% of the target to receive 107% of the
prescribed dose to help bring the Global Dose Maximum down to 111.0% as compared to
121.9%.
Separate Isocenter Planning
McLaren typically approaches a brain SRS with multiple targets by using separate
isocenters. This technique attempts to spare dose to the opposite side of the brain as well as
avoid surrounding critical structures by using multiple partial arcs.
Contouring
For this plan the same physician contours were utilized as well as the same Brain,
brainstem, cochlea, eye, lens, optic nerve, optic chiasm, pituitary gland, retina, and spinal
cord. Along with a planning margin structure, or opti-PTV that is 0.3 cm surrounding the
physician PTV that is used during the optimization process.
Isocenter Location
Isocenters were placed in the geometric center of both PTVs. Locating the Geometric
center can be performed by moving the viewing planes to the PTV structure and placing the
isocenter at those exact coordinates.
Beam Arrangement
For the first plan with a PTV target within the right frontal lobe, there were four partial
arcs used for planning. The first arc was a partial clockwise arc with start angle at 181.0 and
stop angle at 290 collimator set to 315 and table set to 340. The second arc was a partial
counter-clockwise arc with start angle at 290.0 and stop angle at 181.0 collimator set to 45
and table set to 350. The third arc was a partial clockwise arc with start angle at 181.0 and
stop angle at 300.0 collimator set to 45 and table set to 0. The final arc was a partial

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counter-clockwise arc with start angle at 300.0 and stop angle at 181.0 collimator set to
315 and table set to 0 (Figure 4).
The second plan was for a GTV target within the right parietal lobe that also used four
partial arcs. The first arc was a partial clockwise arc with start angle at 181.0 and stop angle
at 0.0 collimator set to 45 and table set to 0. The second arc was a partial counterclockwise arc with start angle at 0.0 and stop angle at 181.0 collimator set to 315 and table
set to 0. The third arc was a partial counter-clockwise arc with start angle at 240.0 and stop
angle at 0.0 collimator set to 315 and table set to 290. The final arc was a partial
clockwise arc with start angle at 0.0 and stop angle at 240.0 collimator set to 45 and table
set to 320 (Figure 5).
Optimization
The optimization technique for the separate isocenter plans relies heavily on the
physician PTV and opti-PTV optimization objectives. The Optimization objectives that were
followed are displayed below:

GTV lower objective set to 99.9% of the target to receive 113% dose with a priority
set to about 50 on a 180 scale. This objective is to attempt to place most of the high
dose within the tumor rather than outside the tumor.

PTV upper objective set to 0.1% of the target volume to receive 101.3% of the
prescribed dose with a priority set to about 150 on a 180 scale. This objective helps
maintain an acceptable global dose maximum.

PTV lower objective set to 99.9% of the target volume to receive 100.6% of the
prescribed dose with a priority set to about 160 on a 180 scale. This objective helps
the target volume receive a minimum of 95% coverage.

PTV-opti upper objective set to 0.1% of the target volume to receive 99.3% of the
prescribed dose with a priority set to about 140 on a 180 scale.

PTV-opti lower objective set to 99.9% of the target volume to receive 98.7% of the
prescribed dose with a priority set to about 150 on a 180 scale.

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This VMAT optimization outline allows for flexible priorities as well placing upper
objectives with a lower priority to minimize dose to critical structures while also
maintaining prescribed coverage.
Plan Evaluations
To evaluate each planning process I followed the same equations that are used for
evaluation at McLaren and in the UAB method. The two major dosimetric indices used for
evaluation in this clinical project are the conformity index (CI) and the homogeneity index (HI).
These values are found by turning the 100% isodose volume to a structure and evaluating that
volume for PIV. The maximum dose is found by evaluating the Dose Volume Histogram (DVH).
And to evaluate the CI and HI values I calculated these values with a calculator by following the
two equations below.
1) CI= Prescription Isodose Volume (PIV)/Target Volume (TV) = measure of dose conformity of
treated volume to the target volume.
2) HI= Maximum Dose (MD)/Prescription Dose (PD) = measure of dose heterogeneity within
target volume.
I also compared pros and cons between the two treatment techniques to evaluate which
plans seem to have an overall treatment planning advantage.
Results
Plan:

UAB method

Right Frontal

Right Parietal

PIV

16.66

13.53

6.57

TV

18.92

12.32

6.62

CI

0.88

1.09

0.99

Max dose (Gy)

16.644

16.259

19.039

Prescribed dose (Gy)

15

15

18

HI

1.1096

1.0839

1.0578

Plan Comparisons

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Result Evaluation
The preferred conformity index value is 1.00. From the results, the right parietal plan had
a near perfect conformity index. The UAB method and Right Frontal plan did not vary too far
from the preferred value as well. The ideal heterogeneity index would be anything below a value
of 2. Each plan showed acceptable RTOG heterogeneity and conformity index values. It is also
important to evaluate isodose distribution and the dose volume histogram (DVH) for each plan.
After reviewing each for all three plans, there was no significant difference between each except
for the 50% isodose line in the UAB method vs. the Right frontal plan (Figure 6). The UAB
method shows a greater 50% dose conformity due to the concentric rings. This comparison
shows why the UAB method is preferable for sparing dose to critical structure in an SRS or
SBRT treatment (Figure 7).
Planning
Ease of planning between the two techniques can vary from one dosimetrist to the other. I
found the UAB method to be a simpler planning platform. The UAB method was much easier to
evaluate dose, select beam arrangements, and create a simpler more consistent clinical treatment.
For example, the dual isocenter technique requires a plan sum and a dose overlap check to
evaluate dose to critical structures. The dual isocenter technique does allow for a flexible
prescription to each PTV. The UAB method, used with the Varian Eclipse V.11 software,
restricts the radiation oncologist to only one prescribed dose to each PTV. I did have some
trouble optimizing with the UAB method guidelines, but with the addition of a lower objective to
the PTV-total I easily obtained a plan with good coverage and an acceptable 111.0 % hotspot.
The use of only two Arcs and only one table kick with the UAB method had less opportunity for
error. Overall, The UAB method, in my opinion, would be a preferable SRS treatment for the
treatment of EKs brain metastases.

References
1. Shaw E, Kline R, Gillin M. Radiation therapy oncology group: radiosurgery quality
assurance guidelines. Int J Radiat Oncol Biol Phys. 1993;27(5):1231-1239.
http://www.ncbi.min.nig.gov/PubMed/8262852
2. Clark GM, Popple RA, Prendergast BM. Plan quality and treatment planning technique
for single isocenter cranial radiosurgery with volumetric modulated arc therapy. Pract
Radiat Oncol. 2012;2(4):306-313. http://dx.doi.org/10.1016/j.prro.2011.12.003
3. Den RB, Andrews DW. Radiotherapy for brain metastases. Neurosurg Clin N Am.
2011;22(1):37-44. http://dx.doi.org/10.1016/j.nec.2010.08.001

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Figures

Figure 1: Sagittal view of right frontal GTV and Right Parietal GTV.

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Figure 2: Sagittal view of outer (light blue), middle (dark green), and inner (dark blue)
concentric shell contours.

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Figure 3: UAB method beam arrangement.

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Figure 4: Dual isocenter beam arrangement for right frontal plan.

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Figure 5: Dual isocenter beam arrangement for right parietal plan.

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Figure 6: Isodose distribution comparison UAB method (left) versus right frontal plan (right).

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Figure 7: DVH comparison of right frontal vs. UAB method.