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Doris Chen
Clinical Practicum 1
April 25, 2015
Using Volumetric Modulated Arc Therapy to Treat the Scalp
History of Present Illness: Patient KB is an 85 year-old gentleman with a history of scalp
lesions that occasionally itched, ulcerated, and bled. The condition persisted for three years
before it alarmed KB to seek medical attention. On September 17, 2014, KB visited his
dermatologist who biopsied five sites: right hand, right and left upper forehead at the hairline,
right posterior scalp, and right anterior scalp. The biopsy results identified that right hand lesion
showed squamous cell carcinoma (SCC) in-situ whereas the other four sites were read as
malignant fibrous atypical fibroxanthoma (AFX) as a consequence of significant sun exposure.
On November 4, 2014, pathology reviewed KBs biopsies, and KB completed a whole body
Positron Emission Tomography/Computed Tomography (PET/CT) to evaluate loco-regional and
distant metastatic movement. The pathologic report confirmed solar lentigo in the left medial
forehead biopsy, in situ SCC in the right hand, and pleomorphic malignant neoplasm in the
right/upper forehead at the hairline, right posterior scalp, and right anterior scalp. The PET/CT
showed two nodules located in the right parietal scalp with the larger one measuring 8mm by
8mm. A subcentimeter nodule was also identified in the right upper lobe. KB declined the
physicians recommendation of a CT-guided biopsy of the upper lobe lung nodule. Instead, a
punch biopsy of the right forehead lesion was performed on December 2, 2014, which found
poorly differentiated epithelial neoplasm in the dermis that was most consistent with
recurrent/metastatic poorly differentiated SCC. KB was not convinced of wide local excision
followed by scalp reconstruction due to complications from wound healing. He decided to
receive external beam radiation therapy.
Past Medical History: The patient has a past medical history of heart-related discomfort that
includes: hypertension, myocardial infarction, atrial fibrillation, and coronary artery disease. The
patient also has experienced emphysema, stroke, gastroesophageal reflux, and arthritis. The
surgical procedures KB underwent are hemorrhoidectomy, common bile duct dilatation, bilateral
lens replacement, transurethral resection of bladder tumor, pacemaker insertion, coronary artery
stenting, and aortic valve replacement.
Social History: Patient KB is a retired security officer. He is a former heavy smoker and

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occasionally drinks alcoholic beverages. He has not been married nor did he father any children.
He noted that his father lost the battle to prostate cancer.
Medications: The patient is currently prescribed Clopidogrel, Aspirin, Lasix, Norvasc, and
Simvastatin.
Diagnostic Imaging: Patient KBs diagnosis started with a visit to his dermatologist who
ordered multiple skin biopsies on September 17, 2014. The results revealed SCC in the right
hand lesion and malignant AFX in the right/left upper forehead at the hairline, right posterior
scalp, and right anterior scalp. Two months later, on November 4, 2014, the pathologic review
supported SCC in the right hand, solar lentigo in the left medial forehead biopsy, and
pleomorphic malignant neoplasm in the remaining biopsied sites. On the same day, the whole
body PET/CT did not find significant lymphadenopathy in the head or neck regions, but
identified two fluorodeoxglucose FDG-avid nodules in the right parietal scalp, the largest
measured 8mm x 8mm. FDG-avid nodules denote abnormally high cellular activity since FDG
accumulates faster in cancer cells and remained metabolically trapped in these cells.1 Another
region of interest the PET/CT found was an FDG-avid subcentimeter nodule in the right upper
lobe. When the physician suggested CT-guided biopsy of the right upper lobe nodule, KB
refused. Rather, KB agreed to a punch biopsy of the right forehead lesion that was performed on
December 2, 2014. The punch biopsy found poorly differentiated epithelial neoplasm in the
dermis without involvement of the overlying epidermis. The result was most consistent with
recurrent or metastatic SCC. Again, the physician suspected lung primary and recommended
biopsy of the lung nodule as this could alter the treatment recommendations; however, KB
declined.
Radiation Oncologist Recommendations: After reviewing the PET/CT and the pathologic
report, the radiation oncologist respected KBs decision to not further investigate subcentimeter
nodule found in the right upper lobe. The focus became treating the scalp lesions found in the
anterior right parietal scalp that extended medially on his forehead. During KBs physical
examination, KB had noticeable right frontal scalp alopecia, which was surrounded by
erythematous ndoules and a dominant right frontal lesion that measured 1cm x 1cm. The
physician did not find any palpable masses in the parotids and no signs of occipital, pre/postauricular, cervical, submandibular, or submental lymphadenopathy. Since KB rejected surgical
excision, KB proceeded with the physicians recommendation of definitive radiation treatment.

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Although the department routinely uses Flap technique with high dose radiation (HDR)
brachytherapy for partial scalp irradiations, large areas pose greater technical and dose
heterogeneity challenges. Flap+HDR is generally feasible alternative for smaller lesions and
lower prescription doses, especially when the patient cannot lie on the treatment table.2
Therefore, the physician decided to use the RapidArc VMAT technique for partial scalp
irradiation. Since KB was the first case in the departments history that did not use Flap+HDR, a
study comparing non-coplanar arcs versus coplanar arcs was developed to determine which
technique best optimizes dosimetric parameters.
The Plan (prescription): The radiation oncologist recommended using VMAT to treat KBs
scalp lesions for two dose levels simultaneously, approximately 60Gy and 70Gy, with 6MV
beams. The two dose levels the radiation oncologist prescribed were 5984 cGy at 176cGy/frac
and 7004 cGy at 206 cGy/frac for total of 34 fractions each. The intent was curative radiation
therapy to provide adequate dose to the large scalp area and to boost three additional sites on the
frontal right parietal region.
Patient Setup/Immobilization: KBs hair was shaved for clear visualization and access to the
lesions. Prior to the CT-scan, skin wires were placed around lesion edges for both treatment dose
levels, 60 Gy and 70 Gy. The physician identified three separate regions to be treated with 70 Gy
shown in Figure 1. KB was immobilized using an Aquaplast mask on a headrest on a 15
inclined headboard. The incline improved the number of axial slices through the target area,
ensuring better target definition. After the first Aquaplast mask was completed, a 1cm bolus was
placed over the target area. The bolus was then sandwiched and secured using a second
Aquaplast mask. CT scans of 3 mm thickness covering whole head to neck region was obtained.
Anatomical Contouring: After the radiation therapist exported KBs CT scans, the resident
imported the scans into Eclipse Version 11.0 treatment planning system (TPS). Under contour
the resident delineated the planning target volumes (PTV) for 60Gy and 70Gy, three clinical
target volumes (CTV), and organs at risk (OR). The OR included normal brain tissue, left/right
lens, and left/right eyebrows. The resident used the wires as a reference to contour the PTV
60Gy, 70Gy, and three separate CTVs located on the right, middle, and left areas of the frontal
scalp that were within proximity of the eyebrows. The physician requested 90% of the prescribed
dose covering 100 % of both PTV 60Gy and PTV 70Gy without hotspots exceeding 110%.
Beam Isocenter/Arrangement: Due to the difficulty plan, the chief physicist was assigned KBs

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plan. The physicist received the physicians request and cleaned up the contours done by the
resident. First, the physicist placed the isocenter 2.2cm to right side of the frontal scalp to ensure
proper dose coverage to the three CTVs. The physicist then derived two plans for comparison in
which he used coplanar partial arcs and noncoplanar partial arcs. Plan A has two coplanar partial
arcs with the following attributes: Arc1 110-245 counter clockwise (CCW) with a 40
collimation and Arc2 240-110 clockwise (CW) with a 320 collimation. Plan B has two
coplanar partial arcs and one noncoplanar arc with the following characteristics: Arc1 110- 245
CCW with a 40 collimation, Arc2 240-110 CW with a 320 collimation, and Arc3 100- 315
CCW with a 320 collimation and a 90 couch rotation. Plan C has one coplanar arc and three
noncoplanar arcs with the following settings: Arc1 110- 245 CCW with a 40 collimation, Arc2
315-100 CW with a 40 collimation and a 315 couch rotation, and Arc3 100-315 CCW with
a 320 collimation and a 90 couch rotation, and Arc4 100-315 CCW with a 320 collimation
and a 45 couch rotation. Each arc fitted the multi-leaf collimator (MLC) to PTV 60Gy with a
8mm margin.
Treatment Planning: First, the physicist created a PTV 60Gy evaluation structure that
excluded PTV 70Gy from the PTV 60Gy. The reason he created this structure was due to the fact
that the overlapping region would not yield desirable coverage, because it would impossible for
the dose to jump from 60Gy to 70Gy since a single contour line did not provide a sufficient
buildup region. The physicist started with Plan A where he placed two coplanar partial arcs and
fitted the MLC with a 8mm margin to PTV 60Gy. When arcs spun around the PTV 60Gy
panoramically, the entire PTV 60Gy did not fit the field size; however, the VMATs intensity
modulated characteristic would be able to compensate for the area of the PTV 60Gy that escaped
the field size. The goal of using partial arcs was to spare the optic lens, which have a max
tolerance of 700cGy individually, and the eyebrows, which have a max tolerance of 2000cGy per
brow. The physicist assigned normal tissue with a priority of 100. He then set upper and lower
bounds for both PTV 60Gy evaluation and PTV 70Gy. He then prioritized the normal brain
structure (mean tolerance of 2000 cGy), followed by the lens and eyebrows. His first iteration
obtained a deliverable plan, but had high dose spillage to the normal brain structure. Therefore,
he increased the priority setting to the normal brain structure and accepted a mean of 1434.5 cGy.
However, the plan failed to meet the radiation oncologists desired PTV coverage of 90% of the

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prescribed dose covering100% of the target volume (90/100). After a couple more iterations, the
physicist ferreted out that it was not feasible to derive a plan that met all of the OR constraints
while giving the PTV 70Gy 90/100. Thus, he discussed with the physician about the limitations
of VMAT and the physician was wiling to accept 98% of the prescribed dose covering 95% of
the target volume. Once the physicist was satisfied with the Plan A, he derived Plan B and Plan C
where he incorporated noncoplanar arcs and used the same set of priority settings as Plan A. The
plans were scored based dose volume histogram (DVH), and conformity indices (CI),
homogeneity indices (HI), and intermediate dose spillage values. Conformity index and HI are
objective tools used to help make a choice to pick a plan that provides maximum coverage to the
tumor while protecting healthy tissues.3 The physicist defined intermediate dose spillage as
volume receiving 30Gy/ volume receiving 60Gy, because these volumes were more
representative. The DVH was used to evaluate the delineated organs at risk (OR), which included
normal brain, optical structures, and eyebrows. Figure 2 shows the dose distribution through the
isocenter in three orthogonal planes for all three plans. Table 1 and Table 2 summarize the PTV
dosimetric parameters and doses received by critical structures. There were no clinically
significant differences among CI values of all three plans. Plan B and Plan C (noncoplanar plans)
have smaller HI values and less intermediate dose spillage, approximately 18.3% less than Plan
A. Plan C is the only plan that does not meet all of the OR constraints, exceeding the left lens,
left eyebrow, and right eyebrow by 11.2%, 6%, and 30.2% respectively. Although Plan A
required the least MU and less setup technique difficulty, it has the highest normal brain mean
dose and greatest intermediate dose spillage. The physicist and the physician proceed with Plan
B, because it met all of the planning objectives, and provided adequate coverage.
Quality Assurance/Physics Check: After Plan B was approved, the physicist created a Quality
Assurance (QA) folder and generated a phantom-based plan that had a 5cm depth for all arcs.
The physicist then copied the approved plan and changed it into a one-fraction plan. The
physicist would calculate the phantom-based plan to make sure the monitor units (MU) of each
arc matched up with the one-fraction plan. After this step had been completed, the phantombased plan was exported and compared. Data and measurements were collected from MapCheck
to compare with the dose grid produced by the Eclipse TPS with an acceptable tolerance of 5%.

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Conclusion: Partial scalp irradiation using VMAT had many challenges, because this was the
first departmental SCC scalp case delivered with external beam rather than brachytherapy and
the planner and to juggle with two separate dose levels, 60Gy and 70Gy. Since the scalp lesions
were located on the right, anterior, frontal scalp, during CT simulation the therapist had difficulty
obtaining axial slices that clearly defined the scalp lesion; thus, physics was called in to rectify
this problem. During the planning process, the physicist was able to derive a plan using two
partial coplanar arcs, however, the mean dose to the normal brain was rather high. Additionally,
the plan did not meet the physicians desired covered of 90% of prescribed dose to 100% of the
target volume. The physicist then re-planned the coplanar arc plan and derived two additional
plans that incorporated noncoplanar arcs. It was found that VMAT noncoplanar plans
demonstrate superiority in physical dose, with better CI, HI, and intermediate dose spillage
values. Although Plan C is able to preserve more of the normal brain tissue, the complexity of
the plan fails to meet all tissue toxicity constraints. Noncoplanar arcs have are angled obliquely,
thus increasing dose to forehead region, increasing dose the lens and eyebrows. With respect to
technique and OR, Plan B best optimizes PTV coverage without compromising critical
structures. This plan pioneered the possibility of using VMAT technique to treat partial scalp
cancer.

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References
1. Takalkar AM, El-Haddad G, Lilien DL. FDG-PET and PET/CT part II. Indian J Radiol
Imaging. 2008;18(1):17-36. doi:10.4103/0971-3026.38504
2. Wojcicka JB, Lasher DE, McAfe SS, et al. Dosimetric comparison of three different
treatment techniques in extensive scalp lesion irradiation. Radiother oncol.
2009;91(2):255-260. http://dx.doi.org/10.1016/j.radonc.2008.09.022
3. Kataria T, Sharma K, Subramani V, et al. Homogeneity index: an objective tool for
assessment of conformal radiation treatments. J Med Phy. 2012;37(4):207-213.
doi:10.4103/0971-6203.103606

Figure 1: Three separate CTV 70Gy regions wired interiorly and the exterior wire defines PTV
60Gy.

Figure 2: Dose distribution through the isocenter shown in three orthogonal planes. The yellow
line represents 70 Gy, green line represents 60Gy, cyan line represents 30 Gy, and orange line
represents 6 Gy.

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Table 1: PTV dosimetric parameters.

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Table 2: Doses to critical structures.