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A dosimetric comparison of coplanar vs. non-coplanar VMAT SBRT techniques for

Authors: Doris Chen, B.S., Wael Makhael, B.S., R.T.(T), Nishele Lenards, M.S., CMD, R.T.(R)
Introduction: The purpose of the study is to dosimetrically compare coplanar and non-coplanar
volumetric modulated arc therapy (VMAT) techniques for early stage non-small cell lung cancer
(NSCLC) to determine whether non-coplanar plans could improve the quality of VMAT SBRT
lung treatments. The department routinely used coplanar arcs to plan stereotactic body radiation
therapy (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. Each plan was scored based on ease of treatment delivery, dose
volume histogram (DVH), conformity index (CI), homogeneity index (HI), and total monitor
units (MU). 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.
Lung cancer is the leading cause of mortality, and the second most common cancer in
both 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 to
complications in wound healing. When a lesion is inoperable, radiation therapy is the one of the
non-surgical modalities to provide curative care or palliative relief.
If lesions have diameters less than 5cm, SBRT is a hypofractionation treatment procedure
that delivers high dose radiation of 10-30 Gy per fraction.2 This procedure incorporates fourdimensional computed tomography (4D CT) and image guidance which all account for patient
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. However, disadvantages of 3D CRT plans included long treatment
times and high toxicity to OR.

When SBRT is delivered with VMAT technique, the arcs use gantry rotation and multileaf collimator (MLC) 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 times, and decrease MU. Coplanar
VMAT plans yield adequate planning target volume (PTV) coverage but the hotspot is generally
higher than desired. It is predicted that this property would decrease the global hot spot and
improve conformity since the planes of non-coplanar plans only intersect at isocenter. However,
since non-coplanar plans have different planar entrances and are spatially spread apart, integral
dose and low dose spillage might be negatively impacted. This can lead to higher integral dose
and an increased risk of secondary 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.
Methods and Materials
Patient Selection & Setup
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 5 cm. 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. 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. Arms were extended above the head holding an indexed handle bar
to allow for multiple gantry angles without treating through the arms. For added comfort and
reproducibility, the arms were relaxed against the wingboard. A Vac-Lok immobilization bag was
placed underneath the patient, which conformed to the patients natural curvature. 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.
Target Delineation

Target volumes and OR contours were delineated 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 contoured OR included: the left and
right lungs, esophagus, spinal cord, chest wall, heart, skin, and brachial plexus.
Treatment Planning
The total prescribed dose was 50 Gy over 5 fractions at 10 Gy/fraction. All plans were
created with 6 MV beams for Varian iX linear accelerator. The coplanar VMAT plans had 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 the couch of the
partial arc would be rotated 345. Figure 1 and Figure 2 show the orientations of conplanar and
noncoplanar arcs respectively.
Plan Analysis and Evaluation
Each of the plans was evaluated with respect to the dose distribution and dose-volume
histograms.3-5 The comparisons of the treatment plans were based on doses delivered to the PTV
and OR. Figure 4 shows the dose-volume histogram (DVH) comparison of coplanar and
noncoplanar plans. The PTV maximum, mean, and minimum doses were evaluated. The CI and
HI were computed using the Paddick formula to evaluate the plan quality with respect to the
tumor dose delivered.
In comparison to 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 MUs of the coplanar plan was higher than the non-coplanar. In addition, the beam
on time of coplanar plan was significantly higher than that of the non-coplanar plan. The noncoplanar treatment plans yielded on average of 8% reduction in dose to the heart and increased
conformity compared with the coplanar plan. The amount of normal tissue receiving 105% of the
prescription dose decreased when using non-coplanar. Dosimetrically the best case was the
reduction of 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 noncoplanar plan. The spinal cord dose decreased from 1370 cGy in the coplanar plan to 1120 cGy

in the non-coplanar plan. The mean lung dose increased from average 338 cGy in the coplanar
plan to 450 cGy in the non-coplanar plan, but 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 due to mechanical collision limitations. Although limitations existed, this
study demonstrated an increase in dose conformity to the target volumes and decreased dose to
the contralateral lung. Using non-coplanar plan reduces the dose to the heart in treating of lower
lung tumors.3

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.

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.
5. Barriger RB, Forquer JA, Brabham JG, et al. A dose-volume analysis of radiation
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.
6. Graham MV, Purdy JA, Emami B, et al. Clinical dose-volume histogram analysis for
pneumonitis after 3D treatment for non-small cell lung cancer (NSCLC). Int J Radiat
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.