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Wael Mekhael Clinical Practicum III October 15, 2015

VMAT Stereotactic Radiotherapy for Brain Tumor

Stereotactic radiosurgery (SRS) and Stereotactic radiotherapy (SRT) treatment is defined as the use of external beam radiation therapy to deliver single high and very precise dose of radiation to a defined tissue volume, even if the treatment exceeds one fraction, it is still considered SRS. SRS allows fast and safer treatment for a variety of conditions, including malignant and benign lesions and brain metastases. Mostly head and neck tumors and disorders are treated with radiosurgery as these are the areas that are able to be fully immobilized for the purpose of the surgery.

Patient is a 71 years old male who was treated before for lung cancer in January 2015, the patient returned for his regular checkup visit, he was complaining of dizziness, fatigue and blurry vision, PET/CT was done to the brain, which showed a right temporal mass. The patient has past medical history of high cholesterol, asthmatic bronchitis and high blood pressure.

The patient is a white American male, married, lives with his wife, unemployed, quit smoking in 2011 after 40 years of smoking. No heavy drinking. Denies any drug use, and has no family history of any type of cancer. No allergies. Patient is under the following medications: Zetia, Spiriva, Advair and Mucinex. For the evaluation of this case study, the stereotactic treatment plan will be discussed in detail.

Radiation Oncologist Recommendations: Radiation Therapy: The patient will benefit from a course of stereotactic radiation therapy to the area of the right temporal. Oncologist discussed the course of treatment with the patient and his wife. The use of stereotactic will allow the delivery of higher dose than usually encountered in adjuvant setting without stepping above the constraints of the adjacent structures namely, brainstem, optic chiasm, right optic nerve, left optic nerve, right lens and left lens. Stereotactic affords the potential to decrease radiation therapy associated toxicity by creating highly conformal dose distributions. 1

The Plan (prescription): The radiation oncologist recommended stereotactic treatment of the lesion located in the right temporal lobe of the brain. The prescription dose for the plan was a total of 3250 cGy at 650 cGy per fraction for 5 fractions, which consisted of 2 ARCs.

Patient Setup/Immobilization: In stereotactic immobilization, devices have to be designed to help decrease setup error and patient motion during the treatment. 2 This may reduce the margin that needs to be placed around the planning tumor volume (PTV), therefore decreasing dose to normal tissue. Patient underwent a computed tomography (CT) simulation scan for radiation therapy treatment. The patient was immobilized in supine position with arms on the side, using a thermoplastic head mask. Please look at the following 2 photos.

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2 Simulation picture 1. Simulation picture 2.

Simulation picture 1.

2 Simulation picture 1. Simulation picture 2.

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Anatomical Contouring: After completion of the CT simulation scan, the CT data set was transferred into the Eclipse v11 radiation treatment planning system (TPS). Contouring is essential in maintaining the dose within the target structure.

At our clinic the medical oncologist contours the PTV as well as organs at risk; oncologist contoured the brain gross tumor volume (GTV). The location and size of the tumor was verified from the PET-CT fusion. Furthermore, the GTV was adjusted with 0.3cm outer margin all around to create the planning tumor volume (PTV).

A prescription was given with objectives sheet to begin treatment planning. the constraints for the OARs was as follows, the optic chiasm max dose 1200 cGy, 10% of the chiasm should not receive more than 800 cGy. Left and right optic nerve 10% should not receive more than 800 cGy. The brainstem, 10cc should not receive more than 1200 cGy.

Treatment Planning: The Varian IX linear accelerator was used for this treatment. The Varian Eclipse V.11 planning software was used for the contouring, optimization, and treatment planning for this clinical project.

My first step always, to evaluate the PTV, meaning how big it is, which side of the body, which organ at risk is more close to the PTV, then looking at the prescription objective sheet to check the constraints for the organs at risk, to get an idea which organ at risk constraints will be hard to achieve, especially if this organ is overlapping with the PTV.

New structure was created and named it (PTV 1cm) I used the add margin tool to add 1 cm outer margin all around the PTV, then created second structure and named it (PTV 3cm). I repeated the previous step but added 3 cm outer margin this time. Then I created another new structure and named it (PTV Ring) and I used the Boolean contouring tool and use the equation (PTV 3cm sub PTV 1cm) to create the ring.

Then another new structure was created and named it Shell, for the shell I used the Boolean contouring tool and use the equation (Body sub PTV + 3cm margin). All the structures I created will help reduce the hot spot, also to get a nice dose fall off and to produce more uniformed isodose lines.

The isocenter was placed in the middle of the PTV. At first I tried to plan utilizing 2 full Arcs both with 6MV energy. The first full Arc start at 179.9 degree and stop at 181.9 degree counter clock wise with collimation of 340 degree and couch set to 0 degree and dose rate of 600 MU/min, second full Arc start at 181.9 degree and stop at 179.9 degree clock wise, with collimation of 20 degree, couch set to 0 degree.

The prescription of 650 cGy per fraction was assigned to 100% of the PTV. Using the TPS beam eye view the field sizes was adjusted for each ARC. Please look at the following 2 photos.

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4 Full ARC 3D view. PTV of the full ARC plan.

Full ARC 3D view.

4 Full ARC 3D view. PTV of the full ARC plan.

PTV of the full ARC plan.

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The optimization for the normal tissue objective setting was as follows, the distance from target border was 0.2 cm, the start dose was 105%, the end dose was 60%, the fall off was set to 0.25.

The objectives for the PTV volume and organs at risk were entered into the optimization modules of the TPS as follows: (the prescribed dose was 3250 cGy)

PTV upper objective set to 0% of the target volume to receive 3400 cGy with a priority set to

140 on a 150 scale. This objective helps maintain an acceptable dose maximum.

PTV lower objective set to 99% of the target volume to receive 3270 cGy with a priority set to

135 on a 150 scale. This objective helps the target volume receive a minimum of 95% coverage,

and sharp dose fall off.

PTV lower objective set to 100% of the target volume to receive 3300 cGy with a priority set to

130 on a 150 scale.

PTV Ring upper objective set to 0% of the target volume to receive 1800 cGy with a priority set to 65 on a 150 scale.

Shell upper objective set to 0% of the volume to receive 850 cGy with a priority set to 65 on a

150 scale.

Right optic nerve upper objective set to 10% of the volume to receive 600 cGy with a priority set to 50 on a 150 scale.

Left optic nerve upper objective set to 10% of the volume to receive 600 cGy with a priority set to 50 on a 150 scale.

Brainstem upper objective set to 0% of the volume to receive 600 cGy with a priority set to 50 on a 150 scale.

Organs at risk set to lower priority than PTV, to minimize dose to critical structures while also maintaining a good PTV coverage. Usually for OARs I start with priority 50 and increase it as needed. To evaluate the results let’s look at the plan DVH and the isodose lines, please look at the photos below.

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6 Full ARC plan DVH. Full ARC plan isodose lines.(red 110%, yellow 100%, green 95%, blue

Full ARC plan DVH.

6 Full ARC plan DVH. Full ARC plan isodose lines.(red 110%, yellow 100%, green 95%, blue

Full ARC plan isodose lines.(red 110%, yellow 100%, green 95%, blue 90%, white 50%)

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Structures

Max Dose(cGy)

L

Len

597.4

R

Len

355.8

R

Optic Nerve

834.5

L

Optic Nerve

568.3

Brainstem

1462.2

Optic Chiasm

435

PTV

3535.4

The OARs max dose for the full ARC plan.

Dose coverage was achieved to the PTV volume with this 2 full Arc plan, but with a hot spot, and brainstem max dose was 1462 cGy which is not acceptable as the oncologist requested max of 1200 cGy for the brainstem. Hotspot was 110%.

Next the plan was copied, the 2 full Arcs were deleted, I tried this time using 2 hemi Arcs, both with 6MV energy. The first partial Arc start at 350 degree and stop at 181 degree counter clock wise with collimation of 340 degree and couch set to 0 degree, second hemi Arc start at 181 degree and stop at 350 degree clock wise, with collimation of 20 degree, couch set to 0 degree, and same prescription of 650 cGy per fraction to 100% of the PTV. Using the TPS beam eye view I adjusted the field sizes of each hemi ARC. Please look at the following 2 photos.

beam eye view I adjusted the field sizes of each hemi ARC. Please look at the

Hemi ARC plan PTV view.

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8 ARC1 and ARC 2 for the Hemi ARCs plan. Isodose lines for the 2 hemi

ARC1 and ARC 2 for the Hemi ARCs plan.

8 ARC1 and ARC 2 for the Hemi ARCs plan. Isodose lines for the 2 hemi

Isodose lines for the 2 hemi ARCs plan.

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9 The DVH for the 2 hemi ARC plan. Uniformed dose distribution and great coverage was

The DVH for the 2 hemi ARC plan.

Uniformed dose distribution and great coverage was achieved to the PTV volume with this 2 hemi ARCs plan, with hot spot of 108%, the dose to left lens, right optic nerve and left optic nerve, were also reduced. All constrains were met except brainstem max dose was reduced to1406 cGy but still not acceptable. Please look at the table below comparing OARs dose between the full and the hemi Arcs plan.

Structures

Full ARC (cGy)

Hemi ARC (cGy)

L

Len

597.4

245.2

R

Len

355.8

362.5

R

Optic Nerve

834.5

784.9

L

Optic Nerve

568.3

471.5

Brainstem

1462.2

1406.3

Optic Chiasm

435

452

PTV

3535.4

3880.5

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By looking at the CT, the anatomy of the patient, you can tell that if you use couch rotation it may help to push brainstem away from the field, with using previous setting, added to the counter clock wise Arc a couch rotation of 345 degree, and the clock wise Arc, added a couch rotation of 15 degree. For physical clearance we don't use couch rotation more than15 degree for each ARC). Please look at the photos below.

degree for each ARC). Please look at the photos below. PTV view after the couch rotation.

PTV view after the couch rotation.

for each ARC). Please look at the photos below. PTV view after the couch rotation. ARC1

ARC1 and ARC2 after couch rotation.

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11 Isodose lines after the couch rotation. DVH after the couch rotation.

Isodose lines after the couch rotation.

11 Isodose lines after the couch rotation. DVH after the couch rotation.

DVH after the couch rotation.

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Structures

Partial ARC (cGy)

Partial ARC / CC (cGy)

L

Len

245.2

145.1

R

Len

362.5

222.4

R

Optic Nerve

784.9

508.1

L

Optic Nerve

471.5

251.2

Brainstem

1406.3

618.6

Optic Chiasm

452

411.4

PTV

3880.5

3496.3

OARs max dose before and after couch rotation.

Hotspot was 108% which is acceptable, the brainstem dose reduced to 618 cGy. I reviewed the OARs dose, the isodose lines, and the dose volume histogram with the medical oncologist, all OARs dose were within tolerance and plan was approved.

Conclusion: The 2 hemi ARC plan with couch rotation achieved adequate prescription coverage and a homogeneous dose distribution throughout the brain tissue.

This project compared VMAT planning utilizing full Arcs, hemi Arcs (coplanar) and hemi Arcs with couch rotation (non-coplanar). The hemi Arcs with couch rotation result in a clinically acceptable plan, adequate target dose and dose to critical organs within prescribed dose constraints. For this patient planning using couch rotation resulted in sparing all of optic chiasm, right optic nerve, left optic nerve, right lens and left lens, with superior sparing of the brainstem, which will lead to less complication probabilities for OARs. 3

One last note, when treating our patients, choosing the right technique should be individualized, meaning it should be based on the patient clinical case, the anatomy and the PTV location. This project was a great experience.

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References

1. Kim H, Potrebko P, Rivera A, et al. Tumor volume threshold for achieving improved conformity in VMAT and Gamma Knife stereotactic radiosurgery. Radiother Oncol. 2015;115(2):229-234.

http://dx.doi.org/10.1016/j.radonc.2015.03.031.

2. Vikraman S, Manigandan D, Karrthick KP, et al. Quantitative evaluation of 3D dosimetry for stereotactic volumetric-modulated arc delivery. J Appl Clin Med Phys. 2014;16(1):5128-5129.

http://dx.doi.org/10.1120/jacmp.v16i1.5128.

3. Zhao B, Yang Y, Li X, et al. Is high-dose rate RapidArc-based radiosurgery dosimetrically advantageous for the treatment of intracranial tumors? Med Dosim. 2015;40(1):3-8.

http://dx.doi.org/10.1016/j.meddos.2014.01.002