Faculty Position Paper On VMAT-Web

POSITION PAPER
THE EVIDENCE BASE FOR MULTIPLE VOLUMETRIC MODULATED ARC THERAPY (VMAT) - A QUALITY PERSPECTIVE
FACULTY OF RADIATION ONCOLOGY
THE ROYAL AUSTRALIAN AND NEW ZEALAND COLLEGE OF RADIOLOGISTS
Name of document and version: Faculty of Radiation Oncology, Position Paper: The Evidence Base for Multiple Volumetric Modulated Arc Therapy (VMAT) A Quality Perspective, version 1 Approved by: Faculty of Radiation Oncology Board Date of approval: 20 May 2011 ABN 37 000 029 863 Copyright for this publication rests with The Royal Australian and New Zealand College of Radiologists The Royal Australian and New Zealand College of Radiologists Level 9, 51 Druitt Street Sydney NSW 2000 Australia Email: ranzcr@ranzcr.edu.au Website: www.ranzcr.edu.au Telephone: +61 2 9268 9777 Facsimile: +61 2 9268 9799 Disclaimer: The information provided in this document is of a general nature only and is not intended as a substitute for medical or legal advice. It is designed to support, not replace, the relationship that exists between a patient and his/her doctor.
TABLE OF CONTENTS
Objectives Executive Summary Background Volumetric Modulated Arc Therapy (VMAT) Faculty of Radiation Oncology Position Bibliography Introduction Appendix I: the Historical and Technical background to VMAT Technical History What is HT? What is VMAT? Single arc or Multiple Arc VMAT Treatment delivery times Radiobiological considerations Head and Neck treatments Prostate Breast Lung Brain Other clinical applications Quality Assurance Comparison of Helical Tomotherapy and VMAT techniques Conclusions Bibliography Appendix I Appendix II: Detailed evidence for the benefits of single and multi arc VMAT Bibliography Appendix II Acknowledgments Acronyms and Abbreviations
2 2 3 3 4 5 6 6 7 7 10 11 12 12 12 13 14 15 16 16 16 17 18 20 30 32 33
THE FACULTY OF RADIATION ONCOLOGY, RANZCR, is the peak bi-national body advancing patient care and the specialty of Radiation Oncology through setting of quality standards, producing excellent Radiation Oncology specialists, and driving research, innovation and collaboration in the treatment of cancer. VISION To have an innovative, world class Radiation Oncology Specialty for Australia and New Zealand focused on patient needs and quality. OUR VALUES In undertaking our activities and in managing the way we interact with our Fellows, trainees, members, staff, stakeholders, the community and all others with whom we liaise, the Faculty of Radiation Oncology, RANZCR, will demonstrate the following values: Quality of Care - performing to and upholding high standards Integrity, honesty and propriety - upholding professional and ethical values Patient orientation - understanding and reflecting the views of Fellows and members and working with them to achieve the best outcomes Fiscal responsibility and efficiency - using the resources of the College prudently. OUR PROMISE TO THE PATIENTS We will advocate for the best possible care for individual patients in multidisciplinary meetings and for all patients with government. OUR PROMISE TO TRAINEES We ensure the highest standard of training in radiation oncology by combining a world-class curriculum with passionate and supportive supervisors. The voice of trainees is valued in Radiation Oncology. OUR PROMISE TO OUR FELLOWS We are a member based organisation that utilises its resources effectively and strategically to fulfil our vision, purpose and core objectives. We strive for best practice and facilitate life-long learning of our members. OUR PROMISE TO OUR PARTNERS & STAKEHOLDERS We are a transparent and collaborative organisation that strives to promote partnerships and participation of all relevant stakeholders to ensure that patients across Australia and New Zealand receive a high-quality, timely and appropriate level of care.
OBJECTIVES
This Position Paper summarises the current evidence (as of 2011) around both Single and Multiple dynamic arc therapy also known as Volumetric Modulated Arc Therapy (VMAT). The aim of the paper is to inform cancer professionals, consumers and interested individuals and to put forward a quality-focused perspective.
Faculty of Radiation Oncology The Evidence Base for Multiple Volumetric Modulated Arc Therapy 3
Appendix I: Provides the historical and technical background to VMAT Appendix II: Provides detailed contemporary international evidence for the benefits of Single and Multi arc Radiotherapy.
EXECUTIVE SUMMARY
There is a very large body of evidence demonstrating that Single or Multi-arc therapy: 1. Achieves superior target dose quality (homogeneity and adjacent normal tissue sparing) in a range of tumour sites when compared to multi- field step and shoot IMRT, particularly for complex targets with adjacent organs at risk. 2. Consistently requires lower radiation doses (Monitor Unit output) than step and shoot IMRT 3. Consistently achieves much shorter treatment times than step and shoot IMRT 4. Provides more efficient RT treatment delivery 5. Is more comfortable for the patient 6. Has improved accuracy with IGRT (Image Guided) performance and dosimetry. There is a very large body of evidence indicating that an improved therapeutic ratio in clinical radiotherapy will translate to meaningful improvements in patient outcomes such as overall survival, disease free survival, reduced toxicity and improved quality of life.
This Position Paper provides significant evidence that volumetric modulated arc therapy, when performed with multiple arcs, achieves superior target dose homogeneity and adjacent normal tissue sparing in a range of tumour sites when compared to 6 field 3D conformal radiotherapy. It is, at a minimum, equivalent to the best planned multiple field IMRT in dosimetric terms and is considerably more efficient in terms of treatment delivery, with important radiobiological advantages to the patient, who also benefits from reduced discomfort associated with a reduction in treatment times, particularly for complex volumes such as head and neck sites.
BACKGROUND
Intensity-modulated radiation therapy (IMRT) produces clinically relevant improved outcomes to three-dimensional conformal radiotherapy (3DCRT), particularly in patients with concave target volumes. Two excellent reviews and a large economic analysis of the evidence provide a useful background to establish without question the real world benefits of this technology. (vide infra). It is therefore important that these new techniques are adopted into mainstream practice. Around 60 quality studies included three Randomised Controlled Trials (RCTs) in head and neck cancer (205 patients) and three in breast cancer (664 patients), showed significant improvements with IMRT in each trial. A recent meta-analysis collated data from 56 trials and showed that IMRT can reduce toxicities when compared to non-IMRT treatments. Data relating to overall survival and local control are inconclusive at this time. Incremental gains in radiotherapy therapeutic ratio and reductions in toxicity may still require very large studies to show survival differences. Toxicity reduction in its own right, is an appropriate outcome measure worthy of use as a benchmark for implementation of a particular technique. Reductions in toxicity lead to improved quality of life and reduced health costs. There have been approximately 70-80 additional non-randomised studies in head and neck cancer, prostate cancer, breast cancer and other tumour sites. Again they report benefits in acute and late toxicity, health-related quality of life and tumour control end points. A further 30 unpublished, ongoing or planned RCTs incorporating IMRT are currently in progress. These studies have reported improved target coverage, and lower doses to adjacent organs-at-risk for CNS tumours, head and neck (H&N), upper abdominal and pelvic cancers. IMRT in the treatment of H&N cancer reduces parotid doses, resulting in less xerostomia and improved quality-of-life. In the dose-escalated treatment of localized prostate cancer, reduced rates of acute gastrointestinal toxicity have been reported after IMRT treatment with a simultaneous integrated boost (SIB) technique compared to a sequential boost technique with 3D-CRT. In addition to these direct approaches, there are hundreds of studies using indirect techniques. This involves the correlation of the improved dose-volume constraints that were achievable with IMRT, with modelled organ function and complication rates. For many organs, IMRT studies have yielded valuable dose-volume-toxicity relations, which are now used as objectives in IMRT optimisation to avoid organ toxicity. There are also some possible practical and theoretical disadvantages of IMRT. Some less experienced units report longer treatment planning processes. Treatment delivery currently requires extensive physics quality assurance. The prolonged beam delivery time of IMRT compared to 3D-CRT has the potential to worsen the accuracy of treatment due to increased intra-fractional patient motion. Patient throughput is reduced in comparison to 3D-CRT. There is a higher integral radiation dose to the patient with IMRT.
The Evidence Base for Multiple Volumetric Modulated Arc Therapy
Faculty of Radiation Oncology
VOLUMETRIC MODULATED ARC THERAPY (VMAT)

VMAT is a new type of intensity-modulated radiation therapy (IMRT) treatment technique that uses the same hardware (i.e. a digital linear accelerator) as used for IMRT or conformal treatment, but delivers the radiotherapy treatment using a rotational or arc geometry rather than several static beams. A generation ago radiotherapy sometimes used old fashioned arc treatments for spherical tumour sites in the midline of the body (e.g. prostate and pituitary). These treatments were performed on older linear accelerators (linacs) or even orthovotage machines and in both their geometry and technical specifications bore no effective resemblance to VMAT apart from the serendipitous use of the word arc. A suitable comparator would be the use of the words deep x-ray therapy to describe megavoltage radiotherapy. Recently, volumetric-modulated arc therapy (VMAT) has gained enormous interest world-wide. This technique uses continuous modulation (i.e. moving the collimator leaves) of the multileaf collimator (MLC) fields, continuous change of the fluence rate (the intensity of the X rays) and gantry rotation speed across a single or multiple 360 degree rotation(s) (see Appendix I). This significantly reduces beam delivery time compared to conventional fixed field IMRT (otherwise known as step and shoot IMRT). This has major benefits for patient comfort. VMAT techniques require a lower number of monitor units (i.e. a lower X ray beam intensity and duration), lessening the risk of accidental overdosage, such has been recently reported in the recent New York Times articles. VMAT improves doseage homogeneity and sparing of critical organs over IMRT for many tumour sites (Appendix II).
FACULTY OF RADIATION ONCOLOGY POSITION

Multiple Arc VMAT has significant dosimetric benefits over IMRT or single arc VMAT, particularly for complex target volumes. Multiple-arc therapy has possible radiobiological advantages over IMRT as a consequence of the shorter delivery times. The evidence around VMAT is further enhanced when considered together with a very large body of International randomized evidence, extending over 15 years (plus), demonstrating the axiom that improved dosimetry translates into improved tumour control and lower normal toxicity rates that are clinically meaningful. It is highly plausible that further improvements in the therapeutic ratio for clinical radiotherapy for most tumour sites will continue to translate into clinical, cost benefit, and cost utility improvement that are very relevant for patients and the community as a whole.
The Evidence Base for Multiple Volumetric Modulated Arc Therapy 5
BIBLIOGRAPHY INTRODUCTION
S. Hummel, E. L. Simpson, P. Hemingway, M. D. Stevenson, and A. Rees, Intensitymodulated radiotherapy for the treatment of prostate cancer: a systematic review and economic evaluation, Health Technology Assessment (Winchester, England), vol. 14, no. 47, pp. 1-108, iii-iv, Oct. 2010.
J. Staffurth, A review of the clinical evidence for intensity-modulated radiotherapy, Clinical Oncology (Royal College of Radiologists (Great Britain)), vol. 22, no. 8, pp. 643-657, Oct. 2010. L. Veldeman, I. Madani, F. Hulstaert, G. De Meerleer, M. Mareel, and W. De Neve, Evidence behind use of intensity-modulated radiotherapy: a systematic review of comparative clinical studies, The Lancet Oncology, vol. 9, no. 4, pp. 367-375, Apr. 2008.
APPENDIX I: THE HISTORICAL AND TECHNICAL BACKGROUND TO VMAT

TECHNICAL HISTORY External beam radiotherapy treatments are conventionally given from one or more fixed gantry angles. For deep seated targets with adjacent critical normal tissues such as prostate and its close proximity to the rectum, or where there is complex geometry, as many as 6-9 beams are utilized to optimize the geometric dose parameters. Multiple non-conformal beams as many as 12-15 per day are used in complex head and neck plans, with set-up and treatment times not uncommonly taking 20-30 minutes per day. Another way of delivering dose in the past has been with a fixed rotational arc. To treat a prostate volume two 155-170 degree arcs were utilized, with the aperture of the beam shape fixed, and the dose rate during uniform gantry rotation also fixed. This technique was popular in some Australian radiotherapy centres treating localized prostate cancer in the mid to late 1990s as an alternative to the three or four field box technique most commonly seen in that era. A tubular Planning Target Volume (PTV), with a circular cross-section was created using this technique. An MBS item number has stayed on the schedule from that time, with the wording stating that the re-imbursement for one arc was to be considered the equivalent of 3 fixed beams, and with two arcs planned and treated each day, the treatment attracted reimbursement equivalent to six static fields. Improvements in beam shaping are accomplished using an important accessory called a multileaf collimator (MLC), a device with 80-120 computer-controlled mechanical tungsten leaves or fingers that move to create apertures of different shapes and sizes. The first MLC was introduced into an Australian department in 1995. All new Linear accelerators introduced this decade incorporate this technology. Newer radiotherapy planning systems use intensity-modulation with fixed beams from multiple gantry angles and a sliding window technique painting dose across the surface of the beam by its division into multiple smaller beamlets. This is achieved by dynamic MLC leaf motion sliding across the window of the beam. Beam-on times are typically 40 to 80 seconds per beam, compared to 10 to 20 seconds for a 3D conformal treatment. There are often an increased number of static IMRT fields, compared to 3D conformal treatments. These are the two main contributing factors to the significantly increased daily treatment time for IMRT treatments. Intensity Modulated radiation therapy (IMRT) using a conventional linear accelerator equipped with a MLC was adapted for clinical use to treat prostate cancer in 1995 (ref 1). This was followed by other treatment sites, including head and neck, brain, and abdomino-pelvic tumours. A recent meta-analysis collated data from 56 trials showed that IMRT can reduce toxicities as compared to non-IMRT treatments. Data relating to overall survival and local control are inconclusive at this time (ref 2). However, small incremental gains in radiotherapy therapeutic ratio and reductions in toxicity may still require very large studies to show survival differences. One could argue however, that toxicity reduction in its own right, is an appropriate outcome measure worthy of being used as a benchmark for implementation of a particular technique. Reductions in toxicity lead to improved quality of life and less cost compared with having to manage a patients toxicity. With data accumulating showing the advantages of IMRT, the impetus in the last decade has been to improve the quality, efficiency and accuracy with image guided radiation therapy (IGRT), as well as the ability to paint dose distributions. Both Helical Tomotherapy (HT) and Volumetric Modulated Arc Therapy (VMAT) are rotational radiotherapy modalities that use continuous gantry rotation with dynamic multi-leaf collimation. HT delivers intensity-modulated fan beams using binary MLC in a helical rotational pattern about
the patient by translating the patient through the rotating gantry (Tomotherapy Hi-Art System, Madison, Wisconsin) VMAT, by comparison, uses a conventional linear accelerator (linac) to deliver radiation in a cone-beam geometry using dynamic MLC, with no couch translation during the treatment. WHAT IS HT? Pioneered by Mackie (ref 22,23) Helical Tomotherapy was made commercially available by Tomotherapy Inc., and has been used for a wide variety of applications. The first Tomotherapy unit in Australia and New Zealand was commissioned in mid 2010. The unit superficially resembles a CT scanner in that the patient is translated through the central aperture of the circular unit as it rotates. Each gantry rotation consists of 51 equally spaced beam projections and 64 binary MLC leaves in each projection. Projection time is limited by gantry speed (15-60 seconds). The degree of intensity modulation is determined by the modulation factor, which is the maximum leaf open time divided by the average leaf open time. Similar to helical CT technology, the degree of fan-beam overlapping is determined by the pitch factor, which is the ratio of couch translation per rotation to the jaw width. In the current software version (version 3.1.4) the jaw width options are 1.0, 2.5 and 5.0cm. The radiation is delivered using a standard 6MV wave guide, very similar to that in a standard linear accelerator. WHAT IS VMAT? Volumetric Modulated Arc Therapy (VMAT) is a major advance over fixed gantry angle IMRT in the efficiency of delivery of the painted dose. Volumetric modulated arc therapy (VMAT) proposed by Otto (ref 3) is an Food and Drug Administration (FDA) approved treatment paradigm, which makes use of conventional current generation Linear Accelerator as are widely available in Australia. There are three mechanical variables in VMAT delivery: Gantry rotation Multileaf collimator motion, and Dose rate modulation Both the MLC aperture and the dose rate can be simultaneously adjusted in an arc of 360 degrees or less, whereas gantry speed is modulated as needed. During a VMAT treatment, the Linear Accelerator rotates around the patient while the radiation beam is shaped and reshaped as it is continuously delivered from virtually every angle in a revolution. During a VMAT treatment, specialized software algorithms will vary the three parameters simultaneously: the speed of rotation around the patient, the shape of the MLC aperture, and the dose delivery rate. The target volume dose does not change when using VMAT. The amount of scatter and leakage radiation dose to the rest of the body is reduced compared to conventional IMRT. VMAT uses a progressive sampling algorithm, which starts sampling from 10 gantry angles, and then with each level of optimization, the resolution is gradually improved. In the first level of optimization, the gap between the 10 gantry angles is 32 degrees, in the second level, there are 21 beams with a gap of 16 degrees, in the third level there are 43 gantry angles with a gap of 8 degrees, in the fourth level there are 87 gantry angles with a gap of 4 degrees and in the 5th and last level there are 177 gantry angles with a gap of 2 degrees.
Faculty of Radiation Oncology 8 The Evidence Base for Multiple Volumetric Modulated Arc Therapy
Figure 1: A diagrammatic representation of the gantry angle samples in the first (darker arrows) and second resolution levels of VMAT planning (author)
Figure 2: A diagrammatic representation of the 177 gantry angles sampled (2 degree separations) in the fifth resolution level of VMAT planning algorithm. (picture source Varian users presentation)
Both the MLC position and the monitor units are included as optimization parameters, with a cost-function based on dose volume constraints of the target and the normal tissues. During optimization, further constraints are imposed on MLC motion, dose rate, and gantry speed such that these variables are within the capability of the linac. The optimization process begins with a small number of points and gradually increases to ensure dose calculation accuracy. Ottos algorithm has been developed by Varian (Varian Medical Systems, Palo Alto, CA, USA) and is marketed as RapidArc. The US FDA approved RapidArc for clinical use in February 2008, with first patients treated in North American centres in May 2008. In its first released software version, only one or two full rotation arcs could be planned (Aria software version 8.5). The early marketing for the Varian VMAT product emphasized the single gantry rotation with the marketing catch phrase One revolution is all it takes! In the second software upgrade (Aria version 8.6) released in the first half of 2009, partial arcs, arcs with exclusion zones (e.g. so that the entry angle through a metallic hip replacement can be avoided) and arcs from different gantry angles (e.g. vertex fields for cranial treatments) allowed greater freedoms of dose intensity modulation for complex target volumes where adjacent critical normal tissue structures need to be avoided. There are currently more than 200 centres worldwide using this technology, including multiple centres in three Australian states, with more to follow. Elekta (Elekta AB, Stockholm, Sweden) also have a product named VMAT, which does not use Ottos algorithm, but uses a proprietary algorithm. This emphasized multiple arcs from the earliest software releases, in contrast to the early Varian releases (ref 4). The European Commission gave regulatory approval to Elekta VMAT in January 2008, with clinical use commencing in the United Kingdom and Austria the same month. The first North American centre went clinical in July 2008, and there are currently more than 200 centres worldwide using this technology. Multiple centres in Australia and New Zealand are close to going clinical with this technology. Early users of both the Varian and Elekta VMAT systems were quick to see the need to characterize the differences in plan quality, planning time, and delivery time for IMRT and VMAT.
Picture 3: Axial view of Multiple arc VMAT treatment in a patient with a metallic hip replacement - showing an exclusion arc segment avoiding entry dose through the prosthesis (Picture source Premion).
SINGLE ARC OR MULTIPLE ARC It was recognized by multiple authors very early on with IMRT that 7 and 9 field fixed gantry sliding window IMRT plans gave superior dose homogeneity to PTV than seen with 5 field treatments, by virtue of greater freedom of intensity modulation from more gantry angles. Similarly, the concern arose that a single 360-degree arc rotation was insufficient in terms of degrees of freedom of modulation for anything but the simplest of targets. Bortfield and Webb wrote a paper questioning the value of single arc treatments, highlighting the planning freedom constraints for complex targets with adjacent organs at risk (OAR) (ref 9). The criticisms in their paper, which was submitted for publication in August 2008, were effectively answered by Verbakel as by that time VMAT was in clinical use in Amsterdam, with VMAT single or double arc treatments having the variations in dose rate that are possible with the technology that had not been seen in earlier algorithms (ref 10). The planning technique for VMAT has evolved with software upgrades.When first introduced, a plan using a double arc to treat a 2 Gray PTV, the first arc optimization is dosed to 1 Gray. The second arc is then optimized to the existing single arc plan, with the smoothing and filling of cold spots and the cooling of hot spots, leading to a more homogenous PTV dosing. With the latest software versions, the planner defines two arcs with starting and stopping positions, and then the optimization occurs to the full 2Gy to the PTV. The VMAT optimization is a two-step process. A set of ideal intensity maps is generated first this takes 10-20 minutes. A leaf sequencing process where leaves move smoothly between adjacent arc segments follows this. This process used to take 20 minutes but has now been substantially shortened by employing four quad processors to optimize four arc segments simultaneously (ref 14). Additional boost volumes can be added with a second or third arc allowing concomitant boosts or field in field effects. The additional arc may also provide supplementary aperture shape variation for a complex dose distribution (ref 19). This is particularly useful in head and neck treatments with primary and nodal PTV, or for boosting a high-risk area within a PTV with a differential dose; and still adhering to theoretical constraints on overall treatment time.
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Figure 4: Diagram showing variation in dose delivery during a single gantry rotation in a VMAT prostate plan. (Picture courtesy Yves Archambauld)
VMAT TREATMENT DELIVERY TIMES At the commencement of treatment the gantry is at 178 degrees, and then travels in an anticlockwise direction (by convention) finishing at gantry position 182 degrees. As described by Ling (ref 11) the current mechanical constraints imposed by the maximum MLC leaf speed is 5mm per degree, corresponding to about 2.5cm per second. The allowable dose rate modulation is 30-600 monitor units per minute. When more than 2MU per degree is needed at certain beam angles, the gantry will decelerate to allow delivery of more radiation dose. This full rotation takes approximately 85 seconds. In a double arc treatment the second arc is typically slightly shorter in duration as there is somewhat less modulation and the combined treatment takes 155-170 seconds, with less than 5 seconds needed between arcs for the collimator to rotate 5 degrees to the new start position. The second arc is given in a clockwise direction starting with the gantry at 182 degrees and finishing at the original start location of 178 degrees. Note in Figure 4 how more MU are delivered in the lateral portals where the gantry rotation slows down. OAR constraints on the bladder and rectum limit dose delivery anteriorly and posteriorly. Also note that in the single arc plan there is asymmetry in that in this case more MU are given in the second half of the rotation than the first half. This asymmetric bias is a feature of the planning system and one of the major factors in the move to double arc treatments where the rotational bias is corrected by re-optimization, with gantry rotation in the opposite direction.
RADIOBIOLOGICAL CONSIDERATIONS The absolute reduction in treatment delivery time achieved by single or double arc VMAT compared to a seven-field sliding window IMRT in the Amsterdam paper ranged between 6 and 11 minutes (ref 6). This reduction in treatment time may increase the effectiveness of a given dose by up to 20%, depending on the tumour type (ref 8). HEAD AND NECK TREATMENTS After Vancouver - where Otto developed his VMAT algorithm-one of the first centres in the world to have access to VMAT was the VU University Medical Centre, Amsterdam, where there is a very strong medical physics research department. The VUMC has research collaborations with Varian Medical Systems. Head and neck treatments require multiple avoidance volumes of normal tissues to be spared including the parotid glands and the spinal cord. The clinical benefits of sparing the parotid glands, with resulting reduction in xerostomia, is a major benefit for IMRT compared to conventional 3D conformal radiotherapy (ref 5). For head and neck treatments, IMRT uses a larger number of static beams and monitor units, which typically leads to treatment times of 20 minutes and more patient exposure to scattered low-dose irradiation. The increase in the number of IMRT beams increases the degrees of freedom, making volumetric modulated arc therapy a logical next step in head and neck treatments. CT scans of 12 patients who had completed IMRT for advanced tumours of the naso-, oro- and hypopharynx were replanned using VMAT with one or two arcs. Calculated doses to the planning target volume (PTV) and organs at risk (OAR) were compared between IMRT and VMAT plans (ref 6). The results of this study were startling. The VMAT plans allowed for a mean reduction in number of monitor units (MU) by nearly 60%, relative to seven-field sliding-window IMRT plans. Dose to healthy organs not in the proximity of the PTV arises largely from collimator transmission and scatter dose from the linac, and this dose is proportional to the MU. Such scattered doses can increase the risk of secondary tumours (ref 7). These chances are now reduced by the use of VMAT without concessions to the dose distributions. The VMAT plans achieved a similar sparing of all OAR as IMRT. Double arc VMAT provided the best dose homogeneity to PTV with a lower standard deviation of PTV dose (1.4Gy) compared to single arc (2.0Gy) and IMRT (1.7Gy). The conclusion of this important study was that VMAT was a fast, safe and accurate technique that uses fewer monitor units than conventional head and neck IMRT. Because the delivery of VMAT was fast and allowed for large reductions in MU, VMAT had replaced IMRT for all indications at VUMC Amsterdam by November 2008. Double arc plans provided at least similar sparing of OAR and better dose homogeneity than single arc or IMRT. The first VMAT head and neck treatments in Australia were planned and carried out in June 2010, using a double arc technique (ref 13). PROSTATE In describing the initial clinical experience of VMAT at the University of Alabama at Birmingham (ref 17), an early adopting centre that started in May 2008, 33 patients with prostate cancer were treated in the first 12 months to April 2009. Of these, 16 were prostate only, 5 were prostate + seminal vesicles and 12 were prostate + SV + pelvic nodes. When compared with 7 field IMRT comparison plans, the mean delivery time difference was 2 min for the prostate only volumes and 6 min for the prostate + SV + nodes volumes favouring VMAT, even though the double arc technique was preferred for the composite volume plans over a single arc. The authors concluded that VMAT was a valuable clinical tool that was able to efficiently able to deliver radiotherapy in 1.5-3 minutes (single or double arcs) (ref 17).
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Picture 5: Coronal cross-sectional view of Multiple arc VMAT treatment targeting prostate and pelvic lymph nodes with differential target doses in a composite plan (Picture source Premion).
The first VMAT prostate treatments in Australia were planned and carried out in March 2009. More centres in Queensland, New South Wales and Victoria have commenced in the last 18 months, with the numbers of patient courses and experience growing. A presentation was given to the RANZCR meeting in October 2009 showing the dosimetric advantages of the double arc technique (ref 14). In a study including 10 high risk prostate cancer patients with seminal vesicle and pelvic lymph node involvement, from Duke University, plan comparisons with IMRT and VMAT were performed with all plans using 18MV photons. For the boost plans that included prostate+SV, dosimetric parameters in double arc plans were comparable to 7 field IMRT, whereas the single arc plans were slightly inferior to IMRT. For the more complicated prostate+SV +nodes volumes, the authors found that 9 field IMRT spared the bladder rectum and small bowel more than did VMAT. The delivery efficiency, in terms of treatment time, was noticeably improved with VMAT when the lymph nodes were involved. The authors point out that this improvement certainly cannot be prioritized over the apparent dosimetric benefit (ref 18). The study was unusual in using 18MV photon planning which is not undertaken by the vast majority of centres using IMRT or VMAT with more monitor unit redundancy with the higher energy beams as well as more collimator scatter and with pair production not seen at lower photon energies, and all of the international focus will continue to be for using 6MV photons. BREAST During left breast radiation therapy, a portion of the heart often receives a substantial dose, especially with the inclusion of the internal mammary nodes (IMN). The most common radiotherapy techniques used to treat the breast + IMN is a modified wide tangent or a matched medial electron strip matched to the photon tangents. IMRT techniques have been developed by many centres and shown to substantially reduce cardiac dose, but such treatments are complex to plan and treat employing between six and nine coplanar modular fields equally spaced in a 180-190 degree arc around the patients left breast and regional nodes.
In a planning comparison study from Vancouver, 5 patients treated with 9 field IMRT were replanned with VMAT (ref 20). For VMAT, a double arc technique using two 190 degree arcs with 2cm overlapping jaws were required to optimize over the large treatment volumes. The authors found that the treatment plans generated using VMAT double arc optimization resulted in PTV homogeneity similar to that of IMRT or modified wide tangents. The average heart volumes receiving > 30Gy for VMAT, IMRT or modified wide tangents were 2.6% +- 0.7%, 3.5% +-0.8%, and 16.4% +- 4.3% respectively.
The average mean dose to the contra lateral medial breast was 3.2 +- 0.6Gy for VMAT, 4.3 +0.9Gy for IMRT, and 4.4 +- 4.7Gy for modified wide tangents. The average ipsilateral lung volumes receiving >20Gy were 16.9% +- 1.1% for VMAT, 17.3% +0.9% for IMRT, and 37.3 % +- 7.2% for modified wide tangents. VMAT reduced the number of monitor units by 30% and the treatment time by 55% compared to IMRT. The authors concluded that double arc VMAT achieved similar PTV coverage and sparing of organs at risk as 9 field IMRT, with fewer monitor units and in a significantly shorter treatment time (ref 20). LUNG Hypo fractionated stereotactic body radiotherapy (SBRT) for stage 1 non-small cell lung cancer has been shown to have superior local control compared with conventionally fractionated radiotherapy (ref 15). In an Amsterdam study, 20 consecutive patients completed VMAT therapy (ref 16). Two-arc optimization was preferred, with the results of the first optimized plan calculated for half of the prescribed dose. This was then used as the base dose for the second arc optimization, which compensated for any under dosage in the PTV in the base dose plan arising from lack of electronic equilibrium at lung-tissue interfaces by giving more dose to these areas. Depending on the fraction size, each SBRT fraction used between 2 and six arcs, as the initial clinical version of VMAT only allowed for a maximum 999 monitor units per arc. In the chest, tumours situated close to critical normal tissues in the mediastinum, or in close proximity to the chest wall, required the most modulated plans. The lung cancer PTV took into account target motion due to respiration, with the VMAT delivery having important practical advantages in delivery over fixed gantry sliding window IMRT, where the direction of the sliding window over time is in one direction and the leaf motion is constantly perpendicular or parallel to the tumour motion due to the collimator fixed at 0 or 90 degrees. This can lead to a greater than 10% dose discrepancy in IMRT delivery. In contrast, VMAT delivers VMAT dose to the whole volume continuously during gantry rotation by use of a collimator angle between 40 and 45 degrees. In addition, the MLC leaves in VMAT plans move in both directions, and not only one way as in sliding window IMRT. Conformal and VMAT techniques Lung SBRT had similar dosimetric quality, but VMAT had improved target coverage and took 59% less time to deliver, although monitor units were increased by 5%. For lung, multiple partial arc treatments produced high quality hypo fractionated plans that could be delivered quickly and spared entrance dose from the opposite lung. For a left sided lung lesion the first anti-clockwise arc would be stopped at a gantry angle of approximately 330 degrees, before a second arc rotated clockwise back to the starting position.
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BRAIN Frameless single shot and fractionated stereotactic radiotherapy and intra-cranial image-guided radiation therapy and intensity modulated radiation therapy for complex shaped base of skull tumours with surrounding organs at risk are major skill sets at leading Australian radiation oncology centres. Carbon fibre customized head and neck immobilization shells are required to be purchased, as part of the rotational arc traverses through the base plate. This has been commissioned and entered clinical practice at a number of centres in 2010, after a series of plan comparisons with conventional four and five field conformal plans have been undertaken. The published literature at this time for VMAT intra-cranial treatments is limited. The lack of current publications under-estimates the high level of interest from clinicians and physicists with stereotactic planning skills. With the updated software version of VMAT (Eclipse version 8.6) as well as partial arcs, arcs at variable couch angles can be modeled and planned, and it was this development that led to the implementation of Australian clinical practice. In particular, the use of a vertex partial arc with the couch at 90 degrees is a major dosimetric advance available in VMAT treatments, with starting and stopping angles avoiding eyes and brainstem structures. This is probably the clinical application showing most clearly the demonstrable superiority of multiple arcs over single arc VMAT treatments. In a recently published study of 12 patients delivering frameless stereotactic radiotherapy (SRT) using VMAT, dosimetric indices for conformality, homogeneity and dose gradient were calculated and compared with published results from other frameless, intracranial SRT techniques, including CyberKnife, Tomotherapy and static beam IMRT. The results showed that dose indices compared favourably with other techniques. Median treatment times with double arc VMAT were 4.8 +/- 1.7 minutes (ref. 25).
Picture 6: Diagram of an Intracranial VMAT beam arrangement using a double-arc technique combining an axial single arc and a non co-planar partial arc. (Picture source: Premion)
OTHER CLINICAL APPLICATIONS In a paper showing the potential benefit of VMAT compared with conformal and IMRT techniques in paediatric cancer, bone marrow sparing whole-abdominopelvic irradiation and, Matuszak et al., when examining the potential benefit of VMAT compared with conventional techniques in paediatric cancer, whole-abdomino-pelvic techniques and stereotactic body radiation therapy (SBRT) of the lung and spine found that VMAT reduced the treatment time of spine SBRT by 37% and improved dose conformality. In more complicated spine cases, the authors found that multiple arc treatments could improve the dose distribution without a significant increase in time or MU (ref 12). In a complex paediatric pelvic case, VMAT reduced the treatment time by 78% and monitor units by 25% compared to IMRT. A double isocentre VMAT technique for whole abdominopelvic irradiation was shown to spare bone marrow whilst maintaining good treatment delivery. This paper (ref 12) used Pinnacle 3 (cubed) treatment planning system from Phillips (Phillips Healthcare, Andover, MA, USA), the VMAT module of which was not at that stage interactive with the MOSAIC linac verification and recording system. The benefits were thus theoretical, but show that other vendors are close behind Varian and Elekta with approved VMAT platforms for clinical treatment. QUALITY ASSURANCE For VMAT commissioning and QA, the two elements to be considered are linac commissioning and patient specific dosimetry. VMAT treatments are a development from IMRT using static fields, and institutions implementing VMAT should be familiar with IMRT commissioning and QA. Standard commissioning includes testing gantry and MLC isocentricity, gantry position indicators, and dose calibration in both static gantry and arc therapy mode. Picket fence tests at multiple gantry angles are also preformed. This establishes the accuracy of dynamic MLC position, and dose-rate. Patient specific dosimetry QA includes the use of phantom dosimetric tests of central isodose using mini-ion chambers and planar dose distributions using calibrated matrix dosimetry devices such as those used in IMRT QA of clinical treatment plans. This is undertaken for all patients (ref 11). COMPARISON OF HELICAL TOMOTHERAPY AND VMAT TECHNIQUES A collaborative dosimetric comparison between HT and single arc VMAT was undertaken in 16 cases. Four cancer sites including brain, head and neck, lung and prostate were selected. Planners were blinded to the plan comparison. For all the 16 cases compared, the average beam on time was 1.4 minutes for VMAT, and 4.8 minutes for Tomotherapy. The total monitor units were lower in VMAT than in Tomotherapy, whereas Tomotherapy delivered better target dose homogeneity (7.6% for VMAT and 4.2% for Tomotherapy). Dose conformation numbers were comparable, with VMAT being superior to Tomotherapy (0.67 vs. 0.60). When the initial blinding was taken away and an opportunity given to re-plan the differences between the two planning techniques in terms of target conformality and avoidance structures narrowed considerably. A comparison with a double arc VMAT technique was not performed in this study, but this could have been expected to further improve the plan dose conformality (ref 24).
16
Helical Tomotherapy is by definition a multiple rotational therapy, with a body of published literature confirming it as a treatment delivery system with many of the same dosimetric advantages that IMRT and VMAT offer, with a unique delivery platform. CONCLUSIONS Currently available radiotherapy treatment techniques differ in terms of the trade-offs between treatment planning time, treatment delivery time, and overall plan quality. IMRT plan generation times are shorter than for VMAT plans. (ref 21) Faster processor speeds and use of 4 quad processors now in use are speeding up the leaf sequencing optimization component of the VMAT planning. VMAT either single arc or double arc has significantly faster treatment delivery times than IMRT. This may have radiobiological advantages in head and neck cancers where the dose rate effect of the 2Gy fraction delivery time may be of clinical relevance, and may be have geometric certainty advantages in targets where intra-fraction organ movement (prostate and lung) is relevant. With respect to plan quality, for simple planning target volumes such as prostate alone, a single arc plan may be acceptable in terms of target coverage and sparing of organs at risk, but sparing of OAR and PTV dose homogeneity can be further improved by adding a second arc and repeating the optimization. For more complex volumes, as shown by multiple authors sited in this document looking at multiple treatment sites in the body, the second arc and optimization is not optional, and the additional arc degrees of modulation are required for optimal plan delivery such that a single arc plan would be an unacceptable compromise. At the ASTRO meeting held in San Diego in November 2010, more than twenty abstracts describing VMAT in multiple clinical settings were presented, with an emerging consensus of its utility and adaptability for state-of-the-art radiotherapy treatment delivery at multiple leading centres around the world. Specifically, this document provides significant evidence that volumetric modulated arc therapy, when performed with multiple arcs, achieves superior target dose homogeneity and adjacent normal tissue sparing in a range of tumour sites when compared to 6 field 3D conformal radiotherapy. It is in all ways equivalent to the best planned multiple field IMRT in dosimetric terms and is considerably more efficient in terms of treatment delivery, with important radiobiological advantages to the patient, who also benefits from reduced discomfort associated with a reduction in treatment times, particularly for complex volumes such as head and neck sites.
BIBLIOGRAPHY APPENDIX I
1. Ling CC, Burman C, Chui CS et al. Conformal radiation treatment of prostate cancer using inversely-planned intensity modulated photon beams produced with dynamic multileaf collimation. Int J Radiat Oncol Biol Phys 1996, 35(4): 721-30 2. Veldeman L, Madani I, Hulstsert F, et al. Evidence behind use of intensity-modulated radiotherapy: a systemic review of comparative clinical studies. Lancet Oncology 2008,9(4): 367-375 3. Otto K. Volumetric modulated arc therapy: IMRT in a single gantry arc. Med Phys. 2008; 35(1): 310-317 4. Elekta Inc. VMAT Technology review 2009 http://www.elekta.com/healthcare_international_ elekta_vmat.php 5. Pow EH, Kwong DL McMillan AS et al. Xerostomia and quality of life after intensity-modulated radiation therapy vs. conventional radiotherapy for early stage nasopharyngeal carcinoma: Initial report on a randomized controlled trial. Int J Radiat Oncol Biol Phys 2006; 66: 981-991 6. Verbakel W, Cuupers J, Hoffmans D et al Volumetric Intensity Modulated Arc Therapy vs. Conventional IMRT in Head and Neck Cancer: A Comparative Planning and Dosimetric Study. Int J Radiat Oncol Biol Phys 2009, 74(1): 252-259 7. Hall EJ Intensity-modulated radiation therapy, protons, and the risk of second cancers. Int J Radiat Oncol Biol Phys 2006; 65(1): 1-7 8. Bewes JM et al. The radiobiological effect of intra-fraction dose-rate modulation in intensity modulated radiation therapy (IMRT) Phys Med Biol 53: 3567 9. Bortfield and Webb. Single Arc IMRT? 2009 Phys Med Biol, 2009; 54: N9-20 10. Verbakel et al. Comments on Single Arc IMRT? Phys Med Biol, 2009; 54: L31-34 11. Ling CC, Zhang P, Archambauld Y. Commissioning and quality assurance of RapidArc radiotherapy delivery system. Int J Radiat Oncol Biol Phys 2008; 72:575-581 12. Matuszak MM, Yan D, Grills I, and Martinez A. Clinical Applications of Volumetric Modulated Arc Therapy. Int J Radiat Oncol Biol Phys 2010; 77(2): 608-616 13. Dr Tom Eade, RNSH, personal communication 14. MacKean J, Buchanan M, Kenny J Murray M. Initial experience with volumetric modulated arc therapy one revolution or two. Presented at RANZCR meeting Oct 2009. 15. Grutters JP et al Comparison of the effectiveness of radiotherapy with photons, protons and carbon ions fore non small cell lung cancer: A meta-analysis. Radiother Oncol 2010; 95:32-40 16. Ong CL, Verbakel W et al. Dosimetric Impact of Interplay effect on RapidArc lung stereotactic lung delivery. Int J Radiat Oncol Biol Phys. 2010 Article in press Oct 1. 17. Pople RA, et al. RapidArc radiation therapy: first year experience at the University of Alabama at Birmingham. Int J Radiat Oncol Biol Phys 2010; 77(3): 932-941 18. Yoo S, Wu J, Lee R, Yin FF Radiotherapy Treatment plans with RapidArc for Prostate Cancer involving Seminal Vesicles and Lymph Nodes. Int J Radiat Oncol Biol Phys 2010; 76 (3): 935-942
18
19. Tang G, Earl MA, Yu CX et al. Comparing radiation treatments using intensity modulated beams, multiple arcs and single arcs. Int J Radiat Oncol Biol Phys 2010; 76(5): 1554-1562 20. Popes CC, Olivotto IA, Beckham WA et al. Volumetric Modulated Arc therapy improves dosimetry and reduces treatment time compared to conventional intensity modulated radiotherapy for locoregional radiotherapy of left sided breast cancer and internal mammary nodes. Int J Radiat Oncol Biol Phys 2010; 76 (1): 287-295
21. Oliver et al. Trade-offs in IMRT, RapidArc and Tomotherapy. Journal of App Clin Med Phys. 2009; 10(4): 117-131 22. Mackie TR. History of Tomotherapy. Phys Med Biol. 2006; 51 : R427-453 23. Mackie TR, Balog J, Ruchala K et al. Tomotherapy. Semin Radiat Oncol. 1999; 9 : 108-117 24. Rong Y, Tang G, Welsh JS et al, Helical Tomotherapy versus Single-Arc Intensity Modulated Arc Therapy: A Collaborative Dosimetric comparison between two institutions. Int J Radiat Oncol Biol Phys article in press Jan 14 2011 25. Mayo CS, Ding L, Addesa A et al, Initial experience with Volumetric IMRT (RapidArc) for Intracranial Stereotactic Radiosurgery. Int J Radiat Oncol Biol Phys 2010; 78 (5): 1457-1466
APPENDIX II: DETAILED EVIDENCE FOR THE BENEFITS OF SINGLE AND MULTI ARC VMAT
No. of Patients 4 No. of Arcs 1/2
Ref
Site H&N
Conclusion IMRT and dual arc VMAT achieved a similar plan quality, while single arc could not provide an acceptable plan quality. Dual arc VMAT delivery time is about 30% of IMRT delivery time. Dual arc VMAT is a fast and accurate technique for the treatment of head and neck cancer. It applies similar number of MUs as IMRT, but the treatment time is strongly reduced, maintaining similar or better dose conformity to the PTV and OAR sparing. Equivalent or superior target coverage and sparing of OARs were achieved with VMAT compared to IMRT. CI(95%) of the elective PTV was improved from 1.7 with IMRT to 1.6 with VMAT. VMAT reduced the number of MUs by 8.5% to 460+/-63 MUs per fraction. The treatment time was on average reduced by 35%. Rapid Arc improved PTV coverage (V(95%) = 90.2% +/- 5.2% for RA compared with 82.5% +/- 9.6% and 84.5% +/- 8.2% for Conformal RT and IMRT, respectively). Most planning objectives for organs at risk were met by all techniques except for the duodenum, small bowel, and stomach, in which the CRT plans exceeded the dose/volume constraints in some patients. The MU/fraction values were as follows: 2186 +/- 211 for RA, 2583 +/- 699 for IM, and 1554 +/- 153 for CRT. Effective treatment time resulted as follows: 3.7 +/- 0.4 min for RA, 10.6 +/- 1.2 min for IM, and 6.3 +/- 0.5 min for CRT. Delivery of SBRT by RA showed improvements in conformal avoidance with respect to standard conformal irradiation. Delivery parameters confirmed logistical advantages of Rapid Arc, particularly compared with IMRT. Dose-volume histogram comparisons demonstrate that this VMAT planning method offers multiple dose level target coverage comparable to that from a standard IMRT approach. The VMAT plans also show superior sparing of critical structures such as the rectum and bladder. Delivery times are reduced with the VMAT method, and the results of dosimetric verification, resilience and repeatability tests indicate that the solution is robust. For OAR sparing, the non-coplanar plans showed significant improvement for the cases with intra-cranial targets. For example, the maximum and mean doses to brainstem were reduced by 23% and 34% reduction. The average maximum dose to the chiasm was also reduced by 61%. For extra-cranial cases, however, there are no consistent improvements in OAR sparing for the non-coplanar plans. The average treatment delivery time increased from 1.9 to 4.5 minutes for the noncoplanar plans. For extra-cranial cases, only modest gains in OAR sparing were observed particularly for structures that are in close proximity to the targets.
(1)
(2)
H&N
25
(3)
Abdominal Nodes
14
(4)
Pelvis
N/S
(5)
CNS H&N Lung Prostate
1-3
20
Ref (6)
Site Brain Mets
No. of Patients 1
No. of Arcs 1-3
Conclusion Multiple noncoplanar arcs showed small improvements in the conformity indexes compared with the single-arc/singleisocenter and triple-arc (coplanar)/triple-isocenter plans. Multiple arc plans (triple-arc (noncoplanar)/single-isocenter and triple-arc (coplanar)/triple-isocenter) showed smaller 12Gy isodose volumes in scenarios involving three metastases spaced closely together, with only small differences noted among all plans involving lesions spaced further apart. Initial results suggest that single-isocenter VMAT plans can be used to deliver conformity equivalent to that of multiple isocenter VMAT techniques. For targets that are closely spaced, multiple noncoplanar single-isocenter arcs might be required. VMAT radiosurgery for multiple targets using a single isocenter can be efficiently delivered, requiring less than one-half the beam time required for multiple isocenter set ups. VMAT radiosurgery will likely replace multi-isocenter techniques for linear acceleratorbased treatment of multiple targets. VMAT had an improved homogeneity (D(5%)-D(95%) = 3.5 +/0.6 Gy for VMAT and 4.3 +/- 0.8 Gy for IMRT) and conformity index (CI(90%) = 1.30 +/- 0.06 for VMAT and 1.41 +/- 0.15 for IMRT). Rectal mean dose was reduced by about 6 Gy. For the bladder, VMAT allowed a reduction of mean dose ranging from approximately 4 to 6Gy. Similar trends but with smaller absolute differences were observed for the small bowel and left and right femur. NTCP calculations on bladder and rectum confirmed the DVH data with a potential relative reduction ranging from 30 to 70% from IMRT to VMAT. The healthy tissue was significantly less irradiated in the medium to high dose regions (from 20 to 30 Gy) and the integral dose reduction with VMAT was about 12% compared to IMRT. VMAT shows significant improvements in organs at risk and healthy tissue sparing with uncompromised target coverage leading to better conformal avoidance of treatments w.r.t. conventional IMRT. For prostate cancer and vertebral metastases single arc VMAT led to similar plan quality as compared to IMRT. For treatment of the hypopharynx/larynx cancer, a second arc was necessary to achieve sufficient plan quality. Treatment time was reduced in all cases to 35% to 43% as compared to IMRT. Times required for optimization and dose calculation, however, increased by a factor of 5.0 to 6.8. Similar or improved plan quality can be achieved with VMAT as compared to IMRT at reduced treatment times but increased calculation times. One P-Arc was to be on average a better technique, as it provides a PTV dose distribution highly conformal (Conformity index 1.45), homogeneous (D(5%)-D(95%)=15.6%), with adequate coverage (V(90%)=96.4%) and a limited involvement of the ipsilateral lung (MLD approximately 9 Gy, V(5 Gy) approximately 36%, NTCP<2%) when compared to four other treatment techniques. For early stage breast cancer when high sparing of lung tissues is required and no involvement of contralateral breast is allowed, the single P-Arc or the 3FieldNon Coplanar techniques might be recommended in terms of dosimetric expectations.
(7)
Cervix
(8)
Various
N/S
1-2
(9)
Breast
7 difficult anatomy
1-2
Ref (10)
Site Prostate H&N
No. of Patients 20
No. of Arcs 1-3
Conclusion Single arc VMAT improved target coverage and dose homogeneity in radiotherapy for prostate cancer. Two and three VMAT arcs were required to achieve equivalent results compared to IMRT in postoperative and primary radiotherapy for pharyngeal cancer, respectively. In radiotherapy for cancer of the paranasal sinuses, multiarc VMAT resulted in increased spread of low doses to the lenses and decreased target coverage in the region between the orbits. The complexity of the target volume determined whether single arc VMAT was equivalent to IMRT. Multiple arc VMAT improved results compared to single arc VMAT at cost of increased delivery times, increased monitor unites and increased spread of low doses. VMAT plans resulted in a statistically significant reduction in the rectal V25Gy parameter of 8.2% on average over the IMRT plans and lower rectal NTCP. 18.6% fewer monitor units and a delivery time reduction of up to 69%. VMAT plans resulted in reductions in rectal doses for all 10 patients in the study. Given the target coverage was equivalent, the VMAT plans were superior. VMAT provided satisfactory target conformality and OAR sparing comparable to IMRT. VMAT required fewer MU than IMRT (relative reduction of 19%; p = 0.006). Mean treatment time was 133 seconds for VMAT, versus 358 seconds for IMRT (p = 0.006). Grade 3 or worse acute toxicities were not seen. VMAT tends to yield similar dose distribution to MRT with fixed gantry. VMAT also decreases monitor units as well as treatment delivery time to less than 5 minutes. However, VMAT is an IMRT technique more difficult to master than S&S IMRT technique because there are more variable parameters. Arc IMRT appears a new promising IMRT modality, decreasing dramatically treatment duration. However, this IMRT-based dosimetric benefit may not be translated into a full clinical benefit, if intra-pelvic prostate motion is not taken in account. Image-guided radiotherapy (IGRT) should be therefore associated with IMRT for a maximal clinical benefit. This article is a literature review showing the interest of both combined approaches.
(11)
Prostate
10
(12)
Prostate
10
(13)
Review Article
N/A
N/A
(14)
Review Article
N/A
N/A
22
Ref (15)
Site Brain Mets
No. of Patients 10
No. of Arcs 1-2
Conclusion Compared with IMRT, the maximum dose in Rapid Arc 2 plans to the brainstem, left and right optic nerves, left and right lens was reduced by 1.6 Gy, 6 Gy, 3 Gy, 1.5 Gy, 1.3 Gy, respectively. The percentage of healthy tissue volume receiving 5 Gy was larger with RA1 (56.7%) and RA2 (57.1%) than with IMRT (52.9%), while the percentages of volume receiving 15 Gy and 20 Gy were smaller with RA1 (27.1%, 18.7%) and RA2 (25%, 16.3%) than with IMRT (28.8%, 19.1%). No significant difference was observed between RA1 and RA2. The mean number of MU per fraction of 5 Gy was 1944 +/- 374 (IMRT), 1199 +/- 173 (RA1) and 1387 +/- 186 (RA2), respectively. Compared with IMRT, the MUs were reduced by 36.8% and 27.2% with RA1 and RA2. The pure beam-on time needed per fraction was 6.5 +/- 1.2 min (IMRT), 1.25 min (RA1) and 2.5 min (RA2), respectively. The beam-on time for RA1 and RA2 was approximately 80% and 40% less compared to IMRT. 2 Arcs achieves slight improvements in PTV coverage and sparing of organs at risk. The treatment efficiency, using less monitor units and shorter treatment delivery time, is the most obvious advantage. Volumetric modulated arc therapy reduced the treatment time of spine SBRT by 37% and improved isodose conformality. Conformal and VMAT techniques for lung SBRT had similar dosimetric quality, but VMAT had improved target coverage and took 59% less time to deliver, although monitor units were increased by 5%. In a complex pediatric pelvic example, VMAT reduced treatment time by 78% and monitor units by 25% compared with IMRT. A double-isocenter VMAT technique for WAPI can spare bone marrow while maintaining good delivery efficiency. Lung V(20/12.5/10/5) were less with VMAT (relative reduction 4.5%, p = .02; 3.2%, p = .01; 2.6%, p = .01; 4.2%, p = .03, respectively). Mean/maximum-doses to PTV, dose to additional OARs, 95% isodose line conformity, and target volume homogeneity were equivalent. VMAT improved conformity at both the 80% (1.87 vs. 1.93, p = .08) and 50% isodose lines (5.19 vs. 5.65, p = .01). Treatment times were reduced significantly with VMAT (mean 6.1 vs. 11.9 min, p < .01) Single arc VMAT planning achieves highly conformal dose distributions while controlling dose to critical structures, including significant reduction in lung dose volume parameters. Employing a VMAT technique decreases treatment times by 37-63%, reducing the chance of error introduced by intrafraction variation. The quality and efficiency of VMAT is ideally suited for stereotactic lung radiotherapy delivery.
(16)
Various
1-2
(17)
Lung
21
Ref (18)
Site Prostate H&N
No. of Patients 10
No. of Arcs 1
Conclusion The VMAT optimization problem is formulated as a large-scale convex programming problem solved by a column generation approach. The algorithm was preliminarily tested on five prostate and five head-and-neck clinical cases, each with one full gantry rotation without any couch/collimator rotations. High quality VMAT plans have been generated for all ten cases with extremely high efficiency. It takes only 5-8 min on CPU (MATLAB code on an Intel Xeon 2.27 GHz CPU) and 18-31 s on GPU (CUDA code on an NVIDIA Tesla C1060 GPU card) to generate such plans. The authors have developed an aperturebased VMAT optimization algorithm which can generate clinically deliverable high quality treatment plans at very high efficiency. VMAT SBRT plans achieved a superior conformity index (CI) and lower V(45 Gy) to chest wall (p<0.05) compared to all other techniques. VMAT led to a small increase in V(5 Gy) to contralateral lung compared to conf-SBRT (4.44% versus 1.21.8%, p=0.011). For other OAR, VMAT and conf-SBRT plans were comparable, and both were superior to Conformal plans. Delivery of a 7.5 Gy-fraction required 3.9 min (VMAT), 11.6 min (conf-SBRT), and 12 min (IMRT). In this work a novel plan optimization platform is presented where treatment is delivered efficiently and accurately in a single dynamically modulated arc. Preliminary results show that plans generated with VMAT optimization exhibit dose distributions equivalent or superior to static gantry IMRT. Timing studies have shown that the VMAT technique is well suited for on-line verification and adaptation with delivery times that are reduced to approximately 1.5-3 min for a 200 cGy fraction. The IMRT and both VMAT techniques resulted in lower doses to normal critical structures than 3D-CRT plans for nearly all dosimetric endpoints analyzed. The lowest doses to organs at risk and most favorable equivalent uniform doses were achieved with vdr-VMAT, which was significantly better than IMRT for the rectal and femoral head dosimetric endpoints (p < 0.05) and significantly better than cdr-VMAT for most bladder and rectal endpoints (p < 0.05). The vdr-VMAT and cdr-VMAT plans required fewer monitor units than did the IMRT plans (relative reduction of 42% and 38%, respectively; p = 0.005) but more than for the 3D-CRT plans (p = 0.005). Therapy for 5 patients previously treated with 50 Gy/25 fractions using nine-field cIMRT was replanned with VMAT and MWT. VMAT achieved similar PTV coverage and sparing of organs at risk, with fewer monitor units and shorter delivery time than cIMRT. VMAT is more efficient, offers equivalent or better dose conformity, delivers lower doses to the ipsilateral lung and breast, and may potentially reduce intrafractional motion.
(19)
Lung
18
(20)
Review
N/A
(21)
Prostate
10
(22)
Breast
(23)
Breast
24
Ref (24)
Site Prostate
No. of Patients 24
No. of Arcs 1
Conclusion Treatment delivery times were 1.5-2 minutes for the VMAT plans vs. 7-9 minutes for the fixed field IMRT plans. VMAT plans that are equivalent to or superior to fixed field IMRT plans can be achieved for most patients with localized prostate cancer. VMAT plans offer the potential for reduced doses to adjacent organs, especially at lower dose levels (V40). VMAT plans can be delivered significantly faster than fixed field IMRT plans, allowing potential for operational efficiency and improved patient comfort. Only 28% of patients experienced G3 mucositis, 14% G3 dermitis 44% had G2 dysphagia. Nobody required feeding tubes to be placed during treatment. These preliminary results stated that volumetric modulated arc therapy in locally advanced head and neck cancers is feasible and effective, with acceptable VMAT and cIMRT boosted an average of 68.8 and 63.5% of the CTV to >or=120% of the prescription dose (P=0.002). All dose constraints were kept within predefined limits. VMAT and cIMRT required an average of 949 and 1819 monitor units and 3.7 and 9.6min, respectively, to deliver a single radiation fraction.VMAT is able to boost more of the CTV to >or=120% than cIMRT without contravening OAR dose constraints, and uses 48% fewer monitor units. Treatment times were 61% less than with cIMRT. There was equivalent PTV coverage, homogeneity, and conformality. VMAT significantly reduced maximum and mean retinal, lens, and contralateral optic nerve doses compared with IMRT (p < 0.05). Brainstem, chiasm, and ipsilateral optic nerve doses were similar. For 2-Gy fractions, mean monitor units were as follows: cIMRT = 789 +/- 112 and VMAT = 363 +/- 45 (relative reduction 54%, p = 0.002), and mean treatment times (min) were as follows: cIMRT = 5.1 +/- 0.4 and VMAT = 1.8 +/0.1 (relative reduction 65%, p = 0.002). VMAT achieved equal or better PTV coverage and OAR sparing while using fewer monitor units and less time to treat high-grade gliomas. Multiarc (IMAT) provided the best plan quality, while singlearc VMAT achieved dose distributions comparable to those of IMRT, especially in the complicated head-and-neck and brain cases. Both VMAT and IMAT showed effective normal tissue sparing without compromising target coverage and delivered a lower total dose to the surrounding normal tissues in some cases. IMAT provides the most uniform and conformal dose distributions, especially for the cases with large and complex targets, but with a delivery time similar to that of IMRT; whereas VMAT achieves results comparable to IMRT with significantly faster treatment delivery. For the smallest tumor (26.7 cc), multiple-arc RA showed advantages over IMRT and HT in PTV coverage, dose homogeneity, and OAR sparing. For the larger brain tumors both HT and RA-NCPA offered high quality of PTV coverage and dose homogeneity.
(25)
H&N
45
N/S
(26)
Prostate
10
N/S
(27)
CNS
10
N/S
(28)
Various
12
N/S
(29)
CNS
N/S
Ref (30)
Site Prostate
No. of Patients 12
No. of Arcs
Conclusion HT provided superior conformity and significantly less rectal volume exposed to 65 Gy and 40 Gy, as well as EUD/NTCP of rectum than step-and-shoot IMRT, whereas VMAT had a slight dosimetric advantage over step-and-shoot IMRT. Notably, significantly lower MUs were needed for VMAT (309.7 +/35.4) and step-and-shoot IMRT (336.1 +/- 16.8) than for HT (3368 +/- 638.7) (p < 0.001). The treatment time (minutes) was significantly shorter for VMAT (2.6 +/- 0.5) than stepand-shoot IMRT (3.8 +/- 0.3) and HT (3.8 +/- 0.6) (p < 0.001). VMAT and step-and-shoot IMRT have comparable dosimetry, but treatment efficiency is significantly higher for VMAT than for step-and-shoot IMRT and HT.
(31)
H&N
12
1-2
RA plans allowed for a mean reduction in number of monitor units (MU) by nearly 60%, relative to seven field sliding window IMRT plans. RA plans achieved similar sparing of all OAR as IMRT. Double arc RA provided the best dose homogeneity to PTV with a lower standard deviation of PTV dose (1.4 Gy), vs. single arc plans (2.0 Gy) and IMRT (1.7 Gy). Film measurements showed good correspondence with calculated doses; the mean gamma value was 0.30 (double arc) and area of the film with a gamma exceeding 1 was 0.82%.RA is a fast, safe, and accurate technique that uses lower MUs than conventional IMRT. Double arc plans provided at least similar sparing of OAR and better PTV dose homogeneity than single arc or IMRT. Both IMRT and RA2 resulted in superior coverage of PTV than RA1 that was slightly inferior for conformity and homogeneity (p < 0.05).Conformity index (CI95%) for the PTV2 was 1.15 0.15 (RA2), 1.28 0.22 (IMRT), and 1.79 0.5 (RA1). Homogeneity (D5% - D95%) for PTV2 was 3.21 1.16 Gy (RA2), 2.98 0.7 Gy (IMRT), and 4.3 1.3 Gy (RA1). VMAT showed to be superior to IMRT in terms of organ at risk sparing. For bowel, the mean dose was reduced by 4 Gy by RA2 compared to IMRT. Similar trends were observed for bladder, femoral heads, and genitalia. The DVH of iliac crests and healthy tissue resulted in comparable sparing for the low doses (V10 and V20). Compared to IMRT, mean MUs for each fraction was significantly reduced with VMAT (p = 0.0002) and the treatment time was reduced by a 6-fold extent. VMAT with 2 arcs was able to deliver equivalent treatment plan to IMRT in terms of PTV coverage. It provided a better organ at risk sparing and significant reductions of MU and treatment time per fraction.
(32)
Anal
10
1-2
26
Ref (33)
Site Review
No. of Patients N/S
No. of Arcs N/S
Conclusion Intensity modulated radiation therapy (IMRT) offers optimal dosimetric and clinical results in terms of acute toxicity, allows augmenting the dose to the target volumes and therefore, appears promising for local control and disease-free survival. However, several pitfalls to this treatment are to be considered, namely a long treatment time and a high number of monitor unit (MU) required. The dosimetric results of the volumetric modulated arctherapy gives at least similar target coverage and preservation of organs at risk, while significantly reducing the number of required MUs and the overall treatment time. This has a potential impact on the treatment quality and the potential risk of secondary cancers. Volumetric modulated arctherapy allows implementation of stereotactic radiation therapy and complex treatments previously considered not feasible with IMRT. The future will involve this technology of high precision to determine the dose and to the target in real time using the image-guided radiotherapy. Tools combining these two methods are in development. RESULTS: For MIMiC/IMRT(MLC)/VMAT2x/VMAT1x/3DCRT, mean CI was 1.5/1.23/1.45/1.51/1.46 and HI was 1.19/1.1/1.09/1.11/1.04. For a prescribed dose of 76 Gy, mean doses to organs-at-risk (OAR) were 50.69 Gy/53.99 Gy/60.29 Gy/61.59 Gy/66.33 Gy for the anterior half of the rectum and 31.85 Gy/34.89 Gy/38.75 Gy/38.57 Gy/55.43 Gy for the posterior rectum. Volumes of non-target normal tissue receiving > or =70% of prescribed dose (53 Gy) were 337 ml/284 ml/482 ml/505 ml/414 ml, for > or =50% (38 Gy) 869 ml/933 ml/1155 ml/1231 ml/1993 ml and for > or =30% (23 Gy) 2819 ml/3414 ml/3340 ml/3438 ml /3061 ml. D(95%) was 69.79 Gy/70.51 Gy/71,7 Gy/71.59 Gy/73.42 Gy. Mean treatment time was 12 min/6 min/3.7 min/1.8 min/2.5 min. All approaches yield treatment plans of improved quality when compared to 3D-conformal treatments, with serial tomotherapy providing best OAR sparing and VMAT being the most efficient treatment option in our comparison. Plans which were calculated with 3D-CRT provided good target coverage but resulted in higher dose to the rectum. RA provides a new alternative for single-fraction SRS irradiation combining advantages of short treatment time with lower number of MU and better conformity in addition to accuracy of stereotactic localisation in selected cases with uncomplicated clinical realization.
(34)
Prostate
1-2
(35)
Brain Mets
10
N/S
Ref (36)
Site Spine
No. of Patients 10
No. of Arcs 1-2
Conclusion The PTV DVHs were comparable between VMAT and IMRT plans in the shoulder (D(99%)-D(90%)), slope (D(90%)-D(10%)), and tail (D(10%)-D(1%)) regions. Only VMAT(2arc) had a better conformity index than IMRT (1.09 vs. 1.15, p = 0.007). For cord sparing, IMRT was the best, and VMAT(1arc) was the worst. Use of IMRT achieved greater than 10% more D(1%) sparing for six of 10 cases and 7% to 15% more D(10%) sparing over the VAMT(1arc). The differences between IMRT and VAMT(2arc) were smaller and statistically nonsignificant at all dose levels. The differences were also small and statistically nonsignificant for other OAR sparing. The mean monitor units (MUs) were 8711, 7730, and 6317 for IMRT, VMAT(1arc), and VMAT(2arc) plans, respectively, with a 26% reduction from IMRT to VMAT(2arc). The mean treatment time was 15.86, 8.56, and 7.88 min for IMRT, VMAT(1arc,) and VMAT(2arc). The difference in integral dose was statistically nonsignificant. Although VMAT provided comparable PTV coverage for spine SBRT, 1arc showed significantly worse spinal cord sparing compared with IMRT, whereas 2arc was comparable to IMRT. Treatment efficiency is substantially improved with the VMAT. The study showed not only that SIB by RA can achieve superior plans compared with SEQ plans on the same platform and SIB plans on HT, but also the feasibility to optimize prescription dose in a SIB plan. A maximal therapeutic ratio can be achieved with BTV dose 50-100% higher than the PTV dose, depending on the shape and position of the tumor. The results show that up to 4 arcs may be necessary to provide uniform dose to the surface of the PTV with the current version of the PRO. In the primary IMRT with PTV(P), average mean doses to bladder, rectum and small bowel were lower by 5.9%, 7.7% and 4.3%, respectively, than in the primary 1ARC and by 3.6%, 4.8% and 3.1%, respectively, than in the primary 2ARC. In the boost IMRT with PTV(B), average mean doses to bladder and rectum were lower by 2.6% and 4.8% than with the boost 1ARC and were higher by 0.6% and 0.2% than with the boost 2ARC. Integral doses were 7% to 9% higher with VMAT than with IMRT for both primary and boost plans. Treatment delivery time was reduced by 2-7 minutes using VMAT. For PTVs including prostate, seminal vesicles, and lymph nodes, IMRT performed better in dose sparing for bladder, rectum, and small bowel than did VMAT. For PTVs including prostate and seminal vesicles, VMAT with two arcs provided plans comparable to those for IMRT. The treatment delivery is more efficient with VMAT. Patient-averaged PTV V95, D95, mean dose, and tumor control probability in VMAT plans were 96%, 82.6 Gy, 88.5 Gy, and 0.920, respectively, vs. 97%, 84.0 Gy, 88.9 Gy, and 0.929 in IMRT plans. All critical structure dose requirements were met. The VMAT plans presented better rectal wall sparing, with a reduction of 1.5% in normal tissue complication probability. An advantage of VMAT plans was that the average number of MUs (290 MU) was less than for IMRT plans (642 MU). The VMAT technique can reduce beam on time by up to 55% while maintaining dosimetric quality comparable to that of the standard IMRT approach.
(37)
Phantom
N/A
N/A
(38)
Prostate
10
1-2
(39)
Prostate
11
28
BIBLIOGRAPHY APPENDIX II
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(12) N. Hardcastle, W. A. Tom, K. Foo, A. Miller, M. Carolan, and P. Metcalfe, Comparison of prostate imrt and vmat biologically optimised treatment plans, Medical Dosimetry: Official Journal of the American Association of Medical Dosimetrists, Aug. 2010. (13) K. Ishii et al., Clinical Application of Aperture-based VMAT with Ring-shaped Region of Interest for Planning in Localized Prostate Cancer, International Journal of Radiation Oncology*Biology*Physics, vol. 78, no. 3, p. S377, Nov. 2010.
(14) C. Lafond et al., (Which IMRT? From step and shoot to VMAT: physicist point of view), Cancer Radiothrapie: Journal De La Socit Franaise De Radiothrapie Oncologique, vol. 14, no. 6, pp. 539-549, Oct. 2010. (15) I. Latorzeff, J. Mazurier, C. Boutry, P. Dudouet, P. Richaud, and R. de Crevoisier, (Benefit of intensity modulated and image-guided radiotherapy in prostate cancer), Cancer Radiothrapie: Journal De La Socit Franaise De Radiothrapie Oncologique, vol. 14, no. 6, pp. 479-487, Oct. 2010. (16) Y. Ma et al., Hypofractionated stereotactic radiotherapy for brain metastases: a dosimetric and treatment efficiency comparison between volumetric modulated arc therapy and intensity modulated radiotherapy, Technology in Cancer Research & Treatment, vol. 9, no. 5, pp. 499507, Oct. 2010. (17) S. D. McGrath, M. M. Matuszak, D. Yan, L. L. Kestin, A. A. Martinez, and I. S. Grills, Volumetric modulated arc therapy for delivery of hypofractionated stereotactic lung radiotherapy: A dosimetric and treatment efficiency analysis, Radiotherapy and Oncology: Journal of the European Society for Therapeutic Radiology and Oncology, vol. 95, no. 2, pp. 153-157, May. 2010. (18) C. Men, H. E. Romeijn, X. Jia, and S. B. Jiang, Ultrafast treatment plan optimization for volumetric modulated arc therapy (VMAT), Medical Physics, vol. 37, no. 11, pp. 5787-5791, Nov. 2010. (19) A. Y. Minn et al., Comparison of intensity-modulated radiotherapy and 3-dimensional conformal radiotherapy as adjuvant therapy for gastric cancer, Cancer, vol. 116, no. 16, pp. 3943-3952, Aug. 2010. (20) K. Otto, Volumetric modulated arc therapy: IMRT in a single gantry arc, Medical Physics, vol. 35, no. 1, pp. 310-317, Jan. 2008. (21) D. Palma et al., Volumetric modulated arc therapy for delivery of prostate radiotherapy: comparison with intensity-modulated radiotherapy and three-dimensional conformal radiotherapy, International Journal of Radiation Oncology, Biology, Physics, vol. 72, no. 4, pp. 996-1001, Nov. 2008. (22) C. C. Popescu et al., Volumetric modulated arc therapy improves dosimetry and reduces treatment time compared to conventional intensity-modulated radiotherapy for locoregional radiotherapy of left-sided breast cancer and internal mammary nodes, International Journal of Radiation Oncology, Biology, Physics, vol. 76, no. 1, pp. 287-295, Jan. 2010. (23) J. Qiu, Z. Chang, Q. J. Wu, S. Yoo, J. Horton, and F. Yin, Impact of volumetric modulated arc therapy technique on treatment with partial breast irradiation, International Journal of Radiation Oncology, Biology, Physics, vol. 78, no. 1, pp. 288-296, Sep. 2010.
30
(24) S. Rosenthal et al., Comparison of Volumetric Modulated Arc Therapy (VMAT) vs. Fixed Field Intensity Modulated Radiation Therapy (IMRT) Techniques for the Treatment of Localized Prostate Cancer, International Journal of Radiation Oncology*Biology*Physics, vol. 78, no. 3, p. S755, Nov. 2010. (25) M. Scorsetti et al., Early clinical experience with volumetric modulated arc therapy in head and neck cancer patients, Radiation Oncology (London, England), vol. 5, p. 93, 2010.
(26) R. Shaffer et al., Volumetric modulated Arc therapy and conventional intensity-modulated radiotherapy for simultaneous maximal intraprostatic boost: a planning comparison study, Clinical Oncology (Royal College of Radiologists (Great Britain)), vol. 21, no. 5, pp. 401-407, Jun. 2009. (27) R. Shaffer et al., A comparison of volumetric modulated arc therapy and conventional intensity-modulated radiotherapy for frontal and temporal high-grade gliomas, International Journal of Radiation Oncology, Biology, Physics, vol. 76, no. 4, pp. 1177-1184, Mar. 2010. (28) C. Tsai, J. Wu, H. Chao, Y. Tsai, and J. C. Cheng, Treatment and Dosimetric Advantages Between Vmat, Imrt, and Helical Tomotherapy in Prostate Cancer, Medical Dosimetry: Official Journal of the American Association of Medical Dosimetrists, Jul. 2010. (29) I. Turesson, G. Notter, I. Wickstrm, K. A. Johansson, and S. Eklund, The influence of irradiation time per treatment session on acute and late skin reactions: a study on human skin, Radiotherapy and Oncology: Journal of the European Society for Therapeutic Radiology and Oncology, vol. 2, no. 3, pp. 235-245, Oct. 1984. (30) L. Veldeman, I. Madani, F. Hulstaert, G. De Meerleer, M. Mareel, and W. De Neve, Evidence behind use of intensity-modulated radiotherapy: a systematic review of comparative clinical studies, The Lancet Oncology, vol. 9, no. 4, pp. 367-375, Apr. 2008. (31) S. Vieillot et al., (Which intensity modulated radiation therapy? From step and shoot to volumetric modulated arc therapy, point of view of the radiation oncologist), Cancer Radiothrapie: Journal De La Socit Franaise De Radiothrapie Oncologique, vol. 14, no. 6, pp. 550-553, Oct. 2010. (32) D. Wolff et al., Volumetric modulated arc therapy (VMAT) vs. serial tomotherapy, stepand-shoot IMRT and 3D-conformal RT for treatment of prostate cancer, Radiotherapy and Oncology: Journal of the European Society for Therapeutic Radiology and Oncology, vol. 93, no. 2, pp. 226-233, Nov. 2009. (33) H. A. Wolff, D. M. Wagner, H. Christiansen, C. F. Hess, and H. Vorwerk, Single fraction radiosurgery using Rapid Arc for treatment of intracranial targets, Radiation Oncology (London, England), vol. 5, p. 77, 2010. (34) D. Wolff et al., Clinical implementation of volumetric intensity-modulated arc therapy (VMAT) with ERGO++, Strahlentherapie Und Onkologie: Organ Der Deutschen Rntgengesellschaft ... (et Al, vol. 186, no. 5, pp. 280-288, May. 2010. (35) Q. J. Wu, S. Yoo, J. P. Kirkpatrick, D. Thongphiew, and F. Yin, Volumetric arc intensitymodulated therapy for spine body radiotherapy: comparison with static intensity-modulated treatment, International Journal of Radiation Oncology, Biology, Physics, vol. 75, no. 5, pp. 1596-1604, Dec. 2009. (36) S. Yoo, Q. J. Wu, W. R. Lee, and F. Yin, Radiotherapy treatment plans with RapidArc for prostate cancer involving seminal vesicles and lymph nodes, International Journal of Radiation Oncology, Biology, Physics, vol. 76, no. 3, pp. 935-942, Mar. 2010.
(37) A. S. Zacarias, M. F. Brown, and M. D. Mills, Volumetric modulated Arc therapy (VMAT) treatment planning for superficial tumors, Medical Dosimetry: Official Journal of the American Association of Medical Dosimetrists, vol. 35, no. 3, pp. 226-229, 2010. (38) T. M. Zagar, C. G. Willett, and B. G. Czito, Intensity-modulated radiation therapy for anal cancer: toxicity versus outcomes, Oncology (Williston Park, N.Y.), vol. 24, no. 9, pp. 815-823, 828, Aug. 2010.
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ACKNOWLEDGMENTS
To Dr James MacKean and Professor Chris Hamilton for researching and writing this Position Paper To Professor Geoff Delaney, John Stubbs and Natalia Vukolova for editorial assistance
32
ACRONYMS AND ABBREVIATIONS

ASTRO CNS CRT CT CTV DVH FDA H&N HT IGRT IMRT IMN Linac MLC MU NTCP OAR PTV QA RANZCR RCT RT SBRT SIB SRT 3DCRT VMAT American Society of Therapeutic Radiology and Oncology Central Nervous System Conformal Radiotherapy Computed Tomography Clinical Target Volume Dose-volume histogram Food and Drug Administration (USA) Head and Neck Helical Tomotherapy Image Guided Radiation Therapy Intensity-Modulated Radiation Therapy Internal Mammary Nodes Linear Accelerator Multileaf Collimator Monitor Units Normal Tissue Complication Probability Organs At Risk Planning Target Volume Quality Assurance Royal Australian and New Zealand College of Radiologists Randomised Controlled Trials Radiotherapy Stereotactic Body Radiotherapy Simultaneous Integrated Boost Stereotactic Radiotherapy Three-Dimensional Conformal Radiotherapy Volumetric Modulated Arc Therapy
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FACULTY OF RADIATION ONCOLOGY

THE ROYAL AUSTRALIAN AND NEW ZEALAND COLLEGE OF RADIOLOGISTS

The Evidence Base for Multiple Volumetric Modulated Arc Therapy

Faculty of Radiation Oncology

VOLUMETRIC MODULATED ARC THERAPY (VMAT)

FACULTY OF RADIATION ONCOLOGY POSITION

The Evidence Base for Multiple Volumetric Modulated Arc Therapy 5

Faculty of Radiation Oncology

The Evidence Base for Multiple Volumetric Modulated Arc Therapy

APPENDIX I: THE HISTORICAL AND TECHNICAL BACKGROUND TO VMAT

The Evidence Base for Multiple Volumetric Modulated Arc Therapy 7

Faculty of Radiation Oncology

The Evidence Base for Multiple Volumetric Modulated Arc Therapy 9

Faculty of Radiation Oncology

The Evidence Base for Multiple Volumetric Modulated Arc Therapy

Faculty of Radiation Oncology

The Evidence Base for Multiple Volumetric Modulated Arc Therapy 11

Faculty of Radiation Oncology

The Evidence Base for Multiple Volumetric Modulated Arc Therapy

Faculty of Radiation Oncology

The Evidence Base for Multiple Volumetric Modulated Arc Therapy 13

Faculty of Radiation Oncology

The Evidence Base for Multiple Volumetric Modulated Arc Therapy

The Evidence Base for Multiple Volumetric Modulated Arc Therapy 15

Faculty of Radiation Oncology

The Evidence Base for Multiple Volumetric Modulated Arc Therapy

Faculty of Radiation Oncology

The Evidence Base for Multiple Volumetric Modulated Arc Therapy 17

Faculty of Radiation Oncology

The Evidence Base for Multiple Volumetric Modulated Arc Therapy

Faculty of Radiation Oncology

The Evidence Base for Multiple Volumetric Modulated Arc Therapy

CNS H&N Lung Prostate

Site Brain Mets

No. of Arcs 1-3

The Evidence Base for Multiple Volumetric Modulated Arc Therapy 21

Faculty of Radiation Oncology

Site Prostate H&N

No. of Arcs 1-3

Faculty of Radiation Oncology

The Evidence Base for Multiple Volumetric Modulated Arc Therapy

Site Brain Mets

No. of Arcs 1-2

The Evidence Base for Multiple Volumetric Modulated Arc Therapy 23

Faculty of Radiation Oncology

Site Prostate H&N

Faculty of Radiation Oncology

The Evidence Base for Multiple Volumetric Modulated Arc Therapy

The Evidence Base for Multiple Volumetric Modulated Arc Therapy 25

Faculty of Radiation Oncology

Faculty of Radiation Oncology

The Evidence Base for Multiple Volumetric Modulated Arc Therapy

No. of Patients N/S

No. of Arcs N/S

The Evidence Base for Multiple Volumetric Modulated Arc Therapy 27

Faculty of Radiation Oncology

No. of Arcs 1-2

The Evidence Base for Multiple Volumetric Modulated Arc Therapy

Faculty of Radiation Oncology

The Evidence Base for Multiple Volumetric Modulated Arc Therapy 29

Faculty of Radiation Oncology

The Evidence Base for Multiple Volumetric Modulated Arc Therapy