1

Simultaneous integrated boost plan comparison of static intensity-modulated radiotherapy

and volumetric-modulated arc therapy for prostate fossa and lymph nodes irradiation: A
Case Study
Author: Titus Kyenzeh, BSc, CMD
Medical Dosimetry Program at the Uniersity o! "isconsin # $a Crosse, "%
Abstract:
Introduction: The aim o! this study &as to ealuate the dosimetric adantages o! olumetric
modulated arc thera'y ()MAT* ersus intensity modulated radiation thera'y (%M+T* in regard to
target dose con!ormity, normal tissue, and critical structure s'aring !or simultaneously integrated
,oost (S%B* treatment 'lans-
Case Description: .our 'reiously treated 'atients &ere randomly selected !rom a 'ool o!
'atients &ith high ris/ adenocarcinoma o! the 'rostate a!ter la'arosco'ic radical 'rostatectomy-
The target olumes &ere de!ined as 'er +T01 2345- The )MAT 'lans consisted o! t&o arcs
running cloc/&ise and counter6cloc/&ise res'ectiely- 7ine eenly s'aced co6'lanar ,eams
&ere used !or the %M+T 'lans- A total o! 8 'lans &ere generated9 5 in each techni:ue- The
'elic nodes &ere treated to 53 1y in 1-8 1y daily !ractions- The 'rostatic !ossa &as
simultaneously treated to ;<-3 1y deliered in <-3 1y daily !ractions- The 'arameters ealuated
included the con!ormity inde= (C%* at the >8? isodose line, the MUs, and the normal tissue
integral dose (7T%D*-
Conclusion: The goal &as to delier the 'rescri'tion dose to coer >3? o! the 'lanning target
olume (PT)* olume- Based on the 5 'atients@ 'lan com'arisons, the con!ormity outcomes !or
,oth techni:ues suggest that )MAT gies a slightly ,etter con!ormity than %M+T &hen
deliering S%B adAuant radiation thera'y !or 'osto'eratie cancer 'atients- %n addition, results
!rom normal tissue integral dose data suggest that the dose deliered to non6tumor tissue &as
lo&er !or )MAT-
Key Words: Prostatic !ossa, normal tissue integral dose (7T%D*, simultaneous integrated ,oost
(S%B*, 'rostate cancer-
<
Introduction
Currently 'rostate cancer is the most common cancer among males in the United States-
Based on the stage, the treatment o'tions aaila,le to 'rostate cancer 'atients include surgery,
radiation thera'y, chemothera'y or a com,ination o! t&o or all the three- According to the
American Cancer Society (ACS*, the estimated ne& 'rostate cancer cases in <215 &ill ,e
<44,222, re'resenting <B-<? o! all cancers in men- A total o! <>,582 deaths !rom 'rostate cancer
are 'roAected to occur in the United States in <215-
1
Currently, the acce'ted treatment o'tions o!
such 'atients include radical 'rostatectomy, e=ternal6,eam radiation thera'y, ,rachythera'y, and
&atch!ul &aiting- AdAuant radiation thera'y is the 're!erred treatment !or high ris/
adenocarcinoma o! the 'rostate a!ter la'arosco'ic radical 'rostatectomy-
<
Co&eer, during
radiation, non6inoled tissue might receie a su,stantial amount o! dose, leading to increased
ris/ o! deelo'ing secondary malignancy- The role o! radiation thera'y in the treatment o!
'atients &ith 'rostate cancer is constantly increasing as less6inasie treatment modalities are
sought !or the management o! this &idely 'realent disease-
4
+adiation thera'y has ,een
associated &ith late occurrences o! radiation6induced malignancies &ithin the surrounding non6
inoled areas due to radiation scatter-
Three dimensional6con!ormal radiation thera'y (4DC+T* &as the standard treatment
'lanning techni:ue in clinics around the &orld until the adent o! intensity modulated radiation
thera'y (%M+T* in the last 16< decades- The latter has ,een sho&n to delier ,etter con!ormed
dose to the targeted treatment area, &hile giing ,etter s'aring o! adAacent critical organs- Uysal
et al-
5
concluded that %M+T is an e!!ectie de!initie treatment tool !or 'rostate cancer &ith
im'roed critical organ s'aring and e=cellent deliery o! a more homogenous dose in target
organs o! the 'rostate and seminal esicles- %n recent years, the second generation o! %M+T
/no&n as olumetric modulated arc thera'y ()MAT* has ,ecome increasingly the techni:ue o!
choice !or treatment o! high ris/ 'rostatectomy 'atients- Com'ared to static ,eam %M+T,
rotational )MAT is su''osed to decrease the treatment deliery times &ith at least similar or
een ,etter 'lan :uality-
3

%n this case study, it &as hy'othesized that in the deliery o! simultaneous integrated
,oost !or 'rostatic !ossa and lym'h node treatments, )MAT may hae su'eriority oer %M+T in
4
terms o! ,oth normal tissue integral dose and dose to organs at ris/ (0+*- There!ore, the case
study &as underta/en to com'are simultaneously integrated ,oost treatment 'lans created using
static %M+T and )MAT techni:ues- The aim o! the case study &as to ealuate the dosimetric
adantages o! each techni:ue in regard to target dose con!ormity, normal tissue and critical
structure s'aring-
Case Description
Patient Selection and Setup
.our 'reiously treated 'atients &ere randomly selected !rom a 'ool o! 'atients &ith high
ris/ adenocarcinoma o! the 'rostate a!ter la'arosco'ic radical 'rostatectomy- All 'atients
receied 'elic lym'hatic radiation- Based u'on +T01 2345 guidelines, all 'atients &ere
simulated head6!irst in the su'ine 'osition- 1eneral Dlectric (1D* Big Bore com'uted
tomogra'hy (CT* scanner &as used to generate <-3 mm thic/ CT images- The 'atient &as
immo,ilized on the CT ta,le &ith the aid o! a !ull6,ody )ac6$o/EBody.i= ,ag- The arms &ere
'laced on the chest holding a ,lue ring !or com!ort (.igure 1*- %n order to de!ine a re!erence
'oint !or treatment 'lanning, tattoo mar/s &ere 'laced on the 'atient@s s/in using the anterior6
'osterior (AP* and lateral room lasers- To ensure setu' re'roduci,ility and that the target
remained in the same treatment 'osition, image guided radiation thera'y (%1+T* &as used-
%mage6guided radiation thera'y not only 'roides accurate in!ormation on 'atient and tumor
'osition on a :uantitatie scale, it also gies an o''ortunity to eri!y consistency o! 'lanned and
actual treatment geometry including ada'tation to daily setu' ariations resulting in an im'roed
dose deliery-
;
Target Delineation
Target olumes &ere outlined in )elocityA% 4-2-1 !usion so!t&are ,e!ore they &ere
e='orted to Phili's Pinnacle >-; treatment 'lanning system (TPS*- The target olumes &ere
de!ined as 'er +T01 2345- The radiation oncologist outlined the gross tumor olumes (1T)*
that &ere e='anded to !orm the clinical target olumes (CT)*- The 'lanning target olumes
(PT)* &ere generated ,y adding a margin to the CT) !or the 'ur'oses o! treatment 'lanning-
The medical dosimetrist contoured the 0+, &hich included the rectum, ,ladder, sigmoid, 'enile
,ul,, small ,o&el and !emoral heads- The 'enile ,ul, &as not gien a constraint ,ut &as used as
a re!erence structure only- All 'lanning &as done on Pinnacle >-; TPS-
5
Treatment Planning
The radiation oncologist 'rescri,ed 53 1y in 1-8 1y daily !ractions to the 'elic nodes-
The 'rostatic !ossa &as simultaneous ,oosted to ;<-3 1y deliered in <-3 1y daily !ractions- A
total o! 8 'lans &ere generated9 5 in each techni:ue- The )MAT 'lans consisted o! t&o arcs
running cloc/&ise and counter6cloc/&ise res'ectiely- The 'ath length o! each arc &as 455F
(8F643<F* &ith the collimator rotated 13F in the !irst arc and >2F in the counter6cloc/&ise arc-
7ine eenly s'aced co6'lanar ,eams &ere used !or the %M+T 'lans- The goal &as to delier the
'rescri'tion dose to coer >3? o! the PT) olume, as 'er ,oth the +T01 2345 and the
institutional 'rotocols- The 0+ constraints are summarized on Ta,le 1-
The medical dosimetrist used a''ro'riate 'arameters !or 'lan o'timization to create
suita,le 'lans that met the set criteria- A <122DG linear accelerator &ith ; megaolts (M)* &as
used to 'lan the treatment- Dach !ield &as gien a margin o! 12 mm around the PT) to
com'ensate !or the ,eam 'enum,ra- The same constraints and dose re:uirements !or the %M+T
'lans &ere also a''lied in the )MAT 'lans- %n order to achiee the constraints o! the small
,o&el, the medical dosimetrist created a secondary target (PT) 0'timization* that e=cluded 'art
o! the ,o&el in the PT)- This is the target structure that &as used in the 'lan o'timization- The
'rimary PT) olumes ('rostatic ,ed and 'elic lym'h node PT)* ranged ,et&een >8;-22 and
1,<<B-22 cc-
Plan Analysis & Evaluation
Although the medical dosimetrist encountered di!!iculties in meeting some o! the gien
constraints, deliera,le 'lans &ere generated in all the 8 cases- The isodose distri,ution o! one o!
the cases is demonstrated in .igure <- A dose olume histogram (D)C* !or the CT), PT),
rectum, sigmoid small, ,o&el and !emoral heads com'aring )MAT and %M+T !or one o! the
'atients is demonstrated in .igure 4- The degree o! con!ormity o! each treatment techni:ue &as
ealuated ,y calculating the con!ormity inde= (C%* at the >8? isodose line- Con!ormity inde=
&as de!ined as the ratio o! the olume o! total tissue receiing the re!erence dose to the olume
o! PT) as 'resented in .igure 5-
B
To calculate the 7T%D, the irradiated non6tumor tissue olume and the dose deliered &ere ta/en
into account- 7ormal tissue integral dose &as calculated manually and de!ined as a mean dose
times the olume o! the structure, .igure 3-
;
%n order to calculate the 7T%D alues, structures
generated !rom the 32?, 52?, 42? and 13? isodose lines &ere used-
3
+esults !rom Ta,le < sho& that the con!ormity inde= !or )MAT is relatiely ,etter than !or
%M+T- This is de'icted in the tight dose distri,utions around the target seen in the )MAT 'lans
(.igure ;*- The con!ormity inde= !or )MAT &as ,etter than %M+T ,y ;-B?- The )MAT 'lans
deliered a''ro=imately 3? MUs less than the %M+T 'lans- .or all the isodose structures
generated, the calculated 7T%D !or )MAT sho&ed im'roed s'aring as com'ared to the %M+T
'lans- The highest dis'arity &as recorded in the 42? isodose structure in all the 5 'atients- 7o
other studies could ,e !ound to su''ort my data-
Conclusion
Simultaneous integrated ,oost may ,e !aster to 'lan and delier since the same treatment
'lan is used !or the entire length o! treatment- Since the treatment time is shorter in S%B
treatments, the com'romise is that the ,oost receies higher !ractional doses (<-3 1yE!raction*-
The ultimate e!!ect is that the surrounding normal tissues &ill also receie higher dose 'er
!raction- The 'ro,a,ility that the normal tissue &ill deelo' second malignant neo'lasms
there!ore increases- %n this study, the con!ormity outcomes !or ,oth techni:ues suggest that
)MAT gies a slightly ,etter con!ormity than %M+T &hen deliering adAuant radiation thera'y
!or high ris/ 'rostatectomy 'atients- .urthermore, the aerage 'ercent di!!erence ,et&een the
t&o techni:ues &as 8?, suggesting that the dose deliered to non6tumor tissue is lo&er in
)MAT- %n terms o! critical structure s'aring, the )MAT techni:ue signi!icantly 'roduced ,etter
s'aring 'lans-
Although this case study is ,ased on only 5 'atients, !urther studies &ill ,e needed to esta,lish
the statistical signi!icance o! di!!erent doses to normal tissue ,et&een the t&o techni:ues-
;
References
1- Prostate cancer- American Cancer Society &e,site-
htt':EE&&&-cancer-orgEcancerE'rostatecancerEdetailedguideE'rostate6cancer6/ey6statistics-
<215- Accessed Huly <5 <215
<- Bur/hardt H, $et&in M, +ose C, et al- Com'aring the costs o! radiation thera'y and radical
'rostatectomy !or the initial treatment o! early6stage 'rostate cancer- J Clin Oncol-
<22<9<2(1<*:<8;>6<8B3- htt':EEd=-doi-orgE12-1<22EHC0-<22<-11-14;
4- Sountoulides P, Koletsas 7, Ki/ida/is D, Paschalidis K, So!i/itis 7- Secondary malignancies
!ollo&ing radiothera'y !or 'rostate cancer- Ther Adv Urol. <2129<(4*:11>61<3-
htt':EEd=-doi-orgE12-11BBE1B3;<8B<124B55;<
5- Uysal B, BeyzadeoIlu M, Sager 0, et al- Dosimetric ealuation o! intensity modulated
radiothera'y and 56!ield 46D con!ormal radiothera'y in 'rostate cancer treatment- al!an
"ed J- <214942(1*:3563B- htt':EEd=-doi-orgE12-313<E,al/anmedA-<21<-2B3
3- Colt A, 1estel D, Arends M, et al- Multi6institutional com'arison o! olumetric modulated
arc thera'y s- intensity6modulated radiation thera'y !or head6and6nec/ cancer: a 'lanning
study- #adiat Oncol. <21498(1*:<;- htt':EEd=-doi-orgE12-118;E1B586B1BG686<;
;- 1u'ta T, 7arayan C- %mage6guided radiation thera'y: 'hysicianJs 'ers'ecties- J "ed Phys-
<21<94B(5*:1B5618<- htt':EEd=-doi-orgE12-5124E2>B16;<24-124;2<
B- Tyagi A, Su'e S, Sandee', Singh M- A dosimetric analysis o! ;M) ersus 13M) 'hoton
energy 'lans !or intensity modulated radiation thera'y (%M+T* o! carcinoma o! ceri=- +e'
Pract 0ncol +adiother- <212913(3*:1<36141- htt':EEd=-doi-orgE12-121;EA-r'or-<212-28-22<
B
igures
igure !- Patient holding a ,lue ring !or com!ort-
igure "- Dose distri,ution on a=ial ie&s !or (a* )MAT and (,* %M+T- )MAT demonstrates
tighter isodose lines around the PT) (green* than %M+T-
8
igure #- A dose olume histogram (D)C* !or the CT), PT), small ,o&el, sigmoid, rectum, and
right !emoral head com'aring )MAT (solid lines* and %M+T (dotted lines* !or one o! the
'atients-
igure $- Con!ormity inde= at the >8? isodose line-
igure %- 7ormal tissue integral dose-
>
igure &- Dose distri,ution com'arison: )MAT 'lans resulted in tighter dose distri,utions
around the target than %M+T 'lans-
12
'ables
'able !: 0,Aecties and Constraints
'able "- Com'arison o! aerage MUs, con!ormity inde=, and normal tissue integral doses-
(arameter )*s CI+,- %.- $.- #.- !%-
/)A'
0Avg1
;51 2-42 145,5;2-<> 185,B4B-34 <5>,358-88 4<>,<55-BB
Static I)R'
0Avg1
;B4 2-<8 14>,5;8-51 <24,141-1B <8<,>48-B1 455,;18-58
(ercent Diff
0-1
3-2 6;-B 4-B 12-2 14-5 5-B