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A Dosimetric Study using Split X-Jaw Planning Technique for the Treatment of Endometrial Carcinoma

Jeanette Keil, BS, RT(R)(T) CMD; Joanne Carda, BS, RT(R)(T); Jade Reihart, BS, RT(T)

ABSTRACT

The aim of this study was to determine if the split x-jaw planning technique could be used to improve plan conformality and limit dose to organs at risk (OAR) in planning target volumes (PTV) that require field sizes larger than the 15 cm extent of the MLC in the x-jaw position. Traditional planning techniques include limited and open x-jaw methods. A retrospective study of 20 patients was conducted; creating split, limited, and open x-jaw volumetric modulated arc radiotherapy (VMAT) plans for each patient for comparison purposes. For each patient, the optimization objectives were kept consistent among the 3 plans to reduce variability. Dose statistics included the PTV conformity index (CI) and dose to OAR were collected and used to evaluate plan performance. Results showed the split x-jaw planning method had the most consistent CI with 0.98±0.02, followed by the open method with 1.01±0.03, and the limited with 1.04±0.05. On average, the split method also spared the OAR. In comparison to the limited technique, the split method reduced the dose by 4.0% to the bowel, 3.4% to the rectum, 2.2% to the sigmoid, 3.5% to the right femoral head, and 3.9% to the left femoral head. The split technique showed improvement over the open method as well limiting the bowel by 3.8%, the rectum by 3.2%, the sigmoid by 2.1%, the right femoral head by 4.5%, and the left femoral head by 6.3%. The split technique also spared the bladder with a 1.1% decrease over the limited method however, the open and split technique showed comparable results. The monitor units (MUs) were highest in the split plans (avg 706 MU), intermediate in the limited plans (avg 650 MU), and lowest in the open plans (avg 583 MU) and reflect plan modulation. The study concluded the split x-jaw technique could be used to produce superior VMAT plans for PTVs larger than the maximum extent of the MLC of 15 cm, in the x-jaw direction. Keywords: Split x-jaw technique, volumetric modulated arc radiotherapy (VMAT), expansive planning target volume (PTV)

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Introduction Linear accelerators are highly technical machines used to deliver radiation for therapeutic cancer treatments. The main goal of this technology is to provide adequate dose to a target volume to eliminate cancer cells while minimizing exposure to surrounding healthy tissues. 1 Two aspects of the mechanical design that allow for beam shaping are the collimator jaws and the multi-leaf collimator (MLC). The collimator jaws are solid lead blocks used to create rectangular treatment fields, while the MLC are comprised of individual movable leaves and provide additional beam shaping. A novel treatment technique utilizing the MLCs is volumetric modulated arc therapy (VMAT). 2 Volumetric modulated arc therapy allows for high quality planning and more efficiency than static gantry angle techniques. Although VMAT greatly enhanced radiotherapy offering increased tumor volume conformality, there are limitations in relation to the MLC. The leaves in the Varian linear accelerator travel on a carriage that allows a maximum extension of the x-jaw to 15 cm. Overextension when using VMAT reduces the modulation level and results in poor target dose distribution and OAR sparing, therefore, to achieve high modulation, adequate dose coverage, and better OAR avoidance, the x-jaw should be limited to 15 cm or less. 1, 3-5 A planning target volume (PTV) may come in a variety of shapes and sizes that includes the gross tumor, sub-clinical disease, and a margin which allows for uncertainties in treatment planning and delivery, specifically setup error and movement. The gross tumor volume (GTV) and clinical target volume (CTV) are extensive in cases with bulky disease and nodal involvement. In conventional VMAT, the typical field size is 20-25 cm along the transverse direction to cover the entire PTV region. 3 Due to the physical limitation of the MLCs in Varian linear accelerators, treatment planning for these cases can become problematic. Current VMAT treatment planning methods include open and limited x-jaw techniques. 3 In open x-jaw plans, the jaw width is automatically set to cover the entire target area. These fields typically extend over the 15 cm MLC limitation and yield reduced modulation and plan conformality. The limited x-jaw technique offers an advantage in that the jaw width remains at 15 cm, resulting in better dose distribution and OAR sparing. 4 However, due to the limited field size, there may be areas in which large PTVs are only partially covered, which can be avoided by using multiple arcs. Both the limited and open methods offer opportunities for improvement.

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The split x-jaw technique divided the open field that contained the entire PTV into 2 fields with overlap on each side of the central axis, resulting in a total of 4 treatment arcs. The fields were limited to 15 cm to offer increased modulation and conformality. The split x-jaw technique has shown positive results in head and neck treatment planning however, exploring the versatility of the technique in other areas of the body, such as the abdomen and pelvis, is necessary. The aim of this paper was to introduce the split x-jaw planning technique for the treatment of endometrial carcinoma and investigate the advantages over open and limited approaches. Methods and Materials Patient Selection Twenty patients diagnosed with endometrial carcinoma in need of radiotherapy were selected retrospectively for this study. To be considered, each case needed an established PTV requiring an x-jaw greater than 19 cm for adequate coverage. The CTV was contoured and expanded by 0.7 cm to create the PTV based on the Radiation Therapy Oncology Group (RTOG) 0921 protocol. Boost plans were not included in the research. The patients were imaged in the treatment position with a Siemens CT scanner using 0.3 cm slice thickness. Each patient was positioned head first and supine with a Vac Fix Cushion under the legs for immobilization. The arms were placed high on the chest holding a blue ring for patients with no nodal disease involvement. Cases with nodal involvement were scanned with the arms up on a wingboard. The attending radiation oncologist placed a vaginal marker for delineation in 19 of the 20 cases and 3-point reference marks were created for setup reproducibility. The scan parameters included anatomy from the second lumbar vertebral body through mid-femur in 14 cases. The remaining 6 patients showed paraaortic nodal involvement and required more margin on the superior aspect of the imaging study. Contouring Following simulation, patient datasets were imported into the Eclipse 13.5 treatment planning system (TPS) for delineation of target volumes and OAR. Target volumes were developed by the attending radiation oncologist to include the GTV and CTV according to the RTOG 0921 protocol guidelines. The CTV was contoured and expanded by 0.7 cm to create the PTV for adequate treatment margin. The OAR were contoured by the medical dosimetrist and included the bladder, rectum, sigmoid, bowel, and right and left femoral heads according to

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RTOG 0921 protocol guidelines. The kidneys were also contoured for paraaortic nodal involvement. Prior to planning for this study, image datasets were evaluated, and contours were modified on an as needed basis for consistency and correctness. Treatment Planning For each case, three separate treatment plans were generated to include the open, limited, and split x-jaw planning techniques utilizing the Eclipse 13.5 TPS. A single dosimetrist completed at 60 plans for this study to reduce variability. Patients were prescribed a dose of 45 Gy in 25 fractions and boost plans were not included in this study. The Eclipse Arc Geometry Tool was used to place the isocenter in the center of the PTV and treatments were executed on a Varian Truebeam linear accelerator with beam energies of 6MV and maximum dose rates of 600 MU/min. The open and limited techniques employed coplanar dual arcs (clockwise rotation from 180° to 179° and counter-clockwise rotation from 179° to 180°) with couch rotation 0°. The collimators were set to 15° and 345° respectively to minimize contribution of the tongue-and- groove effect to the dose. The field size for the open x-jaw method was created automatically using the Arc Geometry Tool, expanding the x-jaw to encompass the entire target volume (Figure 1). The limited x-jaw method utilized the same isocenter but restricted the total x-jaw expansion to 15 cm with 7.5 cm in both the positive and negative direction (Figure 2). The split x-jaw technique employed 4 arcs (2 clockwise rotations from 180° to 179° and 2 counter-clockwise rotations from 179° to 180°) with couch rotation 0°. The first 2 fields were developed by using the Eclipse Arc Geometry tool, expanding the jaws to cover the entire PTV. These fields were duplicated resulting in 2 clockwise and 2 counter-clockwise arcs. The clockwise arcs were named 1 and 1A respectively. Beginning with field 1, the X2 jaw was closed so the maximum width was 15 cm resulting in coverage of the right side of the PTV (Figure 3a). Using field 1A, the X1 jaw was closed so the maximum width was 15 cm resulting in coverage of the left side of the PTV (Figure 3b). These steps were repeated to create the counter-clockwise arcs with names 2 and 2A. Although the split x-jaw method utilized 4 arcs, it essentially divided the open x-jaw fields in half and limited each to 15 cm, therefore, encompassing the same volume as the open field, but creating an advantage of increased modulation with the 15 cm field sizes.

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The 3 VMAT plans were developed using equivalent optimization objectives to reduce variability. The initial objectives were based on the RTOG 0921 protocol constraints. Dose- volumetric parameters were the percentage of bowel and rectum that received a dose of 40 Gy (V40), the percentage of bladder that received 45 Gy (V45), and the percentage of the left and

right femoral heads that received 35 Gy (V35). The specific constraints for each structure were

as follows: bowel V40 < 30%, rectum V40 < 60%, bladder V45 < 35%, and left and right

femoral heads V35 < 15%. The PTV was evaluated based on V45 > 95% and the percentage of PTV that received a dose of 49.5 Gy (V49.5), V45.9 < 110%. These objectives were first applied to the open planning optimization and modified accordingly to achieve acceptable parameters.

The same objectives were then applied to the limited and split plans with no modification for consistency. Treatment planning goals included satisfying target coverage while meeting OAR constraints as identified by the RTOG 0921 protocol. Plan Comparison The open, limited, and split planning methods were evaluated primarily based on plan

conformity and sparing OAR. Data was gathered and recorded for each plan based on the Eclipse TPS dose statistics. Plan conformality was determined from the PTV Conformity Index (CI). A

CI value of 1.0 represents the ideal level of plan conformality. Evaluation indicators for OAR

were recorded based on quantitative data from the dose-volume histogram (DVH). Secondary plan comparison data was based on the maximum dose, the volume of the 50% and 105% isodose regions, and the total MUs. The maximum dose for each plan was restricted to the PTV and recorded based on the Eclipse TPS dose statistics. The volume of the 50% and 105% isodose regions were documented in cm 3 and used as an additional measure of plan conformality. The total MUs were determined by adding the MUs from each treatment field located within the identified plan. Results Patient inclusion data identifed 20 individuals with endometrial carcinoma with PTVs requiring maximum x-jaws of 19.3-20.4 cm. For each case, 3 treatment plans were created for comparison purposes. All three planning methods were capable of delivering 100% of the prescription dose to 95% of the PTV for the entire study sample. The time required to generate the arcs for the open and limited plans was similar. The split method required a few extra minutes to duplicate and divide the fields to create the 2

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additional arcs. The open method required the longest optimization to achieve acceptable dose distributions while, the limited and split techniques used the same objectives for consistency. Conformity Figure 4 summarizes the target coverage between the 3 planning methods. The split technique showed the most consistent PTV conformality with a CI of 0.98±0.02 followed by the open method with a CI of 1.01±0.03. The limited technique had the widest range with 1.04±0.05. Conversely, the limited plans showed a superior CI to that of the split plans in 12 out of 20 cases. OAR Sparing Figure 5 summarizes the average dose to the OAR between the open, limited, and split planning methods. Comparatively, the split technique provided better OAR sparing to the bowel, rectum, sigmoid, and left and right femoral heads. On average, the split method offered the best results in sparing the OAR. In comparison to the limited technique, the split method reduced the dose by 4.0% to the bowel, 3.4% to the rectum, 2.2% to the sigmoid, 3.5% to the right femoral head, and 3.9% to the left femoral head. The split technique showed improvement over the open method as well, limiting the bowel by 3.8%, the rectum by 3.2%, the sigmoid by 2.1%, the right femoral head by 4.5%, and the left femoral head by 6.3%. The split technique also spared the bladder with a 1.1% decrease over the limited method however, the open and split technique showed comparable results. Dose Parameters The split technique provided the lowest maximum dose in all 20 cases with an average of 109%, followed by the open with 110.36%, and the limited with 112.24%. In addition, the volume of the 105% isodose region was minimal using the split planning method with an average of 195.75 cm 3 compared to the limited and open techniques with 687.89 cm 3 and 524.79 cm 3 respectively. The volume of the 50% isodose region was also considered and smallest in the split plans with 5753.16 cm 3 compared to the limited and open techniques with 5878.5 cm 3 and 6036.64 cm 3 respectively. MUs

The MUs reflected plan modulation. As MUs increased, modulation also increased. The MUs were highest in the split plans (avg 706 MU), intermediate in the limited plans (avg 650 MU), and lowest in the open plans (avg 583 MU) and reflect modulation. Discussion

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The primary goal of this study was to introduce a treatment planning technique capable of providing adequate coverage to PTVs larger than the 15 cm MLC limitation on Varian linear accelerators. Plan conformality and limiting dose to OAR were high priority considerations. The preliminary results from this study expanded upon the research completed by Zhang et al, 3 comparing the limited and open planning techniques. The split x-jaw method showed superior results.

Over the course of this retrospective study, the split x-jaw technique delivered the most consistent plan conformality. Dividing each open field into 2 arcs and restricting the field sizes to 15 cm, lead to benefits over the open and limited planning methods. First, the PTV remained within the fields over the entire treatment duration resulting in better dose distribution and target volume coverage. The limited method expanded the x-jaw to 15 cm, leaving portions of the large PTVs partially covered resulting in reduced plan conformality. Although the open planning method included the entire PTV, the field sizes were well beyond the 15 cm limitation of the MLCs, yielding poor modulation and dose distribution. The split method also showed positive results in sparing OAR. Dose to the bowel, rectum, sigmoid, and left and right femurs were considerably reduced using this technique due to increased modulation. The limited method was not capable of shielding OAR regions outside of the MLC leaf span resulting in more dose. Conversely, the open method could not provide adequate modulation to block the OAR leading to more dose. An aspect to consider with the split planning technique is 4 treatment arcs compared to 2 using the open and limited planning methods. The additional arcs resulted in an increase in MUs and treatment time. Patients that have difficulty holding the setup position for extended periods of time may not tolerate the split planning technique. The open and limited planning methods were similar with respect to MUs and treatment time. Target volumes for this study were created by 5 attending radiation oncologists according to the RTOG 0921 protocol guidelines. In addition, OAR contours were created by various medical dosimetrists. Discrepancies may exist within the target volume delineation, however OAR contours were evaluated and modified by a single dosimetrist prior to treatment planning for consistency. All 60 treatment plans for this study were completed by a single dosimetrist to reduce variability. Conclusion

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Current treatment planning techniques used for extensive PTVs offer opportunities for improvement. The limited x-jaw planning method does not provide coverage to the entire PTV, while the open x-jaw technique results in subpar modulation. The split x-jaw planning technique offered dosimetric benefits for PTVs larger than the capable extent of the MLCs in Varian linear accelerators. The technique provided superior target dose distribution and spared OAR more effectively than the limited and open planning methods. In addition, the split technique reduced the 50% and 105% isodose regions, which significantly improved plan conformality. The limitations of this research study include the limited sample size and multiple clinicians that developed contours for each patient. Treatment planning remained consistent with all 60 plans completed by a single dosimetrist. Research should be expanded to include a broader sample. In addition, the split x-jaw treatment planning technique should be applied to other areas of the body with large PTVs, such as the head and neck, abdomen, and pelvic regions, to explore versatility.

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References

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volumetric modulated arc therapy. J Korean Phys Soc. 2015;67(1):243-247.

http://dx.doi.org/10.3938/jkps.67.243

3. Zhang WZ, Lu ZY, Chen JZ et al. A dosimetric study of using fixed-jaw volumetric

modulated arc therapy for the treatment of nasopharyngeal carcinoma with cervical lymph node metastasis. PLoS One. 2016;11(5):e0156675. http://dx.doi.org/10.1371/journal.pone.0156675

4. Rossi M, Boman E, Skytta T, Kapanen M. A novel arc geometry setting for pelvic

radiotherapy with extensive nodal involvement. J Appl Clin Med Phys. 2016;17(4):73-85.

http://dx.doi.org/10.1120/jacmp.v17i4.6028

5. Vieillot S, Azria D, Lemanski C, et al. Plan comparison of volumetric-modulated arc therapy

(RapidArc) and conventional intensity-modulated radiation therapy (IMRT) in anal canal

cancer. Radiat Oncol. 2010;5(1):92. http://dx.doi.org/10.1186/1748-717X-5-92

6. Viswanathan AN, Moughan J, Miller BE, et al. NRG oncology/RTOG 0921: a phase II study

of postoperative intensity modulated radiation therapy (IMRT) with concurrent cisplatin and bevacizumab followed by carboplatin and paclitaxel for patients with endometrial cancer. Cancer. 2015;121(13):2156-2163. https://doi.org/10.1002/cncr.29337

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Figures

10 Figures Figure 1. The open plan was created automatically us ing the Arc Geometry Tool

Figure 1. The open plan was created automatically using the Arc Geometry Tool to expand the x-jaw to encompass the entire PTV.

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11 Figure 2. The limited technique restricted the total x-ja w expansion to 15 cm to

Figure 2. The limited technique restricted the total x-jaw expansion to 15 cm to account for the MLC limitation.

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12 Figure 3a. The split method was created by using the Ec lipse Arc Geometry Tool

Figure 3a. The split method was created by using the Eclipse Arc Geometry Tool to expand the x-jaws to cover the entire PTV and duplicating resulting in 2 fields named 1 and 1A. Beginning with field 1, the X2 jaw was closed to the maximum width was 15 cm resulting in coverage of the right side of the PTV.

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13 Figure 3b. For field 1A, the X1 jaw was closed so the maximum width was

Figure 3b. For field 1A, the X1 jaw was closed so the maximum width was 15 cm resulting in coverage of the left side of the PTV.

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Conformality 1.1 1.08 1.06 1.04 1.02 1 Open Limited 0.98 Split 0.96 0.94 0.92 0.9
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Figure 4. Planning methods were evaluated primarily based on the PTV CI where a value of 1.0 represents the ideal level of plan conformality.

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Average Dose to OAR Left Femoral Head Rt Femoral Head Bladder Sigmoid Rectum Bowel 0.00
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Figure 5. The average dose to the OAR was the least using the split x-jaw planning method compared to the open and limited techniques.