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Comparison of IMRT and VMAT treatment techniques on centrally-located lung tumors

and their effects on V5 Lung doses 
Amber Mehr, B.S., Andrew Edel, B.S, Jenny Huang, B.S., R.T.(T), Ruha Siddiqui, B.S., 
Ashley Hunzeker, M.S., C.M.D., Nishele Lenards, R.T.(R)(T), M.S., C.M.D., FAAMD 

ABSTRACT 
The percentage of lung receiving 5 Gy or more (lung V5 dose) can be crucial in determining
future long-term effects such a pneumonitis. The goal of this study was to determine if there was
a difference or increase in the percentage of lung V5 dose during intensity modulated radiation
therapy (IMRT) or volumetric modulated arc therapy (VMAT) treatment planning. These
treatment techniques are relatively new to the industry and their impact on critical organ dose
requires more exploration. Fourteen patients with centrally located tumors and planning target
volumes (PTV) between 100-1500cc were selected for this research study. Each patient had an
IMRT treatment plan and a VMAT treatment plan created for comparison purposes. A paired t-
test was used to determine if there was a significant difference between the planning techniques.
The t-scores for the lung V5 dose, percentage of lung volume receiving 20 Gy or more (lung V20
dose), percentage of lung volume receiving 30 Gy or more (lung V30 dose) were 3.02, 2.42, and
2.01, respectively. The t-score for lung V30 dose was statistically insignificant meaning that the
percentage of lung volume receiving 30 Gy or more was similar. The t-score for the lung V5 dose
and lung V20 dose was statistically significant, meaning there was an increase in the volume of
lung receiving 5 Gy or higher and 20 Gy or higher when using VMAT instead of IMRT. The
results of this study determined that both IMRT and VMAT planning techniques are comparable
when creating lung treatment plans. The organs at risk (OAR) doses were kept below their
constraints (Table 1). The IMRT planning technique obtained similar PTV coverage when
compared to the VMAT planning technique but IMRT was able to maintain lower lung V5 and
lung V20 dose.

Keywords: Intensity modulated radiation therapy (IMRT), volumetric modulated arc therapy
(VMAT), Lung V5 dose, centrally located lung tumors 
 
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Introduction: 
In the past, 3D conventional radiation therapy (3DCRT) planning was primarily used for
lung treatments and dose constraints were based on dose volume histograms (DVHs) of these
plans.1 The onset of 3DCRT first began in the early 1980s and was an important feat in the world
of radiation therapy. Using 3DCRT allowed the manipulation of spatial orientation, selecting the
number of fields, beam energy, field weighting and more.2 It involved a high degree of technique
among treatment planners to achieve the best plan.
Through advancements in technology, 3DCRT is slowly being overcome by VMAT and
IMRT. Plans using 3DCRT have minor deviations in comparison to IMRT and VMAT planning
and is the sole reason 3DCRT is slowly phasing out for certain circumstances and type of
diseases. Both IMRT and VMAT are types of planning techniques that allow for better dose
computation algorithms, better and precise optimization methods, and ability to target the tumor
more precisely, which in turn creates a better conformal plan in comparison to 3DCRT.2 When
comparing 3DCRT to IMRT and VMAT, the impact on high lung dose has become a topic of
discussion among the radiation oncology field. The advanced treatment planning techniques have
led to more entry points for radiation dose by using multiple beams and continuous arcs. In
retrospect, this has created a risk for increasing the lung V5 dose.3
The purpose of this study was to determine if there was a difference in the lung V5 dose
during IMRT or VMAT treatment planning. The increased lung dose is a concern for patients
because when lung V5 dose increases, there becomes a higher risk for radiation pneumonitis and
other complications.4,5,6 Previous research studies, such as Lievens et al.2, have proposed that
lung V5 dose is not predictive of radiation pneumonitis nor has the study indicated if lung V5
dose levels are higher when dose is delivered with dynamic arcs. Another factor to consider is
whether to evaluate lung V20 dose as a risk for pneumonitis, proposed by a study by Graham et
al.1 While looking at this criterion alone may not be as predictive as previously thought, data
now suggests that lung V5 dose must be considered in addition to lung V20 dose.5,6 
Materials and Methods:  
Patients   
Fourteen patients with lung tumors, that were treated at 3 different cancer centers, were
selected for this study. Patients were prescribed with a dose range between 4500 to 7000 cGy.
The tumors ranged in the type of cancer and their progression which included non-small cell
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lung carcinoma (NSCLC), malignant neoplasm of lobe, squamous cell carcinoma (SCC), small
cell lung carcinoma (SCLC) and left upper lobe (LUL). All patients had centrally located lung
tumors with a PTV between 100-1500 cc (Table 2). To prevent bias of the data set, plans chosen
for comparison purposes had to meet certain criteria to be considered eligible for data collection.
This criterion included remaining within a certain range for the prescription dose, PTV volume
(cc), PTV vertical length (cm), and lung volume (cc).
There were various factors that would prevent patients from being part of the study
including a laterally-located lung tumor, and prior radiation treatments. Plans using lung V5 dose
as an optimization parameter were also excluded to prevent bias within the results. Controlling
this within the study was essential because if lung V5 dose was used as an optimization
parameter, the plan could not be used to determine if IMRT or VMAT planning technique
resulted in greater V5 dose.  
For treatment, all 14 patients were positioned in a similar fashion.  Patients were set up in
the supine head-first position using several immobilization devices during their computed
tomography (CT) simulation (Figure 1). The patient’s arms were placed over their heads using a
T-Bar device to remove the upper extremities from the treatment field. A vacuum-lock bag was
placed underneath the patient’s chest and arms to provide stability and comfort. Lastly, an elastic
band was placed around their feet to limit patient mobility. Once the CT scan was performed, the
isocenter was established by the radiation oncologist and medical dosimetrist within the clinic.
The radiation therapist placed marks on the patient’s skin surface to denote the isocenter
position; these marks were used for daily treatment to ensure reproducibility and patient
alignment to the isocenter.  
Contouring  
 After the CT simulation was performed, the patient CT images were uploaded into either
Pinnacle or Eclipse treatment planning systems (TPS) to be contoured by the radiation
oncologists and medical dosimetrists. The radiation oncologists contoured the gross tumor
volume (GTV), clinical target volume (CTV) and PTV. The GTV was created around the
cancerous tissue determined by imaging. The GTV was then expanded by 0.7 cm in all directions
to create the CTV. To create the PTV, the CTV was expanded 1.0 cm superiorly and inferiorly
and 0.5 cm laterally and medially coinciding with the Radiation Therapy Oncology Group
(RTOG) 0617 Protocol.7 Once the target volumes were completed, the medical dosimetrists
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contoured the thoracic OAR following RTOG 0617 protocol to include spinal cord, lungs,
esophagus, and heart (Table 1).7  
Treatment Planning   
Ten IMRT and VMAT plans were made on Pinnacle 9.3 and 14.0 workstation and treated
on Varian 21iX, Trilogy and Elekta Infinity and Synergy accelerators.  Four IMRT and VMAT
plans were made on Eclipse (Version) workstation and treated on Varian Trilogy accelerators.
Applying proper technique depended on the tumor size, tumor location, OAR and dose-tolerance
criteria. The medical dosimetrists used 6 MV photon beams for both IMRT and VMAT. The
prescriptions ranged between 45 Gy-70 Gy for treatments but was kept consistent when re-
planning using the different treatment technique for the current study (Table 3).
A common treatment planning technique for the treatment of lung cancer is IMRT. The
medical dosimetrists used 5-9 beams for each IMRT plan using a static step-and-shoot approach
(Figure 2) (Table 3). The beams were placed at angles to avoid the OAR.
In this study, the actual IMRT plans were retrieved and re-planned for the VMAT study
using the same treatment objectives. Volumetric modulated arc therapy produced highly
conformal dose distribution, improved the delivery efficiency by reducing treatment time and
produced accurate dosimetric calculations.3 The VMAT beams were arranged as 2 partial arcs, 2
full arcs, 3 partial arcs or 3 full arcs with varying collimator angles (Figure 3). The beams were
planned with different rotational directions, clockwise (CW) and counter clockwise (CCW)
(Table 3). The arcs and collimator angles were chosen to avoid OAR while maintaining the best
coverage of the PTV.
To determine the constraints for the OAR used for planning and optimization, the
radiation oncologist referred to RTOG 0617 for creating the IMRT and VMAT treatment plans.
The plans were optimized according to the desired constraints for the lung(s), spinal cord,
esophagus, and heart, while simultaneously optimizing to obtain PTV coverage (Table 1).
Plan Comparisons  
Once an IMRT and a VMAT plan were created for each patient, the plans were compared
to identify the differences. A paired t-test was selected because it compared the two plans with
the same data set. Differences in anatomy have a large effect on plan results and this statistical
test accounted for this variability. Both IMRT and VMAT were normalized to meet PTV
coverage. Specific metrics were recorded for each plan including lung V30 dose, lung V20 dose,
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lung V5 dose, and objectives of OAR (Table 1). The IMRT and VMAT plans were acceptable if
at least 95% of PTV volume received 100% of the prescribed dose.
A statistical analysis was performed for all lung metrics to allow for a clear plan
comparison of the 2 techniques. The lung V5 dose, lung V20 dose, lung V30 dose and mean dose
were recorded. The percentage volume of heart receiving 60 Gy or more (heart V60 dose) was
also recorded.
Results:
Treatment plans of 14 patients met the previously established requirements. Patients that
were selected were diagnosed with one of the following; NSCLC, SCLC, SSC, or undefined
malignant neoplasms of the lung (Table 4). The physician prescription ranged between 4500 and
7000 cGy (table 5). Only 2 cases were initially planned with IMRT.
The lung volume showed differences in lung V20 and lung V5 dose for VMAT and IMRT
planning. Lung V30 dose in VMAT plans (mean= 19.17, SD= 5.93) was not significantly greater
than IMRT plans (mean= 16.77, SD= 5.03) based on a 2-tailed test for paired samples (t13 = 2.01,
P = .066). However, lung V20 dose in VMAT plans (mean= 27, SD=6.29) was significantly
greater than IMRT plans (mean= 25.72, SD= 6.95) based on a 2-tailed test for paired samples (t13
= 2.42, P = .031). The lung V20 dose is significantly different, however the difference between
plans is under 2%. Lung V5 dose in VMAT plans (mean= 69.57, SD=17.16) was significantly
greater than IMRT plans (mean= 63.5, SD= 14.73) based on a 2-tailed test for paired samples (t13
= 3.02, P = .001). Note that the VMAT mean is greater than 65% which has been suggested as a
reasonable lung V5 dose constraint.
Discussion:
Similarities and differences between IMRT and VMAT treatment planning techniques
were observed throughout this study. The lung V30 dose was comparable for each type of
planning technique. Treatment planning with IMRT instead of VMAT, resulted in less lung V5
and lung V20 dose.
The difference between the percentage of lung V30 dose for IMRT and VMAT was not
statistically significant. When looking at lung V30 dose delivered to the lung, the differences
between treatment techniques became less noticeable. This was due to medical dosimetrists
limiting the amount of dose received by the lung during optimization at lung V30 dose. Through
this optimization, both techniques could lower the lung V30 dose. 
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When comparing the 2 treatment techniques, the difference between the lung V5 dose and
lung V20 dose increased significantly. With VMAT, the dose entered the patient continuously
while the gantry moved along the arc. This resulted in dose being delivered to the patient’s body
through more entry points when compared to IMRT treatment planning. With this change in dose
delivery, patients received a higher integral dose due to the increase in access to the lungs during
movement of the arcs and resulting in more dose entry points. Therefore, the lung V5 dose and
lung V20 for IMRT was lower than the lung V5 dose and lung V20 dose for VMAT plans. 
Conclusion: 
Through advancements in technology, IMRT and VMAT planning are now being used to
perform lung treatments. With the introduction of these techniques, the difference of lung V5
dose required more analysis due to the risk of pneumonitis. Patients with centrally located lung
tumors were selected and IMRT and VMAT plans were created to determine the differences in
lung V5, lung V20, and lung V30 dose. When comparing IMRT and VMAT treatment plans, there
were differences found amongst both techniques. Planning with IMRT and VMAT, resulted in
similar lung V30 dose.  Using the VMAT planning technique however, resulted in higher lung V5
dose and lung V20 dose in patients with centrally-located lung tumors. Both techniques were
beneficial to the medical dosimetrists because coverage was maintained while limiting dose to
critical structures due to blocking and beam placement. The limitations for this study included
the small sample size and the exclusion of 3DCRT as one of the planning techniques for
comparison.  
For future studies, IMRT and VMAT treatments plans should be created focusing only on
laterally-located lung tumors to see if there is a difference in lung V5 dose. The beams should
also be limited to the side of the patient’s body that contains the tumor to lower dose to the
contralateral lung.5 Medical dosimetrists should also look at IMRT planning versus 3DCRT and
VMAT versus 3DCRT to see how much the lung V5 dose has increased with planning technique
advancements. Knowing the amount of lung V5 dose a patient is receiving is important because
increased low lung doses could lead to future radiation damage. 
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References
1. Graham MV, Purdy JA, Emami B, et al. Clinical dose-volume histogram analysis for
pneumonitis after 3D treatment for non-small cell lung cancer (NSCLC). Int J Radiat Oncol
Biol Phys. 1999;45(2):323-329. https://dx.doi.org/10.1016/S0360-3016(99)00183-2 

2. Cai J, Malhotra HK, Orton CJ. A 3D- conformal technique is better than IMRT or VMAT for
lung SBRT. Med Phys. 2014;41(4):040601-040602. https://doi.org/10.1118/1.4856175.

3. Li Y, Wang J, Tan L, et al. Dosimetric comparison between IMRT and VMAT in irradiation
for peripheral and central lung cancer. Oncol Lett. 2018;15(3):3735-3745.
https://dx.doi.org/10.3892/ol.2018.7732 

4. Aaron A, Czerminska M, Jänne P, et al. Fatal pneumonitis associated with intensity-modulated

radiation therapy for mesothelioma. Int J Radiat Oncol Biol Phys. 2006;65(3):640 – 645.
https://dx.doi.org/10.1016/j.ijrobp.2006.03.012  

5. Helen H, Jauregui M, Zhang X, et al. Beam angle optimization and reduction for intensity-
modulated radiation therapy of non–small-cell lung cancers. Int J Radiat Oncol Biol Phys.
2006;65(2):561–572. https://dx.doi.org/10.1016/j.ijrobp.2006.01.033 

6. Lievens Y, Nulens A, Gaber MA, et al. Intensity-modulated radiotherapy for locally advanced
non-small-cell lung cancer: a dose-escalation planning study. Int J Radiat Oncol Biol Phys.
2011;80(1):306-313. https://dx.doi.org/10.1016/j.ijrobp.2010.06.025 

7. Bradley J, Choy H, Komaki R, et al. RTOG 0617: A randomized phase III comparison of
standard-dose (60 Gy) versus high dose (74 Gy) conformal radiotherapy with concurrent and
consolidation carboplatin/paclitaxel +/- cetuximab (IND #103444) in patients with stage
IIIA/IIIB non-small cell lung cancer. Lancet Oncol. 2015(2):187-199.
https://dx.doi.org/10.1016/S1470-2045(14)71207-0 

 
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Figures

 
Figure 1.  Demonstration of patient positioning for CT simulation and treatment delivery
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Figure 2. The arrangement of the beams, for the 7-beam IMRT treatment technique, were
placed to avoid the spinal cord and produced dose conformity.
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Figure 3. An example of a 3-arc VMAT utilizing clockwise and counterclockwise motion to

produce a highly conformal dose distribution. 

 
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Tables 
Table 1. The thoracic constraints used for patient treatment planning in IMRT and VMAT.
Organ at risk  Objectives 
Spinal Cord  Dmax (point dose) < 50 Gy 

Dmax (0.03 cc) < 44-48 Gy 

Lung  V20 < 30-35% 

V30 < 20-25% 

Esophagus  V45 < 33% 
Heart  V60 < 33% 
Abbreviations: Dmax = maximum dose to organ in Gy; V20 = percentage of organ volume
receiving 20 Gy or more; V30 = percentage of organ volume receiving 30 Gy or more; V45 =
percentage of organ volume receiving 45 Gy or more; V60 = percentage of organ volume
receiving 60 Gy or more

Table 2. Patient characteristics

Patient No. Age TNM PTV Volume (cc)
1 362.8
2 629.15
3 1087.87
4 916.54
5 724.13
6 582.27
7 1409.5
8 535.58
9 320.78
10 120.21
11 340.59
12 273.2
13 336.23
14 240.81
Abbreviations: TNM = T describes the size of the tumor, N describes spread of cancer to nearby
lymph nodes, and M describes metastasis.
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Table 3. Summary of treatment planning for VMAT and IMRT

Patient Prescription TPS VMAT, 6 MV IMRT, 6 MV
No.
1 50.4Gy Pinnacle
2 70 Gy Pinnacle
3 60 Gy Pinnacle
4 60 Gy Pinnacle
5 61.2 Gy Pinnacle Arc A: 184-176 CW, coll. 15 Gantry: 180, 140, 20, 340, 300,
260, 220
Arc B: 176-184 CCW, coll. 15
Coll. 0
Arc C: 186-22 CW, coll. 30
6 50 Gy Pinnacle Arc A: 184-176 CW, coll. 15 Gantry: 0, 40, 80, 120, 160, 200

Arc B: 176-184 CCW, coll. 15 Coll. 0

7 45 Gy Pinnacle Arc A: 358-2 CW, coll. 190 Gantry: 0, 40, 80, 120, 160, 200

Arc B: 2-358 CCW, coll. 190 Coll. 0

8 61.2 Gy Pinnacle Arc A: 182-178 CW, coll 10 Gantry: 0, 40, 80, 120, 160, 200,
240, 280, 320
Arc B: 182-178 CW, coll 95
Coll. 0
Arc C: 178-182 CCW, coll 10

Arc D: 178-182 CCW, coll 95

9 60 Gy Pinnacle Arc A: 242-2 CW, coll 190 Gantry: 0, 40, 80, 120, 160, 200

Arc B: 2-242 CCW, coll 190 Coll. 0

10 60 Gy Pinnacle Arc A: 330-178 CW, coll 15 Gantry: 0, 51, 103, 154, 206, 257,
309
Arc B: 178-330 CCW, coll 15
Coll. 0
11 50 Gy Eclipse
12 50.4 Gy Eclipse
13 50 Gy Eclipse
14 60 Gy Eclipse
Abbreviations: TPS = treatment planning system; VMAT = volumetric modulated arc therapy;
IMRT = intensity-modulated radiation therapy; CW = clockwise; CCW = counter clockwise; coll
= collimator
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Table 4. Patient diagnosis frequency

Patient diagnosis Number of patients
Squamous cell carcinoma 4
Non-small cell lung cancer 4
Small cell lung cancer 1
Malignant neoplasm of the upper lung 3
Malignant neoplasm of the lower lung 2

Table 5. Prescription dose frequency

Prescription dose (cGy) Number of patients
4500 1
5000 3
5040 2
6000 5
6120 2
7000 1